Early outcomes of robotic-assisted inguinal hernia repair in obese patients: a multi-institutional, retrospective study.

BACKGROUND: Minimally invasive inguinal hernia repair (IHR) in general and particularly in obese patients has not been widely adopted, potentially due to the perceived technical challenges and the well-documented learning curve associated with laparoscopic repair. Outcomes in robotic-assisted IHR in obese (BMI ≥ 30 kg/m2) patients have not been described and warrant study. METHODS: Seven surgeons conducted a multicenter retrospective chart review of their early robotic-assisted IHR (RHR) cases and compared them with their open IHR (OHR) cases. Demographics, operative characteristics, and perioperative morbidity were compared for unadjusted and propensity-matched populations. RESULTS: 651 robotic-assisted cases and 593 open cases were collected. The outcomes of 148 RHRs to 113 OHRs in obese patients were compared. For obese populations-whether unadjusted (robotic-assisted, n = 148; open, n = 113) or matched (1:1) (robotic-assisted, n = 95; open, n = 93)-the robotic-assisted and open cohorts were comparable in terms of demographics and baseline characteristics. Significantly higher percentages of OHR patients experienced postoperative complications post-discharge (unadjusted: 11.5% vs. 2.7%, p = 0.005; and matched: 10.8% vs. 3.2%, p = 0.047). More concomitant procedures and bilateral repairs were conducted in obese RHR patients than in obese OHR patients (unadjusted 29.7% vs. 16.8%, p = 0.019; and unadjusted 35.1% vs. 11.5%, p < 0.0001-respectively). Prior laparoscopic IHR experience did not affect 30-day outcomes. CONCLUSIONS: Obese patients who undergo RHR have a lower rate of postoperative complications compared to obese patients who undergo OHR. Previous laparoscopic IHR experience, more bilateral repairs, and more concomitant procedures were not associated with increased complications in RHR patients. These outcomes may facilitate increased adoption of minimally invasive IHR approaches in the obese population.

Cosmesis, patient satisfaction, and quality of life after da Vinci Single-Site cholecystectomy and multiport laparoscopic cholecystectomy: short-term results from a prospective, multicenter, randomized, controlled trial.

BACKGROUND: Single-incision laparoscopic cholecystectomy evolved from the traditional multiport laparoscopic technique. Prior trials have demonstrated improved cosmesis with the single-incision technique. Robotic single-site surgery minimizes the technical difficulties associated with laparoscopic single-incision approach. This is the first prospective, randomized, controlled study comparing robotic single-site cholecystectomy (RSSC) and multiport laparoscopic cholecystectomy (MPLC) in terms of cosmesis and patient satisfaction. METHODS: Patients with symptomatic benign gallbladder disease were randomized to RSSC or MPLC. Data included perioperative variables such as operative time, conversion and complications and cosmesis satisfaction, body image perception, quality of life using validated questionnaires, at postoperative visits of 2, 6 weeks and 3 months. RESULTS: One hundred thirty-six patients were randomized to RSSC (N = 83) and MPLC (N = 53) at 8 institutions. Both cohorts were dominated by higher enrollment of females (RSSC = 78%, MPLC = 92%). The RSSC and MPLC cohorts were otherwise statistically matched. Operative time was longer for RSSC (61 min vs. 44 min, P < 0.0001). There were no differences in complication rates. RSSC demonstrated a significant superiority in cosmesis satisfaction and body image perception (P value < 0.05 at every follow-up). There was no statistically significant difference in patient-reported quality of life. Multivariate analysis of female patients demonstrated significantly higher preference for RSSC over MPLC in cosmesis satisfaction and body image perception with no difference seen in overall quality of life. CONCLUSIONS: Results from this trial show that RSSC is associated with improved cosmesis satisfaction and body image perception without a difference in observed complication rate. The uncompromised safety and the improved cosmesis satisfaction and body image perception provided by RSSC for female patients support consideration of the robotic single-site approach. ClinicalTrials.gov identifier NCT01932216.

Robotic-assisted ventral hernia repair: a multicenter evaluation of clinical outcomes.

BACKGROUND: The open approach continues to be widely performed for ventral hernia repair, while the minimally invasive laparoscopic approach has grown adoption over the last decade. Recently, robotic operation was described as a new modality due to the ease for performing intracorporeal closure of the hernia defect. This study is one of the first multi-institutional case series evaluating robotic-assisted laparoscopic ventral hernia repairs, with the goal of describing robotic-assisted surgical techniques for ventral and incisional hernia repair and the outcomes in teaching and community hospital settings. METHODS: Medical records of consecutive patients (including surgeon's learning curve cases) who underwent ventral or incisional hernia repair utilizing the da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale CA) were retrospectively reviewed. Data collected included preoperative history and perioperative outcomes. RESULTS: Data for a total of 368 patients from four institutions involving five surgeons were analyzed. They were predominantly females (60.3 %), and the mean age was 51 years. The majority of the patients were obese or morbidly obese (47.8 and 20.9 %), and 83.2 % of the patients had a history of prior abdominal operation. Conversion rate was 0.8 %, and mean length of stay was 1 day. Total postoperative complications rate up to 30 days was 8.4 %, of which incidence of paralytic ileus was 2.4 %. CONCLUSION: This large case series of 368 patients demonstrates reproducibility of safety and performance associated with robotic-assisted ventral hernia repairs performed by five surgeons at four institutions. In addition, the results of short term perioperative outcomes for surgeons during their early experience for robotic-assisted cases are in the range of what is reported in the existing published data on laparoscopic and open ventral hernia repairs. Further comparative evidence initiatives are being pursued to determine the benefits of robotic-assisted technique and technology for long-term and patient-reported outcomes.

A multicenter study of initial experience with single-incision robotic cholecystectomies (SIRC) demonstrating a high success rate in 465 cases.

BACKGROUND: Recently, the robotic single-site platform has been used to ameliorate the difficulties seen in single-incision laparoscopic surgery (SILC) while preserving the benefits of standard laparoscopic cholecystectomy. The purpose of this study is to describe the clinical outcomes of a large series of single-incision robotic cholecystectomy (SIRC). METHODS: Medical records of consecutive patients who underwent SIRC were retrospectively reviewed. All procedures were performed by six surgeons at five different North American centers involved in the study. All patients included in the study underwent a cholecystectomy attempted through single site at the umbilicus, using the da Vinci(®) Surgical System (Intuitive Surgical Inc. Sunnyvale, CA). RESULTS: A total of 465 patients met study criteria. Median age was 48 years (range 18-89); 351 (75.5 %) were female and 304 (66.4 %) were overweight or obese. Except for gender, case characteristics differed significantly by surgeon/site. Previous abdominal surgery was reported for 226 (48.6 %) cases. SIRC was successfully completed in 455 (97.8 %) cases, and there were no conversions to open surgery. Median surgical time was 52 min with a decreasing trend after 55-85 cases. Male gender, obesity and diagnoses other than biliary dyskinesia were independent predictors of longer surgical times. The complication rate was 2.6 %. CONCLUSIONS: Our large, multicenter study demonstrates that robotic single-site cholecystectomy is safe and feasible in a wide range of patients.

Does robotic-assisted transabdominal preperitoneal (R-TAPP) hernia repair facilitate contralateral investigation and repair without compromising patient morbidity?

Inguinal hernia repair (IHR) is performed through either an open or minimally invasive approach (MIS). MIS allows for exploration and potential repair of an occult contralateral hernia. The aim of this study is to evaluate complications associated with intraoperative contralateral exploration and repair through robotic-assisted (da Vinci®) IHR. 652 robotic-assisted inguinal hernia procedures were uniformly and retrospectively collected from seven surgeons. Incidental contralateral findings were evaluated and populations with and without contralateral findings were compared in terms of demographics, operative characteristics and complications. This case series includes the earliest cases in each surgeon's robotic-assisted IHR experience. Seventy-one percent (71%) of patients presented with a unilateral hernia. Intraoperative/incidental contralateral ("occult") hernias were found in 12.3% of patients with a unilateral diagnosis. For patients with and without contralateral findings, there were no significant differences in demographics and baseline health characteristics. Perioperative morbidity was statistically similar between groups: intraoperative complications (0 vs 0.5%, p = 1.000), postoperative complications prior to discharge (0 vs 3.2%, p = 0.38) and from discharge through 30 days (5.3 vs 4.0%, p = 0.72), as well as readmissions and reoperations related to the repair within 30 days. Differences in setting of care, length of stay, rate of blood transfusions, concomitant procedures and conversions were nonsignificant. Mean operative time was longer in patients with a contralateral hernia by 19 min (p < 0.0001). Intraoperative contralateral exploration and subsequent repair during robotic-assisted IHR does not compromise perioperative patient morbidity. These study results support the increasing evidence for repair of contralateral, incidentally discovered inguinal hernias.Clinicaltrials.Gov ID number: NCT02684448.

Laparoscopic vs Robotic Intraperitoneal Mesh Repair for Incisional Hernia: An Americas Hernia Society Quality Collaborative Analysis.

BACKGROUND: Robotic intraperitoneal mesh placement (rIPOM) has emerged recently as an alternative to laparoscopic intraperitoneal mesh placement (LapIPOM) for minimally invasive incisional hernia repair. We aimed to compare LapIPOM with rIPOM in terms of hospital length of stay (LOS) and 30-day postoperative complications in patients undergoing incisional hernia repair within the Americas Hernia Society Quality Collaborative. STUDY DESIGN: Propensity score analysis was used to compare matched groups of patients within the Americas Hernia Society Quality Collaborative undergoing LapIPOM vs rIPOM. The primary outcomes measure was hospital LOS and secondary outcomes were 30-day wound events. RESULTS: Four hundred and fifty-four (71.9%) patients underwent LapIPOM and 177 (28.1%) underwent rIPOM. The laparoscopic group had an increased median LOS (1 vs 0 days; interquartile range 3.00; p < 0.001). The risk of surgical site occurrence was higher in the LapIPOM group vs the rIPOM group (14% vs 5%; p = 0.001); however, surgical site occurrence requiring procedural intervention was similar between the groups (1% vs 0%; p = 1). Operative time longer than 2 hours was more common in the rIPOM group (47% vs 31%; p < 0.05). CONCLUSIONS: Despite longer operative times using the rIPOM approach, patients undergoing rIPOM had a significantly shorter LOS than LapIPOM, without additional risk of wound morbidity requiring intervention. Additional studies are necessary to identify the best candidates for the rIPOM approach.

Mucinous cystic neoplasms of the pancreas.

Mucinous cystic neoplasms of the pancreas (MCNP) are rare tumors with presentation and findings that differ in most cases from pancreatic pseudocysts. A simple pancreatic cystic lesion in a younger-aged patient with a history of pancreatitis and endoscopic retrograde cholangiopancreatography (ERCP) demonstration of ductal communication with the cyst strongly suggests the diagnosis of a benign pseudocyst. MCNP may have extensive areas without an epithelial lining, adding histologic sampling error to the potential for confusing these two entities. Pancreatic pseudocysts are benign lesions treated by enteric drainage procedures, while MCNP have significant malignant potential, and resection is advised. Even when clinical presentation and imaging are persuasive for a benign cyst, MCNP of the pancreas should be considered in planning, evaluation, and treatment.