Mean Operating Room Time Research Articles

Robot-assisted radical cystectomy for bladder cancer: single-center experience

Abstract Objective Radical cystectomy remains the most effective treatment for patients with localized, invasive bladder cancer and recurrent noninvasive disease. Recently some surgeons have begun to describe outcomes associated with less invasive surgical approaches to this disease, such as laparoscopic or robotic assisted techniques. We report our maturing experience with 100 consecutive cases of robotic assisted laparoscopic radical cystectomy regarding perioperative results, pathological outcomes, and surgical complications. Methods A total of 100 consecutive patients (73 male and 27 female) underwent robotic radical cystectomy with intracorporeal urinary diversion at our institution from February 2018 to February 2021 for clinically localized bladder cancer. Outcome measures evaluated included operative variables, hospital recovery, pathological outcomes, and complication rate. Results The mean age of this cohort was 60.4 years (range 38 to 82). Ninety-five patients underwent ileal conduit diversion, 5 received a neobladder). The mean operating room time for all patients was 184 min (min time was 160 min) and mean surgical blood loss was 286 ml. On surgical pathology, 2% of the cases were pT1, 35% were pT2, 51+12% were pT3/T4 disease and 17% were node positive. The mean number of lymph nodes removed was 16 (range 10 to 40). In no case was there a positive surgical margin. The mean days to flatus were 2.6, bowel movement 2.8 and discharge home 8.2. There were 21 postoperative complications in 20 patients with 4% having a major complication (Clavien grade 3 or higher) and 15% being readmitted within 30 days after surgery. At a mean follow-up of 12 months 3 patients had disease recurrence and died 4 of disease. Conclusions We report a relatively large cohort and maturing experience with robotic radical cystectomy for the treatment of bladder cancer, providing acceptable surgical and pathological outcomes. These results support continued efforts to refine the surgical management of muscle-invasive bladder cancer.

Safety and Intraoperative Results in Live Kidney Donors with Vascular Multiplicity After Hand-Assisted Laparoscopy Living Donor Nephrectomy.

Background and PurposeVascular multiplicity is the most frequent anatomic variation in kidney donors. Despite concerns about risks, these allografts are increasingly used to overcome the shortage of kidney donors. The safety and clinical outcomes in living kidney donors were evaluated with vascular multiplicity after hand-assisted laparoscopic living donor nephrectomy (HALDN).Patients and MethodsData from all living kidney donors who underwent HALDN from 2008 to 2021 was retrospectively reviewed. Patients were divided into two groups as single (SRV) and multiple renal vessels (MRV), and a comparative analysis was done. The primary outcomes include operating room time (ORT), days of hospital stay, estimated blood loss, complications, conversion, and re-operations.ResultsMRV were present in 166 out of 612 donors (27.1%). Among those, 10 (1.6%) donors had simultaneous multiple arteries and veins. Additionally, the prevalence of artery and vein multiplicity was 21.8% (n = 134) and 3.5% (n = 22), respectively. Warm ischemia time was significantly different among the two groups but not clinically important. The number of conversions to open technique, the mean ORT, the median blood loss, and days of hospital stay were similar between the SRV and MRV groups, without significant differences. According to the modified Clavien-classification system, no differences were found in the complication rates between the two groups (p = 0.29). Complication rates were 3.3% and 3.6% for the SRV and MRV groups, respectively.ConclusionHALDN is a procedure with safe intraoperative results, even with vascular multiplicity. The presence of multiple renal arteries or veins has no negative impact on the outcome of the donor after living donor nephrectomy.

Spinal versus general anesthesia for minimally invasive transforaminal lumbar interbody fusion: implications on operating room time, pain, and ambulation.

There has been increasing interest in the use of spinal anesthesia (SA) for spine surgery, especially within Enhanced Recovery After Surgery (ERAS) protocols. Despite the wide adoption of SA by the orthopedic practices, it has not gained wide acceptance in lumbar spine surgery. Studies investigating SA versus general anesthesia (GA) in lumbar laminectomy and discectomy have found that SA reduces perioperative costs and leads to a reduction in analgesic use, as well as to shorter anesthesia and surgery time. The aim of this retrospective, case-control study was to compare the perioperative outcomes of patients who underwent minimally invasive surgery (MIS)-transforaminal lumbar interbody fusion (TLIF) after administration of SA with those who underwent MIS-TLIF under GA. Overall, 40 consecutive patients who underwent MIS-TLIF by a single surgeon were analyzed; 20 patients received SA and 20 patients received GA. Procedure time, intraoperative adverse events, postoperative adverse events, postoperative length of stay, 3-hour postanesthesia care unit (PACU) numeric rating scale (NRS) pain score, opioid medication, and time to first ambulation were collected for each patient. The two groups were homogeneous for clinical characteristics. A decrease in total operating room (OR) time was found for patients who underwent MIS-TLIF after administration of SA, with a mean OR time of 156.5 ± 18.9 minutes versus 213.6 ± 47.4 minutes for patients who underwent MIS-TLIF under GA (p < 0.0001), a reduction of 27%. A decrease in total procedure time was also observed for SA versus GA (122 ± 16.7 minutes vs 175.2 ± 10 minutes; p < 0.0001). No significant differences were found in intraoperative and postoperative adverse events. There was a difference in the mean maximum NRS pain score during the first 3 hours in the PACU as patients who received SA reported a lower pain score compared with those who received GA (4.8 ± 3.5 vs 7.3 ± 2.7; p = 0.018). No significant difference was observed in morphine equivalents received by the two groups. A difference was also observed in the mean overall NRS pain score, with 2.4 ± 2.1 for the SA group versus 4.9 ± 2.3 for the GA group (p = 0.001). Patients who received SA had a shorter time to first ambulation compared with those who received GA (385.8 ± 353.8 minutes vs 855.9 ± 337.4 minutes; p < 0.0001). The results of this study have pointed to some important observations in this patient population. SA offers unique advantages in comparison with GA for performing MIS-TLIF, including reduced OR time and postoperative pain, and faster postoperative mobilization.

P033 IMPLEMENTATION OF A ROBOTIC VENTRAL HERNIA REPAIR PROGRAM IN A EUROPEAN CENTER: RESULTS DURING THE LEARNING CURVE AND EARLY DEVELOPMENT

Abstract Aim This study aims to describe the early results after implementing a robotic ventral hernia repair (RVHR) program in a European university center. Material and Methods All patients undergoing primary (PH) or incisional (IH) RVHR were included in an institutional open-label prospective quality database. Patients' baseline characteristics, intra-operative data, postoperative, and follow-up outcomes recorded from September 2018 to September 2020 were analyzed. Results Twenty-six PH and 58 IH were included; respectively, mean BMIs were 32.8±7.1 and 30.3±5.0kg/m2. Hernia resulted from median laparotomies in 69.0% of the IH patients; 5 patients (8.6%) had defects &amp;gt;10cm in width. In the PH group, the mean total operative room (OR) time was 98.1±42.5min. Mean VAS (Visual Analog Score) was 2.5±1.7 at day 0, 61.5% of patients were ambulatory, and 38.5% stayed 1-2 nights. One (3.8%) recurrence and 1(3.8%) surgical complication (umbilical perforation) occurred with no general complications. In the IH group, 15 patients required transversus abdominis release (TAR, 25.9%). Mean OR time was 179.6±82.3min, mean VAS 1.9±2.0 at day0, 19% of patients were ambulatory, 44.8% stayed 1-2 nights and 27.6% 3-4 nights. Mean follow-up was 71.6±51.8 days. One (1.7%) postoperative complication (bleeding, embolization, no reoperation), 2(3.4%) recurrences occurred. Successful completion of an extraperitoneal (eTEP) RVHR with bilateral TAR was achieved after 18 months and 40 cases, after which we began training a second surgeon. Conclusions Implementation of a RVHR program showed promising results with acceptable operative time even during the learning curve. Postoperative outcomes suggest a potential advantage in postoperative recovery.

Developing a business case for a regional anesthesia block room: up with efficiency, down with costs

BackgroundRegional anesthesia techniques offer many benefits for total joint arthroplasty (TJA) patients. However, they require personnel and equipment resources, as well as valuable operating room (OR) time. A block room...

Comparative outcomes of transthoracic versus transhiatal esophagectomy

BackgroundSurgical resection has become a mainstay of therapy for locally advanced esophageal cancer and can increase survival significantly. With the advancement of minimally invasive surgery, there is still debate on the best approach for esophagectomy. We report a modern analysis of outcomes with transthoracic versus transhiatal esophagectomy. MethodsA prospectively managed esophagectomy database was queried for patients undergoing transthoracic or transhiatal esophagectomy between 1996 and 2016. Continuous variables were compared using the Kruskal-Wallis or the analysis of variance tests as appropriate. Pearson χ2 test was used to compare categorical variables. All statistical tests were 2-sided and an α (type I) error < .05 was considered statistically significant. ResultsA total of 846 patients underwent esophagectomy with a median age of 66 (28–86) years. There was no difference in estimated blood loss for transthoracic and transhiatal, but mean operating room times were longer for transthoracic versus transhiatal (P < .001), and the number of retrieved lymph nodes was higher for transthoracic versus transhiatal (P < .002). Postoperative complications occurred in 207 (29%) transthoracic patients vs 59 (44.7%) transhiatal patients, (P < .001). The most common complications in transthoracic versus transhiatal techniques, respectively, were anastomotic leaks: 4.3% vs 9.8%; (P = .01), anastomotic stricture 7% vs 26.5%; (P < .001), and pneumonia 12.6% vs 22.7%; (P < .002). Median survival significantly improved in patients undergoing transthoracic (62 months) vs transhiatal (39 months) P = .03. ConclusionWe found that a transthoracic approach was associated with lower pneumonias, anastomotic leaks, wound infections, and strictures, with an improvement in nodal harvest. Survival was also significantly improved in patients who underwent transthoracic esophagectomy.

Association of Complications with Healthcare Utilization and Hospital-Borne Costs Among Patients Undergoing Open Low Anterior Resection Using Curved Cutter Staplers.

PurposeThe ability of curved cutter staplers (CCS) to conform to the complex anatomy of the rectum has led to their widespread use in open low anterior resection (LAR). We describe the incidence of complications and their association with healthcare utilization and hospital-borne costs among patients who underwent open LAR with CCS, with the intent to provide contextual epidemiologic and economic burden data for future evaluations of innovations that may lead to a reduced incidence of complications.MethodsRetrospective cohort study using Premier Healthcare Database. Studied patients were ≥18 years who underwent inpatient open LAR with CCS between October 1, 2016 and March 30, 2020 (index admission). Complications of interest included anastomotic leak, bleeding, infection, transfusion, and device complications/adverse incidents during the index admission. Outcomes included index admission hospital length of stay (LOS), non-home discharge status, total operating room (OR) time, total hospital-borne costs, and all-cause readmissions within 30, 60, and 90 days post discharge from index admission. Multivariable regression models were used to compare outcomes between patients with vs without any complication of interest.ResultsThe study included 618 patients with a mean age of 61 years, of whom 57% were males. The incidence proportion of any complication during the index admission for open LAR with CCS was 28% (95% CI: [23.9%, 31.0%], n=170). As compared with patients experiencing no complications, those with a complication had higher adjusted mean total hospital costs ($38,159 vs $22,303, p<0.001), non-home discharge status (21.8% vs 9.2%, p=0.004), mean LOS (13 days vs 6 days, p<0.001), and mean OR time (362 mins vs 291 mins, p<0.001). There were no significant differences in all-cause readmissions between patients with vs without complications.ConclusionAmong patients undergoing open LAR with CCS, over a quarter of patients experienced a complication, resulting in a substantial burden to the healthcare system.

Single-Dose del Nido Cardioplegia Compared With Standard Cardioplegia During Coronary Artery Bypass Grafting at a Veterans Affairs Hospital.

Del Nido cardioplegic solution (DNC), used chiefly in pediatric patients, rapidly induces prolonged cardiac arrest during cardiac surgery. To determine whether surgical outcomes after coronary artery bypass grafting in a United States military veteran population differed when DNC was used instead of our standard Plegisol cardioplegia, we retrospectively reviewed 155 consecutive operations performed from July 2016 through June 2017. Del Nido cardioplegia was used to induce cardiac arrest in 70 patients, and Plegisol in 85. Compared with the Plegisol group, the DNC group had a shorter mean cardiopulmonary bypass time (96.8 vs 117 min; P <0.01) and aortic cross-clamp time (63.9 vs 71.7 min; P=0.02). On multiple linear regression, DNC use and number of bypasses performed were predictors of cardiopulmonary bypass time. The groups were similar in median number of bypasses performed, median time to extubation, intensive care unit stay, and total postoperative stay; however, the DNC group had a shorter mean operating room time (285.8 vs 364.5 min; P <0.01). Del Nido cardioplegia, number of bypasses, cardiopulmonary bypass time, and red blood cell transfusion were predictors of operating room time. Outcomes in the groups were similar for 30- and 180-day death, stroke, renal failure, ventilation time >48 hours, atrial fibrillation, tracheostomy, reintubation, and mechanical circulatory support. We conclude that single-dose DNC is safe, effective, and cost-effective for achieving cardiac arrest in U.S. veteran populations.

Overcoming the Arduous Transition for Robotic Hepatopancreatobiliary Cases: A Multi-Procedure Learning Curve Study Utilizing CUSUM Analysis.

Quick optimization and mastery of a new technique is an important part of procedural medicine, especially in the field of minimally invasive surgery. Complex surgeries such as robotic pancreaticoduodenectomies (RPD) and robotic distal pancreatectomies (RDP) have a steep learning curve; therefore, findings that can help expedite the burdensome learning process are extremely beneficial. This single-surgeon study aims to report the learning curves of RDP, RPD, and robotic Heller myotomy (RHM) and to review the results' implications for the current state of robotic hepatopancreaticobiliary (HPB) surgery. This is a retrospective case series of a prospectively maintained database at a non-university tertiary care center. Total of 175 patients underwent either RDP, RPD, or RHM with the surgeon (DRJ) from January 2014 to January 2020. Statistical significance of operating room time (ORT) was noted after 47 cases for RDP (p < 0.05), 51 cases for RPD (p < 0.0001), and 18 cases for RHM (p < 0.05). Mean ORT after the statistical mastery of the procedure for RDP, RPD, and RHM was 124, 232, 93min, respectively. No statistical significance was noted for estimated blood loss or length of stay. Robotic HPB procedures have significantly higher learning curves compared to non-HPB procedures, even for an experienced HPB surgeon with extensive laparoscopic experience. Our RPD curve, however, is quicker than the literature average. We suggest that this is because of the simultaneous implementation of HPB (RDP and RPD) and non-HPB robotic surgeries with a shorter learning curve-especially foregut procedures such as RHM-into an experienced surgeon's practice. This may accelerate the learning process without compromising patient safety and outcomes.

Using Regression Models to Predict Surgery Duration for Robotic-Assisted Total Laparoscopic Hysterectomy in Endometrial Cancer

Study Objective To develop regression models using preoperative variables that can accurately predict the operating room time of robotic surgery for endometrial cancer. Design A retrospective review using preoperative variables including age, BMI, ASA score, surgery start time, preoperative diagnosis, number of previous abdominal surgeries, parity, and uterine volume were used to develop regression models. These regression models were compared to institutional models that used preoperative estimations of operating room times based on historical averages. Setting An urban, academic hospital. Patients or Participants 348 patients undergoing robotic-assisted total laparoscopic hysterectomy with staging for endometrial cancer between 2016-2020 by six surgeons. Interventions N/A Measurements and Main Results The mean operating room time was 234 minutes (range: 130 – 484). The mean preoperative estimated operating room time was 223 minutes (range: 120 – 390). Linear, ridge, lasso, and elastic net models had relatively similar performance measures, and all models outperformed preoperative estimated operating room duration. Ultimately, the elastic net model performed the best. Elastic net had the smallest median root mean square error (RMSE) 57.97 (CI of 54.44-61.72) and greatest median R-squared 0.22 (CI 0.18-0.26). Surgery start time and preoperative diagnosis were found to be most influential variables in predicting operating room time followed by BMI, uterine volume, and number of prior surgeries. Age, ASA, parity and surgery type were not important in predicting operating room time. Conclusion Regression modeling more accurately predicted operating room time than the institutional standard that used historical averages for robotic-assisted hysterectomy with staging for endometrial cancers. This study is novel in its application to the field of robotic surgery in gynecologic oncology as it builds off of previous work from other disciplines demonstrating improved OR time predictions with regression models. Further studies are needed with expanded databases and more robust variable sets to refine the models ability to account for variance.

Use of a Modified Rep Model in Primary Joint Arthroplasty: Lessons Learned.

Orthopedic implant device sales representatives ("reps") can provide intraoperative guidance based on their product knowledge, as part of their many responsibilities. However, for experienced high-volume arthroplasty surgeons, a representative may not be required in the room for most primary total knee arthroplasty (TKA) procedures. The goal of this study was to describe the authors' experience with a modified rep model for primary TKA. Between January and December 2017, a total of 100 unilateral primary TKAs were performed with a modified rep model and compared with 100 primary TKAs that were performed before this protocol. The authors adopted 2 additional initiatives to institute this protocol safely: (1) improved education of operating room staff and allocation of responsibilities; and (2) reengineering of the existing surgical trays. No perioperative complications, including readmission, periprosthetic fracture, or infection, occurred in either group. In addition, no difference was found in mean length of stay between the modified rep and conventional cohorts (2.2 and 2.4 days, respectively; P=.49). Mean operating room time was less with the modified rep cohort (102.1 vs 117.8 minutes; P<.001), as was total instrument turnover time in the operating room (13.9 vs 29.7 minutes; P<.0001) and in central sterilization (59.4 vs 126.8 minutes; P<.001). No errors occurred with implant accuracy or trays, and there was no need to change the type of implant with the modified rep model, compared with 6% of trays requiring additional sterilization with the conventional model. The negotiated implant cost with the modified rep model was approximately $2000 less than that for the conventional group. This study found that the modified rep model for primary TKA is safe and has the potential for substantial cost savings. [Orthopedics. 2020;43(6):e538-e542.].

Awake breast cancer surgery: strategy in the beginning of COVID-19 emergency

IntroductionCOVID-19 is a declared worldwide pandemic. In our country, due to shortage of hospitals and beds in intensive care unit, oncological and breast cancer (BC) resources are temporarily shifted to COVID-19 patients. In addition, risk of cross-infections should be considered in these frail patients. To accomplish more surgical procedures and to reduce the length of hospital stay (LOS), fast track awake BC surgery should be implemented. The aim of the study is to estimate the effects of surgical shift in our facility during the early COVID-19 outbreak.Materials and methodsFrom 30th January 2020 to 30th of March 2020, 86 consecutive patients were retrospectively enrolled and divided into pre-COVID-19-BC and COVID-19-BC. Clinical parameters and anamnestic data were collected and analyzed. Surgical procedures, relative complications and type of anaesthesia were reported. The effect on surgical time (ST), operative room time (ORT) and length of stay (LOS) were described and examined.ResultsNo statistical difference was found in complications rate, clinical data and surgical procedures (p > 0.05). Awake breast conservative surgery (BCS) was the most frequent procedure in COVID-19-BC (p = 0.006). A statistically significant decrease in ORT and LOS was reported in COVID-19-BC (p = 0.040 and p = 0.0015 respectively), while comparable time resulted for ST (p = 0.976). Mean ORT and LOS reduction were 20.79 min and 0.57 hospital bed days.ConclusionIn the “COVID-19 era”, fast track awake breast surgery provides a reduction of ORT, LOS and potentially surgical treatment for a wider number of oncological patients.

A prospective study of the components of operating room utilisation time for robotic urological surgery in a public teaching hospital setting

Introduction and aim: Although there are several publications on learning curves and patient outcomes in robotic surgery, the literature is lacking in depth analysis of operating room (OR) utilisation time which is an expansive healthcare resource for robotic surgery, especially in urology. Thus, we aimed to study individual operating theatre component times in order to improve performance and efficacy. Method: A cross-specialty robotic-surgery programme was established at our institution in mid-June 2016 using the daVinci Xi dual console robot. A detailed database was established before initiation of the project. The times taken for each element of the preparation and completion of robotic urological procedure were collected by an independent nurse for all the procedures. Primary outcome measures were total OR time, operative time and console time. Secondary outcome measures were port placement time, set-up time and non-operative time. The statistical significance was calculated by using the Student’s t-test, Fisher’s exact test or Wilcoxon matched pairs test where appropriate. Result: Thirty consecutive urological cases were analysed. Mean total OR time, operative time and console time were 320.86 (range 172–485), 235.7 (124–295) and 152.3 min (66–219) respectively. Console time accounted for about less than half of OR time. A significant proportion of OR time was non-operative time (almost one third). After an initial learning curve, set-up time was consistently maintained for most robotic procedures. Conclusions: The findings of this study have three implications for clinical practice. Firstly, console time contributed about half of the OR time. This can be optimised with experience. Secondly robot set-up time is likely to reduce with the experience of the whole team. Finally, non-operative OR time constitute a significant one third of the OR time during robotic surgery. Efforts to reduce non-surgical aspect of OR time will have potential to reduce cost and improve efficiency. Level of Evidence: 4

Outcomes and complications of immediate versus delayed sequential bilateral cataract surgery in children

PurposeTo present the largest series to date comparing outcomes and complications of immediate versus delayed sequential bilateral cataract surgery (ISBCS vs DSBCS) in children at a single center over a 10-year period. MethodsThe medical records of children <2 years of age who underwent ISBCS and DSBCS were reviewed retrospectively. Data was collected on outcomes and complications (ophthalmological and anesthesia-related) up to 8 weeks postoperatively. ResultsA total of 53 children were included: 37 ISBCS and 16 DSBCS. There were no differences between groups with regard to sex, age at surgery, and type of surgery. The ISBCS group had significantly more patients with systemic or ocular comorbidities than the DSBCS group (35% vs 6%; P = 0.029). Mean operating room time was significantly lower for the ISBCS group (3.61 vs 4.09 hours; P = 0.037), whereas total surgical time was similar. No major intraoperative surgical complications or anesthesia-related adverse events occurred in either group. Postoperative complications (most commonly, raised intraocular pressure) occurred in 5 eyes (7%) in the ISBCS group and 8 eyes (25%) in the DSBCS group (P = 0.009). Patients in the ISBCS group required significantly fewer follow-up visits compared to the DSBCS group (4 vs 6; P = 0.0002). ConclusionsISBCS avoids multiple anesthesia sessions and reduces follow-up visits, with intra- and postoperative ophthalmological or anesthesia-related complications comparable to DSBCS.

Robot-Assisted Radical Cystectomy in a Context of Budget Constraints: Description of a Technique with Reduced Economic Impact

Background: Robot-assisted radical cystectomy (RARC) is increasingly being implemented in urologic surgical departments. However, its unclear clinical advantage has to be weighed against its rather increased cost compared with open radical cystectomy. We herein describe a technique reducing the number of robotic surgical instruments and staplers for RARC with intracorporeal urinary diversion, presenting preliminary results of our technique in a prospective cohort of patients. Patients and Methods: Eight patients underwent RARC with intracorporeal urinary diversion using a “low-cost” technique between October 2018 and October 2019. RARC is performed with a DaVinci Xi robot. The demolitive part is completed with three robotic instruments: hot shear scissors, Maryland bipolar grasper, and a Cadiere forceps for retraction; Hem-o-lock clips are used for vascular pedicles, avoiding energy dissection devices. For the reconstructive phase, a robotic needle holder is used for suturing in the right hand, whereas the left hand uses the previously employed Maryland. Bowel manipulation is performed with the Cadiere forceps in the right hand and the Maryland in the left hand. For bowel suturing, an omega-shaped configuration is used to avoid wasting staple lines on bowel isolation. Thus, one first staple line (60 mm laparoscopic EndoGIA) completes the anastomosis itself, and a second throw allows the closure of the access enterotomies in the bowel, isolating the intestinal segment for urinary diversion. The omega-shaped bowel destined for ileal conduit is almost 20 cm in length and is measured visually using the robotic cadiere as reference. For neoladder, the diversion begins with the ileo-urethral anastomosis, then two 20 cm limbs are isolated proximally and distally from the anastomosis. The entire procedure is completed with only four instruments, no energy dissector and two throws of 60 mm laparoscopic staplers. The attached video displays the technique. Results: All eight procedures were completed using only four robotic instruments and two staple lines. Seven of eight patients underwent ileal loop diversion and one of eight orthotopic neobladder. Mean operating room time was 400 minutes with a standard deviation (SD) of 89 and a median of 375 minutes (interquartile range [IQR] 338–435). Mean blood loss was 393 mL (SD 136) with a median of 375 mL (IQR 312–537). No intraoperative complications or conversions to open surgery occurred. Mean lymph node yield was 26 (SD 7.4) with a median of 28 (IQR 17–32). Mean hospital stay was 10 (SD 2.6) with a median of 9 days (IQR 7–11). Three of eight patients experienced complications, of which one Clavien I (paralytic ileus) and two Clavien II (urinary tract infection). We estimated, compared with currently diffused RARC techniques, a reduction in cost of 2500€ based on single use instruments and using Belgian prices as reference (−1000€ robotic instruments, −500€ dissection device, −1000€ staple lines). Conclusions: RARC is feasible using a “low-cost” approach, which includes avoiding energy dissection devices, clever use of robotic instruments, and minimizing bowel staple lines. Our results are encouraging and in line with reported large RARC series. A thorough economic analysis is required to define the impact of our technique on hospitalization costs for RARC in Europe. No competing financial interests exist. Runtime of video: 6 mins

PMD5 COMPARATIVE EFFECTIVENESS ASSESSMENT OF TWO POWERED SURGICAL STAPLING PLATFORMS IN LAPAROSCOPIC SLEEVE GASTRECTOMY

To compare outcomes between the two latest innovations in powered stapling technology, the ECHELON FLEX™ GST system (GSTS) and the Signia™ system (SS), among patients undergoing laparoscopic sleeve gastrectomy (LSG) for obesity. Using the Premier Healthcare Database of US hospital discharge records, we selected patients undergoing inpatient LSG between 3/1/2017 (SS launch)-12/31/2018 (first=index admission). Outcomes measured during the index admission included intra/post-operative bleeding/transfusion (primary outcome), total hospital costs, length of stay (LOS), and operating room time (ORT); 30, 60, and 90-day all-cause inpatient readmissions were also examined. We used 1:1 cardinality matching to balance the GSTS and SS groups on numerous patient and provider/hospital characteristics, allowing a maximum standardized mean difference (SMD)≤0.05 for all matching covariates. Generalized estimating equations (GEE) accounting for hospital-level clustering were used to compare the study outcomes between the GSTS and SS groups. After matching, there were 491 patients in each group (982 total) and all covariates were well-balanced with all SMDs ≤0.05. The incidence proportion of bleeding/transfusion was significantly lower in the GSTS group as compared with the SS group (3 events/491 [0.61%] vs. 11 events/491 [2.24%], GEE-based odds ratio [GSTS=reference]=3.57, 95% CI=1.66-7.69, P=0.0012); this difference was driven primarily by diagnoses of acute post-hemorrhagic anemia: 2 of 3 events in GSTS and 8 of 11 events in SS. Differences between the GSTS and SS groups were statistically insignificant for mean hospital costs ($10,666 vs. $11,562, P=0.184), mean LOS (1.6 vs. 1.7 days, P=0.3624), mean ORT (113 vs. 117 minutes, P=0.1219), and all-cause inpatient readmission at 30 (2.2% vs. 2.1%, P=0.9764), 60 (3.2% vs. 2.9%, P=0.7632), and 90 (3.6% vs. 3.2%, P=0.7968) days. In this retrospective study of 982 patients undergoing LSG, GSTS was associated with a significantly lower rate of a composite bleeding/transfusion outcome as compared with SS, primarily driven by acute post-hemorrhagic anemia diagnoses.

Bariatric efficiency at an academic tertiary care center.

Operating room (OR) efficiency requires coordinated teamwork between the staff surgeon, anesthesia team, circulating nurse, surgical technician, and surgical trainee or assistant. Bariatric cases present unique challenges including difficult airways, challenging intravenous access, use of specialized surgical equipment, and synchronized exchange of orogastric tubes. The high contribution margin of these complex bariatric procedures rests on OR efficiency. To compare the efficiency of bariatric surgeries performed by a single surgeon at a tertiary academic medical center with its inherent variability of OR staff to that of a private hospital with a standardized surgical team. All laparoscopic Roux-en-Y gastric bypasses (LRYGB) performed by a single surgeon at University Hospitals Cleveland Medical Center (UHCMC) and a Community Affiliate (CA) from 2013 to 2015 were retrospectively reviewed.Patient demographics and preoperative comorbidities were compared. The variability of OR staff at each site was described. Four primary endpoints of the different OR phases were measured at the 2 locations and analyzed using standard statistical methods. The OR data of 74 cases of LRYGB at UHCMC and 106 cases at the CA were analyzed. Patient cohorts were comparable by age (45 ± 12 vs. 45 ± 10; p = 0.88), sex (82% vs. 79% female; p = 0.62), BMI (47.16 ± 7.33 vs. 45.91 ± 6.85; p = 0.25), and comorbidities.At CA, the teams who participated in LRYGB cases were fairly constant (8 circulating and scrub nurses, 4 anesthetists, 3 anesthesiologists), whereas at UHCMC there was great variability in the number of staff with 108 staff (39 circulating nurses, 57 scrub nurses/technicians, 59 anesthetists or anesthesia residents, 24 anesthesiologists) participated in LRYGB cases. There was no statistical difference between the total mean OR time and surgical time of the cases performed at the 2 sites (203 ± 59min vs. 188 ± 39min; p = 0.06; 152 ± 56min; 145 ± 37min; p = 0.36). However, the pre- and post-case times were longer at UHCMC compared to the CA (38 ± 9min vs. 33 ± 6min; p < 0.0001; 13 ± 6min vs. 10 ± 3min; p = 0.01). The academic center has much greater variability in staff for these complex bariatric procedures. There was a trend toward longer OR times at the tertiary center as demonstrated by the difference in pre- and post-case times, but the consistent surgeon and assistant allowed for consistent surgical case time regardless of the setting. The implication of variability in OR staff can be overcome by the surgeon directing the procedure itself. The opportunity for improving the efficiency of bariatric surgery should focus on the perioperative care of the patient in OR that requires everyone to be familiar with the procedure.

78: Effect of time of year on surgical outcomes in patients undergoing minimally invasive sacral colpopexy or uterosacral ligament suspension

We sought to evaluate if the month of the year relative to fellow/resident promotions in July effects operating room (OR) time, complication rates, and prolapse recurrence for women undergoing minimally invasive sacral colpopexy (MISC) or uterosacral ligament suspension (USLS). This was a retrospective study evaluating all MISC and USLS performed at a large academic institution between Jan 2009 and Aug 2015. Patient demographics, clinical, and surgical data were compared between months with July defined as month 1 and June defined as month 12, mirroring the academic calendar year. Linear regression assessed OR time (skin incision to closure) by month adjusting for confounders. Similarly, logistic regression assessed prolapse recurrence (a composite of any POP-Q point beyond the hymen, use of pessary, or reoperation) and complications (a composite of transfusion, infection, readmission/return to OR, small bowel obstruction/ileus, mesh complication, conversion to laparotomy, or bowel/bladder/ureteral injury). A total of 1007 subjects were included from 7 surgeons. Mean age was 59.9±9.4, BMI was 27.6±4.2, with gravity 3.0±1.5 and parity 2.6±1.1. The majority had POP-Q stage III (67.7%) or stage II prolapse (25.6%). MISC represented 81.0% of surgeries (58.8% laparoscopic, 41.2% robotic-assisted). Most USLS were performed vaginally (68.1%) vs. laparoscopic/robotic. Median follow-up was 34 weeks (IQR=11–82). Mean OR time was 199.8±66.4 minutes with no impact from month in year after adjusting for confounders (β=-0.6 min, p=0.26). MISC (vs. USLS, β=36.4 min), conversion to laparotomy (β=112.9 min), and concomitant hysterectomy (β=33.4 min) all increased OR time (all p<0.001 on multivariable linear regression). Composite complications ranged from 7.9% (January) to 23.8% (March) with average 17.1%. The most common complications were readmission/return to OR (4.5%) and infections (4.4%, excluding UTI). Complications were unaffected by month (OR=0.99, 95% CI=0.95-1.04) on multivariable logistic regression where USLS was more likely to have complications than MISC (OR=1.55, 95% CI=1.05-2.28). Notably, 3 of the 4 highest complication months occurred in the 2nd half of the year (Mar, May, and Jun) and 3 of the 5 lowest complication months occurred in the 1st half of the year (Sept, Nov, and Dec). Prolapse recurrence was identified in 9.4%. Month was not a significant predictor of recurrence on multivariable logistic regression (OR=0.95, 95% CI=0.88-1.02) where MISC had less recurrence than USLS (OR=0.33, 95% CI=0.18–0.60, p<0.001). Month of year relative to resident/fellow promotion did not impact OR time, complications, or prolapse recurrence, debunking the myth of worse surgical outcomes earlier in the academic year.

1078: Barbed versus conventional suture for uterine closure during cesarean section: An integrated retrospective study

Although a variety of options exist for uterine incision repair during cesarean section (CS) in regards to suture type and repair technique, there is limited evidence on the best approach. The objective of this study was to compare knotless barbed and conventional synthetic suture use for uterine closure in different settings of CS. A retrospective cohort study was conducted using 217 CS cases at a community teaching hospital between January 2016 and May 2019, in which the hysterotomy incision was closed with knotless barbed (n=99, 45.6%) or conventional synthetic suture (n=118, 54.4%). Aggregate cases were further categorized into one or two-layer hysterotomy closure and primary or repeat CS. Parameters of operating room (OR) time, estimated blood loss (EBL), and complication rate were designated for comparison. Patient body mass index (BMI) and assistant post-graduate year (PGY) were correlated with OR time. Statistical analysis was performed to assess whether differences between groups were significant using a p-value of ≤0.05. Mean OR times, mean EBL, and complication rates were lower for knotless barbed compared to conventional synthetic suture across all uterine closure scenarios (Figure 1 and 2). Statistically significant differences were observed for EBL in aggregate (752.9 vs. 820.9 mL; p=0.03), two-layer closure (643.6 vs. 850.4 mL; p=0.002), and repeat CS (712.2 vs. 824 mL; p=0.03) groups. BMI positively correlated with OR time (r=0.205; p=0.002). There was no significant correlation between assistant PGY and OR time (r=-0.067; p=0.325). Using knotless barbed suture compared with conventional synthetic suture for uterine closure during CS is associated with significantly lower EBL, particularly for two-layer closure and repeat CS groups. Consideration of other factors is imperative during such comparison. When selecting suture material for uterine closure, knotless barbed suture may be a favorable option to conventional synthetic suture from a patient care and healthcare cost perspective.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Retroileal anastomosis in hand-assisted laparoscopic left colectomy: experience at a single institution

Left hemicolectomy and complicated sigmoid colectomy require an anastomosis between the transverse colon and rectum. Generous mobilization will typically allow the colon to reach to the rectum. However, despite full mobilization of the splenic flexure and extensive work on the mesentery, there are cases in which reach to the pelvis is still an issue. Retroileal routing of the colon is one technique for overcoming such a reach problem and achieving a tension-free anastomosis. Performing retroileal routing using laparoscopic techniques has been reported rarely, and to date, there are no data on this technique when performed in a hand-assisted laparoscopic fashion. This study aimed to describe the feasibility of doing a retroileal routing using a hand-assisted laparoscopic technique. This was a retrospective chart review of patients who underwent a colon or rectal resection, either open or laparoscopic, with a pelvic anastomosis, by a single colorectal surgeon at an academic institution between 2008 and 2015 with a focus on the immediate and long-term postoperative complications, estimated blood loss, and operating room time for patients having an operation that included retroileal routing for construction of a colorectal anastomosis. A total of 340 patients fit inclusion criteria and of these, 13 underwent hand-assisted laparoscopic procedures with retroileal routing of the proximal colon to the colorectal anastomosis. Postoperative morbidity included intubation for CO2 retention in one patient and a RLL effusion in another patient; there were no anastomotic leaks. Long-term morbidities included two ventral hernias at 2years postoperatively. Mean operating room time was 208min. There were no 30- or 90-day mortalities. Hand-assisted laparoscopic retroileal routing is a feasible and safe technique in accomplishing a tension-free colorectal anastomosis when proximal colon length makes standard routing of the colon to the rectum an issue.