Enrique F. Elli

Indocyanine Green (ICG) Fluorescent Cholangiography During Robotic Cholecystectomy Results of 184 Consecutive Cases in a Single Institution

Background/Aim. Laparoscopic cholecystectomy is currently the gold standard treatment for gallstone disease. Bile duct injury is a rare and severe complication of this procedure, with a reported incidence of 0.4% to 0.8% and is mostly a result of misperception and misinterpretation of the biliary anatomy. Robotic cholecystectomy has proven to be a safe and feasible approach. One of the latest innovations in minimally invasive technology is fluorescent imaging using indocyanine green (ICG). The aim of this study is to evaluate the efficacy of ICG and the Da Vinci Fluorescence Imaging Vision System in real-time visualization of the biliary anatomy. Methods. A total of 184 robotic cholecystectomies with ICG fluorescence cholangiography were performed between July 2011 and February 2013. All patients received a dose of 2.5 mg of ICG 45 minutes prior to the beginning of the surgical procedure. The procedures were multiport or single port depending on the case. Results. No conversions to open or laparoscopic surgery occurred in this series. The overall postoperative complication rate was 3.2%. No biliary injuries occurred. ICG fluorescence allowed visualization of at least 1 biliary structure in 99% of cases. The cystic duct, the common bile duct, and the common hepatic duct were successfully visualized with ICG in 97.8%, 96.1%, and 94% of cases, respectively. Conclusions. ICG fluorescent cholangiography during robotic cholecystectomy is a safe and effective procedure that helps real-time visualization of the biliary tree anatomy.

Robotic-assisted thoracoscopic resection of esophageal leiomyoma

Esophageal leiomyoma represents 70–80% of all benign esophageal tumors but only approximately 0.5% of all esophageal neoplasms; optimal surgical treatment consists of local resection. We present the first reported robotic-assisted thoracoscopic resection of two patients with esophageal leiomyoma using the daVinci Surgical System. Operative technique and technical considerations are presented.

Robotic palliation for unresectable pancreatic cancer and distal cholangiocarcinoma

Optimizing quality of life is a major goal for patients with unresectable pancreatic cancer and distal cholangiocarcinoma. The aim of this study was to assess the value of robotic surgery for palliation in these patients.

Sleeve gastrectomy surgery in obese patients post-organ transplantation.

BACKGROUND Among organ transplant recipients, a common side effect of immunosuppressive therapy is the development of obesity, which affects a third of the patients within 3 years after transplantation. Bariatric surgery represents a possible surgical option for weight loss among posttransplant patients. OBJECTIVES The aim of this study was to examine percent excess weight loss (%EWL), and percent weight loss (%WL) and perioperative and postoperative complications in posttransplant obese patients after sleeve gastrectomy (SG) compared with nontransplant patients. We hypothesize that transplant patients who undergo SG will not significantly differ in their perioperative or postoperative complications or in their %EWL and %WL compared with nontransplant patients who undergo SG. The second aim was to evaluate the impact of SG on graft function and immunosuppressive therapy in transplant patients. SETTING University hospital. METHODS Among 500 consecutive patients who underwent SG from January 2008 to June 2014, 10 patients were organ transplant recipients. The following variables were compared between groups: patient demographic characteristics and co-morbidities, type of transplant surgery, date of transplant surgery, pretransplant body mass index (BMI), date of bariatric surgery, prebariatric surgery BMI, operative time, length of hospitalization, postoperative complications, and change in BMI, %EWL, and %WL. Data were also collected on renal, liver, and pancreas graft function parameters and changes in immunosuppressive medications. RESULTS Six patients had a kidney transplant, 2 patients had a liver transplant, and 2 had a pancreas transplant. No significant differences were observed in %EWL or %WL at 6 and 12 months follow-up between transplant and nontransplant patients. No transplant patients were lost to follow-up at 6 and 12 months. Among nontransplant patients, 36.7% and 35.7% were lost to follow-up at 6 and 12 months, respectively. No postoperative complications were registered in the transplant group. SG did not negatively affect the graft function. CONCLUSION Initials results found that there were no significant differences in %EWL or %WL at 6 and 12 months follow-up between transplant and nontransplant patients. There were also no perioperative and postoperative complications among transplant patients after SG.

The role of the dual console in robotic surgical training

SURGERY is a practical discipline, and proficiency comes through practice. Surgical education is evolving under the pressure of an increasing body of knowledge, working hour restrictions, and subspecialization. Modern surgeons are required to play multiple roles: A professional, a scholar, a health advocate, a manager, a collaborator and, above all, a teacher. One of the most important skills of an academic surgeon, however, is his/her ability to teach operative technique. The fast-paced and ever-changing nature of the surgical profession includes numerous challenges of surgical education and how best to teach technical operative skills. Surgery started as a discipline with no medical dignity, delegated to barbers. Today, it has grown into a field where technology finds one of its greatest expressions. As a result, there is now an enormous gap to be filled with strategies needed to teach the new technology. Education research has established that individuals learn through 4 different learning styles: Convergent (problem solving), accommodative (hands-on experience), assimilative (reflective observation, watching), and divergent (abstract conceptualization, thinking). In the era of open surgery, the techniques of traditional learning of

Mini-laparoscopic placement of a peritoneal dialysis catheter

Background: The laparoscopic placement of continuous ambulatory peritoneal dialysis (CAPD) catheters is now an accepted technique. We evaluated a new technique for CAPD catheter placement that requires only a single 2-mm port. Methods: A pilot study was conducted at an academic minimally invasive surgery center. Seven consecutive patients in whom a CAPD catheter was required underwent placement of a 2-mm Veress port and a laparoscope. A carbon dioxide pneumoperitoneum was induced up to 14 mmHg. Under direct visualization with a 2-mm scope, a CAPD catheter was advanced over the right lower quadrant toward the pelvis using a modified Seldinger technique. Results: Seven patients (four women and three men) with end-stage renal disease underwent mini-laparoscopic placement of a CAPD catheter. Mean patient age was 35.3 ± 11.3 years (range, 17–50). Mean operative time was 20.7 ± 5.0 min (range, 14–29). Patients were dialyzed in the immediate postoperative period. No leaks were identified, and there were no intraoperative or postoperative complications. Conclusion: A mini-laparoscopic technique using a single 2-mm port and a modified Seldinger technique is feasible, safe, and effective for peritoneal dialysis catheter placements.

Laparoscopic sleeve gastrectomy as first-line surgical treatment for morbid obesity among adolescents

BACKGROUND The increasing prevalence of obesity has necessitated the increasing use of bariatric surgery in the adolescent population. Outcomes following laparoscopic sleeve gastrectomy (LSG) among adolescents, however, have not been well-studied. We report outcomes following LSG as a first-line surgical therapy in patients under 21years of age. METHODS All patients who underwent LSG as a primary surgical option for morbid obesity were identified at the University of Illinois at Chicago between 2006 and 2014. Standard clinicopathologic and outcomes data were recorded. RESULTS We identified 18 patients (13 females, 5 males) who underwent LSG. Mean patient age was 17.8±1.7years. Mean BMI among all patients was 48.6±7.2kg/m2 and did not differ by gender (P=0.68). One patient (5.6%) experienced a 30-day perioperative complication (pulmonary embolism). Median LOS following LSG was 3days (IQR: 2, 3). 2 patients (11.1%) were readmitted within 30-days because of feeding intolerance that resolved without invasive intervention. At a median follow-up of 10.6 (range: 0-38) months, percent excess weight loss (%EWL) among all patients was 35.6%. Among patients with at least 2years follow-up (n=3), %EWL was 50.2%. CONCLUSIONS Laparoscopic sleeve gastrectomy in morbidly obese adolescents is a safe and feasible option. Short- and long-term weight loss appears to be successful following LSG. As such, LSG should be strongly considered as a primary surgical treatment option for all morbidly obese adolescents. LEVEL OF EVIDENCE Level IV.

Vitamin D, inflammation, and relations to insulin resistance in premenopausal women with morbid obesity

In this study, the associations between vitamin D, insulin sensitivity, and inflammation and their relationships with adipose tissue expression of vitamin D receptor (VDR) and inflammatory markers in women with morbid obesity were determined.

Bariatric Surgery Is Gaining Ground as Treatment of Obesity After Heart Transplantation: Report of Two Cases

Experience with bariatric surgery in patients after orthotopic heart transplantation (OHT) is still limited. We performed a retrospective review of patients who underwent bariatric surgery after OHT from January 1, 2010 to December 31, 2016. Two post-OHT patients with BMI of 37.5 and 36.2 kg/m² underwent laparoscopic robotic-assisted Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy, respectively. Quality of life substantially improved for both patients. Bariatric surgery is safe and feasible in OHT patients, despite numerous risk factors. Careful selection of patients is required with proper preoperative management and overall care. Due to the complexity of treatment and perioperative care in this specific population, these operations should be done in high-volume centers with multidisciplinary teams composed of bariatric, cardiac transplant surgeons and critical care physicians. Bariatric surgery can be highly effective for treatment of obesity after OHT.

Four-year experience with outpatient laparoscopic adjustable gastric banding

BACKGROUND Outpatient laparoscopic procedures have been performed in various fields of surgery, and laparoscopic gastric banding is no exception. We present our series of outpatient laparoscopic adjustable gastric banding procedures performed at 2 centers. METHODS A total of 348 patients were retrospectively analyzed. All patients met the National Institutes of Health criteria for bariatric surgery. Additionally, to be included in an outpatient surgery procedure, patients had to meet 4 other criteria: body mass index<55, American Society of Anesthesiologists class ≤ 3, no extensive abdominal surgical history (in the upper gastrointestinal tract), and no untreated sleep apnea. RESULTS There were 282 women and 66 men, with a mean age of 41.3 years. The mean preoperative weight and BMI were 266.7 pounds and 43.1 kg/m(2), respectively. The median operative time was 70 minutes, and the median blood loss was 5 mL. The median length of stay was .3 day (range .1-.4). Fifty-seven patients underwent additional associated procedures. During follow-up, 20 patients required a reoperation. Two patients required admission to the hospital. There was no perioperative or postoperative mortality. Before discharge, all patients underwent an upper gastrointestinal swallow. CONCLUSION Outpatient laparoscopic adjustable gastric banding is a well-tolerated, cost-effective bariatric procedure for patients who meet the inclusion criteria.