15TH SLS ANNUAL MEETING AND ENDO EXPO 2006
SEPTEMBER 6-9, 2006 • BOSTON MASSACHUSETTS
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SCIENTIFIC ABSTRACTS
Supplement to JSLS, Volume 10, Number 3
GENERAL SESSIONS
Best of Laparoscopy Updates
Multidisciplinary Plenary Sesssions
Future Technology Session
CONGRESS FEATURES
Sept 6, 2006 Eight intensive half and full-day Master’s Classes
Sept 7, 2006 SLS Special Evening Event: Dinner With Faculty at the John F. Kennedy Library and Museum, featuring Thomas Fogarty, MD, a driving force in medical device development
Sept 7–8, 2006 Over 200 cutting edge scientific presentations including Laparoscopy Updates
Sept 7, 2006 Three new Multidisciplinary Plenary Sessions directed by those at the zenith of minimally invasive surgery: Innovations in Surgery and Medicine: From the Bench to the Bedside; Informatics for the Laparoendoscopic Surgeon; Competency and Its Assessment Metrics
Sept 8, 2006 Watch the Masters perform surgery–LIVE–during two simultaneous telesurgeries
Sept 9, 2006 Be inspired by a vision of the future at the Breakfast and Future Technology Session directed by the brilliant Richard M. Satava, MD, featuring Kenneth Kamler, MD, presenting Medicine in the Extreme, Anthony Atala, MD, with the latest in Growing Organs, and David Hanson presenting Robots and Emotional Expression
ENDO EXPO 2006
Over 50 exhibitors will provide on-going presentations about not only the innovations of the year but also the latest ideas and technological developments to aid surgeons in the operating room
IMPORTANT DEADLINES
July 6, 2006 Registration deadline for $100 SLS member discount
August 7, 2006 Last day to receive discounted room rates at The Westin Copley Place
VISA INFORMATION
International attendees, please apply for your visa now.
If you need a written invitation, please visit www.SLS.org or email Conferences@SLS.org.
Additional visa information is available at www.unitedstatesvisas.gov.
SPECIAL EVENT
SLS EVENING WITH FACULTY AT THE JOHN F. KENNEDY LIBRARY & MUSEUM
Thursday, September 7, 2006
6:00pm–8:30pm
John F. Kennedy Library and Museum
Boston, Mass.
Special Guest Speaker:
Thomas J. Fogarty, MD, presents
Evolution and the Impact of Surgical Technology
Join the SLS faculty, the driving force in minimally invasive surgery, and special guest speaker Thomas J. Fogarty, MD, a driving force in the development of medical devices, for dinner and a lecture at the John F. Kennedy (another driving force) Library and Museum, overlooking Boston Harbor. Thomas J. Fogarty, MD, developed his first medical device, the balloon embolectomy catheter, almost 50 years ago. At the time, it was unheard of to operate within an artery, but Fogarty’s balloon catheter was designed for just that and opened the way for endovascular therapy. It also was the first “less-invasive” medical technique used, resulting in less trauma to patients. Since then, Fogarty has helped launch many start-up medical device companies, including CTS, which makes devices for minimally invasive surgery. Fogarty is Clinical Professor of Surgery and Director of Research at Stanford University School of Medicine in California. Being in California, he has been exposed to winemaking, which he found intriguing, and now has his own winery. Because of wine’s well-documented health benefits, wine should be considered not so much as an adult beverage but as a health food according to Fogarty. Join us for this festive evening and hear about the latest from Dr Fogarty and what’s in store for SLS.
SPECIAL EVENT
EXCEL AWARD PRESENTATION & LECTURE
Friday, September 8, 2006
12:45pm–1:45pm
Excel Award Recipient:
Richard M. Satava, MD, presents
The Impossible Futures of Surgery
Established in 1991, the Excel Award has been presented to 21 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 of various nationalities.
The 2006 recipient of this prestigious award, Richard M. Satava, MD, FACS, has long been active in SLS and numerous other societies, is a past president and member of the SLS Board of Trustees, and is a regular presenter at the SLS annual meeting. Dr Satava is Professor of Surgery at the University of Washington Medical Center, Program Manager of Advanced Biomedical Technology at the Defense Advanced Research Projects Agency (DARPA), and Special Assistant in Advanced Surgical Technologies at the US Army Medical Research and Materiel Command in Ft. Detrick, Maryland. He served on the White House Office of Science and Technology Policy (OSTP) committee on Health, Food and Safety. Dr Satava’s brilliant career has included 23 years of military surgery during which he has been an active flight surgeon, an Army astronaut candidate, MASH surgeon for the Grenada Invasion, and a hospital commander during Desert Storm—all the while continuing clinical surgical practice.
Active in surgical education and research, Dr Satava has contributed to more than 200 publications in diverse areas of advanced surgical technology, including Surgery in the Space Environment, Video and 3-D imaging, Telepresence Surgery, Virtual Reality Surgical Simulation, and Objective Assessment of Surgical Competence and Training. He also sits on the editorial boards of numerous surgical and scientific journals, is a past president of SAGES, and is on the Board of Governors of the NBME.
While striving to practice the complete discipline of surgery, Dr Satava is aggressively pursuing the leading edge of advanced technologies to formulate the architecture for the next generation of Medicine.
SPECIAL EVENT: BREAKFAST AND FUTURE TECHNOLOGY SESSSION
BEYOND HUMAN LIMITATION: PERFORMANCE IN THE EXTREMES, ORGAN REGROWTH, AND EMOTIONAL ROBOTS
Saturday, September 9, 2006
7:30am–10:30am
Richard M. Satava, MD, Director
Keynote Speaker Kenneth Kamler, MD presents
Medicine in the Extreme: Adventures of an Explorer in Extreme Environments
Keynote speaker, Kenneth Kamler, has been on Mt. Everest twice at the request of NASA helping to test space-age remote medical monitoring equipment.
Anthony Atala, MD, presents
Regenerative Medicine: New Approaches in Healthcare for the 21st Century
David Hanson presents
Robots and Emotional Expression
The Future Technology Session offers a look at what science fiction has actually become fact. The keynote speaker, Kenneth Kamler, MD, will show his experience in the most extreme of environments, with truly unbelievable accomplishments in the most unlikely places—the Amazon jungle, miles under the sea and at the top of Mt. Everest. This will give a personal insight into his accomplishments, which he has documented in his award-winning book, Surviving the Extremes. He will be available for a book signing after the session.
Professor Anthony Atala will update us on the latest of human organs he has grown with tissue engineering and stem cells. His success in clinical trials has made the fiction of replacing synthetically grown organs a reality.
Professor David Hanson will take us to the world of robots where their facial expressions are indistinguishable from human emotion. The future of robots in which they look and react like humans is one step closer. David Hanson’s work earned him (and his Einstein robotic face) personal praise from President Bush and a place on the cover of a number of magazines and journals.
CONGRESS EDUCATIONAL METHODS AND OBJECTIVES
The 15th International Congress and Endo Expo 2006 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 congress contributes to the continuation of excellence in minimally invasive surgery.
Upon completion of the congress, 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.
MASTER’S CLASSES | WEDNESDAY, SEPTEMBER 6, 2006
#1 Master’s Class in the Prevention and Management of Laparoscopic and Endoscopic Surgical Complications
9:00am–12:00pm
Faculty
Raymond J. Lanzafame, MD, MBA, Director
Carl J. Levinson, MD, Co-Director
Lawrence C. Biskin, MD
Ceana Nezhat, MD
Howard N. Winfield, MD
Topics
• Introduction and a Disastrous Case
• Detailed Anatomy of Selected Anatomic Sites, Based on Attendee Preconference Questionnaire
• Case Videos and Discussion
• Selected Video Cases/Disasters and Faculty Selected Highlights
#2 Master’s Class in Laparoscopic Treatment of Adhesions for the General Surgeon, Gynecologist, and Urologist Including Abdominal and Pelvic Pain
1:00pm–4:30pm
Faculty
Harry Reich, MD, Director
Michael P. Diamond, MD, Co-Director
James E. Carter, MD, PhD
Nicola Di Lorenzo, MD, PhD
Douglas E. Ott, MD, MBA
Topics
• 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
#3 Master’s Class in Laparoscopy for Complex Problems with Emphasis in Pediatrics and Pregnancy
9:00am–4:30pm
Faculty
Gustavo Stringel, MD, Director
Robert K. Zurawin, MD, Co-Director
Craig Albanese, MD
Tommaso Falcone, MD
Raymond J. Lanzafame, MD, MBA
Topics
• Laparoscopy for Complex Problems in the Pediatric Patient, Including Access and Complications
• Advanced Laparoscopic Procedures in Newborns and Infants
• Laparoscopic Hernia Repair in Children, Including Inguinal Hernia, Umbilical Hernia, and Epigastric and Ventral Hernia
• Laparoscopy for Complex Problems in the Female Adolescent Patient
• Question and Answer with Pediatric Panel
• Laparoscopic Procedures in the Pregnant Patient. Physiological Considerations. Effect on the Mother and Fetus
• Laparoscopic General Surgery Procedures During Pregnancy, Including Laparoscopic Cholecystectomy, Appendectomy and Lysis of Adhesions
• Laparoscopy for Abdominal Tumors: in the Pediatric Patient; in Pediatric and Adolescent Gynecology; in Pregnancy
• The Role of Laparoscopy in Abdominal Pain: the Pediatric Surgeon; the Pediatric Gynecologist; the Pregnant Patient
#4 Master’s Class in Robotic Laparoscopic Surgery Jointly with the Minimaly Invasive Robotic Surgery Association
9:00am–4:30pm
Faculty
Garth Ballantyne, MD, Director and President of MIRA
Santiago Horgan, MD, Co-Director
William E. Kelley, Jr., MD, Co-Director
Arnold Byer, MD
Ara Darzi, MD
Tommaso Falcone, MD
Marc Katz, MD
Jacques Marescaux, MD
Joseph Petelin, MD
Richard M. Satava, MD
Ash Tewari, MD
Topics
• Remote Preserve Robots
• Augmented Reality Surgery
• Telerobotic Bariatric Surgery
• Telerobotic Colorectal Surgery
• Telerobotic Heller Myotomy & Esophagectomy
• MIRA Update
• Telerobotic Urology for Benign Disease
• Telerobotic Preperitoneal Radical Prostectomy
• Telerobotic Vascular Surgery
• Telerobotic Cardiac Surgery
• Telerobotic Gynecologic Surgery
• Remote Mobile Teleconferencing with a Robot Over the Internet
• The Future of Surgical Robotics
#5 Master’s Class in Gynecologic Endoscopic Surgery
9:00am–4:30pm
Faculty
Farr Nezhat, MD, Director
Ceana Nezhat, Co-Director
Jacques Dequesne, MD
Tommaso Falcone, MD
Harrith M. Hasson, MD
Wm. Leroy Heinrichs, MD, PhD
William E. Kelley, Jr., MD
Camran Nezhat, MD
Steven F. Palter, MD
Danny Seidman, MD
Robert Zurawin, MD
Topics
• Safe Abdominal Entry—Complications and Managements
• Laparoscopy and Infertility: Is There any Role?
• Laparoscopic Treatment of Endometriosis in Failed IVF
• Laparoscopy and Hysterectomy: LAVH, TLH, or Supracervical
• Role of Endoscopy in Pelvic Floor Repair
• Anatomical Principals in Laparoscopy: How to Minimize Complications
• New Horizons in Myoma Managements
• Laparoscopy and Gynecological Malignancy: Where We Are and Where We Are Going
• Role of Simulation in Advanced Operative Endoscopy
• Robotics: Past, Present and Future
• Open Laparoscopy: The Original Technique 29 years of Experience
• Evaluation and Management of Bowel Injuries
• My Experience in the Role of Laparoscopy in Japan
• Update in Hysteroscopy, Ablations and Sterilization Techniques
• Hands On Laboratory: New Instruments and Simulators
#6 Master’s Class in Laparoscopic General Surgery Jointly with the Society of American Gastrointestinal and Endoscopic Surgeons
9:00am–4:30pm
Faculty
Michael S. Kavic, MD, Director
W. Peter Geis, MD, Co-Director
William E. Kelley, Jr., MD, Co-Director
Morris E. Franklin, Jr., MD
Santiago Horgan, MD
Raymond J. Lanzafame, MD, MBA
Joseph B. Petelin, MD
Phillip P. Shadduck, MD
Topics
• NOTES: Pipedream or Reality
• Laparoscopic Hernia Repair—the Right Prosthetic
• Endoscopic Options for GERD
• Complex and Recurrent Hiatal Hernia Repair
• Laparoscopic Management Achalsia
• Robotic technology in the Laparoscopic Era
• Laparoscopic Adrenalectomy
• Laparoscopic Splenectomy
• Bariatrics—Laparoscopic Banding/Bypass
• Laparoscopic Options Benign Colon Disease
• Laparoscopic Options Malignant Colon Disease
#8 Master’s Class on How to Assess Competency in Laparocopic Surgery, Includes Hands-On Laboratory
9:00am–4:30pm
Faculty
Harrith M. Hasson, MD, Director
Richard M. Satava, MD, Co-Director
Ara Darzi, MD
Wm. Leroy Heinrichs, MD, PhD
Tadashi Matsuda, MD
Laboratory Faculty
Randy Haluck, MD
Dennis Klassen, MD
Charles H. Koh, MD
Mark L. Smith, MD, PhD
Maria Terry, MD
Topics
• Assessing Cognitive and Technical Skills in Laparoscopic Surgery
• Technical Surgical Proficiency: Basic Laparoscopic Skills
• Virtual Reality Training in Laparoscopic Surgery
• Assessing Laparoscopic Surgical Performance by Reviewing Unedited Video Tapes—The Japanese Experience
• Presentation of Simulators
• Group Discussion With Q&A
• Hands On Practice by Participants
• Summarization
MULTIDISCIPLINARY PLENARY SESSIONS | THURSDAY, SEPTEMBER 7, 2006
INNOVATIONS IN SURGERY AND MEDICINE: FROM THE BENCH TO THE BEDSIDE
Thursday, September 7, 2006
8:30am–10:00am
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, an international, renowned panel will address how to bring an idea to reality for the benefit of 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
Richard M. Satava, MD, Co-Director
Thomas J. Fogarty, MD: How to Start and Bring Your Idea of Surgical Instrument to Reality
Leslie Bottorff, Venture Capitalist: Venture Side of Starting a Company and What to Look for in an Idea
Chris Mitchell, Attorney: How to Start a Company Around Your Idea
INFORMATICS FOR THE LAPAROENDOSCOPIC SURGEON
Thursday, September 7, 2006
10:30am–11:30am
Informatics is primarily concerned with the structure, creation, management, storage, retrieval, dissemination, and transfer of information. This session will provide physicians with introductory knowledge on biomedical informatics with the focus on the current status of telemedicine, electronic medical records, and Internet resources, including medical search engines. Principles of designing a medical database for EMR will be elaborated on, and how to integrate this information into handheld devices will be discussed.
FACULTY AND PRESENTATIONS
Gustavo Stringel, MD, Director: General Informatic Session—Electronic Medical Records, CPOE, HIPAA Compliance, and Evidence Based Medicine
Alex Gandsas, MD, Co-Director:
Your Computer, the Internet and Your PDA (PalmPilot), Searching the Web and Finding Information
Paul Alan Wetter, MD: Introduction—SLS Websites
COMPETENCY AND ITS ASSESSMENT METRICS
Thursday, September 7, 2006
11:30am–12:45pm
Competency and the objective assessment of competency have been mandated by the Accreditation Council on Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS). The Residency Review Committee (RRC) has indicated that all training programs are required to have skills training with the focus of objectively assessing skills competence. This session will review the current approaches to competency and assessment in addition to giving guidance as to the correct definitions and metrics that can be used. There is already a next generation of skills training and methods that are being considered, including criterion-based training and intelligent tutoring, which will be introduced.
FACULTY AND PRESENTATIONS
Richard M. Satava, MD, Director: Competency, Proficiency and the Next Generation of Skills Training and Assessment Curricula Using Simulators
Harrith M. Hasson, MD, Co-Director: Technical Skill—a Component of Surgical Performance
Steve Dawson, MD: A Scientific Basis for Measuring Surgical Skills Using Laparoscopic Simulation
Wm. LeRoy Heinrichs, MD, PhD: Objective Measures of Surgical Competency
Neal Seymour, MD: Predictive Validity of Simulation Performance in Operative Performance
CONCURRENT SCIENTIFIC SESSIONS
LAPAROSCOPY UPDATES
Thurday, September 7, 2006
Presented by the SLS Special Interest Group Committees
Abdominal / Pelvic Pain / Adhesions, Maurice Chung, MD
Biliary Disease and Cholecystectomy, A. Elizabeth Martin, MD
Core Competencies, Gustavo Stringel
Endometriosis/Ovarian, Farr Nezhat, MD
Hernia, Lawrence Biskin, MD
Hysterectomy, Ceana Nezhat, MD
Office and Outpatient Laparoscopy, James F. Carter, MD
Pediatric Surgery, Harsh Grewal, MD
Pelvic Reconstructive Surgery / Stress Incontinence, Conrad Duncan, MD
Robotic Surgery, Ash Tewari, MD
Thoracic Surgery, Neil A. Christie, MD
Urology, Howard Winfield, MD
CONCURRENT SCIENTIFIC SESSIONS
Thursday, September 7, 2006 & Friday, September 8, 2006
Over 200 Scientific Papers, Open Forum Presentations, Videos, and Posters will be presented by SLS members and colleagues from around the world. Preliminary Listing.
GENERAL SURGERY
Role of Subfascial Endoscopic Perforator Surgery (SEPS) by Harmonic Scalpel in Managemant of Chronic Venous Insufficiency of Lower Limbs, Narayan Agarwal MD
Transabdominal Laparoscopic Inguinal Hernia Repair: the Tricks We Have Learned, Which We Want to Propose and Discuss, Ferdinando Agresta MD
Penetrating Abdominal Trauma With no Signs of Peritoneal Penetration, Would a Diagnostic Laparoscopy Avoid a Laparotomy, Syed I Ahmed MD
Gastric Banding Without Fixation Suture
Housam A L Trabulsi MD
Laparoscopic Fundoplication: the Beneficial Effects of Preservation of Short Gastric Vessels, Muhammad Z Aslam MD
Laparoscopic versus Open Nissen Fundoplication in Infants After Neonatal Laparotomy,
Katherine A Barsness MD
One Stage Laparoscopic Roux-en-Y Gastric Bypass Surgery is Safe and Effective in High-Risk Super Obese Patients, Eraj M Basseri MD
Laparoscopic Restorative Proctocolectomy: Is the Anastomosis Compromised?, Joel J Bauer MD
Hand-assisted Laparoscopic Surgery (HALS) in Colorectal Surgery. A Single Institution Experience, Anne-Marie Boller MD
Spleen-preserving Laparoscopic Distal Pancreatectomy, Natalino Bedin MD
Combined Surgical and Endoscopic Rescue of Severe Sepsis Post Bariatric Surgery,
Gianluca Bonanomi MD
Follow-up and Early Referral Are Mandatory in Order to Avoid Late Diagnosis of Adjustable Gastric Banding Complications, Gianluca Bonanomi MD
Seldinger Technique for Band-to-Band Revisional Surgery, Catherine A Boulay MD
Adenomyomatosis and Cholesterolosis of the Gallbladder: Laparotomy Conversion During VLS Cholecystectomy. Case Report, De Werra Carlo MD
Edometriosis of the Cecum Mimicking Acute Appendicitis: a Case Report, Adel Chokki MD
Patient Recall and Comprehension After Laparoscopic Appendectomy, Benjamin L Clapp MD
Minimal Access Thyroidectomy Using an Endoscopic Transaxillary Approach, Titus D Duncan MD
Endoscopic Transaxillary Near Total Thyroidectomy: a Feasibility Study, Titus D Duncan MD
Initial Experience With the Use of the ON-Q Pain Pump During Laparoscopic Ventral Hernia Repair, Roger Ernest DO
Blood Loss in Colonic Surgery. Comparison Between Laparoscopic and Open Techniques,
Greco Francesco MD
Wound Complication in Laparoscopic Roux-en-Y Gastric Bypass, Wesley P Francis MD
Laparoscopic Versus Open Appendectomy in Perforated Appendicitis, Yasuyuki Fukami MD
Laparoscopic Thoracic Duct Ligation, Mark D Gaon MD
Laparoscopic Splenectomy With Hand-Assisted Specimen Extraction in Massive Splenomegaly in Thalassemia Major, Nikolaos I Gatsoulis MD PhD
Videolaparoscopic Treatment of Paraesophageal Hernia, Roberta Gelmini MD
Laparoscopic Nissen With Mesh, George Kevin Gillian MD
Laparoscopic Excision of a Glucagonoma, Timothy E Goundrey MD
Bilateral Pulmonary Artery Thrombus After Laparoscopic Gastric Bypass: a Rare Occurrence,
Ajay Goyal MD
Laparoscopic Retrieval of a Large Retained Fecalith After Laparoscopic Appendectomy,
Bryan S Helsel MD
Mucocele of the Appendix, Fernando A Herrera MD
Laparoscopic Cholecystectomy With Combined Method, Ryuichi Hotta MD
Assessment of Surgical Trainees for Technical Errors Enacted by Using Instrument Differently: Observational Clinical Human Reliability Analysis (OCHRA), Mubashar Hussain Dr Med
Objective Assessment of Surgical Trainees for Their Technical Errors by Observational Clinical Human Reliability Analysis, Mubashar Hussain Dr Med
Small Bowel Obstruction After Laparascopic Roux-en-Y Gastric Bypass, Muhammad Jawad MD
The Impact of Laparoscopic Gastric Bypass Surgery on C-Reactive Protein Levels, Neel R Joshi MD
Conversion to Laparoscopy?, Daniel S Kim MD
Congenital Diaphragmatic Falciform Ligament Herniation: a Rare Case, Dan G Kolder MD
Randomized Clinical Trial of Three-Port vs Standard Four-Port Laparoscopic Cholecystectomy,
Manoj Kumar MD
Gangrenous Cholecystytis: Laparoscopic Treatment, Sebastiano Lacitignola MD
Polytetrafluoroethylene Patch Repair for Large Hiatal Hernia, Luis E. Laguna MD
Laparoscopic Colectomy for Bening and Malignant Diseases, Luis Enrique Laguna MD
The Impact of Routine Preoperative ERCP in Gallstone Pancreatitis, Jonathan A Laryea MD
Selective, Versus Routine, Upper GI Series Leads to Equal Morbidity and Reduced Hospital Stay in Laparoscopic Gastric Bypass Patients, Sophia D. Lee MD
Intracorporeal Stapled Billroth-I Gastroduodenostomy Using Hand-Access Device, Young-Joon Lee MD
Patient Satisfaction After Laparoscopic Cholecystectomy, Kiran M Lodha MD
Patients Paying for Bariatric Surgery Out of Pocket, Atul K Madan MD
Routine Histology of Gallbladder in Laparoscopic Era. Is There Any Justification?, Sajid Mahmud MD
Our Experience in TAPP Hernia Repair, Lombardi Marco MD
Long-term Results in Stapled Hemorrhoidectomy, Lombardi Marco MD
Laparoscopic Resection With Intraoperative Radiotherapy: a New Step in the Multimodal Treatment of Advanced Colorectal Cancer, Civello Ignazio Massimo Prof Dr Med
Is it Appropriate That Laparoscopy-assisted Gastrectomy With Extended Lymph Node Dissection is Performed in Advanced Gastric Cancer?, Young-Joon Moon MD
Laparoscopic Preperitoneal Inguinal Hernia Repair Using Preformed Polyester Mesh Without Fixation—4 Year Study, John E Morrison MD
Role of Diagnostic Laparoscopy in Penetrating Abdominal Stab Wounds, Albeir Mousa MD
Pathophysiology of Parietal and Visceral Peritoneum Tissue Acidosis During CO2 Pneumoperitoneum, Ospan A Mynbaev MD PhD
Pathophysiology of Peritoneal Tissue Acidosis During Laparoscopic Surgery, Ospan A Mynbaev MD PhD
Role and Value of the Predictive Factors of Common Biliary Duct Lithiasis in Preparation to the Laparoscopic Cholecystectomy. Retrospective Study, Vincenzo Neri MD
Significance of Laparoscopic Live Donor Nephrectomy: Lessons Learnd From 128 Cases,
Andreas Paul Prof Dr Med
A Synthetic Cyanoacrylate Tissue Sealant Impairs Tissue Integration of Macroporous Mesh in Experimental Hernia Repair, Alexander H Petter-Puchner MD
Equine Cross Linked Collagen Implants for Experimental Incisional Hernia Repair, Alexander H Petter-Puchner MD
Mesh Fixation With Fibrin Sealant in Transabdominal Preperitoneal Mesh Repair: Recurrence and Impact on Quality of Life Evaluated in a Prospective Manner, Alexander H Petter-Puchner MD
Videothoracoscopic Neurophrenicotomy, Igor Polianskyi Prof Dr Med
Laparoscopic Laddís Procedure in an Adult Male with Symptomatic Malrotation, Emil L Popa MD
A Pilot Study Evaluating a Novel Magnetic Gasless Laparoscopy Device in Porcine Laparoscopic Liver Resections, Adam Howard Power MD
Initial Experience With the Use of the ON-Q Pain Pump During Laparoscopic Inguinal Hernia Repair, Anuj Prashar DO
Chronic Pain After Laparoscopic Repair of Ventral and Incisional Hernia, Srdjan Rakic MD PhD
Laparoscopic Appendectomy in Patients With a Body Mass Index of 25 or Greater, Robert L Ricca MD
Transgastric Surgery: Current Indications and Future Implications, Kurt E Roberts MD
Laparoscopic-assisted, Transgastric Endoscopy: Current Indications and Future Implications,
Roberts E. Roberts MD
Difficulty of Laparoscopic Heller Myotomy Is Not Determined by Preoperative Therapy and Neither Difficulty of Myotomy nor Preoperative Therapy Determine Long-term Outcome,
Alexander Rosemurgy MD
K-ras Mutation as Prognostic Factor in Procedure of the Colorectal Cancer—Laparoscopic vs Laparotomic Approach, Lukas Sakra MD
Autologous Skin Grafting With Bioabsorbable Stent for Widespread Endoscopic Mucosal Resection of the Esophagus, Tadashi Sakurai MD
Assessing Decision Making in Laparoscopic Surgery, Sudip K Sarker MD PhD
Chronic Inguinal Pain After Laparoscopic Inguinal Hernia Repair: the Role of Tack and Mesh Removal, Jeffrey D Sedlack MD
A Ten Year Single Surgeon Experience With Laparoscopic Appendectomy, Jeffrey D Sedlack MD
Laparoscopic Approach in Acute Cholecystitis, Dragos Stojanovic MD PhD
Intussusception as a Complication Following Roux en Y Gastric Bypass, Renee E Thompson MD
Social History of Patients Undergoing Laparoscopic Bariatric Surgery, David S Tichansky MD
Major Bile Duct Injuries After Laparoscopic Choleystectomy: a Tertiary Center Experience,
Juergen Treckmann MD
Laparoscopic Treatment of Rectal Cancer: Tips, Tricks, and Limits, Paolo Ubiali MD
Trocar Port Site Incisional Hernias After Laparoscopic Surgery, Ali Uzunkoy Prof Dr Med
Hernia Recurrence in Right Subcostal Incisions After Laparoscopic Repair, Eelco Wassenaar MD
Laparoscopic Repair of Umbilical Hernia: One Hundred Fifty-four Consecutive Corrections,
Eelco Wassenaar MD
The Aesthetic Inguinal Herniorrhaphy: a Single Umbilical Incision Technique, James A Westervelt MD
GYNECOLOGY
Ruptured Non-Communicating Hemi-uterus Presenting With Acute Pelvic Pain, Mark Howard Amols MD
Biopsy of Sentinel Lymph Node Improves Staging of Early Cervical Cancer, Anne-Sophie Bats MD
Analyzing Tension Free Vaginal Tape-Obturator (TVT-O) Suburethral Sling Procedures With Integrated Definition (IDEF0) Modeling Language and Performance Audits of Intraoperative Video,
James Dean Bauer MD
Embryoscopy in Recurrent Pregnancy Loss, Howard J A Carp Prof Dr Med
Day Surgery Laparoscopic Subtotal Hysterectomy: a Multicentered Study With 250 Patients,
Stefanos Chandakas MD PhD
The Safety of Helica Thermal Coagulator in the Treatment of Endometriosis: a Series of 500 Patients, Stefanos Chandakas MD PhD
Pelvic Peritonitis After Laparoscopic Supra Cervical Hysterectomy, Leroy Charles MD
Reactionary Haemorrhage in Gynaecological Surgery, Mark Erian MD
Intraoperative Sentinel Node Detection Using Technetium-99m Sulfur Colloid Predicts Nodal Metastases in Patients With Early-Stage Cervical Cancer, Amanda Nickles Fader MD
Myolysis Revisited, Herbert A Goldfarb MD
Minimally Invasive Outpatient Treatment for Bowel (Fecal) Incontinence: a New Procedure for the Gynecologist, Stephen A Grochmal MD
The Identification of Bowel Incontinence in Gynecologic Practice: a Multicenter Investigation of a New Questionnaire, Stephen A Grochmal MD
Moving Forward With Breast Endoscopy: From Diagnostic to Interventional Ductoscopy,
Volker R Jacobs MD PhD
Laparoscopic Treatment of Infiltrated Endometriosis, Francesco La Grotta MD
Influence of Surgical Access on Outcome of Early Borderline Ovarian Tumors.,
Fabrice R Lecuru MD PhD
Diagnostic Hysteroscopy Findings During Follow-Up of Women With HNPCC, Fabrice R Lecuru MD PhD
Effect of Carbon Dioxide Pneumoperitoneum During Laparoscopic Surgery on Morphology of Peritoneum, Yan Liu MD
The Anatomic Relationship of the Umbilicus to Retroperitoneal Major Vessels, Yan Liu MD
Complications of Hysterectomy, Sadok Mohamed Dr Med
Ectopic Pregnancy, Sadok Mohamed Dr Med
Breast Cancer, Sadok Mohamed Dr Med
CISH Hysterectomy 15 Year Perspective, John E Morrison MD
A Comparative Study of Hysteroscopic Sterilization Performed In-office Versus a Hospital Operating Room, Mark Nichols MD
Usefulness of Minihysteroscopic Bipolar Coagulation for Bleeding Control After Removal of Transcervically Prolapsed Myoma on OPD Basis, Sung-Tack Oh MD PhD
The Usefulness of Minihysteroscopic Bipolar Coagulation of Bleeding Point, Sung-Tack Oh MD PhD
Second Look Laparoscopy for Severe Endometriosis: Does Reoperation Within One Year of Initial Surgery Improve Patients Pain?, Hilda Elena Rodriguez MD
Laparoscopic Hysterectomy with Retroperitoneal Dissection and Uterine Artery Occulsion,
Jay P Shah MD
Da Vinci Assisted Laparoscopic Sacrocolpopexy, Amir Shariati MD
Laparoscopic Tubal Anastomosis, Jonathan Y Song MD
Laparoscopic Approach to the Large Leiomyoma, Jonathan Y Song MD
Pregnant Woman With Dermoid Cyst Developing in an Accessory Ovary Located in the Left Infundibulopelvic Ligament, Hidenori Takashi MD
Primary Omental Ectopic Pregnancy. A Case Report, Hidenori Takashi MD
Laparoscopic Findings in Serious Surface Papillary Carcinoma—A Case Report, Takashi Yamada MD PhD
Laparoscopic Appendectomies Performed by Gynecologists in Women With Pelvic Pain,
Parveen S Vahora MD
Fertiloscopy: Review of a 1500 Cases Continuous Series, Antoine A Watrelot MD
Laparoscopic Resection of Retroperitoneal Cyst, Tomone Yano MD
UROLOGY
Techniques for Laparoscopic Localization of Intraluminal Ureteral Pathology, Ronney Abaza MD
Da Vinci-assisted vs Pure Laparoscopic Aortorenal Bypass in an Acute Porcine Model, Ronney Abaza MD
Robotic-assisted Pyeloplasty With Synchronous Removal of Renal Calculi in the Adult Patient: Technical Modifications, Fatih Atug MD
Robotic Pyeloplasty in Children, Fatih Atug MD
Transurethral Excision of the Distal Ureter and Retroperitoneoscopic Radical Nephroureterectomy With Three Ports in Modified Lithotomy Position, Yildirim Bayazit MD
Comparison of Healing After Cystotomy and Repair With Fibrin Glue and Sutured Closure in the Porcine Model, James F Borin MD
Robotic Partial Ureterectomy for Upper Ureteral Tumor: a Conservative Approach, Erik P Castle MD
Standardized Evaluation of Complications of Robotic Radical Prostatectomy, Erik P Castle MD
Positive Surgical Margins in Robotic Radical Prostatectomies: Impact of Learning Curve on Oncologic Outcomes, Erik P Castle MD
Laparoscopic En Bloc Resection of Locally Advanced Renal Cell Carcinoma and Overlying Right Colon: a Multidisciplinary Approach, Erik P Castle MD
Laparoscopic Nephrolithotomy: a Minimally Invasive Treatment Option, Erik P Castle MD
Robotic-assisted Radical Cystoprostatectomy With Extended Bilateral Pelvic Lymphadenectomy and Orthotopic Neobladder, Erik P Castle MD
Initial Experience With Robotic-assisted Radical Cystectomy in 17 Cases, Erik P Castle MD
High Power (80 W) Potassium-Titanyl-Phosphate (KTP) Laser Photoselective Vaporization Prostatectomy (PVP) for Symptomatic Benign Prostatic Hyperplasia (BPH), Daniel J Culkin MD
Laparoscopic-assisted Lysis of Fibrotic Capsule Around Penile Prosthesis Reservoir and Placement of Artificial Urinary Sphincter, Brian H Eisner MD
Incidence of Urothelial Carcinoma Recurrence Following Hand-assisted Laparoscopic Nephroureterectomy With Cystoscopic en Bloc Excision of the Distal Ureter and Bladder Cuff,
Arthur E Fetzer MD
Laparoscopic Donor Nephrectomy: a Review of the Last 220 Cases, Christopher Ip MD
Pediatric Laparoscopic Pyeloplasty, Po N Lam MD
Percutaneous Cystolithotomy of Large Urinary Diversion Calculi Using a Combination of Laparoscopic and Endourologic Techniques, Po N. Lam MD
Video of Complications During Laparoscopic Nephrectomy and Adrenalectomy, Michael C Lipke MD
Open Adrenalectomy: Has Laparoscopy Made It Obsolete?, Michael C Lipke MD
Laparoscopic Donor Nephrectomy in the Presence of a Circumaortic Renal Vein, Gregory G Lovallo MD
Conversion From Open to Robotic-assisted Radical Prostatectomy is Associated With a Reduction of Positive Surgical Margins Amongst Private Practice Based Urologists, Ralph R Madeb MD
Tips and Tricks to Facilitate Renal Parenchymal Suturing During Laparoscopic Partial Nephrectomy, Elspeth M McDougall MD
Laparosopic Adrenalectomy for Benign And Malignant Adrenal Lesions Using a Novel Vessel-Sealing System: a Combined Experience, Ravi Munver MD
The Learning Curve for Robotic-assisted Laparoscopic Radical Prostatectomy: a Multiinstitutional Experience of Laparoscopic and Oncologic Trained Urologists, Ravi Munver MD
Robotic Radical Prostatectomy: Histopathologic and Short Term Biochemical Recurrence Data at One Year, Vipul R Patel MD
Laparoscopic Inguinal Hernia Repair During Laparoscopic Radical Prostatectomy, David M Rodin MD
Asymptomatic Unilateral Urolithiasis in Living Donor Transplant Kidneys, Chandru P Sundaram MD
Complications in 253 Laparoscopic Donor Nephrectomies, Chandru P Sundaram MD
Laparoscopic Management of Renal Cell Carcinoma With Complete Renal Vein Tumor Thrombus,
Raju Thomas MD
The Large Adrenal Tumor: Laparoscopic Adrenalectomy Technique, Raju Thomas MD
Laparoscopic Donor Nephrectomy in the Setting of Multiple Vessels or Anomalous Vasculature,
Ilya A Volfson MD
Effect of Vascular Clamping on Partial Nephrectomies, Melissa M Walls MD
High Power (80 W) Potassium-Titanyl-Phosphate (KTP) Laser Photoselective Vaporization Prostatectomy (PVP) for Large Volume Benign Prostatic Hyperplasia (BPH), Carson Wong MD
High Power (80 W) Potassium-Titanyl-Phosphate (KTP) Laser Photoselective Vaporization Prostatectomy (PVP) for Refractory Urinary Retention Secondary to Benign Prostatic Hyperplasia (BPH), Carson Wong MD
MULTISPECIALTY
Intravesical Jump Start Therapy Using a Therapeutic Cocktail for the Treatment of Interstitial Cystitis, Jeffrey R Dell MD
Short-Term Impact of a Laparoscopic Mini-Residency Experience on Postgraduate Urologists Practice Patterns, Elspeth M McDougall MD
Construct Validity Testing of the Lapmentor™ Laparoscopic Surgical Simulator,
Elspeth M McDougall MD
Developing a Laparoscopic Skills Curriculum Using Virtual Reality Simulation, Kurt E Roberts MD
Minilaparoscopy-assisted Natural Orifice Surgery, Daniel A Tsin MD
Laparoscopic Pelvic Lymph Node Dissection and Radical Prostatectomy by a Transperitoneal or an Extraperitoneal Method: Impact of Different Types of Previous Inguinal Hernia Repair,
Ramakrishna Venkatesh MD
GENERAL INFORMATION
CONGRESS FEES
Registration Deadline: August 23, 2006
SLS physician members register online by July 6, 2006 and save $100
Congress $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 Congress Registration fee. Application deadline: May 5, 2006.
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 SLS designates this educational activity for a maximum of 26 category 1 credits toward the AMA Physician’s Recognition Award(TM). Each physician should claim only those credits that he/she actually spent in the activity.
Half-Day Master’s Classes: 3 credits
Full-Day Master’s Classes: 6 credits
15th International Congress: 3 days: 20 credits
DESTINATION: BOSTON, MASSACHUSETTS
Boston is one of America’s oldest cities and is home to some of the world’s finest inpatient hospitals, many institutions of higher education, and numerous cultural and professional sports organizations. Tourism is one of Boston's and New England's largest industries, and as a result you will find that Boston is a city willing to accommodate and entertain you as few other cities can.
For more information on tours, sites, shopping, and everything Boston, visit http://boston.com/travel/boston/.
ACCOMMODATIONS AND TRAVEL
The Westin Copley Place
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EXHIBIT HALL EVENTS
WELCOME RECEPTION: Kick off the congress 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.
Old friends, Paul Alan Wetter and Liselotte Mettler,
meet new technology at Endo Expo 2005
SLS CYBER CAFE: 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 15th International Congress and Endo
Expo 2006. 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, Toll free 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 8, 2006. 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, Toll
free 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 shoot out, you use your nondominant hand. See who’s fastest on the draw—or stitch—in this entertaining, but challenging, training exercise in minimally invasive surgical procedures. Congratulations to last year’s winner, Roderick Brown, MD. See if you will take home the trophy this year and be named the “fastest draw” in SLS’ 2006 Top Gun Laparoscopy Shoot Out!
Top Gun host, James C. Rosser, Jr., and
the 2005 Top Gun winners
15TH SLS ANNUAL MEETING AND ENDO EXPO 2006 SCIENTIFIC ABSTRACTS
Supplement to
JSLS, JOURNAL OF THE SOCIETY OF LAPAROENDOSCOPIC SURGEONS
VOLUME 10, NUMBER 3
6101 General Surgery
Laparoscopic Fundoplication: the Beneficial Effects of Preservation of Short Gastric Vessels
M. Z. Aslam, MBBS, D. Garkuwa, FRCS, S. Johnson, MRCS, R. Rajagopal, FRCS, K. S. Wynne, FRCS
South Shields General Hospital
Introduction: In the operative treatment of gastroesophageal reflux disease, division or preservation of short gastric vessels has always remained a subject of controversy. This randomized study was performed to determine whether the preservation of short gastric vessels during laparoscopic fundoplication achieves an acceptably low incidence of postoperative complications while at the same time providing adequate control of reflux, and conferring long-term clinical benefit to the patient.
Methods: From January 2000 to January 2003, 73 patients (M: 36, F: 37; mean age, 44 years) with proven gastroesophageal reflux disease underwent laparoscopic fundoplication with preservation of short gastric vessels. Patients with esophageal motility disorder, with concurrent abdominal surgery or with a previous reflux surgery were excluded from the study. Clinical assessment was performed using a standardized clinical grading system to assess dysphagia, heartburn, bloating, and epigastric pain at 1, 6, and 12 months postoperatively.
Results: Average operating time was 45 minutes to 60 minutes, no open conversion was needed, and the average hospital stay was 36 hours. Postoperatively, the incidence of heartburn was 7% (5 patients) at 1 month and 1 year. The incidence of postoperative dysphagia and gas bloating was 27% (20) and 10% (7), respectively, at 1 month, which dropped down to 7% (5) and 1.4% (1), respectively, at 1 year. The overall patient satisfaction rate was 90% (65).
Conclusion: Preservation of short gastric vessels brings good results without an increase in dysphagia. The added benefits are reduced bloating, operating time, morbidity, and consequently hospital stay.
6102 Gynecology
Pathophysiology of Peritoneal Tissue Acidosis During Laparoscopic Surgery
O. A. Mynbaev, L. Dollé, S. Pismensky, C. A. Jacobi, B. Vanacker, M. Bracke
VUB, Belgium
Introduction: Parietal peritoneum (PP) acidosis during laparoscopy is a well-established phenomenon and a poorly understood mechanism. Our aim was to study the mechanism of PP acidosis during CO2 pneumoperitoneum.
Methods: “Because venous CO2 tension is considered representative of tissue PCO2.,” we monitored arterial and venous blood gas and acid-base and metabolite-lactate parameters during CO2 pneumoperitoneum in 10 anesthetized-ventilated rabbits (AVR) with increasing intraperitoneal pressure (IPP: 0, 5, 10, 15mm Hg) every 15 minutes. Blood flow was monitored in the abdominal aorta in 5 animals and in the inferior vena cava in another 5. Baseline parameters were obtained from 6 AVR.
Results: We found high pronounced PvCO2 and PaCO2 with corresponding decreased pH and increased lactate concentrations in both venous and arterial blood. Overall acid-base parameter changes were related to CO2 accumulation. Abdominal aorta and inferior vena cava blood flow were significantly affected.
Conclusions: The suggested mechanism of PP tissue acidosis during CO2 pneumoperitoneum is the considerably high mesothelial surface CO2 tension with subsequent CO2 saturation underlying PP tissue due to continuous CO2 insufflation. CO2 passes through PP and accumulates in venous and arterial blood due to increased tissue-to-venous and venous-to-arterial CO2 tension differences. PP acidosis severity directly depends on CO2 insufflation and its absorption, whereas the severity of blood gas and blood flow disturbances is related to the degree of IPP. Increased lactate concentrations and high tissue acidosis in hypoxic PP tissue can be the suitable microenvironment for rapid invasion and metastasis of transplanted cancer cells into the basal membrane after removing malignant tumors from the abdominal cavity via laparoscopy.
6103 Gynecology
Congenital Diaphragmatic Falciform Ligament Herniation: A Rare Case
D. G. Kolder, MD, W. S. Eubanks, MD
University of Missouri Hospitals and Clinics
The occurrence of diaphragmatic herniation involving only the falciform ligament is rare. In the era of minimally invasive surgery, herniation through the falciform ligament from multiple causes has been described. Several types of congenital and acquired hernias of the diaphragm have been well-defined. Anterior congenital hernias of the diaphragm (hernia of Morgagni) are rare and when detected, rarely contain liver or the falciform ligament. We present an unusual case of congenital herniation of the diaphragm containing the falciform ligament. The asymptomatic finding was discovered at laparoscopy, a finding not yet described in the literature.
6104 General Surgery
Randomized Clinical Trial of Three-Port Versus Standard Four-Port Laparoscopic Cholecystectomy
Manoj Kumar, MD, Akshay Pratap, MD, C. S. Agrawal, MD
B. P. Koirala Institute of Health Sciences, Dharan, Nepal
Introduction: Laparoscopic cholecystectomy (LC) for gallstone disease is widely accepted as a standard procedure performed using 4 trocars. The fourth (lateral) trocar is used to grasp the fundus of the gallbladder so as to expose Calot's triangle. It has been argued that the fourth trocar may not be necessary in most cases and that LC can be done safely with only 3 ports. The aim of this study was to investigate the technical feasibility, safety, and benefit of 3-port laparoscopic cholecystectomy versus standard 4-port laparoscopic cholecystectomy in our set up.
Methods: Between September 2004 and January 2005, 70 consecutive patients undergoing elective laparoscopic cholecystectomy for gallstone disease were randomized to be treated via either the 3-port or 4-port technique. Postoperative pain was assessed by using a 10-cm unscaled visual analogue score at the first, sixth, twelfth, and twenty-fourth hours after surgery.
Results: Demographic data were comparable in both groups. No difference was noted in the 2 groups regarding age, sex, weight, and ethnicity. In terms of outcome, no difference existed in success rate, quantity of oral analgesic (diclofenac sodium) requirement, or postoperative hospital stay. Overall pain score and patient satisfaction score were slightly better in the 3-port group. Patients in the 3-port group had shorter mean operative time (42.4 min vs. 64.3 min) than the 4-port group had.
Conclusion: The 3-port technique is as safe as the standard 4-port technique. The main advantages of the 3-port technique are that it causes less pain, is less expensive, and leaves fewer scars.
6106 General Surgery
Histology Examination of the Gallbladder in the Laparoscopic Era: Is it Justified?
Sajid Mahmud, MD, Il Alam, I. Alhamdani
Morriston Hospital, Swansea
Introduction: Gallbladder carcinoma (GBCa) is a rare malignancy that has a very poor prognosis. Laparoscopic cholecystectomy (LC) is the gold standard treatment for symptomatic gallstones. The aim of our study was to assess the incidence of GBCa and the possibility of reducing the routine histological examination of gallbladder specimens.
Method: Pathology laboratory data of gallbladder specimens over a 5-year period (June 2000 through July 2005) were analyzed retrospectively. The case notes were retrieved in all cases of malignancies.
Results: This study comprised 1452 specimen. Four (0.27%) cases of primary GBCa, 1 of primary B-cell lymphoma, 1 of secondary carcinoma, and 1 of intraepithelial neoplasia were detected. Operative notes revealed that a high index existed of suspicion of malignancy in all cases. Of the 4 primary GBCa, 3 were stage T2 and 1 was T4. Preoperative ultrasound suspected carcinoma in only 1 case but a thickened gallbladder wall was noted in all cases.
Conclusion: All cases of GBCa were suspected preoperatively or intraoperatively. Histological examination did not alter the management or outcome in any of the cases. We suggest that selectively sending specimens for histopathological examination would result in reduced demands on the histopathology department without compromising patient safety.
6107 General Surgery
Videothoracoscopic Neurophrenicotomy
Igor Polianskyi, Prof Dr Med, Yaroslav Dupeshko, MD, Vyacheslav Sakhatskyy, MD
Bukovinian State Medical Academy Chernivtsy
Introduction: Videolaparoscopic neurophrenicotomy is used to perform denervation of the diaphragm. The operation is indicated where denervation of the diaphragm is necessary to liquidate the residual cavity after pulmonectomy in cases of involuntary contractions of the diaphragm and in other cases. Morphological studies carried out on adult corpses revealed that phrenic nerves are situated on the surface of the pericardium and associated intimately with a. pericardiacophrenica and v. pericardiacophrenica. This structure reaches the diaphragm through the pericardiophrenicum positioning itself between the ligament’s leaves.
Methods: Based on the discovered patterns of topographic interrelations, we propose a small invasive neurophrenicotomy technique. With the patient in the supine position, the first trocar is inserted into the pleural cavity through the VII to VIII intercoastal spaces on the midauxiliary line. Through this port, a video camera is inserted. The lungs are collapsed by carbon dioxide insufflation. The second trocar is inserted through the IV intercoastal space on the anterior auxiliary line. The pericardiophrenicum ligament is mobilized between the pericardium and diaphragm by using the dissector. The ligament is cut between 2 applied clips. Relaxation of the diaphragm and the absence of its contraction after irritation of the phrenic nerve distal to the severance of the ligament can be used to prove adequate dissection of the phrenic nerve.
Results: The operation ended with pleural cavity drainage through one of the trocars.
Conclusion: The method proposed has been used in the clinical setting with favorable results.
6108 Urology
Conversion from Open to Robotic-Assisted Radical Prostatectomy Is Associated with a Reduction in Positive Surgical Margins Among Private Practice-Based Urologists
Ralph Madeb, Dragan Golijanin, Craig Nicholson, Joy Knopf, Kelly Picone, Frederick Tonetti, John R. Valvo, Louis Eichel
Center of Urology and University of Rochester School of Medicine, Rochester, New York
Introduction: Several recent studies have suggested that leaders in robotic surgery have decreased their own positive margin rates by switching from open to robot-assisted radical prostatectomy. Theoretically, this improvement is largely attributed to enhanced visualization of the deep pelvis and precision of dissection afforded by the instrumentation. To date, it has not been determined whether this phenomenon exists among nonfellowship-trained urologists in private practice. Herein, we describe the positive margin rates of 2 nonfellowship-trained private practice urologists who converted from open radical retropubic prostatectomy to robot-assisted laparoscopic radical prostatectomy.
Methods: The margin positivity data from 2 nonfellowship-trained, private practice urologists (surgeon 1 and surgeon 2) were reviewed retrospectively. The last 50 cases of open radical retropubic prostatectomy from each surgeon were compared with the first 50 and 43 robotic prostatectomy cases of surgeons 1 and 2, respectively. A positive surgical margin was defined as a tumor present at the inked margin of the prostate.
Results: A significant decrease occurred in the overall and pT2 positive margin rates for both surgeons. The overall positive margin rate and pT2 positive margin rate for surgeon 1 dropped from 44% to 20% and from 37% to 5.7%, respectively, after changing from open to robotic prostatectomy. For surgeon 2, the overall positive margin rate changed from 26% to 16% and the pT2 positive margin rate changed from 27.5% to 8% after converting.
Conclusion: Changing from open to robotic-assisted radical prostatectomy may improve the ability of urologists to obtain negative surgical margins. This phenomenon does seem to apply to nonfellowship-trained urologists in private practice and can be realized within the first 50 cases performed.
6109 General Surgery
Role of Subfascial Endoscopic Perforator Surgery (SEPS) by Harmonic Scalpel in the Management of Chronic Venous Insufficiency of the Lower Limbs
P. N. Agarwal, Ravi Kant, Sudhir K. Jain
Maulana Azad Medical College, University of New Delhi, New Delhi, India
Introduction: Thirty patients suffering from chronic venous insufficiency of the lower limbs were selected for this study. Disease in all patients was classified as class 3 through class 5 according to CEAPS classification. Ten patients had only skin changes, 8 had skin changes plus healed venous ulcers, and 12 had active venous ulcers.
Methods: Color Doppler was used in all patients to evaluate the venous system of both lower limbs to look for perforators and incompetence of the sapheno-femoral of sapheno-popliteal junction. All patients underwent subfascial endoscopic perforator surgery (SEPS) with the 2-port technique. A Harmonic scalpel was used to manage the perforators. SEPS was combined with flush ligation of sapheno-femoral junction and stripping of the long saphenous vein up to the knee joint. Patients were followed up in the surgical clinic on a monthly basis for 12 months. At 1-month follow-up, a repeat color Doppler study of the lower limb veins was performed to look for any residual perforators. In the follow-up, patients were monitored for healing of ulcers and reversal of skin changes. A note was also made of cosmetic outcome and return to activity.
Results: Ulcers have healed in all the patients, cosmetic results were good, and return to normal activity was early. No patient has experienced a recurrence. One patient developed wound infection and was managed with appropriate antibiotics. Early discharge of patients from the hospital was possible in all cases.
Conclusion: Our results are very encouraging. SEPS as a procedure of choice for the management of chronic venous disease of the lower limbs may have an appropriate role in the surgeon’s armamentarium.
6110 General Surgery
Combined Surgical and Endoscopic Rescue of Severe Sepsis After Bariatric Surgery
Gianluca Bonanomi, MD, Mario Traina, MD, Ilaria Tarantino, MD, Simona Di Caro, MD, Bruno Gridelli, MD
Minimally Invasive and Bariatric Surgery Program, Istituto Mediterraneo Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
Introduction: Gastric fistula is a serious complication of vertical banded gastroplasty. Failure to control the leakage and development of sepsis can lead to prolonged hospitalization and mortality.
Methods: A 32-year-old morbidly obese male was transferred to our intensive care unit with a clinical picture of severe sepsis following open vertical banded gastroplasty that was performed at another institution. The patient underwent 2 surgical attempts at fistula closure that were unsuccessful. On admission, the patient was critically ill, mechanically ventilated through a tracheostomy, and the abdominal laparotomy was completely dehiscent.
Results: Emergent abdominal CT scan with gastrographin showed the presence of high output gastric fistula at the angle of His and diffuse peritoneal collection. The patient underwent combined surgical placement of peritoneal drains and intraoperative endoscopic injection of cyanoacrylate glue and placement of a self-expanding covered stent over the fistula. The patient recovered from sepsis and was discharged home in fair clinical condition. At 1-year follow-up, the patient was stable, and an upper endoscopy was negative for stenosis or ulceration.
Conclusion: Combined surgical and endoscopic management of high output leakage following vertical banded gastroplasty may be a successful option to rescue patients with life-threatening sepsis.
6112 General Surgery
Role of Diagnostic Laparoscopy in Penetrating Abdominal Stab Wounds
Albeir Mousa, MD
Brookdale University Hospital and Medical Center
Introduction: The role of diagnostic laparoscopy (DL) in abdominal stab wounds (ASW) is not well characterized. This study was to define the role of DL in minimizing the number of exploratory laparotomies (EL).
Methods: Our trauma registry and operative log were used to identify patients with penetrating stab wound injuries to the anterior abdominal wall, who underwent laparoscopy with or without laparotomy during the past 36 months. Patient demographics, operative findings, complications, and length of stay were reviewed. The number of laparoscopic explorations, and therapeutic, nontherapeutic, and negative laparotomies were analyzed.
Results: There were 66 DL performed for ASW. Among those, only 37 were converted to EL. Peritoneal violations (PV) were present in 41 patients, and 30 of 37 (81%) EL were therapeutic laparotomies (TL). By using DL, 25 (38%) EL were prevented. Four patients had peritoneal violations on DL but did not undergo exploratory laparotomy. Seven of the 37 (19%) patients who underwent initial EL had a nontherapeutic laparotomy (NTL). All patients who underwent only DL were discharged within 36 hours, while patients who had NTL were discharged within 72 hours. No mortality and morbidity occurred within the DL group. Mean follow-up was 13 months, and no associated complications were encountered during this time.
Conclusions: Laparoscopy has an important diagnostic role in stable patients with penetrating abdominal trauma. It minimizes the number of negative exploratory laparotomies performed. In carefully selected patients, therapeutic laparoscopy is practical, feasible, and offers all the advantages of minimally invasive surgery. Evidence of PV is a reasonable indicator to determine the need for exploratory laparotomy and reduce nontherapeutic laparotomy.
6113 Gynecology
Embryoscopy in Recurrent Pregnancy Loss
H. J. A. Carp, MB, BS, FRCOG
Department of Obstetrics & Gynecology; Sheba Medical Center, Tel Hashomer, Tel Aviv University, Israel
Recurrent miscarriage can be due to maternal or embryonic causes. Maternal causes have been widely researched, but the treatment of maternal causes has been confounded by abnormal embryos that have not been diagnosed. Fetal causes of pregnancy loss include structural anomalies that are incompatible with life and chromosomal aberrations. The diagnosis of both of these is problematic at present. Eighty-nine percent of recurrent miscarriages occur in the first trimester, when the embryo is too small to be diagnosed as normal or abnormal on ultrasound. Phillip and Kalousek have reported that 31% of missed abortions are "disorganized," ie, structurally abnormal on embryoscopy. Embryonic karyotyping is problematic due to the overgrowth of maternal tissue, infection of the preparation, and culture failure. Ferro et al have used embryoscopy to take a directed sample from the embryo, thereby avoiding contamination by maternal tissue. A pilot study on embryoscopy is being carried out at the Sheba Medical Center to accurately diagnose structural anomalies (disorganized embryos) and to take an accurate biopsy of embryonic tissue for karyotyping. After confirmation of a missed abortion by ultrasound, embryoscopy is performed with the patient under general anesthesia during dilatation and curettage. The embryo is visualized, the findings are recorded, and biopsies are taken from the embryo and placental villi for genetic analysis. The importance of accurate diagnosis in recurrent miscarriage cannot be overstressed. Until now, the various treatments for maternal causes of pregnancy loss (immunotherapy, thromboprophylaxis, hormone support, and others) and for fetal causes (PGD) have been assessed on an empirical basis. Embryoscopy allows these treatment modalities to be assessed rationally in an evidence-based approach when an accurate diagnosis of cause is available.
6114 General Surgery
Laparoscopic Retrieval of a Large Retained Fecalith after Laparoscopic Appendectomy
Bryan S. Helsel, MD, Christopher H. Moon, MD, Richard K. Inae, MD, Ian H. Freeman, MD
Department of Surgery, Tripler Army Medical Center, Tripler, Hawaii
Introduction: Retained fecaliths after an appendectomy is a rare event. Due to the associated high rate of abscess formation, most authorities recommend removal. Difficulty locating a lost fecalith may necessitate open conversion of a laparoscopic procedure.
Methods: We report the case of a 25-year-old male who underwent laparoscopic appendectomy for a gangrenous, perforated appendix. He was found to have a large fecalith, 12x10mm in size. During the procedure, it was lost. Despite a detailed and careful exploration, we were unable to find and extract the fecalith. Postoperatively, the patient developed an ileus. Radiographic studies were performed of adjacent tissue. On postoperative day 4, an exploratory laparoscopy was performed. Trocars were inserted to localize the fecalith, which included a 10-mm infraumbilical port, a 5-mm left lower quadrant port, and a 5-mm right lower quadrant port. This showed it to be in the pelvis with an associated thickened site. Using the radiographic studies as a guide, the fecalith was located and extracted with endograspers and an endocatch bag.
Results: The patient subsequently improved and was discharged 5 days later without further incident.
Conclusion: We conclude that laparoscopic retrieval following radiographic localization of a retained fecalith is a viable alternative to immediate open conversion.The views expressed in this abstract are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.
6115 General Surgery
Laparoscopic Versus Open Appendectomy in Perforated Appendicitis
Fukami Yasuyuki, MD, Hasegawa Hiroshi, MD, Sakamoto Eiji, MD,Komatsu Shunichiro, MD,
Hiromaysu Takashi, MD
Department of Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
Introduction: The purpose of this clinical study was to evaluate the efficacy of
laparoscopic appendectomy in patients with perforated appendicitis.
Methods: Between January 1999 and December 2004, 73 consecutive patients underwent appendectomy for perforated appendicitis. Thirty-nine underwent open appendectomy (OA) during the first 3 years (between January 1999 and December 2001), 34 underwent laparoscopic appendectomy (LA) during the last 3 years (between January 2002 and December 2004). Laparoscopic appendectomy was performed using a 3-trocar technique and the endoscopic stapler.
Results: No case needed to be converted to OA from LA. No statistically significant difference in the operative time in minutes was found between the LA (97.9±30.6) and OA (92.0±31.4). LA required less analgesic useÅ@(LA, 2.7 times; OA, 8.3 times; P<0.001), and oral intake was resumed earlier (LA, 2.6 days; OA, 5.1 days; P<0.05). Postoperative stay was shorter in LA (LA, 11.7 days; OA, 25.8 days; P<0.001). Postoperative wound infection was less frequent in LA (LA, 8.8%; OA, 43.6%; P=0.0022).
Conclusions: Laparoscopic appendectomy for perforated appendicitis has significant advantages over open appendectomy with respect to frequency of analgesic use, start of oral feeding, postoperative stay, and postoperative wound infection.
6115 General Surgery
Laparoscopic Versus Open Appendectomy in Perforated Appendicitis
Fukami Yasuyuki, MD, Hasegawa Hiroshi, MD, Sakamoto Eiji, MD,
Komatsu Shunichiro, MD, Hiromaysu Takashi, MD
Department of Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
Introduction: The purpose of this clinical study was to evaluate the efficacy of
laparoscopic appendectomy in patients with perforated appendicitis.
Methods: Between January 1999 and December 2004, 73 consecutive patients underwent appendectomy for perforated appendicitis. Thirty-nine underwent open appendectomy (OA) during the first 3 years (between January 1999 and December 2001), 34 underwent laparoscopic appendectomy (LA) during the last 3 years (between January 2002 and December 2004). Laparoscopic appendectomy was performed using a 3-trocar technique and the endoscopic stapler.
Results: No case needed to be converted to OA from LA. No statistically significant difference in the operative time in minutes was found between the LA (97.9±30.6) and OA (92.0±31.4). LA required less analgesic useÅ@(LA, 2.7 times; OA, 8.3 times; P<0.001), and oral intake was resumed earlier (LA, 2.6 days; OA, 5.1 days; P<0.05). Postoperative stay was shorter in LA (LA, 11.7 days; OA, 25.8 days; P<0.001). Postoperative wound infection was less frequent in LA (LA, 8.8%; OA, 43.6%; P=0.0022).
Conclusions: Laparoscopic appendectomy for perforated appendicitis has significant advantages over open appendectomy with respect to frequency of analgesic use, start of oral feeding, postoperative stay, and postoperative wound infection.
6116 Gynecology
Reactionary Hemorrhage in Gynecological Surgery
Mark Erian, FRCOG, FRANZCOG, Glenda McLaren, FRCOG, FRANZCOG
Royal Brisbane Women’s Hospital
Introduction: To assess the incidence of reactionary hemorrhage in contemporary gynecological surgery, vaginal hysterectomy, and laparoscopic hysterectomy. This is a retrospective audit in a major teaching tertiary referral center.
Methods: There were 424 vaginal and 211 laparoscopic hysterectomies performed. The number of patients returning to the operating theater within 24 hours following the initial surgery was recorded. Immediate resuscitation was achieved followed by exploration laparoscopy, laparotomy, or both of these. Complete homeostasis must be accomplished before closure of the wound(s).
Results: Each group included 3 patients. The incidence was 0.7% in the vaginal hysterectomy group and 1.42% in the laparoscopic hysterectomy group. No association was noted between the incidence of reactionary hemorrhage and the patient’s BMI, uterine size, or pathology, eg, fibroid, adenomyosis; however, 4 of the 6 patients (2 in each group) had extensive pelvic adhesions attached to the uterus. The mean duration of laparoscopic procedures was 52 minutes (range, 29 to 75). The mean duration of laparotomy procedures was 28 minutes (range, 25 to 80). On average, in-patient hospital stay was prolonged by 1.5 days following laparoscopic management and 3 days in the laparotomy group. The average estimated blood loss was 2.5 liters (range, 2 to 3), as per the combined assessment of the gynecological and anesthetic teams. Following blood transfusion, all patients were started on “double” oral iron tablets, and the hemoglobin level was more than 80g/L before discharge.
Conclusion: Despite meticulous surgical technique, one would expect a very small proportion of patients to suffer from reactionary hemorrhage in contemporary gynecological surgery. Timely intervention is vital.
6117 Gynecology
Minilaparoscopy Assisted Natural Orifice Surgery
Daniel A. Tsin, MD
The Mount Sinai School of Medicine
Introduction: Interest has revived in peritoneoscopy via natural orifice surgery. Several of the limitations of this type of surgery could be solved with the minilaparoscopy assisted natural orifice surgery (MANOS) approach. We are using MANOS in operative culdoscopy.
Methods: The technique of culdolaparoscopy entails the use of minilaparoscopy limited to 3-mm abdominal ports, together with a 12-mm or larger natural orifice site, in this case, a vaginal port. The entrance from the natural orifice site into the peritoneal cavity is visualized and aided with minilaparoscopy. These ports are multifunctional. The natural orifice and the abdominal sites are used for insufflations, visual purposes, and introduction of operative instruments. The natural orifice port is also used for specimen extraction. We have used this technique in appendectomies, cholecystectomies, myomectomies, oophorectomies, and salpingoophorectomies.
Results: We have used this procedure in 100 cases. In this series, we had only one case of postoperative fever after an ovarian cystectomy, which was diagnosed as drug-related fever.
6118 General Surgery
Role and Value of the Predictive Factors of Common Biliary Duct Lithiasis
in Preparation for Laparoscopic Cholecystectomy: Retrospective Study
Vincenzo Neri, MD, Antonio Ambrosi, MD, Tiziano Pio Valentino, MD
University of Foggia
Introduction: The aim of this study was to evaluate the clinical-instrumental predictive
factors of common biliary duct stones (CBDS). Their presence is an indication for endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy (ERCP/ES) before the laparoscopic cholecystectomy (LC).
Methods: From 1997 through 2005, 102 ERCP/ES were performed; 76 patients were examined from 1999 to 2005. Patients with acute biliary pancreatitis (48) were excluded because, in our opinion, in these cases, the ERCP/ES has a therapeutic role, regardless of the suspicion of CBDS. We present a retrospective study of 28 ERCP/ES before the LC with the suspicion of CBDS. The clinical, instrumental, and bio-humoral data were analyzed by univariate and multivariate statistical studies.
Results: The univariate analysis identified alkaline phosphatase (P<0.0001), gamma-gt
(P<0.0001), direct bilirubin (P<0.0001), and CBD dilatation on abdominal ultrasonography (USG) (P<0.0001) as predictors of CBDS. A multivariate analysis subsequently identified alkaline phosphatase (P<0.0001), gamma-gt (P<0.0001), and direct bilirubin (P<0.0001) as independent predictive factors of CBDS; on the contrary,dilatation of the CBD (P=0.0759) was not statistically significant.
Conclusion: The dilatation of the CBD, alone, is not statistically significant.
The concordance of cholestasis factors with the dilatation of the CBD is
statistically significant for the diagnosis of CBDS, and it indicates the need for ERCP/ES before LC; however, the ERCP/ES, as an invasive procedure, cannot be performed before LC, if only the dilatation of the CBD is present, and an increase in cholestasis factors is absent.
6119 General Surgery
Assessing Decision Making in Laparoscopic Surgery
Sudip K. Sarker, MD, PhD, Saif Rheman, Avril Chang
Academic Surgery, Royal Free Hospital, Imperial College London, UK
Introduction: Making correct decisions is pivotal in the delivery of safe, effective, surgical healthcare, as well as being an integral part of surgical competency and excellence. To date, no attempt has been made to assess how and why surgeons make decisions while operating. In the present study, we aimed to develop and validate an operative decision-making tool in laparoscopic surgery.
Methods: Three decision-making modules were developed on a desktop computer program for laparoscopic cholecystectomy: knowledge, technical skill, and dynamics. The modules were based on didactic knowledge, technical skill, and intraoperative dynamic decision making. The last 2 modules were based on answering questions watching recorded live operations. The questions were devised by 2 experienced surgeons with >14 years postgraduate surgical experience. Three groups with varying degrees of surgical experience were assessed: novice (medical students), intermediate (junior surgeons), and expert (senior surgeons). These groups were determined by the number of laparoscopic cholecystectomies performed and the number of years of operative surgical experience.
Results: Thirty-five subjects were assessed: 15 novices, 12 intermediates, and 8 experts. Mean time to perform the program was 32 minutes (range, 21 to 45). Construct validity between the individual groups using the Mann-Whitney test was significant, P<0.05.
Conclusions: Our computer-based decision-making assessment tool in laparoscopic surgery seems to have face, content, concurrent, and construct validities. Surgical decision making is a multifaceted process; by assessing how and why decisions are made effectively, focused surgical training may be achieved.
6120 General Surgery
Preoperative Upper Endoscopy is Useful Prior to Revisional Bariatric Surgery
Benjamin Clapp, MD, Sherman Yu, MD, Trey Sands, MD, Erik Wilson, MD,Terry Scarborough, MD
Introduction: We hypothesized that patients who have previously had bariatric surgery and are undergoing revision to laparoscopic Roux-en-y gastric bypass would have abnormal findings detected by upper endoscopy that could potentially influence patient management. The procedures being revised included vertical banded gastroplasties, laparoscopic adjustable gastric bands, nonadjustable gastric bands, and previous Roux-n-y gastric bypasses (open and laparoscopic).
Methods: We conducted a retrospective chart review of patients who previously had undergone one of the above mentioned bariatric surgeries. We preoperatively performed an upper endoscopy on all patients. The endoscopy reports were reviewed and the findings entered into a database.
Results: Eighty-five percent of 55 patients needing revisional bariatric surgery had an abnormal upper endoscopy. Eleven percent had a gastrogastric fistula. Gastritis and esophagitis were noted in 65% and 37%, respectively. Eleven percent of patients had band erosion, 2 from a nonadjustable band, and 5 from vertical banded gastroplasties. Sixty-five percent of our patients required medical treatment based on our findings.
Conclusions: Preoperative upper endoscopy provides valuable information prior to
revisional laparoscopic bariatric surgery. In addition to identifying patients that need preoperative medications, the preoperative upper endoscopy also provided valuable information regarding pouch size and anatomy. Preoperative upper endoscopy should be performed by the operating surgeon on every patient undergoing revisional bariatric surgery.
6121 Gynecology
Ectopic Pregnancy
M. Sadok, MD, F. Haiba, MD, H. Ouzaa, MD
Hopital Militaire d’Oran-service Maternité
Introduction: Ectopic pregnancy is the development of fertilized ovum outside the uterine cavity. The frequency of ectopic pregnancy compared with the frequency of intrauterine pregnancy has been estimated to be between 1% and 3%. But the incidence is on the rise. We sought to determine the number of ectopic pregnancies managed at the Military Hospital of Oran over a 6-year period.
Methods: From January 2000 to December 2005, a study was conducted of ectopic pregnancies at the Military Hospital of Oran. We reviewed and analyzed the incidence, presentation on admission, and history of patients with ectopic pregnancy. The investigation included a pregnancy test, culdocentesis, transvaginal ultrasound, and laparoscopy.
Results: The total number of deliveries during the study period was 5000. The incidence of ectopic pregnancy was 1 in 100 normal intrauterine pregnancies.The 50 patients who had an ectopic pregnancy were included in the study.
Conclusion: The incidence of ectopic pregnancy at the Military Hospital of Oran over a 6-year period was 1 in 100 normal intrauterine pregnancies.
6122 General Surgery
Patient Recall and Comprehension after Laparoscopic Appendectomy
Benjamin Clapp, MD, Melba Jarmillo, BS, Luis Macias, MD, Valeria Vigil, MD,
Marcia Plett, PA-C, Cuatemoc Gallardo, MD, Andrew Kassir, MD
Introduction: The purpose of this study was to determine patient recall and comprehension after laparoscopic appendectomy in an underserved population.
Laparoscopic surgery can lead to diagnostic uncertainty secondary to poor recall and variable port placement.
Methods: After IRB approval, we identified a cohort of patients who underwent laparoscopic appendectomy from 2000 to 2004 at a single institution. We then attempted to contact the patients to conduct a 16-question telephone survey, which determined whether the patient spoke English or Spanish as a primary language, ethnicity, educational level, and questions about recall of perioperative events and diagnoses. If we could not reach the patient, we tried to call back on 3 different occasions.
Results: Between 2000 and 2004, 186 patients underwent laparoscopic appendectomy. Of these, 65% were Hispanic. We found that only 17% of these patients returned for a postoperative visit. Only 19.3% could be contacted by phone. Forty-seven percent of the patients contacted by phone spoke Spanish exclusively. Overall, 89% of patients contacted knew what operation they had and gave their correct diagnosis.
Conclusions: The low percentage of patients available to follow-up makes this study statistically insignificant. However, we believe that fact in itself is important. In Southwestern states, we see a large migrant population. This highlights the need to communicate effectively with patients at the time of laparoscopic surgery to avoid in the future the diagnostic uncertainty associated with laparoscopic incisions.
6123 General Surgery
K-ras Mutation as a Prognostic Factor in Colorectal Cancer Procedures: Laparoscopic vs. Laparotomic Approach
L. Sákra, MD, M. Sácha, MD, M. Rajman, MD
Surgical Department, General Hospital Pardubice, Czech Republic
Introduction: Colorectal carcinoma is a serious problem in the Czech Republic, and its incidence is on the rise. According to some statistical analyses, the Czech Republic has the highest incidence of colorectal carcinoma of developed countries worldwide. Therefore, it is advisable to incorporate new modalities into examination and therapeutic algorithms that will lead to early diagnosis or to a change in the existing therapeutic procedures.
Method: The main objective of this project was to identify K-ras mutations in colorectal tumors, to detect tumor cells with the K-ras mutation in the peripheral blood, to detect the K-ras mutation in liver metastases, and to verify the hypothesis claiming that tumors with the K-ras mutation have a worse prognosis and often metastasize, mainly to the liver. The outcomes of laparotomic versus laparoscopic procedures were analyzed.
Results: This project has been ongoing since June 2004. Seventy-five patients have met the defined parameters and have been included in the study to date.
Conclusion: The laparoscopic approach was monitored by the detection of the spread of tumor cells with K-ras mutation in the blood. This approach gives the same results as the results with laparotomic procedures.
6125 Gynecology
Complications from Hysterectomy
M. Sadok, MD, F. Haiba, MD, H. Ouzaa, MD
Department of Gynecology-Obstetrics, Oran Hôpital Militaire
Introduction: Hysterectomy is one of the most common major gynecological surgical procedures performed. Our objective was to determine the operative and postoperative complications of this procedure.
Methods: This study was conducted in the gynecology and obstetric service of Oran University Hospital Center from January 2000 to December 2005. Indications, complications, and mortality associated with hysterectomy were assessed.
Results: The number of hysterectomies performed in 6 years at our unit was 300. Major indications for hysterectomies were dysfunctional uterine bleeding (60%) and fibroid uterus, (35%) followed by prolapse (5%). Complications developed in 10% of these. The frequency of complications was related to the indication for hysterectomy, age, parity, and history of associated serious illness. It was found that the frequency of complications in fibroid uterus was higher (8%) than that for dysfunctional uterine bleeding (DUB) (2%). No operative deaths occurred.
Conclusion: We have a fairly high frequency of complications associated with hysterectomy. To reduce these complications, proper selection, preoperative preparation, and less invasive alternative treatment for the commonest indications of hysterectomy (ie, fibroids and DUB), for example various methods of endometrial ablation or resections, can be used.
6127 Gynecology
Moving Forward with Breast Endoscopy: From Diagnostic to Interventional Ductoscopy
Volker R. Jacobs, MD, PhD, MBA, Uta Euler, MD, PhD, Susanne Grunwald, MD, PhD,
Ralf Ohlinger, MD, PhD, Thorsten Fischer, MD, PhD, Marion Kiechle, MD, PhD,Stefan Paepke, MD, PhD
Frauenklinik (OB/GYN), Technical University, Munich, Germany Ernst-Moritz-Arndt-University, Greifswald, Germany
Introduction: Endoscopy of the breast, called ductoscopy, can give additional direct visual information about intraductal breast lesions that cannot be seen with conventional visual diagnostics like sonography, mammography, MRI, or galactography. After development and increasing application of diagnostic ductoscopy in Germany, research interest is shifting to interventional ductoscopy. We describe the evolution of interventional techniques and the use of newly developed devices for interventional ductoscopy.
Methods: In cooperation with PolyDiagnost, Pfaffenhofen, and Storz, Tuttlingen, all German, a variety of different instruments and techniques were developed and evaluated for clinical application. These were the vision-guided ductal lavage, a technique for acquisition of nipple aspirate fluid (NAF), vision-guided brush cytology of suspicious lesions with a 0.38-mm brush, removal of intraductal lesions with a 0.38-mm Titanium basket, a 0.8-mm vision-guided biopsy forceps, alternative visualization of breast ducts with addition of auto fluorescent light as well as use of 0.40-mm thin metal wires through the working channel for marking of intraductal findings or controlled retrieval of breast duct target lesions.
Results: The use of all miniature instruments is simple, safe, and effective. In our series, we have had no intra- or postoperative complications so far. Due to reusability of most instruments after appropriate sterilization according to instrument handling protocols, the instrument costs can be reduced in contrast to costs of disposable instruments. Interventional ductoscopy enhances diagnostic ductoscopy to a comprehensive and independent technique. Until establishment as a new standard, interventional ductoscopy remains experimental and should be further evaluated in multicenter trials for operative safety and equivalence to existing diagnostic and operative standards.
Conclusions: Interventional ductoscopy follows the principle of least minimal invasiveness and opens a variety of new options. With these new technical options, interventional ductoscopy seems to advance to become a potential one-stop screening method as well as a substitute for conventional procedures like ductectomy.
6128 Gynecology
A Comparative Study of Hysteroscopic Sterilization Performed In-office Versus a Hospital Operating Room
Mark Nichols, MD, James Carter, MD, Donald Fylstra, MD, and the Essure® System U.S. Post-Approval Study Group
Introduction: We compared hysteroscopic female sterilization procedures performed in-office versus a hospital operating room (OR) among newly trained physicians.
Methods: Subjects were a subset of a cohort enrolled in an FDA-mandated postapproval study. Both demographic and procedural differences between the groups were examined. For variables that were not normally distributed, the Mann Whitney-U statistic was used to determine whether significant differences existed. Normally distributed variables were evaluated by an independent samples t test or chi-square test, as appropriate.
Results: Inclusion criteria were met by 320 women enrolled in the study. In an OR, 252 procedures were performed, and 68 were performed in-office. No significant difference existed with regard to scope-in and scope-out time, with an average of 17 minutes in the OR and 15 minutes in-office. No significant difference existed in bilateral placement rates between the settings with a success rate of 88% in the OR and 91% in-office. The incidence of minor adverse events was comparable, with 2% of cases involving a minor adverse event in the OR and 1% in-office. Receipt of NSAIDs before the procedure was significantly related to successful bilateral placement. Among cases with successful bilateral placement, only 18% failed to receive NSAIDs before the procedure, whereas 33% of unsuccessful bilateral placements involved no NSAIDs (P=0.03).
Conclusion: No clear advantage exists to performing hysteroscopic sterilization in a hospital operating room. Hysteroscopic sterilization can be performed safely and efficiently in an office setting.
6129 General Surgery
Chronic Inguinal Pain After Laparoscopic Inguinal Hernia Repair: The Role of Tack and Mesh Removal
Jeffrey D. Sedlack, MD, Jonathan A. Laryea, MD
Department of Surgery, Waterbury Hospital, Waterbury, CT
Introduction: Chronic inguinal pain occurs as a postoperative complication in up to 8% of hernia repairs. Inguinal pain after laparoscopic hernia repair will typically resolve with time and conservative management. The question arises as to the treatment of patients with significant, ongoing pain that does not resolve over time.
Methods: Four patients have come under our care in the past year with severe, postoperative inguinodynia after TAPP laparoscopic inguinal hernia repairs with helical tack fixation of polypropylene mesh. All patients reported inguinal pain that continued despite maximal conservative therapy, including physical therapy, wound massage, ilioinguinal blocks, COX-2 inhibitors, and Neurontin. All patients were explored through transverse inguinal incisions. Implanted mesh and all tacks were identified and removed in all patients. Tack impingement of intramuscular segments of iliohypogastric nerves were identified in all cases. Neurolysis of the affected nerves was performed in all patients. In all of the patients, more than 10 fixation tacks were used, and tacks were placed lateral and superior to the inguinal ring.
Results: All patients experienced “significant” to “complete” permanent (>6 month) pain relief.
Conclusion: Removal of mesh and tacks and neurolysis of affected nerves is of benefit in the treatment of refractory inguinal pain after laparoscopic inguinal hernia repair. Further, there is likely a benefit in minimizing tack use and avoiding the superior and lateral quadrant of the inguinal floor to minimize the risk of injury to an intramuscular segment of the iliohypogastric nerve.
6130 General Surgery
The Impact of Routine Use of Preoperative ERCP in Gallstone Pancreatitis
Jonathan Laryea, MD, Jeffrey Sedlack, MD
Introduction: Despite over a decade of experience, the use of preoperative ERCP for the treatment of gallstone pancreatitis remains controversial. The purpose of this study is to determine whether preoperative ERCP is necessary in all patients with gallstone pancreatitis.
Methods: Charts of 30 patients admitted to Waterbury Hospital with a diagnosis of gallstone pancreatitis between 1998 and 2000 were reviewed for demographic data, length of stay, laboratory values (lipase, bilirubin, amylase, alkaline phosphatase levels), and results of radiographic studies. These patients were divided into 2 groups based on whether they underwent preoperative ERCP (n=20) or not (n=10). Differences between the groups in length of stay, complications, and laboratory data were analyzed with the Student t test and Fisher's exact text where appropriate (significance = P<0.05).
Results: Two thirds of the patients (66.7%) underwent preoperative ERCP. Fifty percent of the ERCPs were positive (dilated common bile duct, stones, and/or sludge). The other 50% of ERCPs were nondiagnostic. The mean age was similar between the 2 groups (56 years versus 57 years, P=0.4491). The mean bilirubin level was 3.5 for the ERCP group and 3.1 for the no-ERCP group (P=0.3585). The mean lipase level was 10,000 for the ERCP group compared with 7819 in the other group (P=0.2491). The mean alkaline phosphatase level was 314 in the ERCP group and 176 in the other group (P=0.3141). The ERCP group had an average length of stay of 7 days while the no-ERCP group had an average length of stay of 6 days (P=0.2491). Four patients (20%) developed complications from the ERCP. All 4 developed pancreatitis that was asymptomatic. In the subset of patients who underwent preoperative ERCP, the mean bilirubin level was 5.36±1.91 in those with positive ERCP and 1.73±0.51 in those with negative ERCP (P=0.0417). No significant difference existed between these 2 groups in the other laboratory values.
Conclusions: The use of routine preoperative ERCP in the treatment of mild to moderate gallstone pancreatitis is not always therapeutic and is not without risk of complications. More selective criteria should be developed to determine which subgroup of patients would benefit from preoperative ERCP. MRCP may be useful as a screening tool for determining which patients may benefit from ERCP.
6131 General Surgery
A Pilot Study Evaluating a Novel Magnetic Gasless Laparoscopy Device in Porcine Laparoscopic Liver Resections
Adam Power, MD, Nicholas Power, MD, Michael Lisi, MD, Margherita Cadeddu, MD, Niv Sne, BSc, MD
McMaster University, Hamilton, Ontario, Canada
Introduction: Our main aim was to determine whether a novel magnetic gasless
laparoscopy device could be used to perform laparoscopic liver wedge resections in porcine models. Secondary outcomes included histology of the abdominal wall to assess for tissue damage by the device and a comparison of exposure and suctioning ability of conventional pneumoperitoneum versus using the novel device.
Methods: Five female pigs underwent a laparoscopic left lateral liver lobe wedge resection using the device. Tissue at risk for ischemia and control tissue were assessed by a blinded veterinary pathologist. Digital recordings of the device’s exposure and suctioning ability with controls were evaluated by 3 experts using a laparoscopic visualization scale.
Results: Five liver wedge resections were successfully completed with no evidence of significant abdominal wall tissue damage. The mean visualization scale scores for exposure and suctioning ability of the device when compared with that of conventional pneumoperitoneum showed that the device provided slightly inferior exposure but allowed for far superior suctioning ability.
Conclusions: The novel device was used to successfully perform 5 laparoscopic porcine liver wedge resections without causing significant abdominal wall tissue damage. The exposure provided was slightly inferior to that of conventional pneumoperitoneum but may be an improvement over prior gasless devices. The superior suctioning ability permitted by the device may be useful in solid organ laparoscopic surgery where excessive suctioning is often required. This gasless device may be a safer alternative than conventional pneumoperitoneum in human laparoscopic liver resections by avoiding some of the potential complications associated with gas pneumoperitoneum.
6132 General Surgery
Laparoscopic Restorative Proctocolectomy: Is the Anastomosis Compromised?
Joel J. Bauer, MD, Christopher Foglia, MD, David S. Bub, MD, Stephen R. Gorfine, MD
Introduction: One of the major technical issues in the performance of restorative proctocolectomy (RPC) is the complete mobilization of the small bowel mesentery while maintaining adequate blood supply to the pouch. Inability to adequately mobilize the small bowel can lead to anastomotic tension and ischemia and, subsequently, anastomotic complications or the need for a diverting ileostomy. The aim of this study was to evaluate whether a laparoscopic technique can be used to create an ileal pouch-anal anastomosis (IPAA) without compromising the anastomosis.
Methods: Forty-six patients undergoing laparoscopic RPC were examined over a 7-year period. These patients were matched by age, sex, and operative indication to a group of 44 patients undergoing open RPC. In all patients, the intent was to perform a mucosectomy with hand-sewn IPAA without a complimentary ileostomy. A diverting ileostomy was performed at the discretion of the operating surgeon when it was thought that the anastomosis was compromised. Patient-specific demographics, intraoperative and postoperative variables, and complications were examined retrospectively by using a prospectively gathered database as well as hospital and office chart review.
Results: The laparoscopic (lap) group contained 13 men and 33 women, while the open group contained 14 men and 30 women. No significant differences existed in patient age (mean, lap 32.8, open 34.1), or indications for surgery (lap: ulcerative colitis 43; polyposis syndrome 3; open: ulcerative colitis 40; polyposis syndrome 4). In the lap group, 44 patients (96%) had mucosectomy and 42 patients (91%) had hand-sewn anastomoses vs. 37 patients (84%) who had mucosectomy and hand-sewn anastomosis in the open group. Two patients in the lap group had mucosectomies, but there was not adequate length on the pouch to perform a hand-sewn anastomosis, and a stapled anastomosis was used. All other patients had stapled anastomoses achieved with a double-stapled technique. There were 5 diverting loop ileostomies (11%) created at the time of operation in the laparoscopic group vs. 6 (14%) in the open group. Postoperatively, 7 early anastomotic complications and 9 late strictures occurred in the laparoscopic group vs. 4 early anastomotic complications and 5 late strictures in the open group. These differences were not statistically significant.
Conclusion: The technical issues of pouch mobilization to achieve adequate length for mucosectomy and hand-sewn IPAA are not compromised by using laparoscopy to perform RPC when compared with open surgery. Laparoscopic RPC is a safe and feasible alternative to open surgery.
6133 General Surgery
Mucocele of the Appendix: A Case Report and Review of the Literature
Fernando A. Herera, MD, David W. Easter, MD
Introduction: We aim to discuss the rare diagnosis, mucocele of the appendix, in a patient with known endometriosis.
Methods: We performed a retrospective review of a single case.
Results: Laparoscopic appendectomy with fulguration of intraabdominal endometriosis implants and colonoscopy to rule out synchronous lesions of the colon. Histopathology determined mucinous cystadenoma limited to the appendix.
Conclusion: Mucocele of the appendix is a rare diagnosis that should be included in the differential of right lower quadrant masses. In a patient with an incidental finding of cecal mass, proper management includes colonoscopy to rule out synchronous colorectal lesions. Ultimately, histological pathology determines appropriate surgical treatment. In our patient, laparoscopic exploration with appendectomy confirmed the diagnosis of mucinous cystadenoma confined to the appendix.
6135 General Surgery
The Impact of Laparoscopic Gastric Bypass Surgery on C-Reactive Protein Levels
Neel R. Joshi, MD, Sergey Lyass, MD, Mark Gaon, MD, Gregg K. Nishi, MD, Scott Cunneen, MD, Edward H. Phillips, MD, Theodore M. Khalili, MD
Introduction: Obesity is associated with an increased risk of cardiovascular disease. This elevated risk is reflected in increased levels of markers of inflammation, particularly C-reactive protein (CRP). We sought to determine the impact of laparoscopic gastric bypass surgery (LGB) on cardiovascular risk profiles via analysis of serially obtained CRP levels.
Methods: We performed a retrospective study of all patients undergoing LGB at our institution between April 2003 and April 2004. Data collected included demographics and serial measurements of CRP levels, weight, and body mass index (BMI). Statistical analysis was performed using the Student t test and linear regression models.
Results: Included in our analysis were 69 subjects (59 females and 10 males) who met the necessary clinical and laboratory follow-up criteria. Their demographic parameters were as follows: mean age 43.2 years (range, 24 to 64), mean preoperative weight 138.8kg (range, 98.3 to 206.6), mean preoperative BMI 50.4kg/m2 (range, 37 to 73). A significant reduction in BMI was noted between the preoperative period and the 3-month follow-up visit (50.2±8.9, 41.0±7.8, respectively; P<0.001), with a further significant decrease seen at 6 months (36.7±7.3, P=0.02). Correspondingly, CRP levels fell significantly between the preoperative and 3-month time points (1.8±1.4, 1.1±0.9, respectively; P=0.001), with a further significant decrease seen at the 6-month follow-up (0.8±0.6, P<0.05) (NOTE: "Normal" CRP<0.6 mg/dL).
Conclusion: Patients undergoing LGB at our institution experienced significant postoperative reductions in BMI and CRP levels.
6136 General Surgery
Laparoscopic Treatment of Rectal Cancer: Tips, Tricks, and Limits
P. Ubiali, M. Andretta, M. Ciocca, G. C. Cisana, B. Cirelli, P. R. Binyom
Oncology Surgical Department, Policlinico San Pietro, Bergamo, Italy
The laparoscopic approach to rectal cancer, respecting the rules of a nerve-sparing technique and a total mesorectal excision, is more demanding than a conventional laparoscopic intraperitoneal colectomy. However, the advantages of the laparoscopic approach in terms of shorter hospital stay, less pain, and better cosmetic results are well known. Other advantages may be a more precise dissection, with less blood loss, and less impairment of the immune system. The latter is considered responsible of a better survival rate in T3 colon cancer; therefore, a similar result is a matter of concern for rectal cancer. The main surgical problem, underlined by the authors is the dimension of the tumor, related to the position in the rectum. Although there may be no problem related to a cancer localized in the upper third, even in T3 stage, the problems will arise when the localization is in the mid or lower rectum, particularly for large masses, as in stages T3 or T4, because of the small space available to the surgeon for a correct dissection without disrupting the mesorectal fascia. In male patients, the challenge is greater because the pelvis may be narrow and deep. Two additional problems are the distal margin in the lowest cancer and correct distal stapling. In some situations, an open approach offers the best oncologic results.
6137 Gynecology
Usefulness of Minihysteroscopic Bipolar Coagulation of Bleeding Locations After Removal of Cervical Myoma at an Outpatient Clinic
Sung-Tack Oh, Byung-Ik Lee
Introduction: The most important task after transcervical removal of cervical myoma is control of postoperative bleeding. The purpose of this study was to evaluate the usefulness of minihysteroscopic bipolar coagulation for control of postoperative bleeding.
Method: The study included 64 patients who underwent transcervical removal of cervical myoma at a university hospital. Initially, cervical myomas were removed by a simple rotating movement with tennaculum, and then points of bleeding on the pedicles were controlled by a bipolar coagulator during minihysteroscopy with a 2.7-mm diameter hysteroscope at the outpatient clinic. Total operative times and amount of bleeding were estimated. Late recurrent bleeding after surgery was observed for 3 days.
Result: The average operative time was only 17±8 minutes, and the average amount of bleeding during surgery was only 19±10mL. Late recurrent bleeding was not found in any of the 64 patients.
Conclusions: The transcervical removal of cervical myoma with minihysteroscopic bipolar coagulation of points of bleeding is a very rapid, safe, simple, and effective operative method for cervical myomas.
6138 General Surgery
The Aesthetic Inguinal Herniorrhaphy: A Single Umbilical Incision Technique
James A. Westervelt, MD
Introduction: Early attempts at minimally invasive/laparoscopic inguinal hernia repairs were disappointing. In an effort to further reduce pain and visible scarring, a new minimally invasive inguinal herniorrhaphy is presented in this study. Blending the most recent with more established technologies, this technique may well represent the least invasive and most aesthetic inguinal hernia repair to date.
Methods: From August 2005 through January 2006, 25 adult men, ages 18 to 73, underwent laparoscopic TEP inguinal herniorrhaphies for clinically diagnosed unilateral, reducible inguinal hernias. With patients under general anesthesia, all procedures were performed through a single umbilical incision. Access to the preperitoneal space was made under direct vision with an XCEL 11-mm operating port. Complete exposure of Hasselbach’s triangle and the preperitoneal inguinal region was accomplished by using low-pressure CO2 gas insufflation (8mm Hg to 10mm Hg) and a 10-mm operating laparoscope. All indirect hernia sacs were reduced, and the exposed defects were covered with a tailored onlay of Ultrapro mesh, secured with Protack staples. Twenty milliliters of 0.5% plain Marcaine were instilled into the preperitoneal space upon removal of the gas and operating port. All patients were discharged home on an outpatient basis with postoperative follow-up appointments at 1-, 3-, and 6-week intervals.
Results: Twenty-five patients underwent successful laparoscopic TEP inguinal herniorrhaphies. The average operating time was 32 minutes, and all patients were discharged home following a 2- to 3-hour recovery period. No significant intraoperative or postoperative complications occurred. However, 2 patients experienced shoulder pain secondary to inadvertent pneumoperitoneums. At the first postoperative evaluation, 21 patients (84%) had discontinued narcotic pain medication. By the third postoperative visit, no patients required narcotics, and 23 patients (92%) had resumed normal work responsibilities. The remaining 2 patients took 6 weeks off due to the extreme physical demands of their jobs. No significant complaints were described at the 6-week follow-up.
Conclusion: The ideal inguinal herniorrhaphy remains elusive. The aesthetic inguinal herniorrhaphy presented in this study is a modification of the well-established, reliable laparoscopic TEP repair. In addition to the obvious advantage of a scarless operation, the aesthetic inguinal hernia repair avoids entry into the peritoneal cavity (with its inherent complications) and provides the benefits of less postoperative pain and a shorter recovery time. The anticipated long-term success is expected to be equivalent to that of the standard laparoscopic TEP inguinal herniorrhaphy. It is cost-effective, as there will be little need to purchase new equipment bcause most operating rooms have operating scopes available for their gynecologists, and the use of a single disposable port and stapling device will reduce overall costs for the procedure, especially when compared with a standard laparoscopic TEP hernia repair. Perhaps, given adequate preoperative nerve blockade and preperitoneal space analgesia, it may be possible and reasonable to perform this procedure without general anesthesia.
6139 General Surgery
Blood Loss in Colon Surgery: Comparison of the Laparoscopic and Open Techniques
I. M. Civello, MD, F. Greco, MD, D. Matera, MD, C. Cavicchioni, MD, M. Foco, MD, R. M. Tacchino, MD
Department of Surgery, Unit of General Surgery 3, Catholic University of the Sacred Heart, Rome, Italy
Introduction: This study was performed to evaluate the advantages of using Ligasure in performing laparoscopic colorectal surgery. Advanced laparoscopic procedures require a reliable method of hemostasis. Experimental and clinical results testing Ligasure demonstrate that it is safe and effective in reducing operative time and bleeding in hepatic surgery, hemorrhoidectomy, and extended gastric cancer resection.
Methods: We compared 30 laparoscopic colorectal procedures performed with Ligasure as the only hemostatic instrument (group A) and 27 open procedures performed with conventional suture ligation and monopolar coagulation (group B).
Results: No significant difference existed in ASA class, age, sex, comorbidities, and preoperative hemoglobin levels between the 2 groups. Only 18 in group A were oncology patients, while 23 patients in group B underwent surgery for cancer-related diseases. All these patients were in TNM stage II-III. Mean operative time was longer in the laparoscopic group (131 vs 100 minutes). The overall postoperative morbidity was similar in the 2 groups. An earlier return of bowel motility was observed after laparoscopic surgery (3.2 vs 4.6 days), and in this group, a shorter postoperative hospital stay (6.9 vs 9.6 days) was found. Intraoperative blood loss estimated as total number of patients transfused (2 vs 6), total number of transfusions required (7 vs 14), and mean hemoglobin level at discharge were significantly lower in group A.
Conclusion: The combination of superior views, more accurate technique, and the use of Ligasure reduced intraoperative blood loss during laparoscopic colorectal surgery.
6140 General Surgery
Adenomyomatosis and Cholesterolosis of the Gallbladder: Laparotomy Conversion
During Laparoscopic Cholecystectomy Case Report
C. De Werra, I. Donzelli, M. Perone, S. Tramontano, C. Viviano
Department of General, Oncological, and Video-assisted Surgery, University of Studies of Naples, Federico II, Italy
Introduction: The purpose of this study was to provide the best treatment to patients in case of accidental discovery of a lesion suggestive of malignancy during a laparoscopic cholecystectomy.
Methods: In November 2004, a 58-year-old man with clinical presentation and ultrasonographic features of chronic lithiasic cholecystitis underwent laparoscopic cholecystectomy. A shiny whitish cauliflower-like lesion on the deep portion of the gallbladder caused conversion to open surgery. Intraoperative histological examination was unclear, and en block cholecystectomy with cuneiform hepatectomy, lymphoadenectomy, and placement of a T-tube in the common bile duct was performed. Results: Final histological results were consistent with focal adenomyomatosis and cholesterolosis within perivisceral inflammation.
Conclusion: A wide spectrum of benign neoplasms and tumor-like lesions arise from the gallbladder and bile ducts. These pathologies are uncommon, but their importance is in their ability to mimic malignant lesions. Laparoscopic cholecystectomy is the gold standard for symptomatic gallbladder disease, although an intraoperative appearance of malignancy can necessitate the change in previously established surgical management, and therefore the prognosis is basically dependent on the histological stage established when gallbladder cancer is diagnosed.
6141 Gynecology
Fertiloscopy: Review of a 1500 Continuous Case Series
A. Watrelot, J. M. Dreyfus
Background: Although a consensus may exist about using laparoscopy to treat or sometimes remove obliterated tubes in cases of an abnormal hysterosalpingogram (HSG), a consensus does not exist when HSG is doubtful or normal, or doubtful or slightly abnormal. In these cases, many consider the tubes to be normal, and therefore these patients are classified as having “unexplained infertility” and are referred for assisted reproductive technology (ART), most often in vitro fertilization (IVF). The justification for such an attitude is represented by the risks involved with laparoscopy, which is required if one wants to determine the precise tubo-peritoneal status. It is true that even if very rare, laparoscopy is related to some very serious risks that may not be acceptable when treating a nonvital disease like infertility. Nevertheless, systematic laparoscopy performed in case of normal HSG has an abnormality rate between 25% and 40%, depending of the authors. This percentage is sufficiently high to be an incentive in the promotion of a less risky mini-invasive diagnostic tool, namely fertiloscopy, as we described in 1997. Since then, numerous publications have shown its effectiveness, such as the FLY study that compared fertiloscopy versus laparoscopy in the same patient. It is safe, and we have demonstrated some improvement compared with the early technique by addition of operative capability for fertiloscopy. Therefore, we think it is appropriate to review a rather extensive continuous series to underline the interest and the limits of this approach.
Methods: Between August 1997 and January 2005, 1500 patients with no obvious pathology underwent a fertiloscopy before referral to ART. In addition, 87 fertiloscopies were performed for ovarian drilling purposes for polycystic ovarian syndrome. Fertiloscopy was performed according to the technique we have already described.
Results: Of 1500 fertiloscopies, we had 11 (0.7%) failures due to a false route, and 3 (0.2%) rectal injuries treated conservatively. It was possible to perform microsalpingoscopy (which is a systematic part of fertiloscopy) in 1381(92%) patients for at least one tube. Abnormal findings were present in 584 (38.9%) patients, resulting in the performance of operative fertiloscopy in 288 (19.2%) patients and subsequent laparoscopy in 190 (12.6%). The remaining 106 (7%) patients were referred directly to IVF due to the severity of the lesions encountered.
Conclusions: We have demonstrated the feasibility of fertiloscopy in a routine manner. Other studies have shown its cost effectiveness compared with that of standard laparoscopy. We therefore think that fertiloscopy should be routine in infertile patients with no obvious pathology before any IVF attempt.
6142 General Surgery
Laparoscopic Hiatal Hernia Repair with Mesh (PTFE): A Prospective, Randomized Trial of Laparoscopic Polytetrafluoroethylene (PTFE) Patch Repair vs Simple Cruroplasty for Large Hiatal Hernia
Constantine T. Frantzides, MD,PhD, Luis E. Laguna, MD, Atul K. Madan, MD, Mark A. Carlson, MD, George P. Stavropoulos, MD
Objective: Large hiatal hernias are prone to disruption, resulting in reherniation, when repaired with simple cruroplasty. The use of mesh may decrease the rate of reherniation in the laparoscopic repair of large hiatal hernias. We analyzed recurrences, complications, hospital stay, operative time, and cost in Nissen fundoplication with posterior cruroplasty versus Nissen fundoplication with posterior cruroplasty with an onlay of polytetrafluoroethylene.
Methods: We conducted a prospective, randomized controlled trial at a university affiliated private hospital. Study subjects included 72 individuals undergoing laparoscopic Nissen fundoplication with a hernia defect ≥8cm in diameter (currently 5cm). We performed Nissen fundoplication with posterior cruroplasty (n=36) vs Nissen fundoplication with posterior cruroplasty and an onlay of polytetrafluoroethylene (PTFE) mesh (n = 36).
Results: Patients in both groups had similar hospital stays, but the PTFE group had a longer operative time. The cost of the repair was $960 ± $70 more in the group with the prosthesis. Complications were minor and similar in both groups. There were 8 hernia recurrences (22%) in the primary repair group and none in the PTFE group (P<.006).
Conclusion: The use of prosthetic reinforcement of cruroplasty in large hiatal hernias may prevent hernia recurrences.
6143 General Surgery
Videolaparoscopic Treatment of Paraesophageal Hernia
Roberta Gelmini, MD, Massimo Saviano, MD
Hiatal hernias are classified into 3 types: sliding hernia (type I), paraesophageal hernia (type II), and mixed hernia (type III), which is a combination of type I and II. The paraesophageal and mixed hernias represent about 5% to 10% of surgically treated hiatal hernias. The surgical treatment of the paraesophageal and mixed hernias is unavoidable because of the high risk of severe complications, and it has to be considered in a high percentage of cases. The most important technical difficulty in the videolaparoscopic treatment is represented by the hugeness of the hernial defect and by the challenging reduction of the stomach into the abdomen. A cautious dissection of the hernial sac and diaphragmatic cruses and a careful crural repair make the videolaparoscopic procedure feasible. The operative times are not prolonged, and the results are similar to those of the open technique. In the literature, the incidence of complications, both intra- and postoperative, are not statistically significantly different between the laparoscopic and open technique. Because of the complexity of the laparoscopic procedure, the minimally invasive access has to be reserved for surgeons well trained in these techniques. We describe 2 cases: one paraesophageal and one mixed hernia videolaparoscopically treated with the help, in the second case, of a Gore-Tex mesh. In both cases, the technical results were positive. Intra- and postoperative complications did not occur and, one year after the surgical procedure, both patients were in good health and recurrence free.
6144 General Surgery
Laparoscopic Resection with Intraoperative Radiotherapy: A New Step in the Multimodal Treatment of Advanced Colorectal Cancer
I. M. Civello, MD, C. Cavicchioni, MD, R. M. Tacchino, D. Matera, MD, F. Greco, MD
Objective: Local recurrence is one of the most important problems related to resection of rectal cancer in locally advanced cases (T3-T4). We present the cases of 2 patients affected by advanced rectal cancer in which the surgical laparoscopic procedure was combined with the intraoperative radiotherapy treatment.
Methods: The first patient underwent a low laparoscopic rectal resection with temporary ileostomy, and the second patient underwent a laparoscopic abdominoperineal resection.
Each patient received preoperative radiotherapy (45 Gy to the mesorectum and internal iliac lymphatic drainage and 5.4 Gy boost to the mesorectum corresponding to tumor mass) and concomitant chemiotherapy with cisplatinum.
Results: Laparoscopic rectal resection was performed with a 10-mm, 30-degree digital optic. Four 5-mm to 12-mm trocars were used. All dissection and vessel interruption were performed using a new hemostatic device, the Ligasure Vessel Sealing System. Intraoperative radiation therapy (IORT) was performed, introducing the cone through the Pfannenstiel incision in the first case and through the perineal incision in the second case. In both cases, a boost of 10Gy by electron beam was delivered on the parietal fascia of the mesorectum. Intracorporeal colorectal anastomosis was performed with an EEA stapler 29.
Conclusion: Total mesorectal excision is the mainstay of surgical therapy for rectal cancer and much has been published about the availability and effectivity of IORT associated with preoperative radiochemotherapy in control of locally advanced rectal cancers. IORT is feasible in association with laparoscopic surgical procedures.
6146 General Surgery
Laparoscopic Cholecystectomy: An Audit of Patient Satisfaction by Questionnaire Survey
K. Lodha, F. A. Hasan
Laparoscopic cholecystectomy is now the gold standard for the surgical removal of the gallbladder. However, very little effort has been made to assess the satisfaction of patients regarding recovery and other aspects. At Benenden Hospital, UK, an audit was therefore conducted of the 600 consecutive patients undergoing laparoscopic cholecystectomy performed by a consultant-led laparoscopic unit. Female preponderance (80%) was observed as compared with males (20%). A patient satisfaction survey was conducted by improvising a questionnaire that invited patients themselves to describe their own postoperative recovery. Despite a few complications like bleeding (3.8%), persistent pain (8%), diarrhea (7%), and others, the overall satisfaction rate was 96%. Only 4% of patients were unsatisfied with the outcome of surgery.
6148 Gynecology
Second-Look Laparoscopy for Severe Endometriosis: Does Reoperation Within One Year of Initial Surgery Improve Patient’s Pain?
H. Rodriguez, MD, E. Zaritsky, MD, C. Nezhat, MD
Objective: This study evaluated whether pain from severe endometriosis improved after a second-look laparoscopy within one year of initial surgery.
Methods: This study was a retrospective case series of 17 patients in a tertiary referral clinic for patients with severe endometriosis. Charts were evaluated for stage of endometriosis at first and second laparoscopic surgeries. Procedures performed, relief of pain, complications, and follow-up time between and after surgeries were analyzed. Patients with infertility or malignancy were excluded.
Results: Patients were followed on average for 362 days (SD+151) after the first surgery.
Cul de sac obliteration was present in 76% and 82% in the first and second surgery, respectively. Dense adhesion before and after the first surgery was 94% and 88%, respectively. Filmy adhesions were present in 94% and 100%, respectively. Pain was the primary reason for the first and second surgeries. Twelve of 17 (71%) had improvement of pain after the second surgery. Comorbidities of surgery included 6 patients (35%) requiring a urology consult and ureteral stents secondary to extensive ureterolysis. Two patients required a ureteroneocystostomy. A general surgery consult was required in 3 of the patients (18%).
Conclusions: Second-look laparoscopy for endometriosis does not decrease endometriosis and adhesions associated with the disease. Seventy-one percent reported improvement in their pain after the second surgery. Randomized, controlled studies are needed to investigate the utility of second-look laparoscopy. When counseling patients with severe endometriosis, one should advise them that second-look surgery may not decrease endometriosis but may decrease pain.
6149 General Surgery
Minimal Access Thyroidectomy Using an Endoscopic Transaxillary Approach
Titus D. Duncan, MD, Ijeoma Ejeh, MD, Qammar Rashid, MD, Fredne Speights, MD
The surgical treatment of thyroid disease typically involves a transverse incision made through the skin in the lower neck region. This technique allows for direct exposure and safe dissection of the thyroid gland and its critical adjacent structures. Although this technique has proven to be safe and efficient in the hands of most well-trained surgeons, the end result of such an approach leaves a noticeable scar within a highly visible area of the neck. Unfortunately, this permanent scar can result in hypesthesias, hypertrophy, and paresthesias in the neck in addition to a state of increased self-consciousness. Furthermore, such a scar is left permanently for what commonly turns out to be a benign process involving the thyroid gland. Endoscopic transaxillary approach to the thyroid, eliminates scarring on the neck and anterior chest wall and effectively hides the operative
incisions when the arm is in a normal postural position. This endoscopic approach allows for improved illumination and magnification of the operative field improving visualization thereby enhancing safe dissection. Since the incisions are hidden within the patient’s axilla, larger lesions may be used with this technique without compromising cosmetic outcome. In the event conversion to an open technique becomes necessary, the axillary approach avoids having multiple neck incisions in addition to the cervical incision used in the open approach. We describe our initial technique and results of transaxillary endoscopic approach to the thyroid.
6150 General Surgery
Endoscopic Transaxillary Near Total Thyroidectomy: A Feasibility Study
Titus D. Duncan, MD, Ijeoma Ejeh, MD, Fredne Speights, MD, Qammar Rashid, MD
Endoscopic thyroidectomy has joined the ranks of surgical procedures being performed via a minimally invasive approach. Since its first reported performance in 1996, cervical minimally invasive procedures have been shown to be safe and effective in the treatment of benign thyroid and parathyroid disease. Endoscopic approach to the thyroid and parathyroid gland may be performed through a direct or indirect (remote) technique. The direct approach places the access ports within the cervical region and is considered the least invasive. The indirect approach provides access to the neck through a remote site from the target area. Though this approach provides superior cosmesis, it proves to be the most invasive, requiring a relatively large working space to access the thyroid region. Of the indirect procedures, the transaxillary technique approaches the gland from a remote lateral site to completely hide the surgical scars. Because this is a lateral approach, its primary application has historically been treatment of unilateral thyroid and parathyroid disease. In this study, we examined the safety and feasibility of the transaxillary technique to dissect and remove both sides of the thyroid gland in performing a total or near total thyroidectomy for benign thyroid disease.
6152 Gynecology
Analyzing Tension Free Vaginal Tape: Obturator (TVT-O) Suburethral Sling Procedures with Integrated Definition (IDEF-0) Modeling Language and Performance Audits of Intraoperative Video
James D, Bauer, MD, Roberto J. Nicolalde, MS, Ken Funk II, PhD, Jeffery Stebel, MS
Introduction: The use of minimally invasive surgical procedures in the United States is enormous, and since 1998 the Tension Free Vaginal Tape (TVT) procedure has revolutionized female stress incontinence surgery. Intuitively, TVT-O seems to offer some clear advantages over TVT. To date, no formal analysis has been conducted to explore the apparent advantages and potential vulnerabilities.
Methods: The IDEF-O process model enables the surgeon to understand the TVT-O cognitive tasks, physical movements, and potential vulnerabilities involved in guiding the trocar tip along the correct trajectory. Our group built an IDEF-O process model of the TVT-O sling installation as a surgical procedure imbedded in the OR environment and systems. The model of the elements performed by the surgeon to install the sling provided a logical framework to decompose and catalog time and motion video data and sort errors in a process context, thereby identifying precursors to success and mishap. Analysis of surgical video demonstrated how errors propagate and are trapped within the OR. The end product was a spreadsheet of situational alerts, facility needs, and managerial attention items.
Results: The analysis reveals how ancillary instrument choice, patient obesity, and vaginal topography can influence procedure performance. The surgeons cognitive processing and the manner in which the trocar handles are manipulated while installing the sling are “tightly linked” elements determining whether the trocar will travel along the correct trajectory or stray into a vital structure.
Conclusion: A simulation inclusive of handle actuation haptics is needed to aid surgeon understanding the TVT-0 device operation.
6153 General Surgery
Patients Paying for Bariatric Surgery Out of Pocket
Atul K. Madan, MD, David S. Tichansky, MD, Raymond J. Taddeucci, MD
Minimally Invasive Surgery Section, University of Tennessee Health Science Center, Memphis, Tennessee
Introduction: Although bariatric surgery is a cost-effective treatment of morbid obesity in the long-term, short-term costs of laparoscopic bariatric surgery (LBS) are substantial. This study investigated whether patients would be able to afford LBS. We tested the hypothesis that many patients would not be able or willing to pay for LBS out of pocket.
Methods: Patients who underwent LBS were given a postoperative survey from which it was ascertained how much patients were able or willing to pay out of pocket. Unanswered questions were not included in the data analysis. The study included 93 patients (100% response rate). Average age was 43, and patients were an average of 13 months postoperative. Male:female ratio was 1:9.
Results: Average weight loss was 83 lbs. Household income (in thousands) was <$10: 13%, $10-$25: 15%, $25-$40: 20%, $40-$60: 19%, $60-$75: 13%, $75-$100: 10%, >$100: 9%. Many patients (75%) owned their own house. Average equity for those that owned houses was $70,000. Three (3%) patients’ insurance did not cover LBS. Patients with coverage paid an average of $695 out of pocket. Only 9% of patients stated they could afford to pay over $15,000. Of patients with household income >$60,000 and >$50,000 of equity in their house (n=11), only 3 (37%) claimed to be able to pay >$15,000.
Conclusion: Very few of our patients are able to or willing to, or both able and willing to, pay for LBS out of pocket. Insurance companies, employers, and the government should examine these data to help ensure that LBS is not performed exclusively in the financially elite.
6154 General Surgery
Social History of Patients Undergoing Laparoscopic Bariatric Surgery
Whitney S. Orth, MS, RD, Tracey Dixon, BS, Atul K. Madan, MD, David S. Tichanksy, MD, Mace Coday, PhD
Introduction: Studies have suggested that people with morbid obesity have social issues that result from or contribute to their weight. This investigation explores social histories of laparoscopic bariatric surgery (LBS) patients.
Methods: A retrospective chart review was performed on LBS patients. Each patient completed a social history that was reviewed by an attending bariatric surgeon. The descriptive data that were reviewed included smoking history, drug use, alcohol use, marital status, education, history of sexual abuse, history of abuse, and pregnancies.
Results: The study included 241 patients. There was a low reported rate of drug use (2%) and current smoking history (12%); however, 27% were former smokers. Although alcohol use was not uncommon (35%), few patients (4%) reported moderate use or more. Highest education level was less than high school 6%, finished high school 48%, had some college 2%, finished college 36%, and finished graduate school 9%. Few patients admitted that they experienced verbal (2%), physical (2%), or psychological (2%) abuse. Sexual abuse was reported by 11%. Marital status was 56% married, 22% single, 18% divorced, 3% separated, 2% widowed. There were 31% of patients who stated that they had problems with finances (15%), jobs (9%), children (6%), spouses (5%), other relatives (6%), and other (9%).
Conclusions: Social histories suggest that despite being morbidly obese, most patients have a social history comparable to that of the general population. The assumption that morbidly obese patients have more social barriers should not be perpetuated by the medical and bariatric community.
6155 Gynecology
Intraoperative Sentinel Node Detection Using Technetium-99m Sulfur Colloid Predicts Nodal Metastases in Patients With Early-Stage Cervical Cancer
Amanda Nickles Fader, MD, Lisa Rohan, PhD, Marilyn Cost, BS, Joseph Kelley, MD, John Comerci, MD, Paniti Sukumvanich, MD, Benjamin Schwartz,M.D,Amal Kanbour-Shakir, MD, Jules Sumkin, DO, Robert P. Edwards, MD
Introduction: We sought to determine the reliability and diagnostic accuracy of sentinel node detection using lymphoscintigraphy and intraoperative gamma probe localization in patients with early-stage cervical cancer.
Methods: We recruited 31 patients with FIGO IA2-IIA cervical cancer who were candidates for radical hysterectomy. Hysterectomies were performed by either laparotomy (75%) or laparoscopy (25%). All patients received intracervical injections of technetium-99 sulfur colloid 3 hours to 4 hours before surgery with isosulfan blue injection just before undergoing radical hysterectomy and complete pelvic and paraaortic lymphadenectomy. Lymphoscintigraphy was performed at 0 and 2 hours postinjection, and sentinel nodes were identified in vivo by gamma probe detection. All nodal tissue was submitted for H&E and cytokeratin staining.
Results: Thirty-one patients were evaluated. Twenty-one had squamous cell carcinoma (SCC), 9 had adenocarcinoma, and 1 had features of both. Nine (29%) patients had bulky cervical disease, 28 (90%) had at least 1 sentinel node identified intraoperatively by gamma probe and/or isosulfan blue dye, whereas 21 (68%) patients had sentinel nodes imaged on lymphoscintigraphy. Seventeen (56%) patients had the same sentinel nodes detected by both imaging and intraoperative assessment. Five (16%) patients had metastatic disease present in the lymph nodes. Four (80%) of these patients were identified initially by the presence of metastases in the respective sentinel nodal groups.
Conclusions: We demonstrate that detection of pelvic sentinel nodes in patients with early-stage cervical cancer can be reliably performed using intraoperative gamma probe localization and that this is an accurate tool for predicting the presence of nodal metastases.
6156 Gynecology
Biopsy of the Sentinel Lymph Node Improves Staging of Early Cervical Cancer
Anne-Sophie Bats, Denys Clément, MD, Florence Larousserie, MD, Marie-Aude Lefrère-Belda, MD, Marc Faraggi, MD, Marc Froissart, MD, Fabrice Lécuru, MD
Service de Chirurgie Gynécologique, Hôpital Européen Georges Pompidou, Paris, France
Introduction: We sought to describe sentinel lymph node mapping and prevalence of micrometastases and to confirm the detection rate and negative predictive value of our preliminary study.
Methods: Patients with a supposed early stage cervical cancer have been included (n=24). A lymphoscintigraphy was performed the day before surgery. Sentinel lymph node perioperative detection was realized with a blue dye injection and a gamma probe in pelvic and paraaortic areas; then an ilio-obturator lymphadenectomy was performed. Sentinel and nonsentinel lymph nodes were analyzed separately in anatomopathology. Sentinel lymph nodes were examined with a Hematoxyline-Eosine-Safran coloration, and with immunohistochemistry if negative.
Results: Most sentinel lymph nodes were ilio-obturators (78%). However, 2 were in the parametrium, and 9 were in the common iliac area. Two metastases and 1 micrometastasis were present in the sentinel lymph node. No false-negatives of the sentinel lymph node occurred.
Conclusion: Biopsy of the sentinel lymph node is a useful procedure to find nodes outside systematic lymphadenectomy areas, and reveal micrometastases in 4.2% of sentinel lymph nodes. It improves staging of early cervical cancer.
6157 Gynecology
A Safe and Successful Technique: the Interval Cervical Isthmic Cerclage
Leroy Charles, MD
Preterm labor accounts for a large number of small babies. Incompetent cervical os is one of the main causes. Although transvaginal cerclage is most successful, failures will bring tragic outcomes. Transabdominal cerclage is also a successful technique, but the possibility for excessive blood loss is a real concern. Childers was first to describe an attempt at laparoscopic cervical cerclage during pregnancy. In 1999, the author presented at AAGL (San Francisco) the first video of interval laparoscopic cervical isthmic cerclage. This technique is performed in nonpregnant patients. All 15 patients, to date, had multiple failed vaginal cerclages. We count 9 full-term pregnancies. Two patients are now 20-weeks pregnant. One of these pregnancies is a twin gestation. The operating time is less than 30 minutes. Bleeding is negligible. The interval laparoscopic cervical isthmic cerclage is a simple, safe, bloodless outpatient procedure. We present an update.
6158 Urology
Comparison of Healing after Cystotomy and Repair with Fibrin Glue and Sutured Closure in the Porcine Model
James F. Borin, MD, Leslie A. Deane, MD, Leandro G. Sala, MD, Alfred Krebs Poulson, MD, Farhan Khan, MD, Corollos S. Abdelshehid, BS, Shannon M. White, BS, Elspeth M. McDougall, MD, Ralph V. Clayman, MD
Introduction: We compared healing after laparoscopic cystotomy to determine whether fibrin glue can obviate the need for sutures and whether there is any detriment to using both in combination.
Methods: In 24 Yorkshire pigs, a 3.5-cm vertical cystotomy was created laparoscopically and repaired as follows: Group 1--no closure, Group 2--fibrin glue closure, Group 3--suture repair, Group 4--combined fibrin glue and suture repair. All animals had a Foley catheter for 1 week. In each group, 3 animals were harvested at 1 week (acute) and 6 weeks (chronic).
Results: Acute: Group 1--all pigs had an unhealed defect that leaked on the cystogram. Groups 2, 3, 4--mean leak pressures were 70.6cm, 86.6cm, and 45cm H2O. Mean bladder capacity was 285cc, 517cc, and 327cc. Chronic: No leakage on cystogram at 1 week; at 6 weeks bladders were filled to a mean pressure of 97.1cm H2O without leakage. Histologically, there was more inflammation in the acute vs. chronic pigs. In the chronic pigs, more inflammation was present in the groups containing glue vs. the suture alone or no closure.
Conclusion: Repair of a linear cystotomy with glue alone is a safe effective method of closure in the porcine model. It appears that glue engenders a more intense inflammatory response, and we speculate that this resulted in higher rates of leakage acutely, at physiologic pressures. There did not appear to be an additive or detrimental effect with suture and glue in combination.
6159 Multispecialty
Construct Validity Testing of the LAPMentorTM Laparoscopic Surgical Simulator
Elspeth M. McDougall, Tadashi Matsuda, Peter D. Vlaovic, Federico A. Corica,
John R. Boker, Leandro G. Sala, James F. Borin, Shannon M. White, Yoshinari Ono, Ralph V. Clayman
Departments of Urology, University of California, Irvine, USA and Kansai Medical University, Osaka, Japan
Introduction: Construct and predictive validation of laparoscopic surgical simulation is a mandatory step prior to its incorporation into the surgical education curricula. Herein, we present data on construct validity testing (ie, ability to differentiate based on surgeon experience) of the LAPMentorTM (Simbionix, Cleveland, OH) laparoscopic surgical simulator.
Methods: The LAPMentor is a computer-based virtual reality simulator for learning basic laparoscopic skills; it features 2 virtual working instruments and a camera. Camera and instrument movements are translated into a virtual surgical environment that is displayed on an LCD monitor. Medical students (MS), residents/fellows (R/F), experienced surgeons with <30 laparoscopic cases/year (ES<30), and experienced surgeons with >30 laparoscopic cases/year (ES>30) were tested on 9 skill tasks (SK). Following a single practice trial, participants’ performance was recorded. Group scores were compared and correlations of measures comprising each SK were examined.
Results: Mean MS (n=23), R/F (n=24), ES<30 (n=26), and ES>30 (n=30) ages were 26 (range, 21 to 32), 31 (range, 27 to 39), 49 (range, 31 to 70), and 47 years (range 34 to 69), respectively.
Skill Task (SK) Comparison of Study Group Scores
SK1 - Manipulation of 0o camera ES>30 = ES<30 = R/F = MS (P=0.7)
SK2 – Manipulation of 30o camera ES>30 = ES<30 = R/F = MS (P=0.30)
SK3 – Eye-hand coordination ES>30 = ES<30 = RF > MS (P<0.001)
SK4 – Clipping ES>30 = ES<30 = R/F > MS (P<0.006)
SK5 – Grasping and clipping ES>30 = ES<30 = R/F > MS (P<0.01)
SK6 – Two-handed maneuvers ES>30 = ES<30 = R/F > MS (P<0.009)
SK7 – Cutting ES>30 = R/F > ES<30 = MS (P<0.01)
SK8 – Fulguration ES>30 > R/F (P<0.01) = ES<30 > MS (P<0.001)
SK9 – Object translocation ES>30 = R/F > ES<30 = MS (P<0.001)
OVERALL Performance Score ES>30 = R/F (P=0.95) > ES<30 (P=0.0001)
> MS (P=0.0001)
In the higher level skill tasks (SK7, SK8, SK9) the ES>30 scores tended to be better than the R/F and ES<30, which tended to be similar, and these in turn were significantly better than the MS scores.
Conclusion: The noncamera skills (SK3-9) of the LAPMentor laparoscopic simulator can distinguish between the laparoscopic naïve and the laparoscopic experienced surgeon. Among the 9 tasks, SK8 showed the highest level of construct validity in that it accurately differentiated among the MS, R/F, ES<30, and ES>30.
6160 Urology
Tips and Tricks to Facilitate Renal Parenchymal Suturing During Laparoscopic Partial Nephrectomy
Farhan Khan, James Borin, Federico Corica, Alfred Krebs, Elspeth M. McDougall,Ralph V. Clayman.
Department of Urology, University of California Irvine, Orange, California, USA
Introduction: Laparoscopic partial nephrectomy is rapidly emerging as a potential surgical option for select renal tumors. The most challenging aspect of the procedure is the effective hemostatic closure of the collecting system and the renal parenchyma. We present our modification of Shalhav’s technique to limit warm ischemia time during closure of the collecting system and suturing of the bolster in position during laparoscopic partial nephrectomy. With this approach, needles are not passed into the abdomen and only 2 sutures are used.
Methods: This video demonstrates the use of the LapraTy (Ethicon Endosurgery, Inc., Cincinnati, OH) absorbable suture clips to quicken the time to suture the collecting system and secure the bolster during a laparoscopic upper pole heminephrectomy for renal tumor. Prior to initiating warm ischemia, 2 sutures are placed in the abdomen, a 10-inch length of 0-Vicryl on a CT-1 needle for suturing the bolster and a 6-inch length of 2-0 Vicryl on an SH needle for closure of the collecting system. Each suture has a LapraTy clip affixed on the end. After the hilar vessels have been clamped and excision of the tumor has been performed with a Ligasure device, the parenchymal surface is treated with the argon beam coagulator. Next, the collecting system is closed with the 6-inch suture; a layer of Floseal is applied. Then oxidized cellulose bolsters are placed into the renal parenchymal defect. Renorraphy is performed with the 10-inch suture and LapraTy clip. The needle is passed through one side of the edge of the incised renal parenchyma, over the bolster, and then out the opposite parenchymal edge. The suture is snugged down over the bolster and secured with 1 or 2 LapraTy clips. An additional LapraTy clip is placed π inch from the last clip and the suture is cut between the 2 clips. The needle and suture with the LapraTy clip are now ready to repeat the suturing sequence to place another simple suture. Four sutures are placed in this manner, all with the same suture. As such, no passage of needles into the abdomen during warm ischemia takes place.
Conclusion: This technique provides a rapid, effective hemostatic placement of the bolster during laparoscopic partial nephrectomy. To date, in 10 procedures performed in this manner, there have been no complications of fistulae or bleeding.
6161 Multispecialty
Short-Term Impact of a Laparoscopic “Mini-Residency” Experience on Postgraduate Urologists’ Practice Patterns
Elspeth M. McDougall, Federico A. Corica, John R. Boker, David S. Chou, Shannon M. White, Corollos S. Abdelshehid, Gabriella Stoliar, Leandro G. Sala, Allan M. Shanberg, Ralph V. Clayman
Department of Urology, University of California, Irvine, USA
Introduction: To assist urologists in acquiring and incorporating laparoscopic techniques into their practice, a 5-day mini-residency (M-R) program was established at the University of California Irvine. We present the follow-up practice patterns for the first 32 participants.
Methods: Between September 2003 and September 2004, 32 urologists underwent either the laparoscopic renal ablative (n=17) or the laparoscopic renal reconstructive (n=15) training module. The 5-day course consists of didactic lectures, pelvic trainer and virtual reality simulator practice, animal laboratory sessions, and observation of operative procedures. In addition, trainees are offered proctoring experience at their hospital. A questionnaire assessing practice patterns was mailed to participants 1 to 15 months (mean=8 months) after completing the M-R program. Statistical analysis was performed using the Wilcoxon Signed Rank Exact Test.
Results: A 100% response rate was achieved for the questionnaire. Mean participant age was 49 years (range, 31 to 70). Although no participant had fellowship training in laparoscopy, the majority (72%) had performed between 5 and 15 laparoscopic cases before attending the M-R course. Eight months after completing the program, 26 participants (81%) were practicing laparoscopic surgery. Procedures performed before and after the M-R are compared in the table below.
Type of Laparoscopic Surgery Before M-R (#) After M-R (#) P-value
Hand-Assisted Nephrectomy 41% (13/32) 16% (5/32) 0.008
Radical Nephrectomy 28% (19/32) 53% (17/32) 0.008
Radical Nephroureterectomy 6% (2/32) 44% (14/32) <0.0005
Adrenalectomy 16% (5/32) 31% (10/32) 0.063
Pyeloplasty 0 25% (8/32) 0.008
Partial Nephrectomy 3% (1/32) 19% (6/32) 0.063
Radical Prostatectomy 6% (2/32) 16% (5/32) 0.250
Donor Nephrectomy 0 6% (2/32) 0.500
6162 General Surgery
A Ten-Year, Single Surgeon Experience with Laparoscopic Appendectomy
Jeffrey D. Sedlack, MD, Adam L. Osborn
Department of Surgery, Waterbury Hospital, Waterbury, Connecticut
Introduction: More than 10 years after the introduction of laparoscopic appendectomy as the treatment for acute appendicitis, astonishingly, controversy remains as to its efficacy compared with the efficacy of open surgery. Most studies of laparoscopic appendectomy are uncontrolled for the experience of the operating surgeon. Published studies have described long average operating times, high postoperative complication rates, and extended average hospital stays for both open and laparoscopic procedures.
Methods: This study is a retrospective review of 234 consecutive laparoscopic appendectomies by a single surgeon (JDS) from September 1995 to January 2006. There were 124 females and 110 males. Morbidity was low; 3 (1.3%) conversions were necessary to open appendectomy, and 2 (0.9%) pelvic abscesses and 3 (1.3%) trocar-site soft tissue infections occurred. Average operating room time was 55 minutes (range, 31 to 174, SD=19).
Results: By ANOVA, a significant decrease was noted in average operating room time from 67 minutes for 21 patients in 1996 to 49 minutes for 14 patients in 2005 (P=0.0056). Linear regression confirmed this decrease over time.
Conclusion: This large series of laparoscopic appendectomies demonstrates that laparoscopic appendectomy may be performed safely, efficiently, and effectively in the treatment of acute abdominal pain. This single surgeon, community-based study demonstrates markedly better surgical results for laparoscopic appendectomy compared with the results in published university based studies. A significant improvement in efficiency over time occurred as a result of experience.
6163 General Surgery
Laparoscopic Colectomy for Benign and Malignant Diseases
L. E. Laguna, MD, C. T. Frantzides, MD, PhD, M. Carlson, MD, R. Moore, MD, J. Zografakis, MD, T. Zeni, MD
Introduction: This is a retrospective analysis of our 14 years of experience with laparoscopic colectomies. Analysis included conversion to open, operative time, resolution of ileus, length of stay, type of procedure, oncologic outcomes, and complications.
Methods: Laparoscopic colectomy was performed in 256 patients: 123 patients had colorectal cancer, 80 had inflammatory bowel disease, 45 had diverticular disease, and 8 had other colon ailments.
Results: Of the 256 procedures performed, 121 were right colon or ileocecal resections, 101 left/sigmoid colectomies, 15 total colectomies/proctocolectomies, 6 low anterior resections, 9 transverse colectomies, and 4 abdominoperineal resections. The mean operative time was 182±81 minutes, (this operative time includes concomitant procedures). Resolution of ileus was 2.4±2 days and the length of hospital stay was 4.1±1 days. Ten procedures where converted to open operations (3.9%); 7 conversion were due to adhesions or obesity, or both; 1 for bleeding, 1 because of an enterotomy, and 1 due to stapler misfiring. There were 15 complications (5.8%): 2 enterotomies, 3 hemorrhages, 2 prolonged ileus, 1 intraabdominal infection, 5 wound infections, 1 anastomotic leak, and 1 incisional hernia. There were no mortalities and no trocar-site recurrence for cancer.
Conclusion: Laparoscopic approach for the surgical treatment of benign and malignant colon diseases is as good as open surgery with all the inherent advantages of minimally invasive surgery.
6165 General Surgery
Bilateral Pulmonary Artery Thrombus After Laparoscopic Gastric Bypass: A Rare Occurrence
Alay Goyal, MD, Catherine Boulay, MD
Introduction: The most dreaded perioperative complication following gastric bypass surgery is deep venous thrombosis, resulting in pulmonary embolus. The aim of this study was to document the rare occurrence of a bilateral pulmonary embolus in a patient after laparoscopic gastric bypass surgery.
Methods: A 47-year-old male patient, status postlaparoscopic gastric band with associated sleep apnea (BMI=47kg/m2), presented to the emergency department 4 weeks postoperatively with complaints of abdominal pain, chest pain, and shortness of breath. He was found to have bilateral pulmonary artery thrombus on a CT scan of the chest and elevated cardiac enzymes. A bilateral lower extremity duplex and echocardiogram were negative for venous thrombus. At our institution, deep vein thrombosis prophylaxis includes pneumatic compression boots and postoperative anticoagulation with low molecular weight heparin starting 4 hours after surgery until discharge. After the discovery of the pulmonary embolism, the patient was started on anticoagulation with therapeutic intravenous heparin and subsequently underwent an IVC venogram and filter.
Results: Clinically, the patient remained hemodynamically stable throughout the hospital course despite an oxygen saturation of 88% to 92% of room air. His anticoagulation regimen was converted to coumadin, and the patient was discharged home in stable condition.
Conclusion: The formation of bilateral pulmonary artery emboli is a very rare and dangerous occurrence. This case further illustrates the necessity for aggressive DVT prophylaxis, an extensive preoperative workup, and thorough familial history.
6166 General Surgery
Seldinger Technique for Band-to-Band Revisional Surgery
Catherine Boulay, MD, Ajay Goyal, MD
Introduction: A small percentage of patients who have undergone placement of a laparoscopic adjustable gastric band require reoperative surgery to replace the band. We demonstrate a safe, effective method for removal of the laparoscopic gastric band and placement of a new laparoscopic gastric band.
Methods: We describe the case of a 45-year-old woman with a BMI of 43kg/m2, who was referred to our practice for chronic intolerance of solid food approximately 1 year after placement of a laparoscopic adjustable gastric band. The patient underwent replacement of the standard Lap Band (10-cm diameter) device with the larger VG Lap Band (11-cm diameter) device. This was accomplished with a modification of the Seldinger technique, wherein the new VG Lap Band was placed in the same posterior retrogastric tunnel that had been created by the “pars flaccida” technique during the first procedure.
Results: The band was replaced in the optimal posterior location without additional dissection of the now-scarred retrogastric plane. The patient tolerated the procedure well without any significant perioperative bleeding or gastric injury.
Conclusion: Using this technique, reoperative surgery for band-to-band revision may be accomplished without significant risk of stomach injury or bleeding, while ensuring that the new gastric band is in the preferred pars flaccida location, thus minimizing slippage.
6167 General Surgery
Laparoscopic-Assisted, Transgastric Endoscopy: Current Indications and Future Implications
Kurt E. Roberts, MD, Andrew J. Duffy, MD, Robert Bell MD
Introduction: Endoscopic access of the proximal gastrointestinal tract may prove difficult for a variety of anatomic reasons. Under laparoscopic visualization, trocars can be placed into the stomach with the subsequent introduction of rigid or flexible scopes directly into the body of the stomach. The purpose of this study was to describe the technique and demonstrate that it is safe, effective, and feasible.
Methods: Four patients with altered proximal foregut anatomy were examined.
Three patients had previously undergone laparoscopic Roux-Y gastric bypass and 1 patient had severe distal esophageal stenosis, precluding distal passage of an endoscope. Three patients required endoscopic retrograde cholangiopancreatography (ERCP) and one patient underwent closure of a symptomatic gastrogastric fistula. In each patient, two 5-mm ports were inserted, and tacking sutures were placed between the gastric body and the anterior abdominal wall. Subsequently, a rigid or flexible scope was inserted into the stomach through a gastrotomy under direct visualization. Picture-in-picture technology enabled simultaneous monitoring of the laparoscopic and endoscopic field.
Results: The operative time ranged from 64 to 93 minutes. All therapeutic endoscopic procedures were successful. The anterior gastrotomies were either closed primarily or a feeding tube was placed. Patients reported minimal postoperative pain. There were no complications from the procedures.
Conclusion: In an age where surgeons and gastroenterologists are focusing on the stomach as an access point for transgastric, endoscopic surgery, we view the stomach as a portal into the gastrointestinal tract. In patients with limited access for traditional endoluminal therapy, laparoscopic-assisted, transgastric endoscopy can be performed safely and efficiently.
6168 General Surgery
Follow-up and Early Referral are Mandatory to Avoid Late Diagnosis of Adjustable Gastric Banding Complications
Gianluca Bonanomi, MD, Pierenrico Marchesa, MD, Madelyn H. Fernstrom, PhD, Bruno Gridelli, MD
Minimally Invasive and Bariatric Surgery Program, Istituto Mediterraneo Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy, Weight Management Center, University of Pittsburgh Medical Center, Pittsburgh, PA USA
Introduction: Complications that may require surgical revision can arise following adjustable gastric banding. We describe 2 cases performed in another region of the country, lost at follow-up by the primary center, and presenting with a late diagnosis of gastric erosion and banding slippage.
Methods: Case 1 is a 32-year-old female who developed recurrent port-site infection and epigastric pain 9 months after surgery. She underwent 3 revision surgeries of the port site at a local hospital. Case 2 is a 40-year-old female who, over a period of 6 months, developed epigastric pain and recurrent vomiting 2 years after surgery. The patient was managed conservatively by her primary care physician.
Results: On admission, patient 1 complained of epigastric pain and fever. An upper endoscopy showed partial banding penetration into the gastric lumen, and an abdominal CT scan showed signs of local infection. The patient underwent laparoscopic removal of the banding, drainage of a local abscess and suture repair of a large antero-lateral laceration of the gastric wall. She was discharged on postoperative day 7. Patient 2 was admitted in an advanced state of malnutrition and dehydration due to the inability to eat. An upper gastrointestinal radiograph showed complete posterior slippage of the stomach and torsion of the fundus. Laparoscopic removal of the banding and fixation of the gastric fundus to the diaphragm were performed. She was discharged on postoperative day 3.
Conclusion: Involvement of primary care physicians and early referral to a center with bariatric experience are mandatory for prompt recognition and proper management of complications following bariatric surgery.
6169 Gynecology
Influence of Surgical Access on Outcome of Early Borderline Ovarian Tumors
F. Lécuru, P. Desfeux, U. Metzger, M. A. Le Frère Belda, G. Chatellier, B. Blanc, D. Querleu
Introduction: We compared staging and survival in patients with early borderline ovarian tumors (BOT) operated on by laparoscopy or laparotomy.
Methods: We conducted a retrospective analysis of 118 patients with stage I BOT treated surgically between 1985 and 2001. For each patient, we recorded whether initial surgical staging was by laparoscopy or laparotomy, the procedures done at initial staging surgery, and the outcomes. We carried out a univariate analysis (age, menopausal status, tumor diameter, surgical access, and the like) and then a multivariate model. Similarly, we conducted a univariate and a multivariate analysis for disease-free survival. The logistic regression, Cox model, and log-rank test were done using SPSS 7.5 and STATA.
Results: Initial staging was by laparoscopy in 48 patients, laparotomy in 54 patients, and laparoscopy converted to laparotomy in 16 patients. Mean follow-up was 40 months. We recorded 6 recurrences; 2 of these patients died. Staging analysis: realization of a hysterectomy (P=0.58, odds ratio (OR) =6.3 (95% confidence interval (CI): 0.93 to 43.27), or of a bilateral salpingo-oophorectomy (P=0.01, OR=4.7, 95% CI: 1.28 to 17.52) had an effect on staging. Conversely, surgical access had no effect. Surgical access had no significant effect on survival.
Conclusion: This study found no harmful influence of laparoscopy on staging and outcomes of patients with stage I BOT.
6170 Gynecology
Diagnostic Hysteroscopy Findings During Follow-Up of Women with Hereditary Nonpolyposis Colon Cancer
F. Lécuru, U. Metzger, D. Clément, F. Larousserie, C. Scarabin, F. Le Frère Belda, S. Olschwang, P. Laurent-Puig
Introduction: We report hysteroscopy findings in women with hereditary nonpolyposis colon cancer (HNPCC) and analyze feasibility, visual findings, and cancer diagnoses.
Methods: Sixty-seven women with mismatch repair gene mutations (n=11) or meeting Amsterdam criteria II (n=56) were followed up prospectively from January 1999 to June 2005. Flexible hysteroscopy plus endometrial biopsies were performed.
Result: Of 91 attempted hysteroscopies, 10 failed. The mucosa was normal to inspection in 34 patients. Endometrial polyps were diagnosed in 12 patients, hypertrophy in 10, atrophy in 11, submucosal myoma in 7, and a doubtful appearance on 2 hysteroscopies in 1. Importantly, a micropolypoid appearance was noted in 5 (6%) hysteroscopies. Of 86 endometrial biopsy attempts, 11 (12%) failed. Of the remaining 75 biopsies, 14 were atrophic, 12 proliferative, and 27 secretory; 6 biopsies showed polyps, 3 showed hyperplasia without atypia, and 2 showed cancer. The remaining 11 (12%) biopsies were inadequate or not interpretable. In the 5 hysteroscopies with a micropolypoid appearance, the biopsies showed secretory mucosa in 2 cases (in the same patient), proliferative mucosa in 2 cases, and a noninterpretable appearance in 1 case.
Conclusions: This study established the feasibility of hysteroscopic monitoring of patients with HNPCC. The prevalence of hyperplasia and cancer was similar to that in older women with vaginal bleeding in the general population. The micropolypoid appearance had no consistent histological correlative.
6171 Gynecology
Laparoscopic Appendectomies Performed by Gynecologists In Women with Pelvic Pain
Parveen S. Vahora, MD, Angela Chaudhari, MD, Steven McCarus, MD, Kathy Y. Jones, MD
Introduction: We sought to determine the effectiveness of performing appendectomies in gynecological patients with pelvic pain and to identify the histopathology of the appendix.
Methods: We performed a retrospective analysis of women who had undergone laparoscopic appendectomies at a private gynecologic practice within a community hospital, the Florida Hospital, from January 2000 to January 2005. The study included patients from the Women's Center with complaints of pelvic pain who underwent scheduled or incidental, or both, appendectomies. All patients who presented with complaints of pelvic pain or right lower quadrant pain who had laparoscopic appendectomies performed by the authors were included. Data collection included age, gravity, parity, height, weight, preoperative and postoperative symptoms and diagnosis, and histological diagnosis. The patients were also surveyed regarding their postsurgery status and satisfaction with the surgery. Exclusion criteria included procedures converted to laparotomies.
Results: Many women who present to the gynecologist with complaints of pelvic pain often have chronic or concomitant appendicitis with gynecological pathology. More than half of our patients had acute appendicitis on pathology examination without any typical signs or symptoms of appendicitis on clinical examination. Two thirds of our patients had appendiceal pathology including, appendicitis, endometriosis, parasitic myomas, and fibrous obliteration of the tip.
Conclusions: A laparoscopic appendectomy, in addition to operative gynecological laparoscopy, is an effective procedure for women who present with right lower quadrant pain and pelvic pain. Appendicitis, especially chronic or subclinical appendicitis, should be included in the differential diagnosis in all women who present to the gynecologist with complaints of pain.
6172 Multispecialty
Laparoscopic Pelvic Lymph Node Dissection and Radical Prostatectomy by a Transperitoneal or an Extraperitoneal Method: Impact of Different Types of Previous Inguinal Hernia Repairs
Ramakrishna Venkatesh, MD, Itay Y. Vardi, MD, Jessica Duan, Sam Bhayani, MD, Robert S. Figenshau, MD, Gerald L. Andriole, MD
Introduction: Conversion to an open procedure and complications were evaluated between transperitoneal and extraperitoneal laparoscopic pelvic lymph node dissection (LPND) and laparoscopic radical prostatectomy (LRP) for early prostate cancer in patients who had different types of previous inguinal hernia repairs.
Methods: A review was performed of medical records of patients who had LPND and LRP during the last 5 years at our institution. Details of previous hernia repairs (open/laparoscopic) including the use of prosthetic mesh, patient characteristics, operative details, and complications of LPND and LRP were evaluated.
Results: We identified 31 patients (12%) with previous inguinal hernia repairs from 257 patients who underwent LPND and LRP. A transperitoneal approach for LPND and LRP was used in 16 and an extraperitoneal approach in 15 patients. Four patients (12.9%) required conversion to an open prostatectomy; 2 had an open hernia repair and 2 had an open with subsequent laparoscopic repair for recurrent hernia. Bilateral PLND was successful in all but one patient with previous laparoscopic mesh hernia repair. Complications were seen in 4/31 patients (12.9%), in patients who had either open (3) or laparoscopic (1) repair. No difference occurred in complication (P=0.9) or conversion (P=0.4) rates between a transperitoneal and an extraperitoneal approach.
Conclusions: Bilateral LPND and LRP either by a transperitoneal or an extraperitoneal method was successful in the majority of patients with previous inguinal hernia repair with no major complications directly related to hernia repair. None of the primary laparoscopic mesh hernia repair patients required conversion to an open procedure in our series.
6173 General Surgery
Wound Complications in Laparoscopic Roux-en-Y Gastric Bypass
Wesley P. Francis, MD, Scott Laker, MD, John D. Webber, MD
Minimally Invasive Section, Department of Surgery, Wayne State University,Detroit Michigan
Introduction: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is rapidly becoming the standard in the surgical management of morbid obesity. Wound complications are reported to be low and of minor significance. We evaluated our rate, site location, and late effects of port-site infections.
Methods: We retrospectively reviewed all LRYGB performed from January 2002 through January 2006. Wound complications were categorized according to the CDC definition: superficial, deep incisional, and organ/space surgical-site infection (SSI).
Results: During the specified period, 138 LRYGB were performed. All patients received a preoperative dose of appropriate antibiotics. There were 18 wound infections, which represents a 13% complication rate. The mean age and body mass index were 42 and 53, respectively. Types of infections included 17 superficial SSI, 1 deep incisional SSI, and no organ space infections. The port site through which the EEA stapler was manipulated accounted for the majority of infections. Simple drainage of the wound with site packing was performed 94% of the time, and antibiotics were required in 66% of cases. One patient required hospitalization for intravenous antibiotic therapy. No long-term morbidity has occurred.
Conclusion: We believe that this accurately reflects the incidence of port-site infections in this population. Although this incidence is much higher than that in previous reports, no long-term sequelae seem to exist.
6174 Urology
Laparoscopic Inguinal Hernia Repair During Laparoscopic Radical Prostatectomy
David M. Rodin, MD, Benjamin C. Lee, MD, Douglas M. Dahl, MD
Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts
Introduction: Although simultaneous herniorrhaphy has been performed during open retropubic prostatectomy, it is not well reported with laparoscopic radical prostatectomy (LRP). After disappointing results with simultaneous LRP and laparoscopic inguinal hernia repair (LIHR) with absorbable mesh, we describe our experience with nonabsorbable mesh.
Methods: We retrospectively reviewed 40 patients who underwent simultaneous LIHR and LRP. All procedures were completed via antegrade techniques using Bard 3DMax mesh.
Results: In 40 patients, 48 clinically apparent hernias were repaired. Mean patient age was 60 years. Of 48 hernias repaired, 13 were left-sided, 23 right-sided, and 6 bilateral. Nineteen were direct, 14 indirect, 2 pantaloon, 3 femoral, and in 10 the type was not recorded. Mean operative time was 172 minutes. Mean hospital stay was 1.5 days. Two patients had a urine leak postoperatively that resolved without further intervention. Two patients developed a pelvic lymphocele, one 4 months and another 2 months postoperatively. Two patients required urinary catheter reinsertion for retention after surgical catheter removal on POD#9 and POD#10, respectively. One patient developed a deep venous thrombosis on POD#19. None of 36 patients (90%) available for a mean follow-up of 10 months had a hernia recurrence on the repaired side, while 2 developed a new symptomatic contralateral hernia.
Conclusions: Laparoscopic inguinal hernia repair is a successful and reliable way to treat symptomatic patients who undergo surgical treatment for prostate cancer.
6175 Urology
Laparoscopic Donor Nephrectomy in the Presence of a Circumaortic Renal Vein: The Video
Ilya A. Volfson, MD, Gregory G. Lovallo, MD, Michael E. Shapiro, MD, Ravi Munver, MD
Introduction: More than 64,000 people currently await kidney transplantation in the United States. Improvements in short-term and long-term graft survival and advancements in minimally invasive surgical techniques have resulted in an increase in the number of living kidney donations. Despite continuing proficiency in laparoscopy, anomalous or complex renovascular anatomy can pose a potential obstacle for successful laparoscopic organ harvest. We describe our technique for performing laparoscopic donor nephrectomy in the presence of a circumaortic renal vein.
Methods: The case of a 35-year-old healthy living-related kidney donor is presented. Preoperative imaging revealed complex left-sided vascular anatomy, consisting of 1 renal artery, a circumaortic renal vein, 2 adrenal veins, 1 gonadal vein, and 1 lumbar vein. The right-sided vascular anatomy consisted of 2 renal arteries and a short renal vein. This video highlights our technique for performing transperitoneal left laparoscopic donor nephrectomy.
Results: The procedural steps of our technique are outlined in the video. The retroaortic component of the renal vein was dissected, ligated with clips, and transected with laparoscopic scissors. The operative time was 195 minutes, estimated blood loss 100mL, warm ischemia time 3.3 minutes, and hospital stay was 2 days. The recipient was discharged with a nadir serum creatinine of 1.2 mg/dL. No perioperative complications were encountered.
Conclusion: Laparoscopic renal allograft procurement in patients with complex renovascular anatomy is safe and feasible. The case presented stresses the importance of preoperative radiographic assessment of the vascular anatomy as well as meticulous hilar dissection by an experienced laparoscopic surgeon.
6176 Gynecology
Laparoscopic Tubal Anastomosis
J. Song, MD, N. Rana, MD, C. Sueldo, MD, C. Rotman, MD
Introduction: This video demonstrates the laparoscopic techniques of performing tubal anastomosis to repair tubal disease involving segmental occlusion, or reversing tubal sterilization. We sought to offer patients seeking fertility after tubal sterilization or disease that resulted in segmental tubal occlusion an option other than laparotomy or in vitro fertilization.
Methods: Reproductive age women (range, 27 to 42 years of age) with severe tubal disease involving tubal occlusion or women with previous tubal ligations seeking tubal patency and fertility are enrolled in the study. All surgeries are performed at an outpatient surgical center in a Chicago suburb. This is a step-by-step video presentation of our technique of laparoscopic tubal anastomosis, which consists of minimal surgical trauma that could be performed in an outpatient surgical setting. The end result during a second look laparoscopy is also shown.
Results: The majority of the patients who have undergone this approach demonstrate tubal patency, and many have been able to conceive. There were 2 documented cases of ectopic pregnancy involving the repaired tube.
Conclusion: In most cases, with a certain degree of expertise, abdominal entrance, evaluation of tubal disease, visualization of previous sterilization, and tubal reconstructive surgery with anastomosis are more easily performed by laparoscopy than by laparotomy. Preliminary results in over 200 cases are very encouraging, and future studies will determine the true value of this technique compared with traditional methods.
6177 General Surgery
Endometriosis of the Cecum Mimicking Acute Appendicitis: A Case Report
Adel Chokki, MD, Hajer Ouerghi, MD, Fethi Khomsi, MD, Jamel Ben Hassouna, MD, Youssef Harrath, Tarek Ben Dhiab, MD, Faouzi Chebbi, MD, Chedly Dziri
Introduction: Extrauterine pelvic endometriosis is the presence of endometriotic implants found in other areas of the body. The intestines are involved in 5% to 15% of all cases of endometriosis. We present a case of cecal endometriosis. We will discuss the pathogenesis, and the diagnostic and therapeutic options of cecal endometriosis of this case.
Methods: A 24-year-old unmarried woman was admitted to the hospital with a 1-day history of right iliac fossa pain. She had as associated symptoms, nausea and vomiting. Her menses had been irregular, with occasional dysmenorrhoea. On admission, she had a low-grade fever of 37.9ºC. Pain was localized to McBurney’s point, with tenderness, guarding and rigidity. A diagnosis of acute appendicitis was suggested.
Results: A normal appendix and endometriosis of the cecum were detected at laparoscopic surgery. Pathologic examination confirmed the diagnosis of cecal endometriosis.
Conclusion: Although endometriosis is fairly common, isolated endometriosis of the cecum is very rare. The diagnosis is rarely suspected preoperatively, because of the absence of pathognomonic signs and symptoms for this disease. The purpose of this work is to call attention to this unusual localization that should be taken into account in the practice of surgery.
6178 Gynecology
Laparoscopic Approach to the Large Leiomyoma
J. Song, MD, A. Madanes, MD, C. Rotman, MD
Introduction: Laparoscopic myomectomies have been performed for years by advanced laparoscopic surgeons in the field of infertility. However, by making a few adjustments to traditional methods, even the large leiomyoma can be approached successfully by minimally invasive techniques. We sought to demonstrate our techniques of successfully performing a laparoscopic multiple myomectomy involving a large fibroid.
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 from 16 to 22 weeks gestational size (500 to 1500 grams). This video demonstrates our technique [altered trocar placements and the execution of the Simplified Laparoscopic Abdominal Morcellation (SLAM)] in approaching a large fibroid laparoscopically.
Results: All patients who underwent this approach had uneventful postoperative recoveries with desired outcomes. The majority achieved successful pregnancies either spontaneously or by in vitro fertilization. All patients who underwent the procedure for menorrhagia and anemia achieved complete resolution of their symptoms.
Conclusion: By altering trocar placements and utilizing the SLAM technique, large leiomyomas can be removed safely and quickly laparoscopically, avoiding the use of expensive automatic morcellators and averting potential complications that may arise with its use.
6179 Gynecology
Laparoscopic Resection of a Retroperitoneal Cyst
Tomone Yano, MD, Yutaka Yasuda, MD, Akiko Takashima, MD, Kiwamu Otaka, MD, PhD, Toshihiko Kinoshita, MD, PhD, Motohiro Ito, MD, PhD
Introduction: Retroperitoneal tumors are mostly solid tumors, and cysts are rarely reported. We report herein a case of a retroperitoneal cyst that was laparoscopically resected.
Methods: The patient is 27 years old and sought treatment because of a slight fever before menstruation. A large ovarian cyst was identified, and the patient was admitted to our hospital for further examination.
Results: Ultrasonographic examination showed a simple cyst 15x8cm in size on the left lower abdomen. Tumor marker CA72-4 was elevated (16.0U/mL). The cyst showed a low intensity in T1 and a high intensity in T2 on MRI examination. Upon laparoscopy, the uterus and bilateral adnexas were normal. In the left retroperitoneal space, a soft, smooth surface cyst of about 7x20cm in size was recognized. The cyst was easily separated from the peritoneum and resected. The cyst content was a translucent, light brown, serous fluid. Operation time was 138 minutes, and bleeding was 712mL including cyst content. The outer wall of the cyst consisted of smooth muscle, and the inner wall was lined with squamous to cubic and transitional epithelium. The patient was discharged on postoperative day 4 with no complications.
Conclusion: A retroperitoneal cyst is basically a benign tumor, and resection is recommended because the prognosis after surgery is good and cases of repeated centesis of the recurrent tumor resulting in malignant transformation have been reported. Retroperitoneal cysts are often diagnosed as ovarian cysts. It is thus important to consider the possibility of retroperitoneal cysts when a large cystic mass is recognized.
6180 General Surgery
Laparoscopic Splenectomy with Hand-Assisted Specimen Extraction in Massive Splenomegaly in Thalassanemia Major
Nikolaos Gatsoulis, MD, PhD, Nikolaos Roukounakis, MD, Ilias Kafetzis, MD, PhD, Andreas Mixos, MD, Spiros Spirou, MD
Surgical Department and Thalassemia Unit, General Hospital of Corfu, Greece
Introduction: Laparoscopic splenectomy has been used to manage several hematological disorders. Hypersplenism in _-thalassanemia major is an indication for splenectomy. Usually in these cases, splenomegaly associated and technical difficulties exist. The aim of this study is to present our technique of removing massive spleens and demonstrate the feasibility and efficacy of the laparoscopic procedure.
Methods: Two patients, 1 female and 1 male, 60 and 30 years old, respectively, suffering from b-thalassemia major with splenomegaly and hypersplenism underwent laparoscopic splenectomy.
Results: Dissection of the spleen and division of ligaments and splenic vessels were accomplished laparoscopically. Specimen removal was performed with a hand-assisted technique utilizing a lap disk. Maximum interpole length was 20cm and 24cm. Both patients were transfused intraoperatively receiving 2 and 3 units of packed red cells, respectively. The first operation was concluded in 230 minutes and the second in 160 minutes. Both specimens were weighed and found to be 800g and 1000g. No perioperative morbidity or mortality was noted. Both patients were discharged on postoperative day 4.
Conclusion: Laparoscopic splenectomy with its published advantages is feasible and safe even in cases of massive splenomegaly. Hand-assisted extraction of the specimen is indicated at the final step to remove the spleen from its bed.
6181 General Surgery
CISH Hysterectomy: 15-Year Perspective
John E. Morrison, MD, Volker Jacobs, MD
Introduction: We evaluated the state of CISH hysterectomy after 15 years of use, regarding complications, effectiveness, and cost of the procedure.
Methods: This is a retrospective study regarding CISH hysterectomy since its beginning in 1991, particularly in a rural setting. All procedures were performed in an ambulatory surgery center or acute care hospital facility. CISH is a supracervical hysterectomy with removal of the endocervical canal and transition zone. Exclusion criteria for surgery include carcinoma or patient weight >180kg.
Results: CISH hysterectomy was developed in 1991 with 735 patients being operated on from November 1992 to December 2005 since we began performing the procedure. Three patients were converted to an open procedure, 1 for weight >400lbs and 2 for uterine size. No bowel, bladder, ureter, or vascular injuries have been noted. Average length of stay was 22 hours. Fifty-five percent of patients had more than 1 procedure. Average blood loss was 71mL, and the length of the procedure was 1hour, 26 minutes. All patients were evaluated 1 week and 3 weeks postoperatively and afterwards as needed. Return to work averaged 14 days. Early complications included 1 laparotomy for cervical stump bleeding, 1 pelvic hematoma, 1 ileus, 1 laparoscopy for unusual postoperative pain, and 1 patient with DVT. Complications specific to the procedure include cervical bleeding <21 days, 13/735, 1.7%; bleeding >1 month, 4/735, 0.5%; mucocele 11/735, 1.4%; and 2 patients had excision of cervical stump for pain and 1 for leiomyoma. Three patients had carcinoma noted at the time of surgery, all free of disease 10 years postoperatively. The cost of the procedure averaged $615 for all disposable devices used. The procedure had very high patient satisfaction.
Conclusions: Options for hysterectomy have evolved over the past 10 years to 15 years,
and CISH is just one of them. It has evolved since its beginning in 1991, and as our results show, it is a safe, cost-effective procedure with good long-term results.
6182 Urology
Robot Radical Prostatectomy: Histopathologic and Short-Term Biochemical Recurrence Data at One Year
Vipul R. Patel, MD, Adam Mues, MD
Ohio State University
Introduction: We report our data for biochemical recurrence in patients who are a minimum of 1-year after robot-assisted prostatectomy (RAP).
Methods: RAP was performed in 354 patients who were at least 1 year postsurgery (mean 23 months). Histopathologic outcomes were determined by the TNM stage, Gleason grade, and margin status. Biochemical recurrence was defined as an increase in PSA level >0.2.
Results: Of the 354 patients, postoperative Gleason’s grades were 5(0.3%), 6(53%), 7(42%), 8(1.7%), and 9(3.7%), respectively. The positive margin rate (+M) for the series was 10.7%, and PSA recurrence was seen in 15(4.2%) patients. The first 100 patients had thirteen +M (13%) and 6 recurrences. Recurrence occurred in Gleason grades 7(1), 8(1), and 9(4) and pathologic stages T3a(2), T3b(1), T3c(1), and T4(2). The second 100 cases had a +M rate of 8%, and there were 3 recurrences with Gleason’s of 7 (2) and 9 (1), and all stage T3b. The +M and recurrence for the third series of 100 patients was 13% and 4, respectively. One patient had a grade of Gleason 7, and 3 patients with a grade of 9. Recurrence was found in T3b (2) and T4 (2). The final 54 patients had a +M of 7.4% and demonstrated recurrence in T4 disease only (2 patients with Gleason 7).
Conclusions: PSA recurrence has only been seen for Gleason’s grade 7, 8, and 9 and with extensive T3a, T3b, or T4 disease. Long-term follow-up is necessary.
6183 Gynecology
Laparoscopic Preperitoneal Inguinal Hernia Repair Using Preformed Polyester
Mesh Without Fixation: A 4-Year Study
John E. Morrison Jr., MD, Volker Jacobs, MD
Introduction: We evaluated patient results regarding, pain, recurrence, and complications preoperatively, immediately postoperatively, at 1 month, and long-term with assessment of cost of the procedure in an outpatient setting.
Methods: All patients completed a questionnaire regarding pain and level of activity preoperatively. At follow-up, patients were evaluated for complications, recurrences, and pain level based on the VAS score method. The operating surgeon saw all patients 1 week and 3 weeks postoperatively. Patients were contacted for evaluation of outcome at 1 year and greater depending on when the procedure was performed. All procedures were TEPP with the patient under general anesthesia as an outpatient in an ambulatory surgery center or ambulatory surgery setting in an acute care facility hospital.
Results: Between March 2001 and December 2005, 126 patients were operated on with a total of 170 hernias repaired. Pain scale evaluation preoperatively averaged 6. Immediately postoperatively, it averaged 2 and at 1 month it averaged 1.2. Eighty percent of patients rated their activity level as sportsman, very active or active, only 20% sedentary. Twenty percent of patients have been followed up for over 4 years, 28% over 3 years, 28% over 2 years, and 24% for 1 year or less. There were 2 recurrences, 1 at 1 month and 1 at 1 year for a 1.1% recurrence rate. Two patients experienced urinary retention. No readmissions were necessary, and no bladder, bowel, or vascular injuries occurred. The cost of the disposable devices used in the procedure was $236.59.
Conclusion: Laparoscopic preperitoneal inguinal hernia repair with a preformed polyester mesh is a cost-effective, safe procedure with results comparable to those of other procedures for inguinal hernia repair, with good long-term pain control.
6184 General Surgery
Trocar Port-Site Incisional Hernias After Laparoscopic Surgery
Ali Uzunköy, Prof. Dr.Harran
University School of Medicine,Department of General Surgery, Sanliurfa, Turkey
Introduction: Trocar port-site hernias are a rare complication of laparoscopic surgery. In the literature, the incidence of this complication is reported to be 1% to 6%. Trocar port-site hernias are potentially dangerous. Six cases are presented in this study.
Methods: All patients were women (37 to 58 years old). These patients had trocar port-site incisional hernias after laparoscopic surgery. Five hernias were seen at the umbilicals and 1 hernia was at the epigastric trocar port site. At these hernia sites, trocars ≥10mm in diameter were used during previous laparoscopic surgeries. All patients suffered from abdominal pain. The diagnosis of all cases was confirmed with computerized tomography. One patient was operated on emergently because of an incarcerated hernia. The other patients were operated on electively.
Results: There was no suture material at the hernia site at operative observation in any patient. Hernia repairs were performed by closing the fascia with number 0 propropylene sutures.
Conclusion: If the fascia site with a diameter of ≥10mm at trocar entry is not closed, trocar-site incisional hernias may occur. Therefore, this fascia should be closed.
6185 Gynecology
The Safety of the Helica Thermal Coagulator (Helica) for Treating Endometriosis: A Series of 500 Patients
N. Hill, S. Chandakas, J. Erian
Department of Obstetrics & Gynaecology, Princess Royal University Hospital,London, United Kingdom
Introduction: The Helica thermal coagulator is a new instrument that combines low-pressure helium gas with electrical power and is used to treat endometriosis. The operational power is much lower than that of conventional diathermy yet sufficient to ionize the helium, thereby allowing tissue fulguration and producing an effect similar to that of the argon beam coagulator. The operating power of the device can be precisely regulated to vary the depth of penetration of the beam. Because the depth of penetration is only 1.1mm, the instrument can be used to treat endometriosis near the ureter or on the bowel. The device is very simple to use, and it can rapidly treat large areas of endometriosis or surrounding peritoneum. Any tissue contact that occurs carries less potential for unwanted damage, which appears to make the technique safer than electrocautery or laser. In addition, because the coagulation occurs within the helium beam, no smoke and carbonization is produced. This allows the operator to have a clear view of the endometriosis destruction. We sought to assess the safety of the Helica thermal coagulator in the laparoscopic treatment of endometriosis.
Methods: This is a retrospective, observational study of 500 women with endometriosis treated at the Princess Royal University Hospital, London, UK.
Results: The Helica thermal coagulator was used to laparoscopically treat endometriosis in 500 women. Seventy-eight percent were nulliparous. In a further 29% of patients, dyspareunia was the major problem. Based on the revised American Fertility Classification, 68% had stage 1 disease, 12.5% had stage 2 disease, 6.5% had stage 3 disease, and 12% had stage 4 disease. No major complications occurred in the patients treated with the probe without the cutting end. However, 3 patients had a vagina perforation from the cutting probe. The defect was sutured vaginally, and the patients had an uneventful recovery. No patients had bladder, ureteric, or bowel perforations. When seen for follow-up 6 months later, no major complications were reported, and the success rate was 89% (women feeling less pain than before the operation).
Conclusion: The Helica thermal coagulator is a safe device for the treatment of endometriosis.
6186 Gynecology
Outpatient Surgical Laparoscopic Subtotal Hysterectomy: A Multicenter Study with 250 Patients
S. Chandakas, N. Hill, J. Erian
Iaso Hospital, Department of Minimal Invasive Gynaecological Surgery, Athens,Greece
Department of Obstetrics & Gynaecology, Princess Royal University Hospital,London, UK
2nd Gynaecological Clinic, University of Athens, Aretaieion Hospital,Athens, Greece
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. We sought to demonstrate the safety, feasibility, and morbidity of laparoscopic subtotal hysterectomies in an outpatient setting.
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 36 months (November 2002 to November 2005), data were collected from medical records on how the intervention was performed, and followed up for 12 months. Two surgeons performed 250 laparoscopic subtotal hysterectomies. Instruments powered by PlasmaKinetic energy were used to dissect tissues and to provide hemostasis for all major vessels (uterine, ovarian). A 12-mm morcellator was used to remove the dissected organs. Indications included 21.6% cases for endometriosis, 66.2% for menorrhagia, and 12.05% for endometrial pathology. Median follow-up was 50 weeks.
Results: Duration of surgery and hospital stay, safety (morbidity and mortality), and patient satisfaction were assessed. Estimated blood loss was 100mL (range, 50 to 2000mL). Significant intraoperative complications occurred in 0.5%, vascular injuries occurred in 0%, and nerve or ureter injuries occurred in 0%. Early postoperative morbidity included 0.5% deep vein thrombosis, 0% pulmonary embolism, 2% bladder infection and dysfunction, and 0% vaginal fistula. Late postoperative morbidity consisted of 0% lymphedema, 2% pelvic abscess and lymphocyst formation, 1.7% pelvic cellulites, 1% hyperesthesia of the leg, and 1% small bowel obstruction The overall complication rate was 1.2%. We report 1 bowel and 1 bladder injury, which were sutured laparoscopically by our surgical support team during the operation. Of these 250 patients, 92.5% 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 2.1 days. Reasons for length of stay in this group of patients were 5.5% pain control and 2% social reasons.
Conclusion: Laparoscopic subtotal hysterectomy can be safely performed as an outpatient procedure.
6187 General Surgery
Laparoscopic Cholecystectomy with a Combined Method
Ryuichi Hotta, MD, Toshio Noriyuki, MD, PhD, Fumito Kuranishi, MD, PhD,
Masahiro Nakahara, MD, PhD, Toshikatsu Fukuda, MD, PhD,
Manabu Shimomura, MD, Junko Nambu, MD, Yoshinori Kuroda, MD, PhD
Introduction: We started performing laparoscopic cholecystectomy (LC) in 1992. We have now performed about 900 cases. At first, we used pneumoperitoneum (8mm Hg, 8l/min). In 1993, we introduced a combined method (pneumoperitoneum (4mm Hg, 4l/min) + abdominal wall lifting). This technique makes it possible to perform LC with low abdominal pressure. In this study, we report the effect of this combined method from the standpoint of body temperature (BT).
Methods: From 1992 to 2005, 879 patients underwent LC in our department. We retrospectively reviewed 796 patients. We excluded 28 patients who underwent combined operations (mastectomy and others), had an open conversion (52), or had complications (18). Because we could not confirm BT in 22 patients, we also excluded them. BT change was confirmed from the anesthesia records. We divided the patients into 3 groups: Group A, BT increase; Group B, BT no change; Group C, BT decrease.
Results: Among the 3 groups (A, B, & C), no significant difference occurred in the postoperative course, first walking, first flatus, bowel sound, first stool, laboratory data (WBC, CRP), analgesic use, and postoperative hospital stay, and oral intake. However, in Group C, the degree of BT decrease was significantly different between the pneumoperitoneum (0.56±0.33 _) and combined method (0.44±0.29_) (PÅÉ0.01Åj
Conclusion: This study suggests that from the standpoint of BT, the combined method is useful and causes minimal stress during long operations, not only LC but also other laparoscopic surgeries.
6189 Gynecology
Laparoscopic Hysterectomy with Retroperitoneal Dissection and Uterine Artery Occlusion
Jay P. Shah, MD, Jessica M. Vaught, MD, Paul J. MacKoul, MD
Introduction: We sought to describe the technique and results of retroperitoneal dissection and uterine artery occlusion as a valuable approach to laparoscopic hysterectomy.
Methods: A retrospective chart review performed from January 1, 2004 to December 31, 2005 included 243 patients who underwent laparoscopic hysterectomy. A single surgeon at one teaching institution performed the operations usually with a resident assistant.
Results: At a single institution, 243 consecutive laparoscopic hysterectomies were performed. Average patient BMI was 31kg/m2, and 56% had prior abdominal surgery. Average estimated blood loss was 217mL, and average operating time including morcellation was 97 minutes. The average uterine weight was 391g with a range of 26g to 3283g. The average length of hospital stay was 1.2 days, with 15 patients discharged the same day of surgery. The readmission rate was 3.7% (9 of 243), blood transfusion rate was 3.3% (8 of 243), rate of urinary tract injuries was 1.2% (3 patients with intraoperative laparoscopic cystotomy repairs), and 1.2% rate of bowel related complications. The conversion to laparotomy rate was 0.4% (1 conversion due to complete obliteration of the posterior cul-de-sac).
Conclusions: Retroperitoneal dissection provides isolation and transection of the uterine artery as it diverges from the internal iliac artery and excellent visualization of the ureter. It has been our experience that this technique allows patients to have a safe and efficient laparoscopic hysterectomy regardless of uterine size with minimal blood loss, short hospital stay, and a low rate of complications.
6190 Urology
Techniques for Laparoscopic Localization of Intraluminal Ureteral Pathology
Ronney Abaza, MD
Medical University of Ohio, formerly the Medical College of Ohio
Introduction: Improvements in endoscopic technology have made open ureteral surgery uncommon. There remain cases of ureteral pathology not treatable ureteroscopically, but laparoscopy allows even these complicated cases to be treated in a minimally invasive fashion. Laparoscopic treatment of the ureter requires the ability to localize the diseased segment laparoscopically even when the defect is within the lumen and cannot be seen externally or palpated as in open surgery. We describe 3 techniques to localize pathology within the ureter during laparoscopy and the benefits and limitations of each technique.
Methods: Three cases of laparoscopic ureteral surgery illustrate 3 different techniques used to localize pathology within the ureteral lumen. A ureteral occlusion balloon catheter is used to identify a stricture by distending the collecting system proximal to the obstruction and cinching the balloon against the stricture. In our initial report of the application of laparoscopy to ureteral polyps, a flexible ureteroscope was introduced through a 5-mm port and into the incised ureter to guide excision of extensive polyposis. A third case involving a polyp and stricture illustrates a technique involving retrograde ureteroscopy with “cutting to the light” laparoscopically.
Results: Three techniques were used to successfully localize intraluminal ureteral pathology that could not be identified visually by laparoscopic inspection alone. These techniques also minimized the extent of ureteral dissection to preserve blood supply.
Conclusion: Laparoscopy can be successfully applied to benign ureteral disease not amenable to ureteroscopic treatment. Three cases are presented with video to illustrate 3 techniques for localization of intraluminal ureteral pathology.
6191 General Surgery
Chronic Pain After Laparoscopic Repair of Ventral and Incisional Hernia
Srdjan Rakic, MD, PhD, Eelco Wassenaar, MD, Johan T. F. J. Raymakers, MD
Introduction: After laparoscopic repair of ventral/incisional hernias, some patients suffer chronic postoperative pain that may tend to reduce the overall benefits of the procedure. We analyzed this complication in a series of 325 patients who underwent laparoscopic repair of incisional (n=138) or ventral (n=187) hernias in an attempt to identify important details in their prevention and handling.
Methods: In all patients, a DualMesh (WL Gore) prosthesis overlapping hernia margins by ~3cm was fixed with either tacks (ProTack, TycoUSS) alone (n=102) or tacks and sutures (n=223). Pain resistant to conservative treatment >6 months was defined as “chronic pain.” Fisher’s exact test was used for statistical analysis.
Results: Five patients (1.5%), all with incisional hernias (P<0.05) and with mesh fixation that involved sutures (P>0.05), experienced chronic pain. These patients underwent relaparoscopy and removal of all sutures. Postoperatively, 3 patients had complete pain relief, and 2 patients remained with moderate or marked pain.
Conclusions: An obviously existing entity of chronic postoperative pain following laparoscopic repair of incisional/ventral hernias has received little attention so far. Patients with incisional hernias seem to be at higher risk for occurrence of chronic pain than are patients with ventral hernias. The general opinion that sutures are a source of chronic postoperative pain did not reach statistical significance in this series. Removal of sutures deemed responsible for pain in this series was less effective than previously assumed. This indicates that the role of tacks as a source of the chronic postoperative pain should not be underestimated.
6192 Urology
Laparoscopic Donor Nephrectomy: A Review of the Last 220 Cases
I. P. Christopher, MD, Edward Chin, MD, Michael Edye, MD, Daniel Herron, MD, Michael Palese, MD
Introduction: Morbidity of renal donation to the donor is decreased with the laparoscopic donor nephrectomy (LDN) while providing a renal allograft of quality that equals that of open donor nephrectomy. We evaluated our LDN experience with the most recent consecutive series to study factors influencing the outcomes of our donor population.
Methods: Records of 220 LDN performed by 3 surgeons from March 2000 to December 2005 were retrospectively reviewed. We evaluated preoperative donor characteristics, intraoperative parameters, postoperative recovery, and complications.
Results: Mean age of our patients was 39.4±11.1 years with more females than males donating (F=122, M=98). Average operative time was 179.7±57.6 minutes with a decrease in time when comparing our first 110 cases to the last 110 cases (198.4±52.6 vs.159.9±56.3 min; P<0.05). Average warm ischemia time was 163.0±73.5 seconds with no significant difference between the first and last 110 cases (169.6 vs. 155.3sec). Total estimated blood loss was 164.9mL with no statistical change between the first and last 110 cases (156.1 vs. 174.5mL). A hand-assisted approach was used in 32.7% of patients, and 12.7% of the kidneys were right sided. Intraoperative complications occurred in 17 cases (one major complication required conversion to open). Major postoperative complications occurred in 16 cases. Creatinines preoperatively and on postoperative days 1 and 2 were 0.81±0.20mg/dL, 1.21±0.28mg/dL, and 1.14±0.24mg/dL, respectively. The average length of stay was 2.5 days.
Conclusions: Laparoscopic donor nephrectomy is routine in most transplant centers and appears to be safe, especially in experienced hands.
6193 Urology
Da Vinci-Assisted Versus Pure Laparoscopic Aortorenal Bypass in an Acute Porcine Model
Ronney Abaza, MD
Introduction: Laparoscopic aortorenal bypass (LARB) in a human patient has never been reported. Laparoscopic renal revascularization is limited not only by the technical demands of laparoscopic suturing, but also by the constraints of renal ischemia time. The limit of warm ischemia believed to prevent renal damage is 30 minutes, making it imperative that the surgeon be able to complete the renal arterial anastomosis expeditiously. We previously demonstrated feasibility by safely performing LARB in a porcine model. We now compare our laparoscopic results with our novel report of a da Vinci-assisted technique.
Methods: LARB was performed in 5 pigs laparoscopically with or without the use of the da Vinci robot. Procedures were performed after a regimented training program progressing to LARB modeling using cadaver pig kidneys.
Results: Using pure laparoscopic techniques, initial renal artery anastomosis time was 25 minutes, which fell to 15 minutes by the last procedure with a total renal warm ischemia time of 18 minutes. This best result for pure laparoscopy was matched on the first da Vinci-assisted procedure. Aortic anastomosis time was 13 minutes using the da Vinci robot compared with a mean of 33 minutes laparoscopically, and aortic clamp time was 25 minutes versus 49 minutes, respectively. Mean total operative time was 3:11 hours laparoscopically compared with 2:59 hours with the da Vinci robot.
Conclusion: LARB is feasible, and with proper training any surgeon can become capable of performing it. The da Vinci robot is not necessary for a successful outcome but may allow for less aortic and renal ischemia time and may allow for more widespread application of laparoscopy to this challenging procedure.
6194 Urology
Laparoscopic Adrenalectomy for Benign and Malignant Adrenal Lesions Using a Novel Vessel-Sealing System: A Combined Experience
Ravi Munver, MD, Ilya A. Volfson, MD, Salvatore A. Lombardo, MD,Surena F. Matin, MD
Objective: Laparoscopic adrenalectomy has become the standard technique for surgical removal of the adrenal gland. Technological advances in hemostatic devices have further facilitated this procedure. We compared the LigaSure Vessel-Sealing System (Valleylab, Boulder, CO, USA), a bipolar device, with monopolar and ultrasonic energy devices, and assessed the impact on operative time and blood loss.
Methods: Thirty-two consecutive laparoscopic adrenalectomies [12 right, 20 left] were performed at 2 institutions by 2 surgeons via a transperitoneal (n=25) or retroperitoneal (n=7) approach. Indications included benign [adenoma (n=15), 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)]. In 18 patients,
adrenalectomy was performed using electrocautery shears or the Harmonic scalpel with double hemoclip ligation of the main adrenal vein and accessory vessels (conventional group). In 14 patients, the LigaSure was used following single or double hemoclip ligation of the main adrenal vein (LigaSure group).
Results: No differences existed in mean age [55.4 (conventional); 54.8 (LigaSure)], lesion size [3.7cm (conventional); 3.6cm (LigaSure)], or hospital stay [1.7 days (conventional); 1.8 days (LigaSure)]. Mean operative time [187±45min (conventional); 115±43min (LigaSure)], and blood loss [162±58mL (conventional); 33±27mL (LigaSure)], were significantly less for the LigaSure group (P<0.01). The conventional group received an average of 11 hemoclips while the LigaSure group received 2.5 hemoclips.
Conclusions: The LigaSure Vessel-Sealing system effectively sealed the main adrenal vein and accessory vessels. This device dramatically reduces operative time and blood loss and may have a profound impact on laparoscopic adrenal surgery.
6195 Other
Penetrating Abdominal Trauma with No Signs of Peritoneal Penetration: Would Diagnostic Laparoscopy Avoid a Laparotomy?
Syed I. Ahmed, MD, Irum Chaudhry, MD, Ahmed Khalil, MD, Mohammed N. Islam, MD, Richard Fogler, MD
Introduction: Surgical decision-making in penetrating trauma can be challenging. Some victims who do not have significant abdominal injury still undergo exploratory laparotomy and hence have a prolonged hospital stay. We studied patients who had penetrating abdominal injury but were hemodynamically stable. Decisions were made to convert to exploratory laparotomy on the basis of observation of parietal peritoneal penetration during diagnostic laparoscopy. Several patients with no peritoneal penetration avoided surgery.
Methods: This study included 22 patients with penetrating abdominal injury who were hemodynamically stable and attended by one chief resident. Unstable patients and those with peritoneal violation on local exploration were excluded. The local wound was explored after the patient was given adequate local anesthesia. After conclusive criteria were met, the patients underwent a diagnostic laparoscopy with a 5-mm, 30-degree laparoscope. In the absence of peritoneal violation, the operation was terminated and the patient discharged in 24 hours.
Result: Of 22 patients, 12 (54.5%) had no peritoneal violation and 11 of these were discharged home in 24 hours. One of the 12 had injuries to the limbs and was discharged later. Ten (45.4%) others had peritoneal violation. Of these, 1 (0.045%) had no additional injuries at exploration.
Conclusion: After inconclusive local wound exploration, diagnostic laparoscopy avoids exploratory laparotomy, when managing stable patients with penetrating trauma. The false-positive rate was 0.045%.
6196 Gynecology
Ruptured Noncommunicating Hemi-Uterus Presenting with Acute Pelvic Pain
M. Amols, MD, L. Gavrilova-Jordan, MD, C. Coddington, MD
Introduction: Müllerian anomalies cover a wide range of phenotypic presentations, resulting from multiple defects in müllerian duct maturation. Difficulties in classifying complex abnormalities lead to diagnostic and treatment delays. We demonstrate a symptomatic rare müllerian malformation of vertical and lateral fusion. Most are asymptomatic and are associated with a urologic anomaly 40% of the time.
Methods: A 15-year-old female with 3 years of nonspecific pelvic discomfort presented with 40 hours of acute left pelvic pain with 24 hours of nausea and vomiting and fever. The patient had a history of a possible absent left kidney. CT demonstrated possible tubo-ovarian abscess versus hydrosalpinx versus dilated uterine horn as well as absence of the left kidney. The patient was presumed to have a müllerian anomaly as the cause of her increasing pain. Successful laparoscopic surgery was preformed and revealed a normal right unicornuate uterus and a noncommunicating left hemi-uterus originating from the left pelvic sidewall brim. The left hemi-uterus was dilated (hematometra), and 300cc of clotted blood was present in the pelvis. Left renal agenesis was confirmed. Pathology revealed hemosalpinx with perforation and acute serositis; endomyometrium was identified.
Results: We successfully managed a rare unclassified müllerian anomaly with a laparoscopic approach.
Conclusions: This case demonstrates that rare müllerian anomalies may present with acute onset of pelvic pain and can successfully be treated laparoscopically. A high index of suspicion is required to promptly diagnose and prevent diagnostic delay.
6197 Urology
Robotic-Assisted Pyeloplasty with Synchronous Removal of Renal Calculi in the Adult Patient: Technical Modifications
Fatih Atug, MD, Michael Woods, MD, Scott V. Burgess, MD, Erik P. Castle, MD, Raju Thomas, MD, MHA
Department of Urology, Tulane University Health Sciences Center, New Orleans, Louisiana
Introduction: Laparoscopic pyeloplasty is gaining acceptance as a treatment modality for the repair of ureteropelvic junction obstruction (UPJO) with results comparable to those of open repair. However, this remains a technically challenging procedure requiring advanced intracorporeal suturing skills. We present our modified technique for robotic-assisted laparoscopic pyeloplasty (RALP).
Methods: From November 2002 to February 2005, 45 adult patients underwent RALP for UPJO. A retrospective chart review was performed. Forty-two of the 45 patients have had a minimum 3-month follow-up and were included in this review. All patients had radiographic evidence of UPJO on diuretic renography or excretory urography. Variables analyzed included length of hospital stay (LOS), estimated blood loss (EBL), operative time, and robotic anastomosis time. Postoperatively, patients were evaluated with diuretic renography or excretory urography, or both, at 3 months and beyond.
Results: Anderson-Hynes dismembered pyeloplasty was the preferred reconstructive technique in all patients. All operations were completed robotically, and no conversions to open surgery were needed. Concomitant pyelolithotomy was performed in 8 patients with nonobstructing caliceal stones. The mean operative time, which includes cystoscopy, retrograde ureteropyelography, and stent placement, was 223.6 minutes (range, 130 to 330). The mean anastomosis time was 51.3 minutes (range, 30 to 125). Mean estimated blood loss (EBL) was 56.5cc (range, 10 to 200). At a mean follow-up of 13.5 months (range, 3 to 26), all 42 patients have no evidence of obstruction.
Conclusions: Robotic-assisted laparoscopic pyeloplasty can be successfully performed with results comparable to those of open pyeloplasty.
6198 Urology
Robotic Pyeloplasty in Children
Michael Woods, MD, Fatih Atug, MD, Scott V. Burgess, MD, Erik P. Castle, MD,
Raju Thomas, MD, MHA
Department of Urology, Tulane University Health Sciences Center, New Orleans, LA
Introduction: Historically, open pyeloplasty has been the gold standard for treatment of ureteropelvic junction obstruction (UPJO) in the pediatric age group. The prospect of using technology, such as the robot, in the pediatric group has been a concern. We undertook a retrospective study to evaluate the feasibility and outcomes of performing robotic-assisted laparoscopic pyeloplasty (RALP) in the pediatric population.
Methods: Seven pediatric patients between the ages of 6 and 15 underwent robotic-assisted laparoscopic pyeloplasty (RALP) at our institution from June 2003 through December 2004. All patients underwent dismembered pyeloplasty (Anderson-Hynes). Variables analyzed included length of stay (LOS), estimated blood loss (EBL), operative time, anastomosis time, and docked robotic time.
Results: The mean follow-up was 10.9 months (range, 2 to 18). Mean LOS was 1.2 days (range, 1 to 3). The mean operative time was 184 minutes (range, 106 to 200), with a mean robotic anastomosis time of 39.5 minutes (range, 30 to 46). Mean EBL was 31.4mL (range, 10 to 50). The stent size varied from 3.8Fr to 6Fr. Six of the 7 patients have had follow-up studies showing improved drainage, symptom resolution, and no evidence of obstruction on diuretic renal scans or intravenous pyelogram. The seventh patient is awaiting his 3-month follow-up study.
Conclusion: Robotic-assisted pyeloplasty can be safely performed in the pediatric population. The precision in dissection, incision, and suturing allows for results comparable to those of open pyeloplasty in this age group.
6199 Pediatric Surgery
Laparoscopic Versus Open Nissen Fundoplication in Infants After Neonatal Laparotomy
Katherine A. Barsness, MD, Alexander Feliz, MD, Douglas A. Potoka, MD, Barbara A. Gaines, MD, Jeffrey S. Upperman, MD, Timothy D. Kane, MD
University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh Pennsylvania
Introduction: Laparoscopic procedures after previous laparotomy are technically more challenging, especially in small infants. Laparoscopic Nissen fundoplication after neonatal laparotomy for diseases unrelated to reflux is poorly described. We hypothesize that laparoscopic Nissen fundoplication is technically feasible, safe, and effective to treat gastroesophageal reflux in infants having previously undergone neonatal laparotomy.
Methods: We performed an IRB-approved retrospective review of open versus laparoscopic Nissen fundoplication in infants after neonatal laparotomy (abdominal wall or diaphragmatic defects; intestinal atresias, malrotation or perforation) from January 2000 to September 2005. Data were analyzed by paired t test. P<0.05 significant.
Results: Among infants with prior neonatal laparotomy and subsequent development of gastroesophageal reflux, 12 infants underwent laparoscopic Nissen fundoplication, and 14 infants underwent open Nissen fundoplication. Comparing laparoscopic versus open Nissen fundoplication, no difference existed in mean age at the time of initial open operation (1 vs. 14 days, P=0.08), number of previous open operations (1.7 vs. 1.9, P=0.36), age at time of fundoplication (5.5 vs. 6.6 months, P=0.57), weight at time of fundoplication (5.2 vs. 5.7kg, P=0.51), operative time (131 vs. 164 minutes, P=0.10), or length of stay after fundoplication (14 vs. 26 days, P=0.13). Infants undergoing laparoscopic fundoplication resumed feeds earlier than those who underwent open fundoplication (3.0 vs. 6.3 days, P=0.01). No infant in either group developed recurrent gastroesophageal reflux.
Conclusion: Laparoscopic, compared with open, Nissen fundoplications performed in infants after a neonatal laparotomy were comparable procedures across most data points studied. We conclude that laparoscopic Nissen fundoplication is technically feasible, safe, and effective for treating gastroesophageal reflux in infants who have previously undergone a neonatal laparotomy.
6200 General Surgery
One-Stage Laparoscopic Roux-en-Y Gastric Bypass Surgery is Safe and Effective in High-Risk Superobese Patients
Eraj M. Basseri, MD, Neel R. Joshi, MD, Sergey Lyass, MD, Gregg K. Nishi, MD,
Scott A. Cunneen, MD, Theodore M. Khalili, MD
Introduction: Many authors advocate 2-stage laparoscopic Roux-en-y gastric bypass
(LRYGB) for high-risk, superobese patients. The objective of our study was to review our experience with 1-stage laparoscopic Roux-en-y gastric bypass in superobese male [BMI>50] patients.
Methods: A retrospective analysis of all male patients who underwent LRYGB from
January 1999 to January 2005 was performed. Superobese [BMI>50] male patients were compared with obese [BMI<50] male patients. Data collected included demographics, comorbidities, operative time, and length of stay. The 2 groups were compared with regard to perioperative complications and postoperative weight loss. Perioperative complications evaluated included incidence of anastomotic leak, bleeding, pulmonary embolus, deep vein thrombosis, and bowel obstruction.
Results: During the study period, 71 superobese male patients and 97 obese male patients underwent LRYGB. Mean BMI in the superobese group was 57 (range, 50 to 68) versus 44 (range, 35 to 49) in the obese group. The overall complication rate in the superobese group was 8.5% versus 11.3% in the obese group. Specific complication rates in the superobese and obese groups, respectively, were as follows: anastomotic leak (1.4% vs 3.1%), bleeding (0.0% vs 3.1%), pulmonary embolus (1.4% vs 0.0%), and bowel obstruction (2.8% vs 1.0%). No deaths, conversions to open surgery, or deep venous thromboses occurred in either group. Mean %EWL was 55.3 in the superobese group versus 68.6 in the obese group at 1-year follow-up.
Conclusion: One-stage laparoscopic Roux-en-y gastric bypass surgery can be safely performed in superobese patients with excellent postoperative weight loss and no additional perioperative morbidity.
6201 Urology
Transurethral Excision of the Distal Ureter and Retroperitoneoscopic Radical Nephroureterectomy with Three Ports in the Modified Lithotomy Position
Yildirim Bayazit, MD, Cem Sah, MD, Alper Eken, MD, I. Atilla Aridogan, MD, Saban Doran, MD
Introduction: Laparoscopic radical nephroureterectomy either transperitoneally or retroperitoneally, through 4 or 5 ports in general, with transurethral excision of the distal ureter can be performed for the treatment of upper urinary tract epithelial tumors. To avoid the repositioning of the patient during the operation, a modified lithotomy position was proposed. A novel technique, retroperitoneoscopic nephroureterectomy with 3 ports including transurethral incision of the ureteral orifice without a change in the position of the patient, is presented.
Methods: Laparoscopic nephroureterectomy was planned for a 41-year-old male patient with hematuria who had a 3-cm tumor in his right renal pelvis. The operation was performed retroperitoneoscopically using three 10-mm trocars with the patient in a modified lithotomy position. Ureterectomy was completed with transurethral incision around the ureteral orifice. A 20F Foley catheter was installed. One of the trocars was replaced with a hand port to remove the specimen.
Results: Left-hand instrumentation was more difficult to use than the usual lateral decubitus position. Operation time was 255 minutes and the blood loss was minimal. The patient was discharged on the fourth postoperative day, and the urethral catheter was removed following cystography on the 10th day. High-grade papillary urothelial carcinoma was found on histopathologic examination. No nodal metastases were present in the specimen, and the pathological margins were free of tumors.
Conclusion: This method requires that the surgeon have more experience in laparoscopy than the transperitoneal approach does. Minimal risk of intraabdominal organ injury, no need for vigorous bowel preparation, limitation of urinary leakage (if it occurs) in retroperitoneal area, and no need for a change in the patient’s position are advantages of this technique.
6202 General Surgery
Hand-Assisted Laparoscopic Surgery (HALS) in Colorectal Surgery
A Single Institution Experience
Anne-Marie Boller, MD, Robert R. Cima, MD, David W. Larson, MD,
Eric J. Dozois, MD, John H. Pemberton, MD
Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
Introduction: The aim of this study was to analyze in what manner practice patterns were altered by incorporating a new laparoscopic technology, hand-assisted laparoscopic surgery (HALS).
Methods: A prospectively maintained database of all colon and rectal operations completed by 8 board certified colorectal surgeons was retrospectively reviewed between January 2004 and July 2005 for operations utilizing the HALS technique.
Results: Before the study period (2003), 113 laparoscopic procedures were performed by 2 surgeons not using the HALS technique. During the study period, 7 of 8 surgeons performed 417 laparoscopic procedures, using HALS in 187 procedures (45%). There was an overall increase in laparoscopic cases from 9.4 cases/month to 22 cases/month, 79% of the increase being HALS procedures. The cohort consisted of 100 men (53%) and 87 women (47%). Indications for surgery included cancer (20%), diverticulitis (18%), polyps (6%), Crohn's (7.5%), ulcerative colitis (37%), motility disorders (2.6%), FAP (1.6%), volvulus (1%), and other diagnoses (4.8%). Sixty percent of the operations were complex procedures including IPAA, total proctocolectomy, LAR, APR, subtotal colectomy, and proctectomy. Overall conversion rate was 11%. Complications included wound infection (10%) and anastomotic leaks (2%). Median hospitalization was 6 days (range, 3 to 30).
Conclusion: HALS laparoscopic procedures are safe, effective, and were easily adopted into a colorectal surgery practice within a 2-year period. HALS facilitated complex colorectal resections by surgeons who previously had not routinely performed laparoscopic colorectal surgery. HALS may be a mechanism that will bring the benefits of minimal access colorectal surgery to a larger group of patients.
6204 Urology
Standardized Evaluation of Complications of Robotic Radical Prostatectomy
Erik P. Castle, MD, Fatih Atug, MD, Scott V. Burgess, MD, Rodney Davis, MD, Raju Thomas, MD, MHA
Department of Urology, Tulane University Health Sciences Center, New Orleans, Louisiana
Introduction: Robotic radical prostatectomy is gaining popularity for the treatment of clinically localized prostate cancer. With the advent of new surgical techniques, complications must be recognized and reported. We retrospectively evaluated operative parameters and complications of 90 consecutive robotic radical prostatectomies.
Methods: Between February 2003 and February 2005, 90 patients, age 45 to 71 years, underwent robotic radical prostatectomy by the same surgical team. The Clavien classification system was used to standardize and grade complications.
Results: No operative mortalities occurred. Conversion to open radical prostatectomy was done in 2 of the initial 10 patients, but none since. Morbid obesity and technical difficulty were the causes of said conversions. Pelvic lymphadenectomy was performed in 25 (27.7%) patients. Mean operative time was 270.2 minutes (range, 151 to 679), mean blood loss was 367.7mL (range, 100 to 2000), and mean hospital stay was 1.6 days (range, 1 to 36). Overall, 76 (84.5%) patients were not affected by any complications. However, 14 (15.5%) complications were observed in 90 patients with a mean follow-up of 12.8 months. Complications included 5 grade I complications, 8 grade II complications, and 1 grade III complication. No grade IV complications occurred.
Conclusions: Robotic radical prostatectomy is a safe procedure. It was performed with no complications in 84.5% of patients. Our series provides evidence that the outcomes of robotic radical prostatectomy are comparable to outcomes with other techniques with acceptable complication rates. Consistent reporting and grading of surgical complications via standard classification systems may allow more accurate comparisons among different techniques and treatment centers.
6205 Urology
Positive Surgical Margins in Robotic Radical Prostatectomies: Impact of the Learning Curve on Oncologic Outcomes
Fatih Atug, MD, Erik P. Castle, MD, Scott V. Burgess, MD, Rodney Davis, MD,Raju Thomas, MD, MHA
Department of Urology, Tulane University Health Sciences Center, New Orleans, Louisiana
Introduction: Robotic-assisted prostatectomy (RAP) continues to generate excitement within the urological community. Positive surgical margins following radical prostatectomy is a known risk factor for disease recurrence and may lead to adjuvant treatment. Our goal was to assess the incidence of positive surgical margins in our RAP series and to evaluate the effect of our learning curve on our margin positivity rate.
Methods: Between 2003 and 2005, 90 consecutive RAPs were performed and retrospectively reviewed. The patients were divided into 3 groups based on timeline of surgery. We compared the incidence and location of positive surgical margins between the groups. Additional variables evaluated included preoperative PSA, preoperative Gleason score, and final pathologic stage.
Results: The margin positive rates were 46.6%, 26.6%, and 13.3% for the first, second, and third groups, respectively. Patient demographics and preoperative staging variables were evenly distributed among all 3 groups.
Conclusions: This study illustrates that experience gained with time led to a decrease in the incidence of positive margins. We do not feel that a selection bias affected our results, as patient variables were comparable within the study groups. On further analysis, the negative surgical margin rate increased from 53.4% to 73.4% in group 2 and to 86.7% in group 3, although the Gleason scores were higher in groups 2 and 3. Clearly, a significant learning curve is associated with robotic radical prostatectomy and can affect the oncologic outcome in patients undergoing this procedure.
6209 Urology
High-Power (80W) Potassium-Titanyl-Phosphate (KTP) Laser Photoselective Vaporization Prostatectomy (PVP) for Symptomatic Benign Prostatic Hyperplasia (BPH)
Daniel J. Culkin, MD, Po N. Lam, MD, Glenn M. Sulley, BSN, Carson Wong, MD
University of Oklahoma, Oklahoma City, Oklahoma
Introduction: Potassium-titanyl-phosphate (KTP) laser photoselective vaporization prostatectomy (PVP) is a relatively new minimally invasive technology for the treatment of symptomatic benign prostatic hyperplasia (BPH). We report our initial experience.
Methods: During a 20-week period, 102 consecutive patients with symptomatic BPH who failed medical therapy or desired surgical intervention underwent KTP laser PVP by a single surgeon. With the patient under general anesthesia, transurethral PVP was performed using an 80W KTP side-firing laser system. Voiding trials were performed 2 hours after surgery; if the patient was unable to void, a urethral catheter was replaced.
Results: The mean age of the patients was 70.6 years (range, 49 to 88). The mean prostate volume was 69.7 cm3 (range, 12.8 to 261.0). Mean laser time and energy usage were 32.0 minutes (range, 5.0 to 150.0) and 91.2kJ (range, 4.8 to 393.3), respectively. Perioperative serum sodium and hemoglobin did not change significantly. All were outpatient procedures with the majority of the patients were catheter-free at discharge. Fourteen patients required catheter drainage for 1 week. Six patients developed urinary tract infections with 1 patient requiring hospitalization for pyelonephritis. Eight patients had persistent hematuria for over a week. Two patients developed bladder neck contractures. All patients were able to discontinue their prostate medications following surgery. Mean International Prostate Symptom Score decreased significantly from 27.3 to 15.9 to 11.6 (P<0.001) after 1 and 4 weeks, respectively. Maximum flow rate and postvoid residual values also showed improvement.
Conclusions: Our initial results demonstrate that KTP laser PVP is safe and effective for the treatment of bladder outlet obstruction secondary to BPH, providing excellent results and minimal morbidity.
6210 Multispecialty
Intravesical “Jump Start” Therapy Using a Therapeutic Cocktail
for the Treatment of Interstitial Cystitis
J. R. Dell, S. A. Grochmal, L. P. Shulman, S. Chandakas
Institute For Female Pelvic Medicine, Knoxville, Tennessee, USA, Howard University College of Medicine, Washington, DC, USA, Northwestern University, Feinberg School of Medicine, Chicago, Ilinois, Princess Royal University Hospital, London, United Kingdom
Introduction: We evaluated the response to a specific protocol for intravesical instillation therapy for the relief of symptoms in interstitial cystitis (IC) patients.
Methods: An on-going, prospective, 14-month multicenter study of 257 patients (ages 19 to 65) with IC. Bladder instillation therapy is immediately initiated in addition to oral pentosan polysulfate sodium (PPS) for newly diagnosed IC patients. A specific protocol of 9 intravesical instillations over 7 weeks is administered (3 instillations in the first week, then weekly for 6 weeks). The “cocktail” consists of 3cc of 8.4% sodium bicarbonate, 10cc of 2% lidocaine, and 100mg of PPS. The use of oral PPS in an intravesical solution is an off-label use of the drug. All patients received a baseline potassium sensitivity test (PST) and Pelvic Pain and Urgency/Frequency (PUF) questionnaire. The PSTs were positive (86%) and average PUF score was 16.2. After the fourth and ninth bladder instillations, PUF and Patient Overall Rating of Improvement of Symptoms (PORIS) questionnaires were obtained.
Results: After 4 instillations, average PUF score decreased to 12.1, and 172/257 (67%) patients reported a 50% or better improvement in their symptoms as compared with symptoms at the start of therapy. After the ninth week, average PUF score was 10.2, and 206/257 (80%) patients reported a 50% or greater improvement. During the study period, only 11 (.04%) patients required multimodal therapy.
Conclusion: Initial treatment with oral PPS may take up to 3 months to demonstrate symptom improvement. The use of a PPS “cocktail” for bladder instillation provides immediate relief of IC symptoms, and patients require fewer multiple oral medications, thus reducing their overall drug load. Intravesical instillations can help “jump start” initial long-term oral PPS therapy for IC and provide a meaningful therapeutic benefit.
6211 General Surgery
Initial Experience with the ON-Q Pain Pump During Laparoscopic Ventral Hernia Repair
Roger Ernest, DO, Larry Cohen, DO, Marc Neff, MD
Kennedy Health Systems, Cherry Hill, New Jersey
Introduction: Patients undergoing laparoscopic ventral hernia repair have several benefits over those that undergo open surgery. Most patients, however, require a significant amount of postoperative PO narcotics, and some even remain in the hospital several days postoperatively on IV narcotics. We propose a unique solution using a readily available device, the ON-Q Pain Pump.
Methods: Patients undergoing laparoscopic ventral hernia repair were evaluated in a retrospective fashion. In each patient, the ON-Q Pain Pump catheter was positioned between the mesh and the abdominal wall to anesthetize the parietal surface. The number of catheters, the rate of infusion, the volume of the reservoir, and the anesthetic used in the reservoir were all varied to achieve optimal results.
Results: Twenty patients underwent laparoscopic ventral hernia repair. At the end of each procedure, an ON-Q Pain Pump was positioned such that it rested adjacent to the mesh. The reservoirs ranged from 100cc to 330cc, the catheter infusion rate ranged from 2cc/hr to 5cc/hour, and either 0.5% Marcaine or 1% lidocaine was used in the reservoir. Patients were evaluated at the time of pump removal and at the first postoperative visit on their postoperative pain.
Conclusion: Through use of the ON-Q Pain Pump, patients experience a dramatic decrease in postoperative narcotic use. The majority of patients were able to have the procedure performed on an outpatient basis. The device is simple to use, safe, and effective. Infections are not related to the device use.
6212 Urology
Incidence of Urothelial Carcinoma Recurrence Following Hand-Assisted Laparoscopic Nephroureterectomy with Cystoscopic En Bloc Excision of the Distal Ureter and Bladder Cuff
Arthur E. Fetzer, MD, Carson Wong, MD, Po N. Lam, MD, David L. Clair, MD
University of Oklahoma, Oklahoma City, Oklahoma
Fetzer-Clair Urology Associates, Allentown, Pennsylvania
Introduction: We review the success and recurrence rates of a hand-assisted laparoscopic nephroureterectomy (HALNU) technique for the treatment of upper tract urothelial carcinoma, utilizing cystoscopic en bloc excision of the distal ureter and bladder cuff.
Methods: In the technique, the ureter was isolated and clipped before kidney dissection to prevent distal migration of the tumor. Following liberation of the kidney, the bladder cuff and intramural ureter were excised using a Collings knife under cystoscopic guidance. With the bladder left open, a urethral catheter was placed for drainage.
Results: There were 9 urothelial carcinomas, 9 confined to the intrarenal collecting system and 1 multifocal disease involving the renal pelvis and proximal ureter. One low-grade and 8 high-grade tumors were removed, with pT3 (6), pT2 (2), and pTa (1) disease. A patient with a low-grade pTa urothelial carcinoma developed pulmonary metastasis. Another with a high-grade pT3 tumor developed a low-grade urothelial carcinoma in the bladder contralateral to the site of ureteral excision. At a mean follow-up of 34.3 months (range, 7.9 to 49.0), no evidence was found of tumor recurrence in the pelvis as confirmed by serial computed tomography.
Conclusions: Our technique of HALNU with cystoscopic en bloc excision of the distal ureter and bladder cuff for the management of upper tract urothelial carcinoma does not increase risk for bladder or pelvic recurrence, despite leaving the bladder open following excision of the distal ureter and bladder cuff. By clipping the ureter before kidney dissection, the risk for tumor spillage is minimized.
6213 General Surgery
Laparoscopic Thoracic Duct Ligation
Mark D. Gaon, MD, Neel Joshi, MD, Gregg Nishi, MD, Sergey Lyass, MD, Theodore Khalili, MD
This video presentation involves a 56-year-old male who initially presented with 40-pound weight loss and severe right-sided chest pain. Multiple prior nondiagnostic thoracenteses for recurrent right pleural effusions as well as prior thoracotomy with attempted decortication were performed at outside institutions. Workup at our center ensued, and the patient underwent a right-sided extrapleural pneumonectomy, resection of the pericardium and diaphragm, and reconstruction of the diaphragm with Marlex mesh. Pathology revealed stage III malignant mesothelioma, of the mixed sarcomatoid type. The patient was discharged home with recommendations from medical oncology for subsequent adjuvant chemotherapy and radiation. Two weeks after discharge, however, the patient was readmitted for interval development of massive ascites, which was found on workup to be chyloperitoneum. Given the extensive nature of the previous surgery in the chest, the patient was referred to the minimally invasive surgery service for laparoscopic ligation of the thoracic duct via an abdominal approach. This video clip demonstrates laparoscopic exposure and subsequent ligation of the thoracic duct at its abdominal origin at the aortic hilum.
6214 General Surgery
Laparoscopic Nissen with Mesh
G. Kevin Gillian, MD
Introduction: It is not uncommon to see the failure rate for laparoscopic repair of large hiatal and paraesophageal hernias to exceed 10%. These failures are often a result of a failure of the integrity of the primary tissue closure of the hiatus. Efforts to reinforce these closures with different types of mesh have shown promise in some series. Unfortunately, the techniques are not widely used due to the difficulty in deploying and adequately fixing the mesh to the crura. A simplified mesh closure that is safe and does not require an undue technical burden on the surgeon is demonstrated.
Methods: The study included 40 patients undergoing laparoscopic Nissen fundoplication for the control of medically refractory GERD and obstructive symptoms from paraesophageal hernias that had concomitant mesh reinforcement of their crural closure. After closing the hiatus with nonabsorbable sutures, the Crura Soft mesh patch was secured to the hiatal closure with 10-mm EMS staples. This process typically takes 3 minutes to 5 minutes.
Results: The mesh caused no postoperative complications or delays in diet advancement in these patients. No recurrent hiatal hernias have occurred in this group to date.
Conclusion: The placement of mesh to reinforce the hiatal repair in patients undergoing laparoscopic Nissen fundoplication is easily accomplished and has not resulted in any complications to date. The ease of mesh placement and lack of complications should encourage other surgeons seeking to reduce the chance of recurrent hiatal hernias in patients in their own practices. It is hoped that this technique will show a reduction in recurrent hiatal hernias over an extended follow-up and benefit a larger group of patients as more laparoscopic surgeons adopt it.
6215 Gynecology
Laparoscopic Myolysis Revisited
Herbert A. Goldfarb, MD
Fifteen years ago, Goldfarb presented the first case of coagulation of a uterine myoma performed in the United States. Since that first case, multiple series have been presented using a variety of tools to accomplish the same result. Starting with the ND: YAG laser, subsequent methods have included bipolar needles, Cryo probes, radio frequency probes, MRI-guided laser probes, and finally MRI-guided high-power focused ultrasound. This presentation will review the available techniques used, evaluate efficiency, cost, success rates, and complications.
6216 General Surgery
Laparoscopic Excision of a Glucagonoma
Timothy Goundrey, MD, Richard Newman, MD
This video outlines the surgical treatment of a 60-year-old man with a neuroendocrine tumor of the distal pancreas. In our video, we discuss the technical aspects of performing a laparoscopic distal pancreatectomy. We also discuss some of the pearls and pitfalls of performing laparoscopic pancreatic surgery that we have encountered at our institution.
6217 Gynecology
The Identification of Bowel Incontinence in Gynecologic Practice: A Multicenter Investigation of a New Screening Questionnaire
S.A. Grochmal, J. R. Dell, L. P. Shulman, S. Chandakas, J. Erian
Howard University College of Medicine, Washington, DC
Institute for Female Pelvic Medicine, Knoxville, Tennessee
Northwestern University, Feinberg School of Medicine, Chicago, Illinois
Princes Royal University Hospital, London, United Kingdom
Introduction: We determined the prevalence of bowel incontinence (BI) [fecal incontinence] in gynecologic practice with the use of a screening questionnaire. Methods: We performed a prospective multicenter, 9-month study of consecutive patients (983), ages 17 to 73, seen by their gynecologist for a routine visit. This newly designed questionnaire, the Bowel Incontinence/Anal Sphincter Evaluation (BIASE) was developed as a tool for gynecologists to help identify or discuss, or both identify and discuss, fecal incontinence symptoms with their patients. Exact prevalence of BI is difficult to determine because patients are reluctant to volunteer information, physicians are unaware or lack the proper questions, or both, to either initiate a discussion or possess a simple tool to screen patients for BI. The BIASE questionnaire comprises 8 questions and uses separate 5-point scales to assess symptoms, obstetrical/surgical history, and quality of life parameters. A score of 12 or higher suggests a predisposition to BI and further confirmatory testing is performed.
Results: Of the 983 patients queried, 114 (11.6 %) respondents reported a score between 12 and 25 (average15). Of these 114 responders, 73 were evaluated with transanal ultrasound confirming a diagnosis of incontinent sphincter in 58 (79%) patients. Of an additional 27 respondents with a score between 5 and 11, 9 (33%) had a confirmed diagnosis of BI on transanal ultrasound.
Conclusion: Bowel incontinence can be a psychologically and socially debilitating condition in generally healthy women. It is imperative that gynecologists include a discussion of bowel function with their patients during routine examinations, because most patients are embarrassed or reluctant to discuss their plight. The use of a simple questionnaire to screen for BI can help identify patients who might ordinarily never discuss this condition with their healthcare provider and suffer in silence.
6218 Gynecology
Minimally Invasive Outpatient Treatment of Bowel (Fecal) Incontinence:
A New Procedure for the Gynecologist
S. A. Grochmal, J. R. Dell, L. P. Shulman, N. E. Osborne, L. M. Fromer, F. M. Howard, S. Chandakas, M. Rosenberg, J. Erian, and the GATSB_ Group (Gynecologic Alliance (for the) Treatment (of) Sphincter/Bowel Incontinence)
Howard University College of Medicine, Washington, DC
Institute for Female Pelvic Medicine, Knoxville, Tennessee
Northwestern University, Feinberg School of Medicine, Chicago, Illinois
David Geffen School of Medicine/UCLA, Los Angeles, California
University of Rochester, Rochester, New York
Princess Royal University Hospital, London, United Kingdom
College of Human Medicine, Michigan State University, East Lansing, Michigan
Introduction: Evaluation of a minimally invasive, radiofrequency energy treatment option for bowel (fecal) incontinence in gynecologic patients.
Methods: A large majority of patients with BI are women of reproductive age and older who suffer from this devastating disorder. The Secca procedure (Curon Medical, Freemont, CA) may be advantageous in these patients even if they exhibit a potentially reparable defect, because this technique does not prevent the application of a subsequent procedure. The procedure is performed on an outpatient basis, with the patient receiving local anesthesia and conscious sedation in a dorsolithotomy position. A specially designed hand piece is positioned 0.5cm distal to the dentate line where retractable needle electrodes are then deployed. The continuously monitored, controlled RF energy is applied to all 4 needle electrodes to achieve a target tissue temperature of 85°C. Twenty sets of 4 lesions each are created, starting 5mm distal to the dentate line and at 5-mm increments proximal to the initial tissue treatment site. Each treatment exposure lasts 1 minute. All 4 rectal quadrants are treated in a similar manner with special care taken in the anterior quadrant of female patients to avoid penetrating the posterior vaginal mucosa. Total procedure time is approximately 30 minutes, and patients are discharged within an hour after surgery.
Results: The results of several multicenter studies by colorectal surgical specialists have been published indicating that this procedure, even at 2 years, demonstrates highly significant improvement in mean CCF-FI scores and statistically significant improvement in QOL scores. A multicenter study by members of the GATSB_ group is currently underway to evaluate this treatment option in the gynecologic patient.
Conclusion: BI remains an area of unmet need. Gynecologists are in a unique position to offer a solution to these women. Even if the gynecologist chooses not to perform this procedure, they can refer the patient to a colorectal surgeon, thereby providing the “missing link” to assist patients who suffer in silence from BI.
6219 General Surgery
Assessment of Surgical Trainees for Technical Errors Enacted by Using an Instrument Differently: Observational Clinical Human Reliability Analysis (OCHRA)
M. Hussain, B. Tang, A. Cuschieri
Stepping Hill Hospital, Stockport, United Kingdom
Cuschieri Skills Unit, Ninewells Hospital & Medical School, Scotland United Kingdom
Scuola Superiore S‚ Anna di Studi Universitari, Pisa, Italy
Introduction: We assessed surgical trainees for their technical errors enacted by using an instrument differently.
Methods: For this study, 62 surgical trainees were recruited from basic and advanced laparoscopic courses with 34 and 28 participants, respectively. Animal (nonlive) specimens were used for simulated laparoscopic cholecystectomies that were videotaped. Recorded procedures were analyzed for the task of cystic duct and artery dissection by a single assessor using the OCHRA technique for error identification enacted by using different parts of the hook knife, ie, heel versus tip. According to the nature of errors, observable errors were classified as procedural (omission or rearrangement of correctly undertaken steps) and executional (failure of the surgeon to correctly execute an individual step). Based on impact, the errors were categorized as consequential or inconsequential. Error probability for consequential errors was calculated for each group by using a formula, total errors/total number of instrument movements. The Mann-Whitney U test was used for statistical analyses, with SPSS 11.5 software. P was set at <0.05.
Results: The number of errors enacted by the advanced group by using the heel of the hook knife was 116 (92 inconsequential and 24 consequential) compared with 23 (14 inconsequential and 9 consequential) by basic trainees (P<0.001). Also, for the advanced trainees, the observed errors for using the heel and tip of the hook knife were 116 versus 47 (P<0.02). Error probability for the basic course group was 0.003 while for the advanced group it was 0.018.
Conclusion: The OCHRA technique enables us to assess surgical trainees objectively for the frequency and type of errors enacted by using an instrument in a different fashion.
6220 General Surgery
Objective Assessment of Surgical Trainees for Their Technical Errors by Observational Clinical Human Reliability Analysis
M. Hussain, B. Tang, A. Cuschieri
Stepping Hill Hospital, Stockport, United Kingdom
Surgical Skills Unit, Ninewells Hospital, University of Dundee, Scotland
Scuola Superiore S‚ Anna di Studi Universitari, Pisa, Italy
Introduction: We identified technical surgical errors made by surgical trainees with different levels of experience during laparoscopic training courses.
Methods: For this study, 62 surgical trainees were recruited from essential and advanced laparoscopic courses with 34 and 28 participants, respectively. Animal (nonlive) specimens were used for simulated laparoscopic cholecystectomies that were videotaped. Recorded procedures were analyzed for Calot’s triangle dissection and endoclipping. Observation clinical human reliability analysis (OCHRA) technique was used to identify errors made. Observable errors were classified as procedural (omission/rearranged steps) or executional (failure to correctly execute steps). Based on their impact, errors were also categorized as consequential or inconsequential. Error probability for consequential errors was calculated for each group. Chi-square was used for statistical analysis with a 5% significance level.
Results: The number of consequential errors made by essential course surgical trainees was 335 of 8476 total movements, while advanced trainees made 93 consequential errors of 4262 total movements. Consequential error probability for essential trainees was 5% versus 2% for advanced trainees. Mean of consequential errors made was 10 per trainee for the essential course compared with 3 consequential errors per trainee from the advanced course. More executional errors were made by essential course participants than by trainees attending advanced courses (P<0.001).
Conclusion: OCHRA can determine the varying level of surgical experience of trainees based on their technical skills and the errors made.
6221 General Surgery
Small Bowel Obstruction After Laparoscopic Roux-en-y Gastric Bypass
Muhammad A. Jawad, MD
Bariatric & Laparoscopy Center
Introduction: Small bowel obstruction (SBO) after laparoscopic Roux-en-y gastric bypass is common. Its causes include adhesion, internal hernia, and stricture or obstruction at a J-J anastomosis. Early obstruction is rare, usually related to a hematoma or catching the posterior wall with the stapler. Late obstructions are common and are either due to adhesion or internal herniation. This takes place at the J-J anastomosis, if the mesentery is left open; is due to a Peterson defect either in antecolic or retrocolic anastomosis, or through the omental window.
Methods: From September 1999 to December 2005, 1335 laparoscopic Roux-en-y gastric bypasses were performed, 1255 antecolic, 80 retrocolic. Twenty-eight patients presented with SBO 4 months to 36 months postoperatively, average 18 months.
Results: All of these patients were operated on laparoscopically (except one) with a reduction of small bowel volvulus and repair of internal hernia at the J-J mesentery and Peterson defect. Thirty-three patients presented with unexplained abdominal pain. They also were operated on laparoscopically with closure of the internal hernia. One patient lost 80% of the small bowel because of a misdiagnosis at another institution.
Conclusion: SBO after laparoscopic Roux-en-y gastric bypass can be a serious problem and should be prevented by closing all mesenteric defects. The theory that a large defect will not cause obstruction is not valid. Our video illustrates these findings and the technique of mesentery closure.
6222 General Surgery
Conversion to Laparoscopy?
Daniel S. Kim, MD, Francois I. Luks, MD, PhD
Division of Pediatric Surgery, Brown Medical School
Introduction: Laparoscopy may have to be converted to laparotomy for safety or access reasons. We describe an easy technique to convert an open procedure into a laparoscopic one.
Methods: A disposable hand-assisted laparoscopy device (Lap Disc, Ethicon EndoSurgery) is placed into a 4% to 6% wound and the diaphragm closed around an endoscopic cannula. The airtight fit allows creation of a pneumoperitoneum.
Results: We have successfully used this technique in pull-through operations for ulcerative colitis. Following laparoscopic dissection of the mesocolon, colon removal and J-pouch creation are done through a 4% suprapubic incision. The laparotomy is then converted to a laparoscopy, allowing dissection of the posterior mesentery to the level of the duodenum. Conversion back to laparoscopy has also been used following open extraction of an oversized spleen after laparoscopic splenectomy.
Conclusions: Conversion to an open procedure may be necessary in any laparoscopy. However, conversion of a laparotomy back to a laparoscopic procedure has not been described. This useful technique may add to the versatility of minimally invasive surgery and allow laparoscopic exploration of areas not easily accessible by laparotomy alone.
6223 Pediatric Surgery
Thoracoscopic Resection of a Giant Thymolipoma
Daniel S. Kim, MD, Francois I. Luks, MD, PhD, Michael T. Wallach, MD
Division of Pediatric Surgery, Brown Medical School
Introduction: Thymolipoma is a very rare, benign condition with less than 200 reported cases. We report the first thoracoscopic resection of such a lesion in a young child.
Methods: A 4-year-old girl was incidentally found on a chest radiograph for asthma exacerbation to have a soft tissue mass filling the entire left hemithorax. Computerized tomography showed a chronically compressed left lung and a 10-cm by 5-cm homogenous mass of fat-like density. A preoperative diagnosis of thymolipoma was entertained. She underwent thoracoscopic resection of the mass in which three 5-mm ports were used.
Results: The lesion was dissected free from the left lobe of the thymus and removed with an endoscopic bag. The postoperative course was uneventful, and the patient was discharged 2 days later. The diagnosis of thymolipoma was confirmed pathologically.
Conclusion: Thymolipomas are exceedingly rare lesions that can have a variable radiographic appearance, often containing a mixture of fat and soft-tissue intensity characteristics. The size of these lesions and the uncertain preoperative diagnosis has, in the past, warranted thoracotomy. Precise preoperative diagnosis and growing experience with thoracoscopy in small children now offer a minimally invasive alternative.
6224 Gynecology
Laparoscopic Treatment of Infiltrated Endometriosis
F. La Grotta, MD, S. Lacitignola, MD, A. Condemi, MD, A. De Marco, MD,
M. L. Marra, MD, M. Minardi, MD, E. Stola, MD
Gynecology Department, Massafra Hospital, Taranto, Italy
General Surgery Department, Martina Franca Hospital, Taranto, Italy
Infiltrated endometriosis is the presence of endometrium epithelium outside the uterus. The disease strikes 3% to 10% of reproductive age women, and it has different localizations, such as the peritoneum, anterior and posterior cul-de-sac, ovary, ureter, and bladder. The surgical procedure can be easy but useless for low-grade endometriosis; on the contrary, it is very complicated for the infiltrated forms. In these cases, the only indication for surgery is the pain. The absolute indications are stenosis of the rectum and ureter. Therefore, it is necessary to remove all lesions and to resect the rectum. In this video, we present the laparoscopic surgical treatment of a 28-year-old patient. She experienced pain during defecation and urination. Previously, she had had 4 laparotomic surgical explorations for penetrating endometriosis, without benefit. Abdominal pain and intestinal occlusion have induced the patient to have surgery. The operation was concluded laparoscopically.
6225 Urology
Pediatric Laparoscopic Pyeloplasty
Po N. Lam, MD, Timothy L. Mulholland, MD, Jeffery B. Campbell, MD,
Bradley P. Kropp, MD, Carson Wong MD
University of Oklahoma, Oklahoma City, Oklahoma
Introduction: Laparoscopic dismembered pyeloplasty for correction of ureteropelvic junction obstruction (UPJO) in the pediatric population has been demonstrated to be comparable to open dismembered pyeloplasty in success rates. We review our experience with this technique.
Methods: The hospital records of consecutive children undergoing corrective surgery for UPJO between May 2001 and May 2005 were reviewed.
Results: Fifty-nine children had surgically salvageable UPJO; 4 percutaneous endopyelotomies for concomitant urolithiasis, 27 open dismembered pyeloplasties (parent's choice or under 18 months of age), and 28 laparoscopic dismembered pyeloplasties. One patient had bilateral UPJOs, resulting in 29 laparoscopic pyeloplasties. Twenty-eight of these were successfully completed. Eighteen procedures were performed in males and 11 in females. The mean age was 8.1 years (range, 1.6 to 18.9). The mean operating room time was 255 minutes (range, 157 to 396) with an estimated blood loss <10cc. One patient required hospitalization longer than 23 hours because of a postoperative ileus. Another patient, despite having a ureteral stent, developed a retroperitoneal urinoma that resolved with urethral catheter drainage. The first laparoscopic pyeloplasty resulted in open conversion due to failure of progression of the ureteropelvic anastomosis. At a mean follow-up of 23.4 months (range, 3.6 to 53.0), all patients demonstrated improvement of symptoms and drainage on diuretic renal scintigraphy or a decrease in the grade of hydronephrosis on renal ultrasonography.
Conclusions: Our series of laparoscopic pyeloplasty has excellent results with low patient morbidity. We consider this our primary technique for surgical correction of UPJO in patients over the age of 18 months.
6226 General Surgery
Intracorporeal Stapled Billroth-I Gastroduodenostomy Using a Hand-Access Device
Young-Joon Lee, Soon-Chan Hong, Sang-Gyeong Choi, Soon-Tae Park, Woo-Song Ha
Introduction: Currently, laparoscopic-assisted gastrectomy is widely accepted as the proper surgical treatment for early gastric cancer. When performing Billroth I anastomosis, many surgeons use circular staplers through the minilaparotomy wound to perform anastomosis, but in obese patients, the procedure is difficult because the surgical field is very restricted.
Methods: We performed laparoscopic-assisted distal gastrectomy and intracorporeal stapled Billroth-I anastomosis using a hand-access device in 23 gastric cancer patients to evaluate the feasibility and safety of the procedure. After mobilizing the stomach and dividing the duodenum with a linear stapler, a minilaparotomy wound of 5cm to 6cm was made. After inserting an anvil in the duodenum, the hand-access device (Gelport, Applied Medical, USA) was placed in the minilaparotomy incision, and the dissected stomach was brought out through the hand-access device. A circular stapler was then inserted through a separate gastrotomy incision, and under the pneumoperitoneum and visual guidance of a telescope, a gastroduodenostomy was created intracorporeally.
Results: The mean operation time, mean hospital stay, and morbidity rate was 381.4 minutes, 12.6 days, and 17.3%, respectively. Intracorporeal anastomosis using the above technique provided a distinctly enhanced vision of the procedure, and the anastomotic integrity was ensured by a flexible telescope. The procedure took about 30 minutes, and there was no procedure-related complication.
Conclusion: Intracorporeal stapled anastomosis via a hand-access device is a safe, feasible procedure, and it has the merit of enabling the operating surgeon to guide the procedure with a distinctly enhanced surgical view.
6227 Urology
Open Adrenalectomy: Has Laparoscopy Made It Obsolete?
Michael C. Lipke, Chiba I. Ene, Chandru P. Sundaram
Introduction: We reviewed our institution’s transition from open to laparoscopic
adrenalectomy over the last decade.
Methods: Included in our retrospective study from April 1997 to March 2005 are 75 patients treated at a single institution’s urology service.
Results: Prior to 2001, of 9 adrenalectomies, only 1 was laparoscopic. Since then, 85% (56 of 66) of adrenal masses have been removed laparoscopically, with only 1 conversion to open surgery. The following are data for open and laparoscopic adrenalectomies, respectively: average tumor size 7.9cm (range, 1.2±17) and 3.5cm (range, 0.7 to 11); average OR times 213.4 minutes (range, 150 to 330) and 163.8 minutes (range, 95 to 405); hospitalization 5.6 days (range, 4 to 13) and 2.4 days (range, 1 to 19). Adrenalectomy for malignant neoplasms (including metastatic and primary disease) composed 15% of cases, and 73% of these were performed with a laparotomy. Sixty-one percent of tumors excised were functional, of which 80% were removed laparoscopically. Fifteen patients had pheochromocytomas, and 8 were removed laparoscopically. Whereas 10 patients (18%) underwent laparoscopic adrenalectomy for tumors >5cm, only 2 patients (11%) with tumors <5cm had open adrenalectomy.
Conclusions: Laparoscopic adrenalectomy is now the preferred method for surgical removal of the majority of adrenal masses in our department. Even large tumors (>5cm), which are highly suspicious for adrenal carcinoma, and pheochromocytomas may be successfully removed laparoscopically. However, very large tumors or those with imaging studies that suggest local invasion may be better approached with open adrenalectomy.
6228 Urology
Video of Complications During Laparoscopic Nephrectomy and Adrenalectomy
Michael C. Lipke, Chandru P. Sundaram
Introduction: We sought to identify and treat intraoperative complications during laparoscopic renal and adrenal surgery.
Methods: Digital video capturing of all laparoscopic surgeries are performed and data are saved permanently when the surgeon deems the video to be an aid in surgical education.
Results: Various laparoscopic maneuvers to control hemostasis are demonstrated, including the use of topical agents, thermal energy, and clips. Control of splenic, adrenal and vascular bleeding are displayed, while avoiding conversion to open surgery.
Conclusions: Inadvertent injuries occur during laparoscopic surgery. Significant morbidity ensues when the injuries are not identified at the time of surgery. Reviewing video of complications can aid the surgeon in recognizing these injuries and treating them in a timely fashion.
6229 Gynecology
Effect of Carbon Dioxide Pneumoperitoneum During Laparoscopic Surgery on Peritoneum Morphology
Yan Liu, Qingxiang Hou, PhD
Objective: We sought to evaluate the effect of carbon dioxide pneumoperitoneum during laparoscopic surgery on peritoneum morphology.
Methods: Forty patients with uterine myoma or simple ovarian cysts (excluding peritonitis) were randomized to undergo laparoscopic surgery (n= 20) or laparotomy (n=20). The parietal peritoneum was resected from each patient at different times (0min, 30min, 60min, 90min, 120min) and examined by transmission electron microscopy (TEM) and scanning electron microscopy (SEM) for morphologic changes of the peritoneal mesothelial cells.
Results: There is a lack of marked change in mesothelial cells (eumorphism and integrity of basal lamina) following the start of surgery and at 60 minutes in the laparotomy group. Intercellular clefts were occasionally found at 90 minutes and significantly at 120 minutes. Bulging of mesothelial cells was evident immediately following 0 minute and 30 minutes of pneumoperitoneum in the laparoscopic surgery group. Intercellular clefts were contingently found at 30 minutes. At 60 minutes after insufflation of the pneumoperitoneum, intercellular clefts were found, and parts of the underlying basal lamina were laid bare. It is significant that after 90 minutes and 120 minutes, a small quantity of lymph cell and macrophage were found in the intercellular clefts.
Conclusions: Morphologic peritoneal alterations after carbon dioxide pneumoperitoneum during the gynecologic laparoscopic surgery group differed from those in the laparotomy group and were influenced by duration of insufflation. These peritoneal changes following pneumoperitoneum may contribute to specific intraperitoneal tumor spread after laparoscopic surgery of malignant tumor.
6231 General Surgery
Our Experience with TAPP Hernia Repair
M. Lombardi, E. Puce, B. Brassetti, D. Apa, F. Atella, G. Senni
UOC di Chirurgia Generale Ospedale CTO, A. Alesini, Roma, Italy
Introduction: Laparoscopic inguinal hernia repair with a transabdominal preperitoneal approach is indicated for bilateral hernia, recurrent hernia, and associated pathologies.
Laparoscopic repair has all the advantages of a tension-free repair, offers more rapid recovery and return to work, and less postoperative pain than the traditional open hernia repair. This study aims to review a single institution’s experience with this technique.
Methods: From 1994 to 2005, we performed 397 hernia repairs on 283 patients (265 males, 18 females; median age 57 years, range, 18 to 82). Procedures included 65.7% bilateral hernias, 34.3% monolateral, and 17.3% recurrent. Associated procedures were 16 cholecystectomies, 4 appendicectomies, 2 cystectomies of ovarian cyst, 1 laparoscopic repair of a laparocele, and 1 varicocele.
Results: Patients were evaluated at a median follow-up of 58 months. Recurrence rate was 1.7% (4/5 patients were reoperated on laparoscopically). We did not have conversions to an open procedure or mortality. The minor postoperative complication rate was 4.9% (seroma 2.8%, hematoma 1.4%, postoperative neuralgia 0.3%, hematuria 0.3%). The major complication rate was 1.7% (bowel perforation 0.7%, intestinal obstruction 0.3%, orchitis 0.3%, trocar-site hernia 0.3%). Until 2003, a single mesh (27x13cm) for a bilateral hernia was used. Actually, we prefer a double mesh.
Conclusions: In our experience, the validity of the laparoscopic approach to inguinal hernia repair is confirmed. General anesthesia and higher costs are reasonable compromises for a shorter period of discomfort in patients with a low ASA index and busy work and sports activities. Transperitoneal repair can also be applied in cases of previous preperitoneal operations and can be used to treat contralateral occult hernias and associated pathologies.
6232 General Surgery
Long-Term Results in Stapled Hemorrhoidectomy
M. Lombardi, D. Apa, E. Puce, B. Brassetti, G. Senni, F. Atella
UOC di Chirurgia Generale Ospedale CTO, A. Alesini, Rome, Italy
Introduction: Stapled hemorrhoidopexy is performed to treat grade III-IV hemorrhoids as an alternative to conventional hemorrhoidectomy. We performed a retrospective study in our practice from 1998 through 2005.
Methods: We performed stapled anopexy in 336 patients (217 males, 119 females; median age 47 years, range 34 to 72) during the study period. Mean operative time was 15 minutes (range, 10 to 35), and the mean postoperative stay was 3 days.
Results: Success was achieved in 317 patients (94.3%). The nonsuccess rate (bleeding, prolonged postoperative pain, persistent prolapse, recurrent prolapse) was 5.6%.Early postoperative complications were urinary retention, 7 patients (2%); postoperative hemorrhage, 7 patients (2%); prolonged postoperative pain, 6 patients (1.8 %). Late postoperative complications were persistence of prolapse in 3 cases (0.8%), recurrent prolapse in 3 patients (0.8%), fissure and anal papilla in 1 patient (0.3%). Miscellaneous minor complications (soiling, discharge, urgency) were detected in 12 patients (3.4%). Reoperation was required in the early postoperative period in 3 patients for bleeding. Reoperation for anorectal pathology was required in 7 patients (2.3%) and was performed for the following: reprolapse (3), fissure and anal papilla (1), recurrent prolapse (3). No patient has needed a second procedure for recurrence within 2 years.
Conclusion: The early complication rate is low and similar to rates reported for excisional hemorrhoidectomy. The procedure is associated with a low rate of reoperation for persistence or recurrence of hemorrhoidal prolapse with good patient selection.These series confirm that the operation is safe in experienced hands, rapid, and a relatively painless technique. In the future, it can be performed on an outpatient basis. Patient satisfaction, early return to normal activities, and good long-term results counterbalance the relative high cost of the procedure.
6233 General Surgery
Is It Appropriate for Laparoscopic-Assisted Gastrectomy with Extended Lymph Node Dissection To Be Performed in Advanced Gastric Cancer?
Young-Joon Lee, Chi-Young Jeong, Young-Tae Joo, Eun-Jung Jung, Woo-Song Ha.
Introduction: Laparoscopic-assisted gastrectomy has been established in Korea and Japan as a standard treatment for early gastric cancer. Recently, the use of laparoscopic surgery in advanced gastric cancer has received more attention, possibly because of the increased skill and experience of laparoscopic surgeons.
Methods: A prospective study of laparoscopic-assisted gastrectomy with extended lymph node dissection was performed in 62 patients with advanced gastric cancer.
Results: This series included 42 men and 20 women, age 37 to 75 years. Procedures consisted of 10 total gastrectomies, 2 proximal gastrectomies, 18 Billroth-I, and 9 Billroth-II gastrectomies. Fifteen patients were in stage Ib, 16 in stage II, 16 in stage IIIa, 4 in stage IIIb, and 11 in stage IV. One major intraoperative complication occurred of an inadvertent injury to the common hepatic artery, which was successfully repaired by open conversion. The postoperative course was uneventful in all patients but one, who died of heart failure on day 7. The mean duration of surgery was 390 minutes. Blood loss was as high as 420cc on average. The mean number of dissected lymph nodes was 34.3.
Conclusions: Although laparoscopic gastrectomy in advanced gastric cancer was equivalent to open surgery in several clinical parameters, the relatively long operation time and large amount of bleeding were drawbacks. Its appropriateness in advanced gastric surgery must be verified by further studies.
6234 Urology
The Learning Curve For Robotic-Assisted Laparoscopic Radical Prostatectomy: A Multi-Institutional Experience of Laparoscopic and Oncologic Trained Urologists
Ravi Munver, MD, Jonathan J. Hwang, MD, John L. Phillips, MD, Michael A. Palese, MD, Caner Z. Dinlenc, MD, Felix L. Badillo, MD, Michael D. Stifelman, MD, James A. Eastham, MD, Albert Samadi, MD, Rahuldev S. Bhalla, MD, Isaac Y. Kim, MD, Douglas S. Scherr, MD, David B. Samadi, MD, Waleed A. Hassen, MD, Ashutosh K. Tewari, MD, Ihor S. Sawczuk MD
Introduction: The growing interest in laparoscopic radical prostatectomy (LRP) and robotic-assisted radical prostatectomy (RARP) is evident by the increasing annual trend. We report on the collective academic experience of robotic-assisted prostatectomy in the New York/New Jersey metropolitan area.
Methods: Of 23 academic institutions in the New York Section-American Urological Association, 14 (60%) are equipped with da Vinci Surgical Systems. Twenty-three urologic surgeons at 13 institutions had experience in performing minimally invasive prostatectomies (21 RARP/2 LRP). Each surgeon that performs robotic-assisted prostatectomies was invited to complete a survey regarding their training and experience with open, laparoscopic, and robotic-assisted prostatectomy.
Results: The mean age of the 16 surgeons who responded was 39 (range, 32-53) [age 30 to 39 (n=11), 40 to 49 (n=3), and 50 to 59 (n=2)]. The mean number of years in practice was 5.1 (range, 1 to 22). Fifteen surgeons (94%) had fellowship training in laparoscopy/endourology (n=8) or urologic oncology (n=7). Surgeons had diverse backgrounds in laparoscopic surgery. All surgeons had experience in performing open prostatectomies including <50 cases (n=1), 50 to 100 (n=3), 101 to 200 (n=4), 201 to 300 (n=4), 301 to 400 (n=1), 401 to 500 (n=0), >500 (n=3). The median number of LRPs performed was 7 (range, 0 to 160), and RARPs was 53 (range, 8 to 1200), consisting of <50 cases (n=8), 51 to 100 (n=4), 101 to 200 (n=1), 201 to 300 (n=2), 301 to 400 (n=0), 401 to 500 (n=0), >500 (n=1). The mean number of robotic-assisted procedures at the point surgeons were comfortable with the procedure was 38 cases.
Conclusions: The learning curve for robotic-assisted prostatectomy was dependent on (1) experience with open prostatectomy and (2) experience with laparoscopic prostatectomy. Factors that did not impact the learning curve include surgeon age, fellowship training in laparoscopy vs. oncology, and prior general laparoscopic training.
6236 Gynecology
Total Laparoscopic Radical Hysterectomy and Bilateral Pelvic Lymphadenectomy
Using the Harmonic Scalpel
Nimesh P. Nagarsheth, MD, Monica Prasad, MD, Farr Nezhat, MD
Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai School of Medicine, New York, New York
Total laparoscopic radical hysterectomy with bilateral pelvic lymphadenectomy using the Harmonic scalpel for desiccation and division of all major surgical pedicles, dissection of the pelvic spaces, unroofing of the ureter, and bilateral pelvic lymphadenectomy is demonstrated. The advantages of this technique are outlined.
6237 Gynecology
Laparoscopic Debulking of Matted Precaval Lymph Nodes in a Patient with Recurrent Cervical Cancer
Nimesh, P. Nagarsheth, MD, Michele Peiretti, MD, William Bradley, MD, Farr Nezhat, MD
Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai School of Medicine, New York, New York
We present the technique of laparoscopic debulking of matted precaval lymph nodes using the Harmonic scalpel in a patient with recurrent cervical cancer. The advantages of the laparoscopic approach are outlined, and the methods required to safely perform this procedure are reviewed.
6238 Gynecology
Usefulness of Mini-Hysteroscopic Bipolar Coagulation for Control of Bleeding After Removal of Transcervically Prolapsed Myoma on an OPD Basis
Sung-Tack Oh, Young-Min Choi, Byung-Ik Lee
Department of Obstetrics and Gynecology, Chonnam University Medical School, Seoul National University Medical School, Inha University Medical School, South Korea
Introduction: We evaluated the usefulness of mini-hysteroscopic bipolar coagulation for bleeding control after removal of transcervically prolapsed myoma on an OPD basis.
Method: In 68 patients with transcervically prolapsed myoma, myomas were removed by a simple twisting technique, and bleeding points was controlled by mini-hysteroscopic bipolar coagulation. The only anesthesia used during the surgery was Demerol 50mg.
Results: The successful bleeding control rate after removal of myoma was 100%. No case of delayed bleeding was found. The mean weight of the myoma masses were 18.61±11.35g and 2.11±1.45cm, and the mean operative time and blood loss during the operation were 18.20±7.14 minutes and 3.75±2.45mL.
Conclusion: Control of bleeding by mini-hysteroscopic bipolar coagulation is a very simple, safe operation after removal of transcervically prolapsed myoma on an OPD basis.
6239 Urology
Percutaneous Cystolithotomy of Large Urinary Diversion Calculi Using a Combination of Laparoscopic and Endourologic Techniques
Po N. Lam, MD, Charles C. Te, Bradley P. Kropp, MD, Carson Wong, MD
University of Oklahoma, Oklahoma City, Oklahoma
Introduction: Patients with urinary diversion are at increased risk for developing bladder urolithiasis. We describe our technique for removing such stones using a combination of laparoscopic and endourologic instrumentation.
Methods: With the patient in the lithotomy or supine position, cystoscopy is performed and percutaneous access is obtained by introducing a 10-mm laparoscopic trocar through the scar of the prior suprapubic cystostomy. A laparoscopic entrapment bag is then introduced through the trocar, into which the calculi are collected. The bag is then delivered through the trocar site. A 30F, working sheath is then introduced into the bag. An ultrasonic lithotrite is utilized to fragment and evacuate the calculi within the bag under direct vision through a rigid nephroscope. After clearance of all calculi, the instruments are removed. Closure of the neocystostomy is not performed. A drainage catheter is left in the urethra or stoma for 7 days.
Results: This approach was successfully performed in 7 consecutive patients. Their mean age was 14.7 years (range, 5.6 to 23.1). All calculi were radio-opaque, having a mean linear stone burden of 4.4cm (range, 1.5 to 7.0). The mean operating room time was 108.7 minutes (range, 48 to 228). All 7 patients were rendered stone free with 1 procedure, as confirmed by cystoscopy and a plain abdominal radiograph, and discharged from the hospital within 23 hours after surgery. No immediate or delayed complications have occurred.
Conclusions: Our technique of percutaneous cystolithotomy, utilizing a combination of laparoscopic and endourologic instrumentation, is safe and effective for the removal of large calculi from urinary diversions, obviating the need for an open procedure.
6240 General Surgery
Significance of Laparoscopic Live Donor Nephrectomy: Lessons Learned from 128 Cases
A. Paul, MD, MSc, J. Treckmann, MD, F. Pietruck, MD, M. Malagó, MD,
S. Nadalin, MD, C.E. Broelsch, MD, PhD
Introduction: The purpose of this study was to compare laparoscopic-assisted live donor nephrectomy (LAP) with conventional open approaches regarding feasibility, safety, and morbidity.
Methods: A consecutive series of 28 live donor nephrectomies performed between January 1997 and March 2005 was analyzed. Kidneys were retrieved either by median laparotomy (ML, n=22; initial experience), flank incision (FI, n=57), and more recently by an anterior extraperitoneal approach (AEA, n=18) or since 1999 by laparoscopy in select cases (LAP, n=31). Beside standard intra- and postoperative parameters, complications were documented. Pain at rest and in motion was assessed with a visual analogue scale (VAS) until day 5.
Results: Survival of the live donors [age 51 (range, 24 to 75) years, 61 male/67 female] was 100%. Complications were higher for ML with 13.6% and comparable for FI 8.7%, AEA 5.5%, and LAP 6.4%. Bleeding complications were more frequent in LAP, while wound infection and hernia formation or abdominal wall relaxation occurred more often in ML and FI. One patient in the LAP group developed a pancreatic fistula. In the AEA group, 1 patient developed a small bowel obstruction. Postoperative pain scores were significantly higher after ML. All grafts except 1 functioned initially well, and 1-year graft survival reached 90%.
Conclusion: Due to increased morbidity, laparotomy should be avoided. FI and especially AEA gave superior results. LAP resulted in more serious complications. Safety aspects of LAP have to be monitored closely, especially in small- and medium-volume centers.
6241 General Surgery
A Synthetic Cyanoacrylate Tissue Sealant Impairs Tissue Integration of Macroporous Mesh in Experimental Hernia Repair
R. H. Fortelny, A. H. Petter-Puchner, N. Walder, R. Mittermayr, W. Öhlinger, A. Heinze, H. Redl
Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria in the Research Center for Traumatology of AUVA
II. Department of Surgery, Wilhelminenspital der Stadt Wien, Vienna, Austria
Department of Pathology, City Hospital Krems, Lower Austria, Austria
Introduction: Tissue sealants are discussed as alternatives to permanent fixation devices in hernia repair with the aim to reduce perforation-associated complications and chronic pain. Sealants can be divided into 2 groups: synthetic glues (eg, cyanoacrylate based) and biological products (eg, fibrin sealant). Whereas beneficial effects of fibrin sealant have been reported in both experimental and clinical hernia repairs. Little data exist on synthetic compounds in this field.
Methods: In 16 Sprague Dawley rats, 2 defects per animal were created in the abdominal wall left and right of the linea alba (1.5cm in diameter); the peritoneum was spared. The lesions were left untreated for 10 days to achieve a chronic condition and were then covered with TI-Mesh xl (2x2cm), sealed with Glubran-II. Four rats were sacrificed on the 17th day, 4 on the 28th day, 2 months and 5 months postoperatively. The meshes were biomechanically tested and histology was performed.
Results: Tissue integration of meshes was impaired at all time points by impenetrable plaques of glue. At the sites of application, elasticity of the abdominal wall was significantly reduced due to nonresorbed, rigid glue residues.
Conclusion: Mesh fixation by cyanoacrylate impairs tissue integration, elicits inflammation, and reduces implant elasticity. Results will be compared and reviewed with the results of previous investigations on natural glue in the same model.
6242 General Surgery
Porcine Cross-Linked Collagen Implants for Experimental Incisional Hernia Repair
A. H. Petter-Puchner, R. H. Fortelny, R. Mittermayr, N. Walder, W. Öhlinger, H. Redl
Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria in the Research Center for Traumatology of AUVA
II. Department of Surgery, Wilhelminenspital der Stadt Wien, Vienna, Austria
Department of Pathology, City Hospital Krems, Lower Austria, Austria
Introduction: Porcine collagen is a biomaterial promoted as an alternative to synthetic meshes in hernia repair and is advertised to yield superior biocompatibility and tissue integration. In this study, we tested PermaCol implants in a model of incisional hernia repair in which good results with synthetic meshes were previously found. Based on suggestions from the literature, we modified implants in 2 groups, adding perforations.
Methods: In 20 Sprague Dawley rats, 2 defects per animal were created in the abdominal wall left and right of the linea alba (1.5cm in diameter); the peritoneum was spared. The lesions were left untreated for 10 days to achieve a chronic condition and were then covered with PermaCol (2x2cm), sealed with 0.3mL of fibrin sealant (n=16) or sutured (n=4). Eight meshes were perforated to enhance tissue integration. Time points of euthanasia were 17 days, 28 days, and 3 months postoperative, and biomechanical tests and histology were performed.
Results: Regardless of fixation technique and modification (perforation), meshes showed poor tissue integration and led to massive inflammation. Three meshes had to be removed, and 1 animal had to be euthanized earlier than intended due to abscess at the implant site.
Conclusion: PermaCol invariably elicited pronounced adverse effects and lacked tissue integration in a model of incisional hernia repair.
6243 General Surgery
Mesh Fixation with Fibrin Sealant in Transabdominal Preperitoneal Mesh Repair: Recurrence and Impact on Quality of Life Evaluated in a Prospective Manner
R. H. Fortelny, A. H. Petter-Puchner, K. Puchner, K. Glaser, H. Redl
II. Department of Surgery, Wilhelminenspital der Stadt Wien, Vienna, Austria
Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria in the Research Center for Traumatology of AUVA
Introduction: Transabdominal preperitoneal mesh repair (TAPP) is the most frequent endoscopic technique for inguinal hernia repair. Although TAPP yields excellent results in terms of recurrence, penetrating mesh fixation devices have been associated with trauma to bowel, nerves, and vessels, as well as the development of chronic pain. Fibrin sealant (FS) was found in experimental models to be a feasible alternative to staples, anchors, and sutures.
Methods: Between February and December 2005, thirty consecutive male patients who were operated on with the TAPP technique at our department were included in this study. In these patients, TiMesh (GP Surgical) meshes were sealed with 2mL of Tisseelâ (Baxter). M III hernia was the only exclusion criteria for sealing. Patients were followed up at 10 days, 4 weeks, and 6 months after surgery. Visual Analogue Score and Short Form 36 (SF36) were assessed preoperatively and at 6 months, and results were compared with those of previous studies on TAPP repair with staples.
Results: In our patient population, no recurrence was observed, and 1 minor complication (seroma) occurred. Scores of VAS and SF36 were comparable with previous results of our own stapled patients and reports from the literature.
Conclusion: Fibrin sealant is an excellent alternative to penetrating fixation devices and helps to reduce complications and improve patient safety and satisfaction in TAPP.
6244 General Surgery
Laparoscopic Ladd’s Procedure in an Adult Male with Symptomatic Malrotation
Emil L. Popa, MD, Daniel T. Dempsey, MD, Jennifer L. Denne, MD, Harsh Grewal, MD
Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania
Introduction: We present a case illustrating the use of minimally invasive techniques in the management of intestinal malrotation in an adult patient.
Method: A 53-year-old male patient with no history of previous abdominal surgery, presented with increasing abdominal pain and constipation for 3 months. A double-contrast upper gastrointestinal study showed the entire small bowel to the right and the large bowel to the left of midline with the terminal ileum in the left lower quadrant consistent with malrotation. We used three 5-mm laparoscopic working ports (2 in the right lower quadrant, 1 in the left lower quadrant) and one 10-mm infraumbilical camera port. We identified the stomach, pylorus, and Ladd’s bands coming across the duodenum. We then mobilized the cecum and followed the ileum proximally, and after lysing all the Ladd's bands we straightened the abnormally rotated duodenum. The mesenteric root was widened and the intestine was placed in nonrotation, the small bowel was positioned to the right of the mesenteric root with the colon to the left. An appendectomy completed the procedure.
Results: The procedure was successful with minimal blood loss, without significant postoperative patient discomfort. He was discharged homed on postoperative day 2. Follow-up at 2 weeks confirmed complete resolution of symptoms.
Conclusions: This case illustrates that malrotation can present late in adults. It also demonstrates the ease and safety with which the classic Ladd’s procedure may be performed in an adult by using minimally invasive techniques.
6245 General Surgery
Initial Experience with the Use of the ON-Q Pain Pump During Laparoscopic Inguinal Hernia Repair
Anuj Prashar, DO, Larry Cohen, DO, Marc Neff, MD
Kennedy Health Systems, Cherry Hill, New Jersey
Introduction: Patients undergoing laparoscopic inguinal hernia repair have a number of benefits over those who undergo open surgery. Still, the technique has not resulted in a truly painless surgical procedure as once envisioned. Almost all patients still require postoperative narcotics regardless of the method used to fixate the mesh in the preperitoneal space. We propose a unique solution using a readily available device, the ON-Q Pain Pump.
Methods: A consecutive series of patients undergoing laparoscopic inguinal hernia repair were evaluated in a retrospective fashion. Each patient underwent single or bilateral hernia repair with placement of either 1 or 2 catheters attached to an ON-Q Pain Pump. The number of catheters, the rate of infusion, the volume of the reservoir, and the anesthetic used in the reservoir were all varied to achieve optimal results.
Results: Twenty-five patients underwent laparoscopic inguinal hernia repair in a preperitoneal fashion. At the end of each procedure, an ON-Q Pain Pump was positioned such that it rested adjacent to the mesh. The reservoirs ranged from 100cc to 330cc, the catheter infusion rate ranged from 2cc/hr to 5 cc/hour, and either 0.5% Marcaine or 1% lidocaine was used in the reservoir. Patients were evaluated at the time of pump removal and at the first postoperative visit on their postoperative pain.
Conclusion: Through use of the ON-Q Pain Pump, patients may achieve a nearly narcotic free laparoscopic inguinal hernia repair. The device is simple to use, safe, and effective. There were no infections related to the use of the device.
6246 General Surgery
Cystic Lymphangioma of the Adrenal Gland in a Patient with a Total Situs Inversus: A Case Report
R. Zribi, H. Rekik, A. Chokki, N. Kountchev, A Sassi
Cystic lymphangioma of the adrenal gland are rarely encountered tumoral formations with no clinical expression. Preoperative diagnosis is difficult. Echography and CT scan are essential exploratory techniques; diagnosis is histological. Usually, surgical exploration is indicated due to the uncertain diagnosis. We report a new case of cystic lymphangioma of the adrenal gland in a patient with a total situs inversus and a review of the recent literature.
6247 General Surgery
Laparoscopic Appendectomy in Patients with a Body Mass Index (BMI) of 25 or Greater
Robert L. Ricca MD, Ralph E. Butler MD, Paul A. Lucha DO
Department of General Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia
Introduction: The reported advantages of the laparoscopic approach to appendectomy are shortened stay, less postoperative pain, and earlier return to usual activities (work). However, a prospective, randomized, blind trial comparing laparoscopic with open appendectomy in active duty males failed to disclose a benefit to laparoscopic appendectomy with regards to postoperative pain and return to work. Open appendectomy in obese patients (those with a body mass index of 25 or greater) may be more difficult due to the excessive subcutaneous adipose tissue. Additionally, the open incision may be of considerable size, which may result in increased pain and prolonged convalescence.
Methods: A randomized, double-blind, prospective trial involving 52 patients with a BMI of 25 or greater and symptoms consistent with appendicitis was conducted at our institution. Laparoscopic appendectomy was compared with open appendectomy for the following outcome measures: postoperative pain, length of stay, lost workdays, overall operative time, and hospital costs of care.
Results: Average BMI was greater than 28. There was no difference in patients’ length of stay or lost workdays between the 2 procedures. Open appendectomy was associated with shorter operative time and hospital costs. These patients also reported more pain in the postoperative period than those who underwent laparoscopic appendectomy.
Conclusion: Although there is more pain reported with open appendectomy postoperatively, no significant difference exists with regard to hospital stay and lost workdays. Laparoscopic and open appendectomies are equivalent therapeutic options in the treatment of appendicitis in the obese patient. Further studies in the superobese population may be warranted.
6249 General Surgery
Difficulty of Laparoscopic Heller Myotomy Is Not Determined by Preoperative Therapy, and Neither Difficulty of Myotomy nor Preoperative Therapy Determine Long-Term Outcome
Alexander S. Rosemurgy, MD, Desiree V. Villadolid, MPH, Paul G. Toomey, BS, Sam Al-Saadi, MD, Jennifer C. Cooper, BS, Sarah M. Cowgill, MD, Steven S. Rakita, MD
Introduction: The impact of preoperative endoscopic therapy on the difficulty of laparoscopic Heller myotomy and the impact of the difficulty of the myotomy on long-term outcome have not been determined. This study was undertaken to determine whether the difficulty of laparoscopic Heller myotomy is impacted by preoperative therapy and whether preoperative therapy or difficulty of myotomy impact long-term outcome.
Methods: Since 1992, 305 patients, 55% male, median age 47 years, have undergone laparoscopic Heller myotomy and prospectively followed. Difficulty of laparoscopic Heller myotomy was scored by the operating surgeon, who was blinded to preoperative therapy, for 155 consecutive patients on a scale of 1 (easiest) to 5 (most difficult). Patients scored their symptoms before and after myotomy by using a Likert scale from 0 (never/not bothersome) to 10 (always/very bothersome).
Results: Before myotomy, 70% of patients underwent endoscopic therapy: 58% dilation, 36% Botox, 26% both. Preoperative endoscopic therapy did not correlate with difficulty of myotomy (P=0.88). Median follow-up was 25 months. Regardless of the difficulty of myotomy, dysphagia improved with myotomy (P<0.0001). By regression analysis, the frequency and severity of postmyotomy dysphagia did not correlate with either preoperative endoscopic therapy or with the difficulty of myotomy.
Conclusions: Laparoscopic Heller myotomy improves the frequency and severity of dysphagia. The difficulty of laparoscopic Heller myotomy is not impacted by preoperative therapy, and neither preoperative therapy nor difficulty of myotomy impact long-term outcome.
6250 General Surgery
Autologous Skin Grafting with a Bioabsorbable Stent for Widespread Endoscopic
Mucosal Resection of the Esophagus
Sakurai, Tadashi, Hori, Yoshio
Introduction: Endoscopic mucosal resection (EMR) is a patient-friendly treatment for early stage esophageal cancer. The entire EMR procedure is performed endoscopically and is less invasive. However, the indication of EMR for esophageal cancer is limited even for superficial lesions due to contraction and stricture after widespread resection. Therefore, the current indication of EMR for esophageal cancer is limited to lesions less than 3/4 of the circumference of the esophagus. We performed an experimental study using a swine model to evaluate the effect of autologous skin grafting at the site after EMR for prevention of stricture and stenosis.
Methods: With the pig under general anesthesia, we performed circumferential mucosal resection using the cap technique. The control group of pigs received EMR alone. In the study group, a bioabsorbable stent covered with an autologous skin graft was deployed immediately after resection. Two weeks after EMR, the animals were sacrificed and specimens were evaluated macroscopically and histologically.
Results: At 2 weeks after EMR, scar formation and severe stricture were observed in control lesions. In the autologous skin graft group, animals developed milder stricture compared with that in the control group. Part of the skin graft was engrafted at the site of EMR.
Conclusion: At present, autologous skin grafting with a bioabsorbable stent following a circumferential mucosal resection reduced the degree of stricture. Further investigation including modification of the technique for fixing a stent and skin graft is necessary.
6251 Gynecology
Da Vinci-Assisted Laparoscopic Sacral Colpopexy
Amir Shariati, MD, Douglass S. Hale, MD
Introduction: Our aim is to report the outcomes of da Vinci-assisted laparoscopic sacral colpopexy in our practice.
Methods: We preformed a retrospective chart review of 77 consecutive patients undergoing laparoscopic da Vinci-assisted sacral colpopexy from May 2003 to October 2005. All patients had preoperative urodynamic testing according to International Continence Society recommendations. Postoperatively, objective and subjective outcome measures including Pelvic Organ Prolapse Quantification (POPQ) staging and patient satisfaction were recorded at 6 weeks, 6 months, and 1 year.
Results: Mean follow-up was 7 months (range, 1.5 to 12). Mean age, BMI, and parity were 61.3, 26.1, and 2.9, respectively. Preoperatively, 71 (92%), 60 (78%), and 43 (56%) patients had POPQ Stage 2 or greater in the anterior, posterior, and vaginal vault, respectively. Preoperative urodynamic testing demonstrated urodynamic stress incontinence in 31 (40.3%), intrinsic sphincter deficiency in 10 (13%), and detrusor overactive incontinence in 9 (11.7%) patients. Surgery was completed laparoscopically in 76/77 cases. An additional 101 procedures were also performed. Mean change in Hgb was 2.6. Mean hospital stay was 2.9±1.65 days (range, 2 to 10). Postoperatively, 4 (5%) patients required a procedure for stress incontinence. Overactive bladder was persistent in 1 patient, and 15 (19.5%) had de novo urge incontinence. Suture and mesh erosion occurred in 7 (9%), and 3 (4%) patients, respectively; 3 required operative removal. At 1-year, 1 anterior wall failure was noted, and 94% were satisfied with their results.
Conclusion: The da Vinci robotic system can be adjunctively used to facilitate laparoscopic sacral colpopexy for patients with various stages of prolapse. Objective and subjective outcomes are good with a high level of patient satisfaction.
6252 General Surgery
Laparoscopic Approach in Acute Cholecystitis
D. Stojanovic, D. J. Lalosevic, M. Stojanovic
University Clinic Dr. Dragisa Misovic, Belgrade, Serbia and Montenegro
Introduction: Laparoscopic cholecystectomy is the method of choice and the gold standard for treating gallbladder conditions. Acute cholecystitis is classified as a special category due to specific symptoms of the inflammatory process in organisms, the necessity for a swift diagnosis, adequate and timely surgical intervention, and antibiotic therapy. Inflammation can lead to systematic complications, and locally because of an advanced process with unclear anatomy conditions for nearby tissue injury are created.
Methods: From January 2000 to December 2004, 1536 laparoscopic cholecystectomy (LC) procedures were performed in our department. All patients had uniform preoperative diagnostics (ultrasound, laboratory, and contrast imaging). In some cases with evident or suspected stones in bile ducts, endoscopic evaluation and cleaning of bile ducts were performed (ERCP/EST). Patients with acute cholecystitis (AC) had completed a preoperative diagnostic procedure in the emergency room, and according to severity and progress of symptoms, these patients were divided into 2 groups: (1) operated on within the first 48 hours, (2) operated on 4 to 6 weeks after the first attack.
Results: Calculous acute cholecystitis was present in 116 patients (7.55% of LC). Conversion was made in 19 cases (1.23% of LC and 16.37% of AC). No iatrogenic injuries or deaths occurred. In 2 cases (0.13% of LC) HP revealed adenocarcinoma.In the first group (operated on within the first 48 hours), there were 39 cases (2.54% of LC and 33.62% of AC) with conversion in 9 cases (0.58% of LC and 47.36% of AC). Mean duration of stay in the hospital in this group was 4.5 days. In the second group (operated on 4 to 6 weeks after the first attack), there were 77 cases (5% of LC and 66.38% of AC) with conversation in 10 cases (0.65% of LC and 52.64% of AC). Cholecystoduodenal communications were found in 2 cases (0.13% of LC and 3.84% of AC) and were treated surgically. Mean total hospital stay (2 hospitalizations) in this group was 8.5 days.
Conclusion: Minimal rates of complications and conversions, mean duration of hospital stay, recovery time, and absence of injuries and lethal outcomes are the elements that we conclude make the laparoscopic procedure the gold standard for treating acute cholecystitis in all groups.
6253 Urology
Asymptomatic Unilateral Urolithiasis in Living Donor Transplant Kidneys
George Martin, Michael C. Lipke, Asif Sharfuddin, Mahendra Govani, Chandru P. Sundaram
Introduction: We evaluated the rate of spontaneous passage, development of symptoms, and change in size of asymptomatic renal calculi in donor kidneys transplanted without removal of the calculi.
Methods: Five donor kidneys from living donors were found to have small (<4mm), asymptomatic renal calculi incidentally detected on CT. Donors had neither histories of symptomatic lithiasis, nor any metabolic abnormalities. All kidneys were removed laparoscopically and transplanted with the calculi in situ. Recipients were followed up with serial creatinine, history and physical, and CT scans.
Results: Recipients have not had symptoms consistent with progression of disease, such as decreased urine output, gross hematuria, hydronephrosis, or renal failure (mean follow-up, 508±313 days). Mean creatinine 1 week postoperatively and at long-term follow-up was 1.16±0.59 mg/dL, and 1.16±0.40, respectively. Only 2 patients had evidence of persistent urolithiasis on follow-up CT. One patient showed no change in size of the 2 calculi, and the other patient’s calculus enlarged from 1mm to 2mm. Those with persistent calculi had a significantly shorter length of follow-up (204±72 vs 711±200 days, P<0.05).
Conclusions: Transplant lithiasis is a potentially serious complication that has been reported in the setting of donor-gifted allograft lithiasis. In our series of 5 patients with small symptomatic renal calculi, no patients developed obstructive uropathy, and only 3 of 8 stones were still in situ at follow-up. Transplantation of small (<4mm), asymptomatic stones in situ can be safely performed with adequate follow-up and monitoring for development of obstructing transplant stones.
6254 Urology
Complications in 253 Laparoscopic Donor Nephrectomies
George L. Martin, Michael C. Lipke, Amy I. Guise, Johnathan E. Bernie,
Vladislav Bargman, Chandru P. Sundaram
Introduction: Laparoscopic donor nephrectomy (LDN) is an advanced laparoscopic surgery with the potential for significant complications. To improve donor and recipient outcomes, we studied the complications during our 5-year experience with 253 laparoscopic donor nephrectomies.
Methods: A retrospective chart review was performed on 253 laparoscopic living donors. Complications were graded according to Clavien et al’s method. Graft function and survival were also compared using recipient postoperative creatinine values up to 12 months.
Results: Mean patient age and BMI were 39.3 and 26.1, and 93.7% and 6.3% underwent left and right nephrectomies, respectively. The overall complication rate was 9.9%. There were 7 (2.8%) intraoperative complications, including 4 requiring open conversion, and 1 requiring laparoscopic repair. There were 18 (7.1%) postoperative complications, including 3 requiring reoperation for bleeding. The spectrum of complications is as follows: 60% grade I, 8% grade II, 32% grade III, and no grade IV or V. No intraoperative complications occurred in the right-sided donor group. There was a 5% complication rate in those with BMI >25, with 1 open conversion for renovascular injury. Less than 1% of recipients developed ureteral stricture requiring permanent stent placement or reoperation. Overall, there was a 2% graft loss rate.
Conclusions: Our data support the safety of laparoscopic live donor nephrectomy. There was a low rate of intraoperative and postoperative complications, the majority of which were minor. The complication rate in right-sided nephrectomy or overweight patients did not increase.
6255 Gynecology
A Pregnant Woman with a Dermoid Cyst Developing in an Accessory Ovary Located in the Left Infundibulopelvic Ligament: A Case Report
Hidenori Takahashi, Haruo Katayose, Akira Sato, Rika Suzuki
Fukushima Medical University and Fukushima Hospital
Introduction: Ectopic ovary including accessory and supernumerary ovary is a rare gynecologic condition, and neoplasms arising in ectopic ovaries are extremely rare. We experienced the first case of a woman in early pregnancy with a dermoid cyst developing in an accessory ovary located in the left infundibulopelvic ligament.
Methods: The patient was a para 2, 30-year-old woman. She had no previous operations or pelvic inflammatory disease. At 10 weeks of the current pregnancy, she was diagnosed with an intrauterine pregnancy and had an indistinct irregular mass about 12_8cm in size in the left adnexal near the cul-de-sac area. Ultrasound and MRI showed a cystic mass with fat attenuation. Tumor marker was an increasing CA19-9, but CA125 and CEA were normal. After she was admitted to the Department of Gynecology to undergo cystectomy at 16 weeks of pregnancy, an elective laparoscopic surgery was performed. On operation, the tumor was found to be 12_10cm, like a dermoid cyst, in the cul-de-sac with no connection between the eutopic ovaries, which appeared to be normal. We converted the laparoscopic operation to an exploratory laparotomy because the tumor might be malignant and derived from the intraretroperitoneal tissue.
Results: Based on laparotomy findings, a dermoid cyst derived from the left-side third ovary, the accessory ovary, was found in the left infundibulopelvic ligament adjacent to the retroperitoneum.
Conclusion: After resection of the tumor with the accessory ovary, the postoperative course was uneventful, and the patient was discharged in a healthy state.
6256 Gynecology
Primary Omental Pregnancy A Case Report
Hidenori Takahashi, Haruo Katayose, Akira Sato, Hiroshi Suzuki
Fukushima Medical University and Zyusendo Hospital
Omental pregnancy is an extremely rare form of ectopic pregnancy. Here we present a case of primary omental pregnancy diagnosed at laparoscopic surgical exploration according to Studdiford's criteria. A 26-year-old, para 0,woman presented with severe abdominal pain, without any delay in menstruation. The patient history revealed no use of contraceptives, and pregnancy status was confirmed after admission. There was no intrauterine sac or adnexal mass, but free peritoneal fluid in the cul-de-sac was detected at transvaginal ultrasound examination. Laparoscopy was done according to preoperative diagnosis of ruptured tubal pregnancy. Bilateral tubes and ovaries were intact, omental pregnancy was diagnosed and partial omentectomy was performed by laparoscopic surgery.
6259 General Surgery
Retrograde Intussusception Following Roux-en-Y Gastric Bypass
Renee Thompson, MD, David Earle, MD
Baystate Medical Center, Springfield, Massachusetts
Introduction: In the United States, Roux-en-Y gastric bypass is the most common procedure for morbid obesity. This procedure has a unique set of complications of which surgeons need to be aware. We will analyze 3 patients with reverse intussusception following Roux-en-Y gastric bypass. This is a rare complication of any Roux-en-Y anastomosis, and early diagnosis and treatment is essential to improve outcomes.
Methods: We performed a retrospective review of 3 cases of confirmed retrograde intussusception of the small intestine near the jejunojejunostomy following Roux-en-Y gastric bypass.
Results: All 3 bypasses were performed open, 2 to 9 years before the diagnosis of intussusception. All presented with abdominal pain, 2 acutely, and 1 with chronic, intermittent pain. Two were diagnosed preoperatively with a CT scan. All underwent operative therapy. One intussusceptum was proximal, and 2 were distal to the jejunojejunostomy. Two were repaired laparoscopically with reduction and jejunopexy, and one was repaired with the open method with small bowel resection for ischemia without jejunopexy. Symptoms were successfully relieved postoperatively in all cases, and there has been no recurrence, with a follow-up of 4 to 16 months.
Conclusion: Gastric bypass patients with acute or chronic abdominal pain or small bowel obstruction should have intussusception in the differential diagnosis. CT scan may be diagnostic, but if negative, a diagnostic operation should be considered. Resection should be performed with ischemic bowel, and jejunopexy is probably the best method to prevent recurrence, but we cannot make a definitive statement regarding this with our data.
6260 General Surgery
Major Bile Duct Injuries After Laparoscopic Cholecystectomy: A Tertiary
Center Experience
J. Treckmann, MD, A. Frilling, MD, PhD, J. Li, MD, A. Paul, MD, PhD,
T. Zöpf, MD, M. Malagó, MD, C. E. Broelsch, MD, PhD
Department of General Surgery and Transplantation, University Hospital
Essen and Department of Gastroenterology and Hepatology, University Hospital Essen
Introduction: Bile duct injury is a severe and potentially life-threatening complication of laparoscopic cholecystectomy. The aim of this study was to analyze our institutional experience with surgical repair of complex bile duct injuries.
Methods: Data were collected prospectively from 61 patients with bile duct injuries, all referred for surgical treatment to our center from other hospitals between April 1998 and December 2005. Bile duct injuries were classified according to Strasberg and Bismuth.
Results: Before referral, 53 patients (87.5%) underwent attempts at surgical reconstruction at the primary hospital. In 77.5% of the patients, complex type E1 or type E2 BDI were found. Concomitant with bile duct injury, 11 patients had vascular injuries. Roux-en-Y hepaticojejunostomy was carried out in 82.5% of patients. In 3 patients, Roux-en-Y hepaticojejunostomy and vascular reconstruction were necessary. Right hepatectomy was required in 12.5% of all patients. Two patients, both with bile duct injuries and vascular damage, died postoperatively. Follow-up of patients is 100%. At the median follow-up of 24 months, 82.5% of the patients are in excellent general condition. Signs of chronic cholangitis are present in 17.5% of patients.
Conclusions: Major bile duct injuries remain a significant cause of morbidity and even death after laparoscopic cholecystectomy. Because they present a considerable surgical challenge, early referral to an experienced hepatobiliary center is recommended.
6261 Urology
Laparoscopic Donor Nephrectomy in the Setting of Multiple Vessels or Anomalous Vasculature
Ilya A. Volfson, MD, Joseph J. Del Pizzo, MD, R. Ernest Sosa, MD, Michael A. Palese, MD, Ravi Munver, MD
Introduction: Laparoscopic live donor nephrectomy (LDN) in the setting of multiple vessels or vascular anomalies is technically challenging and may render potential donors as nonideal candidates. We report our experience with LDN in select cases with the goals of preserving aberrant vessels and obtaining adequate vascular length.
Methods: We retrospectively reviewed 300 consecutive LDNs performed from 1999 to 2005. Perioperative parameters were assessed for patients who underwent LDN for more than a single renal artery/vein, retroaortic renal veins, or early vascular bifurcation.
Results: Twenty-three patients (8%) underwent LDN for multiple renal arteries or veins (n=15), retroaortic renal veins (n=3), or other vascular anomalies (n=5). The mean age was 44 years (range, 21 to 60), operative time was 170 minutes (range, 55 to 340), blood loss was 85mL (range, 10 to 400), and hospital stay was 2.9 days (range, 1 to 5). These data were statistically similar to data for the control group (LDN with single vessels and normal vasculature). Mean warm ischemia time was 158 seconds (range, 97 to 285) and was slightly longer than that in the control group; however, this was not statistically significant. Recipient nadir creatinine (1.34 mg/dL) was similar to that in the control group. No perioperative complications or graft losses occurred.
Conclusions: Vascular anomalies and multiplicity can be present in up to 30% of potential renal donors. LDN for patients with complex or anomalous vasculature may improve the availability of allografts by facilitating successful procurement. In select patients, this approach is safe and efficacious and does not negatively impact the complication rate or recipient outcomes.
6262 Urology
Effect of Vascular Clamping on Partial Nephrectomies
Melissa M. Walls, MD, Erik P. Castle, MD, Raju Thomas, MD, MHA, Rodney Davis, MD
Department of Urology, Tulane University Health Sciences Center, New Orleans, LA
Introduction: Nephron-sparing surgery is becoming the preferred method for removal of indicated renal tumors. With advances in laparoscopic surgery, partial nephrectomy can often be done without the need for hilar clamping. We present the differences between laparoscopic and open partial nephrectomies using hilar clamping and nonclamping techniques.
Materials: Over the past 12 months, 38 partial nephrectomies were performed and reviewed. Twenty-seven patients underwent transperitoneal laparoscopic partial nephrectomy (LPN), while 11 patients had an open partial nephrectomy (OPN). Fourteen underwent LPN with the monopolar TissueLink DS (Group A), and 13 underwent hilar clamping (Group B). Of the 11 open partial nephrectomies, 5 were performed with the monopolar TissueLink device (Group C), and 6 had hilar clamping (Group D). Patient selection for clamping versus nonclamping was based on renal tumor size, location, and patient comorbidities.
Results: Average tumor size was <3cm for the LPN (range, 1.5 to 6) and >4cm for OPN (range, 3.0 to 9.5). Average operative time was 3 hours for groups A, B, and D, and 2.2 hours in group C. Median clamp time for LPN vs. OPN was 35 minutes and 41 minutes, respectively. Postoperative serum creatinine was slightly, but not significantly, elevated in groups B and D. All surgical margins were negative for malignancy.
Conclusions: The laparoscopic partial nephrectomy can be safely performed in select patients with good oncologic outcomes. This can be accomplished without hilar clamping and may be preferable in those patients with comorbidities that affect long-term renal function.
6264 Urology
High-Power (80W) Potassium-Titanyl-Phosphate (KTP) Laser Photoselective Vaporization Prostatectomy (PVP) for Large-Volume Benign Prostatic Hyperplasia (BPH)
Carson Wong MD, Po N. Lam MD, Glenn M. Sulley, BSN, Daniel J. Culkin, MD
University of Oklahoma, Oklahoma City, Oklahoma
Introduction: Due to the morbidity associated with transurethral resection of BPH >75 cm3, open prostatectomy is recommended. We evaluated KTP laser PVP as treatment for large volume BPH.
Methods: We prospectively evaluated patients who failed medical therapy for symptomatic BPH with prostate volumes >75cm3. Perioperative antibiotics were provided. With the patient under general anesthesia, transurethral PVP was performed using an 80W KTP side-firing laser system. Voiding trials were performed 2 hours after surgery; if the patient was unable to void, a urethral catheter was replaced.
Results: Thirty-four of 102 consecutive patients were identified, having a mean prostate volume of 130.4cm3 (range, 77.2 to 261.0). Mean laser time and energy usage were 73.4 minutes (range, 34.0 to 150.0) and 198.6kJ (range, 125.9 to 393.3) respectively. Perioperative serum sodium and hemoglobin did not change significantly. All were outpatient procedures with the majority of patients catheter-free at discharge. Nine patients required urethral catheter drainage for 1 week. One patient developed acute urinary retention 3 weeks after surgery, and another had persistent hematuria for 3 weeks. There were no other immediate or delayed complications. All patients were able to discontinue their prostate medications following surgery. Mean International Prostate Symptom Score decreased significantly from 28.5 to 20.6 to 14.5 (P<0.001) at 1 and 4 weeks, respectively. Mean maximum flow rate and postvoid residual values also improved.
Conclusion: Our initial results demonstrate that KTP laser PVP is safe and effective for treatment of symptomatic large-volume BPH, obviating the need for open surgery. Continued follow-up is in progress.
6265 Urology
High-Power (80W) Potassium-Titanyl-Phosphate (KTP) Laser Photoselective Vaporization Prostatectomy (PVP) for Refractory Urinary Retention Secondary to Benign Prostatic Hyperplasia (BPH)
Carson Wong, MD, Po N. Lam, MD, Glenn M. Sulley, BSN, Daniel J. Culkin, MD
University of Oklahoma, Oklahoma City, Oklahoma
Introduction: Urinary retention can pose a challenge for transurethral prostatectomy, having increased risks for sepsis and hemorrhage. We evaluated KTP laser PVP in patients with refractory urinary retention secondary to BPH.
Methods: We prospectively reviewed patients who presented with refractory urinary retention secondary to BPH. Perioperative antibiotics were provided. With the patient under general anesthesia, transurethral PVP was performed using an 80W KTP side-firing laser system. Voiding trials were performed 2 hours after surgery; if the patient was unable to void, the urethral catheter was replaced.
Results: Fourteen of 102 consecutive patients were identified, having a mean prostate volume of 70.5cm3 (range, 29.6 to 121.0). Mean laser time and energy usage were 40.1 minutes (range, 22.0 to 72.0) and 119.1 kJ (range, 58.7 to 252.6), respectively. Perioperative serum sodium and hemoglobin did not change significantly. All procedures were performed on an outpatient basis with the majority of the patients catheter-free at discharge. Two patients required catheter drainage for 1 week. No other immediate or delayed complications occurred. All patients were able to discontinue their prostate medications following surgery. Mean International Prostate Symptom Score decreased significantly from 31.9 to 17.9 to 13.6 (P<0.001) after 1 and 4 weeks, respectively. Maximum flow rate and postvoid residual values also showed improvement.
Conclusions: Our initial results demonstrate that KTP laser PVP is safe and effective for the treatment of refractory urinary retention secondary to BPH. Preoperative urinary retention does not necessarily increase one's risks of sepsis, hemorrhage, or prolonged catheter drainage after surgery. Continued follow-up is in progress.
6266 Gynecology
Laparoscopic Findings in Serous Surface Papillary Carcinoma: A Case Report
Takashi Yamada, MD, Hiroshi Mori, MD
Introduction: Exploratory laparotomy was performed for a diagnosis of serous surface papillary carcinoma.
Methods: A 72-year-old woman was admitted to our hospital with a chief complaint of abdominal distension. Laparoscopy was performed for diagnosis and treatment. After chemotherapy, a second-look laparoscopy was done to determine the curative effect. Then abdominal simple total hysterectomy, bilateral salpingo-oophorectomy, and omentectomy were performed. The pathologic examination was negative for residual tumor.
Results: The patient is alive without disease 60 months after the first chemotherapy.
Conclusions: Laparoscopy was very useful for the confirmed diagnosis, treatment, and the decision regarding the curative effect of serous surface papillary carcinoma.
6267 Cyber Café
Developing a Laparoscopic Skills Curriculum Using a Virtual Reality Simulation
Kurt E. Roberts, MD, Robert L. Bell, MD, Andrew J. Duffy, MD
Introduction: Patient safety concerns and training hour restrictions are challenging surgical education. Simulation training offers a novel opportunity to teach laparoscopic skills. LapSim is a virtual reality simulator that allows the instructor to design customized curricula. The aim of our study is to show that our curriculum will allow novices to develop basic laparoscopic skills and achieve a satisfactory performance on our skills examination.
Methods: We designed a novel computer-based curriculum on the LapSim consisting of practice modules (17 tasks requiring precision, efficiency, and ambidextrous control) and an examination. Tasks were designed and metrics set based on the performance of our “expert” faculty. Subjects are medical students without laparoscopic experience.
Results: Tasks are analyzed with a mean of 11 students (range, 5 to 18) per task. On 8 tasks, the mean number of attempts to pass averaged between 1.08 and 2.94 (range, 1 to 9). Six tasks of moderate difficulty required a mean of 3.0 to 6.6 attempts (range, 1 to 20). The most difficult tasks required a mean of 10.29 (range, 2 to 34), 19.13 (range, 11 to 28), and 31.0 (range, 4 to 52) attempts. The students at the extremes of the ranges both completed the final examination successfully.
Conclusions: Our laparoscopic training curriculum includes tasks to familiarize the user with the device and develop the requisite skills to pass our examination. Integration of this curriculum into the residency-training program should lead to improved technical performance by residence.
6268 Pediatric Surgery
Laparoscopic Management of Giant Splenic Cyst
N. Elizabeth Terry, MD, William C. Boswell, MD, Patrick McGraw, MD
Introduction: Congenital epithelial cysts of the spleen are extremely uncommon. Conventional treatment of these cysts has been total open splenectomy. Recently, laparoscopy has been utilized, but controversy exists over whether or not to remove or marsupialize these cysts, leaving the spleen and potentially segments of the cyst wall in place. In the pediatric population, preservation of the spleen and its immunologic function is ideal. We present a video of a successful laparoscopic splenic cystectomy in a 14-year-old female.
Methods: Exploratory laparoscopy was performed, and the giant 18x13-cm cyst was visualized. The cyst was needle decompressed with return of 1500cc of clear fluid. The epithelial cyst wall was then removed from the spleen with the Harmonic scalpel. A small central portion of the cyst wall was left adherent to the spleen via the "splenic decapsulation" technique. Pathology confirmed the presence of an epithelial lining.
Results: The procedure lasted approximately 20 minutes, and the patient was discharged the next day. She has been seen at 12-month follow-up with no recurrence of the cyst.
Conclusions: Laparoscopic cystectomy is a safe, effective way to remove giant splenic cysts. Despite controversy over the use of this procedure with true epithelial cysts, our patient has recovered well without recurrence. By avoiding splenectomy, she has retained full immunologic function, and through laparoscopy she was spared a larger open procedure.
6269 Gynecology
Laparoscopic Treatment of Polycystic Ovaries with Needle Cautery
Tehrani F. Ramezani, MD, A. Moini MD
National Research Center for Reproductive Health, Tehran, Iran
Introduction: We evaluated the reproductive outcome after standardized laparoscopic treatment of polycystic ovary syndrome (PCOS) in clomiphene-resistant infertile women.
Methods: This was a retrospective study of 68 clomiphene-resistant anovulatory women with PCOS treated at Karaj Hospital by laparoscopic ovarian drilling using a needle cautery. Outcome measures were regular menstruation, ovulatory rate, and pregnancy rate.
Results: After surgery, regular menstruation and ovulation occurred spontaneously in 82.65% and 73.2% of patients, respectively. The cumulative probability of conception at 12, 18, and 24 months after surgery was 36%, 58%, and 68%, respectively. By using the Cox's proportional hazards model, the effects of age, body mass index, and duration of infertility were evaluated. These factors were associated with regular menstruation but not pregnancy rate, but ovarian size had an effect on both outcomes.
Conclusion: Laparoscopic ovarian drilling is an effective alternative treatment in clomiphene-resistant anovulatory women with PCOS. Ovarian size can be considered as a prognostic indicator.
6271 General Surgery
Laparoscopic Small Bowel Obstruction Adhesiolysis
Amir Vejdan, MD
Introduction: The treatment of choice for recurrent small bowel obstruction caused by postoperative adhesions is conventional laparotomy; however, laparoscopic management of acute and recurrent small bowel obstruction has been demonstrated. This study evaluated the clinical outcome and long-term efficacy of laparoscopic adhesion release for recurrent adhesive small bowel obstruction and acute obstruction.
Methods: Elective laparoscopic treatment following conservative management was attempted in 18 patients hospitalized for recurrent small bowel obstruction after abdominal or pelvic surgery.
Results: The sites of postoperative adhesions were identified laparoscopically in all patients except for 1 patient who did not have any adhesions. Complete laparoscopic adhesiolysis was feasible in 14 patients, while conversion to open laparotomy and adhesiolysis was required in 3 patients because of dense adhesions or technical difficulties. Small bowel obstruction did not recur over a mean follow-up period of 8 months.
Conclusion: Laparoscopic adhesiolysis is a safe, effective treatment for recurrent small bowel obstruction in select cases. Conversion to laparotomy should be considered in patients with dense or pelvic adhesion.
6272 Urology
Is the Use of a 2-Way Catheter After TURP Safe?
Faiyaz Kapasi, U. Mufti, MD, Arshid Pandit, MD, P. Chandrasekar, Iqbal Shergill,
K. Ghani, R. Samman, B. S. Potluri, J. S. Virdi
Introduction: We present a retrospective study of patients who underwent transurethral resection of the prostate (TURP) for bladder outflow obstruction due to prostatic enlargement. The aim of the study was to compare the safety of the 2-way catheter with the safety of the 3-way catheter after TURP. The 2-way catheter is advantageous because bladder irrigation is not necessary after TURP, which saves the cost of postoperative normal saline irrigation fluid, reduces nursing time required to change the normal saline bottles and to empty catheter bags, and by not using the irrigation the patient’s catheter can be removed sooner leading to early discharge and postoperative recovery. However, there is also a possibility that by using a 2-way catheter, the patient can experience clot retention that eventually requires either repeated bladder washouts or change of the catheter, which could be difficult to manage for the nursing staff as well as junior medical doctors on call. Also change from a 2-way to a 3-way catheter requires subsequent irrigation.
Methods: We reviewed the records of patients who underwent TURP from March 2005 until October 2005. Of 48 patients, 28 were catheterized with a 3-way catheter and 20 with a 2-way catheter inserted after TURP.
Results:
Problems with catheters 07
2-way 07
3-way 00
Bladder washouts 07
2-way 07
3-way 00
Change of catheter 03
2-way 03
3-way 00
Postoperative catheterization time
2-way 57 hrs
3-way 56 hrs
Conclusion: In a small study, we encountered more problems with a 2-way catheter, and it had no distinct advantages over the 3-way catheter in reducing postoperative catheterization time. We feel that use of the 3-way catheter should be standard practice although irrigation can be commenced only if problems occur due to bleeding after TURP.
6274 Urology
Minimal Tumor on Prostate Biopsy: The Tip of the Iceberg?
Faiyaz Kapasi, K. Ghani, I. Shergill, B. S. Potluir, J. S. Virdi, J. McKenzie
Introduction: We evaluated whether a single positive core at biopsy is predictive of low tumor volume (TV), positive surgical margin (PSM), and extracapsular extension (ECE) at radical prostatectomy (RP).
Methods: Over 3 years, 105 patients underwent RP following biopsy (median cores=14). Thirty-four patients had only one core positive for cancer (Group I), and 71 patients had more than one positive core (Group II). Group I consisted of 50% ‘minimal volume’ (<1mm) cancer [Ia], 26% ‘small volume’ (<3mm) cancer [Ib], and 24% the remainder [Ic]. RP specimen was assessed for TV%, PSM, and ECE.
Results: Mean TV was 14% (Group I) vs 21% (Group II). Within Group I, mean TV was 15%(Ia) vs 9%(Ib) vs 17%(Ic). The number of patients categorized as having PSM and ECE was 26% and 18% in Group I, and 28% and 41% in Group II, respectively. No significant differences existed in PSM between groups I and II, but ECE was significantly different (P=0.025). Subanalysis revealed significant differences in PSM for Group Ic vs Ia/Ib (P<0.05).
Conclusion: A single positive core is not predictive of low tumor volume. PSM is significantly less only when the core contains <3mm of cancer.
6275 Urology
Transperitoneal Laparoscopic Pyeloplasty Procedures and Results at our Center
Kuzgunbay Baris, MD, Kilinc Ferhat, MD, Guvel Sezgin, MD
Introduction: Laparoscopic pyeloplasty has gained great popularity as a minimally invasive alternative to an open procedure for treating ureteropelvic junction (UPJ) obstruction. In this study, we aimed to present the laparoscopic transperitoneal dismembered pyeloplasty procedures performed at our center to treat UPJ obstruction and their results.
Methods: Between February 2004 and April 2006, 7 patients with UPJ obstruction underwent transperitoneal laparoscopic dismembered pyeloplasty. Operations were performed using 4 trocars with the patient in a semilateral decubitus position. One 10-mm and three 5-mm trocars were used. The UPJ and crossing vessels were dissected and narrow segments were extracted. The double-J stent was inserted and anastomosis was performed using a 4-zero polyglactin running suture.
Results: Patients’ mean age was 27.3±8.7 (range, 15 to 37) years. Five were male and 2 were female. Mean operation time was 207.1±78.7 minutes (range, 150 to 370), mean hospital stay was 61.7±16.9 hours (range, 44 to 88) and intraoperative bleeding was less than 50mL in all cases. No major intraoperative complications were seen. Postoperative periods were uneventful. Double-J stents were removed on postoperative day 21 in all cases.
Conclusion: Currently, laparoscopic pyeloplasty is a feasible, safe, and attractive alternative to open surgery. The results of laparoscopic pyeloplasty compare favorably with those achieved by open pyeloplasty with less perioperative morbidity, discomfort, and better cosmesis.
6276 Other
Comparison of Effects of Pethidine (IM) and Diclofenac (Suppository) for Relief of Pain After Laminectomy
Masoumeh Ahmadi, Mohammadreza Emamhadi, Hosein Shojaee
Guilan Trauma Research Center, Poursina Hospital, Guilan Rasht, Iran
Introduction: Pain, in particular postoperative pain, can produce numerous complications including a delay in healing of wounds in patients. For pain relief in patients postoperatively, different drugs are used, for example opioids like pethidine and NSAIDs. The purpose of this study was to compare the effects of IM pethidine and suppository Diclofenac for pain relief after laminectomy following lumbar disc hernia.
Methods: In this study, 108 patients presenting for laminectomy with a diagnosis of lumbar disc hernia and eligible for participation in the study, after completing their informed consent for inclusion in the study, were selected by a convenience sampling method and then divided into 2 groups: Pethidine (P) and Diclofenac (D). Patients’ pain scores were measured by Visual Analogue Scale (VAS). Finally, the data obtained were analyzed by using SPSS.10 statistical software, F test, T test, and X_ test. P<0.05 was considered significant.
Results: Mean pain scores within 24 hours after surgery were calculated in group P as
2.8±2.02 and in group D as 4.46±2.30. There was a statistically significant difference between the reduction in pain scores after surgery in both groups (P<0.005). Nausea was the greatest side effect observed in group P (23%), and epigastric pain was the most common pain found in group D (18%). However, no statistically significant difference was found between the 2 groups in terms of the adverse drug effects.
Conclusion: A statistically significant difference was observed between pethidine ampule and Diclofenac suppository regarding pain reduction after laminectomy. In other words, Diclofenac suppository has less impact on pain reduction compared with Pethidine ampule. To confirm these results, it is suggested that a large-scale, and if possible double-blind, study in terms of age and sex and after orthopedic procedures be carried out.
6277 General Surgery
TEP Repair for Inguinal Hernia
Ashraf Elzoghby, MD
Ain Shams University
Introduction: We present our local experience at Ain Shams University Hospital with total extraperitoneal (TEP) laparoscopic hernia repair.
Methods: Over 1 year, 12 patients underwent 14 TEP repairs for inguinal hernias. Ten patients had unilateral and 2 patients had bilateral hernias. The mean patient age was 42 years; all were males. The mean operative time was 75 minutes for unilateral and 100 minutes for bilateral cases. The mean operative time for the last 4 cases was 50 minutes. No conversions to open surgery were necessary.
Results: A breach in the peritoneum happened in 3 cases treated by insertion of a Veress needle intraperitoneally. One patient had a postoperative seroma that was aspirated safely. A large piece of mesh, 10cm to15cm, without fixation was used, without recurrence; however, the mean follow-up was only 2 months. The mean inpatient hospital stay was one day, and the last 5 cases were discharged without an overnight stay. No patient suffered paraesthesia or groin pain.
Conclusion: TEP offers a viable alternative to open inguinal hernia repair. However, adequate cases should be performed under supervision to overcome the learning curve and to achieve good results. Mesh fixation is not mandatory if a large 10-cm to15-cm piece is used.
6278 General Surgery
Laparoscopic Ileocecectomy for the Asymptomatic Mucocele of the Appendix in a Patient with Ulcerative Colitis: A Case Report
Chang-Mok Lee, MD, Yong-Won Kang, MD, Young-Hee Park, MD, Eu-Gene Kim, MD, Seo-Gue Yoon, MD, Kwang-Yun Kim, MD
Department of Coloproctology, Songdo Colorectal Hospital, Choong-ku, Seoul, Korea
Introduction: The appendiceal mucocele is a rare lesion, characterized by distension of the lumen due to accumulation of a mucoid substance. The incidence ranges between 0.2% and 0.3% of all appendectomies. It is often diagnosed clinically from signs and symptoms of acute appendicitis or, if it is asymptomatic, as an incidental finding during radiologic examinations, or laparotomy. If untreated, it may rupture producing a fatal entity known as pseudomyxoma peritonei. We report the case of a 63-year-old female patient, who was diagnosed with ulcerative colitis in February 2002.
Methods: The disease activity was moderate at the beginning and well controlled with mesalazine. A colonoscopy was done for surveillance of the neoplasm, and the typical bulbous submucosal lesion was seen on the appendiceal orifice. No laboratory alterations were found (including CEA, CA19-9, CRP, and ESR). Abdominal ultrasound and computed tomographic examinations revealed a 10x3.5-cm sized cystic lesion in the inferomedial aspect of the cecum. The patient underwent laparoscopic ileocecectomy without rupturing the tumor during manipulation.
Results: She recovered well and the final histology revealed a mucinous cystadenoma of the appendix. The laboratory and abdominal ultrasonographic findings 1 month after surgery were normal with no signs suggesting the pseudomyxoma peritonei, and the colitis was in remission.
Conclusion: We present the case of a patient with ulcerative colitis and asymptomatic appendiceal mucinous cystadenoma that was successfully resected using the laparoscopic approach. Special attention should be paid to patients with inflammatory bowel disease without ordinary symptoms during follow-up.
6279 General Surgery
Laparoscopic Total Proctocolectomy with Ileal Pouch Anal Anastomosis (IPAA) for the Treatment of Ulcerative Colitis: Early Functional Results
Chang-Mok Lee, MD, Seo-Gue Yoon, MD, Gyu Moon, MD, Eu-Gene Kim, MD, Yong-Won Kang, MD, Kwang-Yun Kim, MD
Dept. of Coloproctology, Songdo Colorectal Hospital, Choong-ku, Seoul, Korea
Introduction: Laparoscopic total proctocolectomy (TPC) is technically difficult, especially in the treatment of patients with ulcerative colitis (UC), whose bowel is severely inflamed. The aim of this study was to clarify the feasibility of laparoscopic TPC with regards to early functional results.
Methods: The study included 9 patients with UC who underwent laparoscopic TPC with ileal pouch anal anastomosis (IPAA). First the left then the right colon was mobilized with splenic mobilization. After mobilization of the transverse colon, rectal mobilization with total mesorectal excision was done. After division of the rectum with a linear cutter, an ileal pouch anal anastomosis was fashioned with a double stapling method. A diverting loop ileostomy was fashioned.
Results: The mean age was 43.8 years, and the median time from first diagnosis to operation was 20 months. The median follow-up was 12 months. The reasons for operation were 7 intractabilities, 1 combined rectal cancer, and 1 perforation with toxic megacolon. The mean operative time and mean blood loss were 309 minutes and 88mL, respectively. Food intake was started within postoperative day 3, and the median hospital stay was 11 days. Four postoperative complications occurred (wound infection, pouchitis, anastomotic stricture, anastomotic leakage). No mortality occurred and no conversion to the open procedure was necessary.
Conclusions: Laparoscopic TPC with IPAA is safe and feasible for treating patients with UC. The long-term functional results were needed to ensure that this procedure is performed more widely.
6280 Urology
Experience with Radiofrequency Ablation of Renal Tumor
Sung Kuk Yun, Gyung Tak Sung
Departments of Urology and Diagnostic Radiology, Dong-A University School of Medicine, Busan, Korea
Introduction: We report our experience with nephron-sparing radiofrequency ablation (RFA) of renal tumor.
Methods: RFA was performed in 17 patients, and 8 patients were followed up. Four percutaneous RFA under combined CT and ultrasonogram-guided, 2 intraoperative ultrasonography-guided laparoscopic RFA, and 2 open RFA have been performed since June 2004. Treatment indications were localized, small (<4cm), solid renal mass in elderly patients and those with comorbid conditions. One patient had a bilateral renal tumor. Follow-up studies included physical examination, CBC, serum creatinine, urine analysis, and kidney computer tomography and were performed on day 1, at 1 week, 1 month, 3 months, 6 months, 1 year after ablation and, thereafter, semi-annually. The mean follow-up duration was 15.8 months (range, 12 to 19).
Results: All 8 patients underwent successful RFA without any serious events. Four patients had mild perinephric hematoma, and the other had mild gross hematuria postoperatively. With a mean follow-up of 15.8 months, none of the patients had any residual tumor on follow-up contrast-enhanced CT after final tumor ablation. Complete tumor ablation was achieved after a single treatment session in 80% of patients, and in 20% of patients after subsequent ablation sessions.
Conclusion: Percutaneous or laparoscopic RFA is promising treatment for select patients with small renal mass and for nephron sparing. Contrast-enhanced CT performed immediately after ablation is reliable for excluding residual viable tumor. The ultimate role of this modality will continue to evolve and warrants further study.
6281 Urology
Laparoscopic Radical Cystectomy with Extracorporeal Reconstruction of Ureterointestinal Anastomosis and Ileal Conduit
Department of Urology, Dong-A University Hospital, Busan, Korea
Introduction: Laparoscopic radical cystectomy (LRC) with extracorporeal reconstruction of ureterointestinal anastomosis (UIA) and ileal conduit (IC) was performed to reduce OR time and minimize intraoperative and postoperative complications of UIA and IC associated with complete intracorporeal techniques.
Methods: LRC with extracorporeal reconstruction of UIA and IC was performed in 11 patients. Mean patient age was 60.1. LRC was performed completely intracorporeally in all cases. Specimen extraction and extracorporeal reconstruction of UIA and IC were performed through supraumbilical mini-incision (4cm). In the latter 6 patients, a modified “pull through” technique was used for UIA.
Results: Mean operative time was 7.1 hours, and mean blood loss was 345cc. Mean hospital stay was 9.8 days. No intraoperative complications occurred. Immediate postoperative complications occurred in 2 patients. One patient on POD 3 was found to have rectal injury, and a diverting loop colostomy was performed. On pathology, this patient was diagnosed with perivesical fat invasion at the site of the rectal injury. The other patient had mild wound infection. In one other case, bladder tumor invaded the anterior vaginal wall; therefore, laparoscopic anterior exenteration was done. The specimen was removed through the vagina. The procedure took 11 hours. Pathology stage ranged from T1NoMo to T3bN1Mo.
Conclusion: LRC with extracorporeal reconstruction of UIA and IC is quite feasible. We believe extracorporeal reconstruction of UIA and IC is easier and simpler to perform than the complete intracorporeal technique.
6282 General Surgery
Outcome Comparison of Laparoscopic to Open Conventional Approaches for Groin Hernia Repairs
M. Hussain, MMAS, FRCS
Objective: Laparoscopic groin hernia repair attracts controversy despite widespread acceptance of minimal access surgery in various surgical specialities. We compared the outcome of laparoscopic repair, ie, transabdominal preperitoneal (TAPP) with the open approach for patient satisfaction, improvement in quality of life (QoL), and change in postoperative chronic groin pain in a single surgical unit district general hospital.
Methods: This retrospective study involved 204 patients (102/group) with 226 hernias repaired from May 2000 to April 2004. Mean patient age was 55 and 57, respectively. Twelve and 10 patients, respectively, had bilateral hernias repaired, whereas 12 and 15 were recurrent hernia repairs in laparoscopic and open group, respectively. Median follow-up was 30 months (range, 12 to 48). Size of trimmed Prolene mesh used was 15x10cm. Written questionnaires with a visual analogue scoring system, used as an assessment were sent to 145 patients in each group. The first 102 replies per group were analyzed after excluding 8 and 13 replies for laparoscopic and open group, respectively. Chi-square and t test were used at P<0.05.
Results: Patient response rate to the questionnaire was 75% and 79% for laparoscopic and open groups, respectively. Satisfaction rate were 96% and 87%, P<0.023; while mean improvement in QoL were 3.75 and 2.17 (mean difference, -1.57) for laparoscopic and open groups, P< 0.001. The differences were significant. Mean postoperative chronic pain reduction was 3.25 and 3.80 (mean difference was -0.5), P<0.19, which was insignificant.
Conclusion: Patient satisfaction rate and improvement in QoL were significantly higher for the laparoscopic group compared with the open group; however, no significant reduction was noted in postoperative groin pain.
6283 General Surgery
Study of Incidence of Recurrence and Numbness After Laparoscopic and Open Groin hernia Repair
M. Hussain, MMAS, FRCS
Objective: Incidence of recurrence and groin numbness remain cause for concern both for laparoscopic and open hernia repair. We compared recurrence rate and postoperative groin numbness of laparoscopic, ie, transabdominal preperitoneal (TAPP), to that of open hernia repair in a single district general hospital unit.
Methods: This retrospective study involved 226 hernias repaired in 204 patients (102 in each group), between May 2000 and April 2004. Mean age was 55 and 57, respectively. Twelve and 10 patients had bilateral hernias repaired, whereas 12 and 15 were recurrent hernia repairs in laparoscopic and open groups, respectively. Median follow-up was 30 months (range, 12 to 48). Size of trimmed Prolene mesh used was 15x10cm. A written questionnaire with visual analogue scoring sent to 145 patients in each group was used as an assessment; and those who complained of recurrence of a groin lump were assessed in follow-up clinics. The first 102 complete replies were analyzed, excluding 8 and 13 for the laparoscopic and open group, respectively. The chi-square test was used for statistical analysis. P was set at 0.05.
Results: Patient response rate to the questionnaire was 75% and 79% in the laparoscopic and open groups, respectively. Postoperative groin dumbness was 16.6% (17) and 6.8% (7); the difference was significant, P<0.03. Three of 8 and 7 of 12 patients in the laparoscopic and open group, respectively, had a recurrence on clinical examination. Recurrence rate was 2.9% and 6.9% for laparoscopic and open groups, respectively, which was insignificant; P<0.19.
Conclusion: Incidence of postoperative numbness was significantly less in the laparoscopic group, whereas there was no significant difference in hernia recurrence rates.
6284 General Surgery
Can Sentinel Node Localization Biopsy Be a Reliable Substitute for Axillary Node Dissection in Some Patients?
M. Hussain, MMAS, FRCS
Objective: Axillary node status has important prognostic implications in breast cancer. Sentinel biopsies may become the surgical staging procedure of choice in the assessment of the axilla. Intraoperative lymphatic mapping with identification of the first draining lymph node (sentinel node) is under investigation as a possible axillary staging procedure in breast cancer patients. We sought to determine the role of sentinel node biopsy as an alternative to formal axillary node dissection in a district general hospital breast unit.
Methods: This was a prospective study conducted between November 1998 and August 2001 with 122 suitable patients, between the ages of 28 and 82 (mean, 56). Patients underwent sentinel node excision with subsequent axillary sampling, in combination with either mastectomy or a breast-conserving procedure. Features considered exclusion criteria to the procedure were a (1) heavy axillary tumour burden as assessed clinically, (2) previous axillary surgery, (3) multifocal disease and therapeutic localization biopsy.
Results: Sentinel node biopsy using a blue dye technique was performed in 122 patients. The sentinel node was identified in 113 patients and accurately predicted the status of the axilla in 108 patients (96%). Of 39 patients who were node positive, the sentinel node was the only positive node in 11 cases (26%). There were 5 false-negatives in patients with a node-positive axilla.
Conclusion: We therefore suggest that sentinel node biopsy may be a feasible yet reliable substitute to formal axillary node dissection in certain patients and that the lack of access to radioisotope facilities in a district general hospital need not preclude such an approach.
6285 Urology
Laparoscopic Transperitoneal Adrenalectomy in Patients with Pheochromocytoma
Tae Hyo Kim, Ki Soo Lee, Seong Ho Cho, Kyung Tak Sung
Objective: Pheochromocytomas are relatively uncommon tumors. Although the safety and efficacy of laparoscopic adrenalectomy are relatively well documented, few studies of pheochromocytomas have been conducted. We report our experience with a laparoscopic transperitoneal adrenalectomy in patients with pheochromocytomas.
Methods: Between January 1998 and August 2005, 22 patients underwent a laparoscopic transperitoneal adrenalectomy (LTA). Twelve males and 10 females were operated on, and average age was 40.4 years (range, 12 to 65). Between January 1998 and January 2002, 11 patients underwent LTA (early group: Group A), after February 2002 11 patients underwent LTA (late group: Group B). We compared the 9 patients in group A with the 10 patients in group B to evaluate the operative time, intraoperative blood loss, the mean time to oral intake, the postoperative hospital stay and intraoperative hypertensive crises.
Results: The mean operative time was 169.4 minutes in group A and 122.5 minutes in group B (P=0.003). The mean blood loss was 149.4cc and 129.5cc, respectively (P=0.045). The mean postoperative hospital stay was 6.5 days in group A and 4.4 days in the group B (P=0.015). The mean time to oral intake was 1.6 days in group A and 1.1 days in group B (P=0.068). At mean follow-up of 34 months, regression of symptoms and control of blood pressure were obtained without additional treatment in all patients.
Conclusion: In our experience, adrenal pheochromocytoma can be treated safely and effectively by a laparoscopic transperitoneal approach.
6286 Multispecialty
Magnetic Resonance Guided Focused Ultrasound Surgery: Current Status
Doron Kopelman, MD, Ferenc A. Jolesz, MD
Objective: Focused ultrasound generates heat, ablating tissue only at the focal point. The effect is similar to that of a magnifying glass used to focus the sun’s energy on a single point. MR guidance and control is important due to 3D anatomic information for exact tumor targeting, beam path visualization for safe treatment, real time MR thermometry to achieve planned outcome, and posttreatment contrast imaging for evaluating treatment outcome.
Methods and Results: MRgFUS has been used to treat breast cancer, provide pain relief in bone metastases, treat liver tumors, and uterine fibroids. In a breast cancer study performed without excision, MRgFUS was used to treat breast carcinoma. Evaluation of safety and long-term local recurrence of up to 1.5cm was analyzed. Patients with MR-identified single focal lesion T1/T2, N0, M0 were treated at Breastopia Namba Hospital, Miyazaki, Japan. Regarding bone metastases, treatment for pain relief displaced the need for radiation. Seven patients were treated at 2 centers. Patients stopped use of any analgesic medications after treatment. In liver tumors, focused ultrasound was used to in animal and FIM studies. The studies demonstrated the capability of treating liver tumors safely while gating breathing. Treatment synchronized with respiration under GA enables consistent target position during sonications for the entire procedure, high quality MR thermal imaging. Liver tissue ablation close to large vessels within the liver is safe. The first 2 human liver treatments were performed successfully at St. Marry’s London. Regarding uterine fibroids, MRgFUS was used to treat 1500 women from around the world with symptomatic uterine fibroids, with up to 36-month follow-up. Significant symptom relief was achieved in 71% to 79% of patients. Larger treatment volumes translate into greater symptom improvement.
Conclusion: MRgFUS offers the advantages are fewer days of missed work, quicker return to normal activity, fewer days in bed, and lower use of medical resources compared with total abdominal hysterectomy.
6287 General Surgery
Usefulness of Mini-Hysteroscopic Bipolar Coagulation of Bleeding Points After Removal of Cervical Myomas at an Outpatient Clinic
Sung-Tack Oh, MD, PhD, Young-Min Choi, MD, PhD, Byung-Ik Lee, MD, PhD
Objective: The most important point is postoperative bleeding control after transcervical removal of cervical myomas. The purpose of this study was to evaluate the usefulness of mini-hysteroscopic bipolar coagulation for this postoperative bleeding control.
Methods: The study included 64 patients who received transcervical removal of cervical myoma at University Hospital. Initially, cervical myomas were removed by a simple rotating movement with tenaculum, and then bleeding points of pedicles were controlled by bipolar coagulator during mini-hysteroscopy with a 2.7-mm diameter hysteroscope in the outpatient clinic. Total operating time and bleeding amount were estimated. Late recurrent bleeding after surgery was observed for 3 days.
Results: The average operation time was only 17±8 minutes, and the average bleeding amount during operation was only 19±10mL. Late recurrent bleeding was not found in any of the 64 patients.
Conclusion: The transcervical removal of cervical myoma with mini-hysteroscopic bipolar coagulation of bleeding points is a very rapid, safe, simple, and effective operative method for cervical myomas.
6288 Urology
Laparoscopic Repair of Intraperitoneal Bladder Rupture
James F. Borin, MD, David S. Yee, MD, Jonathan Kalisvaart, MD
Introduction: Intraperitoneal bladder rupture is an emergency that must be repaired. Traditionally, this has involved a laparotomy; however, there have been a few reports of laparoscopic repair for isolated bladder injuries. In this video, we present a case of traumatic bladder rupture repaired laparoscopically.
Methods: A 30-year-old male with class 2 obesity (1.68m, 108kg, BMI=38 kg/m2) became markedly inebriated; several episodes of emesis and eventual loss of consciousness ensued. Upon awakening, the patient noted abdominal pain that persisted despite opioid analgesics. Two days later, he presented to the emergency room; he denied any known trauma. Serum creatinine was 4.2mg/dL. A computed tomographic cystogram revealed an intraperitoneal bladder rupture.
Results: Because of the intraperitoneal nature of the bladder injury, surgical repair was indicated. Due to the patient’s size, a laparoscopic approach was elected. Cystoscopy revealed an injury at the bladder dome. Trocars were placed at the umbilicus (10mm) and lateral to each rectus muscle (5mm). An assistant’s port (10mm) was placed in the right lower quadrant to facilitate retraction and exposure. Using freehand suturing and knot-tying, the bladder was closed in 2 layers with 3-0 Monocryl then 0-Vicryl (SH needle), and leak tested. A cystogram 11 days later revealed no extravasation; the Foley catheter was removed. The patient is voiding well at 2.5-month follow-up.
Conclusions: In a morbidly obese patient, laparoscopic repair of an isolated, intraperitoneal bladder rupture is feasible. Intraoperative cystoscopy was helpful in confirming the site of injury.
6289 General Surgery
Anastomotic Leaks Following Laparoscopic Gastric Bypass
Alex Gandsas, MD, Christina Li, MD, Rodrick McKinley, Karen Sweeney, RN, Phil Schauer, MD
The purpose of this video is to highlight one of the most devastating complications following laparoscopic gastric bypass—the anastomotic leak. We hope to provide the viewer with some recommendations to avoid this problem. Most leaks following gastric bypass occur as a result of technical or anatomical challenges that lead to technical error, such as faulty placements of staplers or sutures, vascular compromise, or tension at the suture line. As of today, the surgical management of postoperative leaks relies on vigorous lavage of the abdominal cavity; identification and closure, if possible, of the defect; and drainage of the abdominal cavity. Placement of gastrotomy tubes is frequently used to provide both adequate decompression of the GI tract and to secure a route for feeding purposes during the postoperative period. Antibiotics should also be added to control the infection.
6290 General Surgery
The Laparoscopic Repair of Suprapubic Hernia
Timothy M. Geiger, MD, Ziad T. Awad, MD, Bruce Ramshaw, MD
Introduction: Suprapubic hernia is a rare complication of lower midline and transverse incisions.
Methods: A 50-year-old female presented with a symptomatic suprapubic hernia. Surgical history is significant for C-Section (Pfannenstiel incision), hysterectomy (lower midline incision), open umbilical hernia, and open mesh repair of lower midline abdominal wall hernia. The suprapubic hernia was repaired laparoscopically using PTFE mesh. Four ports were used; adhesions from previous surgeries were taken down. A peritoneal flap was developed inferiorly; the bladder was mobilized bluntly off the pubic bone, Cooper's ligament and the iliac vessels bilaterally. The mesh was anchored to the bony and ligamentous structures as well as the abdominal wall by using spiral tacks and transfacial sutures.
Results: The operative time was 90 minutes; blood loss was 15cc. The patient was discharged home on the second postoperative day.
Conclusion: Suprapubic hernia repair is technically demanding. Wide mesh coverage and anchorage to ligamentous and bony structures are essential for a durable repair.
6291 General Surgery
Laparoscopy and Peritoneal Cytology in Patients with Gastrointestinal Malignancy
Maksimvic Sinisa, MD, PhD
Introduction: Preliminary work by our group has shown that peritoneal cytology and laparoscopy are superior in detecting patients with gastrointestinal malignancy.
Methods: Our experience at Bijeljinas General Hospital with staging laparoscopy and peritoneal cytology over the past 8 years (N-131) reveals that approximately 18% of patients without metastases by computed tomography harbor occult metastatic diseases on laparoscopy. The telescope is introduced through a 10-mm trocar, and examination begins by inspection of the lower abdomen and pelvis. Free fluid is aspirated and saved for cytology.
Results: Peritoneal cytology and laparoscopy were performed in 131 patients in the health district in the northeast of Bosnia (population 180,000). Our data reveal that positive cytology occurs in 30.5% (40/131) of patients with visible metastases, but in only 9.1% (12/131) of those without (P<0.001). We advocate the classification of patients with positive peritoneal cytology as M1 in the TNM system as is the case for gastrointestinal cancer.
Conclusions: Laparoscopy with peritoneal cytology detects metastasis in greater than 24% of patients with negative CT scans, and assessment of unresectability may be improved by laparoscopic ultrasound or extended dissection.
6292 General Surgery
Sentinel Node Biopsy (SNB) in the Surgical Treatment of Breast Cancer
Sinisa Maksimovic MD, PhD
Introduction: Sentinel node biopsy (SNB) is a new component of the surgical treatment of breast cancer that predicts axillary status. Although the procedure is still mainly investigational, many patients are requesting SNB to avoid axillary dissection if the sentinel node (SN) is negative.
Methods: From March 1996 to December 2005, 372 patients with breast carcinoma clinically negative axillary nodes underwent breast surgery, mainly conservative, and SNB. If the SN was histologically uninvolved, no further surgical treatment was given. All patients were informed in detail and signed a consent form. SNB involved injection of labeled albumin particles close to the primary tumor, lymphoscintigraphy, and location of the sentinel node with a gamma probe during surgery.
Results: We performed 372 SNBs in 265 patients (3 bilateral). In 107, the SN was positive, and complete axillary dissection wasperformed. In 204 cases in 192 patients, the SN was negative, and no dissection was performed. These were carefully followed with quarterly clinical examinations of the axilla. Seven of the total axillary nodes available for examination were expected to have metastases. No case of clinically evident axillary node metastases occurred.
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 small size breast cancer.
6293 Multispecialty
Laparoscopic Simultaneous Operations in Operative Gynecology
Khusen B. Narzullaev, MD, PhD, Jamshed A. Akhtamov, MD, PhD, Surat A. Azimov, MD, PhD
From 1996 to 2005, 4235 operations were performed. Simultaneous operations made up 195 (4.6%) of those. Patient’s age ranged from 22 to 49 (average 31±3). Indications for simultaneous operations were as follows: calculous cholecystitis + surgical sterilization, 129 (66.2%); calculous cholecystitis + ovarian cyst, 5 (2.6%); uterine myoma + umbilical hernia, 12 (6.1%); uterine myoma + calculous cholecystitis, 12 (6.1%), uterine myoma + adhesive disease, 6 (3.1%), ectopic pregnancy + surgical sterilization, 13 (6.7%); ovarian cyst + surgical sterilization, 18 (9.2%). Moreover, some patients underwent 3 simultaneous surgical interventions for calculous cholecystitis + ovarian cyst + surgical sterilization, 12; calculous cholecystitis + ovarian cyst + umbilical hernia, 5; uterine myoma + hydrosalpinx + adhesial disease, 3; calculous cholecystitis + surgical sterilization + uterine myoma, 4.Laparotomy was performed in 6 patients as follows: hysterectomy + laparoscopic cholecystectomy in 5; extrauterine pregnancy + surgical sterilization because of the presence of a large amount of blood in the abdominal cavity in 1 patient. Length of hospital stay after laparotomy was 6.8 days and after laparoscopy was 1.8 days. Therefore, the joint work of surgeons and obstetrician-gynecologists in one department using the same equipment allows several different operations to be undertaken while the patient is under anesthesia, which sharply reduces the patient’s hospital stay and reduces the cost of treatment and postoperative aftereffects.
6294 General Surgery
Laparoscopic Repair of Inguinal Hernia Using Surgisis Mesh and Fibrin Sealant
Arthur P. Fine, MD
Objective: We tested the hypothesis in a primary care center that laparoscopic inguinal herniorrhaphy using Surgisis mesh secured with fibrin sealant is an effective long-term treatment for repair of inguinal hernia.
Methods: Between December 2002 and May 2005, 38 patients with 45 primary and
6 recurrent inguinal hernias were treated by a single surgeon with laparoscopic repair by the total extraperitoneal mesh placement (TEP) technique using Surgisis mesh secured into place using fibrin sealant. Postoperative complications, incidence of pain, and recurrence were recorded, as evaluated at 2 weeks, 6 weeks, 1 year, and using a follow-up questionnaire and telephone interview conducted in May and June 2005.
Results: The operations were successfully performed on all patients with no complications or revisions to an open procedure. Average follow-up was 13 months (range, 1 to 30). One hernia recurred (second recurrence of unilateral direct hernia), indicating a 2% recurrence rate.
Conclusion: Laparoscopic repair of inguinal hernia using Surgisis mesh secured with fibrin sealant can be effectively used to treat inguinal hernias in adults without complications and minimal recurrence within one year of follow-up.
6295 Urology
Laparoscopic Versus Open Radical Nephrectomy for the Treatment of Xanthogranulomatous Pyelonephritis: Contemporary Outcome Analysis
Brian VanderBrink, Michael Ost, Ardeshir Rastinehad, Michael Levine, Benjamin Lee
Introduction: Early experience with laparoscopic nephrectomy for xanthogranulomatous pyelonephritis (XGP) was associated with a high conversion and complication rate. We sought to determine whether laparoscopic nephrectomy outcomes had improved since earlier reports and how these outcomes compared with a contemporary cohort with XGP treated by open nephrectomy.
Method: We performed a retrospective review of surgical pathology from patients undergoing radical nephrectomy at our institution between 1995 and 2005. A pathology diagnosis of XGP was made in 12 patients with 6 patients having undergone a laparoscopic approach while 6 patients had an open procedure. Intraoperative and postoperative parameters were recorded, including complications.
Result: Transperitoneal laparoscopic nephrectomy was successfully performed in 5/6 (83%) patients. Hand-assist ports were used in 2 patients. Operative times were 301±106 and 167±40 minutes in the laparoscopic and open groups, respectively (P=0.03). No difference occurred with regards to blood loss, transfusion rates, parenteral analgesic requirements, and length of stay between the 2 groups. Complications were noted in 3/6 patients and 2/6 patients in the laparoscopic and open groups, respectively.
Conclusion: Outcomes following laparoscopic nephrectomy for XGP were similar in our series compared with outcomes in initial reports in the literature. This observation may be dependent upon surgeon experience. Similar perioperative outcomes were seen in both groups; however, a trend existed for decreased pain and shorter convalescence times in the laparoscopic group compared with that in the open group. Thus, we recommend offering patients requiring nephrectomy for XGP a laparoscopic approach.
6297 Urology
Heminephrectomy in Horseshoe Kidney: Laparoscopic Technique
Yildiim Bayazit, MD, Volkan Izol, MD, Alper Eken, MD, Arkun Aytutuldu, MD, Saban Doran, MD
Objectives: Heminephrectomy of a horseshoe kidney is technically difficult because of aberrant vessels, abnormal anatomical structure, and renal isthmus. In this video, we present a laparoscopic left heminephrectomy operation performed on a horseshoe kidney with left-side hydronephrosis.
Methods: A 38-year-old man with a history of left flank pain was diagnosed with horseshoe kidney and left-side hydronephrosis. Laparoscopic heminephrectomy was planned for the nonfunctioning left side. Surgery was performed transperitoneally with the patient in a modified right lateral decubitus position, and one 5-mm and three 10-mm trocars were used. After clipping and cutting of the renal vasculature and ureter, heminephrectomy was completed by dividing the thick isthmus with ultrasonic scissors. The isthmus was sutured by 2/0 Vicryl over oxidized cellulose bolster for hemostasis, and a drain was placed.
Results: Operative time was 240 minutes, and estimated blood loss was 250mL. No intraoperative and early postoperative complication was observed. The drain was removed, and the patient was discharged on the third day.
Conclusion: Significant risk of hemorrhage should be considered during laparoscopic heminephrectomy of horseshoe kidneys with a thick isthmus. Meticulous dissection of renal vessels and division of the isthmus by using an instrument with a strong hemostatic effect are important.
6298 General Surgery
Gastric Electrical Stimulation as a Treatment for Gastroparesis
Stacie Perlman MD, Steven Yood, MD
Objective: Patients with severe gastroparesis have few therapeutic options. Gastric electrical stimulation (GES) has been used for this condition. This study investigates the effect of GES on gastric emptying, total symptom score (TSS), health-related quality of life (HQOL), and patient satisfaction.
Methods: This study was prospective, including consecutive patients from 2002 through 2005, receiving continuous high-frequency/low-energy GES (Enterra Therapy, Medtronic, Minneapolis, MN). Symptom scores, HRQOL (SF-36), patient satisfaction, and gastric emptying were assessed. Questionnaires were completed at 3, 6, and 12 months. Gastric emptying scans were completed at 6 and 12 months.
Results: Twelve patients received GES. The average percentage of gastric retention preoperatively was 82.3% at 2 hours. Postoperatively, this dropped to 30%. After 6 months, gastric retention decreased by an average of 48%. Average TSS preoperatively was 45 (range, 26 to 56) compared with 27 (range, 4 to 42) postoperatively. Eighty-six percent of patients had improved TSS scores by an average of 22 points. HRQOL scores were broken into physical and mental components. The average preoperative physical HRQOL component score was 30.1, with a postoperative score of 35.0. The preoperative mental component HRQOL score of 35.6 improved to 45.6 postoperatively. One hundred percent of patients would undergo the procedure again.
Conclusion: Gastric electrical stimulation improved gastric emptying, symptom scores, and quality of life in patients with refractory gastroparesis. This remains an option for patients with refractory gastroparesis.
6299 General Surgery
Laparoscopic Repair of Paraesophageal Hernia: A Case Series of 42 Patients
Introduction: Laparoscopic repair of paraesophageal hernia (PEH) started in the early to mid 1990s. This retrospective study was performed to review the intermediate-term results of the operation.
Methods: This retrospective 8-year case series involved 42 patients. The notes were retrieved and reviewed individually, and data were collected regarding symptoms, investigation, operative details, and follow-up.
Results: The M:F ratio was 1:1.8, and median age was 62.5 years. Symptoms included epigastric/chest pain (69%), heartburn (50%), dysphagia (38%), vomiting (24%), gastric volvulus (19%), and upper GI bleeding (16%). The repair included reduction, sac excision, esophageal mobilization and cruroplasty. Fundoplication (anterior partial) was done in 18 (43%). Median hospital stay was 3 days. The complications included esophageal perforation in one (2.3%), gas-forming mediastinal abscess in one (2.3%), small bowel obstruction in one (2.3%), and bilateral basal atelectasis in two (7%). One patient (2.3%) died due to duodenal perforation and myocardial infarction. Of the 35 (83%) patients followed up (median 18m), 20 (57%) had follow-up investigations. Seven patients (20%) had postoperative dysphagia (>3 months), and 3 (8.5%) had persistent postoperative heartburn (>6 weeks). Five (12%) had recurrence. Symptom outcome was Visick grades I/II (65%), III (23%), and IV (11%).
Conclusion: Laparoscopic repair of PEH resulted in a short length of stay, excellent outcome in 65% of patients, and a recurrence rate of 12%.
6300 Other
The First European-Based Working Group on Natural Orifice Surgery and Scarless Operations (NSO/SLO)
Michael Stark, MD, Liselotte Mettler, Prof Dr Med
Since the 1970s, laparoscopic surgery has replaced gynecological, surgical, and urological laparotomies. Nageshwar Reddy lately popularized the idea of transgastric, intraperitoneal surgery in India. In 2005, the New European Surgical Academy founded the first European-based working group with the goal of developing new procedures and instruments adapted to the transgastric, transvaginal, transuterine, and transrectal routes. The working group believes that this new approach might replace many operative laparoscopic procedures because of fewer complications and better aesthetic results. Similar ideas are being investigated in some other professional groups like the ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery of D. Rattner and Anthony Kalloo. The participants of the interdisciplinary NOS/SLO working group of the NESA are surgeons from various disciplines, pharmacologists, physiologists, and representatives from the industry (specialists for robotics and simulation). The working group not only focuses on natural orifice surgery but also on “scarless operations” like transaxillar and transmamillar operations and the use of MRI-guided focus ultrasound. It elaborates study protocols, conducts preclinical and clinical studies, explores specific physiological and surgical aspects, and develops adapted instruments. The advantages of this new approach as well as the first results of the working group are going to be presented.
6301 Urology
Use of a Novel Plasmakinetic Bipolar Forceps to Occlude and Transect Renal Vessels in a Porcine Model
Brian L. Gallagher, MD, Fadi N. Joudi, MD, Robert Tucker, PhD, MD, Christopher Johnson, MD, Richard D. Williams, MD
Introduction: The bipolar plasmakinetic (PK) forceps currently in use coagulates vessels up to 7mm in diameter. We sought to test the effectiveness and safety of a Gyrus ACMI PlasmaSEAL (PS) forceps that combines sealing and transecting the tissue in establishing adequate hemostasis while transecting renal vessels in a porcine model.
Methods: Bilateral nephrectomies were performed on 5 Sus Scrofa pigs (60lb to 79lb). Standard silk sutures and electrocautery were used and compared with the new PS forceps. We monitored intraoperative blood loss, measured the caliber of the vessels sealed, and tested burst pressures on the sealed and tied vessels. The extent of thermal spread was examined on the PS specimens after H&E staining.
Results: The PS forceps provided excellent seal of the renal arteries, ranging from 3mm to 6mm in diameter. Average blood loss (P=0.4) and procedure time (P=0.5) were not significantly different between the 2 groups. All renal arteries tested accepted the standard pressure of 360mm Hg for 10 seconds. Thermal spread was observed with an average of 1mm from the cut edges of the arteries sealed with the PS forceps.
Conclusion: The new PS can safely and effectively seal and transect arteries up to 6mm in size. Thermal spread affects only 1mm of the transected vessel, so surrounding tissue is unaffected. Further clinical studies are warranted.
6302 General Surgery
Nonabsorbable Polymeric Clips as an Alternative for the Ligation of Appendicular Stump During Laparoscopic Appendectomies
Hanssen Andrés, MD, Plotnikov Sergio, MD, Dubois Rinci, MD
Background: The objectives of this study were to establish whether the occlusion of the appendicular stump using nonabsorbable polymeric clips is technically feasible and whether there are differences in the postoperative course of patients to whom polymeric clips were applied compared with those patients whose appendicular stump was closed with a surgical stapler.
Methods: This was a prospective study in 2 stages. First, 28 consecutive patients operated on for appendix resection between March 2002 and September 2003 were assigned to 1 of 2 groups. In 14 of them, the appendicular base was occluded using an endoscopic lineal cutting stapler, and in the remaining 14, the appendicular base was ligated using nonabsorbable polymeric clips. We compared the surgical time, the hospital stay, the final amounts of the hospital bills, and the complications in both groups. Second, we evaluated 250 laparoscopic appendectomies between March 2002 and March 2006, using the Harmonic scalpel for the section and hemostasis of the appendicular mesentery. Ligation of the appendicular stump was performed using nonabsorbable Hem-o-lockâ.
Results: We found a significant difference in the procedure’s cost, with the endoscopic staplers being more expensive.
Conclusion: The use of polymeric clips is a feasible, safe, and economic alternative for the ligation of appendicular stump during laparoscopic appendectomies.
6303 General Surgery
The Safety and Efficacy of Direct Trocar Insertion for the Creation of Pneumoperitoneum
K. Theodoropoulou, MBBS, H. Alogaily, MBBS, T. Lo, MBBS, Q. A. Ahmad, FCPS,
H. Bradpiece, FRCS
Objective: Recently, direct trocar insertion for the creation of pneumoperitoneum has been described as an alternative to the open technique and to the blind Veress needle technique, but it is largely confined to gynecological procedures. We carried out this study to assess the feasibility and safety of the direct trocar insertion technique in patients undergoing elective laparoscopic procedures performed by a single surgeon.
Methods: From November 2003 to February 2006, 98 consecutive patients were studied retrospectively. All patients (26 men, 72 women) were operated on with direct trocar insertion. The mean age was 53 (range, 23 to 82). Ninety-two patients underwent laparoscopic cholecystectomy, 4 laparoscopic hernia repair, 1 laparoscopic appendicectomy, and 1 Nissen fundoplication.
Results: Direct trocar insertion was feasible in 97.9% of cases, and in 2 cases conversion to the open technique was necessary. Most of the operations (54.5%) were performed in less than 30 minutes, and most patients (72.5%) spent less than 3 days in the hospital.Three major complications were observed; 2 patients had a leak from the common bile duct and one developed obstructive jaundice, but none of them were related to the abdominal access technique. One patient developed infection at the umbilical port site. At a mean follow-up of 16 months (range, 3 to 36), only one incisional hernia from the umbilical port site has been observed.
Conclusion: The results of this study point out that direct insertion of disposable trocars is a safe alternative to the Veress needle insertion technique for the creation of pneumoperitoneum.
6304 General Surgery
Laparoscopic Near Total Gastrectomy for Severe Gastroparesis
Timothy M. Geiger, MD, Ziad T. Awad, MD, James Steven Scott, MD
Introduction: Gastroparesis can be a debilitating condition presenting with symptoms including abdominal pain, nausea, and vomiting. Some patients fail medical management, and surgical options have to be considered.
Method: A 24-year-old male presented for recurrent abdominal pain, nausea and vomiting with a 4-year history of severe gastroparesis, caused by diabetes mellitus and a previous Campylobacter infection. The patient had failed medical therapy and previous surgical interventions, including a gastric pacemaker. The decision was made to perform a near total gastrectomy and Roux-en-Y gastrojejunostomy. The Roux limb was created by transecting the jejunum at a distance about 50cm from the ligament of Treitz, and anastomosing it to a 70-cm intestinal limb. The gastrojejunal anastomosis was created with an EEA stapler with the anvil introduced transgastric. The stomach was mobilized on both the greater curvature and lesser curvature, freeing it from its attachments, and was removed.
Result: The operative time was 173 minutes; blood loss was 25cc. The patient was discharged home on the fourth postoperative day, tolerating oral intake without nausea or vomiting.
Conclusion: Gastroparesis is a challenging problem. Gastric resection may be beneficial in some patients who have failed nonoperative therapy and continue to have symptoms.
6305 Gynecology
Is Sentinel Node Biopsy Feasible in Endometrial Cancer? Results in 26
Patients
Anne-Sophie Bats, Denys Clément, MD, Florence Larousserie, MD, Marie-Aude Lefrère-Belda, MD, Marc Faraggi, MD, Marc Froissart, MD, Fabrice Lécuru, MD
Objectives: We evaluated the detection rate, topography, and false negatives of sentinel lymph nodes in endometrial cancer.
Methods: Twenty-six patients were included. Lymphoscintigraphy was performed the day before surgery. Preoperative detection of the sentinel lymph node was performed with cervical blue dye injection and a gamma probe. Separate pathology examinations were performed for sentinel and nonsentinel lymph nodes. Sentinel lymph nodes were examined with hematoxylin-eosin-safran stain, and immunohistochemistry if negative.
Results: Twenty-six patients had a positive lymphoscintigraphy. Preoperative detection was successful in 21 patients (80.8%): the detection rate with the isotopic method, 19 cases (73.1%), was superior to the dye detection, 15 cases (57.7%). No isolated lombo-aortic sentinel lymph nodes were observed, and all sentinel lymph nodes were in the ilio-obturator region. Seven patients had lymphatic spread, and 4 of them had at least one sentinel node. There was one micrometastasis in a sentinel node, associated with isolated tumoral cells in pelvic lymphadenectomy. There was no false-negative sentinel node.
Conclusion: The biopsy of sentinel lymph node is a feasible procedure in endometrial cancer. There was one micrometastatic sentinel node. However, there was no isolated lombo-aortic sentinel lymph node in this study.
6306 Gynecology
Interest in Sentinel Node Biopsy in Early Cervical Cancer
Anne-Sophie Bats, Denys Clément, MD, Florence Larousserie, MD, Marie-Aude Lefrère-Belda, MD, Marc Faraggi, MD, Marc Froissart, MD, Fabrice Lécuru, MD
Objectives: We evaluated the detection rate, the topography, and false-negatives of sentinel lymph nodes in cervical cancer.
Methods: Twenty-five patients with early stage cervical cancer were included. The day before surgery, 120 MBq of colloidal rhenium sulfur labeled with technicium-99m was injected into the cervix. A lymphoscintigraphy was performed the morning of surgery, and perioperative detection was realized with a blue dye injection and a gamma probe. Sentinel and nonsentinel lymph nodes were analyzed separately. Sentinel lymph nodes were examined with a Hematoxylin-Eosin coloration (2 levels), and with immunohistochemistry if negative (1 level/250µ).
6307 Urology
Comparison of Transfer of Skills in Performing Hand-Assisted Transperitoneal and Retroperitoneal Laparoscopic Procedures from Teaching Staff to Residents in a Residency Training Program
Frank A. Casey, MD, Robert Fontane, MD, C. Sloan Teeple, MD, Jeremy Carrico, MD, Murali K. Ankem
Introduction: Retroperitoneal approach for urologic laparoscopic procedures is perceived as difficult to learn and teach. The transfer of retroperitoneal laparoscopic skills to residents is not well studied or reported. We compared the transfer of skills to residents from a trained laparoscopic surgeon in hand-assisted transperitoneal and retroperitoneal laparoscopic procedures.
Methods: We performed a retrospective chart review of all the laparoscopic procedures performed in an academic year (7/1/04 through 6/30/05) at 2 teaching facilities. All procedures were performed by 2 chief residents under the guidance of a trained laparoscopic surgeon. Reviewed parameters include age, side of pathology, BMI, operative time, estimated blood loss, time to first oral intake, length of stay, conversion rate, and complications.
Results: A total of 33 laparoscopic procedures were performed, the average patient age was 60 years (range, 12 to 69). There were 21 right- and 12 left-sided lesions. The mean BMI for all patients was 28.3 (range, 19.4 to 42.1). There were 17 retroperitoneal (12 radical nephrectomies, 3 simple nephrectomies, 2 adrenalectomies) and 16 hand-assisted transperitoneal procedures (9 simple nephrectomies, 7 radical nephrectomies). Three cases were converted to open (1 hand-assist and 2 retroperitoneal). Three major complications (bleeding secondary to lumbar vein injury in a hand-assisted case and 2 retroperitoneal procedures had bleeding secondary to gonadal vein injury). There were no deaths. At the end of the academic year, both chief residents were proficient in performing both approaches.
Conclusion: Retroperitoneal laparoscopic skills can be transferred to residents in training with the same ease as the hand-assisted techniques with similar operative times and complication rates.
Parameter Retroperitoneal Hand-Assisted Transperitoneal
Number of cases 17 16
Operative time 199 minutes (120-260) 211 minutes (120-300)
Estimated blood loss 187 cc (20-1000) 140 cc (50-400)
Time to first oral intake 1 days (0-3) 1 days (0-3)
Length of stay 2.7 days (1-6) 3.2 days (3-10)
Conversion rate 2 1
Major complication 2 (gonadal vein injury) 1 (lumbar vein injury)
6308 Pediatric Surgery
New Laparoscopic Flip Flap Technique Versus Conventional Inguinal Hernia Repair in Children. Is It Worth It?
Mohamed Ibrahim Hassan, MD, A. R. Mustafawi, MD
Introduction: Inguinal hernia repair is one of the most frequently performed pediatric surgical operations. Due to widespread use of laparoscopy in surgery, pediatric laparoscopic inguinal hernia repairs were introduced. Still debate is unresolved regarding the feasibility of laparoscopy for treating pediatric inguinal hernia.
Methods: A retrospective cohort study was done enrolling 33 patients who underwent congenital inguinal hernia repair from July 2004 to October 2004 by either the new laparoscopic flip flap technique or conventional open repair. Patients were divided into 2 groups according to the type of surgery; Group A underwent the new laparoscopic technique, and group B underwent conventional open repair.
Results: Group A included 15 patients (mean age, 39 months) and group B 18 patient (mean age 44, months). Mean operative time for Group A was 47.5 minutes, while in Group B mean operative time was 27.5 minutes. In group A, intraoperative complications included 1 case (7%) of vas deference injuries, and in 3 cases (20%) the flaps were torn during suturing, while in Group B no intraoperative complications occurred. In both groups, the mean postoperative hospital stay was 5.5 hours. Postoperative follow-up for 3 months revealed recurrence in 4 cases in Group A (27%), but no recurrences existed in Group B.
Conclusion: Our preliminary experience showed unsatisfactory outcomes with the laparoscopic flip flap hernia repair in children. In spite of advancement in the application of laparoscopy in pediatric surgery, still conventional open hernia repair is the gold standard for children.
6309 General Surgery
Laparoscopic Cholecystectomy: to Gram or Not to Gram?
C.K. Chang, MD, Rita Kwan, MD, Rockson Liu, MD, J.C. Choi, MD, P.F. Fuchshuber, MD, PhD, Samuel Liu, MD
Background: We evaluated practice patterns among general surgeons on laparoscopic intraoperative cholangiograms (IOC) in an HMO setting.
Methods: A retrospective survey was sent to all Kaiser Permanente general surgeons in the United States. The online survey was analyzed using SPSS 11.5 (Chicago, IL).
Results: During the 2-week survey, 116 responses were completed. Only 3.0% of the surgeons performed routine IOC, while the remaining surgeons (97%) performed selective IOC. Over 51% of the surgeons had greater than 10 years of clinical experience. The majority of surgeons performed between 4 to 6 laparoscopic cholecystectomies (LC) a month (54.3%) with only 21 surgeons (18.1%) performing more than 10 LC per month. The practice patterns were changed in 65% of the surveys since surgical training. The most cited reasons for performing an IOC were elevated liver function test (73.3%), dilated common bile duct (CBD)/hepatic ducts (70.2%), CBD stone on ultrasound (62.9%), and gallstone pancreatitis (60.3%).
Conclusion: The majority of surgeons use IOC selectively. The use of ERCP either pre- or postoperatively has greatly diminished the need to identify CBD stones during LC. With improving technologies, such as MRCP, endoscopic ultrasound, and laparoscopic ultrasound, surgeons in the future will again change their practice patterns.
6310 General Surgery
Abdominal Pathology Unrecognized During Laparoscopic Cholecystectomy: Intraoperative Pitfalls or Need for a Thorough Preoperative Workup? Concern Remains
Konstantinos Tsalis, Konstantinos Blouhos, Theodore Tsachalis, Konstantinos Vasiliadis, N. Sapidis, Dimitrios Betsis.
Background: The wide acceptance of laparoscopic cholecystectomy (LC) has resulted in increased rates of cholecystectomy. However, the increased rate of LC bears the possibility of concomitantly missing other intraabdominal pathologic states that exist concurrently with this procedure. The aim of our study was to present our experience with regard to missed pathologies in other organs not diagnosed preoperatively and undiscovered during LC.
Methods: This study involved a retrospective analysis of 8 patients hospitalized in our department in the last 3 years. In all of them, laparoscopic cholecystectomy for symptomatic lithiasis had been performed between 1 and 9 months earlier.
Results: Missed pathology of other organs was diagnosed in 5 men and 3 women, age 49 to 76 years. There were 3 cases of colorectal cancer, 1 case of gastric cancer, 1 case of Klatskin tumor, 1 case of intrahepatic cholangiocarcinoma, 1 case of intrahepatic lithiasis, and 1 case of pancreatic cancer. According to retrospective analysis of the symptoms, none of the patients had typical biliary pain at the time of laparoscopic procedure.
Conclusion: The demand for LC from patients and practitioners is becoming increasingly more frequent, as all become aware of its benefits. However, on the basis of data from the literature and our study, we would like to emphasize the need for careful history taking, thorough investigation, and comparison with gallstone symptoms before LC is performed. It is emphasized, however, that surgeons using laparoscopic approaches should learn techniques of full diagnostic laparoscopy, which should be performed at the beginning of every procedure.
6311 General SurgeryI
Bloodless Laparoscopic Hepatectomy Using Radiofrequency: An Experimental Study
Konstantinos Tsalis, Konstantinos Blouhos, Stavros Kalfadis, Konstantinos Vasiliadis, Theodor Tsachalis, Dimitrios Betsis
Objective: The aim of this study was to assess the feasibility and safety of laparoscopic hepatectomy using radiofrequency in a porcine model.
Methods: Fifteen female pigs weighing more than 25 kg were used. Five trocars were used (three 10mm and two 5mm) for the introduction of the video camera and the other laparoscopic instruments. With the porta hepatis not clamped, the liver was inspected and the preferred lobe each time was divided using radiofrequency (cool-tip electrode 3cm) with minimum bleeding. We performed 2 left lateral hepatectomies, 2 right lateral hepatectomies, 2 left hepatectomies, 2 right hepatectomies, 2 left medial hepatectomies, 2 right medial hepatectomies, and 3 wedge resections of the liver. Serum liver enzymes and blood counts were drawn pre- and postoperatively. All animals were killed after one week.
Results: The mean time of the procedures was 119 minutes (range, 100 to 155). No intraoperative complications occurred. Mean blood loss was 27 mL (range 5 to 60), and the mass of the resected specimen was 132.5 g (range, 65 to 305). No postoperative complications or deaths occurred.
Conclusion: Bloodless laparoscopic hepatectomies were technically feasible and safe in the porcine model using a cool-tip electrode and 500kHz radiofrequency generator.
6312 Other
Comparison of Four Energy-Based Vascular Sealing and Cutting Instruments: A Porcine Model
Benjamin Person, David A. Vivas, Dan Ruiz, Michael Talcott, Steven D. Wexner
Objective: We compared the efficacy and safety of 4 commercially available energy-based vascular sealing and cutting instruments.
Methods: Blood vessels of various types (arteries/veins, peripheral/visceral) and diameters were harvested from 4 anesthetized pigs by using 4 instruments: Harmonic ACE Scalpel, LigaSure V (5mm), Atlas (10mm), and EnSeal. Vessel diameter, speed of cutting and sealing process, and bursting pressure of the sealed end of harvested vessels were compared.
Results: Mean diameter of harvested vessels was EnSeal 4.1±1.5, LigaSure V 3.8±1.6, Harmonic ACE 3.3±1.0, LigaSure Atlas 4.8±0.6mm. The only statistically significant difference was LigaSure Atlas vs. Harmonic ACE (P=0.0006); mean speed of sealing and cutting process was EnSeal 4.1±0.9, LigaSure V 5.2±2.1, Harmonic ACE 3.3±1.0 and LigaSure Atlas 7.9±2.2 seconds. The process was significantly shorter with EnSeal vs. LigaSure Atlas (P<0.0001), Harmonic ACE vs. Enseal (P=0.03), LigaSure V (P=0.003) vs. LigaSure Atlas (P<0.0001), LigaSure V vs. LigaSure Atlas (P=0.004). There was no significant difference in sealing and cutting speed between LigaSure V and EnSeal; mean bursting pressure of vessels harvested with EnSeal was 677.8±184.4, LigaSure V 379.5±135.1, Harmonic ACE 434.7±320.7, and LigaSure Atlas 489.2±269.9 mm Hg. These were significantly higher comparing EnSeal to LigaSure V (P<0.0001), Harmonic ACE (P=0.0015) to LigaSure Atlas (P=0.0094); there was no significant difference in bursting pressures among LigaSure V, Harmonic ACE, and LigaSure Atlas.
Conclusions: Harmonic ACE is the fastest sealing instrument and LigaSure Atlas the slowest. Bursting pressures with EnSeal are significantly higher than in the other instruments, and the seal is consistency higher demonstrated by the smaller standard deviation.
6313 General Surgery
Conversion Rate and Complications in Patients Treated by Laparoscopic Resection of the Rectal Carcinoma After Neoadjuvant Therapy for Rectal Cancer
Jan Franko, MD, PhD, Masoud Rezvani, MD, Karin L. Cole, MD, Steven G. Harper, MD, Joseph H. Nejman, MD, Steven A. Fassler, MD, D. Mark Zebley, MD
Objective: We analyzed the immediate outcome (complications, conversion, oncologic adequacy of resection) of patients with rectal cancer undergoing laparoscopic resection of the rectum and preoperative chemoradiation.
Methods: We performed a retrospective analysis of a consecutive series of laparoscopic resections for rectal cancer from 1997 through 2004 (n=60).
Results: Eight patients received preoperative chemoradiation (neoadjuvant group) for rectal cancer, and 52 patients did not (control group). Patient groups did not differ significantly in stage, age, and sex distribution. Conversion rate was higher in the neoadjuvant group, but this did not reach statistical significance (3/8, 37% vs. 7/52, 13%, P=0.12). Complication rates were similar between groups for abscess, overt leak, and intraoperative organ injury. Operative time was longer in the neoadjuvant group (170±60 vs. 228±70 min, P=0.03). Median number of resected lymph nodes was similar between groups (14.5 vs. 16.0, P=0.81).
Conclusion: Laparoscopic resection of rectal cancer in patients after neoadjuvant treatment seems to be associated with a higher conversion rate and a longer duration of surgery. This may reflect a shift from open to laparoscopic procedures for technically challenging and low-seated tumors.
6314 Multispecialty
The Challenges of Setting up a Minimally Invasive Surgery Training Center in a Developing Country
Faruq M. Badiuddin, MD, G. Pincock
Developing countries like the United Arab Emirates have traditionally relied on Western countries, such as the United States and Europe, for surgical training, accreditation, and setting standards of practice. More recently, there is a will by the authorities and the surgical community to set local practice standards for surgery and to develop a training structure locally for the continuing education and skills development of surgeons. The challenges of setting up such a facility are unique when it is necessary to work from scratch in bringing together the various components of the organization, such as identifying the needs of the local community, inspiring the authorities, overcoming the regulatory requirements, financing of the facility, establishing alliances and affiliations, acquiring faculty, the design and equipment plus establishing a curriculum to suit the local scenario. This is a presentation of the early part of the journey in setting up such a facility in Abu Dhabi, the capital of the United Arab Emirates, and how we have accepted this challenge and pieced together such a facility linked to a Center of Excellence for Minimally Invasive Surgery.
6316 Multispecialty
Reconstructive Surgery for Ureteral Endometriosis
Masaaki Andou, MD
Objective: We developed a new technique to manage stenosis or obstruction of the ureter due to deeply infiltrating endometriosis. Treatment of deeply infiltrating endometriosis and severe fibrosis is often challenging, at times requiring segmental resection of organs and reconstructive surgery.
Methods: We have experience with 3 cases, 2 of which will be presented. Case 1 presented with complete obstruction of the right lower ureter at the level of the uterine artery. Case 2 suffered from renal insufficiency due to severe bilateral stenosis. Both patients underwent segmental resection of the involved ureters and subsequent reconstruction with antireflux extravesical ureteroneocystostomy. After incising the detrusor muscle of the bladder, the bladder mucosa was exposed, with the length of the incision being 3 times that of the ureteral diameter. The caudal end of the mucosa was opened, and the caudal end of the transected ureter was anastomosed to the mucosa after
fixation with anchor suture. The detrusor muscle was reapproximated over the ureter and bladder mucosa so as to make an antireflux mechanism.
Results: The postoperative course was uneventful, and no patients experienced leakage from the anastomotic site or stenosis after implantation.
Conclusions: Ureteral endometriosis is a debilitating disease that can be managed efficiently and effectively with this technique. Although demanding, mastering precise suturing techniques inside the body is vital for creating leak-free, stenosis-free, and antireflux anastomosis. Our laparoscopic extravesical ureteral reimplant is safe and feasible with the patient-friendly advantage of being minimally invasive.
6317 General Surgery
Stab Anterior Preperitoneal Hernioplasty in Groin Hernias: A New Technique
Prof. Rajeev Sinha
Background: With laparoscopic hernia repair still not qualifying as the ideal method, the search is still on for the optimal method of intervention combining the advantages of both open mesh repair and laparoscopic repair for groin hernias.
Methods: The modified anterior preperitoneal repair was used in 85 patients with uncomplicated inguinal hernia classified as Nyhus Type 2 or above. The perioperative parameters were studied and comparison with those of totally extraperitoneal repair was done to see the efficacy of the modified approach.
Results: In 84 patients, 88 anterior preperitoneal repairs were carried out. Twenty-one patients were Nyhus Type 2, 17 were Type 3A (direct), 41 were Type 3B (indirect), and 9 were Type 4 (recurrent). The results were compared with TEP parameters done by the same surgeon. The incision size was 2.8cm (range, 2.3 to 4.5). The operating time was 15.7 minutes (range, 11 to 26) compared with 31.2 minutes for the TEP repair. Discharge time was 2.3 days (range, 2 to 4) compared with 2.2 days for TEP. Complications included seroma in 8 patients and pain radiating to the scrotum even at 6 months in 1 patient, and superficial wound infection in 1 patient. Return to work in patients with stab APP was 12.6 days (range, 7 to 15), while it was 10.4 days in TEP repair.
Conclusion: The results with stab anterior preperitoneal repair were comparable to those with TEP repair. The stab APP in addition had the advantage of being easier to learn and can be done faster.
6318 General Surgery
Laparoscopic Totally Extraperitoneal Repair
Prof. Rajeev Sinha
Background: Laparoscopic inguinal hernia repair is still not the gold standard for repair although mesh implantation is unequivocally accepted as an integral part of any groin hernia repair. The aim of this study was to compare the results of anterior preperitoneal mesh repair (APP) with totally extraperitoneal repair (TEP) for inguinal hernias.
Methods: The prospective study was conducted on 241 patients with 247 hernias (from January 2000 to June 2004). Anterior preperitoneal repair was done in 121 patients and 120 patients underwent TEP repair. Repair in both groups was done by using Prolene mesh size 6x4 inches or 6x6 inches. Intraoperative and postoperative parameters and complications were recorded, and the patients were followed up for 1-year after surgery.
Results: For both unilateral and bilateral inguinal hernias, mean operative time was significantly more in patients with TEP repair compared with those with APP repair (P<0.001), and significantly more patients had peritoneal tears in the TEP group (P<0.001). Patients undergoing TEP repair however had significantly less postoperative pain (P<0.05), postoperative hospital stay was shorter (P<0.05), and return to work was significantly earlier is this group (P<0.01 and P<0.001). There was no difference in the recurrence rate between the 2 groups.
Conclusion: Patients with inguinal hernias undergoing laparoscopic repair recover more rapidly and have less incidence of postoperative pain. But it takes significantly more time to perform than APP repair and also the incidence of peritoneal tear is higher.
6319 Gynecology
Comparative Study of Surgical Techniques and Results on TVT Versus TVT-O by the Same Surgeon
Radha Syed, MD
Objectives: We sought to prove that TVT-O is a simpler and more efficient procedure with shorter duration to complete and shorter learning curve while being as equally efficacious as TVT.
Methods: We retrospectively analyzed the clinical data of 15 cases of TVT (Group I) and 15 cases of TVT-O (Group II) in patients presenting with a chief complaint of stress urinary incontinence in the period between January 2004 and April 2006. We assessed the ease of surgical techniques, operating time, perioperative blood loss, complications (short-term and delayed), hospital stay, return to work, and spontaneous voiding. This assessment was performed during clinical encounter.
Results: The mean operating time was 30 minutes for Group I (for TVT alone), ranging from 18 minutes to 50 minutes versus 15 minutes (for TVT-O alone), ranging from 12 minutes to 20 minutes. The intraoperative blood loss, and hospital stay were similar for both procedures. The most common complication for TVT was bladder injury, bleeding, and urinary tract infection. Delayed complication was urinary retention requiring intervention and mesh erosion. In one TVT patient, there was injury to the obturator vein. In TVT-O, there were no cases of bladder injury, bleeding, or UTI, but there were 2 cases of mesh exposure within 2 weeks of surgery. This complication did not occur again after the surgical technique was modified. In both procedures, the cure rates, recovery time, and return to work were similar, and there were low rates of de novo urinary urgency.
Conclusion: Both TVT and TVT-O procedures are highly efficacious for genuine stress urinary incontinence, although TVT is a better procedure for ISD (intrinsic sphincteric defect). However, TVT-O exhibits fewer complications, both immediate and late, shorter duration of surgery, and quicker recovery rates. The learning curve is also much shorter. Prospective comparative trials with long-term follow-up are necessary to confirm these findings.
6320 Gynecology
A New Autofluorescence-Based Endoscopic System for the Detection of Endometriosis
Steven F. Palter
Background: Laparoscopy remains the gold standard for diagnosis of endometriosis but is limited by the ability of the surgeon to diagnose lesions that may be easily missed. Illumination of certain tissues with specific light wavelengths results in autofluorescence of the tissue. By using a combination of illumination and observation filters, specific tissue autofluorescence can be seen. The spectral analysis laparoscopy (SAL) system allows the visualization of tiny amounts of such autofluorescence.
Methods: Women with infertility or chronic pelvic pain undergoing diagnostic laparoscopy for suspected endometriosis underwent systematic evaluation with traditional and autofluorescent laparoscopy systems.
Results: When certain compounds are excited by absorption of light energy from short wavelength (380nm to 430nm) light, the absorbed energy is emitted as light at a longer wavelength (475nm to 800nm) and is observed as fluorescent light. The transmission of the fluorescent light can be observed using special optical filters designed to block the excitation and background light and allow the fluorescent light to be viewed. A specially designed laparoscopy system was developed based on this principle. Suspected lesions were biopsied for confirmation of pathology.
Conclusion: The use of the autofluorescent SAL laparoscopy system allowed the identification of subtle lesions of early stage endometriosis that would otherwise have been missed by traditional white light laparoscopy.
6321 Gynecology
A New Autofluorescence-Based Endoscopic System for the Detection of Surface Pathology Including Endometriosis
Steven F. Palter
Laparoscopy remains the gold standard for diagnosis of endometriosis but is limited by the ability of the surgeon to diagnose lesions that may be easily missed. Illumination of certain tissues with specific light wavelengths results in autofluorescence of the tissue. By using a combination of illumination and observation filters, specific tissue autofluorescence can be seen. The spectral analysis laparoscopy (SAL) system allows the visualization of tiny amounts of such autofluorescence. This video demonstrates the principles behind this system and its use in the detection of surface pathology including endometriosis. When certain compounds are excited by absorption of light energy from short wavelength (380nm to 430nm) light, the absorbed energy is emitted as light at a longer wavelength (475nm to 800nm) and is observed as fluorescent light. The transmission of the fluorescent light can be observed using special optical filters designed to block the excitation and background light and allow the fluorescent light to be viewed. In some cases, the lateral margin of endometriotic implants was seen to extend further using the system allowing a larger more complete excision. We also observed a novel type of small vesicular implant with intense yellow-green autofluorescence. These were also histologically confirmed to be endometriosis or endosalpingiosis and are demonstrated for the first time. The use of the autofluorescent SAL system allows increased identification of subtle lesions of pathology in many body cavities. Early stage lesions of endometriosis that would otherwise have been missed by traditional white light laparoscopy can be seen.
6322 Other
Laparoscopic Small Bowel Anastomosis
Nestor de la Cruz-Munoz, MD, Juan Carlos Cabrera, MD, Luz Velez, MD, Cristina Torres, MD
This is an unedited video of a jejunojejunostomy with bidirectional stapling during a laparoscopic gastric bypass. There are reports in the literature discussing complication rates of 0.5% to 2% after small bowel anastomoses performed laparoscopically. Most of these complications are from obstruction of one of the bowel limbs. We have been using a bidirectional firing technique for the small bowel anastomosis in over 1300 laparoscopic gastric bypasses with 2 complications (one leak and one obstruction with intraluminal clot) for a complication rate of 0.15 % at that anastomosis. Technical points in performing this anastomosis include making the enterotomy on the blind limb side approximately 3cm to 4cm from the end to allow for the proximal staple firing. The proximal firing MUST overlap the distal (first) firing, or there will be a gap on the posterior wall of the anastomosis. This is confirmed after completion of the anastomosis by inspecting it closely, circumferentially. The closure of the enterotomy site is to be performed transversely, as done in the open technique. Closure of the mesenteric defect must be performed with a permanent running suture to prevent internal hernias. These can occur more commonly than in colon surgery because there are few raw tissue edges for natural adhesion formation. Bidirectional stapling can reduce the number of bowel obstructions due to iatrogenic stenosis of the limbs while performing the anastomosis. It can also prevent the "kinking" of the bowel as described elsewhere.
6323 Other
Circumferential Suturing of a Gastrojejunal Anastomosis
Juan Carlos Cabrera, MD, Luz Velez, MD, CristinaTorres, MD, Nestor de la Cruz- Munoz, MD
Laparoscopic gastrojejunal anastomosis for gastric bypass has had a leak rate of 0.5% to 5.4%. Leaks can occur immediately or 5 days to 6 days later due to ischemia. We have performed gastrojejunal anastomosis using circumferential suturing over a stapled anastomosis in over 1000 patients with 1 leak from that anastomosis. Herein, we present the video of that technique. We first approximate the 2 pieces of bowel with one firing of a linear stapler. This comprises about two thirds of the circumference of the anastomosis. We then pass an oral-gastric tube through the opening to prevent closing the lumen of the anastomosis. At this point, we close the defect by hand. The circumferential suturing is accomplished by flipping the anastomosis 180 degrees with the help of the first assistant. The suture is then begun on the posterior wall. The anastomosis is slowly rotated around as the suture is advanced circumferentially as a running Lembert stitch. The Suture is tied to the original tail. This allows inversion of viable tissue into the anastomosis, giving it further strength and helping decrease the risk of an ischemic leak. This technique can be used for all types of intracorporeal bowel anastomosis. It can be used in colon surgery as well, to reduce postoperative leaks and abscess formation.
6324 General Surgery
Internal Hernias after Laparoscopic Surgery
Nestor de la Cruz-Munoz, MD, Luz Velez, MD, Cristina Torres, MD
Objective: It has been shown that laparoscopic surgery has significantly reduced adhesions compared with open surgery. This has become even more evident with the proliferation of laparoscopic bariatric surgery. In 2003, the risk of internal hernias after gastric bypass was first being recognized. We present a retrospective series of 1235 consecutive laparoscopic gastric bypasses done by one surgeon from January 2002 until January 2006.
Methods: From October 2002 until November 2003, 352 bypasses were performed without closure of any hernia defects (Group A). From November 2003 until 2006, 883 bypasses were performed with closure of the jejunal mesenteric defect with permanent running suture (Group B). We then compared the rates of symptomatic internal hernias in these 2 groups.
Results: Group A developed 32 internal hernias at the jejunal anastomotic mesenteric defect (9%) and 6 at Peterson’s defect (2%). Of those, 17% presented acutely with pain or bowel obstruction. The others presented with chronic postprandial pain. Group B has developed 0 hernias at the mesenteric defect (0%) and 1 at Peterson’s defect (0.1%).
Conclusion: Closure of mesenteric defects after gastric bypass significantly decreases internal hernia formation and should be performed with a permanent, running suture. Also, clinicians need to be vigilant for symptoms of internal hernias after laparoscopic surgery to avoid waiting until the development of bowel obstruction with its risks of infarction.
6325 General Surgery
Laparoscopic Roux-en-Y Gastric Bypass in the Golden Years: Is it Feasible?
Kanayochukwu J. Aluka, MD, Dilip Dan, MD, Michael L. Green, MD, Cynthia Long, MD, Marc S. Rickford, MD, Stephen J. McKenna, MD, Patricia L. Turner, MD, Denia Tapscott, MD, Kenneth R. Foxx, MD, David Muguku, MS, Terrence M. Fullum, MD
Objective: Laparoscopic Roux-en-Y gastric bypass surgery is safe for National Institutes of Health eligible morbidly obese patients over the age of 59.
Method: A retrospective analysis of laparoscopic Roux-en-Y gastric bypass surgery from July 2001 to January 2006 resulted in a total of 40 patients (>59). Age, body mass index, American Society of Anesthesiologists physical status classification, length of stay, morbidities, mortalities, and improvements of comorbidities were obtained.
Results: There were 33 (82.5%) females and 7 (17.1%) males. The average age was 64.2 years (range, 60 to 72). The average body mass index was 49.2 kg/m2 (range, 37 to 67 kg/m2). American Society of Anesthesiology classification of 3 was given to 37 patients, 2 to 2 patients, and 4 to 1 patient. There was a 10% perioperative complication rate. Two patients had upper gastrointestinal bleeding requiring endoscopic intervention. Two patients had an extended length of stay of 9 and 6 days secondary to respiratory distress and volume overload, respectively. There was zero perioperative mortality. Improvements in comorbidities included the following: 60.9% (14 of 23) for Type II diabetes, 54.5% (6 of 11) for hyperlipidemia, 50% (2 of 4) for obstructive sleep apnea, 46% (13 of 28) for hypertension, 44% (8 of 18) for gastroesophageal reflux disease, and 34.8% (8 of 23) for osteoarthritis.
Conclusion: Laparoscopic Roux-en-Y gastric bypass surgery is a feasible method of surgical weight loss in patients over the age of 59 with acceptable perioperative morbidity and mortality.
6326 Gynecology
Laparoscopic Procedure for Removal of a “Lost” Intrauterine Device
P. Saccucci, MD, R. Marino, MD, C. Guida, MD, F. Signore, MD
We report the case of an IUD removed by a proper laparoscopic procedure after getting lost within the mesocolic thickness. An intraabdominal IUD was removed from a 36-year-old woman 25 days since insertion. Ultrasound examination showed a missing IUD from the uterus, but radiographs revealed the device in the abdominal cavity. The patient underwent laparoscopy for IUD removal, under general anesthesia. However, IUD direct detection failed because of the position under the bowel. The entire abdominal cavity was explored except for the mesocolic surface obstructed by the falling bowel. About 500mL of saline solution was introduced into the cavity and the bed was placed in a horizontal Trendelenburg position. The bowel begun floating and the liquid separated the colic ansa allowing mesocolon inspection. The entire surgery field was checked out for the IUD, and finally the nylon was detected on the mesocolic surface. By using grasping forceps, the string was held out, and the IUD lowest pole was released by dissection forceps. The pole was grasped and the IUD removed, keeping countertraction over the mesocolic surface. Neither bleeding nor other complications occurred. In conclusion, by considering uterine perforation as an unpredictable accident, ultrasound examination might be advisable in insertion setting. Delayed laparoscopic removal needs skillful management by trained surgeons. The procedure above reported enabled detection of the IUD, otherwise unidentifiable.
6327 Pediatric Surgery
Robotic Surgery for Neonates and Infants: A Single Institutional Review of Patients Weighing Under 10 Kilograms
John Meehan, MD, Anthony Sandler
Objective: Size has been a criticism of robotic surgery when discussing its use in the neonate or infant. We retrospectively reviewed our experience with robotic surgery in children weighing less than 10kg.
Methods: All patients underwent surgery using the 3-arm (1 camera arm, 2 instrument arms) Da Vinci Robot (Table 1). The camera was 12-mm 3-D or 5-mm 2-D; instruments were 8mm or 5mm. Five procedures were performed in the chest (20%) and 20 in the abdomen (80%). Average patient age was 7 months (1 day to 2.3 years). Average weight was 6.4kg (range, 2.3 to 10.0).
PROCEDURES Number % Conversions
Fundoplication 14 56.0% 0
Neuroblastoma 2 8.0% 0
Congenital Diaphragmatic Hernia (CDH) Repair (1 thoracic approach, 1 abdominal)
2 8.0% 1
Congenital Cystic Adenomatoid Malformation (CCAM)
2 8.0% 1
Kasai Portoenterostomy 2 8.0% 0
Duodenal Atresia 1 4.0% 0
Intralobar Sequestration 1 4.0% 0
Bronchogenic Cyst 1 4.0% 0
Total 25 100% 2 (8%)
Results: Twenty-three patients (92%) were completed robotically. The smallest child (2.3kg, 6 days old) had a CDH repaired from the abdomen. The youngest (2.4kg, 1 day old) had duodenal atresia. Two patients (a CDH attempted from the chest and a CCAM) were not completed robotically. The thoracic approach CDH converted to thoracoscopic due to a lack of chest domain and the CCAM was opened because of difficulty identifying the anatomy. Eight-mm instruments were used in 5 patients (20%), and 5-mm instruments in 20 (80%). The 12-mm camera was used in 4 patients (16%), and the 5-mm in 21 (84%).
Conclusion: Robotic surgery can be safely accomplished in small children, particularly neonates and infants. The intrathoracic domain of some neonates may still be a limiting factor. Further studies are required to determine the potential boundaries of robotic surgery for infants and neonates.
6328 Pediatric Surgery
Robotic Ladd’s Procedure
John J. Meehan, MD, Anthony Sadler, MD
Robotic surgery is a new technology that may allow surgeons to perform complex minimally invasive procedures that were too difficult with standard laparoscopic instruments. The potential uses in pediatric surgery are not yet defined. We present a video demonstration of an elective robotic Ladd's procedure in a 12-year-old girl with nonobstructing malrotation. She presented with a 2-year history of mild chronic abdominal pain. An upper GI showed malrotation with an area of mild partial obstruction of the proximal jejunum but with no evidence of volvulus. The procedure was accomplished using the 3-arm version of the standard da Vinci Surgical Robot; one 12-mm robotic camera port, and two 5-mm robotic instrument arm ports. An additional 10-mm nonrobotic accessory port was used by the bedside assistant for a total of 4 ports. The procedure was accomplished in under 2 hours, and the patient had no complications. She was started on an oral diet the evening of surgery and went home on postoperative day 1.
6329 General Surgery
Caesarean Section Scar Endometriosis
Mamoun Nabri, MB, BS, FRCSI, T. O' Hanrahan, BSc, MCh, FRCS, FRSCI, FRCS, (Gen. Surg.), Clive Killgallen, MB, FRCPI, FRCPath
Background: We present the case of a lady who presented with a painful lump at the right edge of a Caesarean section scar. A local surgical excision was undertaken and histology confirmed endometriosis. Incisional endometriosis is a described clinical entity in the gynecological literature, but it is not well recognized among general surgeons. Only 32 cases have been reported in the general surgery literature. The preoperative diagnosis is often mistaken for suture granuloma, lipoma, abscess, cyst, or incisional hernia.
Methods: A 42-year-old woman presented with a 6-month history of a painful lump in the right lower abdomen at the outer edge of a caesarean section scar. The pain was exacerbated during menstruation. Incision and drainage of a hematoma had been done previously at the same site. The patient had 2 caesarean sections, with the last one done 18 months before this presentation, and a history of laparoscopic cholecystectomy and appendectomy.
Results: Examination revealed 2 tender nodules bluish in color between 2 cm and 3 cm at the right lateral part of a Pfannenstiel scar. No cough impulse was present, and the rest of the abdominal examination was normal. Abdominal and pelvic ultrasounds were negative. FNAC revealed inflammatory cells. Wide local surgical excision was done and the wound healed well. The histology report described endometriosis.
Conclusion: Scar endometrioma can mimic many surgical conditions. All surgeons should be aware of the presentations of endometrioma in any woman of reproductive age with an abdominal scar lump, which is painful around menstruation. Wide local excision is still the best treatment.
6330 General Surgery
Isolated Organ Failure Following Bariatric Surgery
C.L. McBride, W. Grant, C. Ringley, D. Oleynikov
Introduction: Unfortunately, bariatric surgery (BS) has rare complications that can lead to isolated organ failure. Our goal was to review these cases and develop preventative strategies.
Methods: Our prospectively collected bariatric and transplantation databases were queried for long-term complications of BS. Charts were reviewed for demographics, conditions leading to OF, and the medical and surgical treatment. Patients with OF from leak/sepsis and with pre-existing OF were excluded.
Results: Fifteen patients had OF following BS. BS consisted of 2 jejunal ileal bypasses (JIB), 10 gastric bypasses (GB), 1 duodenal switch, and 2 revisions. Nine had short bowel syndrome (SBS), 2 had SBS and then liver failure (LF) from TPN, 2 had isolated LF, 1 had LF and kidney failure (KF). One additional patient had reversal of her surgery for impending KF. The SBS was the result of multiple operations for SBO in 2, mesenteric venous thromosis (MVT) in 4, and internal herniation (IH) in 5. Isolated LF was from injury to the portal triad during GB in 1 and from idiopathic cases in the other. The patient with LF and KF had a JIB. Of the 11 SBS patients, one has had small bowel transplantation, 5 are not transplant candidates and remain on TPN, 3 underwent intestinal rehabilitation and are off TPN, and 1 has died of metabolic problems. Of the 4 with LF, 1 is currently UNOS Status 1 for a small bowel/liver, one has received a liver and is on dialysis, and the other 2 died of LF.
Conclusion: As we attempt to prevent this catastrophe, we will discuss preventative strategies.
6331 Pediatric Surgery
PediatricRoboticSurgeons.com: An Educational Website on Robotic Surgery
Ingrid Lizzaraga, MD, John Meehan, MD
Robotic surgery is in its infancy, particularly in children. With the rapidly changing technology, keeping up to date with traditional hard copy information like texts and even peer-reviewed journals seems fruitless because new procedures are accomplished on a weekly basis. To help surgeons stay up to date, we constructed a user-friendly Website (www.PediatricRoboticSurgeons.com) designed to help pediatric surgeons understand the problems and issues concerning robotic surgery in children. Although the Website was constructed mainly for pediatric surgeons, anyone is welcome to view all pages. In addition to the introductory page, links page, and list of surgeons page, a procedures page with nearly 20 narrated videos of basic, moderate, and complex pediatric cases is available for downloading Windows Media videos. Each individual case has been summarized in a 3-minute to 5-minute video that includes patient history, relevant studies, trocar location, robot cart placement, video details of the procedure, and patient outcome. Medical posters that have already been presented at national meetings can be downloaded from a separate page. In the first year of operation, the Website has been viewed by 936 unique visitors, viewing over 4013 pages with over 4.6GB of movie files downloaded. E-mail comments from visitors have been overwhelmingly positive and have come from pediatric surgeons from around the world.
6332 Other
Laparoscopic Gastric Bypass: A Technique for the Community Surgeon
George Woodman, MD, Guy Voeller, MD
The development of bariatric programs for the treatment of morbid obesity is becoming commonplace in most communities today. Many hospital administrations want a bariatric program and purchase turnkey startups for the surgical treatment of this disease. However, finding surgeons who are adept at advanced laparoscopic techniques can be difficult, and many community-based surgeons are intimidated by the procedure, the perioperative care that goes along with this difficult patient population, and the potential for litigation. The technical aspects of laparoscopic gastric bypass surgery can be daunting. The community-based surgeon, however, can reproduce our technique, without access to university resources. This video illustrates our safe and efficient technique for the laparoscopic gastric bypass utilizing a short limb Roux-en-Y placed in an antecolic fashion. The procedure requires a surgeon with advanced laparoscopic skills, an experienced first assistant, an experienced scrub technician, and reliable instrumentation. Our average operating time for this technique is 81 minutes and average hospital stay is 2.8 days. Surgery can be a safe and effective option for treating the epidemic problem of obesity, and it can be accomplished reliably by the community-based surgeon.
6333 Gynecology
A Case of Leiomyomatosis Peritonealis Disseminata
Alfonso Rossetti, MD, Ornella Sizzi, MD, Diana Castagnola, MD, Rocco Spagnuolo, MD, Giuseppe Florio, MD
A 30-year-old nulliparous patient was referred to our division for rapid abdominal swelling in the absence of other pelvic symptoms. Gynecologic examination revealed the presence of an abdominal mass occupying the left quadrant from the pouch of Douglas to the spleen. Cancer markers were negative. Sonographic and RMN findings showed a nonspecific solid, complex soft tissue mass with intralesional vegetations. A diagnostic laparoscopy was scheduled. A mass arising from the uterus developed into the left abdominal cavity. The mass resembled a very large myoma and had a smooth surface without vegetations. On the uterine surface and on the anterior abdominal wall, irregular vegetations with an appearance of vesicles were present. A peritoneal washing and multiple biopsies were performed. Histological examination failed to make a correct diagnosis although orienting toward a possible leiomyomatosis peritonealis disseminata (LPD) with high invasive potentiality while lacking necrosis and atypias. Given the age of the patient and her desire for maintaining the uterus, a conservative intervention was planned. At laparotomy, the pelvic mass turned out to be the left tube completely invaded by hundreds of irregular vesicles. The irregular vegetations on the uterine surface continued with a fibromatous nodule of the uterine fundus that did not have any cleavage plane. Left salpingectomy, nodulectomy, and removal of peritoneal implants were performed. Histological examination confirmed leiomyomatosis peritonealis disseminata with high invasive potentiality. Negative immunohistochemical (IHC) staining for p53 protein was found. When a hormonal stimulus is identified, some advise a conservative approach without extensive surgery. Despite this fact, many patients with LPD have been treated with surgical debulking combined with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Cases of LPD without exogenous or increased endogenous estrogen exposure without uterine leiomyomas, and without ER and PR expression in the nodules may represent a different entity and should be regarded as cases with a high malignant potential. Those patients may need a more aggressive approach with extensive surgery.
6334 Multispecialty
Surgical Sterilization of Women of Fertile Age by Laparoscopic Cholecystectomy
Khusen B. Narzullaev, MD, PhD, Jamshed A. Akhtamov, MD, PhD, Bakhodir B. Negmadjanov, MD, PhD, Surat A. Azimov, MD, PhD, Fakhritdin I. Ganiev, MD
From 1996 to 2005 at the Centre of Endoscopic Surgery in Samarkand, Uzbekistan, 4235 laparoscopic cholecystectomies were performed, 1892 (44.7%) in women of fertile age. Their average age was 38.4±6.1. Patients with chronic calculous cholecystitis were examined and prepared for surgery in the outpatient department, whereas in acute stages emergency operations were carried out. Laparoscopic cholecystectomy was added to surgical sterilization in 186 women, in 25 patients with acute catarrhal cholecystitis. Indications for surgical sterilization in calculous cholecystitis were patients with 2 and more children of different sexes at home, patient’s written consent, age >30 years. Contraindications were massive adhesive or inflammatory process as well as menstruation to be present. Average stay in the inpatient department after surgery, duration of operative intervention, blood loss and rehabilitation time of laparoscopic cholecystectomy and simultaneous operations, ie, laparoscopic cholecystectomy plus surgical sterilization, were not significantly statistically differerent; however, combined performance of these operations is beneficial not only in economic terms because of the shorter hospital stay and less need for medicine but also because of the improved morale-psychological condition. Surgical sterilization during laparoscopic cholecystectomy does not require an additional incision, does not prolong surgical time significantly, does not increase blood loss or rehabilitation time, and does not increase the need for medicine either during the operation and after it.
6335 General Surgery
Demographics of Publications on Robotic Surgery with the da Vinci Surgical System
Monika Hagen, Alain Garcia, Philippe Morel
Background: Robotic surgery is a fast-growing field, and the market is leading to the
dominance of the da Vinci Surgical System. Since FDA approval and start of sales in the year 2000, more than 400 robots have been sold and many published reports can be found.
Literature Review: First publications on the clinical use of the da Vinci robot appeared in the year 2000, and only a few institutions (US/Europe) were working with this system in cardiac surgery (CS). In the following years 2001 to 2002, the number of published reports nearly doubled each year, and publications in urology and general surgery (GS) appeared. During those years, more articles in GS came from the US, whereas Europe concentrated on CS and urology. In 2003, most of the articles came from the US and mainly in GS. During the years 2004, 2005, and 2006, the number of publications remained steady with a clear dominance of the US over Europe (US more urology and CS, Europe more GS). The rest of the world did not publish many articles. Generally, more large patient groups have been reported on recently, but the number of randomized studies remains small. Only a few animal trials can be found, mainly from other fields, such as head/neck surgery or others.
Conclusion: Robotic surgery has grown into a major field of interest for surgeons,
mainly in the US (Urology and CS) and Europe (GS). More recent publications show growing quality due to larger numbers of patients treated. Still there is a need for randomized studies.
6336 Gynecology
Technique for Difficult Laparoscopic Hysterectomy
Ornella Sizzi, MD, Alfonso Rossetti, MD
Objective: We evaluated the feasibility, safety, conversion rate, and complication rate of difficult laparoscopic hysterectomy using a standardized technique adjusted to particular situations. This was a prospective study carried out at a private endoscopic center.
Methods: From May 2005 to April 2006, 212 women underwent total laparoscopic hysterectomy for uteri weighing more than 280 grams, and in presence of previous caesarean deliveries, adhesions, or endometriosis. A total laparoscopic hysterectomy was performed using some tricks: a) A higher trocar position with a supraumbilical trocar for the optics whenever necessary. A fourth 5-mm ancillary trocar was added in case of massive uteri; b) Use of the 30° laparoscope in case of anterior myomas hindering the vision of the vesico-uterine fold; c) Both surgeons and assistant operating on their own sides; d) Lateral access to the vesico-uterine space in case of thick adhesions from previous C-Sections; e) Lateral retroperitoneal access with ureter dissection in case of endometriosis of the cul-de-sac; f) Use of vessel sealing systems, especially in case of varicosities; g) Use of a reusable, user-friendly uterine manipulator that allowed a good delineation of the vaginal fornix (Mangeshikar’s uterine manipulator, K. Bissinger, Germany); h) Vaginal morcellation; i) Vaginal cuff closure both vaginally and laparoscopically for apex support.
Results: All the 212 procedures were completed laparoscopically. The mean uterine weight was 610g (mean, 320 to 1250), 45 patients had uteri >900g. The mean duration of the surgery was 145 minutes (range, 110 to 220): the time included adhesion lysis for 98 patients and endometriosis excision in 57. The average drop in hemoglobin concentration was 1.12g±0.86g/100mL (ranging from 0.7g to 2.2g/100mL). The mean postoperative hospital stay was 2.02 days ± 0.61 days. No major complications occurred. Postoperative urinary infections were the most common minor complications. Vaginal cuff bleeding rarely occurred (5%). The Mangeshikar’s uterine manipulator allowed an easy completion of the bladder dissection, colpotomy, and vaginal cuff closure.
Conclusions: Laparoscopic total hysterectomy is a safe, effective, minimally invasive approach to hysterectomy even in the presence of considered contraindications, such as very large uteri or previous C-Sections. The length of the procedure positively correlates with adhesion removal and uterine morcellation.
6337 General Surgery
Role of Antibiotic Prophylaxis in Mesh Repair of Primary Inguinal Hernias Using Prolene Hernia System: A Randomised Prospective Double-Blind Control Trial
Sudhir K. Jain, MD, P. N. Agarwal, MD
Objective: We sought to find the efficacy of single-dose, intravenous prophylactic Amoxicillin and Sulbactam (AS) in the prevention of wound infections during open repair of primary unilateral inguinal hernias using the Prolene hernia system (PHS).
Inguinal hernia repair is one of the commonest routine operations being performed throughout the world. Prosthetic hernia repair has become the gold standard, and a repair by PHS has gained popularity during the last 5 years. A recent Cochrane meta-analysis concluded that “antibiotic prophylaxis for elective hernia repair can not be firmly recommended or discarded.”
Methods: A prospective, randomized double-blind, placebo-controlled trial was performed comparing wound infection rates in 120 patients (60 received prophylactic single-dose antibiotic and 60 received a placebo) undergoing repair of primary unilateral inguinal hernia using PHS. Two groups were well matched for age, sex, ASA class, and type of hernia, type of anesthesia, and duration of operation. Infections were evaluated at 1 week, 2 weeks, and 4 weeks after operation by an independent surgeon. All complications were recorded, and statistical analysis was performed using appropriate tests.
Results: No difference was noted in the rates of wound infection in the 2 groups. Superficial wound infection occurred in 1.7% of patients in both groups.
Conclusion: Prospective administration of single-dose antibiotic for mesh repairs of primary inguinal hernias using PHS did not decrease the risk of wound infection. Our results do not support the use of antibiotic prophylaxis for mesh repairs of inguinal hernias.
6338 General Surgery
Diagnosis and Surgical Intervention for Appendicitis During Pregnancy
Kathy Gohar, MD, Patrick Lee, MD, David Seubert, MD, Toby Tally, MD
Objective: We examined the role of radiological imaging for diagnosis of appendicitis in pregnancy by performing a Pubmed/Medline review of the English-language literature.
Methods: Two hundred articles were reviewed on appendicitis and safety of diagnostic imaging during pregnancy. As part of our review, radiation dosages of various imaging studies and their safety measures were analyzed. In addition, operative results and follow-up of 6 patients who underwent appendectomy in pregnancy were reviewed.
Results: Two laparoscopic, 2 open, and 2 laparoscopic converted to open appendectomies were performed. Rate of misdiagnosis of appendicitis was documented at 50% with a 17% rate of preterm delivery. The rate of fetal loss was zero, except for one planned early termination for unrelated reasons. The complication rate between patients who underwent laparoscopic versus open appendectomy was similar. Laparoscopic appendectomy had the advantage of decreased postoperative pain, shorter hospital stay, smaller incision, quicker return of bowel activity, and less narcotic requirements with decreased fetal depression compared with that of open appendectomy.
Conclusion: A comparison between the spontaneous incidence of fetal anomalies without radiation versus risks associated with radiation exposure in utero, in addition to associated risks with surgical intervention including preterm delivery, spontaneous abortion, and maternal mortality should be discussed with the patient. With a valid medical indication, a diagnostic study using radiation can be safely performed in a pregnant patient to aid in diagnosis and to prevent unnecessary operative interventions, especially if the benefits outweigh the remote possibility of injury to the fetus or the patient.
15TH SLS ANNUAL MEETING AND ENDO EXPO 2006
SCIENTIFIC AWARD WINNERS AND HONORABLE MENTIONS
Award for Best Scientific Paper by a Resident
Ralph Madeb, MD
Conversion from Open to Robotic Assisted Radical Prostatectomy is Associated with a Reduction of Positive Surgical Margins Amongst Private Practice Based Urologists
Award for Best Multispecialty Scientific Paper
Elspeth McDougall, MD
Short Term Impact of a Laparoscopic Mini-Residency Experience on Postgraduate Urologists Practic Patterns
Award for Best General Surgery Scientific Paper
Alexander Petter-Puchner, MD
A Synthetic Cyanoacrylate Tissue Sealant Impairs Tissue Integration of Macroporous Mesh in Experimental Hernia Repair
Award for Best Gynecology Scientific Paper
Stephanos Chandakas, MD
Day Surgery Laparoscopic Subtotal Hysterectomy: A Multicentered Study with 250 Patients
Award for Best Urology Scientific Paper
David Rodin, MD
Laparoscopic Inguinal Hernia Repair During Laparoscopic Radical Prostatectomy
Award for Best Pediatric Surgery Scientific Paper
Katherine Barsness, MD
Laparoscopic Versus Open Nissen Fundoplication in Infants after Neonatal Laparotomy
Award for Best Poster in Educational Content or Innovation
1st Place
Tadashi Sakurai, MD
Autologous Skin Grafting With Bioabsorbable Stent for Widespread Endoscopic Mucosal Resection of the Esophagus
Award for Best Poster in Educational Content or Innovation
2nd Place
Parveen S. Vahora, MD
Laparoscopic Appecndectomies Performed by Gynecologists in Women With Pelvic Pain
Award for Best Poster in Educational Content or Innovation
3rd Place
Neel R. Joshi, MD
The Impact of Laparoscopic Gastric Bypass Surgery on C-Reactive Protein Levels
Award for Best Multispecialty Video
Masaaki Andou, MD
Reconstructive Surgery for Ureteral Endometriosis
Award for Best General Surgery Video
Mark Gaon, MD
Laparoscopic Thoracic Duct Ligation
Award for Best Gynecology Video
Steven Palter, MD
New Autoflourescence Based Endoscopic System for the Detection of Pathology Including Endometriosis
Award for Best Urology Video
Elspeth McDougall, MD
Tips and Tricks to Facilitate Renal Parenchymal Suturing During Laparoscopic Partial Nephrectomy
Award for Honorable Mention Multispecialty Scientific Paper
Ospan Mynbaev, MD
Pathophysiology of Periotneal Tissue Acidosis During Laparoscopic Surgery
Award for Honorable Mention Multispecialty Scientific Paper
Khusen Baturovich MD
Laparoscopic Simultaneous Operations in Operative Gynecology
Award for Honorable Mention General Surgery Scientific Paper
James Westervelt, MD
The Aesthetic Inguinal Herniorrhaphy: A Single Umbilical Incision Technique
Award for Honorable Mention General Surgery Scientific Paper
Juergen Trackmann, MD
Major Bile Duct Injuries after Laparoscopic Choleystectomy: A Tertiary Center Experience
Award for Honorable Mention General Surgery Scientific Paper
Eraj Basseri, MD
One Stage Laparoscopic Roux-En-Y Gastric Bypass Surgery is Safe and Effective in High-Risk Super Obese Patients
Award for Honorable Mention General Surgery Scientific Paper
Kurt Roberts, MD
Laparoscopic-Assisted, Transgastric Endoscopy: Current Indications and Future Implications
Award for Honorable Mention Gynecology Scientific Paper
Leroy Charles, MD
Pelvic Peritonitis After Laparoscopic Supra Cervical Hysterectomy
Award for Honorable Mention Gynecology Scientific Paper
Ornella Sizzi, MD
Technique for Difficult Laparoscopic Hysterectomy
Award for Honorable Mention Gynecology Scientific Paper
Antoine Watrelot, MD
Fertiloscopy: Review of a 1500 Cases Continuous Series
Award for Honorable Mention Pediatric Surgery Scientific Paper
Mohamed Hassan, MD
New Laparoscopic Flip Flap Technique Versus Conventional Inguinal Hernia Repair in Children. Is it Worth It?
Award for Honorable Mention Pediatric Surgery Scientific Paper
John Meehan, MD
Robotic Surgery for Neonates and Infants: A Single Institutional Review of Patients under 10 kgs.
Award for Honorable Mention Multispecialty Video
James Borin, MD
Laparoscopic Repair of Intraperitoneal Bladder Rupture
Award for Honorable Mention General Surgery Video
Timothy Goundrey, MD
Laparoscopic Excision of a Glucagonoma
Award for Honorable Mention General Surgery Video
Timothy Geiger, MD
Laparoscopic Near Total Gastrectomy for Severe Gastroparesis
Award for Honorable Mention General Surgery Video
Luis Laguna, MD
Laparoscopic Hiatal Hernia Repair with Mesh (PTFE)
Award for Honorable Mention Gynecology Video
Farr Nezhat, MD
Laparoscopic Debulking of Matted Precaval Lymph Nodes in a Patient with Recurrent Cervical Cancer
Award for Honorable MentionGynecology Video
Farr Nezhat, MD
Total Laparoscopic Radical Hysterectomy and Bilateral Pelvic Lymphadenectomy Using the Harmonic Scalpel
Award for Honorable Mention Urology Video
Chandru Sundaram, MD
4-Video of Complications During Laparoscopic Nephrectomy and Adrenalectomy
15TH SLS ANNUAL MEETING AND ENDO EXPO 2006 FACULTY INDEX
KEY
* Nothing to disclose
† Disclosed
‡ Disclosure not received as of print
# VIP Moderator
Ronney Abaza MD
6752 Brintwood
Sylvania OH 43560 USA
Tel: (419) 383-3505
E-Mail: rabaza@meduohio.edu
†# Significant financial interest or other
relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant/Research: Intuitive Surgical
Prem Narayan Agarwal MD
Pocket B-6/35 Sector 7
Rohini New Delhi 110085 INDIA
Tel: 911127054285
Fax: 911123230316
E-Mail: pnagarwal@hotmail.com
*
Craig T. Albanese MD
780 Welch Rd, Suite 206
Stanford CA 94305-5733 USA
Tel: (650) 724-3664
Fax: (650) 725-3664
E-Mail: calbanese@lpch.org
*
Mousa Al-Kurdi Prof Dr Med, MD
15 St Hughs Rd
Buckden
Huntingdon Cambridgeshire PE19 5UB
UNITED KINGDOM
Tel: 447973420153
Fax: 441480810600
E-Mail: mousa@al-kurdi.demon.co.uk
*
Oscar D. Almeida, Jr. MD
7009 Charleston Oaks Dr. S.
Mobile AL 36695 USA
E-Mail: odalmeida@aol.com
#
Kanayochukwu Jacquelyne Aluka MD
8560 2nd Ave #705
Silver Spring MD 20910 USA
Tel: (301) 520-8732
Fax: (202) 529-6808
E-Mail: kanayo02@yahoo.com
†# Discussion of commercial products or services
Grant/Research: Ethicon Endosurgery Inc.
Mark Howard Amols MD
940 Chalet Dr NW
Rochester MN 55901 USA
Tel: (507) 292-9243
E-Mail: amols.mark@mayo.edu
*
Masaaki Andou MD, PhD
250 Bakuro-cho Kurashiki-shi
Okayama-ken 710-0824 JAPAN
Tel: 81 (86) 422-2111
Fax: 81(86) 422-4150
E-Mail: ichi-195@mvc.biglobe.ne.jp
*#
Muhammad Z. Aslam MBBS
15 Vista Court
Penarth South Glamorgan CF64 1DW
UNITED KINGDOM
Tel: 447970825468
E-Mail: mzaslam77@yahoo.com
*
Anthony Atala MD
Wake Forest University School of Medicine
Medical Center Boulevard
Winston-Salem NC 27157 USA
Tel: (336) 716-5701
Fax: (336) 716-0656
E-Mail: aatala@wfubmc.edu
†Significant financial interest or other
relationship with the manufacturer(s) of products or providers of service(s) discussed
Financial interest/arrangement or affiliation with a corporate organization offering financial support or grant monies for this continuing medical education program or with a corporate organization with a financial interest in the subject of my talk.
Stock: Tengion, Inc; Plureon, Inc.
Timothy Averch MD
3471 Fifth Avenue
Suite 700
Pittsburgh PA 15213 USA
Tel: (412) 692-4094
Fax: (412) 692-4101
E-Mail: averchtd@msx.upmc.edu
#
Subhashini M. Ayloo MD
University of Illinois @ Chicago
840 S. Wood Street/M/C 958
Dept of General Surgery
Chicago IL 60612 USA
Tel: (312) 355 1493
Fax: (312) 355 1987
E-Mail: ayloosub@uic.edu
#
Faruq M. Badiuddin MD
PO Box 49147
Dubai UAE DXB UNITED ARAB EMIRATES
Tel: 971.50.6550869
Fax: 971.4.3683762
E-Mail: faruq1@gmail.com
† Discussion of commercial products or services
Garth H. Ballantyne MD
20 Prospect Avenue
Suite #901
Hackensack NJ 07601 USA
Tel: (201) 996-2959
Fax: (201) 996-3222
E-Mail: ghb@lapsurgery.com
† Significant financial interest or other
relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant/Research: Ethicon Endosurgery
Consultant: Ethicon Endosurgery, Autosuture
Speakers Bureau: Ethicon Endosurgery, Autosuture, Intuitive Surgery
Katherine A. Barsness MD
3705 Fifth Avenue
DeSoto Wing 4A 496
Pittsburgh PA 15213-2583 USA
Tel: (412) 692-7282
Fax: (412) 692-8299
E-Mail: timothy.kane@chp.edu
*
Eraj M. Basseri MD
423 South Crescent Drive
Beverly Hills CA 90212 USA
Tel: (310) 801-3181
E-Mail: eraj.basseri@cshs.org
*
Anne-Sophie Bats MD
Gynecology Dept, Georges Pompidou Hospital
20 Rue Leblanc
Paris 75015 FRANCE
Tel: 33 1 56 09 35 84
Fax: 33 1 56 09 25 87
E-Mail: bats@wanadoo.fr
*
Joel J. Bauer MS
25 East 69th Street
New York NY 10021 USA
Tel: (212) 517-8600
Fax: (212) 535-3717
E-Mail: Joel.Bauer@mssm.edu
†Grant/Research: Mt. Sinai Hospital
Yildirim Bayazit MD
Cukurova University, Faculty of Medicine
Department of Urology
Balcali
Yuregir Adana 1330 TURKEY
Tel: 90 322 3386305
Fax: 90 322 3387087
E-Mail: bayazit@cukurova.edu.tr
*#
Robert L. Bell MD
Yale University School of Medicine
40 Temple Street
Suite 3A
New Haven CT 06510 USA
Tel: (203) 764-9060
Fax: (203) 764-9066
E-Mail: robert.bell@yale.edu
#
Charles Bellows MD
Michael E. DeBakey VAMC,OCL 112
2002 Holcombe Blvd.
Houston TX 77030 USA
E-Mail: cbellows@bcm.tmc.edu
#
Desmond H. Birkett MD
Lahey Clinic Medical Center
Dept. Of Surgery
41 Mall Road
Burlington MA 01805 USA
Tel: (781) 744-8576
Fax: (781) 744--5636
E-Mail: desmond.h.birkett@lahey.org
#
Lawrence Biskin MD
100 Delafield Rd.
Suite 213
Pittsburgh PA 15215 USA
Tel: (412) 551-3966
E-Mail: lbiskin@yahoo.com
†Discussion of commercial products or services
Consultant: US Surgical, Ethicon, Gore, I-flow
Speakers Bureau: US Surgical, Ethicon, Gore, I-flow
James P. Boland MD, MPH
WVU Charleston Division / CAMC
3110 MacCorkle Avenue SE
Charleston WV 25304-1210 USA
Tel: (304) 347-1333
Fax: (304) 347-1343
E-Mail: james.boland@camc.org
#
Anne-Marie Boller MD
200 First Street SW
Gonda 9S
Rochester MN 55905 USA
Tel: (507) 266-3588
Fax: (507) 284-1794
E-Mail: boller.anne@mayo.edu
*
James F. Borin MD
UC Irvine--Urology
101 The City Drive
Building 55, 3rd Fl.
Orange CA 92868 USA
Tel: (714) 456-3431
Fax: (714) 456-5062
E-Mail: jborin@aya.yale.edu
†# Significant financial interest or other
relationship with the manufacturer(s) of products or providers of service(s) discussed
Financial interest/arrangement or affiliation with a corporate organization offering financial support or grant monies for this continuing medical education program or with a corporate organization with a financial interest in the subject of my talk.
Grant/Research: Baxter, Astellas, Storz, Intuitive, Simbionix, Ethicon, Endocare
Consultant: CryoLife
Stock: Applied
Other Support: Greenwald Inc, Microvasive, Cook Urological, Orthopedic Systems Inc
Leslie Bottorff MBA
2400 Sand Hill Road
Suite 150
Menlo Park CA 94025 USA
Tel: (650) 529 0700
Fax: (650) 529 0777
E-Mail: leslie@onset.com
† Significant financial interest or other
relationship with the manufacturer(s) of products or providers of service(s) discussed
Stock: ONSET Ventures
Kelly Boyer Registered Dietitian
79 Mt Vernon St
Apt 1R
Boston MA 02108 USA
Tel: (617) 667 9081
Fax: (617) 667 2866
E-Mail: kboyer@bidmc.harvard.edu
*
Viorel Bucuras MD
Timisoara ROMANIA
Tel: 40 722708432
Fax: 40 256306116
E-Mail: Vbucuras@yahoo.com
#
Arnold Byer MD
30 Prospect Ave.
Hackensack NJ 07601 USA
Tel: (201) 996-2626
Fax: (201) 996-2021
E-Mail: abyer@humed.com
*
James E. Carter MD, PhD
26732 Crown Valley Pkwy #541
Mission Viejo CA 92691 USA
Tel: (949) 364-5802
E-Mail: jamescartermd@sbcglobal.net
†# Discussion of commercial products or
services
James F. Carter MD
171 Ashley Avenue
Dept Ob/Gyn, MUSC
Charleston SC 29425 USA
Tel: (843) 792 4500
Fax: (843) 792 0533
E-Mail: carterja@musc.edu
† Grant/Research: Ethicon Advanced Laparoscopy Laboratory
Financial interest/arrangement or affiliation with a corporate organization offering financial support or grant monies for this continuing medical education program or with a corporate organization with a financial interest in the subject of my talk.
Consultant: Ethicon
Speakers Bureau: Boston Scientific
Stefanos Chandakas MD, PhD
15 Sutherland House Marloes Rd
London W85LG UNITED KINGDOM
Tel: 44 790 3652741
Fax: 30 (21) 06437043
E-Mail: stefhand@hol.gr
*#
Leroy Charles MD
10111 F orest Hills Blvd
Suite 231
Wellington FL 33414 USA
Tel: (561) 784-7014
Fax: (561) 784-7922
E-Mail: lbc6@aol.com
†# Speakers Bureau: Gyrus,Adept,Inlet
Allen Chernoff MD
U of IL at Chicago
840 S. Wood Street
Chicago IL 60612 USA
Tel: (312) 966-2779
Fax: (312) 413-0495
E-Mail: achernof@uic.edu
#
Gary Chien MD
Scripps Clinic
343 Ultimo Ave
Long Beach, CA 90814 USA
Tel: (562) 519-1815
Fax: (562) 657-2114
E-Mail: gary.w.chien@kp.org
#
Adel Chokki MD
Service de Chirurgie Hopital de Siliana
Siliana 6100 TUNISIA
Tel: 21698447824
Fax: 21678870019
E-Mail: adel.chokki@rns.tn
*
Neil A. Christie MD
5200 Centre Avenue
Suite 715
Pittsburgh PA 15232 USA
Tel: (412) 623-2025
Fax: (412) 623-0329
E-Mail: christiena@upmc.edu
*
Maurice K. Chung MD
310 S. Cable Road
Lima OH 45805 USA
Tel: (419) 228-1000
E-Mail: endosurgeon85@aol.com
† Speakers Bureau: Ortho McNeil, Norvartis
Massimo Ignazio Civello Prof Dr Med
Largo Agostino Gemelli 8
Rome 168 ITALY
Tel: 0039-0630155398
Fax: 0039-0630156091
E-Mail: imcivello@rm.unicatt.it
*#
Benjamin L. Clapp MD
Ste 4168
6431 Fannin St
Houston TX 77030 USA
Tel: 713 500-7254
Fax: 713 500-7268
E-Mail: b_clapp1@hotmail.com
*
Ara Darzi Prof Dr Med
Dept of Biosurgery & Surgical Technology, 10th Floor
QEQM Building, St Mary's Hospital, Praed Street
London W2 1NY UNITED KINGDOM
Tel: 44 (0)20 7886 1310
Fax: 44 (0)20 7413 0470
E-Mail: a.darzi@imperial.ac.uk
† Grant/Research: Tyco Healthcare
Steven L. Dawson MD
65 Landsdowne Street
Cambridge MA 02139 USA
Tel: (617) 768 8781
Fax: (617) 768 8915
E-Mail: sdawson@partners.org
*
Nestor F. de la Cruz-Munoz MD
Mercy Outpatient Center
3659 South Miami Avenue
Miami FL 33133 USA
Tel: (305) 205-8897
Fax: (305) 856-4301
E-Mail: drdelacruz@dslx.net
† Speakers Bureau: US Surgical Corp, Ethicon Endosurgery
Jacques Dequesne Prof Dr Med
Ch. des Croix-Rouges 16
Lausanne Vaud 01007
SWITZERLAND
Tel: 41213236311
Fax: 41213230124
E-Mail: dequesne.j.md@bluewin.ch
† Grant/Research
Consultant
Speaker's Bureau
Carlo De Werra MD
Via Pansini 5 ed.7
Naples Campania 80131 ITALY
Tel: 393356490788
Fax: 390817462817
E-Mail: carmine.viviano@fastwebnet.it
† Grant/Research
Vipul Dev MD
3508 Via Iglesia
Bakersfield, CA 9331 USA
Tel: (949) 836-1392
Fax: (661) 665-7844
E-Mail: vipdev@earthlink.net
#
Nicola di Lorenzo MD, PhD
Via Salsomaggiore 32
Roma 00135 ITALY
Tel: 39-06-209029-15 or 27
Fax: 39-06-20902893
E-Mail: nicola.di.lorenzo@uniroma2.it
† Discussion of commercial products or services
Consultant: Advisory Board Baxter for adhesion prevention
Speakers Bureau: Baxter
Michael P. Diamond MD
45 Oxford
Grosse Pointe Shores MI 48236 USA
Tel: (313) 993-4523
Fax: (313) 993-4534
E-Mail: mdiamond@med.wayne.edu
† Significant financial interest or other
relationship with the manufacturer(s) of products or providers of service(s) discussed
Presentation includes discussion of the use of product/products for which they are not labeled or are still investigational Financial interest/arrangement or affiliation with a corporate organization offering financial support or grant monies for this continuing medical education program or with a corporate organization with a financial interest in the subject of my talk
Grant/Research: TAP, Pfeizer, Serono
Consultant: Genzyme
Other Support: Advance Reproductive Care
Celia Esther Dominguez MD
Emory Reproductive Center, 18th Floor
550 Peachtree St, Ste 1800
Atlanta GA 30308 USA
Tel: (404) 686-1851
Fax: (404) 686-4956
E-Mail: drchely@msn.com
#
Edward P. Dominguez MD
3545 Olentangy River Rd.
Riverside Surgical Associates
Columbus, OH 43214 USA
E-Mail: e34dominguez@yahoo.com
#
Conrad Jeffrey Duncan MD
9103 Franklin Square Drive
Suite #305
Baltimore MD 21237 USA
Tel: (443) 777-7608
Fax: (443) 777-7618
E-Mail: conrad.duncan@medstar.net
† Speakers Bureau: Pfizer
Titus D. Duncan MD
315 Boulevard Avenue
Suite 224
Atlanta GA 30312 USA
Tel: (404) 881-8020
Fax: (404) 881-8047
E-Mail: titusduncan@msn.com
#
David B. Earle MD
Baystate Medical Center
759 Chestnut St
Springfield MA 01199 USA
Tel: (413) 794-3175
Fax: (413) 794-5940
E-Mail: david.earle@bhs.org
#
Mark Erian MD
T & R, Level 6, Ned Hanlon Building
Royal Brisbane & Women's Hospital
Herston Queensland 4029 AUSTRALIA
Tel: 61 7 3365 5205
Fax: 61 7 3365 5211
E-Mail: ogmerian@ccs.uq.edu.au
*
Roger Ernest DO
1764 Fireside Lane
Cherry Hill NJ 08003 USA
Tel: (856) 665-2017
Fax: (856) 488-6769
E-Mail: mneffyhs@aol.com
† Discussion of commercial products or services
Presentation includes discussion of the use of product/products for which they are not labeled or are still investigational
Tommaso Falcone MD
Cleveland Clinic-Ob Gyn A81
9500 Euclid Avenue
Cleveland OH 44195 USA
Tel: (216) 444-1758
E-Mail: falcont @ccf.org
† Discussion of commercial products or services
Presentation includes discussion of the use of product/products for which they are not labeled or are still investigational
Jose M.M. Ferreira-Coelho MD, PhD
Hospital Julio de Matos
Av. do Brasil No. 53
Lisbon 1749-002 PORTUGAL
Tel: 351 21 9430252
Fax: 351 21 4368417
E-Mail: jferreiracoelho@yahoo.com
#
Arthur P. Fine MD
575 Coal Valley Road
Ste. 372
Jefferson Hills PA 15120 USA
Tel: (412) 469-7035
Fax: (412) 469-7037
E-Mail: arthur_fine@msn.com
*#
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
*
Morris E. Franklin, Jr. MD
4242 E. Southcross, Suite 1
San Antonio TX 78222 USA
Tel: (210) 333-7510
Fax: (210) 333-1912
E-Mail: franklin@texasendosurgery.com
†# Significant financial interest or other relationship with the manufacturer(s) of products or providers of service(s) discussed Financial interest/arrangement or affiliation with a corporate organization offering financial support or grant monies for this continuing medical education program or with a corporate organization with a financial interest in the subject of my talk
Grant Research
Consultant: Gore, Cook, USSC
Other Support: General Support for Meeting
Yasuyuki Fukami MD
Shizuoka Saiseikai General Hospital
Shizuoka, 422-8527 JAPAN
Tel: 054-285-6171
Fax: 054-285-5179
E-Mail: y149004@siz.saiseikai.or.jp
*
Terrence M. Fullum, MD
Providence Hospital, Dept of Surgery
1160 Varnum Street NE, Suite 212
Washington, DC 20017-2106 USA
Tel: (202) 529-6801
Fax: (202) 529-6806
E-Mail: tmalcolm01@yahoo.com
‡
Alex Gandsas MD
Sinai Hospital
2435 West Belevedere Ave
Baltimore MD 21215 USA
Tel: (410) 601-4838
E-Mail: webmaster@laparoscopy.com
*#
Mark D. Gaon MD
8700 Beverly Blvd
Suite 8215
Los Angeles CA 90048 USA
Tel: (310) 721-6177
Fax: (310) 423-2694
E-Mail: gaonm@cshs.org
*
Nikolaos I. Gatsoulis MD, PhD
Ioulias Andreadi 14
Corfu 49100 GREECE
Tel: 0030 6610 42938
Fax: 0030 6610 42938
E-Mail: gats@otenet.gr
*#
Timothy M. Geiger MD
Dept of General Surgery, 4th floor Mchaney Hall
1 Hospital Drive
Columbia MO 65212 USA
Tel: 573-884-2000
E-Mail: geigertm@health.missouri.edu
*
W. Peter Geis MD
21 Crossroads Drive Suite 360
Owings Mills MD 21117 USA
Tel: (410) 552-4202
Fax: (410) 356-6487
E-Mail: wgeis@lifebridgehealth.org
† Significant financial interest or other relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant/Research: Ethicon Endo-Surgery (Fellowship grant)
Consultant: Ethicon Endo-Surgery
Speakers Bureau: Ethicon Inc. and Ethicon Endo-Surgery
Roberta Gelmini MD
University of Modena
via del Pozzo, 71 - Dept of Surgery Policlinico of Modena
Modena 41100 ITALY
Tel: 39 59 42243662
Fax: 39 59 4224370
E-Mail: gelmini.roberta@unimore.it
*#
Kathy Gohar MD
3901 City Ave.
Apt. A1205
Philadelphia PA 19131 USA
Tel: (267) 275-0250
E-Mail: kgoharmd@yahoo.com
kathy-gohar@yahoo.com
*
Herbert A. Goldfarb MD
Dept OB/GYN
170 William Street
New York NY 10038 USA
Tel: (973) 744-7470
Fax: (973) 467- 5175
E-Mail: hgoldfarb@nohysterectomy.com
†# Discussion of commercial products or services
Timothy E. Goundrey MD
1000 Asylum Ave.
Suite 3206A
Hartford CT 06105 USA
Tel: (860) 241-0870
Fax: (860) 241-8296
E-Mail: timgoundrey@yahoo.com
*
Harsh Grewal MD
Temple Children's Med Ctr/Ped Surg
3509 North Broad St, 5 East
Philadelphia PA 19140 USA
‡
Monika Hagen MD, MBA
Hopitaux Universitaires de Geneve, Departement of Surgery
Rue Micheli-du-Crest 24
Geneva 1211 SWITZERLAND
Tel: 41765929753
E-Mail: MonikaHagen@aol.com
† Discussion of commercial products or services
Randy S. Haluck MD
Room C4628
500 University Drive
Hershey PA 17033 USA
Tel: (717) 531-7462
E-Mail: rhaluck@psu.edu
†# Significant financial interest or other relationship with the manufacturer(s) of products or providers of service(s) discussed
Stock: Verefi Technologies, Inc.
David F. Hanson PhD Candidate
3402 Briaroaks
Garland TX 75044 USA
Tel: (214) 840-7174
Fax: (214) 826-1328
E-Mail: david@hansonrobotics.com
† Discussion of commercial products or services
Significant financial interest or other relationship w/the mfrs of any of the prods or providers of svcs intend to discuss
Stock: Hanson Robotics, Inc
Andres Hanssen MD
Instituto Médico La Floresta
Urbanización La Floresta, # 109
Caracas DF 1060 VENEZUELA
Tel: 582122096109
E-Mail: hanssen@movistar.net.ve
† Discussion of commercial products or services
Michael T. Harris MD
5 E. 98 St. 15th Floor, Box 1259
New York NY 10029-6500 USA
Tel: (212) 241-7120
Fax: (212) 410-0111
E-Mail: michael.harris@mssm.edu
#
Mohamed Ibrahim Hassan MD
Alwasl Hospital, Ward 5
Pediatric Surgery
Dubai 9115 UAE
Tel: 9710502459456
Fax: 00971043241717, 00971043113068
E-Mail: DMIA88@HOTMAIL.COM
*
Harrith M. Hasson MD
6250 Winter Haven Rd NW
Albuquerque NM 87120 USA
Tel: (773) 294-5440
E-Mail: drhasson@aol.com
*
William Leroy Heinrichs, MD, PhD
8 Campbell Lane
Menlo Park, CA 94025 USA
Tel: (650) 723-2422
Fax: (650) 498-4082
E-Mail: leroy.heinrichs@stanford.edu
‡
Bryan S. Helsel MD
Department of General Surgery; MCHK-DSG
1 Jarrett White Road
Tripler HI 96859 USA
Tel: (808) 433-3435
E-Mail: christopher.moon@amedd.army.mil
*
Santiago Horgan, MD
University of Illinois at Chicago
General Surgery Division
435 W. Erie, Room 2101
Chicago, IL 60610 USA
Tel: (312) 355-1493
Fax: (312) 355-1987
E-Mail: horgan@miscsurgeons.com
‡
Mubashar Hussain Dr Med
2 Mizzy Road
Rochdale Lancashire OL12 6HW
UNITED KINGDOM
Tel: 44-7743-876-734
E-Mail: m.hussain@doctors.org.uk
*#
Christopher Ip MD
1245 Park Ave
Apt 9 E
New York NY 10128 USA
Tel: (646) 408-0553
E-Mail: chrisip98@yahoo.com
*
Volker R. Jacobs MD, PhD
Frauenklinik of Technical University Munich
Ismaninger Str. 22
Munich Bavaria 81675 GERMANY
Tel: 49-89-4140-5425
Fax: 49-89-4140-4831
E-Mail: volkerjacobs@hotmail.com
†# Discussion of commercial products or services
Grace M. Janik MD
2315 N. Lake Drive
Suite 501
Milwaukee WI 53211 USA
Tel: (414) 289-9668
Fax: (414) 289-0974
E-Mail: drjanik@reproductivecenter.com
†Significant financial interest or other relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant/Research: Adiana - Trial Investigator
Consultant: Storz
Daniel B. Jones MD, MS
Beth Israel Deaconess Medical Center
Boston MA 02215 USA
Tel: (617) 667 5101
Fax: (617) 667 5125
E-Mail: Djones1@BIDMC.Harvard.edu
† Significant financial interest or other relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant/Research: Stryker
Consultant: TNCO
Speaker's Bureau: USSC
Stephanie B. Jones MD
100 Lincoln Rd
Wayland MA 01778 USA
Tel: (617) 754-2733
E-Mail: sbjones3020@comcast.net
*
Neel R. Joshi MD
141 S. Clark Dr., #201
Los Angeles CA 90048 USA
Tel: (310) 948-1715
E-Mail: joshin@cshs.org
*
Kenneth M. Kamler MD
410 Lakeville Road
Suite 100
New Hyde Park NY 11042 USA
Tel: (516) 326-8810
Fax: (516) 328-7165
E-Mail: kenkamler@yahoo.com
*
Faiyaz Kapasi MD
7 Cutlers Close
Bishops Stortford Herts CM 23 4FW UNITED KINGDOM
Tel: 441279757445
E-Mail: FMK110@YAHOO.CO.UK
*
Marc R. Katz MD
7605 Forest Ave
Suite 302
Richmond VA 23229 USA
Tel: (804) 282-8777
E-Mail: mkatz@heartsurgeryva.com
† Discussion of commercial products or services
Michael Kavic MD
1044 Belmont Avenue
Youngstown OH 44501-1790 USA
Tel: (330) 480 3124
E-Mail: michael_kavic@hmis.org
*
William E. Kelley, Jr., MD
8921 Three Chopt Rd.
Richmond VA 23229 USA
Tel: (804) 285-9416
E-Mail: bill.kelley@earthlink.net
† Discussion of commercial products or services
Stuart Kesler MD
Department of Urology
360 Essex Street, Suite 403
Hackensack NJ 07601 USA
Tel: (201) 336-8090
Fax: (201) 336-8221
E-Mail: stukesler@yahoo.com
† Discussion of commercial products or services
Anil Khetarpal MD
Khetarpal Hospital
F-95, Bali Nagar
Main Najafgarh Road
New Delhi 110015 INDIA
Tel: 91 11 25193344
Fax: 91 11 25193344
E-Mail: anilkhetarpal@hotmail.com
#
Daniel S. Kim MD
2 Dudley Street
#180
Providence RI 02905 USA
Tel: (401) 444-8579
E-Mail: dskimmd@yahoo.com
† Discussion of commercial products or services
Dennis R. Klassen MD
Suite 813 Victoria Building
1278 Tower Road
Halifax Nova Scotia B3H 2Y9 CANADA
Tel: (902) 473 5574
Fax: (902) 473 2828
E-Mail: denklas@hotmail.com
*
Charles H. Koh MD
2315 N. Lake Drive
Suite 501
Milwaukee WI 53211 USA
Tel: (414) 289-9668
Fax: (414) 289-0974
E-Mail: drkoh@reproductivecenter.com
†# Significant financial interest or other
relationship with the manufacturer(s) of products or providers of service(s) discussed
Consultant: Cooper Surgical, Storz
Dan G. Kolder MD
2901 Trailside Drive
Columbia MO 65203 USA
Tel: (573) 882-4141
E-Mail: kolderd@health.missouri.edu
*
Doron Kopelman MD
30 Kanarit St
Caesarea 38900 ISRAEL
Tel: 972-50-5371539
E-Mail: kopelmand@bezeqint.net
†# Significant financial interest or other
relationship with the manufacturer(s) of products or providers of service(s) discussed
Presentation includes discussion of the use of product/products for which they are not labeled or are still investigational financial interest/arrangement or affiliation with a corporate organization offering financial support or grant monies for this continuing medical education program or with a corporate organization with a financial interest in the subject of my talk
Grant/Research: InSightec, Haifa, Israel
Consultant: InSightec, Haifa, Israel
Baris Kuzgunbay MD
Univ. of Cukurova-Urology Dept.
Balcali
Adana 01330 TURKEY
Tel: 90 (322) 2359070
Fax: 90 (322) 3271276
E-Mail: kuzgunbay33@yahoo.com
#
Sebastiano Lacitignola MD
Massafra Hospital
Massafra 74016 ITALY
Tel: 39 080 4835282
E-Mail: lacitignola@libero.it
*
Luis E. Laguna MD
2650 Ridge Avenue
Suite 1308
Evanston IL 60201 USA
Tel: (847) 570-1422
Fax: (847) 733-5018
E-Mail: lelaguna2@hotmail.com
*
Jaime Landman MD
Columbia University
161 Fort Washington Ave
New York NY 10032 USA
Tel: (212) 305-5630
Fax: (212) 305-8613
E-Mail: landmanj@yahoo.com
†# Significant financial interest or other relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant/Research: Ethicon Endosurgery, Gyrus-ACMI, American Medical Systems, Cook Urological
Consultant: Ethicon Endosurgery, Gyrus-ACMI, American Medical Systems, Cook Urological
Other Support: Patent / Royalties - Cook Urological, Applied Medical
Raymond J. Lanzafame MD, MBA
1445 Portland Ave #202
Rochester NY 14621-3095 USA
Tel: (585) 922-4505; (585) 395-6095 x4367
Fax: (585) 544-8761
E-Mail: ray.lanzafame@viahealth.org
† Discussion of commercial products or services
Grant/Research: NIH SBIR GRANT Phase 2, Conversion Energy Enterprises
Consultant: Kodak, Surgicon, Lucid, Conversion Energy, Ethicon
Speakers Bureau: Monroe County Medical Assn
Stock: TheraLite, Lucid, Surgicon, Kodak, Jamar
Other Support: RGHF grants
Jonathan A. Laryea MD
107 Newfield Avenue #32
Waterbury CT 06708 USA
Tel: (203) 573-7256
Fax: (203) 573-6073
E-Mail: BLESSJAL@GMAIL.COM
*
Chang-Mok Lee MD
366-144, Shindang-3 Dong, Chunggu
Seoul, 100-453 SOUTH KOREA
Tel: 82222507363
Fax: 82222338528
E-Mail: cmlee3@korea.com
*
Young-Joon Lee MD
Department of Surgery
Gyeongsang National University Hospital
90 Chilam-dong
Jinju Gyeongsangnam-do 660-702 SOUTH KOREA
Tel: 82-55-750-8096
E-Mail: moonhgsurgi@hanmail.net
† Discussion of commercial products or services
Carl J. Levinson, MD
576 Sand Hill Circle
Menlo Park, CA 94025 USA
Tel: (60) 233-0591
E-Mail: carljmd@aol.com
*
Yan Liu MD
Dept. OB/GYN
415 Fengyang Road
Shanghai 200003 CHINA
Tel: 86-21-63610109 X73481
Fax: 86-21-63520020
E-Mail: yliu2004@163.com
*
Kiran M. Lodha MD
Benenden Hospital
Benenden
Cranbrook Kent TN17 4AX UNITED KINGDOM
Tel: 441-580240877
Fax: 441-580240877
E-Mail: JHUMAB5@aol.com
†# Consultant: Benenden Health Care Society
Atul K. Madan MD
956 Court Avenue
Suite G210
Memphis TN 38163 USA
Tel: (901) 449-5910
Fax: (901) 448-1639
E-Mail: amadan@utmem.edu
†# Significant financial interest or other
relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant/Research: Ethicon
Ralph R Madeb MD
4 Eastland Avenue
Rochester, NY 14618 USA
Tel: (585) 750-3641
E-Mail: RRM@ROCHESTER.RR.COM
*
Vijay Maker MD
Metropolitan Group Hospitals Res/GenSurg
836 West Wellington Avenue, #4813
Chicago IL 60657 USA
Fax: (773) 296-5570
E-Mail:
vijay.maker-md@advocatehealth.com
#
Sinisa M. Maksimovic MD, PhD
Sr. Vojske 44
Bijeljina R. Srpska 76300 BOSNIA AND HERZEGOVINA
Tel: 387 55 203 888
Fax: 387 55 210 543
E-Mail: makss@telrad.net
*#
Ali F. Mallat MD
6315 Kingston Pike #904
Knoxville TN 37919-4914 USA
Tel: (413) 588-9721
Fax: (413) 260-0683
E-Mail: ali_mallat@hotmail.com
#
Neil Mandava MD
St. Vincent Catholic Med. Ctr./Surg.
88-25 153rd St./Parsons Manor, Suite 2A
Attn: Rita Raio, Pgr. Coordinator
Jamaica NY 11432 USA
Fax: (718) 558-7090
E-Mail: rraio@svcmcny.org
#
Jacques Marescaux MD
IRCAD-EITS Institute
1 Place de l'HÙpital - BP 426
Strasbourg 67091 FRANCE
Tel: 33 3 88 11 90 06
Fax: 33 3 88 11 90 96
E-Mail: jacques.marescaux@ircad.u-strasbg.fr
*
A. Elizabeth Martin MD
812 Dover Bluff Place
Manakin-Sabot, VA 23103 USA
Tel: (804) 784-0211
E-Mail: agaleo5244@aol.com
*
Tadashi Matsuda MD
Shinmachi 2-3-1
Hirakata Osaka 573-1191 JAPAN
Tel: 81-72-804-0101
Fax: 81-72-804-2068
E-Mail: matsudat@takii.kmu.ac.jp
*
Samer G. Mattar MD
6625 Network Way
Suite 100
Indianapolis IN 46278 USA
Tel: (317) 275-6010
Fax: (317) 275-7012
E-Mail: smattar@clarian.org
† Grant/Research: Wyeth Pharmaceuticals
Consultant: US Surgical Corporation
Corigan L. McBride MD
Nebraska Medical Center
Omaha NE 68198-3280 USA
Tel: (402) 559-5508
E-Mail: clmcbride@unmc.edu
*
Elspeth M. McDougall MD
101 The City Dr.
Bldg. 55, Rt. 81
Orange CA 92686 USA
Tel: (714) 456-3429
Fax: (714) 456-5062
E-Mail: elspethm@uci.edu
†# Significant financial interest or other
relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant/Research: Astellas Pharmaceutical Inc, Endocare
financial interest/arrangement or affiliation with a corporate organization offering financial support or grant monies for this continuing medical education program or with a corporate organization with a financial interest in the subject of my talk
Other Support: Yamanouchi/Astellas; Karl Storz, Intuitive Surgical; Simbionix; Ethicon Endo-Surgery
John J. Meehan MD
200 Hawkins Drive, University of Iowa Hospitals and Clinics
Department of Surgery
Iowa City IA 52242 USA
Tel: (319) 356-1884
E-Mail: john-j-meehan@uiowa.edu
† Discussion of commercial products or services
Chris Mitchell JD
Wilson Sonsini Goodrich & Rosati
650 Page Mill Road
Palo Alto CA 94304-1050 USA
Tel: (650) 354-4116
E-Mail: cmitchell@wsgr.com
*
John E. Morrison, Jr. MD
P.O.Drawer 70
Fayette Alabama 35555 USA
Tel: (205) 932-3879
Fax: (205) 932-5253
E-Mail: drmorjo@aol.com
#*
Ospan A. Mynbaev MD, PhD
Tervuursevest 132
Leuven VB 3000 BELGIUM
Tel: (321) 622-5327
E-Mail: ospanmynbaev@hotmail.com
*
Mamoun Nabri MD
Ardaghowen Lane 3rd Left
The Mall
Sligo Co. Sligo 7191 IRELAND
Tel: 353 86 821 1188
E-Mail: manabri@hotmail.com
*
Khusen Baturovich Narzullaev MD, PhD
Lakhuti Street, # 3
Samarkand Samarkand 703017 UZBEKISTAN
Tel: 998 662 234-25-20
E-Mail: khu-narzullaev@yandex.ru
† Grant/Research
Consultant
Stock
Other Support: Karl Storz
Vincenzo Neri MD
Via Murat 86
Bari 70123 ITALY
Tel: 39 0881 733704
E-Mail: tizpv@tiscali.it
*#
Camran Nezhat MD
900 Welch Rd., Suite 403
Palo Alto CA 94304 USA
Tel: (650) 327-8778
Fax: (650) 327-2794
E-Mail: cnezhat@stanford.edu
*
Ceana Nezhat MD
5555 Peachtree Dunwoody Road
Atlanta GA 30342 USA
Tel: (404) 255-8778
E-Mail: ceana@Nezhat.com
† Discussion of commercial products or services
Consultant: Storz, Valley Lab,Viking, Ethicon
Farr R. Nezhat MD
1176 Fifth Avenue
9th Floor, Box 1173
New York NY 10019 USA
Tel: (212) 241-9434
Fax: (212) 987-6386
E-Mail: farr.nezhat@mssm.edu
*
Charles Ng MD
Villa Bianca, 4 Queen Astrid Gardens
266860 SINGAPORE
Tel: 64662619
Fax: 65 64633876
E-Mail: charles.ng.s.a@sgh.com.sg
#
Amanda Nickles Fader MD
231 Newburn Drive
Pittsburgh PA 15216 USA
Tel: (412) 848-4260
E-Mail: amanditan@yahoo.com
*
Kazem Nouri MD
Lkh Wolfberg
Paulhackhofer Str 9
Wolfsberg Karnten 9400 AUSTRIA
Tel: 43 435 2533505
Fax: 43 435 2533505
E-Mail: nouri100@hotmail.com
#
Sung-Tack Oh MD, PhD
Dept. of Ob/Gyn, Chonnam University Medical School
8 Hakdong, Tongku
Kwangju KJ 501-190 SOUTH KOREA
Tel: 82-62-220-6374
Fax: 82-62-227-1637
E-Mail: ohst@chonnam.ac.kr
*#
Okechukwu O. Okidi MD
Ebonyi State University
Department of Surgery
Abakiliki NIGERIA
E-Mail: okeyokidi@yahoo.com
#
Douglas E. Ott MD, MBA
Georgia BioMedical
161 Gateway Drive
Suite- B
Macon GA 31210 USA
Tel: (478) 477-8996
Fax: (478) 471-6862
E-Mail: gabiomed@mindspring.com
#
Michael A. Palese MD
The Mount Sinai School of Medicine
One Gustave L. Levy Place
Dept of Urology-Box 1272
New York NY 10029 USA
Tel: (212) 214-1883
Fax: (212) 987-4675
E-Mail: Michael.Palese@MountSinai.org
#
Steven F. Palter MD
243 Jericho Tpke
Syosset NY 11791 USA
Tel: (516) 682-8900
Fax: (516) 682-8901
E-Mail: palter@gcivf.com
† Significant financial interest or other
relationship with the manufacturer(s) of products or providers of service(s) discussed
Presentation includes discussion of the use of product/products for which they are not labeled or are still investigational
Financial interest/arrangement or affiliation with a corporate organization offering financial support or grant monies for this continuing
medical education program or with a corporate organization with a financial interest in the
subject of my talk
Consultant: Storz, Impress, Viking
Speakers Bureau: Organon
Rohit Patel MD
1815 J. F. Kennedy Blvd, # 1607
Philadelphia PA 19103 USA
Tel: (267) 330-0787
E-Mail: rohitp@yahoo.com
*
Mary Lou Patton MD
1 Medical Center Blvd
Suite 241
Upland PA 19013-3902 USA
Tel: (610) 872-4015
Fax: (610) 872-4015
E-Mail: loumary@msn.com
#
Stacie E. Perlman MD
75 Middle Road
Preston CT 6365 USA
Tel: (860) 887-9891
E-Mail: perlms@aol.com
† Discussion of commercial products or services
Benjamin Person MD
Cleveland Clinic Florida
2950 Cleveland Clinic Blvd.
Weston FL 33331 USA
Tel: (954) 659-5133
Fax: (954) 659-5587
E-Mail: personb@ccf.org
† Discussion of commercial products or services
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
‡
Alexander H. Petter-Puchner MD
Riglergasse 11/4
Vienna 1180 AUSTRIA
Tel: 43133110464
E-Mail: alexander.petter@lbitrauma.org
†# Discussion of commercial products or services
Presentation includes discussion of the use of product/products for which they are not labeled or are still investigational
Adam Howard Power MD
284 Locke Street South
Hamilton ON L8P4C1 CANADA
Tel: (905) 317-4566
E-Mail: powera2@mcmaster.ca
† Grant/Research: McMaster University Resident Research Fund
Kumuda R. Pradhan
Somerset Hospital
1019 Sunset Dr, Unit 1
Somerset, PA 15501
Tel: (814) 443-3138
E-Mail: k_r_pradhan@hotmail.com
#
Anuj Prashar DO
1764 Fireside Lane
Cherry Hill NJ 08003 USA
Tel: (856) 665-2017
Fax: (856) 488-6769
E-Mail: mneffyhs@aol.com
† Discussion of commercial products or services
Presentation includes discussion of the use of product/products for which they are not labeled or are still investigational
Fahimeh Ramezani Tehrani MD
National Research Center for Reproductive Health
211, Opposite Avesta Park,
Tehran 14155-6193 IRAN
Tel: 98-21-88093518
Fax: 98-21-88364067
E-Mail: frtehrani@yahoo.com
*
Patrick R. Reardon MD
6550 Fannin St.
Suite 2435
Houston TX 77030 USA
Tel: (713) 790-3140
Fax: (713) 790-3235
E-Mail: reardonp@texmist.com
#
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
†# Consultant: Confluent Surgical
Stock: Apple Medical
Masoud Rezvani MD
432 Old Farm Road
Wyncote PA 19095 USA
Tel: (215) 572-1282
E-Mail: mas_rezvani@yahoo.com
† Grant/Research
Consultant
Speakers Bureau
Zribi Riadh MD
Siliana Tunisia 6100 TUNISIA
Tel: 21698286601
Fax: 21678870019
E-Mail: zribiriadhc@yahoo.fr
*
Robert L. Ricca MD
2725 River Oaks Drive
Chesapeake VA 23321 USA
Tel: (757) 465-3080
Fax: (757) 953-0845
E-Mail: rlricca@mar.med.navy.mil
*
Kurt E. Roberts MD
40 Temple St
Suite 3A
New Haven CT 06510 USA
Tel: (203) 764-9060
Fax: (203) 764-9066
E-Mail: robert.bell@yale.edu
*
David M. Rodin MD
Massachusetts General Hospital
55 Fruit Street/GRB 1102
Boston MA 02114 USA
Tel: (617) 216-8736
Fax: (617) 726-6131
E-Mail: drodin@partners.org
† Discussion of commercial products or services
Hilda Elena Rodriguez MD
900 Welch Road Suite 403
Palo Alto CA 94304 USA
Tel: (650) 327 8778
Fax: (650) 327 2794
E-Mail: elena125@stanford.edu
*
Alexander Rosemurgy MD
Tampa General Hospital
PO Box 1289, Suite F145
Tampa FL 33647 USA
Tel: (813) 844-7393
Fax: (813) 844-7396
E-Mail: arosemur@hsc.usf.edu
*
James C. Rosser MD
Beth Israel Medical Center
350 East 17th St.,16BH
New York NY 10003 USA
Tel: (212) 844-1039
Fax: (212) 844-1039
E-Mail: jrosser@chpnet.org
#
Alfonso Rossetti MD
v.le regina Margherita 157
Rome 198 ITALY
Tel: 39 6 8844576
E-Mail: alfonso.rossetti@alfamedica.it
*#
Nick Roukounakis MD
12 Fokeas St
Papagou
Attiki 15569 GREECE
Tel: 30 210 5244694
Fax: 30 210 5240130
E-Mail: nicrouk@ath.forthnet.gr
#
Lukas Sakra MD, PhD
Surgical Dpt. Pardubice
Kyjevsk· 44
Pardubice 53003 CZECH REPUBLIC
Tel: 420 46 601 2999
Fax: 420 46 601 2988
E-Mail: sakra@nem.pce.cz
*#
Tadashi Sakurai MD
1-1 Seiryo Aoba
Sendai Miyagi 980-8574 JAPAN
Tel: 81-22-717-7214
E-Mail: tsakurai@mail.tains.tohoku.ac.jp
*
Ernesto Salgado-Sanchez MD
Diag. Zaragoza 5128-205
San Manuel
Puebla 72590 MEXICO
Tel: 52 22 22 -338130
Fax: 52 22 22 -338130
E-Mail: ernesto_salgado_s@hotmail.com
#
Vivian M. Sanchez MD
17 Oak St
Boston MA 02492 USA
Tel: (781) 453-3650
E-Mail: vmsanche@caregroup.harvard.edu
† Speakers Bureau: Gore
Richard Satava MD
Univ of Washington Dept of Surgery, 35-6410
1959 NE Pacific St, BB487
Seattle WA 98195-6410 USA
Tel: (425) 765-0730
Fax: (206) 543-8136
E-Mail: rsatava@u.washington.edu
*
Michael Schweitzer MD
Dept of Surgery
4940 Eastern Avenue
Baltimore MD 21224 USA
Tel: (410) 550-3345
Fax: (410) 550-0003
E-Mail: schweitzer@doctor.com
† Significant financial interest or other relationship with the manufacturer(s) of products or providers of service(s) discussed
Presentation includes discussion of the use of product/products for which they are not labeled or are still investigational
Financial interest/arrangement or affiliation with a corporate organization offering financial support or grant monies for this continuing
medical education program or with a corporate organization with a financial interest in the
subject of my talk
Grant/Research: Bard
Consultant: US Surgical, Ethicon, Bard
Speakers Bureau: Sanofi-Aventis
Jeffrey D. Sedlack MD
64 Robbins St.
Department of Surgery
Waterbury CT 06721 USA
Tel: (717) 385-1080
Fax: (717) 258-1101
E-Mail: jdscarlisle@aol.com
*
Daniel S. Seidman MD
14 Yehezkel St.
Tel-Aviv 62595 ISRAEL
Tel: 972522801938
Fax: 97236044146
E-Mail: dseidman@post.tau.ac.il
† Discussion of commercial products or services
Neal E. Seymour MD
Dept. of Surgery Baystate Medical Center
759 Chestnut Street
Springfield MA 01199 USA
Tel: (413) 794-4025
Fax: (413) 794-1764
E-Mail: neal.seymour@bhs.org
† Discussion of commercial products or services
Phillip Shadduck MD
Regional Surgical Associates
4301 Ben Franklin-PO Box 15698
Durham NC 27704 USA
Tel: (919) 479-4400
Fax: (919) 479-4415
E-Mail: phil9128@aol.com
†# Discussion of commercial products or services
Consultant: Closure Medical; Ethicon; Bard Davol
Jay P. Shah MD
1200 14th St NW #412
Washington DC 20005 USA
Tel: (202) 607 0488
E-Mail: jayshah01@yahoo.com
† Consultant: Paul Mackoul; Ethicon
Amir Shariati MD
1633 N. Capitol Ave #436
Indianapolis IN 46202 USA
Tel: (317) 962-6600
E-Mail: amirshariati@hotmail.com
*
Rajeev Sinha Prof Dr Med
4/16 MLB Medical College
Jhansi UP 284128 INDIA
Tel: 91-510-2320001
Fax: 91-510-2320002
E-Mail: sinha_rga@yahoo.co.in
*#
Ornella Sizzi MD
via dei Mille 6
Sacrofano Rome 00060 ITALY
Tel: 393358016986
E-Mail: ornella.sizzi@alfamedica.it
†# Discussion of commercial products or services
Marshall l. Smith MD, PhD
Dept of Telemedicine, WT-1, Banner Good Sam
1111 East McDowell
Phoenix AZ 85006 USA
Tel: (602) 239-6507
E-Mail: mark.smith@bannerhealth.com
*
Jonathan Y. Song MD
4N 393 School Rd
St. Charles IL 60175 USA
Tel: (630) 677-1557
Fax: (630) 810-1027
E-Mail: jsong3972@hotmail.com
*
Michael Stark MD
Karower Street 11/214
Berlin 13125 GERMANY
Tel: 49 (0)30 9401 2403
Fax: 49 (0)30 9401 2430
E-Mail: mstark@nesacademy.org
*
Dragos Stojanovic MD, PhD
Vidska 15
Belgrade Serbia 11 000 SERBIA
AND MONTENEGRO
Tel: 381 632 44004
E-Mail: dragoss@net.yu
*#
Gustavo Stringel MD
21 Addison Street
Larchmont NY 10538 USA
Tel: (914) 493-7620
E-Mail: GStringel@aol.com
‡
Ranjan Sudan MD
Creighton Univ. School Of Med./Surgery
601 N. 30 Street, Suite 3700
Attn: Diane Parsons, Pgr. Coordinator
Omaha NE 68131 USA
Tel: (402) 280-4231
Fax: (402) 280-4534
E-Mail: rsudan@creighton.edu
#
Chandru P. Sundaram MD
Department Urology
535 Barnhill Drive
Suite 420
Indianapolis IN 46202-5289 USA
Tel: (317) 278-3098
E-Mail: sundaram@iupui.edu
†# Discussion of commercial products or services
Consultant: Intuitive Surgical
Radha Syed MD
5 Coddington Ave
Staten Island NY 10306 USA
Tel: (718) 351-1247
Fax: (718) 351-1271
E-Mail: radhasyed77@yahoo.com
†# Discussion of commercial products or services
Hidenori Takahashi MD
1 Hikarigaoka
Fukushima 960-1295 JAPAN
Tel: 81-24-547-1290
Fax: 81-24-548-3878
E-Mail: hide-t@fmu.ac.jp
*
Maria L. Terry MD
ACC 2 MS 10-5610
1 University of New Mexico
Albuquerque NM 87131-0001 USA
Tel: (505) 272-0433
E-Mail: mterry@salud.unm.edu
† Discussion of commercial products or services
Nebbie Elizabeth Terry MD
Memorial Health
4700 Waters Ave
Savannah GA 31405 USA
Tel: (912) 660-0975
E-Mail: terrybe1@memorialhealth.com
*
Katina Theodoropoulou MD
Flat 4, Lymington Court
214 Lavender Hill
Enfield EN2 8NE UNITED KINGDOM
Tel: 447812101582
E-Mail: kattheod@aol.com
*#
David S. Tichansky MD
956 Court Avenue
Suite G210
Memphis TN 38163 USA
Tel: (901) 449-5910
Fax: (901) 448-1639
E-Mail: amadan@utmem.edu
†# Significant financial interest or other
relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant/Research: Ethicon
Juergen Treckmann Prof Dr Med
University Hospital Essen, Hufelandstr. 55
Clinic for General Surgery and Transplantation
Essen Nordrhein Westfalen 45122 GERMANY
Tel: 49 201 723 1100
E-Mail: j.treckmann@gmx.net
*
F.H. Maurine Tsakok MD
03-01 Camden Medical Center
One Orchard Blvd
Singapore 248649 SINGAPORE
Tel: 65 68354300
Fax: 65 68354909
E-Mail: mtsakok@pacific.net.sg
#
Konstantinos G. Tsalis Prof Dr Med
Kotyoron 19 55131
Thessaloniki 55131 GREECE
Tel: 302310410768
Fax: 302310358000
E-Mail: ctsalis@med.auth.gr
†# Discussion of commercial products or services
Daniel A. Tsin MD
The Mount Sinai Hospital of Queens
25-10 30th Avenue
Long Island City NY 11102 USA
Tel: (718) 898-5101
Fax: (718) 746-4174
E-Mail: LaserGYN@aol.com
*#
Robert D. Tucker MD, PhD
B044ML/Pathology Dept
U of Iowa Hospital
Iowa City IA 52242 USA
Tel: (319) 335-8257
Fax: (319) 335-7096
E-Mail: robert-tucker@uiowa.edu
†# Discussion of commercial products or services
Grant/Research: Gyrus/ACMI
Paolo Ubiali MD
via Belvedere 25
Alzano Lombardo 24022 ITALY
Tel: 39035512998
E-Mail: paolap57@alice.it
*#
Ali Uzunkoy Prof Dr Med
Harran University School of Medicine
Director of General Surgery Department
Sanliurfa Sanliurfa 63000 TURKEY
Tel: 00.90.414.3141170
Fax: 00.90.414.3151181
E-Mail: aliuzunkoy@yahoo.com
*#
Parveen S. Vahora MD
7333 Islander Lane
Hudson FL 34667 USA
Tel: (727) 843 9350
Fax: (727) 843 9365
E-Mail: Parveensg@gmail.com
*
Bruno van Herendael MD
ISGE
Italielei, 62
B-200 Antwerp B-2000 BELGIUM
E-Mail: bruno@isge.be
#
Ramakrishna Venkatesh MD
PO Box 8242,
4960, Childrens Place, Urology Division, Washington University School of Medicine
St. Louis MO 63110 USA
Tel: (314) 454 8058
Fax: (314) 454 5244
E-Mail: venkateshr@wudosis.wustl.edu
*
Ashley Haralson Vernon MD
Brigham & Women's Hospital
75 Francis Street
Boston MA 02115 USA
Tel: (617) 732-6337
E-Mail: avernon@partners.org
*
Peng-Hui Wang MD, PhD
201, Section 2, Shih-Pai Road
Taipei 112 TAIWAN
Tel: 886 2 28757826 ext 221
Fax: 886 2 28734101
E-Mail: phwang@vghtpe.gov.tw
†# Grant/Research: V95ED1-013/Taipei Veterans General Hospital
Yulun Wang PhD
90 Castilian Drive
Suite 200
Goleta CA 93117 USA
Tel: (805) 562-8686
Fax: (805) 562-8663
E-Mail: ywang@intouchhealth.com
† Discussion of commercial products or services
Significant financial interest or other relationship with the manufacturer(s) of products or providers of service(s) discussed
Stock
Other Support
Antoine A. Watrelot MD
Centre de Chirurgie Gynecologique
Le Britannia 20 Bld E Deruelle
Lyon 69003 FRANCE
Tel: 33 4 37 48 9090
Fax: 33 4 37 48 9094
E-Mail: watrelot@wanadoo.fr
*#
James A. Westervelt MD
601 7th Street South
St Petersburg FL 33701 USA
Tel: (727) 824-8280
Fax: (727) 824-8281
E-Mail: Jwestervelt@suncoastmed.com
† Discussion of commercial products or services
Howard N. Winfield MD
Dept of Urology RCP 3235
200 Hawkins Drive
Iowa City IA 52242 USA
Tel: (319) 384-9183
Fax: (319) 356-3900
E-Mail: howard-winfield@uiowa.edu
† Discussion of commercial products or services
Grant/Research: Yamanouchi- now Astellos
Consultant: Olympus, Intuitive Surgical, Oncura
Carson Wong MD
920 Stanton L. Young Blvd.
WP3150
Oklahoma City OK 73104 USA
Tel: (405) 271-6900
Fax: (405) 271-3118
E-Mail: carson-wong@ouhsc.edu
† Discussion of commercial products or services
George E. Woodman MD
6029 Walnut Grove Road
Suite 100
Memphis TN 38120 USA
Tel: (901) 869-2000
Fax: (901) 869-2009
E-Mail: woodmanmd@aol.com
*
Takashi Yamada MD, PhD
Department Pathology, Osaka Medical College,
2-7 Daigaku-machi
Takatsuki Osaka 569-8686 JAPAN
Tel: 81-72-683-1221
Fax: 81-72-684-6514
E-Mail: yamatakashi@mub.biglobe.ne.jp
*#
Tomone Yano MD
Sakura Hospital, Toho University
564-1 Shimoshizu
Sakura Chiba 285-8741 JAPAN
Tel: 81-43-462-8811
Fax: 81-43-462-8820
E-Mail: tyano@sakura.med.toho-u.ac.jp
*
Bulent Yaycioglu MD
Gazipasa Boulevard
Atesok Ap. No. 31 K-1
Adana 01120 TURKEY
E-Mail: ybulent60@hotmail.com
#
John Yeh
Children's Hospital/Ob-Gyn
219 Bryant Street
Buffalo NY 14222 USA
Tel: (716) 878-7138
Fax: (716) 888-3833
E-Mail: jyeh@buffalo.edu
#
Wen-Yao Yin
Clinical Assistant Professor of Surgery,
Tzu-Chi University
Buddhist Tzu-Chi General Hospital,
No. 2 Ming-Sheng Road, Dalin Town
622 CHINA
Tel: 886-5 2648000
Fax: 886-5 2648999
E-Mail: yaowen@mail.tcu.edu.tw
#
Robert K. Zurawin, MD
6620 Main Street
Suite 1450
Houston, TX 77030-2305 USA
Tel: (713) 798-6666
E-Mail: rzurawin@bcm.edu
† Discussion of commercial products and services Significant financial interest or other
relationship with the manufacturer(s) of products or providers of service(s) discussed
Consultant: Gynecare, Conceptus
Speakers Bureau: Gynecare, Conceptus
15TH SLS ANNUAL MEETING AND ENDO EXPO 2006 GENERAL SESSIONS
BEST OF LAPAROSCOPY UPDATES
7:30am Thursday, September 7, 2006
UPDATE ABDOMINAL AND PELVIC PAIN
Please Check My Bladder Before You Remove My Female Organs! It Is Not Just Endomeriosis: the New Insight of Treating Low Abdominal and Pelvic Pain in Women
Maurice Chung, RPh, MD
Chronic pelvic pain (CPP) is estimated to affect more than 9 million women in the United States. Up to 40% of laparoscopies and 10% to 12% of all hysterectomies are performed for CPP. In addition to lost productivity and decreased quality of life, the diagnosis and treatment of CPP consumes nearly $3 billion of health care expenditures annually.
The management of CPP is challenging due to the numerous possible differential diagnoses and contributing factors associated with this condition. Possible differential diagnoses include endometriosis, endosalpingiosis, pelvic adhesions, ovarian remnant syndrome, interstitial cystitis (IC), adenomyosis, and uterine leiomyomatas. These conditions may present with similar symptoms, and one or more may exist concomitantly in a given patient. Endometriosis is one of the more prevalent gynecologic diagnoses among women with CPP, affecting more than half of those patients who receive a diagnosis for their CPP. The symptoms of endometriosis include dyspareunia, cyclic perimenstrual low abdominal pelvic pain, symptom flares after sexual intimacy, and irritative voiding in the case of urinary tract involvement. A definitive diagnosis of endometriosis requires visual confirmation of the lesion during laparoscopy, and histologic confirmation of the presence of both ectopic endometrial glands and stroma. Interstitial cystitis, or pelvic pain of bladder origin, is a disorder that may be associated with CPP. The etiology of IC is unclear, but it is thought to be multifactorial and progressive, involving bladder epithelial dysfunction, mast cell activation, and bladder sensory nerve upregulation. The prevalence of IC in the United States range from 10 to 510/100,000 cases. Recent evidence suggests that this condition may, in fact, be much more prevalent than current estimates.
The symptoms of IC include urinary urgency/frequency and/or pelvic pain in the absence of urinary tract infection. Patients may also report dyspareunia and/or cyclic pain in association with the menses. Some patients may present with only urologic symptoms; conversely, 15% of patients present with chronic pain and no urologic symptoms. Patients with early IC may have only 1 or 2 symptoms, whereas at later stages, the full spectrum of symptoms may emerge and bladder capacity may be reduced. Recent data suggest that outcomes may be improved when IC is detected and treated at earlier stages. Therefore, it is important that health providers need to think of treating and evaluation chronic pelvic pain as a disease of multi-organ systems in women.
We will discuss some of the new findings in evaluation of chronic pelvic pain in women.
UPDATE BARIATRIC SURGERY
Alex Gandsas, MD
During the 2004 annual meeting, the Bariatric Surgery update was focused on surgical outcomes as well as emergent technologies for bariatric surgery.
This year we are planning to look at the growth of obesity and the increase in the amount spent in treating all major weight related co-morbidities. Interestingly, recent studies have shown that the cost of health care in morbidly obese patient has increased 5 times over the last 18 years.
We will bring an updated report from the Surgical Review Corporation regarding Centers of Excellence and review all necessary steps that are required to obtain such endorsement. We will also look at how the new CPT codes impact the current reimbursement game, including the new Medicare policy to cover weight loss surgery.
Finally, we will discuss the rise of the number of patients requesting revisional surgery, although, not many centers are offering such alternative as well as Centers offering bariatric surgery in the ambulatory setting.
UPDATE FERTILITY
Role of Deep Intramural Fibroids
on In Vitro Fertilization Outcome
Charles H. Koh, MD
The role of deep intramural fibroids that do not distort the uterine cavity in reproduction has not been well categorized in the past. Recently, much literature has emerged comparing IVF outcomes in the presence of such lesions but the conclusions remain controversial. This presentation will review the evidence and present techniques for removing deep intramural fibroids without causing harm to the existing pelvic infrastructure.
UPDATE ROBOTIC SURGERY
Computer Enhanced “Robotic” Surgery
William E. Kelley, Jr., MD
On July 12, 2000, the first computer-enhanced surgical system became FDA approved for abdominal and pelvic laparoscopic surgery in the United States. FDA approval followed in 2003 and 2004 for cardiac surgery, specifically for robot-assisted mitral valve replacement and robot-assisted CABG respectively.
Computer-enhanced surgery provides improved precision through motion scaling technology and electronic filtering. Wrists at the end of the laparoscopic instruments provide 360-degree rotation and flexion within 2 cm of the instrument tips. These mechanical advantages offer the surgeon a precision of movement that cannot be duplicated with traditional laparoscopic or open instruments. In addition, a true 3-dimensional visual system gives the surgeon much more precision with the instrumentation. These mechanical and visual advantages allow most surgeons to be ambidextrous with dissecting and suturing techniques.
At the current stage of development, the computer-enhanced technology has been most useful for complex dissecting and suturing techniques, especially in small, poorly accessible locations. The flexibility of the instrumentation has greatly facilitated dissection and suturing for radical prostatectomy. The majority of centers that currently have robotic systems, many of which had had no previous experience with laparoscopic radical prostatectomy, are utilizing the robot for this technique. Gynecologic applications have thus far been limited to infertility surgery for tuboplasty and tubal reanastomosis.
For general surgery, the instrumentation has shown substantial advantage for laparoscopic Heller myotomy, with a significant reduction in the incidence of mucosal perforation. Other procedures that have been enhanced by this technology include laparoscopic esophagectomy, pancreatectomy, laparoscopic pyloroplasty when performed at the time of anti-reflux surgery, and suturing the posterior suture lines of Toupet fundoplication.
For vascular surgery, experience is now growing with robot-assisted laparoscopic aortofemoral bypass and laparoscopic aortic aneurysmectomy. In our center, we have experienced hospital stays of 2.5 days following aortofemoral bypass, with the patient returning to normal activities in one week.
Cardiac surgery is probably the most spectacular example of this enabling technology. Multiple centers in the United States and in Europe and Canada have performed mitral valve replacement, as well as CABG. Totally endoscopic coronary artery bypass is now being performed with as little as 2-day length of stay, with patients resuming their normal activities one week following surgery.
The greatest promise of computer-enhanced surgery lies in its future applications. Enhanced precision and flexibility and the ability to deliver highly functional instruments to small awkward locations will empower surgeons to develop new techniques that are not currently feasible with MIS techniques. Robotic surgery could very well stimulate a new evolution of surgery in the decade to follow, as the instrumentation evolves and more flexible platforms for instrument delivery are developed.
MULTIDISCIPLINARY PLENARY SESSION
8:30am Thursday, September 7, 2006
INNOVATIONS IN SURGERY AND MEDICINE: FROM THE BENCH TO THE BEDSIDE
How to Start and Bring Your Idea of
Surgical Instrument to Reality
Thomas J. Fogarty, MD
How to overcome the barriers to innovation, the resources, time and personnel involved in the invention process will be presented. Changes that we can directly influence, alliances we can create, and situations we must begin to influence will also be discussed.
Venture Side of Starting a Company and
What to Look for in an Idea
Leslie Bottorff, Venture Capitalist
This presentation includes an overview of how physician entrepreneurs might go about getting funding for their new company concept, including seeking capital from institutional venture capital investors. It includes an explanation of how the venture capital industry works, how firms obtain their funds, structure their investments, and what criterion they will use to evaluate whether to invest in a start-up company or concept. Also included will be some frameworks for evaluating the business potential for a product concept or innovation, and whether seeking venture capital to start a new company is a viable avenue for getting the concept from the bench to commercial viability.
MULTIDISCIPLINARY PLENARY SESSION
10:30am Thursday, September 7, 2006
INFORMATICS FOR THE LAPAROENDOSCOPIC SURGEON
Introduction—SLS Websites
Paul Alan Wetter, MD
SLS endeavors to improve patient care and promote the highest standards of practice through education, training, and information distribution. SLS provides a forum for the introduction, discussion and dissemination of new and established ideas, techniques and therapies in minimal access surgery.
A fundamental goal of SLS is ensuring that its members have access to the newest ideas and approaches, as rapidly as possible. SLS makes information available from national and international experts through its publications, videos, conferences, and other electronic media.
To meet this goal SLS is using advanced internet technologies, to provide information to members and their patients.
This presentation will include a short tour of the SLS internet resources and a behind the scenes look at the technology used to implement them. including: Member listing, online textbook resources, SLS journals online, use of Blog Engines and web based programs.
General Informatic Session—Electronic Medical Records, CPOE, HIPAA Compliance,
and Evidence Based Medicine
Gustavo Stringel, MD
Informatics for the Laparoendoscopic Surgeon.
Information and communication technology (ICT) has been the driving force behind rapid economic growth around the world. It is “transforming social and economic activity faster than the steam engine, railroads, and electricity did in earlier times.” - U.S. Agency for International Development (USAID).
This recent statement by the Agency for International Development summarizes the impact of information and communication technology. The health care industry and physicians have been slow to adopt ICT. There has been a love-hate relationship between physicians and information technology especially with the older generations. The rapid evolution of technology has made it difficult to keep pace with the changes. In terms of dealing with ICT one can quote Mohammed Ali “You can run but you can’t hide”. Sooner or later all Physicians must develop a sophisticated knowledge of ICT.
It is impossible for any physician to function without a computer. In the past few years, there has been no doctor’s office without a computer. It is known that most health organizations spend up to 40% of their capital budgets acquiring and updating information technology. Medical informatics was defined by Edward Shortliffe, “Medical Informatics is the rapidly developing scientific field that deals with the storage, retrieval, and optimal use of biomedical information, data and knowledge for problem solving and decision making.” It is imperative for the laparoendoscopic surgeon to develop the knowledge and expertise in this field in order to take advantage of the new era of the information age. There is virtually no aspect of medicine or health care that has not been affected by information technology. We now see Robots making rounds and dispensing medications. Since the inception of the newly designed PACs system (picture archiving and communication system), radiographs can be reviewed at home, on medical wards, in operating rooms and virtually in every place that has a computer connected to the internet
Evidence Based Medicine
The term “ evidence-based medicine" (EBM) has become part of every day clinical practice. It implies the use of current best evidence in making decisions about the care of individual patients. Patients’ treatment should be based, to the greatest extent possible, on evidence.
In the past, most medical decisions were based on clinical experience, guessing, folklore, tradition, non scientific clinical observations and the art of medicine. With evidence based medicine, it is imperative to have scientific validity (Rose Jeff). The availability of good and reliable information is essential for the practice of EBM.
The principles of EBM were stated in 1980, when the American Cancer Society (ACS) developed its guidelines for the cancer-related health checkup: “First, there must be good evidence that each test or procedure recommended is medically effective in reducing morbidity or mortality; second, the medical benefits must outweigh the risks; third, the cost of each test or procedure must be reasonable compared to its expected benefits; and finally, the recommended actions must be practical and feasible”.(Eddy, DM) Since then, many medical societies have developed guidelines for EBM.
Evidence Based Medicine was initially defined as opposite to clinical experience. The importance of complementing the clinical experience with better evidence is now emphasized. (Timmermans S, and Mauck, A) One common implementation is the use of clinical practice guidelines in decision making to improve outcomes. The Institute of Medicine (IOM) defines clinical guidelines as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” (Field MJ and Lohr, KN)
Critics of clinical guidelines fear that its use and implementation will lead to “cookbook medicine” which will limit the use of practice experience and thwart clinical innovation.
Clinical guidelines have proliferated and there are currently guidelines for almost every disease, with more than 1000 new clinical guidelines created annually. Guideline implementation demands regular review of the scientific literature for necessary updates.
Computerized Physician Order Entry. CPOE
In 1999 the Institute of Medicine (IOM) reported in the article “To err is human,” that between 44,000 and 98,000 patients die in hospitals every year because of medical errors. In March 2001 the IOM released a second report on patient safety called “Crossing the Quality Chasm.” In summary, the IOM report stated that despite having the best acute medical services in the world, the overall U.S. care system is broken and fails to deliver consistent quality, especially for patients with chronic illness.
The IOM made several recommendations, including: creation of a center for patient safety, establishment of mandatory reporting via state agencies, establishment of safety programs in all health care organizations and passage of legislation.
In March 2003 the U.S. House of Representatives Ways and Means Committee passed the Safety Improvement Act by a wide margin. It stated that within 18 months the Secretary of Health and Human Services had to develop voluntary national standards for interoperability of health and information systems, specify medical terminology and evaluate technologies such as computerized physician order entry (CPOE) and medication bar coding,.
Adverse drug effects constitute about 19% of all adverse events, the second category after adverse surgical effects. Approximately 30 % of inpatients had at least one adverse drug effect.
Despite the potential benefits of CPOE, only an estimated 4-10% of U.S. hospital have fully implemented CPOE. (Cuttler DM, Feldman NE and Horwitz JR).
There has been increasing pressure from the IOM and other groups to implement CPOE. One of the main groups involved in the implementation of quality parameters including CPOE to improve quality and reduce error is The Leapfrog group. The Leapfrog group is a consortium of more than 130 fortune 500 companies and other large private and public purchasers of health care, including AT&T, IBM, General Electric and General Motors. They use their combined purchasing power to drive improvements in health care quality and safety. This group has continuously applied pressure to health providers to implement CPOE. In order to obtain Leapfrog certification a hospital must demonstrate that their CPOE system can intercept at least 50% of common serious medication prescribing errors.
There has been legislative pressure to implement CPOE. The state of California passed legislation for health care facilities to adopt a plan for reducing medication errors by 2005. In addition 26 other states have passed legislation to implement health care safety.
The potential savings of implementing CPOE have been emphasized mainly by reducing the number of medication errors. It has been calculated that there is an average cost of $4,685.00 per adverse drug event. CPOE should be recognized as a decision support tool. It can be effective only after a supportive system is implemented; this includes laboratory, pharmacy and dietary department integration. The human factor, not technology, is the main reason for failure. Physician participation and ownership of the project is essential for effective CPOE implementation.
HIPAA
The practice of medicine has significantly changed in the past ten years with an increase in the administrative and legal burdens for physicians. The managed care organizations change reimbursement and medical provider rules frequently. The physician has less time left to spend with the patient since there are increasing time demands for administration and bureaucracy. In the old times the physician’s main focus was treatment of the patient. Nowadays the paradigm has shifted to administrative issues, such as patient coverage, benefits, co-payments, formulary and non formulary medications, HIPAA compliance, referral authorization, and many others.
The Kassembaum-Kennedy Act of 1996, also known as The Health Insurance Portability and Accountability Act (HIPAA), was initially intended to simplify the overwhelming administrative processes and to improve health information security.
Many of the HIPAA regulations deal with simple administrative policies and procedures, such as securing patient privacy, locking office doors, training of personnel in patient privacy, and others. Some other requirements need managerial and technological solutions. Some of the issues initially designed to simplify problems have created sophisticated and expensive complexity for the health care provider.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) prompted new Federal regulations which require physicians to ensure that they are protecting the privacy and security of patients' medical information and using a standard format when submitting electronic transactions, such as submitting claims to payers.
The HIPAA Privacy Standards require physicians to protect the privacy of patients' medical information. Physicians are required to control the ways in which they use and disclose patients' "protected health information." In addition, physicians are required to offer patients certain rights with respect to their information, such as the right to access and copying, the right to request amendments, and the right to request an accounting of their charges. Finally, physicians are required to have certain administrative protections in place (such as a Privacy Officer, staff training, and implementation of appropriate Policies and Procedures) to further protect the privacy of patients' information.
Although HIPAA does not require physicians to use electronic transactions, a related law, the Administrative Simplification Compliance Act, does impose such a requirement. The Administrative Simplification Compliance Act requires that all claims submitted to the Medicare program must be submitted in electronic form. The implication of this requirement is that because the claims are submitted electronically, they will also be required to comply with HIPAA.
Department of Health and Human Services
Office of the Secretary
45 CFR Parts 160 and 164
Standards for Privacy of Individually
Identifiable Health Information; Final Rule
Federal Register / Vol. 67, No. 157 / Wednesday, August 14, 2002 / Rules and Regulations
A. Statutory Background
Congress recognized the importance of protecting the privacy of health information given the rapid evolution of health information systems in the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), Public Law 104–191, which became law on August 21, 1996. HIPAA’s Administrative Simplification provisions, sections 261 through 264 of the statute, were designed to improve the efficiency and effectiveness of the health care system by facilitating the electronic exchange of information with respect to certain financial and administrative transactions carried out by health plans, health care clearinghouses, and health care providers who transmit information electronically in connection with such transactions. To implement these provisions, the statute directed HHS to adopt a suite of uniform, national standards for transactions, unique health identifiers, code sets for the data elements of the transactions, security of health information, and electronic signature.
Health Insurance Portability and Accountability Act of 1996
Summary of Administrative Simplification Provisions
Standards for electronic health information transactions. Within 18 months of enactment, the Secretary of HHS is required to adopt standards from among those already approved by private standards developing organizations for certain electronic health transactions, including claims, enrollment, eligibility, payment, and coordination of benefits. These standards also must address the security of electronic health information systems.
Mandate on providers and health plans, and timetable. Providers and health plans are required to use the standards for the specified electronic transactions 24 months after they are adopted. Plans and providers may comply directly, or may use a health care clearinghouse. Certain health plans, in particular workers compensation, are not covered.
Privacy. The Secretary is required to recommend privacy standards for health information to Congress 12 months after enactment. If Congress does not enact privacy legislation within 3 years of enactment, the Secretary shall promulgate privacy regulations for individually identifiable electronic health information.
Pre-emption of State Law. The bill supersedes state laws, except where the Secretary determines that the State law is necessary to prevent fraud and abuse, to ensure appropriate state regulation of insurance or health plans, addresses controlled substances, or for other purposes. If the Secretary promulgates privacy regulations, those regulations do not pre-empt state laws that impose more stringent requirements. These provisions do not limit a State's ability to require health plan reporting or audits.
Penalties. The bill imposes civil money penalties and prison for certain violations.
Failure to comply with HIPAA can result in civil and criminal penalties (42 USC § 1320d-5).
Civil Penalties. Violations of the Administrative Simplification Regulations can result civil monetary penalties of $100 per violation, up to $25,000 per year.
Criminal Penalties. In June 2005, the U.S. Department of Justice (DOJ) clarified who can be held criminally liable under HIPAA. Covered entities and specified individuals, as explained below, whom "knowingly" obtain or disclose individually identifiable health information in violation of the Administrative Simplification Regulations face a fine of up to $50,000, as well as imprisonment up to one year. Offenses committed under false pretenses allow penalties to be increased to a $100,000 fine, with up to five years in prison. Finally, offenses committed with the intent to sell, transfer, or use individually identifiable health information for commercial advantage, personal gain or malicious harm permit fines of $250,000, and imprisonment for up to ten years.
Electronic Medical Records (EMR)
For many years physicians have used paper-based medical records. Some of the weaknesses of paper-based medical records are obvious and have become more evident in the information age. Paper-based medical records are often illegible because of poor penmanship. They are often ambiguous and contain incomplete information; the clinical data if often fragmented. In addition, paper records are not readily available and require large space for storage. Paper-based medical records are difficult to use to coordinate care, routinely measure quality or reduce medical errors.
Information technology is increasingly recognized as an important tool for improving patient safety and quality of care, and for promoting the practice of evidence-based medicine. Electronic medical records have a great potential for improving quality. Some of the benefits of electronic documentation are easy viewing, accurate and easy prescription and test ordering, and messaging. Other potential benefits of implementing EMR include: analysis and reporting to improve quality and efficiency, patient-directed functionality and billing, which can yield financial benefits through more complete capture of services provided, more defensible Medicare coding at higher coding levels, and reductions in data-entry staff.
Despite this potential for quality improvement few physician practices or health care facilities have embraced the use of Electronic Medical Records. There is increasing interest in EMR among physician groups. In a survey of 1,200 mostly solo/small physician groups, less than 13 percent of respondents said that their practice had EMRs. 32 percent expressed interest in EMRs, and half of these were "very interested." Clearly, the EMR is of growing importance for many physician practices.
Some of the barriers of EMR implementation include: high initial cost and uncertain financial benefits, high initial physician time investment, difficulties with technology, complementary changes and support, and problems with electronic data exchange. Other problems include: lack of incentive and physicians’ attitudes. The support and encouragement from physician champions is extremely important to successfully implement EMR.
MULTIDISCIPLINARY PLENARY SESSION
11:30am Thursday, September 7, 2006
COMPETENCY ISSUES AND ITS ASSESSMENT METRICS
A Scientific Basis for Measuring Surgical Skills Using Laparoscopic Simulation
Steve Dawson, MD
Although procedural simulation is becoming more widely accepted, it will remain outside the mainstream until performance measures are defined which will convince skeptics that learning is possible through medical simulation. Early studies have already shown the elements of validity in current, relatively primitive systems. However, in most simulators, defining metrics for medical simulation remains more of an art than a science.
This presentation will explain our scientific approach to metrics definition, exemplified by CELTS, our prototype Computer-Enhanced Laparoscopic Training System. Our method incorporates a standardized generic scoring system applicable to different laparoscopic trainers and tasks. Following extensive interviews with expert laparoscopic surgeons, the metrics were defined in an explicit way based on the relevant skills that a laparoscopic surgeon should master.
Operator feedback is provided through a 5-dof tracking device and software developed to perform real time analysis of the motion of actual laparoscopic instruments. Performance statistics are infinitely expandable as more users train on the system and can be accessed through a web browser.
This system has been validated in published studies [Surgical Endoscopy, 2006; 20(1): 104-112]. The results show that our metrics and scoring system represents a technically sound approach that can be easily incorporated into a training system, enabling standardized laparoscopic skills performance assessment across all levels of experience. Because of its task-independent design, this system is easily adapted to a variety of surgical tasks without software or system modifications, thus providing flexibility in objective skills assessment.
Objective Measures of Surgical Competency
Wm. LeRoy Heinrichs, MD, PhD
Criterion-based Technical Training for Surgeons
Wm. Leroy Heinrichs, MD, PhD1,2, Brian Lukoff3, Patricia Youngblood, PhD2, Richard Shavelson, PhD3, Parvati Dev, PhD2
With the SLS Ad Hoc Committee on Surgical Simulation: Richard M. Satava, MD5, Harrith M. Hasson, MD4, Elspeth M. McDougall, MD6, Camran Nezhat, MD,3 Paul Alan Wetter, MD7
Objective: The new paradigm in surgical education for basic skills training is using computer-based (manikin, augmented or virtual reality) simulators with embedded criteria to be achieved by students before performing surgery on patients. To establish training criteria, we have assessed the performance of basic technical surgical skills of 18 experienced laparoscopic surgeons recorded electronically in 26 basic skills modules selected in five commercially available, computer-based simulators.
Methods/Procedures: Quantitative data produced by the surgeons practicing repetitively during three one-half day sessions on each of five different simulators were collected in a Stanford IRB-approved study. Eight surgeons are generalists, six are gynecologists, and four are urologists; eleven are academic surgeons, and fifteen perform ≥ ten laparoscopic surgeries per month. Surgeons were randomly assigned to simulator stations (a total of 15 were provided by vendors) during each session. Each surgeon received a demonstration of the functioning of each module by a trained assistant who also logged the surgeon into and out of modules, using assigned participant numbers to assure anonymity. Demographic and opinion data were obtained to facilitate analysis. We developed proficiency score formulas for each module of the form b0 + b1X1 + b2X2 + . . . + bkXk, (1) where b0, b1, b2, . . ., bk are constants (called coefficients) and X1, X2, . . ., Xk are the measures (variables) recorded in the module. Assumptions in the development of the proficiency formulas are that the proficiency levels of experienced subjects is ≥ than 50, best performances do not exceed 100, and that proficiency should increase with practice.
Results: As expected, early practice attempts demonstrate a sharp learning curve and reduced variability among surgeons’ performance. In the third and subsequent practice attempts, performance scores improved little. Median scores and levels of 20, 40, 60, and 80 percent are provided for each module. Construct validity is examined with these data by comparing data for two of the modules from a convenience sample of less-experienced laparoscopic surgeons.
Conclusions: The mathematical method is simple, easily adjustable, and is applicable to the following simulators for which data are available: Lap Mentor (Simbionix), LapSim (Surgical-Science), LTS2000 ISM60 (RealSim), ProMIS (Haptica), and Surgical Sim (METI). Based upon this study, proficiency levels for training courses can now be specified objectively (and tentatively) by residency directors and by professional organizations for different levels of training or post-training assessment of technical performance. We say tentatively because experience with the proficiency scores will provide feedback as to reasonable levels of performance in practice, because none of the simulators were developed as an assessment instrument per se, and because future studies should map the link between performance on the simulator tasks and performance in surgery.
Department of Obstetrics–Gynecology, Stanford University1, Stanford University Medical Media and Information Technologies (Summit)2, School of Education, Stanford University3, RealSim4, Dept. Surgery, Univ. of Washington5, Dept. Urology, Univ. Calif.–Irvine6, Society of Laparoendoscopic Surgeons7
Predictive Validity of Simulation Performance in Operative Performance
Neal Seymour, MD
The demonstration of effectiveness of simulation training in residency curriculum presents challenges to educators. Predictive validity testing requires basic preliminary validation not only of the simulation system to be tested, but of the assessment methodology for the clinical task being trained. Clinical performance for some tasks is difficult to evaluate. Generally, part-task skills such as suturing are the most testable. Alternative approaches to determination of simulation-driven performance improvement include: A) The use of surrogate clinical environments for assessment such as animal OR, and B) longitudinal assessment of clinical performance to ascertain that peer-appropriate performance targets are being achieved. Multiple-observation within subject trials can demonstrate cause-effect relationships between simulation training and improvement in clinical performance and are practical to use during the course of formative training. However, these methods are vulnerable to bias and confounding factors that are more effectively controlled for in drug study-style randomized trials. Other practical considerations in assessment include the fidelity of the assessment methods, frequency of application, and cross-task applicability. At Baystate Medical Center, Springfield, MA, a system of educational program development focusing on computer-based simulation was implemented with separate efforts involving medical student clinical clerks and surgical residents. This system served as the testbed for a larger curriculum effort, also focusing on simulation as the principle teaching method. During the course of training, selected simulation methods were subjected to predictive validity testing by both randomized controlled trial, and within-subject trials. In addition, resident technical performance was tracked globally during all clinical cases with a web-based data gathering tool. These results all suggest that the simulation methods used are effective contributors to resident and student clinical skills. At present the ability to demonstrate clear influence of training on clinical performance with practical outcomes measures is limited. The development of appropriate clinical performance measures and the effort to apply these in connection with simulation training methods that will ensure the quality of the education process as well as the resulting clinical care.
Technical Skill—a Component of Surgical Performance
Harrith M. Hasson, MD
Competency in laparoscopic surgery involves three interdependent components: knowledge, technical skill and judgment. Knowledge & judgment are assessed with objective examinations. Technical skill is still being evaluated through subjective appraisal. Surgical performance is based on technical skill. However, lacking knowledge or good judgment an excellent technician can experience problems and complications. Technical skills are based on inherent abilities which determine the ultimate level of laparoscopic skills. Training and practice help surgeons realize their full potential within the constraints of their natural abilities. There are three levels of skill assessment/ training 1) Basic coordination exercises which assess inherent ability 2) Enabling skill/ task exercises duplicating surgical maneuvers: cannulation, clip application, cutting, camera navigation, ligation, suturing, knot tying and application of energy sources. 3) Simulation of entire laparoscopic procedures. Recent advances in human performance research have identified tools for objective measurement of innate abilities. General System Performance Theory states that to perform a given task successfully, the system (surgeon) must have sufficient resource availability (capacity) to execute the task. If the performance demands of the task are greater that the basic performance resources (BPRs) of the surgeon, the task cannot be successfully performed. BPRs defining laparoscopic abilities include: Simple visual hand response speed, visual information processing speed, visual spatial short term memory capacity and arm neuromotor channel capacity; the most common performance limiting factor. The performance of a laparoscopic task or exercise (real or simulated) is limited by the weakest BPR relative to the demands of the task or exercise. However, experts can compensate for relative deficiency in one BPR by relative surplus in another and end up performing the tasks successfully. Transfer of skills from VR simulators or Box Trainers to the OR has been confirmed in several studies. A new paradigm for surgical training is emerging: residents should be trained to skill proficiency criterion in the safe simulation environment before performing surgery on patients. Simulation practice should continue so as to consolidate & integrate gained skills within established repertoire. Practice helps to maintain proficiency over time. Surgical performance, a complex phenomenon involving dynamic interaction between the surgeon’s knowledge, technical skill and judgment can be evaluated objectively by reviewing unedited videotapes for errors & OSATS global rating scale. To assess technical skills, Reznick & Regehr modified the OSCE (Objective Structured Clinical Exam) into Objective Structured Assessment of Technical Skill (OSATS) Exam. A multi-station task-specific bell ringer exam where performance is assessed by 2 examiners with 2 tools: task-specific check list of relevant items (scored 0/1) and global rating scale of 7 dimensions of operative performance (scored 0 poor to 5 excellent). A system of reviewing unedited videotapes has been implemented by Japanese Urologists and initiated by American Gynecologists through the Accreditation Council for Gynecologic Endoscopy (ACGE). Dr. Matsuda is giving an update at this meeting. Information regarding the ACGE Expertise Recognition Program is available through http://www.accreditationcouncil.org. References on request.
FUTURE TECHNOLOGY SESSION
9:00am Saturday, September 9, 2006
BEYOND HUMAN EXPERIENCE: BREAKING BONDS OF “HUMAN” LIMITATIONS
Keynote Address
Medicine in the Extreme: Adventures of an
Explorer in Extreme Environments
Kenneth Kamler, MD
Regenerative Medicine: New Approaches in Health Care for the 21st Century
Anthony Atala, MD
Patients suffering from diseased and injured organs may be treated with transplanted organs. However, there is a severe shortage of donor organs which is worsening yearly due to the aging population. Scientists in the field of regenerative medicine and tissue engineering apply the principles of cell transplantation, material science, and bioengineering to construct biological substitutes that will restore and maintain normal function in diseased and injured tissues. Therapeutic cloning, where the nucleus from a donor cell is transferred into an enucleated oocyte in order to extract pluripotent embryonic stem cells, offers a potentially limitless source of cells for tissue engineering applications. The stem cell field is also advancing rapidly, opening new options for therapy. We review recent advances that have occurred in regenerative medicine and describe applications of these new technologies that may offer novel therapies for patients with end-stage tissue and organ failure.
Robots and Emotional Expression
David Hanson
Human Simulation Robotics
This presentation will discuss the author's work creating humanlike robots, robot skin materials, and cognitive experiments that gauge human reaction to the robots. Humanoid robots more closely emulate the expressive behavior, personality and tissue composition of people than ever before. The trends related to these advances are not slowing; in fact, according to many metrics, the trends are accelerating. The presentation will discuss the short term and long-term implications of these technology trends, including development of new applications for medicine. Humanlike robotic technologies may offer many new tools for medical simulation, visualization, and therapies, some of which will be discussed in the talk. The presenter will also demonstrate the conversational Albert Einstein robot, featured on the cover of WIRED in January 06.
15TH SLS ANNUAL MEETING AND ENDO EXPO 2006 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 15th International Congress and Endo Expo 2006 in Boston, Massachusetts.
These SIG Committees support the educational mission of SLS and by presenting the popular Laparoscopy Updates at the Congress, 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
MULTI-DISCIPLINARY:
Abdominal/Pelvic Pain/Adhesions
Cancer Surgery
Core Competencies
Endocrine/Solid Organ
Ergonomics/Monitoring/Access/Patient Preparation
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
HERNIA UPDATE
Laparoscopic Hernia Update 2006
Lawrence C. Biskin, MD
It appears that the adoption rate for laparoscopic inguinal hernioplasty has plateaued over the last few years. The reasons why this has occurred are as follows:
1) Other advances in science and technology occupy a surgeon’s time and efforts.
2) The need for continuous professional development does not allow for unilateral surgical focus.
3) Journal articles that downplay the procedure and recommend utilizing the laparoscopic approach for only bilateral and recurrent hernias. This approach is inappropriate with inexperienced surgeons since recurrent and bilateral hernias make up a small percentage of the average general surgeon’s hernia cases, thereby minimizing the experience necessary to operate through the learning curve. The second problem is that recurrent hernias are not free of scar tissue despite the posterior approach and that dissection in the preperitoneal space can be very tedious. This may be more of a push for hernia specialists.
4) Zero tolerance. There is an intense focus on competence, accountability and patient safety therefore complications during the learning curve are no longer acceptable. It has been well documented that the complication and recurrence rate will be higher with surgeons who do only the occasional laparoscopic hernioplasty.
5) The learning curve is steep and the operating time is long initially.
6) The surgeon may not need to do the procedure and the community may not demand it.
7) Hospital costs are higher with long learning times so the focus has been on reducing instrument costs. No mesh fixation to save costs on the tacker is not a good trade-off for potential recurrences.
8) It’s costly in time and money for a surgeon to learn new techniques.
9) Reimbursement is lower.
The laparoscopic repair of inguinal hernias in experienced hands has proven to be as good if not better than the open repair with regard to post-op pain, recurrences, and overall recovery.
Another advantage of laparoscopic inguinal hernioplasty has been the ability to repair concomitant inguinal (ª25%) and umbilical (ª15%) hernias by adding just a few minutes to the operative procedure without a significant reduction in recovery times. This benefits the patient tremendously. The surgeon however will suffer a monetary loss since multiple procedures are only reimbursed at 1/2 the actual cost. The insurance company will benefit monetarily by not only paying the surgeon less but also by not having to pay the hospital costs for a second or even third operation.
Although the TEP repair is a quicker and ultimately better operation (peritoneum not violated) the transabdominal (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 conversion (2%) from TEP. The TAPP approach is the only laparoscopic technique that can be safely used for recurrent posterior repaired hernias or patients with prior prostate or bladder operations. Tissue separating meshes routinely utilized for ventral hernioplasties have a non-adherent side, which should diminish the adhesions to the mesh thereby allowing safe re-entrance into the preperitoneal space.
Since the laparoscopic ventral hernia repair is similar technically and anatomically to the open repair the learning curve is not as steep as the laparoscopic inguinal approach. Adhesiolysis is the most tedious and ominous part of the operation. Electrocautery and ultrasonic dissection can both cause occult intestinal burns and their use is not routinely recommended. Sharp dissection is safer and should eliminate unrecognized bowel injuries.
Some sort of tissue separating mesh should be utilized to minimize adherence to the viscera. The mesh should overlap the defects by at least 5 cm and transabdominal suture fixation is imperative (metallic tacks alone appear to be inadequate for repair). Newer fixation devices may offer more promise.
Pain after laparoscopic inguinal hernioplasty is minimal or nonexistent, however pain after laparoscopic ventral hernioplasty can be worse than the open technique despite the use of local injections, pain pumps, epidural catheters, and various other maneuvers. This does not appear to be a deterring factor since the benefits of lower recurrence and wound complication rates along with the ability to identify and repair multiple abdominal wall defects including difficult parastomal hernias are all helping this operation become the standard of care.
OFFICE AND OUTPATIENT LAPAROSCOPY UPDATE
James F. Carter
We continue to push the envelope in Laparascopic hysterectomies with outpatient laparoscopic supracervical hysterectomies. We are doing more and more difficult cases with minimally invasive incisions that heretofore was not considered possible in the mainstream.
In addition, being able to perform hysteroscopic sterilizations without even the incisions in the abdomen is now here. Can we do these in the office?
Only our imaginations (and bureaucracies in office operating rooms) stand in our way.
PELVIC RECONSTRUCTIVE SURGERY/STRESS URINARY INCONTINENCE UPDATE
Scoping Out New Options in Pelvic Reconstruction
Conrad Duncan, MD
Members of SLS support both the application of minimally invasive innovations as well as the application of evidenced-based medicine in our surgical practices.
In the past 10 years urologists and gynecologists have witnessed the introduction and widespread adoption of the use of synthetic mesh in the management of patients with stress urinary incontinence (SUI). The introduction of the Tension Free Vaginal Tape‚ essentially revolutionized the treatment of SUI. “Long term” (10 yr) data has shown the tension-free mid-urethral sling to be a relatively safe and efficacious minimally invasive treatment option for SUI.
We are now witnessing the propagation of the use of synthetic mesh in the correction of a wide range of vaginal vault defects including total uterine prolapse. Surgical application of mesh for the repair of pelvic organ prolapse has been based on theoretical principles, extrapolation from the general surgery literature, industry sponsorship and surgeon preference, as we do not yet have evidence-based data to support their widespread use. Yet, many pelvic reconstructive surgeons have embraced their application as an even more minimally invasive alternative than laparoscopic pelvic reconstruction.
We will review the anatomical and surgical principles involved in the placement of a total vaginal mesh, review the surgical technique in video and review some of the preliminary surgical outcomes data.
THORACIC UPDATE
Thoracic Surgery. Laparoscopic and
Thoracoscopic Update 2006
Neil A. Christie MD
Progress continues to be made in Minimally Invasive Thoracic Surgery. Minimally invasive techniques are now applied to mediastinal surgery, surgical resection of lung cancer with anatomic lobectomy, and surgical resection for esophageal cancer with laproscopic and thoracoscopic esophagectomy. Laparoscopic approaches for complex benign esophageal disease are also being applied with redo laparoscopic fundoplication and repair of large paraesophageal herniae. Techniques and outcomes in three examples will be reviewed: thoracoscopic lobectomy; laparoscopic and thoracoscopic esophagectomy; and laparoscopic repair of giant paraesophageal herniae with Nissen fundoplication and Collis gastroplasty.
UROLOGY
Urology Laparoscopic and Robotic Surgery Update
Howard N. Winfield, MD, FRCS
Since 1990, urologic surgeons have taken a leading role in minimally invasive surgery (MIS). Laparoscopic radical nephrectomy, first described in 1991, is now considered the “gold standard” for localized renal tumors. Laparoscopic partial nephrectomy for renal masses =/< 4 cm is gaining increasing popularity. However, this procedure continues to present significant challenges requiring laparoscopic suture repair of the surgical defect, hilar control of renal vessels to minimize hemorrhage and concern for warm ischemic damage to the remaining renal parenchyma. Renal cooling and hemostatic techniques are in evolution to overcome these obstacles. Encouraging long term results (>5 years) are maturing to demonstrate the effectiveness of laparoscopic cryoablation and radiofrequency ablation for the treatment of small renal masses. Laparoscopic radical prostatectomy is more popular in Europe and radical cystectomy is performed in select centers in U.S. with promising results.
Robotic surgery has found major applications in the field of Urology. Radical prostatectomy (RRP) is the most frequently performed robotic procedure, outstripping all other surgical disciplines. In 2002 there were only 600 robotic prostatectomies performed whereas in 2004 there were 9600 cases reported. This exponential growth is expected to continue. Oncologic effectiveness, urinary continence and erectile function are very comparable with open surgery. The blood loss and convalescence appear to be superior with robotic RRP. Robotic-assisted pyeloplasty for ureteropelvic junction has gained popularity with excellent results comparable to open or laparoscopic pyeloplasty. Robotic radical cystectomy is performed in select centers with encouraging results.
Urologists continue to play an active role for surgical training in the form of computer virtual reality simulation, validity testing and core programs in minimally invasive surgery for residents. Improved methods to provide continuing medical education in MIS for urologists has become an important focus of the American Urological Association.
15TH SLS ANNUAL MEETING AND ENDO EXPO 2006 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 15th International Congress and Endo Expo 2006.
Anne Marie Boller, MD
ColoRectal
Mayo Clinic
Rochester, Minnesota, USA
Tracey L. Buckley, RN
North Bay Gen. Hosp.
North Bay, , CANADA
Moira Cameron, RN
North Bay Gen. Hosp.
North Bay, , CANADA
Benjamin L. Clapp, MD
General Surgery
Univ of TX Houston
Houston, Texas, USA
Alexander Dzakovic, MD
General Surgery
Harvard Med. School
Boston, Massachusetts, USA
Roger C. Ernest DO
General Surgery
Univ of Med & Dentistry of New Jersey
Haddon Hts., New Jersey, USA
Kathy Gohar, MD
General Surgery
Albert Einstein Med. Ctr.
Philadelphia, Pennsylvania, USA
Mubashar Hussain, MD
General Surgery
Stepping Hill Hosp.
Stockport, United Kingdom
Christopher Ip, MD
Urology
Mt. Sinai School of Med.
New York, New York, USA
Faiyaz M. Kapasi, MD
Gynecology
The Princess Alexandra Hosp.
Stortford, United Kingdom
Stuart S. Kesler, MD
Urology
Robert Wood Johnson University Hospital
Hackensack, New Jersey, USA
Daniel S. Kim, MD
Pediatric Surgery
Brown Medical School
Providence, Rhode Island, USA
Rita Kwan, MD
General Surgery
Univ of California–San Francisco
Oakland, California, USA
Jonathan A. Laryea, MD
General Surgery
Waterbury Hospital
Waterbury, Connecticut, USA
Ingrid M. Lizarraga, MD
General Surgery
Univ of Iowa Hospital
Iowa City, Iowa, USA
Ralph Madeb, MD
Urology
Strong Memorial Hosp.
Rochester, New York, USA
Adam H. Power, MD
General Surgery
McMaster University
Hamilton, Ohio, USA
Anuj Prashar, DO
General Surgery
Univ of Med. & Dentistry of New Jersey
Haddon Hts.,, New Jersey, USA
Masoud Rezvani, MD
General Surgery
Abington Memorial Hospital
Abington, Pennsylvania, USA
Hilda E. Rodriguez, MD
Gynecology
Ctr for Special Minimally Invasive Surgery
Palo Alto, California, USA
Jay P. Shah, MD
Gynecology
Wayne State Univ
Washington, District of Columbia, USA
Lynda A. Simeone, RN
North Bay Gen. Hosp.
North Bay, CANADA
Scholarships awarded at the time of print.
MINIMALLY INVASIVE SURGERY WEEK PODCASTS
SLS • MIRA • SRS JOINT ANNUAL MEETING AND ENDO EXPO 2012
WEDNESDAY, SEPTEMBER 5, 2012
State of the Art Lectures in Robotic Surgery
7:30am-10:15am Lectures (m4a / 156.2 MB)
Moderators: Arnold Advincula, MD & Johannes Bonatti, MD
Nader Sadeghi, MD
Kyu Eun Lee, MD
Farid Gharagozloo, MD
Richard Lazzaro, MD
Franca Melfi, MD
Abbas E. Abbas, MD
Petr Stadler, MD
Changqing Gao, MD
Johannes Bonatti, MD
Allen R. Raczkowski, MD
10:15am-10:15am Lectures (m4a / 63.0 MB)
Moderators: Camran Nezhat, MD & Vincent Obias, MD
Antonio Garguilo, MD
Camran Nezhat, MD
Arnold P. Advincula, MD
Daniel H. Smith, MD
Vincent Obias, MD
12:30pm-3:30pm Lectures (m4a / 137.9 MB)
Moderators: Mehran Anvari, MD, BS, PhD, Carlos Galvani, MD, & Jacques M. Hubert, Prof Dr. Med
Elisabeth C. McLemore, MD
John Meehan, MD
Mehran Anvari, MD, BS, PhD
Jacques M. Hubert, Prof Dr Med
Thomas W. Jarrett, MD
Piyush K. Agarwal, MD
Noel N. Williams, MD
Carlos Galvani, MD
R. Matthew Walsh, MD
Keynote Lecture (m4a / 41.9 MB)
When Will Minimally Invasive and Roboic Surgery Replace Almost All Open Surgeries?
Camran Nezhat, MD
Opening Ceremony (m4a / 74.2 MB)
Paul Alan Wetter, MD, Chairman, SLS
James C. "Butch" Rosser, Jr., MD, Imediate Past President
Maurice K. Chung, RPh, MD, SLS President 2012
Johannes Bonatti, MD, MIRA Welcome
Arnold P. Advincula, MD, SRS Welcome
Maurice K. Chung, RPh, MD, Introduction of Honorary Chair
Professor Jie Qiao, MD, PhD Honorary Chair
Joseph B. Petelin, MD, Introduction of Honorary Chair
Mehran Anvari, MB, BS, PhD, Honorary Chair
THURSDAY, SEPTEMBER 6, 2012
Highlights Session - Highlights of Robotic State of the Arts Lectures (m4a / 11.8 MB)
Gustavo Stringel, MD, MBA
Mona Orady, MD
General Session: Best of Laparoscopy Updates (m4a / 47.6 MB)
Director: William E. Kelley, Jr., MD
Co-Directors: Maurice K. Chung, RPh, MD, Douglas Ott, MD, MBA
Sijo J. Parekattil, MD: Robotic Assisted Microsurgery: Vasectomy Reversal & Groin Pain Procedures (Robotics SIG) (m4a / 47.6 MB)
Kevin J. E. Stepp, MD: Beyond Conventional Laparoscopy: LESS, SILS, Microlaparoscopy and NOTES (NOTES, LESS SPA and Single Port Surgery SIG)
David W. Bliss, MD: Pediatric MAS – Equivalent or Better? (Pediatric Surgery SIG)
Stephen A. Grochmal, MD: Eccentric Hysteroscopy: Expanded Utilization (Fertiloscopy/Transvaginal Endoscopy SIG)
MULTIDISCIPLINARY PLENARY SESSION (Gynecology, General Surgery, Urology)
“Surgery
is a Team sport” Education for the OR from Surgeon, Nurse, Tech,
Anesthesia, Central, etc….How to Run an Efficient, Cost-Effective,
Economically Responsible Operating Room! (m4a / 76.1 MB)
Director: Jay A. Redan, MD
Co-Director: Gustvo Stringel, MD, MBA
Nicholas Archer, Director of Finance, Florida Hospital Celebration Health: How Much Money is Needed for a Safe, Cost Effective and Enjoyable Operating Room Environment?
Gregory H. Adkisson (Anesthesiologist): The Operating Room from the Head of the Table: An Anesthesiologists Perspective
Gustavo Stringel, MD, MBA: Quality
Measures in the Operating Room, What Insurance Companies Want to Know
About You and Your Team...How are Outcomes Measured?
Jay A. Redan, MD: The Surgeon as the Captain of the Ship, What is Needed to Stay Afloat!
The Information You Need When and Where You Need It - SLS Scholarly Search and Interactive E Books (m4a / 20.0 MB)
Paul Alan Wetter, MD
MULTIDISCIPLINARY PLENARY SESSION (Gynecology, General Surgery, Urology)
Single Access and Minimizing Ports: Multidisciplinary Town Hall Challenge/ Debate (m4a / 59.9 MB)
Director: Maurice K. Chung, RPh, MD
Co-Director: William E. Kelley, Jr., MD
James C. "Butch" Rosser, Jr., MD: Traditional Laparoscopy
Gustavo L. Carvalho, MD, PhD: Mini Laparoscopy
David W. Rattner, MD: NOTES
Kevin J.E. Stepp, MD: Single Access and Reduced Port Laparoscopy
MULTIDISCIPLINARY PLENARY SESSION (Gynecology, General Surgery, Urology)
I
Could Use a Robot – But Should I? Who, Why, When, and Where - Town Hall
Debate • Jointly with the Minimally Invasive Robotic Association (MIRA)
and The Society of Robotic Surgery (SRS) (m4a / 57.1 MB)
Director: Howard N. Winfield, MD
Co-Director: Arnold P. Advincula, MD
Howard N. Winfield, MD: Robotic Assisted Partial Nephrectomy: Is it Better than the Laparoscopic or Open Surgical Approach?
Arnold P. Advincula, MD: Robotic-Assisted Hysterectomy is Really Just Open Surgery in Disguise
Ivo A.M.J. Broeders, Prof Dr Med: Is Robotic-Assisted Fundoplication Overkill?
FRIDAY, SEPTEMBER 7, 2012
Highlights Session - Highlights of MultiSpecialty Topics From Concurrent Sessions (m4a / 12.4 MB)
Gustavo Stringel, MD, MBA
Oliver Muensterer, MD
MULTIDISCIPLINARY PLENARY SESSION (Gynecology, General Surgery, Urology)
The Changing Face of Healthcare for Surgeons….Work Time Directives (m4a / 60.5 MB)
Director: Richard M. Satava, MD
Professor Oscar Traynor: The European Perspective and Current Trends within the European Union
Richard K. Reznick, MD, MEd: Current Threats to Surgical Training Require Radical Thinking
James C. Hebert, MD: United States Experience and Coping Strategies for the 80 Hour Week
Presentation of Best Papers, Best Video, and Best Poster Awards (m4a / 23.4 MB)
Session Director: Paul Alan Wetter, MD
Co-Director: Maurice K. Chung, RPh, MD
Presentation of Michael S. Kavic Award for Best Resident Paper
Presentation of the Paul Alan Wetter Award for Best Multispecialty Paper
Presentation of the Carl J. Levinson Award for Best Video
Awarding of Best Poster
Session Director: Gustavo Stringel, MD, MBA
Co-Director: Raymond J. Lanzafame, MD, MBA
Improving the Outcomes for Six Million Surgical Patients - ORReady (m4a / 6.7 MB)
Paul Alan Wetter, MD
20TH SLS ANNIVERSARY MEETING AND ENDO EXPO 2011 PODCASTS
Wednesday, September 14, 2011
Opening Ceremony (m4a / 42.3 MB)
Paul Alan Wetter, MD, Chairman, SLS
Gustavo Stringel, MD, MBA, Imediate Past President
James C. "Butch" Rosser, Jr., MD, SLS President 2011
Professor Wai Lun Law, MS, Honorary Chair
Maurice K. Chung, RPh, MD
Professor Enlan Xia, MD, Honorary Chair
Thursday, September 15, 2011
General Session: Best of Laparoscopy Updates
Director: William E. Kelley, Jr., MD
Co-Directors: Harrith M. Hasson, MD & Douglas E. Ott, MD, MBA
Abdominal Pelvic Pain/Adhesions Committee: CAPPS (Complex Abdominal and Pelvic Pain Syndrom) (m4a / 9.6 MB)
Jay A. Redan, MD
The Information You Need When and Where You Need It - SLS Scholarly Search for Minimally Invasive Surgery (m4a / 9.0 MB)
Paul Alan Wetter, MD
Multidisciplinary Plenary Session: Directed Energy for Tissue Ablative Therapies
Director: Prof. Doron Kopelman, MD
Introduction (m4a / 2.8 MB)
Prof. Doron Kopelman, MD
Plasma Energy for Ablation of Malignant and Benign Pathology (m4a / 6.6 MB)
Farr Nezhat, MD
Long Term Survival of Mammographically Detected Invasive Breaast Cancer Patients Treated with Interstitial Laser Therapy (ILT) (m4a / 6.9 MB)
Kambiz Dowlat, MD
RFA of Kidney Tumors (m4a / 8.0 MB)
Jeffrey A. Cadeddu, MD
Recent Advances in MRgFUS (m4a / 8.5 MB)
Prof Doron Kopelman, MD
Discussion / Q&A (m4a / 2.4 MB)
Multidisciplinary Plenary Session: Smallar or Alternative Access Surgery: Should I Do It? Is it Better for My Patient?
Director: Paul G. Curcillo, II, MD
Co-Director: William E. Kelley, Jr., MD
Traditional Laparoscopy: Is It Really Broken? (m4a / 5.0 MB)
James C. "Butch" Rosser, Jr., MD
Can You Still Do a BIG Operation with Mini-Instruments? Risk, Benefits, Complications and Equipment (m4a / 5.5 MB)
Jay A. Redan, MD
Single Incision Laparoscopic Surgery: LESS is More (m4a / 4.7 MB)
Mihir Desai, MD
NOTES: Current Status - Dead End - or Still a Path to Future Innovation? (m4a / 8.6 MB)
Michael R. Marohn, MD
Multidisciplinary Plenary Session: Synthetic Materials in Minimally Invasive Surgery:
Director: Maurice K. Chung, RPh, MD
Co-Director: Raymond J. Lanzafame, MD, MBA
The General Surgery Perspective (m4a / 5.9 MB)
Stephen M. Kavic, MD
Prosthetics for Hernia Repair (m4a / 4.7 MB)
Phillip Shadduck, MD
Mesh in Pelvic Surgery (m4a / 5.5 MB)
Maurice K. Chung, RPh, MD
The Applications and Complications of Mesh in Minimally Invasive Surgery (m4a / 6.0 MB)
Raymond J. Lanzafame, MD, MBA
Discussion / Q&A (m4a / 2.0 MB)
Friday, September 16, 2011
Multidisciplinary Plenary Session: Minimally Invasive Techniques for Organ Sparing Surgery
Director: Maurice K. Chung, RPh, MD
Gustavo Stringel, MD, MBA
Organ Sparing and the Kidney: Redefining the Term Minimally Invasive (m4a / 5.9 MB)
Jaime Landman, MD
LSH, LIH - Tissue and Nerve Sparing Alternatives at Hysterectomy (m4a / 6.6 MB)
Thomas L. Lyons, MD, MS
Awarding of Best Poster & Presentation of Michael S. Kavic Award for Best Poster & Paul Alan Wetter Award for Best Multispecialty Paper (m4a / 13.5 MB)
Awarding of Best Poster
Director: Harrith M. Hasson, MD
Co-Director: Maurice K. Chung, RPh, MD
Presentation of Michael S. Kavic Award for Best Resident Paper and Paul Alan Wetter Award for Best Multispecialty Paper
Director: Paul Alan Wetter, MD
Co-Director: James C. "Butch" Rosser, Jr., MD
Improving the Outcomes for Six Million Patients - ORReady (m4a / 7.9 MB)
Paul Alan Wetter, MD
Special Presentation: (Nearly) All You Need to Know to be a Great Surgical Teacher (in about 15 Minutes) (m4a / 17.1 MB)
Hilliard Jason, MD, EdD
Saturday, September 17, 2011
Special Event: Breakfast and Future Technology Session: Future of Medicine According to Science Fiction Writers
Director: Richard M. Satava, MD
Bringing Back the Future: Knowledge and Imagination in Biology and Medicine (m4a / 15.4 MB)
Greg Bear
The Future May Be Different: Possible Surprises in Tomorrow's Medicine (m4a / 17 MB)
David Brin
Scenarios for the Future of Medicine (m4a / 15 MB)
Vernor Vinge
Discussion and Q&A (m4a / 29.5 MB)
19TH SLS ANNUAL MEETING AND ENDO EXPO 2010 PODCASTS
Wednesday, September 1, 2010
Opening Ceremony (m4a / 42.3MB)
Paul Alan Wetter, MD, Chairman, SLS
Charles H. Koh, MD, Immediate Past President
Gustavo Stringel, MD, MBA, SLS President 2010
Stefano Bettochi, Prof Dr Med
Gustavo Stringel, MD, MBA
Donald Risucci, PhD, Honorary Chair
Maurice K. Chung, RPh, MD
Ornella Sizzi, MD, Honorary Chair
Thursday, September 2, 2010
General Session: Best of Laparoscopy Updates
Director: William E. Kelley, Jr., MD
Co-Directors: Harrith M. Hasson, MD & Douglas E. Ott, MD, MBA
Fellowship Program Committee: The State of Fellowship (m4a / 6.2 MB)
Stephen M. Kavic, MD
Abdominal/Pelvic Pain/Adhesions Committee: The Evil Trilet of Chronic Pelvic Pain Syndrome: Pudendal Neuralgia (m4a / 6.7 MB)
Maurice K. Chung, RPh, MD
Multidisciplinary Plenary Session: Adhesions/Adhesion Prevention (Jointly with ISGE)
Director: Charles E. Miller, MD
Co-Directors: Raymond J. Lanzafame, MD, MBA
Abdominal and Pelvic Adhesions, the GYN Perspective (m4a / 7.5 MB)
Charles E. Miller, MD
Prosthetics, Synthetics and Biologicals: Solutions from the Laboratory (m4a / 9.4 MB)
Raymond L. Lanzafame, MD, MBA
Adhesions in the Abdomen, the General Surgeon's Perspective (m4a / 6.8 MB)
Stephen M. Kavic, MD
New Strategies in Prevention and Management of Adhesions: The Research Perspective (m4a / 7.2 MB)
Kathleen Rogers, PhD
18TH SLS ANNUAL MEETING AND ENDO EXPO 2009 PODCASTS
Wednesday, September 9, 2009
Opening Ceremony (mov / 47.2MB)
Paul Alan Wetter, MD, Chairman, SLS
William E. Kelley, Jr. MD
Charles H. Koh, MD, SLS President 2009
Gustavo Stringel, MD, MBA
Roberto Gallardo D., MD, Honorary Chair
Charles H. Koh, MD
Suresh Nair, MD, Honorary Chair
Thursday, September 10, 2009
General Session: Best of Laparoscopy Updates
Gynecology Committee: The Use of Mesh for Stress Incontinence and Pelvic Floor Prolapse (mov / 9.5MB)
Steven M. Minaglia, MD, MBA
Gynecology Committee: Pediatric Gynecology (mov / 9.1MB)
Robert K. Zurawin, MD
Multidisciplinary Plenary Session: Image-Guided Surgical Procedures. What a Surgeon Should Know About Non-Surgical Approaches
Role of Robotics in Image Guided Procedures (mov / 18.2MB)
Mehran Anvari, MS, BS, PhD
Stereotactic Radiosurgery (SRS): Is It Radiation Therapy; Why Should I Care? (mov / 8.9MB)
Ron Davis, MD & Paul Goldfarb, MD
The Surgeon's Responsibility for Imaging Utilization During Minimally Invasive Procedures (mov / 7.9MB)
Pat Fulgham, MD
MRI-guided Focused Ultrasound Surgery (MRgFUS) for Uterine Fibroids (mov / 9.6MB)
Elizabeth A. Stewart, MD
Multidisciplinary Plenary Session: Cancer and Laparoscopy - What to Do and What Not to Do
Robotics in Cervical Cancer: the Good, Bad and Ugly (mov / 7.4MB)
Farr Nezhat, MD
The Role of Laparoscopy in Pediatric Abdominal Malignant Tumors (mov / 6.3MB)
Gustavo Stringel, MD, MBA
Advanced Robotic Technique as a Surgical Treatment Option for Prostate Cancer (mov / 6.8MB)
David B. Samadi, MD
Pearls and Pitfalls - Laparoscopy and Malignancy (mov / 6.3MB)
Stephen M. Kavic, MD
Multidisciplinary Plenary Session: The US Health Care System is Broken. What can we do about it?
Introduction (mov / 4.4MB)
Michael S. Kavic, MD
Obstacles to Providing "Universal Care" to the Underserved - a Urologic Perspective (mov / 8MB)
Richard Babayan, MD
Health Disparities: Target Heart Disease (mov / 6.3MB)
William A. Cooper, MD
Catastrophe or mess: burial and phoenix (mov / 11.8MB)
Douglas E. Ott, MD, MBA
Friday, September 11, 2009
Multidisciplinary Plenary Session: NOTES, SPA & Microbots - A Controversy Debate
Single Port Access (SPA) Surgery - In Search of the Critical View (mov / 13.5MB)
Paul G. Curcillo, II, MD
Transvaginal NOTES: Culdolaparoscopy (mov / 8.3MB)
Daniel A. Tsin, MD
Saturday, September 12, 2009
Special Event: Breakfast with Keynote Speaker
Robots in Space (mov / 27.1MB)
Tim Reedman, BASc
Future Technology Session: From the Infinitesimal to the Infinite - Molecules, Energy and Space for Surgeons
Controlling Molecules with Light (mov / 26.1MB)
Harry T. Whelan, MD
Plasma Medicine - Why Energy Is Important to Surgeons (mov / 22.0MB)
Michel Wertheimer, PhD
17TH SLS ANNUAL MEETING AND ENDO EXPO 2008 PODCASTS
Wednesday, September 17, 2008
Opening Ceremony (mov / 73.6MB)
Paul Alan Wetter, MD; Chairman, SLS
Friday, September 19, 2008
Excel Award Presentation and Lecture (mov / 34.7MB)
Harrith M. Hasson, MD; 2008 SLS Excel Award Recipient
Evaluating Surgical Performance
16TH SLS ANNUAL MEETING AND ENDO EXPO 2007 PODCASTS
Friday, September 7, 2007
Resident Award-Winning Paper Presentation (m4a / 10.4MB)
Sohail R. Shah, MD
Minimally Invasive Repair of Congenital Diaphragmatic Hernias: A Review of Our Experience
Friday, September 7, 2007
Excel Award Presentation and Lecture (m4a / 22.2MB)
Elspeth M. McDougall, MD; 2007 SLS Excel Award Recipient
The Future of Surgery is Education
15TH SLS ANNUAL MEETING AND ENDO EXPO 2006 PODCASTS
Wednesday, September 6, 2006
Presidential Address (m4a / 15MB)
Raymond J. Lanzafame, MD, MBA, SLS President 2006
Issues in the Acquisition, Development, and Use of Technology in Health Care
Thursday, September 7, 2006
Introduction—SLS Websites (m4a / 13.2MB)
Paul Alan Wetter, MD; Chairman, SLS
From the Multidisciplinary Plenary Session Informatics for the Laparoendoscopic Surgeons
