19TH SLS ANNUAL MEETING AND ENDO EXPO 2010 SCIENTIFIC ABSTRACTS
Supplement to JSLS, Volume 14, Number 2
10.100 General Surgery
Laparoscopic Approach After Laparoscopic Inguinal Hernia Recurrence
Khaled El Zarrok Elgazwi, MD, PhD, Prof. Ivo. Baca, MD, PhD, Akrem Elshakhy, MD, Arash Khani, MD
Klinikum Bremen ost. Bremen, Germany
Background: Recurrent inguinal hernias have occurred after endoscopic inguinal hernia repair, although far less frequently than after conventional repair (in the literature between 0.1% to 1.5%). The aim of this study was to evaluate whether these recurrences can be repaired by using the laparoscopic approach with acceptable complication and recurrence rates.
Methods: From August 1993 through May 2008, approximately 3823 inguinal hernia patients with 4746 hernias were operated on endoscopically at our institution; 3443 were males and 380 were females. Their age at surgery ranged from 20 years to 93 years. Forty-five patients with recurrent inguinal hernias on physical examination underwent surgery at our institutions. All the recurrences occurred following endoscopic inguinal hernia repair with mesh prostheses. The recurrences were repaired endoscopically by using a transabdominal approach. Depending on the size of the defect, a new polypropylene mesh was used.
Results: Mean surgery time was 48 minutes. There were no conversions to the anterior approach. After a mean follow-up of 12 months, no recurrences had been diagnosed. Mean hospital stay was 1.5 days (range, 1 to 3).
Conclusion: There is a place for laparoscopic surgery in the treatment of recurrent inguinal hernias after endoscopic herniorrhaphy. The transabdominal preperitoneal approach is a reliable technique for recurrent inguinal hernia repair after previous endoscopic herniorrhaphy.
10.101 Gynecology
Effect of 4% Icodextrin Solution on the Reduction of Adhesion Formation Following Gynecological Surgery in Rabbits
Behnaz Khani MD, Nahid Bahrami MD*, Hormoz Naderi Naeni, MD*
*Department of Obstetrics & Gynecology, Alzahra Hospital, Isfahan, Iran.
Objective: To evaluate the effect of 4% icodextrin on the reduction of adhesion formation in rabbits after traumatizing the uterine horns.
Methods: Thirty white female rabbits were randomized into 3 groups. The rabbits were anesthetized, and an abdominal incision was made. Uterine horns were abraded with gauze until bleeding occurred. In the first group, which was the control group, 30cc of sterile water was applied. In the second group, 30cc of 4% icodextrin (Adept, Baxter, UK) was applied, and in the third group, 30cc of human amniotic fluid was applied over the traumatized area before closure of the abdomen. On the seventh day, relaparotomy was performed to determine and compare adhesions in rabbits.
Results: There was a significant difference between the mean adhesion score in the 4% icodextrin group and that in the sterile water group [2.1±0.70 versus 10.4± 0.60, respectively (P<0.05)], but the difference between the mean score of adhesions in amniotic fluid group compared with the sterile water group was not significant (P=0.10). The difference between the mean score of adhesion in the 4% icodextrin group compared with the mean score in the amniotic fluid group was significant (P=0.0/00).
Conclusions: The use of 4% icodextrin solution is effective in reducing adhesions in a gynecological surgery model in rabbits.
10.103 General Surgery
Minimally Invasive Video-Assisted Thyroidectomy Versus Conventional Thyroidectomy: A Single-Blind, Randomized Controlled Clinical Trial
Gouda Mohamed El-labban MD
Department of General Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
Objective: We aimed to test the hypothesis that minimally invasive video-assisted thyroidectomy (MIVAT) affords comparable safety and efficacy to that of open conventional surgery in patients with unilateral thyroid nodules or follicular lesions in terms of cosmetic results, intraoperative and postoperative complications, postoperative pain, and hospital stay.
Methods: This was a single-blind, randomized controlled trial comparing MIVAT with conventional thyroidectomy. The primary endpoints of the study were measurement of postoperative pain 24 hours and 48 hours after the operation and cosmetic outcome 3 months postoperatively. The secondary outcome measures were operative time, incidence of recurrent laryngeal nerve injury, length of incision, and hospital stay.
Results: Operative time was less with open thyroidectomy than with MIVAT, while MIVAT was associated with less pain 24 hours postoperatively. Pain score depicted statistically significant differences in favor of MIVAT after 24 hours. MIVAT was associated with less scarring and more satisfaction with cosmetic results. There was no difference between the procedures for presence of transient recurrent laryngeal nerve palsy and hypoparathyroidism.
Conclusion: MIVAT is a safe procedure that produces outcomes similar to those of open thyroidectomy and is superior in terms of immediate postoperative pain and cosmetic results.
10.104 Urology
Comparison of Contrast-Enhanced Ultrasound (CE-US) and Computed Tomography (CT) in the Evaluation of Complex Cystic Renal Masses Using the Bosniak Classification System
Garcia-Rojo D, Ballesteros E, Malet-Munte A, Prera A, Vicente E, Martos R, Puig J, Gonzalez-Sala JL, Matin J, Barrio M, Abad C, Hannaoui N, Muñoz J, Darnell A, Prats J
Corporacio Parc Tauli, Sabadell, Spain
Introduction: In renal cysts, the likelihood of malignancy is assessed using the Bosniak classification based on intravenous contrast-enhanced CT. CE-US has been recently introduced for the evaluation of complex renal cysts.
Material & Methods: This prospective study included 28 cystic renal masses in 25 patients. The CT and CE-US images were studied using the Bosniak classification. We offered surgery to patients with Bosniak III and IV cysts detected with CE-US or CT. We compared the histological studies of surgical specimens with the findings at CE-US and CT. The Cohen statistic was used to analyze agreement between the diagnostic procedures.
Results: Concordance between CE-US and contrast-enhanced CT was high, k=91%, IC (range, 68.3% to 98.8%). We observed understaging by CT in 2 Bosniak III cysts and in one Bosniak IV cyst. Two of the 3 neoplasms ungraded by CT were surgically removed, and histologic study showed malignancy. Six of the 7 patients with Bosniak IV cysts, and only 1 of the 7 patients classified as having Bosniak III cysts in any of the radiologic studies underwent open or laparoscopic surgery. The histologic findings of all the resected masses showed renal cell carcinoma. We did not observe tumor growth in the remaining 7 patients who were not operated on (mean follow-up of 12.3 months).
Conclusions: In our experience, CE-US was found to be better than TC in the diagnosis of malignancy in Bosniak IIF and III renal cysts. The joint use of CT and CE-US provides useful information for deciding on the management of these lesions.
10.105 General Surgery
Postcholecystectomy Morbidity in the Laparoscopic Era
Vincenzo Neri, Prof Dr Med
General Surgery, University of Foggia, Ospedali Riuniti
Background and Objective: Postcholecystectomy morbidity refers to a wide spectrum of conditions. The etiologic distinctions among these different complications may be useful. The aim of this study was to define a prevention program.
Materials and Methods: We compared the outcomes of cholecystectomy in the following periods: 2005 to 2006 (group A) and 2007 to 2009 (group B). Group A comprised 182 cholecystectomies (videolaparocholecystectomy 81.9%): morbidity was 18.5% (34 patients). Group B comprised 251 cholecystectomies (videolaparocholecystectomy, 88.5%): morbidity was 9.96% (25 patients). Demographic and pathologic data overlapped in both groups.
Results: Morbidity was subdivided according to temporal criteria as early and late. Early morbidity was 12% in group A and 6.3% in group B. Late morbidity was 10.4% in group A and 7.5% in group B. The etiologic criteria show 2 main kinds of postcholecystectomy complications: (1) incomplete preoperative evaluation (recurrent acute biliary pancreatitis, hepatic failure in cirrhotic patients, CBD lithiasis, papillary sclerosis, and others) - group A 17.5%, group B 10.7%; (2) by intraoperative technical errors (site infections, hemorrhagic complications, cystic dehiscence, CBD lesion, and others) - group A 4.9%, group B 3.1%.
Conclusions: The comparison between group A (early period) and group B (late period) shows a global reduction in the complications in group B. The decrease in morbidity is mainly connected to a reduction in complications resulting from incomplete preoperative evaluation; however, a minor reduction occurred in complications resulting from technical errors. This study shows that the etiologic subdivision of the complications of cholecystectomy allows an effective and safe prevention program.
10.106 General Surgery
Long-Term Evaluation of Patients Undergoing Emergent Tube Cholecystostomy for the Treatment of Acute Cholecystitis
Margaret Bower, MD, Andrew Yu, Joseph Park, I. Michael Leitman, MD, Sebastiano Cassaro, MD, Rajesh I. Patel, MD, Martin S. Karpeh, Jr., MD
Departments of Surgery and Radiology, Beth Israel Medical Center, New York, New York
Objectives: Percutaneous cholecystostomy is currently indicated for patients with cholecystitis who might be poor candidates for operative cholecystectomy. This review was performed to evaluate the long-term outcome of patients undergoing emergent tube cholecystostomy.
Methods: This study was a retrospective chart review of patients who underwent tube cholecystostomy from July 1, 2005 to July 1, 2009.
Results: During the study period, 82 patients underwent 125 cholecystostomy tube placements. Four patients died during the 30 days following tube placement (5%). The average hospital length of stay for survivors was 8.8 days (range, 1 to 59). Twenty-eight patients (34%) required at least 1 additional percutaneous procedure (range, 1 to 6) for gallbladder drainage. Twenty-five patients ultimately had cholecystectomy (30%). Surgery was performed an average of 7 weeks following cholecystostomy tube placement. Laparoscopic cholecystectomy was attempted in all operative patients but required conversion to open in 8 cases (32%). Major postoperative complications were limited to 2 patients with postoperative common bile duct obstruction requiring ERCP and 2 patients with bile leak from the cystic duct stump.
Conclusions: These patients represent a high-risk group. Acute cholecystitis may be adequately temporized by tube cholecystostomy. Only about one-third of patients will undergo surgical cholecystectomy, which has an increased risk for conversion to open and biliary complications.
10.108 Gynecology
Laparoscopic Cervical Cerclage in 18-week Pregnant Uterus
Greg J. Marchand, MD and Richard H. Demir, MD
Tempe St. Luke’s Hospital, Tempe, Arizona
The objective of the video is to demonstrate a safe, laparoscopic technique for performance of Laparoscopic Cervico-Isthmic Cerclage in the second trimester. The subject is a 19 year old G4 P0212 female at 18-weeks gestational age whose most recent delivery was at 26 weeks secondary to incompetent cervix. Although ideally performed in the twelve to fourteen week gestational age range, current management algorithms for women at risk for incompetent cervix often involve regular ultrasound surveillance of cervical length with cervical shortening used as a trigger for performance of cerclage. Many clinicians traditionally opt to perform traditional vaginal cerclage, Shirodkar or McDonald, in the mid-trimester. Because it makes sense to place the suture as high as possible, as close to the internal os where the intrinsic defect of incompetent cervix is postulated to exist, laparoscopic placement seems ideal but is often overlooked secondary to the heightened risks of operating adjacent to the dilated uterine vasculature and in confined spaces. This video demonstrates a safe and practical technique for performance of mid-trimester cervical cerclage laparoscopically.
10.109 General Surgery
Laparoscopic Right Hemicolectomy: A Reproducible Operation that Follows Strict Oncologic Principles
Eugene Rubach, MD, Matthew Ostrowitz, MD, George DeNoto, MD, Gary Gecelter, MD
St. Francis Hospital; North Shore Long Island Jewish (LIJ)-Health System, New York
Introduction: We present the video of a single-incision laparoscopic right hemicolectomy performed in an obese patient with a large cecal polyp not amendable to endoscopic resection.
Methods and Procedure: A SILS port was used for the operation. We utilized a 5-mm flexible tip laparoscope, one articulating grasper, one straight grasper, and a LigaSure clamp. All the steps of conventional laparoscopic right hemicolectomy were followed.
First, the ileocolic pedicle was dissected medial-to-lateral. Duodenum was identified and preserved. Ileo-colic vessels were divided by using an EndoGIA vascular stapler. Then, the greater omentum was dissected away from the transverse colon by using blunt dissection and the LigaSure. Hepatic flexure was mobilized. Gentle traction was used to separate mesocolon away from retroperitoneum. Then, lateral attachments of the cecum and ascending colon were divided. Pelvic attachments of the cecum and terminal ileum were subsequently separated. The entire right colon was now dissected and mobilized. The right ureter, kidney, and duodenum were clearly seen. The incision was enlarged and bowel was extracted through a wound protector. The entire specimen was now exteriorized. Conventional side-to-side, functional end-to-end stapled anastomosis was performed. The incision was closed.
Results: Patient’s postoperative recuperation was unremarkable. Total incision size was 3.5cm. The final pathology report revealed villous adenoma without evidence of invasive malignancy with 20 negative lymph nodes.
Conclusions: The technique described herein allows for performance of laparoscopic right hemicolectomy through a single small incision by using commercially available instruments. All surgical and oncologic principles were followed closely, which makes for a safe and reproducible operation.
10.110 General Surgery
Single-Incision Laparoscopic (SILS) Appendectomy for Appendiceal Mucocele
Curtis E. Bower, MD, Jacqueline Carter, MD, Katie Love, MD
ECU Brody School of Medicine, Greenville, North Carolina, USA
Introduction: This video case report describes a new application of SILS in resecting an appendiceal mucocele.
Methods: A 76-year-old male underwent a workup for persistent pelvic pain that resulted in a computed tomography diagnosis of an asymptomatic 9.3-cm appendiceal mucocele. Laparoscopic resection of the appendix was carried out through a transumbilical 2-cm skin incision. The SILS port (Covidien, Norwalk, CT) was inserted through this incision, and a laparoscopic appendectomy was performed with standard straight instrumentation.
Results: There were no intraoperative complications. Postoperatively, the patient did well but did have urinary retention despite not having had a Foley catheter placed during his procedure. Procedure duration was 58 minutes. Final pathology was positive for a mucinous cystadenoma confined to the appendiceal mucosa, and the proximal margin was free of adenomatous epithelium.
Conclusion: Appendiceal mucoceles account for approximately 0.25% of appendectomies performed in the United States. Early recognition and resection are imperative, because some of these mucoceles can be malignant cystadenocarcinomas. Rupture of a cystadenocarcinoma can result in pseudomyxoma peritonei. A safe and adequate resection of an appendiceal mucocele can be achieved with the SILS technique.
10.111 General Surgery
Wide Local Excision and Endoscopic Axillary Clearance in Patients with Early Breast Cancer
G.M. AbulNagah, MD, FRCS, A.T. Awad, MD, H. Wadeia, MS
Department of Surgery, Faculty of Medicine, University of Alexandria, Egypt
Introduction: Conservation surgery is currently the standard treatment for women with stage I or II invasive breast cancer. It has the goal of preservation of cosmesis and function. Axillary dissection has long been associated with multiple complications and hence the attempt at other techniques for axillary staging.
Patients and Methods: This study included 30 patients with operable breast cancer who underwent breast-conserving surgery with the endoscopic technique to accomplish axillary dissection. Total operative time, the time of axillary dissection, postoperative pathological details of the tumors and axillary specimens, drainage amount, seroma formation as well as any surgical complications were recorded.
Results: Mean total operative time and endoscopic axillary dissection were respectively 102 minutes and 56 minutes in the early 10 cases and 78 minutes and 26 minutes in later cases (P=0.003). Mean total number of lymph nodes harvested was 17, which is comparable to that of open techniques at our institution. No significant improvement was noted in seroma formation after endoscopic dissection, but marvelous improvement occurred in patient cosmetic satisfaction.
Conclusion: Although endoscopic axillary clearance in patients with early breast cancer needs special instrumentation and has a relatively long learning curve, it is feasible, comparable to standard surgical axillary clearance, and is accompanied by fewer axillary complications and better cosmesis.
10.112 General Surgery
Abdominal Tuberculosis: A Diagnostic Dilemma Made Easy by Diagnostic Laparoscopy
Arshad M. Malik, MBBS, FCPS, K. Altaf Hussain Talpur, MBBS, FCPS, Abdul Aziz Laghari, MBBS, FCPS, FRCS, Jawaid Naeem Qureshi, MBBS, FRCS, Rafique Pathan, MBBS
Liaquat University of Medical & Health Sciences, Jamshoro, Pakistan
Background: Abdominal tuberculosis is extremely common in developing countries like Pakistan and India. The presentation is varied and nonspecific, making diagnosis extremely difficult at times. This study was performed to determine the scope of diagnostic laparoscopy in the evaluation of abdominal tuberculosis.
Methods: This was a retrospective descriptive analysis of 139 patients with abdominal tuberculosis diagnosed on laparoscopy over 5 years (January 2004 through December 2008) in a teaching hospital and in various private hospitals. All patients with vague abdominal symptoms and suspicion of abdominal tuberculosis were admitted, and a diagnostic laparoscopy was performed after preliminary investigations. The data were collected and statistically analyzed with SPSS version 14 software.
Results: Included in this series were 184 patients with vague abdominal symptoms and an unsettled diagnosis; 139 (7%) of these patients were diagnosed with abdominal tuberculosis on laparoscopy. The common symptoms were pain in the abdomen, changing bowel habits, loss of weight, and generalized weakness. Clinical examination was not significant except for anemia in the majority of patients and generalized abdominal tenderness in a few. Various tuberculous lesions were detected on laparoscopy. Biopsy specimens proved abdominal tuberculosis in 139 patients. Patients were saved from unnecessary laparatomies and were managed on antituberculosis drug therapy.
Conclusion: Diagnostic laparoscopy is an efficient and reliable diagnostic tool for patients suspected of having abdominal tuberculosis.
10.113 General Surgery
Heller Myotomy, Hiatal Hernia Repair with Mesh, and Dor Fundoplication for a Morbidly Obese Patient with Achalasia
Shabirhusain S. Abadin, MD, MPH, Marc Adajar, MD, Elizabeth Revesz, MD,
Ramsen Azizi, MD, Rami Lutfi, MD
St. Joseph Hospital, Chicago, Illinois, USA
Objective: We present the case of a 68-year-old morbidly obese man with long-standing acid reflux and achalasia who we treated with a Heller myotomy, hiatal hernia repair with mesh, and a Dor fundoplication. Our patient, whose BMI was 45, presented with a long-standing history of gastroesophageal reflux disease without any previous surgical treatment and progressive dysphagia over 6 years. The patient had previously been treated for H. pylori gastritis and was continuously treated with a proton-pump inhibitor. Endoscopy, esophageal manometry, and upper GI radiographs were done to confirm the diagnosis of achalasia.
Methods: This is a video case presentation demonstrating the surgical management of gastroesophageal reflux disease and achalasia.
Results: Our patient did well after surgery; he was discharged on postoperative day one and has reported symptom resolution on subsequent follow-up.
Conclusions: This case demonstrates the laparoscopic management of a patient with both gastroesophageal reflux disease and achalasia. In gastroesophageal reflux disease, a fundoplication and repair of a hiatal hernia, if present, are generally needed to reconstruct the physiologic barriers preventing stomach contents from moving into the esophagus. In achalasia, the treatment involves cutting the longitudinal esophageal muscle thereby releasing the lower esophageal sphincter to allow for better passage of food and liquids. The combination of these procedures was used to treat our patient.
10.115 General Surgery
Transvaginal Single-Port Cholecystectomy with a Flexible Endoscope and no Abdominal Ports
Daniel A Tsin, MD, Fausto Davila, MD, Martha R. Davila, MD, Leopoldo Gutierrez, MD, Jose Lemus, MD
Mount Sinai Hospital of Queens, Long Island City, New York, USA (Dr. Tsin).
Hospital Regional, Poza Rica, SESVER, Veracruz, Mexico (Dr. F. Davila).
Hospital Dr. Manuel Gea Gonzalez, Mexico City, Mexico (Dr. M.R. Davila).
Universiad Nacional Autonoma de Mexico (Dr. Gutierrez).
Hospital Regional de Pemex, Poza Rica, Veracruz, Mexico (Dr. Lemus).
Objective: To present an advanced form of culdolaparoscopy cholecystectomy done with a gastroscope, rigid instruments, and percutaneous needles.
Methods: A 26-year-old female patient with cholelithiasis underwent a culdolaparoscopy cholecystectomy at the Hospital Regional of Poza Rica, Veracruz. Mexico. The surgery was performed with a transvaginal 16mm in diameter by 32cm in length port. The instruments included a gastroscope, laparoscopic 5mm in diameter by 43cm in length instruments used in a parallel path and were aided by percutaneous leashes and hook needles. No abdominal ports or Veress needles were used.
Results: The patient was discharged 24 hours after surgery, customary for our hospital, without complications, pain, or visible scars.
Conclusion: Culdolaparoscopy cholecystectomy using a transvaginal single-port approach with a gastroscope and laparoscopic 5-mm instruments in a parallel path is a feasible procedure in select patients.
10.116 General Surgery
Single-Incision Laparoscopic Sigmoidectomy: A Promising Approach for Elective Sigmoidectomy in Diverticular Disease
Boris Vestweber, MD, Franz Haaf, MD, Eberhard Straub, MD, Phillip Lingohr, MD, Karl-Heinz Vestweber, Professor
Klinikum Leverkusen, Germany
Background: Laparoscopic sigmoidectomy has become the standard procedure in elective surgery for recurrent diverticular disease. To further intensify the benefits of the minimally invasive procedure, attempts are made to minimize the number of necessary skin incisions for trocar positioning. One way to do this is to use only one port as a single laparoscopic access for diverticular-related elective sigmoidectomies.
Methods: Since July 2009, 46 consecutive patients have been referred for partial left colon resection due to multiple episodes of diverticulitis. In all cases, the abdomen was approached through a 2.5-cm single incision within the umbilicus followed by the insertion of a SILS port system. Outcomes, such as a change in the procedure, operative time, length of stay, postoperative pain score, and complications are reported.
Results: In this study, 44 of 46 patients were successfully operated on with the SILS procedure, using only one incision in the umbilicus. No mortalities or major complications were noted. The median operative time was 128 minutes, length of stay was 7.5 days, and specimen length was 20cm (post fixation).
Conclusion: Single-incision laparoscopic sigmoidectomy via the umbilicus is a technically feasible and effective alternative to the standard laparoscopic procedure. It is an attractive procedure with the aim to further increase patient comfort after abdominal surgery.
10.117 Multispecialty
Feasibility and Utility of a Clip Applying Exercise for the Fundamentals of Laparoscopic Surgery Technical Skills Curriculum
Omer Burak Argun, MD, Troy Reihsen, Elspeth McDougall, MD, Robert M. Sweet, MD
Department of Urologic Surgery, University of Minnesota, Minneapolis, Minnesota, USA (Drs. Argun, Sweet, Mr. Reihsen); Department of Urology, University of California, Irvine, Orange, California, USA (Dr. McDougall).
Introduction and Objective: We examined the value of the addition of a novel clip-applying exercise to the Fundamentals of Laparoscopic Surgery (FLS) technical skills curriculum.
Methods: We designed a 7-mm to 9-mm artery model and integrated a clip-applying skills task into the FLS skills exercises amongst a cohort of practicing surgeons at the Society for Laparoendoscopic Surgeons meeting 2009 (Boston, MA). Organosilicate models were molded and filled with red colored water to a mean arterial pressure of 80 ± 2mm Hg. Subjects were instructed to place two 10-mm titanium clips within the black lines on both sides of the model (4 clips total), then divide the structure. We measured time to task, clip accuracy, and assessed for leakage. Upon completion, participants filled out a survey assessing face and content aspects of validity on a 5-point Likert scale.
Results: Thirty-seven laparoscopic surgeons (General Surgery=24, Gyn=12, Urol=1) completed the clipping exercise. Mean 5-point Likert assessment scores were as follows: “Exercise is a valuable addition to the curriculum” (4.25); “Artery clamping dividing model fills a needed skill not covered by the other FLS exercises” (3.97); “Tissue behaved like artery” (3.5); “The metrics matched the stated learning objective for the model” (3.92); “The artery clamping/dividing model measured my clip applying abilities” (3.44).
Conclusion: Version 1 of the clipping exercise seems to fill a basic core skill not covered by SAGES FLS Curriculum. These results encourage the future refinements of the model for further investigations.
10.118 Multispecialty
Do Laparoscopic VR Simulators Demonstrate Convergent Validity?
Omer Burak Argun, Troy Reihsen, François Sainfort, Michael S. Kavic, Phillip P. Shadduck, Robert M. Sweet
Department of Urologic Surgery, University of Minnesota, Minneapolis, Minnesota, USA (Drs. Argun, Sweet, Mr. Reihsen); Department of Health Policy/Management, University of Minnesota, Minnesota, USA (Dr. Sainfort); Department of Surgery, Northeastern Ohio University, Ohio, USA (Dr. Kavic); Regional Surgical Associates, Durham, North Carolina, USA (Dr. Shadduck).
Objective: To examine convergent aspects of validity across 3 commercially available laparoscopic simulator platforms for navigation and dissection tasks.
Methods: A single navigation and dissection task was chosen on each simulator vis-a-vis consensus amongst 8 SLS master course directors. A convenient sample of 25 multidisciplinary practicing laparoscopic surgeons performed navigation and/or dissection tasks on 1 or more of 4 simulators [Haptica, METI, Simbionix, and Surgical Science (with and without haptic force-feedback)]. Performance metrics were logged on all simulators and uploaded for subsequent analysis. Pearson and rank-order Spearman correlation analyses were used to analyze the data.
Results: For navigation task completion time, Pearson correlation coefficients are moderate to high (0.619 to 0.807 for Pearson and 0.258 to 0.810 for Spearman) between Haptica, Simbionix, and Surgical Science Haptic. There is no significant correlation between the simulators with the Spearman correlation test for navigation right path length, navigation left path length, and total path length. There is only moderate correlation between Haptica/Simbionix for the navigation right path length with Spearman correlation analysis (0.476). For dissection task completion time, small-to-moderate correlation coefficients was found for Surgical Science with Haptics, Simbionix, Haptica, and METI.
Conclusion: Subjects performed similarly compared with their peers on navigation and dissection tasks across commercially available laparoscopic simulation platforms containing force-feedback. There is small-to-moderate and moderate-to-strong correlation for navigation and dissection skills, respectively. Because convergence contributes to construct validity, this study strengthens the claims of construct validity for navigation and dissection tasks on these simulators.
10.119 General Surgery
Laparoscopic Ventriculoperitoneal Shunts: The New Standard of Care
Tiffany Stoddard, MD, Stephen Kavic, MD
University of Maryland Medical System, Baltimore, MD, USA
Introduction/Objective: Symptomatic hydrocephalus is a surprisingly common clinical condition. Neurosurgeons are expert at ventriculostomy, but minimally invasive peritoneal access is outside the realm of their current training. We have adopted a multidisciplinary approach, with general surgeons positioning the distal shunt. Our objective was to review this recent experience.
Methods and Procedures: A single surgeon with a resident assistance placed all distal shunts. After ventriculostomy, the shunt tubing was tunneled onto the anterior abdominal wall. A Veress needle was placed through the tunnel incision and the abdomen insufflated. A 5-mm optical access trocar and camera were introduced via a separate stab incision. The shunt tubing was then directed into the abdominal cavity by using a Hickman introducer kit, with flow confirmed visually.
Results: In this study, 111 consecutive shunts were placed in patients who had between 0 and 10 previous abdominal operations. One intraoperative complication occurred, a colon injury during trocar placement. In this case, the colotomy was repaired, and the shunt placed in the pleural space. No conversions were necessary to the open abdominal approach. Postoperatively, no wound infections, no cases of shunt malpositioning, and no deaths occurred.
Conclusions: Laparoscopic placement of ventriculoperitoneal shunts is feasible, safe, and carries a low rate of complications. This collaboration produces excellent clinical results for the individual patient, promotes multidisciplinary teamwork, and assists training residents in laparoscopic access. Overall, distal shunt placement with laparoscopic guidance should be the new standard of care.
10.120 General Surgery
What is Laparoscopy? Defining “Laparoscopy” Through Review of Technical Details in JSLS
Daniel J. Eyvazzadeh, MD, Stephen M. Kavic, MD
University of Maryland School of Medicine, Baltimore, MD, USA
Introduction/Objective: The term “laparoscopy” has lost precision due to the proliferation in techniques of access to the abdominal cavity. Procedures performed with radical differences in port number, size, placement, and need for extraction incision may be characterized as “laparoscopic.” However, the general public and many insurers divide procedures into laparoscopic or open. Our objective was to characterize the typical laparoscopic operation through a review of the technical details of a year’s worth of articles in the Journal of the Society of Laparoendoscopic Surgeons (JSLS).
Methods and Procedures: We assembled and analyzed a database of all articles from JSLS from the last year (4 issues starting with Volume 12, #4). For comparison, we also reviewed articles from a decade ago (Volume 2). All procedural details were compiled, including means of access, number/size of ports, incision length, and conversion rates.
Results: There were 81 articles for analysis compared with 39 a decade prior. Few listed all technical details (58% described access, 56% number of ports). Access was nearly evenly divided between Hasson and Veress techniques. The average number of ports in both study periods was 4, although there was a trend toward smaller port sizes in the current year. In studies specifying incision length, the average was 6.1cm in both groups.
Conclusions: Technical operative details are lacking in many reports. Based on a review of published studies, most procedures are done with 4 ports, 2 of which are ≥10mm in size. Until there is greater clarity in technical description, the precise definition of laparoscopy remains elusive.
10.122 General Surgery
Liver Biopsy During Laparoscopic Cholecystectomy
Nikolaos Gatsoulis, MD, PhD, Ilias Kafetzis, MD, PhD, Nikolaos Roukounakis, MD, PhD, Aikaterini Poulou, MD, Georgios Kavalieratos, MD
General Hospital of Corfu, Greece
Introduction: The progress in laparoscopic techniques has made the biopsy of parenchymatic organs, such as the liver, more achievable and safer. In the beginning of minimally invasive surgery, several authors recommended liver biopsy during laparoscopic cholecystectomy (LC), as routine. The aim of this study was to evaluate the experience of the referring method in our hospital.
Methods: During the last 2 years, 71 liver biopsies have been performed during LC. The ratio between male and female was 1/1.4, and the age range was between 46 and 78 years. Liver biopsies were performed in the following cases: cirrhotic patients, suspicious tumors, color alterations of the hepatic surface, and abnormal hepatic tests, preoperatively. The biopsy samples, which included part of the hepatic wedge, were excised en block with the gallbladder. Ultrasound energy generator (Harmonic scalpel) and an endoscopic monopolar radiofrequency device were used.
Results: Histological findings are as follows: cell metaplasia and hyperplasia (5 patients), gallbladder carcinoma (1 patient), polycystic liver disease (8 patients), hepatic cirrhosis (21 patients), and the rest were normal. No conversion to open surgery was needed in this series. No prolonged operative time and hospitalization were necessary. No perioperative deaths or significant postoperative complications were reported.
Conclusions: Liver biopsy during LC is an easy, effective, safe, and rapid procedure. It does not have the aggravation of postoperative complications, and furthermore, it is considered an important method for the diagnosis of hepatic pathologies.
10.123 Urology
Robotic Simple Prostatectomy: An Alternative Minimally Invasive Approach for Prostate Adenoma
Ekong E. Uffort, MD, Adrianna Montgomery, RNFA, James C. Jensen, MD
Edwards Comprehensive Cancer Center, Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia, USA
Purpose: We present a larger series of patients treated with robotic-assisted laparoscopic simple prostatectomy as a viable alternative for the treatment of prostatic adenoma.
Methods: This was a retrospective chart review with IRB approval. Clinical data were collected on referrals to Dr. Jensen from May 2007 to October 2009 for persistent urinary retention from benign prostatic hyperplasia that was treated by robotic simple prostatectomy. Preoperative evaluations recorded include International Prostate Symptom Scores, Prostate-Specific Antigen, cystoscopy, and urodynamics.
Results: Average age in the series was 65.8 years, mean BMI was 30.4kg/m2, mean PSA was 5.17ng/mL, mean symptom score was 23.85, and postvoid urine residual was 265.79mL. Eleven men had complaints of persistent lower urinary tract symptoms despite medical treatment. Intravesical lobe hypertrophy was recorded in 93.3%, 13.3% had bladder diverticula with stones, and mean prostate volume was 70.85mL. Mean operative time was 128.8 minutes, average estimated blood loss was 139.3mL, no blood transfusions were necessary, and average adenoma weight was 46.4g. Mean hospital stay was 2.5 days with an average Foley-catheter time of 4.6 days. The complication in the series was one incarcerated hernia. Symptom score significantly improved to an average of 8.13, and urine residual improved to an average of 44.19mL.
Conclusions: Significant improvement of symptoms from benign prostatic hypertrophy can be achieved with robotic simple prostatectomy, substantiating the fact that it is a feasible alternative minimally invasive procedure with low morbidity compared with open simple prostatectomy.
10.124 Urology
Impact of Obesity on Sexual Function Recovery after Robotic-Assisted Laparoscopic Radical Prostatectomy
Ekong E. Uffort, MD, Adriana Montgomery, RNFA, James C, Jensen, MD
Edwards Comprehensive Cancer Center, Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia, USA
Purpose: To investigate the impact of obesity on recovery of sexual function after robotic radical prostatectomy for localized prostate cancer.
Methods: This was a retrospective analysis of validated outcomes questionnaire responses performed for preoperative and postoperative periods of 12 months. Study patients were categorized into 2 groups of nonobese and obese, and subsequently into 2 subgroups of potent and impotent using the International Index for Erectile Function (short version) scores. Statistical analyses performed included t and z-tests using GraphPad InStat version 3.10 for Windows, and all P values were 2-sided.
Results: IRB approval was obtained for this study, and 131 men met the inclusion criteria. Overall, 32% of nonobese and 20% of obese patients reached baseline functions at 12 months. In preoperative potent men, 23% and 22% in each respective group achieved full potency at 12 months with mean percentage baseline potency of 39% and 47%, respectively. In the preoperative impotent men, 44% and 33% respectively achieved baseline sexual function at 12 months with erectile function recovery of 51% and 44% pre-op values (all p >0.05).
Conclusion: Recovery of sexual function after robotic radical prostatectomy is similar irrespective of obesity and preoperative potency. A preoperative potent non-obese man recovers sexual function at a faster rate but normalizes with time.
10.125 General Surgery
Bariatric Medical Tourism: Are We Ready for the Complications?
Benjamin Clapp, MD
Providence Memorial Hospital, El Paso, Texas, USA
Background and Objectives: Medical tourism is becoming more common. American patients are willing to travel abroad to save money or circumvent their medical insurance policies. When complications occur, US doctors in border communities are asked to care for these patients. What is the current ethical framework for dealing with these patients?
Methods: A case series of postlaparoscopic bariatric surgery complications is used to illustrate the types of problems facing US doctors along the US-Mexico international border. A review of the literature is also conducted to examine the current ethical framework for dealing with the problem of medical tourism.
Discussion: Although the benefits of bariatric surgery have been demonstrated over and over again, payors in the United States still do not provide universal access to bariatric surgery. Some patients respond to this by traveling outside of our borders to obtain their much-needed surgery. Complications will occur, but patients can then be left to fend for themselves, and the burden of care is transferred to US doctors, often in the border communities. These complications are a staggering cost to an already strained system.
Conclusion: Bariatric medical tourism should be discouraged. The cost of complications, however rare, offsets any savings. American payors should be strongly encouraged to provide universal access to bariatric surgery so that American patients do not have to go abroad.
10.126 General Surgery
Tailored Surgery for T2 Diabetes Mellitus: Technical Feasibility in a Porcine Model
German Rosero, MD, Fernando Casabon, MD, Liliana Silva, MD, L.J. Espana, MD,Tito Ortega, MS
Universidad de Narino, Pasto, Colombia
Objective:
Biliopancreatic diversion and RYGB bariatric surgery result in type 2 diabetes mellitus (T2DM) resolution rates of 95.1% and 80.3%, respectively, in morbidly obese patients. Initial experiences in the management of T2DM patients with BMI<35 are promising, and different surgical procedures have shown improvement rates of over 90%. Our objective was to evaluate the technical feasibility of a procedure combining sleeve gastrectomy plus pylorus preservation duodenojejunostomy (SG-PPDJ) in a swine model. Theoretical goals of this procedure are: (1) decreased ghrelin levels; (2) duodenal diversion; (3) distal intestine stimulation; (4) weight and caloric control.
Methods:
After ethics committee approval, 5 healthy Yorkshire pigs (15kg to 20kg) were selected. Through 4 ports of 12mm and 5mm, the greater curvature of the stomach was isolated 3cm distal to the pylorus with a Harmonic scalpel. The duodenum was then sectioned with a stapler preserving the vasculature. A gastric tube was created next. An end-to-side hand-sewn duodenojejunostomy anastomosis finished the procedure. A normal diet was reassumed the next day after surgery
Results:
The average surgical time was 45.8±14.6 minutes. One pig died postoperatively due to malignant hyperthermia. The other 4 survived uneventfully. SG-PPDJ was well tolerated in the 12 weeks of follow-up.
Conclusion:
SG-PPDJ is technically feasible (with a single anastomosis, short operative time) in a porcine model and could be of potential use in the surgical treatment of nonobese patients with T2DM. Further studies are necessary to verify the metabolic effect of this procedure.
10.127 General Surgery
Clinical Analysis of 31 Cases of Pelvic Floor Reconstructive Surgery
Li Huan, Li Rui Zhen, Zhen Li Ping, Wu Rui Fang
Department of Obstetrics and Gynecology, Beijing University Shenzhen Hospital, Guangdong Shenzhen, China
Objective: We analyzed the outcome of pelvic floor reconstructive surgery with Prolene mesh and Prolift in 31 patients with stress urinary incontinence and pelvic organ prolapse at Beijing University Shenzhen Hospital and investigated the effect of pelvic floor reconstructive surgery performed at out hospital.
Methods: Thirty-one patients with stress urinary incontinence and stage I-III pelvic organ prolapse at Beijing University Shenzhen Hospital from June 2006 to June 2008 underwent pelvic floor reconstructive surgery. The effects and syndromes of the operation were retrospectively analyzed.
Results: The mean operative time was 117.58 minutes. The mean time of mesh placement was 77.90 minutes. The mean hemorrhage was 180.48mL. The mean hospitalization time was 10.85 days. The period of follow-up after the operation was
1 month to 12 months. The patients with stress urinary incontinence were generally cured, and interrelated symptoms disappeared or obviously improved. In cases of pelvic organ prolapse after surgery, anterior vaginal wall stage I prolapse occurred in 3 patients, posterior vaginal wall stage I prolapse occurred in one patient, and anterior vaginal wall mesh eroded the vaginal wall in one patient.
Conclusions: Pelvic floor reconstructive surgery can be used in treating stress urinary incontinence and pelvic organ prolapse. Whether preserving the uterine or not, the operation can entirely or partially complete reconstruction of pelvic floor structures and functions. The operation is safe and feasible, and the short-term effect is good. However, the long-term affect is still uncertain.
10.128 General Surgery
Open Cohort Study of 50 Patients with Grades III/IV and IV/IV Hemorrhoids Treated by Using a Closed Bloodless Hemorrhoidectomy (CBH) Technique
Sarkis Yeretsian, MD
Clinique Medic-Aide, Montreal, P.Q. Appletree Medical Center, Ottawa, Ontario Canada.
Background: It has been commonly taught that emergency hemorrhoidectomy is best handled with conservative therapy. The purpose of this study was to perform acute hemorrhoidectomy by using this novel technique.
Methods: An open cohort study was performed with 50 patients with grade III/IV and IV/IV hemorrhoids from August 2006 treated by using the closed bloodless hemorrhoidectomy technique. The mean age of these patients was 54.5 years (range, 20 to 89). With patients under local anesthesia (Xylocaine 2%), a Crile was placed at the perianal skin outside the mucocutaneous junction opposite each primary cushion. Eversion of the hemorrhoidal complex was obtained. A Crile was applied at the base of the internal and external hemorrhoids, and then with catgut chromic No. 2-0, a running suture was passed under the Crile from the anal canal to the perianal skin, and excision of the hemorrhoidal complex was performed. The same procedure was repeated for the remaining cushions.
Results: A few minor complications were observed, which were dealt with by using conservative therapy: one delayed hemorrhage due to 13 liquid stools (diverticular disease), local infection 6%, skin tags 8%, persistent wound discharge 4%, constipation due to narcotics 28%. No life-threatening complications were encountered. The outcomes were very gratifying.
Conclusion: Emergency hemorrhoidectomy could be executed by applying this novel technique.
10.129 Gynecology
Competence at Minimally Invasive Gynecological Surgery Has a High Price Tag
Mark Erian, MD, DM, Dr. Glenda McLaren, MD, FRCOG, FRANZCOG
Queensland University/Senior Consultant Obstetrician and Gynaecologist, Royal Brisbane and Women’s Hospital, Herston, Australia (Dr. Erian); Senior Consultant Obstetrician and Gynaecologist, Brisbane, Australia (Dr. McLaren).
Background and Objective: With the revolutionary advancement of minimally invasive gynecological surgery, most of our trainees in professional vocational training programs are keen to catch up with the trends in contemporary practice. In many cases, this comes with a parallel derogatory effect on the trainees’ ability to perform difficult conventional gynecological surgical procedures. We sought to test the above theory.
Method: This was a retrospective observational study performed at Royal Brisbane and Women’s’ Hospital, the main teaching and tertiary referral center in Queensland, Australia. The performance of trainees (registrars and senior registrars) in accredited training posts of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists from 1990 through 2009 was examined. In our hospital, about 2500 gynecological operations are performed annually, and 20% (500 operations) are classified as major laparotomic or vaginal operations. As an integral part of training, many consultants allow trainees to carry out major operations under the direct supervision of the consultant in charge of the patient. The performance of trainees is monitored and evaluated.
Results: In about 40% of cases, the supervising consultant has to take over either partly or completely to ascertain the safety of the patient and satisfactory completion of difficult laparotomic and vaginal procedures.
Conclusion: With expansion of industrial “safe working hours” of junior doctors and the associated decreased clinical surgical exposure, escalation of lawsuits against the medical profession and expansion of the horizon of laparoscopic and hysteroscopic gynecological operations, junior doctors’ training seems to be lacking in conventional gynecological practice.
10.130 Gynecology
Patient Safety and Outcomes in Resident Training on da Vinci Platforms in Benign Gynecological Surgery
Michael T. Breen, MD
Southwestern Ob Gyn, Austin, Texas USA
Background and Objectives: Multiple barriers exist in the implementation of resident training on da Vinci robotic surgical platforms. The perception is that these procedures are too difficult and dangerous to incorporate into a residency program; however, we illustrate that these may be safely integrated into resident training.
Materials and Methods: Patient outcomes and safety in over 100 da Vinci-assisted procedures over 3 years were reviewed. Hysterectomy, supracervical hysterectomy, myomectomy, excision of retroperitoneal endometriosis were performed by residents under direct supervision. Operative and docking times, and outcomes were tracked. Three platforms of 3 generations were utilized.
Results: All residents completed didactic and simulator training before console access. Some cases had several residents on a console in different phases of the case. Endometriosis cases had excision and pathological confirmation of excised lesions.
Conclusion: Skill levels varied based on Lickert score analysis of residents with outcome results verses controls suggesting that residents can safely participate in benign gynecologic cases without increased risk to patients and with proper didactic and simulator preparation. The intuitive nature of the da Vinci system coupled with the telestrator intraoperative guidance allows easier progression of residents in their skill sets without patient risk. No unexpected outcomes or significant complications could be attributed to resident participation in these cases.
10.131 General Surgery
Early Experience with Laparoscopic Gastrectomy
I. Sifrony, MD, L. Margolin, MD, S. Sapoznikov, MD, B. Yoffe,
Objective: In the past decade, laparoscopic techniques have gained wide clinical acceptance in surgical practice. This approach offers important advantages compared with open surgery, such as reduced intraoperative blood loss, reduced postoperative pain and accelerated recovery, early discharge from the hospital, and lower financial costs. The same advantages have been reported after laparoscopic subtotal or total gastrectomy for benign tumors and early gastric cancers.
Methods: From November 2005 to December 2009, we performed 13 laparoscopic gastrectomies: 8 for gastric carcinoma, 5 for GIST. There were 4 male and 9 female patients with a mean age of 67 years. Preoperative evaluation was performed with endoscopy and CT scan.
Results: We performed 6 laparoscopic subtotal gastrectomies and 2 total gastrectomies in the cases of stomach cancer and 5 laparoscopic wedge resections in the cases of GIST. One patient was diagnosed in stage 0, one in stage I, 3 in stage II, and 2 in stage III. All except one underwent R0 resection, and all patients with carcinoma underwent D1 dissection. Five patients had postoperative complications: intraabdominal abscess, duodenal leak, necrosis of the gastric stump (anastomotic bleeding, pneumonia).
Conclusions: Laparoscopic gastrectomy for gastric cancer is feasible and safe with equivalent radical oncologic resection compared with open surgery. However, the number of observed cases is relatively small and needs to be substantiated by larger prospective randomized controlled cases.
10.132 General Surgery
Postoperative
Choledochoscopy and Percutaneous Transhepatic Cholangioscopic Lithotomy
for Hepatolithiasis: Long-Term Results
Miin-Fu
Chen, MD, Yi-Yin Jan, MD
Department of Surgery, Chang Gung Memorial Hospital, Lin-Kou Medical Center,
Chang Gung University, Taipei, Taiwan
Objective: A
prospective study was undertaken to evaluate the long-term results of
choledochoscopic lithotomy in 558 patients with hepatolithiasis over a 4-year
to 10-year follow-up period.
Methods:
Postoperative
choledochoscopy (POC) was carried out in 510 patients, and percutaneous
transhepatic cholangioscopic lithotomy (PTCSL) was carried out in 48 patients.
Results: Complete clearance of intrahepatic stones in the
POC and PTCSL groups was 84.9% and 83.3%, respectively. The long-term results
of the 355 successful choledochoscopic lithotomy patients included being free
of symptoms and recurrent stones in the POC group, 62.5% and 28.2%,
respectively, and in the PTCSL group 55% and 40%, respectively. Intrahepatic
strictures are a main cause of treatment failure of choledochoscopic lithotomy
and recurrent stones after complete clearance. Eight patients with retained or
recurrent intrahepatic stones received subsequent surgical treatment during the
postoperative follow-up period. Twelve patients (2.8%, 12/427) developed
cholangiocarcinoma in a postoperative follow-up study of hepatolithiasis.
Forty-four patients died during the 4-year to 10-year follow-up period, a
mortality of 10.3% (44/427).
Conclusion: Biliary tract sepsis,
cholangiocarcinoma and biliary cirrhosis with hepatic failure were the most
common causes of death. POC and PTCSL are effective procedures for treating
hepatolithiasis, but recurrent stone rates and repeated symptom rates were high
in long-term follow-up studies. Intrahepatic strictures were a main cause of retained
and recurrent stones.
10.133 Gynecology
Laparoendoscopic Single Site (LESS) in Gynecologic Surgery: Initial Experience and Feasibility
Kevin J. Stepp, MD, Sarah Kane, MD
Urogynecology and Reconstructive Pelvic Surgery and Minimally Invasive Surgery, Cleveland, Ohio, USA
Objective: We describe our initial gynecologic experience with single incision laparoscopic procedures using a multichannel port and identify our learning curve.
Methods: In this retrospective case series, we examined the operative and clinical course of patients who underwent a single incision laparoscopic procedure at an urban tertiary care center from May 2008 through September 2009. Basic medical information regarding demographics, procedural times, pathology, and postoperative course for up to 12 months was abstracted. Statistical analysis was performed using descriptive statistics, chi-square, Fisher’s exact test, and ANOVA where appropriate.
Results: During the study period, 59 patients underwent single incision laparoscopic surgery. Forty-six patients had a hysterectomy. Procedures performed included hysterectomy, excision of endometriosis, sacral colpopexy, appendectomy, and oophorectomy. All surgeries were completed laparoscopically. No intraoperative complications occurred. Mean uterine weight was 313 grams (range, 23 to 1600). Mean length of stay was 10.8 hours (range, 1.0 to 29.0). Patients took narcotics for a mean 4.8 days (range, 0 to 28). No significant difference existed in operative time between the first and last 10 hysterectomy cases, 199.0 vs 183.1 minutes, respectively. Significant differences were noted in uterine weights (mean, 165.7g vs. 350.3g) and in postoperative complications, with 4 in the initial group and none in the last 10 hysterectomies.
Conclusion: Our initial experience suggests that single incision laparoscopy is feasible, well tolerated, and results in essentially no scar for many benign gynecologic conditions. In our first 46 patients, we were able to complete more complex hysterectomies in the same amount of time with fewer complications.
10.134 Gynecology
Single Incision Laparoscopy for Ectopic Pregnancy: A Case Report
Mineto Morita, MD, PhD, Ichiro Uchiide, MD, PhD, Takehiko Tsuchiya, MD, PhD, Masahito Nakakuma, MD, PhD, Yukiko Katagiri, MD, PhD
Department of Obstetrics and Gynecology, Toho University School of Medicine, Japan
Introduction: The laparoendoscopic single-site surgery technique was first introduced into general surgery for cholecystectomy, with the use of a single port through the umbilicus. We present a case of ectopic pregnancy with the use of a single umbilical cutaneous incision.
Case Report: A 14-year-old patient was seen in the emergency department complaining of intense abdominal pain. She had a positive urinary pregnancy test. An ultrasound image revealed a right adnexal mass and free fluid in the cul-de-sac. The serum hCG level was 37,062 IU/L. Ectopic pregnancy was diagnosed. Surgery was performed with the patient under general anesthesia. A 2.5-cm incision was made at the base of the umbilicus. After pneumoperitoneum, a 10-mm trocar was placed for a scope. Two 5-mm trocars were placed on each side of the 10-mm portal, as far apart as the skin incision allowed. In the abdominal cavity, there was about 400mL of blood. The right fallopian tube was swollen 4cm to 5cm, and it had sustained bleeding. A salpingectomy was performed. A tissue collection bag was introduced through the 10-mm trocar, and the tube was removed. The aponeurotic incisions and the skin were closed with absorbable suture. The operative time was 66 minutes, and there were no intraoperative and postoperative complications. She was discharged on postoperative day 5.
Conclusion: This technique is a challenging procedure that needs technical improvements before being recognized as a valid and standard approach for the treatment of usual gynecologic disease.
10.136 General Surgery
Management of Extraperitoneal Colon Perforation for a Huge Parastomal Hernia: Case Report and Literature Review
Wen-Yao Yin, Cheng-Hung Lee, Shih-Pin Lin, Chun-Ming Chang, Chang-kuo Wei
Department of Surgery, Buddhist Dalin Tzu Chi General Hospital
Objective: Parastomal hernia is not rare after surgery. In regard to its complications, small bowel obstruction due to incarceration is not uncommon. In addition, stomal ischemia, stricture, and infection are possible. However, extraperitoneal colon perforation and abscess formation within a parastomal hernia is exceedingly rare and difficult to manage. We report our experience and review the literature.
Methods: A 67-year-old female patient had a history of LGI bleeding s/p Hartmann procedure more than 20 years earlier. Recently, she complained of fever and decreased stool passage from the stoma. Abdominal CT showed a parastomal hernia, >15cm with a large fascial defect and abscess formation at the parastomal hernia. She underwent debridement while under local anesthesia due to unstable hemodynamics. Extraperitoneal colon perforation was found about 4cm distant from the stomal opening. A second operation, T-colostomy was arranged for stool diversion. After wound care for several weeks, the wound became healthier. Then a definite operation comprising wide excision of the parastomal hernia, end T-colostomy creation, and repair of the fascial defect with the aid of large mesh was arranged.
Results: The patient recovered smoothly after these staged operations.
Conclusion: Parastomal hernia could be treated with the laparoscopic or open method with or without mesh repair. But for colon perforation with an infected hernia, how to mange became difficult. We present our experience, a staged operation, as a better approach. To prevent such complications following a parastomal hernia, we suggest early intervention for huge parastomal hernias even when only mild symptoms are present.
10.137 General Surgery
Management of Extraperitoneal Colon Perforation for a Huge Parastomal Hernia: Case Report and Literature Review
Wen-Yao Yin, Cheng-Hung Lee, Shih-Pin Lin, Chun-Ming Chang, Chang-kuo Wei
Department of Surgery, Buddhist Dalin Tzu Chi General Hospital
Objective: Parastomal hernia is not rare after surgery. In regard to its complications, small bowel obstruction due to incarceration is not uncommon. In addition, stomal ischemia, stricture, and infection are possible. However, extraperitoneal colon perforation and abscess formation within a parastomal hernia is exceedingly rare and difficult to manage. We report our experience and review the literature.
Methods: A 67-year-old female patient had a history of LGI bleeding s/p Hartmann procedure more than 20 years earlier. Recently, she complained of fever and decreased stool passage from the stoma. Abdominal CT showed a parastomal hernia, >15cm with a large fascial defect and abscess formation at the parastomal hernia. She underwent debridement while under local anesthesia due to unstable hemodynamics. Extraperitoneal colon perforation was found about 4cm distant from the stomal opening. A second operation, T-colostomy was arranged for stool diversion. After wound care for several weeks, the wound became healthier. Then a definite operation comprising wide excision of the parastomal hernia, end T-colostomy creation, and repair of the fascial defect with the aid of large mesh was arranged.
Results: The patient recovered smoothly after these staged operations.
Conclusion: Parastomal hernia could be treated with the laparoscopic or open method with or without mesh repair. But for colon perforation with an infected hernia, how to mange became difficult. We present our experience, a staged operation, as a better approach. To prevent such complications following a parastomal hernia, we suggest early intervention for huge parastomal hernias even when only mild symptoms are present.
10.138 Gynecology
Robot-Assisted Laparoscopic Hysterectomy Utilizing the 5-mm da Vinci System
Jian Qun Huang, MD, Masoumeh Ghaffari, MD, Ceana Nezhat, MD
Northside Hospital, Atlanta, Georgia, USA
Objectives: One of the drawbacks of robotic surgery has been the size of the lateral ports (8mm), which can result in increased pain and incisional hernias. We report the technique, instrumentation, and outcomes of 17 patients who underwent robot-assisted laparoscopic hysterectomy (RALH) utilizing the 5-mm da Vinci system.
Methods: A retrospective chart review was performed on all patients who underwent RALH in 2008. In 17 cases, an umbilical 12-mm port was used with the 5-mm da Vinci system lateral on each side above the sacroiliac spine and the fundus of the uterus. An additional 5-mm suprapubic canula was used for suction irrigation.
Results: The mean age was 48.1 (range, 33 to 64), median gravidity 3 (range, 0 to 4), and median parity 2 (range, 0 to 3). Indications for surgery included myoma (6), pain (13), and abnormal uterine bleeding (14). Concomitant procedures included adhesiolysis (16), appendectomy (14), bilateral salpingo oophorectomy (12), Moschowitz (13), and treatment of endometriosis (16). All procedures were completed successfully by the robotic technique with no conversions to laparotomy. The average uterine weight was 160g (range, 60 to 311), average EBL<50cc (range, <20 to 100). All patients were discharged within 23 hours. There were no intra- or postoperative complications, incisional hernias, or vaginal cuff dehiscence.
Conclusion: RALH utilizing 5-mm ports and instruments is feasible. Limiting factors, such as lack of bipolar instruments, vessel sealing devices, or hot scissors, can be overcome with suturing capability and Harmonic shears.
10.139 Gynecology
Laparoscopic Treatment of Endometriosis Utilizing the 5-mm da Vinci System
Ceana Nezhat, MD, Kimberly Kho, MD, MPH
Northside Hospital, Atlanta, Georgia, USA
Objectives: To report our experience utilizing the 5-mm da Vinci system in a series of patients undergoing laparoscopic treatment of endometriosis.
Methods: A retrospective chart review was performed on all patients who underwent robot-assisted laparoscopic treatment of endometriosis in 2008. Twenty-one cases were performed utilizing the lateral and suprapubic 5-mm da Vinci system with a 12-mm umbilical port. A 5-mm grasper, sharp scissors, and electrosurgical hook were used.
Results: The mean patient age was 36.4 (range, 21 to 56), median gravidity 4 (range, 0 to 4), median parity 0 (range, 0 to 3). Nine patients had stage I endo, 6 stage II, 2 stage III, and 4 stage IV. Indications for surgery included pain (20), abnormal uterine bleeding (16), pelvic mass (5), and myoma (4). Concomitant procedures included adhesiolysis (20), appendectomy (12), cystectomy (10), and myomectomy (6). All robotic procedures were completed successfully with no conversions to laparotomy. There were no intra- or postoperative complications. Estimated blood loss was <30cc on average (range, <10 to 75).
Conclusion: The 5-mm da Vinci ports and instruments can be used effectively in the laparoscopic treatment of endometriosis. The smaller port size provides the benefit of smaller incisions, along with reduced risk of incisional pain and hernias. The smaller instrumentation may be advantageous in the treatment of endometriosis where detailed dissection and manipulation is required.
10.140 General SurgeryThe Microscopic Significance of Mesorectal Excision Between Open and Laparoscopic Rectal SurgeryDae Hwa Choi, Yeong Cheol Im, Bong Hwa Chung
Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea (Drs. Choi, Im); Department of Surgery, University of Hallym, Chuncheon, Gangwon-do, Republic of Korea (Dr. Chung).
Background: Total mesorectal excision (TME) is the gold standard for rectal cancer surgery and determines the quality of the surgical resection. Although the TME principle should be applied to laparoscopic rectal cancer surgery (LAPA), LAPA is technically a more demanding surgery than conventional resection (OPEN) is. We aimed to determine whether LAPA TME is comparable to OPEN TME, as examined using gross and microscopic inspection of TME specimens.
Method: LAPA was applied to a tumor located in the mid and upper rectum. After resection, we examined the completeness of TME and applied yellow dye at the intact proper rectal fascia area and black dye at the defect site. The stained specimen was dried at room temperature for 10 minutes and then immersed in formalin solution. The pathologist microscopically inspected the specimen and determined whether gross inspection of TME is consistent with microscopic inspection. And we compared LAPA TME with OPEN TME using the pathology reports.
Results: Grossly focal defects of TME specimens occurred in 10 (66%) OPEN patients and 12 (99%) LAPA patients. But only half of the gross defects of the proper rectal fascia were confirmed as having microscopic defects in both groups. The incidence rate of microscopic defects (true defect), regardless of gross finding, was 40% (6 case) in OPEN and 46% (6 case) in LAPA.
Conclusion: This study shows that laparoscopic resection of the mid and upper rectum had no difference in defect grade of TME compared with conventional open surgery. We assume that rectal cancer, excluding low-lying cancer, could be resected safely with laparoscopy.
Clinical Efficacy of Two Minimally Invasive Hysterectomy Techniques for Uterine Fibroid Tumors: Total Laparoscopic Hysterectomy Versus Vaginal Hysterectomy
10.141 Gynecology
Clinical Efficacy of Two Minimally Invasive Hysterectomy Techniques for Uterine Fibroid Tumors: Total Laparoscopic Hysterectomy Versus Vaginal Hysterectomy
Hong-bae Kim, MD
Hallym University Hospital, Seoul, Korea
Objectives: To compare the clinical outcomes of 2 minimally invasive hysterectomy techniques: total laparoscopic hysterectomy (TLH) and vaginal hysterectomy (VH).
Methods: A prospective study of 385 women who underwent TLH and VH at Hallym University Hospital between November 2008 and October 2009 was conducted. Outcome measures were estimated and compared between the 2 groups.
Results: It was found that 198 women underwent VH and 187 underwent TLH. There was no difference between the 2 groups in mean age, estimated blood loss, and hemoglobin changes. But the TLH group had higher BMI (23.49 vs. 24.14, P=0.040) and greater mean uterine mass weight (243.93 vs. 216.94 grams, P=0.019). Operating time was significantly longer (97.2 vs. 142.58 minutes, P=0.000), and total cost was also higher in the TLH group (1728 vs. 2480 x1000won, P<0.01). Bowel motility returned earlier in the VH group (2.27 vs. 2.49 days, P=0.000). However, hospital stay (5.23 vs. 3.50 days, P=0.000) and mean days of analgesic consumption were greater (6.04 vs. 5.35 days, P=0.022) in the VH group. The incidence of intra- and postoperative complications was not different. But urinary problems including urgency and urinary incontinence were more frequent in the TLH group (P=0.029).
Conclusions: VH is a conventional procedure that can easily be performed, making the operating time definitely short. The low cost is another great benefit of VH. Also, VH has many merits, including earlier return of bowel motility and fewer urinary problems. We might conclude that VH should be a primary choice for treatment of uterine fibroid tumors.
10.142 General Surgery
Laparoscopic Management of Blunt Hepatic and Splenic Trauma in Children
Giancarlo Basili, MD, Graziano Biondi, MD, Luca Lorenzetti, MD, Nicola Romano, MD, Orlando Goletti, MD
Health Unit 5 Pisa, Pontedera Hospital, General Surgery Unit, Italy
Introduction: Management of blunt hepatic and splenic injuries in children has evolved over the past 2 decades with a trend towards nonoperative treatment in hemodynamically stable patients. Although increasingly practiced, nonoperative management is not without dangers and limitations, with failure rates from 5% to 20%. The introduction of minimally invasive surgery has revolutionized many surgical diagnostic protocols, and currently the laparoscopic approach could be placed between conservative methods and traditional surgery.
Methods: We present 2 cases of blunt abdominal trauma in children. A II-degree laceration of hepatic and splenic parenchyma is reported. Both patients were hemodynamically stable, and diagnostic laparoscopy was performed with low pressure, and the patients under general anesthesia. Three 5-mm ports and a 30-degree laparoscope were used for exploration. All patients underwent complete exploration of the abdominal cavity. Therapeutic procedures consisted of cauterizing an active bleed from the IV and V hepatic segment and from the upper pole of the spleen. Both patients experienced an uncomplicated recovery. There were no missed injuries.
Conclusion: The optimal role for laparoscopy in trauma has yet to be established. Although well described in adults, relatively little has been written specifically about pediatric abdominal injuries, especially when comparing injury and treatment in children with the treatment received by their adult counterparts. The presented technique enables a systematic laparoscopic exploration of the abdomen. Bleeding from minor injuries of the liver and the spleen, as in the cases observed, can be easily controlled through the laparoscope.
10.143 Gynecology
Laparoscopic Diagnosis of Postpartum Ovarian Vein Thrombosis: An Unpredictable Event
Giancarlo Basili, MD, Nicola Romano, MD, Luca Lorenzetti, MD, Valerio Prosperi, MD, Orlando Goletti, MD
Health Unit 5 Pisa, Pontedera Hospital, General Surgery Unit, Italy
Introduction: Ovarian vein thrombosis is a rare but potentially serious postpartum complication that occurs in 0.05% to 0.18% of pregnancies and is diagnosed on the right side in 80% to 90% of the cases.
Case Report: A 32-year-old woman presented to our emergency department at 15 days postpartum with severe abdominal pain, fever, and abdominal distension. Abdominal examination revealed right lower quadrant pain with rebound tenderness. The plain abdominal radiography evidenced a diffuse fecal stasis; abdominal ultrasound showed the presence of free fluid in the Douglas’ pouch and between small bowel loops. Diagnosis of acute appendicitis was made. The patient immediately underwent explorative laparoscopy; at surgery, a hard tumorous anomaly consistent with right ovarian vein thrombosis was found. Laparoscopic ultrasound confirmed the diagnosis. Anticoagulation therapy and antibiotics were instituted. CT-scan confirmed the presence of thrombosis up to the vena cava. The patient was discharged on postoperative day 4. At 1-month follow-up, she remained stable and symptom free.
Conclusion: Even though postpartum ovarian vein thrombosis is rare, recognition and treatment is needed to institute adequate therapy and avoid potential serious sequelae. The diagnosis can be established by ultrasound, CT scan, and MRI examinations. Although, as in the case described, the limitation of US include obscuration of the gonadic vein by overlying bowel gas. OVT should be considered in any woman in the postpartum period with lower abdominal pain, fever, and leucocytosis.
10.144 Gynecology
Effect of CO2 Pneumoperitoneum on Protein Expression of MMP2 and TIMP-1 of Endometriosis Lesions
Xu Chen, MD, PhD, Runhan Huang, MD, Haifang Liu, MD, PhD, Wei Zhang, MD, Yan Liu MD
Department of Obstetrics and Gynecology, Changzheng Hospital, Second Military Medical University, No. 415 Fengyang Road, Shanghai, China
Objective: To evaluate the effect of CO2 pneumoperitoneum and different pneumoperitoneum pressures on protein expression of MMP2 and TIMP-1 of endometriosis lesions.
Methods: The SD rats were divided randomly into 3 groups (control group, 10mm Hg, and 20mm Hg CO2 pneumoperitoneum, 1h) after the endometriosis model was successfully found. The correlated cytokines of aggression (MMP2/TIMP-1) in endometriosis lesions were determined at the first, second, and sixth week after pneumoperitoneum intervention. We also evaluated the effect of different CO2 pneumoperitoneum pressures on protein expression of cytokines.
Results: Compared with the control group, the protein expression level of MMP-2 in the two CO2 pneumoperitoneum groups decreased significantly in the early postoperative stage (one week after intervention) (P=0.001). And the effect continued for 2 weeks. Moreover, the expression level of MMP-2 in the 10mm Hg group was lower than that in the 20mm Hg pneumoperitoneum group (P=0.001). The protein expression of TIMP-1 increased in both groups, with the higher expression in the 10mm Hg group (P=0.001). And the expression level of MMP-2 increased and TIMP-1 decreased gradually with time after CO2 pneumoperitoneum intervention, and there were no differences compared with that of the control group 6 weeks after the operation (P=0.05).
Conclusion: The expression of MMP-2 decreased and TIMP-1 increased in the early period after the CO2 pneumoperitoneum intervention. Low CO2 pneumoperitoneum pressure is superior to high pressure in inhibiting the aggression of endometriosis lesions.
10.145 General Surgery
Combined Laparoscopic and Endoscopic Excision of Duodenal Tumor
Richy Lee, MD, Bipan Chand, MD, Matthew Kroh, MD
Cleveland Clinic Foundation, Cleveland Ohio, USA
Background: Duodenal carcinoid tumors are rare. Treatment of these submucosal lesions includes surgical excision, but the most effective approach remains controversial. Metastatic potential in lesions <1cm is low, which makes laparoscopic local excision a practical approach. We report a case of combined laparoscopic and endoscopic local resection of a duodenal carcinoid tumor.
Methods: A 79-year-old woman with epigastric pain underwent upper endoscopy and was found to have a 1-cm submucosal duodenal mass. She was referred for surgical excision. After gaining access to the peritoneal cavity, the upper abdomen was inspected. Two additional trocars were placed, and the distal stomach and proximal duodenum were then mobilized via Kocher maneuver. The lesion was identified endoscopically and translated in relation to extraluminal landmarks. A duodenotomy was made on the anterior wall across the pylorus between stay-sutures. The lesion was excised through the duodenotomy with electrocautery and ultrasonic sheer. After confirmation of complete excision of the lesion and hemostasis, the mucosal excision site was closed, and the anterior duodenotomy was closed with Heineke-Mikulicz pyloroplasty.
Results: Operative time was 103 minutes, including frozen-section analysis, and blood loss was estimated at <10mL. The patient was discharged on postoperative day 4. Final pathology confirmed the diagnosis as well-differentiated neuroendocrine neoplasm (carcinoid tumor) infiltrating Brunner’s glands.
Conclusion: Combined laparoscopic and endoscopic excision of a duodenal tumor is safe and feasible in tumors with low metastatic potential. It should be considered as an option for patients with select duodenal tumors.
10.146 General Surgery
A Rare Type of Meckel’s Diverticulum Associated with Intestinal Obstruction
Maheswaran Pitchaimuthu, MS, MRCS, A. Kochman, MD, A.L. Khan, FRCS
Department of General Surgery, Hairmyres Hospital, Eaglesham Road, East Kilbride, United Kingdom
Introduction: Stricture of terminal ileum secondary to Meckel’s diverticulum is a very rare complication.
Case Report: A 61-year-old female patient presented with subacute intestinal obstruction. Small bowel study and CT scan suggested Crohn’s disease. Laparoscopic resection of ileal stricture and inflamed, distended Meckel’s diverticulum was carried out. Histopathology confirmed ileal stricture secondary to Meckel’s diverticulitis and ruled out Crohn’s disease. We present this case with a brief summary of the literature.
Discussion: Meckel’s diverticulum is a congenital anomaly present in 2% of the population. The most common complication associated with Meckel’s diverticulum is intestinal obstruction due to intussusception, volvulus, inflammatory adhesions, and Littre’s hernia. Only one case of symptomatic ileal stricture secondary to Meckel’s diverticulum has been reported. Resection of the involved segment including Meckel’s diverticulum is the standard treatment.
Conclusion: We report this case because of its rarity.
10.147 General Surgery
Is Routine Use of Anticoagulation for the Prevention of Venous Thromboembolic Complications Necessary in the Morbidly Obese Undergoing Laparoscopic Gastric Bypass?
C.T. Frantzides, MD, PhD, J.R. Glover, MD, S.N. Welle, DO
Department of Surgery University of Illinois in Chicago, USA; Chicago Institute of Minimally Invasive Surgery, Skokie, Illinois, USA
Objective: To compare the rate of venous thromboembolism (VTE) by using routine postoperative enoxaparin and sequential compressive devices (SCDs) versus early ambulation, hydration, SCDs, and no prophylactic pharmacologic anticoagulation.
Methods: From October 2001 to October 2008, 1,692 patients undergoing laparoscopic Roux-en-Y gastric bypass were included and divided into 2 groups based on the time period that they were operated on. Group A (435 patients) had SCDs placed before induction of anesthesia, were admitted to the ICU, and received routine enoxaparin 12 hours after surgery. Group B (1,257 patients) received no prophylactic pharmacologic anticoagulation, had SCDs placed before anesthesia induction, were admitted to remote telemetry, ambulated 2 hours after surgery, and hydrated.
Results: Mean BMI was 46.8. Mean operating time was 144±26 minutes (Group A) and 126±15 minutes (Group B). Mean length of stay was 2.3±1.5 days (Group A) and 1.4±1.2 (Group B). Intraluminal bleeding occurred in 21 patients (4.8%) in Group A and 5 (0.9%) in Group B, but none required surgical or endoscopic intervention. Five pulmonary embolisms occurred in Group A (1.1%) and none in Group B. Seven patients in Group A (1.7%) and 6 (0.47%) in Group B had clinically evident DVT. Mortality occurred in 2 patients (0.12%), both in Groups A not related to VTE.
Conclusions: Adequate VTE prophylaxis is achieved using SCDs, early ambulation, and emphasis on hydration. Pharmacologic anticoagulation is not mandatory when these conditions are met. Fewer bleeding complications requiring interventions or blood transfusions occur without the use of anticoagulants.
10.148 General Surgery
Laparoscopic Approach to Distal Pancreatectomy
C.T. Frantzides, MD, PhD, G.D. Ayiomamitis, MD, B.J. Ammori, MD, J.R. Glover, MD, S.N. Welle, DO
Department of Surgery University of Illinois in Chicago, Chicago Institute of Minimally Invasive Surgery, Skokie, Illinois, USA
Department of Hepato-Pancreato-Biliary Surgery, North Manchester General Hospital, Manchester, United Kingdom
Objective: Analysis of morbidity and mortality with laparoscopic distal pancreatectomy (LDP).
Methods: Clinical data for 13 patients undergoing attempted distal pancreatectomies laparoscopically were collected prospectively.
Results: Thirteen patients, ages 32 to 72 years underwent LDP, 6 patients with splenic preservation and 7 patients without. All procedures but one, conversion to open due to widespread liver metastasis, were completed laparoscopically. This patient was the only mortality in the series (9%) and died as a result of rapid disease progression. The operating time was 255 minutes (range, 160 to 390) with a blood loss of 300mL (range, 50 to 800). The morbidities included pancreatic fistula, readmission, reoperation, and in-hospital mortality rates were 38.4%, 30.7%, 0%, 0%, respectively. The postoperative hospital stay was 6 days (range, 4 to 15). Tumors were 1.0cm to 10.5cm in diameter and included endocrine (n=8), adenocarcinoma (n=1), cystadenoma (n=2), pseudopapillary tumor (n=1), and chronic pancreatitis (n=1). At 12 months (range, 2 to 50), one patient died from brain metastases and one was lost to follow-up. One patient with a large endocrine tumor had recurrence in the head of the pancreas and underwent pancreaticoduodenectomy. The remaining patients are disease free.
Conclusion: The laparoscopic approach to distal pancreatectomy offers favorable results compared with those observed after the classical open approach in terms of hospital stay, operative blood loss, splenic preservation, and morbidity.
10.149 General Surgery
Laparoscopic Ladd Procedure for Malrotation in an Adult: A Video Presentation
Zulfiqar Hanif, FRCS, Haitham Qandeel, MRCS, Sujala Kalipershad, MRCS, Abdul Latif Khan, FRCS,
Hairmyres Hospital, NHS Lanarkshire, United Kingdom
Objectives: Malrotation is typically diagnosed in the first few months of life, and 90% are diagnosed during the first year. Congenital midgut malrotation is rarely encountered outside the pediatric population. We present an interesting video of a laparoscopic Ladd procedure for midgut malrotation in a 17-year-old girl presenting with signs and symptoms suggestive of midgut volvulus. The aim of this video presentation is to demonstrate the safety and efficacy of the laparoscopic Ladd procedure for midgut malrotation in an adult.
Methods: A 17-year-old girl presented to us with a history of intermittent central abdominal pain associated with bilious vomiting for the last 2 years. She had a couple of
acute admissions and was treated conservatively elsewhere but had no significant investigations prior to this presentation. She had a CT scan and barium follow through on this occasion. Both of these confirmed midgut malrotation. Because no other cause was found for her symptoms on thorough examination, we were justified to assume that she had intermittent midgut volvulus. Laparoscopic Ladd's procedure was performed with excellent results, as a corrective measure with division of peritoneal bands (Ladd's bands) traversing the posterior abdomen, reduction of volvulus, appendectomy, and functional postioning of the intestine without fixation.
Results: The procedure remained uneventful, and postoperative recovery was smooth. She has been asymptomatic since then, now 2 years down the road.
Conclusions: Clinical manifestations of malrotation and results of Ladd's procedure have been described in adults, but the role of laparoscopic treatment remains to be established as adequate treatment. Surgical correction in the form of a laparoscopic Ladd procedure is safe and rewarding.
10.150 Gynecology
Effect of Adding Lidocaine Ointment Application to the Cervix During Hysteroscopic Operation in the Office
Sung-Tack Oh, MD, PhD, Moon-Kyoung Cho, MD, PhD, Jong-Woon Kim, MD, PhD, Woo-Dae Kang, MD, PhD
Department of Ob/Gyn, Chonnam University Medical School, Kwangju, Korea (South)
Objective: This study was to evaluate the effect of lidocaine ointment applied to the cervix added to conventional parenteral anesthesia during hysteroscopic operations done in the office.
Methods: This was a prospective, randomized study performed at a university hospital.
We performed the simple hysteroscopic operation in our office by using a continuously irrigated mini-hysteroscopic system with 15.5Fr (5.5mm) of the largest outer sheath diameter. In the past, we usually used the parenteral anesthetic system with Demerol and Valium for anesthesia. Forty-one patients underwent a hysteroscopic operation with lidocaine ointment applied to the cervix added to conventional parenteral anesthesia (Group A). They were compared with 45 patients who underwent hysteroscopy with conventional parenteral anesthesia only (Group B). The groups were compared for pain during the procedure, total duration of the procedure, and postoperative complications. If patients complained of any pain during the procedure, it was classified to positive pain. SPSS software was used for statistical analysis.
Measurements & Main Results: The pain complaints during procedures were significantly less in Group A than in Group B (2 of 41 vs. 15 of 45, P<0.01). The total duration of both procedures was not significantly different. There was no postoperative complication with either procedure.
Conclusions: Therefore, lidocaine ointment applied to the cervix added to conventional parenteral anesthesia during hysteroscopic operation in an office is a very helpful and safe addition to the hysteroscopic procedure.
10.151 Multispecialty
Robotic Surgery for Locally Advanced Cervical and Endometrial Cancer
C. Vasilescu, PhD, S. Tudor, MD, Monica Popa, MD, Irina Dinu, MD
Fundeni Institute of Digestive Disease and Liver Transplantation, Bucharest, Romania
Introduction: Robotic surgery overcomes some limitations of laparoscopic surgery for prostate, rectal, and gynecologic cancer. In this study, we analyzed the feasibility of the robotic approach for locally advanced gynecologic cancer in a developing program of robotic surgery.
Material and Methods: Between March 2008 and January 2010, 310 cases of robotic surgery were performed at the Fundeni Institute of Digestive Disease and Liver Transplantation, Bucharest, Romania, out of which 43 cases addressed gynecological conditions. We selected all radical interventions, 33 cases including 29 radical hysterectomies with pelvic lymphadenectomy, 3 anterior pelvic exenterations, and 1 totally robotic total pelvic exenteration.
Results: Our final group consisted of 29 patients, between 23 and 78 years old, with an average age of 50.4 years. Twenty patients were diagnosed with cervical cancer, 10 with endometrial cancer, 1 with cervical cancer relapse, and 2 with endometrial cancer relapse. Mean operative time was 180±23.45 minutes for radical hysterectomies with pelvic lymphadenectomy and 230±20.7 minutes for pelvic exenterations. Oral intake was started the next day after the operation, and the patients were discharged 5±2.4 days postoperatively. There were 3 urinary complications in patients with tumors adherent to the urinary bladder.
Conclusions: We believe that the robotic approach of locally advanced gynecologic cancer is a rapid, feasible, and secure method that should be used whenever available. However, further prospective studies and late follow-up results are needed to fully assess the value of this new technology.
10.152 General Surgery
Laparoscopic Repair of Incisional Hernia
Dr. Mohammad Alkilani
Department of Surgery, Policlinico Madonna della Consolazione, Reggio Calabria, Italy
Introduction: Incisional hernia correction is challenging for surgeons, the greater the breadth of the defect, the greater the difficulty. Laparoscopic access has solved many complications, such as recurrences, infections, seromas, respiratory complications, pain, and embolism.
Materials and Methods: The laparoscopic technique is based on using an intraperitoneal patch suitable for placing in contact with the intestine without the risk of adhesions. The first procedures were performed using a PTFE prosthesis. Other prostheses composed differently were used for the same purpose. We report on our experience in treating incisional hernias using a new prosthesis composed of 2 polypropylene layers, a wide net shape in contact with the abdominal wall and a sheet in contact with bowel. The peculiarity of this prosthesis is that polypropylene in a sheet shape has no tendency to generate adhesions, while a net-shaped polypropylene has a strong ability to do so. We treated 6 patients; the size of the defect varied from 6cm to 20cm in diameter; average patient age was 53 years. We placed 3 trocars along the anterior axillary line, lysed adhesions, liberated loops incarcerated inside the hernia bag, measured the defect width, and fixed the prosthesis with 3cm to 4cm of overlap with clips.
Results: Follow-up was done at 7, 15, and 30 days after surgery. No recurrences, postoperative seromas, or other complications occurred. Average hospital stay was 6 days.
Conclusion: The open technique for treatment of incisional hernias often causes problems because of intraperitoneal pressure increase, respiratory excursion impairment, wound infections, and sometimes bowel obstruction. Laparoscopy resolved such complications and avoided respiratory problems. The prosthesis is equally strong, thin, and manageable. The laparoscopic technique using a polypropylene prosthesis can become the gold standard for incisional hernia correction.
10.153 General Surgery
A Comparison of Clipless Cholecystectomy with Ultrasonic Shears Versus Conventional Laparoscopic Cholecystectomy
S.K. Jain, MS Gen Surgery, Prof. of Surgery, P.N. Agarwal, MS Gen Surgery, Prof. of Surgery, R.C.M. Kaza, MS Gen Surgery, Prof. of Surgery, Raman Tanwar, Surgery Resident
Maulana Azad Medical College and Lok Nayak Hospital
Objective: The study was aimed at comparing the feasibility and advantages of clipless cholecystectomy with ultrasonic shears versus conventional laparoscopic cholecystectomy.
Methods: A prospective randomized control study was done in 100 patients: 50 underwent laparoscopic cholecystectomy by conventional methodology using electrocautery and 50 underwent dissection, ligation of the cystic duct and artery, and removal of the gallbladder from the bed by using ultrasonic shears. Data collected underwent statistical analysis and results were obtained by using the chi-square and t tests.
Results: Patients undergoing laparoscopic cholecystectomy with ultrasonic shears had faster operating times, and decreased postoperative pain in the postoperative period.
Conclusion: Ultrasonic shears can be used safely and effectively to dissect, ligate, and remove the gallbladder from the bed with the advantage of faster surgery and reduced pain after the procedure.
10.154 General Surgery
Postoperative Complications Associated with Two Surgical Procedures Used in the Management of Rectal Endometriosis: Giving our Patients an Informed Choice
Horace Roman, MD, PhD, Benoit Resch, MD, Patrick Hochain, MD, Hend Belhiba, MD, Benoit Lefebure, MD, Jean Jacques Tuech, MD, PhD, Loïc Marpeau, MD, PhD
Department of Gynecology and Obstetrics, University Hospital Charles Nicolle, Rouen, France (Drs. Roman, Resch, Marpeau).; Department of Gastroenterology, Clinique du Cèdre, Bois Guillaume, France (Dr. Hochain); Department of Radiology, University Hospital Charles Nicolle, Rouen, France (Dr. Belhiba); Department of Digestive Surgery, University Hospital Charles Nicolle, Rouen, France (Drs. Lefebure, Tuech).
Objective: To evaluate the postoperative complications associated with surgical management of rectal endometriosis by either colorectal segmental resection or nodule excision.
Method: During 60 consecutive months, 82 women were included in a retrospective comparative study, whose distinguishing feature was that the choice of the surgical procedure was not related to the characteristics of the nodule, but to our thoughts concerning the disease: systematic colorectal resection before November 2007 and rectal nodule excision from that date onward.
Results: Colorectal segmental resection was performed in 28 patients (34%), and rectal nodule excision was performed in 54 women (66%). No intraoperative complications were recorded, but one case of rectal fistulae occurred in each group. In the colorectal resection group, 5 women (18%) had a bladder atony >1 month, 4 women (14%) experienced an increase in chronic constipation, while 2 women (4%) had shank acute compartment syndrome (respectively, P=0.04, 0.01, and 0.11). Delayed functional outcomes were studied in 41 women (50%) whose postoperative follow-up was greater than 18 months. An increase in the number of daily stools ≥3 was observed in 13 (52%) vs. 3 (19%) patients managed, respectively, by segmental resection and excision (P=0.02). Severe constipation appears to be definitive in 3 women having undergone segmental resection. No recurrences were recorded, and pain improvement was comparable between the 2 groups.
Conclusion: Colorectal resection seems to increase the risk of several unfavorable postoperative outcomes. Information about functional outcomes should be provided to patients, and should be considered when the most appropriate treatment for this disease is being decided upon.
10.155 Pediatric
Comparison of 223 Consecutive Laparoscopic and Open Appendectomies in Children
David Bliss, MD, Julie Mckee, PNP
Oregon Health and Science University
Purpose: During a trial of laparoscopic versus open appendectomy, approximately 40% of children with appendicitis were not enrolled. This study examines the characteristics and outcomes of this population.
Methods: We reviewed the records of all children in a pediatric surgical practice who underwent appendectomy outside of a trial of laparoscopic versus open appendectomy from December 2007 through September 2009. Appendixes labeled “normal,” “acute,” or “interval” were grouped as “mild” disease, while the gangrenous and ruptured appendixes were grouped as “complicated.” Statistical significance was determined by chi-squared analysis.
Results: We identified and segregated 223 consecutive patients into 2 groups: I=Laparoscopic (L), n=161, mild [Lm], n=114, complicated [Lc], n=47; and II=Open (O), n=62, mild [Om], n=37, complicated [Oc], n=25. The L and O groups were comparable with regards to mean patient age (L=9.6±3.7 vs. O=9.7±4.3 years), sex (L=57% vs. O=63% male), comorbidity (L=17% vs. O=19%), and percentage complicated disease (Oc=40% vs. Lc=29%, P=0.11). More children in the open group were identified as Hispanic (O=40.3% vs. L=23.6%, P=0.02). Operative times were similar (Lm:0.71±0.35 hours, Om:0.69±0.25 hours; Lc:0.86±0.37 hours, Oc:0.79±0.41 hours). The length of stay (hours) is also similar (Lm:27±21, Om:34±30 [P=NS]; Lc:121±112, Oc:151±96 [P=NS]).
Conclusions: In a review of pediatric open or laparoscopic appendectomies performed outside of a contemporaneous prospective clinical trial, there does not appear to be a difference in regards to the operative times or length of stay of either procedure.
10.156 General Surgery
Laparoscopic Median Arcuate Ligament Release
Kevin El-Hayek, MD, Matthew Kroh, MD
Department of General Surgery, Digestive Diseases Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
Introduction: Abdominal pain secondary to median arcuate ligament syndrome can be made only after other causes are ruled out. Ultimately, documentation of celiac axis stenosis on mesenteric ultrasound, CT angiography, and MRA confirms this challenging diagnosis.
Methods: This video presents the surgical management of a 28-year-old female with chronic abdominal pain who was ultimately diagnosed with median arcuate ligament syndrome. The technique for laparoscopic median arcuate ligament release is illustrated.
Results: Postoperative resolution of celiac axis stenosis was achieved, and at 6-month follow-up, the patient’s symptoms had completely resolved.
Conclusion: For patients with celiac axis stenosis secondary to median arcuate ligament syndrome, the laparoscopic approach is safe and effective, with excellent long-term results.
10.157 Urology
Anchor Tissue Retrieval Bag for Robot-Assisted Laparoscopic Prostatectomy (RALP)
Massimiliano Spaliviero, MD, Kurt Strom, MD, Xiao Gu, MD, Carson Wong, MD
University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
Introduction and Objective: Intracorporal specimen spillage is a concern during laparoscopic oncologic surgery as the integrity of a specimen retrieval bag can be threatened during its removal. We present the specifications of a novel retrieval bag for RALP.
Methods: The features of the TRS−100SB™ (Anchor Products, Addison, IL, USA) are examined to highlight its applications for use in specimen retrieval during RALP.
Results: The TRS−100SB™ has a 10-mm introducer that deploys a 5.6-cm diameter and 14-cm length bag that has a capacity of 235mL. It is constructed of a Rip-Stop nylon polyamide 66 material with specially formulated polyurethane laminate, having a thickness of 0.09mm to 0.11mm and a hydrostatic leak pressure of 4.5PSI. In tests simulating accidental puncture by a blunt 5-mm laparoscopic instrument, it withstands a mean 25 pounds of axial force projected by the tip of a 5-mm stainless steel probe. In comparison with other laparoscopic specimen retrieval bags, it has the highest puncture strength-to-thickness ratio of 260 pounds of force per mm of thickness (lbs/mm). Specimen retrieval does not require excessive fasciotomy length, because the bag exits without concerns of breakage.
Conclusions: The dimensions, high strength-to-thickness ratio, and ease of deployment of the Anchor Products TRS−100SB™ specimen retrieval bag lessen the risk of tumor spillage during RALP specimen retrieval.
10.158 Urology
Recurrence Rates Following Percutaneous and Laparoscopic Renal Cryoablation (RC) of Small Renal Masses (SRM): Does the Approach Make a Difference?
Kurt Strom, MD, Sean P. Stroup, MD, Reza Mehrazin, MD, John B. Malcolm, MD, Xiao Gu, MD, James L'Esperance, MD, Robert Wake, MD, Robert Gold, MD, Michael Fabrizio, MD, Ithaar Derweesh, MD, Carson Wong, MD
University of Oklahoma Health Sciences Center (Drs. Strom, Gu, Wong); University of California, San Diego Naval Medical Center (Dr. Stroup); University of Tennessee Health Science Center (Drs. Mehrazin, Wake, Gold); Eastern Virginia University (Drs. Malcolm, Fabrizio); San Diego Naval Medical Center (Dr. L’Esperance); University of California, San Diego (Dr. Derweesh).
Introduction and Objective: As the incidence of radiologic detection of renal masses increases, poor surgical candidates are offered either percutaneous renal cryoablation (PRC) or transperitoneal laparoscopic renal cryoablation (TLRC). This multicenter experience compares PRC and TLRC.
Methods: Posttreatment surveillance consisted of laboratory studies and imaging at regular intervals. Treatment failure was considered to be if persistent mass enhancement or interval tumor growth was evident.
Results: Sixty-one (67.2% male; 32.8% female) patients underwent PRC, and 81 patients underwent TLRC. Mean tumor size was 2.7±1.1cm (PRC) and 2.5±0.8cm (TLRC) (P=0.153). Renal cell carcinoma (RCC) was biopsy-confirmed in 76.4±42.8% (PRC) and 60.3±49.3% (TLRC) renal masses (P=0.052). The mean follow-up was 31.0±14.1 (PRC) and 39.8±22.6 (TLRC) months (P=0.009), with local tumor recurrence noted in 15.0±36.0% (PRC) and 5.0±21.9% (TLRC) of kidneys (P=0.044).
Conclusions: In this multicenter study of well-matched PRC and TLRC cohorts, PRC had higher primary treatment failure rates than TLRC had. However, a greater percentage undergoing PRC had biopsy-confirmed RCC.
10.159 Urology
Laparoscopic Partial Nephrectomy Versus Renal Cryoablation: A Multicenter Comparison of Intermediate Oncologic Outcomes
Carson Wong, MD, Kurt H. Strom, MD, Sean Stroup, MD, Chong Choe, MD, Reza Mehrazin, MD, John Malcom, MD, Robert Wake, MD, Xiao Gu, MD, Michael Fabrizio, MD, James L'Esperance, MD, Ithaar H. Derweesh, MD
US Naval Medical Center San Diego (Dr. Strom, L’Esperance); University of Oklahoma Health Sciences Center (Drs. Wong, Stroup, Gu); University of California San Diego School of Medicine (Drs. Choe, Derweesh); University of Tennessee Health Science Center (Drs. Mehrazin, Wake); Eastern Virginia University School of Medicine (Drs. Malcom, Fabrizio).
Introduction and Objective: We compared intermediate oncologic and functional outcomes following laparoscopic partial nephrectomy (LPN) and renal cryoablation (RC) from a multicenter experience.
Methods: LPN was performed via the transperitoneal approach. RC was performed via the percutaneous or transperitoneal laparoscopic approach.
Results: Included in the study were 376 (234 LPN, 142 RC) patients. No significant differences with respect to sex, ethnicity, and BMI were noted. Mean follow-up was significantly longer in RC than in LPN (36 vs. 20 months, P<0.001). Mean age was 56.2 (LPN) and 66.8 (RC) years (P<0.001). Diabetes mellitus was present in 18% of LPN and 28% of RC patients (P=0.03). Mean tumor size was 2.5cm (LPN) and 2.5cm (RC) (P=0.34). Preoperatively, 16.4% (LPN) and 38% (RC) had eGFR<60mL/min/1.73m2 (P<0.001). On univariate analysis, development of de novo eGFR<60mL/min/1.73m2 occurred in 9.7% of LPN and 15.6% of RC patients (P=0.125). Tumor persistence/recurrence was noted in 1.7% of LPN and 7.8% of RC kidneys (P=0.042).
Conclusions: In this multicenter intermediate follow-up study, RC had higher primary treatment failure rates than LPN had. RC did not provide superior renal preservation compared with that in LPN.
10.160 Urology
Perioperative and Delayed Adverse Events of Greenlight HPS™ Laser Photoselective Vaporization Prostatectomy (PVP)
Xiao Gu, MD, Kurt Strom, MD, Massimiliano Spaliviero, MD, Carson Wong, MD
University of Oklahoma Health Sciences Center
Introduction and Objective: We report the incidence, prevention, and management of perioperative (<30 days) and delayed (>30 days) adverse events in patients treated with GreenLight HPS laser photoselective vaporization prostatectomy (PVP).
Methods: Patients had American Urological Association Symptom Score (AUASS), Quality of Life (QoL) score, Sexual Health Inventory for Men (SHIM), serum prostate specific antigen (PSA), maximum flow rate (Qmax), and postvoid residual (PVR) determinations and volumetric prostate measurements with transrectal ultrasonography (TRUS). AUASS, QoL, SHIM, Qmax, and PVR were evaluated for up to 24 months after surgery. Adverse events were recorded perioperatively and at each follow-up interval.
Results: GreenLight HPS laser PVP was performed in 181 consecutive patients with a mean age of 67.8±9.7 years, prostate volume of 69.2±40.7mL, and PSA of 2.5±2.5ng/mL. Mean laser, operative times, and energy usage were 13.6±9.9 minutes, 31.9±22.8 minutes, and 90.9±67.5kJ, respectively. All were outpatient procedures. Perioperative complications included nonsignificant intraoperative bleeding (3.3%), postoperative clinically nonsignificant hematuria <7 days duration (63.0%), hematuria requiring clot evacuation (1.1%), urinary retention requiring temporary recatheterization (5.5%), urinary tract infection (5.0%), and prostatitis (0.6%). Delayed complications included hematuria (1.1%), retrograde ejaculation (40.0%), and bladder neck contracture (0.6%). No urethral strictures, urinary incontinence, or erectile dysfunction were noted.
Conclusions: GreenLight HPS laser PVP has a low incidence of perioperative and delayed adverse events.
10.161 Urology
Does Prostate Configuration Affect the Efficacy and Safety of Greenlight HPS™ Laser Photoselective Vaporization Prostatectomy (PVP)?
Xiao Gu, MD, Kurt Strom, MD, Massimiliano Spaliviero, MD, Carson Wong, MD
University of Oklahoma Health Sciences Center
Introduction and Objective: We evaluated the efficacy and safety of GreenLight HPS laser PVP for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) with bilobe and trilobe prostates.
Methods: Based on the results of cystoscopy and transrectal ultrasonography, patients were stratified into 2 groups: bilobe (group I) and trilobe (group II) BPH. American Urological Association Symptom Score (AUASS), Quality of Life (QoL) score, maximum flow rate (Qmax), and postvoid residual (PVR) were measured preoperatively and at 1 and 4 weeks and 3, 6, 12, 18, and 24 months postsurgery.
Results: The study comprised 181 consecutive patients (I: 101, II: 80). Among the preoperative parameters, significant differences were noted in prostate volume (I: 46.5±17.9, II: 97.5±120.2mL, P<0.001.), Qmax (I: 10.1±4.2, II: 8.7±3.5mL/sec, P=0.027), and PVR (I: 60.4±118.8, II: 97.5±154.3mL, P=0.074), while AUASS and QoL were similar. Significant differences in laser utilization (I: 8.9±4.5 II: 19.5±11.7 minutes, P<0.001) and energy usage (I: 59.1±30.0, II: 131.2±79.6kJ, P<0.001) were noted. AUASS, QoL, and Qmax showed immediate and stable improvement during the follow-up period. There were no significant differences in the postoperative clinical outcome parameters between the 2 groups (P>0.05). The incidence of adverse events was low in both groups.
Conclusions: Our experience suggests that BPH configuration has little effect on the efficacy and safety of GreenLight HPS laser PVP.
10.162 Urology
Intermediate Outcomes of Greenlight HPS™ Laser Photoselective Vaporization Prostatectomy (PVP) for Symptomatic Benign Prostatic Hyperplasia (BPH)
Carson Wong, MD, Kurt Strom, MD, Xiao Gu, 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 clinical outcomes.
Methods: Patients had American Urological Association Symptom Score (AUASS), Sexual Health Inventory for Men (SHIM), serum prostate specific antigen (PSA), maximum flow rate (Qmax), postvoid residual (PVR) determinations and volumetric measurements with transrectal ultrasonography.
Results: Included in the study were 181 consecutive patients, having a mean age of 67.8±9.7 years. The mean prostate volume was 69.2±40.7mL. Mean laser time, operating time and energy usage were 13.6±9.9 minutes, 31.9±22.8 minutes, and 90.9±67.5kJ, respectively. At discharge, 99 (54.7%) patients were catheter free. Of those who were discharged with a urethral catheter, 61 (33.7%) patients had it removed the following morning. Nine (5.0%) patients developed a urinary tract infection, 14 (7.7%) patients had persistent nonsignificant hematuria >1 week, and 1 (0.6%) bladder neck contracture and no urethral strictures were noted. Mean AUASS decreased from 23 to 8, 7, 5, 5, 4, 3, 3, and 2 (P<0.05) at 1 and 4 weeks and 3, 6, 12, 18, 24, and 36 months, respectively. Qmax values also showed significant improvement (P<0.05). The SHIM score did not change postoperatively.
Conclusions: Our intermediate results suggest that GreenLight HPS laser PVP is safe and effective for the treatment of LUTS secondary to BPH.
10.163 Urology
Early Urethral Catheter Removal Following Robot-Assisted Laparoscopic Prostatectomy (RALP)
Kurt Strom, MD, Massimiliano Spaliviero, MD, Xiao Gu, MD, Carson Wong, MD
University of Oklahoma Health Sciences Center, USA
Introduction and Objective: Typical urethral catheter duration following radical retropubic prostatectomy (RRP) and RALP is 7 days to 10 days. We review our RALP experience to determine whether urethral catheter removal following office cystography performed within the first postoperative week is feasible.
Methods: Using an anterior approach, we preferentially performed a bladder neck sparing dissection. The urethrovesical anastomosis was completed using a double-armed 3−0 Monocryl suture ± bladder neck tailoring when appropriate. A 20Fr urethral catheter was placed. On postoperative day (POD) 5 or 6 (clinic logistics), the urethral catheter was removed following normal cystography.
Results: Included in the study were 161 patients. The urethral catheter was removed on POD 5 in 90/161 (55.9%) patients, with a mean age of 61.9±9.2 years and PSA of 5.6±3.5 ng/mL. On POD 6 (clinic logistics), 37/161 (23.0%) patients had their urethral catheter removed. Time to urinary continence without pads was 9.5±7.6 weeks. Mean hospitalization was 1.0±0.2 days. One (1.1%) pTx, 15 (16.7%) pT2a, 3 (3.3%) pT2b, 60 (66.7%) pT2c, and 11 (12.2%) pT3 cancers were reported, having a mean prostate volume of 41.1±12.6mL. Adverse events included 2 (2.0%) bladder neck contractures, 5 (6.0%) temporary urinary retentions, and 1 (1.1%) urinary tract infection.
Conclusions: Early urethral catheter removal following RALP is feasible and does not increase patient morbidity in those without urinary extravasation on office cystography.
10.164 Urology
Does Body Mass Index (BMI) Affect the Clinical Outcomes of Robot-Assisted Laparoscopic Prostatectomy (RALP)?
Kurt Strom, MD, Massimiliano Spaliviero, MD, Xiao Gu, MD, Carson Wong, MD
University of Oklahoma Health Sciences Center, USA
Introduction and Objective: With the 35% prevalence of obesity in the United States, a significant proportion of RALP candidates have an elevated BMI. We determine whether this impacts the surgical outcomes and morbidity of the procedure.
Methods: Clinical outcomes and adverse events of consecutive RALP patients were prospectively recorded in obese (I: BMI>30kg/m2), overweight (II: BMI 25 to 30kg/m2) and normal weight (III: BMI<25kg/m2) groups.
Results: Included in the study were 161 patients [I: 47(29.1%); II: 81(50.3%); III: 33(20.4%)]. The mean BMI were significantly different (I: 32.8±2.7; II: 26.1±3.4; III: 23.1±1.6kg/m2, P<0.001). There were no significant differences in mean age, PSA, incidence of bladder neck reconstruction, estimated blood loss, prostate volume, positive surgical margin rate, hospitalization, and time to continence without pads. The median urethral catheter duration was similar in all groups (5.0 days). The operative time was shorter in group 3 compared with both groups I (I: 223.1±59.0 vs. III: 190.8±41.4 minutes, P=0.010) and II (II: 213.6±53.1 vs. III: 190.8±41.4 minutes, P=0.039). Adverse events included pelvic hematoma [I: 1(2.1%); II: 0(0.0%); III: 1(3.0%)], deep vein thrombosis [I: 0(0.0%); II: 2(2.4%); III: 0(0.0%)], and bladder neck contracture [I: 2(4.2%); II: 2(2.4%); III: 1(3.0%)], none of which were significantly different between the 3 groups.
Conclusions: Elevated BMI appears to increase the operative time but has little impact on blood loss, duration of hospitalization, clinical outcomes, or patient morbidity in patients undergoing RALP.
10.165 Urology
Metastatic Survey for Clinical Low-Risk Prostate Cancer: Is There an Indication?
Kurt Strom, MD, Massimiliano Spaliviero, MD, Xiao Gu, MD, Carson Wong, MD
University of Oklahoma Health Sciences Center, USA
Introduction and Objective: The use of diagnostic imaging for patients with low-risk prostate cancer referred to a major Midwest medical center for robot-assisted laparoscopic prostatectomy (RALP) was examined.
Methods: Patients with low-risk prostate cancer (PSA<10, Gleason Score≤6, and clinical stage T1 or T2a) were included for analysis. Whether these patients underwent computerized tomography (CT), nuclear bone scan (NBS), magnetic resonance imaging, (MRI), or all of these preoperatively, the results and the final pathology were recorded.
Results: Low-risk prostate cancer was identified in 119/212 (56.1%) patients undergoing RALP. Initial diagnostic imaging was performed in 26/119 (21.8%) (15 both CT and NBS, 4 NBS only, 6 CT, and 1 NBS and MRI). Of the low-risk patients, 13/119 (10.9%) had high-volume disease (>50% positive biopsy cores). Ten of (76.9%) of these 13 men did not receive preoperative imaging. Comparing patients with low- and high-volume disease, there was no significant difference in patient selection for obtaining preoperative imaging (P=0.910). Radiographic studies of all 26 patients were negative for metastatic disease. On final pathology, there were 2 (1.7%) pTx, 28 (23.5%) pT2a, 3 (2.5%) pT2b, 79 (66.4%) pT2c, 6 (5.0%) pT3a, and 1 (0.8%) pT3c disease. At a mean follow-up of 15.3±10.9 months, no PSA recurrence has occurred.
Conclusions: Performance of preoperative diagnostic imaging appears not to be necessary in patients with clinical low-risk prostate cancer, as its results rarely alter one's treatment plan.
10.166 Urology
Bladder Neck Preservation with a Running Vesicourethral Anastomosis and Urinary Continence Following Robot-Assisted Laparoscopic Prostatectomy (RALP)
Carson Wong, MD, Kurt Strom, MD, Massimiliano Spaliviero, MD, Xiao Gu, MD
University of Oklahoma Health Sciences Center, USA
Introduction and Objective: Detection of clinically localized prostate cancer subjects men to risk of treatment-related urinary incontinence. We review our post-RALP urinary continence rates.
Methods: Using an anterior approach, a bladder neck sparing dissection was preferentially performed. The urethrovesical anastomosis was completed using a running double-armed 3−0 Monocryl suture±bladder neck tailoring when appropriate. A 20Fr urethral catheter was placed. On POD 5 or 6 (clinic logistics), the catheter was removed following normal cystography.
Results: Included in the study were 161 patients, having a mean age of 62.0±8.1 years and PSA of 6.0±4.6ng/mL. Mean estimated blood loss was 93.0±42.0mL. One (0.6%) patient had bladder neck reconstruction, while 133 (82.6%) had a bilateral and 15 (9.3%) had a unilateral nerve sparing prostatectomy. Mean hospitalization was 1.2±1.0 days, and median urethral catheter duration was 5.0±3.9 days. At 6 weeks, 1.4±1.6 reported pads per day usage. At a mean 9.8±8.2 weeks, 119 (73.9%) patients had achieved urinary continence without pads. Adverse events included 5 (3.1%) prolonged urine leaks, 5 (3.1%) bladder neck contractures, and temporary urinary retention in 8 (5.0%) patients.
Conclusions: Our results suggest that a bladder neck sparing dissection with a running 3−0 Monocryl vesicourethral anastomosis allows for early return of urinary continence without pads in the majority of patients following RALP.
10.167 Urology
Early Ambulation Following Robot-Assisted Laparoscopic Prostatectomy (RALP): Is Pharmacologic Thromboembolic Prophylaxis Necessary?
Kurt Strom, MD, Massimiliano Spaliviero, MD, Xiao Gu, MD, Carson Wong, MD
University of Oklahoma Health Sciences Center, USA
Introduction and Objective: Some centers use routine pharmacologic deep venous thrombosis (DVT) and pulmonary embolism (PE) prophylaxis for major surgery, starting therapy prior to intubation. We review our RALP experience in which patients routinely ambulate hours after surgery, focusing on the incidence of DVT and PE.
Methods: Preoperative ted stockings and sequential compression devices (SCD) were provided. Following RALP and transfer to a surgical ward, patients were instructed to ambulate with assistance twice before bedtime the day of surgery. Normal ambulation without assistance resumed on postoperative day 1. Pharmacologic antithrombotic therapy was not administered routinely unless requested by a consulting physician. Rates of common complications associated with immobility were examined.
Results: Included in the study were 161 patients, having a mean age of 62.0±8.1 years, ASA of 2.2±0.5, and BMI of 28.3±3.9 kg/m². The mean operating room time was 213.0±54.0 minutes, and hospitalization was 1.2±1.0 days. The median urethral catheter duration was 5.0±3.9 days. Adverse events included 2 (1.2%) DVT and 0 (0.0%) PE. Antiplatelet therapy was withheld 10 days prior to surgery in one of the DVT patients.
Conclusions: These results suggest that prophylactic pharmacologic intervention may not be required for DVT and PE prophylaxis when ted stockings, SCDs, and early ambulation are used.
10.168 Urology
Baseline Sexual Health Inventory for Men (SHIM) Predictive of Erectile Function Following Robot-Assisted Laparoscopic Prostatectomy (RALP)
Massimiliano Spaliviero, MD, Kurt Strom, MD, Xiao Gu, MD, Carson Wong, MD
University of Oklahoma Health Sciences Center, USA
Introduction and Objective: Preoperative erectile function and age are powerful predictors of erectile function following surgical treatment of clinically localized prostate cancer. We determine whether baseline SHIM is predictive of erectile function following nerve-sparing RALP.
Methods: Consecutive patients who underwent transperitoneal RALP by a single surgeon (CW) were reviewed. Using an anterior approach, a bladder neck sparing procedure was preferentially performed. Bilateral/unilateral nerve-sparing prostatectomy was performed when appropriate. Penile rehabilitation [phosphodiesterase−5 (PDE−5) inhibitor, and vacuum erection device (VED)] was offered to all patients. SHIM was obtained at baseline and q3 months up to 24 months postsurgery.
Results: The study included 161 consecutive patients, of whom 148(91.9%) underwent nerve-sparing prostatectomy [133(82.6%) bilateral; 15(9.3%) unilateral]. Of those undergoing nerve-sparing prostatectomy, 112/148 (75.7%) had penile rehabilitation. The mean baseline SHIM of patients with nerve-sparing prostatectomy and penile rehabilitation was 16.5±8.0. Of the 112 patients, 41(36.6%) had baseline SHIM<15 (7.4±4.5), and 71/112 (63.4%) patients had baseline SHIM≥15 (22.0±3.2). In comparing these patient groups, postoperative SHIMs were similar until the 6-month follow-up interval, where they diverged significantly. Those with a preoperative SHIM≥15 showed significantly greater improvement in erectile function versus those with a preoperative SHIM<15.
Conclusions: Preoperative SHIM is a useful tool in predicting postoperative erectile function in men undergoing RALP with unilateral and bilateral nerve-sparing plus penile rehabilitation therapy.
10.169 Urology
Robot-Assisted Laparoscopic Prostatectomy (RALP): Initial Single Surgeon Series
Carson Wong, MD, Kurt Strom, MD, Massimiliano Spaliviero, MD, Xiao Gu, MD
University of Oklahoma Health Sciences Center, USA
Introduction and Objective: RALP is a relatively new procedure for the treatment of clinically localized prostate cancer. We report our experience.
Methods: Using an anterior approach, we performed a bladder neck sparing RALP. Clinical outcomes and adverse events were analyzed.
Results: The study included 161 patients, having a mean PSA of 6.0±4.6ng/mL. Clinical stage included 151 (93.8%) T1c and 10 (6.2%) T2a, having a mean Gleason score of 6.5±0.8. Average blood loss and hospital duration were 93.0±42.0mL and 1.2±1.0 days, respectively. Of the 161 study patients, 133 (82.6%) had bilateral, 15 (9.4%) had unilateral, and 13 (8.0%) did not undergo nerve-sparing prostatectomy. The urethral catheter was removed at a median 5.0±3.9 days. At a mean 9.8±8.2 weeks, 119 (73.9%) patients had achieved urinary continence without pads. In this study, 112/148 (75.7%) patients had bilateral/unilateral nerve-sparing prostatectomy and postsurgery penile rehabilitation [phosphodiesterase−5 inhibitor ± vacuum erection device (VED)]. Seventy-one of 112 (63.4%) patients had a preoperative SHIM≥15, of whom 37/71 (52.1%) reported sexual potency. Two (1.2%) pTx, 24 (14.9%) pT2a, 7 (4.4%) pT2b, 106 (65.9%) pT2c, and 22 (13.6%) pT3 cancers were reported, patients having a mean prostate volume of 42.5±12.7mL. Adverse events included 5 (3.1%) prolonged urine leaks, 3 (1.8%) pelvic hematomas, 1 (0.6%) urinary tract infection, 2 (1.2%) deep vein thromboses, and 5 (3.1%) bladder neck contractures.
Conclusions: RALP is an effective treatment option for clinically localized prostate cancer with low patient morbidity.
10.170 Urology
Is Prostate Cancer Pathology Following Robot-Assisted Laparoscopic Prostatectomy (RALP) Accurately Predicted by Transrectal Ultrasonographic (TRUS) Guided Biopsy Specimens?
Massimiliano Spaliviero, MD, Kurt Strom, MD, Xiao Gu, MD, Carson Wong, MD
University of Oklahoma Health Sciences Center, USA
Introduction and Objective: Discrepancy between Gleason grade on TRUS biopsy and final pathology may impact management disposition of clinically localized prostate cancer. Pathologic upgrading and downgrading occurs in 20% to 40% and 10% to 20% of cases, respectively. We review the findings in our cohort of RALP patients.
Methods: Consecutive patients who underwent transperitoneal RALP were reviewed. TRUS guided biopsy specimens and final prostate pathology were compared.
Results: Included in the study were 161 patients. At baseline, their mean age was 62.0±8.1 years, body mass index (BMI) was 28.3±3.9 kg/m2, PSA was 6.0±4.6ng/mL, and TRUS volume was 41.9±13.4mL. The mean number of biopsy cores sampled was 12.3±5.9. Clinical stage included 151 (93.8%) T1c and 10 (6.2%) T2a, and mean Gleason score was 6.5±0.8. Of the study patients, 133 (82.6%) had bilateral, 15 (9.4%) had unilateral, and 13 (8.0%) did not undergo nerve-sparing prostatectomy. Two (1.2%) pTx, 24 (14.9%) pT2a, 7 (4.4%) pT2b, 106 (65.9%) pT2c, and 22 (13.6%) pT3 cancers were reported. Mean prostate volume was 42.5±12.7mL. The mean Gleason score was 6.4±0.9. Positive surgical margins overall were present in 29(18.0%) patients. Upgrading on final pathology occurred in 23 (14.2%), downgrading in 25 (15.6%), and 113 (70.2%) prostate specimens remained unchanged.
Conclusions: Our incidence of pathologic upgrading and downgrading following RALP is consistent with that reported in the literature. Whether a TRUS guided biopsy specimen will change on final pathologic evaluation appears to be difficult to predict preoperatively.
10.171 Urology
Comparing the da Vinci SI™ and da Vinci S™ Robot Surgical Systems
Carson Wong, MD, Kurt Strom, MD, Massimiliano Spaliviero, MD, Xiao Gu, MD
University of Oklahoma Health Sciences Center, USA
Introduction and Objective: Recently, the da Vinci Si™ (Intuitive Surgical, Sunnyvale, CA) was introduced, having enhanced features compared with its predecessors. We review these enhancements and contrast them with features of the da Vinci S™ system.
Methods: The novel features of the da Vinci Si™ model are highlighted.
Results: Both the da Vinci Si™ and S™ systems offer 3D vision with up to 10x magnification with either 0° or 30° endoscopes; motion scaling with tremor filtration; 7° of freedom, 180° articulation, and 540° rotation in the arms; 5-mm and 8-mm platforms; multiple instruments and a height-adjusting console. Unique features of the da Vinci Si™ system include the option of 2 consoles, offering the capability for surgeon and trainee exchange of one or more instruments and the endoscope to facilitate training. In addition, the potential for dual surgeon robot-assisted procedures is introduced. The multi-axis adjustable console gives ergonomic tailoring for each individual surgeon. Fingertip controls of the console allow seamless master repositioning and control of camera focus and zoom, while touch pad controls complete the system integration. The 3D high-definition (1080i per eye) visual system improves vertical digital image resolution.
Conclusions: These enhancements make the da Vinci Si™ the first fully integrated 3D high-definition robot surgical system. It has the potential for greater ease of use, improved surgeon training, and expansion of robot-assisted surgery.
10.173 Gynecology
Laparoscopic Major Gynecologic Surgery in Patients with Prior Laparotomy Bowel Resection
Fanning, DO, Rod Hojat, MD, Timothy Deimling, MD
Penn State College of Medicine, USA
Objective: To review the success and morbidity of laparoscopic major gynecologic surgery in patients with prior laparotomy bowel resection.
Methods: This study is a review of a prospective surgical database of all cases of laparoscopic major gynecologic surgery in patients with prior laparotomy bowel resection. No cases were excluded. Bowel diagnosis and procedure were total colectomy for inflammatory bowel disease (3), partial colectomy for colon cancer (2), partial small bowel resection for obstruction (1). Gynecologic diagnosis and procedure were laparoscopic cytoreduction for ovarian cancer (1), lavh/bso/nodes for endometrial cancer (2), lavh/bso or bso for large ovarian mass (3). Median patient age was 57 years, median BMI was 31kg/m2, and all patients had medical comorbidities.
Results: All 6 laparoscopic gynecologic surgeries were successful without conversion to laparotomy and without enterotomy. Abdominal/pelvis adhesions were present in all cases. Median operative time was 2 hours, median blood loss was 100cc, and median hospital stay was 1 day. No postoperative complications occurred.
Conclusions: Laparoscopic major gynecologic surgery in patients with prior laparotomy bowel resection is feasible for experienced laparoscopic surgeons.
10.174 General Surgery
Laparoscopic Distal Pancreatectomy
Sebastiano Lacitignola, MD, Martino Minardi, MD, Anselmo Rosellini, MD
Department of General Surgery, Martina Franca Hospital
Background: Laparoscopic pancreatic surgery has been slow to gain wide acceptance due to the complex anatomy and physiology of the pancreas. Advanced laparoscopic techniques have been adapted to various surgical pathologies, including pancreatic tumors, with the potential benefits of attenuated surgical trauma, faster recovery, and improved cosmesis. The aim of this presentation was to review our experience of laparoscopic left pancreatectomy to establish the feasibility of this approach and the characteristics of the operating procedure.
Methods: Twenty-three patients with benign and malignant pancreatic tumors who underwent laparoscopic distal pancreatectomy in our department of surgery between 2000 and 2009 were studied. Preoperative diagnoses were 11 serous cystoadenoma, 7 mucinous cystoadenoma, 1 endocrine tumor, 3 pseudocysts, and 1 noninvasive mucinous cystadenocarcinoma. Intraoperative and postoperative data were recorded.
Results: Laparoscopic distal pancreatectomy was attempted in all patients and successfully completed laparoscopically in 100% of them. Operative mortality was nil, and one (4.3%) patient required reoperation laparoscopically for abdominal abscesses. The spleen was preserved in 19 patients (82.6%). Postoperative course was uneventful in 19 patients. Minor complications included 1 trocar bleeding and 2 pancreatic fistulas resolved conservatively. Major complications were 1 pancreatic fistula CT drained and 1 abdominal abscess that required reoperation by laparoscopy. Length of stay ranged from 5 days to 25 days.
Conclusion: These preliminary results confirm that in select cases laparoscopic resection of the left pancreas is feasible and safe. However, laparoscopic surgery for malignant pancreatic tumors remains controversial.
10.176 General Surgery
A Metaanalysis Comparing Open with Minimally Invasive Gastric Bypass for the Treatment of Obese Patients
M.R.S. Siddiqui, MRCS, H. Ali, FRCS, A. Nisar, FRCS, A. Zaborszky, FRCS, F. Hasan, FRCS
Benenden Hospital, Cranbrook, United Kingdom (Drs. Siddiqui, Hasan, Zaborszky). Maidstone Hospital, Maidstone, United Kingdom (Drs. Ali, Nisar).
Objectives: A metaanalysis of published literature comparing open gastric bypass (OGBY) with minimally invasive gastric bypass (MiGBY).
Methods: Electronic databases from January 1993 to January 2010 were searched. A metaanalysis was performed to obtain a summation of the outcomes.
Results: Four randomized controlled trials involving 360 patients were analyzed; 173 patients were in the OGBY group, and 187 in the MiGBY group. OGBY took less time to perform than MiGBY did [random effects model: SMD=-1.46, 95% CI (-2.78, -0.15), z=2.18, df=3, P=0.03], but there was significant heterogeneity amongst trials (Q=81.8, P<0.001, I2=96%). There was no significant difference in bleeding (P=0.30), morphine use (P=0.64), or anastomotic leak rates (P=0.85) between OGBY and MiGBY. Patients undergoing MiGBY were more likely to return to work earlier [random effects model: SMD=0.93, 95% CI (0.33, 1.53), z=3.04, df=2, P=0.03] and approached a significant difference in relation to shorter hospital stays (P=0.07). Interestingly patients undergoing MiGBY had a greater weight reduction compared with those undergoing OGBY [random effects model: SMD=-0.53, 95% CI (-1.02, -0.03), z=2.10, df=2, P=0.04]; however, there was significant heterogeneity between trials (Q=6.28, P<0.05, I2=68%).
Conclusions: MiGBY is a safe and effective alternative to OGBY. It has the additional advantage of shorter hospital stays and earlier return to work. OGBY still remains quicker to perform. Some evidence suggests that MiGBY may lead to greater weight reduction; however, more randomized controlled trials are required to confirm this finding.
10.179 General Surgery
Single-Incision Laparoscopic Appendectomy is Feasible and Cost Effective Using Off-the-Shelf InstrumentsBenjamin Clapp, MD, Jarrett Howe, MD
Providence Memorial Hospital, El Paso, Texas, USA (Dr. Clapp); Texas Tech School of Medicine at El Paso, Texas, USA (Dr. Howe).
Objective: Single-incision laparoscopic surgery (SILS) is becoming more common and is being applied to a wide range of laparoscopic operations. SILS techniques are readily applied to laparoscopic appendectomy. There are many products, such as SILS ports, that are being offered to surgeons, ostensibly to make the SILS technique easier. We hypothesize that the SILS approach in appendectomy does not need any special equipment.
Methods: Ten consecutive SILS appendectomies were performed. In all cases, off-the-shelf, straight laparoscopic instruments were used. A 30-degree 5-mm laparoscope was used. A 15-mm vertical umbilical incision was utilized to place two 5-mm ports and a 12-mm port. Data collected prospectively and reviewed included operative times, patient demographics, estimated blood loss (EBL), and appendiceal pathology.
Results: Eight of the 10 patients underwent a SILS appendectomy, while 2 patients had one additional port added. There were 5 females, and the average age was 35.5. The average operative time was 32 minutes (range, 9 to 56). EBL was minimal.
Conclusions: In no case was a specifically designed SILS port or access device used. All cases were completed successfully with off-the-shelf instruments. The devices currently being marketed as SILS access ports can add $500 or more to a case. We feel these devices are costly and unnecessary.
10.180 General Surgery
Does the Patient’s Distance from the Surgeon Impact Weight Loss After Bariatric Surgery?
Saber Ghiassi, MD, MPH, Dan Eisenberg, MD, MS
Department of Surgery, Stanford School of Medicine and VA Palo Alto Health Care System, Palo Alto, California, USA.
Introduction: The impact of travel distance between patient and surgeon on weight loss after bariatric surgery has not been well studied. We assess the relationship between travel distance and excess weight loss (EWL) after laparoscopic adjustable gastric band (LAGB) and gastric bypass (RYGB).
Methods: We performed a retrospective review of patients who had LAGB or RYGB at the Palo Alto VA Health Care System from 2001 to 2007. Travel distance between place of residence and the hospital was calculated by using zip codes. The relationship between percentage EWL and travel distance was evaluated using Pearson’s Correlation Coefficient (r).
Results: Twenty patients underwent LAGB (29% EWL at one year, mean distance 59 miles). There was a negative but not significant correlation between travel distance and percentage EWL (r =-0.367, P=0.10). The RYGB group included 106 patients (69% EWL, mean distance 425 miles). There was no correlation between travel distance and percentage EWL in these patients (r =-0.067). However, in a subgroup of 14 RYGB patients who lived beyond 1000 miles from the hospital, there was a significant negative correlation between distance and percentage EWL (71% EWL, mean distance 2199 miles, r =-0.711, P=0.004)
Conclusion: A negative correlation exists between travel distance and EWL in LAGB and RYGB patients who live >1000 miles from the hospital. These data may help in counseling patients regarding the appropriate weight loss procedure and expected outcomes.
10.182 Gynecology
Effect of Different Types of Pneumoperitoneum on the Ultrastructure of the Extraperitoneal Muscular Tissues in Rats
Liu Haifang, MD, PhD, Chen Xu, MD, PhD, Liu Yan, Prof, et al.
Department of Obstetrics and Gynecology, Changzheng Hospital, Second Military Medical University, Shanghai, China
Objective: To investigate the influence of different types of pneumoperitoneum on the ultrastructure of the extraperitoneal muscular tissues in rats.
Method: By using pulse-mode or constant-pressure mode insufflators, we established CO2 pneumoperitoneum in 80 rats (40 for each) with the pressure set at 15mm Hg. At 60, 90, 120, and 180 minutes after the insufflation, the muscular tissues below the peritoneum of the rats (10 rats at each time point) were obtained to observe the ultrastructure change under a transmission electron microscope (TEM). Ten rats that received anesthesia only were used as a control group.
Results: In both groups, vacuolar degeneration was found in the myocytes below the peritoneum after 60 minutes of pneumoperitoneum and became more and more marked with time. Moreover, the phenomenon was more significant in the pulse-mode insufflator group, in which we observed widened gaps and vacuoles among the myocytes at 180 minutes after the insufflation, while in the other group such changes were not apparently detected.
Conclusions: CO2 pneumoperitoneum may injure the muscular tissues below the peritoneum in rats. Constant-pressure mode insufflator may be helpful to decrease such an injury.
10.183 General Surgery
Natural Orifice Transluminal Endoscopic Surgery: A New Transvesical Technique in a Porcine Model
Jasneet Singh Bhullar, MD, Gokulakkrishna Subhas, MD, Aditya Gupta, Jonathan Cook, Michael J. Jacobs, MD, Boris Silberberg, MD, Lee Andrus, LVT, Melissa Decker, LVT, Vijay K. Mittal, MD, FACS
Department of Surgery, Providence Hospital and Medical Center, Southfield, Michigan, USA (Drs. Bhullar, Subhas, Gupta, Cook, Jacobs, Mittal).
Department of Patient Care Research, Providence Hospital and Medical Center, Southfield, Michigan, USA (Drs. Silberberg, Amdrus, Decker).
Objective: The optimal access route and method for NOTES has not been established. A transvesical approach is an effective clean portal of entry with its low rate of peritoneal contamination, but a safe urinary bladder closure has been a challenge. We developed a new technique for a safe, pure transvesical NOTES approach.
Methods: Four female piglets were used in the study. With the pigs under anesthesia, a flexible cystoscope (15Fr) was used to make an endoscopic cystotomy; diagnostic peritoneoscopy of the abdominal quadrants was done with biopsies and hemostasis. At the end, a Vicryl loop was pushed to close the bladder incision while the incision edges were pulled inwards. The pigs were euthanized after 2 weeks, and necropsies were performed.
Results: No bowel injury was noted in any of the 4 pigs. Satisfactory bladder closure was done in 2 pigs, while a partial closure was achieved in one case. In the postoperative period, none of the pigs showed any signs of pain or distress, voided normally, and had a good appetite. On necropsy, we noted no intraabdominal adhesions, healed cystotomy incision, and no adhesions at the site.
Conclusion: Our new technique for endoscopic cystotomy overcomes previously reported risks for bowel injuries. Using this route gives good spatial orientation and access to all quadrants including the pelvis. Biopsies with good hemostasis can be easily achieved. Endoscopic bladder closure by the described technique has not been previously reported. No postoperative intraperitoneal changes prove that this route is a safe and easy access that can be used in humans for similar procedures.
10.184 Gynecology
A Modified Open Trocar First-Puncture Technique in Gynecologic Laparoscopy: Multicenter Trials of 23 000 Cases
Haifang Liu, MD, PhD, Xu Chen, MD, PhD, Yan Liu, Prof
Department of Obstetrics and Gynecology, Shanghai Changzheng Hospital
Objective: To evaluate the safety of a modified open trocar first-puncture technique.
Methods: Clinical data for 23 000 cases of open trocar first-puncture of laparoscopic surgery (study group) and 10 240 cases using Veress needle puncture (control group) between 1998 and 2007 were analyzed (Shanghai, China). A total of 84 experienced laparoscopists and 271 learners performed the open trocar first-puncture developed by Professor Yan Liu. The method was that the full-thickness skin and umbilical peritoneum were cut open, and then the trocar was inserted directly into the abdominal cavity without any tissue resistance.
Results: Of the 23 000 cases using the modified open trocar first-puncture, “success” was achieved in 21 866 cases, and “not smooth” in 550 cases, with an overall achievement rate of 97.5%, which was significantly higher than that of the control group (90.2%). The difference of the mean achievement rate in the modified open trocar first-puncture was 2.9% versus 10.6% in the control group. Cutaneous emphysema and vascular injury to the omentum majus occurred in 56 and 2 cases of the study group versus 216 and 21 in the control group.
Conclusions: Compared with Veress needle puncture, the modified open first-puncture method significantly increased the achievement rate and reduced the risks of injuries. It is safe, effective, and easy to grasp, especially for learners of laparoscopic surgery.
10.185 General Surgery
Laparoscopic Colorectal Resection in Patients >70 Years Old: Prospective Study
Ivo Baca, MD, PhD, Khaled El Zarrok Elgazwi, MD, PhD
Klinik für Allgemein-und Viszerlalchirurgie. Klinikum Bremen-Ost, Bremen, Germany
Background: The number and proportion of patients aged ≥70 years are increasing. These patients often require special surgical care. The aim of this prospective study was to examine the feasibility and safety of laparoscopic colorectal resection for colorectal malignancies in patients >70 years of age.
Method: Patients aged ≥70 who had colorectal resection from April 1995 through December 2008 were included. Data concerning age, sex, comorbid diseases, details of the operations, stage of the disease, and postoperative events were collected prospectively.
Results: Included in the study were 211 patients who had laparoscopic colectomy during the study period; 91 were males 114 were females. Median ages were 78±5 years. Median operative time was 135±40 minutes, and mean hospital stay was 10±2 days. Conversion to open surgery occurred in 6 patients. Rectum resections were necessary in 64 patients, right hemicolectomy in 52, transverse colectomy in 8, left hemicolectomy in 12, and sigmoidectomy in 69. Mortality rate was 4%, and morbidity rate was 18%, divided into surgical complications as follows: postoperative bleeding (3), wound infection (7), anastomotic leak (8), and medical conditions like heart and lung complications (3). Laparoscopic resection was associated with earlier return of bowel function (3 days) and earlier resumption of a solid diet (3 to 4 days).
Conclusions: Laparoscopic colorectal resection is technically feasible, can be done safely in elderly patients, and is associated with more favorable short-term outcomes in terms of earlier return of bowel function, earlier resumption of solid food, and a shorter hospital stay. It is also associated with less cardiopulmonary morbidity.
10.186 Gynecology
Do More Punctures per Ovary During Laparoscopic Ovarian Drilling Improve
Reproductive Outcomes?
Fahimeh Ramezani Tehrani, Abbas Moieni
Endocrine Research Center, Shahid Beheshti
University of Medical Sciences, Tehran, Iran
Objective: The aim of the present study was to compare the efficacy of a
different number of punctures per ovary in laparoscopic ovarian drilling (LOD)
on the endocrinologic, clinical parameters, and reproductive outcomes of
clomiphene-resistant anovulatory infertile PCOS patients.
Methods: Eighty-nine women with polycystic ovary syndrome (PCOS) who were
clomiphene-citrate-resistant underwent laparoscopic ovarian drilling. They were
randomized into 2 groups: Group 1 (n=47) - 6 punctures per ovary; Group 2 (n=42)
- 10 punctures per ovary. Their hormonal profile, clinical data, and
reproductive outcomes were recorded over the next 2 years.
Results: No significant difference existed in hormonal profile, reproductive
history, and clinical data between these 2 groups at the initiation of the
study. After laparoscopic ovarian drilling, the reproductive outcomes
(percentage of subjects with spontaneous regular menstrual bleeding, ovulation,
and pregnancy) were similar in the 2 groups. Serum testosterone and insulin
were decreased after the procedure in both groups; however, the rate of decline
in Group 2 (10 puncture per ovary) was significantly greater than the decline
in Group 1.
Conclusion: The increased number of punctures per ovary does not improve the
reproductive outcomes of clomiphene-citrate-resistant women with PCOS; however,
it may ameliorate the insulin resistance and hyperandrogenic status of these
women.
10.187 General Surgery
Laparoscopic Repair of Parastomal Hernias
C.T. Frantzides, MD, PhD, G.D. Ayiomamitis, MD, J.R. Glover, MD, S.N. Welle, DO
Department of Surgery, University of Illinois, Chicago Institute of Minimally Invasive Surgery, Skokie, Illinois
Introduction: The purpose of this study was to review our experience with the laparoscopic repair of parastomal hernias.
Methods: Six patients with symptomatic parastomal hernias underwent laparoscopic repair with e-PTFE mesh. Two patients had an ileostomy following total proctocolectomy for the treatment of ulcerative colitis, and 4 patients had colostomies after abdominoperineal resection. In all patients, a single piece of Gore-Tex Dual Mesh with a slit to accommodate the stoma was used. Demographics, operative time, postoperative complications, and hernia recurrences were recorded retrospectively.
Results: The median operating time was 130 minutes (range, 72 to 198). The median postoperative length of stay was 1.7 days (range, 1 to 4). No intraoperative or postoperative complications occurred. No recurrences developed in a median follow-up period of 4 years.
Conclusion: Laparoscopic repair of parastomal hernia is a safe and feasible technique with all the advantages of minimally invasive surgery.
10.188 General Surgery
Postsplenectomy Portal Vein Thrombosis: Personal Experience and Review of the Literature
Vecchio Rosario, MD, Intagliata Eva, MD, Leanza Vito, MD, Marchese Salvatore, MD, Cacciola Emma, MD
Department of General Surgery, University of Catania, Catania, Italy (Drs. Rosario, Eva, Salvatore).
Department of Gynecology, University of Catania, Catania, Italy (Dr. Vito).
Department of Biomedical Science, Section of Haematology, University of Catania, Catania, Italy (Dr. Emma).
Objective: Portal vein thrombosis can be a life-threatening complication of splenectomy if not diagnosed in time and treated properly. The actual incidence of postsplenectomy portal system thrombosis is not clearly determined, ranging between 0.7% and 80%. In this series, we report the incidence and therapeutic strategies.
Methods: Between 1993 and 2008, 162 patients underwent laparoscopic splenectomy for hematologic disease. The main indication was idiopathic thrombocytopenic purpura (106 patients). Portal vein thrombosis was evaluated clinically and diagnosed by using abdominal computed tomography.
Results: Clinically evident portal vein thrombosis has been diagnosed in 4 patients, 3 of them treated by laparoscopic splenectomy. Treatment of these patients was successfully obtained by conservative therapy with high-dose heparin for at least 3 weeks.
Conclusions: Laparoscopy might increase the risk of the development of portal vein thrombosis, because it reduces blood flow in the portal system veins due to pneumoperitoneum. However, it seems to be associated with fewer intraoperative and postoperative modifications of coagulation and fibrinolytic parameters than open surgery is, which might prevent, on the other hand, portal vein thrombosis. Hematologic diseases and greater spleen weight are recognized potential risk factors for portal vein thrombosis, whose incidence proportionally increases with the enhancement of the dimensions of the spleen. Anticoagulation therapy treatment for 3 weeks after splenectomy was successful in all patients. According to authors’ experience, postoperative surveillance for portal vein thrombosis is mandatory in splenectomized patients at high risk. Perioperative thrombotic prophylaxis should be considered in select patients.
10.189 General Surgery
Laparoscopic Splenectomy in Pediatric and Teen-Aged Patients: Authors’ Experience
Vecchio Rosario, MD, Marchese Salvatore, MD, Gelardi Valentina, MD, Intagliata Eva, MD, Cacciola Emma, MD
Department of General Surgery, University of Catania, Catania, Italy (Drs. Rosario, Salvatore, Valentina, Eva).
Department of Biomedical Science, Section of Haematology, University of Catania, Catania, Italy (Dr. Emma).
Background: Pediatric surgery is now in the forefront of minimal access procedures. Although pediatric surgeons have been skeptical about laparoscopic splenectomy, recently the minimally invasive approach for spleen removal has been re-evaluated also in young patients. The purpose of this study was to report our personal experience in patients <18 years of age who underwent laparoscopic splenectomy. Results of the procedure were evaluated.
Methods: A retrospective review was undertaken of 18 splenectomized patients <18 years of age. Indications were hereditary spherocytosis in 10 patients, β-thalassemia in 4, idiopathic thrombocytopenic purpura in 3, and a splenic cyst in 1 child.
Results: No intraoperative complications occurred. No conversion to open surgery was reported. During the follow-up, one case of portal vein thrombosis, treated by medical therapy, was encountered, and no other postoperative complications were observed.
Conclusions: The laparoscopic approach is preferable for all children undergoing spleen surgery. In experienced hands, it has beneficial effects and a very reasonable complication rate.
10.190 Gynecology
Single Port Total Laparoscopic Hysterectomy: Is It Here to Stay?
Stefanos Chandakas, MD, MBA, PhD
Iaso Group of Hospitals, Athens, Greece
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 (SP) total laparoscopic hysterectomy.
Methods: This was a retrospective, descriptive, nonrandomized study, conducted at Iaso Hospital, Athens, Greece. Five patients underwent SP total laparoscopic hysterectomy between October 2008 and January 2010. Indications included 85% dysmenorrhoea and 15% large fibroid uteri.
Results: The duration of the operation and hospital stay, safety (morbidity and mortality), and patient satisfaction were assessed. Estimated blood loss was 120mL (range, 165 to 300). Intraoperative complications were 0% vascular injuries and 0% nerve or ureter injuries. Early postoperative morbidity included no major complications, 0% bladder infection and dysfunction, and 0.1% incision infection. Fifty-five percent of patients were discharged to home the same day, with an average length of stay for these patients of 11 hours.
Conclusion: Single port total laparoscopic hysterectomy seems to be a safe alternative to traditional laparoscopy. Surgical time, safety, and feasibility were similar, as were the cosmetic results, and the postoperative pain levels seem to be better accepted by the female patient.
10.191 Gynecology
Single Port Laparoscopy in Gynecology: A Series of 55 Cases
Stefanos Chandakas, MD, MBA, PhD
Iaso Group of Hospitals and Attikon University Hospital, Athens, Greece
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 conducted at Iaso Hospital and Attikon University Hospital, Athens, Greece. Between October 2008 and January 2010, 55 patients underwent SPL surgery. Indications included 62% salpingo-oophorectomy, 17% diagnostic laparoscopy and treatment of stage 1/3 endometriosis, 12% cystectomy, and 9% hysterectomy.
Results: Duration of surgery and hospital stay, safety (morbidity and mortality), and patient satisfaction were assessed. Estimated blood loss was 65mL (range, 10 to 300). Intraoperative complications were 0% vascular injuries and 0% nerve or ureter injuries. Early postoperative morbidity included no major complications, 0.05% bladder infection and dysfunction, and 0.1% incision infection. Eighty-nine percent of patients were discharged to home the same day with an average length of stay of 11 hours.
Conclusion: Single port laparoscopic surgery seems to be a safe alternative to traditional laparoscopy for the procedures performed in this study. Surgical time, safety, and feasibility were similar, as were the cosmetic results, 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 be able to perform more complicated cases.
10.192 Gynecology
A Comparison of Radical Hysterectomy for Early Stage Cervical Cancer: Laparoscopy versus Laparotomy
Sarah E. Taylor, MD, William C. McBee Jr., MD, Scott D. Richard, MD, Robert P. Edwards, MD
Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
Objectives: Gynecologic oncologists have recently begun using laparoscopic techniques to treat early stage cervical cancer. For treatment of this disease, we evaluated a single institution’s experience with laparoscopic radical hysterectomy and staging compared with laparotomy.
Methods: Stage IA2 and IB1 cervical cancer patients who underwent laparoscopic radical hysterectomy and pelvic lymph node dissection from July 2003 to August 2009 were identified. A 2:1 cohort of patients treated with laparotomy were matched by stage. Statistical analysis utilized a chi-square or t test where appropriate, with significance at P<0.05.
Results: Nine laparoscopic patients (3 stage IA2, 6 stage IB1) with 18 matched controls (6 and 12) were identified. Average age was 41.4 vs. 41.1 years (P=0.648); average BMI was 26.3 vs. 26.9 kg/m2 (P=0.768). Four laparoscopic patients and 7 laparotomy patients had adenocarcinoma. None had positive margins or lymph nodes. An average of 11.2 (range, 5 to 18) vs. 13.9 (range, 6 to 24) pelvic lymph nodes (P=0.237) were removed. Average operating time was 231.7 vs. 207.2 minutes (P=0.434), and the average estimated blood loss was 161.1 vs. 394.4cc (P=0.059). Average length of stay was 2.9 vs. 5.5 days (P=0.012). No transfusions or operative complications were noted in the laparoscopic group vs. 3 each in the open group (P=0.194). No laparoscopic patients and 5 open patients had a postoperative wound infection (P=0.079). One laparoscopic patient and 4 open patients required adjuvant radiation (P=0.484).
Conclusions: Laparoscopic radical hysterectomy is a feasible alternative to laparotomy for early stage cervical cancer. Similar surgical outcomes are achieved with significantly less morbidity.
10.193 Gynecology
Single Incision Laparoscopic Surgery for Adnexal Pathology
Jessica Ybanez-Morano, MD, MPH
Objective: Innovations in various laparoscopic approaches have allowed significant advances in the field of gynecology. By using a single incision laparoscopic surgery technique, complex cases have been managed and have resulted in improved hospital stay, minimized convalescent time, and greater patient satisfaction.
Methods: Single incision laparoscopic surgery using the umbilicus has been used to accomplish various procedures. These 2 videos depict the ability to address 2 common adnexal pathologies encountered in a gynecological practice using this approach. The first video reviews the management of a morbidly obese female with a benign-appearing 10-cm mass. A unilateral oophorectomy was indicated. This was accomplished laparoscopically via a single umbilical incision. The second video is of a single incision laparoscopic-assisted vaginal hysterectomy with the patient noted to have previous adnexal surgery, an enlarged right ovarian cyst, and a third-degree procidentia. Although the patient had a small prolapsed uterus, a vaginal hysterectomy alone would not assure intervention of potential adnexal complications. The single incision laparoscopy allowed adnexal adhesions to be readily visualized and easily dissected. Furthermore, the ovarian cysts were removed with no subsequent complications.
Results: The patients stayed overnight for observation and were discharged to home the following day. Both returned to work in <2 weeks and had minimal scars with the umbilical incision of <2cm in length.
Conclusion: Single incision laparoscopy has improved the patients’ stay with overnight observation admission and 1- to 2-week recovery at home. The patients have a single 1-cm to 2-cm scar, well hidden in the umbilical folds.
10.194 Gynecology
Acute Necrosis Following Endometrioma Vaporization by Plasma Energy is Not Harmful to Underlying Ovarian Tissue
Horace Roman, MD, PhD, Oana Tarta, MD, Ioana Pura, MD, Nicolas Bourdel, MD, Loïc Marpeau, MD, Jean Christophe Sabourin, MD, PhD
Department of Gynecology and Obstetrics, Department of Pathology, Rouen University Hospital, and Department of Gynecology, Obstetrics and Reproductive Biology, Clermont Ferrand University Hospital, France
Objective: To evaluate whether vaporizing ovarian endometriomas with plasma energy allows for the complete ablation of the inner layer of the endometrioma (endometrial epithelium and stroma) without extending beyond the outer layer of the cyst (fibrotic tissue).
Methods: We conducted a pilot study in a series of 10 consecutive ovarian endometriomas requiring surgical management. Plasma energy was used to vaporize the inner layer of the cyst wall, consisting of the endometrial epithelium and stroma. Histological specimens were obtained after complete vaporization of the cyst followed by cystectomy.
Results: Vaporization generates a local acute necrosis of the endometrial epithelium and stroma, which usually does not exceed the thickness of the fibrosis surrounding the endometrial tissue. The mean area of the necrosis on one section was 9.9mm² (SD, 3.3mm²), while the mean area of the endometrioma cyst wall was 30.6mm² (SD, 9.9mm²), giving a necrosis/cyst wall ratio of 0.32±0.05. Less than 5% of intact endometrial epithelium was recorded in only one case. Small areas of necrosis concerned <10% of ovarian parenchyma inadvertently excised during cystectomy in 5 cases, and 20% to 30% in 5 other cases.
Conclusion: As the ablation of endometrial tissue is complete in most cases, and only small areas of underlying ovarian parenchyma were involved by the necrosis, our data suggest that vaporization using plasma energy warrants further evaluation as a treatment of ovarian endometriomas, and that it is probably free of harmful effects on the ovarian parenchyma.
10.195 Gynecology
The Safety and Efficacy of Laparoscopic Surgical Staging and Debulking of Apparent Advanced Stage Ovarian, Fallopian Tube, and Primary Peritoneal Cancers
Farr R. Nezhat, MD, Shaghayegh M. DeNoble, MD, Connie S. Liu, MD, Jennifer E. Cho, MD, Douglas N. Brown, MD, Linus Chuang, MD, Herbert Gretz, MD, Prakash Saharia, MD
Columbia University Department of Obstetrics and Gynecology, Division of Gynecologic Oncology and Minimally Invasive Surgery, Department of Obstetrics and Gynecology, St. Luke's-Roosevelt Medical Center, New York, New York, USA (Drs. Nezhat, DeNoble, Cho, Brown).
Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, New York, USA (Dr. Liu).
Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Science, The Mount Sinai Medical Center, New York, New York, USA (Drs. Chuang, Gretz).
Department of General Surgery, Winthrop University Hospital, Mineola, New York, New York, USA (Dr. Saharia).
Objective: Studies on the role of laparoscopy in cytoreductive procedures for advanced stage ovarian cancer are limited. The objective of this study was to describe our preliminary experience with laparoscopic total primary or interval cytoreduction in patients with advanced ovarian, fallopian, and primary peritoneal cancers.
Methods: This is a prospective case series. Women with presumed advanced cancers deemed appropriate candidates for laparoscopic debulking were recruited. The patients underwent exploratory laparoscopy and subsequent biopsy, primary, or interval cytoreduction by laparoscopy or laparotomy from January 2005 to June 2009. Outcome variables analyzed included stage, site of disease, extent of debulking, operative time, blood loss, length of hospital stay, complications, and survival time. Statistical analysis was performed using Systat 12.0.
Results: Thirty-two patients were recruited. Seventeen underwent total laparoscopic primary/interval cytoreduction, with 88.2% optimally cytoreduced. Eleven underwent diagnostic laparoscopy and conversion to laparotomy for cytoreduction, with 72.7% optimally cytoreduced. Four patients had limited cytoreduction. In the laparoscopy group, 9 patients have no evidence of disease (NED), 6 are alive with disease (AWD), and 2 have died of disease (DOD), with mean follow-up of 19.7 months. In the laparotomy group, 3 patients are NED, 5 are AWD, and 3 have DOD, with mean follow-up of 25.8 months. Complication rates were not different. Median time to recurrence was 31.7 and 21.5 months for the laparoscopy and laparotomy groups, respectively.
Conclusions: Laparoscopy can be used for diagnosis, triage, and debulking of patients with advanced ovarian, fallopian, or primary peritoneal cancers and is technically feasible in a well-selected population.
10.196 Gynecology
Laparoscopic Management of Large Ovarian Cysts
Eun-Ju Lee, Dong-Ho Kim
Chung-Ang University School of Medicine, Seoul, Korea
Objective: To assess the feasibility and surgical outcomes of laparoscopy applied to large ovarian cysts.
Methods: We reviewed 50 consecutive patients with ovarian cysts with a maximum diameter of ≥10cm and radiologic features suggestive of benign disease. Patients’ clinical and radiologic features, CA125 values, complications, and pathologic findings were recorded.
Results: The mean age and body mass index were 36 years (range, 14 to 57) and 22.4kg/m2 (range, 17.9 to 30.9), respectively. The mean operative time, EBL, and hospital stay were 123.7 minutes (range, 50 to 420), 160mL (range, 20 to 900), and 7.46 days (range, 4 to 14), respectively. The surgical procedures performed were unilateral salpingo-oophorectomy (n=39), ovarian cystectomy (n=6), and laparoscopic-assisted hysterectomy and unilateral salpingo-oophorectomy (n=5). The cysts were extracted after aspiration by using an endobag through the 10-mm lower quadrant trocar site and via mini-laparotomy in 3 patients. Pathologic findings included mucinous cystadenoma (n=23), dermoid (n=10), serous cystadenoma (n=6), endometriosis (n=5), struma ovarii (n=2), and benign epithelial-lined cyst (n=4).
Conclusion: Laparoscopy is feasible and safe for women with large ovarian cysts with benign features.
10.197 Gynecology
Is Same-Day Discharge After Laparoscopic Hysterectomy a Safe Option?
Misa Perron-Burdick, MD, Miya Yamamoto, MD, Eve Zaritsky, MD
Kaiser Permanente East Bay, Northern California
Objective: The purpose of this study was to examine the safety of same-day discharge of patients after laparoscopic hysterectomy. Many gynecologic surgeons who perform laparoscopic hysterectomies admit their patients for 1 to 2 days; however, a growing number of gynecologic surgeons are practicing same-day discharge. To date, there have been no large studies examining the safety of this practice.
Methods: This is a retrospective cohort study including all same-day discharge laparoscopic hysterectomy patients from Northern California Kaiser Permanente from 2007 through 2009. The primary outcome of this study is hospital readmission rates for up to one year postoperatively. By referencing available large studies on open hysterectomy and expert opinion, we determined a readmission rate of <6% to be acceptable. Secondary outcomes include emergency room visits, urgent appointments, postoperative complications, operative time, blood loss, and transfusion rates. Bivariate and multivariate analyses were performed to examine outcomes and potential risk factors.
Results: Preliminary analysis of an initial cohort of 399 patients demonstrated a readmission rate of <5%, and an emergency room visit rate of 5%. Estimated blood loss was <150mL. Complication rates were minimal.
Conclusion: Same-day discharge of laparoscopic hysterectomy patients is a safe and acceptable alternative to admission, thus reducing the overall hospital and health care burden.
10.198 General Surgery
Comparison of Complication Rates Between India Ink and Indocyanine Green in Colonoscopic Tattooing for Preoperative Localization
Dae Hwa Choi, Yeong Cheol Im, Bong Hwa Chung
Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea (Drs. Choi, Im).
Department of Surgery, University of Hallym, Chuncheon, Kangwon-do, Republic of Korea (Dr. Chung).
Background: Colonoscopic marking with an India ink tattoo has been commonly used for preoperative localization of nonpalpable small lesions. Some reports indicate that inflammatory complications (local peritonitis, abscess, inflammatory pseudotumor, and others) have been caused by India ink tattoos. Indocyanine green (ICG) has been suggested as a good alternative material for tattooing, because is causes a less inflammatory reaction. We compared the complication rates between the 2 tattooing materials.
Methods: Fifty-seven colorectal lesions marked with a preoperative colonoscopic tattoo with India ink or ICG were resected. An India ink tattoo was used in 42 cases, and ICG was used in 15 cases. We collected posttattoo symptoms (abdominal pain, fever, and others) and intraoperative findings at the tattoo site (intraperitoneal leakage of the tattoo material, abscess, local peritonitis, and others).
Results: A difference was noted in intraperitoneal leakage of the tattoo material that showed an increased incidence in the India ink group compared with the ICG group (P=0.05), and there was a patient who had fever with a blood culture showing many colonies of propionibacterium acne after a colonoscopic tattoo.
Conclusion: This study shows that a difference is likely in safety between India ink and ICG tattoos. And a question remains about preventive antibiotic use for colonoscopic tattooing.
10.199 General Surgery
Decrease Postlaparoscopic Shoulder Pain with Slow Deflation Speed of Abdominal Gas
Vejdan Amir, Dadashi Kataneh, RN, BSCN
Department of General Surgery, Imam Reza Hospital, Birjand University of Medical Sciences, Birjand, Iran (Dr. Amir).
General Surgery/Laparoscopy Team, St. Michael Hospital, Toronto, Ontario, Canada (Ms. Kataneh).
Background: Shoulder pain is a common complaint following laparoscopic surgery, occurring generally in about 35% of patients after laparoscopic surgery. It is more frequent however after some specific types of laparoscopic surgery like Nissen fundoplication and laparoscopic adjustable gastric banding. This investigation evaluates the role of slow deflation of abdominal gas in decreasing the severity and incidence of this problem.
Patients and Methods: Seventy-eight patients with uncomplicated gallstones and early phase acute cholecystitis were randomly divided into 2 groups. In the control group (38 patients), ports were removed rapidly and gas deflated maximally in 10 seconds, but in the study group (40 patients), gas was deflated at a slow rate of 3 minutes. For 8 weeks postoperatively, patients were followed and the incidence and severity of pain were evaluated and compared.
Results: The incidence of postlaparoscopic shoulder pain was 8% and 34% in the study group and control group, respectively (P<0.05). The pain score system shows less severity of pain in the study group, which could lead to a decrease in analgesic prescription and dosage.
Conclusion: Decreasing the speed of abdominal gas deflation at the end of laparoscopic surgeries can significantly decrease the incidence and severity of postlaparoscopic shoulder pain.
10.200 Urology
Robot-Assisted Laparoscopic Left Varicocele Repair in Adolescent Children
John G. Van Savage, MD
Regional Urology, Shreveport, Louisiana
Objective: The left varicocele can produce testicle atrophy and potential infertility. The magnification provided by the da Vinci robot operating system enhances the distinction between the spermatic arteries, veins, and lymphatics. This may translate into a better outcome than with the open approach. We present our experience with robot-assisted laparoscopic left varicocele repair in adolescent children.
Patients: Thirteen boys (mean age, 15 years, range 12 to 19) presented with left varicoceles, which were all grade 3 and easily visible. Three of 13 (23%) patients had left scrotal pain. Three of 13 had testicular atrophy. Three had had open left varicocele (2) or inguinal hernia repairs (1).
Results:
All 13 patients had completion of their laparoscopic left varicocele repair performed with the da Vinci robot operating system as outpatients. There were no open conversions or complications. Seven of 13 patients had a mean follow-up of 3 months (range, 1 to 13). There was no new atrophy. All varicoceles were cured. No hydroceles formed. One of 3 (33%) patients with preoperative scrotal pain still had scrotal pain, albeit milder. All families were pleased with their robot procedure experience.
Conclusions: The robot-assisted laparoscopic left varicocele repair in adolescent boys has a high success rate and limited morbidity in this small series. We originally recommended it for the athletic teenager, but have gradually come to recommend it over the open repair in all patients. It is especially useful for the repeat varicocele repair or in patients with previous inguinal surgery, because it provides a magnified view of an unoperated area.
10.201 General Surgery
Survival After Laparoscopic Colon Cancer Resection
Prof. Dr. Ivo Baca, PhD, Dr. Med. Khaled El Zarrok Elgazwi, MRCS, MD
Klinik für Allgemein-und Viszerlalchirurgie, Klinikum Bremen-Ost, Bremen, Germany
Background: Laparoscopic colon resection (LR) for malignancy remains controversial. Fears regarding compromised oncologic principles and early recurrence were the main causes of this controversy.
Methods: A prospective database of 330 consecutive LRs of colon cancers performed between March 1995 and June 2008 at one institution was reviewed. Data for sex, age, stages of the disease, operative time, morbidity, and mortality were collected. The TNM classification for colorectal cancers and Kaplan-Meier method were used to determine survival curves.
Results: Included in the study were 158 male and 172 female patients with an average age of 69±10 years. Complications occurred in 32 patients (anastomotic leak, 18; peritonitis, 4; wound infection, 6; and postoperative bleeding, 4), and 8 patients died. Procedures included 119 laparoscopic right colectomies, 14 transverse colectomies, 32 laparoscopic left hemicolectomies and sigmoid colectomies in 161 patients. Twelve cases were converted to open surgery. There was one extraction-site recurrence. The mean operative time was 123±42 minutes, and the mean hospital stay was 11±4 days. According to the TNM classification system, 80 patients had Stage I cancer, 102 Stage II, 103 Stage III, and 45 Stage IV. The 5-year relative survival rates according to Kaplan-Meier were 93.5% Stage I, 82.1% Stage II, 71.8% Stage III.
Conclusion: Laparoscopic colon resection for cancer is safe and feasible. Our data suggest that long-term survival after laparoscopic colon resection for cancer is similar to or even better than survival after conventional surgery.
To Compare the Effectiveness of Ultrasonically Activated Scalpel with Electrocautery in Removal of the Gallbladder from the Gallbladder Bed
10.202 General Surgery
To Compare the
Effectiveness of Ultrasonically Activated Scalpel with Electrocautery in
Removal of the Gallbladder from the Gallbladder Bed
P.N. Agarwal, MS Gen Surgery, Prof. of Surgery, S.K. Jain, MS Gen Surgery, Prof. of Surgery, R.C.M. Kaza, MS Gen Surgery, Prof. of Surgery,
Raman Tanwar, Surgery Resident
Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India.
Objectives: This study aimed at comparing the effectiveness of the ultrasonic scalpel with electrocautery in removal of the gallbladder from gallbladder bed.
Methods: A randomized controlled trial was conducted comprising 150 patients randomly divided into the 2 groups. In one group, electrocautery was used and in the other an ultrasonically activated scalpel was used as a means of dissection. The time taken to remove the gallbladder and intraoperative blood loss were noted. Pain scoring was done on postoperative days 0, 1, 7, and 21 along with the number of analgesics consumed. Data collected were statistically analyzed and results were obtained using the chi-square and t test.
Results: With the Harmonic scalpel, average day 1 pain scores were 2/10 in 70 patients compared with 3/10 in the electrocautery group. Average blood loss and time taken to remove the gallbladder from its bed was less using ultrasonic shears. In 80% of cases, the cystic artery was ligated using the Harmonic scalpel with no complications.
Conclusions: The Harmonic scalpel proved to be more efficacious at reducing pain and blood loss in laparoscopic cholecystectomy. It was also a useful energy source to safely ligate the cystic artery.
10.203 Pediatric
Laparoscopic Appendectomy for Torsed Appendix in an 11-Week-Old Girl Presenting with an Acute Abdomen
Lena Perger, MD, Oliver J. Muensterer, MD, PhD
Background: Torsion of an otherwise normal appendix vermiformis is exceedingly rare and presents with symptoms consistent with acute appendicitis.
Methods: An 11-week-old girl was brought to the emergency department with a 48-hour history of abdominal pain, emesis, low-grade fever, and focal right lower quadrant tenderness. Sonography found a noncompressible enlarged appendix in the right lower quadrant. Upon laparoscopy, a torsed, necrotic appendix vermiformis was found.
Results: Appendectomy was performed, and the patient recovered uneventfully.
Conclusion: In an infant girl with lower abdominal pain, the differential diagnosis should include torsed appendix in addition to more common diagnoses, such as torsed ovary, intussusception, or small bowel volvulus. Ultrasound is useful for establishing the diagnosis.
10.204 Urology
Laparoscopic Boari Flap Ureteric Reimplantation
Emad R. Rizkala, MD, Michael Grasso, III, MD
Introduction: Multiple techniques are used in the surgical treatment of distal ureteral strictures. A well-established technique is bladder mobilization along with a Boari flap used to reconstruct the distal ureter after excision of a strictured lengthy ureteral segment. We present a video of the laparoscopic Boari flap ureteral reimplantation technique used at our institution.
Methods and Materials: A 3-port technique is used: 1 camera port and 2 bilateral instrument ports. The bladder is mobilized on the contralateral aspect. The ureter is incised and spatulated proximal to the strictured segment. A JJ-ureteral stent is placed within the ureter. The bladder is incised and a Boari flap is constructed. The free end of the Boari flap is sutured to the spatulated ureter and tubularized using a continuous running stitch. The bladder is filled with indigo carmine mixed with normal saline to test the integrity of the anastomosis.
Results: Median operative time is 3 hours with minimal blood loss and no complications. Patients are usually discharged on the first postoperative day with an indwelling Foley catheter to a leg bag. A cystogram is performed on the fifth to seventh postoperative day, and the stent is removed 6 weeks postoperatively. No long-term complications have occurred.
Conclusion: The video illustrates the technical aspects of performing a laparoscopic Boari flap ureteral reimplantation. This procedure provides a less invasive alternative to the open Boari flap ureteral reconstruction and reimplantation.
10.205 General Surgery
Nontechnical Skills Assessment in the Postoperative Setting
Bharat Sharma, MD, Neil Orzech, MD, Med, Teodor Grantcharov, MD, PhD
University of Toronto, Toronto, Canada
Objectives: Adverse event analysis in surgery continues to highlight the importance of nontechnical skills training. Communication failures, poor decision making, or a lack of leadership skills can disrupt team dynamics and may result in negative patient outcomes. Despite this, most surgical training curricula emphasize technical skill and knowledge acquisition, without formal nontechnical skills training. At present, 3 major nontechnical skills assessment tools, the Non Technical Skills for Surgeons (NOTSS), the revised Non Technical Skills (NOTECHS) Scale, and the Ottawa Global Rating Scale (GRS), have been developed/modified for use in an operative environment. The present study aimed to evaluate the role of these tools in a postoperative crisis environment.
Methods: Using a full body simulator in a Virtual surgical ward environment, surgical residents were exposed to standardized postoperative complications including hemorrhagic shock, septic shock, and pulmonary embolism. All trainees were randomized to one of the scenarios, and their performance was assessed using a scenario-specific checklist. Using NOTSS, NOTECHS, and Ottawa GRS, 2 independent experts assessed study participants’ nontechnical skills.
Results: Scores on the scenario-specific checklist and nontechnical skills global rating scales showed a significant correlation (Spearman correlation=0.68, P<0.01). Furthermore, there was a significant correlation between the various nontechnical skills assessment tools (Spearman correlation=0.95, P<0.001).
Conclusion: Existing nontechnical skills rating systems can be used reliably for assessment of performance during management of standardized postoperative complication scenarios. These tools should be incorporated into future training curricula for surgical residents.
10.206 Urology
Laparoscopic Retroperitoneal Partial Nephrectomy
Emad R. Rizkala, MD, Andrew Fishman MD, Michael Grasso, III, MD
St. Vincent's Medical Center, New York, New York and New York Medical College, USA
Introduction: Nephron-sparing techniques are now the new standard for the surgical treatment of cT1a and some cT1b renal masses. The transperitoneal laparoscopic partial nephrectomy is the most commonly utilized laparoscopic partial nephrectomy technique. However, there are advantages to performing this procedure retroperitoneally. We present a video of the laparoscopic retroperitoneal partial nephrectomy technique performed at our institution.
Methods and Materials: Patients are placed in the flank position. A 3-port technique is used: 1 camera port and 2 instrument ports. A balloon dissector is used to develop the retroperitoneal space. The renal hilum is identified and dissected. The renal tumor is identified using a laparoscopic ultrasound probe. The cutting border of the tumor is made by cauterizing the renal surface using a hook electrode. The renal artery is clamped using laparoscopic bulldog clamps and the tumor is excised. Figure-of-8 stitches are placed in the tumor bed, and a sealing/coagulating agent is placed along with an absorbable hemostatic material. Multiple sutures are placed to close the defect. A Jackson-Pratt drain is placed at the conclusion of the procedure.
Results: Patients undergoing this procedure are usually discharged on postoperative day 1 or 2. In our institution's series of 110 patients, conversion to open surgery occurred in 2 cases and laparoscopic radical nephrectomy was performed in 4 cases. The rate of major complications was 4.5%.
Conclusion: This technique provides quick access to the renal hilum while allowing the containment of blood and urine outside the peritoneal cavity.
10.207 Gynecology
Accessory Polar Renal Artery Encountered in Transperitoneal Systemic Laparoscopic Para-Aortic Lymphadenectomy
Yong Seung Lee, MD, Jung Hun Lee, MD, PhD, Joong Sub Choi, MD, PhD, Chang Eop Son, MD, Seung Wook Jeon, MD, Jong Woon Bae, Jin Hwa Hong, Woong Ju
Yong Seung Lee and Jung Hun Lee contributed equally to this work.
Department of Obstetrics and Gynecology, Flushing Hospital Medical Center, Flushing, New York, USA (Dr. Lee).
Department of Obstetrics and Gynecology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of South Korea (Drs. Lee, Choi, Son, Jeon, Bae, Hong).
Department of Obstetrics and Gynecology, Ewha Woman's University Hospital, Seoul, Republic of South Korea (Dr. Ju).
Objective: To increase vigilance among gynecologic surgeons for the presence of the accessory polar renal artery (APRA) encountered with transperitoneal systemic laparoscopic para-aortic lymphadenectomy (LPAL).
Methods: A retrospective review was conducted of 138 women who underwent LPAL for various gynecologic malignancies between November 2003 and December 2008.
Results: The median age, parity, body mass index, and number of previous abdominal surgeries of the women were 52 years (range, 23±82), 2 (range, 0±7), 24.1kg/m2 (range, 17.4±35.0), and 0 (range, 0±3), respectively. During the study period, we found 4 women with APRA. There were 3 cases of right lower APRA arising from the abdominal aorta, caudal to the inferior mesenteric artery (IMA), terminating at the parenchyma of the lower pole of the right kidney. In the other case, the APRA arose from the abdominal aorta superior to the IMA and terminated at the hilum of the right kidney. There were no vascular complications, such as transection or ligation of the APRA.
Conclusion: It is important for the laparoscopic gynecologic surgeon to have knowledge of retroperitoneal vascular anatomy, experience in laparoscopic surgery, and an accurate surgical technique to avoid vascular injury during LPAL.
10.208 General Surgery
Single-Incision Right Colectomy: Robotic-Assisted vs. Standard Laparoscopic
M. Ostrowitz, G. DeNoto
Background: Application of laparoendoscopic single-site surgery (LESS) is increasing across surgical disciplines. Besides the possibility of decreased postoperative pain, LESS offers better cosmesis with virtually “scarless” surgeries without the increased costs and complexity of natural orifice surgery. Instrument conflict minimization often requires crossing of articulating instruments, which can be more intuitively facilitated using the da Vinci-S robot. We compare our early experience with 4 different techniques for robotic single-incision right colectomy with our standard laparoscopy experience.
Methods: Single-incision right colectomies were performed using either standard laparoscopic equipment or the da Vinci-S robotic system utilizing either a single 4-cm incision, 3 separate skin and fascial incisions, or the SILS port. A medial to lateral approach was used in all, and an extracorporeal resection and anastomosis was performed in all cases.
Results: There were no intraoperative or postoperative complications. Average robotic operative time was 152 minutes vs. 125 for standard laparoscopy. One robotic case was converted to a nonrobotic single-incision right colectomy during mobilization of the ascending colon due to uncontrollable air leakage around the ports.
Conclusions: Single-incision right colectomy can be successfully and safely performed laparoscopically or using the da Vinci-S robotic system. We believe right colectomy lends itself to single-site surgery, because specimen extraction requires a 4-cm incision and may confer patient benefit with decreased postoperative pain and improved cosmesis.
10.209 General Surgery
Negative Outcomes of Laparoscopic Ventral Hernia Repair
Srdjan Rakic, MD, PhD, Ernst Schoenmaeckers, MD, Johannes Raymakers, MD
Department of Surgery, ZGT Twenteborg Hospital, Almelo, The Netherlands
Objective: To review all negative outcomes of laparoscopic ventral/incisional hernia repair.
Methods: Data from 775 consecutive patients undergoing attempted laparoscopic ventral /incisional hernia repair were reviewed (“intention-to-treat” analysis). Mean follow-up was 35.6±20.3 months. All operative and postoperative complications of Clavien grade III (requiring surgical or radiological intervention) and greater were included.
Results: Laparoscopic repair was completed in 752 patients (96.9%). Conversion to an open operation (n=23; 3.1%) was needed in 15 due to severe adhesions (2%) and in 8 due to enterotomy (1.1%). Two patients died postoperatively due to myocardial infarction and mesenteric ischemia (0.3%). Altogether, there were 14 enterotomies (1.8%): 9 recognized intraoperatively (1.2%) and 5 presented postoperatively (0.6%). Three patients had intraabdominal bleeding (0.4%). Two patients had an extreme postoperative ileus (0.3%). There were 15 hernia recurrences (1.9%). Twelve patients had a persistent pain (1.6%). Two patients had a mechanical bowel obstruction long after repair (0.3%). Seven patients got a trocar-site hernia (0.9%). Five patients had a late mesh infection that required mesh removal (0.7%). Four patients had a symptomatic mesh “bulging” (0.5%). One patient had a chronic seroma (0.1%).
Conclusion: Despite some proven benefits of laparoscopic over open ventral/incisional hernia repair, the overall negative outcome rate after laparoscopic repair of 8.9% (67/775) indicates the need for further critical comparative evaluation of all currently used techniques of repair. Recurrence rate after laparoscopic repair reflects only a subset of all negative outcomes and, alone, is not a reliable parameter of the success of the procedure.
10.210 General Surgery
Safety and Outcome of General Surgical Open and Laparoscopic Procedures During Pregnancy
J.K. de Bakker, MD, L.M. Dijksman, MSc, S.C. Donkervoort, MD
Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, Holland (Drs. de Bakker, Donkervoort).
Teaching Hospital, Onze Lieve Vrouwe Gasthuis, Amsterdam, Holland (Dr. Dijksman).
Background: Surgical procedures during pregnancy carry the risk of fetal loss, preterm delivery, or dysmaturity of the fetus. We analyzed the outcome of the open and laparoscopic approaches in patients treated for symptomatic cholelithiasis and suspected appendicitis in our clinic. We reviewed the literature for evidence of the safety of both procedures.
Material and Methods: We retrospectively reviewed data for all patients who underwent surgery for symptomatic cholelithiasis and suspicion of appendicitis during pregnancy between January 2004 and March 2009. Fetal loss, preterm delivery, and maternal outcome were assessed, and surgical complications were scored.
Results: Twenty patients were operated on during pregnancy: 5 (0.8%) of 652 patients with symptomatic cholelithiasis and 15 (4.5%) of 331 patients because of suspected appendicitis. All cholecystectomies were performed by a laparoscopic procedure with excellent outcome. No premature deliveries or fetal deaths occurred. In patients with a suspicion of appendicitis, 3 appendices were found to be healthy by diagnostic laparoscopy, and in 9 patients an appendectomy was performed for appendicitis by laparoscopy. An open approach was used in 3. In patients suffering from appendicitis, 2 preterm deliveries and one fetal death occurred.
Conclusion: Based on a review of our results and the available literature, we strongly believe that the outcome of surgery during pregnancy is not dictated by the type of procedure but by the type of disease. It is not unlikely that the gain for fetal outcome in the future lies in the diagnostic pathway rather than the type of surgery.
10.211 Gynecology
Team Training Reduces the Learning Curve for Robotic Hysterectomy While Maintaining Quality Outcomes.
A.J. Panagiotakis, DO, A. Gaddi, MD, L.R. Bruck, MD
Stamford Hospital, Department of OB/GYN, Affiliate of Columbia University-College of Physicians and Surgeons.
Objective: The purpose of this study was to evaluate whether the incorporation of team training as part of the initiation of a gynecologic robotics program would reduce total operative time, maintain quality, and reduce the learning curve for hysterectomy.
Methods: This was a retrospective case series at a community hospital with patients requiring robotic hysterectomy for benign or malignant disease treated with the da Vinci surgical system. Before the implementation of our gynecologic robotics program, 2 surgical teams had completed the Intuitive on-line training plus 1-day training and didactic session, 2 case observations, 5 hours to 10 hours of inanimate onsite training, 3 proctored cases, and team training that required a minimum of 2 setup drills with the full team comprising surgeons, nurses, and anesthesiologists.
Results: Forty patients were treated with hysterectomies over a 10-month period utilizing the team training approach. Total operating room times averaged 303 minutes, and mean estimated blood loss was 62mL for the first 20 cases. The next 20 cases resulted in reduced average operating room time of 249 minutes, and mean estimated blood loss was 52mL. The mean length of hospital stay was 1.6 days throughout. No complications or transfusions were observed.
Conclusion: Learning curves for various gynecologic surgeries involving robotics has been reported in the past, ranging from 10 cases to 50 cases for proficiency. Our study demonstrated the finding that surgeons with team training experience reduced operating room times for hysterectomy and decreased their learning curve to 20 cases while maintaining quality outcomes.
10.213 Gynecology
Single Port Access Laparoscopic-Assisted Vaginal Hysterectomy for Carcinoma In Situ of Uterine Cervix
Wondeok Joo, MD, PhD, Hyun-Jin Roh, MD, Soo-Jeong Lee, MD, PhD, Hang-Jo Yoo, MD
Department of Obstetrics and Gynecology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
Background and Objectives: We investigated the feasibility of single-port access laparoscopic-assisted vaginal hysterectomy (SPA-LAVH) in patients with carcinoma in situ (CIS) of the uterine cervix. The uterus should not be enlarged, hence it should be easy to handle compared with a fibroid uterus and adenomyosis.
Methods and Procedures: Through a 3-cm vertical incision within the umbilicus, an Alexis wound protector was inserted. A surgical glove wrapped the wound retractor, and three 5-mm trocars were inserted into the fingers of the glove, one for a 5-mm laparoscope, one for a SonoSurge ultrasonic cutter (Olympus, Japan), and one for a forceps. LAVH was performed in the same manner with conventional 3-port LAVH (TP-LAVH), and a uterine manipulator was extensively used like one of the laparoscopic forceps. We performed 15 cases of SPA-LAVH between April 2009 and January 2010. We also enrolled 33 women with CIS of the cervix who received TP-LAVH between March 2006 and April 2009, as a control group. We compared demographic factors and outcomes of surgery between the 2 groups.
Results: There were no significant differences between the SPA-LAVH group and TP-LAVH group in age (mean 45.40±9.55 years vs. 46.75±10.23 years), body mass index (mean 24.52±4.19 vs. 24.08±3.35), parity (mean 2.40±1.05 vs. 2.45±1.14), previous surgery (mean 0.33±0.61 times vs. 0.36±0.96 times), hemoglobin change (mean 1.51±0.61g/dL vs. 1.66±0.96g/dL), and complications (0 vs. 2). Surgery in the SPA-LAVH group took longer (103.80±13.3 minute vs. 91.21±27.69 minutes; P=0.007), and patients had a shorter hospital stay (2.66±0.72 days vs. 3.27±0.94 days; P=0.029).
Conclusions: SPA-LAVH is feasible for the patients with CIS of uterine cervix.
10.214 General Surgery
Laparoendoscopic Single Site (LESS) Nissen Fundoplication
Sharona B. Ross, MD, Kenneth Luberice, BS, Connor A. Morton, BS, Linda K. Barry, MD, Alexander S. Rosemurgy, MD
University of South Florida Department of Surgery, and Center for Digestive Disorders Tampa General Hospital, Tampa, Florida, USA
Background: Laparoendoscopic single site surgery encourages the application of laparoscopic Nissen fundoplication by reducing the number of incisions, thereby improving cosmesis and possibly reducing pain and length of recovery.
Methods: Four 5-mm trocars were utilized in a multi-port trocar placed through a single 12-mm incision at the umbilicus. A 3-mm deflectable tip camera was used. The hiatal hernia was reduced and the sac excised. The distal esophagus was circumferentially dissected from its surrounding tissue, while both the anterior and posterior vagus nerves were preserved. The gastric fundus was mobilized by dividing the short gastric vessels, and the hiatus was reconstructed with interrupted sutures. The posterior fundus was then brought behind the esophagus, and the fundoplication was constructed utilizing 4 interrupted sutures. Once the fundoplication was completed, it was anchored to the right crus to avoid tension, which might promote unraveling of the wrap, and to prevent twisting of the lower esophagus. Finally, the 10-mm trocar site was closed with an absorbable suture placed in a single figure-of-eight fashion.
Conclusion: Laparoendoscopic single site surgery techniques can be used to construct Nissen fundoplications to control GERD without apparent scarring, and possibly less morbidity. Patients will embrace laparoendoscopic single site Nissen fundoplication; laparoscopic surgeons will need to meet patient demands.
10.215 Multispecialty
Multiple Chronic Pelvic Pain Diagnoses in a General Gynecology Setting
Bradford W. Fenton, MD, PhD, Eileen Witten, MD, Lauren Brobeck, Vivian Von Gruenigen, MD
Summa Health System, Department of Obstetrics and Gynecology, Akron, Ohio, USA
Introduction: Chronic pelvic pain (CPP) has several definitions and multiple related conditions of other organ systems, such as interstitial cystitis (IC), irritable bowel syndrome (IBS), and vulvodynia (VVD). Although it is known that multiple pelvic pain related diagnoses coexist in referral populations, it is unclear how frequently these conditions occur in an outpatient setting. Failure to adequately diagnose and manage these other chronic pain syndromes may decrease patient response to treatment.
Methods: While waiting to be seen in an outpatient gynecology resident clinic, 498 women completed the survey instrument. Questions related to the American College of Obstetricians and Gynecologists definitions of cyclic and constant chronic pelvic pain were included, as were standardized questions designed to detect IC, IBS, and VVD.
Results: Cyclic CPP was present in 20%, constant CPP was present in 9%, and CPP by any definition was present in 24%. IC was detected in 6%, IBS in 15%, and VVD in 5% of all respondents. Of patients with any definition of CPP, 8% had IC, 16% had IBS, 11% had VVD, and 31% had at least one other pelvic pain diagnosis; this was significantly related to both cyclic CPP (P=0.039) and constant CPP (P<0.001).
Conclusion: Chronic pelvic pain is a common condition among women presenting for care at a general gynecology clinic. Pain diagnoses in other pelvic organ systems are not as common as gynecologic pain on an individual basis, but frequently coexist with CPP, and would require separate evaluation and management to optimize response to treatment.
10.216 General Surgery
Laparoendoscopic Single Site (LESS) Surgery for Foregut Disorders
Sharona B. Ross, MD, Michelle Vice, Sujat Dahal, MD, Connor A. Morton, BS, Linda K. Barry, MD, Seaborn A. Roddenbery, MD, Michael H. Albrink, MD, Alexander S. Rosemurgy, MD
Department of Surgery, University of South Florida, Tampa, Florida, USA
Introduction: Laparoendoscopic single site (LESS) surgery is being increasingly applied to laparoscopic operations across many surgical disciplines. This study was undertaken to review our experience with LESS surgery for disorders of the foregut.
Methods: Patients were prospectively followed. Duration of operation, conversions, length of stay, perioperative complications, and cosmetic results were recorded.
Results: Since 2007, 365 patients have undergone LESS surgery, which have included 213 cholecystectomies, 61 Heller myotomies, 64 fundoplications, 9 appendectomies, 6 inguinal hernia repairs, and 2 hepatic cyst excisions. LESS cholecystectomy was concomitantly undertaken with 4 LESS fundoplications, 2 LESS Heller myotomies, 1 LESS salpingectomy, and 1 LESS hysterectomy. Seven (3%) cholecystectomies, 11 (18%) Heller myotomies, 8 (12%) fundoplications, and 1 hepatic cyst excision required additional ports. Three (1%) cholecystectomies, 1 (1%) Nissen fundoplication, and 1 (11%) appendectomy were converted to “open.” LESS cholecystectomy was complicated by 1 cystic duct leak and 1 intraoperative arterial hemorrhage. The duration of surgery was very similar between LESS and multi-incision “conventional” laparoscopy. The majority of patients were discharged on the day of the operation. All LESS operations were undertaken without apparent scarring.
Conclusion: LESS surgery can be efficaciously applied to a broad range of operations with the salutary benefits of multi-incision laparoscopy and superior cosmetic results. Transumbilical LESS surgery provides suitable access to all quadrants of the abdomen and pelvis, thereby allowing multiple concomitant operations. The escalating application of LESS surgery across many surgical disciplines is promoted by consumer demand and continuous improvements in instrumentation and imaging.
10.217 General Surgery
Modeling the Fundamentals of Laparoscopic Surgery (FLS) Tasks in Virtual Reality: A Face and Construct Validity Assessment
Vanessa N. Palter, Neil Orzech, Teodor P. Grantcharov
Department of General Surgery, University of Toronto, Toronto, Canada (Drs. Palter, Orzech).
Division of General Surgery, St. Michael's Hospital, Toronto, Canada (Dr. Grantcharov).
Objectives: The Fundamentals of Laparoscopic Surgery (FLS) is a validated program to teach and assess technical skill. Recent advances in technology have allowed for the creation of the FLS tasks in virtual reality (VR). The purpose of this study was to assess the face and construct validity of a model of the FLS tasks in VR.
Methods: Fifteen surgeons participated. Each participant completed 3 FLS tasks (peg transfer, pattern cutting, and Endoloop) on the VR (LapSim, Surgical Science, Sweden), and FLS models. Correlations between the final FLS score for each task and 3 parameters generated by the VR simulator (time, error, economy of motion) were assessed by using Spearman’s correlation coefficient. Face validity was assessed by a short questionnaire.
Results: Significant correlations were observed between the FLS score and the time and economy of movement score on the VR peg transfer and pattern cutting tasks (P<0.05). No significant correlation was found between the FLS score and any of the 3 metrics generated by the VR simulator for the Endoloop task. Half of the participants (6/12) agreed with the overall utility of the LapSim to simulate the FLS tasks; however, all (12/12) participants chose the FLS black box as the preferred simulator. Most participants (10/11) chose the peg transfer and cutting pattern tasks as requiring the most improvement.
Conclusions: This study demonstrates preliminary evidence for the construct validity of the model of the FLS tasks in VR. More developments in VR technology are necessary to increase the face validity of the system.
10.218 General Surgery
Unexpected Findings During Laparoscopic Roux-en-Y Gastric Bypass
Emanuele Lo Menzo, MD, PhD, Mark D. Kligman, MD
Division of Laparoscopic and Bariatric Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
Introduction: The technique for laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been standardized in our center. Unexpected intraoperative findings will occasionally require deviation from the usual practice. We present a collection of these findings and the solutions we implemented.
Methods: We reviewed all the unusual intraoperative findings during LRYGBP at the Bariatric center of the University of Maryland. The patients’ clinical characteristics and the technical aspect of each procedure were then retrospectively analyzed.
Results: Four of the most interesting occurrences were identified. The first case shows the intraoperative incidental finding of multiple splenic lesions and more saddle liver lesions in a patient without risk factors. She underwent an uneventful LRYGBP with spleen and liver biopsies. The pathology was consistent with granulomas. The second case describes the incidental finding of a hepatic mass in a young woman. A liver wedge resection was carried out concurrently with the bypass, and it was consistent with focal nodular hyperplasia. The third case shows the incidental finding of a gastric mass during the creation of the pouch, requiring reshaping of the pouch itself. The pathology was consistent with a low-grade gastrointestinal stromal tumor. The last case presents the inadvertent rotation of the Roux limb during the passage through the mesocolic defect. This was discovered at the end of the procedure and required re-resection and a new anastomosis.
Conclusions: Unexpected findings during LRYGBP require flexibility and adjustment to the new situation. Regardless of the additional procedure performed, the safety of the primary operation has to be maintained.
10.219 General Surgery
Alternative Laparoscopic Technique for Lesser Sac Entry
Emanuele Lo Menzo, MD, PhD, Mark D. Kligman, MD
Division of Laparoscopic and Bariatric Surgery, University of Maryland Medical School, Baltimore, Maryland, USA
Introduction: The dissection of the angle of His is paramount in several foregut procedures. During a gastric bypass, failure to visualize this important landmark can result in gastro-gastric fistulae, inadequate pouch formation, and weight regain. We describe an alternative technique to access the lesser sac during laparoscopic gastric bypass.
Methods: All the laparoscopic Roux-n-Y gastric bypasses performed at our institution from January 2008 and January 2009 were retrospectively reviewed. A total of 230 procedures were performed. All the cases in which the lesser sac was entered behind the gastric fundus, after taking down the angle of His, were identified. Failure, partial success, and success of the maneuver were recorded. A partial success was identified as the complete exposure of the lesser sac except for a thin membrane.
Results: A total of 180 lesser sac dissections were identified. Of these, 140 (77.7%) were considered successful, 30 (16.6%) partially successful, and 10 (5.5%) unsuccessful. The average BMI was 48.2kg/m2 (range, 38 to 94). The dissection was successful in the highest BMI patient of the series (94kg/m2). The dissection did not result in any injury to the esophagus, stomach, or spleen. No gastro-gastric fistulae were recorded.
Conclusions: Entry into the lesser sac from the superior approach is safe and can facilitate the creation of the pouch, even in super-super obese individuals. The technique can be utilized in a variety of laparoscopic foregut procedures.
10.220 General Surgery
What To Do When You Have Nothing Else To Work With
Karla Russek, MD, Morris E. Franklin, Jr., MD
Objective: Surgeons are constantly struggling with complicated patients in need of surgery. In cases of abdominal catastrophes, severe cardiopulmonary problems, and other pathologies, a surgeon must often leave an open abdomen to prevent compartment syndrome or to perform a second-look surgery. We propose an alternative approach to this problem.
Methods: We present 9 cases in which we have used the ABThera device (KCI Inc, San Antonio, TX), which functions with negative pressure and can be applied directly in contact with bowel. Abthera changes are performed every 48 hours until the patient is in an appropriate condition to be closed. The fascia is closed, and a Woundvac device (KCI Inc, San Antonio, TX) is placed until granulation has ensued.
Results: Nine patients were included in the study, 5 female and 4 male patients. They had a median age of 67.5 years (range, 43 to 92). One of the patients had profuse bleeding after an inguinal hernia repair that needed reoperation, 8 patients presented with acute abdomen (intestinal necrosis, strangulated parastomal hernia x 2, perforated colon cancer x 2, and incarcerated incisional hernia x 3). All of our 9 patients had a faster recovery and sooner abdominal closure compared with what is reported in the literature on open abdomen management.
Conclusions: We propose this method for the treatment of complicated patients with open abdomen, because it showed no complications related to the Abthera placement and it seems to help in a faster recovery.
10.221 General Surgery
Resection of Gastric and Duodenal Polyps with a Hybrid Technique
Allen Alvarez, MD, Morris E. Franklin, Jr., MD, Karla Russek, MD
Texas Endosurgery Institute, San Antonio, Texas, USA
Objective: This type of surgery combines flexible endoscopy with laparoscopic surgery (2-mm instruments). It allows treatment of intraluminal processes without resecting the affected organ. If needed, a formal resection of the organ can be performed laparoscopically.
Methods: We present 2 cases of intraluminal resection of polyps. One of the patients had a large polyp (>2cm), and the other patient presented with multiple polyps, both in the stomach and duodenum.
Results: All of the polyps were extracted endoluminally without the need of a resection. The larger polyps were extracted orally with the help of the endoscope. No complications were encountered, and the patient's recovery was uneventful.
Conclusions: The endoluminal approach is safe and feasible for gastric and duodenal polyps. Even in cases of large or multiple polyps, an endoluminal approach should be tried first, and in cases where this is not possible, a laparoscopic approach will always be helpful.
10.222 General Surgery
The Use of Prosthetic Materials to Prevent Stoma Hernias
Karla Russek, MD, Morris E. Franklin, Jr., MD, Jojy George, MD
Texas Endosurgery Institute, San Antonio, Texas, USA
Objective: The incidence of hernias on the stoma site ranges from 5% to 50%, and only 10% of these require surgical treatment. Many kinds of repair for stomal hernias have been proposed. Whatever treatment is chosen, most of the time, the hernia repair surgery is technically difficult and the results commonly disappointing. In this study, we describe our technique for placing prosthetic material at the stoma site during the same procedure as the stoma takedown.
Methods: We have been doing so for the last 2 years, and we have included 25 patients with previous ileostomy or colostomy. All of the surgeries were performed laparoscopically. The bowel is taken down and an intracorporeal anastomosis performed. The stoma defect is closed with nonabsorbable suture, and a mesh is applied with an IPOM technique using staples and transfascial sutures.
Results: We have not encountered hernias in the patients who underwent this type of approach, and no complications have been noted regarding the prosthetic material placement.
Conclusions: The reinforcement of the stoma site with a prosthetic material is safe and feasible, and we have seen no hernia incidence in these patients. There were no complications related to the mesh placement, so we consider this a safe complement to any stoma takedown procedure.
10.223 General Surgery
Use of Negative Pressure Devices to Prevent Hernias in High-Risk Patients
Jojy George, MD, Morris E. Franklin, Jr., MD, Karla Russek, MD
Texas Endosurgery Institute, San Antonio, Texas, USA
Objectives: To evaluate the efficacy, safety, and alleged lower hernia rate after the use of negative pressure devices in contaminated fields in high-risk patients.
Methods: From January 2008 through December 2009, 42 patients were included in the study. All of these patients presented with a contaminated abdomen, and a negative pressure was applied using a Wound VAC device (KCI Inc., San Antonio, TX). All were high-risk patients with comorbidities (obesity, diabetes, previous abdominal surgeries).
Results: Of the 42 patients, 28 were males and 14 were females, with a mean age of 67 years (range, 40 to 82). Thirty percent of patients had previous surgery for colon disease that required reoperation, 23% had some type of abdominal cancer, 14% had small bowel disease, most of them presented with intestinal obstruction. Eighteen percent of patients had complications from a previous hernia, either with incarcerated bowl or mesh infection. Ten percent of patients required reoperation, because of bleeding, and during this second procedure, the Wound VAC was placed.
Conclusions: The largest follow-up we have to date is 2 years, and we have only 2 patients who presented with a hernia in this series (4.76%), compared with 20% to 40% reported in the literature on hernia recurrence in this type of patient.
10.224 General Surgery
Two-Incision Laparoscopic Cholecystectomy Using Conventional Laparoscopic Instruments
Anish Nihalani, MD, Kelechi Akuma, MBBS, Ahmed Al-Bazroon, MBBS
Department of Surgery, John F. Kennedy Medical Center, Edison, New Jersey, USA
Objectives: Laparoscopic cholecystectomy is recognized as the standard of treatment for gallstone disease. Traditionally, 4 ports are used. Single-port laparoscopic cholecystectomy often requires significant additional equipment and has a steep learning curve. We describe our experience using conventional operating room laparoscopic instruments to perform 2-incision laparoscopic cholecystectomy on patients with gallstone disease.
Methods and Procedure: Medical records of 16 patients with symptomatic cholelithiasis, acute cholecystitis, or chronic cholecystitis who underwent consecutive 2-incision LC over an 8-month period were reviewed. A 2-cm infraumbilical incision and 5-mm subxiphoid incision were made. A standard 10-mm Hassan trocar and an additional 5-mm trocar were placed via the umbilical incision. The gallbladder was retracted for exposure of the critical view of Calot’s triangle. The cystic artery and cystic duct were dissected and clipped. The operation was completed using a hook electrocautery device, and the gallbladder was retrieved via the umbilical incision.
Results: Fifteen (93%) patients were female. Patient’s ages ranged from 25 to 73 years, with mean age of 42.5. All cases were completed in the manner described. No conversions or complications were recorded. Blood loss was minimal. Mean operative time was 84.4 minutes (range, 49 to 145). The average length of stay (LOS) was 1.1day.
Conclusions: In our experience, 2-incision laparoscopic cholecystectomy performed by using conventional laparoscopic equipment is safe and feasible. The conversion rate, operative time, and LOS were acceptable. It is also conceivable that postoperative pain, cosmetic outcome, and overall patient satisfaction may be better using this technique. We encourage further, more in-depth studies on this interesting subject.
10.225 General Surgery
Patient’s Perceptions of LESS Surgery: The Cosmetic Effect
Alexander S. Rosemurgy, MD, Connor Morton, BS, Michelle Vice, Andy Roddenbery, MD, Linda Barry, MD, Sharona B. Ross, MD
Department of Surgery, University of South Florida, Tampa, Florida, USA
Introduction: Laparoendoscopic single site (LESS) surgery promotes cosmesis with hopes for less pain and quicker return to functional activities than conventional multi-incision laparoscopic surgery does. The purpose of this study was to determine patients’ perceptions of LESS surgery and to compare how these perceptions change after a patient undergoes LESS surgery.
Methods: Preoperatively and postoperatively, 100 patients (72% female, age 55±16.4 years, BMI=28kg/m2±5.4) undergoing LESS surgery completed with unbiased guidance a validated questionnaire with questions about personal appearance and wellbeing utilizing a Likert scale (1=dissatisfied to 10=very satisfied). Data are presented as mean ± SD.
Results: After LESS surgery, patients ranked in descending importance no complications, minimal postoperative pain, quick return to regular diet and functional activities, short hospitalization, and size and number of incisions. After LESS surgery, there were no reductions in patients’ perceptions of “sexual appeal” (preoperative 6±2.2 vs. postoperative 6±2.0), “looks” (6±2.2 vs. 8±2.0), “clothes fit” (6±2.4 vs. 6±2.2), “others’ opinions” (6±1.8 vs. 8±1.6), and “attractiveness” (8±2.2 vs. 8±2.2). Patients were very satisfied with the appearance of their scar (10.9±1.4) and the appearance of their abdomen (P=0.002).
Conclusion: LESS surgery provides very satisfying cosmetic outcomes. However, patients most appreciated no complications, short hospital stays, and minimal pain. There was no decrease in subjective measures of body image with LESS surgery. While it is easy to focus on the obvious cosmetic advantages of LESS surgery, patients most appreciate its concomitant safety and quick relatively painless recovery.
10.226 General Surgery
A Simple Method for Fascial Repair in Laparoscopic Ports
Tavassoli Alireza, Tavassoli Fatemeh, Makhdoumi Tooran
General Surgery, Ghaem Hospital, Endoscopic & Minimal Invasive Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran (Prof. Alireza).
Obstetrics and Gynecology, Emam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran (Prof. Fatemeh).
Ghaem Hospital, Endoscopic & Minimal Invasive Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran (Mr. Tooran).
Background: The repair of a laparoscopic port >7mm in diameter is necessary, but because the incision is small, fascial repair can be difficult. The aim of this study was to test a simple method for fascial repair in laparoscopic ports.
Methods: Fascial repair in laparoscopic ports was performed using Allis forceps, which were put under the fascia by an assistant using a special maneuver. The suturing of the fascia was performed with the use of PDS 0. The operative time and postoperative outcomes were compared.
Results: This method was used to repair 200 ten- and twelve-mm incisions in 120 patients who underwent laparoscopy. Time duration of fascial repair was between 30 seconds and 70 seconds (mean, 45). No intra- or postoperative complications occurred due to this technique. One-year follow-up showed that no patients had symptoms of incisional hernia.
Conclusion: The use of Allis forceps put under the fascia for suturing is a safe method that facilitates fascial repair in laparoscopic ports.
10.227 General Surgery
An Alternative Technique for Laparoscopic Repair of Inguinal Hernia
Tavassoli Alireza, Tavassoli Fatemeh, Makhdoumi Tooran, Tavassoli Samira
General Surgery, Ghaem Hospital, Endoscopic & Minimal Invasive Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran (Prof. Alireza).
Obstetrics and Gynecology, Emam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran (Prof. Fatemeh).
Ghaem Hospital, Endoscopic & Minimal Invasive Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran (Mssrs. Tooran, Samira).
Background: The application of laparoscopic surgery for hernia repair has resulted in an ongoing debate about what is the best inguinal hernia repair. To achieve satisfactory surgical results with minimal surgical invasiveness and decreasing the cost, a novel technique, laparoscopic-assisted preperitoneal (LAPP) repair was devised. The technical feasibility of this method was evaluated.
Method: We treated 26 unilateral inguinal hernia cases by using laparoscopic assistance during a time period of 15 months. After laparoscopy, we created a retroperitoneal pocket under the inguinal floor. After mobilization of the chord and dissection of the sac, a 12-cm x 15-cm piece of mesh was inserted into the pocket without fixation.
Results: Patients ranged in age from 26 years to 65 years. Their body index ranged from 23% to 39% (median, 28). The LAPP repair was accomplished in 24 (92%) of 26 repairs. In the remaining 2 (8%), the procedure was converted to a conventional TAPP method. Median operative time was 45 minutes. The median 15-month follow-up (range, 6 to 25) revealed that there was no recurrence and no operative or postoperative complication.
Conclusion: Laparoscopic-assisted preperitoneal (LAPP) repair is a safe and feasible technique with acceptable results and could be an alternative method for conventional laparoscopic inguinal hernia repair.
10.228 General Surgery
Laparoscopic Revisional Surgery for Recurrent Paraesophageal Hiatal Hernia with Porcine Cross-Linked Collagen Mesh Hiatoplasty
Stavros A. Antoniou, MD, Rudolph Pointner, MD, Frank A. Granderath, MD
Department of General, Visceral, and Minimally Invasive Surgery,Hospital Neuwerk, Germany, Europe (Drs. Antoniou, Granderath).
Department of General Surgery, Hospital Zell am See, Zell am See, Austria, Europe (Dr. Pointner).
The treatment of hiatal hernia has dramatically evolved over recent years. Ηigh recurrence rates characterizing laparoscopic simple hiatorrhaphy has led to several mesh reinforcement techniques with various synthetic materials. Mesh hiatoplasty, however, has been shown to often be accompanied by several complications, including dysphagia, chest and epigastric pain, tissue erosion, adhesion formation, mesh fibrosis, and shrinkage. The latter may also render revisional operations extremely demanding. Similar complications of abdominal wall hernia repair induced by foreign body reactions led to the evolution of several bioprosthetic materials. Permacol is an acellular porcine-derived dermal collagen implant with its collagen fibers chemically cross-linked, to minimize enzymic degradation by tissue proteases. It is superior to synthetic meshes in terms of adhesion formation, mesh fibrosis and shrinking, and its biodynamic and biotechnical characteristics seem to be comparable to these characteristics in other bioprosthetic materials. We present the first case of laparoscopic hiatal reinforcement with this novel material in a patient with paraesophageal hernia recurrence and a large hiatal defect. The postoperative course was uneventful, and the patient remains asymptomatic 3 months after the operation. The clinical and experimental results of cross-linked porcine dermal collagen implants justify its pilot clinical evaluation in hiatal hernia patients.
10.229 Gynecology
Laparoscopic Primary Cytoreduction of Advanced Ovarian Cancer
Farr R. Nezhat, MD, Douglas N. Brown, MD, Shaghayegh M. DeNoble, MD, Prakash C. Saharia, MD
This video illustrates a 61-year-old who underwent optimal laparoscopic primary cytoreduction of advanced ovarian cancer in the form of a radical hysterectomy, bilateral salpingo-oophorectomy, pelvic mass resection, anterior and posterior culdectomy, omentectomy, posterior exenteration, with end-to-end rectosigmoid anastomosis. Final pathology revealed stage IIIC poorly differentiated papillary serous carcinoma of the ovary, and stage IB well-differentiated endometrial adenocarcinoma, FIGO Grade I. The patient is being followed every 3 months. She will receive a total of 6 cycles of Carboplatinum and Taxol. She is currently alive and well and without any evidence of disease.
10.230 Gynecology
Subtotal or Total Hysterectomy: The Critical Question in Nononcologic Patients
Liselotte Mettler, Prof Dr Med
Introduction: Minimally invasive surgery in benign indications for hysterectomy requires the least radical organ-preserving intervention to solve the patient’s problem.
Methods: Total laparoscopic hysterectomy (TLH) is only indicated if the uterine cervix has a problem or when the fibroids are too big. If laparoscopic subtotal hysterectomy (LSH) solves the patient’s problem, no TLH and more radical surgery are necessary. LSH is unique partial organ-preserving surgery, easily done by laparoscopy with fewer side effects than TLH.
Laparoscopic Subtotal Hysterectomy = LSH is done in 4 steps:
• Step 1 - Dissection of adnexas from uterus or pelvic side wall,
• Step 2 - Dissection, presentation, and coagulation of ascending branches of uterine vessels,
• Step 3 - Delineation of uterine cervix from corpus uterine,
• Step 4 - Morcellation of uterus. Whether to cover the cervical stamp with peritoneum is up to the surgeon to decide.
Results: In 60%, hysterectomy can be performed as LSH.
Conclusions: The choice of the type of hysterectomy, be it laparotomy or laparoscopy, in benign indications is clearly for subtotal hysterectomy–in our hands Laparoscopic Subtotal Hysterectomy.
10.231 General Surgery
Totally Laparoscopic Left Colectomy: NoScar or Hybrid Notes Technique
Paolo Ubiali, MD, Michele Ciocca Vasino, MD, Michele Andretta, MD, Federica Maffeis, MD, Sergio Pastori, MD
Divisione di Chirurgia Generale Policlinico San Pietro-Bergamo-Italy
The authors present a video showing a quite new technique of laparoscopic left colon removal without the classical minilaparotomy for specimen extraction and anvil placement. A minimum trocar number and size is used. The vagina route is avoided.
The operation required simply 3 trocars: two 5mm and one 12mm. The colon is prepared taking down the splenic flexure, then ligating and dividing the inferior mesenteric vessels. The specimen is extracted in a bag through the rectal stump, and the anvil of a circular stapler is inserted via the same route. The anvil is placed in the proximal colon, and the anastomosis fired in the conventional transanal way. At the end of the procedure, only 3 minimal port sites need to be closed.
In our opinion there are no particular limits in the indication except a large specimen or a bulky tumor.
The procedure seems to us to be safe, feasible, and repeatable.
The advantages may be on the postoperative course, in particular less pain. We expect better cosmesis, fewer postoperative adhesions and incisional hernias.
The operation shown may be the gate to the real Notes technique.
10.232 Gynecology
Laparoscopy: Gold Standard for Ovarian Tissue Banking (OTB) in Cancer Patients
Kazem Nouri, MD
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, such as conservative methods like injection of Gn-RH analogue and antagonists or IVF with consequent oocyte or embryo cryopreservation.
Methods: This was a retrospective cohort study performed at the Medical School of Vienna, Department of Gynaecological Endocrinology and Reproduction Medicine. It included 87 patients with the wish of fertility preservation through OTB (Ovarian Tissue Banking). Laparoscopic surgery was performed, taking out one-third of one ovary for ovarian cryopreservation and banking. We measured the operating time, major and minor complications and histological and microbiological results.
Results: 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 (Ovarian Tissue Banking). Laparoscopy is the method of choice for ovarian tissue harvesting. After finishing the chemo- or ionization therapy, the reimplantation of the cryopreserved ovary would also be performed by laparoscopy. To date worldwide, there have been 5 live births by this method of fertility preservation.
10.233 Gynecology
The Role of Minimally Invasive Surgery for Diagnosis and Therapy of Uterine Myoma Before IVF/ICSI Cycle
Kazem Nouri, MD
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 therapy of myoma in ART.
Methods: We reviewed 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. We 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 ten percent of IVF patients have uterine myoma, only in special cases. There is a need for operative intervention. The proper diagnosis is to be done by means of hysteroscopy. The gold standard of therapy is the laparoscopic myomectomy.
Conclusions: Only in rare cases are myomas of the uteri the only presenting cause of infertility. Five to ten percent 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 locations and volumes of the fibroids. Minimally invasive surgery measures like hysteroscopy and laparoscopy are the most important tools in both diagnosis and therapy of myoma in IVF/ICSI patients.
10.234 Gynecology
Strategies to Minimize Adhesion Formation after Laparoscopic Surgery
Patrick F. Vetere, MD, Carlene Mondesir, MD, Kellie Moatschmann, MD, Poonam Khullar, MD, Lorna Ogden, MD
Objective: To compare the degree of adhesion formation resulting from the use of either unipolar cautery scissors or the Harmonic scalpel, 2 of the most popular instruments used for dissection during laparoscopic surgery, and to determine whether any additional benefit is gained by the addition of a suspension of sodium hyaluronate/ carboxymethylcellulose.
Methods: Thirty rabbits survived laparoscopic surgery during which injuries were inflicted on each uterine horn and adjacent pelvic sidewalls by using unipolar cautery or ultrasonic energy on opposite sides. Injuries in alternate animals were bathed in either normal saline or a suspension of sodium hyaluronate/carboxymethylcellulose. Autopsies were performed 3 and 1/2 weeks later. Adhesions were scored clinically. Each horn with attached sidewall underwent histologic grading of inflammation and adhesions. The unpaired t test was used for statistical analysis.
Results: No significant difference in adhesion formation between injuries caused by unipolar cautery or ultrasonic energy was detected (P=1.0000) on clinical evaluation. Histological grading of tissue changes between the 2 modalities also demonstrated no significant difference (P=0.9226 comparing ultrasound with cautery). Also, no difference in adhesion formation could be detected when the suspension of sodium hyaluronate/ carboxymethylcellulose in saline was compared with saline alone by clinical (P=1.33) or histologic (P=0.1944) scoring.
Conclusions: Our results indicate that there is no advantage to prevention of postoperative adhesions in the use of either the unipolar scissors or the Harmonic scalpel during laparoscopic surgery and no additional benefit by the addition of a suspension of sodium hyaluronate/carboxymethylcellulose.
10.235 Gynecology
Laparoscopic Partial Duodenectomy: A Novel Approach to the Surgical Management of Duodenal Tumors
Eugene P. Ceppa, MD, Philip A. Omotosho, MD, Eric Hanly, MD, Alexander Perez, MD
Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
Introduction: Duodenal tumors, such as adenomas and carcinoids, are historically managed with endoscopic resection or laparotomy, depending on size, location, and patient comorbidities. Thus, resection of lesions that are too large for endoscopic techniques and possibly too small to warrant a laparotomy is controversial. The objective of this study was to propose a novel minimally invasive approach combining laparoscopy and endoscopy for a partial duodenectomy of duodenal adenomas.
Methods: A patient with a duodenal adenoma not amenable to endoscopic therapies was referred for resection. The patient’s surgery consisted of a laparoscopic partial duodenectomy with esophagogastroduodenoscopy, which was videotaped.
Conclusions: Laparoscopic partial duodenectomy is a safe and effective procedure for the management of duodenal tumors not amenable via endoscopic therapies. This approach provides another option for the management duodenal tumors.
10.236 General Surgery
Laparoscopic Transhiatal Treatment of Epiphrenic Esophageal Diverticulum in the Elderly
M. Salibra, A.M. Minicozzi, A. Princiotta, C. Lorenzini, E. Cucinotta
Background: Diverticulectomy via a left thoracic approach was considered until some years ago to be the conventional surgical treatment for epiphrenic diverticulum. However, recent reports have shown the feasibility of the laparoscopic approach with good postoperative results. We report our experience with 2 elderly patients.
Methods: We treated 2 patients 71 and 77 years of age. Surgery was indicated by the size of the diverticulum and the severity of symptoms, such as dysphagia, vomiting, and weight loss. Preoperative studies included upper gastrointestinal endoscopy, barium swallow, and esophageal manometry. The diagnosis was confirmed by spiral-computed tomography. Motor abnormalities were present in both patients. The operative treatment comprised diverticulectomy, myotomy, and Dor’s fundoplication.
Results: No intraoperative complications occurred. Gastrografin swallow performed on postoperative day 4 did not show any signs of leakage. The postoperative hospital stay was 5 day. The laparoscopic approach allowed easy performance of myotomy and antireflux fundoplication and obviated the need for thoracotomy and pleural drainage, reducing postoperative pain and respiratory complications. Dysphagia improved significantly in both patients.
Conclusion: In our opinion, the laparoscopic transhiatal procedure is an appropriate treatment for epiphrenic diverticula. This method is feasible even in elderly patients, with the advantage of fewer respiratory complications.
10.237 Gynecology
A Multi-Institutional Experience with Single-Port Laparoscopic Hysterectomy with Staging for Endometrial Cancer
Pedro F. Escobar, MD, Luis Rojas-Espalliat, MD, Amanda Nickles Fader, MD
Section of Gynecologic Oncology, Cleveland Clinic, Cleveland, Ohio, USA (Dr. Escobar).
Section of Gynecologic Oncology, Avera McKenna Cancer Institute, Sioux Falls, South Dakota, USA (Dr. Rojas-Espalliat).
Section of Gynecologic Oncology, Greater Baltimore Medical Center, Baltimore, Maryland, USA (Dr. Fader).
Objective: Recent reports suggest that laparoendoscopic single-site surgery (LESS), also known as single-port surgery, is technically feasible in treating a variety of disease processes. The purpose of this study was to report feasibility and perioperative outcomes for endometrial cancer with LESS hysterectomy and staging.
Methods and Procedures: A multi-institutional single-port surgical consortium was created to evaluate the feasibility and usefulness of LESS for gynecologic oncology surgery. Patients who underwent LESS surgery for presumed early endometrial carcinoma between October 2009 and January 2010 were included. Data collected included age, body mass index, operative time, blood loss, number of lymph nodes, need for conversion to conventional laparoscopy, pain scores, and perioperative morbidity. The Student t test and Pearson product-moment correlation coefficient were used for analysis.
Results: Twenty patients had LESS hysterectomy and staging performed. Median patient age and BMI were 60 years (range, 43 to 84) and 32mg/kg2 (range, 19 to 46), respectively. For cases 1 through 10, mean operative time was 152±23 minutes versus 160±43 minutes for the next 11 to 20 cases, P=0.6. Mean operative time was not significantly decreased after the performance of 10 cases (Pearson’s r=0.34, P=0.7). Median number of pelvic and para-aortic nodes was 16 (range, 11 to 21) and 5 (range, 2 to 12), respectively. One case was converted to conventional multi-port laparoscopy. Median postoperative visual pain score was 4.
Conclusions: Single-port laparoscopic hysterectomy with staging is feasible in patients with presumed early stage endometrial cancer. Additional investigation is needed to evaluate the long-term outcomes of this new approach in the treatment of early stage endometrial cancer.
10.238 Gynecology
Laparoscopic Colorectal Surgery: A District General Hospital Experience
Zulfiqar Hanif, FRCS, Sujala Kalipershad, MRCS, Haitham Qandeel, FRCS, Abdul Latif Khabm, FRCS
Hairmyres Hospital, NHS Lanarkshire, Glasgow, United Kingdom (all authors).
Objective: The aim of this study was to assess the outcome of laparoscopic colorectal procedures performed in a district general hospital within 5 years and to compare it with the outcome for open procedures performed during the same period.
Patients and Methods: Data were collected retrospectively from patient’s case notes retrieved from hospital medical records. One hundred consecutive cases of laparoscopic colonic resection for both benign and malignant diseases from 2004 through 2009 were analyzed for perioperative and long-term outcome and were compared with 100 consecutive cases of open colectomies.
Results: The overall conversion rate was 6%. The mean major complication rate was 5%, and minor complications occurred in 7%. The overall morbidity rate was 12%. In 64 patients, curative laparoscopic resections were performed for colorectal malignancy. The mean lymph node harvest was 13.2 nodes; no port-site recurrence was documented at a mean follow-up of 26 months. Average duration of surgery was 180 minutes. Mean postoperative hospital stay was reduced from 13 days to 7 days (Open Vs Lap). No statistically significant difference was found in morbidity and mortality.
Conclusion: Laparoscopic surgery is safe and feasible in elective colorectal cases and reduces the hospital stay.
10.239 General Surgery
Totally Laparoscopic Right Hemicolectomy with Transvaginal Extraction Using Laparoscopic Posterior Colpotomy: A Single Surgeon’s Experience
Ziad T. Awad, MD, FRCSI, Brent Seibel, MD
Department of Surgery, University of Florida College of Medicine Jacksonville, Florida, USA (Drs. Awad, Seibel).
Objective: Despite the growing acceptance of laparoscopic colon surgery, an abdominal incision is needed to retrieve the specimen and perform the anastomosis. We adopted the technique of totally laparoscopic right hemicolectomy and transvaginal extraction for all females who needed right hemicolectomy.
Method: During a 12-month period, 7 females underwent the procedure. The split leg position was used. Intracorporeal anastomosis was performed, and the specimen was retrieved through the vagina in a plastic bag via a laparoscopic posterior colpotomy that was then closed laparoscopically using a running suture of 0 Catgut.
Results: The procedure was finished laparoscopically in all patients. The ASA was III in 5 and II in 2 patients. Three patients had a BMI>30; 5 patients had previous abdominal surgery. Six patients had colon cancer, and one had carcinoid of the appendix. The size of the lesion ranged from 2cm to 6.5cm; the mean number of lymph nodes retrieved was 20 (range, 13 to 30). The proximal and distal margins were free in all specimens. The staging was I in 4 and III in 3 patients. One patient needed reoperative surgery for intraabdominal bleeding from the vaginal cuff suture line. No other patient had pain or drainage from the extraction site postoperatively.
Conclusion: Laparoscopic right hemicolectomy with transvaginal extraction of the colon is a feasible option that can be added to the armamentarium of surgeons performing laparoscopic colon surgery. This technique may provide both an attractive way to reduce abdominal wall morbidity and a bridge to NOTES colon surgery.
10.240 General Surgery
Transanal Endoscopic Microsurgery (TEM) Resection of Benign and Malignant Rectal Tumors
Jose Alberto G. Gonzalez, MD
Hospital Angeles del Pedregal, Mexico City, Mexico
Objective: Transanal endoscopic microsurgery offers a minimally invasive alternative to radical surgery for excision of benign and malignant rectal tumors. This study reviewed our experience with transanal endoscopic microsurgery to clarify its importance in the treatment of different types of rectal tumors.
Methods: A prospective review documented all patients who underwent transanal endoscopic microsurgery from February 1999 to February 2007. We analyzed patient and operative factors, complications including tumor recurrence, excluding patients with known metastases at initial presentation and those who had immediate radical resection following transanal endoscopic microsurgery.
Results: Transanal endoscopic microsurgery was performed in 150 patients for benign tumors and 110 patients for malignant tumors. Complications related to the procedure occurred in 20% of patients. The most common were urinary retention 10.6%, fecal incontinence 4%, anal stricture 2%, fever 3.6%, suture dehiscence 1.2%, bleeding 1.5%.
Local recurrence rates were 4% for adenomas, 8.66 for T1 adenocarcinoma, 23% for T2 adenocarcinoma, 97% for T3 adenocarcinoma, and 0% for carcinoid tumors. All recurrent adenomas were treated in a second procedure with endoscopic techniques.
Conclusion: Transanal endoscopic microsurgery is a safe, effective procedure for excision of benign and malignant rectal tumors. Transanal endoscopic microsurgery is the best option that can be proposed for curative resection of benign tumors, carcinoid tumors, and select T1 adenocarcinoma in the rectum and as a palliative resection in patients medically unfit or those who refuse radical surgery.
10.241 General Surgery
Transanal Endoscopic Microsurgery: A New Approach for the Treatment of Rectal Cancer
Jose Alberto G. Gonzalez, MD
Hospital Angeles del Pedregal, Mexico City, Mexico
Objective: Transanal endoscopic microsurgery is a procedure that has proved its effectiveness in the resection of rectal cancers.
Methods: This prospective study evaluated patients who underwetn transanal endoscopic microsurgery excision for treatment of rectal cancers between January 2002 to January 2008.
Results: In this review, 56 patients (32 men, 24 women) underwent transanal endoscopic microsurgery with a full-thickness excision. Their average age was 72.4 years (range, 47 to 92). The median diameter of the lesion was 3.50cm (range, 1.4 to 8.2). The median distance of the lesion from the anal verge was 8.6cm (range, 4 to 16). The median operating time was 90 minutes, and the median postoperative stay in the hospital was 3 days. There were 12 minor complications that were resolved completely, 1 major complication, and no deaths. The mean follow-up period was 3 years. None of the patients with pT1 rectal cancers received adjuvant therapy. Six patients with pT2 rectal cancer and 2 with pT3 rectal cancer received postoperative adjuvant therapy. There was no recurrence after excision of T1 cancers, and a 14% rate of recurrence in patients with T2 and T3 rectal cancers.
Conclusion: Transanal endoscopic microsurgery is a safe, effective, and successful procedure in select patients with rectal pT1 cancer with low morbidity and no mortality and for patients with more advanced T2 cancers, in frail patients with T3, or in those who refuse major radical resection.
10.242 Gynecology
Good Indications for Single-Port Access (SPA) Surgery in Gynecology: Single Surgeon’s 200 Experiences
Tae Joong Kim, MD, Hwang Shin Park, MD, Joo Sun Kim, MD, Tae Jong Song, MD, Min Kyu Kim, MD, Yoo-Young Lee, MD, Chul-Jung Kim, MD, Chel Hun Choi, MD, Jeong-Won Lee, MD, Byoung-Gie Kim, MD, PhD, Duk-Soo Bae, MD, PhD
Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (all authors).
Objective: To report our initial 200 single-port access (SPA) gynecologic surgeries and present perioperative outcomes at a single center.
Patients and Methods: A single gynecology surgeon (T.J. Kim) performed SPA gynecologic surgery in 200 well-selected patients from May 2008 to December 2009. The Institutional Review Board of Samsung Medical Center, Korea, approved this prospective data collection.
Measurements and Main Results: Two hundred patients underwent SPA gynecologic surgery (105 total hysterectomy; 11 subtotal hysterectomy; 43 oophorectomy; 31 ovarian cystectomy; 5 salpingectomy; 2 myomectomy; 3 only adhesiolysis). Mean patient age was 45 years. Mean body mass index was 23.3kg/m2. SPA surgery was successfully completed in 187 patients, without the need for ancillary ports (93.5%). Conversion to standard multi-port laparoscopy was necessary in 2 cases, and addition of a single port was necessary in 9 cases. Conversion to open surgery was necessary in 2 cases. Intra- and postoperative complications occurred in 1 and 5 cases, respectively. The complication rate was 3.2%. Mean operative time was 126 minutes for total hysterectomy, 212 for subtotal hysterectomy, 72 for oophorectomy, 105 for cystectomy, and 60 for salpingectomy, respectively.
Conclusion: Single-port surgery is feasible and can be applied to the gamut of gynecologic indications. Additional experience, persistent investigation, and continued innovation in instruments may allow single-port surgery to become a more popular practice.
10.243 Gynecology
Results of Laparoscopic Hysterectomy
Khusen B. Narzullaev, PhD
Samarkand, Uzbekistan
Objective: In connection with the increase in the number of patients with uterine myoma, it is necessary to be highly cautious about the method of operative treatment used.
Methods and Procedures: From 2000 through 2009, at the Samarkand Centre of Endoscopic Surgery, we performed laparoscopic uterine extirpation in 64 patients: 50 patients had subserous-interstitial uterine myoma (78.1%), 5 patients had submucous uterine myoma (7.8%), and 9 patients had endometriosis uteri (14.1%). The average age of patients was 38.2±0.9. Uterine size did not exceed 12 weeks of gestation. So, when uterine size was >12 weeks of gestation, we gave priority to laparotomic surgical procedures.
Results: Two patients (7%) indicated a preference for laparotomy. In one patient, the reason for doing laparotomy was degree III obesity, and in the other it was because of varicosis of the broad ligament of the uterus. Laparotomy was performed when we failed endoscopically to arrest bleeding. The average duration of the operation was 84.32±15.6 minutes, and blood loss was 135.5±20.6mL. The average number of days patients stayed in bed after being operated on was 5.4±0.5 days.
Conclusions: Application of laparotomy allows a significant reduction in operative blood loss, decreases the duration of surgery, and promotes rapid reparation of tissue, better revision of abdominal cavity bodies, and a favorable course in the postoperative period.
10.244 General Surgery
The Use of Laser-Supported Diaphanoscopy for the Accurate Localization of Different Lesions of the GI-Tract During Laparoscopic-Endoscopic Rendezvous Surgery
Maciej Patrzyk, MD, Anne Glitsch, MD, Claus Heidecke, Prof. MD
Department of General, Visceral, Thoracic and Vascular Surgery, Ernst-Moritz-Arndt-University Hospital, Greifswald, Germany
Introduction: Localization of gastrointestinal lesions during laparoscopic surgery continues to be difficult and sometimes inaccurate. The most frequently used methods do not lead to precise localization of the tumor. Furthermore, using these methods, resection of the lesions sacrifices too much normal intestinal tissue.
Method: Herein, we present an innovative method using laser-supported diaphanoscopy for the exact localization of lesions of the gastrointestinal tract during laparoscopic surgery. Our group has developed the instrument. Retrospectively, we evaluated 2 groups of patients suffering from gastrointestinal stromal tumors (GIST). The first group consisted of 10 patients treated by Endolight-guided resection. The second group of 10 patients was treated by standard wedge resection without Endolight. Using the equipment, we also demonstrate a tissue-sparing resection of 2 lesions in the large intestine.
Results: Altogether, 10 patients suffering from GIST have been successfully treated using the laser-supported diaphanoscopy in laparoscopic-endoscopic rendezvous procedures. Ten patients were treated without Endolight. The largest resection margins using Endolight (9.8±3.8mm) were significantly smaller than the largest resection margins using wedge resection (Stapler) without Endolight (21.5±9.1 mm, P<0.0001). In addition, 2 tissue-sparing laparoscopic partial small bowel resections were carried out using Endolight.
Conclusion: This technique allows the exact and precise localization of different lesions of the gastrointestinal tract, leading to their exact and tissue-sparing transmural laparoscopic resection.
10.245 General Surgery
The Results of the Application of a Minimally Invasive Approach to the Surgical Treatment of Diseases of the Esophagus
Vladimir Nikishov, MD, PhD, Azat Latipov, MD, PhD, Eugeny I. Sigal, MD, PhD, Tom Sharapov, MD, Albert Sigal, MD
Clinical Cancer Center, Kazan, Russia
Objective: We describe our experience using thoracoscopy and laparoscopy in the surgical treatment of cancer and esophageal achalasia.
Methods: From November 2009 to January 2010, 7 minimally invasive esophagectomies were successfully performed. Average patient age was 51.7 (range, 46 to 60), 5 men and 2 women. Five patients were diagnosed with cancer in the medium third of the esophagus. One carcinoma was present in the inferior third of the esophagus. All patients underwent preoperative radiation. In one patient, fourth-stage achalasia was present. In all cases, the resection phase was performed thoracoscopically with the patient positioned on the left side. The reconstructive phase was performed laparoscopically. Tumor histology results were 2a and 2b squamous cell carcinoma (pT2N0M0 - 2 cases, pT3N0M0 - 3 cases, pT2N1M0 - 1 case).
Results: Median operative time was 285 minutes (range, 250 to 330). Drainage took place for 2.8 days (range, 2 to 4). Median intensive care unit stay was 2.3 days (range, 2 to 3). Median length of stay was 10.5 days (range, 9 to 11). No operative or hospital mortalities occurred.
Conclusion: Minimally invasive esophagectomy is a safe, feasible operation for cancer of the esophagus and fourth-stage achalasia. Thoracoscopy for esophageal cancer allows the adequate performance of the resection stage of the operation and lymphadenectomy for volume 2F. The reconstructive phase of the operation may be performed without complications, while the operation is not changed. Minimally invasive esophagectomy reduces complications and speeds up the process of rehabilitation.
10.249 Gynecology
Knotless Technique for Laparoscopic Cervical Sacrocolpopexy
Peter G. O'Hare III, MD, Charu Dhingra, MD, Timothy B. McKinney, MD, PhD
Drexel University College of Medicine, Philadelphia, Pennsylvania (USA)
Objective: To demonstrate a novel technique utilizing a barbed suture to perform a laparoscopic cervical sacrocolpopexy.
Methods and Procedure: Standard laparoscopy and mesh placement with barbed suture (Quill Suture).
Results: To show equivalent results of this technique with standard laparoscopic methods.
Conclusion: Utilization of the barbed suture can decrease intraoperative time without compromising patient safety.
10.250 Gynecology
Knotless Technique for Laparoscopic Sacrocolpopexy
Charu Dhingra, MD, Timothy B. McKinney, MD, PhD, Peter G. O'Hare III, MD
Drexel University College of Medicine, Philadelphia, Pennsylvania (USA)
Objective: To demonstrate a novel technique utilizing a barbed suture to perform a laparoscopic sacrocolpopexy.
Methods and procedure: Standard laparoscopy and mesh placement with barbed suture (Quill Suture).
Result: To show equivalent results of this technique with standard laparoscopic methods.
Conclusion: Utilization of the barbed suture can decrease intraoperative time without compromising patient safety.
10.251 General Surgery
Chyloascites Following Laparoscopic Nissen Fundoplication: Management After Failure of Conventional Methods
Paul F. Hwang, MD, Earl Lee, MD, Karen A. Callaghan, MD, Scott T. Rehrig, MD
Walter Reed Army Medical Center, Division of General Surgery, Washington, DC, USA (all authors).
Naval Medical Research Center, Department of Regenerative Medicine, Silver Spring, Maryland, USA (Dr. Hwang).
Background: Chyloascites is a rare and challenging complication that can result from abdominal trauma, neoplasm, inflammatory conditions, or various abdominal surgeries. Only a few cases have been described in the literature secondary to iatrogenic injury from laparoscopic Nissen fundoplication. We describe a case in which the surgery resulted in
chyloascites that was successfully treated with an unconventional method–lymph duct glue embolization.
Methods: We present the case of a 37-year-old male initially treated at an outside institution for signs and symptoms consistent with chronic reflux disease. He underwent an uneventful laparoscopic Nissen fundoplication. Two weeks after surgery, he was admitted for dehydration and prerenal acute renal failure. Throughout his admission, he began to develop a persistent cough, shortness of breath, and abdominal distention. Imaging and fluid analysis from thoracocentesis/paracentesis was consistent with chyle leakage into both areas. The patient’s status did not change despite nonoperative measures to include octreotide therapy.
Results: Thoracic duct ligation was performed, but the patient’s symptoms continued to persist. Bipedal lymphangiography identified an extensive leak at the level of T10, revealing a severely lacerated thoracic duct spilling contrast freely into the left upper quadrant of the abdomen and no contrast entering the thoracic duct in the chest.
The site of injury was successfully sealed off with percutaneous glue embolization through lymph channels.
Conclusion: Chyloascites is a rare complication of laparoscopic Nissen fundoplication. When conservative measures or thoracic duct ligation are not successful, lymphatic glue embolization can provide effective treatment.
10.252 Gynecology
Laparoscopic-Assisted Vaginal Hysterectomy for Gigantic Uterus: A Report of 84 Cases
Xiaoyan Ying, MD
Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
Objective: To investigate the feasibility and clinical value of laparoscopic hysterectomy of the gigantic uterus.
Methods: A retrospective analysis was done on 84 cases of laparoscopic-assisted vaginal hysterectomy (LAVH) of large uteri enlarged more than 12-week gravida, compared with 30 cases of transabdominal hysterectomy (TAH) of large uteri.
Results: All LAVH were performed successfully laparoscopically without any complications. The operative time was 97.7±65.7 minutes. The blood loss during the operation was 132±43mL, and the average hospital stay was 6.1 days. The average duration of LAVH was more than that of TAH (P＜0.001). But the cases of LAVH were significantly less than those of TAH (P＜0.005) in the blood loss, postoperative morbidity rate, and the average hospital stay.
Conclusions: Laparoscopic-assisted vaginal hysterectomy for the gigantic uterus is safe and feasible, but surgeons should have extensive experience in laparoscopic procedures and the skills needed to perform laparoscopy.
10.253 General Surgery
A Safe and Quick Technique for Placement of the First Access Port for Creation of Pneumoperitoneum
Ahmed Khan Sangrasi, FCPS, Abdul Aziz Laghari, FRCS, Mujeeb Rehman Abbasi, FRCS, Naushad A. Shaikh, MS
Liaquat University of Medical & Health Sciences, Jamshoro, Pakistan.
Objective: Both closed and open techniques are being used simultaneously with varying frequencies. Some studies of slight modifications of both basic approaches have been published and others are ongoing. We conducted this study in a pursuit the elimination of some disadvantages of the open technique, an already proven safer technique.
Methods: In 1250 consecutive patients who underwent various laparoscopic procedures, a modified open technique was used. This technique involves identification and incision of a point at the junction of the umbilical stalk and linea alba infraumbilically. By this technique, penetration of a blunt trocar was possible under direct vision with minimal and controlled axial force. Time needed to induce pneumoperitoneum and intraoperative and postoperative complications were recorded.
Results: Intraabdominal access was successfully achieved in all cases without any vascular or solid organ injury except in 3 (0.24%) patients, in whom the procedure failed due to severe adhesions because of previous abdominal surgeries. Mean time taken to induce pneumoperitoneum was 4.0 minutes (range, 2 to 9.5), while time required to close the first access port was 4.5 minutes (range, 3 to 8). Enterotomy was recorded in 2 (0.16%) patients, while postoperative port-site hernia occurred in 2 (0.16%) patients. There was port-site infection in 6 (0.48%) patients and port hematoma in 4 (0.32 %). Gas spillage was recorded only in 6 patients.
Conclusion: We recommend a modified open technique as the technique of choice in all patients requiring laparoscopic surgery in general and in patients in developing countries in particular where intraabdominal adhesions are not uncommon.
10.254 General Surgery
Minimal Access Surgery for Hydatid Cyst of the Liver
Ahmed Khan Sangrasi, FCPS, Abdul Aziz Laghari, FRCS, Mujeeb Rehman Abbasi, FRCS, Naushad A. Shaikh, MS
Liaquat Univerisity of Medical & Health Sciences, Jamshoro, Pakistan.
Objective: Hydatid disease is an endemic condition in several parts of the world, primarily affecting the populations of developing countries. Because we live in an endemic area, we evaluated the feasibility and safety of laparoscopy in the management of hydatid cysts, because further trials are still necessary.
Patients and Methods: All consecutive patients diagnosed with liver hydatid disease were offered laparoscopic management. All patients were given oral albendazole for 2 weeks preoperatively and continued for 4 weeks postoperatively. We performed some selected conservative procedures using standard laparoscopic instruments after sterilization of cysts by 20% hypertonic saline. Deroofing, evacuation, and partial cystectomy were performed. Omentoplasty was done, and the drain was placed in the cyst cavity.
Results: Forty-four patients (M:F=35:9) with 53 cysts were managed successfully by laparoscopy. Mean age of patients was 34.7 years. Mean operative time was 86 minutes (range, 55 to 130). Mean cyst size was 8.5cm (range, 6.6 to 15.5). Mean hospital stay was 3.2 days (range, 1 to 7). No disease or procedure-related mortality occurred. Cyst recurrence was observed in 2 (4.5%) patients. Two patients were converted to open surgery. No major complications occurred. A minor biliary leak was observed in 5 patients and cavity infection in 3.
Conclusion: Laparoscopic treatment of hydatid cysts of the liver is a safe, effective method with low morbidity and recurrence rate in uncomplicated cysts. Despite some of its limitations, the procedure is a good alternate to open surgery in properly selected patients.
10.255 General Surgery
Laparoscopic Cholecystectomy in a Patient with Situs Inversus
Dr. Alfred J. Augustine, MBBS, MS
Department of Surgery, Kasturba Medical College Hospital, Manipal University Attavar, Mangalore India
Objective: Situs inversus totalis is a rare congenital disorder. Symptomatic cholelithiasis is quite common in India; however, it is extremely rare to find it in a patient with situs inversus. We report a case of successful laparoscopic cholecystectomy in a patient with situs inversus totalis.
Methods: mm umbilical port was placed for the camera, and a 5-mm epigastric port was placed. Two subcostal ports were placed on the left side (one 10mm and one 5mm). A mirror was placed opposite the monitor to help in orienting the anatomy. The procedure was completed in 2 hours, and the postoperative period was uneventful.
Results: Dissection from the midclavicular port with the right hand with the lateral displacement of the neck of the gallbladder using the left hand through the subxiphoid port is difficult, because the tip of the dissector will lose its perpendicular angle to the dissection plane and become positioned with a very narrow angle. We performed the dissection alternatively from both ports. The dissection was safe and confirms previous reports of safe laparoscopic cholecystectomy in situs inversus.
Conclusion:
· Orientation confusing: Using a mirror helps in orientation of the anatomy.
· For right-handed surgeons: Using the nondominant hand for dissecting Calot’ triangle is difficult.
10.256 Gynecology
Frequency of Isthmoceles and Treatment: Asymptomatic Isthmocele
Arben Haxhihyseni MD
Objective: We studied the frequency of isthmocele, an obstetric complication of caesarean delivery due to the presence of a diverticulum on the anterior wall of the uterine isthmus or of the cervical canal at the site of a previous cesarean delivery scar that probably is correlated with abnormal postmenstrual uterine bleeding. The aim of our study was to assess the frequency of isthmocele, the correlation between isthmocele/ abnormal postmenstrual uterine bleeding, and the effectiveness of the hysteroscopic surgical technique to correct the anatomic defect and the symptoms.
Methods: The study included 385 women who had one or more cesarean deliveries at Durres Maternity (2008-2009). Patient selection was casual. The isthmocele diagnosis was made throw hysteroscopy with Karl Storz Betochi hysteroscope, and symptomatologic cases were treated with resectoscopic surgery by deleting the entry of the isthmocele and resecting the endometrium at the end of the isthmocele with a 9-mm Olympus resectoscope using a cutting loop and pure cutting current. All procedures were free of complications.
Results: Of the 385 patients, 18 were diagnosed with isthmocele. In 11/18, the isthmocele was in the inferior segment near the isthmus, 7/18 were in the cervical canal, 14/18 were symptomatic, and 4/18 asymptomatic. Anatomic defects were treated 100% with resectoscopic surgery and symptoms were eliminated. Asymptomatic isthmoceles were not treated.
Conclusions: Isthmocele is a cesarean delivery complication and may be symptomatic. This anatomic defect can be diagnosed hysteroscopically, and symptomatic forms can be successfully treated by a resectoscopic technique.
10.257 Pediatric
A Simple Vacuum Dressing Reduces the Wound Infection Rate of Single-Incision Pediatric Endosurgical Appendectomy
Richard Keijzer, MD, PhD, Oliver J. Muensterer, MD, PhD
Division of Pediatric Surgery, Children's Hospital of Alabama, Department of Surgery, University of Alabama at Birmingham, Alabama, USA
Objective: After introducing single-incision pediatric endosurgical (SIPES) appendectomy at our institution, we noticed an increased number of postoperative umbilical infections. The aim of this study was to evaluate the impact of a simple, low-cost wound vacuum dressing on the wound infection rate.
Methods: Over a 5-month period, 1 of the 3 surgeons in our practice used a novel umbilical vacuum dressing in all his patients who underwent SIPES appendectomy. The dressing consists of 2-in x 2-in gauze placed over the incision, covered by a bio-occlusive transparent adhesive membrane. A vacuum is then created using a 10-mL syringe on a 22-g needle. The wound infection rate was compared between patients with the vacuum dressing and those with standard dressing. Statistical analysis was performed using Fisher’s exact test, and P<0.05 was considered statistically significant.
Results: A total of 77 children were included in this study, 48 of which were treated with the vacuum dressing. Perforated appendicitis was found in 11 (23%) patients with vacuum, and 5 (17%) patients with standard dressing. There were no wound infections in the vacuum group, versus 3 infections in patients with standard dressing (P=0.049). One infection occurred after surgery for acute appendicitis, and 2 in the setting of perforated appendicitis.
Conclusions: Using this simple vacuum dressing in patients undergoing single-incision endosurgical appendectomy may lower the postoperative umbilical wound infection rate. It may be equally effective for other indications.
10.258 General Surgery
Treatment of Roux Limb Retrograde Peristalsis Following Laparoscopic Roux-en-Y Gastric Bypass
C. Sanders, DO, M. Neff, MD, L. Shaw, RN, L. Balsama, DO
Kennedy University Hospital, Stratford, New Jersey, USA.
Objectives: Retrograde Roux limb peristalsis following laparoscopic Roux-en-Y gastric bypass (RYGB) can be difficult to identify. It may present as persistent nausea, vomiting, abdominal pain, or even GI bleeding related to an anastomotic ulcer. When this problem is identified, revisional surgery is indicated.
Methods and Procedures: A 51-year-old female underwent an uncomplicated RYGB. For 3 months postoperatively, the patient had persistent problems of nausea, vomiting, and abdominal pain. Despite medical treatment for an anastomotic ulcer identified by EGD, her symptoms continued. Mild dilatation of the Roux limb was evident on CT scan. Upper GI series revealed retrograde peristalsis of the Roux limb. The patient was taken to the operating room for diagnostic laparoscopy. No internal hernia or obstruction was identified. The jejunojejunostomy was revised utilizing an intraluminal stapling technique.
Results: Postoperatively, the patient had complete relief of her GI symptoms. Normal (antegrade) peristalsis of the Roux limb was seen on postoperative upper GI series.
Conclusions: Roux limb retrograde peristalsis following laparoscopic Roux-en-Y gastric bypass is an unusual problem. In this patient, symptoms of persistent nausea, vomiting, and abdominal pain, as well as upper GI bleeding were all clues to this diagnosis. The upper GI series was diagnostic. Although the etiology of this phenomenon is unclear, laparoscopic revision of the jejunojejunostomy in this patient resulted in complete resolution of the signs and symptoms of retrograde peristalsis.
10.259 General Surgery
A Biologic Alternative to Prosthetic Mesh for the Laparoscopic Preperitoneal Extraperitoneal (TEPP) Repair of Inguinal Hernias
Joseph J. Pietrafitta, MD
Background and Objectives: The surgical repair of inguinal hernias has undergone many changes over the past 2 decades, including the introduction of laparoscopic techniques. Laparoscopic repair has undergone a number of modifications from the procedure initially reported. This study was performed to determine the feasibility of using a biologic material (Fetal bovine dermal collage matrix, Surgimend, TEI Biosciences, Boston, MA) for laparoscopic totally extraperitoneal preperitoneal (TEPP) inguinal hernia repair.
Methods: The material used had a nominal thickness of 0.8mm to 1.2mm. It was cut into a standard shape using a template, rehydrated, introduced into the preperitoneal space and secured with a spiral tacker to pubic bone, Coopers ligament and anteriorly and laterally to muscle. Between 10/15/08 and 8/4/09, a total of 26 patients underwent 35 repairs. There were 24 males and 2 females. Fifteen patients had unilateral and 10 had bilateral repairs.
Results: The time required to perform unilateral repairs ranged from 22 to 85 minutes with an average of 39 minutes and for bilateral repairs from 39 to 74 minutes with an average of 52 minutes. Three patients had incidental hernias on the opposite side, 2 not repaired for technical reasons and one repaired with an open technique. There were no intraoperative complications. Postoperative complications included one seroma. Follow-up ranged from 7 to 16.5 months with an average of 12.2 months. There were no acute recurrences. One recurrence occurred at 4 months in the patient who developed the seroma.
Conclusion: This small series demonstrates the feasibility of using biologic material in the laparoscopic repair of inguinal hernias.
10.260 General Surgery
Laparoscopic Resection of a Giant Right Adrenal Tumor
Shabirhusain S. Abadin, MD, MPH, Peter Angelos, MD, PhD
St. Joseph Hospital (Dr. Abadin).
University of Chicago Hospitals, Chicago, Illinois, USA (Dr. Angelos).
Purpose: We present the case of a laparoscopic resection of a giant right adrenal tumor. Our patient, a 52-year-old male, was found to have a 10-cm right adrenal mass on incidental CT evaluation. Biochemical evaluation was negative for a functional tumor, but given the large size, resection was planned.
Methods: This is a video case presentation demonstrating the laparoscopic management of a giant right adrenal tumor.
Results: Our patient did well postoperatively. He was discharged on postoperative day 2, and his final pathology showed a benign adrenal cortical neoplasm confined to the adrenal gland without any lymphovascular invasion.
Conclusions: This case demonstrates the laparoscopic management of a patient with a giant right adrenal tumor. The challenges of this operation are twofold. First, attaining adequate exposure for vascular dissection is integral, especially for a right-sided adrenalectomy. The right adrenal vein is typically larger and much shorter than the vein on the left side. Also, the proximity of the right adrenal vein to the vena cava make exposure that much more important so that injury can be avoided. Secondly, it is critical to maintain control of the large adrenal gland to prevent any tumor spread, because the tumor may be malignant. As such, the use of an Endo-Catch bag to retrieve the large gland helps prevent tumor seeding or port-site metastases. Minimally invasive adrenal resection remains an accessible option even for patients with large adrenal tumors.
10.261 General Surgery
Laparoscopic Repair of Small Ventral Abdominal Wall Hernias Using Bovine Fetal Dermal Collagen Matrix (Surgimend): Technique and Results of a 25-Patient Study
Joseph J. Pietrafitta, MD
Objective: Laparoscopic repair of ventral abdominal wall hernias has been used increasingly in general surgery. There are potential problems related to the prosthetic materials used in this type of repair. These include fibrosis, contraction, infection and promotion of adhesions. Nonadherent surfaces have been developed. This does not however address the other problems related to prosthetic materials. This study was done to determine the feasibility of using a biologic material (bovine fetal dermal collagen matrix, TEI Biosciences, Boston, MA) to repair small ventral abdominal wall hernias.
Methods: All repairs were performed using a 10-cm x 15-cm piece of material cut into an oval shape, rehydrated, and placed in the abdominal cavity with sutures at the 12, 3, 6 and 9:00 positions. The sutures were brought through the abdominal wall and tied. Spiral tacks were then placed around the edge of the material and the edge of the defect. The procedure is described in detail.
Results: From 1/14/09 to 8/4/09, 25 hernias were repaired. Patients included 20 males and 5 females. Thirteen of the hernias were umbilical and 12 were incisional. Fifteen were incarcerated. Procedure times ranged from 22 minutes to 149 minutes with an average of 52. There were no conversions. Follow-up ranged from 6 months 26 days to 13 months 16 days with an average of 10 months 24 days. There were 3 recurrences, which are described in detail.
Conclusion: The use of this material is technically feasible and with modifications can become the procedure of choice for the repair of small ventral abdominal wall hernias.
10.262 General Surgery
Laparoscopic Repair of Large Hiatal Hernias with Acellular Dermal Allograft
Joaquin A. Rodriguez, MD, Brenda L. Holbert, MD
Department of Surgery, Texas A&M HSC/Scott and White Hospital (Dr. Rodriguez).
Department of Radiology, Texas A&M HSC/Scott and White Hospital (Dr. Holbert).
Objective and Hypothesis: To determine the incidence of recurrent hiatal hernia, relief of gastroesophageal symptoms and incidence of postoperative complications in patients with a large (>5cm) hiatal hernia repaired primarily with onlay biological mesh reinforcement. Our hypothesis is that acellular dermal allograft will lower the incidence of hiatal hernia recurrence and relieve reflux symptoms without increasing the incidence of complications.
Methods and Procedures: This was a retrospective chart review of a prospective database maintained by a single surgeon of hiatal hernia repairs with acellular dermal allograft reinforcement in 24 patients with hernias >5cm. Hernia recurrence was determined by the staff radiologist’s reading of esophagrams or CT scans.
Results: Clinical and radiologic follow-up was available on 87.5% and 83% of patients, respectively. Mean radiological follow-up occurred at 16.5-months postoperatively. The incidence of recurrence was 5.0% in patients available for radiologic follow-up. Heartburn and regurgitation were eliminated or improved in 88% and 5.8%, respectively. Chest pain was eliminated or improved in 85% and 5%, respectively. New onset dysphagia occurred in 1 patient for an incidence of 4.8%. There was one incident of deep vein thrombosis diagnosed for a major complication rate of 4.16%.
Conclusions: The use of acellular dermal allograft as an onlay patch to repair hiatal hernia >5cm decreases the incidence of recurrence. Typical GERD symptoms improve in the majority of patients. There does not appear to be an increased incidence of dysphagia or other mesh complications in mid-term outcomes following the repair of hiatal hernias with acellular dermal allograft.
10.263 Gynecology
Laparoscopic Management of Heterotopic Pregnancy
Joong Sub Choi, MD, PhD, Jung Hun Lee, MD, PhD, Chang Eop Son, MD, Seung Wook Jeon, MD, Jong Woon Bae, MD, Jin Hwa Hong MD, Woong Ju, MD
Department of Obstetrics and Gynecology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (Drs. Choi, Lee, Son, Jeon, Bae, Hong).
Department of Obstetrics and Gynecology, Ewha Woman’s University Hospital (Dr. Ju).
Objective: To evaluate the feasibility and efficacy of laparoscopic management for heterotopic pregnancy.
Methods: A retrospective review was conducted of 7 women who underwent laparoscopic surgical management for heterotopic pregnancy between July 2007 and December 2009.
Results: The median age, parity, body mass index, and number of previous abdominal surgeries of the women were 34 years (range, 28±38 years), 0 (range, 0±1), 20.9kg/m2 (range, 18.4±23.0), and 0 (range, 0±1), respectively. The median operating time was 40 minutes (range, 20±75). The median length of hospital stay was 5 days (range, 3±7 days). There was no maternal or fetal mortality or morbidity, conversion to laparotomy, or uterine injury. Five women delivered 6 healthy infants. One patient had a termination due to missed abortion 3 weeks after discharge, and one patient had an ongoing pregnancy.
Conclusion: Laparoscopic management of heterotropic pregnancy is feasible and effective.
10.264 General Surgery
The Virtual World: Initial Impressions of a New Platform for Surgical Education
J. Rosser, MD, P. Wetter, MD, M. Russo, MD, R. Hinrichs, T. Valls, C. Gracia, MD, R. Satava, MD
Morehouse School of Medicine, Atlanta, Georgia, USA.
Introduction: With the institution of additional regulated educational requirements and the fast-paced introduction of new information and procedures, surgeons are challenged to match the pace. It is clear that our current content delivery methodology must be augmented by new educational technology, tactics, and techniques. This abstract reviews an early experience using virtual worlds as a platform for conducting minimally invasive conferences and teaching of surgical procedures.
Methods: This study utilized a private Second Life Virtual World platform Medipelago to distribute live and stored content from the 2009 SLS EuroAmerican Summit IV surgical conference: (1) the proceedings of the first day of the conference and (2) an intracorporeal suturing training presentation.
Results: There were 51 participants with an age distribution of over 59 years = 16; 50 to 59 years = 9; 40 to 49 years = 15; 30 to 39 years = 9; under 30 = 2. Gender distribution was male=40 and female=11. Thirty-six (70.5%) were trained surgeons, and the others were residents or other providers. Forty-two (82.3%) of the participants had previous video game experience. Thirty (58.8%) had no knowledge or experience with virtual worlds. Thirty-nine (76.4%) had no previous knowledge or experience with Second Life. In a survey questionnaire concerning the potential use of virtual worlds for surgical conferences and training, the group responded 88%, 88%, and 74.5% in a favorable fashion.
Conclusion: In spite of the senior nature of the participants and lack of virtual world experience, the group was favorably impressed with the capabilities of virtual worlds as educational platforms. This indicates that more study and due diligence should be directed in validating their potential in surgical education.
10.265 Urology
Robotic-Assisted Laparoscopic Partial Nephrectomy: Single Institution Experience
Alex Gorbonos, MD, Wesley Yip, Clayton S. Lau, MD, Nora Ruel, Timothy G. Wilson, MD, David Y. Josephson, MD
Department of Urology and Urologic Oncology, City of Hope, Duarte, California, USA
Introduction: Recent publication of practice guidelines on the management of renal masses emphasizes the importance of nephron-sparing surgery approaches. Laparoscopic techniques, although associated with longer operative times, have challenged open partial nephrectomy. Robotic assistance serves as an alternative minimally invasive approach. We report on our institutional experience in robotic-assisted laparoscopic partial nephrectomy.
Methods: We retrospectively reviewed our experience with 38 consecutive da Vinci partial nephrectomies performed between March 2005 and November 2009. The clinical, perioperative, and pathologic data were analyzed. The median follow-up was 6.5 months (range, 0.2 to 50).
Results: The median patient age was 59 (range, 31 to 86). The median BMI was 27.8kg/m2. Mean surgery duration was 239 minutes (range, 137 to 403). Median warm ischemia time was 25 minutes (range, 15 to 55). There were 4 perioperative complications. Median blood loss was 291mL (range, 50 to 2300). Median tumor size was 3.0cm (range, 1.1 to 8.6). Twenty-six of 38 (68.4%) cases were performed for a malignant mass. All surgical margins were negative. The average length of stay was 3 days (range, 2 to 6). Average change in serum creatinine was 0.08mg/dL. During follow-up, no patients experienced a significant change in renal function compared with preoperative levels, and there was no evidence of tumor recurrence.
Conclusions: Our results show that robotic partial nephrectomy is effective from oncologic and nephron-sparing standpoints. Robotic assistance may serve as a bridge in the gap in ischemia time associated with open and pure laparoscopic techniques. The morbidity associated with this technique, however, is much more favorable when compared with an open partial nephrectomy.
10.266 Urology
The Use of Fibrin Sealant in the Renal Pelvis When Encountering Active Hemorrhage
Jayram Krishnan, DO, MBA, Kathleen McGinley, DO, Robert Barsky, DO, Gordon Brown, DO, Jerome Pietras, DO
Urologic Surgery Residency Program, University of Medicine and Dentistry of New Jersey, School of Osteopathic Medicine, Stratford New Jersey
Control of active hemorrhage in the renal pelvis is a challenge for the endourologist. We explore the use of a fibrin sealant agent (Tisseel, Baxter Healthcare, Westlake, CA) in the renal pelvis for control of active hemorrhage in a patient who presented with gross hematuria. During flexible ureteroscopy, we safely injected the fibrin sealant directly on the area of bleeding and confirmed hemostasis. The use of fibrin sealant has been shown to be effective in the urinary tract during tubeless percutaneous nephrolithotomy. However, studies of fibrin sealants for acute bleeding in the renal pelvis are sparse. Fibrin sealants have been shown to interact safely and effectively when mixed with urine, forming a solid gelatinous clot, which after 5 days becomes a fine particulate matter. The use of fibrin sealants in the urothelial tract seems promising but will require further in vivo investigation.
10.267 Gynecology
Our Method for the Removal of Laparoscopic Specimens: Large Fibroids, Ovarian Masses, and Ectopic Pregnancy
Gerard Pregenzer, MD, George K. Tweddel, MD, Frederick Perl, MD, Gerard Pregenzer, Jr., BS
Somerset Medical Center, Somerville, New Jersey, USA
Objective: To assess the feasibility, safety, operative time, and efficacy of laparoscopic removal of surgical specimens via a transvaginal approach.
Method: In a prospective observational study, 11 women (ages 21 to 42 years) underwent operative laparoscopy for pelvic masses. Vessel technology was utilized to enucleate or detach the specimen. While anteverting the uterine corpus and stabilizing the uterus with a single tooth tenaculum on the posterior lip of the cervix, a nonbladed 12-mm trocar was passed transvaginally, just under the cervix, into the cul-de-sac in one smooth motion. A large Endopouch bag was placed through this trocar, and the specimens were placed in the bag for removal. Occasionally, the colpotomy, without cautery, was extended, and Breisky-Navratil vaginal retractors were used to facilitate removal of the specimen. Colpotomies were closed with 0-Vicryl suture.
Results: The average time for all these cases was 45 minutes (range, 20 to 70). The specimen weight range was from 28g to 335g. Pathology included leiomyomas, endometriomas, dermoid cysts, and adenofibroma. No significant morbidity was reported, and all patients returned to normal activities within a few days.
Conclusion: We are very pleased with the ease of specimen removal and minimum patient discomfort when specimens are removed transvaginally. Previously, we have removed the specimens via the umbilicus (struggling to keep the incision small) and then taking additional time to close the fascial defect. This welcomed method of specimen removal together with the widespread use of vessel technology have cut most of our operative times in half.
10.268 General Surgery
Efficiency of Laparoscopic Adrenalectomy in the Treatment of Patients with Hypercortisolemia
M. Otto, Prof. Dr. Med, J. Dzwonkowski1, MD, A. Kasperlik-Załuska, Prof. Dr. Med, W. Zgliczyński, Prof. Dr. Med, L. Papierska, MD, J. Szmidt, Prof. Dr. Med
Department of General, Vascular, and Transplant Surgery, The Medical University of Warsaw, Poland (Drs. Otto, Dzwonkowksi, Szmidt).
Department of Endocrinology, Centre for Postgraduate Medical Education, Warsaw, Poland (Drs. Kasperlik-Zaluska, Zgliczyński, Papierska).
Objective: Laparoscopic adrenalectomy (LA) has become a referential treatment for hormone-active adrenal lesions and those without clinical symptoms. The aim of the study was to demonstrate the efficiency of LA in the treatment of patients with ACTH-dependent and ACTH-independent hypercortisolemia.
Materials and Methods: Of the 529 patients operated on at our center from October 10, 2007 through December 12, 2009, 100 (18.9%) patients had hypercortisolemia: 4 (4%) had Cushing disease, 47 (47%) had Cushing syndrome, and 49 (49%) had pre-Cushing syndrome. In case of Cushing disease and Cushing syndrome, 4 (4%) simultaneous bilateral LA and 9 (9%) 2-staged adrenalectomies were performed. In case of pre-Cushing syndrome, 48 (48%) unilateral LA were routinely performed, and only 1 (1%) 2-staged adrenalectomy was performed. The choice of the side of the operation depended on the size of the tumor, intensity of growth, and the density on the MR and CT scans. All patients had arterial hypertension and diabetes. Operations were made via a lateral transperitoneal approach.
Results: Comparing patients with hypercortisolemia with the remaining patients, the mean time of the simultaneous bilateral LA was 307.5 vs. 301 minutes, unilateral LA 138 vs. 134 minutes; conversion was necessary in 2/100 (2%) cases vs.11/429 (2.5%). The mean postoperative hospital stay was the same: 5.2 days. Comparing intra- and postoperative complications, they appeared more often in patients with hypercortisolemia 7% vs. 1.9%. Patients after unilateral adrenal resection in pre-Cushing syndrome had hormonal normalization, without the need for contralateral adrenal resection during observation.
Conclusions: Laparoscopic adrenalectomy via the lateral transperitoneal approach is a safe and efficient operation for patients with hypercortisolemia.
10.269 General Surgery
Does High-Frequency Adjustment in Laparoscopic Gastric Banding Patients Lead to Increased Weight Loss?
A. Kandel, MD, J. Taylor, MD, G. Deutsch, MD, N. Hubbard, MD, D. Gadaleta, MD, L. Gellman, MD
Introduction: Morbid obesity has become a worldwide epidemic. Currently, surgery has been used to treat the disease. Laparoscopic gastric banding, one of the surgical techniques, involves positioning a silicone adjustable device around the gastric cardia.
Our aim was to determine the percentage of excess weight loss in 2 different patient populations that underwent laparoscopic gastric banding at a single institution.
Methods and Results: This study was a retrospective chart review and analysis of 50 patients who underwent laparoscopic gastric banding at a single institution during a 1.5-year period. The above patients were divided into 2 groups for analysis: a historical conservative adjustment control group and a high-frequency adjustment group. Each group had 25 patients. The above groups were similar in age and weight. We compared the percentage loss of excess weight in both groups. The percentage excess weight loss in the conservative group ranged from 5% to 16% and averaged 9%. The percentage excess weight loss in the high-frequency adjustment group ranged from 1% to 26% and averaged 12%. There were no intraoperative complications in either of the 2 groups.
Conclusion: In our study, the conservative group had an average of 9% excess weight loss, while the high-frequency adjustment group had 12% excess weight loss. We believe patients who undergo laparoscopic gastric banding benefit from higher frequency adjustments resulting in a higher percentage of weight loss. Larger studies are needed to support our preliminary findings.
10.270 General Surgery
Comparison of Adhesion and Contracture Characteristics of Permanent and Absorbable Barrier Mesh Products Following Implantation/Fixation with Mechanical Absorbable Fixation in a Porcine Model of Simulated Laparoscopic Ventral Hernia Repair
Corey R. Deeken, PhD, Brent D. Matthews, MD
Washington University School of Medicine, Department of Surgery, St. Louis, Missouri, USA
Background and Objective: Permanent and absorbable barrier meshes provide surgeons with multiple options for laparoscopic ventral hernia repair. The emergence of absorbable mechanical fixation may also represent an advantage due to reduced long-term fastener retention. The objective of this study was to evaluate postoperative adhesions and percentage area mesh contracture.
Methods: The study population consisted of 3 groups of 5 female Yorkshire pigs (n=15), which were laparoscopically implanted with permanent [Ventrio Hernia Patch (VHP)] or absorbable barrier [(Sepramesh IP Composite)(SM), (Proceed Surgical Mesh)(PSM)] meshes measuring 4.3x5.5 inches, and mechanically fixated to the intact peritoneal wall with a SorbaFix Absorbable Fixation Device (SFD) (n=10 meshes/group). After 4 weeks, each mesh product was inspected laparoscopically and grossly for adhesion development and assessed for percentage area mesh contracture via photographic morphometric analysis.
Results: The presence of omental adhesions was demonstrated in 20% (2/10) of VHP and SM products, compared with 70% (7/10) for PSM. Similarly, PSM demonstrated a trend toward a higher adhesion severity score, as well as a significantly greater percentage of area covered by adhesions (score: 1.5/5.0; coverage: 4.8%), compared with VHP (score: 0.4/5.0; coverage: 0.3%, P=0.004) and SM (score: 0.4/5.0; coverage: 0.1%, P=0.003). A significantly higher percentage area mesh contracture was also demonstrated for PSM (26.9%) compared with VHP (14.5%, p=0.001) and SM (9.2%, P=0.000).
Conclusion: This study suggests a greater incidence, severity, and percentage area of coverage of adhesions and demonstrates a significantly higher percentage of mesh contracture for PSM, compared with other permanent (VHP) and absorbable (SM) barrier mesh products, following simulated laparoscopic ventral hernia repair in a porcine model.
10.271 General Surgery
Treatment of Symptomatic Large Gastric Diverticula: A Laparoendoscopic Solution
N. Di Martino, Prof Dr Med, F. Torelli, MD, M. Schettino, MD, L. Marano, MD, R. Porfidia, MD, G.M. Reda, MD, M. Grassia, MD
VIII Department of General Surgery and Gastrointestinal Physiopathology, Second University of Naples, Italy
Gastric diverticula are unusual entities, often asymptomatic, that may present as a variety of vague abdominal symptoms, such as upper abdominal pain, nausea, emesis, and dyspepsia. Moreover, bleeding and perforation represent other rare symptoms. Nowadays, the treatment of gastric diverticula is still debated: although medical treatment is recommended for small diverticula (<2cm), surgical laparoscopic resection represents the best treatment of cases of large (>4cm) or complicated malformation. We report a successful laparoendoscopic approach to 2 symptomatic gastric diverticula. The symptoms were unspecific, being upper abdominal pain, epigastric fullness, and early satiety. The patients underwent barium study, endoscopy, stationary manometry, 24-hour pH-metry, and electrogastrography. Diverticula (6cm and 4cm in length, respectively) were localized to the posterolateral gastric wall: we performed a surgical laparoendoscopic resection. Mean operation time was 85 minutes (range, 60 to 110), the mean blood loss was 43mL (range, 19 to 67), and the mean length of hospitalization was 5.1 days (range, 4 to 7). There were no major perioperative complications or mortalities, and at a 6-month follow-up, patients are symptom free. In conclusion, laparoendoscopic resection is a feasible and effective treatment with excellent outcomes for large and symptomatic gastric diverticula.
10.272 Gynecology
The Safety and Efficacy of Laparoscopic Cytoreduction of Recurrent Ovarian, Fallopian Tube, and Primary Peritoneal Cancers
Farr R. Nezhat, MD, Shaghayegh M. DeNoble, MD, Douglas N. Brown, MD, Jennifer E. Cho, MD, Linus Chuang, MD, Herbert Gretz, MD, Enrique Soto, MD, Prakash Saharia, MD
Division of Gynecologic Oncology and Minimally Invasive Surgery, Department of Obstetrics and Gynecology, St. Luke's-Roosevelt Medical Center, New York, New York, USA (Drs. Nezhat, DeNoble, Brown, Cho).
Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Science, The Mount Sinai Medical Center, New York, New York, USA (Drs. Chuang, Gretz, Soto).
Department of General Surgery, Winthrop University Hospital, Mineola, New York, New York, USA (Dr. Saharia).
Objective: Studies on the role of laparoscopy in secondary or tertiary cytoreductive procedures for recurrent ovarian cancer are limited. The objective of this study was to describe our preliminary experience with laparoscopic secondary, tertiary, and quaternary cytoreduction in patients with recurrent ovarian, fallopian, and primary peritoneal cancers.
Methods: This is a prospective case series. Women with recurrent ovarian cancers deemed appropriate candidates for secondary, tertiary, or quaternary laparoscopic cytoreduction were recruited. The patients underwent exploratory laparoscopy, subsequent biopsy, and either secondary, tertiary, or quaternary cytoreduction by laparoscopy from June 1999 to October 2009. Outcome variables analyzed included stage, site of disease, extent of cytoreduction, operative time, blood loss, length of hospital stay, complications, and survival time. Statistical analysis was performed using Systat 12.0.
Results: Thirty-three patients were recruited. Twenty-five of the patients (76%) were stage IIIC at the time of their initial diagnosis. Twenty-six patients underwent secondary, 6 underwent tertiary, and 1 underwent quaternary cytoreduction. Twenty-nine of the patients (85%) underwent optimal laparoscopic cytoreduction. Overall, 14 patients have no evidence of disease (NED), 8 are alive with disease (AWD), and 11 have died of disease (DOD), with mean follow-up of 26.7 months. Mean operative time was 198 minutes. Mean blood loss was 108mL. Mean hospital stay was 2.82 days. There were no intraoperative complications. There was one postoperative complication (ileus). Median time to recurrence was 16 months.
Conclusions: Laparoscopy can be safely utilized to optimally cytoreduce patients with recurrent ovarian, fallopian, or primary peritoneal cancers, and is technically feasible in a well-selected population.
10.273 Gynecology
Small Duct Endoscopy: New Developments and Progress of Ductoscopy
Volker R. Jacobs, MD, PhD, MBA, John E. Morrison Jr., MD, Peter Mallmann, MD, PhD
Frauenklinik (OB/GYN), University Clinic of Cologne, Cologne, Germany (Drs. Jacobs, Mallmann).
Louisiana State University (LSU), Department of Surgery, Baton Rouge, LA, USA (Dr. Morrison).
Background: Ductoscopy, the endoscopic evaluation of small breast ducts, is increasingly gaining acceptance as a diagnostic procedure worldwide. Recent technical developments of ductoscopes and micro-instruments are shifting research interest from diagnostic to interventional ductoscopy. We describe novel technical aspects and the resulting possible future perspective of ductoscopy.
Methods: This study summarizes an analysis and review of new technical developments from research at Technical University Munich, Germany, and others, as well as a review of the MEDLINE and COCHRANE databases for the keyword ductoscopy.
Results: Diagnostic ductoscopy is performed by many breast physicians worldwide. Interventional ductoscopy, however, depends on an additional working channel and a variety of 0.4-mm to 0.8-mm micro-instruments for procedures inside the breast duct. They are at present not available in the US but are used in Germany and several other countries. Autofluorescence ductoscopy is a new imaging technique used on an experimental basis for clinical evaluation to identify intraductal lesions. Laser ductoscopy for removal of intraductal papillomas and 3-dimensional intraductal tracking systems are projects under development.
Conclusion: Technical innovation and further miniaturization of instruments is supporting a change from diagnostic to interventional ductoscopy. A therapeutic intraductal approach as well as autofluorescence endoscopy could potentially eliminate unnecessary biopsies and offer better identification of intraductal lesions.
10.274 Gynecology
2009 Hysterectomy Experience in a Rural Community Hospital
Jessica Ybanez-Morano, MD, MPH, CPE, Daniel Roques Felbaum, MSIII
Department of Obstetrics and Gynecology, Wheeling Hospital, Wheeling, WV, USA (Dr. Ybanez-Morano).
Marshall University School of Medicine, Huntington, WV, USA (Dr. Felbaum).
Background: The second most common surgery in US women is the hysterectomy with approximately 600,000 performed each year. Minimally invasive techniques are advocated. However, trends in laparoscopic approaches in gynecology are slowly changing. In 2003, approximate rates were assigned to the abdominal approach of 66%, vaginal approach of 22%, and the laparoscopic approach had increased to only 12%. We report the 2009 experience of total hysterectomies in a rural community hospital by a single gynecologic surgeon to show that the minimally invasive approach is feasible with comparable patient profiles, surgical outcomes, and improved hospital stay.
Methods: During 2009, a retrospective review of all hysterectomies (118) was completed. Parameters noted were approach of surgery, age of patients, BMI of patients, uterine specimen weight in grams, EBL in cc, length of OR time and hospital stay in days. Trends in the OR times over the course of the year were documented and comparisons with the change in laparoscopic hysterectomies from multi-port to single-port approaches were recorded.
Results: The hysterectomy rates were as follows: 26.6% abdominal approach, 29.7% vaginal approach, and 45.8% laparoscopic approach. Ranges of age, BMI, uterine weight, complication rates, and EBL were comparable with all 3 approaches. OR time was the least with the vaginal approach, mean time 41 minutes. Hospital stay in days improved for vaginal and laparoscopic hysterectomies (1 day) compared with abdominal hysterectomies (2 days).
Conclusions: Minimally invasive surgery for hysterectomies is feasible with similar patient demographics, comparable surgical outcomes, and improved hospital stay.
10.275 General Surgery
Outcomes of Laparoscopic Adrenalectomies Stratified Amongst Obese, Morbidly Obese, and Nonobese Patients
N. Agee, MD, K.N. Lau, MD, T.R. Martin, MD, B.T. Heniford, MD, K.W. Kercher, MD
Introduction: The evolution of laparoscopic surgery has lead to increasing applications. Reported risks have been identified. Subsets of patients at increased risk are sought. Literature suggests a higher risk for obese patients. However, no study has delineated patients into obese and morbidly obese (BMI>40kg/m2) groups. Our aim was to determine the outcomes of elective laparoscopic adrenalectomies in these populations.
Methods: Data were collected from an IRB-approved prospective database for elective laparoscopic adrenalectomies during a 10-year period. Patients were stratified into groups according to their BMI: <30 (nonobese), 30 to 40 (obese), and >40 (morbidly obese). Parameters analyzed were age, BMI, race, ASA score, diagnosis, comorbidities, operative time, EBL, tumor size, rate of conversion, need for a hand-assisted, 30-day re-admission, complications, and mortality.
Results: In this study, 148 patients were evaluated, including 71 nonobese, 56 obese, and 21 morbidly obese. There were no deaths in the sample. The mean age was significantly lower in the morbidly obese group than in the others (51.0±15.4, 54.0±11.5, and 44.7±11.5, P=0.03, respectively). Obese patients had significantly larger tumors compared with nonobese (3.01±1.97 vs. 4.61±3.17, P=0.01). There was a higher prevalence of hypertension and sleep apnea in the morbidly obese group (P=0.02 and P=0.008, respectively). No differences were observed in the other variables analyzed.
Conclusion: Despite having more comorbidities, morbidly obese patients have outcomes similar to those of obese and nonobese patients for laparoscopic adrenalectomies. These results suggest that the laparoscopic approach is technically feasible and safe not only in obese patients but also in morbidly obese patients as well.
10.276 Urology
Extraperitoneal Laparoscopic Radical Prostatectomy: Experience After 1850 Procedures
A. Polara, L. Aresu L, F. Maritati, M. Occhipinti, G. Grosso
Casa di Cura Pederzoli, Peschiera del Garda (Veron) Italy
Objectives: To evaluate the development of our technique in relation to the reduction in operative time, major complications, functional and oncological results.
Materials and Methods: From January 2001 to December 2009, 1850 patients underwent laparoscopic radical prostatectomy. Extraperitoneal approach was applied to all patients, and operative time, transfusion rate, complications, early and late continence rates were considered.
Results: Since 2001, we observed a reduction in mean operative time (currently 70 minutes) with a perioperative low-morbidity, maintaining oncological results equal to open technique (positive surgical margins <10%); 0% of transfusion rate has been achieved since 2005, with a reduction in major complications: 0% rectal injuries since 2003; 3-month continence rate was 80%, 1-year was 92%; erectile function recovery was 60% in intrafascial procedures.
Conclusions: Although standardization is codified after 1850 procedures, we continuously modify and develop our technique, as the combined antegrade and retrograde prostatectomy, or the dorsal rabdomiosphincter reconstruction. Our procedure is still characterized by extraperitoneal access to avoid the Trendelenburg position and to perform a less-invasive approach; we perform early isolation of seminal vesicles maintaining bladder neck integrity. The isolation of vascular pedicles and their dissection from neurovascular bundles represents in our experience a late step in the learning curve, requiring high-volume laparoscopic skills to perform oncological radical surgery and for the risk of bleeding.
10.277 General Surgery
The Results of Laparoscopic Cholecystectomy in Obese and Nonobese Patients: A Single Author Experience
Uzunkoy Ali, Prof Dr
Harran University School of Medicine, Department of General Surgery, Sanliurfa, Turkey
Objective: Obesity is a significant health problem, and its prevalence is increasing. It has been believed that obese patients have some technical difficulties with laparoscopic surgery. The aim of this study was to evaluate the results of laparoscopic cholecystectomy in obese and nonobese patients.
Methods: The data of the patients undergoing laparoscopic cholecystectomy between 1993 and 2010 was retrospectively analyzed. The cases were divided into 3 groups according to body mass index (BMI). BMI <18.5kg/m2 is defined as group 1. Group 2 (overweight cases) is defined as a BMI >25kg/m2, and group 3 (obese cases) as a BMI >30kg/m2. The cases were operated on with almost the same technique. The results were compared with respect to operative times, conversion rates, morbidity, mortality, and hospitalization times.
Results: There were 861 (703 nonobese, 117 overweight, and 41 obese) patients. No mortality was observed. There were no statistically significant differences among the groups regarding conversion rates to the open procedure, postoperative complications, and hospitalization times (P>0.05). The operation time was significantly higher in the obese patient group (mean: 94 minutes) than in the nonobese patient group (mean: 52 minutes) and the overweight patient group (mean: 56 minutes) (P<0.05). There were no statistically significant differences between group 1 and 2, regarding operation times (P>0.05).
Conclusion: This study shows that laparoscopic cholecystectomy is a safe procedure in obese patients. The results of obese and nonobese patients were the same except for operative time.
10.278 Gynecology
Laparoscopic Surgery for a Patient with Abdominal Pregnancy with Autologous Blood Salvage
Takashi Yamada, MD
Department of Pathology, Osaka Medical College, Osaka, Japan
Introduction: Abdominal pregnancy is so uncommon that the incidence even in the cases of ectopic pregnancy is 1%. We encountered a patient with an abdominal pregnancy who underwent laparoscopic surgery using intraoperative autologous blood salvage for hemoperitoneum.
Case Report: The patient was a 28-year-old woman with complaints of amenorrhea for 6 weeks and mild pelvic pain. A urinary pregnancy test was positive. Vaginal ultrasonography revealed no gestational sac in the uterus but a tumor mass (30mm x 35mm) and an echo-free space in the Douglas pouch. Since ectopic pregnancy with hemoperitoneum was suspected, laparoscopic surgery was performed. After suction of >100mL of accumulated blood, there were no abnormal findings on inspection of the uterus, either Fallopian tube or ovary, but there was what appeared to be a gestational sac implanted on the rectal serosa. In the treatment, the distended site was cut with the Nd-YAG laser, so that the rectum would be preserved as much as possible. The specimen excised was histologically found to be mainly blood clot with chorionic villi. The urine hCG level was decreased after the operation. From these findings, the patient’s condition was definitely diagnosed as abdominal pregnancy. The blood in the peritoneal cavity was recovered with an aspirator with a heparinized saline. After the patient gave informed consent, the obtained processed blood was reinfused into the patient because of a possibility of postoperative bleeding. The postoperative course was uneventful.
Conclusions: Autologous blood salvage may be useful for laparoscopic surgery with hemoperitoneum and a possibility of massive bleeding during the surgery.
10.280 General Surgery
Endosurgery for Multiple Liver Abscesses Combined with Pituitary Abscess: A Case Report
Feng-Chuan Tai, MD, Der-Fang Chen, MD, Chin-Shui Huang, MD, Jing-Shan Huang, MD
Department of General Surgery, Cathay Medical Center, Taipei, Taiwan, Republic of China (Drs. Tai, Chen, C-S Huang).
Department of Neurosurgery, Cathay Medical Center, Taipei, Taiwan, Republic of China (Dr. J-S Huang).
Purpose: We report a rare case of multiple liver cysts with abscess combined with a pituitary abscess. The literature was reviewed, and the etiology and pathogenesis were analyzed.
Materials and Methods: This 63-year-old woman had suffered from intermittent fever, headaches, and epigastralgia since November 2006. A polycystic liver with infection was diagnosed. Laparoscopic liver cyst fenestration with drainage was performed for her. The fever did not subside after surgery and drowsiness with hyponatremia was noted. She was re-admitted several times due to fever of undetermined origin and hyponatremia. Loss of consciousness and convulsion occurred in February 2007. A brain CT scan and MRI showed that a pituitary tumor and meningitis had developed.
Results: Because of a suspicion of the presence of a pituitary tumor, trans-sphenoid Endosurgery for tumor exploration was done, and the pituitary abscess was noted. After abscess drainage and antibiotic treatment, the meningitis was controlled successfully. The patient’s liver abscess was controlled well too, but multiple liver cysts persisted.
Conclusion: Liver abscess combined with pituitary abscess is a relatively rare disease. The origin, cause, and nature of the disease remain uncertain. Preoperative diagnosis remains difficult, even with the help of CT and MRI; it remains difficult to differentiate from a pituitary tumor. Adequate drainage of liver and pituitary abscesses plus antibiotic therapy is the choice of treatment. These surgical procedures can be performed via endoscopic surgery.
10.281 Urology
Comparing Open Versus Laparoscopic Bilateral Partial Nephrectomies
Christina B. Ching, MD, Jianbo Li, PhD, Matthew Simmons, MD, PhD
Glickman Urological and Kidney Institute, Cleveland Clinic Foundation Cleveland, Ohio, USA (Drs. Ching, Simmons).
Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio, USA (Dr. Li).
Objective: Literature evaluating the outcome of laparoscopic versus open bilateral partial nephrectomies is lacking. We evaluated our experience performing open versus laparoscopic bilateral partial nephrectomies looking at the influence of management on renal function, recurrence rate, and mortality.
Methods and Procedures: A retrospective chart review identified all patients undergoing bilateral partial nephrectomies at our institution between 1992 and 2008. The charts were reviewed for past medical history, renal function, ischemia time, pathology, recurrence rate, and mortality. We utilized the Wilcoxon rank sum and chi-square tests where appropriate. Multivariable logistic or regression analysis evaluated factors associated with renal function, recurrence, and mortality.
Results: Bilateral partial nephrectomies were performed in 116 patients: 23 open and 93 laparoscopic. All tumors were synchronous, and all operations but 5 were staged. Patients had significantly lower initial glomerular filtration rates (GFR) in the open group, but there was no difference in postoperative GFR between groups. Upon multivariable analysis, the difference between GFR preoperatively and postoperatively was significantly different (P=0.021). Patients in the open group had significantly larger tumors. The warm ischemia time was longer in the laparoscopic group and for larger sized tumors upon second surgery (P<0.05). Recurrence and mortality rate were not statistically different.
Conclusions: This is the first study directly comparing management techniques of bilateral partial nephrectomies. We did not find that laparoscopy sacrificed oncologic control or survival; however, patients undergoing open partial nephrectomies tended to have larger tumors and a lower initial GFR, while the laparoscopic groups had a larger difference in pre- and postoperative GFR.
10.282 Gynecology
Evaluation of Early and Late Vaginal Dehiscence in Different Types of Laparoscopic Hysterectomy
Enrique Soto, MD, Nicole Astill, MD, Kathryn Friedman, Farr Nezhat, MD, Konstantin Zakashansky, MD, Linus Chuang, MD, Herbert F. Gretz, MD
Mount Sinai School of Medicine, New York, New York, USA (Drs. Soto, Astill, Friedman, Zakashansky, Chuang, Gretz).
St. Lukes Roosevelt Hospital Center, New York, New York, USA (Dr. Nezhat).
Objective: To identify risk factors for early and late vaginal dehiscence after laparoscopic hysterectomy.
Methods and Procedures: This was a retrospective study of 307 women who underwent total or radical laparoscopic hysterectomy (with and without robot). Fisher’s exact and Kruskal-Wallis tests were used for the statistical analysis.
Results: Laparoscopic hysterectomy for benign or malignant indications was performed in 307 women. Patients had a (1) laparoscopic hysterectomy (n=203), (2) robotic hysterectomy (n=67), or (3) laparoscopic-assisted vaginal hysterectomy (n=37). The incidence of vaginal dehiscence was 3.9%, which was not statistically different among the groups (3.33%, 5.97%, 0%). Dehiscences were classified as early (n=5, 1.62%) if diagnosed prior to 6 weeks postoperatively, late (n=7, 2.28%) if afterwards. Four of 5 (80%) early dehiscences had continuous laparoscopic vaginal cuff closure, and 5/7 (71.4%) late dehiscences had interrupted closure. Four early and 5 late dehiscences were malignant cases. Fifty-seven patients with late dehiscences underwent postoperative chemotherapy and/or radiation. The 10 simple dehiscences were repaired vaginally and the 2 complex dehiscences with evisceration were repaired laparoscopically (1) or by laparotomy (1) (100% success) without bowel resection.
Conclusions: There was no statistical difference in incidence of dehiscence between different indications and techniques for laparoscopic hysterectomy. Early detection and surgical repair with vaginal suturing can achieve a successful outcome.
10.283 Urology
Tumor in a Solitary Kidney: Laparoscopic Partial Nephrectomy Versus Laparoscopic Cryoablation
Michael C. Lee, MD, Georges-Pascal Haber, MD, Sebastian Crouzet, MD, Kazumi Kamoi, MD, PhD, Inderbir S. Gill, MD, MCh
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Ohio, USA (Drs. Lee, Haber, Crouzet, Kamoi).
Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles California (Dr. Gill).
Introduction: We compare perioperative, functional, and oncological outcomes of laparoscopic partial nephrectomy versus laparoscopic cryoablation for small renal tumors in patients with a solitary kidney.
Methods: Between 2/1998 and 9/2008, 48 patients underwent laparoscopic partial nephrectomy, and 30 patients underwent laparoscopic cryoablation for small renal tumors in a functionally solitary kidney. Baseline, perioperative, and follow-up data were collected prospectively with retrospective data analysis.
Results: Median follow-up time for laparoscopic partial nephrectomy and laparoscopic cryoablation was 42.7 and 60.2 months, respectively. There were no significant differences between groups with respect to mean age, body mass index, and Charlson Comorbidity Index. Laparoscopic partial nephrectomy was associated with greater blood loss (391 vs 162mL, P=0.003). By 3 months after laparoscopic partial nephrectomy and laparoscopic cryoablation, estimated glomerular filtration rate decreased by 14.5% and 7.3%, respectively (P=0.02). Local recurrence was detected after 0 laparoscopic partial nephrectomies and 4 (13.3%) laparoscopic cryoablations (P=0.02). While overall survival was comparable between laparoscopic partial nephrectomy and laparoscopic cryoablation at 5 years, cancer-specific survival in the laparoscopic partial nephrectomy and laparoscopic cryoablation group was 100% vs. 92%, and recurrence-free survival was 100% vs. 86% at 5 years (P<0.05, for all comparisons).
Conclusion: Both laparoscopic partial nephrectomy and laparoscopic cryoablation are viable nephron-sparing options for patients with tumor in a solitary kidney. Although laparoscopic cryoablation is technically easier and has superior functional outcomes, oncologic outcomes are superior after laparoscopic partial nephrectomy.
10.284 Urology
Comparing Plasma Vaporization with Laser Vaporization of the Prostate
Manuel Ferreira Coelho, MD, Pedro Bargão Santos, MD
Hospital dos Lusíadas, Lisboa, Portugal
Objective: To evaluate and compare the efficacy and safety of bipolar plasma vaporization of the prostate and 980-nm laser vaporization.
Methods: A group of 20 men underwent prostate plasma vaporization (PPV); another 20 underwent prostate laser vaporization (PLV). Assessment was performed at baseline and during the follow-up by using the IPSS, Qmax, quality of life score, and postvoid residual urine. The 2 groups were similar in terms of preoperative parameters: mean age, IPSS score, preoperative TRUS volume, Qmax, Ql, and postvoid residual volumes.
Results: Mean operative time for the PPV group was significantly shorter than that of the PLV group. Change in serum hemoglobin and sodium, postoperative irrigation period and mean catheter-removal time were similar in the 2 groups. At 6 months, the mean Qmax increased to 17.11±4.01mL/s in the PPV group and to 15.70±3.01mL/s in the PLV group. The mean IPSS had decreased to 5.01±2.05 for the PPV group and to 8.50±2.94 for the PLV group.
Conclusion: The 2 procedures are highly effective. Plasma vaporization is safe and has the advantages over laser vaporization of a short operating time and reduced postoperative irritative symptoms, resulting in a better quality of life. The delayed re-epithelization of the prostate fossa is in correlation with persistent irritative symptoms happening more frequently after laser vaporization.
10.285 General Surgery
Live Surgical Broadcasts to the Classroom Enhance Preclinical Medical Student Interest in Surgical Careers
Lillian M. Erdahl, MD, Eric M. Pauli, MD, Timothy R. Shope, MD, Zuhaib Ibrahim, MD
Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA (Drs. Erdahl, Pauli, Ibrahim).
Department of Surgery, Washington Hospital, Washington, DC, USA (Dr. Shope).
Objectives: Live broadcast surgery can enhance medical student education and introduce the operating room in a low-pressure environment. Our objectives were to investigate whether the use of live broadcast surgery increases preclinical medical students’ interest in surgical careers and to identify preclinical medical students’ perceptions of the learning effectiveness of the live broadcast surgery format versus a traditional lecture format.
Methods: Live action from the operating theater (including 2-way video and audio) was streamed over standard Internet Protocol to a classroom with patient consent. Minimally invasive surgeries using video-endoscopes were chosen because of the operating field visibility. Relevant anatomy, pathophysiology, and surgical technique were discussed. Audience questions were directed to the operating room via an in-classroom moderator. An optional, anonymous survey was distributed.
Results: Five sessions were conducted from November 2007 to April 2009. A total of 289 surveys were completed: 200 (69%) from first-year medical students and 89 (31%) from second-year students. Ninety-eight percent rated this format as effective as or more effective than traditional teaching formats. Mean overall satisfaction was 4.3 (very satisfied) on a scale of 1 to 5. Student interest in surgery increased significantly from a mean 3.1 to 3.4 on a 5-point Likert scale, P<0.01 on Mann-Whitney U test.
Conclusion: Early investigation into the use of live broadcast surgery with preclinical medical students shows a high satisfaction rating and statistically significant increased interest in surgery. Future studies might include objective learning measures and more diverse procedures.
10.286 General Surgery
Totally Laparoscopic Transhiatal Gastroesophagectomy for Carcinoma of Cardia
Marko Zelic, MD, PhD, Davror Mendrila, MD, Miljenko Uravic, MD, PhD
Department of Abdominal Surgery, University Hospital Rijeka, Croatia
Objective: The progress of minimally invasive surgery has allowed esophagectomy to be performed by a totally laparoscopic transhiatal approach. The aim of this study was to present our initial experience with totally laparoscopic transhiatal esophagogastrectomies for carcinoma of the cardia.
Methods: The patient was placed in a reverse-Trendelenburg position with split legs. A total of 5 trocars were used. Greater curvature was mobilized by dissection of the greater omentum from the transverse colon. The left gastric vessels were exposed and clipped and divided at their roots with lymphadenectomy. The stomach was divided and tubulized with preservation of right gastric and gastroepiploic arteries. Diaphragmatic hiatus was opened to expose the lower mediastinum. Mediastinal dissection and lymphadenectomy was performed according to oncological principles. Resection of the distal esophagus was done 5cm above the proximal tumor margin. Intrathoracic esophagogastrostomy was accomplished by means of a circular stapler.
Results: Mean operating time was 215 minutes, and no patients required conversion to laparotomy. There were no intraoperative complications. One patient developed effusions in the right pleural cavity. The average length of hospital stay was 12 days.
Conclusion: In select cases, it is possible to perform a distal esophagectomy entirely by laparoscopy, without the need for any thoracic or cervical access.
10.287 General Surgery
Reduced Stricture and Ulcer Rates in Gastric Bypass Patients Using Single Stranded Absorbable Suture at the Gastrojejunal Anastomosis
Ann M. Rogers, MD, Cindy A. Miller, BS, Randy S. Haluck, MD
Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
Objective: Because of a relatively high stricture and ulcer rate using nonabsorbable reinforcing sutures at the gastrojejunal (GJ) anastomosis, we aimed to study our outcomes with absorbable suture. While both complications decreased, the rates were still higher than desired. We then changed from braided to single-strand absorbable suture. While it is too early for statistical significance, early results suggest this leads to an even further decrease in strictures and ulcers.
Methods: We studied all laparoscopic gastric bypasses performed at our institution between June 2006 and December 2009. These were performed identically, with a total linear-stapled GJ anastomotic technique using a 45-mm cutting stapler, with a reinforcing suture at each corner of the anastomosis. In 164 cases, silk (nonabsorbable, multifilament braided) suture was used. In the subsequent 290 cases, Vicryl (polyglycolic acid, absorbable, multifilament braided) was used. In the most recent 33 cases, PDS (polydioxanone, absorbable, monofilament) was used.
Results: With silk suture, stricture and ulcer rates were 20.12% and 9.76%, respectively. With polyglycolic acid, these rates were 16.9% and 2.41%, respectively. With polydioxanone, they were 6.06% and 0%, respectively.
Conclusions: Strictures and ulcers at the GJ are a major source of morbidity in gastric bypass patients. Strictures are reported in 3% to 31% of cases, and marginal ulcers in 1% to 16%. Multiple factors are implicated in their formation, including the use of nonabsorbable rather than absorbable material. To date, there is little published on the difference between single versus multi-stranded material, and nothing on their use as reinforcement sutures.
10.288 General Surgery
Laparoscopic Versus Open Appendectomy: A Multi-Institutional Outcomes Analysis
Arezou Yaghoubian, MD, Shant Shekherdimian, MD, Anisa Buck, MD, Steven L. Lee, MD
Harbor-UCLA and David Geffen School of Medicine at UCLA, Los Angeles, California, USA
Background: The advantages of laparoscopic appendectomy over open appendectomy are unclear. This study compares the outcomes of laparoscopic versus open appendectomy.
Methods: A retrospective study from 1998 through 2008 of patients (≥18 years) with appendicitis was performed. Data were extracted from 12 acute care medical centers. Study outcomes included 30-day postoperative morbidity (wound infection, postoperative abscess drainage, and readmission) and length of hospitalization.
Results: Use of laparoscopy increased from 37% in 1998 to 85% in 2008; 10,075 patients underwent laparoscopic appendectomy (mean age=39 years, 53% male) and 6437 underwent open appendectomy (mean age=41 years, 57% male). Laparoscopic appendectomy for nonperforated appendicitis was associated with a lower wound infection rate (laparoscopic=1.9% vs. open=3.1%, P<0.0001) and shorter hospitalization (laparoscopic=1.4±1.2 vs. open=1.7±1.2 days, P<0.0001). Similar results were seen with laparoscopic appendectomy for perforated appendicitis (wound infection: laparoscopic=5.0% vs. open=9.1%, P<0.0001; hospitalization: laparoscopic 3.8±2.7 vs. open=5.2±3.0, P<0.0001). Postoperative abscess drainage and readmission rates were similar between laparoscopic and open appendectomy for both nonperforated and perforated appendicitis.
Conclusions: Laparoscopic appendectomy has become the preferred operation for appendicitis in adults. Laparoscopic appendectomy was associated with lower wound infection rates and shorter hospitalization compared with open appendectomy. In general, laparoscopic appendectomy should be the preferred approach in patients with appendicitis.
10.289 Urology
Outcomes of Robot-Assisted and Laparoscopic Pyeloplasty: Preliminary Results of a Multi-Institutional Pyeloplasty Study
Steven M. Lucas, MD, Raymond J. Leveillee, MD, Vincent G. Bird MD, Mohamed Aziz, MD, Stephen E. Pautler, MD, Patrick Luke, MD, Peter Erdeljan, MD, J. Stuart Wolf, Jr., MD, Robert B. Nadler, MD, David Rebuck, MD, D. Duane Baldwin, MD, Kamyar Ebrahimi, MD, Jamie Landman, MD, Zhamshid Okhunov, MD, Carson Wong, MD, Kurt H. Strom, MD, Chandru P. Sundaram, MD
Indiana University, USA (Drs. Lucas, Sundaram).
Miami University, USA (Drs. Leveillee, Bird, Aziz).
University of Western Ontario, Canada (Drs. Pautler, Luke, Erdeljan).
University of Michigan, USA (Dr. Wolf).
Northwestern University, USA (Drs. Nadler, Rebuck).
Loma Linda University, USA (Drs. Baldwin, Ebrahimi).
Columbia University, USA (Drs. Landman, Okhunov).
Oklahoma University, USA (Drs. Wong, Strom).
Objective: In this study, we compared the perioperative outcomes of laparoscopic (LP) and robotic pyeloplasty (RP) in a multi-institutional review.
Materials and Methods: Data were collected retrospectively from centers with experience in minimally invasive pyeloplasty. Demographic, anatomic, perioperative, and follow-up data, both symptomatic and radiologic, were included.
Results: We have collected data from 498 patients at 8 centers: 214 LP and 284 RP. LP was similar to RP in median age (35.0yr, IQR=21.0yr vs 36.0yr, IQ=27.0; P=0.685). Median follow-ups for LP and RP were 12.1months (IQR=14.5) and 9.0months (IQR=16.0), P=0.015. Preoperative pain was more frequent in LP than RP: 192 (91%) vs 230 (81%), P=0.016. Each had similar operative times (LP: 200.0min (IQR=120.0); RP: 196.0min (IQR=104.0), P=0.224). Intraoperative complications occurred in 4 LP and 6 RP (P=0.751). Postoperative complications occurred in 17/214 LP (4 urine leaks) and 17/284 RP (4 urine leaks), P=0.257. Postoperative renal function (47.0%, IQR=15.5 vs 45.0%, IQR=12.5; P=0.102) and T1/2 (10.0min, IQR=8.0 vs 10.0min, IQR=7.8, P=0.153) were similar for LP and RP. Postoperative pain worsened or remained unchanged in 7% LP and 2% RP, P=0.005. Postoperative obstruction worsened or remained the same in 9.0% LP and 2.8% RP, P=0.015. Secondary procedures occurred in 16 (7.4%) LP and 6 (2.1%) RP, P=0.004.
Conclusions: Comparison of LP and RP reveals excellent outcomes for both. Differences in postoperative pain may be due to a higher rate of preoperative pain in the LP group. Secondary procedures may reflect different practices that vary by institution.
10.290 General Surgery
The Self-Approximating Transluminal Access Technique (STAT) Permits Transgastric NOTES Cholecystectomy in a Human Cadaver
Jegan Gopal, MD, Eric M. Pauli, MD, Abraham Mathew, MD, Matthew T. Moyer, MD, Sami S. Tannouri, MS, Brooke B. Ancrile, PhD, Randy S. Haluck, MD
Background: A consensus on intraabdominal access method has yet to be determined in natural orifice transluminal endoscopic surgery (NOTES). Prior investigations from our working group have established the self-approximating transluminal access technique (STAT) as a safe, reliable method of transgastric NOTES access in the porcine model. We sought to determine the feasibility of utilizing STAT to access the abdomen and perform a cadaveric cholecystectomy.
Methods: A female adult cadaver (<24hr postmortem) was utilized. Abdominal access was obtained via STAT with a submucosal tunnel created along the posterior gastric wall. After the endoscopic cholecystectomy, the gallbladder was retrieved through the submucosal tunnel. The integrity of the tunnel was assessed by visual inspection. After Endoclip closure of the mucosa, gastrostomy closure was assessed by bubble leak test. An autopsy was performed.
Results: The total procedure time was 168 minutes. Tunneling time was 44 minutes (mucosal pillow to seromuscular incision). The STAT tunnel was approximately 7-cm long and 3-cm wide. The gallbladder (5x11cm, 50cc) was retrieved through the tunnel without difficulty. A small mucosal tear occurred during specimen extraction. At autopsy, a 2-cm serosal tear was identified. There was no evidence of air leak after mucosal closure with 4 Endoclips.
Conclusion: STAT is a feasible abdominal access technique that tolerates the mechanical forces of peroral transgastric cholecystectomy and retrieval and provides a means of secure gastric closure in a human cadaver. Further investigation is ongoing.
10.292 Urology
Laparoscopic Single-Port Applications in Pediatric Urology: Initial Experience
Alejandro R. Rodriguez, MD, Mark Rich, MD, Hubert Swana, MD
University of South Florida, Department of Urology, Tampa, Florida, USA
Objective: Laparoendoscopic single site (LESS) surgery has recently been applied in adult urological cases. We report our initial experience with LESS surgical techniques for the treatment of pediatric urology cases.
Methods and Procedures: From May 2009 to January 2010, 11 LESS surgical cases were performed. We analyzed the single-port device used, patient’s age, height, weight, BMI, operative room (OR) time, complications, and follow-up.
Results: Of the 11 cases performed, 9 were varicocelectomies: 1 total left nephrectomy, and 1 bilateral gonadectomies. In 2 patients, we used the “ASC” single-port device and in 9, the “Covidien” single port. For the varicocele cases and the gonadectomy case, the mean patient age, height, weight, BMI, and OR times were 15 years (range, 11 to 18), 1.6 meters (range, 1.59 to 1.81), 64 kilograms (range, 39 to 121), 21.9 (range, 15.2 to 38.6), 45.5 minutes (range, 29 to 68), respectively. The patient who had the nephrectomy was 14 years, 1.77 meters, weighted 66kg, had a BMI of 21, and the OR time was 150 minutes. The varicocelectomies and gonadectomies were outpatient surgeries. The total left nephrectomy patient was discharged 48 hours after surgery. No patient had intraoperative or early complications. Mean follow-up was 5 months, and no patient had late complications.
Conclusions: LESS surgery in pediatric urological patients is feasible, and our experience is encouraging. LESS surgery should be an option for pediatric surgical candidates who would like the benefit of a keyhole scarless (umbilical) surgery.
10.293 General Surgery
Design of a Multi-Functional Miniature In Vivo Surgical Robot
Tyler D. Wortman, BS, Kyle W. Strabala, MS, Amy C. Lehman, MS, Shane M. Farritor, PhD, Dmitry Oleynikov, MD
University of Nebraska-Lincoln, University of Nebraska Medical Center, Lincoln, Nebraska, USA
The widespread adoption of the Laparoendoscopic Single-Site surgery (LESS) for complex surgeries is dependent on the development of devices that provide a stable multi-tasking platform. Existing methods for performing LESS are limited because of the mechanics of using multiple instruments inserted through a single incision. This results in limited dexterity and poor triangulation and visualization. Prior research within our group has demonstrated the feasibility of using a completely insertable robotic platform consisting of a 2-armed miniature in vivo robot and a remote surgeon interface to address these limitations. Current prototypes are too large to perform a laparoscopic surgery using a purely LESS approach. However, this study presents the kinematic improvement of the multi-functional miniature in vivo robot with the goal of reducing the overall size of the robot. Measurements of the in vivo workspace required by the robot for performing cholecystectomy have been performed during multiple nonsurvival procedures in a porcine model. The actual motion of the robot, as determined from the motor encoders, was recorded during surgery using LabVIEW (National Instruments, Austin, TX) software. This information was used with a kinematic analysis of the existing robot to determine the position of both the cautery and grasping end effectors throughout the procedures. The design of the robot was then kinematically improved to operate within the determined workspace. These studies have contributed to significantly reducing the size of the multi-functional robot to better enable the performance of surgical procedures through a single incision.
10.294 Urology
Comparison of the Outcomes of Pure Laparoscopic Donor Nephrectomy and Hand-Assisted Laparoscopic Donor Nephrectomy in over 200 Consecutive Patients
Steven M. Lucas, MD, Rishi Mhapsekar, MD, Daniel Yelfimov, MD, William C. Goggins, MD, John A. Powelson, MD, Chandru P. Sundaram, MD
Indiana University, Department of Urology (Drs. Lucas, Mhapsekar, Yelfimov, Sundaram).
Indiana University, Department of Transplant Surgery (Drs. Goggins, Powelson).
Objective: In this study, we compared the perioperative morbidity of patients undergoing a purely laparoscopic donor nephrectomy (LDN) versus those undergoing hand-assisted laparoscopic donor nephrectomy (HALDN) and the recipients that receive them.
Methods: Consecutive patients presenting for minimally invasive donor nephrectomy from August 2002 through June 2009 were reviewed. Selection of technique (LDN v HALDN) was based on patient preference and anatomy. The corresponding recipients were also compared. Data included demographic data, intraoperative data, hospital stay, and follow-up renal function.
Results: The study followed 202 renal donors: 133 LDN and 69 HALDN. The LDN patients were younger than the HALDN patients (37.5yr, IQR=16.8yr, versus 41.8yr, IQR=15.4yr, P=0.016). There were 20 right-sided LDN and 25 HALDN (P=0.002), and there were 77 female LDN and 33 HALDN (P=0.173). Operative time and warm ischemia time were longer in LDN versus HALDN: 207.5min (IQR=59min) versus 180.0 (IQR=45min), P=0.001, and 142s (p=65s) versus 120s (P=43s), P=0.001. Open conversions occurred in 2 LDN and 1 HALDN. Major or minor complications occurred in 10 LDN and 6 HALDN. Median postoperative creatinine at 1 month was 1.20mg/dL for each group. Among the corresponding recipients, median length of stay for each group was 5 days (IQR=3d). Postoperative GFR at discharge was 61.2 mL/min/1.73m2 in each group. Final creatinine at last follow-up was 1.4mg/dL versus 1.5m/dL, P=0.312.
Conclusion: HALDN offered quicker operative times and ischemia times, though recipient and donor outcomes were similar in regard to renal function and morbidity. Selection of operative technique should involve discussion of the patient’s preference and anatomy.
10.295 General Surgery
Comparison of Laparoscopic Appendectomy Outcomes Between Teaching and Nonteaching Hospitals: A Multi-Institutional Study
Arezou Yaghoubian, MD, Rebecca Stark, MD, Shant Shekherdimian, MD, Steven L. Lee, MD
Harbor-UCLA and David Geffen School of Medicine at UCLA, Los Angeles, California, USA
Purpose: In this era of heightened emphasis on patient outcomes, it is important to document the effect of residents acting as the surgeon for a surgical procedure. This study compares the outcomes of laparoscopic appendectomy between teaching and nonteaching institutions.
Methods: A retrospective review was performed of patients ≥18 years of age undergoing laparoscopic appendectomy for appendicitis from 1998 through 2007. The outcomes from 2 teaching institutions were compared with outcomes from 11 nonteaching institutions. Study outcomes included postoperative morbidity and length of hospitalization.
Results: At the teaching institutions, 1327 patients were treated (mean age=35 years, male=53%, 17% perforated) and 8748 at the nonteaching institutions (mean age=45 years, male=53%, 20% perforated). Wound infection and postoperative abscess rates were similar between teaching and nonteaching institutions. Readmission rates were lower at teaching institutions for nonperforated (teaching=1.1% vs. nonteaching=3.2%, P=0.0002) and perforated appendicitis (teaching=3.6% vs. nonteaching=7.2%, P=0.05). Hospitalization was longer at teaching institutions for nonperforated (teaching=1.6±1.4 vs. nonteaching=1.3±1.2 days, P<0.0001) and perforated appendicitis (teaching=4.7±3.9 vs. nonteaching=3.8±2.6 days, P<0.0001).
Conclusions: Infectious complications after laparoscopic appendectomy were similar at the teaching institutions. Readmission rates were lower at teaching institutions; however, hospitalization was longer. Overall, the presence of surgical trainees had minimal adverse impact on the outcomes of laparoscopic appendectomy in patients with appendicitis.
10.296 Urology
Transition from Laparoscopic to Robotic Partial Nephrectomy: The Learning Curve for an Experienced Laparoscopic Surgeon
Alexander C. Small, Hugh Lavery, MD, David Samadi, MD, Michael Palese, MD
Department of Urology, The Mount Sinai Medical Center, New York, New York, USA
Objectives: The complexity of laparoscopic partial nephrectomy (LPN) has prompted many laparoscopic surgeons to adopt robotic partial nephrectomy (RPN) for the treatment of small renal masses. This study assessed the learning curve for an experienced laparoscopic surgeon during the transition from LPN to RPN.
Methods: We compared perioperative outcomes of the first 20 patients who underwent RPN to the last 18 patients who underwent LPN by the same surgeon (MP). Surgical technique was consistent across platforms. The learning curve was defined as the number of cases required to consistently perform RPN with shorter average operative times (OT) and warm ischemia times (WIT) than the average of the last 18 LPN. A cubic line of best fit aided graphical interpretation of the learning curve on a scatter diagram of OT v. procedure date.
Results: The 2 groups had comparable preoperative demographics and tumor learning curve. After the first 5 RPN cases, the average OT reached the average OT of the last 18 LPN cases. The average OT of the first 5 RPN patients was 242.8 minutes (range, 180 to 294), compared with 171.3 minutes (range, 111 to 260, P=0.011) in the last 15 RPN patients. Perioperative outcomes were similar between groups.
Conclusion: The transition from LPN to RPN is feasible and rapid in an experienced laparoscopic surgeon. There were no significant differences in WIT, estimated blood loss, or length of hospital stay between LPN and RPN. RPN achieved similar OT and WIT as LPN after 5 procedures.
10.297 Urology
Comparison of Device Failures and Reported Morbidities Associated with the da Vinci S Robot and da Vinci Robot: An FDA Maude Database Review
Steven M. Lucas, MD, Chandru P. Sundaram, MD
Indiana University, USA
Objective: In this study, we compared the types of device failures associated with both the da Vinci S (dVS) and da Vinci (dV) robot, including associated intraoperative morbidity.
Methods: Data regarding device failures were collected from the FDA maude database under the following 2 searches: “da Vinci” and “Intuitive Surgical” from 2002 to the present. Breakage or errors in the instruments, console, patient cart, camera, and cannula accessories were recorded. Intraoperative injuries, complications, conversions, and other aspects were collected.
Results: We reviewed 1,677 reports: 955 dVS and 681 dV. Peak years for reports were 2008 for dVS (571) and 2007 for dV (211), P<0.001. Device failure by category differed significantly (P<0.001), including malfunctions with the console (4.1% dVS and 11.7% dV), patient-side cart (4.6% dVS and 14.0% dV), and reusable instruments (80.1% dvS and 58.3% dV). With regard to instrument failures, arcing episodes and retrievable fragments were more frequent in dV than dVS, 16.7% versus 9.2% and 17.0% versus 5.0%, P<0.001. Open conversions were 7.1% dVS and 23.7% dV, P<0.001. Significant operative delays (>30 min) occurred in 2.9% dVS and 2.0% dV, P=0.375. There were a total of 21 perioperative deaths (18 dVS and 3 dV, P=0.012).
Conclusion: The dVS shows improvements in the frequency of console and patient-side cart problems relative to the dV. Instrument malfunctions are less harmful in the dVS. Differences in overall outcomes may be influenced by temporal changes in reporting, case selection, and robotic experience.
10.298 Urology
Laparoscopic Sacrocolpopexy Approach for Genitourinary Prolapse
Pedro Bargão Santos, MD, Manuel Ferreira Coelho, MD
Hospital dos Lusíadas, Clínica São João de Deus, Lisboa, Portugal
Objective: To evaluate the surgical outcome, benefits, and complications of laparoscopic double promonto-fixation for patients with pelvic prolapse.
Methods: Women with genitourinary prolapse underwent a transperitoneal placement of a 100% polyester mesh on the anterior vaginal wall and a posterior mesh on the levator ani muscle. Both of these were stitched to the sacral promontory. A TVT-O was placed simultaneously in patients who had concomitant stress urinary incontinence.
Results: In 2009, 20 patients were operated on. Their mean age was 64 (range, 38 to 75), and the mean operating time was 120 minutes. There were no surgical conversions. Follow-up was done by a clinic questionnaire and physical examination at 6 months and then yearly. Ninety-five percent were satisfied with the results, and no patients complained about sexual dysfunction. There was no recurrence of the prolapse and no vaginal erosions. One case occurred of urinary retention that required TVT-O section, and one bowel incarceration occurred in one of the laparoscopic 10-mm ports, which was treated by laparoscopy, without the need for intestinal resection.
Conclusions: Laparoscopic sacrocolpopexy is a feasible and highly effective technique. It offers good long-term results with complication rates similar to those of open surgery and with the benefits of minimally invasive surgery.
10.299 General Surgery
Laparoscopic Removal of Retained Gallstones Causing Large Retroperitoneal Abscess Nearly Two Years Postoperatively
C. Finkelman, L. Cohen, M. Neff
UMDNJ-SOM
Objective: Spilled gallstones are a not too infrequent occurrence during laparoscopic cholecystectomies. The long-term fate of these stones is unknown, but felt by most to be inconsequential. We report here a large multiloculated abscess occurring nearly 2 years after a laparoscopic cholecystectomy for acute cholecystitis.
Methods: A 77-year-old previously healthy female who developed a large multiloculated intraabdominal abscess 21 months after a laparoscopic cholecystectomy presented with flank pain, erythema, calor, increased WBCs, and a 10-lb weight loss over 6 months. A 10-cm x 6.5-cm fluid collection with residual stone fragments was found in the subphrenic posterior hepatic region. A second fluid collection in the right posterior flank, measured 12.2cm x 6.4cm and was contiguous with the subphrenic collection. The abscesses were initially drained by interventional radiology. The patient was taken to the operating room for diagnostic laparoscopy. A lysis of adhesions was performed with drainage of the residual intraabdominal abscesses. Laparoscopic removal of the retained stones in the subhepatic space was performed without difficulty.
Results: Postoperatively, the patient had resolution of her abscesses. A CT scan was performed to confirm that all stone and stone fragments were removed. She had gradual return to normal activities over the next several months.
Conclusions: Spilled gallstones during laparoscopic cholecystectomy for acute cholecystitis may present in a markedly delayed fashion with intraabdominal abscess formation. When it does, removal of the inciting source for the infection can be performed laparoscopically.
10.300 General Surgery
Chronic Gastric Volvulus as a Result of a Congenital Diaphragmatic Hernia in an Adult: Report of a Case
Kristine M. O’Hara MD, Ibrahim M. Daoud MD
St. Francis Hospital and Medical Center Hartford, Connecticut, USA
Background: Congenital diaphragmatic hernias are of 3 types: Bochdalek (postero-lateral), Morgagni (antero-medial), and Hiatus hernia. They are rare, occurring in 1:2,500 to 4,000 live births. Morbidity is related to the degree of pulmonary hypoplasia and respiratory distress and usually requires operative treatment in the neonatal period. Here we present a case of congenital diaphragmatic hernia that became symptomatic in adulthood.
Case: A 56-year-old male presented with complaints of left upper quadrant abdominal pain for 1 year associated with 100-pound weight loss. Radiologic investigation demonstrated a large left diaphragmatic hernia with organoaxial volvulus of the stomach. He underwent elective laparoscopic repair of the large defect with mesh closure and made a full recovery.
Conclusion: Diaphragmatic hernias usually present in the neonatal or prenatal period. Here we have demonstrated a large diaphragmatic hernia of unknown direct etiology possibly secondary to a congenital lesion presenting in adulthood with gastric volvulus.
10.301 General Surgery
Single Incision Advanced Laparoscopic Procedures
Fernando Arias, MD, Jairo Dussan, Andres Durán, Adolfo Torres, Virginia Cuevas, Monica Rodríguez
Hospital Universitario de la Fundacion SantaFe de Bogotá
Introduction: This study was undertaken to present our experience with advanced laparoendoscopic single-site surgery (LESS).
Methods: Advanced procedures were defined as those that involved careful and extensive dissection (complicated appendectomies, acute cholecystectomies), organ resections, suturing, and the need for anastomosis. Data were prospectively collected. These operations were performed using several single-port devices and a combination of standard and roticulable laparoscopic instruments.
Results: Between July 2008 and March 2010, we performed LESS procedures in 106 patients for various indications. There were 53 complex procedures including acute appendicitis with peritonitis, acute cholecystitis, cystogastrojejunostomy, resection of a giant mesenteric cyst, gastrojejunostomy, sleeve gastrectomy, splenectomy, bowel resection, and a perforated duodenal ulcer. Conversion to standard multiport laparoscopy was necessary in 2 cases, none to open surgery. No operative site infection was found. The operative time and the hospital stay were similar to those of standard laparoscopic procedures.
Conclusions: The advanced LESS surgery is technically feasible for a variety of ablative and reconstructive applications in general surgery. With proper patient selection, conversion and complication rates are low. Improvement in instrumentation and technology is likely to expand the role of LESS in minimally invasive procedures. More studies are needed to confirm the potential benefits.
10.302 General Surgery
Gallbladder Wall Thickness: A Predictor of Outcome After Laparoscopic Cholecystectomy
Vikram Wadhera, MD, Rupen A. Shah, MD, Dovid S. Moradi, BA, John M. Cosgrove,
MD, Daniel T. Farkas, MD
Bronx-Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx, New York, USA
Objective: Laparoscopic cholecystectomy (LC) is one of the most common general surgical procedures. Many surgeries end up being converted to open surgery, leading to worse outcomes and longer lengths of stay. The purpose of this study was to identify whether gallbladder wall thickness could be used preoperatively to identify those cases at higher risk for conversion.
Methods: All attempted LCs between 2006 and 2008 at our institution were examined. Ultrasound reports were reviewed and categorized based on the presence or absence of a thickened gallbladder wall. Outcomes including conversion and complication rates were evaluated, and statistically analyzed using chi-square tests.
Results: During this 3-year period, 774 LCs were attempted, of which 654 (84.5%) had ultrasound reports available. Of these, 331 (50.6%) were reported as having gallbladder wall thickness (WT+), while 323 (49.4%)
did not (WT-). In the WT+ group, there were 41/331 (12.4%) conversions, whereas in the WT-group, there were 18/323 (5.6%) (P=0.002). In the WT+
group, there were 37/331 (11.2%) complications, whereas in the WT-group there were 18/323 (5.6%) (P=0.01).
Conclusion: Gallbladder wall thickness, as seen on ultrasound, is an independent risk factor for increased conversion and complication rates with laparoscopic cholecystectomy. This should be taken into account when counseling patients before surgery, and when assessing the risk/benefit ratio of surgery for each individual patient.
10.303 General Surgery
Does a Patient’s Insurance Status Affect Outcome After Laparoscopic Cholecystectomy
Rupen A. Shah, MD, Vikram Wadhera, MD, Dovid S. Moradi, BA, John M. Cosgrove, MD, Daniel T. Farkas, MD
Bronx-Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx, New York, USA
Objective: There is currently a renewed interest in the large amount of uninsured patients nationwide. The concern is that without regular outpatient care, these patients present to the hospital in the late stages of disease, and therefore have worse outcomes. The purpose of this study was to evaluate any differences in outcomes for these patients.
Methods: We reviewed all laparoscopic cholecystectomies (LC) done at our institution between 2006 and 2008. Patients were divided into 2 groups: insured patients (IP) and uninsured patients (UIP). Outcomes including conversion and complications rates were examined, and statistically analyzed using chi-square tests.
Results: There were 774 LCs done during the study period: 730 patients (94.3%) were insured (IP) and 44 (5.7%) were uninsured (UIP). In the IP group, there were 60/730 (8.2%) conversions, while in the UIP group there were 4/44 conversions (9.1%). In the IP group, there were 57/730 patients (7.8%) who developed complications, while in the UIP group there were 4/44 (9.1%). There was no statistical difference in either of these categories. In the IP group, 380/730 patients (52.1%) had their surgeries urgently or emergently, while in the UIP group this applied to 39/44 patients (88.6%). This difference was highly significant (P<0.001).
Conclusion: In our study group, being uninsured did not lead to having a higher rate of conversion or complications. However, more uninsured patients had their surgery done emergently, which is associated with longer lengths of study. More research is necessary to better understand the impact of insurance status on patient outcomes.
10.303 General Surgery
Does a Patient’s Insurance Status Affect Outcome After Laparoscopic Cholecystectomy
Rupen A. Shah, MD, Vikram Wadhera, MD, Dovid S. Moradi, BA, John M. Cosgrove, MD, Daniel T. Farkas, MD
Bronx-Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx, New York, USA
Objective: There is currently a renewed interest in the large amount of uninsured patients nationwide. The concern is that without regular outpatient care, these patients present to the hospital in the late stages of disease, and therefore have worse outcomes. The purpose of this study was to evaluate any differences in outcomes for these patients.
Methods: We reviewed all laparoscopic cholecystectomies (LC) done at our institution between 2006 and 2008. Patients were divided into 2 groups: insured patients (IP) and uninsured patients (UIP). Outcomes including conversion and complications rates were examined, and statistically analyzed using chi-square tests.
Results: There were 774 LCs done during the study period: 730 patients (94.3%) were insured (IP) and 44 (5.7%) were uninsured (UIP). In the IP group, there were 60/730 (8.2%) conversions, while in the UIP group there were 4/44 conversions (9.1%). In the IP group, there were 57/730 patients (7.8%) who developed complications, while in the UIP group there were 4/44 (9.1%). There was no statistical difference in either of these categories. In the IP group, 380/730 patients (52.1%) had their surgeries urgently or emergently, while in the UIP group this applied to 39/44 patients (88.6%). This difference was highly significant (P<0.001).
Conclusion: In our study group, being uninsured did not lead to having a higher rate of conversion or complications. However, more uninsured patients had their surgery done emergently, which is associated with longer lengths of study. More research is necessary to better understand the impact of insurance status on patient outcomes.
10.304 Pediatric
Early Experience with Single Port Laparoscopic Surgery in the Pediatric Population
Khanjan H. Nagarsheth, MD, Brent Roaten, MD, Alfred P. Kennedy, MD
East Tennessee Children’s Hospital, University of Tennessee Medical Center, Knoxville, Tennessee, USA
Objective: Laparoscopic surgery has been the standard of care for many surgical procedures performed in the pediatric population. With the recent introduction of newer low-profile laparoscopic instruments and ports, performing single port laparoscopic surgery (SILS) has become a reality. Herein, we report our initial experiences with SILS at a comprehensive regional pediatric center.
Methods: A retrospective review of the operative database at East Tennessee Children’s Hospital (Knoxville, TN) from July 2009 to January 2010 was performed, looking specifically at cases performed with a single laparoscopic incision.
Results: A total of 16 SILS cases were performed in this period that included 1 SILS gastropexy, 2 SILS appendectomies, and 13 SILS cholecystectomies. The patients ranged in age from 8 to 17 years old, and 2 experienced pediatric surgeons performed the procedures. There was no statistically significant difference in time of operation between traditional laparoscopic and SILS procedures (P<0.05). No complications during any SILS procedures were noted on review.
Conclusions: Initial experience with SILS appears to be safe and effective in the pediatric population. Larger series and prospective randomized trials are necessary to clarify additional potential benefits in this population.
10.305 Urology
Laparoscopic Partial Nephrectomy in a Solitary Kidney
Keyur Chavda, MD, Mohammad A. Bhatti, MD, Deepali Bobra, MD
Guthrie Healthcare System, Sayre, Pennsylvania, USA
Introduction: Renal tumors in a solitary kidney are a unique management challenge. Techniques such as laparoscopic partial nephrectomy are more commonly being reported. Our video demonstrates a laparoscopic partial nephrectomy in a solitary kidney.
Patients and Methods: Our 45-year-old male patient was diagnosed with left renal mass as an incidental finding. He has a prior history of right-sided Wilms tumor at 2 years of age. He underwent right nephrectomy and postoperative radiation therapy. His evaluation showed normal renal function. An abdominal CT scan showed a 17-mm mass at the upper pole of the left kidney. Due to the possibility of malignancy, surgery was advised. Laparoscopic left partial nephrectomy was performed. The patient was placed in the left side up position. A 12-mm and two 5-mm ports were placed in the left abdomen. Lysis of adhesions was done. Intraoperative ultrasound was used to identify the tumor margins. Dissection of the hilum revealed a single artery and vein, which were clamped using a vascular clamp. The mass was excised with 1cm of the surrounding normal tissue. A figure-of-eight stitch with Surgicel pledget and intracorporeal knot technique was used to close the bed. Total warm ischemia time was 25 minutes. The patient’s postoperative course was unremarkable. One-week and 6-month follow-ups showed the patient in good health with normal creatinine.
Conclusion: In select patients, minimally invasive techniques can be used for resection of a renal tumor in a solitary kidney. We successfully performed the partial nephrectomy laparoscopically with preservation of renal function.
10.306 Pediatric
Single-Incision Endosurgical Georgeson Procedure for Hirschsprung Disease in Infants
Oliver J. Muensterer, MD, PhD, Erik N. Hansen, MD, Albert Chong, MD,Keith E. Georgeson, MD
Objective: Over the last 15 years, the laparoscopic-assisted endorectal pull-through procedure first described by Georgeson has become the standard treatment for Hirschsprung disease in many centers around the world. We report the first 3 patients who were operated on using a single-incision endosurgical approach.
Methods: Three male infants diagnosed with Hirschsprung disease underwent laparoscopic endorectal pull-through via a single 1-cm horizontal skin incision in the umbilicus. First, laparoscopic seromuscular biopsies of the rectum and sigmoid were obtained. The affected rectosigmoid colon and rectum were then mobilized distally beyond the peritoneal reflection, facilitating the subsequent perineal dissection, pull-through, and coloanal anastomosis.
Results: The patients’ average age and weight were 19 days and 3.7kg, respectively. Operative time ranged from 126 minutes to 220 minutes, with a mean estimated blood loss of 3.3mL. There were no intraoperative complications. Postoperatively, all 3 patients recovered uneventfully and were discharged home on full feeds after 5, 12, and 9 days. On follow-up, the patients had virtually no appreciable scar, were feeding well, passing stool, and gaining weight appropriately.
Conclusion: Although technically challenging, laparoscopic-assisted endorectal pull-through in infants with Hirschsprung disease can be performed through a single umbilical incision with good postoperative results and excellent cosmesis.
10.308 Urology
The Use of Preoperative Cystoscopy and Bladder Neck Preservation During Robotic Prostatectomy
Anthony N. Avallone, MD, Mecheal Boen, RN, J. Stephen Jones, MD
Cleveland Clinic Foundation, Cleveland, Ohio (Drs. Avallone, Jones).
Center for Cancer Care, Goshen General Hospital (Nurse Boen).
Objectives: To determine whether preoperative cystoscopy to assess intraurethral anatomy and a novel technique of bladder neck dissection during robotic prostatectomy adversely influences positive margin rate.
Methods and Procedures: A retrospective chart review was performed on 74 consecutive patients who underwent robotic prostatectomy. All patients underwent preoperative cystoscopy and intraoperative bladder neck preservation. During dissection of bladder neck tissue from the prostatic base, the relative movement of each structure, combined with information on median lobe enlargement obtained by cystoscopy, was used to overcome the lack of tactile sensation inherent in robotic surgery.
Results: Seventy-four patients underwent robotic prostatectomy between September 2008 and January 2010. The average age was 54 years. Preoperative clinical stage was evaluable in 60 patients, including T1c in 47 and T2a/b in 13. Mean PSA was 6.0ng/dL. Preoperative Gleason score was 61% Gleason 6, 30% Gleason 7, and 9% Gleason 8. The positive margin rate for the posterior apex, posterior base, and lateral base was 8%, 3%, and 3%. No patient had a positive bladder neck margin.
Conclusions: Combining preoperative cystoscopy with intraoperative bladder neck preservation allows bladder neck negative margin status during robotic prostatectomy. Identifying the intraurethral anatomy and median lobe status, followed by establishing a plane of dissection utilizing the movement of the bladder neck relative to the prostatic base overcomes the loss of tactile sensation.
10.309 General Surgery
Ileal Adenocarcinoma Presenting As Rectal Cancer: A Case Report and Review of the Literature
R. Constantine, MD, D. Mwanza, DO, K. Wagoner K
Department of Minimally Invasive Surgery, Saint Michael’s Medical Center, Newark, New Jersey, USA
A case of ileal adenocarcinoma manifesting as rectal cancer is presented. A PubMed and MEDLINE literature review (1985 through 2009) was conducted to determine whether such an unusual presentation has been reported. Search terms were any combination of the following: metastatic ileal adenocarcinoma, locally invasive ileal adenocarcinoma, stage IV ileal adenocarcinoma, or synchronous ileal adenocarcinoma and colorectal adenocarcinoma. We report a case of a 54-year-old male who presented with rectal bleeding. The workup and biopsy results showed rectal adenocarcinoma. The patient was managed with neoadjuvant chemotherapy and radiation followed by surgery. At the laparoscopic operation, the patient was noted to have, surprisingly, a frozen pelvis and ileal mass with perforation. Consequently, the procedure was converted to open. The pathology report showed primary ileal adenocarcinoma involving the rectum. This case highlights an unusual presentation of ileal adenocarcinoma and its management.
10.310 Urology
Technique of Robotic-Assisted Laparoscopic Retroperitoneal Lymphadenectomy
Christopher Whelan, MD, Timothy Wilson, MD, David Josephson, MD
City of Hope National Medical Center
Objectives: We highlight the technical aspects of robotically assisted right modified template retroperitoneal lymphadenectomy in a gentleman with mixed germ cell testicular cancer.
Methods and Procedures: The patient is a 20-year-old male with stage 1A mixed germ cell cancer of the right testicle. He was secured to the table in a right modified flank position. Once all ports had been inserted and the robot docked, the operation commenced with medial reflection of the ascending colon to expose the retroperitoneum. The vena cava was identified and exposed using sharp dissection to Kocherize the duodenum. The extent of our dissection was the right ureter laterally, the right renal artery superiorly, the anterior aorta medially, and the right common iliac artery inferiorly.
Results: The procedure time was 180 minutes. Blood loss was 150mL. Thirteen lymph nodes were obtained and were negative for cancer. The patient was discharged home on postoperative day 2 and recovered well with normal ejaculatory function.
Conclusion: Robotic-assisted retroperitoneal lymphadenectomy can be safely performed with reasonable operative time in appropriately selected patients. The improved visibility and dexterity offered by the robot allows for accurate dissection and prompt placement of hemostatic sutures during the procedure.
10.311 Urology
Continence Outcomes Following Robotic-Assisted Laparoscopic Radical Cystectomy with Orthotopic Neobladder Diversion
Christopher Whelan, MD, Nora Ruel, MS, Timothy Wilson, MD, Kevin Chan, MD
Background: There is a paucity of data regarding continence outcomes for orthotopic diversion following robotic-assisted laparoscopic radical cystectomies (RARC). We report our continence outcomes for a large cohort of patients undergoing RARC with orthotopic neobladder urinary diversion.
Methods: All patients who underwent RARC between October 2003 and November 2008 were prospectively assessed. Of 126 cases performed, 96 (76%) patients consented to enrollment in our IRB-approved bladder cancer database. Of these patients, 44 (35%) underwent creation of an orthotopic Studer neobladder. Outcome data were collected prospectively.
Results: Of the 44 patients who received an orthotopic neobladder, 21 received a nerve-sparing radical cystectomy. All diversions were performed extracorporeally. The mean (standard deviation) patient age was 68 (10) years, operative time was 7.5 (1.2) hours, estimated blood loss was 400 (307) cc, length of hospital stay was 10 (3.9) days, and length of follow-up was 15 (14) months. Continence data were available on 40 patients. Of the 22 patients who received a nerve-sparing radical cystectomy, 91% achieved daytime continence and 59% achieved nighttime continence. The 18 patients who did not have nerve-sparing achieved 67% daytime continence and 44% nighttime continence. The odds ratio for daytime continence was 4.99 (95% CI: 0.87, 28.9; P=0.07), favoring the nerve-sparing technique.
Conclusion: RARC combined with open orthotopic neobladder urinary diversion can be accomplished with acceptable long-term continence outcomes. A nerve-sparing technique during RARC may improve daytime continence rates with patients receiving orthotopic neobladders. Larger series are warranted.
10.312 General Surgery
Gastric Schwannoma: Laparoscopic Resection and Review of the Literature
Constantinos Constantinou, MD, Joseph A. Blansfield, MD
Geisinger Medical Center
Introduction: Schwannomas are benign peripheral nerve sheath tumors with a predilection for the soft tissues of the head, neck, and flexor surfaces of the extremities. Involvement of the stomach is rare. Schwannomas represent only 0.2% of all gastric tumors. The literature on laparoscopic resection of these tumors is scant with only 2 cases previously described.
Methods: We describe the case of a gastric schwannoma treated with laparoscopic resection as well as present a review of the current literature for these unique tumors.
Results: We present a 54-year-old man with a gastric mass found on abdominal ultrasound performed for epigastric pain. Further workup included computed tomography and endoscopic ultrasound that confirmed the presence of a tumor in the gastric fundus along the greater curvature. While pathology was inconclusive, radiologic and endoscopic characteristics were suggestive of a gastrointestinal stromal (GIST) tumor. The patient was taken to the operating room, and a laparoscopic partial gastrectomy was performed. Final pathology was consistent with the diagnosis of schwannoma. The patient is doing well postoperatively without evidence of recurrence.
Conclusions: Schwannomas are rare tumors of the gastrointestinal tract. In the stomach, clinical symptoms, radiologic and endoscopic findings are almost identical to those of GISTs, making preoperative diagnosis difficult. Histological and cytological biopsy results are often inconclusive. Resection is required for definitive diagnosis and cure. Excision via a laparoscopic approach is a feasible option for these tumors.
10.313 General Surgery
Injury to the Accessory Ducts of Luschka Requiring Emergent Laparotomy: A Rare Complication Following Laparoscopic Cholecystectomy
Constantinos Constantinou, MD, John Widger, MD
Geisinger Medical Center
Introduction: Laparoscopic cholecystectomy (LC) has become the mainstay for treatment of gallbladder disease. Although complications related to LC have been well described in the surgical literature, little attention has been given to injuries involving the accessory ducts of Luschka (ADL).
Case Presentations: We present 3 patients who returned to the Emergency Department complaining of abdominal pain following discharge after an uneventful LC. Symptoms rapidly progressed to peritonitis requiring emergent laparotomy. Bile leakage from ADL was identified in all 3 patients, and all were successfully ligated. Two of the 3 patients had an uneventful postoperative course, while the third patient’s clinical condition continued to deteriorate following the second operation, and the patient eventually expired from multisystem organ failure.
Conclusion: Injury to the ADL following LC is a rarely described complication. It can present with diverse symptomatology, and different modalities have been described for its diagnosis. However, in the presence of peritoneal signs, emergent re-exploration is required to prevent its devastating sequelae.
10.314 Gynecology
Total Laparoscopic Hysterectomy (TLH): A Reproducible Technique, Instrumentation, and Suturing Algorithm for Fellows In Training
Yaniris R. Avellanet, MD, Charles H. Koh, MD
Reproductive Specialty Center, Milwaukee, Wisconsin, USA
The ability to perform a total laparoscopic hysterectomy (TLH) depends on a good technique, adequate instrumentation, and the ability to perform intracorporeal laparoscopic suturing. The TLH technique, instrumentation, and suturing algorithm developed and described by C.H. Koh is highly reproducible, even among Fellows in training. The instruments include a system that uses a colpotomy assembly consisting of a RUMI uterine manipulator and a Koh Colpotomizer System, composed of a Koh Cup Vaginal Fornices extender and a Colpo-Pneumo Occluder. The key to the success of a TLH is the correct placement of the colpotomy system, and the key to this system is the cup, which provides a distinct landmark that is both visible and palpable at laparoscopy. Vaginal vault closure at laparoscopy requires adequate port placement, proper surgeon position, and instruments, including type of needle and suture, needle holder and helper, and a step by-step suturing technique in the vertical zone. This suturing technique for TLH is a composite of multiple needle driving in the vertical plane and tying a knot at the beginning and end of a 2-layer continuous closure. This video will present various aspects of the TLH technique, emphasizing the correct placement and use of the colpotomy system and the intracorporeal vaginal vault closure in the vertical zone, performed by a Fellow in training.
10.315 General Surgery
Persistent Hyperinsulinemic Hypoglycemia after Roux-en-Y Gastric Bypass: Successful Treatment by Laparoscopic Adjustable Gastric Banding
Collin E.M. Brathwaite, MD, Alexander Barkan, MD, Karen Norowski, RN, George Oswald, PA, Patricia Cherasard, PA, MBA
Department of Surgery, Winthrop University Hospital, Mineola New York
Objective: Pancreatectomy is the recommended treatment for persistent noninsulinoma hyperinsulinemic hypoglycemia after gastric bypass. We describe the successful treatment of this condition by gastric banding.
Methods: A 62-year-old woman who had undergone gastric bypass 5 years earlier, presented with a 1-year history of severe postprandial hypoglycemia. She experienced several syncope episodes resulting in falls causing traumatic brain injury, facial and extremity fractures. She was evaluated with standard plasma measurements, including glucose, insulin, and computed tomography of the pancreas. Percutaneous biopsy of the pancreas was performed to evaluate for nesidioblastosis. A trial of a high-protein, low-carbohydrate diet and frequent small meals was conducted. Because the patient refused to consider pancreatectomy, calcium-stimulated insulin release was not studied. Pharmacologic therapy (diazoxide, octreotide, and nifedipine) was tried for several months.
Results: Metabolic parameters were consistent with the diagnosis of hyperinsulinemic hypoglycemia. Imaging revealed no insulinoma or pancreatic mass. Biopsy demonstrated normal histology. The trial of a high-protein, low-carbohydrate diet and frequent small meals failed to ameliorate her bouts of hypoglycemia. After a failure of medical therapy, the patient underwent laparoscopic adjustable gastric banding to limit the egress of food and pancreatic stimulation. She was experiencing up to 4 hypoglycemic episodes a day prior to surgery, but none since then at 3-months postop.
Conclusion: Laparoscopic adjustable gastric banding may be a simple alternative to partial pancreatectomy in cases of noninsulinoma hyperinsulinemic hypoglycemia after gastric bypass.
10.316 General Surgery
Transanal Endoscopic Microsurgery is Safe and Feasible for Proximal Rectal Lesions in Morbidly Obese Patients: A Case-Control Study
Nandita Chhitwal MD, Allen Chudzinski MD, Lee E. Smith, MD, Thomas Stahl MD, Jennifer Ayscue MD, James FitzGerald MD, Anjali S. Kumar, MD, MPH
Inova Fairfax Hospital, Department of Surgery (Dr. Chhitwal)
Washington Hospital Center, Section of Colon and Rectal Surgery (Drs. Chudzinski, Smith, Sthl, Ayscue, FitzGerald, Kumar).
Objective: We sought to assess the safety and feasibility of transanal endoscopic microsurgery (TEM) among morbidly obese patients.
Methods: From a prospective database of 300 TEM procedures at our institution, we conducted a retrospective case-control study of 9 TEM patients with a body mass index (BMI) range of 35 to 66 with lesions 7cm to 11cm from the anal verge (AV). Cases were compared with 15 nonobese TEM controls matched for age, tumor type, and level. Perioperative outcomes were compared by t test analysis using STATA10. The average BMI of controls was 30, significantly lower than that for cases (P<0.001). Patient and tumor factors, such as age at surgery, distance from AV, and maximum tumor diameter, were not significantly different between the 2 groups. Operative blood loss was higher for morbidly obese patients (max 350mL, mean 72mL, SD 131), than for controls (max 150mL, mean 27mL, SD 47), but this difference was not significant at P<0.05. Operative time (mean 104 vs. 145 minutes in cases vs. controls) and hospital length of stay was not significantly longer among obese patients vs. controls. One postoperative complication in a patient with BMI of 66 involved rectal hemorrhage 9 days after TEM, requiring a 6-unit transfusion. No complications were noted in the control group. All patients had adequate surgical resections with negative margins. No additional rectal resections were undertaken. TEM is a safe and feasible endoluminal surgical alternative for proximal rectal tumors in morbidly obese patients for whom transabdominal pelvic dissection can be prohibitive and fraught with morbidity.
10.317 Gynecology
Comparison of Robotically Assisted and Standard Laparoscopic Procedures in Patients with Endometrial Cancer
Mario M. Leitao, Jr., MD, Kevin Santos, Ginger J. Gardner, MD, Nadeem R. Abu-Rustum, MD, Carol L. Brown, MD, Dennis S. Chi, MD, Yukio Sonoda, MD, Douglas A. Levine, MD, Richard R. Barakat, MD
Memorial Sloan-Kettering Cancer Center, New York, New York, USA
Objective: To compare outcomes between robotically assisted laparoscopic (RBT) and standard transperitoneal laparoscopic (LSC) procedures in patients with endometrial cancer.
Methods: All patients with a preoperative endometrial cancer diagnosis scheduled for RBT and LSC were identified from 5/1/07 to 8/8/09. Operating room time (ORT) was measured from patient arrival in the OR to exit. Operative time (OT) was measured from skin incision to full closure.
Results: Of 153 RBTs and 214 LSCs, conversion to laparotomy was necessary in 16 (10%) RBTs and 30 (14%) LSCs (P=0.3). Median ORT was 315 minutes and 267.5 minutes, respectively (P<0.001). Median OT was 235 minutes and 194 minutes, respectively (P<0.001). Median pelvic, paraaortic, and total nodal counts for RBTs were 14, 6, and 20.5 compared with 16, 5, and 23 for LSCs (P=NS). Median length of hospital stay (LOS) was 1 day for RBTs and 2 days for LSCs (P<0.001). Median estimated blood loss (EBL) for RBTs was 75mL, and 100mL for LSCs (P<0.001). Median change from preop to postop Hgb was -0.5g/dL and -0.7g/dL, respectively (P=0.003). Median change from preop to postop HCT was -1.35% and -2.3%, respectively (P=0.007).
Conclusions: RBT and LSC approaches are both feasible and result in good outcomes in patients with endometrial cancer. RBT was associated with longer ORT and OT compared with LSC in a well-established and experienced LSC program. Patients who underwent an RBT had significantly shorter LOS, lower EBL, and lower median drops in both Hgb and HCT.
10.319 General Surgery
Transaxillary Endoscopic Robot-Assisted Thyroidectomy
Titus D. Duncan MD, Fritz Jean-Pierre MD
Morehouse School of Medicine
Introduction: Recently, endoscopic thyroidectomy has been shown to be an effective and safe approach in select patients requiring excisional thyroid surgery. The use of straight laparoscopic instruments, designed for use in intraabdominal procedures, in the chest and neck area combined with operating in a restricted space with limited maneuverability has limited the acceptance of endoscopic thyroid techniques.
Recent use of robotic surgery with instrumentation that possesses articulating and rotational capability allow fine and deliberate movements within tightly enclosed spaces. We recently explored the feasibility and safety of an endoscopic approach for the removal of a diseased thyroid gland using a robot-assisted technique.
Materials and Methods: After having performed over 100 thyroidectomies using a transaxillary approach, we subsequently performed endoscopic transaxillary thyroidectomy using a robotic-assisted approach in 11 patients presenting with unilateral thyroid nodules.
Results: Seven patients had follicular adenomas and 4 patients had colloid lesions. All patients had successful completion of thyroidectomy using the robot-assisted endoscopic approach. There were no conversions to the open procedure, and there were no complications.
Conclusion: Endoscopic thyroidectomy has been shown to be safe and effective with high patient satisfaction in the treatment of surgical thyroid disease. Use of robotic technology with high definition and magnified 3-D visualization may enhance safety in performing endoscopic thyroidectomy. Furthermore, robotic instrumentation with rotating/articulating capabilities may improve access in highly restricted areas such as that seen in endoscopic thyroid techniques.
10.320 Gynecology
Laparoscopic Excision of a Rudimentary Uterine Horn with an Intrauterine Pregnancy at 96/7 Weeks’ Gestation
A. Karim Nawfal, MD, Charla M. Blacker, MD, Ronald C. Strickler, MD, David Eisenstein, MD
Department of Gynecology, Obstetrics, and Women’s Health, Henry Ford Hospital, Detroit, Michigan, USA
Pregnancy in a rudimentary uterine horn is a rare and potentially lethal condition. It carries risks of uterine rupture, hemorrhage, and maternal death.
In 2005, a 24-year-old lady was diagnosed by imaging studies and laparoscopy to have an absent right kidney, a bicornuate uterus with a right rudimentary uterine horn, and a single cervix, a transverse vaginal septum with hematocolpos, and endometriosis secondary to reflux menstruation. The transverse vaginal septum was excised, and the surgeon observed a single cervix. Oral contraceptives were prescribed as complementary treatment for the endometriosis and associated dysmenorrhea.
In 2009, MRI confirmed resolution of hematocolpos and revealed a right cervix connected to the rudimentary right uterine horn and covered by a partial longitudinal vaginal septum. The patient had a contraception failure and presented in 2010 at 96/7 weeks’ gestation. By ultrasound and subsequent MRI, the pregnancy was in the right uterine horn, and the corpus luteum was on the left ovary. The myometrium was thinned to 2-mm to 3-mm atop the gestational sac.
Using the Harmonic ACE, laparoscopic excision of the right fallopian tube and right rudimentary horn with intact pregnancy was performed in 125 minutes with estimated blood loss of 75mL. The patient was discharged home the same day.
This case illustrates the risk for uterine rupture when pregnancy forms in a rudimentary horn, presumed transperitoneal migration of an ovum that was captured by the opposite fallopian tube, and the surgical management of the intact pregnancy by laparoscopic supracervical excision of the rudimentary horn.
10.321 Gynecology
Compression and Congestion of Ovarian Blood Vessels Causing Acute Abdominal Pain in Pregnancy: A Condition Mimicking Maternal Ovarian Torsion
Noam Smorgick, MD, Msc, Hadar Rosen, MD, Michal Feingold, MD, Moty Pansky, MD
Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, Zerifin, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
Objective: We describe a syndrome of acute abdominal pain in pregnancy, whereby laparoscopy revealed compression of the ovarian vessels against the pelvic brim causing their congestion.
Methods: We retrospectively reviewed the cases of gravid patients presenting with acute nonobstetrical abdominal pain who underwent diagnostic laparoscopy during a 5-year period (2005 through 2009). Of those, we analyzed and compared the clinical characteristics and sonographic findings of women diagnosed with compression of ovarian vessels with those diagnosed with adnexal torsion.
Results: During the study period, 16 cases of adnexal torsion and 8 cases of ovarian compression were treated. The clinical presentation included abdominal pain in all women, and vomiting in 9/16 (56.25%) and 3/8 (37.5%), respectively (P=0.4). Most cases of adnexal torsion occurred in the first trimester (8/16, 50%), whereas ovarian compression was more common in the second trimester of pregnancy (7/8, 87.5%) (P=0.053). The preoperative ultrasound scan showed either a cystic/multicystic adnexum or an enlarged and edematous ovary in cases of torsion (12/16 and 3/16), whereas most cases of ovarian compression showed normal adnexa (6/8) (P<0.001). At laparoscopy, the typical appearance of ovarian compression was of a nontwisted ovary compressed above and against the pelvic brim with congestion of its blood vessels. The adnexa were gently pulled back below the pelvic brim, resulting in relief of symptoms.
Conclusions: Compression of the ovarian vessels causing acute abdominal pain typically occurs in the second trimester of pregnancy, clinically mimicking ovarian torsion. Normal-appearing ovaries on ultrasound scan support this diagnosis.
10.324 Gynecology
Occlusion of Uterine Arteries for Treatment of Symptomatic Uterine Myomas
Adel Helal, MD, Abd El-Mageed Mashaly, MD, Talal Amer, MD
Department of Obstetrics and Gynecology, Mansoura University Hospitals, Faculty of Medicine, Mansoura University, Egypt (Drs. Helal, Mashaly).
Department of Radiology, Mansoura University Hospitals, Faculty of Medicine, Mansoura University, Egypt (Dr. Amer).
Objective: To compare the effectiveness and safety of occlusion of the uterine arteries by laparoscopy versus embolization as a treatment modality for symptomatic uterine fibroid.
Methods: Ninety-six premenopausal women with symptomatic uterine leiomyomata were studied. None of them desired further pregnancy. They were randomized to treatment either by laparoscopic occlusion (group 1) or by radiologic embolization of the uterine arteries (group 2). The primary outcome measure was patient satisfaction as regards menstrual blood loss compared with pretreatment loss. Secondary outcome measures included, postoperative pain, complications, secondary interventions, and failures.
Results: Ninety women were followed for 1, 3, 6, and 12 months after both procedures. The primary outcome was comparable between the 2 groups (86.7% after laparoscopic occlusion versus 88.8% after embolization with no statistically significant difference). After 12 months of follow-up, more patients resumed heavy periods in the uterine artery occlusion group (4/45 patients, 8.8% in occlusion group compared with 3/45 (6.6%) in embolization group, P=0.044).
Conclusion: Both laparoscopic occlusion and superselective embolization of uterine arteries improved clinical symptoms in the majority of patients. Based on 12-month follow-up, embolization might be more effective.
10.325 General Surgery
Expanding Access to Superior Laparoscopic Outcomes with Robot-Assisted Colon Resection By Using a Medial Approach
P. Ikemire, K. Sherafgen, E. Kandil
Tulane University School of Medicine, Department of Surgery, New Orleans, Louisiana, USA
Background: Laparoscopic outcomes are limited by patient condition, user-expertise, and visualization of the operative field. Robotic technology has recently been used in many specialties to overcome limitations. However, few reports of its application to colorectal surgery with a medial approach have been published. We performed a retrospective review to evaluate this technique.
Methods: We performed a retrospective chart review of patients who underwent robot-assisted colorectal surgery between October 2008 and May 2009. Information was extracted regarding age, sex, procedure, operative time, pathology, perioperative course, and complications.
Results: Seven male patients underwent colon resection using robot-assistance. Four had right-hemicolectomy, 2 had left-hemicolectomy, and 1 had LAR. In all cases, a medial approach was performed for vascular control with a robot, followed by extracorporeal anastomosis. Four patients had adenocarcinoma with adequate resection margins, while the others had benign pathology. The mean number of lymph nodes removed was 11.4. Mean operative time was 331 minutes, with one outlier (range, 190 to 400, 535). No intraoperative complications occurred on any of the cases. The mean LOS was 6 days, with one outlier (range, 5 to 7, 18). The median age was 65 years (range, 53 to 81).
Conclusions: This is a single center pilot study showing the feasibility and safety of robot-assisted colorectal surgery with a medial approach. It allows surgeons to overcome the limitations of laparoscopy for meticulous dissections, including limited visualization of operative-field, ergonomic strain, and decreased dexterity while producing excellent pathology, minimal LOS, and intraoperative complications.
10.326 Gynecology
Management of Ovarian Remnant in Severe Cases of Endometriosis
Camran Nezhat, MD, Sumathi Kotikela, MD, Michael Lewis, MD, Arathi Veeraswamy, MD
Center for Special Minimally Invasive and Robotic Surgery, Departments of Obstetrics & Gynecology and Surgery, Stanford University Medical Center, Palo Alto, California, USA (all authors).
Objective: The laparoscope can be used successfully in the management of an ovarian remnant even in patients with severe endometriosis or adhesions.
Methods: We present a case following radical hysterectomy and BSO for cervical cancer and successful removal of an ovarian remnant by laparoscope.
Results: The laparoscope has benefits for treating ovarian remnants in patients with severe endometriosis and adhesions, because it has better visualization and decreased risk of further adhesions.
Conclusions: Management of ovarian remnant could be difficult to treat in cases of severe endometriosis; we present a case of successful removal of an ovarian remnant.
10.327 Gynecology
Novel Technique for Removal of a Uterus After Laparoscopic Hysterectomy
Sumathi Kotikela, MD, Michael Lewis, MD, Arathi Veeraswamy, MD, Camran Nezhat, MD
Stanford University, Palo Alto, California, USA
Objective: A novel technique for removal of large myomatous uteri following laparoscopic hysterectomy in a nulliparous patient.
Procedure: The technique using the Alexis self-retaining retractor (ring retractor) demonstrates how to remove a large myomatous uteri transvaginally following laparoscopic hysterectomy. The Alexis retractor is a flexible polymer membrane, with semisolid rings on both ends. One flexible semisolid ring is placed in the cul-de-sac through the vagina, which is then positioned by folding the outer ring, which compresses the membrane in between. The vaginal orifice then has optimal exposure for the delivery of the specimen transvaginally.
Results: The Alexis retractor helps in the removal of large myomatous uteri with relative ease following laparoscopic hysterectomy in nulliparous patients.
Conclusions: The Alexis self-retaining retractor helps in patients with a narrow vaginal orifice by optimizing visualization, eliminating the need for assistants and the use of metal retractors.
10.329 General Surgery
Single Incision Laparoscopic Hernia Surgery: A Demonstration of Safety and Efficacy in TEP and LVHR
H.M. Tran, L. Saliba
The Sydney Hernia Specialists, Sydney NSW Australia
Introduction: Traditional laparoscopic inguinal/ventral hernia repair requires 3 incisions with potential risks of bowel/vascular injuries from sharp introducers and port-site hernias. Single-incision hernia repair appears to be an attractive technique. This study aimed to identify challenges associated with SILS including loss of triangulation and how to overcome them and to assess safety and early results.
Materials and Methods: The study period was from October 2009 to March 2010. Data collected included hernia type (direct/indirect), unilateral/bilateral, ventral/incisional hernia, duration of surgery, length of hospital stay, postoperative analgesic requirements, recurrence, wound complications, satisfaction survey (1-dissatisfied, 2-satisfied, and 3-very satisfied) and QOL–SF36. Standard dissecting instruments with a 3005.5-mm/52-cm laparoscope were used.
Results: There were 62 inguinal hernias in 44 patients: 17 bilateral/28 unilateral. Mean age was 44 years, and all patients were males. Operation time was 55 minutes for unilateral and 85 minutes for bilateral with no conversion to traditional TEP/open surgery. Day surgery was achieved in all cases. Analgesic requirements were 8 tablets of Di-Gesic. There was no early recurrence with follow-up 1 to 6 months. Return to normal physical activities occurred between 1 to 2 weeks. There were no wound complications, and satisfaction score was 2.8. There were 14 LVHRs with a mean age of 52. There was no conversion to open/3-port surgery. Operation time was 95 minutes. Length of hospital stay was 1 day. There was no recurrence.
Conclusions: TEP/LVHR repair with single incision laparoscopic surgery is safe and efficacious, and loss of triangulation can be overcome with different dissection techniques and aided by smaller/longer laparoscope.
10.330 Multispecialty
Multi-Institutional Validation Study of an OSATS for Cystoscopic and Ureteroscopic Skills
Omer Burak Argun, MD, François Sainfort, PhD, Manoj Monga, MD, Bodo Knudsen, MD, Geoffrey N. Box, MD, David I Lee, MD, Matthew T. Gettman, MD, Robert M Sweet, MD
Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA (Drs. Argun, Monga, Sweet).
Department of Health Policy and Management, University of Minnesota, Minneapolis, Minnesota, USA (Dr. Sainfort).
Department of Urology, Ohio State University, Columbus, Ohio, USA (Dr. Knudsen, Box).
Division of Urology, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA (Dr. Lee).
Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, Minnesota, USA (Dr. Gettman).
Introduction and Objective: The aim of this study was to evaluate the multi-institutional construct validity of an Objective Structured Assessment of Technical Skills (OSATS) developed to assess cystoscopic and ureteroscopic cognitive and psychomotor skills.
Methods: An OSATS was designed by 2 experts targeting both cognitive (14) and psychomotor (4) cystoscopic and ureteroscopic skills. In this study, comprehensive data were collected from 30 urology residents with postgraduate years (PGY), ranging from 1 to 5 across 3 different institutions. Subjects spent 5 minutes on each station and moved from station to station. Evaluation of cognitive skills was done via a written test examining 14 cognitive tasks. Residents performed psychomotor tasks and were directly evaluated by a single expert (OA) blinded to the subjects’ PGY using the global psychomotor skill scale. Both nonparametric Spearman correlation analysis and Mann-Whitney U test were used to analyze performance data correlations with PGY level.
Results: Eleven of 18 cognitive tasks and 8 of 10 psychomotor task parameters demonstrated construct validity. There was no correlation between global psychomotor skills score and video game use, playing of musical instruments, or previous simulation exposure. There was a strong correlation (r=0.827, P<0.01) between Global Psychomotor skill score and the PGY level, which corroborated the pilot test data previously collected.
Conclusion: The cystoscopic and ureteroscopic OSATS showed excellent construct validity as well as a strong correlation between the PGY level and performance of the residents. The OSATS can reliably and validly assess key procedural skills in a formal, structured manner outside of the clinical setting.
10.331 Multispecialty
The Minnesota Pelvic Trainer: A Hybrid 3-D VR/Physical Pelvis for Providing Virtual Mentorship
Omer B. Argun, MD, Vamsi Konchada, Yunhe Shen, PhD, Dan Burke, Anthony Weinhaus, PhD, Arthur Erdman, PhD, Robert M. Sweet, MD
Urologic Surgery, Medical School, University of Minnesota, Minneapolis, Minnesota, USA (Dr. Argun).
Center for Research in Education and Simulation Technologies (CREST), University of Minnesota, Minneapolis, Minnesota, USA (Drs. Argun, Shen, Burke, Sweet).
Computer Science and Engineering, University of Minnesota, Minneapolis, Minnesota, USA (Drs. Konchada, Shen, Burke, Sweet).
Integrative Biology and Physiology, University of Minnesota, Minneapolis, Minnesota, USA (Dr. Weinhaus).
Mechanical Engineering and Medical Devices Center, University of Minnesota, Minneapolis, Minnesota, USA (Dr. Erdman).
Introduction and Objective: Traditionally, anatomic knowledge is imparted through textbooks, atlases, and plastic models for independent learning and cadaveric dissections under the guidance of a tutor. The aim of this project was to create an interactive hybrid physical/virtual pelvis aimed at leveraging the learning advantages of both physical models and virtual models for teaching and retaining basic human anatomy and pathology. We chose the pelvis as our proof-of-concept application due to its challenging conceptual anatomy and complex ring-shaped structure.
Method: A patient-specific virtual-reality model was created, and the DICOM dataset was transformed into a deformable mesh with MIMICS and tailored and textured with realistic texture maps using Z-brush and Maya. An exact 3-D physical replica was then printed. A 6 degrees of freedom track-star magnetic tracking system was attached to the pelvis and an i-pen user device. In parallel, we designed and integrated a curriculum and graphics user interface aimed at teaching pelvic anatomy, physiology, pathophysiology and treatment.
Results: We successfully created a low-cost, realistic hybrid pelvic trainer. The physical and virtual models are perfectly registered in 6 degrees of freedom with >30 frames/second. Urologic anatomy, physiology, pathology, and treatment modules have been created that quiz, track, and score users’ performance.
Conclusion: Our hybrid physical/virtual model of the pelvis with embedded virtual mentorship is worthy of testing for effectiveness in a urologic, orthopedic, and gynecologic anatomy curricula.
10.333 General Surgery
Anatomical Variations and Congenital Anomalies of Extra Hepatic Biliary System Encountered During Laparoscopic Cholecystectomy
K. Altaf Hussain Talpur, Abdul Aziz Laghari, Sikandar Azam Yousfani, Arshad Mahmood Malik, Aamir Iqbal Memon, Sangrasi Ahmed Khan
Liaquat University of Medical & Health Sciences, Jamshoro, Pakistan
Objective: To assess the frequency and importance of anatomical variations of the extrahepatic biliary system in patients undergoing laparoscopic cholecystectomy.
Methods: This was an observational study performed in a teaching hospital for a period of 4 years from January 2004 to December 2007. All patients with cholelithiasis undergoing laparoscopic cholecystectomy were assessed for different anatomical/congenital extra hepatic biliary and vascular anomalies. Structures mainly assessed for anomalies were gallbladder, cystic duct, cystic artery, and hepatic artery. Assessment of variations and anomalies of CBD and hepatic ducts was not done due to the possibility of iatrogenic injuries.
Results: Included in the study were 300 patients with cholelithiasis, comprising 255 (85%) females and 45 (15%) males with a mean age of 39.85 years. Patients mainly presented with upper abdominal pain including pain the in the right hypochondrium (71.67%), pain in the right hypochondrium and epigastrium in 19%, and pain in the epigastrium (9.33%) as main symptoms. Operative findings revealed variations in 61 (20.33%) patients mainly involving cystic artery (10.67%), cystic duct (4.33%), right hepatic artery (2.67%), and gallbladder (2%). Postoperatively, 3.67% revealed bleeding and 1.67% biliary leak from the drain as main complications related to anatomical variations, giving rise to 1% morbidity; however, no mortality was seen in this series.
Conclusion: Congenital anomalies and normal variants of the biliary tree though are not common but may be of significance during laparoscopic surgery because failure to recognize them may lead to various iatrogenic injuries and therefore can increase morbidity and mortality.
10.334 Multispecialty
The International Prostate Symptom Score (IPSS) Predicts Postoperative Urinary Retention after Hernia Repair
Brenda E. Aguilar, MD, Kristi L. Harold, MD, Daniel J. Johnson, MD, Alyssa B. Chapital, James A. Madura, II, Nancy Itano
Mayo Clinic, Phoenix Arizona, USA
Introduction: Urinary retention is a common complication after inguinal hernia repair with a reported incidence of 0.2% to 25%. The IPSS is an 8-question validated questionnaire for the assessment of lower urinary track symptoms (LUTS). Our aim was to evaluate the IPSS as a predictor of postoperative acute urinary retention (AUR) after hernia repair.
Methods: From October 2004 through January 2010, 53 men diagnosed with symptomatic inguinal hernias who met inclusion criteria were evaluated. All completed an IPSS questionnaire preoperatively. Charts were reviewed for demographics, past urologic history, and need for postoperative catheterization. Group A (AUR requiring catheterization) was compared with Group B (no intervention required) using x2 and Student t test. Logistic regression was performed to determine predictive factors of urinary retention.
Results: Fifty-three men underwent 66 hernia repairs: 38 unilateral, 15 bilateral, 33 laparoscopic, and 20 open repairs. Mean age of the patients was 68 years old (SD±11), and the mean IPPS score was 8.38 (SD±6). All the procedures were performed with the patient under general anesthesia. Eighteen (34%) patients developed postoperative urinary retention. Group A patients were older (P=0.014) and obtained a higher IPSS score 9.6 compared with 7.2 (SD±5; P=0.036). Age, reported degree of bother, and IPSS total score had a significant relationship with postoperative urinary retention (P=0.014, 0.004, and 0.016 respectively).
Conclusion: The IPSS is a simple and easy to use tool to predict patients at risk of postoperative AUR and need for bladder catheterization.
10.335 Urology
Techniques for Early Recovery of Continence in Patients with Robotic-Assisted Radical Prostatectomy
Tae Hyo Kim, Gyung Tak Sung
Department of Urology, College of Medicine, Dong-A University, Busan, Korea
Introduction: With the introduction of the da Vinci system, many techniques have been reported to improve the quality of life of patients undergoing robot-assisted radical prostatectomy (RARP). We would like to report our results using the posterior reconstruction and ultra-dissection of the bladder neck technique.
Materials and Methods: From December 2007 to December 2009, we analyzed the postoperative data of 100 patients who had undergone RARP. In group A (n= 32 patients), the posterior reconstruction and the ultra-dissection techniques were not performed. In group B (n=32 patients), only the posterior reconstruction technique was performed. In Group C (n=36 patients), both techniques were utilized. We analyzed the recovery of continence in these 3 groups; “recovery of continence” was defined as the use of 1 pad or less within 24 hours.
Results: Mean age was similar among the 3 groups (P=0.41). Preoperative mean PSA, BMI, and prostate volume had insignificant values statistically, respectively. Mean operative time was 226.3 minutes, 194.2 minutes, and 172.6 minutes (P=0.02), and mean blood loss was 204.2cc, 123.6cc, and 104.2cc (P=0.03) in each group. Recovery rate of continence was 34.4% after 1 month, 68.7% after 3 months, 93.7% after 6 months in group A. Group B was 53.1%, 81.2%, and 96.8% after each interval. Group C was 77.8% after 1 month and 100% after 3 months.
Conclusion: In RARP, the posterior reconstruction and ultra-dissection techniques had a decreased rate of urine leak and increased early recovery of continence.
10.336 Multispecialty
Advanced Technologies for Tissue Fusion: State of the Art
Doron Kopelman, MD
Head Department of Surgery, "Emek" Medical Center, Afula, and Technion, the Israel Institute of Technology
Novel technologies aimed at tissue fusion will be reviewed including RF, laser, and compression fusion. These technologies may develop to become a future laparoscopic surgical tool of tissue fusion and gastrointestinal anastomosis.
Intestinal anastomotic healing requires apposition of the collagen containing submucosal layers of the opposing intestinal walls, which is traditionally achieved by staples or sutures.
LigaSure has been successfully introduced to seal and transect vessels. Preliminary experiments showed that the LigaSure vessel sealing system does not allow safe and effective sealing and division of the small bowel. Nevertheless, a recent publication by J.F. Smulders describes a new generation prototype. A feasibility study of 8 anastomoses in a porcine model was successful.
Laser tissue technology was recently used for the first time in clinical surgical setup for the closure of skin incisions. Early results will be discussed.
The use of shape memory compression devices creates near optimal anastomosis: biological connection completely replaces the mechanical connection within 4 to 5 days, resulting in early epithelization of mucosa, full adaptation of the wall layers, no scarring on the anastomotic line, naturally elastic anastomosis with an anastomotic index of nearly 1. Clinical studies show promising results. By using shape memory alloy properties, it is possible to design simple and effective implants, capable of creating anastomosis in the digestive system, both side-to-side or circular end-to-end and of resolving many problems of existing anastomosing methods based on foreign materials support.
10.337 General Surgery
Higher Doses of Dalteparin Required of the Morbidly Obese Undergoing Bariatric Surgery
Sachin Kukreja, MD, Ana Cox, BS, Matthew Goldblatt, MD, James Wallace, MD, PhD
Medical College of Wisconsin and Froedtert Memorial Lutheran Hospital
Low molecular weight heparin (LMWH) has been shown to significantly reduce postoperative venous thrombosis. Anti-Xa levels are an effective tool for measuring the activity of LMWH and correlate with both the protective effect against venous thrombosis formation and risk of bleeding. Dalteparin, a type of LMWH, is being used in morbidly obese patients undergoing bariatric surgery; however, the effective dose and dosing regimen necessary to obtain adequate thromboprophylactic protection in this population is unknown. The standard dosing calls for 5000 units injected subcutaneously daily (the first dose split in the perioperative period). We gave the full dose (5000 units) preoperatively and followed the manufacturer’s recommendations thereafter. Anti-Xa levels were drawn following the third dose. We evaluated 29 patients undergoing either open or laparoscopic Roux-en-Y gastric bypass with an average BMI and weight of 45.7kg/m2 and 125.0kg, respectively. In our analysis, 62% failed to have adequate prophylactic Anti-Xa levels (Anti-Xa <0.1 IU/mL). One patient had a complication of venous thromboembolism. There was no excessive intraoperative or postoperative bleeding noted. Based on our results, a more aggressive dalteparin dosing regimen is warranted to achieve appropriate prophylaxis in morbidly obese patients.
10.338 General Surgery
The Utility of Ultrasound in Diagnosing Steatohepatitis in the Morbidly Obese
Sachin Kukreja, MD, Matthew Cox, MD, Aaron Carpiaux, BS, Matthew Goldblatt, MD, James Wallace, MD, PhD
Medical College of Wisconsin and Froedtert Memorial Lutheran Hospital
Nonalcoholic steatohepatitis (NASH) is an ever-increasing cause of liver disease and even liver failure in the United States. Although the exact causes are unknown, clear associations with obesity have been identified. All patients undergoing bariatric surgery at our institution who had not previously undergone cholecystectomy received an abdominal ultrasound as a part of their preoperative workup. Intraoperative liver biopsies were routinely obtained to identify patients with steatohepatitis changes (71% overall). After retrospectively comparing the ultrasounds to the histologic changes identified on biopsy (n=106), we found that ultrasound is highly sensitive (87%) at identifying patients with liver disease but does have an unacceptably elevated false-positive rate (specificity of only 52%) in morbidly obese patients across a wide range of BMIs (range, 37 to 73 kg/m2, mean 47.6kg/m2). In patients with a BMI≥50kg/m2, the utility of ultrasound to rule out steatohepatitis appears much greater (negative results 80% to 100% predictive) while the specificity remains low (17% to 67%). As a result, clinicians suspecting NASH must still rely on the gold standard of biopsy for a definitive diagnosis in superobese patients (BMI≥50kg/m2) with an ultrasound suggestive of fatty liver disease but may be able to forgo invasive testing in those with a normal ultrasound.
10.339 General Surgery
Laparoscopic Approach for Gastric Gastrointestinal Stromal Tumors
Sákra Lukáš, MD, PhD, L. Kohoutek, MD, J. Šiller, MD, PhD
Surgical Department of the General Hospital Pardubice, Czech Republic
Institute of Medicine, University of Pardubice
Introduction: This study aimed to evaluate a set of gastrointestinal stromal tumors (GIST) of the stomach managed with a laparoscopic technique and to identify an appropriate surgical approach and its extent in view of the nature of these tumors that include a broad clinical spectrum of tumors from benign to malignant types.
Method: The study covers a period from January 1, 2007 until June 1, 2009 during which 15 patients underwent the laparoscopic removal of stomach tumors in the Regional Hospital in Pardubice. Preoperative endoscopic tattooing, endosonography, biopsy, and a CAT scan were always performed. More precise localization required perioperative gastroscopy in 5 patients. Afterwards, a tumor was removed laparoscopically with a Harmonic scalpel, and the defect created in the stomach wall was sutured laparoscopically as well. On completion, the sufficiency of the sutures was reviewed gastroscopically. Lymphadenectomy was not performed. The surgical approach, complications, and potential tumor relapse or progression were evaluated. Chemotherapy (Imatinib mesylate) was postoperatively administered to 6 patients due to the malignant activity of the tumor.
Results: One patient required repeat surgery owing to the excessive narrowing of the distal part of the stomach. The other patients had no postoperative complications. Suturing dehiscence and other intraabdominal complications were not observed. During gastroscopic and ultrasonographic examinations, all patients were free of signs of tumor progression.
Conclusion: Despite the diverse malignant activities of GIST, our results support the procedure promoting the local removal of a tumor with the healthy border of the stomach tissue without lymphadenectomy as an adequate approach.
10.340 Multispecialty
Necrotizing Fasciitis Following Endoscopic Harvesting of the Greater Saphenous Vein for Coronary Artery Bypass Grafting: A Rare but Potentially Life- Threatening Complication
Benjamin Liliav, MD, Danny Yakoub, MD, PhD, Victor Moon, MD, Armen Kasabian, MD, Warren Widmann, MD
Department of Surgery, Staten Island University Hospital, Staten Island, New York and State University of New York, Downstate Medical Center, Brooklyn, New York, USA
Endoscopic harvesting of the greater saphenous vein for coronary artery bypass grafting has rightfully become accepted as an application of a minimally invasive surgical approach to what was once routinely an open surgical procedure. The harvesting of the saphenous vein was a prelude to the major task of the day, revascularization of the heart. The long incisions and minor wound problems were accepted complications. With the advent of endoscopic harvesting of the greater saphenous vein and with minimally invasive cardio-thoracic surgical approaches, patients could realize the benefits of lessened pain and speedier recovery that made minimally invasive surgery the preferred approach in many general surgical procedures.
We report a case of necrotizing fasciitis that developed after the endoscopic harvesting of the greater saphenous vein with an emphasis on its recognition and treatment including vigorous and wide debridement, antibiotic therapy, meticulous wound care, and early wound coverage as the approach for infection control and effective healing of the limb.
After a minimally invasive saphenous vein harvesting, necrotizing fasciitis is a rare complication. The wound photographs show the progression of the disease process and its effective treatment. Minimally invasive surgery may carry the risk of major complications; in this case, effective management salvaged the patient from the life-threatening complication of necrotizing fasciitis.
10.343 Gynecology
Pregnancy After Laparoscopy in Bilateral Tubal Occlusion and Use of GnRH
Gh. Alavi, H. Fattahi, A. Fattahi, F. Kamali
Ghaem Hospital, Mashhad University of Medical Sciences, Mashad, Iran
Introduction: Bilateral tubal occlusion (BTO) is one of the important causes of infertility (primary or secondary) in women. Laparoscopy (LAP) is one of the best available methods for assessing bilateral tubal occlusion. Gonadotrophin-releasing hormone (GnRH) therapy is one of the effective treatments for pelvic adhesions. The purpose of this study was to evaluate fertility in BTO by a diagnostic LAP and the effect of GnRH in these cases.
Material and Methods: In this prospective pilot study, we suggested laparoscopy to 31 infertile women. In all of the women, hysterosalpingography (HSG) revealed BTO, and the patients had no other causes for infertility. By using diagnostic LAP in 27 patients (4 women refused LAP), we assessed pelvic adhesions and BTO. After the first menses period after the LAP, 3 doses of GnRH were administered every 28 days intramuscularly.
Results: Of 27 patients, 25 had BTO, and 11 patients became pregnant 5 to 9 months after LAP; one had an ectopic pregnancy and 2 had spontaneous abortions.
Conclusion: LAP is the best available method for assessing BTO in infertile women. The administration of GnRH is effective at increasing fertility in BTO infertile patients.
10.344 General Surgery
Laparoscopic Distal Pancreatectomy: Should It Be Performed in a Low-Volume Community Hospital?
Jesus E. Hidalgo, MD, Danny Sherwinter, MD, Harry Adler, MD, Jerzy Macura, MD
Division of Minimally Invasive Surgery, Maimonides Medical Center, Brooklyn, New York, USA
Background: Advanced laparoscopic cases, such as distal pancreatectomy (LDP), have been slow to gain a foothold in all but high-volume tertiary referral centers. The aim of this study was to assess the safety and outcomes of LDP performed in a low-volume community hospital by a diverse group of surgeons, the majority of whom have no specialized laparoscopic background.
Methods: We conducted a retrospective review of all patients who underwent distal pancreatectomy between August 2001 and June 2008. Data included type of surgery, open versus laparoscopy, demographics, operative time, blood loss, length of hospital stay, histopathologic diagnosis, postoperative complications, ASA score, and mortality.
Results: Twenty-seven patients underwent distal pancreatic resection, 59% (n=16) LDP and 41% (n=11) open distal pancreatectomy (ODP). Mean intraoperative time was 231 minutes (range, 195 to 305) for LDP and 240 minutes (range, 150 to 210) for the open technique. Ten had spleen-conserving procedures, while 8 required splenectomy with the open approach. Mean LOS was 8 days (range, 3 to 22) for LDP and 12 days (range, 5 to 32) for ODP, respectively. Overall morbidity was 25% (n=4) in the LDP group, and 81% (n=9) in the open approach. There was no mortality in this series.
Conclusion: This study confirms that LDP can be safely and effectively performed by any surgeon comfortable with basic laparoscopy and does not require specialized training or a specialized center.
10.345 General Surgery
A Safe Efficient New Modification of Laparoscopic Appendicectomy
Katerina Theodoropoulou, MD, Yasser A. Kholeif, MBBCH, MSC, FRCS, RCPSG
Princess Alexandra Hospital, Harlow, United Kingdom
Objective: Acute appendicitis is a common surgical emergency often requiring surgical treatment. The commonest location for the appendix is retrocecal (65%). To achieve better access to a retrocecal appendix or higher in the right paracolic space, we modified the placement of the trocars as follows: supraumbilical, left lateral, and right upper quadrant. This study examines the safety and feasibility of this technique.
Methods: Twenty patients were studied retrospectively from March 2007 to July 2009. All patients underwent laparoscopic appendicectomy by the same experienced surgeon. Fifteen were female and 5 were male. The mean age was 40 years old (range, 15 to 81). The first port (10mm) was inserted in the supraumbilical region and was used for the camera. A second 5-mm port was inserted in the left side of the abdomen at the level of the supraumbilical port and about 10cm lateral to it. A third 5-mm port was inserted in the right hypochondrium in the mid-clavicular line. Dissection of the appendix was much easier in view of the wide arc of movement. The right subcostal port allowed easy lifting of the retrocecal appendix. Instruments used for the appendicectomy were nontoothed grasper, hook, Maryland dissector, Endoclips, 3 Endoloops, and Endoscissors.
Results: All 20 patients underwent successful laparoscopic appendicectomy with the above technique. No intraoperative or postoperative complications were encountered. The majority (18) of patients were discharged home the first postoperative day.
Conclusion: The above technique can be safely used as an alternative method for laparoscopic appendicectomy.
10.346 General Surgery
Single Incision Laparoscopic Surgery (SILS) for Resection of a Liver Tumor: First Known Reported Case
Delfino Randy Garza, MD, PGY-4, Juan Palma-Vargas, MD, Preston F. Foster, MD
Department of Surgery, Paul L. Foster School of Medicine, Texas Tech Health Science Center, El Paso, Texas, USA (Dr. Garza).
Texas Transplant Institute, Methodist Specialty and Transplant Hospital (Drs. Palma-Vargas, Foster).
Introduction: SILS involves an incision in the umbilicus that results in a single, small scar with a superior cosmetic advantage over the multiple scars resulting from standard multi-port laparoscopy. To our knowledge, we report the first case of a liver tumor resection using the SILS procedure.
Methods: A 56-year-old man was referred to our clinic for evaluation of an 8-cm x 5-cm hemangioma on the left lateral lobe of the liver. After discussion with the patient regarding the possible risk of rupture of the giant hemangioma, we proceeded with a SILS approach for tumor removal.
Results: The giant hemangioma was removed in its entirety, without difficulty and with minimal blood loss (<5mL). The patient was admitted for 23-hour observation and discharged the following morning with oral analgesics.
Conclusion: Based on this case, it is possible to remove liver tumors that are reasonably sized by using the SILS procedure. With increased surgeon experience and volume, we believe that operating time will be reduced and this technique will yield better cosmetic results. In addition, with an increased volume of SILS procedures performed at our institution, we may be able to determine whether SILS for liver tumors improves patient recovery, reduces postoperative pain, and decreases surgical wound complications.
10.348 Gynecology
100 Cases of GYN Office Based Surgery: The Complication Rates, Professional Reimbursement, Facility Reimbursement, Expense Analysis, and Patient Satisfaction Survey
Radha Syed, Namrata Singhania, MD
Staten Island University Hospital, New York, USA
Background and Objectives: Office based surgery (OBS) is a legal entity in New York State as of July 2009. Accreditation is mandated with the Joint Commission or other authorities. Relative-value units for hysteroscopic sterilization and endometrial ablation are higher for OBS than for the hospital. We evaluated 100 cases performed since becoming a Joint Commission Accredited facility in May of 2009, the professional and facility reimbursements, and complication rates.
Methods: The study included 100 patients whose ages ranged from 21 years to 65 years. The ASA classification was I-II. All patients had a complete gynecological workup including hysterosonograms. The indications were abnormal Pap smear with unsatisfactory colposcopy, abnormal uterine bleeding, and voluntary sterilization. All patients had a standard preoperative workup. All protocol documents were handed to patients in the preoperative consent session. Standard ASC procedures were followed including time out. IV Propaphol was given to all patients. Patients were discharged from the recovery room.
Results: The 100 cases were evaluated by a retrospective chart review. One minor and one major complication were noted. The minor complication was a seizure secondary to injected Toradol in the preoperative area. The major complication was a uterine perforation from a Thermachoice balloon.
Conclusion: Office based surgery is an innovative concept for gynecologists, which is logistically feasible with low complication rates. There is a financial burden on the physician, but there is improved reimbursement.
10.349 Gynecology
Laparoscopic Supracervical Hysterectomy: Confounding Variables That Determine the Complication Rates: A Retrospective Review of 50 Cases
Radha Syed, MD, Namrata Singhania, MD
Staten Island University Hospital, New York, USA
Background and Objectives: Laparoscopic supracervical hysterectomy (LSH) has become a popular gynecological procedure in recent times. However, complications are associated with this procedure. The objective of this study was to evaluate the variables that increased the risks.
Methods: The 50 consecutive cases were selected from the author’s practice. This was a retrospective chart review that calculated age, parity, pre-existing medical conditions, BMI, previous surgeries on the abdomen, indications, size of the uterus, surgical technique used, additional surgery performed, estimated blood loss, and complications.
Results: Complications resulted from a very large uterus with multiple myomas, previous surgeries/pelvis such as myomectomies. C-sections produced adhesions of the bladder to the cervix and uterus causing bladder injury. Large myomas with distorted uterine vessels resulted in blood loss. Intestinal adhesions caused ileus and delayed recovery. Endometriosis caused persistent pelvic pain. Reverse conization of the cervix prevents cyclic bleeding postoperatively. There were no conversions.
Conclusion: LSH is a safe procedure that requires expertise in handling high-tech instrumentation. Adhesions of the bladder and small intestines offer challenges. Postoperative complications require early recognition and treatment to prevent mortality and morbidity. Lastly, the classic techniques used in abdominal supracervical hysterectomy must be adhered to.
10.350 Gynecology
Manual Morcellation in Laparoscopic-Assisted Supracervical Hysterectomy
Eli Serur, MD, George Ahad, MD, Patrick Hagan, MS4, Robert Robertazzi, MS
Department of Obstetrics and Gynecology, The Brooklyn Hospital Center, Brooklyn, New York, USA
Objective: This case series describes a novel technique for performing laparoscopic supracervical hysterectomy utilizing manual morcellation, and a vinyl specimen retrieval bag (endobag), introduced into the abdominal cavity via trocar cannula, retrieving the dissected uterine corpus without spillage of the infected or malignant tissue by reduction of large masses into smaller fragments, facilitating tissue removal during laparoscopic supracervical hysterectomy (LSH).
Materials and Methods: We reviewed our experience with a series of 46 women who underwent LSH of uterine masses ≥250g, utilizing the endobag retrieval technique. In all cases, the dissected uterine corpus was placed within the bag where it was cut with a surgical knife into smaller tissue fragments utilizing extreme caution in preventing content spillage. The endobag was partially extracted via the laparoscopic suprapubic port after increasing incision size to 5cm to 7cm, allowing specimen retrieval while a portion of the pouch remained within the abdominal cavity.
Results: Mean uterine weight was 490g. The mean operative time was 150±36 minutes, with average blood loss of 174±105cc. No uterine tissue spillage was noted, nor were there any appreciable perioperative complications. The average length of stay was 2.8±2.3 days. Postoperative recoveries were uneventful.
Conclusion: Endobag specimen retrieval is efficacious in abating spillage of uterine contents during LSH. Although similar techniques have been described in removal of ovarian cysts, we believe this is the first description of its extensive usage in the case of uterine corpus extraction during LSH.
10.352 General Surgery
Laparoscopic Repair of a Staple Line Leak After Laparoscopic Sleeve Gastrectomy
M. Merriam, L. Shaw, L. Balsama, M. Neff
Kennedy University Hospitals, Stratford, New Jersey, USA
Objective: Laparoscopic gastric sleeve procedures are growing in popularity. With this growth, comes a recognition that complications, such as staple line leak, will occur with more frequency. With such a new operation, the question of where a leak occurs and whether it can be repaired laparoscopically should be asked.
Methods: A 19-year-old female with morbid obesity underwent an uncomplicated laparoscopic sleeve gastrectomy. Intraoperative EGD failed to reveal a leak, and a drain was positioned next to the staple line. She had mild tachycardia overnight but no change in JP drainage output. An upper GI study the next morning revealed a leak. The patient was taken emergently for repair. A 5-mm gastric perforation in the fundal portion of the staple line was identified. Repair was accomplished with oversewing of the perforation, Tisseel, and an omental patch. The entire procedure was performed laparoscopically, and multiple attempts to insufflate the stomach with an EGD showed no leak.
Results: The patient recovered well from the second procedure, and follow-up UGI showed no leakage. The patient was discharged to home 3 days later. She returned to the hospital briefly for LLL pneumonia. At her 3-week follow-up appointment, she was doing well, without evidence of leakage.
Conclusions: Laparoscopic sleeve gastrectomies are a viable option for weight loss surgery in select patients. The procedure however does involve a long stable line. While the complications of gastric staple lines still exist, repair can be accomplished with a laparoscopic procedure.
10.353 Gynecology
Initial Experience with the Synthetic Adhesion Barrier SprayShield™ on Fertility and Pelvic Pain Patients By Using Second Look Laparoscopies in the Fertility Patient Group
B.J. van Herendael, B. Tas, M. Francx, B. De Vree
ZNA Stuivenberg, Sint Erasmus (Drs. Herendael, Tas)
ZNA Middelheim (Drs. Francx, De Vree).
Background: The incidence of adhesions after intraabdominal surgery varies around 85%. It was common belief that laparoscopic surgery does reduce the number of postoperative adhesions. There is only evidence for the de novo adhesions. The adhesion reformation after laparoscopic adhesiolysis does not differ from adhesiolysis by laparotomy. The use of adhesion barriers is therefore indicated in gynecological laparoscopic surgery.
Methods: A first group of 13 patients participated in a prospective randomized trial. A first-look operative laparoscopy (FLL) was followed by a second-look laparoscopy (SLL) 5 to 8 weeks after the FLL. A second group of 11 patients had previous laparoscopic surgery, and the operative laparoscopy was considered the SLL. The effect of the synthetic adhesion barrier SprayShield (SS) was assessed at SLL and compared with effects in matched patients who did not receive the adhesion barrier.
Results: Of the 13 patients in the first group, 8 received the barrier and 5 patients were in the control group in which no barrier was given. After correction, 5 patients with myomectomy and tubal anastomosis were matched with 4 controls. None of the SS-treated patients had de novo adhesions at SLL versus 75% in the control group. In the endometriosis group, there was a reduction of adhesions by 61% at SLL compared with FLL. In the group of previously operated on patients, the AFS score was 32 and the average time to lyse the adhesions was 63 minutes.
Conclusion: The use of SprayShield (SS), a synthetic site-specific adhesion barrier, did reduce the formation of de novo adhesions in the patients treated with SS during gynecological surgery compared with the nontreated group. At SLL in endometriosis patients, there was a marked reduction in the adhesions scored with AFS.
10.354 Multispecialty
Initial Experience with SILS in Hysterectomy
Bruno J. van Herendael, Benedikt Tas
Ziekenhuis Netwerk Antwerpen Belgium (Prof. van Herendael)
Department Ob/Gyn, Ziekenhuis Netwerk, Antwerpen, Belgium (Dr. Tas).
The authors tried out the single-entry technique for hysterectomy to prove that single entry permits performance of hysterectomy within the time limits set at the department for regular laparoscopic hysterectomy (1 hour theater occupancy). A SILS cone from Covidien was used in the first cases. After closed insufflation up to 20mm Hg, as prescribed by the Flemish Society of Ob/Gyn, an incision of 2.5cm to 3cm was made in the fascia, whereas the skin incision remained at 1.5cm to 2cm. The pneumoperitoneum was restored at 16mm Hg through the SILS cone. The usual high cap trocar (Storz Gmbh & Co Tuttlingen) allowing up to 30L a minute of CO² was inserted in the abdomen through the cone, and two 5-mm Covidien disposable trocars were used. In some cases, the Covidien LigaSure Advance sealer was used, and in others, the new 5-mm LigaSure sealer was used. The advantage of the Advance sealer is that here we could open the vaginal vault over the manipulator cup without changing the instrument, with the monopolar tip at the end of the instrument, whilst with the 5-mm LigaSure the instrument had to be replaced by a classical monopolar hook to perform the same.
The authors believe that SILS hysterectomy is a valuable alternative for classical laparoscopic hysterectomy.
10.355 General Surgery
Efficacy of Subfascial Endoscopic Perforator Surgery (SEPS) Combined with Saphenous Vein Ablation in the Management of Advanced Chronic Venous Insufficiency
P.S. Saramgo, MS, G.J. Singh, MS, PhD, M. Sharma, MS, Ashwani, MBBS
DDU Hospital New Delhi, India (Mssrs. Saramgo, Sharma, Ashwani).
Safdarjang Hospital, New Delhi, India (Mr. Singh).
Introduction: Optimal surgical treatment for advanced chronic venous insufficiency (CVI) remains controversial, and further trials are required. This study was conducted to determine the efficacy of SEPS combined with saphenous vein ablation in cases of advanced chronic vein insufficiency (CEAP Class 4 to 6).
Method: A total of 116 patients (124 limbs) underwent SEPS with stripping of GSV up to the knee/LSV for CVI with incompetent perforators between January 2005 to December 2009 at DDU Hospital, New Delhi. Ninety-two patients had active or healed ulcers (CEAP Class 5 & 6), and 24 patients had lipodermatosclerosis (CEAP Class 4). There was no change in pre- and postoperative ulcer care. Preoperative evaluation confirmed superficial reflux with perforator incompetence in all cases. Outcomes were measured for perioperative complications, ulcer healing, and recurrence. Clinical severity and disability scores were tabulated before and after surgery. Mean patient follow-up was 46 months.
Results: Postoperative complications were found in 8 patients (6.89%), all with C6 disease. Eighty-six of 92 ulcers (93.4%) healed. Six (6.52%) who had persistent perforators had persistent ulcers. Four patients (4.34%) had recurrent ulcerations. Severity and disability scores improved significantly after surgery.
Conclusion: In spite of the limitations, SEPS is effective because it produces early ambulation, faster wound healing, and improvement in clinical severity and disability scores.
10.356 General Surgery
Laparoscopic Cholecystectomy for Intrahepatic Gallbladder with Acute Cholecystitis in a Morbidly Obese Patient: A Novel Approach
J.R. Ramirez, J. Orton, S.K. Shah, D. Alaedeen, P. Raj
Cleveland Clinic, Cleveland, Ohio, USA
Introduction: Laparoscopic cholecystectomy can be challenging when an intrahepatic gallbladder is present. When one encounters this problem in morbidly obese patients with acute cholecystitis, the entire scenario can be extremely difficult. We describe a safe technique for laparoscopic cholecystectomy in this unusual situation.
Methods and Procedures: A 28-year-old morbidly obese female, weight 403lbs with a body mass index of 65.1kg/m2, presented to the emergency room. After the workup, the diagnosis of acute cholecystitis was established. On exploration, hepatomegaly with fatty infiltration was seen without clear visibility of the gallbladder. Marked hypertrophy of the liver lobes was noted making visualization of the gallbladder extremely difficult.
A fundus-down dissection was carried out until the cystic artery was identified, clipped, and divided. Dissection was performed using aqua-dissection to the level of Hartmann’s Pouch. A GIA stapler was used to transect the gallbladder at Hartmann’s pouch. A HIDA scan was obtained on postoperative day one, which demonstrated gallbladder excision and no biliary leak. The patient’s postoperative course was uneventful, and she was discharged on postoperative day one.
Results: Laparoscopic cholecystectomy may be safely performed for an intrahepatic gallbladder even in morbidly obese patients with acute cholecystitis by using the novel technique outlined above. Critical elements of a successful operation include a fundus-down approach to the level of Hartmann’s pouch followed by careful aqua-dissection. The gallbladder should be divided at the level of Hartmann’s pouch with a GIA stapler or Endoloop instead of pursuing identification of the cystic duct to prevent common bile duct injury.
10.357 Urology
Anatomical Retro-Apical Technique of Synchronous (Posterior and Anterior) Urethral Transection: A Novel Approach for Ameliorating Apical Margin Positivity During Robotic Radical Prostatectomy
Abhishek Srivastava, MD, Sonal Grover, MD, Sivaram Rajan, MD, Youssef El Douaihy, MD, Kumaran Mudaliar, MD, David Peters, DO, Robert Leung, MPH, Gerald Y. Tan, MD, Jason Fung, BS, Maria Shevchuk, MD, Ashutosh Tewari, MD
Weill Cornell Medical College, New York, USA
Objective: To describe a novel synchronous approach to apical dissection during robotic-assisted radical prostatectomy (RARP), which augments circumferential visual appreciation of the prostatic apex and membranous urethra anatomy, and assess its effect on apical margin positivity.
Patients and Methods: Positive surgical margins (PSM) during RP predispose to earlier biochemical recurrence and occur most frequently at the prostatic apex. Conventional apical transection after early ligation of the dorsal venous complex (DVC) remains suboptimal, as this approach obscures visualization of the intersection between the prostatic apex and membranous urethra, leading to inadvertent apical capsulotomy and eventual margin positivity. A synchronous urethral transection commenced via a retro-apical approach was adopted in 209 consecutive patients undergoing RARP by one surgeon from April to September 2009. The apical margin rates for this group were compared with those of 1665 previous patients who received conventional urethral transection via an anterior approach after DVC ligation.
Results: Patients receiving synchronous urethral transection had significantly lower apical PSM rates than the control group had (1.4% vs 4.4%, P=0.04). This marked improvement in the retro-apical group occurred despite a significantly higher incidence of aggressive cancer (³pT3a) documented on final specimen pathology (16% vs 10%, P=0.027).
Conclusion: Improved circumferential visualization of the prostatic apex, membranous urethra, and their anatomical intersection facilitates precise dissection of the apex and its surrounding neural scaffold, and optimizes membranous urethral preservation. This has significantly ameliorated apical PSM rates in patients undergoing RARP, despite having to deal with more aggressive cancer on final specimen pathology.
10.358 General Surgery
Change in Body Mass Index is a Better Predictor of Resolution of Comorbidities Than Percentage Excess Weight Loss in Laparoscopic Adjustable Gastric Banding
Anh Q. Nguyen, BA, BS, Alexa L. Schwarzman, BA, Carson D. Liu, MD
Background: Percentage excess weight loss is a common measurement of weight loss. However, percentage excess weight loss alone is not a fair comparison of weight loss for individuals whose body mass index is >50, but rather average weight loss alone and change in body mass index.
Methods: We analyzed 525 patients from a random sampling of 800 patients through electronic medical records spanning 3 years. Patients were divided into 2 groups: body mass index <50 and body mass index >50; each group was then divided into 3 subgroups by date of band implantation. Student t test was used to compare percentage excess weight loss, average weight loss, and change in body mass index for each group across different time periods.
Results: Initial analysis showed patients with body mass index <50 had a significantly higher percentage of excess weight loss (50.47±3.02), (P=7.55E-06). Contrastingly, those with body mass index >50 had significantly greater average weight loss (63.41 РР±3.91), (P=2.17E-07) and change in body mass index (10.4±0.66), (P=8.28, E-08). These differences persisted throughout the 3 years.
Conclusions: Average weight loss and change in body mass index are much better weight-loss indicators than percentage excess weight loss alone. Furthermore, patients with body mass index >50 showed better resolution of comorbidities and maintenance of weight loss after a change of 10kg/m2. Therefore, laparoscopic adjustable gastric banding is a viable, effective, and steady weight loss solution for patients with body mass index >50.
10.359 General Surgery
Robotic Sigmoid Colectomy for Colovesical Fistula May Have Some Advantages Over the Laparoscopic Approach
Henry J Lujan, MD, Irving Jorge, MD, Gustavo Plasencia MD
Laparoscopic Center of South Florida at Jackson South Community Hospital, USA
Objective: The purpose of this study was to compare robotic sigmoid colectomy (RoSC) with laparoscopic sigmoid colectomy (LapSC) in the management of colovesical fistula (CVF) secondary to diverticular disease.
Methods: From June 2009 to December 2009, we performed 21 robotic colectomies. Three robotic colectomies were performed for CVF secondary to diverticular disease. We compared these 3 cases with the 5 most recent LapSC performed for CVF. Total room times (TRT), operative times (OT), estimated blood loss (EBL), length of stay (LOS), conversion rate, and complications were evaluated.
Results: Mean TRT for RoSC was 229 minutes vs. 179 minutes for LapSC. Mean OT was 168 minutes for RoSC and 144 minutes for LapSC. The median LOS was 2 days for RoSC and 3 days for LapSC. Mean EBL was 75mL for RoSC and 233mL for LapSC. Improved visualization was appreciated during RoSC compared with LapSC, specifically with takedown of the CVF and bleeding in the operative field. No cases were converted in either group. No significant complications occurred in either group during a 30-day follow-up period.
Conclusion: Our early experience with the Intuitive da Vinci Robot suggests its use is safe and feasible in the surgical treatment of benign CVF. Improved visualization with the robot appears to contribute directly to easier dissection of the phlegmon/fistula off the bladder and decrease blood loss. TRT and OT were slightly longer for robotic cases. However, EBL and LOS were less than with laparoscopic cases. Conversion and complication rates were similar for both approaches.
10.360 General Surgery
Laparoscopic Spigelian Hernia Repair
Ehab Akkary, MD
West Virginia University, School of Medicine, USA
Objective: Spigelian hernia is a rare ventral hernia that occurs secondary to a defect in the linea semilunaris. There are few reported cases of laparoscopic repair of Spigelian hernia. In this operative video, we present our experience with laparoscopic repair of an incarcerated right Spigelian hernia
Methods: A 51-year-old male presented with right lower quadrant pain and discomfort of a few years duration. He had a history of bilateral open inguinal hernia repair at another institution. Two years prior, he was explored via an open approach, but no hernia was found. CT scan demonstrated a Spigelian hernia with stranding and inflammation, and he was subsequently referred to West Virginia University. On laparoscopic exploration, we identified a Spigelian hernia in the right lower quadrant. The peritoneum around the hernia was incised. We then identified a large amount of preperitoneal fat that was incarcerated in the hernia sac, and this was freed and reduced into the abdominal cavity. The hernia defect was 4cm in diameter and was repaired by a 12-cm x 12-cm dual Gore mesh secured to the abdominal wall with ProTack.
Results: The patient made an uneventful recovery and was discharged the same day. He did not develop any postoperative complications.
Conclusion: Spigelian hernia is rare and needs a high index of clinical suspicion to avoid delay in diagnosis or unnecessary open explorations. CT scan is the imaging study of choice. To date, most repairs have pursued an open approach. We recommend laparoscopic repair as a practical approach for Spigelian hernias.
10.360 General Surgery
Value of Pharmacokinetic Analysis of Dynamic Contrast Enhanced MRI Performed for Preoperative Localization and Staging of Prostate Cancer: Potential Role in Candidates for Active Surveillance, Focal Therapy, and Guided Biopsy
Abhishek Srivastava, MD, Sonal Grover, MD, Sivaram Rajan, MD, Youssef El Douaihy, MD, Kumaran Mudaliar, MD, David Peters, DO, Robert Leung, MPH, Gerald Y. Tan, MD, Jason Fung, BS, Craig Sherman, MD, Ashutosh Tewari, MD
Weill Cornell Medical College, New York, USA
Introduction: The role of conventional magnetic resonance imaging (MRI) in detection of prostate cancer has been controversial with low sensitivity and specificity continuing to be a challenge, prompting surgeons to look for better tools to visualize cancer architecture. We evaluated the role of dynamic contrast enhanced-MRI (DCE-MRI) with pharmacokinetic (PK) analysis in prostate cancer evaluation.
Materials and Methods: Data were collected prospectively from August to October 2009. Consecutive patients with early prostate cancer or increased PSA and/or suspicious biopsy were offered 1.5T T1-weighted DCE-MRI with PK analysis using a pelvic phased array coil as an alternative to conventional 3T T2-weighted endorectal MRI. Fifty-eight patients underwent DCE-MRI with PK analysis and then underwent RARP performed by a single surgeon at our institution. The MRI reports from all these patients were correlated with the final histopathological report of the radical prostatectomy specimen.
Results: Mean age was 58.39 years; mean BMI was 27.91kg/m2; mean PSA was 5.91ng/dL. Of the patients, 44.82% were Gleason 6, 39.28% were Gleason 7, 13.79% were Gleason 8 on biopsy. Pathological T3 cancer was documented in 27.58% of patients. Fifty-six of 58 patients (96.55%) were reported to have visible tumor on MRI that correlated with final histopathology, and 39 of 56 cases (69.64%) correlated accurately with the site of the tumor.
Conclusion: DCE-MRI with PK analysis compares favorably with other published reports related to localization and staging of prostate cancer by conventional eMRI. This is also of great value to a surgeon, because he can objectively select patients for active surveillance, focal therapy, and guided biopsy.
10.361 Urology
Urachal Cyst Presenting as Recurrent Inguinal Hernia
Marianne V. Merritt, BS, Alyssa B. Chapital, MD, PhD, Daniel J Johnson, MD
Mayo Clinic
Background: To describe a complicated case of a recurrent inguinal hernia with intraoperative diagnosis of urachal cyst in a hernia sac.
Method: We present the case of an 80-year-old male undergoing a laparoscopic transabdominal recurrent right inguinal hernia repair found intraoperatively to have a previously undiagnosed urachal cyst.
Results: The patient was approached via a laparoscopic 3-port transperitoneal approach. Intraoperative consultation with a urologist was required to assist in the diagnosis and laparoscopic resection of the urachal cyst in hernia sac.
Conclusion: The laparoscopic transabdominal approach to recurrent inguinal hernia offers the ability to diagnosis and treat additional pathology at the time of hernia repair.
10.363 General Surgery
Contralateral Prostate Cancer Involvement in Potential Candidates for Focal Therapy
Sonal Grover, MD, Abhishek Srivastava, MD, Sivaram Rajan, MD, Youssef El Douaihy, MD, Kumaran Mudaliar, MD, David Peters, DO, Robert Leung, MPH, Gerald Y. Tan, MD, Jason Fung, BS, Maria Shevchuk, MD, AshutoshTewari, MD
Weill Cornell Medical College, New York, USA
Introduction and Objectives: Focal or hemiablative therapy for prostate cancer remains controversial given the multifocal nature of the disease. We sought to identify possible predictors for contralateral involvement and extraprostatic extension (EPE) based on preoperative clinico-pathologic characters.
Methods: Between June 2005 to July 2009, 1861 patients underwent radical robotic prostatectomy at our institution. Of these, 1114 had unilateral disease on preoperative biopsy. Clinical and biopsy variables were correlated with final surgical pathology. Logistic regression and Backward Wald analysis were performed to identify possible predictors of cancer in the contralateral lobe.
Results: Of 1114 patients with unilateral disease on biopsy, 867 (77.89%) had bilateral disease on final pathology. EPE was found in 133 patients (11.9%). Twenty patients (1.8%) had contralateral EPE involvement. HGPIN was the only significant predictor of contralateral involvement on both univariate (P=0.02; OR=1.791) and multivariate (P=0.004; OR=2.677) analysis. We further stratified our cohort based on Gleason scores and clinical stage and found that HGPIN is the significant predictor of contralateral involvement in patients with Gleason score <6 and clinical stage T2 tumor. Clinical stage T2 was the only significant predictor of contralateral EPE on both univariate and multivariate analysis.
Conclusion: HGPIN significantly predicts for contralateral involvement and should be exclusion criteria for focal therapy. Patients with clinical stage T2 should be advised to consider RP as a treatment option, because there is increased risk of having more a aggressive tumor with EPE.
10.364 General Surgery
Routine Upper Endoscopy Before Bariatric Surgery: Clinical Vs Statistical Significance
Mohannad Kusti, MD, Ehab Akkary, MD, Jennifer Lynn Koay, MS, Carlos Jaramillo, MD, Oriana Brusatin, MD, Linda Vona-Davis, PhD, Mounir Gazayerli, MD, FRCSC
West Virginia University, Morgantown, West Virginia and Wayne State University, Detroit, Michigan
Background and Objective: The efforts to optimize the surgical outcomes of bariatric surgery have led to various debates about the preoperative workup. Multiple controversial studies examined the role of preoperative esophagogastroduodenoscopy (P-EGD). We suggest that preoperative endoscopic assessment of the foregut might influence the surgical plan.
Materials and Methods: Between July 2008 and January 2010, 204 patients underwent laparoscopic bariatric surgery at West Virginia University performed by the same surgeon (EA). Revisions were excluded (n=26). The study enrolled 178 patients in 3 groups: Roux-Y Gastric Bypass (LRYGBP) n=61 (9 M, 53 F); Adjustable Gastric Band (LAGB) n=103 (14 M, 89 F); and Sleeve Gastrectomy (LSG) n=13 (5 M, 8 F). Patients underwent routine P-EGD and antral biopsy. The data were collected prospectively and analyzed using the ANOVA test.
Results: The LSG group was older (47.2±7.65) than the LAGB and LRYGBP groups (41.1±11 and 43±11.1) (years). They had the highest weight (318.5±82.1) compared with 279.2±64 and 280.65±51.4 (lbs) and Body Mass Index (BMI) of 52.78±8.7 compared with 45.8±8.1 and 46.5±5.4 (kg/m2), respectively (P<0.05). P-EGD led to change in the surgical plan in 9 (4.4%) patients in the LRYGBP group, 5 (4.9%) in the LAGB group, and 4 (30.8%) in the LSG group. Findings that led to procedure change included large paraesophageal hernia, Barrett’s esophagus, H. Pylori infection, intestinal metaplasia, villous adenoma, and epithelial atypia.
Conclusion: P-EGD is important in decision making in bariatric surgery. The study is limited by weak statistical significance; however, its clinical significance entails better surgical planning and postoperative surveillance if indicated.
10.365 General Surgery
Robotic-Assisted Adrenalectomy with Intraoperative Laparoscopic Ultrasound
Emad Kandil, MD, Paul Ikemire, BS
Tulane University School of Medicine, New Orleans, Louisiana, USA
Robot-assisted adrenalectomy, especially right-sided cases with involvement of the IVC and adrenal vein, can have major complications in obese patients or other similar cases where anatomic identification of the adrenal mass, the adrenal vein, and the inferior vena cava may be difficult. The objective here is to show a technique to reduce intraoperative complications in patients with difficult operative fields, to prevent unnecessary conversion to an open procedure, and to allow more confident, reliable robotic dissection.
The use of intraoperative laparoscopic ultrasound combined with focused robot-assisted laparoscopic surgical technique is shown here to properly map, guide, and perform the meticulous dissection of a difficult operative field with fatty infiltration of the adrenal mass, adrenal vein, IVC, and surrounding tissue.
The resulting ultrasound image provided a quality, reliable, and accurate guide that could be correlated with the operative field anatomy through direct visualization using the laparoscopic camera. The adrenal vein was clearly articulated between the IVC and adrenal mass and was successfully dissected and ligated without intraoperative complications, with minimal blood loss, and under a comfortable operative experience.
The combination of robot-assisted surgery with laparoscopic intraoperative ultrasound may provide advantages when performing adrenal surgery in obese patients or other patients with difficult operative fields, especially right-sided adrenalectomy cases with involvement of the IVC. It provides a safe, confident, and reliable operative experience despite limited operative field visualization or other anatomic anomalies that may normally require conversion to more extensive open procedures.
10.366 General Surgery
Transaxillary Gasless Robotic Thyroid Surgery with Recurrent Laryngeal and Peripheral Nerve Monitoring
Emad H. Kandil, MD, Dali A. Dali, MD
Background:
Robotic thyroidectomy with the gasless transaxillary technique has been FDA approved. The present study reviews the feasibility of added intraoperative monitoring to both recurrent laryngeal nerve (RLN) and peripheral median and ulnar nerves to this procedure.
Methods:
We describe the technique of intraoperative recurrent RLN monitoring, during robotic thyroid surgeries for patients who underwent thyroid lobectomy for suspicious thyroid nodule. Postoperative direct laryngoscopy was performed on their postoperative visit.
Results: The mean age was 41 years (range, 29 to 69), and only 3 of the 30 patients were males. The mean operating time was 119 minutes (range, 101 to 203), and the mean operating time with the da Vinci system was 37 minutes. All patients were discharged home after an overnight stay. One patient developed transient radial nerve neuropathy that resolved spontaneously within 1 week. This specific patient did not have monitoring of peripheral nerves. There were no other postoperative complications. All patients had intact mobile vocal cords on postoperative laryngoscopy.
Conclusions:
Robotic endoscopic thyroid surgery with the gasless transaxillary approach is safe in the treatment of suspicious thyroid nodules. This is the first study to prove the feasibility of monitoring of the RLN during this approach. Monitoring for median and ulnar nerve is feasible and could help avoid postoperative neuropathy related to this procedure.
10.367 General Surgery
Robot-Assisted Colon Resection Using the Medial Approach: A Pilot Study
Emad Kandil, MD, Kashaf Sherfagan, MD, Paul IKmire, MD, Dali Dali, MD, Charles Bellows, MD
Tulane University School of Medicine, New Orleans, Louisiana, USA.
Background: Robotic technology has recently been used in an increasing number of operative specialties to decrease the invasiveness of procedures and improve outcomes. However, there have been limited reports of its application to colorectal surgery. We performed a pilot study to evaluate the use of the da Vinci(R) surgical robot in colorectal surgery cases.
Methods: We performed a retrospective chart review of all patients who underwent robot-assisted colorectal surgery between October 2008 and May 2009. Information was extracted regarding operative time, pathology, perioperative course, and complications.
Results: Seven male patients underwent robotic-assisted colon resection. Four patients had right hemicolectomy, 2 left hemicolectomy, and 1 low anterior resection. In all cases, a medial approach was performed for vascular control using the da Vinci(R) surgical robot, followed by extracorporeal anastomosis. Four patients had adenocarcinoma with adequate resection margins, while the others had benign pathology. The mean number of lymph nodes removed was 15. The mean operative time was 237 minutes (range, 180 to 345 minutes). There were no intraoperative complications. The mean length of hospital stay was 5.5 days.
Conclusions: This is a single center experience showing the feasibility and safety of robot-assisted colorectal surgery. Robot-assisted colorectal surgery is an alternative minimally invasive technique that allows surgeons to overcome the limitations of laparoscopy, including limited visualization of the operative field and decreased dexterity. This approach is helpful for the medial vascular approach.
10.368 Urology
Monitoring Oxygen Saturation of Pelvic Nerve Tissues and Cavernosal Tissue Improves Clinical Outcomes in Patients Undergoing Robotic Radical Prostatectomy
Ashutosh Tewari, MD, Abhishek Srivastava, MD, Sonal Grover, MD, Sivaram Rajan, MD, Youssef El Douaihy, MD, Kumaran Mudaliar, MD, David Peters, DO, Robert Leung, MPH, Gerald Y. Tan, MD, Jason Fung, BS, Maria Shevchuk, MD
Weill Cornell Medical College, New York, USA
Introduction: It is postulated that penile hypoxia in the intraoperative period triggers a series of biochemical events that culminate in erectile dysfunction (ED). We have observed intraoperative penile oxygenation changes by using a pulse oximeter placed on the penis. We have further examined the phenomenon by using a tissue oximeter. We hypothesize that by avoiding excessive tissue traction and overly aggressive dissection during robotic radical prostatectomy, intraoperative penile hypoxia can be prevented.
Materials and Methods: From May 2008 to July 2008, 54 patients were enrolled in our IRB-approved study. The patients underwent continuous penile tissue saturation monitoring that was maintained above 85% throughout the surgery. Surgical dissection was altered or FI O2 was increased whenever the oxygen saturation alarm went off until it was restored to >85%. Postoperatively, functional follow-up was assessed by either telephone and/or in-person interview.
Results: Forty-six patients underwent nerve sparing, and oxygen saturation was maintained above 85% throughout the surgery by making subtle surgical adjustments. Thirty-seven patients (80.43%) had successful return to sexual function after 1 year of follow-up. Thirty-one of these 46 patients had preoperative IIEF score >60, and there was successful return to sexual function in 30 patients (96.77%).
Conclusion: Functional outcomes following robotic radical prostatectomy can be optimized by monitoring and maintaining oxygen saturation of pelvic nerve tissues and cavernosal tissue above 85%. This also provides intraoperative, real-time feedback to the surgeon and assistants to modify technique and improve clinical outcomes.
10.369 Urology
Real-Time Multiphoton Microscopy of Human Periprostatic Tissue Architecture for Improving Identification of Vital Tissue Structures During Nerve-Sparing Radical Prostatectomy
Ashutosh Tewari, MD, Sonal Grover, MD, Abhishek Srivastava, MD, Sivaram Rajan, MD, Youssef El Douaihy, MD, Kumaran Mudaliar, MD, David Peters, DO, Robert Leung, MPH, Gerald Y. Tan, MD, Josh Sterling, BS, Maria Shevchuk, MD, Sushmita Mukherjee, PhD, Fred Maxfield, PhD, Warren R. Zipfel, PhD, Watt W. Webb, PhD
Weill Cornell Medical College, New York, USA
Introduction and Objectives: This was a prospective study involving Multiphoton Microscopy imaging and histopathological correlations of human prostate and peri-prostatic tissue, to assess its potential as a future intraoperative imaging modality. The aim of this study was to improve the results of nerve-sparing radical prostatectomy and decrease the chance of missing extraprostatic extension.
Methods: We used specimens from intraoperative margins, biopsies, and tissue sections obtained from the excised prostate. The imaging was carried out using intrinsic fluorescence and scattering properties of the tissues without any exogenous dye or contrast agent. A custom-built MPM, consisting of an Olympus BX61WI upright frame and a modified Bio-Rad MRC 1024 scanhead was used. A femtosecond pulsed titanium/sapphire laser at 780-nm wavelength was used to excite the tissue. Second harmonic generation (SHG) signals were collected at 390 (±35nm), and broadband autofluorescence was collected at 380nm to 530nm. The images obtained from SHG and from tissue fluorescence were then merged and color-coded during postprocessing for better appreciation of details. The corresponding tissues underwent hematoxylin and eosin staining for histological confirmation of the structures.
Results: High-resolution images of the periprostatic tissue, nerves, prostate capsule, and underlying acini were obtained at varying magnifications. Histological confirmation and correlation of these structures validated the findings of MPM.
Conclusions: We have utilized a novel approach for real-time tissue imaging, which seems to provide microscopy level resolution in fresh tissue, without the need for any extrinsic labeling agents.
10.370 Urology
Prostate Volume and Its Correlation with Final Histopathological Outcomes
Sivaram Rajan, Kumaran Mudaliar, Maria Shevchuk, Youssef El Douaihy, Abhishek Srivastava, Sonal Grover, David Peters, Gerald Tan, Robert Leung, Ashutosh Tewari Weill Cornell Medical College, New York, New York, USA
Introduction and Objectives: We investigated prostate volume and its correlation with final pathological characteristics.
Methods: Data were collected prospectively using our IRB-approved protocol. We looked at 1930 patients from January 2005 to September 2009 who underwent robot-assisted radical prostatectomy performed by a single surgeon at our institution. Preoperative parameters (age, BMI, PSA, Gleason sum, core positivity, maximum percentage cancer biopsy, clinical stage) and the postoperative histopathologic details of the specimen (prostate volume, Gleason sum, EPE, and surgical margin status, percentage cancer) were compared among the small prostate (<40cc), intermediate size (range, 40cc to 70cc), and large prostate (>70cc) groups.
Results: Patients with smaller prostates were younger (P<0.05), had lower BMI (P<0.05), and lower PSA values (P<0.05) preoperatively than patients with larger prostates. Looking at preoperative biopsy characteristics, patients with smaller prostates had higher Gleason biopsy scores (P<0.05), higher maximum percentage cancer on biopsy (P<0.05), and increased core positivity percentage (P<0.05). Postoperatively, patients with smaller prostates had higher surgical margin rates (11.6%) than the intermediate (8.6%) and large (6.6%) prostate groups. The small prostate group also had higher Gleason pathological scores (P<0.05), higher rates of EPE (P<0.05), and an increased percentage of cancer (P<0.05).
Conclusions: Patients with small prostates and prostate cancer tend to be younger with lower PSA values and higher biopsy Gleason scores than patients with larger prostates. Also, there are increased surgical margin rates and incidence of EPE associated with smaller prostates.
10.371 Urology
Optimizing Anastomotic Healing After Robotic-Assisted Radical Prostatectomy: Results of 3 Techniques in 1294 Patients
Sivaram Rajan, Ashutosh Tewari, Abhishek Srivastava, Sonal Grover, Kumaran Mudaliar, David L. Peters, Jason Fung, Youssef El Douaihy
Weil Cornell Medical College, New York, New York, USA
Introduction and Objectives: An optimally apposed, tension-free, well-supported vesicourethral anastomosis remains the cornerstone for anastomotic healing following radical prostatectomy. We report the effect of 3 techniques of bladder neck reconstruction during robotic radical prostatectomy on anastomotic leak, stricture formation, and continence recovery.
Methods: Between January 1, 2005 to July 30, 2008, 1294 consecutive patients underwent robotic-assisted radical prostatectomy by a single surgeon. Of these, 214 underwent conventional vesicourethral anastomosis; 303 men underwent anterior reconstruction only; and 777 men underwent total anatomic restoration. Data elements included patient age, body mass index, preoperative biopsy Gleason score and PSA, prostate volume, total operative time, console time, time for performing vesicourethral anastomosis, estimated blood loss, tumor stage, and margin status on final pathology. Primary endpoints were rates of clinically significant anastomotic leaks, bladder neck contractures, and time to return of continence. Chi-square and Fischer exact tests were used for analysis of variables. Cox proportional hazard model was used for both univariate and multivariate analyses.
Results: Clinically significant anastomotic leakage and bladder neck strictures were significantly fewer in the reconstructed groups (2.3% vs 1.0% vs 0.3% and 3.7% vs 1.3% vs 0.6% in the CA, AR and TR groups, respectively, P<0.01). Continence rates at 1, 6, 12, and 26 weeks following RALP were also significantly better at all time points with anatomic restoration and anterior reconstruction compared with conventional anastomosis alone (P<0.001).
Conclusions: Anatomic restoration of the continence mechanism optimizes vesicourethral anastomosis healing following RALP.
10.372 Urology
Anatomic Distribution of Extracapsular Extension and Surgical Margin Positivity in Patients Undergoing Robotic Radical Prostatectomy: Implications for Surgical Technique
Kumaran Mudaliar, Sivaram Rajan, Ashutosh Tewari, Abhishek Srivastava, Sonal Grover, David L. Peters, Jason Fung, Youssef El Douaihy, Robert Leung
Weil Cornell Medical College, New York, New York, USA
Introduction and Objectives: Extracapsular extension in radical prostatectomy for clinically organ-confined prostate cancer increases the risk of postoperative biochemical failure and clinical recurrence, and predisposes to surgical margin positivity with risk of incomplete extirpation of cancer. We studied the association of anatomic location of ECE with PSM, and attempt to identify possible predictors for the site of ECE using clinical variables and MRI.
Methods: From January 2005 to November 2009, 1948 patients underwent robotic-assisted laparoscopic prostatectomy by a single surgeon. Of these, 207 patients had ECE on final specimen pathology. Pathological staging (pTNM), final Gleason Sum, prostate volume, and positive margins were recorded. Location of EPE on final histopathology in pT3a patients was assigned to apex, base, posterolateral, idprostate (includes lateral, posterior, or anterior involvement), and multifocal EPE. Binary logistic regression was used to determine statistical significance.
Results: Anatomic distribution of ECE on final specimen pathology was 24%, 16%, 13%, 4%, and 3% for posterolateral, multifocal, midprostate, base, and apex, respectively. Distribution of PSM was 75%, 33%, 20%, 18.6%, and 18.4% for apex, base, multi-focal, posterolateral, and midprostate, respectively. Apical ECE was associated with PSM in 75% of involved cases. Preoperative MRI also predicted significantly for ECE at the posterolateral area.
Conclusions: Radiologic evidence of posterolateral ECE on preoperative MRI appears to be the only significant predictor for pT3 disease in the same area. Apical ECE is associated with a high incidence of accompanying margin positivity, and surgical technique should be adjusted accordingly to optimize cancer clearance.
10.373 Urology
Risk-Stratified Approach to Nerve-Sparing Robotic Radical Prostatectomy Based on Fascial Planes of Dissection
Kumaran Mudaliar, Sivaram Rajan, Ashutosh Tewari, Abhishek Srivastava, Sonal Grover, David L. Peters, Jason Fung, Youssef El Douaihy, Robert Leung
Weil Cornell Medical College, New York, New York, USA
Introduction and Objectives: Balancing the aggressiveness of nerve-sparing against risk of surgical margin positivity, we report our experience with a risk-stratified approach based on layers of periprostatic fascial dissection.
Methods: Histologic slide review of 100 patients undergoing robotic-assisted radical prostatectomy facilitated identification of the distribution of periprostatic nerve bundles stained with S100 in distinct fascial planes, leading to our adopting 4 grades of nerve-sparing based on identifiable anatomic landmarks. We report our experience with 417 men with aggressive Grade 1 nerve-sparing from January 2005 to September 2009. Patients completed baseline IIEF questionnaires before surgery and were prospectively followed up at regular intervals over a 12-month period. Potency was defined as erections sufficient for penetrative intercourse with or without medical assistance.
Results: Aggressive Grade 1 nerve sparing was provided to 417 patients. Mean age was 59.2 years. Mean PSA was 4.7ng/dL. Overall, 83.7% of patients had erections sufficient for penetrative intercourse with and without the use of PDE5i at one year after surgery. Return of potency occurred at 31.2%, 1.7%, and 72.3% at the 6-, 12-, 26-week follow-up intervals, respectively. Overall positive surgical margin rate was 5.52%.
Conclusion: Our risk-stratified approach to nerve-sparing robotic prostatectomy delivers early return of sexual function without compromising cancer control.
10.374 General Surgery
Robotic Adrenalectomies with Intraoperative Ultrasound: A Single Surgeon's Experience in a North American Academic Setting
Emad H, Kandil, MD, Dali A. Dali, MD, Paul A. Ikemire, MD, Charles F. Bellows, MD, Raju Thomas, MD, MHA
Department of Surgery, Tulane Medical School, New Orleans, Louisiana, USA
Background: Robotic adrenalectomy is a minimally invasive alternative to traditional laparoscopic adrenalectomy. To date, only case reports and small series of robotic adrenalectomies have been reported. This study presents a single surgeon's series of 16 robotic adrenalectomies, and evaluates the procedure's safety and efficacy. We also evaluated the role of intraoperative laparoscopic ultrasound examination.
Methods: Sixteen patients underwent robotic adrenalectomy at an academic institution in North America between January 2008 and August 2009. Patient morbidity, hospital length of stay, operative time, and conversion rate to traditional laparoscopic or open surgery were reported. Improvement in operative time with surgeon experience was evaluated.
Results: Mean age for the patients was 62 years. Ten of the 16 patients were females. Median operative time was 142 minutes. There was no mortality or major complication. Intraoperative ultrasound examination was able to localize all the adrenal lesions in relation to nearby vascular structures. This technique was very helpful mainly for morbidly obese patients with small adrenal lesions. There were no conversions to traditional laparoscopic or open surgery. The median hospital stay was 1.8 days. Operative time improved significantly with each operation.
Conclusion: To our knowledge, this is the largest series from a single surgeon in North America. Robotic adrenalectomy is a safe and effective alternative to traditional laparoscopic adrenalectomy. Addition of intraoperative ultrasound examination was helpful to localize smaller lesions in morbidly obese patients.
10.375 General Surgery
Laparoscopy with Robotic Assistance in a Gastrectomy Wedge Resection of a Leiomyoma
Michael Thomas, MD, PhD, Emad Kandil, MD, Thomas Chaly, MD
Department of Surgery, Tulane University, New Orleans, Louisiana, USA
Introduction: Gastric leiomyoma may present with an abdominal mass, overt bleeding, and less commonly abdominal pain. The diagnosis is typically made with the finding of a subepithelial mass on upper endoscopy or barium study. A mass may also be seen incidentally on CT scan. We are presenting a case in which the da Vinci robotic system was used for partial gastrectomy and reconstruction.
Methods: We are presenting a 63-year-old gentleman who was found to have an incidental 3-cm antral mass on a CT of the abdomen for abdominal pain. Endoscopy with endoscopic ultrasound (EUS) confirmed the submucosal mass. Biopsy of the lesion was consistent with a leiomyoma. The patient underwent partial gastrectomy with robotic assistance.
Results: Intraoperative endoscopic ultrasound confirmed a prepyloric mass. A robotic ultrasonic scalpel aided in the resection with grossly negative margins. The defect was closed primarily with robotic assistance in a double layer fashion. The patient was discharged home on the second postoperative day. Pathology confirmed a diagnosis of leiomyoma with negative margins. There was no evidence of recurrence on repeat endoscopy 6 months after surgical resection.
Conclusions: Intraoperative ultrasound is helpful to localize small gastric tumors. Robotic assistance in gastric resection is feasible and offers a minimally invasive approach to these tumors.
10.376 General Surgery
Transaxillary Gasless Robotic Thyroid Surgery with Recurrent Laryngeal and Peripheral Nerve Monitoring
Emad H. Kandil, MD, Dali A. Dali, MD
Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
Background:
Robotic thyroidectomy with the gasless transaxillary technique has been FDA approved. The present study reviews the feasibility of adding intraoperative monitoring of both recurrent laryngeal nerve (RLN) and peripheral median and ulnar nerves to this procedure.
Methods:
We report on the technique of intraoperative recurrent RLN monitoring, during robotic thyroid surgeries for patients who underwent thyroid lobectomy for suspicious thyroid nodules. Patients underwent direct laryngoscopy on their postoperative visit.
Results: The mean patient age was 41 years (range, 29 to 69), and only 3 of the 30 patients were males. The mean operating time was 119 minutes (range, 101 to 203), and the mean operating time with the da Vinci system was 37 minutes. All patients were discharged home after an overnight stay. One patient developed transient radial nerve neuropathy that resolved spontaneously within 1 week. This specific patient did not have monitoring of peripheral nerves. There were no other postoperative complications. All patients had intact mobile vocal cords on postoperative laryngoscopy.
Conclusions:
Robotic endoscopic thyroid surgery with the gasless transaxillary approach is safe for treating suspicious thyroid nodules. This is the first study to prove the feasibility of monitoring of the RLN during this approach. Monitoring for median and ulnar nerve is feasible and could help avoid postoperative neuropathy related to this procedure.
10.377 Urology
Finger-Assisted, Single-Port Transvesical Enucleation of the Prostate (F-STEP) for Benign Hypertrophy
Dong Soo Park, MD, PhD, Jong Jin Oh, MD
Department of Urology, Bundang CHA Hospital, CHA University, Seongnam, South Korea
Objectives: To report on a surgical technique, the finger-assisted, single-port transvesical enucleation of the prostate (F-STEP), which is different from the laparoendoscopic single-site (LESS) surgery, for simple prostatectomy for benign hypertrophy which was recently reported.
Methods: From March to December 2009, 27 patients were treated with our surgical technique. After the bladder was filled with normal saline, a 2.5-cm low-vertical skin incision was made at the level of the bladder. After cystotomy, an extrasmall Alexis wound retractor and a surgical glove were fashioned and used as a homemade, single-port device to establish a pneumovesicum. A circular incision was made over the bladder mucosa around the adenoma by using articulating laparoscopic instruments. Careful blunt and electrocautery dissection were performed to reach the capsular plane. The prostatic adenoma was completely enucleated with the index finger. Sutures were placed at the 4- and 8-o’clock positions. A 20-Fr 3-way Foley catheter with continuous irrigation was applied.
Results: The urethral catheter remained approximately 7 days or 8 days for healing of the cystotomy. The average operative time was 117.42±42.55 minutes, and blood transfusions were necessary in 8 cases. The mean weight of the enucleated tissue was 46.76g. Significant symptom improvement (IPSS, QoL, dysuria, Qmax) was observed in all patients.
Conclusion: The F-STEP was technically complex; however, our initial experience suggests that this technique may be an alternative for transurethral resection of the prostate. Comparative studies with current surgical techniques will be needed to determine the usefulness of this technique in the surgical treatment of benign prostatic hyperplasia.
10.378 Gynecology
Correlation of Gastrointestinal and Urinary Tract Endometriosis
Arathi Veeraswamy, MD, Babak Hajhosseini, MD, Michael Lewis, MD, Sumathi Kotikela, MD, Camran Nezhat, MD
Center for Minimally Invasive and Robotic Surgery, Palo Alto, California, USA
Objective: We report the incidence of urinary tract endometriosis in patients with gastrointestinal endometriosis at our institution.
Methods: This was a retrospective data analysis performed between January 2002 and April 2009 at the Center for Minimally Invasive and Robotic Surgery, Palo Alto, California. Records were reviewed of 193 patients with bowel endometriosis confirmed on pathology. We studied the prevalence, clinical characteristics, and stage of endometriosis of patients with bowel endometriosis and associated urinary tract endometriosis.
Results: The chief complaint of 82.4% of patients was pelvic pain, while 36.3% had bowel symptoms and 28.5% had bladder symptoms as their chief complaint. The incidence of bladder endometriosis was 39.5%, and that of ureteral endometriosis was 43.5%.
Conclusions: Endometriosis is rarely fatal, but continues to intrigue patients and clinicians in all disciplines in its presentation and diagnosis. Surgical treatment of bladder and/or ureteral endometriosis requires informed consent of patients and multidisciplinary management. A high clinical suspicion is the only key prior to any surgical intervention.
10.379 General Surgery
Laparoscopic Cholecystectomy in a Patient with Situs Inversus
Krassimir Atanassov, MD, Warren D. Widmann, MD, Nancy Hogle, RS, MS, Jason Maier, BA, Michael Casetellano, MD
Departments of Surgery, Staten Island University Hospital, Staten Island, New York
State University of New York, Downstate Medical Center, Brooklyn, New York, USA
While laparoscopic cholecystectomy is one of the most commonly performed laparoscopic procedures by general surgeons, its performance in a case with situs inversus is 1/10,000 of the overall experience. Thus, a single surgeon is unlikely to encounter such a case in his career, and it is useful to review the technical aspects of performance of a cholecystectomy in such a clinical situation.
In preparation for the operation, the team reviewed the available literature and made the following adjustments. The laparoscopic tower was placed on the patient’s left side, the surgeon stood on the patient’s right side, and the first assistant stood on the patient’s left side.
Inspection of the abdominal cavity confirmed situs inversus totalis with the bulk of the liver found in the left upper quadrant, the transmitted heartbeat noted in the right upper quadrant, and the sigmoid colon located in the right lower quadrant.
The anatomic dissection of the Triangle of Calot and the sequence of clipping and division of the cystic artery and cystic duct as well as the removal of the gallbladder from the liver bed were uneventful. There was no need for the surgeon to switch from the usual use of the instruments in his right and left hands.
We found that with the setup of the room and the positioning of the surgeon and the first assistant essentially in a mirror image from the usual, the operation proceeded without any complications or difficulty.
10.380 Urology
Suprapubic Foley-Free Urinary Diversion Following Robotic-Assisted Radical Prostatectomy: Functional Outcomes at 6 Months Using a Validated Questionnaire
Sonal Grover, MD, Abhishek Srivastava, MD, Sandhya Rao, MD, Sivaram Rajan, MD, Youssef El Douaihy, MD, Kumaran Mudaliar, MD, David Peters, DO, Robert Leung, MPH, Gerald Y. Tan, MD, Jason Fung, BS, Maria Shevchuk MD, Ashutosh Tewari MD
Weill Cornell Medical College, New York, USA
Introduction and Objectives: Urethral Foley catheterization often causes significant discomfort for patients recovering from radical prostatectomy (RP). We recently adopted suprapubic urinary diversion following robotic RP to minimize postoperative discomfort, and herein report continence and sexual outcomes of this Foley-free approach.
Methods: Between October 2008 to May 2009, 50 patients underwent urethral Foley-free robotic RP with suprapubic urinary diversion. Following posterior reconstruction of the vesicourethral anastomosis, a customized splint is placed with the attached Prolene suture passed per urethra for subsequent removal. Subsequent completion of the anastomosis is followed by insertion of a 16Fr Stamey suprapubic tube under direct vision after saline distension of the bladder. The suprapubic tube and anastomotic splint are both removed on the seventh postoperative day. Postoperative sexual and urinary outcomes were recorded using the EPIC questionnaire.
Results: A minimum 6-month follow-up was completed by 41 of 50 patients who received suprapubic urinary diversion. Of these 41 men, 15 had preoperative IIEF<60 (Group 1), and 26 had preoperative IIEF>60 (Group 2). Thirty-three men (80.48%) were able to have erections sufficient for penetrative intercourse. Group 2 had significantly higher return of potency compared with Group 1 patients (88.5% vs. 66.7%) with mean time to potency of 14.4 weeks. Thirty-eight men (92.7%) were continent postoperatively, with mean time to continence of 3.28 weeks. Return of continence occurred in 31.7%, 80.5%, and 92.7%, at 1, 6, and 12 weeks follow-up, respectively.
Conclusion: Suprapubic Foley-free robotic RP in well selected patients facilitates early return of continence and sexual function.
10.381 General Surgery
Laparoscopic Splenectomy: Conventional Versus Robotic Approach: A Comparative Study
R. Gelmini, C. Franzoni, A. Spaziani, A. Patriti, L. Casciola, M. Saviano
Department of Surgery, University of Modena and Reggio Emilia, Modena, Italy (Drs. Gelmini, Franzoni, Saviano).
Department of Surgery, S. Matteo degli Infermi Hospital, Spoleto, Italy (Drs. Spaziani, Patriti, Casciola).
Objectives: Laparoscopic splenectomy (LS) is the gold standard in surgical treatment of splenic hematologic diseases. Robotic surgery (RS) has changed the concept of minimally invasive surgery because of the tridimensional view, degrees of freedom, and accuracy of movements. The aim of this study was to evaluate whether RS has advantages over LS.
Methods: In 2 Surgical Units experienced in laparoscopic spleen surgery, 2 groups of patients underwent LS (45 cases G1) and RS (45 cases G2). The 2 groups were well matched for demographic characteristic, indications, and spleen size. The median bipolar spleen diameter was 15cm and 13cm, respectively.
Results: Between the 2 groups, there were no statistically significant differences in intraoperative blood loss (<100mL in both groups), conversion rate to laparotomy (5 G1, 4 G2), postoperative food intake, drainage removal, postoperative complications (4 hemoperitoneum and 1 pleural effusion G1, 1 hemoperitoneum and 4 pleural effusion G2) and median postoperative hospital stay. On the contrary, statistically significant differences were observed for median operative time (125 minutes G1, 153 G2) and costs (US$1.600 G1, US$6.930 G2). Transfusion and mortality rate were 0%. The follow-up at 6 months does not highlight late-surgical complications.
Conclusion: The analysis of the data does not show advantages of RS over LS. RS even though it offers a tridimensional view of the operative field and the degrees of freedom and accuracy of movement that are superior to that of LS, has longer operative time and higher costs. Therefore, we can conclude that LS is to be considered the gold standard for hematological diseases.
10.382 General Surgery
Covert Laparoscopic Cholecystectomy: A New Minimally Invasive Technique
Hai Hu, MD, PhD, Jiangfan Zhu, MD, Anhua Huang, MD, Ying Xin, MD, Anan Xu, MD, Wenxin Zhang, MD, Bingguan Chen, MD, PhD
Department of Minimally Invasive Surgery, Tongji University Affiliated Shanghai East Hospital, Peoples Republic of China
Objective: Transumbilical endoscopic surgery (TUES) is technically difficult and takes a long time to complete. Based on our TUES experiences, we propose a covert laparoscopic cholecystectomy that leaves no visible scars on the abdomen.
Methods: Twelve patients who were to undergo LC were recruited for this new approach. First, a 10-mm trocar was placed above the umbilicus for inserting the laparoscope. Under laparoscopic guidance, two 5-mm trocars were placed near the right and left ends of the superior margin of the suprapubic hair. The 5-mm 30° laparoscope was shifted to the left suprapubic trocar. A harmonic scalpel (for direct cutting of the cystic vessels) or the electric hook (for dissecting the gallbladder bed) was introduced through the 10-mm umbilical trocar. A 5-mm grasper was inserted through the right suprapubic trocar, for ease of exposure and dissecting.
Results: All gallbladders were successfully removed without intraoperative complications. The mean operating time was 28.5±5.7 minutes (range, 20 to 45). All patients felt well after the operations and did not need postoperative analgesia. They resumed free oral intake 6 hours after the procedure. All patients were satisfied with the appearance of the incisions, which were completely hidden in the umbilicus and suprapubic hair.
Conclusions: The covert LC has overcome both external instrument interference around the umbilicus and the loss of triangulation in the operative field. It is relatively simpler than a typical TUES and offers better cosmetic results.
10.383 Urology
Ureteropelvic Junction Occlusion Balloon Catheter for Prevention of Vesicoureteral Reflux During Formalin Instillation: A Report of Two Cases
Mitchell L. Ogles, MD, E. James Seidmon, MD
University of Mississippi Medical Center, Jackson, Mississippi, USA
Introduction: We present a novel technique for preventing vesicoureteral reflux during formalin instillation using a ureteropelvic junction occlusion balloon catheter placed in the distal ureter.
Methods: Two patients with intractable bleeding demonstrated vesicoureteral reflux during intraoperative cystogram prior to formalin instillation for hematuria refractory to conservative management. One patient demonstrated unilateral vesicoureteral reflux, while the second demonstrated bilateral vesicoureteral reflux. A Cook 6 French ureteropelvic junction occlusion balloon catheter was placed in the appropriate ureteral orifice and the balloon inflated with 1cc of radiopaque contrast. Repeat cystogram demonstrated no further reflux. A 2.5% formalin solution was then instilled for 15 minutes. The formalin was drained and the bladder irrigated. The ureteropelvic junction occlusion balloon catheter was deflated, removed, and continuous bladder irrigation was continued overnight with no further hemorrhage.
Results: In each case, the ureteropelvic junction occlusion balloon catheter was passed completely through a 21 French cystoscope. Follow-up cystogram after placement demonstrated resolution of reflux. No complications were noted.
Conclusion: The use of a ureteropelvic junction occlusion balloon catheter is a safe and effective method to prevent reflux during intravesical formalin instillation. This technique is easier to perform than placement of a Fogarty catheter due to the ability to place this occlusion balloon catheter completely through the working port of the cystoscope as well as having a guide wire to assist with catheter introduction into the ureteral orifice. To our knowledge, this is the first report of using this device for prevention of vesicoureteral reflux during formalin instillation.
10.384 General Surgery
Laparoscopic Subtotal Cholecystectomy in Severe Acute Cholecystitis
A.P. Ukhanov, S.R. Chakhmakhchev, A.I. Ignatjev, B.B. Frumkin, A.I. Bolshakov, F.J. Uvertkin, M.G. Adilov, A.A. Proskurin
First Municipal Clinical Hospital, Velikiy Novgorod, Russian Federation
Objectives: Improvement in treatment results of the patients with severe acute cholecystitis.
Material and Methods: Laparoscopy was performed in 352 patients with acute destructive cholecystitis. In 236 (67.0%) patients, there was phlegmonous or emphysematous cholecystitis, in 116 cases (33.0 %) gangrenous cholecystitis. In 74 (21%) patients, the cholecystitis had been complicated by formation of perivesical infiltrate or abscess. In 84 patients with severe acute cholecystitis, laparoscopic subtotal cholecystectomy was carried out.
Results: Average duration of subtotal laparoscopic cholecystectomy (SLC) was 72.4±13.4 minutes, for typical laparoscopic cholecystectomy (TLC) 58.4±12.6 minutes. Average blood loss for SLC was 87.5±14.2mL, and for TLC 48.4±11.3mL. Conversion rate for SLC was 4.8% (4 patients), and for TLC 2.2% (6 patients). Average length of stay after the operation in patients with SLC was 7.4±2.5 days, and after TLC 5.8±1.8 days. There was no bile duct damage or mortality in each group.
Conclusion: Thus, subtotal laparoscopic cholecystectomy in patients with severe acute cholecystitis technically is more difficult and long, is accompanied by more blood loss, has a higher conversion rate, and longer length of stay than typical laparoscopic cholecystectomy. However, such an operation is feasible and rather safe in heavy forms of destructive cholecystitis, promotes reduction in the threshold of conversion to laparotomy, and diminishes the risk of bile duct damage.
10.385 Gynecology
Changes in Patients’ Preference in Tubal Sterilization: A Single University Experience
Nauman Khurshid, MD
Department of Obstetrics and Gynecology, University of Toledo Medical Center, Toledo, Ohio, USA
Objective: To demonstrate the increase in popularity and patients’ acceptance of the Essure procedures compared with the traditional tubal ligations.
Methods: After IRB approval from the University of Toledo Medical Center, a retrospective analysis of interval sterilizations performed by surgeons who were trained in Essure tubal sterilization was undertaken. From September 2007 to November of 2009, 186 women underwent interval tubal sterilization. Patients were given options of various methods of sterilization and risks discussed and preferences were recorded. They were offered both traditional laparoscopic tubal fulguration and Essure tubal occlusion sterilization. Essure was introduced in the fall of 2008 at the university.
Results: All of the subjects underwent interval sterilization under IV sedations. In the year 2007 through 2008, 100% (N=68) of women underwent laparoscopic tubal fulguration. Implementation of Essure at the university medical center was done in September 2008. In 2008 through 2009, 94%( N=111) of the patients preferred to have Essure tubal occlusion than laparoscopic tubal fulguration 6% (N=7). The most common reason for Essure preference was less pain and early return to daily activity.
Conclusion: Since the training of clinical staffs in a university setting, the trend of female interval sterilization has changed dramatically from 0% to >90% in less than 24 months. The performing surgeons have adapted and implemented this procedure very quickly without compromising patient safety. Patients also preferred minimally invasive interval sterilization to traditional laparoscopic sterilization.
10.386
General Surgery
Laparoscopic Appendectomy in the Treatment of Acute Appendicitis, Complicated
by Peritonitis and Periappendicular Infiltrate or Absces
A. Ukhanov, S. Kovalev, A. Ignatjev, B. Frumkin, S. Bolshakov,
R. Uvertkin, M. Adilov A.Proskurin
First Municipal Clinical Hospital, Velikiy Novgorod, Russia
Objective: Improvement of the
treatment results of patients with acute complicated appendicitis with the use
of endovideosurgical technologies.
Materials and Methods: Seventy-five
patients with acute destructive appendicitis complicated by peritonitis and
periappendicular infiltrate or abscess were operated on laparoscopically. The
study included 26 men and 49 women; median age was 33.8 years (range, 18 to
61). The duration of the disease varied from 18 hours to 8 days. According to
the clinico-morphological form of disease, patients were distributed as
follows: 45 patients had phlegmonous appendicitis, 17 gangrenous, and 13
gangrenous perforated appendicitis. In 69 patients, the disease course has been
complicated by a peritonitis, including 15 patients with diffuse and 54 with
local peritonitis. In 9 patients, there was periappendicular infiltrate and in
11 cases periappendicular abscess. In 14 patients, there was a combination of
periappendicular infiltrate or abscess with peritonitis. Laparoscopic
appendectomy was carried out under endotracheal narcosis with the use of
myorelaxants.
Results: Conversion rate was 5.3% (4
cases). Average time of operation was 56 minutes. Morbidity rate was 8.0% (6
patients), including intraabdominal abscesses in 2, infiltrate in the right
iliac region, and wound suppurations in patients. There was no mortality.
Conclusions: Thus, laparoscopic
appendectomy to treat acute destructive complicated appendicitis is feasible
and a rather safe operative intervention. Contraindications to endosurgical
treatment are appendicular abscess with a dense pyogenic capsule or diffuse
purulent peritonitis with paralytic small bowel ileus.
10.387 General Surgery
Does
High-Frequency Adjustment in Laparoscopic Gastric Banding Patients Lead to
Increased Weight Loss? A Small Comparative Study Done at a Single Institution
A. Kandel, MD, J. Taylor, MD, G.
Deutsch, MD, N. Hubbard, MD, D. Gadaleta, MD, L. Gellman, MD
Introduction: Morbid obesity has
become a worldwide epidemic. Currently surgery has been used to treat the
disease. Laparoscopic gastric banding, one of the surgical techniques, involves
positioning a silicone adjustable device around the gastric cardia.
We sought to determine the percentage of excess weight loss in 2 patient
populations who underwent laparoscopic gastric banding, in a single
institution.
Methods and Results: We performed a
retrospective chart review and analysis of 50 patients who underwent
laparoscopic gastric banding at a single institution during a 1.5-year period.
The above patients were divided into 2 groups for analysis: a historical
conservative adjustment control group and a high-frequency adjustment group.
Each group had 25 patients. The above groups were similar in age and weight. We
compared the percentage loss of excess weight in both groups. The percentage
excess weight loss in the conservative group ranged from 5% to 16% and averaged
9%. The percentage excess weight loss in the high-frequency adjustment group
ranged from 1% to 26% and averaged 12%. There were no intraoperative
complications in either of the 2 groups.
Conclusion: In our study, the
conservative group had an average of 9% excess weight loss, while the
high-frequency adjustment group had 12% excess weight loss. We believe patients
who undergo laparoscopic gastric banding benefit from higher frequency
adjustments resulting in a higher percentage of weight loss. Larger studies are
needed to support our preliminary findings.
10.388 Gynecology
Bilateral
Teratoma: A Case Report of Preservation of Fertility
A. Valero, H. Deschamps, E.
Torreblanca, R. Alvarez, J. Steta, O. Zlochisty
Departamento de Ginecología y Obstetricia, Centro Médico ABC Campus Sta. Fe.
México D.F.
The tumors derived from germ cells represent 15% to 30% of all ovarian tumors.
They probably arise from the germ cells as a result of a failure in meiosis II
or a premeiotic cell that represents a failure in meiosis I.
The cyst teratomas, also called
dermoid tumors, represent 95% of the germ cell tumors and most of the time are
benign. Only 0.5% to 1.8% could transform into malignant tumors like
squamous cell carcinoma, adenocarcinoma, and carcinoid tumors.
To date, sonographic images are the
gold-standard method for diagnosing well- differentiated teratomas, with a 97%
sensitivity and specificity. MRI could detect lesions of 0.5cm in diameter
(bone, cartilage). Tumor markers like Ca125 could not give us any relevant
data. The endoscopic procedure is the best tool for diagnosing and managing
ovarian tumors, making a careful dissection and conserving as much as possible
healthy tissue for preservation of fertility.
10.389 Gynecology
Mucinous
Cystadenoma of the Appendix Presenting as a Pelvic Mass: A Case Report
Justine B. Somoza, MD, Jeffrey A.
Stinson, MD
Department of Obstetrics and Gynecology, South East Area Health Education
Center,
New Hanover Regional Medical Center, Wilmington, North Carolina Affiliated with
The University of North Carolina at Chapel Hill, USA
Background and Objectives: Mucinous
cystadenoma of the appendix is a rare condition with variable presentation. We
report on a 36-year-old female who presented to the emergency department with
pelvic pain and a 10-cm x 5-cm fluid-filled pelvic mass on ultrasound.
Diagnostic laparoscopy revealed an enlarged appendix that was determined to be
a benign mucinous cystadenoma. Laparoscopic appendectomy was performed without
difficulty resulting in improvement in the patient's pelvic pain.
Methods and Procedures: Case report.
Results: A mucinous cystadenoma of
the appendix was found during diagnostic laparoscopy.
Conclusion: Appendiceal pathology
should be included in the differential diagnosis for women with pelvic masses
and pelvic pain.
10.390 General Surgery
Rare Untested Complication of NDO Plicator
Krass Vladimír, Kozumplík Ladislav, Ochmann
Jiří, Maršová Jitka
Traumacentum in Brno, Czech Republic
We received a 2-year grant from the Internal Grant Association of the Ministry
of Health of the Czech Republic (No. IGA MZCR No: 9285-3) to conduct a
comparison study of treatment of gastroesophageal reflux disease by using
endoscopic and laparoscopic approaches.
Patient P.B. is a 57-year-old female admitted to the study to undergo fully
endoscopic examination using the Plicator (NDO Surgical Inc., Mansfield, MA).
All laboratory results were normal. X-rays of the lungs were also normal.
Gastroesophageal reflux disease was treated by application of 2 cartridges of
the Plicator while the patient was sedated with Midazolam. The same day and the
first postoperative day, she was comfortable without any problems. Laboratory
values showed no pathological changes. She was discharged home. Five days
later, the patient was admitted with a high fever and painful cough in the left
side of the chest.
X-ray revealed a mass of fluid in the left lung, and a high level of
inflammatory markers. We did not see any pathological communication between the
esophagus and left lung cavity. The next day, thoracoscopy revealed 500mL of
cloudy yellow fluid that had no odor. In the costophrenic angle, we found
and removed one free cartridge of the Plicator. Lavage and drainage of the left
pleural cavity and antibiotic treatment were provided. After one week, the
patient was without any complaints. The laboratory results were normal. Ten
days after the operation, the patient was discharged home again.
X-rays of the lung were normal. Endoscopy successfully eliminated the
gastroesophageal reflux.
The reason for the complication we suppose was too elevated an angle of the
tissue between the jaws of the Plicator, evidently making a perforation in
thoracic cavity.
10.391 General Surgery
Single-Incision Laparoscopic Cholecystectomy: A Systematic Review
Stavros A. Antoniou, MD,
Rudolph Pointner, MD, Frank A. Granderath, MD
Department of General and
Visceral Surgery, Center for Minimally Invasive Surgery, Hospital "Maria
v. d. Aposteln" Neuwerk, Mönchengladbach, Germany (Drs. Antoniou,
Granderath)
Department of General Surgery, Hospital Zell am See, Zell am See, Austria (Dr.
Pointner).
Background and Objective: To examine the success and the risks of
single-incision laparoscopic cholecystectomy (SILC) and determine its potential
limitations. Laparoscopic techniques have induced a tremendous revolution in
surgery of the biliary tract. A trend towards even more minimally invasive
approaches eventually has led to single-incision and natural orifice
laparoscopic surgery techniques. The evaluation of SILC is rather fragmentary
by single-institution small patient series.
Methods: A systematic review
of the literature was performed to identify relevant articles. Studies
enrolling at least 10 patients undergoing SILC and reporting on analytical
complication data were considered for inclusion.
Results: Twenty-nine studies
including a total of 1166 patients were identified. Success and complication
rates were 90.7% and 6.1%, respectively. Mean adjusted operative time was 70.2
minutes, and mean adjusted hospital stay was 1.4 days. Analysis of outcomes
exhibited higher complication rates for studies with a mean patient age >45
years (P=0.04), and higher
operative time for studies with patients with a mean BMI>30kg/m2 (83.4 vs. 74.5 min) and female percentage lower than 70% (78.7 vs. 68.5
min). Acute cholecystitis was a factor for technical failure (success rate
59.9% vs. 93.0%, P=0.005) and
resulted in an increase in operative time (78.1 vs. 70.6 min). Suture
suspension of the gallbladder yielded significantly lower complication rates
compared with instrument usage (3.3% vs. 13.3%, P<0.0001).
Conclusion: The clinical application of SILC exhibited satisfactory results. Cases
of acute cholecystitis and older patients should be approached with caution,
while improvement in the instrumentation is necessary.
10.392 General Surgery
Wide Local Excision and
Endoscopic Axillary Clearance in a Patient with Early Breast Cancer
G.M. AbulNagah, MD, FRCS,
A.T. Awad, MD, H. Wadeia, MS
Department of Surgery, Faculty of Medicine, University of Alexandria, Egypt
Introduction: Conservation
surgery is currently the standard treatment for women with stage I or II
invasive breast cancer. It has the goal of preservation of cosmesis and
function. Axillary dissection has long been associated with multiple
complications and hence the attempts at other techniques for axillary staging.
Patients and Methods: This study included 30 patients
with operable breast cancer who underwent breast-conserving surgery using the
endoscopic technique to accomplish axillary dissection. Total operative time,
the time of axillary dissection, postoperative pathological details of tumors,
and axillary specimens, drainage amount, seroma formation, as well as any
surgical complications were recorded.
Results: Mean total
operative time and endoscopic axillary dissection were 102 minutes, 56 minutes
in the early 10 cases and 78 minutes, 26 minutes (P=0.003). Mean total number
of lymph nodes harvested was 17, which is comparable to that of open techniques
at our institution. There were no significant improvements in seroma formation
after endoscopic dissection, but there was marvelous improvement in patient
cosmetic satisfaction.
Conclusion: Although
endoscopic axillary clearance in patients with early breast cancer needs
special instrumentations and has a relatively long learning curve, it is
feasible, comparable with standard surgical axillary clearance, and accompanied
by fewer axillary complications and better cosmesis.
10.393 Gynecology
Laparoscopic Strassman Metroplasty for Bicornuate Uterus with Successful
Pregnancy: Report of 5 Cases
Dr. Hossein Asefjah,
Ordibehesht Hospital, Shiraz, Iran
As our experience in laparoscopic suturing techniques and improved pregnancy
outcome is increasing, the ability to do more complicated procedures for the
correction of uterine anomalies is increasing as well. Laparoscopic Strassman
metroplasty was performed in 5 patients with bicornuate uterus with a history
of at least 2 second-trimester abortions. The triple-puncture technique was
used. After a transverse fundal hysterotomy incision including fundal
cleft, unification of the uterus was done with intracorporeal sutures in 2
layers. After 3 months of sequential hormone therapy, an HSG was repeated, and
second-look laparoscopy and hysteroscopy were done. Partial adhesion bands were
released in second-look laparoscopy and hysteroscopy. One patient became
pregnant 6 months after the second-look operation. She received a tocolytic
agent during the late second and third trimesters and delivered a 3300g boy
at 38 weeks of gestation. No defects or dehiscence occurred along side of the
incision line.
10.394 General Surgery
Laparoscopic Resection of
Perforated Jejunal Diverticulitis: A Single Case Experience and Review of
Literature
Eric J. Velazquez, MD,
Caitlin Demarest, Daniel Stephens, MD
Department of Surgery, Metropolitan Hospital Center, New York, New York, USA
Jejunal diverticulosis (JD)
is rare and most often asymptomatic. However, complications include
malabsorption, hemorrhage, diverticulitis, obstruction, abscesses, and
perforation. We emphasize the need to consider perforated jejunal
diverticulitis in the setting of intraabdominal inflammatory processes and
acute abdomen, because delaying the diagnosis is often fatal. The treatment is
mainly surgical, and the conventional approach is open excision via laparotomy,
but recent advances in minimally invasive surgery have led to a less traumatic
approach including laparoscopy, which is both diagnostic and therapeutic.
Herein, we describe a case of perforated jejunal diverticulitis: a 72-year-old
male presented with complaints of cramping, nonradiating, periumbilical pain.
Computed tomography (CT) scan was consistent with jejunal diverticulitis. On
the first night of admission, the patient’s abdominal examination worsened, his
leukocyte count increased, and he developed a fever. The patient was taken to
the operating room where he underwent exploratory laparoscopy, revealing
inflammatory changes in the peritoneal cavity with fibrinous debris and free
purulent fluid. He underwent extracorporeal small bowel resection with primary
anastomosis. A laparoscopic approach is safe and effective in both the
diagnosis and management of complicated jejunal diverticulitis.
10.395 General Surgery
Laparoscopic Resection of
Intraabdominal Esophageal Duplication Cyst in an Adult: A Single Case
Experience and Review of Literature
Eric J. Velazquez, Caitlin
Demarest, Flavia C. Soto, James Pacholka
Department of Surgery, Saint Vincent's Hospital and Medical Centers, New York,
New York, USA
Esophageal duplication cysts (EDCs) normally occur within the mediastinum and
rarely in the abdomen. Treatment is surgical, and the conventional approach is
open excision via thoracotomy or laparotomy, but recent advances in minimally
invasive surgery have allowed for a less traumatic approach. Herein, we
describe a case of intraabdominal EDC: a 27-year-old woman complaining of
dysphagia and epigastric pain was found to have a cystic mass at the
esophagogastric junction and underwent laparoscopic resection. During the
operation, insufflation assisted in inspecting the integrity of the esophageal
wall. Although computed tomography (CT) scan and endoscopic ultrasonography
(EUS) both assisted in determining the correct preoperative diagnosis, the definitive
diagnosis was made following pathological examination of the resected lesion,
which revealed an epithelial-lined fibromuscular cyst, consistent with EDC. A
laparoscopic approach is practical, straightforward, and safe for excision of
intraabdominal esophageal duplication cysts.
10.396 General Surgery
The Feasibility of Sleeve Gastrectomy in Revision of Gastric Banding
Hussam Al Trabulsi, MD, MRCS (Edinburgh)
Laparoscopic & Bariatric Surgery Consultant, AL Dia’a Hospital, Damascus, Syria
Gastric bypass surgery is used to revise complicated and/or unsuccessful gastric band surgeries. This retrospective study was conducted to determine the feasibility and safety of sleeve gastrectomy to revise band surgeries. The results support the hypothesis and show that sleeve gastrectomy can be used as a revision bariatric procedure.
In 2009, sleeve gastrectomy was used to revise band surgeries. It was performed in 10 patients who experienced band-related problems. The study helped classify patients into 3 groups: band slippage, band erosion, and weight loss failure. Different protocols were established maximizing the effectiveness and minimizing mortality. First, band removal using the laparoscopic approach was performed. Patients with band slippage and one with erosion and 2 who failed to loss weight were monitored before the sleeve procedure and for 6 and 12 months, respectively. However, sleeve gastrectomy was implemented as a 1-step surgery for another 2 who failed to loss weight after gastric banding. Preoperative protocols included a full explanation of the various surgical options, along with medical assessments by a surgeon, a dietitian, and an anesthetist. When patients selected the sleeve gastrectomy, they had a preoperative diet. After the surgery, patients were hospitalized for 2 days and followed up by the medical team. They had no complications in the following 6 months.
The results illustrate that sleeve gastrectomy to revise band-failure patients demonstrates weight loss without major complications and the ability for superobese patients to undergo biliary pancreatic diversion later, if needed. Initiation of sleeve gastrectomy as revision in select patients can be done safely.
10.397 General Surgery
Single-Incision Laparoscopic Surgery (SILS™): A Promising Approach For Colon Resection
Boris Vestweber, MD, Eberhard Straub, MD, Franz Haaf, MD, Phillip Lingohr, MD, Angelika Alfes, MD, Karl-Heinz Vestweber, Prof Dr
Klinikum Leverkusen, Leverkusen, Germany
Background: Laparoscopic bowel resection has increasingly become the standard procedure in elective abdominal surgery. To further intensify the benefits of minimally invasive procedures, such as less postoperative pain, faster recovery time, reduced wound complications, and improved cosmetic results, attempts have been made to minimize the number of necessary skin incisions for trocar positioning. One way to do this is to use only one port as a single access for elective bowel resection.
Methods: Over 90 patients have been referred since July 2009 for elective SILS bowel resection. The majority of the procedures were partial left colon resections (diverticulitis). But also right and left hemicolectomies due to cancer, total and subtotal colectomies (ulcerative colitis), appendectomies and ileocecal resections (Morbus Crohn) were performed. In all cases, the abdomen was approached through a 2.5-cm incision within the umbilicus followed by the insertion of a SILS port.
Results: Success was achieved in 86 of 93 patients who were operated on with the SILS procedure using only one incision in the umbilicus. In those cases in which an ileostomy was needed, one additional port was placed in this location.
Conclusion: Single-incision laparoscopic bowel resection via the umbilicus is technically feasible and one effective alternative to the standard laparoscopic procedures. It is an attractive procedure with the aim to further increase patient comfort after abdominal surgery. The video shows a subtotal SILS colectomy (ulcerative colitis) with one additional port in the ileostomy position and the creation of an ileum J-pouch via the transumbilical access with pouch anal anastomosis in a second operation.
10.398 General Surgery
Clinical Study of the Efficacy of Therapies for Persistent
Ectopic Pregnancy
Li Huan, Zhang Lijie, Zheng Yuan, Sui Hongmei, Wu Ruifang, Guo
Yanyan, Ma Huirong
Department of Obstetrics and Gynecology, Beijing University
Shenzhen Hospital, Shenzhen, China
Objective: To investigate the
efficacy of several therapies for persistent ectopic pregnancy (PEP).
Methods: From January 2006 to June 2008, 155 patients with persistent
ectopic pregnancy diagnosed at
Peking University Shenzhen Hospital were divided into expectant treatment GROUP
A, methotrexate local injection treatment GROUP B, and systemic administration of
mifepristone and methotrexate. The other 332 patients in the control group received
no treatment. Success rate, failure rate, side effects, treatment time, and
treatment cost of each group were analyzed and compared.
Results: (1) The success rate of methotrexate local injection
treatment was highest; the failure rate of expectant treatment was highest.
(2) The side effects of systemic administration of mifepristone and methotrexate
were strongest, with fewer side effects in the methotrexate local
injection treatment group. (3) Treatment time was longer in the expectant treatment
group and shorter in the systemic administration mifepristone and methotrexate
group. No statistical differences were found in the time of the 3 treatments.
(4) The cost of systemic administration of mifepristone and methotrexate was
highest, and the cost of methotrexate local injection treatment was lowest, if the
treatment is successful.
Conclusion: Methotrexate local injection treatment is the best therapy for
persistent ectopic pregnancy (PEP).
10.399 General Surgery
Laparoscopic Calibrated Nissen Versus Dor Fundoplication Following Heller Myotomy for Esophageal Achalasia
N. Di Martino, L. Marano, A. Brillantino, F. Torelli, M. Schettino, R. Porfidia, G.M. Reda, M. Grassia
VIII Unit of General and Gastrointestinal Surgery (Chief: Prof N. Di Martino), Second University of Naples, Italy
Background: The type of fundoplication to perform after laparoscopic Heller myotomy for esophageal achalasia is still debated. Although both 180° anterior and 270° posterior partial fundoplications represent the most frequently performed antireflux procedures after myotomy, some authors have reported good outcomes performing a Nissen-Rossetti fundoplication. The present study aimed to compare the surgical and midterm outcomes of laparoscopic calibrated Nissen-Rossetti fundoplication with laparoscopic Dor fundoplication, performed after esophagogastric myotomy, in the treatment of esophageal achalasia.
Methods: We evaluated 56 patients (26 men, 30 women; mean age 42.8±14.7) who presented for minimally invasive surgery for achalasia. All the patients underwent laparoscopic Heller myotomy followed by 180° anterior partial fundoplication in 30 cases (group 1) and calibrated Nissen-Rossetti fundoplication in 26 (group 2). Intraoperative endoscopy and manometry were used to calibrate the myotomy and fundoplication. A 6-month follow-up with symptomatic evaluation and barium swallow was undertaken. Twelve and 24 months after surgery, the patients underwent symptom questionnaires, endoscopy, esophageal manometry, and 24-hour esophagogastric pH monitoring.
Results: At 2-year follow-up, the median symptom score did not show significant differences between the 2 groups (P=0.66; Mann-Whitney U-test). The median percentage time with esophageal pH<4 was significantly higher in the Dor group compared with the Nissen-Rossetti group (2, range 0.8 to 10 vs 0.35, range 0 to 2) (P<0.0001; Mann-Whitney U-test).
Conclusions: Both laparoscopic Dor and calibrated Nissen-Rossetti fundoplication after Heller myotomy are effective treatments for achalasia, achieving similar results in the resolution of dysphagia. However, Nissen-Rossetti fundoplication seems to be more effective in suppressing esophageal acid exposure, compared with Dor fundoplication.
10.400 General Surgery
Biliary Injury After Laparoscopic Cholecystectomy: Experience of 1032 Patients
Asieh S. Fattahi, MD, Abbas Abdolahi, MD, Ghodratollah Maddah, MD, Mohammad Taghi Rajabi, MD, Hosien Shabahang, MD, Mohammad H. Ebrahimzadeh, MD
Endoscopic & Minimally Invasive Research Center, Surgery Department, Ghaem Hospital, Mashhad University Of Medical Sciences, Mashhad, Iran
Background: Laparoscopic cholecystectomy is the gold standard in treatment of cholelithiasis with a low risk of complications. Bile duct injury is one of the most serious problems. The aim of this study was to evaluate the results in our department.
Material & Methods: We reviewed the data of all patients who underwent elective laparoscopic cholecystectomy between 2006 through 2009 at Ghaem & Omid Hospital at Mashhad University of the Medical Sciences, Iran. Demographic data and complications were collected and analyzed with SPSS version 13.
Results: Enrolled in the study were 1032 patients. The male to female ratio were 3.48, with mean age of 41 years. Complications included 9 (0.8 %) patients with biliary injury (5 biloma, 4 choledochal injury); 13 (1.2%) conversions to open surgery because of bleeding, severe inflammation or adhesion, and injury to intraabdominal organs. All bilomas drained percutaneously; 3 patients with choledochal injury had open reconstruction 3 to 5 weeks after the first operation, and the last one was treated with ERCP and stenting. We had one mortality after reconstruction.
Conclusion: Although bile duct injuries are not common after laparoscopic cholecystectomy, it is a significant complication with risk of mortality. Early diagnosis and management are necessary.
10.401 General Surgery
Laparoscopic Extraction of Jejunal Phytobezoar after Roux-En-Y Gastric Bypass
Ramin Roohipour, MD, Leaque Ahmed, MD, Mohammad Sarhan, MD
Columbia University at Harlem Hospital
Objectives: To show the safety of laparoscopic intervention in small bowel obstruction due to phytobezoars in bariatric patients.
Methods: Bezoar-induced SBO after gastric bypass is uncommon. However, it should always be suspected in gastric bypass patients. They are considered high risk due to the previous gastric surgery and their nutritional habits. Early diagnosis and surgical exploration is the key to a successful outcome.
Results: This video describes a patient who underwent laparoscopic gastric bypass who presented several months following surgery with small bowel obstruction due to phytobezoars in the ileum. The bezoar was extracted via a laparoscopic enterotomy. The entire procedure was achieved laparoscopically, and the patient did well without any complications.
Conclusion: In select patients, the laparoscopic approach is a feasible method in the management of bezoar-induced intestinal obstruction when performed by experienced laparoscopic surgeon.
10.402 General Surgery
Laparoscopic Partial Splenectomy for a Splenic Cyst
Hui Sen Chong, MD, Kurt E. Roberts, MD, Robert L. Bell, MD, Andrew J. Duffy, MD
Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA.
Background: The spleen’s role in immunologic function along with a risk of overwhelming postsplenectomy infection has led to an increased popularity of splenic preserving surgery. This is especially true for benign pathologies of the spleen. We herein show a video of laparoscopic partial splenectomy for a 6-cm x 5-cm splenic cyst.
Method: The patient is a 37-year-old female who was referred to our clinic for a 6-cm x 5-cm splenic cyst. The cyst was first noted on an abdominal-pelvic CT scan back in 2004. A repeat CT scan in 2009 once again showed a cyst with calcified rim that has not changed in size since 2004. A splenic cyst >5cm in size has an increased risk of spontaneous rupture during pregnancy, which ultimately leads to poor maternal and fetal outcome. Because the patient wished to conceive, she was consented for laparoscopic partial splenectomy. This will allow the removal of a likely benign cyst while preserving splenic function. The surgery consists of patient positioning, trocar placement, mobilization of the spleen from its embryologic peritoneal attachments, dissection, and transaction of the arterial and venous branches to the respective pole of the spleen, parenchyma division, cauterizing, and obtaining hemostasis at the transected edge, and retrieval of the specimen. The operation took 110 minutes.
Results: The patient was hospitalized for 2 days and was discharged without complications. Histologic examination of the specimen revealed a splenic pseudocyst with focal calcifications.
10.403 Gynecology
Saving Time in Laparoscopy Using a New Safe Entry Trocar
Mark W. Surrey, MD, J. Dietzel, MD, G. Tchartchian, MD, R. De Wilde, MD, Patrick Diesfeld, MD, B. Bojahr, MD
Southern California Reproductive Center, Beverly Hills, California, USA (Dr. Surrey).
Department of Neurology, University of Greifswald, Greifswald, Greifswald, Germany (Dr. Dietzel).
Department of OB/GYN, Pius Clinic, Oldenberg, Oldenberg, Germany (Dr. G. Tchartchian).
Department of OB/GYN, Pius Clinic, Oldenberg, Oldenberg, Germany (Dr. De Wilde).
Women's Partnership Medical Group, Ventura, California, USA (Dr. Diesfeld).
Clinic of Minimally Invasive Surgery, Evangelic Hospital, Hubertus, Berlin, Berlin, Germany (Dr. Bojahr).
Background: This is a first comparative analysis of dislodgement behavior of 3 trocar systems including an innovation in the field: a trocar fixator used in combination with a common working trocar.
Results: Included in the study were 131 patients; 51 consecutive patients were randomized into group A (wire-fitted sleeve), 38 into group B (plain sleeve), and 42 into group C (fixator plus plain sleeve trocar). There was a significant overall difference in the parameters between the 3 groups. The mean intervention time was shortest in group C with 62.1 minutes, and the longest was in group B with 80.3 minutes. The frequency of interruptions of the intervention due to adjustment of the displaced device was significantly lower in groups C and A, and highest in group B, 0.47 vs 0.29, P<0.05. The time loss through adjustment was significantly shorter in group C and longest in group B; 2.13 minutes vs. 0.69 minutes, P<0.05. In these 2 parameters, there was no significant difference between group A and group C.
Conclusion: Tissue-anchoring components lead to a higher stability of port systems and to a significant reduction in operation time due to a significant reduction in interruptions of the surgical intervention and less prolongation of the procedure. In all 3 systems, the correction of the port led to longer intervention time. But comparing the 2 trocar systems with tissue-anchoring properties namely the wire-fitted trocar (A) and fixator (C), mean operation time was significantly lower in the fixator group (C) and the time saving effect higher.
10.404 General Surgery
Laparoscopic Splenectomy: LigaSure or Clip Ligation?
A. Abdollahi, A. Tavassoli A, A. Jangjoo A, G.A. Maddah, M.T. Rajabi, A. Fattahi, M. Mehrabi, H. Shabahang
Endoscopic & Minimally Invasive Surgery Research Center, Assistant Professor of General Surgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran (Drs. Abdollahi, Jangjoo, Fattahi, Shabahang).
Endoscopic & Minimally Invasive Surgery Research Center, Associate Professor of General Surgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran (Drs. Tavassoli, Maddah, Rajabi, Mehrabi).
Objective: Laparoscopic splenectomy is routinely used for spleen removal in pathologic conditions. Both clips and LigaSure are used for vascular ligation, but clip ligation is thought to be safer and used more routinely.
Methods: Forty patients who were candidates for splenectomy were randomly divided into groups either using clips or LigaSure. Time of the operation, need for transfusion, intra- and postoperative bleeding, open conversion, and postoperative complications were evaluated.
Results: Twenty patients were in the clip group, mean age was 27 years, and spleen pathology was ITP in 17 cases. Spherocytosis, lymphoma, and mass were the other 3 cases. Mean operative time was 75 minutes (range, 66 to 110), bleeding volume 50cc (range, 10 to 210), and there was no need for transfusion. Twenty patients were in the LigaSure group, mean age was 25 years, spleen pathology was ITP in 18 cases, with one spherocytosis, and one lymphoma. Mean operation time was 70 minutes (range, 60 to 137), bleeding volume was 40cc (range, 10 to 150). In both groups, there was no need for transfusion, no conversions, and no complications related to clips or LigaSure.
Conclusion: Both clips and LigaSure can be used for vascular control in laparoscopic splenectomy, but LigaSure is more comfortable and simpler with little dissection. It seems that LigaSure is preferable to clips in select cases of splenectomy.
10.405 General Surgery
The Role of Percutaneous Drainage in General Surgery: A Clinical Experience in 42 Patients
Godratollah Maddah, Abbas Abdollahi, Alireza Tavassoli, Asieh Fattahi, Mohamad Taghi Rajabi
Endoscopic & Minimally Invasive Surgery Research Center, Associate Professor of General Surgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran (Drs. Maddah, Tavassoli, Rajabi).
Endoscopic & Minimally Invasive Surgery Research Center, Assistant Professor of General Surgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran (Drs. Abdollahi, Fattahi).
Objective: With an abdominal collection, especially when followed by inflammation of the surrounding tissues and adhesion, even surgery may be followed by complications such as damage to the neighboring viscus. The aim of this study was to evaluate the role of percutaneous drainage in abdominal surgery.
Methods: This descriptive study was performed on 42 patients who from 2006 through 2009 had undergone drainage through the skin due to an abdominal collection, and there was no need for open abdominal surgery. The patients underwent sonography or abdominal CT scan. If drainage was possible, it was performed by sonography in the radiology or surgery ward. The patients were controlled for development and progress of the disease. When drainage was completely performed, then sonography was again done. If the first pathology was removed, then the drain was also removed. Demographic characteristics, clinical signs, type of disease, site of collection, and the results of follow-up were recorded in a questionnaire. Data were analyzed by using SPSS version 13 software.
Results: Of 42 patients (F/M: 25/17) mean age 47.5 years, 11 had complications of cholecystitis (5 cholecystitis, 3 hydrops, 3 empyema), 9 appendicular abscess, 8 biliary collections (biloma) following surgery, 3 cases of abdominal abscess following surgery, 3 breast abscesses, 2 pelvic abscesses (one following trauma, another an appendicular abscess), 4 diaphragmatic and subhepatic abscesses, and 2 had spontaneous abdominal and pelvic collection (one following trauma and the other diverticulitis).
Conclusions: Recently, surgery and treatment intervention with minimally invasive techniques have been noticed. Percutaneous drainage is very useful in general surgery when a collection is present.
10.406 General Surgery
CT Scan to Rule Out Appendicitis: Useful Adjunctive Test or Healthcare Burden?
A.R. Kandel, MD, G.B. Deutsch, MD, N. Pokharel, MD, D. Gadaleta, MD
North Shore University Hospital, Manhasset, New York, USA (Drs. Kandel, Duetsch, Gadaleta).
Interfaith Medical Center, New York, USA (Dr. Pokharel).
Background: Appendicitis is the most common disease process requiring emergency general surgery, with approximately 280,000 appendectomies performed annually. However, not all end up having acute inflammation, and according to recent Surgical Education and Self-Education Program (SESAP) 12% to 17% are negative appendectomies. To reduce or eliminate the negative appendectomy rates, some have been using CT as an adjunct to examination in patients presenting with RLQ pain. While there is some supporting literature, the current consensus is that CT scan is no better than clinical examination in diagnosing acute appendicitis.
Materials and Method: A retrospective review was performed of 400 appendectomies by a single surgical group at 2 institutions between 2000 and 2009. The CT findings, preoperative, postoperative, and pathological diagnoses were obtained. In patients suspected of having appendicitis who underwent radiologic testing, the official report of the abdominal CT was compared with the postoperative diagnosis and then separately with the pathologic diagnosis to assess the positive predictive value.
Results: When comparing the CT abdomen report prior to appendectomy with the postoperative diagnosis, the accuracy of the radiologic testing was 94.7%. After pathologic diagnosis was made, the official CT read was confirmed in the laboratory 93.6% of the time.
Conclusion: Use of CT scan decreases the negative appendectomy rate in patients presenting with RLQ pain and an unclear etiology. The positive predictive value of abdominal CT to diagnose appendiceal pathology is excellent. Given this information, in patients with atypical or confusing presentations, using CT as a useful adjunct can add value to an evaluation for acute appendicitis.
10.407 General Surgery
Laparoscopic Management for Small and Large Bowel Obstruction
Yoshio Miura, MD, Hiroshi Iwako, MD, Takeshi Yamaguchi, MD, Jiro Okiyama, MD, Chiaki Inokuchi, MD
Inokuchi Hospital
Introduction: Ileus is a difficult entity for laparoscopic surgery. Limited space due to dilated intestine, an emergent situation in most cases, and various mechanisms of obstruction make the laparoscopic resolution difficult.
Methods: In the last 26 months, we had 24 patients with small bowel obstruction and 4 patients with large bowel obstruction. Laparoscopic surgery was tried in 9 cases of small bowel obstruction and 3 cases of large bowel obstruction.
Results: Of the 9 cases of small bowel obstruction, 2 simple band obstruction and 1 simple adhesion to the previous wound scar could be managed by laparoscopy. Six cases were converted to open due to severe adhesion in 4, incarcerated hernia in 1, and cancer involvement in 1. Even under inadequate decompression of the intestine, upper small bowel obstruction could be managed by laparoscopic surgery, because of a relatively small volume of dilated intestine. Among the large bowel obstruction in 4 cases, 3 were managed by laparoscopic surgery. Two cases had laparoscopic anterior rectal resection or right hemicolectomy after 7 days of decompression with a long tube. Another case of sigmoid colon cancer had transverse colostomy in the lower midline small incision. This stoma wound was used for the camera port and specimen retrieval for laparoscopic sigmoidectomy 2 weeks later. This method is a good alternative for obstructing left-sided colon cancer if decompression by a long tube was unsatisfactory.
Conclusion: Laparoscopy is a good tool not only for diagnosis but also for resolution in select patients.
10.408 General Surgery
Percutaneous Drainage of Hydatid Liver Cysts
Dr. A. Abdollahi, Dr. A. Alamdaran, Dr. A. Jangjoo, Dr. M. Mehrabi
Endoscopic & Minimal Invasive Surgery Research Center, Mashhad University of Medical Sciences (Drs. Abdollahi, Jangjoo, Mehrabi).
Dean of Mashhad University of Medical Sciences (Dr. Alamdaran).
Background: Hydatid liver cysts have different treatments. In cases in which the cyst is simple and drainage through the skin is possible, it is recommended to aspirate the cyst through the skin. The goal of this study was to introduce the treatment of hydatid liver cysts via drainage through the skin.
Methods: An attempt to drain the cyst was undertaken approximately 10 days after the patient had been receiving albendazole pill under ultrasound guidance. After cyst evacuation, 15% sodium hypertonic serum was injected. After waiting 15 to 20 minutes, the liquid was reaspirated, and the drain from the abdomen was removed. Patients were followed up through ultrasound.
Results: In all, 17 patients were studied, 8 males and 9 females with a mean age of 40 years. In 14 patients, drainage was performed very well. In one case, cyst drainage was not performed due to multi-loculation, and in 2 other patients secretion of bile cyst was evacuated so the drain was put in place but scolicid solution was not injected. In one case, anaphylactic shock was seen which was part of the patient’s history because he was allergic to Lidocaine. In 3 patients, allergic skin reactions were seen. Three patients each had 2 cysts in their liver, and drainage was done in one step. No mortality was observed.
Conclusion: The hydatid liver cyst drainage through the skin according to patient comfort and lack of need for open surgery is beneficial and performed under ultrasound guidance. Two important issues are patient selection and simple cyst.
10.409 Gynecology
TB PCR in Diagnostic Laparoscopy
Manickavasagam
Madhubala, MD DNB MNAMS
Introduction: Primary infertility is on the rise everywhere around the globe. Various investigations are being done, and them diagnostic laparoscopy and hysteroscopy have a special place. Tuberculous organisms can interfere with fertility and if diagnosed and treated, the
chances of success are quite good.
Methods: Fifty-five patients with primary infertility underwent diagnostic laparoscopy and hysteroscopy after giving informed consent about the procedure and the test. Endometrium was taken with a sharp curette and put in a small, sterile container containing normal saline and sen for diagnosis with polymerase chain reaction.
Results: Results were obtained a week later. To our great surprise, 32 (58%) patients had positive tuberculous reports. Patients were counseled about the reports, and antitubercular drugs were started with a 4-drug regimen for 2 months and a 3-drug regimen for 3 months. Of those treated patients, 64% became pregnant during their course of treatment, which was really promising for both the patients and the gynecologist.
Conclusion: Diagnostic hysteroscopy using endometrium samples for TB PCR shows promising results for patients who have difficulty in conceiving.
10.410 General Surgery
Increased Body Mass Index Results in Increased Complication Rates in Patients Undergoing Laparoscopic Adrenalectomy
Horatiu C. Dancea, MD, Vladan Obradovic, MD, Jennifer Sartorius, MS, Nicole Woll, PhD, Joseph Blansfield, MD
Geisinger Medical Center, Danville, PA
Objectives: Laparoscopic adrenalectomy has become the standard of care for resection of adrenal masses, with extremely low morbidity and mortality. However, there are no studies addressing complication rates in obese patients. We compared differences in outcomes in obese and healthy weight patients who underwent laparoscopic adrenalectomy at Geisinger Medical Center.
Methods: We retrospectively reviewed charts of all patients undergoing laparoscopic adrenalectomy at our institution between January 2000 and February 2010 and compared intraoperative and postoperative complications in our patients. A patient with a body mass index >30kg/m2 was considered obese.
Results: Eighty patients (45 women, 35 men) underwent laparoscopic adrenalectomy between January 2000 and February 2010. Forty-nine patients (61%) were obese. Mean operative time was 136 minutes (range, 76 to 330). Mean estimated blood loss was 106mL (range, 5 to 1200). The mean length of stay was 2.1 days (range, 1 to 14). Operative time, blood loss, and length of stay did not differ significantly between the cohorts. There was no 30-day mortality in our population. There were 9 complications in the obese population, and no complications in the healthy weight population (P<0.024). Four obese patients had intraoperative complications including 2 splenic lacerations, 1 pneumothorax, and 1 vascular injury. Five obese patients had postoperative morbidity. These included 3 infectious complications, an intraabdominal hematoma, and a deep vein thrombosis.
Conclusion: Laparoscopic adrenalectomy can be performed in healthy weight and obese individuals. There is a significant increase in intraoperative and postoperative complications for obese individuals undergoing laparoscopic adrenalectomy when compared with healthy weight individuals.
10.411 General Surgery
Laparoscopic Splenectomy: Outcome and Efficacy for Massive and Supramassive Spleens
Vadim P. Koshenkov, MD, Zoltan H. Nemeth, MD, PhD, Mitch Carter, MD
Department of Surgery, Atlantic Health-Morristown Memorial Hospital, Morristown, NJ
Background: Laparoscopic splenectomy is preferred operative approach for normal-sized spleens. Massive and supramassive splenomegaly are still considered to be relative contraindications to pure laparoscopic splenectomy. Hand-assisted laparoscopic splenectomy is being advocated for these situations.
Methods: We performed retrospective review of adult patients having undergone splenectomy 1999-2009. Massive and supramassive splenomegaly were defined as weight ? 600 g and ? 1600 g. Endpoints were estimated blood loss, length of stay, operative time, conversion rate and morbidity. These were compared between laparoscopic and open splenectomy for each group.
Results: 43 patients with massive and 26 patients with supramassive splenomegaly were identified. Laparoscopic and open splenectomy were comparable for spleen weight (1283 ± 158 vs. 1725 ± 280, and 1806 ± 161 vs. 2154 ± 365). Laparoscopic splenectomy was associated with lower estimated blood loss (467 ± 87 vs. 787± 287, and 426 ± 74 vs. 975 ± 435), shorter length of stay (3.9 ± 0.6 vs. 5.5 ± 0.6, and 3.9 ± 0.9 vs. 4.5 ± 0.4), lower morbidity (18.2% vs. 33.3%, and 15.4% vs. 21.4%), no reoperations or mortalities. 2 reoperations (9.5%) and 1 mortality (4.8%) occurred with open splenectomy. Operative times were longer for laparoscopic splenectomy (190 ± 14 vs. 126 ±16, and 207 ± 18 vs. 121 ± 21), while conversion rates were 27.3% and 25%.
Conclusions: In cases of massive and supramassive splenomegaly, better outcomes are accomplished with laparoscopic than open splenectomy. These results are comparable to published results of hand-assisted laparoscopic splenectomy.
10.412 Urology
A New Endoscopic Treatment for Massive Rectal Bleeding Following Prostate Needle Biopsy
Dario Garcia-Rojo, MD, Felix Junquera, MD, Raul Martos, MD, Eduardo Vicente, MD, Carlos Abad, MD, Jesus Muñoz, MD, Jose Luis Gonzalez, MD, Naim Hannaoui, MD, Angel Prera, Enric Brullet, MD, Miriam Barrio, MD, Juan Prats, MD
Urology and Gastroenterology Departments, Corporacio Parc Tauli, Sabadell, Spain (Drs. Junquera, Brullet).
Corporacio Parc Tauli, Sabadel, Spain (Drs. Garcia-Rojo, Martos, Vicente, Abad, Muñoz, Gonzalez, Hannaoui, Prera, Barrio, Prats).
Objective: Immediate or delayed rectal bleeding following transrectal needle biopsy of the prostate has a reported incidence of 0% to 37%, and some cases can require emergency intervention. We describe a new method of treatment in these patients: colonoscopic hemoclip placement.
Methods and Results: A 79-year-old man with elevated prostate specific antigen level underwent transrectal needle prostatic biopsy with an 18-gauge needle. Several hours after the procedure, the patient sought medical attention for rectal bleeding, resulting in a 10-point drop in hematocrit. A flexible colonoscopy showed active arterial bleeding from the biopsy site in the anterior rectal wall. Endoscopic injection of 8mL epinephrine (1:10.000 dilution) was given. Bleeding continued. A clip was deployed (quick-clip) with excellent grasp of the mucosa surrounding the bleeding site. The patient did not require a blood transfusion and was discharged in stable condition after the urethral catheter was extracted.
Conclusions: When hemorrhage appears after prostate biopsy, different maneuvers can be performed: local pressure, transcatheter arterial embolization, proctoscopic thermocoagulation, colonoscopic injection of epinephrine or proctoscopic placement of a rubber band used for hemorrhoid treatment. If other maneuvers are not effective, endoscopic placement of a clip can be used as a treatment for this rare complication.
10.413 Urology
Comparison of Immediate Outcomes in Veterans Administration Patients Undergoing Robot-Assisted Laparoscopic Prostatectomy (RALP) by Residents Supervised by High- and Low-Volume Surgeons
Jeffrey M. Woldrich, MD, Christopher Kane, MD, Tracy Downs, MD, Kyoko Sakamoto, MD
San Diego VA Medical Center, Section of Urology and University of California San Diego, Division of Urology, California, USA
Introduction: We evaluated the initial experience of RALPs at San Diego VA (SDVA) to evaluate safety and efficacy of RALPs in residency training.
Methods: All RALPs at the SDVA between October 2008 and April 2010 were divided into cases supervised by high-volume (HV>20cases) surgeons and newly proctored low-volume (LV) surgeons. The following parameters were compared: patient demographics, tumor characteristics, surgery length (SL), estimated blood loss (EBL), rate of complications (RC), days until catheter removal (DCR), pathological tumor characteristics, and length of hospital stay (HS).
Results: Seventy-one patients underwent RALP: 37 LV and 34 HV. There were no statistically significant differences in mean age (61.7 vs 60.9), mean PSA (7.0 vs 5.7ng/mL), TRUS prostate volume (37.8cc vs 36.7cc), clinical stage, primary biopsy Gleason score, mean SL (288.9 vs 299.6 minutes), mean EBL (146cc vs 171cc), RC (6 vs 8), mean DCR (12.0 vs 11.7 days), mean HS (1.9 vs 1.6 days), positive margins, seminal vesicle invasion, extracapsular extension, primary or secondary Gleason score on final pathology, or final pathologic stage between LV and HV groups. There were statistically significant differences in BMI (30.1kg/m2 LV vs 26.9kg/m2 HV, P=0.007) and secondary biopsy Gleason score (Gleason 4 and 5 LV>HV, P=0.005). The outcome measures did not change after controlling for these parameters.
Conclusion: In the VA cohort, RALPs can be performed safely under the supervision of a newly proctored surgeon. Additional studies examining long-term outcomes, particularly continence and potency, are required to supplement these initial safety data.
10.414 General Surgery
Comparison of Nonexcisional Sleeve Gastroplasty with a Randomized Trial of Gastric Banding and Sleeve Gastrectomy
Robert Rutledge, MD
Center For Laparoscopic Obesity Surgery
Background: Laparoscopic adjustable gastric banding is the most popular restrictive procedure. Sleeve gastrectomy is less common. Nonexcisional sleeve gastroplasty is similar to sleeve gastrectomy without resection and thus is reversible. The aim of this study was to compare the results of nonexcisional sleeve gastroplasty with a trial of gastric band and sleeve gastrectomy reported by Himpens 2006.
Methods: We compared 300 nonexcisional sleeve gastroplasty patients with 80 gastric band or sleeve gastrectomy patients. Median age was 39, 36, and 40, respectively. Median BMI was 39, 37, and 39, respectively.
Results: Median weight loss after 1 year was 28kg, 14kg, and 26kg, respectively, and 32kg, 17kg, and 29.5kg. Late complications requiring reoperation after gastric band included 3 pouch dilations treated by band removal in 2 and 1 laparoscopic conversion to gastric bypass, 1 gastric erosion, and 3 disconnections of the system treated by reconnection. Inefficacy affected 2 patients after gastric band, treated by conversion to bypass and 2 patients after sleeve gastrectomy treated by conversion to duodenal switch.
Conclusion: Weight loss after 1 year and 3 years is better after nonexcisional sleeve gastroplasty and sleeve gastrectomy than after gastric band. The nonexcisional sleeve appears to be similar to the sleeve and more effective than the band. In addition, it is easily revisable and reversible.
10.415 Gynecology
The Role of Laparoscopy in the Evaluation of Tubal Infertility
Martin D. Keltz, MD, Margaret Durante, MD
Division of Reproductive Endocrinology, St. Luke’s-Roosevelt Hospital Center, Columbia College of Physicians and Surgeons, New York, New York, USA
Objective: We conducted a prospective cohort study.
Materials and Methods: This cohort study included all new infertility patients seen at the Continuum Reproductive Center, between July 2007 and June 2009. Included in the study were 1282 subjects who underwent Chlamydia Trachomatis IgG serology, and a chart review was undertaken of their hysterosalpingogram (HSG), and any laparoscopy, and non-IVF pregnancy outcomes.
Results: Of the 1282 new patients, 702 underwent an HSG with 82 (11.7%) abnormal results. Laparoscopy was performed in 157 (12.2%) subjects for suspected tubal infertility with 84 (54.1%) laparoscopies confirming tubal infertility. Chlamydia serology was positive in 70/1282 (5.1%) of the subjects, and they were more likely to have tubal infertility confirmed at laparoscopy, 85.7% vs. 49.3% P<0.001. Chlamydia serology negative subjects, however, were far more likely to have endometriosis as the cause of their tubal infertility at laparoscopy, 40.9% vs. 5.6% P<0.001. Following laparoscopy and tuboplasty, subjects achieved the same cumulative rate of non-IVF pregnancies as subjects without tubal infertility (19.0% vs. 21.2%). Among Chlamydia serology positive subjects, laparoscopic tuboplasty improved the non-IVF pregnancy rate from 5.7% to 22.2% (P=0.045).
Conclusions: Laparoscopy continues to have an important role in confirming tubal infertility after HSG and Chlamydia serology screening. Laparoscopy for endometriosis also furthers the diagnosis and treatment of tubal factor infertility. Laparoscopic treatment of confirmed tubal factor appears to improve the non-IVF spontaneous cumulative pregnancy rate.
10.416 General Surgery
Epiphrenic Diverticula of the Esophagus: 20-Year Surgical Experience
Fariha Sheikh, MD, Brenda Aguilar, MD, Kristi A. Harold, MD, Robert Shen, MD, Francis Nichols, MD, C. Daniel Smith, MD, Dawn E. Jaroszewski, MD, MBA
Department of Surgery, Mayo Clinic Arizona, USA (Drs. Sheikh, Aguilar, Harold).
Department of Surgery, Division of Cardiothoracic Surgery, Mayo Clinic Rochester, Minnesota, USA (Drs. Shen, Nichols).
Department of Surgery, Mayo Clinic Florida, USA (Dr. Smith).
Department of Surgery, Division of Cardiothoracic Surgery, Mayo Clinic Arizona, USA (Dr. Jaroszewski).
Background:
Excision of epiphrenic diverticulum can be performed through chest and/or abdomen. Minimally invasive techniques have changed surgical approaches. A review of experience and outcomes based on differing approaches is presented.
Methods: A retrospective review was performed of patients treated surgically for epiphrenic diverticulum from 1998 through 2008. Operative approach, procedures, and complications were assessed with 2 sample t tests utilized to compare outcomes.
Results: Sixty-nine patients underwent 40 open transthoracic with long esophagomyotomy and 25 fundoplications, 27 laparoscopic abdominal with long esophagomyotomy and 14 fundoplications, 1 thoracoscopic and 2 combined abdominal laparoscopic/thoracoscopic. Mean age was 65 (range, 36 to 81 years). Mean diverticulum size was equivalent in all groups (4cm). Location of diverticulum from incisors was from 26cm to 40cm in the transthoracic group and 28cm to 44cm in the laparoscopic group. Mean operative time and blood loss were higher in the transthoracic group (4.4 vs. 3.2 hours; P=0.001, and 133cc vs. 65cc, P=0.001). Complications occurred in 23% of transthoracic and 26% of laparoscopic patients, P=NS (leaks: transthoracic, 2 pts; laparoscopic, 3 pts). Median hospitalization was shorter for the laparoscopic group than for the transthoracic group (5 days vs. 7 days; P=0.153). Symptom resolution was achieved in 77% of the transthoracic group vs. 89% of the laparoscopic group (P=0.266). Median follow-up was 10 months (range, 1 to 70).
Conclusions:
The laparoscopic abdominal approach for treatment of epiphrenic diverticula was successfully utilized for diverticula located up to 28cm with excellent results. Less blood loss, as well as shorter operative times and hospitalization, occurred in patients having resections performed by abdominal laparoscopy. There was no statistical difference in postoperative complications for patients treated laparoscopically through the abdomen versus the open transthoracic approach.
10.417 Urology
The Learning Curve of Laparoscopic Compared with Robotic Surgeons During the Implementation of a Robotic Prostatectomy Program
Anis Aziz, MD, Howard Jung, MD, Gary Chien, MD
HKaiser Permanente Los Angeles Medical Center, California, USA
Objective: We previously reported on a cohort of 300 patients undergoing robotic radical prostatectomy by either laparoscopic surgeons (LRP) or fellowship-trained robotic surgeons. We studied RALP during the implementation of a robotic radical prostatectomy program. Robotic fellowship training had a beneficial impact on immediate postoperative outcomes, most notably because of lower positive surgical margin rates (PSMR). The purpose of this study was to evaluate the learning curve of the LRP surgeons to see whether their PSMR improved over time.
Methods: We retrospectively reviewed the initial 300 radical prostatectomies performed between August 2008 and March 2009. Four RALP surgeons and 8 LRP surgeons participated. The cohort was chronologically divided into the first, second, and third 100 cases. PSMR was then compared within each division.
Results: RALP surgeons completed 128 cases, and LRP surgeons completed 172 cases. Overall, PSMR rates for RALP surgeons vs LRP surgeons was 24.97% vs 34.55% (OR=1.91). In the initial 100 cases, PSMR rates for RALP surgeons vs LRP surgeons was 22.92% vs. 36.17% (OR=2.00). In the second 100 cases, it was 23.08% vs 37.5%. In the third 100 cases, it was 26.47% vs 30.65% (OR=1.23).
Conclusions: LRP surgeons have worse outcomes than RALP surgeons have. LRP surgeons start to improve after their initial 200 cases, but they still do not perform as well as RALP surgeons. Because of the large number of surgeons participating in this robotics program, these results are more reflective of a community practice model where multiple urologists are granted robotic privileges.
10.418 Urology
Osteoporosis Management Program Decreases the Incidence of Hip Fractures in Patients with Prostate Cancer on Androgen Suppression
Joseph Gleason, MD, Melanie Wuerstle, MD, Howard Jung, MD, Diana Londono, MD, Craig Cheetham, Fang Niu, Richard Dell, MD, Gary Chien, MD
Kaiser Permanente Los Angeles Medical Center, California, USa
Objective: Kaiser Permanente has pioneered an osteoporosis management program that has demonstrated a reduction in hip fracture rates in the osteoporotic population. Our aim was to determine whether patients on androgen suppression due to prostate cancer would benefit as well.
Methods: Since 2002, the Healthy Bones Program has been implemented at all Kaiser Permanente Southern California hospitals. The patients undergo DEXA scanning and are started on treatment if the T score indicates bone loss. We performed a retrospective review of 2182 patients who were diagnosed with prostate cancer from 2003 through 2007 and are on androgen suppression as primary therapy. Patients following the protocol were identified by the presence of DEXA scans, whereas the control patients did not have DEXA scans. Hip fracture data were obtained.
Results: A final group of 1482 patients was identified. There were 1025 study patients, and 457 controls. The total number of hip fractures was 15 for the study group and 13 for the controls. However, the incidence rate of hip fractures per 1000 person-years was lower in the study group, 4.44 vs. 11.96. For patients who sustained hip fractures, median time from first leuprolide dose to hip fracture was longer in the study group, 834 vs. 390 days.
Conclusion: Hip fracture incidence rates are significantly reduced when androgen suppressed patients are enrolled in the Healthy Bones Program. Due to the high healthcare costs and high morbidity and mortality of hip fractures, this finding may have a significant implication in the management of prostate cancer patients.
10.419 Urology
The Effect of Posterior Musculofascial Plate Reconstruction During Robotic Radical Prostatectomy on Quality of Life Outcomes
Anis Aziz, MD, Howard Jung, MD, Gary Chien, MD
Kaiser Permanente Los Angeles Medical Center, California, USA
Objective: Previous studies describe a beneficial impact of posterior musculofascial plate reconstruction on early urinary continence as defined by pad usage or patient questionnaires. However, no studies examine the impact of this technique on comprehensive quality of life during the early months after surgery. The purpose of this study was to describe the effect of this technique on quality of life as defined by the Expanded Prostate Cancer Index Composite (EPIC), which examines irritative/obstructive voiding, sexual, bowel, and hormonal outcomes in addition to urinary continence.
Methods: We retrospectively reviewed 119 robotic radical prostatectomies performed at our single institution from September 2008 through March 2009. Posterior musculofascial plate reconstruction was performed in 81 cases and omitted in 38 cases. EPIC questionnaires were administered during the preoperative visit and during the first and third postoperative months. Urinary continence, urinary irritative/obstructive, sexual, bowel, and hormonal domain scores were recorded and compared.
Results: At baseline, there were no significant differences in EPIC domain scores between the 2 groups. At 1 month, those patients with posterior musculofascial plate reconstruction reported significantly higher urinary continence scores (40 vs 30.1, P<0.5). There were no statistically significant differences in all other domain scores at one month. At 3 months, the same patients still reported higher urinary continence scores (49.1 vs 37.3, P<0.5). There were still no differences in other domain scores.
Conclusions: Posterior musculofascial plate reconstruction provides improved early urinary continence, but it does not affect irritative/obstructive symptoms, sexual function, bowel function, or hormonal symptoms.
10.420 General Surgery
Laparoscopic Treatment of Acute Cholecystitis: What is the Optimal Timing for Surgery?
P. Venezia
Director U.O. Chirurgia Endoscopica e Mini invasiva, Azienda Ospedaliero Universitaria Policlinico, Bari, Italy
Objective: Review the results of laparoscopic cholecystectomy (LC) to define the optimum management, either early or delayed, in patients with acute cholecystitis with particular attention to cost and clinical outcomes.
Methods: The records of all patients having acute cholecystitis from February 2000 to December 2009 were reviewed. Over 10 years, 810 patients received urgent LC and were divided into 2 groups according to the timing of surgery (1) <48 hours in the early group (453 patients) and (2) >48 hours in the late group (357 patients).
Results: Comparing the 2 groups, the conversion rate to an open procedure was significantly less in the early treated patients (% versus 29%). The only factor (eg, preoperative laboratory and ultrasound findings) that affected the outcome of the operation was the duration of symptoms before surgery. The operative time (65 versus 90 minutes, P<0.004), postoperative hospitalization (2 versus 4 days, P<0.001) and total hospital stay (2 versus 5 days, P<0.004) were significantly reduced in patients undergoing early LC. There were no bile duct injuries and no mortalities.
Conclusion: LC for acute cholecystitis performed by experienced surgeons is a safe and feasible technique with the additional benefit of shorter total hospital stay. The duration of symptoms before LC affected the outcome. The conversion rate, hospitality costs, and convalescence time increased in operated-on patients who had symptoms for more than 48 hours.
10.421 General Surgery
Laparoscopic Appendicectomy in a Situs Inversus Totalis Patient
Dr. Rajeev Premnath, MBBS, MS
Ramakrishna Hospital Pvt Ltd, Jayanagar, Bangalore, India
We report a case of situs inversus acute appendicitis in an 18-year-old college student who successfully underwent laparoscopic appendicectomy at our hospital. The incidence of situs inversus varies in different populations but is <1 in 10,000 people. This report highlights the following;
a. The need for the physician to be alert to diagnose patients with mirror image symptomatology.
b. The need for the surgeon to reorient his or her team and equipment in the operating room to successfully treat such patients.
The 18-year-old female college student presented with left lower quadrant pain and vomiting for 2 days prior to admission. She was hemodynamically stable, and her heart sounds were heard better on the right side of the sternum. Ultrasonography of the abdomen revealed situs inversus totalis with acute appendicitis. Her white cell count was 13,000 cells/cumm. After preoperative clearance, she underwent laparoscopic appendicectomy while under general anaesthesia. An 11-mm port was used at the umbilicus for the camera and also to extract the appendix. Two 5-mm ports were used as instrument ports, one each in the suprapubic region and right iliac fossa. The surgeon and his team stood on the right side of the patient, and the monitor and equipment were oriented to the left side of the patient to successfully complete the procedure.
10.422 General Surgery
"One
Shot" Treatment of Acute Cholecystitis Associated with Cholecystoduodenal
Fistula and Common Bile Duct Stones
Giancarlo Basili, MD, Nicola Romano, MD, Dario Pietrasanta, MD, Irene Mosca, MD, Orlando Goletti, MD
We present the case of a 77-year-old patient
affected by acute cholecystitis associated with cholecystoduodenal fistula and
common bile duct stones. Preoperative ultrasonography showed a distended,
edematous gallbladder and pericholecystic fluid. MRCP confirmed a slight
dilatation of the biliary tree with images of stones in the distal biliary
duct. A cholecystoduodenal fistula was suspected. Four port sites were used;
intraoperative transgallbladder cholangiography showed a stone in the distal
biliary duct and the presence of the fistula. After stapling of the fistula, a
transcystic extraction of common bile duct stones was performed by using a
Dormia catheter. Intraoperative transcystic choledoscopy was performed to
confirm clearance of the bile duct.
Between 10% to 18% of patients undergoing cholecystectomy for gallstones have
common bile duct stones. Treatment options for these stones include pre- or
postoperative endoscopy (endoscopic retrograde cholangiopancreatography), open
surgery, or laparoscopic bile duct exploration. Laparoscopic cholecystectomy with
simultaneous laparoscopic bile duct exploration seems to be as safe and as
efficient as endoscopic retrograde cholangiopancreatography, and avoids an
extra procedure.
