Mean EBL Research Articles

Percutaneous lumbopelvic fixation is effective in the management of unstable transverse sacral fractures

ObjectivesHistorically, fractures causing lumbopelvic dissociation have been managed with open lumbosacral fusion and instrumentation. Our aim was to evaluate outcomes and complications following surgical management of unstable transverse sacral fractures with percutaneous lumbopelvic fixation. MethodsDesign: Retrospective case series. Setting: Academic Single Center, Level I Trauma Center. Patient Selection Criteria: Patients with lumbopelvic dissociation undergoing surgery. Outcome Measures and Comparisons: Patient demographics, mechanism of injury, ISS, associated injuries, radiographic classification (Roy-Camille), patient-reported outcomes (PROMIS PI, PF, D, and ODI), and complications were collected. Results27 patients were enrolled with an average follow-up of 18.7 ± 17.6 months and age of 54.4 ± 25.1 years. All patients underwent lumbar pedicle screw and iliac screw placement. Sacral laminectomy was performed if the patient had a preoperative neurological deficit. Patients were counseled on instrumentation removal at 6–12 months. 67 % of patients sustained a fall, and 33 % were involved in an MVA. 52 % were Roy-Camille Type 2, and 32 % and 20 % were Types 1 and 3, respectively. The mean EBL was 261 ± 400 ml. 37 % required concurrent sacral laminectomy. There were no intraoperative complications and four postoperative complications, including surgical site infection, rod dislodgment, and deep venous thrombosis. 63 % underwent removal of instrumentation after fracture healing. ODI scores significantly improved from 6 weeks post-op (35.5 ± 4.5) to one-year follow-up (18.3 ± 9.6, p = 0.005), two-year follow-up (20.3 ± 10.0, p = 0.03), and final follow-up (16.4 ± 8.8, p = 0.002). Statistically significant improvements were observed in the PROMIS PI, PF, and D domains (p < 0.05). ConclusionOur study demonstrates that lumbopelvic instrumentation leads to successful management of unstable transverse sacral fractures, with improvement in PRO. The combination of percutaneous instrumentation without arthrodesis did not result in any fracture non-union. Level of evidenceLevel IV

Comparison of Trifecta and Pentafecta Outcomes across 3 Surgical Modalities of Partial Nephrectomy (PN) - Open, Lap, and Robotic.

Renal cell carcinoma (RCC) is the most common solid tumor in the kidney (90%), accounting for about 3% of all cancers in adults. Partial nephrectomy (PN) is the surgical procedure primarily used for the treatment of localized kidney tumors. Two commonly used terms to describe the complexity and success of a partial nephrectomy procedure are "trifecta" and "pentafecta." Trifecta is defined as Warm ischemia time (WIT) ≤ 25min or Cold ischemia time (CIT) ≤ 60min, Negative surgical margin (NSM), and no perioperative Clavien-Dindo complications (CDC) of Gr 3 or more [8], whereas pentafecta is defined as trifecta plus >90% preservation of e-Glomerular filtration rate (GFR) and no increase in chronic kidney disease (CKD) stage at 12-months post-operative period. We retrospectively analyzed all patients who underwent partial nephrectomy at a single high-volume tertiary centre, from 2012 to 2020. We included patients who underwent partial nephrectomy by any of the three routes including open (OPN), laparoscopic (LPN), or robotic-assisted (RPN), and in which the follow-up data was available. We compared the trifecta and pentafecta outcomes across the three surgical modalities. We had a total of 183 patients in our study. Twenty-nine percent (53 patients) underwent open surgery, 12.6% (23 patients) underwent laparoscopic surgery and 58.5% (107) underwent robotic assisted surgery. The number of patients who fell under the low risk category in the RENAL scoring system were 70(38.3%), intermediate risk 79 (43.2%) and high risk 34 (18.6%). In the high risk RENAL score group, trifecta was achieved in 5 (50%) patients in OPN, 1(50%) in LPN and 7(31.8%) in RPN with no statistically significant difference (p = 0.581) whereas pentafecta was achieved in 3 (30%) patients in OPN, 1 (50%) in LPN and 7 (31.8%) in RPN with no statistically significant difference (0.855). In the overall cohort, mean WIT, mean hospital stay and mean EBL were higher in OPN as compared to LPN and RPN which was statistically significant (p < 0.001), whereas there was no statistical difference in mean operative time between the three modalities (p = 0.580). Renal tumors can be safely treated by RPN or LPN with lesser morbidity as compared to OPN. Trifecta and Pentafecta outcomes had no significant difference among OPN, LPN, and RPN. RPN and LPN may be considered feasible and safe surgical approaches ensuring good functional outcomes.

Single position L5-S1 lateral ALIF with simultaneous robotic posterior fixation is safe and improves regional alignment and lordosis distribution index

PurposeMinimally invasive single position lateral ALIF at L5-S1 with simultaneous robot-assisted posterior fixation has technical and anatomic considerations that need further description.MethodsThis is a retrospective case series of single position lateral ALIF at L5-S1 with robotic assisted fixation. End points included radiographic parameters, lordosis distribution index (LDI), complications, pedicle screw accuracy, and inpatient metrics.ResultsThere were 17 patients with mean age of 60.5 years. Eight patients underwent interbody fusion at L5-S1, five patients at L4-S1, two patients at L3-S1, and one patient at L2-S1 in single lateral position. Operative times for 1-level and 2-level cases were 193 min and 278 min, respectively. Mean EBL was 71 cc. Mean improvements in L5-S1 segmental lordosis were 11.7 ± 4.0°, L1-S1 lordosis of 4.8 ± 6.4°, sagittal vertical axis of − 0.1 ± 1.7 cm°, pelvic tilt of − 3.1 ± 5.9°, and pelvic incidence lumbar–lordosis mismatch of − 4.6 ± 6.4°. Six patients corrected into a normal LDI (50–80%) and no patients became imbalanced over a mean follow-up period of 14.4 months. Of 100 screws placed in lateral position with robotic assistance, there were three total breaches (two lateral grade 3, one medial grade 2) for a screw accuracy of 97.0%. There were no neurologic, vascular, bowel, or ureteral injuries, and no implant failure or reoperation.ConclusionSingle position lateral ALIF at L5-S1 with simultaneous robotic placement of pedicle screws by a second surgeon is a safe and effective technique that improves global alignment and lordosis distribution index.

Complications of the Prone Transpsoas Lateral Lumbar Interbody Fusion for Degenerative Lumbar Spine Disease: A Multicenter Study.

The prone transpsoas (PTP) approach for lateral lumbar interbody fusion (LLIF) is a novel technique for degenerative lumbar spine disease. However, there is a paucity of information in the literature on the complications of this procedure, with all published data consisting of small samples. We aimed to report the intraoperative and postoperative complications of PTP in the largest study to date. A retrospective electronic medical record review was conducted at 11 centers to identify consecutive patients who underwent LLIF through the PTP approach between January 1, 2021, and December 31, 2021. The following data were collected: intraoperative characteristics (operative time, estimated blood loss [EBL], intraoperative complications [anterior longitudinal ligament (ALL) rupture, cage subsidence, vascular and visceral injuries]), postoperative complications, and hospital stay. A total of 365 patients were included in the study. Among these patients, 2.2% had ALL rupture, 0.3% had cage subsidence, 0.3% had a vascular injury, 0.3% had a ureteric injury, and no other visceral injuries were reported. Mean operative time was 226.2 ± 147.9 minutes. Mean EBL was 138.4 ± 215.6 mL. Mean hospital stay was 2.7 ± 2.2 days. Postoperative complications included new sensory symptoms-8.2%, new lower extremity weakness-5.8%, wound infection-1.4%, cage subsidence-0.8%, psoas hematoma-0.5%, small bowel obstruction and ischemia-0.3%, and 90-day readmission-1.9%. In this multicenter case series, the PTP approach was well tolerated and associated with a satisfactory safety profile.

184 Clinical Outcomes of the Prone Transpsoas Lateral Lumbar Interbody Fusion for Degenerative Lumbar Spine Disease: A Multicentre Study

INTRODUCTION: The prone transpsoas lateral lumbar interbody fusion (PTP) is a novel technique for degenerative lumbar spine disease. However, there is a paucity of the literature on the clinical outcomes of this procedure, with all the published being of a small sample size. METHODS: A retrospective electronic medical records review was conducted in ten centers for patients who underwent PTP. We collected the intraoperative data (operative time, estimated blood loss [EBL], intraoperative complications [anterior longitudinal ligament (ALL) rupture, cage subsidence, vascular and visceral injuries), postoperative complications, the patient-reported outcome measures (PROMS) such as back pain visual analogue scale (VAS), and hospital stay. RESULTS: A total of 350 patients were included in the study. There was a significant improvement in the mean VAS by 4.4 ± 6.7 (p &lt; 0.001). 2.8% had ALL rupture, 1.2% had cage subsidence, 0.4% had a vascular injury, and none had visceral injuries. The mean operative time was 229.9 ± 144 minutes, the mean EBL was 134.3±210.2 mL, and the mean hospital stay was 2.6 ± 2.2. In regard to postoperative complications, there was 8.9% new sensory symptoms, 6% transient hip flexor weakness, 1.4% wound infection, 1.4% cage subsidence, 0.6% psoas hematoma, 0.3% ureteric injury, 0.3% small bowel obstruction/ischemia, and 1.6% 90-days readmission. CONCLUSIONS: Multicenter consecutive case series show that PTP is well tolerated and has satisfactory clinical outcomes.

Modified anterior approach preserving Retzius space versus standard anterior approach robot-assisted radical prostatectomy: A matched-pair analysis.

To compare our initial perioperative and postoperative outcomes of the modified anterior approach (MA) with Retzius space preservation robot-assisted radical prostatectomy (RARP) with the standard anterior approach (SA) RARP. A retrospective analysis was performed on 116 patients with RARP completed by the same surgeon between September 2019 and March 2022. They were divided into SA-RARP group (77 cases) and MA-RARP group (39 cases). Propensity score matching was performed using eight preoperative variables, including age, BMI, preoperative PSA, biopsy Gleason score, prostate volume, D'Amico risk classification, SHIM, and clinical T stage. Functional outcome was assessed by urine pad count and SHIM after surgery, and oncological outcome was assessed by statistics of postoperative pathological findings as well as follow-up postoperative PSA. The median follow-up was 13 months and 17 months for MA-RARP and SA-RARP groups respectively. Propensity score matching was performed 1:1, and baseline data were comparable between the two groups after matching. Comparison of postoperative data: MA-RARP group had less mean EBL than SA-RARP group (200 vs 150ml, p = 0.033). PSM did not differ between groups (p = 1). In terms of urinary control recovery, the MA-RARP group showed significant advantages in urinary control recovery at 24h, 2 weeks, 1 month and 3 months after catheter removal, respectively (48.6% vs 5.7%, p < 0.001; 80% vs 22.9%, p < 0.001; 94.3% vs 51.4%, p < 0.001; 100% vs 74.3%, p = 0.002). This advantage gradually disappeared 6 months or more after surgery. The median time to recovery of sexual function was shorter in the MA-RARP group (165 vs 255d, p = 0.001). MA-RARP is safe and reliable, and can achieve better early urinary control function and sexual function recovery while achieving the primary tumor control goal.

Robotic major and minor hepatectomy: critical appraisal of learning curve and its impact on outcomes.

Robotic hepatectomy has gained increasing acceptance across the US. Although the robotic approach offers significant technical advantages, it is still bound by the individual surgeon's learning curve. Proficiency in this approach should theoretically lead to improved peri-operative outcomes. Between 2017 and 2020, data on 148 consecutive robotic hepatectomies performed by a single surgeon was retrospectively analyzed. Using cumulative sum (CUSUM) method, intraoperative blood loss (EBL) and operative time were used to assess learning curves for robotic major (n = 58) and minor (n = 90) hepatectomy patients. Perioperative outcomes were compared in regards with proficiency. Proficiency for robotic major and minor hepatectomy was achieved after 22 cases and 34 cases, respectively. No significant differences were observed in patient demographics or tumor characteristics. For robotic major hepatectomy, when compared to early experience, proficiency was associated with a significant improvement in mean EBL (242mL vs 118mL, p = 0.0004), operative time (330min vs 247min, p = 0.0002), decreased overall complication rate (23% vs 3%, p = 0.039), and length of hospital stay (5.7days vs 4.1days, p = 0.004). No difference in conversion rate, mortality or 30day readmission was seen. For robotic minor hepatectomy, proficiency was associated with significantly decreased mean EBL (115mL vs 54mL, p = 0.005), operative time (168 vs 125min, p = 0.014), and length of hospital stay (2.8days vs 2.1days, p = 0.021). No difference was observed in conversion rate, overall complications, mortality or 30day readmission. In the modern era, robotic hepatectomy offers a safe approach with excellent perioperative outcomes. Post learning curve proficiency is associated with significant improvements in perioperative outcomes in both major and minor hepatectomy. Results from our study can serve as a guide to surgeons and programs looking to adopt this technique.

Strategic response to bleeding in laparoscopic hepato-pancreato-biliary surgery: an intraoperative checklist.

The aim is to develop and test the utility of an event-initiated, team-based check list to optimize the response to bleeding during laparoscopic HPB surgery. To build a checklist for managing bleeding events, we conducted a systematic review. Using nominal group technique (NGT), a checklist consisting of four domains was developed. Following team-based training of anesthesia and surgical staff, the checklist was implemented. HPB cases before and after implementation of the checklist were compared for adverse outcomes, bleeding complications, and transfusions. NGT identified four domains: Communicate Control, Expose, and Repair under which the checklist was organized. Supplemental Video for a detailed review of how each domain was applied to a specific case example. We compared 169 HPB cases before to 53 cases after implementation. We found a significant decrease in mean EBL (from 518±852.8 to 151.5±221.7ml(P=0.001)) for cases performed after implementation of the checklist and a trends toward less volume of pRBC transfused (2.7±2.5 vs 2.3±1.7 units/per patient, P=0.611) and transfusion rates (22% vs 11%, P=0.703). An event-initiated, team-based response to an adverse bleeding event during laparoscopic HPB surgery correlates with positive effects on bleeding management, and transfusion rates.

450 Minimally Invasive Multiple-Rod Constructs With Robotics Planning in Adult Spinal Deformity Surgery: A Case Series

INTRODUCTION: Multiple rod constructs (MRCs) are often used in adult spinal deformity correction for increased stability and rigidity. There are currently no reports showing minimally invasive robotic multi-rod long-segment posterior fixation and its technical feasibility through preoperative software planning. METHODS: Data was collected retrospectively from medical records of 6 consecutive patients who underwent minimally invasive multiple-rod constructs with robotics planning by a single surgeon at an academic center between March-August 2020. RESULTS: A total of 6 patients (4 females, mean age 69.7 years) underwent minimally invasive long-segment (6+) posterior fixation with multiple rods (3+) using the Mazor X Stealth Edition robotics platform. Average follow-up was 9.3 months. All patients underwent oblique lumbar interbody fusion as a first stage, followed by second stage posterior fixation in the same day. The mean number of levels posteriorly instrumented was 8.8. One patient underwent 3 rod fixation (1 iliac, 2 S2AI) and 5 patients underwent quad rod fixation (2 iliac, 2 S2AI). The mean time to secure all rods was 8 minutes 36 seconds. Mean improvement in spinopelvic parameters was -4.9 cm sagittal vertical axis, 18.0° lumbar lordosis, and -10.7° pelvic tilt with an average pelvic incidence of 62.5°. Mean EBL was 200 cc with no blood transfusions, and all but one patient ambulated on postoperative day 1 or 2. CONCLUSION: The preoperative software planning required of spinal robotics allows for not just the accurate placement of each pedicle screw in isolation, but the fine-detailing of an entire spine construct design. This concept is demonstrated in this case series where rod placement in a minimally invasive approach depends upon the preoperative design of the whole construct. Spinal robotics brings us into this new era of minimally invasive construct design. To our knowledge, this is the first description of the technical feasibility of multiple-rod constructs in minimally invasive adult spinal deformity surgery.

806 Do Robotic Procedures Have Improved Perioperative Outcomes After a Learning Curve Period?

INTRODUCTION: Robot-assisted surgical techniques are being increasingly implemented to increase surgeon accuracy and stamina; however, the effects of surgeon learning curve on outcomes have not been well studied. METHODS: Robotic cases were isolated from single center multi surgeon database. Single surgeon cases were ranked by DOS into 3 quartiles. 1st Quartile (Group I) was analyzed against the 3rd Quartile (Group II). Univariate analysis was used to assess differences between quartiles. A propensity score matched (PSM) cohort of patients undergoing identical surgical procedures was included as a control group. RESULTS: 281 patients undergoing robotic surgery met inclusion criteria (Age: 56±12.5, BMI: 30±6, 42% female) with an average of 1.6 levels fused. Group I had 95 patients and Group II had 94. Group II had a lower EBL (314 vs 492, p&lt;0.05), shorter LOS (3.8 vs 4.7, p=.1), greater amount of levels fused (2 vs 1.4, p=.021), greater amount of decompressions (2.5 vs 1, p=.003), with less return to the OR within 30 days (7% vs 14%, p=.2), and a lower rate of overall post-operative complications (34% vs 54%, p=.04). In a PSM cohort, the mean EBL was 411±790, LOS 3.7±2.7, overall post-operative complication rate 58%, and rate to return to OR within 30 days was 8%. CONCLUSIONS: There is a substantial learning curve that exists in order to capture the potential benefits of robotic surgery. Performing more robotic cases over time can potentially result in a surgeon lowering length of stay, EBL, and complication rate. Furthermore, this study shows that progressing through this learning curve allows a surgeon to become more comfortable performing larger surgeries in the form of greater levels of decompression.

The Japanese Difficulty Scoring System Correlates with Postoperative Outcome Assessed by the Comprehensive Complication Index in Patients Undergoing Minimally Invasive Liver Resection

Introduction: The Japanese difficulty score (JDS) was developed to standardize the difficulty grading of laparoscopic hepatectomy. The JDS has not consistently correlated well with postoperative outcomes such as Clavien-Dindo complications. This study aims to determine if the JDS correlates with complications as classified by the more inclusive comprehensive complication index (CCI). Methods: A single institutional database was retrospectively queried for all purely minimally-invasive (MIS) hepatectomies performed between January 2008 and December 2019Patient charts were reviewed and data was collected. Patients were grouped into “Low” (<4), “Intermediate” (4-6), and “High” (7+) difficulty based on JDS. Complications were graded using CCI. Statistical comparisons were made using ANOVA or χ2 test, as appropriate. IRB approval was obtained. Results: 413 pure MIS resections were performed. There were 75 (18.2%) Low, 207 (50.1%) Intermediate, and 131 (31.7%) High difficulty MIS hepatectomies. There were no demographic differences. High difficulty was associated with longer operative time (p<0.001), higher mean EBL (p<0.001), and were more likely to require blood transfusion (p<0.001). Mean length of stay (LOS) was longer for more difficult resections (p<0.001). There was no difference between groups in Clavien-Dindo complications or 30-day readmissions. The CCI was significantly higher (Low 7.0, Intermediate 9.5, High 15.8; p=0.006) for more difficult resections. Post-hepatectomy liver failure (PHLF) occurred more frequently with higher JDS (p=0.0023). Conclusions: MIS liver resections with higher JDS were associated with increased operative times, EBL, blood transfusions, LOS, PHLF and overall complications as indicated by the CCI, despite no difference between groups in Clavien-Dindo complications.

180. Do robotic procedures have improved perioperative outcomes after a learning curve period?

<h3>BACKGROUND CONTEXT</h3> Robot-assisted surgical techniques are increasingly implemented to increase surgeon accuracy and stamina; however, the effects of surgeon learning curve on outcomes have not been well studied. <h3>PURPOSE</h3> Identify differences in outcomes and complication rates between robot-assisted and unassisted lumbar interbody fusions, and determine the presence of a learning curve with regard to surgeon case load. <h3>STUDY DESIGN/SETTING</h3> Retrospective review of a single-center stereographic database. <h3>PATIENT SAMPLE</h3> This study included 581 robotic assisted surgical patients. <h3>OUTCOME MEASURES</h3> Perioperative outcomes (estimated blood loss [EBL], length of stay [LOS]), postoperative complication rates, return to OR (30 days). <h3>METHODS</h3> Robotic cases were isolated from a single center multisurgeon database. Surgeons' cases were ranked by date of surgery into 3 quartiles: 1st quartile 2018 (Early) was analyzed against the 3rd quartile 2020 (Late). Univariate analysis was used to assess differences between quartiles. A propensity score matched (PSM) cohort of patients undergoing identical surgical procedures without robotic assistance was included as a control group and compared to both Early and Late groups. <h3>RESULTS</h3> A total of 281 patients undergoing robotic surgery met inclusion criteria (age: 56±12.5, BMI: 30±6, 42% female) with an average of 1.6 levels fused. Early group had 95 patients and Late group had 94. Late group had a lower EBL (314 vs 492, p<0.05), shorter LOS (3.8 vs 4.7, p=.1), greater amount of levels fused (2 vs 1.4, p=.021), greater amount of decompressions (2.5 vs 1, p=.003), with less return to the OR within 30 days (7% vs 14%, p=.2), and a lower rate of overall postoperative complications (34% vs 54%, p=.04). In the control group, the mean EBL was 390±790, LOS 3.7±2.7, overall postoperative complication rate 58%, and rate to return to OR within 30 days was 8%. When the control cohort was compared to the Early robotic cohort, the robotic cohort had a higher EBL (492ml vs 390ml, p<0.05), greater LOS (4.7 vs 3.7 days, p<0.05), greater return to OR within 30 days (14% vs 8%, p=.1), and a comparable overall rate of complications (54% vs 58%, p>0.05). When the control cohort was compared to the Late robotic cohort, the robotic cohort had a lower EBL (314ml vs 390ml, p=.1), comparable LOS (3.7 vs 3.8 days, p>0.05), similar return to OR within 30 days (7% vs 8%, p>0.05), and a lower overall rate of complications (34% vs 58%, p=.02). <h3>CONCLUSIONS</h3> In this study, perioperative outcomes improved drastically in the later cohort. When compared to an identical control cohort, early robotic cases had worse perioperative outcomes. However, when the later robotics cases were compared to the control cohort, robotic-assisted procedures demonstrate superior clinical outcomes. These findings suggest despite the initial worse outcomes of robotic surgery it proves to be an increasingly viable option for adult spinal deformity surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

P127. Use of osteotomy techniques in cervical deformity procedures: Are approaches and practices changing over the years?

<h3>BACKGROUND CONTEXT</h3> Cervical deformity (CD) corrective procedures are ever-evolving, along with the field of spine surgery. The goal of this study was to examine whether surgical advancements over the years have improved or changed outcomes, and the overall way in which we approach CD surgery. <h3>PURPOSE</h3> To investigate if operative approach and outcomes of CD have changed over time in respect to surgical advancements. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study of a prospective cervical deformity database. <h3>PATIENT SAMPLE</h3> A total of 123 CD patients (≥18 years) with complete BL and 2Y HRQL and radiographic data were included. Descriptive analysis included demographics, radiographic, and surgical details. Patients were stratified into 2 groups based on DOS: early (Group I-2012-2014) and later (Group II-2015-2019). Osteotomies were grouped using grading by Ames et al. into low grade (LGO): Grade 1 & 2, and high grade (HGO): Grade 6 & 7. UVA and MVA analyzed differences in osteotomy usage and radiographic, surgical and clinical parameters. Significant CD was characterized by extension XR TS-CL >17°. Rigid deformity was defined by a change of <10°difference between flexion and extension XR. <h3>OUTCOME MEASURES</h3> Complications, HRQL (NDI, mJOA, EQ5D). <h3>METHODS</h3> CD patients (≥18 years) with complete BL and 2-year HRQL and radiographic data were included. Descriptive analysis included demographics, radiographic, and surgical details. Patients were stratified into 2 groups based on DOS: early (Group I-2012-2014) and later (Group II-2015-2019). Osteotomies were grouped using grading by Ames et al. into low grade (LGO): Grade 1 & 2, and high grade (HGO): Grade 6 & 7. UVA and MVA analyzed differences in osteotomy usage and radiographic, surgical and clinical parameters. Significant CD was characterized by extension XR TS-CL >17°. Rigid deformity was defined by a change of <10°difference between flexion and extension XR. <h3>RESULTS</h3> There were 123 CD patients that met inclusion criteria (61years, 63%F, 29.0kg/m2, CCI: 1±1.4). Radiographically at baseline, patients presented with: PT: 19.6± 11°; PI: 55±13°; PI-LL: .9±17.4°; SVA:-3±68mm, TS-CL: 39 ±21°; cSVA: 45±26. Surgical details were 7.7± 4 levels fused with a mean EBL of 1031mL. By surgical approach, 46% had a posterior approach, 20% anterior, and 37% combined. Group I had 49 patients, and Group II had 74. Group II had a higher CCI (1.1 vs .8, p=.2) while there were no significant differences in number of levels fused, reoperations, DJK development, or HRQL metrics between groups (p>0.05). Overall, 53% of patients had an osteotomy. Patients in Group II had a lower usage of HGO (9% vs 23%, p<0.05). In patients with significant CD, Group II received less HGO (3% vs 33%, p<0.05). In posterior approaches, controlling for age, BL deformity, and CCI, Group II underwent less HGO .32[.08-1.2] p=.1. Controlling for age, CCI, and BL deformity, Group II had lower usage of HGO in rigid deformity (.197[.04-.97], p<0.05). <h3>CONCLUSIONS</h3> Overtime, patients undergoing cervical deformity surgery received less high-grade osteotomies, even with high grade deformities. Despite operating on a cohort with a greater degree of comorbidity, there was no deterioration in clinical and radiographic outcomes. These findings reflect a better understanding of surgical management and the utility of invasive osteotomies in adult cervical deformity. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Less is more: clinical utility of postoperative labs following minimally invasive hysterectomy for endometrial cancer

<h3>Objectives:</h3> With the Increasing rates of same day discharge following minimally invasive endometrial cancer (EC) surgery, the need for and value of routine postoperative testing is unclear. We determined whether routine postoperative labs following minimally invasive hysterectomy for EC led to clinically significant changes in postoperative care. <h3>Methods:</h3> This was a single-institution retrospective cohort study of patients undergoing minimally invasive hysterectomy for EC by a gynecologic oncologist. A random sample was selected from an existing database of patients who underwent surgery for EC between June 2014-2017. Patient demographics, preoperative comorbidities, operative and postoperative data, and pathologic findings were manually extracted from the patients' medical records. The financial burden of laboratory evaluation was computed using hospital-level cost data. <h3>Results:</h3> Of the 266 women included in the analysis, the majority (91.4%) were White, with a mean age of 61.5 years, and mean BMI of 38.0±10.1kg/m². The most common comorbidities were diabetes (29.3%, n=78), chronic pulmonary disease (7.9%, n=21), and renal disease (3.8%, n=10). The mean operative time was 152.1±37.8 minutes and mean EBL was 105±91.7mL. Most patients (66.5%, n=177) underwent LAD, of which 77.4% had sentinel (n=78) and/or complete pelvic LAD (n=128), and an additional 42.4% (n=75) underwent paraaortic lymph node assessment. All patients had post-operative labs ordered: 100% complete blood count, 99.2% chemistry, 55.3% magnesium, 44.7% phosphate, 39.8% calcium, 3.4% PT/PTT/INR, 1.9% liver function tests, and 15% other. The mean pre- and post-operative hemoglobin was 13.5±1.4g/dL and 11.5±1.3g/dL, respectively. Mean pre- and post-operative creatinine were 0.83±0.21mg/dL and 0.78±0.20mg/dL. Thirteen patients (4.9%) had a change in management due to postoperative lab results (Table 1). Of these, only two patients (0.8% of entire cohort) had no symptoms or change in clinical status that would have otherwise prompted labs to be performed: one received a blood transfusion for asymptomatic anemia and the other electrolyte repletion for asymptomatic hypomagnesemia of 1.2mg/dL. There were no preoperative or operative factors significantly associated with a postoperative change in management due to labs, postoperative creatinine or postoperative hemoglobin. Routine postoperative laboratory evaluation in this cohort increased hospital costs by $118,455 or approximately $445 per patient. <h3>Conclusions:</h3> Routine postoperative labs are unlikely to lead to significant changes in management for women undergoing minimally invasive hysterectomy for EC, and may increase cost without providing a discernable clinical benefit. In the setting of strict post-operative guidelines, laboratory tests should be ordered when clinically indicated rather than as part of routine postoperative management for women undergoing minimally invasive hysterectomy for EC.

Unravelling the Complexity Myth for Minimally Invasive Right Hepatectomy: Liver Parenchymal Features and their Correlation to Objective Outcomes in Major Anatomical Resections.

Minimally invasive approaches to major liver resection have been limited by presumed difficulty of the operation. While some concerns arise from mastering the techniques, factors such as tumor size and liver parenchymal features have anecdotally been described as surrogates for operative difficulty. These factors have not been systematically studied for minimally invasive right hepatectomy (MIRH). Seventy-five patients who underwent MIRH during 2007-2016 by the senior author were evaluated; these were compared to control group of open right hepatectomy. Demographics, operative, and post-operative variables were collected. Operative times and estimated blood loss, two objective parameters of operative difficulty were correlated to volume of hepatic resection, parenchymal transection diameter and liver parenchymal features using regression analysis. Thirty-eight (50.6%) resections were performed for malignant indications. Average tumor size was 5.7cm (±3.6), mean operative time was 196min (±74), and mean EBL was 220mL (±170). Average transection diameter was 10.1cm (±1.7). There was no correlation between operative difficulty with parenchymal transection diameter or presence of steatosis. Blood loss was higher with increased right hepatic lobe volume and body mass index. This analysis of a very defined anatomical resection suggests that the often quoted radiographic and pathologic features indicative of a challenging procedure were not significant in determining operative difficulty.

Perioperative blood loss after embolization of hypervascular musculoskeletal tumors outside of the spine: A single-center ten year experience and systematic review of the literature

PurposeTo evaluate outcomes following trans-arterial embolization of hypervascular appendicular bony tumors in patients undergoing orthopedic resection by performing a systematic review including data from the authors' institution. Materials and methodsFrom April 2008 to August 2018, 73 patients (59 males, mean age 58.1 years) with musculoskeletal tumors presented for embolization for preoperative devascularization prior to orthopedic surgery. A retrospective chart review was performed to identify demographic, procedural and surgical data. A systematic review of the Pubmed, Medline, and Web of Science databases was performed to identify studies in which pre-operative embolization was performed of appendicular MSK tumors, and with measurements of estimated blood loss. All the variables listed above were recorded. A patient level analysis was performed to determine average estimated blood loss. Results58 patients (47 men, 11 women, range 21–84 years) were included in our institutional analysis. The median EBL was 500 mL (range 100–3000). There was no difference in EBL between RCC (719.6 ± 626.1) and non-RCC groups (855.6 ± 657.5); p = 0.44. The median intra-operative transfusion requirement was 1.0 unit (range 0–8 ± 2.06). From 1984 to 2015, 9 studies were identified that provided data for a total of 118 patients (46 males, 42 females, range 10–82 years). The mean and median post-surgical EBL across all patients was 976.9 ± 78.5 (SE) and 725 mL (range 10–7000), respectively. There were no complications related to non-target embolization. ConclusionPreoperative trans-arterial embolization of hypervascular MSK neoplasms appears to be safe and effective in minimizing peri- and post-operative bleeding while keeping transfusion requirements low.

The Laparoscopic Feasibility Index: A New Approach to Formally Classifying the Difficulty of a Robotic Case

Study Objective To introduce a new method for formally classifying the difficulty of a robotic case. Design Retrospective chart review Setting Las Vegas, Nevada Patients or Participants Female patients undergoing robotic gynecologic surgery from 2005-2019 by a single gynecologic oncologist (n=1,591). Interventions N/A Measurements and Main Results A high volume gynecologic oncologist developed an index, the Laparoscopic Feasibility Index(LFI). The index had a score from one to five. A score of 1 meant the robotic case could have been done just as easily using conventional laparoscopy. A score of 5 meant the surgeon would not even attempt the case using conventional laparoscopy due to extreme challenges and a high perceived risk of conversion to open. Scores were assigned at the end of each case. We examined 1,591 robotic cases performed between 2005 and 2019. The distribution of scores were: 1(n=463, 29.1%); 2(n=313,19.7%); 3(n=345, 21.7); 4(n=231, 14.5%); 5(n=239, 15.0%). Mean console times were: 0.53hrs (score=1); 0.78hrs (score=2); 0.89hrs (score=3); 1.02hrs (score=4); 1.43hrs (score=5). Use of the 4th arm was: 8.9%(score=1); 26.6%(score=2); 37.4%(score=3); 52.6%(score=4); 89.4(score=5). Mean EBL was: 30.1cc(score=1); 45.9cc(score=2); 57.1cc(score=3); 81.1cc(score=4); and 94.5cc(score=5). All three of these trends were statistically significant. We created a regression model to predict the probability that a case had an LFI score of 5 based on EBL, use of 4th arm, and operative time. The 1591 cases were divided into 2 halves using a random number generator. The model was developed on half of the sample and coefficients applied to the other half of the sample(the validation half). The correlation between predicted and observed probabilities in the validation half of the sample was 0.98. Conclusion The Laparoscopic Feasibility Index appears to have excellent internal validity based on our analysis of over 1500 robotic cases. This index could potentially be used to monitor a surgeon's learning curve and how they progress with the complexity of their robotic cases over time.

Intraoperative red blood cell salvage in posterior spinal fusions for idiopathic scoliosis: identifying potential criteria for selective use.

Retrospective. Evaluate the role and effectiveness of ICS in primary posterior spinal fusion (PSF) for idiopathic scoliosis (IS). Intraoperative cell salvage (ICS) minimizes blood loss and need for allogeneic transfusions. However, it adds substantial charges ($800-1200 US) and may be of less clinical benefit in some PSF for IS. This was a single-hospital, retrospective analysis of 178 consecutive IS cases (10-18years of age) who underwent primary PSF by a single pediatric spine surgeon. Overall, 41% of cases received a mean 167cc of ICS blood, after a mean EBL of 528mL (range 200-1800mL). No blood was returned in 59% of cases, with a mean EBL of 293mL (range 75-700mL). Only 6.5% of the entire cohort received > / = 250cc via ICS, after a mean EBL of 773mL. A positive correlation exists between EBL and vertebral levels fused, preoperative major Cobb angle, and length of anesthesia (p < 0.001). ICS may be more efficacious at an inflection point of 12 vertebral fusion levels, preoperative major Cobb angles > / = 55°, anesthesia exposure > / = 6h, and with use of posterior column osteotomies (PCOs) (p < 0.05). In addition, lack of tranexamic acid use lead to greater EBL (p < 0.0001) and ICS volumes (p = 0.008). The use of ICS in IS patients undergoing PSF resulted in the return of > / = 250cc of ICS blood (similar volume to one allogeneic unit) in only 6.5% of cases. Charges for ICS set-up and processing of one bowl of ICS is much higher than for one allogeneic unit ($1200 vs. $462 US), hence transfusing lower volumes of autologous ICS blood is not cost-effective for all PSF for IS. IV; Therapeutic studies.

P70. A combined anterior-posterior approach in select cervical deformity corrections has potential for superior cost effectiveness driven by outcomes

BACKGROUND CONTEXT The choice of surgical approach in CD surgery is often dictated by surgeon preference and experience. This choice could significantly impact the costs and outcomes of an operation, therefore the approaches should be analyzed in order to determine the optimal approach from a cost-utility perspective. The cost utility of different surgical approaches in cervical deformity (CD) has not been investigated in the literature. PURPOSE Investigate the cost utility of differing approaches in operative CD patients. STUDY DESIGN/SETTING Retrospective review of a prospective multicenter cervical deformity database. PATIENT SAMPLE A total of 105 CD patients. OUTCOME MEASURES Costs, EuroQol-5D (EQ-5D), Quality adjusted life years (QALYs), Cost per quality adjusted life years. METHODS Included CD patients (C2-C7 Cobb>10°or CK>10°, cSVA>4cm or CBVA>25°) >18yr with follow-up (1-year) surgical and health related quality of life scores. Costs were calculated using the PearlDiver database, which reflects both private insurance and Medicare reimbursement claims. QALYs and cost per QALY were calculated using a 3% discount rate to account for residual decline to life expectancy (78.7 years). After accounting for complications, LOS, revisions, and death, cost per QALY at 1Y and life expectancy [LE] were calculated for surgical approach (anterior-only, posterior-only [excluding PSO and VCR to account for differences in instrumentation], combined). In a subanalysis, approach groups were propensity-score matched for TS-CL to account for baseline (BL) deformity. RESULTS A total of 105 CD patients met inclusion criteria (61.9 yrs, 63% female, 28.6kg/m2, CCI: 0.97). By approach, 21.9% underwent anterior only, 37.1% posterior only and 41% combined approaches. Average number of levels fused was 6.9, with a mean EBL of 948 ml and total operative time of 544.2 minutes. Mean EQ5D at BL was 0.74±0.07 and at 1Y was 0.79±0.08 (a difference of 0.05±0.08). Average difference in EQ5D from BL to 1Y was significant (p=0.002) across approach: 0.093 anterior-only, 0.021 posterior-only, 0.044 combined. 13% (3) of anterior-only patients underwent a revision, 10.3% (4) of posterior and 13.9% (6) of combined approaches. The average costs per surgery for CD patients at 1-year undergoing surgery by anterior approach was $27,640.75, $38,499.44 posterior-only, and $36,553.41 combined approach (p>0.05).The cost per QALY was higher for posterior-only patients at 1-year ($948,946.81) compared to anterior-only ($152,616.65) and combined ($424,110.14), p CONCLUSIONS After accounting for comorbidities, complications, revisions, and death, all surgical approaches showed improvement in postoperative EQ5D scores, however posterior approach demonstrated overall lower cost effectiveness. CD patients who underwent anterior-only approach had the lowest average costs for CD corrective surgery, as well as the lowest cost per QALY (best cost-effectiveness) compared to posterior and combined approaches. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

233. Development of risk stratification predictive models for cervical deformity surgery

BACKGROUND CONTEXT As the field of corrective cervical deformity (CD) surgery progresses, surgeons continue to take on more challenging cases. In order to minimize suboptimal postoperative outcomes it is important to develop a tool that allows for proper preoperative risk stratification. PURPOSE Develop individualized predictive models for identification of risk-factors that lead to the development of major complications, revisions, and unplanned reoperation. STUDY DESIGN/SETTING Retrospective cohort study of a prospective adult cervical deformity database. PATIENT SAMPLE A total of 105 CD patients. OUTCOME MEASURES Major complications (prolonged hospitalization, invasive intervention, prolonged or permanent morbidity, death within 1 year[1Y]), unplanned revision or reoperation after CD surgery within 1Y, HRQOL (NDI, mJOA, EQ5D). METHODS CD patients (cervical kyphosis >10°, coronal scoliosis >10°, cSVA >4cm, TS-CL >10°, or CBVA >25°) ≥18 years old with complete baseline (BL), 1Y HRQoL and radiographic data. Patients were stratified into two groups based on their outcome from surgery: revision (Rev) and major complication (MC). Descriptive analysis identified cohort demographics, radiographic parameters and surgical details. Univariate analysis of preoperative and surgical factors was conducted to determine associations with any of the two outcomes. Stepwise logistic regressions identified surgical, radiographic, and HRQL factors that were associated with Rev or MC. Decision tree analysis established cut-offs for predictive variables. RESULTS A total of 105 CD patients were included (61.6yrs, 67%F, BMI: 28.4kg/m2, CCI: 0.96±1.3). Surgical details: 7.6± 3.7 levels fused; mean EBL of 816 mL. By surgical approach, 45.71% had a posterior approach, 35.24% combined approach, and 19.05% anterior approach. Radiographically at baseline, patients presented with: PT: 18.9± 11.3; PI: 53.0±11.2; PI-LL: -0.45±17.2; SVA: -4.3±66.8, TS-CL: 37.9 ±20.2; cSVA: 38.4±19.9. Postoperatively, 20 patients experienced a MC and 17 patients underwent a subsequent rev. instrumentation location (LIV: 1.1[1.0-1.3] and UIV: 1.5[1.1-2.1]) was significantly associated with undergoing a rev after index surgery (all p C3, LIV>T3, C2-T3 SVA 57.6°, CTPA>7.8°, and C2S 59.2°, C2-C7 SVA > 69.1°, C2-T3 SVA 4.25, surgical invasiveness and posterior osteotomies (AUC:0.83). CONCLUSIONS Major adverse events were not uncommon following adult cervical deformity correction. Risk stratification models were developed to predict with high accuracy the occurrence of these common significant postoperative events. Revisions were predicted with an accuracy of 80% using a predominance of radiographic variables, while the occurrence of other major complications was also predicted with high reliability utilizing additional baseline HRQoL data and surgical factors. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.