Mario Masrur

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 sleeve gastrectomy after liver transplantation.

Background: Obesity following liver transplantation is a common medical problem that increases the morbidity and mortality of patients. Still, no standard of treatment for this type of obesity has been identified. While bariatric surgery has been reported as an option, no specific procedure has been defined. Objective: The authors present a robotic sleeve gastrectomy as a suggested treatment option for a patient with increased BMI following a liver transplant. Setting: The University of Illinois at Chicago. Methods: A 62-year-old woman with a history of liver transplantation followed by obesity, with a BMI of 53 kg/m², underwent a robotic sleeve gastrectomy after being enrolled in the bariatric surgery program. Results: The procedure was successfully completed robotically. The operation lasted 158 minutes with minimal blood loss. There were no complications. At 3 months follow up, the patient’s BMI had decreased to 48 kg/m². Immunosuppressive drugs serum levels were unchanged following surgery and she remained at the same immunosuppressive therapy. Conclusion: Robotic sleeve gastrectomy represents a safe alternative for the treatment of obesity in a transplanted patient. The procedure provides good results with no alterations in the immunosuppressive therapy. Longer follow-up and additional data gained from a larger series is needed in order to make more definitive conclusions.

Robotic Roux-en-Y Duodenojejunostomy for Superior Mesenteric Artery Syndrome: Operative Technique

BACKGROUND Superior mesenteric artery (SMA) syndrome, also known as Wilkies syndrome, is a rare condition characterized by vascular compression of the duodenum that leads to intestinal obstruction. While there have been a few recent case reports of laparoscopic duodenojejunostomy performed as an option for surgical treatment, the role of the da Vinci(®) robot in superior mesenteric syndrome has been underestimated. The authors report a robotic Roux-en-Y duodenojejunostomy for the treatment of SMA syndrome. MATERIALS AND METHODS A 39-year-old man with a history of Amyotrophic lateral sclerosis presented with an upper gastrointestinal obstruction with distended abdomen. A computed tomography scan showed a transition in the third portion of the duodenum where the SMA vessels crossed over, with a decompressed jejunum. He was identified as a candidate for a duodenojejunostomy. The da Vinci Surgical System was used to mobilize the colon and duodenum, and a Roux-en-Y duodenojejunostomy was performed with hand-sewn anastomosis. RESULTS There were no intraoperative complications. The blood loss was minimal and operative time was 120 minutes. The postoperative course was uneventful with resolution of intestinal obstruction. CONCLUSION Robotic Roux-en-Y duodenojejunostomy as a surgical option for treatment of SMA syndrome is safe, feasible, and a valid alternative to open surgery with the added benefits of a minimally invasive approach.

Effectiveness of gastric neurostimulation in patients with gastroparesis

Background: Patients with gastroparesis have significantly delayed gastric emptying because of impaired nerve function. Gastric neurostimulation from Enterra Therapy provides electrical pulses to the stomach tissue that promotes stimulation of stomach smooth muscle, thereby enhancing gastric emptying. This study evaluates the effectiveness of Enterra Therapy (Medtronic, Minneapolis, Minnesota) in reducing symptoms and improving the quality of life of patients with drug-refractory gastroparesis. Material and Methods: In this study 25 patients underwent minimally invasive, laparoscopic placement of the Enterra Therapy device. Patients were asked to rank their severity of symptoms and quality of life retrospectively by completing the Gastrointestinal Symptoms Rating Scale and Short Form 36 Health Survey with respect to their condition before and 6 months after initiation of Enterra Therapy. Results: Eighteen patients completed the surveys. Patients showed statistically significant improvement in their overall Gastrointestinal Symptoms Rating Scale scores and the mental health component of the Short Form 36 Health Survey. Discussion: Currently, Enterra Therapy has Humanitarian Use Device status, which means that more clinical evidence is needed to prove its effectiveness in gastroparesis. By showing that Enterra Therapy reduces symptoms of gastroparesis and improves patient quality of life, this study contributes to the increasing amount of data supporting its use and potential Food and Drug Administration approval.

Two-year follow-up of wound complications associated with laparoendoscopic single-site adjustable gastric banding

BACKGROUND In an effort to provide better cosmesis for patients, there has been a surge recently in the use of laparoendoscopic single-site adjustable gastric banding. Few data, however, are available on the long-term wound complications resulting from this technique. We conducted a retrospective review of patients to identify the extent of wound complications found during a minimum follow-up period of 2 years after laparoendoscopic single-site adjustable gastric banding. The complications evaluated included infection, hernia rates, and port and tubing complications. All the laparoendoscopic single-site adjustable gastric banding cases were performed at University of Illinois Medical Center by a single surgeon. METHODS Twenty-five patients underwent single-site laparoscopic adjustable gastric banding from March 2009 to January 2010, and the data were reviewed retrospectively. The single incision was made with multifascial trocar placement using conventional laparoscopic instruments. The patients were followed up during band adjustments and clinic visits and by telephone interview. RESULTS Six months after surgery, 1 patient required port removal because of port site infection with internalization of the tubing. A second patient experienced a foul-smelling, clear discharge and was treated with antibiotics, with no additional consequences. No incisional hernias or flipped ports were noted. CONCLUSION In our experience, laparoendoscopic single-site adjustable gastric banding produced a low rate of port and wound site complications in patients during a minimum follow-up period of 2 years. We believe this is a valid alternative to the standard procedure, providing cosmetic advantages and a low wound complication rate in morbidly obese patients.

Adjustable gastric banding: a comparison of models

BACKGROUND There are several models of adjustable gastric banding in use with little evidence for choosing a particular model. The objective of this study was to evaluate factors for selecting a particular type of band in terms of weight loss, complications, and co-morbidities. METHODS From July 2006 to May 2012, 222 patients underwent laparoscopic adjustable gastric banding (LAGB) by a single surgeon. Patient demographic characteristics, weight loss, body mass index (BMI), percentage of weight loss (%EWL), complications, and co-morbidities were retrospectively reviewed. Patients were grouped according to the band model into 6 categories: 27 LAP-BAND Adjustable Gastric Banding System VG, 25 Allergan-LAGB, 20 LAP-BAND AP(M) Standard, 18 LAP-BAND AP(M) Large, 34 Realize Band, and 98 Realize-C band. RESULTS At 60 months follow up, in the LAP-BAND VG Group, the mean %EWL was 41%, percentage of co-morbidity improvement was 66%, and percentage of complications was 14.3%; the same percentages in the Allergan-LAGB Group were 41%, 0%, and 52%, respectively; in the LAP-BAND AP Standard Group were 42%, 20%, and 40%, respectively; in the LAP-BAND AP Large group were 38% , 12.5%, and 27.8%, respectively (at 48 months); in the Realize Band Group were 37%, 60%, and 0%, respectively (at 48 months); and in the Realize-C Band Group were 48%,12.5%, and 12.2%, respectively (at 36 months). CONCLUSIONS In terms of weight loss and co-morbidities, no differences were found supporting the choice of one model over the others. Short-term and long-term band-related complications occurred without any clear predilection. The port-related complications were significantly lower in the Realize bands.

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.

Robot-Assisted Subtotal Pancreas-Preserving Duodenectomy

The use of robotic assistance to perform subtotal pancreas-preserving duodenectomy appears to be feasible and safe.

Conversion to laparoscopic sleeve gastrectomy after failure of laparoscopic gastric band: A systematic review of the literature and cost considerations

No universal consensus has been achieved as to whether the laparoscopic adjustable gastric band to laparoscopic sleeve gastrectomy conversion should be performed in one or two steps. To determine the differences in operative outcomes and cost, a systematic, comprehensive review of the literature was conducted using the PubMed database from the National Institutes of Health. Nine studies were included with 809 patients. Weighted averages were calculated to compare operative outcomes, and cost analyses were conducted with these averages. Results indicate a longer operative time for the one-step approach than the two-step approach, but studies included in the meta-analysis found no statistical difference between the two. The two-step approach was found to have a longer length of hospital stay, but this finding refuted included studies that indicate no significant difference. Complication rates were higher for the one-step approach than the two-step approach, and costs associated with complications average

Impact of Obesity on Robot-Assisted Distal Pancreatectomy

806 more for one-step patients than two-step patients. This suggests that the two-step approach could prove better for patient safety and cost outcomes, but both approaches are comparable in operating time and length of stay.