Background: Historically, the pathophysiology of Hiatal Hernias (HH) has not been fully understood. As a result, the surgical therapy of HH has focused primarily on gastrointestinal symptoms and Gastroesophageal Reflu...Background: Historically, the pathophysiology of Hiatal Hernias (HH) has not been fully understood. As a result, the surgical therapy of HH has focused primarily on gastrointestinal symptoms and Gastroesophageal Reflux (GERD). This treatment strategy has been associated with poor relief of symptoms and poor long-term outcomes. In fact, until recently, most patients with HH have been watched and referred for surgery as a last resort. Recent experience has shown that a large (giant) Hiatal Hernia (GHH) is a common problem known to impact adjacent organs such as the hearts and lungs. Those referred for surgical repair often complain of dyspnea, which is erroneously attributed to pulmonary compression or aspiration, but has been shown to be from tamponade caused from compression of the heart by herniated abdominal contents. This article reviews the present understanding of GHH, the cardiac complications which result from GHH, and the most advanced robotic minimally invasive surgical approach to the anatomic and physiologic repair of GHH. Methods: In a prospective cohort study, we evaluated patients undergoing RRHH with at least a 2-year follow-up. All patients undergoing elective (RRHH) were identified preoperatively and enrolled prospectively in this study. Preoperative characteristics, medical comorbidities, and clinical information were all recorded prospectively and recorded into a secure surgical outcomes database. All patients received the previously validated Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire preoperatively and at postoperative time points of 1 month, 1 year, and 2 years. Patients routinely had a barium swallow postoperatively before discharge but did not undergo a barium swallow, an endoscopy, or a CT scan study at the 1-month time point unless indicated by symptoms. At 6 months, 1 year, and yearly intervals thereafter, all patients received an endoscopy study to ascertain the presence of a recurrence, regardless of symptoms. Recurrence was defined as over 2 cm or 10% of the stomach above the diaphragm detected by CT, esophagogram or endoscopy. In addition, an extensive search was conducted using Pub Med in order to extract references to the cardiovascular complications of HH. Results: 423 patients underwent RRHH. With a long-term follow-up, there was a significant decrease in the Median Symptom Severity Score from 42.0 preoperatively, to 3.0 postoperatively. Recurrence was seen in 5 patients (5/423) for a recurrence rate of 1.1%. Conclusion: This experience has been the basis of two important realizations: 1) all patients with GHH have at least some degrees of clinically relevant compression of the inferior vena cava and the left atrium which causes tamponade and cardiogenic dyspnea which completely resolves after successful surgical repair;and 2) primary care providers and gastroenterologists who usually treat patients for GHH repair rarely recognize cardiac compression and tamponade as the cause of the shortness of breath and gradual increase in dyspnea on exertion and progressive fatigability in these patients. This article reviews the present understanding of GHH, the cardiac complications which result from GHH and the most advanced robotic minimally invasive surgical approach to the anatomic and physiologic repair of GHH.展开更多
Objective:Transversus abdominus release(TAR)is often required to achieve apposition of the rectus muscles and achieve wide mesh reinforcement of the abdominal wall.Traditionally,TAR has been done with an open techniqu...Objective:Transversus abdominus release(TAR)is often required to achieve apposition of the rectus muscles and achieve wide mesh reinforcement of the abdominal wall.Traditionally,TAR has been done with an open technique(oTAR),and the benefits of the newer robotic approach(rTAR)has not been well established in the Australian setting.The aim of this study was to compare the results of oTAR with rTAR to demonstrate its safety and efficacy.Methods:A retrospective review of patients who underwent rTAR and oTAR at two tertiary hospitals was conducted between January 2018 and January 2020 in New South Wales,Australia.Patient demographics,perioperative and postoperative outcomes were compared in both groups.Results:There were 26 patients identified to have undergone TAR(13 rTAR,13 oTAR).Both groups were comparable in regards to age,sex and defect size.oTAR was associated with a higher American Society of Anaesthesiologist score.rTAR was associated with significantly longer average operative time(260.0±78.9 min vs.185.7±64.5 min,p=0.017)but found to have a significantly shorter length of stay(3.6±2.1 d vs.6.9±3.6 d,p=0.007)with a comparable complication rate.Conclusions:rTAR is associated with shorter length of hospital stay with comparable postoperative outcomes when compared to oTAR.We are seeing increasing evidence supporting the safety and benefits of robotics,however larger scale studies are required to fully understand this approach.展开更多
This paper presents reliability and availability analyses of a model representing a system having one robot and n-redundant safety units with common-cause failures. At least k safety units must function successfully f...This paper presents reliability and availability analyses of a model representing a system having one robot and n-redundant safety units with common-cause failures. At least k safety units must function successfully for the robot system success. The robot and other failure rates and the partially failed system repair rates are assumed constant and the failed robot-safety system repair time is assumed arbitrarily distributed. Markov and supplementary variable methods were used to perform mathematical analysis of this model. Generalized expressions for state probabilities, system availabilities, reliability, mean time to failure, and variance of time to failure are developed. Plots of some resulting expressions are shown.展开更多
文摘Background: Historically, the pathophysiology of Hiatal Hernias (HH) has not been fully understood. As a result, the surgical therapy of HH has focused primarily on gastrointestinal symptoms and Gastroesophageal Reflux (GERD). This treatment strategy has been associated with poor relief of symptoms and poor long-term outcomes. In fact, until recently, most patients with HH have been watched and referred for surgery as a last resort. Recent experience has shown that a large (giant) Hiatal Hernia (GHH) is a common problem known to impact adjacent organs such as the hearts and lungs. Those referred for surgical repair often complain of dyspnea, which is erroneously attributed to pulmonary compression or aspiration, but has been shown to be from tamponade caused from compression of the heart by herniated abdominal contents. This article reviews the present understanding of GHH, the cardiac complications which result from GHH, and the most advanced robotic minimally invasive surgical approach to the anatomic and physiologic repair of GHH. Methods: In a prospective cohort study, we evaluated patients undergoing RRHH with at least a 2-year follow-up. All patients undergoing elective (RRHH) were identified preoperatively and enrolled prospectively in this study. Preoperative characteristics, medical comorbidities, and clinical information were all recorded prospectively and recorded into a secure surgical outcomes database. All patients received the previously validated Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire preoperatively and at postoperative time points of 1 month, 1 year, and 2 years. Patients routinely had a barium swallow postoperatively before discharge but did not undergo a barium swallow, an endoscopy, or a CT scan study at the 1-month time point unless indicated by symptoms. At 6 months, 1 year, and yearly intervals thereafter, all patients received an endoscopy study to ascertain the presence of a recurrence, regardless of symptoms. Recurrence was defined as over 2 cm or 10% of the stomach above the diaphragm detected by CT, esophagogram or endoscopy. In addition, an extensive search was conducted using Pub Med in order to extract references to the cardiovascular complications of HH. Results: 423 patients underwent RRHH. With a long-term follow-up, there was a significant decrease in the Median Symptom Severity Score from 42.0 preoperatively, to 3.0 postoperatively. Recurrence was seen in 5 patients (5/423) for a recurrence rate of 1.1%. Conclusion: This experience has been the basis of two important realizations: 1) all patients with GHH have at least some degrees of clinically relevant compression of the inferior vena cava and the left atrium which causes tamponade and cardiogenic dyspnea which completely resolves after successful surgical repair;and 2) primary care providers and gastroenterologists who usually treat patients for GHH repair rarely recognize cardiac compression and tamponade as the cause of the shortness of breath and gradual increase in dyspnea on exertion and progressive fatigability in these patients. This article reviews the present understanding of GHH, the cardiac complications which result from GHH and the most advanced robotic minimally invasive surgical approach to the anatomic and physiologic repair of GHH.
文摘Objective:Transversus abdominus release(TAR)is often required to achieve apposition of the rectus muscles and achieve wide mesh reinforcement of the abdominal wall.Traditionally,TAR has been done with an open technique(oTAR),and the benefits of the newer robotic approach(rTAR)has not been well established in the Australian setting.The aim of this study was to compare the results of oTAR with rTAR to demonstrate its safety and efficacy.Methods:A retrospective review of patients who underwent rTAR and oTAR at two tertiary hospitals was conducted between January 2018 and January 2020 in New South Wales,Australia.Patient demographics,perioperative and postoperative outcomes were compared in both groups.Results:There were 26 patients identified to have undergone TAR(13 rTAR,13 oTAR).Both groups were comparable in regards to age,sex and defect size.oTAR was associated with a higher American Society of Anaesthesiologist score.rTAR was associated with significantly longer average operative time(260.0±78.9 min vs.185.7±64.5 min,p=0.017)but found to have a significantly shorter length of stay(3.6±2.1 d vs.6.9±3.6 d,p=0.007)with a comparable complication rate.Conclusions:rTAR is associated with shorter length of hospital stay with comparable postoperative outcomes when compared to oTAR.We are seeing increasing evidence supporting the safety and benefits of robotics,however larger scale studies are required to fully understand this approach.
文摘This paper presents reliability and availability analyses of a model representing a system having one robot and n-redundant safety units with common-cause failures. At least k safety units must function successfully for the robot system success. The robot and other failure rates and the partially failed system repair rates are assumed constant and the failed robot-safety system repair time is assumed arbitrarily distributed. Markov and supplementary variable methods were used to perform mathematical analysis of this model. Generalized expressions for state probabilities, system availabilities, reliability, mean time to failure, and variance of time to failure are developed. Plots of some resulting expressions are shown.
