Mean Operating Room Time Research Articles

Evaluation of Use of Video Telescopic Operating Microscope with Operative Microscope in Cervical Spine Surgery

Introduction In cervical spine surgery, it is essential to use the magnification, however, the surgical operating microscope can be expensive, cumbersome, and difficult to set up. Whereas the use of no magnification may lead to failure in removing the disc completely with no improvement of the patient condition. VITOM is an exoscope, which is used in place of operation microscope. It is easy to use and it gives same size magnification as operation microscope. This is a prospective cohort study form July 2013 to February 2014 at Helen Joseph Hospital. This study aims to evaluate the efficacy of video telescope operating microscope (VITOM) as an alternative to operative microscope (OM) in cervical spinal surgery. Patients and Methods Patients undergoing spinal surgery were enrolled in a prospective cohort study between July 2013 to February 2014 at Helen Joseph Hospital. The age, sex, and operation-matched patients undergoing surgery using the standard OM served as the control group. During surgery, the VITOM system was used in place of the OM in 20 patients. Operative time, length of postoperative hospital stay, and intraoperative complications were assessed. Results A total of 10 patients were studied in two equal cohorts of 10 patients each. Within each cohort, patients underwent single-level and two-level cervical spine surgery. There were no significant differences in age or sex between cohorts. There were no statistically significant differences in mean operative room time for single-level decompressions and two-level decompressions. Postoperative length of hospital stay averaged 4 days for the VITOM group versus 5 days for the traditional OM group. Subjectively, surgeon opinion was the quality of image was much higher as compared with operating microscope. Conclusion The VITOM system provides as good a result as compared with operating microscope. However, there was no statically difference in the duration of patient stay in hospital and length of operation and interoperative complications. However, VITOM provide good visualization and better picture quality because of the high-resolution image. It is convenient also for teaching the purpose as well.

Damage control laparotomy and delayed pancreatoduodenectomy for complex combined pancreatoduodenal and venous injuries.

This single-centre study evaluated the efficacy of damage control surgery and delayed pancreatoduodenectomy and reconstruction in patients who had combined severe pancreatic head and visceral venous injuries. Prospectively recorded data of patients who underwent an initial damage control laparotomy and a subsequent pancreatoduodenectomy for severe pancreatic injuries were evaluated to assess optimal operative sequencing. During the 20-year study period, 312 patients were treated for pancreatic injuries of whom 14 underwent a pancreatoduodenectomy. Six (five men, one woman, median age 20, range 16-39years) of the 14 patients were in extremis with exsanguinating venous bleeding and non-reconstructable AAST grade 5 pancreatoduodenal injuries and underwent a damage control laparotomy followed by delayed pancreatoduodenectomy and reconstruction when stable. During the initial DCS, the blood loss compared to the subsequent laparotomy and definitive procedure was 5456ml, range 2318-7665 vs 1250ml, range 850-3600ml (p<0.01). The mean total fluid administered in the operating room was 11,150ml, range 8450-13,320 vs 6850ml, range 3350-9020ml (p<0.01). The mean operating room time was 113min, range 90-140 vs 335min, range 260-395min (p<0.01). During the second laparotomy five patients had a pylorus-preserving pancreatoduodenectomy and one a standard Whipple resection. Four of the six patients survived. Two patients died in hospital, one of MOF and coagulopathy and the other of intra-abdominal sepsis and multi-organ failure. Median duration of intensive care was 6days, (range 1-20days) and median duration of hospital stay was 29days, (range 1-94days). Damage control laparotomy and delayed secondary pancreatoduodenectomy is a live-saving procedure in the small cohort of patients who have dire pancreatic and vascular injuries. When used appropriately, the staged resection and reconstruction allows survival in a previously unsalvageable group of patients who have severe physiological derangement.

MP78-05 OPEN VERSUS ROBOT-ASSISTED RADICAL PROSTATECTOMY: A CONTEMPORARY ANALYSIS OF AN ALL-PAYER DISCHARGE DATABASE

You have accessJournal of UrologyProstate Cancer: Localized VIII1 Apr 2015MP78-05 OPEN VERSUS ROBOT-ASSISTED RADICAL PROSTATECTOMY: A CONTEMPORARY ANALYSIS OF AN ALL-PAYER DISCHARGE DATABASE Jeffrey Leow, Christian Meyer, Julian Hanske, Marianne Schmid, Benjamin Chung, Quoc-Dien Trinh, and Steven Chang Jeffrey LeowJeffrey Leow More articles by this author , Christian MeyerChristian Meyer More articles by this author , Julian HanskeJulian Hanske More articles by this author , Marianne SchmidMarianne Schmid More articles by this author , Benjamin ChungBenjamin Chung More articles by this author , Quoc-Dien TrinhQuoc-Dien Trinh More articles by this author , and Steven ChangSteven Chang More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2821AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robot-assisted radical prostatectomy (RARP) has been rapidly adopted in the United States despite the lack of Level 1 evidence. There is no conclusive evidence regarding its morbidity profile compared to open RP (ORP). The aim of this study was to compare perioperative outcomes of RARP vs. ORP on a contemporary cohort of patients using an all-payer discharge database. METHODS Using the Premier Hospital Database, which collects data from over 600 non-federal hospitals throughout the US, we captured all patients who underwent a radical prostatectomy (ICD-9 code 60.5) with diagnoses of prostate cancer (185) from 2003 to 2013. We classified procedures as “RARP” through a review of the charge description master for each patient specifically identifying supplies unique to robotic procedures. We evaluated 90-day postoperative complications (using Clavien classification), transfusion of blood products, operating room time, and length of stay. We also evaluated 90-day direct hospital costs, including cost breakdowns (room and board, operating room, supplies, etc.) We performed adjusted analyses, adjusting for potential confounders. We accounted for clustering by hospitals and survey weighting to ensure nationally representative estimates. RESULTS Over the 11-year study period, there was a total of 345,313 ORP and 328,731 RARP. The use of RARP grew rapidly from 2% in 2003 to 85% in 2013 (p<0.001) (Fig. 1). On adjusted analyses, compared to ORP, RARP patients were less likely to suffer major complications (OR 0.77, p=0.03), readmissions (OR 0.81, p=0.02), receive blood products (IRR 0.31, p<0.001) or have prolonged LOS (OR 0.27, p<0.001). LOS was shorted in the RARP group by nearly a day (0.88, p<0.001). Mean operating room time for RARP was longer by 71 min (p<0.001); higher surgeon and hospital volume were significant predictors of shorter OR time. RARP incurred $4085 more 90-day direct hospital costs (p<0.001) compared to ORP and this was primarily attributed to OR and supplies costs. CONCLUSIONS Our contemporary analysis of men who underwent radical prostatectomy found that the robotic approach appears to confer a morbidity advantage in the perioperative setting. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1003-e1004 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeffrey Leow More articles by this author Christian Meyer More articles by this author Julian Hanske More articles by this author Marianne Schmid More articles by this author Benjamin Chung More articles by this author Quoc-Dien Trinh More articles by this author Steven Chang More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Open versus robot-assisted radical prostatectomy: A contemporary analysis of an all-payer discharge database.

33 Background: Robot-assisted radical prostatectomy (RARP) has been rapidly adopted in the US despite the lack of Level 1 evidence. There is no conclusive evidence regarding its morbidity profile compared to open RP (ORP). Our aim was to compare perioperative outcomes of RARP vs. ORP on a contemporary cohort of patients. Methods: Using the Premier Hospital Database, an all-payer discharge database representing over 600 hospitals in the US, we captured men diagnosed with prostate cancer (ICD-9 code 185) who underwent a radical prostatectomy (60.5) from 2003 to 2013.We classified procedures as RARP through a review of the charge description master by identifying supplies unique to robotic procedures. We evaluated 90-day postoperative complications (using Clavien classification), transfusion of blood products, operating room time, length of stay and direct hospital costs. We performed regression analyses, adjusting for potential confounders, accounting for clustering by hospitals and survey weighting to ensure nationally representative estimates. Results: Over the 11-year study period, there was a total of 345,313 ORP and 328,731 RARP. The use of RARP grew rapidly from 2% in 2003 to 85% in 2013 (p&lt;0.001). On adjusted analyses, compared to ORP, RARP patients were less likely to suffer major complications (odds ratio [OR] 0.77, p=0.03), readmissions (OR 0.81, p=0.02), or receive blood products (OR 0.28, p&lt;0.001). RARP patients had shorter LOS (-0.88 days, p&lt;0.001). Mean operating room time for RARP was longer by 71 min (p&lt;0.001); higher surgeon and hospital volume were significant predictors of shorter operating time. 90-day direct hospital costs were higher for RARP (+$4085, p&lt;0.001), primarily attributed to operating room and supplies costs. Conclusions: Our contemporary analysis of men who underwent RP found that the robotic approach appears to confer a perioperative morbidity advantage at a higher cost. The widespread adoption of RARP in the management of localized prostate cancer implies a randomized trial will unlikely be conducted; therefore this large retrospective study may represent the best available evidence for the morbidity and cost profile of ORP vs. RARP.

Intraoperative virtual implant planning for volar plate osteosynthesis of distal radius fractures

Digital planning of implants is in most cases conducted prior to surgery. The virtual implant planning system (VIPS) is an application developed for mobile C-arms, which assists the virtual planning of screws close to the joint line during surgery for treatment of distal radius fractures with volar plate osteosynthesis. The aim of this prospective randomized study was to acquire initial clinical experiences and to compare the VIPS method with the conventional technique. The study included 10 patients for primary testing and 30 patients with distal radius fractures of types A3, C1 and C2, divided in 2 groups. In the VIPS group, after placement of the plate and fracture reduction, a virtual 3D model of the plate was matched with the image of the plate from the fluoroscopic acquisition. Next, the length and position of the screws close to the joint line were planned on the virtual plate. The control group was treated with the same implant in the conventional way. Data were collected regarding screw replacement, fluoroscopy and operating room (OR) times. The VIPS group included six A3, one C1 and eight C2 fractures, while the control group consisted of six A3 and nine C2 fractures. Three screws were replaced in the VIPS group and two in the control group (p = 0.24). The mean intraoperative fluoroscopy time of the VIPS group amounted to 2.58 ± 1.38min, whereas it was 2.12 ± 0.73min in the control group (p = 0.26). The mean OR time in the VIPS group was 53.3 ± 34.5 minutes and 42.3 ± 8.8min (p = 0.23) in the control group. The VIPS enables a precise positioning of screws close to joint line in the treatment of distal radius fractures; however, for routine use, further development of the system is necessary.

Influence of trainee participation on operative times for adult and pediatric cochlear implantation

ObjectiveFew studies have examined operative times for cochlear implantation (CI) using multivariable linear regression analyses to identify predictors of case length. Herein, we assess whether trainee participation, among other factors, influences operating room (OR) times.MethodsWe retrospectively reviewed total OR and procedural times for isolated unilateral implants over a 5-year period (2009–2013) in children and adults. Total operating and procedural times were compared. Multivariable linear regression analyses were used to identify predictors of procedural time.ResultsWe identified a total of 455 unilateral CI procedures (n = 35 pediatric, n = 420 adult). Mean total OR time was 193.6 minutes (SD = 58.9 minutes) and mean procedural time was 147.1 minutes (SD = 56.2). The presence of trainees was associated with a significant difference in procedure time: 149.9 minutes (SD = 54.9) with trainees versus 136.6 minutes (SD = 59.9) without trainees, P = 0.0375. Trainee involvement did not significantly increase total OR time: 196.3 minutes (SD = 56.9) with trainees versus 183.8 minutes (SD = 65.0) without trainees, P = 0.0653. Surgeon identity was also associated with differences in procedural time (P < 0.001). Patient age, gender, American Society of Anesthesiologists classification, and pediatric designation had no significant impact on length of case.ConclusionsMajor predictors of longer procedural OR times for CI are surgeon identity and trainee participation. Few published data exist on length of CI in an academic setting using multivariable linear regression analyses. Our data may be instructive for comparative analyses and have implications for operative planning and surgical education.

Single-stage versus 2-stage sleeve gastrectomy as a conversion after failed adjustable gastric banding: 30-day outcomes

Sleeve gastrectomy (SG) is being performed as a conversion after adjustable gastric banding (AGB), often in a single stage. However, some argue that it should be performed in 2 stages to improve safety. Few studies compare complications between 1-stage and 2-stage procedures. Our aim is to compare the 30-day complication rates among these two groups. We retrospectively reviewed patients converted from AGB to SG between 8/2008 and 10/2013 and compared patients undergoing 1-stage and 2-stage techniques. Primary outcome was overall 30-day adverse event rate (postoperative complication, readmission, or reoperation). Secondary outcomes included operating room (OR) time, length of stay (LOS), leak, infection, and bleeding rates, as well as mortality. A total of 83 patients underwent SG after band removal; three were excluded due to short follow-up, leaving 60 1-stage and 20 2-stage. Mean time from band removal to SG for 2-stage was 438 days. Demographics, intraoperative technique (bougie size, staple reinforcement, oversewing staple line, and leak test), and mean follow-up were not statistically different. Mean OR time (132.1 min 1-stage vs. 127.8 min 2-stage, p = 0.702) and LOS (3.1 vs. 2.4 days, p = 0.676) were similar. Overall 30-day adverse event rate was 12 % for 1-stage versus 15 % for 2-stage procedures (p = 0.705). Differences in 30-day readmission (8 vs. 5 %) and reoperation (5 vs. 0 %) were not statistically significant (p = 0.999 and 0.569, respectively). Leak (3 vs. 0 %, p = 0.999), abscess (2 vs. 5 %, p = 0.440), and bleeding rates (2 vs. 0 %, p = 0.999) were not different. There were no deaths. SG performed as a conversion after AGB is safe and feasible. Our findings indicate no statistical difference in 30-day outcomes when performed in 1 or 2 stages. Future studies with larger sample sizes are necessary to further investigate these differences.

Robotic Compared With Conventional Laparoscopy for Treatment of Severe Endometriosis

INTRODUCTION: To determine outcome differences in patients undergoing robotic-assisted compared with conventional laparoscopy for advanced-stage endometriosis. METHODS: Cases were collected from our prospectively maintained computerized database of robotic-assisted and conventional laparoscopic surgical treatments for endometriosis performed by one surgeon experienced in both techniques. Included were all patients treated between July 2009 and October 2012 for endometriosis stage III or IV (American Society for Reproductive Medicine criteria). Compared between robotic-assisted laparoscopic surgery and conventional laparoscopic surgery groups were median age, body mass index, race, extent of surgery, median estimated blood loss, operating room time, length of stay, and intraoperative and postoperative complications. For continuous variables, medians and first and third quartiles were calculated; medians were compared with the Wilcoxon rank-sum test. Distributions of categorical variables were compared with χ2 or Fisher's exact tests. All analyses were two-sided with P<.05 considered significant. RESULTS: Included were 86 conventional laparoscopic surgery and 32 robotic-assisted laparoscopic surgery cases. Compared with the patients undergoing conventional laparoscopic surgery, those who underwent robotic-assisted laparoscopic surgery had a higher body mass index (27.36 kg/m2 [23.90–34.09 kg/m2] compared with 24.53 kg/m2 [22.27–26.96 kg/m2]; P<.008; Table 1) and operating room time (250.50 [176–328.50] compared with 173.50 [123–237] minutes; P<.001; Table 2). No significant differences were noted between the robotic-assisted laparoscopic surgery and conventional laparoscopic surgery groups in age, race, hysterectomy rate, estimated blood loss, length of stay, or in rates of intraoperative or postoperative complications.CONCLUSIONS: Despite a higher mean operating room time in the robotic-assisted laparoscopic surgery group, implementation of this new technology might allow a safe minimally invasive surgical approach for obese patients with all other clinical outcomes comparable to those in nonobese patients undergoing conventional laparoscopic surgery.

Penile straightening maneuvers employed during penile prosthesis surgery: technical options and outcomes

Straightening maneuvers (SM), including manual penile modeling, tunical relaxing incisions and corporal reconstruction using grafting techniques, are occasionally required during inflatable penile prosthesis (IPP) implantation to ensure functional penile straightness. The aim of this study was to compare the outcomes of men undergoing SM employed during IPP implantation compared with those wherein these maneuvers were not required. A retrospective review of 391 patients undergoing IPP implantation at the Johns Hopkins Hospital from January 2000 to December 2011 was performed. Patients in whom some SM was employed (SM, n=93, 23.9% of the overall cohort) were compared with those for whom SM was not required (IPP group, n=298). Seven patients were excluded from final analysis (6 patients with IPPs inserted in neophalli (SM group), and 1 patient with incomplete data (IPP group). Patients in whom a SM was used were younger (55.4 vs 62.3 years), more likely to have Peyronie's disease, and less likely to have prostate cancer, radical prostatectomy or to have previously used erectile aids (all P<0.05). Mean operating room time in the SM group was longer (173.8 vs 152.9 min, P=0.003). Within the SM group, modeling was performed in 40 (43%), tunical relaxing incisions in 37 (39.8%) and tunical reconstruction in 16 (17.2%) (most commonly using allograft dermis or pericardium, or synthetic gore-tex grafts). There were no significant differences in terms of device infection (P=0.15), mechanical failure (P=0.23) or erosion (P=0.96). Although limited in size, this cohort study suggests that IPP implantation in men with penile deformity requiring complex reconstruction to achieve straightening may be done proficiently and without increased adverse outcome risk.

Anterior and posterior cervical fusion in patients with high body mass index are not associated with greater complications

Background contextObesity has been associated with adverse surgical outcomes; however, limited information is available regarding the effect of obesity on cervical spinal fusion outcomes. PurposeTo determine the effect of obesity on complication rates after cervical fusions. Study design/settingRetrospective cohort analysis of prospectively collected data on cervical fusion surgeries. Patient samplePatients in the ACS-NSQIP database from 2005 to 2010 undergoing cervical anterior or posterior fusion. Outcome measuresPrimary outcome measures were 30-day postsurgical complications, including mortality, deep-vein thrombosis, pulmonary embolism, septic complications, system-specific complications, and having ≥1 complication overall. Secondary outcomes were time spent in the operating room, blood transfusions, length of stay, and reoperation within 30 days. MethodsPatients undergoing anterior or posterior cervical fusions in the 2005–2010 American College of Surgeons National Surgical Quality Improvement Program were selected using Current Procedural Terminology codes. Anterior cervical fusion patients were categorized into four groups on the basis of body mass index (BMI): nonobese (18.5–29.9 kg/m2), obese I (30–34.9 kg/m2), obese II (35–39.9 kg/m2), and obese III (≥40 kg/m2). Posterior cervical patients were categorized into two groups based on the basis of BMI: nonobese (18.5–29.9 kg/m2) and obese (≥30 kg/m2) due to the smaller sample size. Patients in the obese categories were compared with patients in the nonobese categories by the use of χ2, Fisher's exact test, Student t test, and analysis of variance. Multivariate linear/logistic regression models were used to adjust for preoperative comorbidities. The authors report no sources of funding or conflicts of interest related to this study. ResultsData were available for 3,671 and 400 patients who underwent anterior or posterior cervical fusion, respectively. Obese class III patients only showed a greater incidence of deep-vein thrombosis after anterior fusions on univariate analysis. Obese patients only showed longer mean surgical times and total operating room times after posterior fusions on univariate analysis. On multivariate analyses, these differences did not remain significant. There were also no differences in multivariate analyses for overall and system-specific complication rates, lengths of hospital stay, reoperation rates, and mortality among the obesity groups when compared with the nonobese groups with anterior or posterior cervical fusions. ConclusionsHigh BMI, regardless of obesity class, does not appear to be associated with increased complications after cervical fusion in the 30-day postoperative period.

Endoscopic-Assisted Management of Sagittal Synostosis

INTRODUCTION: Endoscopic-assisted technique for the treatment of craniosynostosis is gaining in popularity. The benefits in regards to operating room time, blood transfusion rates, hospital stay and reduced cost of treatment have been reported with equivalent improvement in cephalic index compared to open calvarial vault reconstruction.1–3 This study investigates two methods for endoscopic-assisted correction of sagittal synostosis: wide vertex suturectomy and barrel stave osteotomies versus narrow vertex suturectomy. METHODS: The authors prospectively observed patients with nonsyndromic sagittal synostosis treated with the endoscopic-assisted technique and molding helmet therapy. Wide vertex suturectomy (5cm) and barrel stave osteotomies was used exclusively between 2006 and 2010. Narrow vertex suturectomy (2.5 cm) was used between 2011 and 2012. All patients received 3 dimensional photographs for standardized assessment of head shape preoperatively and at subsequent postoperative evaluations. Patients were also measured by direct caliper measures to determine cranial index. The data collected included age at operation, blood loss, postoperative hemoglobin, transfusion rates, operating room times, and cephalic index. RESULTS: Twenty patients (10 wide vertex and barrel stave osteotomies (WV+BSO) and 10 narrow vertex (NV)) with isolated sagittal synostosis were treated by the endoscopic-assisted technique and moulding helmet therapy. Mean age at operation and follow-up time was 3.8 and 10 months for NV and 3.6 and 13 months for WV+BSO. Mean operating room time was 66 minutes for the NV group and 88 minutes for the WV+BSO group. The mean blood loss was 29ml for NV with 0% (0 of 10 patients) transfusion rate versus 49 ml and 0% (0 of 10 patients) transfusion rate for WV+BSO. Postoperative hemoglobin was 8.4g/dL and 7.3g/dL for the NV and WV+BSO groups. The pre- and postoperative cephalic index for the NV technique was 69% and 79% versus 72% and 80% for WV+BSO. CONCLUSION: Narrow-vertex suturectomy and moulding helmet therapy is effective in the treatment of sagittal synostosis. Avoiding additional barrel stave osteotomies can decrease operating room time and risk of transfusion.

A Novel Approach to Treat Women Patients With Palmar Hyperhidrosis: Transumbilical Thoracic Sympathectomy With an Ultrathin Gastroscope

Primary palmar hyperhidrosis is very common in women. Video-assisted thoracic sympathectomy is recognized as an effective treatment for patients with severe hyperhidrosis, which has usually been performed with more than 2 skin incisions. We developed a novel approach for thoracic sympathectomy in women with palmar hyperhidrosis through the umbilicus using an ultrathin gastroscope. The approach requires only 1 tiny incision, which is hidden in the umbilicus. Under general anesthesia, patients were intubated with a dual-lumen endotracheal tube. Through the incision in the umbilicus, a newly developed long trocar was inserted into the abdominal cavity. After insertion of the ultrathin gastroscope through this trocar, a small incision was created on the both sides ofdiaphragm by a needle knife. The endoscope was introduced into the thoracic cavity through the incision made in the left or right diaphragm. The sympathetic chain was identified at the desired thoracic level and ablated. From January 10, 2010, to November 30, 2011, 25 women underwent transumbilical-diaphragmatic thoracic sympathectomy. The mean operating room time for the entire bilateral procedure was 56.9 ± 6.9 minutes. There were no significant postoperative complications. The symptoms disappeared in all patients. Compensatory sweating was reported in 56%. All of the patients were satisfied with the surgical results and the cosmetic outcome of the incision. Transumbilical thoracic sympathectomy with the ultrathin flexible endoscope was a safe and effective option for women with severe palmar hyperhidrosis that provided excellent cosmetic outcomes.

Safety and efficacy of laparoscopic adjustable gastric banding in patients aged seventy and older

BackgroundLife expectancy is increasing, with more elderly people categorized as obese. The objective of this study was to assess the effects of laparoscopic adjustable gastric banding (LAGB) on patients aged≥70 years. MethodsThis was a retrospective analysis of patients aged≥70 years who underwent LAGB at our university hospital between 2003 and 2011. The data included age, weight, body mass index (BMI), and percentage excess weight loss (%EWL) obtained before and after gastric banding. Operative data, length of stay, postoperative complications, and resolution of co-morbid conditions were also analyzed. ResultsFifty-five patients aged≥70 years (mean 73 years) underwent gastric banding between 2003 and 2012. Mean preoperative weight and BMI were 123 kilograms and 45 kg/m2, respectively. On average, each patient had 4 co-morbidities preoperatively, with hypertension (n = 49; 86%), dyslipidemia (n = 40; 70%), and sleep apnea (n = 31; 54%) being the most common. Mean operating room (OR) time was 49 minutes, with all patients discharged within 24 hours. There was 1 death at 4 years from myocardial infarction, no intensive care unit admissions, and no 30-day readmissions. Mean %EWL at 1, 2, 3, 4, and 5 years was 36 (±12.7), 40 (±16.4), 42 (±19.2), 41 (±17.1), 50 (±14.9), and 48 (±22.6), respectively. Follow-up rates ranged from 55/55 (100%) at 6 months to 7/9 (78%) of eligible patients at 5 years and 2/2 (100%) at 8 years. Complications included 1 band slip at year 5, 1 band removed for intolerance, and 1 port site hernia. The resolution of hypertension, dyslipidemia, sleep apnea, lower back pain, and non-insulin-dependent diabetes was 27%, 28%, 35%, 31%, and 35%, respectively. ConclusionsLAGB as a primary treatment for obesity in carefully selected patients aged≥70 can be well tolerated and effective with moderate resolution of co-morbid conditions and few complications.

Single Surgeon Experience with Robot-Assisted Ureteroureterostomy for Pathologies at the Proximal, Middle, and Distal Ureter in Adults

To describe our initial experience with robot-assisted ureteroureterostomy (RUU) at the proximal, middle, and distal ureter. Twelve consecutive patients underwent RUU by a single surgeon (D.D.E.) between July 2009 and November 2012. Indications included three iatrogenic injuries, two impacted stones, two ureterovaginal fistulas, two idiopathic ureteral strictures refractory to conservative treatment, one primary transitional cell carcinoma of the ureter, one colon cancer metastasis to the ureter, and one invasive endometriosis. There were two proximal, three middle, and seven distal ureteral pathologies. Tension-free anastomosis was achieved in all 12 patients. All patients with proximal and middle ureteral pathology received concomitant downward nephropexy (DN) as a standard part of RUU. Mean age of patients at the time of surgery was 52 years (range 30-69), mean body mass index was 30.0 kg/m(2) (range 21-38), mean operative room time was 190 minutes (range 104-354), mean estimated blood loss was 181 mL (range 50-400), and mean length of excised ureter on pathologic analysis was 2.0 cm (range 1.0-4.5). There was one intraoperative complication in which liver and gallbladder laceration occurred during trocar placement. Mean length of hospital stay was 1.4 days (range 1-5), and there were no postoperative complications. Mean follow up was 10 months (range 3-36). One patient had a ureteral stricture recurrence at 7 months postoperatively that led to renal unit loss and eventual nephrectomy. RUU is feasible, safe, and demonstrates good outcomes for pathologies at the proximal, middle, and distal ureter. Concomitant DN during RUU may assist in achieving a tension-free anastomosis for proximal and middle ureteral repairs.

Comparison of Robotic and Laparoscopic Ultrasound Probes for Robotic Partial Nephrectomy

To evaluate and compare perioperative outcomes of robotic partial nephrectomy (RPN) using robotic and laparoscopic ultrasound probe for tumor identification. Data from 75 consecutive RPN procedures using a laparoscopic ultrasound probe (January 2009- November 2010) and 75 consecutive RPN procedures using a robotic ultrasound probe (November 2010- November 2011) were collected. Perioperative outcomes of the two groups were retrospectively analyzed. A total of 72 patients underwent 75 consecutive RPN using the laparoscopic ultrasound probe followed by 73 patients who underwent 75 consecutive RPNs using the robotic ultrasound probe. Characteristics were similar between groups, and tumors had a similar complexity (mean nephrometry score 6.6 vs. 6.8, p=0.534), mean operating room time (234 vs. 218 min, p=0.095), mean console time (173 vs. 156 min, p=0.071), mean blood loss (171 mL vs. 164 mL, p=0.79), and positive tumor margin rates (1.2% vs. 2.2%, p=1) did not achieve significance. All patients are free of cancer recurrence after a mean follow up of 25.7 months in the laparoscopic probe group and of 10.2 months in the robotic probe group. Robotic ultrasound probes for tumor identification during RPN had comparable perioperative outcomes and surgical margin rates as a laparoscopic ultrasound probe, but with the advantage of surgeon autonomy.

Minimally invasive surgery through endoscopic laminotomy and foraminotomy for the treatment of lumbar spinal stenosis

BackgroundLumbar spinal stenosis is a common cause of radicular and generalized back pain among older adults. Endoscopic minimally invasive surgery, in contrast to open decompression, may provide the opportunity for a less invasive surgical intervention. Thus, the purpose of this study is to evaluate the safety (operative complications, estimated blood loss, operative room time) and effectiveness (pre- versus postoperative level of disability and pain severity) of minimally invasive surgery using endoscopic laminotomy and foraminotomy among a large sample of patients with lumbar spinal stenosis. MethodsThis study is composed of 320 consecutive patients with lumbar spinal stenosis who underwent posterior lumbar laminotomy and foraminotomy between 2008 and 2011. Outcome measures consisted of perioperative complications, estimated blood loss, operative room time, level of disability, and pain severity. Pain severity and level of disability were prospectively analyzed to an average of 18 months (12–36 months) post-surgery. ResultsThere was an average estimated blood loss of 39.3 cc and a mean operative room time of 74 min. Seven patients experienced minor operative complications. All patients were discharged the same day as surgery and reported a significantly lower level of disability (p = 0.00) and pain severity (p = 0.00) postoperative compared to preoperative. ConclusionsMinimally invasive surgery using endoscopy for the treatment of lumbar spinal stenosis has a short operative time, a low operative complication rate, and minimal estimated blood loss. This study also indicates that MIS for the treatment of LSS can significantly reduce pain and disability level. Thus, minimally invasive surgery using endoscopic laminotomy and foraminotomy appears to be a safe and effective alternative surgical treatment for open decompression surgery in adult patients with lumbar spinal stenosis.

GreenLight XPS 180W vs HPS 120W Laser Therapy for Benign Prostate Hyperplasia: A Prospective Comparative Analysis After 200 Cases in a Single-center Study

To evaluate the safety, efficacy, and short-term outcomes of the new GreenLight XPS (GL-XPS) 180W laser system (AMS, Minnetonka, MI) in comparison to the former generation GL-HPS 120W system for the treatment of benign prostatic hyperplasia (BPH) in a prospective nonrandomized single-center study. From June 2010 to March 2012, 200 consecutive patients with lower urinary tract symptoms secondary to BPH were included: 80 patients were treated with GL-HPS 120W and 120 with GL-XPS 180W laser vaporization of the prostate. Perioperative variables (International Prostate Symptom Score [IPSS], quality f life [QOL], maximum flow rate (Qmax), post-void residual (PVR), and Sexual Health Inventory for Men (SHIM) were recorded at baseline, 3 months, and 6 months. Serum prostate-specific antigen (PSA) was assessed at baseline and 6-month follow-up. Patient preoperative characteristics were comparable, all P<.05. Mean operating room time (43vs 79 minutes) and mean laser time (22 vs 37 minutes) were significantly shorter for the GL-XPS group (both P<.01) and mean energy delivery was comparable (226 vs 268 kJ, P= .21), GL-XPS vs GL-HPS. Mean fiber use (1.0 vs 1.5) and 3L saline bags (4.1 vs 7) were significantly lower with GL-XPS, all P<.01. There were no significant differences in the 30-day complication rate. To date, no urethral strictures and 1 GL-HPS retreatment were observed. PSA reduction at 6 months was significantly greater with GL-XPS (54% vs 79%, P<.01). Both GreenLight systems provide safe, effective, tissue vaporization with significant clinical relief of BPH obstruction. The GL-XPS 180W system seems to be more favorable with regard to reduced operative time, fiber use, and PSA-reduction, suggesting more cost-effective and efficient tissue removal.

Combined endoscopic and laparoscopic surgery may be an alternative to bowel resection for the management of colon polyps not removable by standard colonoscopy

Benign colon polyps may require bowel resection if endoscopic polypectomy cannot be performed to assess adequately for cancer. However, endoscopic removal still may be possible using combined endoscopic and laparoscopic surgery (CELS). The CELS procedure allows for intra- and extraluminal manipulation of the bowel wall to facilitate polyp removal, thereby avoiding bowel resection. This study evaluated the authors' institutional experience with CELS in this patient population. Between August 2008 and October 2012, all patients referred to undergo surgery for a benign colon polyp were retrospectively reviewed for operative characteristics, pathology, and postoperative outcomes. Of 14 patients, five were considered candidates for CELS and were compared with nine patients who underwent resection. The average patient age was similar between the two groups (CELS, 64.9 years vs. resection, 68.3 years). The mean polyp size was 2.3 cm in the CELS group and 2.9 cm in the resection group. In the CELS group, polyps were successfully removed in all cases. The mean operating room time was 159 min in the CELS group and 205 min in the resection group. The median hospital stay was 1 day in the CELS group and 5 days in the resection group. No complications occurred in the CELS group. Two patients in the resection group (22 %) experienced a wound infection. One patient had a postoperative ileus (11 %). Four patients in the CELS group had a benign adenoma. One patient had a benign frozen section evaluation, but the final pathology showed adenocarcinoma requiring a subsequent colectomy. In the resection group, six patients had a benign adenoma, and three patients had a T1N0 cancer. In the CELS group, repeat endoscopy was performed an average of 9.9 months after CELS. Two patients had a residual polyp, and two patients had new polyps in a different location. All were successfully removed. For benign-appearing polyps not amenable to endoscopic techniques alone, CELS may be an alternative to formal bowel resection for carefully selected patients. The CELS procedure can be performed safely with minimal morbidity and with outcomes that compare favorably with those of formal colectomy.

Laparoendoscopic Single-Site Urologic Surgery in Children Less Than 5 Years of Age

PurposeWe report our experience with laparoendoscopic single-site (LESS) urological procedures in children less than 5 years of age.Materials and MethodsTen patients (11 procedures) underwent LESS through the umbilicus. Seven patients underwent nephrectomy and three patients underwent pyeloplasty (one simultaneous bilateral). R-port port (Advanced Surgical Concepts, Ireland) was used in nine cases, in one case, the Gelpoint access port (Applied Medical, Rancho Santa Margarita, CA, USA) was used. The Olympus Endoeye camera with coaxial light cable was used. The hilum was secured in all cases with Hem-o-Lok clips (Teleflex Medical, Research Triangle Park, NC, USA) except in one case in which an Endo GIA stapler (Covidien Surgical, Norwalk, CT, USA) was used.ResultsAll procedures were technically successful. Accessory port (3 mm) was used in 3 patients. Mean age in nephrectomized patients was 3.14±1.7 years, the mean operative room time (ORT) was 97.5±12.54 minutes. In the pyeloplasty group, mean ORT was 192±47.16 minutes and mean age was 2.43±2.3 years. Bilateral pyeloplasty was done in a 4-month-old infant. The ORT in this case was 180 minutes. A follow-up renogram done in the pyeloplasty patients (n=2) showed good drainage. Mean length of stay was 3.6 days (range, 3 to 6 days).The analgesic requirement was 23.86 mg (range, 12.5 to 50 mg) of diclofenac sodium.ConclusionsLESS is technically feasible in patients as young as 4 months of age. It has the potential to offer better cosmesis. This needs to be proved in further comparative studies. Development of miniature instruments will further the growth of LESS in this age group.

Adult Cleft Lip Repair under Local Anesthesia: An Effective Technique in Resource-Poor Settings

Objective : In developing countries there are many adults with unrepaired cleft lip deformities. These countries often lack the equipment and personnel to provide general anesthesia for all patients; therefore, a technique for repair under local anesthesia would be useful. Method : A retrospective review was performed of 22 adolescent/adult patients on whom primary cleft lip repair was performed under local anesthesia in Bamako, Mali, in 2008 and 2009. Inclusion criteria for this technique were age greater than 12 with unilateral or bilateral deformity and ability to understand and tolerate the procedure under local anesthesia alone. Exclusion criteria included cardiopulmonary disease or inability to tolerate the procedure while awake. Demographic information and outcome data were collected including total time in the operating room, surgical time, and day of discharge. Results : Twenty-two primary cleft lip repairs were completed in 12 male and 10 female patients. Mean age was 22.3years and mean weight was 50kg. Overall, mean total operating room time was 145minutes. Mean operating room time was significantly (p < .01) longer in 2008 (159minutes) than in 2009 (114minutes). Although mean surgical time was 110minutes, there was a similar significant (p = .03) decrease from 2008 (119minutes) to 2009 (91minutes). All patients tolerated the procedure without requiring intubation or intravenous sedation, and all were discharged the same day. Conclusion : Cleft lip repair in adults under local anesthesia is safe and effective. Improvements in technique and efficiency have made this valuable in developing countries.