Viewpoint matters: objective performance metrics for surgeon endoscope control during robot-assisted surgery.

BACKGROUND: Effective visualization of the operative field is vital to surgical safety and education. However, additional metrics for visualization are needed to complement other common measures of surgeon proficiency, such as time or errors. Unlike other surgical modalities, robot-assisted minimally invasive surgery (RAMIS) enables data-driven feedback to trainees through measurement of camera adjustments. The purpose of this study was to validate and quantify the importance of novel camera metrics during RAMIS. METHODS: New (n = 18), intermediate (n = 8), and experienced (n = 13) surgeons completed 25 virtual reality simulation exercises on the da Vinci Surgical System. Three camera metrics were computed for all exercises and compared to conventional efficiency measures. RESULTS: Both camera metrics and efficiency metrics showed construct validity (p < 0.05) across most exercises (camera movement frequency 23/25, camera movement duration 22/25, camera movement interval 19/25, overall score 24/25, completion time 25/25). Camera metrics differentiated new and experienced surgeons across all tasks as well as efficiency metrics. Finally, camera metrics significantly (p < 0.05) correlated with completion time (camera movement frequency 21/25, camera movement duration 21/25, camera movement interval 20/25) and overall score (camera movement frequency 20/25, camera movement duration 19/25, camera movement interval 20/25) for most exercises. CONCLUSIONS: We demonstrate construct validity of novel camera metrics and correlation between camera metrics and efficiency metrics across many simulation exercises. We believe camera metrics could be used to improve RAMIS proficiency-based curricula.

The evolving application of single-port robotic surgery in general surgery.

Advances in the field of minimally invasive surgery have grown since the original advent of conventional multiport laparoscopic surgery. The recent development of single incision laparoscopic surgery remains a relatively novel technique, and has had mixed reviews as to whether it has been associated with lower pain scores, shorter hospital stays, and higher satisfaction levels among patients undergoing procedures through cosmetically-appeasing single incisions. However, due to technical difficulties that arise from the clustering of laparoscopic instruments through a confined working space, such as loss of instrument triangulation, poor surgical exposure, and instrument clashing, uptake by surgeons without a specific interest and expertise in cutting-edge minimally invasive approaches has been limited. The parallel use of robotic surgery with single-port platforms, however, appears to counteract technical issues associated with single incision laparoscopic surgery through significant ergonomic improvements, including enhanced instrument triangulation, organ retraction, and camera localization within the surgical field. By combining the use of the robot with the single incision platform, the recognized challenges of single incision laparoscopic surgery are simplified, while maintaining potential advantages of the single-incision minimally invasive approach. This review provides a comprehensive report of the evolving application single-port robotic surgery in the field of general surgery today.

Single-port robotic cholecystectomy: results from a first human use clinical study of the new da Vinci single-site surgical platform.

OBJECTIVES: To report our results from a first human use clinical study with the da Vinci Surgical single-site instrumentation in patients with gallbladder disease and to perform a retrospective comparison with traditional multiport laparoscopic cholecystectomy. DESIGN: Ten patients underwent robotic single-port cholecystectomy performed with the da Vinci Si robot and novel da Vinci single-site instrumentation. Outcomes and operative times were compared with patients undergoing traditional multiport laparoscopic cholecystectomy during the same period. SETTING: Tertiary care Veterans Administration hospital. PATIENTS: Outpatients older than 18 years with an American Society of Anesthesiologists class of 1 to 3, no prior upper abdominal surgery, and diagnosis of noninflammatory biliary disease. INTERVENTION: Single-site robotic cholecystectomy. MAIN OUTCOME MEASURES: Operative time, complications up to 30 days, pain scores, and overall satisfaction. RESULTS: Nine of 10 patients had completion of robotic single-site cholecystectomy. Average operating room time was 105.3 minutes compared with an average of 106.1 minutes in the standard laparoscopic group. There were no serious adverse events in the robotic surgery group, with an average follow-up of 3 or more months. CONCLUSION: Robotic single-port cholecystectomy is feasible and comparable with standard laparoscopic cholecystectomy in the Veterans Administration medical center setting.

Bariatric surgery.

Bariatric surgery is a growing segment of minimally invasive surgery. Laparoscopic bariatric procedures are considered some of the most technically challenging surgeries, requiring advanced surgical skills. Successful care of the morbidly obese patient requires a multidisciplinary team approach. These unique requirements are difficult to meet during residency and surgeons interested in bariatric surgery should pursue fellowship training in bariatric surgery.

Early, intermediate, and late effects of a surgical skills "boot camp" on an objective structured assessment of technical skills: a randomized controlled study.

BACKGROUND: Surgical interns enter residency with variable technical abilities and many feel unprepared to perform necessary procedures. We hypothesized that interns exposed to a preinternship intensive surgical skills curriculum would demonstrate improved competency over unexposed colleagues on a test of surgical skills and that this effect would persist throughout internship. STUDY DESIGN: We designed a 3-day intensive skills "boot camp" with simulation-based training on 10 topics. Interns were randomized to an intervention group (boot camp) or a control group (no boot camp). All interns completed a survey including demographic information, previous experience, and comfort with basic surgical skills. Both groups completed a clinical skills assessment focused on 4 topics: chest tube insertion, central line placement, wound closure, and the Fundamentals of Laparoscopic Surgery peg transfer task. We assessed both groups immediately (month 0), early postcurriculum (month 1), and late postcurriculum (month 6). RESULTS: Fifteen participants were in the intervention group and 13 were in the control group. Before boot camp, mean comfort levels were similar for the groups. All participants had minimal prior experience. Competency for chest tube insertion and central line placement were considerably higher for the boot camp group at months 0 and 1, although much of this difference disappeared by month 6. There was no substantial difference between the 2 groups in the Fundamentals of Laparoscopic Surgery peg transfer and wound closure skills. CONCLUSIONS: A surgical skills boot camp accelerates the learning curve for interns in basic surgical skills as measured by a technical skills examination for some skills, although these improvements diminished over time. This can augment traditional training and translate into fewer patient errors.

Benefits to patients choosing preoperative weight loss in gastric bypass surgery: new results of a randomized trial.

BACKGROUND: Historically, preoperative weight loss has been encouraged for patients undergoing gastric bypass surgery to decrease liver mass, technically facilitating the procedure. In an earlier prospective randomized trial investigating effects of preoperative weight loss on patients' clinical outcomes, we reported no differences in postoperative complications or weight-loss profiles at 6-month followup. This article demonstrates results of the same study, with 1-year followup. STUDY DESIGN: One hundred consecutive patients in an 18-month period preparing to undergo gastric bypass surgery at Stanford University Medical Center were selected. Fifty patients were randomly assigned to lose 10% or more of their excess body weight preoperatively, and 50 patients were assigned to no preoperative weight-loss requirements. After 1 year, patient demographics and data on postoperative complications, cure or improvement of comorbidities, and differences in weight-loss profiles were collected. RESULTS: At 1 year, the 2 groups had similar preoperative demographics and body mass indexes (BMIs). Patients in the weight-loss group, on average, lost 8.2% of their excess body weight preoperatively compared with the nonweight-loss group, which gained 1.1% (p = 0.007). After a year, the patients in both arms of the study showed no difference in weight, BMI, excess weight-loss, and number of remaining comorbidites. But when patients were divided according to those who had lost at least 5% of their excess body weight preoperatively, the 1-year results for excess weight-loss, weight, and BMI were much lower for the weight-loss group. CONCLUSIONS: Preoperative weight loss in patients undergoing gastric bypass surgery is safe and feasible. It should be encouraged, because it will markedly improve longterm weight loss.

Comparison of hospital charges between robotic, laparoscopic stapled, and laparoscopic handsewn Roux-en-Y gastric bypass.

The feasibility and safety of laparoscopic and robotic Roux-en-Y gastric bypass (RRYGB) have been established. To evaluate the cost-effectiveness of robotic surgery we compared the hospital charges for robotic, laparoscopic stapled (SRYGB), and laparoscopic handsewn Roux-en-Y gastric bypass (HRYGB) at our institution. One hundred thirty-five consecutive patients undergoing Roux-en-Y gastric bypass at Stanford University Medical Center by handsewn, stapled or robotic techniques from 1 July 2005 to 31 December 2005 were evaluated. Medical records of these patients were retrospectively reviewed and the following variables were collected and analyzed: age, gender, body mass index (BMI), number of preoperative comorbidities, length of stay (LOS), operating and anesthesia times, postoperative complications, mortality, professional fees, and hospital and total charges. Twenty-one RRYGB, 78 SRYGB, and 36 HRYGB were performed during the study period. Comparison of the above three groups demonstrated no statistically significant differences in age, gender, BMI, number of preoperative comorbidities, LOS, operating and anesthesia times, postoperative complications, mortality or professional fees. Total charges were higher for RRYGB (US $77,820) when compared with SRYGB (US $66,153) but not when compared with HRYGB (US $68,814). RRYGB higher hospital charges resulted in higher total charges when compared with SRYGB and HRYGB. These differences do not reflect actual cost to the hospital.

Abnormal findings on routine upper GI series following laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: The use of postoperative upper GI series (UGIS) after laparoscopic Roux-en-Y gastric bypass (LRYGBP) varies among bariatric surgeons. The authors describe the findings and impact of UGIS after LRYGBP. METHODS: From July 2003 to January 2006, 487 patients undergoing primary LRYGBP at a single academic institution had a single-contrast Gastrografin UGIS performed on the first postoperative day, without complication. Patient and operative demographics were: mean age 43 years, mean BMI 47 kg/m2, female 84%, and laparoscopic 100%. RESULTS: Of the 487 patients, the UGIS revealed 14 (2.9%) major and 88 (15.2%) minor abnormalities. Among the major UGIS abnormalities, 6 (1.2%) demonstrated a gastrojejunal anastomotic (GJA) leak, 8 (1.4%) confirmed complete obstruction at the GJA, and 1 (0.2%) disclosed a communication with the bypassed stomach. For the minor UGIS abnormalities, 45 (9.2%) displayed significant delay in contrast passage through the GJA, 23 (5.0%) had evidence of dilated loops of small and/or large bowel, and 6 (1.2%) verified miscellaneous abnormal findings (malrotation, lower esophageal dysmotility, jejunal clots). Patients with UGIS abnormalities necessitated additional procedures, delayed oral intake and/or longer length of stay (LOS). CONCLUSIONS: UGIS on postoperative day 1 is a useful means of evaluating postoperative LRYGBP anatomy and influenced postoperative care.

Retrievable inferior vena cava filters may be safely applied in gastric bypass surgery.

INTRODUCTION: Pulmonary embolus (PE) is a potentially devastating and fatal postoperative complication in morbidly obese patients. This study was undertaken to review the safety and efficacy of retrievable prophylactic inferior vena cava (IVC) filters in high-risk morbidly obese patients undergoing gastric bypass. METHODS: Patients who underwent gastric bypass surgery and preoperative insertion of retrievable IVC filters had their records reviewed. Indications for IVC filter insertion were: history of deep venous thrombosis (DVT) or PE, long-standing sleep apnea, venous stasis disease, and/or weight > 400 pounds. RESULTS: 24 patients underwent IVC filter placement before gastric bypass surgery. There were 10 women and 14 men with an average age of 50 +/- 6.3 years (range 39 to 59) and average body mass index (BMI) of 57 +/- 7.5 kg/m(2) (range 49 to 74). BMI greater then 50 kg/m(2) was present in 21 of 24 patients (88%). All patients had successful IVC filter placement. IVC filter retrieval postoperatively was performed in 20 of 24 patients (83%) with three left for clinical reasons and one (4%) left due to technical inability to retrieve. There was one complication directly attributable to IVC filter retrieval. There were no deaths. Five patients (21%) developed DVT or PE postoperatively. Follow-up was 16 +/- 7.6 months (range 8 to 33). CONCLUSIONS: Prophylactic IVC filter placement and retrieval can be safely undertaken in high-risk gastric bypass patients. We recommend preoperative IVC filter placement in selected patients.

Is there a benefit to preoperative weight loss in gastric bypass patients? A prospective randomized trial.

BACKGROUND: Roux-en-Y gastric bypass surgery is the leading surgical treatment of morbid obesity in the United States. The role of preoperative weight loss in gastric bypass surgery remains controversial. We performed a prospective randomized trial to determine whether preoperative weight loss results in better outcomes after laparoscopic gastric bypass. METHODS: A total of 100 patients undergoing laparoscopic gastric bypass surgery from May 2004 to October 2005 were randomized preoperatively to either a weight loss group with a 10% weight loss requirement or a group that had no weight loss requirements. The patients were followed prospectively. The variables analyzed included perioperative complications, operative time, postoperative weight loss, and resolution of co-morbidities. RESULTS: Data were available for 26 patients in the weight loss group and 35 in the nonweight loss group. The 2 groups had similar preoperative characteristics, conversion and complication rates, and resolution of co-morbidities. The initial body mass index was 48.7 kg/m(2) and 49.3 kg/m(2) for the weight loss group and nonweight loss group, respectively (P = NS). The preoperative body mass index was 44.5 kg/m(2) and 50.7 kg/m(2) for the weight loss group and nonweight loss group, respectively (P = 0.0027). The operative time was 220.2 and 257.6 minutes for the 2 groups (P = 0.0084). The percentage of excess weight loss at 3 and 6 months for the weight loss group and nonweight loss group was 44.1% and 33.1% (P = 0.0267) and 53.9% and 50.9% (P = NS), respectively. The interval to surgery from the initial consultation was 5.4 months and 5.2 months for the 2 groups (P = NS). CONCLUSIONS: Preoperative weight loss before laparoscopic Roux-en-Y gastric bypass was associated with a decrease in the operating room time and an improved percentage of excess weight loss in the short term. Preoperative weight loss, however, did not affect the major complication or conversion rates, and its long-term effects were not apparent through this study. Also, preoperative weight loss did not have any bearing on the resolution of co-morbidities.

Gastric bypass reduces biochemical cardiac risk factors.

BACKGROUND: Coronary artery disease (CAD) is the leading cause of death in the United States, with obesity as a leading preventable risk factor for CAD. Certain biochemical markers have demonstrated strong prediction for cardiovascular events. We hypothesized that in addition to weight reduction, gastric bypass will also induce a salutary effect on the biochemical cardiac risk factors. METHODS: At a single academic institution, from 2003 to 2004, we measured the biochemical cardiac risk factors in gastric bypass patients preoperatively and at 3, 6, and 12 months postoperatively. These risk factors included total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein cholesterol, total cholesterol/HDL cholesterol ratio, triglyceride/HDL cholesterol ratio, triglycerides, lipoprotein A, high-sensitivity C-reactive protein, and homocysteine. The data were analyzed using the Wilcoxon signed rank test. RESULTS: The mean age of the 356 patients was 43 years; 84% were women; the mean body mass index was 47 kg/m(2); 33% were diabetic; 50% were hypertensive; 23% were taking lipid-lowering medications; and 2% had known CAD. Significant improvement occurred in the biochemical cardiac factors from preoperatively to 12 months. The beneficial changes were as follows: total cholesterol, 192 mg/dL preoperatively to 166 mg/dL at 12 months; HDL cholesterol, 46 mg/dL preoperatively to 54 mg/dL at 12 months; low-density lipoprotein, 125 mg/dL preoperatively to 88 mg/dL at 12 months; total cholesterol/HDL cholesterol ratio, 4 preoperatively to 3 at 12 months; triglyceride/HDL cholesterol ratio, 3 preoperatively to 2 at 12 months; triglycerides, 133 mg/dL preoperatively to 92 mg/dL at 12 months; lipoprotein A, 14 mg/dL preoperatively to 13 mg/dL at 12 months; high-sensitivity C-reactive protein, 8 mg/L preoperatively to 1 mg/L; and homocysteine, 10 mumol/L preoperatively to 8 mumol/L at 12 months. CONCLUSIONS: The results of our study have shown that gastric bypass significantly improves all biochemical markers of CAD risk, particularly C-reactive protein, which had an 80% reduction. As a result, gastric bypass decreases the cardiac risk by both weight loss and advantageous alterations of biochemical cardiac risk factors.

Postural ergonomics during robotic and laparoscopic gastric bypass surgery: a pilot project.

We hypothesized that a laparoscopic technique for Roux-en-Y gastric bypass surgery is associated with more musculoskeletal discomfort and ergonomic strain than a robotic technique. This pilot project studied one surgeon while he performed four laparoscopic and four robotic (da Vinci system) Roux-en-Y gastric bypass procedures. We measured musculoskeletal discomfort with body part discomfort score (BPD) and ergonomic positioning with the rapid upper-limb assessment tool (RULA). At the end of the case, the robotic cases were associated with more discomfort in the neck (median BPD scores 2.5 versus 1.0, P = 0.028), while the laparoscopic cases were associated with more discomfort in the upper back (median BPD scores 2.0 versus 1.0, P = 0.028). Both the right and left shoulders demonstrated more discomfort with the laparoscopic group (median BPD scores 3.0 versus 1.5, P = 0.057). The RULA analysis demonstrated that the upper arm (1.0 versus 2.25), lower arm (1.125 versus 2.125), wrist (2.5 versus 3.5) and wrist twist (1.25 versus 2) were held in less ergonomically correct positioning (higher score) in the laparoscopic group compared to the robotic group (P = 0.029). In contrast, the trunk (1.5 versus 1.0) had a worse RULA score in the robotic group compared to the laparoscopic cases. These pilot data suggest that robotic Roux-en-Y gastric bypass surgery may result in less musculoskeletal stress to the upper extremities than standard laparoscopic technique. In contrast, robotic surgery seems to offer both postural advantages and disadvantages for the neck and back region. More-detailed studies are needed to fully assess the potential postural advantages of robotic surgical techniques over standard laparoscopy.

Attitude of prospective surgical residents regarding surgery for morbid obesity.

BACKGROUND: Obesity and associated co-morbidities have become an epidemic in the United States. As surgery for obesity becomes more common, surgical training programs need to address this growing demand. We conducted this study to assess prospective surgery trainees' attitudes and knowledge regarding surgery for morbid obesity. METHODS: An anonymous and voluntary questionnaire was given to prospective surgical residency applicants to complete during their interview. The questionnaire included basic demographic information and addressed the applicants' attitudes and basic knowledge about surgery for obesity. RESULTS: 57 applicants to the surgical residency program completed the survey. Demographic information included: 51% male, 36% from the Northeast, 32% with obese family members, and 93% applying for a categorical surgery position. 81% of applicants had been exposed to bariatric surgery. Although 70% of applicants would perform bariatric surgery as part of their practice, only 44% would make this their career. Reasons for reluctance to treat bariatric surgery patients included: more complications (46%), non-compliant patients (33%), and technically demanding surgery (18%). 89% responded that they would recommend bariatric surgery to a family member, but only 77% would consider it for themselves. Overall correct answers regarding bariatric surgery knowledge were 74%. CONCLUSIONS: Attitudes and knowledge about surgery for morbid obesity were generally positive in prospective surgical trainees. Medical school curriculum and surgical training programs should continue to expose trainees to information from this ever-growing field.

Concurrent gastric bypass and repair of anterior abdominal wall hernias.

BACKGROUND: Many patients seeking surgical treatment for morbid obesity present with anterior abdominal wall hernias. Although principles of hernia repair involve a tension-free repair with the use of prosthetic mesh, there is concern about the use of mesh in gastric bypass surgery due to potential contamination with the contents of the gastrointestinal tract and resultant mesh infection. We report our series of patients undergoing Roux-en-Y gastric bypass (RYGBP) and simultaneous anterior abdominal wall hernia repair. METHODS: All patients who underwent simultaneous RYGBP surgery and anterior abdominal wall hernia repair were reviewed. RESULTS: 12 patients underwent concurrent RYGBP and anterior wall hernia repair. There were 5 women and 7 men with average age 54.9 +/- 8.5 years (range 35 to 64) and average body mass index (BMI) 50.4 +/- 10.3 kg/m(2) (range 38 to 70). Two open and 10 laparoscopic RYGBP operations were performed. Nine patients (75%) underwent incisional hernia repairs and 3 patients (25%) underwent umbilical hernia repair concurrent with gastric bypass. Average size of defect was 14.7 +/- 13.4 cm(2). One patient had primary repair and 11 patients had prosthetic mesh repair: polypropylene in 3 patients (25%) and polyester in 8 patients (67%). With a 14.1 +/- 9.3 month follow-up, there have been no mesh infections and 2 recurrences, one in the patient who underwent primary repair and one in a patient repaired with polyester mesh but with two previous failed incisional hernia repairs. CONCLUSION: Concurrent RYGBP and repair of anterior abdominal wall hernias is safe and feasible. In order to optimize success, tension-free principles of hernia repair with the use of prosthetic mesh should be followed since no mesh infections occurred in our series.