Introduction

This month’s issue features an interview with Igor Belyansky, MD. Dr. Belyansky is a Director of Abdominal Wall Reconstruction Program at Anne Arundel Medical Center in Annapolis, Maryland. He has special interest in laparoscopic and robotic abdominal wall reconstruction. He is very involved with the International Hernia Collaboration among other hernia groups, and is recognized as a thought leader in hernia surgery who is generous with his time and sharing of expertise.
At the forefront of robotic hernia surgery since it became a topic for surgeons, he has come to be recognized as an expert on that topic and took time to speak on it at MISS 2019, as well here in this interview. I’d like to extend a very warm thank you to Dr. Belyansky for taking the time to share his insights and experience with us in this interview.
I hope you also enjoy this month’s article recommendations from thought leaders in minimally invasive surgery, brought to you by leaders in surgical research and innovation. Thank you to all of this month’s contributors!

–Colleen Hutchinson

Colleen: Is Botox for use in abdominal wall reconstruction (AWR) ready for prime time?
Dr. Belyansky: On the fence. Some early data from Australia has demonstrated that use of Botox can make abdominal wall more compliant, making it easier to reconstruct linea alba by decreasing the tension on the midline suture line. It is important to consider patient selection. I am personally not sold on using Botox on patients to decrease the need for transversus abdominis release (TAR) procedures and just limiting repair to a Rives and Stoppa repair.

Colleen: Should prophylactic mesh be placed at the time of ostomy creation for all patients undergoing elective surgery where an ostomy is anticipated, or is this overkill?
Dr. Belyansky: On the fence. While there is data that supports use of prophylactic mesh in patients undergoing a procedure with a permanent stoma, this intervention may present several technical challenges at the time of initial surgery. The type of reinforcement, Keyhole underlay versus Sugarbaker versus Retrorectus keyhole versus onlay keyhole, needs to be considered. Furthermore, there is additional time that is needed to place a prophylactic mesh during an already lengthy major case. Most patients at the time of the initial surgery will have a shortened mesentery and will provide a challenge to fashion a Sugarbaker repair, with the other alternative being a type of keyhole repair. Keyhole repair in my own practice has been associated with higher long-term failure as compared to the Sugarbaker repair.   

	Save the date for the 20th Anniversary MISS! March 16 - 19, 2020 Aria, Las Vegas

Colleen: Would you agree that the robot is the most significant recent technological advance in hernia repair?
Dr. Belyansky: The robotic platform has been around for a while, and we have observing a fairly steep adaptation curve of this technology since 2012 in the hernia field. I think this has to do with the variety of additional techniques that have been described on the robot that are challenging to reproduce laparoscopically. Adaptation of robotics in the hernia field may also have to do with a culture change, where some of us are trying to minimize or eliminate the need for penetrating mesh fixation and to keep the mesh outside of the intraabdominal cavity.

Colleen: What is the role of the robot in inguinal and ventral hernia repair?
Dr. Belyansky: I think the use of robotic platform has enabled more surgeons to offer the MIS approach in inguinal and ventral hernias. Specifically in ventral hernias, there have been several techniques such as rTAR and eTEP to access Rives Stoppa repairs and TAR procedures that have been less challenging to reproduce with robotic assistance as compared to laparoscopy, especially in complex patient populations such as high BMI patients and reoperative cases associated with challenging dissection.

Colleen: What is your advice to the surgeon who is contemplating introducing robotics into his or her hernia practice?
Dr. Belyansky: Get on a dry box and a simulator to begin understanding the controls. Go to case observation. Find a mentor with whom you are comfortable. Do a porcine and cadaver lab. Try to do cases that you are already comfortable doing laparoscopically, since you really want to go through one learning curve at a time. Be ready to slow down your practice. The initial learning curve takes 3 to 6 months to get through. Try to get at least one day a week on the robot to improve your skills. DO NOT place the most complex cases on the robot initially, or try techniques that you have never done laparoscopically. Going through two learning curves at the same time is a good formula for failure.

Colleen: What do you think about the other robotic platforms coming to market, such as Senhance, etc.?
Dr. Belyansky: It's certainly nice to see other companies besides Intuitive working on developing robotic platforms. Competition will breed innovation and perhaps we will see a decrease in prices. As of now I have not seen a platform that is superior to what is widely available on the market by Intuitive.

Colleen: What does MISS offer that makes it a valuable and unique meeting?
Dr. Belyansky: This is a really good meeting for general surgeons that are MIS enthusiasts! This meeting addresses a spectrum of general surgery issues, and provides updates on some of the most recent innovations and techniques.

Suggested Readings

Foregut

Article: Meta-analysis of clinical outcome after treatment for achalasia based on manometric subtypes. Andolfi C, Fisichella PM. Br J Surg. 2019 Mar;106(4):332-341.
https://www.ncbi.nlm.nih.gov/pubmed/30690706
The optimal surgical approach for each achalasia subtype (Chicago type I, 2, and 3) identified on high-resolution manometry is unclear. In this study, the authors conducted a meta-analysis that included data from 20 studies and more than 1,500 patients. The investigators found that success rates for Per Oral Endoscopic Myotomy (POEM) were higher than laparoscopic Heller myotomy for both Type 1 and Type 3 achalasia. Type 2 achalasia treatment success rates were similar between POEM and Heller, while pneumatic dilation success rates for Type 2 achalasia were lower than POEM and Heller. These findings suggest that POEM may be advantageous for Type 1 and 3 achalasia patients, possibly because the myotomy can be extended more proximally on the thoracic esophagus. Higher rates of postoperative reflux following POEM (compared to Heller myotomy and fundoplication) remain an ongoing concern regardless of the subtype.

Colon

Article: Standardize the Surgical Technique and Clarify the Relevant Anatomic Concept for Complete Mobilization of Colonic Splenic Flexure Using da Vinci Xi^® Robotic System. Liang JT, Huang J, Chen TC. World J Surg 2019;43(4):1129-1136.
https://www.ncbi.nlm.nih.gov/pubmed/30543043
Dr. Sean Langenfeld: This study, and its accompanying surgical video, provide an outstanding technical outline of an effective alternative approach to the splenic flexure. The authors believe that the da Vinci Xi is more versatile for the flexure when compared to its predecessor, and I would tend to agree.

Hernia

Endoscopy & General

Bariatric

Article: Efficacy and safety of one anastomosis gastric bypass versus Roux-en-Y gastric bypass for obesity (YOMEGA): a multicentre, randomised, open-label, non-inferiority trial. Robert M, Espalieu P, Pelascini E, et al.
Lancet. 2019 Mar 6. pii: S0140-6736(19)30475-1.
https://www.ncbi.nlm.nih.gov/pubmed/30851879
Dr. Ricardo Cohen: One anastomosis gastric bypass (OAGB) is becoming more popular as an option to treat obesity and its comorbidities. This is a multicenter randomized controlled trial designed to assess the safety and outcomes regarding weight loss and resolution of comorbidities, comparing OAGB and Roux-en-Y gastric bypass (RYGB) at 2 years of follow-up.
OAGB was non-inferior to RYGB in terms of weight loss and metabolic control. However, there was a higher incidence of diarrhea and other malabsorptive nutritional complications after OAGB. On top of that, 16% of OAGB patients at 2 years had bile exposure in the stomach, a long-term predisposing condition to gastric cancer. Thus, OAGB needs technical refinements to mitigate the negative (relatively) early nutritional complications and longer-term followup regarding alkaline gastritis and the development of gastric cancer.
Currently, 200 cm biliopancreatic limb OAGB may be non-inferior to RYGB in terms of weight loss. However, the nutritional disadvantages and the potential long-term exposure of the gastric reservoir to bile makes it still not ready for “prime time.”

Dr. Jaime Ponce: This is probably the best quality documented trial comparing RYGB to OAGB. This study is a multicenter, randomized study, sponsored by the France Ministry of Health, and is very good documentation of patient inclusion and exclusions and documentation of outcomes and adverse events. The controversial aspect is that in the United States, the OAGB is not a recognized procedure by the ASMBS and this trial showed equivalence in weight loss, but a significant higher incidence of nutritional adverse events in the OAGB patients. I think this will be the beginning of exploring the OAGB technique as a viable option in the future.
There are some issues and limitations with this data including that is only 2 years follow-up, and the fact that some OAGB surgeons have proposed doing a 150cm BP limb instead of the 200cm that was used in this trial to diminish the risk of nutritional issues. On the other hand, the fact that it was multicenter and randomized gives a higher level of evidence on the positive outcomes at a short-term follow-up. I hope the authors will pursue longer follow-up and publish 5- and 10-year data to address other long-term concerns of possible bile reflux consequences.

Introduction

This month’s issue features an interview with Dr. James Rosser. Butch Rosser has been past president of the Society of Laparoendoscopic Surgeons and was recently elected to the SAGES board. He has been a pioneer and well published contributor to the evolution of minimally invasive surgery for almost 30 years. At the forefront of GERD treatment since it became a topic for surgeons, he has come to be recognized as an expert on that topic and took time to speak on it at MISS 2019, as well here in this interview. I’d like to extend a very warm thank you to Dr. Rosser for taking the time to share his insights and experience with us in this interview.
I hope you also enjoy this month’s article recommendations from thought leaders in minimally invasive surgery, brought to you by leaders in surgical research and innovation. Thank you to all of this month’s contributors!

–Colleen Hutchinson

Colleen: What is the value of MISS for you as a presenter/attendee and for MIS surgeons?
Dr. Rosser: I think that MISS is an invaluable asset for practicing surgeons. The meeting itself has become a platform that serves as a unique crossroads where academia meets practicality. This is a great resource for not only the everyday general surgeon, but academic surgeons who are also on the cutting edge. As for the speakers, it is not a meeting where the attendees are the only ones learning. The other advantage to MISS is that it allows collegial banter back and forth that exposes the nuances of our craft. This is very unique to this conference, and enables attendees to benefit from listening to the experts exchange positions on innovative and sometimes controversial topics. This is what you get from the “MISS Experience.” I call it “real world laparoscopy.”

Colleen: Can you give us what you think are the big takeaway points from the panel discussion you participated in, Surgeon's Personal Journey with Bariatric Surgery, which focused on surgeons who have had surgery?
Dr. Rosser: This panel was extremely interesting because it was comprised of four surgeons who had bariatric surgery. They shared the internal vantage point of “healers (surgeons) who needed to be healed.” This represented two different but interesting, overlapping perspectives. The big takeaways included the fact that all four shared a long and serpentine journey in their battle with obesity. This expedition featured weight loss and regain, self-blame, and feelings of inferiority. All came to a “tipping point” with the realization that they were embraced by a disease that needed a surgical solution. The panel highlighted their struggle to surrender the position of being a clinician and trusting their physician/surgeon as all patients must do. I introduced a less known issue for bariatric patients and that is the lack of support assets for family and love ones who struggle to be a helping hand while addressing their own stressful challenges. My wife Dana Rosser has led the charge to acknowledge that they cry out for assistance with their circumstances as well. She often says, “Ours is a song that no one hears.” Finally, I cautioned bariatric surgeons that they must steadfastly monitor their biases and let compassion be the banner that is always at the “tip of their healing spear.” Size discrimination is the last bastion of bigotry. It cannot dwell within practice patterns because it distorts your evaluation of those who seek your services and your judgment of their success or failure.

Colleen: You also spoke on the diagnosis and conservative treatment of GERD. Can you tell us what were the main points you wanted to drive home for the audience in that presentation?
Dr. Rosser: The news flash is that GERD is not being effectively treated and diagnosed. Upwards of 41% of patients with GERD are misdiagnosed and have diseases from cancer to irritable bowel syndrome to non-allergic chronic rhinitis. Additionally, patients are being exposed to the ravages of the complications associated with inappropriate use of PPIs. Surgeons should seriously consider that they can do a better job for patients. If the goal of better care is to be reached, surgeons must have a thorough, objectively based evaluation of a patient’s symptoms profile both for formulation of a sound diagnostic approach and effective conservative treatment. The routine use of objective evaluation tools is important both for the initial evaluation and tracking treatment success or failure. Up to 12 different diagnostic tests can be needed for patients depending on their presenting symptoms and review of systems. The three mainstays include transnasal esophagogastroenteroscopy (TNEG), Bravo 24- to 48-hour pH studies, and esophageal manometry. TNEG is a diagnostic procedure that allows the cost-effective screening evaluation of symptoms under local anesthesia. It also assists in the evaluation for yeast pharyngitis, which mimics GERD and is frequently missed by standard endoscopy.

	Save the date for the 20th Anniversary MISS! March 16 - 19, 2020 Aria, Las Vegas

Colleen: What are your thoughts on the new tools and technologies for battling GERD? Do you think they are promising?
Dr. Rosser: Some are very hopeful, and some are not as much. I must admit, I myself really lean more toward fundoplication and hiatal hernia repair. If a patient has a hiatal hernia, it has to be repaired. And fundoplication in expert hands can be a great long-term solution. I like to tailor the operation to the patient. Using manometry, I find that I detect motility disorders and this impacts my choice of procedure. I am performing 50% complete wraps (Nissen) and 50% partial wraps. I’ve done the LINX®, and I have had great success but still have some concerns about the long-term erosion issue. But it has potential. Beyond the LINX®, I’m not so excited about some of the things out there on the market. While initial data are good for some of these procedures and treatments, I am not sold on their long-term durability.

Colleen: Are you looking at the 5G-development timeline and its potential impact on medicine given your interest and work in telemedicine and mobile telemedicine applications?
Dr. Rosser: Yes. In 1992, when I first started in telemedicine, everything was about bandwidth or lack thereof. All the early exploration with telemedicine in surgery involved working around the expense and limitation of bandwidth. I have been through bandwidth expansion, starting with dial-up POTS lines, then ISDN and satellite communications, 3G and 4G. Now entering the 5G age, I feel its ultimate impact will be determined by security and not bandwidth availability. I am fearful that this global challenge could provide a similar bottleneck to adoption posed by bandwidth limitation 20 years ago. Finally, it must be remembered you can have all the bandwidth in the world but it is your process and protocols that are at the heart of advancing care and providing great outcomes.

Colleen: As an inventor of educational tools for surgeons, what do you think is needed for the coming robot platforms and challenge to teach the resident of today open, laparoscopic, and multiple platform robotics?
Dr. Rosser: I hope you do not think less of me for shying away from this major controversy. I will only say this about the dilemma illuminated by your question. I want to preface my comments by saying that I think robotics will pay an important role in the future of surgery. Currently, we are on a journey to discover the procedures where it has the most impact. However, just like in aviation, the foundation of the competency of a surgeon cannot rely solely on technology. Look at the recent crashes related to the automated piloting system with certain high-tech Boeing aircraft. The effective application of technological platforms must be leveraged upon a foundation of individual skill, expertise, and competency. In the audience there were upwards of 30 surgeons that had graduated from my Top Gun Laparoscopic Skills and Suturing program and they all agreed with this comment, “Skill determines if you are one of the greatest surgeons of all time and not a legend in your own mind.”

Suggested Readings

Foregut

Article: Comparison of laparoscopic 270° posterior partial fundoplication vs total fundoplication for the treatment of gastroesophageal reflux disease: a randomized clinical trial. Hakanson BS, Lundell L, Bylund A, Thorell A. JAMA Surg. 2019 Mar 6. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/30840057
Rees Porta: The authors randomized 456 patients to laparoscopic Toupee fundoplication (posterior 270° wrap with gastropexy) vs Nissen fundoplication (360°). No bougie was utilized and all patients were operated on by one of the two study surgeons. Patients and followup providers were blinded to the surgery that had been performed. Endoscopy, pH monitoring, manometry, and QoL surveys were used both pre- and post-operatively with followup to 5 years. Interestingly, their study shows no statistically significant superiority with the Nissen regarding acid suppression or GERD symptom control over the partial fundoplication. The Toupee demonstrated statistically significant less dysphasia at 6 weeks for liquids and at 1 and 2 years for solids. This well designed study avoided many of the limitations seen in previous publications and challenges the longstanding notion that the Nissen is the gold standard for anti-reflux surgery.

Article: Early referral for esophageal pH monitoring is more cost-effective than prolonged empiric trials of proton-pump inhibitors for suspected gastroesophageal reflux disease. Kleiman, David, Fahey, Thomas et al. J Gastrointest Surg. 2014 Jan;18(1):26-33
https://www.ncbi.nlm.nih.gov/pubmed/24214090
Dr. Rosser: This article stresses the academic rationale for an objective based evaluation of patients with suspected GERD that have undergone a limited PPI challenge. It is aimed at establishing an accurate diagnosis. Forty-one percent of patients diagnosed as having GERD have other illnesses.

Endoscopy & General

Article: Systematic endoscopy 5 years after sleeve gastrectomy results in a high rate of Barrett’s esophagus: results of a multicenter study. Sebastianelli L, Benois M, Vanbiervliet G, et al. Obes Surg. 2019 Jan 21. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/30666544
Dr. Ricardo Cohen: Sleeve gastrectomy (SG) is the most performed operation in the US and some parts of the world. Regardless that it delivers (absolute) less weight loss long-term and it is a less effective metabolic operation, it carries the incidence of de novo gastroesophageal reflux from 15 to 30%. On top of all that is the incidence of Barrett’s esophagus (BE) of around 18% in 5 years followup. The authors found an association of weight loss failure and BE and recommend systematic endoscopy in all SG after 5 years postoperative. It is known that the vast majority of bariatric surgery centers worldwide has a low follow-up rate. Thus, endoscopic surveillance may be the right recommendation. However, its penetrance in the real world seems to be very low. This paper is a call to remind all healthcare professionals involved in the care of bariatric patients that the indiscriminate indication of SG has serious long-term drawbacks.

Article: New paradigm of live surgical education: synchronized deferred live surgery. Knol J, Bonjer J, Houben B, Wexner SD, Hompes R, Atallah S, Heald RJ, Sietses C, Chadi SA. J Am Coll Surg. 2018 Oct;227(4):467-473.
https://www.ncbi.nlm.nih.gov/pubmed/30118895
Dr. Steven Wexner: Surgery can be taught in many ways: from reading books, perusing photographs and illustrations in journals and textbooks, viewing highly edited truncated videos, or watching live surgery. While live surgery offers numerous significant advantages watching a surgeon work through a problem, discussing the nuances of the surgery with the operating surgeon, and seeing every detail of the operation, it does also have potential theoretical disadvantages. In many instances, the live surgery is performed by a surgeon who arrives in another country in another time zone and has never met or evaluated the patient. The surgeon who is performing the procedure is relying upon the judgment of his or her local hosts to have selected an appropriate case, though the hosts may never have performed the particular surgery being demonstrated. Furthermore, the surgeon may potentially be distracted during the operation by questions from the audience, and the surgeon may also be fatigued due to travel. Even if the surgeon brings his or her own team and equipment, the environment is different and that team must interface with local hosts who may not be fluent in the native language of the visiting surgical team. In an effort to improve upon this paradigm, Joep Knol, the innovator and founder of ilapp (http://ilappsurgery.com), designed dLiveMed (https://www.dlivemed.com), which is a method of synchronized deferred live surgery. He assembled a team including myself to evaluate and describe this technology. One of the main benefits of dLiveMed is the ability to have numerous angles.
In our recent publication in the Journal of the American College of Surgeons, we describe a transanal total mesorectal excision (taTME) procedure recorded with seven cameras, including the 360-degree view of the operating room setup, the “top down” view of the patient, the view of the assisting nursing table and instrumentation, the transabdominal external view, a transabdominal laparoscopic view, a transanal external view, and a transanal endolaparoscopic view. The ability for the surgeon or even the moderator to direct seven cameras while operating live would be at best incredibly challenging and at worst could potentially compromise the integrity and safety of the operation. The potential utility of dLiveMed was highlighted in a wonderful editorial by Julie Ann Freischlag in which she stated: “I think the biggest advantage in using synchronized deferred live surgery is that it takes away almost all of the risk to the patient.” I thank Joep for including me in this remarkable paradigm shifting effort and thank Julie Ann for her tremendously valuable insights. Readers interested in learning more can scan Figure 1 within our article to see the video and picture technology.

Colon

Article: Disease-free survival and local recurrence after laparoscopic-assisted resection or open resection for rectal cancer: the Australasian laparoscopic cancer of the rectum randomized clinical trial. Stevenson ARL, Solomon MJ, Brown CSB, et al. Ann Surg 2019;269:596–602.
https://www.ncbi.nlm.nih.gov/pubmed/30247332
Dr. Sean Langenfeld: This is the 2-year follow up from the ALaCaRT trial, and is accompanied by the 2-year follow up from the ACOSOG Z6051 trial in the same volume (previously presented to the MISS audience). There is no difference in overall survival, disease-free survival, or locoregional recurrence at 2 years when comparing open to laparoscopic approaches. However, this must be interpreted with caution since neither study was powered or designed for these long-term results. One might assume that an important meta-analysis is coming soon that will shed more light on the issue.

Bariatric

Article: The Dutch bariatric weight loss chart: A multicenter tool to assess weight outcome up to 7 years after sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. van de Laar, Nienhuijs, et.al. Surg Obes Relat Dis. 2018 Nov 24. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/30797718
Rees Porta: WHO growth charts are used worldwide by billions of parents and pediatricians. Accurate weight loss charts after bariatric surgery would be immensely helpful for the patient and the surgeon. Dr. van de Laar and colleagues highlight the difficulties with creating these charts (such as length of follow-up and the inherent bias, lack of a standardized measurement of weight loss, and the need for a large multicenter study to ensure proper patient volume) and do an excellent job mitigating these obstacles. Their curves for LSG and RYGB extend out to 7 years and use %AWL, which they describe as the best metric to combat the differences seen with wide preoperative BMI variance. Hopefully we can use the large MBSAQIP database to develop our own graphs. In addition to helping with preoperative expectation management and postoperative monitoring, they could be a valuable tool for further research into identifying risk factors for poor responders (which were identified as male gender, T2DM, and age in this study).

Hernia

Article: Does active smoking really matter before ventral hernia repair? An AHSQC analysis. Petro CC, Haskins IN, Tastaldi L, Tu C, Krpata DM, Rosen MJ, Prabhu AS.
Surgery. 2019 Feb;165(2):406-411.
https://www.ncbi.nlm.nih.gov/pubmed/30220485
Michael Rosen: The authors did a database review of the AHSQC to determine the effect of smoking on clean open ventral hernia repair in a well matched group of 400 active smokers versus 400 never smokers. They found no clinical or statistically significant difference between the groups as far as wound morbidity or overall 30-day postoperative complications. This data calls into question the stance of mandatory smoking cessation for smokers with symptomatic hernias.

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