Robotic Approach to Cholecystectomy

Cholecystectomy is one of the most commonly performed abdominal procedures with more than 600,000 performed annually in the United States. Laparoscopic cholecystectomy, first introduced in the 1980s, offered faster recovery time and a more cosmetic result making it the more favorable approach. In developed countries, up to 90% of cholecystectomies are done via laparoscopy. After the first robotic surgery platform was approved by the FDA in 2000, it provided surgeons with enhanced ergonomic capabilities and visualization and also offered possibility of telemedicine. The first series of robotic cholecystectomies soon followed in the last 15 years, and robotic cholecystectomy has become increasingly popular and has been established as a safe approach. The aims of this chapter are to address the history of robotic-assisted cholecystectomy, the technical aspects of multiport and single-port approaches, use of cholangiography, demonstration of safety and use in both community and academic settings

Robotic Ventral Hernia Repair

Approximately 350,000 to 500,000 ventral hernias are repaired yearly in the United States. These hernias include congenital umbilical hernias, incisional hernias from previous surgeries, or epigastric hernias. The crux of hernia repair is honoring the principle of achieving a tension‐free repair, often achieved with utilization of a synthetic mesh. Over the last quarter of this century, laparoscopic ventral hernia repair has established itself as a valuable tool in repair of ventral hernias, with the advantages of reduced postoperative complications. More recently, the adaptation of the robotic platform has given another tool to perform ventral hernia repairs. The aim of this chapter is to describe the evolution of ventral hernia repairs and highlight the robotic approaches to repair

Tumor Biology and Racial Disparities in Reconstruction After Mastectomy: A SEER Database Analysis

Introduction: Significant disparities in immediate breast reconstruction after mastectomy have persisted, and may even be increasing, despite large-scale efforts to minimize them, such as the Women’s Health and Cancer Rights Act of 1998. Immediate breast reconstruction has been shown to lead to higher rates of surgical satisfaction, minimize delay in post-operative cancer treatment, and improve the quality of life and overall well-being of mastectomy patients. However only 25-40% of eligible women in the United States receive reconstruction. The rate of reconstruction is even lower in African American and Hispanic women compared to White women. To better understand this disparity, this study uses national population-based data to examine how demographic factors, socioeconomic factors, and disease characteristics interact and affect the rate of immediate breast reconstruction (IBR) after mastectomy. Methods: Women with AJCC7 Stage 0-III breast cancer who underwent mastectomy from 2010 to 2012 were identified in the Surveillance, Epidemiology and End Results Program (SEER) database. Race, Hispanic ethnicity, age, marital status, insurance status, tumor grade, AJCC7 stage and hormone receptor/ Her2Neu profile were compared between women undergoing mastectomy with IBR and mastectomy alone using univariate and multivariate analysis. Results: We identified 51,115 women who underwent mastectomy for Stage 0-III breast cancer from 2010-2012, of whom 15,389 (30.1%) received IBR. On multivariate analysis, age (p Conclusion: The decision to undergo reconstruction after mastectomy is influenced by many factors. Our results show that even after adjusting for tumor characteristics, socioeconomic factors are independently associated with receiving IBR after mastectomy. Further research is needed to elucidate the factors that influence the decision to undergo IBR in order to eliminate these persistent disparities

A case of isolated splenic tuberculosis

AbstractThere are few cases of isolated splenic tuberculosis reported in the literature internationally, and nearly none from western medical centers. The incidence of tuberculosis has declined in the United States since the 1950s, with 11,585 reported cases in 2009, 21% of which were exclusively extrapulmonary. Splenic tuberculosis occurs mostly as part of miliary tuberculosis in immunocompromised patients. Isolated splenic tuberculosis is extremely rare, particularly in the immunocompetent patient. Patients susceptible to acquiring splenic tuberculosis usually have one of the following risk factors: immunosuppression, preceding pyogenic infections, splenic abnormalities, prior trauma to the spleen, sickle cell disease and other hemopathies, and in the immunocompetent patient another body site infected by M. tuberculosis. In this report we present the case of a young immunocompetent male with no other significant past medical history with isolated splenic tuberculosis

Management of Ampullary Carcinoid Tumors with Pancreaticoduodenectomy

A 66 year old female was found to have an ampullary mass on endoscopic examination. A pancreaticoduodenectomy was performed and the pathology was consistent with carcinoid tumor. Carcinoid tumors of the ampulla of Vater are rare tumors of the gastrointestinal tract, accounting for 0.3-1% of gastrointestinal carcinoids. Management of ampullary carcinoid tumor with pancreaticoduodenectomy is in accordance with current recommendations

A rare case of splenic pseudoaneurysm in pediatric splenic blunt trauma patient: Review of diagnosis and management

Introduction: Splenic pseudoaneurysms (SPA) are a rare but serious sequela of blunt traumatic injury to the spleen. Management of adult blunt splenic trauma is well-studied, however, in children, the management is much less well-defined. Presentation of case: A 15 year-old male presented with severe abdominal pain of acute onset after sustaining injury to his left side while playing football. FAST was positive for free fluid in the abdomen. Initial abdomen CT demonstrated a grade III/IV left splenic laceration with moderate to large hemoperitoneum with no active extravasation or injury to the splenic vessels noted. A follow-up CT angiography of the abdomen demonstrated a splenic hypervascular structure suspicious for a small pseudoaneurysm. Splenic arteriogram which demonstrated multiple pseudoaneurysms arising from the second order splenic artery branches which was angioembolized and treated. Discussion & conclusion: Questions still remain regarding the timing of repeat imaging for diagnosis of SPA following non-operative blunt splenic trauma, which patients should be imaged, and how to manage SPA upon diagnosis. More clinical study and basic science research is warranted to study the disease process of SPA in pediatric patient. We believe that our proposed management algorithm timely detect formation of delayed SPA formation and addresses the possible fatal disease course of pediatric SPA

Carcinosarcoma of the oesophagus – a rare mixed type of tumor

Oesophageal carcinosarcoma is a rare type of oesophageal cancer composed of both squamous cells and sarcomatous cells. We report a case of a 71 year old man presenting with dysphagia and weight loss. Oesophagogastroduodenoscopy revealed a bulky mass with a preliminary diagnosis of only oesophageal carcinoma, and the oesophageal mass was resected with a transhiatal oesophagectomy. On surgical pathology, it was discovered that the tumor had both squamous cell and sarcomatous cell components, and the final diagnosis was changed to oesophageal carcinosarcoma. We discuss the presentation, differential diagnosis, treatment, and prognosis of this unique entity

Topical intraperitoneal papaverine to minimize non-viable bowel resection from non-occlusive bowel ischemia in neonatal segmental volvulus: A case report

AbstractArrest in the embryologic intestinal rotation around the superior mesenteric artery prevents proper mesenteric attachment and subjects the gut to volvulus and ischemia which may lead to bowel resection. The length of non-viable resected bowel has been shown by Teitelbaum et al. to be an independent predictor of survival in patients with postoperative short bowel syndrome (RR = 5.74, P = .003). Non-occlusive mesenteric ischemia (NOMI) is a feed-forward loop of vasoconstriction that aggravates the primary ischemic injury. It is an initially reversible process and a potential point of intervention for preservation of viable bowel. The Boley et al. algorithm for management of adult NOMI utilizes intravascular papaverine infusion to increase intracellular cAMP, decreasing calcium concentration and halting vasospasm. We present a modified version of this approach using topical papaverine in the setting of neonatal post-ischemic NOMI, with the goal of minimizing bowel resection

Study habits centered on completing review questions result in quantitatively higher American Board of Surgery In-Training Exam scores

The American Board of Surgery In-Training Exam (ABSITE) is administered to all general surgery residents annually. Given the recent changes in the format of the examination and in the material being tested, it has become increasingly difficult for residents to prepare for the ABSITE. This is especially true for incoming postgraduate year (PGY) 1 residents because of the respective variability of the surgical clerkship experience. There have been many studies in the past that support the use of weekly assigned readings and examinations to improve ABSITE scores. Other studies have investigated the study habits of residents to determine those that would correlate with higher ABSITE scores. However, there is a lack of information on whether completing review questions plays an integral role in preparing for the ABSITE. We hypothesize that those residents who completed more review questions performed better on the ABSITE. ABSITE scores of current and past general surgery residents at SUNY Downstate Medical Center, a university hospital, were reviewed (2009-2013). These residents were then polled to determine how they prepared for their first in-training examination. Average ABSITE percentile was 46.4. Mean number of review questions completed by residents was 516.7. Regression analysis showed that completion of more review questions was associated with a significantly higher percentile score on the ABSITE (p < 0.0027). Further analysis showed that for every 100 review questions completed by a PGY 1 resident taking the ABSITE for the first time, the ABSITE percentile score should improve by 3.117 ± 0.969. Average reported study time in hours/week was 9.26. Increased study time was also significantly correlated with higher ABSITE percentile scores (p < 0.007). Again, further analysis showed that for every 1h/wk spent studying, ABSITE percentile score should increase by 1.76 ± 0.62. The Kruskal-Wallis H test showed that studying in group vs individual settings had no effect on ABSITE performance (p = 0.20). It was also used to analyze primary study resource, which demonstrated that there was no significant difference in residents' performance based on their primary study source (p = 0.516). Recent changes in the format of the ABSITE to a 2-tiered examination in 2006 and subsequent plan to return to a unified test for all PGY levels has made preparation difficult. With a more focused, question-based approach to studying, residents may see a demonstrable improvement in their scores. Our study supports this hypothesis-showing that residents who complete more review questions had higher ABSITE percentile scores. In the past, it has been demonstrated that strong ABSITE scores are associated with higher written board scores. With the widespread adoption of the Surgical Council on Resident Education curriculum, we postulate that residency programs that rely on this review question-based curriculum will report improved ABSITE percentile scores and written board pass rates