16TH SLS ANNUAL MEETING AND ENDO EXPO 2007
SEPTEMBER 5-8, 2007 • SAN FRANCISCO, CALIFORNIA
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SCIENTIFIC ABSTRACTS
Supplement to JSLS, Volume 11, Number 2
GENERAL SESSIONS
Best of Laparoscopy Updates
Multidisciplinary Plenary Sesssions
Future Technology Session
CALL FOR ABSTRACTS:
16TH SLS ANNUAL MEETING AND ENDO EXPO 2007
SEPTEMBER 5-8, 2007 • SAN FRANCISCO, CALIFORNIA, USA
Early Bird Registration Opens: March 2007 • Closes: July 5, 2007
Online Registration Closes: August 22, 2007
Make Your Hotel Reservations by August 13, 2007 for Discounted Conference Rates
For more information about the city of San Francisco visit www.MustSeeSanFrancisco.com
EDUCATIONAL METHODS AND OBJECTIVES
The 16th SLS Annual Meeting and Endo Expo 2007 employs a variety of educational formats including topical general sessions, the presentation of scientific papers, open forums, posters, and original videos offered in small specialty-specific breakout sessions, and informal gatherings of participants and expert faculty.
The increasing complexity of minimally invasive diagnostics and therapy requires a continuous educational process. The exchange of knowledge and expertise among the physicians taking part in this conference contributes to the continuation of excellence in minimally invasive surgery.
Upon completion of the conference, participants will be
able to:
• Increase comprehension of the basic and fundamental principles of laparoscopic, endoscopic, and minimally invasive techniques, enhancing the participant's understanding of these techniques;
• Understand the recent advances in laparoscopic, endoscopic and minimally invasive techniques;
• Determine the appropriate use of laparoscopic, endoscopic and minimally invasive equipment as part of a treatment plan in the care of patients;
• Comprehend the developing technologies that will be available in the future to enhance the standard of patient care; and
• Acquire educational information within the physician's specialty, which will enhance their professional development and patient care.
EXHIBIT HALL EVENTS
Welcome Reception: Kick off the conference at an informal reception open to all registrants in the Exhibit Hall. Meet old and new friends, and get a preliminary look at the technical exhibits.
SLS Cyber Café: While away, stay in touch. Check your E-mail, surf the Net, participate in an educational program, or go wireless at the SLS WiFi station. Educational programs will be scheduled throughout the day.
SLS Innovations of the Year: Come see what and how many innovative devices have been developed over the past year. The SLS Innovations of the Year will be recognized at the 16th SLS Annual Meeting and Endo Expo 2007. It is not necessary for a company to exhibit or advertise to be eligible for this recognition. SLS encourages all commercial entities to enter their most innovative product for consideration. Contact SLS for details: Tel. 305.665.9959, Tollfree 1.800.446.2659, Fax. 305.667.4123, Conferences@SLS.org
New Product Presentations by Exhibitors: SLS invites all exhibitors to share information about new products, technology, and developments during the New Product Presentation Session. Exhibitors who submit new product information will be allowed a one-minute presentation during the mid-day break, Friday, September 7, 2007. Note: each exhibitor will be allowed to present only one product that must have been developed within the past year. Contact SLS for details: Tel. 305.665.9959, Tollfree 1.800.446.2659, Fax. 305.667.4123, Conferences@SLS.org
Top Gun: It's High Noon-Are You Ready for a Shoot Out? It doesn't matter whether you're right-handed or left-handed. In this shootout, you use your non-dominant hand. See who's fastest on the draw or stitch in this entertaining, but challenging, training exercise in minimally invasive surgical procedures. See if you will take home the trophy in ‘07 and be named the “fastest draw” in SLS' Top Gun Laparoscopy Shoot Out!
PRELIMINARY PROGRAM
Conference Program Directors
Harrith M. Hasson, MD
William E. Kelley, Jr., MD
TUESDAY, SEPTEMBER 4, 2007
3:00pm-6:00pm MASTER’S CLASSES REGISTRATION
WEDNESDAY, SEPTEMBER 5, 2007 • MASTER'S CLASSES, OPENING CEREMONY, WELCOME RECEPTION
7:00am-9:00am MASTER’S CLASSES REGISTRATION / Complimentary Coffee & Bakery Items (Master's Classes Attendees Only)
6:45am-7:45am SLS BOARD MEETING
9:00am-4:30pm CONCURRENT MASTER’S CLASSES see each course for detailed times
12:00pm-1:00pm Complimentary Light Snacks and Refreshments
2:30pm-3:00pm Refreshment Break
9:00am-12:00pm
Half Day
#1 Master’s Class in the Prevention and Management of Laparoscopic and Endoscopic Surgical Complications
Raymond J. Lanzafame, MD, MBA, Director / Carl J. Levinson, MD, Co-Director / Lawrence C. Biskin, MD / Ceana Nezhat, MD / Howard N. Winfield, MD
1:00pm-4:30pm
Half Day
#2 Master’s Class in Laparoscopic Treatment of Adhesions for the General Surgeon, Gynecologist, and Urologist, Including Abdominal and Pelvic Pain
Harry Reich, MD, Director / Michael P. Diamond, MD, Co-Director / Maurice K. Chung, MD / Joseph Petelin, MD / Douglas E. Ott, MD, MBA
8:00am-4:30pm
Full Day
#3 Master’s Class in Laparoscopic Suturing in the "Vertical Zone"
Charles Koh, MD, Director / Randy Haluck, MD, Co-Director / Keith Isaacson, MD / David M. Boruta, II, MD / Jeremy M. Carver, SA / Tommaso Falcone, MD
9:00am-2:45pm
Half Day
#4 Master’s Class in Robot-Assisted Laparoscopic
Surgery – Jointly with the Minimally Invasive Robotic Surgery
Association (MIRA)
Santiago Horgan, MD, Director / William E. Kelley, Jr., MD, Co-Director / Garth Ballantyne, MD / Richard Satava, MD / Arnold Byer, MD / Joseph Petelin, MD / Howard Winfield, MD / Tommaso Falcone, MD / Yulun Wang, PhD
8:00am-4:30pm
Full Day
#5 Master's Class on Hands-On Gynecologic Endoscopic Surgery- Jointly with the American Association of Gynecologic Laparoscopists (AAGL)
Farr Nezhat, MD, Director / Ceana Nezhat, MD, Co-Director / Andrew Brill, MD / Harry Reich, MD / Tommaso Falcone, MD / Michael Diamond, MD / Wm. Leroy Heinrichs, MD, PhD / William E. Kelley, Jr., MD / Timothy B. McKinney, MD, PhD / Camran Nezhat, MD / Steven F. Palter, MD / Howard Winfield, MD / Robert Zurawin, MD
9:00am-4:30pm
Full Day
#6 Master’s Class in Laparoscopic General Surgery – Jointly with the Society of Gastrointestinal Endoscopic Surgeons (SAGES)
Michael S. Kavic, MD, Director / W. Peter Geis, MD, Co-Director / Phillip P. Shadduck, MD, Co-Director / Santiago Horgan, MD / Morris E. Franklin, Jr., MD / William E. Kelley, Jr., MD / Raymond J. Lanzafame, MD, MBA / Joseph B. Petelin, MD / Titus Duncan, MD
8:00am-4:30pm
Simulation Practice Center- Supporting Masters Classes #3, 4, 5 & 6
Wm. Leroy Heinrichs, MD, PhD, Director / Harrith Hasson, MD, Co-Director
Laboratory Faculty
Jose Benito Abraham, MD
Geoffrey Box, MD
Shoma Datta, MD
Randy Haluck, MD
Senzan Hsu, MD
Radmila Kazanegra, MD
Madeleine Lemyre, MD
Ali Mahdavi, MD
Jaime Ocampo, MD
Naghmeh Salamat Saberi, MD
Ricardo Santos, MD
Mark Smith, MD, PhD
Maria Terry, MD
James Watson, MD
Simulator Companies:
BioCompCenter
Immersion Medical
Medical Education Technologies, Inc.- METI
Mimic Technologies
Symbionix
Surgical Science
Verefi Technologies
12:00pm-6:00pm CONFERENCE REGISTRATION
5:00pm-6:30pm OPENING CEREMONY
Opening Entertainment
Opening Ceremony Remarks
Paul Alan Wetter, MD
Introduction of Benefactors and Corporate Members
5:20pm-5:30pm Presentation of Award Winning Scientific Papers and Videos
Session Director: Paul A. Wetter, MD
Co-Director: Harrith Hasson, MD
5:30pm-5:40pm Introduction of President
Raymond J. Lanzafame, MD, MBA
5:40pm-6:10pm Presidential Address
Harrith Hasson, MD
6:10pm-6:30pm Honorary Chair Presentations
Session Director: Paul Alan Wetter, MD
Introduction: Paul Alan Wetter, MD
Honorary Chair: Mark Erian, MD
Presentation: "The Society of Laparoendoscopic Surgeons and the Future of Endoscopic Surgery Worldwide"
Introduction: Maurice K. Chung, MD
Honorary Chair: Yan Liu, MD
Presentation: "The Economy and Culture of Shanghai and Its Development in Endoscopic Surgery in Gynecology"
6:30pm-8:30pm WELCOME RECEPTION IN EXHIBIT HALL
Recognition of SLS Benefactors & Corporate Members
Innovations of the Year
CYBER CAFE
Raymond J. Lanzafame, MD, MBA- Director / Alex Gandsas,
MD– Co-Director
THURSDAY, SEPTEMBER 6, 2007
6:30am-5:00pm CONFERENCE REGISTRATION
6:45am-7:00am Moderator Briefing
Raymond J. Lanzafame, MD, MBA / Carl J. Levinson, MD
7:00am Exhibits Open
7:00am-7:30am Complimentary Coffee and Bakery Items
7:30am-8:30am General Session: Best of Laparoscopy Updates
Laparoscopy Updates presented by SLS Specialty Interest Group Committee Members highlighting the newest developments and future expectations of surgical and diagnostic procedures.
Session Director: William E. Kelley, Jr., MD / Session Co-Director: Harrith M. Hasson, MD
Speakers/Topics:
7:30am-7:45am
Urology Committee: Howard Winfield, MD - The Winners and Losers: Urologic Update in Minimally Invasive Surgery 2007
7:45am-8:00am
Abdominal/Pelvic Pain/Adhesions Committee: Maurice K. Chung, MD - Does Adhesion Cause Pain? Should We Perform Adhesioloysis for Treatment of Pelvic Pain?
8:00am-8:30am
Keynote Speaker: Thomas Russell, MD- Director of the American College of Surgeons- ACS
8:30am-9:30am MULTI-DISCIPLINARY PLENARY SESSION (Gyn, General Surgery, Urology)
Improving Practice Performance and Quality
Session Director: Gustavo Stringel, MD / Session Co-Director: Alex Gandsas, MD
8:30am-8:35am Gustavo Stringel, MD: Introduction
8:35am-8:50am Gustavo Stringel, MD: Safety Quality and Improving Operating Room Performance
8:50am-9:05am Alex Gandsas, MD: Pay for Performance and Transparency
9:05am-9:20am Raymond J. Lanzafame, MD, MBA: Financial Aspects of Surgical Care - Past, Present and Future
9:20am-9:30am Questions to Panel
9:30am-10:00am Refreshment Break/Visit Exhibits
10:00am-11:00am MULTI-DISCIPLINARY PLENARY SESSION (Gyn, General Surgery, Urology)
How to Bring a New Surgical Idea to the Bedside
Session Director: Camran Nezhat, MD
10:00am-10:20am Thomas J. Fogarty, MD: Bringing Your Surgical Idea to Reality- What Gets in the Way?
10:20am-10:40am Mike Henson: Invention to Commercialization...and Beyond
10:40am-11:00am John Savarese, MD (Montreux Equity Partners): Clinically Driven Entrepreneurships: Bench to Bedside...to Bucks
11:00am-12:00pm MULTI-DISCIPLINARY PLENARY SESSION (Gyn, General Surgery, Urology)
New Directions in Simulation Training and Credentialing
Session Director: Harrith M. Hasson, MD / Co-Director: Richard Satava, MD
11:00am–11:15am Ajit Sachdeva, MD: The ACS Accredited Educational Institutes – The Beginning of the Revolution of Certification of Training Centers
11:15am–11:30am Mika Sinanan, MD: Applying for Certification – Do's and Don'ts
11:30am-11:45am Richard M. Satava, MD: The Consortium of ACS Accredited Educational Institutes – One Solution to Standardization
11:45am-12:00pm Questions and Answers Session
12:00pm-1:00pm Poster Townhall
Best graded Posters will participate in the Oral Poster Session
Directors:
Harrith M. Hasson, MD
William E. Kelley, Jr., MD
Jaime Landman, MD
Raymond J. Lanzafame, MD, MBA
Douglas E. Ott, MD, MBA
Gustavo Stringel, MD
12:30pm-1:45pm Complimentary Light Snacks and Refreshments/Visit Exhibits
1:45pm-5:30pm CONCURRENT SESSIONS: Scientific Papers/Videos/Open Forum Presentations/Laparoscopy Updates
Directors:
Maurice K. Chung, MD
Carl J. Levinson, MD
A. Elizabeth Martin, MD
Farr Nezhat, MD
2:00 pm Exhibits Close
2:00pm-4:00pm Coffee Available in Designated Areas
2:00pm-2:15pm Exhibitor's Meeting
2:15pm-3:00pm Briefing Meeting– AsianAmerican Summit III- February 2008
3:00pm-3:45pm Briefing Meeting– EuroAmerican Summit IV- February 2009
4:15pm-5:00pm SLS Corporate Council Meeting
5:30pm Adjourn for the Day
6:30-9:00pm SLS Group Event- Conservatory of Flowers (Ticket Required)
FRIDAY, SEPTEMBER 7, 2007
6:30am-5:00pm CONFERENCE REGISTRATION
7:00am Exhibits Open
7:00am-7:30am Complimentary Coffee and Bakery Items
7:00am-8:00am SLS Past Presidents Council Meeting
7:30am-8:30am MULTI-DISCIPLINARY PLENARY SESSION (Gyn, General Surgery, Urology)
Next Generation New Technologies for the Laparoendoscopic Surgeon
Session Director: Richard Satava, MD / Co-Director: Alex Gandsas, MD
7:30am-7:45am Timothy Broderick, MD: Telesurgery with a UAV
7:45am-8:00am Jaime Landman, MD: Ablative Technology
8:00am-8:15am Farr Nezhat, MD: Gynecology Technology
8:15am-8:30am Dmitry Oleynikov, MD: General Surgery Technology
8:30am-11:30am LIVE TELESURGERIES
Session Director: Camran Nezhat, MD / Co-Director: William E. Kelley, Jr., MD
Procedure: Laparoscopic Partial Nephrectomy/Radical Nephrectomy for Renal Tumor
Surgeon: Thomas H.S. Hsu, MD
Procedure: Laparoscopic Treatment of Endometriosis Including Segmental Colon Resection and Utereroneocystonomomy with Psoas Hitch
Surgeon: Camran Nezhat, MD
Procedure: Kidney and/or Lung Transplant
Surgeon: Stephan Busque, MD
10:30am-11:00am Refreshment Break/Visit Exhibits
11:30am-12:30pm Complimentary Light Snacks and Refreshments in Exhibit Hall
12:00pm-12:30pm New Product Presentation by Exhibitors
Session Director: Harrith M. Hasson, MD /Co-Director: Francis J. Podbielski, MD
12:30pm-12:45pm Presentation of Best Poster and Presentation of Resident Award-Winning Paper ($1,000 Award for Best Paper)
Directors:
William E. Kelley, Jr., MD
Raymond J. Lanzafame, MD, MBA
Douglas E. Ott, MD, MBA
Gustavo Stringel, MD
Awards Session Director:
Paul Alan Wetter, MD
Co-Director:
Harrith M. Hasson, MD
12:45pm-1:45pm THE EXCEL AWARD LECTURE
Session Director:
Paul Alan Wetter, MD
Introduction:
Ralph Clayman, MD
Recipient:
Elspeth M. McDougall, MD
Presentation: The Future of Surgery is Education
1:45pm-5:30pm CONCURRENT SESSIONS: Scientific Papers/Videos/Open Forum Presentations/ Laparoscopy Updates
Directors:
Maurice K. Chung, MD
Carl J. Levinson, MD
A. Elizabeth Martin, MD
Farr Nezhat, MD
2:00pm Exhibits Close
2:00pm-4:00pm Refreshments Available in Designated Areas
5:30pm Adjourn for the Day
SATURDAY, SEPTEMBER 8, 2007
7:00am-11:15am CONFERENCE REGISTRATION
7:30am-8:00am Sit-down breakfast with spouses/guests
8:00am-9:00am Keynote Speaker
John Kenagy, MD, MBA
Topic: Adaptive Innovation
9:00am-10:30am FUTURE TECHNOLOGY SESSION
"The Edge of Innovation in Surgery, Space and Business"
Session Director: Richard M. Satava, MD
Faculty:
Timothy Broderick, MD - NEEMO Mission
Joseph Bruner, MD - Fetal Surgery
10:30am-10:45am Closing Ceremony – Passing of the Presidential Gavel
President: Harrith M. Hasson, MD
To President Elect: William E. Kelley, Jr., MD
10:45am-11:15am SLS Business Meeting
11:15am-12:15pm SLS Committee Meetings & Post Conference Evaluation
Complimentary Light Snacks and Refreshments
ACCREDITATION
The
Society of Laparoendoscopic Surgeons (SLS) is accredited by the
Accreditation Council for Continuing Medical Education to provide
continuing medical education for physicians.
DESIGNATION
The Society of Laparoendoscopic Surgeons designates this educational activity for a maximum of 26 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Half-Day Master’s Classes: 3 credits
Full-Day Master’s Classes: 6 credits
16th SLS Annual Meeting & Endo Expo: 3 days: 20 credits
CONFERENCE FEES
Conference Registration opens: February 5, 2007
Early Bird Registration Deadline: July 5, 2007
SLS Members- Register Online at www.SLS.org before July 5, 2007 and save $100 on your registration!
Online Registration Deadline: August 13, 2007
Conference $595
Also
includes admission to exhibit hall, welcome reception, 1 ticket to
breakfast with keynote speaker, and future technology session
Master’s Classes
1 half-day class $195
2 half-day classes $295
1 full-day class $295
SCHOLARSHIPS TO ANNUAL MEETING
Residents,
Fellows-in-Training, Nurses, and Affiliated Medical Personnel are
eligible for a $300 scholarship towards the full Conference Registration
fee.
TRAVEL INFORMATION
For negotiated airline discount rates contact Steve at The Store For Travel, toll free at 1.800.284.2538. Outside the United States call 305.251.6331. E-mail: so@sft.webmail.com. Please be sure to mention you are attending the SLS conference in San Francisco, California.
For those attending the conference who require special assistance (accessibility, dietary, etc.), please contact SLS no later than August 13, 2007 with special requests.
Local Transportation
Lorries Shuttle provides door-to-door service between SFO Airport and the Hyatt from 4:30am-11:00pm for $14.00 per person, one way. At the airport, look for Lorrie's red and yellow vans in the shuttle pick up area. Reservations are required. For reservations visit http://www.myhotelshuttle.com. For more information call 415.334.9000.
Super Shuttle Van Service provides door-to-door service between SFO Airport and the Hyatt 24 hours per day, 7 days a week for $15.00 per person, one way. From the Airport, go to the upper level (median strip or courtesy island) and look for the blue and yellow Super Shuttle van. For reservations, call 415.558.8500.
Taxi rides from the SFO airport to the Hyatt are between $35.00 and $45.00.
DESTINATION INFORMATION
Always at the top of everyone's list of favorite travel destinations, San Francisco offers a remarkable number of cultural attractions and world famous landmarks set against a background of extraordinary natural beauty. From boutiques, megastores, and outlets carrying top designers, to purveyors of unique art, crafts, souvenirs, and California bounty products, San Francisco shopping offers something for everyone.
Exciting theme parks, unique museums, historical landmarks, and wild rides are some of the attractions around the Bay Area guaranteed to be amazing, amusing, and fun for the whole family. Take a walking tour, or hop on a cable car and visit some of the most renowned attractions in the world such as Golden Gate Bridge, Pier 39, Fisherman’s Wharf, and Chinatown.
Visit http://www.mustseesanfrancisco.com for more information on tours, sites, shopping, etc.
SPECIAL EVENTS
SPOUSE/GUEST WINE TOUR
Thursday, September 6, 2007
9:30am—4:30pm
Hosted by Patricia Kavic, Marcia Kelley and Lina Guertin
Make your reservations now
Give
us an hour and we will whisk you away to the most spectacular
wine-producing region on the continent. On our way out of San
Francisco, we'll go over the world famous Golden Gate Bridge with a
stop at the view point for a photo op of Alcatraz Island, San Francisco
Bay and everyone's Favorite City.
First stop, Benziger Family Winery.
It's been more than two decades since Mike and Mary Benziger first
drove up Sonoma Mountain and saw the overgrown ranch that would become
Benziger Family Winery.
Their dream to craft wines of uncommon
character with a distinct sense of place has come true and grown in to
one of the most well-known and respected labels in the Valley. At
Benziger, the team is a family, and their passion is Sonoma Mountain
winegrowing.
Today, you’ll take a close look at the vines, learn about the
site-specific farming practices and enjoy the breathtaking scenery. The
Sonoma Mountain winery tour includes a visit to their underground
estate caves and, of course, a tasting of Benzinger’s wines.
Next stop, historic Sonoma Square.
Sonoma's central plaza is the largest of its kind in California. The
plaza was originally surveyed in 1834, and it was dedicated as a
National Historic Landmark on September 24, 1961.
Sonoma Square
boasts numerous historic buildings, quaint boutique shopping, cuisine
to satisfy every palate, and numerous opportunities for wine, cheese
and local produce tastings. Here, you’ll have ample time to enjoy
shopping and lunch before our next destination.
Finally, it’s time to “toast” at lovely Domaine Carneros Sparkling
Winery. The chateau at Domaine Carneros is considered one of the most
beautiful wineries in North America. Designed after the Chateau de la
Marquetterie in Epernay, France, a property of Domaine Carneros
principal founder, Champagne Taittinger, the Domaine Carneros Chateau
is a landmark of the region. You will enjoy a taste of their wines as
well as a tour of their wine-making and bottling facility.
This
concludes our lovely day in Wine Country! Now, it’s time to return to
the hustle and bustle of the City, back to San Francisco!
Ticket Required: $117.00 per person.
Space is limited. Make your reservations now!
A COMPLIMENTARY SAN FRANCISCO NORDSTROM EXPERIENCE FOR SPOUSES/GUESTS
Friday, September 7, 2007
Nordstrom Conference Room A, 865 Market Street.
There will be complimentary shuttle service from the Hyatt to Nordstrom’s.
Get a season fashion trend preview, enjoy morning pastries, coffee, tea, waters, and soft drinks plus receive a Nordstrom exclusive gift certificate for the Nordstrom Bistro—merchandise or food—a
Bonus Book and Tote Bag.
Reservations for Spa Nordstrom, personal stylist (complimentary to SLS spouses/guests), and makeover should be made in advance RSVP to the Concierge Desk: Tel 415-977-5104.
SLS EVENING WITH FACULTY AT THE CONSERVATORY OF FLOWERS
Thursday, September 6, 2007
6:30pm–8:30pm
Conservatory of Flowers
San Francisco, California, USA
Prominently situated near the eastern end of the Golden Gate Park, the Conservatory of Flowers is a gem of Victorian architecture. The Conservatory opened in 1879; and fully restored in September 2003, it is North America’s oldest existing public conservatory. With almost two thousand plant species represented in its exhibits and floral displays, the Conservatory joins a distinctive circle of modern American horticultural museums that are on the cutting edge of botanical interpretation and conservation education. 
The Conservatory of Flowers is a spectacular museum of rare and beautiful tropical plants including palms, orchids, bromeliads, carnivorous plants and much more. This impressive museum of living plants and immersing displays in five galleries engages visitors physically, intellectually, and emotionally. These splendid displays not only delight, but also deliver a moving message about the rapid changes in tropical habitats worldwide and efforts currently underway to conserve these special places.
Join us for an evening of visual splendor, entertainment, and “Food Among the Flowers.”
Photo Credit: © The Conservatory of Flowers/Friends of Recreation and Parks.
EXCEL AWARD PRESENTATION AND LECTURE
Friday, September 7, 2007
12:45 pm – 1:45 pm
Recipient: Elspeth M. McDougall, MD
Established in 1991, the Excel Award has been presented to 22 surgeons deemed by the SLS Advisory Board to have made outstanding contributions to laparoscopy, endoscopy, and minimally invasive surgery. These outstanding surgeons are from various specialties and various nationalities.
Elspeth M. McDougall, MD, the 2007 recipient of this prestigious award, is internationally recognized for her laboratory and clinical research in urologic laparoscopic surgery and for teaching courses on fundamental and advanced endourological and laparoscopic techniques. She completed her medical training at the University of Calgary and the University of Ottawa in Canada, and then undertook a fellowship in endourology and extracorporeal shock wave lithotripsy (ESWL) with Dr. Clayman at Washington University School of Medicine. She joined the faculty at Washington University Medical School in 1991, where she spent nine years in academic urology. Subsequently, she developed the Endourology/Laparoscopic Urology Program at Vanderbilt University in Nashville, Tennessee, during her tenure there as Professor of Urologic Surgery.
Dr. McDougall joined the University of California, Irvine Department of Urology faculty in 2002 to continue her clinical and research work in minimally invasive urologic surgery and assist in the development of a minimally invasive surgery education center. She is a Fellow of the Royal College of Surgeons of Canada (Urology) and certified with the American Board of Urology. Dr. McDougall has published more than 132 peer-reviewed journal articles and numerous book chapters. She is the co-editor of two textbooks on laparoscopic surgery.
Dr. McDougall was chairperson for the Ad Hoc Surgical Simulation Committee and a member of the Laparoscopic Training Committee of the American Urological Association. She is on the editorial boards of the Journal of Endourology and the Journal of the Society of Laparoendoscopic Surgeons. She is Past President of the Society of Laparoendoscopic Surgeons and is a member of the Surgical Simulation Committee of this society. She is a member of the World Congress of Endourology's Scientific Meeting Advisory Committee. She was recently elected to the prestigious American Association of Genitourinary Surgeons.
Dr. McDougall is Director of the Yamanouchi Center for Urological Education at UCI and developed the ongoing, five-day mini-residency training program in minimally invasive urologic surgery for post-graduate urologists.
CONCURRENT SCIENTIFIC SESSIONS THURSDAY, SEPTEMBER 6, 2007 AND FRIDAY, SEPTEMBER 7, 2007
Over 200 Scientific Papers, Open Forum Presentations, Videos, and Posters will be presented by SLS members and colleagues from around the world. Laparoscopy Updates: Current Status, newest developments and future expectations of surgical and diagnostic procedures. Preliminary listing.
LAPAROSCOPY UPDATES
Presented by SLS Special Interest Group Committees
Abdominal / Pelvic Pain / Adhesions
Dan Martin, MD
Endometriosis / Ovarian: Endometriosis and Ovarian Cancer, Is There Any Correlation?
Farr Nezhat, MD
Fertiloscopy / Transvaginal Endoscopy: The Current Status of Transvaginal Hydro-Laparoscopy
Duncan J. Turner, MD
Fibroids
Herbert Goldfarb, MD
Future Technologies
Dmitry Oleynikov, MD
Gastroesophageal Reflux Disease: GERD- Endoluminal Therapies
Phillip Shadduck, MD
Hysterectomy: The Role of Laparoscopy and Robotics in Hysterectomy
Ceana Nezhat, MD
Hernia
Lawrence Biskin, MD
Infertility / Fertility
Grace Janik, MD
Robotic Surgery
James F. Carter, MD
Urology: Update on Urologic Surgery
Thomas H.S. Hsu, MD
GENERAL SURGERY
Laparoscopic Open Appendicectomy: A Single Centre Experience, Simon T. Adams MBChB MRCS
The Laparoscopic Approach in Abdominal Emergencies: A Single-Center Review of a 15-Year Experience, Ferdinando Agresta MD
Laparoscopic Cholecystectomy with Three Trocars and 5 mm Optic Instruments, Ferdinando Agresta MD
Other Psychosocial Impact of Laparoscopic Donor Nephrectomy: Long Term Impressions, Andrew Michael Altman MD
Laparoscopy Versus Observation in Acute Abdominal Pain: Controlled Randomized Trial, Karim Al-Araji MD
Long-term Outcome of Laparoscopic Approach for Duodenal Switch with Sleeve Gastrectomy as a Single Bariatric Procedure, Ghiath A. Alshkaki MD
Laparoscopic Management of Interstitial Pregnancy in our Institution, Yasuyuki Asakawa MD PhD
Two-Step Abdominal Inflation and Scopy- Trocar Insertion Method, Yonghae Baik Prof Dr Med
The Importance of Haptic Feedback in Laparoscopic Suturing Training and the Additive Value of Virtual Reality Simulation, Sanne MBI Botden MSc
Endoscopicly Obtained Bile Aspirate is an Accurate Adjunct in the Diagnosis of Symptomatic Gallbladder Disease, Kerrey B. Buser MD
Laparoscopic General Surgery in the Pregnant Patient: Results and Recommendations from One Surgeon's Experience with 36 Cases in a Rural Hospital, Kerrey B. Buser MD
Nitinol Clips Versus Prolene Suturing Technique for Adjustable Gastric Banding Procedures, Thomas Y. Chua MD
Laparoscopic Management of Small Bowel Intussception in a 16 Year Old with Peutz-Jeghers Syndrome, Benjamin Clapp MD
Preoperative Embolization of Adrenal Pheochromocytoma, Osvaldo Contarini MD
Laparoscopic Colon Resection with High Dexterity Instrumentation, Paul G. Curcillo II MD
The Effects of Race on Weight Loss After Bariatric Surgery, Titus D. Duncan MD
Gastrojejunostomy Strictures After Laparoscopic Gastric Bypass Using the Transabdominal 21mm Circular Stapler, Ward J. Dunnican MD
Virtual Reality Laparoscopic Simulator with Tactile Feedback: Does it Improve Performance?, Dan Eisenberg MD
Laparoscopic Repair of Recurrent Incisional Hernia in Cardiac Transplant Patients, Dan Eisenberg MD
Other Thymoma: Minimally Invasive Transthoracic Approach, Brian C. Fallon MD
Laparoscopic Colon Surgery: The New Gold Standard, Michael E. Fenoglio MD
An Uncommon Situation of Massive Haematemesis - A Really Strange Situation, José M.M. Ferreira-Coelho Prof Dr Med
Other Percutaneous Computer Tomography-Guided Radio Frequency Ablation of Lung Tumors: Case Report and Review of the Literature, Jacques P. Fontaine MD
The Fixation of Hiatal Meshes with Fibrin Sealant in an Experimental Model in Pigs, Rene H. Fortelny MD
Laparoscopic-Assisted Colonoscopic Polypectomy: Long Term Results, Morris E. Franklin MD
The Use Of Small Porcine Bowel Submucosa Mesh in the Treatment of Gastroesophagic Reflux: Long Term Results at the Texas Endosurgery Institute, Morris E. Franklin MD
Laparoscopic Biliary Bypass Procedures: Review of the First 14 Years, Morris E. Franklin MD
Clipless Laparoscopic Cholecystectomy, Roberta Gelmini MD
Robotic Nissen Fundoplication: An Excellent Training Procedure, Monika Hagen MD MBA
Impressions of Inexperienced Individuals and Laparoscopic Surgeons in Their First Use of the da Vinci Surgical System, Monika Hagen MD MBA
Robotic Swenson Pull-Through for Hirschsprung's Disease in Infants, Andre Hebra MD
Applying Ultracision Long Sheers Reduces Operation Time in Transanal Endoscopic Microsurgery, Pleun EA Hermsen MD
Robot Assisted Laparoscopic Distal Gastrectomy with D2 Lymph Node Dissection, Woo Jin Hyung MD PhD
The Effects of Different Surgical Approaches on Systemic Inflammatory Response After Gastrectomy, Woo Jin Hyung MD PhD
Unusual Mechanisms of Failure After Antireflux Surgery: Report of Two Cases, Atif Iqbal MD
Development of Breast Ductoscopy and its Future Perspective, Volker R. Jacobs MD PhD
Laparoscopic Spleen Sparing Distal Pancreatectomy, Uthaiah P. Kokkalera MD
Other Jejunojejunostomy Stricture with Gastric Remnant Perforation After Laparoscopic Roux-en-Y Gastric Bypass, John S. Koppman MD
Other Anastomotic Leaks Following Laparoscopic Gastric Bypass, John S. Koppman MD
Laparoscopic Gastric Bypass for Mobidity Obesity: Prospective Study with Two Gastro-Jejunum Anastomosis Techniques, Jose L. Leyba MD
Early Experiences with Laparoscopic-Assisted Colectomy for Colon Cancer, Rockson C. Liu MD
Bowel Injuries During Laparoscopic Surgery: Benenden Experience, Kiran M. Lodha MD
Sentinel Node Biopsy (SNB) and Extracapsular Extension of the Surgical Treatment of Breast Cancer, Sinisa Maksimovic MD PhD
Laparoscopic Cholecystectomy: Our Experiences After 2000 Patients, Sinisa Maksimovic MD PhD
Our Experience in Laparoscopic Ventral and Incisional Hernia Repair, Lombardi Marco Prof Dr Med
Laparoscopic vs. Open Colectomy for Non Metastatic Colorectal Cancer: A Prospective Study of Long Term Survival, Muhammad S. Mirza MD
Robotic-Assisted Colorectal Surgery: Initial Experience, Philippe Morel Prof Dr Med
Harmonic Scalpel Use in Thoracoscopy and Pulmonary Resection, John Morrison MD
Building a Laparascopic Colorectal Mentoring Program at a Community Hospital: A 3-Year Experience, Prashanth S. Navaran MD
Technique for the Salvage of Infected Mesh Prosthesis without Re-Operation or Mesh Removal: A Case Report, Prashanth S. Navaran MD
Total Laparoscopic Esophagus-Gastrectomy, Salvador A. Navarrete MD
Validity of the Magnetic Resonance Cholangio-Pancreatography (MRCP) Before the Videolaparocholecystectomy (VLC) in Patients with Mild Acute Biliary Pancreatitis, Vincenzo Neri MD
Laparoscopic Total Colectomy and Ileorectal Anastomosis for Colon Cancer, Joseph W. Nunoo-Mensah MD
Laparoscopic Repair of Spiegel's Hernia, Francisco A. Obregon MD
All Laparoscopic Graspers are Known Crushing Systems: Is This a Product Design Defect and Product Liability?, Douglas E. Ott MD MBA
Laparoscopic Adrenalectomy Via Lateral Transperitoneal Approach (1997-2006), Maciej Otto Prof Dr Med
A Novel Technique for Radio Frequency Ablation of Hepatic Dome Neoplasms Using Iatrogenic Hydrothorax, Francesco Palazzo MD
Laparoscopic Resection of Osler-Weber-Rendu Lesion, John Park MD
The Beginning Experiences in Treatment of Ventral Hernias with Composite Mesh, Veroljub Pejcic MD
Therapeutic Evaluation of Laparoscopic Hernioplasty for Inguinal Hernia in Elderly Males, Haifeng Peng MD
Fibrin Sealant for Fixation of cPTFE Meshes in Experimental IPOM Repair- Impact on Adhesion Formation and Reduction of Perforating Fixation Devices, Alexander H. Petter-Puchner MD
The Assessment of the Quality of Life in Laparoscopic Hernia Repair- Suggestions for the Development of Standards Within the SLS, Alexander H. Petter-Puchner MD
Minilaparotomy for GERD Treatment, Juan G. Quiroz MD
Laparoscopic Splenectomy Following Embolization for Blunt Trauma, Kenneth Joe Ransom MD
Transaxillary Endoscopic Parathyroidectomy: Our Initial Series, Qammar N. Rashid MD
Near Total Thyroidectomy Using a Transaxillary Endoscopic Approach, Qammar N. Rashid MD
Metanalysis of Recurrence After Laparoscopic Repair of Paraesophageal Hernia, Munir A. Rathore FRCS
A Novel Technique in Diagnosing a Leak in the Lap Band System, Kurt E. Roberts MD
The Effect of Videogame “Warm-up” on Performance of Laparoscopic Surgery Tasks, James C. Rosser, Jr. MD
Ureteral Clipping During Laparoscopic Donor Nephrectomy Improves Operative Fieled Visibility and Does Not Affect Recipient Outcome, Kamran Sajadi MD
Laparoscopic Surgery for Colorectal Carcinoma: Costs and Benefits in the Europe Region, Lukas Sakra MD PhD
Early Post-Operative Results Comparing Restrictive Procedures in the Massively Super Obese, David L. Schumacher MD
Minimally Invasive Repair of Congenital Diaphragmatic Hernias: A Review of Our Experience, Sohail R. Shah MD
Laparoscopic vs. Laparotomic Approach for Colorectal Carcinoma, Jiri Siller MD PhD
Laparoscopic Adrenalectomy: Transperitoneal or Retroperitoneal Approach, Gintaras Simutis MD PhD
Laparoscopic Transabdominal Hernia Repair for Incarcerated Groin Hernias, Uz Steinhilper Dr Med
Laparoscopic Hernia Repair, Martin Susewind MD
A Laparoscopic Approach to the Surgical Management of Gastrocutaneous Fistula Following Gastrostomy Tube Removal, Nicholas A. Tarola MD
Unusual Delayed Complication Following Laparoscopic Adjustable Gastric Banding, Michael B. Tempel MD
Laparoscopic Hernia Repair: A Two Port Technique, Katerina Theodoropoulou MD
Major Bile Duct Injuries After Laparoscopic Cholecystectomy: Factors That Influence the Results of Treatment, Konstantinos George Tsalis Prof Dr Med
The Effect of Intraperitoneal and Intraincisional Application of Local Analgesic on Pain After Laparoscopic Abdominal Surgery, Ali Uzunkoy Prof Dr Med
Laparoscopic Evaluation for Chronic Post Operative Abdominal Pain, Amir Vejdan Dr Med
Laparoscopic Management of the Upper GI Benign Diseases, Yue Dong Wang MD
Laparoscopic Splenectomy and Azygoportal Disconnection for Bleeding Varices with Hypersplensm, Yue Dong Wang MD
Does the Rate of Achieving Competency on Simulated Laparoscopy Training Programs Predict Actual Skill in Performing Laparoscopic Cholecystectomy?, Warren D. Widmann MD
Technical Aspects of Laparoscopic Splenic Marsupialization, James Briscoe Wooldridge MD
Laparoscopic Ileal Flap for Colpopoiesis, Jixiang Wu MD
Advantages of Laparoscopic Approach Perforated Peptic Ulcers, Bulent Yaycioglu MD
GYNECOLOGY
Diagnostic Performance of Office Hysteroscopy to Detect Endometrial Pathologies in Women with Hereditary Predisposition to HNPCC Syndrome: Results of a Prospsective Study, Anne-Sophie Bats MD
Staging of Advanced Ovarian Cancers: Interest of Thoracoscopy, Anne-Sophie Bats MD
Comparison of Different Approaches in Surgical Management of Endometrial Cancer, Anne-Sophie Bats MD
Removal of Abdominal Cerclage Laparoscopically: A Case Report, James F. Carter MD
Day Surgery Laparoscopic Subtotal Hysterectomy: A Multicentered Study with 500 Patients in Greece and the UK, Stefanos Chandakas MD PhD
Laparoscopic Subtotal Hysterectomy Using the Laploop System: A New, Safe and Time Efficient Technique for Daycase Procedures, Stefanos Chandakas MD PhD
Mega Uterus: Overview of a Technique for Laparoscopic Hysterectomy and Outcome, Leroy Charles MD MBA
Incidence of Pelvic Pain Dyspareunia and Vaginal Spotting After Outpatient Laparoscopic Intracervical Subtotal Hysterectomy (LISH), Maurice K. Chung MD
Endoscopic Treatment of a Chronic Cornual Ectopic Pregnancy, M. Shoma Datta MD
A Comparison of Total Robotic vs. Laparoscopic Radical Hysterectomy and Pelvic Lymphadenectomy for Gynecologic Malignancy Treatment in a Fellowship Training Program, M. Shoma Datta MD
A Clinical Analysis of 112 Cases: Laparoscopic and Hysteroscopic Intrafascial Hysterectomy, Weijie Du MD
The Hidden Risk of Natural Herbs in Gynaecological Surgery, Mark Erian MD
Robotic Surgery in the Gynecologic Oncology Setting: First 120 Cases, Ricardo E. Estape MD
Symptom Severity and Disability in Chronic Pelvic Pain Worsens When an Increasing Number of Pain Diagnoses are Present, Bradford W. Fenton MD PhD
Roboric Sacrocervicocolpopexy in Women at Risk for Future Loss of Vaginal Support, Robert F Flora MD MBA
Robot Assisted Paravaginal Defect Repair, Dobie Giles MD
Adolescent Women with Failed Treatment for Endometriosis and Continued Chronic Pelvic Pain: Consider Interstitial Cystitis, Stephen A. Grochmal MD
Laparoscopic-Assisted Vaginal Hysterectomy for a Term-Size, Myoam Lim Woh Koh MD
Viable Cornual Pregnancy Treated Laparoscopically, Lim Woh Koh MD
Laparoscopic Radical Hysterectomy and Lymphadenectomy for Invasive Cervical Cancer: Techniques, Results and Oncological Outcome in 343 Consecutive Cases, Zhiqing Liang Prof Dr Med
Laparoscopic Sacrospinous Ligament Fixation for Uterovaginal and Vault Prolapse, Zhiqing Liang Prof Dr Med
Mistletoe Therapy in Recurrent Endometriosis Patients, Yong-Taik Lim MD
Laparoscopic Supracervical Hysterectomy: The Learning Curve, Christopher Lindeken DO
The Feasibility of Using Nitinol-U Clips with the daVinci Surgical System to Treat Distal Fallopian Tubal Disease, David McLaughlin MD
Cervical Remnant in CISH Hysterectomy: Short and Long Term Issues, John E. Morrison MD
Laparoscopic Debulking of a Left Pelvic Sidewall Mass in a Patient with Recurrent Ovarian Cancer, Nimesh P. Nagarsheth MD
Incisional Hernia on the Trocar Port Site After Laparoscopy: Prevention, Recognition and Management, Camran Nezhat MD
Laparoscopic Cytoreduction in Primary Advanced or Recurrent Ovarian Carcinoma, Farr R. Nezhat MD
Laparoscopic Intraperitoneal Paraaortic Lymphadenectomy: Our Experience in a Fellowship Training Program, Farr R. Nezhat MD
Laparoscopic Assisted Myomectomy, Mario Nutis MD
Laparoscopic Amputation of a Noncommunicating Uterine Horn, Jaime Ocampo MD
The Advantages of Mini-Laparoscopic Surgery Compared to Conventional Laparoscopic Surgery for Early Stage Endometriosis, Sung-Tack Oh MD PhD
Alternatives to Hysterectomy, Jonathan Y. Song MD
Laparoscopic Hysterectomy for the Enlarged Uterus, Jonathan Y. Song MD
Comparison of Two Transobturator Techniques Regarding Operative Time, Recovery, Complications, and Clinical Efficacy, Radha Syed MD
Case Presentation of Failed Essure Cases- Etiology, Diagnosis, and Corrective Procedures, Radha Syed MD
Laparoscopic Management of Benign Pelvic Masses, Alberto Valero Prof Dr Med
A Case of Large Urachal Cyst Treated by Laparoscopic-Assisted Surgery, Takashi Yamada MD PhD
Hydrodistension for Interstitial Cystitis Consistently Provides Improvement in Properly Selected Patients, Bradford W. Fenton MD PhD
Development of a Method for the Consistent Creation of Experimental Pelvic Adhesions in a Swine Model, Bradford W. Fenton MD PhD
Laparoscopic Diagnosis of a Rare Cause of Abdominal Pain, Atif Iqbal MD
UROLOGY
The Role of Stent Placement in Laparoscopic Ureteroureterostomy, Ronney Abaza MD
A Novel Technique for Laparoscopic Partial Nephrectomy, Ronney Abaza MD
LapED 4-in-1 Silicone Training Aid for Practicing Laparoscopic Skills and Tasks: An Evaluation, Jose Benito Aguila Abraham MD
Comparative Review of Laparoscopic and Robotic-Assisted Radical Cystectomy with Ileal Conduit Urinary Diversion, Jose Benito Aguila Abraham MD
Correlation of Laparoscopic Surgical Experience with Videogame Performance, Reza Alipanah BS
Does Age Affect the Safety and Efficacy of Potassium-Titanyl-Phosphate (KTP) Laser Photoselective Vaporization Prostatectomy (PVP)?, Motoo Araki MD PhD
Catheter Free Potassium-Titanyl-Phosphate (KTP) Laser Photoselective Vaporization Prostatectomy (PVP): Patient Characteristic Analysis, Motoo Araki MD PhD
Management of the Large Median Lobe During Robotic Assisted Radical Prostatectomy, Jeff Bejma MD
Pure Laparoscopic Partial Nephrectomy: The First 50 Cases After Fellowship, Sam B. Bhayani MD
Impact of 3-Dimensional Visualization and Articulating Needle Driver Use on Time and Accuracy of Simulated Laparoscopic Suturing and Knot Tying, James G. Bittner IV MD
In Vivo Lymphatic Sealing Capability in the Porcine Thoracic Duct Comparing LigaSure V, Gyrus Trissector, Harmonic ACE Scalpel, EnSeal, and Monopolar Scissors, Geoffrey N. Box MD
Laparoscopic Pyelo-Ureterolithotomy: Re-Emerging Role in the Management of Complex Stone Disease, Daniel I. Brison MD
Assessment of the Impact of 6 Months of Laparoscopic Radical Prostatectomy (LRP) Fellowship Training Upon the Learning Curve During Initiation of LRP into a Lower Volume Prostatectomy Practice, James A. Brown MD
Robotic-Assisted Radical Cystectomy, Erik P. Castle MD
Robotic-Assisted Radical Cystectomy with Orthotopic Neobladder, Erik P. Castle MD
Paravertebral Blocks for Pain Control in Patients Undergoing Hand-Assisted Laparoscopic Nephrectomy, Steven R. Clendenen MD
Laparoscopic Partial Nephrectomy: Six Degrees of Hemostasis, Leslie Allan Deane MD
Robotic Versus Standard Laparoscopic Partial/Wedge Nephrectomy: A Comparison of Intra- and Peri-Operative Results from a Single Institution, Leslie Allan Deane MD
Sutureless Laparoscopic Heminephrectomy: Safety and Efficacy in the Porcine Model, Ithaar H. Derweesh MD
Preliminary Experience with Sutureless Laparoscopic Partial Nephrectomy for Renal Tumors with Collecting System Entry: Technique and Results, Ithaar H. Derweesh MD
Laparoscopic Management of a 12 cm Adrenal Cyst, Caner Dinlenc MD
Laparoscopic Vas Salvage After Mesh Hernia Repair, Caner Dinlenc MD
Laparoscopic Donor Nephrectomy: A Review of the Last 282, Grant I.S. Disick MD
The Escape™ Nitinol Stone Retrieval Basket Facilitates Laser Fragmentation and Extraction of Ureteral and Renal Calculi: Initial Experience, Grant Disick MD
Endoscopic Management of Ureteral Obstructive in Patients with Bladder Extrophy Diverted by Ureterosigmoidostomy, Michael L. Eisenberg MD
Endoscopic Management of Retained Renal Foreign Bodies, Michael L. Eisenberg MD
Results of Laparoscopic Radical Prostatectomy (LRP), Genoa G. Ferguson MD
Is a Closed Suction Drain Required After Robotic-Assisted Laparoscopic Radical Prostatectomy?, Carl K. Gjertson MD
Bilateral Laparoscopic Ureterolysis, Carl K. Gjertson MD
Rhabdomyolysis Following Laparoscopic Nephrectomy: Case Reports and Review of Literature, Deborah Glassman MD
Radiation Resistant Prostate Cancer: A Single Institution Experience with Laparoscopic and Robotic Salvage Prostate Cancer Surgery, Mark H. Kawachi MD
Evaluation of Laparoscopic Vascular Clamps Using a Load-Cell Device: Are All Clamps the Same?, Hak J. Lee MD
SutureLock: Adjustable Laparoscopic Knotting Clip, Keith L. Lee MD
Laparoscopic Nephrectomy with Autotransplantation for Ureteral Stricture Disease and Renal Tumors: Differences in Perioperative Morbidity and Hospitalization, Keith L. Lee MD
Complications of Hand-Assisted Renal Surgery, Timothy LeRoy MD
Robotic-Assisted Radical Cystectomy in the Female Patient, Richard Matern MD
Robotic-Assisted Sacrocolpopexy, Richard Matern MD
Cryoablation Does Not Adversely Impact Renal Function of Those Patients Who Present with Renal Insufficiency, Joe Miller MD
Introduction of a Robotic Skills Laboratory into a Urology Curriculum, Joe Miller MD
A New Novel Laproscopic Pyeloplasty: Kerithy Technique Minimal Invasive Surgery for the Management of Ureteripelvic Junction (UPJ) Obstruction, Al kerithy Mohammed MD PhD
Will Robotic-Assisted Radical Prostatectomy Become the New Surgical Standard? - United States Trend Mirrors the Trend at Hackensack University Medical Center (2001-2006), Ravi Munver MD
The Impact of Minimally Invasive Technology on Localized Prostate Cancer Practice Patterns at a Single Institution: Robotic-Assisted Radical Prostatectomy vs. Radiation Therapy vs. Cryosurgery, Ravi Munver MD
Novel Technique for Hemostatic Hydrodissection of the Neurovascular Bundles (HYNEB) During Laparoscopic Radical Prostatectomy: Early Potency and Continence Outcomes, Sijo Joseph Parekattil MD
Hemostatic Hydrodissection of the Neurovascular Bundles (HYNEB) During Laparoscopic Radical Prostatectomy: Early Potency and Continence Outcomes, Sijo Joseph Parekattil MD
Robot Assisted Radical Prostatectomy: Histopathologic Data of 1200 Cases, Vipul R. Patel MD
Is the Learning Curve Endless? One Surgeon's Experience with Robotic Prostatectomy, Vipul R. Patel MD
Laparoscopic Radical Nephrectomy for Large Renal Tumors (Greater than 7 cm): Intermediate Oncologic Outcomes, Jay D. Raman MD
Increasing Body Mass Index (BMI) Negatively Impacts Outcomes Following Robotic Radical Prostatectomy, Jay D. Raman MD
Increased Cancer Yield and Decreased Non-Diagnostic Results When Three Cores are Taken Rather Than One Prior to Renal Cryoablation, Bradley F. Schwartz DO
Robotic Radical Prostatectomy: Peri-Operative Outcomes of 1200 Cases, Ketul K. Shah MD
Robot Assisted Radical Prostatectomy: Complication Data of 1200 Cases, Ketul K. Shah MD
Robot Assisted Laparoscopic Pyeloplasty: Tricks of the Trade, Ketul K. Shah MD
Bilateral Hand-Assisted Laparoscopic Renal Surgery in the Supine Position: An Assessment of Efficacy and Complications, Kashif Siddiqi MD
Laparoscopic Radical Nephrectomy with Hilar Lymphadenectomy in Patients with Advanced Renal Cell Carcinoma, Matthew N. Simmons MD PhD
Decreased Complications of Contemporary Laparoscopic Partial Nephrectomy: Use of a Standardized Reporting System, Matthew N. Simmons MD PhD
An Innovative Medical Student Clinical Clerkship in Advanced Urologic Laparoscopy: A Preliminary Experience, Chandru Sundaram MD
Medical Student Satisfaction Following Laparoscopic Skills Testing, Chandru Sundaram MD
Laparoscopic Radical Cystectomy c Extracorporeal Ileal Conduit: Dong-A University Hospital Experience After 20 Cases, Gyung Tak Sung MD PhD
Radiofrequency Ablation of Renal Tumors: Technique and Outcome, Rahul K. Thaly MD
Prospective Comparison of Perioperative and Early Pathologic Outcomes Between Robotic and Open Radical Cystectomy, Gerald J. Wang MD
Transurethral Microwave Dilatation of the Prostate for Management of Symptomatic Benign Prostatic Hypertrophy, Alexei Wedmid MD
Robotic Assisted Laparoscopic Sacrocolpopexy: Technique and Experience, Christopher Whelan MD
Robotic Assisted Laparoscopic Sacrocolpopexy: A New Approach in the Treatment of Vaginal Vault Prolapse, Christopher Whelan MD
Decreased Efficiency of Potassium-Titanyl-Phosphate (KTP) Laser Photoselective Vaporization Prostatectomy (PVP) with Long-Term 5a- Reductase Inhibition Therapy: Is It True?, Carson Wong MD
120 W Lithium Triboride (LBO) Laser Photoselective Vaporization Prostatectomy (PVP) for Symptomatic Benign Prostatic Hyperplasia (BPH), Carson Wong MD
Effect of Tumor Size on Intra-Operative and Peri-Operative Outcomes in Patients Undergoing Laparoscopic Partial Nephrectomy with Hilar Occlusion, Michael Woods MD
Robotic Assisted Ureteral Reimplant, Michael Woods MD
MULTISPECIALTY
Experimental Studies of Peroral Transgastric Abdominal Surgery: Tubectomy, Hysterectomy: Is it the Next Minimally Invasive Approach?, Stefanos Chandakas MD PhD
Painful Bladder Syndrome/Interstitial Cystitis in Patients with Abdominal and Pelvic Adhesion, Maurice K. Chung MD
Damage at the Grasper-Tissue Interface in Minimally Invasive Surgery, Smita De
The Evolution Of Clip-free Laparoscopic Adrenalectomy: A Comparative Evaluation of Electrocautery, Ultrasonic, and Bipolar Energy Sources, Grant Disick MD
Emerging Endoscopic Imaging Technology: A Disposable, Distal Tip CMOS Sensor Endoscope, Stephen A. Grochmal MD
Creaton of a Neovagina by the Vechietti Procedure in a Patient With Corrected High Imperforate Anus (A Case Report), Paul B. Miller MD
Simultaneous Laparoscopic Hysterectomy & Cholecystectomy, Khusen B. Narzullaev MD PhD
Playing an Instrument Has Significant Impact on Surgical Skills Performance, Arup Saha MD
Minilaparoscopy: As a Safer Entry for Natural Orifice Peritoneoscopy, Daniel A. Tsin MD
PRE-CONFERENCE MASTER'S CLASSES WEDNESDAY, SEPTEMBER 5, 2007
Half-Day Courses (3 AMA PRA Category 1 Credits): 9:00am–12:00pm; 1:00pm–4:30pm
Full-Day Courses (6 AMA PRA Category 1 Credits): 9:00am–4:30pm
#1 Master’s Class in the Prevention and Management of Laparoscopic and Endoscopic Surgical Complications
Half-Day (9:00am–12:00pm)
All abdominal and pelvic MIS procedures carry an inherent risk of complications. This interactive course will present a philosophy for the prevention and management of complications during minimally invasive surgery of the abdomen and pelvis. Video segments and case presentations will be used to demonstrate principles and stimulate discussion. Source material will be obtained from students’ “real world” experiences and supplemented with materials selected by the faculty panel and customized based on pre-conference information obtained from registrants. An interactive student and faculty discussion format will be utilized. This course will discuss management paradigms to prevent, recognize, and treat complications appropriately. Careful, methodical assessment and strategies for appropriate action will be stressed. Topical presentations based on student input will highlight detailed surgical anatomy, sound surgical principles and careful technique. Participants are strongly encouraged to submit video or other case material (anonymously) to maximize topical relevance for their individual practice and needs.
Objectives: Recognize and decrease the risk of complications in laparoendoscopic surgeries; Identify and discuss specific conditions affecting appropriate patient selection; Discuss indications, contraindications and limitations of MIS procedures and technologies; Understand relevant surgical anatomy and potential technical pitfalls; Develop management paradigms to prevent and treat complications; Describe the rationale and timing of conversion to open procedures.
Agenda:
• Introduction/Disastrous Case
• Detailed Anatomy of Selected Anatomic Sites Based on Audience Preconference Questionnaire
• Case videos and Discussions
• Selected Video Cases/Disasters/Highlights Selected by Faculty
FACULTY
Raymond J. Lanzafame, MD, MBA, Director
Carl J. Levinson, MD, Co-Director
Lawrence C. Biskin, MD
Ceana Nezhat, MD
Howard N. Winfield, MD
#2 Master’s Class in Laparoscopic Treatment of Adhesions for the
General Surgeon, Gynecologist, and Urologist Including Abdominal and
Pelvic Pain
Half-Day (1:00pm–4:30pm)
This Master’s Class for the advanced, experienced laparoscopist will demonstrate innovative laparoscopic techniques to enter the peritoneal cavity and release omental, small bowel, large bowel, and pelvic adhesions. The faculty will discuss the outer limits about these laparoscopic procedures, including major complication management. Closure of enterotomies by resection or simple suture and repair of ureter and bladder injuries will be addressed. Indications for surgery and prevention of the novo and recurrent adhesions will be discussed.
Objectives: To discuss the causes and frequency of adhesion related disorders (ARD) and whether or not symptoms possibly related to adhesions should be treated surgically or expectantly; To learn more about the role and availability of advanced laparoscopic techniques to release and reduce recurrence of peritoneal cavity adhesions; To describe laparoscopic techniques to excise endometriosis and adhesions involving the cul-de-sac and rectum; To learn the methods of laparoscopic and/or hand-assisted bowel repair or resection during enterolysis cases; To learn the treatment of adhesions found in conjunction with other laparoscopic abdominal surgery, i.e. at the time of Roux-en-Y gastric bypass, colon resection, Nissen fundoplication, hysterectomy, etc.
Agenda:
• Introduction and SCAR Study
• Why is the Surgical Treatment of Patients with Chronic Abdominal Pain from Intraabdominal Adhesions so Controversial?
• What Causes Adhesions? Do Adhesions Cause Pain?
• Abdominal and Pelvic Pain
• The Role of Laparoscopic Adhesiolysis and Adhesion Reduction Adjuvants in Gynecology and Infertility
• What About Acute Bowel Obstruction?
• Laparoscopic Entry Techniques After Multiple Laparotomies
• How Laparoscopy Effects the Peritoneum: Its Effect on Adhesion Formation and Methods of Reduction
• Laparoscopic Adhesiolysis—Surgical Plan and Techniques
• Deep Cul-De-Sac Dissection For Adhesions Involving Fibrotic Endometriosis, Including a Simple Technique to Repair Rectal Enterotomies
• Intraoperative Treatment of Bowel Injuries at the Time of Laparoscopy—Recognition, Repair, Resect, Hand-Assist, Open
• What’s Coming Next in Adhesiolysis and Adhesion Reduction Adjuvants
FACULTY
Harry Reich, MD, Director
Michael P. Diamond, MD, Co-Director
Maurice K. Chung, MD
Douglas E. Ott, MD, MBA
#3 Master’s Class • A Hands-On Course on Laparoscopic Suturing in the “Vertical Zone”
Full-Day (9:00am–4:30pm)
The algorithm for laparoscopic suturing as described in the “Vertical Zone” has been tested over many years nationally and internationally. Proficiency with intracorporeal knotting in less than 3 minutes has been achieved by over 80% of attendees in past courses. This includes practicing gynecologists, residents, and fellows. This result is also mirrored in international courses. Concurrent validity is excellent with the technique described, as the relative hand positions and movements are immediately transferable from the trainer to the O.R. That laparoscopic suturing is essential for today’s laparoscopies would be an understatement. This course equips all attendees with improved suturing skills and insight into applications during surgery.
Objectives: Understand ergonomics, theory and rationale for reproducible laparoscopic suturing; Applications of skills learned in relevant surgical situations; Prevention and management of bowel, bladder and ureteral complications by appropriate suture repair; Pre-test and post-test to demonstrate improvement in skills.
Agenda:
• Introduction, Orientation and Description of Lab Process
• Lecture: Ergonomics, Theory, Construct Validity of the Vertical Zone Technique
• Pretest: Intracorporeal Knot Tying
• LAB I: Drills, Intracorporeal Suturing with ‘Smiley’ needle technique
• Lecture: Expert Knotting, Continuous Suturing, Cinch Knot.
• Applications in surgery including Managing Complications by Suturing
• LAB II: Expert Knotting, Continuous, Cinch
• Posttest: Intracorporeal Knot Tying
FACULTY
Charles H. Koh, MD, Director
Randy Haluck, MD, Co-Director
Keith Issacson, MD
David M. Boruta, II, MD
Jeremy M. Carver, SA
Tommaso Falcone, MD
#4 Master’s Class in Robot-Assisted Laparoscopic Surgery Jointly with the Minimally Invasive Robotic Surgery Association (MIRA)
Half-Day (9:00am–2:45pm)
Leading practitioners in the fields of general, gynecologic, urological and vascular MIS will discuss their experiences with robot-assisted surgery. The advantages and disadvantages of robot-assisted vs. traditional MIS will be discussed and debated, as well as future applications of robotics for each surgical discipline. Gynecology topics will include general as well as fertility surgery. Urological sessions will include treatment of both benign and malignant urological conditions. General surgery topics will include foregut, colorectal, bariatric and vascular applications. Remote tele-presence surgery, remote physician-patient interaction by robot interface, and remote teleconferencing by robot over the internet will be discussed in detail. One presentation will be conducted via remote, transcontinental telepresence.
Objective: To increase participants’ knowledge and understanding of robotics and of the applications of robotics for minimally invasive surgery from the perspective of outstanding practitioners who were and are instrumental in developing and perfecting these techniques.
Participants will have the opportunity to participate in an afternoon laboratory session with a hands-on training session on simulation and metrics for assessing competency in laparoscopic surgery. This session will be included at no extra cost as part of the half-day Robotics PG course.
This course will be presented in cooperation between the Society of Laparoendoscopic Surgeons (SLS) and the Minimally Invasive Robotic Surgery Association (MIRA).
Agenda:
• Telerobotic General Surgery
• Telerobotic Colorectal Surgery
• Telerobotic Gyn Surgery
• MIRA Update
• Telerobotic Urologic Surgery
• Telerobotic Vascular and Cardiac Surgery
• Mobile Teleconferencing with a Robot Over the Internet
• The Future of Surgical Robotics
FACULTY
Santiago Horgan, MD, Director
William E. Kelley, Jr., MD, Co-Director
Garth Ballantyne, MD
Arnold Byer, MD
Tommaso Falcone, MD
Joseph Petelin, MD
Richard M. Satava, MD
Yulun Wang, PhD
Howard Winfield, MD
#5 Master’s Class • Hands-On Gynecologic Endoscopic Surgery Jointly with the American Association of Gynecologic Laparoscopists (AAGL)
Full-Day (9:00am–4:30pm)
This hands-on Master’s Class is designed for advanced gynecologic and other endoscopic surgeons who desire to expand and update their knowledge and surgical skills in diagnosis and endoscopic management of the most common gynecological and pelvic disorders. Also, it will serve to familiarize the participants with the most recent advancements in this discipline of surgery.
Faculty will present updated information on the most common pelvic disorders such as endometriosis, myomas, pelvic floor diseases, gynecologic malignancies, ovarian cysts, laparoscopic evaluation of chronic pelvic pain, etc. The role of laparoscopy in robotics, simulation, adhesion formation, and fertility will be discussed as well.
Indications, contraindications and different techniques for performing laparoscopic assisted vaginal hysterectomy (LAVH), total and supracervical laparoscopic hysterectomy will be presented. Gastrointestinal, urological and vascular complications during laparoscopic pelvic surgery will be discussed.
Time has been allotted in the program to rotate the participants through the Simulation Laboratory to provide hands-on experience with the simulation systems.
Objectives: To give participants up-to-date knowledge of the role of the laparoscope and hysteroscope for the management of pelvic disorders for the Advanced Gynecologic laparoscopist; To give participants the opportunity to practice hands-on with new available instrumentation.
Agenda:
• Safe Abdominal Entry Complications and Management
• Laparoscopy and Infertility: Is There Any Role?
• Role of Simulation in Advanced Operative Endoscopy
• Laparoscopy and Gynecological Malignancy: Where We Are and Where We Are Going
• Role of Laparoscopy in Hysterectomy: LAVH, TLH or Supracervical?
• Adhesion Prevention, Current and Upcoming Agents
• Update in Hysterectomy, Ablations and Sterilization Techniques
• How Can We Progress to Perform More and More Minimally Access Surgeries? Are Robots the Answer?
• Update in Energy Sources and Electrosurgery
• Pelvic Reconstructive Surgery and Prolapse: How to Match the Two Correctly
• Evaluation and Management of Bowel Injuries
• New Horizons in Myoma Management
• Urologic Complications and Management
• Hands-On Laboratory: New Instruments
FACULTY
Farr Nezhat, MD, Director
Ceana Nezhat, Co-Director
Andrew Brill, MD
Michael Diamond, MD
Tommaso Falcone, MD
Wm. Leroy Heinrichs, MD, PhD
William E. Kelley, Jr., MD
Timothy B. McKinney, MD, PhD
Camran Nezhat, MD
Steven F. Palter, MD
Harry Reich, MD
Howard Winfield, MD
Robert Zurawin, MD
#6 Master’s Class in Laparoscopic General Surgery Jointly with the Society of Gastrointestinal Endoscopic Surgeons (SAGES)
Full-Day (9:00am–4:30pm)
Leading practitioners in individual areas of general surgery will discuss advanced laparoscopic interventions and, in selected instances, will contrast open and laparoscopic approaches. Morning presentations will review NOTES (natural orifice transluminal endoscopic surgery); endoscopic and laparoscopic options for GERD; the right prosthetic for inguinal and ventral hernia repair; and laparoscopic management of complex and recurrent hiatal hernia.
The afternoon session will be devoted to cutting edge issues in general surgery covering such topics as: laparoscopic strategies for biliary tract disease; robotics and laparoscopic surgery; laparoscopic gastric banding/ laparoscopic bypass for bariatric patients, laparoscopic splenectomy and adrenalectomy; laparoscopic management of achalasia; laparoscopic management of benign and malignant colonic disease.
Objective: To increase participants’ knowledge of the following areas of minimally invasive surgery from the perspective of outstanding practitioners who were and are instrumental in developing and perfecting these techniques: (1) NOTES—natural orifice transluminal endoscopic surgery (pipedream or the future?); (2) inguinal and ventral hernia repair—the appropriate prosthetic; (3) endoscopic techniques available for GERD; (4) laparoscopic management of complex and recurrent hiatal hernia; (5) robotic technology in an era of laparoscopic surgery; (6) laparoscopic management of biliary tract disease; (7) laparoscopic management of adrenal and splenic disease; (8) laparoscopic management of colonic disease, benign and malignant.
Agenda:
• NOTES: Progress to Date
• Prosthetics for Hernia Repair—Choosing the Right Material and Techniques
• Endoscopic Treatment for Thyroid Disease
• Hiatal Hernia and GERD Management
• Achalasia—Best Options
• Robotics: What’s Hot, What’s Not
• Bariatric Surgery—Bypass or Band
• Laparoscopic Solid Organ Surgery—New Vistas
• Biliary Tract Surgery—The Tough Issues
• Laparoscopic Colon Surgery—Part I
• Laparoscopic Colon Surgery—Part II
FACULTY
Michael S. Kavic, MD, Director
W. Peter Geis, MD, Co-Director
Phillip P. Shadduck, MD, Co-Director
Titus Duncan, MD
Morris E. Franklin, Jr., MD
Santiago Horgan, MD
William E. Kelley, Jr., MD
Raymond J. Lanzafame, MD, MBA
Joseph B. Petelin, MD
Simulation Practice Center
Full-Day (8:00am–4:30pm)
Participants of Master’s Classes #3, #4, #5 and #6 will have the opportunity to practice their laparoscopic skills in the Simulation Laboratory. Time has been allotted in these classes to rotate participants through the Simulation Laboratory to provide hands-on experience with the simulation systems.
Participants of Master’s Class #3 - A Hands-On Course on Laparoscopic Suturing in the “Vertical Zone” will be pre- and post-tested using augmented and virtual reality simulation machines as part of the program. These simulators have embedded assessment metrics capable of measuring various aspects of the suturing task. Thus it will be possible to quantify the amount of skill improvement experienced by tested participants as a result of this Master’s Class.
This will be the first time that the value of a postgraduate course involving laparoscopic skills is measured with detailed objective means.
FACULTY
Faculty
Wm. Leroy Heinrichs, MD, PhD, Director
Harrith M. Hasson, MD, Co-Director
Jose Benito Abraham, MD
Geoffrey Box, MD
Shoma Datta, MD
Randy Haluck, MD
Radmila Kazanegra, MD
Madeleine Lemyre, MD
Ali Mahdavi, MD
Jaime Ocampo, MD
Naghmeh S. Saberi, MD
Mark L. Smith, MD, PhD
Maria Terry, MD
James Watson, MD
INVITED SIMULATOR COMPANIES:
Immersion Medical
Medical Education Technologies, Inc.
Mimic Technologies
National Biocomputation Center – Stanford – SUMMIT
Simbionix
Surgical Science
Verefi Technologies
MULTIDISCIPLINARY PLENARY SESSIONS
IMPROVING PRACTICE PERFORMANCE AND QUALITY
Thursday, September 6, 2007
8:30am–9:30am
Health care has seen a growing emphasis on Quality, Safety and Performance in recent years. There have been efforts by health care groups like the AMA and The Institute of Medicine to define quality in health care as, “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes that are consistent with current professional knowledge.” The delivery of high quality care has been centered on health outcomes and the expectations of patients and other customers of health care.
Quality, Safety and Performance are an integral part of the new culture of health care. Traditionally the blame has been placed on the individual for the lack of quality and safety that cause errors. The new culture of safety analyzes systems that are conducive to poor quality; system failures are identified as opportunities to improve safety and quality.
Pay for Performance systems link compensation to measures of work quality or goals. At the present time, Medicare pays providers for services delivered, regardless of the quality of care. Medicare has various Pay for Performance ("P4P") initiatives in offices, clinics and hospitals, seeking to improve quality and avoid unnecessary health care costs. The Centers for Medicare and Medicaid Services (CMS) have several demonstration projects underway offering compensation for improvements. There is no question that Pay for Performance is here to stay. The government, health insurance companies and other private organizations are actively developing Pay for Performance models. It is important for surgeons to learn and understand this system and its possible impact on their practices.
The new changes in health care have created financial pressures on hospitals. Previously lucrative surgical services are now facing financial challenges. The costs of materials and services continue to increase while the reimbursement for services has remained the same or in many cases has decreased. Many institutions have resorted to increasing their volume of patients, while others have tried to increase the number of lucrative cases. The institutions that have survived have implemented effective changes through improved processes to increase their efficiency and lower their costs.
FACULTY AND PRESENTATIONS
Gustavo Stringel, MD, Director
Alex Gandsas, MD, Co-Director
Gustavo Stringel, MD
Safety Quality and Improving Operating Room Performance
Alex Gandsas, MD
Pay for Performance and Transparency
Raymond J. Lanzafame, MD, MBA
Financial Aspects of Surgical Care: Past, Present and Future
HOW TO BRING A NEW SURGICAL IDEA TO THE BEDSIDE
Thursday, September 6, 2007
10:00am–11:00am
Physician innovators and researchers have made the world a better place. However, these experts by nature lack the experience and the know-how to bring an idea to reality. During this session, the renowned panel will address how to bring an idea to reality for the benefit of the patients. To bring an idea to fruition involves research, patent protection and business dimensions. This session will guide participants one step closer to bringing their dream of innovation to reality for the benefit of mankind.
FACULTY AND PRESENTATIONS
Camran Nezhat, MD, Director
Thomas Fogarty, MD
Mike Henson, MD
Fred Moll, MD
John Savarese, MD
NEW DIRECTIONS IN SIMULATION TRAINING AND CREDENTIALING
Thursday, September 6, 2007
11:00am–12:00pm
The American College of Surgeons (ACS) has taken a bold new step in surgical education by agreeing to become a certifying body for new training centers, referred to as ACS Certified Educational Institutes. This new model will help to ensure the quality of education as well as help to standardize training methodologies, which should serve as an inspiration for other major societies (such as Urology, OB/Gyn, Cardiothoracic, etc.) to follow. This session will summarize the role of the centers, the application process (and the dos and don'ts of applying) and the new consortium of training centers which will begin the process of standardization of training.
FACULTY AND PRESENTATIONS
Harrith M. Hasson, MD, Director
Richard M. Satava, MD, Co-Director
Ajit Sachdeva, MD
The ACS Accredited Educational Institutes–The Beginning of the Revolution of Certification of Training Centers
Mika Sinanan, MD
Applying for Certification–Do’s and Don’ts
Richard M. Satava, MD
The Consortium of ACS Accredited Educational Institutes–One Solution to Standardization
NEXT GENERATION NEW TECHNOLOGIES FOR THE LAPAROENDOSCOPIC SURGEON
Friday, September 7, 2007
7:30am–8:30am
Surgeons are always looking for the next new technology to add to their practice. This session will focus on updating this armamentarium. Some are practical and can be added today, such as Ablation and new gynecologic procedures, while others are still in the research phase, such as miniature intra-abdominal robots and remote telesurgery.
FACULTY AND PRESENTATIONS
Richard M. Satava, MD, Director
Alex Gandsas, MD, Co-Director
Timothy Broderick, MD
Telesurgery with a UAV
Jaime Landman, MD
Ablative Technology
Farr Nezhat, MD
Gynecology Technology
Dmitry Oleynikov, MD
General Surgery Technology
HOTEL ACCOMMODATIONS AND MEETING SITE
Hyatt Regency San Francisco
5 Embarcadero Center
San Francisco, California 94111
USA
Reservations
Toll Free within USA: 1-800-720-0049
Tel: 1-415 788-1234
Fax: 1-415-398-2567
www.sanfranciscohyattregency.com
Overlooking the pristine Bay and its dynamic neighborhood, the Hyatt Regency San Francisco is the only luxury hotel directly on the Embarcadero waterfront. This gleaming choice of downtown San Francisco California hotels showcases a captivating array of shopping, dining, and sightseeing adventures. Hallmark features of our downtown San Francisco hotel accommodations include 802 rooms and suites featuring Hyatt’s Grand Bed, and a revolving rooftop restaurant and lounge. Immerse yourself in the culture, energy, and majestic beauty of "Everyone’s Favorite City" at our luxury hotel in downtown San Francisco, California.
Hotel Rates (USD per night)
Single $175.00; Double $195.00; Triple $213.00; and Quad $238.00
These rates are subject to appropriate state, local and occupancy taxes and do not include meals. The SLS room block will be released after August 3, 2007. After this date, rooms will be on a space available basis only. Rates are applicable 3 days before and after the conference based on availability.
In order to qualify for the special rate, you must make reservations by August 3, 2007, and mention that you are attending the “SLS conference.”
Please make reservations early!
16TH ANNUAL MEETING AND ENDO EXPO 2007 SCIENTIFIC ABSTRACTS
7101 General Surgery
An Uncommon Situation of Massive Hematemesis: A Really Strange Situation
Jose M.M. Ferreira-Coelho
Introduction: The treatment procedures for patients with malignant biliary obstruction are challenging, with strategies involved for all specialists.
Case Report: The patient was a 63-year-old male with a chronic severe narrowed distal common duct without a diagnosis of cancer as the cause. Four successive renewable plastic stents in the lower biliary tract and finally a self-expanding metal stent (SEMS) were deployed. Four months later, the patient experienced 2 episodes of severe hemorrhagic shock. Upper gastrointestinal endoscopy revealed severe hemobilia. Open “life saving” surgery was performed by using sphincterotomy. The distal part of the metal stent was removed by stripping and the proximal part by a hepatico incision. The perfect metal stent was removed. The technique of repair was Roux-en-Y-loop hepatico-jejunostomy.
Results: The pathologic analysis of the specimen showed an invasive cholangiocarcinoma of the terminal bile duct. The patient remained clinically stable after complementary radiotherapy planned for a 5-month period, but he died 2 months later with severe caquexia.
Discussion: The cost effectiveness analysis for treatment of stent occlusion for plastic stents (TT) versus metal stents (SEMS) indicates that SEMS have better patency rates than TT stents do.
Conclusion: It is very important to be aware of the vascular anatomy of the main biliary duct with specific angiographic and micro-angiographic patterns with a strange metal stent in place. Fistulas and hemorrhages are potential occurrences to keep in mind.
7102 General Surgery
Laparoscopic vs Open Colectomy for Nonmetastatic Colorectal Cancer: A Prospective Study of Long-term Survival
Mirza MS, Longman RJ, Farrokhyar F, Sheffield JP, Kennedy RH
Introduction: Long-term data on the safety and efficacy of minimally invasive surgery for treating colorectal cancer remain scarce. We conducted a nonrandomized, prospective comparison of laparoscopic colorectal cancer surgery (LS) with open surgery (OS) to evaluate long-term survival.
Methods: Patients (n=233) with nonmetastatic colorectal cancer underwent either laparoscopic (n=116) or open (n=117) potentially curative resection. Almost all patients between July 1996 and December 2002 were randomized within 2 consecutive trials; however, before this a significant proportion of patients received open surgery. The primary end points were overall survival, disease-free survival, and cumulative disease recurrence. Analysis was by intention to treat.
Results: Median follow-up was 40 months for the LS and 58 months for the OS group. No statistically significant difference was found between LS and OS groups regarding overall survival (P=0.603 colon cancer, P=0.841 rectal cancer), disease-free survival (P=0.684 colon cancer, P=0.625 rectal cancer), and overall recurrence (P=0.383 colon cancer, p=0.166 rectal cancer). Cumulative recurrence rate in colon cancer favored OS (P=0.018). In rectal cancer, this did not differ between the 2 treatment modalities (P=0.965). Perioperative mortality in LS was also no different from that in OS (P=0.644 30-day mortality, P=0.692 in-hospital mortality).
Conclusion: Long-term survival data support laparoscopic surgery as a safe and effective alternative to conventional surgery for treating potentially curative colorectal cancer.
7104 Gynecology
Laparoscopic Management of Benign Pelvic Masses
Alberto Valero, Prof Dr Med; Eduardo Torreblanca, Martin Castillo, Edith Cervantes, Rafael Solano
Incidence: Benign ovarian tumors are most common in women between 20 and 44 years of age. Malignant tumors occur most frequently in women between 45 and 60 years of age. Benign pelvic masses are cysts, semisolid, solid, and hemorrhagic lesions, which could be congenital in origin, neoformations, from ectopic tissues, or benign and malignant masses. Their volume depends on their histological root and on the elapsed time.
Symptoms: The most common symptoms are dyspareunia, dysmenorrhea, polymenorrhea, abdominal distension, infertility, bowel malfunction, and urine troubles. Tumor characteristics are determined by looking at direct mechanical influence (compression of the surrounding organs), blockage of the “cul de sac” by tumor growth, bleeding activation of macrophages, activation of cytokines, and immune system resistance. Ovarian tumors sometimes are complicated by torsion, rupture, bleeding, infection, malignant transformation with ascites, anemia fibrinogen changes, and others. The histological classifications of epithelial ovarian tumors are serous, mucinous, endometrioid, mesonephroid (clear cels), Brenner, mixed, undifferentiated carcinomas, unclassified tumors. The highest incidence of malignant ovarian tumors is in Scandinavian countries and North America, as much as 15 per 1,000,000. The next highest rates occur in central and east Europe and the lowest rates are in Asia, with the least rates in Japan of 5 per 1,000,000.
Diagnosis: Manual delimitation by palpation, hyperpolymenorrhea associated with normocytic and normochromic anemia, elevated serum levels of erythropoietin, tumoral blood markers CA 125, carcinoembryonic antigen, and hCG levels. Abdominal plain films reveal the mass; HSG reveals deformation of the uterine cavity; urography splits the ureters by the mass; and barium enema reveals external compression; abdominal or vaginal sonography reveals cystic, semicystic or solid tumors; Doppler shows neoformation vessels; and finally MRI reveals masses of ≥1cm in diameter. Endoscopic diagnosis and treatment procedures (hysteroscopy & laparoscopy) are the best management tools and can rule out any close organs dysfunction, such as in the ovary, rectum, endometrial dysfunction, pelvic abscess, endometriomas, malignant disease, mesonephric remnants, bladder disease, pregnancy, hyperstimulation syndrome control, pelvic congestion (Taylor syndrome).
Management: Expectant management depends on age, tumor size, symptoms, and pregnancy status. Conservative management is medical (6 weeks before surgery using a goserelin acetate 3.65-mg subdermal implant). Postoperative management depends on the type of pelvic mass (myomas, luteal cyst, endometriomas) and could comprise endocrine inhibition with <30 pg of estradiol E2. Corrective management includes endoscopic, reconstructive, and laparotomy approaches. Treatment can include neurovegetative support, psychoemotional swings, hormonal replacement therapy to avoid bone loss, and painkillers.
7105 General Surgery
Laparoscopic Resection of Osler-Weber-Rendu Lesion
John Park MD, Brian Ellis MD, Christopher Juergens MD
Introduction: Osler-Weber-Rendu (OWR) is a hereditary disease characterized by telangiectasias, arteriovenous malformations (AVM), and aneurysms involving the cutaneous, gastrointestinal, pulmonary, and central nervous systems. OWR is treated endoscopically with electrocautery and pulse dye laser to destroy cutaneous and accessible mucosal lesions. This report describes a combinatorial approach using laparoscopic and intraoperative endoscopy to perform a partial gastric resection of a bleeding AVM.
Case Report: A 70-year-old Caucasian female with a history of bleeding from OWR disease presented complaining of hematemesis. Her vital signs were unstable and she was immediately resuscitated with IV fluids and transfusions. She had previous hospitalizations requiring transfusions and electrocauterizations of her gastric AVM, but had refused surgery until this point.
Results: Intraoperatively, a single lesion was identified along the posterior aspect of the greater curvature of the stomach by using intraoperative endoscopy. Surgical resection margins were identified with metallic clips along the greater curvature of the stomach proximal and distal to the lesion. This allowed the gastric resection to be minimized as much as possible. The blood supply was taken down with a LigaSure and gastric resection with a 60-mm Echelon stapler. Pathology report confirmed the complete resection of the AVM. Patient was discharged home several days later without any complaints.
Conclusion: Little is written about the medical treatment of Osler-Weber-Rendu AVM, let alone surgical treatment. The traditional open approach to gastric resection is established. However, a combinatorial laparoscopic and intraoperative endoscopic approach to gastric resection allows both minimization of the gastric resection and the complete identification and removal of the arteriovenous malformations.
7106 Gynecology
New Technical Developments of Breast Ductoscopy and its Future Perspective
Volker R. Jacobs, MD, PhD, MBA, Stefan Paepke, MD, PhD, Marion Kiechle-Bahat, MD, PhD
Objective: Endoscopy of the female breast, known as ductoscopy, is gaining increasing acceptance as a diagnostic procedure worldwide. The recent technical development of ductoscopes and related micro-instruments is shifting research interest from diagnostic to interventional ductoscopy, which is at present experimental surgery. We describe novel technical developments and a resulting possible future perspective of ductoscopy.
Method: We performed an analysis and review of new technical developments of breast ductoscopy from research and clinical evaluation at the Technical University in Munich, Germany, plus review MEDLINE for the key word ductoscopy.
Results: Only 64 papers with the key word ductoscopy are currently listed in MEDLINE, confirming that this is a rather new endoscopic technique. Purely diagnostic ductoscopy is performed by a larger number of breast physicians worldwide on all continents. Interventional ductoscopy, however, depends on a working channel and a variety of micro-instruments for procedures inside the breast ducts. They are at the present time not available in the US, but are used in Germany and several other countries. Autofluorescence ductoscopy is a new imaging technique being used on an experimental basis for clinical evaluation to identify intraductal lesions and possibly allowing visual semi-quantitative histological evaluation. Laser ductoscopy for removal of intraductal papillomas and 3-dimensional intraductal tracking systems are in development.
Conclusion: Technical development and further miniaturization of instruments is supporting the current change from diagnostic to interventional ductoscopy. This therapeutic intraductal approach combined with autofluorescence endoscopy could eliminate unnecessary biopsies and offer better identification of intraductal lesions. Further technical miniaturization, laser ductoscopy and 3-dimensional tracking systems are intended future developments.
7107 General Surgery
Early Experiences with Laparoscopic-assisted Colectomy for Colon Cancer
Barnard Palmer, MD, C. K. Chang, MD, Samuel Liu, MD, Rockson C. Liu, MD
Background: With multiple randomized trials showing equivalence of laparoscopic and open colectomies, the demand for centers to perform laparoscopic-assisted colectomies (LAC) will rise. Surgeons currently in practice will need to acquire appropriate advanced laparoscopic skills for these technically demanding operations. Our goal was to evaluate the early experiences of surgeons performing LAC for cancer at a single HMO.
Methods: We retrospectively reviewed 37 LAC for colon carcinoma performed at a single institution over a 3-year period. Included patients had isolated, nonrecurrent, nonmetastatic lesions limited to the right or left colon. Of the 7 surgeons, only 2 completed fellowship training (colorectal or advanced laparoscopy). Most surgeons had previously attended hands-on LAC courses. All cases were performed with 2 surgeons interested in LAC.
Results: Mean age was 65.5 years with an average ASA of 2.4. Most had stage 2 disease with tumor diameter averaging 3.3cm. Mean operative time was 185 minutes with an average use of 3.3 ports and an EBL of 97.1mL. Specimens averaged 18.4cm in length and contained an average of 13.4 nodes. All specimens had negative margins. Average times to flatus and discharge were 3.1 and 5.9 days, respectively. The conversion rate was 10.8%. Three patients had reoperations (8.1%), 2 for bleeding and 1 for wound dehiscence. One death (2.7%) occurred due to a massive pulmonary embolus.
Conclusions: The required skills to safely and successfully perform LAC can be learned in an HMO setting by collaboration amongst surgeons of varied laparoscopic abilities and training background.
7108 Urology
SutureLock: Adjustable Laparoscopic Knotting Clip
Keith L. Lee, Benjamin N. Breyer, David Aaronson, Marshall L. Stoller
Introduction and Objective: Laparoscopic intracorporeal knot tying can be technically challenging and time consuming. Many knots need adjustment to set appropriate tension to optimize tissue apposition. The SutureLock clip is a new adjustable device that can fit through a 5-mm port and does not require special applicators or a second clip to hold tissue. We introduce this device and illustrate its tensile strength and application in a porcine model.
Methods: The SutureLock was designed to work with braided sutures and allow for tightening and loosening after deployment. To test this device, a loop of suture was brought through the unilateral locking-teeth. Tensile strength of this “knot” was tested with a 100-Newton load cell. In addition, we mounted a SutureLock on a 2-0 Vicryl suture and loaded it on 5 successive cycles of tightening and loosening to determine whether the device could weaken suture material as the suture was brought in and out of the locking-teeth. Finally, the clip was tested in a porcine partial nephrectomy model.
Results: Repetitive loading after 5 successful cycles surpassed FDA requirements and did not weaken the clip or suture. In the porcine model, the clip was deployed using 2 needle drivers. Tension was easily adjusted after initial device deployment optimizing
hemostasis.
Conclusions: The adjustable SutureLock can eliminate intracorporeal error-knots and optimize tissue apposition. This versatile device does not require special applicators, and can save valuable time from not having to exchange instruments between sewing and knotting.
7109 General Surgery
Sentinel Node Biopsy (SNB) and Extracapsular Extension of the Surgical Treatment of Breast Cancer
Maksimovic Sinisa
Introduction: The aim of this study was to identify predictors of nonsentinel node (NSN) tumor involvement in patients with a tumor-involved sentinel node.
Methods: Between March 1996 and December 2006, 401 patients with clinical T1 or T2 breast cancer underwent LM/SL using a combined blue dye and technetium sulfur colloid technique at General Hospital Bijeljina. In all cases with a tumor-involved SN, axillary lymph node dissection (ALND) was recommended. Statistical analysis, with Pearson, Fisher test, and multiple logistic regressions, was performed.
Results: The SN contained tumor in 132 (33%) patients. ALND was performed in 123 of the 132 patients. ECE of the SN metastasis was present in 35 (28, 4%) of the 123 patients. Patients with ECE of the SN metastasis were more likely to have NSN tumor involvement and had a greater total number of tumor-involved nodes than patients without ECE of the SN metastasis. Increasing size of the SN metastasis and increasing size of the primary tumor, examined as continuous variables, were associated with an increased likelihood of NSN tumor involvement on univariate analysis. However, only ECE of the SN metastasis was associated with NSN tumor involvement on multivariate analysis.
Conclusion: These findings provide further confirmation of the validity of SNB and prompt us to suggest that it should become the method of choice for axillary staging in breast cancer. ECE of the SN metastasis is a strong predictor of NSN tumor involvement.
7110 General Surgery
Laparoscopic Evaluation for Chronic Postoperative Abdominal Pain
Amir Vejdan, MD
Background: Nearly 1500 open laparotomies are performed in our ward each year. Approximately 20% of patients have had chronic postprandial abdominal pain for months after surgery. One half of them have sought treatment. Most surgeons are afraid of reoperation in this condition, and perform conservative treatment with analgesics and sedatives. This study evaluates the cause of this chronic abdominal pain with diagnostic and therapeutic laparoscopic surgery.
Methods: Elective laparoscopic surgery was performed in 76 patients with chronic abdominal pain, mostly after a heavy meal. They did not have any signs and symptoms of acute intestinal obstruction, and the most popular complaints were abdominal pain in 100%, nausea in 30%, vomiting in 10%. Less common symptoms were also present. Diagnostic laparoscopy was performed with positive findings in 81% of patients. At the time of surgery, treatment modalities were performed.
Results: In 81% of patients, the cause of pain was obvious intestinal adhesions. Of the rest, 10% had adhesions without any correlation with the patient's symptoms, and the remaining 9% did not have any positive findings on the diagnostic laparoscopy. Adhesiolysis (sharp release with scissor) is the treatment of choice. Of those patients who underwent adhesiolysis, 95% became pain free for a mean average of 11 months follow-up (preoperative average of pain episode was 4 times per week).
Conclusion: Laparoscopic diagnosis and treatment of chronic postlaparotomy pain is the gold standard with minimal invasion to the patients and good results. General surgeons should not fear performing a diagnostic laparoscopy in such circumstances.
7113 Multispecialty
Minilaparoscopy: As A Safer Entry For Natural Orifice Peritoneoscopy
Daniel A. Tsin, MD
Objective: To present a safer placement of the operative ports in Natural Orifice Translumenal Endoscopic Surgery (NOTES) using Minilaparoscopy Assisted Natural Orifice Surgery (MANOS) approach.
Method: Patients were under general anesthesia in a modified dorsolithotomy position. Minilaparoscopy was done to observe whether additional ports could be added if necessary. The vaginal port was placed similar to the port placement in culdoscopy or was facilitated with an incision in the Pouch of Douglas. Our experience in transgastric NOTES is limited to simulators.
Results: We had a successful clinical experience in more than 100 cases of transvaginal MANOS. Simulator experience suggests a beneficial synergy for transgastric NOTES.
Conclusions: Minilaparoscopy has proven to be safe, and in most cases leaving no visible scars. The insertion of the vaginal port into the Pouch of Douglas is done under minilaparoscopic control to avoid the potential risk of blind entrance. It may take several years for NOTES transgastric or transvaginal to become standard. Meanwhile, MANOS could encourage, facilitate, and expedite this process that gives the safety of minilaparoscopy surveillance.
7114 Urology
Laparoscopic Removal of a Twelve-centimeter Adrenal Cyst
A. D. Smith, A. J. Berman, C. Dinlenc
Objective: Laparoscopy is considered the standard of care of the majority of adrenal masses <8cm. Surgical indications for laparoscopic removal of adrenal cysts include abdominal pain and cyst size ≥5cm. Techniques described include cyst decortication and marsupialization, laparoscopic partial adrenalectomy, and laparoscopic adrenalectomy. We present the first reported case of using the technique of cyst aspiration to remove an intact large adrenal cyst via standard laparoscopy.
Methods: A 29-year-old women presented with left flank pain for one year. CT and MRI confirmed the presence of a 12-cm left adrenal cyst. Urine and metabolic panels were normal. A standard laparoscopic approach was used with a 10-mm camera port and two 5-mm working ports. The cystic adrenal mass was completely mobilized, placed in an Endocatch bag, and delivered to the 10-mm port site where the bag was secured in place. The cyst was then completely aspirated with content sent for cytology; this made possible the easy removal of the specimen via the 10-mm port site.
Results: The patient was discharged within 24 hours. The aspirated cyst contents revealed numerous inflammatory cells and cholesterol. The adrenal tissue was unremarkable.
Conclusion: This was the first reported case, as far as we know, to utilize the technique of cyst aspiration to remove a large intact adrenal mass with standard laparoscopy.
7115 Gynecology
The Advantages of Mini-laparoscopic Surgery Compared with Conventional Laparoscopic Surgery for Early-stage Endometriosis
Sung-Tack Oh, MD, PhD, Yong-Taik Lim, MD, PhD, Young-Min Choi, MD, PhD, Jun-Yong Hur, MD, PhD, Byung-Seok Lee, MD, PhD
Objective: Although laparoscopy is essential for confirmation of endometriosis, sometimes it is avoided due to its invasiveness. Mini-laparoscopy is less invasive than conventional laparoscopy is, and it is a simple surgical procedure. This study was done to evaluate the usefulness of mini-laparoscopy for managing patients with early-stage pelvic endometriosis.
Methods: This prospective, randomized study included 54 patients with early-stage pelvic endometriosis. The mini-laparoscopies were performed in 24 patients (Group A), and conventional laparoscopies were performed in 30 patients (Group B). All laparoscopies were performed with the patient under general anesthesia. The 54 (Group A and B) patients underwent monopolar or bipolar fulguration of lesions. Seven Group A and 9 Group B patients with pelvic adhesions received lysis of adhesions. Four Group A and 5 Group B women received laparoscopic uterosacral nerve ablation (LUNA). The postoperative pain score of each patient was estimated by visual analog scale (VAS). The statistical analysis was done with the Student t test and the Fisher exact test.
Results: The procedures were performed satisfactorily in all patients in both groups without any difficulty. However, in 18 (24%) Group A patients, a skillful doctor was necessary due to weak illumination of the scope. There was no significant difference in operating time, average operating room costs, average ancillary department costs, instrument and supply costs, or length of hospital stay. Postoperative pain was significantly less in Group A than in Group B (VAS 1.4±1.2 vs. 4.8±2.3; P<0.01), and patients requiring analgesia were fewer in Group A than in Group B (1/24 vs. 10/30; P<0.01). Satisfaction with the surgical scar was greater in Group A than in Group B (24/24 vs. 10/30; P<0.01). No postoperative complications occurred in either group.
Conclusions: The success rate of the simple mini-laparoscopy surgical procedures does not differ from the success rate of conventional laparoscopy, but acceptability and satisfaction of patients were greater with mini-laparoscopy and postoperative pain was less. Therefore, mini-laparoscopy seems to be better than conventional laparoscopy for managing patients with suspected early-stage pelvic endometriosis.
7116 General Surgery
Laparoscopic Total Colectomy and Ileorectal Anastomosis for Colon Cancer
Joseph W. Nunoo-Mensah, FRCS (Eng), Robert Rush, MD, Tonia Young-Fadok, MD, MS
Colorectal cancer diagnosed in young patients below the age of 50 is more likely to be hereditary and associated with polyposis (eg, familial adenomatous polyposis) or hereditary nonpolyposis colorectal cancer (HNPCC) syndromes. When colorectal cancer is diagnosed in a patient with HNPCC, the question arises as to whether the patient will benefit from an extended resection, ie, total colectomy or restorative proctocolectomy, because a high risk of metachronous colorectal cancer exists if the tumor is resected by a partial colectomy.
We show video of a 36-year-old female who presented with a near obstructing sigmoid carcinoma who opted for a laparoscopic total colectomy and ileorectal anastomosis to reduce her chances of metachronous colorectal cancer and to allow regular, simple outpatient sigmoidoscopy surveillance of the rectum.
7117 Gynecology
Painful Bladder Syndrome/Interstitial Cystitis in Patients with Abdominal and Pelvic Adhesion
Maurice K. Chung, RPh, MD, Jackie S. Shriver, NP, Jamie Masteller, MA, Rhonda Medina, MD, Jennifer Glance DO
Objective: To demonstrate the incidence of painful bladder syndrome/interstitial cystitis in patients with low abdominal pelvic adhesion.
Methods: At the Midwest Regional Center for Pelvic Pain and Bladder Control, we analyzed the incidence of painful bladder syndrome/interstitial cystitis in 105 prospective consecutive cases of major laparoendoscopic surgery in patients with a previous abdominal pelvic surgery.
Results: Of 105 patients with a history of previous abdominal pelvic surgery, 52 (49.5%) adhesion were found during surgery. In only 13 patients (25%) did problems occur for the surgeons during the initial trocar entry. There were no bowel injuries. Of the 52 patients with a diagnosis of adhesion, 27 (51.9%) had pelvic pain. All 27 patients underwent a potassium sensitivity test (PST). Of these, 20 patients (74%) had a positive PST, and 7 had a negative PST. In the negative group, 2 patients showed glomerulation during cystoscopic hydrodistention, indicative of painful bladder syndrome.
Conclusion: We found that the incidence of painful bladder syndrome/interstitial cystitis was very high (74%) in the group with a positive PST and an additional 7.4% had hydrodistention in this study group. It is imperative to evaluate the painful bladder syndrome before performing any invasive diagnostic procedure. After all, it was the interstitial cystitis that caused the pain. The presence of adhesion may just simply be coincidental.
7118 Gynecology
Laparoscopic-assisted Myomectomy
Mario Nutis, MD, Jaime Ocampo, MD, Camran Nezhat, MD, Ceana Nezhat, MD, Farr Nezhat, MD
In this video, we demonstrate the role of laparoscopic-assisted myomectomy (LAM) in large fibroid uteri. Nezhat et al presented this technique in 1994 for the first time.
Laparoscopic-assisted myomectomy is advocated as a technique that may decrease the prolonged time of anesthesia, blood loss, and possibly risk of postoperative adhesion formation while retaining the benefits of laparoscopic surgery, including, shorter hospital stay, lower costs, and rapid recovery.
Technically, LAM is less difficult than a purely laparoscopic procedure, considerably decreasing operative times. Therefore, LAM may be widely offered to patients with large fibroid uteri who otherwise would only be candidates for laparotomy. This video illustrates the technique on a patient with a 20-week size uterus and multiple subserosal and intramural myomas.
7119 General Surgery
Does the Rate of Achieving Competency on Simulated Laparoscopy Training Programs Predict Actual Skill in Performing Laparoscopic Cholecystectomy?
Warren D. Widmann, MD, Mark A. Hardy, MD, Nancy J. Hogle, MS, Dennis L. Fowler, MD
Objective: To evaluate whether the speed of acquiring competency on computer simulation laparoscopy programs is predictive of actual skill in performing a laparoscopic cholecystectomy.
Methods: Ten PGY1 surgical residents performed laparoscopic cholecystectomies in pigs before and after training to criteria on the LapSim program. Their performance on the pre- and posttraining operations was rated by skilled laparoscopic surgeons using a standardized assessment tool, Global Operative Assessment of Laparoscopic Skills. The length of time required to achieve competency on the LapSim training modules was recorded.
Results: Before training, the residents scored an average of 2.2/5 in the performance of a laparoscopic cholecystectomy; after training the average was 2.7/5. All but 3 (70%) improved their scores after the training. The average score on the final laparoscopic cholecystectomy was 3.2 for the residents with the 3 shortest learning times, while the average score of those with the 3 longest learning times was 2.5.
Discussion/Conclusion: This study shows that the residents with faster acquisition of competency on computer simulation training programs for laparoscopic surgery performed better when actually performing a laparoscopic cholecystectomy than their peers did who also achieved competency on the simulation training program but took longer to do so. Additional time training on the computer may not be the best means for the slow learners to improve, and we will study whether box training or other means may be better suited to their needs.
7120 Gynecology
Laparoscopic Amputation of a Noncommunicating Uterine Horn
Jaime Ocampo, MD, Mario Nutis, MD, Camran Nezhat, MD, Farr Nezhat, MD, Ceana Nezhat, MD
Objective: To demonstrate the laparoscopic management of a noncommunicating rudimentary uterine horn.
Methods: We performed hysteroscopic evaluation to assess the uterine cavity followed by an operative laparoscopy detailing the complete resection of a noncommunicating rudimentary uterine horn. A subsequent cystoscopy was also performed to assess correct implantation of the ureters.
Results: A 13-year-old female presented with onset of dysmenorrhea and pelvic pain since menarche 6 months before our consultation. Initial ultrasound evaluation showed a right adnexal mass. A subsequent diagnostic laparoscopy showed a pelvic mass completely separate from the right adnexa. We performed a second operative laparoscopy and found a pelvic mass consistent with a noncommunicating rudimentary uterine horn. The right adnexa had a normal ovary but poorly formed fallopian tube. The left ovary and tube were normal. This video demonstrates the laparoscopic management of a noncommunicating rudimentary uterine horn.
Conclusion: Management of congenital uterine anomalies is feasible by laparoscopy.
7121 Gynecology
The Hidden Risk of Natural Herbs in Gynecological Surgery
Mark Erian, FRCOG, FRANZCOG, MD, Glenda McLaren, FRCOG, FRANZCOG
Objective: To identify and highlight the hidden risk of natural therapies, that is, self-prescribed “over the counter” medications, and their impact on excessive bleeding in gynecological surgery.
Methods: This study was done at the Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia, which is the largest tertiary referral center in the Southern Hemisphere. This presentation depicts a case of straightforward vaginal hysterectomy, with no known preceding risk factors. The patient denied taking any preoperative medications. She experienced heavy postoperative peritoneal bleeding and underwent operative laparoscopy and 2 successive laparotomies to control her ongoing bleeding. The patient was admitted to the intensive care unit where she confessed to the use of excessive oral raw garlic and garlic extracts up to and including the last meal 6 hours before surgery. A review of the international literature regarding this topic will be presented.
Conclusion: Excessive preoperative intake of natural herbs, such as raw garlic/garlic extracts, has to be outlined in a patient information leaflet. This became a policy in many surgical units in Australia following the above-mentioned episode.
7122 General Surgery
Metaanalysis of Recurrence After Laparoscopic Repair of Paraesophageal Hernia
Munir A. Rathore (FRCS), Muzahir Najfi (FRCS), Arthur McMurray (FRCS)
Introduction: Recurrence and reflux are 2 of the most important remote complications of lap-PEH repair. However, the extent of recurrence remains unknown. We sought to determine the true incidence of recurrence after lap-PEH repair.
Methods: A metaanalysis was carried out. PubMed, Medline, Embase, Cochrane Library, and a hand search were used to access and appraise studies. The inclusion criteria were full-text papers published from 1991 to date describing lap-PEH repair on >25 patients, at least 6-month follow-up, and addressing the issue of recurrence. “Wrap migration” papers were excluded. Papers were appraised, and the data were isolated on summary sheets. MS Office Excel 2003 was used to plot the results and represent results in graphs.
Results: Thirteen studies were eligible (all retrospective case series). A total of 965 patients with 99 recurrences were noted. The overall recurrence rate (in all pts) was 10.25% and was 13.98% if only the followed-up patients (n=658/965) were considered. When patients with objective evidence (follow-up BA esophagogram) were used (301/965), the “true” recurrence rate was 25.58% (ie, 1 in 4 repairs recurred). The learning curve did not appear to be an issue (P=0.1941). The studies revealed broad 95ci and touching the line-of-no-effect, thereby increasing the “chance factor.” When an alternate model was applied, esophageal lengthening (Collis-Nissen) revealed a significant protective influence (P=0.0185).
Conclusion: The true incidence of lap-PEH recurrence is 25.58%. Learning curve is not an adequate explanation. Mandatory (protocol) follow-up esophagograms at 1 year are essential. Two emphasis points in the repair have emerged–hiatoplasty and (superadded) esophageal lengthening (250w).
7123 General Surgery
Laparoscopic Cholecystectomy: Our Experiences After 2000 Patients
Maksimovic Sinisa, PhD, MD
Objective: The aim of this study was to analyze our experience after 2000 laparoscopic cholecystectomies (LC).
Methods: Two thousand patients who underwent LC during a 10-year period (January 1997 to December 2006) were analyzed. There were 456 (22.8%) males and 1544 (77.1%) females. The median age was 56 years (range, 14 to 95), and 61.2% were less than 64 years old, 29.8% were 65 to 74, and 9% were over 75.
Results: The operation was completed laparoscopically in 96.7% of the patients, whilst 64 (3.2%) cases were converted to open surgery. The reason for conversion was the inability to perform a safe dissection in Calot’s triangle due to poor local conditions. Acute inflammation of the gallbladder was found in 31%, empyema in 29%, hydrops in 21%, gangrene in 14%, pericholecystic fluid collection in 5%. In 146 patients, LC was performed after endoscopic papillosphincterotomy. There were 3 (0.15%) common bile duct injuries. The mean duration of the procedure declined during the 10-year period from 90 minutes to 26 minutes. The mean postoperative hospital stay was 2 days. One death occurred in the 1-month period after the procedure.
Conclusion: LC seems to be the gold standard for treatment of cholelithiasis. Further improvement in outcome can be expected from the progress of instrumentation rather than the increased experience of the surgeons.
7125 Gynecology
Incisional Hernia on the Trocar Port Site After Laparoscopy: Prevention, Recognition and Management
Camran Nezhat, MD, Jaime Ocampo, MD, Mario Nutis, MD, Farr Nezhat, MD, Ceana Nezhat, MD
Objective: To demonstrate the laparoscopic management of an incisional hernia on the trocar port site after laparoscopy.
Methods: Laparoscopic evaluation to assess the presence of an incisional hernia after robotic-assisted laparoscopy detailing the complete management.
Results: A 50-year-old female presented with onset of pelvic pain and left lower extremity swelling 6 months before our consultation. Initial ultrasound evaluation showed a fibroid uterus. We performed a robotic-assisted hysterectomy and found a 5-cm fundal uterine fibroid. This video demonstrates early recognition, prevention, and laparoscopic management of a port-site incisional hernia.
Conclusion: Management of a port-site incisional hernia is feasible by laparoscopy.
7126 Multispecialty
Experimental Studies of Peroral Transgastric Abdominal Surgery: Tubectomy, Hysterectomy. Is It the Next Minimally Invasive Approach?
Stefanos Chandakas, MD, MBA, PhD, Chris Feretis, MD
Introduction: Incisionless endoscopic peroral approach to the peritoneal cavity in experimental animals shows promise as a less invasive form of surgery. The aim of this study was to demonstrate the feasibility and safety of peroral transgastric procedures with a 4-week to 6-week survival.
Methods: The procedures were performed on ten 28kg to 50kg anesthetized pigs by using a sterilized double-channel endoscope. The gastric cavity was irrigated with antibiotic solution, and access to the peritoneal cavity was gained after a stomach wall incision with needle knife electrocautery. Peritoneoscopy (10 pigs), liver biopsy (1 pig), cholecystectomy (6 pigs), fallopian tube excision (1 pig), and hysterectomy (1 pig) were carried out.
Results: In 4 animals, acute experiments were performed. Peritoneoscopy liver biopsy and cholecystectomy were successfully accomplished without significant intraoperative complications. Survival studies in 6 pigs that underwent cholecystectomy, tubectomy, and hysterectomy showed uncomplicated recovery at 4 weeks to 6 weeks.
Conclusion: Evidence is given that peroral transgastric surgery is technically feasible and safe in a porcine model. The possibilities and limitations of the new method merit further studies.
7127 Gynecology
Outpatient Surgery Laparoscopic Subtotal Hysterectomy: A Multicenter Study with 500 Patients in Greece and the United Kingdom
S. Chandakas, J. Erian
Introduction: During the last 10 years, minimally invasive surgery has influenced the techniques used in gynecology, with an overall minimization of complications and increased patient satisfaction. The aim of this study was to demonstrate the safety, feasibility, and morbidity of laparoscopic subtotal hysterectomies in an outpatient setting.
Methods: This was a retrospective, descriptive, nonrandomized study carried out at the Princess Royal University Hospital, London, UK and Iaso Hospital, Athens, Greece. For the patients who underwent a laparoscopic subtotal hysterectomy in 50 months (November 2002 through January 2007), data were collected from medical records on how the intervention was performed, and followed for 12 months. Indications included 25% cases for endometriosis, 60% for menorrhagia, and 15% for endometrial pathology.
Results: Estimated blood loss was 128mL (range, 50 to 2000). Intraoperative complications occurred as follows: 0.32% had significant complications, 0.1% had vascular injuries, and 0.11% had nerve or ureter injuries. Early postoperative morbidity included 0.5% deep vein thrombosis, 0% pulmonary embolism, 1.29% bladder infection and dysfunction, and 0% vaginal fistula. Hospital stay: 92% were discharged home the same day with an average length of stay of 8 hours. The average length of stay for the remaining patients was 2.5 days. Causes of the release of these groups of patients were 8% pain control and 2.8% social reasons.
Conclusion: Laparoscopic subtotal hysterectomy can be safely performed as an outpatient procedure.
7128 Gynecology
Laparoscopic Subtotal Hysterectomy Using the Laploop System. A New, Safe, Time-efficient Technique for Outpatient Procedures
Stefanos Chandakas, MD, MBA, PHD, John Erian, MD
Introduction: We sought to demonstrate the safety, feasibility, and morbidity of laparoscopic subtotal hysterectomies in an outpatient setting using the Laploop system.
Methods: This was a retrospective, descriptive, nonrandomized study performed at the Princess Royal University Hospital, London, UK and Iaso Hospital, Athens, Greece. For the patients who underwent a laparoscopic subtotal hysterectomy in 10 months (November 2005 to March 2006), data were collected from medical records on how the intervention was performed, and followed for 2 months. Two surgeons performed 25 subtotal hysterectomies. Indications included 26.6% for endometriosis, 60.2% for menorrhagia, and 11.9% for endometrial pathology. Median follow-up was 8 weeks.
Results: Duration of surgery and hospital stay, safety (morbidity and mortality), and patient satisfaction were assessed. Estimated blood loss was 60mL (range, 50 to 135) Intraoperative complications were as follows: 0% significant complications, 0% vascular injuries, and 0% nerve or ureter injuries, 2% cyclic bleeding. Early postoperative morbidity included 0% deep vein thrombosis, 0% pulmonary embolism, 0.4% bladder infection and dysfunction. The overall complication rate was 0.5%. Of the 25 patients, 96.4% were discharged to home the same day with an average length of stay for these patients of 8 hours.
Conclusion: Laparoscopic subtotal hysterectomy can be safely performed as an outpatient procedure.
7129 General Surgery
Laparoscopic Adrenalectomy via a Lateral Transperitoneal Approach (1997-2006)
Maciej Otto, Jacek Dzwonkowski, Tomasz Ciacka, Ireneusz Nawrot
Introduction: Laparoscopic adrenalectomy (LA) as a method of treatment for adrenal pathology confirmed its safety and efficiency. We presenting our own over 9-year experience and results of LA via lateral transperitoneal approach.
Methods: From October 29,1997 to December 31, 2006, 353 LA were performed in 341 patients. There where 235 (69%) women and 106 (31%) men with a mean age of 51.8 years (range, 11 to 80). The indication for LA was nonfunctioning incidentaloma type tumor in 165 (48.4%) patients and a functioning tumor in 176 (51.6%) patients [hypercortisolemia, 59 (17.3%), Conn’s syndrome, 51 (15%), pheochromocytoma, 65 (19%), adrenogenital syndrome, 1 (0.3%)]. Bilateral lesions were present 51 (15%) patients. The mean size of adrenal tumors was 42.1mm (range, 7 to 95). A history of abdominal surgery was present in 132 (39%) patients; 62 (18.2%) suffered from excessive obesity. All patient were operated on via lateral transperitoneal LA, routinely using 4 trocars and a 30° angled scope. 329 (96,5%) unilateral LA, 12 (3,5%) bilateral LA (simultaneous, 10, two-staged, 2), 2 – sparing LA, 12 (3,5%) simultaneous LA and cholecystectomy were performed.
Results: The mean operating time of the unilateral LA was 145,6 minutes (range 70-390), simultaneous bilateral LA was 266,5 (range 150-420). 12 (3,5%) conversions and 15 (4,4%) complications occured. The mean length of postoperative stay in hospital was 5,6 days. Among patient with non-functional tumour despite meticulous qualification histological examination revealed 7/165 (4,2%) cases of invasive tumors (6 – adrenocortical carcinoma, 1 - angiosarcoma).
Conclusion: AL via lateral transperitoneal became a standard treatment for adrenal pathology.
7130 Urology
Laparoscopic Vas Salvage After Mesh Hernia Repair
Andrew Smith, MD, Caner Dinlenc, MD, Harris Nagler, MD
Objective: Iatrogenic injury to the vas deferens is a well-documented complication of inguinal hernia repair. Recently, obstruction related to the use of polypropylene mesh for hernia repair has been reported. Retrieval of unaffected distal vas for reconstruction requires extensive open dissection. In our video, we describe a case utilizing laparoscopy to mobilize the retroperitoneal vas and deliver it to the healthy vas proximal to the vas trapped in the cicatrix induced by mesh, thus allowing a tension-free microsurgical repair.
Methods: Transperitoneal laparoscopy using 5-mm ports was performed. The vas was dissected from its dense adhesions to the mesh at the level of the internal inguinal ring. A neo-canal was established beyond the external ring. A microsurgical anastomosis between the retroperitoneal vas segment and the testicular vas segment was performed.
Result: A tension-free, patent anastomosis was performed. Sperm was seen on 12-month follow-up semen analysis.
Conclusion: Polypropylene mesh-induced fibrosis of the vas deferens can result in obstructive azoospermia. Laparoscopy can be used to permit a microsurgical bypass of the obstructed segment.
7131 General Surgery
Laparoscopy Versus Observation in an Acute Abdominal Pain “Controlled Randomized Trial”
Dr. Karim AL-Araji, FRCS, CABS
Objective: Acute abdominal pain is any medium or severe abdominal pain with a duration of more than 6 hours and less than 7 days (usually within 48 hours). It accounts for 13% to 40% of all emergency surgical admissions. Most patients can be diagnosed within a short period of assessment and specific treatment started, but there is a group in whom the diagnosis remains equivocal. The aim of this retrospective study was to determine the role of laparoscopy in this group of patients compared with clinical observation.
Methods: This was a controlled, randomized trial conducted on patients with undiagnosed acute abdominal pain after conventional diagnostic methods. Patients were randomly assigned to a laparoscopy group or to a clinical observation group from 2001 to 2005.
Results: In this series of 53 patients with undiagnosed abdominal pain, 49 were females and 4 were males with an age range from 16 years to 48 years. Twenty-nine were assigned to laparoscopy and 24 to observation. In the laparoscopy group, more than 90% of patients could be diagnosed and treated by laparoscopy. Pain was most commonly due to acute appendicitis, thereby avoiding laparotomy with its significant trauma and delayed recovery. Two patients needed conversion to laparotomy. There was no morbidity related to the procedure. In the observation group, most patients remained without a clear diagnosis, and some needed emergency laparotomy for worsening of their condition or were discharged after acceptable improvement but continued to have recurrence and readmission for their undiagnosed disease.
Conclusion: Compared with clinical observation, laparoscopy plays a significant role in diagnosis and treatment of unclear acute abdominal pain providing better care for patients.
7132 Gynecology
Alternatives to Hysterectomy
J. Y. Song, MD, N. Rana, MD, C. Rotman, MD
Introduction: Over 600,000 hysterectomies are performed in the United States each year. Not all uterine fibroid cases should result in a hysterectomy after exhaustion of conservative measures. If a patient wishes to preserve her uterus, the advantages and disadvantages of a laparoscopic multiple myomectomy should be thoroughly discussed, and all options should be provided for the patient. We sought to offer patients seeking fertility or second opinions regarding a hysterectomy, uterine preservation options, performed in a minimally invasive fashion.
Methods: Reproductive age women have been referred to our center for fertility surgery or second opinions regarding uterine preservation surgery. All patients underwent laparoscopic surgery at an outpatient surgical center in a Chicago suburb. The uterine size ranged between 16 weeks and 22 weeks gestational size (500g to 1500g). This video demonstrates our technique in performing a laparoscopic multiple myomectomy with uterine reconstruction.
Results: Including both domestic and international surgeries, we have performed over 2500 laparoscopic myomectomies and multiple myomectomies with rare complications. The majority of these patients were infertility patients, and Cesarean deliveries were performed for obstetrical indications only. The majority of the patients underwent uneventful vaginal deliveries.
Conclusion: Utilizing careful dissection, meticulous hemostasis, and proper suturing techniques, most patients would benefit from this procedure, irrespective of tumor size, number, and location.
7133 Gynecology
Laparoscopic Hysterectomy for the Enlarged Uterus
J. Y. Song, MD, C. Rotman, MD
Introduction: It is still a conventional thought that extremely enlarged uteri would preclude patients from being candidates for a laparoscopic hysterectomy. But under experienced hands at established, designated endoscopy centers, these patients too can benefit from minimally invasive surgical options, sparing them from hospitalization and a prolonged postoperative recovery period, and unwanted large abdominal scars. All patients regardless of benign or malignant diseases or uterine size can enjoy quicker ambulation with shortened recovery. We sought to offer patients minimally invasive surgical options for major gynecologic surgeries, irrespective of uterine size.
Methods: Including international cases that we have performed, over 1600 laparoscopic uterine debulking followed by laparoscopic hysterectomy with bilateral salpingo-oophorectomy (BSO) procedures have been successfully performed thus far, both in hospitals and outpatient surgical centers, but mostly in the latter.
Results: Almost all of the patients who have undergone this procedure had an uneventful postoperative recovery with rare complications, returning to work 1 week to 2 weeks after surgery.
Conclusion: The laparoscopic approach for a hysterectomy and BSO is not only feasible but also is safe for uteri exceeding 1000 grams if performed under capable hands in a prepared and established surgical setting.
7134 Multispecialty
Playing an Instrument Has a Significant Impact on Surgical Skills Performance
J. Bingener, MD, T. Boyd, MS, I. Jung, PhD, K. Van Sickle, MD, A. Saha, MD, W. H. Schwesinger, MD
Objective: Laparoscopic intracorporeal suturing is an advanced surgical skill requiring visio-spatial abilities. Music education impacts the visio-spatial skills of school-age children. We hypothesize that prior music education influences the performance of laparoscopic intracorporeal suturing tasks.
Methods: Thirty novices were introduced to a laparoscopic suturing task using an instruction video. Each participant reported handedness, sex, prior video game experience, prior music education, and underwent 3 consecutive suturing task trials. Suturing task time was measured. A linear mixed model approach was used to examine the effects of sex, video game experience, and prior music education on suturing task time.
Results: Twelve women and 18 men completed the tasks. Six participants had no prior music education and 6 currently played an instrument. When adjusted for video game experience, participants who currently played an instrument performed significantly better than subjects who did not (P<0.001). The model showed a significant sex by instrument interaction. Men who had never played an instrument or currently played an instrument outperformed women in the same group (P=0.002 and P<0.001). There was no sex difference in the performance of the group of participants who had played an instrument in the past (P=0.289).
Conclusion: This study attempted to investigate whether music education influences the initial laparoscopic suturing abilities of novices. Although it is not fully known which visio-spatial skills and abilities contribute to improved laparoscopic skill performance, they may be similar to or enhanced by skills involved in playing an instrument.
7135 Urology
Laparoscopic Nephrectomy with Autotransplantation for Ureteral Stricture Disease and Renal Tumors: Differences in Perioperative Morbidity and Hospitalization
Keith L. Lee, MD, Michael L. Eisenberg, MD, Ali E. Zumrutbas, MD, Chris E. Freise, MD, Marshall L. Stoller, MD
Introduction and Objective: Laparoscopic nephrectomy with autotransplantation (LNA) is indicated in complicated ureteral stricture disease. When combined with ex-vivo partial nephrectomy, patients with complex, centrally located tumors can be treated while renal function is preserved. We compare clinical outcomes for these 2 groups.
Methods: We retrospectively reviewed clinical data of all patients who had undergone LNA between August 2000 and August 2006 for strictures (n=15) and tumors (n=4). Indications in the former group included complex strictures not amendable to ureteroureterostomy, ureteral reimplantation, or bladder flaps. For the second group, 3 had centrally located tumors in a solitary kidney, and the other had chronic renal insufficiency. Laparoscopic nephrectomy was performed transperitoneally, and the extracted kidney was prepared and stored in ice-slush via a live-donor transplantation protocol. Partial nephrectomy when indicated was performed in ice-slush.
Results: Median age was 47 (range, 25 to 66) for patients with strictures and 66 (range, 31 to 68) for those with tumors. Sex, preoperative hematocrit, and comorbidity ASA scores were similar as were operative and warm ischemic times. Mean operative blood loss was significantly higher for the tumor group (1.6L+1.5L versus 0.5L+0.4L). Three of the 4 patients in the tumor group had early perioperative complications compared with only one in the stricture group. Hospitalization was longer for the tumor group at 9d+3d compared with 5d+2d.
Conclusions: Management of patients with limited renal reserve and centrally located renal tumors remains challenging. Ex-vivo partial nephrectomy with LNA is associated with greater morbidity compared with LNA for nonmalignant ureteral stricture disease.
7136 General Surgery
Laparoscopic Bowel Injuries: Benenden Experience
K. Lodha, Fazal Hasan
Although laparoscopic bowel injuries occur infrequently, they may have serious consequences. The reported incidence of bowel injuries during laparoscopic procedures ranges from 0.05% to 0.6%, and the majority involve the small bowel (60%) compared with the large bowel (30%) and rectum (10%). Bowel injuries may happen during access into the peritoneal cavity by Veress needle, during the open technique, or by maneuvering during the actual laparoscopic procedure. Unfortunately, many bowel injuries are missed at the time of the procedure. Delayed recognition may lead to devastating complications including death.
While presenting our own experience in Benenden, UK, we endeavor to outline the mechanism of bowel injuries, techniques to recognize these injuries, and outline the strategy for repair to achieve the best result.
7137 Gynecology
Laparoscopic Debulking of a Left Pelvic Sidewall Mass in a Patient with Recurrent Ovarian Cancer
Farr Nezhat, MD, Michele Peiretti, MD, Nimesh P. Nagarsheth, MD
Objective: To demonstrate the feasibility and safety of laparoscopic debulking of ovarian cancer.
Methods: We present the case of a 52-year-old female with a history of stage II-B poorly differentiated adenocarcinoma of the ovary who was found to have a 3-cm pelvic mass in the left perirectal space with extension to the pelvic sidewall 2 years after her initial treatment. The patient underwent a laparoscopic secondary cytoreductive procedure.
Results: The laparoscopic cytoreduction procedure was successful. No intraoperative or postoperative complications occurred, estimated blood loss was 50mL, and the patient was discharged home on postoperative day 1. She received adjuvant chemotherapy and remains disease-free 1 year after her procedure.
Conclusions: Laparoscopic debulking of recurrent ovarian cancer is a safe, feasible procedure.
7138 General Surgery
The Laparoscopic Approach in Abdominal Emergencies: a Single-center Review of a 15-year Experience
Ferdinando Agresta, MD, Natalino Bedin, MD
Introduction: The aim of the present work was to illustrate retrospectively the results of a case-controlled 15-year-experience of laparoscopic vs. open surgery for abdominal emergencies carried out at our institution.
Methods: From January 1992 through January 2007, 1272 patients underwent emergent or urgent laparoscopy, or both (small bowel obstruction, 45; gastroduodenal ulcer disease, 41; biliary disease, 283; pelvic disease and NSAP, 882; colonic perforations, 21). Peritonitis was not deemed a contraindication to laparoscopy. In the final 5-year experience, a history of malignancy or previous major abdominal surgery and small-bowel occlusion was known (if a place to securely establish a peritoneum was possible to find).
Results: The conversion rate was 2.75% and was mainly due to the presence of dense intraabdominal adhesions. Complications ranged as high as 2.2% with a postoperative mortality of 0.3%. A definitive diagnosis was accomplished in 96.1% of cases, and 97.2% of such patients were treated successfully by laparoscopy.
Conclusion: The present experience shows that the “emergency” laparoscopy is as safe and effective as conventional surgery, has a higher diagnostic yield, and allows for less trauma and a more rapid postoperative recovery. We think that laparoscopy is not an alternative to physical examination/good clinical judgment, but it must be considered first as an effective option in patients (both adults and children) in whom conventional noninvasive methods fail, especially with the increasing experience and skill of the surgeons, and second as a challenging alternative to open surgery in the management algorithm for abdominal emergencies.
7139 General Surgery
Laparoscopic Cholecystectomy With 3 Trocars and 5-mm Instruments/Optics
Ferdinando Agresta, MD, Natalino Bedin, MD
Introduction: Laparoscopic cholecystectomy is the gold standard technique used in every hospital situation, and every surgeon–the expert and the beginner–has to face it sooner or later. Recently, the increasing development of smaller laparoscopes, trocars, and operative instruments, which minimize nerve and muscle damage and optimize esthetic results, has characterized laparoscopy. Our institutions have routinely commenced the use of minilaparoscopy over the last 5 years for the performance of various abdominal procedures, such as appendectomy and inguinal hernia repair (3-mm diameter instruments) and cholecystectomy (5-mm diameter instruments).
Methods: Between July 2002 and July 2005, 518 patients underwent laparoscopic cholecystectomy, 268 (51.7%) of whom were operated on with a 5-mm/3-trocar approach, the rest undergoing conventional laparoscopic cholecystectomy. The primary endpoint was the feasibility rate of the 5-mm/3-trocar technique. Secondary endpoints were safety and the impact of the technique on duration of laparoscopy.
Results: We had 2 conversions to laparotomy–one in each group–while a conversion to the classic approach for the 5-mm/3-trocar group was necessary in 9.3% of patients. Minor difficulties were as high as 3.6% (9 cases) with the conventional approach and 3.7 (10 cases) with the 5-mm/3-trocar approach.
Conclusions: The present experience shows that the 5-mm/3-trocar cholecystectomy is a safe, easy, effective, and reproducible approach to gallbladder diseases. Such features make the technique a challenging alternative to conventional laparoscopy in the approach to cholecystopathy, both in acute and scheduled settings.
7140 Pediatric Surgery
Robotic Swenson Pull-through for Hirschsprung’s Disease in Infants
André Hebra, MD, Jennifer Arenas, PA, Beverly McGuire, RN, Gail Kay, MD, Richard Harmel, MD
Objective: It has been demonstrated that infants with Hirschsprung’s disease can be treated with a 1-stage laparoscopic colo-anal pull-through without a colostomy. However, the feasibility and benefits of performing this operation using robotic technology has not yet been evaluated.
Methods: We reviewed our experience with 10 infants (age <7 months) treated with laparoscopic robotic-assisted colonic resection and pull-through using the da Vinci surgical system (Intuitive Surgical). The average age was 16 weeks, average weight was 6.5kg, and 75% were males. No patients required a preoperative colostomy.
Results: The average operative time was 230 minutes. All patients were treated with a modification of the Swenson operation (total proctectomy). The transition zone ranged from the rectosigmoid region to the midtransverse colon. Average length of stay was 2.5 days. One patient sustained injury to the posterior vaginal wall during rectal dissection. No infectious complications occurred. Six patients required postoperative rectal dilations.
Conclusions: Our experience demonstrates that a 1-stage robotic-assisted pull-through can be safely performed in young infants without preoperative colostomy. The use of robotic technology provided superior dexterity and visualization, essential in performing a more complete rectal dissection beyond the peritoneal reflection. Thus, a complete proctectomy, as originally described by Swenson, could be accomplished, eliminating the risk of leaving a segment of aganglionic rectum behind. Moreover, this may also account for the fact that the occurrence of postoperative rectal strictures was less compared with that in other reported surgical techniques.
7141 General Surgery
Early Postoperative Results Comparing Current Procedures for Treating the Massively Super Morbidly Obese
David L. Schumacher, MD, Mehul Trivedi MD, Jerod Grogg, PA
Background: Optimal surgical management of the massively super obese patient (BMI >60 and/or weight >400lb) is associated with higher morbidity, mortality, and long-term weight loss failures. BMIs continue to rise in the general population, and new interventions are being utilized to achieve acceptable weight loss and resolution of comorbid conditions. We have utilized laparoscopic gastric sleeve (LGS), laparoscopic gastric bypass (LRYGB), and laparoscopic adjustable gastric band (LAGB) in this patient profile. We present our early results, complications, and weight loss results comparing these procedures during the short postoperative period.
Methods: We reviewed all bariatric patients from March 2005 through October 2006. A total of 320 bariatric procedures were performed, 13.4% or 43 patients were massively super morbidly obese. We compared results in 28 patients with LRYGB (mean wt=412.32, mean BMI=64, range, 306.6 to 507.8), 10 patients with LGS (mean wt=535.6, mean BMI=85.9, range, 425.7 to 777), and 5 patients with LAGB (mean wt=387.8, mean BMI=67.2, range, 347 to 460). Postoperative complications and weight loss were compared.
Results: The 28 LRYGB patients had an average length of stay (LOS) of 3.17 days. Complications included 1 leak that resulted in reoperation and mortality, 1 diagnostic laparoscopy, 1 pneumonia, 1 stomal stenosis, 1 gastric ulcer, 2 transfusions, 1 non-Q wave MI, for a 28% complication rate and a 3.1% mortality rate. Weight loss in pounds and change in BMI at 3 months, 6 months, 9 months, and 1 year were 88.9 (13.3BMI), 123.1 (19.7BMI), 150.0 (23.0BMI), and 163.1 (25.8BMI), respectively. The 10 LGS patients had an LOS of 3.9 days, and 1 bilateral DVT occurred for a 10% complication rate, 0% mortality. Weight and BMI at the same increments were 78.9 (11.9BMI), 138.4 (19.2BMI), 219.7 (29.0BMI), with 1-year data pending. The 5 LAGB patients had an LOS of 2.0 days with 1 pneumonia, 20% complication rate, 0% mortality. Weight and BMI at 3-month intervals were 35.1 (6BMI), 59.5 (7.2BMI), 62.6 (9.3BMI), with 1-year data pending.
Conclusion: All 3 operations can be successful in this patient population. In this short-term follow-up period, laparoscopic gastric sleeve patients were the heaviest with the highest risk, yet had the fewest complications and the most weight loss. Long-term results and a larger patient group will be more conclusive regarding ultimate weight loss achievement and risk in this patient profile.
7142 Urology
Endoscopic Management of Ureteral Obstruction in Patients with Bladder Exstrophy Diverted by Ureterosigmoidostomy
Michael L. Eisenberg, Keith L. Lee, Marshall L. Stoller
Introduction: Once routinely performed for supravesical urinary diversion, ureterosigmoidostomy is rarely used today. Nevertheless, patients with bladder exstrophy who were diverted via ureterosigmoidostomy decades ago can present with ureteral obstruction. Endoscopic management of ureteral stricture and urolithiasis is challenging due to the lack of anatomic landmarks. We highlight key factors in operative planning and management required for success.
Methods: We reviewed our prospectively collected database from 1994 until 2006 for all patients with bladder exstrophy who required surgical treatment for ureteral obstruction associated with ureterosigmoidostomy.
Results: Our analysis revealed 3 patients who had ureterosigmoidostomy as a part of bladder exstrophy management decades earlier. All patients presented with renal colic, and 2 also had azotemia due to obstruction. All required percutaneous drainage followed by antegrade endoscopic treatment. Two patients had anastomotic strictures, and one had obstructive urolithiasis. One patient with a stenotic, chronic stricture was managed via endoureterotomy with the Acucise balloon. The second patient, who presented with acute obstruction after colonoscopic biopsy near his ureteral anastomosis, was managed via antegrade balloon dilation. Both patients were stented for 6 weeks postoperatively. The third patient with urolithiasis required antegrade basket stone extraction. Despite reflux of gastrointestinal contents into the collecting system, patients remained asymptomatic and free of infections. Renal function in all patients returned to baseline after intervention, and patients remain stricture free at follow-up.
Conclusions: Obstructive complications in ureterosigmoidostomy can be managed by using antegrade endoscopic techniques. Postoperative ureteral stenting is safe, despite reflux of gastrointestinal contents into the collecting system.
7143 Urology
Endoscopic Management of Retained Renal Foreign Bodies
Michael L. Eisenberg, Keith L. Lee, Marshall L. Stoller
Introduction: Retained foreign bodies in the kidney as a result of prior endoscopic and percutaneous manipulation are technical challenges in management. We reviewed our experience with endoscopic extraction of renal foreign bodies by using both retrograde and antegrade approaches. We assessed preoperative factors associated with renal failure, operative planning and technique, and postoperative outcomes.
Methods: We surveyed our prospectively collected database between November 1992 and September 2006 for patients who underwent complex extraction of a renal foreign body.
Results: Sixteen patients were identified who met the selection criteria (8 male, 8 female). Mean age was 39 years (range, 8 to 92). Renal foreign bodies included indwelling ureteral stents (13), nephrostomy tubes (2), inner guidewire core (1), nephrostomy tube string (1). Eleven patients required antegrade instrumentation via a percutaneous tract to remove the foreign body. Extraction of the nephrostomy string and fragmented guidewire were approached percutaneously. In cases of retained ureteral stents, all but one required a combined antegrade and retrograde approach for extraction. Patients presenting with renal failure (n=2) defined by a creatinine >2mg/dL were obstructed by forgotten ureteral stents that were left in place for the longest period in our cohort (5, 10 years). Each of these patients had improved renal function following endoscopic extraction.
Conclusions: Patients with retained renal foreign bodies benefit from extraction via antegrade or retrograde, or both, endoscopic techniques. In patients presenting with renal failure, improvement in renal function is seen following extraction of a retained renal foreign body.
7144 General Surgery
Laparoscopic Splenectomy Following Embolization for Blunt Trauma
Kenneth J. Ransom, MD, Michael S. Kavic, MD
An injured spleen from blunt trauma can safely be removed laparoscopically following embolization and represents an alternative to open laparotomy. Grade III through V splenic injuries as defined by the American Association for the Surgery of Trauma (AAST) grading scale are associated with hemorrhage and nonoperative failure. Evidence of a splenic vascular injury on CT scan or angiography, including a contrast blush, vascular truncation, and aneurysm or arteriovenous fistula formation especially in the presence of moderate to large hemoperitoneum, is also associated with nonoperative failure. Embolization has been reported to reduce splenic bleeding in 50% to 75% of patients with a high-grade injury. However, splenectomy following embolization may be necessary in patients who continue to bleed or develop splenic infarction with abscess formation. We report our experience with 46 patients admitted over a 36-month period to the senior author at a Level I trauma center. Eight patients required emergency laparotomy and splenectomy for hemodynamic instability. Eight of the remaining 38 patients were felt to be at risk for continued or delayed hemorrhage and underwent splenic angiography with embolization. Three patients developed complications following embolization. The spleen continued to bleed in 2 patients and an abscess formed in the third. All 3 patients underwent successful removal of the spleen with minimally invasive techniques. One patient required hand assistance to control hemorrhage following segmental embolization of the lower pole of the spleen.
7145 General Surgery
The Importance of Haptic Feedback in Laparoscopic Suturing Training and the Additive Value of Virtual Reality Simulation
Sanne M. B. I. Botden, MSc, Fawaz Torab, MD, Sonja N Buzink, MSc, Jack J. Jakimowicz, MD
Objective: From previous study on the difference between augmented and virtual reality (VR) simulation, we know that haptic (tactile) feedback is regarded as an important feature in laparoscopic suturing simulation. Objective feedback is also important to improve skills during training. In this study, we focus on the additive value of VR simulation for laparoscopic suturing training.
Methods: The participants of multiple EAES-approved laparoscopic skills courses, with little or no laparoscopic suturing experience, were divided in 2 groups; A (N=10): started training on the box trainer and secondly the VR simulator (SimSurgery), B (N=8): began on the VR simulator followed by the box. Afterwards, one final knot was examined using a standard evaluation form (8 items on a 5-point-Likert scale). One knot, after the first box training of group A, was examined as a control. All participants (N=44) filled out a questionnaire on their opinion of laparoscopic suturing training. Significant differences were calculated with the independent t test and the paired t test.
Results: The total score for group A was higher than scores for both group B and control (means 30.80, 28.25, 28.20, respectively), but not significantly. The only significant difference was found in “taking proper bites” between groups A and B (means, 4.10, 3.50, respectively, P=0.036). The opinion of the features of the box trainer was significantly higher than opinions of the VR simulator (P<0.001). Of all groups, 46.5% believed that the box alone would be sufficient for laparoscopic suturing training.
Conclusion: From this study, we can conclude that VR simulation does not add significant additional value in laparoscopic suturing simulation.
7146 General Surgery
Jejunojejunostomy Stricture with Gastric Remnant Perforation After Laparoscopic Roux-en-Y Gastric Bypass
John S. Koppman, MD, Stuart Shindel, MD, Christina Li, MD, Alejandro Gandsas, MD
Objective: To provide an overview of the causes, clinical presentation, diagnosis, and treatment of early small-bowel obstruction after laparoscopic Roux-en-Y gastric bypass.
Methods: We present a case report and literature review.
Results: This video examines mechanical small-bowel obstruction due to jejunojejunostomy stricture after laparoscopic, antecolic, antegastric Roux-en-Y gastric bypass, which, in this case, resulted in perforation of the gastric remnant. Clinical presentation and diagnosis of early small-bowel obstruction due to jejunojejunostomy stricture with particular emphasis on the potentially fatal complication of gastric remnant perforation is emphasized. Laparoscopic revision is demonstrated, including omega loop small-bowel bypass between the alimentary limb and the common channel, drainage of the intraabdominal collection, and remnant decompression by tube gastrostomy. Critical points regarding causes, presentation, diagnosis, and treatment of early small-bowel obstruction after laparoscopic Roux-en-Y gastric bypass are reviewed.
Conclusions: Early small-bowel obstruction after antecolic, antegastric laparoscopic Roux-en-Y gastric bypass is most often due to technical error in the creation of the jejunojejunostomy. Although several techniques have been proposed to prevent this complication, none has been shown to do so. Importantly, the treatment of this complication may be achieved laparoscopically in the majority of cases and consists of an omega loop small-bowel bypass and remnant decompression by tube gastrostomy.
7147 General Surgery
The Effect of Intraperitoneal and Intra-incisional Application of Local Analgesic on Pain After Laparoscopic Abdominal Surgery
Ali Uzunkoy, Prof Dr, MD
Objective: Postoperative pain disturbs patient comfort. This study aimed to determine the efficacy of intraperitoneal and intra-incisional application of bupivacaine on postoperative pain and analgesic consumption after laparoscopic abdominal surgery.
Methods: Eighty patients who underwent laparoscopic abdominal surgery were randomized into 2 groups. A solution of 0.25% bupivacaine (0.5% bupivacaine + saline solution) was sprayed into both subdiaphragmatic areas at the end of the operation before the disinflation, and the same concentration of bupivacaine was intra-incisionally injected at all trocar sites. Patients in the second group (control group) did not receive bupivacaine. The pain scores were evaluated by visual analogue pain scale at the second, fourth, twelfth, and twenty-fourth hours. Analgesic requirements of the patients were noted.
Results: The pain score was significantly lower in the group receiving bupivacaine in comparison with the control group at the second, fourth, and twelfth hours (P<0.05). No significant difference was noted at the 24th hour between groups (P>0.05). Analgesic requirements of groups were not significantly different (P>0.05).
Conclusion: The intra-incisional and intraperitoneal administration of a long-lasting local analgesic such as bupivacaine after laparoscopic abdominal surgery reduces the intensity of pain in the early postoperative period and increases patient comfort.
7148 Gynecology
Robot-Assisted Paravaginal Defect Repair
D. Giles, MD, P. Magtibay, MD
Objective: To demonstrate the feasibility and possible advantages of robotic assistance in laparoscopic repair of paravaginal defects.
Methods: We demonstrate our technique utilizing robotics (da Vinci, Intuitive Surgical, Sunnyvale, CA) in the repair of paravaginal defects at the Mayo Clinic College of Medicine, Mayo Clinic Arizona. A 67-year-old female presented with progressively worsening vaginal prolapse. Past medical history is significant for vaginal hysterectomy and a Trans-Obturator suburethral sling. The patient underwent diagnostic laparoscopy, robot-assisted paravaginal defect repair, robot-assisted bilateral salpingo-oophorectomy, and robot-assisted sacrocolpopexy.
Results: The video demonstrates the multiple degrees of freedom achieved with robotics compared with traditional laparoscopy. The articulation of the robotic joints aids in difficult maneuvers, such as suturing and intracorporeal knot tying. Estimated blood loss was minimal, and the patient was discharged home on the second postoperative day with a hemoglobin of 11.
Conclusions: Robot-assisted repair of paravaginal defects is a relatively new modification to the traditional laparoscopic repairs. It reduces the morbidity associated with open procedures while improving efficiency of difficult maneuvers.
7149 General Surgery
Unusual Delayed Complication Following Laparoscopic Adjustable Gastric Banding
Michael Tempel, MD, Sharfi Sarker, MD, Vafa Shayani, MD
Objective: We present an unusual delayed complication following laparoscopic adjustable gastric banding (LAGB).
Methods: The patient is a 32-year-old man who had undergone an uneventful LAGB at age 27. Approximately 4.5 years later, the patient had spontaneous disconnection of his subcutaneous reservoir from the abdominal catheter, which required laparoscopic retrieval and implantation of a new reservoir. Approximately 6 months later, he presented with acute, severe mid abdominal pain. The workup including abdominal X-rays, small bowel series, and CT scan, pointed to possible partial small-bowel obstruction. A diagnostic laparoscopy revealed entanglement of the small bowel with the redundant portion of the abdominal catheter, a process not present 6 months earlier when the catheter was retrieved laparoscopically.
Results: The operative findings clearly supported the diagnosis of intermittent partial small-bowel obstruction. In addition, evidence was present of subserosal erosion of the catheter into the bowel wall without full-thickness damage. No bowel resection was necessary. The catheter was disconnected from and reconnected to the subcutaneous reservoir without difficulty. The patient had an uneventful recovery and was discharged on postoperative day 2.
Conclusion: As the popularity of LAGB increases worldwide, early recognition of unusual late complications of this procedure becomes more significant. A high index of suspicion for a mechanical process should lead to immediate surgical intervention.
7150 Urology
Does Age Affect the Safety and Efficacy of Potassium-Titanyl-Phosphate (KTP) Laser Photoselective Vaporization Prostatectomy (PVP)?
Motoo Araki, MD, PhD, Po N. Lam, MD, Daniel J. Culkin, MD, Glenn M. Sulley, RN, Carson Wong, MD
Objectives: We evaluated the safety and efficacy of KTP laser PVP for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) in patients of varying age groups.
Materials and Methods: We prospectively evaluated our initial 12-month 80W KTP laser PVP experience. Patients were stratified into 2 groups: age<70 (group I) and age≥70 (group II).
Results: The study included 160 consecutive patients (74, group I; 86, group II). Elderly patients (group II) had larger prostate volumes (61cm3 vs. 81cm3, P≤0.05), requiring longer laser time (28 minutes vs. 38 minutes, P≤0.05) and higher energy (85kJ vs. 110kJ, P≤0.05) than did younger patients (group I). International Prostate Symptom Score (IPSS), maximum flow rate (Qmax) and postvoid residual (PVR) values showed significant improvement within each group (P<0.05). Qmax was higher both before and after surgery in group I, but IPSS and PVR values were similar between the 2 groups postsurgery. The incidence of retrograde ejaculation was higher in group I (11% vs. 0%, P≤0.05). The incidence of other adverse events did not show statistical significance.
Conclusion: Despite a higher Qmax in the younger patient group, our experience suggests that age has little effect on the safety and efficacy of KTP laser PVP.
7151 Urology
Catheter-free Potassium-Titanyl-Phosphate (KTP) Laser Photoselective Vaporization Prostatectomy (PVP): Patient Characteristic Analysis
Motoo Araki, MD, PhD, Po N. Lam, MD, Daniel J. Culkin, MD, Glenn M. Sulley, RN, Carson Wong, MD
Objectives: We evaluated the safety and efficacy of catheter-free KTP laser PVP for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).
Methods: We prospectively evaluated our initial 12-month KTP laser PVP experience.
Results: The study included 160 consecutive patients; 98 (61%) were discharged without (C-) and 62 (39%) were discharged with (C+) a catheter. No significant differences existed in preoperative parameters, including age (C-, 69±9 vs. C+, 71±9 years), IPSS
(C-, 27±7 vs. C+, 27±7), Qmax (C-, 12±6 vs. C+, 10±6cc/sec), PVR (C-, 114±125 vs. C+, 101±152cc), and prostate volume (C-, 70±49cm3 vs. C+, 76±50cm3). There were no significant differences in laser utilization and energy usage. IPSS, Qmax, and PVR values showed significant improvement within each group (P<0.05), but no significant differences existed between the 2 groups. All were outpatient procedures. Catheter reinsertion was required in 6/98 (6%) patients in C-. The overall incidence of adverse events was low and did not differ between the 2 groups.
Conclusion: Our experience suggests that catheter-free PVP is safe and effective for the treatment of LUTS secondary to BPH.
7154 General Surgery
Laparoscopic Management of Small-bowel Intussusception in a 16-Year-Old with Peutz-Jeghers Syndrome
Benjamin Clapp, MD, Angel Morales, MD
Introduction: Peutz-Jeghers is a rare autosomal dominant disorder characterized by hamartomatous polyps and discoloration of mucosal membranes. The hamartomatous polyps can occur anywhere in the gastrointestinal tract and can grow large enough to cause bowel obstructions.
Case Report: A 16-year-old male presented to the emergency department with the signs and symptoms of an acute bowel obstruction. He had 2 days of abdominal pain, obstipation, and vomiting. He had a previous history of a colonoscopy with polypectomy at age 4, had hyperpigmentation of his mucous membranes, and his mother and maternal grandfather had a history of gastrointestinal polyps. CT scan revealed an intussusception of the small intestine. He underwent an exploratory laparoscopy and was found to have an intussusception of the mid jejunum. A laparoscopic-assisted small bowel resection was performed. Pathology showed a 5-cm polyp had acted as a lead point for the intussusception. The patient did well postoperatively, and colonoscopy and upper endoscopy revealed 5 more polyps in the stomach and colon that were removed.
Discussion: Three case reports have been published regarding the laparoscopic management of bowel obstructions in Peutz-Jeghers syndrome. Small-bowel obstructions can be managed successfully with minimally invasive approaches. The treatment of obstruction in these patients is to remove the offending hamartomatous polyp(s). The rest of the intestine needs to be examined, and those polyps found should be removed. This can be done intraoperatively with laparoscopic-assisted enteroscopy and colonoscopy.
7155 Gynecology
Diagnostic Performance of Office Hysteroscopy to Detect Endometrial Pathologies in Women With Hereditary Predisposition to HNPCC Syndrome: Results of a Prospective Study
Anne-Sophie Bats, MD, Ulrike Metzger, MD, Luce Tulpin, MD, Marie-Aude Le Frere Belda, MD, Sylviane Olschwang, MD, Pierre Laurent-Puig, MD, PhD, Fabrice Lecuru, MD, PhD
Objective: To describe the follow-up of women with hereditary predisposition to HNPCC syndrome, by diagnostic hysteroscopy ± endometrial sampling. The secondary objective was to determine whether the procedure allowed detection of atypical hyperplasia or asymptomatic carcinoma.
Methods: Sixty-two women were prospectively followed-up during a 125-year exposition period. They were MMR gene mutation carriers or fulfilled the Amsterdam criteria. In the setting of their annual gynecologic examination, an office diagnostic hysteroscopy ± endometrial sampling was performed. Women who had undergone a hysterectomy or refused hysterectomy were not included.
Results: One hundred and twenty-five hysteroscopies have been attempted. Eleven failures were observed (8%). Macroscopic features were considered normal in 46 patients, presenting a benign pathology in 65 patients, and a suspicious feature in 3 examinations, all in women with menometrorrhagia. A “micropolypoid” feature was observed in 6 hysteroscopies (5%). One hundred and sixteen endometrial samplings were attempted with 12 failures (10%). Three hyperplasias without atypia and 3 carcinomas were diagnosed. Micropolypoid features were related to a secretory endometrium, to a proliferative endometrium or were uninterpretable. There were no preinvasive or invasive lesions in the asymptomatic women. No interval cancer was recorded.
Conclusion: Diagnostic hysteroscopy allows the detection of endometrial cancer in women with HNPCC predisposition. However, no cancer has been detected in asymptomatic women. Gynecologic screening should be compared with instruction for early recognition of alarm symptoms, and prophylactic total abdominal hysterectomy and bilateral salpingo-oophorectomy.
7156 Gynecology
Staging of Advanced Ovarian Cancers: Interest in Thoracoscopy
Anne-Sophie Bats, MD, Sandra Cohen-Mouly, MD, Reda Souilamas, MD, Cherazade Bensaid, MD, Marie Junger, MD, Florence Larousserie, MD, Fabrice Leceru, MD, PhD
Objective: To evaluate the interest of thoracoscopy in the management of patients with advanced ovarian cancers and pleural effusions.
Methods: A thoracoscopy was performed in 11 patients: 7 cases before chemotherapy, 3 after chemotherapy, and 1 case for a recurrence after 2 years. Thoracoscopy was performed at the beginning of the operation, before abdominal surgery. Chest wall incisions were made in the fifth intercostal space on the side of the effusion. After thoracoscope introduction, cytology, biopsies of pleura (systematic or oriented by suspicious lesions) were performed through a single incision. Patients with major pleural effusion underwent talc pleurodesis to avoid recurrence. We compared data from thoracic computed tomography with thoracoscopy, then, we investigated a relationship between thoracic and abdominal lesions.
Results: Eight thoracoscopies were performed on the right side and 3 on the left side. One of them was stopped for refractory hypoxemia. Pleural effusion recurred in only one case. Among these 11 patients, 4 women had pleural metastases diagnosed by thoracoscopy, whereas the thoracic CT scan was normal; 3 patients were classified in the 4th stage because of pleural effusion, but thoracoscopy confirmed the diagnosis thanks to negative biopsies. Then in 2 patients, the pleural disease was more severe than abdominal extension. It led to a single abdominal laparoscopy, and these women were proposed for chemotherapy.
Conclusion: Thoracoscopy could improve the staging of ovarian cancer and then change therapeutic management of patients presenting with an advanced ovarian cancer associated with a pleural effusion.
7157 Gynecology
Comparison of Different Approaches to the Surgical Management of Endometrial Cancer
Anne-Sophie Bats, MD, Gilles Chatellier, MD, PhD, Denys Clement, MD, Marie-Aude Le Frere Belda, MD, Fabrice Lecuru, MD, PhD
Objective: To assess the feasibility of laparoscopy in the treatment of endometrial carcinoma and to compare operating data and survival with that of laparotomy.
Methods: This was a retrospective review of 70 consecutive patients with supposed early endometrial cancer managed between December 2000 and December 2005. Two groups were defined, whether they had been operated on by laparoscopy (N=44; LPS group) or laparotomy (N=21; LPM group). Five patients with vaginal hysterectomy were excluded from the study.
Results: Both groups were comparable in mean age and mean body mass index. There was no significant difference in median operating time for the LPS group [240 minutes (range, 90 to 390)] and the LPM group [195 minutes (range, 120 to 600)], (P=0.234). Intraoperative complications occurred in 2 LPS patients (4.7%) and in 2 LPM patients (9.5%). Three patients (6.8%) initially evaluated by laparoscopy were converted to laparotomy. Women who underwent laparoscopy had more pelvic lymph nodes removed [11.5 (range, 2 to 33) versus 7.5 (range, 3 to 37), P<0.05]. There were comparable early and late postoperative complications in patients managed by laparoscopy (5 and 0 cases; 27.8% and 0%) and by laparotomy (5 and 2 cases; 11.6% and 4.5%), (P=0.143 and P>0.999). Hospital stay was longer in the LPM group [9.5 days (range, 6 to 39)] versus the LPS group [5.0 days (range, 4 to 27)], (P<0.05). No significant difference existed in survival between the 2 groups.
Conclusion: Laparoscopic staging combined with vaginal hysterectomy appears to be a feasible alternative to the conventional surgical approach in patients with endometrial carcinoma.
7158 Urology
Radiation Resistant Prostate Cancer: A Single-institution Experience With Laparoscopic and Robotic Salvage Prostatectomy
Mark H. Kawachi, MD, Rosalia Viterbo, MD, Timothy G. Wilson, MD
Introduction and Objectives: Salvage prostatectomy may be considered in select radiation-resistant prostate cancer patients. With a more than 2500-case experience in LRP and RAP, we were able to evaluate how these minimally invasive techniques affect outcomes and morbidity in salvage prostatectomy patients treated at our institution.
Methods: Twenty consecutive salvage prostatectomies (11 LRP, 9 RAP) were evaluated. Salvage surgery was considered only if the patient had biopsy proven radiation resistant disease more than 2 years after completion of treatment, a rising PSA, no evidence of systemic disease, and had a 10-year life expectancy.
Results: Median PSA was 6.7, median operating time was 228 minutes, average blood loss was 200cc, median Gleason score was 7, and median specimen weight was 46 grams. Positive surgical margins were present in 2 of 20, seminal vesicle invasion in 1 of 19, and extracapsular extension in 4 of 20. Pathologic staging ranged from pT2a to pT4. No open conversions, transfusions, intraoperative complications, or deaths occurred. Median hospital stay was 3 days. Postoperative PSA was <0.1ng/mL in 15 of the 20 patients.
Conclusion: While radiation-resistant prostate cancer continues to represent an infrequent but challenging oncologic problem, the short-term results of LRP or RAP procedures in radiation-resistant patients are promising and warrant continued investigation.
7159 General Surgery
Laparoscopic Spleen-sparing Distal Pancreatectomy
Uthaiah Kokkalera, MD, Keyur Chavda, MD, Ali Ghellai, MD
Introduction: Minimal access techniques for the diagnosis and treatment of pancreatic diseases are evolving. Techniques such as laparoscopic distal pancreatectomy are being reported more frequently. Our video demonstrates a laparoscopic spleen-sparing distal pancreatectomy for a distal pancreatic lesion.
Methods: Our 25-year-old female patient presented with a 1-week history of mid abdominal pain and loss of appetite. Prior history for alcohol abuse or pancreatitis was negative. Initial laboratory evaluation showed mildly elevated amylase and a negative CA19-9 level. Ultrasound demonstrated a 3-cm cystic lesion at the junction of the body and tail of the pancreas with a central solid component. Abdominal CT scan confirmed the presence the complex cystic lesion. Due to the premalignant potential of the lesion, surgery was advised. Laparoscopic spleen-sparing distal pancreatectomy was performed. While under general anesthesia, the patient was placed in a low lithotomy position. A 10-mm infraumbilical port and three 5-mm working ports were used. The gastrocolic omentum was opened, and the stomach was retracted to the anterior abdominal wall by using 2 silk sutures. Intraoperative ultrasound was used to locate the mass and assess margins. The splenic artery was identified and divided. A retropancreatic window was created. A 4.8-mm endo-GIA stapler with a seam guard was used to transect the pancreas. The spleen was preserved. Total operative time was 2.5 hours with minimal blood loss. Histology was compatible with congenital cyst. The patient’s postoperative course was remarkable for a very low output pancreatic leak that resolved spontaneously. She was discharged on the 2nd postoperative day.
Conclusion: Distal pancreatectomy is the preferred treatment of neoplasms in the body or tail of the pancreas. In select patients, minimally invasive techniques can be used for resection. If possible, spleen preservation is preferred. Experience with laparoscopic distal pancreatic resection has been favorable in terms of quicker postoperative recovery, minimal morbidity, and shorter hospital stay. We successfully performed laparoscopically the resection of the distal pancreas with the preservation of spleen.
7160 Urology
Novel Technique for Hemostatic Hydrodissection of the Neurovascular Bundles (HYNEB) During Laparoscopic Radical Prostatectomy: Early Potency and Continence Outcomes
Sijo J. Parekattil, Nicholas Franco, Jonathan K. Jay
Objective: Preservation of continence and potency after laparoscopic radical prostatectomy (LRP) are 2 key outcome measures that patients consider when comparing different treatment options for localized prostate cancer. This study presents a novel technique for hemostatic hydrodissection of the neurovascular bundles (HYNEB) during LRP. Early potency and continence outcomes will be assessed.
Methods: This was a prospective analysis of 30 consecutive LRP patients from September 2005 to October 2006 with follow-up ranging from 1 month to 14 months. Standardized, validated quality of life measurement tools including the Sexual Health Inventory for Men (SHIM) were utilized preoperatively and postoperatively at 3-month intervals to assess potency and incontinence outcomes after the HYNEB procedure.
Results: At the time of this analysis, 93% of the patients were continent (defined as using no pads or only 1 pad for safety daily); 37% (11 patients) achieved continence by 1 week after surgery, 63% achieved continence by 1 month, and 90% by 3 months. Of the patients with a preoperative SHIM ≥17 (8 patients), 63% (5 patients) had return to a SHIM score ≥17 (without the use of oral or injectable erectile dysfunction therapy) by 6 months. Two patients were able to have satisfactory intercourse without any oral or injectable therapy by 1 month postoperation.
Conclusions: Hemostatic hydrodissection of the neurovascular bundles (HYNEB) during LRP may promote the early return of continence and erectile function. The preliminary findings appear promising.
7161 Urology
Hemostatic Hydrodissection of the Neurovascular Bundles (HYNEB) During Laparoscopic Radical Prostatectomy: Early Potency and Continence Outcomes
Sijo J. Parekattil, Nicholas Franco, Jonathan K. Jay
Objective: Preservation of continence and potency after laparoscopic radical prostatectomy (LRP) are 2 key outcome measures that patients consider when comparing different treatment options for localized prostate cancer. This study presents the early potency and continence outcomes after hemostatic hydrodissection of the neurovascular bundles (HYNEB) during LRP.
Methods: This study was a prospective analysis of 30 consecutive LRP patients from September 2005 to October 2006 with follow-up ranging from 1 to 14 months. Standardized, validated quality of life measurement tools including the Sexual Health Inventory for Men (SHIM) were used preoperatively and postoperatively at 3-month intervals to assess potency and incontinence outcomes after the HYNEB procedure.
Results: At the time of this analysis, 93% of the patients were continent (defined as using no pads at all or only 1 pad for safety daily); 37% (11 patients) achieved continence by 1 week after surgery, 63% achieved continence by 1 month, and 90% by 3 months. Of the patients with a preoperative SHIM ≥17 (8 patients), 63% (5 patients) had returned to a SHIM score ≥17 (without the use of oral or injectable erectile dysfunction therapy) by 6 months. Two patients were able to have satisfactory intercourse without any oral or injectable therapy by 1 month after surgery.
Conclusion: Hemostatic hydrodissection of the neurovascular bundles (HYNEB) during LRP may promote the early return of continence and erectile function. The preliminary findings appear promising.
7163 General Surgery
Validity of Magnetic Resonance Cholangiopancreatography Before Videolaparocholecystectomy (VLC) in Patients with Mild Acute Biliary Pancreatitis
Vincenzo Neri, MD, Tiziano Pio Valentino, MD
Objective: Therapeutic ERCP before VLC in patients with moderate-severe acute biliary pancreatitis (ABP) is a well-recognized practice; the necessity of ERCP in patients with mild acute biliary pancreatitis is not well defined. We sought to evaluate the usefulness of MRCP before VLC in patients with mild ABP.
Methods: From 2003 through 2006, 25 patients underwent an MRCP (15 females; 10 males; mean age, 62 years, range 32 to 75) with mild ABP (Glasgow’s criteria) without an increase in the cholestasis tests (direct bilirubin, alkaline phosphatase, gamma-GT) and absence of choledocholithiasis at ultrasonography. During a 15-day to 60-day follow-up after the VLC, the presence of jaundice or relapse of ABP was evaluated in all patients by means of clinical/laboratory/instrumental examinations.
Results: Six patients had choledocholithiasis (stones/sand/sludge) at the MRCP, and they underwent an ERCP, stone removal, and afterwards the VLC; 19 patients with a negative MRCP underwent VLC. All 25 patients did not have jaundice or relapse of the ABP during the follow-up period.
Conclusion: MRCP was an accurate investigation for the preoperative diagnosis of choledocholithiasis; therefore, it is an important procedure for patients with mild ABP, avoiding ERCP.
7164 General Surgery
Laparoscopic Open Appendicectomy: A Single-Center Experience
S. T. Adams, M. Dordea, F. Mohammed, M. A. Gok, I. M. Bain
Introduction: Since the introduction of laparoscopic appendicectomy (LA) in 1983, numerous data suggest that LA is a safe and cost-effective treatment for appendicitis compared with open appendicectomy (OA). LA has been carried out safely in the young, elderly, obese, and pregnant patient. However, laparoscopic-open conversion still occurs in 2% to 10 % of attempted LA cases. The aim of the study was to explore the potential causes of laparoscopic-open conversion appendicectomy.
Methods: Since 2005, 12 lap-open conversion appendicectomies have been performed in a 12-month period at UHND. A cohort of 44 LAs and 72 OAs in the same period were recruited as controls. The descriptive demography is presented as mean ± SE. Statistical testing was made by the ANOVA test with P<0.05 being significant.
Results: L A (n=44) O A (n=72) Lap-open conv (n=12) ANOVA (P value)
Age (yrs) 31.45±2.28 28.47±2.21 45.42±5.77 <0.05
Sex (M:F) 14:30 52:20 8:4 <0.05
BMI 27.31±1.22 25.01±0.67 29.06±2.11 NS
ASA (median) 2 1 2 NS
WCC 109/L 13.51±0.60 15.20±0.62 15.20±1.62 NS
CRP mg/L 44.14±9.15 68.70±12.75 142.1±31.87 <0.05
Con: Reg: SHO
(surgeons) 9 : 35 : 0 3 : 54 : 15 2 : 10 : 0 NS
Operation time
(mins) 59.66±2.30 55.69±2.50 83.75±6.88 <0.05
Postop stay
(days) 2.00±0.23 2.65±0.36 4.83±1.53 <0.05
Length of A
(mm) 62.93±2.32 69.17±2.36 79.25±6.31 <0.05
Width of A
(mm) 9.79±0.45 10.31±0.45 14.50±1.71 <0.05
Histology (n)
Normal 7 15 1 NS
Acute Supp 32 53 11 NS
Perforation 5 15 5 0.058
Gangrenous 6 15 3 NS
Peritonitis 9 21 0 0.074
Chronic fibrosis 17 19 0 <0.05
Discussion: Laparoscopic-open conversion was more common in the elderly with severe appendicitis and consequent longer hospital stay. The resultant operation time was prolonged as this included the period of laparoscopy before conversion. Reasons for conversion in this series included appendix not visualized (1), retrocecal appendix (1), pelvic appendix (1), difficult technique (2), gangrenous appendicitis (4), thickened mesoappendix (4), and dense adhesions (3). These causes can be explained by the progressive pathophysiology of appendicitis (ie, severe inflammation or adhesions, perforation, and peritonitis). Other potential causes for conversions include difficult appendix localization, surgical inexperience, bleeding, equipment failure, the marginal patient (cardio-respiratory comorbidities), and the difficult anesthesia.
7165 General Surgery
Anastomotic Leaks Following Laparoscopic Gastric Bypass
John S. Koppman, MD, Stuart Shindel, MD, Christina Li, MD, Alejandro Gandsas, MD
Objective: To give an overview of the cause, diagnosis, and treatment of anastomotic leaks following laparoscopic gastric bypass and to provide recommendations to avoid this problem.
Methods: Case report and literature review.
Results: Anastomotic leaks after gastric bypass occur in as many as 1.6% of open cases and 4% of laparoscopic cases. Most occur as a result of technical error, such as misplacement of sutures or staples, inadvertent vascular compromise, or tension at the suture line. As of today, the surgical management of postoperative leaks relies on vigorous lavage, identification and closure, if possible, of the defect, and drainage of the abdominal cavity. A gastrostomy tube should be placed to decompress the gastrointestinal tract and secure a route for enteral nutrition during the postoperative period. Antibiotics also should be added to control infection.
Conclusions: Anastomotic leaks after gastric bypass surgery are mainly due to technical errors. Performing a leak test, intraoperative endoscopy, or both, is useful in identifying leaks intraoperatively, while hypervigilance with regard to anastomotic tension and ischemia may avoid the development of a leak during the immediate postoperative period.
7166 General Surgery
Laparoscopic Ileal Flap for Colpopoiesis
Jixiang Wu, Bin Li
Objective: To analyze the operational technique of laparoscopic vaginoplasty by transferring ileal segment flaps.
Methods: This was a review of 62 cases of laparoscopic ileal flap for colpopoiesis. Sixteen cases were performed by total laparoscopic surgery and 46 by laparoscopic assistance.
Results: The operations of laparoscopic ileal flap for colpopoiesis were successful in these cases. One patient suffered from ileus and was cured through a second operation by ileal anastomosis after resection of the flap. Stricture of the vaginal placket occurred in 3 patients; 2 were cured by distention and another by plastic surgery.
Conclusion: Laparoscopic ileal flap in vaginoplasty for colpopoiesis is minimally invasive and provides a better outcome.
7167 General Surgery
A Laparoscopic Approach to the Surgical Management of Gastrocutaneous Fistula Following Gastrostomy Tube Removal
Nicholas A. Tarola, MD, Michael Weinstein, MD, Kris Kaulback, MD
Persistent gastrocutaneous fistula (GSF) is an uncommon, but known, complication following gastrostomy tube removal. In the event that initial medical management (ie, parenteral nutrition, gastrointestinal tract decompression, suppression of gastric fluid production, and antibiotic therapy as necessary) fails, surgical closure is usually required. The traditional surgical treatment for the persistent gastrocutaneous fistula consists of a formal laparotomy in the midline or at the fistula site. A laparoscopic approach may be a valid alternative. To date, we have treated 6 patients with persistent gastrocutaneous fistula using a laparoscopic stapling technique as described herein. An umbilical port was placed by using a blunt trocar following incision and dissection into the peritoneum. An additional port was placed under direct visualization. Adhesiolysis allowed complete visualization of the fistula, which was then ligated by using an endoscopic linear cutting stapler. The average operative time was 35 minutes. All 6 cases were completed without complication as well as their postoperative courses. There was no sign of recurrence at the final follow-up visits. We present this laparoscopic approach as a safe and effective alternative for the surgical management of gastrocutaneous fistula.
7168 Urology
Laparoscopic Radical Nephrectomy for Large Renal Tumors (>7cm): Intermediate Oncologic Outcomes
Jay D. Raman, MD, James S. Rosoff, MD, R. Ernest Sosa, MD, Joseph J. Del Pizzo, MD
Introduction and Objective: Laparoscopic radical nephrectomy (LRN) is a reasonable surgical therapy for stage T1 renal cell carcinoma. Data, however, are limited regarding the oncologic efficacy of laparoscopic surgery for bulky renal cell carcinoma. We report outcomes of LRN in 30 patients with large renal tumors (>7cm).
Methods: Thirty patients underwent a laparoscopic (n=23) or hand-assisted laparoscopic (n=7) nephrectomy for renal cell carcinoma. Medical, laboratory, and radiologic records were reviewed.
Results: The mean pathologic tumor size was 8.2cm (range, 7.1 to 14.0). Final pathologic stage was T2 in 18 cases, T3a in 9, T3b in 2, and T4 in 1. Histological analysis revealed the clear cell subtype in 22 cases, papillary in 4, and chromophobe in 4. There was one positive margin (T4 tumor) and no port-site recurrences. At a mean follow-up of 24 months (range, 10 to 45), the recurrence-free, cancer-specific, and overall survival rates were 79%, 96%, and 90%, respectively. All 18 patients with T2 tumors had no evidence of disease recurrence. Five patients were alive with metastatic disease (4 T3a, 1 T3b), 1 died from brain metastases (T4), and 2 died from other causes. The mean increase from baseline serum creatinine in our series was 0.5mg/dL (P=0.70), and no patient became dialysis-dependant.
Conclusions: Intermediate oncologic and clinical outcomes suggest that laparoscopic radical nephrectomy is a reasonable surgical therapy for the management of large renal tumors. While longer-term results are needed, our 2-year follow-up in the hands of experienced laparoscopic surgeons is encouraging.
7169 Urology
Increasing Body Mass Index (BMI) Negatively Impacts Outcomes Following Robotic Radical Prostatectomy
Jay D. Raman, MD, Michael P. Herman, MD, Steven Dong, MD, David Samadi, MD, Douglas S. Scherr, MD
Introduction and Objective: Over 70% of men over age 40 in the United States are overweight (BMI, 25 to 29.9) or obese (BMI >30). We clarify the impact of increasing BMI by describing our experience with patients undergoing robotic radical prostatectomy.
Methods: Patients were divided into 3 cohorts based on preoperative BMI: normal (BMI, 18 to 24.9), overweight, and obese.
Results: Thirty-eight men had a normal BMI, 60 were overweight, and 34 were obese. No differences existed between groups regarding patient age, clinical T stage, biopsy Gleason score, or preoperative PSA. The operative time was longer in obese (304 min) men compared with overweight (235 min) and normal (238 min) BMI patients (P<0.001). The EBL was also greater in both the obese (316mL) and overweight (318mL) groups compared with men with normal BMI (234mL) (P<0.005). Hospital duration was shorter for normal BMI men (1.1 days) than for overweight and obese patients (1.6 and 1.7 days, respectively) (P<0.05). Twenty-three of 132 patients (17%) had a positive surgical margin, with obese (21%) and overweight (20%) men at a greater risk than patients with normal BMI (11%) (P<0.05). There were no significant differences between groups with regard to final pathologic stage, Gleason score, biochemical recurrence, or return of continence at 1-year, and postoperative complication rate.
Conclusion: Overweight and obese men have a longer operative duration, greater blood loss, longer hospital duration, and higher positive surgical margin rate. Robotic prostatectomy in men with elevated BMI is technically more challenging and is associated with more perioperative morbidity.
7170 General Surgery
Therapeutic Evaluation of Laparoscopic Hernioplasty for Inguinal Hernia in Elderly Males
Haifeng Peng, MD, Jinyu Dai, MD, Tongbiao Zhen, MD, et al.
Objective: To evaluate the therapeutic effect of laparoscopic hernioplasty for inguinal hernias in elderly males and to compare the advantages and disadvantages between laparoscopic hernioplasty and traditional hernioplasty.
Methods: Twenty elderly male patients with inguinal hernias were treated with laparoscopic hernioplasty, while another 18 patients were treated with traditional inguinal hernioplasty.
Results: Patients in the laparoscopic hernioplasty group remained immobile (16.65±1.76 vs 169.17±5.47 hours, P<0.05), and stayed in the hospital (7.25±1.07 vs 10.22±1.26 days, P<0.05) for a significantly shorter time than the traditional hernioplasty group did, whereas the mean procedure time was longer (88.90±16.27 vs 52.67±9.22 minutes, P<0.05), and total costs in the laparoscopic hernioplasty group were higher (7309±1999 vs 4148±548 yuan RMB, P<0.05) than in the control group.
Conclusions: Laparoscopic hernioplasty for inguinal hernias in elderly males can clearly shorten the time of hospitalization and postoperative recovery. Along with further improvement of laparoscopic skills and the development of more precise laparoscopic instruments, the time for laparoscopic hernioplasty will be further shortened. The expenses for laparoscopic hernioplasty will decline. Laparoscopic hernioplasty could be a good option for inguinal hernia in elderly males.
7171 General Surgery
Minilaparotomy for GERD Treatment
Juan G. Quiroz, MD, Luis G. Jimenez, MD, Axel Costilla, MD, Alfonso J. Guiroz, MD, Elvia E. T. Nova, MD
Objective: Because the open procedure in the treatment of gastroesophageal reflux disease (GERD) is a sure and still accepted technique with less mechanical failure in the long run, we decided to perform this access with a small incision. This technique was undertaken demonstrating great advantages. Although laparoscopic access is still the first choice of surgeons, the fall of antireflux laparoscopic procedures in the USA is almost 30% today.
Methods: From January 2002 to December 2006, 138 patients were operated on. The primary outcome measures included a small incision, short operating time, pain score, hospital stay, costs, short disability, and early and late complications, such as reflux recurrence and return to PPI medication. Endoscopic study was performed, including biopsy, barium study, manometric and 24-pH monitoring of the esophagus, and a new endoscopic procedure, at 45-day PO, at 6 months, and yearly to evaluate early and late outcomes. We used specific instruments to perform this minilaparotomy.
Results: From January 2002 to December 2006,138 patients underwent this surgical procedure. Females predominated, and the mean age was 40.8. During 5-year follow-up, only 5 cases of reflux recurred, three of them due to mechanical failure because of a large hiatal hernia. The other 2 patients had recurrence because they drank heavily during the 3-month postoperative (PO) period. Early complications were minor and resolved spontaneously. Six cases of wound infection occurred in diabetic patients and were controlled early.
Conclusions: The main fact observed was patient satisfaction and well being, all patients having good intake of food. The low cost, small scar, and short disability similar to that with the LAP procedure are the primary advantages leading to long-term success. The open procedure with a small incision has the advantages of no virtual vision, direct control when bleeding occurs, better liberation of the distal esophagus, good control of fundoplication tailoring, and long-term success manifested by endoscopic procedures in the surveillance PO and of course years of patient satisfaction.
7172 General Surgery
Laparoscopic Hernia Repair – A Two-port Technique
Dr. Katerina Theodoropoulou, MBBS, Dr. Sanjeev Gupta, MBBS, BSc (Hons), Dr. Dean Lethaby, MBBS, BMedSci (Hons), Mr. Howard Bradpiece, FRCS, Mr. Fouad Kaldas FRCS
Objective: The laparoscopic technique has proven safe and effective in the repair of ventral and incisional hernias with low rates of recurrence. The purpose of this study was to document the 2-port technique and demonstrate that it is safe, effective, and rapid. This is the largest report to date regarding this technique.
Methods: Twenty-eight patients with primary and recurrent ventral and incisional hernias underwent laparoscopic repair with a 2-port technique. The technique requires insertion of one 10-mm to 12-mm balloon port and one 5-mm straight port, usually on the left side as laterally as possible. Composite polypropylene and ePTFE meshes were used to cover the defect overlapping the margin circumferentially by 3cm. Mesh diameters ranged from 6.4x6.4cm to 21.0x26.1cm. Meshes were inserted through the balloon port and attached to the abdominal wall by using either 4 peripheral or 1 central stitch secured extracorporeally before being fixed along its perimeter with titanium helical fasteners.
Results: The operative time ranged from 15 minutes to 70 minutes (mean, 36). Twenty-five patients developed no complications. Two patients developed small-bowel obstruction with bowel adhering to the anterior side of the mesh, requiring laparoscopic repair. One developed a seroma. One wound infection was treated successfully with antibiotics. Follow-up ranged from 0 months to 12 months. Most of the patients spent 1 day in the hospital.
Conclusion: Laparoscopic repair of ventral and incisional herniae can be successfully and safely performed using only 2 ports.
7173 Gynecology
Incidence of Pelvic Pain Dyspareunia and Vaginal Spotting After Outpatient Laparoscopic Intracervical Subtotal Hysterectomy (LISH)
Maurice K. Chung, RPh, MD, Jennifer Glance, DO, Jamie Marsteller, MOA, Rhonda Medina, MD, Jackie Shriver, CRNP
Objective: To determine the incidence of postoperative dyspareunia, pelvic pain, and vaginal spotting in patients undergoing LISH.
Methods: This was a prospective cohort study of 133 patients. From 2002 to November 2006, 133 women ages 21 to 56 diagnosed with menorrhagia, dysmenorrhea with or without pelvic pain, or dyspareunia underwent outpatient LISH, and the outcomes were measured.
Results: Abnormal uterine bleeding alone occurred in 114 patients. Abnormal uterine bleeding with pelvic pain or dyspareunia was present in 19 patients. In the 114 patients, no immediate postoperative dyspareunia or pelvic pain occurred during the follow-up period of 6 months. One patient was diagnosed with dyspareunia secondary to vaginal dryness 7 months after surgery. Two patients had a diagnosis of interstitial cystitis after 1 year. Low back pain developed in 1 patient. Two patients had a cervical tear from the tenaculum. There were 19 patients with pelvic pain and dyspareunia in addition to abnormal uterine bleeding. Thirteen of the 19 tested positive for painful bladder syndrome/IC before surgery. They were properly treated prior to LISH. Only 11 patients developed minimal vaginal spotting, one of whom was on Coumadin for thromboembolic disease.
Conclusion: Our study shows the low incidence of postoperative pelvic pain/ dyspareunia and vaginal spotting with LISH. It also clearly demonstrates that pelvic pain/dyspareunia should be evaluated and treated before offering LISH. IC/painful bladder syndrome remains one of the bigger factors for women with dyspareunia and pelvic pain. The LISH procedure may be offered to those patients with dyspareunia or pelvic pain after being properly evaluated and treated for IC/painful bladder syndrome.
7174 General Surgery
Laparoscopic-assisted Colonoscopic Polypectomy: Long-term Results
Morris E. Franklin Jr, MD, Guillermo Portillo, MD, Jefrey L. Glass, MD, John J. Gonzalez Jr, MD
Introduction: Benign polyps are the most common diseases of the colon and are considered by many as premalignant lesions.
Methods: From May 1990 to November 2006, laparoscopic-monitored colonic polypectomies were performed in 144 patients, with 190 polyps being removed. After laparoscopic mobilization of the involved segment of the colon, the proximal bowel was cross-clamped and the colonoscope passed to the involved portion of the colon.
Results: Fifty-one percent of patients were males and 49% were females, with a mean age of 73 years (range, 20 to 95). A total of 190 polyps were removed as follows: 112 right colon (59%), 23 transverse (12%), 12 left colon (7%), and 33 rectosigmoid (22%). In 96% of the patients, laparoscopic-monitored colonic polypectomies were performed successfully. Because of technique problems and positive margins, 4% of the patients required full-thickness resection. The average hospital stay was 1.14 days with a liquid diet started 6 hours postoperatively. Morbidity was 10% (atelectasis, seroma, ileus).
With a mean follow-up of 74 months (range, 1 to 196 months), there have been no recurrences.
Conclusions: The use of a combined endoscopic-laparoscopic approach provides a valid alternative for treating difficult colonic polyps and eliminates the morbidity of a segmental resection. Long-term follow-up demonstrates that this technique is safe and effective.
7175 General Surgery
The Use of Small Porcine Bowel Submucosa Mesh for Treating Gastroesophageal Reflux: Long-term Results at the Texas Endosurgery Institute
Morris E. Franklin Jr, MD, Guillermo Portillo, MD, Jefrey L. Glass, MD, John J. Gonzalez Jr, MD
Introduction: One of the most common complications after antireflux surgery is the recurrence of GERD symptoms. The aim of this study was to analyze the use of Surgisis mesh for treating GERD.
Methods: This was a 6-year prospective follow-up of the use of Surgisis mesh (SIS Cook Biotech Incorporated, West Lafayette, IN, USA) for treating GERD at the Texas Endosurgery Institute. All patients who underwent laparoscopic hiatal hernia (HH) repair at our institution from January 2000 to December 2006 were included in the study.
Results: Laparoscopic Nissen fundoplication and HH repair using a bioabsorbable prosthetic mesh were completed in 46 patients. Twenty-six were females and 21 were males, with a mean age of 59 years (range, 32 to 91). Ten patients had an HH smaller than 5cm (52%); 15 had an HH hernia larger than 5cm (48%). Ten of the patients had a recurrent HH (30%). One patient had an incarcerated HH (2%). All cases were completed laparoscopically with just one conversion (2%). The mean operating time was 175 minutes (range, 75 to 400). Seventeen patients (34%) had severe adhesions present at the HH. There was a 2% complication rate, ie, gastric injury in 1 patient.
Conclusions: The laparoscopic placement of small porcine bowel submucosa mesh in the hiatus is safe and effective to prevent recurrence of reflux symptoms.
7176 General Surgery
Laparoscopic Biliary Bypass Procedures: Review of the First 14 Years
Morris E. Franklin, Jr., MD, Guillermo Portillo Ramila, MD, Jefrey E. Glass, MD, John J. Gonzalez, Jr., MD
Bypass of the biliary tree in the form of choledochoduodenostomy and choledochojejunostomy was described more than 100 years ago. In 1991, the first laparoscopic choledochoduodenostomy was reported, and since then, this procedure has gained popularity among advanced laparoscopic surgeons. We describe 26 patients operated on at the Texas Endosurgery Institute (TEI) in the past 14 years, with favorable results. We conclude that laparoscopic biliary bypass is a safe, effective procedure that should be considered in the arsenal of the laparoscopic surgeon.
7177 Multispecialty
Hydrodistention for Interstitial Cystitis Consistently Provides Improvement in Properly Selected Patients
Bradford W. Fenton, MD, PhD, Robert Flora, MD, James Fanning, DO
Objective: Interstitial cystitis is a common diagnosis in patients with chronic pelvic pain, and cystoscopic hydrodistention (HD) is a frequently applied treatment with variable efficacy and duration of action. The objective of this study was to determine the efficacy and duration of the effect from HD in patients selected for this procedure using a sequential diagnostic algorithm.
Methods: A cohort of chronic pelvic pain patients underwent a sequential diagnostic algorithm to select candidates for HD. A score of >6 on the interstitial cystitis symptom index, bladder pain as a significant component of pelvic pain, and a good response to alkalinized lidocaine instillation were the criteria. All patients received adjuvant treatment including dietary counseling, pentosan, and amitriptyline. Improvement was based on patient reports using a modified Likert-type scale.
Results: Of the 13 patients studied after a total of 23 distensions, 100% of patients reported improvement following HD. For all patients, the number of days of relief is 101 (SEM=17). For patients who have not requested another distension, the average number of days since the HD is 91 (SEM=21; range, 11 to 211). For patients requesting repeat HD, the average number of days between treatments is 110 (SEM=28; range, 26 to 252).
Conclusion: Hydrodistention provides an effective method for relieving interstitial cystitis related symptoms in properly selected patients. Using a sequential diagnostic algorithm preoperatively optimizes the chances of patient response. The effects of distension last approximately 3 months to 4 months, even in the presence of adjuvant therapy.
7178 General Surgery
Symptom Severity and Disability in Chronic Pelvic Pain Worsens When an Increasing Number of Pain Diagnoses Is Present
Bradford Fenton, MD, PhD, Robert Flora, MD, James Fanning, DO
Objective: To compare the number of pain-related diagnoses in patients with chronic pelvic pain to symptom and disability scores.
Methods: Eighty-one patients underwent evaluation at a chronic pelvic pain referral center. This included symptom scores using the visual analog pain scale (VAS), interstitial cystitis symptom index (ICSI), the 5 minor irritable bowel syndrome (IBS) criteria, a disability scale, and the number of myalgia trigger points (FMS), among others. The number and nature of their pain-related diagnoses was based on history, examination, imaging or endoscopic studies, and the outcomes of surgical or medical treatment. The number of pain diagnoses ranged between 1 and 4 and were categorized as gynecologic pain, interstitial cystitis, myalgia, and IBS.
Results: Of the total number of patients, 41% had one, 24% had two, 22% had three, and 11% had all four pelvic pain diagnoses. A Spearman rank correlation between the number of diagnoses and the symptom scores revealed a significant, positive relationship for disability (<0.0141), ICSI (<0.001), IBS (<0.001), FMS (<0.001), and days off per week from pain (<0.0306). There was no correlation with the presenting VAS pain score.
Conclusion: More than half of patients with chronic pelvic pain have more than one pain-related diagnosis. For patients with higher levels of symptom scores, or with extended disability, multiple pain generators should be sought.
7179 General Surgery
Laparoscopic Management of Benign Upper GI Diseases
Yue Dong Wang, MD, Zai Yuan Ye, MD, Yang Wen Zhu, MD, Zhi Jie Xie, MD, Wei Zhang, MD
Objective: To explore the efficacy and safety of laparoscopic paraesophageal hernia repair, laparoscopic vagotomy for duodenal ulcer, laparoscopic resection for gastric benign tumor, and laparoscopic esophagomyotomy for achalasia.
Methods: Between November 1995 and April 2006, 28 patients underwent laparoscopic paraesophageal hernia repair: 24 laparoscopic vagotomies for the treatment of duodenal ulcer, 10 laparoscopic resections for gastric benign tumor, and 3 laparoscopic esophagomyotomies for achalasia.
Results: Laparoscopy was completed in all patients; no conversions from laparoscopic to open surgery were necessary. The operation time averaged 2.5 hours (range, 1.0 to 4.5); postoperative oral feedings were resumed 24 to 72 hours after surgery, and no postoperative complications occurred. The median postoperative hospital stay was 6 days (range, 3 to 7).
Conclusion: Laparoscopic surgery is an effective, safe surgical procedure and has the merit of minimally invasive surgery for the patients with benign upper GI diseases.
7180 Gynecology
Laparoscopic-assisted Vaginal Hysterectomy for a Term-size Uterine Myoma
Lim Woh Koh, MD, Pui Ru Koh, MBBS, Chui Na Wong, MD, En Lun Sun, MD, Min Ho Huang, MD
The first laparoscopic-assisted vaginal hysterectomy (LAVH) was reported in 1989 by Reich H et al. Since then, laparoscopic hysterectomy has been performed increasingly as management for gynecologic disease. Laparoscopic hysterectomy utilizes the latest minimally invasive surgical techniques to remove the uterus through small finger-width (0.5cm to 1cm) abdominal incisions. It has become one of the most common major surgical procedures performed by gynecologists. We present the case of a large uterine myoma, the largest ever reported to the best of our knowledge. It is notable that the largest uterus removed by minilaparotomy assisted LAVH weighed 3250 grams.
7181 Gynecology
A Viable Cornual Pregnancy Treated Laparoscopically
Lim Woh Koh, MD, Pui Ru Koh, MBBS, Chui Na Wong, MD, En Lun Sun, MD, Min Ho Huang, MD
Traditionally, the terms cornual pregnancy and interstitial pregnancy have been used interchangeably, defined as pregnancy developing in one horn of a bicornuate uterus. Cornual pregnancies are the least frequent variety of ectopic pregnancies, accounting for 1.8% of all ectopics and <0.01% of all pregnancies. Except for the rare kind occurring as part of natural conception cycles, cornual pregnancies can lead to catastrophic hemorrhage and maternal jeopardy once rupture occurs. By utilizing the high resolution afforded by transvaginal sonographic techniques, early detection of cornual pregnancies is possible with recognition of characteristic sonographic features. Unruptured cornual pregnancies usually do not give rise to any clinical manifestations. However, when ruptures do occur they are most often in the second trimester, as opposed to the first in tubal pregnancies. After a review of “Medline” for cornual pregnancy entities, most reported cases of cornual pregnancies were diagnosed after uterine rupture, with the median age of 11 weeks to 20 weeks. Here, we present a case of a cornual pregnancy diagnosed at 12 weeks’ gestation.
7182 General Surgery
Preoperative Embolization of an Adrenal Pheochromocytoma
Osvaldo Contarini, MD
Introduction: Laparoscopic adrenalectomy is the most preferred and safest mode of treatment of adrenal tumors and above all pheochromocytomas. Dissection of the gland and control of single venous drainage can be accomplished with minimal handling of the tumor, thus, significantly reducing the risk of a severe intraoperative hypertensive crisis. A recent difficult case of a large adrenal pheochromocytoma has led to seriously considering an important preoperative step to further secure smooth progress of this daunting procedure.
Methods: A 21-year-old young lady was referred for removal of an 8-cm right adrenal pheochromocytoma. Properly diagnosed and controlled with several month’s preparation, she underwent a planned laparoscopically hand-assisted adrenalectomy. Upon initiation of the pneumoperitoneum, her blood pressure became mildly elevated and was controlled by decreasing the intraabdominal pressure. Upon elevation of the liver, a very high spike in her blood pressure occurred, controlled both with drugs and removal of the pneumoperitoneum. Upon restarting of the procedure, despite normalization of the blood pressure, several times the pneumoperitoneum had to be removed due to a significant decrease in oxygen saturation. An intraoperative chest radiography revealing pulmonary edema forced the procedure to be aborted.
Results: Three days later, the adrenalectomy was easily and safely performed without any expected hypertensive crisis, thanks to preoperative venous and arterial embolization of the right adrenal gland. Despite its large size and weighing 179 grams, with production of both adrenaline and noradrenaline in extremely high quantities, this tumor could be safely handled with astonishing simplicity.
Conclusion: Notwithstanding the fact that any literature search has failed to reveal any report of venous embolization, this difficult case has led to the realization that preoperative embolization of the gland leads to very safe removal of this frightening pheochromocytoma, suggesting that almost certainly every pheochromocytoma should be embolized prior to its surgical removal.
7183 Gynecology
Laparoscopic Radical Hysterectomy and Lymphadenectomy for Invasive Cervical Cancer: Techniques, Results, and Oncological Outcome of 343 Consecutive Cases
Zhiqing Liang, Prof Dr. Med, Huicheng Xu, MD, Yong Chen, MD, Qiaoyu Zhang, MD, Yuyan Li, MD
Objective: Cervical carcinoma is likely to become one of the most important indications for laparoscopic radical surgery. The laparoscopic technique combines the benefits of a minimally invasive approach with established surgical principles. In our institution, the laparoscopic radical hysterectomy with the transperitoneal approach lymphadenectomy has become the standard technique for invasive cervical cancer. We report the indications, techniques, and oncological outcome in a single-center experience.
Method: Between July 2000 and March 2006, we performed laparoscopic radical hysterectomy for cervical cancer in 343 patients. Their initial indication, complications, results, and postoperative course were evaluated.
Results: Of 343 procedures, 339 were successful. Paraaortic lymphadenectomy was performed in 170 (49.6%) patients, and pelvic lymphadenectomy was performed in all 343 patients. The median blood loss was 210mL. The mean operation time was 186 minutes, including the learning curves of 3 surgeons. In 4 cases (1.6%), conversion to open surgery was necessary due to bleeding (3 cases) or bowel injury (1 case). Major intraoperative injuries occurred in 4.1% of patients. In 8 patients (2.3%), intraoperative complications were managed laparoscopically; another 6 patients were managed by open surgery. In 46 (13.4%) patients, positive lymph nodes were found. Surgical margins were negative for tumors in all patients. Mean hospital stay was 10.3 days. Postoperative complications occurred in 8.2% of patients. Follow-up was between 9 and 72 months with an average of 38.5 months. The overall disease-free survival was more than 94% for Ia2, 87.8% for Ib, and 84.4% for II until July 2006, respectively.
Conclusion: Laparoscopic radical hysterectomy is a routine, effective treatment for patients with Ia2 to IIb cervical carcinoma. With more surgeon experience, IIb stage patients can be managed safely offering all the benefits of minimally invasive surgery to the patients. Although no long-term follow-up is available, our follow-up data up to 72 months confirm the effectiveness of laparoscopic radical hysterectomy in terms of surgical principles and oncological outcomes.
7184 Gynecology
Laparoscopic Sacrospinous Ligament Fixation for Uterovaginal and Vault Prolapse
Zhiqing Liang, Prof Dr. Med, Huicheng Xu, MD, Yanzhou Wang, MD, Dan Wang, MD
Objective: To investigate the technique, efficacy, and safety of laparoscopic sacrospinous ligament fixation (LSSLF) for stage II and stage III uterovaginal prolapse. The LSSLF technique was used as part of the vaginal repair procedure for markedly uterovaginal prolapse, and in the treatment of vault prolapse.
Methods: LSSLF was used to treat 29 patients with stage II and stage III uterovaginal prolapse and vault prolapse. All patients have clinical symptoms. Regular follow-up was provided at 1, 3, 6, 9, and 12 months after surgery. Patients without any subjective symptoms were defined as having a subjective cure, and a pelvic organ prolapse quantification (POP-Q) of 0 of the uterine and vault was defined as an objective cure.
Result: The procedure was performed on 29 women. The average operative time was 75 minutes (range, 55 to 120), and estimated blood loss was 105mL (range, 60 to 200). The overall hospital stay averaged 4.7 days. The intraoperative complication rate was 2/29 (69.9%). The immediate postoperative complication rate was 2/29 (6.9%). The late postoperative complication rate was 1/29 (3.4%). Patients were followed up for 15 months (range, 2 to 32) after surgery. The subjective cure rate in our department was 27/29 (93.1%), and the recurrence rate was 2/29 (6.9%).
Conclusions: We concluded that laparoscopic sacrospinous ligament fixation is safe and effective for patients with uterovaginal and vault prolapse and with good medium-term results and few postoperative complications.
7185 General Surgery
The Effect of Video Game “Warm-up” on Performance of Laparoscopic Surgery Tasks
James C. Rosser, Jr., MD, Bjorn Herman, BA, Paul Lynch, MD, Douglas Gentile, PhD,
Objectives: “Warming up” before performing a skill can lead to early and sustained excellence. Performing procedures in the laparoscopic arena requires special training to perform at a superior level. Our previous studies suggest that video-game play is associated with superior laparoscopic performance, so we investigated whether surgeons benefited from practicing video games immediately before performing laparoscopic surgical tasks.
Methods: Participants were split into a control (n=180) and experimental group (n=123), similar in years of experience, surgeries performed, and pretest measure of suturing skill. The experimental group played video games for 30 minutes on home video game consoles. Then, all subjects were enrolled in the “Rosser Top Gun Course,” which uses preparatory drills and a structured algorithm to teach intracorporeal suturing. Performances were based on each participant’s speed and accuracy in laparoscopic drills.
Results: Surgeons who played video games before the Cobra Rope drill (in which laparoscopic tools are moved along a piece of string, clamping it at marked intervals) were significantly faster on their first attempt (t=2.17, P<0.05) and across all 10 trials (t=2.28, P<0.05).
Conclusion: This study demonstrated that subjects completing a “warm-up” session with video games before performing laparoscopic tasks were faster than those not engaging in “warm-up.” This study augments our previous research suggesting that video games could serve as a cost-effective training platform when used as a preparatory exercise for minimally invasive surgical procedures.
7186 Gynecology
Robotic Surgery in Gynecologic Oncology: First 120 cases
Ricardo Estape, MD, Eric Estape, ARNP, Robert Diaz, ARNP
Objective: To examine the use of robotic-assisted surgery in a busy gynecologic oncology practice, the operative variables, complications, and outcome of the first 120 procedures performed.
Methods: All patients scheduled for laparoscopic surgery where informed about the procedure and gave consent to be changed to robotic surgery for their procedure from August 7, 2006 to January 15, 2007. Patient status was evaluated by using morbidity, length of surgery, anesthesia time, blood loss, margins, lymph node counts, length of hospital stay.
Results: Many types or combinations of procedures were performed including hysterectomy, radical hysterectomy, pelvic lymphadenectomy, paraaortic lymphadenectomy, uretero-ureterostomy, ureteroneocystostomy, posterior exenteration, salpingo-oophorectomy, and staging procedures, among others. Morbidity, length of surgery, anesthesia time, and length of hospital stay were similar to those for laparoscopic procedures performed by the same surgeon. Blood loss and lymph node counts were significantly improved. Margins seem to be wider but not significantly less involved with tumor. Two cystotomies were seen in the first 2 weeks of the trial, but no other complications occurred after the first week. One case was converted to laparoscopy due to the size of the uterus (20cm to 1250gm), and one case was converted to laparotomy, abdominal cerclage was done at 16 weeks.
Conclusions: Although this is a nonrandomized, single-institution trial, the evidence shows that robotic surgery can be incorporated into a busy gynecologic oncology practice with no increase in morbidity, length of surgery, or hospital stay. The data also suggest that cancer parameters, such as node count and margins, may be improved with the use of robotic surgery.
7187 General Surgery
Advantages of the Laparoscopic Approach for a Perforated Peptic Ulcer
Bulent Yaycioglu, MD, Mustafa Gulkaya, MD, Atilla Akova, MD, Kadir Kara, MD
Aim: Comparison of open and laparoscopic peptic ulcer perforation repair.
Method: Until the last half of 2006, we treated perforated peptic ulcers with classical laparotomy, because we did not have a laparoscopic emergency team. After that, we treated 21 perforated peptic ulcers with the laparoscopic approach. We compared our old cases, which were treated with open surgery, with our new laparoscopic-treated ones.
Results: The operative time was longer with laparoscopy than with the classical approach. Other parameters demonstrated that the laparoscopic method is comfortable, useful, and reliable.
Conclusion: We realized that the laparoscopic approach to treating perforated peptic ulcer is more effective and healthy compared with open surgery. Because perforated ulcer signs look like some other intraabdominal pathologies, the laparoscopic approach is useful to recognize and identify other pathologies. In addition, the patients do not undergo unnecessary abdominal incisions.
7188 Urology
Effect of Tumor Size on Intraoperative and Perioperative Outcomes in Patients Undergoing Laparoscopic Partial Nephrectomy with Hilar Occlusion
Michael E. Woods, MD, Erik P. Castle, MD, Melissa M. Walls, MD, Rodney Davis, MD, Raju Thomas, MD
Objectives: To evaluate the effect of tumor size on laparoscopic partial nephrectomy (LPN) with hilar occlusion.
Methods: A review of patients undergoing LPN at our institution was performed. Seventy-four patients were identified. There were 49 patients who underwent laparoscopic partial nephrectomy with hilar occlusion and had complete data for review. Group 1 had a tumor size ≤3cm (n=30), and group 2 had a tumor size >3cm (n=19) on final pathology. Outcomes between the 2 groups were compared.
Results: Overall, the mean tumor size was 3.0cm (range, 1 to 7), mean warm ischemia was 43.7 minutes (range, 27 to 80), and mean operative time, blood loss, and length of stay were 179 minutes (range, 87 to 360), 200cc (range, 10 to 1000), and 3.0 days (range, 1 to 13), respectively. Three patients (6.1%) had positive margins. The mean tumor size was 2.1cm and 4.3cm for groups 1 and 2. The mean operative time and warm ischemia times were 173 versus 189 minutes (P=0.39) and 41.4 versus 47.0 minutes (P=0.11), for groups 1 and 2. Mean blood loss was 167cc versus 252cc (P=0.30) in groups 1 and 2. Five complications (16.6%) occurred in group 1, and 2 complications (10.5%) occurred in group 2. There were 2 positive margins in group 1 and 1 positive margin in group 2 (6.6% versus 5.2%).
Conclusions: Outcomes were similar between the 2 groups, except that the large tumor group did tend toward longer warm ischemia times, but this did not reach statistical significance. These findings support the idea that laparoscopic partial nephrectomy can be safely performed in properly selected patients with renal tumors >4cm.
7189 Urology
Robotic-assisted Radical Cystectomy
Erik P. Castle, MD, Michael E. Woods, MD, Fatih Atug, MD, Raju Thomas, MD, Rodney Davis, MD
Objectives: To report our technique and initial experience of robotic-assisted radical cystectomy (RARC) in 20 patients.
Methods: Robotic-assisted radical cystectomy (RARC) was performed in 16 male and 4 female patients. Ten neobladders and 10 ileal conduits were performed. All patients underwent an extended lymph node dissection including common iliac lymph nodes. The bladder was removed in a specimen retrieval sac through a small periumbilical incision. In female patients, the bladder was removed through the vaginal incision. Urinary reconstruction was performed extracorporeally, and urethroneovesical anastomosis was performed robotically in cases with orthotopic neobladder.
Result: The overall median operative time was 410 minutes (range, 340 to 660). The median operative time was 415 minutes (range, 330 to 660) for orthotopic neobladder and 390 minutes (range, 340 to 450) for ileal conduits. The median blood loss was 150cc (range, 100 to 600). The median length of stay was 4 days (range, 2.5 to 20). Nerve sparing was performed in 11 of 16 male patients. The mean number of lymph nodes removed was 12 (range, 8 to 18), and 6 patients (30%) had lymph node metastasis. Surgical margins were negative in all patients. Mean follow-up has been 11 months.
Conclusion: RARC is a technically feasible operation with minimal blood loss. Early mobilization of patients shortened convalescence dramatically. Although we have limited follow-up, oncologic outcomes appear favorable and comparable to those of open surgery. Advantages of robotic surgery and minimally invasive surgery may be even more apparent with cystectomy than with prostatectomy.
7190 Urology
Robotic-assisted Radical Cystectomy in the Female Patient
Richard Matern, MD, Erik P. Castle, MD, Michael E. Woods, MD, Raju Thomas, MD, Rodney Davis, MD
Objectives: Robotic-assisted radical cystectomy (RARC) is a new approach in the treatment of bladder cancer. This study evaluates an initial experience with RARC with ileal conduit diversion in women.
Methods: Four women underwent RARC with ileal conduit urinary diversion. The surgical technique is described. A retrospective chart review was performed to evaluate clinical stage, tumor grade, operative times, estimated blood loss (EBL), pathologic stage, lymph node pathology, and complications.
Results: Mean age was 69.5 years. Median operative time was 350 minutes, and median EBL was 300cc. Median length of stay was 5 days with the 2 most recent patients leaving by postoperative day 3. The median number of lymph nodes removed was 12, with one patient revealing node-positive disease. Mean follow-up has been 7 months. Surgical margins were negative for disease in all patients. No patients required blood transfusion or had a major complication.
Conclusions: RARC is a new technique available for the treatment of high-risk or invasive bladder cancer in women. This surgery provides decreased morbidity while maintaining the oncological goals of traditional radical cystectomy.
7191 Urology
Robotic-assisted Radical Cystectomy with Orthotopic Neobladder
Erik P. Castle, MD, Michael E. Woods, MD, Fatih Atug, MD, Raju Thomas, MD, Rodney Davis, MD
Objectives: To report our technique of robotic-assisted radical cystectomy (RARC) with continent diversion.
Methods: Robotic-assisted radical cystectomy with orthotopic neobladder was performed in 10 male patients. All patients underwent an extended lymph node dissection up to the bifurcation of the aorta. The bladder was removed in a specimen retrieval sac through a small periumbilical incision. Urinary reconstruction was performed extracorporeally and urethroneovesical anastomosis was performed robotically.
Results: All cases were completed successfully without need for conversion. Median operative time was 400 minutes (range, 330 to 660). Median length of stay was 4 days. Median blood loss was 150cc (range, 150 to 350). Median number of lymph nodes removed was 12 (range, 8 to 18). No intraoperative complications occurred. One pulmonary embolus occurred. One patient had significant postoperative metabolic acidosis requiring medical treatment, and one patient had a postoperative ureteral stricture treated endoscopically. Surgical margins were negative in all patients. Mean follow-up has been 9 months.
Conclusions: RARC with orthotopic neobladder is technically feasible. Obvious benefits include minimal blood loss and dramatically shortened convalescence. Although we have limited follow-up, oncologic outcomes appear favorable and comparable to those of open surgery.
7192 Urology
Robotic-assisted Sacrocolpopexy
Richard Matern, MD, Erik P. Castle, MD, Scott V. Burgess, MD, Raju Thomas, MD
Objective: Our objective is to present our technique of robotic-assisted sacrocolpopexy (RAS).
Methods: Six patients underwent robotic-assisted sacrocolpopexy (RAS) at our institution. Dissection of the vaginal cuff was performed robotically with a sponge stick in the vagina. The presacral region is dissected to reveal the sacral promontory. A piece of "Y" polypropylene mesh is secured to the vaginal cuff and sacral promontory. The mesh is then retroperitonealized so as to avoid contact with abdominal contents. Concomitant sling placement, or cystocele repair, or both, is then performed vaginally.
Results: Median operative time for RAS was 120 minutes. No intraoperative or postoperative complications occurred. Median blood loss was 75cc. Mean follow-up has been 6 months (range, 4 to 12). Concomitant sling placement was performed in all 6 patients. There have been no recurrences of vaginal prolapse.
Conclusions: Robotic-assisted sacrocolpopexy can be performed safely with minimal blood loss and acceptable results.
7193 Urology
Robotic-assisted Ureteral Reimplant
Michael E. Woods, MD, Erik P. Castle, MD, Raju Thomas, MD
Objectives: Our objective is to describe the technique of robot-assisted ureteral reimplant.
Methods: A 31-year-old male was evaluated for right flank pain and found to have hydronephrosis to the level of the ureterovesical junction (UVJ). Retrograde pyelogram revealed UVJ narrowing, and a Whitaker test confirmed the presence of a functional obstruction. The patient underwent a robot-assisted right ureteral reimplant. The patient had 5 ports placed (3 robotic, 2 assistant) and was placed in a steep Trendelenburg position. The right ureter was dissected to the level of the bladder, transected, and reimplanted in a refluxing manner. The retroperitoneum was closed and a drain placed.
Results: The total operative time was 110 minutes and blood loss was minimal. No intraoperative or postoperative complications occurred. The patient was discharged on POD#1. The abdominal drain and bladder catheter were removed on POD#3 and 12, respectively. The ureteral stent has not been removed to date.
Conclusions: Robot-assisted ureteral reimplant is a feasible, safe, and efficient procedure that may offer a minimally invasive alternative to an open ureteral reimplant in appropriately selected patients.
7194 General Surgery
Long-term Outcomes with the Laparoscopic Approach for Duodenal Switch with Sleeve Gastrectomy as a Single Bariatric Procedure
G. Alshkaki, MD, S. Qadri, MD, O. Chan, MD, H. M. El Elariny, MD, PhD
Objective: We looked into long-term effects of the laparoscopic approach for duodenal switch with a sleeve gastrectomy procedure. Scopinaro described bilio-pancreatic diversion with distal gastrectomy in 1980. Hess combined bilio-pancreatic diversion with duodenal switch and added sleeve gastrectomy. Rabkins reported the hand-assisted technique for this procedure in 2003. Our study describes this operation performed solely by the laparoscopic technique and its outcome.
Methods: This study retrospectively reviewed data from 381 patients who underwent the above procedure between June 2000 and December 2006. Restriction was accomplished by greater curvature gastrectomy over a 60-Fr bougie. The duodenum was transected 4cm from the pylorus, and the proximal duodenum was anastomosed 250cm distal to the ileum by a 2-layer hand-sewn technique. The bilio-pancreatic limb was fashioned to create a 100-cm common channel using end-to-side stapler anastomosis and the mesentery was closed. Duodenal anastomosis was checked for leakage. Liver biopsy and appendectomy were performed.
Results: Age range was 22 to 66 years (mean, 43) including 48 males. Preoperative BMI was 34 to 71 (average, 45.5). The mean operative time was 229.82 minutes (range, 210 to 330) with 1 conversion. Average hospital stay was 2.5 days. Mean BMI 1, 3, 6, 9, 12, 24, 36, and 48 months after the operation was 43.27, 38.93, 34.31, 30.88, 28.64, 28.37, 28.10, and 27.27, respectively. Major, minor, and late complications were 3.16%, 2.53% and 5.38%, respectively. These included gastric staple line, duodenal stump, and distal anastomosis leakages in 2, 1, and 2 cases, respectively.
Conclusion: Sleeve gastrectomy with duodenal switch performed using the laparoscopic approach is safe and efficient with good outcomes.
7195 General Surgery
Endoscopically Obtained Bile Aspirate is an Accurate Adjunct in the Diagnosis of Symptomatic Gallbladder Disease
Kerrey Buser, MD
Introduction: The experience of a single surgeon in a rural hospital over a 10-year period was analyzed with respect to the utilization of endoscopically obtained bile aspirates as an adjunct in the diagnosis of symptomatic gallbladder disease.
Methods: A retrospective study of the author's entire cholecystectomy experience over a 10-year period with 641 patients was conducted to evaluate the utility of the bile aspirate in the preoperative selection of operative candidates and with respect to the ultimate pathologic diagnostic accuracy of the test.
Results: Derivation of preoperative diagnosis via traditional standard means was possible in 479 patients. An endoscopically obtained positive bile aspirate was found in 162 additional patients who failed to have positive traditional diagnostic studies. Micro-pathology was determined to be present in 603 patients (94.07%). In 27 of the 38 negatives, there had been positive radiological studies. In 11 of these 38, a positive, preoperative bile aspirate had been obtained. Of the 162 patients with a positive bile aspirate, 151 (93.21%) of the gallbladder specimens had confirmatory histologic analysis.
Conclusion: In patients with symptoms suggestive of clinical gallbladder disease and negative traditional diagnostic studies, the endoscopically obtained bile aspirate has been shown to be a highly reliable tool in establishing the diagnosis and is recommended as an aid in the appropriate selection of candidates who may benefit from cholecystectomy.
7196 General Surgery
Laparoscopic General Surgery in the Pregnant Patient: Results and Recommendations from One Surgeon's Experience with 36 Cases in a Rural Hospital
Kerrey Buser, MD
Introduction: The complete experience of a single surgeon in a rural hospital over more than 11 years has been evaluated with respect to laparoscopic operations performed upon patients who were pregnant.
Methods: Retrospective analysis of all laparoscopic operations performed by a single surgeon upon pregnant patients was carried out with respect to number and types of operations, stage of pregnancy, complications, and fetal outcomes.
Results: Thirty-six laparoscopic operations were performed upon 35 pregnant patients between October 1995 and January 2007. This represents the largest single-surgeon case experience ever reported for nonobstetric laparoscopic surgery performed during pregnancy. The majority of cases were conducted for severely symptomatic gallbladder disease. There was one complication of uterine penetration by a canula early in the series without fetal injury. Operations were conducted in each trimester, including late third trimester, with 100% live births of normal infants.
Conclusion: Laparoscopic surgery can be safely conducted in pregnant patients, in any trimester. Pregnancy should no longer be considered a contraindication to laparoscopic surgery. The limiting factor of prime importance is an awareness of one's own capabilities and limitations. The surgeon must be skilled in advanced laparoscopic techniques and in surgical obstetrics. A rural hospital setting is suitable for this type of procedure if a strong support structure is in place to deal with potential complications.
7197 General Surgery
The Fixation of Hiatal Meshes with Fibrin Sealant in an Experimental Model in Pigs
R. H. Fortelny, A. H. Petter-Puchner, K. S. Glaser, H. Redl
Introduction: The fixation of hiatal meshes with perforating devices, such as tacks or sutures, can be associated with potentially life-threatening complications. Fibrin sealant (FS, Tissucol, Baxter Biosciences, Vienna, Austria) is successfully used for atraumatic mesh fixation in inguinal and incisional hernia repair. The rationale for this study was to test the potential of FS fixation of hiatal meshes in pigs.
Methods: While under general anesthesia, 6 domestic pigs underwent laparotomy, and designated meshes (Ti-Sure, GfE, Nuremberg, Germany) were implanted at the hiatus. The tetanized polypropylene material was found to be favorable in combination with FS4 in a previous study. Meshes were sealed with 2mL of FS, which was applied with a spray catheter. The observation period was 4 weeks in all animals to assess tissue integration after the FS was already degraded.
Results: All meshes showed excellent integration and no sign of dislocation or perforation into the neighboring organs. Histology confirmed these macroscopic findings.
Conclusion: FS provides a safe, effective alternative to perforating fixation devices in an animal model of hiatal mesh repair.
7198 General Surgery
Laparoscopic Surgery for Colorectal Carcinoma: Costs and Benefits in the European Region
L. Sákra, J. Siller, L. Kohoutek, K. Havlícek
Objective: This study examines the costs related to the laparoscopic approach to treat colorectal carcinoma (CRC) and compares them with costs of adequate open surgery. Colorectal resections for CRC are performed in 6% of cases in Europe and in 9% in the US.
Methods: In the Czech Republic, all health-care costs related to the CRC surgery are covered by statutory public health insurance, regardless of the type of procedure (laparoscopy or open surgery). All the costs of the individual types of surgery were calculated, and the average costs of right colon, left colon, and rectal surgical procedures were evaluated for both laparoscopy and open variants. The OR time and the costs of hospital stays were also included in the total costs. It is impossible to objectively evaluate the cost savings, if any, on the part of a health insurance company as a result of patients' earlier return to their usual way of life.
Results: The overall average costs of the laparoscopic approach (group A) and of the open procedure (group B) in case of right colon surgery amounted to $3833 in group A and $863 in group B; in case of left colon surgery, they amounted to $6226 in group A and to $1961 in group B; and in case of rectal surgery, they amounted to $6914 in group A and to $2699 in group B. The OR time, physicians', nurses' and other staff's salary, as well as the use of disposable instruments were taken into consideration when evaluating the overall costs of surgery. In the specific conditions of the Pardubice Surgery Department (where every patient's medical care and hospital stay are covered by statutory public health insurance) and with the application of re-sterilized instruments, the costs of laparoscopic right colon surgery were $928, the costs of laparoscopic left colon surgery are $1948, and the costs of laparoscopic rectal surgery are $2300. These marked differences are caused by the differences between actual valuation and the subsequent billing of costs to a respective health insurance company.
Conclusion: The laparoscopic approach to CRC has benefits not only for the patients but also for total costs that can be similar to those of open surgery.
7199 General Surgery
Laparoscopic Versus Laparotomic Approach for Colorectal Carcinoma
J. Siller, L. Sákra, L. Kohoutek, K. Havícek
Objective: The aim of this study was to evaluate and compare the results of laparoscopic and open (laparotomic) radical procedures for colorectal carcinoma (CRC).
Method: Patients who underwent surgery in the Pardubice Surgical Department from January 1, 2005 to December 31, 2006 were evaluated prospectively. The study included only the patients in whom RO resection was performed. The patients indicated for abdominoperineal resection and the patients in the T4 stage of CRC were excluded from the study. The open (laparotomic) approach was carried out in compliance with the guidelines for this type of procedures. A totally laparoscopic approach (ie, not a hand-assisted laparoscopic approach) was applied to all patients who underwent laparoscopic surgery. Statistical testing was based on a test of the equality of 2 proportions.
Results: Surgery was performed in 185 patients with CRC. Colon carcinoma was found in 152 (82.2%) patients, and rectal carcinoma was found in 33 (17.8%). A laparoscopic approach was performed in 39 (21.1%) patients with CRC. The average age in the patients who underwent open (laparotomic) surgery (group A) was 68, and the average age of those undergoing a laparoscopic procedure (group B) was 64. The average operating time was 120 minutes in group A and 170 minutes in group B. On average, bowel function returned 3.4 days after procedure A and 2.7 days after procedure B. The length of the hospital stay was 8.2 days in group A and 5.5 days in group B. Three (7.1%) conversions were necessary. Reoperation was required more often in group A [12 (8.2%) versus 1 (2.6%), P=0.001]. Morbidity was greater in group A (10.3% versus 7.8%, P=0.01). Local recurrence was found more often in group A [4.1% versus 3.4%), P=0.02] during a follow-up period. The progression of CRC or of distant recurrence was detected in 6.1% of group A patients and in 5.5% of group B patients. We did not find any port-site metastasis. No deaths occurred in either group.
Conclusion: The laparoscopic approach to CRC presents a safe procedure whose short-term results are more favorable than those of open procedures.
7200 Gynecology
A Clinical Analysis of 112 Laparoscopic and Hysteroscopic Intrafascial Hysterectomy Cases
Weijie Du, MD, Xiaojing Wang, MD, Haibin Zhu, MD
Objective: To evaluate the clinical efficacy of laparoscopic and hysteroscopic intrafascial hysterectomy (LHIH).
Methods: We analyzed retrospectively the operative duration, blood loss, length of hospital stay, and incidence of complications in 96 patients who underwent the classic intrafascial Semm hysterectomy (CISH) and compared them with 112 patients who underwent LHIH between January 2004 and January 2006.
Results: The duration of surgery, blood loss, and length of hospital stay in the CISH group were similar to those in the LHIH group (P>0.05). The postoperative complications in the CISH group were 21 cases of colporrhagia, 2 cases of cervical cyst, 1 case of cervical polypus, 7 cases of residual erosive cervix. The same postoperative complications in the LHIH group were negative.
Conclusion: LHIH is as effective in treating hysterectomy as is CISH, and it has its own virtues in reducing the postoperative complications in the cervix.
7201 Urology
Laparoscopic Pyelo-Ureterolithotomy: Re-emerging Role in the Management of Complex Stone Disease
Daniel I. Brison, George Dakwar, Rahuldev S. Bhalla, Pedram Ilbeigi
Introduction and Objective: Laparoscopic Pyelo-Ureterolithotomy is seldom performed. When indicated, it remains a viable single-stage minimally invasive alternative to repeated endoscopic therapies and open surgery. Stones are often large, inaccessible, impacted, or have failed endoscopic manipulations. In this video, we describe our approach, techniques and methods of laparoscopic stone extraction at various locations along the collecting system.
Methods: This video illustrates the laparoscopic management of a complex proximal ureteral stone via a transperitoneal approach. Management of impacted distal ureteral and large renal pelvic stones is also demonstrated.
Results: The procedural steps of our technique are outlined: 1) transperitoneal exposure of retroperitoneum, 2) localization and dissection of the affected ureteral segment, 3) creation of a pyelotomy/ureterotomy 4) identification and extraction of calculi, 5) repair of the pyelo-ureterotomy and removal of specimen.
Conclusions: Compared with open surgery, laparoscopy allows for reduced analgesic requirements, shorter hospital stays, faster recovery, and early convalescence. For large, hard, or impacted ureteral calculi, or both, laparoscopic ureterolithotomy may be preferable as initial therapy to multiple endourological or lithotripsy procedures. Concomitant use of laparoscopic pyelolithotomy and reconstructive procedures allows for a single minimally invasive procedure that is feasible, safe, and reproducible.
7202 General Surgery
Laparoscopic Repair of Spiegel's Hernia
Francisco Obregon, MD, Salvador Navarrete Aulestia, MD, Jose Luis Leyba, MD, Salvador Navarrete LLopis, MD
Objective: Spiegel's hernia is an unusual abdominal wall hernia that represents about 1% of all hernias. At present, diagnosis and treatment are controversial due to its rare presentation. We present our experience on video laparoscopic repair of one case of Spiegel's hernia treated with preperitoneal polypropylene-polyglactin mesh.
Method: The patient was a 57-year-old male with chronic, intermittent abdominal pain at the inferior left quadrant of the abdominal wall concomitant with constipated periods associated with a palpable mass in this area. A computed tomography with oral contrast provided evidence of a portion of the sigmoid colon inside across the left semilunar line. A laparoscopic approach was performed using 4 trocars, and a 30-degree optical camera confirmed a left Spiegel's hernia with viable sigmoid colon in the interior. After a peritoneal flap was made, parietal dissection of the hernia sac was performed with placement of a polypropylene/polyglactin mesh on the defect by one extraperitoneal cardinal dot and the rest using an endostapler. Finally, the mesh was covered by the peritoneal flap to avoid contact with intraperitoneal structures. The operating time was 90 minutes.
Results: The patient had a satisfactory evolution and was discharged on the next day. No morbidity or mortality was associated with this procedure.
Conclusion: Laparoscopic repair of Spiegel's hernia with mesh is a feasible and safe procedure.
7203 General Surgery
Fibrin Sealant for Fixation of cPTFE Meshes in Experimental IPOM Repair: Impact on Adhesion Formation and Reduction of Perforating Fixation Devices
A. H. Petter-Puchner, N. Walder, R. H. Fortelny, H. Redl
Introduction: The use of fibrin sealant (FS, Tissucol, Baxter Biosciences, Vienna, Austria) for mesh fixation in hernia repair decreases the risk of tissue trauma and incidence of chronic pain. This study was designed to assess the potential impact of FS fixation on adhesion formation to cPTFE (condensed polytetrafluoroethylene) meshes (MotifMeshes, MM, Proxy Biomedical, Ireland) in experimental intraperitoneal onlay mesh repair (IPOM).
Methods: Sixteen rats and 4 domestic pigs were assigned to the implant of MM with 4 nonresorbable sutures and additional FS sealing vs. MM with 6 nonresorbable sutures only (n=8 per group in rats; n=4 per group in pigs). One MM, 2cm in diameter, was implanted per rat, 4 MMs (oval shaped, 6x8cm) per pig, and 0.3mL of FS were applied for fixation in rats, 1mL per MM in pigs. The observation period was 17 days and 4 weeks in rats and 4 weeks in pigs. Adhesions were scored using the Vandendael score. Histology was performed.
Results: All MMs without FS elicited severe (grade III) adhesions to bowel, liver, and the omentum. Eleven of 12 sealed MMs were scored mild (7) to moderate (4). The margins of the MM as well as the suture knots were defined as critical areas primarily provoking adhesions.
Conclusion: In an experimental model of IPOM repair, FS fixation reduces the number of perforating fixation devices and helps to prevent adhesion formation. According to the literature, our results emphasize the problematic issue of adhesion formation to corner zones of implants.
7204 General Surgery
The Assessment of the Quality of Life in Laparoscopic Hernia Repair: Suggestions for the Development of Standards within SLS
A. H. Petter-Puchner, R. H. Fortelny, K. Puchner, K. S. Glaser
Introduction: The acceptance of laparoendoscopic techniques for hernia repair as the standard of care was primarily based on convincing results in terms of recurrences and patient satisfaction. However, more than 15 years after its introduction, the impact of various techniques on quality of life (QoL) remains widely unclear due to different and often nonstandardized tests and questionnaires.
Methods: The authors will present an overview of QoL research in the field and emphasize the importance of producing valid, comparable, and reproducible data in clinical trials, based on own experiences. Existing recommendations and guidelines of specialized societies and leading experts will be discussed and the definition of common standards and protocols within SLS will be encouraged.
Conclusion: QoL is an essential outcome parameter, providing valuable information on effect and acceptance of laparoendoscopic surgery. Its assessment should be performed with standardized tools, and specific guidelines, eg, for hernia repair, are required.
7205 General Surgery
Major Bile Duct Injuries After Laparoscopic Cholecystectomy: Factors That Influence the Results of Treatment
K. Tsalis, K. Blouchos, K. Vasiliadis, S. Kalfadis, E. Christoforidis, D. Betsis
Background: Laparoscopic cholecystectomy (LC) is said to have clear benefits compared with conventional open cholecystectomy (OC) in terms of shortened hospital stay, reduced postoperative pain, and return to normal activities. Bile duct injury (BDI) is probably the most feared complication after cholecystectomy, and its incidence after LC is shown to be 2 to 3 times that of open cholecystectomy. The aim of this study was to present our experience with the management and outcome of major BDI after LC.
Methods: From 1996 to 2006, 24 patients with BDI after LC were treated in our department. Twelve of them had major BDIs and were classified as E1 in 2 cases, E2 in 3, E3 in 4, and E4 in 3. Nine of these patients were referred from other hospitals after receiving primary treatment. In particular, in 3 patients, the BDI was recognized intraoperatively, and primary suture repair by end-to-end anastomosis of the injured bile duct over a T-tube was performed. In 9 patients, BDI was identified postoperatively. A first repair of major BDI was performed during the immediate postoperative period in 7 patients, by an end-to-end anastomosis in 4 of them, by a Roux-en-Y hepaticojejunostomy in 2 patients, and by hepaticoduodenostomy in 1 patient before their referral to our department.
Results: A Roux-en-Y hepaticojejunostomy was performed in all patients. The identified risk factors for the anastomotic stenosis were inflammation and abscess in one case, nonabsorbable sutures in one case, postoperative bile leak in 2 cases, and long bile duct stump in one patient. One patient died 25 days after LC due to multiple-organ dysfunction syndrome.
Conclusion: After a median follow-up of 76.3 months, no evidence of biliary disease has been detected among our patients. BDIs should be managed in a specialist unit where surgeons skilled at performing such repairs should undertake definitive treatment.
7207 Gynecology
Laparoscopic Supracervical Hysterectomy, the Learning Curve: Evaluating Blood Loss, Uterine Weight, and Experience in the First 100 Cases Performed by One Surgeon
Christopher Lindeken, DO, Anthony Quartell, MD
Introduction: Laparoscopic supracervical hysterectomy is a newer approach to hysterectomy. Many gynecologists are hesitant to perform this approach secondary to its technical difficulty. Two questions were asked in this study. First, what is the relationship between operative blood loss and uterine size and pathology? Second, how is the previous relationship affected by operator experience? The authors were also interested in identifying an upper limit of uterine weight/volume that would be appropriate with this approach.
Methods: The study was a retrospective review of the first 100 patients with a laparoscopic supracervical hysterectomy performed by a single surgeon at a single hospital. Patients were selected for menorrhagia, symptomatic leiomyomata, or adenomyosis uteri. Preoperative and postoperative hematocrits and uterine weight per pathology were analyzed.
Results: Statistical significance for hematocrit change was found comparing uterine weight. Surgical time was significantly dropped. Blood loss decreased as experience increased. Adenomyosis increases absolute hematocrit change. Very few complications were noted.
Conclusion: Blood loss is directly proportional to uterine size. Blood loss is more profoundly affected by operator experience. Even with larger uteri, complications were minimal. Hematocrit change did not result in patients requiring transfusion or extended hospital stay. Uterine size is clinically difficult to correlate with uterine weight. There appeared to be increased blood loss in adenomyosis compared with blood loss in leiomyomata on an equal sized basis.
7208 Urology
Cryoablation Does Not Adversely Impact the Renal Function of Those Patients Who Present With Renal Insufficiency
Joe Miller, MD, John C. Rewcastle, PhD, J. Clifton Vestal, MD, Bradley F. Schwartz, DO
Objectives: Renal cryoablation has been shown to have a negligible impact on renal function by comparing the average creatinine level of a patient population before cryoablation with the average creatinine level of the population after cryoablation. The effect of renal cryoablation on patients with preoperative renal insufficiency has not been reported. The purpose of this investigation was to determine creatinine level changes for patients with renal insufficiency undergoing renal cryoablation.
Methods: Patient charts were retrospectively reviewed. Only those for whom both pre- and postoperative creatinine levels were included. Renal insufficiency was defined as a creatinine level >1.3mg/dL. Patients were stratified according to their pretreatment renal sufficiency status. Changes in creatinine levels for the 2 populations were compared using the Student t Test.
Results: Thirty-eight (38) patients were identified with pre- and postoperative creatinine levels. Of the 38 patients, 31 (81.6%) had normal renal function before cryoablation. Their average pre- and posttreatment creatinine levels were 0.99±0.17 and 0.98±0.23, respectfully (P=0.70). For the 7 patients with renal insufficiency before cryoablation, their pre- and postoperative creatinine levels were 2.28±1.45 and 2.13±1.22, respectfully (P=0.21). No patients with renal sufficiency before cryoablation had insufficiency after treatment, and the largest change in creatinine level was 0.4.
Conclusions: Renal cryoablation appears to have minimal effect on renal function regardless of precryoablation renal function status. Renal cryoablation is a minimally morbid nephron-sparing technique that should not be withheld as an option based on preoperative renal insufficiency.
7209 Urology
Introduction of a Robotic Skills Laboratory Into a Urology Curriculum
Joe Miller, MD, Aaron Benson, MS4, Bradley F. Schwartz, DO
Introduction and Objectives: We have previously described the formal skills laboratory curriculum at our institution. A skills module pertaining to the Da Vinci robot was constructed to facilitate skills acquisition and decrease residents’ learning curve during robotic urologic procedures. Herein, we describe the content and early outcomes.
Methods: All residents (13) and medical students (3) were required to complete an online tutorial produced by the robot manufacturer, and pass an online test. Once the test was completed, they participated in a laboratory session composed of robot setup, troubleshooting, docking, instrument familiarity, and instrument insertion and removal, and console familiarity. This was followed by object transfer, suturing, and fine motor skills practice. The robotic nursing staff, manufacturer’s representative, and faculty also attended.
Results: All participants completed the 45-minute online tutorial. Participants then underwent 4 hours of hands-on training as described above. Four residents went on to perform robotic suturing of the anterior anastomosis of a dismembered pyeloplasty and the anterior graft sutures of a robotic sacrocolpopexy. To date, residents have performed 13 robotic procedures based on their skill laboratory performance.
Conclusions: Our robotic skills laboratory is an effective means of skill acquisition for a new technology. During the skills laboratory, stresses associated with the operating room can be attenuated and demands of patient care decreased. Assessment of skills acquired in this laboratory can be used to assess resident readiness for the operating room. In our model, residents gained enough skills to complete the tasks of 13 robotic procedures involving live patients.
7210 Urology
Increased Cancer Yield and Decreased Nondiagnostic Results When Three Cores Are Taken Rather Than One Before Renal Cryoblation
Bradley F. Schwartz, DO, Joe Miller, MD, John C. Rewcastle, PhD, J. Clifton Vestal, MD
Introduction and Objectives: Five-year outcomes have established cryoablation as a primary treatment for small renal masses. Biopsy is performed intraoperatively before initiation of freezing. One core is taken to reduce the potential of tumor seeding. However, no reports have been published of tumor formation attributed to biopsy before renal cryoablation. In March 2005, we began to take 3 biopsy cores rather than one in an attempt to decrease our nondiagnostic rate.
Methods: Biopsy results were retrospectively reviewed for patients who underwent renal cryoablation between February 2001 and March 2006. Findings were stratified according to the number of cores taken, either 1 or 3. Tests for significance were performed using Fisher’s exact test to determine whether statistically significant differences existed in nondiagnostic rates and cancer yield rates.
Results: Eighty-one (81) biopsy results were reviewed. Of those, a single core was taken from 64 (79.0%) lesions. Of these, 35 (54.7%) were malignant and 11 (17.2%) were nondiagnostic. The remaining 17 (21.0%) had 3 cores taken; 12 (70.5%) of which were malignant and none (0%) were nondiagnostic. The P-values for cancer yield and nondiagnostic rates were 0.108 and 0.280, respectfully.
Conclusions: Using a 3-core biopsy strategy resulted in a 15% increase in cancer yield and a 17% reduction in the nondiagnostic rate. These results are not significant, likely due to the relatively small number of 3-core biopsies in our series. Continued investigation is warranted and underway.
7211 General Surgery
Laparoscopic Diagnosis of a Rare Cause of Abdominal Pain
Atif Iqbal, MD, Brent Miedema, MD
Introduction: Ventriculoperitoneal shunts for hydrocephalus have many common complications including failure and infection. A rarely reported complication is symptomatic abdominal pseudocyst. Most of these cases are described in the pediatric population; this complication has rarely been reported in adults. We present the case report of an adult patient who presented with abdominal pain and was found to have this rare complication.
Methods: A 20-year-old white female with a history of a ventriculoperitoneal shunt for hydrocephalus presented to us with a 2-week history of right-sided abdominal pain, nausea, and vomiting. The patient underwent laboratory investigations that were futile.
Results: CT scan showed a 25-cm fluid collection compressing the surrounding bowel with the distal tip of the shunt within it. Diagnostic aspiration of the shunt revealed CSF fluid. The patient underwent diagnostic laparoscopy, laparoscopic visualization of the cyst, therapeutic aspiration, and cyst wall biopsy, which was found to be nonepithelialized. The patient's symptoms subsequently improved.
Conclusion: Abdominal CSF pseudocysts are a rare complication of ventriculoperitoneal shunts. Less than 1% of all shunted patients develop a pseudocyst, although higher rates have been reported. Sterile pseudocysts without a prior history of infections, as was the case in this patient, are even more rare and almost exclusively reported in children. This report shows the very rare incidence of such sterile pseudocysts after a ventriculoperitoneal shunt in the adult population.
7212 Urology
Sutureless Laparoscopic Heminephrectomy: Safety and Efficacy in the Porcine Model
Ithaar H. Derweesh, John B. Malcolm, Christopher DiBlasio, Reza Mehrazin, Scott Jackson2
Objective: Widespread application of laparoscopic partial nephrectomy has been limited by the potential for collecting system entry, requiring sutured repair with prolonged warm ischemic time. We sought to develop a streamlined sutureless system of repairing large parenchymal and collecting system defects using BioGlue (bovine albumin-glutaraldehyde adhesive) and Propatch (bovine pericardial patch graft) in the porcine model under physiological conditions and mechanical stress imposed by ureteral obstruction.
Methods: Four pigs (8 kidneys) underwent staged left-side transperitoneal laparoscopic heminephrectomy, followed 2 weeks later by right-sided heminephrectomy with ipsilateral ureteral transection to provide a mechanical stressor on the repair, followed 2 weeks later by euthanasia. In each case, after hilar clamping, the lower pole was removed with the Trisector-bipolar dissector (GYRUS). Hemostasis was obtained with argon beam coagulator (Conmed) and FloSeal (thrombin-gelatin matrix), followed by sutureless repair. At euthanasia, harvested renal remnants underwent ex-vivo retrograde pyelography and histopathological examination to rule out urinoma/perinephric fluid collection and to determine the extent of collecting system and parenchymal healing.
Results: Mean operative time was 76.3 minutes. Mean warm ischemia time was13.6±6.5 minutes. Estimated blood loss was 113.8±69.3cc. Ex-vivo retrograde pyelography failed to demonstrate any collecting system leakage, and closure and healing were confirmed in all. Two pigs were euthanized for causes unrelated to procedures 1 week before the study end.
Conclusions: Our preliminary experience with porcine sutureless laparoscopic heminephrectomy demonstrates safety and efficacy in physiological and obstructed conditions. The procedure is reproducible and resection/renorrhaphy can be completed on average in less than 15 minutes warm ischemia time.
7213 Other
Psychosocial Impact of Laparoscopic Donor Nephrectomy: Long-term Impressions
Andrew M. Altman, MD, Douglas Slakey, MD, MPH, Junaid Bhutto, BSM, Anil Paramesh, MD, Brent Alper, MD, Ruben Zhang, MD, Mary Killackey, MD, Sander Florman, MD
Objective: Laparoscopic donation has become the standard for living donor kidney transplantation. Our aim was to characterize long-term follow-up data to assess donor perceptions.
Methods: We created a questionnaire of 30 items, inquiring into predonation concepts, hospital experiences, and postdonation psychosocial issues. Between March 2001 and July 2005, 81 patients who had undergone laparoscopic donation with at least 1-year follow-up were identified, and 96% of them were interviewed.
Results: Mean time since surgery was 1836 days. Twenty-one percent first heard about this procedure from sources other than healthcare workers or their recipients. Overall, 99% believed they were adequately informed. Seventy-four percent of patients reported a positive impression of the hospital stay, although 52% reported more postoperative pain than expected. Sixty-one percent of patients returned to work within a month. Nine percent reported financial burden, and 6% reported problems with insurance.
Conclusions: This study confirms that long-term donor perceptions of laparoscopic nephrectomy remain favorable. Most donors are knowledgeable about this procedure, but perceptions may be erratic due to varied sources and must be identified. Early contact with the transplant team is essential in providing an educational and streamlined experience to the laparoscopic donor in renal transplant.
7214 Urology
Laparoscopic Radical Cystectomy Extracorporeal Ileal Conduit: Dong-A University Hospital Experience After 20 Cases
Gyung Tak Sung, MD, PhD, T. H. Kim, MD
Objective: Radical cystectomy is the gold standard treatment for transitional cell carcinoma of the bladder, and the laparoscopic approach is currently being evaluated world wide and suggested to be a feasible procedure. We report our preliminary results using this procedure.
Methods: Between March 2003 and October 2006, 20 patients with bladder cancer who were candidates for radical surgery underwent laparoscopic radical cystectomy. Extracorporeal ileal conduit was performed in 16 patients. Three patients were female, so laparoscopic pelvic exenteration was performed. The mean age was 63 years old (range, 57 to 74). Mean BMI was 23.5kg/m2 (range, 19.6 to 26.3).
Results: The mean time of the overall procedure was 385 minutes (range, 240 to 510) for the extracorporeal ileal conduit or ureterocutaneostomy. Laparoscopic radical cystectomy was 195.1 minutes (range, 150 to 240). Mean estimated blood loss was 264.5mL (range, 150 to 380). Histopathology revealed 10 pT1N0G3, 6 pT2N0G2, 1 pT3aN0G3, 2 pT3aN0G3, 1 pT3bN1M0 with surgical margins free except one. Metastasis occurred in 2 patients at 34 months and 27 months after surgery. One was in bone and the other was in the obturator lymph node. They were treated by gemcitabine chemotherapy.
Conclusions: We believe that laparoscopic radical cystectomy is easily reproducible and indicated for patients affected by clinically organ-confined invasive bladder cancer. The extracorporeal urinary diversion is easier than the intracorporeal procedure, makes the operative time shorter, and helps in recovery.
7215 Urology
Preliminary Experience with Sutureless Laparoscopic Partial Nephrectomy for Renal Tumors With Collecting System Entry: Technique and Results
Ithaar H. Derweesh, MD, John B. Malcolm, MD, Christopher DiBlasio, MD, Reza Mehrazin, MD, Ramsey Chichakli, MD
Objective: Laparoscopic partial nephrectomy is technically challenging, with frequent collecting system entry requiring sutured repair. Sutureless laparoscopic partial nephrectomy involves parenchymal and collecting system closure with BioGlue (bovine albumin-glutaraldehyde) and Surgisis (porcine small intestinal submucosa). We present our short-term outcomes with this approach.
Methods: A prospective study of 6 patients who underwent transperitoneal laparoscopic partial nephrectomy was conducted between May and October 2006. After obtaining hilar control with a vascular clamp, tumor and 5-mm to 10-mm margin of healthy tissue was removed using the Trisector-bipolar dissector (Gyrus). Collecting system entry was confirmed by retrograde indigo carmine injection; hemostasis was obtained with Argon Beam Coagulator (Conmed) and FloSeal (thrombin-gelatin mixture), followed by sutureless collecting system closure with BioGlue and Surgisis, and drain placement to monitor for hemorrhage and urinoma. Follow-up CT scanning was performed 1 and 3 months after surgery. Demographic, clinical, and intraoperative variables and complications were recorded.
Results: Four men and 2 women (mean age, 51.9 years) underwent the procedure. Mean tumor size was 3.1±1.0cm (final pathology: clear cell carcinoma, 3; papillary cell carcinoma, 1; oncocytoma, 1; angiomyolipoma, 1), mean warm ischemia time was 24.8±4.3 minutes, mean operative time was 210.0±25.5 minutes, and mean blood loss was 283.3±103.3cc. Mean preoperative and 3-month postoperative serum creatinine were 1.2±0.2ng/dL and 1.3±0.2, respectively. No positive margins, hemorrhage, urinoma, or residual tumor enhancement were identified. Complications were fever/cellulitis in one.
Conclusion: Our preliminary experience with sutureless laparoscopic partial nephrectomy in select cases that involve collecting system entry is positive and deserves further evaluation.
7216 General Surgery
Unusual Mechanisms of Failure After Antireflux Surgery: Report of Two Cases
Atif Iqbal MD, Vanessa Salinas MD, Mumnoon Haider MD, Charles J. Filipi, MD,
Background: As laparoscopic antireflux surgery gains popularity, complications that are unique or occur more frequently with this approach become more evident. Two such unusual cases are reported here.
Methods: The first patient presented immediately after laparoscopic Nissen fundoplication with recurrent reflux that was seen on an esophagogram. Endoscopy showed a distorted fundoplication. Intraoperatively, the stomach was wrapped over a 60-Fr dilator after crural closure and takedown of the greater curvature vessels. During the surgical revision, the wrap was repositioned over a 50-Fr dilator. No abnormalities were seen on subsequent endoscopy. After 12 years, the patient reports a satisfaction score of “10” (scale of 1 to 10) and an “excellent” subjective outcome. The patient has not required further dilations or surgery.
The second patient presented with recurrent dysphagia 5 weeks after a laparoscopic Nissen fundoplication that persisted despite dilations. The patient did not have preoperative dysphagia. During the reoperation, intraoperative endoscopies showed significant resistance at the level of the crus closure both before and after the fundoplication was taken down but was not felt after a cruroplasty was performed. After 5 months, the patient reported a satisfaction score of 10, an “excellent” outcome and denies any dysphagia to date.
Conclusion: This report focuses on 2 unique complications of laparoscopic Nissen fundoplication. In the first case, the fundoplication was “too loose” as confirmed during the reoperation. This was one of our first fundoplications. The second patient was diagnosed with hiatal stenosis; however, the patient did not have any risk factors, such as fibromyalgia or radiotherapy.
7217 Gynecology
Mistletoe Therapy in Recurrent Endometriosis Patients
Lim Yong-Taik, Lee Kyu-Sup, Lee Taek-Hoo, Oh Sung-Tack, Choi Young-Min,
Objective: To determine the clinical effect of mistletoe therapy for management of symptoms in recurrent endometriosis patients.
Methods: This was a clinical prospective study. We administered subcutaneous mistletoe therapy to 32 endometriosis patients with much pain who underwent laparoscopic surgery for endometriosis (Group I), and intralesional mistletoe therapy in 34 endometriosis patients who complained of recurrent pelvic pain following hysterectomy (Group II). Clinical analyses were carried out based on subjective symptoms, pelvic findings, and visual pain scales. Visual pain scales were reduced from 10 to 0 to 2.
Results: All group I patients had definitive subjective symptomatic relief without ovarian suppression. Minimal side effects, such as skin rashes, skin irritation, and mild fever, were observed in 20 group I patients. Clinically evident symptomatic relief was also observed in all group II patients. Skin rashes following the intralesional mistletoe therapy were observed in 3 group II patients.
Conclusion: Mistletoe therapy can be the new medical therapeutic agent in the management of symptomatic recurrent endometriosis patients following laparoscopic or open surgery.
7218 Urology
An Innovative Medical Student Clinical Clerkship in Advanced Urologic Laparoscopy: A Preliminary Experience
Chandru P. Sundaram, Yousef Mohammadi, Carl K. Gjertson
Introduction: We describe a unique medical student education initiative, ie, an elective clinical clerkship in laparoscopic urology.
Methods: An elective 4-week rotation in urologic laparoscopy was approved by the medical school in 2005 and provides level III competency in basic clinical skills. Clerkship objectives are to learn the principles of laparoscopy, to assess and improve laparoscopic skills, and to learn the indications for and techniques of urologic laparoscopic surgery. The elective has 5 components: 1) once weekly clinic with a urology attending, 2) completion of a CD-ROM laparoscopy course, 3) participation in a training lab involving six 1-hour box trainer sessions, 4) observing and assisting in urologic laparoscopy cases, 5) participation in a clinical research project (if desired). Six students have completed the elective to date.
Results: Overall satisfaction with the clerkship was high, scoring a mean 4.89 out of a possible 5 on student evaluations. Intentions for residency training included urology for 3, Ob/Gyn for 1, neurosurgery for 1, and plastic surgery for 1. There were no changes in desired residencies after completion of the clerkship. Performance on the box trainer improved significantly but did not differ from that of 14 other students who had completed the laparoscopy training lab but were not enrolled in the elective.
Conclusions: There is substantial interest among medical students in advanced laparoscopic surgery, and it can support a fourth-year clinical clerkship in laparoscopic urology. Student evaluations revealed very high satisfaction. This elective is of benefit to students interested in urology and other surgical specialties.
7219 Urology
Medical Student Satisfaction Following Laparoscopic Skills Testing
Chandru P. Sundaram, MD, Michael Lipke, MD, Yousef Mohammadi, Carl K. Gjertson, MD
Introduction: We present initial results of a medical student laparoscopic training course.
Methods: Twenty third- and fourth-year students have participated since July 1, 2005. All exercises were performed on a laparoscopic box trainer. Students finished 6 sessions of 5 laparoscopic exercises. 1) Peg board - move 4 pegs on a cribbage board. 2) Pattern cutting - cut out a circle from a gauze dressing. 3) Letter board - place 9 wooden letters onto a 3x3 checkerboard. 4) String running - move from end to end of a 24-inch string, grasping at marked intervals. 5) Suturing - approximate the cut ends of a Penrose drain with a surgeon's knot. Questionnaires were completed regarding physical and emotional comfort, overall satisfaction, and residency plans.
Results: Mean times and physical and emotional comfort improved significantly for all exercises. Of the 20 students, 6 were interested in urology, 11 in another surgical specialty, and 3 in medicine. Overall satisfaction with the course was high. Nineteen of 20 students felt that they improved and that the training increased their understanding of laparoscopy and surgery in general. However, there was no increased interest in surgery or urology. Three students changed their choice of residency after the training course, one from pediatrics to Ob/Gyn, one from surgery to medicine, and one from medicine to surgery.
Conclusions: Voluntary medical student participation in a laparoscopy training course resulted in significantly faster performance of laparoscopic exercises. Student satisfaction was high but increased interest in surgery was not generated.
7220 Urology
Will Robotic-assisted Radical Prostatectomy Become the new Surgical Standard?: United States Trend Mirrors the Trend at Hackensack University Medical Center (2001-2006)
Ravi Munver, MD, Grant Disick, MD, Stuart S. Kesler, MD, Ihor S. Sawczuk, MD
Objective: Robotic-assisted radical prostatectomy is steadily gaining interest throughout the nation. We compared the United States trend for this procedure with the trend at our institution.
Methods: A retrospective review was conducted of radical prostatectomies performed between January 2001 and December 2006 at Hackensack University Medical Center. Our medical center has acquired 4 da Vinci Surgical Systems: 2 in 2000, 1 in 2002, and 1 in 2006. The trends for open and robotic-assisted prostatectomies at our institution, and in the US, were analyzed.
Results: Between 2001 and 2006, 1162 radical prostatectomies were performed by 17 urologists: 379 (33%) open radical prostatectomies (ORP) and 783(67%) robotic-assisted radical prostatectomies (RARP). The urologists performing RARP increased from 3 (18%) in 2001 to 11 (65%) in 2006. The total annual number of radical prostatectomies increased from 2001 (n=125) to 2006 YTD (n=335). The annual proportion of RARPs increased as follows: 9.6% (2001), 28.0% (2002), 40.4% (2003), 72.7% (2004), 96.2% (2005), and 93% (2006). The number of RARPs performed in the US exceeded 200est. (<1%) in 2001, 750est. (<1%) in 2002, 2500est. (3%) in 2003, 8500est. (10%) in 2004, 18,000est. (20%) in 2005, and 31,500est. (35%) in 2006.
Conclusions: The introduction of the da Vinci System has had a dramatic impact on surgical therapy for localized prostate cancer. When comparing the growth rate of RARP at our institution with that in the US, the national rate is lagging by slightly more than 3 years. If the national rate continues to mirror that at our institution, robotic-assisted radical prostatectomy may become the surgical standard for localized prostate cancer in the US as early as 2009.
7221 Urology
The Impact of Minimally Invasive Technology on Localized Prostate Cancer Practice Patterns at a Single Institution: Robotic-Assisted Radical Prostatectomy Vs. Radiation Therapy Vs. Cryosurgery
Ravi Munver, MD, Grant Disick, MD, Stuart S. Kesler, MD, Glen Gejerman, MD,
Ihor S. Sawczuk, MD
Objective: Open radical prostatectomy and radiation therapy are established standards for the management of localized prostate cancer. Robotic-assisted surgery and cryosurgery are becoming increasingly appealing to physicians and patients. We report on the impact of these minimally invasive surgical therapies at a single institution that offers radical prostatectomy (RP), radiation therapy (RT), and cryosurgery (CRYO).
Methods: We reviewed all encounters for patients who received treatment for localized prostate cancer between January 2000 and December 2006. Therapies included RP [(open or robotic-assisted), RT [external beam radiation therapy (3-D conformal; intensity modulated) or brachytherapy (low dose rate; high dose rate)], and CRYO. We implemented robotic-assisted RP in 2001 and CRYO in 2002. The annual volume of each treatment modality was recorded and trends were analyzed.
Results: A total of 2363 treatments were administered, including 1252 radical prostatectomies (53%), 1012 radiation treatments (43%), and 99 cryosurgeries (4%). The number of RP [2000 (n=90), 2001 (n=125), 2002 (n=143), 2003 (n=151), 2004 (n=143), 2005 (n=265), 2006 (n=335)], and CRYO [2000 (n=0), 2001 (n=0), 2002 (n=5), 2003 (n=10), 2004 (n=10), 2005 (n=30), 2006 (n=44)], increased annually. The number of RT treatments steadily decreased [2000 (n=139), 2001 (n=180), 2002 (n=176), 2003 (n=198), 2004 (n=119), 2005 (n=101), 2006 (n=99)]. Between 2000 and 2003, RT outnumbered RP and CRYO. Since 2004, robotic-assisted RP has become the leading therapy.
Conclusions: The availability of robotic-assisted surgery and cryosurgery led to a shift in treatment for localized prostate cancer. As a result, the percentage of RP and CRYO procedures steadily increased over time, while trends in the RT group decreased. Practice patterns appear to be changing, as minimally invasive surgical therapies become more widely available alternatives to radiation therapy.
7222 General Surgery
Nitinol Clips Versus Prolene Suturing Techniques for Adjustable Gastric Banding Procedures
Thomas Y. Chua, MD, Eric Valladares, MD, Carlos Tan, MD, Laura July, MD, Goran Rudic, MD, Deb Kneisler, PA-C, Valerie Black, PA
Background: Gastric banding procedures are one of the most commonly performed bariatric surgeries for morbid obesity. The purpose of this retrospective analysis was to compare nitinol clips and Prolene for securing adjustable gastric bands, and the safety of the clips.
Methods: We studied 635 gastric band patients; 90, 175, and 370 Prolene perigastric, Prolene pars flaccida and nitinol clip pars flaccida techniques, respectively. Two cohorts, the Prolene (n=60) and Clip (n=60) group, were further evaluated for operative times and complications. Complications of the 370 cases using nitinol clip pars flaccida were reviewed.
Results: Groups were divided by BMI into the following categories: morbidly (40 to 49), super (50 to 59) and super, super (60 to 69) obese. Mean operative times for the Prolene group were 63, 74, and 89 minutes for the morbidly, super, and super, super obese patients, respectively. Mean operative times for the Clip group were 50, 52, and 53 minutes, respectively. This represents a 13-, 22-, and 36-minute reduction in mean operative times. Clip complications included 3 flipped ports and 1 painful port, while 1 slippage, 2 tube leaks, and 2 flipped ports were reported for the Prolene group. Of the 370 cases using the nitinol clips, there were 8 slippages (2.2%), no erosions, and no infections were noted.
Conclusions: Gastric band placement using nitinol clips is a safe and effective alternative to suturing, significantly reducing mean operating times, especially for super and super, super obese patients.
7223 Gynecology
A Case of Large Urachal Cyst Treated by Laparoscopic-assisted Surgery
Takashi Yamada, MD, Hiroshi Mori, MD
Introduction: Urachal cysts develop from persistent urachal remnants, and symptomatic remnants are usually treated with laparotomy. We performed laparoscopic-assisted removal of a large urachal cyst.
Case Report: A 48-year-old woman had no complaints that would indicate an abdominal tumor. Echography and magnetic resonance imaging revealed an abdominal cyst of about 10cm in diameter. Serum tumor markers (CA125, CA19-9, CEA, SCC antigen) were within normal ranges. Laparoscopic surgery was performed with the clinical diagnosis of an ovarian cyst. Through a laparoscope, a cystic mass was seen hanging from the anterior abdominal wall. The uterus and bilateral adnexa appeared normal. After suction of cystic fluid, the tissue was removed through the abdominal wound, which was expanded to 3cm where the second cannula had been inserted. The stalk of the cyst was clamped and excised, and an uninterrupted suture of peritoneum was made extracorporeally. Histology showed that the inner surface of the cyst was lined with a layer of cuboidal or low columnar epithelium without atypia and surrounded by a smooth muscle layer, leading to the diagnosis of urachal cyst.
Conclusion: Laparoscopic-assisted removal of a large urachal cyst can be effective for both diagnosis and treatment.
7225 General Surgery
Laparoscopic Splenectomy and Azygoportal Disconnection for Bleeding Varices With Hypersplenism
Yue Dong Wang, MD, Zai Yuan Ye, MD, Yang Wen Zhu, MD, Zhi Jie Xie, MD
Background: Bleeding from esophageal varices is a significant cause of morbidity and mortality in patients with portal hypertension. The ideal surgical procedure should control bleeding, with as little impairment to liver function as possible and with low rates of encephalopathy. Recently, significant progress in laparoscopic technology enabled laparoscopic splenectomy and devascularization of the lower esophagus and upper stomach in a less-invasive way.
Methods: Laparoscopic splenectomy and devascularization of the lower esophagus and upper stomach were performed in 20 patients with cirrhosis, bleeding portal hypertension, and secondary hypersplenism between January 2000 and June 2006. Among them, 5 patients underwent a laparoscopic modified Sugiura procedure, the lower esophagus was transected and then reanastomosed with a circular stapler.
Results: Laparoscopic splenectomy and azygoportal disconnection were completed in all patients. The operation time ranged from 4.0 to 5.5 hours, and the blood loss was 100mL to 400mL.The postoperative hospital stay was 6 days to 15 days. During a postoperative follow-up period of 6 months to 5 years in 15 patients, neither esophagus variceal bleeding nor encephalopathy has recurred.
Conclusion: Laparoscopic splenectomy and azygoportal disconnection are feasible, effective, and safe surgical procedures and have all the benefits of minimally invasive surgery for patients with bleeding portal hypertension and hypersplenism. Laparoscopic splenectomy and azygoportal disconnection offer a new operative method for treatment of bleeding portal hypertension with hypersplenism.
7226 General Surgery
Two-step Abdominal Inflation and Scopy-Trocar Insertion Method
Baik Yonghae, MD, Choi Wonyong, MD
Introduction: Gastric cancer is the second leading cause of cancer in the world. Annual endoscopic checkups make early detection of gastric cancer possible. For quality of life, laparoscopic gastrectomy was introduced and is an accepted alternative treatment in early gastric cancer patients. As laparoscopic instruments developed, the flexible scope was developed that can provide a wider and more accessible view, but more distance from the working area is necessary. So scope port was punctured on supra-pubic area which means it possibly caused port complication.
Method: From November 2005 through December 2006, 33 patients underwent laparoscopic gastrectomy. Among them the distance from xipoid to umbilicus less than 20 cm were 18 patients. In that case we first did a Veress needle puncture in umbilicus and inflation until abdominal pressure was 12mmHg, then safely another guide STEPR Veress needle puncture supra pubic area and process the scope.
Result: Male and female ratio was 1:1(9/9) and mean age was 59 years (27~70). Mean body weight was 58.5kg (48~69.5Kg) and mean height was 158cm (152.5~164.4cm). Mean BMI was 22.65(18.32-26.8) There was no Intra operative complication. Intra operative retrieved lymph node number was 25.6(14~48). Every surgery finished successfully.
Conclusion: Using two-step abdominal inflation and scopy- trocar insertion method is a less invasive procedure during laparoscopic surgery with flexible scopy.
7227 Urology
The Role of Stent Placement in Laparoscopic Ureteroureterostomy
Jonathan Picard, MD, Ronney Abaza, MD
Objective: Laparoscopic ureteral surgery is becoming more common but requires advanced laparoscopic skills due to the precise suturing involved. Additionally, due to the size of the ureter and need for careful apposition of mucosal edges to prevent structuring, there is less room for error than with other sutured tasks or larger lumens as in pyeloplasty. We sought to identify the better technique for performing the ureteroureteral anastomosis both for the novice and more experienced laparoscopist in terms of whether the presence of a stent is a benefit or a hindrance.
Methods: Eight ureteroureteral anastomoses were performed on each ureter of a 50kg female pig for a total of 16 anastomoses. Eight anastomoses were performed with a 6 French stent in place during division and spatulation of the ureter, and 8 anastomoses were performed without a stent. An equal number of anastomoses with and without a stent were performed by a novice and an experienced laparoscopist. Anastomoses were graded according to the time required to complete and the quality of the anastomosis based on the presence and size of defects [none, small, large] and patency of the ureteral lumen.
Results: The overall times required for completion of the ureteral division and spatulation, initial stitch placement, completion of the anastomosis, and total time for the stented and nonstented procedures were 4.3 vs. 2.2 minutes, 4.2 vs. 4.4 minutes, 10.4 vs. 13.5 minutes, and 18.3 vs. 20.1 minutes, respectively. In the stented and nonstented ureters, 3 vs. 5 anastomoses were found to have no or very small gaps, 5 vs. 1 anastomoses were found to have large gaps, and 0 vs. 2 anastomoses were found to occluded lumens, respectively.
Conclusions: For both the novice and experienced surgeon, the presence of a ureteral stent reduced the overall time for completing ureteroureteral anastomoses despite the longer time needed to divide and spatulate the ureter. Additionally, the stent prevented ureteral obstruction from “back-walling” during suture placement.
7228 Urology
Novel Technique for Laparoscopic Partial Nephrectomy
Jonathan Picard, MD, Ronney Abaza, MD
Objective: Surgical partial nephrectomy involves removal of a renal mass while sparing the normal parenchyma. Classically, this procedure is indicated in patients with a solitary functioning kidney, bilateral tumors, or compromised renal function. Required elements of this procedure include hemostasis, repair of collecting system defects, and adequate tumor excision. Hemostasis is often achieved by applying a vascular clamp on the renal artery or vein, or both, with the resulting concern of limiting warm ischemia time to limit irreversible injury. Our goal was to investigate the feasibility of a novel approach to laparoscopic partial nephrectomy with the potential to both minimize ischemia time as well as maximize visualization and precision of tumor excision.
Methods: Eight partial nephrectomies were performed in 45-kg to 50-kg female pigs with excisions ranging from 2cm x 2cm to 5cm x 3cm. Laparoscopic dissection of the kidney and renal hilum was performed, and the excision sites were marked on the renal capsule with a hook monopolar cautery before excision. Before vascular clamping, sutures were preplaced in the renal parenchyma along the length of the simulated tumor under laparoscopic ultrasound guidance, leaving the needles in the tissue for optimal visualization and leaving the suture material attached to the needle outside the kidney with a single LapraTy clip in place. Vascular clamping with laparoscopic bulldog clamps was not performed until after all sutures were preplaced. Cold scissor dissection was then used to perform the resection using the needles as a guide. The base of the resection site was oversewn, and the needles were then passed out of the parenchyma until the LapraTy clip was against the renal capsule, allowing for a second clip to be placed on the other side of the suture under tension, creating a set of classic bolster sutures all of which were placed but left in the kidney before ischemia time began. The animals were kept alive for 2 weeks following the resections.
Results: All animals survived for 2 weeks without complications. Eight resections were performed: 2 wedge resections, 4 polar nephrectomies, and 2 heminephrectomies. The needle placement and parenchyma were easily visualized on laparoscopic ultrasound. The mean warm ischemia time (WIT) was 16 minutes and 17 seconds. Estimated blood loss was minimal in most cases with 100cc as the maximum in one case.
Conclusion: Preplacement of needles with attached bolster sutures before vascular clamping under laparoscopic ultrasound guidance is a technically feasible approach to performing laparoscopic partial nephrectomies. In addition to using the preplaced needles as a guide for resection, the preplaced bolster sutures may reduce warm ischemia time.
7229 General Surgery
Laparoscopic Adrenalectomy: Transperitoneal or Retroperitoneal Approach
G. Simutis, K. Strupas, V. Beisa
Background: Transperitoneal and retroperitoneal endoscopic approaches are currently used for laparoscopic adrenalectomy (LA). There is still some debate about the indications and optimal access used for a minimally invasive approach.
Methods: Patients who underwent LA for benign adrenal disorders at our center between October 1999 and December 2006 were grouped according to one of the two approaches, transperitoneal and retroperitoneal. For each group, demographics, comorbidities, clinical presentation, imaging studies, operative intervention, and outcome were analyzed retrospectively.
Results: Sixty-eight patients (56 women; 12 men) underwent LA during the study period. A transperitoneal approach was used for the first 38 patients (A group), and a retroperitoneal approach was used for the last 30 patients (B group). Forty-six right-sided lesions and 22 left-sided lesions were removed. The most common indication for LA was nonfunctioning adrenal adenoma (n=29, 43%). Average operative time for the retroperitoneal approach was significantly shorter than that for the transperitoneal approaches (mean, 101.8 min vs 127.2 min, p=0,012). Conversion to open surgery was required in 6 (15.8%) patients in the A group and in one patient in the retroperitoneal approach group. Postoperative complications developed in 6 (15.8%) patients, and 1 (2.4%) patient died due to thrombosis a. pulmonalis in the A group. There were no postoperative complications or mortalities in the B group.
Conclusion: An uneventful postoperative period, shorter operative time, and hospital stay were achieved in patients undergoing LA by the retroperitoneal approach. These findings indicate that the retroperitoneal approach is superior in patients with benign adrenal lesions who undergo LA.
7230 Urology
Assessment of the Impact of Six Months of Laparoscopic Radical Prostatectomy (LRP) Fellowship Training on the Learning Curve During Initiation of LRP Into a Lower Volume Prostatectomy Practice
James A. Brown, Kamran Sajadi
Introduction: Our aim was to determine whether 6 months of fellowship training decreases the 40- to 60-case LRP learning curve when incorporating a program into a lower volume practice.
Methods: An attending urologist (JAB) performed two 3-month laparoscopy fellowships (Thomas Jefferson University, 2002 and Massachusetts General Hospital, 2003), which included LRP training (transperitoneal and extraperitoneal). He observed 15, first-assisted on 10, performed portions of 26, and all of 2 LRPs (operative times 3 hours). He then started an LRP program (using AESOP 3000, Computer Motion) performing 32 procedures (4 transperitoneal and then 28 extraperitoneal) from July 2003 through June 2006, excluding a 3-month robotic surgery training sabbatical. Five procedures were performed at VA hospitals during 2004 without the AESOP 3000. Six residents assisted.
Results: LRP was performed in 32 men (ages, 46 to 71) with a mean body mass index of 29 (range, 21 to 37) and preoperative PSA of 6.7ng/mL (range, 3.2 to 13.6). Mean operative time was 418 minutes (range, 282 to 652), and median estimated blood loss was 400mL (range, 50 to 1700). Ten (31%) underwent pelvic lymphadenectomy. Six (10%) were converted and 5 (16%) received transfusion. Fifteen (47%) had positive surgical margins (43% pT2, 56% pT3): 14 (44%) apical and 7 (22%) elsewhere. Complications (some patients had >1) included 7 (22%) anastomotic leaks, 3 (9%) bladder neck contractures, 2 (6%) meatal stenoses, 1 (3%) bulbar stricture, 1 (3%) rectal injury/fistula, 1 (3%) pelvic abscess in a person with diabetes, 1 urinary tract infection, 1 acute renal insufficiency, 1 ulnar neuropathy, and 2 (6%) cardiovascular events. Four (13%) have received adjuvant radiation treatment. Of patients with 1-year follow-up data, 12 of 20 (60%) are completely continent/pad free, and 4 (27%) of 15 potent patients remain so with/without PDE5 inhibitor.
Conclusion: A 38-case, 6-month fellowship training experience did not eliminate the LRP learning curve. A 1 case per month volume practice with multiple first assistants (6) may propagate the learning curve. Continued critical assessment of LRP is warranted.
7231 Urology
Transurethral Microwave Dilatation of the Prostate for Management of Symptomatic Benign Prostatic Hypertrophy
Alexei Wedmid, MD, Grant I.S. Disick, MD, Simon J. Hall, MD, Michael A. Palese, MD
Introduction: Transurethral Microwave Dilatation (TUMD) is an office-based procedure that combines 2 minimally invasive techniques, microwave therapy and balloon dilation, for the treatment of symptomatic benign prostatic hypertrophy. We review our initial experience with the Prolieve Thermodilatation System method of TUMD.
Methods: Eighteen men underwent in-office TUMD while under local anesthesia with an average of 6 months follow-up. TUMD was performed with a 45-minute thermotherapy cycle of microwave energy (915mHz ± 5mHz; 50-watt maximum) with regulation of rectal temperature at 41°C to 42°C, followed by a 5-minute thermodilution period using a 46F balloon. Parameters examined included prostate volume, pre- and posttreatment uroflow, postvoid residual, and International Prostate Symptoms Scores (IPSS). Statistical analysis was performed using the Student t test.
Results: Patient age ranged from 46 years to 83 years (mean, 67) and included 37% who had prior surgical intervention on their prostate and 82% already on traditional medical therapy for BPH. Mean prostatic volume was 41cm3 (range, 13.9 to 68.7). At follow-up, uroflow measurement showed that Qmax had improved from 10.9mL/s to 15mL/s, mean postvoid residual improved from 84cc to 36cc, and mean IPSS score improved from 17 to 10.6. Additionally, 14/18 (78 %) men reported improved results with respect to their presenting problem, while only 1/18 (6%) men has required further surgical intervention to date.
Conclusions: TUMD is a minimally invasive technique that can be performed in-office, with the patient under local anesthesia with reasonable short-term success and may reduce the need for more invasive transurethral interventions. As such, it can be used as an effective tool in obviating the need for more invasive surgical treatments in poor surgical candidates.
7232 Gynecology
The Feasibility of Using Nitinol-U Clips With the da Vinci Surgical System to Treat Distal Fallopian Tubal Disease
David McLaughlin, MD
Background: Minimally invasive fimbrioplasty and neosalpingostomy were attempted using nitinol-U clips (Medtronic, Minneapolis, MN) applied through the da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA).
Methods: Although U clips were initially devised for cardiovascular surgery, no adverse effects were found during mouse embryo culture with the U clips, indicating the feasibility of using them for female fertility-promoting procedures. A 27-year-old, gravida 0, patient complaining of pelvic pain from her right hydrosalpinx underwent da Vinci right neosalpingostomy, and 39-year-old, gravida 6, para 0, ab 2, ectopic 4, with 2 failed IVF cycles, wishing to preserve/enhance her fertility, underwent da Vinci left fimbrioplasty using nitinol-U clips. Traditional microsurgical laparoscopic techniques were used to open and evert the fimbriae. S-60 U clips were used to attach the everted fimbrial serosa back upon the more proximal tubal serosa atraumatically.
Results: Both patients underwent the proposed surgeries as planned with rapid recovery and no complications. The first patient is pain free, and the second is attempting pregnancy.
Conclusion: Treatment of distal tubal disease is feasible by combining U clips and the da Vinci surgical system for reproductive women wishing to relieve pain or preserve their fertility.
7234 Urology
Ureteral Clipping During Laparoscopic Donor Nephrectomy Improves Operative Field Visibility and Does Not Affect Recipient Outcome
Kamran Sajadi, James J. Wynn, James A. Brown
Introduction: Typically, the donor ureter is left open after division. We have found clipping the ureter yields a cleaner operative field and therefore easier hilar vessel division. The aim of this study was to assess the impact of temporary ureteral obstruction on surgical outcomes.
Methods: We reviewed the intraoperative and postoperative outcomes of all HALDNs performed at our center by a single surgeon (JAB). We compared operative and outcome data on donor operations before and after ureteral clipping was initiated, examining estimated blood loss (EBL), operative time, urologic complications, and recipient factors, especially warm ischemic time, initial 24-hour urine output (UOP), initial drop in creatinine, and the recipient’s serum creatinine at the most recent follow-up.
Results: Fifteen patients underwent HALDN between November 2003 and August 2005, before we began ureteral clipping, and 12 patients subsequently underwent HALDN between September 2005 and June 2006. The kidney was placed at rest (desufflated peritoneum) for at least 15 minutes after the renal hilum was irrigated with papaverine in all cases before ureteral division. No statistically significant differences existed in EBL or operative time. No urologic complications occurred in either group. Two recipients experienced acute rejection episodes, both before the initiation of ureteral clipping. Median warm ischemic time was 3 minutes (range, 1 to 6), and the recipient’s initial 24-hour UOP was similar between groups (3849mL). Similarly, the recipients averaged a 44% (range, 13% to 80%) decrease in serum creatinine in the first postoperative day, and their most recent creatinine averaged 1.5 mg/dL (range, 0.9 to 3.5), which was similar in both groups.
Conclusion: Ureteral clipping improves visibility during division of the renal hilum during HALDN. Concerns about obstructing the ureter or inability to visualize urine output during procurement before transplantation are unfounded, because graft viability and recipient outcomes are unaffected.
7235 Pediatric Surgery
Minimally Invasive Repair of Congenital Diaphragmatic Hernias: A Review of Our Experience
Sohail R. Shah, MD, Jessica Wishnew, Katherine Barsness, MD, Barbara A. Gaines, MD, Douglas A. Potoka, MD, George K. Gittes, MD, Timothy D. Kane, MD
Objectives: Minimally invasive techniques continue to expand in pediatric surgery. In this study, we describe our institution’s experience with minimally invasive repair of congenital diaphragmatic hernias.
Methods: We reviewed all cases of congenital diaphragmatic hernia at a tertiary-care pediatric hospital since 2001with an initial attempt at minimally invasive repair.
Results: Seventeen children underwent attempted minimally invasive repair for congenital diaphragmatic hernia (12 Bochdalek and 5 Morgagni). Children ranged from 1 day to 6 years of age (mean, 17±25 months) and weighed 2.57kg to 21kg (mean, 8.36±5.70) at the time of surgery. All 5 Morgagni hernias were successfully repaired laparoscopically. Of the 12 Bochdalek hernias, 2 were successfully repaired laparoscopically, and 6 were repaired thoracoscopically. The only right-sided hernia defect was initially approached thoracoscopically but converted to laparotomy, while 2 other Bochdalek hernias were successfully repaired by thoracoscopy with mini-thoracotomy for lateral stitch placement. Only 1 patient required a patch, which was performed by thoracotomy after thoracoscopic bowel reduction and finding of a very large diaphragmatic defect. No deaths and only 1 recurrent hernia developed (follow-up, 1 week to 5 years). Six neonates (age range, 1 day to 14 days) had Bochdalek hernias and underwent an initial attempt at thoracoscopic repair. Three underwent thoracoscopic repair alone (1 developed the aforementioned recurrence); 2 underwent thoracoscopy with mini-thoracotomy or thoracotomy, respectively. One required conversion to laparotomy due to oxygen desaturation.
Conclusion: Congenital diaphragmatic hernias can be managed successfully by thoracoscopy or laparoscopy, depending on the type of hernia and patient age.
7236 Urology
Robotic-assisted Laparoscopic Sacrocolpopexy: Technique and Experience
Christopher M. Whelan, MD, Joe Miller, MD, Timothy Powell, MD, Brandan Kramer, MD, Bradley F. Schwartz, DO
Introduction: Robotic-assisted laparoscopic sacrocolpopexy is a new surgical approach for the repair of vaginal vault prolapse. We present video detailing our surgical technique and experience.
Methods: Women with high-grade vaginal vault prolapse following hysterectomy were offered robotic-assisted laparoscopic sacrocolpopexy. The surgical approach involves 5 laparoscopic ports: 4 robotic ports and 1 assistant port. A polypropylene Y-graft is secured to the anterior and posterior vagina by using interrupted synthetic absorbable sutures. The mesh is secured to the sacral promontory with synthetic nonabsorbable sutures. Operative time, blood loss, hospital stay, and complications were reviewed.
Results: From July 2005 through June 2006, 14 patients underwent robotic-assisted laparoscopic sacrocolpopexy for high-grade vaginal vault prolapse. Mean patient age was 63 years. Blood loss was less than 50cc. Average operative time, including robot docking, was 2 hours, 56 minutes. All patients were discharged home on postoperative day 1. Mean follow-up was 6 months. There was no recurrence of vault prolapse. One patient developed a small-bowel obstruction on day 5, requiring an exploratory laparotomy.
Conclusions: Robotic-assisted laparoscopic sacrocolpopexy is a new minimally invasive approach to vaginal vault prolapse. This technique offers minimal blood loss, acceptable operative time, and a short hospital stay.
7238 Urology
Laparoscopic Donor Nephrectomy: Improving on a New Standard of Care
Grant Disick, MD, Christopher Ip, MD, Edward Chin, MD, Michael Edye, MD, Daniel Herron, MD, Michael Palese, MD
Introduction and Objective: Laparoscopic donor nephrectomy (LDN) has decreased the morbidity of renal donation while consistently providing a renal allograft of quality that equals open donor nephrectomy. We evaluate our LDN experience to examine how surgical experience affects intraoperative parameters, as well as postoperative outcomes of the donor.
Methods: Records of 282 LDNs performed by 3 surgeons from March 2000 to January 2007 were retrospectively reviewed. We evaluated preoperative donor characteristics, intraoperative parameters, postoperative recovery and complications, and compared 127 cases before January 2005 with 155 cases after January 2005.
Results: Mean age of our patients was 39.7±11.4 years with more females than males donating (F=152, M=123). Average operative time was 181.8±56 minutes with a statistically significant decrease in time when comparing cases before January 2005 with cases after January 2005 (200.7±55.9 vs.166.6±51.7 min; P<0.05). Average warm ischemia time was 165.1±69.4 seconds with no significant difference between the 2 groups (170.7 vs. 166.6 sec). Total estimated blood loss was 189.5mL with no statistical change between groups (151.5mL vs. 218.3mL). Thirty-eight percent of procedures were performed via a hand-assisted approach, and 19% of the kidneys were right sided. Intraoperative complications occurred in 19 cases (with 3 conversions to open). Major postoperative complications occurred in 16 cases. Creatinines preoperatively and on postoperative days 1 and 2 were 0.8±0.20mg/dL, 1.22±0.28mg/dL, and 1.24±0.3mg/dL, respectively. The average length of stay was 2.2 days.
Conclusions: Laparoscopic donor nephrectomy has become the standard of care for renal donation. With increased experience, surgeons are demonstrating decreased operative times while continuing to produce safe and reproducible outcomes in regards to blood loss, warm ischemia time, and postoperative renal function of the donor. As such, the option of renal donation may be expanded to an even larger population.
7239 General Surgery
Laparoscopic Gastric Bypass for Morbid Obesity: Prospective Study With Two Gastrojejunal Anastomosis Techniques
Jose L. Leyba, Salvador Navarrete, Jose Isaac, Salvador Navarrete, Francisco Obregón, Carlos Bravo
Objective: We present a prospective series of laparoscopic gastric bypass with 2 techniques of gastrojejunostomy in patients with morbid obesity.
Methods: Eighty consecutive patients underwent Roux-en-y laparoscopic gastric bypass between September 2005 and August 2006. All patients were randomly assigned to 2 groups. In group (A), the gastrojejunal anastomosis was performed with a 21-mm circular endostapler, and in group (B) the anastomosis was performed with a 45-mm linear endostapler. The rest of the procedure was identical in both groups. Variables evaluated were morbidity in relation to the type of anastomosis, operating time, length of hospital stay, and loss of excess weight.
Results: Both groups were comparable regarding age and body mass index. No patients experienced leakage or gastrojejunal anastomosis fistula, but group (A) patients had stenotic anastomosis more frequently (P<0.05). Operative time and length of hospital stay were comparable in both groups (P>0.05). Excess weight loss in patients followed for a year was satisfactory in both groups, with better results in group (A), without statistical significance (P=0.06).
Conclusion: Gastrojejunal anastomosis seems to be an independent factor in excess weight loss in morbidly obese patients undergoing laparoscopic gastric bypass. Endo-circular 21-mm anastomosis and 45-mm endo-linear anastomosis are safe and effective. The first one has a greater index of stenosis but better efficacy. It is necessary to follow these patients a long time to determinate the success rates with both techniques.
7240 Gynecology
Comparison of Two Transobturator Techniques for Stress Urinary Incontinence Regarding Operative Time, Recovery, Complications, and Clinical Efficacy
Radha Syed, MD
Objective: To compare 2 different techniques of transobturator midurethral tension free vaginal sling procedures, one "inside out approach" provided by TVT-O by Gynecare versus the other TOT (Obtryx) "the outside in approach" provided by Boston Scientific. These 2 procedures were studied for the operative time and ease of technique, recovery time, complications, and clinical efficacy.
Methods: A retrospective analysis was performed of the charts of 5 patients who had the TVT-O procedure and charts of 5 patients who had the TOT procedure in successive time periods from January 2006 to February 2007. Clinical efficacy was determined by improvement in the symptomatology of genuine stress urinary incontinence. Further complications, immediate and remote, were studied by patient follow-up for a period of 3 months to 9 months. All patients underwent urodynamic testing in the office before surgery. All patients had urine culture sensitivity and voiding diary assays before the procedure. In the postoperative followup, these modalities were reassessed. A urologist performed cystoscopy on all patients immediately postprocedure. The OR time for each procedure was obtained from the OR logs. All patients went home with an indwelling Foley catheter, which was removed 3 days to 5 days postoperatively.
Results: Both TVT-O and TOT are equally minimally invasive procedures requiring short operative times and exhibited equal ease of performance. The blood loss from both procedures was not significantly different. No immediate or remote complications occurred. Clinical efficacy was equal with resolution of major stress urinary incontinence and continuous improvement occurring in the following months. There was some degree of urgency and frequency resulting in the immediate postoperative period that resolved in 3 months to 6 months.
Conclusion: This author found no significant difference between TVT-O and TOT in any of the categories tested. A literature review shows a slightly increased incidence of pelvic hematomas in the latter procedure. Several more cases need to be performed for proper statistical evaluation of the said complication.
7241 General Surgery
Total Laparoscopic Esophagogastrectomy
Salvador Navarrete, MD, Jose Leyba, MD, Salvador Navarrete LLopis, MD, Francisco Obregón, MD, Jose Isaac, MD
Objective: We present the videolaparoscopic technique of partial esophagus-gastrectomy in one patient with gastroesophageal junction adenocarcinoma.
Methods: The patient was a 54-year-old male who presented with dysphagia, regurgitation, and weight loss for 2 months. A superior digestive endoscopy was performed, which revealed a developing gastroesophageal tumor involving 2cm of distal esophagus with a positive biopsy for gastroesophageal adenocarcinoma. Endoscopic ultrasound revealed a 4-cm gastrojejunal tumor with esophageal extension that invaded the gastric serosa without a pathological lymphatic node layer (T3 N0 M0). No evidence of metastasis was present. Laparoscopic esophagogastrectomy was done beginning with a gastroesophageal junction dissection to separate a 4-cm tumor from the diaphragmatic pillars where it was attached. Peritumoral node biopsy was negative. After a trinocular vagotomy, the thoracic esophagus was resected 5cm above the lesion with a 45-mm endo-lineal stapler and then the head of a 21-mm circular endostapler with an 18-French orogastric tube was passed through the mouth. The distal stomach was resected with a 45-mm endo-lineal stapler 6cm from the pylorus, making a gastric tube. The resection was completed with clipping of the left gastric artery, an extramucosal pylorotomy with separated stitches, continual invagination suture of the gastric tube free border and through gastrotomy. We performed gastroesophageal anastomosis with a 21-mm circular endostapler.
Results: Operative time was 295 minutes; oral intake began on the fourth day with progression to a liquid diet on the sixth day. No morbidity or mortality has occurred, and the final biopsy report indicates an adenocarcinoma T3 N0 with free invasion wedges.
Conclusion: Laparoscopic esophagus-gastrectomy for junction adenocarcinoma (T3/N0) is a feasible, safe procedure with an oncological basis.
7242 Gynecology
Case Presentation of Failed Essure (Conceptus) Bilateral Tubal Occlusion Procedure in Four Consecutive Patients: Cause, Diagnosis, and Corrective Procedures
Radha Syed, MD
Objective: To study the reasons and clinical circumstances contributing to failure of bilateral tubal occlusion by Essure methods in a private community practice setting.
Methods: Four patients who underwent a bilateral Essure tubal occlusion procedure from January 2006 to July 2006 but were subsequently found to have patent tubes by hysterosalpingogram were studied by chart review and review of HSG films. A repeat hysterosalpingogram was performed 3 months after the initial HSG as per protocol, and failure of Essure was confirmed. Subsequent laparoscopic tubal ligation of the patent tube was performed in 2 patients. Two of the other patients have decided to continue alternative contraception of a nonpermanent nature. All patients underwent the Essure procedure, performed by the author, as outpatients while under general anesthesia. Preoperative injection Depo Provera 150mg was given to 3 of 4 patients for interval contraception. The fourth patient had oral contraceptives. All patients underwent HSG performed by the author 3 months to 4 months postoperatively and were found to have a single tube patent. All patients were informed of these conditions and agreed to continue alternative contraception until 6-month HSG reconfirmed the patency of the tube.
Results: Study of the charts, the OR report, and 2 HSG reports on each patient (3 months apart) have failed to show any significant common cause for continued patency of the tube. There was apparent difficulty with the Essure micro-insert introduction in the tube in question in 2 of the patients during the sterilization surgery. However, after following the protocol of the manufacturer, these issues resolved with proper introduction of the micro-insert. There were no postoperative complications, no significant pain symptoms, or abnormal bleeding in any of these patients.
Conclusion: It is difficult to evaluate either preoperatively or postoperatively those patients who will lend themselves to failure of the Essure procedure. There are no historical or physical and anatomical pointers to differentiate these patients from the other patients who have had successful Essure procedures. The author believes that the failures may be a result of minor anatomical variation in the tube or deficient approximation of the micro-insert to the tubal endothelium, either because of diameter variation or slight migration of the micro-insert into a larger portion of the tube. A postoperative histology of the tube needs to be studied to confirm this hypothesis.
7243 Urology
Is a Closed Suction Drain Required After Robotic-assisted Laparoscopic Radical Prostatectomy?
Carl K Gjertson, MD, Erin Flaherty, MD, Thomas Gardner, MD, Michael Koch, MD, Chandru P. Sundaram, MD
Introduction: With the advent of robotic-assisted laparoscopic radical prostatectomy, we now omit perivesical drain placement in the majority of cases. We reviewed our robotic prostatectomy series to determine the incidence of drain placement, length of catheterization, and continence.
Methods: Between January 1, 2004 and July 1, 2006, 351 robotic-assisted prostatectomies were performed by 3 surgeons at a single institution. A running suture was attempted for vesicourethral anastomosis in all patients. The decision to leave a drain was made by the surgeon on a case-by-case basis. All catheters were irrigated, and the anastomosis visually inspected for leakage before closure. A cystogram was performed approximately 7 days postoperatively before catheter removal. Continence was evaluated by using questions 8 thru 12 of the SF-12 v2 health survey.
Results: Thirty-nine patients had drains and 312 did not. Mean blood loss, operative time, and hospitalization were significantly greater in patients with drains (P<0.001). Thirty-two patients had an anastomotic leak visualized intraoperatively: 21 received drains and 11 did not. For this subgroup, the incidence of leak on POD 7 cystogram was significantly less for those with drains (P=0.043), and the mean length of catheterization was 5 days shorter (P=0.061). At 1 and 12 months after surgery, no significant differences were noted in continence scores between patients with or without drains.
Conclusion: Perivesical drains were used in 11% of 351 robotic-assisted prostatectomies. We recommend drain placement if there is any intraoperative evidence of anastomotic leak, because it is associated with significantly fewer leaks 1 week postoperatively and a trend toward earlier catheter removal.
7244 Gynecology
Mega Uterus: Overview of a Technique for Laparoscopic Hysterectomy and Outcome
Leroy Charles, MD, Lionel Leroy, MD
Background: The size and shape of the uterus, as well as the location of the fibroids and careful preparation of the surgery, impact in the successful completion of total laparoscopic hysterectomy in the very large uterus.
Methods: This case series was selected from our experience in 1256 laparoscopic hysterectomies performed over the past 15 years.
Results: Of those cases, 76 (6.05 %) were in patients with a uterus weighting more than 900g. The weight ranged from 950g to 3840g, with an average weight of 1,200g. Median blood loss was 135mL. The median surgical time was 105 minutes. There were no conversions to laparotomy. One patient (1.31%) required blood transfusion of 2 units for postoperative bleeding, and one (1.31%) patient with 3 previous Cesarean deliveries had a bladder lesion diagnosed and repaired during surgery. All patients were discharged in 23 hours.
Conclusion: Total laparoscopic hysterectomy is possible in the very large uterus (mega uterus) in experienced hands, with very low complication rates and overnight stay in the hospital.
7246 General Surgery
Robotic-assisted Colorectal Surgery: Initial Experience
Philippe Morel, Monika Hagen, Pascal Gervaz, Ihsan Inan
Background: Laparoscopic colorectal surgery is generally feasible but may be technically challenging. We hypothesize that robotic-assisted surgery, with its enhanced dexterity and superior visualization, might offer technical advantages over traditional laparoscopy in this setting. The aim of this study was to assess the feasibility of robotic-assisted colorectal surgery and oncological safety of robotic-assisted total mesorectal excision (TME).
Methods: Five patients (median age 64 years) with rectal cancer were scheduled for a robotic-assisted TME. A pathologist evaluated the operative specimens. Three patients (median age 51 years) with diverticular disease underwent robotic-assisted sigmoid resection. Duration of operation, robot docking, hospital stay, and complications of all patients were evaluated prospectively.
Results: The median operative time and duration of hospital stay in the patients undergoing TME were 260 minutes (range, 210 to 360) and 10 days (range, 8 to 23). All resections were R0, and the median distal resection margin was 4cm (range, 1.4 to 6). The median number of retrieved lymph nodes was 14 (range, 7 to 15). Postoperatively, one patient reported bladder dysfunction. Median operative time for robotic sigmoid resection was 170 minutes (range, 150 to 360) and hospital stay was 6 days (range, 5 to 19). Median robot-docking time of all colorectal procedures was 7 minutes (range, 3 to 13). No complications occurred after sigmoid resection.
Conclusion: These initial data suggest that robotic-assisted colorectal surgery is technically feasible, and robotic-assisted TME can be performed with oncological safety. Learning curves both for the procedure and docking of the robot are rapid. Whether this new technique is superior to the conventional approach remains hypothetical.
7247 General Surgery
Impressions of Inexperienced Individuals and Laparoscopic Surgeons in Their First Use of the da Vinci Surgical System
M. Hagen, I. Inan, Ph. Morel
Background: Due to its typical characteristics (improved ergonomics, comfortable sitting position, intuitive control, and others), the da Vinci Surgical System is supposed to be extremely comfortable and should be instantly preferred over conventional laparoscopy. We tested the above hypothesis in a trial with both beginners and laparoscopically experienced surgeons in their first use of the da Vinci Surgical System.
Methods: Thirty-four individuals performed tasks in a pelvi-trainer as their first use of the da Vinci robot and in conventional laparoscopy. Group 1 included 18 surgical inexperienced individuals; group 2 included 16 laparoscopically trained surgeons. All probands were surveyed about their impressions after about 1 hour at the surgical console.
Results: Both groups indicated an equal comfort level of 9.2 on a scale of 1 (not at all) to 10 (very much). None of the probands would have preferred conventional laparoscopy at any time. Group 1 found the robot suitable for the tasks of 9.2 and Group 2 of 9 on the same scale (differences without statistical significant, P>0.05). Fifty percent of both groups had the perception of haptic feedback as an indication of comfort.
Conclusion: The data support the conclusion that novices to robotic surgery feel extremely comfortable with the da Vinci surgical system from the first moment of use. There seems to be no difference in comfort with the robot between laparoscopically inexperienced individuals and trained surgeons. Furthermore, robotic surgery is preferred instantly over conventional laparoscopy.
7248 General Surgery
Transaxillary Endoscopic Parathyroidectomy: Our Initial Series
Qammar N. Rashid, MD, Titus D. Duncan, MD, Ijeoma Ejeh, MD, Fredne Speights, MD
Introduction: We retrospectively reviewed the charts of 17 patients who underwent parathyroidectomy using a transaxillary endoscopic technique. The resulting incisions are well hidden within the axillary fossa and imperceptible with the patient’s arm is in a natural anatomic position. The technique and advantages of parathyroidectomy using a transaxillary endoscopic approach are discussed.
Methods: We performed 18 parathyroidectomies in 17 patients by using a transaxillary approach between July 2004 and December 2006. All patients had hypercalcemia and clinical symptoms compatible with hyperparathyroidism. Unilateral parathyroid adenomatous disease as the cause of hypercalcemia in these patients was suggested by preoperative laboratory and localizing radiographic studies. The average age of the patients in this series was 53 (range, 34 to 75).
Results: The final pathology in each case was benign parathyroid adenoma(s) with an average weight of 1550mg (range, 100 to 2400). Sixteen patients had a single hyperplastic parathyroid lesion, while 1 patient had 2 ipsilateral hyperplastic glands. All patients had complete resolution of their clinical symptoms of hyperparathyroid state. There were no postoperative complications.
Conclusion: Takami pioneered an endoscopic approach to the thyroid by using a remote technique through transaxillary incisions. The advantages of this approach include superior visualization of critical anatomy of the neck, and superior cosmetic outcome with no visible scar in the neck region. The transaxillary approach to the parathyroid gland is a safe and feasible alternative to the open technique of parathyroidectomy for single or unilateral glandular disease.
7249 General Surgery
Percutaneous Computed Tomography-guided Radiofrequency Ablation of Lung Tumors: Case Report and Review of the Literature
J. P. Fontaine, D. Ouellette, G. Beauchamp, F. J. Podbielski
We report the use of percutaneous computed tomography-guided radiofrequency (RF) ablation of a single lung metastasis in a 35-year-old man. The patient had his primary sarcoma resected from his right femur in 2002 followed by adjuvant chemo- and radiotherapy. He had a recurrence twice of bilateral pulmonary metastasis. He twice underwent staged bilateral thoracotomies for lung metastatectomies. Fifteen months later, he presented with a single 2.5-cm left upper lobe lung metastasis. His primary tumor was otherwise well controlled. To preserve a maximum of normal lung parenchyma and to avoid a third thoracotomy requiring extensive and hazardous lysis of adhesions, percutaneous RF to successfully ablate his metastasis was used. A description of the technique and a review of the literature on this innovative option for the treatment of lung tumors are provided. The mechanism of action, the indications, the complications, and mid-term results are discussed.
7250 General Surgery
Laparoscopic Transabdominal Hernia Repair for Incarcerated Groin Hernias: Technique, Pitfalls, Results
Dr. med. U. Steinhilper, Dr. med. E. Bielesch, Dr. med. D. Laqua
Introduction: Laparoscopic hernia repair for incarcerated hernias is rarely performed standardized and seldom has been published in studies. We present our experiences in 54 emergency cases of TAPP for acutely incarcerated hernias (learning curve/acquiring a standardized technique/results). Further on, we will give a review of literature.
Method: Since 1995, beside 3600 scheduled hernia procedures, we operated laparoscopically on 54 patients with acutely incarcerated inguinal or femoral hernias in a standardized transabdominal laparoscopic procedure (TAPP) with application of a titanium coated mesh after reduction of the hernia sac. We investigated difficulties in laparoscopic hernia sac reduction, estimation of the vitality of the incarcerated tissue, intraoperative complications, and postoperative outcome.
Results:
Acutely incarcerated hernias: N=54 (100%)
Small-bowel obstruction: 39 (72.2%)
Reduction problems: 7 (13%)
Conversion due to major complication (small-bowel perforation): 1 (1, 85%)
Simultaneous operation of the contralateral side: 10 (18, 5%)
Wound-mesh infection: 0
Further results will be given.
Conclusions: Standardized laparoscopic repair of incarcerated groin hernias is feasible and safe. The main advantage is the meticulous assessment of the previously incarcerated organs with respect to their vitality in combination with a minimally invasive one-step procedure. No infections occurred; however, there is a learning curve for technical skills for hernia sac reduction at low risk.
7251 Urology
Prospective Comparison of Perioperative and Early Pathologic Outcomes Between Robotic and Open Radical Cystectomy
Gerald J. Wang, MD, Daniel A. Barocas, MD, Jay D. Raman, MD, Philip S. Li, MD, Douglas S. Scherr, MD
Objectives: Open radical cystectomy (RC) is the gold standard for treatment of muscle-invasive bladder cancer. Here, we present our initial series of robotic-assisted RCs and compare perioperative and early pathologic outcomes to a concurrent series of open RCs.
Methods: From February to December 2006, 43 consecutive patients underwent RC by a single surgeon at our institution. Twenty-two were performed open, 21 were robotic. Data were collected prospectively and analyzed using the chi-square, Fisher's exact, and Student t tests.
Results: Mean operative time was greater in the robotic cohort (402 minutes vs. 336 minutes, P<0.05). However, the robotic group demonstrated improved perioperative outcomes compared with the open group, with decreased blood loss (462mL vs. 1023mL, P<0.005), mean transfusion requirement (1.2 units vs. 2.6 units, P<0.05), time to regular diet (4 days vs. 5 days, P<0.005), and length of hospitalization (6.5 days vs. 10.0 days, P<0.05). No difference existed in tumor grade, stage, or surgical margin status between the 2 groups. There was also no difference in either the total number of lymph nodes removed in the open versus robotic cohorts (18.9 vs. 16.1, P=0.4) or the number of positive lymph nodes identified.
Conclusions: Our initial series of robotic-assisted RC demonstrates longer operative time but improved perioperative outcomes compared with open RC. The robotic method also demonstrates equivalent early pathologic outcomes. Long-term functional and oncologic outcomes are needed to better define the role of robotic-assisted RC in the surgical management of bladder cancer.
7252 General Surgery
Laparoscopic Colon Surgery: The New Gold Standard
Michael E. Fenoglio, MD
Background: Colorectal resections are common surgical procedures all over the world. Laparoscopic colorectal surgery is technically feasible in a considerable number of patients under elective conditions. Several short-term benefits of the laparoscopic approach to colorectal resection have been proposed (less pain, less morbidity, improved recovery, and better quality of life). We present our experience with laparoscopic colon surgery.
Objectives: We reviewed the results of our cases of laparoscopic colon resections with regards to benefits of the laparoscopic method and the results of our resections.
Results: We have performed 349 laparoscopic colon cases. These include left colon, right colon, subtotal colon, and takedown of colostomies. The average length of stay was 3.4 days. Return of bowel function was faster with laparoscopic colon resection than with open cases, and no difference in complication rates occurred between laparoscopic and open cases at our institution. Oncologic results in laparoscopic and open cases were the same in terms of margins obtained and lymph nodes obtained.
Conclusions: Laparoscopic colonic resections show clinically relevant advantages. Long-term oncologic results of laparoscopic resection of colonic carcinoma have been shown to have equivalent results. We feel the laparoscopic approach should be preferred in patients suitable for this approach to colectomy.
7253 Multispecialty
Development of a Method for the Consistent Creation of Experimental Pelvic Adhesions in a Swine Model
Bradford W. Fenton, MD, PhD, Michelle Evancho-Chapman, James Fanning, DO
Objective: Current research on adhesion prevention is hampered by the lack of an animal model where an easily replicable wound produces consistent pelvic adhesions for use in adhesion prevention research. This study was designed to identify and optimize a surgical technique for creation of adhesions between the uterus and pelvic sidewall by varying the sidewall wound, uterine wound, and survival time.
Methods: Fourteen conditioned young adult female swine were used according to federal guidelines and an approved institutional protocol. The pelvic sidewall wounds included no injury, or complete stripping of the adjacent peritoneum, or a longitudinal high- or low-powered electrocautery injury. Uterine wounds included a complete longitudinal hysterotomy and a longitudinal high- or low-powered electrocautery injury. Evaluation was done between 7 days and 42 days.
Results: Hysterotomy, sidewall stripping, or high-power injury completely enveloped the cornu into the pelvic sidewall. A low-powered electrocautery injury to both the sidewall and uterus consistently produced dense adhesions limited to the area of injury. Adhesions had formed after 7 days, increasing in density in up to 14 days. After 14 days, adhesions did not change substantially.
Conclusion: A technique consisting of a low-powered longitudinal electrocautery injury to the pelvic sidewall adjacent to a similar injury of the uterus and held in place with retention sutures for 14 days consistently generates dense but anatomically delimited adhesions between the pelvic sidewall and uterine horn. This technique can provide the basis for further potentially quantitative analysis of adhesion prevention techniques.
7254 Urology
Impact of 3-dimensional Visualization and Articulating Needle Driver Use on Time and Accuracy of Simulated Laparoscopic Suturing and Knot Tying
J. G. Bittner, A. M. Deladisma, S. Shah, C. Hathaway, J. A. Brown
Introduction: We hypothesized that no difference exists between standard 2D video monitor and 3D head-mounted display visualization or standard and articulating needle driver use on time and accuracy of simulated laparoscopic suturing and knot tying across laparoscopic skill levels.
Methods: Novice (n=2) and intermediate (n=2) surgical residents plus laparoscopic-trained urologists (n=2) completed all simulated tasks on a box trainer. The 2 tasks were 4 running sutures, and a simple suture with 5 intracorporeal knots using 12cm, 2-0 polyglactin suture. With left and right 45-degree angle object orientation, right-handed participants performed each task twice using 2D/standard driver, 2D/articulating driver, 3D/standard driver, and 3D/articulating driver in random order. Outcomes included time to complete the task, maximum distance, and average distance from specified marks to determine accuracy. One-way ANOVA for 2 independent samples (alpha=0.05) was used to establish significance.
Results: No difference existed in time or maximum distance related to angle of the sutured object. Right-angle orientation yielded greater average distances (P<0.0001) from specified marks. No difference exists in outcomes when comparing suturing with 2D or 3D visualization. Use of an articulating driver compared with a standard driver prolonged time to complete suturing (P<0.0001) and resulted in greater maximum (P=0.003) and average (P=0.003) distances from desired points. Regarding knot tying, no difference in outcomes for 2D or 3D visualization exists; however, articulating driver use significantly increased task completion time (P=0.005).
Conclusion: Use of a 3D head-mounted display does not seem to significantly impact outcomes, and it appears that articulating driver use may increase the burden of laparoscopic suturing and knot tying.
7255 General Surgery
Applying Ultracision Long Sheers Reduces Operation Time in Transanal Endoscopic Microsurgery
Pleun E. A. Hermsen, MD, Wim C. J. Hop, PhD, Ifesegun D. Ayodeji, MD, Geert W. M. Tetteroo, PhD, Eelco J. R. de Graaf, MD
Objective: Previous research indicates that application of Ultracision sheers significantly reduces operation time in transanal endoscopic microsurgery. Frequently, other instruments were required to complete resection. We investigated whether the new Ultracision long sheers are better equipped for transanal endoscopic microsurgery compared with the regular Ultracision sheers.
Methods: From 2001 to 2006, 162 tumors (146 adenomas, 47 carcinomas; mean distance 9cm; mean area 27cm2) were excised in 161 patients (80 men, 81 women; mean age 66 yrs).
Results: Ninety-one resections were performed with regular sheers, and 71 with long sheers. Tumor and patient characteristics were similar except for specimen area. Tumors resected by long sheers were smaller (37cm2 versus 45cm2; Mann-Whitney-U test, P<0.001). Mean operation time was 52 minutes and proportionate to the area in both groups (univariate analysis of variance, P=0.02). Mean operation time was 58 minutes using regular sheers and 44 minutes using long sheers (t test, P<0.001). After correction for area, operation time was reduced 10% by applying long sheers instead of regular sheers (t test, P<0.05). Long sheers are singly capable of completing resection in 87% compared with 25% for regular sheers (Mann-Whitney-U test, P<0.001). Mean blood loss (11cc), mean hospital stay (3 days), morbidity (5.6%), mortality (0.5%), and recurrence rate in adenomas (3.5%) were similar in both groups (Fisher's exact test).
Conclusion: Performing transanal endoscopic microsurgery with Ultracision long sheers reduces operation time compared with regular sheers, and completing resection seldom requires other instruments.
7256 General Surgery
Laparoscopic Colon Resection with High-dexterity Instrumentation
Paul G. Curcillo II, MD
Background: Laparoscopy has required adaptation to rigid instrumentation. The loss of articulation mandated port position as well as increased numbers of ports in some cases. Although easing some maneuvers, the initial introduction of articulation in robotic surgery defined specific port positioning and left little room for multiple quadrant surgery without repositioning the instrumentation. In addition, the cost, training, and operative time for setup and repositioning can increase relative to standard laparoscopy. A new surgical device (RealHand™ Laparoscopic Instrumentation) reintroduces articulation into laparoscopy. Representing a new class of laparoscopic instruments, high-dexterity (HD) instrumentation functions through a series of cables and links to allow simple wrist action to translate into 7 degrees of freedom of movement at the tip.
Methods: A comparison of 10 initial robotic colon resections with 10 initial HD laparoscopic colon resections was performed. Each series included the first 10 colon resections performed with each of the devices. All procedures in both groups were completed laparoscopically, and all patient results were similar.
Results: Improvements were noted in freedom of port placement, setup and breakdown time, as well as ability to use the same 3 ports for multiple quadrant surgery (as in near total proctocolectomy) in the HD group. Difficultly in approaching more than one quadrant in the robotic group necessitated “redocking” and combining standard laparoscopy with robotic surgery in some patients. Training time for use of the high-dexterity instrumentation was minimal for surgeon, assistant, and staff. In addition, in the HD group, port placement could be determined based on patient and abdominal environment encountered rather than being dependent on the equipment’s limitations. Instrument exchange was greatly improved as well in the HD group.
Conclusion: The need for articulation in laparoscopy is evident. However, this need should be met with instrumentation that adapts to the surgery rather than adapting the surgery to the instrumentation. High-dexterity instrumentation provides this articulation with a versatile adaptability that will further enhance advancement in minimally invasive surgery.
7258 General Surgery
Building a Laparoscopic Colorectal Mentoring Program at a Community Hospital: A 3-Year Experience
Prashanth S. Navaran, MD, Kennedy Gabregeorgish, MD, Stuart Shindel, MD, W. Peter Geis MD
Objectives: To study the feasibility of establishing a laparoscopic colorectal mentoring program in a community hospital. The goals were to introduce and facilitate the performance of minimally invasive colectomies by surgeons with variable laparoscopic experience.
Methods: Data were collected on all colectomies performed within a 3-year time frame; 1 year before implementation of the program, and 2 years postimplementation. The number of open versus laparoscopic colorectal procedures performed was documented. Preoperative and postoperative conferences were conducted. The surgeons were asked to self-report their perceptions regarding satisfaction with the program, acquisition of laparoscopic skills, and patient outcomes.
Results: Thirteen surgeons participated. In the year before initiation of the program, 123 colectomies were performed; 120 open and 3 laparoscopic with 0 conversions. In the first year postinitiation, 142 cases were performed with 67 open and 73 laparoscopic with 2 conversions. In the second year, 167 cases were performed with 84 open and 76 laparoscopic with 2 conversions. All participating surgeons self-reported a positive experience with the mentorship program to include performance satisfaction and skills acquisition. All surgeons reported improved patient satisfaction, decreased use of postoperative pain medication, and decreased hospital stay.
Conclusions: We have established a successful laparoscopic mentorship program for general surgeons in private practice at a community hospital. We have identified factors and strategies that will contribute to the success of such a program.
7259 Urology
Complications of Hand-assisted Laparoscopic Renal Surgery: A Retrospective Review
T. J. LeRoy, R. W. Pak, M. J. Wehle, T. E. Brisson, P. R. Young, S. P. Petrou, W. Hewitt, T. C. Igel
Introduction: Hand-assisted laparoscopic renal surgery has become a pervasive procedure performed by many urologists with minimal formal laparoscopic training. We review our experience with intraoperative, postoperative, and delayed complications related to hand-assisted laparoscopic nephrectomy, partial nephrectomy, nephroureterectomy, and living-donor nephrectomy.
Methods: We conducted a retrospective review of all hand-assisted laparoscopic renal surgeries performed at our institution from March 1999 to June 2006. The medical records were reviewed for intraoperative, postoperative, and long-term complications.
Results: During the study period, 365 hand-assisted laparoscopic renal surgeries were performed. Patients in the nephroureterectomy group were older with an average age of 75 years. Anesthesia risk and body mass index scores were not significantly different. Operative complications included 15 (4.1%) open conversions, 11 vascular/visceral injuries, and 7 anesthesia-related complications. Visceral injuries documented include liver, spleen, or bowel lacerations. Postoperative complications included 24 ileus, 15 hand-port hernias, 8 wound infections, 2 thromboembolisms, 2 deaths, and 1 port-site tumor recurrence. Average follow-up for the entire cohort was approximately 59 weeks (range, 0.4 to 312). Only 1 patient in the nephrectomy group developed a hand-port related tumor recurrence on follow-up imaging. Our overall morbidity and mortality rate was 13.4% and 0.5%, respectively.
Conclusion: Hand-assisted laparoscopic renal surgery is safe and associated with acceptable complications when compared with open or laparoscopic series. Open conversions were more likely with earlier cases and associated with intraoperative vascular injuries. Hand-assist port-site hernias may be related to fascial trauma, surgical technique, body mass index, and surgeries performed for malignancy.
7260 Urology
Robot-assisted Radical Prostatectomy: Histopathologic Data of 1200 Cases
Ketul Shah, MD, Arend David, MD, Thaly Rahul, MD, Kenneth Palmer, MD, J. Woolard, Patel Vipul, MD
Objectives: We evaluated the histopathologic outcomes with a focus on the rate of positive surgical margins in patients undergoing robotic-assisted laparoscopic radical prostatectomy in 1200 consecutive cases performed by a single surgeon.
Methods: Over a 53-month period, 1200 consecutive patients underwent robotically assisted radical prostatectomy, for clinically localized adenocarcinoma of the prostate. A positive surgical margin, defined as extension of the tumor to the inked surface of the specimen, was present.
Results: Postoperative histopathologic analysis showed that the mean Gleason's score was 6.6 (range, 5 to 10). The number of patients with Gleason's <6 (1%) were 6 (36.3%), 7 (35.3%), 8 (3.5%), 9 (3.4%), and 10 (<1%). Pathologic stage T2a, T2b, T2c, T3a, T3b, and T4 were found in 14%, 3%, 60%, 15%, 6%, and 2%, respectively. Mean prostate volume on weighed specimen was 49.9 grams (range, 15.3 to 195.5). Peri-neural invasion was found in 37.4% of patients. Lymph node dissection was performed in 128 (10.5%) patients, out of which 19 (1.5%) had positive nodes. Forty-four of 1238 (11.6%) patients had positive surgical margins on final pathology. Positive margins based on stage were T2 (4%), T3 (34%), and T4 (40%). The distribution of positive surgical margins was apex (23%), bladder neck (14.5%), peripheral (36.7%), and multifocal (24.7%).
Conclusions: Our initial experience with robotic prostatectomy has fostered optimism for the future. The overall positive margin rate and that for organ-confined tumors is low in comparison with contemporary open or laparoscopic series. Long-term PSA recurrence data are necessary to determine the true oncologic efficacy of robotic prostatectomy.
7261 General Surgery
A Novel Technique for Diagnosing a Leak in the Lap Band System
Kurt Roberts, MD, Andrew J. Duffy, MD, Dan Eisenberg, MD, Robert L. Bell, MD
Background: Band leakage is a known complication after laparoscopic adjustable gastric banding (LAGB), occurring in up to 4.4% of patients. Of utmost importance is to localize the leak within the band system so the correct component can be replaced or repaired. The injection of iodine-based contrast under fluoroscopy is the standard technique, but is contraindicated in patients with known allergies. The use of 99m Tc-colloid scintigraphy has been reported but may have limited availability. We propose a third technique for diagnosing a leak after LAGB using gadolinium.
Methods: The patient is a 40-year-old female who underwent LAGB 3 years ago. During the 6 months before presentation, she regained 75% of her initial weight loss. Outpatient access of the port revealed no fluid within the reservoir. The patient has a known anaphylactoid reaction to iodine-based contrast. Given the ease of access to our fluoroscopy suite, the band system was evaluated fluoroscopically with gadolinium.
Results: Under fluoroscopic evaluation, we injected 4cc of gadolinium-based contrast into the port. There was clear visualization of the port, connection tubing, and the band itself. One minute after injecting gadolinium, leakage was visualized from the band near the angle of His. The patient tolerated the procedure well with no adverse reactions.
Conclusion: The use of gadolinium to demonstrate leakage from a gastric band is safe, feasible, and diagnostic when iodinated contrast is contraindicated. This is the first description of this technique and should be considered in patients with known iodine contrast allergies that require band studies.
7262 General Surgery
Technique for Salvage of Infected Mesh Prosthesis without Reoperation or Mesh Removal: A Case Report
Prashanth S. Navaran, MD, W. Peter Geis, MD
Objectives: To describe our method for infected prosthetic mesh salvage after laparoscopic ventral hernia repair with the objective of avoiding reoperation and mesh removal.
Methods: We describe the case of a 56-year-old male who underwent a recurrent ventral incisional hernia repair. During the repeat operation, extensive adhesiolysis was performed, and a second mesh prosthesis was placed in apposition to the previous one. Three weeks later, the patient presented with symptoms of mild partial small-bowel obstruction, fever, and elevated white blood cell count. An abdominal CT scan revealed a 10-cm intraabdominal abscess underlying the mesh prosthesis. A CT-guided drainage catheter was placed through the mesh into the abscess. After the abscess had been well drained and the drain output was scant, antibiotic irrigation with Bacitracin in saline was begun. The drain was positioned such that both surfaces of the mesh received irrigation. Twice daily administration of 100cc was performed utilizing the drainage catheter. The patient also received concomitant intravenous antibiotics.
Results: The patient had resolution of his small-bowel obstruction, and his temperature curve and white blood count normalized. A repeat CT scan revealed resolution of the abscess and the catheter was removed. Two weeks after hospital discharge, a follow-up CT scan confirmed resolution of the infection, and an intact hernia repair. At 6-month follow-up, the patient remains symptom free.
Conclusion: We have developed a method for catheter drainage and antibiotic irrigation for mesh prosthesis-related infection. In select patients, this approach can obviate the need for reoperation and mesh removal.
7263 Urology
Robotic Radical Prostatectomy: Perioperative Outcomes of 1200 Cases
Ketul Shah, MD, Rahul Thaly, MD, Kenneth Palmer, MD, Vipul Patel, MD
Objectives: We report our perioperative outcomes for robotic radical prostatectomy.
Methods: A total of 1200 consecutive patients underwent robot-assisted radical prostatectomy for clinically localized prostate cancer over a 5-year period by a single surgeon. The procedure was performed transperitoneally via a 6-trocar technique. Prospective data collection included basic demographics, prostate specific antigen (PSA), clinical stage, Gleason grade, and a quality of life EPIC questionnaire. Operative outcome measures included operative time, estimated blood loss, and complications. Early postoperative outcome measures included hospital stay, catheter time, complications, and histopathology.
Results: Average age, PSA, and Gleason's score was 61.1 years (range, 35 to 79), 6.1 (range, 0.4 to 43.1), and 6.39 (range 5 to 10), respectively. Average OR time was 95.4 minutes (range, 45 to 360). The conversion rate was 0.23% with no mortality or return to the OR for any secondary procedure. The estimated blood loss was 106mL (range, 25 to 500), and 2 complications occurred in the OR (rectal injury). Postoperatively, 5 patients (0.4%) required blood transfusion for delayed hemorrhage. Average length of stay was 1.1 days, and average catheter time was 6.3 days (range, 5 to 28). Overall perioperative complication rate was 3.7%. The overall margin positive rate (MPR) was 11% for the entire series, including an MPR of 4% for organ-confined disease (T2) and 34% for nonorgan-confined prostate cancer.
Conclusion: Our initial experience with robotic prostatectomy has shown the benefits of minimally invasive surgery with low complication rates and acceptable histopathologic outcomes.
7264 Urology
Robot-assisted Radical Prostatectomy: Complication Data of 1200 Cases
Ketul K. Shah, MD, Ashay Patel, MD, Rahul K, Thaly, MD, Kenneth Palmer, MD, Vipul R. Patel, MD
Introduction: Our experience with radical robotic prostatectomy (RALP) is now over 1200 cases. We reviewed the incidence of intra-, peri-, and postoperative complications following RALP.
Methods: We prospectively analyzed 1258 consecutive patients who underwent RALP over a 5-year period by a single surgeon. The approach was transperitoneal by a 6-trocar technique. Outcome data were collected and complications were analyzed.
Results: The overall complication rate was 3.7% (47/1258) with no mortality or immediate return to the operating room for a secondary procedure. The open conversion rate was 0.15% (2/1258); the initial 2 cases were converted due to lack of progression. One case was converted to standard laparoscopy after technical failure of the robot. Two patients had rectal injury in the initial part of the series that was recognized and primarily repaired. Five (0.4%) patients required blood transfusion. Average hospital stay was 1.1 days, and average duration of the catheter was 6.3 days. The perioperative complications included prolonged anastomotic leakage (5), ileus (3), hemorrhage (5), deep vein thrombosis (4), pulmonary embolism (3), myocardial infarction (2), bowel herniation at the trocar site (1), and cholecystitis (1). The average follow-up was 23 months. Late postoperative complications included urinary retention (6), meatal stenosis (1), epididymitis (1), lymphocele (2), bladder neck contracture (3), and incisional hernia (4).
Conclusion: In our single-surgeon experience, the overall complication rate was 3.7%. Our data suggest that the majority of complications occurred during the initial experience of the first 200 cases. After the initial learning curve, the complications are mostly self-limited.
7265 Urology
Is the Learning Curve Endless? One Surgeon’s Experience With Robotic Prostatectomy
Vipul Patel, MD, Ketul Shah, MD, Rahul Thaly, MD
Introduction: After performing 1,200 robotic prostatectomies, we reflected back on our experience to determine what defined the learning curve and the essential elements that were the keys to surmounting it.
Method: We retrospectively assessed our experience to attempt to define the learning curve(s), key elements of the procedure, technical refinements, and changes in technology that facilitated our progress.
Result: The initial learning curve to achieve basic competence and the ability to smoothly perform the procedure in less than 4 hours with acceptable outcomes was approximately 25 cases. A second learning curve was present between 75 to 100 cases as we approached more complicated patients. At 200 cases, we were comfortably able to complete the procedure routinely in less than 2.5 hours with no specific step of the procedure hindering our progression. At 500 cases, we had the introduction of new instrumentation (fourth arm, biopolar, monopolar scissors), which changed our approach to the bladder neck and neurovascular bundle dissection. The most challenging part of the procedure was the bladder neck dissection.
Conclusion: No single parameter can be used to assess or define the learning curve. We used a combination of factors to make our subjective definition, which included operative time, smoothness of technical progression during the case, along with clinical outcomes. The further our case experience progressed the more we expected of our outcomes, thus we continually modified our technique and hence embarked on yet a new learning curve.
7266 Urology
Robot-assisted Laparoscopic Pyeloplasty: "Tricks of the Trade"
Ketul Shah, MD, Rahul Thaly, MD, Vipul Patel, MD
Objectives: To evaluate the feasibility and efficacy of robotic-assisted laparoscopic pyeloplasty. We present what we have learned during our series and demonstrate the "tricks of the trade" that facilitate successful robotic pyeloplasty.
Methods: The essential steps include dissection of the UPJ, dismemberment of the UPJ with robotic scissors, lateral spatulation of the ureter with the scissors beyond the area of obstruction, reduction and molding of the redundant renal pelvis, and reanastomosis of the ureter to the renal pelvis utilizing hemi-circumferential running sutures.
Results: Fifty patients underwent robotic-assisted laparoscopic dismembered pyeloplasty. A 4-trocar technique was used. The average estimated blood loss was 40mL. The operative time averaged 122 minutes. Crossing vessels were present in 30% of the patients and were preserved in all cases. The time for the anastomosis averaged 20 minutes (range, 10 to 100). Intraoperatively, no complications occurred. Postoperatively, the average hospital stay was 1.1 days. After an average follow-up of 11.7 months, 48 patients (96%) demonstrated stable renal function, improved drainage, and no evidence of recurrent obstruction.
Conclusions: Robotic pyeloplasty is a feasible alternative to laparoscopic pyeloplasty. Short-term results indicate equivalent outcomes with the laparoscopic procedure. Robotic pyeloplasty is still in its infancy as more hospitals acquire the da Vinci robot and as more urologists become trained in its use. Long-term studies are still needed to compare robotic and open pyeloplasty outcomes, and to define the role of robotic pyeloplasty in a cost prohibitive health care system.
7267 Urology
Radiofrequency Ablation of Renal Tumors: An Alternative for Patients With Imperative Indication for Nephron-sparing Surgery or Those With Significant Comorbidities
Rahul Thaly, MD, Ketul Shah, MD, Vipul Patel, MD
Objective: Minimally invasive nephron-sparing alternatives are valuable for imperative indications for nephron sparing or for those with significant comorbidities. We reviewed the outcome of radiofrequency ablation (RFA) of renal tumors.
Methods: Over a 3-year period, 75 patients with 93 renal tumors underwent RFA. Average patient age was 64.5 years with an ASA of 2.9. Indications for nephron sparing were imperative in 33 (solitary kidney, 21; renal insufficiency, 12). Seventeen patients had significant comorbidities with ASA scores of 3 or more. Five were Jehovah's Witness patients. Average tumor size was 3.2cm (range, 1.5 to 4.0). Ablation was performed using both laparoscopic and real-time ultrasound imaging of the borders of the tumor. Patients were followed at 3-month intervals with CT scan or MRI to evaluate efficacy of the ablation.
Results: Average operative time was 109 minutes, and average EBL was <25cc. Mean hospital stay was 1.4 days. At average follow-up of 19.2 months (range, 2 to 24), one lesion showed evidence of tumor recurrence that was corrected surgically. Of patients with follow-up greater than 12 months, 75% had lesions of decreased size, and 25% had no change in size. No complications were seen.
Conclusion: RFA of renal tumors is a feasible alternative for patients who have imperative indications for nephron-sparing surgery or those who have significant comorbidities. Laparoscopic and ultrasound visualization of the ablation allows accurate needle placement and real-time evaluation of the ablation. The procedure is expedient, efficacious, and carries minimal morbidity.
7268 General Surgery
Virtual Reality Laparoscopic Simulator With Tactile Feedback: Does it Improve Performance?
Dan Eisenberg, MD, MS, Robert L. Bell, MD, MA, Andrew J. Duffy, MD
Introduction: Surgical simulation is used to enhance operative skills. Although capable of distinguishing novice and expert surgeons, the LapSim (Surgical Science, Goteberg, Sweden) does not provide tactile feedback. We hypothesize that adding tactile feedback (haptics) will decrease total time required to successfully complete designed simulator modules.
Methods: We designed a 9-module examination on the LapSim, a PC-based trainer. Subjects with simulator experience were required to complete an elemental course on the LapSim. Each participant then completed the 9 tasks on a LapSim with haptics. Performance in the examination was compared with the same tasks repeated on the standard LapSim simulator. Total time to completion and number of repetitions required were compared using the Student t test.
Results: Five subjects were included in the study. The average time to completion of the examination was 441 seconds using the haptic LapSim compared with 445 seconds using the standard LapSim. Thirteen attempts were required to pass on the haptic simulator, while 11 attempts were needed on the standard LapSim. A clip application drill, requiring fine manipulation, was executed 10% faster on the haptics machine (47 seconds vs. 52 seconds), and a fine dissection drill using a hook was completed 13% faster (75 seconds vs. 86 seconds). There was no difference in tissue damage between the 2 simulators.
Conclusions: Proficiency in LapSim simulator use is transferable to the LapSim with haptics in experienced subjects. Haptics allows quicker completion of fine laparoscopic tasks. Further studies are necessary to determine whether haptics provides a more valid model for live patient surgery.
7269 General Surgery
Gastrojejunostomy Strictures After Laparoscopic Gastric Bypass Using the Transabdominal 21-MM Circular Stapler
Charles J. Dolce, MD, Ward J. Dunnican, MD, Emma Bendana, BS, T. Paul Singh, MD
Introduction: The use of intraluminal staplers for gastrojejunostomy construction during Roux-en-Y gastric bypass may be associated with a significant percentage of postoperative strictures. We analyzed our outcomes of a transabdominal circular-stapled Roux-en-y gastric bypass with particular attention to short- and long-term anastomotic complications.
Methods: All laparoscopic Roux-en-y gastric bypass procedures performed by a single surgeon between January 2004 and December 2005 at an academic institution were reviewed. The gastrojejunostomy was created using the transabdominal passage of a 21-mm intraluminal circular stapler into an antecolic, antegastric Roux limb. This retrospective chart review analyzes patient demographics, mean excess weight loss, and anastomotic complications.
Results: Between January 2004 and December 2005, 196 patients underwent gastric bypass at our institution. Of this group, 159 underwent transabdominal circular-stapled Roux-en-y gastric bypass. Fifteen patients developed strictures at the gastrojejunostomy, all requiring endoscopic balloon dilatation. One of these patients required laparoscopic revision of the gastrojejunostomy. Eleven strictures occurred after 30 days, whereas only 4 strictures occurred within 30 days of surgery. One marginal ulceration was seen within 1 year of surgery.
Conclusion: Our 9% stricture rate parallels what has been reported in the literature, and the majority of strictures were amenable to endoscopic treatment. Marginal ulceration rates were much lower than what is to be expected in this group. Transabdominal circular-stapled gastrojejunostomy is a reproducible construct for use in bariatric surgery.
7270 General Surgery
Near-total Thyroidectomy Using a Transaxillary Endoscopic Approach
Qammar N. Rashid, MD, Titus D. Duncan, MD, Ijeoma Ejeh, MD, Fredne Speights, MD
Introduction: Endoscopic thyroidectomy using a remote transaxillary approach has typically been reserved for patients requiring surgery for unilateral thyroid disease. We herein report our series of patients undergoing near-total thyroidectomy using an endoscopic transaxillary approach.
Methods: We performed near-total thyroidectomies in 24 patients by using a transaxillary endoscopic approach between September 2004 and December 2006. The ipsilateral gland was excised, followed by exposure and near-total excision of the contralateral gland. All glands were excised using a unilateral axillary approach. The recurrent laryngeal nerve was identified bilaterally in all cases.
Results: All procedures were successfully completed using the transaxillary approach. The average operative time was 3.4 hours (range, 2 to 4.5). Size of excised specimen ranged from 27g to 392g (average, 66). All specimen results showed benign nodular hyperplasia consistent with multinodular goiter. Micropapillary carcinoma (<1cm) was found in 2 patient specimens on final pathologic sectioning. No recurrent laryngeal nerve injuries and no clinical evidence of parathyroid injury were discovered. One patient was returned to the operating room for postoperative bleeding from an anterior chest wall vessel. This was successfully controlled endoscopically.
Conclusion: The benefits of a minimal access endoscopic approach to the thyroid gland have been previously described. Improved illumination and magnification using an endoscopic approach may allow safer dissection. An improved cosmetic outcome results from incisions hidden within the axilla. Transaxillary endoscopic near-total thyroidectomy may provide a safe alternative to the open approach for patients requiring subtotal resection of thyroid gland for benign disease.
7271 Urology
Paravertebral Blocks for Pain Control in Patients Undergoing Hand-assisted Laparoscopic Nephrectomy
Steven R. Clendenen, MD, Kristopher Whitehead, MD, Richard Lewis, Paul Young, MD, Michael Wehle, MD
Introduction: Hand-assisted laparoscopic nephrectomy (HALN) has become the preferred surgical technique over the classic open approach because of its decreased hospital stay, incidence of complications, and blood loss in patients undergoing total or partial nephrectomy. We therefore performed a chart review to test the hypothesis that the incidence and severity of pain and the amount of morphine use will be less in patients receiving a paravertebral block (PVB) than in those undergoing HALN with traditional postoperative analgesia.
Methods: The charts of 9 consecutive patients who underwent HALN with unilateral PVB at T11-L1 were reviewed. Blocks were performed at T11-L1 with 5cc of 1.0% ropivacaine. The total morphine consumption and visual analog scale (VAS) scores for the 9 patients were obtained and compared (unpaired t test) with a matched historical control of HALN patients who received traditional parenteral postoperative analgesia. A value of P<0.05 was considered statistically significant.
Results: Total morphine consumption for the first 48 postoperative hours was 10.67±5.6mg (mean ± SD), and the mean VAS score on a 10-cm scale was 3.7 (range, 0 to 7). A previous prospective study of patients undergoing HALN without PVB reported a mean morphine consumption of 58±62mg and a VAS mean score of 2.2 (range, 1 to 3) for 48 hours postoperatively. The PVB group of patients’ morphine requirements was significantly lower than that in the parenteral analgesia group (P=0.031, unpaired t test).
Conclusion: Our initial pilot chart review suggests that PVB may have significant postoperative analgesic benefits compared with traditional IV morphine analgesia by significantly decreasing the postoperative morphine requirements.
7272 General Surgery
Laparoscopic Repair of Recurrent Incisional Hernia in Cardiac Transplant Patients
Dan Eisenberg, MD, Wanda Popescu, MD, Andrew J. Duffy, MD, Kurt E. Roberts, MD, Robert L. Bell, MD
Background: Subxiphoid incisional hernia is an uncommon complication after sternotomy, occurring in 1 to 4 per 100 cases. Subxiphoidal incisional hernias have poor results with conventional repair and present an especially challenging problem in heart transplant patients due to systemic immunosuppression. The minimal tissue trauma, superior visualization, and subfascial placement of mesh makes laparoscopic repair attractive in these patients.
Methods: From April 2003 to January 2007, 178 patients undergoing laparoscopic incisional hernia repair were entered into a prospective longitudinal database. Four patients had previously undergone heart transplantation. These patients were compared with patients whose incisional hernias were not due to heart transplantation. Defect size, operative time, and postoperative length of stay were analyzed using the Student t test.
Results: The heart transplant patients developed a subxiphoid hernia a mean of 64.3 months after the heart transplant. All underwent open hernia repair followed by symptomatic recurrence. In each case, the defect involved the caudal extension of the previous sternotomy. All patients were appropriately immunosuppressed at the time of laparoscopic repair. The mean operative time, defect size, and postoperative length of hospital stay were statistically insignificant when compared with those in nonheart transplant patients. One heart transplant patient had significant postoperative morbidity (25%); he developed fluid overload and pulmonary edema that was successfully treated with aggressive diuresis. None of these patients has yet to develop a symptomatic recurrence.
Conclusion: Incisional hernia is a challenging problem in patients with a history of sternotomy. Laparoscopic repair is feasible and safe in immunosuppressed patients who had previously undergone cardiac transplantation.
7273 Urology
Bilateral Laparoscopic Ureterolysis
Carl K. Gjertson, MD, Chandru P. Sundaram, MD
Introduction: Ureterolysis is performed for the surgical management of idiopathic retroperitoneal fibrosis with ureteral obstruction. We present a technique for laparoscopic ureterolysis and perform bilateral ureterolysis at a single session.
Methods: A video presentation demonstrates dissection of the ureters from a fibrotic retroperitoneal mass and interposition of peritoneal flaps.
Results: Successful placement of the ureters into the peritoneal cavity without angulation or tension is demonstrated.
Conclusions: Laparoscopic ureterolysis is a technically feasible procedure, allows tissue interposition similar to that of the open procedure, and bilateral disease can be managed at a single session.
7275 Multispecialty
All Laparoscopic Graspers are Known Crushing Systems: Is This a Product Design Defect and Product Liability?
Douglas Ott
Objective: To assess grasping pressure of laparoscopic instruments.
Methods: At a university and private research laboratory, we analyzed laparoscopic grasping instrument force and tissue damage assessment using force feedback measurement. A strain gauge, thin film load cell, or piezo-resistive sensors were incorporated into laparoscopic grasping devices to measure tissue-grasping force. Doppler assessment of blood flow was done before, during, and after grasping use.
Measurement of laparoscopic grasping force, blood flow, and tissue damage characteristics of tissue samples using laparoscopic graspers were assessed.
Results: Grasp strength equaled crush strength for all instruments on all tissues tested. Traumatic ischemia was found with all devices tested. The mechanical advantage of grasping devices far exceeded tissue stiffness to prevent ischemic compression. Peritoneal damage was common with all graspers analyzed.
Conclusions: Laparoscopic grasping instruments are exceptional at grasping, causing crush ischemia and traumatizing tissue. Laparoscopic graspers manipulate tissue in a one crush-strength fits all manner. Grasping strength of laparoscopic instruments should allow for tissue stabilization without ischemia and result in minimal tissue damage. The force required for laparoscopic grasping instruments to perform their function properly is dramatically less than current instruments provide and may be a design defect that needs correction.
7276 Urology
In Vivo Lymphatic Sealing Capability in the Porcine Thoracic Duct Comparing LigaSure V, Gyrus Trissector, Harmonic ACE Scalpel, EnSeal, and Monopolar Scissors
Geoffrey N. Box, MD, Hak J. Lee, MD, Jose Benito A. Abraham, MD, Leslie A. Deane MD, Erick R. Elchico, Corollos A. Abdelshehid, BS, Reza Alipana, Michael B. Taylor, BS, James F. Borin, MD, Robert A. Edwards, MD, PhD, Lorena Andrade, BS, Elspeth M. McDougall, MD, Ralph V. Clayman, MD
Objective: Very little has been published on the lymphatic channel-sealing efficacy of the various energy sources used during laparoscopic surgery. We sought to compare the quality of lymphatic sealing by each of 4 commonly used laparoscopic dissection devices.
Methods: Twelve domestic pigs were used to test monopolar scissors (Ethicon Endo-Surgery), Harmonic ACE Scalpel (Ethicon Endosurgery), Ligasure V (Valleylab), EnSeal (SurgRx), and Gyrus Trissector (Gyrus/ACMI) dissecting devices. The thoracic duct was isolated, and each device was used to seal an area of the duct. In group 1 (6 pigs), the thoracic duct was cannulated and the seal was subjected to burst pressure testing. In group 2 (6 pigs), each seal was immediately sent for histopathologic evaluation.
Results: Sixty-four seals were created, and 35 were subjected to burst pressure testing. No acute seal failures were seen with any of the bipolar or the harmonic devices; however, 2 immediate failures were seen with the monopolar scissors. The mean burst pressures (mm Hg) for the monopolar scissors, Harmonic ACE scalpel, LigaSure V, Enseal, and Gyrus Trissector were 46 (range, 0 to 165), 540 (range, 175 to 795), 258 (range, 75 to 435), 453 (range, 255 to 825), and 379 (range, 175 to 605), respectively (P=0.163). The Gyrus Trissector, Harmonic Scalpel, and EnSeal generated seals with significantly better burst pressures than those of the monopolar scissors (P=0.0021). Histopathologic evaluation revealed that LigaSure caused less thermal damage than did Gyrus and Enseal (P=0.0008).
Conclusion: All of the devices tested with the exception of the monopolar scissors consistently produced a supraphysiologic seal and should be suitable for sealing lymphatic vessels during laparoscopic surgery.
7277 Urology
LapED 4-in-1 Silicone Training Aid for Practicing Laparoscopic Skills and Tasks: An Evaluation
Jose Benito A. Abraham, MD, Corollos S. Abdelshehid, Reza Alipanah, BS, Hak J. Lee, MD, Eric R. Sargent, MD, Geoffrey N. Box, MD, Leslie A. Deane, MD, Elspeth M. McDougall, MD, Ralph V. Clayman, MD.
Objective: We developed a simple model to simulate 4 reconstructive laparoscopic procedures: pyeloplasty, urethrovesical anastomosis, bladder injury repair, and reconstruction following partial nephrectomy.
Methods: A commercially available silicone (Smooth-On Inc., Easton, PA) was applied to a standard wine glass, which was treated with a releasing agent to allow for easy removal. The glass had a bowl diameter of 7cm, bowl length of 9.5cm, stem length of 7cm, and stem diameter of 8mm. Silicone was cured for 35 minutes before another coat was applied. The process was repeated until a 3-mm to 4-mm thickness had accumulated. A questionnaire was distributed to participants at our training program and during the 2006 AUA reconstructive pyeloplasty course where the models were used.
Results: A total of 56 urologists have evaluated the models and completed the questionnaire. All (100%) of the surgeons who considered themselves experienced (>20) in performing laparoscopic pyeloplasty (n=10) would recommend surgeons to use this model for training. In addition, 100% (n=11) of surgeons who considered themselves experienced (>20) in robotic or laparoscopic prostatectomy, or both, would recommend this model to surgeons in training. Overall, 86% (n=48) of all participants said they would recommend this model to surgeons training in laparoscopy, and 89% (n=50) of all participants would recommend this model for residents in training.
Conclusion: We present a simple, inexpensive model for standard laparoscopic and robotic simulated practice used in 4 different laparoscopic reconstructive procedures. Our results support the face and content validity of this model for pyeloplasty and urethrovesical anastomosis.
7278 Urology
Evaluation of Laparoscopic Vascular Clamps Using a Load-cell Device: Are all Clamps the Same?
Hak J. Lee, MD, Reza Alipanah, BS, Erick R. Elchico, BS, Mike B. Taylor, MD,
Jose Benito A. Abraham, MD, Corollos S. Abdelsheheid, BS, Geoffrey N. Box, MD, Leslie A. Deane, MD, Elspeth M. McDougall, MD, Ralph V. Clayman, MD
Objective: Laparoscopic partial nephrectomies are performed with increasing frequency as more urologists become comfortable with the technique. Based on our experience, the occlusive capabilities of vascular clamps appear to be variable, thus we sought to determine whether this variability was due to the clamps themselves.
Methods: Laparoscopic vascular clamps Aesculap (Germany), Klein Surgical Inc. (San Antonio, TX), and Karl Storz Inc. (Culver City, CA) were tested with a load cell (2.2mm) and measured with a force transducer in pound-force (Interface, Scottsdale, AZ). The variables included instrument type (bulldog, Satinsky, and DeBakey), old vs. new bulldogs, position of application (tip, middle, end), and change in force after 1 hour of clamping a 20F latex catheter.
Results: The externally applied vascular clamps consistently provided average forces significantly greater than the internally applied bulldog clamps regardless of the position of application. Three-year-old Klein bulldogs showed an approximate 35% decrease at all positions compared with new bulldogs, whereas the 3-year-old Aesculap bulldogs maintained their force. Application at full length of the instrument (ie, “end”) provided the greatest force compared with the other positions for all instruments. All instruments maintained force after 1 hour of clamp time.
Conclusion: The forces generated by the clamps tested were variable depending upon the type (internal vs. external) and positioning of the jaw (tip, middle, end). Furthermore, with years of use, the clamping force of some bulldog clamps can diminish, leading to variability in vessel occlusion.
7279 Urology
Comparative Review of Laparoscopic and Robotic-assisted Radical Cystectomy With Ileal Conduit Urinary Diversion
Jose Benito A. Abraham, MD, Jennifer L. Young, MD, Geoffrey N. Box, MD, Hak J. Lee, MD, Leslie A. Deane, MD, David K. Ornstein, MD
Objective: To compare our experience with laparoscopic-assisted radical cystectomy (LACIC) and robotic-assisted radical cystectomy with ileal conduit (RACIC).
Methods: Between August 2002 and July 2005, data were gathered on 20 consecutive LACIC patients and from March 2005 to October 2006 on 13 consecutive RACIC (using the da Vinci Surgical System) patients. In both, radical cystectomy and lymphadenectomy was performed intracorporeally, and ileal conduit urinary diversion was performed extracorporeally.
Results: No significant difference occurred in terms of preoperative factors or baseline tumor characteristics. There was no difference in operative time (419min vs. 416min). RACIC patients had less blood loss (213cc vs. 653cc; P<0.0001) and a lower transfusion rate (38% vs. 70%; P<0.0011). One intraoperative complication occurred, but no conversions were necessary in RACIC. LACIC had 3 intraoperative complications that all led to conversion. The postoperative complication rates were 15% and 55% for RACIC and LACIC, respectively. Convalescence was shorter in RACIC in terms of mean days to oral intake (2.3 vs. 6.1; P<0.013) and shorter hospital stay [5.8 (range, 4 to 7) vs. 9.5 (range, 4 to 32) P=0.35]. No significant difference in number of lymph nodes was noted (P=0.13), with a mean of 20.6 (range, 13 to 29) in RACIC and 16.4 (range, 7 to 26) in LACIC patients. No positive margins were noted in LACIC, and one (7.6%) was noted in RACIC in a patient with pT4 disease.
Conclusion: Both RACIC and LACIC are feasible and can be performed without compromising accepted oncologic standards. The robotic-assisted approach is associated with less blood loss, fewer complications, and earlier return of bowel function.
7280 General Surgery
Pure Laparoscopic Partial Nephrectomy: The First 50 Cases After Fellowship
Sam B. Bhayani, MD
Introduction: Laparoscopic partial nephrectomy is a technically challenging procedure. Published series are from experienced laparoscopic surgeons. In this communication, we review a single surgeon’s experience with the first 50 cases.
Methods: All patients undergoing LPN were reviewed. All patients had renal hilar dissection and control. All patients required intracorporeal laparoscopic suturing. Records were reviewed for clinical and pathological information. Information on conversions and complications were also reviewed.
Results: LPN was attempted in 52 patients. Two cases were converted electively to open partial secondary to adhesions or difficult dissection. Fifty cases were successfully completed. There were no conversions to radical nephrectomy. Mean patient age was 58 years; mean ASA score was 2.4. Mean operative time was 156 minutes. Mean EBL was 182cc, and mean warm ischemia time was 26 minutes. Mean length of stay was 3 days. Mean tumor size was 2.8cm, and mean specimen size was 4.6cm. Renal malignancies (clear and papillary) were present in 30/50 cases (60%), oncocytoma in 10/50 (20%), and the remainder comprised other benign renal neoplasms or benign complex cysts. Complications occurred in 10/50 patients. All margins were negative. One patient with multifocal disease in the specimen had ipsilateral recurrence and underwent subsequent radical nephrectomy.
Conclusion: Laparoscopic partial nephrectomy can be accomplished with excellent results after a physician receives adequate training.
7281 Urology
Management of the Large Median Lobe During Robotic-assisted Radical Prostatectomy
Jeff Bejma, Michael Woods, Raju Thomas, Rodney Davis
Objectives: Robotic-assisted radical prostatectomy is becoming widespread throughout the United States. Median lobes are commonly encountered in men undergoing this procedure. These large median lobes can be challenging to manage, especially early in a surgeons experience. The goal of this video is to summarize some of the techniques we have used when large median lobes are encountered.
Methods: We have performed approximately 300 robotic-assisted radical prostatectomies at our institution. We have selected 3 patients with large median lobes and reviewed the video of those surgeries. We then compiled video clips to summarize important technical points in the management of median lobes.
Results: We found several techniques that were helpful during robotic-assisted radical prostatectomy with large median lobes: meticulous dissection of the bladder neck from the intravesical prostate without reconstruction, excision of the mucosa overlying the intravesical prostate with reconstruction of the bladder neck, and the use of feeding tubes to identify the ureteral orifices when resection of the median lobe is close to the trigone.
Conclusion: Although large median lobes can present a challenge during robotic prostatectomy, the outlined techniques can assist during bladder neck dissection and aid in safe bladder neck reconstruction.
7282 Urology
Laparoscopic Partial Nephrectomy: Six Degrees of Hemostasis
Leslie A. Deane, MBBS, FRCSC, Geoffrey N. Box, MD, Hak J. Lee, MD, Jose B. Abraham, MD, Farhan Khan, MD, Alfred Krebs, MD, James F. Borin, MD, Donna J. Jackson, Elspeth M. McDougall, MD, FRCSC, Ralph V. Clayman, MD
Objective: Laparoscopic partial nephrectomy is widely performed, especially in centers with extensive laparoscopic expertise. Time constraints imposed by warm ischemia mandate that a single attempt be made at achieving 3 simultaneous objectives: 1) tumor-free margin, 2) perfect hemostasis, and 3) an accurate, water-tight collecting system closure. Herein, we report our technique for achieving these objectives.
Methods: We reviewed the medical records of 11 consecutive patients undergoing laparoscopic partial nephrectomy. The steps are as follows:
1) Excise tumor using LigaSure or Harmonic Scalpel;
2) Coagulate cut surface with Argon Beam Coagulator;
3) Suture repair of collecting system;
4) Application of Floseal to the defect;
5) Deep parenchymal suturing and placement of Surgicel bolsters;
6) Application of Floseal followed by Tisseel cap.
Results: The mean age of the treated patients was 54.5 years. The mean tumor size was 3.2cm (range, 1.7 to 7.5). The mean warm ischemia time was 35 minutes. The mean estimated blood loss was 198mL (range, 75 to 500). The mean fall in hematocrit after surgery was 6.4%. In neither group was there bleeding from the resection site upon release of the vascular clamps. Analysis of the margin status was not affected by thermal injury. The length of hospital stay was 3.1 days.
Conclusion: Compared with the reports in the literature on laparoscopic partial nephrectomy, the mean blood loss using this technique appears lower than that with a cold cut excision technique. Determination of margin status is not affected by an energy-based excision.
7283 Urology
Robotic Versus Standard Laparoscopic Partial/Wedge Nephrectomy: A Comparison of Intra- and Perioperative Results From a Single Institution
Leslie A. Deane, MBBS, FRCSC, Geoffrey N. Box, MD, Hak J. Lee, Jose B. Abraham, MD, James F. Borin, MD, Elspeth M. McDougall, MD, FRCSC, Ralph V. Clayman, MD, David K. Ornstein, MD.
Introduction: Similar to laparoscopic radical prostatectomy, laparoscopic partial/wedge nephrectomy is a technically challenging procedure. This analysis compares the outcomes of our initial experience with robotic partial/wedge nephrectomy performed by an experienced open surgeon to that of standard laparoscopic partial nephrectomy being performed by 2 expert laparoscopic surgeons.
Methods: The medical records of 11 consecutive patients undergoing standard laparoscopic partial nephrectomy (EMM, RVC) (Group 1) and 5 consecutive patients undergoing robotic partial nephrectomy (DKO) (Group 2) between March 2004 and October 2006 were reviewed.
Results: The mean age of the patients was 54.5 years in group 1 and 58.8 years in group 2. The mean tumor size was 3.2cm (range, 1.7 to 7.5) in group 1 and 3.32cm (range, 2.5 to 4) in group 2. The mean total procedure time was 289 minutes (range, 145 to 369) in Group 1 and 290 minutes (range, 98 to 375) in Group 2. The mean estimated blood loss was 198mL (range, 75 to 500) in group 1 versus 120mL (range, 25 to 300) in group 2 (P=0.32). The mean warm ischemia time was 36 minutes (range, 15 to 49) in group 1 and 35.4 minutes (range, 30 to 45) in group 2 (P=0.87). The hospital stay for group 1 was 3.1 days versus 2 days for group 2 (P=0.03).
Conclusion: Robotic laparoscopic partial nephrectomy when performed by an experienced, fellowship-trained oncologist can be performed with outcomes similar to those achieved by expert laparoscopic surgeons.
7284 Urology
Correlation of Laparoscopic Surgical Experience With Video Game Performance
Reza Alipanah, BS, Jose Benito A. Abraham, MD, Corollos Abdelshehid, BS, Alex Nguyen, Shahrouz Ganjian, BS, Hak J. Lee, MD, Elspeth M. McDougall, MD, Ralph V. Clayman, MD
Objective: Because of certain similarities between laparoscopy and video games, some have suggested that a high level of performance in video games correlates positively with level of expertise in laparoscopic surgery. We sought to verify this hypothesis.
Methods: Experienced urologists, fellows, residents, and medical students played the Monkey Ball 2 video game (SEGA, Inc). This game has 10 levels of difficulty, of which 3 were chosen for testing purposes: Red (1/10), Purple (6/10), and White (8/10). Participant level scores, total scores, and performance times were analyzed to detect differences based on age, sex, and level of surgical expertise. Independent samples test was performed to detect sex-related differences between scores.
Results: Males achieved higher scores at the Red and Purple levels compared with females. Poor performance was noted across all groups at the White level. Medical students and residents scored higher than fellows did on the Red level. However, practicing urologists scored lower than any other group on the Red level, and scored lower than medical students and residents on the Purple level. Participants aged 25 to 35 years achieved higher Purple level scores than those aged 35 to 55.
Conclusion: Video game performance does not appear to have a positive correlation to the level of laparoscopic urological experience. However, it does appear to discriminate based on sex and age, suggesting that males generally score higher than females, and younger participants perform better than older participants.
7285 Urology
Cervical Remnant in CISH Hysterectomy: Short- and Long-term Issues
John E. Morrison, MD, Volker R. Jacobs, MD, PhD, MBA
Objective: Evaluate the creation and handling of the cervical stump in CISH hysterectomy with particular attention to short- and long-term problems.
Methods: We describe the creation of the cervical stump during a CISH hysterectomy compared with traditional supracervical hysterectomy and discuss a retrospective evaluation of the short-term and long-term issues in 810 patients.
Results: All procedures were performed in an acute-care hospital or ambulatory surgical center in the rural US over a 15-year-period. Exclusion criteria included presence of carcinoma or weight >180kg. The cervical stump is created by excision of the transition zone and endocervical canal using either a morcellator or cautery. The defect is sutured closed. Twelve patients had bleeding for <21 days. Three were treated in the ER, 4 in the OR, and 5 required packing. Five had bleeding >21 days, 2 at 2 years, 1 at 2.5 years, 1 at 4 years, and 1 at 5 years. Two were treated with conization, 2 had resection of the stump, and 1 had no treatment. Three patients had resection of the stump for pain, at 5, 8, and 9 years. One developed a leiomyoma at 6.5 years. Fourteen developed a mucocele, ranging from 2 to 72 months postoperatively, the majority being treated by marsupialization.
Conclusion: Although excision of the transition zone and endocervical canal reduces the potential for malignancy, the long-term difficulties are similar to those of traditional supracervical hysterectomy, with the exception of mucocele formation, which is a minor problem.
7286 General Surgery
Harmonic Scalpel Use in Thoracoscopy and Pulmonary Resection
John E. Morrison Jr. MD
Objective: To discuss the use of the Harmonic scalpel with fibrin sealant in thoracoscopy compared with a linear cutting staple device for pulmonary resection.
Methods: This study was an ongoing, retrospective evaluation of efficacy of the Harmonic scalpel in combination with fibrin sealant versus a stapling device in pulmonary resections, with regards to cost, air leak duration, and length of chest tube drainage.
Results: Eleven patients underwent thoracoscopy with wedge resection or blebectomy by using either a linear cutting stapling device or a Harmonic scalpel with fibrin sealant in an acute-care hospital in the rural southeast US over a 1-year period. Air leak average for blebectomy was 2.5 days, wedge resection with stapler was 1.5 days, and resection with the Harmonic scalpel was 2 days. Chest tube duration for blebectomy was 5.2 days; wedge resection with stapler, 5 days; and resection with the Harmonic scalpel, 4 days. When the stapler was used, an average of 4 reload cartridges was necessary for a cost of $663.44. Harmonic scalpel with fibrin sealant cost $801.10. The majority of patients where the Harmonic scalpel was used had deep pulmonary parenchymal lesions, making staple device use difficult. Length of chest tube drainage, duration of air leak, and cost are comparable between these 2 techniques.
Conclusion: Harmonic scalpel with fibrin sealant used in thoracoscopy is comparable to stapling devices with regards to the duration of air leak, chest tube drainage, and cost. In deep parenchymal lesions, its use is preferred.
7287 Multispecialty
Damage at the Grasper-tissue Interface in Minimally Invasive Surgery
Smita De, PhD, Jacob Rosen, PhD, Andrew Wright, MD, Blake Hannaford, PhD, Mika Sinanan, MD, PhD
Background: Poor tactile sensation from tools used in minimally invasive surgery can lead to inadvertent tissue damage due to excess stress application during manipulation. The purpose of this work was to systematically characterize the relationship between damage and stress at the grasper-tissue interface in minimally invasive surgery.
Methods: Controlled compression stresses typical to minimally invasive surgery (magnitudes of 0kPa to 300kPa and durations of 10 seconds to 60 seconds) were applied in vivo to porcine liver, small bowel, and ureter by using a motorized endoscopic grasper. Acute tissue damage was measured based on cellular death and inflammation using histological and image analysis methods and modeled using regression techniques. Finite element analysis was used to approximate stress distributions experienced by the tissues between the grasper jaws.
Results: Bowel, liver, and ureter typically had increased evidence of tissue injury at stresses greater than 150kPa. Stressed bowel segments exhibited inflammation, while liver demonstrated acute signs of necrosis in 40% to 90% of the injury site. Stress durations tested did not appear to have any significant effect. Finite element analysis produced expected stress distributions in tissue models and qualitatively correlated with damage observed in vivo.
Conclusions: Grasping stress magnitudes well within the range of loads applied in minimally invasive surgery cause significant acute injury to both liver and bowel. It may be possible for researchers to create “smart” surgical instruments, including surgical robots, which could guide a surgeon to limit grasping stress and minimize resulting damage. This study provides preliminary data to achieving this goal.
7288 Urology
Results of Laparoscopic Radical Prostatectomy (LRP)
Genoa G. Ferguson, MD, Gerald L. Andriole, MD
Introduction: LRP has grown in popularity as definitive treatment for localized prostate cancer.
Methods: This is a retrospective chart review of all patients who underwent extraperitoneal LRP by a single surgeon (GLA) during 2005 and 2006. IRB approval was obtained before conducting the study. LRP was performed using 3D imaging (Viking Endosite 3Di, San Diego, CA)
Results: The 361 men were an average age of 61 years (range, 40 to 79), and had a median preoperative PSA of 5.3ng/mL (range, 0.7 to 54.1). The median operative time was 190 minutes (range, 102 to 309), and median estimated blood loss was 350mL (range, 20 to 1200). The mean hospital stay was 1.28 days (range, 1 to 14). The median prostate weight was 52.2 grams (range, 21 to 155). High-grade prostate cancer was present in 18.6%. Positive surgical margins were found in 83 patients (23.0%), extracapsular extension was found in 66 patients (18.3%), and 7 patients had positive lymph nodes (1.9%). Catheters were usually removed at 1 week, unless evidence was present of a urinary leak (N=18, 5.0%). Two men had deep vein thrombosis and pulmonary embolism (0.6%), 1 had pulmonary embolism only (0.3%), 1 had a myocardial infarction (0.3%), and 1 had pneumothorax (0.3%). There were 12 intraabdominal fluid collections (3.3%). Thirteen patients (3.6%) had a PSA recurrence (>0.2ng/mL).
Conclusion: Extraperitoneal LRP using 3D imaging is safe and effective even in a high-risk group, like our patient population. The specific advantages of 3D for men with large prostates and large middle lobes will be presented.
7289 Urology
The Escape™ Nitinol Stone Retrieval Basket Facilitates Laser Fragmentation and Extraction of Ureteral and Renal Calculi: Initial Experience
Grant Disick, MD, Stuart S. Kesler, MD, Sean A. Pierre, MD, George E. Haleblian, MD, Glenn M. Preminger, MD, Ravi Munver, MD
Objective: Ureteroscopy is at the forefront of surgical stone management; however, stone migration continues to plague urologists. We report on our initial experience using the Escape Basket (Boston Scientific, Natick, MA), a nitinol stone retrieval basket, specially designed to capture calculi and allow laser lithotripsy in situ.
Methods: A prospective evaluation of patients undergoing ureteroscopic holmium:YAG laser lithotripsy for ureteral or renal calculi, or for both, was performed at 2 institutions. The Escape Basket was utilized to prevent ureteral stone migration or to facilitate fragmentation and extraction of large renal calculi. A 200-µm laser fiber and stone basket were used in conjunction through the working channel of a semirigid or flexible ureteroscope. Intraoperative parameters and stone-free rates were assessed.
Results: Eighteen patients, (mean age, 57.4 years), were treated for renal (n=8) or ureteral (n=10) calculi. The mean stone diameter was 1.6cm (range, 0.4 to 2.5), and the mean fragmentation time was 52 minutes. No complications were encountered. Of 14 patients who had follow-up imaging studies, 10 (71%) with calculi (mean diameter 1.7cm) were stone free. One patient (7%) with a 2.5-cm renal calculus had residual fragments >3mm, and 3 patients (21%) with renal calculi (mean diameter, 2.2cm) had residual fragments <3mm.
Conclusion: Using this novel basket, the position of a calculus, relative to the laser fiber, could be easily changed during the procedure. Stone engagement and disengagement was performed without difficulty in all instances. Based on our experience, the Escape Basket appears to be safe and efficacious in preventing stone migration during ureteroscopic laser lithotripsy.
7290 Gynecology
A Comparison of Total Robotic vs. Laparoscopic Radical Hysterectomy and Pelvic Lymphadenectomy for Gynecologic Malignancy Treatment in a Fellowship Training Program
M. Shoma Datta, MD, Linus Chuang, MD, Gazi Yildirim, MD, Konstantin Zakashansky, MD, Farr Nezhat, MD
Objective: To describe the feasibility, safety, and outcome of total robotic radical hysterectomy (RRH) vs. laparoscopic radical hysterectomy (LRH) with pelvic lymphadenectomy.
Methods: Procedures were performed in a tertiary care center with a gynecologic oncology attending, fellow, and resident using the da Vinci Robotic Surgical System (Intuitive, Inc., Sunnyvale, CA). Clinical data on 7 cases of total robotic and 30 cases of laparoscopic radical hysterectomy were retrospectively collected. Patient characteristics, operative variables, complications, and outcomes were compared using the Fischer exact chi-square testing.
Results: Eleven patients underwent robot-assisted radical hysterectomy and pelvic lymphadenectomy for cervical cancer from April 2003 to January 2007, 7 being total robotic radical hysterectomies. A comparable group of 30 patients underwent total laparoscopic radical hysterectomy and pelvic lymphadenectomy for cervical cancer. Operative variables of surgery time, blood loss, and hospital stay were not statistically different. No conversions from either approach occurred. Mean pelvic node counts were significantly different in the 2 groups: robotic 20 vs laparoscopic 30 nodes. Complications were also statistically similar. The robotic group had postoperative complications of one prolonged urinary retention and C. dificile colitis. The laparoscopy group complications included 2 cases of cystotomy, deep vein thrombosis, ileus, and C. dificile colitis, and one case of urinary retention, fever, and vaginal bleeding.
Conclusion: Total robotic radical hysterectomy appears to be an acceptable alternative to the laparoscopic approach. At this time, technical ease and dexterity seem to remain the largest advantages of the robotic surgical approach for radical hysterectomy.
7291 Gynecology
Laparoscopic Cytoreduction in Primary Advanced or Recurrent Ovarian Carcinoma
Farr Nezhat, MD, M. Shoma Datta, MD, Mehran Langroudi, MD, Linus Chuang, MD
Objective: To describe feasibility, safety, and outcome of laparoscopic cytoreduction in primary advanced or recurrent ovarian carcinoma.
Methods: Cases of 23 patients who underwent 27 laparoscopic cytoreductions for primary advanced or recurrent ovarian cancer between June 1999 and January 2007 were retrospectively reviewed.
Results: Mean patient age was 56 years. Twenty-one cases were performed for recurrent disease with prior cytoreduction and multi-agent chemotherapy. Six initial cytoreductive procedures were performed for the following: 2 stage II, 3 stage III, 1 stage IV case. One stage II patient underwent interval cytoreduction, and the stage IV patient had neoadjuvant chemotherapy prior to end staging. Cytoreductive procedures included hysterectomy, salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, omentectomy, splenectomy, liver resection, trachelectomy, and bowel resection. Mean operating time was 222 minutes with a mean blood loss of 148mL. Two ureteral transections occurred, one being intentional for optimal cytoreduction. Both cases were corrected with laparoscopic ureteroneocystostomy. Length of stay averaged 3.1 days. Mean follow-up was 18.3 months. Two patients developed acellular ascites. The first case required paracentesis, and the second resolved spontaneously. Twenty-two patients underwent subsequent adjuvant multi-agent chemotherapy, and 2 received pelvic radiation. Seven patients had recurrence at sites outside of cytoreduced areas or trocar sites. At last follow-up, 5 patients expired, 6 were living with disease, 1 had no evidence of disease, and 1 was lost to follow-up.
Conclusions: Laparoscopic cytoreduction for ovarian carcinoma can be effective in select patients by experienced gynecologic oncologists. A larger long-term study is needed for further outcome and survival data.
7292 Gynecology
Laparoscopic Intraperitoneal Para-aortic Lymphadenectomy: Our Experience in a Fellowship Training Program
Farr Nezhat, MD, M. Shoma Datta, MD, Gazi Yildirim, MD, Jyoti Yadav, MD
Objectives: To compare surgical outcomes of laparoscopic para-aortic lymphadenectomy performed by a single surgeon when stratified by time.
Methods: Laparoscopic intraperitoneal para-aortic lymphadenectomies performed for gynecologic malignancy from April 2000 to January 2007 were retrospectively collected. Surgical variables and outcomes were analyzed with the Student t test.
Results: Seventy-eight para-aortic lymphadenectomies were performed by a single gynecologic oncology attending in a fellowship training program. The exact procedures were 60 complete para-aortic dissections, 13 samplings, and 5 biopsies. Thirty-eight cases of complete para-aortic dissections were performed in conjunction with bilateral pelvic lymphadenectomy. Complete dissections were divided according to the first and second 30 cases performed chronologically. The groups had similar characteristics and hospital stay. Group 2 had a significant lower blood loss of 121mL vs. 176mL, although specific blood loss for lymphadenectomy alone was not calculated. Group 2 also had a lower node count of 13 versus 17 nodes. Of importance, group 2 had only 2 lymphadenectomies performed above the inferior mesenteric artery (IMA) versus 5 in group 1. When samplings and biopsies were included in the analysis, the node counts of the 2 groups were similar (14 vs 11 nodes). Complications were as follows: group 1 had 1 IMA injury, 2 fevers, 2 transfusions, and 1 port-site metastasis, and group 2 had 1 transfusion, 1 fever, 1 deep vein thrombosis, and 1 small-bowel obstruction.
Conclusion: This study confirms laparoscopic para-aortic lymphadenectomy by an experienced gynecologic oncologist is feasible, safe, and accomplishes adequate node retrieval with acceptable complication rates.
7293 Gynecology
Endoscopic Management of a Chronic Cornual Ectopic Pregnancy
M. Shoma Datta, MD, Farr Nezhat, MD
Objective: To demonstrate the hysteroscopic and laparoscopic management of a chronic cornual ectopic pregnancy.
Methods: A 36-year-old para 0010 presented 7 months after a spontaneous abortion with persistently positive _hCG levels. She had undergone a dilation and curettage at the time of initial diagnosis, but final pathology revealed that no products of conception were obtained. The patient underwent administration of 3 doses of methotrexate. _hCG levels dropped, but never normalized. Sonograms remained significant for a persistent intrauterine mass in the right uterine cornua. The patient was carefully counseled and underwent an operative hysteroscopy, dilation and curettage, and pelviscopy.
Results: Operative findings were significant for a 2.5-cm lesion in the right uterine cornua, consistent with imaging. Routine dilation and curettage likely failed to resect the specimen due to its cornual location. The lesion was completely resected with an operative resectoscope set at 80 watts. On diagnostic laparoscopy, it was evident that full thickness uterine resection had occurred at the site of the lesion, and the defect was repaired with laparoscopic intracorporeal suturing using 0 polyglactin absorbable suture. The frozen section preliminary reading was positive for trophoblastic tissue. The patient’s postoperative recovery was uncomplicated. A postprocedure _hCG level 2 weeks later was negative. The patient was carefully counseled that she is to undergo Cesarean deliveries in the future due to full thickness uterine resection required by her procedure.
Conclusion: Chronic ectopic pregnancy can be managed successfully by endoscopic techniques when routine treatment has failed.
7294 Multispecialty
The Evolution of Clip-free Laparoscopic Adrenalectomy: A Comparative Evaluation of Electrocautery, Ultrasonic, and Bipolar Energy Sources
Grant Disick, MD, Stuart S. Kesler, MD, Surena F. Matin, MD, Ravi Munver, MD
Objective: Laparoscopic adrenalectomy is the standard technique for the surgical removal of the adrenal gland. Vast arterial cascades and anomalous veins can lead to excessive bleeding and complicate this procedure. We report on our experience using electrocautery, ultrasonic energy, and bipolar energy devices in an effort to reduce blood loss and operative time.
Methods: Thirty-seven laparoscopic adrenalectomies (13 right/24 left) were performed at 2 institutions via a transperitoneal (n=30) or retroperitoneal (n=7) approach. Indications for surgery included benign lesions [adenoma (n=20); pheochromocytoma (n=3); ganglioneuroma (n=2); hemorrhagic cyst (n=2); myelolipoma (n=1); adrenal hyperplasia (n=1)] and malignant metastatic lesions [renal cell carcinoma (n=6); prostate adenocarcinoma (n=1); lung carcinoma (n=1)]. Initially, adrenalectomy was performed using electrocautery shears (n=7) or Harmonic scalpel (n=11) with double hemoclip ligation of the main adrenal vein and accessory adrenal vessels. In the subsequent 14 cases, single hemoclip ligation of the main adrenal vein and bipolar energy for accessory vessels was used. In the final 5 cases, bipolar energy was used for all vessels without the use of hemoclips.
Results: There was no difference in mean adrenal mass size [3.7cm (electrocautery/ ultrasonic); 3.6cm (bipolar)], or hospital stay [1.7days (electrocautery/ultrasonic); 1.8 days (bipolar)], between the groups. Mean operative time [187±45min (electrocautery/ultrasonic); 121±41min (bipolar)] and blood loss [162±58mL (electrocautery/ultrasonic); 28±19mL (bipolar)] were significantly less for the bipolar group (P<0.01). The electrocautery/ultrasonic group received an average of 11 hemoclips, and the bipolar group received 2.5 hemoclips (n=14) or 0 hemoclips (n=5).
Conclusions: Laparoscopic bipolar devices effectively seal the main adrenal vein and accessory vessels. The use of these devices may have a dramatic impact on laparoscopic adrenal surgery by facilitating a reduction in blood loss and operative time.
7295 General Surgery
The Effects of Different Surgical Approaches on Systemic Inflammatory Response After Gastrectomy
W. J. Hyung, J. W. Song, S. H. Choi, S. H. Noh, H. S. Chi
Background: Systemic inflammatory response has been commonly studied to measure the invasiveness of surgical intervention especially in the field of minimally invasive surgery. C-reactive protein (CRP) is the generally accepted and most frequently studied molecule for measuring systemic inflammatory response. The aim of this study was to quantify the difference in tissue damage between laparoscopic-assisted gastrectomy (LAG) and robot-assisted gastrectomy (RAG) by examining postoperative serum values of CRP.
Methods: A total of 204 gastric cancer patients were evaluated. Of these, 183 received LAG and 23 underwent RAG. High sensitivity CRP was measured serially, and surgicoclinical parameters were compared between the groups.
Results: Significant differences existed with respect to age, sex, and resection extent between groups. Serum CRP level increased gradually after surgery and peaked on POD3 and decreased thereafter regardless of types of operation. The peak CRP level was significantly lower in RAG group (68.1mg/L) than in LAG group (95.7ml/L) (P=0.014).
Conclusions: Although there have been some differences in surgicoclinical characteristics, robot-assisted gastrectomy showed less acute-phase response than laparoscopic-assisted gastrectomy. These findings provide a basis for a future prospective randomized study to compare the different types of minimally invasive surgery for gastric cancer.
7296 Other
Thymoma: Minimally Invasive Transthoracic Approach
Brian C. Fallon, MD, David Zeltsman, MD
Objective: Video-assisted minimally invasive thoracic surgery is rapidly gaining popularity among thoracic surgeons and is a preferred approach to a wide variety of intrathoracic pathology, including disorders of the thymus. We evaluated the feasibility of minimally invasive transthoracic thymectomy in patients with early clinical stage thymomas.
Methods: Right video-assisted thoracic surgery is preferred. Single-lung ventilation with a double-lumen endotracheal tube allows for clear visualization of anterior mediastinum. Mediastinal pleura are open along the right phrenic nerve, and resection of the fat pad and thymus is carried out in anatomic fashion. Left pleura are open under direct vision to facilitate entire removal of fat, thymic gland, and thymoma. Thyrothymic tracts are divided to complete the dissection. A specimen is removed from the chest within a plastic bag to protect surrounding structures. A single drain is left in the mediastinum before closure.
Results: Surgery is well tolerated in this group of patients; the drain is normally removed on the same day of surgery, and patients are discharged from the hospital on postoperative day 1.
Conclusions: Minimally invasive video-assisted thoracic surgery provides excellent exposure and allows for radical resection of early stage thymomas. This technique avoids cervical incisions and sternotomy and its associated complications, is cosmetically pleasing to the patients, and decreases hospital stay compared with that of sternotomy.
7297 General Surgery
A Novel Technique for Radiofrequency Ablation of Hepatic Dome Neoplasms Using Iatrogenic Hydrothorax
Francesco Palazzo, Francis E. Rosato, Jr, Bernadette Profeta, Karen Chojnacki, Lawrence Needleman, Ernest L Rosato
Objective: Radiofrequency ablation is an accepted treatment modality for unresectable primary and metastatic tumors of the liver. Intraoperative ultrasound is necessary to evaluate probe placement and completeness of ablation. When lesions are found high on the dome of the liver, ultrasound imaging becomes extremely challenging. In an effort to improve the visibility of hepatic dome neoplasms, the authors have used an iatrogenically induced hydrothorax at the time of ablation.
Methods: Six patients, 5 with metastatic colonic adenocarcinoma and 1 with primary hepatocellular carcinoma, had either a single hepatic dome lesion (4 patients) or bilobar disease with a subphrenic lesion. Mean tumor size was 3.5cm (range, 1.0 to 5.5). Once access to the right pleural space was attained (thoracoscopically or percutaneously) instillation of 1 liter of normal saline solution was performed. All procedures were performed using the Radionics radiofrequency ablation device. All patients received a chest tube postoperatively.
Results: All dome lesions were successfully visualized. Average operative time was 60 minutes (range, 45 to 145). No procedure-related mortalities were observed. Morbidities included chest wound cellulitis with shortness of breath in one patient and prolonged intercostal discomfort in another. All chest tubes were removed within the first 24 hours except for that in the one patient who complained of shortness of breath. All lesions were successfully ablated, 2 patients remain disease free, 3 patients have stable disease, and 1 patient is deceased at 36 months follow-up.
Conclusion: Iatrogenic hydrothorax represents a safe and valuable tool for radiofrequency ablation of high dome liver lesions.
7298 General Surgery
The Effects of Race on Weight Loss After Bariatric Surgery
Titus D. Duncan, MD, Qammar N. Rashid, MD, Larry L. Hobson, MD
Introduction: In contradiction to some recent reports that suggest black female patients lose less weight and have a significantly higher rate of weight regain following surgical weight loss procedures than their white counterparts, we present the results of our series. We compare the percentage of excess body weight loss (%EBWL) between black and white female patients following laparoscopic Roux-en-y gastric bypass surgery.
Methods: Since 2001, we have performed over 4000 laparoscopic gastric bypass procedures for treatment of obesity. Over 3000 of these procedures were done in women, and over 900 of these women were African American. These patients were followed for at least 3 years, and their total weight loss and %EBWL were reviewed and compared between the 2 groups, African American and non-African American.
Results: There were no statistically significant differences in %EBWL at 1, 2, or 3 years between the 2 groups. Both groups had similar resolution or improvement, or both, in preoperative comorbid conditions.
Conclusions: Several studies document differences in weight loss following surgical weight loss procedures between black and white patients. To accommodate for such differences, we have incorporated practices in an attempt to improve and maintain the amount of fat loss following surgery. There were no significant differences in long-term weight loss between black and white patients following laparoscopic gastric bypass surgery in this series.
7299 General Surgery
Clipless Laparoscopic Cholecystectomy
R. Gelmini, MD, A. Andreotti, MD, C. Franzoni, MD, A. Farinetti, MD, M. Saviano, MD
Background: Laparoscopic cholecystectomy is the gold standard treatment of gallstones. The ultrasonically activated scalpel (Harmonic scalpel, Ethicon) may be used as the sole instrument for both gallbladder dissection and section of the cystic artery and duct with no need of further ligatures.
Methods: In a series of 40 consecutive patients, laparoscopic cholecystectomy was performed with the Harmonic scalpel. In 8 patients, an additional cystic duct ligature with clips was performed because of the large size of the duct (5 cases of associated common bile duct stones, 1 of acute cholecystitis, and 2 of gallbladder empyema). There were 31 females and 9 males. Indications were 27 simple gallstones, associated in 5 cases with common bile duct stones; 12 acute cases of cholecystitis; and 2 cases of gallbladder empyema. Associated procedures were performed in 11 cases.
Results: The mean operative time was 62 minutes. Intraoperative cholangiography was performed in 5 cases and common bile duct exploration in 3. A drain was left in 17 patients. No conversions were necessary. No patients developed postoperative complications, and the mean postoperative hospital stay was 2.1 days.
Conclusions: Laparoscopic cholecystectomy performed with an ultrasonically activated scalpel is feasible and effective. The advantages are represented by using a unique instrument both for dissection of the gallbladder and division of the artery and duct. Furthermore, because of the minimal thermal dispersion, the use of the Harmonic scalpel reduces the risk of injuries. The main limit of the procedure is represented by the cystic duct size: if more than 5mm in diameter an additional ligature is necessary.
7300 General Surgery
Our Experience in Laparoscopic Ventral and Incisional Hernia Repair
E. Puce, MD, D. Apa, MD, B. C. Brassetti, MD, F. Atella, MD, G. A. Senni, MD, P. Iani, MD, M. Lombardi, MD
Background: Recurrence rates after repair of incisional and ventral hernias range from 18% to 52%. Prosthetic open repair has decreased this rate, but it requires significant soft tissue dissection in tissues that are already of poor quality, increasing complication rates. Laparoscopic repair offers an alternative.
Methods: A retrospective study was performed including 58 patients (32 men, 26 women) with a mean age of 61.6 years (range, 31 to 85) having incisional or ventral hernias that underwent laparoscopic repair at our institution between 2001 and 2006. Sites of hernias were 36 median incisional hernias, 18 umbilical hernias, 2 parastomal hernias, 2 umbilical + inguinal hernias. Abdominal wall defect size ranged from 4x3cm and 15x25cm, and sizes of mesh (56 Gore-Tex dual mesh, 2 Composix Bard mesh) ranged from 8x6cm to 20x30cm. Repair in low abdominal wall hernias was performed by tack fixation to the Cooper ligament.
Results: The mean operative time was 90 minutes. No open conversions were necessary, and one intraoperative complication (missed intestinal perforation) occurred. After 1 year, 1 patient died of cardiac failure. There was 2 wound and mesh infections (3.4%). Immediate postoperative minor complications occurred in 8% of patients (3 seromas, 2 local pain). The mean hospital stay was 1.8 days. During a mean follow-up of 30 months, the recurrence rate was 3.4% (2 patients).
Conclusion: In our experience, the laparoscopic approach to incisional and ventral hernia repair is safe and effective. This operation appears to decrease postoperative pain and is associated with shorter hospital stays and lower wound infection rates, and it seems to reduce recurrence rate. The impact on postoperative quality of life and cost implications needs further evaluation.
7301 General Surgery
Technical Aspects of Laparoscopic Splenic Marsupialization
James Wooldridge, MD, Tim Geiger, MD, Dan Kolder, MD, Steve Eubanks, MD
Traditionally, symptomatic cysts have been treated by splenectomy using an open technique. However, splenectomy has the potential for short- and long-term complications, which has led to emphasis on conservation of splenic tissue. We present a 28-year-old female who was found on CT scan to have an 11.9x11.3-cm symptomatic splenic cyst. We demonstrate and describe a laparoscopic technique used to marsupialize a splenic cyst.
7302 Multispecialty
Creation of a Neovagina by the Vechietti Procedure in a Patient with Corrected High Imperforate Anus: A Case Report
Paul B. Miller, MD, David A. Forstein, DO, Michael W. Gauderer, MD
Background: Vaginal atresia is often associated with a high imperforate anus. Because the commonly used methods of surgical vaginal creation (eg, McIndoe, intestinal segment interposition) may adversely affect urinary and fecal continence, the less invasive Vechietti procedure was selected for a young adult with a successfully corrected high imperforate anus.
Methods: A 21-year-old was born with a high imperforate anus, vaginal atresia, right hemi-uterus, and left renal agenesis. A colostomy was done at birth, a pull-through procedure at 9 months, and a stoma closure 3 months later. At age 13, an obstructed and dilated right hemi-uterus and tube were resected. A laparoscopic version of the Vechietti procedure was used. A continuous monofilament suture was threaded through a 2-cm acrylic bead. These sutures were placed through the apex of the vulvar invagination then advanced extraperitoneally under laparoscopic guidance along the proposed path of the neovagina. Exiting through the hypogastrium, the sutures were attached to an external device that exerts gentle, continuous traction, invaginating the bead below. Cystoscopic control was used to protect the bladder.
Result: After 2 days of hospitalization, traction was gradually advanced every other day in the office. At 2 weeks postoperatively, the bead was removed revealing a 7-cm vagina. Further elongation was achieved using the Frank method, while continence remained intact.
Conclusion: The Vechietti procedure is an attractive, minimally invasive alternative for creation of a neovagina in patients at risk for compromise to their vesico-ano-rectal continence.
7303 Gynecology
Robotic Sacrocervicocolpopexy in Women at Risk for Future Loss of Vaginal Support
Robert Flora, MD, Priya Maseelall, MD, Tonya Babbitt, PAC, James Fanning, DO
Objective: Women at risk of vaginal weakening, such as current or future tamoxifen users or chronic heavy lifters, may not be the ideal candidates for traditional sacrocolpopexies due to the risk of erosion and failure. The objective of this study was to describe our experience with robotic sacrocervicocolpopexy.
Methods: The setting was a urogynecology and reconstructive pelvic surgery practice in a community based, university affiliated teaching hospital. All women felt at risk presenting with severe POPQ grade 3 to 4 uterovaginal prolapse were offered supracervical hysterectomy followed by immediate colpopexy using the cervical stump as the attachment point. They had no prior history of abnormal cervical cytology and agreed to continue cervical screening after the procedure. Patients underwent preoperative evaluation including urodynamics. Anterior and posterior arms of soft Prolene mesh were utilized in all cases. Other procedures were also performed concomitantly. Patients were examined at 1 week, 1, 2, 3 months, and 1 year, postoperatively.
Results: Five patients underwent the procedure. All cases were uncomplicated and successfully completed. Average age was 64, operating time ranged from 4 to 6 hours, and the length of stay ranged from 24 to 36 hours. Minimum follow-up was 12 months. No recurrence of apical prolapse has been noted to date.
Conclusion: The cervix serves as the attachment point for the ligaments and fascia supporting the pelvic floor. Using the cervix as the mesh attachment point may be a better choice in this group of patients. Further investigation into this option is needed.
7304 Urology
Rhabdomyolysis Following Laparoscopic Nephrectomy: Case Reports and Review of the Literature
Deborah T. Glassman, MD, William G. Merriam, MD, Edouard J. Trabulsi, MD, Dolores Byrne, PhD, Leonard Gomella, MD
Background and Objectives: Laparoscopic renal surgery has become a widely applied technique in recent years. The development of postoperative rhabdomyolysis is a known but rare complication of laparoscopic renal surgery; however, its incidence is yet to be determined. Herein, 4 cases of rhabdomyolysis that have occurred at our institution are presented as well as a review of recent literature with respect to pathogenesis, treatment, and prevention of this dire complication.
Methods: A retrospective review of over 600 laparoscopic renal operations over the past 8 years was performed. All cases of postoperative rhabdomyolysis were identified. Additionally, A Medline search was performed to find articles related to the development of postoperative rhabdomyolysis. Cases were cited of rhabdomyolysis developing after laparoscopic renal surgery, and common risk factors between cases were identified.
Results: The incidence of postoperative rhabdomyolysis in our series is 0.67%. This rate is similar to the rate reported in other series. Male sex, high BMI, prolonged operative times, and the lateral decubitus position are all risk factors for the development of rhabdomyolysis.
Conclusion: The prevention and optimal management of postoperative rhabdomyolysis following laparoscopic renal surgery remains to be defined. The risk factors we identified in obese patients should be carefully addressed. Attempting to keep operative times acceptably short, careful patient positioning with adequate padding to spread pressure equally, and regular rotation of patients to periodically shift pressure points may help minimize or prevent this serious complication.
7306 Gynecology
Removal of Abdominal Cerclage Laparoscopically
James F. Carter, MD, David E. Soper, MD
Abdominal cerclage is necessary when the more commonly utilized transvaginal cerclage fails or anatomical abnormalities of the cervix preclude transvaginal placement. The disadvantage of an abdominal approach is that the patient can expect 2 laparotomies during her pregnancy: one for cerclage placement and the other associated with Cesarean delivery. We report a case of an abdominal cerclage removed laparoscopically in the case of an intrauterine fetal death at 17 weeks. This minimally invasive surgical technique eliminates the need for laparotomy in response to a poor previable pregnancy outcome.
7307 Multispecialty
The Simultaneous Laparoscopic Hysterectomy and Cholecystectomy
Khusen B. Narzullaev, MD, PhD
Background: The frequency of uterine myomas and calculary cholecystitis is 8% to 9%, which dictates the need for simultaneous laparoscopic surgeries.
Methods: From 1997 through 2006, at the Samarkand Center of Endoscopic Surgery (Republic of Uzbekistan), 75 simultaneous laparoscopic operations were performed in connection with cholelithic illnesses and uterine myomas in fertile-aged women. The mean patient age was 41.8±2.4. All patients were examined and prepared for the operation in the ambulatory method. For such operations, uterine size may not be greater than that of a 12-week pregnancy, the anamnesis of a normal birth must be present, a history of laparotomy must be absent, and inflammation of the gallbladder must be absent.
Results: First, laparoscopic cholecystectomy using standard ports with the removal of the gallbladder from the 11-mm middle port was performed, and then 2 additional 5-mm trocars were inserted into the left and right iliac regions to perform a hysterectomy. The laparoscopic hysterectomy was done with the help of a Klermont-Ferrand (Karl Storz) uterus manipulator. The ligamentous and fixative device of the uterus were distinguished and separated with the help of mono- and bipolar coagulation. The removed uterus was extracted from the abdominal cavity through the vagina. Thus, the vagina was taken in from the outside with Vicryl. The peritonization of the wound surface of the small pelvis was not realized. A transition to laparotomy was necessary in 2 cases (2.6%) because of third-degree adiposity and varicose veins in the broad ligament of the uterus. The laparoscopic combination of these surgeries is cost effective; the period of rehabilitation is the same as that for surgeries done with laparotomy.
Conclusions: The combination of cholelithiasis and uterine myomas is 8% to 9%, which dictates the need for simultaneous surgeries. The simultaneous surgeries are not traumatic operations; they reduce the treatment period, medical expenses, and rehabilitation time. All this dictates the need for creating Centers of Endoscopic Surgery and attracting surgeons, obstetrician/ gynecologists, and urologists.
7308 Multispecialty
A New Laparoscopic Pyeloplasty Approach: Kerithy Technique Minimally Invasive Surgery for the Management of Ureteropelvic Junction (UPJ) Obstruction
Al Kerithy Mohammed
Objective: To describe the results of the Kerithy technique for the management of ureteropelvic junction (UPJ) obstruction.
Methods: From January 2004 to December 2004, 5 patients with UPJ obstruction were managed by laparoscopic pyeloplasty using the minimally invasive Kerithy surgical technique. Following CO2 intraperitoneal insufflation with a Veress needle with the patient in a supine position, a 3-cm to 5-cm vision port is inserted at the umbilicus. The patient is then placed in a lateral decubitus position. Two ports are inserted, a 5-mm working port located at the anterior axillary line and a 1.5-cm port placed medial to the 11th rib. The second 2-mm port is located at the McBurny point for handling the bowl. After mobilization of the colon and identification of the lower pole of the kidney, the renal pelvis and proximal ureter are dissected completely. Then UPJ is identified, and a marking pen is used to mark the respective renal pelvis. The lateral wall of the ureter is marked as well. Then the renal pelvis with proximal ureter is brought through the working port and delivered outside the abdomen for the needed resection and micro-anastomosis.
Results: All operations were completed laparoscopically with negligible blood loss. Mean postoperative hospitalization was 2 days (range, 1 to 3). Mean operative time was 60 minutes (45±80). Successful relief of obstruction was achieved in 100% of patients determined 3 months postoperatively by US and Lasix nuclear renography.
Conclusion: The Kerithy technique is a safe, effective means for management of primary and secondary UPJ obstruction.
7311 Urology
Laparoscopic Radical Nephrectomy With Hilar Lymphadenectomy in Patients With Advanced Renal Cell Carcinoma
Matthew N. Simmons, MD, PhD, Jihad Kaouk, MD, Inderbir Gill, MD, Amr Fergany, MD, PhD
Objectives: Lymphadenectomy (LAD) at the time of radical nephrectomy in patients with nodal metastasis may improve accuracy of staging, decrease recurrence rates, and improve survival. LAD has traditionally been conducted using open surgery, but the laparoscopic technique is being more frequently applied. This report comprises the largest number of patients undergoing laparoscopic radical nephrectomy (LRN) with LAD to date.
Methods: Patients undergoing laparoscopic nephrectomy with LAD between July 1997 and September 2006 were reviewed. Patient demographics, operative data, pathologic data, outcomes, and complications data were analyzed.
Results: Of 700 total laparoscopic nephrectomies, 14 patients (13 male, 1 female) underwent laparoscopic LAD. Transperitoneal LRN was conducted in 12 (86%) patients. Retroperitoneal LRN and partial nephrectomy were each conducted in 1 patient (7%). LAD yielded an average of 2.7 lymph nodes. Median tumor size was 9.5cm (range, 1.5 to 13), and median lymph node size was 2.3cm (range, 0.8 to 11). Tumor stage was >T2 in 9 cases (64%), and distant metastases were present in 7 patients (50%). Hand-assist conversion was required in 1 case (7%). Elective open conversion was required in one case. Median blood loss was 250mL (range, 100 to 2100). Median length of hospital stay was 2.5 days (range, 2 to 5). Median operative time was 199 minutes (range, 152 to 260). There was a single (7%) Grade 1 complication.
Conclusions: Patients with advanced RCC may require cytoreductive nephrectomy before adjunctive therapy. Lymphadenectomy may improve outcomes in these patients. Laparoscopic LAD is both feasible and safe. Furthermore, decreased morbidity associated with the laparoscopic approach is beneficial in this patient population with advanced disease.
7312 Urology
Decreased Complications of Contemporary Laparoscopic Partial Nephrectomy: Use of a Standardized Reporting System
Matthew N. Simmons, MD, PhD, Inderbir S. Gill, MD, MCh
Objective: Comparison of laparoscopic partial nephrectomy (LPN) outcomes data is limited by lack of uniform reporting methods. Our intention was to analyze complications in a contemporary cohort of 200 patients from an LPN database containing over 500 patients by using a standardized complications reporting system.
Methods: We reviewed 200 consecutive patients who underwent LPN between September 2003 and November 2005. Mean tumor size was 3cm, and mean parenchymal invasion depth was 1.8cm. There were 97 central tumors (48.5%) and 9 tumors in solitary kidneys (4.5%). Complications were graded using NCI-CTC v2.0 reporting criteria. Statistical analysis was used to assess complication risk factors.
Results: Thirty-five patients (17.5%) had complications. The overall complication rate was 19%. Of the complications, 29% were grade I, 42% were grade II, 26% were grade III, and 2.6% were grade IV. There were no grade V complications. Median blood loss was 150mL. Hemorrhagic and urine leak complications occurred in 9 (4.5%) and 4 (2%) patients, respectively. Conversion to open partial and laparoscopic radical nephrectomy was done electively in 2 (1%) and 1 (0.5%) patients, respectively. Compared with the first 200 patients in our LPN cohort, this contemporary cohort had significant decreases in overall (P=0.02), urologic (P=0.04), and hemorrhagic (P=0.04) complication rates despite an increase in tumor complexity.
Conclusions: Increased experience with advanced laparoscopic techniques has allowed for a significantly reduced complication rate following contemporary LPN, which now appears comparable to that of open partial nephrectomy. A standardized complication reporting system is advocated.
7313 General Surgery
Laparoscopic Removal of an Angelchik Antireflux Device with Immediate Nissen Fundoplication: Video Case Report
Mark Kiefer, MD, Nitin Rangnekar, MD, Bruce Ramshaw, MD
Hiatal hernia with or without gastroesophageal reflux disease is a common ailment that is frequently seen in general surgery clinics. In the past, surgical options were often explored for long-term relief of symptoms, and in recent years, minimally invasive surgical techniques have become useful tools in the treatment of this disease. In some cases, patients with previous surgery for hiatal hernia, gastroesophageal reflux, or both, return for recurrence of symptoms that are similar or identical to those present before the original treatment or for complications associated with the previous surgery. A 75-year-old lady with a history of open surgical treatment for hiatal hernia with gastroesophageal reflux via placement of an Angelchik device presented to our clinic with complaints of returning symptoms of abdominal pain, worsening nausea, and cough. She was taken to the operating room where we were able to successfully identify and remove the Angelchik device and then performed immediate Nissen fundoplication. Both of these procedures were accomplished using minimally invasive techniques. By using completely laparoscopic techniques, the patient was discharged quickly without the morbidity associated with major open abdominal surgery. The video presentation shows the method used for the identification and removal of the Angelchik device and the subsequent Nissen fundoplication.
7315 General Surgery
Laparoscopic Vagotomy and Pyloroplasty
Victor J. Hassid, MD, Sadir Alrawi, MD, Ziad Awad, MD
Objective: Despite successful medical treatment to reduce acid hypersecretion and eradicate Helicobacter pylori, surgery still plays an important role in the management of complicated peptic ulcer disease. The role of laparoscopic versus open surgery remains an ongoing debate.
Methods: The video is a case presentation of a patient with a long-standing history of a recurrent bleeding duodenal ulcer not responsive to medical or endoscopic management. Laparoscopic vagotomy, pyloroplasty, and under running the bleeding vessel were performed.
Results: The patient was discharged home on the fourth postoperative day without any complications.
Conclusions: Laparoscopic surgery can be included in the surgeon’s armamentarium for the management of complicated peptic ulcer disease. Prospective randomized studies are needed.
7316 General Surgery
Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery Syndrome
Ziad T. Awad, MD, Matthew Cole, MD, Victor Hassid, MD
Background: Superior mesenteric artery (SMA) syndrome is a rare cause of proximal intestinal obstruction. Diagnosis and treatment of this syndrome can be challenging. Surgical treatment is indicated for patients who fail conservative management.
Methods: The video is a case presentation of a 37-year-old female who presented with an 8-month history of postprandial epigastric pain, vomiting, nausea, and profound weight loss. Small-bowel enteroscopy revealed extrinsic compression at the junction of the second and third parts of the duodenum. CT scan of the abdomen revealed compression of the third portion of the duodenum by the SMA. The patient failed conservative management. She underwent laparoscopic duodenojejunostomy.
Results: The patient had complete resolution of vomiting and abdominal pain but continued to have some nausea. UGI showed free flow of contrast into the jejunum.
Conclusion: Laparoscopic duodenojejunostomy is a feasible option for treating SMA syndrome.
7317 Urology
Increased Incidence of Ureteral Stenosis After Ureteroscopy: Risk Stratification
Viorel Bucuras, Petru Boiborean, Mircea Botoca, Razvan Bardan, Claudiu Comsa
Introduction: The study intends to evaluate whether the rate of postureteroscopic ureteral strictures is influenced by several factors, including the difficulty of the procedure, caliber of the semirigid ureteroscope, and the size and location of the stones.
Method: Between January 2002 and December 2006, 381 therapeutic semirigid ureteroscopies for ureteral lithiasis were performed in the Department of Urology in Timisoara. We have analyzed the data regarding the location and size of the ureteral stones and the ureteroscopic procedure details. All the patients were followed for at least 1 year after the procedure, and the cases of symptomatic ureteral stenosis were investigated by using intravenous urography and retrograde ureteropyelography.
Result: We stratified the patients into 2 groups. The first group (205 patients) was considered at low risk for ureteral stenosis, including procedures for small ureteric stones, situated in the distal segment of the ureter. The second group (176 patients) had higher risk of ureteral stenosis, due to larger stones, or stones situated in the upper segment of the ureter, necessitating longer and more difficult procedures. The incidence of postoperative ureteral stenosis 1 year after the ureteroscopy was 4 cases (1.95%) in the first (“low-risk”) group and 9 cases (5.11%) in the second (“high risk”) group (P<0.003).
Conclusion: A clear relationship exists between the difficulty of the ureteroscopic procedure and the rate of postoperative ureteral stenosis. Further studies are necessary to establish the methods for reducing the complication rate, including the utility of postoperative stenting.
7318 General Surgery
Primary Hydatid Cyst of the Adrenal Gland: Report of One Case
Zribi Riadh, MD, Hichem Rekik, MD, Chokki Adel, MD, Riahi Khalifa, MD
Primary hydatid cyst on the adrenal gland is still an exceptional location. The adrenal gland is an uncommon site even in our country in which echinococcal disease is endemic. We report one case of primary hydatid cyst of the adrenal gland in a patient who presented with isolated abdominal pain. The diagnosis was based on CT-scan, which showed a unilocular cystic mass of the right adrenal gland. The echinococcal immunologic test (ELISA) was positive in this case. The surgical treatment consisted of a total resection of the cyst, without rupture of the cystic wall, and preservation of the gland. The diagnosis was confirmed on histological examination of the resected piece. The postoperative course was uneventful. No recurrence had taken place after 24 months of follow-up.
7319 Multispecialty
A Novel Pneumoperitoneum Creation Assist Device
Rene Charles, MD
Objective: This clinical trial was performed to demonstrate the safety and efficacy of a new device developed to assist in pneumoperitoneum creation. The LapCap is clear and dome-shaped, with a central needle pass-through and a vacuum-line port.
Methods: Forty-eight female gynecologic patients (mean age, 36 years; mean BMI, 27) were enrolled into this prospective, single-arm trial. The LapCap was placed on the patient’s periumbilical abdominal wall. In 15 cases (31%), vacuum was applied, elevating a cone of full-thickness abdominal wall and peritoneal cavity into the device dome. A Veress needle was passed through the device into the elevated cone of abdominal wall and peritoneal cavity. In 33 women (69%), the needle was initially placed through the device until the tip was positioned superficially in the periumbilical incision, and suction was applied, elevating a cone of full-thickness abdominal wall and peritoneal cavity onto the needle. The vacuum was relieved, and the LapCap and needle were lifted off the abdomen following a drop test and CO2 insufflation.
Results: In all patients, the Veress needle was correctly positioned on the first attempt and a pneumoperitoneum established. Mean suction plus needle passage time was 19 seconds (SD, 18; range, 4 to 90). No patient suffered a complication or abdominal wall skin trauma (including petechiae or discoloration) from procedure performance through the first postdischarge visit.
Conclusion: This trial demonstrated the safety and efficacy of the LapCap in elevating a cone of full-thickness abdominal wall and peritoneal cavity, allowing for simple, rapid, reproducible Veress needle passage.
7320 Gynecology
Robotic-assisted Radical Hysterectomy With Bilateral Pelvic Lymphadenectomy
Norma Steiner, MD, Linus Chuang, MD, Shoma Datta, MD, Farr Nezhat, MD
This is an educational DVD about a woman with stage IBI cervical carcinoma who is undergoing a robotic-assisted radical hysterectomy with bilateral lymphadenectomy. Traditionally, this procedure is performed via laparotomy. However, this DVD shows how a new technique using robotic surgery can be used for the treatment of gynecologic malignancies. A role exists for robotic surgery in the treatment of cervical carcinoma.
7321 General Surgery
Emergency and Urgency Laparoscopy: Our Experience
D. Apa, B. C. Brassetti, E. Puce, G. Senni, F. Atella, P. Iani, M. Lombardi
Background: Laparoscopic surgery has now been described in many abdominal emergencies. This approach allows both the evaluation of acute abdominal pain and the treatment of many common acute abdominal disorders. We performed a retrospective analysis of our experience in emergency laparoscopic surgery.
Methods: From 1991 and 2006, 5000 patients underwent emergent or urgent surgery. Among them, 584 (317 women and 267 men; mean age, 44.92 years, range 9 to 92) were operated on laparoscopically: 228 for acute cholecystitis (39%), 214 for appendicitis (36%), 52 for pelvic inflammatory disease (9%), 32 for perforated peptic ulcer (5.4%), 32 for bowel obstruction (25 adhesive disease, 5 neoplastic obstruction, 2 inflammatory bowel disease) (5.4%), 10 for colic perforation (1.7%), 8 for traumatic lesions (4 spleen traumas, 2 for penetrating trauma to the abdominal wall, 2 for diaphragmatic injuries) (1.3%), 8 for peritonitis of different causes (1.3%), and 3 for spontaneous rupture of liver tumors (0.5%). The primary aim of laparoscopy in treating trauma is diagnostic with an accuracy rate of 100%.
Results: The conversion rate was about 8% (45 patients and was mainly observed in peritonitis of diverticular perforation (7/10), hemoperitoneum of different causes (9/9) or intestinal occlusion (14/30). The conversion was often due to the presence of dense intraabdominal adhesions or to main bowel distension, and, in colorectal urgency, it was sometimes possible to eliminate the intervention after colon mobilization. Morbidity and mortality rates were 8% (24 patients) and 0.5 (3 cases), respectively. The mean operative time was 90 minutes, and the mean hospital stay was 7 days (range, 2 to 10).
Conclusion: The laparoscopic approach to abdominal emergencies and urgencies is a valid alternative to conventional surgery. Baroscopic surgery is firmly established as superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or gynecological emergencies. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering exploratory surgery. In trauma, it has a role in hemodynamically stable patients. Laparoscopy is an excellent modality in the evaluation of the diaphragm in penetrating thoracoabdominal injuries and has been shown to be highly effective at determining peritoneal penetration.
7322 Urology
Operative Complications of Robotic-assisted Radical Prostatectomy: The Learning Curve and Beyond, A Single-surgeon Series
Ashay Patel, Ketul K. Shah, Rahul K. Thaly, Vipul R. Patel
Introduction: The technical advantages provided by the application of robotic technology have the potential to improve patient outcomes. However, as with the introduction of any innovative new technology or procedure, there is a learning curve and therefore a potential for an initial increased number of complications. Our experience with radical robotic prostatectomy (RALP) is now over 1200 cases. We reviewed the incidence of intra-, peri-, and postoperative complications following RALP.
Methods: We prospectively analyzed 1258 consecutive patients who underwent RALP performed by a single surgeon over a 5-year period. The approach was transperitoneal by a 6-trocar technique. Outcome data were collected, and complications were analyzed.
Results: The overall complication rate was 3.7% (47/1258) with no mortalities or immediate return to the operating room for secondary procedures. The open conversion rate was 0.15% (2/1258); the initial 2 cases were converted due to the lack of progression. One case was converted to standard laparoscopy after technical failure of the robot. Two patients had rectal injury in the initial part of the series that was recognized and primarily repaired. Five (0.4%) patients required blood transfusion. Average hospital stay was 1.1 days, and average duration of the catheter was 6.3 days. The perioperative complications included prolonged anastomotic leakage (5), ileus (3), hemorrhage (5), deep vein thrombosis (4), pulmonary embolism (3), myocardial infarction (2), bowel herniation at the trocar site (1), and cholecystitis (1). The average follow-up was 23 months. Late postoperative complications include urinary retention (6), meatal stenosis (1), epididymitis (1), lymphocele (2), bladder neck contracture (3), and incisional hernia (4).
Conclusion: In our single-surgeon experience, the overall complication rate is 3.7%. Our data suggest that the majority and severity of the complications occurred during the initial experience of the 200 cases. After the initial learning curve, the complications are mostly self-limited.
7323 General Surgery
Is Laparoscopic Appendicectomy an Appropriate Training Operation? Learning Curve of a Junior Trainee
U. Jaffer, A. Cameron
Introduction: Appendicectomy had traditionally been a training operation for junior surgical trainees. With the increased incidence of laparoscopic appendicectomy, there has been concern as to the safety of this far more technically demanding procedure in the hands of junior surgical trainees. The learning curve of a junior surgeon is presented.
Methods: Consecutive patients having laparoscopic appendicectomy were studied. A 3-port Hasson technique was used. Patient demographics, conversion rate and reason for conversion, operative times, number of complicated cases (retrocecal position, dense adhesions, perforated/gangrenous/abscess associated appendicitis), and postoperative complications were recorded. The moving average method was used to delineate the learning curve.
Results: A total of 31 patients were studied. Median age was 26 (IQR: 20.75, 40.25. Twenty-one (68%) were female. Data were not available for 3 patients; the remainder forms the basis of this study.
Group n Conversions Complicated Op. time Complications
to open Appendicitis (mean ±SEM)
1 6 3 3 83.16 ± 10.37 1 suprapubic port site hernia
2 9 1 4 97.11 ± 5.13 1 wound infection
3 8 3 6 62.5 ± 4.5 1 prolonged ileus
In Group 1, one procedure was converted to open due to the consultant’s choice. A statistically significant improvement occurred in operating time between group 2 and group 3, P<0.0001 (95% CI 21.23 to 47.99)
Conclusion: Laparoscopic appendicectomy is a safe procedure for junior trainees and the learning curve stabilizes by 20 cases performed.
7324 Gynecology
Tumor Suppressors and Oncogenes Selected Expression Profiling of the Endometrium of Women With Endometriosis
Piotr Laudanski, MD, PhD, Jacek Szamatowicz, MD, PhD, Oksana Kowalczuk, PhD, Malgorzata Oniszczuk, MD, Lech Chyczewski, MD, PhD
Objective: It is becoming increasingly evident, that the eutopic endometrium of women with endometriosis shares certain alterations with the ectopic lesions that are not found in the endometrium of disease-free women. It implies that the primary defect, like recently suggested aberrant expression of some oncogenes and tumor suppressor genes, may be rooted in the eutopic endometrium of affected women. The aim of this study was to compare the expression level of mTOR (mammalian target of rapamycin) oncogene-related genes in the endometrium of women with and without endometriosis.
Methods: Endometriosis was diagnosed during laparoscopy performed in the first phase of the menstrual cycle. We applied the novel micro-fluid gene array to examine the expression of 15 human tumor suppressors and oncogenes in eutopic endometrium of 41 women with endometriosis and 38 controls. Control women comprised patients with histologically confirmed benign ovarian cysts (n=11) and 27 infertile individuals without any signs of visible endometriosis. We chose the following genes: NF1, RHEB, mTOR1, AKT-1, PTEN, TSC1, TSC2, KRAS, RPS6KB1, 4EBP1, TP53, EIF4E, STK11, PIK3CA and BECN1.
Results: Among all of the studied genes, we found significantly higher levels (P=0.039) of transcription factor EIF4E in the endometrium of women with endometriosis compared with the endometrium of fertile patients with benign ovarian cysts.
Conclusions: The low-density array is an effective technique to examine the expression of different genes in the endometrium of patients with endometriosis. Our results suggest that up-regulation of transcription factor EIF4E may be associated with the pathogenesis of endometriosis.
7325 General Surgery
Hand-assisted Laparoscopic Donor Nephrectomy: Advantages Over the Standard Laparoscopic Approach
Michael E. Fenoglio, MD, John T. Moore
Objective: Living-donor nephrectomy has long been an accepted standard in the field of kidney transplantation. One major side effect is the morbidity for the donor. This operation has resulted in a long hospitalization and up to a 6-week recovery period. Recent advances in laparoscopic approaches have resulted in a shorter hospital stay and an overall abbreviated recovery. Several problems with the laparoscopic approach have been noticed, including the degree of expertise required and the possibility of higher ATN rates in the postoperative period. We believe a modification of this technique, using the hand-assisted laparoscopic approach, provides a safe alternative to full laparoscopy. We present our technique for the operation and the results of 48 patients who have undergone this procedure.
Methods: We use 2 laparoscopic ports and the hand-assisted port for all of our cases. Rarely are any other accessory ports needed. The use of a hand port allows the surgeon to place a hand in the abdomen while maintaining a pneumoperitoneum. Standard dissection of the kidney proceeds, facilitated by the surgeon’s left hand. The kidney is removed with minimal warm ischemia time and no systemic heparinization. The kidney is immediately handed to the recipient team, flushed, and prepared for transplantation on the back table.
Results: We have performed 48 living donor operations using this technique. All were left nephrectomies. We have had a 0% ATN rate in the recipient population. We have safely used kidneys with multiple renal arteries, multiple renal veins, dual ureters, and retroaortic renal veins with no postoperative dysfunction in the transplanted kidneys and no complications in the donors. Results were as follows: average operating time 176 minutes, mean warm ischemia time 160 seconds, mean length of stay 2.4 days, EBL <100cc/case.
Conclusion: Using the hand-assisted method of laparoscopic nephrectomy adds advantages over the full laparoscopic technique without compromising kidney function or donor recovery. It adds tactile sensation, ease of retraction, immediate digital hemostasis in case of unexpected bleeding, and decreased warm ischemia time to the kidney. We feel these factors contribute to achieving a 0% ATN rate in the transplanted kidneys performed using this technique. This operation can also be taught to surgeons who do not have extensive laparoscopic experience.
7327 General Surgery
Laparoscopic Heller Myotomy Improves Symptoms of Achalasia and Results in a High Degree of Patient Satisfaction
M. E. Fenoglio, MD, John T. Moore, MD
Objective: Laparoscopic Heller myotomy will improve the symptoms of achalasia and result in a high degree of patient satisfaction. We sought to prove this hypothesis.
Methods: Between April 1994 and July 2006, 49 patients underwent laparoscopic Heller myotomy for achalasia. A retrospective survey of these patients was conducted. Patients were asked to quantitatively compare preoperative and postoperative symptoms during a telephone interview. Questions relating to preoperative medications and procedures, postoperative recovery, and overall satisfaction were also addressed.
Results: Mean follow-up was 44.5 months. Survey results demonstrate significant improvement in symptoms. Patients uniformly stated that they were satisfied with their operation and that they would recommend the operation to a friend or family member with achalasia.
Conclusion: Laparoscopic Heller myotomy significantly improves symptoms of achalasia and results in a high degree of patient satisfaction.
7328 Urology
Does Purchasing a da Vinci Robot Make Sense for a Mature Laparoscopic Prostatectomy Program?
Peter L. Steinberg, MD, Paul A. Mergurian, MD, John A. Heaney, MB, William Bihrle, III, MD, John D. Seigne, MB
Introduction and Objectives: Outcomes for robotic-assisted prostatectomy (RAP) and laparoscopic prostatectomy (LRP) are equivalent, but RAP constitutes 40% of the prostatectomy market. We performed a cost benefit analysis of obtaining a da VinciAE robot to offer informed recommendations on transitioning from LRP to RAP.
Methods: Caseload, operative times, and profits were obtained from a single institution. Cost of the da VinciAE robot was obtained from Intuitive Surgical. All costs were amortized over 5 years. The analysis included $1.5 million robot; $112,000 service contract per year; and an added $200 per case of disposables. Reimbursement and outcomes were considered equal between LRP and RAP. If the robot were donated, the institution pays for disposables and the service contract.
Results: Seventy-eight cases per year are needed to cover the costs of a purchased robot, while only 20 cases per year are needed if a robot is donated. Once robot costs are covered, increases in caseload lead to increased income.
Conclusions: Our data suggest a high volume LRP program can convert to RAP and maintain profits; however, the cost of the robot precludes equal income as that with LRP. Purchasing a robot is not fiscally viable in a low volume program. A donated robot lessens costs and allows reasonable revenue without drastic increases in caseload. Given comparable outcomes between LRP and RAP, hospitals need to decide whether market forces or the intangible benefits of robotics outweigh the expenses of obtaining and operating a robot.
7329 General Surgery
Thoracoscopic Bronchial Artery Clipping: A New Option for Treatment of Hemoptysis?
Hsing-Hsien Wu, MD
Introduction: Hemoptysis, especially life-threatening hemoptysis, is a challenging issue in thoracic surgery. Till now, bronchial artery embolization (BAE) and surgical pulmonary excision are the main treatments. We report a case that received thoracoscopic bronchial artery clipping for treatment of hemoptysis that recurred after BAE.
Method: The 52-year-old patient had a case of stable bronchiectasis, but he had suffered mild hemoptysis at times in recent years. In October 2006, he underwent BAE for treatment of hemoptysis. In January 2007, the hemoptysis recurred. This time, we performed thoracoscopic bronchial artery clipping. The procedure was approached by 3-port (one 10-mm, two 5-mm) video-assisted thoracic surgery (VATS). Under video vision, we identified the kinked bronchial artery and occlude the blood stream by endoscopic clips.
Results: The procedure was performed smoothly, and the blood loss was minimal. The chest tube was extracted 2 days later. The length of stay was 4 days. The postoperative angiography revealed total occlusion of the kinked bronchial artery. No complications developed. The patient has been followed up until the present time with no recurrences.
Conclusions: Thoracoscopic bronchial artery clipping is an effective and minimally invasive surgical procedure for treatment of hemoptysis. The procedure may become an option other than BAE and pulmonary resection.
7330 General Surgery
Development of a Novel Method for Mesh Fixation During Laparoscopic Herniorrhaphy Using Laser-assisted Tissue Soldering in a Porcine Model
R. J. Lanzafame, B. A. Soltz, I. Stadler, R. Soltz
Background: This study describes the development of instrumentation and techniques for laparoscopic herniorrhaphy using laser-assisted soldering techniques. Results of animal studies to date indicate that solder is capable of providing stable fixation for surgical meshes without interfering with tissue integration into the mesh and without an increased incidence of adhesion formation or inflammation.
Methods: Anesthetized 20-kg to 5-kg female Yorkshire pigs underwent laparoscopy with a 3-trocar technique. Segments of Parietex TET, Parietex TEC, and Prolene mesh (5x5cm) were embedded in 55% collagen solder. The segments were inserted using a specially designed introducer and fixed to the peritoneum using the CEE laser (1.4m, 3W CW, 4mm spot, 55°C set temperature) with a custom laparoscopic handpiece. Parietex Composite mesh segments were inserted and affixed using the Endo-hernia stapler (Control). The animals were recovered and underwent second look laparoscopy at 6 weeks, and the mesh sites were harvested after the animals had been euthanized.
Results: The mesh-solder constructs were easily inserted and affixed to the peritoneum. However, the Prolene mesh tended to curl at its edges as the solder material was melted. Postoperative healing was similar to healing with the Control segments.
Conclusion: Collagen-based tissue soldering permits normal wound healing and may mitigate or reduce use of staples or other foreign bodies for IPOM reissue ischemia and possibly nerve entrapment resulting in severe postoperative pain. Laser-assisted mesh fixation is a promising alternative for laparoscopic herniorrhaphy. Further development of this strategy is warranted.
* Supported by NIDDK #1R43 DK62571-03
7331 Urology
The Cost of Learning Robotic-assisted Prostatectomy
Peter L. Steinberg, Paul A. Merguerian, William Bihrle III, John D. Seigne
Objective: To model the cost of the learning curve for robotic-assisted prostatectomy.
Methods: We developed a literature-based model that assumed a surgeon's first robotic-assisted prostatectomy lasts 8 hours, then lasts 3 or 4 hours after mastering the learning curve. Improvement between cases of either 1 minute or 10 minutes was modeled, based on literature estimates. The nadir in operative time corresponded to the end of the learning curve. The cost of the learning curve equals the average published cost of operating room time from several centers, $10.50 per minute, multiplied by the length of the learning curve in minutes.
Results: Improving 1 minute per case requires 240 cases to achieve a 4-hour prostatectomy, or 300 cases to reach a 3-hour prostatectomy. Progressing 10 minutes per case requires either 24 cases or 30 cases to achieve an operative time of 3 or 4 hours, respectively. It costs $911,000 to achieve a 4-hour case and $1,047,000 to achieve a 3-hour case, with 1 minute of improvement per case. Finally, improving 10 minutes per case costs $95,000 to achieve a 4-hour case and $107,000 for a 3-hour case.
Conclusions: Published estimates of the robotic-assisted prostatectomy learning curve range from 30 cases to 300 cases—a $900,000 difference in costs. Swift mastery of robotic prostatectomy is cheaper than a lengthy learning process. Aside from the robot, service contract, and instruments, the cost and length of the learning curve should be considered when adopting robotic-assisted prostatectomy, especially at low volume prostatectomy centers.
7333 General Surgery
Embryo Cryopreservation in a Patient With Massive Recurrence Borderline Tumor in a Single Ovary
Afaf Abdulmutaleb Felemban, MD
The natural history of serous borderline (SBTs) of the ovary varies considerably. Advanced stage tumors with noninvasive implants are common, characteristically behave in a benign fashion, and can be safely treated conservatively. Our young infertility patient had a history of encapsulated serous papillary cystic borderline malignancy treated by oophorectomy. An atypical presentation of recurrent ovarian tumor was discovered during her in vitro fertilization pregnancy. An emergency plan was decided upon after her delivery. Because she is young and desires to become pregnant again, 3 IVF trials with 10 embryos cryopreserved were done before the surgery. Conservative left salpingo-oophorectomy surgery was performed with a histopathology of noninvasive SBT.
7334 General Surgery
Laparoscopic Omental Repair of Perforated Marginal Ulcer Following Laparoscopic Roux-en-Y Gastric Bypass
Andrew A. Wheeler, MD, Timothy P. Mayfield, MD, Roger A. de la Torre, MD, James S. Scott, MD
Marginal ulcer formation is a known complication of laparoscopic Roux-en-y gastric bypass with a reported postoperative incidence of 2%. Occasionally, patients with marginal ulcers develop perforation at the site of ulceration, yet the optimal method for repairing these perforations has yet to be determined. Only 2 cases were identified in the literature citing laparoscopic omental patch repair for perforated marginal ulcer in a patient having previously undergone laparoscopic Roux-en-y gastric bypass. We present a 31-year-old male who developed a perforation in a marginal ulcer at the gastrojejunostomy and describe our technique for laparoscopic repair using an omental patch for coverage of the defect. We propose that the routine use of laparoscopic omental patch repair of perforated marginal ulcers by surgeons trained in advanced laparoscopic techniques is a reasonable option for repairing this injury and still maintains the advantages that exist with a minimally invasive surgical procedure.
7336 General Surgery
A Case Report of Primary Jejunal Adenocarcinoma with Signet Cell Features
Jennifer L Marti, MD, Nicole White, MD, Erik Ballert, MD
Introduction: Small intestinal malignancies are very rare, with an incidence of less than 2 per 100,000 adults. Only 3 cases of adenocarcinoma of the jejunum with signet cell features have been described.
Methods: The medical records of a patient with primary adenocarcinoma of the jejunum with signet cell features were reviewed.
Case Report: A 56-year-old man presented with acute vomiting and obstipation with a 3-week history of bloody diarrhea. He had severe cramping abdominal pain with a distended and tender abdomen. A CT scan revealed a small-bowel obstruction, concerning for Crohn’s disease. The patient was treated with bowel rest, nasogastric tube decompression, and steroids. He failed to clinically improve and exploratory laparoscopy was performed, revealing a stricture with 2 masses in the mid-jejunum. A laparoscopic small-bowel resection was performed. Pathology revealed a pT3N1 jejunal signet-ring cell adenocarcinoma with 2 positive lymph nodes. The patient will receive chemotherapy.
Conclusions: We present a rare case of primary signet-ring cell jejunal adenocarcinoma. Small-bowel tumors may not initially be suspected in patients presenting with small-bowel obstruction, and if encountered, should be treated with wide resection including regional lymph nodes and, depending on pathology, may require adjuvant chemotherapy. Small-bowel adenocarcinoma may have signet cell features, possibly signifying a more aggressive tumor biology.
7337 General Surgery
Iatrogenic Gastric Pneumatosis
Jennifer L. Marti, MD, Marsha A. Harris, MD, Emil J. Balthazar, MD, Peter Shamamian, MD
Introduction: Gastric pneumatosis or emphysema is rare in adults. We report a case resulting from nasogastric tube placement.
Methods: The medical records and radiologic studies of a patient diagnosed with gastric pneumatosis were reviewed.
Case Report: A 75-year-old male nursing home resident with a history of GERD and erosive esophagitis presented with 1 episode of coffee ground emesis. He was afebrile with normal vital signs, mild epigastric tenderness, a normal white blood cell count, hematocrit of 48%, and guaiac positive stool. An abdominal plain film was unremarkable. A nasogastric tube was placed in the emergency department, and gastric lavage returned murky brown fluid. Computed tomography revealed extensive pneumatosis along the greater curvature and body of the stomach, with no signs of visceral perforation or pneumoperitoneum. The patient was managed with bowel rest and antacid therapy. Repeat CT 5 days later revealed complete resolution of gastric pneumatosis. The patient tolerated an oral diet without difficulty and was discharged.
Conclusions: Gastric pneumatosis after nasogastric tube insertion has been reported once in the world literature. It is critical to rule out other possible causes of pneumatosis, and to differentiate this generally self-limited process from cases of infectious emphysematous gastritis, which carries a high mortality rate.
7338 General Surgery
Robotic Roux-en-Y Gastric Bypass With Robotically Sewn Single-Layer Gastro-Entero and Entero-Entero Anastomoses
Ph. Morel, M. Hagen, G. Chassot, I. Ihnan
Background: The gold standard for Roux-en-Y gastric bypass (RYGB) is currently a laparoscopic approach with stapled anastomoses. This laparoscopic approach is feasible, but technically challenging and associated with a high rate of complications (overall, >30%, leakage, >2%, strictures, >4%). Some centers worldwide perform either totally robotic RYGB or robotically assisted RYGB, both with a robotically sewn double-layer gastro-entero-anastomosis and stapled entero-entero-anastomosis with promising results. The authors of the study hypothesize that robotically assisted surgery with both anastomoses performed robotically 1) may offer significant technical advantages over traditional laparoscopy at crucial parts of the procedure and 2) may provide better quality of anastomoses even if performed with a single-layer technique.
Methods: We evaluated our first 31 robotic RYGBs with robotically sewn gastro-entero and entero-entero anastomoses concerning complications (regarding anastomoses and overall complications), duration of suturing of anastomoses, and complete procedure.
Results: Until now, we have performed 31 robotically assisted RYGBs with 58 robotically sewn, single-layer anastomoses. The duration of these first 58 anastomoses ranged from 35 to 145 minutes with a very rapid learning curve (first, 145 minutes; last, 35 minutes, median, 50 minutes). Duration of operation ranged from 230 minutes to 540 minutes (median, 334 minutes). Until now, we have not observed any leaks, strictures, or other complications with the anastomoses. One patient with arterial bleeding from laparoscopic stapling line had to be reoperated on.
Conclusion: The data support the conclusion that robotically sewn gastro-entero and entero-entero-anastomoses in RYGB for obesity are superior compared with stapled anastomoses in laparoscopy. A single-layer technique seems to be sufficient. Initially, the long duration of suturing is very quickly overcome and anastomoses can be performed in acceptable time.
7339 General Surgery
Is Robotic Surgery More Time Consuming Than Conventional Laparoscopy?
M. Hagen, I. Inan, Ph. Morel
Objective: Robotic surgery is a field of growing interest in modern surgery. However, critics point out that robotic surgery is more expensive and—mainly due to robotic docking—more time consuming compared with conventional laparoscopy.
Methods: First, we conducted a Medline-based search on evidence-based data about the duration of robotic procedures. Secondly, we prospectively evaluated robotic docking times of our first 30 da Vinci procedures.
Results: Only a few prospective randomized trials on robotic surgery can be found, and data with evidence-based level 1and 2 are exclusively available for Nissen fundoplication. Different publications indicate longer, shorter, or assimilable OR-times of robotic Nissen procedures compared with laparoscopy. In our first 30 da Vinci procedures, overall median docking time was 10.5 minutes (range, 3 to 25). The robot was placed either over the patient’s head (11), left (6) or right shoulder (6), at the left thigh (3), or between the legs (4). Median time of straight robot docking over the head or between the legs was 5 (range, 3 to 10) and 12.5 (range, 5 to 12) minutes. Median time for angular robot docking over patient’s right and left shoulder and at the thigh was 11 (range, 6 to 25), 12 (range, 10 to 25) and 13 (range, 10 to 20) minutes. (All differences in docking time showed no statistical significance). Docking time showed a rapid learning curve.
Conclusions: Presently, existing data demonstrate no clear disadvantage regarding OR times of robotic surgery compared with conventional laparoscopy. However, robotic docking is learned very rapidly and therefore does not seem to play a major role in overall OR times of robotic operations. Longer duration of robotic surgery compared with laparoscopy may mainly be a natural effect of learning.
7340 Gynecology
Linear Salpingostomy for Ectopic Pregnancy: Effect on Fertility
Jagdip T. Shah, Sanjay M. Mehta
Objective: To evaluate fertility status and persistence of disease in the cases of laparoscopic linear salpingostomy performed at Pooja Hospital from January 1996 to December 2006.
Methods: Laparoscopic surgery was performed in 289 patients with ruptured or unruptured ectopic pregnancies during the study period. Of those, 173 laparoscopic linear salpingostomy patients were called and requested for consultation at Pooja Hospital. One hundred fifteen patients responded. A detailed medical history and examination were performed. The findings were compared with the operative notes in a well-defined structured manner that includes postoperative pain, menstrual irregularities, and fertility. Forty-nine patients requiring postoperative methotrexate were compared with those who did not. Salpingostomy was only offered to those patients who wanted to preserve fertility. All patients were told about chances of persistence; requirements and side effects of methotrexate; chances of repeat ectopic pregnancies; and chances of infertility.
Results: Fifty-nine (51.3%) patients conceived spontaneously without any treatment. Twenty-one (18.2%) conceived after treatment. Thirty-five (30.4%) did not conceive in spite of treatment. Only 5 patients had repeat ectopic pregnancies; 9 of 16 infertile patients who underwent laparoscopy had normal patency of the operated tube. Of 13 fertile patents who had undergone repeat laparoscopy, 7 had normal patency in the operated tube. The 18 patients who could not conceive had bilateral tubal block.
Conclusion: 1) Fertility and tubal patency are not affected much after linear salpingostomy. 2) Laparoscopic linear salpingostomy with or without single-dose methotrexate should be the gold standard for those patients with ectopic pregnancies who want to preserve fertility.
7341 General Surgery
The Laparoscopic Management of Acute Small-bowel Obstruction
Wan Sung Kim, MD, Hyoun Jong Moon, MD
Objective: The laparoscopic management of acute small-bowel obstruction has not been favored due to the presumed increased risk of bowel injury. The aim of this study was to evaluate the feasibility of a laparoscopic procedure for the management of patients with acute small-bowel obstruction.
Methods: Sixteen patients underwent laparoscopic procedures for radiologically documented small-bowel obstruction from 2002 to 2007. Bands or local adhesions caused 13 obstructions, 2 patients had a small-bowel mass, and 1 patient have an incarcerated inguinal hernia.
Results: The operation was completed laparoscopically in 12 patients (75%) and with laparoscopic-assisted procedures in 2 (12.5%). Two (12.5%) patients required conversion to open laparotomy because of dense adhesions and possible small-bowel necrosis. Two iatrogenic enterotomies occurred during bowel manipulation. The mean operating time was 105 minutes. Two (12.5%) postoperative procedure-related complications (wound infection, intraabdominal abscess) occurred, and the mean length of hospital stay was 8.1 days. At median follow-up of 34 months, 13 of 14 patients managed laparoscopically or with laparoscopic-assisted procedures remain asymptomatic, and one patient had intermittent abdominal pain.
Conclusion: Laparoscopic treatment of small-bowel obstruction is effective and has good long-term results. The laparoscopic management of small-bowel obstruction should be considered in appropriately selected patients.
16TH SLS ANNUAL MEETING AND ENDO EXPO 2007 GENERAL SESSIONS
BEST OF LAPAROSCOPY UPDATES
7:30am Thursday, September 6, 2007
UPDATE UROLOGY
The Winners and Losers: Urologic Update in Minimally Invasive Surgery 2007
Howard Winfield, MD
Urology has always been at the forefront of the remarkable changes and advancements that have occurred in minimally invasive surgery. Almost all types of abdominal and pelvic urologic surgical procedures have been attempted laparoscopically and/or robotically over the last 15 years. Some have proven to be “true winners” demonstrating marked advantages for the patients in comparison to the more traditional open surgical approach. Naturally some laparoscopic procedures have been shown to be of no advantage and in some cases worse than traditional approaches (“the losers”).
The true urologic winners may now be considered the “gold standards”. Such procedures include laparoscopic radical, simple and donor nephrectomy as well as laparoscopic adrenalectomy. Patients undergoing these procedures have a markedly improved postoperative course. The end points of oncologic cure or removal of the diseased organ is equal to open surgery.
Robotically-assisted radical prostatectomy for prostatic carcinoma has gained a huge following over the last 5 years. In fact, it is anticipated that over 50% of the radical prostatectomies performed in 2007 will be done using robotic techniques. To date, comparative data against standard radical retropubic prostatectomy (RRP) would indicate that robotic RRP is as good as the open approach and in some spheres (blood loss, continence, hospitalization and convalescence) may be superior. The oncologic effectiveness of robotic RRP is the same as open RRP.
Procedures such as laparoscopic partial nephrectomy, radical cystectomy and urinary diversion, ureterolysis for retroperitoneal fibrosis, and retroperitoneal lymph node dissection for testis tumor are procedures still in evolution and have not been clearly shown to be far superior to open surgery and would not be considered gold standard. These procedures continue to be improved and ultimately may become procedures of choice.
Laparoscopic varix ligation for treatment of varicoceles and bladder neck suspension for female stress urinary incontinence are procedures that appear to be inferior or more invasive than the more popular approaches of microsurgical varix ligation and transvaginal bladder suspension, respectively.
Pediatric laparoscopic and robotic procedures are still in evolution but do have a minority of very strong proponents.
UPDATE ABDOMINAL AND PELVIC PAIN AND ADHESIONS
Does Adhesion Cause Pain? Should We Perform Adhesioloysis for Treatment of Pelvic Pain?
Maurice K. Chung, MD
Adhesions are bridges of newly formed fibrous tissues connecting to organs that are normally separated. It develops in response to tissue hypoxia and represents a means by which the body can resupply oxygen and new treatments to the injured tissue.
The incidence of adhesions formation following pelvic reconstructive surgery ranges from 55-100%. De Novo adhesions occur as a result of a surgical procedure and Reformed adhesions occur at the same location as previous adhesions that were excised. There were studies that showed the pelvic adhesion formation following laparoscopy ranges from 17-23% or even higher, however Reformed adhesions range from 60-80%. With pelvic laparotomy, the formation of adhesions ranges from 68-82% whereas in laparoscopy it ranges from 66-87%. Laparoscopy is the gold standard for diagnosing pelvic adhesive disease; however, the presence of adhesions is not a reliable prediction of pelvic pain. It has not been possible to demonstrate a relationship between duration and severity of pain and extent or location of adhesions.
Clinical consequences of adhesions include infertility, chronic pelvic pain, small bowel obstruction, intraoperative complications that subsequently lead to subsequent surgeries. There were pain mapping laparoscopy studies clearly shows that the relationship of the adhesions to the peritoneum when the adhesions are mobile there is more pain; when the adhesions are fixed there is no pain. At least 35% of the pain in the study group was referred pain.
The most common cause of small bowel obstruction is post operative adhesions. Bowel obstruction can occur many years after the initial surgery and 20% of small bowel obstructions require surgical correction and the mortality rate was up to 10%. It is frequently underestimated by gynecologists since patients are often re-admitted to general surgeon services. The treatment of pelvic adhesions is controversial. The best treatment is prevention. Treatment may cause additional adhesions. Currently, there are no randomized controlled trials of laparoscopic treatment of adhesions associated with pelvic pain and the relationship of adhesions and chronic pelvic pain is still controversial. Pelvic adhesions are present in about 15-45% of patients with chronic pelvic pain; however, it may or may not be the cause of chronic pelvic pain.
Adhesiolysis decreases pain or is beneficial in a large percentage of patients; however, many patients have a recurrence of pain or increased pain over time. Laparoscopic adhesiolysis for chronic abdominal pelvic pain was successful in about 45% of patients. Pain from adhesiolysis in general recurs anywhere from 2 months following the time of surgery.
A recent study at the Midwest Regional Center for Chronic Pelvic Pain with 105 patients with previous abdominal surgeries, 52 patients had adhesions (50%) on second look, 27 patients had pain (52%), however, 20 out of the 27 patients had a positive potassium sensitivity test (74%), and 2 patients had a positive cystoscopy/hydrodistention (7.4%) which indicated painful bladder syndrome. When these patients were treated for IC/PBS prior to second laparoscopy the pain subsided or decreased by at least 50%.
*References will be furnished upon request.
BEST OF LAPAROSCOPY UPDATES
Afternoon, Thursday, September 6, 2007
1:45-2:00pm Seacliff C
UPDATE HYSTERECTOMY
The Role of Laparoscopy and Robotics in Hysterectomy
Ceana Nezhat, MD
Despite general preference for minimally invasive procedures, 2 out of 3 hysterectomies are performed abdominally. However there has been a gradual increase in the number of laparoscopic and laparoscopic assisted vaginal hysterectomies (LAVH) over the past 2 decades. The overall rate of hysterectomies has remained stable while the number of LAVH has more than doubled. Additionally, more complicated hysterectomy procedures, such as advanced procedures in patients with malignancy and hysterectomies via robotics, are being explored laparoscopically. New and improved instrumentation is emerging which will further decrease OR time, reduce morbidity and patient recovery time, and advance minimally invasive hysterectomies.
Advances in vessel sealing devices are evolving with progress in radio frequency (RF) technology. This allows for quick sealing of the uterine vessel and ligaments with very little concomitant tissue damage or charring. Recent studies have shown that this new technology is greatly decreasing OR time, blood loss, and recovery time thereby giving patients a fresh alternative for abdominal hysterectomy. Another area of advancement is robotic surgery. While laparoscopy has long been the preferred surgical method over laparotomy, robotics gives the surgeon even greater advances. Some of the key differences in robotic surgery over laparoscopy include improved physical comfort for the surgeon, better visualization with 3 dimensional images and magnification, and instrumentation that corrects for hand tremor and allows for better access. Drawbacks include high cost of the equipment, lack of tactile feedback for the surgeon, and increased prep time and training for the staff.
Afternoon, Thursday, September 6, 2007
2:00-2:15pm Seacliff C
UPDATE ENDOMETRIOSIS/OVARIAN
Endometriosis and Ovarian Cancer, Is There Any Correlation?
Farr Nezhat, MD
SPECIAL EVENT
8:00am, Thursday, September 6, 2007
KEYNOTE SPEAKER
The Responsibility of the Surgeon in the
New Health Care System
Thomas Russell, MD
Executive Director of the American College of Surgeons
The American Health Care System is under great scrutiny at this point, and obviously will be a pivotal issue in the presidential 2008 election. The issues that are significantly pushing the current system revolve around inconsistent quality, excessive costs and problems with access to care. This is further compounded by the uninsured, and there are significant issues with respect to a pending workforce shortage. The large databases that the insurers and the government have in other organizations, such as the Dartmouth Atlas, continue to point out the inequities in our system with respect to the value and variability of care. These databases are factually pointing out to us some of these important difficulties. Thus, the sovereign and autonomous medical profession of the 20th Century is going to be significantly different, and with a multitude of stakeholders having a significant interest. Many have pointed out that one of the significant problems with our current system is that we have not aligned the competitive appropriately around outcomes and what is valuable for the patient.
Thus, the surgeon of the future is going to have to be acutely aware of the value that they are offering to patients, and will have to be much attuned to their own outcomes and quality reporting. We are going into an era of the electronic medical record, and there will be significant changes with respect to the reporting of outcomes and cost in a much more transparent fashion. Furthermore, new technology will drive all of this out of our specialty silos, and will make us look more at the best ways of taking care of patients in a more organized and mature system of care.
The American College of Surgeons is diligently working on efforts to improve surgical care around issues of structure, process of care and outcomes. To that end, the National Surgical Quality Improvement Program is a major initiative at the College to help surgeons in hospitals truly measure the value of their care.
The surgeon of the future and surgery of the future will be redefined in ways that were unimaginable in the past. Surgeons will have to be very adept and have abilities to image disease processes throughout the body, and be able to manipulate those disease tissues in different ways.
Thus, because of these changes the surgeon will really need to participate in quality indicators, make certain there is true value in all of this to avoid waste, and be adept in transforming electronic medical records. These are all exciting changes and things that should be embraced by the surgical profession.
MULTIDISCIPLINARY PLENARY SESSION
8:30am, Thursday, September 6, 2007
IMPROVING PRACTICE PERFORMANCE AND QUALITY
Safety, Quality and Improving Operating Room Performance
Gustavo Stringel, MD
Surgical errors have been defined as pathologic processes that affect patients after a surgical procedure. They may not be related to the disease for which the surgery was done. Surgical errors have been reported more frequently over the last few years. This could be directly related to the increase in the number and complexity of surgical procedures performed in combination with public awareness about this problem. More than 50% of surgical errors can be avoided. National estimates of wrong site surgery range from one in 10,000 surgical procedures to one in 113,000.
Healthcare organizations have implemented systems to prevent surgical errors; simple measures such as taking “time-out” or marking the surgical site before the operation can be effective. It is important for hospitals to create a culture of safety that extends across the entire organization.
Surgical services contribute significantly to hospital revenues, accounting for over 50% of a hospital’s margin. It is essential for hospitals to provide support for surgical services in order to remain profitable. Performance improvement systems play an important role in obtaining and analyzing data necessary to improve areas of poor or deficient performance. The main areas of interest are: the preoperative process, the surgical procedure itself, the recovery room, the hospital stay, and the equipment and materials utilized. The complexity of the perioperative process and the personnel involved can create a variety of hurdles and delays in the operating room. The surgeon needs to be an integral part of the decision making process. Involvement and cooperation by the surgeon is essential to improve perioperative performance.
Pay for Performance and Transparency
Alex Gandsas, MD
Financial Aspects of Surgical Care. Past, Present and Future
Raymond J. Lanzafame, MD, MBA
MULTIDISCIPLINARY PLENARY SESSION
10:00am, Thursday, September 6, 2007
HOW TO BRING A NEW SURGICAL IDEA TO THE BEDSIDE
Bringing Your Surgical Idea to Reality
What Gets in the Way?
Thomas J. Fogarty, MD
Invention to Commericialization… and Beyond
Mike Henson
Michael R. Henson has founded 16 medical device companies. Six have been sold to larger medical technology players; seven have reached the initial public offering stage. The remainder are still private. While the advice from experts in every start-up was that all of them would fail for various reasons, thus far, none have failed.
Nearly all of these companies have been founded with an active physician who is intellectually, financially and emotionally committed to the success of the project. The MedFocus Fund, started by Henson, assumes the financial and administrative roles of each start-up firm. By relieving the companies of the average day-to-day activities, such as: facilities, cash flow, and health care management; the individuals of the companies are then able to concentrate solely on the accelerated development of the fundamental technology – critical to the success of the project.
Success at this level of early-stage start-up is based on intensity –intense focus on the technology and intellectual property, intense focus on cash flow management and intense focus on strategy (i.e., partnering, exit and organizational and technology versatility).
Clinically Driven Entrepreneurships:
Bench to Bedside…to Bucks
John Savarese, MD
Innovation in the life sciences industry comes from a variety of sources. The role of the clinician inventor has deep historical roots. Today, the confluence of capital, industry management, and intellectual property resources available to support clinician-driven innovation creates ever increasing opportunity for physicians interested in roles in industry. Because clinicians sit in a privileged position between patient and procedural needs and product requirements, they often are ideally suited for significant roles in therapeutic innovation. However, ideas are not enough. To succeed in bringing an idea to market reality requires navigation through complex technical, management, financial, and regulatory paths. This discussion will touch upon these topics and will include profiles of several such examples where clinician-driven innovation successfully navigated from bench to bedside…and beyond.
MULTIDISCIPLINARY PLENARY SESSION
11:00am, Thursday, September 6, 2007
NEW DIRECTIONS IN SIMULATION TRAINING AND CREDENTIALING
The ACS Accredited Educational Institutes—
The Beginning of the Revolution of Certification of Training Centers
Ajit Sachdeva, MD
The Division of Education of the American College of Surgeons (ACS) has undertaken a number of innovative initiatives to support surgeons’ efforts to acquire skills in new procedures and emerging technologies and has supported advances in surgical skills education for residents. The use of simulation has remained an area of major focus. Verification of knowledge and skills following completion of experiential courses has been pursued and a consortium of ACS-accredited Education Institutes has been established. Eighteen institutes have been accredited at the comprehensive Level I following stringent review and additional institutions will continue to be accredited. These ACS-accredited institutes will be key to ACS’ efforts to offer contemporary simulation-based surgical education at regional sites. The institutes will comprehensively address the learning needs of practicing surgeons, surgical residents, and members of the surgical team. This presentation will provide information on the underpinnings and key features of these new ACS initiatives
Applying for Certification—Do’s and Don’ts
Mike Sinanan, MD
The Consortium of ACS Accredited Educational Institutes—One Solution to Standardization
Richard M. Satava, MD
Surgical Education is now in a revolutionary new phase for teaching technical skills-criterion-based training. The science of modeling & simulation has been accepted by the surgical education community as a validated methodology and is now beginning to enter into the mainstream of residency training programs. In order to insure that this new methodology for training is of the highest caliber, the American College of Surgeons has developed a voluntary program of certification - the ACS Accredited Educational Institutes (AEI).
The newly certified ACS AEI held their first meeting to establish the Consortium of ACS Accredited Educational Institutes. The overall goal is to take advantage of this historic moment in surgical educational history, when all program directors are trying to begin a new training component to their programs, and provide nation-wide curriculum, assessment and outcomes tools to assist in enhancing their training programs and meeting the newly mandated requirements for skills training by the Residency Review Committee. By convening the ACS AEI, the consortium will be adopting numerous curricula (which are being developed by the ACGME, RRC, ASPD and others) which will be shared among consortium members. As the number of AEI increases, it will result in a single (standardized?) curriculum base which may become one means of establishing a national standardized training, assessment and certification process.
MULTIDISCIPLINARY PLENARY SESSION
7:30am, Friday, September 7, 2007
NEXT GENERATION NEW TECHNOLOGIES FOR THE LAPAROENDOSCOPIC SURGEON
Recent Advances in Robotic Telesurgery
Timothy J. Broderick, MD
The convergence of computers, telecommunications, robotics, and surgery continues to improve the care of patients. The digital evolution of surgery is particularly promising with regards to simulation and telesurgery. Over the past several years, we have collaborated with government, industrial, and academic partners to improve surgical care in remote and extreme places. Initially, our team focused on simulation and telementoring surgeons at distant sites. Recently, we have explored telerobotic surgery using: the da Vinci Classic over the Internet, the University of Washington Raven robot in the California desert over a wireless link provided by an unmanned airborne vehicle; and the UW Raven and SRI International M7 robots in the Aquarius undersea habitat over a wireless microwave link. Ongoing research includes robotic telesurgery in microgravity and far forward semi-autonomous telerobotic combat casualty care within the Defense Advanced Research Projects Agency (DARPA) Trauma Pod program. In our collaborative research, surgeons have operated at communication latencies or lag times of over 2 seconds, which suggests a terrestrial surgeon could help treat a sick astronaut on the Moon. To overcome communication issues such as latency, the telemanipulation systems also have started to perform simple tasks and truly function as “robots”. Our research suggests that telesurgery can deliver expert surgical care at a distance, but routine clinical use will occur only after the business opportunities are clearly defined.
Ablative Technology
Jaime Landman, MD
Minimally invasive surgical techniques and technologies have positively impacted clinical care in every surgical discipline. The introduction of advanced laparoscopic and endoscopic procedures has allowed even the most complex disease to be treated with less patient discomfort and an expedited convalescence. Despite the incredible impact of minimally invasive surgery, the majority of changes remain evolutionary; modifications of existing techniques usually with novel access approaches.
The application of ablative technologies, however, is truly revolutionary. The substitution of ablation for extirpation is a major change in surgical thinking that has started to penetrate clinical practice worldwide. Advances in both ablative modalities and in associated imaging technologies have engendered a movement away from extirpation in many clinical settings, and ablative technologies have been applied for both benign and malignant disease.
While clearly an important part of the future of surgical medicine, the introduction and transition to ablation has resulted in substantial controversy. Patient selection issues, long-term oncologic control, which ablation modality to apply, and even which surgeon (or interventionalist) should perform each procedure all remain in question. The current presentation will review the state-of-the-art of ablation and ablative technologies, and will attempt to put clinical ablation into perspective for the practicing surgeon.
Gynecology Technology
Farr Nezhat, MD
General Surgery Technology
Dmitry Oleynikov, MD
Next generation laparoscopic surgeons won’t be laparoscopic surgeons at all. They will be natural orifice surgeons using robotic tools in order to create incisionless operations. The technology promises to revolutionize how we perform surgical procedures over the next ten to twenty years. More and more procedures are going to be done through endoscopic means with the help of robotic tools. The endoscopic environment is far more challenging than the laparoscopic environment and requires additional mechanical augmentation in order to perform complex surgeries. These will include robots capable of operating by themselves in order to create better lighting, better camera stabilization and allow the surgeon to perform natural orifice operations. Laparoscopy with also be utilized but with far fewer incisions and far smaller incisions. One incision will be created through which multiple instruments will be placed simultaneously in order that a combined laparoscopic and natural orifice procedure can be done with almost no pain and much quicker recovery. These technologies are not on the drawing board but are already in prototype and being used currently.
FUTURE TECHNOLOGY SESSION
8:00am, Saturday, September 8, 2007
THE EDGE OF INNOVATION IN SURGERY, SPACE AND BUSINESS
Keynote Address: Designed to Adapt—the New Competitive Advantage in Healthcare
John Kenagy, MD, MBA
Great new technologies promise wonderful improvements in patient care. But improving patient care means something will be different than before, i.e., patient care will change. Effecting change in established organizations, even in places with dynamic and powerful leaders, is a lot harder than most people realize.
Our and many others’ research and experience have documented abundant evidence, from both outside and inside healthcare, that:
1. Future competitive success is not dependent on what you do now, but rather on how you adapt what you do to constantly changing needs (Adaptive Innovation).
2. The established structures and systems of high performing organizations and the habits, behaviors and values of people embedded within them almost always slow, stall and eventually stop adaptive change.
3. Organizations culturally and operationally “designed to adapt” have competitive advantage in complex, dynamic environments.
The evidence is clear: to achieve lasting results, you can’t just change “things,” like facilities, product lines, technology or org charts; it means having the capacity to change minds and develop people. We will give the audience the evidence-base for creating competitive advantage based on adaptive capacity. This presentation will focus not so much on “what to do,” but rather on “how to do it;” – developing the organizational DNA “designed to adapt.
Surgery in Space
Timothy J. Broderick, MD
President Bush recently announced a new vision for space exploration that includes manned missions to the Moon and Mars during the next two decades. The exploration focus includes development of autonomous medical capabilities required to maintain astronaut health and safety throughout such missions. As prolonged spaceflight results in physiologic changes that increase an astronaut’s susceptibility to illness and injury, surgery has been designated a key capability required for future planetary exploration.
Prior surgical research, including small animal experiments performed during spaceflight, indicate that surgical care in microgravity is feasible. Ideally, surgery in space incorporates advances in care but remains easy for a crew medical officer (CMO) to perform. Minimally invasive surgery (MIS) could provide operative containment as well as benefit the extraterrestrial patient via less wound complications, less pain and faster recovery than traditional open surgery. Research performed during parabolic flight has demonstrated the feasibility and highlighted the challenges of microgravity MIS. Surgeons apply more force, take longer and make more errors when performing laparoscopy in microgravity. Simulated Hand Assisted Laparoscopy Surgery (HALS) is easier to perform in microgravity than laparoscopy and could facilitate MIS surgery during spaceflight by less proficient CMOs. Human patient simulators have been found to be helpful with regards to microgravity medical training and refinement of microgravity emergency care. Finally, decades of research and billions of dollars have matured aerospace technologies and many of these technologies can be easily adapted for use in surgery. We are exploring technologies such as surgical robots within parabolic flight and undersea within NASA Extreme Environment Mission Operations (NEEMO). Similar to “fly-by-wire” systems, digital “surgery-by-wire” systems will prove valuable in future planetary missions.
Fetal Surgery
Joseph Bruner, MD
Surgery typically evolves from large, morbid, invasive procedures to the use of smaller, less morbid, minimally invasive techniques. The development of maternal-fetal surgery follows the same pattern, with many illustrative examples. One exception to this trend is intrauterine repair of spina bifida. First attempted by means of standard laparoscopic techniques, this approach was abandoned when the limitations of the technology became fully appreciated. Open maternal-fetal surgery through a hysterectomy proved much more successful, and is now the most common procedure performed for the treatment of fetal developmental defects. Recently, new developments have offered the possibility of a return to a minimally invasive approach to intrauterine spina bifida surgery. Experimental repair of a spina bifida-like lesion in fetal lambs was performed using a da Vinci robotic endoscopic operating system. Although engineering and surgical obstacles remain, this natural evolutionary step may reduce the risk of surgery for mother and fetus, making the treatment available to many additional patients.
16TH SLS ANNUAL MEETING AND ENDO EXPO 2007 LAPAROSCOPY UPDATES
Special Interest Group (SIG) Committees
Members of the Society of Laparoendoscopic Surgeons’ (SLS) Special Interest Group (SIG) Committees present Laparoscopy Updates at the 16th SLS Annual Meeting and Endo Expo 2007 in San Francisco, California.
These SIG Committees support the educational mission of SLS and by presenting the popular Laparoscopy Updates at the conference, take an important leadership role in preparing physicians for the future.
SIG committees prepare “Patient Information Pages” on topics such as endometriosis, hysterectomy, hernias, laparoscopic cholecystectomy, laparoscopic colon surgery and minimally invasive therapies for kidney and ureteral diseases among others. These pages are posted on the SLS website www.sls.org and offer information to the public accessing the SLS web page for medical information.
The committees “meet” and communicate online via email throughout the year. At the members’ convenience, they have the opportunity to communicate with colleagues from all over the world who share the same professional interests.
Participation on the SIG committees is open to SLS members. If you are interested in joining a committee or would like a copy of the SIG Committee guidelines, please stop by the SLS Exhibit Booth and Cyber Café.
BARIATRICS
GASTROINTESTINAL:
Biliary Disease and Cholecystectomy
Colon
Gastroesophageal Reflux Disease
GYNECOLOGY:
Endometriosis/Ovarian
Fertiloscopy/Transvaginal Endoscopy
Fibroids/Abnormal Uterine Bleeding
Hysterectomy
Infertility/Fertility
MULTIDISCIPLINARY:
Abdominal/Pelvic Pain/Adhesions
Cancer Surgery
Core Competencies
Endocrine/Solid Organ
Ergonomics/Monitoring/Access/Patient Preparation
Fellowship Program
Future Technologies
Hernia
Nurse Technician
Office and Outpatient Laparoscopy
Pelvic Reconstructive Surgery/Stress Incontinence
Robotic Surgery
Ultrasound
Telemedicine, Video and Multimedia Communications
PEDIATRIC SURGERY
UROLOGY
VASCULAR/THORACIC:
Cardiac Surgery
Thoracic
Trauma
Vascular
GASTROESOPHAGEAL REFLUX DISEASE UPDATE
GERD: Endoluminal Therapies
Phillip Shadduck, MD
Gastroesophageal reflux disease is prevalent (20-30% US population), is generally mild, and often responds well to lifestyle modification and medical therapy. Surgical therapy is usually reserved for medical treatment failures (refractory symptoms, intolerable side effects) and complicated GERD (severe esophagitis, esophageal stricture, Barrett’s metaplasia). Even in these patients, laparoscopic fundoplication can be accomplished with minimal morbidity (serious complications <2%) and excellent results (relief of symptoms in 90% of patients, healing of esophagitis, stabilization of Barrett’s, 90% patient satisfaction, and favorable cost profile).
There is a subgroup of GERD patients (perhaps 10-20%) with typical symptoms and a good response to medical therapy, who dislike taking medications, but are either not candidates for or willing to under fundoplication. For this group, endoluminal therapies may have a role. The theoretical mechanism for an endoluminal approach is the reduction of transient LES relaxations by improving the LES yield pressure via “bulking” at the LES/cardia. Endoluminal approaches include: (1) radiofrequency lesions (Stretta); (2) endoluminal suturing (EndoCinch, Plicator, ESD, Syntheon ARD); and bulking (3) Enteryx, Gatekeeper, Plexiglass microspheres). Stretta, Endocinch, and Plicator are FDA approved. Review of available RCT/prospective data for these three therapies reveals: (1) study inclusion criteria are patients with mild disease (typical symptoms, good response to medical therapy); (2) patients with complicated GERD are usually excluded (hiatal hernia 2cm, severe esophagitis, Barrett’s metaplasia); (3) obese patients are usually excluded; (4) primary endpoints are usually subjective (symptom improvement, medication use, HRQL) and less often objective (LES resting pressure, LES length, acid exposure); (5) follow up is usually short (<24mo); (6) the procedures can be accomplished endoscopically, under conscious sedation, in 20-70min, as an outpatient, with return to diet and activity in 1-2 days; (7) major complications are rare (<0.3%); (8) subjective improvement occurs in the majority of patients; and (9) there is little to no change in objective endpoints (LES P, acid exposure).
In summary, endoluminal therapies for GERD are early in their development. Instrumentation and procedural details are evolving. Current results are mild-modest. A commonly performed endoscopic antireflux procedure is likely to emerge.
FERTILOSCOPY/TRANSVAGINAL ENDOSCOPY UPDATE
The Current Status of Transvaginal Hydro-Laparoscopy
Duncan J. Turner, MD
FIBROIDS AND UTERINE BLEEDING UPDATE
Herbert Goldfarb, MD
The current state of minimally invasive techniques to treat myomas and uterine bleeding will be reviewed. Diagnostic techniques include EndoVaginal ultrasound, fluid sonography, diagnostic hysteroscopy and MRI.
Myomectomy techniques will be described: Traditional endometrial ablation versus global techniques Thermachoice, Novasure, cryo ablation hydrothermablation, microwave ablation. Alternative therapies include uterine embolization, myolysis and varients, cryomyolysis, radiofrequency ablation, MRI- guided high frequency ultrasound ablation of myomas, and intravaginal uterine artery occlusion.
INFERTILITY/FERTILITY UPDATE
Grace Janik, MD
ABDOMINAL/PELVIC PAIN/ADHESIONS UPDATE
Robots and Adhesions
Dan Martin, MD
Adhesions are a major problem after surgery. Consequences for patients include small bowel obstruction, chronic pelvic pain, infertility and repeat operations. This presentation covers decreased mobilization and increased control with robotic surgery and the use of adhesion prevention solutions at laparoscopy.
Robotic surgery incorporates an increased use of the basic principles of microsurgery into operative laparoscopy. Although these have been used at laparoscopy in the past, these are facilitated by the increased control of the basics of robotics. Those include the mechanical advantage of the system and the ability to keep the assisting arm steady.
The use of Adept (4% icodextrin) or lactated Ringer’s solution at a volume of 1,000 cc decreases adhesions compared with the previous literature on volumes on up to 300 cc. Adept is a peritoneal dialysis solution modified for use at surgery. Significantly more Adept patients achieved clinical success than lactated Ringer’s solution patients in a study on the web and to be published in November.
These are contrasted with normal saline. Normal saline contains sodium and chloride in equal concentration that do not reflect ratio present in human extracellular fluid. A variety of metabolic and tissue effects are produced by this abnormal ratio. Normal saline may predispose to the formation of peritoneal adhesions and fibrosis of the peritoneum when left in the pelvis. Use of normal saline to wash the peritoneal cavity after chronic peritoneal dialysis appears more likely to produce adhesions than is no irrigation at all.
CANCER SURGERY UPDATE
Comparison of Total Laparoscopic and Abdominal Radical Hysterectomy for Patients with Early-Stage Cervical Cancer
Pedro Ramirez, MD
Operative laparoscopy has long been a mainstay in the treatment of benign gynecologic conditions. Total laparoscopic radical hysterectomy (TLRH) for the treatment of patients with cervical cancer was also first described in the early 1990s. However, unlike in the case of endometrial cancer, only recently have authors begun to publish their experiences with this approach, likely because recent advances in laparoscopic techniques and equipment have made TLRH feasible and safe.
FUTURE TECHNOLOGIES UPDATE
Dmitry Oleynikov, MD
Miniaturization of robotic technology is ongoing in all facets of surgical development whether it is endoluminal surgery, endoscopic procedures or complex laparoscopic surgeries. Miniaturized surgical instruments as well as robotic instruments are paving the way to a new approach to surgical problems. Miniature robots including a cardiac robot as well as a laparoscopic robot as well as urologic robots are being developed around the world to help with complex laparoscopic procedures. These act as the surgeons’ eyes, ears, and hands and allow for greater dexterity inside the peritoneal cavity as well as the chest cavity. It is very interesting to see that we are moving further away from large robotic systems which are costly and bulky to smaller more portable systems whether it is computer aided instrumentation or wireless miniature robots surgery is being changed by new technology.
HERNIA UPDATE
What Have We Learned About Laparoscopic Hernia Repairs?
Lawrence C. Biskin, MD
After approximately 15 years of performing laparoscopic hernia repairs, improvements with techniques and advancements in technology have provided alternative and better approaches to the repair of all types of hernias.
The laparoscopic repair of inguinal hernias in experienced hands has proven to be better than the open repair with regard to post-operative pain, recurrences, and overall recovery. Although there is a monetary loss to the surgeon, the ability to repair concomitant umbilical hernias (approx. 15%), and contra lateral inguinal hernias (approx. 25%) is a tremendous advantage to the patient by adding only a few minutes to the operative procedure without a significant increase in recovery time.
Although the TEP repair is a quicker and ultimately better operation (peritoneum not violated) the TAPP approach provides better recognition of the posterior anatomy allowing a safe and smooth transition to the TEP repair. Familiarity with the TAPP prepares the surgeon for the occasional (2%) conversion from TEP. Recurrent posterior repaired hernias or patients with prior prostate or bladder operations can be repaired by the TAPP technique and should not be attempted with the TEP.
The laparoscopic technique should not be utilized only for bilateral and recurrent hernias since they are more difficult repairs and account for a small percentage of the hernia operations performed on average by a surgeon. It has been well documented that the complication and recurrence rate is much higher with surgeons who do only the occasional laparoscopic herniaplasty.
Sports/stress hernias ("athletic pubalgia") can be approached laparoscopically and allow close inspection of the myopectineal orifice and other areas. Hernias and cord lipomas that were not appreciated on clinical evaluation can be identified during the operation. Reinforcement of the posterior pelvic floor with mesh not only repairs the hernias but has also been shown to support injured muscle and tendons, providing a lattice for repair.
Despite claims made by many companies, pore size, thickness, softness, type of weave or component make-up of mesh have not been definitely shown to improve the ultimate recovery or outcome of the repair. Certain types of mesh have proven to be disastrous for many patients and these have been, or will be, withdrawn from the market.
Tissue separating meshes or mesh that has a non-adherent side should help diminish adherons to the mesh allowing safe re-entrance into the pre-peritoneal space after a TAPP/TEP procedure for future urologic or vascular access. This type of mesh should also be routinely utilized for laparoscopic ventral hernia repairs.
The adoption rate for laparoscopic ventral hernioplasties has been much quicker than the TAPP or TEP since it is technically and anatomically similar to the open repair. Adhesiolysis is the most ominous part of the operation and sharp dissection using hemolocks for hemostasis should eliminate occult intestinal burns and unrecognized bowel injuries. The surgeon should have a very low threshold to return to the operating room with any patient demonstrating signs of sepsis. Recurrence after laparoscopic ventral herniaplasties should be minimal when the mesh is overlapping the defect by at least five centimeters and fixation of the mesh is done with trans-abdominal sutures as well as tacks. Pain after laparoscopic inguinal herniaplasty is minimal or non-existent, however pain after laparoscopic ventral hernioplasty can be worse than the pain following open technique. Using and minimizing different types of tacks or anchors, injecting local anesthetics, tying loose transfixation sutures, and inserting pain pumps or epidural catheters have given inconsistent results in reducing post-operative pain. Extended hospital stays and sometimes large amounts of analgesics may be required initially to control patient discomfort.
The benefits of a lower recurrence and wound complication rate along with the ability to identify and repair multiple abdominal wall defects, including difficult parastomal hernias, will eventually make their operation the standard of care. As the demand for these advanced procedures increases, the number of surgical hernia specialists will continue to evolve.
ROBOTIC SURGERY UPDATE
Robotic Surgery: Coming to a Hospital Near YOU Soon!
James F. Carter, MD
With the rapid increase in more and more simulation labs and the validation of improved resident and Attending skills in the actual, operating room, the next logical step was the addition of Robotic Laparoscopic Surgery. It is able to overcome the failure of the standard laparoscopic instruments in surgical suturing, human fatigue and increase tactile feedback. We are just scratching the surface of Robotics, but already it has revolutionized Urology and we expect it to do the same with Gynecology.
UROLOGY UPDATE
Update on Laparoscopic Urologic Surgery
Thomas H.S. Hsu, MD
Providing decreased patient morbidity and convalescence, laparoscopy has revolutionized the field of urology since its introduction in the 1990s. Recently, the introduction of robotics has further enhanced the dissemination of laparoscopy in urology, especially in the area of radical prostatectomy.
Laparoscopy, with and without robot, has been successfully applied to practically all major intra-abdominal urologic structures including the kidney, ureter, bladder, and prostate, with excellent clinical outcomes in both adult and pediatric patient populations. Laparoscopy has now replaced a significant portion of conventional open urologic surgery.
A review of the current status of various urologic laparoscopic procedures including radical nephrectomy, partial nephrectomy, pyeloplasty, and radical prostatectomy will be provided. Application of robotics to urologic laparoscopy will also be included in the presentation.
16TH SLS ANNUAL MEETING AND ENDO EXPO 2007
SCIENTIFIC AWARD WINNERS AND HONORABLE MENTIONS
Award for Best General Surgery Scientific Paper
Morris E. Franklin, Jr., MD
Laparoscopic-Assisted Colonoscopic Polypectomy. Long Term Results
Award for Honorable Mention General Surgery Scientific Paper
Raymond J. Lanzafame, MD, MBA
Development of a Novel Method for Mesh Fixation During Laparoscopic Herniorraphy Using Laser-Assisted Tissue Soldering in a Porcine Model
Award for Honorable Mention General Surgery Scientific Paper
Yue Dong Wang, MD
Laparoscopic Splenectomy and Azygoportal Disconnection for Bleeding Varices with Hypersplensm
Award for Honorable Mention General Surgery Scientific Paper
Munir A. Rathore, FRCS
Metanalysis of Recurrence After Laparoscopic Repair of Paraesophageal Hernia
Award for Honorable Mention General Surgery Scientific Paper
Fernando Agresta, MD
The Laparoscopic Approach in Abdominal Emergencies: A Single-Center Review of a 15-Year Experience
Award for Best General Surgery Video
Alejandro Gandsas, MD
Anastomotic Leak Following Laparoscopic Gastric Bypass
Award for Honorable Mention General Surgery Video
Andrew Allen Wheeler, MD
Laparoscopic Omental Repair of Perforated Marginal Ulcer Following Laparoscopic Roux-en-Y Gastric Bypass
Award for Honorable Mention General Surgery Video
Victor Joseph Hassid, MD
Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery Syndrome
Award for Best Gynecology Scientific Paper
Jagdip T. Shah, MD
Linear Salpingostomy for Ectopic Pregnancy – Effect on Fertility
Award for Best Gynecology Scientific Paper
Anne-Sophie Bats, MD
Staging of Advanced Ovarian Cancers: Interest of Thoracoscopy
Award for Honorable Mention Gynecology Scientific Paper
Stefanos Chandakas, MD, PhD
Day Surgery Laparoscopic Subtotal Hysterectomy: A Multicentered Study with 500 Patients in Greece and the UK
Award for Honorable Mention Gynecology Scientific Paper
Piotr Laudanski, MD, PhD
Tumor Suppressors and Oncogenes Selected Expression Profiling of Endometrium of Women with Endometriosis
Award for Honorable Mention Gynecology Scientific Paper
Anne-Sophie Bats, MD
Diagnostic Performance of Office Hysteroscopy to Detect Endometrial Pathologies in Women with Hereditary Predisposition to HNPCC Syndrome: Results of a Prospective Study
Award for Honorable Mention Gynecology Scientific Paper
Anne-Sophie Bats, MD
Comparison of Different Approaches in Surgical Management of Endometrial Cancer
Award for Honorable Mention Gynecology Scientific Paper
Farr R. Nezhat, MD
Laparoscopic Ingtraperitoneal Paraaortic Lymphadenectomy: Our Experience in a Fellowship Training Program
Award for Best Gynecology Video
Farr Nezhat, MD
Laparoscopic Debulking of a Left Pelvic Sidewall Mass in a Patient with Recurrent Ovarian Cancer
Award for Honorable Mention Gynecology Video
Camran Nezhat, MD
Incisional Hernia on the Trocar Port Site After Laparoscopy, Prevention, Recognition and Management
Award for Honorable Mention Gynecology Video
Jonathan Y. Song, MD
Laparoscopic Hysterectomy for the Enlarged Uterus
Award for Best Urology Scientific Paper
Jose Benito Aguila Abraham, MD
Comparative Review of Laparoscopic and Robotic-Assisted Radical Cystectomy with Ileal Conduit Urinary Diversion
Award for Honorable Mention Urology Scientific Paper
Chandru Sundaram, MD
An Innovative Medical Student Clinical Clerkship in Advanced Urologic Laparoscopy: A Preliminary Experience
Award for Honorable Mention Urology Scientific Paper
Grant Disick, MD
The Impact of Minimally Invasive Technology on Localized Prostate Cancer Practice Patterns at a Single Institution: Robotic-Assisted Radical Prostatectomy vs. Radiation Therapy vs. Cryosurgery
Award for Best Urology Video
Gerald J. Wang, MD
Prospective Comparison of Perioperative and Early Pathologic Outcomes Between Robotic and Open Radical Cystectomy
Award for Honorable Mention Urology Video
Sijo Joseph Parekattil, MD
Novel Technique for Hemostatic Hydrodissection of the Neurovascular Bundles (HYNEB) During Laparoscopic Radical Prostatectomy: Early Potency and Continence Outcomes
Award for Best MultiSpecialty Scientific Paper
Stefanos Chandakas, MD, PhD
Experimental Studies of Peroral Transgastric Abdominal Surgery: Tubectomy, Hysterectomy. Is it Next Minimal Invasive Approach?
Award for Honorable Mention Multispecialty Scientific Paper and Honorable Mention Paper by a Resident
Geoffrey N. Box, MD
Evaluation of Laparoscopic Vascular Clamps Using a Load-Cell Device: Are All Clamps the Same?
Award for Honorable Mention Multispecialty Scientific Paper
Rene Charles, MD
A Novel Pneumoperitoneum Creation Assist Device
Award for Honorable Mention Multispecialty Scientific Paper
Geoffrey N. Box, MD
In Vivo Lymphatic Sealing Capability in the Porcine Thoracic Duct Comparing LigaSure V, Gyrus Trissector, Harmonic ACE Scalpel, EnSeal, and Monopolar Scissors
Award for Best Pediatric Surgery Scientific Paper
Andre Hebra, MD
Robotic Swenson Pull-through for Hirschsprung’s Disease in Infants
Award for Best Pediatric Surgery Scientific Paper and Best Scientific Paper by a Resident
Sohail R. Shah, MD
Minimally Invasive Repair of Congenital Diaphragmatic Hernias: A Review of Our Experience
Award for Honorable Mention Scientific Paper by a Resident
Usman Jaffer, MD
Is Laparoscopic Appendicectomy an Appropriate Training Operation? Learning Curve of a Junior Trainee
Award for Honorable Mention Scientific Paper by a Resident
Matthew N. Simmons, MD, PhD
Decreased Complications of Contemporary Laparoscopic Partial Nephrectomy: Use of a Standardized Reporting System
Award for Honorable Mention Scientific Paper by a Resident
Genoa G. Ferguson, MD
Results of Laparoscopic Radical Prostatectomy (LRP)
16TH SLS ANNUAL MEETING AND ENDO EXPO 2007 SCHOLARSHIP RECIPIENTS
The Society of Laparoendoscopic Surgeons recognizes the following Residents, Fellows-in-Training, Nurses, and Affiliated Medical Personnel who are recipients of an SLS Scholarship for the 16th SLS Annual Meeting and Endo Expo 2007.
Erika Benabe, MD
San Juan City Hospital
San Juan, Puerto Ri
James Bittner, MD
Medical College of Georgia Medical Center
Augusta, Georgia, USA
Stefanos Chandakas, MD
Athens, GREECE
Grant Disick, MD
Hackensack University Medical Center
New York, New York, USA
A. Khaliq Eltom, MD
Zayed Military Hospital
Al Ain, UNITED ARAB EMIRATES
Carl Gjertson, MD
Indiana University Medical School
Indianapolis, Indiana, USA
Andrew Gumbs, MD
Institut Mutualistte Montsouris
Paris, FRANCE
Sedigheh Haddadianpour, MD
Geisinger Medical Center
Danville, Pennsylvania, USA
Usman Jaffer, MD
Norfolk & Norwich University Hospital
Peterborough, UNITED KINGDOM
Anna Jang, MD
University of Pennsylvania Health Systems
Philadelphia, Pennsylvania, USA
Mark Keldahl, MD
Loyola University Medical Center
Chicago, Illinois, USA
Denise Klinkner, MD
Medical College of Wisconsin
Greenfield, Wisconsin, USA
Caroline Laroche, MD
University of Montreal
Montreal, CANADA
Deni Malave, MD
San Juan Hospital
Bayamon, Puerto Rico, USA
Jennifer Marti, MD
New York University School of Medicine
New York, New York, USA
Richard Matern, MD
Tulane University
New Orleans, Louisiana, USA
Joe Miller, MD
SIU School of Medicine
Springfield, Illinois, USA
Angel Morales, MD
TX Tech Univ Health Sciences Center/El Paso
El Paso, Texas, USA
Francesco Palazzo, MD
Thomas Jefferson University
Philadelphia, Pennsylvania, USA
Jay Raman, MD
Cornell Medical College
Dallas, Texas, USA
Tammy Shim, MD
Washington University
St. Louis, Missouri, USA
Matthew Simmons, MD
Cleveland Clinic
Cleveland, Ohio, USA
Peter Steinberg, MD
Ohio Medical Center
Lebanon, New Hampshire, USA
Chandru Sundaram, MD
Indiana School of Medicine
Indianapolis, Indiana, USA
Nicholas Tarola, MD
Thomas Jefferson University
Philadelphia, Pennsylvania, USA
Gerald Wang, MD
NY Presbyterian Hosp/Weill Med College of Cornell Univ
New York, New York, USA
Emily Webb, MD
Univ of KS School of Medicine
Newton, Kansas, USA
Scholarships awarded at the time of print.
16TH SLS ANNUAL MEETING AND ENDO EXPO 2007 FACULTY INDEX
KEY
l Nothing to disclose
u Disclosed
n Disclosure not received as of print
s VIP Moderator
Jose Benito Aguila Abraham MD
101 The City Drive South
Bldg 55 Rm 112A
Orange CA 92868 USA
Tel: (714) 456-6481
E-Mail: jbabraha@uci.edu
l
Ferdinando Agresta MD
Via Borgo Coilsola n.1
Fregona (TV) 31010 ITALY
Tel: 393284180898
Fax: +39.0438.665511
E-Mail: fagresta@libero.it
sl
Ghiath A. Alshkaki MD
4294 Pineapple Henry Way
Fairfax VA 22033 USA
Tel: (703) 419-8011
Fax: (703) 865-6166
E-Mail: galshkaki@hotmail.com
su Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Consultant: Ethicon Endosurgery,USSC
Gerald L. Andriole MD
WA Univ School Of Medicine
4960 Children's Place, Campus Box 8242
St Louis MO 63110 USA
Fax: (314) 361-2203
E-Mail: andrioleg@wustl.edu
s
Yonghae Baik Prof Dr Med
ILsandonggu
Goyang Kynggi 410-773 KOREA
Tel: 081 031-961-7264
E-Mail: whitedrag@duih.org
u Discussion of commercial products or services
Garth H. Ballantyne MD
Minimally Invasive Institute
20 Prospect Ave, Suite 901
Hackensack NJ 07601 USA
Tel: (201) 996-2959
Fax: (201) 996-3222
E-Mail: ghb@lapsurgery.com
n
Anne-Sophie Bats MD
20, rue Leblanc
Paris 75015 FRANCE
Tel: 156093586
E-Mail: anne-sophie.bats@egp.aphp.fr
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Joel Bauer MD
25 East 69th Street
New York NY 10021 USA
Tel: (212) 517-8600
Fax: (212) 535-3717
E-Mail: joel.bauer@mssm.edu
s
Robert Bell MD MA
Yale University School of Medicine
40 Temple Street, Suite 7B
New Haven CT 06510 USA
Tel: (203) 764-9066
Fax: (203) 764-9066
E-Mail: robert.bell@yale.edu
s
Charles Bellows MD
2218 Shore Creek Drive
Pearland TX 77584 USA
Fax: (713) 794-7352
E-Mail: cbellows@bcm.tmc.edu
s
Sam B. Bhayani MD
660 S. Euclid Avenue
Box 8242
St Louis MO 63110 USA
Tel: (314) 362-2612
Fax: (314) 454-5244
E-Mail: bhayani@wustl.edu
u Grant Research: MSI
Lawrence C. Biskin MD
100 Delafield Rd.
Suite 213
Pittsburgh PA 15215 USA
Tel: (412) 784-5100
Fax: (412) 784-5102
E-Mail: lbiskin@yahoo.com
u Discussion of commercial products or services
Speaker’s Bureau: Ethicon, US Surgical
James G. Bittner IV MD
Medical College of Georgia, Department of Surgery
1120 15th Street
Augusta GA 30912 USA
Tel: (706) 721-1078
E-Mail: jbittner@mcg.edu
l
David Michael Boruta MD
1621 East Cumberland Blvd.
Whitefish Bay WI 53211 USA
Tel: (414) 906-1701
E-Mail: dboruta@columbia-stmarys.org
l
Sanne MBI Botden MSc
Dep. of Surgery, Michelangelolaan 2
Eindhoven Noord-Brabant 5623EJ THE NETHERLANDS
Tel: 31642396621
Fax: 31402455035
E-Mail: S.Botden@student.unimaas.nl
u Discussion of commercial products or services
Grant Research: Scientific Fund Catharina Hospital
Geoffrey N. Box MD
UC, Irvine Medical Center, Department of Urology
101 The City Drive, Building 55, Rm 360
Orange CA 92868 USA
Tel: (714) 456-3431
Fax: (714) 456-5062
E-Mail: gbox@uci.edu
u Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant Research: Valleylab, SurgRx, and Gyrus/ACMI
Other Support: Karl Storz
Tanner Boyd MS
7703 Floyd Curl Drive
UTHSCSA, Dept of Surgery
San Antonio TX 78229 USA
Tel: (210) 567-5730
Fax: (210) 567-5797
E-Mail: bingenercas@uthscsa.edu
u Grant Research: US Surgical
Andrew I. Brill MD
3700 California St
CPMC, CASOG, #G330
San Francisco CA 94118
Tel: (415) 600-1941
E-Mail: brilla@sutterhealth.org
u Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Consultant: Gynecare, Storz, Gyrus, Smith and Nephew
Speaker’s Bureau: Gynecare, Ethicon, Conceptus
Timothy J. Broderick MD
231 Albert Sabin Way, Suite 1466
Cincinnati OH 45267-0558
Tel: (513) 558-8670
Fax: (513) 558-3788
E-Mail: timothy.broderick@uc.edu
u Discussion of commercial products or services
Grant Research: US Army TATRC
Consultant: General Dynamics Robotic Systems
Michael Brodman MD
Main Street Women's Health
9th Floor Box 1170
New York NY 10029 USA
E-Mail: michael.brodman@mssm.edu
s
James A. Brown MD
1120 15th Street, BA-8408
Augusta GA 30912 USA
Tel: (706) 721-0984
Fax: (706) 721-2548
E-Mail: jimbrown@mcg.edu
l
Joseph P. Bruner MD
645 Cheowa Circle
Knoxville TN 37919 USA
Tel: (865) 541-2020
Fax: (865) 541-2019
E-Mail: jbruner@covhlth.com
u Discussion of commercial products or services
Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational
Amy M. Bruton MD
3213 Peninsula Drive
Jamestown NC 27282 USA
Fax: (336) 882-6700
E-Mail: ambruton@triad.rr.com
s
Viorel Bucuras MD PhD
10 Dr. I. Bulbuca Blvd.
Timisoara Timis 300376 ROMANIA
Tel: 40256306115
Fax: 40256306116
E-Mail: vbucuras@yahoo.com
sl
Miguel Burch MD
Boston University
88 E. Newton St, D501c
Boston MA 02118 USA
Tel: (617) 414-8052
Fax: (617) 414-8053
E-Mail: miguel.burch@bmc.org
s
Kerrey B. Buser MD
1101 Buffalo Bend
Lexington NE 68850 USA
Tel: (308) 324-5660
E-Mail: kerreyb@hotmail.com
l
Arnold Byer MD
Hackensack Univ. Med. Ctr, Dept of Surgery
30 Prospect Ave, Room 2651
Hackensack NJ 07601 USA
Tel: (201) 996-2626
Fax: (201) 996-2021
E-Mail: abyer@humed.com
l
James F. Carter MD
171 Ashley Avenue, Med. Univ of SC
Dept of OB/GYN, Suite 635
Charleston SC 29425 USA
Tel: (843) 792-4500
Fax: (843) 792-0533
E-Mail: carterja@musc.edu
u Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant Research: Ethicon, Storz
Consultant: Ethicon, Boston Scientific
Speaker’s Bureau: Boston Scientific
Jeremy M. Carver MD
2315 N. Lake Dr. Ste. 501
Reproductive Specialty Center
Milwaukee WI 53211 USA
Tel: (414) 289-9668
Fax: (414) 289-0947
E-Mail: jcarver@reproductivecenter.com
l
Stefanos Chandakas MD PhD
4 Papadiamanti Str
Paleo Pshiko
Athens 15452 GREECE
Tel: 306974442000
Fax: 302106770176
E-Mail: stefhand@hol.gr
sl
Rene Charles MD
c/o Peter Edelstein, MD
1810 Embarcadero Rd, Suite B
Palo Alto CA 94303 USA
Tel: (650) 543-3123
Fax: (650) 813-1857
E-Mail: ccunningham@aragonsurgical.com
u Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant Research: VereSure, Inc.
Consultant: Aragon Surgical, Inc.
Stock Shareholder: Aragon Surgical, Inc.
Angela Chaudhari MD
30 North 1900 East, 2B200
Salt Lake City UT 84132 USA
Fax: (801) 585-5146
E-Mail: chaudhari5@yahoo.com
s
Emmanuella Cherisme MD
401 Merchant Street
Cherry Hill NJ USA
Fax: (856) 356-2122
E-Mail: cherismemd@yahoo.com
s
Gary W. Chien MD
Kaiser Permanente
9449 Imperial Highway D231
Downey CA 90242 USA
Tel: (562) 657-4545
Fax: (562) 657-2114
E-Mail: gary.w.chien@kp.org
s
Thomas Y. Chua MD
5707 Foxley Ct.
Greendale WI 53129 USA
Tel: (414) 281-9665
Fax: (414) 281-9674
E-Mail: packerchua@aol.com
u Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant Research: Medtronic
Consultant: Inamed (Allergan)- Certified Proctor for Lap-Band
Maurice K. Chung MD RPh
310 South Cable Road
Lima Ohio 45805 USA
Tel: (419) 228-1000
Fax: (419) 227-3085
E-Mail: Endosurgeon85@aol.com
s Speaker’s Bureau: Ortho McNeil, Norvartis, Astella, Pfizer
Benjamin Clapp MD
1700 N. Oregon
Ste 500
El Paso TX 79902 USA
Tel: (915) 351-6020
E-Mail: b_clapp1@hotmail.com
l
Ralph V. Clayman MD
101 The City Dr.
Bldg. 55, Rte. 81, Room 304
Orange CA 92868 USA
Tel: (714) 456 3330
Fax: (714) 456 5062
E-Mail: rclayman@uci.edu
u Grant Research: Endocare, Cook Urological, Boston Scientific, Astellas Pharma. Inc.
Consultant: Karl Storz, Inc.; Endocare
Stock Shareholder: Applied Medical
Other Support: Royalties: Boston Scientific, OSI, Greenwald Inc., Cook Urological
Steven R. Clendenen MD
4500 San Pablo Road
Jacksonville FL 32224 USA
Tel: (904) 296-5287
Fax: (904) 296-3877
E-Mail: Clendenen.steven@mayo.edu
l
Osvaldo Contarini MD
6320 Wood Valley Rd.
Jacksonville FL 32217 USA
Tel: (904) 737-3150
Fax: (904) 399-1314
E-Mail: fusignano@aol.com
l
Paul G. Curcillo II MD
219 North Broad Street
10th Floor
Philadelphia PA 19031 USA
Tel: (215) 762-5577
Fax: (215) 762-5588
E-Mail: paul.curcillo@drexelmed.edu
u Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational
Consultant: Davol, Ethicon, Novare
Speaker’s Bureau: Davol
Other Support: Expense Reimbursement
M. Shoma Datta MD
1176 Fifth Ave
Klingenstein Pavillion, 9th floor
New York NY 10029 USA
Tel: (718) 216 6319
E-Mail: shoma.datta@mssm.edu
l
Smita De (PhD Candidate)
6401 NE Radford Dr. #412
Seattle WA 98115 USA
Tel: (206) 616-4936
Fax: (206) 221-5264
E-Mail: sd6@u.washington.edu
Grant Research: NIH
Ithaar H. Derweesh MD
Department of Urology
956 Court Avenue, Rm H210
Memphis TN 38163 USA
Tel: (901) 448-1554
Fax: (901) 448-1044
E-Mail: iderweesh@gmail.com
u Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational
Grant Research: Cryolife, Inc.
Consultant: SurgRx, Inc.
Speaker’s Bureau: SurgRx, Inc.
Michael Peter Diamond MD
3750 Woodward Avenue
Suite 200-D
Detroit Michigan 48201 USA
Tel: (313) 993-4523
Fax: (313) 993-4534
E-Mail: mdiamond@med.wayne.edu
u Grant Research: Serono, Meditrina Pharmaceuticals, Jackson Laboratories, Boehringer Ingelheim, Glaxco-Smith-Klein
Consultant: Kytogenics, Genzyme, Omrix
Speaker’s Bureau: Genzyme
Stock Shareholder: Advanced Reproductive Care
Grant Disick MD
360 Essex Street, Suite 403
Department of Urology
Hackensack NJ 07601 USA
Tel: (201) 336-8090
Fax: (201) 336-8221
E-Mail: rmunver@humed.com
l
Edward P. Dominguez MD
3545 Olentangy River Road, Suite 525
Columbus OH 43214 USA
Fax: (614) 261-7538
E-Mail: e34dominguez@yahoo.com
s
Matei Dordea MD
30 Colleridge Grove
Beverley East Yorkshire HU178XD UNITED KINGDOM
Tel: +0044 1482 887 765
Fax: +0044 191 3332337
E-Mail: rpbgt@hotmail.com
l
Weijie Du MD
Zhejiang Provincial People’s Hospital
HangzhouZhejiang 310014 CHINA
Tel: 86-571-85239988
Fax: 86-571-85131448
E-Mail: wydong2003@hotmail.com
l
Titus D. Duncan MD
315 Boulevard NE
Suite 224
Atlanta GA 30308 USA
Tel: (404) 881-8020
Fax: (404) 881-8047
E-Mail: titusduncan@gmail.com
su Grant Research: Ethicon Endo Surgery
Consultant: Ethicon Endo Surgery
Speaker’s Bureau: Ethicon Endo Surgery
Ward J. Dunnican MD
Albany Med Center, Dept of Surgery
47 New Scotland Ave, MC 61
Albany NY 12208 USA
Tel: (518) 262-5615
Fax: (518) 262-4926
E-Mail: DunnicW@mail.amc.edu
su Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Consultant: T. Paul Singh, Ethicon consultant
Dan Eisenberg MD
40 Temple Street
Suite 3A
New Haven CT 06510 USA
Tel: (203) 764-9060
Fax: (203) 764-9066
E-Mail: dan.eisenberg@yale.edu
u Discussion of commercial products or services
A. Khaliq A. Eltom MD
Zayed Military Hospital
PO Box 20387
Al Ain UNITED ARAB EMIRATES
Fax: 9713-7615008
E-Mail: eltom68@hotmail.com
s
Mark Erian MD
Level 6, Teaching & Research, Ned Hanlon Building
Royal Brisbane & Women's Hospital, Herston
Brisbane Queensland 4029 AUSTRALIA
Tel: 61 07 3843 2790
Fax: 61 07 3398 1491
E-Mail: ogmerian@ccs.uq.edu.au
l
Norman C. Estes MD
University of IL College of Med, Dept of Surgery
624 NE Glen Oak Ave, Suite 2676
Peoria IL 61603-3135 USA
Tel: (309) 655-2383
Fax: (309) 655-3630
E-Mail: nestes@uic.edu
s
Royice B. Everett MD
3366 NW Expressway
Suite 600
Oklahoma City OK 73112 USA
Fax: (405) 942-5794
E-Mail: reverett@fsamail.com
s
Tommaso Falcone MD
9500 Euclid Avenue, A81
Cleveland OH 44195 USA
Tel: (216) 444-1758
Fax: (216) 445-6325
E-Mail: falcont@ccf.org
l
Afaf Abdulmutaleb Felemban MD
P.O. Box 22490
King Fahand National Guard Hospital
Riyadh Central 11426 SAUDI ARABIA
Tel: 966555441287
E-Mail: afelemban@hotmail.com
u Grant Research: (Detail not listed)
Consultant: Dr. Samar Hassan, Dr. Fahad Alsalman, Dr. Haya Alfozan
Speaker’s Bureau: Dr. Samar Hassan, Dr. Fahad Alsalman, Dr. Haya Alfozan
Michael E. Fenoglio MD
3109 East Ohio Way
Denver CO 80209 USA
Tel: (303) 229-8158
Fax: (303) 733-2384
E-Mail: fenogliomd@comcast.net
u Discussion of commercial products or services
Speaker’s Bureau: ValleyLab
Bradford W. Fenton MD PhD
525 E. Market St
Med 2 271
Akron OH 44309 USA
Tel: (303) 375-7896
Fax: (330) 375-7813
E-Mail: fentonb@summa-health.org
u Grant Research: Summa Foundation Grant
Genoa G. Ferguson MD
4960 Children's Place
Box 8242
Saint Louis MO 63108 USA
Tel: (314) 362-8365
E-Mail: fergusong@wudosis.wustl.edu
u Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Consultant: Viking
José M.M. Ferreira-Coelho MD PhD
Hospital Júlio de Matos
Av.do Brasil - nº 53
Lisbon 1749-002 PORTUGAL
E-Mail: jferreiracoelho@yahoo.com
s
Elizabeth A. Ferries-Rowe MD
550 N. University Blvd, Rm 2440
Indianapolis IN 46202 USA
Fax: (317) 630-6524
E-Mail: eferries@iupui.edu
s
Robert F. Flora MD MBA
95 Arch Street
Suite 165
Akron OH 44304 USA
Tel: (330) 375-6119
E-Mail: florar@summa-health.org
u Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Other Support: Proctor
Thomas J. Fogarty MD
3270 Alpine Road
Portola Valley CA 94028 USA
Tel: 650-854-1822
Fax: 650-854-2778
E-Mail: tjf@fogartybusiness.com
l
Morris E. Franklin, Jr. MD
4242 E. Southcross Blvd
Suite 1
San Antonio TX 78222 USA
Tel: (210) 333-7510
Fax: (210) 333-1912
E-Mail: texasendosurgery@texasendosurgery.com; franklin@texasendosurgery.com
su Grant Research: USSC, Gore, Cook, Ethicon
Consultant: USSC, Ethicon, Gore, Cook, Stryker
Speaker’s Bureau: Ethicon, US Surgical, Gore, Cook
Alex Gandsas MD
2435 West Belvedere Ave
Hoffberger 15
Baltimore MD 21215 USA
Tel: (410) 601-4838
Fax: (410) 601-9014
E-Mail: webmaster@laparoscopy.com
u Consultant: IntouchHealth
Stock Shareholder: IntouchHealth
W. Peter Geis MD
21 Crossroads Drive
Ste. 360
Owings Mills MD 21117 USA
Tel: (410) 552-4202
Fax: (410) 356-6487
E-Mail: wgeis@lifebridgehealth.org
u Grant Research: Ethicon EndoSurgery - Fellowship Grant
Consultant: Ethicon Endo Surgery
Speaker’s Bureau: Ethicon EndoSUrgery
Roberta Gelmini MD
via del Pozzo, 71 - Policlinico of Modena
Modena 41100 ITALY
Tel: 390594223662
Fax: 390594224370
E-Mail: gelmini.roberta@unimore.it
sl
Dobie Giles MD
Mayo Clinic Arizona
5777 East Mayo Blvd
Phoenix AZ 85054 USA
Tel: (480) 342-0612
Fax: (480) 342-2944
E-Mail: giles.dobie@mayo.edu
l
Carl K. Gjertson MD
535 N. Barnhill Dr
Suite 420
Indianapolis IN 46202 USA
Tel: (317) 278-3098
Fax: (317) 274-0174
E-Mail: c.gjertson@yahoo.com
l
Deborah Glassman MD
1015 Walnut Street
Suite 1100
Philadelphia PA 19107 USA
Tel: (215) 955-5158
Fax: (215) 923-1884
E-Mail: deborah.glassman@jefferson.edu
l
Herbert A. Goldfarb MD
35 Delwick Lane
Short Hills NJ 07078 USA
Tel: (973) 699-1904
Fax: (973) 467-5175
E-Mail: hgoldfarb@nohysterectomy.com
suDiscussion of commercial products or services
Andrew A. Gumbs MD
Institut Mutualiste Montsouris
Department of Digestive Diseases, 42, Boulevard Jourdan
Paris FRANCE
Fax: +33.(0)1.56.61.63.23
E-Mail: ag2462@columbia.edu
s
Randy S. Haluck MD
500 University Dr
Hershey, PA 17033 USA
Tel: (717) 531-7462
Fax: (717) 531-4729
E-Mail: rhaluck@psu.edu
u Discussion of commercial products or service
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Stock Shareholder: Verefi Technologies
Victor Joseph Hassid MD
653-2 West 8th Str.
Jacksonville FL 32209 USA
Tel: (904) 244-3903
Fax: (904) 244-3870
E-Mail: hassidv@ufl.edu
l
Harrith M. Hasson MD
6250 Winter Haven Rd NW
Albuquerque NM 87120 USA
Tel: (505) 792-0240
Fax: (505) 792-0241
E-Mail: drhasson@aol.com
l
Andre Hebra MD
Medical University of South Carolina
96 Jonathan Lucas St; 418 CSB-Pediatric Surgery
Charleston SC 29425 USA
Tel: (727) 8924109
E-Mail: hebra@pediatricsurgicalgroup.com
Nothing to Discuss
Wm. LeRoy Heinrichs MD PhD
Stanford Hills Consulting
8 Campbell Lane
Menlo Park CA 94025 USA
Tel: (650) 723-2422
Fax: (650) 498-4082
E-Mail: leroy.heinrichs@stanford.edu
u Grant Research: Stanford
Consultant: Stanford
Speaker’s Bureau: Stanford
Stock Shareholder: Immersion Medical
Other Support: Stanford
Michael R. Henson
13900 Alton Parkway
Suite 125
Irvine CA 92618 USA
Tel: (949) 581-7250
E-Mail: mhenson@fund-mgmt.com
u Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Pleun EA Hermsen MD
Prins Constantijnweg 2
Capelle aan den IJssel Zuid-Holland 2906 ZC THE NETHERLANDS
Tel: 003110-2585000
Fax: 00316-24256923
E-Mail: pleunhermsen@gmail.com
l
Santiago Horgan, MD
5725 Caminito Empresa
La Jolla, CA 92037-7148 USA
Tel: (312) 355-1493
Fax: (312) 355-1987
E-Mail: shorgan@ucsd.edu
n
Senzan Hsu MD
698 Gull Avenue
Foster City CA 94404 USA
Tel: (650) 327-8778
E-Mail: hsuz@yahoo.com
l
Thomas H. HsuMD
698 Gull Ave
Foster City CA 94404 USA
Tel: (650) 725-5544
Fax: (650) 723-0765
E-Mail: hsut1@yahoo.com
sl
Atif Iqbal MD
Dept of General Surgery, University of Missouri Columbia
One Hospital Drive
Columbia MO 65212 USA
Tel: (573) 529-6386
Fax: (573) 884-5184
E-Mail: iqbalat@health.missouri.edu
sl
Keith B. Isaacson MD
34 Hyde Ave
Newton MA 02458 USA
Tel: (617) 571-0808
Fax: (617) 243-5029
E-Mail: kisaacson@partners.org
u Speaker’s Bureau: Karl Storz Endoscopy
Usman Jaffer MD
5 Saint Andrew's Road
London NW11 0PH UNITED KINGDOM
Tel: 00 44 (0) 208 455 3079
E-Mail: usman.jaffer@doctors.org.uk
l
Grace M. Janik MD
Reproductive Specialty Center
2315 N. Lake Drive, Suite 501
Milwaukee WI 53211 USA
Tel: (414) 289-9668
Fax: (414) 289-0974
E-Mail: drjanik@reproductivecenter.com
sn
Michael Stephen Kavic MD
1044 Belmont Avenue
Youngstown OH 44501-1790
Tel: (330) 480 3124
E-Mail: michael_kavic@hmis.org
u Grant Research: Boston Scientific
Stephen M. Kavic MD
2 S. Greene St., Rm S4809
Baltimore MD 21201 USA
Tel: (410) 452-7373
Fax: (410) 328-5919
E-Mail: skavic@yahoo.com
s
Mark Keldahl MD
Loyola University Department of Surgery
2160 S. 1st Ave.
Maywood IL 60302 USA
Tel: (708) 327-2335
E-Mail: mkeldahl@lumc.edu
l
William E. Kelley, Jr. MD
25 Highland Rd.
Richmond VA 23229
Tel: (804) 285-9416
Fax: (804) 285-8257
E-Mail: bill.kelley@earthlink.net
l
John W. Kenagy MD
625 Mt. Auburn Street, 1
Cambridge MA 02138 USA
Tel: (617) 491-1476
Fax: (617) 864-5161
E-Mail: jkenagy@kenagyassociates.com
u Consultant: Kenagy Associates, LLC
Mark Adrian Kiefer MD
425 E. Starla Rd.
Columbia MO 65202 USA
Tel: (573) 639-1186
E-Mail: kieferm@health.missouri.edu
u Discussion of commercial products or services
Consultant: WL Gore, Tyco/USSC/Sofradim, Ethicon Endosurgery, Ethicon, Inc., Tissue Sciences Laboratory, Cook Surgical, Stryker
Wan Sung Kim MD
Department of Surgery
1-Myongji Hospital
146-92 Hwajeong, Deogyang
Goyang Gyeonggi 412-270 KOREA
Tel: (82) 31-810-6330
E-Mail: toto68@freechal.com
l
Charles H. Koh MD
2315 North Lake Drive
Milwaukee WI 53211 USA
Tel: (414) 289-9668
Fax: (414) 289-0974
E-Mail: drkoh@reproductivecenter.com
su Discussion of commercial products or services
Other Support: Royalty: KOH Needle Driver
Muhammad Saeed Kummah MD
Malik Hospital
Khushab Road
Sargodha PAKISTAN
Fax: 92483724188
E-Mail: kummah1919@yahoo.com
s
Alex Jenny Ky MD
5 East 98th Street
Box 1259
New York NY 10029 USA
Fax: (212) 534-2654
E-Mail: alex.ky@mountsinai.org
s
Po N. Lam MD
1226 E. Water St..
Syracuse NY 13210 USA
Fax: (315) 475-0840
E-Mail: ponlam@hotmail.com
s
Jaime Landman MD
201 West 70th St., Apt 18K
New York NY 10023 USA
Tel: (212) 305-5630
Fax: (212) 342-0694
E-Mail: landmanj@yahoo.com
su Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant Research: Galil Medical, Endocare
Consultant: Galil Medical
Raymond Joseph Lanzafame MD MBA
1445 Portland Ave #202
Rochester NY 14621 USA
Tel: (585) 922-4505
Fax: (585) 544-8761
E-Mail: ray.lanzafame@viahealth.org
u Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational
Grant Research: NIH SBIR PHASE 2 Grant # 1R43DK62571-0 2A1; NIH SBIR Phase2 GRANT:NIDDK #1R43 DK62571-03
Consultant: Conversion Energy Enterprises, Eastman Kodak, Surgicon, Lucid, Uvacide, CEE, Raymond J. Lanzafame, MD PLLC
Speaker’s Bureau: ASLMS, SLS, Monroe County Medical Society
Stock Shareholder: Conversion Energy Enterprises, Kodak, Lucid, Jamar, Surgicon
Other Support: Society Of Laparoendoscopic Surgeons Board/Officer, Rochester General Hospital Foundation
Piotr Laudanski MD PhD
ul. Marii Sklodowskiej-Curie 24a
Bialystok Podlasie 15-276 POLAND
Tel: 4885608344788
E-Mail: plauda@amb.edu.pl
Madeleine Lemyre MD
Center for Special Minimally Invasive Surgery
900 Welch Road, Suite 403
Palo Alto California 94304 USA
Tel: (650) 327-8778
Fax: (650) 723-7737
E-Mail: basdelaine@hotmail.com
u Discussion of commercial products or services
Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational
Carl J. Levinson MD
576 Sand Hill Circle
Menlo Park, CA 94025 USA
Tel: (650) 233-0591
Fax: (650) 233-9629
E-Mail: carljmd@aol.com
l
Jose L. Leyba MD
Clinica Santa Sofia piso 3 Consultorio 330
Urbanizacion Santa Sofia
Caracas Miranda 1080 VENEZUELA
Tel: 582129856774
E-Mail: jlleyba@yahoo.es
u Grant Research: Hospital Universitario de Caracas
Consultant: Clinica Santa Sofia
Brittany Nicole Liedstrand
100 N Whisman Rd, 1312
Mountain View CA 94043 USA
Tel: (408) 464-9385
E-Mail: bliedstr@ucsc.edu
l
Yong-Taik Lim MD
Department of OB/GYN
Kang Nam St. Mary's Hospital
505 Banpodong, Seochoku
Seoul 137-040 SOUTH KOREA
Tel: (822) 590-2745
Fax: (822) 534-2230
E-Mail: ymandi@ksog.org
s
Tristan Lissitzky MD
Chirurgie Viscérale, Centre Hospitalier "Léon Binet", BP 212
PROVINS Cedex 7488 FRANCE
Fax: +33 164 604 396
E-Mail: tlissitzky@wanadoo.fr
s
Yan Liu MD
No. 415, Fengyang Road, Dept. OB/GYN
Shanghai 200003 CHINA
Tel: 86-21-65349877
Fax: 86-21-63528552
E-Mail: yliu2004@163.com
l
Ali Mahdavi MD
820 Turtle Crest Drive
Irvine CA 92603 USA
Tel: (949) 838-7189
Fax: (714) 456-7754
E-Mail: amahdavi@uci.edu
l
Jennifer L. Marti MD
321 East 43rd St
Apt 702
New York NY 10017 USA
Tel: (646) 246-6252
E-Mail: jlmarti@hotmail.com
l
Dan C. Martin MD
7945 Wolf River Boulevard
Suite 320
Germantown TN 38138 USA
Tel: (901) 347-8331
Fax: (901) 339-0888
E-Mail: dmarti27@utmem.edu
u Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Speaker’s Bureau: Baxter BioSurgical
Richard Matern MD
1430 Tulane Ave
SL-42
New Orleans LA 70112 USA
Tel: (504) 780-4442
E-Mail: rmatern@tulane.edu
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Elspeth M. McDougall MD
UCIMC-Dept. of Urology
101 The CIty Drive
Bldg. 55, Rt. 81, Rm. 302
Orange CA 92868 USA
Tel: (714) 456-3429
Fax: (714) 456-5062
E-Mail: elspethm@uci.edu
u Grant Research: EndoCare
Other Support: Karl Storz; Intuitive Surgical; Simbionix; Ethicon Endo-Surgery
Timothy B. McKinney MD
151 Fries Mill Road
Suite 301
Turnersville NJ 08012 USA
Tel: (856) 374-1377
Fax: (856) 374-2177
E-Mail: joyoffaith1@hotmail.com
u Discussion of commercial products or services
Consultant: Pfizer
Speaker’s Bureau: Ethicon
Stock Shareholder: T-Doc Company
David McLaughlin MD
9660 East 146th St., Suite 300
Noblesville IN 46060 USA
Tel: (317) 774-1200
Fax: (317) 774-1222
E-Mail: dr.mac007@mac.com
u Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational
Stock Shareholder: Intuitive Surgical
Other Support: Intuitive Surgical-have served as proctor for another surgeon
Joe Miller MD
SIU Division of Urology
PO Box 19665
Springfield IL 62704 USA
Tel: (217) 545-8860
Fax: (217) 545-7305
E-Mail: jmiller5@siumed.edu
l
Paul B. Miller MD
890 West Faris Road
Suite 470
Greenville SC 29605 USA
Tel: (864) 455-8446
Fax: (864) 455-8489
E-Mail: pmiller@ghs.org
l
Muhammad S. Mirza MD
86 Manor Park Court
Uttoxeter New Road
Derby Derbyshire DE22 3QH UNITED KINGDOM
Tel: 447771536362
E-Mail: msmirza@doctors.org.uk
l
Subhasis Mitra FRCS
9 Craigenbay Crescent
Lenzie
Glasgow Scotland G66 5JW UNITED KINGDOM
Fax: 00441417760197
E-Mail: mitrasubhasis@hotmail.com
s
Philippe Morel Prof Dr Med
Rue Micheli-du-Crest 24
Geneva 1211 SWITZERLAND
Tel: +41 22 372 33 11
E-Mail: philippe.morel@hcuge.ch
u Discussion of commercial products or services
John E. Morrison, Jr. MD
375 Highforest Dr.
Fayette AL 35555 USA
Tel: (205) 932-3879
Fax: (205) 932-5253
E-Mail: drmorjo@aol.com
u Discussion of commercial products or services
Prashanth S. Navaran MD
c/o Dr. Peter Geis
21 Crossroads Drive, Suite 360
Owings Mills MD 21117 USA
Tel: (240) 683-0943
Fax: (410) 356-6487
E-Mail: pnavaran@hotmail.com
u Consultant: Ethicon-Dr. Peter Geis
Speaker’s Bureau: Ethicon-Dr. Peter Geis
Salvador A. Navarrete MD
Clinica Santa Sofia piso 3 Consultorio 330
Urbanizacion Santa Sofia
Caracas Miranda 1080 VENEZUELA
Tel: 582129856774
E-Mail: navarretesalvador@yahoo.com
Grant Research: Hospital Universitario de Caracas
u Consultant: Clinica Santa Sofia
Vincenzo Neri MD
Via Murat 86
Bari 70123 ITALY
Fax: (39) 0881 733704
E-Mail: tizpv@tiscali.it
sl
Camran Nezhat MD
900 Welch Road Suite 403
Palo Alto CA 94304 USA
Tel: (650) 327-8778
Fax: (650) 327-2794
E-Mail: cnezhat@stanford.edu
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Ceana Nezhat MD
5555 Peachtree Dunwoody Rd.
Suite 276
Atlanta GA 30342 USA
Tel: (404) 255-8778
Fax: (404) 255-5627
E-Mail: ceana@nezhat.com
u Speaker’s Bureau: Valleylab, US Surgical, Ethicon EndoSurgery
Farr R. Nezhat MD
1176 Fifth Avenue
Klingenstein Pavillion, 9th floor
New York NY 10029 USA
Tel: (646) 201-6200
Fax: (212) 987-6386
E-Mail: farr.nezhat@mssm.edu
u Discussion of commercial products or services
Francisco A. Obregon MD
Calle Oeste. Manzanares Edificio Cantaclaro
PH-3
Caracas Miranda 1083 VENEZUELA
Tel: 582129769494
E-Mail: franobre@hotmail.com
u Grant Research: Universidad Central de Venezuela
Consultant: Hospital Universitario de Caracas, Clinica Santa Sofia
Jaime E. Ocampo MD
501 7th Ave
San Francisco CA 94118 USA
Tel: (415) 794-2716
E-Mail: ocampojaime@sbcglobal.net
l
Sung-Tack Oh MD PhD
Dept. of Ob/Gyn
8 Hakdong, Tongku
Kwangju KJ 501-190 KOREA (SOUTH)
Tel: 82-62-220-6374
Fax: 82-62-227-1637
E-Mail: ohst@chonnam.ac.kr
sl
Dmitry Oleynikov MD
983280 Nebraska Medical Center
Omaha NE 68198-3280 USA
Tel: (402) 559-4581
Fax: (402) 559-6749
E-Mail: doleynik@unmc.edu
u Speaker’s Bureau: Tyco
Douglas E. Ott MD MBA
161 Gateway Drive
Macon GA 31210 USA
Tel: (478) 477-8996
Fax: (478) 471-6862
E-Mail: gabiomed@mindspring.com
s Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant Research: Georgia BioMedical, Inc.
Stock Shareholder: Johnson and Johnson
Other Support: Georgia BioMedical stockholder
Francesco Palazzo MD
Thomas Jefferson University - Dept. of Surgery
1015 Walnut Street , Suite 620
Philadelphia PA 19107 USA
Tel: (215) 955-6864
Fax: (215) 955-2878
E-Mail: Francesco.Palazzo@mail.tju.edu
sl
Michael A. Palese MD
Mount Sinai School of Medicine
One Gustave L. Levy Place
Dept of Urology-Box 1272
New York NY 10029 USA
Tel: (212) 241-7442
Fax: (212) 987-4675
E-Mail: Michael.Palese@MountSinai.org
s
Barnard Palmer MD
Kaiser Permanente
1425 S. Main St #68
Walnut Creek CA 94596 USA
Tel: (925) 295-5311
Fax: (925) 295-4766
E-Mail: bjapalmer@yahoo.com
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Steven F. Palter MD
243 Jericho Tpke
Syosset NY 11791 USA
Tel: (516) 682-8900
Fax: (516) 682-8901
E-Mail: palter@gcivf.com
u Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational
Grant Research: Karl Storz Endoscopy America
Consultant: Impress Medical, Viking Medical
Sijo Joseph Parekattil MD
1600 SW Archer Road
Room N-217, PO Box 100247
Gainesville FL 32610-0247 USA
Tel: (352) 273-6815
E-Mail: sijo_p@hotmail.com
u Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Consultant: ERBE
John Park MD
Hatton Research - Good Samaritan Hospital
375 Dixmyth Ave.
Cincinnati OH 45220 USA
Tel: (513) 872-3543
Fax: (513) 872-1549
E-Mail: amy_engel@trihealth.com
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Marylou Patton MD
1 Medical Center Blvd
Suite 241
Upland PA 19013-3902 USA
Fax: (610) 872-4015
E-Mail: loumary@msn.com
s
Haifeng Peng MD
Department of General Surgery
The Ninth People's Hospital of Shenzhen City
Longgang District
Shenzhen City Guangdong Province 518116 P.R. OF CHINA
Tel: 0086-755-28926677
E-Mail: penghaifeng99@hotmail.com
l
Joseph B. Petelin MD
9119 West 74th Street
Suite 255
Shawnee Mission KS 66204 USA
Tel: (913) 432-5420
Fax: (913) 432-7749
E-Mail: j2pete@mindspring.com
u Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational
Stock Shareholder: Intouch Health
Other Support: Tyco Fellowship
Francis J. Podbielski MD
Division of Thoracic Surgery
271 Carew Street
Springfield Massachusetts 01104 USA
Tel: (413) 748-9628
Fax: (413) 748-9662
E-Mail: Francis.Podbielski@sphs.com
sl
Juan G. Quiroz MD
Ap.31 San Mateo Atenco
Barrio de San Nicolas
San Mateo Atenco Estado de Mexico 52100 MEXICO
Tel: 52 728 28 70054
Fax: 52 728 28 7 04 96
E-Mail: drjuan_quiroz@yahoo.com
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Jay D. Raman MD
435 East 70th Street, Apartment 29A
New York NY 10021 USA
Tel: (212) 517-3291
Fax: (212) 746-8153
E-Mail: jay_d_raman@yahoo.com
sl
Pedro T. Ramirez, MD
UT MD Anderson-Gyn Oncology
PO Box 301439 Unit 1362
Houston, TX 77230 USA
Tel: (713) 745-5498
Fax: (713) 792-7586
E-mail: peramire@MDAnderson.org
u Speakers Bureau: GSK, Ethicon
Kenneth Joe Ransom MD
7400 East Osborn
Scottsdale AZ 85251 USA
Tel: (480) 882-4903
E-Mail: kransom@shc.org
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Munir A. Rathore FRCS
23 Wallace Avenue
Lisburn N/Ireland BT27 4AE UNITED KINGDOM
Tel: (0) 7916 14 66 29
E-Mail: munirrathore@yahoo.com
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Harry Reich MD
245 N. Memorial Hwy.
Shavertown PA 18708 USA
Tel: (570) 674-2256
Fax: (570) 674-2263
E-Mail: reichh_paoffice@msn.com
Stock Shareholder: Apple Medical
Kurt E. Roberts MD
40 Temple St
Suite 3A
New Haven CT 06510 USA
Tel: (203) 764-9060
E-Mail: kurt.roberts@yale.edu
u Discussion of commercial products or services
James C. Rosser, Jr. MD
25602 Colonial Pines Court
Spring TX 77389 USA
Tel: (646) 772-4213
E-Mail: jrosser@chpnet.org
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Nicolas Roukounakis MD
12 Fokeas Street
Attiki 15569 Greece
Tel: 30 210 5244694
Fax: 30 210 5240130
E-Mail: nicrouk@ath.forthnet.gr
s
Thomas Russell MD
633 North Saint Clair St, 28th Floor
Chicago, IL 60611-3211
Tel: (312) 202-5305
Fax: (312) 202-5016
E-Mail: TRussell@FACS.org
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Naghmeh Salamat Saberi MD
UCIMC
101 The City Dr., Bl. 56
Orange CA 92868 USA
Tel: (714) 456-6853
Fax: (714) 456-7180
E-Mail: nsalamat@uci.edu
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Ajit K. Sachdeva MD
American College of Surgeons
633 N. Saint Clair Street
Chicago IL 60611 USA
Tel: (312) 202-5405
Fax: (312) 202-5011
E-Mail: asachdeva@facs.org
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Lukas Sakra MD PhD
Kyjevsk· 44
Pardubice 530 02 CZECH REPUBLIC
Tel: +420 46 601 2999
Fax: +420 46 601 2988
E-Mail: sakra@nem.pce.cz
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Ricardo J. S. Santos MD
101 The City Dr.
Bldg 55, Rt 81, Rm 302
Orange CA 92868 USA
Tel: (714) 456-3429
Fax: (714) 456-5062
E-Mail: ricardojuveniz@yahoo.com.br
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Richard M. Satava MD
10206 NE 68 th St
Apt C-202
Kirkland WA 98033 USA
Tel: (425) 765-0730
E-Mail: rsatava@u.washington.edu
su Consultant: Karl Storz
Stock Shareholder: InTouch Health Technologies
John Savarese MD
3000 Sand Hill Road
Bldg. 1, Ste. 260
Menlo Park CA 94025 USA
Tel: (650) 234-2384
E-Mail: john@mepvc.com
u Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Stock Shareholder: Montreux Equity Partners
David L. Schumacher MD
303 Willowood Drive
Springboro OH 45066 USA
Tel: (937) 514-6007
E-Mail: David.Schumacher@kmcnetwork.org
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Bradley F. Schwartz DO
SIU Division of Urology
PO Box 19665
Springfield IL 62704 USA
Tel: (217) 545-8860
Fax: (217) 545-7305
E-Mail: jmiller5@siumed.edu
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Phillip Shadduck MD
4301 Ben Franklin Blvd
PO Box 15698
Durham NC 27704 USA
Tel: (919) 479-4400
Fax: (919) 479-4420
E-Mail: phil9128@aol.com
u Discussion of commercial products or services
Consultant: Closure Medical Corp; Ethicon; Ethicon EndoSurgery; Bard/Davol
Jagdip T. Shah MD
Pooja Hospital, Bhatwadi,
Ghatkopar-West,
Mumbai Maharastra 400084 INDIA
Tel: 0091 22 25153896
Fax: 0091 22 25113559
E-Mail: poojahospital@gmail.com
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Sohail R. Shah MD
Division of Pediatric Surgery
3705 Fifth Ave, 4A-485
Pittsburgh PA 15213 USA
Tel: (412) 414-4610
E-Mail: sohail.shah@chp.edu
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Jiri Siller MD PhD
Kyjevsk· 44
Pardubice 530 02 CZECH REPUBLIC
Tel: +420 46 601 2999
Fax: +420 46 601 2988
E-Mail: siller@nem.pce.cz
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Matthew N. Simmons MD PhD
Glickman Urological Institute
Cleveland Clinic A100
Cleveland OH 44122 USA
Tel: (216) 445-1530
Fax: (216) 445-7031
E-Mail: simmonm2@ccf.org
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Mika N. Sinanan MD PhD
BB430
1959 N.E. Pacific St.
Seattle WA 98195 USA
Tel: (206) 543-5511
Fax: (206) 543-8136
E-Mail: mssurg@u.washington.edu
u Consultant: Valleylab, Genzyme
Marshall L. Smith MD PhD
SimET Center, WT-1, Banner Good Samaritan
1111 East McDowell Rd
Phoenix AZ 85028 USA
Tel: (602) 239-6507
E-Mail: mark.smith@bannerhealth.com
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Jonathan Y. Song MD
4N393 School Rd
St. Charles IL 60175 USA
Tel: (630) 677-1557
E-Mail: jsong3972@hotmail.com
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Peter L. Steinberg MD
DHMC Section of Urology
One Medical Center Drive
Lebanon NH 03755 USA
Tel: (603) 650-6052
Fax: (603) 650-4985
E-Mail: peter.steinberg@hitchcock.org
u Discussion of commercial products or services
Uz Steinhilper Dr Med
Marsstrasse 13
Munich Bavaria 80335 GERMANY
Tel: 011 49 89 594379
Fax: 11498988922918
E-Mail: Dr.Steinhilper@t-online.de
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Gustavo Stringel MD
21 Addison Street
Larchmont NY 10538 USA
Tel: (914) 833-2311
E-Mail: GStringel@aol.com
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Chandru Sundaram MD
535 N. Barnhill Dr.
Suite 420
Indianapolis IN 46202 USA
Tel: (317) 278-3098
Fax: (317) 274-0174
E-Mail: cg3@iupui.edu
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Radha Syed MD
5 Coddington Avenue
Staten Island NY 10306 USA
Tel: (718) 351-1350
Fax: (718) 351-1271
E-Mail: radhasyed77@yahoo.com
su Discussion of commercial products or services
Nicholas A. Tarola MD
126 East Wayne Ave
Aldan PA 19018 USA
Tel: (610) 417-0897
Fax: (215) 955-2878
E-Mail: nicholas.tarola@mail.tju.edu
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Maria L. Terry MD
1 University of New Mexico
MSC 10-5610
Albuquerque NM 87131-0001 USA
Tel: (505) 272-0433
Fax: (505) 272-0432
E-Mail: mterry@salud.unm.edu
u Discussion of commercial products or services
Katerina TheodoropoulouMD
Flat 4
Lymington Court, 214 Lavender Hill
Enfield Greater London EN2 8NE UNITED KINGDOM
Tel: 447812101582
E-Mail: kattheod@aol.com
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Konstantinos George Tsalis Prof Dr Med
Konstantinos Tsalis
Kotyoron 19 Kalamaria
Thessaloniki Thessaloniki 55131 GREECE
Tel: 302310410768
Fax: 302310358000
E-Mail: ctsalis@med.auth.gr
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Daniel A. Tsin MD
25-10 30th Avenue
Long Island City NY 11102 USA
Tel: (718) 899-7878
Fax: (718) 746-1625
E-Mail: LaserGYN@aol.com
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Duncan J. Turner MD
219 Nogales Ave. Suite A
Santa Barbara CA 93105 USA
Tel: (805) 682-6340
Fax: (805) 563-8576
E-Mail: dturnermd@aol.com
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Alberto Valero Prof Dr Med
Sta. Teresa 1055 Suite 301 Col. H. Padierna
Hospital Angeles del Pedregal
Mexico D.F. Mexico City 10700 MEXICO
Tel: 5255 5652 22 73
Fax: 5255 55683178
E-Mail: valero_alberto@hotmail.com
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Amir Vejdan Dr Med
Taleghany st. Immam Reza's Hospital
Birjand South Khorasan 97917 IRAN
Tel: 0098 9151613885
E-Mail: vejdan_sa@yahoo.com
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Gerald J. Wang MD
445 E. 68th St.
Apt. 11A
New York NY 10021 USA
Tel: (917) 291-0167
Fax: (212) 746-8153
E-Mail: geraldwang1@gmail.com
u Discussion of commercial products or services
Yue Dong Wang MD
Zhejiang Provincial People?s Hospital
158 Shangtang RD
Hangzhou Zhejiang 310014 CHINA
Tel: 86-571-88975812
Fax: 86-571-85131448
E-Mail: wydong2003@hotmail.com
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Yulun Wang PhD
90 Castilian Drive
Suite 200
Goleta CA 93117 USA
Tel: (805) 562-8686 ext 101
Fax: (805) 562-86863
E-Mail: smartin@intouchhealth.com
u Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Stock Shareholder: InTouch Technologies
James A. Watson MD
2850 Middlefield Rd
Palo Alto CA 96403 USA
Tel: (860) 534-0678
E-Mail: watsonj76@hotmail.com
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Alexei Wedmid MD
Mount Sinai Medical Center
Dept. of Urology
New York NY 10029 USA
Tel: (917) 885-1089
Fax: (212) 876-3246
E-Mail: awedmid@gmail.com
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Andrew Allen Wheeler MD
One Hospital Drive
Columbia MO 65203 USA
Tel: (573) 882-4000
E-Mail: wheeleraa@health.missouri.edu
u Consultant: Ethicon Endo-Surgery; Satiety, Inc
Warren D. Widmann MD
Milstein Hospital Building 7 GS 313
177 Fort Washington Avenue
New York NY 10032 USA
Tel: (212) 305-3038
Fax: (212) 305-8321
E-Mail: wdw2@columbia.edu
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Howard N. Winfield MD
Dept Urology-RCP 3235, UIHC
200 Hawkins Drive
Iowa City Iowa 52242 USA
Tel: (319) 384-9183
Fax: (319) 356-3900
E-Mail: howard-winfield@uiowa.edu
su Discussion of commercial products or services
Grant Research: Aventis Pharmaceuticals
Consultant: Gerson Lehman Medical Consulting
James Briscoe Wooldridge MD
1 Hospital Drive
MC 405
Columbia MO 65212 USA
Tel: (573) 884-2000
Fax: (573) 884-3691
E-Mail: wooldridgejb@health.missouri.edu
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Hsing-Hsien Wu MD
3F-2,No16, Lane 185, Chung-Hwa E Rd, East District,
Tainan 701 TAIWAN
Tel: 886-6-2609926
Fax: 886-6-2606351
E-Mail: kenwu489@ms18.hinet.net
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Takashi Yamada MD PhD
Department of Pathology, Osaka Medical College
2-7 Daigaku-machi
Takatsuki Osaka 569-8686 JAPAN
Fax: 81-72-684-6514
E-Mail: yamatakashi@mub.biglobe.ne.jp
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Bulent Yaycioglu MD
Adana 1120 TURKEY
Tel: 0090537 44279 55
Fax: 0090 322 458 9833
E-Mail: ybulent60@hotmail.com
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Sen-Chang Yu MD PhD
National Taiwan Univ Hospital
No. 7 Chang-Shan S. Rd.
Taipei 100 TAIWAN
Fax: 886-2-23949675
E-Mail: senchang@ha.mc.ntu.edu.tw
s
Robert K. Zurawin MD
6620 Main Street, Suite 1450
Houston TX 77030 USA
Tel: (713) 798-6666
Fax: (713) 798-8897
E-Mail: rzurawin@bcm.edu
su Consultant: Conceptus, Ethicon Women’s Health
