A comparison of robotic enhanced-view totally extraperitoneal approach versus trans-abdominal retro-muscular approach for midline ventral hernias.

BACKGROUND: The evolution of midline ventral hernia repair has progressed from the open Rives-Stoppa technique to minimally invasive robotic approaches, notably the trans-abdominal retromuscular (TARM) and enhanced-view Totally Extraperitoneal (eTEP) methods. This study compares these two robotic techniques in repairing medium-sized midline ventral hernias. METHODS: A retrospective comparative study of electronic medical records from 2015 to 2021 was conducted on patients undergoing robotic TARM or eTEP at NYU Langone Hospital-Long Island. Data on demographics, comorbid conditions, surgical history, intraoperative details, hernia characteristics, and postoperative outcomes were analyzed. RESULTS: Both eTEP and TARM groups exhibited comparable outcomes regarding operative duration, hernia defect size, and overall complications. However, notable differences were observed in patients' BMI, implanted mesh area, mesh composition, and fixation techniques across the groups. The TARM group required a longer hospital stay (median: 1 day) in contrast to the eTEP group (median: 0 days). Additionally, eTEP patients indicated reduced postoperative pain scores (median: 2) compared to TARM (median: 3), with both differences being statistically significant (p < 0.001). CONCLUSION: The robotic eTEP approach is associated with lower post-operative pain scores, decreased hospital length of stay, and larger areas of mesh implantation as compared to the TARM approach. Other variables are largely comparable between the two techniques. LEVEL OF EVIDENCE: Level III.

Association Between Thenar Musculature and Carpal Tunnel Syndrome.

Background: Dynamic forces acting on the transverse carpal ligament (TCL) may influence the mechanics of the carpal tunnel (CT), thus affecting the occurrence of CT syndrome (CTS). Previous studies demonstrated an association between muscle overlying the CT and the diagnosis of CTS. Understanding the location of insertion/origin of the thenar musculature will allow mechanical analysis of the forces applied to the TCL during performance of individual tasks. Our purpose was to determine the location of muscle overlying the CT on magnetic resonance imaging (MRI) in CTS and controls. Methods: Case-control study of 21 normal adult wrist MRI scans. MRI measurements were performed on an axial cut at the level of the hook-of-hamate. Median nerve cross-sectional area (CSA), median nerve shape and increased signal intensity within the CT were associated with CTS. The amount and length of muscle crossing the midline and the CT on the same cut was measured and the association with the occurrence of CTS was analysed. Results: We found an inverse relationship between the amount of muscle crossing the midline and the size of the CT, and a direct relationship with occurrence of CTS p less than 0.01, but no differences regarding length of muscle crossing the midline. Conclusions: This study supports an association between the thenar musculature location relative to the CT and the predictors of CTS on MRI. Since the location of muscle origin/insertion is variable, their effect may differ accordingly, therefore, further study is needed to describe the exact location of origin/insertion and its differential dynamic or static effect on the pathogenesis of CTS. Level of Evidence: Level IV (Diagnostic).

Lateral hernia secondary to colorectal submucosal resection repaired by robotic-assisted approach: Case report.

INTRODUCTION AND IMPORTANCE: Lateral abdominal wall defects are a rare event and commonly result from iatrogenic causes and trauma. We report the first known case of flank hernia after endoscopic submucosal resection of a colonic polyp complicated by colonic perforation. CASE PRESENTATION: This is a case of a 50-year-old male who underwent endoscopic colonic resection complicated by perforation of the colon. Eight months later, he presented with an enlarging, asymptomatic left flank bulge. CT showed a large flank hernia which was successfully repaired using a robotic transabdominal preperitoneal (TAP) approach. CLINICAL DISCUSSION: The hypothesis is that the endoscopic resection with colonic perforation caused an iatrogenic injury to the abdominal wall creating a lateral abdominal hernia. Injury to abdominal wall musculature may take months to develop into a clinically apparent hernia. Flank hernias can be successfully repaired using a robotic minimally invasive approach. CONCLUSION: Flank bulge and hernias must be included or at least be considered as consequence of a potential complication from endoscopic colonic perforation. Surgeons and endoscopists must be aware of this potential complication and its latent presentation. This case stresses the importance of long-term outcomes monitoring, particularly with innovative procedures.

Neural Monitoring for Robotic Abdominal Wall Reconstruction.

INTRODUCTION: Positioning-related neural injuries are an inherent risk in surgery, particularly in robotic-assisted abdominal wall reconstruction because of unique patient positioning and increased operative times. The implementation of intraoperative neurophysiological monitoring should be considered in such cases. METHODS: This was a two-armed study with one prospective intervention group and one retrospective control group. All patients underwent robotic abdominal wall reconstruction at an academic center. The prospective arm underwent robotic reconstruction from January through July 2019. The retrospective database reviewed patients who underwent the same procedure from August 2015 through July 2018. Factors assessed included: demographics (age, gender, body mass index, comorbidities), surgical details (American Society of Anesthesiologists class, procedure, operative time, positioning), outcomes (length of stay, 30-d readmission, reoperation), and any new-onset intraoperative or postoperative neuropathy. Patients were seen in the clinic postoperatively at weeks 1 and 6. RESULTS: Ten patients were included in the prospective arm. All received intraoperative neurophysiological monitoring using somatosensory evoked potentials. They were compared with 47 patients in the retrospective arm who underwent surgery without intraoperative neurophysiological monitoring. One position-related neural response from baseline was detected intraoperatively in the prospective arm; however, there were no peripheral neurological symptoms present postoperatively. Two patients in the control group developed transient peripheral neuropathies that resolved within 6 weeks. Demographics, surgical procedures, and length of surgery were similar in both groups. The prospective group had a higher rate of preoperative neuropathy and intraoperative use of vasopressors. CONCLUSION: Incorporation of neurophysiological monitoring in robotic surgery is feasible and may lead to the prevention and reduction in positioning-related injuries.

Ciliary body metastasis from renal cell carcinoma successfully treated with intravitreal bevacizumab.

PURPOSE: To report an innovative new treatment option for ciliary body tumor metastasis from renal cell carcinoma treated with intravitreal bevacizumab. OBSERVATIONS: A 70-year-old Caucasian man presented with a ciliary body tumor as a result from metastasis from renal cell carcinoma. It was preferable to treat the ciliary body tumor in the least invasive manner possible based on the patient's health, systemic metastasis, and the invasiveness of local resection. The tumor was treated with intravitreal bevacizumab for attempted tumor regression. Complete tumor resolution occurred following three injections. CONCLUSIONS AND IMPORTANCE: There is no consensus on treatment for ciliary body metastases from renal cell carcinoma. Based on the successful result of our patient, intravitreal bevacizumab could be an acceptable treatment option for this type of intraocular tumor. It affords a relatively non-invasive method of tumor regression without undergoing major intraocular surgery.

Traumatic reopening of macular hole following successful surgical repair.

A 75-year-old Caucasian female with a full-thickness macular hole underwent a successful surgical repair. Vision improved from 20/400 to 20/30 after surgery. Two years later, the patient presented with a decreased vision after a fall onto her face with a reopened full-thickness macular hole. Vision decreased to 20/400 and then she underwent a second surgery with an internal limiting membrane peeling, which resulted in a second successful closure of her macular hole. Vision following the second surgery was 20/100. Reopening of a surgically repaired macular hole commonly follows cataract surgery, epiretinal membrane formation, and development of cystoid macular edema. This case demonstrates that surgically repaired macular holes may reopen after trauma as well.

Postoperative Endophthalmitis Caused by Staphylococcus haemolyticus following Femtosecond Cataract Surgery.

A 53-year-old Caucasian man underwent femtosecond cataract surgery and then presented with pain and hand motions vision 1 day following surgery. Anterior segment examination showed a 2-mm-layered hypopyon, a well-centered intraocular lens in the sulcus, and an obscured view to the fundus. B-scan ultrasonography showed significant vitritis and that the retina was attached. A tap and an injection of vancomycin 1 mg per 0.1 ml and of ceftazidime 2.25 mg per 0.1 ml were performed. The tap eventually yielded culture results positive for Staphylococcus haemolyticus, which was sensitive to vancomycin. We report a case of endophthalmitis that occurred on postoperative day 1 following complicated cataract surgery. This is an uncommon bacterium that is not widely reported in the literature as a cause of endophthalmitis in the postoperative period. We urge clinicians to consider S. haemolyticus as an offending agent, especially when the infection presents very early and aggressively in the postoperative period.