20TH SLS ANNIVERSARY MEETING AND ENDO EXPO 2011 SCIENTIFIC ABSTRACTS
Supplement to JSLS, Volume 15, Number 3

Abstract Reviewers

11.100 General Surgery
Combined Laparoscopic and Transanal Approach to Rectal Procidentia
Pedro Basilio, MD, MSc, Marleny Figueiredo, MD, Leandro Basto, MD
Military Police Hospital Brazil, Clinica de Saúde Intestinal Brazil

Objective: This technical note video introduces a new combined approach to rectal procidentia.

Method: Our patient was a 56-year-old male with no other comorbidities who presented to the ER with an incarcerated procidentia that was successfully reduced after clinical treatment. Seven days later, surgery was carried out. We performed a laparoscopic sacral rectopexy using a prosthetic mesh in a 180-degree fashion. After that, we observed a significant residual mucosal prolapse, which was followed by transanal mucosectomy with a PPH device to establish a complete cure.

Results: The patient was discharged 48 hours after the procedure. The follow-up so far is 7 months with no recurrence, change in bowel habits, or any other complaints. The patient has achieved perfect continence.

Conclusion: Our technique was successful for the complete repair of rectal procidentia. 

11.101 Gynecology
Laparoscopic Strassman Metroplasty for Bicornuate Uterus with Successful Pregnancy
Dr. Hossein Asefjah
Ordibehesht Hospital, Shiraz, Iran

As our experience with laparoscopic suturing techniques and improved pregnancy outcome increase, the ability to do more complicated procedures to correct uterine anomalies increases as well. Laparoscopic Strassman metroplasties were performed in 5 patients with a bicornuate uterus who had a history of at least two 2nd trimester abortions. Using the triple puncture technique, after transverse fundal, a hysterectomy incision including the fundal cleft, unification of the uterus was performed with intracorporeal sutures in 2 layers. After 3 months of sequential hormone therapy, a hysterosalpingogram was repeated and second-look laparoscopy and hysteroscopy were done. The partial adhesion bands were released during the second-look laparoscopy and hysteroscopy.  One patient became pregnant 6 months after the second-look operation. She received a tocolytic agent during the late 2nd and 3rd trimesters and delivered a 3300-g boy at 38 weeks of gestation. No defects or dehiscence along side of the incision line occurred.

11.102 General Surgery
Biliary Cysts of the Liver
Gerard Adhoute, MD
General Hopital Bonnet, France

Objective: This video demonstrates that a biliary liver cyst, a congenital disease, can be safely and effectively removed via laparoscopic surgery. Biliary cysts are usually small, asymptomatic, and require no treatment. However, when the volume of the liver cyst is significant, we remove the cyst via laparoscopic surgery. In this video, we demonstrate the laparoscopic, surgical technical procedure used to remove thees cysts.

Methods: The cysts are removed via a laparoscopic minimally invasive procedure.

Results: We have performed approximately 10 laparoscopic procedures to remove biliary cysts. All 10 procedures were completed successfully without complications.

Conclusions: Our experience shows that this procedure is a safe, nonintrusive method for removing biliary cysts. Advantages include (1) expedited recovery time: hospital stay is usually ≤1 day; (2) less pain: patients report less pain during recovery compared with general surgery; (3) minimally invasive: the procedure does not require opening the abdominal wall; thus, it minimizes abdominal wall trauma.

11.103 General Surgery
Single-Port Verses Two-Port Verses Traditional Four-Port Cholecystectomy: Outcomes and Cost Benefit Comparison Analysis
Michael Parra, MD, Edgar Rodas, MD, Mark Christensen, MS-IV, Jakub Bartnik, MS-IV

Introduction: Theoretically, newer methods of laparoscopic cholecystectomy provide improved cosmetic results and a decrease in postoperative pain. The purpose of this study was to compare the cost and patient outcomes of 3 laparoscopic cholecystectomy techniques.

Methods: This was a retrospective study of 30 patients who underwent cholecystectomy performed by the same surgeon between September 2007 and March 2010. Ten underwent 4-port cholecystectomy (FPC), 10 two-port cholecystectomy (TPC) and 10 single-port cholecystectomy (SPC). Patients were compared as to age, sex, preoperative diagnosis, intraoperative time, postoperative complications, and hospital stay. A patient satisfaction phone survey was conducted to compare scar appearance, postoperative pain, and hospital course.

Results: Of the 30 cholecystectomy cases, 2 minor complications occurred. A conversion to open surgery was needed in one SPC due to dense adhesions. One TPC was followed immediately by a total abdominal hysterectomy, effecting operative time and hospital stay. Operation time (FPC:49min, TPC:71min, SPC:69min) was shortest for FPC and similar for TPC and SPC. Hospital stay (FPC:1.132days, TPC:1.667days,  SPC:1.332days) was similar among all procedures. Overall costs were lowest for TPC. The cost of the FPC was approximately 1.5 times the cost of TPC. The SPC cost was significantly higher at 3 times to 4 times that of TPC. The patient satisfaction survey showed no significant difference between the 3 techniques.

Conclusions: Newer methods of cholecystectomy are safe and result in comparable patient satisfaction. The cost of single-port cholecystectomy is significantly higher and therefore limits its use in many instances. Two-port cholecystectomy is the most cost-effective method and has the greatest potential of improvement over the traditional 4-port technique.

11.104 General Surgery
Transumbilical Multi-Mini Port Clipless Cholecystectomy Without Using Triport
Mustfa Kamal Pasha, MBBS, FRCS, Muhammad Nadeem
Head of Surgery Ward # 6, Nishtar Medical College & Hospital, Multan, Punjab, Pakistan (Prof. Dr. Pasha)
Final year MBBS student, Nishtar Medical College, Multan Punjab, Pakistan (Mr. Nadeem). 

Transumbilical multi-mini port clipless laparoscopic cholecystectomy is a novel laparoscopic surgical technique for cholecystectomy utilizing only a transumbilical incision, which eliminates any visible abdominal scars and improves cosmesis. This pilot study was conducted to assess the safety, feasibility, and short-term outcomes of transumbilical multi-mini port clipless laparoscopic cholecystectomy using conventional laparoscopic equipment. Transumbilical multi-mini port clipless cholecystectomy without using the triport technique takes about 55 minutes less time. After the initial expense of buying a Harmonic scalpel, it is economical for patients in poor countries that cannot afford the expensive triport. Fifteen patients (14 females average age 40 years and 1 male age 45 years) underwent laparoscopic cholecystectomy. To reduce the cost, an innovative technique was used in which 3 small incisions were made along the edge of the umbilicus in a “J” fashion. The duration of surgery was 55±20 minutes. Blood loss, patient recovery, and outcomes were comparable to those of using the triport technique, so this single-port technique is feasible for performing routine laparoscopic procedures.

11.105 Gynecology
Supracervical Hysterectomy with Manual Morcellation of the Uterus
Eli Serur, MD, Nisha Lakhi, MD
Richmound University Medical Center, Division of Gynecology Oncology,
Staten Island, New York, New York, USA (all authors).

Our objective was to design a technique for rapidly extracting large uteri that can be used for both malignant and benign pathologies. The technique involves placing the uterine corpus into an endoscopic bag intraabdominally and manually morcellating the specimen. This eliminates the risk of vascular or bowel injury from morcellator blades as well as the complications that can result from spillage of the specimen into the abdominal cavity, including dissemination of malignant cells. We have successfully accomplished over 200 laparoscopic hysterectomies on uteri ranging from 250g to 2100g in patients ranging in BMI from 24.5kg/m² to 37.5kg/m². It is safe and appropriate for malignant pathology, because there is no spillage of the specimen. Manual morcellation is easy to master, results in shorter operative times, and yields good cosmetic results.

11.106 Gynecology
Total Laparoscopic Hysterectomy after Five Previous Cesarean Deliveries with a McCall Culdoplasty
Eli Serur, MD, Nisha Lakhi, MD
Richmound University Medical Center, Division of Gynecology Oncology, 
Staten Island, New York, New York, USA (all authors).
 
This video is of a total laparoscopic hysterectomy in a patient after 5 previous cesarean deliveries. Techniques of adhesiolysis and hemostasis that can be used for difficult hysterectomies are demonstrated. The patient had a fixed cervix that was adherent to the bladder. We first amputated the uterine corpus from the cervical stump, and then proceeded to mobilize the cervix. The procedure was finished with a McCall culdoplasty and reinforcement of the posterior vaginal wall to the uterosacral ligament midline to prevent enterocele formation. Laparoscopic hysterectomy can be successfully performed in patients with multiple abdominal incisions. 

11.107 Multispecialty
A Survey of Faults and Related Complaints in Laparoscopic Surgery Between 2002 and 2008 Registered at Tehran Medical Legal Center
Khavanin Zadeh Morteza, Gholipour Fatemeh
Hasheminejad Kidney Center, Tehran University of Medical Sciences, Tehran, Iran (all authors).

 Objective: The trend and outcome of surgical operations can always be associated with some unwanted complications. To improve the outcome of surgeries and to prevent the complications due to physician error, it is advisable to scrutinize the complaints in which the physician is convicted.

Methods: In a descriptive cross-sectional study, all files with complaints about complications of laparoscopic surgeries were studied. These files were recorded in the Medical Courts of Tehran Province from 2002 to 2008. All data related to management, need for surgical operation, medical faults and their types, and surgeon's specialty were gathered and analyzed with SPSS software (version 11.5, Chicago, IL, USA).

Results: We found 1771 medical complaints filed during a 6-year period in the fields of surgery, urology, and gynecology. Fifty-nine complaints (3.33%) in the medical courts were about laparoscopic surgeries. The majority of complaints came from private practice (72.3%) rather than public hospitals (27.1%). The complaints were postlaparoscopic body injuries 20 cases (35.08%), death 13 cases (22.80%), unsuccessful operation 10 cases (17.54%), carelessness and negligence 8 cases, misdiagnosis 4 cases, and high-risk therapies 2 cases.

Conclusion: Regarding the complications and motivations for complaints, the following points are suggested:
1) ‪Improvement of the physician–patient relationship can prevent many of the official complaints.‬
2) ‪Providing an informed written consent from the patient after a thorough description of procedures and probable complications.‬
3) ‪ The patients and his/her family should be informed of any probable complications.‬
4) ‪The surgeon should update his skills.

11.108 General Surgery
Optimizing Clinical Outcomes of Laparoscopic Cholecystectomy with Concomitant Laparoscopic Common Bile Duct Exploration
Shahram Nazari, MD, S. M. Khosroushahi, MD, S. H. Saba, MD, A. Amini, MD, S. Agah, MD, H. R. Sarie, MD, M. Asadi Ghafari, MD
Department of Surgery, Erfan Hospital, Tehran, Iran (Drs. Nazari, Khosroushahi, Amini, Saba, Agah, Sarie, Ghafari).
Department of Surgery, Milad Hospital, Tehran, Iran (Dr. Nazari).
Department of Surgery, Madaen Hospital, Tehran, Iran (Dr. Nazari).
Department of Emergency Medicine, Imam Hosain Hospital, Tehran, Iran (Dr. Amini).

Background: Common bile duct (CBD) stones are found in approximately 16% of laparoscopic cholecystectomies (LC). Clinical models are inaccurate in predicting CBD stones. At the beginning of the laparoscopic era, because of an obvious lack of expertise in laparoscopic surgery, if the diagnosis of choledocholithiasis was established during intraoperative cholangiography (IOC), the surgeons preferred postoperative ERCP instead of conversion to open surgery (2-stage surgery). Prior to the development of LC, the management of these patients included CBD exploration at the time of cholecystectomy. With the increasing experience of laparoscopic surgeons, it seemed logical to develop a mini-invasive 1-stage laparoscopic approach. 

Methods: This study evaluated our results with laparoscopic common bile duct exploration (LCBDE) in a series of 690 patients treated over 56 months, and we evaluated the feasibility and safety of LCBDE during LC.

Results: CBD stones were demonstrated in 68 patients by routine IOC. In 7 patients, endoscopic sclerotherapy was performed, with successful stone clearance after completion of LC. LCBDE, completed laparoscopically, was performed in 61 patients. In 21 patients, the CBD was closed with a C-Tube, and in 10 the surgery was completed with T-tube insertion. In 6 cases, no CBD drainage was performed. In 60 cases, flexible choledochoscopy was done. Choledochoduodenostomy was done in 24 cases. The operative time ranged from 90 minutes to 130 minutes (mean 95), which is significantly greater than time with conventional LC (range, 20 to 40 minutes, mean 30). LCBDE was performed without immediate or late complications.

Conclusion: There are no debates about the detection and management of CBD stones in the era of LC. LCBDE is cost-effective, efficient, and minimally invasive.


11.109 General Surgery
Early Severe Acute Biliary Pancreatitis: Mini-Invasive Approach
 Neri Vincenzo, Prof Dr Med
Department of Surgery, University of Foggia, Italy

Objective: The aim of this study was to evaluate the clinical features and management of patients with early severe acute pancreatitis (ESAP).

Patients and Methods: From 1997 through 2010, we evaluated and treated 261 patients with acute biliary pancreatitis. In this group, the occurrence of severe acute pancreatitis (SAP) was 22% (58); of these 58 SAP, 12 (20%, 12/58) ESAP were defined as the presence of organ dysfunction within 72 hours after onset of symptoms. Clinical features, organ failure, therapeutic choices, and results of SAP (46) and ESAP (12) were compared.

Results: The results of the comparison between SAP and ESAP are as follows: degree of impairment of the pancreas (Balthasar CT score): SAP 2.3, ESAP 3.85; abdominal compartment syndrome (ACS): ESAP 8.33%; multiple-organ failure syndrome (MODS): ESAP 41.6%; simple organ dysfunction: SAP 13%, ESAP 58.3%; hypoxemia: SAP 45.6%, ESAP 66.6%; pancreatic infections: SAP 4.34%, ESAP 8.3%; mortality: SAP 4.34%, ESAP 8.3%. The mini-invasive therapeutic ESAP approach is based on intensive care, improvement of hypoxemia, assured papillary patency (cholestasis verification, ERCP/ES), control and treatment of pancreatic/peri-pancreatic necrotic, infected gatherings.

Conclusion: The main characteristic factors of ESAP are MODS, early hypoxemia, and severe impairment of the pancreas. These patients need close intensive therapy and longer hospital stay; mortality rate is higher with ESAP than with SAP: 8.3% vs 4.34%. The mini-invasive therapeutic ESAP approach is safe and effective.

11.110 General Surgery
Laparoscopic Greater Curvature Plication: Initial Results of an Alternative Restrictive Bariatric Procedure
Farahmand Mohammadreza, Najjaran Vahid, Mumivand Shapur
Laparoscopy Department, Erfan Hospital, Tehran, Iran

Background: Sleeve gastrectomy is a surgical technique that involves resection of a significant portion of the stomach. The present study reports findings from laparoscopic greater curvature plication, which is an alternative bariatric procedure similar to sleeve gastrectomy but without the need for gastric resection.

Methods: A prospective study was carried out, following gastric plication in 52 morbidly obese patients (40 females/12 males) with a mean age of 29.3 years and mean BMI of 41 kg/m². Through a 4-port approach, the stomach was reduced by dissecting the greater omentum and short gastric vessels, as in sleeve gastrectomy, and the greater curvature was then invaginated using continuous nonabsorbable suture performed over a 32-Fr bougie to ensure a patent lumen.

Results: Mean operative time was 45 minutes, and mean hospital stay was 36 hours. Patients returned to their regular activities on average 7 days following surgery. No intraoperative complications occurred. Postoperative bleeding and leakage was not seen in any patient. Reoperation was done in one patient who had continuous vomiting because of obstruction of the gastric lumen plication. All patients experienced excess weight loss of at least 20% after 1 month. Mean estimated weight loss was 62% in 9 patients after 18 months.

Conclusions
Laparoscopic gastric curvature plication is feasible, safe, and effective for at least 18 months when performed on morbidly obese patients. Longer follow-up and prospective comparative trials are needed.

11.111 General Surgery
Laparoscopic Greater Curvature Plication: Initial Results of an Alternative Restrictive Bariatric Procedure
Farahmand Mohammadreza, Najjaran Vahid, Mumivand Shapur
Laparoscopy Department, Erfan Hospital, Tehran, Iran

Background: Sleeve gastrectomy is a surgical technique that involves resection of a significant portion of the stomach. The present study reports findings from laparoscopic greater curvature plication, which is an alternative bariatric procedure similar to sleeve gastrectomy but without the need for gastric resection.

Methods: A prospective study was carried out, following gastric plication in 52 morbidly obese patients (40 females/12 males) with a mean age of 29.3 years and mean BMI of 41 kg/m². Through a 4-port approach, the stomach was reduced by dissecting the greater omentum and short gastric vessels, as in sleeve gastrectomy, and the greater curvature was then invaginated using continuous nonabsorbable suture performed over a 32-Fr bougie to ensure a patent lumen.

Results: Mean operative time was 45 minutes, and mean hospital stay was 36 hours. Patients returned to their regular activities on average 7 days following surgery. No intraoperative complications occurred. Postoperative bleeding and leakage was not seen in any patient. Reoperation was done in one patient who had continuous vomiting because of obstruction of the gastric lumen plication. All patients experienced excess weight loss of at least 20% after 1 month. Mean estimated weight loss was 62% in 9 patients after 18 months.

Conclusions
Laparoscopic gastric curvature plication is feasible, safe, and effective for at least 18 months when performed on morbidly obese patients. Longer follow-up and prospective comparative trials are needed.

11.112 General Surgery
Minimally Invasive Surgery for the Treatment of Palmar Hyperhidrosis: A Sutureless Surgery with Mini-Thoracoscopic Bilateral Cervical Sympathectomy
Farahmand Mohammadreza, Toulabi Karam Allah
Department of Laparoscopic Surgery, Erfan Hospital, Tehran, Iran

Background: Palmar hyperhidrosis due to sympathic overactivation has an unfavorable psychosocial effect on a patient’s life and work. Cervical sympathectomy is a curative operation for this situation. We report a new sutureless surgery by mini-thoracoscopic bilateral cervical sympathectomy for the treatment of palmar hyperhidrosis.

Patients and Methods: Between May 2006 and December 2009, 18 patients with palmar hyperhidrosis underwent sutureless mini-thoracoscopic bilateral sympathectomy. The operation was performed with 3 mini-thoracoscopic ports (2.5m). After resection of the 2nd and 3rd cervicothoracic sympathic ganglions and inflating the lung, port sites were closed with adhesive tape.

Results: All patients had dry hands at the end of the operation. A chest tube was not inserted in any patient. Mean hospital stay was 18 hours (range, 16 to 24). Median operation time was 55 minutes. An early complication, atelectasia of the left upper lobe, occurred in one patient (5.5%) and was managed with medical treatment. Mean follow-up was 22 months (range, 13 to 28).

Conclusion: Bilateral cervical sympathectomy performed with a mini-thoracoscopic sutureless method is a safe and effective approach for the treatment of palmar hyperhidrosis.

11.113 Multispecialty
Laparoscopy and Natural Orifice Surgery: First Entry Safety Surveillance Step
Daniel A. Tsin, MD, Andrea Tinelli, MD, Antonio Malvasi, MD, Fausto Davila, MD, Ramiro Jesus, MD, Raul Castro–Perez, MD
The Mount Sinai Hospital of Queens, Long Island City, New York, USA, Member of the New European Surgical Academy (NESA); Natural Orifice Surgery working group (Dr. Tsin).
 Department of Obstetrics and Gynecology, Division of Experimental Endoscopic Surgery, Imaging, Technology and Minimally Invasive Therapy, Vito Fazzi Hospital, Lecce, Italy,
Member of the New European Surgical Academy (NESA); Natural Orifice Surgery working group (Dr. Tinelli).
 Department of Obstetrics and Gynecology, Santa Maria Hospital, Bari, Italy, Member of the New European Surgical Academy (NESA); Natural Orifice Surgery working group (Dr. Malvasi).
 Universidad Autonoma de Mexico. Facultad de Estudios Superiores, Iztacala, Mexico (Drs. Davila, Jesus).
 Hospital Universitario Abel Santamaría Cuadrado, Pinar del Río, Cuba; Universidad de Ciencias Médicas de Pinar del Río, Cuba (Dr. Castro-Perez).

Objective: The study focused on surveillance of the first entrance port in laparoscopic and natural orifice transvaginal endoscopy surgery, without analyzing other surgical findings.

Methods: Laparoscopic surgery was performed in 168 women with previous abdominal pelvic surgeries. Another 145 patients had transvaginal minilaparoscopy assisted natural orifice surgery (the “hybrid procedure”), and 3 patients had pure natural orifice transvaginal endoscopic surgery (the “pure procedure”). For patients who had laparoscopy or hybrid procedures, the surveillance was from a laparoscope or gastroscope placed in a secondary port. Surveillance in pure procedures was done using a gastroscopic retro view to see the pouch of Douglas.

Results: The laparoscopic procedures were gynecological surgeries. The hybrid procedures included gynecological surgeries as well as appendectomies and cholecystectomies. The pure procedures were limited to cholecystectomies. There were a few minor vascular and bowel injuries in the laparoscopy group. There were no injuries in the transvaginal hybrid or pure procedures.

Conclusions: Surveillance of the first entrance port is precautionary. In addition, the results of this study suggest that such surveillance in patients with previous surgery enables the recognition of complications that could otherwise be missed. 

11.114 Gynecology
Itinerant “Coils”
Mark Erian, MD, FRCOG, FRANZCOG,
Glenda Mc Laren, MD, FRCOG, FRANZCOG

Background: The use of intrauterine contraceptive devices (coils) is increasing worldwide, as is the incidence of reported cases of extrauterine migration. The authors report 4 cases of missing coils; all were successfully removed.

Methods: All patients underwent ultrasound scanning (USS) to localize the coils, and 2 out of these 4 had computerized tomography (CT) scans in an attempt to accurately locate the coils.


Results:
Case 1: CT scan located the coil underneath the right rectus abdominal muscle. The coil was found attached to the cecum and was retrieved laparoscopically.

Case 2: USS showed the coil was in the Pouch of Douglas. However, laparoscopy located the coil in the left upper quadrant of the peritoneal cavity, about 3cm below the left leaf of the diaphragm. Laparoscopic removal was affected.

Case 3: USS revealed that the coil was “low in the pelvis.” Laparoscopy revealed the coil attached to the external stomach wall. Laparoscopic removal of the coil was done.

Case 4: USS showed the coil to be inside the uterus, as did CT scan. However, hysteroscopy showed an empty uterine cavity, and cystoscopy excluded the urinary bladder as its location. Laparoscopy showed that the coil had penetrated the uterus through a previous caesarean delivery scar. The coil was removed per vaginam under laparoscopic guidance.

Conclusion: The use of multiple diagnostic and endoscopic modalities is helpful in determining the exact location of the mobile extra-uterine coils, and in facilitating their retrieval.

11.115 Multispecialty
Deployment of Remote Operated Mini-Instruments in Single-Port Laparoscopy and Natural Orifice Surgery
Daniel A. Tsin, MD, Martha R. Davila, MD, Fausto Davila, MD, Guillermo Dominguez, MD, Andrea Tinelli, MD, Michael Stark, MD
The Mount Sinai Hospital of Queens, Long Island City, New York, USA (Dr. Tsin).
Universidad Nacional Autonoma de Mexico, Poza Rica, Veracruz, Mexico (Drs. M. and F. Davila).
Hospital de Clinicas, Universidad de Buenos Aires, Buenos Aires, Argentina (Dr. Dominguez).
Division of Experimental Endoscopic Surgery, Vito Fazzi Hospital, Lecce, Italy (Dr. Tinelli).
The New European Surgical Academy (NESA), Berlin, Germany (Dr. Stark).
   
Objective: The concept of secured independent tools for the deployment of miniature instruments may solve some issues, such as direct current powered engines, electronic transmission devices, exposure, illumination, mobilization, retraction, traction, and triangulation.
 
Methods: We used a laparoscopic trainer, micro clips with 1 or 2 strings as tails and cables for engines and lights. The above instruments were introduced via a 12-mm or 15-mm port. Clips were placed for traction, retraction, and exposure, mobilization, and triangulation; lights were used for illumination and motors for potential work. A laparoscopy port closure or suture passer was introduced percutaneously to grab and extract the strings or cables outside of the simulated abdominal cavity. The engines and lights were powered by a direct electric current plugged to exteriorized outlets.
 
Results: Clips, engines, and lights performed well. The single port remains unobstructed for surgery, while the tools were secured at the parietal peritoneum.
 
Conclusions: We replaced cannulas with strings or cables. This technique provides sufficient strength for grasping and pulling. It also has the potential to power wired machines and signal transmissions using fiberoptic micro cables for remote operated devices.

11.116 General Surgery
Laparoscopic Complications: Peripheral Nerve Injury
Sákra Lukáš, MD, PhD, L. Kohoutek, MD, E. Ehler, MD, PhD, J. Siller, MD, PhD
Surgical Department of the General Hospital Pardubice, Czech Republic (Drs. Lukáš, Kohoutek, Siller).
Neurologic Department of the General Hospital Pardubice, Czech Republic
The Institute of Medicine of the University of Pardubice (Dr. Ehler).

Introduction and Objective: Laparoscopic approaches predominate over almost all types of surgical procedures. Unlike open procedures, laparoscopic procedures are gentler on most tissues. However, iatrogenic injuries to peripheral nerves occur even in procedures performed with well-mastered laparoscopic skills. Their treatment is very difficult, long-term, and sometimes unsuccessful.

Methods: The authors present a summary of the most frequent laparoscopic procedures and of the occurrence of peripheral nerve injuries after various procedures. They make an effort to show situations that lead to iatrogenic lesions, to identify the causes of nerve injuries, and to explain the consequences of necessary preventive measures. Referring to a group of their own patients after laparoscopic groin hernia repair procedures, the authors identify the causes, incidence, and the possible methods of preventing such lesions.

Results: Between January 1, 2007 and December 31, 2010, we performed 519 TAPPs and managed 456 patients (87.8%). Neuralgia was identified in 8 patients (1.7%). According to pain localization, 3 patients (0.66%) suffered damage to the lateral cutaneous nerve of the thigh, 3 damage to the femoral branch of the genitofemoral nerve (0.66%), and 2 damage to the genital branch of the genitofemoral nerve (0.44%).

Conclusion: The perfect knowledge of anatomy, the mastering of the difficult laparoscopic technique, and the knowledge of typical iatrogenic nerve injuries after laparoscopic procedures forms a crucial preventive step. A great majority of these lesions require only conservative treatment, and the neurosurgeon treats only a small amount of serious denervation or painful nerve injuries.

11.117 General Surgery
Laparoscopic Repair of a Perforated Marginal Ulcer 4 Years After Gastric Bypass: A Case Report
Anna Goldenberg-Sandau, DO, Lyudmila Nikolaychook, DO, Lisa Shaw, Marc Neff, MD 

We performed a comprehensive literature review (PubMed and Cochrane 1997-date) of the current diagnostic and surgical treatments of perforated marginal ulcers after gastric bypass surgery. Based on this review, we found that the operation with the greatest longevity is the Roux-en-Y gastric bypass (RYGB). It has been the most effective means of long-term weight loss with over 20 years of data to support it. Although we have come a long way in reducing the morbidity and mortality of gastric bypass, complications still arise. The incidence of marginal ulcers is reported to be 1% to 16% after open bypass and 7% after laparoscopic bypass. It is reported that very few ulcers perforate. We present the case of a 48-year-old man who underwent a laparoscopic RYGB and approximately 4 years later presented to the emergency room with severe abdominal pain. X-rays revealed free air, and he was taken emergently to the operating room for laparoscopic exploration. Intraoperatively, he was diagnosed with a perforated ulcer on the roux limb just below the gastrojejunostomy. A laparoscopic repair was performed using a Graham patch technique. The patient’s postoperative course was uneventful, and he was discharged home on postoperative day 5. He underwent endoscopy 6 weeks postoperatively at which time no ulcerations were seen.

11.118 General Surgery
Laparoscopic Left Adrenalectomy for Giant Pheochromocytoma
Gordon G. Wisbach, MD, Daniel T. Ruan, MD, Ashley H. Vernon, MD
Surgery, Naval Medical Center San Diego, San Diego, California, USA (Dr. Wisbach).
Surgery, Brigham & Women's Hospital, Boston, Massachusetts, USA (Drs. Ruan, Vernon). 

Introduction: The laparoscopic approach has become the preferred technique for removing the adrenal gland. Relative contraindications include size >6cm and obesity. We present the case of a laparoscopic left adrenalectomy for a giant pheochromocytoma (13cm) in a morbidly obese patient.

Methods: A 45-year-old woman with BMI of 40.5 kg/m² and a past medical history of hypertension had a retroperitoneal mass incidentally discovered during laparoscopic adjustable gastric band placement (LAGB). Postoperative laboratory evaluation revealed elevated catecholamine and metanephrine levels, and MRI showed a 13x11x11-cm left adrenal mass. In the operating room, the patient was placed in a right decubitus position with the table flexed. The abdomen was explored via 4 trocars in the left upper quadrant, and the massive left retroperitoneal mass was easily identified. During retraction, the patient’s hemodynamic status became labile and required releasing pressure on the gland with simultaneous administration of appropriate intravenous medication. This video highlights techniques to overcome the challenging size of the adrenal gland as well as large body habitus.

Results: The massive adrenal gland was successfully removed laparoscopically in 210 minutes with estimated blood loss of approximately 100cc. She recovered well and was discharged home on postoperative day 3. Pathologic evaluation revealed a benign adrenal pheochromocytoma. At a recent 9-month follow-up appointment, her symptoms and hypertension had resolved, laboratory values had normalized, and she had lost 40 pounds since her LAGB.

Conclusion:  A laparoscopic approach remains the preferred technique for adrenalectomy, even in the setting of some relative contraindications, and requires an experienced surgeon to complete safely.

11.119 General Surgery
Laparoscopic Gastric Bypass Technique Using an Anterior Approach to the Ligament of Treitz
Gordon G. Wisbach, MD, Janey S. Pratt, MD
Surgery, Naval Medical Center San Diego, San Diego, California, USA (Dr. Wisbach).
Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA (Dr. Pratt). 

Background: Laparoscopic Roux-en-Y gastric bypass (LGBP) remains the “gold standard” weight loss procedure, and most bariatric surgeons use a set operative technique. We present an alternative approach for Roux limb construction when access to the infra-mesocolic abdomen is challenging. 

Methods: The patient is a 46-year-old super-super obese woman with a BMI of 67kg/m² and past medical history of hypertension, hyperlipoproteinemia, gastroesophageal reflux disease, and obstructive sleep apnea. Her past surgical history is significant for cholecystectomy and total abdominal hysterectomy/bilateral salpingo-oophorectomy. She was deemed a suitable candidate for weight loss surgery and consent was obtained for an LGBP. Initial intraabdominal inspection revealed a limited working space due to profound visceral obesity, a massive omentum, and dense adhesions in the lower abdomen. Due to these limitations, avoiding the infra-mesocolic abdomen by using an anterior approach to the ligament of Treitz was optimal. This video highlights the steps of this useful technique to create a retrocolic Roux limb and tension-free gastrojejunostomy.

Results: We successfully completed an LGBP in a super-super obese patient with limited abdominal domain and significant adhesive disease from prior abdominal surgeries. The operation was performed in 210 minutes with 50cc of estimated blood loss. Her recovery was uneventful, and she was discharged home on postoperative day 2. Five and a half months later, she was doing well and had an estimated body weight loss of 35%.

Conclusion: The anterior approach to the ligament of Treitz for Roux limb construction during LGBP is a useful alternative technique in the armamentarium of the laparoscopic bariatric surgeon.

11.120 Gynecology
Laparoscopic Approach for the Large, Broad Ligament Leiomyoma
Jonathan Y. Song, MD, William Culver, RN, BSN
TLC Medical Group, SC, Delnor Hospital, Rush University Medical Center, Geneva, Illinois (Dr. Song).
Delnor Hospital, Geneva, Illinois (Mr. Culver)

Background and Objectives: Conventional sites for trocar placement may compromise the surgical approach in dealing with specimens exceeding 20cm in size in laparoscopic surgery. The objective of this video is to demonstrate our technique of laparoscopic resection of a 24-cm broad ligament leiomyoma.

Methods: Our surgical technique is explained step-by-step by describing the process of determining where the camera and ancillary ports should be placed, enucleation of the fibroid, and dissection of the retroperitoneum, demonstrating our Simplified Laparoscopic Abdominal Morcellation technique (SLAM), and extracting the large specimen.

Results: Fibroids exceeding 1000 grams have been safely removed laparoscopically in over 30 patients.

Conclusion: Under capable hands in an established surgical setting, very large fibroid tumors can be safely removed laparoscopically regardless of size, number, and/or anatomic location.

11.121 Gynecology
Laparoscopic Fimbrioplasty
Jonathan Y. Song, MD, Nasir Rana, MD, Carlos Rotman, MD
TLC Medical Group, SC, Delnor Hospital, Rush University Medical Center, Geneva, Illinois, USA (Dr. Song).
Oak Brook Institute of Endoscopy, Oak Brook, Illinois, USA (Dr. Rana).
Oak Brook Institute of Endoscopy, Oak Brook, Illinois, USA (Dr. Rotman).

Background and Objectives: The introduction of in-vitro fertilization/embryo transfer (IVF-ET) resulted in a worldwide decline in tubal reconstructive surgery. Couples that cannot afford the expense and time commitment required by IVF are often left without any options. The objective of this video is to show that for hydrosalpinges, tubal reconstructive surgery is a viable alternative to IVF-ET.

Methods: Our group's experience with both IVF-ET and tubal reconstructive surgery has shown that the initial approach to tubal factor infertility should be surgical, at which time the tubes can be either repaired or removed.

Results: Cases of hydrosalpinges (as seen in this presentation) should be treated by fimbrioplasty, preferably laparoscopically, in all cases where preservation of mucosal integrity is demonstrated during surgery, irrespective of size, anatomic distortion, or presence of extensive pelvic adhesions. Preliminary results are encouraging.

Conclusion: Laparoscopic fimbrioplasty in properly selected cases consistently produces pregnancy rates that equal or exceed those attained by IVF-ET. Our approach to the laparoscopic management of large hydrosalpinges is shown in this video presentation.

11.122 General Surgery
Robotic Vascular Surgery
Stadler Petr, Assoc Prof, MD, PhD, Dvoracek Libor, MD, Vitasek Petr, MD, Matous Pavel, MD
Department of Vascular and Robotic Surgery, Na Homolce Hospital, Prague, Czech Republic (all authors).

Objective: The feasibility of robotically assisted laparoscopic aortic surgery has been adequately demonstrated. The robot represents the next step in the use of minimally invasive surgery. Our clinical experience with robot-assisted aortoiliac reconstruction for occlusive diseases, aneurysms, and hybrid procedures performed using the da Vinci system is herein described.

Methods: Between November 2005 and December 2010, we performed 190 robot-assisted laparoscopic aortoiliac procedures. 154 patients were prospectively evaluated for occlusive diseases, 31 patients for abdominal aortic aneurysm, 2 for a common iliac artery aneurysm, 1 for a splenic artery aneurysm, and 2 for hybrid procedures. The robotic system was applied to construct the vascular anastomosis, for the thromboendarterectomy, for the aorto-iliac reconstruction with a closure patch, for dissection of the splenic artery, and for the posterior peritoneal suture. A combination of conventional laparoscopic surgeries and robotic surgeries were routinely included. A modified, fully robotic approach without laparoscopic surgery was used in the last 20 cases in our series.

Results: 183 cases (96%) were successfully completed robotically; one patient's surgery was discontinued during laparoscopy due to heavy aortic calcification. In 6 patients (3%), conversion was necessary. The 30-day mortality rate was 0.5%, and nonlethal postoperative complications were observed in 9 patients (4.7%).

Conclusions: Our clinical experience with robot-assisted laparoscopic surgery has demonstrated the feasibility of this technique for aortoiliac vascular and hybrid procedures. The da Vinci robotic system facilitated the creation of the aortic anastomosis and shortened the aortic clamping time compared to purely laparoscopic techniques.

11.123 Urology
Laparoendoscopic Single Site Surgery: The Initial Experience at the University of South Florida
Alejandro R. Rodriguez, MD, Hubert Swana, MD, Mark Rich, MD, Raul Ordorica, MD, Jorge Lockhart, MD
University of South Florida, Department of Urology, Tampa, Florida, USA (all authors).

Objective: To report our initial experience with laparoscopic endoscopic single site (LESS) surgical techniques for the treatment of pediatric and adult urology cases.

Methods and Procedures: From May 2009 to January 2011, 17 LESS cases were performed. We analyzed the single-port device used, patient’s age, BMI, operating room (OR) time, complications, and follow-up. 

Results: Twelve procedures were varicocelectomies, 2 simple nephrectomies, 2 partial nephrectomies, and 1 bilateral gonadectomies. The ASC, Gelpoint, and Covidien single port were used in 2, 1, and 14 patients, respectively. For the varicocele cases and the gonadectomy case, the mean patient age, BMI, and OR times were: 15 years (range, 11 to 18), 21.9 (range, 15.2 to 38.6), 45.5 minutes (range, 29 to 68), respectively. The patients who had the simple nephrectomy were 14 and 50 years old, had a BMI of 21, and the OR time was 150 and 120 minutes, respectively. The transperitoneal partial nephrectomy patient was 62 years old, had a BMI of 31, and the OR time was 160 minutes. The retroperitoneal partial nephrectomy patient was 61 years old, had a BMI of 31, and the OR time was 60 minutes. The 2 patients who underwent simple left nephrectomies were discharged within 48 hours after surgery. The patients who underwent transperitoneal and retroperitoneal partial nephrectomies were discharged 3 days and 23 hours after surgery. Mean follow-up was 10 months, and no patient had complications.

Conclusions: LESS in pediatric and adult urological patients is feasible, and our initial experience is encouraging. LESS should be an option, in select cases, for both pediatric and adult surgical candidates who would like the benefit of a keyhole scarless (umbilical) surgery.

11.124 General Surgery
Overnight Stay Colon Surgery for Adenocarcinoma 
Andrew Dobradin, MD, PhD, Pran Kar, MD, James Rogers, MSc, Shaan E. Alam, MS-3
Winter Park Memorial Hospital, University of Central Florida, Orlando, Florida, USA (all authors).
 
Background and Objectives: A short hospital stay is one of the main advantages of laparoscopic surgery. A fast-track process contributed to a better understanding of the elements of perioperative care that influence further improvement in the hospital length of stay (LOS) after colectomies, reducing LOS down to 2 days to 5 days. With following a well-recognized multimodal approach, further decreases in LOS can be expected.

Methods and Procedures: A review of the 2010 practice cases of a single surgeon revealed 2 patients who were discharged home after laparoscopic right hemicolectomies for adenocarcinoma in <24 hours after admission to the surgical ward. Both patients had invasive malignant disease and required extensive harvesting of the mesenteric tissue for lymph node sampling. Average age was 82. Patients were placed on an oral diet immediately after the procedure. They had active bowel sounds on POD#1 and were passing flatus. 

Results: Two octogenarian patients receiving laparoscopic hemicolectomy for malignant disease were discharged home in <24 hours after surgery.
Postoperative follow-up did not show any adverse reaction to the early discharge.
Patients were very happy with their short hospital stay. 

Conclusions: Modification of multimodal perioperative care with further refinement of the surgical technique allows patients to be discharged home in the first 24 hours after laparoscopic colectomy for ascending colon carcinoma. Careful follow-up is necessary, because anastomotic leak, the most detrimental complication of colonic surgery, is usually observed after POD#5. 

11.125 General Surgery
Single Incision Laparoscopic Intragastric Surgery Using the Sils Port: A Feasibility Study on a Porcine Model
Zhu Jiangfan, Xin Ying, Li Xiaoxian, and others
Minimally Invasive Surgery Center, East Hospital of Tongji University, Shanghai, China (all authors).
 
Objective: The aim of this study was to evaluate the feasibility, safety, and efficiency of single-incision laparoscopic intragastric surgery by using the Sils Port.

Methods: Six pigs were used in this study. The Sils Port was introduced into the arterial wall of the stomach through a 3-cm long abdominal incision. Two simulated operative maneuvers, which included gastric mucosa resection and suturing, and mucosa resection by using staples, were performed in 3 pigs each. Operative time, intraoperative bleeding, and postmortem examination were recorded.

Results: All the surgeries were completed successfully in the 6 pigs without obvious intraoperative bleeding and complications. The time for setting up the intragastric ports ranged from 8 minutes to 40 minutes (average, 16.2±12.2) and decreased with experience. The total surgery time for the 3 pigs in which partial gastric mucosa resection was performed by using the stapler was 75.45±38min, and for the other 3 pigs in which partial resection was performed by using the ultra shear and suturing surgical time was 80, 85, and 70 minutes, respectively. Postmortem examination revealed that the simulated resected sites were secure without leakage and bleeding.

Conclusion: A simple, stable intragastric surgery platform can be set up by introducing the Sils Port into the stomach, which can decrease the operative time and make the technique easier compared with the conventional intragastric laparoscopic technique. It is possible to use this new approach safely in patients.

11.126 Gynecology
Different Intraabdominal Pressures in Gynecologic Laparoscopic Surgeries: An Investigation of Two Types of CO₂ Insufflators
 Haifang Liu, MD, PHD, Yan Liu, MD, Hai Zhuang
Dept. of OB&GYN, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China (all authors).
 
Objective: We compared the effects of the electronic pulse mode CO₂ insufflator versus the constant-pressure mode type insufflator on intraabdominal pressure (IAP) of patients in gynecological laparoscopic surgeries.

Methods: Using 2 different types of CO₂ insufflators and a pressure-testing device, we measured the real-time IAP of patients undergoing gynecological laparoscopic surgeries to detect the instant variation of IAP with each insufflator, respectively.

Results: With the electronic pulse mode pneumoperitoneum, IAP may peak at 40mm Hg, more than twice of the set point of 15mm Hg, as well as declining to zero, which is a huge difference. When the constant-pressure mode insufflator is used, the IAP fluctuates from 14mm Hg to 16mm Hg, around the set point of 15mm Hg.

Conclusions: With the pneumoperitoneum established by using the constant-pressure mode insufflator, the IAP of patients appears fairly steady, but the electronic pulse mode insufflator may cause greater variations in the IAP in laparoscopic surgeries. It can be inferred that the electronic pulse mode insufflator may affect the IAP more than the constant-pressure type does, and the latter may be safer for patients who undergo gynecological laparoscopic surgeries.

11.127 Gynecology
The Cost of a Hysterectomy:  Equipment Costs Versus Operating Room Costs
Kelly N. Wright, MD, Selena Jorgensen, Gudrun M. Jonsdottir, Jon I. Einarsson, MD, MPH
Division of Minimally Invasive Gynecologic Surgery, the Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts, USA (Drs. Wright, Einarsson, Mr. Jonsdottir).
Harvard Medical School, Boston, Massachusetts, USA (Drs. Wright, Einarsson, Ms. Jorgensen,).

Objective: Requirements for savings in the health system have led to the need to evaluate the cost of treatments. Hysterectomy is the most common gynecologic surgical procedure performed in the United States. Our objective was to evaluate the equipment costs and costs based on operative time to see which has more impact on the cost of a hysterectomy.

Methods: We performed a retrospective cohort analysis of 1066 consecutive cases of all patients (ages 18 to 91) who underwent a hysterectomy by any method in the year 2009 at Brigham and Women’s Hospital, an urban academic tertiary care center. All operating room charges were obtained. Operating room charges were broken out into cost based on operative time and cost based on equipment (disposables).

Results: 1066 women were included who underwent hysterectomy at Brigham and Women’s in 2009. The mean operative charge for all hysterectomies was $33,668. The mean charge based on operating room time was $22,223, while the mean charge based on equipment was $2351 (p<.001, 95%CI: 19,345 – 20,361). R2 tests were performed. Charges based on operating room time account for 92% of the variance in total operative charges, while charges based on disposable equipment account for only 6% of the variance.

Conclusion: Charges based on operative time account for the majority of the cost of a hysterectomy. On average, disposables cost nearly 10-times less than the cost of the operating room. Surgeons should consider time to be of most importance when considering costs.

11.128 Gynecology
Single Port Laparoscopy in Gynecology: A Series of 100 Cases, The Greek Experience
Stefanos Chandakas, MD, MBA, PhD
Iaso Group of Hospitals and Attikon University Hospital, Athens, Greece

Background and Objective: Minimally invasive surgery has influenced the techniques used in gynecology, with an overall minimization of complications and increased patient satisfaction. The study objective was to demonstrate the safety and feasibility of single port laparoscopic (SPL) surgery in gynecology.

Methods: This was a retrospective, descriptive, nonrandomized study performed at Iaso Hospital and Attikon University Hospital, Athens, Greece.
100 patients underwent SPL surgery between October 2008 and January 2011. Indications included 68% salpingo-oophorectomy, 14% diagnostic laparoscopy and treatment of Stage 1/3 endometriosis, 8% cystectomy, 10% total hysterectomy.

Results: Duration of operation and of hospital stay, safety (morbidity and mortality), and patient satisfaction were assessed. Estimated blood loss was 85mL (range, 10 to 360). Intraoperative complications were 0% vascular injuries and 0% nerve or ureter injuries. Early postoperative morbidity included no major complications, 0.15% bladder infection and dysfunction, and 0.2% incision infection. 92% of patients were discharged to home the same day with an average length of stay for these patients of 10.2 hours.

Conclusion: Single port laparoscopic surgery seems to be a safe alternative to traditional laparoscopy for the procedures performed in this study. Surgical time, safety, and feasibility were similar, whereas the cosmetic result and the postoperative pain levels of SPL seem to be preferred by the female patient.

11.129 Gynecology
Single Port Total Laparoscopic Hysterectomy: The Greek Experience of Introducing Innovative Surgery in a Financial Crisis Environment
Stefanos Chandakas, MD, MBA, PhD
Iaso Group of Hospitals, Athens, Greece

Background and Objectives: Minimally invasive surgery has influenced the techniques used in gynecology, with an overall minimization of complications and increased patient satisfaction. The study objective was to demonstrate the safety and feasibility of single port (SP) total laparoscopic hysterectomy.

Methods: This was a retrospective, descriptive, nonrandomized study conducted at Iaso Hospital and Attikon University Hospital, Athens, Greece. 22 patients underwent SP total laparoscopic hysterectomy between October 2008 and January 2011. Indications included 88% dysmenorrhoea and 12% large fibroid uteri.

Results: The duration of surgery and hospital stay, safety (morbidity and mortality), and patient satisfaction were assessed. Estimated blood loss was 110mL (range, 165 to 300). Intraoperative complications were 0% vascular injuries and 0% nerve or ureter injuries. Early postoperative morbidity included no major complications, 0% bladder infection and dysfunction, and 0.22% incision infection. 51% of patients were discharged to home the same day with an average length of stay for these patients of 14 hours. The cost with compared with the cost of traditional laparoscopic hysterectomy was 22% lower, mainly due to the use of reusable instruments and just one special single use single port trocar.

Conclusions: Single port total laparoscopic hysterectomy seems to be a safe and more cost-effective alternative to traditional laparoscopy for the procedure. Surgical time, safety, and feasibility are similar, whereas the cosmetic result and the postoperative pain levels of SP seem to be better accepted by the female patient.

11.130 Multispecialty
Update: Balloon-Assisted Endoscopic Retroperitoneal Gasless Retroperitoneal Lumbar Interbody Fusion
Richard M. Vazquez, MD, Giri T. Gireesan, MD
The Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA (all authors).

Background: We are updating our experience with balloon-assisted endoscopic retroperitoneal gasless laparoscopic-assisted exposure for anterior lumbar interbody fusion with a variety of interbody fusion devices. 


Methods: Since February 2002, we have performed an additional 81 lumbar interbody fusions with carbon fiber Brantigan cages with BMP and posterior stabilization. There were 71 males and 10 females in the group. The average age was 40 years. The average hospital stay was 3 days. The operations were performed for severe back and leg pain in individuals who had not obtained relief of their pain with nonsurgical treatments for a period of 0.5 to 2 years. The indications were discogenic low back and leg pain, grade 1 spondylolisthesis, and retrospondylolisthesis at lumbar discs L5, L4, and L3. The procedures were performed with the patients positioned supine on a radiolucent table. Retroperitoneal access was gained in a manner similar to a totally extraperitoneal hernia repair. The rest of the procedure was performed in a gasless fashion using standard orthopedic and laparoscopic instruments. We converted 4 patients to open procedures due to technical difficulties secondary to peritoneal tears. Segments Accessed: L5=40, L4=12, L3=2, and L4-S1=20.

Results: Three patients experienced minor venous bleeding episodes. Pulmonary edema, bladder injury, and pseudo-gout were each experienced once. No patient reported retrograde ejaculation.

Conclusion: The retroperitoneal gasless laparoscopic approach permits anterior lumbar spine interbody fusion with a complication rate comparable to that of an open operation. 

11.131 General Surgery
Conversion to Open Cholecystectomy: A Failure or a Success?
A. M. Malik, S. Bughio, A. H. Talpur, J. N. Qureshi, N. A. Sheikh
Department of Surgery Liaquat University of Medical & Health Sciences, Hyderabad/ Jamshoro, Pakistan (all authors).

Objective: To assess the overall impact of conversion of laparoscopic cholecystectomy to open cholecystectomy.

Methods: This was an observational descriptive study conducted in a teaching institute and various private hospitals in the same town from June 2003 to June 2008. A total number of 936 laparoscopic cholecystectomies were performed of which 36 (3.31%) were converted to open cholecystectomy for various reasons. Another 13 patients in the same series developed different complications, because laparoscopic dissection continued despite facing difficulty. The details of all the converted patients were recorded on a ProForma to study the reasons for conversion, duration of operation, outcome, hospital stay, and follow-up of the patient. The data were analyzed using SPSS version 17.

Results: The mean age was 45.49 years with a mode of 55, range of 64 (87±23), and Std of 12.347. There were 839 (89.63%) females and 97(10.36%) males. Of all the patients 108 (11.53%) presented with a solitary gallstone while the remaining 828 (88.46%) had multiple gallstones. Of the total study population, 10.36% had complicated gallstone disease with varying proportions of empyema, acute cholecystitis, mucocele, and others. Various difficulties encountered during laparoscopic dissection are discussed with reasons to convert to open cholecystectomy in 36 (3.31%) patients.

Conclusion: A low threshold for conversion to open cholecystectomy can save the life of patients as continued dissection in difficult situations can lead to life-threatening complications.

11.132 Gynecology
Pregnancy Outcome of Laparoscopic Myomectomy/Laparoscopically Assisted Myomectomy for Myoma-Associated Infertile Patients in our Hospital
H. Matsumi, M. Nakabayashi, O. Nishii
Department of Obstetrics and Gynecology, Toho University Ohashi Medical Center, Mizonokuchi, Japan (Dr. Matsumi).
Department of Obstetrics and Gynecology, Mitsui Memorial Hospital, Mizonokuchi, Japan (Dr. Nakabayashi).
Department of Obstetrics and Gynecology, Teikyo University School of Medicine University Hospital, Mizonokuchi, Japan (Dr. Nishii).
   
Objective: Uterine myoma is one cause of infertility; therefore, myomectomy is widely accepted in myoma-associated infertile patients. The aim of this study was to elucidate the clinical pregnancy outcome of laparoscopic myomectomy (LM)/laparoscopically assisted myomectomy (LAM) in these patients.

Methods: We conducted a retrospective, follow-up study using a postal questionnaire sent to 32 patients for our analyses, which included (1) pregnancy outcome after surgery, such as rates of pregnancy and miscarriage for all patients; (2) comparison of the pregnancy rate between 2 subgroups with or without postsurgical ART treatments; (3) comparison of the pregnancy rate between 2 subgroups divided by the preoperative uterine cavity deformation induced uterine myoma.

Results: No statistically different characteristics were found between the resected myomas: (1) clinical patient profiles, such as age at operation, an infertile period, other infertility factors, and resected uterine myoma divided by pregnancy was not statistically different among patients. (2) The rate of pregnancy and miscarriages was 53.3% and 42.9%, respectively. (3) The rate of pregnancy and miscarriage of patients who received ART postsurgically was 75% and 60%, respectively. (4) The rate of pregnancy was not statistically different between the 2 groups divided by the preoperative uterine cavity deformation. (5) No surgical complications and conversion to laparotomy were necessary.

Conclusions: Laparoscopic surgical myomectomy for myoma-associated infertile patients is effective, such as ART historical treatment records before operations and normal uterine cavity structure; however, the miscarriage rate is relatively high.

11.133 General Surgery
Laparoscopic Roux-en-Y Esophagojejunostomy for Recurrent Achalasia in a Morbidly Obese Patient
Jessica M. Gutierrez, MD, James M. Swain, MD
Mayo Clinic Rochester, Rochester, Minnesota, USA (all authors).

Background: Achalasia in a morbidly obese patient is a rare medical condition. Maladaptive eating with calorie dense foods can lead to weight gain. Traditionally, a Heller myotomy has been the surgical treatment for achalasia and gastric bypass for morbid obesity. Treatment for both can be challenging even more so in the setting of recurrent achalasia.

Methods: We report the case of a 24-year-old morbidly obese female (BMI 48) with achalasia who underwent a laparoscopic Heller myotomy with Toupet fundoplication. She developed recurrent achalasia, despite adjuvant medical treatment. The patient completed an intensive bariatric surgery program and achieved mild weight loss.

Results: The patient underwent a laparoscopic resection of distal esophagus and proximal stomach with conversion to Roux-en-y-esophagojejunostomy. She had no postoperative complications. At 5-week follow-up, she had resolution of her symptoms of dysphagia and a 13kg weight loss.

Conclusions: Surgical treatment for patients with recurrent achalasia and morbid obesity can be challenging. Laparoscopic Roux-en-y-esophagojejunostomy may be a more prudent operation than redo myotomy in the morbidly obese patient.

11.134 Multispecialty
In Vitro Analysis of Cell Salvage Blood Collection Using a Laparoscopic Suction Device
Nimesh P. Nagarsheth, Apurva Shah, Erin Moshier, Rosalyn Stahl, Aryeh Shander
Mount Sinai School of Medicine, New York, New York, USA (Drs. Nagarsheth, Shah, Moshier).
Englewood Hospital and Medical Center, Englewood, New Jersey, USA (Drs. Stahl, Shander).

Objective: To determine if cell salvage blood collection using a laparoscopic suction device is inferior to using a traditional Yankauer suction device.

Materials and Materials: Donated packed red cells were diluted, divided, and suctioned using either a laparoscopic suction device or a Yankauer plastic suction catheter tip connected to double lumen cell salvage tubing with a diluted heparin drip (pressure of -100mm Hg). Collected blood was processed using a cell salvage device.
Blood samples were collected from predetermined time points from each study arm and analyzed for concentration. Hemolysis testing was performed using the index based on bichromatic wavelengths. Mean hemolysis indices were compared using a 2-sample t test. Assuming a clinically acceptable limit of loss to be 7%, percentage loss in red cell volume was tested using a 95% one-sided confidence limit to assess noninferiority.

Results: The mean hemolysis index was 43.33 with the laparoscopic suction method and 34.67 with the Yankauer suction method. The mean difference of 8.67 [95% CI: -1.56, 18.89] was not significant (P=.074). The percentage loss in red cell volume after suctioning and cell salvage processing was 33.2% with the laparoscopic method and 29.57% with the Yankauer method. The mean difference between methods was 3.63% with a 95% upper confidence interval of 6.28% (within the 7% acceptable loss limit; testing for noninferiority P=.0278).

Conclusions: Laparoscopic blood collection is not inferior to the standard Yankauer method for cell salvage collection. Cell salvage blood collection should be considered in patients undergoing laparoscopic procedures when significant blood loss is anticipated.

11.135 Urology
Predictors of Long-Term Oncological Outcomes of Laparoscopic Nephroureterectomy for Upper Tract Transitional Cell Carcinoma
Michael C. Lee, MD, Kazumi Kamoi, MD, PhD, Georges-Pascal Haber, MD, Sebastian Crouzet, MD, Inderbir S. Gill, MD, MCh
Cleveland Clinic, Cleveland Ohio, and University of Southern California, Los Angeles California, USA (all authors).

Introduction: Laparoscopic nephroureterectomy (LNU) is an accepted treatment alternative for patients with upper tract transitional cell carcinoma (UT-TCC). We analyzed factors that predict disease-specific (DSS) and recurrence-free survival (RFS) in patients following LNU.

Methods: 217 consecutive patients underwent LNU for UT-TCC between 9/1997 and 2/2008. Data were collected prospectively and retrospectively when missing. Factors affecting DSS and RFS were analyzed using the Cox proportional hazard model.

Results: At 2, 5, and 8 years, overall survival was 72%, 54%, and 43%. DSS was 81%, 76%, and 73%, and RFS was 64%, 60%, and 58%, respectively. In multivariate analysis, T stage (muscle invasive) and positive surgical margin were independent predictors for DSS (P<.01 for both). In multivariate analysis, a grade 3 tumor in the pathological specimen was an independent predictor for RFS (P<.05).

Conclusion: Long-term oncological outcomes for LNU appear comparable to those of open surgery. For patients undergoing LNU, T stage 2 or higher was an independent predictor for DSS, and tumor grade 3 was an independent predictor for RFS. Patients with positive surgical margins had an overall poor prognosis.

11.136 Gynecology
Laparoscopic Surgery in the Treatment of Early Stage Ovarian Cancer
Karapetyan Victoria
N.N. Blokhin, Russian Cancer Research Center, Russian Academy of Medical Sciences, Moscow

Objectives: To evaluate the effectiveness of laparoscopy in the treatment of early stage ovarian cancer.

Methods: The study included 38 patients after nonradical surgery for Stage I ovarian cancer.

Results: Repeated laparoscopic operations were performed from 1 to 3 months after the first operation, as follows: contralateral ovarian biopsy and SRGO (subtotal resection of the greater omentum) in 21 patients; adnexectomy plus SRGO in 15 patients; supravaginal amputation of the uterus with the second appendages plus SRGO in 2 patients. In all cases, histological and cytological studies were urgent in nature. According to the histological structure, tumors in 16 patients were classified as tumor border, in 11 as serous adenocarcinoma, in 6 as endometrioid adenocarcinoma, in 3 as mucinous adenocarcinoma, in 2 as clear cell tumor. In a histological study of 5 patients with detected micrometastases in the peritoneum, 2 patients had lesion of the contralateral ovary. Seven-year follow-up showed that 7 patients had relapses, including 2 patients who died of disease progression.

Conclusions: Thus, the use of laparoscopy in the treatment of early stages of ovarian cancer is possible. However, given the aggressive course of malignancies of the gonads, it is necessary to carry out resection of the second ovary, subtotal resection of the greater omentum, urgent morphological examination, and cytology.

11.138 General Surgery
Laparoscopic Incisional Hernia Repair: Indications and Limits
Sebastiano Lacitignola
General Surgery Unit, Martina Franca Hospital, Martina Franca (Ta), Italy

Background and Objective: Postsurgical hernia is defined as the release of viscera through a breach of the musculo-aponeurotic wall near a surgical incision. The predisposing factors are wound infection, sutures under tension, size of the defect and the surgical technique. The authors present here their 7-year experience and discuss the criteria that are important for achieving the best outcomes with the fewest complications, such as thorough preoperative evaluation of patients, and cognizance of the indications of and contraindications for the laparoscopic approach to hernia repairs.

Method: From April 2003 to April 2010, 218 patients underwent treatment for abdominal hernia. Laparoscopic surgery, according to a set of specific criteria related to the useful disposable surface, the morphology of the patient, and the size of the defect, was performed in 120 (55%) patients. No border or lateral defects were treated laparoscopically.

Results: Twelve of the 120 patients (10%) undergoing a laparoscopic approach had to be converted to the open technique. The average hospital stay was 3.5 days. A persistent seroma was found in one (0.8%) patient, while 2 patients (1.6%) needed a second laparoscopic intervention for intestinal occlusion caused by adhesion syndrome. Only one patient had a recurrence of an abdominal hernia.

Conclusions: We believe that the long-term success of the laparoscopic technique of abdominal hernia repair depends on the correct evaluation of the defect of the wall, the surface of the abdomen, and the morphology of the patient.

11.139 General Surgery
Single Incision Pancreatic Cyst-Gastrostomy
Shabirhusain S. Abadin, MD, MPH, Rami Lutfi, MD
Saint Joseph Hospital, Chicago, Illinois, USA (all authors).

Objective: We report the case of a patient with a persistent pancreatic pseudocyst that was drained with a cyst-gastrostomy by using the single incision laparoscopic technique.

Methods: This is a video that was recorded and edited demonstrating the use and instruments needed to perform a successful single incision laparoscopic pancreatic cyst-gastrostomy.

Results: A 53-year-old woman presented with acute biliary pancreatitis and was subsequently found to have a 9-cm pancreatic pseudocyst. After 6 months of conservative management, the patient continued to have a persistent pseudocyst of similar size. As such, the patient was offered a single incision laparoscopic pancreatic cyst-gastrostomy for her ailment. The procedure was performed successfully, and the patient was discharged home after 48 hours in the hospital.

Conclusion: This video demonstrates the safe and effective use of the single incision technique for performing a pancreatic cyst-gastrostomy.

11.140 General Surgery
Postlaparoscopic Cholecystectomy Exploration: The Home Truths
K. Altaf Hussain Talpur, FCPS, Arshad Mehmood Malik, FCPS, Sangrasi Ahmed Khan, FCPS, Abdul Aziz Laghari, FCPS, FRCS, Jawed Naeem Qureshi, FRCS, Champa Susheel, FCPS
Liaquat University of Medical & Health Sciences, Jamshoro, Pakistan (all authors).
 
Objective: This study analyzed 1000 cases of cholelithiasis to identify complications after laparoscopic cholecystectomy and how they were managed.

Methods: This was a prospective observational study performed at the Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan from January 2003 to December 2010.
 
Patients and Methods: Over 8 years, 1000 cases of cholelithiasis were treated by  laparoscopic cholecystectomy. Patients were observed through their recovery and to document postoperative complications. Patients who developed major problems were assessed clinically and by investigations like LFT, ultrasound, CT scan, and ERCP to determine the cause. These patients were operated on once a firm indication for exploration was made. The patients were included in the study after signing an informed consent for the first operation and for the re-do surgery if anyone required it.

Results: Of 1000 cases, 58 patients (5.8%) who required surgery for one reason or another developed unidentified complications during laparoscopic cholecystectomy. The main problems found after exploration were bleeding 2.2%, biliary leak 1.9%, and obstructive jaundice 10% as main causes for exploration. The cases were managed by various open surgical procedures, depending on the pathology found during exploration.
 
Conclusion: Laparoscopic cholecystectomy although considered the gold standard for cholelithiasis is still not free of complications and can result in major problems for patients who had either difficult cholecystectomy or overlooked congenital anomalies of the biliary tree.

11.141 Pediatric Surgery
The Role of Laparoscopy Sleeve Gastrectomy in the Treatment of Morbidly Obese Children and Adolescents: Where Are We Now?
Van Cauwenberge Sebastiaan, Dillemans Bruno, Vandelanotte Michel, Aubry Estelle, Besson Rémi
Department of General and Pediatric Surgery, AZ Sint Jan Brugge-Oostende AV, France (Drs. Sebastiaan, Bruno, Michel).
Department of Pediatric Surgery, Hôpital Jeanne De Flandre, CHRU Lille, France (Drs. Estelle, Rémi).
 
Background and Objectives: In the last few decades, the prevalence of obesity in children and adolescents has substantially increased. Active intervention is necessary because an overweight child or adolescent is likely to become an obese adult. For those children who fail behavioral interventions and pharmacotherapy, bariatric surgery remains the last valid option. Laparoscopic sleeve gastrectomy (LSG) is a restrictive technique that nowadays is performed more frequently by bariatric surgeons. Theoretically, LSG may be the ultimate operation for children and adolescents, because it does not involve malabsorptive side effects.

Methods: This presentation focuses on the current available data in the medical literature regarding LSG and its results in the pediatric population.

Results: Data on LSG in children and adolescents are very limited. To date, only case series with limited postoperative follow-up have been published in the medical literature. However, both vitamin B12 and iron deficiencies are reported. Also on the hormonal level, the operation is not without a risk. Ghrelin plays an important role in growth hormone release and bone mineralization during childhood, putting a child after LSG at a potential risk for growth disturbances and osteomalacia later in life.

Conclusions: Until more long-term data are available, LSG should be considered investigational and should not be implemented in a pediatric bariatric surgical practice except within the context of a controlled prospective study. In the meantime, surgeons should be encouraged to report their long-term results and to participate in further research regarding the procedure.

11.142 Gynecology
Analysis of the Pelvic Lesions and Fertility Outcome of 294 Infertile Women Treated by Laparoscopy
 XIA Enlan, MD, GUO Yan, MD, XIAO Yu MD
Hysteroscopic Center, Fuxing Hospital, Capital Medical University, Beijing, China (all authors).
 
Objective: We evaluated the value of laparoscopic surgery in the diagnosis and treatment of women with infertility.

Methods: This was a retrospective study of 424 infertile women admitted from June 2006 to June 2009 to Fuxing Hospital. Factors related to infertility and fertility outcome after laparoscopic treatment were analyzed.

Results: Of the 424 women screened, 130 (30.66%) were lost to follow-up; therefore, 294 (69.34%) were included in the study. Reasons for infertility included most commonly abnormal fallopian tube, pelvic adhesions, or both together (53.06%, 156/294); endometriosis was the second cause (16.66%, 49/294). Total pregnancy rate after laparoscopic surgery was 41.38% (123/294). The pregnancy rate for women with abnormal fallopian tubes and pelvic adhesions was 36.53% (57/156), endometriosis 48.97% (24/49), PCOS 58.65% (17/29), and myoma 56.52% (13/23). After surgery, 1 of 10 patients who suffered from peritoneum tuberculosis with a normal uterine cavity with a pathologically normal endometrium became pregnancy by artificial insemination, and 1 of 10 patients with a benign ovarian cyst became pregnant after surgery. The pregnancy rate for patients with unexplained infertility after bilateral tubal hydrotubation was 50% (10/20). The mean pregnancy time after treatment was 10.44 months.

Conclusions: Laparoscopy can determine the pelvic causes of infertility directly and accurately as well as possible corresponding treatment. Laparoscopic pelvic surgery for the diagnosis of female infertility and treatment of diseases is of great value.

11.144 General Surgery
Laparoscopic Appendectomy for Entrapped Foreign Bodies
Benjamin Sweet, Daniel Calva, MD, Hui Sen Chong, MD
Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA (all authors).

Background: Foreign bodies are a rare cause of appendicitis with an incidence of 1 in 20,000 appendectomies. For small round objects like screws, the greatest danger is not perforation but obstruction, as the object becomes a nidus for fecaliths. Removal of foreign bodies from the appendix either by colonoscopy or surgery is recommended even in the asymptomatic patient, because there can be occult inflammation leading to perforation. This video presents a laparoscopic appendectomy for 2 foreign objects lodged in the appendix.

Method: The patient is a 38-year-old white male with a history of bipolar disorder and multiple suicide attempts. The patient swallowed 23 thumbtacks and a screw, of which 20 thumbtacks passed spontaneously. Two were removed via colonoscopy, but 2 objects remained in the appendix and could not be retrieved. Serial X-rays over the next 5 days and a pill endoscopy showed persistence of the 2 objects in the right lower quadrant region. A CT scan demonstrated that one was located in the appendiceal tip, and the other about 1.8cm from the appendiceal orifice. There was no sign of appendicitis. A semi-elective laparoscopic appendectomy was therefore performed.

Results: The patient remained hospitalized for one day following surgery and was discharged without surgical complication. Histologic examination of the appendix demonstrated an inflamed appendix with evidence of mural irritation. 

11.145 Gynecology
Complex Cases Accomplished by Laparoendoscopic Single Site Surgery
Jessica Ybanez-Morano, MD, MPH, CPE
Wheeling Hospital, Wheeling, West Virginia, USA

Objective: Innovations in laparoscopic approaches have allowed significant advances. Laparoendoscopic single site surgery has been used in complex cases to enhance anatomical access, to shorten hospital stay, to minimize convalescent time, and to provide greater patient satisfaction.

Methods: Transumbilical single incision laparoscopic surgery has been used to accomplish procedures that previously required full abdominal laparotomies. Three video cases depict the ability to address procedures encountered in practice using this new approach. The first video reviews management of a morbidly obese female with removal of a 400+gram fibroid uterus. The second video highlights the ability to facilitate lysis of dense pelvic adhesions in patients with previous abdominal surgery. The third video shows management of a recto-sigmoid/tubo-ovarian abscess by drainage, irrigation, and pelvic/abdominal drain placement.

Results: Single incision laparoscopic surgery has allowed the surgeon to visualize anatomical landmarks more readily, to facilitate better anatomical access, to shorten patient hospitalization, and to decrease patient recovery time. The majority of patients had overnight hospital stays, were discharged to home the next day, returned to work in <2 weeks, and had minimal scars with umbilical incisions of <2cm. 

Conclusion: Single incision laparoscopic surgery has improved surgical technique and anatomical access. Patients benefit by shortened hospital stays overnight and 1 week to 2 weeks of convalescence. Aesthetically, patients have a single 1-cm to 2-cm scar, well hidden in the umbilical folds.

11.146 General Surgery
Elective Colectomy, Emergency Colectomy, or No Colectomy in Patients with Inflammatory Bowel Disease
J. Sekáč, PhD, J. Škultéty, Prof, PhD, M. Huťan, MD, T. Hlavatý, PhD, T. Koller, PhD, A. Prochotský, Prof, PhD 
University Hospital, Commenius University, Bratislava, Slovak Republic (all authors).

Objective: The chronic inflammatory bowel diseases—ulcerative colitis and Crohn's disease—affect 1.4 million people in the United States and 2.2 million people in Europe. Despite a variety of advances in medical treatment, 20% to 30% of patients with ulcerative colitis need surgery at some time, and the lifetime risk of surgery for Crohn's disease is as high as 80%. The aim of this study was to compare morbidity and mortality outcomes after elective colectomy, no colectomy, and emergency colectomy in people admitted to the hospital for inflammatory bowel disease.

Methods: Our patients are comparable to patients reported in literature sources.  

Results: Our study highlights the increased morbidity and mortality after emergency colectomy or after no colectomy.

Conclusions:  The evidence is strong that morbidity and mortality among people admitted for inflammatory bowel disease are significantly better after elective colectomy than after no colectomy or emergency colectomy. Surgery can be regarded as a cure for ulcerative colitis.

11.147 Urology
Laparoscopic Partial Cystectomy for Symptomatic Paraganglioma of the Urinary Bladder
F.M.W. Wu, S. L. Kao, T. P. Thamboo, W. C. Tsang, C. T. Heng, H. Y. Tiong
Department of Urology, National University Hospital, Singapore (Drs. Wu, Tsang, Heng, Tiong).
Department of Endocrinology, National University Hospital, Singapore (Dr. Kao).
Department of Pathology, National University Hospital, Singapore (Dr. Thamboo).
 
Introduction: Paragangliomas of the bladder are uncommon neuroendocrine neoplasms. As a result of their rarity, a standard operative method has not been established. An open partial cystectomy is usually performed, because all layers of the bladder are involved. We report an initial case of laparoscopic partial cystectomy to minimize the surgical morbidity of the transabdominal approach and review the management of this condition.

Method: A 43-year-old female presented with symptomatic paraganglioma of the bladder. The patient was pretreated with alpha- and beta-adrenergic blockers before laparoscopic partial cystectomy was carried out. A 4-port technique was performed with the patient in the Trendelenburg lithotomy position. The bladder mass was excised with a rim of normal mucosa under both cystoscopic and laparoscopic vision. The bladder was closed intracorporeally, and the specimen removed through the 12-mm right iliac fossa port.

Results: The operation was uncomplicated. Total operative time was 170 minutes, and blood loss was <100m/L. The patient’s blood pressure remained stable throughout the operation. Normal diet was resumed 2 days after the operation, and the patient was discharged with an indwelling catheter. A cystogram performed after the operation showed no leakage. The final histology showed a 6-cm paraganglioma with clear resection margins.

Conclusions: Laparoscopic partial cystectomy is a feasible method of excising a symptomatic paraganglioma with adequate preoperative adrenergic blockage to prevent a hypertensive crisis during resection.

11.148 General Surgery
A Comparative Clinical Trial of Laparoscopic Incisional and Ventral Hernia Repair With or Without Closure of the Hernial Defect
Dr. Bhupinder Pathania, MBBS, MS, FMAS, FICS
Professor, Postgraduate Department of Surgery, Medical College, Jammu, J&K, India

Background and Objective: Problems in laparoscopic ventral and incisional repair still persist. In addition to recurrence and postoperative pain, the problem of seroma with persistent postoperative bulge and loss of body image render the procedure unacceptable to patients. This was the basis on which a comparative trial was conducted. We evaluated and compared the postoperative morbidity in 2 groups of patients.

Methods: We compared 30 patients in group A (where the sac was closed before mesh was placed) and 30 patients in group B (where the sac was not closed and mesh was placed directly over the defect).

Results: In this study, the average defect size was 21.64cm². In our study, the incidence of postoperative seroma in the closure group was 6.6%, whereas it was 53% in the nonclosure group. There was 3.33% recurrence with closure of the sac and 6.6% in the nonclosure group in follow-up of 8 to 25 months. 100% of patients in the closure group were very satisfied with their body image, whereas only 25% of patients in the nonclosure group were very satisfied with their body image.

Conclusions: The advantage of closure of the sac in laparoscopic ventral hernia repair has been established. A drastic decrease in the incidence of seroma has occurred. Quality of life in the postoperative period is better, because there is no bulge and patients are satisfied. The correlation with reduction in the incidence of recurrence needs further follow-up.

11.149 General Surgery
Laparoscopic Ventral and Incisional Hernia Repair: A Single Center Experience
E. Puce, MD, D. Apa, MD, F. Atella, MD, E. Breda, MD, M. Lombardi, MD
UOC Chirurgia generale CTO A. Alesini Rome, Italy (all authors).

Introduction: The laparoscopic approach is now well established for ventral/incisional hernia repair.

Methods: This retrospective study included 100 patients (53 men, 47 women), with a mean age of 62.6 years who underwent laparoscopic repair at our institution between 2001 and 2010. Sites of hernia were 68 median incisional, 25 umbilical, 2 parastomal, 3 umbilical + inguinal hernias, 2 trocar sites. 7% were recurrent hernias. Sizes of mesh (86 Gore-Tex dual mesh, 3 Composix Barb mesh, 7 Proceed, 4 Dyna mesh) ranged from 8cm x 6cm to 30cm x 30cm (overlap about 3cm). A double crown of tacks was performed in all cases. Repair in low abdominal wall hernias was performed by tack fixation to the Cooper ligament.

Results: The mean operative time was 50 minutes. There were 2 open conversions in complicated recurrent hernias, and 2 intraoperative missed intestinal perforations with subsequent wound and mesh infection and mesh removals. Immediate minor postoperative complications occurred in 9% of cases (5 seromas, 4 local pain). Abdominal bulging was observed in 4%. The mean hospital stay was 1.8 days. Two patients died of other causes later. During a mean follow-up of 40 months, recurrence rate was 4%. The type of mesh was not significantly correlated with the complications rate.

Conclusion: Laparoscopic correction is an effective method of treating abdominal wall hernias with low rates of recurrence and wound infections. Occult hernias are diagnosed and optimally treated. In our experience, patients with very large incisional hernias are those who benefit the most from laparoscopic treatment.

11.150 General Surgery
Minimally Invasive Surgery in Nontraumatic Emergencies: Our Experience
D. Apa, MD, E. Puce, MD, F. Atella, MD, E. Breda, MD, M. Lombardi, MD
UOC Chirurgia generale CTO A. Alesini Rome, Italy (all authors).

Objective: In this retrospective study, we report our experience in laparoscopic procedures for nontraumatic emergencies.

Methods: From 1991 to 2009, 727 patients (388 women; 339 men; mean age 45 years, range 9 to 98) underwent laparoscopic procedures in an emergency setting. Among them, there were 10 traumatic lesions (1.4%). The other surgical indications in the laparoscopic group were acute cholecystitis 280 (38.5%), appendicitis 266 (36.5%), pelvic inflammatory disease 60 (8.3%), bowel obstruction 41 (5.6%), perforated peptic ulcer 36 (5%), peritonitis of different causes 14 (2%), perforated diverticulitis 13 (1.8%), spontaneous rupture of liver tumor 3 (0.4%), colon cancer perforation 2 (0.3%), nontraumatic hemoperitoneum 2 (0.3%).

Results: The conversion rate was about 7% (52 patients) and was mainly observed in hemoperitoneum, fecal peritonitis, or intestinal occlusion. Laparoscopic lavage-drainage and diversion was performed in 3 cases of diverticulitis Hinchey III-IIB; 3 patients with fecal peritonitis underwent a laparoscopic Hartmann's procedure.
Morbidity and mortality were 5.3% and 0.7%, respectively. The mean operative time was 90 minutes, and the mean hospital stay was 7 days (range, 2 to 10).

Conclusions: The laparoscopic approach to abdominal emergency provides high diagnostic accuracy and therapeutic options. It is firmly established as being superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or gynecological emergencies. It has limited value for adhesive bowel obstruction, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia. Primary laparoscopic lavage-drainage for complicated diverticulitis may be a promising alternative to more radical surgery in select patients with a lower incidence of wound infections.

11.151 General Surgery
Laparoscopic Cholecystectomy: Experience at a University Hospital in Eastern Nepal
A. Bajracharya, MBBS, MS, S. Adhikary, MBBS, MS, C. S. Agrawal, MBBS, MS
Department of Surgery & Minimally Invasive Surgery, B. P. Koirala Institute of Health Sciences, Dharan, Nepal (all authors).

Introduction: Laparoscopic cholecystectomy has become the standard treatment for symptomatic gallstone disease. The objective of this study was to assess the safety of this procedure, and to audit the conversion and bile duct injury rates and the factors that influence these.

Methods: Demographics and ethnic groups, conversion to open operation, and bile duct injury were recorded. Preoperative, operative, and the relevant data were collected prospectively. The chi-square test was used to determine the significance of any differences between subgroups.

Results: A total of 346 laparoscopic cholecystectomies were performed over a 6-month period (April 15, 2010 through October 14, 2010); male to female ratio was 1:4. The most common indication for surgery was biliary colic/dyspepsia (51%), cholecystitis (chronic, 49.4%, acute,12%), pancreatitis, gallbladder polyp, history of recurrent attacks 16.5%, obesity 19.1%. A consultant performed 128 operations, junior consultants 170, and senior residents 48. There were no statistically significant differences found in the duration of surgery between consultants and junior consultants (P=.264); however, significant differences did occur between consultants and senior residents (P=.001). The overall open conversion rate was 2.9%, and there was a single case of bile duct injury equating to a bile duct injury rate 0.3%.

Conclusion: Despite limited resources, laparoscopic cholecystectomy is a feasible, safe procedure for gallstone disease even in a developing country like Nepal.

11.152 General Surgery
Stapled High Chest Anastomosis After Esophageal Resection
J. Škultéty, J. Sekáč, M. Huťan, D. Škultétyová
University Hospital, Bratislava, Slovak Republic (all authors).

Background and Objective: Although the fact that all reconstructions after esophagectomy result in a cervical or thoracic anastomosis, controversy still exists as to the optimal place for the anastomosis. Both neck and chest anastomoses have been advocated. Stapled high chest anastomoses for thoracic anastomoses are now preferred. The purpose of this study was to compare in retrospective fashion a stapled esophagogastric anastomosis both in the neck and in the chest after esophageal resection and gastric tube reconstruction.

Methods: Between May 30, 2005 and December 25, 2010, 25 patients undergoing esophageal resection were prospectively randomized to receive an esophagogastric anastomosis in the neck (6 patients) or an esophagogastric anastomosis in the chest (19 patients).

Results: One patient (4%) died in the hospital on the third day after surgery from a heart attack, and the remaining 24 patients left our hospital postoperatively. The leakage rate was 4% (one case in 25) for neck anastomosis and 12% (3 cases in 25) for thoracic anastomosis, but for high chest anastomosis no leakage or mortalities occurred.

Conclusions: Neck and high chest anastomoses after esophageal resection have comparable safety. Stapled high chest anastomosis is the correct procedure after esophagectomy by gastric tube reconstruction.

11.153 General Surgery
Midline Incision Mucous Fistula After a Laparoscopic Subtotal Colectomy and Brooke Ileostomy for Severe Ulcerative Colitis: Report of a Case
Vittorio Lombardo, MD, Teresa Arena, MD, Giuseppe Calandruccio, MD
Department of Surgery, Papardo Hospital, Contrada Papardo, Messina, Italy (all authors).

Objective: Patients with ulcerative colitis often require an urgent subtotal colectomy with end ileostomy. Such individuals may be heavily immunosuppressed, making management of the rectal stump problematic. If closed and left within the peritoneal cavity, it can break down, resulting in pelvic sepsis. A mucous fistula avoids intraabdominal sepsis and facilitates topical postoperative treatment. 

Methods: We report the case of a steroid-dependent patient with severe ulcerative colitis, multiple blood transfusions, weight loss, and albumin level <3.0gm/dL. The patient was hospitalized and had continued symptoms after several days of maximal medical therapy. We performed a laparoscopic subtotal colectomy and Brooke ileostomy with a midline wound mucous fistula.

Results: The patient did well postoperatively and was discharged home on postoperative day 4. She did not have a wound infection at 1-month follow-up.

Conclusions: Laparoscopic subtotal colectomy in ulcerative colitis seems a feasible, safe, and largely predictable operation that allows for early hospital discharge. Laparoscopic colectomy may facilitate subsequent proctectomy and pouch construction. A mucous fistula avoids the potential and serious complication of rectal stump break down that results in intraabdominal sepsis. In addition, the mucous fistula may be used for topical treatment of the rectal stump before proctectomy and pouch construction.

11.154 General Surgery
Laparoscopic Technique is Helpful in Transplant Patients with Acute Abdomen: Three Case Reports and Literature Review
Wen-Yao Yin, Chun Ming Chang, Ta-Wen Hsu, Chang-Kuo Wei, Cheng-Hung Lee 
Department of Surgery, Dalin General Hospital, Dalin Town, Chiayi, Taiwan, R.O.C (all authors).
Hualien Tzu Chi University, Hualien, Taiwan (Dr. Yin).

Objective: We review the rare but possible acute appendicitis in patients with solid organ transplantation. A high index of suspicion and detailed study including laparoscopic technique is fundamental for early diagnosis and successful treatment.
 
Methods: Due to the high risk of complications in transplant recipients, we usually treat such patients more conservatively rather than performing effective surgery quickly. Delayed diagnosis, delayed operation, and high morbidity and mortality are more common in transplant patients with GI disease in the literature than we expected. There are relatively few reports of appendicitis in solid organ transplant recipients, and it has rarely been reported after liver transplantation.
 
Results: We have operated on 2 cases for acute appendicitis among 200 cases of kidney and liver transplantation in our series within the last 15 years. Another living donor living transplant (LDLT) patient presented with acute signs and symptoms similar to those of acute appendicitis. A CT of the abdomen and preoperative colonoscopy identified cecal cancer as the cause of the symptoms. Laparoscopic appendectomy was used for acute appendicitis in liver and kidney transplant patients, and right hemicolectomy was performed for colon cancer in the LDLT patient, with an uneventful postoperative course.
 
Conclusions: Here we would like to share clinical symptoms, diagnosis, management, and feasibility of laparoscopic technique in such posttransplant patients. A high index of suspicion, early image study with computed tomography, and available laparoscopy could prevent a high perforation rate of acute appendicitis and reduce morbidity and mortality.

11.155 General Surgery
Use of Virtual Colonography to Plan Trocar Placement in Robotic-Assisted Laparoscopic Sigmoidectomy in a Patient with Complete Intestinal Malrotation
Luca Giordano MD
Aria Health, Philadelphia, Pennsylvania, USA
 
Background and Objective: Complete intestinal malrotation is a rare condition. Trocar placement in robotic-assisted laparoscopic surgery is of paramount importance to avoid internal and external collision of the robotic arms. Virtual colonography can be of determinant assistance in choosing the most appropriate location for the placement of the robotic trocars.
 
Methods: A 55-year-old obese patient was admitted to the hospital with the diagnosis of recurrent sigmoid diverticulitis and intractable abdominal pain for the past few months. A preadmission colonoscopy was unsuccessful in examining the colon beyond 40cm due to extreme tortuosity of the colon. An inpatient CT scan revealed mild sigmoid diverticulitis and evidence of intestinal malrotation. A virtual colonoscopy was obtained to rule out possible abnormality in other segments of the colon and to assist in the appropriate placement of the robotic trocars for the planned sigmoidectomy. Surgery was uneventful, and the patient was discharged home on postoperative day 4. The pathology examination revealed sigmoid diverticulitis with perforation.
 
Conclusion: Robotic-assisted laparoscopic surgery is a valuable surgical technique that enhances precision in minimally invasive surgery. Virtual colonography is a useful adjunct in planning the placement of robotic trocars.

11.156 General Surgery
An Unusual Complication of Laparoscopic Gastric Banding: Large Bowel Obstruction Due to the Connecting Tubing
Rakhshanda Akram, MD, Elizabeth Renza-Stingone, MD, Madhu Rangraj, MD, Leonard Maffucci, MD, Michael Silberstein, MD, Matthew Ostrowitz, MD
Sound Shore Medical Center, Surgical Weight Loss Center, New Rochelle, New York, USA (all authors).

Laparoscopic adjustable gastric banding (LAGB) is the least invasive of the bariatric surgical procedures. Despite being a relatively simple procedure, there is a potential for complications with LAGB, mostly involving band slippage, erosion, or port-site complications. We report a rare complication of large bowel obstruction due to gastric band tubing, 4 years following LAGB. The patient presented to the emergency room with a large bowel obstruction. Preoperative computerized tomographic scan confirmed the gastric band tubing caused this obstruction. The patient underwent diagnostic laparoscopy at which time the tubing was divided for the relief of the obstruction. There was concern for the viability of the colon at the time of the laparoscopy; therefore, the patient was taken back to the operating room the following day for a second-look laparoscopy. At that time, the bowel appeared healthy, and we reconnected the gastric band tubing. A few months later, the patient presented with cecal volvulus, unrelated to the band tubing, and ultimately underwent right hemicolectomy. Despite her multiple surgeries, we were able to salvage the gastric band. We report this case in an effort to enlighten practitioners regarding the possibility, although unusual, of this potential pitfall associated with laparoscopic gastric banding procedures as well as discuss the fate of the band following contaminated abdominal surgeries.

11.157 General Surgery
Laparoscopic Loop Ileostomy Reversal: Reducing Morbidity While Improving Functional Outcomes
Morris E. Franklin, MD, Jojy M. George, MD, Karla Russek, MD, Pedro Cuevas-Estandia, MD, Naveed Zafar, MD
Texas Endosurgery Institute, San Antonio, Texas, USA

Introduction: Loop ileostomy reduces the morbidity associated with pelvic anastomotic leakage. However, loop ileostomy reversal carries a 10% to 30% complication rate. We present our technique for laparoscopic ileostomy closure.

Methods: We conducted a retrospective chart review of subjects undergoing laparoscopic loop ileostomy closure between 2006 and 2009. Operating time, length of hospital stay, return of bowel function, and complication rates were assessed.

Results: There were 24 (13 males) patients. Average age was 63 with a BMI of 25.9. Eighteen (75%) had a planned loop ileostomy, and 6 (25%) were emergent. Average time to reversal was 135 days. Average length of surgery was 79 minutes (range, 48 to 186), average stay was 4 days, and return to bowel function was 3.6 days. We had no wound infections. Our complication rate was 29% (n=7) and reoperation rate was 12.5% (n=3). There was one major complication, an anastomotic dehiscence.

Conclusion: A thorough well-visualized lysis of adhesions and mobilization of the stoma and surrounding small bowel is the main advantage of our approach. We had no wound infections and no reoperation for bowel obstruction, which we feel is a direct advantage of our technique. Our complication rate, and surgical time are comparable to those of the open technique.

11.158 General Surgery
Laparoscopic Colon Surgery in Obese Patients: The Way Forward
Morris E. Franklin, N. Zafar, K. Russek, S. Sherwell
Texas Endosurgery Institute, San Antonio, Texas, USA (all authors).

Introduction: By the year 2025, 40% of the population in the United States will be obese. This health problem is well known to predispose to numerous diseases and to increase postoperative morbidity and mortality, particularly in open surgery. The laparoscopic approach offers the best benefit for obese patients, lowering the incidence of surgical complications. The aim of this study was to show the feasibility and the outcomes of laparoscopic colorectal surgery in obese patients.
 
Materials and Methods: We retrospectively reviewed 845 cases of preobese and obese (BMI ≥25) patients who underwent colorectal surgery from January 1991 to December 2009. We compared and analyzed the different parameters, such as BMI, age, sex, associated disease, as well as the diagnosis, type (total laparoscopic vs. laparoscopic-assisted) and duration of the procedures, conversion rate, and the perioperative and postoperative complications.
 
Results: 363 (42.9%) patients underwent intracorporeal anastomoses, 215 (25.4) patients had laparoscopic-assisted anastomoses, and 183 (21.6%) patients had no anastomosis performed. Procedures performed totally laparoscopically had lower intraoperative (1.4% vs. 3.5%) as well as postoperative (4.8% vs. 14.7%) complication rates compared to laparoscopically assisted colectomies. 
 
Conclusion: The laparoscopic approach has been shown to lower the incidence of pulmonary complications, incisional hernia, and wound infection, with less postoperative pain and shortened length of stay. Our findings demonstrate that the severity of obesity is a very important risk factor for complications and outcomes.

11.159 Gynecology
Laparoscopic Supracervical Hysterectomy and Vagino-Cervico-Sacropexy
Greg J. Marchand, MD, Richard H. Demir, MD
Arizona Regional Medical Center, Mesa, Arizona, USA (all authors).
 
The objective of the video is to demonstrate a safe, economical technique for performing laparoscopic supracervical hysterectomy with vagino-cervico-sacropexy.
 
The subject of this video is a 50-year-old, G 6, P 6006, female with Grade 3 uterine prolapse, anterior compartment prolapse, pelvic pain, and a normally functioning bladder. An 8-cm firm uterus was noted. Bard polypropylene mesh was fashioned into a “Y” graft and affixed to the anterior and posterior aspects of the cephalad-vaginal barrel and cervical stump using the Endo Stitch from Covidien and 2-O Surgidac suture with extracorporeal knot tying. The base of the Y graft was tacked to the sacrum. The graft was then retroperitonealized.
 
Operating time for the entire case was 152 minutes with 110 minutes specifically dedicated to the vagino-cervico-sacropexy and closure. Use of the Endo Stitch and this technique results in a surgical time well less than that reported in a recent study¹ both for laparoscopic (269 minutes) and robotic (328 minutes) routes.
 
This laparoscopic technique, relying on the Endo Stitch and removing the corpus without a morcellator, saves money by markedly reducing operating room time, equipment, and associated time-related charges. Use of laparoscopy without robotic-assistance further decreases cost by not adding robot-related charges and by not adding the additional time-related charges associated with robotic surgery.
 
¹Judd JP, Siddiqui NP, Barnett JC, Visco AG, Havrilesky LJ, Wu JM. Cost-minimization analysis of robotic-assisted laparoscopic, and abdominal sacrocolpopexy. J Minim Invasive Gynecol. 2010;17(4):493-499.

11.160 Gynecology
Total Laparoscopic Hysterectomy and Vaginal Morcellation
Greg J. Marchand, MD, Richard H. Demir, MD
Arizona Regional Medical Center, Mesa, Arizona, USA (all authors).
 
The objective of the video is to demonstrate a safe, economical technique to perform total laparoscopic hysterectomy in women with large uteri without the use of laparoscopic morcellating devices. Commercially available, laparoscopic morcellating devices from manufacturers, such as Gynecare, Gyrus, and Storz, run between $150 and $848 per disposable and between $15,000 and $30,000.00 for generator acquisition. Significant per use cost is added to the surgery when these devices are employed compared to use of standard instruments universally available in a vaginal hysterectomy tray.
 
The subject of this video is a 42-year-old, G 4, P 2022, female with menorrhagia, severe dysmenorrhea, and a distended, firm lower abdomen. Imaging demonstrated a uterine fibroid extending well cephalad to the umbilicus. Hemoglobin was 7.4 grams with an MCV of 62. Endometrium was benign. Total laparoscopic hysterectomy was performed with manual vaginal morcellation. Specimen weight of 1852 grams was reported with adenomyosis and leiomyomata.
 
Vaginal morcellation in experienced hands is quicker than its laparoscopic alternatives as the vaginal aperture is bigger and larger volumes of tissues can be removed in the same period of time. Vaginal morcellation decreases cost both by eliminating equipment costs and by decreasing operating room, time-related charges.
 
Because of the ongoing effort to decrease cost of healthcare while maintaining outcomes, this video demonstrates a safe, economical technique to perform total laparoscopic hysterectomy in women with large uteri without use of laparoscopic morcellating devices.

11.161 Urology
Secondary or Tertiary Treatment of Benign Prostatic Hyperplasia with GreenLight HPS™ Laser Photoselective Vaporization Prostatectomy: Clinical Outcomes
Xiao Gu, MD, PhD, Kurt H Strom, MD, Massimiliano Spaliviero, MD, Carson Wong, MD, FRCSC
The University of Oklahoma Health Sciences Center, Department of Urology, Oklahoma City, Oklahoma, USA (all authors).
 
Background and Objective: We evaluated the GreenLight HPS™ laser photoselective vaporization prostatectomy (PVP) as a treatment for symptomatic benign prostatic hyperplasia (BPH) previously treated with surgical management. 
   
Methods: We prospectively evaluated our initial GreenLight HPS™ laser PVP experience. Only patients who failed prior surgical therapy were included. Transurethral PVP was performed using a GreenLight HPS™ side-firing laser system. 
 
Results: Prior surgical management included TURP (18), TUMT (9), KTP laser PVP (8), HoLAP (2), TUMT and TURP (1), and TUMT and KTP laser PVP (1) in 39 of 178 consecutive patients. Mean prostate volume was 80.8±50.0 mL. Mean laser and operative times and energy usage were 12.5±10.5 minutes, 30.0±24.0 minutes and 83.2±64.4 kJ, respectively. Five patients developed a urinary tract infection. Thirty-six patients had nonsignificant hematuria for less than one week. Three patients had persistent urinary retention requiring clean intermittent catheterization. No urethral strictures or urinary incontinence were noted. All patients were able to discontinue their prostate medications following surgery. Mean American Urological Symptom Association Score (AUASS) decreased significantly from 22.8 to 8.2, 6.5, 6.5, 5.5, 4.6, 3.6 and 4.6 (P<.05) at 1 and 4 weeks and 3, 6, 12, 18 and 24 months, respectively. Mean maximum flow rate (Qmax) and post void residual measurements also showed significant improvement from baseline. The incidence of adverse events was low.
 
Conclusion: Our initial results demonstrate that GreenLight HPS™ laser PVP is safe and effective for the treatment of symptomatic BPH recurring following prior surgical management.

11.164 Urology
Is the Efficacy and Safety of GreenLight HPS™ Laser Photoselective Vaporization Prostatectomy (PVP) Affected by Age?
Xiao Gu, MD, PhD, Kurt H Strom, MD, Massimiliano Spaliviero, MD, Carson Wong, MD
 
The University of Oklahoma Health Sciences Center, Department of Urology, Oklahoma City, Oklahoma, USA (all authors).
 
Introduction: We evaluated the efficacy and safety of GreenLight HPS laser PVP for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) in patients of different age groups.
 
Methods: Patients were stratified into 2 groups: age<70 (group I) and age≥70 (group II) years. Transurethral PVP was performed using a GreenLight HPS side-firing laser system. American Urological Association Symptom Score (AUASS), Quality of Life (QoL) score, maximum flow rate (Qmax), and postvoid residual (PVR) were measured preoperatively and up to 36 months postoperatively.
 
Results: 206 consecutive patients were identified (I: 112; II: 94). Among the preoperative parameters, there were significant differences (P<.05) in prostate volume (I: 63.8±35.0; II: 73.8±43.8mL) and PSA (I: 2.2±2.6; II: 2.7±2.6ng/mL), while AUASS, QoL, Qmax, and PVR were similar (P>.05). No significant differences (P>.05) in laser utilization, energy usage, and operating time were noted. Clinical outcomes (AUASS, QoL, Qmax, and PVR) showed immediate and stable improvement from baseline (P<.05) within each group, while no significant differences between the 2 groups were observed during the follow-up period (P>.05). The incidence of adverse events was low and similar in both groups.
 
Conclusion: Our experience suggests that age has little effect on the efficacy and safety of GreenLight HPS laser PVP.

11.166 General Surgery
Novel Approach to Rectal Foreign Body Extraction
Margaret Merriam, DO, David A. Berg, MD, Marc Neff, MD
University of Medicine and Dentistry of New Jersey, Stratford, USA (Dr. Merriam).
Kennedy University Hospitals, Kennedy Health System, Voorhees, New Jersey, USA  (Drs. Berg, Neff).
 
Objective: The impacted rectal foreign body often poses a management challenge. Ideally, such objects are removed in the emergency room utilizing a combination of local anesthesia, sedation, minimal instrumentation, and manual extraction. In some instances, simple manual extraction is unsuccessful, and general anesthesia may be necessary. We describe a novel approach to retrieval and removal of a rectal foreign body utilizing a SILS™ port.
 
Methods: A 31-year-old male presented to the emergency room approximately 12 hours after transanal insertion of a plastic cigar case. Abdominal examination revealed no evidence of peritonitis. On rectal examination, the tip of the cigar case was palpable. The foreign body, however, was unable to be removed manually in the emergency room.
 
Results:  In the operating room, with the patient under general anesthesia, multiple attempts to remove the object were unsuccessful. A SILS port was inserted transanally. The rectum was then insufflated manually by attaching the diaphragm of the rigid sigmoidoscope to the SILS insufflation port. A 5-mm, 0° laparoscope was placed through the SILS port. An atraumatic laparoscopic grasper was then placed through the port and used to grasp the visible end of the cigar case. The rectal foreign body was removed expeditiously. Rigid sigmoidoscopy revealed no evidence of injury. The patient was discharged home shortly after the procedure.
 
Conclusions: The SILS port permits a minimally invasive extraction of rectal foreign bodies not amenable to simple manual extraction. It provides excellent visualization and eliminates the morbidity inherent in more invasive and traditional methods of retrieval. 

11.167 Gynecology
Laparoscopic Versus Vaginal Hysterectomy: An Evaluation of Length of Stay and Surgical Complications 
Annika Malmberg, MD, Eve Zartisky, MD, Dennis Idowu, MD
Kaiser Permanent Oakland, California, USA (all authors).

OBJECTIVE: To date, no large study comparing laparoscopic to vaginal hysterectomies has been published in the United States. The purpose of this study is to evaluate the length of hospital stays for laparoscopic hysterectomies (LH) versus vaginal hysterectomies (VH) performed for benign indications.

METHODS: This is a retrospective cohort study including all healthy adults undergoing an LH or VH for benign indications in the Kaiser Permanente Northern California system from 2008 to 2010. The primary focus of this study is length of stay. Secondary interests include complications, surgical time, blood loss, uterine weights, and demographic characteristics. Bivariate and multivariate analyses will be performed to examine outcomes and potential risk factors.

RESULTS: Preliminary analysis of an initial cohort of 400 randomly selected charts demonstrated a significantly shorter hospital stay and less blood loss for LH compared to VH (P≤.05). The average length of stay for LH was 10 hours compared to 26 hours for VH. Complication rates were minimal and without a significant difference between the groups. The laparoscopic group also trended towards longer surgical time and increased uterine weights.

CONCLUSION: Compared to vaginal hysterectomy, laparoscopic hysterectomy resulted in fewer days spent in the hospital with no evidence of increased complications with increased uterine weights.

11.168 Urology
Intratumoral Acetic Acid Injection Eradicates Human Prostate Cancer Tumors in a Murine Model
Jasneet Singh Bhullar, MD, Gokulakkrishna Subhas, MD, Erina Kansakar, MD, Boris Silberberg, MD, Jacqueline Tilak, BS, Jasper Gill, BS, Lee Andrus, LVT BIS, Milessa Decker, LVT, Patrick Hurley, MD, Jeffrey O’Connor, MD Vijay K. Mittal, MD
Department Surgery, Providence Hospital and Medical Centers, Southfield, Michigan, USA (Drs. Bhullar, Subhas, Kansakar, Hurley, O’Connor, Mittal).
Department of Patient Care Research, Providence Hospital and Medical Centers, Southfield, Michigan, USA (Drs. Silberberg, Tilak, Gill, Andrus, Decker).

Background and Objective: Prostate cancer treatment is associated with substantial morbidity. Ideal treatment of localized prostate cancer would be an effective local therapy with minimal morbidity. Direct injections have been used to treat benign prostatic hyperplasia without major complications. We evaluated the local oncotoxic effects of acetic acid in a prostate cancer xenograft murine model.
 
Methods: PC3 and LNCaP human prostate cancer cell lines were used to grow subcutaneous tumors in SCID mice. For each cell line, 14 mice underwent tumor injection with 25% acetic acid (0.05mL/100mm³ of tumor) after the tumor was >300mm³. Posttreatment, 1 mouse/group was euthanized after 6 hrs, 24 hrs, 1 week, and 2 weeks; remaining mice (n=10) were sacrificed at 120 days. Control mice (8/group) were euthanized after they met the humane criteria for tumor burden and overall health.
 
Results: Tumor necrosis was noted immediately after injection; by 24 hours, ulceration and crusting of overlying skin were noted, which healed into scars by 23±5 days. Histological examination showed tumor degeneration and necrosis with feeding vessel obstruction. Ten treated mice in both groups survived for 120 days, which was much longer than mean survival of PC3 (40±9 days) and LNCaP (56±10) control mice.
 
Conclusions: Direct injection of acetic acid successfully eradicated both tumors grown from both cell lines. This treatment option could potentially be used in humans for treatment of early localized prostate cancer and nonoperative management of locally advanced cases. This is the first report of successful local chemical therapy for prostate cancer.

11.169 General Surgery
Laparoscopic Ileo-Colic Resection with Radiofrequency Device in Crohn Disease
Roberta Gelmini, Prof Dr Med, Chiara Franzoni, MD, Massimo Saviano, Prof Dr Med
University of Modena and Reggio Emilia, Italy (all authors).

Objective: Since the introduction of laparoscopic colorectal surgery, several studies have demonstrated the advantages of mini-invasive segmental colon resections in the treatment of benign diseases. Laparoscopic ileo-colic resection in complicated Crohn’s disease is often difficult. The presence of fistula, abscess, and inflammation could make the dissection challenging. The use of a radiofrequency vessel-sealing system device both in dissection and vessel ligation, as a unique instrument, seems to make the procedure easier with a low rate of conversion. The aim of this report is to show the feasibility and safety of laparoscopic ileo-colic resection with a radiofrequency device.

Materials and Methods: Between January 2009 and December 2010 at our institution, 13 patients underwent to laparoscopic ileo-colic resection with a radiofrequency device for complicated Crohn’s disease.

Results: The mean age was 42.3 years, and the preoperative endoscopy showed an ileocecal valve of distal ileum stenosis or fistula. Mean operative time was 166 minutes, and the estimated mean blood loss was 100cc. No conversions occurred. In all cases but one, the margins of resection were disease free. Two postoperative complications occurred: 1 anastomotic dehiscence and 1 intestinal perforation, both surgically treated. No mortalities occurred. The mean hospital stay was 8 days.

Conclusions: The analysis of our data highlights that laparoscopic ileo-colic resection with a radiofrequency device is effective and feasible even if this procedure, because of its complexity and for the intrinsic characteristics of the disease, has to be reserved for well-trained laparoscopic surgeons and does not eliminate the risk of postoperative complications.

11.170 Urology
Kidney Access Device: A New Concept and Invention
Jasneet Singh Bhullar, MD, Robert T. Scott, Gokulakkrishna Subhas, MD, Vijay K. Mittal, MD
Departments of Surgery, Biomedical Engineering, and Patient Care Research, Providence Hospital and Medical Centers, Southfield, Michigan, USA (all authors).

Background: Percutaneous nephrolithotomy is the most complicated stone surgery technique to teach. The steep learning curve is mainly related to obtaining the precise renal access by puncturing the correct calyx. A minimally misaligned puncture may lead to torrential bleeding, failure of surgery, and loss of the kidney. Renal puncture can take up to an hour even in trained hands. Moreover, increased fluoroscopic time is a hazard for the patient and surgeon.
 
Methodology: We designed the Kidney Access Device (KAD), which aligns the 3-dimensional target under fluoroscopy for precise needle placement. Only the needle is visualized under fluoroscopy while allowing access to all calyces at all angles. A 3-step puncture technique was formulated for puncturing with KAD in a porcine model (comparable renal size and anatomy with humans). KAD was used to puncture 3 targeted calyces of both kidneys, and guidewires were inserted into the renal collecting system through the needle.
 
Results: Mean time per puncture was 4±2 minutes. Necropsy showed no retroperitoneal hematoma, colonic or liver injury, or active bleeding from the kidneys. They were dissected and precise intrarenal placements of guidewires in relation to targeted calyces were noted in all 6 sites.
 
Conclusion: This is the first reported successful kidney puncture device with an animal trial. The device, with the 3-step technique, aids the safe and correct placement of the puncture needle even in novice hands, while drastically reducing the operative and fluoroscopy time. KAD can also be used to access other organs and has potential applications in minimally invasive surgery.
 

11.171 General Surgery
Laparoscopic Stump Appendectomy
Sharon L. Ream, BS, Peter F. Lalor, MD
University Of Toledo College of Medicine, Toledo, Ohio USA (Ms. Ream).
Wood County Hospital, Bowling Green, Ohio, USA (Dr. Lalor).

Objective: Appendicitis is a common condition that is managed surgically with minimal complications. Stump appendicitis is a rare complication following appendectomy. We report the case of a 33-year-old male with abdominal pain and tenderness 5 months following laparoscopic appendectomy.

Methods: Clinical and radiographic findings are reviewed with video presentation of laparoscopic stump appendectomy. Pertinent literature review is also included.

Results: Stump appendicitis is a rare complication after open or laparoscopic appendectomy. Clinical suspicion and radiological imaging are paramount in diagnosis.

Conclusions: Laparoscopic stump appendectomy is a feasible surgical option for stump appendicitis after previous open or laparoscopic appendectomy.

11.172 Gynecology
Effects of CO₂ Pneumoperitoneum on Establishment of a Rat Endometriosis Model
Xu Chen, MD, Haifang Liu, MD, Yan Liu, MD
Department of Obstetrics and Gynecology, Changzheng Hospital, Second Military Medical University, Shanghai, China (all authors).
 
Objective: To evaluate the effects of CO₂ pneumoperitoneum on establishment of a rat endometriosis model.

Methods: Forty mature female SD rats were chosen to establish the rat endometriosis model with autologous transplantation. Estradiol benzoate (0.1mL/kg, IM) was administered to bring all animals into the same estruation. Endometrial tissue was autologously transplanted to the peritoneum. The rats were divided randomly into 4 groups: the control group; and CO₂ pneumoperitoneum (15mm Hg, 1h) intervention groups: A) before operation; group B) 4th day postoperation; C) 10th day postoperation. To determine the achievement rate of model establishment, the endometriosis lesions and vascular endothelial growth factor (VEGF)/endostatin (ENS) were determined to evaluate the effects of CO₂ pneumoperitoneum on establishment of rat endometriosis model.

Results: The achievement rate of rat model establishment was 100% in the control group and group A compared with 70% and 80% in groups B and C, respectively. But there was a more significant decrease of VEGF/ENS in group B and C than in group A (P=.05). Moreover there was no statistic difference between group B and C (P=.05).

Conclusion: The achievement rate of rat model establishment was decreased when intervention was performed with CO₂ pneumoperitoneum, which may activate the angiogenesis inhibition factor.

11.173 General Surgery
Does Male Sex Have an Impact on the Outcomes of Laparoscopic Cholecystectomy?
George Bazoua, MD, MSc, FRCS, Michael P Tilston, FRCS, Avril A Chung, MBBS, FRACS
Diana Princess of Wales Hospital, Grimsby, England, UK (Drs. Bazoua, Tilston).
Kings College Hospital, London, England, UK (Ms. Chung).

Objective: Predicting difficulties in laparoscopic cholecystectomy (LC) has always been under evaluation. Studies have failed to conclude that male sex is an independent risk factor. The aim of this study was to evaluate the impact of male sex on the outcomes of LC by isolating other risk factors.

Methods: A quantitative comparative study was set up on a background of the null hypothesis: male sex has no impact on the outcomes of LC. Retrospective study of 241 patients measured the duration of surgery, postoperative hospital stay, conversion, and procedure-specific complications. Risk factors for conversion were excluded. Inferential statistics were applied, and a 2-sided P value of <.05 was considered as a cut off point to indicate the amount of evidence against the null hypothesis. SPSS version 12 for Windows was used. Parametric data were analyzed using the independent sample t test, and nonparametric data were analyzed using the chi-square (χ2) test.

Results: Conversion rate was 7.5% in males and 2.9% in females. Perioperative morbidity in males was 12.1% and in females 10.2%. Mean duration of surgery was 67.9±27.8 minutes in males and 56.5±23.98 in females. Both sexes had an equal postoperative hospital stay. There were no statistical differences between the 2 sexes in terms of the outcomes measured except for operating time.

Conclusions: Male sex has no impact on the outcomes of LC. Sex does affect duration of surgery. A larger scale study may disclose factors responsible for variations in length of surgery and its impact on outcomes.

11.174 General Surgery
The Effect of Laparoscopy on the Production of Proinflammatory Cytokines by Peritoneal Macrophages 72 Hours After Surgery in Rats
Halka Lotkova, MD, PhD, Lukas Sakra, MD, PhD, Lukas Kohoutek, MD, Jiri Siller, MD, PhD, Zuzana Cervinkova, Prof, MD, PhD
Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic (Drs. Lotkova, Cervinkova).
Department of Physiology, Hradec Kralove, Czech Republic, Regional Hospital in Pardubice, Department of Surgery, Pardubice, Czech Republic (Drs. Sakra, Kohoutek, Siller).

Introduction: Intraabdominal surgery can cause local stress, leading to activation of peritoneal macrophages. Alteration of local immune response induced by laparoscopy is experimentally evaluated mostly within a period of 24 hours after surgery. The aim of our study was to determine the peritoneal macrophage activity at a later time—72 hours after surgery.

Materials and Methods: Male Wistar rats underwent laparoscopic or laparotomic surgery. Control animals were given anesthesia. Peritoneal lavage was performed 72 hours after surgery. Then isolated macrophages were cultured for 24 hours without further stimulation, or they were stimulated by lipopolysaccharide (Escherichia coli, Sigma-Aldrich). Concentration of cytokines TNF alpha, interleukins 1 and 6 were measured using ELISA kits. Statistical analysis was done using GraphPad Instant 3.06 for Windows (USA).

Results: Seventy-two hours after surgery, basic production of TNF alpha and interleukin 1 increased compared with that in controls (P<.001). Production was more pronounced after laparoscopy compared with laparotomy (P<.001). Concentration of interleukin 6 was not detectable. Stimulated macrophages increased the production of all cytokines, but the production was lower after laparoscopy compared with laparotomy (P<.001).

Conclusion: Laparoscopic surgery induced higher production of proinflammatory cytokines by nonstimulated peritoneal macrophages than does laparotomy that could manifest a more intensive inflammatory response. Nevertheless, the increase in the secretory activity of macrophages stimulated after laparoscopy was attenuated. Whether this preservation of macrophage activity could display a better tolerance to noxious stimuli thus diminishing postoperative complications remains to be verified.

11.176 General Surgery
Laparoscopic Conversion of Gastric Band to Roux-en-Y Gastric Bypass
Jonathan M. Tomasko, MD, Michael Fishman, MD, Seth Judd, MD, Randy S. Haluck, MD, Jerome Lyn-Sue, MD, Ann M. Rogers, MD
Division of Minimally Invasive and Bariatric Surgery, Penn State Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania USA (all authors).

Background: Adjustable gastric banding can be a safe and effective tool for weight loss, but has a relatively high failure and reoperation rate. The need for band removal and conversion to a different form of surgical weight loss can be expected to increase with time.
 
Methods: We present a patient with dysphagia, dysmotility, and failure of weight loss with the gastric band. She requested band removal and conversion to gastric bypass.
 
Results: This video demonstrates laparoscopic removal of an adjustable gastric band and conversion to gastric bypass, as well as some technical challenges that may be encountered.
 
Conclusion: Laparoscopic revisional gastric bypass after removal of adjustable gastric band can be safe and effective as a single-stage procedure. Attention to technical details assures good outcomes.

11.177 General Surgery
"Greenhorn” Study: Single-Port Versus Standard Laparoscopy in the Training Laboratory
Kerstin Kleinfelder, Simon Kuesters, MD, Arkadiusz Miernik, MD, Martin Schönthaler MD, Ulrich Wetterauer, MD, Alexander Frankenschmidt, MD, Ulrich T. Hopt, MD, Wojciech K. Karcz, MD
University Hospital Freiburg, Germany

Objectives: Single incision laparoscopic surgery (SILS) is a new concept in laparoscopic surgery. In this surgery, a special trocar (single-port) is inserted through a single incision, mostly at the umbilicus, or small trocars are inserted in several small incisions grouped in one location. A direct comparison between standard laparoscopy and single incision laparoscopic surgery was performed to evaluate the time duration, feasibility, and potential problems.

Methods: Standard laparoscopy and single incision laparoscopy were compared, using a single-port trocar with specifically bent laparoscopic instruments. In this randomized study, 92 persons each tested one of the investigated methods by performing the same 4 tasks on a training model. Persons with practical experience in laparoscopic surgery were excluded.

Results: In all evaluated categories, the comparison indicated that standard laparoscopy was preferable to single incision laparoscopy with a significance of >99,999. The obstruction of the bent instruments resulted in multiple problems including an increased expenditure of energy, snagging of the instruments, and difficulty in centering the image.

Conclusion: Although there are many optimistic publications concerning single port surgery, this direct comparison demonstrated poorer results using this new method. 
The study suggests that single incision laparoscopy should be used by advanced laparoscopic surgeons after special training. In particular, further clinical use is necessary to prevent the problems that this study has highlighted. Modifications to the instruments have the potential to advance single incision laparoscopic surgery into a more safe and effective procedure.

11.178 General Surgery
Early Results of Single Incision Sleeve Gastrectomy
Shabirhusain S. Abadin, MD MPH, Rami Lutfi, MD
Chicago Institute of Bariatrics, Saint Joseph Hospital, Chicago, Illinois, USA (all authors).

Objective: To evaluate the early weight loss results and operative technique of the sleeve gastrectomy performed using the novel single incision laparoscopic technique.

Methods: All patients underwent single incision sleeve gastrectomy at a single institution performed by one surgeon over 13 months. Outcomes measured included averages in 3-month excess weight loss, operative time, volume of resected stomach, and number of stapling cartridges used for resection.

Results: A single surgeon performed 75 sleeve gastrectomies, 22 of which were single incision procedures. Ten patients had at least a 3-month follow-up. The average operative time was 144 minutes, without any conversion to traditional laparoscopy. The average number of stapler cartridges used to complete resection was 6.7, and the average specimen volume was 1153cc. Average 3-month excess weight loss was 55%.

Conclusions: Limited preliminary data on the single incision sleeve gastrectomy shows that this operation is technically feasible with encouraging early weight loss results.

11.179 General Surgery
Single Incision Laparoscopic Surgery versus Conventional Laparoscopic Surgery
Aliu Sanni, MD, Henry Talus, MD
Division of Colorectal Surgery, Department of Surgery, SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, New York, USA (all authors).

Introduction: Single incision laparoscopic surgery (SILS) has evolved from an effort to minimize tissue trauma, limit morbidity, and maximize cosmetic benefit of conventional laparoscopic surgery (CLS). This approach can be adopted in a safe and efficacious manner. The aim of this study was to compare patient outcomes using single incision laparoscopy versus conventional laparoscopic surgery.


Materials and Methods: Prospectively collected data were retrospectively analyzed for all single incision laparoscopic procedures and conventional laparoscopy surgery performed by a single surgeon between February 2008 and December 2009 at our institution. Demographics, indications for surgery, operative times, length of hospital stay, time to oral intake, lymph nodes harvested, conversion rate, and complications were outcomes measured. All patients were followed for an average of 7.5 months (range, 3 months to 17 months). Statistical analysis was done using the Student t test for continuous data and chi-square analysis for categorical data.

Results: A total of 26 patients (18 female and 8 male) ranging from 25 to 74 years of age were enrolled in this study. Right hemicolectomy was performed in 9 patients (35%), sigmoidectomy in 5 patients (19%), appendectomy in 5 patients (19%), left hemicolectomy in 4 patients (15%), and low anterior resection in 3 patients (12%). The operative times (P=.53), complication rates (P=.97), hospital stay (P=.2), and lymph node harvests (P=.77) were not significantly different between these 2 groups. The SILS group patients tolerated diet earlier than the conventional laparoscopic group (P=.03).

Conclusion: Single incision laparoscopy is as safe as conventional laparoscopic surgery.

11.180 General Surgery
Laparoscopic Splenectomy for Refractory Splenic Abscesses
Modesto Colon, MD, Linda Zhang, MD, Dana Telem, MD, Edward Chin, MD, Celia Divino, MD, Scott Nguyen, MD
Department of General Surgery, Mount Sinai School of Medicine, New York, New York, USA (all authors).
 
Objective: Laparoscopic splenectomy has been proven to be an effective approach for the treatment of different pathologies. In this video, we demonstrate this procedure in a case of refractory splenic abscesses.

Methods: This is the case of a 46-year-old male with a past medical history of HIV, Hepatitis C, diabetes mellitus, and chronic abdominal pain. CT scan demonstrated an enlarged spleen with multiple low-density lesions. Differential diagnosis included an infectious, inflammatory, or neoplastic process. He underwent multiple splenic biopsies that were unsuccessful in establishing a positive culture or pathology. He had intractable symptoms, and the decision was made to proceed with laparoscopic splenectomy. On exploration, an intense inflammatory reaction was found surrounding the spleen with significant adhesions to the omentum, stomach, colon, and abdominal wall. Difficulty was encountered with bleeding from the splenic vein and with the dissection of the surrounding adhesions.

Results: The spleen was successfully removed laparoscopically. Final pathology showed abundant necrotizing granulomas with occasional AFB-positive bacilli, consistent with Mycobacterium avium intracellulare. His postoperative course was complicated by clostridium difficile colitis. He was discharged on postoperative day 14, and he has been symptom-free for 6 months.

Conclusion: Laparoscopic splenectomy was safely performed for intractable splenic abscesses caused by Mycobacterium avium intracellulare in an immuno-compromised patient.

11.181 Gynecology
Risk Factors Related to Recurrence of Endometrial Polyps after Hysteroscopy Polyp Resection
Antoniu Cringu Ionescu, MD, PhD, Diana Gheorghiu, MD, PhD, Irina Pacu, MD, PhD, Mihai Dimitriu, MD, Horatiu Haradja, MD, UMF Carol Davila
Clinical Hospital Sf Pantelimon, Bucharest, Romania (all authors).

Objectives: Endometrial polyps are very frequent entities that can return after a first treatment. The aim of our study was to evaluate the different risk factors that are involved in recurrence after a hysteroscopic polyp resection.

Methods: This was a retrospective study of 112 patients in whom a polypectomy by hysteroscopy was performed between January 2004 and January 2007. Follow-up was 3 years. The aim was to detect patients with recurrence and estimate the principal risk factors involved. The main risk factors studied were age, menopause, symptoms, hormone replacement therapy (HRT), polyp size, and body mass index.

Results: In the 112 cases, we found a 12% recurrence, with a greater percentage of recurrences (29%) in patients on HRT. The size of the initial polyp was also greater. Neither age, menopause, nor body mass index influenced the recurrence.

Conclusions: Only the patients taking HRT had a major risk of recurrence after polypectomy, but our sample size is relatively small, and a larger prospective study is needed.

11.182 Gynecology
Superficial Endometriosis: Coagulation or Excision?
Antoniu Cringu Ionescu, MD, PhD, Diana Gheorghiu, MD, PhD, Irina Pacu, MD, PhD, Bogdan Davitoiu, MD, Mihai Dimitriu, MD, Ramona Rotaru, MD, PhD, UMF Carol Davila
Clinical Emergency Hospital Sf Pantelimon, Bucharest, Romania (all authors).

Objective: We compared the effectiveness of 2 laparoscopic approaches for mild endometriosis, excision versus coagulation.

Methods: This was a retrospective study of 62 patients between 2004 and 2008 with mild, peritoneal only, endometriosis. Of these, 39 were treated with electrocoagulation and 23 were treated by sharp excision. The treated patients were followed up for 2 years for their symptoms (dyspareunia, dysmenorrhea) and further medical treatment. We evaluated the results histologically and with a questionnaire using a pain score for the symptoms.

Results: Both methods showed convincing results concerning symptom recurrences (1.8% excision and 3.8% coagulation). A lower recurrence rate was seen in the excision group.

Conclusions: In cases of superficial endometriosis, laparoscopic surgery has good results with a small recurrence rate of symptoms. The sharp excision has better results regarding symptoms.

11.183 General Surgery
Transumbilical Laparoscopic Cholecystectomy in the Treatment of Patients with Gallstone Disease and Acute Cholecystitis
A. Ukhanov, MD, A. Ignatjev, MD, G. Khachatrjan, MD
First Municipal Clinical Hospital, Velikiy Novgorod, Russia (all authors).
 
Background: Transumbilical laparoscopic cholecystectomy with the help of a Covidien SILS port was performed in 82 patients with acute cholecystitis during 2010.

Methods: Standard laparoscopic instruments and 10-mm clip applicator with medium-large clips were used for gallbladder dissection. There were 74 women and 8 men. Age of patients ranged from 22 years to 88 years. All patients were admitted on an emergency basis with a diagnosis of acute cholecystitis.

Results: During the operation, 38 patients (46.3%) were found to have catarrhal cholecystitis, 27 (32.9%) phlegmonous cholecystitis or empyema of the gallbladder, and 17 (20.7%) gangrenous cholecystitis. Surgery by transumbilical access only was  performed in 54 patients (65.9%). The introduction of an additional trocar was required in 7 patients (8.5%) and 2 additional trocars were needed in 15 patients (18.3%). Conversion to standard laparoscopic cholecystectomy with the 4-port technique was needed in 6 patients (7.3%).
No cases required transition to laparotomy. Mean duration of surgery was 62.8 minutes. In patients with catarrhal cholecystitis, the mean time of operation was 53.9 minutes, with phlegmonous cholecystitis 67.0 minutes, and gangrenous cholecystitis 75.4 minutes. No intraoperative morbidity occurred. Postoperative morbidity was 4.9% (4 patients).

Conclusion: Thus, transumbilical laparoscopic cholecystectomy is a promising minimally invasive method for removing the gallbladder for acute cholecystitis. It is particularly indicated in people previously operated on though the abdominal cavity and having a ventral or umbilical hernia.

11.184 General Surgery
Use of Videolaparoscopy in the Diagnosis and Treatment of Acute Appendicitis and its Complications
D.V. Zakharov, Aleksandr Ukhanov, A. I. Ignatjev, S. V. Kovalev, T. V. Dunaeva
First Municipal Clinical Hospital, Velikiy Novgorod, Russia (all authors).

Aim: We sought to improve the results of surgical treatment in patients with acute appendicitis by using endovideosurgical technology.

Materials and Methods: 385 patients with acute appendicitis were operated on laparoscopically. Based on morphology, the patients were distributed as follows: catarrhal appendicitis was found in 45 (11.7%) patients, phlegmonous appendicitis in 255 (66.2%), gangrenous appendicitis in 65 (16.9%), and gangrenous perforated appendicitis in 20 (5.2%). In 131 patients, acute appendicitis was complicated by peritonitis including local peritonitis in 80 (20.8%) patients, diffuse peritonitis in 31 (8.6%), and periappendicular abscess in 20 (5.2%). 


Results: In 25 (6.5%) cases, conversion to laparotomy was necessary. Postoperative complications were observed in 21 (5.5%) patients, including intraabdominal abscess in 5 (1.3%), postoperative peritonitis in 2 (0.5%), suppurations of wounds in 8 (2.1%), paralytic ileus in 3 (0.8%), thrombophlebitis of lower extremities in 2 (0.5%), and pneumonia in 1 (0.3%). Mean length of stay was 6.5±0.3 days. No postoperative mortalities occurred. Comparison of results of laparoscopic appendectomy with traditional interventions shows that in the group of 543 patients with typical appendectomy, postoperative complications occurred in 42 patients (7.7%) and average length of stay was 9.4±0.4 days (Р<.05).

Conclusion: Introduction of videoendosurgical technology into the treatment of acute appendicitis and its complications is very feasible, reduces postoperative morbidity, and shortens hospital stay.

11.185 General Surgery
Endovideosurgical Treatment for Blunt Penetrating Injuries of the Diaphragm
S. Gadgiev, MD, A. Ukhanov, MD
First Municipal Clinical Hospital, Velikiy Novgorod, Russia (all authors).

Endovideosurgical treatment was performed in 92 patients. In 81 cases, the rupture was sewn by continuous suture, and in 11 patients mesh graft was used. Videoscopic intervention in 53 (57.6%) patients was started with thoracoscopy, and in 39 (42.4%) patients with laparoscopy. Damage to the left diaphragm was found in 51 (55%) and to the right in 41 (45%) patients. To study the effect that the type of access has, we analyzed the incidence of complications and results of treatment in 2 groups of patients with rupture of diaphragm. One group of 26 patients was operated on by the traditional approach, and the other group of 28 patients was treated endovideosurgically. Both groups were matched for sex, age, the nature of the injury and the severity of the condition. The mean duration of videoscopic operation was 52 minutes; the traditional was 78 minutes. Postoperative complications in the group of patients operated on videoscopically were mild. Need to perform repetitive operations has not occurred. No deaths were observed. Two (7.7%) patients operated on with traditional access have died. Thus, endovideoscopic intervention in blunt chest and abdominal trauma with rupture of the diaphragm, performed according to indications, has obvious advantages over traditional operations. It is less traumatic, resulting in a significantly shorter postoperative period. Postoperative morbidity decreased by 5-fold. Material costs for the treatment of patients is lower when endovideosurgical treatment was used. In addition, the period of social and medical rehabilitation in patients operated on videoscopically is 2 times shorter than in the group of patients who underwent traditional interventions.

11.187 General Surgery
First Human Surgery Using the da Vinci Single-Site Platform to Perform Cholecystectomy
Kevin El-Hayek, Steven Rosenblatt, Bipan Chand, Pedro Escobar, Jihad Kaouk, Sricharan Chalikonda, Matthew Kroh
Ceveland Clinic, Digestive Disease Institute, Cleveland, Ohio, USA (Drs. El-Hayek, Rosenblatt, Chand, Chalikonda, Kroh).
Cleveland Clinic, Women's Health Institute, Cleveland, Ohio, USA (Dr. Escobar).
Cleveland Clinic, Glickman Urologic Institute, Cleveland, Ohio, USA (Dr. Kaouk).

Background and Objectives: Interest in single incision laparoscopic techniques continues to grow. Despite these technical advances, certain challenges, such as external clashes, poor visualization of critical structures, and surgeon fatigue, remain. Applications of robotics to this newer technique are evolving. The da Vinci Single-Site robotic surgery platform is a new, semi-rigid robotic operative system designed to work with the Intuitive Surgical da Vinci Si operative system. The authors present a video of the first human experience with this new device in performance of single incision laparoscopic cholecystectomy.

Results: A patient with symptomatic cholelithiasis was offered robotic-assisted cholecystectomy using the new single-site platform. Critical view of safety was obtained, and the operation was completed successfully. No transgallbladder suture retraction was required. There were no intraoperative or postoperative complications. Two-week follow-up revealed no pain and a barely visible scar through the umbilicus. 
 
Conclusion: Cholecystectomy using the da Vinci Single-Site system is feasible. Availability of this new semi-rigid, robotic surgery platform may increase access to potential advantages of single site surgery. Additional advantages of single site surgery may be elucidated with further studies.

11.188 General Surgery
Totally Robotic Roux-en-Y Gastric Bypass: A Single-Docking Technique Using Four Robotic Arms 
Collin E.M. Brathwaite, MD, Alexander Barkan, MD, George Oswald, RPA-C, MPA, Patricia Cherasard RPA-C, MBA
Division of Minimally Invasive Surgery, Winthrop University Hospital, Mineola, New York, USA (all authors).

Objective: Robotic gastric bypass has been performed for some time using either a process of docking the robot twice to accomplish the different stages of this complex procedure, or by a partially laparoscopic (hybrid) technique. The purpose of this video is to demonstrate our totally robotic, single-docking technique for Roux-en-Y gastric bypass utilizing 4 robotic arms.

Methods/Procedures: Key changes to existing techniques are made. Port placement is modified to facilitate the fourth robotic arm. The pouch is created prior to the jejunojejunostomy. The fourth arm is used for dissection with the energy source, and for manipulating the stomach. The pouch is sutured to the jejunum by using 2-0 PDS and incorporating the staple line; however, the anastomosis is completed later. The Roux limb is sutured to the bilio-pancreatic approximately 6cm from the pouch. The fourth arm of the robot provides traction on this suture during the anastomosis. The surgeon places the bowel onto the stapler. This is critical in avoiding injury to the bowel. Traction sutures are then placed and the common enterotomy closed. The posterior mucosal layer of the gastrojejunal anastomosis is approximated using color-coded 2-0 Vicryl suture pieces tied together to facilitate the corner knot. The anterior sero-muscular layer is then completed using the other end of the previous PDS suture.

Result: A simplified totally robotic approach is achieved without having to re-dock the robot. 

Conclusion:  This is a simple alternative to complicated existing techniques.

11.190 General Surgery
Single Incision Laparoscopic Cholecystectomy: Who Should Grasp the Laparoscope?
Hiroyuki Kashiwagi, Kenta Kumagai, Eiji Monma, Mutsumi Nozue
Department of Surgery, Shounai-Amarume Hospital, Yamagata, JAPAN (all authors).

Introduction: Single incision laparoscopic cholecystectomy (SILC) is becoming common throughout the world. However, technical problems have been reported, because of restricted access for surgical instruments and narrow visualization of the working field. Therefore, the laparoscopic surgeon who performs SILC needs to have experience in this limited operative area. In addition, the laparoscopic assistant also may need to be experienced. We report a single surgeon’s series of SILC at a single institution.

Methods: Twenty-three patients were included in this study. An experienced surgeon (over 300 cases of laparoscopic cholecystectomy) performed each SILC with a laparoscopic assistant who is a 2-year resident or 1 of 3 experienced surgeons (over 10 year’s experience). A flexible laparoscope was used for all cases.

Results: The first case of SILC and a severe adhesional case with acute cholecystitis required the placement of an additional port to complete the procedure. One case was converted to an open procedure because of intraoperative bleeding. No major complication was shown after SILC. The mean operative time was 85.5 minutes. A 2-year resident participated in 78.3% (18/23) of all cases as a laparoscopic assistant. The graph describing the approximate operative time for all cases showed a flat line. However, increased experience tended to reduce the operating times in cases involving the 2-year resident assistant.

Conclusion: These results indicate that the laparoscopic procedure of SILC is not equivalent to a conventional laparoscopic procedure, and SILC requires not only an experienced surgeon but also a laparoscopic assistant experienced in single-port surgery.

11.191 General Surgery
Totally Extraperitoneal Repair of Inguinal Hernia: The Limits, Applicability, and Safety
Arshad M. Malik, MBBS, FCPS, K. Altaf Hussain Talpur, MBBS, FCPS, Abdul Aziz Laghari, MBBS, FCPS, FRCS, Jawaid Naeem Qureshi, MBBS, FRCS, Sara Qasim Bughio, MBBS
Department of Surgery, Liaquat University of Medical & Health Sciences, Jamshoro, Pakistan (all authors).

Objective: To study the limitations and applicability of the totally extraperitoneal repair (TEP) in different varieties of inguinal hernias and to study the safety of this technique, depending on the experience of the operating surgeon and the type and other characteristics of the hernia itself.

Methods: This was an observational prospective descriptive study including a total of 186 patients with 197 (11 bilateral) inguinal hernias operated on by the totally extraperitoneal (TEP) technique over a 3-year period in a teaching hospital as well as various private hospitals. Patients with recurrent or complicated hernias were excluded. All the patients were operated on by the TEP technique. The variables studied to confirm the safety and validity of the technique were recorded and analyzed on SPSS version 17.

Results: A total 186 patients with 197 inguinal hernias were operated on with the TEP procedure. Of these, 59.89% of patients had right-sided inguinal hernia, 57 (28.93%) left-sided, and 11 (5.58%) bilateral inguinal hernias. A vast majority of the inguinal hernias were small/incomplete, while only 16 (8.12%) were complete scrotal hernias. Initial bleeding occurred in 16 patients operated on by trainee registrars (P<.001), while complete hernias presented difficulties in 32 patients operated on by junior consultants (P<.001). Nineteen patients operated on by junior consultants needed conversion, because of complications (P<.001).

Conclusion: TEP is an excellent technique for inguinal hernia repairs. However, patient selection and surgeon experience are crucial for its safety and utility.

11.192 Multispecialty
Robotic Surgery for Pelvic Cancers: Urological Implications - Single Team Experience
Catalin Vasilescu, Stefan Tudor, Bogdan Trandafir, Dana Elena Giza, Ladislau Neagoe, Calin Chibelean, Gabriel Gluck
Department of General Surgery, Fundeni Clinical Institute, Bucharest, Romania (Drs. Vasilescu, Tudor).
Carol Davila University of Medicine and Pharmacy, Bucharest, Romania (Drs. Vasilescu, Trandafir, Giza, Gluck).
Institute of Nephrology, Dialysis and Kidney Transplantation Fundeni, Bucharest, Romania (Drs. Neagoe, Chibelean, Gluck).

Introduction: Robotic surgery overcomes some limitations of laparoscopic surgery for pelvic cancers. The aim of the present study was to analyze the urological implications of the robotic approach for locally advanced gynecologic and rectal cancer.

Methods: Between March 2008 and January 2010, 420 cases of robotic surgery were performed at the Fundeni Clinical Institute, Bucharest, Romania, from which 74 addressed gynecological conditions and rectal cancer. This study analyzed 64 cases performed by a single team: 43 women diagnosed with locally advanced cervical cancer, 12 with endometrial cancer, 2 patients with low rectal cancer, and 7 patients with middle and upper rectal cancer.

Results: The following robotic procedures were performed: 47 radical hysterectomies with pelvic and lumbo-aortic lymphadenectomy, 5 anterior pelvic exenterations, 3 total pelvic exenterations, 2 abdominoperineal rectum resections, and 7 anterior resections of the rectum with total mesorectal excision. The mean operative time was 180±23.45 minutes for radical hysterectomies with pelvic lymphadenectomy, 230±20.7 minutes for pelvic exenterations, and 145±23.45 minutes for rectal surgery. Procedures performed in these patients included 2 ureteral reimplantations, 1 partial cystectomy with ureteral reimplantation, and 8 total cystectomies.

Conclusions: Urological implications are frequent during robotic surgery of advanced pelvic nonurological cancers. Therefore, the pelvic oncological surgeon has to be trained in performing urological procedures (especially ureteral reimplantation and partial and total cystectomy) and eventually to cooperate with a urological surgeon. In this respect, we can conclude that robotic surgery of pelvic cancers represents a typical interdisciplinary approach.

11.193 General Surgery
Laparoscopic Subtotal Cholecystectomy in the Treatment of Severe Acute Cholecystitis
A. Ukhanov, MD, A. Ignatjev, MD, S. Kovalev, MD, G. Khachatrjan, MD
First Municipal Clinical Hospital, Veloikiy Novgorod, Russia (all authors).

Aims: Improvement of treatment results in patients with severe acute cholecystitis. 


Methods: 352 patients with acute destructive cholecystitis were operated on laparoscopically. In 236 (67.0%) patients, there was phlegmonous or emphysematous cholecystitis, in 116 (33.0%) patients gangrenous cholecystitis. In 74 (21.0%) patients, the cholecystitis was complicated by formation of perivesical infiltrate or abscess. In 84 patients with severe acute cholecystitis, laparoscopic subtotal cholecystectomy was carried out. 


Results: Average duration of subtotal laparoscopic cholecystectomy (SLC) was 72.4±13.4 minutes, and typical laparoscopic cholecystectomy (TLC) was 58.4±12.6 minutes. Average blood loss for SLC was 87.5±14.2mL, for TLC 48.4±11.3mL. Conversion rate for SLC was 4.8% (4 patients), for TLC 2.2% (6 patients). Average length of stay after operation in patients with SLC was 7.4±2.5 days, after TLC 5.8±1.8 days. No bile duct damage or mortalities occurred in either group.

Conclusion: Thus, subtotal laparoscopic cholecystectomy in the patients with severe acute cholecystitis technically is more difficult and longer, is accompanied by more blood loss, and has a higher conversion rate, and longer length of stay than typical laparoscopic cholecystectomy. However, such an operation is feasible and rather safe in heavy forms of destructive cholecystitis, promotes a reduction in the threshold of conversion to laparotomy, and diminishes the risk of bile duct damage.

11.194 General Surgery
Use of Videolaparoscopic Technology in the Diagnosis and Treatment of Patients with Acute Appendicitis with Atypical Location of the Appendix
T. Dunaeva, MD, D. Zakharov, MD, A. Ignatjev, MD, S. Kovalev, MD, A. Ukhanov, MD
First Municipal Clinical Hospital, Velikiy Novgorod, Russia (all authors).

We observed 332 patients with atypical location of the appendix. Retrocecal location was observed in 249 patients or 10.6%, retroperitoneal in 5 (0.02%), subhepatic in 42 (1.8%), and pelvic in 36 (1.5%). Laparoscopic appendectomy was performed in 152 (45.8%) patients, and 180 (54.2%) patients were operated on in the traditional manner. Among 152 patients with acute appendicitis with atypical location of the appendix in which laparoscopic appendectomy was performed, 8 (5.3%) operations were converted to laparotomy. Intraoperative complications occurred in 11 (7.2%) patients. Complications in the postoperative period occurred in 10 (6.6%) patients. To compare the results of laparoscopic and traditional appendectomy in patients with atypical location of the appendix, comparative analysis was carried out using the results of treatment of 180 patients who underwent appendectomy with laparotomy access. The patient groups were comparable in sex, age, type of lesion of the appendix, and the extent of peritonitis. Studies have shown that the number of intraabdominal abscesses in laparoscopic appendectomy was somewhat greater than that in open appendectomy, but the difference is not statistically significant (2.0% and 1.7%, respectively, P>.05). With regard to the number of wound complications, there was a significant increase in their numbers after open surgery (7.8% and 2.6%, respectively, P<.05). Thus, the use of endovideosurgery allows most patients with acute appendicitis with atypical location of the appendix to undergo appendectomy by the mini-invasive method. Laparoscopic appendectomy significantly reduces the number of wound complications and shortens the hospital stay compared with the open treatment.

11.195 Gynecology
Minimally Invasive Surgery for a Large Ovarian Cyst in an Elderly Female
Takashi Yamada, MD
Department of Pathology, Osaka Medical College, Osaka, Japan

Introduction: Recently, the number of laparoscopic surgical procedures has increased even in elderly patients.

Case Report: An 81-year-old woman was admitted with complaints of lower abdominal pain and lumbago. Her past medical history revealed renal failure, hypothyroidism, cerebral infarction, osteoporosis, and gastritis. Pelvic examination showed a 12-cm cystic tumor in the pelvis, as well as a very thin abdominal wall. The laparoscopy was performed with the patient in the supine position under general anesthesia without pneumoperitoneum. The abdominal wall was incised 1.2cm long vertically in the midline between the umbilicus and the pubic symphysis, and then an intraperitoneal space was opened via the open method. A blunt trocar was inserted into the abdominal wall orifice; when the trocar was pulled up to lift the abdominal wall, the organs in the intraperitoneal space became easily visible. The trocar was withdrawn, and the incision was enlarged to 2cm. Direct, visualized puncture of the cystic tumor was performed using a SAND Balloon Catheter. Approximately 820mL of serous fluid was aspirated without leakage into the peritoneal cavity. The cyst was pulled out extracorporeally and right oophorosalpingectomy was performed directly. After returning the cut-end of the right adnexa into the intraperitoneal space, laparoscopic observation was again performed. All of the manipulations were possible through a 2-cm incision in the abdominal wall. The patient had no complaints of postoperative pain and was able to walk on the second postoperative day.

Conclusions: Laparoscopic-assisted surgery with only one small abdominal incision is considered very useful in elderly patients.

11.196 General Surgery
Hand-Assisted Laparoscopic Splenectomy for Thrombocytopenia in Patients with Hypersplenism Due to Hepatitic C Cirrhosis
K. Tamaki, T. Yumiba, Y. Yamasaki, M. Fujii, Y. Morimoto, Y. Akamaru, E. Kono, S. Hasegawa, K. Murakami, M. Kajiwara, Y. Tanaka, K. Kawai, H. Kasashima
Department of Surgery, Osaka Kosei-Nenkin Hospital, Osaka, Japan (all authors).

Aim: Patients with hepatitis C cirrhosis have been treated with interferon. Pancytopenia is a common side effect of this treatment, and we often have difficulty applying this therapy to patients with thrombocytopenia by hypersplenism due to liver cirrhosis. We have taken hand-assisted laparoscopic splenectomy (HALS splenectomy) for these patients. The aim of this study was to clarify the efficacy and safety of HALS splenectomy for thrombocytopenic patients with hypersplenism due to hepatitis C cirrhosis.

Method: HALS splenectomy was performed to reverse thrombocytopenia in patients with hypersplenism due to hepatitis C cirrhosis, who would be treated with interferon. Platelet count was <100,000/mL in this preoperation condition. Six patients with hepatitis C cirrhosis and thrombocytopenia underwent HALS splenectomy so they could undergo interferon therapy.

Results: All 6 patients had Child-Pugh class A or B. Average platelet count was 63,000/mL (26,000/mL to 106,000/mL) before surgery. HCV genotype was type 1 in all patients. Average operation time was 177 minutes (range, 90 to 267) and average blood loss was 317g (range, 160 to 650). All patients had increases in platelet count (average 63,000/mL to 189,000/mL) at 4 weeks postsurgery. Platelet count remained more than 50,000/mL during the following interferon therapy. Five patients completed interferon therapy. One patient stopped interferon therapy because of angina pectoris.

Conclusion: HALS splenectomy for thrombocytopenia in patients with hepatitis C cirrhosis can be done safely with less blood loss. It is thought to be useful to reverse thrombocytopenia effectively and allow these patients to undergo interferon therapy.

11.197 Gynecology
Laparoscopy in Patients with Primary Sterility
Khusen Narzullaev
Samarkand, Uzbekistan

Objective: Application of laparoscopy in ovarian polycystic disease and uterine occlusion is of great priority.

Methods: At the Samarkand Centre of Endoscopic Surgery from 2005 through 2010, diagnostic laparoscopy was performed in 75 patients with a diagnosis of polycystic ovaries and primary sterility. The average age of patients was 24.9±1.2. Before laparoscopy, all patients had often been examined and received conservative treatment for 4 to 10 years but there was no effect.

Results: Laparoscopy of ovarian clinoid resection was performed in 47 patients (62.7%) with ovarian polycystic disease, and 28 patients (37.3%) had fibrinolysis. Further supervision of the patients revealed the resumption of menstruation in all of them, but the signs of pregnancy was not noted in any woman during the 1-year follow-up period. In tubal sterility, patients develop peritubal commissures like those that occur with chlamydia, and these were successfully disconnected.

Conclusion: Laparoscopic diagnosis of sterility and disturbance of menstruation in ovarian polycystosis gives value-added information about the state of internal genitals.

11.198 General Surgery
The Usefulness of 64 MDCT in the Diagnosis of Gastric Cancer for Laparoscopy-Assisted Gastrectomy
Hasegawa Shinichiro
Department of Surgery, Osaka Kosei-Nenkin Hospital, Osaka, Japan

Aims: The exact preoperative diagnosis is thought to be important for performing laparoscopic-assisted gastrectomy (LAG) safely. The aim of this study was to determine the usefulness of 64 MDCT in the diagnosis of gastric cancer for LAG.

Patients & Method: We evaluated 77 patients, who had been diagnosed with gastric cancer by an endoscopy and biopsy, from May 2008 to December 2009. Surgery consisted of laparoscopic surgery (n=26) and open surgery (n=51). Patients underwent 64 MDCT evaluations with the TOSHIBA Aquillion 64. After overnight fasting, the patients underwent CT with the stomach walls inflated, and we diagnosed the depth of cancer invasion. Iopamiron 300 100mL was injected venously at a rate of 4mL/sec. We evaluated the passages of the celiac artery and superior mesenteric artery and of the left gastric vein. We used 3D angiography for both.

Results: In all 26 laparoscopic surgeries, we did not convert any to an open procedure. The accuracy of T factors was 57.1%. We could demonstrate the gastric surrounding arteries in all cases (68/68, 100%). There were 63 (92.6%) cases normal branches, 2 cases (2.9%) in which the celiac artery and superior mesenteric artery had a common trunk, and 3 cases (4.4%) in which the common hepatic artery branched off the superior mesenteric artery. We could detect the left gastric vein in 35 cases (35/70, 50%). It joined the portal vein in 22 patients (62.9%), the splenic vein (SV) in 10 patients (28.6%), and the junction of superior mesenteric vein (SMV) and SV in 3 patients (8.6%).

11.199 General Surgery
Amyand's Hernia Identified During Interval Laparoscopic Appendectomy After Perforated Appendicitis
Joshua Gustafson, MD, Harry L. Anderson, III, MD
Boonshoft School of Medicine, Wright State University, Dayton, Ohio, USA (all authors).

Amyand's hernia consists of an appendix found in the inguinal canal. It is usually diagnosed when the patient is undergoing surgery for repair of the hernia. However, it can also be discovered during surgery for acute appendicitis. The following case is a patient with an Amyand’s hernia, found during an interval (delayed) appendectomy.

A 54-year-old African-American male had intermittent right lower quadrant pain for the last few years. He presented with a 4-day history of abdominal pain, which gradually localized to the right lower quadrant. A CT scan of his abdomen revealed an intraabdominal abscess consistent with perforated appendicitis. He subsequently underwent percutaneous drainage of the abscess, and was discharged. As an outpatient, he underwent screening colonoscopy, followed by laparoscopic interval appendectomy. The appendix was found to be in the right inguinal canal, consistent with an Amyand’s hernia. It was excised and the patent processus vaginalis obliterated with an Endoloop. Pathology of the specimen was unremarkable.

Dr. Claudius Amyand was an English surgeon in the 18th century who first described an appendix within the inguinal canal. Since that time, many have described findings of the appendix in many different types of hernias, including de Garengeot (femoral hernia), and obturator hernias. In spite of the rarity of Amyand’s hernia, we were unable to identify any description of the discovery of Amyand’s hernia during an interval appendectomy.

11.200 General Surgery
Reversal of Ileostomy Using Laparoscopic Assistance
Ahmed Khan Sangrasi, FCPS, Abdul Aziz Laghari, FRCS, Altaf K. Talpur, FCPS, Mujeeb Rehman Abbasi, FRCS, Javaid Naeem Qureshi, FRCS, Naushad A. Shaikh, FCPS
Liaquat University of Medical & Health Sciences, Jamshoro, Sindh, Pakistan (all authors).

Objective: Exteriorization of the bowel is a social stigma, and patients face many physical and psychological problems. Ileostomy is quite common in the third world, and the standard open approach for closure of an ileostomy carries significant morbidity. This study was done to observe the benefit of minimally invasive surgery in an attempt to reduce morbidity and mortality in this group of patients.

Patients and Methods: All patients who were previously exteriorized in our emergency unit and came for reversal after about 3 months were included. Three ports were placed at appropriate sites, depending on the location of the previous laparotomy incision. Adhesiolysis was done laparoscopically, and bowel was freed up to the ileo-cecal junction. Stoma was mobilized and brought out through the same wound; hand-sewn end-to-end ileo-ileal anastomosis was done. Operative and postoperative variables were recorded and analyzed.

Results: A total of 32 patients, 23 men and 9 women with mean age of 42.1 years underwent laparoscopic-assisted reversal of ileostomy. The procedure was completed in 29 patients; 3 (9.3%) patients were converted to laparotomy. Mean operative time was 110 minutes (range, 80 to 150), mean estimated blood loss was 150mL (range, 90 to 185). Mean hospital stay was 7.5 days. There were no major complications except intestinal obstruction in 1 patient (3.1%). Mean follow-up was 18 months. There was no operative mortality.

Conclusion: Laparoscopic-assisted reversal of ileostomy is feasible and safe with low morbidity and mortality. Along with all the benefits of minimally invasive surgery, it saves many patients from having a second laparotomy. 

11.201 General Surgery
Management of  Peritonitis by Minimally Invasive Surgery
Ahmed Khan Sangrasi, FCPS, Abdul Aziz Laghari, FRCS, Mujeeb Rehman Abbasi, FRCS, Altaf K. Talpur, FCPS, Javaid Naeem Qureshi, FRCS, Naushad A. Shaikh, FCPS
Liaquat University of Medical and Health Sciences, Jamshoro, Sindh, Pakistan (all authors).

Objective: Laparoscopy has gained clinical acceptance in many subspecialties in the last decade. Conventional open surgery for peritonitis carries significant morbidity and mortality. This study was done to extend and evaluate benefits of minimally invasive surgery in this subset of patients.

Methods: All diagnosed and hemodynamically stable patients were included in this study after initial resuscitation. All procedures were performed with the patient under general anesthesia, by using 3 standard ports at appropriate sites according to pathology. Patients were treated either laparoscopically or with laparoscopic assistance after diagnosis. Operative and postoperative data were collected and analyzed.

Results: Ninety-two patients with peritonitis underwent diagnostic and therapeutic laparoscopy. Mean patient age was 46.5 years. Twenty-four patients were diagnosed with perforated duodenal; in 14 (58.3%) of these patients, laparoscopic suture repair was done and in 10 (41.6%) a small upper midline incision was made, and the perforation was repaired. Of 32 patients with perforated appendix, 25 (78.1%) underwent laparoscopic appendectomy, while in 7 (21.8%) perforation was dealt with by laparoscopic assistance. Of 14 patients with ileal perforation, 6 (42.8%) with minimal contamination received laparoscopic suturing, while in 8 (57.1%) perforated loop was brought out by making a small window, and the perforation was closed. All 22 patients with pelvic sepsis needed aspiration of pus and peritoneal lavage. Only one patient died postoperatively, and 2 (2.1%) patients developed fistula. Six (6.5%) patients developed port-site infection.

Conclusion: Laparoscopic management is a viable and safe surgical option for properly selected patients with peritonitis due to different pathologies.

11.202 Gynecology
An Analysis of Phase II and Phase III Procedures of Radiofrequency Volumetric Thermal Ablation of Symptomatic Fibroids
Donald I. Galen, MD
Reproductive Science Center of the San Francisco Bay Area, San Ramon, California, USA.

Objective: To review phase II and phase III treatments of symptomatic fibroids using laparoscopic radiofrequency volumetric thermal ablation.

Methods: Retrospective, multicenter clinical analysis of 206 consecutive cases of ultrasound-guided radiofrequency thermal ablation of symptomatic fibroids was conducted under 2 phase II studies/2 sites (n=69) and 1 phase III study/11 sites (n=137). Descriptive and exploratory, general trend, and matched-paired analyses were applied.

Results: All procedures in both studies were performed laparoscopically on an outpatient basis in university hospital clinic surgery centers or in office-based operating rooms. From baseline to 12 months in the phase II study: mean transformed symptom severity scores improved from 53.1 to 5.5, P<.001 (n=53); health-related quality-of-life scores improved from 48.8 to 95.7, P<.001 (n=53); mean uterine volume decreased from 213.9 cm³ to 138.1 cm³, P<.001 (n=53); and reported heavy-to-very-heavy bleeding decreased from 78.9% to 1.9%, P<.001 (n=53). Patients returned to normal activity in a median of 4 days (range, 1 to 11). Device-related adverse events were <3%. In the phase III study, 25% of patients have been followed for 12 months. Patients returned to normal activity in 7 to 10 days. Peri-procedural device-related adverse events were <4%. Despite enrollment requirement for subjects to have completed childbearing, 3 pregnancies occurred out of the 206 patients.

Conclusions: Radiofrequency volumetric thermal ablation provides a minimally invasive and uterine-sparing procedure with rapid recovery, significant reduction in uterine size, significant reduction or elimination of fibroid symptoms, and significant improvement in quality of life. Further results from the phase III study are pending follow-up and regulatory reporting. 

11.203 Gynecology
Robotic-Assisted Hysterectomy: Initial Two-Year Experience at a Community Hospital
A. J. Panagiotakis, DO, L. R. Bruck, MD
Stamford Hospital, Department of Obstetrics and Gynecology, Stamford, Connecticut, USA (all authors).

Objective: Robotic-assisted hysterectomy for benign and malignant cases is a rapidly emerging application of the robotic platform. To assess the benefits of this technology in treating gynecologic patients, a critical review of outcomes is required. The purpose of our study is to report the initial 2-year experience at Stamford Hospital, a community based hospital.

Methods: This was a prospective database review of all robotic-assisted hysterectomies performed between October 2008 and January 2011 in a northeastern United States community hospital. Analysis was carried out on operative times, hospital length of stay, estimated blood loss, and operative complications.

Results: From October 2008 to January 2011, 136 robotic-assisted laparoscopic hysterectomies were performed. Ninety-three were for benign and 43 were for malignant conditions. The mean operative time (skin incision to closure) was 209 minutes, mean estimated blood loss was 59.1mL, and mean hospital length of stay was 1.8 days. Complications included a single case of bleeding requiring blood transfusion and subsequent uterine artery embolization, 1 case of bowel injury during morcellation, 2 cases of vaginal cuff dehiscence, 1 reoperation for bleeding at the vaginal cuff site, 1 case of lymphocele, and 1 readmission for ileus.

Conclusion: The current literature suggests that there is a decrease in complications when robotic hysterectomy is utilized. Our study showed that this minimally invasive approach to hysterectomy is feasible in a community hospital setting with a complication rate that is lower than reported for open, vaginal, and laparoscopic procedures. We believe that robotic-assisted hysterectomy should be considered for most patients when required.

11.205 Gynecology
Stump Appendicitis in the Adult Population

Karina Gotliboym, Roy Sandau, DO, Adeshola Fakulujo, MD, Alex Gandsas, MD
Department of Surgery, UMDNJ – School of Osteopathic Medicine. Stratford, New Jersey, USA (all authors).

Objective: Our objective is to present 2 cases of stump appendicitis, a rare surgical emergency. Stump appendicitis is a delayed complication following incomplete appendectomy.

Methods: A chart review of 1874 laparoscopic appendectomies between January 2005 and December 2010 was conducted.

Results: During the period described above, 2 cases of stump appendicitis were identified. Both patients underwent re-laparoscopic appendectomy with resolution of the symptoms.

Conclusion: Stump appendicitis should be part of the differential diagnosis of any patient complaining of right lower quadrant pain with a previous surgical history of appendectomy. Failure to diagnose and delay of treatment may result in stump perforation and intraabdominal sepsis. This report emphasizes technical and anatomical aspects of proper removal of an inflamed appendix and how this complication can be prevented.

11.207 Urology
Quality and Outcomes of Robotic Lymphadenectomy for Prostate Cancer in Obese and Morbidly Obese Patients
Daniel Mulligan, MD, Ronney Abaza, MD
Robotic Urologic Surgery, Department of Urology, Ohio State University Medical Center & James Cancer Hospital, Columbus, Ohio, USA (all authors).

Objective: Robotic prostatectomy (RALP) is feasible in obese patients with body mass index (BMI) ≥30kg/m², but some have shown increased operative times and complications. We offer RALP regardless of weight and routinely perform pelvic lymph node dissection (PLND). We assessed ability to perform PLND in obese and morbidly obese patients (BMI≥40kg/m²) by evaluating nodal yield and positivity.

Methods: We reviewed RALP procedures by a single surgeon (RA) between February 2008 and October 2010. Extended PLND was performed for high-risk cancers and limited PLND in all others. Outcomes were compared for BMI<30, 30-39, and ≥40kg/m².

Results: Mean BMI among the 819 patients was 30kg/m² (range, 18 to 52) with 421 with BMI<30kg/m², 358 obese, and 40 morbidly obese, and no difference among groups in proportion of high-risk patients. Mean total operative time was 148min, 157min, and 178min for normal, obese, and morbidly obese patients, respectively (P<.05). Estimated blood loss was 109mL, 128mL, and 156mL (P<.05) with a transfusion rate of only 0.4% and none in the morbidly obese group. Mean hospitalization was 1 day in all 3 groups. Mean nodal yields were 9.6, 9.9, and 10.6 nodes for normal, obese, and morbidly obese patients (P=NS). Extended PLND was performed in 18%, 19%, and 15% with mean yields of 16.7, 15.3, and 16.5 nodes, respectively (P=NS). Node positivity was identified in 5.2%, 6.7%, and 12.5% (P=NS). Complications of PLND occurred in 2%, 2%, and 5%, which were mostly symptomatic lymphoceles.

Conclusions: Robotic PLND can be performed with equal efficacy in obese and morbidly obese patients.

11.208 Urology
Impact of Transition to Early Unclamping in Robotic Partial Nephrectomy
Daniel Mulligan, MD, Ketul Shah, MD, Ronney Abaza, MD
Robotic Urologic Surgery, Department of Urology, Ohio State University Medical Center & James Cancer Hospital, Columbus, Ohio, USA (all authors).

Objective: Minimizing warm ischemia time (WIT) during robotic partial nephrectomy (RPN) reduces renal injury, but adequate renorrhaphy prevents bleeding and urine leak. Early unclamping (EU) of the renal artery before completing renorrhaphy reduces WIT in laparoscopic partial nephrectomy. Robotics may also reduce WIT, but the impact of adding EU to RPN is unknown. We evaluated the impact of transitioning to routine EU by comparison with traditional renorrhaphy completion under ischemia.

Methods: We reviewed 104 RPNs by a single surgeon (RA) excluding 27 off-clamp resections and one with renal arterial cold perfusion, leaving 34 EU and 42 non-EU procedures. Of the initial 62 of 104 procedures, EU was used only 4 times after which it became routine when clamping. Procedures with and without EU were compared.

Results: There was no difference between groups in mean age, BMI, ASA score, or preoperative creatinine. Mean tumor size was higher for EU at 4.1cm (range, 1.6 to 11) vs. 3.2cm (range, 1.3 to 5.9) as was R.E.N.A.L. nephrometry score at 8.6 (range, 6 to 11) vs. 7.4 (range, 4 to 10) and frequency of collecting system entry (68% vs. 48%). Nevertheless, mean WIT was shorter with EU (P=.03) at 14.6 minutes (range, 7.5 to 27.3) vs. 17.2 minutes (range, 9.5 to 30.0). There was no difference in mean blood loss, operative time, or postoperative creatinine. No EU patient experienced urine leak, hemorrhage, positive margin, or required transfusion.

Conclusions: Despite increasing size and complexity of tumors, transition to EU did not increase complications. Although WIT reduction was not substantial, EU allowed more complex RPN with uniformly <30min of WIT and an average of 15min.

11.209 Urology
Safety of Enoxaparin Thromboprophylaxis in Robotic Prostatectomy
Benjamin Gibson, MD, Ronney Abaza, MD
Ohio State University Medical Center & James Cancer Hospital, Columbus, Ohio, USA (all authors).

Objective: Perioperative heparin for thromboprophylaxis in prostatectomy is controversial. Recent literature suggests that thrombotic events after robotic prostatectomy (RALP) are rare enough that prophylaxis may be inadvisable given the potential effect on blood loss, transfusion rate, and re-explorations. We assessed our experience with perioperative enoxaparin thromboprophylaxis with RALP.

Methods: We reviewed the outcomes of 879 patients who underwent RALP with lymphadenectomy by one surgeon (RA) over 35 months. All received 40mg of enoxaparin before surgery and daily until discharge, except 4 patients given standard heparin due to renal function. We analyzed perioperative outcomes, including blood loss, thrombotic events, blood transfusions, hospital stay, and re-operation for bleeding.

Results: Mean blood loss was 118mL (range, 10 to 400cc). Twelve patients had a previous history of deep vein thrombosis (DVT). Four patients (0.5%) developed symptomatic thrombosis within 30 days, including 2 with DVTs and 2 with pulmonary emboli (PE). Of these thrombotic events, one with PE had a history of DVT, and the other PE patient had received heparin. One patient had superficial thrombosis and 2 had DVTs diagnosed beyond 60 days after surgery. None required reoperation for bleeding, and only 4 (0.5%) required transfusion within 2 weeks after surgery. With 99.1% discharged on the first postoperative day, 3 of 8 patients required longer hospitalization due to bleeding with up to 3-day stays. 

Conclusion: In our series, use of enoxaparin thromboprophylaxis was safe. Although the rate of thrombosis was low, routine prophylaxis did not appear to increase the rate of adverse outcomes compared with other contemporary series.

11.210 Urology
Causes for Readmission After Routine Overnight Stay Following Robotic Prostatectomy
Achal Modi, MD, Robert Bahnson, MD, Ronney Abaza, MD
Ohio State University Medical Center & James Cancer Hospital, Columbus, Ohio, USA (all authors).

Introduction: One-day hospitalization is typical after robot-assisted laparoscopic prostatectomy (RALP) and, while possible, may not be as uniform with open prostatectomy. We analyzed how uniformly we applied overnight stay after RALP and reasons for readmissions or unscheduled visits to confirm if a 1-day stay was appropriate.

Methods: Over 35 months beginning February 2008, 879 patients underwent RALP with lymphadenectomy by one surgeon (RA), after excluding 21 patients unable or unwilling to consent. Patient characteristics and length of stay were analyzed as well as unscheduled visits and readmissions.

Results: Mean age, BMI, operative time, and blood loss were 61yrs, 30kg/m², 154min, and 118mL, respectively. Five underwent salvage RALP for radiation failure. Of 879 patients, 871 (99.1%) were discharged home on postoperative day one (POD#1). Of those discharged on POD#1, 42 (4.8%) were readmitted for any cause within 90 days of surgery, of which 23 (2.6%) were within 30 days, and 5 (0.6%) were within 7 days. Another 28 had an emergency or unscheduled clinic visit within 7 days, with only 3 (0.3%) for reasons other than urinary retention after catheter removal (23 patients) or catheter occlusion (2 patients). Reasons for readmission within 7 days included one each with ileus, anemia, urine leak, unrecognized rectal injury, and C. difficile infection.

Conclusions: One-day stay is possible in almost all RALP patients with infrequent readmissions, reflecting reasonable discharge decision-making. Causes of readmission were highly variable with most unscheduled visits for urinary retention. While overnight stay is possible with open surgery, the high consistency in RALP with infrequent readmissions may represent an advantage.

11.211 Urology
Do Nomograms Accurately Predict Nodal Positivity with Extended Lymphadenectomy for High-Risk Prostate Cancer?
Ryan Novak, PharmD, MD, Hugh J. Lavery, MD, Ronney Abaza, MD
Robotic Urologic Surgery, Department of Urology, Ohio State University Medical Center & James Cancer Hospital, Columbus, Ohio, USA (all authors).

Objective: Nomograms are often used before prostatectomy to predict likelihood of nodal involvement and determine need for lymphadenectomy. Commonly used nomograms are not based on extended pelvic lymph node dissection (ePLND) and may therefore underestimate lymph node positivity (LN+) in higher-risk patients. We assessed the predicted versus actual LN+ rate after ePLND during robotic prostatectomy.

Methods: All robotic prostatectomy procedures with ePLND performed by a single surgeon (RA) between February 2008 and December 2010 were reviewed. Indications for ePLND included PSA≥10, Gleason≥8, stage≥cT3a, and >50% of biopsied tissue involved by tumor, or a combination of these. Predicted LN+ was calculated from preoperative characteristics using the Partin and MSKCC nomograms and compared with observed LN+ on pathology. Patients were stratified by nomogram-predicted risk for LN+ of <5%, 5% to 10%, and >10%.

Results: A total of 155 patients underwent ePLND with median PSA of 6.9ng/mL (range, 1 to 114.5). Overall mean yield was 15 nodes with LN+ identified in 38 patients (24.5%). Sufficient clinical data were available for 135 patients for Partin and 130 patients for MSKCC nomogram calculations. The median Partin and MSKCC nomogram-predicted rates of LN+ were both 6%. For Partin nomogram-predicted probability of LN+ of <5%, 5% to 10%, and >10%, observed LN+ rates were 12.5%, 28.6%, and 31.8%, respectively. For MSKCC nomogram-predicted probability of LN+ of <5%, 5% to 10%, and >10%, observed LN+ rates were 10.9%, 25.5%, and 35.1%, respectively.

Conclusions: Commonly used nomograms underpredicted nodal disease in patients with higher-risk prostate cancer undergoing ePLND. Nomograms should be used with caution in these patients to avoid inappropriately omitting lymphadenectomy.

11.212 Gynecology
The Classic Pudendal/Pelvic Block: An Innovative Way to Reduce the Need for Diagnostic Laparoscopy
Maurice K. Chung, MD, Cherie W. Chung, Shannon Armbruster, Lisa M. Chung
The University of Toledo College of Medicine, Toledo, Ohio, USA (all authors).

Objective: To determine the efficacy of pelvic/pudendal nerve blocks (PNB) in treating chronic pelvic pain (CPP) patients with pudendal neuralgia and interstitial cystitis/painful bladder syndrome (IC/PBS).

Methods: This was a prospective cohort study of 46 women from April 2008 to August 2010 presenting with CPP who qualified for diagnostic laparoscopy but were evaluated through an alternate algorithm. Patients were diagnosed with IC/PBS through a positive Potassium Sensitivity Test and pudendal neuralgia through a sensory pinprick test for perineodynia and pressure test for the "Valleix phenomena." 43 patients completed intravesical therapy with some symptom relief, but without adequate pain improvement. All patients were treated with transvaginal PNBs containing a 20cc mixture of 1% lidocaine, 0.5% Marcaine, and 20mg triamcinolone. Treatment was evaluated through PUF, AUA, and ICSI questionnaires.

Results: After PNBs, 33(72%) patients reported improvement. The patients’ mean PUF, AUA, and ICSI scores dropped 26.7% (P=1.1E-05), 26.0%(P=1.6E-03), and 32.4%(P=3.3E-06), respectively. This corresponded to a subjective improvement of 75% of their symptoms.

Conclusion: The pudendal nerve provides mixed innervations to the bladder, pelvic floor muscles, and genitals. Previous studies have shown that in CPP patients, up to 76% have IC/PBS, 88.5% have pudendal neuralgia, and 69.8% have both. By putting the CPP patient through our alternate algorithm to treat their pelvic pain, we eliminated the need for invasive diagnostic laparoscopy. Following intravesical therapy, PNBs should be considered the next line of treatment for those patients without significant relief. PNBs are an effective, minimally invasive treatment option for pudendal neuralgia that may also reduce the symptoms of IC/PBS.

11.214 General Surgery
A Ten-Year Follow-Up: Outcomes of Percutaneous Endoscopic Gastrostomy Tube Placement in Malnourished Patients
Sammy D. D. Eghbalieh, MD, Mackenzie L. Bear, MSC, Kenneth R. Ziegler, MD, Babak Eghbalieh, MD, Giang T. Bui, BS, Andrew Ferrante, Michael S. Ajemian, MD
Saint Mary’s Hospital, Waterbury, Connecticut, USA (Drs. S. Eghbalieh, Bear, Bui, Ferrante, Ajemian).
Yale University School of Medicine, New Haven, Connecticut, USA (Drs. S. Eghbalieh, Bear, Ziegler).
UCSF-Fresno Department of Surgery, UCSF Medical Education Program, Fresno, California, USA (Dr. B. Eghbalieh).

Introduction: Percutaneous endoscopic gastrostomy (PEG) tube is widely used in patients of all age groups who require alternative nutritional support. However, the use of PEG tubes has become a controversial issue particularly among the geriatric population residing in nursing homes who suffer from severe dementia. Grant and Rudberg showed that the majority of these patients failed to achieve any meaningful improvement in nutritional status, functional status, or subjective benefit after the placement of PEG. This study hypothesizes that malnourished patients experience a higher number of post-PEG tube placement complications.
 
Methods: This was a retrospective chart review of 427 subjects from January 2000 through August 2010 at a community based teaching hospital. Mean age was 75 years old. Nutritional status was measured by preoperative albumin levels. Albumin levels were defined as normal ≥3.51g/dL, mildly malnourished ≥3.01 to 3.50g/dL, moderately malnourished ≥2.51 to 3.00g/dL, and severely malnourished ≤2.50g/dL. Post-PEG tube placement complications that required tube replacement either percutaneously or operatively were analyzed. 
 
Results: Ten percent of patients (38/380) had postoperative complications, which required replacement of the gastrostomy tube. 89% of these patients (34/38) were malnourished. Severely malnourished patients (25/38) were found to have the most complications, compared to moderately malnourished (4/38) and mildly malnourished (5/38) patients, respectively (P<0.05).
 
Conclusions: Malnourished patients have a significantly higher rate of complications requiring gastrostomy tube replacement compared to patients with adequate preoperative nutritional status. We recommend that malnourished patients receive nutritional support via other means (ie, naso-enteric feeding tube or hyperalimentation) prior to PEG tube placement.

11.215 Gynecology
Treatment of Focal Endometriosis and Adenomatoid Tumors
L. Mettler, I. Alkatout
Department of Obstetrics & Gynecology, University Hospitals Schleswig-Holstein, Campus Kiel, Germany (all authors).

Introduction: From the surgical point of view, hysterectomy is currently considered the most and only effective treatment for symptomatic adenomyosis besides laparoscopic excision. We wish to present laparoscopic excision of adenomyosis and 2 cases of adenomatoid tumors.
 
Methods: Endometriotic lesions were biopsied, and the pathohistological outcome was compared to the suspected diagnosis in 216 patients. We performed histological diagnosis either by ultrasound-guided needle biopsy or by endometrial resection or by needle biopsy during laparoscopy (n=15). Two women of reproductive age with uterine adenomatoid tumors.
 
Results: In black and red lesions, including endometriomas, the suspected diagnosis was confirmed in >90% of cases. In white lesions, however, the diagnosis could only be verified in 53% of cases. In all patients, we performed a laparoscopic resection partly combined with a resectoscopic resection in cases of menorrhagia. Tumor excision is difficult, because of the missing capsule. Adenomatoid tumors need to be cut out of the myometrium, but there is no clear plane of cleavage.
 
Conclusion: Purely morphological criteria are not sufficient for the diagnosis of endometriosis, but these laparoscopic findings are still our most reliable points of reference. Vaginal ultrasound combined with transabdominal or transvaginal myometrial biopsy established the diagnosis of adenomyosis in 15 infertility patients. The proper laparoscopic handling of these tumors is crucial, because malignancy exclusion is only possible by histologic workup

11.217 General Surgery
Routine Use of a Drain After Laparoscopic Cholecystectomy Is Not Needed
Shaikh Abdul Razaque, FCPS, Prem Kumar, FRCS, Nandlal FCPS
Liaquat University of Medical and Health Sciences (LUMHS), Jamshoro Sindh, Pakistan (all authors).

Objective: To observe the effects of omitting routine drainage after laparoscopic cholecystectomy, with respect to hospital stay, morbidity, and mortality.

Methodology: This comparative observational study was carried out in the department of surgery, at Liaquat University of Medical and Health Sciences, Jamshoro, from January 2009 to December 2009. The study comprised 100 cholelithiasis patients, undergoing laparoscopic cholecystectomy, with 78 females and 22 males, with a mean age of 37.86 years. The patients were divided into 2 groups, 50 in each group, with respect to the use of a drain, and the effects regarding hospital stay, morbidity, and mortality were observed.

Results: Avoiding drainage after laparoscopic cholecystectomy has decreased the postoperative hospital stay of patients from a mean of 3.58 days to 2.1 days (with a statistically significant difference of 0.000 using the Student t test). Moreover, the use of a drain has also been found to be associated with significant drain-site pain and discomfort.

Conclusion: Routine placement of a drain after laparoscopic cholecystectomy not only prolongs the postoperative hospital stay of patients but it also leads to drain-site pain and discomfort.

11.218 General Surgery
Single Port Laparoscopic Harvest of Omental Flap for Reconstruction of Refractory Ulceration of the Irradiated Chest Wall and Pulmonary Fistula
Keiichi Fujino, MD, PhD, Ryuichi Azuma, MD, Kaoru Kumano, MD, Yusuke Matsumoto, MD, Hironori Tsujimoto, MD, PhD, Yuji Tanaka, MD, PhD
National Defense Medical College, Japan (all authors).

Introduction: Single-port laparoscopic surgery (SPLS) is a new surgical technique that decreases postoperative scarring and parietal trauma. SPLS might be an ideal procedure for scarless surgery. We report a case of omental harvest in which the SPLS technique was applied.

Case report: A 65-year-old woman underwent left standard radical mastectomy with radiation therapy in May 1986. Twenty-three years later, she developed infected ulceration of the irradiated supraclavicular region and pulmonary fistula. Because of infection and bleeding, an urgent debridement was performed with resection of the clavicula and the first rib. And then, we performed an operation to close the refractory ulcer after receiving written informed consent in December 2010. Operative procedure: A 3-cm transumbilical incision was made, and the abdominal cavity was accessed. The port device for SPLS was made with a wound retractor and a surgical glove. We dissected the greater omentum along with the right gastroepiploic vessel through the umbilical incision. And then, a free graft of omentum was used to fill the huge cavity of radiation-induced ulcer. The vessel of the omental flap was microscopically anastomosed. The omentum flap was covered with a split thickness skin graft. The duration of the SPLS procedures was 90 minutes. The patient was discharged after 14 days and had dramatic general improvement in her clinical condition with regards to optimal wound healing and disappearance of air leakage.

Conclusion: Single-port laparoscopic omentoplasty is more cosmetically acceptable and less invasive than laparotomy in obtaining the omentum.

11.220 General Surgery
Earlier Thoracoscopic Exploration Was Essential for Better Complicated or Multiple Loculated Thoracic Empyema
Seok-Whan Moon, MD,  Deok-Gon Jo, MD,  Young-Jo Sa, MD, Si-Young Choi, MD
Department of Thoracic and Cardiovascular Surgery, Holy Family Hospital, St.Paul Hospital, The Catholic University of Korea, Seoul, Korea (all authors).

Background: Early diagnosis and treatment is essential for properly treating acute pleural empyema or early stage exudative pleural effusion; otherwise, it may sometimes necessitate more invasive procedures, particularly when complicated with multi-loculated or space-occupying pleural lesions (SOL). Recently, thoracoscopy has been increasingly considered as a safe and excellent approach. However, when and how to treat SOL in acute pleural empyema with thoracoscopy is not well known.

Methods: We retrospectively reviewed our surgical experiences in terms of duration of preoperative symptoms and outcomes.

Results: From May 1996 to December 2010, 69 patients (mean age, 40.9±22.1 years old) were first medically treated and transferred for surgery. Of 40 (58%) patients, 26 underwent tube thoracostomy drainage, 16 image-guided catheter drainage, and 4 intrapleural fibrinolytics. Thoracoscopic techniques included simple pleural adhesiotomy in 11 and extensive decortication in 58. There was no operative mortality or severe complications, with the exception of one death not related to the operation. According to postoperative chest X-ray findings, surgical outcomes were classified into 3 categories: class I (n=32, no or minimal pleural lesion), and class II (n=26, elevated diaphragm or incomplete reexpansion of lung), and class III (n=11, persistent or recurrent SOL). The multivariate regression model showed that surgical outcome was mostly influenced by duration of preoperative symptoms (P=.02), not severity of SOL (P=.09).

Conclusion: Earlier thoracoscopic surgery is essential for better surgical outcomes, particularly when the acute empyema is associated with multiple SOL.

11.221 Urology
An Intracorporeal Knotting Technique for Single Port Surgery
Philippe Grange, MD, Paul Rouse, DM, Amrith Rao, FRCSUrol, Anya Kypke
King’s College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom (all authors).

Objective: Laparoendoscopic Single Site (LESS) urological procedures are gaining popularity across the globe. Most reported case-series of reconstructive LESS urological procedures, such as partial nephrectomy and pyeloplasty, describe the use of an additional needle driver port to accomplish an intracorporeal knot. We will demonstrate in this video a step-by-step guide to achieve complete intracorporeal knotting technique making pure LESS a possibility.

Methods: Initial design and proof of concept was on a box trainer. A single-port device along with the needle holder and a grasper are used to demonstrate the knotting technique. Along with the video, illustrations that can be easily understood will be shown. We have since applied this technique for complex LESS reconstructive procedures.

Results: Step-one of the knotting involves the needle within the needle holder to rotate 3 times in a clockwise direction. This forms 3 loops around the shaft of the needle holder. Needle is then transferred across to the grasper, which frees the needle-holder to grasp the short end of the suture. The knot is tightened by a push and pull method as opposed to the horizontal method that can be achieved in the traditional multiport laparoscopic technique. The knot is further secured by repeating the above steps in the opposite direction.

Conclusion: We demonstrate an innovative easy-to-learn intracorporeal knotting technique that can be utilized without the need for any additional port. This technique will be useful for pure LESS procedures, such as partial nephrectomy, pyeloplasty, and other reconstructive urological operations.

11.222 Gynecology
Comparison of Robotic Surgery Versus Laparoscopic Surgery for Benign
Gynecological Conditions: A Beginner’s Perspective
Radha Syed, MD
Staten Island, University Hospital, New York, New York, USA

Background and Objectives: Recent conversion from laparoscopic to robotic (da Vinci SI) surgery made it evident that there are several parameters that are vastly different between the 2 types of procedures for the same surgery. This study compares the obvious and the remote.

Methods: Ten consecutive robotic hysterectomy/myomectomy/bilateral salpingo-oophorectomy cases were compared with 10 consecutive laparoscopic procedures cases by the same surgeon. OR time, blood loss, recovery, complications, and untoward events were compared amongst others. There were no conversions to laparotomy.

Results: The OR time was prolonged due to the learning curve required for “docking” of the robot. This time declined with the later cases. The actual procedure time was reduced considerably.

Conclusion: The procedure of robotic surgery is prolonged primarily due to “docking” blues. Once the OR team and the surgeon are trained together to target this area, this time will decline but will never be eliminated. Further research needs to be done to minimize the size of the robot and simplify the “docking” experience.

11.223 Gynecology
Comparison of Essure™ Hysteroscopic Sterilization versus Adiana™ Hysteroscopic Sterilization in an Office-Based Surgery
Radha Syed, MD
Staten Island, University Hospital, New York, New York, USA

Background and Objectives: Both Adiana™ and Essure™ are procedures designed for hysteroscopic sterilization and are very conducive to Office-Based Surgery. Their techniques are similar, but the method used for cornual occlusion differs vastly. OR time, ease of surgery, pain, recovery, and follow-up for tubal occlusion were compared between these 2 procedures performed by the same surgeon for sterilization.

Methods: Fifteen consecutive cases of Essure hysteroscopic sterilization performed in the office were compared to 15 consecutive Adiana procedures. Both were performed as per manufacturer’s guidelines. The categories of comparison included time of procedure, the ease (qualitative), recovery time, pain, other postoperative symptoms, complications, and hysterosalpingogram (3 months postop) for tubal occlusion.

Results: The number of cases compared did not reach a significant enough proportion to make a scientific conclusion. However, there is a trend that shows that the Adiana procedure, though very easy to perform and shorter in duration, has a slightly higher incidence of tubal patency, as per 3-month hysterosalpingogram.

Conclusion: The author concludes that a change in the design of Adiana to increase the size of the matrix used in the interstitial portion of the tube may improve the occlusion rate. Both procedures in experienced hands lend themselves elegantly to efficient tubal occlusion surgery with minimal side effects or complications.

11.224 Urology
Radiation-Free Percutaneous Nephrolithotomy (PCNL) in Pregnancy
Mohammad Mehdi Hosseini, Alireza  Aminsharifi, Abdoreza Haghpanah, Sepideh Sefidbakht, Zahra Zare, Sedighe Amooee
Urology, Radiology and Obstetric/Gynecology Departments,Shiraz University of Medical Sciences, Shiraz, Iran (all authors).

Background and Objective: Urolithiasis during pregnancy is a clinical dilemma due to potential risks for mother and fetus. Management of these patients needs a multidisciplinary approach, including urologist, obstetrician, anesthesiologist, radiologist, and perinatalogist. We report our experience with percutaneous nephrolithotomy (PCNL) in pregnancy under complete ultrasound guidance.

Materials and Methods: Our cases were 9- and 14-week pregnant women referred by their obstetrician, because of fever, urinary symptoms, several episodes of severe right flank pain, and gross hematuria. Both were in their second pregnancy and had a history of renal stone. One patient had a history of 1 PCNL session for the left kidney 2 years earlier. Ultrasonography (US) revealed normal alive fetuses, right-sided severe hydronephrosis, and multiple stones measuring 7mm to 21mm, the largest one in ureteropelvic junction causing obstruction. Patients refused any temporary procedure, such as a JJ stent or percutaneous nephrostomy and even abbreviated excretory urography. They completed and signed the consent for PCNL with US guidance. So, a second US was performed by an expert radiologist, and the patient underwent PCNL with US guidance.

Results: Patients are in a stone-free state based on a sonogram 2 weeks after operation. No complications occurred in the perioperative period. Both patients are symptom-free, one with the fetus in good condition at 13 weeks of pregnancy, and the other now with a 3-month old boy.

Conclusions: PCNL with US guidance seems to be a safe and effective modality for large symptomatic stones during pregnancy without any radiation to the mother or fetus.

11.225 Gynecology
Retrospective Study of Single Incision Laparoscopic and Vaginal Hysterectomy in 95% of all Hysterectomies Performed in 2010
Jessica Ybanez-Morano, MD, MP
Department of Obstetrics and Gynecology, Wheeling Hospital, Wheeling, West Virginia

Background: The second most common surgery in US women is hysterectomy with approximately 600,000 done yearly. Minimally invasive techniques are advocated. In 2003, rates cited were abdominal 66%, vaginal 22%, and laparoscopic, which has increased to only 12%, with a combined minimally invasive rate of 34%. This retrospective analysis of 114 hysterectomy cases performed at our institution in 2010 shows 95% minimally invasive approaches of single incision laparoscopic and vaginal hysterectomy. It is feasible in cases in spite of perceived contraindications, such as obesity, prior surgeries, and nulliparity. This analysis reviews patient demographic characteristics, surgical outcomes, complication rates, and improved convalescence.

Methods: A retrospective review of all hysterectomies (114) performed in 2010 was done to determine trends and outcomes. Analysis included the hysterectomy approach, patients’ age, BMI, uterine specimen weight, EBL, and OR time. The 3 hysterectomy approaches evaluated included abdominal (6), vaginal (53), and single incision laparoscopy (55). 

Results: Hysterectomy approach rates were as follows: 5% abdominal, 47% vaginal, and 48% single incision laparoscopic, with a combined minimally invasive rate of 95%. Surgical time averaged 30 minutes with vaginal, 57 minutes with laparoscopic, and 52 minutes with the abdominal approach. EBL was 81cc for vaginal hysterectomies, 183cc for single incision laparoscopic hysterectomies, and 192cc for abdominal hysterectomies. More comparisons were made with BMI, age, and uterine specimen weights.

Conclusions: Minimally invasive surgery approaches for hysterectomies are feasible in the majority of patients with benign gynecological conditions. 

11.226 General Surgery
Simple Solution for Giant Postgastric Bypass Internal Hernia
Nicole A. Kissane, MD, Ozanan R. Meireles, MD, Gill Pratt, PhD, Janey S. A. Pratt, MD
Massachusetts General Hospital, Boston, Massachusetts, USA (Drs. Kissane, Meireles, Pratt).
Olin College, Needham, Massachusetts, USA (Dr. Pratt).

Introduction: Abdominal pain, nausea, and vomiting are concerning symptoms after gastric bypass. The cause of this pain is broad and often nondescript. Life-threatening causes must be promptly identified, as many necessitate emergent surgical intervention.

Methods/Procedures: A 38-year-old female 1-year postlaparoscopic retrocolic gastric bypass presented to our bariatric center with an escalating history of intermittent epigastric abdominal pain, nausea, and vomiting. Physical examination was benign, laboratory findings were normal, and CT scan and abdominal ultrasound were unremarkable. Due to the persistent nature of the symptoms and high clinical concern, the patient was taken to the operating room for diagnostic laparoscopy.

Results: Intraoperative findings included a massive transmesocolic internal hernia. The hernia comprised the patient's entire small bowel. There was no obstruction and minimal adhesions. All bowel was viable and easily reduced. The large perimeter of the 15cm mesenteric defect was identified and linearly closed with a running 2-0 silk suture. Postoperative course was unremarkable with advancement of clear diet on the first postoperative day and subsequent discharge.

Conclusions: Giant transmesocolic small bowel herniation in postretrocolic gastric bypass patients presents as intermittent, chronic pain that is transient in nature, and oftentimes is not identified on routine imaging or laboratory studies. Diagnostic laparoscopy facilitates hernia reduction, and simple closure of the defect provides resolution of symptoms.

11.227 Pediatrics
Single-Port Transumbilical Cholecystectomy in Children: Renaissance of a First-Generation Laparoscopic Instrument
J. R. Ramirez, D. K. Magnuson, F. G. Seifarth

Introduction: In adults, different single-port techniques have been successfully implemented for laparoscopic cholecystectomy. Most of the commercially available devices still require considerable incisions that make them less attractive for the application in children. The search for improved cosmetics, practicability, and cost efficiency has directed us to the revival of a first-generation laparoscopic instrument, the 10-mm Storz telescope. The combination of this single-port instrument with portless percutaneous graspers allowed us to develop a virtually scarless and safe procedure in children.

Methods: We describe the operative technique: the clipless and scarless single-port cholecystectomy. One 11-mm umbilical port incision and 2 abdominal stab incisions for percutaneous 2-mm Minilap gator graspers (Stryker) are necessary. The 10-mm Storz Hopkins telescope with 6-mm working channel is used. The dissection is carried out with bariatric length instruments. Division of both the artery and cystic duct are performed with LigaSure.

Discussion: Single-port surgery has gained great popularity among surgical specialists. In pediatric surgery, it remains controversial due to relatively large port sites and limited intracorporeal working spaces. Inspired by a first-generation single-port instrument, we developed the above-described novel technique. By using the 5-mm LigaSure device, the entire operation can be accomplished through a 5-mm working channel. Limiting is the 0° optic that can be compensated for by proper retraction.

Conclusion: This procedure has been shown to be safe, cost effective, and with virtually scarless results. It was successful in children and nonobese, adult-sized teenagers.

11.228 Urology
Examining the Comparative Outcomes of a Progressive Training Program in Robotic-Assisted Laparoscopic Prostatectomy Within a Veterans’ Affairs Population
Seth A. Cohen, MD, Jeffrey Woldrich, MD, Wassim Bazzi, MD, Kerrin Palazzi-Churas, MPH, Christopher J. Kane, MD, Kyoko Sakamoto, MD
Division of Urology, Department of Surgery, University of California at San Diego and Veterans’ Affairs San Diego Healthcare System, San Diego, California (all authors).

Introduction: As robotic laparoscopic surgery becomes a defined skill set, questions remain as to how to share this technology with novice robotic surgeons. In this study, we sought to determine whether surgeons participating in a progressive training program had similar perioperative outcomes.

Methods: Ninety robotic-assisted laparoscopic prostatectomies were performed under the auspices of a progressive training program. A single experienced robotic surgeon provided extended mentorship during the first 30 cases for a novice robotic surgeon. The initially novice surgeon went on to amass her own case series during the following 30 cases. In the last 30 cases, she was then the senior mentor for urology residents, operating as the primary surgeons. Independent t test, chi-square, ANOVA, and Kruskal-Wallis tests compared the demographics and operative outcomes in these patient populations.

Results: The patient populations (n=30), were similar in age (P=.867), clinical T-stage (P=.247), and D’Amico Risk Group (P=.076). There was a statistically significant difference in the median preoperative prostate specific antigens (PSAs) of these populations (P<.001), with the last 30 patients having the highest median (IQR) preoperative PSA, 8 (range, 5 to 12.8). The last 30 patients also had the largest prostates, 47.8 grams (range, 35.8 to 62.9, P=.044). Estimated blood loss (P=.568), rate of blood transfusion (P=.129), length of hospital stay (P=.075), pathologic T-stage (P=.357), and rate of positive margins (P=.812) were comparable in all groups.

Conclusion: Using this model of progressive training, perioperative outcomes of surgeons, trained under the tutelage of a relatively new robotic mentor, are similar to the outcomes of surgeons trained directly by an experienced robotic mentor.

11.229 Gynecology
Low Incidence of Vaginal Cuff Dehiscence Following Robotic-Assisted Laparoscopic Procedures using Harmonic Energy for Colpotomy
Tyler C. Ford, MD, Audoen Maddock, MD, Daniel C. Kredentser, MD, Timothy J. McElrath, MD, Thomas P. Morrissey, MD, Patrick F. Timmins MD
Department of Obstetrics and Gynecology, Albany Medical Center, Albany New York (Drs. Ford, Maddock).
Women’s Cancer Care Associates, LLC, Albany New York (Drs. Kredentser, McElrath, Morissey, Timmins).

Objectives: To evaluate the incidence of postoperative vaginal cuff dehiscence (POVCD) following robotic-assisted laparoscopic procedures (RALP).

Methods: A retrospective review of the records from a 4-physician gynecologic oncology group was performed to obtain a complete list of robotic procedures where a colpotomy was made. A total of 853 cases were reviewed. All colpotomies were performed with the Harmonic LCS-C5 Ultrasonic Shears. The vaginal cuff was re-approximated in a continuous fashion; 3 surgeons used 3-0 Monocryl, and 1 used 0 Vicryl.

Results: Nine of 853 (1.0%) patients were identified as having a POVCD. Four of the 9 patients had gynecologic malignancy. The mean BMI was 28.9±2.8. Two of the 9 had tobacco exposure, 1 type II diabetes, and 4 used HRT. The trigger event in 4 patients was coitus, for 2 patients it was a bowel movement, and 3 underwent spontaneous dehiscence. Four patients presented with vaginal bleeding and serous drainage, whereas the remainder had bleeding with abdominal pain. One patient presented with small bowel evisceration. All POVCDs were repaired vaginally. There was no significant difference in number of cuff dehiscences per surgeon.

Conclusion: Our incidence rate over 2 and a half years is significantly below that of previous reported values. In all cases, Harmonic energy was used to perform the colpotomy. Previous studies have shown reduced thermal spread of Harmonic energy (0-3mm) when compared to monopolar energy (up to 1cm). We contend that this may be due to less thermal injury with the use of the Harmonic energy source.

11.230 Multispecialty
Better Quality Conduits Using Humidified Gas for Endoscopic Vessel Harvesting for Coronary Artery Bypass Graft Procedures
Douglas E. Ott, MD, MBA, Talley Culclasure, MD, Darian Kameh, MD, Whitney Hartz, CVT
Mercer University School of Engineering, Mercer University, Macon, Georgia, USA (Dr. Ott)
Mercer University School of Medicine, Mercer University, Macon, Georgia, USA (Dr. Culclasure).
Florida Hospital Celebration Health, Medical Laboratory, Celebration, Florida, USA (Dr. Kameh).
Florida Hospital Nicholson Center for Surgical Advancement, Celebration, Florida, USA (Ms. Hartz).
 
Objective: Endoscopic vessel harvesting uses traditional dry, cold carbon dioxide to distend a working space. It is known from laparoscopy that by changing the quality of gas to humidified and warmed, there is less tissue desiccation, inflammatory response, and scaring. A newly developed device, the Vessel Guardian, which humidifies and warms the gas, was evaluated to determine efficacy and compare vessel integrity and morphology with dry, cold gas.
 
Methods: Veins the size of the human saphenous were harvested from 35-kg pigs. Veins were exposed to volumes of gas up to 60 liters under 2 separate conditions following standards for endoscopic vessel harvesting, group 1 traditional dry cold gas and group 2 humidified warmed gas (Vessel Guardian), surgically biopsied and histologically evaluated by hematoxylin and eosin, collagen, and elastin staining by a pathologist blinded to sequence and group.
 
Results: Vessels harvested under dry gas conditions with as little as 6 liters of gas exposure had progressive desiccation of the tunica adventitia and media with up to 14% shrinkage, losing normal endothelial morphology seen as tortuous convolutions resulting from radial constriction and contraction due to collagen and elastin dehydration induced by evaporative desiccation. The humidified, warmed gas group maintained normal size, shape, and morphology at all volumes of gas. 
 
Conclusion: Contraction and constriction occurs when the saphenous vein is harvested using dry, cold gas. Vascular integrity and morphology are maintained when vascular structures are harvested using humidified warmed gas. Prevention of desiccation results in a better quality conduit for coronary artery bypass grafting. 

11.231 Gynecology
Technique for Laparoscopic Retroperitoneal Uterine Vessel Sealing
Taryn Gallo, MD, Masoud Azodi, MD
Yale New Haven Health/Bridgeport Hospital, Connecticut, USA (all authors).

Objective: To demonstrate our technique for robotic-assisted laparoscopic retroperitoneal uterine vessel sealing.

Methods: The da Vinci Surgical System was used to perform robotic-assisted laparoscopic hysterectomy. Two cases are presented that demonstrate our technique for laparoscopic sealing of the uterine vessels when enlarged uteri prevent safe intraperitoneal vessel ligation. Both patients had symptomatic 18-week size myomatous uteri. 

Results: There were no complications. The estimated blood loss for both patients was <150cc. Both patients were discharged home on postoperative day 1. Uterine specimens weighed 790g and 832g, respectively.

Conclusions: When a large uterus or myoma inhibits access to the uterine vessels intraperitoneally, knowledge of pelvic anatomy and proficiency with retroperitoneal dissection can facilitate safe uterine vessel sealing. 

11.232 Pediatrics
Single-Incision Pediatric Endosurgery (SIPES)-Assisted Ileocecectomy for Resection of an NEC Stricture
Richard Keijzer, MD, PhD, Oliver J. Muensterer, MD, PhD,
Division of Pediatric Surgery, Children’s Hospital of Alabama University of Alabama at Birmingham, Birmingham Alabama, USA (all authors).
Department of Pediatric Surgery, University of Manitoba, Winnipeg, Manitoba, Canada (Dr. Keijzer).
Division of Pediatric Surgery, Weill Cornell Medical College, New York, New York, USA (Dr. Muensterer).
 
Background: Single-incision pediatric endosurgery (SIPES) is gaining popularity in many centers, but has not been typically used for operations in premature infants yet.

Materials and Methods: We report the case of a 3-month-old, 25-week premature infant who underwent SIPES-assisted ileocecal resection for an intestinal stricture after previous medically treated necrotizing enterocolitis. A single 1.2-cm incision was made in the umbilicus, and the cecum and ascending colon were mobilized endosurgically to facilitate an extracorporeal resection and anastomosis.

Results: The patient recovered uneventfully, was on full enteral feeds at 6 days, and was discharged home at 15 days after surgery with good weight gain. The procedure left almost no appreciable scar.

Conclusion: SIPES is a reasonable alternative for NEC stricture resection in premature infants. Prematurity should not be considered a contraindication to single-incision endosurgery.

11.233 Pediatrics
Single-Incision Pediatric Endosurgery for Ovarian Pathology
Oliver Muensterer, Martin Lacher, Lena Perger, Charles J. Aprahamian, Carroll M. Harmon

Background and Objectives: Despite being pioneered by gynecologists, single-incision endosurgery has not been widely reported for the treatment of ovarian and adnexal pathology in neonates, children, and adolescents. We describe our initial experience using single-incision pediatric endosurgery (SIPES) for these indications and discuss advantages and drawbacks.

Methods: All children who underwent SIPES with a preoperative diagnosis of ovarian or adnexal pathology were retrospectively reviewed. Data on age, operative time, complications, length of hospital stay, and outcome were collected.

Results: From January 2010 until February 2011, 10 girls (age 1 month to 15.9 years, weight 4.9 to 90 kg) underwent SIPES procedures for ovarian or adnexal diagnoses, including hemorrhagic cysts (n=5), torsion (n=5), tumor (n=2), and parauterine cyst (n=1). The operations included cyst unroofing (n=5), detorsion/oophoropexy (n=3), oophorectomy/salpingo-oophorectomy (n=3), and cyst aspiration (n=1). Operative time was 45±25 minutes, and there were no conversions to conventional laparoscopy or open surgery. Nine patients were discharged within 24h after the procedure. There were no peri- or postoperative complications. Histopathology showed simple hemorrhagic cysts in 5 cases, calcified dystrophic ovarian tissue after previous torsion in 2 cases, and mature teratoma in 1 case.

Conclusion: SIPES is an excellent and scarless alternative to conventional laparoscopy for the treatment of adnexal pathology. Using a single umbilical incision that can be enlarged instead of 3 smaller trocar sites facilitates the resection and extraction of ovarian masses without compromising cosmesis. To avoid rupture and spillage, an endoscopic retrieval bag is mandatory for potential malignancy.

11.234 Urology
Nephrometry Plus: Accounting for Upper Pole and Posterior Location in Assessment Tumors Treated with Laparoscopic and Robotic Partial Nephrectomy
Steven M. Lucas, Matt J. Mellon, John L. Davisson, Luke Ernstberger, Chandru P. Sundaram
Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, USA (all authors).

Objective: We compared the nephrometry score to a scale that includes upper pole and posterior locations in addition to the original nephrometry score. 

Methods: Laparoscopic and robotic partial nephrectomies were reviewed. Nephrometry score was calculated from preoperative images by size, proximity to collecting system, percent exophytic, and position relative to the hilum: low=4 to 5, medium=6 to 7, high≥8. The adjusted nephrometry score adds upper pole (3pts) versus other locations (1pts) and posterior (3pts) versus anterior (1pts). On this scale, tumors were scored as low (6 to 8), medium (9 to 11), and high (12 to 14) complexity lesions.

Results: Fifty-six partial nephrectomies (18 laparoscopic, 38 robotic) were reviewed. Complexity was similar in 66.7%, decreased in 18.5%, and increased in 14.8% using adjusted versus original scores. Correlation between operative time and nephrometry score was 0.278 (P=.042), while adjusted was 0.367 (P=.004). Correlation between warm ischemia time and nephrometry score was 0.436 (P=.002), while adjusted was 0.414 (P=.003). Using nephrometry score, decline in postoperative GFR≥10% occurred in 8/13 patients scored ≥8, and 14/38 scored <8, (P=.121). Using the adjusted score, 8/12 scored ≥12 and 14/39 scored <12 declined in GFR≥10% (P=.060). Two cases converted to radical nephrectomy (1 multifocal disease, and 1 highly complex on both scales), 1 open (low versus intermediate on original versus adjusted scales), and one had a urine leak (highly complex on both scales). 

Conclusion: Adjustment of the nephrometry score to include upper pole and posterior locations resulted in improved correlation with operative time, while both scales were similarly predictive of ischemia time and complications. 

11.235 General Surgery
Laparoendoscopic Single-Site Surgery for Complicated Appendicitis
Fernando Arias, MD, Nubia Prada, MD, Evelyn Dorado, MD, Luis Felipe Cabrera, MD, Natalia Cortés, Alvaro Montenegro
Fundación Santafé de Bogotá, Columbia (Drs. Arias, Prada, Cabrera)
Universidad CES, Medellin, Columbia (Dr. Dorado).
Universidad de los Andes, Bogatá, Columbia (Ms. Cortés).
Universidad Nacional de Colombia, Bogatá, Columbia (Mr. Montenegro).

Objective: Laparoscopic appendectomy has gained acceptance in recent years. There is still controversy regarding its use in complicated appendicitis. To reduce abdominal trauma and improve cosmesis, surgeons have adopted a single-port laparoscopic appendectomy for acute appendicitis. We report our experience using this technique for appendectomy in complicated cases.

Materials and Methods: Forty-six patients with complicated appendicitis who underwent laparoscopic single-site appendectomy between January 2008 and February 2011 were evaluated regarding operative time, intraoperative findings, onset of diet, length of hospital stay, postoperative pain, drain requirement, postoperative complications, and readmissions. A multichannel single port was created using a surgical glove. The procedure was similar to conventional laparoscopic appendectomy.

Results: All procedures were carried out successfully. The most common intraoperative finding was phlegmon in 71% of cases, the mean operative time was 76.9 minutes, with an average in-hospital stay of 41.5 hours. A drain was kept in 66% of the patients; 82% of the patients resumed eating in the first 12 hours after surgery. There were no conversions. One of the patients had a hospital stay of 373 minutes due to a prolonged ileus. Mean postoperative pain was 2.53. One patient attended the emergency room for postoperative pain and was discharged a few hours later with NSAIDs. A superficial surgical site infection was observed.

Conclusion: Laparoscopic single-site appendectomy is a feasible option for select cases. It is associated with shorter hospital stay, reduced abdominal complications, less postoperative pain, and excellent cosmetic result. Additional studies are necessary to define its true benefits. 

11.236 Pediatrics
Surgical Treatment of Ileocolic Intussusception by Single-Incision Pediatric Endosurgery (SIPES)
Martin Lacher, MD, Albert Chong, MD, Oliver J. Muensterer, MD, PhD
Division of Pediatric Surgery, Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, Alabama, USA (all authors).
Division of Pediatric Surgery, Weill Cornell Medical College, New York, New York, USA (Dr. Muensterer).
 
Background and Objective: Several pediatric surgical centers have adapted single-incision pediatric endosurgery (SIPES) for standard operations, such as appendectomy or cholecystectomy. The approach is infrequently used for other indications. We describe our experience with SIPES reduction of ileocolic intussusception.

Methods: Two 9-month-old boys presented with signs of intussusception. The diagnosis was confirmed by ultrasound. Air enema reduction was unsuccessful, prompting transfer to the operating room for surgery. A 1.5-cm longitudinal incision was made in the umbilicus, and a laparoendoscopic single-site trocar was placed. Using a combination of ileal traction and cecal pressure, the intussusception was completely reduced in both cases.

Results: Both operations were completed via SIPES (operative times 28 to 36 minutes). Intraoperatively, a serosal tear of the ileum was noted in the first patient. It was imbricated using 5-0 polyglactin after removing the trocar and exteriorizing the portion of bowel through the umbilicus. The patient recovered uneventfully and was discharged home on full feeds. There were no complications in the second patient. However, recurrent crampy abdominal pain prompted laparotomy on postoperative day 3. No abnormalities or recurrent intussusception were found. The patient recovered and was discharged home 3 days later.

Conclusion: SIPES ileocecal intussusception reduction is a challenging procedure due to the geometric in-line configuration of the instruments and lack of triangulation. Care must be taken not to injure the manipulated bowel, particularly when using traction to reduce the intussuscepted ileum. More experience is necessary before SIPES intussusception reduction can be recommended universally.

11.237 General Surgery
Laparoendoscopic Single Site (LESS) Drainage & Unroofing of Hepatic Cyst
Farhaad C. Golkar, MD, Sharona B. Ross, MD, Harold Paul, BS, Natalie Donn, BS, Kenneth Luberice, BS, Alexander S. Rosemurgy, MD
University of South Florida Division of General Surgery and Tampa General Hospital Center for Digestive Disorders, Tampa, Florida (all authors).

The applications of LESS surgery are growing rapidly, and patients are requesting this emerging approach of minimally invasive surgery with increasing frequency. LESS surgery is safe and is as efficacious as multi-incision laparoscopy with improved cosmesis, reduced pain, and faster recovery time.

This video demonstrates LESS drainage and unroofing of a giant hepatic cyst. A 12-mm vertical incision was made at the umbilicus. A multi-trocar port was placed and four 5-mm trocars were inserted through the port. A 5-mm deflectable tip laparoscope, an ultrasonic dissector, an articulating grasper, and a needle-tip suction device were utilized. The giant hepatic cyst was drained using the needle-tip suction device, and >2 liters of serous fluid were removed. The ultrasonic dissector was then utilized to unroof the cyst in a circumferential manner while avoiding damage to adjacent hepatic parenchyma. The roof of the cyst was extracted via the 12-mm umbilical defect that was closed with an absorbable monofilament suture placed in a figure-of-eight fashion. The skin was approximated with interrupted absorbable suture and a sterile dressing was applied. The patient tolerated the procedure well and was discharged home the same day.

Patient demand for better cosmesis will increase the application of LESS surgery, and laparoscopic surgeons will need to meet patient demands.

11.238 Multispecialty
Vascular Conduit Desiccation Due to Traditional Harvesting Methods as Measured by Bioelectrical Impedance but Preserved by Humidifying and Warming the Gas 
Douglas E. Ott, MD, MBA, Talley Culclasure, MD, Whitney Hartz, CVT
Mercer University School of Engineering, Mercer University, Macon, Georgia, USA  (Dr. Ott).
Mercer University School of Medicine, Mercer University, Macon, Georgia, USA (Dr. Culclasure).
Florida Hospital Nicholson Center for Surgical Advancement, Celebration, Florida (Ms. Hartz).

Objective: Carbon dioxide used for endoscopic vessel harvesting is very dry and cold. It is hypothesized that vascular drying occurs during harvesting and can be mitigated by humidifying and warming the gas as measured by a change in impedance during and as a result of differing harvesting conditions.
 
Methods: Veins the size of the human saphenous vein were harvested from 35-kg pigs. They were exposed to volumes of gas up to 60 liters under 2 separate conditions, group 1 dry and cold and group 2 humidified and warmed, following standards for endoscopic vessel harvesting, and evaluated by bioelectrical impedance measurement to evaluate water content. 
 
Results: Bioelectrical impedance of tissues varies with water content. Vessels harvested under dry gas conditions with as little as 6 liters of gas exposure showed progressive changes in bioelectrical impedance that are associated with dehydration and desiccation and increased progressively over gas volume exposure. No change from original baseline normal impedance measurement was seen in the humidified warmed vessel group. 
 
Conclusion: Changes in bioelectric impedance occur in vessels harvested using traditional dry cold gas. Bioelectrical impedance changes demonstrate that there is dehydration and desiccation to vascular structures when dry cold gas is used. There are no changes seen in vessels harvested using humidified warmed gas. To maintain normal moisture content and prevent vascular dehydration and desiccation humidified warmed gas should be used for endoscopic vessel harvesting.

11.239 Urology
Laparoscopic and Robotic Pyeloplasty Collaborative Group: Is Posterior Transposition of Crossing Vessels Necessary During Minimally Invasive Pyeloplasty?
Steven M Lucas, Chandru P Sundaram, Raymond  J Leveillee, Vincent G Bird, Mohamed Aziz, Stephen E Pautler, Patrick Luke, Peter Erdeljan, J Stuart Wolf Jr, D. Duane Baldwin, Kamyar Ebrahimi, Robert B. Nadler, David Rebuck, Raju Thomas, Benjamin R Lee, Ugur Boylu, Robert S. Figenshau, Ravi Munver, Timothy D Averch, Bishoy Gayed, Arieh L Shalhav, Mohan S Gundeti, Erik P Castle, J Kyle Anderson, Branden G. Duffy, Jaime Landman, Zhamshid Okhunov, Carson Wong, Kurt H Strom
Indiana University,  Bloomington, Indiana, USA (Drs. Lucas, Sundaram).
University of Miami, Miami, Florida, USA (Drs. Leveillee, Bird, Aziz).
University of Western Ontario, Ontario, Canada (Drs. Paulter, Luke, Erdeljan). 
University of Michigan, Ann Arbor, Michigan, USA (Dr. Wolf).
Loma Linda University, Loma Linda, California, USA (Drs. Baldwin, Ebrahimi). 
Northwestern University, Evanston, Illinois, USA (Drs. Nadler, Rebuck).
Tulane University, New Orleans, Louisiana, USA (Drs. Thomas, Lee, Boylu).
Washington University, St. Louis, Missouri, USA (Dr. Figenshau). 
Hackensack University Medical Center, Hackensack, New Jersey, USA (Dr. Munver).
University of Pittsburgh, Pittsburgh, Pennsylvania, USA (Drs. Averch, Gayed). 
University of Chicago, Chicago, Illinois, USA (Drs. Shalhav, Gundeti).
Mayo Clinic Scotsdale, Scotsdale, Arizona,  USA (Dr. Castel).
University of Minnesota, Minneapolis, Minnesota (Drs. Anderson, Duffy).
Columbia University, New York City, New York, USA (Drs. Landman, Okhunov).
University of Oklahoma, Norman, Oklahoma, USA (Drs. Wong, Strom).

Objective: In this multicenter trial, we reviewed patients undergoing either a robotic or laparoscopic pyeloplasty with lower pole crossing vessels to compare outcomes of patients in whom vessels were transposed posteriorly versus those that were not.

Methods: 487 cases from 15 centers had details regarding intraoperative crossing vessels. Posterior transposition was defined as moving the vessels posterior to the anastomosis. Cases performed without posterior transposition were either not transposed or transposed superiorly. Subjective failures were defined as unchanged or worsened pain. Radiographic failures were defined as worsening T1/2 or hydronephrosis on renal scan, CT, or ultrasound. 

Results: 261/487 cases had crossing vessels reported intraoperatively. Of 261 patients, 95 had posterior transposition, 129 did not, and 37 were unknown. Patients who underwent posterior transposition versus those that did not were similar in median preoperative T1/2 (30min for both) and differential renal function (42%, IQR=18, versus 40%, IQR=20, P=.432). Preoperative stenting occurred in 42.9% in the posterior transposition group versus 34.1% in those that did not. Operative time was 225min (IQR=147) for posteriorly transposed cases and 215min for nontransposed cases (IQR=126), P=.572. Subjective failures occurred in 4.5% posterior transposition and 5.0% without (P=.99), while obstruction recurred in 5.9% posterior transposition and 3.8% without (P=.721). Urine leak occurred in 4 posterior and 3 nonposterior, P=.505. Secondary procedures were required in 5.3% with posterior transpositions and 6.2% without posterior transposition, P=.767.

Conclusion: Posterior transposition of crossing vessels is not required for all patients during pyeloplasty and should depend on individual anatomic considerations.

11.240 General Surgery
The Learning Curve of Laparoendoscopic Single Site (LESS)
Fundoplication: Definable, Short, and Safe
Sharona Ross, Lotiffa Colibao, Kenneth Luberice, Natalie Donn, Harold Paul, Farhaad Golkar, Jon Hernandez, Alexander Rosemurgy
University of South Florida Division of Surgery and Tampa General
Hospital Center for Digestive Disorders, Tampa Florida, USA (all authors).

Introduction: Initial reports of laparoendoscopic single site (LESS) fundoplication for GERD suggest excellent symptom resolution and cosmesis. Because of the novelty of this approach, this study was undertaken to determine the “learning curve” for implementing LESS fundoplication.

Methods: 100 patients, 37% male, age 61 years (range, 56±14.8) and BMI 26 kg/m² (range, 26±3.2), underwent LESS fundoplications. The operative times, placements of additional trocars, conversions to open operations, and complications of 25-patient cohorts were compared to establish a learning curve. Data are reported as median, mean±SD, where appropriate.

Results: The median operative times and complications did not differ among cohorts. Additional trocars were placed in 27 (27%) patients, of whom 18 (67%) were in the first 25-patient cohort (P<.05). Patients undergoing LESS fundoplication experienced dramatic relief in the frequency and severity of all symptoms of reflux across all cohorts equally (P<.05), particularly for heartburn and regurgitation, without causing dysphagia.

Conclusions: LESS fundoplication ameliorates symptoms of GERD with unapparent scarring. Notably, fewer operations required additional trocars after the first 25-patient cohort, and patient selection became more inclusive (eg, more “redo” fundoplications), while operative times and complications remained unchanged. The learning curve of LESS fundoplication is definable, short, and safe; patients will seek LESS fundoplication, because of efficacy and superior cosmetic outcome; surgeons will need to meet this demand.

11.241 General Surgery
Laparoscopic Splenectomy for a Traumatic Splenic Injury Following a Screening Colonoscopy
S. Abunnaja, MD, L. Panait, MD, S. Macaron, MD
Saint Mary’s Hospital, Waterbury, Connecticut, USA (all authors).

Background: Colonoscopy is a widespread diagnostic and therapeutic procedure. The most common complications include bleeding and perforation. Splenic rupture following colonoscopy is rarely encountered, and is most likely secondary to traction on the spleno-colic ligament. Exploratory laparotomy and splenectomy were most commonly used in the reported cases in the literature. We describe the case of a patient with this potentially fatal complication treated by laparoscopic splenectomy.
 
Methods: A 62-year-old female underwent screening colonoscopy with polypectomy at the cecum, descending colon, and rectum. The patient developed abdominal pain and a syncopal episode immediately following the procedure. Clinical, laboratory, and imaging findings were suggestive of massive hemoperitoneum.
 
Results: Diagnostic laparoscopy was emergently performed and revealed grade IV splenic laceration and hemoperitoneum. Laparoscopic splenectomy was completed safely. The patient recovered uneventfully after the operation.
 
Conclusion: Splenic rupture after colonoscopy is a rare but dangerous complication. A high index of suspicion is needed to recognize it early. Awareness of this potential complication can lead to optimal outcome. To our knowledge, this is the first report in the literature of laparoscopic splenectomy as a successful treatment of splenic rupture following colonoscopy.

11.242 General Surgery
The Effect of Product Safety Courses on the Adoption and Outcomes of Laparoendoscopic Single Site (LESS) Surgery
Alexander Rosemurgy, MD, Natalie Donn, BS, Harold Paul, BS, Michelle Vice, Michael Albrink, MD, Sharona Ross, MD
University of South Florida Division of General Surgery and Tampa General Hospital Center for Digestive Disorders, Tampa, Florida, USA (all authors). 

Introduction: As technology in surgery evolves, industry is inevitability involved to promote interest in, utilization of, and application of their products. This study was undertaken to evaluate industry supported product safety courses in LESS surgery using the metrics of surgeon adoption, safety, and surgeon perception of LESS surgery.

Methods: 248 surgeons attended LESS surgery courses that involve didactic lectures, videos, operation observation, collaborative learning, and simulation. With IRB approval, surgeons were queried before and immediately after the courses to assess surgeon attitudes towards LESS surgery. Distant to the courses, surgeons were contacted repeatedly to complete questionnaires.

Results: Before the courses, 82% of surgeons undertook >10 laparoscopic operations per month. Immediately after the courses, 83% of surgeons felt prepared to undertake LESS surgery. Distant to the courses, 77% had adopted LESS surgery, primarily cholecystectomy. 73% felt that operating room observation was the most helpful learning experience. 88% of surgeons added an additional trocar(s) 0% to 20% of the time. Complications with LESS surgery were noted by 12%. Advantages of LESS surgery were felt to be better cosmesis (58%) and patient satisfaction (39%); disadvantages were risk of complications (37%) and more difficult operations (25%). 78% of surgeons felt LESS surgery was an advance in surgery.

Conclusion: After multifaceted product safety courses, safe adoption of LESS surgery and industry’s return on investment is unknown; despite aggressive attempts at follow-up, only a minority of surgeons provided feedback. We must critically evaluate the introduction of new technology in surgery.

11.243 General Surgery
Our Experience in Minimally Invasive Treatment of Liver Hydatidosis
C. Duta, MD, PhD, F. Lazar, Prof Dr Med, C. Lazar, MD, D. Barjica, MD, M. Papurica, MD, C. Balasa, MD
Surgical Clinic 2, University of Medicine and Pharmacy, ""Victor Babes"", Timisoara, Romania (all authors).

In the last decades, the treatment of liver hydatidosis has changed. Open surgery remains the option for complicated liver hydatid cysts. For simple uncomplicated hydatid cysts, there are very good therapeutic alternatives: medical treatment alone, echo-guided puncture, laparoscopic treatment. The authors review a series of 244 cases of hepatic hydatidosis treated with surgery from 1996 to 2007, and compare the results of conservative and surgical procedures. 158 patients (64.8%) were treated with the PAIR (puncture, aspiration, injection, respiration) technique. 34 patients (13.9 %) were treated laparoscopically, and in 52 cases (21.3 %) we performed conventional surgery for complicated liver hydatid cysts. The patients were successfully treated, and the mean follow-up time was 54.7±15.5 months involving ultrasound, computed tomography, and serology tests that showed no local recurrence or spread of the disease. The patients treated by PAIR were cured in 95.6% of cases, and those treated laparoscopically were cured in 90.5% of cases. In 6 cases from the first group, it was necessary to perform another puncture up to 2 years later, because the cavity did not disappear. In 4 patients, we performed a classical operation for 2 hepatic abscesses and 2 biliary fistulas. Two patients from the laparoscopic lot developed one subhepatic abscess and one biliary fistula that required open surgery. In conclusion, the procedure for the treatment of hepatic hydatidosis should be tailored to the needs of each patient, depending on the size, location and complications of the cyst and high surgical risk should be avoided in view of the benign nature of the disease. 

11.244 Pediatrics
Treatment of Malrotation by Single-Incision Pediatric Endosurgical (SIPES) Ladd Procedure
Charles J. Aprahamian, MD, Martin Lacher, MD, Oliver J. Muensterer, MD, PhD

Division of Pediatric Surgery, Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, Alabama, USA (all authors).
Division of Pediatric Surgery, Weill Cornell Medical College, New York, New York, USA (Dr. Muensterer).
 
Background and Objectives: The laparoscopic Ladd procedure for malrotation is one of the most intricate procedures in pediatric surgery. So far, a single-incision laparoscopic approach has not been reported. We report on 2 patients who underwent a single-incision pediatric endosurgical (SIPES) Ladd procedure.

Methods: Two patients (ages 15 months and 10 years) presented with intermittent vomiting. An upper gastrointestinal contrast study demonstrated malrotation without volvulus. They were scheduled for a SIPES Ladd procedure.

Results: Operative times were 57 and 61 minutes. Proprietary laparoendoscopic single-site trocars were used in both cases. In the second patient, a 2-mm percutaneous grasper was added to retract the gallbladder and liver and improve exposure of the duodenum. There was no conversion to triangulated laparoscopy or open surgery, and no intra- or postoperative complications were noted. The patients were discharged 5 and 4 days after the operations on full feedings. On follow-up 2 and 4 weeks later, the scars at the base of the umbilicus had healed well and were hardly visible.

Conclusion: A SIPES Ladd procedure is technically feasible with good postoperative results. Because of the complexity of the operation, it should be attempted only by pediatric surgeons with advanced laparoscopic skills and extensive SIPES experience.

11.245 General Surgery
Laparoscopic Cholecystectomy and Bile Duct Injuries
Kafetzis Ilias, MD, PhD, Gatsoulis Nikolaos, MD, PhD, Roukounakis Nikolaos, MD, PhD, Dimas Spiridon, MD, PhD, Mouziouras Vasilis, MD, Andromanakos Nikolaos, MD PhD
Department of Surgery, General Hospital “Athens Polyclinic”, Greece (Drs. Ilias, R. Nikolaos, Spiridon, Vasilis, A. Nikolaos).
Department of Surgery, District General Hospital of Corfu, Greece (Dr. G. Nikolaos).
 
Background and Objective: The most serious complication is bile duct injury that occurs in 0.4% to 1.4% of laparoscopic cholecystectomies (LC). The number of LC performed yearly is about 750,000. The aim of this study was to present the incidence of common bile duct injuries and our experience with the complications during LC. Additionally, we discuss the determination of the exact point of injury and therapy, regarding the worldwide experience.

Methods: From 2004 to 2008, 1390 LC were performed at both hospitals. Twenty 1.48%) were converted to open during the laparoscopic procedure, so they are excluded from this study. 62 patients (4.52%) left the hospital the same day (outpatients) and 1096 the day after surgery (1-day surgery). The majority were women (67.2%, 921 pts), and the rest men (32.8%, 449 pts) with a mean age of 56.4 years. In 14 (1.02%) patients, a bile duct injury occurred during LC. All injuries were identified 1 day to 2 days after the main operation. Based on the Stransberg classification, 9 were A, 2 were E, and the other 3 were D.

Results: The 4 patients with descending cholorrhea were treated conservatively. Nine patients had an ERCP and a stent in the bile duct, with good results. In 3, a Roux-en-Y was performed after 1 month (for 1pt) and 1 year, respectively.

Conclusions: The bile duct injuries augmented during LC declined after the learning curve. After an injury, specialists must cooperate to solve the problem.

11.246 General Surgery
Laparoscopic Ventral Hernia Repair with Posterior Rectus Sheath Component Separation
Nicholas Verdura, MD, Timothy Kuwada, MD
Carolinas Medical Center, Charlotte, North Carolina, USA (all authors).

Objective: Bridging mesh underlay is a common technique for laparoscopic ventral hernia repair. Closure of the defect prior to mesh placement may improve abdominal wall function, decrease seroma formation, and reduce diastasis. Component separation (CS) is a technique for increasing abdominal wall mobilization. Endoscopic CS with division of the external oblique is a well-described technique. We present our technique for laparoscopic posterior rectus sheath component separation (LPRSCS).
 
Methods and Procedures: A 49-year-old female presented with a recurrent, symptomatic ventral hernia 6 months after a combined laparoscopic gastric bypass and ventral hernia repair with a synthetic bioabsorbable mesh. An elective repair was performed. To allow for tension-free closure of the defect, the rectus sheaths were incised vertically. The closed defect and posterior rectus sheaths were reinforced with a bridging underlay mesh.
 
Results: The procedure was completed in 1.5 hours. Estimated blood loss was 50cc. The patient had an uneventful postoperative hospital course and was discharged home on POD 3. At 2-month follow-up, there was no evidence of recurrence or seroma. 
 
Conclusions: Compared to endoscopic external oblique division, our technique is simple and does not require an intermuscular dissection. This reduces the risk of seroma and tissue devascularization. This technique facilitates primary closure of fascial defects prior to mesh underlay and is ideal for smaller hernia defects. Additional studies are required to further define the role and benefits of LPRSCS.
 

11.248 General Surgery
Laparoscopic Sleeve Gastrectomy as an Outpatient Procedure
Brian Quebbemann, MD, Justin Braverman, MD, Channing Chin, MD
The N.E.W. Program, Newport Beach, California, USA (all authors).

Background: Outpatient surgery has become increasingly common. Bariatric surgery is currently at its plateau, with approximately 205,000 cases performed annually. Gastric banding is the only primary bariatric surgery accepted as an outpatient procedure in select patients. We present data that supports laparoscopic sleeve gastrectomy as an outpatient surgery.

Methods: A retrospective review was performed on 77 consecutive patients who underwent laparoscopic sleeve gastrectomy from 2008 through 2010 in a private practice community setting. Outpatient was defined as a patient who was discharged <6 hours after the procedure. Demographics, comorbidities, perioperative complications, emergency room visits, and readmissions were recorded for patients who had outpatient surgery.

Results: 29/77 gastrectomies were selected to be performed on an outpatient basis. Mean age was 46; 82% were women. Average weight (pounds) and body mass index were 234 and 38, respectively. Major comorbidities were hypertension 6 (21%), obstructive sleep apnea 5 (17%), diabetes mellitus 4 (14%), asthma 2 (7%), and coronary artery disease 2 (7%). There were no mortalities or major complications (bleeding, leak, abscess, obstruction, deep venous thrombosis/pulmonary embolism) in the outpatient group. Minor complications were dehydration 2 (8%), chest pain 1 (3%), and anxiety 1 (3%). This resulted in 4 (14%) emergency room visits. All these patients were discharged without admission. One (3%) hospital readmission for pancreatitis occurred on postoperative day 21.

Conclusions: Laparoscopic sleeve gastrectomy, as in gastric banding, can be performed safely in the outpatient setting with appropriately selected patients. Further studies need to be done to determine patient selection criteria.

11.249 General Surgery
Mesh vs Fixation of Injection Ports for Laparoscopic Gastric Band Procedures: Our Institution’s Experience
  

Danielle Giesler, MD, Valerie Sams, MD, Gregory Mancini, MD, Matthew Mancini, MD
University of Tennessee Medical Center, Knoxville, Tennessee, USA (all authors).
 


Objective: The objective of this study was to compare 2 methods of gastric band port implantation: port with mesh sutured to the base and mechanical fixation of the port to the fascia using sutures or clipping devices. We hypothesized that port implantation with mechanical fixation results in a lower complication rate.

Methods: This was a single institution retrospective study involving 97 patients who underwent laparoscopic gastric band placement from December 2007 to October 2010. The Center’s database, hospital records, radiographic records, and operative reports were reviewed. We compared the complications defined as patients requiring radiographic guidance to access port and patients requiring reoperation for repositioning between those who had ports mechanically fixed (n=66) versus those who had mesh sutured to the base of the port (n=31).
 


Results: The follow-up was a minimum of 1 year. A total of 5 patients (5%) had complications as defined above. No patient who underwent port fixation using suture or a clipping device required reoperation. However, 2 (3%) of these patients did have mal positioning requiring radiographic guidance for filling. Of the patients who had ports placed with mesh sutured to the back of the port and no fixation, 3 (10%) had complications; 2 required reoperation for repositioning and 1 required radiographic guidance for filling. 
 


Conclusions: Reoperation for repositioning and needing radiographic guidance to access ports inflicts inconvenience and risk to patients undergoing laparoscopic gastric band placement and band adjustment. Based on our review, mechanical fixation portends fewer complications to the patient and specifically lower risk for reoperation for repositioning.

11.250 Gynecology
Reducing Cost Associated with Total Laparoscopic Hysterectomy
Katharine Esselen, MD, MBA,
Marcela Del Carmen, MD, Annekathryn Goodman, MD, John Schorge, MD,
David Boruta, MD,
Whitfield Growdon, MD
Massachusetts General Hospital, Division of Gynecologic Oncology,
Harvard Medical School, Boston, Massachusetts, USA (all authors).

Objective: Total laparoscopic hysterectomy (TLH) is a common surgery performed by gynecologic oncologists. Given the healthcare financial crisis, it is essential to understand the cost drivers associated with TLH to facilitate cost containment.

Methods: A retrospective review identified 259 patients who underwent TLH at our institution from 2007 through 2010. 56 patients were excluded (47 robotic surgeries, 2 conversions to laparotomy, 7 incomplete billing data). Clinical factors and surgical data were correlated with billing data using univariable and multivariable linear regression models.

Results: Indications included benign conditions (n=48), uterine cancer (n=140), cervical cancer (n=10), and ovarian cancer (n=5). Median age and BMI were 53 (range, 26 to 88) and 30 (range, 18 to 73), respectively. Mean hospital days were 1.5 (range, 0 to 12). 119 women underwent TLH±BSO; 84 also had laparoscopic lymph node dissection. The mean operating room (OR) time was 253 minutes (range, 127 to 446), and nonoperative OR time averaged 61 minutes (range, 11 to 142). Frozen sections were sent in 80 cases. Complications were nerve injury (1.4%), vaginal cuff dehiscence (1.0%), and urinary tract injury (1.0%). Total billed costs ranged from $27,108 to $95,307. Surgical complexity (P<.001), operative time (P<.001), hospital days (P<.001), and complications (P<.028) were independently associated with increased charges.

Conclusion: Costs billed were elevated by surgical complexity, complications, hospital days, and increased OR time. Hospital stay and OR time are modifiable; thus, efforts should be made to decrease OR time and promote convalescence outside the hospital.

11.251 General Surgery
Does Liver Disease Predict Postoperative Weight Loss After Gastric Bypass Surgery?
Nicholas Verdura, MD, H. James Norton, PhD, Dimitris Stefanidis, MD, PhD, Keith Gersin, MD, Timothy Kuwada, MD
Carolinas Medical Center, Charlotte, North Carolina, USA (all authors).
 
Background: Nonalcoholic fatty liver disease (NAFLD) is associated with obesity. However, the pathophysiology of NAFLD is multi-factorial, and the degree of liver disease is not directly proportional to weight. Metabolic factors likely play a role in NAFLD. Similar metabolic factors may also affect weight loss after bariatric surgery. This study investigates the relationship between the degree of NAFLD and weight loss after gastric bypass surgery. 



Methods: Data were prospectively collected on a consecutive, single-surgeon series of laparoscopic gastric bypass procedures with routine intraoperative liver biopsy from 2006 through 2009. Hepatic steatosis (percentage) and the presence of nonalcoholic steatohepatitis (NASH) were recorded. Steatosis was categorized into 4 groups (<5, 5 to 33, 34 to 66, >66%). Weight loss 12 months after surgery was recorded as total weight loss (TWL) and excess percentage weight loss (%EWL). Data analysis included ANOVA, t test, and Pearson correlation. 



Results: 119 patients met inclusion criteria with follow-up at 1 year. There was no significant difference in weight loss between the 4 steatosis groups. The Pearson correlation demonstrated negligible correlation between steatosis and TWL or %EWL at 12 months following surgery (r=0.06 and -0.10, respectively). The t test illustrated no difference between NASH and 12 month %EWL (P=.995).



Conclusion: To our knowledge, this is the largest study investigating the relationship between NAFLD and postoperative weight loss. Our study did not reveal any association between NAFLD (either steatosis or NASH) and weight loss after gastric bypass surgery. Further studies are needed to identify metabolic derangements that may influence NAFLD and weight change.

11.252 Urology
Clinical Series of Transverse Versus Vertical Camera Port Incisions: Predictive Factors of Incisional Hernias, Their Incidence Reduction, and Improved Cosmesis by Adopting Transverse Incisions
Thomas E. Ahlering , Shawn Beck, Douglas Skarecky, Kathy Osann, Reina Juarez
University of California Irvine, Department of Urology, Orange, California, USA (all authors).
  
Objective: Robot-assisted radical prostatectomy (RARP) historically uses a vertical midline camera port incision to extract the prostate. We examined the incidence and predictive factors of incisional hernias (IH) and propose a simple modification to reduce IHs.
 
Methods: Of 900 consecutive RARPs, the initial 735 had a vertical (V) and subsequent 165 transverse (T) incisions. Two methods were used to identify IH; clinic visits noted in the prospective database and screening via E-mail. We compared baseline factors between vertical IH and IH-free cohorts. Maximum scar width was recorded in 178 consecutive men presenting to our clinic: V (n=107) and T (n=71).
 
Results: IH occurred significantly more often following vertical incision (5.3% vs. 0.6%, P=.005). Using E-mail respondents, IH rates in vertical incisions are estimated as high as 16.7% (18/108) or as low as 3.3% (21/627) based on clinic follow-up. In univariate analyses, baseline age, IIEF-5, prostate weight, Bother score (all P≤.05), and BMI (P=.058) were associated with increased risk of IH. After adjusting for baseline factors in multivariable logistic regression, the relative odds for IH with vertical vs. transverse incision were 11 (95% CI 1.5-82). Average maximum scar width was reduced from 5.5mm to 2.0mm (P<.0001).
 
Conclusions: In this sample population, the vertical IH rate is estimated potentially as low as 3.3% or as high as 16.7%. In multivariable analysis, higher BMI and larger prostate size significantly increased the risk of hernias. Transverse incisions dramatically reduced the rate of IH and maximum scar width. IH rates varied significantly by reporting method.

11.254 Urology
Robotic-Assisted Laparoscopic Bilateral Ureterolysis with Omental Wrap
J. K. Jhaveri, P. Chhabra, S. Chan, J. Kashanian, R. Shabsigh, D. Silver
Division of Urology, Department of Surgery, Maimonides Medical Center, Brooklyn New York, USA (all authors).

Background and Objectives: Technological advances coupled with innovative surgical approaches have propelled robotic-assisted laparoscopic surgery to the forefront of minimally invasive surgery. Creative tactics are now used to treat diseases that were predominantly treated with open approaches. We present our initial experience with robotic-assisted laparoscopic bilateral ureterolysis with omental wrap.

Methods: A 43-year-old male presented with complaints of flank pain, nausea, and vomiting over 4 days. History was significant for hypercholesterolemia and hypertension without prior surgery. A diagnostic workup revealed anemia with serum creatinine of 16mg/dL. CT scan of the abdomen/pelvis demonstrated moderate bilateral hydroureteronephrosis and a retroperitoneal mass encasing both ureters. IR biopsy revealed fibrosis, and ureteral stents were placed; nadir creatinine was 1.8mg/dL. Four weeks later, the patient returned to the OR and was placed in a modified right lateral decubitus position (30-degree angle), and pneumoperitoneum was established. Four ports were placed, one 12-mm camera port, two 8-mm robotic ports, and one 5-mm assistant port. The right distal ureter was identified and dissected free from the fibrous tissue. An omental wrap was interposed between the fibrous tissue and ureter to maintain proper position. This procedure was then repeated on the left side.

Results: Operative time was 220 minutes, blood loss was 25mL, and the patient had an uncomplicated postoperative course. He was discharged on postoperative day 3, stents were removed 4 weeks later, and follow-up creatinine was stable.

Conclusions: In the carefully selected patient, robotic-assisted laparoscopic bilateral ureterolysis with omental wrap is a feasible and effective treatment for idiopathic retroperitoneal fibrosis.

11.255 General Surgery
Is Weight Loss Correlated with Race in Laparoscopic Adjustable Gastric Banding (LAGB) Patients? Yes.
David A. Nguyen, BA, BS, Grace J. Kim, BA, Carson D. Liu, MD
Skylex Advanced Surgical, Inc. Santa Monica, California, USA (all authors).

Introduction: Variability of percentage excess weight loss (%EWL) in LAGB patients can be influenced by many preoperative factors, such as sex, race/ethnicity, and age. We hypothesize that race/ethnicity is an important predictor in the postoperative weight loss.

Methods: A retrospective analysis of 428 patients using electronic medical records was performed to assess differential %EWL for patients across a period of 3 years after band implantation, with an average of 1.53 years for all groups and no significant differences between ethnic groups. Average initial BMI was 42±5. ANOVA was used to analyze data, and P<.05 was considered significant.

Results: Compared to %EWL in the Caucasian group (N=209)(66.33±2.4%), %EWL achieved by patients in the Asian group (N=23) was 88.6%±7.7% (P=.44), followed by the Hispanic group (N=123) 50.2%±2.3% (P=1.5E-05), and the African American group (N=73)44.4%±3.3% (P=9.96E-06). Furthermore, the average number of adjustments was 6 for the Caucasian group, 5 for the Asian group, and 4 for the Hispanic and African American groups.

Conclusion: Our findings suggest that weight loss outcome for LAGB may be related to a patient’s race/ethnicity. Patients in the Caucasian group have significantly more adjustments than any other group. Excess weight loss is correlated with race and number of adjustments as well as willingness to diet and exercise. Cultural differences in types of food and exercise are also important in weight loss outcome. 

11.256 General Surgery
Peritoneal Entry During Transanal Endoscopic Microsurgery: Paving the Way for Natural Orifice Surgery
Anjali S. Kumar, MD, MPH, Shafik Sidani, MD, Kirthi Kolli, MBBS, Lee E. Smith, MD
Section of Colon and Rectal Surgery, Washington Hospital Center and Department of Surgery and Georgetown University School of Medicine, Washington, DC, USA (all authors).
 
Introduction: We aimed to understand the impact of peritoneal entry during transanal endoscopic microsurgery (TEM). Strategies and techniques used during minimally invasive transanal resections must be well understood to avoid conversions to radical procedures like proctectomy.
 
Methods: We retrospectively reviewed data from a prospective database of over 325 patients who underwent TEM over a 20-year period. Operative and oncologic variables were reviewed using STATA9. We selected video clips of technically challenging cases that resulted in peritoneal entry that best illustrated the complication.
 
Results: Mean tumor diameter was 3.2cm, and mean distance from anal verge was 8cm. Twenty-five percent of lesions were in an anterior position, and 2% of patients had circumferential lesions. Full-thickness resection was performed in 240 patients. Peritoneal entry occurred in 9 patients (2.8%) and was significantly associated with an anterior tumor location (P<.02). In our early experience with peritoneal entry, we converted one patient's procedure to a transabdominal resection. In subsequent cases, we used preoperative rectal washout, watertight closure, and perioperative antibiotics with no significant postoperative sequelae. One patient experienced the dreaded complication of missed peritoneal entry, which resulted in laparotomy, washout, and diversion. However, since the TEM resection had been adequate, we still averted the need for pelvic dissection and proctectomy. Patients in the supine position may benefit from simultaneous laparoscopy to conduct a pneumoinsufflation leak-test.
 
Conclusion: Controlled or anticipated peritoneal entry during transanal resection ultimately paves the way for natural orifice transluminal endoscopic surgery and natural orifice specimen extraction.

11.257 General Surgery
Comparison of Single-Incision Flexible Laparoscopic and Traditional Four-Port Cholecystectomy
Joaquin A. Rodriguez, MD, Robert O. Carpenter, MD
Texas A&M Health Science Center, College Station, Texas, USA (all authors).

Objective and Hypothesis: We sought to determine the feasibility of cholecystectomy using a single-incision flexible laparoscopic platform (SPIDER). The secondary objective was to compare SPIDER cholecystectomy with traditional 4-port cholecystectomy.

Methods and Procedures: We performed a retrospective chart review comparing experience with the initial 15 SPIDER with 15 traditional cholecystectomies. Data obtained include age, sex, BMI, cause of biliary disease, and duration of surgical procedure, time to dismissal from end of surgical procedure, VAS pain score, and administration of intravenous pain medication.

Results: SPIDER cholecystectomy procedure time was 134.5 minutes, time to dismissal was 177.5 minutes, VAS averaged 3.5, and 1.19mg of hydromorphone (Dilaudid) was administered per patient. Traditional cholecystectomy procedure time was 86.5 minutes, time to dismissal was 165.9 minutes, VAS pain score was 3.85, and hydromorphone administered was 1.86mg per patient.

Conclusions: SPIDER cholecystectomy allows safe single-port access cholecystectomy. Operative times are longer than times of traditional cholecystectomy. Prospective randomized studies are needed to determine differences in postoperative pain between the 2 procedures.

11.258 General Surgery
Surgical Management of Gastrojejunal Anastomotic Ulcers after Roux-en-Y Gastric Bypass  
Keneth N. Hall, MD, Darlinda Minor, BA, Collin E. M. Brathwaite, MD, Alexander Barkan, MD
Division of Minimally Invasive and Bariatric Surgery, Department of Surgery
Winthrop University Hospital, Mineola, New York, USA (all authors).

Objective: The objective of this study was to evaluate the experience of patients treated surgically at our institution for anastomotic ulcers after gastric bypass.

Methods: We conducted a retrospective review of patients treated between November 2008 and January 2011 at our Center of Excellence designated bariatric surgery program. 

Results: Fourteen patients were identified. Ten patients had laparoscopic gastric bypass, 4 open, and most (12) had it elsewhere. All patients (mean age 44.9 years; range, 36 to 66) were female. The mean body mass index was 31.5kg/m² (range, 19.4 to 53.1). Major presenting complaints were epigastric pain (12), melena (1), and hematemesis (1). Alcohol (10; 71%) and tobacco (7; 50%) consumption were common. Eleven patients (79%) were on proton pump inhibitors when they presented. Surgery involved mainly minimally invasive techniques with 8 patients undergoing laparoscopic resection, 5 robotic resection, and 1 open. Two patients had erosion into the liver, and one had penetrated into the pancreas. No postoperative leaks or deaths occurred. For laparoscopic and robotic groups, average postoperative length of stay was 3.0 and 3.2 days, respectively. Laparoscopic postoperative complications included anastomotic stricture in (1) and persistent pancreatic fluid drainage (1). In the robotic group, 1 patient had a recurrent ulcer. 

Conclusions: Robotic surgery and laparoscopy may be safely used as effective modalities in treating gastrojejunal ulcers after Roux-en-Y gastric bypass, even in patients with prior open surgery. The contribution of sex to intractability needs to be investigated. 

11.259 General Surgery
Cholecystectomy Using a Single-Incision Flexible Laparoscopic Platform
Joaquin A. Rodriguez, MD, Robert O. Carpenter, MD
Texas A&M Health Science Center, College Station, Texas, USA (all authors).

Objective and Hypothesis: There is an increasing trend in general surgery to perform procedures through reduced access ports. SILS is a popular technique, but many surgeons are not comfortable with the “sword fighting” or would like a platform that more closely resembles traditional laparoscopic cholecystectomy. Single-incision flexible laparoscopy combines single-incision access to the abdominal cavity with true intraabdominal triangulation. The objective is to determine the feasibility of performing cholecystectomy with a single-access flexible laparoscopic platform (SPIDER), to delineate critical steps, point out differences in technique from traditional laparoscopic cholecystectomy, and illustrate difficulties in the performance of SPIDER cholecystectomy. We hypothesize that the intraabdominal triangulation provided with the SPIDER platform will allow for the familiar progression of the traditional 4-port cholecystectomy.
                     
Methods and Procedures: Video documentation of SPIDER cholecystectomy shows critical steps, natural progression of the procedure without “sword fighting” and achievement of “the critical view of safety” prior to clipping of cystic duct and artery. A simple technique for extraction is also documented.

Results: One SPIDER cholecystectomy required conversion to traditional 4-port cholecystectomy due to choledocholithiasis and a large cystic duct. This was the only patient admitted overnight for ERC. Operative time was 134.5 minutes. In the first 5 cases, it was 161.6 minutes and decreased to 106.4 in the next group of 5. No injuries or complications were encountered.

Conclusions: Flexible laparoscopy eliminates “sword fighting” and provides a safe platform for single-access cholecystectomy. Operative times are prolonged but decrease with experience.

11.260 General Surgery
The Feasibility of Laparoscopic Surgery in the Management of Small Bowel Obstruction
Sung Il Choi, MD, SangHyun Kim, MD, Yong Ho Kim, MD, Bum Su Kim, MD  
Department of Surgery, School of Medicine, KyungHee University Hospital at Kangdong, Seoul, Korea (all authors).

Aims: Laparoscopy is used increasingly for the management of small bowel obstruction (SBO), but few studies have been conducted about the indication and utility of laparoscopic surgery in SBO.

Methods: From June 2006 to March 2010, 72 patients underwent surgery for SBO. Patients treated by laparoscopy were compared to those treated by laparotomy for differences in operative time, postoperative hospital stays, and return of bowel function, as evidenced by toleration of a liquid diet, surgical-site infection, and recurrence rate.

Results: Of the 72 cases, the laparoscopic group comprised 30 cases (41.7%) and the laparotomy group comprised 42 cases (58.3%). Open conversions were necessary in 8 cases (26.7%). Postoperative hospital stays in the laparoscopic group were significantly shorter than in the laparotomy group (8.1±5.8 vs. 14.9±15.2 days, P<.01), and the period of return of bowel function was significantly shorter in the laparoscopic than in the laparotomy group (3.9±3.2 vs. 6.6±3.6 days, P<.01). Surgical-site infection in the laparoscopic group tended to be lower than in the laparotomy group (4.6% vs. 23.8%, P=.05). The 2 groups did not differ in operative time (76.3±28.0 in laparoscopic group vs. 96.8±56.4 minutes, P=.12) and recurrence rate (0/22, 0% vs. 3/42, 7.1%, P=.20). The conversion rate to open surgery was 26.7% (8/30).

Conclusions: Laparoscopic surgery in the management of SBO had a shorter hospital stay, earlier recovery of bowel function, and lower surgical-site infection rate compared with laparotomy.

11.261 Gynecology
The Reproductive Outcome of Patients with Mild Endometriosis After Laparoscopic Ablation of Lesions
Fahimeh Ramezani Tehrani, Abbas Moieni
Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Dr. Tehrani).
Laparoscopy Research Center, Hamedan University of Medical Sciences, Hamedan, Iran (Dr. Moieni).
 
Objective: We aimed to investigate the impact of thermal coagulation on the reproductive outcome of patients with unexplained infertility, who underwent laparoscopic evaluation and had mild endometriosis.

Methods: Thirty-nine healthy infertile women with unexplained infertility who underwent exploratory laparoscopy and had mild endometriosis were included in the present study and were followed for 18 months. All visible endometriotic lesions and adhesions were coagulated at the same time of diagnostic laparoscopy. Following laparoscopy, women attempted to conceive and were followed for 18 months.
 
Results: Of the 39 women, 11 got pregnant during the follow-up, 2 of them ended with abortions, and the others ended with healthy-term pregnancies. The cumulative pregnancy rate was 28.2% (11/39), and the cumulative term delivery was 23.1%. No surgical complications were encountered.
 
Conclusions: These findings suggest that laparoscopy should be strongly considered for examining women with unexplained infertility, and coagulation of mild endometriotic lesions improve these patients’ reproductive outcomes.

11.262 General Surgery
Novel Single-Incision Laparoscopic Surgical Techniques for Invasive Rectal Carcinoma
Ami D. Sood, MD, Morteza Dowlatshahi, MD, DABR, Nang T. T. Nguyen, DO, Huy T. T. Nguyen, DO
Regional Medical Center of San Jose, San Jose, California, USA (all authors).

Background: Single-incision laparoscopic surgery is an emerging concept in colorectal surgery. We describe novel approaches for a case of extensive rectal carcinoma utilizing this technique.
 
Methods: A 67-year-old female with rectal bleeding was found to have a 4-cm rectal mass beyond the dentate line. Pathology showed moderately differentiated adenocarcinoma staged at T₃N₀. The patient first underwent a single-incision laparoscopic diverting sigmoid colostomy to prevent proctitis from neoadjuvant therapy. A 2-cm umbilical site incision was made, 3 individual ports were inserted, and the sigmoid was divided and pulled up as a permanent colostomy. Six weeks after receiving concurrent chemoradiation, the patient underwent a single-incision laparoscopic abdominoperineal resection. Access was gained through the previous umbilical incision, and a single-incision port device was placed. A 12-cm portion of rectum and anus was resected. Because of positive radial margins and likelihood of tumor penetration through the vaginal wall, additional radiotherapy was warranted. The final procedure provided laparoscopic guidance for placement of interstitial implant probes for brachytherapy. The same umbilical incision was made, a single-incision port device inserted, and optimal placement of the implant was achieved.
 
Results: Mean hospital stay for all procedures was 4 days with no perioperative or postoperative complications. Ideal cosmetic results were achieved, and minimal pain was reported postoperatively. During laparoscopic abdominoperineal resection, 9 lymph nodes were harvested.
 
Conclusion: This appears to be the first report of single-incision laparoscopy for a complex case of invasive rectal carcinoma. This experience has shown that it is technically feasible, safe, and yields favorable cosmetic results.

11.263 Gynecology
Transvaginal Laparoendoscopic Single-Site Surgery for Tubal Ectopic Pregnancy
Xiaoyan Ying, MD, Professor
Department of Ob/Gyn, The Second Affiliated Hospital of Nanjing Medical University,
Nanjing, P.R. of China.
 
Objective: To explore the feasibility of transvaginal endoscopic salpingectomy for tubal ectopic pregnancy without complications.

Methods: From May 2009 to May 2010, 6 cases of tubal ectopic pregnancy without complications were treated by transvaginal endoscopic salpingectomy (1 case was completed with endoscopic and laparoscope pneumoperitoneum, 5 cases were completed with endoscopy only). A double-channel endoscope (Olympus GIF一2TQ260M) was inserted on the posterior fornix. Then the fallopian tube with ectopic pregnancy was incised with a nylon loop and snare.

Results: Six operations were completed successfully. The average operating time was 62.17±15.54 minutes, and the average hemorrhage was 35.00±18.71mL. The tresis vulnus on the posterior fornix healed well in 7 days, and the serum levels of β-HCG decreased to a normal range in 9 days. No tresis vulnus infection, hemorrhage, or organ injury occurred.

Conclusions: Transvaginal endoscopic salpingectomy is feasible for tubal ectopic pregnancy without complications.

11.264 General Surgery
Laparoendoscopic Single Site (LESS) Cholecystectomy
Sharona B. Ross, MD, Harold Paul, BS, Natalie Donn, BS, Alexander S. Rosemurgy, MD
 
This is a video of a LESS cholecystectomy for symptomatic cholelithiasis. A 12-mm umbilical incision, a multi-trocar port, and a 5-mm deflectable tip laparoscope were utilized. The fundus was retracted cephalad with an EndoGrab™ retraction device. Next, the infundibulum was literally retracted with an endoriticulating grasper, which nicely exposed the “critical view.” A window was developed between the infundibulum and liver bed. The cystic duct and artery were clearly identified and were clipped and divided. The gallbladder was dissected off the liver bed with hook cautery and extracted through the umbilicus. The umbilical defect was closed, and the skin approximated with excellent cosmesis.

11.265 General Surgery
Laparoendoscopic Single Site (LESS) Cholecystectomy with Concomitant Total Hysterectomy and Bilateral Salpingo-oophorectomy
Alexander S. Rosemurgy, MD, Larry Glazerman, MD, Harold Paul, BS, Kenneth Luberice, BS, Sharona B. Ross, MD
 
This video is of a LESS cholecystectomy for symptomatic cholelithiasis and total hysterectomy for metromenorrhagia and bilateral salpingo-oophorectomy for a complex ovarian cyst. A 12-mm incision in the umbilicus, a hidden multi-trocar port, and a 5-mm deflectable tip laparoscope were utilized. For cholecystectomy, 2 graspers and a hook cautery were used. The cystic duct and artery were dissected, clipped twice proximally and distally, and divided. The gallbladder was dissected off the liver bed with hook cautery. Prior to disengaging the gallbladder from the liver, homeostasis was ensured.

The patient was then placed in a deep Trendelenburg position and attention was directed to the pelvis. With a LigaSure Advance^TM device, the infundibulopelvic ligaments were divided. Then, anterior and posterior colpotomy were performed using monopolar energy. Round and broad ligaments of the uterus were divided. The uterus, fallopian tubes, ovaries, and gallbladder were then delivered into the vagina and extracted, and using an Endo Stitch^TM, starting at the lateral aspect of the vaginal incision, the vaginal incision was closed. A Roeder knot was placed at the lateral aspect, and the Endo Stitch was used to re-approximate the vaginal mucosa from each end to the midline. An adhesion barrier was placed over the vaginal cuff. The umbilical defect was closed and skin approximated.

11.267 General Surgery
Single-Port Laparoscopic Colectomy: Short-Term Outcome
Ovunc Bardakcioglu, MD
Saint Louis University, Saint Louis, Missouri, USA.

Background and Objectives: Single-port laparoscopic colectomy is described as a new technique in colorectal surgery. These initial case reports show the feasibility, but in only highly select cases. We report our learning curve and short-term outcome for the initial 20 consecutive single-port laparoscopic right hemicolectomies without selection bias.

Methods: Twenty consecutive patients with the indication for a right hemicolectomy underwent a single-port laparoscopic approach. The only exclusion criterion was a prior midline laparotomy. The patients were followed for 30 days.

Results: The median age was 65 (range, 59 to 88). Ninety percent of patients were males. The median BMI was 28 (range, 20 to 35). Seventy-five percent of patients had significant comorbidities with an ASA class of 3 and 4. The estimated blood loss was 25cc (range, 25 to 250). The mean operative time for the first 10 cases was 198 minutes (range, 148 to 272) and for the following 10 cases 123 minutes (range 98 to 150). The median number of pathologic lymph nodes for patients diagnosed with adenocarcinoma was 16 (range, 8 to 23). There was one conversion to hand-assisted laparoscopic colectomy and one to open colectomy due to the inability of safe vessel ligation. The median hospital stay was 4.5 days (range, 3 to 7). There were no significant postoperative complications within 30 days. 

Conclusion: Single-port laparoscopic right hemicolectomy can be safely performed with a very low postoperative complication rate and an acceptable learning curve.

11.268 Gynecology
Robotic-Assisted Laparoscopic Repair of a Vesicouterine Fistula
Uchenna Acholonu, Jr., MD, Shao-Chun Rose Chang-Jackson, MD, Farr R. Nezhat, MD
Department of Obstetrics and Gynecology, St. Luke’s-Roosevelt Hospital, New York, New York, USA (all authors).

Objective: As cesarean deliveries have become a more common mode of childbirth, they have become the most likely cause of vesicouterine fistula formation. The associated pathology with repeat cesarean deliveries may make repair of these fistulas difficult. Computer-enhanced telesurgery, also known as robotic-assisted surgery, offers a 3-dimensional view of the operative field and allows for intricate movements necessary for complex suturing and dissection. These qualities are advantageous in vesicouterine fistula repair.

Methods: A healthy 34-year-old woman who underwent 4 cesarean deliveries presented with a persistent vesicouterine fistula. Conservative management with bladder decompression and an amenorrhea-inducing agent failed. Robotic-assisted laparoscopic repair was offered.

Results: The procedure was successfully performed, and the patient remains asymptomatic.

Conclusion: Robotic-assisted laparoscopic repair of a vesicouterine fistula offers a minimally invasive approach to treatment of a complex disease process.

11.269 Urology
Radiofrequency Ablation of Renal Tumor: Intermediate Oncologic Outcome
Gyung Tak Sung, MD
Dong-A University Hospital, Busan, Korea

Purpose: To report the intermediate oncological outcome of nephron-sparing radiofrequency ablation (RFA) of renal tumors.

Materials and Methods: Since August 2004, 51 patients with renal tumors were treated with either percutaneous or laparoscopic RFA. Forty patients underwent percutaneous and 11 underwent laparoscopic-assisted RFA. Forty-six patients were radiologically diagnosed with renal cell carcinoma. The cool-tip RF system manufactured by Radionics was used. The follow-up for each patient included a physical examination, chest radiography, liver function tests, and a contrast-enhanced CT or MRI. The mean follow-up duration was 30.3 months.

Results: Complete response was achieved in 48/51 patients (94%). The mean tumor size was 2.5cm. Of 51 patients, repeat RFA was necessary in 8 patients (16%). To confirm pathologic criteria of complete ablation, 28 patients underwent 6-month or 1-year follow-up biopsy. Three patients were found to have recurrence at various follow-up intervals. No distant metastasis developed during the mean follow-up of 30.3 months. Twenty-three patients (45 %) experienced complications, and all but one necessitated intervention. Major complications were a bowel injury and mild hydronephrosis during laparoscopic-assisted RFA, a liver injury, and a renocolic fistula from percutaneous RFA. Distant metastasis was not found in any cases, and all patients are alive on serial follow-up.

Conclusions: Percutaneous or laparoscopic RFA is considered useful treatment for select patients with small renal masses, and for nephron sparing. With mean follow-up of 30 months, our intermediate data suggest excellent oncological outcomes with RFA while achieving effective local tumor control and preserving renal function.

11.270 General Surgery
Addition of Alvimopan to a Standard Perioperative Recovery Pathway Decreases Length of Stay and the Incidence of Postoperative Ileus After Elective, Uncomplicated Laparoscopic Partial Colectomy 
George Y. Apostolides, MD, Edward A. Itawi, MD, Lisa M. Savoie, MD, Amy J. Hanna, MD
Division of Colorectal Surgery, Greater Baltimore Medical Center, Towson, Maryland, USA (all authors).

Background: Alvimopan, a peripherally acting mu-opioid receptor antagonist, was shown in Phase 3 trials to decrease time to gastrointestinal recovery and hospital length of stay in open bowel resection patients. However, the benefit in laparoscopic colectomy patients remains unclear. Therefore, we investigated outcomes in laparoscopic colectomy patients with and without alvimopan exposure.

Methods: A retrospective case series review was performed to study the effect of adding alvimopan to a well-established standard perioperative recovery pathway for elective laparoscopic colectomy. Pre-alvimopan controls were identified based on whether they would have been candidates for alvimopan. The main outcome measures were length of stay and incidence of charted postoperative ileus. Wilcoxon and chi-square tests were used to calculate P values for length of stay and postoperative ileus endpoints, respectively.

Results: Demographic and baseline characteristics from the 101 alvimopan and 64 control patients were generally comparable. Mean length of stay in the alvimopan group was 1.55 days shorter than that in the control group (alvimopan, 2.81±0.95 days; control, 4.36±2.4 days; P<.0001). The proportion of patients with postoperative ileus was also significantly reduced in the alvimopan group compared with controls (alvimopan, 2%; controls, 20%; P<.0001).

Conclusion: In this case series, addition of alvimopan to a standard perioperative recovery pathway decreased length of stay and incidence of postoperative ileus for elective uncomplicated laparoscopic colectomy. The improvement in the mean length of stay for patients who receive alvimopan is a step forward in achieving a fast-track surgery model for elective laparoscopic colectomies.

11.271 Urology
Percutaneous Renal Surgery in the Valdivia Position
Santos P. Bargão, Coelho M. Ferreira
Department of Urology, Hospital Prof. Doutor Fernando Fonseca, Lisboa, Portugal (all authors).

Introduction and Objectives: Percutaneous renal surgery (PRS) has traditionally been performed with the patient in the prone position, but there are disadvantages to anesthesia and ergonomic working conditions. The supine (Valdivia) position is much more comfortable for the anesthesia team and the surgeons. We present our experience with this position and show a video that illustrates the procedure.

Materials and Methods: From January 2009 to August 2010, a total of 30 patients underwent PRS in the supine position. Several surgeons performed the procedures. The group included 16 males and 14 females with a median age of 47 years and a mean body mass index was 27.2. The procedure was performed with the approach described by Mr. Valdivia Uria. A rigid nephroscope was used with a Lithoclast® Master lithotripter.

Results: Multiple stones were present in 40% of the patients. Stag horn calculi were present in 19% of the patients. Average stone diameter was 27mm. General anesthesia was used in all patients. Mean operative time was 90.3 minutes. Mean hospital stay was 4 days. Stone-free rate was 53%, and residual fragments <6mm were present in 11% of the patients. Residual fragments >5mm were found in 31% of the patients. Second-look surgery was done in 1 patient. Extracorporeal shock wave lithotripsy was necessary in 4 patients.

Conclusions: PRS with the patient in the supine position is a safe and effective procedure. According to the literature, the results are comparable to results with the prone position. The supine position facilitates the anesthesia and provides a more comfortable working position for the surgeon.

11.272 Gynecology
Expanded Use of Robotic Technology in the Treatment of Intraperitoneal and Retroperitoneal Endometriosis 
Michael T. Breen, MD
Department of Robotic & Minimally Invasive Surgery, University of Texas Southwestern Medical School, Department of Obstetrics & Gynecology-Austin, Austin, Texas, USA.

Background and Objective: Long having been a major cause of patient pain, infertility, emotional and physical morbidity, endometriosis has for years been treated surgically with the traditional minimally invasive techniques of intraabdominal CO₂ laser, and the more technically challenging excision using traditional or "straight stick" laparoscopy. This presentation/paper describes 70 cases of varied AFS stages of endometriosis treated robotically using one of 3 da Vinci systems.

Methods: Treatment consisted of both wristed thulium laser excision and vaporization, as well as the da Vinci wristed purely excisional technique using sharp dissection. Cases included first-time laparoscopies with patients with a strong presumptive diagnosis of endometriosis, and repeat laparoscopies on patients with known and biopsy confirmed endometriosis. All patients had excisional biopsies sent for confirmation of disease. Resident participation on the console also occurred via a double console da Vinci S1.

Results: All patients were outpatients, and all reported significant improvement in pain evaluated in 3 particular categories pre- and postprocedure (dysmenorrhea, dyspareunia, dyschezia) and the general category of "pelvic pain." There were no unexpected adverse effects, and the myth that all da Vinci cases require multiple large ports was overcome by using in many cases an 8-mm camera system, with two 5-mm ports for smaller wristed instruments and the 5-mm wristed thulium laser.

Conclusion: Wristed robotic technology allows for excision and laser vaporization of endometriosis in a safe intuitive manner and provides another modality in the treatment of endometriosis. This technology can be introduced safely into Ob/Gyn residency training programs.

11.273 Urology
Improve of Vesicourethral Anastomotic Times on the Laparoscopic Radical Prostatectomy by the Use of a Novel Absorbable Suture
Ferreira Coelho M ¹, Bargão Santos P ²
1 Urologist
2 Urology Resident
1 Department of Urology, Hospital Prof. Doutor Fernando Fonseca – Lisboa, Portugal

INTRODUCTION AND OBJECTIVES: To demonstrate a novel technique of anastomosis using a barbed and looped running suture during laparoscopic radical prostatectomy (LRP).

PATIENTS AND METHODS: This is a feasibility study of 15 patients who were submitted to this novel self-cinching anastomotic technique using a V-Loc™ 180 absorbable barbed suture after LRP for clinically localized prostate cancer. The results were then compared with 15 patients who underwent LRP by the same surgeon before this new technique. The novel technique was examined for the effects on the vesicourethral anastomosis time and total operative time.

RESULTS: The V-Loc™ 180 group had significantly shorter vesicourethral anastomotic times (20 min vs 46 min; P ≤ 0.001). By inference, this meant that operative times was also significantly less (148.3 min vs 194.2 minutes; P ≤ 0.001).

CONCLUSION: We have shown that this technique is feasible and improves anastomotic and operative times. Further follow-up will determine any benefits of this technique on anastomotic urinary leak rates, continence and catheter removal times.

11.274 General Surgery
Minimally Invasive Parathyroidectomy in the Reoperative Neck
N. Roukounakis, S. Dimas, V. Mouziouras, I. Kafetzis, N. Andromanakos
"POLYKLINIKI" General Hospital, Department of Surgery, Athens, Greece (all authors).

Objective: Reoperative neck or previous neck surgery (PNS) patients with sporadic primary hyperparathyroidism (PHP) is considered a contraindication for minimally invasive parathyroidectomy (MIP). The purpose of our study was to determine the effectiveness of MIP in such patients.

Methods: From January 1998 to February 2011, 425 patients with PHP were treated in our department. Forty of them had PNS. Twenty-three of them were selected to have MIPs, while the other 17 patients had traditional neck explorations. Selection criteria for MIP in PNS patients were unilateral single or 2-gland disease localized preoperatively with at least 2 imaging techniques. Unilateral focused explorations via a lateral approach with patients under local anesthesia (16 patients), or general (4 patients), or local followed by general (one patient) anesthesia were performed.

Results: Twenty-three of the 24 patients became normocalcemic after the operation. There was no conversion to traditional exploration. A single adenoma was found in 22 patients and hyperplasia in one. There were no postoperative complications. Mean duration of the procedure and length of stay were similar to duration of MIP in patients without PNS. Mean follow-up of 39 months (range, 3 to 78) did not reveal any recurrence.

Conclusion: These results illustrate that MIP is a feasible option in select patients with sporadic PHP and PNS with a high biochemical cure rate. Localization with at least 2 or more imaging techniques could avoid intraoperative sestamibi or quick parathormone test, substantially lowering the cost of the procedure.

11.276 General Surgery
Design and Development of a Laparoscopic Nissen Simulation Training Curriculum
Erlan Santos, Roger Tatum, Sayeed Ikramuddin, Carlos Pellegrini, Robert M. Sweet
Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA (Drs. Santos, Ikramuddin, Sweet).
Department of Surgery, University of Washington, Seattle, Washington, USA (Drs. Tatum, Pellegrini).

Background and Objective: Acquisition of laparoscopic skills on simulators is becoming an essential part of surgical education. A standardized LNF curriculum with summative and formative assessment and  feedback is lacking. Our aim was to develop a comprehensive laparoscopic Nissen fundoplication (LNF) educational curriculum. Our goal was to create a training and assessment tool for LNF training and promote the safe dissemination of LNF skills.

Methods: Three LNF subject matter experts following SAGES consensus guidelines and one simulation development expert defined the desired outcome and trainer goals/objectives. We performed task deconstruction to define the optimal training and assessment formats as well as the safety and efficiency metrics and critical errors and steps for LNF. Cognitive and psychomotor models and exercises were then designed towards these objectives.

Results: We developed a comprehensive LNF curriculum. The cognitive objectives are primarily met vis-à-vis Simpraxis a computer-based interactive video-based simulation platform. The psychomotor objectives are primarily met vis-à-vis an artificial Lap Nissen Model. Our LNF curriculum consisted of 8 cognitive and 13 psychomotor tasks. It includes a standardized sequence and an alternative sequence for this procedure. For each task, we defined safety (no errors) and efficiency (time, accuracy of position) metrics. We also defined and selected the laparoscopic instruments to be used in each of these tasks.
 
Conclusion: A comprehensive LNF curriculum containing both cognitive and psychomotor skills has been designed. The next step will be to validate the models and assess the ability of the curriculum to enhance skill, minimize error, and shorten the learning curve for LNF.

11.277 General Surgery
Appendiceal Stump Closure by Metallic Clip Application for Various Clinical Stages of Acute Appendicitis: Is it a Safe and Effective Approach?
Carlos Augusto Gomes, PhD, Tarcizo Afonso Nunez, PhD, Cleber Soares Junior, MSc, Rodrigo de Oliveira Peixoto, MSc, Camila Couto Gomes
Department of Surgery, Hospital Universitário (HU), Universidade Federal de Juiz de Fora (UFJF), MG, Brazil (Drs. C. A. Gomes, Soares Junior, de Oliveira Peixoto).
Department of Surgery, Hospital Universitário (HU), Universidade Federal de Minas Gerais (UFMG), MG, Brazil (Dr. Nunez).
Morphology Department, Universidade Federal de Juiz de Fora (UFJF), MG, Brazil (Ms. Gomes). 

Background and Objective: The appendiceal stump closure during laparoscopy has been performed by different methods; however, a prospective study about the effectiveness of metallic clip application for various clinical stages of acute appendicitis has not been evaluated yet. We sought to verify the safety and effectiveness of appendiceal stump closure by metallic clip application for various clinical stages of acute appendicitis.

Method: This was a prospective study of 186 patients with a presumed diagnosis of acute appendicitis, who underwent a laparoscopic appendectomy. The appendix was graded as to different levels based on its visual appearance: grade 0 (normal looking), 1 (redness and edema), 2 (fibrin), 3A (segmental necrosis), 3B (base necrosis), 4A (abscess), 4B (regional peritonitis), 5 (diffuse peritonitis). The outcome variables that were chosen to verify the effectiveness of the procedure were viability of clip application, surgical-site infection, operative time, and conversion and reoperation rates.

Results: The clip application was viable in 93% of the cases. The other alternatives were intracorporeal knot in 5.4%, endo-suture in 0.5%, and laparotomic suture in 1.1%. The main factors that impaired the procedure were the large appendicular diameter and necrosis of the appendicular base. The wound and intraabdominal infection rates were 1.1% and 1.6%, respectively. The median operative time was (38.2±25.5 minutes). The conversion rate was 1.1%, and 1 patient (0.5%) underwent a laparoscopic reoperation for bladder injury.

Conclusion: Appendiceal stump closure by metallic clip application was safe and effective for various clinical stages of acute appendicitis. It should be the procedure of first choice during laparoscopic appendectomy.

11.278 Gynecology
Laparoscopic Removal of an Abdominal Cerclage Suture in a 19-Week Pregnancy with Spontaneous Rupture of Membranes
Ashlyn H. Savage, MD, James F. Carter, MD
Medical University of South Carolina, Charleston, South Carlina, USA (all authors).

Objective: To demonstrate that it is possible to perform an abdominal cerclage suture removal via laparoscopy in a pregnancy at 19 weeks where there is little room to dissect the suture and successfully remove it, saving the patient a second laparotomy.

Methods: Experienced laparoscopic surgeons on our operating room team and our chief resident performed an advanced laparoscopic technique, which included laparoscopic needled drivers, laparoscopic "bowel" fan, laparoscopic Maryland and laparoscopic instruments, to make a 10-mm Hasson navel incision, two 5-mm lateral incisions at the level of the navel, and 5-mm suprapubic incision including a Foley catheter in the patient's bladder. We used general anesthesia and 14mm Hg to 15mm Hg CO₂ intraabdominal pressure. To our knowledge, a laparoscopic removal of a cerclage suture in a pregnancy this far along has not been successfully accomplished.

Results: We were able to remove a previously placed abdominal cerclage via operative laparoscopy. The suture had been placed via laparotomy. The patient was a 39-year-old, G4, P0, A3 who presented at 19 weeks with ruptured membranes. The patient had a previous vaginal cerclage that had failed and attempted laparoscopic cerclage (that we had not been involved in) that was converted to laparotomy with concomitant myomectomy performed as an interim procedure. We removed the abdominal cerclage laparoscopically. The patient was subsequently delivered via dilatation and evacuation the following day vaginally.

Conclusions: With skilled advanced laparoscopic surgeons, it was possible to remove a previously placed abdominal cerclage suture and thus prevent a second laparotomy in this patient, avoiding the morbidity associated with laparotomy.

11.279 General Surgery
Veress Needle Insertion Through Left Lower Intercostal Space for Creating Pneumoperitoneum: Experience with 75 Cases
Dr. Kumar, Sunil, MS
University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden, Delhi, India.

Background and Objectives: Veress needle insertion (VNI) at the subumbilical fold (SUF) midline is associated with serious intraabdominal injuries. The aim of this study was to evaluate safety and efficacy of the left lower intercostal space (LICS) for VNI.

Methods and Material: This prospective observational study was conducted in 3 parts in Surgery-II, Department of Surgery, GTBH-UCMS, Delhi. In part 1, skin fold thickness (SFT) was measured in 32 patients at SUF, LICS, right iliac fossa (RIF), and Palmer’s point. In part 2, in these patients, VNI was carried out from LICS under laparoscopic guidance. In part 3, the same technique of VNI was used in 43 patients with suspected intraabdominal adhesions undergoing laparoscopy for various reasons. Observations were made regarding ease of insertion, attempts needed at successful entry, loudness or clarity of give-way feeling of Veress needle, intraabdominal bleeding at the point of emergence of the Veress needle, hemopneumothorax, bowel or vascular injury. SFT was expressed as mean (SD), and ANOVA and Tukey’s test were used to find the statistical significance.

Results: SFT at LICS was significantly less compared to SUF and Palmer’s point. VNI at LICS was easy to carry out. It could be successfully done in the first attempt in all patients and was associated with very clear and loud give-way feelings. There were no instances of intraabdominal bleeding at the point of emergence of the Veress needle, hemopneumothorax, bowel, or vascular injury.

Conclusions: VNI at LICS as described here is safe and effective.

11.280 General Surgery
Laparoscopy Grading System of Acute Appendicitis: New Insight for Future Trials
Carlos Augusto Gomes, MD, PhD, Tarcizo Afonso Nunes, MD, PhD, Cleber Soares Junior, MD, MSc, Camila Couto Gomes, Igor Vitoi Cangussú
Department of Surgery, Hospital Universitário (HU), Universidade Federal de Juiz de Fora (UFJF), Brazil (Drs. Gomes, Soares Junior, C. C. Gomes, Cangussú).
Department of Surgery, Hospital Universitário (HU), Universidade Federal de Minas Gerais (UFMG), Brazil (Dr. Nunes).

Purpose: To validate the laparoscopic grading system of various clinical stages for acute appendicitis.

Method: Prospective study of 186 patients with presumed acute appendicitis who underwent an appendectomy if diagnostic laparoscopy showed a sick appendix, or normal-looking appendix without any other intraabdominal disease. The appendix was graded as to different levels based on its visual appearance: grade 0 (normal looking), 1 (redness and edema), 2 (fibrin), 3A (segmental necrosis), 3B (base necrosis), 4A (abscess), 4B (regional peritonitis), 5 (diffuse peritonitis). This was then compared with a histological assessment of the removed appendix supplemented by a biochemical study of collected peritoneal fluid (gold standard) to determine the diagnostic indexes. Besides that, the kappa coefficient confirmed concordance between them.

Results: Laparoscopic sensitivity, specificity, and accuracy for an acute appendicitis diagnosis were 100%, 63.3%, 84.1%, respectively, and had substantial concordance (K=0.74 [IC 95%=0.60 to 0.88]). Sensitivity, specificity, and accuracy of the laparoscopic grading system were 63%, 83.3%, 80.1%, and had moderate concordance (K=0.39 [IC 95% = 0.23 to 0.55]). The biochemical-histological grading system changed in 48 (25.8%) patients who had been previously classified by surgeons during laparoscopy. Most mistakes occurred in grades 0 and 1. The presence of exudates was confirmed in all cases classified as grades 4A, 4B, and 5.

Conclusion: Laparoscopy showed good to excellent accuracy for diagnosis and grading of acute appendicitis. The better grading system allowed the evaluation of patients with acute appendicitis in the same clinical stage.

11.281 General Surgery
Symptomatic Jejunal Varices After Roux-en-Y Gastric Bypass: A Rare Complication
Young Erben, Jane C. Carlon, Louis M. Wong Kee, Michael L. Kendrick, James M. Swain 

Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota, USA (Drs. Erben, Swain).
Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA (Dr. Carlon).
Department of Gastroenterology and Hepatology,
Mayo Clinic, Rochester, Minnesota, USA (Dr. Kee).

The obesity epidemic has increased the demand for bariatric procedures. Roux-en-Y gastric bypass (RNYGB) has become the most common operation performed in this patient population. As the number of RNYGB operations continues to rise, incidence of complications will also increase. Many of the serious complications are well described, including internal hernias, gastro-gastric fistula, marginal ulcers and bleeding, malnutrition, and vitamin deficiencies. As more experience with RNYGB and long-term data become available, this operative technique continues to evolve to include the closure of mesenteric defects that eliminates the risk for internal hernias. Herein, we report on 2 patients with refractory anemia due to gastrointestinal (GI) blood loss that required multiple transfusions of packed red blood cells (PRBC) caused by mesenteric thrombus and subsequent varices following RNYGB. The use of endoscopic hemoclips and argon plasma coagulation to treat the culprit varices was of limited benefit. Due to continued hemoglobin drops and bleeding episodes, surgical resection of the involved jejunojejunal (JJ) anastomosis was necessary. The patients recovered without sequelae and continue to do well at follow-up with no bleeding recurrence and stable hemoglobin.

11.282 Gynecology
Appendiceal Endometriosis and its Relation to Chronic Pelvic Pain
Maher S. Hassan, MD, Ehsan Refaie, MD, Maged El Shamy, MD, Nasser Al Lakkanny, MD, Hossam Roshdi General Surgery, Mansoura Faculty of Medicine, Mansoura, Egypt (Drs. Hassan, Refaie, El Shamy, Al Lakkanny).
Obstetrics & Gynecology, Mansoura Faculty of Medicine, Mansoura, Egypt (Dr. Roshdi).

Background and Objective: Although endometriosis is fairly common, the occurrence of endometriosis in the appendix is very rare. Correct preoperative diagnosis is uncommon, and a definitive diagnosis is established only by histopathologic examination of the appendix. The aim of this study was to evaluate appendiceal endometriosis in female patients of childbearing age presenting with appendicitis and to study the prevalence of appendiceal disease in women with chronic pelvic pain undergoing laparoscopy.

Patients and Methods: This was a prospective study conducted from January 2009 to January 2010. It included 2 groups of patients: Group I: 98 females with a mean age of 26±3.2 years presenting with symptoms suggesting appendicitis, for whom appendectomy was performed. Group II: 32 women with a mean age 32±5.2 who underwent laparoscopy for chronic pelvic pain; laparoscopic appendectomy was undertaken in 4 cases for suspected appendiceal morphology. All removed appendices were examined histopathologically.

Results: Appendiceal endometriosis was detected in 1.02% in group I, while it was higher in cases with chronic pelvic pain (group II) being 3.1%.

Conclusion: Appendiceal endometriosis is rare, and never correctly diagnosed preoperatively. A multidisciplinary team approach is needed (surgeon, gynecologist, and pathologist) in managing cases of chronic pelvic pain.

11.283 General Surgery
The Role of Laparoscopic Staging in Digestive Tract Tumors
Vecchio Rosario, MD, Intagliata Eva, MD, Marchese Salvatore, MD, Tropea Alessandro, MD
Department of General Surgery, University of Catania, Italy (all authors).

Objective: Thanks to technological processes in diagnostic imaging, the laparoscopic technique represents one of the greatest achievements of mini-invasive surgery in recent decades. Laparoscopy facilitates the exploration of the abdominal cavity by improving the possibility for pretherapeutic staging of digestive system neoplasms. The authors discuss, according to their experience and a literature review, the role and indications of laparoscopic staging in gastrointestinal tumors.

Methods: The authors reviewed the literature regarding the staging role of laparoscopic surgery in several tumors of the gastrointestinal tract.

Results: For diagnostic purposes, laparoscopy allows evaluation of tumors and lymph node infiltration before “open” laparotomy in areas of suspected neoplasia, lymph node biopsy, and evaluation of tumor resectability before laparotomy, with minimal bodily impact. Laparoscopy with ultrasonography allows the possibility of visual inspection of the whole abdominal cavity also in inaccessible areas like the retroperitoneum, and to find out small metastases in the hepatic parenchyma.

Conclusions: In the literature, laparoscopic surgery seems to be an important tool for the staging of gastrointestinal tumors.

11.284 General Surgery
Laparoscopic Treatment of a Unique Case of Jejunal Mucinous Adenocarcinoma
Vecchio Rosario, MD, Marchese Salvatore, MD, Intagliata Eva, MD
Department of General Surgery, University of Catania, Italy (all authors).

Objective: Mucinous adenocarcinoma of the small bowel is very rare, and only a few cases have been described in the literature. The authors report a unique case of jejunal mucinous adenocarcinoma in which a concomitant atrophy of the intestinal villi was histologically recognized. The difficult diagnosis and the role of laparoscopic surgery are discussed.

Methods: A 49-year-old man presented with recurrent melena, nausea, vomiting, and anemia over the last 2 years. A stenosis of the jejunum was documented by means of CT scan and video-capsule enteroscopy. A laparoscopy was scheduled.

Results: A tumor, found in the first jejunal loop, was removed by laparoscopic surgery and an intestinal anastomosis was accomplished. Histopathology revealed a rare mucinous adenocarcinoma associated with intestinal villous atrophy.

Conclusion: Although small bowel tumors are a rare entity, in patients with malabsorptive complaints and altered intestinal transit or occult bleeding, an appropriate workup should be planned for their diagnosis. Mucinous type intestinal adenocarcinoma, even if only occasionally reported before, could be observed. Laparoscopic surgery is often essential for their diagnosis and treatment.

11.285 Urology
Effect of Median Lobes on Perioperative Outcomes and Urinary Function After Robotic Prostatectomy
Humberto J. Martinez-Suarez, MD, Ronney Abaza, MD
The Ohio State University Medical Center and James Cancer Hospital, Columbus, Ohio, USA (all authors).

Introduction: Enlarged median lobes (ML) may affect perioperative and urinary function outcomes after robotic prostatectomy (RP). We assessed ML incidence among our patients and compared their outcomes to patients without ML.

Methods: We reviewed 632 RP by a single surgeon with at least 3 months of follow-up. Urinary function was assessed by patient self-reported questionnaires, including AUA-Symptom Score (AUA-SS).

Results: ML was identified in 134 patients (21.2%). Mean age was higher in ML patients (62.2yrs vs. 60.7yrs, P=.03) as was gland size (68.2g [34.7-160g] vs. 53.2g [20.1-257.9g], P<.05). Mean blood loss was higher in ML patients (128.5mL vs. 115.3mL, P<.01), but only one ML patient and 2 non-ML patients required transfusion. There was no difference in mean operative time (150.5min vs. 145.7min, P=.10), mean hospitalization time (1.01 vs. 1.02 days, P=.94), or need for bladder neck reconstruction (3% vs. 2.4%, P=.71). A JP drain was not used in any ML patients and was used in 5 (1%) non-ML patients. Median catheterization time was 6.0d in both groups, but mean catheterization time was longer in ML patients (6.3 vs. 5.6d, P=.01). Preoperatively, ML patients had higher mean AUA-SS (12.5 vs. 9.7, P<.01) but not significantly different from non-ML patients at 3 months (8.0 vs. 9.1, P=.10). At 3 months, there was no difference in urinary frequency, nocturia episodes, or urgency, and self-reported continence (0-1 pads/day) was achieved in 77% of ML patients and 70.4% of non-ML patients (P=.26).

Conclusions: Presence of ML did not greatly impact perioperative outcomes, and no difference had occurred in urinary function at 3 months.

11.287 Gynecology
Laparoscopic Surgery in the Treatment of Early Stage Ovarian Cancer
Victoria Karapetyan, MD
N. N. Blokhin Russian Cancer Research Center, Russian Academy of Medical Sciences, Moscow, Russia. 



Objectives: To evaluate the effectiveness of laparoscopy in the treatment of early stage ovarian cancer.

Methods: The study included 38 patients after nonradical surgery for stage I ovarian cancer.

Results: Repeat laparoscopic operations were performed 1 to 3 months after the first operation. In 21 patients, they included contralateral ovarian biopsy and SRGO (subtotal resection of the greater omentum), in 15 patients adnexectomy + SRGO, in 2 patients supravaginal amputation of the uterus with the second appendages + SRGO. All cases required urgent histological and cytological studies. According to the histological structure of the tumor, patients were classified as having tumor border (16), serous adenocarcinoma (11), endometrioid adenocarcinoma (6), mucinous adenocarcinoma (3), and clear cell tumors (2). In a histological study of 5 patients with detected micrometastases in the peritoneum, 2 patients had lesions in the contralateral ovary. In 7-year follow-up, 7 patients had relapses, including 2 patients who died of disease progression.

Conclusions: The use of laparoscopy in the treatment of early stages of ovarian cancer is possible. However, given the aggressive course of malignancies of the gonads, it is necessary to carry out resection of the second ovary, subtotal resection of the greater omentum, and urgent morphological examination and cytology is required.

11.288 General Surgery
The Feasibility of Sleeve Gastrectomy to Correct Gastric Band Surgeries
Hussam Al Trabulsi, MD, MRCS (Edinburgh)
Laparoscopic & Bariatric Surgery Consultant, AL Dia’a Hospital, Damascus, Syria

Background: This retrospective study was conducted to determine the feasibility and safety of sleeve gastrectomy to correct any gastric band surgery. The results show that sleeve gastrectomy in correcting gastric band surgery is very beneficial in multiple ways in patients dissatisfied with their bands.

Methods: In 2009 through 2011, sleeve gastrectomy was introduced as an option for correcting band surgeries. It was performed in 12 patients who experienced band-related medical conditions, which helped in classifying patients into 3 groups: band slippage, band erosion, and weight loss failure. Band removal using a laparoscopic approach was performed before doing the sleeve gastrectomy.

Results: Three patients with band slippage and one patient with band erosion were monitored before the sleeve procedure for 6 and 12 months, respectively (2009). However, gastrectomy was performed during the same operating session of the last group (1 patient in 2009/7 patients in 2010). Before undergoing sleeve gastrectomy, patients who chose to undergo the operation consumed a 7-day high-protein preoperative diet. After the surgery, patients were hospitalized for 2 days and followed up by the medical team. All the patients reported great satisfaction in terms of weight loss, cost of the procedure, days of hospitalization, with no surgical complications.

Conclusion: The results illustrate that sleeve gastrectomy to correct any band surgery is beneficial for gastric band patients. Patients demonstrate weight loss without complications and the ability to undergo biliary pancreatic diversion in the future. Initiation of sleeve gastrectomy as a first line in correcting complicated and/or unsuccessful band surgeries is highly recommended.
 

11.289 Gynecology
Laparoscopic Excision of Bowel Endometriosis
Louise King, MD, Mona Gomaa, MD, Camran Nezhat, MD
Center for Minimally Invasive and Robotic Surgery, Stanford University Medical Center, Palo Alto, California, USA (all authors).

Objectives: To demonstrate the safety and feasibility of laparoscopic surgery in complete resection of bowel endometriosis.

Methods: Video presentation of a case report. This is a 39-year-old, G2P0, with no previous medical or surgical history. The patient presented to our clinic complaining of severe dysmenorrhea associated with significant rectal pain and pressure. Ultrasonography demonstrated a cystic lesion abutting the rectosigmoid colon suspicious for an endometrioma. Upon entry with the laparoscope, we noted evidence of complete posterior cul-de-sac obliteration as well as deep fibrotic endometriosis of the lower portions of both ureters and pelvic sidewalls, the rectovaginal septum, and the anterior wall of the rectum. Specifically, we observed a large mass measuring approximately 4cm to 5cm extending from the rectovaginal septum to the rectal wall, which we resected meticulously using both the PlasmaJet and the CO₂ laser.

Results: In this case, we were able to perform complete excision of bowel endometriosis without the need for bowel resection and without compromising the integrity of the bowel. There were no intraoperative or postoperative complications. Six weeks after surgery, at a routine follow-up visit, the patient was improving clinically and had no complaints.

Conclusions: Complete resection of bowel endometriosis without need for disk excision or segmental resection can be accomplished laparoscopically in experienced hands using both the PlasmaJet and the CO₂ laser. We intentionally avoid using other forms of electrocautery in cases of bowel endometriosis, as these modalities have a higher incidence of associated bowel perforation and delayed necrosis.

11.290 Gynecology
Laparoscopic Hysterectomy in a Patient for Cervical Myoma
Sumathi Kotikela, MD, Michael Lewis, MD, Arathi Veeraswamy, MD, Mona Gomaa, MD, Louise King, MD, Camran Nezhat, MD
Center for Minimally Invasive and Robotic Surgery, Stanford University Medical Center, Palo Alto, California, USA (all authors).

Objective: To demonstrate the safety and feasibility of laparoscopic hysterectomy in a patient with a large cervical myoma.

Methods: Video presentation of a case report. The patient was a 65-year-old, G2P2, with no previous abdominal surgeries referred to our center for pelvic pain and pressure secondary to a fibroid uterus. After a full discussion of risks, benefits, and alternatives, the patient opted for surgical management. Upon laparoscopic entry, we noted a large cervical fibroid. We proceeded first with a myomectomy to facilitate the eventual hysterectomy.

Results: There were no intraoperative or postoperative complications. At the follow-up visit, the patient noted resolution of her pelvic pain and pressure.

Conclusion: Laparoscopic hysterectomy in patients with large cervical myomas can be accomplished by an experienced surgeon. The hysterectomy can be facilitated by first performing a cervical myomectomy.

11.291 Gynecology
Laparoscopic Trachelectomy for Persistent Chronic Pelvic Pain
Camran Nezhat, MD, Arathi Veeraswamy, MD, Sumathi Kotikela, MD, Michael Lewis, MD, Louise King, MD, Mona Gomaa, MD
Center for Minimally Invasive and Robotic Surgery, Stanford University Medical Center, Palo Alto, California USA (all authors).

Objectives: To demonstrate the safety of laparoscopic removal of the cervical stump after supracervical hysterectomy in patients with endometriosis.

Methods: Video presentation of a case report. The patient was a 50-year-old who underwent supracervical hysterectomy at another institution 5 years before presenting to our clinic. Thereafter, she experienced persistent pelvic pain, and after a full discussion of the risks, benefits, and alternatives, desired definitive surgical treatment. She underwent laparoscopic trachelectomy, bilateral salpingo-oophorectomy, and treatment of endometriosis. During the case, we encountered adhesions of bowel to the cervical stump and to the ovaries and tubes bilaterally. We were able to lyse these adhesions and excise the endometriotic lesions using the CO₂ laser and thereafter perform the trachelectomy laparoscopically.

Results: We encountered minimal blood loss during the case. There were no intraoperative or postoperative complications. At follow-up, the patient noted significant improvement in her pelvic pain.

Conclusions: Laparoscopic trachelectomy can be performed safely by an experienced surgeon. Supracervical hysterectomy is not the preferred method for hysterectomy and should certainly be avoided in patients with endometriosis, as it not infrequently will result in persistent pelvic pain requiring subsequent trachelectomy.

11.292 Gynecology
Laparoscopic Treatment of Endometriosis With the PlasmaJet
Camran Nezhat, MD, Ben C. Li, MD, Arathi Veeraswamy, MD, Mojgan Mohammadi, MD, Odysseas Ath. Savvouras, MD, Louise King, MD, Mona Gomaa, MD
Center for Minimally Invasive and Robotic Surgery, Stanford University Medical Center, Palo Alto, California, USA (all authors).

Objectives: To demonstrate the use of the Plasmajet in the laparoscopic treatment of endometriosis.

Methods: Video presentation of a case report. The patient was a 36-year-old, G0, with no past medical or surgical history who was seen in our office for chronic pelvic pain and infertility. Upon entry with the laparoscope, we found stage IV endometriosis. This video demonstrates the use of the PlasmaJet to treat extensive endometriosis.

Results: We were able to achieve complete and safe excision of all the endometriosis from the pelvis including near the rectum and the ureters. There were no intraoperative or postoperative complications. At the follow-up visit, the patient noted resolution of her pelvic pain.

Conclusions: The PlasmaJet uses an electrically neutral stream of pure plasma to cut and coagulate tissue. This simple and safe method should be contrasted with other surgical techniques for cutting and coagulation. In electrosurgery and in argon beam coagulation, an electric current flows from the active electrode through the patient to the ground pad. With the PlasmaJet system, the plasma is electrically neutral, no current flows through the patient, no ground pad is used, and complete coagulation of the tissue surface is achieved with a controlled and thin layer of tissue damage. The PlasmaJet is thus an excellent modality for the effective and safe laparoscopic treatment of endometriosis.

11.293 Urology
A Novel “No Touch” Robot-Assisted Laparoscopic Technique Facilitates Ureteral Reconstructive Surgery
Kelly A. Swords, MD, Mark A. Rich, MD, Hubert S. Swana, MD
Nemours Children’s Clinic, Orlando, Florida, University of South Florida, Tampa, Florida, USA (all authors).

Objectives: One of the current limitations of robotic surgery is the lack of haptic feedback. To overcome this obstacle, we developed a “No-Touch” technique utilizing the distal portion of a feeding tube to intubate and manipulate both the ureter and the renal pelvis during anastomosis.

Materials and Methods: Ureteral spatulation and pelvic reduction were performed as necessary. An 8-cm distal end segment of a 3-French to 5-French feeding tube was used to intubate and manipulate the lumen of the proximal ureter and renal pelvis or recipient ureter during anastomosis. Manipulation of the discarded segment of the pelvis served as a handle to control and limit tissue handling. The No-Touch technique allows for precise suture placement and prevented inadvertent back wall suture placement, thus ensuring luminal patency. No nephrostomy tubes or ureteral stents were utilized during these procedures. Patients were followed every 3 months for the first year with renal ultrasonography. Review of operative videos and surgical results was performed.

Results: Ten robotic pyeloplasties, 1 robotic pyeloureterostomy, and 1 robotic distal ureteroureterostomy were performed using the No-Touch technique. No tissue crush or crimping injuries or back wall suture placements occurred in any case. There were no intraoperative or postoperative complications. Resolution of hydronephrosis was demonstrated in all patients on postoperative renal ultrasound.

Conclusions: A No-Touch robotic technique utilizing the distal blunt end of a feeding tube is a safe, effective, and inexpensive adjunct tool that minimizes tissue handling in robot-assisted laparoscopic surgery.

11.294 Urology
Robotic-Assist Laparoscopic Nephropexy in Children with Symptomatic Nephroptosis
Kelly A. Swords, MD, Mark A. Rich, MD, Hubert S. Swana, MD
Nemours Children’s Clinic, Orlando, Florida, University of South Florida, Tampa, Florida, USA (all authors).

Objectives: Symptomatic nephroptosis is a controversial and often-delayed diagnosis. Patients are commonly misdiagnosed and subjected to multiple studies. Surgical intervention becomes necessary when symptoms persist despite conservative management. Many nephropexy techniques have been described. We report our experience with robotic-assist laparoscopic nephropexy in children.

Materials and Methods: Three female patients presented with a long-term history of intermittent right flank pain. All had multiple radiographic studies performed to diagnose nephroptosis, including ultrasonography, CT scan, intravenous pyelography, and nuclear renal scan. Cystoscopy and retrograde ureteropyelography were performed in 2 patients in supine and upright positions at the time of nephropexy, demonstrating position-dependent obstructive uropathy. Robotic-assisted laparoscopic nephropexy was performed using 4 ports. After mobilization, the kidney was pexed to the abdominal wall utilizing four 2-0 sutures secured with Lapra-Ty clips prior to tying in 2 patients, and intracorporeal suturing in 1 patient. The kidneys were retroperitonealized with running 3-0 Vicryl. No drains were used. Patients were followed at 3 months with a renal ultrasound. Outcome measures included operative time, hospital stay, relief of symptoms, and complications.

Results: Three female patients, ages 15 to 17, underwent right-sided robotic-assisted laparoscopic nephropexy. The mean operative time was 195 minutes (range, 172 to 218). No intraoperative or postoperative complications occurred. The mean hospital stay was 36 hours (range, 23 to 48). All 3 patients reported complete resolution of their pain at follow-up and remain symptom free. Mean follow-up is 10 months.

Conclusions: Robotic-assist laparoscopic nephropexy is a safe, effective procedure to perform in children with symptomatic nephroptosis.

11.295 General Surgery
Laparoscopic Management of Colovesicular Fistula from Diverticulitis
Brian A. Coakley, MD, Edward Chin, MD, Celia Divino, MD, Scott Q. Nguyen, MD
Department of Surgery, The Mount Sinai Medical Center, New York, New York, USA (all authors).

Background and Objective: Colovesicular fistulas represent the most common type of fistula developing as a complication of colonic diverticular disease. Published reports state that 2% to 22% of patients with active diverticular disease will develop a colovesicular fistula at some point. Definitive management of this condition includes primary resection with anastomosis. We present the case of a 34-year-old male with untreated diverticulitis who presented with a complaint of pneumaturia and fever.

Methods: Laboratory analysis revealed a WBC over 13,000, and a CT scan subsequently showed significant stranding around the sigmoid colon with evidence of a large colovesicular fistula. The patient was admitted, made NPO, and started on antibiotics targeting gram-negative as well as anaerobic bacteria.

Results: After 48 hours, the patient was taken to the operating room. After cystoscopic placement of bilateral ureteral stents, the patient underwent laparoscopic takedown of the colovesicular fistula, with resection of the sigmoid colon and primary colorectal anastomosis. The patient’s Foley catheter was removed on postoperative day 7, and he was discharged home 48 hours later after an uneventful postoperative course. The patient has not experienced any recurrent symptoms after 1 year of outpatient follow-up.

Conclusion: Our case shows that a laparoscopic approach may be considered as a viable treatment option for colovesicular fistulas involving the sigmoid colon.
 

11.296 General Surgery
Barriers to Laparoscopic Simulation Among General Surgery Trainees
Dahlia Tawfik, MD, Stephen Wise, MD, Thomas Vargish, MD, Sachin Kukreja, MD
University of Illinois at Mount Sinai Hospital, Chicago, Illinois, USA (all authors).

Background and Objectives: Fundamentals of Laparoscopic Surgery (FLS) has been shown to improve laparoscopic skills when practiced regularly; however, many surgery residents may not be fully utilizing the laparoscopic simulation lab. The purpose of this study was to identify factors affecting the frequency of laparoscopic skills practice among residents. 

Methods: A 25-question survey was sent to program directors and residency coordinators of the 246 residency programs in the United States, with the request to forward it to their residents. The only identifiers included PGY year and program (voluntary). 

Results: 255 individuals (of 1847 queried) from 66 institutions responded. Residents cited lack of time as the largest hindrance to practice (90.3%, 121/134) and were more often expected to use free time vs. protected time for practice (46.6%, 103/221 vs. 29.0%, 64/221, P=.0001). Most residents used the simulation lab less than once a month or not at all (57.9%, 146/252). Residents would use the lab more often if they had scheduled testing (42.5%, 93/219) or required proficiency in a laparoscopic skill before scrubbing cases (39.3%, 86/219). As most residents used self-teaching for training (58.4%, 129/221), many (38.8%, 85/219) felt that greater mentorship would increase participation. Lab access and location was also a limitation (22.2%, 49/221 and 34.4%, 76/221), and one program lacked a simulation lab altogether.

Conclusion: While time is likely to remain a barrier in the era of work-hour restrictions, improvements can be made to curriculum structure, lab access and location, and collaboration between institutions to promote laparoscopic skills training among general surgery residents.

11.297 General Surgery
Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery (SMA) Syndrome: A Video Presentation
Pieter Smit, MD, Stelin Johnson, RPA-C, Karen E. Gibbs, MD
Division of Minimally Invasive Surgery, Staten Island University Hospital, Staten Island, New York, USA (all authors).

Background and Objectives: Superior mesenteric artery (SMA) syndrome is an atypical cause of proximal gastrointestinal obstruction, recognized as weight loss, nausea, vomiting, and postprandial pain due to compression and partial obstruction of the third portion of the duodenum by the SMA. When nonsurgical management is not possible or the problem is refractory, surgical intervention is recommended. We submit a video presentation of a laparoscopic duodenojejunostomy for treatment of SMA syndrome.

Methods: A 35-year-old bedbound female with cerebral palsy and epilepsy, who presented with a 2-month history of intermittent nausea and bilious vomiting, was diagnosed with SMA syndrome. The patient was prepared for surgery after failed medical treatment. She was placed in the lithotomy position, and 4 laparoscopic ports were required to perform a laparoscopic duodenojejunostomy.

Results: The patient did well postoperatively. An upper GI study revealed no leak, with patency of the duodenojejunal anastomosis. She developed an ileus postoperatively but was subsequently able to be discharged home on a soft diet.

Conclusion: Laparoscopic duodenojejunostomy is a viable option to treat SMA syndrome. It provides definitive treatment while preserving the benefits of minimally invasive surgical techniques in the debilitated patient.

11.298 Urology
Clinical Analysis of 135 Patients with Stress Incontinence
LI huan, HU Yan, WU Rui-fang, LI Rui-zheng, ZHANG Li-jie, WANG Shu-mei, ZHANG Wei-ying
Department of Obstetrics and Gynecology, Beijing University Shenzhen Hospital, Guangdong Shenzhen, China (all authors).

Objective: To evaluate 2 treatment strategies, we conducted a controlled study of 135 patients with stress incontinence treated in the different ways.

Methods: From June 2006 to June 2010, 135 patients with stress incontinence were treated at the department of gynecology and obstetrics in Peking University Shenzhen Hospital. 91 patients were divided into Group A (low-frequency electric stimulation and biofeedback therapy group) and Group B (44 treated by improved transobturator tension-free vaginal tape [TVT-O]). We compared the recovery rate, the recovery rate of patients with urge incontinence, cost of treatments, and complications.

Results: Group B’s recovery rate for stress incontinence was 100%. The recovery rate for first-degree stress incontinence in Group A was higher, recovery rate for second-degree stress incontinence in Group B was lower, and recovery rate for third-degree patients was 0%. Only 1 patient had an abnormal urine stream, 2 had urinary retention, but the symptoms disappeared after the treatment. No obvious complications occurred in Group B. Great differences occurred in the cost between the 2 groups; the effect in Group B for patients with urge incontinence improved, but not in Group A.

Conclusion: The 2 treatments were safe and effective for stress incontinence, but great differences were noted in the therapeutic efficacy between the 2 groups.

11.299 Gynecology
First-Generation Endometrial Ablation Procedures: Long-Term (20 Years) Patient Results From “Vintage” Technology
Stephen A. Grochmal, MD, Stuart J Sherry, MD
Division of Minimally Invasive Surgery, Department of OBGYN, Howard University College of Medicine, Washington, DC, USA (Dr. Grochmal).
United Hospital District Clinic, Blue Earth, Minnesota, USA (Dr. Sherry).
 
Objective: To determine long-term treatment results in patients treated with first-generation endometrial ablation methods.
 
Methods: This was a prospective, 20-year follow-up of 287 patients with heavy uterine bleeding. All patients experienced office-based endometrial ablation/resection with either laser (Nd:YAG) energy (n=145) or electrical energy (n=142) utilizing either 1000 micron bare laser fiber or loop/rollerball electrodes in saline or glycine distention media and with the patients under IV conscious sedation anesthesia.
 
Results: Patients were evaluated annually with a pelvic examination, hysteroscopy (with biopsy when indicated), vaginal ultrasound, serum hormones, and review of uterine bleeding record/QOL assessment and symptom improvement. After 20 years, these are the results: Laser group-96/145 (66%) reported amenorrhea, 40(27.6%) demonstrated hypomenorrhea, 2 had a hysterectomy after failed ablation treatments, 1 patient no change after 2 ablations and refused further intervention, 4 became menopausal, and 2 were lost to follow-up. Electricity group-91/142 (64%) reported amenorrhea, 32 (22.5%) hypomenorrhea, 5 patients had eventual hysterectomy, 8 entered menopause, 2 had no change after 2 treatments and refused further intervention, 3 were lost to follow-up, and 1 patient died (MVA). Overall the combined amenorrhea rate was 65%, hypomenorrhea rate 31.3%, and failure rate was 4%. Complications: 2 endocervical perforations and 2 fluid overloads. Benign endometrial hyperplasia was documented in 39/280(14%) with no endometrial cancer detected in 20 years. Uterine cavity persistence: laser group-139/145 (96%), electricity group-73/142 (51.4%).
 
Conclusions: First-generation endometrial ablation/resection provides an enduring, long-term result. The long-term persistence of amenorrhea and presence of a patent uterine cavity are extraordinary benefits.
 

11.300 Gynecology
“Would You Recommend Office Hysteroscopy to a Friend?” A Patient Survey of Tolerability of Office-Based Hysteroscopy
Stephen A. Grochmal, MD, Stuart J. Sherry, MD, Stefanos Chandakas, MD, PhD, MBA
Division of Minimally Invasive Surgery, Department of OBGYN, Howard University College of Medicine, Washington, DC, USA (Dr. Grochmal).
United Hospital District Clinic, Blue Earth, Minnesota, USA (Dr. Sherry).
University of Athens School of Medicine, Athens, Greece (Dr. Chandakas).

Objective: Determine patient tolerability and impression of office-based diagnostic hysteroscopy compared to other commonly performed in-office gynecologic procedures.

Methods: Diagnostic hysteroscopic procedures were performed in 1047 patients who were included in the study. The survey contained 3 blocks of questions. Block One - Likert Scale (0 to 10) questions: patients were asked if the procedure was tolerable or painful and if they were happy to have the procedure performed. Block Two - a yes-or-no question: “Would you recommend office hysteroscopy to a friend?” Block Three (4 responses: nonapplicable, worse, same, or better) - compare the office hysteroscopy to other commonly performed gynecologic office procedures like speculum/pap/digital examination, colposcopy with biopsy, IUD insertion or removal, vaginal saline infusion ultrasound, and blood draw.

Results: Office hysteroscopy was well tolerated (mean score 8.6). Most patients experienced mild discomfort (mean pain score, 3.3), almost all indicated they were very happy (mean score 9.9) to have the test performed, and almost all (99.2%) indicated they would recommend the office hysteroscopy experience to a friend. Patients found the discomfort from office hysteroscopy the same or better than other office gynecologic procedures: 3% thought discomfort from office hysteroscopy was worse than vaginal SI ultrasound; 7% worse than speculum/pap/digital examination, 9% worse than IUD insertion/removal, 11% worse than colposcopy/biopsy, and 21% worse than blood draw.

Conclusion: Results suggest that any perceived discomfort from an office-based hysteroscopy procedure is very tolerable and that the relief patients feel from having their condition accurately diagnosed offsets any discomfort they might experience.

11.301 Gynecology
Evolving Endoscopic Imaging Technology: Disposable, Distal Tip CMOS Sensor Laparoscope
Stuart J. Sherry, MD, Stephen A. Grochmal, MD, Stefanos Chandakas, MD, PhD, MBA
United Hospital District Clinic, Blue Earth, Minnesota, USA (Dr. Sherry).
Division of Minimally Invasive Surgery, Department of OBGYN, Howard University College of Medicine, Washington, DC, USA (Dr. Grochmal).
University of Athens School of Medicine, Athens, Greece (Dr. Chandakas).

Objective: Compare image quality/features of current reusable rod lens and electronic distal tip CCD sensor laparoscopes to new disposable, distal tip CMOS sensor laparoscopes.

Methods: Randomized, blinded, side-by-side image evaluations were offered to experienced laparoscopic surgeons of 5mm/10mm rod lens and electronic distal tip CCD laparoscopes compared to disposable, distal tip CMOS sensor endoscopes. All 3 platform types were evaluated for image clarity, resolution, depth of field, and color accuracy. Sensor size and pixel array were examined in relation to image quality.

Results: In all categories, CMOS sensor imaging was comparable to CCD imaging systems and superior to rod lens laparoscopic imaging systems. When just CCD and CMOS sensor images were compared, experienced surgeons could not differentiate between the image quality generated by either sensor type or by the size of the individual sensor chip.

Conclusions: Rod lens laparoscopes utilize 60-year-old technology with up to 30% degradation of image quality, and electronic distal tip CCD laparoscopes are not yet de rigueur in the MIS suite mainly due to a high cost of ownership. These systems must also be cleaned, disinfected, or sterilized after each surgical procedure. Emerging CMOS technology offers the promise of no reprocessing after each procedure (disposable) and zero cost of ownership. These CMOS chip sensors are 60% to 75% smaller with a 3x to 5x increase in resolution. They offer equivalent, if not superior, image quality and are manufactured at 45 times less than the cost of CCDs, thereby providing the advantage of disposability.


11.302 Multispecialty
Expanding the Availability of Hysteroscopic Sterilization Procedures in Rural Areas of the United States. A Survey of Primary Care Practice Trends Following Hysteroscopy Training
John L. Pfenninger, MD, Stephen A. Grochmal, MD, Grant C. Fowler, MD, Stuart J. Sherry, MD
Department of Family Medicine, Michigan State University College of Human Medicine, East Lansing, Michigan, (USA) (Dr. Pfenninger).
Division of Minimally Invasive Surgery, Department of OBGYN, Howard University College of Medicine, Washington, DC, USA (Dr. Grochmal).
Department of Family and Community Medicine, University of Texas Medical School at Houston, Houston, Texas, USA (Dr. Fowler).
United Hospital District Clinic, Blue Earth, Minnesota, USA (Dr. Sherry).

Objective: We conducted a survey of practice trends after primary care physicians (PCP) completed diagnostic/operative hysteroscopy training.

Methods: Since 2000, courses on hysteroscopy skills have been available through The National Procedures Institute (NPI), now a joint CME venture of the American Academy of Family Physicians, Society of Teachers of Family Medicine, and the Texas Academy of Family Physicians. These are intensive 2-day programs taught by gynecologists with extensive experience in hysteroscopy. A gynecologist proctors attendees until clinical proficiency with hysteroscopy is achieved and privileges granted. A survey of 114 former NPI hysteroscopy course attendees (2003 to 2007) was obtained. Survey questions included whether PCPs (1) initiated hysteroscopy into their practice after course attendance; (2) performed hysteroscopy routinely for more than 3 years afterwards; (3) whether the hysteroscopy procedures they performed were other than just diagnostic; (4) if they were performing only diagnostic hysteroscopy, would they desire training in advanced procedures; and (5) where they performed hysteroscopy procedures.

Results: 91/114 responded as follows: 94% initiated hysteroscopy after course attendance, training and credentialing; 67% continue hysteroscopy for >3 years; 29% were performing global endometrial ablation and hysteroscopic sterilizations; 75% desired additional training in advanced procedures, and 61% utilized the hospital/outpatient setting, while 39% had transitioned to the office-based environment.

Conclusions: Hysteroscopy training venues for PCPs providing OBGYN services in rural parts of the country is a beneficial endeavor. This survey indicates hysteroscopy skills are readily assimilated into practice, well utilized over time, and provide these physicians with diagnostic, operative, and sterilization treatment options.

11.303 Gynecology
Survey of the Level of Concordance Between Hysterosalpingography (HSG) and Laparoscopy in the Diagnosis of Tubo-Peritoneal Factors on Infertile Women
Dr. Zahiri Sirouri Ziba, Sattari Nejad Seyedeh Soudabeh
Guilan University of Medical Sciences, Rasht, Iran (Dr. Ziba).
Obstetrician and Gynecologist, Rasht, Iran (Dr. Soudabeh).

Objective: HSG is a noninvasive method for tubal assessment in infertile couples and is used as a screening test, but laparoscopy is the “gold standard” of tubal disease diagnosis. Because of different results about concordance between these 2 methods, this study was undertaken. The aim of this study was to assess concordance between HSG and laparoscopy for tubal disease.

Methods: This is a prospective study, and laparoscopy was done on 200 patients who underwent HSG for assessment of tubal disease in Alzahra Hospital. Sensitivity, specificity, positive predictive value and negative predictive value of HSG in tubal obstructive, hydrosalpinx and peritoneal adhesion were assessed. The concordance between the 2 procedures was calculated.

Results: The mean patient age was 28.5±5.1.The mean duration of infertility was 3.8±3.1 years. The results show that the sensitivity and specificity of HSG in tubal obstruction and concordance with laparoscopy are 60%, 81%, and 36%, respectively. The sensitivity and specificity of HSG in hydrosalpinx and concordance with laparoscopy are 23%, 95%, and 23%, respectively. The sensitivity and specificity of HSG in peritoneal adhesions, endometriosis, and concordance with laparoscopy are 37%, 79%, and 17%, respectively.

Conclusions: Our results show that HGS is not a procedure for diagnosis of tubo-peritoneal pathology. It seems that not doing HSG by only one radiologist can interfere with the results, because of different radiologist’s experience in taking film and reports of graphs; therefore, it can lead to false interpretations. It is suggested that another study for completing these results should be carried out.

11.304 Gynecology
Diagnostic Value of the Shock Index to Predict Ruptured Ectopic Pregnancy
Dr. Faraji Roya, Dr. Aghazadeh Sohrab, Aghazadeh Mohammad Hosein, Aghazadeh Ali
Guilan University of Medical Sciences, Rasht, Iran (all authors).

Objective: Less than 2% of all pregnancies are ectopic. Ruptured ectopic pregnancy (EP) remains the leading cause of pregnancy related maternal death in the first trimester. The greatest danger is related to the undiagnosed early stage of tubal rupture. The aim of this study was to determine the ability of the shock index to identify a ruptured ectopic pregnancy.

Method: This cross-sectional survey was conducted on 99 patients with ectopic pregnancy beginning in 2005 for 2 years at Rasht Alzahra Hospital. We calculated the shock index for all patients, and then we calculated sensitivity, specificity, and positive and negative predictive values for each index. We determined the cut-off point of the shock index with Roc curve and evaluated the correlation between the shock index and hemoperitoneum. Statistical significance for variables was determined with the x², Student t test, Pearson coefficient, and logistic regression. All statistical calculations were made with Stat.V8, SPPS V14, and a probability value of <.05 was set for significance.

Results: 38 of 99 patients had ruptured EP, and 61 of 99 patients had nonruptured EP. The mean shock index in the ruptured group was 0.99±0.05 and in the nonruptured group 0.82±0.02. There was a significant difference between the 2 groups (P=.001). Cut-off point of the shock index was ≥0.89.There was a significant correlation between hemoperitoneum and the shock index (P≤.001; r=.54)

Conclusion: A shock index >0.89 is a valuable predictive factor for ruptured EP and have a correlation with hemoperitoneum.

11.305 Pediatric Surgery
Single-Incision Pediatric Endosurgery (SIPES): Assisted Ileocecectomy for Resection of a NEC Stricture
Richard Keijzer, Oliver J. Muensterer
Division of Pediatric Surgery, Children’s Hospital of Alabama University of Alabama at Birmingham, Birmingham Alabama, USA (all authors).
Department of Pediatric Surgery, University of Manitoba, Winnipeg, Manitoba, Canada (Dr. Keijzer).
Division of Pediatric Surgery, Weill Cornell Medical College, New York, New York, USA (Dr. Muensterer).

Background: Single-incision pediatric endosurgery (SIPES) is gaining popularity in many centers but has not been typically used for operations in premature infants yet.

Materials and Methods: We report the case of a 3-month-old, 25-week premature infant who underwent SIPES-assisted ileocecal resection for an intestinal stricture after previous medically treated necrotizing enterocolitis. A single 1.2-cm incision was made in the umbilicus, and the cecum and ascending colon were mobilized endosurgically to facilitate an extracorporeal resection and anastomosis.

Results: The patient recovered uneventfully, was on full enteral feeds at 6 days, and was discharged home at 15 days after surgery with good weight gain. The procedure left almost no appreciable scar.

Conclusion: SIPES is a reasonable alternative for NEC stricture resection in premature infants. Prematurity should not be considered a contraindication to single-incision endosurgery.
 

11.306 General Surgery
The One That Got Away: Delayed Finding of Lost Gallstones

Mingli Wang, MD, Kuldeep Singh, MD, Warren D. Widmann, MD

Staten Island University Hospital, State of New York Downstate Medical Center, Staten Island, New York, USA (all authors).

Objective: With the advent of laparoscopic cholecystectomy, we have seen a “disease of medical progress” (DOMP). Herein, we report a complication that developed 7 years after laparoscopic cholecystectomy. 



Methods: A 42-year-old woman presented with worsening right-sided abdominal pain and tenderness. Seven years prior, she underwent a laparoscopic cholecystectomy. Computed tomography demonstrated a subhepatic retroperitoneal inflammatory mass. On open exploration, a 4cm x 6cm retroperitoneal mass was excised. The mass contained purulent material and gallstones. 



Results: Laparoscopic cholecystectomy has become the “gold standard” for the treatment of symptomatic gallstones. Prior to laparoscopic cholecystectomy, there was no body of literature about lost gallstones, thus making this a DOMP. In contrast, it is reported that as many as 5% to 40% of laparoscopic cholecystectomies have stones spilled with variable rates of retrieval. Complication rates from lost dropped gallstones are reported at 1.7 per 1000 cholecystectomies. Our case demonstrates an extreme example of a complication resulting 7 years after a laparoscopic cholecystectomy with gallstones left behind.

Conclusion: Recognizing that gallstones will be lost during some cases of laparoscopic cholecystectomy, we must remain vigilant and make a full attempt to retrieve all stones to prevent rare but not insignificant potential complications.

11.308 General Surgery
Use of a Biomimetic Matrix for the Repair of Inguinal Hernias
Arthur Fine, MD
Department of Surgery, Jefferson Regional Medical Center, Pittsburgh, Pennsylvania, USA (Dr. Fine).
 
Background and Objective: Materials utilized for the repair of hernias fall into 2 broad categories, synthetics and biologics. Each has its merits and drawbacks. The synthetics have a permanent inherent strength, but are associated with some incidence of chronic pain. The biologics rely on variable tissue regeneration to give strength to the repair, requiring their use to be limited to specific situations, but, thanks to their transient presence and tissue ingrowth, do not result in a significant incidence of chronic pain. We studied the use of a biomimetic (Revive/Biomerix) in this setting in an attempt to obviate the disadvantages of each material.
 
Methods: Fourteen patients underwent laparoscopic repair, by TEP and TAPP techniques, of 16 inguinal hernias. Follow-up has been as long as 19 months, 8 for over 12 months, with no recurrences, and a 5% incidence of functionally insignificant discomfort.
 
Results: Revive is shown in histology and in vivo to demonstrate regeneration and tissue ingrowth into the polycarbonate/polyuria matrix rather than scarring or encapsulation similar to the biologics. There have been no recurrences, indicating its strength and resilience as a permanent repair, similar to the synthetics.
 
Conclusion: This is proof of the concept that a biomimetic may bridge the gap between the biologics and synthetics and may be able to be utilized on a regular basis with the benefits of both materials and neither of their drawbacks.

11.310 General Surgery
Safe Laparoscopic Access in Bariatric Surgery
Sharfi Sarker, MD
Loyola University Medical Center, Maywood, Illinois, USA.

Background: Safe and effective laparoscopic access is a prerequisite for the performance of any laparoscopic operation. Access options may be limited and more difficult in morbidly obese patients. Most life-threatening laparoscopic complications are associated with placement of the first trocar. Hereafter, we present data on our approach to laparoscopic access in patients undergoing laparoscopic adjustable gastric banding (LAGB).
  
Methods: Charts including operative reports of patients undergoing LAGB by a single surgeon between September 2004 and September 2010 were retrospectively reviewed via the electronic medical record. Demographics and data regarding previous abdominal operations, method of laparoscopic access, and access-related complications were collected.
  
Results: There were 193 patients. Mean preoperative weight and BMI were 136.4kg (range, 89.1 to 265.9) and 48.6 kg/m² (range, 35 to 75.2), respectively. Fifty-seven patients (29.5%) had no previous abdominal operations. The remaining patients had a mean of 1.6 (range, 1 to 7) previous abdominal operations. An optical trocar was successfully used for access in 190 patients (98.4%) with an open Hasson method in the remaining 3 patients. Mean estimated operative blood loss was 15cc (range, 5 to 750). No major or minor access-related visceral or vascular injury occurred.
  
Conclusions: In experienced hands, the optical trocar is a safe and effective method of obtaining laparoscopic access in morbidly obese patients undergoing LAGB. However, sound clinical judgment should be used in selecting the method of laparoscopic access in bariatric patients.

11.311 General Surgery
Gastric Volvulus After Laparoscopic Adjustable Gastric Banding: An Unusual Complication
Sharfi Sarker, MD
Loyola University Medical Center, Maywood, Illinois, USA.

Background: Perioperative complications following laparoscopic adjustable gastric banding (LAGB) have been well described. Band slippage is an uncommon, but commonly recognized, complication of LAGB that may present months or years after the initial operation. Hereafter, we present an unusual case of gastric volvulus after replacement of a slipped gastric band.
  
Case Report: A 35-year-old woman (103.2kg, BMI=39kg/m²) presented to the emergency department with nausea, vomiting, and epigastric pain. She had undergone LAGB 4 years earlier with subsequent 65.9kg weight loss. Her band was completely deflated the previous day for dysphagia to liquids and fluoroscopic evaluation consistent with band slippage. Repeat imaging confirmed complete stomal obstruction. She underwent laparoscopic replacement of the band. A large proximal pouch was reduced. Fluoroscopic evaluation on postoperative day (POD) 1 revealed patent stoma and an appropriately positioned band. However, she continued to have epigastric pain and developed nausea and vomiting on POD 2. High-grade stomal obstruction with large air-fluid level below the band was noted on repeat imaging. Diagnostic laparoscopy revealed volvulus of the enlarged pouch below the band. The band was removed and gastric volvulus reduced. A gastric serosal tear was observed, but no evidence of ischemia was present. The patient had an uneventful postoperative recovery.
  
Conclusion: Gastric volvulus of an enlarged gastric pouch is a rare but potentially disastrous complication of LAGB. Few case reports are available that describe this rare occurrence. A high index of suspicion based on clinical and radiological findings and prompt surgical intervention may help prevent more serious complications.

11.312 General Surgery
Laparoscopic Excision of Primary Retroperitoneal Hydatid Cyst: A Case Report
E. Puce, MD, D. Apa, MD, F. Atella, MD, E. Breda, MD, M. Lombardi, MD
UOC Chirurgia Generale CTO A, Alesini Rome (all authors).

Introduction: Hydatid cysts are most commonly seen in the liver and lungs, but retroperitoneal hydatid cysts are very rare. Extrahepatic localization is reported in 14% to 19% of all cases of abdominal hydatid disease. We report the case of a large echinococcal cyst localized in the upper retroperitoneal space.

Case Report: A 28-year-old woman was admitted to a surgical ward with left flank abdominal pain and discomfort lasting for 6 month. Ultrasonography and computed tomography scan revealed a large retroperitoneal multilocular cystic mass (9cm x 7cm) located above the left kidney, displaced frontally by the pancreatic tail and spleen and compressing splenic vessels. No cysts were present in any other location. Diagnosis of a multilocular kidney cyst was performed, and laparoscopic resection was planned. At intervention, the solid and encapsulated mass of about 10cm in diameter was found compressing the splenic vessels with adhesion into surrounding tissues. Complete laparoscopic resection of the mass with spleen was performed. Histopathological results revealed the diagnosis of hydatid cyst type III a. Antihelminthics were administered postoperatively, and the patient was discharged after day 4 and is now being closely followed up.

Conclusion: Total cystectomy when possible represents the treatment of choice for large extrahepatic echinococcal cysts. A totally laparoscopic resection is feasible and useful.

11.313 General Surgery
Linea Alba-Based Covert Laparoscopic Cholecystectomy in a Series of 20 Patients
Hai Hu, MD, PhD, Anhua Huang, MD, Weidong Wang, MD, Wenxin Zhang, MD, Bingguan Chen, MD, PhD
Department of Minimally Invasive Surgery, Tongji University Affiliated Shanghai East Hospital, Pudong New District, Shanghai, P. R. China (all authors).

Objective: To further improve the technology and patient satisfaction, we developed a linea alba-based covert laparoscopic cholecystectomy based on the concept of minimally invasive surgery.

Methods and Procedures: Twenty patients (14 female and 6 male) with gallbladder stones (17/20 cases) and polypus (3/20 cases) were recruited for this new approach. First a 10-mm trocar was placed in the upper edge of the umbilicus for inserting a 5-mm laparoscope through a converter. Under laparoscopic guidance, a 2-mm trocar for grasper was placed at the subxiphoid linea alba and another 5-mm trocar was placed at the suprapubic linea alba. The 5-mm 30° laparoscope was then shifted into the suprapubic trocar. A Harmonic scalpel or electric hook was introduced through the umbilical trocar where the gallbladder was retracted.

Results: All gallbladders were successfully removed without intraoperative complications. The mean operating time was 28.5±5.7 minutes (range, 20 to 45). All patients felt well without pain after surgery. They resumed free oral intake 6 hours after the procedure. All patients were satisfied with the appearance of the incisions, which were completely hidden in the umbilicus and suprapubic hair without a visible mark in the right upper quadrant. All patients were discharged 24 hours after the operation and returned to work within 5 postoperative days. 

Conclusions: Important merits of the approach we developed include short operation time and learning curve due to less instrumental clashing during the surgery, better cosmetic results, and less pain after surgery because of avoidance of muscle damage in the upper abdomen.

11.314 General Surgery
Single Incision Laparoscopic Cholecystectomy (SILC): A Novice Technique and Initial Experience
Dr. Vikas Singh
Department of Surgery, UP Rural Institute of Medical Sciences & Research, Saifai, Etawah, India.

Laparoscopic cholecystectomy has been recognized since 1992 as the “gold standard” procedure for gallbladder surgery. Single-incision laparoscopic cholecystectomy (SILC) is a relatively new technique that has attracted the attention of all the laparoscopic surgeons worldwide. The author shares his small experience of single-incision laparoscopic cholecystectomy in 80 cases as a step toward less invasive surgical procedures. The procedure was done with the conventional instruments used for laparoscopic cholecystectomy. A single intraumbilical 15-mm to 20-mm incision was made. Two ports, one 10mm and the other 5mm, are introduced through the incision with a fascial bridge between them (one for 5-mm 30° laparoscope and other for 10-mm right-angled dissector). The gallbladder was retracted by 2 sutures placed through abdominal wall. After Calot’s triangle dissection, cystic duct and artery were clipped and divided. Cholecystectomy was completed with electrocautery, and the gallbladder was retrieved through the  umbilical incision. As per the available literature, the SILC technique is safe, feasible, and reproducible. The learning curve can be shortened with experience, and better results can be obtained.

11.315 General Surgery
County Versus Private Hospitals: Does Hospital Type Affect Access to Care, Management, and Outcomes for Patients with Appendicitis?
Steven L. Lee, MD, Arezou Yaghoubian, MD, Ronnie Sullins, MD, Amy Kaji, MD, PhD
Department of Surgery and Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA (all authors).

Purpose: Race/ethnicity and socioeconomic status may affect healthcare access (higher appendiceal perforation [AP] rates), management (lower laparoscopic appendectomy [LA] rates), and outcomes in patients with appendicitis. This study determines if these disparities exist between county and private hospitals.
 
Methods: A review of patients ≥18 years treated for appendicitis from 1998 through 2007 was performed. Data from a county hospital were compared with data from 12 private hospitals. Study outcomes were AP rates, LA rates, and length of hospitalization (LOH). Higher preoperative AP rates suggest poorer access to healthcare, whereas increased LOH suggests greater resource utilization. Independent variables included age, sex, race/ethnicity, per-capita income, and hospital type. 
 
Results: 16,512 patients were identified (county=1,293, private=15,219). On univariate analysis, patients at the county hospital had lower mean per-capita incomes ($13,412 vs. $17,584, P<.0001) and similar AP rates at presentation (26% vs. 24%, P=.10). However, multivariable analysis demonstrated higher odds ratios (OR) for AP (1.4, 95%CI 1.2 to 1.6, P<.0001) and LA (OR=1.9, 95%CI 1.7 to 2.2, P<.0001), as well as longer LOH (parameter estimate=0.4, P<.0001) at the county hospital. Once within the county hospital, AP rate, LA rate, and LOH were similar across all races/ethnicities and income levels.
 
Conclusions: Patients with appendicitis treated at a county hospital were of lower socioeconomic background, had higher AP rates, and longer LOH, but were more likely to undergo LA. Yet, once within the county hospital, racial and socioeconomic disparities were no longer apparent; thus, these differences between county and private institutions may be due to differences in access to healthcare. 

11.319 Urology
Robotic Prostatectomy for Locally Advanced Prostate Cancer: A Multi-Institution Analysis
Jonathan J. Hwang, MD, Anup Vora, MD, Keith Kowalczyk, MD, Reza Ghasemian, MD, Mohan Verghese, MD, Edward M. Uchio, MD



Georgetown University/Washington Hospital Center and Yale School of Medicine, USA (all authors).





Background and Objectives: Robotic-assisted laparoscopic prostatectomy (RALP) offers minimally invasive treatment with reportedly comparable oncologic outcomes for localized disease compared with open radical retropubic prostatectomy (RRP). Herein, we report our experience with RALP and RRP in men with locally advanced prostate cancer (CaP).




Methods: Data for patients with locally advanced CaP were collected prospectively for the
RALP cohort and retrospectively for RRP patients. Clinicopathologic features including age, clinical stage, PSA, surgical margin status, and pathologic Gleason score were reviewed with multivariate analysis. We further examined the incidence of positive surgical margins, the effect of the learning curve on margin status, and the need for adjuvant therapy. 




Results: From 2003 to 2010, 1011 patients underwent RALP at our institutions. An additional 415 RRP patients were identified from 1997 through 2010. On final pathology, 145 patients in the RALP group and 95 in the RRP group had locally advanced CaP. The overall positive margin rate in the RALP group was
47.1% compared with 51.4% in the RRP group. A trend towards a lower positive margin rate was seen after 300 cases in the RALP
group. In addition, a lower incidence of biochemical recurrence was also noted in the latter cases (30.6% vs. 9.5%). 




Conclusion: Up to 2 out of 3 men had positive margins during our initial RALP experience. However, with increasing surgeon experience the overall positive margin rate decreased significantly
and was comparable to that of the RRP group.

11.320 General Surgery
The Prediction of Incidental Gallbladder Cancer in Patients Undergoing Laparoscopic Cholecystectomy for Benign Gallbladder Disease is Feasible
Vadim P. Koshenkov, MD, Rami Bustami, PhD, Mitchell Carter, MD
Department of Surgery, Morristown Memorial Hospital, Atlantic Health, Morristown, New Jersey, USA (Drs. Koshenkov, Carter).
Office of Grants and Research, Atlantic Health, Morristown, New Jersey, USA (Dr. Bustami).

Introduction: Over the past 2 decades, cholecystectomy for gallbladder disease has become more frequent due to the adoption of laparoscopy. Discovery of incidental gallbladder cancer (IGC) remains a dilemma for general surgeons worldwide. Gallbladder spillage during the operation can disseminate cancer and upstage the patient’s disease. 

Methods: All patients who had laparoscopic cholecystectomy for benign gallbladder disease from 1/1996 through 9/2010 were reviewed. Controls were randomly selected for 32 patients with IGC from the group of patients in the study period in a 3 to 1 ratio, without any matching. Variables such as age, sex, diagnosis, presence of gallstones, large gallstones, polyps, gallbladder wall thickening, dilated bile ducts, elevated liver function tests, and low albumin were compared between the 2 groups. 

Results: A total of 126 patients were included, with mean age of 71 for cases and 50 for controls; 75% were female in both groups. Two groups had statistically significant differences in age, diagnosis, presence of gallbladder wall thickening, dilated ducts, polyps, elevated LFTs, and low albumin in unadjusted analysis. Multivariate analysis showed that higher risk of IGC was significantly associated with age >65 (OR=8.6, P<.001), dilated ducts (OR=4.6, P=.045), and low albumin (OR=5.1, P=.039).

Conclusion: IGC is more likely to be found in patients presenting for cholecystectomy for benign gallbladder disease when age is ≥65, with the presence of dilated ducts and low albumin. Preoperative suspicion of gallbladder cancer should prompt the surgeon to either perform open cholecystectomy or be more careful not to perforate the gallbladder during the laparoscopic approach and to use a retrieval bag for the specimen.

11.321 General Surgery
Laparoscopic Transabdominal Repair of a Large Diaphragmatic Hernia 15 Years After a Traumatic Injury: Case Report and Literature Review 

Anna Goldenberg-Sandau, DO, Christopher Falcon, DO, Bernadette Profeta, MD

Department of Surgery, University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine and Department of Surgery, Our Lady of Lourdes Medical Center, Camden, New Jersey, USA (all authors).



Background and Objectives: In the current literature, traumatic diaphragmatic hernias (TDH) occur in 5% of patients hospitalized after motor vehicle accidents and 10% of patients with a penetrating chest injury. With ongoing advances in trauma, most patients are diagnosed at initial survey. Yet, as many as 10% of patients are diagnosed months to years after the initial injury, with a 20% to 36% mortality with latent presentation. The aim of this study was to review methods of diagnosis of TDH, criteria for repair, and analyze various options of surgical management.

Case Report/Methods: We present a case of a 58-year-old female who presented to the office with complaint of chronic esophagitis and a CAT scan finding of a paraesophageal hernia. Intraoperatively, she was found to have a TDH with incarcerated transverse colon that occurred 15 years prior from a motor vehicle accident. She underwent a laparoscopic transabdominal repair and was discharged home on postoperative day 4. We performed a comprehensive literature review (PubMed, Cochrane, Ovid 1990-current) of the current diagnostic and surgical treatment of latent TDH.
 
Results: Through the case report and literature review, we conclude that laparoscopic repair of TDH is a safe and feasible option but depends on the hernia, the patient, and the comfort level of the surgeon.

Conclusion: Laparoscopic repair of TDH is an option for surgeons proficient in minimally invasive techniques.

11.322 General Surgery
Laparoendoscopic Single-Site Morgagni Hernia Repair
Nicole Sharp, MD, Paul F. Buckley, MD

Objective: This is a retrospective case report of a laparoendoscopic single-site Morgagni hernia repair that will serve for discussion our initial experience with this technique.

Methods: This is a retrospective case report of a 63-year-old male undergoing a laparoendoscopic single-site Morgagni hernia repair in January of 2011. The patient’s only associated symptom was periodic right-sided chest pain. American Society of Anesthesiologists score was 3. Body mass index was 34.8 kg/m². Preoperative CT scan of the chest and abdomen was obtained and verified the presence of a large fat-containing anteromedial right diaphragmatic hernia. The procedure was performed through a 2-cm vertical umbilical incision. A Covidien SILS port was utilized with a combination of straight and articulating instruments. The defect measured 7cm in length and 5cm in width. Incarcerated omentum and colon was reduced. The hernia sac was excised using a LigaSure device. A 20 x 15 piece of Parietex Composite mesh was used to cover the defect. Mesh was secured with a combination of absorbable tacks and nonabsorbable 0 sutures on a ski needle.  

Results: Total operative time was 119 minutes. The patient was discharged home on postoperative day one. The patient tolerated the procedure well without any intraoperative complications. In 4 months of follow-up, there have been no postoperative complications.

Conclusions: Laparoendoscopic single-site Morgagni hernia repair is safe and feasible in the hands of experienced laparoscopic surgeons. This technique provides an alternative to open and standard laparoscopic repair.

11.323 General Surgery
Suture Migration: Unusual Cause of Abdominal Pain After Gastric Bypass Surgery
Benjamin Shadle, MD, Saber Ghiassi, MD, MPH, Keith Boone, MD, FACS, Kelvin Higa MD
Department of Surgery, University of California, San Francisco, Fresno, California, USA (all authors).

Introduction: Closure of mesenteric defects with permanent sutures in laparoscopic Roux-en-Y gastric bypass (RYGB) prevents internal hernias. Migration of sutures into the bowel lumen presents an unusual source of abdominal pain after RYGB. We present the largest case series of this rare complication and its management.

Methods: Retrospective review of prospectively maintained database and clinical charts was performed.

Results: Forty-seven patients with suture migration and bezoars were identified. All had undergone retrocolic, antegastric RYGB with closure of all potential hernia spaces. The most common presentation was abdominal pain (96%), followed by nausea/vomiting (49%), and dysphagia (14%). Average interval between RYGB and presentation was 28.6+2.5 months. Twenty-three CT scans were performed, with 8 positive findings. Thirty-nine endoscopies were performed in 37 patients. Thirty-four were diagnostic, and 21 were therapeutic. Thirty-four patients underwent surgical exploration and management (33 laparoscopies and 1 laparotomy). Suture migration and bezoars were identified in the Roux limb at the mesocolic closure in 45 patients, at the jejunojejunostomy in 4 patients, at both mesocolon and jejunojejunostomy in 4 patients, and at gastrojejunostomy in 2 patients. Symptoms improved or resolved in 37 (67%) patients. Mean excess weight loss was 71.7%±2.9 at 38.5±2.8 months after RYGB.

Conclusion: Intraluminal migration of sutures into the intestine is a rare cause of abdominal pain after RYGB. This is most common at the transverse mesocolon. Endoscopy can be both diagnostic and therapeutic, but many patients require surgical intervention. Noncircumferential closure of the mesocolic defect may decrease the incidence of this complication.

11.324 General Surgery
Transanal Endoscopic Microsurgery Using a Single Incision Laparoscopic Surgery Port Device
Anita Rao, MD, Rouzbeh Ahmadian, MD, Minia Hellan, MD
Wright State Univeristy Boonshoft School of Medicine, Dayton, Ohio, USA (all authors).
 
Transanal endoscopic microsurgery is a minimally invasive technique used as an alternative to transanal excision or radical surgery for select rectal tumors. The goal is to treat tumors more proximal in the rectum than is feasible with transanal excision. It also avoids the morbidity of radical surgery while providing similar oncologic outcomes. Despite clear advantages of this procedure, its use has been limited due to access and expense of specialized equipment. The instrumentation includes specially manufactured rigid proctoscopes with ports for insufflation, exsufflation, and manipulation of instruments. Our technique offers a solution to the access and cost issues by using the Single Incision Laparoscopic Surgery port device. This system is easily accessible at most institutions, uses standard laparoscopic instruments, and has recently been approved for transanal endoscopic microsurgery. This port causes less trauma to the sphincter and allows for increased flexibility in instrumentation. There is an insufflation port, however, no dedicated exsufflation port, which can be a pitfall of the system. We present a video of a male with a 3-cm preoperatively staged T1 lesion measuring 3cm in diameter (4cm from the anal verge) undergoing transanal endoscopic microsurgery using the Single Incision Laparoscopic Surgery port device. Full-thickness excision was performed, and the wall defect was closed. Our final pathology report confirmed a T1 lesion with clear margins and 3 negative lymph nodes. This patient did well postoperatively, and did not suffer any complications. He remains disease free to date, approximately 1 year.

11.325 Gynecology
Effectiveness of Robotic Surgery in the Management of Endometrial Cancer
Paul Lin, MD, Mark Wakabayashi, MD, Ernest Han, MD, Amy Hakim, MD
City of Hope National Medical Center, Duarte, California, USA (all authors).

Objective: To determine the efficacy of robotic-assisted laparoscopy in the management of endometrial cancer.

Methods: We conducted a retrospective review of patients with endometrial cancer who have undergone robotic-assisted laparoscopy.

Results: 110 patients were identified. The distribution of grade included 70 grade 1, 29 grade 2, and 8 grade 3 amongst the endometrioid histologies. In addition, there were 1 clear cell, 1 papillary serous, and 1 carcinosarcoma. The distribution of stages:  IA 81, IB 13, II 2, IIIA 5, IIIB 1, IIIC1 7, IVB 1. With a median follow-up time of 23.5 months (range, 12.0 to 50.8), 10 (9%) patients have recurred. Three patients had isolated vaginal recurrence, all of whom are free of disease after radiation. Seven patients (6.3%) had extravaginal recurrences. One patient had recurrence confined to the pelvis. Six patients had extrapelvic recurrences; 4 of these patients have died, and the remaining 2 are currently receiving therapy and are alive with disease. Of the 7 patients who recurred outside of the vagina, one had identification of intraperitoneal disease at the initial surgery.

Conclusion: The overall recurrence rate with a median follow-up of 24 months is 9%. Using extravaginal recurrence rate as a surrogate for determining adequacy of surgical staging, excluding the patient who had intraperitoneal disease identified at the time of initial surgery, 6/110 (5.5%) had extravaginal recurrences. Our series suggests that robotic-assisted laparoscopy is an effective approach in the management of endometrial cancer.

11.326 Urology
Hand-Assisted Laparoscopic Nephrectomy for Polycystic Kidney Disease: The Preferred Technique?
Mary Eng, MD
University of Louisville, Louisville, Kentucky, USA (all authors).

Background: Patients with adult polycystic kidney disease (PCKD) often have large kidneys that require removal prior to transplantation to create space for the renal allograft. Avoidance of transfusion is preferred so as to not sensitize patients against blood proteins in anticipation of transplantation. Previously, nephrectomy was done with an open technique. With the popularity of laparoscopic surgery, hand-assisted laparoscopic nephrectomy has become the procedure of choice at our institution.
 
Methods: Charts of patients who underwent nephrectomy by a transplant surgeon diagnosed with PCKD from January 2005 to December 31, 2010 were reviewed. The laparoscopic group was compared to the open group. Data collected included unilateral vs. bilateral, operative time, complications, transfusion requirement, and length of stay (LOS).
 
Results: Of the 53 nephrectomies, 4 were open transabdominal, 47 were hand-assisted laparoscopic and 2 were laparoscopic converted to open nephrectomies. Operative times were similar (206±76 minutes for open and 211±78 minutes for laparoscopic). Transfusion (100% open, 21% laparoscopic; P<.05) and LOS (6.3±1.3 days for open, 4.2±1.8 days for laparoscopic; P=.03) were less in the laparoscopic group. Overall rate of complications was similar (25% open, 23% laparoscopic). Complications associated with laparoscopic nephrectomy include thrombosis of the arteriovenous fistula and the development of an incisional hernia at the hand-port site.
 
Conclusion: Hand-assisted laparoscopic nephrectomy can be safely performed without increased operative times or complications. Patients who underwent the laparoscopic approach enjoyed shorter LOS, and fewer received a transfusion. Avoidance of transfusion is important to prevent sensitization of the potential transplant recipient.

11.328 General Surgery
Multipurpose Internal Retractor for Single-Incision Surgery (SIS)
Angela Echeverria, MD, Rakesh Hedge, MD, Alberto S. Gallo, MD, Carlos Galvani, MD
University of Arizona, Tucson, Arizona, USA (Drs. Echeverria, Hedge, Galvani).
University of Illinois at Chicago, Chicago, Illinois (Dr. Gallo).
 
Objectives: The advent of single-incision surgery (SIS) has eliminated the need for multiple ports. However, technical difficulties have emerged due to the impossibility of using assistants during the procedure. To overcome this obstacle, a multipurpose internal retractor was developed.
 
Methods: This retractor was developed by attaching a Lone Star retractor hook (Lone Star Medical Products, Stafford, TX) to a laparoscopic bulldog clamp (Aesculap, Tuttlingen, Germany). The back of the bulldog clamp was encircled with the Lone Star retractor and then attached with 2 silk sutures. The retractor was introduced into the abdomen, attached to the organ to be retracted and secured to the parietal peritoneum. The SIS procedures performed were cholecystectomy, gastric band placement, hiatal hernia repair with gastric band placement, sleeve gastrectomy, and Nissen fundoplication.
 
Results: Between October 2008 and April 2011, 91 SIS procedures were performed with the assistance of an internal retractor. Of these, 63 were gastric banding (27 patients underwent a simultaneous hiatal hernia repair), 9 sleeve gastrectomy, 18 cholecystectomy, and 1 Nissen fundoplication. The mean age of the patients in this evaluation was 38±4 years. There were 79 female and 12 male with a BMI of 45.2±2. 
 
Conclusion:  The internal retractor has shown to be adaptable, reliable, safe, and easy to use, thereby lessening some of the natural challenges of SIS. This technique has been used successfully for several different single-incision laparoscopic procedures with satisfactory results.
 

11.329 General Surgery
Laparoscopic Reduction of an Internal Hernia with Midgut Cecal Volvulus 3 Years After Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity: A Case Report
Alia Abdulla, DO, Adeshola Fakulujo, MD
University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine, Stratford, New Jersey, USA (all authors).

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is associated with a relatively high incidence of internal hernias (IH) compared to the open operation. Some studies report IH after LRYGBP has an incidence of 2.51%.

Methods: We describe the clinical and radiologic presentation of a 49-year-old female with an internal hernia with midgut volvulus in which the cecum was relocated to the left upper quadrant. We performed a comprehensive literature review (PubMed, Cochrane, Ovid 1990-current) (keywords: obesity, laparoscopy, gastric bypass, and internal hernia).

Results: Successful reduction of the internal hernia and midgut volvulus was performed laparoscopically. 

Conclusions: A delay in the diagnosis and management of this complication may result in catastrophic outcomes. Management should include the early involvement of a bariatric surgeon. 

11.330 General Surgery
Laparoscopic Reduction of an Internal Hernia with Midgut Cecal Volvulus 3 Years After Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity: A Case Report
Alia Abdulla, DO, Adeshola Fakulujo, MD
University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine, Stratford, New Jersey, USA (all authors).

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is associated with a relatively high incidence of internal hernias (IH) compared to the open operation. Some studies report IH after LRYGBP has an incidence of 2.51%.

Methods: We describe the clinical and radiologic presentation of a 49-year-old female with an internal hernia with midgut volvulus in which the cecum was relocated to the left upper quadrant. We performed a comprehensive literature review (PubMed, Cochrane, Ovid 1990-current) (keywords: obesity, laparoscopy, gastric bypass, and internal hernia).

Results: Successful reduction of the internal hernia and midgut volvulus was performed laparoscopically. 

Conclusions: A delay in the diagnosis and management of this complication may result in catastrophic outcomes. Management should include the early involvement of a bariatric surgeon. 

11.331 General Surgery
Multipurpose Internal Retractor for Single-Incision Surgery (SIS)
Angela Echeverria, MD, Rakesh Hedge, MD, Alberto S. Gallo, MD, Carlos Galvani, MD
University of Arizona, Tucson, Arizona, USA (Drs. Echeverria, Hedge, Galvani).
University of Illinois at Chicago, Chicago, Illinois (Dr. Gallo).
 
Objectives: The advent of single-incision surgery (SIS) has eliminated the need for multiple ports. However, technical difficulties have emerged due to the impossibility of using assistants during the procedure. To overcome this obstacle, a multipurpose internal retractor was developed.
 
Methods: This retractor was developed by attaching a Lone Star retractor hook (Lone Star Medical Products, Stafford, TX) to a laparoscopic bulldog clamp (Aesculap, Tuttlingen, Germany). The back of the bulldog clamp was encircled with the Lone Star retractor and then attached with 2 silk sutures. The retractor was introduced into the abdomen, attached to the organ to be retracted and secured to the parietal peritoneum. The SIS procedures performed were cholecystectomy, gastric band placement, hiatal hernia repair with gastric band placement, sleeve gastrectomy, and Nissen fundoplication.
 
Results: Between October 2008 and April 2011, 91 SIS procedures were performed with the assistance of an internal retractor. Of these, 63 were gastric banding (27 patients underwent a simultaneous hiatal hernia repair), 9 sleeve gastrectomy, 18 cholecystectomy, and 1 Nissen fundoplication. The mean age of the patients in this evaluation was 38±4 years. There were 79 female and 12 male with a BMI of 45.2±2. 
 
Conclusion:  The internal retractor has shown to be adaptable, reliable, safe, and easy to use, thereby lessening some of the natural challenges of SIS. This technique has been used successfully for several different single-incision laparoscopic procedures with satisfactory results.

11.332 General Surgery
An Effective Cosmetic Technique in Bariatric Surgery: An Alternative to “Single Incision Laparoscopy”
Titus Duncan, MD, Karleena Tuggle, MD, Katy Smith, DPN, APRN-BC
Atlanta Medical Center, Atlanta, Georgia, USA.

Objective: Single incision laparoscopic surgery (SILS) has recently been advocated in several minimally invasive procedures as improving overall cosmetic results. However, the cost/benefit ratio in its use in bariatric surgery has been questioned. The purpose of this study was to propose an acceptable, cost-effective cosmetic alternative to “single incision” laparoscopic surgery in bariatric patients having gastric banding.
 
Methods: We reviewed the records of 30 patients who underwent laparoscopic adjustable gastric band surgery between January 2010 and June 2011. Laparoscopic adjustable gastric banding was performed using a 4-trocar technique (three 5-mm peripheral trocars and one 12-mm umbilical trocar). The port was placed in a tunnel at the 12-mm umbilical port site, camouflaging the largest incision site. Operative time and overall cosmetic outcomes were measured. An objective as well as subjective cosmetic score was obtained at 3-month intervals for up to 12 months following surgery.
 
Results: Patients with the 4-trocar/umbilical port placement had high satisfaction cosmetic scores. Mean operative time was <1 hour. All patients achieved high objective aesthetic scores, and some scars were difficult to find after the patient had significant weight loss.
 
Conclusion: Decreasing the number of trocars and placing the port at the umbilicus is an acceptable method to improve the cosmetic result of patients having laparoscopic gastric banding. This procedure avoids the technical difficulty and increased costs of single site surgery techniques.
 

11.333 General Surgery
Appropriate Prophylaxis for Venous Thromboembolism in Laparoscopic Adjustable Gastric Banding Patients
Sharfi Sarker, MD
Loyola University Medical Center, Maywood, Illinois, USA.

Background: Controversy exists over the appropriate prophylaxis against deep venous thromboembolism (DVT) in morbidly obese patients undergoing bariatric surgery. We present our protocol for DVT prophylaxis for patients undergoing laparoscopic adjustable gastric banding (LAGB).
 
Methods: A retrospective review of 208 consecutive patients undergoing LAGB between 9/2004 and 4/2011 was performed. Routine DVT prophylaxis included subcutaneous administration of 5000 units of unfractionated heparin given pre- or intraoperatively and continued every 8 hours for the duration of the hospital stay. Sequential compression devices (SCDs) are applied prior to induction of anesthesia. Patients on preoperative therapeutic anti-coagulation are bridged with low molecular weight heparin. Patients are fully ambulatory within 24 hours postoperatively.
 
Results: Five patients had a history of DVT. Two of those patients had a history of pulmonary embolism (PE). Two additional patients had a history of PE without DVT. Mean preoperative weight and BMI were 136kg (range, 89.1 to 265.9) and 48.5 kg/m² (range, 34.6 to 75.2), respectively. Mean operative time (OR) was 78 minutes (range, 30 to 516). Estimated blood loss was 15cc (range, 5 to 750). There were no peri-operative transfusions. Median length of stay (LOS) was 1 day (range, 0 to 8). No patients had symptomatic DVT or PE within 30 days of their operation.
 
Conclusion: Peri-operative administration of subcutaneous unfractionated heparin, in conjunction with SCDs, is a safe and effective method of DVT prophylaxis in LAGB patients. We believe that the lack of thromboembolic complications in our patients is attributed to our prophylaxis regimen. The short OR and LOS likely further reduce the risk of DVT in this high-risk patient population.

11.334 General Surgery
The Prevalence of Nonalcoholic Steato-Hepatitis in Patients Undergoing Laparoscopic Adjustable Gastric Banding
Matthew Pittman, MD, Sharfi Sarker, MD
Loyola University Health System, Maywood, Illinois, USA (all authors).

Objective: Morbid obesity is a risk factor for nonalcoholic fatty liver disease/steato-hepatitis (NAFLD/NASH), the most common liver diseases in the US. However, the prevalence of NASH in the bariatric surgery population is unknown. Liver biopsy is required for diagnosis. We present our data on the incidence of NASH in patients undergoing laparoscopic adjustable gastric banding (LAGB).
 
Methods: Between 3/2007 and 1/2011, 141 patients underwent LAGB. Patients with elevated LFTs were offered a liver biopsy concurrent with LAGB. Data regarding age, preoperative weight, BMI, major co-morbidities, ASA classification, estimated blood loss (EBL), and operative time (OR) were collected and analyzed.
 
Results: Mean preoperative weight and BMI were 133kg (range, 89 to 238) and 48kg/m² (range, 35 to 75), respectively. Twenty-three patients (16.3%) had elevated LFTs. Nineteen of these patients underwent liver biopsy with LAGB. Three patients had a preoperative diagnosis of NASH, one who underwent additional biopsy. Liver biopsy revealed NASH in 14 patients (73.4%) and NAFLD in the others. There were no statistically significant differences in the mean age, preoperative weight, BMI, major co-morbidities, ASA, EBL, or OR between patients with and without elevated LFTs.
 
Conclusion: The incidence of elevated LFTs is low in patients undergoing LAGB. NASH is highly prevalent in this patient population. Elevated LFTs are generally thought to be poor predictors of NASH, and no other additional risk factors for NASH were identified in this study. As such, we call for further studies utilizing universal liver biopsy in patients undergoing LAGB to determine the true prevalence of NASH in this high-risk population. 

11.335 General Surgery
The Effect of Surgical Plume Generation by Ultrasonic Dissectors on Laparoscopic Visibility (Covidien Sonicision Cordless, Harmonic Ace, and Olympus SonoSurg)
David Sehrt, BS, Wilson Molina, MD, Fernando Kim, MD
Denver Health Medical Center, Denver, Colorado, USA (all authors).

Objective: To analyze the effect of surgical plume generation from various ultrasonic dissectors on laparoscopic visibility, including the first cordless ultrasonic dissector.
 
Materials and Methods: The Covidien Sonicision Cordless, Harmonic Ace, and Olympus SonoSurg were applied to bovine liver ex vivo with the maximum and industry specified coagulation settings. Consecutive activations were digitally captured in real-time from a laparoscope positioned to mimic the clinical setting. Plume was recognized by ImageJ software, and the percentage of pixels containing plume in each video frame was calculated. ANOVA statistical multi-analysis and Welch’s t test were computed for all P-values. Histological analyses of liver samples were examined blindly by a pathologist.
 
Results: Average maximum plume produced by the Sonicision, Ace, and SonoSurg with the maximum setting were 8.76% (range, 4.32% to 17.41%), 18.04% (range, 9.07% to 55.12%), and 9.46% (range, 5.68% to 22.12%), respectively (P=.02). Deviations between the Ace and the other devices were statically significant (P<.05). The average maximum plumes produced with the coagulation setting were 4.80% (range, 0.24% to 19.8%) for the Sonicision, 26.63% (range, 8.12% to 3.5%) for the ACE, and 0.21% (range, 0.06% to 1.0%) for the SonoSurg (P=6.86E-10). The differences between all instruments in the coagulation setting were statistically significant. Histological analysis of liver samples revealed no difference among specimens.
 
Conclusion: The devices studied exhibited different degrees of plume production according to their maximum, coagulation settings. Minimizing plume is critical to improving laparoscopic visualization thus decreasing surgeon frustration and increasing patient safety. Although factors such as cost and instrument ergonomics must be evaluated in selecting an ultrasonic device; surgical plume production should also be considered.

11.336 General Surgery
Comparison of Single-Incision Flexible Laparoscopic and Traditional Four-Port Cholecystectomy
Joaquin A. Rodriguez, MD, Robert O. Carpenter MD
Texas A&M Health Science Center, College Station, Texas, USA (all authors).

Objective: To determine the feasibility of cholecystectomy using a single incision flexible laparoscopic platform (SPIDER). Secondary objective was to compare SPIDER cholecystectomy with traditional 4-port cholecystectomy.

Methods: We conducted a retrospective chart review comparing experience with the initial 15 SPIDER with that of the 15 traditional cholecystectomies. Data obtained include age, sex, BMI, cause of biliary disease, and duration of surgical procedure, time to dismissal from the end of the surgical procedure, VAS pain score, and administration of intravenous pain medication.

Results: SPIDER cholecystectomy procedure time was 134.5 minutes, time to dismissal was 177.5 minutes, VAS pain score was 3.5, and 1.19mg of Dilaudid was administered per patient. Traditional cholecystectomy procedure time was 86.5 minutes, time to dismissal was 165.9 minutes, VAS pain score was 3.85, and Dilaudid administered was 1.86mg per patient.

Conclusions: SPIDER cholecystectomy allows safe single-port access cholecystectomy. Operative times are longer than times with traditional cholecystectomy. Prospective randomized studies are needed to determine differences in postoperative pain between the 2 procedures.

11.338 Gynecology
Effectiveness of Robotic Surgery in the Management of Cervical Cancer


Paul Lin, MD, Ernest Han, MD, Mark Wakabayashi, MD, Amy Hakim, MD
City of Hope National Medical Center, Duarte, California, USA (all authors).

Objective: To determine the efficacy of robotic-assisted laparoscopy in the management of cervical cancer.

Methods: Retrospective review of patients with cervical cancers who have undergone robotic surgery. To better assess efficacy, only patients followed for at least 12 months were included in our analysis.

Results: Twenty-two patients were identified who had a median age of 49 years old. Two underwent radical parametrectomy after initially having had simple hysterectomy for IB1 cervical neoplasms, and the remainder underwent radical hysterectomy. Histology was evenly divided between adenocarcinoma or adenosquamous carcinoma (11) and squamous cell carcinoma (11). The median BMI was 24.8 (range, 19.5 to 40.5). Tumor size ranged from microscopic to 6cm. With respect to FIGO stage, there were 1 IA1, 2 IA2, 18 IB1, and 1 IB2. Seven patients underwent adjuvant therapy, 3 for positive lymph nodes, 1 for ovarian involvement, 1 for deep stromal invasion and lymphovascular space invasion, 1 for parametrial extension, and only 1 because of positive margins. With median follow-up of 23.3 months (range, 12.0 to 32.2), there have been 2 recurrences, one in the pelvis at the apex of the vaginal cuff, and a second on the vulva.

Conclusion: Robotic radical hysterectomy and parametrectomy in the management of cervical cancer appears to be effective with the ability to achieve adequate margins, and with a low recurrence rate. Moreover, robotic surgery allows the ability to perform radical hysterectomy on obese patients that otherwise would be deemed unfeasible via an open approach.

11.339 General Surgery
Laparoscopically Assisted Incisional Hernia Repair
G. Rustamov, Prof., MD, E. Rustamov, MD
Tusi Memorial Clinic, Baku, Azerbaijan (all authors).

Background: The laparoscopic approach to incisional hernia repair is already well established because of its advantages. We evaluated the possibility of using a laparoscopically assisted approach whenever conversion to open repair was considered.

Patients and Methods: We operated laparoscopically on 72 patients for postoperative ventral hernia (POVH), 7 of whom had undergone laparoscopically assisted repair. The reasons for considering conversion were mainly technical difficulties in adhesiolysis and hernia reduction, and the suspected possibility of intestinal injury during dissection. The assisted approach included creation of a short incision over the fascial defect, exploration of the hernia contents and correction of any intestinal injury, completion of adhesiolysis, closure of the abdominal cavity, and laparoscopic accomplishment of the repair.

Results: Following open exploration, 2 iatrogenic intestinal perforations and one serosal injury were found and repaired. In 4 cases, only the completion of adhesiolysis was necessary. The postoperative convalescence was uneventful, and no recurrence has been recorded to date.

Conclusions: The laparoscopically assisted approach to difficult POVH repair is feasible and safe, and it helps to preserve the advantages of the laparoscopic approach. We recommend this approach whenever conversion to open surgical repair is under consideration during laparoscopic repair.

11.340 General Surgery
Robotic-Assisted Laparoscopic Liver Resection


Emad Kandil, MD, Saleh A. Massasati, MD, Salem I. Noureldine, MD, Natalia Hannan, MD, Joseph F. Buell, MD
Department of Surgery, Endocrine and Oncological Surgery Division,
Tulane University School of Medicine, New Orleans, Louisiana, USA (all authors).



Background: The development of minimally invasive surgery has led to an increase in the use of laparoscopic liver resections. However, laparoscopic liver resection remains technically challenging and is not widely developed. Robotic technology has been recently introduced to overcome these limitations and has gained wide popularity. However, the application of these instruments in the field of liver surgery has not yet been extensively reported. Herein, we describe the technique used and report the initial American experience in this field.

Methods: Three robotic-assisted laparoscopic liver resections were performed at one center. We performed 3 robotic-assisted laparoscopic liver resections using the da Vinci S surgical system. The operations began by placing 4 ports. One 12-mm camera port, two 8-mm robotic ports for the pro grasp and Harmonic scalpel, and a 12-mm port was placed for the assistant. The use of the vascular reticulating endoscopic stapler allowed safe control of the major vessels from the hepatic parenchyma. The hepatic surfaces were inspected for any evidence of bile leaks, and homeostasis was obtained.



Results: Patients had successful operations and recovered without complications. Patients had shorter hospital stays and earlier start of oral feeding.



Conclusion: Robotic-assisted liver surgery is a new field in its developing stage. Our experience shows that robotic-assisted laparoscopic liver resection is feasible and safe in select patients. It allows surgeons to perform advanced procedures especially with the 3-dimensional view of the surgical site and the potential for improved precision and ergonomics.

11.341 General Surgery
Robotic Transaxillary Right Thyroid Lobectomy of a Follicular Neoplasm

Emad Kandil, MD, Saleh A. Massasati, MD, Salem I. Noureldine, MD, Rizwan Aslam, DO, MS, Paul L. Friedlander, MD, Natalia Hannan, MD
Department of Surgery, Endocrine and Oncological Surgery Division
, Tulane University School of Medicine, New Orleans, Louisiana, USA (Drs. Kandil, Massasati, Noureldine).
Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA (Drs. Aslam, Friedlander, Hannan).

Background/Purpose: Minimally invasive thyroid surgery using various techniques is well described. The purpose of this video is to show a robotic-assisted transaxillary right thyroid lobectomy for a follicular neoplasm with intraoperative nerve monitoring and stimulation of recurrent laryngeal nerve. Herein, we show our experience with the technique and its safety and feasibility.

Methods: We performed a right thyroid lobectomy on a 33-year-old patient using the da Vinci-Si-HD Surgical System. The operation was done via a single axillary incision, 5cm in length. The flap creation time was approximately 26 minutes. The robot docking time was 6 minutes. The recurrent laryngeal nerve was identified and nerve stimulation was used to stimulate with 0.5 amps. The operative console time was 21 minutes. Total operative time was 69 minutes. 


Results: The procedure was successfully completed. Blood loss was minimal. Postoperative laryngoscopy showed intact and mobile bilateral vocal cords. There were no complications. The patient was discharged 4 hours after surgery. 


Conclusions: Robotic transaxillary endoscopic gasless thyroid surgery with monitoring and stimulation of the RLN is feasible and safe. This technique eliminates a visible neck scar and affords excellent high-definition optics of the cervical anatomy. This new technique can be accomplished on an outpatient basis.

11.342 Urology
Comparison of Laparoendoscopic Single-Site Adrenalectomy and Conventional Laparoscopic Adrenalectomy for Benign Adrenal Tumor
Deok Hyun Han, MD, Bong Hee Park, MD, Hong Seok Kim, MD, Jae Deok Choi, MD, Byong Chang Jung, MD, Seong Il Seo, MD, Seong Soo Jeon, MD, Hyun Moo Lee, MD, Han Yong Choi, MD
Department of Urology, Samsung Medical Center, Seoul, Korea (all authors).

Objective: To identify surgical outcomes of LESS adrenalectomy for benign adrenal tumor.

Methods: Sixty-one patients who underwent LESS adrenalectomy (LESS-A, n=30) and conventional laparoscopic adrenalectomy (CLA, n=31) for an adrenal mass from January 2009 to October 2010 were included in this study. Clinical and surgical data were collected and analyzed retrospectively. All baseline and surgical parameters between LESS-A and CLA were compared. To analyze the operative time, the first 15 LESS cases were compared to the last 15 LESS cases.

Results: There were 5 conversions to conventional laparoscopic surgery in the LESS-A. There was no conversion to open surgery in both cases. There were no significant differences in operative time, estimated blood loss, resumption of oral intake, or day of discharge between the 2 groups. The postoperative 1-day pain scale in the LESS-A was significantly lower than that in the CLA. In the LESS-A, the operative time (92.6 min) and estimated blood loss (123.3) in the last 15 cases were decreased compared to the operative time (121.0 min) and estimated blood loss (346.6mL) in the first 15 cases without significant difference. Furthermore, the postoperative 1-day pain scale was decreased in the last 15 cases compared to the first 15 cases (4.4±1.1 vs. 3.8±1.5, P=.250).

Conclusions: Despite the technical limitations, LESS-A could be performed effectively compared with conventional CLA. The operation time in LESS-A tended to decrease as the number of operations increased. These data demonstrate that LESS-A could be an effective alternative to adrenalectomy for benign adrenal tumors.

11.343 Urology
Initial Experience with Laparoendoscopic Single-Site Adrenalectomy for Pheochromocytoma
Deok Hyun Han, MD, Bong Hee Park, MD, Hong Seok Kim, MD, Jae Deok Choi, MD, Byong Chang Jung, MD, Seong Il Seo, MD, Seong Soo Jeon, MD, Hyun Moo Lee, MD, Han Yong Choi, MD
Sungkyunkwan University School of Medicine/Department of Urology, Samsung Medical Center, Seoul, Korea (all authors).

Background and Purpose: To describe our initial experience with and assess the feasibility of laparoendoscopic single-site (LESS) adrenalectomy for pheochromocytoma.

Patients and Methods: Twenty-one patients diagnosed with pheochromocytoma between January 2009 and June 2010 were included in this study. Seven patients underwent LESS adrenalectomy (LESS-A), and 14 underwent conventional laparoscopic adrenalectomy (CLA). All clinical and surgical data for the LESS-A group, including tumor size and operative time, as well as intraoperative change of blood pressure, complications, and conversions were compared to that of the CLA group.

Results: There were no significant differences in laterality, operative time, and estimated blood loss. Tumor size in the LESS-A group was significantly smaller than that in the CLA group. There was one conversion to conventional laparoscopy in the LESS-A. There were no significant differences in operative time or estimated blood loss between the groups. Intraoperative hypertension occurred in 3 patients (42.9%) in the LESS group and 4 patients (28.6%) in the LA group (P=.638). There were no significant postoperative complications in either group.

Conclusions: From this initial series of LESS-A, the intraoperative hypertension rate in the LESS group was higher than in the LA group. Despite the technical limitations of LESS-A, it could be performed safely in a select patient. However, large prospective studies seem to be necessary to support the safety of LESS-A for pheochromocytoma.

11.344 Gynecology
Urinary Tract Endometriosis    
De Bruin Abri, MBChB, MMed (OetG), FCOG(SA)
MEDICLINIC Kloof, Stellenbosch, South Africa

Urinary tract endometriosis involves the bladder as well as the ureter. Bladder endometriosis is rare and represents <1% of all endometriosis cases. Bladder endometriosis should be defined as full-thickness detrusor lesions. It is important to recognize the association between bladder endometriosis and other endometriosis in the pelvis, not least ureteric and recto-vaginal endometriosis. A cystoscopy is important to do to confirm if there is full-thickness infiltration as well as placing JJ-stents if surgery will be done close to the ureteric openings. So far in the literature, partial cystectomy or segmental resection of the bladder has been considered the treatment of choice.
 
Ureteric endometriosis is a rare condition, but with severe sequelae. In patients with endometriosis, it is estimated to occur in about 0.08% to 1% of patients with endometriosis. A distinction should be made between extrinsic and intrinsic ureteric endometriosis. The late consequence of ureteric endometriosis is the silent loss of renal function caused by progressive obstruction of the lower part of the ureter by the endometriosis/adenomyotic nodule. This unique type of endometriosis is mostly associated with patients with recto-vaginal endometriosis with a prevalence of 4.5%. Isolated ureteric endometriosis is not observed. A higher prevalence of ureteric endometriosis is noted in patients with recto-vaginal nodules >3cm. Although this condition is rare, it is very serious due to the possibility of loss of renal function. Optimal management of both these entities is crucial to ensure the best results.

11.345 Gynecology
The Impact of Personal Feedback in Surgical Virtual Reality Simulation
J. Oestergaard, MD, PhD fellow, F. Bjerrum, MD, J. L. Sorensen, MD, MMEd, C. R. Larsen, MD PhD, C. Gluud, MD, Dr. Med Sci Professor, C. Ringsted, MMEd, PhD, Professor, T. Grantcharov, MD, PhD, B. Ottesen, MD, Professor
Rigshospitalet, Department of Obstetrics and Gynecology, University Hospital of Copenhagen, Copenhagen, Denmark (Drs. Oestergaard, Bjerrum, Sorenen, Larsen, Ottesen).
Copenhagen Trial Unit, University of Copenhagen, Denmark (Dr. Gluud).
Center for Clinical Education, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark (Drs. Ringsted, Grantcharov)
St. Michael's Hospital, Department of General Surgery, University Hospital of Toronto, Toronto, Canada
 
Objective: The impact of personal feedback is unexplored when training on virtual reality (VR) simulators. We wanted to explore whether personal feedback compared to VR simulator-generated feedback has an effect when using training operation modules on a surgical VR simulator. Furthermore, we wanted to examine whether personal feedback has an influence on self-perception concerning surgical skills. 
 
Methods: In a randomized controlled trial, 96 participants (medical students in their fourth to sixth year, out of 6 years) were divided into a control group (no personal feedback) and an intervention group (3 times personal feedback); we measured repetitions and time spent to complete an operation module (a right side laparoscopic salpingectomy) on a VR simulator (LapSimGyn®, Surgical Science, Sweden). Completion of the module was a predetermined setting on the simulator. All participants were given a questionnaire concerning their own surgical skills before and after the trial.
 
Results: Results for 75 participants (the trial ends April 2011) showed that personal feedback has a significant effect on both repetitions; 27 vs. 49 (median), and time spent in minutes; 151 vs. 271 (median). Nonparametric statistics were used. Furthermore, the participants in the intervention group, as opposed to the control group, expressed higher self-confidence towards their own surgical skills after the trial.
 
Conclusions: When training with operation modules on a VR simulator, personal feedback has a significant positive impact on time, repetitions, and self-confidence. It is necessary to incorporate personal feedback when using VR simulation in a surgical curriculum.

11.346 General Surgery
Robotic Clipless Adrenalectomy of an Aldosteronoma
Salem I. Noureldine, MD, Saleh A. Massasati, MD, Emad Kandil, MD
Division of Endocrine and Oncological Surgery, Department of Surgery, Tulane University, School of Medicine, New Orleans, Louisiana, USA (all authors).

Background/Purpose: Robotic adrenalectomy is a minimally invasive alternative to traditional laparoscopic adrenalectomy. To date, only case reports and a small series of robotic adrenalectomies have been reported in the American literature. Additionally, few cases were reported using clipless and sutureless laparoscopic adrenal surgery. The purpose of this video is to show the feasibility and technical aspects of clipless and sutureless robotic adrenal surgery.

Methods: We performed an adrenalectomy on a 60-year-old patient by using the da Vinci-Si-HD Surgical System. The robotic docking time was 7 minutes. The operations began by placing 4 ports. One 12-mm camera port, two 8-mm robotic ports for the pro grasp and Harmonic scalpel, and a 12-mm port was placed for the assistant. Intraoperative ultrasound was very helpful in localizing the adrenal lesion in relation to nearby vascular structures. The surgery was carried out without the use of clips or sutures and instead only with the use of the ultrasonic shears.

Results: The adrenalectomy was completed safely with a total operative console time of 18 minutes and total operative time of 49 minutes. Blood loss was minimal, and the patient was discharged home after an overnight stay in the hospital.

Conclusion: Robotic adrenalectomy is a safe and effective alternative to traditional laparoscopic adrenalectomy. Based on our initial experience, clipless and sutureless robotic adrenalectomy using devices such as ultrasonic shears is feasible and safe.

11.348 General Surgery
Robotic Single-Incision Laparoscopic Liver Resection

Emad Kandil, MD, Saleh A. Massasati, MD, Salem I. Noureldine, MD,
 Joseph F. Buell, MD
Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA (all authors).

Background: The development of minimally invasive surgery has led to an increase in the use of laparoscopic liver resections. However, it remains technically challenging and is not widely developed. Robotic technology has been recently introduced to overcome these limitations and has gained wide popularity. However, the application of these instruments in the field of liver surgery has not yet been extensively reported. Herein, we describe a robotic-assisted single-incision laparoscopic liver resection and report the initial American experience.



Methods: We performed robotic surgery with the da Vinci Si-HD Surgical System. The operation began by placing one 3-cm incision at the umbilicus, and a GelPOINT Advanced Access Platform was placed. The port contains 3 cells. Two of the cells were used for the robotic arms, one for the pro grasp, and the second for the Harmonic scalpel. The third cell was used for the camera. A 12-mm port was placed in the left upper quadrant for the assistant. The use of the vascular reticulating endoscopic stapler allowed safe control of the major vessels from the hepatic parenchyma.



Results: The patient had a successful operation and recovered without complications.



Conclusion: Robotic single-incision laparoscopic liver resection is a new field in its developing stage. Our experience shows that robotic-assisted laparoscopic liver resection is feasible and safe in select patients. It allows surgeons to perform advanced procedures especially with the feature of a 3-dimensional view of the surgical site and the potential for improved precision and ergonomics.




11.349 Gynecology
Learning Curve for Robotic Hysterectomy: The Henry Ford Experience
Mona E. Orady
Department of Obstetrics, Gynecology, and Women’s Health, Henry Ford Health System, Detroit, Michigan, USA.

Objective: To evaluate the effect of the learning curve on surgical outcomes of patients undergoing robotic-assisted laparoscopic hysterectomy (RH) at Henry Ford Health System hospitals.

Materials & Methods: A retrospective cohort analysis was made of all RH performed for benign indications (N=231) by 7 surgeons from their first case until December 2010. Case number, patient demographics, procedure details, pathology, operative time (OT), estimated blood loss (EBL), length of hospitalization (LOS), and complications were recorded. Assessments of operative outcomes versus case number were performed, accounting for uterine weight and body mass index (BMI). Univariate statistical analyses and regression using generalized estimating equations were performed.

Results: OT decreased significantly for each surgeon with increasing numbers of cases (P=.006). OT decreased by half a minute with each sequential case (SE=.25, P=.044). Other factors that significantly increased OT were BMI, uterine weight, and assisting surgeon expertise. Cases were prolonged by an average of 18 minutes when BMI exceeded 25 (SE=8.5, P=.0338), and by 67 minutes when uterine weight exceeded 250 grams (SE=9.6, P<.0001). Compared to an expert assistant, procedures were prolonged by 6.5 minutes with an attending, 13 minutes with a fellow, and 19.5 minutes with a resident assistant (SE=3.2, P=.041). A statistically significant decrease in EBL (P=.009) and LOS (P=.0323) without a difference in major complications from early to late cases (P=.516) was also noted. 

Conclusion: Operative time for RH decreases with surgeon’s experience, but is significantly affected by assistant expertise, uterine weight, and BMI of the patient. EBL and LOS also decrease with experience, but complications are stable throughout the learning curve.

11.350 Gynecology
Pain and Well-Being After Hysterectomy for Benign Indications: A Prospective Analysis and Comparison by Hysterectomy Type
Mona E. Orady, MD
Department of Obstetrics and Gynecology and Women’s Health Services, Henry Ford Health System, Detroit, Michigan, USA.

Objective: To assess the effect of hysterectomy method on patients’ pain levels or sense of well-being postoperatively.

Materials & Methods: We performed a prospective cohort study of all patients scheduled for hysterectomy for benign indications at Henry Ford Health System hospitals who wished to enroll. Patients underwent baseline telephone interviews prior to surgery, then on postoperative days (POD) 4, 7, 14, and 28. Women were asked to rate their pain and sense of overall well-being on a scale of 0 to 10 by blinded interviewers. For preliminary analysis, patients (n=135) were placed into  abdominal, vaginal, robotic, or laparoscopic hysterectomy groups, and a statistical analysis was conducted.

Results: Although pain scores were similar between robotic (n=53) and laparoscopic (n=43) groups on POD#4, patients with an abdominal (n=18) or vaginal (n=10) hysterectomy had significantly greater pain (mean=5.3) than at baseline. Pain scores were significantly less for the laparoscopic and robotic groups, compared to the abdominal groups on POD#7 (P=.008) with robotic patients having the greatest decrease in pain overall. All groups had a resolution of their pain by POD#28. Pain scores also correlated with well-being scores (P<.001) that followed the same pattern with robotic patients having the greatest increase in well-being scores by POD#7 (P=.04). For all groups, well-being increased beyond baseline by POD#7 and continued increasing to POD#28.

Conclusion: Robotic hysterectomy patients may have less pain and faster increase in well-being by POD#7 compared to patients undergoing laparoscopic, abdominal, or vaginal hysterectomy. Patients’ sense of well-being correlates with pain and surpasses baseline for all groups by POD#7.

11.351 Gynecology
Laparoscopic Approach to Torsion of a Massive Ovary
Mona E. Orady, MD
Division of Minimally Invasive Gynecology and Robotic Surgery, Department of Obstetrics, Gynecology, and Women’s Health, Henry Ford Health System, Detroit, Michigan, USA.

Ovarian torsion is an acute process that often involves a massively enlarged ovary. The laparoscopic approach benefits the patient in many ways allowing a shorter hospital stay, quicker recovery, and faster return to work. Often care is needed to remove a large torsed ovary intact, especially in older individuals secondary to concern about malignancy. This can often present a challenge to the surgeon.

This is the case of a 45-year-old morbidly obese female (BMI=40) presenting with acute abdominal pain suspicious for ovarian torsion. CT scan revealed a 13-cm ovary with a large cystic structure that was thought to arise from the left side. Despite flow to the ovary on CT scan, because the patients’ pain increased and white blood cell count was elevated, the decision was made to take the patient for diagnostic laparoscopy. Torsion of a massively enlarged right ovary now with edema and necrosis was discovered. This video illustrates the laparoscopic approach to this case showing how the blood supply was identified and isolated and the approach to removal of such a large structure through a laparoscopic port without spillage.

11.352 Gynecology
Robotic-Assisted Laparoscopic Removal of the Retained Ovary
Mona E. Orady, MD
Division of Minimally Invasive Gynecology and Robotic Surgery, Department of Obstetrics, Gynecology, and Women’s Health, Henry Ford Health System, Detroit, Michigan, USA.

Despite the seeming simplicity of an oophorectomy, removal of ovaries retained after hysterectomy in patients with prior abdominal procedures can often be challenging secondary to the commonly encountered presence of pelvic adhesions. The da Vinci robot provides the advantage of enhanced 3-dimensional vision (high-definition and 10X magnification) and increased precision and dexterity of motor movements of the laparoscopic instrumentation. This allows for easier dissection of extensive adhesions and delineation of difficult anatomy.

Herein is the case of a 60-year-old female with a previous history of multiple abdominal surgeries, including an abdominal hysterectomy performed for endometriosis. She initially presented with complaints of pelvic pressure, pain, and generalized discomfort. Evaluation and close follow-up revealed a slowly enlarging complex ovarian mass. Tumor markers were within normal limits. Ultrasound and MRI showed an 11 x 8 x 9-cm left adnexal mass consistent with a probable benign ovarian tumor. The patient desired a minimally invasive approach for surgery. Given the expectations of extensive adhesions and difficult removal of the retained ovary, she was counseled regarding a robotic-assisted laparoscopic procedure. Gynecologic oncology back-up was arranged.

The video presentation illustrates the careful and precise dissection made possible using da Vinci robotic assistance for laparoscopic removal of the retained ovary. This modality allowed for efficient and safe removal of this enlarged ovary in a minimally invasive manner. Approach to the dissection of the retroperitoneal space and techniques of removing the ovary laparoscopically are discussed.

11.353 Gynecology
Robotic Hysterectomy: Approach to the Bulky Fibroid Uterus
Mona E. Orady, MD
Division of Minimally Invasive Gynecology and Robotic Surgery, Department of Obstetrics, Gynecology, and Women’s Health, Henry Ford Health System, Detroit, Michigan, USA.

Minimally invasive hysterectomy offers patients smaller incisions, decreased blood loss, decreased length of stay, and a faster recovery and return to normal activities. Since the FDA approval of the da Vinci Surgical System for use in gynecology in April 2005, robotic hysterectomy has helped to extend the ability of surgeons to perform hysterectomy in patients who may not otherwise have been candidates for a minimally invasive approach, such as in those with extremely large bulky uteri making traditional laparoscopic hysterectomy difficult.

This is the case of a 39-year-old, gravida 3, para 3, woman who presented with a large, bulky fibroid uterus causing menorrhagia, dysmenorrhea, and pelvic pain symptoms. Childbearing was complete. She had failed medical management in the past and desired definitive management with hysterectomy. Uterine depth sounded to 13cm, and on pelvic MRI the uterus measured 15 x 7 x 12cm. The largest fibroid was posterior, measured 9cm, and filled the pelvis. The patient was offered a robotic-assisted total laparoscopic hysterectomy of this very large bulky uterus to avoid laparotomy.

This video presentation illustrates the careful and precise dissection made possible using the assistance of the da Vinci robot. The magnified 3-dimensional vision and the precision and dexterity of the robotic instruments facilitated manipulation of the uterus and dissection of the retroperitoneal space allowing for efficient and safe removal of this bulky uterus in a minimally invasive manner. Approach to the side-wall to side-wall uterus is discussed and techniques for manipulating and removing such a large structure are illustrated.

11.354 Gynecology
Injury of the Branches of the Inferior Vena Cava During Operative Laparoscopy 
Abdulrahim A. Rouzi, MB, ChB, FRCSC, Wafa Sait, MB, ChB
Department of Obstetrics and Gynecology, King Abdulaziz University, Jeddah, Saudi Arabia (all authors).

Objective: We report the case of a patient who underwent immediate laparotomy for retroperitoneal hematoma during operative laparoscopy.
 
Methods and Procedures: A 20-year-old lady underwent operative laparoscopy for removal of a persistent and symptomatic 7 x 6-cm left ovarian cyst. Her weight was 105kg, and her height was 165cm. Abdominal examination revealed no masses. With the patient under general anesthesia, entry through the umbilicus was not possible. The left subcostal route was used. Visualization of the entry site revealed hematoma. The decision was made to stop and convert the procedure to laparotomy. The vascular surgeon was consulted. The patient's vital signs changed, and she went into shock. Exploration of the abdomen showed retroperitoneal hematoma around the inferior vena cava, which was managed by pressure. Resuscitation with intravenous fluids and packed red blood cells was done. The hematoma was opened and evacuated. There was no injury to the major blood vessels, and the bleeding point was not identified. Evacuation of the hematoma was achieved. Left ovarian cystectomy was also performed. 




Results: The patient had an uneventful postoperative period and went home on the fifth postoperative day in good condition. 



Conclusion: Immediate laparotomy is necessary in some iatrogenic retroperitoneal hematomas during laparoscopy.

11.355 General Surgery
A Hit and A Miss: Incidental Finding of a Cholecystohepatic Duct During Laparoscopic Cholecystectomy and Hepatic Injury with a Laparoscopic Peanut Dissector
Adeyemi A. Ogunleye, MD, SM, Charan Donkor, MD, Giuliana L. Gallagher, Hector A. DePaz, MD
Department of Surgery, Harlem Hospital Center, Columbia University College of Physicians & Surgeons, New York, New York, USA (Drs. Ogunleye, Donkor, DePaz).
Sophie Davis School of Biomedical Education Physician, The City College of New York, New York, New York, USA (Dr. Gallagher).

Objective: We report 2 important unexpected events in a laparoscopic cholecystectomy performed on a 56-year-old hypertensive female with acute-on-chronic choleystitis.

Methods and Procedures: The patient underwent a standard 4-port laparoscopic cholecystectomy performed while she was under general anesthesia.

Results: During gallbladder dissection from the liver bed, a solitary whitish duct-like structure was observed straddling the dissection plane, coursing from the gallbladder to the caudate lobe of the liver. The structure was identified as a cholecystohepatic duct. The duct was isolated, clipped, and divided.

A laparoscopic peanut dissector being used to increase exposure of the gallbladder bed during irrigation and hemostasis inadvertently caused a 1-cm hepatic laceration. The bleeding laceration was cauterized, and a Jackson-Pratt drain was left in the subhepatic space and removed on the second postoperative day after the patient made an uneventful recovery.

Conclusion: Our report highlights the risk of bile leaks due to aberrant cholecystohepatic ducts and an inadvertent liver laceration from a peanut dissector. Awareness of the possibility of these injuries will guide surgeons to increase vigilance during gallbladder dissection and make safer operative technique choices.

11.356 General Surgery
Robotic Repair of Median Arcuate Ligament Syndrome
Abbas Abbas, MD, Saleh A. Massasati, MD, Hernan Bazan, MD, Jay Luke, MD, 
Mathew Gaudet, MD
Ochsner Medical Center, New Orleans, Louisiana, USA (Drs. Abbas, Bazan, Luke, Gaudet).
Tulane University School of Medicine, New Orleans, Louisiana, USA (Dr. Massasati).

Background: Median arcuate ligament syndrome (MALS) is an uncommon, nevertheless significant, cause of abdominal pain. There have been reports of laparoscopic dissection of the median arcuate ligament providing relief of symptoms. Robotic-assisted laparoscopy for treatment has recently been described as well. Robotic-assisted laparoscopy provides for a precise dissection around the aorta, its branches, and nerves. Here we provide a case of a MALS, description of the operative technique, and postoperative outcome.



Methods: A robotic-assisted laparoscopic dissection of the median arcuate ligament was performed in a patient by using the da Vinci Si Surgical System. One 12-mm supraumbilical port is placed for the camera. A 5-mm port is placed in the right flank for the liver retractor. Three 8-mm robotic ports are then placed in the left flank, right and left subcostal. A combination of Harmonic scalpel and permanent hook cautery were used to divide the tissues and the offending fibrous bands.



Results: The patient underwent a successful operation with an uncomplicated postoperative course. She had subjective relief of symptoms. There was notable improvement in celiac artery velocity compared to preoperative mesenteric duplex.



Conclusion: Robotic-assisted laparoscopy is gaining acceptance in many general surgical operations. The robotic approach to surgical resolution of median arcuate ligament syndrome is safe and has met with excellent outcomes, subjective and objective alike.



11.357 General Surgery
Single-Access Laparoscopic Colonic Resections with Further Reduced Invasiveness: Feasible and Reasonable?
K. H. Vestweber, E. Staub, F. Haaf, A. Alfes, P. H. Lingohr, B. Vestweber

Background & Objectives: Laparoscopic colon resections have gained worldwide acceptance. Natural orifice access is still problematic, at least through the stomach, vagina, and the colon. To minimize the number of necessary skin incisions further, an attractive possibility is to use only one port as a single access for bowel resections.

Methods: We developed a technique utilizing the SILS-Port together with an ALEXIS-wound protector for entering the abdomen through an approximately 2.5-cm transumbilical incision (technical details are shown in short video clips). Three instruments can be inserted.

Results: Since July 2009, 245 patients have had SILS-bowel-procedures. The majority of procedures were left-sided colon resections (sigmoidectomies for diverticulitis, 145). But also, right and left hemicolectomies, total colectomies, ileocecal-resections, and rectum resections could be done. There were no mortalities and a low complication rate. Median operative time was 145 minutes for sigmoidectomies. Various procedures can be illustrated by short video clips.

Conclusion: Single-incision laparoscopic bowel resections via the umbilicus are feasible with operative time and complications comparable to those of conventional laparoscopic procedures. It is an attractive procedure for many patients because usually no scar can be seen.

11.358 General Surgery
A Novel Softly-tethered Camera Robot Enabling Multi-instrument Access in Laparoendoscopic Single-site Surgery: Preliminary Experience
Giancarlo Basili, MD (*), Massimiliano Simi, MscBE (§), Dario Pietrasanta, MD (*), Irene Mosca, MD (*),  Pietro Valdastri, MD (§), Paolo Daio, Prof (§), Orlando Goletti, MD (*)
(*) General Surgery Unit, Pontedera Hospital, Health Unit 5 Pisa, Italy
(§) The BioRobotics Institute, Scuola Superiore Sant’Anna

Introduction: Magnetic cameras hold the promise to improve triangulation and prevent instrument collisions in LESS surgery. However, manual movement of the external magnet, trans-abdominally coupled with the camera, may result in an unstable video stream. We describe a preliminary experience with a softly-tethered camera robot, with diameter compatible with a standard 12mm trocar. Thanks to its reduced dimensions, the proposed system can be introduced through a channel of a standard LESS multiport.

Methods: The camera tilting module hosts a laparoscopic 500x582 CCD imager, LED-based illumination, two donut-shaped magnets, and a robotic mechanism to precisely adjust the tilt angle. This module is connected to a second one to enable panning. Manual translation and panning are obtained by moving an external handle, while precise robotic tilting by operating a pushbutton interface.

A small bowel resection with intracorporeal anastomosis was performed using a SILSTM port and introducing the camera robot through a 12mm standard trocar.

Results: Device introduction and magnetic coupling were trivial. All three cannulas available in the port were used for introducing articulated instruments, thus improving procedure outcomes. Once the camera was manually moved and panned towards the surgical scene, fine adjustments of the tilt angle were obtained using the robotic mechanism. Bowel manipulation was carried out without too much difficulty as the camera allowed complete exploration through different points of view.

Discussion: Improved triangulation, instrument collision prevention, organ inspection from multiple sides, image stability during operation were further features confirmed by this preliminary experience.

11.359 Multispecialty
Laparoscopic Ventral Mesh Rectopexy for Internal Rectal Prolapse
Sara Lazzaro MD, Luana Franceschilli MD, Giulio P. Angelucci MD, Elisabetta De Luca MD, Stefano D’Ugo MD, Achille L. Gaspari MD, Pierpaolo Sileri MD, PhD
University of Rome Tor Vergata, Rome Italy

Background and objective: Laparoscopic Ventral Mesh Rectopexy is a novel and effective procedure to correct rectal prolapse. Over the last decade biological mesh have been used to correct pelvic floor disorders, but literature data is scant. In this study we present our experience with this procedure using biological mesh.

Methods: Prospectively collected data on Laparoscopic Ventral Mesh Rectopexy were analysed. All patients underwent preoperative defaecating proctography and/or pelvic dynamic MRI, full colonoscopy, anal physiology studies, and endo-anal ultrasound.

End-points were surgical complications and functional results such as changes in bowel function (Wexner Constipation Score and Faecal Incontinence Severity Index-FISI) at 3 and 6 months.

Results: Thirty-three patients underwent Laparoscopic Ventral Mesh Rectopexy with a median follow up of 6 months. Twenty-eight patients (85%) had a constipation score >5, while 12 (36%) a FISI score >10. Five patients (15%) had mixed obstructed defecation and faecal incontinence.

One patient required conversion to open (3%). Median length of stay was 2 days. Overall morbidity rate was 21% including 2 transient subcutaneous emphysemas, 2 urinary tract infections, 1 sacral pain, 1 wound haematoma and 1 adhesional small bowel obstruction. Preoperative constipation (median Wexner score 17) and faecal incontinence (median FISI score 11) improved significantly at 3 months (Wexner 4, FISI 5, both p<0.001). Two patients (6%) required Stapled Trans-anal Rectal Resection for persisting symptoms within 1 year after surgery.

Conclusions: Laparoscopic Ventral Mesh Rectopexy using biological mesh is safe and effective in ameliorating symptoms of obstructed defecation and faecal incontinence.

11.360 General Surgery
Adhesional Small Bowel Obstruction After Open and Laparoscopic Colorectal Surgery: A Prospective Longer-Term Study 
Authors: Pierpaolo Sileri MD, PhD, Luana Franceschilli MD, Stefano D’Ugo MD, Sara Lazzaro MD, Nicola Di Lorenzo MD, PhD, Achille L. Gaspari MD
Department of Surgery, University of Rome Tor Vergata, Rome, Italy

Background and Objective: Open colorectal surgery leads to high rates of adhesive small bowel obstruction (SBO). We evaluated the cumulative incidence of access related complications in a cohort of patients who underwent open and laparoscopic colorectal surgery.

Methods: Case notes of elective or emergency colorectal surgery patients were studied for SBOs requiring admission or re-interventions. Data were analyzed using Mann-Whitney U, chi-square and Kaplan Meier tests.

Results: From 01/03 to 11/10, 911 patients underwent elective (52.6%) or emergency (47.4%) colorectal surgery (68.7% open and 31.3% laparoscopic). Median follow-up was 46.2 months. Sixty-three patients (6.9%) experienced 83 SBOs and 22 required surgery (2.4%). There was a large variation in the time of first SBO occurrence, 43.9% occurred within 3 months, 29.3% between 3 and 12 months and 26.8% after 1 year. The risk of surgery at first admission for SBO 24.1% and the number of readmissions predicted the need of surgery. The risk of reoperation was greatest during the first year after CRS and steadily raised every year thereafter. SBO was higher after pelvic surgery or extensive resections compared to minor procedures (13.8% vs 3.1%; p<0.001).

Likewise, SBO risk was higher after elective compared to emergency surgery (11.1% vs 6.9%; p=0.03), but similar after open compared to laparoscopic surgery (9.9% vs 7.3%; p>0.05). Any previous or additional surgery raised the overall risk of SBO from 5.4% to 16.4%.

Conclusions: Colorectal surgery results in significant ongoing risk of SBO according to the colorectal type of procedure.