Technical feasibility of robot-assisted ventral hernia repair.

BACKGROUND: The da Vinci robotic laparoscopic incisional hernia repair with intracorporeal closure of the fascial defect and circumferential suturing of the mesh may offer an alternative to current fascial closure and transabdominal sutures and tackers. METHODS: From 2009 to 2011, a retrospective review of 13 patients with a mean age of 51 years, median body mass index (BMI) of 31.53 kg/m(2), and small and medium-sized ventral hernias (mean fascial defect 37.39 cm(2)) were treated with the da Vinci robot system using intracorporeal primary closure of the fascial defect with a running O-absorbable suture followed by underlay mesh fixation using a continuous running, circumferential, nonabsorbable suture. This study aimed to assess the technical feasibility of the procedure. In addition, the operating time and specific morbidity of postoperative pain, and long-term recurrence were recorded. RESULTS: The mean operating time was 131 min. There were no conversions to open or standard laparoscopic techniques. There were no postoperative deaths. The overall morbidity rate was 13%. One patient remained in hospital for pain control, and another experienced urinary retention that required a Foley catheter. The mean hospital stay was 2.4 days. During a median follow-up period of 23 months, one of the patients experienced a recurrent hernia. None experienced chronic suture site pain or discomfort. CONCLUSIONS: This is a retrospective series review of robot-assisted ventral hernia repair using intracorporeal primary closure followed by continuous running, circumferential fixation. The findings show that this technique is feasible and may not be associated with chronic postoperative pain. Further evaluation is needed, and long-term data are lacking to assess the benefit to the patient, but this series can be the basis for future studies.

Robotic-assisted Roux-en-Y gastric bypass: update from 2 high-volume centers.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (RYGB) is a challenging operation in the most experienced hands. Robotic surgery allows the capabilities of the minimally invasive surgeon to be extended. An increasing number of robotic gastric bypasses are being performed each year with the assumption that the complication rates are decreased. The objectives of the present study were to review the results of robotic-assisted RYGB (RARYGB) from 2 high-volume centers, including 1 university and 1 private practice. METHODS: We report the most recently compiled, largest series of RARYGB in the world to show the effectiveness, morbidity, and mortality of this method. Databases were searched for patients undergoing RARYGB from 2002 to 2010, and the endpoints were recorded. RESULTS: A total of 1100 RARYGBs matched our search. The patients had a mean preoperative age of 46.9 years, mean weight of 131.9 kg, and mean body mass index of 47.9 kg/m(2). The mean operative time was 155 minutes. There were no conversions. The mean body mass index was 39.8 kg/m(2) at 3 months postoperatively (79% follow-up). Complications were few, and included 2 cases of pulmonary embolism (.19%), 3 cases of deep venous thrombosis (.27%), 1 case of gastrojejunal anastomotic leak (.09%), and 9 cases of staple line bleeding (.82%). No patients died. CONCLUSION: RARYGB is safe and effective. Although the operative time might be increased, the complication rates, most notably of anastomotic leak, are extremely low.

Congenital diaphragmatic hernia in the preterm infant.

BACKGROUND: Congenital diaphragmatic hernia (CDH) remains a significant cause of death in newborns. With advances in neonatal critical care and ventilation strategies, survival in the term infant now exceeds 80% in some centers. Although prematurity is a significant risk factor for morbidity and mortality in most neonatal diseases, its associated risk with infants with CDH has been described poorly. We sought to determine the impact of prematurity on survival using data from the Congenital Diaphragmatic Hernia Registry (CDHR). METHODS: Prospectively collected data from live-born infants with CDH were analyzed from the CDHR from January 1995 to July 2009. Preterm infants were defined as <37 weeks estimated gestational age at birth. Univariate and multivariate logistic regression analysis were performed. RESULTS: During the study period, 5,069 infants with CDH were entered in the registry. Of the 5,022 infants with gestational age data, there were 3,895 term infants (77.6%) and 1,127 preterm infants (22.4%). Overall survival was 68.7%. A higher percentage of term infants were treated with extracorporeal membrane oxygenation (ECMO) (33% term vs 25.6% preterm). Preterm infants had a greater percentage of chromosomal abnormalities (4% term vs 8.1% preterm) and major cardiac anomalies (6.1% term vs 11.8% preterm). Also, a significantly higher percentage of term infants had repair of the hernia (86.3% term vs 69.4% preterm). Survival for infants that underwent repair was high in both groups (84.6% term vs 77.2% preterm). Survival decreased with decreasing gestational age (73.1% term vs 53.5% preterm). The odds ratio (OR) for death among preterm infants adjusted for patch repair, ECMO, chromosomal abnormalities, and major cardiac anomalies was OR 1.68 (95% confidence interval [CI], 1.34-2.11). CONCLUSION: Although outcomes for preterm infants are clearly worse than in the term infant, more than 50% of preterm infants still survived. Preterm infants with CDH remain a high-risk group. Although ECMO may be of limited value in the extremely premature infant with CDH, most preterm infants that live to undergo repair will survive. Prematurity should not be an independent factor in the treatment strategies of infants with CDH.

Outcomes of truncal vascular injuries in children.

BACKGROUND: Pediatric truncal vascular injuries occur infrequently and have a reported mortality rate of 30% to 50%. This report examines the demographics, mechanisms of injury, associated trauma, and outcome of patients presenting for the past 10 years at a single institution with truncal vascular injuries. METHODS: A retrospective review (1997-2006) of a pediatric trauma registry at a single institution was undertaken. RESULTS: Seventy-five truncal vascular injuries occurred in 57 patients (age, 12 +/- 3 years); the injury mechanisms were penetrating in 37%. Concomitant injuries occurred with 76%, 62%, and 43% of abdominal, thoracic, and neck vascular injuries, respectively. Nonvascular complications occurred more frequently in patients with abdominal vascular injuries who were hemodynamically unstable on presentation. All patients with thoracic vascular injuries presenting with hemodynamic instability died. In patients with neck vascular injuries, 1 of 2 patients who were hemodynamically unstable died, compared to 1 of 12 patients who died in those who presented hemodynamically stable. Overall survival was 75%. CONCLUSIONS: Survival and complications of pediatric truncal vascular injury are related to hemodynamic status at the time of presentation. Associated injuries are higher with trauma involving the abdomen.