Robotic hiatal hernia repair without mesh.

Background: Newer minimally invasive techniques have supplanted laparotomy and thoracotomy for management of hiatal hernias. Limited data exists on outcomes after robotic hiatal hernia repair without mesh despite the increasing popularity of this approach. We report our high-volume experience with durable robotic hiatal hernia repair with gastric fundoplication without mesh. Methods: A retrospective review was conducted on patients with type I-IV hiatal hernias who underwent an elective robotic-assisted repair from 2016 to 2019 using a novel technique of approximating the hiatus with running barbed absorbable (V-locTM) suture and securing it with interrupted silk sutures. Main outcomes included length of stay, readmission rate, and recurrence rate. Results: A total of 144 patients were reviewed. The average age of the patient was 61 years. Most of the patients were female [95 females (66%) to 49 males], and the average body mass index (BMI) was 29.96 kg/m2. The average operating time was 173 minutes (standard deviation 62 minutes). The average length of stay in the hospital was 2 days, and 89% of patients went home within the first 3 days. Ten patients (6.9%) were readmitted within 30 days, there were no mortalities in 30 days, and there were 6 (4.2%) recurrences on follow up requiring reoperation. Conclusions: Elective robotic hiatal hernia repair with fundoplication and primary closure of the hiatus with V-locTM and nonabsorbable suture without mesh is safe and effective. The robotic approach has similar operative times, lengths of stay, and complications compared to nationally published data on laparoscopic hiatal hernia repairs.

Pancoast tumor: a modern perspective on an old problem.

PURPOSE OF REVIEW: Pancoast tumors, also known as superior sulcus tumors, to this day remain a complex and challenging condition. This review will explore the evolution of the treatment of these tumors over the better part of a century. It will illustrate how with a multidisciplinary approach and the use of trimodality therapy this entity has evolved from a universally fatal disease to one that is treatable with outcomes similar to those of other stage-matched nonsmall cell lung cancers. RECENT FINDINGS: The Southwest Oncology Group 9416 Intergroup 0160 trial reported in 2007 By Rusch et al. culminated years of research showing that trimodality therapy with chemotherapy, radiation and surgery provided optimal outcomes. Since that time, there have been studies corroborating these outcomes and utilization of novel surgical approaches including Video-assisted thoracoscopic surgery; however, no change in survival has been reported. SUMMARY: The treatment of tumors of the superior sulcus has evolved over the years, so that outcomes approach those of other stage-matched nonsmall cell carcinomas. In the future, new approaches, perhaps the detailed genetic analysis of tumors and guided treatments, will have a positive impact on nonsmall cell carcinomas. The tumors of the superior sulcus will hopefully follow suit in their improved outcomes.

Switching from Thoracoscopic to Robotic Platform for Lobectomy: Report of Learning Curve and Outcome.

OBJECTIVE: The optimal minimally invasive surgical management for patients with non-small-cell lung cancer (NSCLC) is unclear. For experienced video-assisted thoracoscopic surgery (VATS) surgeons, the increased costs and learning curve are strong barriers for adoption of robotics. We examined the learning curve and outcome of an experienced VATS lobectomy surgeon switching to a robotic platform. METHODS: We conducted a retrospective review to identify patients who underwent a robotic or VATS lobectomy for NSCLC from 2016 to 2018. Analysis of patient demographics, perioperative data, pathological upstaging rates, and robotic approach (RA) learning curve was performed. RESULTS: This study evaluated 167 lobectomies in total, 118 by RA and 49 by VATS. Patient and tumor characteristics were similar. RA had significantly more lymph node harvested (14 versus 10; P = 0.004), more nodal stations sampled (5 versus 4; P < 0.001), and more N1 nodes (8 versus 6; P = 0.010) and N2 nodes (6 versus 4; P = 0.017) resected. With RA, 22 patients were upstaged (18.6%) compared to 5 patients (10.2%) with VATS (P = 0.26). No differences were found in perioperative outcome. Operative time decreased significantly with a learning curve of 20 cases, along with a steady increase in lymph node yield. CONCLUSIONS: RA can be adopted safely by experienced VATS surgeons. Learning curve is 20 cases, with RA resulting in superior lymph node clearance compared to VATS. The potential improvement in upstaging and oncologic resection for NSCLC may justify the associated investments of robotics even for experienced VATS surgeons.

A case of bronchial granular cell tumor in a pediatric patient.

Only nine cases of bronchial granular cell tumor have previously been reported in pediatric patients. We present a 15-year-old girl with acute-onset right shoulder pain, discovered to have a granular cell tumor causing bronchial stenosis and a cavitating post-obstructive right upper lobe pneumonia. The patient was treated with lobectomy. Bronchial granular cell tumors are benign neoplasms that typically present with recurrent pneumonia. Imaging may demonstrate an endobronchial lesion or an associated post-obstructive opacity, but diagnosis requires tissue sampling. To our knowledge, this is the tenth case of bronchial granular cell tumor in a pediatric patient to be reported since 1926.

Acute surgical pulmonary embolectomy: a 9-year retrospective analysis.

Acute pulmonary embolism is a substantial cause of morbidity and death. Although the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines recommend surgical pulmonary embolectomy in patients with acute pulmonary embolism associated with hypotension, there are few reports of 30-day mortality rates. We performed a retrospective review of acute pulmonary embolectomy procedures performed in 96 consecutive patients who had severe, globally hypokinetic right ventricular dysfunction as determined by transthoracic echocardiography. Data on patients who were treated from January 2003 through December 2011 were derived from health system databases of the New York State Cardiac Surgery Reporting System and the Society of Thoracic Surgeons. The data represent procedures performed at 3 tertiary care facilities within a large health system operating in the New York City metropolitan area. The overall 30-day mortality rate was 4.2%. Most patients (68 [73.9%]) were discharged home or to rehabilitation facilities (23 [25%]). Hemodynamically stable patients with severe, globally hypokinetic right ventricular dysfunction had a 30-day mortality rate of 1.4%, with a postoperative mean length of stay of 9.1 days. Comparable findings for hemodynamically unstable patients were 12.5% and 13.4 days, respectively. Acute pulmonary embolectomy can be a viable procedure for patients with severe, globally hypokinetic right ventricular dysfunction, with or without hemodynamic compromise; however, caution is warranted. Our outcomes might be dependent upon institutional capability, experience, surgical ability, and careful patient selection.

Metastatic meningioma extending into the left atrium through the pulmonary vein.

Left atrial extension of pulmonary tumors through the pulmonary vein is most often associated with primary malignancies and is rarely associated with metastatic disease. We present the first, to our knowledge, reported case of a patient with a history of intracranial meningioma resections presenting with metastatic meningioma to the right lower lobe with extension into the left atrium through the pulmonary vein.

Avoiding the left internal mammary artery during anterior pericardiocentesis.

In patients with pericardial effusions who require anterior pericardiocentesis, it is important to avoid trauma to the left internal mammary artery. Such trauma could result in severe bleeding or tamponade. This article describes how the left internal mammary artery may be identified by duplex ultrasound, and therefore avoided. It is also important to ensure that the needle stick is just lateral to the artery, to avoid hitting the left lung.