Less Morbidity with Robot-Assisted Gastric Bypass Surgery than with Laparoscopic Surgery?

INTRODUCTION: Although several studies have compared totally robot-assisted gastric bypass (RA-GB) to laparoscopic gastric bypass (L-GB), the clinical benefit of the robotic approach remains unclear. MATERIALS AND METHODS: We compared perioperative outcomes of 82 consecutive patients undergoing RA-GB between 2013 and 2016 to 169 consecutive patients having undergone L-GB between 2009 and 2016. Secondary endpoints included duration of hospitalization, readmission rate, weight loss at 1 year, and the learning curve of RA-GB, assessed by operation times and complication rates. RESULTS: There were no statistically significant differences between groups concerning age (43.5 ± 11.2 vs. 42.2 ± 12.4 years), body mass index (42.4 ± 5.0 vs. 43.6 ± 7.2 kg/m2), or comorbidities. The rate of revision surgery was higher in L-GB group without reaching statistical significance. No statistically significant difference was observed for duration of operation (134 ± 35 vs. 135 ± 37 min), readmission rate at 90 days (4.9% vs. 8.9%), or percentage of excess weight loss at 1 year (RA-GB vs. L-GB) (76.8% ± 20.5 vs. 73.1% ± 23.5). There were fewer statistically significant complications overall in RA-GB (9.8% vs. 21.9%, p = 0.019). Median duration of hospital stay was shorter for RA-GB (3 vs. 4 days, p < 0.0001). The mean duration of operation for RA-GB decreased from 153 min in 2014 to 122 min in 2016; p = 0.004. CONCLUSION: In our experience, the robotic approach for gastric bypass was associated with fewer postoperative complications compared to traditional laparoscopic gastric bypass. Cost increment associated with RA-GB remains an important drawback that hampers its widespread.

Operative start time may impact the quality of mesorectal excision in minimally invasive rectal surgery: retrospective analysis of 137 patients.

INTRODUCTION: Timing of major elective operations is a potentially important outcome variable. This study examined the impact of operative start time (OST) on pathologic and short-term outcomes of minimally invasive rectal surgery (MIRS). METHODS: All rectal tumors patients who underwent MIRS from May 2012 to April 2016 were identified. Peroperative outcomes and the oncological quality of surgical excision were compared between patients with OST before 13.00h and after. RESULTS: A total of 137 patients were included in the study (71 Romarobot-assisted and 66 conventional laparoscopic). Ninety-nine (72%) patients were operated before 13.00h and 38 after 13.00h. The majority of cases were low/middle rectal tumors (69%). Patient's baseline characteristics were quite similar in both groups. The rate of severe complication (p=0.460) or reoperation (p=0.614) was the same. Pathologic criteria (T or N stage, number of harvested lymph nodes, and presence of any positive margin) were the same between groups except for the quality of mesorectal excision (ME) that was significantly poorer for cases beginning after 13.00h (complete 91% vs 74%; p=0.016). The OST was found to be the only parameter associated with a poor quality of ME [OR 2.55 (1.08 - 6.36)]. CONCLUSION: Perioperative outcome after MIRS does not appear to be influenced by OST. Poorer quality of ME was observed and may thus raise important questions about the timing and sequence of case scheduling.

Is the image "right" for everyone? Introduction to the parallax effect in laparoscopic surgery.

AIM OF THE STUDY: During minimally invasive abdominal surgery, a laparoscope is used to film the procedure, which is transmitted to a flat screen monitor. The horizontality of the image depends on the orientation in space and the visual comfort of the surgeon. Observing the screen via a lateral angle of incidence frequently results in the camera assistant making errors in determining the horizontality of the image. Thus, what is "right" for the camera assistant is not necessarily 'right' for the surgeon. We aimed to explain the impact of these errors in laparoscope manipulation, by the description of the parallax effect. PATIENTS AND METHODS: To describe this phenomenon of perceptions changing depending on the angle of view, from the basis of the parallax effect, we observed the change of position and for two observers, (the surgeon and the camera assistant) seated at two different locations, using an experimental set up (i.e., photography equipment, a screen and a pelvitrainer). RESULTS: The position of the camera assistant positioned at an angle of incidence of 45° from the surgeon, the observation of the screen with a lateral incidence changes the perception of the image viewed on the screen. For correcting the conflict between the subjective visual perception of the camera assistant and the actual image horizon, the camera assistant instinctively rotates the image, which can lead to an "incorrect" image, deleterious for the surgeon. CONCLUSIONS: This article introduces a previously unexplained concept in medical literature, called the parallax effect. The parallax effect results in the camera assistant making systematic errors in determining image horizontality on the screen.