Trash to treasure Retcam.

Digital fundus imaging is being used in diagnosis, documentation, and sharing of many retinal diseases and hence forms an essential part of ophthalmology. The use of smartphones for the same has been ever increasing. There is a need for simpler devices to couple the 20D lens and smartphone so as to take fundus photographs which can help in fundus documentation. This article describes a simple inexpensive technique of preparing a smartphone fundus photography device (Trash To Treasure (T3) Retcam) from the used materials in the clinics within minutes. This article will also review the optical principles of the T3 Retcam and describe the step-by-step method to record good-quality retinal image/videos. This inexpensive device is made by recycling and modifying the plastic hand sanitizer bottle in the clinics/hospitals which can be used for documenting, diagnosing, screening, and academic purposes.

Vitamin D, inflammation, and relations to insulin resistance in premenopausal women with morbid obesity.

OBJECTIVE: In this study, the associations between vitamin D, insulin sensitivity, and inflammation and their relationships with adipose tissue expression of vitamin D receptor (VDR) and inflammatory markers in women with morbid obesity were determined. METHODS: An oral glucose tolerance test prior to surgery was completed by healthy premenopausal women (n = 76) seeking bariatric surgery. Abdominal subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) were collected during surgery. RESULTS: Approximately, 70% of our subjects were vitamin D sufficient or optimal, and 80% had normal glucose tolerance. No significant association between serum 25-hydroxyvitamin D [25(OH)D] with circulating inflammatory markers or insulin sensitivity was identified. In subjects with waist circumference of <139 cm (n = 42), log25(OH)D positively predicted VAT logIL-6 mRNA expression (P = 0.003). LogVDR expression was positively correlated with the expression of inflammatory markers in both SAT (logIL-1ß mRNA: r = 0.95, P < 0.0001; logTNF mRNA: r = 0.82, P < 0.0001) and VAT (logIL-1ß mRNA: r = 0.89, P < 0.0001; logTNF mRNA: r = 0.75, P < 0.0001). VAT logVDR expression positively predicted logHOMA-IR in non-African American subjects (P = 0.05). CONCLUSIONS: The beneficial effects of vitamin D on inflammation and insulin sensitivity were not supported by our findings. VDR does not appear to possess a protective effect in adipose tissue.

Combined Robot-assisted Kidney Transplantation and Sleeve Gastrectomy in a Morbidly Obese Recipient.

BACKGROUND: Kidney transplantation confers a well-documented survival advantage for patients with end-stage renal disease (ESRD) over dialysis, regardless of body mass index (BMI). However, obese patients with ESRD have limited access to kidney transplantation. In most transplant centers, a patient with a BMI above 35 to 40 kg/m is either completely excluded from transplantation or is required to lose weight before being considered for transplantation. MATERIALS AND METHODS: Herein, we present the first case of a 35-year-old woman with a BMI of 42 kg/m (96.8 kg) and ESRD, who underwent combined robot-assisted kidney transplant and sleeve gastrectomy. RESULTS: The total operative time was 318 minutes with an estimated blood loss of 125 mL. At 24 months after transplantation, the patient's weight, BMI, creatinine, and estimated glomerular filtration rate were 81.9 kg, 35.1 kg/m, 0.79 mg/dL, and 81.2 mL/min per 1.73 m, respectively. CONCLUSIONS: Combined robot-assisted kidney transplant and sleeve gastrectomy is feasible in morbidly obese patients and adds little additional operative time.

Robotic revisional bariatric surgery: single-surgeon case series.

BACKGROUND: Bariatric surgery is the only effective treatment for the long-term maintenance of significant weight loss. Minimally invasive revisional procedures are on the rise. Data is lacking in terms of safety, feasibility and outcomes with robotic revisional procedures. METHODS: Robotic revisional bariatric procedures (RRBPs) of gastric band to Roux-en-Y gastric bypass and sleeve gastrectomy, revision of gastro-jejunal anastomosis and stricturoplasty performed during 2009-2013 were retrospectively reviewed. RESULTS: RRBPs were performed on 14 patients with mean age, pre-operative body mass index (BMI) and weight of 45.2 ± 11.4 years, 40.1 ± 8.7 kg/m2 and 109.4 ± 26 kg, respectively. The mean operative time, estimated blood loss and length of hospital stay were 220.6 ± 64.3) min, 31 ± 22.7 ml and 3.3 ± 1.5 days, respectively. There were no conversions, blood transfusions, gastrointestinal leaks, intraoperative complications or mortalities. CONCLUSION: RRBP can be performed safely without increased morbidity and with the added benefit of a minimally invasive approach. Copyright © 2014 John Wiley & Sons, Ltd.

Adjustable gastric banding: a comparison of models.

BACKGROUND: There are several models of adjustable gastric banding in use with little evidence for choosing a particular model. The objective of this study was to evaluate factors for selecting a particular type of band in terms of weight loss, complications, and co-morbidities. METHODS: From July 2006 to May 2012, 222 patients underwent laparoscopic adjustable gastric banding (LAGB) by a single surgeon. Patient demographic characteristics, weight loss, body mass index (BMI), percentage of weight loss (%EWL), complications, and co-morbidities were retrospectively reviewed. Patients were grouped according to the band model into 6 categories: 27 LAP-BAND Adjustable Gastric Banding System VG, 25 Allergan-LAGB, 20 LAP-BAND AP(M) Standard, 18 LAP-BAND AP(M) Large, 34 Realize Band, and 98 Realize-C band. RESULTS: At 60 months follow up, in the LAP-BAND VG Group, the mean %EWL was 41%, percentage of co-morbidity improvement was 66%, and percentage of complications was 14.3%; the same percentages in the Allergan-LAGB Group were 41%, 0%, and 52%, respectively; in the LAP-BAND AP Standard Group were 42%, 20%, and 40%, respectively; in the LAP-BAND AP Large group were 38% , 12.5%, and 27.8%, respectively (at 48 months); in the Realize Band Group were 37%, 60%, and 0%, respectively (at 48 months); and in the Realize-C Band Group were 48%,12.5%, and 12.2%, respectively (at 36 months). CONCLUSIONS: In terms of weight loss and co-morbidities, no differences were found supporting the choice of one model over the others. Short-term and long-term band-related complications occurred without any clear predilection. The port-related complications were significantly lower in the Realize bands.

Two-year follow-up of wound complications associated with laparoendoscopic single-site adjustable gastric banding.

BACKGROUND: In an effort to provide better cosmesis for patients, there has been a surge recently in the use of laparoendoscopic single-site adjustable gastric banding. Few data, however, are available on the long-term wound complications resulting from this technique. We conducted a retrospective review of patients to identify the extent of wound complications found during a minimum follow-up period of 2 years after laparoendoscopic single-site adjustable gastric banding. The complications evaluated included infection, hernia rates, and port and tubing complications. All the laparoendoscopic single-site adjustable gastric banding cases were performed at University of Illinois Medical Center by a single surgeon. METHODS: Twenty-five patients underwent single-site laparoscopic adjustable gastric banding from March 2009 to January 2010, and the data were reviewed retrospectively. The single incision was made with multifascial trocar placement using conventional laparoscopic instruments. The patients were followed up during band adjustments and clinic visits and by telephone interview. RESULTS: Six months after surgery, 1 patient required port removal because of port site infection with internalization of the tubing. A second patient experienced a foul-smelling, clear discharge and was treated with antibiotics, with no additional consequences. No incisional hernias or flipped ports were noted. CONCLUSION: In our experience, laparoendoscopic single-site adjustable gastric banding produced a low rate of port and wound site complications in patients during a minimum follow-up period of 2 years. We believe this is a valid alternative to the standard procedure, providing cosmetic advantages and a low wound complication rate in morbidly obese patients.

Robotic thyroidectomy: an initial experience with the gasless transaxillary approach.

BACKGROUND: Thyroid surgery has recently emerged as one of the most promising fields for the application of robotic surgery. We report the results of the first year of experience with a gasless transaxillary thyroidectomy. SUBJECTS AND METHODS: From January 2009 to December 2009, 10 consecutive patients (8 women) underwent robotic thyroidectomy through a gasless transaxillary approach. The median age was 44 years (range, 27-42 years). Eight total and two partial thyroidectomies (one left and one right) were performed using the da Vinci(®) Robotic Surgical System (Intuitive Surgical, Sunnyvale, CA). Preoperative diagnosis included solitary nodules with a median size of 16±11 mm (range, 3-44 mm) at preoperative imaging. RESULTS: All procedures were successfully completed robotically, except one that was converted because of difficulty in achieving an optimal exposure. The overall mean operative time was 177.4±40 minutes (range, 120-240 minutes) with minimal blood loss (<10 mL). Pathological diagnoses included papillary carcinoma (n=6), colloid nodule (n=2), and multinodular goiter (n=2). The mean number of lymph nodes harvested in the cases of malignant disease was 4±5 (range, 3-15). The median postoperative length of stay was 1.05 days (range, 1-1.4 days). CONCLUSIONS: Thyroid surgery using a gasless transaxillary approach can be performed safely for selected benign and malignant pathology. This approach offers superior cosmetic results and a short hospital stay over conventional thyroid surgery. For selected patients, this technique offers a promising scarless option for minimally invasive thyroid surgery.

Perioperative risk assessment in robotic general surgery: lessons learned from 884 cases at a single institution.

OBJECTIVE: To assess factors associated with morbidity and mortality following the use of robotics in general surgery. DESIGN: Case series. SETTING: University of Illinois at Chicago. PATIENTS AND INTERVENTION: Eight hundred eighty-four consecutive patients who underwent a robotic procedure in our institution between April 2007 and July 2010. MAIN OUTCOMES MEASURES: Perioperative morbidity and mortality. RESULTS: During the study period, 884 patients underwent a robotic procedure. The conversion rate was 2%, the mortality rate was 0.5%, and the overall postoperative morbidity rate was 16.7%. The reoperation rate was 2.4%. Mean length of stay was 4.5 days (range, 0.2-113 days). In univariate analysis, several factors were associated with increased morbidity and included either patient-related (cardiovascular and renal comorbidities, American Society of Anesthesiologists score ≥ 3, body mass index [calculated as weight in kilograms divided by height in meters squared] <30, age ≥ 70 years, and malignant disease) or procedure-related (blood loss ≥ 500 mL, transfusion, multiquadrant operation, and advanced procedure) factors. In multivariate analysis, advanced procedure, multiquadrant surgery, malignant disease, body mass index of less than 30, hypertension, and transfusion were factors significantly associated with a higher risk for complications. American Society of Anesthesiologists score of 3 or greater, age 70 years or older, cardiovascular comorbidity, and blood loss of 500 mL or more were also associated with increased risk for mortality. CONCLUSIONS: Use of the robotic approach for general surgery can be achieved safely with low morbidity and mortality. Several risk factors have been identified as independent causes for higher morbidity and mortality. These can be used to identify patients at risk before and during the surgery and, in the future, to develop a scoring system for the use of robotic general surgery

Cost and validity of early postoperative contrast swallow after laparoscopic adjustable gastric banding.

BACKGROUND: To assess the validity and cost of early routine upper gastrointestinal (UGI) studies after laparoscopic adjustable gastric banding (LAGB) at a university hospital in the United States. Today, although there is widespread use of LAGB, and it is considered a safe procedure, it also can result in some specific early complications. In most centers, an UGI series after bariatric surgery is performed to rule out these potentially dangerous complications. METHODS: From March 2006 to July 2010, 183 LAGB procedures were performed by a single surgeon. All data were collected prospectively in a computerized database and reviewed retrospectively. The patients underwent water-soluble UGI studies during the early postoperative phase (2-24 h) to exclude gastrointestinal perforation, obstruction, and gastric band malposition. RESULTS: No intraoperative complications occurred. One conversion to an open procedure was required because of massive adhesions. A total of 21 postoperative complications (11.5%) occurred. None of the 183 patients who underwent an early UGI series experienced leakage, gastric band malposition, or slippage. The only radiologic abnormality was a stomal obstruction (.5%) requiring reoperation. The total cost for the 183 UGI studies was $54,900. The mean hospital stay was .5 day (range .1-5.6). Approximately 90% of patients were discharged within the first 24 hours. CONCLUSION: The fear of acute perforation or obstruction has been the rationale for obtaining UGI studies after LAGB. We found this to be expensive and of limited value in an experienced center and have created a decisional algorithm to determine when its use is appropriate for symptomatic patients.

Laparoendoscopic single-site adjustable gastric banding: technical considerations.

PURPOSE: Recently, laparoendoscopic single-site surgery (LESS) has been proposed to minimize the invasiveness of laparoscopic surgery. We present our standardized technique of LESS adjustable gastric banding. METHODS: Data of 25 patients who underwent LESS adjustable gastric banding between March 2009 and January 2010 was reviewed retrospectively. All procedures were performed with multiple low-profile trocars through a single incision using conventional laparoscopic instruments. RESULTS: Mean operative time was 78 minutes. Mean blood loss was 8 mL and the median stay was 0.3 days (range, 0.1 to 3 d). No mortality was noted and there was 1 reoperation in the perioperative period due to stoma obstruction. CONCLUSIONS: LESS adjustable gastric banding with traditional rigid instruments is feasible and safe but requires working with limited triangulation. Short-term outcomes are promising but long-term follow-up is needed in weighing in the potential benefits to the patient against the technical challenges that arise with this technique.

Robotic Roux-en-Y duodenojejunostomy for superior mesenteric artery syndrome: operative technique.

BACKGROUND: Superior mesenteric artery (SMA) syndrome, also known as Wilkie's syndrome, is a rare condition characterized by vascular compression of the duodenum that leads to intestinal obstruction. While there have been a few recent case reports of laparoscopic duodenojejunostomy performed as an option for surgical treatment, the role of the da Vinci(®) robot in superior mesenteric syndrome has been underestimated. The authors report a robotic Roux-en-Y duodenojejunostomy for the treatment of SMA syndrome. MATERIALS AND METHODS: A 39-year-old man with a history of Amyotrophic lateral sclerosis presented with an upper gastrointestinal obstruction with distended abdomen. A computed tomography scan showed a transition in the third portion of the duodenum where the SMA vessels crossed over, with a decompressed jejunum. He was identified as a candidate for a duodenojejunostomy. The da Vinci Surgical System was used to mobilize the colon and duodenum, and a Roux-en-Y duodenojejunostomy was performed with hand-sewn anastomosis. RESULTS: There were no intraoperative complications. The blood loss was minimal and operative time was 120 minutes. The postoperative course was uneventful with resolution of intestinal obstruction. CONCLUSION: Robotic Roux-en-Y duodenojejunostomy as a surgical option for treatment of SMA syndrome is safe, feasible, and a valid alternative to open surgery with the added benefits of a minimally invasive approach.

Robotic extended pancreatectomy with vascular resection for locally advanced pancreatic tumors.

OBJECTIVES: Limited involvement of the major peripancreatic vessels is no longer considered a contraindication for resection in cases of locally advanced pancreatic cancer. Extended open pancreatectomies associated with vascular resection are performed in experienced centers with mortality and morbidity rates comparable to standard pancreatic resection. We evaluate the safety, feasibility, and outcomes of robotic extended pancreatectomy with vascular resection. METHODS: We reviewed data of 5 patients with a median age of 60 years (range, 52-74 years) who underwent robotic surgery for pancreatic tumors with vascular involvement between May 2007 and March 2010 at our institution. The types of resection included 2 left-sided splenopancreatectomy with celiac axis resection, 1 left-sided splenopancreatectomy with portal vein resection, and 2 pancreaticoduodenectomy with portal vein resection. RESULTS: No conversions occurred. The overall mean operating time was 392 ± 66 minutes (range, 310-460 min). The overall mean blood loss was 200 ± 61 mL (range, 150-300 mL) with no transfusions. No mortalities occurred. At a median follow-up of 6 months (range, 3-20 months), 4 patients were alive and disease free. CONCLUSIONS: This early series by a single surgeon supports the feasibility and safety of robotic pancreatectomy with vascular resection for selected patients with locally advanced pancreatic tumor.

Totally robotic right hepatectomy: surgical technique and outcomes.

HYPOTHESIS: Robotic surgery for performance of right hepatectomy is safe and effective. DESIGN: Case series from 2 medical institutions. SETTING: University of Illinois at Chicago and Misericordia Hospital, Grosseto, Italy. PATIENTS: Twenty-four patients underwent right hepatectomy between March 1, 2005, and January 31, 2010, using a robotic surgical system. MAIN OUTCOME MEASURES: Intraoperative blood loss, operative time, morbidity, mortality, and long-term oncologic follow-up. RESULTS: The procedure was converted to open surgery in 1 patient (4.2%). The overall mean (SD) operative time was 337 (65) minutes (range, 240-480 minutes), and the mean (SD) intraoperative blood loss was 457 (401) mL (range, 100-2000 mL). Three patients (12.5%) underwent blood transfusion. There were no perioperative deaths and no reoperations. Six patients (25.0%) experienced postoperative morbidity, including transitory liver failure in 2 patients and pleural effusion, bile leak, fluid collection, and deep venous thrombosis in 1 patient each. The patients' diagnoses included colorectal liver metastases (n = 11), noncolorectal liver metastases (n = 4), hemangioma (n = 4), adenoma (n = 2), hepatocellular carcinoma (n = 1), hepatoblastoma (n = 1), and biliary amartoma (n = 1). At a mean follow-up duration of 34 months, no port site metastases were observed in patients with malignant pathologic findings. CONCLUSIONS: The zero mortality and acceptable morbidity of our series indicate that in experienced hands, robotic right hepatectomy is feasible and safe. Robotic surgery offers a new technical option for minimally invasive major hepatic resections. Long-term results seem to confirm oncologic effectiveness of the procedure.

Traditional versus single-site placement of adjustable gastric banding: a comparative study and cost analysis.

In bariatric surgery, laparoscopic adjustable gastric banding (LAGB) has proven effective in reducing weight and improving obesity-associated comorbidities. Recently, however, laparoendoscopic single-site (LESS) surgery has been proposed to minimize the invasiveness of laparoscopic surgery. The aim of this study is to compare the operative cost and peri-operative outcomes of these two approaches. We undertook a retrospective review of a prospectively maintained database of patients undergoing either LAGB or LESS between March 2006 and October 2009. The outcomes and cost of 25 LESS gastric bandings were compared to 121 standard LAGB. Costs included operative time, consumables, and laparoscopic tower depreciation. Both groups had similar patient demographics, body mass index, and comorbidities; with the exception of age (37 year for single site vs. 44 years for standard; P=0.002). There were no statistical differences for operative time (78 vs. 76 min, P=0.69), blood loss (8.4 vs. 9 ml, P=0.76), pain score (0.81 vs. 0.84 at 1 week, P=0.95) or complication rates (12% vs. 14%, P=1). Length of stay was shorter for the LESS group (0.5 day vs. 1.5 days, P=0.02). The mean operative cost for the LESS banding was $20,502/case vs. $20,346/case for the standard LAGB, with no statistically significant difference between the approaches (P=0.73). Operative costs and peri-operative outcomes of LESS gastric banding are comparable with those of the standard LAGB procedure. As a result, single-site surgery can be proposed as a valid alternative to the standard procedure with cosmetic advantage and comparable complication rate.

Robot-assisted versus laparoscopic Roux-en-Y gastric bypass: is there a difference in outcomes?

BACKGROUND: Application of the robot for Roux-en-Y gastric bypass has been slow to evolve, despite its rapid acceptance in other fields. This is largely due to associated costs of technology, reports of increased operative time, and inadequate data available to correlate the benefits of robotics to a clinical outcome. The authors present a comparative study between laparoscopic and robot-assisted Roux-en-Y gastric bypass performed at a specialized institution for robotic surgery. MATERIALS AND METHOD: A total of 135 consecutive Roux-en-Y gastric bypass procedures were performed from January 2006 to December 2009 by a single surgeon. The first 45 were performed laparoscopically and the remaining 90 were robot-assisted. Patient demographics, operative time, complication rate, length of stay, long-term weight loss, and follow-up for the two groups were gathered from a prospectively maintained database and statistically analyzed. RESULTS: The overall operative time was significantly shorter for the robot-assisted procedures than for the laparoscopic procedures (207 ± 31 vs. 227 ± 31 min) (P = 0.0006). The robotic set-up time remained constant at 13 ± 4 min. 30 robotic cases were necessary in order to perform the procedure in less time than with the laparoscopic approach (P = 0.047). Mortality was 0% in both groups, with no conversions to open surgery and no transfusions. Early morbidities and percentage of excess weight loss at 1 year were comparable for the two groups. CONCLUSIONS: The use of the robot for performing the gastrojejunostomy during laparoscopic Roux-en-Y gastric bypass does not increase the operative time or the rate of specific complications. The short-term outcomes of the robot-assisted procedure are comparable to those found with the conventional laparoscopic method.

Robot-assisted hybrid laparoscopic Roux-en-Y gastric bypass: surgical technique and early outcomes.

BACKGROUND: Roux-en-Y gastric bypass performed laparoscopically remains the gold standard in bariatric surgery. The role of robot-assisted laparoscopic Roux-en-Y gastric bypass has not been clearly defined. METHODS: We present 80 consecutive cases of robot-assisted laparoscopic Roux-en-Y gastric bypass performed at a single institution. Mechanics, early outcomes, and learning curve are evaluated. Eighty robot-assisted laparoscopic Roux-en-Y gastric bypasses were performed on 71 women and 9 men with a mean age of 39 years, mean preoperative weight of 134 kg, and mean BMI of 48. RESULTS: Total mean operative time was 209 minutes. There was no mortality, leak, stricture, or obstruction. CONCLUSION: Robot-assisted laparoscopic Roux-en-Y gastric bypass is a safe and feasible option for bariatric surgery. Its role in improving surgical outcomes needs to be defined further.

Outcomes of robot-assisted pancreaticoduodenectomy in patients older than 70 years: a comparative study.

BACKGROUND: Minimally invasive pancreaticoduodenectomy (PD) remains one of the most challenging abdominal procedures and its application in the elderly population is poorly reported in the literature so far. The goal of this study was to demonstrate that robot-assisted PD can be safely performed in patients aged 70 years and older. METHODS: Forty-one consecutive robot-assisted PD performed between April 2007 and January 2010 were prospectively entered in a dedicated database. Patients were stratified into two groups: group 1, aged > or =70 years (n = 15, 36.6%); and group 2, aged <70 years (n = 26, 63.4%). The data were reviewed retrospectively. RESULTS: Indications for surgery and patient characteristics were the same in both groups, with the exception of age. There was no statistical difference in terms of operative time (P = 0.376), blood loss (P = 0.989), conversion rate (P = 0.52), mortality (P = 0.36), or overall morbidity rate (P = 0.74). The mean hospital stay was 14.3 days in group 1 and 11.2 days in group 2. This was not statistically significant (P = 0.136). CONCLUSIONS: Robot-assisted pancreaticoduodenectomy can be performed safely in elderly patients with comparable mortality, morbidity, and outcomes compared with a younger population. Age alone should not be a contraindication for robotic pancreatic resection.

Ascaris lumbricoides in the lacrimal passage.

Ascariasis is caused by the roundworm, Ascaris lumbricoides. We report an additional case of live Ascaris lumbricoides removed from the lacrimal puncta of a 10-year-old boy.