Current status of resident simulation training curricula: pearls and pitfalls.

BACKGROUND: Residency programs are required to incorporate simulation into their training program. Ideally, simulation provides a safe environment for a trainee to be exposed to both common and challenging clinical scenarios. The purpose of this review is to detail the current state of the most commonly used laparoscopic, endoscopic, and robotic surgery simulation programs in general surgery residency education, including resources required for successful implementation and benchmarks for evaluation. MATERIALS AND METHODS: Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Resident and Fellow Task Force (RAFT) Committee performed a literature review using PubMed and training websites. Information regarding the components of the most commonly used laparoscopic, endoscopic, and/or robotic simulation curriculum, including both formal and informal benchmarks for evaluating training competence, were collected. RESULTS: Laparoscopic simulation revolves around the Fundamentals of Laparoscopic Surgery (FLS). Proficiency-based as well as virtual simulation have been utilized for FLS training curricula. Challenges include less direct translation to the technical complexities that can arise in laparoscopic surgery. Endoscopic simulation focuses on the Fundamentals of Endoscopic Surgery. There are virtual reality simulation platforms that can be used for skills assessment and training. Challenges include simulator types and access, as well as structured mentoring and feedback. Robotic simulation training curricula have not been standardized. Simulation includes one primary technology, which can be prohibitive based on cost and requirements for onboarding. CONCLUSIONS: While surgical simulation seems to be a fundamental and integrated part of surgical training, it requires a significant number of resources, which can be daunting for residency training programs. Regardless of the barriers outlined, the need for surgical simulation in laparoscopy, endoscopy, and robotics at surgical education training programs is clear.

Automated task-level autonomy assessment in robotic surgery.

INTRODUCTION: Surgical autonomy for trainees has remained elusive to quantify. Proportion of active control time (ACT) of a trainee during a robotic case can be used as a broad measure of autonomy. However, this metric lacks in the granular detail of quantifying at what specific steps trainees were actively participating. We aim to quantify trainee involvement during robotic-assisted hiatal hernia repair at a task-specific level. METHODS: We performed a retrospective review of surgical performance data from robotic-assisted hiatal hernia repairs performed. These cases were segmented into 5 tasks by AI-assisted annotation with human review. The segmented tasks included: hiatal dissection, gastric fundus mobilization, mediastinal dissection, cruroplasty and fundoplication. Tasks were excluded if video segmentation of tasks was incorrect. During each task, ACT was recorded for resident, fellow and attending. Resident and fellow ACT per task was compared using the Mann-Whitney U test. RESULTS: Residents had the highest %ACT in the hiatal dissection (53%), gastric fundus mobilization (84%) and fundoplication (57%) tasks. Fellows had greater than 80% ACT in all 5 tasks, with the highest %ACT in the gastric fundus mobilization (100%) and hiatal dissection (88%). There was a significant difference between resident and fellow ACT during mediastinal dissection and cruroplasty. CONCLUSIONS: This study demonstrates how objective performance metrics and automated case segmentation can quantify trainee participation at a task-specific level. By utilizing data afforded by a robotic surgery platform, we are able to provide an objective and automated form of assessment with minimal impact on the workflow of attendings and residents. Our findings can serve to inform residents on what steps they can expect to be involved in during the procedure, appropriate to their PGY level. With this task-level data, we can provide a roadmap for trainee progression to achieve full surgical autonomy.

Clinical Outcomes of a Large, Prospective Series of Gastric Electrical Stimulation Patients Using a Multidisciplinary Protocol.

BACKGROUND: Gastric electrical stimulation (GES) is an intervention used in the treatment of medically refractory gastroparesis. There are few large series demonstrating efficacy over a long-term follow-up period. This study reports clinical outcomes for patients from a single institution up to 5 years. STUDY DESIGN: A prospective database of patients undergoing GES implantation for gastroparesis was collected and reviewed. Patients were selected according to a multi-disciplinary institutional protocol. Baseline characteristics, including age, sex, smoking history, etiology of gastroparesis, and duration of gastroparesis symptoms, were collected. Symptomatic response was evaluated utilizing Gastroparesis Cardinal Symptom Index (GCSI) surveys pre-operatively and at subsequent follow-up visits. Other clinical outcome variables include medication use, hospitalizations due to gastroparesis, and overall satisfaction with symptom relief. Patient outcomes regarding reoperation and explantation were also recorded. RESULTS: 157 patients underwent GES at our institution since 2012. GCSI scores were collected in all patients at baseline, in 141 patients at 1 year follow-up, and in 110 patients at 5 years follow-up. Symptom severity in all 9 gastroparesis symptoms evaluated by the GCSI, as well as the total GCSI score, was reduced significantly at 1 year post-operatively, and these results were sustained at 5-year follow-up. Use of prokinetic and antiemetic medications was reduced during the follow-up period. Hospitalizations due to gastroparesis symptoms were also reduced. GES devices were explanted in 5 patients, 12 patients required generator exchanges, and 7 patients required reoperation due to displaced/eroded device leads during the study period. CONCLUSION: Gastric electrical stimulation is associated with sustained symptomatic relief, reduced reliance on medications, and reduced hospitalizations in gastroparesis patients selected utilizing our institutional protocol.

Perioperative Risk Factors for Persistent Postsurgical Pain After Inguinal Hernia Repair: Systematic Review and Meta-Analysis.

Persistent postsurgical pain (PPSP) is one of the most bothersome and disabling long-term complications after inguinal hernia repair surgery. Understanding perioperative risk factors that contribute to PPSP can help identify high-risk patients and develop risk-mitigation approaches. The objective of this study was to systematically review and meta-analyze risk factors that contribute to PPSP after inguinal hernia repair. The literature search resulted in 303 papers included in this review, 140 of which were used for meta-analyses. Our results suggest that younger age, female sex, preoperative pain, recurrent hernia, postoperative complications, and postoperative pain are associated with a higher risk of PPSP. Laparoscopic techniques reduce the PPSP occurrence compared to anterior techniques such as Lichtenstein repair, and tissue-suture techniques such as Shouldice repair. The use of fibrin glue for mesh fixation was consistently associated with lower PPSP rates compared to tacks, staples, and sutures. Considerable variability was observed with PPSP assessment and reporting methodology in terms of study design, follow-up timing, clarity of pain definition, as well as pain intensity or interference threshold. High or moderate risk of bias in at least one domain was noted in >75% of studies. These may limit the generalizability of our results. Future studies should assess and report comprehensive preoperative and perioperative risk factors for PPSP adjusted for confounding factors, and develop risk-prediction models to drive stratified PPSP-mitigation trials and personalized clinical decision-making. PERSPECTIVE: This systematic review and meta-analysis summarizes the current evidence on risk factors for persistent pain after inguinal hernia repair. The findings can help identify patients at risk and test personalized risk-mitigation approaches to prevent pain. PROSPERO REGISTRATION: htttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=154663.

A Capstone Course for Senior Medical Students: from Innovative Elective to Required Core Curriculum.

We describe our institution's development and implementation of our Capstone course from a small elective course to the only required fourth-year course. The course's structure evolved from mostly didactic to one including various workshops and simulation sessions. Course content has become increasingly specialty-specific. Implementation requires high faculty and resident involvement. Evaluations indicate a positive impact of the course on participants' self-reported confidence and residency preparedness. Assessment remains pass/fail with more specialty-specific questions. As steadily increasing numbers of medical schools are developing transition to residency courses, we share our Capstone course's evolution and lessons learned over the past nine years. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01880-2.

Successful Percutaneous Ultrasonic Lithotripsy of Gallstones.

Background: Acute calculous cholecystitis is the obstruction of the cystic duct by a gallstone that leads to inflammation of the gallbladder necessitating cholecystectomy. Case Series: We present the cases of 2 patients with acute calculous cholecystitis who were deemed ineligible candidates for cholecystectomy because of their complicating medical histories. Both patients initially underwent cholecystostomy and drain placement with interventional radiology for management of acute calculous cholecystitis. Their large gallstones remained refractory to attempts at removal by electrohydraulic lithotripsy via the cholecystostomy access. The patients' gallstones were successfully removed via percutaneous ultrasonic lithotripsy during a collaborative procedure with interventional radiology and urology. Conclusion: An interdisciplinary approach using percutaneous cholecystolithotomy with rigid ultrasonic lithotripsy is an effective method for removing challenging gallstones in patients for whom traditional approaches fail.

Practical Guide to Ethics in Surgical Education Research.

This Guide to Statistics and Methods describes ethical considerations when a study population includes learner participants.

Use of targeted educational resources to improve robotic bariatric surgery training.

BACKGROUND: Evidence for how to best train surgical residents for robotic bariatric procedures is lacking. We developed targeted educational resources to promote progression on the robotic bariatric learning curve. This study aimed to characterize the effect of resources on resident participation in robotic bariatric procedures. METHODS: Performance metrics from the da Vinci Surgical System were retrospectively reviewed for sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) cases involving general surgery trainees with a single robotic bariatric surgeon. Pictorial case guides and narrated operative videos were developed for these procedures and disseminated to trainees. Percent active control time (%ACT)-amount of trainee console time spent in active instrument manipulations over total active time from both consoles-was the primary outcome measure following dissemination. One-way ANOVA, Student's t-tests, and Pearson correlations were applied. RESULTS: From September 2020 to July 2021, 50 cases (54% SG, 46% RYGB) involving 14 unique trainees (PGY1-PGY5) were included. From November 2021 to May 2022 following dissemination, 29 cases (34% SG, 66% RYGB) involving 8 unique trainees were included. Mean %ACT significantly increased across most trainee groups following resource distribution: 21% versus 38% for PGY3s (p = 0.087), 32% versus 45% for PGY4s (p = 0.0009), and 38% versus 57% for PGY5s (p = 0.0015) and remained significant when stratified by case type. Progressive trainee %ACT was not associated with total active time for SG cases before or after intervention (pre r = - 0.0019, p = 0.9; post r = - 0.039, p = 0.9). It was moderately positively associated with total active time for RYGB cases before dissemination (r = 0.46, p = 0.027) but lost this association following intervention (r = 0.16, p = 0.5). CONCLUSION: Use of targeted educational resources promoted increases in trainee participation in robotic bariatric procedures with more time spent actively operating at the console. As educators continue to develop robotic training curricula, efforts should include high-quality resource development for other sub-specialty procedures. Future work will examine the impact of increased trainee participation on clinical and patient outcomes.

National ABSITE Preparation Practices: A Survey of General Surgery Residency Program Directors.

OBJECTIVE: The American Board of Surgery In-Training Examination (ABSITE) was designed as a low-stakes, medical knowledge examination for US general surgery residency programs. However, in practice, this exam has been utilized for higher stakes purposes, such as resident promotion or remediation, and fellowship selection. Several studies have demonstrated the efficacy of ABSITE preparation resources, but best practices for ABSITE preparation and national preparatory habits are currently unknown. The aim of this work was to determine current residency programs' strategies for ABSITE preparation. DESIGN: We distributed an electronic survey to program directors or program coordinators of US general surgery programs asking them to anonymously report program ABSITE educational practices and ABSITE scores. We analyzed the proportion of responses using descriptive statistics and compared the effect of various strategies using the Mann-Whitney testing for nonparametric data. An average ABSITE percentile score was calculated for each residency based on program self-reported scores. SETTING: Association of Program Directors (APDS) Listserv PARTICIPANTS: General surgery residency programs participating at the time of distribution (278). RESULTS: Response rate was 24% (66/278); 41 programs (62.1%) identified as university-affiliated, and 25 (37.9%) were community-based. Median intern class size was 8 (range: 3-14), including preliminary interns. Average ABSITE percentile score was 52.8% (range 36.9%-67.6%). There were no significant differences in ABSITE scores based on affiliation or program size. Educational resources utilized for ABSITE preparation included SCORE (89.3%), Q-banks (50%), and surgical textbooks (25.8%). The majority (56.1%) of programs reported using a year-long curriculum for ABSITE preparation, and 66.6% used a time-limited curriculum completed in the months immediately prior to ABSITE. Most programs reported that ABSITE scores were a low priority (63.6%) or not a priority (13.6%). The existence of a year-long curriculum for ABSITE was positively correlated with score as compared to programs without a year-long curricula (53.9% vs 48.5%, p <0.01). Programs using a time-limited curriculum demonstrated lower scores as compared to programs without time-limited curricula (51.3% v 56.1%, p < 0.01). CONCLUSION: General surgery programs use a variety of strategies to prepare residents for the ABSITE. Despite reporting that they utilize ABSITE scores for a variety of high stakes purposes including evaluation for promotion and as a predictor of the preparedness for the ABS QE, many programs reported that they consider ABSITE scores as a low priority. A year-long focused curriculum was the only strategy correlated with increased scores, which may reflect the value of encouraging consistent studying and spaced repetition. Additional work is needed to guide programs in optimal utilization of ABSITE scores for remediation and resident evaluation, as well as understanding how ABSITE preparatory strategies correlate with clinical performance.

The Advanced Certifying Exam Simulation-Pro assessment instrument: evaluating surgical trainee examsmanship in virtual oral exams.

Purpose: In response to the COVID-19 pandemic, many educational activities in general surgery residency have shifted to a virtual environment, including the American Board of Surgery (ABS) Certifying Exam. Virtual exams may become the new standard. In response, we developed an evaluation instrument, the ACES-Pro, to assess surgical trainee performance with a focus on examsmanship in virtual oral board examinations. The purpose of this study was two-fold: (1) to assess the utility and validity of the evaluation instrument, and (2) to characterize the unique components of strong examsmanship in the virtual setting, which has distinct challenges when compared to in-person examsmanship. Methods: We developed a 15-question evaluation instrument, the ACES-Pro, to assess oral board performance in the virtual environment. Nine attending surgeons viewed four pre-recorded oral board exam scenarios and scored examinees using this instrument. Evaluations were compared to assess for inter-rater reliability. Faculty were also surveyed about their experience using the instrument. Results: Pilot evaluators found the ACES-Pro instrument easy to use and felt it appropriately captured key professionalism metrics of oral board exam performance. We found acceptable inter-rater reliability in the domains of verbal communication, non-verbal communication, and effective use of technology (Guttmann's lambda-2 were 0.796, 0.916, and 0.739, respectively). Conclusions: The ACES-Pro instrument is an assessment with evidence for validity as understood by Kane's framework to evaluate multiple examsmanship domains in the virtual exam setting. Examinees must consider best practices for virtual examsmanship to perform well in this environment. Supplementary Information: The online version contains supplementary material available at 10.1007/s44186-023-00107-7.

Common Components of General Surgery Robotic Educational Programs.

OBJECTIVE: Robotically assisted surgery has become more common in general surgery, but there is limited guidance from the Accreditation Council for Graduate Medical Education (ACGME) regarding this type of training. We sought to determine common elements and differences in the robotic educational curricula developed by general surgery residency programs. DESIGN: Robotic educational curricula were obtained from the 7 individuals who presented at the workshop, "Robotic Education in General Surgery" at the 2023 Association of Program Directors in Surgery annual meeting. RESULTS: All 7 general surgery programs had training beginning intern year, required online robotic modules, had at least 1 dedicated simulation training console not used for clinical purposes, and ran dry and wet (tissue) robotic labs at least annually. All programs had bedside and console surgeon case minimums and had administrative support to run the educational programs. Differences existed regarding how training intern year was executed, the simulations required, clinical practice minimum requirements, how progress was monitored over time, and how case numbers were tracked. Some programs had salary support for a director of robotic education. CONCLUSIONS: There are several common elements to robotic educational curricula in general surgery, however significant variation does exist between programs. Given the frequency of robotic use in general surgery and current lack of standardization, formal guidance from the ACGME specifically regarding robotic education in general surgery residency is warranted.

How Does Robotic-Assisted Surgery Change OR Safety Culture?

Robotic-assisted techniques in surgery require complex equipment setup and create surgeon isolation through loss of normal operative visual and auditory exchanges. These changes demand enhanced team communication and feedback in operating room settings so that robotic-assisted surgery does not compromise safe, efficient surgical care. Diverse simulation and training methods should be incorporated and studied based on local needs to determine how these techniques influence operating room communication, workflow, and safety culture.

Active control time: an objective performance metric for trainee participation in robotic surgery.

Trainee participation and progression in robotic general surgery remain poorly defined. Computer-assisted technology offers the potential to provide and track objective performance metrics. In this study, we aimed to validate the use of a novel metric-active control time (ACT)-for assessing trainee participation in robotic-assisted cases. Performance data from da Vinci Surgical Systems was retrospectively analyzed for all robotic cases involving trainees with a single minimally invasive surgeon over 10 months. The primary outcome metric was percent ACT-the amount of trainee console time spent in active system manipulations over total active time from both consoles. Kruskal-Wallis and Mann-Whitney U statistical tests were applied in analyses. A total of 123 robotic cases with 18 general surgery residents and 1 fellow were included. Of these, 56 were categorized as complex. Median %ACT was statistically different between trainee levels for all case types taken in aggregate (PGY1s 3.0% [IQR 2-14%], PGY3s 32% [IQR 27-66%], PGY4s 42% [IQR 26-52%], PGY5s 50% [IQR 28-70%], and fellow 61% [IQR 41-85%], p = < 0.0001). When stratified by complexity, median %ACT was higher in standard versus complex cases for PGY5 (60% vs. 36%, p = 0.0002) and fellow groups (74% vs. 47%, p = 0.0045). In this study, we demonstrated an increase in %ACT with trainee level and with standard versus complex robotic cases. These findings are consistent with hypotheses, providing validity evidence for ACT as an objective measurement of trainee participation in robotic-assisted cases. Future studies will aim to define task-specific ACT to guide further robotic training and performance assessments.

Video Interviews and Surgical Applicants' Ability to Assess Fit to Residency Programs.

INTRODUCTION: Due to the COVID-19 pandemic, the recruitment cycle for the 2021 Match was performed virtually. This Association for Surgical Education (ASE)-sponsored survey set out to study applicants' ability to assess the factors contributing to fit through video interviews. METHODS: An IRB-approved, online, anonymous survey was distributed to surgical applicants at a single academic institution and through the ASE clerkship director distribution list between the rank order list certification deadline and Match Day. Applicants used 5-point Likert-type scales to rate factors for importance to fit and their ease of assessment through video interviewing. A variety of recruitment activities were also rated by applicants for their perceived helpfulness in assessment of fit. RESULTS: One hundred and eighty-three applicants responded to the survey. The three most important factors for applicant fit were how much the program cared, how satisfied residents seem with their program, and how well residents get along. Resident rapport, diversity of the patient population, and quality of the facilities were hardest to assess through video interviews. In general, diversity-related factors were more important to female and non-White applicants, but not more difficult to assess. Interview day and resident-only virtual panels were the most helpful recruitment activities, while virtual campus tours, faculty-only panels, and a program's social media were the least helpful. CONCLUSIONS: This study provides valuable insight into the limitations of virtual recruitment for surgical applicants' perception of fit. These findings and the recommendations herein should be taken into consideration by residency program leadership to ensure successful recruitment of diverse residency classes.

Active bystandership by youth in the digital era: Microintervention strategies for responding to social media-based microaggressions and cyberbullying.

Microaggressions are intentional or unintentional slights, insults, invalidations, and offensive behaviors that communicate hostile or derogatory messages to minoritized populations. When microaggressions cross over to social media, they can be considered a form of cyberbullying, which occurs over digital devices and harms, threatens, undermines, or socially excludes others. Microaggressions and cyberbullying have adverse mental health outcomes for racial and cultural minority youth, and there is an urgent need for practical strategies youth can use online to interrupt and disarm negative and harmful social media content. We used a multimethod approach to critically appraise and adapt Sue et al.'s (2019) microinterventions framework for use on social media with youth bystanders. Our analysis found high compatibility between microinterventions and youth bystander research, supporting transferability to social media for use with youth. Relevant adaptations include incorporating strategies that promote cognitive appraisal, cognitive empathy, education via social media, and use of social media features for external support. Using a social media microaggression example for each of the four microinterventions, we provide concrete tactics and example social media posts that youth can use when they come across insulting or offensive commentary online. The resulting framework offers a promising set of theory and research-informed strategies ready for further testing and refinement. When validated and refined, these microinterventions could be used as stand-alone strategies and/or incorporated into existing cyberbullying prevention or media literacy programs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The case for a new post-graduate hernia designation: a review of fellowship council case logs from the past twelve-years.

BACKGROUND: The Fellowship Council (FC) is a robust accreditation body with numerous fellowships; however, no specific criteria exist for hernia fellowships. This study analyzed the case log database to evaluate trends in fellowship exposure to hernia repairs. METHODS: FC hernia case log records (2007-2019) were coded as inguinal or ventral hernias and with or without mesh repair. Retrospective analysis examined total hernia repairs logged, type of repair, program designation, and robotic adoption. Robotic adoption was categorized by quartiles of program performance according to the final year of analysis (2018-2019); yearly performance was then graphed by quartiles. RESULTS: Over this twelve-year period, 93,334 hernia repairs, 5 program designations, 152 unique programs and 1,558 unique fellows were analyzed. The number of fellows grew from 106 (2007-2008) to > 130 (2018-2019). Total hernias repairs per fellow increased from an average of 41.2 in 2007-2008 to 75.7 in 2018-2019 (183.7%). Open and robotic hernia repairs increased by 241.9% and 266.3%, respectively; laparoscopic hernia repairs decreased by 14.8%. Inguinal and ventral hernia repairs comprised 48.1% and 51.9% of total cases, respectively. Advanced GI/MIS and Advanced GI/MIS/Bariatrics programs logged the majority of hernia repairs (86.0-90.2%). 2014 began an exponential rise in robotic adoption, with fellows averaging < 1 robotic repairs before and > 25 repairs in 2019. A significant difference was found between all groups when comparing quartiles of robotic adopters (median robotic repairs per fellow; IQR): first quartile (72.0; 47.9-108.8), second quartile (25.5; 21.0-30.6), third quartile (13.0; 12.0-14.3) and fourth quartile (3.5; 0.5-5.0) (p-value < 0.05). CONCLUSIONS: This twelve-year analysis shows a near doubling in the growth of total hernia repairs, with a decrease in laparoscopic repairs as robotic repairs increased. These data show the importance of hernia repairs in FC fellows' training and warrant further granular analysis to determine specific accreditation criteria for hernia fellowship designations.

The use of advanced robotic simulation labs to advance and assess senior resident robotic skills and operating room leadership competency: a pilot study.

BACKGROUND: General surgery has the fastest growing robotic operative volume in the United States, but most robotic curricula are focused on basic psychomotor skills. There are limited curricula focused on advanced robotic technical and related non-technical skills. We describe a novel pilot curriculum for robotic hiatal hernia repair developed for senior surgical residents to provide training and standardized assessment of higher-order robotic technical and leadership skills. METHODS: Twelve senior residents, post-graduate year (PGY) 4 & 5, participated in a robotic hiatal hernia repair skills curriculum. Residents completed a pre- and post-survey on confidence and ability ratings on a 5-point Likert-type Scale, and a knowledge assessment. An informal faculty-led didactic was provided prior to the simulation. Residents were scored on two validated assessment tools: Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) and Global Ratings Scale of Operative Performance (GRS) by faculty proctors. RESULTS: Confidence in ability to independently complete a robotic hiatal hernia case increased from mean of 2.6 ± 0.8 to 3.3 ± 0.6 (p = 0.0007). Following the simulation, residents reported increased overall confidence and ability to operate independently with mean scores of 3.3 ± 0.8 and 3.8 ± 0.9, respectively. Mean O-SCORE and GRS scores were 3.6 (range 2 - 4) and 25.4 (range 12 - 31), respectively. Number of prior live robotic cases was strongly positively correlated to O-SCORE (R = 0.84, p = 0.0006) and GRS (R = 0.88, p = 0.0002). CONCLUSION: Our pilot study suggests live-operative robotic training is not sufficient alone for advanced robotic skill training. Simulations such as this can be used to (1) practice advanced robotic technical and relevant non-technical skills such as communication and operating room leadership in a low stake setting and (2) assess residents in a standardized environment to eventually evaluate robotic competency.

Robotic median arcuate ligament release: management algorithm and clinical outcomes from a large minimally invasive series.

BACKGROUND: Median arcuate ligament syndrome (MALS) is a rare and debilitating condition that remains difficult to diagnose. Proper patient selection remains key to achieving favorable outcomes for those undergoing MALR. The robotic technique facilitates a minimally invasive MALR approach given the fine precision of the instrumentation and stability of visualization. Here we describe our management algorithm and clinical outcomes for a large series of robotic MALR patients. METHODS: This retrospective cohort study analyzed adult patients who underwent robotic MALR performed by a single surgeon at a tertiary academic hospital from 2014 to 2021. The diagnosis of MALS was made using objective criteria from celiac artery duplex ultrasound with a peak systolic velocity of > 350 cm/s combined with a right upper quadrant abdominal ultrasound, esophagogastroduodenoscopy, and computer tomography or magnetic resonance angiography to exclude other diagnoses. Information on patient demographics, perioperative factors, and patient reported symptoms up to 1-year post-operatively were collected. RESULTS: A total of 74 patients underwent robotic MALR during the study period. The mean age was 27.3 ± 7.9 years and the majority of patients were female (n = 60/74, 81.1%). The most common presenting symptom was post-prandial abdominal pain (n = 65/74, 87.7%). The mean operative time was 52.6 ± 18.1 min. There were no conversions to open surgery and minimal blood loss (mean = 13.9 ± 8.4 mL). At 3-months, 12% (n = 9/74) of patients had persistent abdominal pain and underwent additional imaging. 5 of these 9 patients had persistently elevated DUS expiratory PSV and were referred for angioplasty. 3 of these 5 referred patients had resolution of abdominal pain after angioplasty. At 1-year follow up, 90.3% (n = 56/62) continued to have no abdominal pain. CONCLUSIONS: Through this series, the largest set of minimally invasive (laparoscopic or robotic) MALR procedures published to date, we show that with strict adherence to a management algorithm, the robotic approach to MALR is safe and feasible, with good patient outcomes.