Robotic vs. laparoscopic colorectal surgery: an institutional experience.

BACKGROUND: Robotic colorectal surgery is gaining interest in general and colorectal surgery. The use of the da Vinci(®) Robotic system has been postulated to improve outcomes, primarily by increasing the dexterity and facility with which complex dissections can be performed. We report a large, single institution, comparative study of laparoscopic and robotic colectomies, attempting to better elucidate the benefits of robotic surgery in patients with colorectal disease. METHODS: We conducted a retrospective review of 171 patients who underwent robotic and laparoscopic colectomies (79 and 92, respectively) at our institution between November 2004 and November 2009. Patients in both groups had well-matched preoperative parameters. All cases were further subdivided by their anatomical location into right-sided and left-sided colectomy, and analysis was performed within these two subgroups. Perioperative outcomes reported include operative time, operative blood loss, time to return of bowel function, time to discontinuation of patient controlled analgesia, length of stay, and intraoperative or postoperative complications. RESULTS: Our results indicate that there is no statistical difference in length of stay, time to return of bowel function, and time to discontinuation of patient-controlled analgesia between robotic and laparoscopic left and right colectomies. Interestingly, the total procedure time difference between the laparoscopic and robotic colectomies was much smaller than previously published accounts (mean 140 min vs. 135 min for right colectomy; mean 168 min vs. 203 min for left colectomy). CONCLUSIONS: Our study is one of the largest reviews of robotic colorectal surgery to date. We believe that our results further demonstrate the equivalence of robotic surgery to laparoscopic surgery in colorectal procedures. Future research should focus on surgeon-specific variables, such as comfort, ergonomics, distractibility, and ease of use, as other ways to potentially distinguish robotic from laparoscopic colorectal surgery.

Intermediate results of a prospective randomized controlled trial of traditional four-port laparoscopic cholecystectomy versus single-incision laparoscopic cholecystectomy.

BACKGROUND: Minimally invasive techniques have become an integral part of general surgery, with recent investigation into single-incision laparoscopic cholecystectomy (SILC). This study presents a prospective, randomized, multicenter, single-blind trial of SILC compared with four-port cholecystectomy (4PLC) with the goal of assessing safety, feasibility, and factors predicting outcomes. METHODS: Patients with biliary colic and documented gallstones or polyps or with biliary dyskinesia were randomized to SILC or 4PLC. Data measures included operative details, adverse events, and conversion to 4PLC or laparotomy. Pain, cosmesis, and quality-of-life scores were documented. Patients were followed for 12 months. RESULTS: Two hundred patients were randomized to SILC (n = 117) or 4PLC (n = 80) (3 patients chose not to participate after randomization). Patients were similar except for body mass index (BMI), which was lower in the SILC patients (28.9 vs. 31.0, p = 0.011). One SILC patient required conversion to 4PLC. Operative time was longer for SILC (57 vs. 45 min, p < 0.0001), but outcomes, including total adverse events, were similar (34% vs. 38%, p = 0.55). Cosmesis scores favored SILC (p < 0.002), but pain scores were lower for 4PLC (1 point difference in 10-point scale, p < 0.028) despite equal analgesia use. Wound complications were greater after SILC (10% vs. 3%, p = 0.047), but hernia recurrence was equivalent for both procedures (1.3% vs. 3.4%, p = 0.65). Univariate analysis showed female gender, SILC, and younger age to be predictors for increased pain scores, while SILC was associated with improved cosmesis scores. CONCLUSIONS: In this multicenter randomized controlled trial of SILC versus 4PLC, SILC appears to be safe with a similar biliary complication profile. Pain scores and wound complication rates are higher for SILC; however, cosmesis scores favored SILC. For patients preferring a better cosmetic outcome and willing to accept possible increased postoperative pain, SILC offers a safe alternative to the standard 4PLC. Further follow-up is needed to detail the long-term risk of wound morbidities, including hernia recurrence.

Bridged repair of large ventral hernia defects using an ovine reinforced biologic: A case series.

Introduction: Of all hernia types, large ventral hernias have the most impact on patient quality of life, however they are also the most difficult type of hernia to repair and are associated with high rates of complications. This case series describes repair of large ventral hernias with an ovine reinforced biologic in a complex patient cohort with comorbidities and concomitant procedures. Methods: The author performed bridged repair with an ovine reinforced biologic in 19 consecutive high-risk patients over a 5-year period. In all cases the reinforced biologic was used as an underlay. Outcomes: Of the 19 patients, six (32%) experienced a surgical site occurrence including infection, seroma, abscess, fistula, bioloma, or bowel obstruction. Three patients (16%) had recurrences with two out of three of the recurrences occurring within 6 months of surgery. Conclusions: Rates of SSO's and recurrences using ovine reinforced tissue matrix (RTM) were in line with or better than other published studies of bridged repair utilizing biologic or synthetic mesh reinforcement. Ovine RTM's should therefore be considered in complex large ventral hernia repairs.

24-Month results of the BRAVO study: A prospective, multi-center study evaluating the clinical outcomes of a ventral hernia cohort treated with OviTex® 1S permanent reinforced tissue matrix.

Background: This study evaluated the performance of OviTex® 1S (TELA Bio Inc., Malvern, PA, USA) over 24 months when used for ventral hernia repair. Methods: This was a prospective, single-arm, multi-center clinical trial (ClinicalTrials.gov/NCT03074474). A ninety-two patient cohort with ventral hernias were enrolled. The surgical approach (open, laparoscopic, or robotic) and plane of placement (retrorectus, intraperitoneal, or pre-peritoneal) were at the discretion of the surgeon. Patients were characterized as high risk for a surgical site occurrence (SSO) based on the following comorbidities: BMI between 30 and 40, active smoker, chronic obstructive pulmonary disease (COPD), diabetes mellitus, coronary artery disease, advanced age ( ≥ 75 years). Subjects underwent physical examinations to evaluate safety events and completed quality of life surveys at 1 months, 3 months, 12 months, and 24 months post-surgery. Results: Sixty-five of the 92 enrolled patients (70.7%) completed 24-month follow-up. The Kaplan Meier estimate for risk of recurrence at day 730 (24 months) was 2.6%; among subjects who completed their 24-month visit or had a previous recurrence, the unadjusted rate of recurrence was 4.5% (3/66). SSOs were observed in 38.0% of patients (35/92). The most prevalent SSO was surgical site infection occurring in 20.7% (19/92) of patients, followed by seroma formation, which occurred in 13.0% of patients; however, only 3.3% required intervention. HerQLes and EQ-5D assessments showed improvement from baseline as soon as 3 months post-surgery. Continued improvement was observed through 24 months. Conclusions: Overall the BRAVO study demonstrates that use of the ovine reinforced tissue matrix OviTex 1S is a viable option for use in ventral hernia repair. Additional studies with longer term follow-up data are needed to draw definitive conclusions on the use of OviTex 1S.

A Polymer-Biologic Hybrid Hernia Construct: Review of Data and Early Experiences.

Surgical mesh reinforcement of the human abdominal wall has been found to reduce the chance of recurrence in hernia repairs. While traditionally polymer meshes have been used in hernia repair, alternative mesh options have been engineered to prevent the inflammatory foreign body response invoked by polymers. A reinforced tissue matrix (RTM) mesh has been developed by embedding a polymer within a decellularized extracellular matrix. This combination has been attributed to the recruitment of host cells, a pro-healing response, and attenuation of the foreign body response. This has been observed to lead to the regeneration of functional tissue within the repair site that is reinforced by the polymer to offload abdominal pressures over time. This manuscript presents the review of OviTex, an RTM, in several types of hernia repair. The authors have found that the use of RTM in hernia repair is effective in preventing foreign body response, promoting wound healing, and providing reinforcement to lower the risk of hernia recurrence.

A Prospective, Single Arm, Multi-Center Study Evaluating the Clinical Outcomes of Ventral Hernias Treated with OviTex® 1S Permanent Reinforced Tissue Matrix: The BRAVO Study 12-Month Analysis.

BACKGROUND: Conflicting results from previous studies have led to dissent over whether surgical mesh is safe and effective in ventral hernia repair. A newer class of mesh known as a reinforced tissue matrix, combining a biologic scaffold and minimal polymer reinforcement, offers promise in reducing inflammatory response and increasing abdominal wall support. This study sought to assess the clinical utility of a reinforced tissue matrix (OviTex) in ventral hernia repair 12 months after implantation. METHODS: This is a prospective, single-arm, multi-center study to evaluate the clinical performance of OviTex® 1S Permanent (OviTex) in the repair of primary or recurrent ventral hernias (VH) in consecutive patients (ClinicalTrials.gov/NCT03074474). The rate of surgical site occurrences (SSOs) was evaluated 90 days post-surgery as the primary endpoint. Hernia recurrence and the incidence of postoperative events were evaluated between three and 12 months as secondary endpoints. The incidence of other complications and patient-reported outcomes were also recorded. RESULTS: Ninety-two (92) patients were enrolled in the study, of whom seventy-six (76) reached the 12-month follow-up. All patients were at least 18 years of age with a BMI of <40 kg/m2. Hernia defects were <20 × 20 cm, classified as class I-III according to the CDC wound classification system. Of the 76 patients who reached 12-month follow-up, twenty-six (34%) had previous VH repairs and thirteen (17%) had previous surgical infection. Sixty (79%) had factors known to increase the risk of recurrence. Twenty patients (26%) experienced SSOs, with ten (13%) requiring procedural intervention. Two of the 75 patients (2.7%) experienced a recurrence. CONCLUSIONS: The low rate of hernia recurrence and SSOs requiring intervention illustrates the potential that reinforced tissue matrices, and OviTex 1S, in particular, have to improve outcomes in VH repairs. Follow-up to 24 months is ongoing.

Laparoscopic Hartmann's procedure: a viable option for treatment of acutely perforated diverticultis.

BACKGROUND: A laparoscopic technique for acutely perforated diverticulitis (i.e., laparoscopic Hartmann's procedure) has not been described. The authors present their technique for laparoscopic sigmoid resection, end colostomy, and subsequent laparoscopic takedown of colostomy. METHODS: A retrospective review of patients with Hinchey III/IV diverticulitis who underwent a laparoscopic Hartmann's procedure was performed in this study. Laparoscopic takedown of sigmoid colostomy was performed 2 to 3 months later. Data from these procedures including estimated blood loss (EBL), length of the operative procedure, patient outcomes, and demographics were evaluated. RESULTS: Seven patients with a mean age of 49.7 years underwent laparoscopic sigmoid colectomy with end colostomy. None of these patients had a history of diverticulitis. Their mean EBL was 138 ml, and their mean operative time was 154 min. None of the procedures required conversion to use of a hand port or conversion to open procedure. The average time to return of bowel function was 3.7 days, with one patient experiencing a postoperative ileus. The mean postoperative hospital stay was 6.6 days. There were no complications. Laparoscopic Hartmann's takedown was performed for all the patients approximately 2 to 3 months later. The mean EBL was 107 ml, and the average operative time was 189 min. One patient had intraoperative anastomotic leak, which was successfully repaired and retested. Again, none of the procedures required the use of a hand port or a laparotomy. The average time to return of bowel function was 3.4 days. The average length of hospital stay was 5.3 days, with one patient experiencing a fat necrosis. CONCLUSIONS: Laparoscopic Hartmann's procedure and laparoscopic takedown are technically feasible procedures with reasonable outcomes.

Extended mesh repair with external oblique muscle reinforcement for abdominal wall contour abnormalities following TRAM flap.

Many patients undergoing reconstructive surgery after mastectomy opt for reconstruction with the transverse rectus abdominis myocutaneous (TRAM) flap. Among the morbidities related to TRAM flap reconstruction is the development of abdominal wall contour abnormalities, including bulges or hernias. Several repair techniques at the flap abdominal wall donor site have been described for use at the time of flap harvest in an attempt to reduce the risk of such abdominal wall complications. For patients that develop abdominal wall contour abnormalities, numerous reconstructive options have been reported, with mixed results. Ten patients were identified as having abdominal wall contour abnormalities after a TRAM flap and underwent an extended mesh repair with external oblique muscle reinforcement. The mesh was secured to the bony landmarks of the lower abdomen and the abdominal wall fascia. All patients achieved complete resolution of abdominal wall bulging. In the follow-up period, no recurrences, infections, or seromas were noted. One patient, who failed an earlier repair at the inferior abdominal wall, reported symptoms consistent with a scar neuroma. Symptoms were treated successfully with gabapentin and a nonsteroidal anti-inflammatory drug. We propose a novel and reliable method of lower abdominal wall reconstruction for patients with post-TRAM flap abdominal wall contour abnormalities. This technique incorporates the use of a large Marlex mesh reinforced with bilateral external oblique muscle flaps. We report a series of 10 patients who have achieved resolution of their symptoms and have regained a natural, flat-appearing abdominal wall contour.

Fate of retained capsule: a pathognomonic for surgery.

Since its introduction in 2001, Wireless Video Capsule enteroscopy is gaining acceptance due to its high diagnostic potential and minimal risk. In some centers, it offers an alternative approach to visualize the small intestine and to evaluate patients with suspected small bowel disease. We present a series of known complications of this procedure and call for a more proactive role in the management of retained capsule.

A standardized technique for robotically performed sigmoid colectomy.

BACKGROUND: We describe a standarized eight-step technique to perform sigmoid colectomy using the da Vinci robot (Intuitive Surgical, Sunnyvale, CA) in both the left upper and lower abdominal quadrants. MATERIALS AND METHODS: Between March 2005 and June 2006, 11 robotic sigmoid colectomies were performed on patients with diverticulitis or cancer. The procedures were performed through 4 ports, using a medial to lateral approach and involved moving the robot during the procedure. RESULTS: We describe the data and results from our first 11 robotically performed sigmoid colectomies using this technique. Operative times during each step of the procedure were collected and reported. By the eighth case, our team required only 4 minutes to undock, move, and redock the robot. The average operative time was 197 minutes and the average length of hospital stay was 3.4 days. There were no complications and no conversions to open colectomy. CONCLUSION: Robotically performed sigmoid colectomy is a feasible and safe procedure. The robot can be moved efficiently during surgery to allow a totally robotically performed sigmoid colectomy. The three-dimensional view, articulating instruments, intuitive movement, motion scaling, stable camera platform, and comfortable surgeon ergonomics facilitate splenic flexure mobilization and dissection and division of the inferior mesenteric artery and inferior mesenteric vein. Further studies will be needed to determine clinical benefit and economic feasibility.

Laparoscopic Repair of Foramen of Winslow Hernia.

Foramen of Winslow hernia is a rare surgical entity with very few reported cases in literature. Preoperative diagnosis used to be difficult but with emerging computed tomography technology, diagnosing this internal abdominal hernia has become easier. We present an unusual case report of foramen of Winslow hernia in a 77-year-old patient who presented with severe abdominal pain. The patient underwent laparoscopic repair of the hernia and recovered well postoperatively. This presentation of symptoms in a 77-year-old male is unusual and laparoscopic management of foramen of Winslow hernia presents an interesting and challenging management scenario.

Competence acquisition for single-incision laparoscopic cholecystectomy.

BACKGROUND AND OBJECTIVES: Within the past few years, there has been a push for an even more minimally invasive approach to biliary disease with the adoption of single-incision laparoscopic cholecystectomy. We sought to compare 4 individual surgeon experiences to define whether there exists a learning curve for performing single-incision laparoscopic cholecystectomy. METHODS: We performed a retrospective review 290 single-incision laparoscopic cholecystectomies performed by a group of general surgeons, with varying levels of experience and training, at 3 institutions between May 2008 and September 2010. The procedure times were recorded for each single-incision laparoscopic cholecystectomy, ordered chronologically for each surgeon, and subsequently plotted on a graph. The patients were also combined into cohorts of 5 and 10 cases to further evaluate for signs of improvement in operative efficiency. RESULTS: Of the 4 surgeons involved in the study, only 1 (surgeon 4, laparoscopic fellowship trained with <5 years' experience) confirmed the presence of a learning curve, reaching proficiency within the first 15 cases performed. The other surgeons had more variable procedure times, which did not show a distinct trend. When we evaluated the cases by cohorts of 5 cases, surgeon 4 had a significant difference between the first and last cohort. Increased body mass index resulted in a slightly longer operative time (P < .0063). The conversion rate to multiport laparoscopic surgery was 3.1%. CONCLUSIONS: Our results indicate that among experienced general surgeons, there does not seem to be a significant learning curve when transitioning from conventional laparoscopic cholecystectomy to single-incision laparoscopic cholecystectomy. The least experienced surgeon in the group, surgeon 4, appeared to reach proficiency after 15 cases. Greater than 5 years of experience in laparoscopic surgery appears to provide surgeons with a sufficient skill set to obviate the need for a single-incision laparoscopic cholecystectomy learning curve.

Single-incision laparoscopic cholecystectomy is associated with improved cosmesis scoring at the cost of significantly higher hernia rates: 1-year results of a prospective randomized, multicenter, single-blinded trial of traditional multiport laparoscopic cholecystectomy vs single-incision laparoscopic cholecystectomy.

BACKGROUND: Minimally invasive techniques have become an integral part of general surgery with recent investigation into single-incision laparoscopic cholecystectomy (SILC). This study presents the final 1-year results of a prospective, randomized, multicenter, single-blinded trial of SILC vs multiport cholecystectomy (4PLC). STUDY DESIGN: Patients with biliary colic and documented gallstones or polyps or with biliary dyskinesia were randomized to SILC vs 4PLC. Data measures included operative details, adverse events, and conversion to 4PLC or laparotomy. Patients were followed for 12 months. RESULTS: Two hundred patients underwent randomization to SILC (n = 119) or 4PLC (n = 81). Enrollment ranged from 1 to 50 patients with 4 sites enrolling >25 patients. Total adverse events were not significantly different between groups (36% 4PLC vs 45% SILC; p = 0.24), as were severe adverse events (4% 4PLC vs 10% SILC; p = 0.11). Incision-related adverse events were higher after SILC (11.7% vs 4.9%; p = 0.13), but all of these were listed as mild or moderate. Total hernia rates were 1.2% (1 of 81) in 4PLC patients vs 8.4% (10 of 119) in SILC patients (p = 0.03). At 1-year follow-up, cosmesis scores continued to favor SILC (p < 0.0001). CONCLUSIONS: Results of this trial show SILC to be a safe and feasible procedure when compared with 4PLC, with similar total adverse events but with an identified significant increase in hernia formation. Cosmesis scoring and patient preference at 12 months continue to favor SILC, and more than half of the patients were willing to pay more for a single-site surgery over a standard laparoscopic procedure. Additional longer-term population-based studies are needed to clarify if this increased rate of hernia formation as compared with 4PLC will continue to hold true.

Prospective study of single-stage repair of contaminated hernias using a biologic porcine tissue matrix: the RICH Study.

BACKGROUND: In the presence of contamination, the repair of a ventral incisional hernia (VIH) is challenging. The presence of comorbidities poses an additional risk for postoperative wound events and hernia recurrence. To date, very few studies describe the outcomes of VIH repair in this high-risk population. METHODS: A prospective, multicenter, single-arm, the Repair of Infected or Contaminated Hernias study was performed to study the clinical outcomes of open VIH repair of contaminated abdominal defects with a non-cross-linked, porcine, acellular dermal matrix, Strattice. RESULTS: Of 85 patients who consented to participate, 80 underwent open VIH repair with Strattice. Hernia defects were 'clean-contaminated' (n = 39), 'contaminated' (n = 39), or 'dirty' (n = 2), and the defects were classified as grade 3 (n = 60) or grade 4 (n = 20). The midline was restored, and primary closure was achieved in 64 patients; the defect was bridged in 16 patients. At 24 months, 53 patients (66%) experienced 95 wound events. There were 28 unique, infection-related events in 24 patients. Twenty-two patients experienced seromas, all but 5 of which were transient and required no intervention. No unanticipated adverse events occurred, and no tissue matrix required complete excision. There were 22 hernia (28%) recurrences by month 24. There was no correlation between infection-related events and hernia recurrence. CONCLUSION: The use of the intact, non-cross-linked, porcine, acellular dermal matrix, Strattice, in the repair of contaminated VIH in high-risk patients allowed for successful, single-stage reconstruction in >70% of patients followed for 24 months after repair.

Prospective randomized controlled trial of traditional laparoscopic cholecystectomy versus single-incision laparoscopic cholecystectomy: report of preliminary data.

BACKGROUND: This study presents preliminary data from a prospective randomized multicenter, single-blinded trial of single-incision laparoscopic cholecystectomy (SILC) versus standard laparoscopic cholecystectomy (4PLC). METHODS: Patients with symptomatic gallstones, polyps, or biliary dyskinesia (ejection fraction <30%) were randomized to SILC or 4PLC. Data included operative time, estimated blood loss, length of skin and fascial incisions, complications, pain, satisfaction and cosmetic scoring, and conversion. RESULTS: Operating room time was longer with SILC (n = 50) versus 4PLC (n = 33). No differences were seen in blood loss, complications, or pain scores. Body image scores and cosmetic scores at 1, 2, 4, and 12 weeks were significantly higher for SILC. Satisfaction scores, however, were similar. CONCLUSIONS: Preliminary results from this prospective trial showed SILC to be safe compared with 4PLC although operative times were longer. Cosmetic scores were higher for SILS compared with 4PLC. Satisfaction scores were similar although both groups reported a significantly higher preference towards SILC.

Concurrent robotic trans-abdominal pre-peritoneal (TAP) herniorrhaphy during robotic-assisted radical prostatectomy.

BACKGROUND: Robotic prostatectomy (RP) is now increasingly performed because it allows for precise dissection of neurovascular structures with better outcomes. It is estimated that 5-12% of candidates for radical prostatectomy have detectable inguinal hernias, and simultaneous mesh hernioplasty is now well supported. A disadvantage of radical prostatectomy is obliteration of the preperitoneal space of Bogros, which can make future totally extraperitoneal (TEP) herniorrhaphy difficult and prone to complication. METHODS: Four patients underwent RP using the DaVinci system. Six clinically detectable inguinal hernias were repaired. Upon completion of the prostatectomy, the peritoneum overlying the myopectineal orifice of Fruchaud was opened, the orifice was dissected free and the hernia reduced. A 3 x 6 inch polypropylene mesh or 4 x 6 inch polyester mesh was then affixed overlying the orifice with titanium tacks, and the peritoneum was closed over the mesh using a running absorbable suture. RESULTS: The mean operating time for the TAP was 24 min. There were no postoperative complications. At a mean follow-up of 34 months, no recurrence was noted. CONCLUSIONS: With the increasing incidence of RP, we advocate the concurrent repair of any detectable inguinal hernias at the time of prostatectomy. The preperitoneal placement of a polypropylene or polyester mesh secured with a tacking device and a peritoneal closure performed with a running absorbable suture is uniquely suited to the abilities of the robot, and provides a durable repair.

Robotic-assisted single-incision right colectomy: early experience.

BACKGROUND: Application of laparoendoscopic single-site surgery (LESS) is increasing across surgical disciplines. In addition to the possibility of decreased postoperative pain, LESS offers better cosmesis with virtually 'scarless' surgeries, while avoiding the increased costs and complexity of natural orifice surgery. Instrument conflict minimization often requires the crossing of articulating instruments, which we believe can be more intuitively facilitated using the daVinci-S((R)) robotic system. We describe our early experience with three robotic single-incision right hemicolectomies. METHODS: Three robotic single-incision right hemicolectomies were performed using the daVinci-S robotic system, utilizing a single 4 cm incision through or around the umbilicus. The procedure was performed using three robotic arms, a 12 mm camera and two 8 mm robotic ports. A medial to lateral approach was used and an extracorporeal resection and anastomosis was performed after undocking the robot. RESULTS: There were no intraoperative or postoperative complications. Average operative time was 152 min. The first case was converted to non-robotic single-incision right hemicolectomy during mobilization of the ascending colon, due to uncontrollable air leakage around the ports. The second and third cases were successfully completed without air loss by purse-stringing sutures around each individual port and the use of the SILS() port, respectively. CONCLUSIONS: Robotic-assisted single-incision right hemicolectomy can be successfully and safely performed using the daVinci-S robotic system. Several techniques may be employed to prevent the loss of pneumoperitoneum. We believe right hemicolectomy lends itself to single-site surgery because specimen extraction requires a 4 cm incision and may confer patient benefit, with decreased postoperative pain and improved cosmesis. By crossing the robotic instruments and reassigning control of the arms, the robot represents a means to help perform these procedures safely by allowing them to be performed in a more intuitive fashion.