Laparoscopic-Assisted Transvaginal Cholecystectomy - the US Military Experience With Long-Term Follow Up.

Objectives: We present our initial clinical experience applying Natural Orifice Transluminal Endoscopic Surgical (NOTES) technique to perform cholecystectomy in ten patients at a military institution. Methods: A posterior colpotomy was created to accommodate a single site working port used to facilitate dissection and gallbladder mobilization under direct visualization via an infraumbilical port. The specimen was retrieved through the vagina and the colpotomy was closed with absorbable suture under direct visualization. Long-term follow up was performed over the phone to assess quality of life with 2 widely used health-related quality of life (HRQoL) surveys including RAND-36 Health Item Survey (Version 1.0),1 and the Female Sexual Function Index (FSFI).2. Results: Ten women underwent a laparoscopic-assisted transvaginal cholecystectomy (TVC) with 7 available for long-term follow-up. The average age was 28.9 years (20-37) and the indications for surgery included symptomatic cholelithiasis (9) and biliary dyskinesia (1). The mean operative time was 129 mins (95-180), and median blood loss was 34 ml (5-400). There were no conversions and the average length of stay was 9.98 hours (2.4-28.8). Pain (analogue scale 1-10) on postoperative day three was minimal (mean 2.3) and was limited to the infraumbilical incision. On average patients returned to work by postoperative day six and resumed normal daily activities at seven days. Immediate postoperative complications included one incident of postoperative urinary retention requiring bladder catheterization. One intra-operative cholangiogram was successfully performed due to elevated preoperative liver enzymes without significant findings. Long-term complications included one asymptomatic incisional hernia repair at the infraumbilical port site. The RAND-36 survey demonstrated an average physical and mental health summary score of 82.2 and 63.7 with an average general health score of 63.6. The average FSFI total score was 21.8. Conclusion: TVC is safe and effective. Implementation may improve operational readiness by returning service members to normal activities more expeditiously than conventional laparoscopy.

Surgical tele-mentoring using a robotic platform: initial experience in a military institution.

BACKGROUND: Surgical tele-mentoring leverages technology by projecting surgical expertise to improve access to care and patient outcomes. We postulate that tele-mentoring will improve surgeon satisfaction, procedural competence, the timeliness of operative intervention, surgical procedure efficiency, and key intra-operative decision-making. As a first step, we performed a pilot study utilizing a proof-of-concept tele-mentoring process during robotic-assisted surgery to determine the effects on the perceptions of all members of the surgical team. METHODS: An IRB-approved prospective feasibility study to determine the safety and efficacy of remote surgical consultation to local surgeons utilizing robotic surgery technology in the fields of general, urology, gynecology and thoracic surgery was performed. Surgical teams were provided a pre-operative face-to-face orientation. During the operation, the mentoring surgeon was located at the same institution in a separate tele-mentoring room. An evaluation was completed pre- and post-operatively by the operative team members and mentor. RESULTS: Fifteen operative cases were enrolled including seven general surgery, four urology, one gynecology and three thoracic surgery operations. Surveys were collected from 67 paired survey respondents and 15 non-paired mentor respondents. Participation in the operation had a positive effect on participant responses regarding all questions surveyed (p < 0.05) indicating value to tele-mentoring integration. Connectivity remained uninterrupted with clear delivery of audio and visual components and no perceived latency. Participant perception of leadership/administrative support was varied. CONCLUSIONS: Surgical tele-mentoring is safe and efficacious in providing remote surgical consultation to local surgeons utilizing robotic surgery technology in a military institution. Operative teams overwhelmingly perceived this capability as beneficial with reliable audio-visual connectivity demonstrated between the main operative room and the Virtual Medical Center. Further study is needed to develop surgical tele-mentoring to improve patient care without geographic limitations during times of peace, war and pandemic outbreaks.

Does Liposomal Bupivacaine Decrease Postoperative Opioid Use in Conjunction with an Enhanced Recovery After Bariatric Surgery Pathway? A Prospective, Double-blind, Randomized Controlled Trial.

BACKGROUND: Minimization of opiate use is an important focus in the setting of the severe national opioid crisis. This study evaluated the role of liposomal bupivacaine (LB) in decreasing postoperative opioid use before and after implementation of a bariatric enhanced recovery after surgery (ERAS) program. METHODS: We performed an IRB-approved, prospective, double-blind, randomized controlled trial of LB versus plain bupivacaine (PB) in patients undergoing elective, minimally invasive, weight loss surgery at a comprehensive metabolic and bariatric surgery program from November 2017 to December 2019. Primary outcomes were postoperative morphine milligram equivalents per day (MME/day) and average subjective inpatient pain level. Secondary outcomes were length of hospital stay (LOS) and adverse events (AEs). RESULTS: Of the 100 patients enrolled, 78 were randomly assigned to LB (42) or PB (36). Thirty-four received the ERAS protocol, and 44 did not. The mean MME/day use did not differ significantly by the bupivacaine group [median, IQR PB: 20.3 (40.95); LB: 33.0 (42.9); p = .314], but it did differ by the ERAS group [median, IQR no ERAS 33.2 (47.1), ERAS 24.0 (34.0); p = .049]. Length of stay, inpatient pain score, and AEs did not differ significantly by either the bupivacaine or the ERAS group. CONCLUSIONS: In our study, liposomal bupivacaine did not significantly decrease postoperative opioid use either before implementation of ERAS or as part of an enhanced recovery after surgery program for minimally invasive bariatric surgery procedures.

Why the military committee is important to SAGES?

BACKGROUND: SAGES established a military committee in 2009 and since that time. It may not be readily clear why a traditionally laparoscopic and endoscopic surgical society should have a military committee whose members' primary mission is combat surgery. Military surgeons have a second mission, though, which is to provide care for all its beneficiaries in all the surgical subspecialties. They also have a third mission, which is to train the next generation of military surgeons. The aim of this paper is to discuss the relationship with SAGES that enables the military to succeed in these missions and the benefits it provides to SAGES. METHODS: A historical review of the military committee and its activities since its inception in 2009. RESULTS: Through SAGES, military surgeons have a cost-effective means of developing professionally and receiving education in surgical areas outside of the battlefield arena, which the DOD does not provide. For 13 years, SAGES has also provided an academic venue for research in these specialties. With the addition of military members, SAGES can access more surgeons and surgical innovation like surgery in space and worldwide telemedicine. The military committee also gives SAGES an opportunity to directly contribute to the care of military service members, retirees, and VA beneficiaries, which benefits the United States as a whole. CONCLUSIONS: SAGES and the military have enjoyed a mutually beneficial relationship. The contributions of SAGES have undoubtedly saved and improved US service member and beneficiary lives. It has also improved the education and academic advancements of the military surgeons. SAGES also reaches more surgeons and has another platform for surgical innovation. The relationship should continue and be allowed to grow.

Impact of the COVID-19 pandemic on American College of Surgeons-Accredited Education Institutes & American Society of Anesthesiologists-Simulation Education Network: Opportunities for interdisciplinary collaboration.

BACKGROUND: The COVID-19 pandemic presented challenges for simulation programs including American College of Surgeons Accredited Education Institutes and American Society of Anesthesiologists Simulation Education Network. American College of Surgeons Accredited Education Institutes and American Society of Anesthesiologists Simulation Education Network leadership were surveyed to identify opportunities to enhance patient safety through simulation. METHODS: Between January and June 2021, surveys consisting of 3 targeted domains: (I) Changing practice; (II) Contributions and recognition; and (III) Moving ahead were distributed to 100 American College of Surgeons Accredited Education Institutes and 54 American Society of Anesthesiologists Simulation Education Network centers. Responses were combined and percent frequencies reported. RESULTS: Ninety-six respondents, representing 51 (51%) American College of Surgeons Accredited Education Institutes, 17 (31.5%) American Society of Anesthesiologists Simulation Education Network, and 28 dually accredited centers, completed the survey. Change of practice. Although 20.3% of centers stayed fully operational at the COVID-19 onset, 82% of all centers closed: 32% were closed less than 3 months, 28% were closed 3 to 6 months, 8% were closed 7 to 9 months, and 32% remained closed as of June 6, 2021. Most impacted activities were large-group instruction and team training. Sixty-nine percent of programs converted in-person to virtual programs. Contributions. The top reported innovative contributions included policies (80%), curricula (80%), and scholarly work (74%), Moving ahead. The respondents' top concerns were returning to high-quality training to best address learners' deficiencies and re-engagement of re-directed training programs. When asked "How the American College of Surgeons/American Society of Anesthesiologists Programs could best assist your simulation center goals?" the top responses were "facilitate collaboration" and "publish best practices from this work." CONCLUSION: The Pandemic presented multiple challenges and opportunities for simulation centers. Opportunities included collaboration between American College of Surgeons Accredited Education Institutes and the American Society of Anesthesiologists Simulation Education Network to identify best practices and resources needed to enhance patient safety through simulation.

Surgical Management of a Chronic Neck Abscess in a U.S. Navy Bottlenose Dolphin.

Surgical intervention on cetaceans is rarely performed due to challenges including general anesthesia and post-operative wound healing. This report describes the evaluation and treatment of an adult female bottlenose dolphin (Tursiops truncatus) with the US Navy Marine Mammal Program, with a chronic ventral cervical abscess caused by Candida glabrata. Despite aspiration and lavage along with multiple antifungal drugs, the patient developed inspiratory stridor with decreased performance level and surgical treatment was pursued. Under general anesthesia with the dolphin in dorsal recumbency position a 12-cm longitudinal ventral midline neck incision was used for exploration. Intraoperative ultrasound aided the identification of surgical landmarks and the abscess cavity. After adequate drainage and curettage, a closed-suction drain was placed in the surgical site. Retention sutures were used to close the incision and the external drain bulb was secured to a pectoral fin strap. One-year post-op, the dolphin was clinically normal and follow-up imaging showed no significant recurrence of the abscess. This case demonstrates a novel surgical approach of managing abscesses in dolphins, including placement and management of a negative suction drain in a submerged patient. The successful collaboration between veterinary anesthesiology, veterinary medicine, radiology, and general surgery allowed the patient to continue her normal activities as a full-duty service member.

A multicenter study of routine versus selective intraoperative leak testing for sleeve gastrectomy.

BACKGROUND: Staple line leaks after sleeve gastrectomy are dreaded complications. Many surgeons routinely perform an intraoperative leak test (IOLT) despite little evidence to validate the reliability, clinical benefit, and safety of this procedure. OBJECTIVES: To determine the efficacy of IOLT and if routine use has any benefit over selective use. SETTING: Eight teaching hospitals, including private, university, and military facilities. METHODS: A multicenter, retrospective analysis over a 5-year period. The efficacy of the IOLT for identifying unsuspected staple line defects and for predicting postoperative leaks was evaluated. An anonymous survey was also collected reflecting surgeons' practices and beliefs regarding IOLT. RESULTS: From January 2010 through December 2014, 4284 patients underwent sleeve gastrectomy. Of these, 37 patients (.9%) developed a postoperative leak, and 2376 patients (55%) received an IOLT. Only 2 patients (0.08%) had a positive finding. Subsequently, 21 patients with a negative IOLT developed a leak. IOLT demonstrated a sensitivity of only 8.7%. There was a nonsignificant trend toward increased leak rates when an IOLT was performed versus when IOLT was not performed. Leak rates were not statistically different between centers that routinely perform IOLT versus those that selectively perform IOLT. CONCLUSIONS: Routine IOLT had very poor sensitivity and was negative in 91% of patients who later developed postoperative leaks. The use of IOLT was not associated with a decrease in the incidence of postoperative leaks, and routine IOLT had no benefit over selective leak testing. IOLT should not be used as a quality indicator or "best practice" for bariatric surgery.

Noninvasive positive pressure ventilation in the immediate post-bariatric surgery care of patients with obstructive sleep apnea: a systematic review.

BACKGROUND: Obstructive sleep apnea is common in morbidly obese patients, and noninvasive positive pressure ventilation (NIPPV) is the standard treatment. Postoperatively, NIPPV is highly effective in preventing hypoxia and apneic episodes; however, the concern of gastric distention leading to increased risk of an anastomotic dehiscence limits universal acceptance. OBJECTIVE: To perform a systematic review of the literature to determine if the use of NIPPV during immediate post-bariatric surgery care is safe. METHODS: Between January 1, 2000 and January 1, 2015 a comprehensive literature search for English-language articles was performed. Search terms were related to NIPPV use and bariatric surgery. Three reviewers independently reviewed the full-text version of the articles for relevance. Due to lack of randomized controlled trials and common incidence of zero for leak rate, a meta-analysis was not conducted. RESULTS: A total of 824 studies were identified for screening using our search criteria, and 811 were rejected based on exclusion criteria. Thirteen studies with 5465 patients were identified for abstract review. All articles were either favorable or equivocal on the use of NIPPV in this patient population. Comparative studies did not identify an increased rate of anastomotic dehiscence in the patients who did receive NIPPV. The use of NIPPV was associated with a decreased risk of respiratory complications but not of reintubation or unplanned intensive care unit admission. CONCLUSION: This systematic review of the available literature does not provide evidence of a signal that there is an increased anastomotic dehiscence risk when NIPPV is administered during immediate post-bariatric surgery care.

Comparison of laparoscopic sleeve gastrectomy to laparoscopic Roux-en-Y gastric bypass for morbid obesity in a military institution.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is gaining acceptance in the bariatric community as a definitive weight loss procedure; however, longitudinal data remain limited. The objective of this study was to compare weight loss results of LSG with laparoscopic Roux-en-Y gastric bypass (LRYGB) up to 5 years postoperatively using anthropometric measurements. METHODS: Prospectively collected bariatric database at the Naval Medical Center San Diego was retrospectively reviewed from 2005-2011 . Anthropometric factors, including weight and hip circumference were measured during standard yearly follow-up appointments. Surgical outcomes were tested by the Student t test and demographic variables by Fisher's exact and Wilcoxon rank-sum tests. RESULTS: Follow-up was achieved in 147/226 LRYGB versus 130/208 LSG at year 1, 92/195 versus 81/151 at year 2, 64/145 versus 50/100 at year 3, 32/81 versus 18/54 at year 4, and 12/42 versus 14/15 at year 5. The excess weight loss (EWL) for LRYGB versus LSG was 72% versus 64.7% at 1 year (P = .002), 71.3% versus 65.5% at 2 years (P = .113), and 68.3% versus 57.4% at 5 years (P = .252), respectively. Similarly, the body mass index (BMI) decrease was statistically significant at 1 year (P = .001) but not on subsequent annual visits. Mean percent body adiposity index (BAI) decrease was 28.4% for LRYGB versus 26.8% for LSG at 1 year (P = .679) and 21.8% versus 29.8% at 2 years (P = .134), respectively. Weight loss measured in terms of %EWL and decrease in BMI and BAI did not show significance between LRYGB and LSG 2 years after surgery. CONCLUSION: Our study provides similar long-term weight loss between LSG and LRYGB, and therefore, LSG is a viable option as a definitive bariatric procedure.