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Multiple studies have linked obesity to an increased risk of cancer. The correlation is so strong that the national cancer prevention guidelines recommend weight loss for patients with obesity to reduce their risk of cancer. Bariatric surgery has been shown to be very effective in sustained weight loss. However, there have been mixed findings about bariatric surgery and its effects on the risk of colorectal cancer.This study sought to examine bariatric surgery patients and their risk of pre-cancerous or cancerous polyps to elucidate any risk factors or associations between bariatric surgery and colorectal cancer.A retrospective review of the academic medical center's bariatric surgery database was performed from January 2010 to January 2017. Patients who underwent medical or surgical weight loss and had a subsequent colonoscopy were included in the study. Positive colonoscopy findings were described as malignant or premalignant polyps.A total of 1777 patients were included, with 1360 in the medical group and 417 in the surgical group. Data analysis included patient demographics, co-morbidities, procedure performed, surgical approach, weight loss, and colonoscopy findings. A multivariate analysis was used to determine whether an association exists between weight loss and incidence of colorectal polyps, and if so, whether the association different for medical versus surgical weight loss.A higher percentage of body mass index (BMI) reduction was seen in the surgical group. An overall comparison showed average reductions in BMI of 27.7% in the surgical group and 3.5% in the medical group (P.0001). Patients with the greatest reduction in BMI, regardless of medical or surgical therapy, showed a lower incidence of precancerous and cancerous polyps (P = .041).This study offers a unique approach in examining the incidence of colorectal polyps related to obesity. Patients with the greatest reduction in their BMI, more common in the surgical group, had a lower incidence of precancerous and cancerous polyps.

Achievement goal orientation (GO) theory describes Mastery (M), one's intrinsic drive for competency for the sake of competency, and performance approach (PAP), a drive for competency by displaying competency, which are both adaptive. In learners motivated by performance avoid (PAV), showing competency by avoiding appearing incompetent dominates (maladaptive). The aim of this study was to determine differences in GO by gender and training (PGY) level.A prospective, multi-institutional cohort of general surgery trainees participated in a cross-sectional study (2020-2021). Participants completed a 10-item instrument (the Goal Orientation in Surgical Trainees, GO-ST) measured on a 5-pointLikert scale (1 = never,3 = weekly,5 = daily). Student's t-tests and ANOVA F-test were used as appropriate.A total of 144/164 trainees participated (87.8%). The sample was 40.0%(n = 56) female and 57.9%(n = 81) male; 21.3%(n = 30) were PGY1, 22.0%(n = 31) PGY2, 24.8%(n = 35) PGY3, 18.4%(n = 26) PGY4, 13.5%(n = 19) PGY5. There were no significant differences in mean scale scores by gender for Mastery (3.3 vs 3.5; p = 0.17), or PAP (3.7 vs 3.5; p = 0.10), but mean PAV scores were significantly higher for females (3.6 vs 3.3; p = 0.04). While there were no significant differences in mean Mastery and PAP scale scores by training level (p = 0.44; p = 0.31), there was a significant difference in PAV scores (p0.01). The frequency of PAV feelings decreased over 5 years.Only PAV motivation differed by gender and training level. Understanding the psychology of motivation with this framework can aid both residents and programs in re-focusing on more adaptive learning strategies and supporting trainees in their transition to master surgeons.

BACKGROUND The aim of this meta-analysis was to evaluate whether adoption of DaVinci Xi® had any impact upon intra- and postoperative metrics in colorectal surgery. METHODS The Pubmed, CINAHL, Cochrane Library and MEDLINE (Ovid) databases were systematically searched. Operating time as well as docking and surgeon console times were the primary endpoints. Conversion and postoperative complication rates were the secondary endpoints. RESULTS Six studies totaling 610 patients (320 Si and 290 Xi) were included. Total operating time [MD (95% CI) = 30.553 (15.071, 46.035); p

Background: Robotic inguinal hernia repair is the latest iteration of minimally invasive herniorrhaphy. Previous studies have shown expedited learning curves compared to traditional laparoscopy, which may be offset by higher cost and longer operative time. We sought to compare operative time and direct cost across the evolving surgical practice of 10 surgeons in our healthcare system. Methods: This is a retrospective review of all transabdominal preperitoneal robotic inguinal hernia repairs performed by 10 general surgeons from July 2015 to September 2018. Patients requiring conversion to an open procedure or undergoing simultaneous procedures were excluded. The data was divided to compare each surgeon’s initial 20 cases to their subsequent cases. Direct operative cost was calculated based on the sum of supplies used intra-operatively. Multivariate analysis, using a generalized estimating equation, was adjusted for laterality and resident involvement to evaluate outcomes. Results: Robotic inguinal hernia repairs were divided into two groups: early experience (n = 167) and late experience (n = 262). The late experience had a shorter mean operative time by 17.6 min (confidence interval: 4.06 – 31.13, p = 0.011), a lower mean direct operative cost by $538.17 (confidence interval: 307.14 – 769.20, p < 0.0001), and fewer postoperative complications (p = 0.030) on multivariate analysis. Thirty-day readmission rates were similar between both groups. Conclusion: Increasing surgeon experience with robotic inguinal hernia repair is associated with a predictable reduction in operative time, complication rates, and direct operative cost per case. Thirty-day readmission rates are not affected by the learning curve.

Minimally invasive techniques have gained popularity in colorectal surgery due to their numerous benefits: shorter length of stay, lower complications, and high-definition visualization. However, increased adoption of laparoscopy in the challenging confines of the narrow pelvis and the need to operate in multiple quadrants was met with steep learning curves and increased conversion rates. Furthermore, recent multicenter randomized controlled trials have cast doubt on the ability of laparoscopic total mesorectal excision to achieve pathologic outcome noninferiority compared to open resection in locally advanced rectal cancers. Robotics mitigates these shortcomings using three-dimensional optics, wrist-like motion, tremor filtering, motion scaling, better ergonomics, and less fatigue. This translates into a lower conversion rate, easier learning curve, and the ability to operate in constricted spaces and in multiple quadrants. We have found these advantages when performing robotic partial colectomy, low anterior resection, total colectomy, abdominoperineal resection, and rectopexy. Robotic-assisted intracorporeal anastomoses are noticeably easier to perform compared to laparoscopic, limiting excessive handing of bowel that leads to ileus and possibly improper orientation. Extraction sites no longer need to be in the midline, which decreases incisional hernia occurrence and patient morbidity. Improved visualization, particularly in the narrow pelvis, helps attain completeness of the mesorectal envelope and decreases the conversion rate. Surgeries are performed using either the da Vinci Xi or Si (Intuitive Surgical Inc., Sunnyvale, California, United States) iterations of the robotic system. The advantages of the newly introduced Xi Surgical System overcome the robotic arm restrictions and difficulty operating in multiple quadrants common with its predecessor. Critics of robotics cite cost as the major deterrent to adopting new technology. However, this can be offset with increased case volume, instrument use optimization, and previously mentioned clinical benefits.

Background. Prior studies have shown a better prognosis with medullary colon cancer (MCC) compared to nonmedullary colon carcinomas (NMC); however, data are inconsistent and lacking the evaluation of treatments received. As we did not see similar survival outcomes, we aimed to retrospectively examine survival and receipt of treatment differences between MCC and NMC within the Geisinger Health System. Methods. The Cancer Registry was retrospectively reviewed for MCC and NMC from 2006 to 2017. Demographics and treatments were compared using T-test and chi-squared analyses, also comparing MCC to poorly differentiated (PD) or undifferentiated (UD) NMC. Overall survival was analyzed using Kaplan–Meier curves and log-rank tests. Results. 33 MCC and 1775 NMC patients were identified and 31 (93.9%) MCC and 1433 (87.0%) NMC underwent resection. MCC were older (p=0.0002), had a higher Charlson Comorbidity Index (p=0.013) and were more likely right sided (p=0.013). Seven patients (22.6%) with MCC vs. 149 (10.4%) NMC underwent resection of contiguous organs. Overall median survival was significantly worse for MCC as compared to NMC (19.6 vs. 60.5 months, p=0.0002). Only stage 3 patients had a significantly worse median survival when compared to PD/UD NMC (9.6 vs. 47.2 months, p<0.001). Contiguous organ resection and failure to receive chemotherapy were not found as contributing factors to decreased survival. Conclusion. Multiple previous studies showed a better prognosis for MCC compared to PD/UD NMC. We, however, found stage 3 patients had a worse prognosis which may be secondary to higher comorbidities, increased stage, and higher rate of UD.

Background Insufficient perfusion to anastomoses in colorectal surgery is known to lead to complications. This study aims to evaluate whether routine use of fluorescence angiography (FA) alters the incidence of anastomotic leaks after colorectal surgery. Methods This was a retrospective study of 554 colorectal resections with and without the use of intraoperative fluorescence angiography. Anastomotic leak rates and whether angiography altered surgical management were the main outcomes measured. Results The anastomotic leak rate was found to be 1.3% both with and without use of FA (p > 0.05). Significantly more alterations were made to planned anastomotic site in FA group (n = 13, 5.6%) as compared to the group prior to use of FA in whom no alterations were made (p Conclusions No significant difference was found in anastomotic leak rates between the two groups studied. Routine use of fluorescence angiography significantly altered intra-operative decision-making without discernible change in clinical outcome.

Background: Advances in modern medicine and surgical technique have allowed patients with multiple comorbidities to undergo invasive surgery electively. This places additional stress on hospital resources to anticipate and deal with potential complications. We have introduced a preoperative safety concept called “Anesthesia Alert”. The surgeon or preoperative interviewing anesthesiologist assigns an Anesthesia Alert when booking to denote possible difficulty with anesthesia induction or intubation. As a result, two anesthesiologists and fiber optic equipment are made available on the day of surgery. Methods: A retrospective study of patients from all surgical specialties who were assigned Anesthesia Alerts between January 2012 and November 2012. Records were analyzed for reasons requiring Anesthesia Alerts. Patient demographics, comorbidities, and perioperative complications were reviewed. Results: A total of 112 patients formed this study group. Difficult airway comprised the majority of Anesthesia Alerts (n = 75, 67.0%). Hypertension was the most prevalent comorbidity among patients. There were only 7 patients (6.3%) admitted to the ICU postoperatively and no mortalities. Conclusion: Perioperative patient safety is an evolving concept that requires a team approach amongst the surgeon, anesthesiologist, and operating room staff. An Anesthesia Alert raises awareness for possible complications during anesthesia induction as well as allocates resources to increase patient safety and avoid preoperative delays. Most importantly, this concept places the onus on the surgeon to alert the anesthesiologist for possible complications during induction and extubation.

Introduction: Urachal remnants are rare in adulthood with only a few cases of urachal-sigmoid fistula reported in the literature. We report the first case of a laparoscopic resection of a urachal-sigmoid fistula resulting from diverticulitis in an immunosuppressed heart transplant patient. Case Description: The patient is a 43-year-old male who underwent an orthotopic heart transplant one month prior for dilated cardiomyopathy. His presenting symptom was abdominal pain and imaging showed a sigmoid-urachal fistula. A laparoscopic sigmoidectomy with resection of the urachal cyst and drainage of pelvic abscess was performed. The cyst was found to be contiguous and inseparable from the bladder, and therefore a small cuff of bladder was included with the specimen followed by primary laparoscopic cystorrhaphy. He had an uncomplicated hospital course. Discussion: Our case contained several unique aspects that altered the ultimate care and hospital course of the patient. Immunosuppressed patients possess multiple risk factors predictive of poor surgical outcome—infection, bleeding, and hollow organ perforation. The patient in this study was on multiple immunosuppressants and exhibited no peritoneal signs despite an elevated leukocytosis and some worrisome radiologic findings. Our decision to operate early was influenced by the aforementioned factors and led to an uncomplicated recovery.

Background: Endarterectomy has long been the standard for common femoral artery (CFA) occlusive disease. Hybrid procedures utilizing endovascular and open techniques have recently been used for revascularization. The purpose of this study was to evaluate the effectiveness of the use of a stent graft to stabilize the distal flap and prevent further dissection after extensive endarterectomy. Methods: All patients from Monmouth Medical Center in Long Branch, NJ from September 2008 to March 2013 who underwent an extensive common and superficial femoral (SFA) endarterectomy combined with the use of a Viabahn (Gore Medical) stent graft to stabilize the distal flap were included in the study. These stents were deployed in the proximal SFA after extensive endarterectomy, under direct visualization, without the aid of fluoroscopy. Due to the location in the SFA, these flaps were not amenable to suture tacking. Results: Fifteen patients met these criteria and were included in our study. Twelve patients underwent femoral endarterectomy for severe claudication and three patients for limb salvage. Technical success was achieved in all 15 patients. Five patients also had stents placed proximally to increase inflow and one patient had an additional stent placed distally to improve outflow. There were no intraoperative or postoperative complications. Conclusion: Stent graft placement allows a more extensive endarterectomy to be performed by stabilizing the distal flap allowing a safe transition into the true lumen that is not possible with suture tacking.

Purpose. Squamous cell carcinoma (SCC) developing within fistulae and chronic wounds in patients with Crohn’s disease is a rare phenomenon with few reported studies in the literature. Clinical suspicion for SCC in Crohn’s disease patients with chronic painful fistulae is low, leading to delayed diagnosis and treatment. We present a patient with long-standing Crohn’s disease complicated by malignant degeneration of an enterocutaneous fistula tract. Methods. Workup with MRI, CT, and fistulogram revealed a 7 × 3 cm fistulous connection between a loop of small intestine and the patient’s perineum. Biopsies of the fistula tract confirmed the diagnosis of SCC. Results. The patient underwent an abdominoperineal resection with positive margins and is currently awaiting radiation therapy. Conclusions. This is the second case reported within the English literature of SCC arising from an enterocutaneous fistula in the setting of Crohn’s disease. Based on the findings in this case report and others presented in the literature, a high degree of suspicion of malignancy should be present in patients with chronic painful, poor-healing fistulae, especially in the absence of infection.

Background Morbid obesity is associated with increased rates of hiatal and paraesophageal hernias. Although laparoscopic sleeve gastrectomy is gaining popularity as the procedure of choice for morbid obesity, there is little data regarding the management of paraesophageal hernias found intraoperatively. The aim of this study was to evaluate the feasibility and benefits of a combined sleeve gastrectomy and paraesophageal hernia repair in morbidly obese patients. Methods From May 2011 to February 2013, 23 patients underwent laparoscopic sleeve gastrectomy combined with the repair of a paraesophageal hernia. Only 4 patients had a large hiatal hernia documented preoperatively on esophagogastroduodenoscopy (EGD). The body mass index (BMI), operative time, length of stay, and complications were evaluated. Results The average operative time was 165 minutes (115–240 minutes) and length of stay was 2.83 days (2–6 days). All patients were female except for one, with an average age of 53.4 years and a BMI of 41.9 kg/m 2 . There were no complications during the procedures. Mean follow-up was 6.16 months (1–19 months), and mean excess weight loss was 39%. The average cost of admission for a combined procedure ($10,056), was slightly higher than a laparoscopic sleeve gastrectomy ($8905) or laparoscopic paraesophageal hernia repair ($8954) done separately. Conclusions Laparoscopic sleeve gastrectomy combined with a paraesophageal hernia repair is well-tolerated and feasible in morbidly obese patients. Surgeons should be aware that preoperative EGD is not effective at diagnosing large hiatal or paraesophageal hernias. Surgeons with the skill set to repair paraesophageal hernias should do a combined procedure because it is well-tolerated, feasible, and can reduce the cost of multiple hospital admissions.

The newly introduced da Vinci Xi Surgical System hopes to address the shortcomings of its predecessor, specifically robotic arm restrictions and difficulty working in multiple quadrants. We compare the two robot platforms in multiquadrant surgery at a major colorectal referral center. Forty-four patients in the da Vinci Si group and 26 patients in the Xi group underwent sigmoidectomy or low anterior resection between 2014 and 2016. Patient demographics, operative variables, and postoperative outcomes were compared using descriptive statistics. Both groups were similar in age, sex, BMI, pelvic surgeries, and ASA class. Splenic flexure was mobilized in more (p = 0.045) da Vinci Xi cases compared to da Vinci Si both for sigmoidectomy (50 vs 15.4%) and low anterior resection (60 vs 29%). There was no significant difference in operative time (219.9 vs 224.7 min; p = 0.640), blood loss (170.0 vs 188.1 mL; p = 0.289), length of stay (5.7 vs 6 days; p = 0.851), or overall complications (26.9 vs 22.7%; p = 0.692) between the da Vinci Xi and Si groups, respectively. Single-dock multiquadrant robotic surgery, measured by splenic flexure mobilization with concomitant pelvic dissection, was more frequently performed using the da Vinci Xi platform with no increase in operative time, bleeding, or postoperative complications. The new platform provides surgeons an easier alternative to the da Vinci Si dual docking or combined robotic/laparoscopic multiquadrant surgery.

The essentials for any bowel anastomosis are: adequate perfusion, tension free, accurate tissue apposition, and minimal local spillage. Traditionally, perfusion is measured by assessing palpable pulses in the mesentery, active bleeding at cut edges, and lack of tissue discoloration. However, subjective methods lack predictive accuracy for an anastomotic leak. We used intraoperative indocyanine green (ICG) fluorescence angiography to objectively assess colon perfusion before a bowel anastomosis. Seventy-seven laparoscopic colorectal operations, between June 2013 and June 2014, were retrospectively reviewed. The perfusion to the colon and ileum was clinically assessed, and then measured using the SPY Elite Imaging System. The absolute value provided an objective number on a 0–256 gray-scale to represent differences in ICG fluorescence intensity. The lowest absolute value was used in data analysis for each anastomosis (including small bowel) to represent the theoretical least perfused/weakest anastomotic area. The lowest absolute value recorded was 20 in a patient who underwent a laparoscopic right hemicolectomy for an adenoma, with no postoperative complications. Four low anterior resection patients had additional segments of descending colon resected. There was one mortality in a patient who underwent a laparoscopic right hemicolectomy. This study illustrates an initial experience with the SPY system in colorectal surgery. The SPYprovides an objective, numerical value of bowel perfusion. However, evidence is scant as to the significance of these numbers. Large-scale randomized controlled trials are required to determine specific cutoff values correlated with surgical outcomes, specifically anastomotic leak rates.

Background and Objectives: Laparoscopic adjustable gastric banding is considered the least invasive surgical option for the treatment of morbid obesity. Its initial popularity has been marred by recent long-term studies showing high complication rates. We sought to examine our experience with gastric banding and factors leading to reoperation. Methods: We reviewed retrospective data of 305 patients who underwent laparoscopic adjustable gastric banding between 2004 and 2011 at a single institution, 42 patients of whom required a reoperation, constituting 13.8%. Patients undergoing elective reoperations for port protrusion from weight loss as a purely cosmetic issue were excluded (n = 10). Patients' demographic data, weight loss, time to reoperation, and complications were analyzed. Results: Of 305 patients, 42 (13.8%) required reoperations: 26 underwent band removal (8.5%) and 16 underwent port revision (5.2%). The mean weight and body mass index for all patients who underwent reoperations were 122.6 kg and 45.0 kg/m2, respectively. The most common complication leading to band removal was gastric prolapse (n = 14, 4.6%). The most common indication for port revision was a nonfunctioning port (n = 10, 3.3%). Conclusion: Laparoscopic adjustable gastric banding was initially popularized as a minimally invasive gastric-restrictive procedure with low morbidity. Our study showed a 13.8% reoperation rate at 3 years' follow-up. Most early reoperations (2 years) were likely to be performed for band removal. Laparoscopic adjustable gastric banding is associated with high reoperation rates; therefore bariatric surgeons should carefully consider other surgical weight-loss options tailored to the needs of the individual patient that may have lower complication and reoperation rates.

A hostile abdomen index presents a way to stratify risk and help track laparoscopic surgical complications., Background: Common life-threatening complications associated with laparoscopy, including bleeding and inadvertent enterotomy, are described in the literature. We investigated the application of the Hostile Abdomen Index related to these complications. We hypothesize that the preoperative score may guide a surgeon in risk stratification. Methods: We used data from Monmouth Medical Center morbidity and mortality conferences and reviewed bleeding and enterotomy complications in laparoscopic abdominal surgery. Complications were tracked using the Hostile Abdomen Index compared between 2 periods: published early experience with laparoscopic surgery (1998–2003) and unpublished late experience (2004–2010). The index ascribes a number (1–4) before a laparoscope is inserted and another number (1–4) after the laparoscope is inserted into the abdomen. Results: From 1998 to 2010, 43 patients had bleeding complications (0.45%) and 28 had inadvertent enterotomies (0.29%). There was no difference in bleeding between the early and late experiences. Enterotomy complications decreased in the late experience (P < .001). Our rescue success was 97.2% over 13 years. Those laparoscopic cases with high preoperative scores (3–4) had a higher rate of conversion to open procedures. Conclusions: The Hostile Abdomen Index can be used to track 2 potentially life-threatening laparoscopic complications. The index score has been explained to our surgeons on numerous occasions. A higher chance of bleeding and enterotomy or risk stratification correlates with a preoperative 3 or 4 score and may lead to a more cautious approach toward initial laparotomy or earlier conversion.

Dorsal lumbar hernias are rare pathologies of the abdominal wall. Such hernias may manifest within the superior lumbar triangle of Grynfeltt (TG) or the triangle of Petit. The aim of our study was to identify and describe variations in the size and anatomy of the TG. The triangle was studied in 50 adult human cadavers, and dimensions and surface area were measured. The TG was identified in 82% of cases. Based on surface area parameters, we were able to classify the triangles into four distinct types. Type I (50%), or small triangles, had a surface area of5 cm(2). Type II (22%, n=22) were defined as triangles intermediate in size with surface areas of 5-15 cm(2). Type III (10%, 10) were large triangles with surface areas of15 cm(2). Finally, Type 0 (18%, 18) did not exhibit a triangle; instead, the aponeurosis of the transversus abdominis was enclosed by the external abdominal oblique muscle and the sacrospinalis muscle. We present these data with the hope that after further investigation in a clinical setting, they may serve practitioners in predicting which morphometric variations of the TG most predispose patients to posterior wall herniation.

Torsion of a wandering spleen is a rare cause of acute abdomen in pediatric patients. Congenital absence of the splenic ligaments predisposes the spleen to axial rotation around its vascular pedicle and may lead to infarction. Computed tomography and/or ultrasound are valuable in making a timely diagnosis. Detorsion and splenopexy permit splenic salvage, potentially reducing late post-splenectomy associated complications. We report the case of a 9-year-old female with an upper respiratory tract infection and infarction of a wandering spleen. We review the literature on the management of this condition and hypothesize that vigorous coughing associated with upper respiratory infections may have caused the wandering spleen to undergo axial rotation around its pedicle.