Douglas R. Ewing

The Learning Curve Measured by Operating Times for Laparoscopic and Open Gastric Bypass: Roles of Surgeon's Experience, Institutional Experience, Body Mass Index and Fellowship Training

Background: Surgeons must overcome a substantial learning curve before mastering laparoscopic Rouxen-Y gastric bypass (LRYGBP). This learning curve can be defined in terms of mortality, morbidity or length of surgery. The aim of this study was to compare the learning curves in terms of surgical time for the first 3 surgeons performing LRYGBP in our hospital with the length of surgery for open gastric bypass (CONTROLS). Methods: We compared 494 primary LRYGBPs performed by 3 surgeons (393 by 1st SURGEON, 57 by 2nd SURGEON and 44 by 3rd SURGEON) to 159 open vertical banded gastroplasty-Roux-en-Y gastric bypasses (CONTROLS). Data for LRYGBP patients were prospectively recorded while those for CONTROLS were retrospectively obtained. Factors that significantly affected the length of surgery were identified by univariate and multivariate linear regression analysis. Results: LRYGBP and CONTROL patients were similar in age, height, weight and BMI, although more CONTROLS were male. Median time for the 1st SURGEON performing LRYGBP dropped for each subsequent 100 operations: 1st 100 – 190 min, 2nd 100 – 135 min, 3rd 100 – 110 min and 4th 100 – 100 min. Median time for the 2nd SURGEON performing LRYGBP was 120 min, 3rd SURGEON 173 min and CONTROLS 64 min. Length of surgery significantly correlated with surgical experience in terms of number of operations and BMI of patient. Times for 2nd SURGEON, a fellowship trained laparoscopic surgeon, started significantly faster than 1st SURGEONs, but did not significantly improve with experience. 3rd SURGEONs initial times were similar to 1st SURGEONs, but his times improved more rapidly with experience. Times for CONTROLS were significantly faster than all laparoscopic groups and did not correlate with operation number or patient BMI. Conclusions: The length of surgery for LRYGBPs continued to shorten beyond 400 operations for the first surgeon performing LRYGBP in our hospital. Previous fellowship training in LRYGBP shortened surgical times during initial clinical experience as an attending for the second surgeon. The learning curve for a subsequent experienced laparoscopic surgeon was truncated because of the already established LRYGBP program.

Short-term outcomes for super-super obese (BMI ≥60 kg/m2) patients undergoing weight loss surgery at a high-volume bariatric surgery center: laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and open tubular gastric bypass

BACKGROUND We previously reported significantly longer operating room times and a trend toward increased complications and mortality in the super-super obese (body mass index [BMI] > or =60 kg/m(2)) early in our experience with laparoscopic Roux-en-Y gastric bypass. The goal of this study was to re-examine the short-term outcomes for super-super obese patients undergoing weight loss surgery at our high-volume bariatric surgery center well beyond our learning curve. METHODS The records for all patients who had undergone weight loss surgery at Hackensack University Medical Center from 2002 to June 2006 were harvested from the hospitals electronic medical database. This population was analyzed as 2 groups (those with a BMI <60 kg/m(2) and those with a BMI > or =60 kg/m(2)), as well as by type of operation. Step-wise and univariate logistic regression analyses assessed the effect of BMI on the outcome variables, including mortality, length of surgery, length of hospital stay, and disposition at discharge. RESULTS A total of 3692 patients were studied. Of these patients, 3401 had a BMI <60 kg/m(2) and 291 had a BMI > or =60 kg/m(2). Of the 291 super-super obese patients, 130 underwent vertical banded gastroplasty-Roux-en-Y gastric bypass, 116 laparoscopic Roux-en-Y gastric bypass, and 45 laparoscopic adjustable gastric banding. The proportion of male patients, black patients, and patients with sleep apnea was increased in the BMI > or =60 kg/m(2) group. The number of co-morbid diseases per patient correlated with age but not BMI. The BMI > or =60 kg/m(2) group required a significantly longer total operating room time (136 versus 120 min). Hospital length of stay was significantly longer only in the laparoscopic Roux-en-Y gastric bypass patients (3 d for the BMI > or =60 kg/m(2) group versus 2 d for the BMI <60 kg/m(2) group). A significantly greater percentage of patients in the super-super obese group were discharged to chronic care facilities. The overall in-hospital mortality rate was 0.15% (5 of 3692) but did not significantly differ between the 2 groups: BMI <60 kg/m(2), rate of 0.12% (4 of 3401 patients), and BMI > or =60 kg/m(2), rate of 0.34% (1 of 291 patients). The type of operation did not significantly affect the disposition at discharge or in-hospital mortality. CONCLUSION Super-super obese patients required longer total operating room times, a longer hospital length of stay, and were more likely to be discharged to chronic care facilities than were patients with a BMI <60 kg/m(2); however, the in-hospital mortality was similar for both groups.

Robots in the Operating Room—The History

The history of robotics can be traced back to the automata of ancient Greece, but it has only been within the last 50 years that machines have been made to mimic human actions in order to perform labor rather than to entertain and amuse. Furthermore, it has been only within the last 20 years that robotic technology has been applied to the practice of surgery. The goal of this technology has not been to replace the surgeon, but rather to enhance his or her performance with highly advanced tools. We present a brief history of some of the key points in the development of surgical robotics and discuss the advantages and disadvantages of the various US Food and Drug Administration-approved robotic surgical systems and surgical robots in general.

Telerobotic-assisted laparoscopic right hemicolectomy: lateral to medial or medial to lateral dissection?

Background We previously reported that telerobotic-assisted laparoscopic colectomy was feasible and could be accomplished safely. Nonetheless, we found that the current iteration of da Vinci was not well suited to a lateral to medial (LtM) dissection of the colonic mesentery. The motion scaling made the large excursion arcs required for adequate exposure in a LtM dissection cumbersome to achieve. Aim As a result, the aim of this study was to compare the ability of the da Vinci telerobotic surgical system to perform telerobotic-assisted laparoscopic right hemicolectomy using a LtM dissection with a medial to lateral (MtL) dissection technique. Methods We compared 8 consecutive da Vinci-assisted laparoscopic right hemicolectomies performed using a LtM dissection to 8 consecutive operations using a MtL dissection technique. Results were compared using analysis of variance. Results Age for the 2 groups were not significantly different: LtM 64 (43 to 71) years and MtL 56 (39 to 68) years. Body mass index was similar: LtM 27 (22 to 34) and MtL 25 (20 to 32) kg/m2. Total surgical time (including cystoscopy and intraoperative colonoscopy) were similar: LtM 212 (188 to 610) minutes and MtL 203 (135 to 220) minutes. There was no significant difference in lymph node harvest: LtM 12 (3 to 20) lymph nodes and MtL 18 (3 to 35) lymph nodes. There were no deaths or anastomotic leaks in either groups. Median length of stay was similar for both groups: LtM 5 (3 to 10) days and MtL 4 (2 to 9) days. Conclusions da Vinci-assisted laparoscopic right hemicolectomy using a MtL dissection technique achieves similar outcomes as a LtM dissection approach.

Large series examining laparoscopic adjustable gastric banding as a salvage solution for failed gastric bypass

BACKGROUND The Roux-en-Y gastric bypass (RYGB) has long been considered the gold standard of weight loss procedures. However, there is limited evidence on revisional options with both minimal risk and long-term weight loss results. OBJECTIVE To examine percent excess weight loss, change in body mass index (BMI), and complications in patients who underwent laparoscopic adjustable gastric banding (LAGB) over prior RYGB. SETTING Academic hospital. METHODS Retrospective analysis of a single-center prospectively maintained database. Three thousand ninety-four LAGB placements were reviewed; 139 were placed in patients with prior RYGB. RESULTS At the time of LAGB, the median BMI was 41.3. After LAGB, we observed weight loss or stabilization in 135 patients (97%). The median maximal weight loss after LAGB was 37.7% excess weight loss and -7.1 change in BMI (P < .0001). At last follow-up visit, the median weight loss was 27.5% excess weight loss and -5.3 change in BMI (P < .0001). Median follow-up was 2.48 years (.01-11.48): 68 of 132 eligible (52%) with 3-year follow-up, 12 of 26 eligible (44%) with 6-year eligible follow-up, and 3 of 3 eligible (100%) with >10-year follow-up. Eleven bands required removal, 4 for erosion, 4 for dysphagia, and 3 for nonband-related issues. CONCLUSIONS LAGB over prior RYGB is a safe operation, which reduces the surgical risks and nutritional deficiencies often seen in other accepted revisional operations. Complication rates were consistent with primary LAGB. Weight loss is both reliable and lasting, and it can be considered as the initial salvage procedure in patients with failed gastric bypass surgery.