Is the Caribbean ready for robotics?

The Caribbean region is part of the world which lagged by 10 years compared to the rest of the developed world nations in the field of minimal access surgery (MAS). The implementation of basic and advanced laparoscopy only came to fruition until a group of surgeons created a partnership across the region. The introduction of robotic surgery to the world possess yet another challenge to the surgical leaders and the people of the developing Caribbean countries.

Does robotic-assisted transabdominal preperitoneal (R-TAPP) hernia repair facilitate contralateral investigation and repair without compromising patient morbidity?

Inguinal hernia repair (IHR) is performed through either an open or minimally invasive approach (MIS). MIS allows for exploration and potential repair of an occult contralateral hernia. The aim of this study is to evaluate complications associated with intraoperative contralateral exploration and repair through robotic-assisted (da Vinci®) IHR. 652 robotic-assisted inguinal hernia procedures were uniformly and retrospectively collected from seven surgeons. Incidental contralateral findings were evaluated and populations with and without contralateral findings were compared in terms of demographics, operative characteristics and complications. This case series includes the earliest cases in each surgeon's robotic-assisted IHR experience. Seventy-one percent (71%) of patients presented with a unilateral hernia. Intraoperative/incidental contralateral ("occult") hernias were found in 12.3% of patients with a unilateral diagnosis. For patients with and without contralateral findings, there were no significant differences in demographics and baseline health characteristics. Perioperative morbidity was statistically similar between groups: intraoperative complications (0 vs 0.5%, p = 1.000), postoperative complications prior to discharge (0 vs 3.2%, p = 0.38) and from discharge through 30 days (5.3 vs 4.0%, p = 0.72), as well as readmissions and reoperations related to the repair within 30 days. Differences in setting of care, length of stay, rate of blood transfusions, concomitant procedures and conversions were nonsignificant. Mean operative time was longer in patients with a contralateral hernia by 19 min (p < 0.0001). Intraoperative contralateral exploration and subsequent repair during robotic-assisted IHR does not compromise perioperative patient morbidity. These study results support the increasing evidence for repair of contralateral, incidentally discovered inguinal hernias.Clinicaltrials.Gov ID number: NCT02684448.

Early outcomes of robotic-assisted inguinal hernia repair in obese patients: a multi-institutional, retrospective study.

BACKGROUND: Minimally invasive inguinal hernia repair (IHR) in general and particularly in obese patients has not been widely adopted, potentially due to the perceived technical challenges and the well-documented learning curve associated with laparoscopic repair. Outcomes in robotic-assisted IHR in obese (BMI ≥ 30 kg/m2) patients have not been described and warrant study. METHODS: Seven surgeons conducted a multicenter retrospective chart review of their early robotic-assisted IHR (RHR) cases and compared them with their open IHR (OHR) cases. Demographics, operative characteristics, and perioperative morbidity were compared for unadjusted and propensity-matched populations. RESULTS: 651 robotic-assisted cases and 593 open cases were collected. The outcomes of 148 RHRs to 113 OHRs in obese patients were compared. For obese populations-whether unadjusted (robotic-assisted, n = 148; open, n = 113) or matched (1:1) (robotic-assisted, n = 95; open, n = 93)-the robotic-assisted and open cohorts were comparable in terms of demographics and baseline characteristics. Significantly higher percentages of OHR patients experienced postoperative complications post-discharge (unadjusted: 11.5% vs. 2.7%, p = 0.005; and matched: 10.8% vs. 3.2%, p = 0.047). More concomitant procedures and bilateral repairs were conducted in obese RHR patients than in obese OHR patients (unadjusted 29.7% vs. 16.8%, p = 0.019; and unadjusted 35.1% vs. 11.5%, p < 0.0001-respectively). Prior laparoscopic IHR experience did not affect 30-day outcomes. CONCLUSIONS: Obese patients who undergo RHR have a lower rate of postoperative complications compared to obese patients who undergo OHR. Previous laparoscopic IHR experience, more bilateral repairs, and more concomitant procedures were not associated with increased complications in RHR patients. These outcomes may facilitate increased adoption of minimally invasive IHR approaches in the obese population.

Robotic-assisted ventral hernia repair: a multicenter evaluation of clinical outcomes.

BACKGROUND: The open approach continues to be widely performed for ventral hernia repair, while the minimally invasive laparoscopic approach has grown adoption over the last decade. Recently, robotic operation was described as a new modality due to the ease for performing intracorporeal closure of the hernia defect. This study is one of the first multi-institutional case series evaluating robotic-assisted laparoscopic ventral hernia repairs, with the goal of describing robotic-assisted surgical techniques for ventral and incisional hernia repair and the outcomes in teaching and community hospital settings. METHODS: Medical records of consecutive patients (including surgeon's learning curve cases) who underwent ventral or incisional hernia repair utilizing the da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale CA) were retrospectively reviewed. Data collected included preoperative history and perioperative outcomes. RESULTS: Data for a total of 368 patients from four institutions involving five surgeons were analyzed. They were predominantly females (60.3 %), and the mean age was 51 years. The majority of the patients were obese or morbidly obese (47.8 and 20.9 %), and 83.2 % of the patients had a history of prior abdominal operation. Conversion rate was 0.8 %, and mean length of stay was 1 day. Total postoperative complications rate up to 30 days was 8.4 %, of which incidence of paralytic ileus was 2.4 %. CONCLUSION: This large case series of 368 patients demonstrates reproducibility of safety and performance associated with robotic-assisted ventral hernia repairs performed by five surgeons at four institutions. In addition, the results of short term perioperative outcomes for surgeons during their early experience for robotic-assisted cases are in the range of what is reported in the existing published data on laparoscopic and open ventral hernia repairs. Further comparative evidence initiatives are being pursued to determine the benefits of robotic-assisted technique and technology for long-term and patient-reported outcomes.

Feasibility of robotic inguinal hernia repair, a single-institution experience.

BACKGROUND: With the growth of the discipline of laparoscopic surgery, technology has been further developed to facilitate the performance of minimally invasive hernia repair. Most of the published literature regarding robotic inguinal hernia repair has been performed by urologists who have dealt with this entity in a concomitant way during radical prostatectomies. General surgeons, who perform the vast majority of inguinal herniorrhaphies worldwide, have yet to describe the role of robotic inguinal hernia repair. Here, we describe our initial experience and create the foundation for future research questions regarding robotic inguinal hernia repair. METHODS: A retrospective chart review was performed in 78 patients who underwent robotic transabdominal preperitoneal TAPP inguinal hernia repair with a prosthetic mesh using the da Vinci platform (Intuitive Surgical Inc). Data collected included patient demographics, past medical history, previous surgeries, details related to the surgical procedure, perioperative outcomes and complications. RESULTS: A total of 123 hernias were repaired. Forty-five patients had bilateral robotic inguinal herniorrhaphies, and the mean age was 55.1 years (SD 15.1), with a mean BMI of 27.6 (SD 6.1). There were 71 male and 7 female patients. Surgical complications included hematoma in three patients (3.9 %), two seromas (2.6 %) and one superficial surgical site infection at a trocar site (1.3 %), which resolved with oral antibiotics. Chronic postoperative complications (>30 days post-surgery) included the persistence of hematomas in two patients (2.6 %). Same day discharge was achieved in 60 patients (76.9 %) with a mean length of stay of 8 h (SD 2.65). Neither mortality nor conversion to open surgery occurred. CONCLUSION: Our early experience has demonstrated that the robotic transabdominal preperitoneal (TAPP) inguinal hernia repair is a safe and versatile approach that allows the general surgeon to perform this procedure in more complex cases such as those involving incarcerated and/or recurrent hernias.

A multicenter study of initial experience with single-incision robotic cholecystectomies (SIRC) demonstrating a high success rate in 465 cases.

BACKGROUND: Recently, the robotic single-site platform has been used to ameliorate the difficulties seen in single-incision laparoscopic surgery (SILC) while preserving the benefits of standard laparoscopic cholecystectomy. The purpose of this study is to describe the clinical outcomes of a large series of single-incision robotic cholecystectomy (SIRC). METHODS: Medical records of consecutive patients who underwent SIRC were retrospectively reviewed. All procedures were performed by six surgeons at five different North American centers involved in the study. All patients included in the study underwent a cholecystectomy attempted through single site at the umbilicus, using the da Vinci(®) Surgical System (Intuitive Surgical Inc. Sunnyvale, CA). RESULTS: A total of 465 patients met study criteria. Median age was 48 years (range 18-89); 351 (75.5 %) were female and 304 (66.4 %) were overweight or obese. Except for gender, case characteristics differed significantly by surgeon/site. Previous abdominal surgery was reported for 226 (48.6 %) cases. SIRC was successfully completed in 455 (97.8 %) cases, and there were no conversions to open surgery. Median surgical time was 52 min with a decreasing trend after 55-85 cases. Male gender, obesity and diagnoses other than biliary dyskinesia were independent predictors of longer surgical times. The complication rate was 2.6 %. CONCLUSIONS: Our large, multicenter study demonstrates that robotic single-site cholecystectomy is safe and feasible in a wide range of patients.

Intravenous acetaminophen in bariatric surgery: effects on opioid requirements.

BACKGROUND: Opioids are commonly used after bariatric surgery for pain control because of their potent analgesic effects. Nevertheless, the morbidly obese patient has increased risk for developing adverse effects produced by opioids (such as sedation, apnea, hypoxemia, ileus, and vomiting). Intravenous acetaminophen (IVA) has been evaluated in some specialties showing a reduction in opioid consumption. The purpose of this study was to evaluate the effect on opioid consumption when IVA is administered in bariatric surgery patients. MATERIAL AND METHODS: A retrospective study was performed in patients who underwent bariatric surgery. Group A included those patients who received IVA perioperatively and group B those who did not. The amount of opioids administered was calculated and compared for each group. RESULTS: Group A included 38 cases (44.7%) and group B included 47 cases (55.3%). A comparison was performed in terms of age (P = 0.349), body mass index (P = 0.311), gender (P = 0.890), American Society of Anesthesiologist score (P = 0.438), total surgical time (P = 0.497), perioperative complications (P = 0.786), number of procedures per surgeon (P = 0.08), and type of surgical procedure (P ≤ 0.01). Group A had a mean 24-h total opioid dose of 99.5 mg, whereas group B of 164.6 mg (P = 0.018). Group A received 39.5% less opioids than group B. A post hoc analysis determined a statistical power of 0.74. CONCLUSIONS: IVA used perioperatively can decrease opioid consumption in patients after bariatric surgery. Randomized trials are needed to corroborate these results.

A comparative retrospective study of robotic sleeve gastrectomy vs robotic gastric bypass.

BACKGROUND: The introduction of the robotic platform to bariatric surgery has brought forth a novel approach, with modifications to the standard laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (LGB). The purpose of this study was to match robotic gastric bypass (RGB) vs robotic sleeve gastrectomy (RSG) and compare them to those observed with the laparoscopic platform. METHODS: A retrospective data collection of RSGs and RGBs from a single institution was performed. Groups were compared. RESULTS: This study included 134 RSG and 165 RGB patients. RGB has a longer surgical time (p < 0.001) and a higher incidence of long-term complications (p = 0.005) but similar lengths of hospital stay (p = 0.093), rate of perioperative complications (p = 0.487) and EWL% at 1 year of follow-up compared to RSG. CONCLUSIONS: RSGs had shorter surgical times and a lower incidence of long-term complications when compared with RGBs. These results appear to be similar to those studies reporting the laparoscopic approach. Copyright © 2014 John Wiley & Sons, Ltd.

Laparoscopic ventral hernia repair with primary closure versus no primary closure of the defect: potential benefits of the robotic technology.

BACKGROUND: Some authors recommend primary closure of the defect before placement of the mesh. The purpose of this study is to compare laparoscopic ventral hernia repair (LVHR) without primary closure of the defect (NPCD) versus LVHR with primary closure of the defect (PCD). METHODS: A retrospective review of 134 LVHR was performed. Each group included 67 cases. For the PCD group the robotic platform was used. RESULTS: Groups were similar in terms of demographics and comorbidities. For NPCD and PCD groups mean surgical time was 87.9±53.1 and 107.6±33.9 minutes (p = 0.012); conversion to open surgery was seen in 3(4.5%) and 1(1.5%) (p = 0.310); complications were 7(10.4%) and 2(3%) (p = 0.084); and finally, recurrences were seen in 5(7.5%) and 1(1.5%) (p = 0.095). CONCLUSIONS: PCD has longer surgical time, however, a tendency in terms of complications and recurrences was found favoring the PCD group. The robotic assistance is a good alternative when primary closure of the defect is attempted.

Single-incision cholecystectomy: a comparative study of standard laparoscopic, robotic, and SPIDER platforms.

BACKGROUND: Many series have shown the feasibility and safety of single-incision laparoscopic cholecystectomy (SILC), but this technique still has limitations such as instrument collisions and lack of triangulation. Recently, two single-incision platforms, robotic and SPIDER, have attempted to ameliorate such problems. This study aimed to compare three different techniques of single-incision cholecystectomy: standard laparoscopic, robotic, and SPIDER approaches. METHODS: The authors retrospectively collected data from their first 166 single-incision robotic cholecystectomies (SIRCs) and compared the findings with the data from their first 166 SILCs and the first 166 s-generation SPIDER procedures. All the SILCs were performed with three trocars placed in one umbilical incision and with gallbladder retraction using a Prolene stitch on the right upper quadrant. All the robotic cases were managed using the da Vinci Single-Site Surgical System, and all the SPIDER procedures were performed using the SPIDER Surgical System. RESULTS: The SILC, SIRC, and SPIDER groups consisted respectively of 129 (76.3%), 131 (78.9%), and 136 (81.9%) women with the respective mean ages of 44.5 ± 14.3, 51.6 ± 15.9, and 46.4 ± 15.2 years. The mean body mass indexes (BMIs) were respectively 29.1 ± 5.6, 29.4 ± 6.2, and 27.5 ± 4.8 kg/m(2), and the mean surgical times were 37.1 ± 13.3, 63.0 ± 25.2, and 52.8 ± 18.7 min. The total hospital stays were respectively 1.3 ± 5.3, 1.2 ± 2.2, and 1.5 ± 2.6 days, and complications were seen respectively in three SILC cases (1.8%), three SIRC cases (1.8%), and two SPIDER cases (1.2%). CONCLUSIONS: The results of this study demonstrate similar results among the three platforms for most of the parameters measured. The SILC procedure appears to be superior to SIRC and SPIDER in terms of surgical time, but selection bias could be the cause. The SILS, SIRC, and SPIDER procedures all are similar in terms of complication profile. It can be concluded that SILC, SIRC, and SPIDER all are feasible and safe alternatives when used for single-incision cholecystectomy.

Robotic sleeve gastrectomy: experience of 134 cases and comparison with a systematic review of the laparoscopic approach.

BACKGROUND: Robotic technology has recently emerged in different surgical specialties, but the experience with robotic sleeve gastrectomy (RSG) is scarce in the literature. The purpose of this study is to compare our preliminary experience with RSG versus the descriptive results of a systematic review of the laparoscopic approach. METHODS: Data from our RSG experience were retrospectively collected. Two surgeons performed all the cases in one single surgery center. Such information was compared with a systematic review of 22 selected studies that included 3,148 laparoscopic sleeve gastrectomy (LSG) cases. RSG were performed using the daVinci Surgical System. RESULTS: This study included 134 RSG vs. 3,148 LSG. Mean age and mean BMI was 43 ± 12.6 vs. 40.7 ± 11.6 (p = 0.022), and 45 ± 7.1 vs. 43.6 ± 8.1 (p = 0.043), respectively. Leaks were found in 0 RSG vs. 1.97% LSG (p = 0.101); strictures in 0 vs. 0.43% (p = 0.447); bleeding in 0.7 vs. 1.21% (p = 0.594); and mortality in 0 vs. 0.1% (p = 0.714), respectively. Mean surgical time was calculated in 106.6 ± 48.8 vs. 94.5 ± 39.9 min (p = 0.006); and mean hospital length of stay was 2.2 ± 0.6 vs. 3.3 ± 1.7 days (p = <0.005), respectively. Four (2.9%) complications were found in our robotic series. CONCLUSIONS: Our series shows that RSG is a safe alternative when used in bariatric surgery, showing similar results as the laparoscopic approach. Surgical time is longer in the robotic approach, while hospital length of stay is lower. No leaks or strictures were found in the robotic cases. However, further studies with larger sample size and randomization are warranted.

Robotic repair of giant paraesophageal hernias.

BACKGROUND AND OBJECTIVES: Giant paraesophageal hernia accounts for 5% of all hiatal hernias, and it is commonly seen in elderly patients with comorbidities. Some series report complication rates up to 28%, recurrence rates between 10% and 25%, and a mortality rate close to 2%. Recently, the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) has shown equivocal benefits when used for elective surgeries, whereas for complex procedures, the benefits appear to be clearer. The purpose of this study is to present our preliminary experience in robotic giant paraesophageal hernia repair. METHODS: We retrospectively collected data from patients who had a diagnosis of giant paraesophageal hernia and underwent a paraesophageal hernia repair with the da Vinci Surgical System. RESULTS: Nineteen patients (12 women [63.1%]) underwent surgery for giant paraesophageal hernia at our center. The mean age was 70.4 ± 13.9 years (range, 40-97 years). The mean American Society of Anesthesiologists score was 2.15. The mean surgical time and hospital length of stay were 184.5 ± 96.2 minutes (range, 96-395 minutes) and 4.3 days (range, 2-22 days), respectively. Nissen fundoplications were performed in 3 cases (15.7%), and 16 patients (84.2%) had mesh placed. Six patients (31.5%) presented with gastric volvulus, and 2 patients had other herniated viscera (colon and duodenum). There were 2 surgery-related complications (10.5%) (1 dysphagia that required dilatation and 1 pleural injury) and 1 conversion to open repair (partial gastric resection). No recurrences or deaths were observed in this series. CONCLUSION: In our experience robotic giant paraesophageal hernia repair is not different from the laparoscopic approach in terms of complications and mortality rate, but it may be associated with lower recurrence rates. However, larger series with longer follow-up are necessary to further substantiate our results.