Improving vision for surgeons during laparoscopy: the Enhanced Laparoscopic Vision System (ELViS).

BACKGROUND: For many abdominal surgical interventions, laparotomy has gradually been replaced by laparoscopy, with numerous benefits for the patient in terms of post-operative recovery. However, during laparoscopy, the endoscope only provides a single viewpoint to the surgeon, leaving numerous blind spots and opening the way to peri-operative adverse events. Alternative camera systems have been proposed, but many lack the requisite resolution/robustness for use during surgery or cannot provide real-time images. Here, we present the added value of the Enhanced Laparoscopic Vision System (ELViS) which overcomes these limitations and provides a broad view of the surgical field in addition to the usual high-resolution endoscope. METHODS: Experienced laparoscopy surgeons performed several typical procedure steps on a live pig model. The time-to-completion for surgical exercises performed by conventional endoscopy and ELViS-assisted surgery was measured. A debriefing interview following each operating session was conducted by an ergonomist, and a System Usability Scale (SUS) score was determined. RESULTS: Proof of concept of ELVIS was achieved in an animal model with seven expert surgeons without peroperative adverse events related to the surgical device. No differences were found in time-to-completion. Mean SUS score was 74.7, classifying the usability of the ELViS as "good". During the debriefing interview, surgeons highlighted several situations where the ELViS provided a real advantage (such as during instrument insertion, exploration of the abdominal cavity or for orientation during close work) and also suggested avenues for improvement of the system. CONCLUSIONS: This first test of the ELViS prototype on a live animal model demonstrated its usability and provided promising and useful feedback for further development.

Salvage Robotic Roux-en-Y Fistulojejunostomy for Chronic Gastro-Colic Fistula After Laparoscopic Sleeve Gastrectomy.

Roux-en-Y fistulojejunostomy (RYFJ) has been proposed as a surgical option for the treatment of a chronic fistula after sleeve gastrectomy but can be technically challenging. The robotic approach in bariatric surgery has emerged as a new rapidly evolving technology and allows performing more complex surgical procedures. Here we present the case of a 42-year-old man referred to our university tertiary center for a chronic gastro-colic fistula after laparoscopic SG who underwent a salvage robotic RYFJ. The aim of this video is to present our management of a chronic gastro-colic fistula after laparoscopic SG demonstrating the technical advantages of a robotic approach to a RYFJ.

Assessment of haemorrhoidal artery network using Doppler-guided haemorrhoidal artery ligation for haemorrhoids and pathogenesis implications.

BACKGROUND: Some authors, either with anatomical studies or Doppler laser flowmetric investigations have shown the blood flow to the posterior midline of the anus to be potentially deficient. This relative local ischaemia might explain pathogenesis of anal fissure, which is often located posteriorly. The aim of this study was to record the exact position of the distal branches of the superior rectal artery during Doppler-guided haemorrhoidal artery ligation-rectoanal repair (HAL-RAR) procedures with special reference to posterior distribution of the arteries. METHODS: All consecutive patients with symptomatic haemorrhoids who were treated with the HAL-RAR procedure between February 2008 and February 2014 in a single institution were included in the study. Number and position of Doppler-guided ligations were prospectively collected. Pearson's chi-squared test was used to compare artery locations. RESULTS: A total of 150 patients (75 women) with symptomatic haemorrhoids were included in the study. Median age was 53 years (range 23-83). A median of 10 ligations were placed per patient (range 3-18). A significantly lower number of cumulative arterial ligations was recorded in the posterior position (88 ligations overall, P = 0.025). CONCLUSIONS: The number of distal branches of the superior rectal artery that have been localized by the Doppler-guided HAL-RAR technique is lower at the posterior midline than in the other segments of the lower rectum. This is another evidence of the vascular deficiency at the posterior pole of the anal canal that might explain the pathogenesis of the anal fissure.

Bariatric surgery improves the employment rate in people with obesity: 2-year analysis.

BACKGROUND: Beyond medical complications, people with obesity experience dramatic impairment of quality of life, including adverse workplace effects. Obesity results in weight-based discrimination and a high rate of unemployment because of work disability, absenteeism, loss of productivity, and cost. A few studies have been performed to assess the relationship between obesity surgery and the workplace, finding an improvement in weekly working hours and productivity and a decrease in absenteeism, days of sick leave, and state benefit claims. However, the results are still controversial concerning the overall employment rate. OBJECTIVES: This study aimed to compare the employment rate before and 2 years after obesity surgery and to evaluate the difference in weight loss between worker and nonworker patients. SETTING: Participants were recruited from a tertiary care university hospital in France. METHODS: The 2-year outcomes of all patients who underwent obesity surgery between 2010 and 2015 were retrospectively reviewed. The employment status was recorded preoperatively and postoperatively. Retired or permanently disabled patients were excluded from the analysis. RESULTS: Preoperatively, 158 of 238 patients were employed compared with 199 of 238 postoperatively (P < .0001). There was no difference in weight loss between the worker and nonworker patients regarding the percentage of excess weight loss and the change in body mass index. CONCLUSION: This study supports the finding that bariatric surgery also has a positive impact on the professional sphere, providing the opportunity for unemployed patients to return to work.

Damage Control Surgery for Non-traumatic Abdominal Emergencies.

BACKGROUND: Damage control surgery (DCS) was a major paradigm change in the management of critically ill trauma patients and has gradually expanded in the general surgery arena, but data in this setting are still scarce. The study aim was to evaluate outcomes of DCS in patients with general surgery emergencies. METHODS: Between 2005 and 2015, 164 patients (104 men, age 66) underwent DCS for non-traumatic abdominal emergencies. The decision to perform DCS was triggered by the presence of at least one trauma DCS criterion: hypotension (<70 mmHg), hypothermia (<35 °C), acidosis (pH < 7.25), coagulopathy (INR ≥ 1.7) and massive (>5 RBC) transfusion. Statistical tests were performed to identify risk factors for operative mortality. Observed outcomes were compared to those predicted by commonly employed scores (APACHE II, POSSUM, P-POSSUM, SAPS II). RESULTS: DCS was performed for acute mesenteric ischemia (n = 68), peritonitis (n = 44), pancreatitis (n = 28), bleeding (n = 14) and other (n = 10). Abdominal compartment syndrome was associated in 52 patients (32%). Seventy-four (45%) patients died and 150 patients (91%) experienced complications. On multivariate analysis, age (p = 0.018) and INR ≥ 1.7 (p = 0.001) were independent predictors of mortality. Mortality was 24% (13/55), 48% (22/46) and 62% (39/63) in patients with one, two and ≥3 DCS criteria, respectively. Comparison of observed and score-predicted mortality suggested DCS use resulted in significant survival benefit of the whole cohort and of patients with pancreatitis and postoperative peritonitis. CONCLUSIONS: DCS can be lifesaving in critically ill patients with general surgery emergencies. Patients with peritonitis and acute pancreatitis are those who benefit most of the DCS approach.

Totally Robotic Reversal of Omega-Loop Gastric Bypass to Normal Anatomy.

BACKGROUND: Gastric bypass procedures can potentially lead to middle and long-term complications (Podnos et al. Arch Surg 138(9):957-61, 2003). For several years, Roux-en-Y gastric bypass reversal procedures performed by laparotomy or laparoscopic way have been described in literature (Moon et al. Surg Obes Relat Dis 11(4):821-6, 2015). Major complications are anastomotic ulcers, anastomotic complications or functional disorder such as dumping syndrome, hypocalcemia, severe hypoglycemia, and malnutrition (Moon et al. Surg Obes Relat Dis 11(4):821-6, 2015; Campos et al. Surg Obes Relat Dis 10(1):36-43, 2014). One-anastomosis gastric bypass (OAGB) also called omega-loop gastric bypass (OLGB) or mini-gastric bypass (MGB) is a technique that has demonstrated similar results to traditional Roux-en-Y procedures in terms of weight loss and postoperative quality of life (Lee et al. Ann Surg 242(1):20-8, 2005). However, in a recent description of 1000 patients, the percentage of malnutrition was 0.2 % (two patients) with an indication to revert omega-loop gastric bypass back into normal anatomy (Chevallier et al. Obes Surg 25(6):951-8, 2015), but technical details have not been exposed yet. The first robotic gastric bypass was published by Horgan and Vanuno in 2001 (Horgan and Vanuno J Laparoendosc Adv Surg Tech A 11(6):415-9, 2001). The present work describes for the first time a robotic procedure to reverse OLGB into normal anatomy. METHODS: We present the video report of a 69-year-old woman suffering of severe malnutrition (weight of 42 kg, body mass index of 15.8 kg/m(2), albumin 21 g/l) who had undergone laparoscopic omega-loop gastric bypass 2 years ago (initial weight of 104 kg and initial body mass index of 39.6 kg/m(2)). She was referred to our Bariatric Surgery Unit, and after a period of parenteral nutrition support to improve nutritional status (albumin 32 g/l), we decided in a multidisciplinary staff to perform a reversal omega-loop gastric bypass back into normal anatomy using the DaVinci Si™ system by Intuitive Surgical Inc ®, Sunnyvale, CA. RESULTS: In this high definition video, we present step-by-step robotic reversal of the omega-loop gastric bypass. The procedure began with a careful adhesiolysis of the left lobe of the liver, small gastric pouch, and omega-loop. Then, the gastro-jejunostomy was transected with a 45-mm Endo GIA endocutter with purple staples. The key-point was the creation of a gastro-gastric anastomosis between the small gastric pouch and the excluded stomach. Omega-loop jejunum was resected and the anastomosis was performed in order to avoid intestinal stenosis. The operative time was 232 min. Postoperative course was uneventful and the patient was discharged in postoperative day 8. One month after the procedure, she has gained 10 kg (albumin 34 g/l) and stabilized her nutritional status without further nutritional support. CONCLUSIONS: This is the first case described in the literature of a reversal omega-loop gastric bypass into normal anatomy and the first description of the use of a robotic approach. This intervention is challenging, but a feasible procedure. This technology may increase the number of surgeons who are able to provide the benefits of minimal invasive surgery to their patients without the increased risks of complications associated with initial learning curves. The three-dimensional robotic vision, a stable camera, and the multiples degrees of freedom of the robotic instruments are the features that seem to provide greater surgical precision for these complex laparoscopic operations.