We would like to acknowledge the Division of Thoracic and Foregut Surgery and the Department of Surgery at the University of Minnesota for helping us proceed with this study.

The protocol and methods described here were approved and followed the ethical guidelines of the Institutional Review Board (IRB) of the University of Minnesota. Described here is a reoperative hiatal hernia repair and takedown of a previous Nissen fundoplication in a 73-year-old woman. The patient presented to the clinic with a history of laparoscopic hiatal hernia repair and a fundoplication 5 years ago at an outside hospital for epigastric pain and fullness after meals. She also complained of significant reflux and dysphagia with solid food intake. Her symptoms had temporarily resolved after the first surgery but had now recurred. Of note, her body mass index (BMI) at the time of consultation was 40. No previous preoperative workup could be obtained prior to the consultation. The patient provided written informed consent before redo&#160;foregut surgery.
1. Patient preparation and operative set-up
<ol>
	<li>Preoperative workup and testing
	<ol>
		<li>Discuss the possibility of reoperation and proceed with a thorough workup as mentioned:
		<ol>
			<li>Perform an esophagram. The esophagram of this patient showed moderate to severe esophageal dysmotility (Figure 1).</li>
			<li>Perform endoscopy. For this patient, upper endoscopy showed no stenosis or strictures but&#160;demonstrated a portion of the stomach herniating upward through the diaphragm on a retroflexed view, which confirmed a hiatal hernia.</li>
			<li>Perform computed tomography of the abdomen. This test also confirmed a herniated wrap (Figure 2).</li>
			<li>Perform wireless esophageal pH testing. This showed a DeMeester score24,25 of 38.4 with borderline symptom association probability for acid reflux.</li>
			<li>Perform high-resolution manometry. In this patient, it showed a nonspecific motility disorder.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Preoperative planning
	<ol>
		<li>Ensure initial recommendations include weight loss and hence referral to a bariatric surgeon if needed. 
		NOTE: The patient did well with the weight loss program and could bring down her weight to a BMI of 32. At this point, she continued to have symptoms, and&#160;her case was discussed at the multidisciplinary esophageal conference for operative planning. The consensus was that the manometric findings were likely due to reflux and hernia and that a reoperative hernia repair with a loose fundoplication would be appropriate.</li>
	</ol>
	</li>
	<li>Anesthesia
	<ol>
		<li>Perform anesthesia following institutional guidelines. Intubate the patient with a single lumen endotracheal tube with rapid sequence intubation because of the risk of aspiration from reflux and a hiatal hernia. She had an arterial line for hemodynamic monitoring.</li>
	</ol>
	</li>
	<li>Positioning
	<ol>
		<li>Position the patient supine with her arms out and a footboard to facilitate steep reverse Trendelenburg positioning26.&#160;The chest and abdomen are always prepped into the field for foregut surgeries to have adequate access to the abdomen and chest if needed.</li>
	</ol>
	</li>
	<li>Port placement and docking
	<ol>
		<li>Use the open Hasson technique27 to enter the peritoneal cavity in the left supra-umbilical space. Insert the camera port here.</li>
		<li>Insert two more 8 mm ports in the left upper quadrant and one 8 mm port in the right upper quadrant. Place the ports about 10 cm above the umbilicus and ensure a handbreadth space between the ports.</li>
		<li>Place the assistant port in the right lower quadrant. Insert the liver retractor (see Table of Materials) through a 5 mm port placed in the extreme lateral portion of the right upper quadrant. 
		NOTE:&#160;It is the authors&#39; preference to place a left-sided chest tube during surgery because the hernia sac tends to be tethered to the pleura, especially in reoperative surgeries.</li>
		<li>Perform this before starting the dissection to minimize the chances of having to undock and reposition during the operation if there are significant hemodynamic changes from a pneumothorax that develops acutely during dissection.</li>
		<li>Dock the robot (see Table of Materials).</li>
	</ol>
	</li>
</ol>
2. Surgery procedure
<ol>
	<li>Reducing hiatal hernia
	<ol>
		<li>Remove&#160;the adhesions of the bowel to the abdominal wall and open the gastrohepatic ligament&#160;using a robotic bipolar surgical energy device.</li>
		<li>Open the lesser sac by removing adhesions and additional short gastric artery branches.</li>
		<li>Dissect&#160;the hernia sac&#160;circumferentially at the hiatus using a combination of blunt and electrocautery dissection with the robot.</li>
		<li>Dissect the dense adhesions between the liver and stomach carefully with laparoscopic scissors (see Table of Materials).</li>
	</ol>
	</li>
	<li>Takedown of previous fundoplications. 
	NOTE: Some but not all sutures from the previous wrap were visible.
	<ol>
		<li>Perform sharp dissection with laparoscopic scissors and undo the wrap to completely free the stomach.</li>
		<li>Carefully stay in the thin scar tissue to avoid damage to the stomach or esophagus.</li>
	</ol>
	</li>
	<li>Esophageal mobilization
	<ol>
		<li>Mobilize the esophagus transhiatally in the mediastinum. Perform this with a combination of blunt and sharp dissection and minimize the use of energy close to the esophagus.</li>
		<li>Next, confirm at least 3 cm of intraabdominal esophagus length. Use endoscopy to locate the gastroesophageal&#160;junction (GEJ)&#160;and measure the esophagus from the hiatus to the GEJ to confirm the adequate length.</li>
	</ol>
	</li>
	<li>Leak test
	<ol>
		<li>Perform endoscopy and visualize the mucosa clearly to ensure no injuries. Fill the upper abdomen with warm water and&#160;insufflate the esophagus and stomach to ensure no air leakage.</li>
	</ol>
	</li>
	<li>Hiatal repair
	<ol>
		<li>Perform crural repair using 0-silk sutures with two posterior crural stitches and one anterior crural stitch.</li>
		<li>Pass a 56 Fr bougie (see Table of Materials) into the esophagus, and with the bougie in place, pass a grasper comfortably into the hiatus. This is to ensure that the crural repair was not too tight.</li>
	</ol>
	</li>
	<li>Nissen fundoplication
	<ol>
		<li>Bring the fundus across the right side, posterior to the esophagus, and under the vagus nerve.</li>
		<li>Pass a 58 Fr bougie (see Table of Materials) into the esophagus.</li>
		<li>Perform a loose fundoplication over the bougie with three 2-0 silk sutures. 
		NOTE: Endoscopy confirmed a loose stack of coin-like appearance.</li>
	</ol>
	</li>
	<li>Gastropexy and G tube
	<ol>
		<li>Insert a percutaneous endoscopic gastrostomy tube into the stomach to serve as a gastropexy and a venting tube.</li>
	</ol>
	</li>
</ol>
3. Follow-up procedure
<ol>
	<li>Postoperatively, administer antiemetics to minimize the risk of postoperative nausea and vomiting as&#160;retching can disrupt the hernia repair or cause early recurrence.</li>
	<li>Initially, the gastric tube is left open to serve as a vent to prevent gastric distention. Eventually, clamp it on postoperative day 2 or 3 once the patient is tolerating liquids.</li>
	<li>Provide the patient with ice chips on the night of surgery. On postoperative day 1, ask the patient to start with sips of clear liquids with the gastric tube still open. On postoperative day 2, initiate a clear liquid diet and if the patient tolerates well, clamp the gastric tube. 
	NOTE: If tolerating clear liquids while clamped, a full liquid diet is started.</li>
	<li>Finally, instruct the patient on the advancement to a soft diet after 1 week with plans for clinic follow-up in 4 weeks with an esophagram and plans for gastric tube removal if not requiring significant venting.</li>
</ol>

Reoperative Hiatal Hernia Repair

<ol>
	<li>Awais, O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reoperative+antireflux+surgery+for+failed+fundoplication:+an+analysis+of+outcomes+in+275+patients.">Reoperative antireflux surgery for failed fundoplication: an analysis of outcomes in 275 patients.</a> The Annals of Thoracic Surgery. 92 (3), 1083-1089 (2011).</li><li>Furnee, E. J., Draaisma, W. A., Broeders, I. A., Gooszen, H. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+reintervention+after+failed+antireflux+surgery:+a+systematic+review+of+the+literature.">Surgical reintervention after failed antireflux surgery: a systematic review of the literature.</a> Journal of Gastrointestinal Surgery. 13 (8), 1539-1549 (2009).</li><li>Singhal, S., Kirkpatrick, D. R., Masuda, T., Gerhardt, J., Mittal, S. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Primary+and+redo+antireflux+surgery:+outcomes+and+lessons+learned.">Primary and redo antireflux surgery: outcomes and lessons learned.</a> Journal of Gastrointestinal Surgery. 22 (2), 177-186 (2018).</li><li>van Beek, D. B., Auyang, E. D., Soper, N. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+comprehensive+review+of+laparoscopic+redo+fundoplication.">A comprehensive review of laparoscopic redo fundoplication.</a> Surgical Endoscopy. 25 (3), 706-712 (2011).</li><li>Witek, T. D., Luketich, J. D., Pennathur, A., Awais, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Management+of+recurrent+paraesophageal+hernia.">Management of recurrent paraesophageal hernia.</a> Thoracic Surgury Clinics. 29 (4), 427-436 (2019).</li><li>Bathla, L., Legner, A., Tsuboi, K., Mittal, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+and+feasibility+of+laparoscopic+redo+fundoplication.">Efficacy and feasibility of laparoscopic redo fundoplication.</a> World Journal of Surgery. 35 (11), 2445-2453 (2011).</li><li>Pessaux, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+antireflux+surgery:+five-year+results+and+beyond+in+1340+patients.">Laparoscopic antireflux surgery: five-year results and beyond in 1340 patients.</a> The Archives of Surgery. 140 (10), 946-951 (2005).</li><li>Skinner, D. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+management+after+failed+antireflux+operations.">Surgical management after failed antireflux operations.</a> World Journal of Surgery. 16 (2), 359-363 (1992).</li><li>Nandipati, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reoperative+intervention+in+patients+with+mesh+at+the+hiatus+is+associated+with+high+incidence+of+esophageal+resection--a+single-center+experience.">Reoperative intervention in patients with mesh at the hiatus is associated with high incidence of esophageal resection--a single-center experience.</a> Journal of Gastrointestinal Surgery. 17 (12), 2039-2044 (2013).</li><li>Parker, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hiatal+mesh+is+associated+with+major+resection+at+revisional+operation.">Hiatal mesh is associated with major resection at revisional operation.</a> Surgical Endoscopy. 24 (12), 3095-3101 (2010).</li><li>Ashfaq, A., Rhee, H. K., Harold, K. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Revision+of+failed+transoral+incisionless+fundoplication+by+subsequent+laparoscopic+Nissen+fundoplication.">Revision of failed transoral incisionless fundoplication by subsequent laparoscopic Nissen fundoplication.</a> World Journal of Gastroenterology. 20 (45), 17115-17119 (2014).</li><li>Bell, R. C., Kurian, A. A., Freeman, K. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+anti-reflux+revision+surgery+after+transoral+incisionless+fundoplication+is+safe+and+effective.">Laparoscopic anti-reflux revision surgery after transoral incisionless fundoplication is safe and effective.</a> Surgical Endoscopy. 29 (7), 1746-1752 (2015).</li><li>Puri, R., Smith, C. D., Bowers, S. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+spectrum+of+surgical+remediation+of+transoral+incisionless+fundoplication-related+failures.">The spectrum of surgical remediation of transoral incisionless fundoplication-related failures.</a> Journal of Laparoendoscopic &amp; Advanced Surgical Techniques. 28 (9), 1089-1093 (2018).</li><li>Del Campo, S. E. M., Mansfield, S. A., Suzo, A. J., Hazey, J. W., Perry, K. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+redo+fundoplication+improves+disease-specific+and+global+quality+of+life+following+failed+laparoscopic+or+open+fundoplication.">Laparoscopic redo fundoplication improves disease-specific and global quality of life following failed laparoscopic or open fundoplication.</a> Surgical Endoscopy. 31 (11), 4649-4655 (2017).</li><li>Smith, C. D., McClusky, D. A., Rajad, M. A., Lederman, A. B., Hunter, J. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=When+fundoplication+fails:+redo.">When fundoplication fails: redo.</a> Annals of Surgery. 241 (6), 861-869 (2005).</li><li>Wilshire, C. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+outcomes+of+reoperation+for+failed+antireflux+operations.">Clinical outcomes of reoperation for failed antireflux operations.</a> The Annals of thoracic surgery. 101 (4), 1290-1296 (2016).</li><li>Zundel, N., Melvin, W. S., Patti, M. G., Camacho, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Benign Esophageal Disease: Modern Surgical Approaches and Techniques. , (2021).</li><li>Addo, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+revision+paraesophageal+hernia+repair:+a+16-year+experience+at+a+single+institution.">Laparoscopic revision paraesophageal hernia repair: a 16-year experience at a single institution.</a> Surgical Endoscopy. 37 (1), 624-630 (2023).</li><li>Autorino, R., Zargar, H., Kaouk, J. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+laparoscopic+surgery:+recent+advances+in+urology.">Robotic-assisted laparoscopic surgery: recent advances in urology.</a> Fertility and sterility. 102 (4), 939-949 (2014).</li><li>Matanes, E., Lauterbach, R., Boulus, S., Amit, A., Lowenstein, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+laparoendoscopic+single-site+surgery+in+gynecology:+a+systematic+review.">Robotic laparoendoscopic single-site surgery in gynecology: a systematic review.</a> European Journal of Obstetrics &amp; Gynecology and Reproductive Biology. 231, 1-7 (2018).</li><li>Font, A. C., Farrarons, S. S., Bosch, C. A., Mart&#237;n, M. V., Savall, E. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=635+robotic+redo+funduplication+for+a+two+time+recurrent+hiatal+hernia.+How+we+do.">635 robotic redo funduplication for a two time recurrent hiatal hernia. How we do.</a> Diseases of the Esophagus. 34 (Supplement_1), (2021).</li><li>Soliman, B. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+hiatal+hernia+repair+demonstrates+favorable+short-term+outcomes+compared+to+laparoscopic+hiatal+hernia+repair.">Robot-assisted hiatal hernia repair demonstrates favorable short-term outcomes compared to laparoscopic hiatal hernia repair.</a> Surgical Endoscopy. 34 (6), 2495-2502 (2020).</li><li>Tolboom, R. C., Draaisma, W. A., Broeders, I. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+conventional+laparoscopic+versus+robot-assisted+laparoscopic+redo+hiatal+hernia+and+antireflux+surgery:+a+cohort+study.">Evaluation of conventional laparoscopic versus robot-assisted laparoscopic redo hiatal hernia and antireflux surgery: a cohort study.</a> Journal of robotic surgery. 10, 33-39 (2016).</li><li>Jamieson, J. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ambulatory+24-h+esophageal+pH+monitoring:+normal+values,+optimal+thresholds,+specificity,+sensitivity,+and+reproducibility.">Ambulatory 24-h esophageal pH monitoring: normal values, optimal thresholds, specificity, sensitivity, and reproducibility.</a> American Journal of Gastroenterology. 87 (9), 1102-1102 (1992).</li><li>Johnson, L. F., DeMeester, T. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+of+the+24-hour+intraesophageal+pH+monitoring+composite+scoring+system.">Development of the 24-hour intraesophageal pH monitoring composite scoring system.</a> Journal of clinical gastroenterology. 8, 52-58 (1986).</li><li>Siegal, S. R., Dolan, J. P., Hunter, J. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Modern+diagnosis+and+treatment+of+hiatal+hernias.">Modern diagnosis and treatment of hiatal hernias.</a> Langenbeck's Archives of Surgery. 402 (8), 1145-1151 (2017).</li><li>Hasson, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+modified+instrument+and+method+for+laparoscopy.">A modified instrument and method for laparoscopy.</a> American Journal of Obstetrics and Gynecology. 110 (6), 886-887 (1971).</li><li>Al Hashmi, A. -. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+retrospective+multicenter+analysis+on+redo-laparoscopic+anti-reflux+surgery:+conservative+or+conversion+fundoplication.">A retrospective multicenter analysis on redo-laparoscopic anti-reflux surgery: conservative or conversion fundoplication.</a> Surgical Endoscopy. 33 (1), 243-251 (2019).</li><li>Broeders, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Systematic+review+and+meta-analysis+of+laparoscopic+Nissen+(posterior+total)+versus+Toupet+(posterior+partial)+fundoplication+for+gastro-oesophageal+reflux+disease.">Systematic review and meta-analysis of laparoscopic Nissen (posterior total) versus Toupet (posterior partial) fundoplication for gastro-oesophageal reflux disease.</a> Journal of British Surgery. 97 (9), 1318-1330 (2010).</li><li>Bakhos, C. T., Petrov, R. V., Parkman, H. P., Malik, Z., Abbas, A. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Role+and+safety+of+fundoplication+in+esophageal+disease+and+dysmotility+syndromes.">Role and safety of fundoplication in esophageal disease and dysmotility syndromes.</a> Journal of Thoracic Disease. 11 (Suppl 12), S1610 (2019).</li><li>Barnett, D. R., Balalis, G. L., Myers, J. C., Devitt, P. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnosis+and+treatment+of+pseudoachalasia:+how+to+catch+the+mimic.">Diagnosis and treatment of pseudoachalasia: how to catch the mimic.</a> 3, (2020).</li><li>Bonavina, L., Bona, D., Saino, G., Clemente, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pseudoachalasia+occurring+after+laparoscopic+Nissen+fundoplication+and+crural+mesh+repair.">Pseudoachalasia occurring after laparoscopic Nissen fundoplication and crural mesh repair.</a> Langenbeck's Archives of Surgery. 392 (5), 653-656 (2007).</li><li>Haj Ali, S. N., Nguyen, N. Q., Abu Sneineh, A. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pseudoachalasia:+a+diagnostic+challenge.+When+to+consider+and+how+to+manage.">Pseudoachalasia: a diagnostic challenge. When to consider and how to manage.</a> Scandinavian Journal of Gastroenterology. 56 (7), 747-752 (2021).</li><li>Felix, V. N., Murayama, K. M., Bonavina, L., Park, M. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Achalasia:+what+to+do+in+the+face+of+failures+of+Heller+myotomy.">Achalasia: what to do in the face of failures of Heller myotomy.</a> Annals of the New York Academy of Sciences. 1481 (1), 236-246 (2020).</li><li>Gorecki, P. J., Hinder, R. A., Libbey, J. S., Bammer, T., Floch, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Redo+laparoscopic+surgery+for+achalasia.">Redo laparoscopic surgery for achalasia.</a> Surgical Endoscopy. 16 (5), 772-776 (2002).</li><li>Markakis, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Belsey+Mark+IV:+an+operation+with+an+enduring+role+in+the+management+of+complicated+hiatal+hernia.">The Belsey Mark IV: an operation with an enduring role in the management of complicated hiatal hernia.</a> BMC surgery. 13, 1-6 (2013).</li><li>Cowgill, S. M., Arnaoutakis, D., Villadolid, D., Rosemurgy, A. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=34;Redo&amp;#34;+fundoplications:+satisfactory+symptomatic+outcomes+with+higher+cost+of+care.">34;Redo&amp;#34; fundoplications: satisfactory symptomatic outcomes with higher cost of care.</a> Journal of Surgical Research. 143 (1), 183-188 (2007).</li><li>Makris, K. I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+role+of+short-limb+Roux-en-Y+reconstruction+for+failed+antireflux+surgery:+a+single-center+5-year+experience.">The role of short-limb Roux-en-Y reconstruction for failed antireflux surgery: a single-center 5-year experience.</a> Surgical Endoscopy. 26 (5), 1279-1286 (2012).</li><li>Wendling, M. R., Melvin, W. S., Perry, K. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+transoral+incisionless+fundoplication+(TIF)+on+subjective+and+objective+GERD+indices:+a+systematic+review+of+the+published+literature.">Impact of transoral incisionless fundoplication (TIF) on subjective and objective GERD indices: a systematic review of the published literature.</a> Surgical Endoscopy. 27 (10), 3754-3761 (2013).</li><li>Parker, B., Reavis, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Benign+Esophageal+Disease.">Benign Esophageal Disease.</a> , 71-89 (2021).</li></ol>

The authors have nothing to disclose.

Reoperative foregut surgery is technically challenging but can be performed safely with a well-planned and thoughtful surgical approach. A thorough preoperative evaluation is essential to determine the etiology of symptoms and to guide diagnostic adjuncts. It is of utmost importance to determine the correct diagnosis prior to reintervention in order to determine the proper surgery and approach. For example, in patients undergoing redo&#160;anti-reflux&#160;surgery (ARS) after Nissan fundoplication, one should understand ...

Over the past century, improvements in the understanding and diagnosis of foregut disorders have led to the evolution of better procedures and surgical approaches. This innovation brings new challenges related to complications and reoperation for the foregut surgeon. Surgical reinterventions are particularly challenging from a technical perspective due to multiple factors, including dense adhesions, scarring, obliteration of tissue planes, and altered anatomy1,2,3,4,5. These redo foregut surgeries&#160;have increased morbidity in patients with higher incidences of esophageal perforation, delayed gastric emptying, and vagal nerve injury1,6,7,8. Mesh repairs at the hiatus complicate reintervention further, having higher rates of major resection requiring complex reconstruction9,10. The advent of advanced endoscopic therapies creates ever-evolving challenges for foregut surgeons when dealing with their associated complications or failures11,12,13. Furthermore, redo foregut operations are associated with worsening success rates and patient satisfaction with successive reoperations compared with primary intervention14,15,16,17. This highlights the importance of patient selection and accurate diagnosis prior to redo surgery for optimal outcomes.
While traditionally performed using an open approach, laparoscopic approaches to redo foregut surgery are safe and efficacious14,18. However, due to the greater difficulty associated with altered anatomy and adhesions, conversion to open surgery is still a possibility. With the emergence of robot-assisted surgery in urology and gynecologic surgery19,20, the superior visualization and dexterity compared to laparoscopy would appear to likely have some benefit in redo foregut surgery as well. Indeed, emerging research has shown safety and improved outcomes, including less conversions to open surgery and decreased hospital stays compared with the laparoscopic approach for redo foregut surgery21,22,23.
Although it is ultimately up to the foregut surgeon to determine the safest procedure, this article aims to demonstrate the approach and technical considerations for redo foregut surgery to provide a &#34;framework&#34; when confronted with this challenge. While a robotic-assisted approach is described, the principles described could be similarly applied to laparoscopy.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Bravo calibration-free reflux testing system</td>
			<td>Medtronic</td>
			<td>FGS-0635</td>
			<td>Wireless esophageal pH testing system</td>
		</tr>
		<tr>
			<td>Cadiere forceps</td>
			<td>IS</td>
			<td>470049</td>
			<td>Used as a grasper</td>
		</tr>
		<tr>
			<td>da Vinci Surgeon Console</td>
			<td>IS</td>
			<td>SS999</td>
			<td>Used to control surgical robot</td>
		</tr>
		<tr>
			<td>da Vinci Vision Cart</td>
			<td>IS</td>
			<td>VS999</td>
			<td>Houses advanced vision and energy technologies to provide communication across the platform components</td>
		</tr>
		<tr>
			<td>da Vinci Xi</td>
			<td>IS</td>
			<td>K131861</td>
			<td>The surgical robot</td>
		</tr>
		<tr>
			<td>da Vinci Xi Endoscope with Camera, 8 mm, 30&#176;</td>
			<td>IS</td>
			<td>470027</td>
			<td>The camera for the da Vinci robot</td>
		</tr>
		<tr>
			<td>Lapro-Flex Articulating Retractors</td>
			<td>Mediflex</td>
			<td>91682</td>
			<td>Used as liver retractor</td>
		</tr>
		<tr>
			<td>Large needle driver</td>
			<td>IS</td>
			<td>470006</td>
			<td>Used as a needle driver</td>
		</tr>
		<tr>
			<td>Maloney Tapered Esophageal Bougie, 56 Fr</td>
			<td>Pilling</td>
			<td>507956</td>
			<td>Esophageal bougie for hiatal repair</td>
		</tr>
		<tr>
			<td>Maloney Tapered Esophageal Bougie, 58 Fr</td>
			<td>Pilling</td>
			<td>507958</td>
			<td>Esophageal bougie for wrap creation</td>
		</tr>
		<tr>
			<td>Mega SutureCut needle driver</td>
			<td>IS</td>
			<td>470309</td>
			<td>Used as a needle driver</td>
		</tr>
		<tr>
			<td>Monolithic FlexArm Plus</td>
			<td>Mediflex</td>
			<td>99045-QC</td>
			<td>Used to hold liver retractor to OR bed</td>
		</tr>
		<tr>
			<td>Round tip scissors</td>
			<td>IS</td>
			<td>470007</td>
			<td>Used for cutting</td>
		</tr>
		<tr>
			<td>Shiley Hi-Lo oral/nasal endotracheal tube cuffed, 8.0 mm</td>
			<td>Covidien</td>
			<td>86113</td>
			<td>Endotracheal tube for intubation</td>
		</tr>
		<tr>
			<td>SynchroSeal</td>
			<td>IS</td>
			<td>480440</td>
			<td>Used for dissecting, vessel sealing, and dividing</td>
		</tr>
		<tr>
			<td>Tip-Up fenestrated grasper</td>
			<td>IS</td>
			<td>470347</td>
			<td>Used as a grasper</td>
		</tr>
	</tbody>
</table>

technical considerations and approach to redo foregut surgery

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical considerations have arisen when dealing with reoperation for complications or surgical failure. This study focuses on the technical considerations and approach when dealing with reoperative foregut surgery, particularly redo&#160;hiatal hernia repair. We describe our approach starting from the preoperative workup to the procedural steps of the surgery. The present study describes the main steps for robotic reoperative hiatal hernia repair in a patient who had previously undergone laparoscopic hiatal hernia repair with Nissen fundoplication but did not present a recurrence of reflux and dysphagia symptoms. The patient is positioned supine with arms out and a footboard for steep Trendelenburg. We place six trocars, including an assistant port and a liver retractor port,&#160;to facilitate visualization and retraction. After docking the robot, we use a combination of electrocautery and sharp dissection&#160;to free the hernia sac and reduce the hiatal hernia. The previous fundoplication is then taken down carefully and the esophagus is mobilized through a transhiatal approach with a combination of blunt and sharp dissection until at least 3 cm of intra-abdominal esophageal length is achieved, after which a leak test is performed. We then perform a crural repair to reapproximate the hiatus with two posterior stitches and one anterior stitch. Lastly, a redo Nissen fundoplication is performed over a bougie, and endoscopy is used to confirm a loose stack-of-coin appearance. By emphasizing the crucial steps of redo hiatal hernia repair, including preoperative evaluation, our goal is to provide an approach for the foregut surgeon to maximize patient outcomes.

The patient had an uneventful postoperative course. She slowly advanced to a full liquid diet over a period of 3 days and was then discharged on a liquid diet with instructions to advance to a soft diet after 1 week.
By virtue of being a quaternary referral center and a major university hospital, we frequently manage patients needing reoperative foregut surgery. Our data from the last 5 years with 43 patients undergoing reoperative hiatal hernia repairs showed a mean length of stay of 7 days a...

Watch this Scientific Journal Video about Technical Considerations and Approach to Redo Foregut Surgery at JoVE.com

Author Spotlight: Recent Advancements in Reoperative Foregut Surgery

Redo foregut surgery is associated with increased patient morbidity and presents a technical challenge for the surgeon. We describe our approach and considerations when performing a redo hiatal hernia repair to provide a guide for other surgeons and improve patient outcomes.

Technical Considerations and Approach to Redo Foregut Surgery

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical ...

technical-considerations-and-approach-to-redo-foregut-surgery

Research

JoVE Journal

Medicine

402 Views.  University of Minnesota. Redo foregut surgery is associated with increased patient morbidity and presents a technical challenge for the surgeon. We describe our approach and considerations when performing a redo hiatal hernia repair to provide a guide for other surgeons and improve patient outcomes.

Video: Author Spotlight: Recent Advancements in Reoperative Foregut Surgery

Microvascular Decompression: Salient Surgical Principles and Technical Nuances

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports indicate that 80-90% of cases are related to compression of the trigeminal nerve by an adjacent vessel. The majority of patients with trigeminal neuralgia eventually require surgical management in order to achieve remission of symptoms. Surgical options for management include ablative procedures (e.g., radiosurgery, percutaneous radiofrequency lesioning, balloon compression, glycerol rhizolysis, etc.) and microvascular decompression. Ablative procedures fail to address the root cause of the disorder and are less effective at preventing recurrence of symptoms over the long term than microvascular decompression. However, microvascular decompression is inherently more invasive than ablative procedures and is associated with increased surgical risks. Previous studies have demonstrated a correlation between surgeon experience and patient outcome in microvascular decompression. In this series of 59 patients operated on by two neurosurgeons (JSN and PEK) since 2006, 93% of patients demonstrated substantial improvement in their trigeminal neuralgia following the procedure&#x2014;with follow-up ranging from 6 weeks to 2 years. Moreover, 41 of 66 patients (approximately 64%) have been entirely pain-free following the operation.
In this publication, video format is utilized to review the microsurgical pathology of this disorder. Steps of the operative procedure are reviewed and salient principles and technical nuances useful in minimizing complications and maximizing efficacy are discussed.

There are many available options for management of the patient with trigeminal neuralgia. Microvascular decompression, while the most invasive of all options, is also the most effective at achieving long term remission of symptoms. Video instruction on how to maximize efficacy and minimize complications with this procedure is described.

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports ...

Technical Aspects of the Mouse Aortocaval Fistula

Technical aspects of creating an arteriovenous fistula in the mouse are discussed. Under general anesthesia, an abdominal incision is made, and the aorta and inferior vena cava (IVC) are exposed. The proximal infrarenal aorta and the distal aorta are dissected for clamp placement and needle puncture, respectively. Special attention is paid to avoid dissection between the aorta and the IVC. After clamping the aorta, a 25 G needle is used to puncture both walls of the aorta into the IVC. The surrounding connective tissue is used for hemostatic compression. Successful creation of the AVF will show pulsatile arterial blood flow in the IVC. Further confirmation of successful AVF can be achieved by post-operative Doppler ultrasound.

The goal is to produce an arteriovenous fistula that is simple and reproducible. This method does not use sutures or glue adhesive. Therefore the samples can be used with the least amount of foreign materials for analysis.

Technical aspects of creating an arteriovenous fistula in the mouse are discussed. Under general anesthesia, an abdominal incision is made, and the aorta ...

Tissue-simulating Phantoms for Assessing Potential Near-infrared Fluorescence Imaging Applications in Breast Cancer Surgery

Inaccuracies in intraoperative tumor localization and evaluation of surgical margin status result in suboptimal outcome of breast-conserving surgery (BCS). Optical imaging, in particular near-infrared fluorescence (NIRF) imaging, might reduce the frequency of positive surgical margins following BCS by providing the surgeon with a tool for pre- and intraoperative tumor localization in real-time. In the current study, the potential of NIRF-guided BCS is evaluated using tissue-simulating breast phantoms for reasons of standardization and training purposes.
Breast phantoms with optical characteristics comparable to those of normal breast tissue were used to simulate breast conserving surgery. Tumor-simulating inclusions containing the fluorescent dye indocyanine green (ICG) were incorporated in the phantoms at predefined locations and imaged for pre- and intraoperative tumor localization, real-time NIRF-guided tumor resection, NIRF-guided evaluation on the extent of surgery, and postoperative assessment of surgical margins. A customized NIRF camera was used as a clinical prototype for imaging purposes.
Breast phantoms containing tumor-simulating inclusions offer a simple, inexpensive, and versatile tool to simulate and evaluate intraoperative tumor imaging. The gelatinous phantoms have elastic properties similar to human tissue and can be cut using conventional surgical instruments. Moreover, the phantoms contain hemoglobin and intralipid for mimicking absorption and scattering of photons, respectively, creating uniform optical properties similar to human breast tissue. The main drawback of NIRF imaging is the limited penetration depth of photons when propagating through tissue, which hinders (noninvasive) imaging of deep-seated tumors with epi-illumination strategies.

Near-infrared fluorescence (NIRF) imaging may improve therapeutic outcome of breast cancer surgery by enabling intraoperative tumor localization and evaluation of surgical margin status. Using tissue-simulating breast phantoms containing fluorescent tumor-simulating inclusions, potential clinical applications of NIRF imaging in breast cancer patients can be assessed for standardization and training purposes.

Inaccuracies in intraoperative tumor localization and evaluation of surgical margin status result in suboptimal outcome of breast-conserving surgery ...

A Murine Model of Arterial Restenosis: Technical Aspects of Femoral Wire Injury

Cardiovascular disease caused by atherosclerosis is the leading cause of death in the developed world. Narrowing of the vessel lumen, due to atherosclerotic plaque development or the rupturing of established plaques, interrupts normal blood flow leading to various morbidities such as myocardial infarction and stroke. In the clinic endovascular procedures such as angioplasty are commonly performed to reopen the lumen. However, these treatments inevitably damage the vessel wall as well as the vascular endothelium, triggering an excessive healing response and the development of a neointimal plaque that extends into the lumen causing vessel restenosis (re-narrowing). Restenosis remains a major cause of failure of endovascular treatments for atherosclerosis. Thus, preclinical animal models of restenosis are vitally important for investigating the pathophysiological mechanisms as well as translational approaches to vascular interventions. Among several murine experimental models, femoral artery wire injury is widely accepted as the most suitable for studies of post-angioplasty restenosis because it closely resembles the angioplasty procedure that injures both endothelium and vessel wall. However, many researchers have difficulty utilizing this model due to its high degree of technical difficulty. This is primarily because a metal wire needs to be inserted into the femoral artery, which is approximately three times thinner than the wire, to generate sufficient injury to induce prominent neointima. Here, we describe the essential surgical details to effectively overcome the major technical difficulties of this model. By following the presented procedures, performing the mouse femoral artery wire injury becomes easier. Once familiarized, the whole procedure can be completed within 20 min.

The mouse femoral artery wire injury model of restenosis is technically challenging. In this protocol we show the key technical details essential for successfully performing wire injury to induce consistent&#160;neointima for studies of restenosis.

Cardiovascular disease caused by atherosclerosis is the leading cause of death in the developed world. Narrowing of the vessel lumen, due to ...

Murine Flexor Tendon Injury and Repair Surgery

Tendon connects skeletal muscle and bone, facilitating movement of nearly the entire body. In the hand, flexor tendons (FTs) enable flexion of the fingers and general hand function. Injuries to the FTs are common, and satisfactory healing is often impaired due to excess scar tissue and adhesions between the tendon and surrounding tissue. However, little is known about the molecular and cellular components of FT repair. To that end, a murine model of FT repair that recapitulates many aspects of healing in humans, including impaired range of motion and decreased mechanical properties, has been developed and previously described. Here an in-depth demonstration of this surgical procedure is provided, involving transection and subsequent repair of the flexor digitorum longus (FDL) tendon in the murine hind paw.&#160;This technique can be used to conduct lineage analysis of different cell types, assess the effects of gene gain or loss-of-function, and to test the efficacy of pharmacological interventions in the healing process. However, there are two primary limitations to this model: i) the FDL tendon in the mid-portion of the murine hind paw, where the transection and repair occur, is not surrounded by a synovial sheath. Therefore this model does not account for the potential contribution of the sheath to the scar formation process. ii) To protect the integrity of the repair site, the FT is released at the myotendinous junction, decreasing the mechanical forces of the tendon, likely contributing to increased scar formation. Isolation of sufficient cells from the granulation tissue of the FT during the healing process for flow cytometric analysis has proved challenging; cytology centrifugation to concentrate these cells is an alternate method used, and allows for generation of cell preparations on which immunofluorescent labeling can be performed. With this method, quantification of cells or proteins of interest during FT healing becomes possible.

Flexor tendons in the hand are commonly injured, leading to impaired hand function. However, the scar-tissue healing response is not well characterized. A murine model of flexor tendon healing is demonstrated here. This model can enhance overall understanding of the healing process and assess therapeutic approaches to improve healing.

Tendon connects skeletal muscle and bone, facilitating movement of nearly the entire body. In the hand, flexor tendons (FTs) enable flexion of the fingers ...

A Clinical Trial Assessing the Safety, Efficacy, and Delivery of Olive-Oil-Based Three-Chamber Bags for Parenteral Nutrition

Limited evidence exists to precisely estimate efficacy and safety differences between parenteral nutrition (PN) prepared using olive-oil-based three-chamber bags (3CBs) and soybean-oil-based compounded bags (CoBs) in hospitalized adult patients. We designed a multicenter, randomized, prospective, open-label, noninferiority protocol to compare the efficacy, safety, and distribution of olive-oil-based 3CBs and soybean-oil-based CoB formulations in adult Chinese patients requiring PN during surgical intervention. Subjects were randomized to receive either one of the study treatments using an interactive voice or web-based recognition system in accordance with the randomization code. Randomization was further stratified based on the study site and surgical category. Both treatment groups received similar amounts of calories and protein. In addition, the two study treatments contained a similar composition of the amino-acid component. The only difference between the two PN formulations was the lipid constitution. The duration of administration of study treatments was a minimum of 5 days up to a maximum of 14 days after the surgical procedure. The primary efficacy endpoint was serum prealbumin levels on day 5 of the study. Noninferiority was proved if the anti-log of the lower bound of the 95% confidence interval (CI) of the treatment difference was at least 0.80. Other efficacy measures included treatment preparation time; duration to achieve tolerability of oral nutrition; associated infectious complications; length of hospitalization; and laboratory assessment of markers of nutrition, inflammation, metabolism, and oxidative stress. A total of 458 patients were enrolled in the study. The results showed that olive-oil-based 3CBs were non-inferior to soybean-based CoBs, besides being well tolerated. The infection rate was found to be significantly lower in the olive-oil-based 3CB group. Thus, this study may be used as a reference for future research on lipid emulsion and 3CBs.

Here, we present a protocol for a study comparing the efficacy, safety, and delivery of olive-oil-based 3CB and soybean-oil-based CoB formulations in adults requiring parenteral nutrition. The results revealed that olive-oil-based 3CBs is non-inferior and well tolerated compared to soybean formulations.

Limited evidence exists to precisely estimate efficacy and safety differences between parenteral nutrition (PN) prepared using olive-oil-based ...

Designing CAD/CAM Surgical Guides for Maxillary Reconstruction Using an In-house Approach

Computer-aided design/computer-assisted manufacturing (CAD/CAM) is now being evaluated as a preparative technique for maxillofacial surgery. Because this technique is expensive and available in only limited areas of the world, we developed a novel CAD/CAM surgical guide using an in-house approach. By using the CAD software, the maxillary resection area and cutting planes and the fibular cutting planes and angles are determined. Once the resection area is decided, the necessary faces are extracted using a Boolean modifier. These superficial faces are united to fit the surface of the bones and thickened to stabilize the solids. Not only the cutting guides for the fibula and maxilla but also the location arrangement of the transferred bone segments is defined by thickening the superficial faces. The CAD design is recorded as .stl files and three-dimensionally (3-D) printed as actual surgical guides. To check the accuracy of the guides, model surgery using 3-D-printed facial and fibular models is performed. These methods may be used to assist surgeons where commercial guides are not available.

Methods for designing a computer-aided design/computer-aided manufacturing (CAD/CAM) surgical guide are shown. Cutting planes are separated, united, and thickened to easily visualize the necessary bone transfer. These designs can be three-dimensional printed and checked for accuracy.

Computer-aided design/computer-assisted manufacturing (CAD/CAM) is now being evaluated as a preparative technique for maxillofacial surgery. Because this ...

Orthotopic Rat Kidney Transplantation: A Novel and Simplified Surgical Approach

Kidney transplantation offers increased survival rates and improved quality of life for patients with end-stage renal disease, as compared to any type of renal replacement therapy. Over the past few decades, the rat kidney transplantation model has been used to study the immunological phenomena of rejection and tolerance. This model has become an indispensable tool to test new immunomodulatory pharmaceuticals and regimens prior to proceeding with expensive preclinical large animal studies.
This protocol provides a detailed overview of how to reliably perform orthotopic kidney transplantation in rats. This protocol includes three distinctive steps that increase the probability of success: perfusion of the donor kidney by flushing through the portal vein and the use of a cuff system to anastomose the renal veins and ureters, thereby decreasing cold and warm ischemia times. Using this technique, we have achieved survival rates beyond 6 months with normal serum creatinine in animals with syngeneic or tolerant kidney transplants. Depending on the aim of the study, this model can be modified by pre- or posttransplant treatments to study the acute, chronic, cellular, or antibody-mediated rejection. It is a reproducible, reliable, and cost-effective animal model to study different aspects of kidney transplantation.

The purpose of this manuscript and protocol is to explain and demonstrate in detail the surgical procedure of orthotopic kidney transplantation in rats. This method is simplified to achieve the correct perfusion of the donor kidney and shorten the reperfusion time by using the venous and ureteral cuff anastomosis technique.

Kidney transplantation offers increased survival rates and improved quality of life for patients with end-stage renal disease, as compared to any type of ...

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic platform, including three-dimensional vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate the principles of open pancreatoduodenectomy allowing safe oncologic dissection, hemostasis, and meticulous reconstruction. Over the course of the past decade, significant strides have been achieved in outlining the safety, feasibility, and learning curve of the robotic Whipple. When performed by high volume pancreatic surgeons experienced in RPD, recent comparative effectiveness studies show potential advantages compared to the open technique, including reductions in hospital stay and morbidity. National data also show reductions in conversion rates compared to its laparoscopic counterpart. Although long-term oncologic data are still needed, short-term oncologic surrogates of margin resection and lymph node harvest suggest no compromise in oncologic outcomes. As pancreatic surgeons increasingly integrate robotics into their practice, proficiency-based training and credentialing will be necessary for the safe application and dissemination of RPD. Here, we provide the detailed steps of a robotic pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.&#160;

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

The Microscopic Transcanal Approach in Stapes Surgery Revisited

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the external auditory canal, the middle ear, and epitympanon. Such an approach avoids a retroauricular or endaural skin incision; however, working through a narrow space needs angled microsurgical instruments and specific training in otologic surgery. The transcanal approach restricts the working space; however, it offers a binocular microscopic vision into the middle ear without extended skin incisions and thus, reducing post-operative pain and bleeding. In addition, this minimally invasive approach avoids scar tissue complications, hypoesthesia of the auricle, and potential protrusion of the pinna. Despite its numerous advantages, this method is still not routinely performed by otologic surgeons. Since this minimally invasive technique is more challenging, there is a need for extensive training in order for it to be widely adopted by otologic surgeons. This article provides step-by-step surgical instructions for stapes surgery and reports possible indications, pitfalls, and limitations using this microscopic transcanal technique.

This article describes the microscopic transcanal technique for stapes surgery, providing step-by-step surgical instructions for familiarizing surgeons with this approach.