18TH SLS ANNUAL MEETING AND
ENDO EXPO 2009
SEPTEMBER 9–12, 2009 • BOSTON, MASSACHUSETTS
SCIENTIFIC ABSTRACTS
Supplement to
JSLS, Volume 13, Number 2
GENERAL SESSIONS
Opening
Ceremony
Best of
Laparoscopy Updates
Multidisciplinary Sessions
Future Technology Sessions
18TH SLS ANNUAL MEETING AND ENDO EXPO 2009
PRELIMINARY PROGRAM
Conference Program Directors
Charles H. Koh, MD
Gustavo Stringel, MD, MBA
TUESDAY, SEPTEMBER 8, 2009
3:00pm-6:00pm MASTER’S CLASSES REGISTRATION
4:00am-5:00pm MASH Committee Meeting
6:30pm-7:00pm Train the Trainers Session
WEDNESDAY, SEPTEMBER 9, 2009 • MASTER'S CLASSES & OPENING CEREMONY
7:00am-9:00am MASTER’S CLASSES REGISTRATION / Complimentary Coffee & Bakery Items (Master's Classes Attendees Only)
8:00am-4:30pm CONCURRENT MASTER’S CLASSES see each course for specific times
8:00am-4:30pm
Simulation Practice Lab - Supporting All Masters Classes
"Simulation Practice Lab/Introduction to the Fundamentals of Laparoscopic Surgery"
Training Simulators Provided by 3-Dmed
Simulators on Display from
Immersion
Red Llama, Inc.
Surgical Science
Faculty:
Robert M. Sweet, MD, Director
Harrith M. Hasson, MD, Co-Director
J. Kyle Anderson, MD
Burak Argun, MD
Leslie Deane, MD
Troy E. Reihsen
8:00am-12:00pm • Half Day
Master’s Class #1 Smart Surgeons Learn From Their Mistakes, Brilliant Surgeons Learn From Other Surgeons' Mistakes: Prevention and Management of Laparoscopic and Endoscopic Surgical Complications
Raymond J. Lanzafame, MD, MBA, Director
Ceana Nezhat, MD, Co-Director
Lawrence C. Biskin, MD
James F. Carter, MD
Carl J. Levinson, MD
Howard N. Winfield, MD
8:00am-4:30pm • Full Day
Master’s Class #2 NOSCAR, NOTES, and SPA: More Than an Incision Decision
William E. Kelley, Jr., MD, Director
Camran Nezhat, MD, Co-Director
Paul G. Curcillo, II, MD, Co-Director
Matthew Brengman, MD
Jihad H. Kaouk, MD
Stephanie A. King, MD
Michael R. Marohn, MD
Farr Nezhat, MD
Daniel A. Tsin, MD
8:00-4:30pm
Suturing Center
Supporting Master's Class #3
8:00am-4:30pm • Full Day
Master’s Class #3 Laparoscopic Suturing in the "Vertical Zone" The Next Level Beyond Triangulation
Charles H. Koh, MD, Director
John E. Morrison, Jr., MD, Co-Director
Yaniris R. Avellanet, MD
Tommaso Falcone, MD
Dobie Giles, MD
Keith Isaacson, MD
8:00am-4:30pm • Full Day
Master’s Class #4 Ways for You and Your Patients to Hurt Less: New Insight Into the Diagnosis and Treatment of Abdominal and Pelvic Pain (Jointly with AAGL and IPPS)
Maurice K. Chung, R.Ph, MD, Director
Harry Reich, MD, Co-Director
Fred M. Howard, MD, MS, Co-Director
Raymond J. Lanzafame, MD, MBA
Richard P. Marvel, MD
Juan Diego Villegas-Echeverri, MD
Robert K. Zurawin, MD
8:00am-4:30pm • Full Day
Master's Class #5 Fundamentals Make Masters: Laparoscopic General Surgery (Jointly with SAGES)
Michael S. Kavic, MD, Director
Phillip P. Shadduck, MD, Co-Director
Paul G. Curcillo, II, MD
Morris E. Franklin, Jr., MD
Terrence M. Fullum, MD
John E. Morrison, Jr., MD
Joseph Petelin, MD
James C. "Butch" Rosser, Jr., MD
Richard M. Satava, MD
Richard M. Vazquez, MD
10:00am-10:30am Refreshment Break
12:00pm-6:00pm CONFERENCE REGISTRATION
12:00pm-1:00pm Master's Class Lunch with Special Lecture:
Gerald B. Healy, MD, presents The Challenges Facing 21st Century Surgery
Introduction: Richard M. Satava, MD, Director & Robert M. Sweet, MD, Co-Director
2:30pm-3:00pm Refreshment Break
4:00pm-5:00pm Poster Gallery
5:00pm OPENING CEREMONY
Paul Alan Wetter, MD, Director
Charles H. Koh, MD, Co-Director
Opening Remarks
Paul Alan Wetter, MD
Presidential Address
Introduction: William E. Kelley, Jr., MD
Presidential Address: Charles H. Koh, MD
Honorary Chair Presentations
Introduction: Gustavo Stringel, MD, MBA
Honorary Chair: Roberto Gallardo D., MD • The Development of Laparoscopic Surgerin Guatemala and Central America
Introduction: Charles H. Koh, MD
Honorary Chair: Suresh Nair, MD • The Evolution of Minimal Access Surgery in Gynecology in Singapore
Presentation of Awards for the Best Scientific Papers and Videos
Paul Alan Wetter, MD
Charles H. Koh, MD
Recognition of Sponsors and Corporate Members and Innovations of the Year
Paul Alan Wetter, MD
Charles H. Koh, MD
6:40pm-8:30pm WELCOME RECEPTION IN EXHIBIT HALL
6:40pm-8:30pm CYBER CAFE
Volker R. Jacobs, MD, PhD, MBA, Director
Phillip P. Shadduck, MD, Co-Director
THURSDAY, SEPTEMBER 10, 2009
6:30am-5:00pm CONFERENCE REGISTRATION
6:45am-7:00am VIP Moderator Briefing Meeting
Raymond J. Lanzafame, MD, MBA / Carl J. Levinson, MD / Gustavo Stringel, MD, MBA
7:00am-2:00pm Exhibits Open
7:00am-7:30am Complimentary Coffee and Bakery Items / Special Presentations by Exhibitors
7:00am-5:00pm Poster Gallery Open
7:30am-8:30am GENERAL SESSION: Best of Laparoscopy Updates
Laparoscopy Updates presented by SLS Special Interest Group Committee Members highlighting the newest developments and future expectations of surgical and diagnostic procedures.
William E. Kelley, Jr, MD, Director
Harrith M. Hasson, MD, Co-Director
• MultiSpecialty Committee: Duncan J. Turner • Office Cosmetic Procedures
• Urology Committee: Thomas Sean Lendvay, MD • Pediatric Urology
• Gynecology Committee: Steven M. Minaglia, MD, MBA • The Use of Mesh for Stress Incontinence and Pelvic Floor Prolapse
• Gynecology Committee: Robert K. Zurawin, MD • Pediatric Gynecology
8:30am-9:45am MULTIDISCIPLINARY PLENARY SESSION (Gynecology, General Surgery, Urology)
Image Guided Surgical Procedures. What a Surgeon Should Know About Non-Surgical Approaches
William E. Kelley, Jr., MD, Director
Richard M. Satava, MD, Co-Director
Mehran Anvari, MB, BS, PhD
Ron Davis, MD
Pat F. Fulgham, MD
Paul Goldfarb, MDElizabeth A. Stewart, MD
9:45am-10:00am SLS WEBSITE: Paul Alan Wetter, MD
10:00am-10:30am Refreshment Break/Visit Exhibits/Special Presentations by Exhibitors
10:30am-11:30am MULTIDISCIPLINARY PLENARY SESSION (Gynecology, General Surgery, Urology)
Cancer and Laparoscopy—What to Do and What Not to Do
Farr Nezhat, MD, Director
Gustavo Stringel, MD, MBA, Co-Director
David B. Samadi, MD
Stephen M. Kavic, MD
11:30am-12:30pm MULTIDISCIPLINARY PLENARY SESSION (Gynecology, General Surgery, Urology)
The US Health Care System Is Broken. What Can We Do About It?
Michael S. Kavic, MD, Director
John E. Morrison, Jr., MD, Co-Director
Richard Babayan, MD
William A. Cooper, MD
Douglas E. Ott, MD, MBA
12:30pm-1:45pm Complimentary Light Snacks and Refreshments/Visit Exhibits/Special Presentations by Exhibitors
12:45pm-1:45pm Poster Town Hall
Best-graded posters from each specialty will participate in the Oral Poster Session
Harrith M. Hasson, MD, Director
Thomas Sean Lendvay, MD, Co-Director
Judging Committee:
Maurice K. Chung, R.Ph, MD
William E. Kelley, Jr., MD
Charles H. Koh, MD
Raymond J. Lanzafame, MD, MBA
John E. Morrison, Jr., MD
Phillip P. Shadduck, MD
Gustavo Stringel, MD, MBA
Robert M. Sweet, MD
Howard N. Winfield, MD
1:45pm-5:30pm CONCURRENT SESSIONS: Scientific Papers / Videos / Open Forum Presentations / Laparoscopy Updates
Directors: MASH Committee Members
1:45pm SIG Committee Lap Updates
2:00pm Exhibits Close
2:00pm-4:00pm Complimentary Coffee Available in Designated Areas
2:00pm-2:15pm Exhibitors Meeting at CCA
2:30pm-3:15pm Briefing Meeting: AsianAmerican Multispecialty Summit IV- February 2010
3:15pm-4:00pm Briefing Meeting: EuroAmerican Multispecialty Summit V- February 2011
5:30pm Adjourn for the Day
6:30pm SLS Evening Event with Faculty at Westin Copley Place featuring the 2009 Excel Award Recipient as Special Guest Speaker (Ticket Required)
Introduction: Richard M. Satava, MD
2009 Excel Award Recipient: James C. "Butch" Rosser, Jr. MD
FRIDAY, SEPTEMBER 11, 2009
6:30am-5:00pm CONFERENCE REGISTRATION
7:00am-7:30am Complimentary Coffee and Bakery Items/Visit Exhibits
7:00am-7:30am Top Gun Shoot Out
7:00am-2:00pm Exhibits Open
7:00am-2:00pm Poster Gallery Open
7:30am-8:30am MULTIDISCIPLINARY PLENARY SESSION (Gynecology, General Surgery, Urology)
NOTES, SPA & Microrobots — a Controversy Debate
John E. Morrison, Jr., MD, Director
Thomas Sean Lendvay, MD, Co-Director
Paul G. Curcillo, II, MD
Daniel A. Tsin, MD
8:30am-11:00am SURGICAL SURPRISES
William E. Kelley, Jr., MD, Director
Camran Nezhat, MD, Co-Director
Panel:
William E. Kelley, Jr., MD
Charles H. Koh, MD
Elspeth M. McDougall, MD, MHPE
Liselotte Mettler, Prof Dr Med
John E. Morrison, Jr., MD
Camran Nezhat, MD
Gustavo Stringel, MD, MBA
9:30am-12:30pm Spouse/Guest Beantown Trolley Tour & Boston Harbor Cruise (Ticket Required)
10:30am-11:00am Refreshment Break/Visit Exhibits
11:00am-11:30am Awarding of Best Poster
Harrith M. Hasson, MD, Director
Thomas Sean Lendvay, MD, Co-Director
Presentation of Best Resident Paper
Paul Alan Wetter, MD, Director
Charles H. Koh, MD, Co-Director
11:30am-1:00pm SLS FILM CHALLENGE: "Madden-Style" Cut-by-Cut Deconstructed Breakdown by Master Surgeons
James C. "Butch" Rosser, Jr., MD, Director
Maurice K. Chung, R.Ph, MD, Co-Director
William E. Kelley, Jr., MD, Co-Director
Gustavo Stringel, MD, MBA, Co-Director
12:00pm-12:30pm New Product Presentations by Exhibitors in Exhibit Hall
Harrith M. Hasson, MD, Director
12:00pm-1:45pm Complimentary Light Snacks and Refreshments in Exhibit Hall / Special Presentations by Exhibitors
1:45pm-5:30pm CONCURRENT SESSIONS: Scientific Papers / Videos / Open Forum Presentations / Laparoscopy Updates
Directors: MASH Committee Members
2:00pm Exhibits Close
2:00pm Poster Gallery Closes
2:00pm-4:00pm Refreshments Available in Designated Areas
5:30pm Adjourn for the Day
SATURDAY, SEPTEMBER 12, 2009
7:00am-11:15am CONFERENCE REGISTRATION
7:30am-9:00am BREAKFAST WITH KEYNOTE SPEAKER
Keynote Speaker Tim Reedman, BASc, MEng presents Robots in Space
Introduction: Richard M. Satava, MD
9:00am-10:30am FUTURE TECHNOLOGY SESSION
From the Infinitesimal to the Infinite - Molecules, Energy and Space for Surgeons
Richard M. Satava, Director
Harry T. Whelan, MD: Controlling Molecules With Light
Michel Wertheimer, PhD: Plasma Medicine - Why Energy Is Important to Surgeons
10:30am-10:45am Closing Ceremony – Passing of the Presidential Gavel
President: Charles H. Koh, MD
President Elect: Gustavo Stringel, MD, MBA
10:45am-11:15am SLS Business Meeting—Open to all SLS members
11:15am-12:15pm SLS Committee Meetings
Schedule, Topics, and Faculty Subject to Change
CONFERENCE EDUCATIONAL METHODS AND ATTENDEE OBJECTIVES
The 18th SLS Annual Meeting and Endo Expo 2009 employs a variety of educational formats including topical general sessions, the presentation of scientific papers, open forums, posters, and original videos offered in small specialty-specific breakout sessions, and informal gatherings of participants and expert faculty.
The increasing complexity of minimally invasive diagnostics and therapy requires a continuous educational process. The exchange of knowledge and expertise among the physicians taking part in this conference contributes to the continuation of excellence in minimally invasive surgery.
Upon completion of the conference, participants will be able to:
• Increase comprehension of the basic and fundamental principles of laparoscopic, endoscopic, and minimally invasive techniques, enhancing the participant’s understanding of these techniques;
• Understand the recent advances in laparoscopic, endoscopic and minimally invasive techniques;
• Determine the appropriate use of laparoscopic, endoscopic and minimally invasive equipment as part of a treatment plan in the care of patients;
• Comprehend the developing technologies that will be available in the future to enhance the standard of patient care; and
• Acquire educational information within the physician’s specialty, which will enhance their professional development and patient care.
CONTINUING MEDICAL EDUCATION PROCESS FOR THE SOCIETY OF LAPAROENDOSCOPIC SURGEONS
The Society of Laparoendoscopic Surgeons (SLS) follows the Essential Areas and Criteria of the Accreditation Council for Continuing Medical Education in planning and developing CME activities. You may view the complete process online at our website, www.SLS.org.
HOTEL ACCOMMODATIONS AND MEETING SITE
The Westin Copley Place
10 Huntington Avenue
Boston, Massachusetts 02116
USA
Tel: 1.617.262.9600
Fax: 1.617.424.7483
MAKE YOUR RESERVATIONS EARLY…
An idyllic urban retreat for travelers, The Westin Copley Place is set in the center of one of historic Boston's finest neighborhoods, Back Bay. The hotel features Westin's exclusive 10-layer Heavenly Bed, the WestinWORKOUT Powered by Reebok Gym with indoor pool, shopping in the retail gallery at Copley Place, skywalk access to more than 100 shops at Copley Place and the Prudential Center as well as the newly-opened Grettacole Spa, located adjacent to the hotel lobby.
Single or Double Room: $275.00 per night.
Junior Suite: $315.00 per night
In order to qualify for these special rates, you must make reservations by August 9, 2009, and mention that you are attending the “SLS Conference.” Rates are subject to appropriate state, local and occupancy taxes and do not include meals.
TRAVEL INFORMATION For negotiated airline discount rates contact Steve at The Store For Travel, toll free at 1.800.284.2538. Outside the United States call 305.251.6331. E-mail: so@sft.webmail.com. Please be sure to mention you are attending the SLS conference in Boston, Massachusetts. For those attending the conference who require special assistance (accessibility, dietary, etc.), please contact SLS no later than August 9, 2009, with special requests. DESTINATION INFORMATION Boston is one of America’s oldest cities and is home to some of the world’s finest inpatient hospitals, many institutions of higher education, and numerous cultural and professional sports organizations. Tourism is one of Boston's and New England's largest industries, and as a result you will find that Boston is a city willing to accommodate and entertain you as few other cities can. For more information on tours, sites, shopping, and everything Boston, visit www.Boston.com/travel/boston. CANCELLATION POLICY Full registration fees are refundable if registrant cancels before August 7, 2009. An administrative fee of $150.00 will be deducted from fees for cancellations postmarked on or after August 7, 2009 through August 21, 2009. Refund requests will not be considered after this date, including visa denial refunds. All requests for refunds must be made in writing and received by SLS, attention Flor Tilden, by the appropriate dates. Refunds will be processed within 6 to 8 weeks after the conference. VISA INFORMATION (Click Here)
No refunds will be made after August 21, 2009.
SPECIAL EVENT: SPOUSE / GUEST BEANTOWN TROLLEY TOUR & BOSTON HARBOR CRUISE
Friday, September 11, 2009
9:30am – 12:30pm
Register Online or Download the PDF registration form and fax to Conferences at 305.667.4123.
Begin your day with a private Beantown Trolley tour of the city of Boston. The best of Boston will unfold before your eyes on this two-hour tour as you are offered lots of little known facts and interesting insights about the unique and wonderful city of Boston. After the trolley ride, you will embark on another sightseeing journey, a glorious one-hour cruise around Boston Harbor—site of the Boston Tea Party and a popular vantage point for whale watchers. Re-board the trolley after the cruise and hop on / off touring the city at your leisure for the remainder of the day, or take the next stop to the Copley Square and make your way back to the Westin Copley. The entire tour loop on the trolley and the harbor cruise total approximately 3 hours.
CONFERENCE EDUCATIONAL METHODS AND ATTENDEE OBJECTIVES
The 18th SLS Annual Meeting and Endo Expo 2009 employs a variety of educational formats including topical general sessions, the presentation of scientific papers, open forums, posters, and original videos offered in small specialty-specific breakout sessions, and informal gatherings of participants and expert faculty.
The increasing complexity of minimally invasive diagnostics and therapy requires a continuous educational process. The exchange of knowledge and expertise among the physicians taking part in this conference contributes to the continuation of excellence in minimally invasive surgery.
Upon completion of the conference, participants will be able to:
• Increase comprehension of the basic and fundamental principles of laparoscopic, endoscopic, and minimally invasive techniques, enhancing the participant’s understanding of these techniques;
• Understand the recent advances in laparoscopic, endoscopic and minimally invasive techniques;
• Determine the appropriate use of laparoscopic, endoscopic and minimally invasive equipment as part of a treatment plan in the care of patients;
• Comprehend the developing technologies that will be available in the future to enhance the standard of patient care; and
• Acquire educational information within the physician’s specialty, which will enhance their professional development and patient care.
CONTINUING MEDICAL EDUCATION PROCESS FOR THE SOCIETY OF LAPAROENDOSCOPIC SURGEONS
The Society of Laparoendoscopic Surgeons (SLS) follows the Essential Areas and Criteria of the Accreditation Council for Continuing Medical Education in planning and developing CME activities. You may view the complete process online at our website, www.SLS.org.
PRE-CONFERENCE MASTER'S CLASSES WEDNESDAY, SEPTEMBER 9, 2009 Master's Classes include the Simulation Practice Lab / Introduction to the Fundamentals of Laparoscopic Surgery. #1 Master’s Class All abdominal and pelvic MIS procedures carry an inherent risk of complications. This interactive course will present a philosophy for the prevention and management of complications during minimally invasive surgery of the abdomen and pelvis. Video segments and case presentations will be used to demonstrate principles and stimulate discussion. Source material will be obtained from students’ “real world” experiences and supplemented with materials selected by the faculty panel and customized based on pre-conference information obtained from registrants. An interactive student and faculty discussion format will be utilized. This course will discuss management paradigms to prevent, recognize, and treat complications appropriately. Careful, methodical assessment and strategies for appropriate action will be stressed. Topical presentations based on student input will highlight detailed surgical anatomy, sound surgical principles and careful technique. Participants are strongly encouraged to submit video or other case material (anonymously) to maximize topical relevance for their individual practice and needs. Objectives: FACULTY #2 Master’s Class Leading practitioners in the fields of general, gynecologic, and urological MIS will discuss their experiences with single port access (SPA), or single incision laparoscopic surgery (SILS), and natural orifice transluminal enteric surgery (NOTES). The advantages, risks, and disadvantages of SPA and NOTES vs. traditional MIS will be discussed and debated, as well as future applications of the respective technologies. Current positions of NOSCAR, the combined ASGE and SAGES working group on the development, research, and introduction of NOTES technology will be discussed. Objectives: FACULTY #3 Master’s Class We challenge you to liberate yourself from the limitations imposed on laparoscopic suturing by the "Triangulation" algorithm. For gynecologists closing the uterus and vagina transversely, urologists anastomosing urethra to bladder, performing uretero-ureterostomy surgeons closing colon and rectum transversely - the needle needs to move in the sagittal plane, not the side to side or coronal plane of the triangulation style. The "Vertical Zone" describes our technique of suturing with two hands ipsilaterally that allows the needle to operate in the sagittal plane, while permitting a restful and relaxed attitude of the elbows, forearms and hands. In numerous courses nationally and internationally this algorithm has allowed over 80% of participants to succeed in tying an intracorporeal knot within 3 minutes after 4 hours of training. With excellent fidelity, the relative hand positions and movements are immediately transferable from the trainer to the O.R. This course equips all attendees with improved suturing skills and insight into applications during surgery. Objectives: FACULTY #4 Master’s Class This Master's Class will include discussion on a newer approach in evaluation and treatment of Chronic Pelvic Pain Endometriosis/Adenomyosis, Interstitial Cystitis/Painful Bladder Syndrome, Inguinal and Obturator Hernia, Bowl Obstruction Adhesion, Pelvic Congestion Syndrome and Pelvic Myofacial Syndrome. In addition, participants will be learning updates on treating abnormal uterine bleeding by in office procedure and hysteroscopic endometrial ablation. They will also learn pearls in treating abdominal pain and laparoscopic complication from the General Surgery of view. FACULTY #5 Master’s Class Full-Day (8:00am-4:30pm; 7 AMA PRA Category 1 Credit(s)™) This year's Master’s Class in Laparoscopic General Surgery will devote a portion of the morning session to practical issues involved with the business of doing surgery today. Presenters will explore topics such as the Business of Surgery, Practical Means to Augment a Surgical Practice, and Ultrasound Based Procedures for General Surgeons. These discussions will emphasize those acceptable practices; technologies and techniques practicing surgeons can use to assure their economic well being in today's world. Also included in the day-long Masters Class will be sessions devoted to cutting-edge presentations in those areas of biliary disease, adhesions, hernia repair, and colon surgery important to the modern general surgery practice. Objectives: FACULTY
Master's Class Attendees are invited to a Special Lunch Lecture featuring Gerald B. Healy, MD, presenting "The Challenges Facing the 21st Century Surgery"
Smart Surgeons Learn From their Mistakes, Brilliant Surgeons Learn from Other Surgeons' Mistakes
Master's Class in the Prevention and Management of Laparoscopic and Endoscopic Surgical Complications
Half-Day (8:00am-12:00pm; 4 AMA PRA Category 1 Credit(s)™)
Course participants will be better able to:
• Recognize and decrease the risk of complications in laparoendoscopic surgeries;
• Identify and discuss specific conditions affecting appropriate patient selection;
• Discuss indications, contraindications and limitations of MIS procedures and technologies;
• Understand relevant surgical anatomy and potential technical pitfalls;
• Develop management paradigms to prevent and treat complications;
• Describe the rationale and timing of conversion to open procedures.
Raymond J. Lanzafame, MD, MBA, Director
Ceana Nezhat, MD, Co-Director
Lawrence C. Biskin, MD
James F. Carter, MD
Carl J. Levinson, MD
Howard N. Winfield, MD
NOSCAR, NOTES, and SPA: More Than an Incision Decision
Full-Day (8:00am-4:30pm; 7 AMA PRA Category 1 Credit(s)™)
At the conclusion of this course, participants will understand the indications and contradictions of SPA, be familiar with facilitating instrumentation and technology, and understand the choreography and technical concepts of SPA surgery. They will be familiar with evolving technology of NOTES, understand the potential risks and benefits peculiar to NOTES and SPA, and be able to compare these two technologies and judge whether either or both of these technologies would be applicable to their individual surgical practices. They will increase understanding of NOTES and the positions and recommendations of NOSCAR.
William E. Kelley, Jr., MD, Director
Camran Nezhat, MD, Co-Director
Paul G. Curcillo, II, MD, Co-Director
Matthew Brengham, MD
Jihad H. Kaouk, MD
Stephanie A. King, MD
Michael R. Marohn, MD
Farr Nezhat, MD
Daniel A. Tsin, MD
Laparoscopic Suturing in the "Vertical Zone" - The Next Level Beyond Triangulation
Full-Day (8:00am-4:30pm; 7 AMA PRA Category 1 Credit(s)™)
Course participants will be better able to:
• Understand ergonomics, theory and rationale for reproducible and efficient laparoscopic suturing
• Learn port positions, instruments and tips to minimize fulcrum and maximize efficiency
• Perform interrupted suturing, continuous suturing, cinch knotting
• Application of skills learned in relevant surgical situations
• Prevention and management of bowel, bladder and ureteral complications by appropriate suture repair
• Pre-test and post-test to demonstrate improvement in skills
Charles H. Koh, MD, Director
John E. Morrison, Jr., MD, Co-Director
Yaniris R. Avellanet, MD
Tommaso Falcone, MD
Dobie Giles, MD
Keith Isaacson, MD
Ways for You and Your Patients to Hurt Less: New Insight Into the Diagnosis and Treatment of Abdominal and Pelvic Pain (Jointly with AAGL and IPPS)
Full-Day (8:00am-4:30pm; 7 AMA PRA Category 1 Credit(s)™)
Objectives:
• To master the newer approach in office evaluation and treatment for difficult Pelvic Pain patients;
• To learn more about new techniques such as abdominal and pelvic trigger points injection, office cystoscopy, intravesical therapy for interstitial cystitis and fluoroscopy for pelvic congestion syndrome. This includes office endometrial ablation and hysteroscopy.
Maurice K. Chung, R.Ph., MD, Director
Harry Reich, MD, Co-Director
Fred M. Howard, MD, MS, Co-Director
Raymond J. Lanzafame, MD, MBA
Richard P. Marvel, MD
Juan Diego Villegas-Echeverri, MD
Robert K. Zurawin, MD
Fundamentals Make Masters: Laparoscopic General Surgery (Jointly with SAGES)
To increase participants' knowledge of the art and practice of minimally invasive surgery needed to survive in the 21st century. Areas to be explored by active practitioners in the field include:
• The business of surgery
• Practical means to augment a surgical practice
• Office-based ultrasound for the general surgeon
• Common bile duct surgery
• Prosthetics for hernia repair
• Minimally invasive colon surgery
• Adhesions - what to do
• Future of general surgery and the general surgeon
Michael S. Kavic, MD, Director
Phillip P. Shadduck, MD, Co-Director
Paul G. Curcillo, II, MD
Morris E. Franklin, Jr., MD
Terrence M. Fullum, MD
John E. Morrison, Jr., MD
Joseph Petelin, MD
James C. "Butch" Rosser, Jr., MD
Richard M. Satava, MD
Richard M. Vazquez, MD
2009 SLS Annual Meeting and Endo Expo Honorary Chairs
Roberto Gallardo D., MD
Dr Gallardo was born in Guatemala City, Guatemala in 1959. He graduated from the School of Medicine of Francisco Marroquin University with full residence in General Surgery at the Social Security General Hospital in Guatemala, where he served for 13 years.
He was the President of the Guatemala Congress 2008, which took place in Guatemala City in July 2008; there he was the President of the VIII Latin-American Endoscopic Surgery Congress, the XI Central American Surgical Congress and the XXXV Congress of the Guatemalan Surgical Association.
Dr Gallardo currently serves as the President of Latin-American Endoscopic Surgery Association (ALACE) and is also the President of the Federation of Association of Surgery of Central America and Panama (FECCAP).
He is the Secretary of the Editor Committee of the Guatemalan Surgical Journal and is a member of many surgical societies in Guatemala and Latin America.
Suresh Nair, MBBS (S'pore), MMED (O&G, Spore), FRCOG (UK)
Dr Suresh Nair is a senior consultant obstetrician and gynaecologist currently in group practice in Gynecology Consultant's Clinic and Surgery at the Mount Elizabeth Medical Centre at the Mount Elizabeth Hospital, Singapore.
His areas of subspeciality interests are:
(1) Minimally invasive laparoscopic and hysteroscopic surgery
(2) Robot-assisted laparoscopic surgery
(3) Assisted reproductive technologies including ovarian tissue cryopreservation in oncological patient
He was awarded the Singapore Government Training Programme, where he spent 2 years training in endoscopic surgery from (1991 to 1993) in the United States of America, United Kingdom, France, and Germany.
He is currently the Vice President of the Obstetrical and Gynaecological Society of Singapore and the Secretary to the Singapore College of Obstetrician and Gynaecologist. He is also the Clinical Director of the Parkway Fertility Centre and is a Visiting Consultant to the National University Hospital and KK Women's and Children's Hospital.
Dr Nair has been invited as faculty to lecture and conduct training programmes in assisted reproductive and endoscopic surgery at regional and international meetings,has contributed to peer-reviewed journals, and written chapters in several authoritative books.
He derives great joy and acknowledgement in proctoring and guiding those who wish to improve in their clinical skills but is ever willing to learn from both his senior and junior colleagues.
MULTIDISCIPLINARY PLENARY SESSIONS IMAGE GUIDED SURGICAL PROCEDURES. WHAT A SURGEON SHOULD KNOW ABOUT NON-SURGICAL APPROACHES With technology racing ahead, there are many technologies that could replace surgery. In previous decades flexible endoscopy was given to gastroenterologists and pulmonologists, and endo-vascular procedures were largely given to cardiologists and radiologists. New opportunities are evolving in various forms of image-guided surgery, from pre-operative planning/surgical rehearsal, to intra-operative navigation, image-guided tissue ablation and even complete tumor and metastasis ablation using robotics and energy sources such as high-intensity focused ultrasound, radiofrequency, and cyberknife therapy. Likewise, surgeons need to participate in the telemedicine revolution, and be aware of the opportunities in tele-surgery. It is critical that surgeons learn about these emerging technologies to insure that they participate when possible, and capture when appropriate, the emerging approaches to diseases that have traditionally been treated surgically. FACULTY AND PRESENTATIONS William E. Kelley, Jr., MD, Director Richard M. Satava, MD, Co-Director CANCER AND LAPAROSCOPY-WHAT TO DO AND WHAT NOT TO DO Laparoscopy has multiple benefits in the cancer patient, including image magnification to visualize metastatic or recurrent disease, improved dissection in challenging areas, decreased hospital stay, and rapid recovery. Significant progress has been made in the last few decades as this technique has blossomed and developed. The leaders of laparoscopy from different disciplines in general surgery, gynecologic oncology, pediatric, and urology, will discuss the latest innovative procedures and proper application of laparoscopy in the realm of oncology. Laparoscopy is a viable alternative to traditional laparotomy approaches in the management of several aspects of oncologic patients. The advantages and disadvantages, possible pitfalls and benefits of novel advances will be examined. The role of laparoscopy continues to expand with continual advancements in technology and techniques, and future directions of research will also be explored. Adequate time will be allocated for active interaction of the participants during the session. FACULTY AND PRESENTATIONS Farr Nezhat, MD, Director Stephen M. Kavic, MD THE U.S. HEALTH CARE SYSTEM IS BROKEN. WHAT CAN WE DO ABOUT IT?
Physicians, perhaps the main players in the delivery of
health care, have been subject to almost a decade of relentlessly decreasing
reimbursement, increasing regulatory and compliance dictates, and having to
interact with a general public that has been made to believe doctors are paid
too much. An increasing number of insurance companies implicated in corrupt
practices have also been added to this mix. The health care treasury has been depleted by these corrupt
practices and the multi million dollar salaries garnered by top insurance
executives who are usually guaranteed a “golden parachute” if things go awry. It would seem that the US health care system is broken, if
not moribund. What can we do about it? Join this distinguished panel and learn
the dimensions of the problem and possible solutions in the very real world we
live in. FACULTY AND PRESENTATIONS Michael S. Kavic, MD, Director Richard Babayan, MD NOTES, SPA & MICROROBOTS - A CONTROVERSY DEBATE
Techniques in minimally invasive surgery continue to evolve.
While some are being widely adopted, others are slow to develop and others are
in their infancy but have great potential. This session centers on the push to
minimize the number of access ports down to one while maintaining adequate
visualization and access while still being able to safely perform surgery. This
plenary session gathers recognized experts in their fields of interest and has
them give their experience with and the current status of their areas of expertise.
Dr. Paul Curcillo will discuss the more widely adapted Single Port Access
procedures and give his experience with and predictions for the future of this
technique. Dr. Daniel Tsin will discuss the less widely adopted NOTES and give
his look into the future and development of this technique. Dr. Dmitry Oleynikov
will end the session with a look into the future of microrobotics and the role
that this exciting new field will play in surgery. At the end of the session, participants
should have a better grasp of the nature and place for these techniques and
have a sense of which one of these methods may be best suited for their
particular practice. FACULTY AND PRESENTATIONS John E. Morrison, Jr., MD, Director Thomas Sean Lendvay, MD, Co-Director Paul G. Curcillo, II, MD
Thursday, September 10, 2009
8:30am-9:45am
Mehran Anvari, MB, BS, PhD
Role of Robotics in Image Guided Procedures
Ron Davis, MD & Paul Goldfarb, MD
Sterotatic Radiosurgery (SRS) - Is it Surgery? Is it Radiation Therapy? Why Should I Care?
Pat F. Fulgham, MD
The Surgeon's Responsibility for Imaging Utilization during Minimally Invasive Procedures
Elizabeth A. Stewart, MD
MRI-guided Focused Ultrasound Surgery (MRgFUS) for Uterine Fibroids
Thursday, September 10, 2009
10:30am-11:30am
Robotics in Cervical Cancer: The Good, Bad and Ugly!
Gustavo Stringel, MD, MBA, Co-Director
The Role of Laparoscopy in Pediatric Abdominal Malignant Tumors
David B. Samadi, MD
Advanced Robotic Technique as a Surgical Treatment Option for Prostate Cancer
Pearls and Pitfalls - Laparoscopy and Malignancy
Thursday, September 10, 2009
10:30am-11:30am
John E. Morrison, Jr., MD, Co-Director
Obstacles to Providing "Universal Care" to the Undeserved - a Urologic Perspective
William A. Cooper, MD
Health Disparities: Target Heart Disease
Douglas E. Ott, MD, MBA
Catastrophe or mess: burial and phoenix
Friday, September 11, 2009
7:30am-8:30am
Single Port Access (SPA) Surgery - In Search of the Critical View
Daniel A. Tsin, MD
Transvaginal NOTES: Culdolaparoscopy
SPECIAL EVENT: MASTER'S CLASS LUNCH WITH LECTURE
The Challenges Facing 21st Century Surgery
Presented by Gerald B. Healy, MD
Wednesday, September 9, 2009
(12:00pm–1:00pm; 1 AMA PRA Category 1 Credit(s)™)
Richard M. Satava, MD, Director
Robert M. Sweet, MD, Co-Director
New mandates for training, certification, and re-training/re-certification are now in place. Residency training programs must have access to a simulation (skills) training center or the Residency Review Committee will put them on probation. Surgical Residents must have documentation that they have passed the Fundamentals of Laparoscopic Surgery skills course or their application for board certification as a surgeon will not be accepted. The American College of Surgeons has certified the quality of simulation centers, and after application, surveyors and review, they are awarded an Accredited Education Institute certificate. And training has moved from training-over-time to competency-based (to standard benchmarks) training, regardless of time to train. Finally, maintenance of certification will soon move to every 5 years (instead of 10 years) and perhaps eventually more frequent. In short, in just a few years a radical revolution in surgical training has occurred - for both residents to become surgeons and for practicing surgeons to maintain their board certification. These issues, and solutions, will be addressed.
________________________________________________________
GERALD B. HEALY, MD, FACS
The Healy Chair in Pediatric Otolaryngology and
Professor of Otology & Laryngology, Harvard Medical School
Otolaryngologist-in-Chief, Children's Hospital, Boston
Gerald B. Healy, M.D., was born in Boston, Massachusetts and received his undergraduate degree with honors from Boston College in 1963 and his MD degree from Boston University in 1967. Dr. Healy is currently the Gerald B. Healy Chair in Pediatric Otolaryngology at Children's Hospital Boston and Professor of Otology and Laryngology at Harvard Medical School. He is the former Surgeon-in-Chief at The Children's Hospital.
Dr Healy is a member of numerous honorary societies, including the American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, the Triological Society, the American Laryngological Association, the American Society of Pediatric Otolaryngology and the American Society of Head and Neck Surgery. He has served as President of the Massachusetts Chapter of the American College of Surgeons, the American Society of Pediatric Otolaryngology, the American Bronchoesophageal Association, and the Triological Society (the leading academic society in the specialty of Otolaryngology-Head and Neck Surgery). He has served as Secretary and President of the American Laryngological Association. He is a Fellow of the Royal College of Surgeons of Ireland and the Royal College of Surgeons of England. He has served as a Chairman of the Board of Regents of the American College of Surgeons and is the Immediate-Past President of the American College.
In 1986, Dr Healy was elected to the Board of Directors of the American Board of Otolaryngology and served as its Executive Vice-President until 2004. He has also served as a Director of the American Board of Emergency Medicine and as a Trustee of the Children's Hospital Boston.
An active scholar and lecturer, Dr. Healy publishes extensively in professional journals, books, and editorials. He has been the principal investigator of NIH funded research addressing diseases affecting infants and children and has been cited for his pioneering work with laser surgery in children. In addition, Dr. Healy is the author of several books and book chapters and/or monographs, and is extensively published in peer-reviewed journals.
Lunch is included for all Master's Class registrants.
SPECIAL EVENT: SLS EVENING WITH FACULTY FEATURING 2009 EXCEL AWARD RECIPIENT / CAPTIVATING CIRQUE DE SLS ENTERTAINMENT Thursday, Sept. 10, 2009 Join us for this captivating and momentous evening which includes dinner, the aerial event Cirque De SLS, and a presentation by the 2009 Excel Award recipient. Established in 1991, the Excel Award has been presented to 24 surgeons deemed by the SLS Advisory Board to have made outstanding contributions to laparoscopy, endoscopy, and minimally invasive surgery. These outstanding surgeons are from various specialties and various nationalities. This year’s Excel Award recipient, a leading surgeon and medical educator, Dr James “Butch” Rosser, Jr. received his undergraduate degree in chemistry and biology from the University of Mississippi and completed his medical training at the University of Mississippi, School of Medicine before completing a five-year surgical residency at Akron General Medical Center, where he served as Chief Resident (1984-85). Dr. Rosser began a private surgical practice at Akron General Medical Center and accepted a position as Assistant Professor of Surgery at Northeastern Ohio Universities College of Medicine. For his outstanding contributions to medical education there, he received the 1991 “Golden Apple Professor of the Year” award. Early in his career, inspired by Dr Herbert Awender, Dr Rosser realized the potential of endoscopic and minimally invasive surgery, leading him to pioneer a number of minimally invasive procedures, most notably his streamlined laparoscopic suturing technique. He now travels the globe teaching his Top Gun Laparoscopic Skills and Suturing Course and other techniques to surgeons. He has also distinguished himself by performing laparoscopic cholecystectomy procedures on some of the youngest individuals in the world (15, 17, and 19 months), which earned him Kent State University’s “Minority Achievement Award.” Dr Rosser is currently Professor of Clinical Surgery at Morehouse School of Medicine. Prior to joining Morehouse he held appointment as Chief of Minimally Invasive Surgery at Beth Israel Medical Center in New York, as well as the Director of Beth Israel's Advanced Medical Technology Institute. Before joining Beth Israel, he was Associate Professor and Director of Endo-Laparoscopic Surgery at Yale University. He has been a contributing editor of Surgical Laparoscopy and Endoscopy, a moderator at the Fourth World Endoscopic Congress, and chairperson of the minimally invasive post-graduate course for the American College of Surgeons, Society of American Gastrointestinal Endoscopic Surgeons (SAGES), American Medical Association and Southern Medical Association. As the founder of the non-profit organization Modern Day Miracle Incorporated, Dr Rosser's goal is to expose the 'modern day miracle' of minimally invasive surgery to underprivileged and undereducated countries around the world, many times via telemedicine, the remote care of patients using modern telecommunications. Tickets required.
6:30pm-8:30pm Excel Award Recipient: James C. "Butch" Rosser, Jr., MD
Introduction: Richard M. Satava, MD
SCIENTIFIC ABSTRACTS
GENERAL SURGERY
Routine Upper Endoscopy Before Bariatric Surgery, Would it
Influence the Surgical Plan?
Ehab Akkary, MD
Learning Curve Using Robotic Assisted Laparoscopic
Cholecystectomies Surgery
Haytham H. Alabbas, MD
Laparoscopic Right Adrenalectomy using the EnSeal System
Fuad Alkhoury, MD
The Sleeve Gastrectomy as a 1st Choice Procedure for Morbid
Obesity Treatment
Mohammad Alkilani, MD
SILS. Single Port Laparoscopic Surgery: Initial Experience
Fernando Arias, MD
Single Incision Laparoscopic Resection of Giant Mesenteric
Cyst
Fernando Arias, MD
Preliminary Results with Endoscopic Plicatin for Revision of
Gastric Bypass
Dimitrios V. Avgerinos, MD
Robotic Resection of the Left, Right, and Sigmoid Colon
Nadav Aviv, DO
Robotic Adrenalectomy
Nadav Aviv, DO
Laparoscopic Adjustable Gastric Banding in Situs Inversus
Totalis
Ramy A. Awad, MD
Laparoscopic Reintervention After Roux-en-Y Gastric By-pass
for Morbid Obesity
Carlos Ballesta, MD
Management of Anastomotic Leaks After Laparoscopic Roux-en-Y
Gastric Bypass
Carlos Ballesta, MD
The Staged Approach to Acute Gastric Prolapse in
Laparoscopic Adjustable Gastric Banding
Raffi Barsoumian, MD
Risk Factors for Prolonged Operative Time in Laparoscopic
Cholecystectomy
Yasser Ahmed Bashin, Dr Med
Laparoscopic Subtotal Colectomy for Multiple Colon
Polyposis
Giancarlo Basili, MD
Portal Hypertension Secondary to a Spontaneous Splenic
Arteriovenous Fistulae, Treated by Laparoscopic Splenopancreatectomy. A Case
Report and Review of the Literature
Walid Salem Beainy, MD
Enabling NOTES- Using a Robotic Surgical Platform to
Facilitate Navigation, Camera/Instrument Repositioning and Stability During
Surgery
Amir Belson, MD
Pyloromyotomy Length Directed by Pre-operative Ultrasound
Measurement Minimizes Incomplete Laparoscopic Pyloromyotomy in Infants
Denis David Bensard, MD
Types of Reconstruction and Functional Outcomes from
Laparoscopic Distal Gastrectomy for Gastric Cancer
George Bouras, MRCS
Totally Laparoscopic Reconstruction During Laparoscopic
Pylorus-preserving and Segmental Gastrectomy for Gastric Cancer
George
Bouras, MRCS
A Novel Approach to Gastric Wedge Resection Using Single Incision Laparoscopic Surgery (SILS)
Curtis E. Bower, MD
Recurrent Stricture in a High Risk Patient after Vertical
Banded Gastroplasty: Treatment by a Novel Simultaneous Natural Orifice and
Laparoscopic Endogastric Technique
Collin E. Brathwaite, MD
Hole-Mesh Device Allows Accessing the Bypassed Stomach in
Patients Who Underwent Roux-en-Y
Gastric Bypass for Severe Obesity
Giovanni Cesana, MD
Laparoscopic Inguinal Hernia Repair IPOM with Dual-Mesh:
Feasibility and Advantages
Giovanni Cesana, MD
A Six Year Experience in the Laparoscoic Treatment of
Incisional Hernias
Ignazio Massimo Civello, MD
Laparoscopic Treatment of Colorectal Tumors. Miscellaneous
of 4 Year Experience
Ignazio Massimo Civello, MD
Laparoscopic Retroperitoneoscopic Lumbar Sympathectomy for
the Treatment of Plantar Hyperhidrosis: a Case Report and Review of the
Literature
Derrick Dione Cox, MD
Outcomes of Minimally Invasive Myotomy for the Treatment of
Achalasia in the Elderly
Randall O. Craft, MD
Cerebral Gas Embolism Due to Upper Gastrointestinal
Endoscopy
Roeland Den Boer, MD
Sleeve Gastrectomy versus Roux-en-Y Gastric Bypass: a
Comparison of Weight Loss and Diabetes Resolution
Lisa Derr, DO
The Calibrated Laparoscopic Heller's Myotomy with
Fundoplication in the Surgical Treatment of Esophageal Achalasia
Natale Di
Martino, Prof Dr Med
Laparoscopic Approach to Gastrointestinal Atromal Rumors
(GISTs) of the Stomach: Our Experience
Natale Di Martino, Prof Dr Med
Laparoscopic Duodenojejunostomy for the Superior Mesenteric
Artery Syndrome: Surgical Management for an Irreversible Cause?
Marquinn D.
Duke, MD
Endoscopic Transaxillary Periareolar Thyroidectomy
Titus D. Duncan, MD
Laparoscoic Sigmoid Colectomy for Diverticulitis: a
Prospective Study of 260 Patients
Khaled Khalil Elzarrok, MD
Laparoscopic Resection of Duodenal GIST Tumour
Khaled Khalil Elzarrok, MD PhD
A Chronic Cholecystitis in a Chilaiditi's Syndrome
Josè M.M. Ferreira-Coelho, MD PhD
A Novel Technique for Endoscopic Repair of Symptomatic
Diastasis Recti With or Without Simultaneous Ventral Hernia
Richard P.
Franklin, MD
Side-to-side Gastro-Colic Anastomosis Provides Drastic
Weight Loss: Anastomotic Size Is an Important Variable
Michel Gagner, MD
Laparoscopic Transduodenal Sphincteroplasty
Michel Gagner, MD
Management of Chyloperitoneum Following Redo-Laparoscopic
Nissen Fundoplication in a 23 Month-Old Female
Edgar Luis Galiñanes, MD
Initial Outcomes Following Laparoscopic Sleeve Gastrectomy
as a Single Stage Procedure for Morbid Obesity
Alex Gandsas, MD MBA
Integrating Emergent Abdominal Laparoscopic Procedures into
the Armamentarium of Laparoscopic Surgeons on a Consistant Basis: a
Prospective, Identifiable, and Consistent Model
W. Peter Geis, MD
Acute Appendicitis or Gynecological Disease? The Role of
Videolaparoscopic Approach
Roberta Gelmini, Prof Dr Med
The Routine Preoperative Typing and Screening Prior to
Elective Surgery – a Necessary Safeguard or a Misuse of Resources?
Silvio F.
Ghirardo, MD
Laparoscopic Ventral Hernia Repair without Suture Fixation
G. Kevin Gillian, MD
The Best of Both Worlds: Open Incisional Hernia Repair with
Laparoscopic Mesh Underlay
Gopal Grandhige, MD
Necessity for Improvement in Endoscopy Training During
Surgical Residency
Aditya Gupta, MD
Laparoscopic Right Hemicolectomy for Cecal Duplication Cyst
in an Adult: a Case Report
Amy J. Hanna, MD
Minimal Esophageal Dissection During Laparoscopic Nissen
Fundoplication in Infants Reduces the Risk of Post-operative Hiatal Hernia and
Wrap Herniation
Richard J. Hendrickson, MD
The Learning Curve of Laparo-Endoscopic Single Site (LESS)
Cholecystectomy: Definable, Short, and Safe
Jonathan M. Hernandez, MD
Technique of Laparoscopic Transgastric Gastrointestinal
Stromal Tumor Excision with Gastric Bypass
Juliet Georgia Holder-Haynes, MD
The Learning Curve of Laparoscopic Cholecystectomy
Mubashar
Hussain, Dr Med
Laparoscopic Repair of Bilateral Spigelian Herniae
Usman Jaffer, MBBS, BSc, MSC
Core Appendectomy-A New Technique for Delayed Appendicitis
Shenoy Kudige Jayarama, MBBS, MS
Early Surgical Consultation for Acute Cholecystitis and
Biliary Symptoms: Is There a Difference in Outcome?
Sigi P. Joseph, MD
Transumbilical Laparoscopic Assisted Non-insufflated
Appendectomy (TULANIA)
Sungwoo Jung, MD
MIS Fellowship Influence on Obtaining Adequate Regional
Lymph Node Specimens in Laparoscopic Colectomies
Harish Kakkilaya, MD
Robotic Gastrointestinal Surgery: Series of Our First 50
Consecutive Cases
Emad Kandil, MD
Robotic Adrenalectomy: a Report of Our Early Experience at
Tulane
Emad Kandil, MD
Herniotomy in Infants, Children and Adolescents Without
Disruption of External Ring
Ahmed Alwan Kareem, MD
A New Idea to Identify the Anatomy of the Colonic Artery in
the Laparoscopic Colorectal Surgery - The Usefulness of the Transillumination
Technique
Iwao Kobayashi, MD PhD
Pre-peritoneal Bupivacaine Instillation Significantly
Reduces 'Dissectalgia' Following TEP, Without Affecting Time of Resuming Job:
Results of Prospective Randomized Controlled Trial
Sunil Kumar, MS
An Unusual Presentation of Carcinoid Tumor of the Appendix
Yong Kwon, MD
Laparoscopic Distal Gastrectomy and D1 Lymphadenectomy for
Gastric Adenocarcinoma
Eddie Lambert, MD MBA
Laparoscopic Re-banding for Failed Gastric Banding
Leonid Lantsberg, Prof Dr Med
Laparoscopic Sigmoid Resection for Complicated Diverticular
Disease is Associated with Better Outcomes
Jonathan A. Laryea, MD
Timing of Elective Laparoscopic Cholecystectomy After Acute
Cholangitis and Subsequent Clearance of Choledocholithiasis
Vicky Ka Ming Li,
MBBS FRCS
Laparoscopic Splenectomy for Multiple Distal Aneurysm of the
Splenic Artery
Marco Lombardi, MD
Laparoscopic Resection of Retroperitoneal Mass
Marco Lombardi, MD
Sentinel Lymph Node Mapping in Patients with Differentiated
Thyroid Carcinoma (DTC): Our Experience
Sinisa Maksimovic, Prof Dr Med
Laparoendoscopic Single Site Cholecystectomy With
Intraoperative Cholangiography
Kellie McFarlin, MD
The Resection of a Mid-Esophageal Diverticulum Complicating
Palliated Achalasia
Kellie McFarlin, MD
Avoiding Major Common Bile Duct Injuries in Cases With
Unidentifiable Cystic Duct
Subhasis Misra, MD
Inferior Epigastric Artery Bleeding During Laparoscopic
Procedure
Subhasis Misra, MD
Laparoscopic Management of Small Bowel Volvulus
Subhasis
Misra, MD
Laparoscopic Management of Appediceal Mucocele and Torsion
Subhasis Misra, MD
Laparoscopic Cholecystectomy for Gallbladder Stones of
Helminthic Origin
Subhasis Misra, MD
Completion Proctectomy after Laparoscopic vs. Open Subtotal
Colectomy for Ulcerative Colitis: Is There a Difference?
Angel Mario Morales
Gonzalez, MD
NOTES Perforated Viscus Repair is Feasible and Comparable to
Laparoscopy in a Porcine Mode
Erica A. Moran, MD
Laparoendoscopic Single Site (LESS) Toupet Fundoplication
John Mullinax, MD
The Role of Laparoscopy in Emergency General Surgery and its
Effect on Trainees' Experience in a UK District General Hospital
Senthil
Nachimuthu, MS, MRCSEd
Laparoscopic Repair of Spigelian Hernia Mimicking
Post-Operative Ileus Following Perineal Rectosigmoidectomy
Khanjan H.
Nagarsheth, MD
NOTES Transvaginal Cholecystectomy: a Modified Surgical
Technique
Giuseppe Navarra, Prof Dr Med
Prophylaxis of Recurrent Pancreatitis: Miniinvasive
Approach
Vincenzo Neri, Prof Dr Med
Transanal Endoscopic Microsurgery for Rectal Adenomas: a
Comparison of Two- and Three-Dimensional Visualization
D.H. Nieuwenhuis, MD
Thymectomy by Thoracoscopic Approach: Experience and
Outcomes
Vladimir N. Nikishov, MD PhD
Laparoscopic Treatment of Peptic Ulcer Disease
Francisco A. Obregon, MD
Atraumatic Repair of Ventral Hernias Using Fibrin Glue
Stefano Olmi, MD
Laparoscopic Repair of Incarcerated Incisional Hernias: Our
Experience
Stefano Olmi, MD
Validity of Resident Self-Assessment in Minimally Invasive
Surgery
Neil Orzech, MD
Transumbilical Single Incision Laparoscopic Adjustable
Gastric Banding: Making Patients Smaller Through Smaller Incisions
Matthew B.
Ostrowitz, MD
Postoperative Inflammatory Response following Laparoscopic
versus Robotic Colorectal Surgery
Yoon Ah Park, MD PhD
Laparoscopic Right Hemicolectomy, Notes Extraction vs.
Counter Incision. A Prospective Study
Guillermo Portillo, MD
Laparoscopic Approach to Colonic Emergencies
Guillermo Portillo, MD
Is There Any Value Of Totally Intracorporeal Anastomosis In
Laparoscopic Colon Surgery?
Guillermo Portillo, MD
Involution or Evolution Minilap Approach for GERD Treatment
Juan G. Quiroz, MD
Laparoscopically-assisted Placement of Ventriculoperitoneal
Shunts Helps to Avoid Unnecessary Abdominal Incisions
Usama Qumsieh, MD
Laparoscopic Cholecystectomy in Gallstone Disease with
Cirrhosis of the Liver
Prasanta Raj, MD
Association of Intraoperative Cholangiography with Common
Bile Duct Injury
Prasanta Raj, MD
Reinforced Circular Stapler in Bariatric Surgery. Is There
Any Benefit?
Marcela Carolina Ramirez, MD
Prevention of Post-op Bowel Obstruction After Rectal
Resection: Results of Pelvic Omental Pedicled Shelf from Open Surgery with
Applicability to Laparoscopic Surgery
Munir A. Rathore, FRCS
Role of Initial Clinical Assessment in the Diagnosis of
Acute Diverticulitis
Munir Ahmad Rathore, FRCS
Surgery for the Chronic Abdominal and Pelvic Pain Syndrome
(CAPPS) Is Surgery Indicated in these Patients?
Jay A. Redan, MD
Hand-Assisted Laparoscopic Repair of Large and Complex
incisional Hernia (Panama Technique)
Rafael Victor Reyes, MD
Laparoscopic Revision of Open Roux-En-Y Gastric Bypass with
Fundus Resection
Ramin Roohipour, MD
Laparoscopic Reduction of Intussusception Following
Laparoscopic Roux-En-Y Gastric Bypass Surgery
Ramin Roohipour, MD
Late Results After Laparoscopic Fundoplication Denote
Durable Symptomatic Relief of GERD
Sharona B. Ross, MD
Dissatisfaction After Laparoscopic Heller Myotomy Due To
Esophageal Dysmotility
Sharona B. Ross, MD
Laparoscopic Resection For Benign Gastric Tumor Around
Esophagogastric Junction
Seong-Yeob Ryu, Prof Dr Med
Single Port Transumbilical Laparoscopic Intragastric
Resection
Seong-Yeob Ryu, MD PhD
Single-Incision Laparoscopic Surgery (SILS) and Natural
Orifice Transluminal Endoscopic Surgery (NOTES) Cholecystectomy: Is It Just
About Cosmesis?
Sujit Vijay Sakpal, MD
Laparoscopic Conversion of Common Surgical Procedures: an
Analysis of Patient-specific and Surgeon-specific Factors at a Community
Hospital
Sujit Vijay Sakpal, MD
Laparoscopic Assisted Management of Impalpable Testis in
Patients Older Than 10 Years
Ahmed Khan Sangrasi, FCPS
Six Sigma, Statistical Process Control, and Quality
Improvement for Appendectomy
Jeffrey D. Sedlack, MD
Silent Entry of a Sharp Metallic Foreign Body into the
Abdomen: Diagnosis and Treatment Using Laparoscopy and CT Scan
Udayan B. Shah,
MD
Laparoscopic Cholecystectomy in Cirrhotic Patients in
Tertiary Care Hospital in Pakistan
Abdul Razaque Shaikh, FCPS
Trends and Correlations of MORBID Scores for Adjustable
Gastric Band: Weight Loss, Resolution of Comorbid Diseases, and Quality of
Life
Brad E. Snyder, MD
Laparoscopic Appendectomy Using LIGASURE™ for the
Mesoappendix Homeostatic Control
Vicente Spinelli, MD
Impact of Robot in Vascular Surgery
Petr Stadler, MD PhD
Development of a Laparoscopic Colorectal Service in the
Northern HSC Trust, Northern Ireland - Progress So Far
Richard P. Stevenson,
Dr Med
Resection of Gastrointestinal Stromal Tumor of the Rectum by
Transanal Endoscopic Microsurgery
Paul R. Sturrock, MD
Learning Curve in Transanal Endoscopoic Microsurgery:
Surgeon or Operating Room Staff Dependent?
Paul R. Sturrock, MD
Prolonged (> 3 Hours) Laparoscopic Cholecystectomy -
Reasons and Results
Gokulakkrishna Subhas, MD
Laparoscopic Loop Ileostomy With a Single Port Stab
Incision
Gokulakkrishna Subhas, MD
A Novel Technique for Laparoscopic Seprafilm Application
Adithya Suresh, MD
Two-Trocar Single Incision Appendectomy
Dana A. Telem, MD
Combined Open-Laparoscopic Technique for Difficult
Incisional Herniae
Katerina Theodoropoulou
Development of a New Device for Displacement of the Small
Intestine in Laparoscopic Rectosigmoid Surgery
Shinobu Tsuchida, MD PhD
Laparoscopic Treatment of Rectal Cancer: the Results of a
Single Centre Experience
Paolo Ubiali, Prof Dr Med
Robotic Surgery of Advanced Gastric Cancer - Preliminary
Experience
Catalin Vasilescu, MD PhD
Robotic Versus Laparoscopic Partial Splenectomy
Catalin Vasilescu, MD PhD
Post Laparoscopy Pain Control With Tarns Port Local
Anesthesia
Amir Vejdan, Dr Med
Laparoscopic Colectomy for Colon and Upper Rectal Cancer
Pietro Venezia, Prof Dr Med
Natural Orifice Surgery in Gastric Bypass Patients Who
Regained Weight: a Feasibility Study
Chiranjiv Singh Virk, MD
Laparoscopic Colectomy: Does the Learning Curve Extend
Beyond Colorectal Surgery Residency?
Joshua A. Water, MD
149 LCBDE Cases Evaluating the Use of the Multi-Channel
Instrument Guide in the Community Hospital Setting
Donald E. Wenner, MD
Lessons Learned in 149 LCBDE Cases Applied to Procedural
Algorithm
Donald E. Wenner, MD
Single Port Acess (SPA) Hepatic Sling Technique
Andrew S. Wu, MD
An Institutional Comparison of Laparoscopic vs. Open
Adrenalectomy
Gazi B. Zibari, MD
GYNECOLOGY
Laparoscopic Hysterectomy and Colpopexy with Polypropylene
Strip
Mohammad Alkilani, MD
Meckel's Diverticulum Causing Intestinal Obstruction in
Third Trimester of Pregnancy
Farhad Anoosh, MD
Effectiveness of Microwave Endometrial Ablation for
Adenomyosis
Yasuyuki Asakawa, MD PhD
Integration of Formal Robotic Training Into a Four Year
Obstetrics and Gynecologic Residency
Michael T. Breen, MD
Time to Diagnoses of Rectal Endometriosis May be Prolonged
Among Patient with Chronic Pelvic Pain
Aileen Caceres, MD, MPH
Multi-disciplinary Approach to the Surgical Management of
Deep Infiltrating Pelvic Endometriosis Involving the Recto-sigmoid
Aileen Caceres,
MD, MPH
A Multicentered Series of over 1000 Laparoscopic Subtotal
Hysterectomies in the UK and Greece: the New Approach to Hysterectomy
Stefanos
Chandakas, MD, MBA, PhD
Single Port Laparoscopy in Gynaecology, What Can We Perform:
a Series of 35 Cases
Stefanos Chandakas, MD MBA PhD
Fertility-Sparing Robotic-assisted Radical Trachelectomy and
Bilateral Pelvic Lymphadenectomy in Early Stage Cervical Cancer
Linus Chuang,
MD
The Evil Triplet of Chronic Pelvic Pain Syndrome: Pudendal
Neuralgia
Maurice K. Chung, R.Ph, MD
Dysautonomias Are Not Associated With Chronic Pelvic Pain
Andrea K. Crane, MD
Lifelong Dysmenorrhea Is Associated With Other Muscle
Tension Pain Syndromes
Andrea K. Crane, MD
Use of Bidirectional Barbed Suture in Gynecologic
Laparoscopy
Jon Ivar Einarsson, MD
Medico-Legal Problems With Advanced Gynecological Operative
Endoscopy
Mark Erian, MD
Transvaginal Application of a Laparoscopic Bipolar Cutting
Forcep to Assist Vaginal Hysterectomy in Extremely Obese Endometrial Cancer
Patients
James Fanning, DO
Laparoscopic Cytoreduction for Primary Advanced Ovarian
Cancer
James Fanning, DO
Limbic Brain Areas are Activated in Chronic Pelvic Pain
Bradford W. Fenton, MD PhD
Treatment of Severe Uterine Hemorrhage using Hydrothermal
Ablation
Herbert A. Goldfarb, MD
Saline Infusion Sonohysterography in Elderly Patients. Risks
and Feasibility
Emil L. Gurshumov, MD
Can Laparoscopic Myomectomy Replace Open Myomectomy?
Richard L. Heaton, MD
Use of PlasmaJet System in the Laparoscopic Treatment of
Endometriosis: Early Experience
Kimberly Kho, MD
Report of the Largest Case Series of Parasitic Myomas
Kimberly Kho, MD
Laparoscopic Approach for the Presacral Tumors: Early
Experience of Initial 19 Cases
Zhiqing Liang, MD PhD
171 Laparoscopic Surgeries Using a Seprafilm Slurry
Lioudmila Lipetskaia, MD
To Study the Feasibility, Morbidity and Outcome Following
Laparoscopic Myomectomy for Large Fibroids
Sheila Mehra, MD
Adhesion Prevention with a Resorbable Hydrogel Following
Myomectomy
Liselotte Mettler, Prof Dr Med
Laparoscopic Gonadectomy for Androgen Insensitivity Syndrome
With Serous Gonadal Cyst
Mineto Morita, MD PhD
Results Laparoscopic Hysterectomy
Khusen B. Narzullaev, MD PhD
Total Laparoscopic Radical Hysterectomy and Robotic Radical
Hysterectomy with Pelvic Lymphadenectomy in Treatment of Early Cervical Cancer:
Recurrence and Survival
Farr Nezhat, MD
Laparoscopic Modified Radical Hysterectomy and Staging for
Uterine Papillary Serous Carcinoma With Cervical Involvement
Farr Nezhat, MD
The Role of Minimally Invasive Surgery for Diagnosis and
Therapy of the Uterine Myoma Before IVF/ICSI Cycle
Kazem Nouri, MD
Laparoscopy: Gold Standard for Ovarian Tissue Banking (OTB)
in Cancer Patients
Kazem Nouri, MD
An Innovative Electric Converter(M/BAC*) for Laparoscopic
Surgery
Youngse Park, Prof Dr Med
Transumbilical Laparoscopic Hysterectomy Using the Ligasure™
Device: Initial Experience of 25 Cases
Muthukumaran Rangarajan, MBBS MS
Laparoscopic Replacement of Inguinal Ovaries Associated with
Mayer-Rokitansky-Kuster-Hauser Mullerian Agenesis Syndrome
Muhieddine A-F
Seoud, MD
Effects of Transvaginal Hydrolaparoscopy and Laparoscopy
Operation on Enzymogram and Neuroendocrine Hormones
Wang Shao-Juan, Prof Dr
Med
Transvaginal Ultrasound Prediction of Surgical Specimen
Weight in Laparoscopic Supracervical Hysterectomy
Michael Swor, MD MBA
Post-Operative Change in Vaginal Length After Laparoscopic
Supracervical Hysterectomy With Uterosacral Ligament Plication
Michael Swor,
MD MBA
Primary Pelvic Floor Repair With Laparoscopic Supracervical
Hysterectomy
Michael Swor, MD MBA
To Assess the Surgical Feasibility of Utilization of a Mesh
Kit (Avaulta Plus™ Biosynthetic Support System)
Radha Syed, MD
To Assess the Clinical Efficacy of Integrating Sacral
Neuromodulation Intistim Inplants in Gynecological Private Practice for
Treatment of Intractable Urinary Urgency
Radha Syed, MD
Robotic Surgery in a Medium-Sized Integrated Community and
Academic Program in Gynecology
Sean S. Tedjarati, MD
Laparoscopic Isthmic Cerclage: a Simplified Technique
Antoine A. Watrelot, Prof Dr Med
A Case of Bilateral Tubal Pregnancy After Puerperal Tubal
Ligation
Takashi Yamada, MD PhD
6 Case Reports of Ileum Colpopoiesis by Laparoscopy
Xiaoyan
Ying, MD
UROLOGY
Early Results of Robotic Lymphadenectomy for Renal Cell
Carcinoma
Ronney Abaza, MD
Initial Report of Robotic Radical Nephrectomy with Vena
Caval Tumor Thrombectomy
Ronney Abaza, MD
Margin Status of Men Undergoing Extraperitoneal,
Extrafascial Laparoscopic Radical Prostatectomy (LRP)
Gerald Louis Andriole,
MD
Comparing Diode Laser With KTP Laser
Manuel Ferreira Coelho, MD
Transmesenteric Robotic Assisted Laparoscopic Pyeloplasty: a
Simple Approach for Pediatric Ureteropelvic Junction Obstruction Repair
Roger
E. De Filippo, MD
Robotic Pyeoloplasty With Pyelolithotomy
Mark T. Edney, MD
Preoperative Renal Insufficiency Is an Independent Predictor
of Adverse Surgical Outcomes in Partial Nephrectomy
A. Ari Hakimi, MD
Evaluation of Age and Adverse Outcomes in Laparoscopic
Partial Nephrectomy
A. Ari Hakimi, MD
Robotic Assisted Laparoscopic Radical Cystectomy: the City
of Hope Experience
Ciamack Kamdar, MD
Robotic Assisted Laparoscopic Radical Cystectomy in the
Octogenarian
Ciamack Kamdar, MD
Results of Robotic Limited and Extended Pelvic
Lymphadenectomy for Prostate Cancer
Hugh Lavery, MD
Individualize Management of Ureteropelvic Junction
Obstruction During Robot Assisted Laparoscopic Dismembered Pyeloplasty
Michelle Lerner, MD
Safety and Peri-operative Outcomes During Learning Curve of
Robotic-assisted Laparoscopic Prostatectomy (RALP): a Multi-institutional Study
of Fellowship Trained (FEL) Robotic Surgeons Versus Experienced Open Radical
Prostatectomy (RRP) Surgeons Incorporating RALP
Timothy J. LeRoy, MD
Three-Port Robotic Urologic Surgery Without a Laparoscopic
Bedside Assistant
Gregory Lowe, MD
Median Lobe In Robotic Prostatectomy: Bladder Neck
Reconstruction and Pelvic Drain Not Routinely Required
Humberto
Martinez-Suarez, MD
Laparoscopic Donor Nephrectomy: Caution on the Use of
Kidneys with Multiple Arteries
Anil S. Paramesh, MD
Trans-Ileal-Conduit-Resection (TICR) of the Recurrent
Urothelial Carcinoma in Iileal Conduit
Dong Soo Park, MD PhD
Bigger is Better: Implication of Small Prostate Volume in
Patients Who Qualify for Active Surveillance for Prostate Cancer
Nishant D.
Patel, MD
Investigation of an Ultrasound Imaging Technique to Target
Didney Stones in Lithotripsy
Anup Shah, MD
Ultrasound to Facilitate Clearance of Residual Stones
Anup
Shah, MD
Comparision of Intraoperative Outcomes With New and Old
Generation DaVinci Robot for Robotic Prostatectomy
Ketul Shah, MD
Incidence, Management and Prevention of Perioperative
Adverse Events of GreenLight HPS Laser Photoselective Vaporization
Prostatectomy: Experience in the Initial 70 Patients
Massimiliano Spaliviero,
MD
Tissue Effects of GreenLight HPS and Evolve SLV Lasers on
Canine Prostates: an Acute In-Vivo Model
Massimiliano Spaliviero, MD
Laparoscopic Ureterolithotomy for Large Proximal Ureteral
Calculi
David Spencer, MD
Posterior Rhabdosphincter Reconstruction May Delay Time to
Continence Recovery Following Robot-Assisted Radical Prostatectomy
Joshua M.
Stern, MD
Urethral Length as Measured on MRI is Associated With Time
to Continence
Joshua Stern, MD
GreenLight HPS Laser Photoselective Vaporization Prostatectomy
(PVP) for Failed Prior Surgical Treatment of Benign Prostatic Hyperplasia
(BPH)
Kurt Strom, MD
Does Age Affect the Safety and Efficacy of GreenLight HPS
Laser Photoselective Vaporization Prostatectomy (PVP)
Kurt Strom, MD
Comparison of Laparoscopy Training Using a Box Trainer
versus a Virtual Trainer
Chandru Sundaram, MD
The Safety of Radiofrequency Ablation for Renal Tumor Based
on Renal Biopsy After 6 Months
Gyung Tak Mario Sung, MD PhD
A Comparison of Robotic Assisted Versus Pure Laparoscopic
Radical Prostatectomy: a Single Surgeon Experience
Gyung Tak Mario Sung, MD
PhD
Complications for Laparoscopic Surgery for Urologic
Malignancy: a Single Surgeon Experience
Daniel R. Tare, MD
Robotic-assisted Laparoscopic Excision of Bladder Wall Leiomyoma
David D. Thiel, MD
Robotic Assisted Laparoscopic Reconstruction of the Upper
Urinary Tract: Tips and Tricks
David D. Thiel, MD
Clinical Pathway for Early Discharge After Robotic
Cystectomy
Asha White, MD
Short-Term Outcomes of GreenLight HPS Laser Photoselective
Vaporization Prostatectomy (PVP) for Benign Prostatic Hyperplasia (BPH)
Carson
Wong, MD
Decreased Efficiency of GreenLight HPS Laser Photoselective
Vaporization Prostatectomy (PVP) With Long-Term 5a-Reductase Inhibition
Therapy: Is it True?
Carson Wong, MD
MULTISPECIALTY
Minimally Invasive Video-assisted Thyroidectomy with
Intraoperative Recurrent Nerve Monitoring
Haytham H. Alabbas, MD
Experimental Model in Pig as Training Tool in Endoscopic
Axillary Dissection
Maria E. Aponte-Rueda, MD PhD
Laparoscopic Appendectomy During Pregnancy
Joong Sub Choi, Prof Dr Med
Small Bowel Obstruction After FloSeal Use
Benjamin L. Clapp, MD
Combined Thoracoscopic and Laparoscopic Repair of a
Traumatic Diaphragmatic Hernia: a Tale of Two Techniques
Hang Dang, DO
Electronic Detection of the Entry of Verres Needles Into the
Peritoneal Cavity
Michael C. Doody, MD PhD
Laparoscopic Repair of Rectal Injury During Laparoscopic
Radical Prostatectomy
William Duncan, MD
Laparoscopic Application of a Hyaluronate
/Carboxymethylcellulose Slurry Does Not Increase Postoperative Adhesions
Bradford W. Fenton, MD PhD
Pediatric Surgery
Arnaldo Miguel Angel Gonzalez, MD
Ten Year Experience with Minimally Invasive Surgery (MIS) in
Pediatric Cancer Patients
Gloriamaria Gonzalez, MD
Laparoscopic Gastrostomy Is Safe and Beneficial in Infants
Under 10 Kilograms with Congenital Heart Disease Utilizing a Multidisciplinary
Approach
Richard J. Hendrickson, MD
Effect of 4% Icodextrin Solution on the Reduction of
Adhesion Formation Following Gynecological Surgery in Rabbits
Behnaz Behnaz
Khani Rabati, MD
Minimally Invasive Surgery Group: Cutting Edge Goes a Cut
Above
Dean K. Matsuda, MD
Hip Arthroscopic Surgery for Femoroacetabular Impingement in
the Athlete
Dean K. Matsuda, MD
Allodynia in Reverse: a Quantitative Demonstration of
Abdominal Wall Muscle Pain Relief Following Bladder Pain Treatment
Thida
Nunthirapakorn, MD
Microcirculatory Changes During Pneumoperitoneum
Douglas E.
Ott, MD MBA
Changes in Organ Perfusion During Laparoscopy
Douglas E. Ott, MD MBA
Transvaginal Cholecystectomy. From Hybrids to Pure
Daniel
A. Tsin, MD
SPECIAL EVENT: BREAKFAST AND FUTURE TECHNOLOGY SESSION
From the Infinitesimal to the Infinite - Molecules, Energy and Space for Surgeons
Saturday, September 12, 2009
7:30am-10:30am
Richard M. Satava, MD, Director
Keynote Speaker, Tim Reedman, presents Robots in Space
Harry T. Whelan, MD presents Controlling Molecules With Light
Michel Wertheimer, PhD presents Plasma Medicine - Why Energy Is Important to Surgeons
Brace yourself for a vision of the future. Directed by Richard Satava, MD, and featuring an exciting keynote speaker, this session promises to inspire all interested in the future of the medicine.
While most surgeons concentrate upon what procedure they must master for their next patient, there are some incredible new technologies that are going to radically influence decisions for how they treat their next patient. The scope of Science is expanding - reaching down to nanoscale and manipulating individual molecules, or stretching the reach out into the Universe - and surgeons must consider how to take advantage of these new opportunities. And not only are we able to manipulate individual molecules or atoms, but we have harnessed the power of energy (rather than building devices) to control the molecules or reach into Space. As examples of the vast opportunities that exist today and may soon be in the hands of surgeons, presentations will address how we are using light to improve wound healing and other basic biological processes by controlling molecules, how generating energy in the form of plasma ion clouds can kill bacteria yet spare cells or control the coagulation cascade to stop hemorrhage, and how research in space robotics will let surgeons think about surgery at places as remote as the Space Station or beyond.
Tickets are required for accompanying guests. See Registration Form.
ACCREDITATION Half-Day Master’s Classes: 4 credits
The Society of Laparoendoscopic Surgeons (SLS) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
DESIGNATION
The Society of Laparoendoscopic Surgeons designates this educational activity for a maximum of 31 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Full-Day Master’s Classes: 7 credits
Master's Class Lunch Lecture: 1 credit
18th SLS Annual Meeting & Endo Expo: 3 days: 23 credits
18TH SLS ANNUAL MEETING AND ENDO EXPO 2009 SCIENTIFIC ABSTRACTS:
Supplement to JSLS, Volume 13, Number 2
9100 General Surgery
Involution or Evolution: Minilaparotomy Approach to GERD Treatment
J.
Quiroz, MD, L. Guerrero, MD, J. A. Quiroz, MD, E. EN. Nova, M. EN. Flores, I. IN.
Ramirez
Centro Hospitalario San Nicolas, San Mateo Atenco Estado
de Mexico-Mexico
Background:
Gastroesophageal reflux disease (GERD) is a very serious problem. Despite the improvements
in antireflux surgery (ARS), new challenges are still ahead. We sought to
demonstrate the endpoints achieved by the minilaparotomy approach, which
include safety, excellent mobilization of the distal esophagus, and performance
of an excellent fundoplication. We
discuss the open access approach in the progression of ARS and that mini-access
is considered the evolution of surgical alternatives.
Method:
Between 2003 and 2008, 200 patients underwent minilaparotomy, clinical
evaluation, endoscopy-biopsy, manometry, 24h pH monitoring (some cases), and barium
study. Data collected included age, sex, typical and atypical symptoms, time
from onset, comorbidities, length of operating time, cost, hospital stay,
disability, complications, and medication used. Long instruments, Harmonic scalpel,
intracorporeal cool light, and special retractors were used to perform a total
floppy Nissen fundoplication. Indications
included esophagitis because of lower esophageal sphincter incompetence, hiatal
hernia, and Barrett’s-esophagus without dysplasia. Follow-up included assessment
of an annual endoscopy, quality of life (well-being index and symptom scale
rating), 3-year postoperative manometry, and 24-h pH monitoring (some cases).
Results:
Access was accomplished through an 8-cm to 9-cm long incision. Operating time was
60 minutes to 70 minutes. Cost was lower because several disposable devices
were used. Hospital stay was short at 2 days, and recovery time was short.
Complications included seroma 9 (0.4%), dysphagia 2%, bloating 10%, need for medication
<20%. Two procedures had to be redone because of reherniation. One major
complication occurred in a diabetic patient who experienced an intraabdominal
abscess, which was managed successfully.
Conclusion:
Minilaparotomy is highly effective for GERD treatment, considering that laparoscopic-ARS
has declined up to 30% in the USA and the field for endoluminal treatment is limited.
Minilaparotomy is becoming safe, durable, and a practical alternative to
laparoscopy and requires only a small incision.
9101 General Surgery
Laparoscopic Subtotal Colectomy for Multiple
Colon Polyposes
Giancarlo Basili, MD, Luca
Lorenzetti, MD, Graziano Biondi, MD, Orlando Goletti, MD
Pontedera Hospital
Introduction: Laparoscopic subtotal colectomy is probably one of the most
difficult and complex procedures in laparoscopic colorectal surgery. The
potential benefit of minimally invasive surgery, such as improved cosmesis,
reduced postoperative pain, shorter length of hospitalization, and faster
return to normal activity, could be overcome by higher complication rates and
longer lengths of surgery.
Methods: We report the case of a
55-year-old man who underwent laparoscopic subtotal colectomy for multiple
colon polyposes. A preoperative colonoscopy highlights the presence of multiple
colon polyps, with evidence of moderate to severe dysplasia.
Results: The most difficult and also
time-consuming part of the procedure is the mobilization of the transverse
colon and division of the middle colic vessels. Each branch is treated with
care, and proximal control of vessels is maintained at all times. Because this
area may be difficult to expose, a fundamental understanding of the vessels
encountered here is extremely important. The vascular pedicle should be
confirmed before division as the superior mesenteric artery and vein lie deep
to the dissection line and the pancreas is fully exposed as dissection
progresses.
Conclusions: The laparoscopic
approach to subtotal colectomy is especially attractive as there are a variety
of benign indications for this procedure and a previously necessary long
midline incision for surgery is avoided and replaced by a short McBurney
incision with all the favorable postoperative effects of minimally invasive
surgery. Although technically demanding and requiring significant expertise,
laparoscopic subtotal colectomy may be performed in select individuals.
9102 Gynecology
Transvaginal Application of a Laparoscopic Bipolar Cutting Forceps to Assist
Vaginal Hysterectomy in Extremely Obese Endometrial Cancer Patients
James Fanning, DO, Rod Hojat, MD, Jil Johnson, DO, Bradford
Fenton, MD, PhD
Summa Health System, Northeastern Ohio
Universities College of Medicine
Introduction: The purpose of this
report is to evaluate our experience with transvaginal application of a
laparoscopic bipolar cutting forceps to assist vaginal hysterectomy in extremely
obese women with endometrial cancer in whom obesity precluded LAVH/BSO and
lymphadenectomy and vaginal obesity limited visualization and exposure.
Materials and Methods: We performed
a retrospective review and identified 6 consecutive cases. No cases were
excluded. A laparoscopic 33-cm Plasma Kinetic (PK) cutting forceps with a 5-mm
diameter was applied transvaginally to coagulate and cut the uterosacral and
cardinal ligaments, uterine vasculature, and ovarian ligaments. The uterus was
delivered vaginally. Staging lymphadenectomy was not performed.
Results: Median patient age was 51
years, median weight was 405lb, and median BMI was 66kg/m2. Five of
6 cases were successfully performed vaginally (83%). Median operative time was
1 hour and 10 minutes, median blood loss was 500cc, and pain was only
discomforting. All patients were discharged the day after surgery. No
complications occurred. At median follow-up of 1 year, all patients were alive
with no evidence of disease.
Conclusion: It is our opinion that
the transvaginal application of a laparoscopic bipolar cutting forceps can
successfully assist vaginal hysterectomy in extremely obese endometrial cancer
patients who cannot tolerate LAVH/BSO and lymphadenectomy and vaginal obesity
limits visualization and exposure.
9103 Gynecology
Laparoscopic
Cytoreduction for Primary Advanced Ovarian Cancer
James Fanning, DO, Rod Hojat, MD, Jil Johnson, DO, Bradford
Fenton, MD, PhD
Summa Health System, Northeastern Ohio
Universities College of Medicine
Introduction: We evaluated the
feasibility of laparoscopic cytoreduction for primary advanced ovarian cancer.
Methods: All patients with presumed
stage 3/4 primary ovarian cancers underwent attempted laparoscopic
cytoreduction. All patients had CT evidence of omental metastasis and ascites.
A 5-port (5-mm) transperitoneal approach was used. A bilateral
salpingo-oophorectomy, supracervical hysterectomy, and omentectomy were
performed with the Plasma Kinetic (PK) cutting forceps. A laparoscopic 5-mm
Argon-Beam Coagulator was used to coagulate tumor in the pelvis, abdominal
peritoneum, intestinal mesentery, and diaphragm.
Results: Nine of 11cases (82%) were
successfully debulked laparoscopically without conversion to laparotomy. Median
operative time was 2.5 hours, and median blood loss was 275cc. All tumors were
debulked to less than 2cm, and 45% of patients had no residual disease. Stages
were as follows: 1-3B, 7-3C, and 1-4. Median postoperative length of stay was
one day. Median VAS pain score was 4 (discomforting). Two of 11 patients (18%)
had postoperative complications.
Conclusion: We present the original
series of laparoscopic cytoreduction for primary advanced ovarian cancer.
Laparoscopic cytoreduction was successful and resulted in minimum morbidity.
Because of our small sample size, additional studies are needed.
9104
Urology
Trans-Ileal-Conduit-Resection (TICR) of a Recurrent Urothelial Carcinoma in the
Ileal Conduit
Dong Soo Park, MD, PhD, Woong
Ki Jang, MD, Jong Jin Oh, MD, Sang Hyun Jee, MD
Bundang CHA
Hospital, Pochon CHA University, Sung Nam, South Korea
Introduction
and Objective: Management of
recurrent urothelial carcinoma at the uretero-ileal anastomotic site is
challenging. We present our experience with endoscopic surgical treatment of a
delicate tumor.
Methods:
A 59-year-old male was diagnosed
with invasive bladder cancer, and he had undergone a radical cystectomy with
ileal conduit urinary diversion 8 years earlier. He presented with intermittent
right flank pain and gross hematuria for 6 months. The contrast enhanced
computed tomography of the abdomen and pelvis demonstrated the presence of
hydronephrosis and a large enhancing mass in the ileal conduit. Flexible
cystoscopy confirmed a tumor in the ileal conduit arising presumably from the
right uretero-ileal junction. After formation of a right percutaneous
nephrostomy, complete trans-ileal-conduit-resection (TICR) of the tumor using
the usual resectoscopic instrument was done. Pathology of the tumor showed
high-grade urothelial cancer extending to the small bowel smooth muscle tissue.
During follow-up, right hydronephrosis redeveloped. Repeat TICR was performed.
Results:
Pinpoint right-side uretero-ileal
junction was found with difficulty. After resection around the right-side
ureteral orifice, a ureteral stent was indwelled retrogradely. The resected
tissues were cancer free on pathologic examination.
Conclusions:
Recurrence of the urothelial cancer
in the ileal conduit is extremely rare. Recurrent urothelial cancer at the
uretero-ileal junction can be controlled with TICR, avoiding complicated
surgery.
9105 General Surgery
Outcomes of Minimally Invasive Myotomy for the Treatment of Achalasia in the
Elderly
Randall O. Craft, MD, Colleen Flahive, Mark C. Mason, MD, Marianne Merritt,
RNFA, Kristi L. Harold, MD
Mayo Clinic Arizona
Objective: The goal of our study was to review our experience with
minimally invasive myotomy (MIM) in patients aged 65 and older.
Methods: We reviewed 52 patients (22
males and 30 females) 65 years or older (mean age 73.6; range, 65 to 89)
diagnosed with achalasia who underwent MIM at our institution over a 9-year
period. Prior therapies were evaluated (pneumatic dilations, Botox injection,
prior myotomy), as well as clinical outcomes. Both nonsurgical and surgical
postoperative interventions (redo myotomy, esophagectomy, Botox injections)
were also analyzed.
Results: Of the 52 patients, 29
(56%) had had prior endoscopic therapy. Twenty-two (76%) received pneumatic
dilation, 20 (69%) received Botox, and 2 (7%) had prior myotomy. Range of ASA
classification was 2 to 4. Mean duration of symptoms was 10.9 years
(range, 0.5 to 50). No perioperative mortalities occurred; mean hospital stay
was 3 days. Forty-eight patients (92.3%) had a fundoplication: 13 (27%) Dor and
35 (73%) Toupet. Three patients (5.8%) had complications. Two had pleural
effusions. One had a hole in the gastric mucosa, which was repaired
intraoperatively. Eleven patients (21%) had additional therapy postoperatively;
10 (91%) had additional pneumatic dilations, and 7 (64%) received additional
Botox injections. One (1.9%) patient had further surgical intervention,
receiving an esophagectomy. Of the 42 patients who had notes detailing their
follow-up, all claimed overall symptom improvement.
Conclusion: Age does not appear to
adversely affect outcomes of laparoscopic Heller myotomy.
9106
General Surgery
Prophylaxis of Recurrent Pancreatitis: Mini-Invasive Approach
Vincenzo Neri, Prof Dr Med
University of Foggia, Italy
Aim: Acute biliary pancreatitis (ABP) is caused by the alteration of
papillary patency. The normal transpapillar flux and the cleaning of the common
biliary duct (CBD) may prevent potentially avoidable recurrent pancreatitis.
Patients and Methods: From September
1997 to December 2008, we treated 224 cases of ABP (34 severe, 190
mild/moderate): 162 (72.4%) with the first attack, 62 (27.6%) with recurrent
ABP (second or further attack). The patients with recurrent pancreatitis had
not undergone, in the previous hospital stay elsewhere, the evaluation and, if
necessary, the treatment of the papillary obstacle and/or CBD stones, sludge,
etc. In our hospital, all patients had undergone complete treatment of ABP,
which included clinical intensive therapy, instrumental control of the
papillary patency, then ERCP/ES(180% to 80%) within 72 hours from the onset in
all SAP, in mild/moderate cases with signs of papillary lithiasic obstacle
(US/MRCP confirmation), in all recurrent pancreatitis, and
videolaparocholecystectomy.
Results: In the follow-up of
recurrent pancreatitis, we have controlled, clinical, and instrumental data,
after 90 days and 180 days in 35 patients (56%, 27 lost): 21 SAP, 14
mild/moderate. Further recurrence occurred in only 1 patient (2.8%); in the
other controls recurrence of ABP was not reported; laboratory (amylases,
cholestasis) and instrumental tests (abdominal US) have been normal.
Conclusions: Recurrent ABP has
occurred in patients discharged from the hospital without additional treatment,
by a persistent papillary obstacle (small stones, sludge, cholesterol crystals,
etc.). Therefore, we confirm the therapeutic validity of the instrumental
control (US/MRCP) and the possible treatment of the papillary or biliary
lithiasic obstacle for the prevention of recurrent ABP.
9107 General Surgery
Core Appendectomy: A New
Technique for Delayed Appendicitis
Jayarama K. Shenoy, MD, MBBS,
MS
Kasturba Medical College, Karnataka, India
Background: Acute
appendicitis is primarily an inflammation starting in the lymphoid tissue
in the submucosa of the appendix. It spreads to involve muscle and serosal
layers later in the course of development. Delayed appendicitis is treated with
the Ochsner Sherren regimen, because appendectomy has a high-risk of bowel
injury and fistulation. Surgery is performed only to drain the abscess and
peritonitis and later for a definitive second surgery.
Methods: Thirty
patients with acute appendicitis presenting after 3 to 4 days of medical
treatment with formation of phlegmon underwent operative removal of the core of
the appendix comprising mucosa and submucosa, leaving the outer shell of the
musculo-serous layer adherent to the colonic wall (24 by open and 6 by laparoscopic
technique). This is contrary to the conventional approach of the Ochsner
Sherren regime. The base of the appendix is divided as the first step followed
by dissection to create a plane between the submucosa and outer muscular layer
through the divided end of the appendix. The core of the appendix is
pulled out of the distal shell of the muscular layer and adherent serosa.
Results: The operative complications
included minor ooze from inflamed tissue (3 cases of open and one
laparoscopic), accidental division of the friable appendix requiring
getting the tip of the appendix in 2 open cases. All patients recovered without
postoperative complications.
Conclusion: Core appendectomy provides a safe surgical
technique, open or laparoscopic, for delayed acute appendicitis with mass
formation. It avoids the need for a second elective surgery.
9108 Urology
Robotic Pyeloplasty with Pyelolithotomy
Mark T. Edney, MD, Thomas M. DeMarco, MD
Peninsula Regional Medical Center, Salisbury, Maryland
Background: The use of robotics in urology has increased
significantly in the past 5 years. Robotic-assisted laparoscopic pyeloplasty is
an established urological application. We report a robotic dismembered
pyeloplasty with concomitant pyelolithotomy.
Case Report: A
39-year-old man presented with intermittent left flank pain. Intravenous
pyelogram revealed 3 stones in the left renal pelvis and evidence of
ureteropelvic junction obstruction. Retrograde ureteropyelogram confirmed the
obstructing lesion.
The Da Vinci S surgical system was used with a 3-arm technique.
The ureteropelvic junction and renal pelvis were isolated. After dividing the
ureter at the ureteropelvic junction, the pyelotomy was extended cephalad. The
first stone was immediately visible and extracted with the curved bipolar
forceps. Next, the bedside assistant advanced a flexible
cystoscope through a 12-mm port into the renal pelvis. Normal saline was
used for irrigation and a suction cannula was positioned inferior to the renal
pelvis. The remaining 2 stone were captured during pyeloscopy and extracted
using a nitinol zero tip basket. Each stone, once removed from the pelvis, was
secured with a grasper and removed through the 12-mm port. After stone removal,
the anastomosis was performed.
Conclusion:
Renal stones can occur as a result of urinary stasis from ureteropelvic
junction obstruction. We present a report of the successful repair of
ureteropelvic junction obstruction with concomitant pyelolithotomy using the
DaVinci S system.
9109 Gynecology
Treatment of Severe Hemorrhage Using Hydrothermal Endometrial Ablation
Herbert A. Goldfarb, MD
New York Downtown Hospital, New
York, New York
Introduction: Of the 600 000 hysterectomies performed each year,
over 150 000 are in patients with severe uterine bleeding as a significant
diagnosis. Many patients have bleeding to the point of severe anemia and often
require transfusion to accomplish the end point of hysterectomy. Many of these
hysterectomies as well as unnecessary transfusions can be avoided. In the
majority of cases involving severe uterine hemorrhage, we have found large
submucosal and intrauterine fibroids. Medical therapy has frequently
failed to control hemorrhage. This case report will describe a group of 6
patients treated from 2003 thru 2005 who have undergone hydrothermal
endometrial ablation to control severe persistent uterine hemorrhage. We
describe a technique for treating persistent uterine hemorrhage unresponsive to
medical therapy.
Methods: Six patients from the Department of Gynecology at an academically
affiliated general hospital underwent hydrothermal endometrial ablation after
failed medical therapy for unremitting uterine bleeding.
Results: All procedures were successful.
Conclusion: Hydrothermal endometrial ablation is effective in controlling
severe uterine bleeding in patients with large intrauterine fibroids.
9110 General Surgery
Trends and
Correlations of MORBID Scores for Adjustable Gastric Band: Weight Loss,
Resolution of Comorbid Diseases, and Quality of Life
Brad E. Snyder, MD, Todd Wilson,
MD, Ben Leong, MD, Connie Klein, NPC, Erik B. Wilson, MD
The University of Texas Health
Sciences Center at Houston, Texas
Background: To determine a patient’s success after
weight loss surgery, we must measure outcomes. The Measured Outcome Results of
Bariatric Interval Data (MORBID) score is a sum of measured quality of
life, excessive weight loss, and resolution of comorbid conditions scores used
to define outcome.
Methods: A prospective cohort
of 305 consecutive postoperative gastric banding patients was collected, and
MORBID scores were calculated. Each component of the MORBID score was divided
into quartiles. ANOVA between age, BMI, YOS, EW, %EWL, ethnicity, and other
MORBID groups were performed. Sex was analyzed with the Student t test, and trends over time were
analyzed with a correlation matrix.
Results: The average MORBID score
was 5.5±1.7. No differences were found between men and women. Quality of life
decreased over time (r=-0.73) and with weight loss (r=-0.82) after surgery.
Weight loss and comorbid scores increased over time (r=0.90 and 0.92,
respectfully), and the resolution of comorbid conditions was related to weight
loss (r=0.77). Quality of life and excessive weight loss synergistically
increased the total score (r=0.91).
Conclusion: Quality of life
decreases over time after adjustable gastric banding despite significant weight
loss and resolution of comorbid conditions. The overall outcome was a “very
good” one, but this is because of excellent weight loss scores. There are
significant psychological components of gastric banding that must be fully
addressed by weight loss programs to improve the quality of life of patients
because weight loss and resolution of comorbid conditions are not enough to
improve their overall health.
9111 Urology
Safety and Perioperative Outcomes During the Learning Curve of Robotic-Assisted
Laparoscopic Prostatectomy (RALP): A Multi-institutional Study of
Fellowship Trained (FEL) Robotic Surgeons Versus Experienced Open Radical
Prostatectomy (RRP) Surgeons Incorporating RALP
Timothy J. LeRoy, David D. Thiel, David A. Duchene, Todd C.
Igel, Michael J. Wehle, Manilo Goetzl, J. Brantley Thrasher
Mayo Clinic Florida, Jacksonville Florida
University of Kansas Medical Center, Kansas City, Kansas
Background: No
consensus exists on the number of cases and/or training required for
credentialing for robotic-assisted
laparoscopic prostatectomy (RALP). We elected to compare the safety and
perioperative outcomes of fellowship trained (FEL) versus experienced open
radical prostatectomy (RRP) surgeons incorporating RALP into their practice.
Methods: Prospective data were compiled on the initial 30
cases each of 2 FEL robotic surgeons directly following fellowship completion.
This was compared with the first 30 RALPs of 3 experienced RRP surgeons who had
incorporated RALP into their practice. The second 30 cases of the RRP group
were also compared with the first 30 of the FEL group to document improvement
with experience (Study N=240).
Results: Open
conversion (0% vs 3%), prolonged catheterization (over 14 days) (5% vs 20%),
and reoperation (0% vs 8%) were more common in the RRP group than in the FEL
group. The FEL group had a lower margin positive rate (15% vs 34%) compared
with the RRP group, but this improved to 19% in the second 30 cases for the RRP
group (P=0.009). Early PSA recurrence was higher in the RRP group compared with
the FEL group (11% vs 2%), but this dropped to 4% in the second 30 cases for
the RRP group.
Conclusion: Experienced
RRP surgeons can safely incorporate RALP into their practice without an
increased number of hospital days compared with FEL. Open conversion, prolonged
catheterization, and reoperation are more likely initially with RRP surgeons in
their first 30 cases. Margin positivity and PSA recurrence rates are higher
with RRP surgeons initially but approach those of FEL surgeons after 30 cases.
9112 General Surgery
Impact of the Robot in Vascular Surgery
Petr Štádler, MD, PhD
Na
Homolce Hospital, Prague, Czech Republic
Objective: The safety, benefits, and usefulness of laparoscopic surgery
have been demonstrated. The robot represents the next step in using the
minimally invasive technique in surgery. We describe our clinical experience
with robot-assisted aortoiliac reconstruction for occlusive disease, aneurysm,
and 2 hybrid procedures performed using the da Vinci system.
Methods: Between November
2005 and December 2008, we performed 130 robot-assisted laparoscopic aortoiliac
procedures. We prospectively evaluated 116 patients for occlusive disease, 10
patients for abdominal aortic aneurysm, 2 for a common iliac artery aneurysm,
and 2 for hybrid procedures. Dissection of the aorta and the iliac arteries was
performed laparoscopically, and the robotic system was used to construct the
vascular anastomosis, for the thromboendarterectomy, for the aorto-iliac
reconstruction with the patch closure and for the posterior peritoneal suture.
Results: We successfully completed
126 cases (97%) robotically, in 1 patient laparoscopy was stopped because of
heavy aortic calcification, and in 3 (2.3%) patients conversion was necessary.
Thirty-day survival was 100%, and nonlethal postoperative complications were
observed in 3 patients (2.3%).
Conclusion: Our clinical experience with robot-assisted laparoscopic
surgery shows that it is a feasible technique for aortoiliac vascular and
hybrid procedures. The da Vinci robotic system facilitated the creation of the
aortic anastomosis and shortened aortic clamping time compared with purely
laparoscopic techniques. Robotic
surgery can help us in the future in hybrid procedures.
9113
Urology
Posterior Rhabdosphincter Reconstruction May Delay Time to Continence Recovery
Following Robot-Assisted Radical Prostatectomy
Joshua T. Stern, MD, R. Caleb Kovell, Mary Nguyen, RN, BSN, Meredith
Bergey, Ph.D., David I. Lee, MD,
University of Pennsylvania
Introduction: Posterior
rhabdosphincter reconstruction (PRR) as a technical modification to radical
prostatectomy has been suggested to improve rate of return to continence. We
examined continence outcomes for patients undergoing PRR during robot-assisted
radical prostatectomy (RARP).
Methods: Continence
outcomes were compared for 265 consecutive patients who underwent RARP with PRR
to a historical control of 130 RARP patients. PRR involved a running stitch
taken to approximate Denonvillier’s fascia to the posterior rhabdosphincter.
Continence was defined as use of 0 pads. Per day (PPD). We also examined
outcomes for reaching social continence 1PPD. Nerve sparing, prostate size, and
extracapsular invasion were other variables analyzed.
Results: Average age
was 59.7 and BMI 28.0. On multivariate analysis, age, prostate volume, and PRR
were significant variables. Patients undergoing PRR were less likely to achieve
continence (HR = 0.65 [0.47, 0.91], p = 0.01) such that median time to
continence was 36 weeks for the PRR group and 13 weeks for the control (p =
0.007). PRR diminished continence at 4 weeks by 45% (13% v. 24%) and at 13
weeks by 24% (39% v. 51%). PRR only modestly affected median time to 1
ppd (4 v. 7 weeks, p = 0.053). Patient age (HR = 0.98 [0.97, 1.00], p =
0.02) and prostate volume (HR = 0.99 [0.98, 1.00], p = 0.053) modestly delayed
return to continence.
Conclusions:
In our series, our method of PRR during RARP
significantly diminished early continence rates. Prospective, randomized trials
are necessary to validate this data.
9114 Urology
Laparoscopic Donor Nephrectomy: Caution in the Use of Kidneys With Multiple
Arteries
Anil S.
Paramesh, MD, Rubin Zhang, MD, Sander S. Florman, MD, Haythem Al-Abbas, MD,
Lillan C. Yau, PhD, Mary T. Killackey, MD, Brent Alper, MD, Douglas Slakey,
MD,MPH
Tulane Abdominal Transplant Institute, Tulane University School of Medicine,
New Orleans, LA
Background: Multiple arteries during
a laparoscopic donor nephrectomy may lend to longer operative times and increased
risk of donor/recipient complications with consequent decreased graft function
and survival. This study examines our experience with single vs. multiple
artery kidneys procured laparoscopically over an 11-year period.
Methods: We identified all donor/recipient
pairs who underwent living donor kidney transplants from 8/98 through
8/2008. Single (SA) vs. multiple artery (MA) groups were compared with
respect to donor and recipient demographics, operative variables, postoperative
complications, graft function, and survival for up to 5 years
posttransplant.
Results: During this time period,
278 donor/recipient pairs (218 SA & 60 MA) underwent surgery. Mean
follow-up was 3.77 years. All donors underwent a hand-assisted laparoscopic
nephrectomy. The operative time (P=0.03) and rejection rates (P=0.006) were
significantly higher in the MA group. No significant difference existed in
donor complications. There was a trend towards more ureteral complications
among the MA recipients (P=0.06). SA kidneys had a significantly better GFR
than the MA kidneys did up to 3-years posttransplant. Graft survival rates at
1, 3, and 5 years were 94.4%, 90.6%, and 86% for the SA group vs. 89.6%, 83.2%,
and 71.8% for the MA group (P=0.05).
Conclusion: Caution must be advised
in the laparoscopic procurement of kidneys with multiple arteries. These
kidneys may have a higher risk of rejection, worse graft function and survival
compared with single artery kidneys.
9115 General Surgery
Cerebral Gas Embolism Due to Upper Gastrointestinal Endoscopy
R. den Boer, MD, E. Totte, MD, R. A. van Hulst, MD, PhD, K. van
der Linde, MD, PhD, W. van der Kamp, MD, PhD, J. P. E. N. Pierie, MD, PhD
Introduction: Cerebral gas embolism as a result of upper gastrointestinal
endoscopy is a rare complication and bares a high morbidity.
Case Report: A patient is presented
who underwent an upper endoscopy for evaluation of a gastric-mediastinal
fistula after subtotal esophagectomy and gastric tube reconstruction because of
esophageal cancer. During the procedure, cerebral gas emboli developed
resulting in an acute left-sided hemiparesis. After hyperbaric oxygen therapy,
the patient recovered almost completely.
Discussion: The literature
concerning cerebral gas embolism associated with upper endoscopy is reviewed.
Conclusion: Once cerebral gas emboli
are recognized, patient outcome can be improved by hyperbaric oxygen therapy.
9116 Gynecology
Adhesion Prevention with a Resorbable Hydrogel Following Myomectomy
L. Mettler, MD, PhD
University Clinics of
Schleswig-Holstein/ Campus Kiel, Germany
Background: This multicenter,
randomized, single-blind study assessed the safety
and efficacy of a resorbable hydrogel (‘Hydrogel’) for
the reduction of postoperative adhesion formation following myomectomy.
Methods: Women (n=71) who were undergoing
laparoscopic (67.6%) or laparotomic myomectomy
were randomized (2:1) to Hydrogel (sprayed over surgically treated
areas prior to wound closure, n=48)
or to control (standard care, n=23). Patients (38 Hydrogel, 20
control) returned 8 weeks to 10
weeks later for a second look. Adhesions were
graded using a modified American Fertility Society (mAFS) scoring
method. The primary efficacy measure was the posterior uterus
mAFS score.
Results: For Hydrogel and control
patients, respectively, mean±SD mAFS scores were 0.5±1.4 and 0.0±0.0 at baseline,
and 1.1±1.9 and 2.6±2.2 at the second look.
Similarly, mean changes from baseline were 0.8±2.0 and 2.6±2.2 (P=0.01); 95% confidence intervals for
these mean changes were 0.16 to 1.44 and 1.64 to 3.56. Adverse
events were reported by 9.6% and 17.4% of Hydrogel and control
patients, respectively. No intraabdominal infections or
postoperative site infections were reported.
Conclusion: This 71-patient study
provides the first clinical evidence of the
safety and efficacy of Hydrogel for the reduction of adhesions following
myomectomy.
9117 Gynecology
Six Cases: Reports of Ileum Colpopoiesis
by Laparoscopy
Xiaoyan Ying, MD
The second affiliated
Hospital of Nanjing Medical University, Nanjing, China
Objective: To study the
feasibility and clinical outcome of laparoscopic vaginoplasty using
transforming lineal segments with blood vessels.
Methods: Six cases
of congenital absence of the vagina were assigned to total laparoscopic (2
cases) and laparoscopically assisted ileum colpopoiesis (4 cases) from April
2006 to July 2008.
Results: We have successfully completed the operations for 6 patients and
made 3 months to 24
months of follow-up. All the artificial vaginas were well done, and their
features and physical functions were close to the natural female vagina.
Patients wore a vaginal mould for at least 6 months to 8 months, and their
intercourses were satisfactory. No complications after the surgery have been
reported.
Conclusion: The procedures of total laparoscopic and laparoscopically
assisted ileal segment transplantation for vaginal construction are ideal to
this day.
9118
General Surgery
Laparoscopic Colectomy: Does the
Learning Curve Extend Beyond Colorectal Surgery Fellowship?
Joshua A. Waters, MD, Ray Chihara,
MD, Jose Moreno, MD, Bruce Robb, MD, Virgilio George, MD
Indiana University School of
Medicine
Background: As minimally invasive
colon and rectal resection has become increasingly prevalent over the past
decade, the role that fellowship training plays has become an important
question. This analysis examines the learning curve of one fellowship trained
colorectal surgeon in the first 100 cases.
Methods:
This is a prospectively collected
retrospective analysis of the first 100 laparoscopic colon and rectal
resections performed between July 2007 and July 2008 by a CRS fellowship
trained surgeon at a VA and county hospital. Included were all
nonemergent laparoscopic cases.
Results: Mean age was 63 years
(range, 36 to 91). These 100 resections included 42 right, 6 left, 32 sigmoid,
13 rectal, and 7 total colectomies. Indications were 55% cancer, 19% unresectable
polyp, 18% diverticular disease, 4% inflammatory, and 4% other. Overall
mortality was 3%. Morbidity including wound infection was 28%. Early and late
groups showed no difference in age, ASA, or indication. Overall conversion rate
was 4%. No statistical difference was seen in mortality, morbidity, EBL, LOS,
margin, lymph nodes, or conversions between the first and second 50 cases
(P<0.05). Right and sigmoid colectomy operative time decreased by 35% and
19%, respectively.
Conclusions:
Prior investigators have
demonstrated a significant learning curve in laparoscopic colorectal surgery.
In the first 100 cases, no difference in mortality or morbidity occurred
between early and late cases. Alternatively, operative times decreased over the
first 100 cases. Laparoscopic experience during CRS fellowship surpasses the
learning curve in regard to safety and outcome, whereas operative efficiency
increases over the first year of practice.
9120 Urology
Urethral Length on MRI Is Predictive of Early Return to Continence After
Robotic-Assisted Radical Prostatectomy
Joshua M. Stern, Robert Kovell, Mary
Nguyen, Rachel Natale, Kelly Monahan, David I. Lee, William Jaffe
University of Pennsylvania
Introduction: Postoperative
incontinence is multifactorial after radical prostatectomy. Using endorectal
coil MRI, we examined features of the male urethra and its accompanying
muscular sphincter to predict postoperative continence after robotic
prostatectomy.
Methods:
Eighty patients underwent preoperative
1.5 Tesla endorectal MRI. Urethral length was measured in the coronal plane.
All patients underwent robotic prostatectomy. Patients completed questionnaires
at monthly intervals. The primary end point was time to achieving continence
requiring 0 to 1 pad per day (PPD). Statistical analysis was performed using
Cox regression models to create both univariate and multivariate survival
models.
Results:
Mean age was 59.7 (SD, 7.1).
Bilateral nerve sparing was present in 98%. Mean urethral length was 17.1mm
(SD, 4.5mm). Mean sphincter thickness was 8mm (SD, 2.1). Mean prostate size was
34.7cc (SD, 17.8). Sixty patients achieved 1 PPD (mean, 8.1 weeks; SD, 9.4) and
34 patients achieved 0 PPD (mean, 10.5 weeks; SD, 8.0). On multivariate
analysis, larger prostate size (HR, 0.97; P<0.04) and older age (0.96,
P<0.07) were associated with a longer time to achieve 0 PPD. Urethral
length, as a continuous variable was associated with an increase in the
likelihood of achieving 0 PPD postoperatively (HR, 1.10; P<0.02). When
controlling for age and MRI urethral length, patients with a prostate size ≥50
grams had a 76% lower likelihood of achieving 0 PPD at any point in time than
did patients with <50 gram prostate (HR, 0.24; P<0.05).
Conclusion:
Longer urethral length increased the
likelihood of achieving continence at any time point. Increasing age and larger
prostate size were negatively associated with achieving continence.
9121 General Surgery
Chronic Calculous Cholecystitis in Chilaiditi’s Syndrome
José M. M. Ferreira-Coelho, MD, PhD
Background: The epidemiology, etiology, clinical features, differential
diagnosis, and treatment of Chilaiditi’s syndrome were analyzed.
Methods: The patient was a
69-year-old man with chronic calculous cholecystitis, with acute periods,
associated with vomiting, irregular bowel habits, and pseudo-obstruction. The
clinical situation was complex and special tests, such as chest X-ray,
abdominal plain X-ray, ultrasonography of the abdomen, and endoscopy (total
colonoscopy) did not help identify the cause of the patient’s symptoms. The
diagnosis could only be made by CT.
Results: Surgical treatment by
“minimally invasive surgery” was chosen. The hepatic flexure and transverse
colon were established by retraction and the division of the hepatocolic
ligament to make a correct cholecystectomy possible. To avoid any iatrogenic
lesion in a highly vulnerable colon, we established pneumoperitoneum and set
the first trocar, the 12-mm camera trocar, a small 2-cm laparotomy umbilically
as the main step.
Conclusion: Very good surgical
results were achieved, and the patient was discharged 24 hours after surgery.
At 5-year follow-up, the patient remains in good condition.
9122 General Surgery
A Novel Approach to Gastric Wedge Resection Using Single Incision Laparoscopic
Surgery (SILS)
Ricardo M. Mendoza, MD, Curtis E. Bower, MD, Walter E. Pofahl,
MD
Brody School of Medicine, Greenville, NC
Introduction: Single incision laparoscopic surgery (SILS) is an advanced
laparoscopic approach, offering potential benefits of improved cosmesis,
decreased pain, shorter hospitalization, and quicker return to work. We
describe a SILS approach to perform a laparoscopic gastric wedge resection.
Case Report: A 69-year-old male with vitamin B12 deficiency and a
gastric carcinoid was offered a SILS approach for resection. Two 5-mm ports
were placed through a 1-inch umbilical incision. Concurrent upper endoscopy was
performed, and the mass identified. A 2-0 nylon on a Keith needle was passed
percutaneously through the stomach wall at the site of the mass and used as a
retraction stitch. One 5-mm port was exchanged for a 12-mm port, and a stapled
wedge resection was performed. Upper endoscopy and specimen examination
confirmed removal of the mass. On POD 1, the patient was advanced to a regular
diet and discharged home on POD 2. Final pathology revealed a type I, 0.9-cm
carcinoid with clear margins. Chronic atrophic gastritis was also noted.
Discussion: SILS is more cosmetic and potentially offers decreased pain
and quicker recovery. However, this technique is technically more challenging
due to instrument conflict and restricted movement compared with traditional
multiport laparoscopy. The availability of flexible laparoscopes and roticulating
instruments has assisted in overcoming these difficulties.
Conclusion: SILS is an advanced laparoscopic approach and can be safely
applied to small gastric mass wedge resection. The clear benefit to this
approach is cosmetic, and clearly more research and development need to be
performed to further delineate advantages and disadvantages to this approach.
9123 Gynecology
Laparoscopic Replacement of Inguinal Ovaries in Mayer-Rokitansky-Kuster-Hauser
Müllerian Agenesis Syndrome.
Muhieddine Seoud, MD, Fayek
Jamali, MD
American University of
Beirut Medical Center, Beirut
Lebanon.
A 12-year-old girl presented with cyclic, monthly, alternating inguinal pain.
She had 2 previous bilateral inguinal explorations performed in another country
for possible herniorrhaphy. Review of histology slides of biopsies taken during
the second surgery revealed normal ovarian tissue. Examination revealed a
normal-looking girl for her age (breasts and pubic hair: Tanner II-IV). She had
normal external genitalia. There were bilateral scars in the groin areas where
no masses could be palpated. An ultrasound revealed inguinal structures having
the appearance of normal ovaries. The uterus, cervix, and upper vagina could
not be visualized. Magnetic resonance imaging confirmed these findings and
showed, in addition, the right kidney to be in its normal position and the left
kidney to be at the level of the right iliac fossa (cross ectopia). No
vertebral abnormality was found. Laboratory workup revealed the following: FSH
and LH, 2.72 and 1.33 mIU/mL, respectively; E2, 72 pg/mL; and T, 0.08 nmol/mL.
The karyotype (blood, R banding) was 46,XX. The diagnosis was
Mayer-Rokitansky-Kuster-Hauser müllerian agenesis syndrome (congenital absence
of the uterus and vagina) with bilateral inguinal ovaries (only 7 such cases
have been reported).
During laparoscopy, the infundilo-pelvic ligaments were both identified and
adhesions around them released. They were both followed through the inguinal
rings leading to both ovaries. These were adherent to surrounding tissues.
After lysis of the adhesions, both ovaries were replaced into the pelvis and
fixed to prevent future torsion.
Three years later, the patient is pain free with minimal cyclic pelvic
ovulation pains.
9124 Multispecialty
Transvaginal Cholecystectomies: From Hybrids to Pure
Daniel Tsin, MD1, Nestor Gomez, MD2, Guillermo Dominguez3, Fausto
Davila4
1The Mount Sinai Hospital of Queens, Long Island City, New York, USA
2Universidad de Guayaquil School of Medicine, Guayaquil, Ecuador
3Sanatorio Mitre Buenos Aires, CF, Argentina
4Universidad Nacional Autonoma de Mexico, Poza Rica, Veracruz, Mexico
Objective: To present our evolution in transvaginal cholecystectomies
since 1999.
Methods and Procedures: Transvaginal cholecystectomies were done
with rigid instruments via a circular colpotomy during vaginal hysterectomies
at The Mount Sinai Hospital of Queens in 1999. We began the use of the
transvaginal gastroscope via posterior minilaparoscopic culdotomy at the
Universidad de Guayaquil, Ecuador in 2007. In 2008, we introduced the use of a
magnetic grasper to aid in this surgery, and a pure transvaginal
cholecystectomy was performed with an operative laparoscope via a posterior
colpotomy using a vaginal port without a Veress needle or any other type of
abdominal port at the Universidad Nacional Autonoma de Mexico, Poza Rica,
Veracruz.
Results: All patients were ambulatory a few hours after surgery and
were discharged the next day without complications.
Conclusions: The experience included the hybrid technique of
culdolaparoscopy, a minilaparoscopy assisted natural orifice surgery (MANOS),
as a prelude to a pure transvaginal approach. In our opinion, an expert team
and careful progression are needed in this evolution.
9125 General Surgery
Laparoscopic Right Hemicolectomy, Notes Extraction vs. Counter Incision: A
Prospective Study
Guillermo Portillo MD, Morris E Franklin MD
Texas Endosurgery Institute, San Antonio, Texas, USA
Background: Laparoscopic colectomy
is now accepted for both benign and malignant colon diseases as safe and
effective as the open approach. Based on our experience with laparoscopic
right hemicolectomy with intracorporeal anastomosis, we designed a
nonrandomized prospective study comparing NOTES extraction (transvaginal) vs
counter incision extraction of the specimen.
Methods: From December 2007 to February 2009, all laparoscopic right
hemicolectomies were analyzed. The operative procedures and instrumentation
were standardized for all laparoscopic right hemicolectomies with either NOTES
extraction or counter incision extraction.
Results: Thirty female patients were prospectively followed. Fifty percent
received laparoscopic hemicolectomy with intracorporeal anastomosis and NOTES
extraction (transvaginal) and 15 patients laparoscopic right hemicolectomy with
intracorporeal anastomosis and counter incision extraction (RLQ muscle
splitting). The mean operative time for the NOTES extraction was 159.6±27.1
minutes vs. 133.5±29 minutes for the counter incision, the mean blood loss was
83.3±14.4mL vs. 89.0±5.5mL for the counter incision, the mean hospital stay was
5.5±2.5 days vs. 5.9±2.8 days for the counter incision, the intraoperative and
postoperative morbidity rates were 0% and 0.66%, respectively vs. 0% and 13%
for the counter incision.
Conclusion: Laparoscopic colectomy
with intracorporeal anastomosis is safe and effective for managing a variety of
colonic diseases, including malignant disease. NOTES extraction resulted in
increased operative time but decreased postoperative complications.
9126 General Surgery
Laparoscopic Approach to Colonic Emergencies
Guillermo Portillo, MD, Morris E. Franklin, MD, Sameer Mohiuddin, DO
Texas Endosurgery Institute, San Antonio, Texas
Objective: Many colonic pathologies warrant emergency treatment. However,
little has been published regarding a laparoscopic approach to colonic
emergencies. We have approached almost all colonic emergencies laparoscopically
for the past 17 years with the benefit of making subsequent clinical decisions
based on the findings of laparoscopy.
Methods: From April 1991 to July
2008, 179 patients requiring emergency laparoscopic colon procedures for right
and left colon pathologies as well as rectal emergencies were prospectively
studied at the Texas Endosurgery Institute. Data were gathered into categories
of age, sex, indication of surgery, disease process, operative time, blood loss
during surgery, length of hospitalization, postoperative complications,
conversion rate and long-term results.
Results: The indications for surgery
included acute diverticulitis (Hinchey IIb, III, IV) in 32%, perforation in
27%, obstruction in 22%, ischemic colitis in 9%, volvulus in 4%, fistula in 2%,
intussusception in 1%, and other causes in 3%. The laparoscopic procedures
included lavage and drainage, repair of perforations, segmental colonic
resection, ostomy formation, and adhesion take down. The mean operative time
was 134.3 minutes, and the mean EBL was 149.45mL. The laparoscopic approach was
100% effective in identifying the colonic pathology and was used to effectively
treat 79% of the patients. Thirty-eight patients required conversion to open
procedures (21%),
Conclusion: In experienced hands, a
laparoscopic approach to colonic emergency situations can be effective and safe
with an acceptable conversion rate. A laparoscopic approach seems to be an
effective diagnostic tool for colonic emergencies and can be a guide in
treatment strategies.
9127 General Surgery
Is There Any Value to Totally Intracorporeal Anastomosis in Laparoscopic Colon
Surgery?
Guillermo Portillo, MD, Morris E. Franklin, MD
Texas Endosurgery Institute, San Antonio, Texas
Objective: A laparoscopic approach to colon resection has been quoted as
showing numerous advantages when compared with similar open procedures.
However, controversy exists regarding the value of totally intracorporeal
anastomosis. We present our experience with intracorporeal anastomosis for
right and left colon.
Methods: From April 1991 to July
2007, 1651 patients requiring laparoscopic colon resection for right, rectal,
and left colon were prospectively followed.
Intracorporeal anastomosis (ICA)
was completed with transanal extraction (left colon) or counter incision
extraction (left, right colon). Extracorporeal anastomosis was completed with
counter incision extraction of the specimen.
Results: Of our 1240 laparoscopic
left-colon resections, 769 could be completed with transanal specimen
extraction (62%). The average operating time was 152 minutes for transanal
extraction and 170 minutes for the counterincision group. Average EBL was 94cc
for transanal extraction, but 204cc for the counterincision group.
Of our 411
patients who underwent right colon resections, 288 (65.7%) received ICA, while
the remaining 123 patients (27.4%) had ECA. The mean operative time for ICA was
159.6±27.1 minutes, and mean blood loss was 83.3±14.4mL. For ECA, the mean
operative time was 165.5±29 minutes, and mean blood loss was 135.0±65.5mL.
Conclusion: It is possible that
totally intracorporeal anastomosis may have value and may become the procedure
of choice in the future, potentially with an increased interest in natural
orifice surgery.
9128 Urology
Short-Term Outcomes of GreenLight HPS™ Laser Photoselective Vaporization
Prostatectomy (PVP) for Benign Prostatic Hyperplasia (BPH)
Carson Wong, MD, Kurt Strom, MD,
Massimiliano Spaliviero, MD
University of Oklahoma Health
Sciences Center
Introduction and Objective: GreenLight HPS laser PVP is a treatment option
for lower urinary tract symptoms (LUTS) secondary to BPH. We review our
experience using the GreenLight HPS laser system.
Methods: We prospectively
evaluated our experience with GreenLight HPS laser PVP. All patients who failed
medical therapy/surgery underwent GreenLight HPS laser PVP (CW). All had
American Urological Association Symptom Score (AUASS), Sexual Health Inventory
for Men (SHIM) Score, American Society of Anesthesiologists (ASA) risk score,
serum prostate specific antigen (PSA), maximum flow rate (Qmax) and postvoid
residual (PVR) determinations, and volumetric measurements with transrectal
ultrasonography. Transurethral PVP was performed using the GreenLight HPS side-firing
laser system.
Results: The patient cohort included 140 consecutive
patients with a mean age of 68±9 years. The mean prostate volume was 72±42mL, and
the mean ASA score was 2.3±0.7. Mean laser time, operating time, and energy
usage were 13±11 minutes, 32±24 minutes, and 89±71kJ, respectively. All were
outpatient procedures with 75 (54%) patients catheter-free at discharge.
Fifteen patients required catheter drainage for one week. Eight patients
developed a urinary tract infection. Fourteen patients had persistent hematuria
for >1 week. No urethral strictures or urinary incontinence was noted. Mean
AUASS decreased from 23 to 8, 7, 5, 5, and 4 (P<0.05) at 1, 4, 12, 24, and 52 weeks, respectively. Qmax
values showed statistically significant improvement (P<0.05) during the follow-up period. SHIM score did not
change postoperatively.
Conclusion: Our short-term results suggest GreenLight HPS
laser PVP is safe and effective for the treatment of LUTS secondary to BPH.
9129 Urology
Decreased Efficiency of GreenLight HPS™ Laser Photoselective Vaporization
Prostatectomy (PVP) With Long-Term 5α-Reductase Inhibition Therapy: Is it True?
Carson Wong, MD, Kurt Strom, MD,
Massimiliano Spaliviero, MD
University of Oklahoma Health Sciences Center
Introduction: 5α-reductase inhibitors
(5ARI) have been postulated to affect the efficiency of GreenLight HPS laser
PVP. We evaluated GreenLight HPS laser PVP as treatment for benign prostatic
hyperplasia (BPH) in patients on long-term 5ARI.
Methods: We prospectively
evaluated our GreenLight HPS laser PVP experience in patients with and without
long-term 5α-reductase inhibition.
Results: We identified 140 consecutive patients; 46 were on
finasteride/dutasteride for more than 6 months and 94 were not. Mean prostate
volumes were 71±35mL and 73±45mL (P=0.56), and mean PSA values were
2.1±2.3ng/mL and 2.8±2.7ng/mL (P=0.15), respectively. No significant
differences occurred in the parameters of laser utilization (14±8 and 12±8
minutes, P=0.45) and energy usage (85±54 kJ and 83±56kJ, P=0.97). All were
outpatient procedures with the majority of patients catheter-free at discharge.
All patients were able to discontinue their prostate medications following
surgery. The mean rates of prostate vaporization (3.7±2.2mL/min and
3.0±1.4mL/min, P=0.11; 0.55±0.33mL/kJ and 0.59±0.71mL/kJ, P=0.77) and TRUS
volume decrease 12 weeks postsurgery (54±14% and 51±12%, P=0.32) were similar
between the 2 groups. AUASS, Qmax, and PVR values showed significant
improvement within each group through 1 year (P<0.05), but the degree of
improvement between the 2 groups did not show statistical significance.
Conclusion: Our experience suggests
that 5ARI does not have a detrimental effect on the efficiency and efficacy of
GreenLight HPS laser PVP.
9130 Urology
GreenLight HPS™ Laser Photoselective Vaporization Prostatectomy (PVP) for
Failed Prior Surgical Treatment of Benign Prostatic Hyperplasia (BPH)
Kurt Strom, MD, Massimiliano
Spaliviero, MD, Carson Wong, MD
University of Oklahoma Health
Sciences Center
Introduction: Secondary procedure
rates of surgical therapy for BPH range from 1% to 14%. We evaluated GreenLight
HPS laser PVP as a treatment for symptomatic BPH previously treated with
surgical management.
Methods: We prospectively
evaluated our GreenLight HPS laser PVP experience. Only patients who failed
prior surgical therapy (transurethral prostate resection (TURP), transurethral
microwave therapy (TUMT), holmium laser ablation of prostate (HoLAP) and
potassium-titanyl-phosphate (KTP) laser PVP) for symptomatic BPH were included.
Transurethral PVP was performed using a GreenLight HPS side-firing laser
system.
Results: Thirty of 140 consecutive patients were
identified, having a mean prostate volume of 80±49mL. Prior surgical management
included TURP (14), TUMT (7), KTP laser PVP (5), HoLAP (2), TUMT and TURP (1),
and TUMT and KTP laser PVP (1). Mean laser and operative times and energy usage
were 12±10 minutes, 29±25 minutes, and 76±60kJ, respectively. One patient
developed a urinary tract infection. Two patients had persistent nonsignificant
hematuria for one week. One patient 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 Association Symptom
Score decreased significantly from 23 to 9, 7, 7, 6, and 5 (P<0.05) at 1, 4, 12, 24 and 52
weeks, respectively. Mean maximum flow rate and postvoid residual measurements
also showed significant improvement (P<0.05).
Conclusions: Our initial results
demonstrate that GreenLight HPS laser PVP is safe and effective for the
treatment of patients with failed prior surgical management of BPH.
9131 Urology
Does Age Affect the Safety and Efficacy of GreenLight HPS™ Laser Photoselective
Vaporization Prostatectomy (PVP)?
Kurt Strom, MD, Massimiliano
Spaliviero, MD, Carson Wong, MD
University of Oklahoma Health
Sciences Center
Introduction: We evaluated the safety
and efficacy of GreenLight HPS laser PVP for the treatment of lower urinary
tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) in
patients of varying age groups.
Methods: We prospectively evaluated our initial GreenLight
HPS laser PVP experience. Patients were stratified into 2 groups: age<70
(group I) and age≥70 (group II). Transurethral PVP was performed using a
GreenLight HPS laser system. Voiding trials were performed 2 hours postsurgery.
American Urological Association Symptom Score (AUASS), maximum flow rate
(Qmax), and postvoid residual (PVR) were measured preoperatively and at 1, 4,
12, 24, and 52 weeks postsurgery.
Results: We identified 137 consecutive patients (73 group
I, 64 group II). No significant differences existed in preoperative parameters
[AUASS (I: 23±6, II: 22±6), Qmax (I: 10±4, II: 9±4mL/sec), PVR (I: 59±89,
II: 75±106mL), prostate volume (I: 64±39, II: 83±44mL)]. Additionally, there
were no significant differences in the parameters of laser utilization (I:
13±8, II: 13±8 minutes) and energy usage (I: 83±56, II: 85±55kJ). AUASS and
Qmax values showed significant improvement within each group (P<0.05). There were no significant
differences between the 2 groups. The incidence of adverse events was low and
did not differ between the 2 groups.
Conclusion: Our experience suggests that age has little effect
on the safety and efficacy of GreenLight HPS laser PVP.
9132 Urology
Incidence, Management, and Prevention of Perioperative Adverse Events of
GreenLight HPS™ Laser Photoselective Vaporization Prostatectomy: Experience in
the Initial 70 Patients
Massimiliano Spaliviero, MD, Kurt
Strom, MD, Carson Wong, MD
University of Oklahoma Health Sciences Center
Purpose: We report the incidence, prevention, and
management of perioperative adverse events in patients treated with GreenLight
HPS laser photoselective vaporization prostatectomy (PVP).
Materials and Methods: Transurethral PVP was performed using a
GreenLight HPS side-firing laser system. Patients had American Urological
Association Symptom Score (AUASS), Quality of Life (QoL) score, Sexual Health
Inventory for Men (SHIM) score, serum prostate specific antigen (PSA), maximum
flow rate (Qmax), and postvoid residual (PVR) determinations and volumetric
prostate measurements with transrectal ultrasonography (TRUS). Laser and
operative times and energy usage were recorded. AUASS, QoL, SHIM, Qmax, and PVR
were evaluated 1, 4, 12, 24, and 52 weeks postsurgery. Serum PSA and TRUS were
obtained at 12 weeks, and serum PSA was repeated at 52 weeks. Adverse events were
recorded perioperatively and at each follow-up interval.
Results: Seventy
consecutive patients with median age of 67 years (range, 45 to 87), median
prostate volume of 61.6mL (range, 20.9 to 263.0), and median PSA of 1.4ng/mL
(range, 0.1 to 10.1) underwent GreenLight HPS laser PVP from July 2006 to March
2008. Mean laser and operative times and energy usage were 13 minutes (range, 3
to 34), 30 minutes (range, 6 to 100), and 85kJ (range, 11 to 235),
respectively. All were outpatient procedures. Perioperative complications
included intraoperative bleeding (1.4%), postoperative clinically
nonsignificant hematuria (75.7%), hematuria requiring clot evacuation (1.4%),
urinary retention requiring recatheterization (2.8%), urinary tract infection
(4.3%), and prostatitis (1.4%). No urethral strictures, bladder neck
contracture, or urinary incontinence were noted.
Conclusions: GreenLight HPS laser PVP appears to have a
low incidence of perioperative adverse events.
9133 Urology
Tissue Effects of GreenLight HPS™ and Evolve SLV™ Lasers on Canine Prostates:
an Acute In-Vivo Model
Massimiliano
Spaliviero, MD, Roman Wolf, DVM, Stanley Kosanke, DVM, Marie Chavez-Suarez, MD, Fred Broach,
Carson Wong, MD
University
of Oklahoma Health Sciences Center, Oklahoma City, OK
Introduction: We evaluated the tissue
effects and efficacy of the GreenLight HPS and Evolve SLV lasers for prostate
vaporization in living dogs.
Methods: Prostate vaporization was performed either with
GreenLight HPS (Group I) or Evolve SLV (Group II) systems. Forty kJ of energy
were delivered with both systems on canine prostates. Dogs were euthanized 2
hours following completion of prostate vaporization and prostates were excised en bloc. The volume of vaporized tissue
was determined by taking multiple measurements of the 3-dimensional cavity.
Prostates were then sectioned (3mm to 5mm) and stained with
triphenyltetrazolium chloride (TTC) and nitroblue tetrazolium (NBT) to
establish the thickness of necrotic and healthy tissue zones.
Results: Five (I) and 5 (II) consecutive mongrel dogs
underwent prostate vaporization. Mean age (I: 9±1 years, II: 8±1 years) and
weight (I: 25±1kg; II: 28±3kg) were similar between the 2 groups. Despite
similar energy utilization (I: 40.0±0.4kJ; II: 40.0±0.1kJ), laser time was
shorter in Group II (I: 359±19 seconds, II: 269±1 seconds, P<0.001).
Measurement of the vaporization cavity revealed it to be comparable (I:
3.06±1.52mL, II: 1.73±0.41mL, P=0.18). However, the depth of thermal necrosis
was thicker in Group II (TTC: I: 2.1±0.4mm, II: 5.8±0.8mm, P=0.0002; NBT: I:
2.6±0.8mm, II: 3.9±1.0mm, P=0.07) prostate specimens.
Conclusion: Despite the formation of a comparable vaporization
cavity, the depth of thermal necrosis was thinner in Group I. This factor may
have implications in the clinical outcomes of prostate vaporization in human
subjects.
9134 General Surgery
Completion Proctectomy after Laparoscopic vs. Open Subtotal Colectomy for
Ulcerative Colitis: Is There a Difference?
A. M. Morales Gonzalez, D. Geisler, F. Remzi, V. W. Fazio, R.
P. Kiran
The Cleveland Clinic Foundation
Introduction: For patients undergoing a staged total
proctocolectomy and ileoanal pouch (IPAA), the relative merits of a
laparoscopic or open approach during the colectomy or subsequent completion
proctectomy (CP) with IPAA have not been evaluated. We compare outcomes in CP
with IPAA for ulcerative colitis by the laparoscopic and open approaches after
a previous subtotal colectomy (STC) by either laparoscopic or open methods.
Methods: Patients
who underwent CP with IPAA after laparoscopic STC for UC were matched by age,
sex, body mass index, year of operation, and ASA score to twice the number of
patients who underwent open STC followed by CP/IPAA. Three groups were
obtained: laparoscopic STC followed by laparoscopic CP (LSTC/LCP), laparoscopic
STC followed by open CP (LSTC/OCP), and open STC followed by open CP (OSTC/OCP)
and compared for operative time, estimated blood loss (EBL), length of stay,
use of a diverting stoma, and complications including pouch failure.
Results: LSTC/LCP (n=23), LSTC/OCP (n=28), and OSTC/OCP (n=101) were
comparable for the matched characteristics. The 3 groups had similar EBL
(P=0.33), use of stoma (P=0.25), anastomotic leak (P=0.4), overall
complications (P=0.11), and pouch failure (P=0.11). LSTC/LCP was associated
with significantly longer operative time (P<0.001) but with a significantly
shorter length of stay (P<0.002) (4.6 days) compared with LSTC/OCP (7.7) and
OSTC/OCP (6.7).
Conclusion: The use of an LCP after LSTC is associated with the
advantage of a significantly reduced length of stay compared with that for OSTC
or LSTC followed by OCP despite comparable risk of complications and long-term
outcomes.
9135 Multispecialty
Minimally Invasive Surgery Group: Cutting Edge Goes a Cut Above
Dean K. Matsuda, MD, Kirk
Tamadoon, MD, Seth Kivnik, MD, Robert Casillas, MD, Benjamin Kim, MD
Kaiser West Los Angeles Medical
Center
Objective: To share our
collective experience and potential benefits derived from a hospital-based
minimally invasive surgery group.
Methods: Our hospital-based minimally invasive surgery
group’s 3-year experience is presented. A unique collection of endoscopic
surgeons at one site provides many opportunities that go beyond any marketing
hype. With surgeons offering everything from advanced arthroscopic hip surgery
to laparoscopic hysterectomy, robotic prostatectomy to minimally invasive
bariatric surgery, the latest technological advances and innovative techniques
are harnessed for significant patient benefit.
Results: Data favorably comparing our MIS equivalents to
more open invasive surgeries with resultant shorter hospital stays (many
outpatient procedures), minimal blood loss, quicker recovery/rehabilitation,
reduced complications (including some specific to MIS procedures), and improved
cosmesis and patient-satisfaction is discussed in this open forum. One example
is outpatient arthroscopic surgery for athletes with femoroacetabular
impingement having a 99% outpatient rate compared with 3-days to 4 days of
hospitalization for the open surgical equivalent, minimal blood loss with 0%
transfusion rate, accelerated rehabilitation with exercise bicycling 24 hours
postoperation, and an average reduction in postoperative recovery from 6 months
to 8 months (open surgery) to 3 months (arthroscopic procedure). Moreover, the
benefits of surgeon cross-education with creative innovation,
multi-disciplinary camaraderie, improved patient education, and group
purchasing power with resultant cost savings will be highlighted.
9136 Multispecialty
Arthroscopic Hip Surgery for Femoroacetabular Impingement in the Athlete
Dean K. Matsuda, MD
Objective:
To inform the audience of the latest developments in the arthroscopic
management of athletes with femoroacetabular impingement. Present
our inter-regional prospective treatment outcomes.
Methods/procedures: Femoroacetabular impingement has become an
established clinical entity causing pain and early osteoarthritis in a
relatively young and athletic group of patients. For this open forum venue, we
first show our surgical techniques for comprehensive 2-portal arthroscopic
surgery. We demonstrate via professional video and animation arthroscopic rim
trimming using a fluoroscopic templating technique designed by the author,
femoral head-neck resection osteoplasty, as well as labral refixation and even
labral reconstructive arthroscopic surgery. We then will share the early
outcomes from our inter-regional prospective study using the validated
Non-arthritic Hip Score. We conclude with the author's personal experience
(with surgical video capture) having had both hips treated for this condition.
Results: We enrolled 105 patients (52% F, 48% M), mean age
of 38.4 years, with symptomatic femoroacetabular impingement. Ninety patients
had cam-pincer FAI, 6 cam, and 7 pincer variants. Mean labral damage by Beck
scale was 2.10, Outerbridge 2.43, and Beck cartilage damage 2.76. Patients
showed a 14.43-point improvement in mean hip score, 16.60-point improvement in
mean pain scores, and 19.66-point improvement in functionality score subset.
Conclusion: Comprehensive arthroscopic surgery for
symptomatic femoroacetabular impingement improves pain and functional level in
many athletic patients.
9137 Multispecialty
Laparoscopic Appendectomy During Pregnancy
Joong Sub Choi, MD1, Jung Hun Lee,
MD1, Hyung Ook Kim, MD1, Hungdai Kim, MD1, Seon Hye Park, MD2, Moon Il
Park, MD2
1Kangbuk Samsung Hospital, Sungkyunkwan
University School of Medicine
2College of Medicine, Hanyang
University, Seoul, Korea
Objective: To evaluate the safety, feasibility, and pregnancy outcomes of
laparoscopic appendectomy (LA) during pregnancy.
Methods: This was a retrospective clinical study (Canadian Task Force
classification II-2) performed at a university teaching hospital. The study
cohort included 8 pregnant women who underwent LA from January 2007 to December
2008.
Results: The median age of the patients and median parity were 29.5 years
(range, 25 to 34 years) and 0 (range, 0 to 1), respectively. The median
operating time of LA was 22.5 minutes (range, 15 to 40). The median length of
hospital stay was 3 days (range, 2 to 4). No maternal or fetal mortality or
morbidity, laparoconversions, or uterine injuries occurred. Four patients
delivered 4 healthy infants, and the pregnancies of 3 patients are progressing
without complications. One patient underwent an elective abortion. All resected
appendices were acute appendicitis.
Conclusion: Laparoscopic
appendectomy performed during pregnancy by expert gynecological laparoscopists
is feasible and safe and does not lead to adverse pregnancy outcomes.
9138 Gynecology
Robotic Surgery in a Medium-Sized, Integrated Community and Academic Program in
Gynecology
Sean Tedjarati, MD, Karen Ballard, DO, Greg May, MD, Jay Anderson, MD, Katie
Brading, Anne Doughty, Robert Kauffman, MD
Objectives: We reviewed the evaluable RAL cases performed from 8/07 to 7/08
in a medium-sized community, and analyzed demographic, clinical, operative, and
pathologic data/outcomes.
Methods: All demographics, clinical, operative, and pathologic data were
collected and analyzed. The institutional review board approved the study.
Results: Fifty-six cases
were reviewed with follow-up of 20 weeks (range, 10 to 42). Mean age and body
mass index (BMI) were 47 years (range, 22 to 88), and 30.3 (range, 19.2 to 44).
BMI was ≥25 in 72% and ≥30 in 54%. Hysterectomy ± bilateral
salphingo-oophorectomy ± lymph node dissection were the most common
procedures. Conversion to laparotomy was 3%. Docking time was 2.4 minutes
(range, 2 to 6). Total operative and console time were 138 minutes (range, 48
to 366) and 107 minutes (range, 29 to 300). Estimated blood loss (EBL) was 76cc
(range, 10 to 300) with 1 preoperative transfusion. Uterine weight was 141g
(range, 49 to 258). Mean lymph nodes retrieved were 19 (range, 10 to 34).
Operative and postoperative complications were 1.8% and 10% with fever being
most common. Only oral analgesics were required by 70%. Length of stay (LOS)
was 1.5 days (range, 1 to 4). There were no wound infections.
Conclusions: A successful RAL
program in a medium-sized community among surgeons with variable experience is
feasible. Transition from laparotomy to RAL was achieved with results
comparable to those of larger, more experienced centers. Over half of patients
were obese with lowered LOS, EBL, recovery period, and no wound infections.
9139 General Surgery
Reinforced Circular Staples in Bariatric Surgery: Is there Any Benefit?
Marcela Ramirez, MD, Flora Varghese, MD, Richard Symmonds, MD, Joaquin
Rodriguez, MD
Scott & White Memorial, Hospital Texas A&M
Background: With the increasing prevalence of morbid obesity,
a growing demand for bariatric surgery exists. Roux-en-Y gastric bypass (RYGBP)
is the most common procedure, but has multiple complications. This study
evaluates the use of the reinforced circular stapler and its effects on
reducing gastrojejunal anastomotic complications.
Methods: Data were obtained using retrospective chart review
between January 2007 and November 2008 from a single institution. During this
time period, 287 laparoscopic RYGBP were performed. Comparison was made between
2 groups. The nonreinforced circular stapler (NRCS) group consisted of 182
patients, and the reinforced circular stapler (RCS) group consisted of 105
patients. Perioperative complications and postoperative complications were
compared between both the RCS and NRCS groups.
Results: Complications from gastrojejunal anastomosis were
found in 44 patients (15.33%). There were 10 (9.52%) patients from the RCS
group and 34 (18.68%) patients from the NRCS group with anastomotic
complications (P=0.0381). Neither group had anastomotic leaks. The bleeding
rate was 4.90% in the RCS group vs. 6.49% in the NRCS group. The stricture rate
was 1.96% in the RCS group vs. 6.49% in the NRCS group. Ulcer formation occurred
in 2.86% of the RCS group vs. 6.04% of the NRCS group.
Conclusion: The application of RCS reduced the incidence of
gastrojejunal anastomotic complications. Therefore, it is beneficial to utilize
reinforced circular staplers for the gastrojejunal anastomosis in laparoscopic
RYGBP procedures. Patients are 2.182 times more likely to develop complications
when no RCS device is used.
9140 General Surgery
Prolonged (>3 Hours) Laparoscopic Cholecystectomy: Reasons And Results
Gokulakkrishna Subhas, MD, Aditya Gupta, MD, Lorenzo Ferguson, MD, Michael
J. Jacobs, MD, William Kestenberg, MD, Ramachandra B. Kolachalam, MD, Sumet
Silapaswan, MD, Vijay K. Mittal, MD
Providence Hospital and Medical Centers, Southfield,
Michigan
Background: For the experienced surgeon, the average operative time for a
laparoscopic cholecystectomy is <1 hour. No study has documented the causes
and results of prolonged (>3 hours) surgery.
Methods: A retrospective study was
done of patients who underwent cholecystectomy from January 2003 to December
2007. In all, 3126 cholecystectomies were done. After excluding patients who
had a planned open cholecystectomy and patients who had additional (hepatic,
pancreatic, gynecological, and colonic) surgeries, we identified 70 patients
who had a planned laparoscopic cholecystectomy with operative time exceeding 3
hours. Charts were reviewed to look at the indications, investigations, and
procedure details.
Results: Patients ranged from 21 to
92 years of age (mean, 57) with most of the patients being females (n=53).
Operative time ranged from 3 hour to 6:40 hours (mean, 3:37).
Emergency:elective admission ratio was 5:9. Acute cholecystitis (n=40) was the
most common indication, followed by symptomatic gallstones (n=24) and gallstone
pancreatitis (n=6). Laparotomy had to be done in 30 patients. Common
characteristics were obesity (n=44), dense intraabdominal adhesions (n=43),
previous abdominal surgeries (n=40), obstructive jaundice (n=14), large
gallstones (>2.5cm) (n=12), and intraoperative cholangiography (n=12).
Intraoperative complications included spillage of stones (n=6), bile duct
injury (n=3), and bleeding (n=3). Histopathological examination revealed 12
gangrenous gallbladders. Postoperative stay ranged from 1 day to 41 days (mean,
5 days), and one mortality occurred.
Conclusions: The possibility of
prolonged laparoscopic cholecystectomy should be anticipated in patients with
obesity and previous abdominal operations. Prolonged surgery increases the risk
of complications (bile duct injury, bleeding) and prolongs the postoperative
hospital stay.
9141 Gynecology
Effectiveness of Microwave Endometrial Ablation for Adenomyosis
Yasuyuki Asakawa, Yasuhiro Yamamoto,
Tsuchiya Takehiko, Mami Fukuda, Nobuyuki Sakurai, Hideki Taoka, Toshimitsu
Maemura, Mineto Morita, Kaneyuki Kubushiro
Toho University School of Medicine
Objective: In recent years, microwave endometrial ablation (MEA) has been
more closely analyzed as a therapeutic option for hypermenorrhea, due to its
reduced invasiveness compared with total hysterectomy. With approval from the
hospital ethics review board, we have performed MEA on 6 consenting patients
with adenomyosis since 2004. Postoperative clinical outcomes are described
herein.
Methods: In all patients, MEA was
performed using a microwave coagulator operating at 2.45GHz, and the
endometrium was coagulated at several locations with 70W output and 50-s
conduction time. After MEA, coagulation inside the uterus cavity was confirmed
by hysteroscopy. Postoperative MRI was used to examine the extent of
endometrial coagulation.
Results: Hypermenorrhea improved in
all patients with adenomyosis, and 2 patients became amenorrheic. Significant
improvements were seen in postoperative anemia. A visual analog scale was used
to assess satisfaction, menstrual blood loss, and menstrual pain before and
after MEA. Statistical analysis showed significant improvements in
satisfaction, menstrual blood loss, and menstrual pain. No notable
postoperative infections or complications were seen.
Conclusions: These results suggest
that MEA for adenomyosis is a noninvasive and safe technique that coagulates
the endometrium in a short period of time, significantly improving
hypermenorrhea and dysmenorrhea. In the future, MEA will offer a useful
therapeutic option to take the place of total hysterectomy.
9142 General Surgery
Herniotomy in Infants, Children, and Adolescents Without Disruption of External
Ring
Ahmed A. Kareem, MBChB, DGS, Kasim M. Juma'a, BSc, MSc
Baquba Teaching Hospital, Diayla, Iraq
Background: Inguinal hernia represents one of the most common pediatric
problems that requires surgical repair as early as possible to avoid
complications that may be life threatening. In addition, operative technique
and highly qualified surgical skills used in management of inguinal hernia may
effectively contribute to reduction in cost, mortality, and morbidity,
especially the recurrence rate which represents a challenge in this type of
surgical operation.
Methods: This prospective study
included 252 inguinal hernia patients, ranging in age from 7 years to 15 years
of both sexes. The patients were admitted to Baquba General Hospital from June
2005 to March 2007. They were managed surgically with a nonlaparoscopic minimum
access method and followed up for 1 year for detection of recurrence rate.
Results: Patients tolerated this
surgical procedure very well with no need for strong analgesia. Also the new
surgical technique produced a clean wound with no incidence of wound infection.
For this reason, use of antibiotics was unnecessary. At 1-year follow-up, the
recurrence rate was zero. This type of surgical operation will decrease
in-hospital length of stay and cost.
Conclusion: Laparoscopic inguinal
hernia repair in children is not the most superior minimally invasive
technique. Open surgery can be done in a less invasive manner with lower cost,
fewer complications, maintaining the tactile sensation of the surgeon with a
most delicate and pleasurable procedure.
9143 General Surgery
Laparoscopic Loop-Ileostomy With A Single-Port Stab Incision
Gokulakkrishna Subhas, MD, Elizabeth Kim, MD, Vijay K. Mittal, MD, Alasdair
McKendrick, MD
Providence Hospital and Medical Centers, Southfield,
Michigan
Background: Loop-ileostomy is an effective means of temporary fecal
diversion. Fecal diversion may be needed as an isolated procedure in patients
with complicated perianal fistula, perianal sepsis, or distal Crohn’s disease.
With the advent of laparoscopy, many of these loop ileostomies are being
performed with laparoscopic assistance. Studies have proved the beneficial
effects of laparoscopically created loop ileostomy over the open technique for
fecal diversion.
Methods: Techniques for performing
laparoscopic loop-ileostomy have been described using 2 or more 10-mm to 12-mm
ports with Hasson’s technique at the umbilical site for pneumoperitoneum
creation. Babcock forceps holds the loop of terminal ileum through the port
placed at the ostomy site. The presence of Babcock’s forceps with the port
cannula at the site of the ostomy interferes with the expansion of the opening
in the rectus sheath. We are describing a new technique, wherein the
pneumoperitoneum is created using a 10-mm port at the site of the future
ileostomy and a second 5-mm port placed under vision at the umbilical site. The
camera is passed through the ostomy site port, and the umbilical port is used
for Babcock’s forceps. There is no interference while expanding the skin and
rectus sheath incision at the ostomy site. A final look is taken through the
umbilical port before maturing the ostomy.
Conclusion: This technique decreases
the risk of bowel injury. The umbilical port site being 5-mm does not need
closure; thus, it reduces port-site hernia and patient discomfort. Also
minimizing the intervention reduces the operative time and decreases postoperative
ileus and adhesion formation.
9144 General Surgery
NOTES Transvaginal Cholecystectomy: A Modified Surgical Technique
Giuseppe Currò, MD, Giuseppe La
Malfa, MD, Emanuela Molino, MD, Mariangela Pataria, MD, Giuseppe Sarra, MD,
Giuseppe Navarra, MD
University Hospital of Messina, Messina, Italy
Objective: Natural orifice transluminal endoscopic surgery (NOTES) allows
cholecystectomy to be performed by means of a flexible scope introduced through
the stomach, rectus, bladder, or vagina. However, available endoscopes have
several limitations if utilized in the peritoneal cavity. We describe a new
technique that overcomes these limitations by using conventional 5-mm
laparoscopic instruments through the umbilical scar and transabdominal sutures
for retraction.
Methods: After creating the
pneumoperitoneum with a Veress needle, a 5-mm port is introduced into the
umbilicus followed by a 5-mm 30° scope. A culdotomy is then performed under
direct and laparoscopic view. The flexible endoscope is inserted into the
pelvis through the vagina and advanced to expose the gallbladder. Three or more
transabdominal sutures are placed through the gallbladder wall for retraction.
Cholecystectomy is then conventionally performed. Finally, stay sutures are
removed and the specimen is retrieved through the vagina.
Results: Six female patients
underwent hybrid transvaginal cholecystectomy. Average age was 52 years (range,
46 to 65) with an average body mass index of 32 (range, 30 to 37). No problems
or complications occurred related to the culdotomy, trocar, or stay suture
placement. No conversions were necessary, and all the procedures were performed
as planned without complications within an average of 52 minutes (range, 40 to
65).
Conclusion: In our opinion, this
hybrid approach increases safety, overcomes the limitation of the current
instrumentation, and maintains most of the advantages of NOTES.
9145 Gynecology
Medico Legal Problems with Advanced Gynecological Operative Endoscopy
Professor Mark Erian, FRCOG, FRANZCOG, MD, Dr. Glenda McLaren, FRCOG,
FRANZCOG
Objective: The purpose of this study
was to analyze the complication factors in gynecological operative endoscopy,
and to appreciate elements leading to litigation against gynecological surgeons
and ways to minimize (or completely eradicate) medico legal risk factors and,
consequently, lawsuits that can be costly in terms of monetary and emotional
expenses to the patient, health care industry, gynecologists, their practices,
and even families.
Methods: This was an observational
study performed in the Obstetrics and Gynaecology Department, Royal Brisbane
and Women’s Hospital (RBWH). This is a major tertiary referral teaching
hospital. We studied the main complications occurring at RBWH as a result of
laparoscopic and hysteroscopic operative interventions between 1990 and 2007
(inclusive) with analysis of the causative factors and ways to prevent the
same.
Results: Nearly always, there is a
reason(s) behind the complication(s), and these failures to inform, perform
and/or communicate. Advances in modern technology have improved the outcome of
simple and complicated operative laparoscopic and hysteroscopic surgery.
Nevertheless, the authors stress the importance of training, credentialing, and
maintaining a system of quality assurance (QA) that should be adhered to.
Conclusion: Advanced operative
gynecological endoscopy offers the patient an attractive alternative to
conventional surgery with less pain and discomfort, quicker return to the
workforce, and better cosmetic results. Not only does the patient benefit from
this approach but also the hospital and the national economy in general
benefit. However, the gynecological surgeon must endeavour to excel in
knowledge, manual dexterity, and communication skills if litigations are to be
avoided or reduced to an absolute minimum.
9146 General Surgery
Surgery for Chronic Abdominal and Pelvic Pain Syndrome (CAPPS)
“Is Surgery Indicated in these Patients?”
Jay A. Redan, MD, Greg McClain, MD, Steven McCarus, MD, John Kim, MD,
Aileen Caceres, MD
Florida Hospital-Celebration Health
Background: One of the most commonly encountered problems today is
abdominal/pelvic pain associated with adhesions from prior surgery. Patients
normally have a battery of studies that often leave the doctor without answers
and patients without proper treatment. We retrospectively analyzed 31 CAPPS
patients to determine the best course of treatment for them.
Methods: A retrospective chart
review of a single institution’s practice involved the treatment of CAPPS
(n=31) following prior abdominal surgery(s) from 2006 to 2008. The data set
includes patient information obtained in the preoperative interview and
postoperative follow-up at 3-, 6-, 9-, and 12-month intervals. The data points
included patients’ age, sex, and pain scale at each interval, employment
status, use of narcotics, and number of surgeries.
Results: Mostly women (n=29,
P<0.05), the age ranged from 16 to 63 years (mean, 42). The number of
abdominal surgeries ranged from 1 to 7 with an average of 2.67. Preoperative
pain averaged 7.8 on a scale of 0 to 10; 3-month follow-up was 4.7, 6-month was
3.07, 9-month was 2.5, and 12-month was 1.5. Also a 66% decrease occurred in
the use of narcotics following surgical treatment.
Conclusion: The treatment of
patients with CAPPS secondary to adhesions poses a unique and often difficult
challenge to caregivers. We offer patients diagnostic laparoscopy, lysis of
adhesions, and indicated procedures including bowel resection for chronic large
and small bowel obstructions. Our follow-up data show that the pain reported by
the patients is improved and the use of narcotics decreased.
9147 General Surgery
Laparoscopic Appendectomy Using LIGASURE™ for Mesoappendix Hemostatic Control
Vicente Spinelli, MD, Luis F. Guada, MD, William Guada, MD
Hospital Cruz Roja, Instituto de Especialidades Quirurgicas Los Mangos
Universidad de Carabobo, Valencia, Edo Carabobo Venezuela
Background: Laparoscopic
appendectomy is frequently performed where technical resources are available.
The aim of the present study was to evaluate the LIGASURE vessel sealing system
in laparoscopic appendectomy for mesoappendix hemostatic control.
Methods: This was a prospective,
nonexperimental study of 44 patients at 3 surgical centers in Valencia
city. All patients had abdominal
pain with a diagnosis of acute appendicitis. They were operated on
laparoscopically using LIGASURE, from January 2005 to December 2006.
Results: The mean operative time was
69.32 minutes (SD, 14.25). The mean hospital stay was 1.43 days (SD, 1.021).
The operation was converted to open appendectomy in only 2 patients because of
technical difficulties of dissection. Neither surgical Endoclips nor an
endostapler were used in any patients. We observed postoperative complications
in 11 patients (25%), mainly infectious. No intraabdominal abscesses were
present. We reoperated on one patient with hemoperitoneum due to bleeding from
an epigastric vessel injury after trocar insertion, identified postoperatively.
No burn injuries occurred due to use of the LIGASURE system. Pathological
diagnosis identified 50% of the ailments as phlegmonous appendicitis.
Conclusion: Laparoscopic
appendectomy using LIGASURE is a safe and efficient procedure for hemostatic
control of mesoappendix, and it has similar operative time and hospital stay as
other laparoscopic methods for hemostatic control.
9148 General Surgery
Learning Curve in Transanal Endoscopic Microsurgery: Surgeon or Operating Room
Staff Dependent?
Paul R. Sturrock MD, Ronald Figuerido, MD, Matthew Vrees, MD,
Adam Klipfel, MD, Jorge A. Lagares, MD
Rhode Island Colorectal Clinic, Pawtucket, Rhode Island
Introduction: The learning curve for transanal endoscopic
microsurgery (TEMS) is poorly described in the literature, but some studies
indicate a lack of a significant operative learning curve when surgeons have
minimally invasive experience. The aim of our study was to evaluate surgical
times of our experience with TEMS since its inception in a colorectal practice.
Methods: Thirty-two
consecutive cases have been evaluated since March 2007. Two dedicated surgeons
(A and B) with extensive experience in laparoscopic colorectal surgery
performed all the procedures. Demographic, intraoperative, and pathologic data
were collected. Comparisons and statistical analysis were performed by a
surgeon and staff learning curve using the variables early (first 15 cases)
versus late experience (>15 cases).
Results: To date, 32 cases have been performed. Average
patient age was 60 years with equal sex distribution. Mean operating room setup
time, operation length, and total procedure time were 33, 34, and 61 minutes,
respectively. Tumor surface mean was 20.4cm2,
and specimen surface averaged 32.3cm2.
Mean setup time was significantly different between the early (37 minutes) and
the late experience (30 minutes) (P<0.05), while operation length and
overall operating room time did not differ, regardless of tumor size.
Conclusion: TEMS operating room times are related to the setup
time and operating room staff familiarity with equipment and patient setup
early on in the experience. There was no difference regarding surgeon times in
early vs. late experience.
9149 General Surgery
Laparoscopic Sigmoid Resection for Complicated Diverticular Disease is
Associated with Better Outcomes
J. A. Laryea2, J. Cannon1, E. Pennington1, M. Ferguson1, M. Schertzer1, W.
Ambroze1, G. Orangio1
1Georgia Colon and Rectal Surgery Clinic, Atlanta, Georgia
2University of Arkansas for Medical Sciences, Little Rock, Arkansas
Purpose: To compare the outcomes of open versus
laparoscopic sigmoid resections for complicated diverticular disease in a large
private colorectal practice with an ACGME-approved fellowship-training program.
Methods: A retrospective review of 169 consecutive patients
undergoing sigmoid resection for complicated diverticular disease between
January 2002 and June 2007 was done. These included patients with diverticular
abscesses, phlegmon, recurrent diverticulitis, and colovaginal and colovesical
fistulas. Five experienced colorectal surgeons performed the surgeries with or
without a fellow. Follow-up ranged from 2 months to 4 years. The primary
outcomes evaluated were EBL, LOS, and complications. Univariate and
multivariate linear regression analysis was done using the SAS 9.1 (SAS
Institute, Cary, NC) statistical software. Significance was set at P<0.05
Results: There were 169 consecutive sigmoid resections for
diverticular disease (72 open and 97 laparoscopic). The laparoscopic group had
significantly lower EBL (160.4±109.8 vs. 230.7±237.0; P=0.0359) and a shorter
length of stay (5.4±2.8 days vs. 7.1±2.9 days; P=0.0003). Overall, no
significant differences existed in complications between the 2 groups
(P=0.846). On multivariate analysis, the laparoscopic procedure (P<0.0001)
and younger age (P=0.0367) were associated with a shorter length of stay. The
presence of a fellow was associated with a lower EBL (P=0.0623).
Conclusions: Laparoscopic sigmoid resection for complicated diverticular
disease is associated with better outcomes and is as safe as open sigmoid
resection.
9150 Gynecology
Can Laparoscopic Myomectomy Replace Open Myomectomy?
M. Sami Walid, MD1, PhD, Richard
L. Heaton, MD2
1Medical Center of Central Georgia, Macon, Georgia
2Houston County Medical Center, Heart of Georgia Women’s
Center, Warner Robins, Georgia
Introduction: Laparoscopic myomectomy is a procedure that
requires laparoscopic suturing skills. We report our 10-year experience with
laparoscopic myomectomy, its advantages, and possible complications.
Materials and Methods: From October 1998 to July 2008, 41
myomectomies were performed in a suburban gynecology practice. Patients were 16
to 55 years old, gravida 0-4 and para 0-2. Eleven patients had prior cesarian
deliveries, and 6 patients had prior myomectomies.
Results: One open myomectomy, 6 hysteroscopic myomectomies,
and 34 laparoscopic myomectomies, including 2 combined with the hysteroscopic
route were performed during that period. In the laparoscopy group, 10 patients
had prior cesarian deliveries, and 4 patients had prior myomectomies. Patients
had 1 to 7 fibroids in their uteri of different types, pedunculated, subserous,
and intramural. Six patients were treated with Lupron before surgery. Pitressin
was used in 19 patients during surgery. Resected fibroids weighed up to 555
grams. One case required staged myomectomy because of bleeding (800cc) after
the large fibroid was removed. Estimated blood loss was 20cc to 1200cc. No
patient required a transfusion. Sixteen patients required morcellation. No
patient required conversion to an open technique. No infections occurred. Two
patients had successful pregnancies after myomectomy. Subsequent hysterectomy
was performed in 6 patients.
Conclusions: Laparoscopic myomectomy is a safe procedure in the
hands of an experienced surgeon. Bleeding is the most common intraoperative
complication that may require performing a staged laparoscopic myomectomy.
Maintaining homeostasis is the mainstay to successfully complete the procedure.
Decreased hospital time and decreased patient pain are the most important
advantages of this procedure.
9151 General Surgery
Laparoscopic Colectomy for Colon and Upper Rectal Cancer
Pietro Venezia, MD
Azienda Ospedaliero Universitaria
Policlinico, Bari, Italy
Objective: Laparoscopic
colectomy for the management of colon and upper rectal cancer at my institution
has required advanced laparoscopic experience. This report supports the
laparoscopic procedure without compromising the completeness of the resection.
Methods: Intraoperative
colonoscopy validated the solitary localization of the adenocarcinoma and with
tattooing with methylene blue precisely identified the limits of the resection
line. Laparoscopic “classic” colectomy was performed using 3 additional ports
with the patient in a Trendelenburg-lithotomy position, and confirmation of the
preoperative staging (T2, N0, Mx) with the absence of peritoneal carcinosis.
Reconstruction was performed using lymph node dissection, extraction through
one port site for the trocars, enlarged and intracorporal for left and
extracorporal for right-sided lesions.
Results and Conclusions: From March 1999 to
September 2006, we performed 49 laparoscopic colectomy for colon and upper
rectal cancer. The length of the specimen, with clear margins and sampling of
the nodes (T2, N0, Mx) confirmed that laparoscopic colectomy is technically and
surgically acceptable. The yearly oncologic follow-up after 6 cycles of
chemotherapy and CT scan demonstrated there were no trocar site implants or
local or distal recurrence of tumor. The less-suppressed immune system may have
implications for tumor recurrence and long-term patient survival. The lifting
of the colon during the operation can reduce the number of surgical staff and
the expense of the procedure. All patients are today alive. We believe this
procedure was a better choice for the patient, certainly for the surgeon and
probably for the community too.
9152 Urology
Robotic-Assisted Laparoscopic Excision of Bladder Wall Leiomyoma
David D. Thiel, MD, Bryant F. Williams, MD, Murli Krishna, MD,
Timothy J. Leroy, MD, Todd C. Igel, MD
Mayo Clinic Florida
Introduction/Objectives: Leiomyoma
is the most frequent nonepithelial benign tumor of the bladder, and only about
170 cases have been reported in the literature. Most bladder wall leiomyomas
are found incidentally and can be observed if imaging and biopsy are consistent
with the diagnosis. Mass resection occurs for symptomatic or enlarging masses
and is indicated if the diagnosis of benign leiomyoma is in question. Our
objective was to show a minimally invasive approach to resection, if indicated.
Methods: We show resection of a
bladder wall leiomyoma with the da Vinci surgical system. This includes
demonstrations on imaging, port placement, and operative technique.
Results: Intraoperative video and
diagrams are shown of operative resection.
Conclusions: Final surgical pathology
and operative outcomes of the first reported case of robotic-assisted
laparoscopic resection of a bladder wall leiomyoma are shown.
9153 Urology
Robotic-Assisted Laparoscopic Reconstruction of the Upper Urinary Tract: Tips
and Tricks
David D. Thiel1, Timothy J. LeRoy1, Howard N. Winfield2, Todd C Igel1
1Mayo Clinic Florida, Jacksonville, Florida
2University of Iowa Hospitals and Clinics, Iowa City, Iowa
Introduction/Objectives: Urology has embraced the use of the da Vinci
surgical system for procedures that require complex laparoscopic maneuvers,
such as pyeloplasty and radical prostatectomy. A natural extension of these
techniques is to use the system for complex urinary reconstruction. The
objective of this video is to demonstrate these techniques.
Methods: Using intraoperative
video and representative diagrams, this video presentation shows various
aspects of upper urinary tract reconstruction.
Results: Video tips and tricks are
presented for the imaging, patient positioning, port placement, and operative
technique of urinary reconstruction.
Conclusions: Robotic-assisted
laparoscopic techniques are well suited for upper tract urinary reconstruction
as would be used in congenital, traumatic, iatrogenic injuries, or disease.
9154 Urology
Laparoscopic Ureterolithotomy for Large Proximal Ureteral Calculi
David Spencer, William L.Duncan
University of Mississippi School of
Medicine, Jackson Mississippi
Laparoscopy has gained greater acceptance in the world of urologic surgery.
Endourology is the mainstay for surgical management of urinary calculi. For
large calculi, regardless of location in the urinary tract, multiple endoscopic
procedures are commonly required. We evaluated the safety and efficacy of
laparoscopy for proximal ureteral calculi. This was performed in one procedure
with complete stone clearance. In this case, multiple procedures and multiple
anesthetics were avoided. Laparoscopic ureterolithotomy, although technically
challenging, is a feasible technique for treatment of large proximal ureteral
calculi. It has the potential for high rates of success and decreasing the
number of procedures required for large urinary calculi.
9155 General Surgery
Pyloromyotomy Length Directed by Preoperative Ultrasound Measurement Minimizes
Incomplete Laparoscopic Pyloromyotomy in Infants
Denis D. Bensard, MD, Richard J.
Hendrickson, Katie J. Giesting, CNP, Joshua M. Careskey, MD, Evan R. Kokoska,
MD
Peyton Manning Children’s Hospital,Cincinnati Children’s Hospital Medical Center,
University of Cincinnati School of Medicine
Background: Laparoscopic
pyloromyotomy is associated with an increased risk of incomplete myotomy (5% to
7%) compared with open myotomy (2% to 3%). In contrast, the risk of mucosal
perforation (2% to 3%) appears less when pyloromyotomy is performed
laparoscopically. We hypothesized that utilizing ultrasound-measured length
rather than visual estimation of laparoscopic pyloromyotomy would reduce the
risk of incomplete pyloromyotomy without a concomitant increase in the risk of
mucosal perforation.
Methods: In a children’s hospital, all infants (n=43) with
hypertrophic pyloric stenosis diagnosed by ultrasound over a 2-year period
(12/2006 to 12/2008) were offered laparoscopic pyloromyotomy. Pyloromyotomy
length was guided by preoperative ultrasonographic measurements. Laparoscopic
pyloromyotomy was considered complete if the measured length correlated with
the ultrasound measurement. Infants were followed prospectively for time to
full feeding, time to discharge, and complications.
Results: Forty-three infants (38 male, 5 female; mean age
37±13 days, range 17 to 72) underwent ultrasound (length 1.9±0.2mm; thickness
4.4± 0.9mm) and laparoscopic pyloromyotomy. Infants achieved full feeding 28±16
hours postoperatively and were discharged 33±13 hours postoperatively (range, 15
to116). No infant required reoperation for incomplete myotomy. One infant
sustained mucosal perforation during laparoscopic pyloromyotomy (2.3%),
recognized intraoperatively, and completed open. No patient required
readmission or suffered other complications.
Conclusion: Utilizing preoperative ultrasound measurement of
pyloric channel length to determine the length of laparoscopic pyloromyotomy
rather than visual cues alone appears to minimize the risk of incomplete
pyloromyotomy without an increase in the risk of mucosal perforation in
infants.
9156 Multispecialty
Small Bowel Obstruction after FloSeal Use
Benjamin Clapp, MD1, Antonio Santillan, MD2, Bruce
Applebaum, MD1
1Providence
Memorial Hospital, El Paso, Texas
2Texas Tech University School of Medicine at El Paso, Texas
Objective: FloSeal is a
thrombin-gelatin hemostatic matrix that is used to obtain hemostasis. There
have been isolated case reports of FloSeal causing bowel obstructions requiring
surgical intervention. We report 2 cases of what we believe were
FloSeal-induced small bowel obstructions.
Methods: This
is a case series report and review of the literature. We report a case of a
small bowel obstruction after a laparoscopic gastric bypass where FloSeal was
used on a bleeding staple line and also of a small bowel obstruction after a
robotic-assisted hysterectomy.
Results: In
both patients, FloSeal was used for hemostasis. In each instance, a small bowel
obstruction developed within days. Both patients were reexplored
laparoscopically and found to have an intense inflammatory reaction at the site
of the FloSeal. The adhesions were lysed and both cases of obstruction
resolved.
Conclusions: FloSeal
should be used with caution, because it may cause small bowel obstructions.
Whether this is an immune/allergic response or a mechanical response of the
bowel to a thrombin-based substance is yet to be determined.
9157 General Surgery
Single-Incision Laparoscopic Surgery (SILS) and Natural Orifice Transluminal Endoscopic
Surgery (NOTES) Cholecystectomy: Is It Just About Cosmesis?
Sujit
Vijay Sakpal, MD1, Ronald Scott Chamberlain, MD, MPA1,2
1Saint Barnabas Medical Center, Livingston, New Jersey
2University of Medicine & Dentistry of New Jersey, Newark, New
Jersey
Background and Objectives: Laparoscopic
cholecystectomy is the most commonly performed minimally invasive procedure.
Significant efforts have been applied towards developing the technique and
equipment for performing this procedure using either a single-incision
laparoscopic surgery (SILS) or natural orifice transluminal endoscopic surgery
(NOTES) method. It has been suggested that these innovative techniques will
reduce postoperative pain and limit scarring while also improving cost
effectiveness and patient safety. This review highlights the technical
challenges associated with these procedures and the potential benefits, if any,
they may offer.
Methods: A comprehensive review of the worldwide literature
pertaining to “less” minimally invasive cholecystectomies—SILS and NOTES
cholecystectomy—was performed to evaluate the potential benefits, limitations,
and risk of these novel procedures.
Results: Both SILS and NOTES cholecystectomy have the
potential to produce cosmetic benefits. Whether these procedures result in less
postoperative pain is so far a subjective conclusion, lacking objective data
supporting this claim. Intraoperative or postoperative complication rates and
the safety and efficacy associated with these procedures remains undetermined.
Conclusion: Clinical reports of both SILS and NOTES are rare
and limit the ability to draw meaningful conclusions. Reports of technical
complexity, low success rates, and avoidable complications raise doubts as to
the broad applicability of these techniques. Extensive research and development
into the technical aspects of these procedures and randomized studies to
compare them with traditional laparoscopy are essential.
9158 General Surgery
Sentinel Lymph Node Mapping in Patients with Differentiated Thyroid Carcinoma
(DTC): Our Experience
Sinisa Maksimovic
General Hospital St. Vracevi Bijeljina, R. Srpska, Bosnia and Herzegovina
Introduction:
The aim of this study was to evaluate sentinel lymph node mapping in patients
with differentiated thyroid carcinoma
(DTC).
Methods:
From 2001 to 2008, we performed sentinel lymph node mapping (SLNb) in 37
patients with DTC. Before mobilization of the thyroid gland, approximately
0.2mL of 1% solution of methylene blue dye was injected peritumorally. After
approximately 10 minutes, the dissection was continued above and beyond the
omohyoid muscle towards the internal jugular vein and common carotid artery until
the blue stained lymph nodes were found and recognized and sent for frozen
section examination. If any of the nodes were positive on frozen section, a
modified radical neck dissection was performed after total thyroidectomy and
routine dissection of the central neck compartment.
Results:
Twenty-two patients had papillary thyroid carcinoma, 11 follicular carcinoma,
and 4 benign tumors. Identification of blue-stained SLN was successful in 93.5%
of cases. Negative and positive predictive values were 94.7% and 100%, while
overall accuracy of the methods was 95.6%. In the one patient with follicular
carcinoma, SLN detection failed. Four patients had one radioactive node, 1 had
3, and 1 had 4.
Conclusion:
Our results imply that SLN biopsy in the jugulo-carotid chain using methylene
blue dye mapping is a feasible and accurate method for estimating lymph node
status in the lateral neck compartment. The method could be helpful in
detection of true positive but nonpalpable lymph nodes and may be useful in
patients with DTC.
9159 Gynecology
Use of the PlasmaJet System in the Laparoscopic Treatment of Endometriosis: Early Experience
Kimberly A. Kho, MD, MPH, Ceana Nezhat, MD
Northside Hospital, Atlanta, Georgia
Objective: To examine the feasibility of the use of neutral
argon plasma for the laparoscopic treatment of endometriosis.
Methods: In this prospective pilot
study, 20 patients undergoing laparoscopic treatment of endometriosis were
included. Characteristic endometriotic lesions throughout the pelvis were
vaporized or resected using neutral argon plasma by the PlasmaJet System (PJS).
Specimens were evaluated for the presence of endometriosis and thermal effects
on tissue. The bases of the treated lesions were biopsied to determine whether
residual endometriosis was present.
Results: PlasmaJet was used in 18 of the 20 patients for
laparoscopic treatment of pelvic endometriosis. Forty-six lesions were
vaporized or excised with the PJS. Twenty-seven lesions were vaporized, and
biopsy of the base of the lesions was performed in 7 of these sites. Nineteen
lesions were resected using the PJS with biopsy of the base in 8 of these
sites. All biopsies confirmed complete vaporization or resection with no
residual endometriosis at the base. Endometriosis was identified on pathology
examination in all lesions excised using PJS. Thermal effects did not interfere
with histologic analysis in any of the lesions. No complications occurred.
Conclusions:
Neutral argon plasma may be an effective new modality for the treatment of
endometriosis. The PJS can be utilized as a multi-functional device that has vaporization,
coagulation, and superficial cutting capacities with minimal thermal spread.
The PJS appears to be efficacious for the complete treatment of endometriotic
implants.
9160 General Surgery
Laparoscopic Inguinal Hernia Repair (IPOM) with Dual-Mesh: Feasibility and
Advantages
Giovanni Cesana, MD, Stefano Olmi,
MD, Enrico Croce, MD
San Giuseppe Hospital, University of Milan, Italy
Objective: Inguinal hernia repair by the laparoscopic approach is commonly
performed by TEP or TAPP technique. The mesh is usually placed in a
retroperitoneal position and fixed with mechanical clips. These procedures are
quite long and complicated, and many authors have shown that the learning curve
may be a serious issue. The laparoscopic inguinal hernia repair (IPOM) technique
could be an interesting alternative, as this technique is much easier and
faster.
Methods: From January 2003 to
December 2008, we performed 96 inguinal hernia repair procedures with the
laparoscopic approach (94 males, 2 females, mean age 60 years, mean weight
76kg), with the IPOM technique and using Parietex Composite mesh (Sofradim,
France) and fibrin glue (Tissucol, Baxter, USA) for mesh fixation.
Results: Mean operative time was 10
minutes. Mean hernia diameter was 2.5cm (±0.8cm), 16 hernias were direct, 80
were indirect, and 20 of 96 were recurrent. We did not have to convert any of
the laparoscopic procedures. The mean time of discharge was 1 day, and the mean
time for resumption of physical or working activities was 5 days. With a mean follow-up
of 36 months, only 1.6% of the patients had hematoma at the trocar site; no
additional complication was reported, in particular no recurrence, no mesh
migration, no occlusion, and no fistula were observed.
Conclusion: IPOM is the easiest and
fastest hernia repair technique. This study shows that with the right material
it is feasible and without serious complications.
9161 General Surgery
Atraumatic Repair of Ventral Hernia Using Fibrin Glue
Stefano Olmi, MD, Giovanni Cesana,
MD, Enrico Croce, MD
San Giuseppe Hospital, University of Milano, Italy
Objective: The aim of this study was to establish the efficacy and
tolerability of human fibrin glue (Tissucol) for the nontraumatic fixation of a
composite prosthesis (Parietex) and a new mesh (Hi-Tex, Textile) in the
laparoscopic repair of small and medium incisional hernias and primary defects
of the abdominal wall.
Methods: From October 2003 to
December 2007, 77 patients with abdominal wall hernia underwent laparoscopic
repair; all meshes were implanted in an intraperitoneal position. Follow-up
visits were scheduled for 7 days and 1, 6, and 12 months, and 2, 3, and 5 years. These included
assessments for pain and postoperative complications.
Results: Seventy-seven patients (44
females, 33 males) with a mean age of 50 years (range, 26 to 65) and a mean BMI
of 27 (range, 25 to 30) were included in the study. Twenty-four patients had
incisional hernias, and 53 had primary defects. The size of the defects varied
from 2cm to 7cm. Adhesiolysis was necessary in 62.5% of cases. No
intraoperative complications or conversions occurred. After a mean follow-up of
32 months (range, 2 to 50), no postoperative complications were observed. The
mean surgical intervention time was 36 minutes (range, 12 to 40) with an average
hospitalization time of 1 day.
Conclusion: The use of fibrin glue provided stable and uniform fixation of
the prosthesis and minimized intra- and postoperative complications.
Consequently, laparoscopic treatment of small- to medium-sized abdominal
defects using this approach is our therapeutic option of choice.
9162 General Surgery
Laparoscopic Repair of Incarcerated Incisional Hernia: Our Experience
Stefano Olmi, MD, Giovanni Cesana,
MD, Enrico Croce, MD
San Giuseppe Hospital, University of Milan, Italy
Objective: The emergency treatment of incisional hernias can be
accomplished by the laparoscopic approach to avoid the common postoperative
complications of the open technique.
Methods: From January 2001 to
December 2007, we performed the laparoscopic approach in an emergency regime to
treat incarcerated hernias. We used 2 types of mesh: Parietex (Covidien) and
Hi-Tex (Textile), and for dissection we used a 5-mm ultrasound dissector
(Ultracison, Ethicon)
Results: Forty-five patients with
incisional hernia (29 females and 16 males) underwent emergency treatment, due
to incarcerated incisional hernia. Exclusion criteria for the study were the
eventual necessity of intestinal resection due to intestinal necrosis (3 cases)
or the presence of great incisional hernia with loss of domain (2 cases). A
severe respiratory insufficiency (2 patients) and cardiocirculatory problem (2
patients) were not contraindications to the laparoscopic technique. Mean
operating time was 62 minutes (range, 45 to 80). The average hospitalization
time was 4 days (range, 3 to 6). Surgical complications were 8 seromas treated
by medical therapy with seroma aspiration. No prosthesis infection occurred. No
metabolic or infective complications occurred. No surgical complications, need
for reintervention, recurrence, or deaths occurred.
Conclusion: These results prove the
feasibility of the emergency laparoscopic approach to incarcerated incisional
hernias, using new generation meshes.
9163 General Surgery
Hole-Mesh Device Allows Accessing the Bypassed Stomach in Patients Who Undergo
Roux-en-Y Gastric Bypass for Severe Obesity
Giovanni Cesana, MD, Stefano Olmi,
MD, Antonio Catona, MD, Enrico Croce, MD
San Giuseppe Hospital, University of Milan, Italy
Objective: Roux-en-Y gastric bypass (RYGBP) is the current standard of care
in bariatric surgery. It has been reported to cure type II diabetes in obese
patients. There have been reported cases of mucosal dysplasia and cancer in the
bypassed stomach following RYGBP. No possibilities to explore the residual
stomach have yet been described.
Methods: We have developed
Hole-Mesh, a specific device to access the bypassed stomach after RYGBP. It is
made of a central part (12-mm diameter and 10-mm thickness) with a radiopaque
wire at the edge, located in the middle of a 30-mm diameter polypropylene mesh.
The device is placed in the residual stomach during the RYGBP
video-laparoscopic intervention. It allows the gastric wall to connect to the
parietal peritoneum.
Results: An experimental study in
pigs has shown the feasibility of the procedure. Up to now, we have positioned
Hole-Mesh in 5 patients without any complications with a median follow-up of 6
months. The device permits radiological examination of the bypassed stomach
through the introduction of Gastrografin by a syringe; it allows making an
endoscopic exploration of the cavity through a trocar to analyze the gastric
content through needle aspiration and to establish enteric nutrition through a
catheter in case of leakage of the gastroenteric anastomosis.
Conclusion: Hole-Mesh is well
tolerated by patients, without complications. It allows exploring the bypassed
stomach, duodenum, and ileum after RYGBP. It may be useful in understanding the
biologic mechanisms of metabolic changes especially in obese diabetic patients.
9164 General Surgery
Laparoscopic Sigmoid Colectomy for Diverticulitis: A Prospective Study of
260 Patients.
Prof. Dr. Ivo. Baca, Khaled Elzarrok, Leszek Grzybowski, Armin
Jaacks
Klinik fuer Allgemein-, Viszeral- und Unfallchirurgie, Klinikum
Bremen Ost, Bremen, Germany
Background: Surgical treatment of
complicated colonic diverticular disease is still debated. The aim of this
prospective study was to evaluate the outcome of laparoscopic sigmoid colectomy
for diverticulitis. Indications for laparoscopic surgery were acute complicated
diverticulitis (Hinchey stages I and IIa), chronically recurrent
diverticulitis, bleeding, or sigmoid stenosis caused by chronic diverticulitis.
Method:
All patients who underwent laparoscopic colectomy within a 12-year period were
prospectively entered into a PC database registry. One-stage laparoscopic
resection and primary anastomosis constituted the planned procedure. A 4-trocar
approach with suprapubic minilaparotomy was used. Main data are age, sex,
postoperative pain, return of bowel function, operation time, duration of
hospital stay, and early and late complications.
Results: During the study period,
260 sigmoid colectomies were performed for diverticulitis. Patients included
104 males and 156 females. M:F ratio is 4:6. Postoperative pain was controlled
by NSAIDs or a weak opioid, and 15 patients (5.7%) required conversion from
laparoscopic to open colectomy. Most common reasons for conversion were
directly related to the inflammatory process, abscess, or fistulas. Mean
operative times were 130±54. Average postoperative hospital stay was 10±3 days.
A longer hospital stay was required for those in Hinchey IIa. Complications
were recorded in 32 (12.3%). The most common complication requiring reoperation
was hemorrhage in 5 (1.9%) patients. Anastomotic leak occurred in 11 patients
(3 of them required reoperation). The mortality was 2 patients (0.76%).
Conclusions: Laparoscopic surgery for
diverticular disease is safe, feasible, and effective. Therefore, laparoscopic
colectomy has replaced open resection as standard surgery for recurrent and
complicated diverticulitis at our institution.
9165 General Surgery
Management of Chyloperitoneum Following Redo-Laparoscopic Nissen Fundoplication
in a 23-Month-Old Female
E. L. Galiñanes, MD, A. A.
Wheeler, MD, T. P. Mayfield, MD, V. Ramachandran, MD
University of Missouri, Columbia, Missouri
Background: Chyloperitoneum is a rare complication that has been described
after abdominal aneurysm repair, retroperitoneal node dissection, or nephrectomy
due to disruption of the cisterna chyli or thoracic duct. Rarely has it been
described in conjunction with laparoscopic surgery. We describe a case of
chyloperitoneum occurring after redo-laparoscopic Nissen fundoplication that
was successfully treated with conservative management.
Methods: We present the case of a
girl born at 25 weeks gestation with cerebral palsy, feeding difficulty, and
reflux. She received a gastrostomy and Nissen fundoplication. One year later,
she presented with a hiatal hernia and symptoms of reflux, weight loss, and
vomiting. At diagnostic laparoscopy, the previously placed wrap was found to
have slipped into the mediastinum. Operatively, it was mobilized back into the
abdominal cavity, the wrap taken down and reapplied. Postoperatively, the
patient developed abdominal distention, nausea, and vomiting prompting
reoperation. Copious milky fluid was noted, aspirated, and later confirmed to
be chyle.
Results: A pyloroplasty was
performed for delayed gastric emptying, no drains were placed, and the patient
was further treated conservatively with total parenteral nutrition. The
chyloperitoneum resolved over the course of 5 days, and the patient was then
transitioned to medium chain fatty acid lipid tube feeds.
Conclusion: We describe a rare
complication of laparoscopic foregut surgery in pediatric patients. Although
usually described after surgery involving hindgut structures whereby the
cisterna chyli are disrupted, foregut surgery more likely disrupts the thoracic
duct near its diaphragmatic hiatus but can be successfully treated with a
diet/enteral feeding with medium fatty acids.
9166 General Surgery
Laparoscopic Ventral Hernia Repair without Suture Fixation
Kevin Gillian MD
Background: The
technique for laparoscopic repair of ventral hernias has been shown to be an
effective technique for repair. Disagreements arise over which mesh should be
utilized and how it should be fixed to the abdominal wall. Laparoscopic ventral
hernia repair with polypropylene mesh fixation using a double crown of 5-mm
tacks has been shown to be a feasible repair with excellent outcomes for the
patient.
Methods: A
retrospective review of laparoscopic repair of ventral hernias utilizing a
variety of polytetrafluoroethylene (ePTFE) meshes by a solo surgeon was
undertaken. These repairs were performed without transfascial suture fixation.
Data were obtained from patient records and phone interviews.
Results: Laparoscopic
ventral hernia repair was performed in 100 patients with one conversion to open.
Multiple hernia defects were noted in 45 patients. The mean age of the patients
was 56 (range, 21 to 89) with 44 men and 56 women. Comorbidities most common in
this population were obesity (45%) and diabetes (7 %). No deaths and one
complication occurred in this series. Follow-up ranged from 33 to 84 months
(mean, 44.37). Patient satisfaction was noted on the Carolina Comfort Scale.
There were no recurrences or mesh removals during this medium-term follow-up
study.
Conclusion: Our
results support the concept that transfascial fixation can be eliminated in the
laparoscopic repair of ventral hernias with polypropylene/ePTFE mesh while
preserving low postoperative morbidity and high patient satisfaction.
9167 General Surgery
Postlaparoscopy Pain Control with Tarns Port Local Anesthesia
S. A. Vejdan, MD
Imam Reza Hospital, Birjand Medical University of Science
Objective: Laparoscopic surgery has
a short painful period after operation, but it is not a painless procedure.
Conventional painkillers in laparoscopic surgery consist of NSAIDs and
narcotics that have their specific side effects, but their use is unavoidable.
This study evaluated the role of local trans-port anesthesia with local
anesthetic drugs to reduce postlaparoscopic pain and narcotic use.
Methods and Procedures: At the end
of laparoscopic surgeries, before port withdrawal, a local anesthetic mixture
[a short-acting (Lidocaine 2%) plus a long-acting (Bupivacaine 5%)] was
instilled through the port lumen between the abdominal wall layers. This study
was performed in 2 groups of patients. Group 1, the control group, was given
traditional painkillers like narcotics and NSAIDs. Group 2 was given the
trans-port mixture. Efficacy of the medications was compared. This is
prospective clinical trial.
Results: In group 1, 95% received
Meperidine 50mL to 200mL 1 to 4 times for pain control and group 2 was
controlled with transrectal NSAIDs. In group 2, pain in 65% of the patients was
controlled with just local anesthetic drugs (this method), 30% needed NSAIDs,
and only 5% needed narcotics.
Conclusions: Use of local anesthetic
drugs for pain control after laparoscopic surgery is a modality with a low
complication rate, is very effective in all conditions, and can reduce the side
effects of narcotics.
9168 General Surgery
Laparoscopic Splenectomy for Multiple Distal Aneurysms of the Splenic Artery
M. Lombardi, MD, E. Puce, MD, D. Apa, MD, B. C. Brassetti, MD,
G. A. Senni, MD, F. Atella, MD
Introduction: Splenic artery
aneurysm is a rare pathology that carries the risk of rupture (3% to 9.6%)
when the transverse diameter reaches 2cm or more. This is associated with a
high mortality rate of 36% that increases to 75% among pregnant women. The risk
factors include portal hypertension, vasculitis, arteriosclerosis, arterial
fibrodysplasia and female sex. These aneurysms are usually incidental findings.
Management choices include open, laparoscopic, and endovascular procedures.
Case Report: We report on a
57-year-old female with a past history of insipid diabetes and
hypercortisolemia. The aneurysm was asymptomatic and was an incidental finding
as a result of a helical contrast computed tomography to investigate adrenal
glands. CT scan revealed multiple distal aneurysms of the splenic artery that
measured >2cm in diameter. We performed a laparoscopic splenectomy using a
lateral approach with optimal visualization of splenic vessels. No
postoperative complications occurred, and the patient was discharged on the
fourth postoperative day.
Conclusion: Splenic artery aneurysm
is a rare yet very important clinical entity because of its potential for
rupture with fatal consequences. Surgical treatment is recommended for
aneurysms >2cm. Angiographic interventions and laparoscopic exclusion of
splenic artery aneurysm have been shown to provide adequate therapy without the
morbidity associated with open procedures. Although many can be treated with
percutaneous embolization, tortuosity of the artery may render this approach
impossible. For distal and hilar located multiple aneurysms, laparoscopic
splenectomy represents a reasonable option.
9169 General Surgery
Laparoscopic Resection of a Retroperitoneal Mass
M. Lombardi, MD, D. Apa, MD, E. Puce, MD, B. C. Brassetti, MD,
G. A. Senni MD, F. Atella, MD
Introduction: We describe the laparoscopic resection of a
retroperitoneal mass with radiological impression of adrenal
“incidentaloma.” Surprisingly, histopathology revealed a “well-differentiated
retroperineal liposarcoma.”
Case Report: An asymptomatic
42-year-old female referred to our hospital after a screening ultrasonography
with detection of an incidental retroperitoneal tumor.
Helical CT scan and magnetic resonance imaging showed a large
solid mass >5cm in maximum diameter in the left adrenal gland space. The
tumor appeared hypervascularized, containing a large area of necrosis. The
pancreatic vessels and pancreatic tail were displaced by the mass without
images of invasion surrounding organs. Fine needle aspiratory cytology was
inconclusive due to suboptimal cellularity. With the clinical diagnosis of a
nonfunctioning adrenal tumor, the patient received laparoscopic resection. The
operation was difficult because of hypervascularization of the mass and
tenacious adherences to the left renal capsule that was resected. The
pathological diagnosis was well-differentiated liposarcoma, sclerosing type.
The histological margins were negative. After 1 year, a radiological suspect
appeared of lymphatic relapse on the celiac axis.
Conclusion: Liposarcoma is the most
frequent histotype of rare retroperitoneal tumors. The histological subtype and
margin of resection are prognostic for survival in primary tumors. Local
recurrences are the most frequent cause of failure of the surgery. The
feasibility of complete resection is crucial for prognosis. The open approach
is the gold standard, but in this case, laparoscopy was technically safe and
successful in maintaining oncologic principles of radicality. In select cases,
this approach represents a feasible alternative to open surgery.
9170 Gynecology
Laparoscopic Isthmic Cerclage: A Simplified Technique
Antoine Watrelot, Jean Michel
Dreyfus
Centre de Recherche et d'Etude de la Stérilité (CRES), Lyon, France
We describe the technique of laparoscopic isthmic cerclage for cervical incompetency.
By using an artefact described by Tulandi, we performed the technique using a
percutaneous needle. The technique is therefore very simple and easy to learn.
Indications for isthmic cerclage are not so frequent, but due to the
mini-invasiveness of this approach it is probably suitable to propose this
operation even if the patient has only one late miscarriage (and not 2 as
classically recommended). To date, we have performed 7 cerclages with this
technique; 5 patients have been pregnant and have undergone a caesarian
delivery between 32 to 36 weeks of gestation. The 2 other patients are
still not pregnant, 6 and 10 months after surgery, respectively. We
believe that the laparoscopic isthmic cerclage (namely Benson's cerclage) is an
attractive alternative to the vaginal Shirodkar technique.
9171 Gynecology
Report of the Largest Case Series of Parasitic Myomas
Kimberly Kho, MD, MPH, Ceana Nezhat, MD
Atlanta Center for Special Minimally Invasive Surgery &
Reproductive Medicine, Atlanta, Georgia
Objective:
To report the largest case series of parasitic myomas in the medical
literature, and an examination of causes, associations, and risk factors.
Methods:
A retrospective chart review was performed on 12 patients found to have
parasitic myomas between August 2000 and September 2008. The following data
were systematically collected: surgery date; indications for surgery; number,
dates, and types of prior surgeries; prior use of morcellation; and locations
of parasitic myomas. Pathologic confirmation of all specimens was obtained.
Results:
Laparoscopic evaluation confirmed the presence of intraperitoneal and
retroperitoneal myomas distinct from the uterus in 12 patients. Ten of the 12
patients had prior abdominal surgery. Six patients had prior morcellation
procedures during laparoscopic myomectomy, and 2 patients had abdominal
myomectomies. Three patients had multiple parasitic fibroids; all of them had a
history of laparoscopic myomectomy with morcellation. The majority (14/15) of
parasitic myomas were found in the pelvis, 2 of which were retroperitoneal.
Conclusion:
Parasitic myomas may occur spontaneously as pedunculated subserosal myomas lose
their uterine blood supply and parasitize to other organs. However, this series
supports what the literature has suggested; more parasitic myomas may be
iatrogenically created after prior surgery, particularly surgery using
morcellation techniques. With increasing rates of laparoscopic procedures,
surgeons should be aware of the potential for iatrogenic parasitic myoma
formation, their likely increasing frequency, and intraoperative precautions to
minimize occurrence.
9172 Multispecialty
Laparoscopic Gastrostomy Utilizing a Multidisciplinary Approach is Safe and
Beneficial in Infants Under 10 Kilograms with Congenital Heart Disease
Richard Hendrickson, MD2, Denis
Bensard, MD2, Monte Harrison, DO1, Katie Giesting, PNP1, Simon Abraham, MD1, Josh
Careskey, MD1, Evan Kokoska, MD2
1Peyton Manning Children’s Hospital at St. Vincent, Cincinnati, Ohio
2University of Cincinnati School of Medicine, Cincinnati, Ohio
Background: Infants with
congenital heart disease often have feeding difficulties and poor weight gain.
Cardiac procedures may require staged correction. Feeding access is often
beneficial. The safety and efficacy in this cohort of cardiac patients
undergoing laparoscopic procedures is unclear. We hypothesized that a
multidisciplinary team approach and laparoscopic gastrostomy can be
performed safely.
Methods: In a women’s and
children’s hospital, all complex congenital heart disease infants with failure
to thrive and poor enteral intake (n=10) were offered a laparoscopic approach
for enteral access over a 15-month period (09/2007 to 12/2008). All patients
had at least one cardiac procedure and had demonstrated failure to thrive
without clinical or radiographic evidence of gastroesophageal reflux.
Pediatric cardiology, cardiac surgery, intensivist, neonatologist, and surgery
personnel all participated in the pre-, intra- and postoperative management.
Results: Ten infants (6 male, 4
female; average age at surgery 12 weeks (range 3 to 51) underwent
laparoscopic-assisted gastrostomy placement. Average operative weight
was 4.2 kilograms (range 2.75 to 6.8). Operating room time average was 80
minutes (range, 59 to 120). Average surgical time was 38 minutes (range,
28 to 70). All patients were started on feeds within 24 hours and reached full
feeds on average in 92 hours (range, 58 to 141). No infant required conversion
to an open procedure. No intra- or postoperative complications occurred.
Conclusion: Utilizing a
multidisciplinary approach in infants with complex congenital heart disease
safely permits minimally invasive feeding access.
9173 Multispecialty
Laparoscopic Application of a Hyaluronate/Carboxymethylcellulose Slurry Does
Not Increase Postoperative Adhesions
Bradford W. Fenton, MD, PhD
Summa Health System Department of Obstetrics and Gynecology, Pelvic Pain
Specialty Center
Background: Postoperative adhesion
formation is a significant problem with any surgery, but most approved adhesion
prevention measures are difficult to apply through the laparoscope. Cut up
sheets of hyaluronate/carboxymethylcellulose can be suspended in saline and
then applied as a slurry through a laparoscopic irrigator. It is unknown
whether the slurry formulation retains adhesion prevention properties, or if it
might induce more adhesions after application.
Method: A slurry of
hyaluronate/carboxymethylcellulose was created by cutting three 5x7-cm sheets
into squares <1cm each, and suspending them in 60cc of 2% lidocaine. The
resultant slurry was then applied following laparoscopic fulguration of
endometriosis and lysis of adhesion for chronic pelvic pain in 2 patients.
Following 1 year of medical suppression therapy, the patients requested a
repeat of the fulguration for their recurrent pain. The number of sites of
fulguration and adhesion lysis at the initial laparoscopy were evaluated at the
second laparoscopy for the presence of adhesions.
Results: No adhesions were
encountered at the level of the umbilicus or upper pelvis. At the sites of
hyaluronate/carboxymethylcellulose slurry application, previous fulguration,
and adhesion lysis, no adhesions were encountered.
Conclusion: Prevention of
postoperative adhesions depends on many factors, and application of adhesion
barriers provides a potential to decrease postoperative adhesion formation.
Using a slurry of hyaluronate/carboxymethylcellulose extends the options for
adhesion prevention in laparoscopic surgery. From these patients, there is no
evidence that the hyaluronate/carboxymethylcellulose slurry increases adhesion
formation.
9174 Gynecology
Dysautonomias Are Not Associated with Chronic Pelvic Pain
Andrea Crane, MD, Bradford W. Fenton, MD, PhD
Summa Health System, Pelvic Pain
Specialty Center
Background: Several studies have suggested that disorders of the autonomic
nervous system are associated with chronic pelvic pain (CPP) and interstitial
cystitis (IC) in particular. Because diagnostic criteria are available for
several dysautonomias, this association can be investigated with a survey.
Method: As part of an ongoing
survey, 100 women in an urban, resident-run gynecology practice and 73 women in
a CPP referral center (CPPrc) filled out identical surveys with the diagnostic
criteria for postural orthostatic (POTS), vasodepressor syncope (VDS), chronic
fatigue (CFS), irritable bowel syndrome (IBS), migraines, and IC. IC was
diagnosed by cystoscopy in the CPPrc. CPP patients also underwent orthostatic
blood pressure and pulse testing.
Results: No patient met criteria for
VDS or CFS in either group. In the general gynecology population, 21% had CPP,
16% had POTS, 24% had migraines, 5% had IC, and 4% had IBS. The presence of CPP
was associated (chi square; P<0.001) with migraines, but not POTS, IC, or
IBS. In the CPPrc, 32% had POTS, 36% had migraines, 16% had IC, and 33% had
IBS. The presence of IC was associated with IBS (P=0.04), but not POTS or
migraines. Hemodynamic parameters were not related to the presence of IC.
Conclusion: Although it has been
suggested that chronic pain syndromes are associated with dysautonomias, no
clear relationship was demonstrated by this data set. The lack of change in
orthostatic blood pressure testing supports these conclusions. A larger series
or more intensive testing may produce different results.
9175 Gynecology
Lifelong Dysmenorrhea is Associated with Other Muscle Tension Pain Syndromes
Andrea Crane, MD, Eileen Witten, MD, Bradford W. Fenton, MD,
PhD
Summa Health System, Pelvic Pain
Specialty Center
Background: Dysmenorrhea is a significant problem that is one component of
chronic pelvic pain (CPP), a standardly defined syndrome. Several other chronic
pain disorders have similarly defined criteria, which can be used to construct
diagnostic surveys. It is unknown whether a lifelong history of dysmenorrhea
(painful menses from menarche onward) has any relationship to other chronic
pain disorders. If so, it may suggest that these women have an inherent
heightened sensitivity to pain.
Methods: As part of an ongoing
survey, 100 women seen in an urban residency clinic filled out a survey
containing the definitional criterion for chronic pelvic pain, irritable bowel
syndrome (IBS), interstitial cystitis (IC), migraines, and scales for traumatic
stress, childhood trauma, abuse, anxiety, depression, and fibromyalgia (FMS).
Results: Lifelong dysmenorrhea (LD)
was present in 38% and was significantly more frequent (chi squared: P<0.05)
in patients with any or all criteria for CPP, IC, and migraines, and was
related to (t test: P<0.05) higher
FMS scores. Neither a history of abuse nor IBS was more common in LD patients.
LD patients were not significantly older (average age 34), of higher parity,
nor had higher anxiety, depression, traumatic stress, or childhood trauma
scores.
Conclusion: The association of LD
with other muscle tension pain syndromes (migraines, FMS, and IC) suggests that
these patients may have an inherent, possibly cerebral, hypersensitivity to
pain. In this population of LD patients, psychiatric symptoms were not more
pronounced, suggesting that centralized pain sensitivity may not be related to
trauma, abuse, or other experiences.
9176 Gynecology
Limbic Brain Areas are Activated in Chronic Pelvic Pain
Bradford W. Fenton, MD, PhD
Summa Health System, Pelvic Pain
Specialty Center
Introduction: Interstitial cystitis (IC) is one of several entities
commonly associated with chronic pelvic pain. Due to the association of IC with
other chronic pain disorders, it has been suggested that some of these patients
may have a heightened sensitivity to pain. If this is the case, then it is
unknown whether the medial limbic pain pathway is more active, as has been
suggested, or if the lateral nociceptive pathway is more active.
Methods: In this pilot study, 4
healthy controls and 2 patients with simple IC underwent localization of
electroencephalographic (EEG) brain frequency analysis with their bladder
empty. All patients underwent a visual evoked oscillations assessment using a
fearful faces presentation. Comparison between groups was done using a
nonparametric log f test.
Results: In IC patients, complexity
of the EEG (omega), a global measure reflecting degree of spatial
synchronization, was significantly increased in the anterior cingulate gyrus.
Delta wave activity was also significantly increased in the anterior cingulate
in IC patients. Other frequencies were variably different: IC patients had more
alpha activity in the occiput, and controls had more diffuse beta activity,
particularly middle temporal.
Conclusions: Interstitial cystitis patients,
even immediately after voiding, continue to feel pain through an activated
medial pain perception pathway, which terminates in the anterior cingulate
gyrus. This occurs through theta wave activity, and is confirmed by the
increase in omega in these areas, consistent with other studies of affective
pain. This pilot study indicates that the limbic pain perception pathways are
activated in IC.
9177 Gynecology
An Innovative Electric Converter (M/BAC*) for Laparoscopic Surgery
Youngse Park
CHA University, CHA General Hospital, Korea
Objective: To evaluate the efficacy and safety of a new electric converter
(M/BAC*: Monopolar/Bipolar Automatic Converter) for laparoscopic surgery.
Methods: This was a
retrospective, comparative study reviewing DVDs of 40 women who underwent total
laparoscopic hysterectomy from November 2006 to September 2008 due to benign
pathology. Study populations were divided into 4 groups according to
instruments used, and each group consisted of 10 women: conventional alternate
bipolar/monopolar instruments (group 1), above instruments with both hands
(group 2), combo-coagulator* using M/BAC* (group 3), and LigaSure* (group 4).
The following were examined: (1) numbers of instrument changes per case and (2)
elapsed time for controlling bleeders in each group. Exclusion criteria
were women with any previous pelvic surgery, any concurrent surgeries, moderate
to severe pelvic adhesions, ureteral, uterine artery dissection, any
complications, RUMI system failure, and a uterus that was too small (<100g)
or too large (>500g).
Results: Baseline
characteristics were similar among the 4 groups (P>0.05). Median numbers of
instrument changes per case were 40, 25, 7.5, and 29.5 (P=0.0000),
respectively. Median elapsed time (seconds) for bleeding control was 17, 4, 3
(P=0.0000), but if blurring positive, 84 (group 1) vs. 28 (group 2).
Statistical analysis was performed using one-way analysis of variance,
Kruskal-Wallis test (a level of significance: P<0.05).
Conclusions: (1) Group 3 had
the smallest number of instrument changes (1/5 of group 1), and the shortest in
elapsed time for bleeding control. (2) M/BAC* decreased operation time, blood
loss, costs, and no related problems occurred.
9178 General Surgery
Preliminary Results with Endoscopic Plication for Revision of Gastric Bypass
Dimitrios V. Avgerinos, MD, Chiranjiv Virk, MD, Omar H. Llaguna, MD, John
L. Holup, DO, I. Michael Leitman, MD
Beth Israel Medical Center and Albert Einstein College
of Medicine, New York, New York
Objective: A new technique for endoscopic plication and revision of gastric
pouch (EPRGP) for patients who underwent gastric bypass (RGB) surgery was
evaluated in patients with severe GERD, dumping syndrome, and/or failure of
weight loss.
Patients and Methods: Patients
underwent EPRGP over an 8-month period. The StomaphyX device (Endogastric
Solutions, Redmond, WA) was utilized over a standard flexible gastroscope.
Patients were kept on a clear liquid diet for 1 week after the procedure.
Results: The study included 30
patients with a mean age of 46.3 years. EPRGP was performed an average of 4.9
years following RGB. The mean preoperative BMI was 41kg/m2. The
indications were dumping syndrome (21), GERD (6), and failure of weight loss
(3). The mean follow-up period was 4.3 months (range, 1 to 8). The average
operative time was 57 minutes, with a significant reduction with increased
operator experience. There was only one (3.3%) intraoperative complication
during the early period (equipment failure), which did not result in any
morbidity. All patients were discharged home after overnight observation.
Postoperatively, all were free of symptoms from dumping syndrome or reflux,
with no further operative-related complications. The mean weight loss was 9.2
lbs.
Conclusions: This study demonstrates
the technical feasibility and safety of EPRGP. This is a valuable technique for
the treatment of some of the gastrointestinal complications of RGB with modest
early weight loss. Further studies and extended follow-up are necessary to
determine the durability of weight loss.
9179 Gynecology
Laparoscopic Approach for Presacral Tumors: Early Experience of Initial 19
Cases
Huicheng Xu, MD, Yong Chen, MD, Yuyan Li,
MD, Junnan Li, MD, PhD, Dan Wang, MD, Zhiqing Liang, MD, PhD
Southwest Hospital, Third Military Medical University,
Chongqing, PR China
Objective: The aim of this study was to evaluate the complete surgical
resection by a laparoscopic surgical technique normally undertaken for tumors
under the sacral promontory.
Methods: This was a retrospective
review of the clinical features and results of surgical treatment of 19
patients who had laparoscopic resection of presacral tumors between 2005 and
2008.
Results: All 19 patients underwent
the laparoscopic procedure, and complete tumor resection was obtained. The mean
operative time was 182 minutes (range, 115 to 328), with a mean blood loss of
180mL (range, 120 to 230), and the average hospital stay was 6.2 days (range, 6
to 9). Pathological findings included 6 teratomas, 6 dermoid cysts, 3
schwannoma, 2 tailgut cysts, 1 hamartoma, and 1 aggressive angiomyxoma. No
complications occurred interoperatively. One patient has transitory left leg
motor dysfunction. No postoperative mortality or complication was seen. In
addition, no sensory or motor dysfunction of the bladder or rectum was observed
postoperatively. The median follow-up was 16 months (range, 3 to 32). The
postoperative course was uneventful, with one teratoma recurrence at 12 months
and 1 aggressive angiomyxoma recurrence at 29 months.
Conclusion: Laparoscopic surgery for
the removal of presacral tumors is feasible. The use of this new technical
approach offers many advantages but requires extensive experience in pelvic
surgery and laparoscopic skills. It is suggested that such laparoscopic
procedures be reserved for select cases of benign tumors, and its application
must be verified by further studies.
9180 Gynecology
Laparoscopic Gonadectomy for Androgen Insensitivity Syndrome with Serous
Gonadal Cyst
Mineto Morita, MD, Takehiko Tsuchiya, MD, Ichiro Uchiide, MD,
Masahito Nakakuma, MD, Yukiko Katagiri, MD
Toho University School
of Medicine
Introduction: Androgen insensitivity syndrome is caused by a
mutation in the androgen receptor gene. The frequency varies from 1/10,000 to
1/62,400 women. We report on a patient with androgen insensitivity syndrome
with a serous gonadal cyst who underwent laparoscopic surgery.
Case Report: The
patient was a 15-year-old phenotypic woman with height 162.5cm and weight
63.0kg. Her breasts were Tanner stage III. Abdominal findings included
bilateral inguinal scars consistent with hernia repair. Pelvic examination
revealed normal external female genitalia with Tanner stage I pubic hair. The
vaginal vault ended in a blind pouch and was approximately 8-cm deep.
Ultrasound and magnetic resonance imaging revealed the presence of a 36-mm
cystic smooth mass close to the left external iliac vein and artery. Serum
hormone concentrations were FSH 12.0mIU/mL, LH 30.5mIU/mL, E2 36.25pg/mL, T
10.12ng/mL, PRL 23.9ng/mL. The chromosome test revealed a normal 46,XY. The
diagnosis of androgen insensitivity syndrome was made on these findings.
Bilateral laparoscopic gonadectomy was performed with the patient under general
anesthesia. Histopathological finding of the gonads was immature testis.
Estrogen therapy was initiated postoperatively.
Conclusion: Due
to the reduced morbidity, shorter hospital stay, and safety, laparoscopic
gonadectomy can be considered the treatment of choice for removal of gonads in
patients with androgen insensitivity syndrome.
9181 General Surgery
Resection of Gastrointestinal Stromal Tumor of the Rectum by Transanal
Endoscopic Microsurgery
Paul R. Sturrock, MD, John C. Fondran,
MD, Adam A. Klipfel, MD, Jorge A. Lagares-Garcia
Rhode Island Colorectal Clinic,
Pawtucket, Rhode Island
Objective:
Gastrointestinal stromal tumors (GIST) involving the rectum represent a rare
clinical entity. We propose that transanal endoscopic microsurgery (TEM) may
represent an acceptable option for surgical resection of rectal GIST.
Methods: Case report and review of the literature.
Results: This case represents a successful resection
of a GIST of the rectum via TEM.
Conclusion: While currently little evidence exists in
the literature regarding the application of TEM to GIST of the rectum,
extrapolation from series in other areas of the gastrointestinal tract
indicates complete resection of the lesion is the goal of surgery. TEM may
allow a minimally invasive approach to these lesions in select patients.
9183 Multispecialty
Experimental Model in a Pig as a Training Tool in Endoscopic Axillary
Dissection
María Eugenia Aponte-Rueda,
MD, PhD, Ramón A. Saade Cárdenas, MD,
Rodolfo Miquilarena, MD
Caracas University Hospital, Central University of
Venezuela, University City,
Caracas-Venezuela
Background: Endoscopic axillary lymphatic dissection is part of our
surgical options, but its use has not been accepted with great enthusiasm.
Several factors have accounted for this, including the lack of an effective
experimental model that allows obtaining skills and abilities. The aim of this
study was to develop a training tool for endoscopic axillary dissection and to
evaluate its applicability in a pig model.
Methods: Twenty endoscopic
dissections of the axilla were performed in 10 pigs of 4 to 6 months (weight,
25 to 35kg) by a single surgeon. Subcutaneous axillary space was dissected with
blunt dissection and kept with CO2. Surgical workflow was segmented
into temporal operative phases (space creation, trocar placement, dissection,
and lymphadenectomy). Time necessary to perform this action was compared
throughout the study.
Results: The mean dissection time
was 26+7 minutes (range, 19 to 33). The axillary content was separated
from the other anatomical elements under complete visualization (85% to 100% of
the cases). Intraoperative complications happened in 2 dissections of 20 (10%)
including uncontrollable bleeding and subcutaneous emphysema. Residual
fibrofatty tissue was removed in 3 of 20 dissections.
Conclusion: We defined a pig model for commencement of training in
endoscopic axillary dissection. With this model, the surgeon can learn to
handle the structures atraumatically, to remove nodes, and to use instruments
in a close workspace with complicated anatomy, which allow the development of a
valid model for obtaining advanced laparoscopic skill that may be applicable to
other endoscopic axillary procedures.
9184 Urology
Median Lobe in Robotic Prostatectomy: Bladder Neck Reconstruction and Pelvic
Drain Not Routinely Required
Humberto J. Martinez-Suarez, MD, Asha White, MD, Ronney
Abaza, MD
Ohio State University Medical Center and James Cancer Hospital
Introduction: A median lobe (ML) may affect the outcomes of
robotic prostatectomy. We do not routinely perform cystoscopy prior to
prostatectomy, use pelvic drainage, or bladder neck reconstruction. We assessed
the incidence of ML among our patients and compared their outcomes,
specifically addressing whether bladder neck reconstruction (BNR) or use of a
drain was needed.
Methods: We reviewed 250 consecutive
robotic prostatectomies to identify patients with a median lobe and their
perioperative outcomes compared with those without ML.
Results: Forty patients had ML
(16%). Mean operative time was 171.7 minutes and 165.5 minutes, respectively
(P=0.36). Mean blood loss was 145mL (range, 50 to 500) in those with ML, which
was higher than the 116mL (range, 20 to 500) in those without (P=0.02). No
patients with ML required transfusion, while 1.4% of others did. Mean gland
size of 73.5g (range, 35.9 to 148.1) was larger in those with ML compared with
51.7g (range, 25.5 to 151.7) in those without (P<0.005). There was no
difference between those with and without ML in length of hospitalization (1.0
vs 1.0 days, P=0.56), catheterization time (5.08 vs 5.77 days, P=0.13),
anastomotic leak on cystogram (2.6% vs 1.5%, P=0.15), drain use (2.5% vs 1.4%,
P=0.42), or need for BNR (7.5% vs 3.3%, P=0.22).
Conclusion: Patients with ML had a
greater gland size and blood loss but no additional need for transfusion,
bladder neck reconstruction, or drain use and no additional catheterization
time or risk of leak. With proper handling, ML can be addressed without adverse
outcomes and without routine use of pelvic drainage or BNR.
9185 Urology
Results of Robotic Limited and Extended Pelvic Lymphadenectomy for Prostate
Cancer
Hugh J. Lavery, MD, Ronney Abaza, MD
Ohio State University Medical Center and James Cancer Hospital, Columbus, Ohio
Objectives: The
optimal extent of pelvic lymphadenectomy (PLND) for prostate cancer is unknown.
Some advocate selective lymphadenectomy; others advocate extended dissections
in all. Concerns have been raised regarding the quality of PLND with
robot-assisted laparoscopic prostatectomy (RALP). We reviewed our experience
with extended and limited PLND to determine nodal yield, complications, and
rate of node positivity.
Methods: We
reviewed 250 consecutive RALPs with PLND from February 2008 to January 2009 by
a single surgeon. “Low-risk” patients underwent limited PLND including external
iliac and obturator nodes. “High-risk” patients with PSA >10ng/dL, cT3
disease, Gleason ≥8, or biopsy ≥50% cancer had ePLND adding nodes medial to the
genitofemoral nerve including hypogastric and common iliac nodes up to the
ureter.
Results: Of
250 patients, 173 underwent limited PLND and 77 ePLND. Mean yield was 11 nodes,
with 8.6 and 16.5 nodes for limited and ePLND, respectively. Seventeen (7%)
node-positive (N+) patients were identified, 2 (1.1%) in the limited and 15
(19.4%) in the ePLND group. Of 183 organ-confined (OC) tumors, only 1 was N+
(0.5%) compared with 16 of 67 (24%) non-OC tumors. Complications of PLND
included 4 symptomatic lymphoceles, 1 ureteral injury requiring a temporary
stent, and 1 obturator nerve palsy for a PLND complication rate of 2.4%.
Conclusions: Pelvic
lymphadenectomy for prostate cancer can be safely and effectively performed
robotically with nodal yields and rate of positivity comparable to that of open
series. Given the low rate of nodal positivity in lower risk patients, the role
of limited PLND needs further evaluation.
9186 Urology
Clinical Pathway for Early Discharge After Robotic Cystectomy
Asha D. White, MD, Ronney Abaza, MD
Ohio State University Medical Center and James Cancer Hospital
Objective:
Typical reported lengths of stay for open or laparoscopic cystectomy are 7 days
to 8 days, with 5.1 days as the lowest reported mean for robotic cystectomy
(RC). We developed a clinical pathway for early discharge after RC and analyzed
our initial outcomes.
Methods: Twelve patients
underwent RC by a single surgeon. All were placed on a clinical pathway
developed at our institution with extraction incision of ≤3 inches, no ICU
stay, and no NG tube. For pain, a continuous catheter-infused local anesthetic
at the extraction site, oral analgesia, and intravenous ketorolac were used.
Patients were required to ambulate on postoperative day (POD) zero or one, with
clear liquids on POD#1 then regular food on POD#2 or #3 with discharge when
tolerating food.
Results: Mean
age was 64.1 years (range, 46 to 86), and mean operative time was 420.5
minutes. All ambulated on POD#1. Seven had a regular diet on POD#2, 3 on PO#3,
and 2 on POD#4. Four required any intravenous narcotics while 8 had none. Ten
were discharged on POD#3 and 2 on POD#4 for a mean of 3.1 days. One returned to
the emergency department on POD#6 for emesis resolving with promethazine. No
others visited the emergency department or clinic or were readmitted within the
first 7days after discharge.
Conclusion:
Our clinical pathway after RC allows shorter hospital stays than typical and
is, to our knowledge, the shortest hospitalization time reported after
cystectomy by any technique. Only one unplanned visit occurred during the first
10 days. Further experience will be necessary to confirm the initial
success.
9187 Urology
Comparison of Intraoperative Outcomes with New and Old Generation da Vinci
Robots for Robotic Prostatectomy
Ketul Shah, MD, Ronney Abaza, MD
Ohio State University Medical Center, Columbus, Ohio
Introduction: Surgical technology continues to evolve. As robotic
technology improves, the impact of new platforms on surgical procedures has not
been evaluated.
Methods: We reviewed 100 robotic
prostatectomy procedures and compared intraoperative outcomes for procedures
using the da Vinci S robot versus the previous generation “standard” robot.
Procedures where the S was specifically requested were excluded. Otherwise, procedures
were randomly performed on one robot or the other.
Results: Mean operative time for
robotic prostatectomy with lymphadenectomy was 191 minutes using the standard
robot (range, 132 to 266) versus 169 minutes with the S robot (range, 98 to
230), representing a mean difference of 22 minutes (P=0.002). This was despite
no difference in mean patient BMI of 30.6 (range, 19 to 51) for standard versus
29.3 (range, 21 to 37) for S (P=0.31), no difference in mean prostate size of
54.6g (range, 26 to 101) for standard versus 57.3g (range, 32 to 151) for S
(P=0.55), no difference in frequency of nerve-sparing, and no difference in the
portions performed by residents, which ranged from none to all of the
procedure. The standard was more often used for the surgeon’s first case of the
day than for the second, third, or fourth of the day (P=0.006). There was no
difference in blood loss (P=0.08), positive margins (P=0.87), or mean lymph
nodes removed (10.7 vs 10.6).
Conclusions: Both generations of da
Vinci robotic technology are equally effective, but the S appears to allow
shorter procedure times. This may be due to ease of docking or fewer
arm-position changes needed to adjust for shorter arm length and less range of
motion.
9188 Urology
Three-Port Robotic Urologic Surgery Without a Laparoscopic Bedside Assistant
Gregory Lowe, MD, Ronney Abaza, MD
Ohio State University Medical Center and James Cancer
Hospital
Objective: The role of robotics for upper tract urologic surgery has been
questioned in part due to the perceived need for additional bedside-assistant
ports beyond those for laparoscopy and for an experienced laparoscopist at the
bedside. We review our experience with 3-port robotic renal, adrenal, and upper
tract reconstructive surgery.
Methods: Between June 2008 and January 2009, 32 procedures were
performed through 3 ports, one for the robotic scope and 2 robotic instrument
ports. No assistant was needed beyond the scrub technician. Procedures included
4 simple nephrectomies, 14 pyeloplasties, 2 ureteral reimplantations, 1
ureteral reconstruction, 2 adrenalectomies, and 9 radical nephrectomies.
Results: Mean operative times from incision to dressing were 106 minutes
for simple nephrectomy, 159 minutes for pyeloplasty, 122 minutes for ureteral
reimplantation, 180 minutes for ureteral reconstruction, 70 minutes for
adrenalectomy, and 170 minutes for radical nephrectomy including
lymphadenectomy. During the same time period, 4 radical nephrectomies but no
other procedures required a 4-port approach, including for a 19-cm renal mass,
an enlarged liver, excessive intraabdominal fat, and one planned partial
nephrectomy. Four patients were discharged the day of surgery, and all others
the day after. Mean blood loss was difficult to measure because suction was not
routinely used.
Conclusions: Three-port robotic urologic surgery is feasible. The
ability to perform robotic upper-tract surgery without an assistant experienced
in laparoscopy is encouraging, particularly as a potential transition to
single-port or natural-orifice robotic surgery. Having developed intraoperative
strategies to minimize reliance on an assistant, most but not all procedures
can be performed without an assistant.
9189 Urology
Early Results of Robotic Lymphadenectomy for Renal Cell Carcinoma
Ronney Abaza, MD
Ohio State University Medical Center and James Cancer
Hospital
Introduction: Laparoscopic nephrectomy for renal cell carcinoma
has gained acceptance in the urologic community, but lymphadenectomy is not
uniformly performed during open or laparoscopic nephrectomy. With the advent of
targeted medical therapy for metastatic renal cell carcinoma, lymphadenectomy
for identification of micrometastatic disease may merit reconsideration. We sought
to determine whether lymphadenectomy can be performed at the time of
laparoscopic radical nephrectomy with the aid of robotic instrumentation and
present the first such cases of robotic retroperitoneal lymphadenectomy for
renal cell carcinoma.
Methods: Robotic
radical nephrectomy with lymphadenectomy was performed in 13 patients. For
right-sided tumors, the lymphadenectomy included paracaval, retrocaval, and
interaortocaval nodes, and left-sided tumors included interaortocaval and
paraaortic nodes.
Results: Mean
tumor size was 6.7cm (range, 2.2 to 19), with all revealing renal cell
carcinoma on pathology. Six were locally invasive with four T3a and two T3b
tumors. Mean operative time was 198 minutes (range, 120 to 350). A mean of 9.8
lymph nodes was obtained (range, 4 to 24), and all were negative for carcinoma.
Estimated blood loss was 65cc (range, 10 to 200). A total of 3 ports were used
in 9 of 13 cases. No patient required intravenous narcotics postoperatively,
and 11 of 13 patients were discharged on the first postoperative day with the
other 2 on the second day. One patient had a cautery injury to the bowel due to
a defect in the insulation on a robotic instrument, but there were no vascular
injuries or other complications of the lymphadenectomy.
Conclusion: Robotic
radical lymphadenectomy is feasible and safe, but the benefits are yet
uncertain.
9190 Urology
Initial Report of Robotic Radical Nephrectomy with Vena Caval Tumor
Thrombectomy
Ronney Abaza, MD
Ohio State
University Medical Center & James Cancer Hospital
Objective: Robotic surgery is increasingly being applied to
complex urologic conditions. The first report of robot-assisted laparoscopic
nephrectomy for renal cell carcinoma (RCC) with caval tumor thrombus is
presented.
Methods: A 70-year-old male was
found to have a 7.5-cm mass consistent with renal cell carcinoma with renal
vein involvement but equivocal for vena caval involvement. Thoracoscopy was
consistent with low-volume, isolated metastatic renal cell carcinoma.
Cytoreductive nephrectomy was recommended. Minimally invasive nephrectomy was
offered to potentially reduce recovery time and allow institution of
antineoplastic medical therapy.
Results: The procedure was performed
through 3 ports without a bedside assistant port. The inferior vena cava (IVC)
was dissected circumferentially at the level of the insertion of the right
renal vein. It became apparent by visual palpation of the IVC with the robotic
instruments that the tumor thrombus protruded at least midway into its lumen.
The IVC was clamped with a curved laparoscopic Satinsky clamp introduced
percutaneously and closed at a point approximately one-third of the way across
the lumen. The wall of the IVC was then incised and the tumor thrombus
delivered intact. The IVC was then closed with 2 layers of polypropylene suture
maintaining more than half of its lumen. Estimated blood loss was <50cc.
Total operative time from incision to dressing was 266 minutes. The patient was
discharged on the second postoperative day and has achieved stability of
disease with medical therapy now 4 months after surgery.
Conclusion: Robotic surgery was
safely applied for RCC with IVC tumor thrombus.
9191 Gynecology
To Assess the Clinical Efficacy of Integrating Sacral
Neuromodulator InterStim Implants in Gynecological Private Practice for
Treatment of Intractable Urinary Urgency
Radha Syed, MD
Staten Island University Hospital, Staten Island, New
York
Objective: To assess the clinical feasibility of integrating sacral
neuromodulation into a general gynecological practice for treatment of
intractable and severe urge incontinence.
Methods: Five consecutive patients
with refractory urinary urge incontinence whose ages ranged between 45 and 65
years old (mean age, 55) were selected from the private practice patient pool.
Patients had already undergone clinical investigation, urodynamic testing, and
urine culture. An evaluation by a urologist had been conducted. Patients were
unresponsive to pharmacologic and behavioral therapy and pelvic floor
reeducation. Minimally invasive screening test to assess the efficacy of
InterStim therapy was performed in the office. The successful lead test led to
the second stage, the implant procedure for the InterStim neurostimulator.
InterStim II INS (Model 3058) was permanently implanted with the patient under
anesthesia in an outpatient setting. Quantitative assessment was performed by
preoperative and postoperative 3-day bladder diaries.
Results: The cure rate was
associated with age–individuals younger than 55 years having a statistically
significant greater cure (65% vs. 35%) than the older individuals. Having a
chronic medical condition was associated with a lower cure rate as an
independent factor. Minor complications were associated with permanent
implantation including pain and infection at the site of implantation,
technical problems with lead migration, and need for repositioning.
Conclusion: Sacral nerve stimulation
is an effective therapy for decreasing the symptoms of urge incontinence that
can be easily integrated into gynecological private practice. Adequate
knowledge and training are necessary prior to undertaking this new modality.
9192 Urology
Comparing Diode Laser with KTP Laser
Manuel Ferreira Coelho, MD, Pedro Bargão Santos, MD
Hospital dos Lusíadas, Clínica São João de Deus, Lisboa, Portugal
Objective: The wavelength 980nm of a
recently introduced diode laser system for treatment of benign prostatic
enlargement and the potassium-titanyl-phosphate (KTP) laser offer a high
simultaneous absorption in water and hemoglobin and are postulated to combine
high tissue ablative properties with good hemostasis.
Methods: The Ceralas HPD150 diode
laser system was evaluated in 20 patients, and the KTP laser was evaluated in
another 20 patients. The aim of the study was to evaluate tissue ablation
capacity and hemostatic properties at different generator settings. A
histological examination of the ablated tissue followed. The results were compared
with the reference standards transurethral resection of the prostate (TURP).
Results: The diode laser displays a
higher tissue ablation capacity, reaching 7.25±1.50g after 10 minutes, compared
with the KTP laser (3.90±0.46g; P<0.05). The corresponding depths of the
coagulation zones are 295.1±47.0µm for the diode laser, 650.9±65.0µm for the
KTP laser (P<0.05), and 289.1±28.5µm for TURP.
Conclusion: The 980-nm diode laser
offers a higher tissue ablation capacity and similar hemostasis compared with
the KTP laser. In comparison with TURP, both tissue ablation and bleeding are
significantly reduced.
9193 General Surgery
Necessity for Improvement in Endoscopy Training During Surgical Residency
Aditya Gupta, MD, Gokulakkrishna Subhas, MD, Vijay K. Mittal, MD
Providence Hospital and Medical Centers,
Southfield, Michigan
Background:
ACGME has increased requirements to ensure that surgical residents obtain
adequate endoscopy skills. A survey questionnaire was sent to surgical program
directors to look at residents’ endoscopic training.
Methods: A
10-question survey was sent to all program directors in surgery. Endoscopic
training patterns, facilities, their views, and performance of residents were
examined. The national averages for the last 3 years for endoscopic procedures
were collected.
Results: Seventy-one
directors (30%) responded to the questionnaire. Of these, 42% (n=30) had a
program size of 3 to 4 residents. Ten percent (n=7) of programs could not
fulfill the minimum ACGME requirements. Only 55% (n=39) of programs had a
dedicated rotation in endoscopy, which ranged from 0.5 months to 3 months. Most
program directors (82%, n=58) thought that their residents’ exposure to
endoscopy was sufficient. Only 55% (n=39) had an endoscopic skills training
laboratory in their program. The average numbers of staff surgeons in programs
performing endoscopy were 5 for colonoscopy, 6 for gastroscopy, and only 0.2
for ERCP. Few programs had their residents performing more than 100 cases of
gastroscopy (18%) and colonoscopy (21%). According to program directors, the
average number of cases needed to achieve competency for colonoscopy (n=60),
gastroscopy (n=41), and ERCP (n=56) were more than the national averages for
the last 3 years (33, 25, and 0.3, respectively).
Conclusion: Future
endoscopy training for surgical residents needs to increase opportunities so
that they are able to perform endoscopy with confidence. This would include
provision of endoscopic skills laboratory, dedicated endoscopic postings, and
hiring staff surgeons who perform endoscopic procedures.
9194 Gynecology
Laparoscopy: Gold Standard for Ovarian Tissue Banking (OTB) in Cancer Patients
Kazem Nouri
Medical University
of Vienna
Objective: To analyze and give a
summary of our experience with laparoscopic ovarian tissue banking for ovarian
cryopreservation as a means of fertility preservation in cancer patients,
comparing this method with more conservative methods like injection of Gn-RH
analogue and antagonists or IVF with subsequent oocyte or embryo
cryopreservation.
Methods: This was a retrospective
cohort study performed at the Medical School of Vienna, Department of
Gynaecology, Endocrinology and Reproductive Medicine. The study cohort
comprised 87 patients with the wish of fertility preservation through ovarian
tissue banking (OTB). Laparoscopic surgery was performed to take out one-third
of one ovary for ovarian cryopreservation and banking.
Results: The operating time, major
and minor complications, histological and microbiological results were
analyzed. Eighty-five patients underwent cryopreservation of ovarian tissue,
mostly for malignant diseases (78/85, 91.8%). The median operating time was 30
minutes (range, 10 to 75). The intraoperative course was uneventful in these
patients. Histological examination revealed intact ovarian tissue with
primordial follicles in 81/85 patients (95.3%).
Conclusion: The increasing life
expectancy after chemo and ionization therapy brings about new aspects into the
life of cancer patients. One of the new issues and challenges in this group of
patients is to maintain fertility despite the cancer therapy. One of the most
promising new therapy options is OTB. Laparoscopy is the method of choice for
ovarian tissue harvesting. After chemo or ionization therapy, the
reimplantation of the cryopreserved ovary would also be performed by
laparoscopy. To date, worldwide 5 live births have resulted from this method of
fertility preservation.
9196 Gynecology
The Role of Minimally Invasive Surgery for Diagnosis and Treatment of Uterine
Myoma Before IVF/ICSI Cycle
Kazem Nouri
Medical
University of Vienna
Objective: To give a summary of current indications for operative therapy
of myoma before starting IVF, and to give an overview of the role of minimally
invasive surgery in both diagnosis and treatment of myoma in assisted
reproductive technology.
Methods: We performed a review of
the current available literature on the relationship between fibroids and
IVF/ICSI therapy with particular emphasis on the benefits of myomectomy
performed by minimally invasive methods and present our data and experience in
the reproductive surgery unit of the Medical School of Vienna. Approximately
20% to 40% of women of reproductive age are known to have uterine myomas. It
has been estimated that only 5% to 10% of infertile women have fibroids, and
when all other causes of infertility are excluded, myomas alone may be
responsible for only 2% to 3% of infertility cases.
Results: Five to 10% of IVF patients
have uterine myomas. Only in special cases is it necessary to intervene
surgically. The proper diagnosis is to be done by hysteroscopy. The gold
standard of therapy is the laparoscopic myomectomy.
Conclusion: Only in rare cases are
myomas of the uteri the only presenting cause of infertility. Five to 10% of
the patients for whom an IVF/ICSI cycle is indicated have fibroids. Whether
these fibroids reduce the chances of pregnancy is dependent on many factors
like their location and volume. Minimally invasive surgery measures like
hysteroscopy and laparoscopy are the most important tools in both diagnosis and
treatment of myomas in IVF/ICSI patients.
9197 General Surgery
Combined Open-Laparoscopic Technique for Difficult Incisional Hernias
K. Theodoropoulou, MBBS, A. Syed,
MBBS, J. Hill, MBBS, H. Bradpiece, FRCS
Princess Alexandra Hospital,
Essex, United Kingdom
Objective: Despite the fact that
laparoscopic incisional hernia repair is very popular among general surgeons,
there is always a small percentage of patients in whom the laparoscopic
approach is not feasible and conversion to an open technique is required. The
purpose of this study was to describe the combined approach and to demonstrate
that it is effective, realistic, and safe.
Methods: Three patients with incisional hernias were
examined. All 3 patients had incarcerated or irreducible bowel in the hernia
sac that could not be reduced safely, and conversion to an open technique was
essential. Each of these cases was commenced with a combined laparoscopic
approach. We always started the hernia
repair laparoscopically and converted to open only when further dissection and
adhesiolysis were not feasible. A smaller incision than usual was performed
followed by safe dissection and reduction of hernia sac content. Composite
polypropylene and ePTFE mesh was placed intraperitoneally and fixed in 4 sites
with staples. The abdominal wall was closed, and the fixation of the mesh was
completed laparoscopically.
Results: All 3 patients underwent successful repair
without any intraoperative complications. Two had uneventful postoperative
recovery. One patient developed superficial wound abscess that required
drainage but not removal of the mesh, as the aponeurosis was intact. No
recurrence has been recorded (follow-up, 2 to 7 months)
Conclusion: The combined approach can offer all the
advantages of an open approach and preserve most of the advantages of the
laparoscopic technique. We advocate it as an alternative to the open technique
when conversion to open is essential for patient’s safety.
9198 General Surgery
Laparoscopic Treatment of Peptic Ulcer Disease
F. Obregon, MD, M.
Vasallo, MD, H. Malave, MD, S. Navarrete, A MD
Hospital Universitario de Caracas, Caracas, Venezuela
Objective: Since the
development of proton pump inhibitors as a treatment for peptic ulcer disease,
its complications and recurrence have decreased. However, for some rare cases
of recurrence or complications such as stenosis, the role of laparoscopic
surgery has been established. We present the results of our experience with
these procedures.
Methods:
From October 2004 to December 2008, we performed 6 laparoscopic procedures for
peptic ulcer disease. Patients were 2 males and 6 females with a mean age of
51.16 years (range, 38 to 68). All patients were studied with upper digestive
endoscopy and biopsy and signed an informed consent. Preoperative diagnoses
were 3 duodenal stenoses and 3 ulcer recurrences on gastrojejunal anastomosis,
one of them with atypias. We performed 2 distal gastrectomies with Billroth II
reconstructions, 1 hemigastrectomy with posterior truncal vagotomy and anterior
selective vagotomy Billroth II type with Brown’s anastomosis, and 3
regastrectomies with resection of previous gastrojejunal anastomosis and Roux
en Y reconstruction. All the procedures were performed totally laparoscopically
using lineal endostaplers and intracorporeal suture.
Results:
The mean operative time was 145.83 minutes (range, 110 to 210). Blood loss was as high as 100cc on average.
Postoperative oral intake in all patients was on the third day, and length of
postoperative stay was 5 days on average (range, 4 to 6). We had no
conversions. No morbidity or mortality related to these procedures has
occurred. Final results of all biopsies were benign, and at 3-month follow-up,
upper digestive endoscopy was perform without pathological findings.
Conclusion: Laparoscopic
surgery for peptic ulcer disease and its complications is a feasible and safe
procedure.
9199 General Surgery
A Novel Technique for Endoscopic Repair of Symptomatic Diastasis Recti With or
Without Simultaneous Ventral Hernia
Richard P. Franklin, MD, Robert S.
Baxt, MD
Northwest Hospital
Objectives: To be able to repair symptomatic diastasis recti laparoscopically.
The repair of a diastasis should address multiple issues: restoring normal
anatomy by reapproximation of the muscles to midline, improving abdominal wall
mechanics, resolution of the abdominal wall bulge, and low risk of recurrence.
Methods: We repaired 5 patients (3
men, 2 women) with symptomatic diastasis, 4 of which had concomitant ventral
hernias either adjacent to or just inferior to the diastasis.
This study was performed at a single center community hospital, and is a
2-surgeon series of repairs. Patients were repaired laparoscopically with an
intraabdominal mesh (CQUR Edge - Atrium) and transabdominal sutures that
allowed reapproximation of the rectus abdominus muscles in the midline, with
recreation of the linea alba, and transfascial fixation of the mesh to the
abdominal wall. In addition, the mesh covered of all defects in the standard
fashion for laparoscopic ventral hernia repair with an overlap of at least 5cm
using standard tacks Absorbatac (Covidian) or Protac (Autosuture) for lateral fixation
of the mesh to the abdominal wall.
Results: All 5 repairs
(follow-up 2 to 12 months) have excellent results without recurrence of
symptoms or abdominal wall bulge. No clinical recurrences of hernia or
diastasis bulge are apparent, and all patients are back to their normal
occupations.
Conclusion: Laparoscopic repair
of symptomatic diastasis recti is a feasible repair leading to loss of
abdominal bulge, resolution of pain, better abdominal wall mechanics, and good
cosmetic outcomes.
9200 General Surgery
Laparoscopic Repair of Bilateral Spigelian Hernias (TAPP)
Usman Jaffer, BSc (Hons), MB BS,
MSc, MSc (Ultrasound), MRCS(Eng), FHEA, DIC, Periyathambi Jambulingam, FRCS
The Luton and Dunstable NHS Trust,
Luton, United Kingdom.
Objectives:
To demonstrate a technique of
laparoscopic repair of bilateral Spigelian hernia.
Methods:
A 3-port technique was used. The
transabdominal preperitoneal approach (TAPP) was used. A right-sided direct
inguinal hernia was also encountered. This was also repaired using the same
peritoneal incision by deepening the preperitoneal plane appropriately. Two
pieces of Prolene mesh were placed in the preperitoneal space and secured with
metal tacks. The peritoneum was also closed similarly.
Results:
A sound repair was achieved. The
patient was discharged home the next day.
Conclusion:
The laparoscopic TAPP approach can
be performed safely and effectively for bilateral Spigelian hernias.
9201 Gynecology
A Multicenter Series of Over 1000 Laparoscopic Subtotal Hysterectomies in the
UK and Greece: The New Approach to Hysterectomy
Stefanos Chandakas, MD, MBA, PhD
Background: Minimally invasive surgery has influenced the techniques used
in gynecology, with an overall minimization of complications and increased
patient satisfaction. We sought to demonstrate the safety and feasibility of
laparoscopic subtotal hysterectomies in an outpatient setting.
Methods: This was a retrospective,
descriptive, nonrandomized study performed at Princess Royal University
Hospital, London, United Kingdom and Iaso Hospital, Athens Greece. For the
patients who underwent a laparoscopic subtotal hysterectomy in the last 60
months, data were collected from medical records on how the intervention was
performed, followed for 18 months. Two surgeons performed 1008 subtotal
hysterectomies. Indications included 21.6% for endometriosis, 68.2% for
menorrhagia, and 11.2% for endometrial pathology.
Results: Duration of surgery and
hospital stay, safety (morbidity and mortality), and patient satisfaction were
assessed. Estimated blood loss was 75mL (range, 20 to 2300). Intraoperative
complications were as follows: 0.4% had significant complications; 0% vascular
injuries and 0% nerve or ureter injuries; 2.2% had cyclic bleeding. Early
postoperative morbidity included 0.2% deep vein thrombosis, 0% pulmonary
embolism, 1.1% bladder infection and dysfunction. The overall complication rate
was 1.8%. Three patients required drainage for intraabdominal abscess.
Regarding hospital stay of these 1008 patients, 91% were discharged home the
same day with an average length of stay of 9 hours.
Conclusion: Laparoscopic subtotal
hysterectomy can be safely performed as an outpatient procedure.
9202 Gynecology
Single-Port Laparoscopy in Gynecology: What Can We Perform?
A Series of 35 Cases
Stefanos Chandakas, MD, MBA, PhD
Background: Minimally invasive surgery has influenced the techniques used
in gynecology, with an overall minimization of complications and increased
patient satisfaction. We sought 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. It included 35 patients who underwent SPL
surgery between October 2008 and February 2009. Indications included 55%
salpingo-oophorectomy, 26% diagnostic laparoscopy and treatment of stage 1/2
endometriosis, 19% cystectomy.
Results: Duration of surgery and
hospital stay, safety (morbidity and mortality), and patient satisfaction were
assessed. Estimated blood loss was 35mL (range, 10 to 230). Intraoperative
complications were as follows: 0% vascular injuries and 0% nerve or ureter
injuries. Early postoperative morbidity included no major complications, 0.1%
bladder infection and dysfunction, and 0.3% incision infection. All patients
were discharged home the same day with an average length of stay for these
patients of 8 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 are
similar, whereas the cosmetic result and the postoperative pain levels seem to
be better accepted by the female patient. Further studies need to be performed,
and new instrumentation is necessary to perform more complicated cases.
9203 Urology
Robotic-Assisted Laparoscopic Radical Cystectomy: The City of Hope Experience
Ciamack Kamdar, MD, Rebecca A. Nelson, PhD, David Y. Josephson,
MD, Kevin G. Chan, MD, Clayton S. Lau, MD, Jason T. Jankowski, MD, Laura E.
Crocitto, MD, Josh Carleton, Timothy G. Wilson, MD
City of Hope,
Duarte, California
Objectives: We present a large series of robotic-assisted
laparoscopic radical cystectomies (RARC) and urinary diversions and evaluate
outcomes, morbidity, and mortality.
Methods: All patients who underwent RARC between October
2003 and April of 2008 were prospectively assessed. Of 101 cases performed, 76
patients with primary urothelial carcinoma of the bladder consented to be
enrolled in our IRB-approved bladder cancer database and were evaluated.
Clinical and pathologic outcomes were evaluated.
Results: The 76 patients had a
mean age of 71.6 years and an average ASA of 2.92. Mean operative time was 7.7
hours. Median blood loss was 400mL. Urinary diversions consisted of 34 Studer
pouches, 22 Indiana pouches, and 20 ileal conduits. The mean number of lymph
nodes examined on lymphadenectomy was 24.7. There were 3 positive margins and
no port-site metastasis. All diversions were done extracorporeally. There was
one intraoperative complication consisting of a rectal injury. Mean time to
clear liquid diet was 7.1 days. Median length of hospital stay was 10 days.
Overall, 69.7% of patients experienced a complication within 90 days of
surgery. Minor and major complications occurred in 49 and 4 patients,
respectively. There were 2 perioperative mortalities. Median follow-up was 11
months overall and 17 months for patients alive at last contact (n=47). At 2
years, overall survival was 54%, disease-free survival was 74%, and
disease-specific survival was 84%.
Conclusions: RARC performed by
experienced robotic surgeons can be accomplished with acceptable outcomes compared
with open radical cystectomy.
9204 Urology
Robotic-Assisted Laparoscopic Radical Cystectomy in the Octogenarian
Ciamack Kamdar, MD, Rebecca A. Nelson, PhD, David Y. Josephson,
MD, Clayton S. Lau, MD, Kevin G. Chan, MD, Jason T. Jankowski, MD, Laura E.
Crocitto, MD, Josh Carleton, Timothy G. Wilson, MD
City of Hope,
Duarte, California
Objectives: To evaluate the feasibility, outcomes,
morbidity, and mortality associated with robotic-assisted laparoscopic radical
cystectomy (RARC) and urinary diversion in the octogenarian with carcinoma of
the bladder.
Methods: We reviewed all the records of patients who
underwent RARC from October 2003 through April 2008. Of 101 RARC, 18
(17.8%) patients were identified as 80 years or older with primary urothelial
cancer of the bladder. Operative and outcome data were evaluated.
Results: Eighteen
patients had a median age of 84 years and an average ASA of 2.9. Mean operative
time was 6.7 hours. Median blood loss was 400mL. Twelve patients had an ileal
conduit urinary diversion (66.7%), 3 had an Indiana pouch (16.7%), and 3 had a
Studer pouch (16.7%). The mean number of lymph nodes examined on
lymphadenectomy was 25.4 (range, 2 to 49). Median number of days to a clear
liquid diet was 6.0, and median number of days to a regular diet was 8.0.
Median length of hospital stay was 12 days. Minor complications occurred in 14
patients during the first 90 days of surgery. One major complication occurred,
consisting of sepsis, which led to a perioperative mortality during the first
90 days. Overall survival at 24.6 months was 53.0%. Disease-specific survival at
24.6 months was 88.9% and disease-free survival at 27.4 months was 53.3%.
Conclusions: Robotic-assisted
laparoscopic radical cystectomy in the octogenarian is a feasible option and
can be accomplished with acceptable morbidity and mortality when performed by
experienced surgeons.
9205 General Surgery
The Role of Laparoscopy in Emergency General Surgery and its Effect on
Trainees’ Experience in a UK District General Hospital
Senthil
Nachimuthu, Szabolcs Gergely
Hinchingbrooke Hospital,
Huntingdon, United Kingdom
Objectives:
The role of laparoscopic surgery in the
emergency setting varies because of different preferences, availability of
equipment, and expertise. We analyzed our activity in the last 2 years to
assess the scope of emergency laparoscopic surgery and training opportunities.
Methods:
Data from medical records of patients
undergoing emergency laparoscopic general surgery between January 2007 and
December 2008 were analyzed retrospectively in terms of numbers and types of
procedures performed, conversion rates, training opportunities, and laparoscopy
related morbidity.
Results:
The
total number of cases performed was 469, which included laparoscopic
appendicectomy(LA), 199(42.4%); emergency laparoscopic cholecystectomy(LC), 163(34.8%);
laparoscopic common bile duct exploration(LCBDE), 10(2.1%); esophagogastric
procedures, 4(0.9%); small bowel and colorectal procedures, 18(3.8%);
adhesiolysis, 9(1.9%); intraabdominal abscess drainage, 14(3%); and
incarcerated abdominal wall hernia repair, 10(2%). Trainees performed 51% of
the total cases and 73.9% of LA and 38% of LC cases compared with consultants.
The overall conversion rate was 6.4%. Conversion rate for LA was 6.5% and LC
was 0.6%. Only 4 cases required relaparoscopy for further management of bile
leak and intraabdominal abscess following LC and LCBDE. No bile duct injuries
occurred. No laparoscopy related intraoperative complication was encountered.
Conclusion:
Emergency
laparoscopic general surgery is safe and feasible in a district general
hospital setting. The increasing use of laparoscopy for the management of
common acute general surgical emergencies including emergency laparoscopic
cholecystectomy for acute cholecystitis and laparoscopic appendicectomy
enhances trainees’ experience and exposure to laparoscopic cases.
9206 General Surgery
Laparoscopic Right Hemicolectomy for Cecal Duplication Cyst in an Adult: A Case
Report
A. J. Hanna, MD, G. Y. Apostolides, MD
Greater Baltimore Medical Center
Background: Duplication cysts
of the gastrointestinal tract can be found from the esophagus to the rectum and
usually present in infancy or childhood with various symptoms depending on the
location. Symptomatic colonic duplication in adulthood is rare and preoperative
diagnosis can be challenging. In addition, malignancies have been reported
within duplication cysts in adults. We report the case of an adult male who
underwent laparoscopic exploration and oncologic resection for a cecal
duplication cyst. The literature is reviewed, and diagnostic challenges and
treatment options are discussed.
Methods: A 44-year-old
otherwise healthy male presented with persistent right-sided abdominal pain, a
1-month history of diarrhea, and unintentional weight loss. The patient
underwent evaluation including physical examination, stool studies,
colonoscopy, and imaging. He was counseled and treated, based on the results of
his evaluation, with laparoscopic exploration and right hemicolectomy.
Results: Physical examination
and stool studies were unremarkable. Colonoscopy revealed a 3-cm to 4-cm
submucosal mass at the ileocecal junction with biopsies negative for
malignancy. Thickening of the wall of the cecum and ascending colon was seen on
CT scan. The patient underwent an uncomplicated laparoscopic right
hemicolectomy followed by an uneventful recovery. Pathologic review of the
specimen was consistent with a benign duplication cyst at the ileocecal valve.
Conclusion: Colonic
duplication cyst, although rare in adults, should remain in the differential
diagnosis of a submucosal mass, and laparoscopic resection should be offered to
symptomatic patients.
9207 General Surgery
Transumbilical Laparoscopic-Assisted Noninsufflated Appendectomy (TULANIA)
Sung
Woo Jung, MD, Hyoun Jong Moon, MD, Jong Hoon Lee, MD, Jong In Lee, MD
Myongji Hospital, Kwandong University College of Medicine, Goyang,
Korea
Objective: Generally,
laparoscopic appendectomy is performed using 3 ports. To reduce abdominal wall
trauma, we tried transumbilical laparoscopic-assisted noninsufflated
appendectomy (TULANIA) with a single incision.
Methods: A total
of 13 patients diagnosed with uncomplicated acute appendicitis underwent
TULANIA at our hospital between January 2009 and February 2009. To perform TULANIA,
we make a 2-cm single vertical midline incision through the umbilicus and
establish peritoneum without using a trocar. Instead of CO2 gas
insufflation, the assistant retracts the abdominal wall using a Hösel retractor
to make an operative field. A 5-mm, 0° rigid scope is introduced, and once
located, the appendix is grasped and extracted via the umbilicus. The appendix
is ligated at its base by using black silk 2/0 and excised extracorporeally.
Results: The mean
patient age was 28.1 years (range, 16 to 45); 7 were male and 6 were female;
and median BMI was 22.4 (range, 18.9 to 28.4). Mean operating time was 44
minutes (range, 30 to 80). Two were conversions to conventional laparoscopic
appendectomy due to intraabdominal adhesions. The distribution according to
appendix was as follows: preileal paracecal type, 6; postileal medial paracecal
type, 3; retrocecal type, 2; subcecal type, 1; lower pelvic type, 1. The mean
postoperative stay was 3.2 days (range, 2 to 7). No postoperative complications
were noted.
Conclusions: Using a
single transumbilical incision reduces postoperative pain and also gives better
cosmetic results. By using nondisposable laparoscopic instruments, the
procedure is less expensive. In our experience, the TULANIA technique is easy and
safe compared with conventional laparoscopic appendectomy and is another option
for scarless appendectomy.
9208 General Surgery
149 LCBDE Cases Evaluating the Use of the Multi-Channel Instrument Guide in the
Community Hospital Setting
Donald E. Wenner, MD1, Paul R. Whitwam, MD1, James C. Rosser, Jr.
MD2
1Roswell Regional Hospital, Eastern New Mexico Medical Center
2Morehouse School of Medicine
Objective: To develop LCBDE
procedural methodology applicable to virtually all cases of choledocholithiasis
that is safe and efficient and adaptable to a community hospital setting.
Methods: LCBDE technique using the
2.8-mm flexible choledochoscope and multi-channel instrument guide (MIG) was
developed and tested in 149 cases of choledocholithiasis that presented to our
surgical team. Cases were performed using either transcystic duct or
choledochotomy techniques. Factors favoring transcystic duct or choledochotomy
approaches were analyzed. Operative time, stone clearance rate, and incidence
of postoperative pancreatitis were analyzed.
Results: Overall successful bile
duct stone clearance was achieved in 96% of cases. The mean operative time for
transcystic duct LCBDE cases was 98 minutes; choledochotomy cases took a mean
of 148 minutes. Transcystic duct LCBDE was achieved in over 70% of cases. All
patients with CBD stones >1cm required choledochotomy LCBDE procedures.
Significant clinical pancreatitis did not develop as a result of the LCBDE
procedure in any patient.
Conclusion: Virtually all cases of
choledocholithiasis can be resolved in the community hospital setting by using
the 2.8-mm flexible choledochoscope and the MIG. Procedures can be completed in
an efficient time frame with a high rate of success. Postoperative pancreatitis
has not been a significant problem. Stone size over 8mm favors a choledochotomy
approach, with most cases with smaller stones being resolved via a transcystic
duct approach.
9209 General Surgery
Transumbilical Single-Incision Laparoscopic Adjustable Gastric Banding: Making
Patients Smaller Through Smaller Incisions
M. Ostrowitz, L. Gellman, D.
Gadaleta
North Shore University Hospital, Manhasset, New York
Background: Single-port laparoscopic
surgery (SPLS), where multiple ports are placed through one incision, usually
at the umbilicus, is seeing increased application in a number of different
urological and general surgical procedures. In addition to the possibility of
decreased postoperative pain, SPLS offers better cosmesis, with virtually
“scarless” surgeries, while avoiding the increased costs, manpower, and
complexity of natural orifice surgery. We present our technique for placement
of a Lap-Band through the smallest and what we feel is the most cosmetically
appealing incision possible.
Methods: A 15-mm VersaStepTm trocar
is placed through a curvilinear 3-cm supraumbilical incision. After inspecting
the abdomen to assess feasibility, the Lap- BandTm is placed through the port,
which is then removed leaving only a 7-mm defect. One of three 5-mm trocars,
placed in an inverted V formation, goes through the defect. Liver retraction
may be provided by either inserting an epigastric or fourth umbilical port, or
intracorporeally. Using one articulating instrument, one straight instrument,
and a “Flex-tip” laparoscope, the procedure follows the established steps of
band placement.
Results: The procedure is
successfully completed in 75 minutes with minimal blood loss and no
complications.
Conclusions: While ultimately
requiring randomized clinical trials for confirmation, limiting the surgical
incision to only that which is required for insertion of the Lap-Band and
creation of the reservoir pocket is safe, technically feasible, and appears to
improve cosmesis, patient satisfaction, and may decrease postoperative pain.
9210 General Surgery
Types of Reconstruction and Functional Outcomes from Laparoscopic Distal
Gastrectomy for Gastric Cancer
George Bouras, MRCS, Eiji Nomura,
MD, PhD, Sang-Woong Lee, MD, PhD, Soichiro Tsunemi, MD, Nobuhiko Tanigawa,
MD, PhD
Osaka Medical College,
Takatsuki, Japan
Objectives: To compare functional
outcomes from laparoscopic distal gastrectomy (LDG) between various types of
reconstruction including Billroth-I through mini-laparotomy (BIML), totally
intracorporal Billroth-I (BIIC), and intracorporal Roux-en-Y (RYIC).
Methods:
Following our initial experience
with BIML, we now also perform BIIC and RYIC, depending on the size of remnant
stomach. Body weight (BW), food intake (FI), and abdominal symptoms (AS) were
measured at 1 year after surgery in 4 subgroups of patients categorized by type
of reconstruction and size of remnant stomach.
Results:
Overall, anastomotic leak rates
for patients undergoing BIML (n=60), BIIC (n=50), and RYIC (n=66) were 6.3%,
0%, and 1.5%, respectively, while anastomotic stenosis occurred in 3.1%, 2%,
and 0%. Subgroup analysis revealed that patients undergoing BIML with 1/2
remnant stomach (1/2BIML, n=17), BIML with 1/3 remnant stomach (1/3BIML, n=16),
BIIC with 1/2 remnant stomach (1/2BIIC, n=37), and RYIC with 1/3 remnant
stomach (1/3RYIC, n=40) had postoperative BW of 93.4%, 89.6%, 93.1%, and 87.8%;
FI of 80.0%, 65.6%, 73.0%, and 68.4%; and no AS in 68.8%, 31.3%, 83.3%, and
51.1%, respectively. Overall, BW, FI, and lack of postoperative symptoms in
patients undergoing 1/2BIML and 1/2BIIC were greater than in patients
undergoing 1/3BIML and 1/3RYIC.
Conclusions:
Billroth-I reconstruction seems
appropriate when the remnant stomach is large, while Roux-en-Y should be
reserved for small remnant stomachs. Intracorporal reconstruction was
associated with no disadvantages while offering advantages including safety by
improved visualization during anastomosis and better cosmetic result.
9211 General Surgery
Totally Laparoscopic Reconstruction During Laparoscopic Pylorus-Preserving and
Segmental Gastrectomy for Gastric Cancer
George Bouras, MRCS, Takaya Tokuhara,
MD, PhD, Eiji Nomura, MD, PhD, Toshikatsu Nitta, MD, Nobuhiko Tanigawa, MD, PhD
Osaka Medical College, Japan
Objective:
To assess the safety and
feasibility of totally laparoscopic reconstruction during pylorus-preserving
gastrectomy (PPG) and segmental gastrectomy (SG) for gastric cancer.
Methods: PPG and SG are indicated for early gastric
cancers of the body of the stomach with enough prepyloric and proximal stomach
left following resection allowing for safe functional gastro-gastric
anastomosis. Results from our initial experience with hand-sewn reconstruction
through a mini-laparotomy (RML) are compared with totally laparoscopic
reconstruction (TLR) performed by functional end-to-end anastomosis during the
last year.
Results:
Of 496 minimally invasive nontotal
gastric resections performed, 169 (34%) patients underwent PPG or SG. Twenty
patients underwent TLR. There were no significant differences in demographic
data between patients undergoing RML and TLR. Mean follow-up for patients in
the TLR group was 6.4 months. Anastomotic leakage occurred in 1/149 patient
(0.7%) for RML and 1/20 patient (5.3%) for TLR. Stasis was only encountered for
RML in 10/149 patients (6.7%). There were no major disadvantages for TLG
compared with RML during the study period.
Conclusions:
In our experience, TLG is safe and
feasible. Observed advantages of TLG over RML include safety by improved
visualization during intracorporal anastomosis and better cosmetic result. The
association between type of anastomosis (hand-sewn RML or mechanical TLR) and
postoperative stasis needs to be explored further.
9212 Gynecology
A Case of Bilateral Tubal Pregnancy After Puerperal Tubal Ligation
Takashi Yamada, MD
Introduction: Ectopic pregnancy is relatively rare after tubal ligation. An
extremely rare case of bilateral tubal pregnancy occurred at different times after
tubal ligation.
Case Report: A 39-year-old, gravid
4, para 4 woman had a 2-month history of abdominal pain. She had undergone
puerperal tubal ligation by the Madlener technique after the delivery of her
fourth child 61 months earlier. Echography showed a cystic tumor 61mm x 50mm on
the right side of the uterus. Because her menstruation was regular and urinary
pregnancy test was negative, laparoscopic surgery was performed due to
suspicion of an ovarian cyst or hydrosalpinx. Laparoscopic adhesiolysis and
right salpingectomy were performed. Macroscopically, hematosalpinx was evident
in the right salpinx, but histologic examination showed chorion in the salpinx,
leading to the diagnosis of an old ectopic pregnancy at the tubal ampulla.
Nineteen months after the first ectopic pregnancy, the woman complained of
lower abdominal pain. Urinary pregnancy test was positive and echography
revealed a cystic tumor and echo-free space in the Douglas pouch. Laparoscopic
left salpingo-oophorectomy was performed. Histologic diagnosis was left tubal
pregnancy and left ovarian hemorrhagic corpus luteum.
Conclusion: We recommend prophylactic
repeat tubal sterilization or
salpingectomy of the contralateral tube if ectopic pregnancy is recognized
after tubal ligation.
9213 General Surgery
Routine Upper Endoscopy Before Bariatric Surgery. Would It Influence the
Surgical Plan?
Ehab Akkary, MD, Jennifer Lynn
Koay, MS, Carlos Jaramillo, MD, Oriana Brusatin, MD, Linda Vona-Davis, PhD, M.
Gazayerli, MD
West Virginia University, Morgantown, West Virginia and Wayne State University,
Detroit, Michigan
Background and Objective: The role
of preoperative esophagogastroduodenoscopy (P-EGD) in bariatric surgery remains
undefined. Published studies are controversial. We suggest that pathologic and
anatomic findings might influence the surgical plan.
Materials and Methods: Between July
and December 2008, 67 patients underwent laparoscopic bariatric surgery at West
Virginia University. Revisions were excluded (n=6). Sixty-one were enrolled in
3 groups: Adjustable Gastric Band (LAGB) (n=33, 2M31F), Roux-Y Gastric Bypass
(LRYGBP) (n=22, 4M18F) and Sleeve Gastrectomy (LSG) (n=6, 2M4F). Patients
underwent P-EGD and antral biopsy. Analysis was performed using ANOVA.
Results: The LSG group was older
(52±8.9y) than the LAGB and LRYGBP groups (43±11.2 and 43.5±7.8y) with higher
weight (347.6±111.3 compared with 266.1±53.7 and 307.8±55.8lb) and BMI
(55.2±12.7 compared with 44.3±8 and 49.4±6.5kg/m2) respectively
(P<0.05). In the 3 groups, P-EGD led to plan change in 6 (18.2%), 8 (36.4%)
and 2 (33.3%) patients. (1) LAGB: 1 (3%) was diagnosed with large, entirely
intrathoracic, paraesophageal hiatal hernia (HH). The procedure was changed
from LRYGBP to LAGB to avoid prolonged anesthesia time. All 6 required HH
repair prior to band placement. (2) LRYGBP: 1 (4.5%) acquired Helicobacter
pylori. Surgery was delayed for treatment. Seven (31.8%) required HH repair
prior to creating the gastric pouch. (3) LSG: Intestinal metaplasia and villous
adenoma diagnosis changed the procedure from LRYGBP to LSG, which is superior
to LAGB and LRYGBP to facilitate periodic endoscopic follow-up and decrease the
gastric mucosal surface area.
Conclusions: P-EGD is of utmost
importance in the decision making in bariatric surgery. LSG should be
considered in patients with gastric mucosal abnormalities that require frequent
surveillance.
9214 General Surgery
The Calibrated Laparoscopic Heller’s Myotomy with Fundoplication in the
Surgical Treatment of Esophageal Achalasia
Natale Di Martino, Prof, Antonio
Brillantino, MD, Luigi Marano, MD, Francesco Torelli, MD, Michele Schettino,
MD, Raffaele Porfidia, MD, GianMarco Reda, MD
Second University of Naples, Italy
Background: Esophageal achalasia is
the most common primary esophageal motor disorder. Laparoscopic Heller’s
myotomy combined with fundoplication represents the treatment of choice for
this disease, achieving good results in more than 90% of patients. However,
about 10% of treated patients report persistent dysphagia, maybe because of an
inadequate myotomy. We sought to evaluate the effectiveness of the laparoscopic
calibrated Heller myotomy by means of intraoperative manometry and endoscopy.
Methods: From 2002 to 2008, 56 patients with achalasia underwent
laparoscopic calibrated Heller myotomy followed by fundoplication (26 Nissen,
30 Dor). The calibrated Heller myotomy was extended for at least 2.5cm on the
esophagus and for 3cm on the gastric side. Each step was evaluated by intraoperative
manometry. Moreover, the intraoperative manometry and endoscopy were used to
calibrate the fundoplication. One-year follow-up with symptoms questionnaires,
endoscopy, and manometry was also undertaken.
Results: The preoperative mean LES-P was 37.73±12.21. After esophageal
and gastric myotomy, the mean pressure drop was 21.3% and 91.9%, respectively.
No mortality was reported, and the morbidity rate was 5.3%. The postoperative
dysphagia score was significantly lower than the preoperative one (9±1 vs 0.8±0.1,
P<0.0001; t test).
Conclusions: Laparoscopic calibrated Heller myotomy with fundoplication
achieves a good outcome in the surgical treatment of achalasia. The use of
intraoperative manometry enables an adequate calibration of myotomy, being
effective in the evaluation of the complete pressure drop, avoiding too-long
esophageal myotomy and, especially, too-short gastric myotomy, which may be the
cause of surgical failure.
9215 General Surgery
Robotic Surgery of Advanced Gastric Cancer: Preliminary Experience
Catalin Vasilescu, PhD, Stefan
Tudor, MD, Monica Popa, MD
Centre of General Surgery
and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
Objective: Minimally
invasive surgery is evolving as a therapeutic tool. However, laparoscopic D2
lymphadenectomy has not gained wide acceptance due to the technical difficulty
and risk of bleeding during the dissection around major vessels. Nevertheless,
the use of robotic surgery in gastric cancer treatment has not been extensively
reported. The aim of this study was to assess the safety and feasibility of
robotic surgery in gastric cancer.
Methods: Between January 2008 and February 2009, we
performed 12 robotic procedures for gastric malignancies. There were 11
total/subtotal radical-D2 gastrectomies and one gastrointestinal diversion. We evaluated disease-related variables,
surgical variables, and postoperative outcome.
Results: The mean operative time was 350±38 minutes
with minimal bleeding. There were no conversions or intraoperative
complications. Resection margins were negative in all cases, and the number of
harvested lymph nodes was comparable to that of open surgery: median of 22
(range, 18 to 29). The morbidity rate was 8.33%: 1 case of wound infection at
the site of specimen extraction. The mortality rate was null. Patients resumed
a solid diet on day 5 postoperatively. The mean hospital stay was 6 days
(range, 4 to 10).
Conclusion: Our preliminary experience suggests that
robotic lymphadenectomy and anastomoses are safe and feasible. The 3D-view,
tremor filtration, scale motion ability, and the internally articulated
instruments allow precise fine dissection, adequate lymph node retrieval, and
intracorporeal anastomoses. The operative time is not significantly increased
in the totally robotic approach compared with cases with extracorporeal
anastomoses. However, further studies are necessary to better define the role
of robotic surgery in gastric cancer treatment.
9216 General Surgery
Robotic Versus Laparoscopic Partial Splenectomy
Catalin Vasilescu, PhD, Stefan Tudor, MD, Monica Popa, MD
Centre of General Surgery and Liver Transplantation, Fundeni Clinical
Institute, Bucharest Romania
Background: Laparoscopic partial
splenectomy has been proved to be an efficient surgical therapy with various
indications and good results. Its main benefit is the preservation of the
immune function of the spleen. This retrospective study compares robotic with
laparoscopic partial splenectomy in terms of surgical technique and short-term
outcome to assess whether the robotic approach is technically feasible and
advantageous over laparoscopy.
Methods: Between June 2002 and
December 2007, 22 cases of laparoscopic partial splenectomy were performed for
spherocytosis (18 cases), splenic cysts (2), portal cavernoma (1), and
thalassemia (1). After that date, following the acquisition of the da Vinci S
robotic system, 6 cases of robotic partial splenectomy were performed (4 cases
of hereditary spherocytosis and 2 splenic cysts).
Results: Patients in the 2 groups
were 5 to 37 years old with similar average age. The preoperative hemoglobin
value ranged between 7.1mg/dL to 9.9mg/dL, and all patients received blood
transfusions. Average operative time was 86±12 minutes in the laparoscopic group
and 93±14 minutes in the robotic group. Hospital time was 3.1±1.2 days in group
1 and 3.8±2 days in group 2. Morbidity was similar, and no mortalities
occurred.
Conclusions: These data suggest that
robotic partial splenectomy is as effective as laparoscopic partial splenectomy
while preserving the immune function of the spleen and has the advantage of
better visualization and dissection of the splenic vessels.
9217 General Surgery
Laparoscopic Transduodenal Sphincteroplasty
Trelles Nelson, MD, Palermo Mariano, MD, Gagner Michel, MD
Mount Sinai Medical Center, Miami Beach, Florida
Introduction: This video illustrates the key aspects of laparoscopic
transduodenal sphincteroplasty for distal common bile duct (CBD) stricture. We
present the case of a 67-year-old man who was referred to us after failure of
endoscopic treatment (ERCP) of CBD stenosis. The patient had a history of CBD
stones, CBD dilatation, and elevation of liver enzymes. He developed
stenosis of the distal CBD that was treated unsuccessfully with multiple ERCP
and stent placements over the last 14 years. A preoperative magnetic resonance
cholangiopancreatography revealed a dilated CBD tapering in the lower CBD
without evidence of tumor.
Methods: A laparoscopic transduodenal sphincteroplasty was performed
with the patient in the split-leg position. After the CBD was exposed just
above the duodenum, a cholangiogram was performed directly in the CBD, showing
no evidence of any CBD stones and a short stenotic area at the ampulla. Then,
through a 10-cm longitudinal duodenotomy, a sphincterotomy using the Harmonic
scalpel was performed after a transcystic catheter was pushed down through the
ampulla. A sphincteroplasty was then performed followed by a 2-layered closure
of the duodenum.
Results: The patient tolerated the procedure well. On the first
postoperative day, an upper gastrointestinal study showed no evidence of leak.
So, diet was resumed safely and the patient was discharged home uneventfully on
the third postoperative day.
Conclusion: We conclude that laparoscopic transduodenal sphincteroplasty
for CBD stenosis is a safe and feasible alternative to choledochoduodenostomy.
9218 General Surgery
Acute Appendicitis or Gynecological Disease? The Role of the Videolaparoscopic
Approach
Roberta Gelmini, Prof Dr Med,
Chiara Franzoni, MD, Veronica Casolari, MD, Massimo Saviano, Prof Dr Med
Background: The laparoscopic
approach for suspected appendicitis is increasingly gaining acceptance even if
it remains controversial. Many authors suggest the usefulness of the
laparoscopic approach in women of reproductive age because of the high rate of
wrong diagnoses for gynecological diseases.
Material and Methods: During a
period of 2 years at our institution, 104 patients underwent appendectomy for
suspected acute appendicitis. Of those, 27 were females of reproductive age who
underwent a laparoscopic procedure. In 23 cases, a preoperative gynecological
examination was carried out and was negative.
Results: In all cases, the procedure
was completed laparoscopically, and the postoperative complication rate was 0%.
The definitive diagnosis was acute appendicitis in 12 cases (44.45%),
complicated appendicitis with abscess or peritonitis in 10 cases (37.03%), and
gynecological unknown disease in 5 cases (18.52%) associated with chronic
appendicitis. In the last group of patients, both appendicitis and
gynecological disease were treated in the same procedure.
Conclusions: Laparoscopic
appendectomy is to be considered as safe as open appendectomy. If in male patients it does not have
obvious advantages, in women of reproductive age it contributes to a correct
differential diagnosis of pelvic diseases, and it permits treatment of
different disorders during a sole procedure with the same mini-invasive
accesses. The high rate of false-negatives in the diagnosis of pelvic diseases
in the preoperative diagnostic tests justifies the systematic use of the
laparoscopic approach in female patients with suspected acute appendicitis.
9220 General Surgery
Timing of Elective Laparoscopic Cholecystectomy After Acute Cholangitis and
Subsequent Clearance of Choledocholithiasis
Vicky Ka Ming Li, MBBS, FRCS, Jonathane Kai Yum Lau, MBBS, MRCS, Yuk Pang
Yeung, MBBS, FRCS
Kwong Wah Hospital, Hong Kong SAR, China
Objectives: Elective laparoscopic cholecystectomy is recommended after
endoscopic clearance of choledocholithiasis for patients with acute
cholangitis, according to Tokyo guidelines. We aimed to compare the
perioperative outcomes of patients with early and late laparoscopic
cholecystectomy after the last cholangitic attack and identify risk factors for
postoperative complications.
Methods: A retrospective review was
performed for patients with elective laparoscopic cholecystectomy between
January 2002 and June 2008 after endoscopic clearance of choledocholithiasis,
following a cholangitic attack. Exclusion criteria were (1) concomitant acute
cholangio-pancreatitis, cholecystitis, or liver abscess; (2) uncertain ductal
clearance; (3) emergency surgeries for recurrent biliary events; (4) recurrent
pyogenic cholangitis. Perioperative outcomes were compared between patients
with early (<6weeks) and late (>6weeks) surgeries, while risk factors for
postoperative complications were sought with multi-variate analysis.
Results: We analyzed 112 patients with a mean age of 64
years (range, 30 to 85). Two or more medical comorbidities were present in 33
(29.5%) patients. Median waiting interval and operative time were 10.5 weeks
(range, 1 to 107) and 90 minutes (range, 35 to 366), respectively. Rate of
conversion and intraoperative and postoperative complications (classified by
Dindo) were 21.4% (24/112), 22.3% (25/112), and 34.8% (39/112), respectively.
The median hospital stay was 4 days (range, 2 to 25). Late surgery group had
significantly more intraoperative (27.5% vs 9.4%, P=0.045) and postoperative
complications (42.5% vs 15.6%, P=0.007) compared with the early surgery group.
No differences existed in conversion rate, operative time, and hospital stay.
Multivariate analysis showed that both late surgery [P=0.008, 95%CI
(1.47-12.5)] and history of endoscopic sphincterotomy [P=0.038, 95%CI
(1.06-8.26)] were independent risk factors for postoperative complications.
Conclusion: Patients with endoscopic
clearance of choledocholithiasis, especially after endoscopic sphincterotomy,
should receive elective laparoscopic cholecystectomy <6 weeks after a
cholangitic attack.
9221 Gynecology
Total Laparoscopic Radical Hysterectomy and Robotic Radical Hysterectomy with
Pelvic Lymphadenectomy in Treatment of Early Cervical Cancer: Recurrence and
Survival
Farr Nezhat, MD1, M. Shoma Datta,
MD1, Linus Chuang, MD2, Connie Liu3, Konstantin Zakashansky2
1St. Luke’s-Roosevelt Hospital Center, New York, New
York
2Mount Sinai Medical Center, New York, New York
3NYU Medical Center, New York, New York
Objective: To assess recurrence and survival rates among
patients with early stage cervical cancer treated with either total
laparoscopic or robotic radical hysterectomy with pelvic lymphadenectomy.
Methods: We retrospectively analyzed recurrence and
survival rates among all cases of total laparoscopic radical hysterectomy
(TLRH) and robotic radical hysterectomy (RRH) with pelvic lymphadenectomy
performed for treatment of early cervical cancer from 2000 to 2008.
Results: A total of 30 patients underwent TLRH and pelvic
lymphadenectomy, and 22 patients underwent RRH and pelvic lymphadenectomy. Two
patients were stage IA1; 9 were stage IA2; 35 were stage IB1; 3 were stage IB2;
and 3 were stage IIA. Pathological risk factors for disease recurrence were
analyzed: 1 patient had a positive parametrial margin; 7 had positive lymph
nodes: 5 pelvics and 2 parametrial; 12 patients had outer third cervical wall
invasion; 5 had cervical lesion >2cm; and 22 patients had lymphovascular
invasion. Based on a combination of these risk factors, 20 patients (39%) underwent
adjuvant chemoradiation. Follow-up has been provided every 3 months, and with a
median follow-up of 20 months all the patients are alive with no documented
recurrences.
Conclusions: Both TLRH and RRH with pelvic lymphadenectomy
have comparable recurrence rates and disease-free survival compared with
reports in the current literature. There is also a suggestion that RRH and TLRH
have similar rates of recurrence and disease-free survival despite the
minimally invasive approach.
9222 Urology
Comparison of Laparoscopy Training Using a Box Trainer versus a Virtual Trainer
Yousef Mohammadi, Amanjot Sethi, MD, Michelle Lerner, MD, Chandru Sundaram,
MD
Indiana University School of Medicine
Objective: The objective of this study was to validate a developed
laparoscopic virtual trainer as an educational tool. The effectiveness of the
virtual trainer was compared with the box trainer, which was developed based on
the validated McGill Inanimate System for Training and Evaluation of Laparoscopic
Skills.
Methods: Participants (n=46)
included urology medical students, residents, fellows, and attending surgeons
at Indiana University School of Medicine. Thirty-five subjects were trained
using the box trainer (CG), and 11 were trained using the virtual simulator
(EG). All exercises were scored for time and accuracy for a total of 10
variables. Participants were asked to complete a self-evaluation survey after
each session and a user-satisfaction questionnaire at the end of the training.
Results: The EG (72.7%) group
developed more interest in urology as a result of their experience than the CG
(44.8%) group did. Of the CG group, 65.7% believed they were adequately
evaluated versus 90.9% of the EG group. There was no statistically significant
difference between the improvement of the EG versus the CG group regarding
accuracy. However, the CG group significantly improved compared with the EG
group in the pegboard time (P=0.04), checkerboard time (P=0.001), and suturing
time (P=0.01). There were no statistically significant differences between the
groups in knot tying and pattern cutting time.
Conclusion: We conclude that the
virtual simulator is a reasonable alternative to the box trainer for
laparoscopic skills training.
9223 Gynecology
“Transumbilical” Laparoscopic Hysterectomy Using the LigaSure Device: Initial
Experience of 25 Cases
Dr. Muthukumaran Rangarajan, MS, DNB, DipMIS, Dr. Dinakaran Kaarthesan, MS, Dr.
Ranganathan Kribakaran MS, DNB, MRCS, Dr. Chandrabose Karpagavel, MS, Dr.
Sivacharan Reddy, MS
Rajah
Muthiah Medical College & Hospital, Annamalai University, Annamalainagar,
Tamilnadu, India
Aims: Laparoscopic hysterectomy with all its variations
is almost an established procedure now in the treatment of various diseases of
the uterus. In this study, we hope to establish the feasibility of laparoscopic
hysterectomy using just 2 transumbilical ports and conventional nonroticulating
laparoscopic instruments.
Methods: From October 2008 through January 2009, all patients that
needed laparoscopic hysterectomy for diseased but normal- or small-sized
uteruses were short listed to undergo our approach. Of 30 cases, the
transumbilical approach was possible in 25, while the rest were converted to
conventional laparoscopic hysterectomy. Two conventional 10-mm
transumbilical ports for a 30-degreee telescope and an instrument were used to
complete the procedure in all cases. A vessel-sealing system was used
for most of the dissection, including control of the uterine artery. Uterine
manipulation was achieved via an instrument in the vagina.
Results: The median patient age was 47.5 years and mean BMI was 29.4. Mean
operating time was 72.5 minutes, with a conversion (to conventional
laparoscopy) rate of 16.6%. The mean hospital stay was 14 hours. There were no
postoperative complications except dyspareunia in 12%. At short-term follow-up,
there were no problems.
Conclusions: Laparoscopic hysterectomy using this approach is certainly
feasible, at least for normal- or small-sized uteruses. This technique of using
conventional laparoscopic instruments through a natural scar is probably
cheaper and more readily available than other specialized single-port devices.
Loss of triangulation is the biggest disadvantage, but can be overcome with a
short learning curve.
9224 Urology
Individualized Management of Ureteropelvic Junction Obstruction During
Robot-Assisted Laparoscopic Dismembered Pyeloplasty
Michelle Lerner, MD, Chandru
Sundaram, MD
Indiana
University School of Medicine
Objective: The surgeon performing
robot-assisted laparoscopic dismembered pyeloplasties (RALDP) must have
adaptability and knowledge of various pyeloplasty techniques. The surgery
should be tailored to an individual patient’s specific anatomy. We present 3
illustrative cases of RALP.
Methods: Digital video capturing is
performed during all laparoscopic procedures. Video segments determined by the
surgeon to have educational value are archived and later used to create
educational videos.
Results: The video highlights the
standard maneuvers used for RALDP using contemporary laparoscopic and robotic
techniques. Laparoscopic devices, such as bipolar electrocautery, ultrasonic
shears, and Hem-o-lok polymer ligating clips, are featured. Nephroscopy for the
management of nephrolithiasis at the time of dismembered RALP is highlighted.
Variations in the management of lower pole crossing vessels are demonstrated
using techniques of cephalad transposition and posterior transposition. We have
performed 52 robot-assisted laparoscopic pyeloplasties at our institution of
which 41 are RALDP. Lower pole crossing vessels were transposed posteriorly in
13 patients and cephalad in 4 patients. On postoperative lasix renogram after
RALDP, 95.1% (39/41) of the patients had a normal drainage curve. All patients
with cephalad transposition of the lower pole vessels had no evidence of
obstruction postoperatively. Flank pain resolved in 97.6% (40/41) of patients.
The patient who had persistent flank pain had no evidence of obstruction on a
postoperative lasix renogram.
Conclusions: This video clarifies
the essential steps involved in a standard RALDP and the need for
individualized management of patients with ureteropelvic junction obstruction.
9225 General Surgery
Minimal Esophageal Dissection During Laparoscopic Nissen Fundoplication in
Infants Reduces the Risk of Postoperative Hiatal Hernia and Wrap Herniation
Richard Hendrickson, MD2, Denis
Bensard, MD2, Carla Fyffe, CPNP1, Joshua Careskey, MD1, Evan Kokoska, MD2
1Peyton Manning Children’s Hospital
at St. Vincent
2Cincinnati Children’s Hospital Medical Center
Background: Laparoscopic Nissen
fundoplication is effective in the control of gastroesophageal reflux in
infants. However, up to 15% of infants who undergo Nissen fundoplication will
require reoperation primarily due to postoperative hiatal hernia and wrap
migration. The mechanism of failure remains unclear. We hypothesized that
minimal esophageal dissection and avoidance of crural disruption would reduce
the risk of hiatal hernia and wrap failure in infants.
Methods: From May 2006 to January 2009, all infants
suffering refractory gastroesophageal disease on maximal medical therapy (n=65)
were offered a laparoscopic Nissen fundoplication in a Women’s and Children’s
hospital. Infants underwent circumferential crural dissection with repair
(Group I, n=8); circumferential crural dissection and repair with bioprosthetic
patch (Group II, n= 21); anterior crural dissection only (Group III, n= 25); or
no crural dissection (Group IV, n= 11).
Results:
Sixty-five infants with a mean
age (weeks) and weight (kilograms) for Group I: 12.25, 4; Group
II: 17, 5.65; Group III: 22.8, 5.1; and Group IV: 19.5, 4.9 underwent
a laparoscopic Nissen fundoplication. Ten infants (15.3%) demonstrated a hiatal
hernia with wrap herniation: Group 1 – 25%, Group 2 – 28.5%, Group 3
– 8 %, and Group 4 – 0%. No infant required conversion to an open procedure,
and no intraoperative complications occurred. All patients were followed
postoperatively, and none were lost to follow-up.
Conclusion: Unlike adults, nearly all infants demonstrate
adequate intraabdominal esophagus and do not appear to require crural
dissection. These data suggest that avoiding crural dissection may
eliminate postoperative wrap herniation.
9226 General Surgery
A Six-Year Experience in the Laparoscopic Treatment of Incisional Hernias
I. M.
Civello, MD, F. Brandara, MD, L. Ciccoritti, MD, F. Cannemi, MD, V. Antonacci
MD
Operative Unit
General Surgery, “Civile – Maria Paternò Arezzo” Hospital, Ragusa, Italy
Aim:
Laparotomic treatment of incisional hernias according to the Rives procedure is
usually used for large and complex hernias. After extensive experience with the
laparotomic approach, in the last 6 years we introduced laparoscopic
repair for all defects of the abdominal wall. This experience is now evolving
because of the disposability of new materials and continuous improvements
in technical procedures. We present the experience of 6 years in the
laparoscopic treatment of all types of incisional hernias.
Methods:
In the last 6 years (from January 2003 to December 2008), we
treated 120 patients; 60 (group A) using Gore-Tex mesh and 60 (group B) using
Parietal Composite mesh with the laparoscopic approach. In both groups, we
fixed the mesh with metallic stitches.
Results:
Mean operative time was 90 minutes. Twenty percent of patients underwent
previous repair attempts. No conversions or deaths occurred. The overall
complication rate was similar in the 2 groups (8% vs 10%). Postoperative
hospital stay ranged from 2 days to 6 days. Median follow-up was 58 months
(range, 3 to 72). Three recurrences (1 in A group and 2 in B group) were
observed.
Conclusion:
Laparoscopic repair of incisional hernias is an effective alternative approach
to the traditional Rives laparotomic procedure in cases of abdominal wall
defects without severe adhesions to the hernia sac. The laparoscopic approach
is a safe and effective treatment with low morbidity, low recurrence rates,
shorter hospital stay, and early resumption of normal activities.
9227 General Surgery
Six Sigma, Statistical Process Control, and Quality Improvement for
Appendectomy
Jeffrey D. Sedlack, MD
Waterbury Hospital, Waterbury, Connecticut
Background: Quality improvement of industrial processes requires
statistical process identification and mapping, and then identification,
control, and improvement of each step in the process. The standard to be
achieved with statistical process control is 3.1 errors per million
opportunities (DPMO), which is known as the “six sigma” standard.
Methods: Six sigma methodology was
applied to the process of appendectomy. Twenty-eight steps were identified
taking a patient from entry to the Emergency Room to Discharge. Statistical
process controls were applied using length of stay (LOS) as the end point for
quality of process. Between 9/25/1992 and 10/16/2008, 1659 patients underwent
appendectomy for uncomplicated appendicitis. Length of stay (LOS) followed a
gamma distribution with an average LOS of 2.09 days. The statistical upper
control limit (avg. + 3 sd) was 5.93 days. There were 66 failures for the upper
control limit. No statistical difference existed for sex, diagnosis code,
laparoscopic or open approach, or operating surgeon.
Results: Failure Modes and Effects
Analysis (FMEA) was performed using these data. There were 7 principal modes of
failure that included misdiagnosis at admission, inappropriate radiologic
testing and antibiotic use, postoperative ileus, and fever. A quality
improvement plan was developed and controls for the process are currently being
implemented.
Conclusion: Industrial process
control tools were applied to the process for treating appendectomy. The
identified process operates at 4.5 sigma (1421.5 DMPO) with an industrial
standard of 3.DMPO. FMEA identified 7 most common errors, and quality efforts
are ongoing to improve and better control this process.
9228 General Surgery
Laparoscopic Treatment of Colorectal Tumors: 4-Year Experience
I. M. Civello, MD, F. Brandara, MD, L. Ciccoritti, MD, F. Cannemi, MD, V.
Antonacci, MD
“Civile – Maria Paternò
Arezzo” Hospital, Ragusa, Italy
Objective: Mortality in colorectal cancer has significantly
decreased. This can be attributed to improved surgical technique as well as a
multimodal treatment strategy. The role of the laparoscopic approach has been
demonstrated in the literature. We present our experience of 4 years in the
laparoscopic treatment of colorectal cancer.
Methods:
In the last 4 years (from January 2005 to December 2008), we have
treated 100 patients with T1-3 N0 M0 cancer: 70 with sigmoid cancer and 30 with
rectal cancer. We performed 70 sigmoid resections, 26 rectal resections, and 4
abdominoperineal resections.
Results:
Laparoscopic treatment was completed successfully in 98 patients.
Conversion was required in 2 cases (2%).
Mean operative time was 180 minutes. The overall morbidity rate was 5%, with an overall anastomotic leak
rate of 1%. No deaths occurred.
Duration of ileus was 2.5 days; postoperative hospital stay was 7.5 days. Mean
follow-up was 25 months (range, 6 to 48). There were no trocar site
recurrences. The local recurrence rate was 2%. All patients are alive at different follow-up periods.
Conclusions:
Laparoscopic techniques can be applied to a wide range of colorectal tumors
without sacrificing oncologic results during long-term follow-up. The
laparoscopic approach is an effective treatment with low morbidity, low
recurrence rates, shorter hospital stay, and early resumption of normal activities.
9229 General Surgery
Laparo-Endoscopic Single Site Cholecystectomy with Intraoperative Cholangiography
Kellie McFarlin, MD, Harold Paul,
Connor Morton, BS, Sharona Ross, MD, Alexander Rosemurgy, MD
University of South Florida and Tampa General Hospital Center for Digestive
Disorders
Introduction: Laparo-Endoscopic
Single Site (LESS) cholecystectomy is an effective method of cholecystectomy,
has a short definable learning curve, and can be undertaken with currently
available instrumentation. This video demonstrates LESS cholecystectomy with
the utilization of intraoperative cholangiography.
Methods: The operation is undertaken
via a 12-mm vertical incision at the umbilicus where a 5-mm trocar is inserted
through the natural umbilical defect. A second 5-mm trocar is placed cephalad
through a separate fascial incision at the umbilicus. Percutaneously, a suture
is placed at the right upper quadrant through the gallbladder fundus and used
for retraction and exposure of the infundibulum and Calot’s triangle. A second
suture is utilized to manipulate the infundibulum and facilitates dissection of
the cystic duct and artery. The "critical" view is easily obtained.
The cystic duct is partially divided in preparation for the cholangiogram
catheter. The catheter system is inserted through the umbilical skin incision
and directed toward the right upper quadrant. The catheter is visualized,
directed into the cystic duct, and secured with laparoscopic clips. The
cholangiogram is undertaken; the biliary tree is clearly visualized. Next, the
cystic duct and artery are doubly clipped and divided; the gallbladder is
dissected in a standard fashion from the liver bed with hook cautery and
extracted through the umbilical incision.
Conclusions: LESS cholecystectomy
with intraoperative cholangiography can be safely undertaken. Intraoperative
cholangiography should be a functional tool in the armamentarium of LESS
cholecystectomy, which offers a "no scar" approach for
cholecystectomy.
9230 General Surgery
Laparoscopic-Assisted Management of Impalpable Testis in Patients Older Than 10 Years
Ahmed Khan Sangrasi, FCPS, Abdul Aziz Laghari, FRCS, Mujeeb Rehman Abbasi, FRCS
Liaquat University of Medical & Health Sciences, Jamshoro, Pakistan
Objective: Cryptorchidism affects 1% of male births. The majority of patients
with undescended testis are identified and treated in childhood, but a
significant proportion of them especially in third-world countries are
neglected and present late. Herein, we present our initial experience of
managing impalpable testis with laparoscopic assistance in older children and
adults.
Patients and Methods: This study was conducted from 2003 to 2008 at LUMHS
Jamshoro, Pakistan. Thirty-two patients with 40 impalpable testes were included
in this study. Laparoscopy was performed in 32 patients who were under general
anesthesia. Diagnostic laparoscopy was done. Laparoscopic orchiopexy or
orchiectomy was performed in patients with intraabdominal testis. Testicular
vessels and vas deferens were mobilized and after getting sufficient length
were brought through the posterior wall of the inguinal canal by creating a neo-inguinal
ring medial to the epigastric vessels after a small inguinal incision.
Results: Of 40 impalpable testis, ultrasound located 16
(40%) of them; on laparoscopy, 36 (90%) of these were identified as intraabdominal.
The remaining 4 patients were diagnosed as having vanishing testis (anorchia).
Laparoscopic orchiectomy was performed in 14 of these testes, while all other patients
underwent laparoscopic-assisted orchiopexy. No major complications occurred. If
a hernia was found, it was simultaneously repaired laparoscopically.
Conclusion: Laparoscopy is a safe and effective modality in the
diagnosis and management of impalpable testis in adolescents and older persons,
especially when ultrasonography is not informative enough. An additional
benefit of shortening the usual course of spermatic cord was beneficial for fixing
testis in the scrotum without tension.
9231 General Surgery
Laparoscopic Treatment of Rectal Cancer: A Single Center Experience
Paolo Ubiali, MD, Michele Ciocca
Vasino, MD, Michele Andretta, MD, Giovanni Puletti, MS
Policlinico San Pietro, Bergamo, Italy
The treatment of rectal cancer, respecting oncological principles, is well
known, as is the laparoscopic feasibility of treatment. More concern
exists about standardization of a good technique based on oncological criteria.
Our experience began in January 2007. We have laparoscopically treated 35 cases
of T1-T3 stage rectal cancer, without renouncing the open treatment, which was
performed during the same period in 31 patients. No randomization was
performed. The selection criteria were surgeon experience, previous pelvic
surgery in males, and obesity. Only 1 patient in the lap group was converted because
of anatomical doubts. In both groups, patients were treated with total
mesorectal excision, nerve-sparing technique, temporary diverting ileostomy,
colo-anal stapled anastomosis, Miles' operation, depending on the
localization of tumor. Patients with T3 stage tumor, located from 2cm to 10cm
from the anal verge underwent neoadjuvant chemotherapy before
surgery. One surgeon performed the lap procedure, 2 surgeons the open one.
The surgical team is well trained in oncological and advanced laparoscopic surgery:
with more than 300 lap colectomies performed. The results in terms of
complications, operative time, postoperative course, and oncological outcome
are very encouraging. Some tips and tricks are suggested. As for colon cancer,
we believe it is possible to standardize a lap procedure to treat rectal
cancer after adequate training.
9232 General Surgery
Avoiding Major Common Bile Duct Injuries in Cases with Unidentifiable Cystic Duct
Prasanta K. Raj, MD, Subhasis Misra, MD, Richard C. Treat, MD
Fairview Hospital, Cleveland Clinic Health System
Objective: Unexpected injuries to the common bile duct (CBD) have been one of the major complications of laparoscopic cholecystectomy. Laparoscopic cholecystectomy becomes a challenging problem in Mirizzi’s syndrome or in cases where the cystic duct is not easily visualized or where the cystic duct, Hartmann’s pouch, and CBD are fused. We describe a new technique that can be successfully used to perform laparoscopic cholecystectomy in these circumstances.
Methods and Procedures: We encountered 5 such cases where it was apparent that continued dissection to identify the cystic duct might lead to major bile duct injuries because of surrounding adhesions, inflammation around Hartmann’s pouch, and CBD. We proceeded to dissect the gallbladder by using a fundus down technique and continued till Hartmann’s pouch was reached and CBD identified. We attempted to do cholangiography through the Hartmann’s pouch. As the cystic duct was not identified, an endo-GIA stapler was used to staple across the Hartmann’s pouch close to the CBD, after the stones were moved to the gallbladder. One closed suction drain was placed near the area of the dissection site and left for a day.
Results: In all cases performed with this technique, there were no complications. Placing drains did not show any added benefit.
Conclusions: When one encounters difficulty in identifying the cystic duct and suspicion of Mirizzi’s syndrome is raised, we recommend the fundus down technique to dissect the gallbladder till Hartmann’s pouch is reached. Endo-GIA stapling of Hartmann’s pouch is a feasible alternative to division of cystic duct.
9233 General Surgery
Inferior Epigastric Artery Bleeding During Laparoscopic Procedure
Prasanta K. Raj, MD, Subhasis Misra, MD, Richard C. Treat, MD
Fairview Hospital, Cleveland Clinic health System
Objective: Trocar site bleeding due to injury of
superior and inferior epigastric arteries can lead to high morbidity. Hence,
identification and management of the epigastric artery bleeding should be done
promptly. The hallmark of a major epigastric bleed is blood dripping along the
trocar during insertion. We present a case of inferior epigastric artery
bleeding with a focus on identifying and managing such an eventuality.
Methods and
Procedures: During laparoscopic tubal ligation and
insertion of a 5-mm trocar in the right lower quadrant, a 41-year-old female
had excessive bleeding along the trocar site. When an attempt was made for
intracorporeal suturing, a large amount of blood was noted over the liver and
in the lower pelvis. The trocar insertion site was then observed by
minilaparotomy incision, and the presence of clot in the rectus sheath was
noted. The bleeding artery was localized, which showed a large amount of blood
and the bleeding vessel was seen and easily controlled.
Results: Unlike
a superior epigastric bleed, which can be self-limited because of a tamponading
effect, inferior epigastric artery bleeding can be significant. This is because
the inferior epigastric artery course has no posterior rectus sheath below the
arcuate line to have a tamponading effect, which may lead to severe bleeding
and hematoma making laparoscopic closure very difficult.
Conclusions: For
significant inferior epigastric artery bleeding, we recommend local exploration
for satisfactory hemostatic control and thereby minimize complications. We
recommend immediate minilaparotomy to control bleeding, which can prevent other
complications. Laparoscopic suturing may not work satisfactorily in these
instances, as the bleeding can be massive.
9234 Multispecialty
Electronic Detection of the Entry of Veress Needles into the Peritoneal Cavity
Michael C. Doody, MD, PhD
Fort Sanders West Surgery Center,
Knoxville, Tennessee
Objectives: Many
of the catastrophic complications of closed laparoscopy occur during the
initial blind insertion of instruments into the abdominal cavity. We explored
the possibility that an electronic instrument could be constructed that would
be more sensitive and specific than the tactile sense of a skilled laparoscopic
surgeon to the penetration of Veress needles into the peritoneal cavity.
Methods: One hundred patients undergoing outpatient laparoscopy were studied.
Standard Veress needles were attached with sterile couplers to a prototype
complex impedance measurement device. The instrument was optimized for use
in an operating room environment. Radiofrequency impedance measurements
were measured and recorded as the tips of the needles were advanced through the
layers of the abdominal wall. Frequencies from 1 to 105 megahertz and power
outputs ranging from the picowatt range to the microwatt range were
investigated.
Results: Major changes in complex impedance (Ohms and capacitance/inductance)
were seen at the transitions between air, subcutaneous tissue, fascia,
preperitoneal space, and the peritoneal space. In 100% of the cases, a
significant final change in impedance was noted at a depth consistent with
probable peritoneal entry. Type 1 discrepancies occurred when the entry of the
needle into the peritoneum was suggested by the instrumentation before the
surgeon was aware of it by tactile sense. Type 2 discrepancies occurred when
the surgeon felt that the needle tip was in the peritoneum when the impedance
changes suggested otherwise.
Conclusion: It was the final
surgeon’s opinion that his initial assessment was in error in all of the
discordant situations.
9235 Urology
Margin Status of Men Undergoing Extraperitoneal, Extrafascial Laparoscopic
Radical Prostatectomy (LRP)
Genoa G. Ferguson, MD, Peter A. Humphrey, MD, Gerald L.
Andriole, MD
Washington University School of
Medicine, Saint Louis, Missouri
Objective: Our goal in adopting
nonrobot-assisted LRP is to replicate the classic open anatomical prostatectomy
in a minimally invasive manner.
Methods: Using our technique, we
replicate the open approach because the surgery is performed extraperitoneally;
modified or extended pelvic lymph node dissection is routinely performed; the
prostate is dissected extrafascially; “classis” or “veil” nerve-sparing is
selectively applied; and 3D imaging with the Viking Endosite 3Di System
(San Diego, CA) is used.
Results: Patients included 420 men
[average age of 61 years (range, 40 to 79)] with a median PSA of 5.2ng/mL
(range, 0.6 to 54.1) and a mean hospital stay of 1.27 days (range, 1 to 14).
Positive surgical margins were found in 101 patients (24.0%) and varied by pT
stage.
Conclusion: LRP performed extraperitoneally, with selective nerve
sparing, and using 3D imaging is safe and effective in achieving negative
surgical margins and a low PSA failure rate.
9236 General Surgery
An Unusual Presentation of Carcinoid of the Appendix
Yong Kwon, MD, Derrick Cox, MD, Parag Bhanot, MD
Georgetown University Hospital
Introduction: Gastrointestinal
carcinoids are rare tumors and are often asymptomatic. The most common site is
the appendix followed by the rectum, ileum, lungs and bronchi, and stomach.
Most appendiceal carcinoids are found incidentally during surgery for acute
appendicitis, which comprises approximately 0.3% to 0.9% of patients undergoing
appendectomy. We present a case report of a healthy 42-year-old male with an
unusual presentation of carcinoid tumor of the appendix. We then review and
summarize the most recent published literature on carcinoid of the appendix
with focus on its diagnosis, histopathological features, clinical
manifestations, and management.
Methods: Extensive literature review
from Pubmed.
Results: Patients underwent
laparoscopic appendectomy, and pathology demonstrated appendiceal carcinoid.
Patients subsequently underwent a laparoscopic right hemicolectomy. There were
no associated morbidities.
Conclusion: Appendiceal carcinoids
are most often rare, asymptomatic tumors. If symptomatic, they are found
incidentally during appendectomies, and the diagnosis is rarely suspected
before histological examination. Appendiceal carcinoid tumor can be managed by
simple appendectomy or right hemicolectomy dependent on the size and
location of the tumor as well as lymph node, or serosal involvement, or
involvement of both.
9237 General Surgery
Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery Syndrome:
Surgical Management for an Irreversible Cause?
Marquinn Duke, MD, Joshua B.
Alley, MD
University Health Systems, Wilford Hall Medical Center/Lackland Air Force Base
Background: Extrinsic compression
of the duodenum by the superior mesenteric artery, resulting in relative
obstruction, is known as superior mesenteric artery syndrome or Wilkie’s
syndrome. Both medical and surgical management have been advocated in the
published literature.
Case Report: We report the case of a
paraplegic man with SMA syndrome. After initial medical management, he
underwent a laparoscopic duodenojejunostomy with successful results.
Conclusion: Although the indications
for surgical correction of SMA syndrome may be debated, the cause of each
patient’s syndrome must be considered. In patients without an easily reversible
cause, laparoscopic duodenojejunal bypass should be strongly considered. Barium
upper GI series should be part of the preoperative evaluation, because it
provides information about both functional and anatomic characteristics of
duodenal compression.
9238 General Surgery
Laparoscopic Retroperitoneal Lumbar Sympathectomy for the Treatment of Plantar
Hyperhidrosis: A Case Report and Review of the Literature
Derrick D. Cox, MD, Yong Kwon, MD, Parag Bhanot, MD
Georgetown University Hospital
Introduction: Primary hyperhidrosis is a socially embarrassing and
distressing condition involving increased production of sweat, most commonly of
the axilla, palms, and soles of the feet. It has been estimated to have a
prevalence of 2.8% in the United States. Neither systemic nor topical
drugs have been found to satisfactorily alleviate the symptoms. In severe cases
of plantar hyperhidrosis,
it is recommended that lumbar sympathectomy be performed because interruption to the sympathetic innervations of
eccrine sweat glands causes anhidrosis of the feet. We present the case of a
28-year-old female with primary hyperhydrosis who previously underwent
successful bilateral thoracic sympathectomies but now suffered from
plantar hyperhydrosis. We then review and summarize the most recent published
literature on surgical treatment of primary hydrosis, specifically laparoscopic
lumbar sympathectomy.
Methods:
We performed an extensive review of the English literature from Pubmed using
the keywords “plantar hyperhydrosis” and “lumbar sympathectomy.”
Results:
The patient had successful bilateral lumbar sympathectomies (each side done
separately with a 2-week interval). She was followed and subsequently had
complete anhidrosis of bilateral plantar surfaces. There were no associated
morbidities.
Conclusion:
Primary hyperhydrosis is a pathological condition of overperspiration caused by
excessive secretion of the eccrine sweat glands and is usually idiopathic.
Various medical treatments may decrease but do not ameliorate symptoms. In
severe cases of plantar hyperhydrosis, laparoscopic retroperitoneal lumbar
sympathectomy can safely be performed to achieve anhidrosis.
9239 General Surgery
Transanal Endoscopic Microsurgery of Rectal
Adenomas: A Comparison of Two – and Three-Dimensional
Visualization
D. H. Nieuwenhuis, MD1, P. G. Doornebosch, MD2, D. J. Kuik1, E. C.
J. Consten, MD, PhD3, E. J. R. de Graaf, MD, PhD2
1VU Medical Center, Amsterdam, The
Netherlands
2IJsselland Hospital, Capelle aan den
IJssel, The Netherlands
3Meander Medical Center, Amersfoort, The
Netherlands
Introduction: Originally, transanal
endoscopic surgery was performed using 3D stereo-optic and specially designed
equipment (TEM). Recently, use of standard endoscopic instruments and a 2D
optical system has been described (TEO). We compared the results of 2 matched
groups after TEM and TEO.
Patients and Methods: From data of all patients
with rectal adenomas (RA) who underwent TEM or TEO in 2 university affiliated
hospitals, 2 groups were selected, matched for distance and diameter of RA.
Results: From 1996 to 2008, 169 RA, matching in
diameter and distance, were excised with TEM and 26 with TEO. Mean operation
time using TEM was 41 minutes and using TEO it was 56 minutes (P<0.05).
Mean blood loss was 15cc and 0cc (P=0.049), and mean hospital stay was 2.8 and
3.6 days (P>0.05), respectively. In both groups, one major complication
occurred (P>0.05). Fragmentation of the specimen was observed in 0.6% after
TEM and 11% after TEO (P<0.05) and clear margins in 86% and 81%
(P<0.001), respectively. With a median follow-up of 25 months, local
recurrences occurred in 2.4% after TEM and 0% after TEO.
Conclusion: For RA, TEM, compared
with TEO, provides shorter operative time, less fragmentation, and more often
clear margins of the excised specimen.
9240 Urology
The Safety of Radiofrequency Ablation for Renal Tumor Based on Renal Biopsy
After 6 Months
Gyung Tak Mario Sung, MD
Purpose: To report on the safety of
nephron-sparing radiofrequency ablation (RFA) of renal tumor based on renal
biopsy after 6 months.
Materials and Methods: Between June
2004 to October 2008, 65 patients underwent radiofrequency ablation of renal
tumor. Fifty-five cases of combined computed tomography (CT) and
ultrasonogram-guided percutaneous RFA and 10 intraoperative ultrasonography
guided laparoscopic RFA were performed. Kidney CT/MRI were performed on day 1,
and at 1 week, 1 month, 3 months, 6 months, and 1 year after ablation,
thereafter, semiannually. At 6 months, we performed renal biopsy of patients
who underwent RFA for confirmation of remnant tumor. Thirty-seven of 65
patients underwent renal biopsy 6 months after RFA. The mean follow-up was 11.7
months (range, 6 to 16). The biopsy has done on 7 cores from around the site
where the RFA was performed.
Results: The mean patient age was
61.3 years, and mean tumor size was 3.1cm. In 17 patients with confirmation of
remnant tumor on follow-up CT, repeat RFA was performed at 1 or 3 months. The
other patients finished one session. At 6-month follow-up biopsy, 1 patient had
remnant tumor, whereas the others had no tumor.
Conclusions: At the 2007 AUA
meeting, one report was presented of a high remnant tumor rate at 6-month renal
biopsy after RFA. But in our study, the results showed opposite data. At our
center, the 6-month postoperative biopsy data for RFA lesions are on the way.
The ultimate role of this modality will continue to evolve and warrants further
study.
9241 Urology
A Comparison of Robotic-Assisted Versus Pure Laparoscopic Radical
Prostatectomy: A Single Surgeon Experience
Gyung Tak Mario Sung, MD
Purpose:
We
compared a single institution experience with radical prostatectomy performed
using a pure laparoscopic technique vs a robotically assisted technique with
regard to preoperative, intraoperative, or postoperative parameters.
Materials
and Methods: From May 2006 to December 2008, we reviewed 70 consecutive patients
who underwent robot-assisted radical prostatectomy and compared them with 70
match-paired patients treated with a pure extraperitoneal laparoscopic
approach. The patients were matched for age, body mass index, prostate specific
antigen, pathological stage, and Gleason score. Preoperative, perioperative,
and postoperative data, including complications and oncological results, were
analyzed between the 2 groups.
Results:
The 2
groups were statistically similar with respect to age (P=0.31), body mass index
(P=0.34), prostate specific antigen (P=0.21), Gleason score, and clinical stage
(P=0.19). Statistical differences existed between the robotic surgery group and
the laparoscopic surgery group regarding operative time (P=0.001), estimated
blood loss (P=0.03), and bladder catheterization (P=0.002). The transfusion
rate was 5.7% and 0% for laparoscopic radical prostatectomy and
robotic-assisted laparoscopic prostatectomy, respectively (P=0.02). The
percentage of major complications was 17.0% vs 5.7%, respectively (P=0.62). The
overall positive margin rate was 27.4% vs 22.8% for laparoscopic radical
prostatectomy and robotic-assisted laparoscopic prostatectomy, respectively
(P=0.38).
Conclusion:
We
demonstrated that the robot-assisted laparoscopic radical prostatectomy is
superior to laparoscopic radical prostatectomy with respect to operative time,
operative blood loss, and length of bladder catheterization.
9242 General Surgery
The Learning Curve of Laparo-Endoscopic Single Site (LESS) Cholecystectomy:
Definable, Short, and Safe
Jonathan Hernandez, MD, Connor
Morton, BS, Kellie McFarlin, MD, Farhaad Golkar, MD, Michael Albrink, MD,
Sharona Ross, MD, Alexander Rosemurgy, MD
University of South Florida, Tampa, Florida
Introduction: Great enthusiasm surrounds Laparo-Endoscopic Single Site
(LESS) surgery. Its applications, including cholecystectomy, are occurring
quickly, though little is generally known about issues associated with the
"learning curve" of this new procedure, including safety,
complications, conversion rates, and operative time. This study was undertaken
to compare our initial experience with LESS cholecystectomy with our latest
experience to delineate the learning curve.
Methods: Since 2007, we have
prospectively followed patients undergoing LESS cholecystectomy. Results of our
initial experience (first 50 patients) were compared with our latest experience
(last 50 patients). Data are reported as median, mean ± SD, where appropriate
and are compared using the Mann-Whitney U-test.
Results: Patients undergoing LESS
cholecystectomy during our initial experience were similar to patients during
our latest experience with regard to age, sex, and BMI. No differences existed
in length of operation, intraoperative blood loss, gallbladder pathology,
length of hospital stay, and the incidence or nature of complications.
Additional trocars at distant sites were applied in 6 patients, 4 of whom were
in our latest experience. Additionally, 1 cystic duct stump leak occurred in
our latest experience.
Conclusions: By 50 LESS
cholecystectomies, the learning curve of the operation has long been
"flat." The learning curve does not require many operations (ie, it
is definable and short) and is not associated with complications beyond
standard multiport laparoscopic cholecystectomy (ie, it is safe). Cosmesis
after LESS cholecystectomy will cause consumers to demand it and surgeons to
provide it.
9243 General Surgery
MIS Fellowship Influence on Obtaining Adequate Regional Lymph Node Specimens in
Laparoscopic Colectomies
Harish Kakkilaya, MD, Blasker
Reddy, MD, Udayan B. Shah, MD, W. Peter Geis, MD
Northwest Hospital, Randallstown, Maryland
Introduction: Both oncologists and
insurance payors have voiced opinions as to the adequacy of numbers of lymph
nodes in the resected specimens following the performance of colectomies for
cancer--either by laparoscopic or open technique--focusing on operative
performance.
Methods: We have designed an MIS
Fellowship Program at our hospital with 9 surgeons as faculty. Each surgeon
performs his/her laparoscopic colectomies (both benign & malignant cases)
with the fellow as educateé, and the MIS Program Director as educator-mentor.
In the past 4 years, the number of colectomies has averaged 100 plus cases per
year. The focus in all cases has been verbally, visually, and technically to
precisely obtain regional resections and remove larger than average numbers of
nodes.
Results: Lymph node numbers have
been excellent and well above the minimum expected for these procedures (both
elective and emergent). Further, lymph node numbers have been equally numerous
in laparoscopic colectomies for benign disease.
Conclusions: The facilitation of
regional laparoscopic colon resections--with focus on appropriate
landmarks--through education of the MIS fellow (using repetitive verbal, and
visual stimuli) plus demonstrations of various steps in procedures by the
educators, actively improves the precision of each of these procedures through
interactive concentration. These behaviors improve the consistency and quality
of the technical aspects of each of these procedures. Adding the benign disease
procedures to the experience, further increases consistency through repetition
and increasing familiarity for the entire surgical team.
9244 General Surgery
Laparoendoscopic Single Site (LESS) Toupet Fundoplication
John Mullinax, MD, Connor Morton,
BS, Sharona Ross, MD, Michael Albrink, MD, Alexander Rosemurgy, MD
University of South Florida, Tampa General Hospital
Center for Digestive Disorders, Tampa, Florida
Introduction: Laparo-Endoscopic
Single Site (LESS) surgery encourages application of laparoscopic Toupet
fundoplication by reducing the number of incisions, thereby improving cosmesis.
Methods: One 10-mm trocar and two
5-mm trocars are placed through one 10-mm incision at the umbilicus. Sutures
are placed in the fundus and along the lesser gastric curve to facilitate
exposure. The hiatal hernia is reduced and the hernia sac excised. The distal
esophagus is circumferentially dissected from its surrounding tissue, while
both the anterior and posterior vagus nerves are identified and preserved.
Next, the gastric fundus is mobilized by dividing the short gastric vessels,
and the hiatus is reconstructed with interrupted sutures. The posterior fundus
is then brought behind the esophagus, and the fundoplication is constructed
utilizing 8 interrupted sutures; the first 2 fix the anterior fundus and
posterior fundus to the lateral surfaces of the esophagus, which allows the
next 6 interrupted sutures to construct the fundoplication. Once the
fundoplication is completed, it is anchored to the right crus to avoid tension
and prevent twisting or breakdown. Finally, the 10-mm trocar site is closed
with a single interrupted suture.
Conclusion: Laparoendoscopic Single
Site Toupet fundoplication will be embraced by patients; laparoscopic surgeons
will need to meet patient demands.
9245 Multispecialty
Effect of a 4% Icodextrin Solution on the Reduction of Adhesion Formation
Following Gynecological Surgery in Rabbits
Behnaz Khani, MD, Nahid Bahrami, MD,
Hormoz Naderi Naeni, MD
Alzahra Hospital,
Isfahan Medical University, Iran
Objective: To evaluate the effect of 4% icodextrin on
the reduction of adhesion formation in rabbits after traumatizing uterine horns
and comparing the effect with sterile water and human amniotic fluid.
Materials and Methods: Thirty
white female New Zealand rabbits were randomized into 3 groups. The rabbits
were anesthetized and then an abdominal incision was made. Uterine horns were
abraded with gauze until bleeding occurred. The first group acted as the
control group for which 30cc of sterile water was poured over the traumatized
area. In the second group, 30cc of 4% Adept (icodextrin) was administered over
the area, and the third group received 30cc of human amniotic fluid before
closure of the abdomen. On the seventh day after surgery, a laparotomy was
performed to determine and compare adhesion formation in the rabbits.
Results: There was a significant difference between
the mean adhesion score in 4% of the icodextrin group compared with that
in the sterile water group, 2.1±0.70
versus 10.4±0.6, respectively (P=0.000). The difference was not significant between the
mean adhesion score in the amniotic fluid group compared with that in the
sterile water group,
2.1±0.70 versus 8.7±0.84, respectively
(P=0.10). Also a significant difference was found between the mean adhesion
score in 4% of the icodextrin group compared with that in the amniotic fluid
group (P=0.000).
Conclusion: The use of a 4% icodextrin solution was effective
in reducing adhesions in a gynecological surgery model in rabbits.
9246 General Surgery
Minimally Invasive Video-Assisted Thyroidectomy with Intraoperative Recurrent
Nerve Monitoring
Haytham Alabbas, MD, Nadav Aviv,
MD, Obai Abdullah, Shafik N. Wassef, Paul Friedlander, MD, Emad Kandil, MD
Tulane
University School of Medical, New Orleans, Louisiana
Objective:
The aim was to study the
feasibility of using intraoperative neuromonitoring in minimally invasive
video-assisted thyroidectomy with emphasis given to the identification of
recurrent laryngeal nerves (RLN).
Methods: Consecutive series of 37
patients with 67 recurrent at risk laryngeal nerves undergoing both minimally
invasive video-assisted thyroidectomy (MIVAT) and intraoperative nerve
monitoring (IONM) were enrolled in this retrospective, nonrandomized analysis
study. All operations were performed by the same surgeon within an academic
institution setting. Demographics, pathological characteristics, thyroid size,
operative time, intraoperative and postoperative complications following
surgery including incidence of temporary or permanent laryngeal nerve injury
were collected.
Results:
Of 67 RLNs, one permanent
unilateral RLN injury (1.4%) occurred in a patient with advanced papillary
thyroid cancer, managed by cord injection. No instances of equipment
malfunction or interference occurred.
Conclusion: The technical
feasibility of IONM seems acceptable and may serve as a meaningful adjunct to
the visual identification of nerves. Neuromonitoring during MIVAT is effective
in providing identification of laryngeal nerves and enables surgeons to feel
more comfortable. Comparative series are needed for further evaluation.
9247 General Surgery
Learning Curve for Robotic-Assisted Laparoscopic Cholecystectomy
Haytham Alabbas, MD, Nadav Aviv,
MD, Obai Abdullah, Salem Noureldine, Emad Kandil, MD
Tulane University School of Medicine, New
Orleans, Louisiana
Background: Robotic assistance in
laparoscopic surgery is a new and fast developing technology of this decade.
While robotic-assisted laparoscopy overcame conventional laparoscopy with its
3D visualization, it significantly improved mobility of instruments thereby
improving surgeon ergonomics and eliminated the handshake transition on an
instrument. The aim of this study was to explore surgical expertise and
training.
Method:
From May 2008 to February
2009, a single surgeon and an assistant resident performed 26 robotic-assisted
laparoscopic cholecystectomies (RALC) using the da Vinci robot. Clinical data
were collected prospectively and analyzed. The main intraoperative parameters
assessed were the following: operative time, robot docking time, blood loss,
transfusion rate, conversion rate, intra- and postoperative complications, and
hospitalization time.
Result: After completion of the
first 7 cases (first group), the median operative time was 150 minutes. While
in the 19 cases (second group), it was 57 minutes. Robot docking time was 60
minutes in the first group and 25 minutes in the second group. In both groups,
mean blood loss was minimal, no patients required blood transfusion, no
conversions to open or laparoscopic surgery occurred, and no postoperative
complications were reported. Median hospitalization was 24 hours in both
groups.
Conclusion: (RALC) is a feasible and
reproducible technique with a short learning curve and low intraoperative
complications. Only 7 cases are required to improve the technical skills of the
surgical resident.
9248 General Surgery
Late Results After Laparoscopic Fundoplication Denote Durable Symptomatic
Relief of GERD
Sharona Ross, MD, Kenneth
Luberice, Yasir Abunamous, Connor Morton, BS, Javier Gonzalez, Michael Albrink,
MD, Alexander Rosemurgy, MD
University of South Florida, Center for Digestive
Disorders, Tampa General Hospital, Tampa, Florida
Introduction: Laparoscopic Nissen
fundoplication is the "gold standard" in treating GERD. Early
outcomes are promising, but late outcomes in large numbers are only now available.
This study was undertaken to document late outcomes after fundoplication and
compare them with early outcomes to assess durability.
Methods: Since 1990, 925 patients
have undergone laparoscopic Nissen fundoplication and were prospectively
followed; 425 patients underwent fundoplication at least 10 years earlier (ie,
late). Preoperatively and postoperatively, patients scored the frequency and
severity of symptoms using a Likert scale (0=never/not bothersome to
10=always/very bothersome). Symptom scores before, early after, and late after
fundoplication were compared using the Wilcoxon matched-pairs test and Mann
Whitney U-test. Median symptom scores are presented.
Results: Early after
fundoplication, significant improvements were noted in the frequency (8 to 2)
and severity (10 to 1) of heartburn, and the frequency (6 to 0) and severity of
regurgitation (6 to 0) (P<0.001, for each). Similarly, late after
fundoplication, significant improvements were maintained in the frequency (2)
and severity of heartburn (1) and the frequency (0) and severity of
regurgitation (0). When comparing early vs. late outcomes after fundoplication,
symptom scores were not different. At latest follow-up, 88% of patients were
pleased with their symptom resolution.
Conclusion: Laparoscopic Nissen
fundoplication is highly effective at reducing symptoms of GERD. Laparoscopic
Nissen fundoplications are durable, as the great majority of patients maintain
dramatic symptom improvement with follow-up at 10 years, and they provide satisfying
outcomes with extended follow-up.
9249 General Surgery
Enabling NOTES: Using a Robotic Surgical Platform to Facilitate Navigation,
Camera and Instrument Repositioning, and Stability During Surgery
Amir Belson, MD, Eric Storne, BS,
MBA
NeoGuide Systems, Inc.
NOTES adoption is challenged by a dearth of adequate instruments and platforms.
NOTES surgeries to date utilizing standard endoscopes, specialized endoscopic
sheaths and instruments suggest many potential benefits but at high cost with
respect to workload, skill required, and procedure duration. Until the workload
for NOTES can be reduced to resemble that of laparoscopy, NOTES may continue to
be a surgical curiosity relegated to the distant future.
NeoGuide has developed a flexible
robotic endoscopic surgical platform for NOTES designed to minimize the
surgeon’s workload in positioning the camera and instruments with respect to
the surgical field, while providing a stable platform from which surgical
instruments are deployed. Computer algorithms are used to manipulate proximal
segments of the system to safely position the camera and tools as desired by
the physician. The surgeon simply points the camera and instruments with a
user-input device. Once in position, the platform provides rigidity for the
manipulation of tissue with surgical instruments. The system enables
repositioning of the camera and instruments without losing sight of the target
organ in the camera field of view. Any position about a target organ can be
“memorized” by the system and recalled to move back and forth between
positions. The platform is designed to provide an easy-to-learn, low-task load
environment for NOTES, so that the surgeon may instead focus on surgery. This
may help reduce the adoption hurdles faced by NOTES today.
9250 General Surgery
Laparoscopic Cholecystectomy in Gallstone Disease with Cirrhosis of the Liver
Prasanta Raj, MD, MS, Neilendu Kundu, MD
Fairview Hospital/Cleveland Clinic Health Systems, Cleveland, Ohio
Introduction: Symptoms of gallstone
disease and cirrhosis of the liver can be similar. Therefore, proper judgment
needs to be used to determine when laparoscopic cholecystectomy (LC) is
appropriate. The purpose of this report is to outline certain intraoperative
parameters to proceed with LC in the presence of cirrhosis of the liver.
Methods: Fifteen consecutive cases
of LC with cirrhosis of the liver were reviewed. LC was performed on 6
patients, with one patient requiring 2 units of blood transfusion and the other
9 patients just having a liver biopsy, without complications. In early
cirrhosis, LC was performed with symptomatic relief without complications. If
extensive macro and micro nodular cirrhosis, enlargement of the caudate lobe,
increased portal hypertension with large varices, inadequate exposure of
Hartman's pouch and Calot's triangle, a contracted and stiff liver, and a
gallbladder fundus well below the liver margin are noted, hindering the ability
for proper traction, our management was to perform only a liver biopsy.
Results: Of 6 LC patients, only 2
achieved symptomatic relief, and 1 patient required 2 units of blood
transfusion. Nine patients, who only underwent a liver biopsy, had no
postoperative complications and were treated with medical management without
the need for a cholecystectomy.
Conclusion: Differentiating between
gallstone disease and cirrhosis symptomatology can be difficult. LC can safely
be performed in early cirrhosis with relief of symptoms. However, in advanced
stages, there is less symptomatic relief with increased technical difficulties,
as well as increased serious complications, for which we recommend only
performing a liver biopsy.
9251 General Surgery
Association of Intraoperative Cholangiography with Common Bile Duct Injury
Prasanta Raj, MD, MS, Neilendu Kundu, MD
Fairview Hospital/Cleveland Clinic
Health Systems, Cleveland, Ohio
Introduction: The
role of intraoperative cholangiography (IOC) in the prevention of common bile
duct (CBD) injury has been debated since the advent of the laparoscopic
cholecystectomy. We postulate that adhering to proper technique and accurate
interpretation, prior to dividing major structures, aids in preventing CBD
injuries.
Material: We
performed a retrospective review of 300 consecutive laparoscopic
cholecystectomies with IOC. Cholangiogram was performed after complete
occlusion of the cystic duct. We used cystic duct cannulation and recommended
dye concentration for the cholangiogram. We visualized the complete biliary
duct system, ie, hepatic bifurcation, course of the right hepatic duct,
presence of the ducts of Lushka, ampulla of Vater, and flow of dye into the
duodenum. Visualization of the gallbladder, while the cystic duct is completely
occluded, indicates the presence of the ducts of Lushka.
Results: Two
cases were identified where a small ductotomy was performed on the CBD. Proper
interpretation increased our suspicion, and the correct diagnosis of ductotomy
of the CBD was made. One case was managed by placement of a T-tube. The other
patient had a postoperative ERCP with stent, as the CBD was extremely small,
precluding the use of a T-tube. In both cases, major CBD injury was prevented
because of the use of IOC. We believe that improper technique including
inappropriate concentration of dye, incomplete cholangiogram, misleading
cholangiogram, and misreading of the cholangiogram are the probable reasons for
CBD injury after performing IOC.
Conclusion: Adhering
to the proper technique and correct interpretation of the findings, prior to
dividing structures, can aid in the prevention of major CBD injuries.
9252 General Surgery
Ten-Year Experience with Minimally Invasive Surgery (MIS) in Pediatric Cancer
Patients
Gloriamaria Gonzalez, MD, Amy Schwartz, PA, Stephen J. Shochat,
MD, Bhaskar N. Rao, MD, Andrew M. Davidoff, MD
St. Jude Children’s Research Hospital
Background:
In pediatric oncology, minimally invasive surgery (MIS) has proven to be an
effective approach in the diagnosis of cancer, but has had a limited role in
the resection of tumors. The aim of this study was to review the indications
for MIS in a pediatric cancer center.
Method: We conducted a retrospective
review of all minimally invasive procedures performed between 1998 and 2008.
Results:
During this period, 180 procedures were performed in 162 patients. Of these, 91
were laparoscopic procedures, 28 for diagnostic purposes, 19 for tumor
resection, and 44 to treat complications of the tumor or its therapy (12
oophoropexies, 9 splenectomies, 10 fundoplications, 11 cholecystectomies, 1
appendectomy, and 1 reduction of an intussusception). In the same period, 89
thoracoscopies were performed, 14 to evaluate a mediastinal mass, 53 to biopsy
pulmonary nodule(s), 6 to resect tumors, and 16 to evaluate diffuse lung
processes. Seven tumor resections (7.6% of 91 cases) were performed in the
first 5 years of the study, and 18 (20% of 89 cases) were performed in the last
5 years. Conversion to open surgery occurred in 11% of the laparoscopies and
15% of the thoracoscopies. No major complications occurred. Of 111 biopsies,
110 were successful in obtaining a pathologic diagnosis.
Conclusion:
This experience highlights the broad indications for MIS in pediatric oncology.
MIS can be performed safely and consistently accomplish the desired goal.
Interestingly, over time, the percentage of cases that were performed for tumor
resection has increased. Future indications for tumor resection with an MIS
approach warrant further monitoring.
9253 General Surgery
Side-to-Side Gastro-Colic Anastomosis Provides Drastic Weight Loss: Anastomotic
Size is an Important Variable
Michel Gagner1,2, David Blaeser3, Dale
Spencer3
1Mount Sinai Medical Center, Miami Beach, Florida
2Florida International University, Miami, Florida
3EndoMetabolic Solutions Inc., Minneapolis, Minnesota
Introduction: Partial bypass of the
GI tract may promote weight loss by decreased absorption of nutrients and
changes in incretins. The aim of the study was to evaluate the safety and
efficacy of performing a side-to-side gastro-colic anastomosis.
Methods: Six pigs of 40kg to 60kg
were allocated to a 1-cm gastro-colic side-to-side anastomosis or a control
(gastric and colic opening and closure). Four 20kg to 22kg dogs had a 5-cm
gastro-colic anastomosis. Body weights were followed up to 40 days.
Results: Pigs with a 1-cm
anastomosis failed to lose weight and gained 20.4% similarly to controls that
had gained 21.4% at 40 days. At autopsy, anastomosis had failed and prematurely
closed. However, dogs had shown a drastic weight loss of -19.8% after 30 days,
or a difference of 4kg to 6kg. A plateau trend for weight loss had been reached
between 25 days and 35 days.
Conclusion: In this canine model
with short follow-up, a side-to-side gastro-colic anastomosis of 5cm provided
excellent weight loss and is safe. A small side-to-side gastro-colic
anastomosis (ie, ≤1cm) failed to provide a similar weight loss in another
mammal model.
9254 General Surgery
Video Presentation: Robotic Resection of the Left, Right, and Sigmoid Colon
Nadav Aviv, DO, Emad Kandil, MD
Department of Surgery, Tulane University School of Medicine, New Orleans,
Louisiana
Background: Robot-assisted colon surgery has been shown to be safe and
efficacious. The robotic technique offers some advantages over the
laparoscopic, namely better visualization of the operating field
and instruments with a greater degree of dexterity. While studies
comparing the 2 techniques have not demonstrated a clear advantage for one over
the other, many agree that the advantages of the robot become most evident in
colonic surgery when operating in the pelvis and on the splenic flexure,
especially in patients with abnormal anatomy. Here we present footage from 3 patients
who were operated on at our medical center and underwent robotic left, right,
and low anterior colonic resections. Major steps of the operative procedures
are highlighted.
Methods: Three
patients underwent right, left, and low anterior colonic resections performed
with the da Vinci robot. In this footage, we highlight the major salient steps
of the dissection and operative procedure including the takedown of the splenic
flexure and pelvic dissection.
Results: All
3 patients experienced no perioperative complications, had minimal blood loss,
and a normal postoperative course.
Conclusion: Robotic
colon surgery is safe and effective. We offer this video to demonstrate our
technique and highlight the advantages afforded by robotic surgery.
9255 Gynecology
Laparoscopic Modified Radical Hysterectomy and Staging for Uterine Papillary
Serous Carcinoma with Cervical Involvement
Farr Nezhat, MD1, Connie Liu MD2,
Dimitry Lerner MD3
1St. Luke’s-Roosevelt Hospital center,
New York, New York
2NYU Medical Center, New York, New York
3Mount Sinai Medical Center, New York, New York
Objective: To illustrate a case demonstration of
laparoscopic modified radical hysterectomy in a patient with uterine papillary
serous carcinoma involving the endocervical canal.
Methods: This 47 year-old, para-3 woman with no family
history of cancer and 3 prior cesarean deliveries presented with postmenopausal
bleeding. Endometrial biopsy revealed a mixed poorly differentiated papillary
serous and endometrioid carcinoma. On initial examination, a cervical lesion
was noted and endocervical curettage was positive for a poorly differentiated adenocarcinoma
with squamoid features. Due to the endocervical involvement, modified radical
hysterectomy was recommended. All options for management were reviewed with the
patient, and she consented to laparoscopic surgical staging.
Results: She underwent laparoscopic modified radical
hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and paraaortic
lymphadenectomy, and omentectomy without complication. Her total operative time
was 330 minutes with a total blood loss of 100cc. She was discharged on
postoperative day 3 and had postoperative urinary retention that was treated
conservatively until she could void appropriately on postoperative day 14.
Final pathology revealed a stage IIIC uterine papillary serous carcinoma. She
underwent postoperative chemotherapy with Taxol, Adriamycin, and Cisplatin. She
is currently with no evidence of disease at 10 months follow-up.
Conclusions: Laparoscopic modified radical hysterectomy with
staging as described is a feasible treatment approach and alternative to
laparotomy for patients with advanced uterine papillary serous carcinoma.
9256 General Surgery
Robotic Adrenalectomy
Nadav Aviv
Introduction: Robotic adrenalectomy compared with the
laparoscopic technique has been shown to produce similar outcomes in patients.
Both methods result in decreased blood loss, morbidity, and hospital length of
stay compared with open surgery. The robotic technique provides the operator
with the added benefit of a 3-dimensional view of the operative field and 7
degrees of dexterity. Here, we present video footage from a right robotic
adrenalectomy performed at our institution.
Methods: The patient in the video is a 60-year-old female
with Cushing’s syndrome who underwent a right adrenalectomy performed using the
da Vinci robot at our institution. Footage highlighting the salient steps of
the procedure is presented.
Results: The patient did well and was discharged on the
second day following surgery.
Conclusion:
Robotic adrenalectomy is an
alternative minimally invasive technique that allows surgeons to overcome the
limitations posed by laparoscopy, namely limited visualization of the operative
field and decreased dexterity. This video demonstrates the advantages of using
the da Vinci robot to perform this procedure.
9257 General Surgery
Robotic Gastrointestinal Surgery: Our First 50 Consecutive Cases
Emad Kandil, MD, Nadav Aviv, DO
Tulane University School of
Medicine, New Orleans, Louisiana
Background: Robots are being used increasingly to perform gastrointestinal
procedures. Robotic surgical systems have the advantage over laparoscopic
techniques of providing surgeons a 3-dimensional view of the operating field,
articulating instruments with 7 degrees of freedom, dampening of hand tremors,
and the ability to operate with the camera and instruments in line with
the target, eliminating counterintuitive motions. Maneuvers such as
intracorporeal suturing, complex dissections in confined spaces such as the
pelvis, and dissection of fine structures are all facilitated by the robot.
Here, we present the results of our first 50 robotic gastrointestinal cases
performed by one single surgeon.
Methods: Outcomes from the first 50
patients who underwent robotic adrenalectomies, Heller myotomies,
cholecystectomies, colectomies, and a gastrectomy at our institution were
analyzed.
Results: We had no open conversions
or perioperative complications in our first 50 patients.
Conclusion: Robotic gastrointestinal
surgery is a safe and effective modality for minimally invasive surgery.
9258 General Surgery
A Novel Technique for Laparoscopic Seprafilm Administration
Adithya Suresh, MD, Ziad T. Awad,
MD
University of Florida College of Medicine- Jacksonville
Background: Patients undergoing
surgery to the abdomen and pelvis often develop postoperative adhesions.
Adhesion formation remains one of the leading causes of intestinal obstruction.
Adhesions make reoperative surgery challenging and complex. With this in
consideration, there is a real need to develop methods of reducing
postoperative adhesions.
Methods: Seprafilm (Genzyme,
Cambridge, MA) is an anti-adhesive sheet composed of sodium hyaluronate –
carboxymethylcellulose. Approximately 24 hours to 48 hours after placement, the
membrane becomes a hydrated gel that is slowly resorbed within one week.
Multiple studies have shown that the use of Seprafilm after laparotomy has
reduced the incidence, extent, and severity of adhesions. Using Seprafilm
laparoscopically is challenging due to the physical properties of the material.
It is brittle when dry and difficult to manipulate through small incisions.
When wet, it sticks to foreign surfaces, thus impairing the surgeon’s ability
to deliver it to sites of surface damage. We have developed a simple technique
for administering Seprafilm sheets onto the abdominal viscera following
laparoscopic surgery.
Results: The Seprafilm sheets are
dissolved prior to the end of surgery in warm normal saline, and the solution
is placed into a Toumey catheter tip syringe. The syringe is then attached to a
Robinson catheter that is introduced into the abdomen via a laparoscopic trocar.
Under direct visualization, the Seprafilm solution is squirted onto the damaged
peritoneal surfaces.
Conclusion: Long-term studies are
needed to assess whether our Seprafilm solution technique has the same efficacy
as the application of whole sheets placed directly on the abdominal wall and
the bowel.
9260 General Surgery
Robotic Adrenalectomy: A Report of Our Early Experience
Emad Kandil, MD, Nadav Aviv,
DO
Tulane
University School of Medicine, New Orleans, Louisiana
Introduction: Robotic
adrenalectomy has been shown to produce similar outcomes in patients compared
with the laparoscopic technique. Both methods result in decreased blood loss,
morbidity, and hospital length of stay compared with open surgery. The robotic
technique provides the operator with the added benefit of a 3-dimensional view
of the operative field and 7 degrees of dexterity. The largest series of 30
cases reported a median operative time of 185 minutes, and an average hospital
length of stay of 2 days. We report the results from the first 8 robotic
adrenalectomies, with video footage, performed at our institution.
Methods: Eight patients, ages 33 to
70, underwent robotic adrenalectomies, by a single surgeon, for functional
adrenal nodules.
Results: Patients had an average
hospital length of stay of 1.5 days, with no associated postoperative
complications, minimal blood loss, and no incidences of open conversion. The
average operative time was 184 minutes (range, 304 to 95).
Conclusion: Robotic adrenalectomy is
an alternative minimally invasive technique that allows surgeons to overcome
the limitations posed by laparoscopy, namely limited visualization of the
operative field and decreased dexterity. Our experience demonstrates that
results commensurate with those reported by others can be achieved relatively
early when an experienced surgeon performs the procedure.
9261 General Surgery
Laparoscopic Repair of Spigelian Hernia Mimicking Postoperative Ileus Following
Perineal Rectosigmoidectomy
K. H. Nagarsheth, MD, D. Sutphin, MD, G. Mancini, MD, J. Solla, MD
University of Tennessee Medical Center, Knoxville,
Tennessee
Objective: To present the case of a
laparoscopic repair of an incarcerated spigelian hernia in a patient who
presented initially with rectal prolapse and underwent perineal
rectosigmoidectomy.
Methods: Case report.
Results: An 87-year-old woman presented with a large, full-thickness,
rectal prolapse that was not reducible. This patient was deemed high risk for
an intraabdominal procedure and thus underwent a perineal rectosigmoidectomy.
Postoperatively, this patient became distended and began to have tenderness in
her abdomen. It was felt that the patient had a postoperative ileus, which was
strange because she had no intraabdominal procedure performed. With her
increased distention, nausea, and vomiting, a CT scan of the abdomen was
obtained that revealed an enlarged spigelian hernia with a portion of ileum
that appeared kinked. The patient was taken to the OR emergently for a
laparoscopic hernia repair with mesh. Postoperatively, the patient began having
flatus and bowel movements on POD 2, and her nausea and vomiting had resolved.
Conclusions: Spigelian hernias are a rare entity, and although a number of
cases have been reported in the literature, there is no clear consensus as to
the optimal way of repair, whether laparoscopic or open. In this case, the
patient’s incarcerated spigelian hernia was mistaken for a postoperative ileus
because this was not the patient’s presenting complaint.
9262 Gynecology
Transvaginal Ultrasound Prediction of Uterine Specimen Weight in Laparoscopic
Supracervical Hysterectomy
Michael Swor, MD
Sarasota Memorial Healthcare Systems
Background: Assessing uterine size
prior to laparoscopic surgery is important for preoperative planning and choice
of approach.
Methods: Endovaginal ultrasound was performed by the surgeon in 40
consecutive laparoscopic supracervical hysterectomy (LSH) patients. All
patients had benign disease and either no oophorectomy or unilateral
oophorectomy with a small ovary. Ultrasound measurements of uterine length,
width, and AP diameter were calculated to estimated uterine volume based on
general ovoid shape by using internal ultrasound software.
Results: Estimated preoperative
uterine volume ranged from 34.7cc to 210.3cc with a mean volume of 96.0cc. The
surgical pathology department weighed the morcellated fixed specimens and
provided gram weight reports. The LSH specimen weights ranged from 33g to 285g,
with a mean 106g. A relative reference mass comparable to water was used where
1cc=1g. The absolute difference between estimated and actual uterine specimen
weight ranged from 0g to 78.4g (0% to 50%), with a mean of 18g or 17%.
For the 9 specimens with weights over 150g, the predicted value was generally
underestimated by approximately 20%.
Conclusion: Endovaginal ultrasound
can be used as a reasonable predictor of surgical specimen weight, which
surgeons can use to improve laparoscopic surgery planning. This planning might
include decisions on port location, size, facility, and assistant choice,
operative time estimate, instrument choice (such as morcellator size), and
optional in-suite fresh specimen weighing for insurance coding.
9264 Gynecology
Primary Pelvic Floor Repair with Laparoscopic Supracervical Hysterectomy
Michael Swor, MD
Sarasota Memorial Healthcare Systems
Laparoscopic supracervical hysterectomy (LSH)
is a common advanced laparoscopic procedure offered as treatment for several
gynecologic problems. Ideas vary among surgeons regarding optimal closing
techniques of the cervix and pelvic floor. Many advocate no closure at all.
Another consideration with LSH is adjunctive treatment of uterine prolapse
either identified preoperatively, or noted with hypermobility in the post-LSH
cervix at surgery.
In this video, I am
demonstrating a technique for primary cervix and pelvic floor closure. In addition,
I show a simple technique for uterosacral reattachment or plication for support
of the residual post-LSH cervix and vaginal vault. This can be done with or
without the robotic technique. It can be done with total hysterectomy as well. In
the video, the da Vinci-S robotic technology is being used with the advantages
of improved instrument dexterity and visualization. I use sharp dissection and
intermittent pulsed radio-surgical desiccation.
The purpose of primary
pelvic floor repair and uterosacral plication is to enhance apical pelvic floor
support, increase or maintain vaginal length, and provide peritoneal closure
for reduced adhesions.
After over 150 cases, my
experience has been very favorable outcomes and no major complications. A few
patients have been evaluated with repeat laparoscopic procedures by the author
and no significant adhesions have been noted. Favorable postoperative objective
and subjective findings regarding pain, bladder, bowel, and sexual function are
comparable to findings with other laparoscopic procedures. Uterosacral
plication or reattachment adds a measurable improvement in post-LSH vaginal
length and apical support. Most importantly, patient satisfaction scores are
high with this procedure.
9265 Urology
Transmesenteric Robotic-Assisted Laparoscopic Pyeloplasty: A Simple Approach
for Pediatric Ureteropelvic Junction Obstruction Repair
Roger De Filippo, MD1, Andy
Chang, MD1, Craig Peters, MD2, Chester Koh, MD1
1Children’s Hospital Los Angeles, Keck School of Medicine, University of
Southern California
2University of Virginia Children
Objective: Robotic-assisted laparoscopic pyeloplasty is a minimally
invasive option in pediatric urology for ureteropelvic junction obstruction. We
describe a transmesenteric approach of left-sided cases that provides direct
access to the renal pelvis without mobilization of the descending colon.
Methods: We reviewed our initial
series of pediatric pyeloplasties performed using robotic assistance. Medical
records including operative reports, hospital charts, imaging studies, and
video records were reviewed.
Results: We reviewed 12 charts. The
patient mean age was 8 years (range, 3 to 14). Obstruction was confirmed on MAG
3 renal scan and retrograde pyelograms. Four right-sided pyeloplasties with a
retrocolic approach and 8 left-sided pyeloplasties with a transmesenteric
approach were performed using a dismembered technique. Right-sided procedures
began with mobilization of the colon along the avascular line of Toldt. For
left-sided procedures, the renal pelvis was visualized through the colon
mesentery. After excision of the diseased segment, reconstruction was performed
using running 6-0 Monocryl. For left-sided procedures, the mesenteric window
was closed with a running 4-0 Vicryl suture. There was a trend toward reduced
total operative times (226 vs 238, p=0.362) and console times (156 vs 175,
p=0.197) in the transmesenteric group compared with that in the retrocolic
group.
Conclusion: Robotic-assisted
laparoscopic transmesenteric pyeloplasty appears to be feasible in the
pediatric population based on this initial series. Statistical analysis reveals
a trend toward shorter procedures with time reductions similar to those seen
with laparoscopic pyeloplasties performed in a transmesenteric fashion.
9266 Gynecology
Fertility-Sparing Robotic-Assisted Radical Trachelectomy and Bilateral Pelvic
Lymphadenectomy in Early Stage Cervical Cancer
Linus Chuang, MD2, Connie Liu, MD3,
Dimitry Lerner, MD2, Farr Nezhat, MD1
1St. Luke’s-Roosevelt Hospital center, New York, New York
2Mount Sinai Medical Center, New York, New
York
3NYU Medical Center, New York, New York
Objective: To illustrate a case of robotic-assisted radical
trachelectomy in a patient with invasive adenocarcinoma of the cervix.
Methods: This 30-year-old,
para-1 woman was diagnosed with adenocarcinoma in situ of the cervix in an
endocervical polyp when she presented without complaint to her postpartum
visit. She was a nonsmoker with no history of abnormal Pap smears. She
subsequently underwent a cold knife conization that revealed invasive
adenocarcinoma of the cervix with lymphovascular invasion. Endocervical
curettage and endometrial biopsy were benign. Pelvic examination revealed a
stage IB1 adenocarcinoma of the cervix. All options for management were
reviewed, and the patient expressed a strong desire for fertility sparing
surgery.
Results: She underwent a
robotic-assisted radical trachelectomy and bilateral pelvic lymphadenectomy to
treat her early stage cervical cancer. A polyethylene cerclage was placed at
the termination of the procedure. Her estimated blood loss was 200cc, and she
suffered no postoperative complications. She resumed a normal menses 4 weeks
postoperatively.
Conclusions: This represents the
first case of a patient with early cervical adenocarcinoma managed with
robotic-assisted radical trachelectomy and pelvic lymphadenectomy. This
technique combines the advantage of open and laparoscopic procedures with a
familiar anatomic approach, increased magnification, and the superior dexterity
of robotic surgery. We hope, with rapid acceptance of robotic surgery in
gynecologic oncology, robotic radical trachelectomy will make fertility sparing
options a more accessible option for select women with early stage cervical
cancer who desire fertility preservation.
9267 General Surgery
Dissatisfaction After Laparoscopic Heller Myotomy Due To Esophageal Dysmotility
Sharona Ross, MD, Kellie McFarlin,
MD, Connor Morton, BS, Chinyere Okapaleke, BS, Melissa Rosas, Alexander
Rosemurgy, MD
University of South Florida and Tampa General Hospital Center for Digestive Disorders
Introduction: Achalasia is
characterized by aperistalsis of the esophagus and failure of the lower
esophageal sphincter to relax. Laparoscopic Heller myotomy is undertaken to
incapacitate the lower esophageal sphincter, but does not impact esophageal
dysmotility. This study was undertaken to determine the causes of
dissatisfaction after myotomy and, specifically, the relative importance of
dysmotility or inadequate myotomy in causing dissatisfaction after Heller
myotomy.
Methods: Since 1992, 414 patients
have undergone laparoscopic Heller myotomy with anterior fundoplication.
Preoperatively and postoperatively, patients scored the frequency and severity
of symptoms of achalasia and graded their outcomes from Very Satisfying
to Very Dissatisfying. Patients denoting dissatisfaction underwent evaluation,
including endoscopy, timed barium study/upper GI, and ambulatory pH study. Data
are reported as median.
Results: Twenty-five (6%) patients
reported dissatisfaction after laparoscopic Heller myotomy. Preoperatively,
dysphagia, regurgitation, and choking were frequent and severe. Hospitalization
lasted 1 day. Follow-up is 27 months. Postoperatively, symptoms including
dysphagia and choking improved (p<0.05, Wilcoxon), but persisted. Persistent
troublesome symptoms were due to profound esophageal dysmotility in 10 patients
and inadequate myotomy in 2 patients. New symptoms of gastroesophageal reflux
led to dissatisfaction in 4 patients.
Conclusions: Dissatisfaction is
uncommon after myotomy and is generally a result of persistent or new symptoms
due to a variety of causes. Dissatisfaction is most often a consequence of
persistent symptoms due to profound esophageal dysmotility rather than inadequate
myotomy, but other causes (eg, peptic stricture) must be ruled out.
Laparoscopic Heller myotomy effectively palliates symptoms of achalasia, and
its application is encouraged.
9268 General Surgery
The Resection of a Mid Esophageal Diverticulum Complicating Palliated Achalasia
Kellie McFarlin, MD, Connor
Morton, BS, Nitin Babel, MD, Sharona Ross, MD, Alexander Rosemurgy, MD
University of South Florida and Tampa General Hospital Center for Digestive
Disorders, Tampa, Florida
Introduction: A diverticulum can develop as a consequence of high
intraesophageal pressures when failure of the lower esophageal sphincter to
relax occurs in the presence of spastic esophageal contraction. A large
esophageal diverticulum acts as a reservoir for food and can exacerbate
dysphagia associated with achalasia.
Methods: This video presentation is
of a thoracoscopic diverticulectomy for symptomatic thoracic esophageal
diverticulum complicating palliated achalasia. This middle-aged female was
treated with Botox injection into her lower esophageal sphincter, with
resultant defunctionalization. However, food continued to preferentially enter
and be retained in her mid esophageal diverticulum. She was positioned in a
modified left lateral position. Three 5-mm trocars were placed in the left
thorax in a position of triangulation to facilitate dissection of the esophagus
at the level of the sixth intercostal space. Single lung ventilation was
utilized, and the lung retracted with a fan retractor.
Results: The diverticulum was
dissected free with an ultrasonic dissector to the wall of the esophagus and
amputated at its neck with an articulating linear stapler. A myotomy was
deferred because intraoperative endoscopy confirmed preoperative studies
documenting a patulous gastroesophageal junction. The diverticulum was removed
through a trocar and a thoracostomy tube was placed through a trocar site.
Conclusion: A midesophageal
diverticulum can be removed videoscopically with minimal morbidity, and
resection is recommended when such a diverticulum symptomatically complicates
achalasia.
9269 General Surgery
Natural Orifice Surgery in Gastric Bypass Patients Who Regained Weight: A
Feasibility Study
Chiranjiv Virk, MD,
Elliot Goodman, MD
Beth Israel Medical
Center, Albert Einstein College of Medicine New York, New York
Objective: Approximately 10% to 40% of gastric
bypass (GB) patients regain weight 2 years to 7 years following surgery due to
dilation of either the pouch or gastrojejunostomy. Revision surgery is
associated with significant morbidity: less invasive endoluminal procedures may
represent safer alternatives. We sought to evaluate the safety and efficacy of
StomaphyX to correct either a dilated gastric pouch or gastrojejunostomy in
post-GB patients who regained weight.
Methods:
Pouch revision using
StomaphyX, an incisionless transoral, fastening device, was performed in 30
consecutive patients.
Results: All 30 patients [97% female, median age
46 years (range, 24 to 66), and median BMI 41 (range, 31 to 59)] lost at least 50%
EWL following RNYGB and regained at least 20% EWL, representing a median 53lb
(range, 22 to 107) regained weight (RW) within 5 years (range, 1 to 10) after
primary surgery. The median operative time was 55 minutes (range, 35 to 130).
The procedure resulted in a 75% to 90% reduction in gastric pouch size through
formation of 10 to 40 plications. No postoperative complications occurred.
Eighteen patients were available for complete follow-up assessment (at median 3
months, range 1 to 5). Four patients did not loose any RW. The remaining 14
patients experienced a median weight loss of 15lb (range, 11 to 27),
representing 8% EWL (range, 4 to 20) and 26% RW loss (range, 15 to 50).
Conclusion:
StomaphyX appears safe.
It effectively plicates the gastric pouch, promoting a promising 15% to 50%
reduction in regained weight in 79% of post-GB patients within 1 month to 5
months.
9270 General Surgery
SILS. Single-Port Laparoscopic Surgery: Initial Experience
Fernando Arias, MD, Francisco Diaz,
MD, Armando Rojas, MD, Lina Bermeo, MD, Diana Baptista, MD
Fundación Santafe de Bogotá.
Objective: To review our initial
experience with single-port laparoscopic surgery, which is rapidly becoming
popular due to excellent results.
Methods and Procedures: Over 9
months, 24 appendectomies, 12 cholecystectomies, 1 intraoperative
cholangiography, 2 abdominal lymph node biopsies, 1 splenectomy, 1
mesenteric cyst resection, and 1 sleeve gastrectomy for morbid obesity were
performed. We used several devices to perform the procedures (Triport, Gelport,
Alexis wound retractor). Short videos are presented.
Results: In most procedures, the
operative time was comparable to the time for standard laparoscopic surgery.
All patients remained symptom free at follow-up. No complications were recorded,
except for moderate intraoperative bleeding in the splenectomy.
Conclusions: These cases represent
our initial experience with single-port laparoscopic surgery. SILS is feasible. The majority of
patients can tolerate fast-track surgery. Morbidity is minimal, and the
cosmetic result is excellent.
9271 General Surgery
Sleeve Gastrectomy Versus Roux-en-Y Gastric Bypass: A Comparison of
Weight Loss and Diabetes Resolution
Seema Dhorajia, DO, Lisa Derr, DO,
Shabnam Zarrabi, Louis Balsalma, DO, Marc Neff, MD
UMDNJ-SOM, Stratford,
New Jersey
Background: Since its introduction
in 1999, the sleeve gastrectomy (SG) has become a very popular weight-loss
procedure. Long-term data on the procedure, however, are lacking. The benefits
to diabetes control and resolution after Roux-en-Y gastric bypass (RYGB) are
well documented. We sought to examine the relationship between weight loss and
diabetes resolution with respect to the 2 operative procedures.
Methods: A retrospective chart
review was performed on a prospectively maintained database of patients
undergoing sleeve gastrectomy and RYGB as a weight-loss surgical procedure from
January 2007 to February 2009. Twenty-four patients underwent sleeve
gastrectomies. Follow-up for these patients was 96%. Patients were evaluated
at 1 month, 3 months, 6 months, and 1 year. Data were then compared
with that of patients who underwent RYGB during the same time period with
respect to weight loss and diabetes resolution.
Results: Resolution of diabetes was
observed in nearly all patients who underwent weight loss surgery. The majority
went home off of their diabetic medications. Weight loss and diabetes
resolution in the first 6 months were comparable to that in a similar group of
patients who underwent RYGB during the same time period.
Conclusions: Sleeve gastrectomy is
an effective weight-loss surgery with similar resolution of weight loss and
diabetes compared with the standard RYGB.
9272 General Surgery
Single-Port Mesenteric Cyst Resection
Fernando Arias, MD
Fundación Santafe de Bogotá.
This video shows a totally transumbilical single-port resection of a mesenteric
cyst 30cm in diameter. The patient is a 17-year-old girl with a history of
increased abdominal perimeter, and an ultrasound was indicated. This revealed a
unilocular cystic lesion 30cm x 20cm, displacing the abdominal viscera. A
CT scan was done showing a mass 32cm x 25cm from the celiac trunk to the
pelvis, suggesting a giant mesenteric cyst. The patient underwent a
laparoscopic complete resection of the mesenteric cyst that severely elongated
the left fallopian tube, which was also removed. The procedure was performed
without complications, and the operative time was 120 minutes. The pathologic
study confirmed a simple unilocular mesenteric cyst and an elongated normal
fallopian tube. The patient was discharged from the hospital after 24 hours.
This is a feasible procedure with excellent results.
9273 General Surgery
Combined Thoracoscopic and Laparoscopic Repair of a Traumatic Diaphragmatic Hernia:
A Tale of Two Techniques
Hang Dang, DO, Toni
Green, DO, Morris Eisen, DO, Marc Neff, MD
UMDNJ-SOM, Stratford,
New Jersey
Introduction: Surgeries performed in conjunction with other disciplines
(urology, transplant, thoracic) are now the exciting front lines of surgical
investigation. Our case represents just that, the marriage of thoracoscopic and
laparoscopic techniques.
Case Report: The patient was involved in a motor
vehicle accident approximately 4 weeks prior to presentation. She was seen and
evaluated at a local Level I trauma center and discharged home uneventfully.
She subsequently presented to her PCP complaining of chest pain/tightness, and
a chest X-ray performed revealed a hiatal hernia, which was subsequently
confirmed with CT and UGI.
Methods:
The patient was placed
in the left lateral decubitus position. A double-lumen endotracheal tube was
placed. A thoracoscope was placed into the chest cavity. Four 5-mm
incisions were placed in the left upper quadrant. A large defect was identified
anterior to the hiatus that contained incarceration of the greater body of the
stomach and transverse colon. Once the adhesions were taken down, the
incarcerated contents were reduced. The defect was measured at 5cm. A Composix
mesh was inserted and partially sutured and partially tacked to the diaphragm
with a spiral tacker. The entire procedure was visualized with both a
thoracoscope and a laparoscope to ensure no damage was done to mediastinal
structures or lung.
Conclusion: This case
demonstrates a perfect example of the knowledge and expertise of surgeons
familiar with minimally invasive techniques to combine their abilities
to aid a patient with a complicated and interesting problem.
9274 General Surgery
Lessons Learned in 149 LCBDE Cases Applied to Procedural Algorithm
Donald E. Wenner, MD1, Paul R
Whitwam, MD1, James C Rosser, Jr., MD2
1Roswell Regional Hospital, Eastern New Mexico
Medical Center
2Morehouse School of Medicine
Objective: To develop a procedural algorithm based on an experience
of 149 LCBDE cases using the 2.8-mm flexible choledochoscope and the
multi-channel instrument guide (MIG).
Methods: The MIG was developed to protect the
fragile choledochoscope and to add procedural enhancements to the LCBDE
procedure. The procedure has evolved as experience with this instrument has
accumulated. Patterns of use based on stone location, size, and surgical
history have emerged. These have been incorporated into the development of a
procedural algorithm to guide surgical choices during the LCBDE procedure.
Results: A transcystic duct LCBDE is applicable
to cases where the stones are smaller than 8mm, are fewer than 20 in number,
and are lodged in the distal CBD. A choledochotomy approach is required in
patients with large stones >8mm, in those with large numbers of stones
(>20), in those with hepatic duct stones, and in patients who have undergone
a previous cholecystectomy.
Conclusion: In our series of 149 patients, we have
found 70% of our choledocholithiasis patients have stones that can be cleared
using transcystic duct techniques. Fortunately, patients with large stones and
patients with a history of previous cholecystectomy have large diameter CBDs,
and these are amenable to a choledochotomy approach. Procedural enhancements
provided by MIG protect the fragile choledochoscope from damage and offer
significant advantages to both transcystic duct and choledochotomy LCBDE
procedures. A logical procedural algorithm has been developed to cover most
choledocholithiasis circumstances.
9275 General Surgery
Laparoscopic Resection For Benign Gastric Tumor Around Esophagogastric Junction
Seong-Yeob Ryu, MD, Ho-Kun Kim, MD,
Mi-Ran Jung, MD, Dong-Yi Kim, MD, Young-Jin Kim, MD
Chonnam National
University Medical School, Korea
Background: Laparoscopic operations are useful in many fields.
Removal of a primary lesion with a clear operative margin is the standard
treatment for benign gastric tumors. And the most recent benign gastric tumor
was safely removed by laparoscopic wedge resection. In particular, we analyzed
the laparoscopic approach to benign gastric tumors in the esophagogastric
junction.
Method: From April 2004 to March 2008, 134 patients
underwent laparoscopic wedge resection for gastric submucosal tumors. Of 134
patients, 30 had gastric submucosal tumors in the esophagogastric junction. We
analyzed 30 patients, their age, sex, the presenting symptoms, diagnostic
modalities, size and location of the masses, the operative time, the pathologic
diagnosis, the postoperative hospital course, and recurrence.
Results: The mean size of the tumors was 3.2±1.54cm (range,
1.2 to 7.8). All operative margins were clear. The time to first flatus was
1.9±0.51 days (range, 1 to 3), liquid diet feeding was started for 5.9±1.26
days (range, 4 to 9). No case of open conversion, reoperation, and operative
mortality and morbidity occurred in this study. The median follow-up period was
16.6±12.96 months (range, 1 to 51), and there have been no recurrences or
distant metastases.
Conclusion: We conclude that laparoscopic wedge resection in
the esophagogastric junction is safe and feasible.
9276 Gynecology
Feasibility, Morbidity, and Outcome Following Laparoscopic Myomectomy for Large
Fibroids
Sheila Mehra, MD, MRCOG
(LONDON), FRCOG (LONDON), Gautam Mehra, MD, MRCOG (LONDON)
Objective: To study
the feasibility, morbidity, and outcome following laparoscopic myomectomy for
large fibroids.
Methods: This was a prospective observational
study in which data were collected on operating time, hospital stay, blood
transfusion rate, complications, and reproductive outcomes in women with
infertility or symptoms secondary to fibroids with abdomino-pelvic mass
requiring laparoscopic myomectomy.
Results: Over a period of 21 years, 910 women
with fibroid uterus were chosen for laparoscopic surgery. The mean hospital
stay was 2 days, while the mean operating time was 116±10 minutes. Blood
transfusion rate was 1.6%. Complications included hemorrhage (2), significant
postoperative pain (5), febrile illness (10), wound infection (15), UTI (10),
and voiding problems (15). Overall patient satisfaction was 90%, while 85% had
total relief of symptoms at follow-up. Median follow-up was 62 months (range,
36 to 180); 120 had infertility; 72/80 women conceived; 15/80 women had early
pregnancy loss; 90% had a caesarean delivery.
Conclusion: Laparoscopic myomectomy is feasible
and safe in women with large fibroids following appropriate selection. It has a
reasonably low morbidity, good patient satisfaction rates, and acceptability
with an encouraging reproductive outcome.
9277 General Surgery
Laparoscopically Assisted Placement of Ventriculoperitoneal Shunts Helps to
Avoid Unnecessary Abdominal Incisions
Usama Qumsieh, MD, Marek
Rudnicki, MD, Leonard I. Kranzler, MD
Metropolitan Group
Hospitals/University of Illinois Surgery Residency Program, Chicago, Illinois
Introduction: Ventriculoperitoneal shunts are
traditionally tunneled subcutaneously from the occipital area using multiple
skin incisions over the neck, chest, and abdominal wall and inserted blindly
into the peritoneal cavity. Here, we describe a laparoscopic technique that
prevents unnecessary incisions and assures a more accurate placement of the
catheter in the abdominal cavity.
Methods: Five patients underwent laparoscopic
distal end placement of a ventriculoperitoneal catheter. After the proximal end
was placed in the cerebral ventricles, a 5-mm port was inserted into the
abdomen to guide the distal end of the shunt. A guiding probe was then tunneled
from the lateral neck to the perixiphoid area subcutaneously. At that moment,
by applying manual pressure and under direct laparoscopic vision, the probe was
introduced into the peritoneal cavity without any further incisions. The
catheter was then advanced into the peritoneal cavity through a previously
created subcutaneous tunnel. Direct visualization of cerebrospinal fluid in the
peritoneum confirms its appropriate function and successful placement.
Results: No complications occurred, and all
catheters functioned properly in patients undergoing this procedure.
Conclusions: This laparoscopically assisted
procedure allows the ventriculoperitoneal catheter to be placed from the neck
to the peritoneal cavity under direct visualization, without the need for any
further skin incisions. This technique may decrease shunt-related complications
like catheter malplacement, clogging, shunt infections, and others.
9278 General Surgery
NOTES Perforated Viscus Repair is Feasible and Comparable to Laparoscopy in a
Porcine Model
Erica Moran, MD, Christopher
Gostout, MD, Juliane Bingener, MD
Mayo Clinic-Rochester, Minnesota
Objective: Procedure-related complications contribute to
1-year mortality in patients with perforated ulcers. This IACUC-approved study
investigated whether natural orifice transluminal endoscopic surgery (NOTES)
offers a new approach.
Methods: Swine were
randomized to laparoscopic or NOTES ulcer repair. Gastric wall perforations
were created laparoscopically, followed by 4 hours waiting time. After saline
irrigation, repair was performed with a laparoscopic omental patch or NOTES
approach. For NOTES repair, an endoscope was advanced through the perforation,
omentum grasped with biopsy forceps, pulled into the gastric lumen, and fixed
to the mucosa with clips. Procedure times and clinical parameters including
necropsy at 2 weeks were recorded.
Results: Nine animals were
randomized to NOTES and 6 to laparoscopic repair. NOTES repair failed in 1
animal (inability to pass the endoscope through the perforation); this repair
was completed laparoscopically; data were analyzed as intention to treat. Mean
total procedure time (setup, irrigation, repair) for laparoscopy (excluding
trocar placement) was 90 minutes compared with 133 minutes for NOTES repair
(p=0.003). Mean isolated repair time for the laparoscopic omental patch was 47
minutes versus 25 minutes for NOTES repair (p=0.04). Two animals (one from each
group) succumbed to airway compromise in recovery; 1 NOTES animal failed to
thrive on POD 7. No intraabdominal cause of death was found. At necropsy, all
repairs were intact.
Conclusion: Endoscopic
ulcer repair appears technically feasible with outcomes in the porcine model
similar to outcomes with laparoscopy. Evaluation whether it is feasible in
humans, possibly with less anesthesia, appears warranted.
9279 General Surgery
Laparoscopic Cholecystectomy in Cirrhotic Patients in Tertiary Care Hospital in
Pakistan
Dr. A. Razaque Shaikh, MBBS, FCPS, Prof. of Surgery
Liaquat University of Medical & Health Sciences Jamshoro
Objectives: Gallstones are twice as
common in cirrhotic persons as in the general population. Although laparoscopic
cholecystectomy has become the gold standard for symptomatic gallstones,
cirrhosis has been considered as an absolute or relative contraindication. We
reviewed our patients retrospectively and assessed the safety of LC in cirrhotic
patients at our hospital.
Methods: A retrospective study from
January 2003 to December 2005 was conducted at SU III Liaquat University of
Medical & Health Sciences Jamshoro. All cirrhotic patients having
Child-Pugh class A and B undergoing laparoscopic cholecystectomy (LC) were
included in the study. Cirrhosis was diagnosed on the basis of clinical,
biochemical, ultrasonography, intraoperative findings of the nodular liver, and
histopathological study.
Results: Of 250 patients undergoing
LC, 20 (12.5%) were cirrhotic. Of the 20 patients, 12 (60%) were classified as
Childs group A and 8 (40%) were classified as Childs group B. And 30% were
hepatitis B positive and 70% were hepatitis C positive. Preoperative diagnosis
of cirrhosis was possible only in 20% of cases, and 80% were diagnosed during
the operation. Morbidity rate was 15% and mortality rate was 0%. Two patients
developed postoperative ascites, and hospital stay was 2 days to10 days. Of 20
cases, 2 (10%) were converted to open cholecystectomy. The mean operation time
was 70.2±32.54 minutes.
Conclusion: Laparoscopic
cholecystectomy is a safe procedure in cirrhotic patients with advantages over
open cholecystectomy of a lower morbidity rate and reduced hospital stay.
9280 Gynecology
171 Laparoscopic Surgeries Using a Seprafilm Slurry
Lioudmila Lipetskaia, MD, Jamie Avellini, MD, David F. Silver,
MD
St. Luke’s Hospital Network
Objectives: To evaluate the use of
Seprafilm slurry in complex gynecologic laparoscopies.
Materials and Methods: Three sheets
of Seprafilm are crumbled and mixed into 60cc of saline. A gel-like mixture is
poured into a catheter-tipped syringe. A rubber catheter is attached to the
syringe, and the tip of the catheter is cut leaving a single opening. The
catheter is placed through a trocar that is manipulated to guide the tip of the
catheter to the specific surgical sites where the slurry can be applied. The
slurry is used to coat all pedicels and deperitonealized pelvic surfaces.
Outcomes of 171 consecutive laparoscopies were recorded prospectively.
Results: We recorded no
postoperative bowel obstruction, 1 pelvic hematoma in a patient on Plavix
immediately prior to surgery, 8 cases of postoperative ileus, and 1 bowel
perforation recognized postoperatively. The bowel perforation occurred in a
patient with extensive adhesiolysis and intraoperative bowel suturing.
Conclusion: Thirty-seven percent of
the patients underwent TLH/BSO/LND. This report describes an easy approach to
the laparoscopic application of Seprafilm. The hematoma occurred in a patient
who was on Plavix for medical reasons prior to surgery. Caution should be taken
if Seprafilm is applied after significant bowel suturing as 1 of 9 patients
with extensive adhesiolysis requiring suturing of the sigmoid colon developed
sigmoid perforations.
9281 General Surgery
Development of a New Device for Displacement of the Small Intestine in
Laparoscopic Rectosigmoid Surgery
Shinobu Tsuchida1, Masahiro
Tominaga1, Takeshi Nakamura1, Takeyuki Hamaguchi2, Yonson Ku3
1Hyogo Cancer Center, Akashi City, Hyogo, Japan
2Kawamoto Corporation, Osaka, Japan
3Kobe University School of
Medicine, Kobe, Japan
Objective: One problem in laparoscopic rectosigmoid surgery is that the
surgical field is interrupted by the small intestine. Therefore, a sponge that
could be inserted through a port was prepared with a dry compatible material,
expanded while in the abdominal cavity, and it was then determined whether the
expanded sponge could secure the surgical field by displacing the small
intestine.
Methods: The special sponge was shaped into a slender bar (250mm x
8mm x 8mm) by compression. A living pig was placed in a head-down position while
under general anesthesia. Then, the sponge was inserted from a port into the
abdominal cavity and was positioned to cover the root of the mesentery. Enough
physiological saline was sprayed to swell the sponge and displace the small
intestine. The body was returned to a horizontal position, and the descending
degree of the small intestine was evaluated.
Results: The sponge was expanded to a size of 270mm x 8mm x 72mm by
spraying physiological saline on it, and the small intestine did not descend
into the pelvic cavity even if the operating table was returned to a horizontal
position. Rectal low anterior resection could be completed keeping a horizontal
position, and the sponge was removed from a small 4-cm long laparotomy wound
that was created to take a sample.
Conclusion: This sponge is considered useful to secure the surgical
field without an extreme head-down position in laparoscopic rectosigmoid
surgery.
9282 General Surgery
Early Surgical Consultation for Acute Cholecystitis and Biliary Symptoms: Is
There a Difference in Outcome?
Sigi Joseph, MD, Surya Mundluru, Ammar Habib, Michael Amini,
Angie Tripp, Susan Young, Daniel Margolin, MD
St. Luke’s Hospital, Kansas City, Missouri
Background: This study was
undertaken to evaluate whether a difference exists in outcome of patients with
biliary symptoms seen in the emergency department (ED) who had a delayed or
missed diagnosis of acute cholecystitis.
Methods: Data were obtained from ER
physicians’ history, physical examination records, surgical consultation
reports, ultrasound, pathology reports, and operative notes on all patients
with ED visits for right upper quadrant abdominal pain and who underwent
cholecystectomy. Retrospective data were obtained from electronic records for
June 2006 through May 2007.
Results: During the 1-year period,
102 patients with features suggestive of biliary pathology were seen in the ED.
Surgical consultation was obtained for 55 patients, and delayed referral
through the surgical clinic was done for 47 patients. Those patients who were
evaluated by surgery had a shorter median length of stay after ED than the
delayed surgery group had (4 vs. 5, p=0.04). When the propensity score
adjustment model was used for length of stay after ED, the estimated means for
“surgery consulted group” and “surgery not consulted group” were 5.02 and 7.8,
respectively, p=0.0082. There was no significant difference noted between
groups in terms of total duration of stay postoperatively, conversion to open,
resolution of symptoms, and morbidity or mortality.
Conclusion: Patients who present
with biliary symptoms to the emergency department, if seen by the surgical team
on their initial visit, are likely to have a shorter total duration of hospital
stay; early surgical consultation should be sought for these patients.
9283 General Surgery
Sleeve Gastrectomy as a First Choice Procedure for Treatment of Morbid Obesity:
Preliminary Experience
Mohammad Alkilani, MD, Elvira Puntorieri, MD, Giuseppe Pavone,
MD
Policlinico Madonna della Consolazione, Raggruppamento Chirurgico, Reggio
Calabria, Italy
Introduction: Effectiveness of
sleeve gastrectomy as a first choice procedure for the treatment of morbid
obesity was the result of the attempt to minimize operative hazards in
superobese patient candidates for BPD–DS.
Methods: We performed this procedure
in 6 patients by using the laparoscopic technique with 4 trocars, 30° optic,
40-ch calibration tube. We sectioned the great stomach curve beginning 6cm from
the pylorus to the Hiss angle after section of omentum and compared results
with data reported in the Italian Register of Obesity. All patients were
female, median age 34 years (range, 28 to 50), median weight 113.5kg (range, 94
to 136), median BMI 42.52 (range, 36.5 to 53). One patient had a previous
bariatric procedure (gastric banding).
Results: Five patients had a regular
postoperative course, and 1 patient had postoperative lower limb phlebitis.
Median weight loss after 3 months was 11.6kg, and 18kg after 12 months. Median
BMI after 12 months was 36.1 (range, 28.1 to 44.3).
Discussion: Sleeve gastrectomy is a
restrictive technique. By resection of the stomach, we obtained a reduction in
volume and secretion of Ghrelin.
Conclusion: Good results, compared
with 329 patients reported in the SICOB register, are confirmed. No mortalities
or intraoperative complications were reported in the Italian register. Fourteen
patients had postoperative complications (2 suture leak, 7 hemoperitoneum, 4
scare infections, and 3 respiratory complications). Complication rate (0.042%)
is the lowest of all bariatric procedures. We can say that this technique is
feasible, save, and effective.
9284 General Surgery
The Best of Both Worlds: Open Incisional Hernia Repair with Laparoscopic Mesh
Underlay
Gopal Grandhige, MD, Kurt E.
Roberts, MD, Andrew J. Duffy, MD, Robert L. Bell, MD
Yale
University School of Medicine
Background:
The open intraperitoneal underlay
technique of incisional hernia repair has proven efficacy, with recurrence
rates ranging from 0% to 10%. Extensive adhesions, intraperitoneal mesh
explantation, and a cosmetically unacceptable scar necessitate an open repair
even in the laparoscopic era. Nevertheless, the laparoscopic technique provides
superior visualization for precise mesh placement. We describe a novel, hybrid
technique of open incisional hernia repair with laparoscopic mesh underlay.
Methods:
From November 2006 to January 2009,
8 patients underwent open incisional hernia repair with laparoscopic mesh
underlay. In all cases, the abdominal scar was excised and adhesions were lysed
via laparotomy. Previously placed mesh was explanted in 5 patients (63%). In
all patients, the hernia sac was excised and the fascia closed primarily. Prior
to fascial closure, a large mesh was inserted into the abdominal cavity.
Laparoscopically, the mesh was affixed into position, buttressing the primary
closure, overlapping the closure by at least 5cm.
Results:
Four patients were female and 4
patients were male. The mean operative time was 117 minutes. One patient
(16.7%) developed pneumonia and a severe cough, postoperatively. Two patients
(25%) developed a wound infection. Nevertheless, zero patients developed a
seroma, and zero recurrences were observed at a mean of 8 months follow-up.
Conclusion:
The hybrid technique of open
incisional hernia repair with laparoscopic mesh underlay has the best features
of both techniques. A large incision is necessary for scar revision and
facilitates mesh explantation. Hernia sac excision and primary fascial closure
minimizes seroma formation and the laparoscopic underlay provides the
durability of repair.
9285 General Surgery
Time to Diagnoses of Rectal Endometriosis May be Prolonged in Patients with
Chronic Pelvic Pain
Aileen Caceres, MD1, MPH, Jay A. Redan, MD1, Katherine D. Matta, MD2, John C.
Kim, MD1, Gregory D. McClain, MD1, Steven D. McCarus, MD1
1Florida Hospital
Celebration Health, Celebration, Florida
2Loyola University Hospital, Chicago Illinois
Objective: Endometriosis is a
complex condition. Patients with chronic pelvic pain may present with vague
symptoms related to deep pelvic endometriosis involving the bowel. The aim of
this study was to identify and analyze the characteristics of patients with
bowel endometriosis presenting to our center.
Methods: All patients presenting to
the Division of Gynecology and Surgery with stage IV endometriosis and bowel
symptoms from January 2004 to December 2007 were identified. Data analyses
included age, parity, prior procedures, prior medical therapy, and symptoms.
Results: Twenty-one patients were
identified. Median age was 35 (range, 28 to 50) and 67% of patients were
nulliparous. Pelvic pain (71%) was the most common presenting symptom, followed
by cyclic and noncyclic rectal bleeding (28%), recurrent diarrhea (10%),
dyschezia (10%), and dyspareunia (11%). Eighteen patients (85%) had prior
laparoscopy, laparotomy, or a combination of both, before presenting to our
center. Prior to our evaluation, patients underwent colonoscopy, magnetic
resonance imaging, barium enemas and/or rectal ultrasounds. All patients had
pathologically confirmed endometriosis involving the anterior rectum, ileum,
and/or sigmoid after undergoing surgical management. Patients reported experiencing
symptoms for 3.5 years (range, 1 to 5) before final pathologic diagnosis of
rectal endometriosis.
Conclusion: Endometriosis is a
complex condition that may present with rectal involvement among patients with
chronic pelvic pain. Among this group, bowel-related symptoms are present for 3
or more years before final pathologic diagnosis of rectal endometriosis. We
need further studies to identify women who are at increased risk of rectal
endometriosis.
9286 Gynecology
Implementation of Formal Robotic-Assisted Surgical Training in an Obstetrics
and Gynecology Residency Program
Michael T. Breen, MD
University of Texas Medical Branch
Background: The exponential growth of benign gynecologic
surgery using robotic-assisted technology has prompted numerous practicing
gynecologists to train for this new technology. A systematic approach was
implemented over 4 years of training to provide formal didactic, simulator, and
hands-on robotic-assisted instruction during the 4 years of residency training.
Methods: A model of didactic,
computer simulation, hands-on robotic console inanimate model, and live
teaching methods were utilized. Three da Vinci consoles were used (2 standard
consoles and 1 da Vinci "S" with instructive screen graphics used for
educational purposes). Hospital credentialing committees required proctoring
status of attendings before allowing upper level residents to use the console.
Evaluation and assessment by faculty (n=1) used Lickert scale1-5 evaluating 5
categories: preparation and knowledge of robotic console; control familiarity
and dexterity during preprocedure "dry run" on console; facility of
use of controls (clutch and camera pedals) during case; frequency of
head removal from console cradle to visualize floor controls; and overall
impression of residents’ confidence, skill, and comfort level on console.
Results: No adverse events or
unexpected complications occurred when residents were on the console.
Resident Lickert scores trended up over PG-Y 2, 3, 4 years. Long gaps in time
between cases on the console affected the observed skill of the residents’
progression.
Conclusion: Robotic-assisted surgical exposure can be safely incorporated
in a systematic fashion in a 4-year residency program.
9287 General Surgery
Laparoscopic Approach to Gastrointestinal Stromal Tumors (GISTs) of the
Stomach: Our Experience
Natale Di Martino, Prof, Francesco
Torelli, MD, Luigi Marano, MD, Michele Schettino, MD, Antonio Brillantino, MD,
Raffaele Porfidia, MD, GianMarco Reda, MD
Second University of Naples
Background:
Gastric GISTs are a group of rare neoplasms that require a complete resection
to achieve a definitive cure. Although the role of the laparoscopic approach
for these lesions has been established, the long-term safety and efficacy of
this technique is still debated. A complete resection of these neoplasms seems
to be possible by means of laparoscopy, resulting in lower perioperative
morbidity and an effective long-term disease-free survival.
Methods:
All the patients referred for gastric GIST between 2005 and 2008 were reviewed.
Presentation, preoperative investigations, management, and follow-up were
recorded.
Results:
Six patients, mean age 56 years (range, 43 to 74), underwent gastric resection.
Two of them had an open total gastrectomy; the other 4 had a laparoscopic wide
resection. GI bleeding and abdominal pain were the most common symptoms
observed in these last patients; mean tumor size was 4.3cm (range, 2.5 to 5.2),
and the majority of lesions were located in the proximal stomach. Mean
operation time for laparoscopy was 142 minutes (range, 60 to 219), mean blood
loss was 73mL (range 10 to 157), and mean length of hospitalization was 5.1
days (range, 4 to 7). There were no major perioperative complications or
mortalities. All lesions had negative resection margins. No patients showed
local relapse after 25 months mean follow-up (range, 3 to 41).
Conclusions:
A laparoscopic approach to surgical resection of gastric GISTs is associated
with low morbidity and short hospitalization. The long-term disease-free
survival observed in all our patients shows that laparoscopic resection is safe
and effective in treating small- and medium-size gastric GISTs.
9289 Gynecology
Multidisciplinary Approach to the Surgical Management of Deep Infiltrating
Pelvic Endometriosis Involving the Recto-sigmoid
Aileen Caceres, MD, MPH1, Jay A. Redan, MD1, Katherine
D. Matta, MD2, John C. Kim, MD1, Gregory
D. McClain, MD1, Steven D. McCarus, MD1
1Florida Hospital Celebration Health, Celebration, Florida
2Loyola University Hospital, Chicago Illinois
Objective:
Patients with deep pelvic endometriosis may undergo insufficient curative
resections due to underestimation of the severity of disease at the time of
initial surgery. The aim of this study is to describe a multidisciplinary
surgical approach to the management of deep pelvic endometriosis.
Method: All patients presenting to the Division of
Gynecology and Surgery with stage IV endometriosis and bowel involvement from
January 2004 to December 2007 were identified.
Results: Twenty-one patients were identified who had deep pelvic
endometriosis undergoing surgical management at our center. All patients had
rectal involvement. Seventeen (80%) patients underwent laparoscopic
recto-sigmoid resection while 4 patients (17%) underwent exploratory
laparotomy. The median age was 35 (range, 28 to 50) with presenting symptoms as
pelvic pain (71%), rectal bleeding (28%), diarrhea (10%), dyspareunia (11%). At
the time of combined procedures, 33% had hysterectomy or/and adnexectomy; low anterior
resection (86%), hemi-colectomy (10%), and transvaginal bowel resection (5%).
Estimated blood loss was 150mL (range, 50 to 300). Median procedure time was
130 minutes (range, 65 to180), and average hospital stay was 3 days (range, 1
to 8). All patients had pathologically confirmed endometriosis of gynecologic
organs and bowel. One intraoperative ureteral injury occurred requiring an
ureteroureterostomy. Six (35%) patients were converted to laparotomy. Two
patients had postoperative complications: acute renal failure resolving
spontaneously and anastomotic ulcer spontaneously resolved.
Conclusion: Patients with deep pelvic endometriosis involving bowel may
present surgical challenges due to extensive disease. Patients may benefit from
a multidisciplinary approach to achieve complete excision of lesions.
9290 General Surgery
Utilization of the GP Cushion for the Floating Adjustable Gastric Band
R. Barsoumian, MD, A. Geiss, MD, C. Powers, MD, J. Warman, N. Kern, B. Gohil,
MD
Background and Objectives: Laparoscopic adjustable gastric banding
(LAGB) continues to grow in popularity as a surgical option for the treatment
of morbid obesity. While the optimal technique for routine anatomy and
placement has been standardized with the pars flaccida approach, many
considerations persist pertaining to unique anatomic considerations. As the
currently available bands shift to a larger circumference/ lower pressure
design, optimal positioning, and restriction from the band can prove
challenging in patients with lower body mass indexes or minimal tissues at the
level of the gastroesophageal junction.
Methods: A surgical technique is
described and illustrated in which a neo-epigastric fat pad or cushion is
created from the mobilized greater omentum. This is placed adjacent to the
anterior stomach wall and within the band stoma. This new technique allows for
secure fixation and avoids the “floating” band, which does not allow for
restriction in the immediate perioperative phase and may result in a low riding
anterior axis to the device.
Results and Conclusions: An evolving
technique is presented in which the GP (Geiss-Powers) cushion has been utilized
without increased operative time, increased incidence of short-term stomal
obstruction, or acute gastric prolapse. LAGB is a procedure that continues to
be refined with further technical adjustments to minimize gastric prolapse,
gastric erosion, and optimize long-term weight loss in this high-volume
operation. The presented technique is a new approach to facilitating optimal
band orientation in situations where anatomy is atypical.
9291 Gynecology
To Assess the Surgical Feasibility of Utilization of a Mesh Kit (Avaulta Plus
Biosynthetic Support System) in the Treatment of Pelvic Floor Reconstruction
Radha Syed, MD
Staten Island University Hospital, Staten Island, New York
Objective: To assess the surgical
feasibility of utilization of a mesh kit (Avaulta Plus Biosynthetic Support
System) in the treatment of pelvic floor reconstruction.
Methods: Two patients with
anterior vaginal prolapse were selected for Avaulta Plus Biosynthetic Support
System for pelvic floor reconstruction. One patient had a vaginal hysterectomy
performed before use of the Avaulta Plus kit. The other patient refused
hysterectomy. Preoperative evaluation consisted of clinical examination, q-tip
test, urodynamic testing, and urine culture and pelvic ultrasound. Ages of
patients were 55 and 60 years. No significant medical problems were reported.
Surgical guidelines for utilization of this mesh kit were adhered to, and the
procedure was performed without complications. Stress urinary incontinence
procedures were additionally performed using transobturator techniques.
Postoperative recovery was less than 2 weeks. Patients were treated with local
estrogen cream, preoperatively and postoperatively. Patients were assessed at 2
and 4 weeks and 3 months.
Results: Both patients underwent the
procedure without complications and had a significant reduction in anterior
prolapse. There was no mesh exposure. The stress urinary incontinence was
separately addressed with a transobturator suburethral sling.
Conclusion: Avaulta Plus
requires considerable knowledge and training both in cadaver and observation of
live surgery. Prior knowledge of pelvic floor anatomy and previous experience
in use of mesh placement without a kit is critical to master this technique.
Based on my initial experience with this mesh kit, this procedure is indeed
surgically feasible for pelvic floor reconstruction. However, more study needs
to be completed.
9292 General Surgery
Silent Entry of a Sharp Metallic Foreign Body into the Abdomen: Diagnosis &
Treatment Using Laparoscopy & CT Scan
Udayan B. Shah, MD, Harish Kakkilaya, MD, Bhasker Reddy, MD, W.
Peter Geis, MD
Northwest Hospital, Randallstown, Maryland
Introduction: We re-assessed and
reviewed the inadvertent finding of a sewing needle in the liver of a patient
with the “eye” of the needle adjacent to the gastric lesser curvature, and its
tip abutting left intrahepatic vessels. Epigastric pain was the
presentation.
Methods: This 74-year-old female
presented with epigastric pain, normal WBC, and normal abdominal radiographs.
Later, abdominal CT scan delineated a sewing needle in the epigastrium located
horizontally and 90% within the left hepatic lobe substance. The eye of the
needle was at the mucosa of the lesser curve of the stomach.
Results: GI physicians recommended
upper endoscopy. Safe removal was considered best accomplished by laparoscopy.
At laparoscopy, the needle was in the liver–not in the stomach. The needle was
gently removed; no bleeding occurred. The needle was very rusty. The patient
does not sew and does not place needles in her mouth.
Conclusions: If searching for a thin
foreign body in the torso, or for pain of unknown cause, use CT scan;
radiographs may be falsely negative. Unless it is totally in the available GI
lumen, foreign bodies anywhere in the abdomen should be evaluated for removal
initially by laparoscopy. If not located in the GI lumen, then a combination of
simultaneous laparoscopy and endoscopy should be used.
9293 General Surgery
Endoscopic TransAxillo-Periareolar Thyroidectomy
Titus D. Duncan, MD, Ravi Rao, MD, Fredne Speights, MD
Morehouse School of Medicine
Background: Traditional open
surgeries for diseases that require total thyroidectomy are usually approached
through a generous transverse cervical incision. Endoscopic thyroidectomy has
recently gained popularity as an alternative to the open thyroid approach.
Improved visualization through focused illumination and image magnification has
led to increased safety for this procedure. Furthermore, the resultant improved
cosmesis has lead many to advocate endoscopic surgery as a viable alternative
to the open approach. We recently reported our experience using an endoscopic
transaxillary technique for unilateral thyroid disease. However, attempts at
total thyroidectomy using this ipsilateral approach afforded limited
visualization of the contralateral side. We herein describe our experience for
performing total thyroidectomy using an endoscopic transaxillo-periareolar
(ETAP) approach. We discuss the advantages, technique, and visualization using
this approach for thyroid disorders requiring total thyroidectomy.
Methods: We retrospectively reviewed
charts of 31 patients undergoing total thyroidectomy using an endoscopic
transaxillo-periareolar (ETAP) approach from August 2006 to September January
2009. Only patients with suspected benign disease were included in this study.
Results: All procedures were
completed using the endoscopic transaxillo-periareolar approach. There were no
conversions to open, and all patients were discharged on the first
postoperative day. There were no complications, and overall patient
satisfaction with cosmesis was excellent.
Conclusion: Although a pure
transaxillary approach has proven effective for unilateral thyroid disease, its
use in patients requiring total thyroidectomy has been limited. The endoscopic
transaxillo-periareolar approach allows for superior visualization and safe
dissection of the ipsilateral as well as the contralateral lobe for patients
requiring total thyroidectomy.
9294 General Surgery
Thymectomy by the Thoracoscopic Approach: Experience and Outcomes
V. N. Nikishov, MD, PhD, E. I. Sigal, MD, PhD, E. I. Bogdanov,
MD, PhD, A.M. Sigal, MD
Clinical Cancer Center, Kazan, Russia
Objective: The thoracoscopic
approach entails less injury compared with the open approach. We conducted a
retrospective study of the efficiency of thoracoscopic thymectomy in the
treatment of different thymus disorders.
Methods: From 1995 to 2008, 50
patients (26 women, 24 men), mean age 42 (range, 16 to 69) underwent thymectomy
by a left thoracoscopic approach (25 thymomas, 20 myasthenia gravis, 2 thymus
cysts, 2 lymphoepithelial thymoma, 1 teratoma). All patients were under general
anesthesia with double lumen intubation.
Results: Thoracoscopic thymectomy
was performed in 50 patients. The average operating time was 76 minutes (range,
30 to 170). Conversions to thoracotomy were necessary in 6 patients. The
reasons were tumor size, invasion into nearby structures, difficulty to
continue dissection, adhesion in the pleural cavity. Morbidity occurred in 6%
of the cases and included 1 myasthenic crisis and 2 pneumothoraxes. No
postoperative mortalities occurred.
Conclusion: Thymectomy by the
thoracoscopic approach is feasible and safe and is an alternative treatment for
thymus disorders.
9295 Gynecology
Effects of Transvaginal Hydrolaparoscopy and Laparoscopy on Enzymogram and
Neuroendocrine Hormones
Wang Shao-Juan (Pro for Zunyi Medical College)
Longgang Central Hospital, Shen Zhen, GuangDong
Province, China
Objective: To compare the effects of transvaginal
hydrolaparoscopy (THL) and laparoscopy (LAP) on enzymogram and neuroendocrine
hormones.
Methods: Sixty cases were
divided into 2 groups according to the operative approach: THL and LAP. Serums
CK, CK-MB, GOT, and LDH were measured before the operation and 24 hours after
the operation. Serum cortisol, T3, T4, and TSH were measured before the
operation, 20 minutes after incision, at the end of the operation, and 24 hours
after the operation.
Results: Serums CK, CK-MB, GOT, and LDH at the 24th hour after the
operation were significantly more than those before the operation in the LAP
group P<0.01,
but there were no significant differences 24 hours after the operation compared
with before the operation in the THL group (P<0.05). In the LAP group, T3 values decreased
after the operation (P<0.01),
and a further decrease was observed 24 hours postoperatively (P<0.01). T4 and TSH level
increased significantly following the operation (P<0.01) and returned to
normal levels 24 hours after surgery.
Cortisol reached its peak values in the 20-minute operation,
which was statistically higher (P<0.01) than the
preoperative cortisol. At the end of surgery and 24 hours after surgery,
cortisol in the LAP group was significantly higher than the cortisol level
during the same periods in THL group (P<0.01).
Conclusion: LAP may lead to myocardial and neuroendocrine
damage. THL is a suitable method for outpatient care.
9296 General Surgery
A New Idea to Identify the Anatomy of the Colonic Artery in Laparoscopic
Colorectal Surgery: The Usefulness of the Transillumination Technique
Iwao Kobayashi
Hyogo Cancer Center, Akashi City, Hyogo, Japan
Objectives: In laparoscopic
colorectal surgery, it is very important to identify the anatomy of the colonic
artery for accurate lymph-node dissection. However, it is not always easy in
the case of a portly patient, and the structure of the colonic artery sometimes
has several variations. This time, in a porcine model, we inserted another
scope as only a light resource and evaluated whether we could identify the
colonic arterial branch connection.
Methods: A pig was placed under
general anesthesia. The main surgeon dissected the colon mesentery from the
retroperitoneal fascia by intra-approach. After dissecting it, another scope
used as the light resource apart from the main scope was inserted into the back
space of the dissected mesentery, and the light volume of the main scope was
gradually decreased to transilluminate the mesentry.
Results: The anatomical structure of
blood vessels was easily understood because the mesentery was made transparent
by decreasing the light volume of the main scope. Mesentery of the porcine
model is very thin, so we placed 3 surgical rubber gloves on the mesentery to
produce the same condition as in a clinical situation. Under such a condition,
the anatomical structure of the blood vessels was easily transilluminated and
morphologically recognized by this technique.
Conclusion: In laparoscopic
colorectal surgery, this technique is very useful for easily grasping the
anatomical structure of blood vessels of the colon, even in the obese patient
or a patient with some anatomical variations.
9297 General Surgery
Laparoscopic Management of Small Bowel Volvulus
Subhasis Misra, MD,
Prasanta K. Raj, MD, Richard C. Treat, MD
Fairview Hospital,
Cleveland Clinic Health System
Objective: Patients with small bowel obstruction
managed with operative intervention have traditionally had laparotomy
incisions. A recent literature review suggests the increasing role of
laparoscopy in such settings. We present our experience with laparoscopic management
of small bowel obstruction secondary to volvulus.
Methods
and Procedures: A
60-year-old female presented to the emergency department with a 6-hour history
of sudden onset epigastric pain with subsequent generalized abdominal pain,
with associated nausea and vomiting. On examination, there was tenderness and
guarding over the right lower quadrant. The patient underwent diagnostic
laparoscopy. Several loops of collapsed, distal ileum and distended loops of
proximal jejunum were noted. Given this scenario, a search was undertaken for a
definite point of transition, and complete inspection of the bowel was done
using atraumatic graspers. The point of transition was due to an adhesion, and
this created a closed loop of small bowel volvulus, about 6 inches long. Lysis
of adhesion resulted in the opening up of the isolated stricture of the small
bowel and spontaneous correction of the volvulus. Bowel viability at the end of
the procedure was satisfactory. Routine follow-up of this patient was
uneventful as well.
Conclusions: With increasing experience,
laparoscopic management of small bowel obstruction due to adhesions and
volvulus can be safe and successful. We therefore recommend an initial
laparoscopic approach as the preferred method, but conversion to an open
incision should be done in case of difficulty or the presence of necrotic
bowel.
9298 General Surgery
Laparoscopic Management of Appendiceal Mucocele and Torsion
Subhasis Misra, MD,
Prasanta K. Raj, MD, Richard C. Treat, MD
Fairview Hospital, Cleveland
Clinic Health System
Objective:
Laparoscopic
appendectomy is now becoming a common procedure. However, unique presentations
present with their own difficulties. We present a case of appendiceal mucocele
and appendicular torsion managed laparoscopically.
Methods:
A 44-year-old female
presented with a 1-week history of right lower quadrant pain. Initial
evaluation with ultrasound and CT scan was consistent with a ruptured ovarian
cyst and possible right hydrosalpinx. However, after 2 days of no clinical
improvement, the patient underwent diagnostic laparoscopy.
Results: Intraoperatively, the base of the
appendix was found to have twisted 360 degrees times 2. A large mucocele at the
base of the appendix was also noted. GIA stapler was used to divide the
appendiceal base and appendicular artery. Placement of the mucocele in the
endobag was difficult given its large size, and hence the infraumbilical
incision was extended and the specimen delivered intact. This was done to
minimize the chances of infection and the possibility of pseudomyxoma
peritonei. The patient tolerated the procedure well, and routine follow-up was
uneventful. The pathology report showed acute appendicitis and mucinous
cystadenoma.
Conclusion:
Appendicular tumors and
mucocele can successfully be removed via a laparoscopic method. Extracting
specimens within the laparoscopic retrieval bag may help in preventing
pseudomyxoma peritonei.
9299 General Surgery
Laparoscopic Cholecystectomy for Gallbladder Stones of Helminthic Origin
Prasanta K. Raj, MD,
Subhasis Misra, MD, Richard C. Treat, MD
Fairview Hospital,
Cleveland Clinic Health System
Objective: Gallbladder stones are mainly
cholesterol or pigment stones but can also be due to other causes.
Cholecystitis due to helminthic infection has been reported. However,
helminthic infestation causing symptomatic gallbladder stones is a rare entity.
We present a case of a laparoscopic cholecystectomy for gallbladder stones of
helminthic origin.
Methods: A 47-year-old male who presented with
right upper quadrant pain and discomfort underwent an ultrasound, which showed
gallstones. He underwent a successful laparoscopic cholecystectomy with a
normal intraoperative cholangiogram. Pathology confirmed the presence of
helminths in the gallstone. The patient had a history of travel to Vietnam.
Stool was evaluated for the presence of ova and parasites, and the patient was
treated appropriately. The patient had an uneventful recovery.
Conclusion: We report a rare case of gallbladder
stones of helminthic origin, and given the variable nature of the presence of
helminths, we recommend intraoperative cholangiogram as helminthiasis may be
visualized in the biliary system. Proper diagnosis and management should be
undertaken to eradicate the helminthic infestation once the diagnosis is made.
9300 General Surgery
Laparoscopic Re-banding for Failed Gastric Banding
L. Lantsberg, Y. Stabholz, E.
Avinoach, B. Kirshtein, S. Mizrahi
Soroka University Medical Center, Be'er-Sheva, Israel
Objectives: Since 1996, our department has offered LAGB as the
preferred therapy for morbidly obese patients. When late complications occurred
(slippage, device malfunction, and others.) we performed a re-banding operation
as the surgery of choice. We explored retrospectively the outcome of re-banding
surgery as a preferable management for these complications.
Patients and Methods: We
evaluated 2471 charts of patients who underwent primary LAGB in our department
between 1996 and 2006. Of this group, 345 underwent revisional re-banding
surgery. The data collected from their charts included age, sex, BMI at
revisional surgery, time since original operation, duration of operation, early
postoperative complications, and length of postoperative hospital stay.
Results: Of the 345 patients who underwent secondary re-banding, only 54
(15%) required an additional (third) surgery. Of these 54 patients, 39 patients
(72%) presented with recurrent slippage that was repaired by band repositioning
in a third surgery. The remaining 15 patients underwent band removal due to
erosion (1), abscesses (4), and patient intolerance (10). The mean period
between the second and third revisional surgeries was 23 months. Two hundred
ninety-one (84.5%) of the 345 reviewed patients maintained a BMI below 29 and
were free of symptoms for at least 4 years after the revisional surgery.
Conclusions: Laparoscopic re-banding operation for failed gastric
banding remains our strategy of choice due to its low morbidity, zero
mortality, safety, and efficacy.
9301 General Surgery
Preperitoneal Bupivacaine Instillation Significantly Reduces “Dissectalgia”
Following TEP, Without Affecting Time of Return to Work: Results of Prospective
Randomized Controlled Trial
Sunil Kumar, MS
University College of Medical Sciences and Guru Teg
Bahadur Hospital, Delhi, India
Background: We observed that
“Dissectalgia” (pain over a wide area corresponding to the area of
preperitoneal dissection) following TEP hampers ambulation more than pain at
trocar sites, and responds poorly to routine analgesics. We sought to find the
effect of preperitoneal bupivacaine instillation on dissectalgia and return to
work.
Methods: Fifty-three consecutive ASA
grade I adult males undergoing TEP for groin hernia were randomized into
control (group A, n=28) and test (group B, n=25), receiving 30mL saline or
0.25% bupivacaine preperitoneally after mesh was placed, respectively.
Assessment parameters included time to rescue analgesia, number of patients
needing injection tramadol at night during hospital stay, VAS score for pain at
24h, 48h, and then weekly for 4 weeks, and time of returning to work.
Results: Time to rescue
analgesic was significantly shorter in group A (4.50±2.3h) than in group B
(7.00±4.1h), p=0.0077. A significantly greater number of group A patients
needed tramadol injection at bedtime than group B patients (24 vs. 6,
respectively, p=0.0042 on 1st night; 11 vs. 2, respectively, p=0.0108 on 2nd
night). VAS scores were significantly higher in group A patients than in group
B patients (3.47±1.04 vs 1.69±1.04, respectively at 24h postoperatively,
p=<0.0001; 2.29±1.44 vs 1.36±0.81, respectively at 48h postoperatively,
p=0.0063. However, subsequent VAS scores till 4 weeks postoperatively were
comparable, as was the time of resuming work. No patient had chronic pain and
recurrence, minimum follow-up being 3 years.
Conclusion: Dissectalgia following TEP deserves due recognition.
Preperitoneal bupivacaine instillation significantly reduces it, although time
to resuming work remains unaffected.
9302 General Surgery
Laparoscopic Resection of a Duodenal GIST Tumor
Prof. Ivo Baca, Dr.
Khaled Elzarrok, Dr. A. Jaacks
Clinic for General
Visceral Surgery, Center of Minimal Invasive Surgery, Klinikum Bremen-Ost
Bremen Deuschland
Background: A 56-year-old
male patient underwent laparoscopic duodenal-conserving resection of a GIST
tumor. The patient was admitted to our surgical ward after an
esophagogastric-duodenal endoscopy was performed that revealed a duodenal mass
in the second part of the duodenum. CT scan of the abdomen revealed an
intramural mass in the outer wall of the duodenum that started about 1.5cm
below the ampulla. Endoscopic ultrasound also revealed a postampullary
intramural tumor.
Methods: We
used the laparoscopic technique of organ-conserving excision of the duodenal
GIST tumor, which was performed by the intraoperative video-recording method as
follows:
1-entry to the abdomen
and trocar placement.
2-duodenal-conserving
excision of the GIST tumor.
3-extraction of the
tumor by using an Endobag.
Results: Postoperative study using contrast
medium revealed complete excision of the duodenal tumor with lumen-free passage
of the contrast material through the duodenum.
Conclusion: Organ-conserving duodenal GIST tumor
can be excised curatively laparoscopically with all benefits and advantages of
this minimally invasive technique.
9303 General Surgery
Prevention of Postoperative Bowel Obstruction after Rectal Resection: Results
of Pelvic Omental Pedicled Shelf from Open Surgery with Applicability to
Laparoscopic Surgery
Munir Ahmad Rathore, FRCS, Muhammad Iqbal Bhatti, MRCS, Arti
Garg, MRCS, Maurice Fernando, MRCS, Adel Osman, MRCS, Mohey Ismail, FRCS,
Victor Loughlin, FRCS
Lagan Valley Hospital Lisburn, Northern Ireland, United
Kingdom
Medical Illustration, Belfast City Hospital Belfast, United Kingdom
Introduction: We believe the
dominant cause of postoperative bowel obstruction after rectal resection lies
in pelvic incarceration of bowel loops and that greater omental pedicle in the
pelvic hollow would reduce the incidence. We describe our technique of omental
pedicled shelf (OPS).
Methods: Patients requiring anterior
resection or APR were eligible for the flap. The OPS was a random pattern flap
devised by preserving the omental branch of the left gastroepiploic artery and
requiring omental mobilization, lengthening, and transfer. It was transferred
to the pelvis after the completion of resection/anastomosis. Exclusion was OPS
for nonpelvic causes. End-point: bowel obstruction or last follow-up.
Results: Thirty-seven eligible patients over 2 years underwent treatment,
which included anterior resection (n=30) and APR (n=7). The OPS was placed in
the pelvis after the anastomosis. M:F ratio was 1.1:1, median age=67y. Majority
of patients had BMI of 25 to 29 and ASA-II. The indication was cancer in 30/37
and benign conditions in 7/37. The procedure was technically simple. Median
operative time was 10 minutes. Median time to return of bowel activity=1 day,
to ambulation=1 day. No bowel obstructions occurred and no relaparotomies were
necessary. The complications included Clavien 0=27, I=1, II=2, III=5, and
Clavien IV=2 (30-day mortality due to pulmonary complications). No OPS-related
complications occurred. Median LOS=7days. Median follow-up=8 months. There were
0/37 events in this study (p=0.03). ARR=11% (95%CI=4.8% to 17.1%). Number
needed to treat (NNT)=0 (95%CI=5.8 to 20.5).
Conclusion: Results of OPS revealed
it to be a safe and simple procedure with no OPS-related complications, no
cases of postoperative bowel obstruction, and with likely secondary benefits.
9305 General Surgery
Role of Initial Clinical Assessment in the Diagnosis of Acute Diverticulitis
Munir Ahmad Rathore, FRCS, Muhammad Iqbal Bhatti, MRCS, Adel
Oman, MRCS, Maurice Fernando, MRCS, Elizabeth Hand, Nurse Endoscopist, Victor
Loughlin
Lagan Valley Hospital, Lisburn, United Kingdom
Introduction: Acute diverticulitis
is a frequent clinical diagnosis in acute abdominal pain. Our aim was to
determine the diagnostic accuracy of initial clinical assessment in the
diagnosis of acute diverticulitis (AD).
Patients & Methods: This was a retrospective analysis. All patients
admitted to the surgical unit via A&E over a 4-year period were identified.
Additionally, the results of all LGI endoscopy carried out during the study
period were analyzed. Modified Hinchey score (0-IV) was used to describe the
severity of diverticulitis.
Results: Over 4 years, 3647 surgical
admissions occurred via A&E (3.3% of the hospital catchments population).
Patients with a GI emergency including acute abdomen equaled 2360. Acute
diverticulitis of the GI tract was identified in 121 patients. Three were
excluded (small bowel diverticulitis). From the remaining 118 records, there
were more exclusions, yielding 80 eligible patient records. Confirmed AD was
seen in 32/80 patients. The median age was 65 years M:F=0.7:1. The diagnostic
capability of the initial clinical assessment revealed a sensitivity of 47%,
specificity of 96.8%, false-negative rate of 53%, false-positive rate of 60%,
an AD prevalence of 40% from the initial AD-coded patients, and an overall
accuracy of 42.5%. The initial diagnosis agreed with the final one only on the
basis of chance (k=-0.127 SE=0.1 95CI -0.34 to 0.082). A strong correlation of
acute diverticulitis was seen with CRP (r=0.5) and WCC (r=0.3).
Conclusion: The initial clinical
assessment in the diagnosis of acute diverticulitis is correct in less than
half of patients and then on the basis of chance. It has highly successful in
excluding acute diverticulitis (negative predictive value=96.8%).
9306 General Surgery
Laparoscopic Revision of Open Roux-En-Y Gastric Bypass with Fundus Resection
Ramin Roohipour1, Leaque Ahmed1,2
1Columbia University at Harlem Hospital, New York, New York
2Columbia University College of Physicians and Surgeons, New York, New
York
This video presents a 37-year-old female with a BMI of 57. In 1994, she
underwent open gastric bypass surgery but never achieved the desired weight
loss. Esophagogastro-duodenoscopy showed a large pouch. The patient was taken
to the OR for laparoscopic revision of the bypass. The stomach was mobilized,
and by using green load EndoGIA, the stomach was divided just below and above
the previous staple lines. Fundus was then divided and resected. The jejunum
was divided from the gastrojejunostomy by using a blue load EndoGIA. The
gastrojejunostomy was reconstructed in 2 layers over a 34F bougie. On POD 1,
UGS showed a functional small pouch without evidence of leakage. At 6-month
follow-up, the patient had lost 81 pounds. Laparoscopic revision of open
Roux-En-Y gastric bypass surgery is safe and feasible, even in patients who
have had a previous open weight loss procedure.
9307 Gynecology
Saline Infusion Sonohysterography in Elderly Patients: Risks and Feasibility
Emil Gurshumov, MD, Boris Petrikovsky, MD, PhD, Allan Klapper, MD
New York Downtown Hospital-member
NY-Presbyterian Healthcare
Background: Saline Infusion
Sonohysterography (SIS) is a well-accepted technique that yields valuable
information about endometrial condition. It is usually well tolerated by
patients and has very few complications. However, most of studies on SIS have
dealt with young and middle-aged women. Our goal is to report our experience
with SIS in an elderly population.
Material and Methods: The study
group included 19 patients aged 66 to 81 referred for SIS for accepted clinical
indications; 68 patients aged 26 to 65 comprised the control group. The
following parameters were analyzed in both groups:
(1) Need for tenaculum or/and dilators
(2) Overall success rate
(3) Patient perception of the procedure.
Results: Sixteen patients in the
study group (84%) rated the procedure as painful. One rated it as very
uncomfortable versus 7 patients in the control group. SIS failed in 7 patients
(37%) in the study group and in 4 (5.9%) in the control group due to cervical
stenosis, poor uterine distensibility, or severe patient discomfort.
Conclusions: SIS in elderly patients
appears more technically difficult and less successful compared with SIS in
younger women.
9308 General Surgery
Laparoscopic Reduction of Intussusception Following Laparoscopic Roux-En-Y
Gastric Bypass
Ramin Roohipour1, Leaque Ahmed1,2, Khalil Beeman1
1Columbia University at Harlem Hospital, New York, New York
2Columbia University College of Physicians and Surgeons, New York, New
York
This video presents a 35-year-old female who had undergone Roux-En-Y gastric
bypass surgery 3 years prior to her recent admission. She recently presented to
the emergency department with vague epigastric pain, nausea, and 2 episodes of
nonbilious vomiting.
Abdominal CT with contrast was performed. This showed 2 areas of jejunojejunal
intussusception without evidence of obstruction. Laparoscopy was performed. On
initial inspection, the small bowel was mildly distended. The small bowel was
run from the gastrojejunostomy site. We encountered 2 areas of intussusception
in the alimentary limb; the proximal intussusception was antegrade and the
distal intussusception was retrograde.
The antegrade intussusception was reduced by applying gentle pressure on the
distal segment and by careful pulling of the proximal segment of the
intussusception. The area seemed to be intact without evidence of ischemia. The
retrograde intussusception was reduced without difficulty. We have previously
treated similar conditions with simple reduction of the intussuscepted areas
without the need for resection, and have achieved successful results in
long-term follow-up. We carefully examined the area of intussusceptions and did
not find any evidence of ischemia or gangrene. The internal hernia sites (the
Peterson’s and the jejunojejunostomy defects) were closed.
Postoperatively, the patient did well, and at 6-month follow-up, she remained
asymptomatic. To the best of our knowledge, this is the first video report of
the laparoscopic reduction of the jejunojejunal intussusception without the
need for resection.
For long-segment intussusceptions, the recommended treatment has been
resection. In our experience, for early and mild intussusception, gentle
reduction is usually curative.
9309 Gynecology
Laparoscopic Hysterectomy and Colpopexy with Polypropylene Strip
Alkilani Mohammad, MD, Puntorieri Elevira, MD, Pavone Giuseppe, MD
Policlinico Madonna della Consolazione – Dipartimento di Chirurgia – Reggio
Calabria Italy
Introduction: Uterine prolapse is a disabling disease that causes
impairment in quality of life. The laparoscopic approach is a valid solution
for this disease.
Materials and Methods: Within the
last 3 years, 15 patients, median age 70 years (range, 62 to 78), have been
treated in our department by using laparoscopic hysterectomy and fixation of
the vagina to the sacral promontory with a polypropylene extraperitoneal strip.
Three patients had a previous hysterectomy and presented with vaginal prolapse.
We used 3 trocars and 30° optic.
Results: All procedures were carried
out with the laparoscopic technique, and no conversion to the open technique
was necessary. We observed one complication consisting of adhesions between the
polypropylene strip and right ureter resolved by ureter stinting. Median
postoperative hospitalization was 2 days, and the results at follow-up were
good.
Conclusion: The postoperative
quality of life, short hospitalization times, and the short recuperation time
indicate that this technique is the gold standard for this disease. Patients
with stress incontinence must undergo control for an adequate period after the
operation.
9311 General Surgery
Development of a Laparoscopic Colorectal Service in the Northern HSC Trust:
Progress So Far
Dr. R. P. Stevenson, Mr. C.
K. Byrnes, Mr. G. C. Beattie
Whiteabbey & Antrim Area Hospitals, Northern HSC Trust, Northern Ireland
Objectives: Laparoscopic colorectal surgery has been performed in the
Northern Trust since May 2007. An audit of laparoscopic colorectal practice to
date was carried out.
Methods: Data were collected both retrospectively from patient records and
from prospectively collected databases over a 19-month period.
Results: Between May 2007 and December 2008, 101 laparoscopic cases were
undertaken, 90 for malignancies and 11 for benign conditions. Twelve were
converted to open. Mean patient age was 66 years (range, 25 to 90). Fifty-two
patients were males, 49 were females. Thirty-three percent had previous
abdominal surgery. Of the rectal cancers (n=29), 27.6% were treated with
short-course neoadjuvant radiotherapy, and 17.2% with chemoradiotherapy. Of the
cases performed, 7 were ultra-low anterior resections (ULAR), 24 were
high-anterior resections, 2 Hartmann’s, 11 abdominoperineal excision of rectums
(APER), 13 sigmoid resections, 2 left hemicolectomies, 33 right
hemicolectomies, 2 subtotal colectomies, 1 panproctocolectomy, 4 defunctioning
colostomies, 1 defunctioning ileostomy. Thirty-seven percent of patients had
early complications; 11% had late complications. Within 30 days, 12 unscheduled
returns to the operating theater were necessary. No 30-day mortalities
occurred. Mean nodal yield was 18. Median length of stay with no early
complications was 5 days (range, 3 to 12), and 9 days (range, 5 to 90) for
those with complications. Thirty-seven percent of patients required adjuvant or
palliative chemotherapy with or without radiotherapy.
Conclusion: Having undertaken a considerable workload, including a high
number of malignant cases, the peri- and postoperative outcomes compare
favorably with outcomes reported in the published literature.
9312 General Surgery
The Routine Preoperative Typing and Screening Prior to Elective Surgery: A
Necessary Safeguard or a Misuse of Resources?
Silvio Ghirardo, MD, Ishwaria Mohan, Mitchell I. Chorost, MD
Maimonides Hospital, Brooklyn, New York
Alicia Gomensoro: Blood Bank, Maimonides Hospital, Brooklyn, New York
Objective:
To assess the necessity of routine preoperative type and screen testing before
cholecystectomy, hernia repair, or appendectomy based in the risk of
transfusion at our department.
Methods:
We conducted a retrospective analysis of the surgical database at Maimonides
Medical Center over the 2-year period from July 1, 2005 to July 1, 2007,
cataloging all patients who underwent a cholecystectomy, an appendectomy, or a
hernia repair. We then matched this information with the database of the
Maimonides Blood Bank to identify the patients who were given transfusions with
RBC on the day of surgery, on the first postoperative day, or on both of these
days.
Results:
We examined 3424 patients who underwent a cholecystectomy, hernia repair, or
appendectomy over a 2-year period and examined how many patients required a red
blood cell transfusion on the day of surgery or on postoperative day 1. Of our
3424 patients, 11 required a transfusion (1 appendectomy, 5 cholecystectomy,
and 5 hernia repairs) in the aforementioned time frame. None of the transfused
patients received an emergency transfusion intraoperatively, and none received
more than 2 units of red blood cells. Consequently, the risk of being transfused
in this perioperative period is 0.32%.
Conclusion:
Because of this low probability of a patient requiring blood products during or
immediately after surgery, our data and supporting literature firmly support
the elimination of the routine type and screen before cholecystectomy, hernia
repair, and appendectomy without diminishing the quality of patient care.
9313 Urology
Predictors of Gleason Sum Upgrading in Potential Candidates for Active
Surveillance of Presumed Low-Risk Prostate Cancer: Time to Refine Existing
Selection Criteria?
Nishant Patel, Gerald Y. Tan, Casey K. Ng, Philip H. Dorsey, Ashutosh K. Tewari
Weill Medical College of Cornell University, New York
Background: Gleason sum (GS) upgrading occurs in up to 50% of
contemporary series of men managed with active surveillance (AS), resulting in
worse pathologic features and earlier biochemical failure following radical
prostatectomy. We sought to identify better predictors of Gleason upgrading in
AS-eligible men.
Methods: Of the 897 men who underwent robotic-assisted radical
prostatectomy by a single surgeon, 413 could have qualified for AS based on
current selection criteria, comprising Gleason sum ≤6, clinical stage ≤T2a
disease, PSA ≤10ng/mL, ≤3 positive cores, and ≤50% cancer present in a single
core. Binary logistic regression was used to evaluate age,
preoperative PSA (Log), PSA density, core positivity, maximum % Ca in bx core,
biopsy Gleason, clinical stage, BMI, and prostate volume (log) as predictors of
Gleason score upgrading. Receiver operating characteristics (ROC) were
generated for significant predictors and AUC was determined. Final pathology
outcomes were determined in 182 consecutive specimens sent to an offsite GU
pathologist for external validation.
Results: On the final pathology following radical prostatectomy,
169 patients (40.9%) had Gleason upgrading. Prostate volume <45gm, PSA
density >0.1ng/mL/cm3, maximal percentage of cancer >13.5% in any
core, and BMI >29kg/m2 are all significant independent predictors
for GS upgrading, their optimal cutoff values determined from their ROC curves.
External validation concordance rate was 89% congruent with our institutional
final histopathology reports.
Conclusions: Prostate size, PSA density, BMI, and biopsy core
cancer density are significant predictors of aggressive pathology and should be
incorporated into contemporary selection criteria for AS protocols.
9313 Urology
Bigger is Better: Implication of Small Prostate Volume in Patients who Qualify
for Active Surveillance for Prostate Cancer
Nishant Patel, MD, Gerald Y. Tan, MD, Casey K. Ng, MD, Philip
H. Dorsey, MD, Ashutosh K. Tewari, MD MCh
Weill Cornell Medical College
Objective: Active surveillance has
been shown to prevent or delay definitive treatment for low-risk prostate
cancer patients. Because small prostate volume has been associated with Gleason
upgrading, we hypothesize that active surveillance eligible patients with small
prostates are also more likely to have Gleason upgrading, making them
unsuitable for active surveillance.
Methods: Records
from 897 prostate cancer patients who underwent robotic prostatectomy were
retrospectively reviewed. Of the 897 patients, 413 who chose surgical therapy
could have qualified for active surveillance based on the following criteria:
clinical stage ≤cT2a, PSA≤10, Gleason≤6, ≤3 positive cores and ≤50% of cancer
present in any one core. Preoperative parameters were compared by using
univariate and multivariate analysis between patients who did and did not have
a Gleason upgrade on final pathology (≥Gleason 7). Receiver operative
characteristic curves were used to evaluate variables that were significant on
multivariate analysis.
Results: Of
the 413 possible active surveillance patients, 169 (40.9%) had Gleason
upgrading. Elevated BMI, elevated PSA, and reduced prostate volume were
statistically correlated with Gleason upgrading. Age, percentage of positive
cores, and maximum percentage of cancer in each biopsy core were not
significantly correlated with Gleason upgrading. BMI>29.0m2/kg,
PSA>4.95ng/mL, and prostate volume <47.9cm3
were found to be optimal cutoff values for predicting Gleason upgrading.
Conclusions: Prostate
size is inversely correlated with pathologic Gleason upgrading. This represents
a novel variable in predicting patients who may harbor more aggressive prostate
cancer. Patients with a prostate volume of <47.9 should be excluded from
active surveillance protocols.
9314
General Surgery
Laparoscopic Reintervention After Roux-en-Y Gastric Bypass for Morbid Obesity
C. Ballesta, MD, R. Berindoague,
MD, M. Cabrera, MD, O. Al-Sunidar, MD
Centro Laparoscópico de Barcelona, Centro Médico Teknon Barcelona
Background: Roux-en-Y gastric bypass (RYGBP) is one of the best surgical
approaches to morbid obesity; however, it still has significant operative
complications. In terms of managing these complications surgically during the
immediate postoperative period, laparoscopic reoperation is considered feasible
and highly successful. Our aim was to evaluate the laparoscopic reintervention
in treating immediate postoperative complications of LRYGBP with manual G-J
anastomosis, and to assess how safe and successful this procedure is in
obtaining good results.
Methods and Materials: From December
2001 to June 2007, 87 (6.4%) patients out of 1358 who developed immediate
postoperative complications were retrospectively reviewed.
Results: The indications for
reintervention were acute gastric dilatation (29), fistulas (25), bleeding
(16), intestinal perforation (4), intestinal obstruction (3), and other causes
(12). The approach was by laparoscopy in 82 (93.7%) and by laparotomy in 5
(6.3%). Two-thirds of patients (58) recovered well, but one-third (29) had
perioperative complications, which were treated conservatively in 21 (72.5%).
Eight (27.5%) patients needed another reintervention (7 laparoscopy and 1
laparotomy). The overall mortality rate was 7%.
Conclusion: Based on our own
experience, different complications will arise with LRYGBP for treating
obesity. It is recommended that surgeons consider the laparoscopic
reintervention as one of the successful, safe techniques for management. Also,
it seems to be feasible even for a third-time reoperation in treating newly
arising complications.
9315
General Surgery
Management of Anastomotic Leaks After Laparoscopic Roux-en-Y Gastric Bypass
C. Ballesta, MD, R. Berindoague,
MD, M. Cabrera, MD, O. Al-Sunidar, MD
Centro Laparoscópico de Barcelona, Centro Médico Teknon Barcelona
Background: Anastomotic leaks after
bariatric surgery carry high morbidity and mortality. We aimed to describe our
experience of the diagnosis and management of gastrointestinal anastomotic
leaks in patients undergoing laparoscopic gastric bypass.
Methods: Of 1200 patients who
underwent laparoscopic Roux-en-Y gastric bypass (RYGBP) with manual
gastrojejunal anastomosis (GJA) for morbid obesity from January 2002 to January
2007, we retrospectively analyzed 59 patients with anastomotic leak. The
location of the leak, day of diagnosis, diagnostic methods, clinical
manifestations, treatment modalities, associated complications, and length of
hospital stay were analyzed.
Results: Leaks were located as
follows: 67.8% in the gastrojejunostomy, 10.2% in the gastric pouch, 3.4% in
the excluded stomach, 5.1% in the jejunojejunal anastomosis, 3.4% in the
gastrojejunostomy plus pouch, 3.4% in the pouch plus excluded stomach, and 6.8%
in undetermined sites. Routine upper gastrointestinal series revealed contrast
extravasation in 9 patients (15.3%). Leaks were asymptomatic at diagnosis in 29
patients (49.2%). Surgical reintervention was carried out in 23 patients and
conservative treatment was provided in the remaining 36, with 5 deaths (0.4%).
Conclusion: In our experience, most
anastomotic leaks can be managed with conservative measures alone. In many
patients, abdominal drains are effective in the management of leaks, obviating
the need for reintervention. Nasoenteral nutrition was effective in the
nonoperative management of gastrojejunal leaks in patients without signs of
systemic toxicity.
9316 Gynecology
Use of Bidirectional Barbed Suture in Gynecologic Laparoscopy
Jon Ivar Einarsson, MD, MPH, James A. Greenberg, MD
Brigham and Women’s Hospital, Harvard Medical School
Background: Laparoscopic suturing
and knot tying can be a challenging and time-consuming task. We began using a
bidirectional barbed suture for laparoscopic suturing in March of 2008, mainly
for closure of the vaginal cuff during a total laparoscopic hysterectomy and
for closure of the hysterotomy site during a laparoscopic myomectomy. Since
then, we have performed well over 100 cases using this suture material with
excellent results.
Methods: The
suture has a needle on each end with small barbs incorporated into the suture.
The barbs run in the opposite direction to the needles, similar to the concept
of an arrowhead. This ensures that the suture slides easily through the tissue,
but will not slide back. The wound closure tension is thereby evenly
distributed throughout the suture as opposed to only at the ends. In addition,
because the barbs coming from each needle are running in opposite directions,
there is no need to tie knots at the end of the suture. The lack of backsliding
is especially useful in myomectomy closures where there is frequently high tension
on the closure site.
Results: In our experience, this
suture material greatly facilitates laparoscopic suturing and results in a
secure and hemostatic closure.
Conclusion: We
present our laparoscopic suturing technique with this novel suture material for
vaginal cuff closure and hysterotomy closure in this video.
9317 Multispecialty
Laparoscopic Repair of Rectal Injury During Laparoscopic Radical Prostatectomy
William L. Duncan, Hampton Rutland
University of Mississippi, Jackson Mississippi
This video demonstrates the feasibility of laparoscopic repair of a rectal
injury during laparoscopic radical prostatectomy. During the case, a rectal
injury was identified during the posterior dissection of the prostate from the
rectum. The injury was evaluated after the prostate was detached. It was felt
that the injury could be repaired primarily using intracorporeal laparoscopic
suturing techniques. The injury was repaired laparoscopically in 2 layers using
absorbable suture. Without gross contamination, a colostomy was not required.
In conclusion, a rectal injury identified during radical prostatectomy can be
repaired laparoscopically thus avoiding a laparotomy for repair.
9318
Gynecology
Meckel's Diverticulum Causing Intestinal Obstruction in the Third Trimester of
Pregnancy
Farhad Anoosh, MD,
Dildeep Ambujakshan, MD, Kalyana Nandipati, MD, Ravindra Kakarla, MD, James
Turner, MD
New York Hospital
Queens, New York
Introduction: Intestinal obstruction is a rare but
serious complication of pregnancy. The incidence is 1 in 3000 pregnancies.
Delay in the diagnosis will lead to significant maternal and fetal morbidity
and mortality. The usual causes of obstruction in pregnancy are adhesions,
volvulus, and hernias. The other rare causes are intussusceptions and small
bowel tumors. However, intestinal obstruction in pregnant patients secondary to
Meckel’s diverticulum has not been reported in the literature. The usual
presentation of Meckel’s diverticulum is diverticulitis and peritonitis
secondary to perforation. The incidence of Meckel’s producing an obstruction in
this population in unknown.
Methods: We report on a pregnant female who
presented with abdominal pain and was admitted with the diagnosis of labor
pain. With further clinical observation and diagnostic workup, she was found to
have an intestinal obstruction. She underwent exploratory laparotomy, and the
operative finding revealed Meckel’s diverticulum as the cause of obstruction.
Results and Conclusion: The symptoms of intestinal obstruction
are the same in pregnant as in nonpregnant women, but they are masked by
pregnancy symptoms, so often the diagnosis is delayed. Treatment of bowel
obstruction in pregnancy is the same as in the nonpregnant state. Meckel’s
diverticulum if presenting with bleeding or perforation should be resected and
if presenting with band or adhesion causing obstruction as in our case should
only be lysed. The risk to the fetus and mother is high with complications like
peritonitis secondary to perforation or leak of intestinal anastomosis.
9319 Urology
Preoperative Renal Insufficiency is an Independent Predictor of Adverse
Surgical Outcomes in Partial Nephrectomy
A. Ari Hakimi, MD, Reza Ghavamian, MD
Montefiore Medical Center, Albert Einstein College of
Medicine, Bronx, New York
Introduction: We sought to evaluate
the effects of renal insufficiency on length of stay and complication rate in a
single surgeon’s series of partial nephrectomies for renal cortical neoplasms.
Materials and Methods: Over a
10-year period, 146 consecutive patients were analyzed. Preoperative patient
characteristics were recorded as well as renal function using the MDRD
equation, type of surgery (open or laparoscopic), tumor size and location,
operative time, and blood loss. We then divided the cohort into those with
preoperative MDRD >60, and those with renal insufficiency (MDRD <60).
Using logistical and linear regression, we performed a multivariate analysis.
Results: The renal insufficiency
cohort had an average length of stay of 5.3 days compared with 3.6 days for
those patients with normal renal function (P=0.003). When further controlling
for body mass index (BMI), the Charlson comorbidity score (CCS), estimated
blood loss, tumor size and location, the difference in length of stay remained
1.6±0.55 days (P=0.004). There were 15 complications in 13 patients (39%) in
the renal insufficiency group compared with 17 complications in 16 patients
(14%) in the other cohort [P=0.003, relative risk (RR) 2.2 (range, 1.49 to
4.63)]. When controlling for age, sex and race, BMI, CCS, estimated blood loss,
tumor size and location, the renal insufficiency cohort had an odds ratio (OR)
of 4.17 (CI 1.56 to 11.15) for the risk of complications.
Conclusion: Preoperative renal
insufficiency defined as MDRD <60 is an independent risk factor for
increased length of hospital stay and increased complication rate in patients
undergoing partial nephrectomy.
9320
Urology
Complications for Laparoscopic Surgery for Urologic Malignancy: A Single
Surgeon Experience
Daniel R. Tare, MD, A. Ari Hakimi,
MD, Reza Ghavamian, MD
Albert Einstein College of
Medicine, Bronx, New York
Purpose: We assessed the complications associated with laparoscopic surgery
for urologic malignancy performed by a single surgeon.
Materials and Methods: A
retrospective review was performed of 648 patients between 2001 and 2008.
Laparoscopic surgeries performed included radical nephrectomy (82), partial nephrectomy
(85), laparoscopic prostatectomy (207), robotic-assisted prostatectomy (243),
cystectomy (22), and nephroureterectomy (13). We classified complications as
both intraoperative and postoperative (within 30 days). Postoperative
complications were graded using the Clavien classification system. Additional
data collected included patient age and Charlson Co-morbidity scores.
Results: A total of 147 (22.5%)
patients experienced complications. There were 14 (2.1%) intraoperative
complications and 171 postoperative complications. No perioperative mortalities
occurred. The majority of complications were minor: Grade I in 68 (39.8%) or
Grade II in 83 (48.5%). Ileus was the most common grade I complication in 22
(32.4%), and postoperative transfusion represented 49.4% of the grade II
complications. There were 8 deep vein thromboses and 5 pulmonary embolisms in
the entire cohort. Two conversions to open surgery were necessary, and 3
robot malfunctions occurred, which required 2 conversions to traditional laparoscopic
surgery. There were statistically significant increases in Charlson
Co-morbidity scores and complications in the radical nephrectomy,
nephroureterectomy, and cystectomy cohorts (P<0.05).
Conclusions: The data presented here
help define the complications of laparoscopic urological oncologic surgery in a
contemporary single surgeon experience. Although the overall complication rate
was 22.5%, about 90% of them were minor.
9321
Urology
Evaluation of Age and Adverse Outcomes in Laparoscopic Partial Nephrectomy
A. Ari Hakimi, MD, Reza Ghavamian,
MD
Albert Einstein College of
Medicine, Bronx, New York
Introduction and Objective: Laparoscopic
partial nephrectomy (LPN) has become a viable option for nephron-sparing
surgery for suspicious renal cortical neoplasms. Because it is technically
challenging with a steep learning curve, alternative energy based ablation
techniques have been proposed as a more suitable alternative for older
patients. We sought to determine whether advanced age leads to adverse
outcomes.
Methods: A single surgeon performed 85 consecutive laparoscopic partial
nephrectomies. The cohorts were divided into 2 groups based on age <65 and
≥65. Preoperative variables, such as race, sex, tumor size, preoperative renal
function based on MDRD and comorbidities (Charlson comorbidity index) were
reviewed. Surgical outcomes, postoperative renal function, and complications
were assessed.
Results: There were statistically
significant differences in the 2 cohorts in terms of Charlson comorbidity
scores and preoperative renal function. Despite this fact, no significant
differences existed in the operating time, estimated blood loss, percentage
decline in GFR or complication rates. All grades of complications were
included. In the younger cohort, one patient required embolization for an
arteriovenous fistula, and one patient required a ureteral stent for a
persistent urine leak. In the older cohort, 2 patients underwent embolization:
1 for a pseudoaneurysm and 1 for persistent bleeding. One patient required a
delayed nephrectomy due to intractable hemorrhage. There were no positive
margins or recurrences in either group.
Conclusion: LPN is a safe operation to
perform in the elderly, despite their inherently higher preoperative
comorbidities and preoperative renal impairment.
9322
Gynecolgoy
The Evil Triplets of Chronic Pelvic Pain Syndrome: Pudendal Neuralgia
Maurice K. Chung, MD, Cherie W.
Chung, Rhonda J. Medina, MD, Jennifer Glance, DO, Jackie S. Shriver CNP
Midwest Regional Center for Chronic Pelvic Pain and Female Pelvic Medicine in
Lima, Ohio
Objective: To determine the incidence of pudendal neuralgia and painful
bladder syndrome in patients with chronic pelvic pain.
Method: Prospective cohort study of
96 women (aged, 18 to 83) from April 1, 2008 to March 1, 2009 that presented
with chronic pelvic pain with or without irritable voiding symptoms. All
patients exhibited bladder tenderness and negative urinary and genital
cultures. Patients completed PUF, AUA, and ICSI questionnaires and underwent
potassium sensitivity testing. Clinical evaluations established pudendal
neuralgia by testing for perineodynia through a sensory pinprick test of cutaneous
pudendal nerve branches and a pressure sensation test of the pudendal nerve for
the “Valleix phenomena.” Patients with potassium sensitivity, indicative
of painful bladder syndrome, underwent intravesical therapy. Pudendal
perineuronal injections were given as indicated.
Results: The Potassium Sensitivity
Test was positive in 73 (76%) patients. Pudendal neuralgia was present in 85
(88.5%) patients, of which 67 (78.8%) had positive potassium sensitivity tests.
Thirty-three patients with painful bladder syndrome finished intravesical
therapy. Their mean PUF, AUA, and ICSI scores dropped 44%, 54%, and 51%,
respectively. Thirteen patients with <20% improvement after intravesical
therapy were given pudendal perineuronal injections. Their mean PUF, AUA, and
ICSI scores dropped an additional 43%, 47%, and 51%, respectively.
Conclusion: Previous
publications have shown that interstitial cystitis/painful bladder syndrome and
endometriosis are the “Evil Twins” of chronic pelvic pain syndrome. The
significant incidence of pudendal neuralgia (88.5%) in this study suggests that
this disease entity and the “Evil Twins” should be at the top of the
differential diagnosis for chronic pelvic pain syndrome as the “Evil Triplets.”
9323 General Surgery
An Institutional Comparison of Laparoscopic Versus Open Adrenalectomy
Gazi B.
Zibari, MD, Matt Sanders, MS3, Hany M. Dabbous, MD, Steven Levine, MD, Hosein
Shokouh-Amiri, MD
Background: Laparoscopic adrenalectomy has become the surgical
approach of choice for removing adrenal lesions. Advantages of laparoscopic
adrenalectomy include less intraoperative blood loss, shorter hospital stay,
better cosmesis, and need for less postoperative narcotic than the open
approach. The purpose of this study was to analyze causes and surgical
approaches to adrenal lesions and associated morbidity and mortality.
Methods: Adrenalectomy was performed
in 44 patients from 1998 to 2009 at our institution. Patient demographics,
tumor characteristics, blood loss, complications, mortality, and hospital
course data were collected. Laparoscopic, hand-assisted, and open
adrenalectomies were performed in 24, 6, and 14 patients, respectively.
Results: Laparoscopic adrenalectomy
demonstrated less blood loss than did the hand-assisted and open approaches
(119mL, 470mL, and 1591mL), respectively. Average tumor size in the
laparoscopic, hand-assisted, and open groups were 4.6cm 7.5cm,
7.3cm, respectively. The mean total hospital stay was 5.5 days in
laparoscopic adrenalectomy compared with 12.8 days for hand-assisted and 12.1
days for the open cases. There were 3 conversions from laparoscopic to open due
to one tumor invasion to the IVC, 1 severe
adhesion, and 1 laparoscopic staple malfunction. There were no postoperative
complications in the laparoscopic group, while the hand-assisted and open
groups had 1 and 5 postoperative complications, respectively.
Conclusion: Laparoscopic adrenalectomy has been proven to be safe and is
associated with less blood loss, fewer perioperative complications, and shorter
total hospital stay. Whenever possible, the laparoscopic and hand-assisted
approaches should be utilized.
9324 General Surgery
Laparoscopic Conversion of Common Surgical Procedures: An Analysis of
Patient-Specific and Surgeon-Specific Factors at a Community Hospital
Sujit
Vijay Sakpal, MD1, Supreet Singh Bindra, BA1, Christina Paruthi, BSc1, Ronald
Scott Chamberlain, MD, MPA1,2
1Saint Barnabas Medical Center, Livingston, New Jersey
2University of Medicine & Dentistry of New Jersey, Newark, New
Jersey
Background: Laparoscopic
cholecystectomy (LCCR) and appendectomy (LACR) conversion rates remain in
excess of 8%. We analyzed the impact of patient- and surgeon-specific factors
on conversion rates (CR) over a 5-year period.
Methods: We analyzed 2,205 laparoscopic cholecystectomies
and 745 laparoscopic appendectomies performed over 5-years.
Results: Overall CR was 4.75% (LCCR 4.94% and LACR 4.17%).
Males and patients >50 years old had a higher likelihood of LCC (9.14%
versus 3.52%, P<0.0001 and 8.80% versus 1.47%, P<0.0001, respectively).
Females and patients >37 years old had a higher likelihood of LAC (4.30%
versus 4.02%, P=0.994 and 6.84% versus 1.78%, P=0.0011). The most common reason
for conversion was adhesions; however, 59.29% of all patients who required
conversions had no prior abdominal surgery. CR was higher among high-volume
surgeons [≥200 (mean=392) cases] compared with low-volume surgeons [50 to 200
(mean=121) cases] (5.16% versus 4.32%, P=0.3665, respectively). CRs were lower
among surgeons who completed residency training after 1990 (4.38% versus 5.51%,
P=0.1134) and those with fellowship training (3.44% versus 5.10%, P=0.0963).
Conversions due to technical difficulty/intraoperative complications were lower
among those with fellowship training (25% versus 35.79%, P=0.51) but higher
among those who completed residency training after 1990 (38.33% versus 29.09%,
P=0.3964).
Conclusion: Conversions occurred in ~5% of common
laparoscopic procedures at our institution. CR decreased progressively over the
study period. LCCR was higher in males and patients >50 years old, and LACR
was higher in females and patients >37 years old. Adhesions were the most
common reason for conversions; however, most patients whose procedure required
conversion had no prior abdominal surgery. Surgeon-specific factors had no significant
impact on CR.
9325 Multispecialty
Changes in Organ Perfusion During Laparoscopy
Douglas E. Ott, MD, MBA
Mercer University, School of Engineering
Background: Increased intraabdominal
pressure (IAP) causes reduced tissue perfusion and oxidative stress. Changes in
organ perfusion with increasing IAP during laparoscopy were evaluated.
Methods and Procedure: Laparoscopy
was performed on 12 pigs with IAP of 0, 10, 14, and 20mm Hg using carbon
dioxide. Observation points were parietal peritoneum, rectus sheath, stomach,
duodenum, jejunum, liver, mesenteric artery, cecum, colon, ovary, and fallopian
tube blood flow measured using laser Doppler flowmetry.
Results and Conclusions: Maintaining
normal systemic arterial blood pressure and respiratory function in all
structures decreased blood flow with increasing IAP. Increasing IAP from 10mm
Hg to14mm Hg decreases blood flow in the parietal peritoneum 55%, rectus sheath
by 26%, stomach 45%, duodenum 9%, jejunum 29%, liver 36%, mesenteric artery
40%, cecum 34%, colon 39%, ovary 14%, and fallopian tube 47%. Increasing IAP
from 14mm Hg to 20mm Hg further decreases perfusion to the parietal peritoneum
by an additional 18% (total reduction from 10mm Hg to 20mm Hg 73%), rectus
sheath 15% (41%) stomach 12% (57%), duodenum 3% (12%), jejunum 5% (34%), liver
6% (42%), mesenteric artery 29% (69), cecum 7% (41%), colon 9% (48%), ovary 4%
(18%), and fallopian tube 13% (60%). Increased IAP results in a significant
decrease in blood flow, microcirculation, and increased hypoxia to all tissues
within the abdominal cavity.
9326 Multispecialty
Microcirculatory Changes During Pneumoperitoneum
Douglas E. Ott, MD, MBA
Background: Circulatory changes
occur as a result of pneumoperitoneum pressure. How different
intraabdominal pressures effect blood flow is the focus of this study.
Methods and Procedure: Laparoscopy
was performed using 6 pigs at intraabdominal pressures of 0, 10, 14 and 20mm
Hg, using CO2, He, and air. Gastric,
duodenal, jejunal, colon, hepatic, and peritoneal blood flow was measured using
a laser Doppler flowmetry probe.
Results and Conclusions: Increasing
the intraabdominal pressure from 10mm Hg to14mm Hg decreases blood flow in
the rectus sheath by 27%, parietal peritoneum 55%, stomach 47%, jejunum
29%, liver 36%, duodenum 9%, and colon 41%. Increasing the intraabdominal
pressure from 14mm Hg to 20mm Hg further decreases perfusion
to the parietal peritoneum by an additional 18% (total reduction from
10mm Hg to 20mm Hg 73%), stomach by 12% (9%), jejunum 5% (34%), liver 6% (42%),
duodenum 3% (12%), and colon 9% (50%). When the end point of abdominal wall
compliance is reached, increasing intraabdominal pressure severely compromises
organ blood flow. This increases hypoxia, tissue repair, and may contribute to adhesion
formation.
9327
Gynecology
The Evil Triplet of Chronic Pelvic Pain Syndrome: Pudendal Neuralgia
Maurice K. Chung MD, Cherie W.
Chung, Rhonda J. Medina MD, Jennifer Glance DO, Jackie S. Shriver CNP
Midwest Regional Center for Chronic Pelvic Pain and Female Pelvic Medicine in
Lima, Ohio
Objective: To determine the incidence of pudendal neuralgia and painful
bladder syndrome in patients with chronic pelvic pain.
Method: We conducted a prospective
cohort study of 96 women (ages 18 to 83) from April 1, 2008 through March 1,
2009 who presented with chronic pelvic pain with or without irritable voiding
symptoms. All patients exhibited bladder tenderness and negative urinary and
genital cultures. Patients completed PUF, AUA, and ICSI questionnaires and
underwent potassium sensitivity testing. Clinical evaluations established
pudendal neuralgia by testing for perineodynia through a sensory pinprick test
of cutaneous pudendal nerve branches and a pressure sensation test of the
pudendal nerve for the "Valleix phenomena." Patients with
potassium sensitivity, indicative of painful bladder syndrome, underwent
intravesical therapy. Pudendal perineuronal injections were given as indicated.
Results: The Potassium Sensitivity
Test was positive in 73(76%) patients. Eighty-five (88.5%) patients had
pudendal neuralgia, of which 67 (78.8%) had positive potassium sensitivity
tests. Thirty-three patients with painful bladder syndrome finished
intravesical therapy. Their mean PUF, AUA, and ICSI scores dropped 44%, 54%,
and 51%, respectively. Thirteen patients with <20% improvement after
intravesical therapy were given pudendal perineuronal injections. Their mean
PUF, AUA, and ICSI scores dropped an additional 43%, 47%, and 51%,
respectively.
Conclusion: Previous publications
have shown that interstitial cystitis/painful bladder syndrome and
endometriosis are the “Evil Twins” of chronic pelvic pain syndrome. The
significant incidence of pudendal neuralgia (88.5%) in this study suggests that
this disease entity and the “Evil Twins” should be at the top of the
differential diagnosis for chronic pelvic pain syndrome as the “Evil Triplets.”
9328 General Surgery
Laparoscopic Right Adrenalectomy using the EnSealTM System
(Video Submission)
Fuad Alkhoury, MD, Jeremiah T. Martin, MD, William S. Helton, MD, Steven Yood,
MD, MPH
Hospital of Saint Raphael, New Haven, Connecticut
Objective: A 54-year-old woman
presented with a symptomatic right adrenal adenoma. During her workup,
metastatic lung cancer was found. Her Cushing’s symptoms were significant, and
a right adrenalectomy was performed to palliate her condition before she
underwent chemotherapy.
Methods: Laparoscopic right
adrenalectomy was performed. Arterial supply was cauterized with the EnSeal
device, which uses nanotechnology principles to control current delivery and
minimize thermal spread. The adrenal vein was divided with a US Surgical
Endo-GIA stapler.
Results: The patient recovered well
from her surgery and underwent adjuvant therapy for her lung cancer. The final
pathology revealed a 5x4x4-cm 45-g adrenal adenoma with a metastatic non
small-cell lung cancer (NSCLC) focus within the adenoma.
Conclusion: Laparoscopic
adrenalectomy remains the preferred approach for many adrenal masses. It was
associated with a quick recovery in this patient. The EnSeal Tissue Sealing and
Hemostasis system was found to be safe and effective in our first experience
with this device during adrenalectomy. The finding of tumor-to-tumor metastasis
in this setting is exceptionally rare with an incidence in lung-cancer patients
of 0.14% to 0.63%. Resection of metachronous adrenal masses in NSCLC is associated
with improved survival.
9329 General Surgery
Recurrent Stricture in a Complex High-Risk Patient after Vertical Banded
Gastroplasty: Treatment by a Novel Simultaneous Natural Orifice and
Laparoscopic Endogastric Technique
Collin E. M. Brathwaite, MD, Kenneth
Hall, MD, Alex Barkan, MD, Sven Hida, MD, Stavros Stavropoulos, MD
Winthrop University Hospital, Mineola, New York
Objective: We present a novel approach to the management
of a complicated problem of stomal stricture in a high-risk morbidly obese
patient.
Methods: A 40-year-old female was transferred to our hospital after
repeated bouts of vomiting, hematemesis, and abdominal pain. She was 10 years
post open vertical banded gastroplasty and had undergone multiple endoscopic
balloon dilatations for recurrent stricture at the band site. Past history
included severe asthma, epilepsy, uncontrolled diabetes mellitus, hypertension,
cardiomegaly, chronic angina, bradycardia, permanent pacemaker, deep venous
thrombosis, and Von Willebrand’s disease. After preoperative preparation, she
underwent surgery. At laparoscopy, extensive lysis of adhesions and exposure of
the stomach was performed. A 12-mm balloon tipped trocar was then introduced
via the abdominal wall. The tip was inserted into the stomach through a purse
string gastrotomy and the balloon inflated. Simultaneous intraoperative
transoral gastroscopy was then performed to operate inside the stomach. The
strictured band site was transected using a 45-mm stapler passed
endogastrically via the balloon tipped trocar.
Results: Intraoperative gastroscopy demonstrated a patent stoma.
The postoperative course was uneventful. The patient’s vomiting resolved. Upper
gastrointestinal series performed immediately postoperatively as well as at 6
months revealed no stricture.
Conclusions: This novel technique mitigated the risk of an open
procedure in this complex patient and may be useful for other intragastric
procedures, such as the management of GIST tumors.
9330
General Surgery
Two-Trocar Single Incision Appendectomy
Dana A. Telem, MD, Saber Ghiassi,
MD, Celia M. Divino, MD, Scott Q. Nguyen, MD, Edward H. Chin, MD
The Mount Sinai Medical Center, Department of Surgery, Division of General
Surgery, New York, New York
Introduction: The patient is a 30-year-old male who underwent an interval
single-port appendectomy 6 weeks after resolution of mild appendicitis.
Methods: The patient was placed in a
supine position. A 10-mm, infraumbilical incision was made and dissection
carried down to the anterior fascia. While elevating the abdominal fascia, a
Veress needle was passed and pneumoperitoneum established to 15mm Hg. A
low-profile, reusable 5-mm trocar was placed at the inferior medial portion of
the trocar incision. A 5-mm, 30-degree laparoscope was inserted, and an
additional 5-mm trocar placed through the superolateral portion of the
umbilical incision. A 5-mm grasping instrument was then bluntly placed through
the fascia between the 2 trocars. An ultrasonic coagulating device was used to
release the lateral attachments and divide the mesoappendix. Once dissection
was complete, the base of the appendix was ligated flush to the cecum using a
pretied ligature. The appendix was amputated, and the mucosa briefly
coagulated. A second ligature was then placed to reinforce the appendiceal
stump. The inferomedial 5-mm trocar was then upsized to a 10-mm trocar to allow
a specimen retrieval bag to be introduced for specimen extraction. The surgical
field was inspected for hemostasis and trocars removed. The fascial defect at
the umbilical incision was reapproximated, followed by skin closure.
Results: The patient tolerated the
procedure well without complication. He was discharged home several hours
later, after tolerating a regular diet.
Conclusion: Performing single
incision appendectomy in this manner is safe, technically feasible,
cost-effective, and can be performed with standard laparoscopic instruments and
trocars.
9331
General Surgery
Integrating Emergent Abdominal Laparoscopic Procedures into the Armamentarium
of Laparoscopic Surgeons on a Consistent Basis: A Prospective, Identifiable,
and Consistent Model
W. Peter Geis, MD, Harrish
Kakkilaya, MD, Udayan B. Shah, MD, E. James Hanowell, MD, Bhasker Reddy,
MD
Northwest Hospital, Baltimore, Maryland
Introduction: Emergency abdominal
surgical procedures have only sporadically and selectively been approached
by laparoscopy, in spite of its identifiable benefits.
Methods: In our MIS
Fellowship Program, we have focused on laparoscopy as the first step
to diagnose and treat abdominal surgical emergencies available to our team.
Assessment of factors influencing successful implementation was recorded. Protocols
designed to optimize laparoscopic best outcomes were identified along with
skills necessary to accomplish various emergency procedures.
Results: We performed 243
laparoscopic procedures: 31 for adhesive small bowel obstruction, 9 for large
bowel obstruction, 14 for adhesive SBO requiring SB resection, 9 for iatrogenic
perforated small bowel, 3 for perforated duodenal ulcer, 58 for appendicitis,
18 for perforated appendicitis, 1 for diverticulitis with perforation, 5 for
colonic fistula, and 3 for spontaneous peritonitis and ascites. Also, of 101
patients with ventral hernias, 3 required resection of incarcerated small
bowel, 3 had flank hernias, 1 had incarcerated bowel obstruction requiring
resection, and 11 had colostomy closures.
Conclusions: Patients with
emergent abdominal surgical procedures and those with expected intense
abdominal adhesions should be operated on laparoscopically. Skills required to
safely perform these procedures are laparoscopic adhesiolysis, laparoscopic
manipulation of distended/obstructed bowel, laparoscopic exposure of structures
when bowel is distended/obstructed, laparoscopic suturing (especially
intestine), laparoscopic decisions regarding choice of mini-incision to
complete procedures requiring greater exposure, removal of a large specimen,
repair of bowel etc., or resection of intestine. Each of these skills may be
learned during other less urgent operative procedures including closure of
colostomy, VIH repair, uncomplicated appendicitis, closure of ileostomy,
and elective colectomy.
9332 General Surgery
Single-Port Transumbilical Laparoscopic Intragastric Resection
Seong-Yeob Ryu, MD, Hoi-Won Kim, MD,
Ho-Kun Kim, MD, Mi-Ran Jung, MD, Dong-Yi Kim, MD, Young-Jin Kim, MD
Chonnam National
University Medical School
Background: Laparoscopic intragastric surgery has been performed for the
treatment of mucosal or submucosal gastric lesions. The procedure was useful
for gastric lesions that cannot be treated by gastrofibroscopy. A new
laparoscopic surgery, “single-port transumbilical laparoscopic intragastric
resection,” has been designed and performed on 4 patients since May 2008. We discuss the feasibility of this new laparoscopic
surgery through the umbilicus.
Method: We use homemade single ports that consist of 2 wound retractors
and surgical gloves. The first wound retractor is inserted into the peritoneal
cavity through a small 2-cm umbilical incision. After gastric dilatation, we
pick up the greater curvature of the stomach via the umbilical opening and make
an incision in it. The second wound retractor is then inserted into the stomach
and covered by a glove through which 3 trocars are inserted into
the digital tips. Using this port and special instrument, we performed
laparoscopic intragastric resections.
Results: All 4 patients were female. Mean age was 44 years (range,
35 to 59). Mean body mass index was 23.1kg/m2 (range, 18.7 to 28.5).
No case required additional skin incisions or trocars. Mean operation time was
150 minutes (130 to 180), and blood loss was minimal in all cases. The
tumor size raged from 1.0cm to 3.0cm (mean, 2.1), and histologic results
showed 2 GIST and 2 leiomyomas.
Conclusion: Single-port transumbilical laparoscopic intragastric
resection is technically easy, safe, and feasible. There was only one scar to
the stomach compared with scars with conventional laparoscopic intragastric
surgery and no visible external scar as with NOTES. Single-port
transumbilical laparoscopic gastric resection could be a new alternative
treatment for benign gastric tumors.
9333 Multispecialty
Allodynia in Reverse: A Quantitative Demonstration of Abdominal Wall Muscle
Pain Relief Following Bladder Pain Treatment
Thida Nunthirapakorn, MD, Bradford W. Fenton, MD, PhD
Summa Health System, Pelvic Pain
Specialty Center
Background: Chronic pelvic pain is a syndrome composed of pain from one or
more pelvic organs and includes interstitial cystitis (IC) from the bladder and
myofascial pain syndrome (MFPS) from the anterior abdominal wall. When multiple
pain generators are present, it is not known how treatment of one influences
the other. To evaluate this, a patient with both IC and MFPS underwent
quantitative abdominal wall pain testing before and after hydrodistension.
Method: A patient with a known
history of both IC and MFPS was identified following a flare of her bladder
pain. Quantitative abdominal wall pain testing was done using pain pressure
threshold (PPT) algometry across 14 points on the infraumbilical anterior
abdominal wall before and after treatment of her IC with hydrodistension. In
PPT testing, lower numbers are worse and indicate a lower pain threshold.
Results: For the inguinal ligaments,
PPT improved from an average of 1.6kgf to 2.7kgf (P=0.009). For the lower
abdominal wall points, PPT improved from an average of 2.26 to 2.97
(p<0.001). Self-reported back pain using a visual analog scale (VAS, 0 to
10) improved from 7.6 to 6.0. Regional pain scale scores decreased from 111 to
7 following HD.
Conclusion: Chronic pelvic pain frequently
involves pain spreading to multiple organs, or allodynia. This case
demonstrates the opposite phenomenon: relief of pain in adjacent areas
following localized treatment of a different organ. Taken together, these
results indicate that central nervous system dysfunction must be included in
any understanding of CPP.
9336 Urology
Investigation of an Ultrasound Imaging Technique to Target Kidney Stones in
Lithotripsy
Anup Shah, Marla Paun, Oleg A.
Sapozhnikov, John Kucewicz, Manjiri Dighe, Hunter A. McKay, Mathew D. Sorensen,
Michael R. Bailey
University of Washington School of Medicine
Moscow State University, Moscow,
Russia
The Polyclinic, Seattle, Washington
Objectives: Localization of
kidney stones and targeting for lithotripsy treatment can be challenges
especially with ultrasound. However, a “twinkling” artifact has been observed
in which Doppler ultrasound imagers assign color to the stone. This work
reports preliminary investigation of how this artifact occurs and observation
in a porcine model.
Methods: Glass beads, cement stones,
and human stones were surgically implanted through the ureter to positions
within the kidney collecting system. The stones were imaged with several
combinations of transducers and ultrasound imagers.
Results: In all cases, the artifact
was observed on the stone, and its appearance, as well as RF signature, was
unique from blood flow. Calcium oxalate monohydrate stones and smooth stones did
not cause a greater challenge as has been previously reported. Sensitivity to
any user controls was low with focal depth and gain having the most influence.
Twinkling started at the lateral edges of the stone and spread over the stone
as gain was increased.
Conclusions: The evidence supports
the hypothesis that the artifact is due to the angle of the backscatter at the
near grazing angle that is finely sensitive to slight motion of the stone,
which may result from elastic waves or radiation force.
9337 Urology
Ultrasound to Facilitate Clearance of Residual Stones
Anup Shah1, Mathew D. Sorensen1,
Marla Paun1, Barbrina Dunmire1, John Kucewicz1, Bryan W. Cunitz1, Frank Starr1,
Peter J. Kaczkowski1, Oleg A. Sapozhnikov1,2, Michael R. Bailey1
1University of Washington School of Medicine, Seattle,
Washington, USA
2Moscow State University, Moscow,
Russian Federation
Purpose: To describe the use of
transcutaneous focused ultrasound to manipulate the location of stone fragments
within the renal collecting system to facilitate stone clearance.
Methods: Natural and artificial
stones were placed in a transparent kidney phantom and in cadaveric porcine
kidneys. Stone motion was observed visually in the kidney phantom and by using
diagnostic ultrasound in the porcine kidneys. The ultrasound device was created
by combining a commercial ultrasound imaging system with a research-focused
ultrasound therapy system focused at depths ranging from 4.5cm to 8.5cm.
Results: Stones in the kidney
phantom were seen to move as shown. Stone velocities were on the order of
1cm/s. Operators could generally control the direction of stone movement. No
evidence of thermal necrosis of kidney tissue was observed on gross
examination.
Conclusion: Focused ultrasound can
be used to move stones within the collecting system to optimize rates of stone
clearance.
9338 General Surgery
Initial Outcomes Following Laparoscopic Sleeve Gastrectomy as a Single-Stage
Procedure for Morbid Obesity
Alex Gandsas, MD, MBA, Christina Li, MD, Marvin Tan, MD, Nancy
Lum, RD, Harish Kakkilaya, MD
Sinai Hospital of Baltimore,
Baltimore, Maryland
Background:
Laparoscopic sleeve gastrectomy
(LSG) is still considered a controversial operation when it is chosen as a single-stage
procedure to treat patients suffering from morbid obesity. The present study
evaluates our initial outcomes using this technique as a single surgical
approach for morbid obesity.
Methods:
We conducted a retrospective review
of 229 consecutive patients undergoing a single-stage LSG from October 2006 to
February 2009. The technique involved the use of linear staplers loaded with
bovine pericardial strips and a 40Fr to 42Fr bougie.
Results:
This study comprises 189 females and
40 males with a mean age of 42 years (range, 18 to 66), a mean body mass
index (BMI) of 48kg/m2 (range, 35 to 69), and a mean weight of 297lbs
(range, 198 to 477). The mean follow-up was 7 months (range, 1 to 24). No
conversions to laparotomy were necessary. The mean hospital stay was 1.7 days
(range, 1 to 4). One patient developed a trocar site infection, 2 patients
suffered from postoperative bleeding, 1 patient suffered from deep venous
thrombosis, and 1 patient was diagnosed with pulmonary embolism. There were no
gastric leaks or deaths in this study. The average percentage weight loss was
23% (n=176), 36% (n=130), 49% (n=87), 57% (n=37), and 60% (n=44) at 1, 3, 6, 9,
and 12 months, respectively.
Conclusions:
These data suggest that LSG is a
safe and effective treatment that results in significant weight loss at 1 year
when offered as a single-stage procedure.
9339 General Surgery
Adjustable Laparoscopic Gastric Banding in Situs Inversus Totalis
Ramy A. Awad, MD, Angel M. Caban
MD, Juan C. Cendan MD
University
of Florida, Gainesville, Florida
Background:
Morbid obesity is a serious health
issue with a rising incidence and a strong association with increased mortality
and comorbidities. Situs inversus totalis is an uncommon anatomic anomaly,
which denotes complete right-left inversion of thoracic and abdominal viscera.
Recently, several laparoscopic operations have been reported in patients with
situs inversus (SI). We describe laparoscopic adjustable gastric banding in
such a patient utilizing the pars flaccida technique.
Methods: The patient is a
34-year-old morbidly obese female (BMI=47) with a known history of SI who
desires gastric banding. She underwent successful laparoscopic gastric banding
with an uneventful postoperative course. A 4-port technique was used
with exposure of the gastroesophageal junction with use of the Nathanson liver
retractor. The band was introduced via a 15-mm left subcostal trocar.
Results: Careful consideration of
the mirror-image anatomy permitted safe operation using techniques not
otherwise differing from those in ordinary cases. Special consideration
regarding the fixed shape of the liver retractor and location of the dominant
suturing hand was necessary.
Conclusion: Although technically
more challenging, laparoscopic gastric banding surgery for morbid obesity in
the presence of situs inversus is feasible and safe.
9340 General Surgery
Risk Factors for Prolonged Operative Time in Laparoscopic Cholecystectomy
Dr. med.
Yasser Bashin
University of Aden, Yemen
Objective: Prolonged operative time in patients undergoing
laparoscopic cholecystectomy is a risk factor for perioperative complications.
This study aimed to determine risk factors that can predict prolonged operative
time.
Methods: Data collected retrospectively on 677 patients who
underwent laparoscopic cholecystectomy between April 2004 and November 2007 at
the university hospital of Tuebingen, Germany were analyzed. Eighty-one patients
who underwent conversion to an open procedure, intraoperative cholangiography,
or both, were excluded. Factors evaluated included age, sex, body mass index
(BMI), American Society of Anesthesiology (ASA) class, previous abdominal
surgery, preoperative endoscopic retrograde cholangiopancreatography (ERCP),
acute cholecystitis, and surgeon’s experience. Univariate and multivariate
analyses were performed to identify factors predicting a long operation.
Results: We analyzed 596
patients with a mean (± SD) age of 52.2±16.7 years (range, 16 to 89) and a
male-to-female ratio of 1:2. Acute cholecystitis was found in 105 patients
(18%). The median operative time was 80 minutes (range, 15 to 281). Predictors
of prolonged operative time were acute cholecystitis and surgeon’s own
experience (P<0.0001), obesity (P<0.001), previous upper abdominal
surgery, and male sex (P<0.05).
Conclusion: Preoperative prediction of whether a laparoscopic
procedure will take additional time through recognition of such risk factors
may have several practical applications. In addition to allowing better
planning of anesthesia management and theater lists, both in terms of service
provision and training of junior doctors, it may allow a more efficient
selection of patients for ambulatory LC.
9341 General Surgery
Single Port Access (SPATM) “Hepatic Sling” Technique Video
Andrew S. Wu, MD, Erica R. Podolsky, MD, Paul G. Curcillo II,
MD
Drexel University, College of Medicine,
Philadelphia, Pennsylvania
Background: We have applied Single Port Access (SPA) surgery
to procedures of the gastroesophageal (GE) junction through a single skin
incision, usually placed within the umbilicus. This type of minimal access
surgery requires retraction of the liver. To eliminate an externally placed
liver retractor from our limited port of entry within the umbilicus, we have
now developed and applied the placement of an intracorporeal “Hepatic Sling”
consisting of a simple Penrose drain to retract the liver and maintain exposure
of the GE junction.
Methods: After entry is obtained
through the umbilicus using the SPA technique for the camera, 2 trocars, and
one trocarless entry site, a 1-inch or ½-inch Penrose drain is inserted into
the abdomen. Once the liver is retracted toward the anterior abdominal wall,
the drain is secured to the diaphragm above the esophageal hiatus with a tack.
The other end is passed under the left lateral lobe of the liver and tacked to
the right anterior abdominal wall. A second Penrose drain may be looped around
the first one in a “T” formation for additional support and retraction of a
large lateral lobe. At the end of the procedure, the tacks are removed and
slings are withdrawn.
Conclusion: The
intracorporeal hepatic sling eliminates the need for an additional port site
and provides a safe, effective, and applicable means to retract the liver for
Single Port Access (SPA) surgical procedures involving dissection of the GE
junction.
9342 General Surgery
Validity of Resident Self-Assessment in Minimally Invasive Surgery
Neil Orzech, MD1, Vanessa Palter, MD1,
Rajesh Aggarwal, PhD, MA, MRCS2, Allan Okrainec, MD3, Teodor Grantcharov, MD, PhD1
1St. Michael’s
Hospital, University of Toronto, Canada
2Imperial College London, United Kingdom
3Toronto
Western Hospital, University of Toronto, Canada
Objective: To evaluate whether senior surgical
residents in general surgery accurately self-evaluate their performance with
respect to intracorporeal suturing.
Methods: Fifteen senior general surgery residents
participating in an advanced laparoscopy workshop performed intracorporeal
suturing tasks on 3 simulated models: the Fundamentals of Laparoscopic Surgery
(FLS) intracorporeal suturing task; a bench-top laparoscopic Nissen
fundoplication model; and a Virtual Reality surgical simulator suturing task.
Residents’ technical performance was evaluated using a laparoscopic suturing
checklist and the Objective Structured Assessment of Technical Skills global
rating scale. Upon completion of their suturing task on each of the respective
simulated models, residents evaluated their own performance using the same 2
evaluative tools. The correlation between Faculty Assessment and resident
Self-Assessment was calculated using the Spearman rank correlation coefficient.
Results: There was poor correlation between faculty
assessment scores and self-assessment performed by the residents in all 3
models (rs<0.5, P>0.05). Residents’ self-assessment scores were
consistently higher, but this difference did not reach statistical significance
(Mann-Whitney’s test, P>0.05).
Conclusion: Senior surgical residents cannot perform
accurate and objective self-assessment of their laparoscopic skills using
validated tools. Surgical residency programs should consider implementing
proficiency-based training of intracorporeal suturing that relies on faculty
assessment.
9343 General Surgery
Laparoscopic Distal Gastrectomy and D1 Lymphadenectomy for Gastric
Adenocarcinoma
Ziad Awad, MD, Eddie Lambert MD,
MBA
University of Florida-Jacksonville
The application of laparoscopic surgery in the management of gastric cancer is
not well-defined in the Western world. The objective of this video is to
demonstrate that laparoscopic surgery is feasible in select cases of gastric
cancer. The subject was a 79-year-old female with a recent diagnosis of gastric
adenocarcinoma. Computed tomography (CT) of the abdomen showed thickened
pyloric antrum and gastric outlet obstruction. Endoscopic ultrasound (EUS)
established T2 N0 tumor staging. Laparoscopic distal gastrectomy with D1
lymphadenectomy was performed without complication. The postoperative hospital
course was unremarkable, and the patient was discharged home on day 2.
Histopathologic analysis confirmed staging as T2a N0 Mx with 31 lymph nodes
negative for evidence of cancer. At 12-month follow-up, the patient continues
to do well with no evidence of recurrence.
9344 General Surgery
Single Port Access (SPA) Proximal Gastric GIST Resection Video
Andrew S. Wu, MD, Nithin Karanth,
MD, Paul G. Curcillo II, MD
Drexel University College of Medicine, Philadelphia,
Pennsylvania
Background: Recent advances in
minimally invasive surgery have included methods for reducing the number of
incisions for trocar placement. Single Port Access is a novel method allowing
the performance of standard laparoscopic procedures through one incision.
We have applied Single Port Access (SPA) surgery to procedures of the
gastroesophageal (GE) junction through a single skin incision, usually placed
within the umbilicus. We report the first Single Port Access resection of a
proximal 3cm x 3cm GIST tumor in a
patient presenting with an upper gastrointestinal bleed.
Methods: Entry into the abdomen was
achieved through an 18-mm umbilical incision for placement of a 5-mm trocar for
the laparoscope. Skin flaps were subsequently created lateral to the
laparoscope for placement of 2 additional trocars for the dissecting
instruments. Once the single-port access had been achieved, the dissection of
the mass was carried out with the collaboration of the gastroenterologist who
performed an upper endoscopy, aiding in the eversion and dissection of the mass
and evaluating the gastric resection site intraluminally. The mass was removed
successfully, and no intraoperative and postoperative complications occurred.
Conclusion: This is our first GIST
resection done via a combined NOTES/Single Port Access approach. The principles
for laparoscopic dissection and resection of the GIST tumor performed via the
single-port access approach remain the same as standard multi-port laparoscopy.
9345 Other
Laparoscopic Management of Ureteral Endometriosis: The Stanford University
Hospital Experience of 96 Consecutive Cases
Dorian Bosev, MD1,2, Linda M. Nicoll, MD1, Madeleine Lemyre, MD1,3,
Christopher K. Payne, MD1, Harcharan Gill, MD1, Camran Nezhat, MD1
1Stanford
University Medical Center, Palo Alto, California
2Medical
University, Maichin Dom Hospital, Sofia, Bulgaria
3Laval University, Quebec, Canada
Purpose: To describe the clinical characteristics and
principles of laparoscopic management of women with ureteral endometriosis at
our institution.
Materials and Methods: We retrospectively reviewed the charts of 96
consecutive women with ureteral endometriosis confirmed by pathology report who
were treated between January 2002 and October 2008 at our academic referral
center.
Results: Preoperatively, almost all patients complained of
pain (97%) but only a third had urinary symptoms. The operative findings showed
stage IV endometriosis in 43% of women. The left ureter was most commonly
affected (64%), and the disease was bilateral in 10% of patients. There was
concomitant involvement of the ipsilateral ovary in more than two-thirds of
cases. Four patients had hydroureter, and 2 had hydronephrosis. All patients
underwent ureterolysis with excision or ablation of endometriosis. Two patients
required partial ureteral resection and ureteroneocystostomy with a psoas
hitch. Two complications were noted: one patient developed septic pelvic
thrombophlebitis and the other a positional ureteral stricture.
Conclusions: To the best of our knowledge, this report
constitutes the largest series of laparoscopically treated and pathologically
confirmed ureteral endometriosis to date. It confirms that laparoscopic
diagnosis and management of ureteral endometriosis is safe and efficient. All
patients undergoing laparoscopy for endometriosis should be evaluated for the
possibility of ureteral involvement regardless of the presence or absence of
urinary symptoms or prior radiologic evaluation, because undiagnosed ureteral
disease may result in loss of renal function. The aim of treatment should be to
remove endometriotic lesions, to relieve ureteral compression, and to avoid
recurrence.
9346 Multispecialty
Endometriosis of the Diaphragm: A Description of 4 Cases Treated
Thoracoscopically and a Review of the Literature
Linda M. Nicoll, MD1, Dorian
Bosev, MD1,2, Ramin Beygui, MD1, Camran Nezhat, MD1
1Stanford
University Medical Center, Palo Alto, California
2Medical University,
Maichin Dom Hospital, Sofia, Bulgaria
Purpose: To describe the clinical characteristics and
principles of combined laparoscopic and thoracoscopic management of women with
diaphragmatic endometriosis at our institution.
Materials and Methods: We retrospectively reviewed the charts of 4
consecutive women with diaphragmatic endometriosis who were treated between
January 2002 and October 2008 at our academic referral center.
Results: Four patients underwent a combination of
laparoscopy for treatment of abdominopelvic endometriosis and thoracoscopy for
treatment of diaphragmatic endometriosis. All patients had a history of chest
pain. Three-quarters had a history of pelvic pain. Half had a history of
catamenial hemo- or pneumothorax. Half had been previously diagnosed with
endometriosis. All had uneventful recoveries without complications.
Conclusions: To the best of our knowledge, this report
constitutes the only reported series of patients with endometriosis who
underwent a procedure combining both laparoscopy and thoracoscopy for treatment
of abdominopelvic and thoracic disease. It confirms that combined laparoscopic
and thoracoscopic diagnosis and management of diaphragmatic endometriosis is
safe and efficient. The inferior aspect of the diaphragm should be evaluated in
all patients undergoing laparoscopy for endometriosis. Concomitant thoracoscopy
should be considered for all patients with a history of catamenial
hemopneumothorax, cyclic chest or shoulder pain, or cyclic dyspnea. The aim of
treatment should be to remove endometriotic lesions, to provide symptomatic
relief, and to avoid recurrence.
9347 Other
Vaginal Reconstructive Surgery Using Pinnacle Mesh Kit vs Open Abdominal vs
Laparoscopic Sacrocolpopexy: Comparison of Outcomes
Sternschuss Gina, MD, Cynthia Hall, MD Sharon Jakus, MD
Cedars-Sinai Hospital and Medical Center, Los Angeles, California
Objective: Primary objective of this study was to compare and determine
the success rates of 3 types of surgery for pelvic organ prolapse (abdominal
sacrocolpopexy vs laparoscopic sacrocolpopexy vs vaginal mesh procedure) in an
attempt to prove that vaginal surgeries using mesh are not inferior to the
"gold standard" surgery for POP-sacrocolpopexy. The secondary
objective was to prove that the rate of complication (mesh erosion) after
vaginal mesh surgery is no higher than the rate of mesh erosion after the “gold
standard” surgery for POP-sacrocolpopexy.
Methods: Retrospective analysis of POP repair cases, primary repair via
abdominal SCP, laparoscopic SCP, or vaginal mesh/Pinnacle repair performed
from 2005 to 2009. All female patients who underwent open or laparoscopic
sacrocolpopexy as a primary surgery or treatment for POP and all female
patients who underwent vaginal mesh primary surgery by a single urogynecologist
at a major academic institution in Southern California from 2005 to 2009 were
included. Twenty-six patients underwent LSC sacrocolpopexy, 18 underwent
open abdominal sacrocolpopexy, and 23 underwent vaginal mesh/Pinnacle system
repair.
Results: All groups were found to be similar in background (age,
parity, degree of POP). Success rates for LSC SCP was 100% for anterior
compartment prolapse, 100% for apical, 96% for posterior compartment. Open SCP
success rate was 94% for anterior, 100% for apical, 100% for posterior. Vaginal
mesh surgery success was 96% in all compartments. Median change in grade
was similar in all 3 groups. Follow-up period I operative and postoperative
complication rates were similar. EBL was higher in the vaginal repair group.
The erosion rate was higher in the vaginal mesh group.
Conclusion: Success
of vaginal mesh kit prolapse repair is similar to the success of the “gold
standard” surgery for POP-sacrocolpopexy. But erosion rate in vaginal mesh
prolapse repairs remains high.
9348 Urology
Laparoscopic Extraperitoneal Radical Prostatectomy: Impact of the Learning
Curve on Perioperative Outcomes and Margin Status
Alejandro R. Rodriguez, MD1, Julio M. Pow-Sang, MD1,2
1University of South Florida Health Sciences Center,
Tampa, Florida
2Genitourinary Oncology Program, Moffitt Cancer Center and Research Institute,
Tampa, Florida
Objectives: After improved technical modifications that followed the
reports by pioneering laparoscopic surgeons, the real impact of the learning
curve has not been objectively assessed for laparoscopic extraperitoneal
radical prostatectomy (LERP). We assessed the impact of the learning curve on
operative and oncologic outcomes at a high surgical volume institution.
Methods: We prospectively analyzed
400 consecutive patients with prostate cancer treated with LERP between January
2004 and July 2006. Patients were divided into 4 equal groups (1-100, 101-200,
201-300, and 301-400). Kruskal-Wallis test was performed to determine whether
all the preoperative variables were comparable among groups. Fisher’s exact
test was performed to determine the association of margin status with
pathological stage. The chi-square test was performed to determine whether
margin status was associated with groups (1 vs. 2, 3, and 4). Wilcoxon rank-sum
test was used to determine whether operative time was statistically different
in group 1 vs. groups 2, 3, and 4.
Results: All groups were comparable
with respect to preoperative data. Positive margin rate significantly decreased
after the first 200 cases for patients with pT2a-c disease (28.4% to 31.9% vs.
11.6% to 11.5%). Margin status was significantly associated with groups (Group
1 & 3: P=0.0044 and Group 1 & 4: P=0.0021). Operative time
significantly decreased after the first 100 cases (350 min vs. 218 min, 192
min, and 223 min)(P=<0.0001).
Conclusions: Operative and
pathological outcomes improved significantly with increased surgical experience
after 100 and 200 cases, respectively.
9352 Gynecology
Laparoscopic Cytoreduction for Advanced Primary and Recurrent Ovarian,
Fallopian Tube, or Primary Peritoneal Cancer
Farr
Nezhat, MD1, Jennifer Cho, MD1, Connie Liu, MD2, Herbert Gretz, MD3, Linus Chuang,
MD3
1St Luke’s-Roosevelt Medical Center, New York, New York
2New York University Langone Medical Center, New York, New York
3Mount Sinai Medical Center, New York, New York
Objective: To describe our experience with total primary,
interval, or secondary/tertiary laparoscopic tumor debulking in patients with
advanced ovarian, fallopian tube, or primary peritoneal cancer.
Methods:
This is a prospective case series. Women with confirmed advanced ovarian,
fallopian tube, or primary peritoneal cancer who were medically stable to
undergo laparoscopy were recruited. They underwent complete laparoscopic
primary, interval, or secondary/tertiary cytoreduction for advanced cancer at 2
major institutions and affiliates from 1996 to 2009. Outcome variables analyzed
included stage, sites of disease, extent of debulking, operative time, blood
loss, hospital stay, complications, and follow-up time.
Results:
A total of 43 patients were recruited. Eighteen of them underwent primary or
interval cytoreduction, and 25 underwent secondary/tertiary laparoscopy and
cytoreduction. In the primary and interval cytoreduction group, the mean
operation time was 301 minutes, average blood loss 197mL, and hospital stay of
5.6 days. Fourteen patients (or 77.7%) were optimally cytoreduced to <1cm or
microscopic disease. The follow-up time was anywhere from 1 month to 23 months.
In the secondary/tertiary cytoreduction group, the average operation time was
198 minutes, blood loss 104mL, and hospital stay 2.9 days. Complications
included ureteral transections (n=2), ileus or partial bowel obstruction (n=2),
hemorrhage (n=1), sepsis (n=1), perforated diverticulum (n=1), hemothorax
(n=1).
Conclusion: Laparoscopic
cytoreduction in patients with advanced ovarian cancer is technically feasible
with acceptable morbidity in a well-selected population.
9353 Gynecology
Asymptomatic Perforation and Migration into the Omentum: A Case Report
Raisa Platte, MD, Deborah Poplawsky, MD
Geisinger Medical Center, Danville,
Pennsylvania
Introduction: Nearly 160 million
women currently use IUDs. One of the rare complications is IUD perforation of
the uterus. We report a unique case of asymptomatic uterine perforation by
LNS-IUD into the omentum. The location of the IUD was precisely mapped by
computed tomography (CT) and successfully removed via laparoscopy.
Case Report: An 18-year-old female
6-weeks postpartum after a cesarean delivery had an uneventful LNS-IUD
insertion. At the follow-up visit, the clinician was not able to identify the
strings of the IUD at the cervical os. Ultrasound confirmed the absence of the
IUD in the uterine cavity. A plain film of the abdomen showed the approximate
anatomical location. CT scan showed the IUD embedded in the omentum at the
ileo-sigmoid junction. The LNS-IUD was laparoscopically removed.
Discussion: The LNS-IUD was
introduced in the United States in 2001. More than 2 million devices have been
used by women in this country. A myriad of rare complications have been
reported. Uterine perforation occurs during IUD insertion and complicates 0.87
to 1.6 per 1000 insertions. The standard imaging modality for extrauterine IUD
location is X-ray imaging.
Conclusion: This case uniquely
demonstrates exact topographical localization of an intraabdominal IUD on CT
scan. This in turn led to successful intraoperative identification of the IUD
and uneventful laparoscopic retrieval.
9354 General Surgery
Resident Perceptions of Advanced Laparoscopic Skills Training
Vanessa Palter, MD1, Neil Orzech,
MD1, Rajesh Aggarwal, MD, PhD3, Allan Okrainec, MD2, Teodor Grantcharov, MD, PhD1
1St Michael's Hospital,
Toronto, Canada
2University Health Network,
Toronto, Canada
3Imperial College, London,
United Kingdom
Objectives: To explore surgical residents’ perceptions regarding their
training in laparoscopy, and to determine their opinions regarding the current
methods of teaching laparoscopic suturing in a surgical skills laboratory.
Methods: This study included 14
general surgery residents who had participated in a workshop on advanced
laparoscopy. Four training tools were utilized in the workshop: the
Fundamentals of Laparoscopic Surgery (FLS) black box suturing model, a
Synthetic Nissen Fundoplication model, a Virtual Reality (VR) Simulator
Suturing Task, and a porcine jejunojejunostomy model. After the workshop,
residents completed a questionnaire relating to their experience with
laparoscopy, and their opinions regarding the 4 models. Descriptive statistics
were used for analysis.
Results: The majority of
participants had performed over 40 basic laparoscopic cases during the course
of their residency; however, half of the residents felt that their exposure to
advanced laparoscopy was insufficient. Residents ranked the animal model as
their preferred training tool for laparoscopic suturing, followed by the FLS
black box, with the VR Simulator Task being the least preferred tool
(P<0.05). When asked to rate each task individually, the majority of
residents rated the porcine (9/11 residents), FLS (8/14 residents), and Nissen
model (8/14 residents) as “extremely helpful” on a Likert scale. The VR model,
however, was rated as either “neutral” or “unhelpful” by the majority of
participants (11/14).
Conclusions: These results indicate
that future developments in VR simulation are necessary to provide a realistic
experience with intracorporeal suturing. Resident opinions should be taken into
account when planning a surgical skills curriculum.
9355 General Surgery
Hand-Assisted Laparoscopic Repair of Large and Complex Incisional Hernias
(Panama Technique)
Rafael V.
Reyes Richa
Social Security
Hospital-Panama
Objective: To describe a new and alternative laparoscopic method
for repair of large and difficult incisional hernias using a hand-assisted
device.
Methods and Procedures: A small 6-cm to
7-cm incision is used to gain access to the peritoneal cavity, away from the
previous scars, and lateral to the hernia defect. The hand port is introduced
through the incision and pneumoperitoneum is established. One optic of 5mm and
30 grades is used, and 3 or 4 additional 5-mm ports are placed. The
surgeon’s left hand is introduced through the hand port to make the traction
and facilitate the adhesiolysis, which is performed using a sharp
dissection or Harmonic scalpel. The mesh is inserted through the lap disc and
over the hand, intraperitoneally. The mesh is positioned and anchored with the
standard technique. A lateral border of the mesh (a flap) with the fascia is
used to close the incision or defect of the hand port.
Results: From September 2004 to
September 2008, we operated on 32 patients. No mortalities occurred in this
series. The mean of postoperative days was 2 days. The complications were
seroma (3.1%), hematoma (3.1%), and enteric fistula (3.1%).
Conclusions: The advantages of this
approach are (1) shorter operating room time; (2) it facilitates lysis of
adhesions and decreases the possibility of intestinal perforation; (3) it
decreases the conversion rate in very difficult cases; (4) it is easier for
mesh insertion and positioning; (5) it maintains all the advantages of
conventional laparoscopic surgery and is an alternative method in difficult
cases.
9356 Urology
Robotic Distal Ureterectomy with Psoas Hitch and Ureteroneocystostomy for
Primary Endometriosis of the Ureter
Graham VerLee, MD, Ashay Kparker, MD, Leslie Deane, MD
University of Illinois at Chicago, Illinois
Introduction: Robotic surgery in urology has been applied to
many clinical situations traditionally treated by open techniques. We report a
case of primary endometriosis of the ureter treated by robotic distal
ureterectomy with psoas hitch and ureteral reimplantation.
Methods:
A 28-year-old female presented with bilateral hydronephrosis and renal failure
with a nonfunctioning and atrophic left kidney. She was found at ureteroscopy
to have a polypoid lesion in the distal right ureter 3cm from the right
ureterovesical junction. She presented for definitive management of the right
ureteral lesion. It was felt that the lesion was too large to be ablated
endoscopically, and thus a transabdominal approach was planned.
Results:
A robotic distal ureterectomy with simultaneous intraoperative ureteroscopy,
psoas hitch, and ureteral reimplant was performed. The total console time was
6.5 hours. The estimated blood loss was <50mL. No complications occurred.
The hospital stay was 4 days. The final pathology showed endometriosis of the
ureter with negative margins. The ureteral stent was removed at 5 weeks, and
ultrasound at 3 months showed almost total resolution of hydronephrosis. The
patient’s serum creatinine improved to 1.3mg/dL.
Conclusion:
Robotic distal ureterectomy and ureteral reimplantation is safe and feasible in
cases of distal ureteral obstruction.
9357 General Surgery
The Effect of Helicobacter Pylori on
Gastroesophageal Reflux Disease
Fatin R. Polat, MD, Sabriye Polat, MD, Ayşe Çevoirme
State Hospital Sakarya, Turkey
Background:
We retrospectively studied
the influence of Helicobacter pylori
(HP) on the reflux esophagitis of 2442
consecutive patients who underwent gastroscopy.
Patients and Methods:
A standard endoscopic procedure was carried out in all patients.
Hematoxylin-eosin and Geimsa staining were performed on all specimens.
Results:
The median age of the patients was 44.54 years (range, 17 to 92). HP was severe
in GORD patients; nevertheless, a correct ratio between the severity of HP and
grades of GORD was not seen.
Conclusions:
There is still a controversial association between gastroesophageal reflux
disease (GORD) and HP infection. Based on our study findings, it seems that
there is no significant evidence of a significant role for HP infection in the
development of erosive esophagitis. Nevertheless, current data do not provide
sufficient evidence to define the relationship between HP and GORD; however,
our results show that the prevalence of HP in patients with GORD was 58.8%.
9359 Gynecology
Treatment and Diagnosis of Uterine Adenomyoma
Olav
Istre, MD, PhD
Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
Objective: An adenomyoma is a benign tumor composed of
smooth muscle cells and endometriosic tissue, typically originating within the
uterus.
Methods: These patients
usually present with monthly pain due to embedded blood in the adenomyotic
cyst.
Results: Diagnosis is
established on transvaginal ultrasound, and this also will guide surgeons in
choosing the correct management approach. This video shows ultrasound pictures
and presents hysteroscopic and laparoscopic treatment of the problem.
Conclusions: Adenomyoma uteri are
rare; however, ultrasound detects the clinical situation and guides the
endoscopic approach.
9360 General Surgery
Novel Approach to Preventing Primary and Secondary Adhesions
Adebola Obayan, MBBS, PhD
Introduction: Considerable evidence
exists indicating that adhesions are the most frequent unresolved complication
of abdominal surgery and particularly colorectal surgery today. Of patients
undergoing laparatomy, 93% subsequently develop adhesions. Although
laparoscopic adhesiolysis is fast becoming the preferred treatment, 97% of
these patients develop adhesions at the same site within 3 months. A better
understanding of the pathophysiology of adhesion formation is necessary for
adhesion prevention. Therefore, a novel approach based on this understanding
will lead to the prevention of the development of adhesions. The hypothesis is
that Evitar is safe and effective in preventing both primary and secondary
adhesions.
Methods: The primary adhesion study
involved the use of 10 male Wistar rats randomly distributed into treatment and
control. The rats were reviewed after about 4 weeks. Ten Wistar rats randomly
distributed into treatment and control groups had secondary adhesions 4 weeks
after the first surgery. The treatment arm had 1g of Evitar inserted into the
abdomen while control rats had no treatment. To ensure adhesion formation, the
adhesion surgery was a modified cecal perforation with a pulstring closure.
Results and Conclusion: Adhesion
formation was prevented in all 5 treatment rats compared with significant
adhesion formation in control rats. We also had reversal of adhesions after
adhesiolysis in the treatment group compared also with controls. We conclude
that Evitar is effective in preventing primary adhesions and in reversing
secondary adhesions.
9361 General Surgery
Single Incision Laparoscopic Incisional Hernia Repair
Curtis E. Bower, MD, Katie M.
Love, MD, Timothy L. Fitzgerald, MD
East Carolina University Department of Surgery, Brody School of Medicine,
Greenville, North Carolina
Introduction: Single incision
laparoscopic surgery (SILS) is an advancement in current laparoscopic
techniques. It involves placement of 2 or more ports through the same small
incision. The procedures are then carried out in a fashion similar to their
multi-port counterparts. This new approach is being utilized for many different
procedures. Here, we present a video of a single incision laparoscopic
incisional hernia repair.
Methods: The patient is a 61-year-old male who underwent
an uneventful laparoscopic hand-assisted right hemicolectomy for a sessile
polyp. He developed a postoperative wound infection and eventually an
incisional hernia at the location of the hand port site. He was counseled on
repairing his hernia with a SILS approach and was agreeable. Standard
instrumentation was used to perform a single incision laparoscopic incisional
hernia repair.
Results: The patient tolerated the procedure well. He was
discharged home on postoperative day one and has had an uneventful recovery
with no recurrence or complication to date.
Conclusions: SILS is a technique with multiple applications.
Definite benefits at this point are cosmetic. The outcomes for large numbers of
patients will need to be evaluated to determine any other benefits or pitfalls
associated with these procedures. This demonstration is intended to aid other
surgeons in applying and refining the techniques shown.
9362 Urology
Laparoscopic Donor Nephrectomy: The Massachusetts General Hospital Experience
Polyxeni Agorastou, MD, Georgios
Tsoulfas, MD, Dicken Ko, MD, Martin Hertl, MD, Nahel Elias, MD, Reza Saidi, MD,
Peter Kennealey, MD, James Markmann, MD, Tatsuo Kawai, MD
Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
Objective: To review 278 consecutive laparoscopic donor
nephrectomies performed at Massachusetts General Hospital to determine whether
extraction of the right versus the left kidney affects the outcome.
Methods: From August 1998 to April 2009, 278 patients (259
left and 19 right) underwent laparoscopic living donor nephrectomy. The 2
procedures were compared in regards to various intraoperative and postoperative
parameters.
Results: The 2 groups were similar in donor preoperative
GFR (L=129.5 vs R=127.3), operating time (L=228min vs R=226min), donor
postoperative Cr (L=1.36 vs R=1.48), conversion to open (L=6.6% vs R=5.3%),
delayed graft function (L=7.2% vs R=6.3%) and recipient postoperative
creatinine (L=1.54 vs R=1.32). Three intraoperative donor complications occurred
in the left group (bleeding with one requiring transfusion), but none in the
right group. Similarly, more postoperative major complications occurred in the
left group (6) with one in the right group. The right kidney was used
because of the number of vessels (5pts), cysts (5pts), kidney size and function
(6pts), renal stones (2pts) and tortuous ureter (1pt). The reasons for
conversion included bleeding, anatomical issues, and adhesions, although it
should be noted that there have been no conversions to open in the last 3
years, whereas the only conversion in the right group was the first case.
Conclusions: Operative and postoperative parameters are
comparable between the 2 groups. Considering sample size limitations, right
nephrectomy may be just as safe and efficient as the left one. The elimination
of any conversions in the last few years underscores the importance of the
learning curve.
9363 Urology
Laparoscopic Partial Cystectomy
Joshua Griffin, MD, William L.
Duncan, MD
University of Mississippi, Jackson Mississippi
Background: Laparoscopy has gained
wide acceptance in urology since the first laparoscopic nephrectomy was
performed in 1991. Laparoscopic cystectomy and partial cystectomy have been
previously described. Our video demonstrates the safety and feasibility of
laparoscopic partial cystectomy.
Methods: The patient was
incidentally found to have a urachal remnant on computed tomography during an
evaluation for abdominal pain. The patient was counseled on treatment options
and elected to have a laparoscopic partial cystectomy due to the malignant
potential of urachal remnants.
Results: Laparoscopic partial
cystectomy was performed using pure laparoscopic techniques. Knowledge of
intracorporeal suturing is required.
Conclusion: Minimally invasive
surgery should be offered in the face of benign bladder pathology as
demonstrated in this case. It offers the patient the conventional benefits of
laparoscopic surgery with an equivalent result as open partial cystectomy. Although
technically challenging, our technique of laparoscopic partial cystectomy is
safe and a viable option for patients with benign bladder pathology who are
candidates for partial cystectomy.
9365 Gynecology
Laparoscopic Approach for Presacral Tumors: Early Experience of Initial 19
Cases
Huicheng Xu, MD, Yong Chen, MD,
Yuyan Li, MD, Junnan Li, MD, PhD, Dan Wang, MD, Zhiqing Liang MD, PhD
Southwest Hospital, Third Military Medical University, Chongqing, PR China
Objective: The aim of this study was to
evaluate the complete surgical resection by a laparoscopic surgical technique
normally undertaken for tumors under the sacral promontory.
Methods: This was a
retrospective review of the clinical features and results of surgical treatment
of 19 patients who had laparoscopic resection of presacral tumors between 2005
and 2008.
Results: All
19 patients underwent the laparoscopic
procedure, and complete tumor resection was
obtained. The mean operative time was 182 minutes (range, 115 to 328),
with a mean blood loss of 180mL (range, 120 to 230), and the average hospital
stay was 6.2 days (range, 6 to 9). Pathological
findings included 6 teratomas, 6 dermoid cysts,
3 schwannoma, 2 tailgut cysts, 1 hamartoma, and 1 aggressive angiomyxoma. No intraoperative complications were observed. One patient has transitory left leg motor dysfunction. No other postoperative morbidities and complications
were seen. In addition, no sensory or motor dysfunction of the bladder
or rectum was observed postoperatively. The median
follow-up was 16 months (range, 3 to 32). The postoperative course was
uneventful, with one teratoma recurrence at 12 months and one aggressive
angiomyxoma recurrence at 29 months.
Conclusion: Laparoscopic surgery for the removal of presacral tumors is feasible. The
use of this new technical approach offers many advantages but requires
extensive experience in pelvic surgery and laparoscopic skills. It is suggested
that such laparoscopic procedures be reserved for select cases of benign
tumors, and its application must be verified by further studies.