Decreasing Colectomy Rates in Advanced Adenomas.

Advanced colon adenomas are commonly treated with colectomy, which is associated with substantial morbidity and mortality. Novel endoscopic resection techniques have been described, including endoscopic mucosal resection (EMR) and endoscopic submucosal resection (ESR), which demonstrate promise in treating these neoplasms without colectomy. We performed a retrospective review of patients with advanced adenomas who were referred to a colorectal surgeon for evaluation for resection over 4 years. 40 of 46 (87%) of these patients underwent a successful endoscopic resection. 10 of 46 (21.6%) patients ultimately underwent an operation for a variety of reasons: inability to resect endoscopically (n = 6), invasive cancer on the excised specimen (n = 2), complication of procedure (n = 1), colectomy after polyp recurrence (n = 1). Our study demonstrates EMR and ESD offers an alternative to colectomy in appropriately selected patients with a high success rate. As more surgeons learn advanced endoscopic techniques, there is potential to decrease colectomy rates in benign disease.

Robotic Repair of a Symptomatic Perineal Hernia With Self-Fixating Synthetic Mesh.

Primary acquired perineal hernias are rare defects through the pelvic floor diaphragm. The optimal surgical technique for repair remains unknown, and recurrence rates approach 50%. We present a 65-year-old female without previous obstetric or pelvic surgical history who was found to have herniated sigmoid colon through a 2×2 cm levator ani defect. The patient underwent robotic transabdominal hernia repair with a synthetic self-fixating underlay mesh. The peritoneum was primarily closed and the patient was discharged the same day. There is no sign of recurrence to date. Our minimally invasive approach with extraperitoneal mesh placement provided us with several advantages: ambulatory surgery; excellent visualization of the defect; easier suturing in the deep pelvis compared to traditional laparoscopy; and mesh reinforcement while minimizing the risks of erosion, migration, adhesion, and fistula formation.

Robotic inguinal lymph node dissection for melanoma: a novel approach to a complicated problem.

BACKGROUND: Indications for superficial inguinal lymph node (ILN) dissection in melanoma include fine needle aspiration or clinically positive ILN and sentinel lymph nodes (SLN). Open inguinal lymphadenectomy may be complicated by poor wound healing, deep vein thrombosis, and lymphedema. Technical considerations and case series of a novel surgical approach, robotic inguinal lymphadenectomy, are presented. METHODS: This is a case series of four robotic ILN dissections for melanoma at a tertiary care facility. Each patient had previously diagnosed melanoma by lymph node biopsy. Physician and patient jointly decided on robotic procedure after disclosure of this novel approach. Demographic, complication, pathological outcome, estimated blood loss (EBL), operative time, and length of stay (LOS) data were collected. RESULTS: No cases were aborted due to technical difficulty. The median patient age was 44.5 years (range 22-53 years) and median BMI was 27.5 (range 20.4-40.2). Operative time range was 120-231 min and EBL from 0 to 100 mL. Median nodal count was 5.5 (range 1-14 nodes). Patient LOS ranged from 0 (discharged from post anesthesia care unit) to 96 h. There was one complication of port site cellulitis, one seroma formation, and no instances of lymphedema. To date, there have been no deaths or melanoma recurrences in this population. CONCLUSION: Recent data suggest a minimum node count of six to seven for inguinal dissection. Of our four dissections, two were above this threshold and there were minimal postoperative complications. Given our limited sample size, future focus should be on increasing the data on this approach to optimize surgical outcomes and oncologic results.

Evaluating Surgery Resident Technical Skills: Intestinal Anastomosis in a Porcine Model.

Because work hour restrictions and technological developments such as staplers change the surgical landscape, efficient resident training methods are necessary to ensure surgical quality. This study evaluates efficacy of a porcine skills laboratory for teaching surgery residents to perform handsewn intestinal anastomoses based on a validated subjective tool and novel objective measurements. We hypothesized that resident performance would improve postintervention; junior residents would improve more than the seniors would. This prospective study was completed over a period of four months in 2015. Participants performed standardized two-layer, handsewn, end-to-end small intestine anastomosis in a live porcine model before (pretest) and after (posttest) an educational intervention. The intervention consisted of an instructional module and skills laboratory teaching session by attending surgeons. Participants were evaluated based on objective measurements of the anastomosis and blinded video evaluations using objective structured assessment of technical skills. Twenty-eight residents in a six-year general surgery program started and completed the study. The objective structured assessment of technical skills ratings demonstrated that the whole resident cohort had statistically significant improvement in pre- to posttest scores, 11.16 to 24.59 (P < 0.001). Junior and senior residents improved independently, 9.59 versus 22.53 (P < 0.001) and 13.59 versus 27.77 (P < 0.001), respectively. Finally, the cohort significantly improved in number of full-thickness Lembert sutures (2.36 vs 0.93, P = 0.001) and time to completion (31.28 vs 28.2 minutes, P = 0.046). Anastomotic leak pressure, anastomotic narrowing, and anastomotic tensile strength all trended toward improvement. A structured educational intervention, teaching intestinal anastomosis in a live porcine model produced significant improvement in residents' technical skills.