ABDOMINAL / PELVIC PAIN / ADHESIONS COMMITTEE
The Evil Triplet of Chronic Pevic Pain Syndrome: Pudendal Neuralgia
Maurice K. Chung M.D., Cherie W. Chung, Rhonda J. Medina M.D., Jennifer Glance D.O., Jackie S. Shriver C.N.P.
Objective: To determine the incidence of pudendal neuralgia and painful bladder syndrome in patients with chronic pelvic pain.
Prospective cohort study of 96 women (ages 18-83) from 4/1/08-3/1/09 that presented
with chronic pelvic pain with or without irritable voiding symptoms. All
patients exhibited bladder tenderness and negative urinary and genital
cultures. Patients completed PUF, AUA, and ICSI questionnaires and
underwent potassium sensitivity testing. Clinical evaluations established
pudendal neuralgia by testing for perineodynia through a sensory pinprick test
of cutaneous pudendal nerve branches and a pressure sensation test of the
pudendal nerve for the "Valleix phenomena." Patients with potassium
sensitivity, indicative of painful bladder syndrome, underwent intravesical
therapy. Pudendal perineuronal injections were given as indicated.
Results: The Potassium Sensitivity Test was positive in 73(76%) patients. 85(88.5%) patients had pudendal neuralgia, of which 67(78.8%) had positive potassium sensitivity tests. 33 patients with painful bladder syndrome finished intravesical therapy. Their mean PUF, AUA, and ICSI scores dropped 44%, 54%, and 51% respectively. 13 patients with less than 20% improvement after intravesical therapy were given pudendal perineuronal injections. Their mean PUF, AUA, and ICSI scores dropped an additional 43%, 47%, and 51% respectively.
Conclusion: Previous publications have shown that interstitial cystitis/painful bladder syndrome and endometriosis are the “Evil Twins” of the chronic pelvic pain syndrome. The significant incidence of pudendal neuralgia (88.5%) in this study suggests that this disease entity and the “Evil Twins” should be at the top of the differential diagnosis for chronic pelvic pain syndrome as the “Evil Triplets.”
Report on the 2nd International Consensus Summit on Sleeve Gastrectomy-Miami Beach, March 19-21, 2009
Michel Gagner, MD. FRCSC, FACS
a successful First International Consensus Summit for Sleeve Gastrectomy in New
York City last October 2007, I sense that 18 months later another summit was
necessary, in part due to rapid emergence of new knowledge with this operation,
and also because its adoption in every continent of the world, has caught like
wild fire. The second Second International Consensus Summit for Sleeve
Gastrectomy was held March 19-21, 2009 at the renovated and recently revived
Fontainebleau Hotel in Miami Beach. The meeting had 375 participants from more
than 30 countries, and was partitioned in 3 segments over 3 days; a live
surgery session of 9 technically different cases, a full day of oral
presentations, and a half-day of debates.
The Oral presentations session, had invited speakers and presenters who
submitted abstracts, and due to the abundance of accepted material, was
separated in 2 or 3 rooms simultaneously. They were divided in sessions
discussing mechanisms of action, cohorts with 5 years data, and the effect of
sleeve gastrectomy on type-2 diabetes, special cohorts (low BMI, adolescents,
elderly, high-risk patients, quality of life), new emergent technology
surrounding sleeve gastrectomy, complications and revisions. The half day of
debates centered on six controversies, with voting from the audience. The
sleeve gastrectomy is now accepted as a primary operation, on par with
adjustable gastric band and gastric bypass.
CORE COMPETENCIES COMMITTEE
The Role of Simulation Training and Skill Evaluation in Maintenance of Certification
Harrith Hasson, MD, UNM, Albuquerque, NM, John Morrison, MD, LSU, New Orleans, LA
The American Board of Surgery revamped the Maintenance of Certification program in 2005 changing the recertification process. The 6 basic physician competencies are reflected in the 4 components of maintenance of certification: professional standing, lifelong learning and self-assessment, cognitive expertise, and evaluation of surgical performance outcomes. Proficiency will be defined on the basis of objective assessment models and the information collected then used for credentialing and certification. Simulation based training and testing programs are being utilized for assessing technical and nontechnical skills in all four components of the certification process. The availability of simulation programs with measurable objective evaluation criteria has fueled this change. The successful transfer of skills acquired by virtual reality simulators or Box-Trainers to the OR has been confirmed, and the manual laparoscopic skills acquired have been shown to also be directly transferable to the OR. Successful completion of the FLS program using a low fidelity box trainer is currently a requirement for resident eligibility for board examination, so basic and complex skills testing for practicing surgeons can’t be far behind The evaluation of surgical performance has not yet been finalized, however, recent developments in sophisticated recognition software may make this possible.. The ultimate goal of training and skill acquisition, is good patient outcomes and simulation programs play a significant role in building, maintaining and assessing the tools necessary for competent medical care.
What’s New in Laparoscopic Colon Surgery 2009
Arthur Fine, MD, FACS
It has been seventeen years since the first reported laparoscopic colon surgery. It was followed by a flurry of reported procedures that either were independently developed in the fertile climate of video laparoscopy or copied. As most colon surgery is done for malignancy, so were these. Enthusiasm for the less traumatic procedure, backed up by hard survival data, had a wet blanket thrown on it by anecdotal reports of trocar site recurrences and a moratorium was called for.
Although there had only been one paper as the source for data on wound recurrences in open surgery, that did not stop established surgeons whose reputations were built on the foundation of details of technique of the more dramatic open procedure from casting aspersions on the newcomer. Scores of studies and dozens of papers were offered attempting to explain these cancerous recurrences although those with the larger series’ had reported none. Hard science seemed to develop, similar to the science of peptic ulcer we learned to design effective surgery to address that pathology before we realized that what we thought was rocket science was in reality a germ and that trocar site recurrences had more to do with technique than it did with carbon dioxide.
Quickly the COST study was followed by COLOR and CLASICC, with a recent meta-analysis combining all three, showing indeed that the laparoscopic and open versions of cancer surgery were equally efficacious and, as in recent large laparoscopic hernia series’, in the hands of experienced surgeons, and confirmed in a national comparison reported this year, safer.
With the brakes removed, data showing that 5% of colon procedures were performed laparoscopically in 2000 and, including hand assisted surgery, 15% in 2001, reversed, in some locations with some centers reporting 60% of patients having surgery for colon cancer in the period 2005-2007 had the minimally invasive procedure.
We learned other things while these series accrued patients. We learned that the immune system of the patient as a whole and the peritoneal cavity in particular were differentially affected by the choice of surgical procedure. Perhaps it would affect outcome, although only Franklin’s and Lacy’s series, both performed by a single surgeon, seemed to show a small but significant survival advantage for Stage 3 patients. Perhaps this was a clue to therapy. Is there a difference in peritoneal recurrence in patients who survived an anastamotic leak? Australian researchers, as in the home of helicobacter pylori, have recently reported engineering bacteria to deliver minicell versions of their cell membranes containing tumoricidal bombs to the malignant cells that phagocytize them.
We learned that the choice of procedure also affects the levels of vascular endothelial growth factor in the early post operative period, a finding suggested by the small study I reported in 2002 and which has since been confirmed by Belizon in 2006. To what end? Similar to the mouse studies of Fisher on breast cancer, where a burst of cell division in model metastasis followed the removal of the primary, one would have expected that perioperative chemo would have been shown to make a difference, and a larger difference would have been seen in the stage three survival in all series of laparoscopic surgery.
Perhaps we haven’t seen the ultimate in minimally invasiveness. Certainly Morris Franklin’s procedures for both right and left colectomy now come close to being SILS if not NOTES. Or perhaps we are seeing the limits of invasive surgery and have to wonder if there is a prospect of non-invasive surgery.
Following the publication of the COST trial in NEJM, Heidi Nelson mused that perhaps the future was surgery as a method of delivering the ultimate mode of therapy to the tumor. Nanomedicine gives some promise of delivering therapies that malignant cells can neither become immune to or attenuate. .
So far, general surgery is macrosurgery, whether open or laparoscopic, in that it involves gross manipulation of tissues by either human hands or hand held instruments. The last twenty years has seen the miniaturization of tissue trauma. Robotics so far has involved making the tissue manipulation more precise by placing robotic hands on the instruments. The NanoRobotics Laboratory at the Carnegie-Mellon University is taking this further.
Those surgeons who perform colonoscopies may soon be involved in nanodiagnostics. Nanobiochips programmed to recognize the DNA sequence of an adenocarcinoma may be used to test stool samples. Nanobiosensors may become either integral parts of the business end of a colonoscope or a device which can be affixed to an area and which may give a signal when a characteristic change occurs in the nature of the mass. Similarly, Quantum Dots which are inorganic flourophores, may be used for visualizing and staging of peritoneal metastasis in the course of laparoscopy.
We may deliver the strains of engineered bacteria I mentioned earlier, so that the harmless microbe or their split of microcells may be engulfed and deliver gene therapy to a malabsortive bowel or cytocidal bombs to a tumor.
Some drug delivery systems may use a self-assembling container the size of a speck of dust which can release a drug in response to an integral biosensor or in response to a radio signal.
A surgeon, instead of performing procedures from outside of the body, will manipulate and guide nanorobots to a location where they will act as an on-site surgeon on a scale we could never approach. So far, other than the cult classic movie, ‘Fantastic Voyage’, these ideas have all been artist conceptions
At CMU in Pittsburgh they are developing the ‘gutbot’.which will attach to the wall of the bowel for diagnosis and, one day, treatment. You and I may wind up being the delivery vehicle. (See picture). Even smaller robots are being developed. I wish to thank Dr. Robert Freitas, the author of the two-volume text, Nanomedicine, for enabling me to show you an example of one such device which has jumped off the pages and into reality at CIT. (see picture). This ‘tetherless gripper’ is described by its developer as a step towards a biocompatible, ‘minimally invasive’, autonomous microtool.
So while our patients are reaping the benefits of what has now been shown to be safer and more effective yet less invasive surgery, I want to invite you to consider that the future may be smaller than you think.
FIBROIDS / ABDOMINAL UTERINE BLEEDING COMMITTEE
Advances in the Treatment of Abnormal Uterine Bleeding and Uterine Fibroids
Herbert A. Goldfarb, MD
Purpose: To review the current state if minimally invasive techniques to treat Myomas and Uterine Bleeding.
Diagnostic Techniques: include EndoVaginal Ultrasound,Fluid sonography,Diagnostic Hysteroscopy and MRI.
Myomectomy: Techniques Will be described.
Traditional: Endometrial Ablation VS Global Techniques Thermachoice,Novasure,Cryo Ablation Hydrothermablation,Microwave ablation
Alternative Therapy: Uterine Embolization Myolysis and varients, Cryomyolysis, Radiofrequency Ablation, MRI guided High Frequency Ultrasound Ablation of Myomas, Intravaginal Uterine Artery Occlusion.
Conclusion: Gynecologic Surgeons should be versatile and prudent.
Laparoscopy and Ovarian Cancer: Paradigm Change in Surgical Management of Ovarian Cancer
Farr Nezhat, MD, FACOG, FACS
Ovarian cancer is the leading cause of death from gynecologic cancer in the United States. The traditional approach for ovarian cancer or suspicious adnexal masses was traditionally surgical exploration via midline vertical incision. However, with recent advances in technology, the role of laparoscopy in managing these conditions has continued to expand. Currently, laparoscopy is the favored approach in gynecology for the management of adnexal masses. Current literature demonstrates no difference between laparoscopic and laparotomy procedures in staging quality or progression-free survival implying that laparoscopy is a feasible and efficacious alternative to laparotomy in treating borderline ovarian tumors. Early invasive ovarian cancer requires complete surgical staging to obtain important prognostic information, avoid understaging patients, and dictate postoperative management. Multiple studies have demonstrated that laparoscopy is both a feasible and effective alternative to laparotomy in staging or restaging early ovarian cancer. The current literature suggests three potential roles of laparoscopy in advanced ovarian cancer: triage for resectability, performance of second look assessments, and primary or secondary debulking in select cases. Despite these applications, there are three main concerns that have limited the widespread use of laparoscopy in ovarian cancer: the potential for peritoneal tumor dissemination due to carbon dioxide pneumoperitoneum, a higher incidence of cyst rupture, and port-site metastases. The role of laparoscopy in ovarian cancer is continuing to expand with developments in technology and techniques. Current literature supports that laparoscopy is a viable alternative to traditional laparotomy in the management of several aspects of ovarian cancer.
Overcoming the “Achilles heel” of laparoscopic myomectomy by telemanipulator “robotic” suturing
Suresh Nair, MD
One of the most demanding of laparoscopic surgeries is myomectomy. It requires significant surgical prowess and dexterity to reconstruct the uterine defect after the relatively simpler enucleation of the fibroid. Not only must the reconstruction withstand the rigors of a future pregnancy but also has got to be performed with strict adherence to microsurgical principles, as myomectomy is one of the most adhesiogenic procedures in pelvic surgery.
However, the main rate-limiting step an indeed the key reason for the poor update of laparoscopic myomectomy is the tremendous skill and dexterity required for proper suture repair of the uterine defect.
Laparoscopic surgery makes suture repair of myomectomy defects burdensome by its fixed fulcrum effect, counterintuitive movements, lack of three-dimensional vision affecting depth perception, restricted 4 degrees of freedom of movement of instruments from non inflexible instruments and uncomfortable positions the surgeon has to adopt which might result in fatigue and diminution of the surgeon’s efficiency which in turn might heighten the risk of errors and complications.
In the da Vinci robot assistance, the surgeon uses a telemanipulator that provides through a console where he/she is seated comfortably to manipulate instruments intuitively through 7 degrees of freedom of movement with an ability to motion scale for fine suturing and that allows ambidexterity, overall, making suture repairing the myomectomy defect attainable without an arduous learning curve, to a large number of surgeons. In this way, multi layered secure repair with the expectation of good obstetric integrity and minimal risks of de novo adhesions can be easily achieved.
Landmark papers have been published on the tremendous utility of the da Vinci robot in performing myomectomy with good obstetric outcomes.1,2 With the da Vinci robot, laparoscopic myomectomy has extended it conventional limitations both in number and size of fibroids that can be extirpated and the defect securely reconstructed expeditiously without resulting to “short-cuts” such as single en-masse closures with inept suture placement over the serosa. The da Vinci system has allowed surgeons to improve their suturing dexterity by 93%3 hence enabling them to surmount the “Archilles heel” of this procedure.
Last update in Fertiloscopy :a 10 Year Reappraisal
Antoine Watrelot, Prof Dr. Med
Since our first description of fertiloscopy, a little more of 10 years are spent. It is probably a good opportunity to review this technique and its place in the infertile work-up. Many papers have shown the reproducibility of fertiloscopy as well as the safety of the procédure. The FLY study (comparing fertiloscopy and laparoscopy)published in 2003 has demonstrated the accuray of fertiloscopy. Moreover the technique allows the routine practise of salpingoscopy and microsalpingoscopy which is not the case with laparoscopy.
Today, the place of fertiloscopy may be considered as central allowing to determine the best therapeutic option according to the findings : Intra utérine insémination when everything is normal including, tubal mucosa, surgery when either endometriosis or peri tubal adhésions are found but with normal tubal mucosa and in vitro fertilization (IVF) in case of abnormal mucosa. Therefore fertiloscopy appears to be a complimentary tool to artificial reproductive technologies such as IIU or IVF. So if practised early in the infertile work-up then pregnancy may be obtained avoiding unecessary delay which are always stressful for infertile women. Today thanks to the experience of fertiloscopie we are moving to transvaginal NOTES. We have therefore described a simplified endoscopic transvaginal approach which allows to perform NOTES technique in a much easier manner than the classical culdotomy technique.
Definitions, Diagnoses and Products for Abdominal Wall and "Groin" Hernias
Mary Lou Patton, M.D.
This presentation will include abdominal wall hernias, i.e. inguinal, femoral, obturator, spigelian, complex recurrent, port site, and the “sportsman hernia.” Our armamentarium for the diagnosis includes, but is not limited to, physical examination, ultrasound, barium studies, CT scan, MRI, and last but not least, laparoscopy.
A look at the current products available for repair (tissue-separating meshes, biological meshes, and mesh fixation devices) and their benefits and drawbacks will also be included.
There will be a glance at our post-procedure issues of chronic pain, infection, bleeding, and recurrence.
Finally, a discussion of open versus laparoscopic approach and/or combination of the two and their long-term outcomes will be discussed.
UROLOGIC SURGERY COMMITTEE
Advances in Urologic Laparoscopy and Robotic Surgery
Chandru P. Sundaram, MD
Laparoscopic surgery in urology is rapidly advancing with the incorporation of cutting edge technologies. In this century the adoption of robotic technology has been rapid and today over 70% of prostatectomies for prostate cancer in the country are being performed with robotic assistance. More recently robotic assistance is also being routinely used for reconstructive renal surgery like partial nephrectomy and pyeloplasty. The use of robotic ureteroscopy and micro robots are being investigated. Cost of technology is also being discussed especially with the country’s debate on spiraling health care costs. Robotic technology is being adapted for laparo-endoscopic single site surgery (LESS). LESS is being utilized for several surgeries, though patient selection has been very restrictive. There have been significant advances in flexible scopes and instruments to facilitate LESS. Image guided surgery is being developed for urologic laparoscopic procedures like partial nephrectomies for better visualization of renal tumors. Percutaneous and extracorporeal ablative modalities are being used for urologic neoplasms. The incorporation of natural orifice translumenal endoscopic surgery (NOTES) in urology has been slow, but further advances in instrumentation will help define its role in the future. Virtual reality simulators are being developed to help surgeons with training on these constantly evolving technologies.
PELVIC RECONSTRUCTIVE SURGERY / STRESS INCONTINENCE COMMITTEE
Update: Synthetic Mesh for the Correction of Pelvic Organ Prolapse
Conrad Duncan, MD, JD, FACS, FACOG
The use of vaginal ‘mesh kits’ for the correction of pelvic organ prolapse continues to evolve and gain clinical momentum. The increase use of theses kits appears to have arisen from a confluence of many factors including the search for better clinical outcomes, the desire to utilize minimally invasive surgical techniques as well as industry promotion.
The use of synthetic mesh for the surgical correction of Stress Urinary Incontinence (SUI) followed a similar historic pathway in becoming a viable treatment option. After great scrutiny and the application of rigorous clinical trials it has now become the ‘Gold Standard’ in the treatment of SUI. But what is our clinical evidence supporting the use of synthetic mesh for the correction of Pelvic Organ Prolapse?
We will examine the current clinical evidence as well as review the anatomical considerations for the placement of mesh. We will also review the surgical procedure with some ‘best practice’ tips and review the current trends within the industry including changes in mesh design as well as newer delivery systems.
At the conclusion of the presentation the participant should understand the state of the clinical evidence used to support the application of synthetic mesh for the correction of POP as well as an understand of the current trends in the evolution of ‘mesh kits’.