Minimally Invasive Surgery Procedures Research Articles

Postoperative venous thromboembolism in gynecologic oncology patients undergoing minimally invasive surgery: does modality matter?

<h3>Objectives:</h3> Minimally invasive surgery (MIS) is increasingly utilized for gynecologic cancers. While rates of venous thromboembolism (VTE) after MIS are low overall, risk factors such as malignancy and prior pelvic surgery may increase risk of perioperative VTE. Various guidelines exist regarding extended chemoprophylaxis with low molecular weight heparin (LMWH) for VTE prevention. Our objective was to determine incidence of 30-day postoperative VTE in patients undergoing MIS for gynecologic malignancies and to determine differences in the incidence of VTE by MIS modality. <h3>Methods:</h3> We collected demographic and perioperative variables for all patients undergoing MIS (robot-assisted, multi-port laparoscopy, single-port laparoscopy) for gynecologic cancers between January 2014 and December 2018. Patients <18 years, with benign pathology, or on preoperative anticoagulation were excluded. Logistic regression, Chi-square, Fisher's exact test, and one-way ANOVA were performed to determine risk factors related to VTE occurrence. <h3>Results:</h3> We identified 818 patients who underwent MIS (median age 61, 97% non-Hispanic White, mean BMI 34 kg/m²). Most had Stage I disease (81.4%) and uterine cancer (81.6%). 99.9% received intraoperative unfractionated heparin (UFH) and 96.6% received immediate postoperative UFH. Three VTE events occurred within 30 days following surgery (0.3%). Twelve patients received extended chemoprophylaxis with LMWH (1.5%); 11 patients received a 28-day course while one patient received a 14-day course. VTE was diagnosed in a total of 17 patients within 18 months of surgery (2%, median time to VTE 12 months). Of those diagnosed with VTE, 11 patients underwent robot-assisted laparoscopy, 4 patients underwent multi-port laparoscopy and 2 patients underwent single-port laparoscopy. Incidence of VTE did not differ between MIS modalities (<i>p</i>=0.6). Patients with Stage III disease (<i>p</i><0.001) and longer operative time (<i>p</i>=0.04) were more likely to experience postoperative VTE. Age, smoking status, BMI, and cancer type were not significant risk factors for postoperative VTE. <h3>Conclusions:</h3> The incidence of postoperative VTE in patients with gynecologic cancers undergoing MIS is low and does not differ by modality. Extended chemoprophylaxis is unlikely to be beneficial in patients with gynecologic malignancies undergoing MIS procedures.

Peri-Surgical Inflammatory Profile Associated with Mini-Invasive or Standard Open Lumbar Interbody Fusion Approaches.

Background: Different surgical approaches are available for lumbar interbody fusion (LIF) to treat disc degeneration. However, a quantification of their invasiveness is lacking, and the definition of minimally invasive surgery (MIS) has not been biochemically detailed. We aimed at characterizing the inflammatory, hematological, and clinical peri-surgical responses to different LIF techniques. Methods: 68 healthy subjects affected by single-level discopathy (L3 to S1) were addressed to MIS, anterior (ALIF, n = 21) or lateral (LLIF, n = 23), and conventional approaches, transforaminal (TLIF, n = 24), based on the preoperative clinical assessment. Venous blood samples were taken 24 h before the surgery and 24 and 72 h after surgery to assess a wide panel of inflammatory and hematological markers. Results: martial (serum iron and transferrin) and pro-angiogenic profiles (MMP-2, TWEAK) were improved in ALIF and LLIF compared to TLIF, while the acute phase response (C-reactive protein, sCD163) was enhanced in LLIF. Conclusions: MIS procedures (ALIF and LLIF) associated with a reduced incidence of post-operative anemic status, faster recovery, and enhanced pro-angiogenic stimuli compared with TLIF. LLIF associated with an earlier activation of innate immune mechanisms than ALIF and TLIF. The trend of the inflammation markers confirms that the theoretically defined mini-invasive procedures behave as such.

Surgery in the era of COVID-19: implications for laparoscopy and natural-orifice endoscopic surgery: a narrative review

Controversy exists regarding the use of minimally invasive surgery (MIS) during the corona virus disease 2019 (COVID-19) pandemic. Several surgical societies have issued recommendations regarding precaution measures during MIS, nonetheless these recommendations were conflicting with respect to the use of laparoscopy with little or no inference to natural-orifice endoscopic surgery. A comprehensive literature search was performed to explore the available evidence pertinent to the novel coronavirus 2 (SARS-CoV-2) transmission dynamics in MIS, and benefits of MIS procedures in patients with transmissible viral diseases. According to the current evidence, SARS-CoV-2 has a multi-route transmission, including fecal-oral transmission. Evidence on airborne transmission in the operative setting are however limited. In addition to nasopharyngeal screening, it would seem prudent to perform routine fecal testing for SARS-CoV-2 in patients undergoing positive-pressure transanal minimally invasive procedures. This is particularly relevant to regions with high level of epidemicity. In patients with confirmed SARS-CoV-2 infection, conventional laparoscopic and robotic approaches, and atmospheric transanal surgery with high volume smoke evacuation may be safer alternatives. Considering the high rates of postoperative pulmonary complications and mortality associated with SARS-CoV-2 infection, use of laparoscopy is advised in suspected or confirmed COVID-19 patients who require abdominal surgery, particularly older patients and those with comorbidities. Laparoscopy may decrease the probability of postoperative disease exacerbation, and provide earlier recovery, less morbidity and mortality, and shorter hospital stay with subsequent decreased risk of in-hospital secondary transmission. High index of suspicion in postoperative patients with fever or respiratory symptoms is necessary to timely diagnose COVID-19. Chest computed tomography scan has a higher sensitivity compared to real-time PCR and can potentially be used to assist in the diagnosis, particularly in elderly patients.

Epidural analgesia and mortality after colorectal cancer surgery: A retrospective cohort study

BackgroundEpidural analgesia (EA) has been the standard of care after major abdominal surgery for many years. This study aimed to correlate EA with postoperative complications, short- and long-term mortality in patients with and without EA after open surgery (OS) and minimally invasive surgery (MIS) for colorectal cancer. MethodsPatient, clinical and outcome data were obtained from the Swedish Colorectal Cancer Registry and the Swedish Perioperative Registry. All adult patients diagnosed with colorectal cancer without metastases who underwent elective curative MIS or OS for colorectal cancer between January 2016 and December 2018 and who had data recorded in both registries, were included in the study. Data were analyzed for OS and MIS procedures separately. A Poisson regression model was used to investigate the association between EA and the outcomes of interest. ResultsFive thousand seven hundred sixty-two patients were included in the study, 2712 in the MIS and 3050 patients in the OS group. After adjusting for patient specific and clinically relevant variables in the regression model, no statistically significant difference in risk for complications; 30-day, 90-day, and up to 3-year mortality following either MIS or OS could be detected between the EA+ and EA-cohorts. ConclusionsIn this large study cohort, EA as part of the comprehensive care provided was not associated with a reduction in postoperative complications risk or improved 30-day, 90-day, or 3-year survival after MIS or OS for colorectal cancer.

Training for Minimally Invasive Surgery for IBD: A Current Need.

Surgery for inflammatory bowel diseases (IBD) management has passed through an important evolution over the last decades, with innovative strategies and new technologies, especially in minimally invasive surgery (MIS) approaches. MIS procedures for IBD include multiport laparoscopy, single-port surgery, robotics, and the use of transanal platforms. These approaches can be used in the surgical management of both Crohn's disease (CD) and ulcerative colitis (UC). There are significant peculiarities in the surgical field in CD and UC, and their perfect understanding are directly related to better outcomes in IBD patients, as a consequence of improvement in knowledge by IBD surgeons. Different strategies to train colorectal surgeons were developed worldwide, for better application of MIS, usually for malignant or non-IBD benign diseases. There is a significant lack of evidence in specific training strategies for MIS in the IBD field. In this review, the authors outline the importance of adequate surgical training in IBD MIS, by discussing the current evidence on different approaches and emphasizing the need for better training protocols included in multidisciplinary teams in IBD centers throughout the globe.

Consulting ‘Dr. Google’ for minimally invasive urological oncological surgeries: A contemporary web‐based trend analysis

To determine web-based public interest in minimally invasive surgery (MIS) specifically for urological oncological surgical procedures and how interest in robotics and laparoscopy compares over time. Worldwide search-engine trend analysis included electronic Google queries of MIS urologic options from January 2004 to August 2019, worldwide. Join-point regression was performed. Comparison of annual relative search volume (ARSV) and average annual percentage change (AAPC) were analysed to assess loss or gain of interest. Evaluations were made regarding 1) penetrance of interest for MIS in Urology; 2) how MIS urologic procedures compared over time; and 3) which were the top related queries to searches for urologic oncology procedures. Increased interest was found for all of the MIS procedures evaluated. Mean ARSV for robotic approach was higher for the search term 'prostatectomy" (44.8 vs. 13.5; p<0.001) and 'partial nephrectomy" (27.1 vs.11.5; p=0.02). No statistical difference was found for the search terms 'cystectomy" or 'nephrectomy". The analysis of mean (∆-ARSV) of MIS procedures measured between the first and last 12 months of the study period showed an increased interest with a more pronounced ∆-ARSV for robotic procedures. The top related searches for all surgical procedures were examined showing an increasing inquisitiveness with regards of type of urological cancers, treatment options, type of surgery and prognostic outcomes. People are increasingly searching the web for MIS urological procedures. A growing appeal for robotics is demonstrated, especially for prostatectomy and partial nephrectomy where the robotic approach is gaining traction, suggesting a shift in mind-set amongst people seeking urological healthcare information.

Minimally Invasive Management of Bladder Stones in Children.

Background: Bladder stones (BS) are rare in children. Minimally invasive surgery (MIS) seems to be nowadays the procedure of choice to treat pediatric patients with BS. This study aimed to analyze retrospectively our experience with percutaneous cystolithotomy, endourological treatment with Holmium laser and robotic cystolithotomy in children with BS.Methods: We retrospectively analyzed the data of 13 children (eight boys and five girls) with BS who were treated at our centers between July 2013 and July 2020. The patients received three different MIS procedures for stones removal: five underwent robotic cystolithotomy, five underwent endourological treatment and three received percutaneous cystolithotomy (PCCL). We preferentially adopted endourological approach for stones <10 mm, percutaneous approach between 2014 and 2016 and robotic approach since 2016 for larger stones.Results: Mean patients' age at the time of diagnosis was 13 years (range 5–18). Ten/13 patients (76.9%) had primary BS and 3/13 patients (23.1%) had secondary BS. Mean stone size was 18.8 mm (range 7–50). In all cases the stones were removed successfully. One Clavien II post-operative complication occurred following PCCL (33.3%). All the procedures were completed without conversions. Operative time ranged between 40 and 90 min (mean 66) with no significant difference between the three methods (p = 0.8). Indwelling bladder catheter duration was significantly longer after PCCL (mean 72 h) compared with robotic and endourological approaches (mean 15.6 h) (p = 0.001). Hospitalization was significantly longer after PCCL (mean 7.6 days) compared with the other two approaches (mean 4.7 days) (p = 0.001). The endourological approach was the most cost-effective method compared with the other two approaches (p = 0.001).Conclusions: Minimally invasive management of bladder stones in children was safe and effective. Endourological management was the most cost-effective method, allowing a shorter hospital stay compared with the other procedures but it was mainly indicated for smaller stones with a diameter < 10 mm. Based upon our preliminary results, robotic surgery seemed to be a feasible treatment option for BS larger than 15–20 mm. It allowed to remove the big stones without crushing them with a safe and easy closure of the bladder wall thanks to the easy suturing provided by the Robot technology.

The Use of Minimal Invasive Surgery versus Open Approach in Hospitalized Cases.

Backgtound: The progress in development and application of Minimal Invasive Surgery (MIS) requires clinical and managerial decisions that must be evidence based; the current available scientific evidence for the Romanian medical practice is missing. Our study aims to analyze the use of MIS and open surgery in Romania and the impact of the type of surgery on the hospitalization. Methodology: A cross-sectional study analyzed the activity of the Romanian hospitals reporting primary Diagnostic Related Group (DRG) data at the patient level in the period 2008-2018; all episodes of abdominal and thoracic surgical interventions which may be performed either by MIS or an open approach were extracted from the DRG National database (www.drg.ro). A comparative analysis in terms of the volume of activity and their impact on the hospital average length of stay (ALOS) has been performed. Results: The pattern of use for MIS and open surgery interventions was changed in 2008-2018; MIS procedures doubled while open surgery interventions did not follow the same growth rate; ALOS for the MIS procedures decreased annually at a faster rate as compared to the ALOS for the open surgery and the gap between the two gradually increased in favour of the MIS interventions. The most pronounced shortening of ALOS after MIS procedures has been found for Gallbladder Surgery (by 7.95 days), Gastric Surgery (by 5.64 days) and Incisional Hernia surgery (by 4.33 days). Meanwhile, the reimbursement level for the MIS versus open surgery interventions did not changed over the analyzed period. Conclusions: MIS is significantly reducing the ALOS in Romania with a potential positive influence on the national healthcare budget. However, the pattern of use for MIS interventions is not financial incentives based and calls for in-depth analysis on other factors belonging rather to specific pathology, technology or medical practice (experience in using MIS, endowment, safety, efficacy, surgical approach area etc.) is urgently required.

Reoperation, Readmission, and Discharge Disposition for Patients With Degenerative Lumbar Pathology Treated With Either Open or Minimally Invasive Techniques: A Single-Center Retrospective Review of 1435 Cases.

Spine surgery has been transformed by the growth of minimally invasive surgery (MIS) procedures. Previous studies agree that MIS has shorter hospitalization and faster recovery time when compared to conventional open surgery. However, the reoperation and readmission rates between the 2 techniques have yet to be well characterized. To evaluate the rate of subsequent revision between MIS and open techniques for degenerative lumbar pathology. A total of 1435 adult patients who underwent lumbar spine surgery between 2013 and 2016 were included in this retrospective analysis. The rates of need for subsequent reoperation, 30- and 90-d readmission, and discharge to rehabilitation were recorded for both MIS and traditional open techniques. Groups were divided into decompression alone and decompression with fusion. The rates of subsequent reoperation following MIS and open surgery were 10.4% and 12.2%, respectively (P=.32), which were maintained when subdivided into decompression and decompression with fusion. MIS and open 30-d readmission rates were 7.9% and 7.2% (P=.67), while 90-d readmission rates were 4.3% and 3.6% (P=.57), respectively. Discharge to rehabilitation was significantly lower for patients under 60 yr of age undergoing MIS (1.64% vs 5.63%, P=.04). The use of minimally invasive techniques for the treatment of lumbar spine pathology does not result in increased reoperation or 30- and 90-d readmission rates when compared to open approaches. Patients under the age of 60 yr undergoing MIS procedures were less likely to be discharged to rehab.

Use of an Aortic Valve Replacement Simulation Model to Understand Hospital Costs and Resource Utilization Associated With Rapid-deployment Valves

PurposeAortic stenosis (AS) is the most common cause of adult valvular heart disease. In the past decade, minimally invasive surgery (MIS) to treat AS has gained popularity, especially if performed in combination with rapid deployment valves (RDVs), which shorten cross-clamp time (XCT). This study examines specific outcomes and related costs of aortic valve replacement (AVR) before and after the introduction of RDVs. MethodsWe used the AVR simulator, an economic model developed to correlate cost and resource utilization associated with the adoption of RDVs, to compare 2 scenarios: (1) a current scenario based on standard AVR practices and (2) a proposed scenario based on increasing use of RDVs and an MIS approach. Both scenarios involved 3 subgroups of patients treated with (1) conventional AVR, (2) MIS, and (3) AVR combined with a coronary artery bypass graft. The current scenario (status quo) involved patients treated with traditional biological valves, and the proposed scenario involved patients who underwent implantation with an RDV. The AVR simulator was fed with real-world input data to estimate complication rates and resource consumption in the proposed scenario. Real-world input data for this analysis were obtained from patients diagnosed with a symptomatic heart valve disease between 2015 and 2018, at Clinica-San-Gaudenzio, Novara, Italy. Lastly, the AVR simulator estimated hospital savings by comparing the 2 scenarios. FindingsA total of 132 patients underwent implantation with a traditional biological valve, and 107 were treated with a commercial valve system. The RDV was associated with an increase of 52% of patients undergoing MIS, which generated a 6.1-h reduction of XCT and a total savings of €6695. RDVs also reduced intensive care unit (ICU) and hospital ward length of stay (LOS), leading to savings of €677 and €595 per patient, respectively. Mortality and blood transfusions also improved. The savings for the hospital (related to shorter XCT, hospital ward LOS, and ICU LOS) amounted to €144.111. Our findings were consistent with data gathered from our real-word setting, and results of a sensitivity analysis indicate that our findings were robust across different possible situations. ImplicationsSwitching to RDVs and MIS procedures for AVRs was associated with a reduction of costs related to XCT, hospital ward LOS, and ICU LOS. Hospitals can upload literature- and experience-based clinical and cost values to the AVR simulator to estimate a hospital's performance with the introduction of RDVs compared with standard biological valves. This study was not randomized, so more extensive studies could confirm our results in the future.

Trainee Autonomy in Minimally Invasive General Surgery in the United States: Establishing a National Benchmark

Minimally invasive surgery (MIS) is an integral component of General Surgery training and practice. Yet, little is known about how much autonomy General Surgery residents achieve in MIS procedures, and whether that amount is sufficient. This study aims to establish a contemporary benchmark for trainee autonomy in MIS procedures. We hypothesize that trainees achieve progressive autonomy, but fail to achieve meaningful autonomy in a substantial percentage of MIS procedures prior to graduation. Fifty General Surgery residency programs in the United States, from September 1, 2015 to March 19, 2020. All Categorical General Surgery Residents and Attending Surgeons within these programs were eligible. Data were collected prospectively from attending surgeons and categorical General Surgery residents. Trainee autonomy was assessed using the 4-level Zwisch scale (Show and Tell, Active Help, Passive Help, and Supervision Only) on a smartphone application (SIMPL). MIS procedures included all laparoscopic, thoracoscopic, endoscopic, and endovascular/percutaneous procedures performed by residents during the study. Primary outcomes of interest were "meaningful autonomy" rates (i.e., scores in the top 2 categories of the Zwisch scale) by postgraduate year (PGY), and "progressive autonomy" (i.e., differences in autonomy between PGYs) in MIS procedures, as rated by attending surgeons. Primary outcomes were determined with descriptive statistics, one-way analysis of variance (ANOVA) and Z-tests. Secondary analyses compared (i) progressive autonomy between common MIS procedures, and (ii) progressive autonomy in MIS vs. non-MIS procedures. A total of 106,054 evaluations were performed across 50 General Surgery residency programs, of which 38,985 (37%) were for MIS procedures. Attendings performed 44,842 (42%) of all evaluations, including 16,840 (43%) of MIS evaluations, while residents performed the rest. Overall, meaningful autonomy in MIS procedures increased from 14.1% (PGY1s) to 75.9% (PGY5s), with significant (p < 0.001) increases between each PGY level. Meaningful autonomy rates were higher in the MIS vs. non-MIS group [57.2% vs. 48.0%, p < 0.001], and progressed more rapidly in MIS vs. non-MIS, (p < 0.05). The 7 most common MIS procedures accounted for 83.5% (n = 14,058) of all MIS evaluations. Among PGY5s performing these procedures, meaningful autonomy rates (%) were: laparoscopic appendectomy (95%); laparoscopic cholecystectomy (93%); diagnostic laparoscopy (87%); upper/lower endoscopy (85%); laparoscopic hernia repair (72%); laparoscopic partial colectomy (58%); and laparoscopic sleeve gastrectomy (45%). US General Surgery residents receive progressive autonomy in MIS procedures, and appear to progress more rapidly in MIS versus non-MIS procedures. However, residents fail to achieve meaningful autonomy in nearly 25% of MIS cases in their final year of residency, with higher rates of meaningful autonomy only achieved in a small subset of basic MIS procedures.

Management of Displaced Intra-Articular Calcaneal Fractures: A Comparative Study of Open and Minimally Invasive Surgery

ObjectivesThe ideal treatment of displaced intra-articular calcaneal fractures continues to be a subject of debate. The aim of the study was to compare the radiological outcome, cumulative radiation exposure, surgical time, time to surgery, wound healing times and cost involved in minimally invasive surgery (MIS) and open reduction internal fixation (ORIF) for calcaneal fractures.MethodsThis was a retrospective study of 39 calcaneum operated in our unit during 2012 to 2019, of which 20 had undergone ORIF and 19 had been operated upon following MIS.ResultsA total of 39 calcanea (37 patients) were operated, of which 20 had open procedure and 19 had MIS procedure, including one bilateral surgery in each group. Mean age of the patients in the MIS group was 42.18 years (range: 15-68 years) and that of the patients in the open group was 43 years (range: 21-75 years). Of the fractures, 53.84% (n = 21) was Sanders type III, 28.20% (n = 11) was type II and 17.94% (n = 7) was type IV. There was no statistically significant difference in the mean correction of Bohler’s angle and Gissane’s angle between the groups. The mean cost for implant used for each open procedure was £882.79, and the implant cost for each MIS procedure was £142.89. Mean utilisation of cumulative X-ray dose was significantly higher in MIS (0.764 mGy) in comparison to open surgery (0.392 mGy). The average surgical time for MIS was 64.9 minutes and that of open surgery was 106.3 minutes. Average waiting time for MIS was 6.6 days and that for ORIF was 9.8 days. Wound healing was quicker (average 13.4 days) in MIS than ORIF (average 17.2 days). All these differences were statistically significant.ConclusionsMinimally invasive calcaneal fracture surgery is quicker and cheaper and can be performed earlier. It is associated with early wound healing, although it requires higher cumulative radiation dose.

Postoperative Urinary Retention after Benign Gynecologic Surgery with a Liberal versus Strict Voiding Protocol

Surgeons employ various methods for evaluating what is considered a common occurrence after gynecologic operations, postoperative urinary retention (POUR). Few have reported the incidence of POUR with a liberal voiding protocol (no requirement to void before discharge). The primary objective of this study was to evaluate the risk of POUR after benign gynecologic surgery, comparing a liberal voiding protocol with more strict voiding protocols. Secondary outcomes included length of hospital stay (LOS) and urinary tract infection (UTI). Retrospective cohort study. Quaternary-care academic hospital in the United States. Patients undergoing hysterectomy or myomectomy at Cedars-Sinai Medical Center from August 2017 through July 2018 (n = 652). Cases involving incontinence operations, correction of pelvic organ prolapse, malignancy, or peripartum hysterectomy were excluded. Hysterectomy, myomectomy. POUR, defined as the need for recatheterization within 24 hours of catheter removal, along with UTI and LOS were compared between liberal and strict voiding protocols. A subgroup analysis was performed for those undergoing minimally invasive surgery (MIS). A total of 303 (46.5%) women underwent surgery with a liberal postoperative voiding protocol and 349 (53.5%) women with a strict voiding protocol. Overall, the incidence of POUR was low at 3.8% and not different between the groups (2.6% liberal vs. 4.9% strict, p = .14). UTIs also occurred infrequently (2.8% overall, 2.6% liberal vs. 2.9% strict, p = .86). Similar results were seen specifically among those who underwent MIS: POUR (3.7% overall, 2.8% liberal vs. 5.3% strict, p = .17) and UTI (3.3% overall, 2.4% liberal vs. 4.7% strict, p = .28). The median LOS (interquartile range) was much shorter for MIS patients with a liberal voiding protocol (median 15 hours overall [interquartile range 15 hours], 9 [4] hours liberal vs. 36 [34] hours strict, p <.01). Among those discharged the same day (72.6% of the MIS cases), patients with a liberal voiding protocol had a significantly shorter LOS than those with strict (mean [standard deviation] 9.4 [2.5] hours vs. 10.6 [35] hours, p <.01). Postoperative complications occurred less frequently in those with MIS procedures (11.8% in MIS vs. 20.2% in laparotomies, p <.01) and those with liberal voiding protocols (11.2% liberal vs. 16.9% strict p = .04). Overall, POUR occurs infrequently after major benign gynecologic surgery and does not differ between those with liberal and strict voiding protocols. Our data suggest that same-day discharge after MIS hysterectomy and myomectomy without a requirement to void does not increase the risk of POUR and shortens LOS. Eliminating voiding protocols after these procedures may facilitate greater efficiency in the postanesthesia recovery unit and may contribute to enhanced recovery after surgery protocols.

The Reverse ‘Glove-finger’ Technique for laparoscopic retrieval of appendix

Minimally invasive surgery (MIS) is now common in the paediatric age group, again highlighting the relevance of ‘clean’ retrieval of surgical specimens. Since disposable tissue bags can be expensive, we have developed a low-cost method for specimen retrieval using a modified finger from a surgical glove. We have used this technique mostly for laparoscopic appendectomy. There was no spillage of contents or surrounding tissue contamination and all wounds healed well without any infection from exit wound. There was no break in the glove or dispersion of glove fragments within the peritoneum. We believe that the Reverse Glove-finger Technique is a safe, quick, easy and low-cost technique that is freely available to all, for retrieval of small specimens during MIS procedures.

Minimally Invasive Surgery Is Feasible in Patients with Liver and Kidney Transplantation.

BackgroundMinimally invasive surgery (MIS) has rapidly advanced, but its use in transplant patients has lagged. We share our experience of MIS for patients after kidney and liver transplantation and compare our results with similar studies in the literature.Material/MethodsThis study included 14 MIS (12 laparoscopic, 2 transvaginal) procedures for 13 transplant cases (6 liver and 7 kidney) done from May 2006 to May 2018. Gastrointestinal surgery was performed in 6 cases: appendectomy performed 8 months after liver transplant and 16 months after kidney transplant in 2 cases, radical right hemi-colectomy performed 6 weeks after liver transplant in 1 case; exploration for chylous ascites 6 months after liver transplant in 1 case, sleeve gastrectomy performed 3 years after kidney transplant in 1 case, and partial hepatectomy performed 12 years after kidney transplant in 1 case. For urological problems, 2 patients received ipsilateral right-side nephroureterectomy performed 10 and 12 years after kidney transplant, and 1 patient received contralateral left-side nephroureterectomy performed 12 years after kidney transplant. The 2 liver transplant patients with huge incisional hernias received repair approximately 3 and 2 years after liver transplant. Three patients underwent gynecological surgery: 2 transvaginal for pelvic floor reconstruction in 1 patient with liver transplant and 1 hysterectomy in a kidney transplant patient, and 1 laparoscopic-assisted hysterectomy in a kidney transplant patient. We retrospectively analyzed the clinical presentation, operative findings, operation time, postoperative complications, and length of stay.ResultsThe postoperative course was uneventful, with early resumption of oral intake, including immunosuppressants administered the same as in the non-transplant patients. All surgical procedures in these transplant patients were achieved without conversion, showed stable kidney and liver function, had better surgical outcomes in comparison with traditional surgery, and most of them were discharged within 1 week.ConclusionsLaparoscopic and non-laparoscopic MIS surgery are feasible and safe for abdominal organ transplant patients and are helpful for timely intervention in cases with acute abdomen. No adjustment of immunosuppressant is usually needed, as oral intake can be resumed very soon after surgery.

Minimally invasive surgery for early-stage ovarian cancer: Association between hospital surgical volume and short-term perioperative outcomes

ObjectiveTo examine trends and associated characteristics and outcomes of minimally invasive surgery (MIS) for women with early-stage ovarian cancer. MethodsThe National Inpatient Sample was queried to examine early-stage ovarian cancer treated with MIS from 2001 to 2011. Annualized hospital surgical volume was defined in the unweighted model as the average number of procedures performed per year in which at least one case was performed. Trends, characteristics, and outcomes related to MIS use were assessed in the weighted model. ResultsAmong 73,707 oophorectomy cases, there were 4822 (6.5%) MIS cases. Utilization of MIS increased from 3.9% to 13.5% from 2001 to 2011 (3.5-fold increase, P < 0.001), and the number of MIS-offering centers also increased from 10.6% to 36.2% (3.4-fold increase, P < 0.001). MIS was associated with a decreased complication rate (20.3% versus 35.4%) and shorter hospital stay (median, 2 versus 4 days) compared to laparotomy (both, P < 0.001). Of the 472 hospitals at which MIS was performed, the majority were minimum-volume with one MIS oophorectomy per year (340 [72.0%], n = 1929 [40.0%]), followed by mid-volume (85 [18.0%], n = 1272 [26.4%]) and topdecile-volume (47 [10.0%] hospitals, n = 1621 [33.6%]). The topdecile-volume group had the highest rate of lymphadenectomy compared to other groups (62.2% versus 39.2–55.1%, P < 0.05). On multivariable analysis, a one increment increase in annualized hospital surgical volume was associated with an 11% decrease in multiple complications (adjusted-odds ratio 0.89, 95% confidence interval 0.82–0.97, P = 0.006). ConclusionUtilization of MIS for early-stage ovarian cancer has significantly increased in the United States in 2000s. In 2011, one in eight surgeries performed for early ovarian cancer were performed via MIS. MIS procedures performed at hospitals with a higher surgical volume may be associated with improved short-term perioperative outcomes.

The shifting trends towards a robotically-assisted surgical interface: Clinical and financial implications

ObjectivesSome hospitals have invested in robotic surgery platforms to stimulate the uptake of minimally invasive surgery (MIS) and offer its benefits to more patients. The objectives were to determine the clinical and financial effects, as well as the policy implications, of a robotics program in an academic gynecologic oncology division over time. MethodsPatients treated for endometrial, cervical, and ovarian cancer within a gyn-oncology division between 2003 and 2016 were included in the current study. Clinical outcomes were described in function of surgical approach (laparotomy, laparoscopy, and robotic surgery) and tumor site. The net present value and the return on investment of the robotics program were approximated using previously reported treatment costs from our center. ResultsThe use of MIS soared from a high of 15% to 91% before and after the introduction of robotics in December 2007, respectively. Across all tumor sites, MIS procedures were associated with diminished blood loss and a shorter hospital stay (p < 0.0001). The use of robotics in gyn-oncology resulted in cost savings. ConclusionsRobotic surgery was instrumental in catalyzing the shift from open surgery to MIS and amplifying the number of patients who benefited from less invasive surgery. Continued investments in robotics and the digitization of surgery could help further drive innovation and expand its applications.

PSU30 EQUITY OF ACCESS TO MINIMAL INVASIVE SURGERY FOR WOMEN WITH ENDOMETRIAL CANCER

The benefits derived from minimally invasive surgery (MIS) for endometrial carcinoma (EC) are well known, however uptake across different populations in England is uncertain. Our study objective was to examine the clinical outcomes following a hysterectomy and explore the impact of different surgical approaches and equity of access. Hospital Episode Statistics (HES) for England 2011-2017/18 was analysed for all women undergoing an open (OH) or laparoscopic/robotic hysterectomy (LH/RH) for EC. Patient characteristics analysed included age, ethnicity, Index of Multiple Deprivation (IMD), Charlson Comorbidity Index (CCI) alongside hospital characteristics of geographic region, hospital volume and the proportion of MIS procedures undertaken. A propensity score was created from a logistic regression which enabled the inverse probability weighting of treatment (IPTW) to be applied to adjust for observed potential confounders between the surgical approaches. The number of procedures performed totalled 35,304 with 20,405 (57.8%) MIS (LH 18,604 and RH 1,801), 14,291 (40.5%) OH. The rate of MIS rose from 40.3% to 68.7% across the study period, however there was significant geographical variation (p<0.001). The overall mortality up to 90 days after surgery following IPTW was significantly higher with OH rather than MIS (OR, 0.34; 95% CI 0.18-0.62; p=0.0002). Disparities in the provision of MIS were seen in women from the lowest socioeconomic group as compared to women from the highest group (55.4% versus 59.9%, p<0.01), and in Black populations as compared to White and Asian populations (40.4% versus 58.6% and 56.0%, p<0.0001). Inequalities in access exist in the provision of MIS for the treatment of EC in England. Further research is needed to understand potential barriers to MIS in clinical practice and to improve access so that as many women as possible may benefit from the reduced morbidity and mortality associated with MIS.

2485 Identifying Barriers for Same-Day Discharge of Minimally Invasive Hysterectomies

Study Objective Minimally invasive surgery (MIS) has provided patients with decreased post-surgical pain, faster recovery, and shorter hospital stay. Currently, the trend with MIS procedures is to have same-day discharge. The purpose of this study is to determine which patient-based and post-surgical factors are barriers to same-day discharge and lead to hospital re-admission. Design Quality assurance, retrospective cohort study. Setting Single academic institution Patients or Participants Chart review for patients undergoing laparoscopic, vaginal, laparoscopic assisted vaginal or robotic hysterectomy from July 2014 to April 2017. Cohort of 541 patients from 18-84 years-old with a mean age of 48. Interventions No interventions. Descriptive study of post-operative hospital stay following surgery. Measurements and Main Results We performed an electronic medical record chart review to evaluate time in the recovery room following surgery, route of hysterectomy, reasons for prolonged hospital stay, and re-admission. Out of 541 patients, 395 (73%) were general gynecology patients and 146 (27%) were urogynecology patients. Despite the goal of same-day discharge, only 252 (47%) of patients were discharged the same day. Of those patients, 83% were vaginal hysterectomies and 84% were laparoscopic hysterectomies that were discharged in less than 6 hours. 145 (99.3%) urogynecology patients stayed admitted overnight. There was an association between length of case, urogynecology patients, and overnight stay (OR 1.23, CI 1.006 - 1.521), but no association was found between length of stay in recovery with estimated blood loss. There was no statistical significance (p>0.05) between hours of recovery room stay with emergency room visits or re-admissions. Conclusion The majority of the patients in the cohort were not discharged the same-day given that data was altered by urogynecology patients despite having MIS procedures. Barriers to same-day discharge included length of procedure, voiding dysfunction and pain. Further studies include implementing enhanced recovery after surgery and voiding trials for same-day discharge, as well as evaluating urogynecology patients separate from general gynecologic procedures.

Characterization of Patients with Minimally Invasive Surgery Converted in a Pediatric Hospital.

Introduction: Minimally invasive surgery (MIS) in pediatric surgery is now the standard of care for various surgical conditions. We have seen an increase in MIS with some of the procedures requiring intraoperative conversion to open surgery. Materials and Methods: This is a single-institution retrospective study of patients who underwent MIS between 2009 and 2017 requiring conversion to open surgery. Preoperative characteristics, cause of conversion, and postoperative factors were recorded. Results: A total of 154 patients had converted to MIS, 89.6% underwent laparoscopic procedures. Mean age was 8.5 years, 53.9% were male. Primary cause leading to surgery was not oncologic (89.6%), dirty contaminated wound was found in 49.35%, inflammatory response markers were altered, and 38.9% of our patients were American Society of Anesthesiologists physical status classification 3. Principal causes of conversion were failure in progression (53.25%) and loss of anatomic reference (24.5%). A total of 44.16% of the patients required postoperative pediatric intensive care unit admission, 29.2% required reintervention, and mortality rate was 0.65%. We detailed data regarding thoracoscopic, appendectomy, and laparoscopic procedures. Conclusion: Conversion to MIS is a decision the surgeon must make in different scenarios. This study allowed us to characterize our population regarding converted MIS procedures. Male gender, age group, altered inflammatory markers, not oncologic pathology, and dirty wound were frequently found, but we cannot establish any of them as risk factors. Main cause for conversion to open surgery was failure in the progression of the procedure in our study according to reported literature. We intend to develop further studies to determine risk factors.