History Of Prior Abdominal Surgery Research Articles

Determining the etiology of small bowel obstruction in patients without intraabdominal operative history: a retrospective study.

Most of the causes of small bowel obstruction (SBO) in patients without a history of abdominal surgery are unclear at initial assessment. This study was conducted to identify the etiology and clinical characteristics of SBO in virgin abdomens and discuss the proper management. A retrospective review involving operative cases of SBO from a single institute, which had no history of abdominal surgery, was conducted between January 2010 and December 2020. Clinical information, including radiological, operative, and pathologic findings, was investigated to determine the etiology of SBO. A total of 55 patients were included in this study, with a median age of 57 years and male sex (63.6%) constituting the majority. The most frequently reported symptoms were abdominal pain and nausea or vomiting. Neoplasm as an underlying cause accounted for 34.5% of the cases, of which 25.5% were malignant cases. In patients aged ≥60 years (n=23), small bowel neoplasms were the underlying cause in 12 (52.2%), of whom 9 (39.1%) were malignant cases. Adhesions and Crohn disease were more frequent in patients aged <60 years. Coherence between preoperative computed tomography scans and intraoperative findings was found in 63.6% of the cases. There were various causes of surgical cases of SBO in virgin abdomens. In older patients, hidden malignancy should be considered as a possible cause of SBO in a virgin abdomen. Patients with symptoms of recurrent bowel obstruction who have no history of prior abdominal surgery require thorough medical history and close follow-up.

Differences in Outcome Between Open vs Laparoscopic Insertion of Ventriculoperitoneal Shunts.

Abdominal access during ventriculoperitoneal (VP) shunt insertion has historically been obtained by neurosurgeons via an open abdominal approach. With recent advances in laparoscopy, neurosurgeons frequently consult general surgery for aid during the procedure. The goal of this study is to identify if laparoscopic assistance improves the overall outcomes of the procedure. This retrospective study included all patients who underwent open or laparoscopic VP shunt placement between September 2012 and August 2020 at our tertiary referral hospital. Patient demographics, comorbidities, prior history of abdominal surgery, open vs. laparoscopic insertion, operation time, and complications within 30days were obtained. Neurosurgery placed 107 shunts using an open abdominal technique and general surgery placed 78 using laparoscopy. The average OR time in minutes was 75.5minutes for the open cohort and 61.8 for the laparoscopic cohort (p = 0.006). In patients without a history of abdominal surgery, the average OR time in minutes was 79.4 in the open cohort and 57.1 in the laparoscopic cohort (p = 0.015). The postoperative shunt infection rate was 10.2% in the open group and 3.8% in the laparoscopic group (p = 0.077). Laparoscopic placement of VP shunts is a reasonable alternative to open placement and results in shorter OR times. There is also a trend toward few infections in the laparoscopic placement. There appears to be an advantage with a team approach and laparoscopic placement of the peritoneal portion of the shunt.

Impact of prior abdominal surgery on short-term outcomes following laparoscopic colorectal cancer surgery: a propensity score-matched analysis.

Whether laparoscopic surgery after prior abdominal surgery (PAS) is safe and feasible for colorectal cancer (CRC) remains controversial. The present study aimed to evaluate the impact of PAS on short-term outcomes following laparoscopic CRC surgery. We performed retrospective analysis used propensity score-matched analysis to reduce the possibility of selection bias. Participants comprised 1284 consecutive patients who underwent elective laparoscopic CRC surgery between 2010 and 2020. Patients were divided into two groups according to PAS. Patients with PAS were then matched to patients without these conditions. Short-term outcomes were evaluated between groups in the overall cohort and matched cohort, and risk factors for conversion to laparotomy and severe postoperative complications were analyzed. After propensity score matching, we enrolled 762 patients (n = 381 in each group). Before matching, significant group-dependent differences were observed in sex, age, primary tumor site, pathological (p) T stage, and type of procedure. No significant difference was found between groups in terms of rate of conversion to laparotomy, estimated blood loss, rate of extended resection, length of postoperative stay, and postoperative complications. After matching, estimated operative time was significantly longer in the PAS group (p = 0.01). Significant differences were found between groups in terms of reason for conversion to laparotomy. Multivariate analyses identified significant risk factors for conversion to laparotomy as pT stage ≥ 3 (odds ratio [OR] 2.36; 95% confidence interval [CI] 1.05-5.26) and body mass index ≥ 25kg/m2 (OR 3.56; 95% CI 1.07-11.7). Multivariate analyses identified rectum in the primary tumor site as the only significant risk factor for severe postoperative complications (OR 2.37; 95% CI 1.08-5.20). Laparoscopic CRC surgery after PAS showed acceptable short-term outcomes compared to Non-PAS. The laparoscopic approach appears safe and feasible for CRC regardless of whether the patient has a history of PAS.

The Impact of Prior Abdominal Surgery on Complications of Abdominally Based Autologous Breast Reconstruction: A Systematic Review and Meta-Analysis.

Approximately half of all patients presenting for autologous breast reconstruction have abdominal scars from prior surgery, the presence of which is considered by some a relative contraindication for abdominally based reconstruction. This meta-analysis examines the impact of prior abdominal surgery on the complication profile of breast reconstruction with abdominally based free tissue transfer. Literature search was conducted using PubMed, Scopus, and Web of Science. Included studies examined patients with a history of prior abdominal surgery who then underwent abdominally based free flap breast reconstruction. Prior liposuction patients and those with atypical flap designs were excluded. The Newcastle-Ottawa Scale was used to assess study quality. Flap complications included total and partial flap loss, fat necrosis, infection, and reoperation. Donor-site complications included delayed wound healing, infection, seroma, hematoma, and abdominal wall morbidity (hernia, bulge, laxity). Relative risk and 95% confidence intervals (CIs) between groups were calculated. Forest plots, I 2 statistic heterogeneity assessments, and publication bias funnel plots were produced. Publication bias was corrected with a trim-and-fill protocol. Overall effects were assessed by fixed-effects and random-effects models. After inclusion and exclusion criteria were applied, 16 articles were included for final review. These included 14 cohort and 2 case-control studies, with 1,656 (46.3%) patients and 2,236 (48.5%) flaps having undergone prior surgery. Meta-analysis showed patients with prior abdominal surgery were significantly more likely to experience donor-site delayed wound healing with a risk ratio of 1.27 (random 95% CI [1.00; 1.61]; I 2= 4) after adjustment for publication bias. No other complications were statistically different between groups. In patients with a history of prior abdominal surgery, abdominally based free tissue transfer is a safe and reliable option. Abdominal scars may slightly increase the risk of delayed donor-site wound healing, which can aid the surgeon in preoperative counseling.

Comparison of Differences in Patient Outcomes for Surgeries Performed By Fellowship-Trained Gynecologists Compared to Generalists

Study Objective To compare patient characteristics and surgical outcomes for surgeries performed by fellowship-trained gynecologic surgeons (MIGS) to OB/GYNs without additional training (Generalists). Design Literature review using PubMed/Medline. Setting Academic university and community hospitals. Patients or Participants Eight retrospective cohort studies including total of 8,888 patients undergoing minimally invasive surgery by MIGS and Generalists Interventions Compare patient BMI, uterine weight, and prior surgical history; evaluate difference in surgical complexity, operative times, blood loss, length of hospital stay, occurrence of complications, hospital costs. Measurements and Main Results Majority of studies included benign hysterectomies performed over an average of 3.75 years (range 1-9 years). Fellowship training included MIGS; only one study included gynecologic-oncologists and urogynecologists. Compared to Generalists, MIGS operated on patients with higher BMI (OR 2.030 for BMI 40+), greater uterine weight (649.9 g v. 320.7 g, p=0.01), and a history of prior abdominal surgeries (42.7% vs 17.2%; p=0.001). MIGS performed more difficult procedures related to resection of endometriosis (22.9% vs. 4.4%, p MIGS had significantly shorter operative times, lower blood loss during surgery, and decreased length of stay after surgery. Patient and hospital charges were lower for surgeries performed by MIGS (patient cost: $28,063 vs. $36,612, p Majority of the studies show a decrease or no difference in rate of total, postoperative or intraoperative complications with MIGS. Conclusion MIGS fellowship training is associated with improved perioperative outcomes, despite the increase in surgical complexity. This finding indicates that surgical volume is not the only determinant of outcomes. Unlike other surgical residencies, this higher level of technical ability is not consistently obtained in the current structure of OB-GYN residency, underlining the importance of additional training, which ultimately may be required for those who wish to practice gynecologic surgery in the future.

Factors Influencing Symptomatic and Nonsymptomatic Bulge Rates in the Abdominal Donor Site of Autologous Breast Reconstruction

INTRODUCTION: With continued demand for abdominal based breast reconstruction, it is important to understand all the factors influencing donor site morbidity. Previous studies mostly focus on type of flap and its associated donor site complications. However, we aim to assess other factors, including history of prior abdominal surgery, body mass index (BMI), and specific operative details such as the total area of muscle harvested, portion of the rectus muscle harvested, status of the anterior fascia after abdominal closure, use of mesh, and the status of abdominal wall nerves. METHODS: A retrospective chart review of patients undergoing autologous breast reconstruction from May 2012 to October of 2017 by 2 surgeons at a single institution was performed. Only patients with abdominal-based breast reconstruction were included in the study. Demographics, prior medical and surgical history, intraoperative data, and postoperative course were collected. Primary outcomes of interest were nonsymptomatic bulge found on physical exam and symptomatic bulge requiring surgical correction. RESULTS: One-hundred twenty women were identified with 39 undergoing unilateral and 81 undergoing bilateral breast reconstruction. Within the unilateral patient group, 30 patients underwent ms-Transversal Rectus Abdominis Muscle (TRAM) and 9 patients underwent deep inferior epigastric artery perforator (DIEP) reconstruction. The breakdown in the bilateral group is as follows: 39 bilateral ms-TRAM, 5 bilateral DIEP, 37 a combination of ms-TRAM and DIEP. The average follow-up was 2.01 years (range, 0.04–7.52 years). Thirteen (10.8%) patients developed nonsymptomatic bulge and 14 (11.7%) patients developed symptomatic bulge requiring surgical correction. Patient with BMI ≥ 30 were 3 times more likely to develop a symptomatic bulge (P = 0.029). Similarly, patients with prior abdominal surgery were 7.2 times more likely to develop a symptomatic bulge (P = 0.047). Patients with bilateral ms-TRAM reconstruction had higher rate of nonsymptomatic and symptomatic bulge compared with any other reconstruction type (P = 0.050). Size of muscle harvested did not have an effect on bulge development (P = 0.674). Higher percentage of patients with muscle harvested from the central portion of the rectus muscle developed non-symptomatic bulge (P = 0.008). In contrast, patients with muscle harvested from the medial or lateral portion of the rectus muscle had a 15% increased risk of developing symptomatic bulge (P = 0.023 and P = 0.021, respectively). The use of mesh, type of mesh, and location of mesh placement during abdominal wall reconstruction did not affect bulge development (P = 0.236, P = 0.285, P = 0.195, respectively). Whether the anterior rectus fascia was closed or left open at the end of the case did not influence the bulge rate (P = 0.122). Similarly, number of nerves severed did not influence the bulge rate (P = 0.575). CONCLUSION: High BMI and previous abdominal surgery significantly increase the risk of symptomatic bulge development. Location of muscle harvest from the rectus muscle influenced the rates of nonsymptomatic and symptomatic bulge development, with muscle from the central portion of the rectus muscle resulting in significantly higher rate of nonsymptomatic bulge, and muscle from medial or lateral portion of the rectus muscle resulting in higher rate of symptomatic bulge. Total muscle area harvested, use of mesh in abdominal reconstruction, or nerve preservation did not affect the rate of bulge development.

258. Exploring perioperative complications of anterior lumber interbody fusion in patients with a history of prior abdominal surgery: a retrospective cohort study

258. Exploring perioperative complications of anterior lumber interbody fusion in patients with a history of prior abdominal surgery: a retrospective cohort study

PD43-03 PERIOPERATIVE OUTCOMES BETWEEN SINGLE-PORT AND MULTI-PORT ROBOTIC ASSISTED RADICAL PROSTATECTOMY: A SINGLE INSTITUTIONAL EXPERIENCE

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy II (PD43)1 Apr 2020PD43-03 PERIOPERATIVE OUTCOMES BETWEEN SINGLE-PORT AND MULTI-PORT ROBOTIC ASSISTED RADICAL PROSTATECTOMY: A SINGLE INSTITUTIONAL EXPERIENCE Ava Saidian*, Andrew Fang, Ornin Hakim, Cristina Magi-Galluzzi, Jeffrey Nix, and Soroush Rais-Bahrami Ava Saidian*Ava Saidian* More articles by this author , Andrew FangAndrew Fang More articles by this author , Ornin HakimOrnin Hakim More articles by this author , Cristina Magi-GalluzziCristina Magi-Galluzzi More articles by this author , Jeffrey NixJeffrey Nix More articles by this author , and Soroush Rais-BahramiSoroush Rais-Bahrami More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000930.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Surgical approaches to the radical prostatectomy have evolved over the past few decades due to advances in minimally invasive surgery, with the most common approach involving multi-port (MP) robotic systems including the da Vinci® SI and XI (Intuitive Surgical, Sunnyvale, Ca, USA) robotic platforms. The recent FDA approval of the first single-port (SP) robotic system, the da Vinci® SP robotic platform, has led to a few small cohort studies supporting its safety and feasibility for RP in patients with prostate cancer. However, there is no data on its perioperative outcomes compared to the standard MP robotic approach. METHODS: All patients who underwent radical prostatectomy by two high-volume robotic prostate surgeons at our institution between October 2018 and June 2019 were retrospectively reviewed. All patient’s preoperative demographic data, operative reports, anesthesia reports, and perioperative outcomes were collected and analyzed using t-test, chi-square, and Fischer exact statistical measures. RESULTS: A total of 95 patients who underwent RP at our institution were included in our study with 47 patients using the SP approach and 48 with the MP approach. Demographic and clinical parameters including age, body mass index (BMI), history of prior abdominal surgery, and biopsy grade group were similar between the two groups. No significant differences in estimated blood loss (169.2±114.2 versus 157.7±125.4 ml, p=0.64), operative time (255.9±44.1 versus 274.7±50.4 ml, p=0.06), length of hospitalization (1.1±0.5 versus 1.4±1.1 days, p=0.17), and rate of perioperative inpatient Clavien-Dindo complications ≥2 (4.3% versus 6.3 % p=0.66) were noted between the SP and MP approaches, respectively. Furthermore, no significant difference was noted in pathologic positive margin rates between the SP and MP approaches (21.3% and 27.1%, p=0.51). CONCLUSIONS: The da Vinci SP robotic system is not only a safe and feasible approach to RP but has comparable operative and perioperative outcomes to the standard MP robotic approach. However, further research with longer follow-up and larger population data is needed to establish noninferiority between the two robotic approaches. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e900-e901 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ava Saidian* More articles by this author Andrew Fang More articles by this author Ornin Hakim More articles by this author Cristina Magi-Galluzzi More articles by this author Jeffrey Nix More articles by this author Soroush Rais-Bahrami More articles by this author Expand All Advertisement PDF downloadLoading ...

MP68-19 THE MAP SCORE CAN HELP PREDICT LONGER OPERATIVE TIME IN OPEN PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy VI (MP68)1 Apr 2020MP68-19 THE MAP SCORE CAN HELP PREDICT LONGER OPERATIVE TIME IN OPEN PARTIAL NEPHRECTOMY Katherine Cockerill*, Amanda Kahn, Daniella Haehn, Colleen Ball, and David Thiel Katherine Cockerill*Katherine Cockerill* More articles by this author , Amanda KahnAmanda Kahn More articles by this author , Daniella HaehnDaniella Haehn More articles by this author , Colleen BallColleen Ball More articles by this author , and David ThielDavid Thiel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000948.019AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The Mayo Adhesive Probability (MAP) score incorporates measures of perinephric fat and fat stranding in the prediction of adherent perinephric fat (APF) at the time of renal surgery. The purpose of our study is to evaluate the association between MAP score and total operative time (OT) in patients undergoing open partial nephrectomy (OPN). We also examined the association of other preoperative variables with OT. METHODS: We performed a 10 year retrospective review of 102 patients who underwent open partial nephrectomies performed for T1 tumor by a single fellowship trained surgeon at our institution. A linear regression analysis was used to examine the association of MAP score with OT in patients undergoing OPN. We also examined the association of sex, age, BMI, patient comorbidities, history of prior abdominal surgery, renal mass size, and R.E.N.A.L. score. RESULTS: A total of 102 patients underwent open partial nephrectomy at a single institution from 2008-2019 for a renal mass less than 7cm. Mean patient age was 66 years (range 57-71) and mean BMI was 30.5 kg/m2 (IQR 26.1, 33.1). Ten patients (9.8%) had partial nephrectomy performed on a solitary kidney. Median tumor size was 4.0 cm (IQR 3,6). Mean total operative time was 176 minutes (SD 62). A majority of the renal tumors were located posterior (71.7%). The location of the tumor varied between upper pole (32.4%), mid pole (14.7%), lower pole (29.4%), and hilar (27.5%) in location. Ipsilateral renal MAP score was 4-5 in 39.2% of the patients and 0-3 in 60.8%. In single variable analysis, a 1 unit increase in MAP score was associated with an 8 minute increase in OT (95% CI 2-14 minutes, p=0.01). In additional single variable analysis, only male sex (+34.8 min, p<0.001) and MAP score of 4 vs. 2 (+16 min, p=0.01) were associated with longer operative times in patients undergoing OPN. CONCLUSIONS: Higher MAP score and male sex appear to be associated with longer operative time in patients undergoing OPN for T1 renal tumors. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1042-e1043 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Katherine Cockerill* More articles by this author Amanda Kahn More articles by this author Daniella Haehn More articles by this author Colleen Ball More articles by this author David Thiel More articles by this author Expand All Advertisement PDF downloadLoading ...

Exploring perioperative complications of anterior lumber interbody fusion in patients with a history of prior abdominal surgery: A retrospective cohort study

BACKGROUND CONTEXTAnterior lumbar interbody fusion (ALIF) exposes the anterior aspect of the spine through a retroperitoneal approach. Access to the anterior spine requires mobilization of intra-abdominal viscera/vasculature, which can become complicated as scarring and/or adhesions develop from prior abdominal surgical interventions, increasing risk of intraoperative complications. The literature suggests that “significant prior abdominal surgery” is a relative contraindication of ALIF surgery; however, there is no consensus within the literature as to what defines “major/significant” abdominal surgeries. Additionally, the association between the number of prior abdominal surgeries and perioperative complications in ALIF surgery has not been explored within the literature. PURPOSEThis study seeks to explore the association between perioperative complications of ALIF surgery and the type (major and/or minor) and number of prior abdominal surgeries. DESIGNA retrospective cohort study was performed to examine perioperative complications in ALIF patients with or without prior history of abdominal surgery. PATIENT SAMPLEAll consecutive patients undergoing ALIF with or without a history of prior abdominal surgery from 2008 to 2018 at a single tertiary center were evaluated. Patients under the age of 18, patients with spinal malignancy, or patients who had ALIF above L3 were excluded. OUTCOME MEASURESPerioperative complications included intraoperative complications during ALIF surgery and postoperative complications within 90 days of ALIF surgery. Intraoperative complications include vascular injury, ureter injury, retroperitoneal hematoma, etc. Postoperative complications include urinary tract infection, revision of abdominal scar, ileus, deep vein thrombosis, pulmonary embolism, etc. Other outcome measures include readmission within 90 days, length of ALIF surgery, and length of hospital stay. METHODSElectronic medical records of 660 patients who underwent ALIF between 2008 and 2018 were retrospectively reviewed. Patient demographics, Charleston Comorbidity Index (CCI), level of fusion, past abdominal surgical history, use of access surgeon during exposure, intraoperative, and postoperative complications were collected. Predictors of intraoperative and postoperative complications were analyzed using simple and multivariable logistic regression. Statistical analysis was performed using JMP 14.0 (SAS, Cary, NC, USA) software. RESULTSAfter controlling for age, length of ALIF, gender, multilevel ALIF, and the use of an access surgeon, there was no significant association between the type of prior abdominal surgery (major and/or minor) and intraoperative complications on multivariable logistic regression analysis (Minor: odds ratio [OR]=1.68; 95% confidence interval [CI]: 0.58–4.86 & Major: OR=1.99; 95% CI: 0.80–4.91). On multivariable logistic regression, the odds of developing an intraoperative complication increases by 52% for each additional prior abdominal surgery after adjusting for age, length of ALIF, gender, multilevel ALIF, and the use of an access surgeon (OR=1.52, 95% CI: 1.10–2.11). Iliac vein laceration was the most common intraoperative complication (n=27, 4%). Neither the type (major and/or minor) nor the number of prior abdominal surgeries were significant predictors of postoperative complications (Minor: OR=1.29; 95% CI: .72–2.31, Major: OR=1.24; 95% CI: 0.77–2.00, & Number: OR=1.03; 95% CI: .84–1.26). CONCLUSIONWith each additional prior abdominal surgery, accumulation of scarring and adhesions can likely obscure anatomical landmarks and increase the risk of developing an intraoperative complication. Therefore, the number of prior abdominal surgeries should be taken into consideration during planning and operative exposure of the anterior spine via a retroperitoneal approach.

Role of CTA in Women with Abdominal Scars Undergoing DIEP Breast Reconstruction: Review of 1,187 Flaps

This study examines the effect of prior abdominal surgery on flap, donor-site, and overall complications in women undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction and assesses whether preoperative computed tomography angiography (CTA) affects outcomes. All DIEP flaps performed at our institution between 2004 and 2015 were identified retrospectively. Patients were stratified based on a history of prior abdominal surgery and whether or not they underwent a preoperative CTA. A subgroup analysis was performed to compare operative times and incidence of complications using adjusted odds ratios (ORs). Over a 12-year period, 425 patients (640 flaps) had prior abdominal surgery, and 393 patients (547 flaps) had no prior abdominal surgery. Of the patients with previous abdominal surgery, 67 (15.7%) underwent preoperative CTA and 333 (78.4%) did not. Patients with prior abdominal surgery were more likely to have donor-site wound complications (OR: 1.82, 95% confidence interval [CI]: 1.15-2.87, p = 0.01), fat necrosis ≥2cm of the transferred flap (OR: 1.39, 95% CI: 1.0-1.94, p = 0.05), and were more likely to have bilateral DIEP flap reconstruction (OR: 1.61, 95% CI: 1.22-2.12, p < 0.001). Preoperative CTA did not reduce the risk of complications and did not affect operative times. DIEP flap reconstruction can be safely performed in women with prior abdominal surgery. However, these patients should be counseled that they are at an increased risk for donor-site wound breakdown and fat necrosis of the reconstructed breast. Preoperative CTA does not reduce complication rate, overall operative time, or time needed to dissect perforators in women with abdominal scars.

Persistent Descending Mesocolon as a Key Risk Factor in Laparoscopic Colorectal Cancer Surgery.

Persistent descending mesocolon (PDM) is a rare colonic anatomical variant. However, PDM's impact on the technical aspects and outcomes of laparoscopic colorectal cancer resection are unclear. This retrospective clinical cohort study was conducted at a high-volume cancer center in Japan to evaluate intra- and postoperative outcomes of laparoscopic colorectal cancer surgery in patients with (PDM+) or without (PDM-) PDM over the past 7 years. Between January 2012 and September 2019, 2,775 patients underwent laparoscopic colorectal cancer resection at our center, including 60 (2.1%) cases of PDM. Preoperative detection was achieved in only 5 patients (8.3%), 39 patients were men, and 21 patients were women. The average age was 67 years. Twenty patients had a history of prior abdominal surgery (33.3%), with little or no subsequent adhesions. The average duration of sigmoidectomy in PDM+ patients (n=17; 217.7±14.2 min) was significantly longer than that in PDM- patients (n=547; 176.2±2.4 min; p=0.003), as was average blood loss (32.3±10.6 ml vs. 16.7±2.8 ml; p=0.03). Likewise, average operative time for high anterior resection in PDM+ patients (n=11; 227.1±20.2 min) was significantly longer than that in PDM- patients (n=294; 195.6±3.0 min; p=0.048). Rates of postoperative anastomotic leakage and postoperative recurrence did not differ in both groups. In PDM+ patients, retention of left colic artery had no impact on proximal specimen margins or occurrences of anastomotic leakage. PDM prolongs operative times and increases bleeding in laparoscopic colorectal cancer surgery and should be considered a risk factor when encountered.

Safety and feasibility of laparoscopic liver resection in patients with a history of abdominal surgeries

BackgroundLaparoscopic techniques have become the standard approach for most liver resections. Clinical studies providing conclusive evidence which patients benefit most from minimal-invasive surgery remain limited. MethodsWe retrospectively analyzed data of all consecutive cases of laparoscopic liver resection between 2015 and 2018 at our center. We compared patients with and without prior abdominal surgeries with respect to postoperative complications (Clavien-Dindo score), length of operation, length of ICU stay and length of hospitalization in univariate and multivariate analyses. ResultsWithin the study period 319 patients underwent laparoscopic liver resections, 44% of which had a history of abdominal surgeries. Pre-operative characteristics were similar to patients without prior surgeries. Both groups showed comparable rates of post-operative complications (Clavien-Dindo score ≥3a; 12% in patients without vs. 16% with prior surgeries, p = 0,322). There were no significant differences in length of surgery or length of stay in the ICU or in the hospital. ConclusionOur data suggest that history of prior abdominal surgery is not a risk factor for post-operative complications after laparoscopic liver resection. We conclude that prior abdominal surgery should not be considered a contra-indication for laparoscopic approach in liver resection.

2529 Increased Surgical Site Infections in Robotic Hysterectomies in a Large Health System

Study Objective To describe cases of surgical site infection (SSI) after hysterectomy in a large health system and investigate adherence to infection prevention guidelines Design Retrospective observational study Setting 6 hospitals in New York, both community and academic centers Patients or Participants Patients with surgical site infections as defined by CDC after hysterectomy in 2016 and 2017 Interventions n/a Measurements and Main Results Available data from 6 hospitals across a large health system in New York were analyzed. A total of 4589 inpatient open, robotic, and laparoscopic hysterectomies were performed in 2016 and 2017 of which 48 cases of surgical site infection were identified and reviewed. Overall SSI incidence was found to be 1.05%. Mean age of SSI cases was 53.5, and mean BMI 33.7. Among the SSI cases, 20 (41.7%) originated from a robotic approach, 1 (2.1%) straight laparoscopic, and 27 (56.2%) were open. This gave an SSI incidence of 1.98% for robotic, 0.13% for straight laparoscopic, and 0.97% for open approach. 41 (85.4%) SSI cases had total hysterectomies vs 7 (14.6%) supracervical. 34 (70.8%) of cases had a history of prior abdominal surgery. The most common infection type was intraabdominal at 19 cases (39.6%). Incisional infections accounted for 11 cases (22.9%), and vaginal cuff infection accounted for 4 (8.3%). The most common pathogens encountered were bacteroides fragilis (16.2%) and staphylococcus aureus (16.2%). Of 10 cases that used second-line antibiotics, 70% did not adhere to system protocol for dosing or antibiotic choice. Conclusion A review of cases reveals robotic hysterectomies as having the largest rate of SSI in the 6 hospitals examined at 1.98% as compared to laparoscopic hysterectomies with an SSI rate of 0.13% over 2 years. Further research is needed to validate these findings over time and geographic location, and examine reasons why robotic surgery may confirm a higher infection rate than laparoscopic in these locations.

Laparoscopic repair of hiatal hernia.

Laparoscopic hiatal hernia repair is a complex surgery typically performed by general abdominal surgeons because it typically involves an abdominal approach. Here, we report our experiences on laparoscopic repair of hiatal hernia as thoracic surgeons. Based on our experience of minimally invasive esophageal surgery (MIES) for esophageal cancer, we began performing laparoscopic repair of hiatal hernia in 2009. We analyzed the surgery-related data and postoperative outcomes of 18 consecutive patients we operated on from 2009 to 2017. There were 1 male and 17 female patients with a median age of 73 years (range, 37-81 years). Ten of 14 symptomatic patients experienced reflux symptoms, such as heartburn. Four patients had a history of prior abdominal surgery. Hiatal hernia types I, II, III, and IV were observed in 3, 9, 5, and 1 patients, respectively. Two (11.1%) laparoscopic procedures required conversion. Modified Collis gastroplasty was used as an esophageal lengthening procedure in 5 patients (27.8%). Mean operation time was 213.8±70.1 minutes and mean hospital stay was 6.2±1.5 days. There were no postoperative complications. At the last follow-up, 15 patients (83.3%) were asymptomatic; however, 3 (16.7%) complained of reflux or dysphagia. Recurrent hiatal hernia was detected on an esophagogram in only 1 patient at 3.5 years after laparoscopic surgery. Laparoscopic repair of hiatal hernia is a feasible technique with a satisfactory surgical outcome. Importantly, it can be performed by thoracic surgeons who are experienced in the laparoscopic approach.

Factors Associated with Symptomology of Celiac Artery Compression and Outcomes following Median Arcuate Ligament Release

This study aims to identify potential risk factors for becoming symptomatic in patients with radiographic celiac artery compression (CAC) as well as prognostic factors for patients with median arcuate ligament syndrome (MALS) who underwent surgical ligament release. This is a retrospective cohort study of patients with findings of CAC on computed tomography or magnetic resonance angiography (CT/MRA) who were asymptomatic and who were diagnosed with MALS at a single university hospital between January 2001 and2018. Following a review of 1,330 CT/MRA reports, a total of 109 patients were identified as having radiographically apparent CAC. Among these, 48 (44.0%) patients were symptomatic. Univariate comparison between those with and without symptoms showed that symptomatic patients were more commonly younger than 30years old [17/48 (35.4%) vs. 8/61 (13.1%), P=0.006], had a history of prior abdominal surgery [25/48 (52.1%) vs. 18/61 (29.5%), P=0.017], and had high-grade stenosis [32/43 (74.4%) vs. 25/61 (41.0%), P=0.001]. Among 41 included patients who underwent surgical release of the median arcuate ligament including open, laparoscopic, and robotic approaches, 82.9% reported overall clinical improvement, 5/41 (12.2%) reported persistent pain, and 13/36 (36.0%) experienced pain recurrence. The only identified risk factor associated with symptom recurrence was American Society of Anesthesiologists class III [7/13 (53.8%) vs. 4/23 (17.4%), P=0.029]. The severity of stenosis and prior abdominal surgery both contributed to symptom development in patients with radiographically apparent CAC from the median arcuate ligament.

Feasibility and Outcome of Laparoscopic Approach for Acute Generalized Peritonitis in Africa: Single Low-Center Results After 25 Consecutive Cases in Cameroon

surgery is associated with lower morbidity and mortality. However, the laparoscopic approach to the management of peritonitis remains marginalized in low and middle-income countries (LMICs) due to financial and technical limitations.Methods: We conducted a seven-year prospective study on patients with acute generalized peritonitis in Yaounde, Cameroon. Inclusion criteria were an age range of between 5 to 55 years, admission within 48 hours after the onset of symptoms, hemodynamic stability, and no major comorbidities. Excluded from this study were patients with colonic perforation, prior history of abdominal surgery, or primary and localized peritonitis after proper resuscitation. The patients included were managed via laparoscopy; operative and postoperative data were collected and analyzed. Some technical artifices were used to circumvent the lack of standardequipment. Results: The study involved twenty-five patients with a mean age of 32.1 years. The etiology of peritonitis was identified as appendicitis in 20 cases, perforated duodenal ulcer in 2 cases, gastric ulcer perforation in 2 cases, and jejunal perforation in 1 case. In two cases (8%), the operation was onverted to laparotomy. The postoperative course was uneventful in 21 cases (84%), whereas morbidity was seen in 4 cases (16%); no mortality was recorded. The mean length of hospital stay was 5.5 days.Conclusions: This study demonstrates that the laparoscopic management of acute generalized peritonitis in African LMICs is afeasible, safe, and effective surgical option in properly selected patients.

Incidence and risk factors of early postoperative small bowel obstruction in patients undergoing hysterectomy for benign indications

Small bowel obstruction (SBO) is a major cause of postoperative mortality and morbidity following abdominal and pelvic surgery, with 225,000-345,000 annual admissions. SBO may be classified based on onset from day of surgery. Early SBO occurs within the first 30 days following surgery, whereas late SBO occurs after the initial 30-day postoperative window. The majority of either type of bowel obstruction is believed to be secondary to intra-abdominal adhesions. Early SBO warrants special attention because of the difficulty in distinguishing between mechanical and nonmechanical obstruction during this period. Whereas conservative management often leads to resolution of nonmechanical obstruction and some partial SBO, surgical management is associated with a higher rate of complications compared to surgery for late SBO because of the presence of hypervascular adhesions in the early postoperative period. The current literature regarding SBO, and early SBO in particular, following hysterectomy is limited. Given that approximately 400,000 hysterectomies are performed annually, understanding the risk factors associated with SBO following these types of surgeries is imperative for improving patient outcomes. The objective of this study was to evaluate the incidence of and risk factors for early small bowel obstruction (SBO) after hysterectomy for benign indications. This was a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2014 to 2016. Current Procedural Terminology codes were used to identify patients undergoing hysterectomy for benign indications with or without concomitant colpopexy, lysis of adhesions (LOA), adnexectomy, or appendectomy. Data on patient demographics and clinical and surgical factors were obtained. Patients were then stratified into those with and those without SBO. Pairwise comparison was performed using the Wilcoxon rank-sum test and Fisher exact tests. Multivariable logistic regression was used to identify significant independent predictors of SBO. Of 47,937 hysterectomies, SBO occurred in 286 patients, at a rate of 5.9 per 1000 hysterectomies. Comparing patients with and without SBO, those with an obstruction were older (49 vs 46 years, P<.001) and were more likely to smoke (21.0% vs 15.8%, P= .02), to have a history of prior abdominal surgery (73.4% vs 65.4%, P= .005), and to have medical comorbidities such as hypertension and dyspnea. Patients experiencing SBO were also more likely to undergo abdominal hysterectomy (72.0% vs 21.2%, P < .001), adhesiolysis (5.2% vs 2.1%, P < .001), appendectomy (1.7% vs 0.5%, P= .02), and cystotomy repair (1.0% vs 0.3%, P= .002). After logistic regression, route of hysterectomy was not a significant risk factor for SBO, whereas wound class ≥3 (adjusted odds ratio [aOR], 5.96; 95% confidence interval [CI], 2.71-12.99) and perioperative transfusion (aOR, 5.01; 95% CI, 3.54-7.13) were the most significant risk factors. Additional risk factors for early SBO included nonwhite race (aOR, 1.84; 95% CI, 1.33-2.48), increasing age (aOR, 1.04; 95% CI, 1.02-1.05), prior abdominal or pelvic surgery (aOR, 1.49; 95% CI, 1.17-2.03), operating times >170 minutes (aOR, 1.90; 95% CI, 1.37-2.58), uterine weight >250 g (aOR, 1.54; 95% CI, 1.11-2.14), lysis of adhesions (aOR, 2.10; 95% CI, 1.23-3.66), and concurrent appendectomy (aOR, 2.64; 95% CI, 1.06-6.65). Early SBO is a rare complication of benign hysterectomy. Although route of hysterectomy was not found to be a significant risk factor for early SBO, variables typically associated with abdominal hysterectomy compared to minimally invasive hysterectomy, including higher wound class, larger uteri, and perioperative transfusion (a marker of intraoperative blood loss), were strongly correlated with subsequent development of early obstruction.

Recurrent abdominal wall endometriosis at the trocar site of laparoscopy: A rare case

Surgical scar endometriosis is typically presented as a slow-growing, painful abdominal mass near the site of a past surgery. Endometriosis on the trocar port site is rare. To best of our knowledge, only 17 cases have been reported in the literature. The nonspecific nature of endometriosis presents a diagnostic challenge, and it is often considered as an incisional hernia or other conditions. Here, we described our experience with a recurrent abdominal scar endometriosis case at the trocar port site of a previous laparoscopy, which was initially thought to be an incisional hernia. Abdominal wall endometriosis should be considered as an important differential diagnosis in females with a positive history of prior abdominal surgery, presented with painful nodule or mass at the site of the surgery.

Radiographic and Clinical Factors in Pediatric Patients With Surgical Small-bowel Intussusception

BackgroundWhen evaluating a pediatric patient with abdominal pain, identification of a small bowel–to–small bowel intussusception (SBI) on radiologic imaging can create a diagnostic dilemma. The clinical significance and need for surgical exploration of SBI is highly variable, as most of them are considered clinically insignificant. We hypothesize that combination of clinical and radiologic factors in an exclusively SBI population will yield factors that guide the clinician in making operative decisions. MethodsA comprehensive database from a pediatric tertiary hospital was reviewed from January 1, 2011, to December 31, 2016, for any radiographic study mentioning intussusception. Results were reviewed for patients having only SBI (i.e., not ileocolic intussusception), and this comprised the study cohort. The electronic medical records for these patients were reviewed for clinical presentation variables, need for operative intervention, and identification of the intussusception during surgery. Patients with SBI due to enteral feeding tubes were excluded from the study. ResultsWithin the study period, 139 patients were identified with an SBI on radiologic imaging. Univariate analysis yielded numerous clinical and radiologic factors highly predictive of the need for surgical intervention. However, upon multivariate analysis, only a history of prior abdominal surgery (odds ratio [OR]: 7.2; CI: 1.1-46.3), the presence of focal abdominal pain (OR: 22.1; CI: 4.2-116.3), and the intussusception length (cm; OR: 10.6; CI: 10.3-10.8) were correlated with the need for surgical intervention. ConclusionsSBI is a disease process with a highly variable clinical significance. The presence of focal abdominal pain, a history of prior abdominal surgery, and the intussusception length are the greatest predictors of the need for operative intervention. Level of evidenceLevel II.