Global benchmarks in primary robotic bariatric surgery redefine quality standards for Roux-en-Y gastric bypass and sleeve gastrectomy.

BACKGROUND: Whether the benefits of the robotic platform in bariatric surgery translate into superior surgical outcomes remains unclear. The aim of this retrospective study was to establish the 'best possible' outcomes for robotic bariatric surgery and compare them with the established laparoscopic benchmarks. METHODS: Benchmark cut-offs were established for consecutive primary robotic bariatric surgery patients of 17 centres across four continents (13 expert centres and 4 learning phase centres) using the 75th percentile of the median outcome values until 90 days after surgery. The benchmark patients had no previous laparotomy, diabetes, sleep apnoea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI greater than 50 kg/m2, or age greater than 65 years. RESULTS: A total of 9097 patients were included, who were mainly female (75.5%) and who had a mean(s.d.) age of 44.7(11.5) years and a mean(s.d.) baseline BMI of 44.6(7.7) kg/m2. In expert centres, 13.74% of the 3020 patients who underwent primary robotic Roux-en-Y gastric bypass and 5.9% of the 4078 patients who underwent primary robotic sleeve gastrectomy presented with greater than or equal to one complication within 90 postoperative days. No patient died and 1.1% of patients had adverse events related to the robotic platform. When compared with laparoscopic benchmarks, robotic Roux-en-Y gastric bypass had lower benchmark cut-offs for hospital stay, postoperative bleeding, and marginal ulceration, but the duration of the operation was 42 min longer. For most surgical outcomes, robotic sleeve gastrectomy outperformed laparoscopic sleeve gastrectomy with a comparable duration of the operation. In robotic learning phase centres, outcomes were within the established benchmarks only for low-risk robotic Roux-en-Y gastric bypass. CONCLUSION: The newly established benchmarks suggest that robotic bariatric surgery may enhance surgical safety compared with laparoscopic bariatric surgery; however, the duration of the operation for robotic Roux-en-Y gastric bypass is longer.

Pericardiocentesis followed by thoracotomy and repair of penetrating cardiac injury caused by nail gun injury to the heart.

INTRODUCTION: Work site injuries involving high projectile tools such as nail guns can lead to catastrophic injuries. Generally, penetrating cardiac injuries are associated with a high mortality rate. PRESENTATION OF CASE: A construction worker was brought to the emergency room having sustained a nail gun injury to the chest. The patient was hypotensive, tachycardic with prominent jugular venous distention, and had a profound lactic acidosis. Bedside ultrasound confirmed the presence of pericardial fluid. Pericardiocentesis was performed twice using a central venous catheter inserted into the pericardial space, resulting in improvement in the patient's hemodynamics. Thereafter he underwent left anterolateral thoracotomy and repair of a right atrial laceration. He recovered uneventfully. DISCUSSION: Penetrating cardiac injuries caused by nail guns, although rare, have been previously described. However, pericardiocentesis, while retaining a role in the management of medical causes of cardiac tamponade, has been reported only sporadically in the setting of trauma. We report a rare case of penetrating nail gun injury to the heart where pericardiocentesis was used as a temporizing measure to stabilize the patient in preparation for definitive but timely operative intervention. CONCLUSION: We propose awareness that percardiocentesis can serve as a temporary life saving measure in the setting of trauma, particularly as a bridge to definitive therapy. To our knowledge, this represents the first reported case of catheter pericardiocentesis used to stabilize a patient until definitive repair of a penetrating cardiac injury caused by a nail gun.

How Informed is "Informed Consent" for Robotic Cardiothoracic Surgery?

OBJECTIVE: : The education of patients in the informed consent process remains a challenge for many surgeons. In cardiothoracic surgery, emerging minimally invasive techniques including robotics add another level of complexity to the patient education process. We sought to evaluate our patients' perceptions and informed knowledge after robotic-assisted cardiothoracic surgery. METHODS: : A survey containing questions designed to elicit patients' perceptions about robotic cardiothoracic surgery was given postoperatively by telephone 1 month to 12 months after surgery. The survey included questions about the type of procedure, function of the organ operated on, purpose of the operation, primary "surgeon" (robot vs. human), patients' opinion about robotic-assisted surgery, educational level, and socioeconomic background. Continuous variables are reported as mean ± SD. Continuous and categorical variables were compared using the Student t test and Pearson χ test, respectively. Ordinal variables were compared using the Mann-Whitney U test. P values of <0.05 were considered significant. RESULTS: : Between 2002 and 2007, 198 patients underwent robotic cardiothoracic surgery. One hundred fifty patients (76%) were contacted and 89 (45%) fully completed the survey. Of the respondents, there were 31 coronary artery bypasses, 33 pacemaker lead implantations, esophageal resections, 8 thymectomies, and 9 others. The mean age of the patients was 61.1 ± 15 years (range, 23-87) and there were 52 men (58.4%). A total of 96.6% of patients were satisfied with the information provided by the surgeon and 92.1% felt that they understood the information. The diagnosis, target organ, and procedure were correctly identified by 81 (91.0%), 83 (93.3%), and 76 (85.4%) of the patients, respectively. A total of 80 (89.9%) knew a robot was involved and 73.8% understood the role of the robot in the surgery. These results were independent of age, income, and education level achieved. CONCLUSIONS: : Overall, patients demonstrated an understanding of the role of the robot in their cardiothoracic surgery. Despite the increasing complexity of robotics, preoperative patient education can result in patients who are both satisfied and well educated about their cardiothoracic surgery procedures.