Bariatric Surgeon Ergonomics: A Comparison of Laparoscopy and Robotics.

INTRODUCTION: Bariatric surgery is routinely performed using laparoscopic and robotic approaches. Musculoskeletal injuries are prevalent among both robotic and laparoscopic bariatric surgeons. Studies evaluating ergonomic differences between laparoscopic and robotic bariatric surgery are limited. This study aims to analyze the ergonomic, physical, and mental workload differences among surgeons performing robotic and laparoscopic bariatric surgery. MATERIALS AND METHODS: All primary laparoscopic and robotic bariatric surgeries, Roux-en-Y gastric bypass, and sleeve gastrectomy between May and August 2022 were included in this study. Objective ergonomic analysis was performed by an observer evaluating each surgeon intraoperatively according to the validated Rapid Entire Body Assessment tool, with a higher score indicating more ergonomic strain. After each operation, surgeons subjectively evaluated their physical workload using the body part discomfort scale, and their mental workload using the surgery task load index. RESULTS: Five bariatric surgeons participated in this study. In total, 50 operative cases were observed, 37 laparoscopic and 13 robotic. The median total Rapid Entire Body Assessmentscore as a primary surgeon was significantly higher in laparoscopic (6.0) compared to robotic (3.0) cases (P < 0.01). The laparoscopic and robotic approaches had no significant differences in the surgeons' physical (body part discomfort scale) or mental workload (surgery task load index). CONCLUSIONS: This study identified low-risk ergonomic stress in surgeons performing bariatric surgery robotically compared to medium-risk stress laparoscopically. Since ergonomic stress can exist even without the perception of physical or mental stress, this highlights the importance of external observations to optimize ergonomics for surgeons in the operating room.

The Association of Preoperative Food Insecurity With Early Postoperative Outcomes After Bariatric Surgery.

INTRODUCTION: To assess the rate of food insecurity in patients undergoing bariatric surgery. To compare the rates of 30-d postoperative complications based on food security status. METHODS: Patients undergoing primary Roux-en-Y gastric bypass or sleeve gastrectomy between 7/2020 - 3/2022 were screened for food insecurity via telephone using questions from the Accountable Health Communities Health-Related Social Needs Screening Tool. Screens were matched to patient data and 30-d outcomes from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. RESULTS: In total, 213 (59%) of the 359 bariatric surgery patients were screened with 81 (38%) screening positive for food insecurity. Evaluation of preoperative variables based on food security status showed comparable age, body mass index, and comorbidity status. Food insecure patients were found to have an increased length of stay following surgery compared to food secure patients (P = 0.003). Food insecurity was not associated with higher rates of Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program reported 30-d postoperative complications including emergency department/urgent care visits (P = 0.34) and hospital readmissions (P = 0.94). CONCLUSIONS: Food insecurity was prevalent at 38% of the bariatric surgical population. Food insecure patients had a statistically longer length of stay after primary bariatric surgery but were not associated with an increased risk of 30-d complications. Future studies are needed to determine the mid-term and long-term effects of food insecurity status on bariatric surgical outcomes and the potential impact of food insecurity on length of stay.

Robotic Repair: An Alternative Technique for Rectus Diastasis and Abdominal Bulge Following DIEP Flap Breast Reconstruction.

BACKGROUND: The Deep Inferior Epigastric Artery Perforator (DIEP) flap is the gold standard in autologous breast reconstruction. Despite advances in perforator dissection, abdominal morbidity still occurs. Traditional rectus diastasis (RD), abdominal bulge, and hernia repair with open techniques are associated with higher complication rates and recurrence. OBJECTIVES: We present a novel case series of robotic repair of symptomatic RD and/or abdominal bulge with concurrent hernia following DIEP flap surgery. METHODS: A single-center, retrospective review was conducted on 10 patients who underwent bilateral DIEP flap breast reconstruction and subsequent robotic repair of RD and/or abdominal bulge and hernia. Pre-operative demographics and post-operative clinical outcomes were reviewed. RD up to 5 cm, abdominal bulge, and any concurrent ventral/umbilical hernias were repaired robotically via retrorectus plication and macroporus mesh reinforcement. RESULTS: The average age and BMI were 49 years (range 41-63) and 31 kg/m2 (range 26-44), respectively. The average number of perforators harvested per flap was 2.5 (range 1-4). Average RD and hernia size were 3.95 cm (range 2-5) and 5.8 cm2 (1-15), respectively. Eight patients stayed one night in the hospital, two went home the same day as the robotic repair. No patients converted to open technique and none experienced complications within 30 days. CONCLUSIONS: For the patients who experience donor site morbidity following DIEP flap breast reconstruction, minimally invasive robotic repair of RD and/or abdominal bulge with hernia can be performed with mesh reinforcement. This technique is effective with low complication rates and should be considered over open repair.

Effectiveness of Body Mass Index-Based Prophylactic Enoxaparin Dosing in Bariatric Surgery Patients.

INTRODUCTION: Enoxaparin is administered for venous thromboembolic (VTE) prophylaxis in bariatric surgery patients. There is concern whether body mass index (BMI)-based enoxaparin dosing consistently achieves prophylactic targets in patients with severe obesity. METHODS: This retrospective study included patients who underwent bariatric surgery at an academic medical center from Jan 2015-May 2021 and had an anti-Xa level drawn 2.5-6 h after ≥3 doses of BMI-based prophylactic enoxaparin. The primary outcome was the percentage of patients who achieved a target anti-Xa level. Secondary outcomes were prevalence of venous thromboembolic and bleeding events within 30 d post-operatively. RESULTS: Overall, 137 patients were included. Mean BMI was 59.1 ± 10.4 kg/m2, mean age was 43.9 ± 13.3 y and 110 patients (80.3%) were female. Target anti-Xa levels were achieved in 116 patients (84.7%); 14 (10.2%) were above target and 7 (5.1%) were below target. Patients with above target anti-Xa levels were significantly shorter in height than those within target range (167.1 versus 159.8 cm, P = 0.003). Five patients (3.6%) had a bleeding event; no thromboembolisms occurred. Anti-Xa levels correlated more strongly with enoxaparin dose per unit estimated blood volume (EBV) than dose per unit BMI (Rho = 0.54 versus Rho = 0.33). CONCLUSIONS: Target range anti-Xa levels were achieved in 85% of patients using BMI-based enoxaparin dosing. Patients with above target anti-Xa levels were significantly shorter by nearly 3 inches, suggesting an increased risk of overdosing enoxaparin in shorter, obese patients. An EBV-based dosing regimen may better account for patient height and is supported by a greater correlation with anti-Xa levels with dosing based on EBV than BMI.

Robotic simulation: validation and qualitative assessment of a general surgery resident training curriculum.

BACKGROUND: The da Vinci skills simulation curriculum has been validated in the literature. The updated simulator, SimNow, features restructured exercises that have not been formally validated. The purpose of this study is to validate the SimNow resident robotic basic simulation curriculum. This study also consists of a qualitative assessment that gives greater insight into the learner's experience completing the robotic curriculum. METHODS: There were 18 participants in this study: 6 novices, 6 competent surgeons, and 6 expert surgeons. The curriculum comprised 5 exercises; participants completed three consecutive scored trials. Computer-derived performance metrics were recorded. The NASA Task Load Index survey was used to assess subjective mental workload. Subjects were asked a series of open-ended questions regarding their experience that were recorded and transcribed. Codes were identified using an inductive method, and themes were generated. RESULTS: Performance metrics were significantly different between novice versus competent and expert surgeons. There was no significant difference in any score metric between competent and expert surgeons. On average, overall score percentages for competent and expert surgeons were between 90.4 and 92.8% versus 70.5% for novices (p = 0.02 and p = 0.01). Expert surgeons perceived a higher level of performance completing the exercises than novice surgeons (15.8 vs. 45.8, p = 0.02). Participants noted a similar robotic experience, utilizing efficiency of motion and visual field skills. Participants agreed on exercise strengths, exercise weaknesses, and software limitations. Competent and expert surgeons were better able to assess the exercises' clinical application. CONCLUSIONS: The SimNow curriculum is a valid simulation training as part of a general surgery resident robotic curriculum. The curriculum distinguishes between novices compared to competent and expert surgeons, but not between competent and expert surgeons. Clinical training level does not affect the experience and mental workload using the robotic simulator, except for competent and expert surgeons' ability to better assess clinical application.

Preparing for and passing the fundamentals of laparoscopic surgery (FLS) exam improves general surgery resident operative performance and autonomy.

BACKGROUND: The American Board of Surgery made the Fundamentals of Laparoscopic Surgery (FLS) exam a prerequisite for board certification in 2009. Some residency programs have questioned the need for a continued FLS testing mandate given limited evidence that supports the impact of FLS on intraoperative skills. The Society for Improving Medical Professional Learning (SIMPL) app is a tool to evaluate resident intraoperative performance. We hypothesized that general surgery resident operative performance would improve immediately after preparing for the FLS exam. METHODS: The national public FLS data registry was matched with SIMPL resident evaluations from 2015 to 2021 and de-identified. SIMPL evaluations are scored in three categories: supervision required (Zwisch scale 1-4, 1 = show and tell and 4 = supervision only), performance (scale 1-5, 1 = exceptional and 5 = unprepared), and case complexity (scale 1-3, 1 = easiest and 3 = hardest). Statistical analyses compared pre and post-FLS exam resident average operative evaluation scores. RESULTS: There were a total of 76 general surgery residents, and 573 resident SIMPL evaluations included in this study. Residents required more supervision in laparoscopic cases performed before compared to after the FLS exam (2.84 vs. 3.03, respectively, p = 0.007). Residents performance scores improved from cases before compared to after the FLS exam (2.70 vs. 2.43, respectively, p = 0.001). Case complexity did not differ before versus after the FLS exam (2.13 vs. 2.18, respectively, p = 0.202). PGY level significantly predicted evaluation scores with a moderate correlation. A sub analysis grouped by PGY level revealed a significant improvement after the FLS exam in supervision among PGY-2 residents (2.33 vs. 2.58, respectively, p = 0.04) and performance among PGY-4 residents (2.67 vs 2.04, respectively, p < 0.001). CONCLUSIONS: Preparation for, and passing, the FLS exam improves resident intraoperative laparoscopic performance and independence. We recommend taking the exam in the first two years of residency to enhance the laparoscopic experience for the remainder of training.

Enhancing robotic efficiency through the eyes of robotic surgeons: sub-analysis of the expertise in perception during robotic surgery (ExPeRtS) study.

BACKGROUND: Robotic technology affords surgeons many novel and useful features, but two stereotypes continue to prevail: robotic surgery is expensive and inefficient. To identify educational opportunities and improve operative efficiency, we analyzed expert commentary on videos of robotic surgery. METHODS: Expert robotic surgeons, identified through high case volumes and contributions to the surgical literature, reviewed eight anonymous video clips portraying key portions of two robotic general surgery procedures. While watching, surgeons commented on what they saw on the screen. All interactions with participants were in person, recorded, transcribed, and subsequently analyzed. Using content analysis, researchers double-coded each transcript applying a consensus developed codebook. RESULTS: Seventeen surgeons participated. The average participant was male (82.4%), 47 (SD = 6.6) years old, had 13.2 (SD = 8.23) years of teaching experience, worked in urban academic hospitals (64.7%) and had performed 643 (SD = 467) robotic operations at the time of interviews. Emphasis on efficiency (or lack thereof) surfaced across three main themes: overall case progression, robotic capabilities, and instrumentation. Experts verbally rewarded purposeful and "ergonomically sound" movements while language reflecting impatience with repetitive and indecisive movements was attributed to presumed inexperience. Efficient robotic capabilities included enhanced visualization, additional robotic arms to improve exposure, and wristed instruments. Finally, experts discussed instrument selection with regards to energy modality, safety features, cost, and versatility. CONCLUSION: This study highlights three areas for improved efficiency: case progression, robotic capabilities, and instrumentation. Development of education materials within these themes could help surgical educators overcome one of robotic technology's persistent challenges.

Implementation of a standardized multimodal pain regimen significantly reduces postoperative inpatient opioid utilization in patients undergoing bariatric surgery.

BACKGROUND: Routine opioid use in surgical patients has received attention given the opioid epidemic and a renewed focus on the dangers and drawbacks of opioids in the postoperative setting. Little is known about opioid use in bariatric surgery, especially in the inpatient setting. We hypothesize that a standardized opioid-sparing protocol reduces postoperative inpatient opioid use in bariatric surgery patients. METHODS: A retrospective cohort study was conducted of bariatric surgery patients at a single institution. From March to September 2019, a standardized intraoperative and postoperative opioid-sparing protocol was designed and implemented along with an educational program for patients regarding safe pain management. Inpatient opioid utilization in patients undergoing surgery in the preintervention phase between April and March 2019 was compared to patients from a postintervention phase of October 2019 to December 2020. Opioid utilization was measured in morphine milliequivalents (MME). RESULTS: A total of 359 patients were included; 192 preintervention and 167 postintervention. Patients were similar demographically. For all patients, mean age was 44.1 years, mean BMI 49.2 kg/m2, and 80% were female. Laparoscopic sleeve gastrectomy was performed in 48%, laparoscopic gastric bypass in 34%, robotic sleeve gastrectomy in 17%, and robotic gastric bypass in 1%. In the postintervention phase inpatient opioid utilization was significantly lower [median 134.8 [79.0-240.8] MME preintervention vs. 61.5 [35.5-150.0] MME postintervention (p < 0.001)]. MME prescribed at discharge decreased from a median of 300 MME preintervention to 75 MME postintervention (p < 0.001). In the postintervention phase, 16% of patients did not receive an opioid prescription at discharge compared to 0% preintervention (p < 0.001). When examining by procedure, statistically significant reductions in opioid utilization were seen for each operation. CONCLUSION: Implementation of a standardized intraoperative and postoperative multimodal pain regimen and educational program significantly reduces inpatient opioid utilization in patients undergoing bariatric surgery.

Laparoscopic versus robotic inguinal hernia repair: 1- and 2-year outcomes from the RIVAL trial.

INTRODUCTION: Robotic inguinal hernia repair is growing in popularity among general surgeons despite little high-quality evidence supporting short- or long-term advantages over traditional laparoscopic inguinal hernia repair. The original RIVAL trial showed increased operative time, cost, and surgeon frustration for the robotic approach without advantages over laparoscopy. Here we report the 1- and 2-year outcomes of the trial. METHODS: This is a multi-center, patient-blinded, randomized clinical study conducted at six sites from 2016 to 2019, comparing laparoscopic versus robotic transabdominal preperitoneal (TAPP) inguinal hernia repair with follow-up at 1 and 2 years. Outcomes include pain (visual analog scale), neuropathic pain (Leeds assessment of neuropathic symptoms and signs pain scale), wound morbidity, composite hernia recurrence (patient-reported and clinical exam), health-related quality of life (36-item short-form health survey), and physical activity (physical activity assessment tool). RESULTS: Early trial participation included 102 patients; 83 (81%) completed 1-year follow-up (45 laparoscopic vs. 38 robotic) and 77 (75%) completed 2-year follow-up (43 laparoscopic vs. 34 robotic). At 1 and 2 years, pain was similar for both groups. No patients in either treatment arm experienced neuropathic pain. Health-related quality of life and physical activity were similar for both groups at 1 and 2 years. No long-term wound morbidity was seen for either repair type. At 2 years, there was no difference in hernia recurrence (1 laparoscopic vs. 1 robotic; P = 1.0). CONCLUSIONS: Laparoscopic and robotic inguinal hernia repairs have similar long-term outcomes when performed by surgeons with experience in minimally invasive inguinal hernia repairs.

The evolution of the general surgery resident operative case experience in the era of robotic surgery.

BACKGROUND: Robotic-assisted general surgery procedures are becoming commonplace, requiring more residency programs to establish training curricula for residents. Concerns exist regarding the impact this will have on surgical residents' operative case distribution in laparoscopic and open surgery. This study aimed to analyze the impact of a growing robotic operative case volume and established robotic surgery training curriculum on the general surgery resident operative experience. METHODS: The robotic surgery training curriculum at the Medical College of Wisconsin was established in 2017. ACGME operative case logs of residents from 2014 to 2020 were analyzed to determine resident participation in open, laparoscopic, and robotic cases. Case categories included alimentary tract, abdomen, endocrine, thoracic, pediatric, and trauma. A one-way analysis of variance (ANOVA) was used to analyze overall cases, as well as participation by case type, post-graduate year (PGY) level, resident role, and institution type. Statistical significance was defined as a p value < 0.05. RESULTS: Operative case logs from 77 residents were analyzed with a total of 34,757 cases: 59.3% open, 39.6% laparoscopic, and 1.1% robotic. There was no significant change in open or laparoscopic case volumes. However, there was a 3.4% increase in robotic cases, from 2014 to 2020 (p = 0.01), specifically in foregut (4.0%, p = 0.01), intestinal (1.6%, p = 0.03), and hernia (8.3%, p = 0.003) procedures. Academic (2.8%, p = 0.01) and veterans' hospital (2.0%, p = 0.01) institutions saw a significant increase in their residents' robotic cases. The only resident role with a significant increase in robotic cases was first assistant (8.0%, p = 0.004). There was no significant difference across PGY levels by surgical approach. CONCLUSIONS: This study highlights that the growth of robotic cases has not had a detrimental effect on the resident experience with open and laparoscopic cases. As robotic cases continually increase, the impact on laparoscopic and open case volumes must be monitored to ensure a well-balanced training experience.

Robotic surgery training curricula: prevalence, perceptions, and educational experiences in general surgery residency programs.

BACKGROUND: Utilization of robotics in general surgery has increased exponentially in the past decade. The purpose of this study was to provide an updated analysis of the prevalence of robotic training curricula among general surgery residency programs across the United States. METHODS: A 19-item survey was distributed to program directors of the Association of Program Directors in Surgery email list. The survey focused on the programs' demographics, program directors' opinions of robotic surgery, and status of robotic surgery curricula. Data was compiled and analyzed using Qualtrics Survey Software, Microsoft Excel and IBM SPSS. Chi-Squared statistical significance was defined as a p value of < 0.05. RESULTS: Of the 280 program directors, 107 (38.2%) responded. Overall, 75 (70%) residency programs provided a formal robotic surgery curriculum. Regarding the importance of robotics to general surgery training, 67 (89%) programs that provided a formal robotic surgery curriculum stated it was either 'Very important' or 'Probably important' as opposed to 23 (72%) programs that did not offer a formal robotic surgery curriculum (p = 0.017). 73 of the 75 residency programs with a formal robotic surgery training curriculum answered the curriculum specific questions. 58 (79%) had been present for 3 years or less. Bedside assisting began in 62 (85%) programs as a post-graduate year (PGY) 1 or PGY2 and residents began operating on the console as a PGY2 or PGY3 in 53 (72%) programs. However, there was variability regarding the percentage of the case a senior resident actually operated on the robotic console. CONCLUSIONS: A majority of general surgery residency programs offer formal robotic surgery curricula and have been present for 3 years or less. Most residencies begin their curricula in PGY1 or PGY2 year, with an opportunity to bedside assist and operate on the robotic console in the first 3 years of residency. Operative barriers and defined milestones for general surgery trainees need to be identified.

Examining current patterns of opioid prescribing and use after bariatric surgery.

BACKGROUND: Evidence-based guidelines on the appropriate amount of opioid medications to prescribe following bariatric surgery are lacking. We sought to determine our current opioid-prescribing practices, patient utilization, and satisfaction with pain control following elective bariatric surgery. METHODS: A retrospective chart review and phone survey were conducted on patients who underwent laparoscopic or robotic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from April 2018 to March 2019 at a single academic medical center. Opioid medications were converted to morphine milligram equivalents provided (MMEs). RESULTS: In total, 192 patients met inclusion criteria. The median amount of opioid medication prescribed on discharge was 300 oral MMEs, although there was a significant difference between the MMEs prescribed to patients with and without chronic opioid therapy (median 300 MMEs opioid naïve vs. 375 MMEs chronic opioid therapy, p = 0.01). Significantly fewer SG patients required a refill of their opioid medication compared to RYGB (8.3% vs. 23.9%, p = 0.003). Of the 192 patients, 87 (45.3%) completed the phone survey. Fifty-six patients (64%) reported that they took half or less of the initially prescribed opioids. Of the patients with leftover medication, 36% reported that they did not dispose of the medication. Overall understanding of pain control options after surgery was significantly lower in patients who felt they were prescribed "too little" opioids (p = 0.01), patients requiring refills (p = 0.02), and patients who were not satisfied with their pain control (p = 0.02). CONCLUSION: There is a gap between the amount of opioid medication prescribed and taken by patients following bariatric surgery in our practice. Patients who were least satisfied with their pain control reported knowledge gaps about pain control options that were more significant than patients who were more satisfied. Future initiatives should focus on the reduction of opioids prescribed to bariatric surgery patients post-operatively and on opioid education for patients.

Transversus abdominis plane blocks for complex abdominal wall reconstruction decrease hospital length of stay compared to epidurals.

BACKGROUND: Complex abdominal wall reconstruction for ventral and incisional hernias can be quite painful with prolonged length of stay (LOS). There are a variety of options to manage post-operative pain after a ventral hernia repair, including epidural catheters, transversus abdominis plane (TAP) blocks, and intravenous narcotic pain medications (IVPM). We hypothesized that TAP blocks with liposomal bupivacaine decrease the LOS compared to epidurals and IVPM. METHODS: A retrospective review of all patients who underwent an open ventral hernia repair with retromuscular mesh between 2016 and 2020 was conducted. LOS was used as the primary outcome. Secondary outcomes included post-operative pain and 90-day post-operative complications. RESULTS: An epidural was used in 66 patients, a TAP block with liposomal bupivacaine in 18 patients, and IVPM in 11 patients. The epidural group was noted to have a significantly longer duration of surgery (251.11 vs. 207.94 min; P < 0.05) and larger area of mesh (461.85 vs. 338.17 cm2; P < 0.05) when compared to the TAP block group. Hospital LOS was significantly shorter for the TAP block group compared to the epidural group (4.22 vs. 5.62 days; P < 0.05). There were no differences in post-operative complications between the groups. The epidural group reported significantly lower post-operative day one (POD1) pain scores measured on a 10-point scale, compared to the IVPM and TAP block groups (5.00 vs. 6.91 vs. 7.50; P < 0.05). CONCLUSION: Patients who received a TAP block for post-operative pain management had a significantly shorter length of stay compared to those patients who received an epidural. While the TAP block group reported higher POD1 pain scores, they did not have a significant difference in post-operative complications. TAP blocks with liposomal bupivacaine should be considered for post-operative pain control in complex ventral hernia repairs.

The Impact of Hemoglobin A1c on Post-operative Outcomes in Bariatric Surgery Patients.

INTRODUCTION: Pre-operative hemoglobin (Hb) A1c levels ≥ 8% can lead to increased post-operative complications. In bariatric surgery patients, attaining a pre-operative HbA1c < 8% can be a challenge. The purpose of this study was to identify the association of pre-operative HbA1c on post-operative outcomes in bariatric surgery patients. MATERIAL AND METHODS: A retrospective chart review was conducted on diabetic patients (HbA1c ≥ 6.5%) who underwent primary bariatric surgery at a single institution between the years 2013 and 2019. Patients were divided into two groups based on their pre-operative HbA1c levels of < 8% and ≥ 8%. Univariate analyses were performed to determine an association between pre-operative HbA1c levels and post-operative outcomes. RESULTS: There were 351 primary diabetic bariatric surgery patients, 270 HbA1c <8%, and 81 HbA1c ≥ 8%. Procedure selection was significantly different between the HbA1c < 8% and HbA1c ≥ 8% group (49.3% sleeve, 50.4% bypass and 0.4% band versus 43.2% sleeve, 53.1% bypass and 3.7% band respectively, P < 0.04). There was no statistically significant difference in any 30-day post-operative outcome between the two groups. Post-operative HbA1c was significantly less in the HbA1c < 8% group at 3-6 month (6.0% ± 0.9 versus 7.4% ± 1.4, P <0.001) and 6-12 month (6.0% ± 1.1 versus 7.2% ± 1.4, P <0.001) follow-up. CONCLUSIONS: This study demonstrated no difference in post-operative outcomes of primary bariatric surgery patients based on a HbA1c cut-off of 8%. This highlights that bariatric surgery can be considered and safely performed in patients with a pre-operative HbA1c ≥ 8%.

Ten-year trends in minimally invasive hernia repair: a NSQIP database review.

BACKGROUND: Utilization of minimally invasive techniques for ventral and inguinal hernia repairs continues to rise. The purpose of this study was to provide updates on national utilization trends and wound complications of minimally invasive versus open ventral and inguinal hernia repairs. METHODS: Data were accessed from the 2006 to 2017 National Surgical Quality Improvement Program database. All CPT codes that correlated to laparoscopic and open inguinal and ventral hernia repairs were queried. The total number of cases and wound complications, including superficial surgical site infection (SSI), deep SSI, organ space SSI, and wound dehiscence, was collected for each respective CPT code and compared for each year. IBM SPSS Statistics Software and Microsoft Excel were used to collect and analyze the data. RESULTS: Between 2009 and 2017, the percentage of minimally invasive inguinal hernia repairs increased from 23.1 to 37.8%, whereas the percentage of minimally invasive ventral hernias only increased from 31.5 to 36.6%. Open inguinal hernia repairs had a wound complication rate ranging from 0.60 to 0.74%, which was double the rate of minimally invasive repairs (0.24 to 0.49%) for nearly each respective year. Minimally invasive ventral hernia repairs had total wound complication rates ranging from 0.91 to 1.37%, whereas open ventral hernias had the highest total wound complication rates ranging from 5.07 to 6.26%. CONCLUSIONS: Over the last ten years, the utilization of minimally invasive inguinal and ventral hernia repair has increased by nearly two-fold. A larger proportion of this increase has been secondary to minimally invasive inguinal compared to ventral hernia repairs. Wound complications across all techniques remained stable or improved, and remained significantly less in the minimally invasive compared to open approaches. This study highlights the continued growth of minimally invasive techniques in hernia repair over the last decade.

The impact of nausea on post-operative outcomes in bariatric surgery patients.

INTRODUCTION: The evaluation and treatment of post-operative nausea in bariatric surgery patients has not been standardized. In this patient population, nausea can have a significant impact on quality outcomes. The primary objective of this study was to determine the impact of nausea on post-operative outcomes in bariatric surgery patients. METHODS: A retrospective chart review was conducted of adult patients who underwent a primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG) between 2014 and 2017 at a single institution. Patients with post-operative nausea were identified. Post-operative nausea was defined as patients who had nausea that was documented by multiple providers, and which interfered with their oral intake. Demographic variables were identified for patients with and without documented nausea. Univariate analyses were performed to determine the impact of post-operative nausea on patients' length of stay, readmissions, reoperations, and overall complications. RESULTS: There were 449 primary bariatric surgery patients in the study period, 197 (43.9%) LRYGB and 252 (56.1%) LSG. Of these patients, 160 (35.6%) had documented post-operative nausea. Demographic factors that contributed to post-operative nausea included African-American race and undergoing a LSG (p = 0.004 and p = 0.01, respectively). Patients who underwent a LSG had a 2.0 times increased risk of post-operative nausea compared to LRYGB (p = 0.01). Patients with documented nausea had a statistically significant increased length of stay (2.4 ± 1.9 days vs. 1.6 ± 1.0 days; p ≤ 0.01). Documented nausea patients had an increased incidence of Emergency Department visits within 30 days post-operatively (p = 0.02). CONCLUSIONS: Post-operative nausea was more likely in patients who underwent a sleeve gastrectomy. Gastric bypass and sleeve gastrectomy patients with documented nausea had an increased length of stay and Emergency Department visits. These results highlight the need for a metric to more accurately measure post-operative nausea, as well as a standardized anti-emetic treatment pathway to improve quality outcomes.

Postoperative Urinary Retention After Bariatric Surgery: An Institutional Analysis.

BACKGROUND: Postoperative urinary retention (POUR) can impact quality outcomes, leading to urinary tract infections, longer lengths of stay, and increased healthcare costs. The incidence of POUR in bariatric patients is unknown. Our primary objective was to determine the incidence and risk factors contributing to POUR in primary bariatric surgery. METHODS: A retrospective review was conducted on patients who underwent a laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2013 to 2017. POUR was defined as the inability to urinate postoperatively, requiring urinary catheterization. Univariate and multivariate analyses were performed on perioperative variables and their correlation with POUR. RESULTS: During the study period, 603 patients underwent surgery: 317 (52.6%) LSG and 286 (47.4%) LRYGB. Overall, 49 (8.1%) patients developed POUR. There were no significant differences in preoperative demographics between patients with and without POUR. Patients who underwent an LSG had an increased incidence of POUR compared with LRYGB (P = 0.002). In both procedures, POUR was associated with decreased neostigmine, isolated nondepolarizing muscle relaxant, and reduced intraoperative fluid. LSG and congestive heart failure, as well as LSG and body weight, were independently associated with POUR. Female patients who experienced POUR had significantly increased length of stay. CONCLUSIONS: Risk factors associated with POUR after primary bariatric surgery include LSG, less intraoperative neostigmine and intravenous fluids, and isolated nondepolarizing muscle relaxants. These risk factors can help educate patients and providers, as well as identify quality initiatives that focus on perioperative and anesthetic management to reduce POUR and length of hospital stay.

C-Reactive protein as a predictor of post-operative complications in bariatric surgery patients.

BACKGROUND: The primary objective of this study was to evaluate the utility of CRP in early identification of post-operative complications after bariatric surgery. The ability of this marker to acutely predict post-operative complications in bariatric surgery patients has not been determined. METHODS: A retrospective chart review was conducted of adult patients who underwent a primary and revisional laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG) between 2013 and 2017 at a single institution. Patients were identified using the prospective Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. CRP levels were drawn on post-operative day one per standard protocol. Univariate analyses were performed to determine the predictive impact of CRP levels on post-operative complications, readmissions, and reoperations. RESULTS: There were 275 patients who underwent bariatric surgery, 222 primary and 53 revisional. Of the 275 patients, 36 (13.1%) had a complication. Bariatric surgery patients with a post-operative complication had higher CRP levels compared to those who did not (4.8 ± 4.6 vs. 2.9 ± 2.0; p = 0.02). A CRP ≥ 5 mg/dL had a sensitivity for a complication of 27% and a specificity of 88%. There was no difference in CRP levels for patients with a 30-day reoperation or readmission. There were no mortalities. CONCLUSIONS: Bariatric surgery patients with elevated post-operative CRP levels are at increased risk for 30-day complications. The low sensitivity of a CRP ≥ 5 mg/dL suggests that a normal CRP level alone does not rule out the possibility of a post-operative complication. However, with its high specificity, there should be an elevated clinical suspicion of a post-operative complication in patients with a CRP ≥ 5 mg/dL.

Linear vs. circular-stapled gastrojejunostomy in Roux-en-Y gastric bypass.

BACKGROUND: Various surgical techniques exist to create the gastrojejunostomy during laparoscopic Roux-en-Y gastric bypass (LRYGB). Linear-stapled anastomosis (LSA) and circular-stapled anastomosis (CSA) are two commonly employed techniques. We hypothesized that CSA is associated with an increased rate of surgical site infection (SSI) and gastrojejunostomy stenosis when compared to LSA. METHODS: This study is a retrospective review of patients who underwent LRYGB for morbid obesity at a single institution between 2012 and 2016. Three bariatric surgeons contributed patients to this series. Clinical information and perioperative outcomes were collected through 90 days after surgery. RESULTS: 171 patients met the inclusion criteria. Two patients did not complete 90-day follow-up and were excluded from the analysis (88 patients CSA, 81 LSA; 99% 90-day follow-up). Patient demographics did not differ between groups. The LSA technique was associated with a significantly reduced rate of SSI (0 (0%) vs. 6 (6.8%), p = 0.02) and stenosis (2 (2.5%) vs. 17 (19.3%), p < 0.01). The CSA technique demonstrated a greater number of endoscopic dilations per stenotic event (1.5 ± 0.8 vs. 1.0 ± 0, p = 0.03). CONCLUSION: In our experience, a gastrojejunostomy constructed with an LSA technique was associated with a significantly reduced rate of stenosis and SSI compared to the CSA technique. LSA is currently our anastomotic technique of choice in LRYGB.

Peri-operative, intravenous clindamycin may improve the resolution rate of hypertension after Roux-en-Y gastric bypass in morbidly obese patients.

BACKGROUND: Recent studies have suggested that potential aberrant alterations in the gastrointestinal microbiome contribute to the development of cardiovascular disease, specifically hypertension. Bariatric surgery produces significant sustained weight loss and hypertension resolution likely through multiple mechanisms which includes beneficial changes in the gut microbiome. We hypothesized that the type of prophylactic antibiotic given for bariatric surgery could impact the resolution rate of hypertension by altering the post-operative gastrointestinal microflora. METHODS: A retrospective analysis of adult bariatric patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2012 and 2016 was conducted. The standard antibiotic prophylaxis was cefazolin, or clindamycin in patients with a penicillin allergy. Univariate analyses were performed comparing the differing peri-operative antibiotic treatments with resolution of hypertension at 2-week (± 1 week), 6-week (± 2 weeks), 3-month (± 2 weeks), 6-month (± 6 weeks), and 1-year (± 2 months) follow-up appointments. The criterion for resolution of hypertension was no longer requiring medication at time of follow-up. RESULTS: In total, 123 RYGB and 88 SG patients were included. No significant differences were found between cefazolin and clindamycin regarding hypertension resolution rates after SG. However, patients who underwent RYGB and received clindamycin had a significantly higher rate of hypertension resolution compared to cefazolin. This effect started at 2 weeks post-operatively (52.4% vs. 23.5% respectively, p = 0.008) and persisted up to the 1-year (57.9% vs. 44.0% respectively, p = 0.05). CONCLUSION: Prophylactic peri-operative, intravenous clindamycin was associated with significantly increased resolution of post-operative hypertension compared to cefazolin. This finding was not observed in SG patients. Future studies are needed to confirm the mechanism of action for this novel finding is due to the differing modifications of the gastrointestinal microflora after RYGB resulting from the specific peri-operative antibiotic administered.