Minimally Invasive Surgery Approach Research Articles

Open Versus Minimally Invasive Emergent Colectomy for Diverticulitis.

The role of minimally invasive surgery (MIS) in the acute management of diverticulitis remains controversial. Using a national cohort, we examined the relationship between operative approaches with acute clinical and financial outcomes. Adults undergoing emergent colectomy for diverticulitis were tabulated from the 2015-2020 American College of Surgeons National Surgical Quality Improvement Program. Regression models were developed to analyze the association between open and MIS approaches with major adverse events (MAE), as well as secondary endpoints. A subgroup analysis was conducted to compare outcomes between open and MIS requiring conversion to open (CTO). Of 9194 patients, 1580 (17.3%) underwent MIS colectomy. The proportion of MIS resection increased from 15.1% in 2015 to 19.1% in 2020 (nptrend<.001). Compared to Open, MIS patients were younger, equally likely to be female, had a lower proportion of patients with ASA class ≥3, and a higher BMI. Preoperatively, MIS patients were less frequently diagnosed with sepsis. Following adjustment with open as reference, MIS approach had reduced odds of MAE (AOR .56), ostomy creation (AOR .12), shorter postoperative length of stay (LOS; β -1.63), and a lower likelihood of nonhome discharge (AOR .45, all P < .001). Additionally, CTO was linked to decreased likelihood of MAE (AOR .78, P = .01), ostomy creation (AOR .02, P < .001), comparable LOS (β -.46, P = .41), and reduced odds of nonhome discharge (AOR .58, P < .001), relative to open. Compared to planned open colectomy, MIS resection was associated with improved clinical and financial outcomes, even in cases of CTO. Our findings suggest that whenever possible, MIS should be attempted first in emergent colectomy for diverticulitis. Nevertheless, future prospective studies are likely needed to further elucidate specific patient and clinical factors.

Quality of life after robotic versus conventional minimally invasive cancer surgery: a systematic review and meta-analysis.

Optimizing postoperative quality of life (QoL) is an essential aspect of surgical oncology. Minimally invasive surgery (MIS) decreases surgical morbidity and improves QoL outcomes. This meta-analysis aimed to compare post-operative QoL after oncologic resections using different MIS modalities. The PubMed, Embase, Scopus, and CENTRAL databases were searched for articles that compared post-operative QoL in patients undergoing video-assisted thoracoscopic (VATS) or laparoscopic surgery (LS) versus robotic surgery (RS) for malignancy. Quality assessment was performed using the ROBINS-I and Cochrane Risk of Bias 2 (RoB-2) tools. Meta-analysis was performed using an inverse-variance random effects model. 27 studies met the inclusion criteria, including 5 randomized controlled trials (RCTs). 15 studies had a low risk of bias, while 11 had a moderate risk of bias and 1 had serious risk of bias. 8330 patients (RS: 5090, LS/VATS: 3240) from across 25 studies were included in the meta-analysis. Global QoL was significantly better after robotic surgery in the pooled analysis overall (SMD: -0.28 [95% CI: -0.49, -0.08]), as well as in the prostatectomy and gastrectomy subgroups. GRADE certainty of evidence was low. Analysis of EPIC-26 subdomains also suggested greater sexual function after robotic versus laparoscopic prostatectomy. Robotic and conventional MIS approaches produce similar postoperative QoL after oncologic surgery for various tumor types, although advantages may emerge in some patient populations. Our results may assist surgeons in counseling patients who are undergoing oncologic surgery.

A retrospective study comparing minimally invasive versus open surgical resection of small intestinal neuroendocrine neoplasms at a tertiary referral center

IntroductionNeuroendocrine neoplasms (SI-NEN) are the commonest malignancies of the small intestine. Traditionally, surgical treatment for SI-NEN has been open surgery. PurposeThe purpose of this study was to compare minimally invasive surgery (MIS) with the traditional open surgery approach for treating SI-NEN in a Swedish population. MethodsPatients with histopathological confirmed SI-NEN who underwent open surgery or MIS resection within 2009–2021 were extracted from the hospital's medical records. Results65 patients were included in this study, with 35 (54 %) undergoing MIS and 30 (46 %) undergoing open surgery. We found no statistically significant difference (p = 0.173) in the frequency of R0 resections (MIS group n = 34 (97 %), open surgery group n = 26 (87 %)). Nor was there a significant difference (p = 0.101) when comparing the median number of resected lymph nodes (MIS group n = 13.5, open surgery group n = 10). A post-operative paralytic ileus was more often reported (p = 0.052) in the MIS group (n = 9, 26 %) compared to the open surgery group (n = 2, 7 %). In light of this, the days of hospital stay did not differ significantly (MIS group median = 6, IQR (5–8), open surgery group median = 6, IQR (5–9)). The Kaplan-Meier analysis did not reveal differences concerning cancer-related deaths (p = 0.109). ConclusionThe results from this study support that a MIS approach for the treatment of SI-NEN may not be inferior to open surgery. The higher number of resected lymph nodes and R0 resections may even speak in favor for a MIS approach. More studies with a longer time of observation are needed to further support this conclusion.

Are complications after repairing acute Achilles tendon ruptures related to the surgical approach or the patient’s comorbidities?*

Objective: Analyze the postoperative complications after repairing acute Achilles tendon rupture and compare them according to the surgical approach (open surgery (OS) or minimally invasive surgery (MIS)) and the patient’s comorbidities. Methods: A retrospective analytical study including 154 consecutive patients with an acute Achilles tendon rupture submitted to surgery and divided into OS and MIS cohorts. The following relevant comorbidities were analyzed: obesity, diabetes mellitus, smoking, dyslipidemia, gout, chronic corticosteroid use, connective tissue pathologies, transplant history, cancer treatment patients, and postoperative complications. Results: Seventy-eight patients (50.6%) were treated surgically with an OS technique and 76 (49.4%) with an MIS approach. Twenty patients (13%) had postoperative complications between the two cohorts (OS 11.5%; MIS 14.5%; p = 0.588). No statistically significant difference was found in the logistic regression of the risk of the surgical approaches and complications. Obesity had a significant statistical difference when complications and comorbidities were compared. Conclusions: Patients with obesity have a higher risk of developing postoperative complications with both OS and MIS techniques. No relationship was found between the type of surgical approach and a higher percentage of postoperative complications in treating acute Achilles tendon rupture.

Reduced Long-Term Bowel Obstruction Risk With Minimally Invasive Diaphragmatic Hernia Repair

IntroductionThe introduction of minimally invasive surgery (MIS) for repair of congenital diaphragmatic hernias (CDH) has reduced postoperative length of stay, postoperative opioid consumption, and provided a more esthetic repair. In adult abdominal surgery, minimally invasive techniques have been associated with decreased long-term rates of small bowel obstruction (SBO), although it is unclear if this benefit carries over into the pediatric population. Our objective was to evaluate the rates of SBO following open versus MIS CDH repair. Material and methodsInfants who underwent CDH repair between 2010 and 2021 were identified using the PearlDiver Mariner database. Kaplan-Meier curves and Cox proportional hazards models were used to evaluate time to SBO by surgical approach (MIS versus open) while adjusting for mesh use, patient sex, and length of stay. ResultsOf 1033 patients that underwent CDH repair, 258 (25.0%) underwent a minimally invasive approach. The overall rate of SBO was 7.5% (n = 77). Rate of SBO following MIS repair was lower than open repair at 1 y (0.8% versus 5.1%), 3 y, (2.3% versus 9.0%), and 5 y (4.4% versus 10.1%, P = 0.004). Following adjustment, the rate of SBO following MIS repair remained significantly lower than open repair (adjusted hazard ratio: 0.37, 95% confidence interval: 0.18, 0.79). ConclusionsFollowing CDH repair, long-term rates of SBO are lower among patients treated with MIS approaches. Long-term risk of SBO should be considered when selecting surgical approach for CDH patients.

A hybrid approach: a safe option for surgical treatment of early-stage cervical cancer.

The aim of the study was to describe the surgical treatment of early-stage cervical cancer (CC) via minimally invasive surgery (MIS) and a sequential hybrid approach combining MIS and mini-Pfannenstiel. Evaluate sentinel lymph node (SLN) detection using a hybrid tracer (ICG-99m Tc nanocolloid). Prospective, observational, descriptive, single-center study conducted at Son Espases University Hospital between January 2019 and September 2021. Patients with early-stage CC (FIGO 2018 IA1 with ILV-IIA1) who underwent surgical treatment with a follow-up of at least one year were included. Thirty early-stage CC patients were included, of whom four (13.3%) were upstaged due to positive SLNs. In these cases, laparotomy was avoided, and paraaortic lymphadenectomy was performed via MIS approach. Twenty-six patients had a radical hysterectomy: 15 underwent a hybrid approach, 10 laparoscopy, and one laparotomy. Patients undergoing laparoscopic surgery had a smaller estimated tumor size than those undergoing the hybrid approach. The overall SLN detection rate was 96.1%, with 88.5% of cases occurring bilaterally. Five out of 26 patients (19.2%) presented SLN macrometastases, and five (19.2%) had atypical drainage. Surgery refined staging in 33.3% (10/30) of cases. No recurrences were reported after an average follow-up of 32 months. MIS for SLN avoids laparotomy leading to rapid recovery and early adjuvant treatment initiation in nodal metastasis. In our study, tumor size is an important clinical implication in the surgical approach to be used. The hybrid tracer provided a high detection rate and combined the advantages of the two tracers. The hybrid approach has a quick recovery and optimal results.

167. NATIONAL TRENDS IN TECHNIQUE UTILIZATION FOR ESOPHAGECTOMY: DOES PRIMARY SURGEON SPECIALTY MATTER?

Abstract Background Cardiothoracic surgeons (CTS) and general surgeons (GS; including surgical oncologists) perform the vast majority of esophagectomies nationwide. We hypothesize that different clinical focus and training background could lead to different distribution in the use of open and minimally invasive surgery (MIS) techniques. Furthermore, we sought to explore whether specialty driven differences in surgical approach affect outcomes. Methods In a retrospective review of the ACS-NSQIP esophagectomy targeted participant user file (2016–2018), patients who underwent esophagectomy were sorted into CTS and GS cohorts. Perioperative characteristics and postoperative outcomes were compared using chi-square analysis or independent t-tests. Multivariate logistic regression controlling for perioperative variables was performed to generate risk adjusted odds ratios of postoperative outcomes by specialty. Results Of 3247 patients included, 1792 (55.2%) underwent esophagectomy by CTS and 1455 (44.5%) by GS as primary surgeon. CTS were more likely to use traditional MIS (p = 0.0004) or open approach (p &amp;lt; 0.0001) and less likely to use robotic surgery (p = 0.04) or a hybrid robotic/traditional approach (p &amp;lt; 0.0001) (Figure). CTS performed more Ivor Lewis esophagectomies and fewer transhiatal and McKeown esophagectomies (p &amp;lt; 0.0001). After risk-adjustment, there were no differences in rates of post-esophagectomy complications or rate of positive margins between CTS and GS (all p &amp;gt; 0.05). However, CTS were more likely to treat anastomotic leaks with surgery rather than other procedural interventions. Conclusion CTS and GS use MIS subtypes differently within esophagectomy. However, all risk adjusted differences in postoperative complications were driven by patient and operative characteristics rather than surgical subspecialty. Esophagectomy is being performed safely by surgeons with different clinical specialties and training pathway, with no differences in perioperative and oncologic outcomes.

Comparison of Minimally Invasive and Open Approaches for Midfoot Charcot Neuroarthropathy Reconstruction

Charcot neuroarthropathy (CNA) is a progressive disease affecting the bones and joints of the foot that can lead to instability, breakdown, and collapse. Minimally invasive surgery (MIS) techniques are becoming a popular option within musculoskeletal surgery of the foot and ankle and may be an alternative to aggressive dissection seen during corrective surgery. An MIS approach minimizes vascular disruption, provides structural stability at an osteotomy or arthrodesis site, and encourages early mobilization if indicated. This retrospective study compares 17 patients who underwent an open approach for midfoot CNA reconstruction with 17 patients who underwent an MIS approach for midfoot CNA reconstruction. Preoperative and postoperative radiographic parameters were measured: lateral talus-first metatarsal, anteroposterior (AP) talus-first metatarsal, calcaneal pitch, and cuboid height. Difficulties that occurred during treatment were gathered and sorted into postoperative problems (stage I), obstacles (stage II), and complications (stage III). Changes from preoperative to postoperative radiographic lateral talus-first metatarsal and AP talus-first metatarsal angles were statistically significant (P < 0.001) for both the MIS and open approach. No true postoperative complications (stage III) were observed at last follow-up. The most common difficulty encountered was pin-site infection (stage I; in 23.5% of patients) in the MIS group. In the open group, the most common complications were wound development (stage I; 23.5%) and nonunions (stage II; 23.5%). Our findings suggest that midfoot CNA reconstruction with MIS methods offers similar outcomes to the open approach. LEVEL OF CLINICAL EVIDENCE: III.

Minimally Invasive Surgery in Total Hip Arthroplasty: Analysis of Clinical Results and Practical Implications

This study presents a comprehensive analysis of the clinical results and practical implications of minimally invasive surgery (MIS) in total hip arthroplasty (THA). The study aimed to evaluate the outcomes of MIS-THA compared to traditional open surgery, focusing on postoperative pain, functional improvement, complications, and patient satisfaction. A retrospective analysis was conducted on a cohort of 20 patients who underwent MIS-THA. The results showed significant improvements in postoperative pain levels and functional outcomes among patients who underwent MIS-THA. The MIS approach demonstrated reduced tissue trauma, shorter hospital stays, and faster recovery times compared to traditional open surgery. Complication rates were also found to be lower in the MIS-THA group. Additionally, patient satisfaction scores were higher in the MIS-THA group, highlighting the positive impact of this technique on patient experience. The findings of this study support the use of MIS in THA as a viable alternative to traditional open surgery. The benefits of MIS include reduced postoperative pain, improved functional outcomes, shorter hospitalization, and enhanced patient satisfaction. These results have important implications for clinical practice, as MIS-THA can contribute to improved patient outcomes and cost-effective healthcare delivery.

Biomechanical Evaluation of Fourth Generation Minimally Invasive Distal First Metatarsal Osteotomy-Akin Osteotomy Technique on First Ray Articular Contact Properties.

Hallux valgus is a common deformity encountered but remains a complex clinical entity. Fourth-generation minimally invasive surgery (MIS) techniques consisting of a percutaneous distal metatarsal transverse osteotomy combined with an Akin osteotomy have been used to address mild to severe hallux valgus deformities. The benefits of an MIS approach include improved cosmesis, faster recovery, lower opiate requirement, immediate weightbearing, and favorable outcomes relative to a traditional, open procedure. An understudied area with respect to hallux valgus correction is the effect that osteotomies can have on the articular contact properties of the first ray following correction. Sixteen paired cadaveric specimens were dissected to include the first ray and tested in a customized apparatus. Specimens were randomized to receive a distal transverse osteotomy translated either 50% or 100% of the width of the first metatarsal shaft. The osteotomy was performed with either a 0° or 20° distal angulation of the burr relative to the shaft in the axial plane. Specimens were tested in the intact state and following the distal first metatarsal osteotomy for peak pressure, contact area, contact force and center of pressure at the first metatarsophalangeal (MTP) and first tarsometatarsal (TMT) joints. An Akin osteotomy was then performed on each specimen, and peak pressure, contact area, contact force, and center of pressure were recalculated. There was a notable decrease in peak pressure, contact area, and contact force across the TMT joint with greater shifts of the capital fragment. However, at 100% translation of the capital fragment, distal angulation of the osteotomy by 20° appears to improve loading across the TMT joint. Addition of the Akin osteotomy at 100% translation also aids in increasing the contact force across the TMT joint. The MTP joint is less sensitive to changes in shifts and angulation of the capital fragment. The Akin osteotomy also leads to increased contact force across the MTP joint when the capital fragment is translated 100%. While the clinical significance is unknown, larger shifts of the capital fragment lead to greater load alterations at the level of the TMT joint than the MTP joint. Distal angulation of the capital fragment and the addition of an Akin osteotomy can aid in reducing the size of those changes. The Akin can lead to increased contact forces at the MTP joint with 100% translation of the capital fragment. Not applicable, Biomechanical study.

Minimally Invasive Staging of Early-Stage Epithelial Ovarian Cancer versus Open Surgery in Terms of Feasibility and Safety: A Systematic Review and Meta-Analysis.

Epithelial ovarian cancer is women's fourth most common oncological cause of death. One of the main prognostic factors in ovarian cancer is the tumor stage. For instance, surgical staging of the disease is focal when choosing the best therapeutic option for each case. Although open surgery is the prevalent approach for staging and treating ovarian cancer, the use of minimally invasive surgery (MIS) has found recent application in staging or restaging cases of early disease. Our work compares oncological outcomes after MIS staging for FIGO I epithelial ovarian cancer with the laparotomic approach. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations, we systematically searched the Pub Med and Scopus databases in February 2023. No temporal nor geographical limitation was made. We included the articles containing data about Disease-Free Survival (DFS) and Overall Survival (OS), Recurrence Rates (RR), and Upstaging Rates (UpR). We used comparative studies for the meta-analysis. After the database search and article selection, 19 works matched the inclusion criteria for the systematic review. Eleven of these were comparative studies between MIS and Open Surgical Staging (OSS) approaches for ovarian cancer staging and were included in the meta-analysis. The meta-analysis did not show a statistically significant difference between the MIS and the OSS group concerning DFS, OS, and RR. Only Upstaging Rate ≥ FIGO Stage II was statistically significative higher in the OSS group. Likewise, MIS is confirmed to be an approach with a lower profile of surgical complications. In conclusion, our study did not show one approach to be safer than the other. However, the lack of dedicated studies limits the evidence of our study. For instance, we recommend adequately selecting the specimen, minimizing the risk of spillage, and optimizing surgical staging.

Impact of surgical approach on short- and long-term outcomes in gastroenteropancreatic neuroendocrine carcinomas

BackgroundLiterature is lacking on the impact of advancements in minimally invasive surgery (MIS) on outcomes for patients with gastroenteropancreatic neuroendocrine carcinomas (GEP-NECs). Herein, we compared perioperative and oncologic outcomes among patients with GEP-NECs undergoing open, laparoscopic, and robotic resection. MethodsPatients with GEP-NECs diagnosed 2010-2019 were identified from the National Cancer Database (NCDB). We used the inverse probability of treatment weighting method to account for selection bias. Patients were stratified by surgical approach; and pairwise comparisons were conducted by analyzing short- and long-term outcomes. ResultsReceipt of MIS increased from 34.2% in 2010 to 67.5 % in 2019. Altogether, 6560 patients met study criteria: 3444 (52.5%) underwent open resection, 2783 (42.4%) underwent laparoscopic resection and 333 (5.1%) underwent robotic resection. Compared with open resection, laparoscopic or robotic resection were associated with shorter post-operative length of stay, reduced 30-day and 90-day post-operative mortality, and prolonged overall survival (OS). Compared with laparoscopic resection, robotic resection was associated with reduced 90-day post-operative mortality, however, there was no significant difference in OS. ConclusionThis NCDB analysis demonstrates that MIS approaches for treating GEP-NECs have become more common, with improved perioperative mortality, shorter post-operative length of stay and favorable OS, compared with open resection.

Open approach for ileocolic resection in Crohn's disease in the era of minimally invasive surgery: indications and perioperative outcomes in a referral center.

Minimally invasive surgery (MIS) is the first-line approach for ileocolic resection in Crohn's disease (CD), and it is safe and feasible, even with severe penetrating CD or redo surgery. While MIS indications are continually broadening, challenging CD cases might still require an open approach. This study aimed to report rate and indications for an upfront open approach in ileocolic resection for CD. Comprehensive perioperative data for all consecutive patients undergoing ileocolic resection for CD between 2014 and 2021 in a high-volume referral center for CD and MIS, were collected retrospectively. Indications for an upfront open approach were reviewed separately by two authors according to the preoperative visit. Among 319 ileocolic resections for CD, 45 (14%) were open and 274 (86%) MIS. Two or more of the below indications were present in 40 patients (89%) in the open group, while only in 6 patients (2%) in the MIS group (p < 0.0001). Indications for upfront open approach were severe penetrating disease (58%), adhesions at previous surgery (47%), history of abdominal sepsis (33%), multifocal and extensive disease (24%), abdominal wall involvement (22%), concomitant open procedures (9%), small bowel dilatation (9%), and anesthesiologic contraindications (4%). MIS was never performed in a patient with abdominal wall involvement, concomitant open procedure, and anesthesiologic contraindication to MIS. This study can help guide patients, physicians, and surgeons. An abdominal wall involvement or the presence of two of the above indications predicts a high surgical complexity and may be considered as a no-go for the MIS approach. These criteria should prompt surgeons to strongly consider an upfront open approach to optimize the perioperative planning and care of these complex patients.

The MIS-COVID-AGICT Study: Trend of Minimally Invasive Surgery for Gastrointestinal Cancer Treatment During the First Waves of the COVID-19 Pandemic in Italy. Subgroup Analysis from the COVID-AGICT Study: COVID-19 and Advanced Gastrointestinal Cancer Surgical Treatment.

Background: A preliminary analysis from the COVID-Advanced Gastrointestinal Cancer Surgical Treatment (AGICT) study showed that the rate of minimally invasive surgery (MIS) for elective and urgent procedures did not decrease during the pandemic year. In this article, we aimed to perform a subgroup analysis using data from the COVID-AGICT study to evaluate the trend of MIS during the COVID-19 pandemic period in Italy. Methods: This study was conducted collecting data of MIS patients from the COVID-AGICT database. The primary endpoint was to demonstrate whether the SARS-CoV-2 pandemic scenario reduced MIS for elective treatment of gastrointestinal cancer (GIC) in Italy in 2020. The secondary endpoint was to evaluate the impact of the pandemic period on perioperative outcomes in the MIS group. Results: In the pandemic year, 62% of patients underwent surgery with a minimally invasive approach, compared to 63% in 2019 (P = .23). In 2020, the proportion of patients undergoing elective MIS decreased compared to the previous year (80% versus 82%, P = .04), and the rate of urgent MIS did not differ between the 2 years (31% and 33% in 2019 and 2020 - P = .66). Colorectal cancer was less likely to be treated with MIS approach during 2020 (78% versus 75%, P < .001). Conversely, the rate of MIS pancreatic resection was higher in 2020 (28% versus 22%, P < .002). Conversion to an open approach was lower in 2020 (7.2% versus 9.2% - P = .01). Major postoperative complications were similar in both years (11% versus 11%, P = .9). Conclusion: In conclusion, although MIS for elective treatment of GIC in Italy was reduced during the COVID-19 pandemic period, our study revealed that the overall proportion of MIS (elective and urgent) and postoperative outcomes were comparable to the prepandemic period. ClinicalTrial.gov (NCT04686747).

Surgeon-level versus hospital-level quality variance in kidney cancer surgery.

To determine whether variance in kidney cancer surgery quality indicators (QIs) is most impacted by surgeon-level or hospital-level factors in order to inform quality improvement initiatives. The ICES and Veterans Affairs (VA) databases were queried for patients undergoing surgery for localized kidney cancer. Kidney cancer surgery QIs were defined within each cohort. Quality of care was benchmarked at a surgeon- vs. hospital-level to identify statistical outliers, using available clinicopathological data to adjust for differences in case-mix. Variance between surgeons and hospitals was calculated for each QI using a random-effects model. The QI with the greatest amount of variance explained by hospital and surgeon-level factors was proportion of cases performed with minimally invasive surgery (MIS). The majority of this variance was due to surgeon-level factors for both the VA and ICES cohorts. The proportion of cases performed using an MIS approach was also the QI with the greatest number of outlier hospitals and surgeons compared to the average performance. The proportion of partial nephrectomies performed for patients at risk of chronic kidney disease was the QI with the greatest amount of variance due to hospital-level factors for the ICES cohort. The proportion of localized kidney cancer cases performed using an MIS approach is the QI requiring the greatest attention. Quality improvement initiatives should focus on surgeon-level factors to increase the number of MIS cases being performed for patients with localized renal masses.

Evolving Trends in the Use of Sacroiliac Fusion From 2015 to 2020.

Retrospective cohort analysis. To assess the evolution of patients undergoing sacroiliac (SI) fusion with minimally invasive surgery (MIS) relative to open approaches. The SI joint can be a contributor to lumbopelvic symptoms. The MIS approach to SI fusion has been shown to have fewer complications compared with the open approach. Recent trends and evolved patient populations have not been well-characterized. Data were abstracted from the large, national, multi-insurance, administrative 2015-2020 M151 PearlDiver database. The incidence, trends, and patient characteristics of MIS, as well as open, SI fusions for adult patients with degenerative indications, were determined. Univariable and multivariable analyses were then performed to compare the MIS relative to open populations. The primary outcome was to assess the trends of MIS and open approaches for SI fusions. In total, 11,217 SI fusions were identified (of which 81.7% were MIS), with a clear increase in numbers over the years from 2015 (n=1318, 62.3% of which were MIS) to 2020 (n=3214 86.6% of which were MIS). Independent predictors of MIS (as opposed to open) SI fusion included: older age (odds ratio [OR] 1.09 per decade increase), higher Elixhauser-Comorbidity Index (OR 1.04 per two-point increase), and geographic region (relative to South, Northeast OR 1.20 and West OR 1.64). As might be expected, 90-day adverse events were lower for MIS than open cases (OR 0.73). The presented data quantify the increasing incidence of SI fusions over the years, with the increase being driven by MIS cases. This was largely related to an expanded population (those who are older and with greater comorbidity), fitting the definition of disruptive technology with lesser adverse events than open procedures. Nonetheless, geographic variation highlights the differential adoption of this technology.

658 Pseudarthrosis and Reoperation Rates in Minimally Invasive Adult Spinal Deformity Correction

INTRODUCTION: Adult spinal deformity (ASD) has historically been corrected via open surgery (OS). Recent developments in minimally invasive surgery (MIS) have made ASD correction possible with less blood loss, shorter hospital stays, and fewer complications. However, it has been proposed that inherent exposure constraints in MIS approaches limit proximal construct fusion, resulting in pseudarthrosis and potentially proximal junctional kyphosis and failure. METHODS: We initially screened 66 abstracts in PubMed. Manuscripts were initially included if they described outcomes from an MIS to correct ASD, including those comparing outcomes between MIS and OS or hybrid open-MIS. Exclusion criteria included failure to mention pseudarthrosis and surgeries performed on 2 levels or fewer. After independent review by two authors, 10 papers were selected. Patient demographics, perioperative and postoperative characteristics were calculated. RESULTS: Within the 10 articles, 509 MIS patients were reviewed. The average age was 65.5 years; 64.8% were female. An average of 6 levels (4.2 - 11) were fused per patient. Perioperative characteristics include mean follow-up time of 26.9 months, mean estimated blood loss (EBL) of 527 mL, mean operating time (OT) of 297.9 minutes, and mean length of stay (LOS) of 7.7 days. Among manuscripts comparing MIS to OS, all reported a statistically significant lower EBL in MIS patients. Conversely, OT and LOS were less consistently reported as lower in MIS compared to OS. The overall proximal pseudarthrosis rate among MIS patients was 6.2%. Among patients with pseudarthrosis, 88.2% underwent revision. CONCLUSIONS: The results of this analysis demonstrate a measurable risk of pseudarthrosis when using MIS to treat ASD, overwhelmingly requiring reoperation. Considering this risk of pseudarthrosis and subsequent revision surgery against the benefits of MIS is crucial to evaluate surgical treatment options for patients with ASD.

Insurance Disparities in Access to Robotic Surgery for Colorectal Cancer.

The use of the robotic approach is increasing for colorectal cancer operations, but the added cost of the platform has the potential to introduce challenges in its dissemination. We hypothesized that adoption of the robot is introducing new disparities in access to minimally invasive surgery (MIS) for colorectal cancer, especially across patient insurance groups. This cross-sectional study analyzed surgical cases of stage I-III colorectal cancer from the National Cancer Database (NCDB) between 2010 and 2019. The primary outcome was surgical approach (robotic, laparoscopic, or the composite "MIS"). The predictor was a patient's primary payor. Potential confounders included sociodemographics, tumor characteristics, and the facility. Hierarchical multivariable models were generated, and sensitivity analyses were performed. For colorectal cancer operations, the MIS approach increased from 39% in 2010 to 73% in 2019, driven predominantly by an increase in the robotic approach from 2 to 24%. For laparoscopy, the size of the disparity between patients with Private insurance and Medicaid shrank from 11% (2010) to 4% (2019), whereas this disparity increased for the robotic approach from 1% (2010) to 5% (2019). On adjusted analysis, patients with Medicaid (odds ratio [OR] 0.86 [CI 0.79-0.95]) and the Uninsured (OR 0.67 [CI 0.56-0.79]) had lower odds of receiving a robotic operation than those with Private insurance in 2019. This disparity remained consistent across five sensitivity analyses. As the field of colorectal cancer surgery shifts away from laparoscopy and toward robotics, new inequities across patient insurance are emerging. Proactive efforts are needed to ensure all patients benefit from a minimally invasive approach.

Does minimally invasive surgery have a different impact on recurrence and overall survival in patients with pancreatic head versus body/tail cancer?

This study sought to investigate the impact of minimally invasive surgery (MIS) on recurrence and overall survival between patients with pancreatic head versus body/tail cancers. The risk factors associated with recurrence and long-term outcomes were analyzed according to tumor location and operative modality. A total of 288 and 87 patients underwent surgical resection for pancreatic head cancer and body/tail cancer, respectively. The perioperative outcomes and histopathologic results were comparable in open and MIS approach in both head and body/tail groups. There was no difference in local or systemic recurrence patterns and disease-free and overall survival rates according to primary tumor location and surgical modality. During subgroup analysis by stage; however, patients with stage III pancreatic head cancer in the MIS group had a decreased disease-free survival compared with those in the open surgery group (p = 0.020). On multivariate analysis, MIS was not a risk factor of total or local recurrences. Recurrence patterns and overall survival rates of patients did not differ according to tumor location and surgical approach. However, patients with stage III pancreatic head cancer in the MIS group showed inferior disease-free survival relative to patients who underwent open surgery.

Minimally Invasive versus Open Ureteral Reimplantation in Children: A Systematic Review and Meta-Analysis.

We performed a systematic review and meta-analysis to compare the safety and efficacy of minimally invasive surgery (MIS) versus open ureteral reimplantation (OUR) in children. Literature searches were conducted to identify studies that compared MIS (laparoscopic ureteral reimplantation or robot-assisted laparoscopic ureteral replantation) and OUR in children. Parameters such as operative time, blood loss, length of hospital stay, success rate, postoperative urinary tract infection (UTI), urinary retention, postoperative hematuria, wound infection, and overall postoperative complications were pooled and compared by meta-analysis. Among the 7,882 pediatric participants in the 14 studies, 852 received MIS, and 7,030 received OUR. When compared with the OUR, the MIS approach resulted in shorter hospital stays (I 2 = 99%, weighted mean difference [WMD] -2.82, 95% confidence interval [CI] -4.22 to -1.41; p < 0.001), less blood loss (I 2 = 100%, WMD -12.65, 95% CI -24.82 to -0.48; p = 0.04), and less wound infection (I 2 = 0%, odds ratio 0.23, 95% CI 0.06-0.78; p = 0.02). However, no significant difference was found in operative time and secondary outcomes such as postoperative UTI, urinary retention, postoperative hematuria, and overall postoperative complications. MIS is a safe, feasible, and effective surgical procedure in children when compared with OUR. Compared with OUR, MIS has a shorter hospital stay, less blood loss, and less wound infection. Furthermore, MIS is equivalent to OUR in terms of success rate and secondary outcomes such as postoperative UTI, urinary retention, postoperative hematuria, and overall postoperative complications. We conclude that MIS should be considered an acceptable option for pediatric ureteral reimplantation.