Trocar site hernia (TSH) is a rare and typically morbid complication of minimally invasive surgery, with limited data regarding its incidence in contemporary robotic platforms. We report a case of early TSH following robotic-assisted laparoscopic Roux-en-Y gastric bypass (RYGB) with the novel da Vinci 5 system. A 48-year-old woman with obesity underwent RYGB utilizing an 8-mm hexagonal high-flow configuration (HHFC) trocar in the left abdomen. On post-operative day two, she developed emesis and epigastric pain. Cross-sectional imaging demonstrated small bowel dilation with a transition point at the left 8-mm trocar site, consistent with trocar site hernia causing small bowel obstruction. Urgent diagnostic laparoscopy confirmed herniation of small bowel through the fascial defect. Reduction and primary fascial closure were performed. The patient recovered appropriately. This case highlights the potential for clinically significant TSH at 8-mm HHFC trocar sites in high-risk settings and supports consideration of selective fascial closure in such patients.

e14596 Background: Local recurrence contributes to the poor prognosis for patients with Stage IV metastatic or recurrent solid tumors, despite advances in standard care. We report the clinical outcome of intra-operative Cold Atmospheric Plasma (CAP) combined with standard surgical procedures. Methods: The trial was a Phase I, multi-center, open-label, prospective, controlled study. Eligible patients undergoing surgery for advanced Stage IV metastatic or recurrent solid tumors were enrolled and preoperative treatments (neoadjuvant chemotherapy, immunotherapy, radiation, and primary surgery) were permitted. Participants were recruited from Rush University Medical Center in Chicago, Illinois and Sheba Medical Center in Tel HaShomer, Israel. Twenty patients (age 26-85 years) between March 2020 to April 2021 received intra-operative CAP treatment following surgical macroscopic tumor removal. The primary endpoint was safety, and the secondary endpoint was ablation of the local microscopic tumor bed without damaging the surrounding normal tissue. Results: Physiological data (blood pressure, pulse, body temperature, End Tidal CO 2 , and oxygen saturation) was recorded continuously throughout surgery. There were no significant changes (p > 0.05) during intra-operative CAP treatment. One adverse event grade 3 or higher was reported but no adverse events were related to CAP. As of February 13, 2023, 10 patients died of their disease between 3-32 months. Kaplan-Meier overall survival curves show the interim 31-month rate is 24% (95% confidence interval [CI], 5.0 – 100.0%). Median survival is 23 months. For R0 patients, the Kaplan Meier local non-recurrence probability showed that the interim 28-month rate is 75% (n=8; 95% CI, 50.3 – 100.0%) as of February 13, 2023. Histological staining, TUNEL assay, and confocal imaging of the surgical margins revealed cancer cell death and no damage to the surrounding normal tissue. Primary culture of the tumor confirmed total cessation of cancer cell survival. Conclusions: CAP treatment in combination with surgery for high-risk stage IV solid tumors is safe and induces cancer cell death at the surgical bed without damaging non-cancerous tissue. The survival rate in R0-resected CAP-treated patients was significantly improved compared to R1 and R2 patients and local non-recurrence rate for R0 patients was noteworthy. Clinical trial information: NCT04267575 . [Table: see text]

Mesenteric cysts are benign congenital cysts typically discovered incidentally during abdominal explorations for other reasons. When feasible, they should be excised to prevent recurrence, bowel obstruction or volvulus, and resulting complications. We present a unique case of an infant, diagnosed prenatally by ultrasound with possible bowel obstruction, found to have micro and macro chylous mesenteric cysts. Although initially asymptomatic with normal abdominal x-ray and discharged on day of life 2, the parents were taught how to recognize symptoms of bowel obstruction. He presented at 1 month with obstructive symptoms, was confirmed to have large mesenteric cystic structures on ultrasound, and was immediately taken to the operating room. Due to the extensive number of cysts and intimate involvement of the largest cyst with the superior mesenteric artery, he was treated with partial excision and observation since resection may have resulted in short gut syndrome. Given a prenatal ultrasound suggestive of mesenteric cysts, we recommend abdominal imaging at birth with close follow-up until the appropriate time for elective resection. When disease is extensive precluding full enucleation and resection, we advocate for enucleation in combination with unroofing of as many cysts as possible followed by postoperative surveillance ultrasounds and family counseling.

Chandra, Raghav BA; Jacobson, Richard A. MD; Millikan, Keith W. MD; Poirier, Jennifer PhD; Siparsky, Nicole MD Author Information

Myoepitheliomas are rare tumors that occur in the salivary glands. These lesions are extremely rare, and there are no specific guidelines for its treatment. Here, we report a case in which a myoepithelial carcinoma was found after a right groin lipoma excision. We discuss the surgical technique and the pathology. Myoepitheliomas are tumors of epithelial origin. While most of these are benign, myoepithelial carcinomas do exist and comprise 10 per cent of myoepitheliomas.1, 2 Myoepithelial carcinomas may occur with preexisting benign lesions such as pleomorphic adenomas.3 Most of these tumors occur in the salivary glands. Histologically, cells assume a myoepithelioid appearance with increased mitotic activity4 (Fig. 1). Most of these tumors are insidious in onset. The patient may only notice a painless mass, delaying the diagnosis by months to years. When these tumors occur in the oropharynx or nasopharynx symptoms such as nasal obstruction, ear fullness, and otitis media can occur.3, 4 Therefore, when these masses occur in areas such as the thigh, diagnostic imaging such as CT and MRI allow for anatomy and extension of the tumor to be better delineated. A 54-year-old female with a history of papillary thyroid cancer status after thyroidectomy and radioactive iodine was incidentally diagnosed with myoepithelial carcinoma of the right groin. At initial presentation, she reported noticing a new mass medial to a previous lipoma excision that occurred 7 years earlier. She underwent an excision of the mass, measuring 7.5 cm in diameter. Histopathologic review demonstrated myoepithelial carcinoma with positive microscopic margins. Review of outside-hospital slides showed malignant spindle and epithelioid cells consistent with myoepithelial carcinoma. Mitoses were less than 5 per high-powered field. Positron emission tomography-computed tomography scan performed at that time showed uptake in the surgical bed and did not show uptake at other sites. Given the positive microscopic margins along with increased uptake seen on positron emission tomography-computed tomography, wide local excision of the previous surgical site was pursued to obtain negative margins. A 6-cm elliptical incision was made starting over the pubic bone, extending toward the anterior superior iliac spine. The area of excision was carried down to fascia. The external oblique aponeurosis was removed, and the inguinal ligament was kept intact. Lymph nodes below the inguinal ligament down to the femoral vessels were removed as well. A Jackson–Pratt drain was placed in the cavity to prevent potential seroma formation. She recovered well postoperatively and was discharged home from hospital on day 2. The final pathology showed four lymph nodes negative for tumor or malignancy. The specimen did show a minute focus of residual malignant neoplasm (1 mm in size) with negative margins. The patient’s final stage was T2bN0. Patient proceeded to receive four weeks of radiation therapy to that area. Presently, the patient is doing well without any complications. She will obtain repeat CT imaging and MRI imaging to assess disease regression and to monitor for recurrence. Myoepithelial carcinomas (malignant myoepitheliomas) are soft tissue tumors that usually occur in the salivary gland. While most of them are benign, some are carcinomas. They are usually multinodular in appearance, with diverse cytologic and morphologic patterns including nests, cords, and sheets of epithelioid, clear, spindle, or plasmacytoid cells in hyalinized or chondromyxoid stroma. Tumors with benign morphology or mild low-grade atypia are classified as myoepitheliomas. Those that have severe atypia are classified as carcinomas or malignant mixed tumors.4 Hornick et al.4 studied 101 cases of myoepithelial tumors and showed that in 33 cases with low-grade cytology, 18 per cent recurred locally and none metastasized. Among Address correspondence and reprint requests to Jennifer D. Son, M.D., Department of Surgery, Rush University Medical Center, Chicago, IL 60612. E-mail: jennifer.d.son@gmail.com.

Background Consensus guidelines recommend against elective ventral hernia repair (VHR) in patients with BMI >30 kg/m2 without preoperative weight loss intervention. We aim to compare hernia recurrence and perioperative complications in VHR utilizing anterior component separation (CS) in patients with class III obesity (BMI >40 kg/m2). Methods A retrospective review of patients undergoing VHR with CS was performed. The primary endpoint was hernia recurrence; secondary endpoints were wound complications, postoperative medical complications, mortality and length of stay. Results 185 consecutive patients were identified from 2008 to 2016. There were no significant differences between groups: hernia recurrence (6.9% BMI >40 kg/m2, 2.4% BMI <39.9 kg/m2, p = 0.21), wound complications (58.6% BMI >40 kg/m2, 47.2% BMI <39.9 kg/m2, p = 0.16), postoperative complications (39.7% BMI >40 kg/m2, 26% BMI <39.9 kg/m2, p = 0.08), mortality (1.6% BMI >40 kg/m2, 3.4% BMI <39.9 kg/m2, p = 0.59), and length of stay (10.6 days BMI >40 kg/m2, 11.2 days BMI <39.9 kg/m2, p = 0.5). Conclusion This study demonstrates similar outcomes in class III obesity patients undergoing elective VHR compared to patients with BMI <39.9 kg/m2.

Background: Patients undergoing ventral hernia repair (VHR) with separation of components (SOC) often require or request concurrent panniculectomy. However, the impact of panniculectomy on outcomes is incompletely understood.We aim to compare hernia recurrence and complications in VHR with SOC utilizing a vertical incision (VI) versus panniculectomy (P). Methods: A retrospective review of patients undergoing VHR with SOC was performed. The primary endpoint was hernia recurrence; secondary endpoints were wound and postoperative medical complications. Results: The overall hernia recurrence rate was 4%; recurrence with P was 9.3% versus 1.9% with VI (p=0.06). The overall rate of wound complications was 50.6%; (51% P, 50.4% VI, p> 0.99). The overall rate of postoperative complications was 30.7%; (37.2% P, 28% VI, p=0.33). Conclusion: The overall recurrence rates for both groups are low compared to historically reported data. Panniculectomy patients did not have significantly higher rates of recurrence or complications despite significantly higher BMI and operative time. Panniculectomy can improve mobility and satisfaction in morbidly obese patients and should be considered a viable adjunct procedure to complex VHR with SOC.

Tobacco smoking is a known risk factor for complications after major surgical procedures. The full effect of tobacco use on these complications has not been studied over large populations for ventral hernia repairs. This effect is more important as the preoperative conditioning, and optimization of patients is adopted. We sought to use the prospectively collected ACS-NSQIP dataset to evaluate respiratory and infectious complications for patients undergoing both laparoscopic and open ventral hernia repairs.

With an estimated 10 per cent obesity rate worldwide, bariatric surgeries have gained popularity, increasing in number over the past 10 years.1 In 2011, almost 350,000 bariatric surgeries were performed in the United States, half of which were roux-en-Y gastric bypasses (RYGB).1 As the operation becomes more prevalent, rare complications are beginning to be recognized. One of these emerging complications is the unusual postbariatric gastric cancer. Gastric cancer has presented after bariatric procedures in a number of reports. Patients who have undergone multiple bariatric operations may be thought to have a compounded risk, given the extra staple lines and continued obesity. With approximately 5 per cent of patients receiving revision to RYGB,2 this is an important group for heightened screening. Despite the theoretical increased risks in this group, no cases of gastric cancer after multiple operations have been reported in the literature. We present the first case of gastric cancer after multiple bariatric procedures and discuss surveillance considerations in revisional bariatric procedures. A 73-year-old male presented to our clinic for evaluation of gastric cancer. The patient was morbidly obese and had undergone vertical banded gastroplasty in 1986 followed by roux-en-Y gastric bypass in 2007 for inadequate weight loss. No preoperative workup had been performed before RYGB. He had developed early satiety. Esophagogastroduodenoscopy revealed a large polyp at the gastroesophageal junction of the gastric pouch. Biopsies were positive for invasive gastric adenocarcinoma. Endoscopic ultrasound showed a mass at the gastric cardia, with no lymph nodes visualized. CT/positron emission tomography imaging was negative for metastatic disease. The patient was medically ineligible for neoadjuvant chemotherapy. After appropriate preoperative medical evaluation and optimization, he proceeded to the operating room for total gastrectomy with roux-en-y esophagojejunostomy. Postoperatively, pathology revealed a grade II pT1Nx adenocarcinoma with negative margins invading into submucosa. No lymph nodes were identified. Postoperative course was uncomplicated. Gastric cancer after bariatric surgery has appeared in 23 cases in the past 22 years2; cancer after standard Roux-en-Y gastric bypass has been noted in seven cases since 1991. Of these, four cases were found in the gastric pouch or at the gastrojejunal anastomosis, and three in the excluded stomach. These cancers appeared at three to 18 years after RYGB2 with a median of five years. Of the five cases with known staging, three presented at T3 and above, and three had nodal disease; none was metastatic.2 Despite wellstudied risk factors, little systematic study has been devoted to the actual risk of cancer in the postbariatric patient population, and the literature is currently restricted to reviews without prospective information or prevalence estimates. Furthermore, no cases prior to ours have yet emerged in patients with multiple prior bariatric procedures. Patients with prior bariatric procedures have specific risk factors. Obesity has been linked to esophagogastric cancer in epidemiological data, with an odds ratio of at least 2.1 In patients with successful weight loss, this risk may be decreased; however, in patients such as ours who undergo revision for inadequate weight loss, the increased odds of cancer remain. Almost 70 per cent of revisions after prior bariatric surgery have lack of weight loss as an indication.1 Compounding the risk of gastric cancer, metaplasia has been noted on examination in patients after bariatric procedures. Gastric mucosal changes have been documented after vertical banded gastroplasty and This paper will be presented at the 2016 Southeastern Surgical Congress in Atlanta, Georgia. Address correspondence and reprint requests to Vidya A. Fleetwood, M.D., Department of General Surgery, 1653 West Congress Parkway, 786 Jelke, Chicago, IL 60612. E-mail: vidyaratna_a_fleetwood@rush.edu.

Ovarian carcinomatosis poses a dilemma for the surgeon. When resecting colon for tumor invasion, one must decide between diversion and primary anastomosis (PA). We examined the National Surgical Quality Improvement Program to determine whether PA associated with more complications than ostomy. The National Surgical Quality Improvement Program dataset was queried for patients with ovarian carcinomatosis between 2007 and 2012. Current Procedural Terminology codes were used to further identify patients undergoing colectomy with PA or ostomy. Logistic regression was used to evaluate 30-day morbidity and mortality. The 1013 ovarian carcinomatosis patients who underwent elective colon surgery were divided into primary repair (n = 453, 43.5%) or ostomy (n = 586, 56.5%) groups. Preoperative demographics were similar; however, ostomy patients had more severe preoperative laboratory derangements. The 30-day mortality and postoperative transfusion requirements were higher in the ostomy group. On multivariate analysis controlling for confounders, the differences were no longer significant. In conclusion, 30-day mortality and postoperative complications were increased in the ostomy group. Given the laboratory derangements in this group, this may reflect tendency to allocate ostomies to more ill patients. Primary repair in a selected population does not worsen outcomes. Prospective evaluation would help determine the impact of PA in the ovarian carcinomatosis population.

Numerous prospective studies and randomized controlled trials have demonstrated shorter length of stay, lower morbidity rates, and similar recurrence rates with laparoscopic ventral hernia repair (VHR) when compared to open VHR. Despite these promising results, previous data showed low utilization of laparoscopic VHR. The aim of our study was to evaluate the utilization of laparoscopic VHR using the most updated information from the American College of Surgeons—National Surgical Quality Improvement Project (NSQIP) dataset. The secondary aim was to evaluate the outcomes from NSQIP for patients undergoing open versus laparoscopic VHR for the outcome of 30-day mortality and the peri-operative morbidities listed in the NSQIP dataset.

Since the widespread adoption of laparoscopic techniques in biliary surgery, the incidence of bile duct injures (BDI) has not significantly declined despite increased operative experience and recognition of the critical view of safety (CVS) method for anatomic identification. We hypothesized that operative approaches in clinical practice may vary from well-described technical recommendations. The objective of this study was to access how practicing surgeons commonly identify anatomy during laparoscopic cholecystectomy (LC).

Background and Objectives: The advantages of laparoscopy over open surgery are well established. Laparoscopic resection for gastric cancer is safe and results in equivalent oncologic outcomes when compared with open resection. The purpose of this study was to assess the use of laparoscopy to treat gastric cancer and the associated outcomes. Methods: The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) dataset was queried for patients with gastric cancer (ICD-9 Code 151.0–151.9) from January 2005 through December 2012. Logistic regression was used to evaluate the 30-day morbidity and mortality of open gastrectomy (CPT code 43620-2, 43631-4) versus that of the laparoscopic procedure on the stomach (CPT code 43650), while adjusting for preoperative risk factors. Results: A total of 4116 patients with gastric cancer were identified and divided by surgical approach into 2 groups: open gastrectomy (n = 3725; 90.5%) and laparoscopic procedure on the stomach (n = 391; 9.5%). After adjustment for preoperative risk factors, complications were significantly fewer in laparoscopic versus open gastric resection (odds ratio [OR] 0.61, 95% confidence interval [CI] = 0.45–0.82; P = .001). After adjusting for preoperative risk factors, there was no statistically significant difference in mortality with laparoscopic compared to open gastric resection (OR 0.74; 95% CI = 0.32–1.72; P = .481). Conclusions: Laparoscopy is underused in the treatment of gastric cancer. Given that laparoscopic gastric resection has a lower morbidity in comparison to open resection, steps should be made toward advancing the use of laparoscopy for gastric cancer.

Purpose Curative intent management of retroperitoneal sarcoma (RPS) requires gross total resection. Preoperative radiotherapy (RT) often is used as an adjuvant to surgery, but recurrence rates remain high. To enhance RT efficacy with acceptable tolerance, there is interest in delivering “boost doses” of RT to high-risk areas of gross tumor volume (HR GTV) judged to be at risk for positive resection margins. We sought to evaluate variability in HR GTV boost target volume delineation among collaborating sarcoma radiation and surgical oncologist teams. Methods Radiation planning CT scans for three cases of RPS were distributed to seven paired radiation and surgical oncologist teams at six institutions. Teams contoured HR GTV boost volumes for each case. Analysis of contour agreement was performed using the simultaneous truth and performance level estimation (STAPLE) algorithm and kappa statistics. Results HRGTV boost volume contour agreement between the seven teams was “substantial” or “moderate” for all cases. Agreement was best on the torso wall posteriorly (abutting posterior chest abdominal wall) and medially (abutting ipsilateral para-vertebral space and great vessels). Contours varied more significantly abutting visceral organs due to differing surgical opinions regarding planned partial organ resection. Conclusions Agreement of RPS HRGTV boost volumes between sarcoma radiation and surgical oncologist teams was substantial to moderate. Differences were most striking in regions abutting visceral organs, highlighting the importance of collaboration between the radiation and surgical oncologist for “individualized” target delineation on the basis of areas deemed at risk and planned resection.

Background Determine the utility of mock oral examinations in preparation for the American Board of Surgery certifying examination (ABS CE). Methods Between 2002 and 2012, blinded data were collected on 63 general surgery residents: 4th and 5th-year mock oral examination scores, first-time pass rates on ABS CE, and an online survey. Results Fifty-seven residents took the 4th-year mock oral examination: 30 (52.6%) passed and 27 (47.4%) failed, with first-time ABS CE pass rates 93.3% and 81.5% (P = .238). Fifty-nine residents took the 5th-year mock oral examination: 28 (47.5%) passed and 31 (52.5%) failed, with first-time ABS CE pass rates 82.1% and 93.5% (P = .240). Thirty-eight responded to the online survey, 77.1% ranked mock oral examinations as very or extremely helpful with ABS CE preparation. Conclusions Although mock oral examinations and ABS CE passing rates do not directly correlate, residents perceive the mock oral examinations to be helpful.

Background Surgery is indicated for acute uncomplicated appendicitis but the optimal timing is controversial. Recent literature is conflicting on the effect of time to intervention. Methods We queried the American College of Surgeons National Surgical Quality Improvement Project dataset for patients undergoing laparoscopic and open appendectomy between 2007 and 2012. Logistic regression was used to evaluate 30-day morbidity and mortality of intervention at different time periods, adjusting for preoperative risk factors. Results A total of 69,926 patients undergoing appendectomy were identified. Groups were divided by time to intervention: group 1, less than 24 hours (n = 55,839; 79.9%); group 2, 24 to 48 hours (n = 13,409; 18.6%); and group 3, greater than 48 hours (n = 1,038; 1.5%). After adjustment, the risk of complication remained increased for group 3 versus group 1 or 2 (odds ratio 1.66, 95% confidence interval 1.34 to 2.07). Conclusions These data demonstrate equivalent outcomes between time to appendectomy of less than 24 and 24 to 48 hours. There was a 2-fold increase in complication rate for patients delayed longer than 48 hours.

Introduction To date, no study has compared laparoscopy (LB) to percutaneous (PB) biopsy for the diagnosis of abdominal lymphoma. The objective of this study is to compare the success rate and safety profile of laparoscopic lymph node biopsy to the percutaneous approach in patients with intra-abdominal lymphadenopathy concerning for lymphoma. Materials and methods We performed a multi-institution, retrospective review of patients undergoing lymph node biopsy for suspected intra-abdominal lymphoma between 2005 and 2013. Our primary outcome was adequate tissue yield between the two techniques, both for histologic diagnosis and for ancillary studies such as flow cytometry. Secondary outcomes included 30-day morbidity, 30-day readmission rates, the need for additional lymph node biopsy procedures, and length of stay. Results All 34 of the LB patients had adequate specimen for histologic diagnosis compared to 92.3 % of patients with a PB ( p = 0.18). Significantly more patients in the LB group had sufficient tissue for ancillary studies when needed than in the PB group, 95.5 and 68.2 %, respectively ( p = 0.04). A second biopsy was pursued in 23.1 % of failed PB patients, 0 % with success on second attempt. Discussion When index of suspicion is high or when biopsy is performed for patient previously diagnosed with lymphoma and recurrence/transformation is suspected, LB safely and consistently provides adequate tissue for initial diagnosis and for ancillary studies. In contrast, image-guided PB may be more appropriate for patients for whom ancillary studies are unlikely to add to planned treatments or when there is a high risk of complications from either general anesthesia or patient comorbidities.

We hypothesize that currently minimally invasive techniques are underutilized, leading to unnecessary morbidity and mortality. The objective of the study was to compare morbidity and mortality rates in patients receiving a minimally invasive (MIS) small bowel resection to patients receiving an open (OP) small bowel resection.