Initial clinical outcomes of robotic resection for perihilar cholangiocarcinoma: Is it safe and effective?

BACKGROUND AND OBJECTIVES: We aimed to describe our outcomes of robotic resection for perihilar cholangiocarcinoma, the largest single institutional series in the Western hemisphere to date. METHODS: Between 2016 and 2022, we prospectively followed all patients who underwent robotic resection for perihilar cholangiocarcinoma. RESULTS: In total, 23 patients underwent robotic resection for perihilar cholangiocarcinoma, 18 receiving concomitant hepatectomy. The median age was 73 years. Operative time was 470 min with an estimated blood loss of 150 mL. No intraoperative conversions to open or other intraoperative complications occurred. Median length of stay was 5 days. Four postoperative complications occurred. Three readmissions occurred within 30 days with one 90-day mortality. R0 resection was achieved in 87% of patients and R1 in 13% of patients. At a median follow-up of 27 months, 15 patients were alive without evidence of disease, two patients with local recurrence at 1 year, and six were deceased. CONCLUSIONS: Utilization of the robotic platform for perihilar cholangiocarcinoma is safe and feasible with excellent perioperative outcomes. Further studies are needed to determine the long-term oncological outcomes.

Epidural versus general anesthesia for laparo-endoscopic single-site cholecystectomy: a randomized controlled trial.

INTRODUCTION: This study compares outcomes after LESS cholecystectomy utilizing epidural versus general anesthesia. METHODS: Patients undergoing LESS Cholecystectomy were randomized into receiving epidural or general anesthesia by protocol. Patients used a Visual Analog Scale to rate pain from 0 (no pain) to 10 (severe pain). Data presented as median (mean ± standard deviation). RESULTS: 75 patients underwent LESS cholecystectomy with general anesthesia [32 patients (22% men) after five patients withdrew consent] or epidural anesthesia [23 patients (22% men) after 15 patients withdrew consent]. Respectively, they were of age 38 years (41 ± 15.1) and 47 years (48 ± 13.9), BMI 29 (28 ± 4.9) kg/m2 and 28 (28 ± 3.8) kg/m2, and ASA 2 (2 ± 0.5) and 2 (2 ± 0.3) (p > 0.05 for all). LOS for patients receiving general vs. epidural anesthesia was 72 min (122 ± 104.4) vs. 95 min (113 ± 77.5) (p = 0.25). On POD 0, patients receiving general anesthesia rated pain as 4 (4 ± 2.9) vs. 0 (1 ± 2.2) for epidural anesthesia (p = 0.02). On POD 1, they rated pain as 6 (5 ± 2.3) vs. 6 (6 ± 2.9) (p = 0.68). On POD 6, patients rated pain as 3 (3 ± 2.7) vs. 4 (3 ± 2.2) (p = 1.00). For patient satisfaction with incisional scars for those receiving general vs. epidural anesthesia, patients rated their scars to be 10 (8 ± 3.6) vs. 10 (9 ± 1.2) (p = 0.21). Total costs for the hospital using general vs. epidural anesthesia were found $6,909 (7,167 ± 2,083.8) vs. $6,225 (5,848 ± 1530.1) (p = 0.014), respectively. Patients self-assessed satisfaction on a scale of 1 (worst) to 5 (best) as a 5 (5 ± 0). CONCLUSIONS: Patients undergoing LESS cholecystectomy with general vs. epidural anesthesia had similar demographics, LOS, and pain scores. Patients that received epidural anesthesia reported less pain and incurred less cost. Utilization of epidural anesthesia in lieu of general anesthesia for LESS cholecystectomy is safe, reduces pain, and offers potential cost savings.

A decade of experience with minimally invasive anti-reflux operations: robot vs. LESS.

BACKGROUND: The increasing use of robotic systems for anti-reflux operations prompted this study to evaluate and compare the efficacy of robotic and Laparo-Endoscopic Single-Site (LESS) approaches. METHODS: From 2012, 228 robotic fundoplication and 518 LESS fundoplication patients were prospectively followed, analyzing perioperative metrics. Data are presented as median (mean ± SD); significance at p ≤ 0.05. RESULTS: Patients undergoing a robotic vs. LESS fundoplication were 67 (64 ± 13.7) vs. 61 (59 ± 15.1) years-old with BMIs of 25 (25 ± 3.2) vs. 26 (25 ± 3.9) kg/m2 (p = 0.001 and 1.00, respectively). 72% of patients who underwent the robotic approach had a previous abdominal operation(s) vs 44% who underwent the LESS approach (p = 0.0001). 38% vs. 8% had a re-operative fundoplication (p = 0.0001), 59% vs. 45% had a type IV hiatal hernia (p = 0.0004). Operative duration was 160 (176 ± 76.7) vs. 130 (135 ± 50.5) min (p = 0.0001). There were 0 (robotic) vs. 5 (LESS) conversions to a different approach (p = 0.33). 5 Patients vs. 3 patients experienced postoperative complications (p = 0.06), and length of stay (LOS) was 1 (2 ± 2.6) vs. 1 (1 ± 3.2) days (p = 0.0001). Patient symptomatic dysphagia preoperatively for the robotic vs. LESS approach was scored as 2 (2.4 ± 1.9) vs. 1 (1.9 ± 1.6). Postoperatively, symptomatic dysphagia was scored as 1 (1.5 ± 1.6) vs. 1 (1.7 ± 1.7). The change in these scores was - 1 (- 1 ± 2.2) vs. 0 (- 0.5 ± 2.2) (p = 0.004). CONCLUSION: Despite longer operative times and LOS in older patients, the robotic approach is efficient in undertaking very difficult operations, including patients with type IV or recurrent hiatal hernias. Furthermore, preoperative anti-reflux operations were more likely to be undertaken with the robotic approach than the LESS approach. The patient's postoperative symptomatic dysphagia improved relatively more than after the LESS approach. The vast majority of patients who underwent the LESS approach enjoyed improved cosmesis, thus, making LESS a stronger candidate for more routine operations. Despite patient selection bias, the robotic and LESS approaches to anti-reflux operations are safe, efficacious, and should be situationally utilized.

Unplanned conversions of robotic pancreaticoduodenectomy: short-term outcomes and suggested stepwise approach for a safe conversion.

OBJECTIVE: With the increased adoption of robotic pancreaticoduodenectomy, the effects of unplanned conversions to an 'open' operation are ill-defined. This study aims to describe the impact of unplanned conversions of robotic pancreaticoduodenectomy on short-term outcomes and suggest a stepwise approach for safe unplanned conversions during robotic pancreaticoduodenectomy. METHODS: This is an analysis of 400 consecutive patients undergoing robotic pancreaticoduodenectomy in a single high-volume institution. Data are presented as median (mean ± SD), and significance is accepted with 95% probability. RESULTS: Between November 2012 and February 2023, 184 (46%) women and 216 (54%) men, aged 70 (68 ± 11.0) years, underwent a robotic pancreaticoduodenectomy. Unplanned conversions occurred in 42 (10.5%) patients; 18 (5%) were converted due to unanticipated vascular involvement, 13 (3%) due to failure to obtain definitive control of bleeding, and 11 (3%) due to visceral obesity. Men were more likely to require a conversion than women (29 vs. 13, p = 0.05). Conversions were associated with shorter operative time (376 (323 ± 182.2) vs. 434 (441 ± 98.7) min, p < 0.0001) but higher estimated blood loss (675 (1010 ± 1168.1) vs. 150 (196 ± 176.8) mL, p < 0.0001). Patients that required an unplanned conversion had higher rates of complications with Clavien-Dindo scores of III-V (31% vs. 12%, p = 0.003), longer length of stay (8 (11 ± 11.6) vs. 5 (7 ± 6.2), p = 0.0005), longer ICU length of stay (1 (2 ± 5.1) vs. 0 (0 ± 1.3), p < 0.0001) and higher mortality rates (21% vs. 4%, p = 0.0001). The conversion rate significantly decreased over time (p < 0.0001). CONCLUSIONS: Unplanned conversions of robotic pancreaticoduodenectomy significantly and negatively affect short-term outcomes, including postoperative mortality. Men were more likely to require a conversion than women. The unplanned conversions rates significantly decreased over time, implying that increased proficiency and patient selection may prevent unplanned conversions. An unplanned conversion should be undertaken in an organized stepwise approach to maximize patient safety.

The robotic-assisted laparoscopic approach to biliary tract resection and reconstruction for benign indications: A single-center experience.

BACKGROUND: Benign biliary disease (BBD) is a prevalent condition involving patients who require extrahepatic bile duct resections and reconstructions due to nonmalignant causes. METHODS: This study followed all patients who underwent biliary resections for BBD between 2015 and 2023. We excluded those with malignant conditions and patients who had an 'open' operation. Based on the patient's anatomy, the procedures employed were either robotic Roux-en-Y hepaticojejunostomy (RYHJ) or robotic choledochoduodenostomy (CDD). RESULTS: From the 33 patients studied, 23 were female, and 10 were male. Anesthesiology (ASA) class was 3 ± 0.5; the MELD score was 9 ± 4.1; the Child-Pugh score was 6 ± 1.7. The primary indications for undergoing the operation included iatrogenic bile duct injuries, biliary strictures, and type 1 choledochal cysts. The average surgical duration was about 272 min, and the average blood loss amounted to 79 mL. Postoperatively, three patients experienced major complications, all attributed to anastomotic leaks. The average hospital stay was 4 days, with a readmission rate of 15% within 30 days. During an average follow-up period of 33 months, one patient had to undergo a revision at 18 months due to stricture. This necessitated further duct resection and reanastomosis. Notably, there were no reported hepatectomies, no conversion to the 'open' method, no intraoperative complications, and no mortalities. CONCLUSIONS: Robotic extrahepatic bile duct resection and reconstruction with Roux-en-Y hepaticojejunostomy or choledochoduodenostomy is safe with an acceptable postoperative morbidity, short hospital length of stay, and low postoperative stricture rate at intermediate duration follow-up.

Outcomes after pancreaticoduodenectomy with or without preoperative hyperbaric oxygen therapy.

Background: Hyperbaric oxygen (HBO2) therapy is an alternative method against the deleterious effects of ischemic/reperfusion (I/R) injury and its inflammatory response. This study assessed the effect of preoperative HBO2 on patients undergoing pancreaticoduodenectomy. Study Design: Patients were randomized via a computer-generated algorithm. Patients in the HBO2 cohort received two sessions of HBO2 the evening before and the morning of surgery. Measurements of inflammatory mediators and self-assessed pain scales were determined pre-and postoperatively. In addition, perioperative variables and long-term survival were collected and analyzed. Data are presented as median (mean ± SD). Results: 33 patients were included; 17 received preoperative HBO2, and 16 did not. There were no intraoperative or postoperative statistical differences between patients with or without preoperative HBO2. Erythrocyte sedimentation rate (ESR), IL-6, and IL-10 increased slightly before returning to normal, while TGF-alpha decreased before increasing. However, there were no differences with or without HBO2. At postoperative day 30, the pain level measured with VAS score (Visual Analog Score) was lower after HBO2 (1 ± 1.3 vs. 3 ± 3.0, p=0.05). Eleven (76%) patients in the HBO2 cohort and 12 (75%) patients in the non- HBO2 had malignant pathology. The percentage of positive lymph nodes in the HBO2 was 7% compared to 14% in the non-HBO2 (p<0.001). Overall survival was inferior after HBO2 compared to the non- HBO2 (p=0.03). Conclusions: Preoperative HBO2 did not affect perioperative outcomes or significantly change the inflammatory mediators for patients undergoing robotic pancreaticoduodenectomy. Long-term survival was inferior after preoperative HBO2. Further randomized controlled studies are required to assess the full impact of this treatment on patients' prognosis.

Robotic Klatskin Type 3A Resection with Biliary Reconstruction: Description of Surgical Technique and Outcomes of Initial Series.

INTRODUCTION: Minimally invasive resection for perihilar cholangiocarcinoma is an emerging technique that requires both mastery in minimally invasive liver resection and biliary reconstruction. Due to technical difficulties in biliovascular dissection, radical portal lymphadenectomy and the need for fine suturing during bilioenteric anastomosis, this type of resection is generally not performed laparoscopically, even at high-volume, liver-surgery centers.1-3 In modern literature, a detailed, operative description of robotic technique for this operation with outcome data is lacking. This video article demonstrates a pure robotic Klatskin Type 3A resection with clinical outcomes of our initial series. VIDEO: A 77-year-old man presented with jaundice and findings of bilateral, intrahepatic, ductal dilation (Right > Left). Radiological imaging showed a type 3A Klatskin tumor with associated thrombosis of the right, anterior portal vein. A further endoscopic evaluation with cholangioscopy confirmed a high-grade Bismuth 3A biliary malignant stricture. Endoscopic drainage was achieved with placement of two, 7-French, 15-cm, plastic, endobiliary stents. A 3-D anatomical liver reconstruction showed a 2-cm mass located in the area of right, anterior, sectoral, Glissonean pedicle with standardized, future, liver-remnant (left hepatic lobe) volume of 50%. The patient was placed supine on the operating table. General endotracheal anesthesia was administered. After exclusion of metastatic peritoneal disease with diagnostic laparoscopy, cholecystectomy and systematic radical portal lymphadenectomy were first completed with a goal to obtain more than six lymph nodes. After appropriate portal lymphadenectomy, the common bile duct was isolated and transected at the level of pancreatic head. The plastic, endobiliary stents were removed, and a distal common bile duct margin was sent for a frozen-section examination to rule out distal extension of the cholangiocarcinoma. A small, accessory, right, hepatic artery lateral to the main portal vein was ligated with locking clips and removed together with the adjacent nodes and lymphatic bearing tissues. The intrapancreatic portion of the distal common bile duct was suture closed once the distal common bile duct margin was confirmed to be negative for neoplasia by the frozen-section examination. The proximal bile-duct dissection commenced cephalad toward the hilar bifurcation. Once the biliary bifurcation has been adequately dissected and detached from the hilar plate, the distal, left, hepatic duct was then transected near the base of the umbilical fissure to gain an R-0 resection margin. A second frozen-section specimen was obtained from the left, hepatic duct cut edge to ensure an absence of infiltrating tumor cells on the future, bile-duct remnant side. Division of short, hepatic veins off the inferior vena cava (IVC) were next completed. Once the line of hepatic-parenchymal transection was confirmed by using indocyanine green administration, the right hepatic artery and portal vein were ligated and clipped. The liver, parenchymal transection began with a crush-clamp technique utilizing robotic, fenestrated bipolar forceps and a vessel-sealing device. Preservation of the middle hepatic vein is always the preferred technique to avoid congestion of the left medial sector of the liver. The entire right hepatic lobe and the caudate lobe were removed en bloc. A large, Makuuchi ligament was isolated and divided by using a robotic, vascular-load stapler once the liver is open-booked. Finally, the root of the right hepatic vein was exposed and transected flush to the IVC by using another load of robotic vascular stapler. The biliary reconstruction then began by creating a 60-cm, roux limb for a hepaticojejunostomy bilioenteric anastomosis. A side-to-side, stapled jejunojejunostomy was created by using two applications for robotic 45-mm, blue load staplers. The common enterotomy was closed with running barbed sutures. The roux limb was then transposed retrocolically toward the porta hepatis. A single end-to-side hepaticojejunostomy anastomosis was created with running absorbable 4-0 barbed sutures. Finally, a closed suction abdominal drain was placed before closing. RESULTS: The operative time was approximately 8 hours with 150 ml of blood loss. The postoperative course was unremarkable. The final pathology report confirmed a moderately differentiated perihilar cholangiocarcinoma with negative resection margins. Ten lymph nodes were harvested. No nodal metastasis or lymphovascular invasion was found. Since 2021, we have undertaken robotic resection of Klatskin 3A tumor in four patients with a median age of 70 years. All patients presented with jaundice, and they mainly underwent preoperative biliary drainage using ERCP. The median operative duration was 508 minutes with estimated blood loss of 150 ml. R-0 resection margins were obtained in all patients. One patient suffered from postoperative complications requiring treatment of line sepsis using intravenous antibiotics. We did not find a 90-day mortality in this series. At a median follow-up period of 15 months, all of the patients were alive without any evidence of disease recurrence. CONCLUSIONS: Robotic resection of Type 3A Klatskin tumor is safe and feasible with appropriate experience in robotic hepatobiliary surgery, as demonstrated in this video article.

Does metabolic syndrome affect perioperative outcomes in patients undergoing robotic hepatectomy? A propensity score-matched analysis.

BACKGROUND: Metabolic syndrome is a known risk factor for postoperative complications after general surgical procedures. Literature analyzing perioperative outcomes of patients with metabolic syndrome undergoing a minimally invasive hepatectomy is limited. We sought to investigate if metabolic syndrome significantly impacts the perioperative course and outcomes of patients undergoing robotic hepatectomy. METHODS: With IRB, we prospectively followed patients who underwent robotic hepatectomy from 2016 through 2020. A 1:1 propensity score-matched (PSM) analysis was applied to patients with and without metabolic syndrome. Demographic and clinical data were analyzed for those cohorts before and after PSM. Metabolic syndrome was defined as BMI ≥ 28.8 kg/m2, diabetes, and hypertension. RESULTS: A total of 272 patients underwent robotic hepatectomy, 39 (14%) of whom had metabolic syndrome. After performing PSM, we ended up with 74 patients, 37 in each cohort, 28% of them had liver cirrhosis. Patients with metabolic syndrome had higher BMI (34 ± 5.6 vs. 28 ± 5.9 kg/m2, p < 0.001) and MELD scores (10 ± 4.5 vs. 8 ± 3.2, p < 0.001) compared to patients without metabolic syndrome. Additionally, patients with metabolic syndrome had an increased incidence of liver cirrhosis (33% vs. 9%, p = 0.0002). Following PSM, BMI (34 ± 5.7 vs. 26 ± 4.4 kg/m2, p < 0.001) was the only preoperative variables associated with metabolic syndrome. There were no statistical differences before and after PSM between patients with and without metabolic syndrome in terms of intraoperative metrics including operative time, blood loss, conversion to 'open,' and intraoperative complications. All postoperative outcomes metrics before and after PSM did not correlate with the presence or absence of metabolic syndrome. CONCLUSIONS: Metabolic syndrome had no impact on intra- or postoperative metrics, complications, or outcomes after robotic hepatectomy. We believe that the robotic approach may mitigate the adverse effects of metabolic syndrome for patients undergoing robotic hepatectomy.

Validity of the Institut Mutualiste Montsouris classification system for robotic liver resection.

BACKGROUND: The Institut Mutualiste Montsouris (IMM) classification system is one of several widely accepted difficulty scoring systems for laparoscopic liver resections. Nothing is yet known about the applicability of this system for robotic liver resections. METHODS: We conducted a retrospective review of 359 patients undergoing robotic hepatectomies between 2016 and 2022. Resections were classified into low, intermediate, and high difficulty level. Data were analyzed utilizing ANOVA of repeated measures, 3 x 2 contingency tables, and area under the receiving operating characteristic (AUROC) curves. Data are presented as median (mean ± SD). RESULTS: Of the 359 patients, 117 were classified as low-difficulty level, 92 as intermediate, and 150 as high. The IMM system correlates well with tumor size (p = 0.002). The IMM system was a strong predictor of intraoperative outcomes including operative duration (p<0.001) and estimated blood loss (EBL) (p<0.001). The IMM system also showed a strong calibration for predicting an open conversion (AUC=0.705) and intraoperative complications (AUC=0.79). In contrast, the IMM system was a poor predictor of postoperative complications, mortality, and readmission. CONCLUSION: The IMM system provides a strong correlation with intraoperative, but not postoperative outcomes. A dedicated difficulty scoring system should be developed for robotic hepatectomy.

Robotic Extrahepatic Biliary Resection with Roux-en-Y Hepaticojejunostomy for Type 2 Klatskin Tumor.

BACKGROUND: Despite the widespread of laparoscopic technique in hepatobiliary tumor resection, nearly all Klatskin tumor resection is undertaken using an open approach (Marino et al. in Updates Surg 72(3):911-912. https://doi.org/10.1007/s13304-020-00777-8 ; Sucandy et al. in Am Surg, 2020. https://doi.org/10.1177/0003134820956336 , Am Surg, 2020;86(3):200-207; Luberice et al. in HPB (Oxford), 2020. https://doi.org/10.1016/j.hpb.2020.10.008 ; Ciria et al. in J Hepatobiliary Pancreat Sci, 2020. https://doi.org/10.1002/jhbp.869 ; Chong and Choi in J Gastrointest Surg 23(9):1947-19488, 2019. https://doi.org/10.1007/s11605-019-04242-9 ). A minimally invasive approach for malignant extrahepatic biliary resection is rarely used due to technical complexity and concerns of oncological inferiority. In the United States, robotic technique for Klatskin tumor resection has not been adequately described. This video described our technique of robotic extrahepatic biliary resection with Roux-en-Y hepaticojejunostomy (HJ) for type 2 Klatskin tumor. METHODS: A 77-year-old man presented with obstructive jaundice. Endobiliary brushing confirmed adenocarcinoma. MRI/MRCP showed a focal lesion at the cystic duct entrance into the common hepatic duct, extending cephalad toward the biliary bifurcation. No obvious vascular invasion was identified on the CT scan. RESULTS: The operation was undertaken using a six-port technique. Systematic portal dissection was undertaken to identify the bile duct at the level of the pancreas up toward the hepatic hilum. A partial Kocher maneuver was performed to expose the area dorsal to the distal common bile duct, which allows for a more thorough lymphadenectomy and facilitates creation of a later tension-free hepaticojejunostomy. The distal common bile duct was transected, and the distal margin was sent for frozen section. The right hepatic artery coursing posterior to the common hepatic duct was skeletonized and preserved. Biliary duct bifurcation was transected at the level of the right and left duct, removing the cancer completely. Portal lymphadenectomy was completed as part of oncological staging and treatment. A total of eight lymph nodes were removed and all confirmed to be nonneoplastic on the final pathology report. For the purpose of the biliary reconstruction, a standard side-to-side stapled jejunojejunostomy was created. A jejunal mesenteric defect was closed to prevent a future internal herniation. A 60-cm Roux limb was transposed antecolically for the Roux-en-Y hepaticojejunostomy. A running technique was used to create a watertight end-to-side bilioenteric anastomosis, using 3-0 barbed sutures, 6 inches in length. A closed suction drain was placed before closing. Pathology report confirmed intraductal papillary adenocarcinoma with R-0 resection margins (proximal, distal, and radial margin). Perineural invasion was present; however, lymphovascular invasion was not identified. Total operative time was 240 minutes with 75 ml of estimated blood loss. The postoperative recovery was uneventful. One-year follow-up showed no evidence of disease recurrence or HJ anastomotic stricture. CONCLUSIONS: This video demonstrates a safe and feasible application of the robotic platform in extrahepatic bile duct cancer resection requiring fine biliary reconstruction.

Robotic resection of extrahepatic cholangiocarcinoma: Institutional outcomes of bile duct cancer surgery using a minimally invasive technique.

BACKGROUND AND OBJECTIVES: The purpose of this study is to report our early experience and outcomes, the first in North America, of Extrahepatic Cholangiocarcinoma (EHC) resection with Roux-en Y Hepaticojejunostomy reconstruction via the robotic approach. METHODS: With Institutional Review Board approval, 15 patients who underwent robotic resection of EHC were studied. RESULTS: Patients were 74 (73 ± 8.9) years of age. There were 9 men and 6 women. Average body mass index was 24 (27 ± 6.3) kg·m-2 . Mean & Median ASA class was 3. Median Tumor size was 2 (2 ± 1.3) cm. There were no intraoperative complications. Operative duration was 453 (443 ± 85.0) minutes and the estimated blood loss was 150 (182 ± 138.4) ml. No patient required admission to the intensive care unit. Hospital length of stay was 4 (6 ± 3.2) days. There was one patient with Clavien-Dindo Class 3 or greater complication. No mortality was seen in this series. DISCUSSION: Robotic resection of EHC is safe, feasible, and reproducible with excellent clinical outcomes. Consequently, the robotic technique should be considered in some patients requiring EHC resection.

Propensity score matched comparison of robotic and open major hepatectomy for malignant liver tumors.

BACKGROUND: Outcome data on robotic major hepatectomy are lacking. This study was undertaken to compare robotic vs. 'open' major hepatectomy utilizing patient propensity score matching (PSM). METHODS: With institutional review board approval, we prospectively followed 183 consecutive patients who underwent robotic or 'open' major hepatectomy, defined as removal of three or more Couinaud segments. 42 patients who underwent 'open' approach were matched with 42 patients who underwent robotic approach. The criteria for PSM were age, resection type, tumor size, tumor type, and BMI. Survival was individually stratified for hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (IHCC), and colorectal liver metastases (CLM). The data are presented as: median (mean ± SD). RESULTS: Operative duration for the robotic approach was 293 (302 ± 131.5) vs. 280 (300 ± 115.6) minutes for the 'open' approach (p = NS). Estimated Blood Loss (EBL) was 200 (239 ± 183.6) vs. 300 (491 ± 577.1) ml (p = 0.01). There were zero postoperative complications with a Clavien-Dindo classification ≥ III for the robotic approach and three for the 'open' approach (p = NS). ICU length of stay (LOS) was 1 (1 ± 0) vs. 2 (3 ± 2.0) days (p = 0.0001) and overall LOS was 4 (4 ± 3.3) vs. 6 (6 ± 2.7) days (p = 0.003). In terms of long-term oncological outcomes, overall survival was similar for patients with IHCC and CLM regardless of the approach. However, patients with HCC who underwent robotic resection lived significantly longer (p = 0.05). CONCLUSION: Utilizing propensity score matched analysis, the robotic approach was associated with a lower EBL, shorter ICU LOS, and shorter overall LOS while maintaining similar operative duration and promoting survival in patients with HCC. We believe that the robotic approach is safe and efficacious and should be considered a preferred alternative approach for major hepatectomy.

Applying IWATE criteria to robotic hepatectomy: is there a "robotic effect"?

BACKGROUND: The objective of this study is to apply this criteria to determine its applicability to robotic hepatectomy. METHODS: We prospectively followed 105 patients undergoing robotic hepatectomy. Operations were categorized into Low (0-3), Intermediate (4-6), Advanced (7-9), and Expert (10-12). RESULTS: Patients had a median age of 62 (61 ± 13.1) years, with a BMI of 28 (29 ± 6.1) kg/m2; 38% were women. ASA class was 3 (3 ± 0.6). Of the 105 operations, 2 were categorized as Low, 31 as Intermediate, 49 as Advanced, and 23 as Expert. EBL and operative duration were found to be significantly greater as the operative difficulty level increased (p < 0.03 and p < 0.01, respectively). Intraoperatively, when comparing Expert and Intermediate, EBL and operative duration were significantly greater (p = 0.0001 and p = 0.0031, respectively). In the comparison of Expert with Advanced, operative duration was significantly longer (p = 0.0001). Postoperatively, comparisons between Expert and Intermediate, Expert and Advanced, and Advanced and Intermediate showed no differences. CONCLUSION: EBL and operative duration increased with IWATE scores reflecting more difficult robotic hepatectomies. However, with the robotic approach, our postoperative outcomes were similar irrespective of IWATE difficulty scores. Perhaps, the robotic approach potentially has a mitigating effect on postoperative outcomes regardless of difficulty level.

Robotic Major Hepatectomy: An Institutional Experience and Clinical Outcomes.

INTRODUCTION: Most of the literature has only reported outcomes on robotic minor non-anatomical hepatectomy. This study was undertaken to analyze and examine the safety, feasibly, and perioperative outcomes of robotic major hepatectomy at our institution. METHODS: All patients undergoing robotic major hepatectomy were prospectively followed. Major hepatectomy was defined as a resection of 3 or more segments. Data are expressed as median (mean ± SD). RESULTS: A total of 170 consecutive patients underwent robotic hepatectomies, of which 100 were major resections involving at least 3 segments. The 100 patients were of median 62 (61 ± 13.0) years, and 46% were women. Median BMI was 29 (29 ± 5.9) kg/m2 and median ASA class was 3 (3 ± 0.5). Thirty percent of robotic major hepatectomies were for hepatocellular carcinoma, 28% were for metastatic adenocarcinoma, 9% were for cholangiocarcinoma, and 5% were for metastatic neuroendocrine tumor. Prep time (in the room until incision) was a median 58 min (62 ± 18.4), extraction time (incision until specimen extraction) was 124 min (146 ± 99.5), console time was 198 min (210 ± 123.9), closure time (extraction until dressing placement) was 109 min (131 ± 93.8), operative duration was 246 min (269 ± 123.2), and time under anesthesia was 330 min (353 ± 109.6). Estimated blood loss was 175 ml (249 ± 275.9) and length of stay was 4 days (5 ± 4.3). Seven patients experienced postoperative complications. Thirteen patients were readmitted within 30 days, and one patient died within 30 days. CONCLUSION: Application of the robotic platform to major hepatectomy is safe and feasible. Our early experience shows that this minimally invasive approach results in excellent short-term outcomes.

Men surgeons' perceptions of women surgeons: is there a bias against women in surgery?

BACKGROUND: Surgery has long been a man-dominated discipline with gender roles traditionally defined along societal norms. Presumably, as society has evolved, so have men surgeons' perceptions of women surgeons, though data are lacking. This study was undertaken to determine if men surgeons' perceptions of women surgeons represent a bias against women in Surgery. METHODS: 190 men surgeons were queried about attitudes toward women surgeons utilizing a validated questionnaire. The survey included binary, multiple choice, and Likert scale questions (1 = definitely disagree to 5 = definitely agree). RESULTS: 84% of the men surgeons have been attending surgeons for more than 5 years; 80% deem women surgeons as capable as their man colleagues. 80% of respondents consider it possible for a woman to be a good surgeon, mother, and spouse; however, 76% believe women surgeons experience more pressure to balance work and family. 75% of the men surgeons think women surgeons have the same advancement opportunities as men, though 30% believe gender discrimination exists in Surgery. 45% of the respondents consider the "surgical discipline" accountable for fewer women finishing training, yet 57% think the rate of women entering Surgery is not a problem to address. CONCLUSION: While most men surgeons have favorable opinions of the personal and professional abilities of women surgeons, favorable opinions are not universal; a bias against women persists in Surgery. Considering most medical students today are women, the discipline of Surgery dismisses this talent pool only to its detriment. Surgery, and men in Surgery specifically, must evolve to eliminate bias against women in Surgery, promoting an equitable and inclusive work environment for the betterment of Surgery and all its stakeholders, including patients.

Doing more with less: our decade of experience with laparo-endoscopic single site Heller myotomy supports its application.

BACKGROUND: Achalasia is a rare esophageal motility disorder that affects 1 in 100,000 individuals. Currently, laparoscopic Heller myotomy with anterior fundoplication is the 'gold standard' therapy for achalasia, alleviating symptoms by de-functionalizing the lower esophageal sphincter mechanism. The advent of the Laparo-Endoscopic Single Site (LESS) technique provides a more minimally invasive approach to Heller myotomy. METHODS: With IRB approval, 179 patients who underwent LESS Heller myotomy with anterior fundoplication since 2007 have been prospectively followed. Patients self-assessed symptom frequency and severity preoperatively and postoperatively using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Patients scored their scar satisfaction (1 = revolting to 10 = beautiful). Data are presented as median (mean ± SD). Significance was accepted with 95% probability. RESULTS: Fifty-one percent of patients were men, of age 55 (53 ± 17) years and BMI of 25 (25 ± 6.1) kg/m2. Patients had an operative time of 134 (135 ± 34.3) minutes with an estimated blood loss (EBL) of 50 mL. Postoperative complications occurred in 18% of patients (e.g., urinary retention, capnothorax). Length of stay was 1 (2 ± 2.1) day. Preoperatively, symptoms (e.g., dysphagia, regurgitation) were frequent and severe; following myotomy, all symptoms queried were significantly less frequent and severe with follow-up of 28 (34 ± 18.4) months (p < 0.0001 for all, paired Student's t test). Eighty-seven percent of patients reported they were 'very satisfied' or 'satisfied' with their experience and 95% of patients would undergo the operation again knowing what they know now. Patients scored their satisfaction with their scar as 10 (9 ± 1.6). CONCLUSION: Heller myotomy with anterior fundoplication undertaken via the LESS approach provides efficacious, satisfactory, and durable amelioration of symptoms. Patients reported significant symptom resolution as well as satisfaction with their overall experience. Our decade of experience documenting the salutary benefits of LESS Heller myotomy should be more than enough to encourage surgeons to incorporate the approach into their armamentarium.

Heller myotomy with esophageal diverticulectomy: an operation in need of improvement.

BACKGROUND: This study was undertaken to evaluate the outcomes after laparoscopic Heller myotomy with anterior fundoplication and diverticulectomy for patients with achalasia and esophageal diverticula. METHODS: 634 patients undergoing laparoscopic Heller myotomy and anterior fundoplication from 1992 to 2015 are prospectively followed up; patients were stratified for those undergoing concomitant diverticulectomy. Patients graded symptom frequency and severity before and after myotomy, using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Median data are presented (mean ± SD). RESULTS: Forty-four patients, age 70 years (65 ± 14.2), underwent laparoscopic Heller myotomy, anterior fundoplication, and diverticulectomy. Operative time was 182 min (183 ± 54.6). Fifty percentage of patients had a postoperative complication: Most notable were leaks at the diverticulectomy site (n = 8) and pulmonary complications (n = 11; 10 effusion, 1 empyema). Length of stay (LOS) was 3 days (5 ± 8.3). All leaks occurred after discharge and resolved without sequelae using transthoracic catheter drainage and parenteral nutrition; two patients received endoscopic esophageal stents. Median follow-up is 39 months. Symptoms amelioration was significant postoperatively, including severity of dysphagia [6 (6 ± 3.9) to 2(4 ± 3.6)]. Seventy-six percentage of patients rated their symptoms at last follow-up as satisfying/very satisfying. Seventy-seven percentage of patients had symptoms once per week or less. Eighty-one percentage would have the operation again knowing what they know now. CONCLUSIONS: Laparoscopic Heller myotomy, anterior fundoplication, and diverticulectomy well palliate the symptoms of achalasia with accompanying esophageal diverticulum. The operations are generally longer than those without diverticulectomy and are accompanied by a relatively longer LOS. Complications are relatively frequent and severe (e.g., leaks and pneumonia). In particular, leaks at the diverticulectomy site are unpredictable, occur after discharge, and remain vexing. Nevertheless, for this advanced form of achalasia, long-term symptom relief and patient satisfaction are high after anterior fundoplication with concomitant diverticulectomy. New and innovative techniques are needed to decrease the frequency of leaks at the diverticulectomy site.

Does the cost of robotic cholecystectomy translate to a financial burden?

INTRODUCTION: Robotic application to cholecystectomy has dramatically increased, though its impact on cost of care and reimbursement has not been elucidated. We undertook this study to evaluate and compare cost of care and reimbursement with robotic versus laparoscopic cholecystectomy. METHODS AND PROCEDURES: The charges and reimbursement of all robotic and laparoscopic cholecystectomies at one hospital undertaken from June 2012 to June 2013 were determined. Operative duration is defined as time into and time out of the operating room. Data are presented as median data. Comparisons were undertaken using the Mann-Whitney U-test with significance accepted at p ≤ 0.05. RESULTS: Robotic cholecystectomy took longer (47 min longer) and had greater charges ($8,182.57 greater) than laparoscopic cholecystectomy (p < 0.05 for each). However, revenue, earnings before depreciation, interest, and taxes (EBDIT), and Net Income were not impacted by approach. CONCLUSIONS: Relative to laparoscopic cholecystectomy, robotic cholecystectomy takes longer and has greater charges. Revenue, EBDIT, and Net Income are similar after either approach; this indicates that costs with either approach are similar. Notably, this is possible because much of hospital-based costs are determined by cost allocation and not cost accounting. Thus, the cost of longer operations and costs inherent to the robotic approach for cholecystectomy do not translate to a perceived financial burden.