The prevention of extraction site incisional hernia after robotic-assisted radical prostatectomy.

Extraction site incisional hernia (IH) has been recognized as an important complication in minimally invasive procedures but has not been as well characterized following robotic-assisted laparoscopic prostatectomy (RALP). Approximately 29% of IH required surgical repair. A number of techniques have been utilized to reduce the rates of IH following minimally invasive procedures. First, off-midline extraction was investigated, this did not demonstrate a reduction in incisional hernia rates. Recently, supra-umbilical transverse incisions have been utilized to extract prostate specimen and this method decreased the extraction site IH rate compared to the vertical midline incision. In addition, the choice of fascial closure technique and choice of the suture may influence the incidence of extraction site IH. For example, studies showed that abdominal fascial closure using a nonabsorbable suture and a continuous running suture technique decreased IH rate from 32 to 17%. Finally, "the small bites technique" has been recommended to reduce hernia incidence after midline fascial closure following a randomized controlled trial (RCT) which demonstrated the superiority of the small-bite technique. In summary, a supra-umbilical transverse incision to extract the specimen was shown to decrease the rate of extraction site IH. In vertical midline incisional closure, the small bites technique with slowly- or non-absorbable suture, such as #0 or 2-0 PDS II with SH or CT-2 needle (26 mm arch length), reduces the IH rate. Urologists should consider this data to reduce the risk of IH following RALP.

Robotic-assisted adrenalectomy using da Vinci Xi vs. Si: are there differences?

Da Vinci Xi, the fourth generation platform, was released in 2014 and introduced as the successor to the Si platform for minimal invasive surgery. We reviewed our experience with robotic-assisted adrenalectomy and compared peri-operative outcomes using the da Vinci robot model Xi vs. Si. Since June of 2014, 85 consecutive patients underwent robotic-assisted adrenalectomy by a high-volume adrenal surgeon at our institution. Patients were divided into two groups: Xi group (n = 25) and Si group (n = 60). The average anesthesia time was 145.8 min for the Xi group and 170.4 min for the Si group (p = 0.001). The mean procedure time for the Xi group (skin to skin) was 92.1 min and for the Si group it was 122.5 min (p = 0.001). The average docking time for the Xi group was 18.2 min and for the Si group 20.3 min (p = 0.04). The average consumables fees for the Xi group were $1246 and for the Si group $1106 (p = 0.04). The calculated relative costs for the Xi group were $3375 and for the Si group $3527 (p = 0.03). The average post-operative hospital stay for the Xi group was 1.6 days and for the Si group 1.7 days (p = 0.18). Robotic-assisted adrenalectomy using the da Vinci Xi system is effective and efficient. This study shows that outcomes were similar between Xi and Si groups.

A cost-conscious approach to robotic adrenalectomy.

In recent years, the use of robotic-assisted adrenalectomy (RA) has increased; however, many surgeons question its reported higher cost. In this study, we review our experience and strategies to reduce the cost of RA comparing it to Laparoscopic adrenalectomy (LA). Since May of 2010, 122 consecutive patients underwent minimally invasive adrenalectomy (58 RAs and 64 LA) by a high-volume adrenal surgeon at our institution. A cost analysis was performed for RA versus LA. Cost calculations included anesthesia professional fee, procedure time and consumables fees. The calculated relative costs were $3527 for RA and $3430 for LA (p = 0.59). The average anesthesia time was 172.4 and 178.3 min for RA and LA, respectively (p = 0.40). The mean procedure times (skin-skin) were 124.4 min for RA and 129.1 min for LA (p = 0.50). Procedure time for the retroperitoneal approach was significantly shorter than the transabdominal approach for both the RA (101.2 vs. 126.6 min, p = 0.001) and LA group (104.4 vs. 135.4 min, p = 0.001). The average consumables fees were $1106 for RA versus $1009 for LA (p = 0.62). The average post-operative hospital stay was 1.7 days for RA and 1.9 days for LA (p = 0.18). This study shows that anesthesia and procedure times for RA were similar to those of LA. It also demonstrates that limiting the number of robotic instruments and energy devices while utilizing an experienced surgical team can keep the costs of RA comparable to those of LA.

Bilateral robotic transabdominal adrenalectomy in a patient with intestinal malrotation.

Bilateral adrenalectomy is the preferred surgical approach for patients with failed treatments for pituitary-based Cushing's syndrome. Intestinal malrotation (IM) is a rare congenital anatomic variant that rarely affects adults. The abnormal abdominal anatomy is concerning to surgeons planning elective procedures in such patients. Here, we describe a bilateral robotic transabdominal adrenalectomy (RTA) in a patient with IM. A 29-year-old female presented with refractory pituitary-based Cushing's syndrome and was found to have IM on preoperative CT scan. The RTA was performed using one 10-12 mm camera trocar, two 8 mm robotic trocars per side and two midline 5 mm assistant ports. The 8 mm robotic cardiere forceps and the 8 mm robotic cautery hook were used on the left and right ports, respectively. Total operation time was 165 min (62 min on the right, 93 min on the left and 21 min for re-positioning). Total console time was 114 min (45 min on the right and 69 min on the left). Blood loss was minimal and there were no complications. She was discharged on post-operative day one. Anatomic variations were noted and the procedure modified. To our knowledge, this is the first reported case of bilateral RTA in a patient with IM. Surgeons should always review the anatomy on preoperative imaging. During the procedure, care should be taken to avoid damage to the multiple loops of small bowel located in the right upper quadrant. On the left side, the colonic splenic flexure is not encountered making access to the underlying left adrenal and kidney easier. The vascular anatomy was normal.

Robotic retroperitoneoscopic adrenalectomy: useful modifications of the described posterior approach.

Herein we describe a technique modification of the robotic posterior retroperitoneoscopic adrenalectomy (RPRA). Three patients presented to our clinic with adrenal lesions. The average BMI and tumor size was 29.3 kg/m2 and 4.6 cm, respectively. All had prior major abdominal procedures. Long robotic trocars were used. A 5-mm assistant port was added and the number of robotic instrument use was minimized. The average total operation time was 136 min, average docking time was 14.7 min and the average console time was 108.7 min. Blood loss was minimal and there were no complications. In patients with prior history of extensive abdominal procedures, RPRA is safe and effective when performed by surgeons with PRA and robotic experience. Long robotic trocars effectively minimized external robotic arm collisions. Adding a 5-mm assistant trocar maximized the first assistant and console surgeon abilities. Limiting the number of robotic instruments and energy devices contained cost.

Effect of glutamine on the initiation and promotion phases of DMBA-induced mammary tumor development.

BACKGROUND: Oral glutamine (GLN) has been shown to up-regulate tissue glutathione (GSH), augment natural killer (NK) cell activity, and prevent tumor growth in an implantable breast cancer model (MTF-7). We hypothesized that dietary GLN would likewise antagonize the induction or promotion of tumor formation by 7,12-dimethylbenz[a]anthracene (DMBA) via up-regulation of GSH or augmentation of NK activity. METHODS: At age 55 days, 81 Sprague-Dawley rats were gavaged with a one-time dose of 80 mg/kg DMBA, time 0. Rats were randomized into 3 groups (GLN+DMBA, Freamine [FA]+DMBA, water (H2O)+DMBA), pair-fed chow, and gavaged with 1.0 g/kg/day GLN or isonitrogenous amount of FA or H2O for the indicated times: PreFed (-1 to + 16 weeks), Short-Fed (-1 to + 1 weeks) and PostFed (+ 1 to +16 weeks). After 16 weeks, rats were killed and examined for mammary tumors, blood was assayed for GLN and GSH content, and spleens were assayed for NK cytotoxicity. RESULTS: Over the 4-month study period, there was no significant difference in tumorigenesis between FA and H2O groups, regardless of timing of feeding and amino acid diet, except GLN. In Pre- and PostFed GLN groups, there was no significant difference between groups, but there were significant decreases in tumorigenesis in GLN groups compared with either FA or H2O groups. However, in the Short-Fed group, there was no significant difference in tumorigenesis from the GLN, FA, or H2O groups. CONCLUSIONS: Continuously supplemented GLN significantly reduced DMBA-induced breast cancer growth when compared with the non-GLN-supplemented and Short-Fed supplemental GLN groups. Furthermore, GLN appears to have its primary effect on promotion and not initiation of tumor formation. This decreased tumor formation was associated with significantly higher arterial GLN and GSH levels and NK activity at killing in the GLN+DMBA group. Protein in the presentation of FA did not promote or prevent tumor growth. These data indicate that GLN may be useful in the chemoprevention of breast cancer.

Robotic-assisted Roux-en-Y gastric bypass in a patient with situs inversus.

We report the case of a morbidly obese patient with situs inversus who presented for robotic-assisted Roux-en-Y gastric bypass. To do the procedure, the ports were reversed and the first assistant stood on the opposite side of the table. With these minor modifications to technique, the surgery was successfully performed without confusion over the patient's anatomy. There were no intraoperative complications. The patient's postoperative course was uneventful and he was discharged on postoperative day 3. We believe this is the first reported robotic-assisted Roux-en-Y gastric bypass in a patient with situs inversus.

Salvage of limb and function in necrotizing fasciitis of the hand: role of hyperbaric oxygen treatment and free muscle flap coverage.

We report a case of necrotizing fasciitis of the hand treated by urgent debridement followed by serial debridements, hyperbaric oxygen, and delayed free muscle flap coverage. After control of the infection, a major soft-tissue defect remained on the dorsum of the wrist and hand, exposing all extensor tendons. A rectus muscle free flap was used for wound coverage and salvage of the exposed tendons; the muscle flap was covered with a delayed skin graft. The patient regained satisfactory function with ability to extend all digits. This case emphasizes the importance of aggressive debridement and hyperbaric oxygen treatment and shows the valuable role of free muscle flap wound coverage for preservation of function in cases of necrotizing fasciitis of the hand.

Scalp necrotizing fasciitis with osteomyelitis of the skull from Aspergillus.

Necrotizing fasciitis of the scalp is a life-threatening condition. When Aspergillus is the infectious organism, treatment of the wound and salvage of the patient become a formidable challenge. The authors present an extremely rare case of the successful treatment of scalp necrotizing fasciitis combined with osteomyelitis of the calvarium involving Aspergillus.