20TH SLS ANNIVERSARY MEETING AND ENDO EXPO 2011 LAPAROSCOPIC UPDATE ABSTRACTS
Thursday, September 15, 2011 Beverly Hills
The Current State of Minimally Invasive Surgery for the Gallbladder and Biliary Tract
Edward H. Chin, MD
Since the first laparoscopic cholecystectomy was performed in 1985, significant progress has been made for surgery on the gallbladder and biliary tract. Minimally invasive surgery has become the gold standard for the treatment of gallstone disease, and laparoscopic cholecystectomy has become one of the most common elective abdominal procedures performed. While NOTES cholecystectomy (natural orifice transluminal endoscopic surgery) received much attention in its early period, interest in NOTES has decreased substantially, which can be attributed in part to the rising popularity of LESS (laparoendoscopic single site) cholecystectomy. First reported in 2008, laparoscopic cholecystectomy performed through a single umbilical incision now has several hundred articles published in peer reviewed journals. Proposed benefits of LESS cholecystectomy include better cosmesis, decreased pain, and higher patient satisfaction. Techniques for LESS cholecystectomy include the use of multi-port access devices and flexible laparoscopes and instruments to completely conventional equipment and trocars. Laparoscopic bile duct exploration is also an important tool for the minimally invasive surgeon. The current state of minimally invasive cholecystectomy and biliary tract surgery will be presented.
Thursday, September 15, 2011 Brentwood
Overview and Update on Robotics in Benign Gynecology
Aileen Caceres, MD
Robotic technology is continuously changing with its utility becoming increasingly prevalent in benign gynecologic surgery. An overview of robotics demonstrates that the technology has been available with application for common gynecologic procedures such as hysterectomies, myomectomies and adnexal masses. With more advances and training, its utility has been expanded to include its application to more complex procedures such as pelvic adhesive disease, tubal re-anastomoses, and sacrocolpopexies. Even though robotics can be utilized for many procedures in benign gynecology, physicians may face multiple barriers in adopting the technology. Challenges exist with learning curves, access to the operating room robot, and associated costs. Robotic procedures may confer the same benefits as laparoscopic surgery without additional complications, but more information is needed in this area. The advantages to robotic surgery include improved visualization of the operative field with increased dexterity allowing more precise movements. More information is needed in understanding adoption rates, learning curves, and complication associated with robotics in benign gynecology.
Update on Laparoscopic Evaluation of the Female Infertility Tract
Hugo C. Verhoeven, Prof Dr Med
The implementation of ambulatory surgical procedures in endoscopic surgery has been inspired by several coincidental factors. First, there is a necessity to reduce the cost of interventions because of government restrictions on payments, and second, there is a general tread to reduce the invasiveness of endoscopic procedures, thus pushing companies to develop smaller endoscopes without loss of optical quality. As accuracy of smaller-diameter endoscopes with very high optical quality is comparable with that of larger endoscopes, surgeons were inspired to become less invasive at surgery and to use smaller instruments. As a result, performing diagnostic procedures and minor interventions under local anesthesia became possible. Despite these advances, ambulatory surgery must not diminish the quality of care for patients. For the patient's benefit and also for medico-legal reasons, full laparoscopies have to be performed in a fully equipped operating theater. Ambulatory surgical procedures must offer patients the requirements of classical surgery in terms of safety and quality.
Ambulatory reproductive surgery involves both uterine and tubo-ovarian interventions. All intrauterine pathology, congenital and acquired, related to reproduction can be treated in a 1-day clinical setting. As for tubo-ovarian surgery, endometriosis coagulation, resection of endometrioma and ovarian capsule drilling can be performed.
The introduction of small-diameter endoscopes of high optical quality facilitates the success of minimal access surgery. However, the final invasiveness of the procedure is in the hands of the reproductive surgeon. As for microsurgery, a minimal invasive approach is not only a matter of technique, but also and essentially of philosophical and personal attitude.
Fertiloscopy/Transvaginal Endoscopy Update
Antoine A. Watrelot, Prof Dr Med
Since it has been demonstrated that fertiloscopy is the instrument of choice to detect any pelvic abnormalities including subtle tubal abnormalities,1 we have studied the impact of such pathology on fertility using fertiloscopy.
Recently several works have emphasized the importance of hydatid of Morgani2 on fertility but we have also seen that all subtle abnormalities seems to have an impact such accessory tube, ampullary sacculation, congenital phimosis as well as big para tubal cyst.
We report our series of operative fertiloscopies and laparoscopies performed to treat these abnormalities with a good crude pregnancy rate (42%) obtained in less than 6 months.
It seems therefore important to detect and treat any tubal pathology prior to ART when infertility seems unexplained.
For this purpose, fertiloscopy allows to achieve this goal in a very safe and mini invasive way.
1. FLY study Watrelot, A et al. Human Reprod 2006.
2. Rasheed SM EJOG 05-2011.
Challenges of Uterine Fibroids
Liselotte Mettler, Prof Dr Med
LPS Management of Endometriotic Ureteral Involvement
Alfonso Rossetti, MD
Endometriosis is a disease of the peritoneum and infiltrating the retroperitoneal spaces involving the pelvic organs like bowel, bladder, ureters , sometimes with neurovascular infiltration.
Usually the ureteral dissection is mandatory for the removal of the posterior leaf of the broad ligament involved with endometriosis during the removal of endometriomas, or to open the pararectal spaces for the excision of the rectovaginal septum endometriosis.
But sometimes the ureter presents an obstruction often due to the “ab estrinseco” compression caused by endometriosis and fibrosis of the peritoneum and of the retroperitoneal space.
Usually in these cases ureterolysis is feasible. When the obstruction is very low and very severe, it can be useful to dissect also the hypogastric artery and the uterine artery. The uterine artery is followed from its origin, dissecting the fibrotic tissue underneath while freeing the ureter.
The endometriotic infiltration can sometimes involve the ureteral wall.
In these cases the segmental resection is mandatory followed by termino-terminal reanastomosis if the length of the ureter is enough for allowing a tension-free suture.
If the ureter length is not enough, it is mandatory to perform the ureteral reimplantation into the bladder and, when needed, fixing the bladder to the Psoas muscle (Psoas hitch).
Advanced Gynecologic Oncology Update - Robotic Pelvic Exeneration with Intracorporeal Urinary Diversion: A Case Series
Salvatore LoCoco, MD
Objective: The purpose of this review is to describe our experience with offering all candidates for pelvic exenteration a minimally invasive approach utilizing the daVinci Robotic platform.
Materials: In our database of all gynecologic oncology patients seen between 31 May 2007 and 6 July 2011 between 2 institutions, we have taken 10 consecutive patients to the OR for a robotic approach to pelvic exenteration.
Results: We offered all patients a robotic attempt at pelvic exenteration. We have completed 5/10 successfully with the daVinci Robotic Platform. In 3 of the last 4 cases we successfully completed an intracorporeal ileal conduit. Morbidity included 2 UTIs while urinary diversion catheters were in place, 2 patients had a prolonged adynamic ileus. There were no patients with DVT/PE, no wound infections and no perioperative deaths.
Conclusions: We have clearly been able to demonstrate the feasibility of pelvic exenteration utilizing the daVinci; Gynecologic oncologists familiar with performing the procedure in an open manner must "translate" maneuvers employed through open techniques to a closed space utilizing a 3D High-def immersive view while getting familiar with this technology. We have worked through the steps in order to describe the procedure. This is critical information to share in order for us to work together as a specialty to generally decrease the morbidity of open surgery. For those of us in education, as we "translate" our procedures from open to robotic, the paradigm shift will come when we are teaching procedures such as robotic pelvic exenteration as the principle procedure.
Future Technologies in Gynecologic Surgery, 2011
Jessica Ybanez-Morano, MD
Background: There has been so much attention given to the trends in various approaches for hysterectomy. The focus on minimally invasive techniques is advocated strongly. In 2003, approximate rates have been cited that abdominal approach is 66%, vaginal approach is 22% and laparoscopic approach is 12%. In the recent few years, the advocacy for minimally invasive procedures has been emerging by new development of equipment, devices, instrumentation and educational forums. This review will focus on the future technologies in gynecologic surgery.
Objective: The appraisal of the technologies available will highlight the new innovations useful in minimally invasive gynecological surgery. The review will focus specifically on energy based devices, laparoscopic access for classic multi-ports and single-port, optics, endoscopic suturing devices and endoscopic instruments.
Methods: The evaluation included investigation, assessment and inquiry with the various opportunities, prospects and options in the research and development for gynecological instruments. This was undertaken by review of current data and interviews of the various surgical device manufacturers. This presentation also delineates the objective, advocacy and focus on minimally invasive approaches for gynecology.
Conclusion: Minimally invasive surgery for gynecology is facilitated with the future development of equipment, devices, and instrumentation. The need for educational opportunities for the surgeons is crucial. It is indispensable to stay current, gain competency and proficiency with the dynamic emerging technical developments.
Thursday, September 15, 2011 Encino
Robotic Assisted Microsurgery: Vasectomy Reversal & Groin Pain Procedures
Sijo J. Parekattil, MD
Since its inception in the early 2000’s, robotic assistance with urologic procedures continues to expand. The magnification, three dimensional visualization, and surgical control offered by the latest daVinci® Si-HD system has led to its integration into microsurgical procedures for male infertility. The addition of robotic assistance may allow an improvement in outcomes similar to when the operating microscope was introduced in microsurgery. Though the use of robotics in microsurgery is still in its early phases, initial findings are encouraging.
This presentation covers robotic microsurgical procedures and tools for male infertility and chronic orchialgia/ testicular pain such as: vasovasostomy, vasoepididymostomy, targeted denervation of the spermatic cord and targeted abdominal denervation. Preliminary human clinical studies appear to show improved operative efficiency and comparable outcomes. The use of robotic assistance during robotic microsurgical vasovasostomy appears to decrease operative duration and improve the rate of return of post-operative sperm counts compared to the pure microsurgical technique.
Long-term prospective controlled trials are necessary to assess the true benefit for robotic assisted microsurgery. The preliminary findings are promising, but further evaluation is warranted.
Thursday, September 15, 2011 Santa Monica
Tele-Surgery with Haptic Sensation - The Renaissance of Abdominal Surgery
Michael Stark, Prof Dr Med
The 19th century was the era of abdominal surgery, whereas the 20th century became the era of endoscopy with further developments in the last 20 years, when some so-called “robotic” systems were introduced with the purpose of value-added accuracy and precision. The description of these systems as “robots” is misleading, as no artificial intelligence is behind them, but they might play a major role in operation theatres in the 21st century.
These systems improved surgical results in some disciplines, such as urology, due to better ergonomics as well as non-tremor and articulated instruments, however the main issue remained unanswered, namely, lack of haptic sensation.
Musicians use their fingertips to play the piano or manipulate strings. The feedback they get is the key for sensitivity and excellence. Surgeons traditionally used their fingertips when holding scalpels or forceps, and when palpating anatomical and pathological findings. When endoscopy was introduced, palpation and sight became indirect, and the use of the fingertips was abandoned.
Many of the endoscopic instrumentation are manipulated by the fists or by the proximal part of the fingers. The optimal future surgical tools should follow the principle of “Back to the fingertips”.
To answer this issue a new concept has been evolved through a novel system, the TELELAP Alf-x, which is a joint project of the EU commission, SOFAR in Milan and the NESA. This is an advanced tele-surgical system which enables the surgeon to feel the consistency of the tissues with newly designed handles enabling delicate movements and tactile feedback enabling the detection of hidden structures such as lymph nodes, and, at the same time, to feel the force exerted while stitching and tying knots.
In extensive preclinical studies, the system has proven to be efficient and reliable. It includes 3D vision and an eye-tracking system, the latter of which serves as a safety tool. In addition to the activation of the required instrument by looking at the respective icon displayed on the screen, the system’s arms will stop any movement should the surgeon lose sight of the operative site, and will move any spot looked at to the centre of the screen.
Although operating endoscopically with all the advantages involved, the surgery feels very similar to laparotomy. It therefore becomes the “prodromos” (forerunner) of a new surgical era, namely the “Renaissance of the abdominal surgery”.
Various operations, such as hemicolectomy, have been done experimentally. These operations proved further advantages, such as extremely quick docking and a high degree of versatility.
Parallel to the technical development, evidenced-based optimized surgical methodologies are designed by an international team of opinion leaders in endoscopy. This will secure the accuracy and safety of this surgical system.
Endoscopic Anti-reflux Procedures for Reflux Disease
Charles Filipi, MD
Successful endoscopic anti reflux procedures for gastroesophageal reflux disease (GERD) have been elusive. Ever since Paul Swain, an English gastroenterologist developed EndoCinch with Bard Medical there has been a growing pessimism about the benefit of the endoscopic approach for GERD. Many devices have been tried without objective (pH monitoring normalization) success and although Esophyx data is improved, the durability and true effectiveness is still unknown.
I have been engaged in this area of research for 20 years, first performing anti-reflux in baboons in 1992. There have been multiple clinical trials and I have learned several lessons that have been recently applied to a new procedure. Mucosa to mucosa suturing does not work, scar tissue may work in decreasing the compliance of the gastroesophageal junction (GEJ) (the Stretta procedure) and any surgical manipulation under tension, as in the Nissen fundoplication, must be substantial and with full thickness sutures.
We have worked on a new procedure and set of devices that excises mucosa at the GEJ and then places full thickness sutures within the excision beds to create substantial scar tissue at the GEJ on the greater curvature side; where tissue attenuation occurs with a failed valve. The procedure will be described and preliminary clinical results reviewed.
Bariatric Update
Alex Gandsas, MD, MBA
This year update will focus on new procedures such as the gastric plication and how it is compared to the sleeve gastrectomy when it comes to choose an effective metabolic operation.
We will elaborate on the federal government's decision to make the LapBand available to patients with a BMI between 30 to 35 kg/m2, suffering from at least one obesity-related medical condition and its financial impact on the overall cost of health care.
Concomitantly, insurance companies are on the alert pushing for a more robust and creative cost containment strategies such as “out patient bariatric surgery” programs.
The debate also continues regarding the efficacy of emergent technologies such as the single incision laparoscopy surgery or SILS, endoscopy approaches for weight loss and the use of robotics in bariatric surgery.
Thursday, September 15, 2011 Sherman Oaks
Laparoscopic Training Update
Elizabeth Ball, MD, PhD
With the rise in numbers of laparoscopic interventions and the decrease in training time viable options for achieving competency must be found.
According to Malcolm Gladwell the pathway from novice to expert takes 10,000 hours of training.
It is no longer acceptable for trainees to operate on patients at the start of the learning curve. Simulator training is becoming more acceptable and part of curricula and to achieve basic skills before moving to the OR. We examine how simulator training has been delivered traditionally and present the benefits of novel concepts of open access labs with modular training and take home trainers combined with modular courses.
Core Competencies Update
Gustavo Stringel, MD, MBA
The six core competencies of Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism and Systems Based Practice, were endorsed in 1999 by the Accreditation Council of Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS).
These competencies are now an active part of the education of surgical residents. The general competencies were designed to emphasize educational outcome assessments during residency and in the accreditation process. All residents must develop competency in all six areas in order to graduate.
The new emphasis of surgical programs is to graduate surgeons who are competent and who are able to provide quality of care in a safe environment to produce the desired outcomes. It is important for the surgeon, not only to obtain desired outcomes comparable to that of others, but to deliver this care in a confident, empathetic, humane, personal, and respectful manner. The surgeon must also deliver this care in a financially responsible manner. It is especially important for the laparoendoscopic surgeon to be able to work in a technologically advanced environment since many of the procedures performed are technically demanding and equipment dependent.
The American Board of Surgery has incorporated some of the core competencies in the Maintenance of Certification Program (MOC). The new certification process requires Evidence of Professional Standing, Commitment to Lifelong Learning and Self-Assessment, Cognitive Expertise and Evaluation of Performance in Practice.
The surgeon must comply with all these requirements in order to maintain certification by the American Board of Surgery.
Updates from the Simulation Special Interest Group
Thomas S. Lendvay, MD
Surgical simulation curriculum has evolved from being an afterthought to being an integral part of surgical education for the surgeon and for the patient. In an effort to reduce medical errors among surgical trainees and practicing clinicians, various simulation methodologies are being explored. The two most promising areas of research and practice are in the use of surgical pre-rehearsal: the use of pre-procedural ‘warm-up’ and the use of patient-specific simulation. Although the literature is still sparse for surgical warm-up and only a few groups have described warm-up in the operating room, preliminary data show performance benefits when using a virtual reality (VR) or dry lab simulation curriculum prior to surgery. The use of simulators modeling robotic and laparoscopic surgery remain expensive and it is conceivable that off-the-shelf video gaming platforms and perhaps hand-held devices with video-game ‘Apps’ directed at key surgical tasks will be employed.
The follow-on to pre-procedural warm-up is the use of the patient’s own pre-operative imaging and health information to model a virtual reality operative case scenario. Already some groups have been able to take pre-operative CTs and generate VR representations of the target anatomy, it’s vasculature, and surrounding organs, import these data into a laparoscopic module, and provide the surgeon with a means of ‘doing the surgery’ before doing the surgery. Other groups are tackling patient-specific tissue modeling through tissue deformation research.
The surgeon, however, is not the only potential benefactor of surgical simulation. Some groups are exploring the use of VR simulation as part of patient education. Either for improving medical knowledge to enable patients to have an active role in their health care or for enhancing surgical understanding for informed consent, simulation may prove to be a surgeon’s most reliable means of bringing a patient to an enlightened state about their care.
Pediatric MAS - Equivalent or Better?
David W. Bliss, MD
The rapid adoption of minimal access procedures across the range of Surgical specialties has been perceived as a significant advance in minimizing pain and improved cosmesis, recovery, intracavitary adhesions, and patient satisfaction. A growing body of data supports many of these assertions in Adult Surgery. However, while Pediatric Surgeons have been early adopters of these approaches and have innovated many operations, they have only recently begun to rigorously study the differences between open and minimal access procedures.
There is a broad repertoire of MAS operations being performed on children ranging in age from premature newborns to adult-sized teenagers. There has been nearly universal adoption of laparoscopy for pyloromyotomy, appendectomy, cholecystectomy, and gastroesophageal fundoplication. In addition, a growing number of Pediatric Surgeons are now performing complex procedures including major thoracic (esophageal atresia, diaphragmatic hernia, anatomic lung resection), hepatobiliary (choledochal cyst, biliary atresia, hepatic resection), oncology (biopsy and/or resection of Wilms tumor, Neuroblastoma), and gastrointestinal (atresia, colectomy and ileoanal pull-through, Hirschsprung’s disease, and anorectal malformations).
Until recently, reported series were small and were lacking comparison groups. However, Pediatric Surgeons have begun publishing better retrospective studies with control groups and have generated comparative trials to objectively evaluate the merits of MAS. From Nissen fundoplication, pyloromyotomy, and appendectomy to more complex matters such as anorectal reconstruction and congenital diaphragmatic hernia, there is a growing body of data to support that MAS is at least comparable to open approaches and, in select circumstances, seems to have improved outcomes.
Friday, September 16, 2011 Brentwood
Incorporating Robotic Surgery Training into Ob/Gyn Residency Training
Cecelia Boardman, MD
Objective: To determine the effect of implementation of a formal DaVinci robotic surgery training curriculum on Ob/Gyn resident surgical training.
Methods: Review of resident surgical logs.
Results: A formal DaVinci surgical curriculum was developed and implemented in 2008-2009 academic year. This consisted of completion of the online DaVinci tutorial and test, equipment identification test, DaVinci system familiarization and console training, dry lab simulation, proctored experience as the bedside assistant, and completion of ten proctored cases as the primary surgeon at the console. Resident role, type of case, and console time was tracked in a procedure log. In January 2009, the first obstetric and gynecology resident completed the first proctored DaVinci hysterectomy at the console. Of the six residents in the class of 2009, two graduated with robotic certification, one with twelve console cases and the other with eleven. The remaining residents completed cases on the console but required five to seven additional proctored cases to gain full endorsement from the residency program. Three graduates from the class of 2010 received robotic certification with twenty two, seventeen, and twelve cases respectively. The remaining three graduates required less than five additional proctored cases for endorsement. The graduating class 2011 all completed the requirements for robotic certification, having begun their chief year with one to eight cases at the console as junior residents.
Conclusions: DaVinci robotic surgical training can be rapidly incorporated into an Ob/Gyn residency program through the introduction of a formal curriculum.
Robotic Myomectomy: The Complete Minimally Invasive Solution
Leslie S. Kardos, MD
Uterine myomas occur in 25-30% of reproductive age women. They are the cause for many of the 600, 000 hysterectomies performed annually in the U.S. Many women, however, wish to preserve their uterus and their future fertility. The AAGL stated this year that all women needing hysterectomy for benign disease should be offered a minimally invasive( MI) surgical approach. What will their position be regarding myomectomies?
Myomectomy can be challenging using traditional laparoscopic techniques. Myomas are often large, numerous, located in the posterior uterus or broad ligament. These challenging locations may lead to conversions or at best very long laparoscopic proceedures. The majority of myomectomies are still done through open incisions because of these limitations. The advent of barbed suture has made three layered closures easier but the most crucial aspect of a myomectomy is a successful uterine reconstruction, which will allow for future pregnancy if so desired.
Robotic myomectomy (RM) is a more flexible approach. Wristed instruments allow the surgeon to move around complex pathology. The ability to do easy intracaporeal suturing allows for quick and complex repairs of the uterine defects. There are no limitations by fibroid location, relative number or size ( as long as one can place laparoscopic ports). The one limitation is lack of haptics which is overcome by practice. RM generally results in less blood loss, pain and fewer conversions to open surgery for the patient. This is a patient centric procedure. There are also better ergonomics for the surgeon.
I have followed 88 RM prospectively in my private practice and have followed 11 of their subsequent completed pregnancies, two pregnancies in progress ( second and third trimester) and three miscarriages (first trimester). There were no placental abnormalities, no preterm labor or complications thus far. Based on this preliminary case series, I feel RM is the optimal way to offer reproducible, MIS surgery to patients requiring myomectomy. I think it will allow more patients’ access to MIS for their myomectomies. I will share data and video to demonstrate my point.
Strategies for Difficult Laparoscopic Myomectomy
Ornella Sizzi, MD
Objectives: We have evaluated how experience helped to overcome problems related to approaching difficult myomectomies through laparoscopy. When dealing with larger myomes, the preoperative workouts are explained and different trocar positions are underlined. We have statistically evaluated how the learning curve, improving in surgical devices or changing in technique have influenced our procedures and to study intra- and post-operative complications and characteristics influencing this risk.
Design: We analyzed as the use of vasoconstrictive agents or different techniques of suturing have influenced operating time and blood loss. To study complications we have considered 2050 patients who were operated on in Four Italian Referral Centres by 5 already experienced surgeons during six years.
Results: Data showed significantly reduced Hb drop after introduction in 1998 of the use of vasoconstrictive agents (∆ Hb 1.62 gr/100 ml versus 0.95; p< 0.001). The running suture had advantages in term of haemoglobin drop (∆Hb 1.1 gr/100 ml vs 0.61, p<0.01). Total complication rate was 11.1%: minor complications 9.1%, major complications 2.2. Odds ratio computed to estimate the risk of complications, showed that the probability of complications significantly rises with an increase in the number (OR: 4.46, P <.001), and with intramural (OR: 1.48, p <0.055) or infraligamentous myomas (OR: 2.36, p < 0.01) while the myoma size seems to influence particularly the risk of major complications (OR: 6.88, p< 0.001).
Conclusion: Over the years the experience, the technical improvements and the clinical results have changed our approach and decision making regarding laparoscopic myomectomy. The complication rate appears to be better than acceptable in comparison with complication rates reported after laparotomic myomectomies.
Feasibility of Robot-Assisted Versus Standard Laparoscopy in the Treatment of Pelvic Pain Indicative of Endometriosis
John Dulemba, MD
Objective: To examine the feasibility of treating pelvic pain in patients with suspected endometriosis using robot-assisted laparoscopic techniques compared with standard laparoscopy.
Design: A retrospective review from a single surgeon’s practice, including the first 180 robot-assisted and the last 100 standard laparoscopic surgeries.
Setting: Private practice gynecology clinic.
Patients: Consecutive series of patients with pelvic pain who had surgery between December 2004 and January 2010.
Interventions: Comparison of perioperative outcomes and postoperative pain in patients who had robot-assisted versus CO2 laser laparoscopy for pelvic pain.
Measurements and Main Results: Patients were comparable on gravidity, BMI, prior endometriosis, prior abdominopelvic surgery, AFS stage, and biopsy rates. Operative time (77 vs. 72min), blood loss (29 vs. 25mL), and complication rates (1.1 vs. 0%) in robotic vs. standard laparoscopy were low and similar for both approaches. Differences were apparent in biopsies confirming endometriosis (all: 80 vs. 56.8%, robot vs. standard, p<.001; appendiceal: 28.6 vs. 3.3%, p=.015). Most patients reported improved postoperative pain (85% vs. 80%, p=.365); however, among those with the most severe disease (AFS stage = IV), a significantly greater proportion of robotic than laparoscopic patients experienced pain improvement (96.2% vs. 58.8%, p = .007).
Conclusions: Perioperative outcomes were achieved with robotic surgery, comparable to those using standard laparoscopy. Robotics provided better visual acuity identification, and excision of endometriosis, as confirmed on biopsy.
Eccentric Hysteroscopy: Expanded Utilization
Stephen A. Grochmal, MD
Hysteroscopy is one of the oldest endoscopic procedures described in the medical literature and was first performed by Pantaleoni in 1869. Until recently, diagnostic and operative hysteroscopy had been an underutilized and challenging procedure for the majority of practicing gynecologists. Due to a concerted effort by specialty organizations (like SLS) promoting hysteroscopy training venues in conjunction with improved technologies from device manufacturers, the interest, enthusiasm and utilization of hysteroscopy is now on the rise. Hysteroscopy is considered the platinum standard for diagnosing, sampling, and treating intrauterine disease and is recognized as a safe, office-based procedure. But this is only the beginning. As hysteroscopy continues to become de rigueur in the treatment repertoire, we can anticipate an expansion of novel and unique (eccentric) applications.
This update provides a brief overview of hysteroscopy’s evolution with a focus on new “outside the paradigm” procedure applications and techniques expanding the hysteroscopy envelope as we know it. The latest technological advances and accoutrement for improving the performance and safety of hysteroscopy procedures resulting in enhanced standard of care will be discussed. Although often difficult to look ahead and imagine the future, novel hysteroscopy design concepts influenced by third generation nanotechnologies will also be highlighted. Lastly, we discuss unique situations where hysteroscopy procedures have crossed over to other medical specialties leading to enhanced patient care. In conclusion, we may ponder the conundrum if these are really eccentric, expanded applications or just evolutionary next steps?
Comparison of Robot-Assisted Hysterectomy to Laparoscopic Assisted Hysterectomy. Revolution or Evolution?
Ceana Nezhat, MD & Adi Katz, MD
Objective:
1. At the conclusion of this presentation, participants will know the advantages of robotics.
2. At the conclusion of this presentation, participants will know the drawbacks of laparoscopic assisted surgery compared to robot-assisted surgery.
Summary: Despite the proven benefits of laparoscopy and minimally invasive surgery in other disciplines, its application in hysterectomy has been much lower than expected. Among the more than 600, 000 hysterectomies done in the US, 65% are done by laparotomy. Only about 10% of all hysterectomies are performed laparoscopically (Whiteman et al.).
The inherited difficulties of laparoscopic surgery, that include the concern for patient’s safety, steep learning curve of laparoscopy and ability to operate off the remote screen with no perception of depth, limited time allowed for laparoscopic training in most educational programs are the major factors that hinder the widespread use of advanced laparoscopic techniques in gynecologic surgery. Introduction and use of computer-enhanced robotic systems that provide immersive “laparotomy-like” environment can ease the major difficulties that are encountered by the laparoscopic surgeon and facilitate the learning process while preserving the minimally invasive approach favored by many patients and physicians.
1. Nezhat C, Nezhat F, Nezhat CH. Nezhat’s Operative Gynecologic Laparoscopy and Hysteroscopy. 3rd edition. New York: Cambridge University Press, 2008.
2. Moy, M Louis. Byun, Sharon Y., Role of robotic surgery in urogynecologic surgery. Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) Current Opinion in Urology. 20(1):70-4, 2010 Jan.
3. Gaia, Giorgia. Holloway, Robert W. Santoro, Luigi. Ahmad, Sarfraz. Di Silverio, Elena. Spinillo, Arsenio., Robotic-assisted hysterectomy for endometrial cancer compared with traditional laparoscopic and laparotomy approaches: a systematic review. Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) Obstetrics & Gynecology. 116(6):1422-31, 2010 Dec.
4. Swan, Kimberly. Advincula, Arnold P., Role of robotic surgery in urogynecologic surgery and radical hysterectomy: how far can we go? Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) Current Opinion in Urology. 21(1):78-83, 2011 Jan.
5. Gargiulo, Antonio R. M.D. 1; Nezhat, Ceana M.D., Robot-Assisted Laparoscopy, Natural Orifice Transluminal Endoscopy, and Single-Site Laparoscopy in Reproductive Surgery. Seminars in Reproductive Medicine. The Role of Modern Reproductive Surgery for the Evaluation, Therapy, and Preservation of Fertility. 29(2):155-168, March 2011.
Role of Laparoscopic Reproductive Surgery in a World of IVF
Mark W. Surrey, MD
Infertility can be due to disorders of the uterus, the ovary, and the fallopian tube, which can be treated surgically by endoscopic procedures. The advent of IVF (in vitro fertilization) has changed the indications for endoscopic surgery for fertility patients.
Surgery has traditionally been the mainstay of treatment for uterine disorders. Optimizing for IVF has resulted in increased diagnosis and treatment of even asymptomatic submucosal fibroids and endometrial polyps.
Suspected endometriosis was the basis for many diagnostic laparoscopies in infertility patients in the past. However, randomized controlled studies have shown disappointingly low pregnancy rates after their surgical management compared to IVF.
Proximal and distal tubal obstruction have been treated by recanalization and salpingostomy respectively. However, tubal repair surgeries are associated with moderate pregnancy rates and risks of re-occlusion, tubal perforation and ectopic. Despite restoring tubal patency, often the tubal epithelium is intrinsically damaged.
Tubal re-anastamosis has the highest subsequent pregnancy rate, and young patients may still benefit from surgery as opposed to IVF.
Large ovarian mass can impede the oocyte retrieval procedure with IVF and possibly with follicular development. Cystectomy must be performed with care to avoid unintentional removal of healthy stromal tissue, as well as the damage from thermal cautery.
IVF has become more and more prevalent, and success rates can range up to a 50% pregnancy rate per cycle. Optimizing for IVF has likely increased our endoscopic interventions for uterine and ovarian disease, but has largely supplanted tubal surgery.
Friday, September 16, 2011 Santa Monica
Updates in Robotic Colorectal Surgery
Joe K.M. Fan, MBBS, MS, FRCSW(Ed)
Minimally invasive surgery with robotic system has been shown to be beneficial in prostatectomy and hysterectomy. However, its role in colo-rectal resection remains controversial. Currently only small cases series available for review that demonstrated comparable outcome to laparoscopic counterparts in terms of short-term results. Potential benefits of robotic assisted rectal resection include precise and meticulous tissue dissection with three dimension visual system, pelvic nerves preservation avoids bladder and sexual dysfunction post-operatively, robotic arm allows forceful and steady retraction during difficult cases like large uterine fibroid or large rectal tumor. There are lots to overcome before the generalization of technique in patients requires rectal surgery: Fighting and entanglement between robotic arms is the major concern of most surgeons and this can be solved by proper measurement and position of the ports; Docking of the arms is time consuming in initial cases; Transection of distal rectum with endoscopic staplers is another difficulty especially when robotic system is docked, etc. Current development, modifications of technique and possible solutions will be discussed.
Pushing the Envelope: Uniportal Video Assisted Thoracic Surgery
David Zeltsman, MD
Video-Assisted Thoracic Surgery (VATS) is a well established technique to perform thoracic surgical interventions while also providing the means of minimally invasive access to intrathoracic pathology. It is feasible to address both benign and malignant conditions of the lung, esophagus, mediastinum, pleura, and diaphragm with this procedure. The implication of using VATS is that there is no need for rib spreading and a specimen can be removed through one of the access incisions. Though the number of incisions in VATS differs, most utilize two to four.
Although others reported using a single-trocar method of operating for noncomplex thoracic disorders, we present our technique of uniportal VATS for performing advanced complicated interventions including but not limited to anatomic VATS lobectomies and segmentectomies, mediastinal lymphadenectomy and mediastinal lymph node dissection, resection of mediastinal masses, resection of duplications cysts, esophageal surgery, etc. The size of an incision is determined by the size of the tumor, and normally ranges from 1.5 to 3.5 centimeters. We have not encountered procedure related complications and were able to complete all cases intended to be performed via VATS without conversion to an open thoracotomy.
Uniportal VATS is truly a minimally invasive technique and allows for a full range of thoracic operations to be performed without compromising standards of anatomic dissection or oncologic principles.
Friday, September 16, 2011 Sherman Oaks
Beyond Conventional Laparoscopy: LESS, SILS, Microlaparoscopy, and NOTES
Kevin J.E. Stepp, MD
Teaching an Old Dog New Tricks
Marshall E. Noel, MD
In the past decade, robotically-assisted laparoscopic surgery has stormed the Minimally Invasive Surgery scene. For gynecology, there has been a five year surge in the number of robotically-assisted total laparoscopic hysterectomies and myomectomies. In the process of implementing the use of technologically complex articulating instruments under computer-aided control, what is the influence of a surgeon's age and experience on successfully learning robotic surgery? "It's in the outcome." After three decades as an evolving operative laparoendoscopist and the recent skeptical adoption of using a robot to assist in laparoscopic procedures for treating complex pathology and distorted anatomy, many concepts and misconceptions arose. Controversies and prejudices were encountered. Alternatives were discovered. To better understand the available novel equipment and innovative surgical approaches, the author's challenging sexagenarian trek in acquiring new laparoscopic skills will be discussed.
Big Cancer Surprise
Enrico Di Vaio, MD
Updates in Pediatric Surgery 2011
Robert K. Zurawin, MD
Pediatric surgery continues to push the frontiers of surgery, mainly in the realm of minimally invasive surgery. Refinements in existing techniques in addition to the adoption of new technology, specifically robotic surgery, have enabled pediatric surgeons to perform more procedures with greater safety and faster recovery. Controversial topics such as bariatric surgery in the adolescent population will also be discussed.
