Use of Absorbable Dermal Staples in Bilateral Breast Reduction Surgery: Effects on Operative Times, Surgical Outcomes, and Procedure Charges.

BACKGROUND: Use of the absorbable deep dermal stapler in wound closure has become more common in plastic surgery because of its possible reduction in operative times and subsequent decrease in operative room costs. In this study, we examine the effects of this stapler on operative times and postoperative complications in bilateral reduction mammaplasties. METHODS: A retrospective, observational cohort study was conducted via electronic chart review on patients who underwent bilateral reduction mammaplasties. Patients were stratified by wound closure method. One group was closed with sutures only, and in the other group, deep dermal staples were used during closure of the inframammary fold incision. Incidences of patient comorbidities and postoperative complications were compared. In addition, a financial cost analysis was performed. RESULTS: The final patient cohort included 62 patients. Operative time was reduced by an average of 21.8 minutes when using deep dermal staples during closure, compared with when closing solely with sutures (P = 0.032). When controlling for mass of breast tissue removed and type of pedicle, deep dermal staple closure still predicted a reduction of 26.5 (SE, 9.9) minutes in operative time (P = 0.010). Postoperative complications were not affected by wound closure method (odds ratio, 4.36; 95% confidence interval, 0.91-31.7, P = 0.087). Though not statistically significant, financial charge was decreased with usage of deep dermal staples (P = 0.34). CONCLUSIONS: Use of absorbable deep dermal staples produces a significant decrease in operative time for reduction mammaplasties with no increase in postoperative complication rates.

Clinical outcomes following direct anterior approach during total hip arthroplasty without hip extension: a retrospective comparative study.

BACKGROUND: Traditional total hip arthroplasty (THA) using the direct anterior approach (DAA) requires a hip extension. This study aimed to compare the clinical outcomes of patients undergoing THA with DAA using either the no hip extension (NHE) or the traditional hip extension (THE) strategy. METHODS: A retrospective analysis of demographics, clinical and radiological outcomes, and occurrence of complications was performed using data from 123 patients treated between January 2020 and November 2021. The patients were categorised into two groups: NHE (84 patients) and THE (39 patients). RESULTS: The NHE group exhibited shorter operative time and had more male participants with higher ages. Comparable outcomes were observed in the visual analogue scale, Harris Hip, and Oxford Hip scores at the final follow-up. Furthermore, complications were observed in the NHE and THE groups, including two and one greater trochanteric fractures and three and one transfusions, respectively. CONCLUSIONS: Compared to the THE, employing the NHE strategy during THA with DAA in elderly and young female patients resulted in comparable clinical outcomes with several advantages, such as favourable surgical time. The NHE method also exhibited good safety and effectiveness. Therefore, the NHE strategy may be a favourable option for elderly and young female patients.

Single-port robotic subcostal major pulmonary resection using the single-port robotic system.

BACKGROUND: The da Vinci single-port system (SPS) (Intuitive Surgical, Sunnyvale, CA, USA) was designed for single-port (SP) surgery. Although we have reported our clinical outcomes using the SPS for a simple procedure in general thoracic surgery, major pulmonary resection had been performed only in cadaveric experiments to date. This study evaluated the feasibility of SP subcostal robotic major pulmonary resection using the SPS. Here, we present our initial clinical experience of SP subcostal robotic major pulmonary resection at our institution. METHODS: Twenty-five patients with lung cancer underwent SP major subcostal pulmonary resection using the SPS between March and November 2022. Patient characteristics, intraoperative and perioperative outcomes were assessed. Questionnaires were used to evaluate patient satisfaction with the cosmetic results and quality of life through face-to-face or telephone interviews on postoperative day 30. RESULTS: All patients underwent major pulmonary resection with complete radical resection (R0). Nineteen patients underwent lobectomy, whereas six patients underwent segmentectomy. The mean docking time and total operative time were 4.16 ± 1.19 min (range, 2.3-7.8 min) and 197.6 ± 55.33 min (range, 130-313 min), respectively. No patients underwent conversion to open thoracotomy. One patient required an additional assistant port due to severe pleural adhesions. CONCLUSIONS: SP subcostal robotic major pulmonary resection using the SPS is feasible and safe. With the continuous development of robotic technology and surgical techniques, we believe that more complex general thoracic surgeries will be performed in the future using SPS.

Quantification of surgical workflow during robotic proctectomy.

BACKGROUND: Surgical workflow assessments offer insight regarding procedure variability. We utilised an objective method to evaluate workflow during robotic proctectomy (RP). METHODS: We annotated 31 RPs and used Spearman's correlation to measure the correlation of step time and step visit frequency with console time (CT) and total operative time (TOT). RESULTS: Strong correlations were seen with CT and step times for inferior mesenteric vein dissection and ligation (ρ = 0.60, ρ = 0.60), lateral-to-medial splenic flexure mobilisation (SFM) (ρ = 0.63), left rectal dissection (ρ = 0.64) and mesorectal division (ρ = 0.71). CT correlated strongly with medial-to-lateral (ρ = 0.75) and supracolic SFM visit frequency (ρ = 0.65). TOT correlated strongly with initial exposure time (ρ = 0.60), and medial-to-lateral (ρ = 0.67) and supracolic SFM visit frequency (ρ = 0.65). CONCLUSION: This study correlates surgical steps with CT and TOT through standardised annotation, providing an objective approach to quantify workflow.

Single incision robotic myomectomy: selection criteria, learning curve and cost.

The article "Comparison of operative and fertility outcomes of single-incision robotic myomectomy: a retrospective single-center analysis of 286 cases" by Kim et al. compares the effectiveness of robotic single-port myomectomy against the traditional multiport approach. The study finds similar operating outcomes, complication rates, and pregnancy rates in expert hands for both methods. Our systematic review supports these findings, revealing no significant differences in operative time, blood loss, or complication rates. Recent meta-analysis further emphasizes the benefits of the single-port approach in reducing morcellation time, overall operative duration, and blood loss. Our letter seeks insights on patient selection criteria to minimize conversion rates between surgical approaches and inquiries on learning curve differences. Additionally, we seek cost analysis details for both techniques. We appreciate the authors' valuable contributions to this field.

Emerging multi-port soft tissue robotic systems: a systematic review of clinical outcomes.

Multiple novel multi-port robotic surgical systems have been introduced into clinical practice. This systematic review aims to evaluate the clinical outcomes of these novel robotic systems to conventional laparoscopic technique and established da Vinci robotic surgical platforms. A literature search of Embase, Medline, Pubmed, Cochrane library, and Google Scholar was performed according to the PRISMA guidelines from 2012 to May 2023. Studies comparing clinical outcomes of novel multi-port robotic surgical systems with laparoscopic or the da Vinci platforms were included. Case series with no comparison groups were excluded. Descriptive statistics were used to report patient and outcome data. A systematic narrative review was provided for each outcome. Twelve studies comprised of 1142 patients were included. A total of 6 novel multi-port robotic systems: Micro Hand S, Senhance, Revo-i MSR-5000, KangDuo, Versius, and Hugo™ RAS were compared against the laparoscopic or the da Vinci robotic platforms. Clinical outcomes of these novel robotic platforms were comparable to the established da Vinci platforms. When compared against conventional laparoscopic approaches, the robotic platforms demonstrated lower volume of blood loss, shorter length of stay but longer operative time. This systematic review highlighted the safe implementation and efficacy of 6 new robotic systems. The clinical outcomes achieved by these new robotic systems are comparable to the established da Vinci robotic system in simple to moderate case complexities. There is emerging evidence that these new robotic systems provide a viable alternative to currently available robotic platforms.

Comparative analysis of robotic single-site cholecystectomy outcomes between novice and expert surgeons.

Single-incision laparoscopic cholecystectomy (SILC) has declined in popularity, posing a challenge for novice surgeons. However, robotic single-site cholecystectomy (RSSC) has gained popularity in hepatopancreatic surgery, suggesting a paradigm shift in minimally invasive procedures due to the advantages of robotic platforms. The purpose of this study was to compare the surgical outcomes and learning curves between experts and novices without SILC experience, and discuss the utility and potential of RSSC for novice surgeons. A total of 235 patients underwent RSSC between April 2019 and June 2023 at the OOO University Hospital. Among them, 31 cases from novice and expert surgeons were selected to compare their initial experience. Comprehensive demographic and perioperative factors were analyzed and statistical comparisons were made, including cumulative sum analysis (CUSUM) for learning curves. The demographic factors showed no statistically significant differences between the two groups. Although the docking time (P < 0.001) and hospital stay (P = 0.014) were statistically significant, the total operative time and other perioperative factors were comparable. Novice surgeons demonstrated a shorter absolute total operative time, primarily attributed to differences in docking time. The CUSUM analysis indicated a shorter learning curve for novice surgeons. This study shows that the inherent benefits of the robotic platform make it an accessible and reproducible technique for novices. The benefits of integrating observational learning into robotic surgery training programs and the intrinsic advantages of the robotic platform in minimizing the learning curve for RSSC were also highlighted.

Robotic versus laparoscopic right hemicolectomy: a systematic review of the evidence.

Robotics may facilitate the realization of fully minimally invasive right hemicolectomy, including intra-corporeal anastomosis and off-midline extraction, when compared to laparoscopy. Our aim was to compare laparoscopic right hemicolectomy with robotic right hemicolectomy in terms of peri-operative outcomes. MEDLINE was searched for original studies comparing laparoscopic right hemicolectomy with robotic right hemicolectomy in terms of peri-operative outcomes. The systematic review complied with the PRISMA 2020 recommendations. Variables related to patients' demographics, surgical procedures, post-operative recovery and pathological outcomes were collected and qualitatively assessed. Two-hundred and ninety-three publications were screened, 277 were excluded and 16 were retained for qualitative analysis. The majority of included studies were observational and of limited sample size. When the type of anastomosis was left at surgeon's discretion, intra-corporeal anastomosis was favoured in robotic right hemicolectomy (4/4 studies). When compared to laparoscopy, robotics allowed harvesting more lymph nodes (4/15 studies), a lower conversion rate to open surgery (5/14 studies), a shorter time to faeces (2/3 studies) and a shorter length of stay (5/14 studies), at the cost of a longer operative time (13/14 studies). Systematic review of existing studies, which are mostly non-randomized, suggests that robotic surgery may facilitate fully minimally invasive right hemicolectomy, including intra-corporeal anastomosis, and offer improved post-operative recovery.

How experienced robotic nurses adapt to the Hugo™ RAS system.

No studies have reported on the impact at team level of the Medtronic Hugo™ RAS system. We described the work patterns and learning curves of an experienced robotic nurse team adapting to the new robotic system. We prospectively recorded the robotic nurse team's preoperative, perioperative, and postoperative tasks on the first 30 robotic procedures performed. The data were descriptively analyzed, and Gantt Charts were created for a timeline overview of the work patterns. We compared the operative times between the Medtronic Hugo™ RAS and the Davinci® system. The preoperative phase seemed to improve with a median time of 94 min (IQR 81-107). After 20 surgeries, the work pattern became more consistent where the scrub and circulating nurses worked simultaneously. There was no noticeable improvement for the perioperative and postoperative phases with a stable median time of 170 min (IQR 135-189) and 26 min (IQR 22-31). We found that the work pattern seemed to stabilize after 20 surgeries but with a continued decrease in preoperative time without a learning curve plateau. The robotic nurse team suffered from few breaks and long working hours because only a few nurses at our facility were trained in the Hugo™ system.

One vs. two-stage arteriovenous loops in lower extremity reconstruction with free flaps: Systematic review and metanalysis.

BACKGROUND: Arteriovenous loops are one of the main therapeutic alternatives to address the absence of recipient vessels in lower extremity microsurgical reconstruction. However, there is no consensus on whether to perform them in one or two surgical stages. The objective of this work is to determine whether the outcome of lower limb free flaps anastomosed to vascular loops depends on the number of surgical stages. MATERIALS AND METHODS: A literature review was conducted, following PRISMA guidelines, on vascular loops and free flaps in lower limb. Survival rate, as well as major and minor complications were studied. A forest plot and Pearson's chi-square were used for statistical analysis. Study quality was assessed in duplicate using Methodological Index for Non-Randomized Studies (MINORS) and Joanna Briggs Institute (JBI) tool. This study was registered on PROSPERO. RESULTS: Thirty-two articles using free flaps anastomosed to vascular loops in lower limb, either one or two-stage, were selected. A total of 296 flaps were included, 52% (n = 154) in one and 48% (n = 142) in two surgical times. No statistically significant differences were found in the survival rate (OR = 1.85, 95% CI 0.62; 5.47, p = .09 and p = .344) or major complications (OR = 0.70, 95% CI 0.31; 1.57, p = .56 and p = .92) of flaps between both groups. CONCLUSIONS: According to the available evidence, the outcome of free flaps anastomosed to vascular loops in the lower limb does not depend on the number of surgical stages they undergo. Although there is some heterogeneity in the groups studied, the decision on the number of procedures to be performed should be determined by the surgeon, concerning the clinical situation of the patient, as well as to the vascular, bone and soft tissue status of the extremity.

Operative Time Accuracy in the Era of Electronic Health Records: Addressing the Elephant in the Room.

GOAL: Accurate prediction of operating room (OR) time is critical for effective utilization of resources, optimal staffing, and reduced costs. Currently, electronic health record (EHR) systems aid OR scheduling by predicting OR time for a specific surgeon and operation. On many occasions, the predicted OR time is subject to manipulation by surgeons during scheduling. We aimed to address the use of the EHR for OR scheduling and the impact of manipulations on OR time accuracy. METHODS: Between April and August 2022, a pilot study was performed in our tertiary center where surgeons in multiple surgical specialties were encouraged toward nonmanipulation for predicted OR time during scheduling. The OR time accuracy within 5 months before trial (Group 1) and within the trial period (Group 2) were compared. Accurate cases were defined as cases with total length (wheels-in to wheels-out) within ±30 min or ±20% of the scheduled duration if the scheduled time is ≥ or <150 min, respectively. The study included single and multiple Current Procedural Terminology code procedures, while procedures involving multiple surgical specialties (combo cases) were excluded. PRINCIPAL FINDINGS: The study included a total of 8,821 operations, 4,243 (Group 1) and 4,578 (Group 2), (p < .001). The percentage of manipulation dropped from 19.8% (Group 1) to 7.6% (Group 2), (p < .001), while scheduling accuracy rose from 41.7% (Group 1) to 47.9% (Group 2), (p = .0001) with a significant reduction of underscheduling percentage (38.7% vs. 31.7%, p = .0001) and without a significant difference in the percentage of overscheduled cases (15% vs. 17%, p = .22). Inaccurate OR hours were reduced by 18% during the trial period (2,383 hr vs. 1,954 hr). PRACTICAL APPLICATIONS: The utilization of EHR systems for predicting OR time and reducing manipulation by surgeons helps improve OR scheduling accuracy and utilization of OR resources.

What should the optimal access site be for percutaneous treatment of anterior lower pole calyx stones?

OBJECTIVES: Compared to other stone groups, anterior calyx stones are more challenging for endourologists to treat. This study aims to evaluate the differences between our latest technique and conventional techniques for treating anterior calyx stones in the lower pole. MATERIALS AND METHODS: Patients with isolated anterior lower pole calyx or complex lower pole stones with anterior calyx branching were included in the study. The first group included lower pole access, while the second group included percutaneous treatment through the middle or upper pole. In the first group, the posterior calyx or direct anterior calyx approach was utilised depending on whether the stone was isolated calyx, complex structure or calyx anatomy, while in the second group, percutaneous nephrolithotomy was performed through the middle or upper pole posterior calyx access. RESULTS: There were 37 patients in Group 1 and 25 patients in Group 2. Both groups were similar regarding patient age, sex, stone burden, and stone localisation (p > 0.05). When comparing operative and post-operative data between groups, it was found that the stone clearance rate, number of accesses, and haematocrit decrease were statistically superior in the second group (p: 0.003, p: 0.002, p: 0.018), with no significant difference in mean operative time, length of hospital stay, fluoroscopy time and pain score (p > 0.05). CONCLUSIONS: Percutaneous surgery utilising an access from a calyx distal to the stone may offer better clearance and lower morbidity rates for lower pole stones involving the anterior calyx.

The Direct Superior Approach in Total Hip Arthroplasty: A Systematic Review.

BACKGROUND: Evolution of the surgical approach for total hip arthroplasty (THA) has led to the development of the minimally invasive direct superior approach (DSA). It is hypothesized that the DSA reduces postoperative pain and hospital length of stay (LOS). We aimed to provide an overview of current evidence on clinical, functional, and radiological outcomes with respect to risk of revision, complications, pain scores, physical function, operative time, LOS, blood loss, radiological outcomes, and learning curve. METHODS: A comprehensive search of Medline, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar, reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search extension guidelines, was conducted to identify studies evaluating clinical, functional, and radiological outcomes of the DSA. Quality assessment was performed using the Cochrane Risk of Bias tool and Newcastle-Ottawa Scale. The review protocol was prospectively registered in the International Prospective Registry of Systematic Reviews. RESULTS: Seventeen studies were included, generally of moderate quality. Qualitative synthesis evidenced accurate implant positioning, short LOS, and a short learning curve. Conflicting findings were reported for postoperative complications compared with conventional approaches. Better functional outcomes were seen in the early postoperative period than the posterolateral approach (PLA). Outcomes such as blood loss and operative time exhibited conflicting results and considerable heterogeneity. CONCLUSION: Based on moderate-certainty evidence, it is uncertain if the DSA provides short-term advantages over conventional approaches such as PLA. There is limited evidence on long-term outcomes post-THA using the DSA. Further studies and ongoing registry monitoring is crucial for continuous evaluation of its long-term outcomes. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of prolonged operative time on short-term outcomes of open vs minimally invasive proctectomy.

BACKGROUND: Minimally invasive proctectomy (MIP) may offer advantages over open proctectomy (OP). Increased operative times (OTs) are linked to inferior outcomes for various operations; however, the interplay between OT and approach for proctectomy is not well-established. This study aimed to evaluate associations of increasing OT on 30-day morbidity in OP and MIP cohorts. METHODS: The American College of Surgeons National Quality Improvement Program Targeted Proctectomy Dataset was used to identify patients undergoing proctectomy. Cases were stratified by open or minimally invasive surgical approach and following propensity score matching between the groups, and OT quartiles were established for each group. Perioperative outcomes were compared among quartiles, and multivariate regression was used to identify factors associated with prolonged OT. RESULTS: The median OT was longer for MIP (271 vs 232 min; P < .01). Although increased OT was associated with higher overall morbidity for both open and minimally invasive approaches, this effect was more pronounced in OP than in MIP (63.2% vs 38.4%, respectively; P < .001). Factors associated with prolonged OT included the procedure performed, male sex, higher body mass index scores, diverting ileostomy, and, in malignant disease, mid or lower and T4 tumors (all P < .05). CONCLUSION: Herein, prolonged OT was associated with worse short-term outcomes for both OP and MIP cases; however, its detrimental effect was more pronounced for open surgery than for minimally invasive surgery. Our data suggested that MIP may offer short-term advantages for demanding cases requiring longer OTs.

Postoperative outcomes and costs of laparoscopic versus robotic distal pancreatectomy: a propensity-matched analysis.

BACKGROUND: Minimally invasive distal pancreatectomy (MIDP) has established advantages over the open approach. The costs associated with robotic DP (RDP) versus laparoscopic DP (LDP) make the robotic approach controversial. We sought to compare outcomes and cost of LDP and RDP using propensity matching analysis at our institution. METHODS: Patients undergoing LDP or RDP between 2000 and 2021 were retrospectively identified. Patients were optimally matched using age, gender, American Society of Anesthesiologists status, body mass index, and tumor size. Between-group differences were analyzed using the Wilcoxon signed-rank test for continuous data, and the McNemar's test for categorical data. Outcomes included operative duration, conversion to open surgery, postoperative length of stay, pancreatic fistula rate, pseudocyst requiring intervention, and costs. RESULTS: 298 patients underwent MIDP, 180 (60%) were laparoscopic and 118 (40%) were robotic. All RDPs were matched 1:1 to a laparoscopic case with absolute standardized mean differences for all matching covariates below 0.10, except for tumor type (0.16). RDP had longer operative times (268 vs 178 min, p < 0.01), shorter length of stay (2 vs 4 days, p < 0.01), fewer biochemical pancreatic leaks (11.9% vs 34.7%, p < 0.01), and fewer interventional radiological drainage (0% vs 5.9%, p = 0.01). The number of pancreatic fistulas (11.9% vs 5.1%, p = 0.12), collections requiring antibiotics or intervention (11.9% vs 5.1%, p = 0.12), and conversion rates (3.4% vs 5.1%, p = 0.72) were comparable between the two groups. The total direct index admission costs for RDP were 1.01 times higher than for LDP for FY16-19 (p = 0.372), and 1.33 times higher for FY20-22 (p = 0.031). CONCLUSIONS: Although RDP required longer operative times than LDP, postoperative stays were shorter. The procedure cost of RDP was modestly more expensive than LDP, though this was partially offset by reduced hospital stay and reintervention rate.

Minimally invasive splenectomy is associated with a low perioperative complication rate and short operative time in cats.

OBJECTIVE: To report the perioperative outcome and complications in cats undergoing minimally invasive splenectomy. ANIMALS: 17 client-owned cats. METHODS: Perioperative data were collected from cats undergoing minimally invasive splenectomy from September 2010 to June 2023. Data included history, signalment, preoperative examination and diagnostic testing results, operative technique and time, perioperative outcomes, complications, hospitalization duration, histopathological diagnosis, and outcome. RESULTS: 13 spayed females and 4 neutered males were included, with a median age of 144 months (48 to 196 months). Seven cats underwent total laparoscopic splenectomy (TLS), with 1 cat requiring conversion from TLS to laparoscopic-assisted splenectomy (LAS) due to splenomegaly and an additional cat requiring conversion from TLS to open splenectomy due to uncontrollable splenic capsular hemorrhage. Ten cats underwent LAS, with 1 cat requiring conversion to open splenectomy due to splenomegaly. Additional procedures were performed in 13 cats, with the most common being liver biopsy in 10 cats. Median operative times were 50 minutes (45 to 90 minutes) for TLS and 35 minutes (25 to 80 minutes) for LAS. An intraoperative complication occurred in 1 cat. All but 1 cat survived to discharge. Median follow-up time was 234 days (18 to 1,761 days), with 15 of 16 cats confirmed alive at 30 days and 9 of 16 cats alive at 180 days postoperatively. CLINICAL RELEVANCE: Minimally invasive splenectomy in this cohort of cats was associated with short operative times and a low perioperative complication rate. Veterinary surgeons may consider minimally invasive splenectomy as an efficient and feasible technique in the treatment of splenomegaly or modestly sized splenic masses for diagnostic and therapeutic purposes in cats.