Article 1
Robotic Technology in Emergency General Surgery Cases in the Era of Minimally Invasive Surgery. Lunardi N, Abou-Zamzam A, Florecki KL, Chidambaram S, Shih I, Kent AJ, Joseph B, Byrne JP, Sakran JV. JAMA Surg. 2024 May 1;159(5):493-499.
Minimal invasive surgery (MIS) techniques have now become the prevalent modality of operations in almost every general surgery subspecialty. It appears that Emergency General Surgery (EGS), the last stalwart of maximally invasive surgery, is not immune to this trend either. Robotic Surgery (RS) has made inroads into EGS where Laparoscopic Surgery (LS) and Open Surgery (OS) reign supreme. In their study, Lunardi et al., performed a retrospective cohort study to evaluate temporal trends in the use of MIS approaches in common EGS procedures and compared outcomes between RS and LS. They used an administrative database that represents a diverse group of hospitals (nonprofit, nongovernmental, community, teaching, rural, and urban) accounting for approximately 25% of annual inpatient admissions in the United States.
Adult patients who underwent emergent or urgent cholecystectomy, colectomy, inguinal hernia repair, or ventral hernia repair between 2013 and 2021 were included in the analysis. The primary outcome was the temporal trend in use of each surgical approach. Secondary outcomes included conversion to OS during an MIS procedure and LOS.
They identified a total of 1,067,263 emergent or urgent operations (74.4% cholecystectomy, 8.4% colectomy, 6.2% inguinal hernia repair, and 11.0% ventral hernia). The use of RS increased for all procedures:
- Cholecystectomy from 2.5% to 8.8% with a 0.7% increase per year
- Colectomy from 1.4% to 8.8% with a 0.9% increase per year
- Inguinal hernia repair from 0.4% to 15.3% with a 1.9% increase per year
- Ventral hernia repair from 0.7% to 9.6% with a 1.1% increase per year
RS was associated with a significantly lower risk of conversion to OS compared with LS, regardless of the procedure: cholecystectomy, 1.7% vs 3.0%; colectomy, 11.2% vs 25.5%; inguinal hernia repair, 2.4% vs 10.7%; and ventral hernia repair, 3.5% vs 10.9%.
RS was associated with a decreased total LOS for both inguinal hernia repair and colectomy. Additionally, there was a significant decrease in postoperative LOS for RS colectomy, inguinal hernia repair, and ventral hernia repair compared with LS.
This is the first study to directly compare the outcomes between LS and RS propensity score– matched cohorts for a typical caseload found in the EGS setting. They found that the use of RS significantly increased for all four procedures by two-fold in the final three years of the study. They hypothesized that features such as deep magnification, stereoscopic vision, motion scaling, and better ergonomics, may facilitate the ability to perform these procedures optimizing outcomes. Furthermore, they state that hospitals have recognized this trend and are increasing investment in staff training and infrastructure to use RS at a higher level and faster pace in the acute care setting.
As for limitations, this was a retrospective cohort study and thus predisposed to selection bias and unmeasured confounding. Furthermore, administrative datasets are imperfect in that there may be unidentifiable coding errors and may not capture all relevant outcomes. The conversion to OS diagnosis codes accounts for RS or LS cases that were converted to open however, they were unable to identify RS cases that were converted to LS. Additionally, they did not compare procedure specific outcomes, including complications or mortality, nor did they compare costs which has classically been a barrier to rapid RS adoption.
Article 2
Patient outcomes and cost in robotic emergency general surgery. Grimsley EA, Janjua HM, Herron T, Read MD, Lorch S, Cha JY, Farach SM, Douglas GP, Kuo PC. J Robot Surg. 2023 Dec;17(6):2937-2944.
In this study, Grimsley et al., used a two-pronged approach to study outcomes and costs of Robotic Emergency General Surgery (REGS). The first portion of the study was a retrospective review of a Florida state specific database for adult patients undergoing emergency general surgery within 24 hours of admission from 2018 to 2020. They used data from 119 hospitals totaling 60,733 operations. The incidence of REGS and the four most common robotic procedures (cholecystectomy, appendectomy, inguinal and ventral hernia repair) were used to analyze patient outcomes. For hospital cost comparisons, their propensity matched patients 1:1 from robotic and laparoscopic emergency general surgery (LEGS) equivalents based on demographics, insurance, comorbidities, LOS, ICU admission, and in-hospital mortality. Cost outliers (<1st and > 99th percentile) were excluded from analysis. Top 10 and bottom 10 (by volume) hospitals for REGS were compared for number of annual EGS cases, admissions, discharges, hospital beds, emergency room visits, overall surgeries, average bed occupancy, operating margin, net income, and number of physicians and residents. For the second portion of the study, a telephone survey of the operating room charge-nurse or manager of the top 10 REGS hospitals (by volume) was performed to identify key qualities of successful REGS programs.
Over the study period, 6% of the total EGS operations were performed robotically with a significant year-over-year increase in robotic surgery, 66% more between 2018 to 2019 and 40% more from 2019 to 2020 or an additional 500 cases a year, each year.
After propensity matched adjustment, total cost for all four robotic procedures were significantly higher than their laparoscopic equivalents (all p< 0.01). This was due to higher surgical costs, as non-operative costs did not differ. On average, appendectomy was $2200 more, cholecystectomy was $1800 more, inguinal hernia was $2500, and ventral hernia was $4000 more. However, they did not find a significant difference in patient outcomes and complication rates.
For the survey portion, 100% of the top 10 REGS programs responded with 80% of them performing REGS with robotic-trained staff available 24/7. Most respondents identified the following as important: (1) all staff being trained with the robot, (2) having adequate infrastructure to support robot use at all times of day, and (3) surgeons who prefer and request to use the robot for their emergency general surgeries.
The increased adoption of robotic technology in EGS is undeniable but there must be intentional expansion with adequate support from hospital administration and appropriate patient selection to ensure favorable outcomes.
Article 3
Open Retromuscular Sugarbaker vs Keyhole Mesh Placement for Parastomal Hernia Repair: A Randomized Clinical Trial. Maskal SM, Ellis RC, Fafaj A, et al. JAMA Surg. Published online June 12, 2024.
Parastomal hernia is a challenging problem with reported hernia recurrence rates >45% due to the necessary defect created in the abdominal wall. In this single institution RCT, two specific open techniques to address parastomal hernia were compared in patients with permanent stomas from 2019-2022. The Sugarbaker technique, with a retromuscular mesh placement offsetting the stoma apertures in the anterior and posterior rectus sheaths, was compared to the keyhole technique, with the anterior and posterior sheath apertures aligned with the retromuscular mesh stoma aperture. Over the study period 150 patients with parastomal hernia were randomized to receive the Sugarbaker or keyhole procedure using medium-weight polypropylene mesh. The primary outcome was parastomal hernia recurrence at two years, with recurrence defined by a composite blinded review which included imaging interpretation, clinical exam and patient-reported bulging at the site. Authors hypothesized that the Sugarbaker technique would result in 20% absolute reduction in parastomal hernia recurrence compared to keyhole. The overall parastomal hernia recurrence rate at two years was 21% with no statistically significant difference in unadjusted or adjusted recurrence rates based on Sugarbaker or keyhole technique with >90% of patients receiving complete follow up. There were no significant differences in surgical site infection, reoperations, mesh-related complications or stoma necrosis between the two techniques. Mesh-related complications overall were low (4 in Sugarbaker, 1 in keyhole). Authors concluded that the retromuscular Sugarbaker approach may not be worth the increased technical difficulty over the keyhole for open parastomal hernia repair.
This study illustrates the importance of longer-term follow up for complex hernia patients. At one year, only 8% of the Sugarbaker patients vs. 21.3% of the keyhole patients had recurred. While this difference in recurrence was not statistically significant (P=0.04), it would be feasible to draw conclusions about the superiority of the retromuscular Sugarbaker technique looking at these numbers. Following the patients out to two years resulted in a substantial increase in Sugarbaker recurrence rates and a slight increase in keyhole (17% Sugarbaker, 24% keyhole). The authors do not comment on why the Sugarbaker patients seemed to recur chronologically later and that would be worth additional investigation as it does appear to be a potentially more durable repair in the shorter-term. The authors elaborate on adaptations to the Sugarbaker technique in the discussion, including the retromuscular placement of non-absorbable mesh as well as omission of transfascial mesh fixation which they postulate may have contributed to the low incidence of ostomy necrosis reported. A multi-site study with a diverse cohort of surgeons performing these repairs as described would provide interesting data to really put these two repairs to the test, both from a technical feasibility standpoint as well as providing a larger study sample for increased power. As it stands now with this data, the less technically challenging retromuscular keyhole with non-absorbable mesh appears to be the reasonable option for an open repair. A major limitation of this study of course is generalizability, as many surgeons may approach parastomal hernia with MIS techniques which were not evaluated in the study. Additional limitations include a lack of standardization of the stoma itself (e.g. ileostomy vs. colostomy, left in situ vs. re-sited) although this was controlled for in adjusted analysis, and the inclusion of a few patients undergoing primary ostomy creation (not parastomal repair) at the time of ventral hernia repair for unclear reasons which may have confounded the results.
