Robotic Heller's myotomy using the new Hugo™ RAS system: first worldwide report.

BACKGROUND: Achalasia is a rare disorder of the esophagus characterized by motor dysfunction in the esophagus and relaxation failure of the lower esophageal sphincter (LES). Currently, surgical myotomy procedures are considered the standard of care. Robotic Heller's myotomy (RHM) with fundoplication has been gaining popularity due to documented advantages in the precision of myotomy as well as avoiding the potential reflux following per-oral endoscopic myotomy (POEM). To the best of our knowledge, RHM has thus far has been performed exclusively by the da Vinci surgical system. The new Hugo RAS™ system offers a unique modular design and an open console which offers better maneuverability and docking options. In this study, we present the first worldwide series of patients undergoing RHM using the new Hugo RAS™ platform. Our objective is to propose optimal operating configuration and setup to fully harness the advantages of the unique modular design of this system. METHODS: Ten consecutive achalasia patients underwent Robotic Heller's myotomy (RHM) with the Hugo RAS™ system. We prospectively collected patient data, including demographics, comorbidities, ASA class, Eckardt scores, pre-operative manometric data, and EndoFlip parameters. Additionally, we recorded the docking and total operative times. RESULTS: Between December 2022 and August 2023, 10 patients underwent RHM with the Hugo™ RAS system. Patients had a median age of 42.5 years, 60% were female, and mean BMI was 23.2. Fifty percent had achalasia type 2 and 50% type 1. The median pre-operative integrated relaxation pressure (IRP) was 24.9. Median docking time was 10 min and overall operative time was 129.5 min. All patients, except one with acute coronary syndrome, had an uneventful peri-operative course and were discharged on post-operative day 2. CONCLUSION: The Hugo™ RAS system is well designed for robotic Heller myotomy. The operative and clinical results are similar to the currently used robotic system; however, the modular design of the system has some differences. These translate to better docking angles and maneuverability as well as console surgeon's ergonomics. Further experience is needed to explore the advantages of the system's modular design and function.

Robotic inguinal hernia repair with the new Hugo RASTM system: first worldwide case series report.

INTRODUCTION: Robotic-assisted surgery has been a part of surgical procedures for more than two decades. Recently new robotic platforms with a different design entered the market. The modular design with independent arms enables increased flexibility of arm docking to increase the range of motion and instrument maneuverability. We herein present the first case series of robotic inguinal hernia repair using the Hugo RAS system (Medtronic, Minneapolis, MN, USA). MATERIAL AND METHODS: Thirteen inguinal hernia repairs were performed on ten patients. A description of the Hugo RAS system as well as the new concept of modular design is presented along with the description of the operation setup. RESULTS: Mean docking time was 9.5 min and mean console time was 50.3 min and 74.7 min for unilateral and bilateral inguinal hernia repair, respectively. No intraoperative or postoperative complications occurred. There was one conversion to laparoscopic surgery due to a technical issue with the robot. Conclusions: The modular design of independent arms seems to enhance maneuverability of the instruments and contribute to fewer arm collisions. Further clinical data and experience with this new surgical system are necessary to understand if this new design has advantages over the standard robotic platforms.

Is it possible to continue academic teaching in surgery during the COVID pandemic era?

In the era of the novel coronavirus (COVID-19) pandemic, we critically appraised the literature by means of a systematic review on surgical education and propose an educational curriculum with the aid of available technologies. We performed a literature search on 10 May 2020 of Medline/PubMed, Embase, Google Scholar and major journals with specific COVID-19 sections. Articles eligible for inclusion contained the topic of education in surgery in the context of COVID-19. Specific questions we aimed to answer were: Is there any difference in surgical education from pre-COVID-19 to now? How does technology assist us in teaching? Can we better harness technology to augment resident training? Two-hundred and twenty-six articles were identified, 21 relevant for our aim: 14 case studies, three survey analyses, three reviews and one commentary. The collapse of the traditional educational system due to social distancing caused a fragmentation of knowledge, a reduced acquisition of skills and a decreased employment of surgical trainees. These problems can be partially overcome by using new technologies and arranging 2-weeks rotation shifts, alternating clinical activities with learning. While medical care will remain largely based on the interaction with patients, students' adaptability to innovation will be a characteristic of post-COVID classes.

Complete vs partial fundoplication: a laboratory measurement of functionality and effectiveness.

BACKGROUND: Complete or partial fundoplication remains controversial for the surgical treatment of GERD. While partial fundoplication is considered less effective, it is associated with less post-operative dysphagia and gas bloating compared with complete fundoplication. AIM: To compare the mechanical efficiency of the three different types of fundoplication. MATERIAL AND METHOD: Two studies of the LES were performed on explanted stomachs: distensibility and failure point. Measurements were taken before and after fundoplication. RESULTS: There was no difference in distensibility between Nissen and Toupet fundoplication, however, the EGJ was more distensible following Dor fundoplication. According to failure point measurements, Nissen fundoplication was significantly more effective than Toupet, Toupet was significantly more effective than Dor (p = .016, p = .017, respectively). CONCLUSIONS: There were significant differences in distensibility between Dor and both Nissen and Toupet, however no statistical difference between Toupet and Nissen. There was a significant difference in effectiveness between all three types of fundoplication according to the failure point. These laboratory findings demonstrate that the mechanical orientation of Nissen and Toupet have similar functionality suggesting that Toupet is as good as Nissen. While in clinical studies Toupet has fewer post-operative complications these findings support the proponents of Toupet for GERD. Abbreviation: GERD: Gastroesophageal reflux disease.

Sutureless energy-based wound closure: a step in the quest for trocar site hernia prevention.

OBJECTIVE: Easy and safe methods of fascia closure are needed in order to reduce the risk for trocar site hernias without affecting procedure time significantly. Here we present a method for port site closure using heat induced collagen denaturation. MATERIAL AND METHODS: Controlled heat-induced collagen denaturation was applied to laparoscopic trocar sites in living porcine animal models. These were compared to control trocar sites which were left open. Port sites were evaluated visually at days 14 and 28 after the procedure, and both visually and pathologically at post-procedural day 42. RESULTS: A total of 12 port sites were evaluated in three pigs. No incisional hernias were noted at any of the trocar sites in both groups. Histological evaluation revealed that one of the six control ports appeared to have a complete transfascial defect, whereas none of the study group trocars showed this finding. Furthermore, the study port sites showed a more robust scarring pattern. CONCLUSIONS: Heat-induced collagen denaturation in this preliminary study was found to be safe and allowed better scarring of the healing port sites. We believe that this technology may offer a safe and efficient closure of laparoscopic trocar sites. More studies are needed to further evaluate the true effectiveness of this technology.

The impact of preoperative vitamin administration on skeletal status following sleeve gastrectomy in young and middle-aged women: a randomized controlled trial.

BACKGROUND: The appropriate strategies to minimize skeletal deterioration following bariatric surgeries are inconclusive. This randomized controlled trial evaluated the effect of preoperative vitamin supplementation on bone mineral density (BMD) and biochemical parameters in females post-sleeve gastrectomy (SG). METHODS: Participants were randomized to a 2-month preoperative treatment with a multivitamin and vitamin D 4000 IU/d (intervention arm) or 1200 IU/d (control arm). Preoperative and 12-month postoperative follow-up evaluations included anthropometrics, biochemical parameters, and dual energy X-ray absorptiometry (DEXA). RESULTS: Sixty-two females (median age 29.7 years and median BMI 43.4 kg/m2) were recruited, 87% completed the 12-month follow-up. For the intervention and control arms, significant and similar reductions at 12-months post-surgery were observed in BMD of the hip (-6.8 ± 3.7% vs. -6.0 ± 3.6%; P = 0.646) and of the femoral neck (-7.1 ± 5.8% vs. -7.2 ± 5.5%; P = 0.973). For the intervention compared to the control arm, the 25 hydroxyvitamin D (25(OH)D) increment was greater after 2 months treatment, and vitamin D deficiency rates were lower at 3 and 6-months follow-up (P < 0.016). However, at 12-months postoperative, 25(OH)D values and vitamin D deficiency were comparable between the arms (P > 0.339). Predictors for BMD decline in the total hip were the percentage of excess weight-loss, age>50 years, and lower initial BMI (P ≤ 0.003). CONCLUSIONS: SG was associated with a significant decline in BMD of the hip and femoral neck in young and middle-aged women, and was unaffected by preoperative vitamin D supplementation. Females who are peri-menopausal or with greater postoperative weight-loss should be particularly followed for BMD decline.

The POEM bottom-up technique for achalasia.

BACKGROUND: POEM (Per Oral Endoscopic Myotomy) is rapidly becoming a valid option for surgical myotomy in achalasia patients. Several techniques to perform POEM are described, but all concentrate on the division of the circular muscle fibers in a proximal-to-distal fashion. Our aim is to present the distal-to-proximal, or the bottom-up technique using the Flush/Dual knife, which overcomes the disadvantages of the standard technique. METHODS: A retrospective study on a prospectively maintained database was performed on all patients treated by POEM in our institution. Clinical presentation, operating time, adverse events, and outcomes were studied. RESULTS: POEM was performed on 105 achalasia patients. The first 15 cases were performed using the standard technique and were compared to the next 90 cases performed using the bottom-up technique. The average preop Eckardt scores in the standard and bottom-up groups were 9.5 and 8.8, respectively, declining to 1.4 and 0.5, 3 months post myotomy (p < 0.001). The average procedure time was 111.2 min for the standard technique and 74.3 for the bottom-up technique. (p = 0.002). Perioperative adverse events included 14 instances of pneumoperitoneum, 3 tunnel leaks, and 4 patients with fever on postoperative day one. Pneumoperitoneum needing decompression and postoperative fever were more prevalent in the standard technique group. CONCLUSIONS: As POEM is becoming more common for the treatment of achalasia, refinements of the technique and instruments used are valuable. We compared our experience of the standard technique to our bottom-up technique and found the latter to be equally effective as well as safer, faster, and easier. We, therefore, suggest considering performing POEM in this technique.

The risk of COVID-19 transmission by laparoscopic smoke may be lower than for laparotomy: a narrative review.

BACKGROUND: Surgical smoke is a well-recognized hazard in the operating room. At the beginning of the COVID-19 pandemic, surgical societies quickly published guidelines recommending avoiding laparoscopy or to consider open surgery because of the fear of transmission of SARS-CoV-2 through surgical smoke or aerosol. This narrative review of the literature aimed to determine whether there are any differences in the creation of surgical smoke/aerosol between laparoscopy and laparotomy and if laparoscopy may be safer than laparotomy. METHODS: A literature search was performed using the Pubmed, Embase and Google scholar search engines, as well as manual search of the major journals with specific COVID-19 sections for ahead-of-print publications. RESULTS: Of 1098 identified articles, we critically appraised 50. Surgical smoke created by electrosurgical and ultrasonic devices has the same composition both in laparoscopy and laparotomy. SARS-CoV-2 has never been found in surgical smoke and there is currently no data to support its virulence if ever it could be transmitted through surgical smoke/aerosol. CONCLUSION: If laparoscopy is performed in a closed cavity enabling containment of surgical smoke/aerosol, and proper evacuation of smoke with simple measures is respected, and as long as laparoscopy is not contraindicated, we believe that this surgical approach may be safer for the operating team while the patient has the benefits of minimally invasive surgery. Evidence-based research in this field is needed for definitive determination of safety.

The use of 3D laparoscopic imaging systems in surgery: EAES consensus development conference 2018.

BACKGROUND: The use of 3D laparoscopic systems is expanding. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference with the aim of creating evidence-based statements and recommendations for the surgical community. METHODS: Systematic reviews of the PubMed and Embase libraries were performed to identify evidence on potential benefits of 3D on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by an international surgical and engineering expert panel which were presented and voted at the EAES annual congress, London, May 2018. RESULTS: 9967 abstracts were screened with 138 articles included. 18 statements and two recommendations were generated and approved. 3D significantly shortened operative time (mean difference 11 min (8% [95% CI 20.29-1.72], I2 96%)). A significant reduction in complications was observed when 3D systems were used (RR 0.75, [95 CI% 0.60-0.94], I2 0%) particularly for cases involving laparoscopic suturing (RR 0.57 [95% CI 0.35-0.90], I2 0%). In 69 box trainer or simulator studies, 64% concluded trainees were significant faster and 62% performed fewer errors when using 3D. CONCLUSION: We recommend the use of 3D vision in laparoscopy to reduce the operative time (grade of recommendation: low). Future robust clinical research is required to specifically investigate the potential benefit of 3D laparoscopy system on complication rates (grade of recommendation: high).

Introduction to artificial intelligence in medicine.

The term Artificial Intelligence (AI) was coined by John McCarthy in 1956 during a conference held on this subject. However, the possibility of machines being able to simulate human behavior and actually think was raised earlier by Alan Turing who developed the Turing test in order to differentiate humans from machines. Since then, computational power has grown to the point of instant calculations and the ability evaluate new data, according to previously assessed data, in real time. Today, AI is integrated into our daily lives in many forms, such as personal assistants (Siri, Alexa, Google assistant etc.), automated mass transportation, aviation and computer gaming. More recently, AI has also begun to be incorporated into medicine to improve patient care by speeding up processes and achieving greater accuracy, opening the path to providing better healthcare overall. Radiological images, pathology slides, and patients' electronic medical records (EMR) are being evaluated by machine learning, aiding in the process of diagnosis and treatment of patients and augmenting physicians' capabilities. Herein we describe the current status of AI in medicine, the way it is used in the different disciplines and future trends.

[PER-ORAL ENDOSCOPIC MYOTOMY - SUMMARY OF FIVE YEARS EXPERIENCE].

INTRODUCTION: Esophageal achalasia is a rare condition, characterised by progressive dysphagia due to innervation of the esophageal muscles and non-relaxation of the lower esophageal sphincter. The standard of care of surgical treatment is laparoscopic Heller myotomy. POEM-Peroral endoscopic myotomy is a new approach offering incision-less and selective myotomy. AIMS: This study aims to describe our experience and outcomes using this new surgical technique. METHODS: We performed a retrospective study using prospectively maintained data of all achalasia patients treated by POEM in our department. Data collected included patient demographics, gender, age, BMI, data related to the disease course in addition to data related to the surgery itself as well as both short and long term post-operative follow-up. RESULTS: Over the course of five years we performed 86 POEM operations, demonstrating a decrease in the Eckardt score from a mean of 8.87 to a mean of 0.7 in the immediate postoperative. Mean operative time was 86 minutes, with mean hospitalization time of 4 days. Intraoperative complications included 2 mucosal injuries while post-operative complications included 4 incomplete mucosal closures, 5 recurrent dysphagia and 5 patients with reflux requiring medical therapy. CONCLUSIONS: In the last decade, POEM procedure is being performed worldwide and has been performed in our department for the past five years. Our results show a success rate of 94.2% with minor complications. In our institution, as in many institutions globally, POEM is the preferred method for treating achalasia.

It is time for a better clip applier - 3 mm, percutaneous, non-crushing and locking.

INTRODUCTION: Since the advent of laparoscopy there have been attempts to minimize abdominal wall incisions. For this purpose smaller instruments have been produced. Our aim was to develop the first 3 mm percutaneous clip applier and to make it better than the standard clips of today. MATERIAL AND METHODS: The ClipTip clip is made of Nitinol and has a crocodile shaped jaws, which when apposed effectively seal vessels. The shaft operates as a retractable needle permitting percutaneous insertion. Closing, reopening and reclosing is possible. The physical properties of the device were compared to three commercially available clip appliers. Surgeries were performed on porcine animals by experienced surgeons. RESULTS: In comparison to available clips, the superiority of the ClipTip is a combination of wide effective length alongside the ability to withstand strong forces. In live animal studies the Cliptip was inserted into the peritoneal cavity without any injuries. Vessels were ligated successfully and no clip dislodgement or leakage occurred. CONCLUSIONS: We developed the next generation clip applier with better properties. Advantages include its length, the needleoscopic caliber, non-crushing effect, locking mechanism and wide aperture. The device has performed safely and effectively in pre-clinical tests. Further studies are planned in humans.

Should We Operate Nonagenarians with Symptomatic Giant Paraesophageal Hernias?

Introduction: Hiatal hernia (HH) is a common disorder of the upper gastrointestinal (UGI) tract that general surgeons encounter. Giant paraesophageal is a subtype of HH in which more than 30% of the stomach is located in the chest. It can cause symptoms such as dysphagia, UGI bleeding, gastroesophageal reflux disease, and vomiting. As the life expectancy of the general population increases, the incidence of giant HH increases and can cause morbidity, including recurrent admissions and prolonged length of hospitalization. In this article, we describe a cohort of nonagenarian patients with HH who were admitted to our institution and were treated either surgically or medically. Methods: We retrospectively reviewed our prospectively maintained database of all nonagenarians who were admitted to our center between 2018 and 2022 with the diagnosis of HH. We compared the demographic data, clinical data, and outcomes between patients undergoing operative and nonoperative management. Results: Twenty patients of age over 90 years were hospitalized with HH-related symptoms. Six underwent surgery, whereas 14 received medical management. Surgical patients had fewer overall hospitalization days, shorter length of stay, and less blood product requirements. Notably two cases of in-hospital mortality occurred in the nonoperative group, whereas none occurred in the operative group. All surgical procedures were performed laparoscopically, with two minor perioperative complications. Conclusion: In selected nonagenarian patients, laparoscopic HH repair is safe and should be considered favorably. It can reduce hospitalization time and can mitigate morbidity.

The Angle of His as a Measurable Element of the Anti-reflux Mechanism.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common condition, resulting from the loss of the anti-reflux barrier. Laparoscopic fundoplication is the surgical procedure of choice for treatment of GERD; however, there remains a debate on the exact mechanism through which it prevents reflux. OBJECTIVES: Our aim was to understand the relationship between reflux, fundoplication, and the angle of His on an experimental model. METHODS: The study was conducted on four groups of fresh explanted swine stomachs: control group, myotomy, myotomy with Nissen fundoplication, and myotomy with Toupet fundoplication. The stomachs were placed in a specially designated container on an inclinable platform which would increase the hydrostatic pressure on the esophago-gastric junction. Measurements of the angle of His using fluoroscopy and the esophago-gastric orifice area using endoscopy were performed, and the occurrence of reflux was documented. RESULTS: Each group of the study contained nine swine stomachs. In the control and myotomy groups, the angle became wider as the incline level increased the pressure and was significantly different between the groups (p < .001). Both groups demonstrated an increase in the orifice area as the incline level increased the pressure. There was a significant correlation between the angle of His and the area of the esophago-gastric orifice (p < .001). In the control group, the reflux began at the 0°. In the myotomy group, it began at the + 15° incline (less pressure). Reflux rarely occurred in the Nissen and Toupet groups, with the breaking point being mostly defined as "beyond - 30°". A significant difference was noted in the occurrence of reflux between fundoplication and the non-fundoplication groups (p < 0.001), while there was no significant difference between the Toupet and Nissen groups (p = 0.134). Analysis showed a significant independent correlation between both the angle of His and the orifice area with the presence of reflux (p = .002 and p = .024 respectively). CONCLUSIONS: In this study, we developed an experimental model to enable careful evaluation of the elements of the anti-reflux mechanism, of which, the angle of His has a measurable element. We demonstrated that as the angle of His becomes wider the esophago-gastric orifice area becomes larger. Additionally, a wider angle of His and a larger esophago-gastric orifice area were correlated independently with more reflux. This suggests that the fundoplication creates an acute angle of His which is correlated with a smaller area of the esophago-gastric orifice and eventually with a lower incidence of reflux.

Post-POEM Contrast-Enhanced Swallow Study: Is It Always Necessary?

BACKGROUND: Peroral endoscopic myotomy (POEM) is rapidly becoming the procedure of choice for treating esophageal achalasia. In most centers, contrast-enhanced swallow studies (CESS) are routinely performed postoperatively to confirm mucosal integrity. The aim of this study was to determine the necessity of performing these studies routinely after POEM. METHODS: A retrospective review of a prospectively maintained database of patients who underwent POEM between December 2012 and November 2020 was performed. All patients underwent a CESS on the first postoperative day. Medical records including vital signs, complete blood count, and POD-1 CESS were evaluated. RESULTS: One hundred thirty-four consecutive patients were included in the study. Sixty-nine (51.49%) CESS showed abnormal findings; while most findings did not change the postoperative course, five (7.2%) demonstrated tunnel leaks, which did alter the overall management. Screening patients for fever, tachycardia, or leukocytosis on POD-1 had a 100% sensitivity and a 62% specificity for finding a clinically significant complication on CESS. CONCLUSIONS: The study findings suggest that performing routine contrast-enhanced swallow studies on all patients is not necessary following POEM, as leaks can be screened for by clinical or laboratory abnormalities. Herein, we propose an algorithm based on objective measurable findings for the selection of patients who should undergo CESS.

Minimally invasive surgery and the risk of work-related musculoskeletal disorders: Results of a survey among Israeli surgeons and review of the literature.

BACKGROUND: Minimally invasive surgery (MIS) has many advantages for patients, however, it places surgeons at risk for Work-related musculoskeletal disorders (WMSD). Recently, the importance of prevention of such injuries and improvement of the ergonomics of the operating room is increasing. OBJECTIVES: To assess the prevalence of WMSD among minimally invasive surgeons in Israel, discuss the contributing factors and the overall awareness for ergonomic training. In addition, a review of the literature on the topic was conducted. METHODS: An online questionnaire was sent to the members of the Israeli Society of Endoscopic Surgery. The results were analyzed and summarized. For literature review, PubMed was used to search for English-language publications related to the issue. RESULTS: Of 83 respondents, the majority (77%) have considerable experience in MIS (more than 10 years). The prevalence of WMSD was 12% before beginning the practice of laparoscopy compared to 78% after 15-20 years of practice. Injury sites included back pain, neck and upper extremity (shoulder pain, tennis elbow and carpal tunnel syndrome) in 41%, 25% and 34% respectively. More than two thirds of responders unaware of possible ergonomic solutions and didn't consider adopting any appropriate preventive measures. CONCLUSIONS: The incidence of WMSD among MIS surgeons is high and underestimated. There is a desperate need to prevent such morbidity among surgeons by increasing awareness and providing the means to improve their work environment. Surgeons should adhere to ergonomic recommendations for positioning of monitors, table height, posture, foot pedal placement and laparoscopic devices use.

Reproductive Outcomes Among Women of Childbearing Age with Achalasia After Peroral Endoscopic Myotomy: A Single-Center Experience.

Background: Achalasia may occasionally occur among women of childbearing age. Pregnancy may lead to deterioration of the disease and negatively affect maternal and perinatal outcomes. However, the impact of peroral endoscopic myotomy (POEM) on reproductive outcomes has been understudied. Methods: A retrospective study on prospectively maintained database, including women aged 18-45 who underwent POEM during 2012-2017 at a university hospital. Results: During the study period, POEM was performed in 86 patients. Of them, 23 were women of childbearing age (median age 31.9 [26.0-40.7] years). Follow-up data were available for a median of 24 [16-41] months. Treatment success (Eckardt score <3) was achieved in 22 (95.7%) women. Six (26.1%) women reported attempting to conceive after POEM. Overall, 7 post-POEM pregnancies among 5 women were encountered. All 7 pregnancies were naturally conceived with a median surgery-to-conception interval of 16 [10-21] months. The median gestational weight gain was 10 kg, and was insufficient in all pregnancies. None of the women was hospitalized during the index gestation. All pregnancies resulted in term live-birth vaginal delivery. The median neonatal birthweight was 2940 g, with only one case of a small-for-gestational age infant. Achalasia-related symptoms recurred during 2 pregnancies, with resolution following delivery. Conclusions: Pregnancy after POEM for the treatment of achalasia was associated with favorable maternal and perinatal outcomes. This data should reassure women who wish to conceive following peroral myotomy.