Sharona B. Ross

Consensus statement of the consortium for laparoendoscopic single-site surgery

Inderbir S. Gill • Arnold P. Advincula • Monish Aron • Jeffrey Caddedu • David Canes • Paul G. Curcillo II • Mihir M. Desai • John C. Evanko • Tomasso Falcone • Victor Fazio • Matthew Gettman • Andrew A. Gumbs • Georges-Pascal Haber • Jihad H. Kaouk • Fernando Kim • Stephanie A. King • Jeffrey Ponsky • Feza Remzi • Homero Rivas • Alexander Rosemurgy • Sharona Ross • Philip Schauer • Rene Sotelo • Jose Speranza • John Sweeney • Julio Teixeira

Survival After Pancreaticoduodenectomy is not Improved by Extending Resections to Achieve Negative Margins

Objective:This study was undertaken to determine the survival benefit of extending resections to obtain microscopically negative margins after positive intraoperative frozen sections. Summary Background Data:The impact of residual microscopic disease after pancreaticoduodenectomy is currently a point of controversy. It is, however, generally believed that microscopically positive margins negatively impact survival and this may be improved by ultimately achieving negative margins. Methods:Since 1995, patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma have been prospectively followed. Margin status has been codified as macro/microscopically negative (R0) or macroscopically negative/microscopically positive (R1). The impact of margin status on survival was evaluated utilizing survival curve analysis. Data are presented as median, mean ± SD where appropriate. Results:For pancreatic adenocarcinoma, 202 patients underwent pancreaticoduodenectomy. R0 resections were achieved in 158 patients, 17 of whom required extended resections to achieve complete tumor extirpation after an initially positive intraoperative frozen section (R1 → R0). R1 resections were undertaken in 44 patients. Median survival for patients undergoing R0 resections was 21 months, 26 ± 23.4 months versus 13 months, 17 ± 21.0 months for patients undergoing R1 resections (P = 0.02). Median survival for patients undergoing R1 → R0 resections was 11 months, 16 ± 17.3, (P = 0.001). Margin status had a significant correlation with “N” stage and AJCC stage but not “T” stage. Conclusion:Survival after pancreaticoduodenectomy is not improved by extending pancreatic resections to achieve negative margins after initially positive intraoperative frozen sections. Tumor-specific factors beyond the presence of disease at a surgical margin are responsible for the abbreviated survival seen in patients undergoing R1 resections.

The Learning Curve of Laparoendoscopic Single-Site (LESS) Cholecystectomy: Definable, Short, and Safe

BACKGROUND The applications of laparoendoscopic single-site (LESS) surgery, including cholecystectomy, are occurring quickly, although little is generally known about issues associated with the learning curve of this new technique including operative time, conversion rates, and safety. STUDY DESIGN We prospectively followed all patients undergoing LESS cholecystectomy, and compared operations undertaken at our institutions in cohorts of 25 patients with respect to operative times, conversion rates, and complications. RESULTS One-hundred fifty patients of mean age 46 years underwent LESS cholecystectomy. No significant differences in operative times were demonstrable between any of the 25-patient cohorts operated on at our institution. A significant reduction in operative times (p < 0.001) after completion of 75 LESS procedures was, however, identified with the experience of a single surgeon. No significant reduction in the number of procedures requiring an additional trocar(s) or conversion to open operations was observed after completion of 25 LESS cholecystectomies. Complication rates were low, and not significantly different between any 25-patient cohorts. CONCLUSIONS For surgeons proficient with multi-incision laparoscopic cholecystectomy, the learning curve for LESS cholecystectomy begins near proficiency. Operative complications and conversions were infrequent and unchanged across successive 25-patient cohorts, and were similar to those reported for multi-incision laparoscopic cholecystectomy after the learning curve.

A single institution's experience with more than 500 laparoscopic Heller myotomies for achalasia.

BACKGROUND Long-term symptom relief and patient satisfaction after Heller myotomy are being reported. Herein, we report the largest experience of laparoscopic Heller myotomy for the treatment of achalasia. STUDY DESIGN Since 1992, 505 patients have been prospectively followed after laparoscopic Heller myotomy. Until 2004, concomitant fundoplication was undertaken for a patulous hiatus, a large hiatal hernia, or to buttress the repair of an esophagotomy, then concomitant fundoplication became routinely applied. More recently, laparo-endoscopic single site (LESS) Heller myotomy has been performed when possible to improve cosmesis. Before and after myotomy, patients scored their symptoms. RESULTS Before myotomy, 60% of patients underwent endoscopic therapy; of these patients, 27% had Botox (Allergan) therapy alone, 52% underwent dilation therapy alone, and 21% had both. Esophagotomy occurred in 7% of patients. Concomitant diverticulectomy was undertaken in 7%, fundoplication was performed in 59%, and LESS Heller myotomy was done in 12%. Median length of stay was 1 day. With mean follow-up at 31 months, the severity of all symptoms improved significantly. After myotomy, 95% experienced symptoms less than once per week, 86% believed their outcome is satisfying or better, and 92% would undergo myotomy again, if necessary. Symptoms after myotomy are similar with or without fundoplication and regardless of the laparoscopic approach used. CONCLUSIONS Laparoscopic Heller myotomy safely and durably relieves symptoms of dysphagia. Confinement is short and satisfaction is very high. Relief of esophageal obstruction is paramount; the approach used or the application of a fundoplication has a lesser impact. Laparoscopic Heller myotomy, preferably with anterior fundoplication using a single site laparoscopic approach, is strongly encouraged for patients with symptomatic achalasia and is efficacious even after failures of dilation and/or Botox therapy.

A Wireless Robot for Networked Laparoscopy

State-of-the-art laparoscopes for minimally invasive abdominal surgery are encumbered by cabling for power, video, and light sources. Although these laparoscopes provide good image quality, they interfere with surgical instruments, occupy a trocar port, require an assistant in the operating room to control the scope, have a very limited field of view, and are expensive. MARVEL is a wireless Miniature Anchored Robotic Videoscope for Expedited Laparoscopy that addresses these limitations by providing an inexpensive in vivo wireless camera module (CM) that eliminates the surgical-tool bottleneck experienced by surgeons in current laparoscopic endoscopic single-site (LESS) procedures. The MARVEL system includes1) multiple CMs that feature awirelessly controlled pan/tilt camera platform, which enable a full hemisphere field of view inside the abdominal cavity, wirelessly adjustable focus, and a multiwavelength illumination control system; 2) a master control module that provides a near-zero latency video wireless communications link, independent wireless control for multiple MARVEL CMs, digital zoom; and 3) a wireless human-machine interface that gives the surgeon full control over CM functionality. The research reported in this paper is the first step in developing a suite of semiautonomous wirelessly controlled and networked robotic cyberphysical devices to enable a paradigm shift in minimally invasive surgery and other domains such as wireless body area networks.

Prosthetic H-Graft Portacaval Shunts vs Transjugular Intrahepatic Portasystemic Stent Shunts: 18-Year Follow-Up of a Randomized Trial

BACKGROUND Widespread application of transjugular intrahepatic portasystemic shunt (TIPS) continues despite the lack of trials documenting efficacy superior to surgical shunting. Here we present an 18-year follow-up of a prospective randomized trial comparing TIPS with small-diameter prosthetic H-graft portacaval shunt (HGPCS) for portal decompression. STUDY DESIGN Beginning in 1993, patients were prospectively randomized to undergo either TIPS or HGPCS as definitive therapy for portal hypertension due to cirrhosis. Complications of shunting and long-term outcomes were noted. Failure of shunting was prospectively defined as the inability to place shunt, irreversible shunt occlusion, major variceal rehemorrhage, unanticipated liver transplantation, or death. Survival and shunt failure were compared using Kaplan-Meier curve analysis. Median data are reported. RESULTS Patient presentation, circumstances of shunting, causes of cirrhosis, severity of hepatic dysfunction (eg, Childs class, Model for End-Stage Liver Disease score), and predicted survival after shunting did not differ between patients undergoing TIPS (n = 66) or HGPCS (n = 66). Survival was significantly longer after HGPCS for patients of Childs class A (91 vs 19 months; p = 0.009) or class B (63 vs 21 months; p = 0.02). Shunt failure occurred later after HGPCS than TIPS (45 vs 22 months; p = 0.04). CONCLUSIONS Compared with TIPS, survival after HGPCS was superior for patients with better liver function (eg, Childs class A or B). Shunt failure after HGPCS occurred later than after TIPS. Rather than TIPS, application of HGPCS is preferred for patients with complicated cirrhosis and better hepatic function.

MARVEL: A wireless Miniature Anchored Robotic Videoscope for Expedited Laparoscopy

This paper describes the design and implementation of a Miniature Anchored Robotic Videoscope for Expedited Laparoscopy (MARVEL) and Camera Module (CM) that features wireless communications and control. The CM decreases the surgical-tool bottleneck experienced by surgeons in state-of-the art Laparoscopic Endoscopic Single-Site (LESS) procedures for minimally invasive abdominal surgery. The system includes: (1) a near-zero latency video wireless communications link, (2) a pan/tilt camera platform, actuated by two motors that provides surgeons a full hemisphere field of view inside the abdominal cavity, (3) a small wireless camera, (4) a wireless illumination control system, and (5) a wireless human-machine interface (HMI) to control the CM. An in-vivo experiment on a porcine subject was carried out to test the performance of the system. The robotic design is a Research Platform for a broad range of experiments in a range of domains for faculty and students in the Colleges of Engineering and Medicine and at Tampa General Hospital. This research is the first step in developing semi-autonomous wirelessly controlled and networked laparoscopic devices to enable a paradigm shift in minimally invasive surgery and other domains such as Wireless Body Area Networks.

Laparoendoscopic Single-Site Combined Cholecystectomy and Hysterectomy

Laparoendoscopic single-site (LESS) surgery has gained increased acceptance among surgeons in various specialties. The universal nature of port placement in the umbilicus during LESS surgery may enable concomitant procedures to be performed in these surgical specialties via this single incision. This case report presents a 37-year-old woman who underwent concomitant LESS cholecystectomy and hysterectomy to treat a symptomatic fibroid uterus and symptoms of cholelithiasis. The surgical procedure was performed in approximately 3 hours without any complications, and the patient was discharge to home 18 hours after the procedure. This case demonstrates that increasingly complex concomitant procedures can be performed using a LESS surgical approach.

SAGES TAVAC safety and effectiveness analysis: da Vinci ® Surgical System (Intuitive Surgical, Sunnyvale, CA).

AbstractBackgroundThe da Vinci® Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is a computer-assisted (robotic) surgical system designed to enable and enhance minimally invasive surgery. The Food and Drug Administration (FDA) has cleared computer-assisted surgical systems for use by trained physicians in an operating room environment for laparoscopic surgical procedures in general, cardiac, colorectal, gynecologic, head and neck, thoracic and urologic surgical procedures. There are substantial numbers of peer-reviewed papers regarding the da Vinci® Surgical System, and a thoughtful assessment of evidence framed by clinical opinion is warranted.Methods The SAGES da Vinci® TAVAC sub-committee performed a literature review of the da Vinci® Surgical System regarding gastrointestinal surgery. Conclusions by the sub-committee were vetted by the SAGES TAVAC Committee and SAGES Executive Board. Following revisions, the document was evaluated by the TAVAC Committee and Executive Board again for final approval.ResultsSeveral conclusions were drawn based on expert opinion organized by safety, efficacy, and cost for robotic foregut, bariatric, hepatobiliary/pancreatic, colorectal surgery, and single-incision cholecystectomy.ConclusionsGastrointestinal surgery with the da Vinci® Surgical System is safe and comparable, but not superior to standard laparoscopic approaches. Although clinically acceptable, its use may be costly for select gastrointestinal procedures. Current data are limited to the da Vinci® Surgical System; further analyses are needed.

Surgery residency training programmes have greater impact on outcomes after pancreaticoduodenectomy than hospital volume or surgeon frequency

BACKGROUND Hospital volume of pancreaticoduodenectomy (PD) and surgeon frequency of PD have been shown to impact outcomes. The impact of surgery residency training programmes after PD is unknown. This study was undertaken to determine the impact of surgery training programmes on outcomes after PD, as well as their importance relative to hospital volume and surgeon frequency of PD. METHODS The State of Florida Agency for Healthcare Administration Database was queried for patients undergoing PD during 2002-2007. Measures of outcome were compared for patients undergoing PD at centres with vs. without surgery residency training programmes. RESULTS A total of 2345 PDs were identified, of which 1478 (63%) were undertaken at training centres and 867 (37%) were performed at non-training centres. Patients undergoing PD at training centres had shorter lengths of stay, lower hospital charges and lower in-hospital mortality. Relative to surgeon frequency of PD, training centres had a greater favourable impact on hospital length of stay, hospital charges and in-hospital mortality (P < 0.001 for each, ancova). Relative to hospital volume of PDs undertaken, training centres had a greater impact on hospital charges (P < 0.001, ancova). CONCLUSIONS Surgery residency training programmes have a favourable effect on outcomes following PD and their impact on outcome is greater than the impact of hospital volume or surgeon frequency of PD.