Robotic Inguinal Hernia Repair Outcomes: Operative Time and Cost Analysis.

BACKGROUND: Robotic inguinal hernia repair is the latest iteration of minimally invasive herniorrhaphy. Previous studies have shown expedited learning curves compared to traditional laparoscopy, which may be offset by higher cost and longer operative time. We sought to compare operative time and direct cost across the evolving surgical practice of 10 surgeons in our healthcare system. METHODS: This is a retrospective review of all transabdominal preperitoneal robotic inguinal hernia repairs performed by 10 general surgeons from July 2015 to September 2018. Patients requiring conversion to an open procedure or undergoing simultaneous procedures were excluded. The data was divided to compare each surgeon's initial 20 cases to their subsequent cases. Direct operative cost was calculated based on the sum of supplies used intra-operatively. Multivariate analysis, using a generalized estimating equation, was adjusted for laterality and resident involvement to evaluate outcomes. RESULTS: Robotic inguinal hernia repairs were divided into two groups: early experience (n = 167) and late experience (n = 262). The late experience had a shorter mean operative time by 17.6 min (confidence interval: 4.06 - 31.13, p = 0.011), a lower mean direct operative cost by $538.17 (confidence interval: 307.14 - 769.20, p < 0.0001), and fewer postoperative complications (p = 0.030) on multivariate analysis. Thirty-day readmission rates were similar between both groups. CONCLUSION: Increasing surgeon experience with robotic inguinal hernia repair is associated with a predictable reduction in operative time, complication rates, and direct operative cost per case. Thirty-day readmission rates are not affected by the learning curve.

Splenic rupture secondary to amyloid light-chain (AL) amyloidosis associated with multiple myeloma.

Splenic rupture in the absence of major trauma is a rare occurrence, which may occur by idiopathic means or a specific pathologic process. One such condition, amyloidosis, involves the extracellular deposition of abnormally folded 'amyloid' protein, which can affect the spleen. Protein infiltration in the organ may cause splenomegaly and potentially capsular rupture in advanced cases. We describe a 68-year-old male with a history of end-stage renal disease status-post living donor renal transplant on chronic immunosuppression and Coumadin that presented with abdominal pain, weakness and hypotension. The patient was found to have hemoperitoneum secondary to splenic rupture and was emergently taken for exploratory laparotomy and splenectomy. The pathology of the spleen revealed AL amyloidosis. He was subsequently found to have advanced plasma cell neoplasm by bone marrow biopsy with numerous osseous lytic lesions, consistent with a monomorphic post-transplant lymphoproliferative disorder.

Equivalent Peri-Operative Outcomes for Laparoscopic Roux-En-Y Gastric Bypass Patients Discharged on Post-Operative Day One.

BACKGROUND: Previous studies have evaluated the safety of post-operative day one (POD #1) discharge after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. Few studies, however, have evaluated the impact of a standardized POD #1 discharge pathway on peri-operative outcomes. This study aims to evaluate peri-operative outcomes after implementation of an enhanced recovery pathway for RYGB patients. METHODS: Data from a prospectively maintained database identified 2,049 patients (pre-implementation n = 904; post-implementation n = 1,144) who underwent LRYGB between 2008 and 2016. The POD1 discharge pathway was implemented in July 2011. Patient demographics and outcomes before and after implementation of the POD1 pathway were compared using univariate analysis and propensity matching. RESULTS: A propensity-matched group of all patients (n = 714) and POD #1 candidates (n = 490) pre- and post-pathway implementation were analyzed. Successful POD #1 discharges were significantly increased after introduction of the pathway (54.3 vs 17.8%, p < 0.0001). The post-implementation groups demonstrated no differences in mortality, Emergency department (ED) visits, readmissions, reoperations, and major or minor complications. CONCLUSIONS: Early discharge after bariatric surgery has a significant impact on the cost effectiveness of surgery, patient comfort, potential reduction of medical errors, and exposure to hospital-acquired infections. Our results demonstrate that a standardized POD #1 discharge pathway can be safely implemented and in turn, reduce hospital LOS without negatively affecting peri-operative morbidity, mortality, ED visit, readmission, or reoperation rates.