Vernissia Tam

A systematic review and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair

BACKGROUND Equipoise exists regarding whether mesh cruroplasty during laparoscopic large hiatal hernia repair improves symptomatic outcomes compared with suture repair. DATA SOURCE Systematic literature review (MEDLINE and EMBASE) identified 13 studies (1,194 patients; 521 suture and 673 mesh) comparing mesh versus suture cruroplasty during laparoscopic repair of large hiatal hernia. We abstracted data regarding symptom assessment, objective recurrence, and reoperation and performed meta-analysis. CONCLUSIONS The majority of studies reported significant symptom improvement. Data were insufficient to evaluate symptomatic versus asymptomatic recurrence. Time to evaluation was skewed toward longer follow-up after suture cruroplasty. Odds of recurrence (odds ratio .51, 95% confidence interval .30 to .87; overall P = .014) but not need for reoperation (odds ratio .42, 95% confidence interval .13 to 1.37; overall P = .149) were less after mesh cruroplasty. Quality of evidence supporting routine use of mesh cruroplasty is low. Mesh should be used at surgeon discretion until additional studies evaluating symptomatic outcomes, quality of life, and long-term recurrence are available.

Minimally Invasive Pancreas Surgery

Abstract The introduction of laparoscopy in the 1980s has revolutionized the field of complex abdominal surgery. Traditional operations for almost all pancreatic resections and reconstructions have been described and replicated through a laparoscopic approach. Minimally invasive pancreatic surgeries are now well integrated into routine pancreatic resections and reconstructions at high-volume centers, with equivalent rates of mortality compared with open procedures. With the advent of robotic assistance, patients benefit from less intraoperative blood loss, expedited functional recovery, and shorter hospital stays. Meanwhile, surgeons benefit from binocular three-dimensional vision, scaling, stabilization of tremor, reduced operator fatigue, and improved ergonomics from the console-surgeon interface. This chapter will focus on the robotic approach, summarizing the data on the safety, efficacy, and technique of robotic approaches to minimally invasive pancreas surgery for both benign and malignant indications, showcasing the diversity of the platform for complex pancreatic operations.

Proficiency-based training and credentialing can improve patient outcomes and decrease cost to a hospital system

BACKGROUND While proficiency-based robotic training has been shown to enhance skill acquisition, no studies have shown that training leads to improved outcomes or quality measures. METHODS Board-certified general surgeons participated in an optional proficiency-based robotic training curriculum and outcomes from robotic hernia cases were analyzed. Multivariable analysis was performed for operative times to adjust for patient and surgical variables. RESULTS Six out of 16 (38%) surgeons completed training and 210 robotic hernia cases were analyzed. Longer operative times were associated with bilateral repairs (observed-to-expected operative time ratio [OTR] = 1.41, p < 0.001) and incarceration (OTR = 1.24, p = 0.006), while female patients (OTR = 0.87, p = 0.001) and increasing chronologic case order (OTR = 0.94, p < 0.001) were associated with shorter operative times. Surgeons who completed robotic training achieved shorter OTRs than those who did not (p = 0.03). Comparing non-risk adjusted hospital costs, trainees had an average of

Mastery-Based Virtual Reality Robotic Simulation Curriculum: The First Step Toward Operative Robotic Proficiency

1207 in savings (20% reduction) per robotic hernia case. CONCLUSIONS A structured proficiency-based robotics training curriculum is an effective way to reduce operative times and costs.