17TH SLS ANNUAL MEETING AND ENDO EXPO 2008 LAPAROSCOPY UPDATES

Abdominal / Pelvic Pain / Adhesions Committee
Update on Adhesion Reduction
Ceana Nezhat, MD

Peritoneal adhesions can cause intestinal obstruction, pelvic pain, and infertility. Intraabdominal adhesions between the abdominal scar and the underlying viscera are a common consequence of laparotomy. Patients undergoing laparoscopy after a previous laparotomy should be considered at risk for the presence of adhesions between the old scar and the bowel and omentum.

Since the development of postoperative adhesions is a major factor in deciding the outcome of fertility-promoting operative procedures, surgeons should understand the mechanism of their formation, use optimal techniques for adhesiolysis, and apply agents or devices to reduce their development.

While significant progress has been made toward understanding the development of postoperative adhesions and their prevention, adjuvants and minimally invasive surgery have not eliminated them. Operative laparoscopy may be more effective than laparotomy in reducing their formation and should be the first procedure in their management.

Although adhesions are not preventable, adhesion reduction materials are available and new materials are being researched. This presentation will give an update on the adhesion reduction methods and materials that are available and a report of what is under investigation.

Bariatrics Committee
Update on Bariatrics
Dana Portenier, MD

Core Competencies Committee
Competencies and the American Board of Surgery
Gustavo Stringel, MD

The six core competencies of Patient Care: Medical Knowledge, Practice-Based learning and improvement, Interpersonal and Communication Skills, Professionalism and Systems Based Practice, were endorsed in 1999 by the Accreditation Council of Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS).

These competencies are now an active part of the education of surgical residents. The general competencies were designed to emphasize educational outcome assessments in residency and in the accreditation process. All residents must develop the competency in all six areas in order to graduate.
The new emphasis of surgical programs is to graduate surgeons who are competent and who are able to provide quality of care in a safe environment to produce the desired outcomes. It is important for the surgeon, not only to obtain desired outcomes comparable to that of others, but also to deliver this care in a confident, empathetic, humane, personal, and respectful manner. The surgeon must also deliver this care in a financially responsible manner. It is especially important for the laparoendoscopic surgeon to be able to work in a technologically advanced environment since many of the procedures performed are technically demanding and equipment dependent.

The American Board of Surgery has incorporated some of the core competencies in the Maintenance of Certification Program (MOC).  The new certification process requires Evidence of Professional Standing, Commitment to Lifelong Learning and Self- Assessment, Cognitive Expertise and Evaluation of Performance in Practice. The surgeon must comply with all these requirements in order to maintain certification in the American Board of Surgery.

Endocrine / Solid Organ Committee
Innovative Endoscopic Thyroid Surgery
Tahar Benhidjeb, MD (NESA)

The technology development of the past two decades in the field of video-assisted surgery has opened up new opportunities, including in thyroid surgery. The first endoscopic thyroid lobectomy was performed in 1996. The technique of minimally invasive video-assisted thyroidectomy (MIVAT) is the method that has so far become most widespread. Limiting factors of this method include the 20mm small cervical incision and consequently the size of the specimen resected. Furthermore, young women in particular consider such cervical scars as disturbing, even when they are quite small and unobtrusive. Several papers describing an access outside the front neck region have been published. Such approaches are chest, axillary, and a combined axillary bilateral breast approach (ABBA). However, these techniques just moved the scars from the front neck region to the axilla or the chest where they are still visible. Furthermore, these approaches do not comply with the use of the term “minimally invasive”, since they are associated with an extensive dissection of the chest and neck region, thus being rather maximally invasive for the patients. In order to achieve at the same time a cosmetically optimal result and a minimally invasive approach, our group has investigated in human cadavers the transoral access, the so-called transoral video-assisted thyroidectomy (TOVAT).

Fibroids / Abdominal Uterine Bleeding Committee
Laparoscopic Myolysis Revisited
Herbert Goldfarb, MD

Fifteen years ago Dr. Goldfarb presented the first case of coagulation of a Uterine Myoma performed in the United States. Since that first case multiple series have been presented using a variety of tools to accomplish the same result. Starting with the NdYag laser, subsequent methods have included Bipolar Needles,Cryo probes, Radio frequency probes, MRI guided Laser probe and finally MRI guided high power focused ultrasound. This presentation will review the available techniques used, evaluate efficiency, cost ,success rates and complications.

Multidisciplinary Committee
The Future of Abdominal Surgery —The Natural Orifice Surgery
Michael Stark, MD (NESA)

Most surgical, urological and gynaecological abdominal operations have endoscopic alternatives. In comparison to patients undergoing laparotomies, patients having endoscopic procedures need less postoperative analgesics and have decreased morbidity and shorter hospital stay. Laparoscopic procedures have never proved to be risk less and are usually performed using general anaesthesia with intra-abdominal pressure up to 15 mm Hg and with insertion of up to four trocars.
Next to the recently developed transgastric operations, the use of the Douglas pouch as an entry for different abdominal operations is becoming a subject for experimental as well as clinical use.
The pouch of Douglas has also been used as an entry for infertility work-up, appendicectomy, and cholecystectomy. The New European Surgical Academy is preparing the prerequisites to use the pouch of Douglas as a single entry for abdominal operations in women. The expected advantages of this approach are the following:

1.   The introduction of the instruments can be done under vision and parallel to the major blood vessels, with low CO2 pressure.
2.    The vagina can be easily cleaned and disinfected and repairs without leaving visible scars.
3.    The transdouglas approach improves operation ergonomics.
4.    There is no risk of herniation or eventration.

A multidisciplinary surgical team are joining forces to design transdouglas operations such as cholecystectomies, appendicectomies, hysterectomies and nephrectomies. A multi-channel instrument respecting the pelvic anatomy and enabling to perform operations in the upper and lower abdomen has been designed and will be introduced next to the planned procedures, simulations and first results.

Office and Outpatient Laparoscopy Committee
Office Cosmetic Procedure
Duncan Turner, MD

With the increasing pressure from managed care in conjunction with increasing malpractice cost, the OB/GYN frequently is finding difficulty in maintaining a constant income.  Many physicians are choosing to increase the spectrum of their practice to better serve their patients and one of these areas that is working well for this specialty is cosmetic/elective procedures.

In 2004, the American Society of Plastic Surgeons published a practice advisory on liposuction stating that any board certified surgeon could be trained to perform these procedures within their area of expertise.  They described the training that was thought to be necessary.

Having taken the recommendations of the American Society of Plastic Surgeons in terms of training, I have been involved with both ultrasound and laser-based technologies for body sculpting from the upper abdomen into the mid-thigh. This has been an interesting addition to my practice; patients have been very receptive to this, particularly as these procedures are extremely safe being performed in an office setting entirely under local anesthesia with no IV or conscious sedation.

Pediatric Surgery Committee—Pediatric General Surgery
The Race in Pediatric MIS: Hit the Gas!...But be Ready to Slam on the Brakes
John Meehan, MD

Many advances in MIS have highlighted a great year in pediatric surgery. Although equipment advances in pediatric surgery seem to lag the higher market areas of adult surgery, several new techniques and devices have been developed which have helped pediatric surgeons bring more MIS  procedures to kids around the world. However, certain MIS problems have been discovered, too. Pediatric surgeons need to stay informed as to the latest ideas that work as well as the lessons we learned for things that may not be as good as we thought. This presentation will summarize some of the highlights and new discoveries in MIS pediatric surgery as well as summarize the areas where MIS has failed.

Pediatric Gynecology—Pediatric General Surgery
Robert Zurawin, MD

Pediatric Urology
Thomas Lendvay, MD
The incorporation of pure laparoscopic and robotic-assisted laparoscopic (RAL) techniques in pediatric urologic disease management is an area of rapid growth.  Clinicians are utilizing robotics for the most complex urologic reconstructions and more providers are appreciating the benefits of RAL surgery.  RAL continence procedures are now being adopted in children with complex congenital diseases such as spina bifida.  In addition, we are pushing the envelope on the applications of laparoscopic techniques in children less than 6 kgs.  Others, however, caution on the realities of using robotic techniques in children less than 6 months of age due to size limitations.  In an effort to replicate open renal reconstructive surgery, authors have described the safety and efficacy of RAL retroperitoneopscopic pyeloplasties in children and data is emerging that MIS techniques in children do show a decreased narcotic requirement in the peri-operative period as has been seen for years in the adult MIS literature.  The outcomes have now been published on the largest series of patients undergoing RAL ureteral reimplantation surgery for vesicoureteral reflux and it appears that the success is at least similar to the gold-standard of open ureteral reimplant surgery.  As the demand for decreasing the degree of invasiveness in pediatric urology increases, miniaturization of MIS instrumentation and improved visualization will lessen the technical challenges of MIS in smaller children.  Our sub-specialty must now utilize rigorous prospective evaluations of open and MIS reconstructions in the pediatric population.

Pelvic Reconstructive Surgery / Stress Incontinence Committee
The Use of Mesh for Stress Incontinence and Pelvic Floor Prolapse
Steven Minaglia, MD

Robotic Surgery Committee
New Developments in Robotic Surgery
Andrew Wright, MD

In this session we will review new clinical data in surgical robotics for general surgery, urology, and gynecology. This will include the evolving number of general surgical procedures including gastrectomy, hepatobiliary procedures, and colorectal surgery. In urology we will discuss new multi-center trials of ureteral reimplantation, additional clinical data on robotic prostatectomy, and an extension of robotic techniques into pediatric urology. There has been a rising interest in the gynecologic literature regarding robotic fertility surgery as well as new applications of the robot in gynecologic cancer. We will also discuss exciting new pre-clinical developments in the world of robotic surgery. Featured will be robotic Natural Orifice Transluminal Access Surgery (NOTES), single port access robotic surgery, ultra-miniaturized surgical robots, and semi-autonomous robot behavior. We will also show new innovations in training for surgical robotics, including new VR simulators and the use of standardized training programs for robotics such as adaptations of the Fundamentals of Laparoscopic Surgery.

Thoracic Committee
Minimally Invasive Esophagectomy
Neil A. Christie, MD