Metabolic and bariatric surgery (MBS) is the most effective intervention for severe adolescent obesity, yet persistent disparities exist in surgical access. The COVID-19 pandemic disrupted elective surgery and may have altered access for historically underserved populations. Using MBSAQIP, we identified adolescents aged 19 years or younger who underwent MBS from 2015 to 2023, stratified into three phases: pre-COVID (2015–2019), acute COVID (2020–2021), and recovery (2022–2023). Race/ethnicity was classified using Hispanic-priority methodology. Racial and ethnic composition, comorbidity burden, and 30-day outcomes were compared using Fisher’s exact and Kruskal–Wallis tests. Firth penalized logistic regression was used for sensitivity analysis of rare outcomes. Overall, 5432 adolescents underwent MBS from 2015 to 2023. White representation declined from 49

Augmented reality (AR) head-mounted displays enable customizable intraoperative visualization of surgical video and ancillary data. However, real-world experience with implementation in surgical environments remains limited. We describe the first institutional deployment of the Apple Vision Pro (AVP; Apple Inc., Cupertino, CA, USA) across multiple surgical and procedural services within a single academic medical center. We conducted a prospective observational cohort study from August 2024 to January 2026. AVP was deployed as the primary visualization platform across operating rooms, an ambulatory surgery center, and procedural suites for minimally invasive surgery (MIS), interventional pulmonology (IP), and oculoplastic surgery (OP). Conventional monitors were maintained as backup. Primary outcomes included intraoperative safety events, workflow interruptions, and headset utilization. Exploratory outcomes included user feedback and NASA Task Load Index (NASA-TLX) scores. Thirty-five users employed AVP during 174 procedures (136 MIS, 30 IP, and 8 OP), representing 227 headset uses. No AVP-attributable intraoperative complications, conversions, or adverse events occurred; headsets required removal in 6 cases (2.6%). NASA-TLX scores decreased with exposure, suggesting a learning curve that varied by training level. AR spatial computing was safely integrated for surgical visualization across diverse workflows, providing a framework for institutional adoption of AR technologies in the digital operating room.

Robotic-assisted inguinal hernia repair continues to evolve with the introduction of novel surgical platforms designed to improve costs, workflow integration, and ergonomics. The Dexter Surgical System has recently entered clinical practice; however, its use for inguinal hernia repair in the USA has not been reported. This study evaluated feasibility, safety, and early operative outcomes in a United States cohort. A retrospective review was conducted of consecutive patients undergoing robotic inguinal hernia repair with Dexter at a single academic center between November 2024 and November 2025. Primary outcomes included intraoperative complications, device-related adverse events, and conversion to open or laparoscopic surgery. Secondary outcomes included operative time, console time, docking time, length of stay, and 30-day outcomes. Learning curve analysis was performed using cumulative sum methodology, along with a comparison of the primary surgeon’s first five versus final five cases. Twenty-six patients underwent robotic inguinal hernia repair performed by two fellowship-trained minimally invasive surgeons with extensive prior robotics experience. All procedures were completed without conversion, complications, or device-related events, and all patients were discharged the same day. Mean operative time was 63.1 ± 18.5 min, with mean console time of 38.5 ± 15.7 min and docking time of 6.1 ± 2.2 min. One patient (3.8

The implications of complex robotic surgery on the well-being of surgeons remains widely unexplored. The DEXTER Robotic Surgery System offers an open concept where the surgeon console can be used in a sterile manner, allowing flexibility to switch between the robotic system and conventional laparoscopy. The aim of this study was to evaluate surgical ergonomics during the use of the DEXTER Robotic System. A prospective, non-randomized international multicenter trial evaluating surgical ergonomics during the routine clinical practice was performed in Switzerland and USA. A photo camera captured the surgeon’s posture at the console during surgery. Using picture editing programs, image analyses were created showing the surgeon’s average posture and corresponding angles. Furthermore, sound levels were measured during cases. Data were compared to previous measurements (n = 33 surgeries) of a closed console robotic system using the same methodology. A total of 83,025 images from 40 surgical procedures were analyzed, performed by five surgeons. Knee, back, and elbow angles were within recommended ergonomic limits whereas neck and hip positions were classified as high-risk. Compared with a closed console robotic system, neck posture was significantly improved (p value 0.0001). Mean sound levels were 60.24 dB for all surgeries. Comparison to a robotic system with a closed console revealed a statistically quieter OR setting for the open DEXTER system (mean sound level 64.35 dB vs. 59.5 dB; p value 0.0001). The application of ergonomic measurements during a real-life setting for robotic surgery helped to reveal ergonomic advantages and challenges faced when using a new robotic technology. This is the first study providing ergonomic insights in the DEXTER surgical system, identifying individual possibilities for improvement. Future studies and recommendations will may lay the foundation for a personalized training and education in surgical ergonomics leading to a healthier workspace for all surgeons and their future careers.

OBJECTIVES:Pulsed shortwave therapy (PSWT) is a nonpharmacologic/noninvasive modality that may offer analgesic benefits without notable side effects or complications. This pilot study aimed to assess the feasibility of a PSWT protocol and provide an estimate of its treatment effects. MATERIALS AND METHODS:The study included adults who underwent cholecystectomy or unilateral total hip or knee arthroplasty. Participants were randomized to eight days of either PSWT with a single functioning device (SofPulse, Endonovo Therapeutics, Woodland Hills, CA) or a sham device placed over the surgical bandages in a participant- and assessor-masked fashion. The primary end point was the sum of the average and worst (maximum) daily pain intensity as measured with the numeric rating scale collected over the first seven postoperative days. RESULTS:No systemic side effects or significant complications occurred. During the first seven postoperative days, the sum of the daily pain intensity scores in the active group was a mean (SD) of 28 (11) vs 34 (14) in sham: difference -6.5 (95% CI, -12.4 to -0.6), p = 0.032. During the same period, cumulative oxycodone consumption in the active group was a mean (SD) of 4.6 (4.9) mg vs 5.1 (7.3) mg in sham: difference -0.5 (95% CI, -3.4 to 2.5), p = 0.761. Subgroup analysis suggested that the analgesic effect for knee arthroplasty was greater than for the other surgical procedures. CONCLUSIONS:PSWT is feasible for inpatients and outpatients, and reduced pain over the first postoperative week. These results are preliminary and should be replicated with a subsequent study before being considered definitive. Although this pilot study was inadequately powered to conclusively identify statistically significant differences between treatments for the secondary end points, if the analgesic improvements are successfully replicated in a definitive trial, they would meet or exceed the benefits identified for oral acetaminophen. Data from this pilot study may be used to help plan future trials. CLINICAL TRIAL REGISTRATION:The Clinicaltrials.gov registration number for the study is NCT05796583.

Fluorescence cholangiography (FC) with indocyanine green (ICG) enables real-time intraoperative visualization of extrahepatic biliary anatomy during laparoscopic cholecystectomy (LC). There is no consensus on the optimal ICG dose or timing of administration for LC. The goal of this study was to implement a simple intraoperative low-dose (“microdose”) ICG protocol that facilitates non-inferior biliary visualization compared to a standard dose protocol to streamline perioperative workflows. A retrospective review of a prospectively maintained database identified patients who underwent LC at our institution from 2021 to 2024. Microdose protocol patients were intravenously administered 0.5 mg ICG upon induction of general anesthesia, while standard protocol patients received 7.5 mg ICG 60–120 min preoperatively. Operative video from cases in both groups were reviewed to compare the frequency of cystic duct (CD), common bile duct (CBD), and common hepatic duct (CHD) visualization with FC. A 4-point Likert scale survey was completed for each case to compare ICG signal strength (1 = no signal; 4 = very strong), clarity from background interference (1 = cannot discern signal from background; 4 = no interference), and usefulness in clinical decision-making (1 = no benefit; 4 = essential). A total of 100 patients were identified (N = 50 microdose; N = 50 standard). For microdose cases, the mean time from ICG administration to skin incision was 16.7 ± 5.6 min, and mean operative time was 47.4 ± 20.2 min. Compared to 50 standard dose cases, CD visualization before hepatocystic triangle dissection with the microdose protocol was 86.0

Potential barriers exist for patients who desire bariatric surgery. Medical tourism, defined as international travel for the purpose of seeking medical care, has emerged as a popular alternative. Despite attempts at care standardization, substantial variation remains regarding institutional accreditation and the availability of appropriate postoperative bariatric care abroad. Management of postoperative complications therefore often falls to providers in the patient’s home country. We present our experience with the clinical and financial implications of bariatric tourism as an academic center located 30 miles from the US-Mexico border. A retrospective review of a prospectively maintained database identified patients who underwent cross-border bariatric surgery and then presented to our institution for management of postoperative complications from 2014 to 2024. Outcomes included type and number of procedural interventions required for complication management, length of stay (LOS), total intensive care unit (ICU) days, emergency department (ED) visits, readmissions, and mortality. Hospital charge and payment data for each patient were obtained, accounting for total LOS, interventions performed, readmissions, and ED visits. A total of 91 patients were identified. The most common index procedure performed abroad was laparoscopic sleeve gastrectomy (N = 63, 69.2

Augmented reality (AR) is an evolving technology with the potential to transform surgical practice. By superimposing digital information onto the surgeon's field of view, AR headsets provide an unobstructed view of the minimally invasive operative field, eliminating the need to divert attention to external monitors. We present the first series of minimally invasive general surgery (MIS) cases performed using the Apple Vision Pro headset in the USA. Attending surgeons and trainees performed consecutive MIS cases at our institution while wearing the headset from August 2024 to December 2024. Using open-source software, laparoscopic/endoscopic video sources were displayed as virtual monitors in the physical operating room space. The virtual monitors served as the primary monitors through which surgeons performed each case. Standard monitors remained present to enable other members of the operative team to view the operations. At the conclusion of each case, the operating surgeon completed the NASA Task Load Index (NASA-TLX) assessment tool to evaluate perceived workload while operating with the headset. 30-day perioperative complications were also assessed. A total of 41 MIS cases were performed by 3 attending surgeons and 4 trainees. The most common procedure was laparoscopic sleeve gastrectomy (N = 9, 22.0%). Open-source software enabled simultaneous viewing of up to 3 virtual displays that could be individually positioned in the surgeon's visual field. The mean NASA-TLX score for all participants was 22.3 ± 4.7, indicating a low perceived intraoperative workload. There was no significant difference in NASA-TLX scores between attending surgeons and trainees (19.8 ± 5.3 vs 24.8 ± 3.0, p = .23). There were no intraoperative complications; 30-day morbidity and mortality were 0%. This study serves as a proof of concept for the use of an augmented reality headset in minimally invasive general surgery.

In the high-pressure environment of surgical training, effective stress management is crucial for optimal performance and well-being. This study employs mobile EEG technology to monitor cortical indices of stress responses during surgical training tasks. We posit that variations in specific EEG parameters, particularly frequency-specific bandpower and coherence, can offer quantifiable neural markers for stress in surgical settings, as they will reflect self-reported stress levels. Additionally, we have implemented a suite of machine learning classifiers -Support Vector Machines, XGBoost, and Neural Networks- that capitalize on these EEG features. We found a reliable relationship between beta and gamma bandpower and coherence on perceived stress levels. Further, our classifiers demonstrated accuracy rates ranging from 76

Obesity is a risk factor for complications after abdominal hernia repair. Glucagon-like-peptide-1 (GLP-1) receptor agonists are effective weight loss medications that may help patients reach weight loss goals for surgery. In this study, we examine our outcomes utilizing GLP-1 agonists for preoperative weight loss in obese patients undergoing elective hernia repair. A retrospective review identified obese patients who were prescribed GLP-1 agonists for weight loss in addition to lifestyle changes before elective hernia repair from 2021 to 2024. Patients were managed by a multidisciplinary team and asked to achieve a body mass index (BMI) ≤ 33 kg/m2 before surgery. Primary outcomes were preoperative mean percentage total weight loss (

Magnetic-assisted robotic surgery (MARS) is a new platform developed to maximize the benefits of minimally invasive surgery for patients while enhancing surgeon control and visualization. The system is composed of two robotic arms that enable surgeon control of the laparoscopic camera and a deployable intraperitoneal magnetic grasper designed to provide incisionless retraction. The aim of this study was to evaluate the outcomes of the MARS platform following its use in outpatient laparoscopic cholecystectomy by a solo surgeon and examine patient perceptions of this approach. A retrospective review of a prospectively maintained database identified all patients who underwent outpatient reduced port laparoscopic cholecystectomy assisted by MARS for symptomatic cholelithiasis from January 2024 to August 2024 at a tertiary care hospital. All cholecystectomies were performed without a surgical assistant. Primary outcomes were 30-day morbidity, 30-day readmission, operative time, and 30-day patient satisfaction as measured by a modified version of the Surgical Satisfaction Questionnaire (SSQ). Fifty-one patients were identified. Mean age was 47.3 ± 13.9 years and most patients were female (N = 45, 88.2

INTRODUCTION:Magnetic sphincter augmentation (MSA) with the LINX® device is an effective surgical option for gastroesophageal reflux disease (GERD), offering benefits such as preservation of belching and reduced gas bloat syndrome compared to Nissen fundoplication. However, postoperative dysphagia is common complication, occurring in approximately 15-30 % of patients. CASE PRESENTATION:We report the case of a 66-year-old female who underwent laparoscopic hiatal hernia repair with concurrent LINX® device placement for GERD. Three weeks postoperatively, she developed progressive dysphagia that was initially responsive to corticosteroids but recurred. Barium swallow demonstrated mild narrowing at the gastroesophageal junction. Despite three serial endoscopic dilations, her symptoms persisted. High-resolution manometry (HRM) revealed new-onset ineffective esophageal motility (IEM), in contrast to her preoperative study, which showed normal esophageal peristalsis. The LINX device was surgically removed due to refractory symptoms. Post-removal, the patient experienced significant symptomatic improvement. Repeat HRM one year later showed improved motility findings. DISCUSSION:This case illustrates the potential for MSA to contribute to the development of esophageal dysmotility in patients with subtle or predisposing motility abnormalities. Early postoperative dysphagia should prompt repeat manometric evaluation and consideration of device removal in refractory cases. CONCLUSION:MSA may lead to de novo IEM. Thorough preoperative evaluation and timely reassessment of postoperative symptoms are key to optimizing patient outcomes.

Aim: Weight recidivism following bariatric surgery has major physical and psychological consequences. Revisional surgery is a common management option but is associated with increased complications compared to primary surgery. The objective of this study was to assess the efficacy and safety of revisional bariatric surgery for weight regain at our institution. Methods: A retrospective database review identified patients who underwent revisional bariatric surgery for weight regain at our institution from 2014 to 2023. Emergent operations were excluded. The primary outcomes were percentage total (%TWL) and excess weight loss (%EWL) using revisional surgery weight as the baseline. Secondary outcomes were 30-day morbidity, mortality, readmission, and reoperation rates. Results: Seventy patients were identified. Five types of revisional procedures were performed: 39 (55.7%) Roux-en-Y gastric bypass (RYGB) revisions (21 endoscopic, 11 laparoscopic, 6 robotic, 1 open), 15 (21.4%) sleeve gastrectomy (SG) to one-anastomosis gastric bypass (OAGB) conversions (8 robotic, 7 laparoscopic), 8 (11.4%) SG revisions (7 laparoscopic, 1 robotic), 7 (10.0%) laparoscopic gastric band to SG conversions, and 1 (1.4%) laparoscopic gastric band to OAGB conversion. SG to OAGB conversion had the largest mean 12-month %EWL at 67.9 ± 25.1, which was significantly greater than SG revision at 47.4 ± 6.7 (P = 0.04) and gastric band to SG conversion at 44.1 ± 21.1 (P = 0.04). SG to OAGB conversion also had the largest mean 12-month %TWL at 19.1 ± 9.4, significantly greater than RYGB revision at 9.0 ± 6.0 (P < 0.001). The 30-day morbidity rate for all patients was 7.1% (N = 5), including 1 anastomotic leak following an SG revision requiring 1 reoperation (1.4%). The 30-day readmission rate was 5.7% (N = 4) and there were no 30-day mortalities. Conclusion: Revisional bariatric surgery is an effective tool for addressing weight regain and achieving sustained weight loss. Among the revisional options, converting SG to OAGB was most effective at promoting significant weight loss at 12 months. These findings highlight the important role of tailored revisional procedures in the broader context of bariatric care.

BackgroundNonthermal, pulsed shortwave (radiofrequency) therapy (PSWT) is a nonpharmacologic, noninvasive modality that limited evidence suggests provides analgesia. Its potential favorable risk-benefit ratio stems from its lack of side effects and significant medical risks, applicability to any anatomic location, long treatment duration, and ease of application by simply affixing it with tape. Even with a relatively small treatment effect, PSWT might contribute to a multimodal analgesic regimen, similar to acetaminophen. However, widespread clinical use is hindered by a lack of systematic evidence. The current randomized, controlled pilot study was undertaken to determine the feasibility and optimize the protocol for a subsequent definitive investigation and estimate the treatment effect of PSWT on postoperative pain and opioid consumption.MethodsWithin the recovery room following primary knee and hip arthroplasty, cholecystectomy, hernia repair, and non-mastectomy breast surgery, we applied 1-3 PSWT devices (Model 088, BioElectronics Corporation, Frederick, Maryland) over the surgical bandages. Participants were randomized to 28 days of either active or sham treatment in a double-masked fashion. The outcomes of primary interest were the cumulative opioid consumption and the mean of the "average" and "worst" daily pain measured with the Numeric Rating Scale over the first 7 postoperative days.ResultsDuring the first 7 postoperative days, oxycodone consumption in participants given active treatment (n = 55) was a mean (SD) of 21 mg (24) versus 17 mg (26) in patients given sham (n = 57): difference 4 (95% CI, -5 to 13), p = 0.376. During this same period, the "average" daily pain intensity in patients given active treatment was 2.4 (1.6) versus 2.6 (1.7) in sham: difference -0.2 (95% CI -0.8 to 0.5), p = 0.597. Concurrently, the worst/maximum pain for the active group was 4.6 (2.0) versus 4.7 (2.1) in sham: difference -0.1 (95% CI -0.8 to 0.7), p = 0.888. No device-related systemic side effects or serious adverse events were identified.ConclusionsPulsed shortwave (radiofrequency) therapy did not reduce pain scores and opioid requirements to a statistically significant or clinically relevant degree during the initial postoperative week in this pilot study. These results must be replicated with a subsequent study before being considered definitive. Data from this preliminary study may be used to help plan future trials.

BACKGROUND:This study tested the measurement of operator physiology during performance on robot-assisted surgery simulations to determine if these signals can identify errors and classify high and low performers. METHODS:57 participants performed digital simulations on da Vinci Xi system. Simulation videos, electrocardiogram (EKG), and electroencephalography (EEG) were analysed using linear mixed effects models. RESULTS:Relative to non-error intervals, errors elicited significant differences in EKG and EEG measures, including high-frequency power, interbeat interval and ratio of theta-to-alpha EEG power. High and low performers differed significantly in several of these measures, while classification models were accurate for the detection of errors (85.7%) and performance groups (96.3%), and using physiological signals leading up to errors, could accurately predict upcoming errors (85.7%). CONCLUSIONS:Noninvasive recording of physiology can differentiate error from non-error intervals and performance groups, leading to the possibility that online physiology can develop into training or early warning systems.

Background: Robotic-assisted bariatric surgery is growing rapidly. The optimal approach to minimize complications remains unclear. Objective: Assess robot utilization and compare 30-day outcomes for laparoscopic and robotic primary sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Setting: United States. Methods: A retrospective analysis of the MBSAQIP database identified primary SG and RYGB cases from 2015 to 2022. Revisions/conversions, cases converted to another approach, and combined cases other than esophagogastroduodenoscopy were excluded. Outcomes were compared with logistic regression following 1:1 propensity-score matching to adjust for differences in patient demographics/comorbidities and operative variables. Results: A total of 823,902 cases (591,118 SG; 232,784 RYGB) were included. From 2015 to 2022, the percentage of SG and RYGB performed robotically increased from 6.7% and 6.9% to 29.5% and 31.8%, respectively. Compared to laparoscopic, robotic SG had significantly higher overall morbidity (odds ratio 1.14 [1.07-1.21], P < .001), leak (1.24 [1.05-1.46], P = .03), and bleeding rates (1.34 [1.13-1.58], P < .001). Robotic RYGB had significantly lower overall morbidity (.75 [.70-.81], P < .001) and bleeding (.80 [.68-.94], P < .01) with similar leak rates (.87 [.71-1.07], P = .18). Combined robotic SG and RYGB outcomes were similar to laparoscopic for 2020-2022 cases, except for higher rates of organ/space infection, readmission, and septic shock in the robotic group. Conclusion: Robotic SG has higher complication rates compared to laparoscopic, while robotic RYGB is protective against bleeding complications. Short-term outcomes for robotic surgery have become more similar to laparoscopic, but remain inferior. Further studies are warranted to elucidate the factors driving these findings. (c) 2025 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Gastroparesis is a rare disorder characterized by delayed gastric emptying in the absence of mechanical obstruction. Initial management of gastroparesis consists of dietary modification, prokinetic agents, antiemetics, and optimizing underlying medical conditions (eg, glycemic control in diabetic patients). In a subset of patients, surgical intervention may be necessary such as with gastric pacemaker, pyloroplasty/pyloromotomy, or G-POEM. A further subset of patients may require sleeve gastrectomy or conversion to Roux-en-Y gastric bypass. Here, we focus on the indications and outcomes of sleeve gastrectomy and Roux-en-Y bypass for treatment of refractory gastroparesis.

Robotic-assisted metabolic and bariatric surgery (MBS) is gaining popularity. Revisional MBS is associated with higher perioperative morbidity compared to primary MBS. The optimal surgical approach to minimize complications in these complex cases is unclear. The goal of this study was to assess robot utilization in revisional MBS and compare laparoscopic and robotic revisional MBS outcomes in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. A retrospective review of the MBSAQIP database was performed identifying revisional sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) cases from 2015 to 2022. Primary MBS, open/emergent cases, cases converted to another approach, and combined cases other than esophagogastroduodenoscopy were excluded. 30-Day outcomes for laparoscopic and robotic cases were compared using multivariate logistic regression adjusting for patient demographics, comorbidities, and operative variables. 41,404 Cases (14,474 SG; 26,930 RYGB) were identified. From 2015 to 2022, the percentage of revisional SG and RYGB cases performed robotically increased from 6.1