Abstracts of Presentations Made at MISWEEK 2022

Objective: Minimally invasive techniques for Heller Myotomies have become the gold standard for the treatment of symptomatic Achalasia, given the safety and efficacy of the approach. Several studies have shown improved safety with the Robotic platform. Our video case series aims to show our approach to a Heller Myotomy for Achalasia is using the Robotic platform. Methods and Procedures: A video case review describing our approach to a Heller Myotomy using ta robotic surgical platform was performed. Results: The robotic platform is the ideal approach to a Heller Myotomy for symptomatic Achalasia. Upon review of the literature, there does not appear to be statistically significant differences in operative time, blood loss, conversion rates or length of hospitalization when comparing both minimally invasive approaches. However, robotic assisted Heller Myotomies are associated with lower rates of intraoperative esophageal perforations. The increase in degree of movement with the robot, improved ergonomics and more precise handling in small spaces also allows for easier repair of such injuries. Conclusions: Current data appears to support the idea that the robotic approach to Heller Myotomy for Achalasia confers similar outcomes as laparoscopic surgery, with the added advantage of less intraoperative esophageal perforations. We need better powered prospective randomized controlled trials to draw more definite conclusions comparing both modalities.

Objective: Surgical technologic advancement has paralleled growing bariatric surgery demands. We present our series of sleeve gastrectomy (SG) cases performed with the assistance of a robotic platform with haptic feedback (R1), the first such report involving this platform. We also demonstrate R1's utility and safety in obese patients, comparing R1 outcomes to SGs performed laparoscopically or with a common four-arm robotic platform (R2). Methods and Procedures: All SG performed laparoscopically, using R1, or R2 by a single surgeon at an academic center from Jan 2019–Jul 2021 were retrospectively reviewed. Primary outcomes and quality measures were 30-day complications, operative times and length of stay (LOS). Group comparisons were conducted via Fisher's exact tests and ANOVA. Covariate adjusted comparisons of complications were conducted via logistic regression. Analyses were performed in SAS/STAT v9.4. Results: 268 SG patients, including 161 laparoscopic, 92 R1, and 14 R2 cases were included. Operative times were significantly longer with R1(115.7m) and R2(122.7m), compared to laparoscopic (94.8m,p < .0001). R1(1.8d) and R2(2.2d) groups had higher average LOS, compared to laparoscopic cases (1.5d,p < .0001). These differences remained significant after controlling for age, sex and BMI. 30-day complication rates were not significantly different in R1 (8.7%, n = 8), R2 (7.1% n = 1) or laparoscopic (2.5% n = 4) groups (p = 0.0567). Conclusion: R1 is safe in bariatric patients with no significant difference in 30-day complications compared to R2. System docking times may account for significantly increased operative times with both systems. As novel technology, R1 times may reflect learning curve-related differences. ★ Michael S. Kavic Award for Best Scientific Paper by a Resident ★ Best General Surgery Scientific Paper

Objective: Heterotopic (ectopic) pancreatic tissue refers to tissue located outside the borders of the main pancreas. It is rarely found in gallbladders and can cause biliary disease, with only a few documented cases in the surgical literature. Here, we present the unusual case of a 21-year-old female with acute on chronic cholecystitis caused by obstruction of the cystic duct with ectopic pancreatic tissue. Our objective is to describe the significance of ectopic pancreatic tissue in biliary pathology and bring awareness to clinicians about this rare entity. Methods and Procedures: We performed a laparoscopic cholecystectomy with intraoperative cholangiogram. The specimen was examined on the back table then sent to pathology. Results: The gallbladder was inflamed and distended. Aspiration of its contents revealed hydrops with clear fluid only. Intraoperative cholangiogram showed nonobstructing choledocholithiasis and a patent CBD stent. Evaluation of the specimen revealed a submucosal lesion obstructing the cystic duct at its junction with the gallbladder. Pathology showed this to be benign ectopic exocrine pancreatic tissue (type 3; acinar cells only) with acute and chronic inflammatory changes. Pathology also confirmed cholecystitis. Conclusion: Our patient's chronic biliary colic was at least partially caused by the ectopic pancreatic tissue. Presence of hydrops was consistent with prolonged obstruction of the cystic duct. It is also possible for ectopic pancreatic tissue to become inflamed, and this pancreatitis can itself cause disease in the host organ. This case demonstrates a rare cause of cholecystitis and highlights the importance of formulating a broad differential when evaluating a patient with biliary symptoms. ★ Gustavo Stringel Award for Best Poster by a Student

Objective: Recurrent inguinal hernioplasty following previous preperitoneal mesh repair may occur for numerous reasons: mesh too small, mesh too flimsy, late incorporation, migration of hernia sac beneath mesh or inadequate fixation. Background: Despite using larger and stronger mesh, lateral eventuation through the internal ring or "clam shelling" still occur. Fibrin glue has not prevented with either. Method: The "no flip stitch" (NFS) is lateral fixation of mesh over the triangle of pain. NFS is an absorbable "U" stitch through the lateral posterior portion of the peritoneal flap, through mesh only, and back through the peritoneum. Results: NFS helps maintain proper mesh poisitioning during mesh incorporation. Conclusion: After 2 1/2 years of adding the NFS to mesh fixation, no early recurrence has surfaced. ★ Best General Surgery Video

Objective: Giant hiatus hernia (GHH) repair is undertaken electively in symptomatic patients, to prevent complications such as volvulus of the stomach with resultant mortality. Advances in laparoscopy and perioperative care have reduced the risk of operation, and improvement in quality of life (QoL) has become an important outcome measure. “Quality of Life in Reflux and Dyspepsia” (QOLRAD) questionnaire is a disease specific validated tool used to assess QoL. We present our prospective data assessing change in QoL following GHH repair. Methods and Procedures: Symptomatic patients undergoing elective repair of GHH, by a single surgical team, between Jan 2010 and Dec 2021 were identified from a prospectively kept database. Demographic data and operative details were recorded from patient notes. From 2015 onwards the QOLRAD questionnaire was introduced. Patients who underwent GHH repair completed the questionnaire preoperatively and then at 6 weeks, 6 months, 1 year and 2 years postoperatively. Patients, who were not operated on, completed the questionnaire at 6-month intervals over 2 years. Mann-Whitney U test was used to compare QOLRAD scores between hernia size, type and symptomatology. Results: Sixty-eight patients underwent GHH repair from 2010 to 2014. Statistically significant (p < 0.001) improvement in QoL was only seen in patients with ‘heartburn’ symptoms. Forty-six patients were included in the post 2015 group. Statistically significant improvement in all QOLRAD domains was observed post operatively over the follow up period. Conclusion: GHH repair is a safe operation in symptomatic patients that results in an improvement in QoL across all QOLRAD domains and may prevent deterioration in QoL.

Objective: Appendiceal endometriosis is commonly encountered by gynecologists during laparoscopy for endometriosis or chronic pelvic pain. This video reviews appendiceal endometriosis, highlights important anatomical landmarks for appendectomy and demonstrates a novel technique for laparoscopic appendectomy using a CO2 Laser at the time of surgical management of endometriosis. Methods and Procedures: This video uses still images, video footage and narration to review appendiceal endometriosis and laser-assisted appendectomy. The laser appendectomy approach is reviewed in four steps, addressing preoperative and intraoperative considerations. Results: When performing a laparoscopy for endometriosis or chronic pelvic pain assess the appendix for signs of endometriosis. The four key steps when planning a laser appendectomy are (1) patient preparation, (2) isolate the appendix, (3) secure blood supply, and (4) remove appendix. Conclusion: Appendiceal endometriosis is common and preoperative diagnosis is challenging. Appendectomy should be considered at the time of gynecologic surgery for endometriosis or chronic pelvic pain. This video can be used as a reference for gynecologists when performing appendectomy at the time of hysterectomy or laparoscopy for endometriosis or chronic pelvic pain.

Objective: The objective of this project is to assert that robotic resection of gastric gastrointestinal stromal tumors (GISTs) is the superior approach for surgical resection of gastric GISTs located in challenging areas of the stomach. Surgical resection is the standard of treatment for gastric GISTs. However, there is not a consensus on the best surgical approach for resection of these tumors. Robotic surgery is a surgical approach that is gaining popularity and prominence in many different types of surgeries. Methods and Procedures: A robotic resection of a gastric GIST was recorded to demonstrate the steps that are included in this robotic procedure and to show the ease and superiority of this approach in gastric fundic masses. This operative video was condensed into a shortened video summary of the case and then added into a recorded presentation. Results: The patient had an uneventful perioperative course. Intraoperatively, the gastric GIST was resected without complication and the patient was admitted afterward for routine postoperative care. She tolerated a regular diet and she was discharged home on postoperative day two in stable condition. The patient was doing well on her first follow-up appointment in clinic with no acute issues appreciated. Conclusion: The ease with which a robotic gastric GIST resection can be performed and the smooth perioperative course that this patient experience support that the robotic approach is the superior approach in gastric GIST resection.

A Abboud Elia C, 1 Abboud Elia Charbel, 1 Abdou Hossam, 5 Abuzeid Mostafa, 16 Abuzeid Omar, 16 Al-Alao Osama, 12 Ali Akbar, 1 Alligood-Percoco Natasha, 2 Anderson Ashley D, 11 Anderson Christofer, 9 Anderson Michael S, 1 Anne Kump Dorothy, 2 App Samantha, 3, 10 Araya Joseph Sewell, 12 Arcerito Massimo, 4 Arjani Simran, 5, 10 Ashraf Mohammad, 16 Atiemo Kofi, 12 Avila Azalia, 3 B Baghli Adnan, 13 Baiocchi Michael, 4 Baldonado Jobelle J, 9 Benlolo Samantha, 10 Bhattacharyya Eesha, 14 Bilik Sophie, 12 Birungi Judith F, 1 Bourdeau Timothy, 11 Bowers Steven P, 7 Breen Michael T, 14 Butano Vince, 3 Butano Vincent, 3, 11 C Cabrera Victor, 2 Cain Abigail, 14 Canton Silvio Alenn, 6 Carnabatu Christopher, 12 Cervone Agostino, 6 Chaudhury Maddhu, 5 Chhikara Priya M, 7 Chin Chih Peng, 12 Chokshi Ravi J, 5, 10 Cibulas Megan, 3 Cook Michael W, 7 Crespo Kaitlyn, 3, 11 Crowley Marci, 11 D Danos Denise, 7 Degen Michael, 8-9, 13 del Rosario Stefania P, 2 DeLong Jonathan C, 4 Desai Amar, 10 Desai Nasreen, 5 Dishno Morgan M, 2 Doerhoff Carl R, 4 Dokus Katherine, 8 Dua Monica M, 4 E Elli Enrique F, 7 Elniel Mohammed, 5 F Faizi Zaheer, 7 Fang Francia, 5 Fontaine Jacques P, 9 Friedman Patricia, 6 Fusco Lisa, 12 G Gannon Christopher J, 3 Garden Evan B, 12 Garrett Joseph R, 9 Ghazi Ahmed, 8 Grasso Sierra A, 6 Greenseid Samantha A, 6 Gupta Shreya, 7 H Hand Audrey, 4-5 Hauser Elizabeth, 12 Helbig Katie, 8 Herbig Kelly A, 2 Hernandez Pamela, 1 Hernandez Roberto, 8 Hlopak Joseph, 7 Huggler Angela, 2 I Ichikawa Michelle, 14 Ignatius Josh, 3 Issacson Erin, 14 J Jacoby Harel, 3 Jain Varun, 7 Jamet Antoine, 13 Jensen Christopher W, 4 Jeon Hoonbae, 9, 12 Johnson Kalley N, 2 Joseph Coté John, 2 Joseph Coté Quinlan, 2 Joseph Jean V, 8 K Kang Juhye, 5 Kashyap Randeep, 8 Kasinath Pooja, 2 Kavic Stephen M, 5 Killackey Mary, 12 King Natalie, 4-5 Kondylis Philip, 2 Kubicki Natalia, 5 Kuo Jennifer, 8-9, 13 Kurian Ashwin, 6 L Levy Elias Charua, 15 Levy Micah, 12 Lichon Jenny, 12 Lima Diego, 6 Llaguna Omar H, 3 Louridas Marisa, 10 M Malat Jaclyn, 4-5 Malcher Flavio, 6 Mamik Mamta M, 16 Marina Trimmer T, 1 Mazeaud Charles, 13 McCabe Michael, 8 McCaffrey Carmen, 10, 14 McDermott Victoria, 12 McDonald Michael, 8 McQuillen Alexandra, 2 Melnyk Rachel, 8 Mendoza MaryCarmen, 1 Mendoza Patricio, 1 Miazga Elizabeth, 10, 14 Montane Bryce, 9 Moodie Carla C, 9 Morales Joseph, 7 Munver Radha, 8 Munver Ravi, 8-9, 13 Munver Sujan, 9 N Nair Amit, 8 Nemeth Denise V, 1 Nensi Alysha, 14 Nezhat Farr, 8 Ngongoni Rejoice F, 4 Norton Jeffrey A, 4 O Oliver Joseph B, 10 Orloff Mark, 8 Otcenasek Michal, 11 P Palese Michael A, 12 Panse Neal, 5, 10 Paramesh Anil, 12 Park Hye-In, 12, 15 Pasquali Claudio, 6 Pereira Xavier, 6 Peronard Tristan, 12 Pineda-Solis Karen, 8 Poultsides George A, 4 Prasath Vishnu, 5, 10 Primus Jasmine, 3 Q Quinn Patrick, 10 R Rayman Shlomi, 3, 11 Redwood Emile, 12, 15 Rehman Subhia, 16 Rodriguez Kathryn, 9 Romero-Velez Gustavo, 6 Rosemurgy Alexander, 3, 10-11 Ross Sharona, 3, 10-11 Rua Juan P, 11 S Salah Mohamed H, 15 Salom Emery, 15 Salom Emery M, 15 Samuels Shenae, 3 Satarasinghe Praveen, 7 Schroeder Nicole, 14 Schulte Alejandra Martínez, 15 Seraji Shadi, 8 Serrano Luis, 2 Serrano Luis F, 11 Shapera Emanuel A, 10 Shedd-Hartman Kelly-Anne, 12 Shishkina Anna, 10 Singh Adityabikram, 10 Skolnik Emma, 14 Sowby Taralyn C, 15 Sreeramoju Prashanth, 6 Starkman Hava, 14 Staudinger Kelsey A, 6 Sucandy Isawnto, 11 Sucandy Iswanto, 3, 10 Sulger Elisabeth, 12, 15 Swor Michael, 12 Syblis Cameron, 3, 11 T Tagerman Daniel, 6 Takei Thomas H, 4 Tatum Danielle, 12 Taylor Jeremy, 8 Tekin Yunus B, 1 Tew Jenna, 9 Timmerhuis Hester C, 4 Tohamy Aley, 7 Toloza Eric M, 9 Tong Ernest, 8-9, 13 Toomey Paul, 4-5 Toosi Kavian, 9 Torres-Aguiar Roberto M, 2 Tran Tuan, 7 V Vasicka Ian M, 11 Velazco José H, 1 Velez Frank O, 9 Vennirro Erika, 8 Vijay Adarsh, 9, 12 Visser Brendan C, 4 W Warda Hussein, 16 Wise Eric S, 5 Worth Patrick J, 4 Wu Guan, 8 Y Youssef Youssef, 16 Z Zorn Julia S, 6

Objective: To evaluate the perioperative safety as well as the long-term outcomes for the use of barbed suture for the primary closure of hernia defects in robotic ventral hernia repair (rVHR). Methods: This is a retrospective study of adult patients who underwent rVHR with a barbed suture for fascial defect closure from Aug 2018 to Aug 2020 in an academic center. All patients included were queried by phone to complete a quality-of-life assessment to assess patient reported outcomes (PRO). Results: A total of 81 patients with 102 hernias were analyzed. Sixty patients (74%) were successfully reached and completed the PRO form at median postoperative day 356 (range 43–818). Thirteen patients (22%) reported feeling a bulge at their previous hernia site, and 24 patients (40%) reported physical pain or symptoms at the site of the operation. Median HerQLes score was 82 (IQR 54–99). Patients with a single hernia defect, when compared to those with multiple defects, had a lower rate of both a bulge (15% vs 30%) and symptoms (33% vs 48%) as well as a higher median HerQLes score (85 vs 62) at the time of PRO follow up. Patients with previous hernia repair had a lower median HerQLes score of 65 (IQR 43–90) vs 88 (IQR 62–100). These patients also had a higher rate of sensing a bulge (29% vs 18%), while a sense of symptoms at the site was less (33% vs 44%). Conclusions: Barbed suture was both safe and effective for the use of fascial defect closure in rVHR.

Introduction: Pseudomyxoma peritonei (PMP) is a rare condition in which there is mucin present in the peritoneal cavity. This condition is closely associated with the presence of either an appendiceal or an ovarian malignancy. The incidence is estimated to be 1–2 out of a million. 1 It is usually discovered at an advanced stage and severely impacts quality of life. 2 We present a case of pseudomyxoma peritonei in a 86 yr old female, with no observable appendiceal or ovarian pathology. Case Presentation: An 86-year-old female patient presented to the emergency department (ED) of a rural hospital with a chief concern of abdominal bloating of insidious onset. She had undergone an abdominal paracentesis in Mexico five days prior, in which a minuscule amount of gelatinous ascites was retrieved and sent for cytopathologic evaluation, which reported an “acellular sample”. In the ED, a CT revealed a large amount of ascites. A repeat abdominal paracentesis was performed confirming the presence of mucin. Cytopathology was unremarkable and all tumor markers were negative. The patient was referred to a specialist in a tertiary center, where a thorough evaluation failed to reveal the cause of her PMP. Due to her cardiovascular status no further interventions were done. The patient was returned to the rural setting with increased discomfort. Conclusion: Decision was made to take the patient to the operating room for an exploratory laparoscopy and placement of peritoneal dialysis catheter for palliative measures. The procedure was uneventful, and the patient experienced long standing relief.

Objective: Rectal injury during robotic-assisted radical prostatectomy (RARP) may be underreported in the literature due to the absence of postoperative sequelae following intraoperative repair. We present our experience with this complication, as well as a method for intraoperative detection in the absence of visual cues. Methods and Procedures: IRB-approved databases were reviewed for 905 patients who underwent robotic-assisted radical prostatectomy. Patient characteristics, perioperative parameters, pathological findings, and rectal injury diagnosis and management were assessed. Results: Nine (0.99%) rectal injuries were identified, of which 7 were identified and repaired intraoperatively. Two patients had delayed recognition of rectal injury on postoperative days 4 and 8. These patients presented with sepsis and underwent exploratory laparotomy by general surgeons. The initial 5 rectal injuries occurred in the first 664 RARPs of which 3 were visually diagnosed intraoperatively and 2 were diagnosed postoperatively. Subsequent to these rectal injuries, we instituted the practice of placement of a rectal catheter, filling the empty prostatic fossa with irrigation fluid, and insufflating the rectum to monitor for air bubbles that would suggest rectal injury. During the next 241 RARPs, 1 rectal injury was visually diagnosed intraoperatively and 3 were diagnosed by a positive rectal insufflation air bubble test. All injuries were primarily repaired without postoperative sequelae. There was no association of rectal injury with patient demographics, intraoperative differences, or pathology. Conclusion: Rectal injury, when unrecognized, can be a devastating complication. Our experience highlights the value of the rectal insufflation test as a reproducible method to detect rectal injury when not noted on visual inspection.

Objective: Complications rates in paraesophageal hernia repair operations have decreased with utilization of minimally invasive surgery. Increased adoption of the robotic platform may provide additional benefits. This study aimed to assess cost-effectiveness of robotic and laparoscopic approaches to paraesophageal hernia repair. Methods: A decision tree was created analyzing cost-effectiveness of robotic and laparoscopic paraesophageal hernia repair. Costs were obtained from 2021 Medicare data and were calculated from costs accumulated within 18 months after surgery. Effectiveness was measured in quality-adjusted life-years (QALYs). Branch-point probabilities and costs of robotic surgery consumables were obtained from published literature. Capital costs and yearly maintenance costs were not considered. One-way, two-way, and probabilistic sensitivity analyses were performed by varying branch-point probabilities. Results: Robotic repair yielded 1.09 QALYs at $34,569.17, while laparoscopic repair yielded 1.08 QALYs at $35,017.91. A robotic approach was the dominant strategy, as it resulted in more QALYs at a lower cost. Sensitivity analyses favored robotic repair in all cases except when there was a large difference in hernia recurrence rates needing repair following robotic and laparoscopic surgery. Conclusion: Our model demonstrates a cost-effectiveness benefit of robotic paraesophageal hernia repair in comparison to laparoscopic repair. Due to a learning curve associated with robotic surgery, benefits may initially be limited. However, with experienced surgeons, robotic surgery may improve outcomes and reduce costs in paraesophageal hernia repair.

Objective: The purpose of this video is to highlight the technical skills required for successful robotic inguinal hernia repair as taught to a surgical fellow. Methods and Procedures: This video includes clips from three patients undergoing elective robotic inguinal hernia repair with a single surgeon. The procedure was completed with three ports and use of self-fixating mesh. After creation of the peritoneal flap and hernia sac dissection, there is an emphasis on creating a large, flat plane for mesh placement and positioning. This is accomplished with retroparietal spermatic sheath dissection and creation of a spermatic cord keyhole. All patients were discharged home the same day. Results: Mean procedure time was 51 minutes. The retroparietal spermatic sheath dissection allowed for flat mesh placement and the mesh keyhole with placement of the cord structures posterior to the mesh helped to keep the inferior aspect of the mesh in place. Both of these maneuvers help to decrease inguinal hernia recurrence. During the first five years, robotic inguinal hernia repairs recurrence rate decreased from 15% to 0%. Conclusion: Robotic inguinal hernia repair can be optimized through experience and taught in a stepwise fashion to trainees to build technical skills with a focus on mesh placement to reduce hernia recurrence.

Objective: This film aims to describe a unique approach to safe removal of a rare and potentially life-threatening condition, the cornual ectopic pregnancy. These make up 2–3% of all ectopic pregnancies and require early diagnosis with ultrasound imaging, preoperative planning and skilled surgical technique in order to avoid uterine rupture. The cornual site is unique in its risks to carrying future pregnancies once treated, depending on mode of treatment. Methods and Procedures: This patient had the risk factors of being over the age of forty, receiving ART and prior tubal damage. Ultrasound showed an eccentrically located six week and 5-day pregnancy with "interstitial line" and less than 5 mm myometrial mantle, all the key diagnostic criteria. There are several options for management in these cases, methotrexate, cornuostomy and cornual resection being the most common. In this case, methotrexate was administered prior to surgery and a right cornual resection and salpingectomy was performed with robotic assisted laparoscopy. Petrussin was injected circumferentially prior to resection and the incision was closed with layers of running suture. Results: In the course of this procedure, the ectopic pregnancy was removed successfully. The patient was discharged home meeting postoperative milestones and was seen for follow up one week later. Conclusion: With a laparoscopic approach and the fine motor skills afforded a robotic approach, the resection of cornual pregnancy can be performed safely and with minimal blood loss.

Objective: To evaluate a virtual reality imaging platform and its use in presurgical planning. Methods and Procedures: We evaluated a patient with a renal hilar tumor with computerized tomography scans, magnetic resonance imaging and terra reconstructive 3-dimensional imaging. We then compared and contrasted this with reconstructed images used in virtual reality imaging to help determine tumor location, size and its relationship to the renal hilar vessels. Results: In this case virtual reality imaging helped to distinguish the location of a right renal hilar tumor with better imaging and a clear view of the pathology better than typical imaging modalities. Conclusions: Virtual reality imaging and 3 dimensional views can help to improve presurgical planning especially in difficult surgical cases.

Objectives: Compare a custom laparoscopic controller versus standard video game controllers used as a warm-up prior to completing simulator skills in students and assess resident simulation usage. Methods and Procedures: First, we performed a randomized controlled trial involving medical students. Participants were randomized into one of three groups: group 1 (warm-up with the validated video game using standard video game controllers), group 2 (warm-up with custom-made laparoscopic controllers), and group 3 (no warm-up). Participants in each group completed a pretest without warm-up on a validated laparoscopic simulator. Two days later, participants in each group then completed a posttest on the simulator after using the warm-up of their assigned group. Finally, we surveyed OB/GYN residents about simulation usage, improved access with a video game simulator within the call room and then resurveyed the residents. Results: Fifty-two students enrolled in the study. Subgroup analysis utilizing a mixed model and ANCOVA was performed. Regardless of analysis, a statistically significant (p < 0.001) decrease from Time 1 to Time 2 was constant across groups with no between-group differences at Time 1 or Time 2. Within the survey of fifteen residents, mean simulator use significantly increased from 0.214 to 0.643 p = 0.027. Conclusions: With students, warm-up using either controller did not provide significant improvement over no warm-up. Power analysis indicates that approximately 20 more study participants are required to unveil a statistically significant improvement between standard video game controllers and no warm-up. With residents, overall improved access within the call room increased monthly laparoscopic simulator use.

Objective: In this article, we describe the case of a 60-year-old female who presented with a painless right inguinal mass which increased with Valsalva maneuvers. Methods and Procedures: The De Garengeot hernia refers to a femoral hernia in which the cecal appendix is found confined in the hernial sac. The patient underwent laparoscopic inguinal hernia repair during which the cecal appendix was found to be incarcerated in a femoral hernia (De Garengeot hernia). The hernia was managed without complications by laparoscopy and placement of a knitted polypropylene preformed mesh. The surgical team did not consider the need for an appendectomy. Results: The patient had a favorable surgical outcome and therefore was discharged one day post operated. Conclusion: Our surgical team concluded that since there was no evidence of appendicitis or another complication (appendiceal abscess, gangrenous appendicits or perforation) an appendectomy should be avoided, and that the hernia was adequately repaired with a synthetic mesh without further complication.

Introduction: This study was undertaken to determine whether perioperative variables predict survival following a robotic distal pancreatectomy and splenectomy for pancreatic adenocarcinoma or neuroendocrine tumor. Methods: We prospectively followed 67 patients who underwent robotic distal pancreatectomy and splenectomy for adenocarcinoma (n = 38) or neuroendocrine tumor (n = 29). Associations between perioperative variables were determined utilizing a correlation matrix. Relationships between perioperative variables and survival were determined utilizing a Cox-model of Proportional Hazards. Data are presented as median (mean±SD). Results: For patients with adenocarcinoma, correlations were found between tumor size and mortality (p = 0.01), operative duration and length of stay (LOS) (p = 0.003), and operative duration and Clavien-Dindo score≥III complications (p = 0.006). Sex, age, BMI, ASA class, operative duration, EBL, major complications, LOS, and readmission within 30 days did not influence long-term survival. Only tumor size was a predictor of long-term survival (p = 0.03). For patients with neuroendocrine tumors, men (p = 0.04) and positive margins (p = 0.002) correlated with short-term mortality. Men also had a greater BMI (p = 0.01), ASA class (p = 0.009), and operative duration (p = 0.01) while positive margin status increased LOS (p = 0.003). There were no significant associations or influences between perioperative variables and duration of survival. Conclusion: For patients undergoing robotic distal pancreatectomy and splenectomy for adenocarcinoma, only tumor size had a significant association with duration of survival. For patients with neuroendocrine tumors, no perioperative variables tested influenced duration of survival. Tumor size can be used to predict duration of survival for patients with adenocarcinoma, while there are no perioperative variables that predict duration of survival for patients with neuroendocrine tumors.

Introduction: Minimally invasive surgery (MIS) has increased for lung resection, such as robotic-assisted video-assisted thoracoscopic (R-VATS) lobectomy, but little is known about its learning curve. A surgeon's surgical training, previous experience with MIS, and inclusion of more advanced cancers can define the learning curve. This study sought to determine the learning curve for R-VATS lobectomy by a surgeon with significant VATS lobectomy experience. Methods and Procedures: We retrospectively analyzed perioperative outcomes of consecutive patients who underwent R-VATS lobectomy by one surgeon between Sep 2010 and Jan 2015. Patients were grouped chronologically into one of five quintiles. Operative times, intraoperative estimated blood loss (EBL), perioperative complications, chest tube duration, hospital length of stay (LOS), and in-hospital mortality were compared among the quintiles. Results: A total of 280 patients underwent R-VATS lobectomy by one surgeon between Sep 2010 and Jan 2015. Each of the 5 quintiles had emergency conversion rates of ≤6%. In-house mortality showed a decreasing trend with each subsequent quintile, while hospital LOS significantly decreased with subsequent quintiles. Additionally, pulmonary and cardiac-related postoperative morbidity showed a decreasing trend with subsequent quintiles. Conclusions: In the hands of a thoracic surgeon with significant conventional VATS lobectomy experience, a biphasic learning curve for R-VATS lobectomy was demonstrated by increased operative times during subsequent extension of R-VATS to more complicated cases after establishment of initial R-VATS lobectomy success (the 1st phase), while operative times, hospital LOS, and in-house mortality decreased with improved patient selection together with additional R-VATS experience (the 2nd phase).

Objective: Ectopic pregnancy is an uncommon event; however the prevalence is increasing due to use of assisted reproductive technologies. Ectopic pregnancy occurring in the tubal stump after a salpingectomy occurs in about 0.4% of all ectopic pregnancies. This video demonstrates the use of a single-port laparoscopic approach to surgically manage a tubal pregnancy. Methods and Procedures: A single 2.5 cm umbilical incision was made, and a single-site access port was inserted. Placement was verified using a flex-tip laparoscope. Additional instruments advanced included a suction/irrigator, hybrid ultrasonic/bipolar scalpel. Using the single port, a pelvic survey was performed revealing a right ovarian cyst that was drained, hemoperitoneum that was evacuated, and a left tubal ectopic pregnancy that was cauterized, cut, and removed under direct visualization. Results: This is the first reported case of successfully using a single-port laparoscopic approach to surgically manage a tubal pregnancy. Conclusion: This video demonstrates that a single-site laparoscopic approach is an option for diagnosing and treating tubal stump ectopic pregnancies and may offer benefits compared to conventional laparoscopy including decreased postoperative pain and improved cosmesis.

Objective: The attached video is a presentation of a 57-year-old woman with a past medical history of a known large hiatal hernia with intrathoracic, organoaxial stomach rotation on abdominal imaging who presented from her rehabilitation facility with new onset of decreased oral intake, dysphagia, and coffee ground emesis. The patient noticed increased gagging with attempted oral intake and retching with small brown specimen in her phlegm upon production. Vital signs were within normal limits and the patient appeared in no apparent distress upon presentation, with a benign abdominal examination. Lactic acid was slightly elevated at 1.2 and hemoglobin fell from 10.0 to 8.6. Methods and Procedures: The patient underwent emergency robotic-assisted hiatal hernia repair for potential GEJ obstruction. After stomach reduction into the abdomen, the robotic vessel sealer was used to dissect the hernia sac from the diaphragm. The pleura was found to be scarred down to the hernia sac and was very difficult to release. Penrose introduction allowed for retraction of the esophagus and continued posterior hernia sac reduction with pleural separation. Robotic assistance allowed for excellent approximation of both crura posterior to the esophagus. At this point our lung was noted to be bulging into our operative field. Results: A red rubber catheter was introduced into this space after transfacial gastropexy, allowing for residual air removal and reduction of our iatrogenic pneumothorax at the conclusion of our case. This was confirmed with postoperative X-RAY. Conclusion: Intraoperative reduction of pneumothorax by red rubber catheter can be selectively employed as a safe and effective method.

Introduction and Objective: Despite the feasibility of open transplant nephrectomy for failed allograft, the procedure is maximally invasive with significant morbidity and mortality. A minimally invasive alternative, robotic assisted transplant nephrectomy, potentially offers significant patient benefit. This technique has not been widely adopted, in part due to lack of training opportunity. We aimed to develop a perfused, high-fidelity, full immersion platform for simulation training in this operation with a goal of increasing accessibility. Methods: A three-dimensional computer aided design model consisting of a kidney, pelvicalyceal system, renal artery and vein was created from a computed tomography scan of a transplant nephrectomy patient. 3D-printed negative casts from the model were injected with a polyvinyl alcohol hydrogel formulation to fabricate an anatomically accurate kidney phantom and surrounding abdominal cavity. Surgeons rehearsed robotic assisted transplant nephrectomy on this platform and after completion, pilot operations were undertaken on five patients requiring nephrectomy for failed allograft. Results: Five patients underwent robotic assisted transplant nephrectomy; 4 male and 1 female; average age was 47 years. The most common indication was abdominal pain secondary to rejection (3/5). Average blood loss was 188 mL; average operative time was 243 minutes. Average length of stay was 4.5 days. There were no perioperative or wound complications, nor readmissions related to surgery. Conclusions: Using 3D-printing and hydrogel injection casting technologies, a fully immersive simulation platform for robotic assisted transplant nephrectomy was developed. Surgeon training on this platform allowed pilot implementation of this operation which demonstrated excellent outcomes with low blood loss and no perioperative complications. ★ Best Multispecialty Video

Objective: Individuals with complex renal anatomy may not be considered candidates for living donor nephrectomy due to concerns of surgical complexity. We describe the use of novel artificial intelligence (AI) software to create virtual segmented three-dimensional (3D) anatomical kidney models for preoperative planning to facilitate donor nephrectomy in this cohort. Methods and Procedures: Since Jun 2020, 73 living renal donors underwent preoperative computed tomography angiography (CTA). Segmented modeling delivered a virtual 3D model from the CTA, highlighting renal anatomy and vasculature. The CTA and 3D models were reviewed by living donor/recipient teams to assess the candidacy of donors with complex anatomy. Results: Six of 73 individuals (8.2%) were not considered candidates for donation based on CTA or magnetic resonance imaging findings, including 3 renal arteries bilaterally (n = 1), 2 left renal arteries and circumaortic renal vein (n = 1), right renal artery/vein anomalies (n = 3), and a 3 cm perirenal hilar mass (n = 1). Following review of the 3D reconstructions, all patients were cleared for donor nephrectomy based on the additional detailed information. In the patient with the perirenal mass, 3D imaging delineated the mass as arising from the renal parenchyma. This patient underwent robotic donor nephrectomy and ex-vivo mass excision (pathology: lipid-poor renal angiomyolipoma), with successful subsequent renal transplantation. All patients underwent uneventful laparoscopic or robotic donor nephrectomy without complications in the donors or recipients. Conclusion: AI virtual 3D anatomical modeling assists in facilitating donor nephrectomy in patients with complex anatomy that may otherwise be excluded from donation, thus expanding the pool of potential renal donors. ★ Paul Alan Wetter Award for Best Multispecialty Scientific Paper ★ Best Urology Scientific Paper

Objective: Textbook oncologic outcome (TOO) is a composite outcome measure of short-term quality metrics following oncologic operations. This study examined whether minimally invasive gastrectomy is associated with increased likelihood of TOO in patients with gastric adenocarcinoma. Methods: The 2010 – 2016 National Cancer Database (NCDB) was queried for patients with gastric adenocarcinoma who underwent open (OG), laparoscopic (LG), or robotic (RG) gastrectomy. TOO was defined as having met: R0 resection, n ≥ 15 lymphadenectomy, no prolonged length of stay, no 30-day readmission, and no 30-day mortality. Categorical and continuous variables were analyzed using Pearson's χ 2 test or Fisher's exact test, and one-way analysis of variance, respectively. Overall survival (OS) rates were estimated using Kaplan-Meier method with log-rank test. Results: Of 21,015 patients, 5,708 (27.2%) underwent LG (21.9%) or RG (5.3%). RG patients were more likely to have negative margins, adequate LAD, no prolonged LOS, no 30-day readmission, and to achieve TOO. OG patients were more likely to have no 30-day mortality. RG patients were more likely to achieve TOO compared to those who underwent OG (AOR = 1.44, P = 0.000). LG patients who achieved TOO had the highest median OS (86.7 months), while OG non-TOO patients experienced the lowest (34.6 months). The median OS for the RG TOO group was not estimable due to insufficient number of events to reach the median, however the mortality rate (0.7%) was lowest. Conclusion: RG resulted in a significantly increased likelihood of TOO attainment. Attainment of TOO following minimally invasive gastrectomy is associated with a statistically significantly higher median OS.

Objective: The objective of this pilot project is to assess the effectiveness of virtual mindfulness-based stress reduction (MBSR) program to improve quality of life in people with endometriosis. Secondary objectives were to assess for an improvement in pain, psychological stress and sexual function. Methods and Procedures: This was a mixed methods before and after study design. 15 patients with a clinical or surgical diagnosis of endometriosis were recruited from a tertiary-care gynecology clinic. Participants completed the validated Endometriosis Health Profile (EHP) tool, and a pain medication questionnaire before and after a virtual eight-week MBSR program. A focus group was held after the course to assess experiences using mindfulness for endometriosis management. Descriptive statistics and paired-samples t-tests were used to analyze the quantitative data. Qualitative data was thematically analyzed. Results: 67% of people enrolled completed the MBSR course (10/15). Following the MBSR program participants had a statistically significant decrease in four components of the EHP: control and powerlessness t(9) = 3.16, p = 0.12, emotional well-being t(9) = 2.29, p = .048, social support t(9) = 2.58, p = .030, and self-image t(9) = 3.04, p = .014. There was no change in pain scores. Three themes identified through qualitative analysis included: sense of community, education about their condition, and comfort with the virtual format. Conclusions: This pilot project found that virtual MBSR can improve quality of life domains in people with endometriosis but does not impact pain. Further research will focus on assessing the MBSR program in a randomized control trial. ★ Best Gynecology Scientific Paper

Objective: The impact of COVID-19 in the United States has adversely impacted physicians. Fears of contracting SARS-CoV-2 has led to institutions requiring preoperative COVID screening in patients undergoing surgery. We present the results at a single institution with regard to the effectiveness of a screening program in patients scheduled for minimally invasive surgery. Methods and Procedures: Since Apr 2020, all patients that were scheduled for elective minimally invasive surgery by a single surgeon underwent COVID testing between 48 and 72 hours prior to surgery. Patients were advised to self-quarantine between the testing date and surgery date. In patients that tested positive for SARS-CoV-2, the surgery was postponed. The surgeon also underwent routine COVID testing between 1–4 times per month during this time period. Results: A total of 631 surgeries were scheduled between Apr 2020 and Feb 2022. Of these, 221 were performed in 2020, 352 in 2021, and 58 in 2022 YTD. Nine asymptomatic patients (1.4%) tested positive for SARS-CoV-2 and had surgery postponed for a minimum of 2 weeks. Eight patients rescheduled surgery after a repeat negative test result. The surgeon tested negative for SARS-CoV-2 based on rapid and PCR testing. Conclusion: At a time when the physician burnout rate is high, the added stress of the COVID-19 pandemic has had a deleterious effect on the quality of life of physicians. The institution of mandatory COVID screening in patients prior to surgery is not only effective in protecting the physical health of surgeons, but it can also have a positive impact on mental wellbeing.

Introduction: Approximately 5% of Bochdalek and Morgagni hernias present in adulthood. Diaphragmatic hernias occur when abdominal organs protrude into the thoracic cavity via a defect in the diaphragm. CDH presentation in adults may be incidental, symptomatic, or a surgical emergency. Symptoms of abdominal pain, nausea, and bloating are more common than respiratory symptoms including dyspnea and cough. Acute presentations of incarcerated diaphragmatic hernia include obstruction from incarceration or strangulation, bleeding, volvulus, and gangrene. Bochdalek and Morgagni hernias in adults should be repaired in medically fit patients, even in the absence of symptoms owing to the risk of complications. Congenital diaphragmatic hernias may be repaired via transabdominal or transthoracic approach. Smaller hernias may be repaired primarily with nonabsorbable sutures, but larger defects may require a prosthesis for repair. An overall operative mortality rate of 2.7% is described. We present the case of 50 y/o female with no significant past medical history who presented with a one-day history of intermittent epigastric abdominal pain associated with nausea and vomiting. Patient denied any prior surgical history or trauma. CT scan of the abdomen and pelvis was consistent with distended loops of small bowel and a right posterior diaphragmatic hernia containing dilated loops of small bowel. Patient was managed with surgical intervention via laparoscopy with reduction and repair of diaphragm with biologic mesh. CDH is an uncommon diagnosis in adults. Prompt diagnosis and apate surgical intervention are key to prevent associated morbidity and mortality. ★ Gustavo Stringel Award for Best Poster by a Resident

Objective: A robotic approach to repair an interstitial hernia following abdominal wall trauma. Methods and Procedures: An interstitial hernia is a fascial defect with the hernia sac in between muscle layers of the abdominal wall. Interstitial hernias most often present in adults after abdominal operations or trauma. These hernias can present as a diagnostic challenge as a fascial defect cannot typically be palpated in these cases. The anatomy, clinical relevance and repair of interstitial hernias makes them an important and sometimes overlooked diagnosis. Results: We present a case report of a female with multiple previous abdominal surgeries, including incisional ventral hernia repair 1 year prior to presentation, who was evaluated after a motor vehicle accident in which she sustained abdominal wall trauma. She was found to have an interstitial hernia containing intra-abdominal fat along the right lateral abdominal wall musculature at the exact site of her prior trauma. This hernia sac protruded through the internal oblique muscle but not through the external oblique. A robotic hernia repair with mesh was utilized to treat this hernia and is illustrated in the associated video. A robotic approach provided a clear picture of the anatomy and the planes used to adequately dissect, reduce the hernia sac, and close the fascial defect with subsequent mesh placement. Conclusion: This patient benefited from a robotic approach to interstitial hernia repair as the anatomy was clearly delineated and this method provided for complete resolution of symptoms and closure of the fascial defect.

Objective: To illustrate laparoscopic cornuostomy technique for interstitial ectopic pregnancies (IEP). Methods and Procedures: A video footage presenting a case series of IEP managed surgically through laparoscopic cornuostomy, illustration of the technique with successful treatment at advanced gestational age. Results: The postoperative course was uncomplicated. All patients were discharged on the following day of surgery. The B-hcg levels dropped significantly after 48 hours and were followed to nonpregnant levels in all cases. There were no cases of persistent interstitial ectopic pregnancy requiring additional medical methotrexate. Three patients (number 1, 2, 4) had successful subsequent pregnancies and deliveries without any complication. Patient number 3 was lost for follow up. Conclusion: In the presence of an experienced laparoscopic surgeon, laparoscopic cornuostomy is safe and effective in treating IEP even in cases with advanced gestational age. Click here to view the Disclosure Index

In well-trained clinician's hands, real-time transvaginal ultrasound imaging and expanded documentation provides an enhanced anatomical profile and presurgical evaluation of gynecologic patients. Key information is obtained and utilized by gynecologic surgeons prior to procedures including hysterectomy, laparoscopy and hysteroscopy. We describe an advanced imaging and documentation protocol to be utilized in gynecologic patient evaluation, especially prior to surgery. As an example, more accurate uterine volume estimates help surgeons choose the best approach and tissue extraction method for hysterectomy. We use size estimate and other characteristics to choose the best trocar number, size and site placement for laparoscopic procedures. We also suggest that endometrial cavity orientation, thickness, character and length assessment and cervical length can better enable hysteroscopic instrument selection and procedure planning. Preoperative transvaginal ultrasound assessments and surgeries were completed by the author over a twenty-year period. A standardized volumetric assessment of predicted uterine mass was determined and compared to pathology-measured gram weight in hysterectomy procedures. There were 100 supracervical and 263 total hysterectomies reviewed where complete ultrasound and pathology data was retrievable. Uterine mass ranged from 20–1339 grams using length, width and height algorithms. Cervix length and width calculations were used to measure cervix volume/mass estimates. Endometrial assessment was refined and a documentation method described. Ultrasound imaging was also used to provide more comprehensive evaluation of the pelvic floor, bladder, culdesac, adnexa and surrounding structures to better prepare gynecologic surgeons for anatomy, pathology and findings.

Objective: The clinical significance of an abnormally high platelet count in patients undergoing surgery is not well understood, as platelet count thresholds at which major surgery may safely proceed are poorly defined. We present our experience with patients with elevated blood platelet counts and associated postoperative complications following robotic-assisted radical prostatectomy (RARP). Methods and Procedures: The records of 912 patients who underwent RARP by a single operative team were reviewed. Patient characteristics, perioperative parameters, and complications were analyzed in patients with elevated blood platelet counts. Results: Two (0.21%) of 912 patients were identified. A 63-year-old male (OR 167 min, EBL 180 mL) had essential thrombocythemia (platelet count 705 × 103/mcL) and developed bleeding on the first postoperative day, requiring platelet transfusions, 6U packed red blood cells, and IV aminocaproic acid. He was discharged on postoperative day 4 and expired on postoperative day 19 from a pulmonary embolus. A 53-year-old male, (OR time 245 min, EBL 350 mL) had secondary thrombocytosis (platelet count 597 × 103/mcL) and had intraoperative bleeding but did not require blood transfusion. He was discharged on the first postoperative day and was readmitted on postoperative day 18 for gross hematuria with clots, requiring urethral catheterization and manual clot evacuation. Following two additional bleeding episodes and hospitalizations over the next 4 weeks, his hematuria resolved. Conclusion: Patients with abnormally elevated platelet counts undergoing RARP are at risk for major bleeding complications due to platelet dysfunction. The increased risk of bleeding should be a consideration when counseling patients with regards to treatment options.

Objective: To safely confirm the presence and location of a suspected cesarean section ectopic pregnancy using readily available instruments prior to a cesarean scar resection and an ectopic pregnancy excision attempt. Methods and Procedures: The patient was taken to the operating room after proper discussion of the indication, risks and benefits of the procedure and informed consent was obtained. The patient then received general anesthesia and was endotracheally intubated. After proper preparation and sterile draping was performed, a diagnostic hysteroscope was inserted into the endometrial cavity and used to locate and verify the presence of a suspected ectopic cesarean scar pregnancy. After visual confirmation, laparoscopic abdominal entry was obtained, and robotic surgical system was employed to resect the pregnancy and revise the hysterotomy. Finally, the hysteroscope was again used to confirm complete closure of the uterine defect. Results: This procedure proved adequate for visually confirming a suspected diagnosis of a cesarean scar ectopic pregnancy and the robotically-assisted resection was performed without complication. Final postoperative pathology confirmed the presence of decidua, smooth muscle and degenerating chorionic villi consistent with products of conception. The patient recovered appropriately with resolution of vaginal bleeding within 24 hours and of her pain within 5 days and no complications were identified. Results: This case serves to present a safe method to confirm presence of a suspected cesarean scar ectopic pregnancy prior to abdominal surgical resection. The described procedure resulted in effective management of a rare conception complication.

Objective: The standard approach to robotic-assisted Roux en Y gastric bypass (RYGB) is to have a surgical assistant – through an accessory port- pass and retrieve surgical needles as they are used. We sought to estimate the rate of nonretrieval of surgical needles by this technique and determine if this practice can be improved upon with an innovative approach, consisting of a simple device for intracavitary management of needles, made using existing surgical materials. Methods: Between 1/1/2017 and 1/1/2021, 460 robotic RYGB cases were performed at a single teaching institution. Two techniques were utilized for passage and retrieval of surgical needles [standard (N = 348) and innovative (N= 112) approaches]. Categorical General Surgery Residents (N = 11) were surveyed of their personal experience with nonretrieval of a surgical needle during RYGB. Intraoperative radiographs of all RYGB cases were reviewed. Results: All 11 residents witnessed nonretrieval of a surgical needle during RYGB, exclusively by the standard approach. Of 348 standard RYGB cases, five patients underwent intraoperative radiographs with intent to identify a nonretrieved needle (1.4%). In two of the standard approach cases, a surgical needle was present in the abdominal cavity on imaging. In no case was a needle retained at completion of operation. There were no cases of nonretrieved surgical needle by the innovative approach. Conclusions: Nonretrieved surgical needles are a real problem and a source of stress and frustration for the entire surgical team. A simple surgical device mitigates this problem.

Objective: Minimally invasive distal pancreatectomy (MIDP) has established advantages over the open approach. The costs associated with robotic DP (RDP) versus laparoscopic DP (LDP) makes the robotic approach controversial. We sought to compare outcomes after LDP and RDP using propensity matching analysis at our institution. Methods and Procedures: 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 using MatchIt. Between-group differences were analyzed using the Mann–Whitney U test for continuous data, and Fisher's exact test for categorical data. Primary outcomes included operative duration, conversion to open surgery, postoperative length of stay, incidence of pancreatic fistula and pseudocyst requiring intervention. Results: 302 patients underwent MIDP, 183 (61%) were laparoscopic and 118 (39%) were robotic. All RDPs were matched 1:1 to a laparoscopic case with absolute standardized mean differences for all matching covariates below 0.10. Patients who underwent RDP had longer operative times (268 vs 175 minutes, p < 0.01), shorter length of stay (2 vs 4 days, p < 0.01), and decreased incidence of pancreatic fistulas grade B or C (5% vs 15%, p = 0.02). Conversion rates (4 vs 5, p = 1.00) and incidence of pseudocyst requiring intervention (6 vs 8, p = 0.78) were comparable to patients who underwent LDP. Conclusion: Although RDP required longer operative times than LDP, postoperative stays were shorter and a decreased incidence of pancreatic leaks was found. An ongoing cost-effectiveness analysis will determine if the decreased morbidity offsets the intra-operative surgical costs.

Objective: Robotic hysterectomy allows the surgeon improved visualization, range of motion, and ergonomics which in some cases may obviate the need for an assistant surgeon. In rural hospitals where physician shortages remain a major barrier to care, reducing the number of surgeons necessary to perform hysterectomy would be of significant consequence. We sought to evaluate the impact of robotic surgery on the need for an assistant surgeon at time of hysterectomy at a rural community hospital. Methods and Procedures: We performed a retrospective chart review of hysterectomies performed at our hospital by general gynecologists focusing on the 12-month period prior to, and the 12-month period 2 years following, implementation of a robotic surgical program. We allowed 2 years for gradual surgeon adoption of robotic technology. Our primary outcome was need for an assistant surgeon at time of hysterectomy. Our secondary outcome was route of hysterectomy. Billing records were cross-referenced against the medical record, and statistical analyses performed. Results: We observed a statistically significant decrease in the need for an assistant surgeon at the time of hysterectomy (p < 0.05). There was an increase in the percentage of hysterectomies performed by minimally invasive technique (laparoscopic, robotic, and vaginal) versus open technique (total abdominal). Conclusion: Access to robotic surgical technology reduced the need for an assistant surgeon at the time of hysterectomy by generalist obstetrician gynecologists. Additionally, we saw a significant increase in the rate of minimally invasive hysterectomy performed. These findings are of particular relevance to rural hospitals facing physician shortages. ★ Gustavo Stringel Award for Best Poster

Objective: To present our approach for robotic-assisted laparoscopic repair of rectovaginal fistula. Methods and Procedures: This is a 55-year-old female with history of invasive rectosigmoid colon adenocarcinoma status post laparotomy low anterior resection complicated by anastomotic dehiscence and pelvic abscess. She underwent sigmoidoscopy with closure of dehiscence with endosuture. Patient was asymptomatic for 3 years when she presented with rectovaginal fistula, status post failed attempted sigmoidoscopy with endosuture. Results: Patient had no complication intraop and postop and was discharged home on postop day 2. Conclusion: She was seen 2 and 6 weeks postop with no fistula recurrence and is doing well. ★ Best Gynecology Video

Objective: Assess the feasibility of a canine model in robot-assisted radical prostatectomy (RARP) training. Methods and Procedures: RARP was performed step-by-step in five dog cadavers using a surgical robot. Steps were defined according to the RARP score, a validated training tool describing 17 key steps and 4 levels of difficulty; each step was scored to reflect the anatomical and technical similarities, realism of dissection, and face validity of the canine model compared to the human procedure. Results: 14 steps were performed during each procedure. Face validity was scored as high or very high for 5 of the 9 steps of difficulty levels 1 and 2 as well as 5 of the 8 steps of difficulty levels 3 and 4, especially nerve preservation, vesicourethral anastomosis and lymph node dissection. Conclusions: The cadaveric canine model seems to be a realistic and relevant training model for key steps of RARP.

Robotic assistance seems to be associated in some indications with improved perioperative results at the expense of higher implementation costs for the health care institution. The economic literature on robotic-assisted partial nephrectomy is scarce in Europe in general and in France in particular. Therefore, the objective of this study was to evaluate the efficiency of the use of robotic assistance in the management of small kidney tumors by partial nephrectomy compared to open surgery. This medico-economic study was conducted from the perspective of the French Assurance Maladie using retrospective data. Clinical data were obtained from the medical records of 395 patients, divided into two surgical approaches: open partial nephrectomy (OPN) and robotic-assisted partial nephrectomy (RAPN). These approaches were compared on their effectiveness, defined as major complications avoided up to 12 months postoperatively, and on their direct costs to the public payer. We expressed the cost in euros (€). The study shows a clear difference in terms of major complications avoided between the two surgical approaches. These complications were avoided for 82.47% of patients in the NPO group and for 93.53% of patients in the NPRA group. Robotic assistance thus improved efficiency by 11.06%. The average costs of the stays were respectively 9 636.54 €and 8 305.18 €in the NPO and NPRA groups. Robotic assistance was also associated with a reduction in average cost of €1,331.36. The incremental cost-effectiveness ratio (ICER) is estimated at -12,039.66 €. The use of robotic assistance in partial nephrectomy is associated with better postoperative outcomes and improved efficiency for Medicare.

Objective: Test the technical feasibility of the “Slim-Mesh” technique using multiple “Slim-Meshes” during an operation for multiple spaced ventral hernias in the same patient; verify the long-term results of a 12-year follow-up. Methods and Procedures: From Sep 2009 to Dec 2019, 8 patients with the above hernias were treated exclusively with the “Slim-Mesh” technique at our Department. This was a prospective (63%)-retrospective study Results: This study comprised 6 males and 2 females. Mean age was 57 years. Three of the 8 cases had a triple spaced ventral hernia (group 1): 2 of the 3 were treated with 2 “Slim-Meshes” each, and the remaining patient with 3. The remaining 5 cases had one double spaced ventral hernia each (group 2); each case was operated on with 2 “Slim-Meshes”. During operation, we also found and repaired associated diastasis recti in 38% of cases, doing so without using additional "Slim-Meshes". Mean operation time for all 8 cases, group 1 and group 2 was 153, 220 and 112 minutes respectively. Composite mesh, noncomposite mesh, titanium tacks and absorbable straps for mesh fixations were used in 87%, 13%, 25% and 75% of cases respectively. Mean length of hospital stay was 3 days. Mean follow-up time was 6 years. No early or long-term postoperative complications occurred. Conclusion: Our study revealed the existence of a new patient-type, namely one with multiple spaced ventral hernias (7%). The “Slim-Mesh” technique facilitates intra-abdominal introduction and fixation of successive multiple meshes during the same operation, proving to be safe, fast and economical, even for the above patient-type.

Background: This comprehensive review serves to determine the current role of Laparo-Endoscopic Single Site (LESS) Surgery in General Surgery and evaluate its advantages and disadvantages relative to conventional laparoscopy. Methods: MEDLINE, the Cochrane library, and Ovid were queried using a wide range of keywords. Types of studies, patient demographics, techniques, lengths of incisions, types of ports, laparoscopes, and instruments used, operative times, pain scales, blood loss, narcotic requirements, conversion rates, intraoperative and postoperative complications, lengths of hospital stay, costs, patient satisfaction, and lengths of follow-up were collected. Results: Over 2000 publications were identified with over 800 excluded for not pertaining to General Surgery. Studies not in English or lacked patient data were excluded. Most publications included were classified as 2b level of evidence. Conclusions: The application of LESS surgery has expanded, producing safe and reproducible outcomes. Most studies had patients who underwent LESS surgery with reduced postoperative pain, shorter lengths of stay, and quicker returns to normal activity when compared with conventional laparoscopic surgery, in addition to improved cosmesis and patient satisfaction. The main concerns from surgeons were the longer operative times and technical difficulties of learning a more advanced laparoscopic approach. Operative times were reduced with experience to times similar to conventional laparoscopy and technical issues could be alleviated with training and experience, as well as with specialized ports and modified instruments and technology. Overall, LESS surgery was found to be safe, feasible, and attractive for many operations in General Surgery. ★ The Medical Educator Consortium Award for Best Scientific Paper

Objective: Laparoscopic cholecystectomy (LC) is the current standard of care for symptomatic cholelithiasis, however, there has been an increasing trend towards robotic management with the wide adoption of robotic surgical systems. While robotic surgery (RS) offers better dexterity and visualization, concerns regarding higher costs without evidence to suggest a difference in clinically relevant outcomes has impeded widespread endorsement. Methods and Procedures: The purpose of this study was to construct a decision tree model to compare both costs and clinical outcomes associated with LC and RS in patients with symptomatic cholelithiasis. Costs within the model were selected from 2021 Medicare reimbursement data. Effectiveness was represented by quality-adjusted life-months (QALMs) based upon patient preference, morbidity, and postoperative complications within a 30-day time frame. Utility weights, complication rates, and robotic surgery cost data were extracted from published literature. The primary outcome measure was incremental cost-effectiveness ratio (ICER), with a willingness-to-pay threshold of $8,333 for each additional month of perfect health obtained (1 QALM). Results: LC produced 0.9449 QALMs costing $24,224.92. RC produced 0.0015 more QALMs at an additional cost of $1,802.27, with an ICER of $1,201,510.70. This exceeds the willingness-to-pay threshold; therefore, LC was the more cost-effective strategy. Sensitivity analyses varying branch-point probabilities did not alter results. Conclusion: At present, there is not enough clinical benefit from robotic cholecystectomy, in comparison to a laparoscopic approach, to overcome its associated costs. Therefore, it was not the preferred treatment modality for symptomatic cholelithiasis.

The prevention of pelvic floor trauma during spontaneous vaginal delivery is paramount to good obstetrical practice. The obstetrician is no longer only responsible for the delivery of a healthy baby but also for the preservation of maternal pelvic floor function. In order to achieve this goal, certain strategies can be clinically utilized based on an understanding of the theoretical framework of pressure regulation, mechanism of tissue tearing around the dilatation zone, and the protective effects of episiotomy implementation. Maternal position, metabolism, hydration, nutrition, and therefore, overall regulation of physiological function also plays an essential role in achieving successful clinical outcomes in addition to the avoidance of emergency situations (maternal or fetal) requiring clinical intervention. The aim of this presentation will be to describe in depth the biophysical parameters such as uterine contractile activity, fundal pressure, and clinical interventions of counter pressure during the second stage of labor, which can contribute to or prevent maternal pelvic floor trauma. The controversial role of episiotomy (routine versus indicated) including both the protective and detrimental effects in preservation of pelvic floor function will be examined in the context of older and more recent data. Lastly, the importance of maternal birthing position in relation to fetal head descent, bearing downloads, and effects of gravity to minimize risks of maternal pelvic floor trauma as well as effective clinical interventional methods such as modified Ritgen maneuver, adaptation of maternal position, and consideration for maternal recovery during the birthing process as possible preventive strategies will be described.