Minimally Invasive Surgery Week

17TH SLS ANNUAL MEETING AND ENDO EXPO 2008
SEPTEMBER 17–20, 2008 • CHICAGO, ILLINOIS

                                             

SCIENTIFIC ABSTRACTS                                         
Supplement to JSLS, Volume 12, Number 3

GENERAL SESSIONS
Opening Ceremony
Best of Laparoscopy Updates
Multidisciplinary Plenary Sesssions
Future Technology Session

LAPAROSCOPY UPDATES

PHOTO GALLERY

AWARD WINNERS

SCHOLARSHIP RECIPIENTS

FACULTY INDEX

PRELIMINARY PROGRAM

CONFERENCE EDUCATIONAL METHODS AND ATTENDEE OBJECTIVES

The 17th SLS Annual Meeting and Endo Expo 2008 employs a variety of educational formats including topical general sessions, the presentation of scientific papers, open forums, posters, and original videos offered in small specialty-specific breakout sessions, and informal gatherings of participants and expert faculty.

The increasing complexity of minimally invasive diagnostics and therapy requires a continuous educational process. The exchange of knowledge and expertise among the physicians taking part in this conference contributes to the continuation of excellence in minimally invasive surgery.

Upon completion of the conference, participants will be able to:

• Increase comprehension of the basic and fundamental principles of laparoscopic, endoscopic, and minimally invasive techniques, enhancing the participant’s understanding of these techniques;

• Understand the recent advances in laparoscopic, endoscopic and minimally invasive techniques;

• Determine the appropriate use of laparoscopic, endoscopic and minimally invasive equipment as part of a treatment plan in the care of patients;

• Comprehend the developing technologies that will be available in the future to enhance the standard of patient care; and

• Acquire educational information within the physician’s specialty, which will enhance their professional development and patient care.

CONTINUING MEDICAL EDUCATION PROCESS FOR THE SOCIETY OF LAPAROENDOSCOPIC SURGEONS

The Society of Laparoendoscopic Surgeons (SLS) follows the Essential Areas and Criteria of the Accreditation Council for Continuing Medical Education in planning and developing CME activities.  You may view the complete process online at our website, www.SLS.org.

The Society of Laparoendoscopic Surgeons (SLS) follows the Essential Areas and Criteria of the Accreditation Council for Continuing Medical Education in planning and developing CME activities.  You may view the complete process online at our website, www.SLS.org.

17TH SLS ANNUAL MEETING AND ENDO EXPO 2008
PRELIMINARY PROGRAM

Conference Program Directors
William E. Kelley, Jr., MD
Charles H. Koh, MD

TUESDAY, SEPTEMBER 16, 2008
3:00pm-6:00pm    MASTER’S CLASSES REGISTRATION

WEDNESDAY, SEPTEMBER 17, 2008 • MASTER'S CLASSES, OPENING CEREMONY, WELCOME RECEPTION
7:00am-9:00am    MASTER’S CLASSES REGISTRATION / Complimentary Coffee & Bakery Items (Master's Classes Attendees Only)

8:00am-4:30pm    CONCURRENT MASTER’S CLASSES see each course for detailed times
12:00pm-1:00pm  Master's Class Lunch with Lecture: How to Prepare for the Coming of Simulation Certification
                           Director: Richard M. Satava, MD
                           Co-Director: Robert M. Sweet, MD
                           Faculty: Ajit Sachdeva, MD
2:30pm-3:00pm    Refreshment Break

9:00am-12:00pm
Half Day
#1 Master’s Class in the Prevention and Management of Laparoscopic and Endoscopic Surgical Complications
Raymond J. Lanzafame, MD, MBA, Director
Ceana Nezhat, MD, Co-Director
Faculty: Lawrence C. Biskin, MD / Carl J. Levinson, MD / Howard N. Winfield, MD

1:00pm-4:30pm
Half Day
#2 Master’s Class in The New Insight in Diagnosing and Treatment of Abdominal and Pelvic Pain for General Surgeons, Gynecologists, and Urologists; Including Simple Office Evaluation and Treatment of Interstitial Cystitis, Cystoscopy, Vulvovestibulitis, Hernias, Adhesions, Pelvic Congestion Syndrome, Pudendal Nerve Neuralgia, Trigger Points Injection and Pain Mapping, Jointly with the International Pelvic Pain Society (IPPS)
Harry Reich, MD, Director
Maurice Chung, MD, Co-Director
Faculty: James F. Carter, MD / Fred Howard, MD / John Morrison, Jr., MD / Alfredo Nieves, MD

8:00am-4:30pm
Full Day
#3 Master’s Class in Laparoscopic Suturing in the "Vertical Zone"
Charles Koh, MD, Director
Faculty: David M. Boruta, II, MD / Jeremy Carver, SA / Tommaso Falcone, MD / Keith Isaacson, MD / John Morrison, Jr., MD

9:00am-4:30pm
Full Day
#4 Master’s Class in Robotic Laparoscopic Surgery Jointly with the Minimally Invasive Robotic Surgery Association (MIRA)
William E. Kelley, Jr., MD, Director
Santiago Horgan, MD, Co-Director
Faculty: Arnold Advincula, MD / Horacio Asbun, MD / Arnold Byer, MD / Elspeth McDougall, MD / Farr Nezhat, MD / Joseph Petelin, MD / Leela Prasad, MD / Richard M. Satava, MD / Gregory Zagaja, MD

8:30am-4:30pm
Full Day
#5 Master's Class on Multidisciplinary Approach to Gynecologic Endoscopic Surgery Jointly with the American Association of Gynecologic Laparoscopists (AAGL)
Ceana Nezhat, MD, Director
Farr Nezhat, MD, Co-Director
Faculty: Masaaki Andou, MD / Tommaso Falcone, MD / Keith Isaacson, MD / Grace Janik, MD / William E. Kelley, Jr., MD / Charles Miller, MD / Camran Nezhat, MD / Harry Reich, MD / Howard N. Winfield, MD / Robert Zurawin, MD

8:00am-4:30pm
Full Day
#6 Master’s Class in Laparoscopic General Surgery Jointly with the Society of American Gastrointestinal Endoscopic Surgeons (SAGES)
Michael S. Kavic, MD, Director
W. Peter Geis, MD, Co-Director
Phillip Shadduck, MD, Co-Director
Faculty: Paul G. Curcillo, II, MD / Morris Franklin, Jr., MD / B. Todd Heniford, MD / John Morrison, Jr., MD / Joseph Petelin, MD

8:00am-4:30pm
Simulation Practice Center- Supporting Masters Classes
Robert M. Sweet, MD, Director
Harrith M. Hasson, MD, Co-Director

Laboratory Faculty: Kyle Anderson, MD / Magdy Milad, MD / Leslie Deane, MD / G. Fernando Perego, MD / Abraham Shashoua, MD / Kevin Zorn, MD

Simulator Companies
Haptica, Inc.
Immersion Medical
METL
Mimic Technologies, Inc.
Red Llama, Inc.
Simbionix USA Corp.
Surgical Science

12:00pm-6:00pm CONFERENCE REGISTRATION

4:00pm-5:00pm   Poster Gallery
5:00pm-6:40pm   OPENING CEREMONY
5:00-5:15pm       Opening Entertainment
5:15-5:20pm       Opening Ceremony Remarks
                          Paul A. Wetter, MD
                          Introduction of Sponsors and Corporate Members
5:20pm-5:30pm   Presentation of Award Winning Scientific Papers and Videos
                          Session Director: Paul A. Wetter, MD
                          Co-Director: William E. Kelley, Jr., MD
5:30pm-5:40pm   Introduction of President
                          Harrith Hasson, MD
5:40pm-6:05pm   Presidential Address
                          William E. Kelley, Jr., MD
6:05pm-6:30pm   Honorary Chair Presentations
                          Session Director: Paul A. Wetter, MD
                          Introduction: William E. Kelley, Jr., MD
                          Honorary Chair: Mokote Hashizume, MD, PhD - Japan
                          Presentation: "Image-Guided Minimally Invasive Robot-Assisted Surgery"
                          Introduction: Charles H. Koh, MD
                          Honorary Chair: Errico Zupi, MD - Italy
                          Presentation: "Actuality and Future Perspectives of N.O.T.E.S. (Natural Orifice Transluminal Endoscopic Surgery)"

6:30-6:40pm     Virtual World Environments and their Potential Impact on Surgical Training and Care
                          James C. Rosser, MD
6:40pm-8:30pm   WELCOME RECEPTION IN EXHIBIT HALL
                          Recognition of SLS Sponsors & Corporate Members
                          Innovations of the Year
                          CYBER CAFE
                          Raymond J. Lanzafame, MD, MBA, Director

THURSDAY, SEPTEMBER 18, 2008

6:30am-5:00pm  CONFERENCE REGISTRATION
6:45am-7:00am  Moderator Briefing
                         Raymond J. Lanzafame, MD, MBA / Carl J. Levinson, MD
7:00am              Exhibits Open
7:00am-7:30am  Complimentary Coffee and Bakery Items / Special Presentations by Exhibitors
7:00am-4:30pm  Poster Gallery Open

7:30am-8:30am  General Session: Best of Laparoscopy Updates
Laparoscopy Updates presented by SLS Specialty Interest Group Committee Members highlighting the newest developments and future expectations of surgical and diagnostic procedures.
Session Director: Harrith Hasson, MD /  Session Co-Director: Lawrence Biskin, MD
Speakers/Topics:
7:30am-7:45am   Fertiloscopy/Transvaginal Endoscopy Committee: Duncan Turner, MD- The Current Status of Transvaginal HydroLaparoscopy
7:45am-8:00am   Robotic Surgery Committee: James F. Carter, MD- Robotic Surgery: Coming to a Hospital Near YOU Soon
8:00am-8:15am   Abdominal/Pelvic Pain/Adhesions Committee: Dan Martin, MD- Pelvic Pain and the Reduction of Adhesions
8:15am-8:30am   Infertility/Fertility Committee: Grace Janik, MD- Laparoscopic Update on Infertility/Fertility

8:30am-10:00am MULTIDISCIPLINARY PLENARY SESSION (Gynecology, General Surgery, Urology)
Multidisciplinary Approach to Adhesions
Session Director: Raymond J. Lanzafame, MD, MBA / Session Co-Director: Charles Koh, MD
8:30am-8:35am    Raymond J. Lanzafame, MD, MBA: Introductory Remarks
8:35am-8:50am    Charles H. Koh, MD: Abdominal and Pelvic Adhesions, the GYN Perspective
8:50am-9:05am    Phillip Shadduck, MD: Adhesions in the Abdomen, the General Surgeon's Dilemma
9:05am-9:25am    Kathleen Rodgers, PhD: New Strategies in Prevention and Management of Adhesions: The Research Perspective
9:25am-9:40am    Raymond J. Lanzafame, MD, MBA: Prosthetics, Synthetics and Biologicals: Notes from the Laboratory
9:40am-10:00am  Panel Discussion/Scenarios/Q&A from Audience

10:00am-10:30am  Refreshment Break/Visit Exhibits/Special Presentations by Exhibitors

10:30am-11:30am    SPECIALTY BREAK-OUT CONCURRENT SESSION (Gynecology)
Hysterectomy Debate: With or Without Removing the Cervix or Ovaries
Session Director: Farr Nezhat, MD / Session Co-Director: Tommaso Falcone, MD
11:00am-11:15am   Farr Nezhat, MD: Oophorectomy at the Time of Hysterectomy: Pros & Cons
11:15am-11:30am   Tommaso Falcone, MD (Con): Why Total Hysterectomy and Not Supracervical Hysterectomy?
11:30am-11:45am   Charlie Miller, MD (Pro): Why Supracervical Hysterectomy and Not Total Hysterectomy?
11:45am-12:00pm   Question and Answers

10:30am-11:30am   SPECIALTY BREAK-OUT CONCURRENT SESSION (Urology)
Treatment Strategies for the Small Renal Mass
Session Director: Robert M. Sweet, MD / Session Co-Director: J. Kyle Anderson, MD
10:30am-10:45am   Arieh L. Shalhav, MD: Lap Partial Nephrectomy
10:45am-11:00am   J. Kyle Anderson, MD: Radiofrequency Ablation
11:00am-11:15am   David Chen, MD: Active Surveillance of the Small Renal Mass
11:15am-11:30am   Robert M. Sweet, MD: Development of a VR Training Module for Lap Renal Skills

11:30am-12:30pm  Poster Townhall
Best graded posters will participate in the Oral Poster Session
Directors:
Maurice Chung, MD
Harrith M. Hasson, MD
William E. Kelley, Jr., MD   
Charles H. Koh, MD
Jaime Landman, MD
Raymond J. Lanzafame, MD, MBA 
Gustavo Stringel, MD
Robert Sweet, MD
Howard N. Winfield, MD

12:30pm-1:45pm   Complimentary Light Snacks and Refreshments/Visit Exhibits/Special Presentations by Exhibitors

1:45pm-5:30pm    CONCURRENT SESSIONS: Scientific Papers / Videos / Open Forum Presentations / Laparoscopy Updates
Directors:
MASH Committee Members

SIG Committee Lap Updates:
Abdominal/Pelvic Pain/Adhesions
Ceana Nezhat, MD: Update on Adhesion Reduction

Bariatrics
Dana Portenier, MD: Update on Bariatrics

Core Competencies
Gustavo Stringel, MD: Competencies and the American Board of Surgery

Endocrine/Abdominal Uterine Bleeding
Tahar Benhidjeb, MD (NESA): Innovative Endoscopic Thyroid Surgery

Fibroids/Abdominal Uterine Bleeding
Herbert Goldfarb, MD: Laparoscopic Myolysis Revisited

Multidisciplinary
Michael Stark, MD (NESA): The Future of Abdominal Surgery- The Natural Orifice Surgery

Office and Outpatient Laparoscopy
Duncan Turner, MD: Office Cosmetic Procedure

Pediatric
Thomas Lendvay, MD: Pediatric Urology
John Meehan, MD: Pediatric General Surgery: The Race in Pediactric MIS: Hit the Gas! But be ready to slam on the Brakes!
Robert Zurawin, MD: Pediatric Gynecology

Pelvic Reconstructive Surgery/Stress Incontinence
Steve Minaglia, MD: The Use of Mesh for Stress Incontinence and Pelvic Floor Prolapse

Robotics
Andrew Wright, MD: New Developments in Robotic Surgery

Thoracic
Neil A. Christie, MD: Minimally Invasive Esophagectomy

2:00pm               Exhibits Close
2:00pm-4:00pm   Coffee Available in Designated Areas
2:30pm-3:15pm   Briefing Meeting– EuroAmerican Summit IV- February 2009
3:15pm-4:00pm   Briefing Meeting– AsianAmerican Summit IV- February 2010
4:15pm-5:00pm   SLS Corporate Council Meeting
5:30pm               Adjourn for the Day
6:30pm-9:00pm    SLS Evening with Faculty Event (Ticket Required)
                            Adler Planetarium and Astronomy Museum   
                            Guest Speaker: David Williams, MD: Telerobotic Surgery in Extreme Environments

FRIDAY, SEPTEMBER 19, 2008

6:30am-5:00pm  CONFERENCE REGISTRATION
7:00am              Exhibits Open
7:00am-7:30am  Complimentary Coffee and Bakery Items / Special Presentations by Exhibitors
7:00pm-9:00pm  Poster Gallery Open

7:30am-8:30am  MULTIDISCIPLINARY PLENARY SESSION (Gynecology, General Surgery, Urology)
Pay for Performance (P4P)
Session Director: Gustavo Stringel, MD / Co-Director: Raymond J. Lanzafame, MD, MBA
7:30am-7:35am    Gustavo Stringel, MD: Introduction
7:35am-7:50am    Gustavo Stringel, MD: Safety, Quality and Improving Operating Room Performance
7:50am-8:05am    Alex Gandsas, MD: Pay for Performance and Transparency
8:05am-8:20am    Raymond J. Lanzafame, MD, MBA: Financial Aspects of Surgical Care. Past, Present and Future
8:20am-8:30am    Questions to the Panel

8:30am-11:30am   LIVE TELESURGERY
Session Director:  William E. Kelley, Jr., MD / Co-Director: Camran Nezhat, MD
Gynecologic Surgery Procedure: Total Laparoscopic Hysterectomy for Endometriosis
Surgeon: Robert Zurawin, MD, St. Luke's Episcopal Hospital, Houston, TX
Moderator: Ceana Nezhat, MD

10:00am-10:30am    Refreshment Break/Visit Exhibits

11:30am-12:30pm    Complimentary Light Snacks and Refreshments in Exhibit Hall

11:30am-12:00pm    Special Presentations by Exhibitors

12:00pm-12:30pm    New Product Presentation by Exhibitors
Session Director:  Harrith M. Hasson, MD

12:30pm-12:45pm    Awarding of Best Poster ($500.00 Award for Best Poster) and Presentation of Resident Award-Winning Paper ($1,000 Award for Best Paper)
Poster Session Directors:
Maurice K. Chung,MD
Harrith Hasson, MD
William E. Kelley, Jr., MD
Charles H. Koh, MD
Jaime Landman, MD
Raymond J. Lanzafame, MD, MBA
Gustavo Stringel, MD
Robert Sweet, MD
Howard N. Winfield, MD
Awards Session Director:
Paul A. Wetter, MD
Awards Session Co-Director:
William E. Kelley, Jr., MD

12:45pm-1:45pm   THE EXCEL AWARD LECTURE
Session Director: Paul A. Wetter, MD
Introduction: Charles H. Koh, MD
Recipient: Harrith Hasson, MD
Presentation: Evaluating Surgical Performance

1:45pm-5:30pm  CONCURRENT SESSIONS: Scientific Papers / Videos / Open Forum Presentations / Laparoscopy Updates
Directors:
MASH Committee Members

2:00pm               Exhibits Close
2:00pm               Poster Gallery Closes
2:00pm-4:00pm   Refreshments Available in Designated Areas
5:30pm               Adjourn for the Day

SATURDAY, SEPTEMBER 20, 2008

7:00am-11:15am  CONFERENCE REGISTRATION
7:30am-8:00am    Sit-down breakfast with spouses/guests 
8:00am-9:00am    Keynote Speaker
                           Leigh R. Hochberg, MD, PhD: Brain-Computer Interfaces: Frontiers in Restorative Neurotechnology
9:00am-10:30am  FUTURE TECHNOLOGY SESSION: Beyond Human Control
                           Session Director: Richard M. Satava, MD 
9:00am-9:45am    Orlando Portale, MS: Simulated Reality: Exploring the Virtual Hospital of the Future
9:45am-10:30am  Kit Parker, PhD: Intracellular Surgery- The Next Surgical Frontier?

10:30am-10:45am   Closing Ceremony – Passing of the Presidential Gavel
                              President: William E. Kelley, Jr., MD
                              To President Elect: Charles H. Koh, MD

10:45am-11:15am   SLS Business Meeting open to all SLS members

11:15am-12:15pm   Post Conference Evaluation & SLS Special Interest Group (SIG) Committee Meetings
12:30pm-2:00pm    Board of Directors & SLS Standing Committee Annual Report Meeting

2:00-4:00pm           JSLS Editorial Board Meeting

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 28.25 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Half-Day Master’s Classes: 3 credits
Full-Day Master’s Classes: 6 credits
Master's Class Lunch with Lecture: 1 credit
Opening Ceremonies: 1.5 credits
17th SLS Annual Meeting, 3 days: 19.75 credits

HOTEL ACCOMMODATIONS AND MEETING SITE

Hyatt Regency McCormick Place
2233 S. Martin L. King Drive
Chicago, Illinois 60616, USA

Reservations
Tel: +1-312-567-1234
Fax: +1-312-528-4000

Visit the following online reservation site exclusively for SLS conference attendees: http://mccormickplace.hyatt.com/groupbooking/chimcilap2008

The Hyatt Regency McCormick Place rises 33 stories adjacent to the McCormick Place convention complex. This contemporary hotel welcomes business travelers and conventioneers attending numerous events. An enclosed pedestrian skybridge links the hotel to the McCormick Place convention complex. The Hyatt hotel is just a mile from Soldier Field, home of the NFL Chicago Bears, two miles from Downtown Chicago and provides complimentary daily shuttle service to nearby attractions such as Navy Pier, the Magnificent Mile, and several famous museums.

In addition to a staffed business center, the hotel offers 24-hour Internet office with high-speed Internet access. Wireless Internet access is available in public areas. Self-service kiosks in the lobby allow guests to print their boarding passes and check in and out with ease. TV monitors display conference events and times.

Other amenities such as the on-site health club includes a 24-hour fitness center, an indoor lap pool with outdoor sundeck, and a sauna. Dining options include a Chicago-style grill and a casual Italian trattoria. A café serves Starbucks coffee, freshly baked pastries, and other fare, while a lounge offers a small-plates menu and signature cocktails.

Hotel DAILY Rates
Single / Double $217.00; Triple $242.00; Quads $267.00

These rates are subject to appropriate state, local and occupancy taxes and do not include meals. The SLS room block will be released after August 22, 2008. After this date, rooms will be on a space available basis only at the hotel’s prevailing rates. Conference rates are applicable 3 days before and 1 day after the conference based on availability. In order to qualify for the special rate, you must make reservations by August 22, 2008, and mention that you are attending the “SLS Conference.” Please make reservations early!

TRAVEL INFORMATION

For negotiated airline discount rates contact Steve at The Store For Travel, toll free at 1.800.284.2538. Outside the United States call 305.251.6331. E-mail: so@sft.webmail.com. Please be sure to mention you are attending the SLS conference in Chicago, Illinois.

For those attending the conference who require special assistance (accessibility, dietary, etc.), please contact SLS no later than August 22, 2008, with special requests.

AIRPORTS
Chicago O’Hare International Airport is 17 miles from downtown, and about 45 minutes from the Hyatt.
10000 West O’Hare
Chicago, Illinois 60666
Tel: 773.686.2200
Website: www.ohare.com

Miday Airport is 10 miles from downtown, and about 30 minutes from the Hyatt.
5700 S. Cicero Ave.
Chicago, Illinois 60638
Tel: 773.838.0600
Website: www.chicago-mdw.com

LOCAL TRANSPORTATION
Airport Express provides shuttle service and airport shuttle service for guests of all-major hotels. The shuttle may be picked up curbside at both O’Hare and Midway Airports. Contact Airport Express or the hotel concierge for rates and scheduling.
Tel: 888.284.3826
Website: www.airportexpress.com.

Taxicabs are available on a first come, first serve basis. Shared ride service is available. There are no flat rates. Expect to spend $35 to $50. For wheelchair accessible vehicles contact United Dispatch at 800.281.4466. For taxi company listings visit www.flychicago.com

DESTINATION INFORMATION

Chicago is one of the greatest cities in the world. With its beautiful lakefront, incredible architecture and cosmopolitan culture, Chicago attracts millions from around the globe every year. In fact, more people visit Chicago for business than any other destination in the United States. Chicago has been called America’s Best City for Dining. Its 5,500 restaurants feature everything from prime steakhouses to famous deep-dish pizza and every imaginable ethnic cuisine. The Magnificent Mile, one of the world’s great shopping boulevards, is just steps from downtown hotels, as are chic shops on Oak Street and the historic department stores on State Street. Over 8.5 million visitors enjoy Navy Pier every year, making it the city’s most popular attraction. From Broadway musicals to award-winning drama to hilarious improvisational comedy, Chicago’s 200 theaters offer something for everyone. Incredible live blues and jazz, plus eclectic clubs all over town. Visit www.choosechicago.com for information on tours, sites, shopping, etc. in the city of Chicago.

CANCELLATION POLICY

Full registration fees are refundable if registrant cancels before August 13, 2008. An administrative fee of $150.00 will be deducted from fees for cancellations postmarked on or after August 13, 2008 through August 22, 2008. Refund requests will not be considered after this date, including visa denial refunds. All requests for refunds must be made in writing and received by SLS, attention Flor Tilden, by the appropriate dates. Refunds will be processed within 6 to 8 weeks after the conference.
No refunds will be made after August 22, 2008.

VISA INFORMATION (Click Here)

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SPECIAL EVENT: SLS EVENING WITH FACULTY FEATURING KEYNOTE SPEAKER
DAVID WILLIAMS, MD presents TELEROBOTIC SURGERY IN EXTREME ENVIRONMENTS
EXPLORING SPACE AT THE ADLER PLANETARIUM AND ASTRONOMY MUSEUM

Thursday, September 18, 2008
6:30pm – 9:00pm

Join SLS in Exploring Space at the Adler Planetarium and Astronomy Museum...

Join SLS in Exploring Space at the Adler Planetarium and Astronomy Museum with special guest speaker, astronaut Dave R. Williams, MD, directly from NASA. A veteran of two space flights, STS-90 in 1998 and STS-118 in 2007, Dave Williams has logged over 687 hours in space including 3 spacewalks (EVAs) totaling 17 hours and 47 minutes. He served as the manager of the Missions and Space Medicine Group within the Canadian Astronaut Program; and through his participation in the joint NASA-NOAA (National Oceanic and Atmospheric Administration) NEEMO 1 mission, Williams became the first Canadian to have lived and worked in space and in the ocean.

Max Adler founded the Adler Planetarium & Astronomy Museum in 1930, recognizing the complementary roles of a planetarium and astronomical artifacts. Adler purchased a collection of about 500 astronomical, navigational, and mathematical instruments from Anton Mensing in the Netherlands. Housed in the Adler's Webster Institute for the History of Astronomy, the Scientific Instrument Collection contains about 2000 instruments and models from the 12th through the 20th centuries. It is the largest collection of such material in the Western Hemisphere and one of the most significant in the world.

Other featured exhibits will include the Solar System, Atwood Sphere, the Milky Way Galaxy and a new permanent exhibit Shoot for the Moon. This new permanent exhibition highlights the exciting stories of space exploration and America's bold plans to return to the Moon. The exhibition begins with "A Journey with Jim Lovell," featuring the fully-restored Gemini 12 spacecraft and the Lovell Collection of personal space artifacts.

After guests have enjoyed a tour of the exhibits, the group will adjourn to the Galileo’s Café for dinner with an unforgettable view of the Chicago skyline, and the keynote presentation. 

SPECIAL EVENT: SPOUSE / GUEST ARCHITECTURE TOUR
A DAY OF MESMERIZING ARCHITECTURAL CHICAGO HISTORY

Friday, September 19, 2008
9:30am – 4:00pm
Register online or Download and print the PDF registration form and fax to Conferences at 305.667.4123.

This tour will begin traveling the streets of Chicago towards the Frank Lloyd Wright Museum and Studio located in Oak Park. This extraordinary building was the Wright family residence from 1889 to 1909. Wright began the construction of this house in 1889 shortly after his marriage to Catherine Tobin. The Wright family - Frank and Catherine, and their six children - lived here while he developed his architectural practice, creating what became the "Prairie Style" of architecture. The studio annex was completed in 1898, and is one of the most marvelous workspaces to be imagined! See the reception area, the octagonal designed hanging lights in the drafting room, the presentation library, and much more. After this tour guests will be dropped off at a local Chicago restaurant for a leisurely lunch and then off to First Lady Cruises Chicago's Architecture Tour. This tour on the river will showcase Chicago’s world renowned architecture with style, class, and comfort aboard an open air and air-conditioned seated ship. You will learn about the architecture and design of over 50 buildings with CAF certified docents/guides.

Do not miss out on a day of mesmerizing architectural Chicago History.

SPECIAL EVENT: EXCEL AWARD PRESENTATION AND LECTURE

Friday, Sept. 19, 2008
12:45pm-1:45pm

Recipient: Harrith M. Hasson, MD
Presentation: Evaluating Surgical Performance

Established in 1991, the Excel Award has been presented to 23 surgeons deemed by the SLS Advisory Board to have made outstanding contributions to laparoscopy, endoscopy, and minimally invasive surgery. These outstanding surgeons are from various specialties and various nationalities.

Dr Harrith Hasson received his Medical degree from Ein Shams University Cairo, Egypt. He completed his residency at St. John’s Episcopal Hospital, Brooklyn, New York. He also completed his OB/GYN residency at Presbyterian St. Lukes and West Suburban Hospitals in Chicago. Dr. Hasson served as Chairman of OB/GYN at Grant Hospital in Chicago (currently Lincoln Park Hospital) from 1981-1995. Following his term at Grant Hospital, he served as Chairman at Weiss Hospital in Chicago from 1996-2003.

Dr Hasson served as Assistant Professor at Northwestern University, Associate Professor at Rush University, and Clinical Professor at University of Chicago. Currently he serves as voluntary Associate Professor at University of New Mexico. Dr Hasson has published and lectured extensively on intrauterine contraception, laparoscopic surgery, and simulation. He currently serves on the editorial and advisory board of several Journals. He founded the Society for the Advancement of Contraception (SAC), and served as trustee and president of the AAGL and the SLS. Currently, Dr Hasson serves as the Immediate Past President of SLS.

Dr Hasson retired from practice in 2003 to devote his time to developing laparoscopic simulators and teaching. In 2004, he founded RealSim Systems, a company dedicated to developing laparoscopic surgical simulators. Dr Hasson holds 52 patents in medical devices and has developed the technique and instrumentation of open laparoscopy for which he received several awards. He is currently dedicated to replacing the current system of evaluating laparoscopic technical skills and operative performance on the basis of subjective evaluations with one based on objective measures and to enable doctors to achieve technical proficiency in laparoscopic surgery through simulation training. He currently writes, lectures on surgical simulation and assessment of core competency in laparoscopic surgery.

PRE-CONFERENCE MASTER'S CLASSES WEDNESDAY, SEPTEMBER 17, 2008

#1 Master’s Class in the Prevention and Management of Laparoscopic and Endoscopic Surgical Complications
Half-Day (9:00am-12:30pm; 3 AMA PRA Category 1 Credits)

All abdominal and pelvic MIS procedures carry an inherent risk of complications. This interactive course will present a philosophy for the prevention and management of complications during minimally invasive surgery of the abdomen and pelvis. Video segments and case presentations will be used to demonstrate principles and stimulate discussion. Source material will be obtained from students’ “real world” experiences and supplemented with materials selected by the faculty panel and customized based on pre-conference information obtained from registrants. An interactive student and faculty discussion format will be utilized. This course will discuss management paradigms to prevent, recognize, and treat complications appropriately. Careful, methodical assessment and strategies for appropriate action will be stressed. Topical presentations based on student input will highlight detailed surgical anatomy, sound surgical principles and careful technique. Participants are strongly encouraged to submit video or other case material (anonymously) to maximize topical relevance for their individual practice and needs.

Course participants will be better able to:
• Recognize and decrease the risk of complications in laparoendoscopic surgeries;
• Identify and discuss specific conditions affecting appropriate patient selection;
• Discuss indications, contraindications and limitations of MIS procedures and technologies;
• Understand relevant surgical anatomy and potential technical pitfalls;
• Develop management paradigms to prevent and treat complications;
• Describe the rationale and timing of conversion to open procedures.

FACULTY
Raymond J. Lanzafame, MD, MBA, Director
Ceana Nezhat, MD, Co-Director
Lawrence C. Biskin, MD
Carl J. Levinson, MD
Howard N. Winfield, MD

#2 Master’s Class  in New Insight in Diagnosing and Treatment of Abdominal and Pelvic Pain for General Surgeons, Gynecologists, and Urologists: Including Simple Office Evaluation and Treatment of Interstitial Cystitis, Cystoscopy, Vulvovestibulitis, Hernias, Adhesions, Pelvic Congestion Syndrome, Pudendal Nerve Neuralgia, Trigger Points Injection and Pain Mapping - Jointly with the International Pelvic Pain Society (IPPS)
Half-Day (1:00pm-4:30pm; 3 AMA PRA Category 1 Credits)

This Master’s Class will include discussions on a newer approach in evaluation and treatment of Chronic Pelvic Pain, Endometriosis / Adenomyosis, Interstitial Cystitis / Painful Bladder Syndrome, Inguinal and Obturator Hernia, Bowel Obstruction Adhesion, Pelvic Congestion Syndrome and Pelvic Tension Myofascial Syndrome.

Objectives:

• To master the newer approach in office evaluation and treatment for difficult pelvic pain patients.

• To learn more about new techniques such as abdominal and pelvic trigger points injection, office cystoscopy, intravesical therapy for interstitial cystitis and fluoroscopy for pelvic congestion syndrome.

FACULTY
Harry Reich, MD, Director
Maurice K. Chung, MD, Co-Director
James F. Carter, MD
Fred Howard, MD
John E. Morrison, Jr., MD
Alfredo Nieves, MD

#3 Master’s Class • Hands-On Course on Laparoscopic Suturing in the “Vertical Zone”
Full-Day (8:00am-4:30pm; 6 AMA PRA Category 1 Credits)

The algorithm for laparoscopic suturing as described in the “Vertical Zone” has been tested over many years nationally and internationally. Proficiency with intracorporeal knotting in less than 3 minutes has been achieved by over 80% of attendees in past courses. This includes practicing gynecologists, residents, and fellows. This result is also mirrored in international courses. Concurrent validity is excellent with the technique described, as the relative hand positions and movements are immediately transferable from the trainer to the O.R. That laparoscopic suturing is essential for today’s laparoscopies would be an understatement. This course equips all attendees with improved suturing skills and insight into applications during surgery.

Objectives:

• Understand ergonomics, theory and rationale for reproducible laparoscopic suturing;

• Applications of skills learned in relevant surgical situations;

• Prevention and management of bowel, bladder and ureteral complications by appropriate suture repair;

• Pre-test and post-test to demonstrate improvement in skills

FACULTY
Charles H. Koh, MD, Director
David M. Boruta, II, MD
Jeremy M. Carver, SA
Tommaso Falcone, MD
Keith Issacson, MD
John E. Morrison, Jr., MD

#4 Master’s Class in Robotic Laparoscopic Surgery Jointly with the Minimally Invasive Robotic Surgery Association (MIRA)
Full-Day (9:00am-4:30pm; 6 AMA PRA Category 1 Credits)

Leading practitioners in the fields of general, gynecologic, urological and vascular MIS will discuss their experiences with robot-assisted surgery. The advantages and disadvantages of robot-assisted vs. traditional MIS will be discussed and debated, as well as future applications of robotics for each surgical discipline. Gynecology topics will include general, oncologic, and fertility surgery. Urological sessions will include treatment of both benign and malignant urological conditions. General surgery topics will include foregut, hepatobiliary, colorectal, bariatric and vascular applications. Remote telepresence surgery, remote physician-patient interaction by robot interface, and remote teleconferencing by robot over the internet will be discussed as well. One presentation will be conducted via remote, transcontinental telepresence.

At the conclusion of this course, participants will increase their knowledge and understanding of robotics and of the applications of robotics for minimally invasive surgery from the perspective of outstanding practitioners who were and are instrumental in developing and perfecting these techniques.

Participants will have the opportunity to participate in a one-hour afternoon robotics simulation laboratory session with a hands-on experience on DaVinci robotic simulators. This session will be included at no extra cost as part of the full-day Robotics post graduate course.

This course will be presented in cooperation between the Society of Laparoendoscopic Surgeons (SLS) and the Minimally Invasive Robotic Surgery Association (MIRA).

FACULTY
William E. Kelley, Jr., MD, Director
Santiago Horgan, MD, Co-Director
Arnold Advincula, MD
Horacio Asbun, MD
Arnold Byer, MD
Elspeth M. McDougall, MD
Farr Nezhat, MD
Joseph Petelin, MD
Leela Prasad, MD
Richard M. Satava, MD
Gregory Zagaja, MD

#5 Master’s Class • Multidisciplinary Approach to Gynecologic Endoscopic Surgery Jointly with the American Association of Gynecologic Laparoscopists (AAGL)
Full-Day (8:30am-4:30pm; 6 AMA PRA Category 1 Credits)

When performing gynecologic endoscopy, particularly with advanced pathology, the surgeon needs to be aware of the benefit of a multidisciplinary approach and how to proceed while collaborating with other specialties. The goal of this Master’s Class is to increase the knowledge and skills necessary to handle advanced cases, whether from the perspective of the novice laparoscopist or the advanced specialist. This will benefit general and gynecologic surgeons and urologists as well as ancillary OR personnel.

We will demonstrate a step-wise approach to gynecologic cases emphasizing knowledge of anatomy, anatomic variation, safe abdominal entry, and the management of potential complications. Suturing, current trends, and up-and-coming technology will be covered.

An open-communication video session on complications will provide examples of known, expected, and incidental complications, which will highlight the importance of a multi-disciplinary approach. The faculty as a panel will address management of complications related to gynecologic endoscopy.

Objectives:

• Recognize essential pelvic anatomy and be aware of anatomic variations;

• Select the best method of abdominal entry to minimize complications;

• Identify situations that warrant a multi-disciplinary approach and manage advanced cases and/or complications utilizing multiple specialties;

• Be aware of current trends and technologies in gynecologic endoscopy;

• Utilization of new technology in office-based procedures.

FACULTY
Ceana Nezhat, MD, Director
Farr Nezhat, MD, Co-Director
Masaaki Andou, MD
Tommaso Falcone, MD
Keith Isaacson, MD
Grace Janik, MD
William E. Kelley, Jr., MD
Elspeth McDougall, MD
Charles Miller, MD
Camran Nezhat, MD
Harry Reich, MD
Howard N. Winfield, MD
Robert Zurawin, MD

#6 Master’s Class in Laparoscopic General Surgery Jointly with the Society of Gastrointestinal Endoscopic Surgeons (SAGES)
Full-Day (8:00am-4:30pm; 6 AMA PRA Category 1 Credits)

The Master’s Class this year is specifically designed to take practicing surgeons, already adept at advanced minimally invasive techniques, to an even higher level of surgical knowledge and technical skill.

The morning session will consist of didactic lectures. Leading practitioners will discuss advanced laparoscopic interventions, focusing on the recent developments and technical nuances of greatest utility to practicing surgeons. Key developments have been selected from the following areas of general surgery: prosthetics in hernia repair, ventral hernia repair, gastroesophageal surgery, colorectal surgery, and solid organ surgery.  A special lecture has been added this year regarding maintenance of certification (MOC), including the role of surgical simulation.

The afternoon session will offer an SLS first: a unique, in-depth exposure to surgical simulation.  Instructors will present a brief history of simulation, the current rationale for surgical simulation for practicing surgeons, and an individually instructed, hands-on experience with current simulation devices.

Attendance in the Master’s Class this year will be limited.

FACULTY
Michael S. Kavic, MD, Director
W. Peter Geis, MD, Co-Director
Phillip P. Shadduck, MD, Co-Director
Paul G. Curcillo, II, MD
Morris E. Franklin, Jr., MD
B. Todd Heniford, MD
John E. Morrison, Jr., MD
Joseph Petelin, MD

Master's Class Lunch with Lecture: How to Prepare for the Coming of Simulation Certification
12:00pm–1:00pm

In this session, participants will learn about the current and future roles and impact that the American College of Surgeons Accredited Education Institutes program is having on surgical education.  Specifically how standards for surgical curricula augmented by simulation are being used for training and assessment with implications going beyond UME and GME towards skills certification and maintenance of certification.

FACULTY
Richard M. Satava, MD, Director
Robert M. Sweet, MD, Co-Director
Ajit Sachdeva, MD

Master's Class Simulation Practice Center
Open Full Day (8:00am-4:30pm)

The Simulation Practice Center will give Master’s Class participants the opportunity to practice their laparoscopic skills and provide hands-on experience with the simulation systems.

FACULTY
Robert M. Sweet, MD, Director
Harrith M. Hasson, MD, Co-Director
Kyle Anderson, MD
Leslie Deane, MD
G. Fernando Perego, MD
Abraham Shashoua, MD
Kevin Zorn, MD

CONCURRENT SCIENTIFIC SESSIONS THURSDAY, SEPTEMBER 18, 2008 AND FRIDAY, SEPTEMBER 19, 2008
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

Prospective Double Blind Randomized Control Study Evaluating the Outcomes of Laparoscopic Cholecystectomy Without Using Energy Source Performed by a Higher Surgical Trainee Versus Consultant, Brij B. Agarwal MS, Dip. in Yoga, FIMSA

Single Port Transaxillary Endoscopic Excision of Benign Breast Lumps? Preliminary Results of a Prospective Study, Brij B. Agarwal MS, Dip Yoga, FIMSA

Stapled Hemorrhoidopexy as a Day Care Surgical Procedure in Indian Setup, Prem Narayan Agarwal Prof Dr Med

A Prospective Randomized Controlled Study for Effects of Practice of Yoga on the Patient Reported Outcomes in Day Care Minimally Invasive Surgery Practice, Sneh Agarwal Prof Dr Med

Sutureless Laparoscopic Ventral Hernia Repair in Obese Patients, Ehab El Akkary MD

The Best of Both Worlds: Open Incisional Hernia Repair with Laparoscopic Mesh Underlay, Ehab El Akkary MD

Effective Exercise Habits of the Formerly Obese, Ehab Akkary MD

Laparoscopic Approach for the Treatment of Huge Hiatus Hernia, Mohammad Alkilani Dr Med

Study of the Pelvic Floor Muscles & External Anal Sphincter and Role of Laparoscopy in Rectal Prolapse, Mahmoud Badawi Prof Dr Med

Interactive Virtual Instructors Plus Virtual Reality Endoscopy Simulators Equals Real-Time, Curriculum-Based, Verbal and Haptic Feedback on Learner Performance, James G. Bittner MD

Face and Construct Validity of a Computer-Based Virtual Reality Simulator for Endoscopic Retrograde Cholangiopancreatography, James G. Bittner MD

Radiographic Diagnosis and Laparoscopic Repair of a Right Paraduodenal Hernia: A Video Case Report and Review of the Literature, James G. Bittner IV MD

A New Technique for Totally Intracorporeal Laparoscopic Colorectal Anastomosis using Circular Stapler, Pascal Bucher MD

Single Midline Working Port for TEP Inguinal and Crural Hernia Repair, Pascal Bucher MD

A Call for Raised Awareness and Appropriate Treatment of Symptomatic Gallbladder Disease in the Pediatric Population, Kerrey B. Buser MD

Case Reports: Rock Candy and Spaghetti-O Gallstones; Atypical Cholelithiasis Presentations, Undetectable by Ultrasound, Identified via Bile Aspirate Analysis, Kerrey B. Buser MD

Sleeve Gastrectomy in a Morbidly Obese Patient with Giant Paraesophageal Hernia, Brian Carmine MD

Prospective Trial to Compare Postoperative Complications and Length of Stay for Open versus Laparoscopic Methods of Enteric Perforation Repair, Jaideep Singh Chahal MD

Can Harmonic Energy Technology Effectively Seal the Pancreatic Ducts and Prevent Pancreatic Leak? Feasibility Evaluation and Testing in a Survival Porcine Model, Ronald Scott Chamberlain MD

Clinical Dilemma! How to Deal With Rare Congenital Gall Bladder Anomalies, Ashfaq Hussain Chandio MBBS, FRCS

Factors Influencing Successful Completion of Laparascopic Cholecystectomy, Ashfaq Hussain Chandio MBBS, FRCS

Agenesis of Gall Bladder, Ashfaq Hussain Chandio MBBS, FRCS

Right Hepatic Duct Opens Into Cystic Duct, Ashfaq Hussain Chandio MBBS, FRCS

Laparoscopic Lumber Hernia Repair, Keyur A. Chavda MD

Minimal Invasive Approach of the Liver Hydatidosis, Duta Ciprian MD PhD

Our Experience in the Laparoscopic Resection of Advanced Low Rectal Cancer with Intraoperative Radiotherapy, Ignazio Massimo Civello Prof Dr Med

Chronic Biloma Ten Years After Laparoscopic Cholecystectomy, Benjamin L. Clapp MD

Radiofrequency-assisted Liver Resection in Patients with Hepatocellular Carcinoma and Cirrhosis: Preliminary Results, Giuseppe Currò MD

The Relation of Reduction of Hernial Ring And Reoccurrence Rate in Laparoscopic Trans Abdominal Pre-Peritoneal Inguinal Hernia Repair, Zarija Djorovic MD

Laparoscopic Skill Acquisition from a Novel Simulator Curriculum is Independent of Video Gaming Experience and is Maintained After Training, Andrew J. Duffy MD

Transaxillary Endoscopic Periareolar Approach (TEPA) to Total Thyroidectomy, Titus D. Duncan MD

Indications for Laparoscopic Sigmoid Resection and End-Colostomy in Spinal Cord Injury Patients, Dan Eisenberg MD

Laparoscopic Repair of Post-esophagectomy Hiatal Hernia, Thomas Fabian MD

Key Points of the Arterial Vascularization of the Main Biliary System–The Right Importance to a Correct Procedure in All Surgical Attitudes, José M. M. Ferreira-Coelho Prof Dr Med

The Use of Bioabsorbable Staple Line Reinforcement for Circular Stapler (BSG “Seamguard”) in Colorectal Surgery, Morris E. Franklin MD

Total Laparoscopic Right Hemicolectomy with Intra Corporal Anastomosis and Transvaginal Extraction of the Specimen, Morris E. Franklin MD

Low Anterior Resection With Total Mesorectal Excision: The Texas Endosurgery Institute Experience, Morris E. Franklin MD

Laparoscopic Right Hemicolectomy. 15 Years and 411 Patients, Morris E. Franklin MD

Laparoscopic Treatment of Achalasia. The Texas Endosurgery Institute Experience, Morris E. Franklin MD

Laparoscopic versus Robotic Assisted Laparoscopic Roux-en-Y-Gastric Bypass: The Da-Vinci Robotic System Improves Outcomes?, Alberto S. Gallo MD

Robotic Assisted Laparoscopic Repair of Paraesophageal Hernia with Mesh and Nissen Fundoplication, Carlos A. Galvani MD

Project REACH: Robotic Expertise Allowing Collaborate Help. A New Paradigm in Post Graduate Surgical Training, Alex Gandsas MD

Laparoscopic Total Colectomy for Polyposis and Ulcerative Colitis with Ileorectal Anastomosis, Roberta Gelmini Prof Dr Med

Single-Port Laparoscopic Colectomy (eNOTES): Ready for Primetime!, Dan Geisler MD

Laparoscopic Sigmoidectomy with Suture Rectopexy for Full-thickness Rectal Prolapse, Dan Geisler MD

Laparoscopic Proctosigmoidectomy with Vertical, Double-Stapled Anastomosis, Dan Geisler MD

Laparoscopic Total Proctocolectomy And Ileal-Pouch Anal Anastomosis, Dan Geisler MD

Laparoscopic Ileocolectomy in Adult with Malignant Ileocecal Intussusception, Dan Geisler MD

Short Term Outcomes after Simultaneous Laparoscopic Adjustable Gastric Banding and Hiatal Hernia Repair, Maria V. Gorodner MD

Robotic Surgery Made Cost Efficient!, Monika Hagen Dr Med, MBA

Pure NOTES Repair of Umbilical Hernia in a Human Cadaver, Monika Hagen Dr Med, MBA

Validity Assessment of a Novel “Serious Game” to Train and Assess Laparoscopic Suturing, Usman Jaffer MB BS

Role of Ultrasonic Scalpel in Subfascial Endoscopic Perforator Surgery in Chronic Venous Insufficiency of Lower Limbs, Sudhir Kumar Jain MS, FRCS, FICS, FACS

Small Bowel Obstruction after Laparoscopic Roux-en-Y Gastric Bypass, Muhammad A. Jawad MD

Laparoscopic Reversal of Roux-en-Y Gastric Bypass, Muhammad A. Jawad MD

A Novel Technique for Laparoscopic Gastrostomy: A Simple, Safe, and Minimal Invasive Technique, Emad Kandil MD

Improvement of Serum Creatinine Levels in Type 2 Diabetics Following Roux-en-Y Gastric Bypass, Stephen R. Kerr MD

Repair of Hiatal Hernia and Reinforcement with Bovine Pericardium, Kenneth Phillip Kleinpeter MD

Nitinol Based Compression Anastomosis Devices - Is It the Optimal Anastomotic Technology?, Doron Kopelman Prof Dr Med

Laparoscopic Nissen Fundoplication: a Correct Choice for GERD Treatment, Sebastiano Lacitignola MD

Laparoscopic Complications in Pancreatic Surgery, Sebastiano Lacitignola MD

RCT to Determine the Need for Prophylactic Antibiotics in Elective Laparoscopic Cholecystectomy, Jude Lee Dr Med

Laparoscopic Surgery in the Obstetric Patient: A Case Series of Thirteen Patients, Szczurek Linda DO

Laparoscopic Sleeve Gastrectomy versus Laparoscopic Roux-en-Y Gastric Bypass: a Case Series, Szczurek Linda DO

Laparoscopic Assisted Percutaneous Gastrostomy Tube Placement: Aiding An Old Technique, Gustavo Lopes DO

Laparoscopic Esophagomyotomy, Minh Luu MD

Minimally Invasive Colorectal Surgery, Minh Luu MD

Jejunal Erosion in Laparoscopic Adjustable Gastric Banding, Yohannes Mahtemework MD

Prognostic Significance Peritoneal Lavage and Laparoscopy in Patients with Gastrointestinal Malignancy, Sinisa Maksimovic MD PhD

Laparoscopic Cholecystectomy: Our Experiences After 2500 Patients, Sinisa Maksimovic MD PhD

Thoracoscopic Enucleation of Leiomyoma, Jeremiah T. Martin MD

A Safe Technique: The Hand-Sewn Laparoscopic Roux-en-Y Gastric Bypass, Lisa R. Martin-Hawver MD

Superiority of Laparoscopic Resection Over Open Surgery for Rectal Cancer, Andre L. Moreira MD

NOTES Roux-en-Y Gastric Bypass in Human Cadavers, Philippe Morel Prof Dr Med

Total Robotic Roux-en-Y Gastric Bypass, Philippe Morel Prof Dr Med

Miniinvasive Treatment of the Severe Acute Biliary Pancreatitis, Vincenzo Neri Prof Dr Med

Thymectomy by Thoracoscopic Approach: Experience and Outcomes, Vladimir N. Nikishov

Laparoscopic Approach in Abdominal Trauma, Francisco A. Obregon MD

Are Postoperative Doses of Prophylactic Antibiotics Necessary in Laparoscopic Bariatric Surgery?, Alexander Onopchenko MD

Unusual Clinical Presentation of Visceral Perforation, Dhaval Patel MD

The Evaluation of Endoscopic Therapy in Acute Biliary Pancreatitis, Haifeng Peng MD

Laparoscopic Reversal of Hartmann’s Procedure, Sotero E. Peralta MD

Laparoscopic Reversal of a Laparoscopic Hartman’s Procedure for Diverticulitis, Sotero E. Peralta MD

Laparoscopic Roux-en-Y Gastric Bypass in the Setting of Intestinal Malrotation, George A. Poulos DO

From NOTES to Minimally Invasive Surgery: Two Ports Sigmoidectomy, Francois Pugin MD

Laparoscopic Cholecystectomy in Cirrhotic Patients in Tertiary Care Hospital in Pakistan, Shaikh Abdul Razaque Prof Dr Med

Laparosopic Incisional Hernia Repair in Liver Transplant Patients:Single Center Experience, Manuel I. Rodriguez-Davalos MD

Laparoscopic Liver Resection: Our Initial Experience and Results, Manuel I. Rodriguez-Davalos MD

Single Incision Laparoscopic Heller Myotomy and Anterior Fundoplication, Sharona B. Ross MD

Laparoscopic Management of Amyand’s Hernia, Rajinder Kaur Saggu MS FIAGES

Laparoscopic Management of Adrenal Tumour, Sukhvinder Singh Saggu

Nerve Sparing TAPP Hernioplasty Feasible and Neccessary?, Lukas Sakra MD PhD

Laparoscopic Type IV Hiatal Hernia Repair with Mesh, J. R. Salameh MD

Recurrent Incarcerated Suprapubic Incisonal Hernia: Laparoscopic Management, Luis E. Salgado MD

Laparoscopic Treatment of Primary Omental Torsion: Case Report and Literature Review, Luis E. Salgado MD

Gallstone: a Stone Too Precious to Be Lost, Tushar Satish Samdani MS, DNB (General Surgery), MRCS

Balloon Retention Facilitates Laparoscopic Transgastric Cystogastrostomy, Craig Swafford MD

Laproscopic Surgery in Patient of Situs Inversus Totalis, Saleem Mohammad Syed

Robotic Assisted Iliac Node Dissection for Melanoma, Vijay Trisal MD

Transgastric Endoscopic Bloodless Liver Resection Using Radiofrequency Thermal Energy. An Experimental Study, Konstantinos G. Tsalis Prof Dr Med

Does Acute Cholecystitis Affect Conversion Rates in Laparoscopic Cholecystectomy?, Ali Uzunkoy Prof Dr Med

Laparoscopic Evaluation for Bilateral Hernia in Children, Amir Vejdan Dr Med

The Laparoscopic Assisted Abdominoperineal Resection for Lower Rectal Cancer (LAPR) in our Experience, Pietro Venezia Prof Dr Med

Gastro-jejunal Stapling During Natural Orifice Translumenal Endoscopic Surgery (NOTES) in Human Cadavers: Material, Techniques and Stapler Modifications, Oliver J. Wagner MD

Unusual Presentation of Choledochal Cyst at the Age 87, Velupillai WignaKumar MD

GYNECOLOGY

Preoperative Parameters of Increased Surgical Risk in Patients with Endometriosis, Ilana B. Addis MD, MPH

Laparoscopic Vascular Injury Repair, Masaaki Andou MD PhD

A Case Report of CO2 Gas Embolism in the Laparoscopic Myomectomy, Yasuyuki Asakawa MD PhD

Porcine Model for Laparoscopic Salpingostomy and Salpingectomy, Amy Broach MD

Her Option FOR Her, Jaswant S. Chaddha MD

The Use of Bipolar Energy and Saline in Hysteroscopic Surgery: a Series of 65 Patients, Stefanos Chandakas MD MBA PhD

A Multicentered Series of 850 Daycase Laparoscopic Subtotal Hysterectomies in the UK and Greece: The New Approach to Hysterectomy, Stefanos Chandakas MD MBA PhD

A New Narrow Band Imaging Endoscopic System for the Detection of Surface Pathology including Endometriosis: A Series of 75 Patients, Stefanos Chandakas MD MBA PhD

A Randomized Controlled Study Comparing Two Standardized Closure Methods of Laparoscopic Port Sites, Kai Chen MD

Medico-legal Problems with Advanced Gynaecological Operative Endoscopy, Mark Erian MD

The Presence of Endometriosis Increases the Risk for Myofascial Pain and Pelvic Floor Tension Myalgia in Patients with Chronic Pelvic Pain, Bradford W. Fenton MD PhD

Mylosis Revisited, Herbert A. Goldfarb MD

Laparoscopic Assisted Myomectomy Using Mobius Retractor, Herbert A. Goldfarb MD

Laparoscopic Myomectomy for Large Cervical Fibroids-Repair for the Lacerated Endocervical Mucosa, Tomonori Hada MD

Analysis of Operative Indication of TVH and LAVH, Tang Jiasong MD

Clinical Effects of Laparoscopic Colposuspension with Round-Infundibulopelvic Ligament in High Grade Procidentia Uteri, Dong Ho Kim MD

Laparoscopic Colposuspension with Round-Infundibulopelvic Ligament in Procidentia Uteri, Dong Ho Kim MD

Different Approaches to Identifying the Obturator Nerve During Laparoscopic Pelvic Lymphadenectomy, Connie Liu MD

23,600 Cases of Study on the Reforming Open Trocar First-Puncture in Multiple Centers, Haifang Liu MD
Treatment and Survival Analysis of Ovarian Cancer Discovered by Laparoscopy Unexpectedly, Jun Xiao Liu MD

The Effect of Two Kinds of Insufflator with Different Work Principles on Intra-abdominal Pressure of Patients During Gynecological Laparoscopic Operations, Yan Liu MD

The Prognosis of Surgical Treatment Using Laparoscopy in Patients with Endometrial Cancer-The Result of 15 Years’ Follow Up, Yan Liu MD

17,100 Cases of Study on the Modified Open Trocar First-Puncture in Multiple Centers, Yan Liu MD

Five Year Prospective Follow Up of the Results of Roller Ball Endometrial Ablation for Women with Menorrhagia, Atieh Mansouri Associated Professor

Laparoscopic Management of Adnexal Tumors, Liselotte Mettler Prof Dr Med

Retrospective Analysis of Laparoscopic Myomectomy: 750 Cases, Mineto Morita MD

LTH Report for 150 Cases With No Complications with the RUMI System and Koh Cup, Manuel Mota MD

The Result of Laparoscopic Cure of the Ovary Endometriosis, Khusen Narzullaev MD PhD

Comparison of Robot-Assisted Hysterectomy to Laparoscopic Assisted Hysterectomy, Ceana Nezhat MD

Consistent Outcomes of Laparoscopic Intraperitoneal Paraaortic Lymphadenectomy Support Incorporation into Fellowship Training Program Curricula, Farr Nezhat MD

Robotic Assisted Total Pelvic Exenteration, Farr Nezhat MD

Robotic Assisted Ovarian Transposition and Pre-Treatment Surgical Staging in Cervical Cancer, Farr Nezhat MD

The Comparison of Postoperative Re-adhesion Formation After Previous Laparoscopic and Laparotomic Adhesiolysis for Stage IV Endometriosis, Sung-Tack Oh MD PhD

Comparison of Laparoscopic-assisted Vaginal Hysterectomy with Traditional Hysterectomy in Omolbanin Hospital (2005 Jan-2007 Sep), Monireh Pourjavad Professor in OB/GYN

Outcomes of Retroperitoneal Uterine Artery Ligation During Laparoscopic Hysterectomy: a Retrospective Review of 419 Cases, Ruchi Puri MD

Comparative Evaluation of Tubal Sterilization by Two Methods: Laparoscopy-Filshi Clips and Minilaparatomy Pomeroy Technique, Nafiseh Saghafi Prof Dr Med

Endometrial Ablation for the Treatment of Dysfunctional Uterine Bleeding Using Hysteroscopic Resectoscope, Nafiseh Saghafi Prof Dr Med

Scarless (Microlaparoscopic) Prophylactic Oopherectomy with NOTES Technique, Tamer Seckin MD

Profile of Lupron Use in the Community Setting for Pelvic Pain, Sangeeta Senapati MD

Laparoscopic Resection of Cervical Stump, Jonathan Y. Song MD

Laparoscopic Approach for the Large Cervical Leiomyoma, Jonathan Y. Song MD

Laparoscopic Tubal Anastomosis, Jonathan Y. Song MD

Vulvar Hematoma Following Laparoscopic Ovarian Cystectomy?, Mehrnaz Valadan Prof Dr Med

Full Thickness Bladder Endometriosis. Bloodless Excision Using Ultracision, Johannes J. van Beek MD MBA

Clinical Comparison of Classic Intrafascial Semm Hysterectomy and Laparoscopically Assisted Vaginal Hysterectomy, Shaojuan Wang MD

Fertiloscopic Ovarian Drilling: Review of 160 Cases, Antoine A. Watrelot Prof Dr Med

A Case of Recurrent Laryngeal Nerve Paralysis After Laparoscopic Surgery, Takashi Yamada MD PhD

UROLOGY

Robotic Repair of Access-Related Aortic Injury, Ronney Abaza MD

Comparison of Open and Laparoscopic Nephroureterectomies for Managing Upper Urinary Tract Transitional Cell Carcinoma, Muhammad Z. Aslam MRCS

Transperitoneal Pure Laparoscopic Partial Nephrectomy: Previous Abdominal Surgery is not a Contraindication, William J. Badger MD

Laparoscopic Management of Coexisting Calyceal Diverticulum and Peripelvic Cyst, William Badger MD

Video Demonstration of Robotic and Laparoscopic Partial Nephrectomy Without Vascular Clamping and Renal Ischemia, Carl Bischoff MD

Comparison of Vascular Clipping and Stapling Techniques for Renal Artery Occlusion During Hand-Assisted Laparoscopic Donor Nephrectomy, James G. Bittner MD

Buttressed, Double-Armed, Crossed Horizontal Mattress Suture Closure After Partial Nephrectomy: A Novel Modification Using Cadaveric Pericardium (with Video), James G. Bittner MD

Comparison of Vascular Clipping and Stapling Techniques for Renal Artery Occlusion During Hand-Assisted Laparoscopic Donor Nephrectomy, James G. Bittner IV MD

Is Sutured Repair Necessary During Laparoscopic Partial Nephrectomy?, Matthew Christman MD

Laparoscopic Versus Percutaneious Renal Cryoablation: Single Center Experience and Intermediate-Term Outcomes, Ithaar H. Derweesh MD

Treatment of Post Transplantation Vesicoureteral Reflux with Injection of Dextranomer/Hyaluronic Acid Copolymer, Ithaar H. Derweesh MD

Can Laparoscopic Pyeloplasty Be Considered “Gold Standard” in the Treatment of Uretero-Pelvic Junction Obstruction?, Mario Falsaperla MD

Laparoscopic Ablative Renal Surgery Using Single Kind of Hem-o-Lok Clips for Global Vascular Control,
Mario Falsaperla MD

Robotic Pelvic Lymph Node Dissection in Patients Undergoing Radical Cystectomy for Bladder Cancer, Aldrin Joseph R. Gamboa MD

Robot-Assisted Laparoscopic Radical Cystectomy For Bladder Cancer: An Analysis of Perioperative Surgical Outcomes, Aldrin Joseph R. Gamboa MD

A Case Control Analysis of Robotic-assisted Laparoscopic Varicocelectomy, Josephine Hidalgo-Tamola MD

Are the Complications of PCNL High? (Report of 2800 Cases in Two Referral Training Center), Mohammad Mehdi Hosseini Prof Dr Med

Comparison of Complete Intracorporeal Construction of an Ileum Neobladder Utilizing Standard Sutured Techniques and Novel Technologies, Gregory W. Hruby BA

Laparoscopic Ureteroureterosotomy for a Retrocaval Ureter, Hak J. Lee MD

Outcomes of a Robotic Training Program for Community-Based Urologists and Fellows, Hossein Mirheydar BS

3-Dimensional Visualization During Conventional Laparoscopic and Robotic-Assisted Surgery: A Look Into The Future?, Ravi Munver MD

Does Age Affect the Safety And Efficacy of Lithium Triborate (LBO) Laser Photoselective Vaporization Prostatectomy (PVP)?, Jay B. Page MD

Lithium Triborate (LBO) Laser Photoselective Vaporization Prostatectomy (PVP) for Large Volume Benign Prostatic Hyperplasia (BPH), Jay B. Page MD

Robotic and Laparoscopic Partial Nephrectomy without Vascular Clamping and Renal Ischemia, Sijo J. Parekattil MD

Decreasing Operative Time with Doppler Identification of Crossing Vessel During Robotic and Laparoscopic Pyeloplasty, Sijo J. Parekattil MD

Oncologic Significance of Pathologic T2 Positive Surgical Margin in Robotic-Assisted Laparoscopic Prostatectomy, Zamip Patel MD

Early Oncologic Outcomes after Robotic Assisted Laparoscopic Radical Prostatectomy by D’Amico Risk Stratification, Zamip Patel MD

The Effect of Erythropoietin on Ischemic Damage in the Canine Kidney, Courtney K. Phillips MD

Interinstitutional Variations in Robotic Prostatectomy Pathologic Outcomes for a Single Surgeon and Team, David Samadi MD

Extending the Robotic Prostatectomy Learning Curve Beyond 750 Cases with a Single Surgical Team, David Samadi MD

Long-term Impact of a Laparoscopic Renal Surgery Mini-Residency on Post Graduate Urologic Practice Patterns, Rosanne Santos BS

Long-term Impact of a Robot Assisted Laparoscopic Prostatectomy Mini-Residency Training Program on Post-Graduate Urologic Practice Patterns, Rosanne Santos BS

Efficacy and Safety of the Vivostat System for Hemostasis in Laparoscopic Partial Nephrectomy, Luigi Schips Prof Dr Med

Laparoscopic Adrenalectomy: Anatomic and Technical Considerations, Amanjot Singh Sethi MD

Hand-Assisted and Pure Laparoscopic Nephrectomy: A Quantitative Comparison of Outcomes, Jonathan Silberstein MD

Case-Control Analysis of Pediatric Robotic Pyeloplasty and the Impact of Mechanical Failures, Mathew D. Sorensen MD

Initiation of a Pediatric Robotic Surgery Program and a Case-Control Analysis of Pediatric Robotic Ureteral Reimplantation, Mathew D. Sorensen MD

Catheter Free Lithium Triborate (LBO) Laser Photoselective Vaporization Prostatectomy (PVP), Massimilano Spaliviero MD

Efficiency of Lithium Triborate (LBO) Laser Photoselective Vaporization Prostatectomy (PVP): Kinetic Performance Study, Massimilano Spaliviero MD

Does Lithium Triborate (LBO) Laser Photoselective Vaporization Prostatectomy (PVP) Affect Sexual Function?, Massimilano Spaliviero MD

Randomized Prospective Evaluation of the Effect of Patient Positioning on Surgical Outcomes During Laparoscopic Renal and Adrenal Surgery, Chandru P. Sundaram MD

Radiofrequency Ablation of Small Renal Tumor: 2-year Follow-up, Gyung Tak Sung MD PhD

Short-term Outcomes of Laparoscopic Radical Cystectomy with Extracorporeal Ileal Conduit, Gyung Tak Sung MD MBA

Towards a VR Laparoscopic Trainer for Nephrectomy: A Unique Collaboration Between the AUA, Academia and Industry, Robert M. Sweet MD

Robotic-Assisted Laparoscopic Radical Prostatectomy for High Risk Prostate Cancer: Initial Experience And Short-Term Outcomes, Jayant Uberoi MD

Decreased Efficiency of Lithium Triborate (LBO) Laser Photoselective Vaporization Prostatectomy (PVP) With Long-Term 5a-Reductase Inhibition Therapy: Is It True?, Carson Wong MD

120 W Lithium Triborate (LBO) Laser Photoselective Vaporization Prostatectomy (PVP) For Symptomatic Benign Prostatic Hyperplasia (BPH), Carson Wong MD

Predication and Implementation Strategies in Laparoscopic Education, Saleem Zafar MD

Experimental Control of Renovascular Injuries During Laparoscopic Nephrectomy, Saleem Zafar MD

MULTISPECIALTY

Laparoscopic Repair of a Diaphragmatic Injury, Kanayochukwu Jacquelyne Aluka MD

Laparoscopic Ultra-radical Parametrectomy (Piver type 5), Masaaki Andou MD PhD

A Practical Guide to Teaching Residents Laparoscopic Surgery, Joy Brotherton MD

Cesarean Delivery Increases the Risk for Development of Interstitial Cystitis but not Other Chronic Pelvic Pain Related Diagnoses, Bradford W. Fenton MD PhD

Severe Hypoglycemia After Gastric Bypass, Case Report and Review of Literature, Gloria Henao MD

The New Theory of Carcinogenesis - The Theory of Gene Multiple Hits, Xu Han-You DO

Content and Face Validity of a Cost-Effective Personal Laparoscopic Trainer Designed for at Home Use, Gregory W. Hruby BA

Comparative Study of Single versus Double-Lumen Endotracheal Tube Anesthesia for Needlescopic Bleb Resection, Hyun Koo Kim MD PhD

Hip Arthroscopy for Femoroacetabular Impingement in the Athlete, Dean Matsuda MD

Minimally Invasive Surgery Group: Cutting Edge Goes a Cut Above, Dean Matsuda MD

Face and Content Validation of a Novel Robotic Virtual Reality Simulator, Amanjot Singh Sethi MD

A Comparison of Conventional and Second Generation Articulating Laparoscopic Instruments, Chandru S. Sundaram MD

Natural Orifice Surgery from the Middle of The World, Daniel A. Tsin MD

Multidisciplinary Utilization Patterns of Robotic Technology at an Institution with 6 Da Vinci Surgical Systems: the Impact of Robotic-Assisted Surgery on Surgical Subspecialties, Jayant Uberoi MD

Biliary Endoscopic Lithotripsy, Joseph Wyatt MD

Cystoscopic Removal of Transvesical Sling with Holmium Laser, Joseph Wyatt MD

Laparoscopic Excision of Urachal Cyst, Robert G. Yavrouian MD

HONORARY CHAIRS

Honorary Chairs, Makote Hashizume, MD, PhD, and Errico Zupi, MD, will make their presentations on Wednesday, September 17, 2008 during the Opening Ceremony, which begins at 5:00pm.

Makote Hashizume, MD, PhD, presents Image-Guided Minimally Invasive Robot-Assisted Surgery

Dr Makoto Hashizume graduated after Kyushu University School of Medicine in 1979. He finished residency at General Surgery II, Kyushu University Hospital. He obtained his PhD in 1984 from the Graduate School of Medical Sciences, Kyushu University, in the area of pathology for portal hypertension. He worked in Laser Vascular Endoscopy as a Research Assistant Professor at Hahnemann University, Philadelphia from 1985 to 1986. He has been working in the field of minimally invasive surgery including endoscopic surgery, robotic surgery and portal hypertension. He is currently the director of Emergency & Critical Care Centre, the director of Training Centre for Endoscopic Surgery, Professor of Department of Advanced Medicine and Innovative Technology, Kyushu University Hospital, and Professor and Chairman of Department of Advanced Medical Initiatives, Faculty of Medical Sciences, Kyushu University.

Errico Zupi, MD, presents Actuality and Future Perspectives of N.O.T.E.S. (Natural Orifice Transluminal Endoscopic Surgery)

Dr Zupi currently practices gynecologic endoscopy at the Fatebenefratelli Hospital and is Associate Professor of the Department of Obstetrics and Gynecology at the University of “Tor Vergata” in Rome.

Dr Zupi has published over 100 papers and chapters in endoscopic books and has won a number of awards including: Winner of the Award for the Best Paper on Hysteroscopy at the AAGL 23rd International Congress of Gynecologic Endoscopy, 1994, New York; Winner of the Award for the Best Paper on Hysteroscopy at the AAGL 25th International Congress of Gynecologic Endoscopy, 1996, Chicago; Winner of the Award for the Best Paper on Minilaparoscopy at the 26th International Congress of Gynecologic Endoscopy, 1997, Seattle; and Winner of the Award for the Best Paper on Mini-laparoscopy at thse 27th International Congress of Gynecologic Endoscopy, 1998, Atlanta.

Dr Zupi believes his strength lies in his vast experience of mentoring younger physicians and teaching them to learn endoscopic surgery, publish their findings, and then to teach the next generation of their peers.

17TH ANNUAL MEETING AND ENDO EXPO 2008 SCIENTIFIC ABSTRACTS

8103 General Surgery
Nitinol-Based Compression Anastomosis Devices – Is it the Optimal Anastomotic Technology?
Kopelman Doron, MD

    The creation of anastomosis between various parts of the gastrointestinal tract is a major task in daily surgical practice and a major task in the evolving field of NOTES. Anastomosing techniques today involve the use of sutures or metal staples. Both techniques involve foreign material penetrating the tissue and evoking a localized inflammatory response, increasing the propensity to anastomotic-related morbidity. It has been obvious to many researchers since the 19th century that avoiding any foreign material within the anastomotic line could prove to be beneficial. The history and evolving characteristics of this technology will be reviewed. The strengths of the Nitinol (a shape memory alloy)-based compression technology obviously lies exactly where the weaknesses of stapling are. The best arguments in favor of the revival of this old-new technology are (1) the theoretical concept of sutureless or stapleless anastomosis is favored by most surgeons, and (2) historical failures are well understood and are mostly answered by the characteristics of the Nitinol alloy. Nitinol-based compression instrumentation may be applied in the future to most surgical procedures in reconstructive, oncological, and transplant surgery. The primary and most significant future applications of this technology should be with NOTES, with distal rectal anastomosis, gastric anastomotic procedures, and anastomosing narrow, hollow organs like the ureters and bile ducts. Nitinol-based solutions for the creation of compression anastomosis will be evaluated for their possible revolutionary impact on present surgical methods and anastomosing technology in the alimentary tract and beyond.

8104 General Surgery
Clinical Dilemma! How To Deal with Rare Congenital Gallbladder Anomalies!
A. Chandio, S. Timmons, M. Abbasi, F. Biswas, F. Aftab, A. Twomey

    We report 2 rare cases of congenital anomaly of the gallbladder diagnosed perioperatively. The first patient, a 32-year-old female presented with features of obstructive jaundice and was found to have agenesis of the gallbladder at operation. This is a rare congenital malformation often associated with other anomalies. Agenesis of the gallbladder is difficult to diagnose clinically, and discovery is often incidental during laparotomy for cholecystectomy. The second patient, a 67-year-old female, was electively admitted for laparoscopic cholecystectomy. Liver function tests showed a slightly deranged picture, CRP was elevated, and the tumour marker CA19.9 was raised. CT of the abdomen and pelvis demonstrated acute-on-chronic cholecystitis. The initial laparoscopic cholecystectomy was converted to open laparotomy due to difficult anatomy. This revealed anomalous insertion of the right hepatic duct into the cystic duct. These anomalies are important to recognize, because great care must be taken to avoid inappropriate division of ducts and arteries in the course of cholecystectomy.

8105 General Sugery
Factors Influencing Successful Completion of Laparoscopic Cholecystectomy
A. Chandio, S. Timmons, F. Biswas, M. Abbasi, A. Twomey, F. Aftab

Objectives: To analyze the factors contributing to the decision to convert from a laparoscopic to an open cholecystectomy and the trend for conversion to open surgery over a 3-year period.

Methods: A retrospective study was performed of all patients undergoing cholecystectomy at Mallow General Hospital Co. Cork from January 2004 to December 2006.

Results: Of 326 laparoscopic cholecystectomies attempted in this 3-year period, 39 (12%) required conversion to open cholecystectomy. The rate was higher in men than in women (16% versus 10%, P<0.06), as has been previously described. This may be partly explained by the fact that male patients were older than female patients were (56 versus 49 years), as conversion rates are known to correlate with age. The most common reasons for conversion were inability to adequately define anatomy and the presence of dense adhesions. Gallbladder wall thickness on ultrasound examination was predictive of conversion, as has been previously reported. The conversion rate was higher in 2004 than in subsequent years (18%, versus 8% and 10%), despite no increase in the rate of planned open procedures in these latter years due to individual patient factors.
Conclusion: In this small, general hospital, the conversion rate of 12% compares favorably with reported rates elsewhere.

8112 Gynecology
Retrospective Analysis of Laparoscopic Myomectomy: 750 cases
Mineto Morita, MD, Ichiro Uchiide, MD, Takehiko Tsuchiya, MD, Masahito Nakakuma, MD

Objective: We sought to determine the safe indications for and the limitations of laparoscopic myomectomy surgery.

Methods: The same surgical technique was used in all patients: general anesthesia, pneumoperitoneum (carbon dioxide gas), 4-puncture method, and complete intraabdominal suture technique. GnRH analogue was administered to all patients for 3 to 6 months before surgery. From January 1996 to December 2006, laparoscopic myomectomy was performed in 750 patients (395 intramural myoma, 355 subserosal myoma, grouped by existence of maximum nodule) at our hospital. Parameters measured were age (35.2±4.8 years, range 20 to 52), maximum diameter of enucleated myoma nodules (6.6±2.0cm, range 1 to 15), number of enucleated myoma nodules (2.0±1.7, range 1 to 16), operation time (100.2±30.1 minutes, range 25 to 210), amount of bleeding (98.1±87.2mL, range 10 to 650), and weight of enucleated specimens (162.9±139.5g, range 4 to 1400).

Results: The maximum diameter of enucleated nodules and the weight of specimens were greater in the subserosal myoma group. The amount of bleeding and length of operation time were greater in the intramural myoma group. These results show that when the maximum diameter of enucleated myoma nodules increases, the amount of bleeding and length of operation time also increase. The amount of bleeding was 56.6±42.2mL (range, 10 to 205) in enucleated myoma nodules with a diameter <5cm. In nodules >10cm, the amount of bleeding was significantly increased to 224.7±159.8mL (range, 45 to 620).
Conclusion: Our results show that the diameter of myoma nodules is an important factor for safe surgery, and that the maximum diameter for safe surgery is approximately 10cm.

8114 General Surgery
Agnesis of the Gallbladder
A. Chandio, S. Timmon, F. Biswas, K. Khalil, A. Twomey, F. Aftab

    We report the case of a 32-year-old female who presented with features of obstructive jaundice and was found to have agenesis of the gallbladder. This is a rare congenital malformation often associated with other anomalies. Agenesis of the gallbladder is difficult to diagnose clinically, and discovery is often incidental and is usually discovered at laparotomy for cholecystectomy.

8115 General Surgery
Right Hepatic Duct Opens Into Cystic Duct
A. Chandio, S. Timmons, F. Biswas, A. Twomey, F. Aftab

Introduction: Anatomic variations in the hepatic duct and cystic duct are common. Anomalous insertion of the right hepatic duct into the cystic duct is a rare variation. Anomalies of the biliary duct may be problematic during surgical interventions apart from iatrogenic injury to bile ducts during cholecystectomy formation of bile duct calculi, pancreatitis, and cholangitis.

Case Report: A 67-year-old lady underwent an elective laparoscopic cholecystectomy. She had diarrhea and vomiting. There was an incidental finding of hepatomegaly. Her complete blood count was normal. Liver function tests showed a slightly deranged picture with normal bilirubin but elevated GGT, alkaline phosphatase, and ALT. CRP was elevated at 33, and tumor markers show a raised CA 19.9. Abdominal ultrasound showed gallstones and normal gallbladder wall thickness. CT of the abdomen and pelvis showed a thick gallbladder wall, pericholecystic fluid, and fat stranding that may represent acute or chronic cholecystitis. However, an additional CT was advised in 6 weeks time to rule out a gallbladder neoplasm. Colonoscopy was normal.

Results: The gallbladder was very distended. Severe adhesions were present, and the anatomy was difficult, so the procedure was converted to an open exploration of the gallbladder wall, revealing a thickened cystic duct and multiple stones. Perioperative cholangiography showed that the cystic duct appeared to enter the right hepatic duct rather than the bile duct. The patient’s postoperative recovery was uneventful.

Conclusion: Awareness of variations in the biliary duct and sound knowledge of all anatomic structures is essential before ligation and division to prevent duct injury. It is equally important to understand congenital variation of biliary and vascular anatomy as well as their operative implications.

8116 Gynecology
Vulvar Hematoma Following Laparoscopic Ovarian Cystectomy
Assistant Professor Mehrnaz Valadan, Hossein Ashegh, MD, Soodabeh Darvish, MD 

Objective: Complications of laparoscopy vary significantly.

Methods: We report a case of vulvar hematoma in a 20-year-old virgin female, presenting after laparoscopic ovarian cystectomy due to right epigastric vessel injuries.

Results: The hematoma was removed by cold compression therapy.

Conclusions: In some vulvar hematoma due to laparoscopic surgery, we can use cold compression therapy to improve hematoma and stabilize the patient to prevent the risk of repeat surgery on such patients.

8117 Urology
Comparison of Open and Laparoscopic Nephroureterectomies for Managing Upper Urinary Tract Transitional Cell Carcinoma
M. Z. Aslam, MRCS, M. D. Dooldeniya, FRCS, C. S. Biyani, FRCS

Introduction: We report our experience with laparoscopic nephroureterectomies and compare it with the open technique.

Materials and Methods: Between 2000 and 2004, we performed 59 radical nephroureterectomies. Of the patients, 18 underwent laparoscopic nephroureterectomy (LNU), and 41 had open procedures (ONU). No significant difference existed between the 2 groups in terms of age, sex, BMI, ASA classification, and pathologic parameters.

Results: The average duration of procedures was 286 minutes for LNU and 221 minutes for ONU. Intraoperative complications were similar (22%) in both groups. LNU was superior in terms of need for perioperative blood transfusion [2 patients (10%) versus 13 patients (32%)], hospital stay (11 days vs 15 days), and postoperative complications [1 vs 8 (20%) patients]. Clear oncological margins were achieved in all 18 LNU patients and in 37 (88%) in the ONU group. Average follow-up was 25.5 months (LNU) and 34 months (ONU). The 2 groups were similar in terms of bladder recurrence (27% in LNU and 22% in ONU) and metastatic disease (22% and 24%). Local recurrence was higher in ONU (15%) than in LNU (5.5%). Cancer-related mortality occurred in 4 patients (22%) in the LNU group and 5 patients (12%) in the ONU group at a mean interval of 15 months.

Conclusions: ONU still remains the gold standard for managing upper tract transitional cell carcinoma. LNU appears to be a safe, effective technique in experienced hands with comparable oncological outcomes. However, long-term follow-up and a large sample size are still needed to prove the superiority of this procedure over the open technique.

8119 Urology
Comparison of Vascular Clipping and Stapling Techniques for Renal Artery
Occlusion During Hand-Assisted Laparoscopic Donor Nephrectomy
James G. Bittner, IV, MD, Kamran Sajadi, MD, James J. Wynn, MD,
James A. Brown, MD, FACS

Objective: This study aimed to assess the differences in outcomes between renal artery clipping and stapling techniques in hand-assisted laparoscopic donor nephrectomy (HALDN).

Methods: One laparoscopic urologist conducted left kidney HALDN on 55 donors over 48 consecutive months. Donors were divided into those who underwent renal artery
occlusion with 2 Hem-o-Lok clips over 30 months (Group 1, n=27) or with 3-row vascular stapling over the subsequent 18 months (Group 2, n=28). Outcomes of interest included total operative and warm ischemic times, estimated blood loss, and decrease in postoperative hemoglobin concentration, serum creatinine changes from baseline on the first postoperative day, and recipient and donor complications. Data are given as medians and analyzed using nonparametric tests (alpha=0.05).

Results: Groups 1 and 2, respectively, did not vary in age (33 and 39 years; P=0.12), sex (P=0.31), body mass index (26 and 27; P=0.15), preoperative serum creatinine (0.9 and 0.8 mg/dL; P=0.29), or first postoperative day creatinine (1.5 and 1.3 mg/dL; P=0.38). Estimated blood loss was similar (both 100mL; P=0.21) and postoperative hemoglobin decreased equally regardless of technique (P=0.15). Operative time in Groups 1 and 2, respectively, was not significantly different (271 and 281 minutes; P=0.25); however, warm ischemic time was shorter in the vascular stapling group (3 and 2 minutes; P<0.01). No technique-related complications were noted in donors.

Conclusions: Renal artery occlusion during HALDN with a standard 3-row vascular stapler is feasible and safe. In addition, renal vessel stapling may decrease warm ischemic time compared with vascular clip application.

8120 General Surgery
Radiographic Diagnosis and Laparoscopic Repair of a Right Paraduodenal
Hernia: A Video Case Report and Review of the Literature
James G. Bittner, IV, MD, Michael A. Edwards, MD, Paul Karmin, MD,
Bruce V. MacFadyen Jr., MD, John D. Mellinger, MD

Background: Paraduodenal hernias (PDH), a rare cause of small bowel obstruction, exhibit male and left-sided predominance. Ours is the second report to describe the preoperative diagnosis and laparoscopic repair of a right PDH.

Case Report: A 26-year-old female presented with intermittent, bilateral inguinal and epigastric pain associated with nausea and emesis. Further questioning revealed a 6-year history of cramping and intermittent abdominal pain that worsened during menstruation. Physical examination demonstrated only lower quadrant tenderness. Her symptoms led to abdominal ultrasonography and laboratory studies, demonstrating no abnormalities. Helical computed tomography revealed jejunum encased within the right upper quadrant suspicious for right PDH. The patient underwent elective laparoscopic internal hernia repair using one infraumbilical and 3 additional abdominal trocars. Exploration revealed a right retrocolic mass effect from herniated jejunum within the PDH sac. Following reduction of the herniated jejunum, the right and proximal transverse colons were mobilized using a lateral approach, and the hernia sac was opened completely. Careful inspection of the entire bowel demonstrated no other abnormalities. The patient was discharged on the first postoperative day and has exhibited no sequelae after 9 months.

Conclusion: High clinical suspicion and computed tomography permit preoperative diagnosis of PDH. Following diagnosis, laparoscopic repair of right PDH can be performed safely and may shorten hospital stay

8121 Gynecology
Myolysis Revisited: A Review of Ablative Myoma Techniques
Herbert A. Goldfarb, MD

Minimally invasive treatment of uterine fibroids and abnormal bleeding was pioneered by Dr. Robert Neuwirth and Dr. Milton Goldrath. Myolysis was first performed in the United States by the author in 1990. Since that initial surgery, multiple techniques have gained in popularity including uterine artery embolization, cryomyolysis, MRI-guided percutaneous ablation, MRI-guided focused ultrasound, and uterine artery mechanical occlusion. The original technique has not gained in popularity however. This review discusses these techniques in depth and their relationship to the myolysis technique.

8123 General Surgery
Laparoscopic Reversal of Hartmann’s Procedure
Sotero E. Peralta, MD, Michael L. Arvanitis, MD, Frank J. Borao, MD, Roy M. Dressner, MD

Background: Reversal of Hartmann’s procedure is a major operation; it is associated with high morbidity that includes wound infection, anastomotic leaks, and incisional hernias. A laparoscopic reversal approach offers the opportunity of faster recovery time, early hospital discharge, and lower perioperative morbidity.

Methods: We performed a retrospective chart review of patients who underwent a Hartmann’s procedure, in which a subsequent laparoscopic reversal was attempted. Data were obtained on diagnosis, time for reversal of ostomy, conversion to open surgery, discharge time, and perioperative complications.
Results: We identified 7 patients who underwent laparoscopic reversal of Hartmann’s procedure. Four of the 7 patients were male, 3 female, with a mean age of 43.8 years (range, 31 to 62). A Hartmann’s procedure was performed in 6 of the 7 patients due to diverticulitis and in one patient due to colon cancer. The average time for laparoscopic reversal after Hartmann’s procedure was 4.1 months. The average length of stay was 4.5 days. No conversions to an open procedure were needed in this series. Postoperative complications included an anastomotic stricture managed endoscopically in one patient, and a postoperative blood transfusion was needed in another patient.

Conclusion: Laparoscopic reversal of Hartmann’s procedure offers the advantage of avoidance of laparotomy, a decreased length of hospital stay, and the opportunity of using the previous ostomy site as a balloon port. Our series demonstrated that laparoscopic reversal of ostomies is a feasible and safe procedure that offers the advantages of a laparoscopic approach.

8124 General Surgery
Mini-Invasive Treatment of the Severe Acute Biliary Pancreatitis
Vincenzo Neri, Prof Dr Med, Tiziano Pio Valentino, MD

Background: Of all occurrences of pancreatitis, about 20% are severe acute biliary pancreatitis (SABP). The relapse of untreated cases is >20%. The aim of the study was to define a mini-invasive approach to SABP: the removal of the Vater’s papilla obstacle to biliary flow, and the treatment of peripancreatic fluid accumulation and gallstones.

Methods: From 1999 through 2007, 198 patients were treated: 172 mild/moderate acute
biliary pancreatitis (ABP) cases, 26 severe. CT-scan revealed 18 necrotizing cases, and 8 pancreatic edema cases. Within 72 hours, an ERCP/ES was programmed in all patients and successfully executed in 16. In 7 patients, the procedure was delayed for 10 days for temporary Vater’s papilla impracticability, and it was not practical in 3 patients. CT-scan guided percutaneous drainage was performed for 1 infected peripancreatic gathering and 2 intrahepatic ones. Another infected gathering was drained by laparotomic access. Cholecystectomy for lithiasis was executed within 30 days: laparoscopic in 24 patients, laparotomic in 2.

Results: Comparing ERCP/ES, 4 cases of post-ERCP pancreatitis (15.4%), 3 cases (11.5%) of procedure failure, and no cholangitis, hemorrhages or duodenal perforations occurred. The percutaneous drainage did not result in morbidity, and resolution occurred within 10 days. The cholecystectomy did not result in major morbidity. One patient (3.8%) died on the 20th day because of DIC.

Conclusion: The mini-invasive approach to SABP was an efficacious and safe therapeutic program with a long period of resolution (mean, 35 days) but with satisfying results.

8125 General Surgery
Laparoscopic Nissen Fundoplication: A Correct Choice for GERD Treatment
Lacitignola Sebastiano MD, Minardi Martino MD

Background: Gastroesophageal reflux disease (GERD) is a common chronic disorder affecting the gastrointestinal tract. The resulting esophagitis occurs in all age groups, and medical therapy is not always successful. Laparoscopic fundoplication represents a good solution for this chronic disease.
The aim of this study was to demonstrate the efficacy of Nissen-Rossetti fundoplication in 100 patients with symptomatic reflux.

Methods: One surgeon performed all the operations. We analyzed the results obtained with the laparoscopic technique with a follow-up at 4 weeks, 6 months, and from year to year for 5 years.
Results: We obtained satisfactory results with low morbidity and no mortality.

Conclusion: Laparoscopic Nissen-Rossetti fundoplication is a good solution in patients with chronic and pathologic disorders of the gastroesophageal junction.

8126 Multispecialty
Severe Hypoglycemia After Gastric Bypass: Case Report and Review of Literature
Gloria Henao, MD, Ravinder Dhatt, MD, Renu Joshi, MD

Background: An increased incidence of severe hypoglycemia is being seen after gastric bypass surgery. We present a case of severe neuroglycopenia after bariatric surgery.

Case Report: A 60-year-old female had a history of morbid obesity after gastric bypass, and 6 weeks after surgery she woke up with dizziness, ate a meal, and 2 hours later was found unresponsive with questionable seizure activity. In the ER, her blood sugar was 19mg/dL, and an amp of D50 was given. She was admitted for a workup of hypoglycemia. During hospitalization, she had several blood sugar measurements of 23mg/dL to 25mg/dL, requiring D10 drip and octreotide for several days to improve her hypoglycemia. The workup revealed high C peptide and insulin with a BG of 38. GTT did not reveal evidence of dumping syndrome. CT of the abdomen was negative for insulinoma. The patient was discharged after her BG remained stable after consuming 6 small low-carbohydrate meals.

Discussion: Dumping syndrome is the most common cause of hypoglycemia after bypass due to rapid absorption of glucose. However, endogenous hyperinsulinemic hypoglycemia after bypass surgery in adults is, in most cases, due to nesidioblastosis and rarely insulinoma. There have been case reports of nesidioblastosis after bypass surgery. The cause of the nesidioblastosis is less clear. Obesity causing pancreatic beta cell hyperplasia is one thought. This causes excess insulin production leading to hypoglycemia. Treatment includes restricting intake of simple carbohydrates and 6 equal small meals. Octreotide therapy is required for severe cases. If no improvement occurs, patients may need to undergo partial pancreatectomy.

8127 General Surgery
Laparoscopic Complications in Pancreatic Surgery
Lacitignola Sebastiano MD, Minardi Martino MD

Background: The aim of this study was to evaluate, on the basis of our experience, laparoscopic procedures for pancreatic neoplasms in connection with the complications that laparoscopy allows, especially during pancreatic surgery.

Methods: We re-examined all patients who underwent laparoscopic procedures for pancreatic lesions, considering the rate of complications compared with those in patients operated on with the open technique, and their effect on hospital stay, cost, and mortality.

Results: Laparoscopy performed for pancreatic surgery allows an increase in morbidity not only because of the intrinsic complications of pancreatic surgery but also because of the laparoscopic maneuvers.

Conclusion: Based on our experience, we maintain that the laparoscopic technique for the pancreas has increased complications of various causes. Therefore at the moment, this procedure should be used only in select patients.

8128 General Surgery
Total Laparoscopic Right Hemicolectomy with Intracorporal Anastomosis and Transvaginal Extraction of the Specimen
Morris E. Franklin, Jr. MD, Guillermro Portillo, MD, Jeffrey L. Glass, MD, John J. Gonzalez, MD, Sameer S. Mohiuddin, MO, Loretta Brestan, MD

Background: Multiple indications exist for right hemicolectomy or right colon segmental resections including benign noninflammatory disease, polyps, benign inflammatory disease, malignancies, trauma, and diverticular disease. Many techniques have been used for the colonic resection in the past, but traditionally, open surgery (laparotomy) was the only choice for this procedure. Recent advances in minimally invasive surgery have made possible laparoscopic colon resection with very good results, but even with advances in endoscopic surgery an abdominal wall incision would still have to be made to retrieve the specimen either by a midline, Pfannenstiel, or muscle splitting incision. To decrease the bodily insult, natural orifice approaches have been investigated for colon surgery. Transanal extraction has been used successfully for sigmoid specimen extraction, and recently transvaginal extraction has been described for laparoscopic left colectomies

Methods: We report the technical results of a total laparoscopic right hemicolectomy with transvaginal extraction of specimens in 2 patients.

Results: On postoperative day one, the patient had minimal pain with a pain score of 2/10 (analog scale) from the 5-mm to 12-mm port in the right lower quadrant, requiring one dose of mild narcotics. She had no vaginal pain and was tolerating a clear liquid diet, ambulating, and passing flatus. On postoperative day 3, she was transferred to the floor subsequently developing new-onset atrial fibrillation. The pathology report showed a pT2pN1 lesion, and a referral was made to a medical oncologist. At the time of discharge, the patient had no vaginal discharge or pain, was tolerating a diet, and having bowel movements.

Conclusion: With total laparoscopic procedures that do not require one large incision for removal of specimens and construction of the anastomosis, we showed decreased morbidities compared with that of open and laparoscopic-assisted colectomies. We found that patients will benefit from this less-invasive surgery. As the patient population becomes more sophisticated about surgical options they will demand total laparoscopic procedures. The description of this technique will advance the technical options in the field of natural orifice surgery.

8129 General Surgery
Low Anterior Resection With Total Mesorectal Excision: The Texas Endosurgery Institute Experience
Morris E. Franklin, Jr. MD, Guillemro Portillo, MD, Jeffrey L. Glass, MD, John J. Gonzalez, MD, Sameer S. Mohiuddin, MO, Loretta Brestan, MD

Introduction: The introduction of total mesorectal excision by Dr. Heald improved local control and survival in patients with rectal cancer. Recent multicentric randomized studies have demonstrated equal or better results with the laparoscopic approach for colonic pathologies. Little information is available about the laparoscopic approach for rectal pathologies, and laparoscopic TME remains a controversial procedure. We present data collected prospectively from a single institution over a 16-year period on laparoscopic low anterior resection with total mesorectal excision.

Methods: All patients undergoing laparoscopic low anterior resection with total mesorectal excision from May 1991 to April 2007 at Texas Endosurgery Institute, San Antonio, Texas were included in the study and prospectively followed. Data were collected on the preoperative workup, operative time, blood loss, pathologic details of the surgical specimen, and postoperative course.

Results: A total of 424 patients underwent laparoscopic low anterior resection with total mesorectal excision; 94 patients (22.2%) for benign disease and 330 for malignant disease (77.8%). The mean age of 68.13 years (range, 24 to 97), 220 were males (52%) and 204 were females (48%). Thirty patients required conversion to an open procedure (7%). However, conversion to an open procedure has been substantially reduced in the last 5 years. The mean operating time was 186 minutes (range, 105 to 508). Mean and median blood loss was 123mL (range, 25 to 600). The average number of lymph nodes harvested was 15 with a median of 17 lymph nodes. Median postoperative hospital stay was 4.5 days (range, 3 to 18). Anastomotic leak rate was 2.6%, and 3 patients (0.7%) had some degree of anal transitory incontinence. Local recurrence rate was 2.6%, and 5-year survival in patients who had been followed up for a minimum of 5 years has been 85%. No recurrences at the wound or trocar site have been noted.

Conclusion: Laparoscopic low anterior resection with total mesorectal excision can be performed safely and effectively to treat rectal malignancy.

8130 General Surgery
Laparoscopic Right Hemicolectomy: 15 Years and 411 Patients
Morris E. Franklin, Jr., MD, Guillemro Portillo, MD, Jeffrey L. Glass, MD,
John J. Gonzalez, MD, Sameer S. Mohiuddin, MO, Loretta Brestan, MD

Introduction: Totally laparoscopic or laparoscopic-assisted (LA) right hemicolectomies (RHC) have been reported as acceptable procedures for both benign and malignant colon diseases. Laparoscopic RHC either with a totally intracorporeal or extracorporeal anastomosis has been performed for the treatment of ascending colon diseases including cancer, polyps, chronic inflammatory bowel diseases, AVM. However, research has not been conducted on clinical distinctions of any of 2 different approaches for constructing anastomosis either intracorporeal (IC) or extracorporeal. Based on extensive experience in laparoscopic colon surgery, we designed a nonrandomized prospective study comparing laparoscopic right hemicolectomy with either totally IC anastomosis or LA anastomosis.

Methods: A consecutive series of patients requiring laparoscopic RHC for various right colon diseases from April 1991 to March 2007 at the Texas Endosurgery Institute, San Antonio, Texas, was prospectively studied. The operative procedures and instrumentation were standardized for all laparoscopic right hemicolectomies with either IC or LA anastomosis.
Results: Since April 1991, 423 (RHC) have been attempted laparoscopically following selection criteria for the procedure, and 411 (97.1%) have been completed. Of these 411 cases, the procedure for 288 patients (65.7%) was IC, while the remaining 123 patients (27.4%) had LA hemicolectomy with extracorporeal anastomosis. The mean operative time for laparoscopic colectomies with ICs was 159.6±27.1 minutes, mean blood loss was 83.3±14.4mL, mean length of postoperative hospitalization was 8.7±8.5 days, and procedure-related intraoperative and postoperative morbidity rates were 1.6% and 5.2%, respectively. For LA procedures with extracorporeal anastomosis, the mean operative time was 165.5±29 minutes, mean blood loss was 135.0±65.5mL, mean length of hospital stay was 6.9±2.8 days, intraoperative complication rate was 4.0%, and postoperative complication rate was 17%.

Conclusion:  Laparoscopic colectomy either with IC or LA anastomosis can be performed safely and effectively to manage a variety of colonic diseases, including malignant colonic neoplasia with reasonable operation time, hospital stay, and much less blood loss. IC anastomosis has a shorter operation time, less intraoperative blood loss, and lower intraoperative and postoperative complication rates, especially when comorbidities are counted.

8131 General Surgery
Laparoscopic Treatment of Achalasia: The Texas Endosurgery Institute Experience
Morris E. Franklin, Jr. MD, Guillemro Portillo, MD, Jeffrey L. Glass, MD, John J. Gonzalez, MD, Sameer S. Mohiuddin, MO, Loretta Brestan, MD

Introduction: The cause of achalasia is unknown. Theories on causation invoke infection, heredity, or an abnormality of the immune system that causes the body itself to damage the esophagus (autoimmune disease). Treatments for achalasia include oral medications, dilation, or stretching of the lower esophageal sphincter (dilation), and the injection of botulinum toxin (Botox) into the sphincter. All these forms of treatment have high recurrence rates. The most effective treatment for achalasia is surgery. We describe our experience with esophagomyotomy by laparoscopic means with a follow-up of up to 12 years. This prospective study analyzes the long-term results of laparoscopic esophagomyotomy at the Texas Endosurgery Institute.

Methods: Thirty-five patients were found to have achalasia. They were prospectively followed, 18 females and 17 males. The surgery indications were failure of medical treatment (n=15), failure of pneumatic dilatation (n=13), failure of botulinum toxin (n=13).

Results: In 100% of the patients, Heller modified esophagomyotomy was completed. Dor fundoplication was performed in 34 and Nissen fundoplication in 1 patient. No conversions to open surgery were necessary. With a mean follow-up of 6 years (6 months to 12 years), 5 patients developed dysphagia, 2 of whom required pneumatic dilatations, but there have been no recurrences to date.

Conclusions: The treatment of achalasia continues to be a surgical challenge. Laparoscopic esophagomyotomy is safe and effective and should be considered the treatment of choice.

8132 General Surgery
Laparoscopic Treatment of Achalasia: The Texas Endosurgery Institute Experience
Morris E. Franklin, Jr. MD, Guillemro Portillo, MD, Jeffrey L. Glass, MD, John J. Gonzalez, MD, Sameer S. Mohiuddin, MO, Loretta Brestan, MD

Introduction: The cause of achalasia is unknown. Theories on causation invoke infection, heredity, or an abnormality of the immune system that causes the body itself to damage the esophagus (autoimmune disease). Treatments for achalasia include oral medications, dilation, or stretching of the lower esophageal sphincter (dilation), and the injection of botulinum toxin (Botox) into the sphincter. All these forms of treatment have high recurrence rates. The most effective treatment for achalasia is surgery. We describe our experience with esophagomyotomy by laparoscopic means with a follow-up of up to 12 years. This prospective study analyzes the long-term results of laparoscopic esophagomyotomy at the Texas Endosurgery Institute.

Methods: Thirty-five patients were found to have achalasia. They were prospectively followed, 18 females and 17 males. The surgery indications were failure of medical treatment (n=15), failure of pneumatic dilatation (n=13), failure of botulinum toxin (n=13).
Results: In 100% of the patients, Heller modified esophagomyotomy was completed. Dor fundoplication was performed in 34 and Nissen fundoplication in 1 patient. No conversions to open surgery were necessary. With a mean follow-up of 6 years (6 months to 12 years), 5 patients developed dysphagia, 2 of whom required pneumatic dilatations, but there have been no recurrences to date.

Conclusions: The treatment of achalasia continues to be a surgical challenge. Laparoscopic esophagomyotomy is safe and effective and should be considered the treatment of choice.

8132 General Surgery
"Rock Candy" and "Spaghetti-O" Gallstones: Atypical Cholelithiasis Presentations, Undetectable by Ultrasound, Identified Via Analysis of Endoscopically Obtained Bile Aspirate
Kerrey B. Buser, MD

    Two cases are detailed in which atypical gallstones were found in patients undergoing laparoscopic cholecystectomy after gallbladder disease was diagnosed via duodenal bile aspirate analysis. Clinical symptoms suggested biliary disease, but traditional ultrasonographic imaging was nondiagnostic. Positive results from endoscopically obtained duodenal bile aspirates prompted surgery. Two very unusual cholelithiasic states were found: one with large translucent sheet crystals, resembling "Rock Sugar Candy," and the other being a cystic duct (intraluminal cast) cholesterol stone with a central fenestration, resembling a "Spaghetti-O." Atypical cholelithiasis may be undetected by traditional ultrasound imaging. When clinical symptoms raise the index of suspicion concerning the presence of a diseased gallbladder, duodenal bile aspirate may help uncover the hidden pathologic source and lead to its definitive treatment via laparoscopic cholecystectomy.

8134 General Surgery
A Call for Raised Awareness and Appropriate Treatment of Symptomatic Gallbladder Disease in the Pediatric Population
Kerrey B. Buser, MD

Objective: One surgeon's experience with symptomatic gallbladder disease in the pediatric population of a small rural Nebraska community was reviewed over a 12-year period to determine the characteristics of that population and the operative findings.

Methods: A retrospective study was conducted of the author's experience with laparoscopic cholecystectomy in the pediatric population of a small rural community. Methods of preoperative diagnosis, operative and pathologic specimen findings, and patient demographics were evaluated.

Results: Thirty-nine patients who had been operated on were evaluated. Twelve patients were 19 years old, and of these 5 were pregnant. The age range was 11 years to 19 years. Many had missed significant school time due to their illness. Overall, 71.8% had positive preoperative radiologic gallbladder imaging, and 33.3% had positive duodenal bile aspirates. Approximately 88% had positive specimen micropathology. Over 28% of the group would not have undergone surgery if a positive ultrasound were the only accepted prerequisite for diagnosis.

Conclusion: Adult-pattern gallbladder disease is present in the general pediatric population and can be diagnosed by traditional radiologic means in over 70% of symptomatic patients. The endoscopically obtained bile aspirate can diagnose the nearly 30% of patients who will otherwise be missed if only radiologic inquiry is made. The relatively higher number of 19 year olds probably reflects the bias of health care providers looking for a more "traditionally adult disease" when presented with the same symptom complexes and may reflect an underdiagnosed population below that age. Gallbladder dysfunction can be severe in this population and cause disruption of education, health, and well-being. The community's physicians should not confuse "cholecystitis" with "schoolitis"; the pediatric patient with gallbladder disease symptoms should not be ignored and deserves as thorough an evaluation and treatment as that given to any adult with the same symptoms.

8135 General Surgery
Does Acute Cholecystitis Affect Conversion Rates in Laparoscopic Cholecystectomy?
Prof. Dr. Ali Uzunkoy, MD

Objective: Laparoscopic cholecystectomy has been accepted as the gold standard for chronic cholecystitis, but there is some argument about the acute stage of cholecystitis. It is thought that the laparoscopic technique may increase conversion rates to open surgery at the acute stage of cholecystitis. This study was planned to evaluate the effect of the laparoscopic technique on conversion rates at the acute stage of cholecystitis.

Methods: Hospital records were reviewed retrospectively. The cholecystitis cases were divided into 2 groups: acute and chronic. The demographic findings, operative findings, complications, mortality rates, and conversion rates were compared.

Results: In this study, laparoscopic cholecystectomy was attempted in 768 patients with symptomatic acute or chronic cholecystitis. The chronic cholecystitis group comprised 695 patients. The acute cholecystitis group comprised 73 patients. Seventeen cases (2.2%) were converted to the open procedure. Fifteen converted cases (2.2%) were from the chronic cholecystitis group and 2 (%2.7) were from the acute cholecystitis group. No significant difference existed in conversion rates between the groups (P>0.05).

Conclusion: The conversion rates are not different between the acute and chronic cholecystitis patients undergoing laparoscopic surgery. Laparoscopic cholecystectomy for acute cholecystitis is a safe, effective treatment for acute cholecystitis.

8137 Gynecology
Laparoscopic-Assisted Myomectomy Using the Mobius Retractor
Herbert A. Goldfarb, MD

Objective: To demonstrate the technique of minimally invasive laparoscopic-assisted myomectomy facilitated by the Mobius Retractor

Methods: The laparoscopic and minimally invasive techniques are described. Laparoscopic procedure is begun with injection of a diluter pitressin solution into the myoma. Incision through the serosa into the myoma capsule is made and the myoma dissected toward the base. At this point, a mini 3-cm to 4-cm incision is made in the suprapubic area. The Mobius Retractor is inserted, and the myoma is freed from its base attachment and removed using a morcellation technique. Precise suturing is then performed in multiple layers as needed.

Results: The described technique allows the laparoscopic surgeon to remove significant-sized myomas 10cm and larger using minimally invasive techniques with minimal bleeding, operating time, and complications.

Conclusions: Laparoscopic-assisted minimally invasive myomectomy using the Mobius Retractor is a technique that promotes a more user-friendly, reliable, and safe approach to the removal of large myomas with decreased operating time and potential complications.

8138 General Surgery
Role of the Ultrasonic Scalpel in Subfascial Endoscopic Perforator Surgery in Chronic Venous Insufficiency of the Lower Limbs
Sudhir Jain, Amit Gupta, R.C.M. Kaza

Background: The aim of this study was to determine the feasibility of using the ultrasonic scalpel in subfascial endoscopic perforator vein surgery (SEPS) and to study the results of ulcer healing and reversal of skin changes.

Methods: From January 2003 to November 2006, we performed 57 SEPS in 52 patients under spinal anesthesia using a 2-port technique. All patients had chronic venous insufficiency (CVI) ranging from class IV to VI.

Results: The duration of surgery for SEPS averaged 30 minutes with no postoperative mortalities. One patient developed wound infection at the port site that was managed conservatively. None of the procedures required conversion to open surgery. We have had no recurrence of venous ulcers so far. Barring one patient, all patients returned to their normal routine within 5 days after surgery. In more then 90% of patients, ulcer healing was achieved within 8 weeks of surgery.

Conclusions: Our study clearly shows that the ultrasonic scalpel is a very safe and reliable tool in SEPS, as there was very low morbidity regarding wound complications and other perioperative or postoperative complications, which can occur when one uses the metallic clips or electrocautery for SEPS. 

8139 Urology
Comparison of Vascular Clipping and Stapling Techniques for Renal Artery Occlusion During Hand-Assisted Laparoscopic Donor Nephrectomy
James G. Bittner, IV, MD, Kamran Sajadi, MD, James J. Wynn, MD, James A. Brown, MD

Objective: This study aimed to assess the differences in outcomes between renal artery clipping and stapling techniques in hand-assisted laparoscopic donor nephrectomy (HALDN).

Methods: One laparoscopic urologist conducted left kidney HALDN on 55 donors over 48 consecutive months. Donors were divided into those who underwent renal artery occlusion with 2 Hem-o-Lok clips over 30 months (Group 1, n=27) or with 3-row vascular stapling over the subsequent 18 months (Group 2, n=28). Outcomes of interest included total operative and warm ischemic times, estimated blood loss and decrease in postoperative hemoglobin concentration, serum creatinine change from baseline on the first postoperative day, and recipient and donor complications. Data are given as medians and analyzed using nonparametric tests (alpha=0.05).

Results: Groups 1 and 2, respectively, did not vary in age (33 and 39 years; P=0.12), sex (P=0.31), body mass index (26 and 27; P=0.15), preoperative serum creatinine (0.9 and 0.8mg/dL; P=0.29), or first postoperative day creatinine (1.5 and 1.3mg/dL; P=0.38). Estimated blood loss was similar (both 100mL; P=0.21), and postoperative hemoglobin decreased equally regardless of technique (P=0.15). Operative time in Groups 1 and 2, respectively, was not significantly different (271 and 281 min; P=0.25); however, warm ischemic time was shorter in the vascular stapling group (3 and 2 min; P<0.01). No technique-related complications were noted in donors.

Conclusions: Renal artery occlusion during HALDN using a standard 3-row vascular stapler is feasible and safe. In addition, renal vessel stapling may decrease warm ischemic time compared with vascular clip application.

8140 General Surgery
Buttressed, Double-Armed, Crossed Horizontal Mattress Suture Closure After Partial Nephrectomy: A Novel Modification Using Cadaveric Pericardium (with video)
James G. Bittner IV, MD, James A. Brown, MD

Introduction: This report demonstrates the use of human cadaveric pericardium as a bolster for double-armed, crossed horizontal mattress suture closure after partial nephrectomy (PN).

Methods: Three open and one hand-assisted laparoscopic PN were performed in 4 patients with renal cell carcinoma. The kidney was mobilized with exposure of the renal hilum, and vascular control was obtained. Renal hypothermia and temporary vascular occlusion preceded sharp dissection and excision of the tumor to negative margins. Visible vessels were suture ligated, and the cut surface of the parenchyma was cauterized with an argon beam laser. One piece of hydrated cadaveric pericardium cut in a pantaloon configuration was placed circumferentially around the defect edges. Each bolster leg was approximately the length of the defect (5cm to 6cm) and 1.5-cm wide. A double-armed, crossed horizontal mattress suture of #1 polydioxanone was used to anchor the cadaveric pericardium bolster and approximate the defect edges. Thrombin/gelatin granules were applied, and the renal hilum clamps were removed. No additional hemostatic or pelvicaliceal suture repairs were necessary. In all cases, ischemic time was less than 30 minutes.

Results: At follow-up (range, 3 to 12 months), all patients experienced no tumor recurrence. There were no postoperative urologic or hematologic complications related to closure, and serum creatinine levels returned to baseline after surgery.

Conclusions: The use of cadaveric pericardium to bolster closure of moderate to large parenchymal defects after PN is safe and effective. The novel double-armed, crossed horizontal mattress suture technique has the potential to simplify laparoscopic PN by limiting intracorporeal knot tying and ensuring proper hemostasis.

8141 General Surgery
Interactive Virtual Instructors Plus Virtual Reality Endoscopy Simulators Equals Real-Time, Curriculum-Based, Verbal and Haptic Feedback on Learner Performance
James G. Bittner IV, MD, Adeline M. Deladisma, MD, MPH, John D. Mellinger, MD, Bruce V. MacFadyen Jr., MD, Edward J. Kruse, DO, Benjamin C. Lok, PhD, D. Scott Lind, MD

SAGES Fundamentals of Endoscopy Task Force recommends a comprehensive, standardized endoscopic assessment tool complete with a validated curriculum and real-time feedback for skills training. One way to address this need is to use a novel, fully interactive virtual instructor. We introduce this technology and describe its potential role in curriculum-based endoscopy training. In addition, we prospectively outline the utility of combining a validated virtual endoscopy simulator with a virtual instructor, which provides real-time verbal feedback based on a predetermined curriculum. Simultaneous virtual instruction and simulator-based feedback may improve novice learner endoscopy performance compared with complete absence of feedback or simulator-based feedback alone, decrease patient exposure to untrained individuals, and lessen the time and financial burdens on attending faculty involved in simulation skills training.

8145 Gynecology
Results of Laparoscopic Treatment of Ovarian Endometriosis
Khusen B. Narzullaev, MD, PhD

Introduction: We analyzed the results of laparoscopic treatment of endometriosis in 52 fertile-aged women.

Methods: At the Samarkand Center of Endoscopic Surgery (Republic of Uzbekistan) 52 patients, 20 to 47 years of age, underwent laparoscopic adnexectomy, ovarian resection, and cyst enucleation.

Results: Laparoscopic adnexectomy was performed in 6 (11.5%) patients, laparoscopic resection of the ovary was performed in 32 (61.5%), and laparoscopic enucleation of the cyst was performed in 11 (21.2%) patients. In 3 (5.8%) of the cases, a vast commissural process was found in the small pelvis involving of the small bowel and the sigma entrails. In connection with this, conversion to laparotomy was necessary. In 2 cases, the surgery ended with the extirpation of the uterus and its appendages. In one case, it ended with the resection of the small bowel and the excretion of ileostomy. No fatal outcomes occurred. In the postoperative period, all patients were prescribed hormonal therapy.

Conclusions: Laparoscopy serves as the method of choice in the surgical treatment of patients with endometriotic lesions of the ovary. It has a number of advantages compared with laparotomy. After laparoscopic surgery, return to a high quality of life occurs twice as fast and is more complete than with laparotomy. This is especially important for able-bodied women of childbearing age.

8146 General Surgery
Randomized Controlled Trial to Determine the Need for Prophylactic Antibiotics in Elective Laparoscopic Cholecystectomy
Dr. Jude Lee, FRCSEd

Introduction: The need for antibiotic prophylaxis in elective laparoscopic cholecystectomy is controversial. The benefit of avoiding a low incidence of wound infection needs to be weighed against emerging antibiotic resistance from widespread use of antibiotics.

Methods: In this study, 91 patients were randomized into 2 groups. Group A (n=43) received prophylactic antibiotics, and Group B (n=48) did not. Patients were assessed for infective complications perioperatively, at 1 week, and 1 month.

Results: Altogether, 4 port-site wound infections occurred, 3 at the umbilicus, and 1 at the epigastric port (4/91= 4.4%). Two occurred in Group A (2/43=4.65%) and 2 in Group B (2/48=4.17%). No statistical difference existed in the infection rate between the 2 groups. The number of positive bile cultures was 10 (11%), and this did not translate into an increased wound infection rate.

Conclusion: Hence, prophylactic antibiotics are not required for low-risk elective laparoscopic cholecystectomy.

8147 Gynecology
Comparison of Robot-Assisted Hysterectomy to Laparoscopic-Assisted Hysterectomy
Ceana Nezhat, MD, Vadim Morozov, MD, Tannaz Adib, MD

Objective: Outcome comparison of robot-assisted hysterectomy (RALH) with laparoscopic-assisted hysterectomy (LAH).

Methods: Prospective analysis of 97 patients who underwent hysterectomy at a tertiary care center. None of the patients were candidates for vaginal hysterectomy due to the nature and complexity of the cases. Patients with a history of peritonitis, massive intraabdominal adhesions, and bowel surgery were excluded. Robotic cases were performed as a teaching aid to fellows and preceptees. Robot availability and the presence of trainees were selection criteria. All procedures were completed as planned.

Results: Patient demographics and preoperative diagnoses were comparable between both groups. Mean estimated blood loss was <70cc in both groups. Mean uterine weight was 190g for LAH and 160g for RALH. There was one intraoperative ureterotomy in the LAH group, and one cystotomy in the RALH group. In the LAH group postoperatively, one ureterovaginal fistula was repaired laparoscopically. In the RALH group, one patient required vaginal cuff repair 4 weeks postoperatively.

Conclusion: For experienced laparoscopic surgeons, LAH is superior to RALH, specifically when treating severe endometriosis, adhesions, and extrapelvic pathology. However, the suturing of the vaginal cuff is easier with robotics. Robotic hysterectomy can be used as a teaching tool and facilitator for transition from abdominal to the laparoscopic approach. The robot offers the surgeon ergonomic, tremorless, 3-D capabilities. The cost and additional training requirement of dedicated staff for robot-assisted surgery may limit its widespread use; however, it may bridge the gap between laparotomy and laparoscopic surgery, which is limited by a steep learning curve.

8148 Urology
Hand-Assisted and Pure Laparoscopic Nephrectomy: A Quantitative Comparison of Outcomes
Jonathan Silberstein, MD, J. Kellogg Parsons, MD, MHS

Objective: Debate continues as to the relative merits of hand-assisted versus pure laparoscopic nephrectomy. We compared outcomes of these techniques utilizing evidence-based analysis.

Methods: We performed a systematic review and metaanalysis of observational studies directly comparing hand-assisted with pure laparoscopic nephrectomy. We searched MEDLINE, the Cochrane Library, and EMBASE through July 2007 and abstracts from the Annual Meeting of the American Urological Association (2002 to 2007). Primary outcomes were operative blood loss, operative time, length of hospital stay, perioperative transfusions, and perioperative complications.

Results: Twenty-six studies (n=3716 patients) met inclusion criteria for this analysis. Hand-assisted nephrectomy was associated with significantly less operative blood loss (SMD -0.28, 95% CI -0.55 to -0.006, P=0.05) and decreased risk of conversion (RR 0.45, 95% CI 0.25 to 0.83, P=0.01). No significant differences existed in mean operative time (SMD -0.07, 95% CI -0.81 to 0.68, P=0.81), length of stay (SMD -0.28, 95% CI -0.07 to 0.05, P=0.10), or risks of perioperative transfusion (RR 1.32, 95% CI 0.95 0.59 to 2.99, P=0.50) or complication rate (RR 1.00, 95% CI 0.75 to 1.34, P=0.99). Sensitivity and subgroup analyses indicated significantly decreased operative time for the hand-assisted approach in nontransplant patients (SMD -1.42, 95% CI -2.05 to -0.79, P<0.001).

Conclusions: In this analysis, hand-assisted laparoscopic nephrectomy was associated with significantly less operative blood loss and risk of conversion compared with pure laparoscopic nephrectomy. These data suggest that although these techniques result in similar outcomes, the hand-assisted approach has advantages in select situations.

8149 Other
The New Theory of Carcinogenesis: The Theory of Gene Multiple Hits
Han-You Hu

Objective: To find the development mechanism for cancer for the best cancer cure and treatment.

Method: Summarization of scientific cancer research findings.

Results: We provide an explanation of the genetic multiple-hit theory. We have known that long-term effects of carcinogens cause cancer. Carcinogens include environmental or chemical factors, biological factors, physical factors, hereditary factors, and other things. All of these factors have complicated effects on the human body. Therefore, cancer develops; many different proto-oncogenes and tumor suppressive genes are affected by many different carcinogenic hits and damage. And finally cancer develops.

Conclusion: The significance of the new multiple-hit theory is great. The new theory not only fully explains the research findings for the cancer development mechanism but also summarizes the huge amounts of different scientific research findings. This single new theory represents the entire spectrum of related scientific research findings. The new theory clearly addresses the cancer development mechanism, which indicates the new theory is a very good theory. The new gene multiple-hit theory provides the best direct references for further cancer research, prevention, early diagnosis, early cure, and cancer treatment.

8150 Multispecialty
A Practical Guide to Teaching Residents Laparoscopic Surgery
Joy Brotherton, MD, James Bonheur, MD

Background: The benefits of minimally invasive surgery (MIS) are well recognized. However, creating competent surgeons with the skills to perform these procedures is a challenge facing most of today’s residency programs. For both OB/GYN and general surgery residencies, limited work hours have resulted in decreased surgical volume and technical experience. Moreover, the fact that many surgeons feel inadequately prepared to perform advanced laparoscopic procedures upon completion of their surgical training, seeking additional training in fellowships, workshops, and conferences underscores the need for structured skills training during residency. Simulator-based training has become quite popular in many programs. It is a safe, cost-effective means to enhance practical surgical techniques that are transferable to the operating room. Current simulator-based training is highly variable amongst programs with few standardized training protocols. Our goal was to present some of the training modalities and simulators available so that a laparoscopic curriculum can be easily created and implemented.

Database: A Medline and Web search was conducted to locate modules, Web sites, articles, and equipment that may be utilized to create a laparoscopic curriculum.

Discussion: A wide array of modalities is available to help residency directors teach laparoscopic surgery. It is not necessary to “re-invent the wheel.”  By compiling all of these resources into one paper, we hope to provide a reference for those wishing to create a practical curriculum and ultimately improve resident skills in MIS. We also make some suggestions for creating a successful curriculum.

8151 Gynecology
23,600 Cases in Multiple Centers of the Reformed Open Trocar First-Puncture
Haifang Liu, MD, Hui Ning, MD, Tang Jiasong, MD, Zhu Danyan, MD, Bai Yanqing, MD, Wu Yunyan, MD, Shang Jiuxiang, MD, Yan Liu, MD

Objective: To analyze the safety of the reformed open trocar first-puncture and investigate how to decrease complications of the first-puncture.

Methods: Clinical data of 23,600 cases with open trocar first-puncture were analyzed retrospectively in 7 hospitals from September 1998 to September 2007. There were 25 experienced operators and 180 learners who performed open trocar first-puncture. Two kinds of open trocar first-puncture techniques were adopted in all cases; one was by puncturing directly with the trocar after cutting the skin and thickness fascia of the umbilicus and the other by inserting the sheath into the abdominal cavity directly after cutting the whole umbilicus layer.

Results: Successful puncturing was achieved in 23,600 cases. Rough puncturing occurred in 22 cases, and 2 cases were changed to traditional Veress needle puncture due to patients’ BMI of 28. Complications occurred in 3 cases, 2 of which were cutaneous emphysemas and the other was injury of a blood vessel in the omentum. No major vessel was injured.

Conclusions: The reformed open first-puncture reduces the chance of injuries when needle puncture is performed. To cut open the umbilicus reduces resistance or causes no resistance. It is a safe and practicle first-puncture technique in laparoscopic surgery, especially for new learners.

8152 Gynecology
The Effect of Two Kinds of Insufflators with Different Work Principles on Intraabdominal Pressure during Gynecological Laparoscopic Operations
Yan Liu, Haifang Liu, Hai Zhuang   

Objective: To study the influence of 2 types of insufflators working under 2 different principles on intraabdominal pressure (IAP) during gynecological laparoscopic surgeries.

Methods: We measured real-time IAP during laparoscopic surgery to detect the transient variation of IAP influenced by the 2 different types of insufflators: the traditional electronic pulse-wave mode and a new constant-pressure mode.

Results: When the electronic pulse-wave mode insufflator is working, IAP in patients may reach 40mm Hg to 50mm Hg, more than twice that of the standard setting, 15mm Hg. When the constant-pressure insufflator is used, IAP in patients fluctuates ±10% of the setting 15mm Hg.

Conclusions: When the constant-pressure insufflator is used in gynecological laparoscopic surgeries, IAP in patients is comparatively constant, but the electronic pulse-wave mode may lead to great variations of IAP during surgery. As far as the influences on hemodynamics, peritoneum morphology, and acid-based equilibrium are concerned, it can be inferred that the electronic pulse-wave mode insufflator affects patient security more than the constant-pressure insufflator does.

8153 General Surgery
Effective Exercise Habits of the Formerly Obese
Ehab Akkary, MD, Cassius Chaar, MD, Kanishka Rajput, MD, Sunkyung Yu, MS, Dziura James, PhD, Andrew Duffy, MD, Kurt Roberts, MD, Robert Bell, MD, MA

Background: Patients must subscribe to behavioral and lifestyle modifications for continued success after weight loss surgery (WLS). Few data exist about the ideal type, duration, and intensity of exercise for WLS patients. After surgery, should we mandate that patients exercise like young, lean individuals? To reconcile this, we compared the exercise habits of successful bariatric surgery patients with those of physically fit controls.

Methods: Enrolled in the study were100 individuals, comprising 2 groups: the operative group (WLS) included 50 laparoscopic Roux-Y gastric bypass patients (LRYGB) who achieved excess weight loss of at least 80%; the control group (CG) included 50 individuals with normal BMI who exercised regularly and did not undergo LRYGB. The exercise habits were compared by using Fisher’s exact and Mantel-Haenszel chi-square tests.

Results: The 2 groups had equivalent BMIs (24.7 vs. 23.4 kg/m2). The WLS group was older (39.5 years) than the CG (26.2 years). There is a statistically significant difference between the groups regarding cardiovascular exercise, 80% walking (WLS) vs. 60% running (CG). WLS patients exercised longer and with similar frequency as the CG. A high proportion of CG lifted weights (86%) vs. WLS (44%). Sixty percent of CG performed recreational sports compared with 34% of WLS.

Conclusion: Regular exercise is of utmost importance in maximizing and maintaining weight loss after WLS. Although patients who undergo WLS are older than the typical exercise enthusiast, they can achieve excellent weight loss and sustain a normal BMI with regular exercise habits that are quite distinct from those of younger individuals whose bodies have never been undermined by obesity.

8154 Gynecology
A Case Report of CO2 Gas Embolism during Laparoscopic Myomectomy
Yasuyuki Asakawa, MD, PhD, Yasuhiro Yamamoto, MD, Mami Fukuda, MD, Hideki Taoka, MD, Toshimitsu Maemura, MD, PhD, Mineto Morita, MD, PhD, Kaneyuki Kubushiro, MD, PhD

Background: It has been reported that a CO2 gas embolism has occurred in 65 000 pneumoperitoneal laparoscopies. These cases have a high lethality. This is a case report of a CO2 gas embolism during laparoscopic myomectomy.

Case Report: A 37-year-old infertile woman was treated for a uterine myoma. Laparoscopic myomectomy was performed with the patient under general anesthesia administered through endotracheal intubation and in the dorsolithotomy position. Pneumoperitoneum was established with a Veress needle that was placed though the umbilicus. Intraabdominal pressure of 10mm Hg was achieved and maintained. Vecuronium bromide was added 10, 25, and 40 minutes after the surgical technique began because of spontaneous ventilation. SpO2 went to 88%, and an end-tidal partial pressure of CO2 concentration became 33mm Hg at 45 minutes. The SpO2 was 97% even after the pneumoperitoneum and the dorsolithotomy position were reversed. The laparoscopic surgical technique was changed laparotomy. A borderline was observed in the right atrium by transesophageal ultrasonography. SpO2 levels were checked in the ICU after the operation. The endotracheal tube was removed on day 3, and no sequelae were observed at day 10.

Conclusion: CO2 gas embolism has a high degree of lethality; however, it can be rapidly diagnosed because CO2 gas easily decomposes into small foam particles. Depression of CO2 is one of the phenomenons that can occur with CO2 gas embolism during pneumoperitoneal laparoscopies.

8155 General Surgery
Unusual Presentation of Perforated Appendix
Dr. Dhaval Patel, MS

Objective: In recent years, new technologies have been proposed and applied in abdominal surgery, among them radiological diagnosis and clinical procedures. The author reviews the relevant medical literature on the influence of these new techniques on the treatment of the unusual presentation of perforated appendix.

Methods: This is a retrospective, observational study from a medical center with more than 500 beds. The outcome variable was perforated appendix, and the predictive variables included clinical and radiological factors.

Results: During a 1-year period, appendectomies were performed on 50 patients ranging in age from 10 years to 40 years. A perforated appendix was found in 10 people. Predictive factors significantly associated with the perforated appendix were abdominal pain of more than 2 days' duration, temperature >37.9ºC, and peritoneal signs. However, 1 patient had an unusual presentation with a 10-day history of right upper abdominal pain, diarrhea, and yellowish discoloration of the urine. The patient had no tenderness, guarding in the right ileac fossa/lumbar region. An abdominal sonography was inconclusive. Computed tomography of the abdomen was performed to investigate further. It revealed right ileac fossa, visceral perforation, and pus in the right hypochondrium with bowel wall thickening.
Conclusion: Recognizing this clinical and radiographic association could lead to earlier diagnosis and treatment.

8156 Gynecology
Laparoscopic Management of Adnexal Tumors
Prof. Dr. med. Liselotte Mettler

Background and Objectives: Most adnexal tumors can be managed laparoscopically. In case of an ovarian cancer with an indication for radical surgery, the resection of the uterus, tubes, and ovaries as well as an extensive pelvic and para-aortic lymphadenectomy together with omentum resection is generally possible. However, the surgical treatment of ovarian cancer by laparoscopy is still not widely accepted, and the key general surgical options remain to be performed via laparotomy.
Methods: Two laparoscopic surgical procedures are analyzed in detail:
    1. Ovarian cyst enucleation: Under aqua dissection, the cyst is enucleated in its proper anatomical plane.
    2. Adnexectomy
Results: Every ovarian cyst without any suspicion of malignancy in the reproductive age should be enucleated laparoscopically conserving the organ. Any functional cyst in this age range, however, should first be treated by estrogen suppressants and be excised only if it persists. Each adnexal tumor with an ovarian cyst should be carefully evaluated preoperatively by imaging techniques, tumor marker measurement, and palpation. During endoscopic surgery, the most modern oncological criteria must be observed.

Conclusions: Laparoscopic adnexal surgery has replaced laparotomy, but every effort is made to avoid intraoperative capsule rupture during primary surgery. If rupture does occur, irrigation is carried out carefully with copious Ringer’s lactate. Vergotte demonstrated in a multivariate analysis of surgery in 1545 patients with ovarian cancer that the degree of differentiation is the most powerful prognostic indicator of disease-free survival followed, however, by rupture before surgery, rupture during surgery, and age.

8157 General Surgery
Significance of Peritoneal Lavage and Laparoscopy in Patients with Gastrointestinal Malignancy
Maksimovic Sinisa, PhD, MD

Background: Laparoscopy is a safe and useful method to examine local extent and regional spread of patients with gastrointestinal malignancy.

Methods: The study comprised 145 patients with potentially resectable gastrointestinal cancer who were prospectively studied and underwent laparoscopy with cytologic examination. Aspirated fluid of the peritoneal cavity was centrifuged and submitted to cytologic examination with the Giemsa and Papanicolaou methods. The patients were surgically treated and followed for 84 months. Free fluid was aspirated and saved for cytology examination.

Results: Intraperitoneal free cancer cells (IFCC) were detected in 43% of the patients, 66% in patients with ascites and 28% by peritoneal lavage. In the absence of macroscopic peritoneal dissemination, IFCC were found in 29% of the patients. As a result of the peritoneal lavage cytology, 9/21 (42.8%) of the patients were re-classified from stage III to stage IV. In 23 cases (15.8%), laparoscopy revealed carcinomatosis and/or multiple liver metastases, so laparotomy was not performed. Palliative surgery without resection was performed in 35 (24.1%) patients and resections in 87 (60%). Of those, 42 (29%) underwent palliative gastrectomy and 45 (31%) curative gastrectomy. Overall survival adjusted for type of resection also demonstrated a favorable outcome for negative IFCC patients. 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.

8158 General Surgery
Laparoscopic Cholecystectomy: Our Experiences After 2500 Patients
Maksimovic Sinisa, PhD, MD

Purpose: The aim of this study was to present our experience after 2500 laparoscopic cholecystectomies (LC).

Methods: Twenty-five hundred patients underwent LC during a10-year period (January 1997 to December 2007). There were 575 (23%) male and 1925 (77%) female patients. The median age of the patients was 56 years (range, 14 to 95), and 62% were <64 years old, 28% were 65 to 74, and 10% were >75.
Results: The operation was completed laparoscopically in 97% of the patients whilst 75 (3%) cases were converted to open surgery. The reason for conversion was the inability to perform a safe dissection in Calot’s triangle due to bad local conditions. Acute inflammation of the gallbladder was found in 31%, empyema in 29%, hydrops in 21%, gangrene in 14%, and pericholecystic fluid collection in 5% of cases. In 146 patients, LC was performed after endoscopic papillosphincterotomy. There were 3 (0, 12%) common bile duct injuries. The mean duration of the procedure declined during the 10-year period from 90 minutes to 26 minutes. The mean postoperative hospital stay was 2 days. There was one death one month after the procedure.

Conclusions: LC seems to be the gold standard for treatment of cholelithiasis. Further improvement in outcomes can be expected from the progress of instrumentation rather than the increased experience of the surgeons.

8159 General Surgery
Stapled Hemorrhoidopexy as an Outpatient Surgical Procedure in India
Dr. P.N. Agarwal, MS, Dr. Vivek Bindal, MBBS, MS

Introduction: Hemorrhoidectomy is the most effective long-term treatment for hemorrhoids. In 1993, prolapse reduction using the circular stapler for the treatment of hemorrhoidal disease was proposed. The procedure has shown early promise in terms of minimal postoperative pain, early discharge from the hospital, and quick return to work. This study aimed at evaluating the above technique using general/regional anesthesia to identify the advantages and feasibility of stapled hemorrhoidectomy with special focus on the efficacy of same day discharge in an Indian setup. We evaluated the feasibility of stapled hemorrhoidopexy as outpatient surgery for management of grade III and IV hemorrhoids.

Methods: Twenty-five patients with grade III and IV hemorrhoids were admitted in the morning after preoperative evaluation and preparation. They underwent stapled hemorrhoidopexy while under general (16 patients) or regional (9 patients) anesthesia, and those patients who fulfilled the surgical and anesthetic discharge criteria were discharged the same evening of surgery.
Results: Twenty-two patients were discharged the same evening of surgery. Three patients had to be kept until the next morning, as they could not fulfil all the criteria for discharge. No postoperative complication was noted in any of the discharged patients after they left the hospital premises. Postoperative pain scores, postoperative analgesic requirements, duration of hospital stay, and level of patient satisfaction were also evaluated.

Conclusion: Stapled hemorrhoidopexy can be adopted as a safe outpatient surgical procedure for management of grade III and IV hemorrhoids.

8162 Urology
Outcomes of a Robotic Training Program for Community-Based Urologists and Fellows
Hossein Mirheydar, BS, Robert M Sweet, MD

Objective: In urology, the demand for robotic surgery training continues to increase in the community. Often, robotic training occurs at courses far from the learner, and long-term proctoring and follow-up are lacking. The objective of this prospective study was to assess the long-term impact of our program.

Methods: In January 2005, our institution initiated a robotic training program targeting urologists interested in performing robot-assisted procedures. Nine urologists have participated in the program. The curriculum consists of 3 phases: (1) obtaining familiarity with our training robot; (2) serving as assistant to the proctor on 5 cases; and (3) controlling the console and performing 15 cases while the proctor is assistant. The proctors continued to be available as assistants for additional cases. All participants were contacted to fill out a survey.

Results: Nine urologists have completed the curriculum and 7 returned our survey. The mean score evaluating effectiveness of the curriculum was “Agree somewhat.” The mean number of cases performed at console to achieve competence was 19. All 7 respondents had access to at least 1 clinical robot. All continue to perform robotic surgery and together have performed 300 robot-assisted prostatectomies, 3 partial nephrectomies, and 16 pyeloplasties. The median number of robot-assisted prostatectomies performed was 2/month. All 7 endorsed the utility of a VR robotic trainer.

Conclusions: Our robotic program has effectively disseminated robotic skills to practicing urologists. We believe it is the extended-proctoring aspect of our curriculum that has led to this success. We are integrating a virtual reality trainer into our curriculum.

8163 General Surgery
Small Bowel Obstruction after Laparoscopic Roux-en-y Gastric Bypass
Muhammad A. Jawad, MD

Background: Small bowel obstruction after laparoscopic Roux-en-y gastric bypass is common. Causes include (1) adhesion, (2) internal hernia, (3) stricture or obstruction at the J-J anastomosis, and (4) intussusception. Early obstruction is rare and is usually related to an obstruction at the J-J anastomosis caused by a hematoma or catching the posterior wall with a stapler. Late obstructions are common either due to adhesions, internal hernia, or intussusception. This takes place at the (1) J-J anastomosis, if the mesentery is left open; (2) Peterson defect, either in the ante colic or retro colic anastomosis; or (3) through the omental window.

Methods: From January 1999 through December 2007, 1987 laparoscopic Roux-en-y gastric bypasses were performed by a single surgeon at the same institution; 1907 were performed ante colic, and 80 retro colic.

Results: Small bowel obstruction was diagnosed in 41 patients between 4 months to 36 months, with an average of 18 months after surgery. Unexplained abdominal pain occurred in 33 additional patients. All of these patients were operated on laparoscopically (except one who required open surgery) with reduction of the small bowel volvulus or repair of the internal hernia at the J-J mesentery, or both, and Peterson defect. One patient lost 80% of the small bowel due to a misdiagnosis at another institution.

Conclusion: Small bowel obstruction after laparoscopic Roux-en-y gastric bypass can be a serious problem and should be prevented by closing all mesenteric defects. The theory that leaving large defects will not cause obstruction is not valid. The video presentation will illustrate these findings, and the mesentery closure technique.

8164 Gynecology
The Use of Bipolar Energy and Saline in Hysteroscopic Surgery: A Series of 65 Patients
Stefanos Chandakas, MD, MBA, PhD, Stephen Grochmal, MD, Professor E. Salamalekis

Objective: To evaluate operative hysteroscopy using bipolar energy and saline electrode excision for the treatment of endometrial polyps or fibroids.

Methods: This was a prospective, randomized study conducted at a University Hospital and a major Gynecological Hospital in Athens, Greece. The study cohort included 65 consecutive patients with endometrial polyps or fibroids, up to 4cm, in need of hysteroscopic resection. Patients underwent diagnostic hysteroscopy, followed by operative resectoscopy using the bipolar/saline electrode system by Olympus passed through the operating sheath of a small-caliber hysteroscope.

Results: Operating times, difficulty of the operation, surgeon satisfaction with the procedure, intra- and postoperative complications, postoperative pain, and patient satisfaction were recorded. The majority of women were premenopausal (81%). Operative hysteroscopy was performed with a bipolar electrosurgical device to cut, vaporize, and coagulate. Main outcome measures were pain control during the procedure, the postoperative pain score at 15min, 60min, and 24h after the procedure, and patients' satisfaction rate. All procedures were completed within 48 min. The amount of saline used varied from 500mL to 2250mL.

Conclusions: Operative resectoscopy with bipolar energy and the use of saline appears to be the technique of choice for endometrial polyps or fibroids up to 4cm. The length of the procedures is similar to that of existing techniques, and the safety and satisfaction rate both for the surgeon and patient are better.

8165 Gynecology
A Multicenter Series of 850 Outpatient Laparoscopic Subtotal Hysterectomies in the UK and Greece: The New Approach to Hysterectomy
Stefanos Chandakas, MD, MBA, PhD, Nick Hill, FRCOG, Professor John Erian

Background: During the last 10 years, minimally invasive surgery has influenced the techniques used in gynecology, with an overall minimisation 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 conducted at Princess Royal University Hospital, London, UK and Iaso Hospital, Athens, Greece. For patients who underwent a laparoscopic subtotal hysterectomy between November 2002 and January 2008, data were collected from medical records on how the intervention was performed, followed up for 18 months. Two surgeons performed 850 subtotal hysterectomies. Indications included 22.6% of cases for endometriosis, 67% for menorrhagia, 11.4% for endometrial pathology. Median follow-up was 82 weeks.

Results: Duration of operation and hospital stay, safety (morbidity and mortality), and patient satisfaction were assessed. Estimated blood loss was 60mL (range, 50 to 2000). Significant intraoperative complications occurred in 0.45%; 0% had vascular, nerve or ureter injuries. Cyclic bleeding occurred in 2.4%. Early postoperative morbidity included 0.22% deep vein thrombosis, 0% pulmonary embolism, 1.2% bladder infection and dysfunction. The overall complication rate was 1.73%. Three required drainage for intraabdominal abscesses. Regarding hospital stay, 92.8% were discharged home the same day with an average length of stay of 10 hours.

Conclusions: Laparoscopic subtotal hysterectomy can be safely performed as an outpatient procedure.

8166 Gynecology
A New Narrow Band Imaging Endoscopic System for the Detection of Surface Pathology Including Endometriosis: A Series of 75 Patients
Stefanos Chandakas, MD, MBA, PhD, Stephen Grochmal, MD, Professor John Erian, FRCOG

Objective: The purpose of introducing optical electronics into video endoscopes is to improve the accuracy of diagnosis through image processing and digital technology. Narrow-band imaging (NBI), one of the most recent techniques, involves the use of interference filters to illuminate the target in narrowed red, green, and blue (R/G/B) bands of the spectrum. This results in different images at distinct levels of the mucosa and increases the contrast between the epithelial surface and the subjacent vascular network. NBI can be combined with magnifying endoscopy with an optical zoom. The aim of this new technique is to characterize the surface of the distinct types of gastrointestinal epithelia.

Methods: This was a retrospective study conducted at a university hospital and a major gynecological hospital in Athens, Greece. Study patients included 75 women, mean age 33.9 years, with a possible diagnosis of endometriosis, 55% of whom underwent surgery for fertility.

Results: We used NBI with magnifying endoscopy to image and biopsy randomly selected areas in all 75 patients. A systematic image and a biopsy specimen evaluation process were followed, including unblinded assessment of an exploratory set of images and biopsy specimens, and blinded evaluation of learning and validation sets. Of the lesions, 84.7% were labelled as endometriosis, whereas only 55.2% of the patients were initially diagnosed with endometriotic lesions.

Conclusions: NBI and other similar technologies provide an easier electronic alternative to chromoendoscopy to aid the endoscopist in differentiation among benign, premalignant, and malignant mucosal patterns, as well as early-stage endometriosis.

8167 General Surgery
Laparoscopic Reversal of Roux-en-y Gastric Bypass
Muhammad A. Jawad, MD

    From January 1999 through November of 2007, I performed 2050 Roux-en-y gastric bypass surgeries, 1987 laparoscopically and 63 open. Anastomotic ulcers developed in 41 patients. Of these ulcers, 4 were perforated (3 required patching and closure, and one required resection and revision of the ulcer). Two patients had bleeding that required resection and revision of the gastrojejunostomy, and 2 patients had chronic pain and nonhealing ulcers that required resection of the ulcer and revision of the gastrojejunostomy. Of the patients who underwent the resection and revision of the gastrojejunostomy, 2 had a recurrence of ulcers requiring reversal of the Roux-en-y gastric bypass. One patient was diabetic; the other was a heavy smoker. Anastomotic ulcers developed in 2% of patients who underwent Roux-en-y gastric bypass. Whether this is related to a compromised blood supply, acid production, or trauma to the anastomosis, the cause is unclear. Most of these anastomotic ulcers heal with conventional medical therapies. Those that do not heal, that bleed or perforate, will require resection of the ulcer and revision of the gastrojejunostomy. Most patients respond well. If the ulcer reoccurs after the resection, the only option is to perform a reversal of the Roux-en-y gastric bypass. The 2 patients that required this reversal have not complained of ulcer symptoms postreversal, but have regained most of their weight.
Therefore, reversal of the Roux-en-y gastric bypass in patients with ulcer reoccurrence after revision is feasible, but rare.

8168 General Surgery
Minimally Invasive Colorectal Surgery
Minh Luu, MD, Constantine T. Frantzides, MD, PhD, Atul K. Madan, MD, Mark A. Carlson, MD, Luis E. Laguna, MD, Tallal M. Zeni, MD, John G. Zografakis, MD, Ronald M. Moore, MD, Mick Meiselman, MD   

Background: The technical feasibility of minimally invasive colectomy was reported in 1991 and now is a treatment option for both benign and malignant colorectal disease. Widespread application of the technique in benign disease long preceded malignant colorectal disease. Reluctance came from early reports of port-site implantation and fear of inadequate resection. Now, many reports show noninferiority of minimally invasive colectomy to open colectomy from an oncologic standpoint. We performed a retrospective analysis of all minimally invasive colorectal procedures done by the principle author and the respective fellow within the laparoscopic fellowship program from 1991 to 2007.

Methods: A retrospective analysis of minimally invasive colectomies was performed. Indications, complications, and outcome were reviewed. Retrospective data on 35 open colectomies were collected for comparison.

Results:  There were 286 cases. Colorectal carcinoma was the operative indication in 43%, inflammatory bowel disease in 31%, diverticular disease in 20%, and other in 5% of the cases. There were 128 right, 128 left, 16 subtotal, 7 abdominal perineal, 6 low anterior, and 2 transverse colon resections. The conversion rate was 3.5%. The major complication rate was 5.6%, including 5 wound infections, 1 intraabdominal abscess, and 1 anastomotic leak. No mortalities occurred. Nodal clearance and longitudinal margins in the laparoscopic specimens were equivalent to those in the open comparison group. No tumor port-site recurrence occurred in the follow-up period.

Conclusions: Minimally invasive colectomy performed in a laparoscopic fellowship program produce low morbidity and mortality that are comparable to that of open colectomy.

8169 General Surgery
Laparoscopic Esophagomyotomy with Nissen Fundoplication
Constantine Frantzides, MD, PhD, Minh Luu, MD

Introduction: Minimally invasive esophagomyotomy for achalasia has become the preferred surgical treatment; the use of a concomitant partial or complete fundoplication with the myotomy is controversial. The case is of a 33-year-old woman with achalasia. She was diagnosed 15 years earlier and underwent multiple endoscopic dilations. The patient's symptoms became progressively severe requiring parenteral nutrition during her pregnancy. She presented for laparoscopic esophagomyotomy.

Methods: Laparoscopic esophagomyotomy with Nissen fundoplication is shown in our video. Our previous publication, which compared partial versus complete (360 degree) fundoplication, showed the superiority of the latter to the former in controlling reflux. We have performed >60 cases utilizing this technique with excellent results. Several technical aspects, however, have to be observed to accomplish the desired "valve-effect" without undue constriction of the esophagus. These important aspects are pointed out in this video.

Results: The patient had a normal upper gastrointestinal contrast study postoperatively, tolerated a liquid diet, and was discharged home on postoperative day 1. She was seen in clinic for follow-up at 1 week, 1 month, 3 months, and 6 months without complications. She had a complete resolution of her preoperative symptoms and did not develop gastroesophageal reflux disease.
Conclusion: Laparoscopic esophagomyotomy with Nissen fundoplication is a sage and effective treatment for achalasia. Herein, we report a representative video of our minimally invasive esophagomyotomy with Nissen fundoplication.

8170 Gynecology
Medico Legal Problems with Advanced Gynecological Operative Endoscopy
Professor Mark Erian, FRCOG, FRANZCOG, MD, Dr. Glenda McLaren, FRCOG, FRANZCOG

Objective: The purpose of this study was to analyze the complication factors in gynecological operative endoscopy, and to appreciate elements leading to litigation against gynecological surgeons and ways to minimize (or completely eradicate) medico legal risk factors and, consequently, lawsuits that can be costly in terms of monetary and emotional expenses to the patient, health care industry, gynecologists, their practices, and even families.

Methods: This was an observational study performed in the Obstetrics and Gynaecology Department, Royal Brisbane and Women’s Hospital (RBWH). This is a major tertiary referral teaching hospital. We studied the main complications occurring at RBWH as a result of laparoscopic and hysteroscopic operative interventions between 1990 and 2007 (inclusive) with analysis of the causative factors and ways to prevent the same.

Results: Nearly always, there is a reason(s) behind the complication(s), and these failures to inform, perform and/or communicate. Advances in modern technology have improved the outcome of simple and complicated operative laparoscopic and hysteroscopic surgery. Nevertheless, the authors stress the importance of training, credentialing, and maintaining a system of quality assurance (QA) that should be adhered to.

Conclusion: Advanced operative gynecological endoscopy offers the patient an attractive alternative to conventional surgery with less pain and discomfort, quicker return to the workforce, and better cosmetic results. Not only does the patient benefit from this approach but also the hospital and the national economy in general benefit. However, the gynecological surgeon must endeavour to excel in knowledge, manual dexterity, and communication skills if litigations are to be avoided or reduced to an absolute minimum.

8172 Gynecology
Laparoscopic Resection of the Cervical Stump
J.Y. Song, MD, E. Yordan, MD, C. Rotman, MD

    This video demonstrates our technique for performing a laparoscopic resection of the cervix in a patient who had undergone a laparoscopic supracervical hysterectomy (LSH) years earlier. A 47-year-old multiparous patient, who underwent an LSH 7 years prior for symptomatic uterine fibroids was referred to us due to continuous vaginal spotting and severe mucorrhea unresponsive to conservative, medical management. The patient had normal pap smears. A step-by-step video demonstration of a laparoscopic resection of the cervix is shown. The patient's symptoms resolved following the procedure. Laparoscopy is a safe and effective method for cervical stump removal and compares favorably with the vaginal or abdominal approach.

8174 Multispecialty
A Comparison of Conventional and Second-Generation Articulating Laparoscopic Instruments
Amanjot S. Sethi, Carl K. Gjertson, Yousef Mohammadi, Chandru P. Sundaram

Objectives:  To compare conventional laparoscopic and second-generation articulating instruments when used in a series of standardized tasks performed by novices.

Methods:  Thirty-one medical students without previous laparoscopic experience performed multiple sessions of 5 standardized tasks: (1) Peg board, (2) Pattern cutting, (3) Letterboard, (4) String running, and (5) Suturing. The first 20 consecutive students completed the tasks with conventional laparoscopic instruments. An additional 6 students completed the tasks using Autonomy Laparo-Angle (ALA) second-generation articulating laparoscopic instruments. Speed, accuracy, and emotional/physical comfort were compared between the groups.

Results: Although both groups had significant improvement in speed across all exercises, neither demonstrated a statistically significant improvement in accuracy. Physical and emotional comfort improved with each session for both groups. The students using ALAs were significantly slower in the pattern cutting exercise (P=0.01). However, their accuracy was significantly better for this task (P=0.003). There were no other statistically significant differences in speed, accuracy, or comfort between the 2 groups.

Conclusions: The limitations of conventional laparoscopy have driven the development of articulating instruments, a technology that has been slow to evolve. Although more complex, the skills needed for the effective use of articulating laparoscopic instruments can be acquired by novices through the repetition of standardized tasks. Moreover, second-generation articulating laparoscopic instruments compare well to conventional laparoscopic instruments in surgically applicable exercises such as suturing and cutting. These instruments may help expand the indications for conventional laparoscopy especially in areas where robotic technology is not available or affordable.

8175 Multispecialty
Face and Content Validation of a Novel Robotic Virtual Reality Simulator
Amanjot Sing Sethi, MD, William J. Peine, PhD, Yousef Mohammadi, BA, Thomas A. Gardner, MD, Chandru P. Sundaram, MD

Objective: To evaluate the face and content validity of what is to our knowledge the only available virtual reality (VR) simulator based on a complete kinematic representation of the da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA.)

Methods: A total of 5 experts (ES) and 12 novices (NV) completed a series of standardized exercises on the Mimic dV-Trainer (Mimic Technologies, Seattle, WA). ES were urologists who had completed more than 50 robotic cases. NV included participants with limited robotic exposure. Participants rated parameters of face and content validity on a 5-point Likert scale. Workload imposed by the simulator was assessed using a NASA-TLX questionnaire.

Results: Face validity of the MdVT was established as all 20 participants rated the MdVT between average to easy to use. Similarly, both ES and NV rated the MdVT above average to high in all parameters of realism. Participants in both ES and NV groups rated the MdVT's overall relevance to robotic surgery as very high. All participants assessed the MdVT to be an extremely good practice format and very useful for training residents thereby affirming content validity. The overall NASA-TLX workload score was 58.5 for novices and 41.5 for experts (P<0.05).

Conclusions: The Mimic dV-Trainer demonstrated excellent face and content validity as well as reasonable workload parameters. The use of this simulator in resident training may help bridge the gap between the safe acquisition of surgical skills and effective performance during live robot-assisted surgery.

8176 Multispecialty
Natural Orifice Surgery from the Middle of the World
Daniel Tsin, MD, Nestor Gomez, MD, Cesar Cabezas, MD, Stanley Jama, MD, Carlos R. Cassis, MD

Objective: To present the groundwork for transvaginal cholecystectomies done in Ecuador.

Methods: Two minilaparoscopy assisted natural orifice transvaginal cholecystectomies were done at the Policentro (Grupo Hospitalario Kennedy) Guayaquil, Ecuador in November 2007. One patient had multiple gallbladder stones and the other a large polyp. Dr. Gomez, the principal investigator from Ecuador, contacted Dr. Tsin, an expert in the field, for collaboration on this project. The special Committees of the Sociedad Ecuatoriana de Cirugia Endoscòpica, The School of Medicine of the Universidad de Guayaquil, and the ethics committee of Grupo Hospitalario Kennedy approved the operations. The surgical team included the author and coauthors.

Results: Both patients were ambulatory a few hours after surgery and were discharged the next day without immediate complications.

Conclusions: The procedures were done successfully. All researchers agreed to carry out these procedures under the defined protocol approved by the medical and ethics committees. This arrangement could serve as a model to other investigators seeking to implement this type of surgery.

8177 Urology
Laparoscopic Adrenalectomy: Anatomic and Technical Considerations
Amanjot S. Sethi, Chandru P. Sundaram

Objective: Laparoscopic adrenalectomy has gained widespread acceptance for the surgical management of adrenal masses. We present a teaching video with the purpose of detailing the crucial steps needed to successfully complete right and left laparoscopic adrenalectomy.

Methods: Digital video capturing is performed during all laparoscopic procedures performed at our institution. Video segments determined by the surgeon to have educational value are archived and later used to create educational videos.

Results: The video highlights the critical maneuvers performed during laparoscopic adrenalectomy. Contemporary laparoscopic devices such as bipolar electrocautery, ultrasonic shears, electrothermal bipolar tissue sealers and Hem-o-lok polymer ligating clips are featured. The differences in anatomy and dissection are compared between right- and left-sided procedures.

Conclusions: Laparoscopic adrenalectomy provides a safe and feasible approach to the surgical management of adrenal masses. We hope this video will help clarify the essential steps and detail the important anatomical and technical considerations specific to right and left laparoscopic adrenalectomy.

8179 General Sugery
Laparoscopic Total Colectomy with Ileo-Rectal Anastomosis for Polyposis and Ulcerative Colitis
Roberta Gelmini, Prof Dr Med, Massimo Saviano, Prof Dr Med

Objective: Since the introduction of laparoscopic colorectal surgery, several studies have demonstrated the advantages of mini-invasive segmental colon resections in the treatment of benign and malignant diseases. On the contrary, the use of laparoscopy for total colectomy and proctocolectomy is not accepted worldwide first of all because of the technically challenging nature of these procedures. The aim of this report is to show the feasibility and safety of straight laparoscopic total colectomy (LTC) for polyposis (P) and ulcerative colitis (UC).

Methods: Between January 2006 and June 2007 at our institution, 5 patients underwent LTC with ileorectal anastomosis plus temporary loop ileostomy for P (2 cases) and UC (3 cases).
Results: The mean age was 69.2 years (range, 62 to 77). In all cases, the preoperative endoscopy showed the distal rectum almost without signs of disease. Mean operative time was 320 minutes, and the estimated mean blood loss was 250cc. No transfusions or conversions were necessary. The mean surgical specimen length was 100cm, and in all cases the margins of resection were disease free. Considering the postoperative course, no morbidity and mortality occurred. The mean hospital stay was 8 days. The temporary ileostomy was suppressed in all patients within 3 months after the procedure.

Conclusions: The analysis of our data highlights the fact that LTC is effective and feasible even if its use, because of its complexity, has to be reserved for well-trained laparoscopic surgeons.

8180 General Surgery
Are Postoperative Doses of Prophylactic Antibiotics Necessary in Laparoscopic Bariatric Surgery?
A. Onopchenko, MD, R. Davis Bohs, RN, BSN, L. A. Janssen, RN, N. V. Stickel

Background: Since March 2002, the primary author has been performing elective laparoscopic bariatric surgery at AtlantiCare Regional Medical Center, beginning with laparoscopic gastric bypass (LRYGB) and then adding Lap-Band (LAGB) in December 2003. Routine prophylactic antibiotics have been administered to all patients. Patients receive one dose preoperatively and 2 doses postoperatively. In 2006, after institutional review of antibiotic usage and with no literature evidence supporting more than one dose preoperatively of prophylactic antibiotics for elective general surgery patients, the use of any postoperative prophylactic antibiotics for both band and bypass patients was discontinued. This one-year, retrospective study was undertaken to evaluate the clinical effect of this change.

Methods: This was a retrospective chart review.

Results: Elective laparoscopic bariatric surgery was performed in 195 patients for morbid obesity, meeting NIH criteria during the 12-month study period. No conversions to open surgery were necessary. The first study group received both a single preoperative dose and 2 postoperative doses of antibiotics. There were 96 patients in this first arm. Two were excluded from receiving antibiotics on the basis of SBE prophylaxis leaving 94 patients (40 LRYGB, 54 LAGB). One superficial surgical site infection was noted in an LRYGB patient in the first arm of the study. The second group received a single preoperative dose. There were 99 patients and again there were 2 exclusions for SBE prophylaxis, leaving 97 patients (35 LRYGB, 62 LAGB). No surgical site infections were noted in this second arm.

Conclusion: A single preoperative dose of antibiotics is sufficient to prevent surgical site infections in elective, laparoscopic bariatric surgery patients.

8181 Multispecialty
A Practical Guide to Teaching Residents Laparoscopic Surgery
Joy Brotherton, MD, James Bonheur, MD

Background: The benefits of minimally invasive surgery (MIS) are well recognized. However, creating competent surgeons with the skills to perform these procedures is a challenge facing most of today’s residency programs. For both OB/GYN and general surgery residencies, limited work hours have resulted in decreased surgical volume and technical experience. Moreover, the fact that many surgeons feel inadequately prepared to perform advanced laparoscopic procedures upon completion of their surgical training, seeking additional training in fellowships, workshops and conferences underscores the need for a structured skills training during residency. Simulator-based training has become quite popular in many programs. It is a safe and cost-effective means to enhance practical surgical techniques that are transferable to the operating room. Current simulator-based training is highly variable amongst programs with few standardized training protocols. Our goal was to present some of the training modalities and simulators available so that a laparoscopic curriculum can be easily created and implemented.

Database: A Medline and Web search was conducted to locate modules, Web sites, articles, and equipment that may be utilized to create a laparoscopic curriculum.

Discussion: There is a wide array of modalities available to help residency directors teach laparoscopic surgery. It is not necessary to “re-invent the wheel.” By compiling all of these resources into one paper, we hope to provide a reference for those wishing to create a practical curriculum and ultimately improve resident skills in MIS. We also make some suggestions for creating a successful curriculum.

8182 Gynecology
Laparoscopic Approach to Large Cervical Leiomyoma
J.Y. Song, MD, C. Rotman, MD

Objective: To offer all patients (especially fertility patients) with large fibroids an option other than a laparotomy or a hysterectomy, regardless of size, type, or anatomical location of the fibroids.

Methods: This video demonstrates our technique for performing a laparoscopic myomectomy of a large cervical leiomyoma at a suburban Chicago outpatient surgical center. A 29-year-old, nulligravida with a large cervical fibroid was told that conservative surgery would be impossible to perform, and a hysterectomy was recommended, eliminating the patient’s chances of having a child. This patient sought a second opinion at our clinic regarding this proposed management plan.

Results: The patient underwent laparoscopic removal of the leiomyoma and demonstrated excellent healing with a normal-appearing uterus and bilateral tubal patency on second-look laparoscopy.
Conclusions: As demonstrated in this video, regardless of size, type, and anatomical position of the fibroid(s), the laparoscopic approach for even a large cervical leiomyoma is not only feasible, but also safe if performed by capable hands in a well-prepared and established surgical setting. After a comprehensive world literature search, the authors believe that this case may represent the first instance of a true, large, full-thickness (not pedunculated) cervical fibroid arising from the posterior aspect of the cervical musculature to be conservatively managed by complete laparoscopic resection.

8183 Gynecology
Laparoscopic Tubal Anastomosis
J.Y. Song MD, N. Rana MD, C. Sueldo MD, C. Rotman MD

Objective: 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: This video demonstrates the laparoscopic technique of for tubal anastomosis to repair tubal disease involving segmental occlusion, or reversing tubal sterilization. Procedures were performed at a suburban Chicago outpatient surgical center. Reproductive age women with severe tubal disease involving tubal occlusion, or women with previous tubal sterilization seeking tubal patency and fertility underwent laparoscopy. A step-by-step video presentation of our technique for performing a laparoscopic tubal anastomosis is demonstrated, with the end result during a second-look laparoscopy.

Results: The majority of patients who have undergone this approach demonstrated tubal patency and achieved pregnancy.

Conclusion: In most cases if the surgeon has 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. Results in over 300 cases are very encouraging, and future studies will determine the true value of this technique compared with traditional methods.

8184 General Surgery
Laparoscopic Evaluation for Bilateral Hernia in Children
Amir Vejdan, MD

Background: Nearly 60 hernia operations are performed in children each year in our ward. One of the major concerns is whether the hernia is unilateral or hidden bilateral. We approach and evaluate this problem with laparoscopic surgery.

Method: Elective open surgery was performed in 43 patients with unilateral inguinal hernia. After dissection of Cord and Hernia's sac, we performed a diagnostic laparoscopy for simultaneously hidden hernia on the other side. If we come across an opened internal ring, we close it laparoscopically with a simple nonabsorbable nylon suture.

Results: In 12% of all patients, the internal ring of the other side was opened. (It is not clear whether every open sac can produce a real inguinal hernia). After one-year of observation, no complications have occurred.

Conclusions: Laparoscopic diagnosis of hidden contralateral hernia is a good, safe, and rapid method for preventing future hernia occurrence. But the major concern is that a small number of unclosed internal rings will result in a real indirect inguinal hernia.

8185 General Surgery
Laparoscopic Reversal of a Laparoscopic Hartman’s Procedure for Diverticulitis
Sotero E. Peralta, MD, Michael L. Arvanitis, MD, Frank J. Borao, MD, Roy M. Dressner, MD

Background: Reversal of Hartmann’s procedure is a major operation; it is associated with a high morbidity, which includes wound infection, anastomotic leaks, and incisional hernias. We present the case of a 54 year-old female who presented to the emergency room with abdominal pain. The patient underwent an abdomino\pelvic CT scan, which showed evidence of intraperitoneal and retroperitoneal air consistent with perforated sigmoid diverticulitis.

Methods: A laparoscopic rectosigmoid resection was performed with creation of an end colostomy and Hartman’s pouch. Three 5-mm ports and a 15-mm suprapubic port were used. After stapled resection of the rectosigmoid, drainage of a pelvic abscess and mesentery, an end colostomy was created in the left lower quadrant. The patient was discharged 5 days later after an uneventful admission; she completed a 7-day antibiotic treatment.

Results: Four months later, a laparoscopic reversal of the Hartman’s procedure was performed. A 4-port approach was performed after a traditional ostomy takedown. A lack of adhesions was found on the laparoscopic evaluation. The patient was discharged on postoperative day 5, and she recovered bowel function in 3 days.

Conclusion: A laparoscopic approach to diverticulitis is feasible, has a decreased length of hospital stay, and the opportunity of using the previous ostomy site as a balloon port.

8186 General Surgery
Is Nerve-Sparing TAPP Hernioplasty Feasible and Necessary?
Lukas Sakra, MD, PhD, Jiri Siller, MD, PhD, Lukas Kohoutek, MD, Charles  Havlicek,MD, PhD

Objective: Nerve injury during TAPP procedures is not a life-threatening complication, yet it may temporarily impair the quality of life by damaging the iliohypogastric nerve, the ilioinguinal nerve, the femoral branch (FBGN), and genital branch (GBGN) of the genitofemoral nerve and the lateral cutaneous nerve of the thigh (LCNT). The TAPP method is most often associated with damage to the FBGN and LCNT. Subsequent neuralgia is reported in 0.1% to 4.5% of cases. Nerve visualization during TAPP could reduce the number of these complications. However, the identification of nerves may not always be successful owing to anatomic variability and the rather demanding technical nature of visualization.
Methods: Between January 1, 2005 and December 31, 2007, we performed 519 TAPPs and controlled 456 patients (87.8%). Neuralgia was identified in 8 patients (1.7%). According to pain localization, 3 patients (0.66%) suffered damage to the LCNT, 3 damage to the FBGN (0.66%), and 2 damage to the GBGN (0.44%). Prospectively, attempts on the unambiguous visualization of LCNT and FBGN during TAPP were made in 30 patients. The time limit for visualization performance was 15 minutes. Afterwards, the percentile amount of successful visualizations was evaluated.

Results: LCNT and FBGN were simultaneously detected in 26 (86.7%) patients. No nerve was identified in 2 (6.7%) patients. Only LCNT or only FBGN was found in one patient each.

Conclusions: LCNT and FBGN visualization during TAPP does not prove unambiguously successful and cannot lead to a marked decrease in neuralgia complications. Nerve damage can be prevented by a proper surgical technique.

8187 Gynecology
The Comparison of Postoperative Re-adhesion Formation After Previous Laparoscopic and Laparotomic Adhesiolysis for Stage IV Endometriosis
Sung-Tack Oh, Chul-Hong Kim , Yong-Taik Lim, Kyu-Sup Lee, Jun-Young Hur

Objective: It is well known that postoperative adhesions occur less with laparoscopy than with laparotomy. However, in stage IV where severe adhesions are already present, it is uncertain whether laparoscopic adhesiolysis also produces fewer re-adhesions than laparotomic adhesiolysis.

Materials and Methods: The re-adhesion ratio was compared between 24 patients previously operated on with laparotomy (Group A) and 31 patients operated on with laparoscopy (Group B) when they underwent laparoscopy due to the recurrence of endometriosis. In the first operation, in both groups a large amount of lactated Ringer solution was put into the abdominal cavity after surgery, and Interceed were applied.

Results: The durations of recurrences were 4.2±1.6 in Group A and 5.3±1.8 in Group B (P=NS). All patients in Group A had severe re-adhesion formation on the second operation, but 6 of 31 patients (19.4%) in Group B had severe re-adhesions and 25 patients (80.6%) had minimal to mild re-adhesions only (P<0.01).

Conclusions: Therefore, laparoscopic adhesiolysis is essential for the first operation for stage IV endometriosis, especially in infertile or unmarried patients, although it is a very difficult procedure.

8188 Multispecialty
Laparoscopic Excision of Urachal Cyst
Robert Yavrouian, MD, Christopher Solis, MD, Ahmed Mahmoud, MD,

Objective: We report a case of laparoscopic excision of a urachal cyst and demonstrate the technique in a video.

Methods: Using laparoscopy, the entire urachal cyst, both medial umbilical ligaments, and the peritoneum from umbilicus to bladder dome were excised.

Results: Successful laparoscopic excision was performed in 125 minutes. The patient was discharged home on postoperative day 2. There were no complications.

Conclusion: A laparoscopic approach to excision of urachal remnants is a safe, feasible, and effective alternative to the traditional open technique and should be considered in patients with this uncommon disease.

8189 Urology
A Case Control Analysis of Robotic-Assisted Laparoscopic Varicocelectomy
Josephine Hidalgo-Tamola, MD, Mathew D. Sorensen, MD, Jeff B. Bice, Thomas S. Lendvay, MD

Objectives: We performed a case-control analysis comparing operative time and hospital charges between robotic-assisted laparoscopic varicocelectomy and age-matched controls who underwent laparoscopic varicocelectomies.

Methods: We identified all patients who underwent robotic-assisted laparoscopic varicocelectomy since April 2006. For each case, we selected 2 age-matched controls who underwent laparoscopic varicocelectomies. We compared the groups in terms of operative times and hospital charges. Statistics were performed using the Student t test, with significance set at P<0.05.

Results: Four patients with a mean age of 15.9 years (SD, 1.5) underwent robotic-assisted laparoscopic varicocelectomy. All varicoceles were left-sided. The most common surgical indication was debilitating unilateral scrotal pain (83%) despite conservative management. Fifty percent had testicular size discrepancy at presentation. Mean operative times were 112 minutes for robotic-assisted laparoscopic varicocelectomy versus 73 minutes for laparoscopic varicocelectomy (P=0.02). No intraoperative complications were experienced. The mean total hospital charge, including facility, equipment, anesthesiology, and recovery room fees, but excluding surgeon’s professional fees, was significantly higher for the robotic group ($15,800 vs $8,600, P=0.0005).

Conclusion: We describe the first report of robotic-assisted laparoscopic varicocelectomy in a pediatric patient population. We demonstrate that it is technically feasible with no intraoperative complications. It remains to be seen whether robotic-assisted laparoscopic varicocelectomy is more cost effective than laparoscopic varicocelectomy.

8190 General Surgery
Laparoscopic Management of Adrenal Adenoma
Dr. S. S. Saggu, Dr. P. Mehta, Dr. R. K. Saggu

Objectives: The adrenal gland is the seat of many pathologic conditions in which it is necessary to remove the gland to cure the patient. Our operative strategy is based on complete dissection of the left adrenal gland without specifically identifying the mass itself. We would like to present our personal experience with laparoscopic adrenalectomy.

Methods: A 34-year-old male patient presented with uncontrolled hypertension, weakness of the lower limbs, and recently diagnosed diabetes mellitus. A physical examination revealed a moon face and purple stretch marks over the abdomen and thighs with central obesity. His BP was 220/130 and fasting blood glucose was 123mg. Serum cortisol and 24 hours of urinary cortisol were markedly raised with normal 24-hour urinary catecholamines and VMA levels. NCCT-abdomen revealed a well-defined round homogeneous mass 2.5cm x 2.7cm in the left suprarenal region. Cortisol secreting adrenal adenoma with Cushing’s syndrome was diagnosed. Laparoscopic left adrenalectomy performed.

Results: Postoperatively, the patient’s BP and blood sugar were near normal. The patient was allowed a liquid diet on the same day and discharged on the second postoperative day. Histopathology report suggested adrenal cortical adenoma.

Conclusion: Laparoscopic approach has become the gold standard for benign disorders as it avoids a big laparotomy incision and confers all the benefits of minimally invasive surgery to the patient.

8192 Urology
Can Laparoscopic Pyeloplasty be Considered the “Gold Standard” in the Treatment of the Uretero-Pelvic Junction Obstruction?
M. Falsaperla, A. Saita, D. Aleo, G. Salemi, G. L. Salerno, B. Tomasi, M. Motta, G. Morgia

Objectives: This is a report of the experience we gained from the transperitoneal videolaparoscopic technique in the reconstructive treatment of uretero-pelvic junction obstruction (UPJO).

Methods: Between May 2004 and October 2007, we performed 28 laparoscopic transperitoneal pyeloplasties for UPJO. The surgical operation was performed through the positioning of 3 operative trocars. In all cases, we performed the Anderson-Hynes dismembered pyeloplasty technique, and positioned a proximal pyelic traction through a percutaneous suture via a straight needle. This device allowed us to shorten the operating time, shifting between 115 minutes and 189 minutes (average, 135), according to the rectilinearization of the rima of the pyelic suture (running 4-0 Vicryl suture) after reductive plasty. The pyeloureteral anastomosis was always performed with 4-0 Vicryl with 2 running 4-0 Vicryl sutures, one anterior and one posterior, after the positioning of a pyeloureteral distal stitch. The double J stent was placed on a hydrophilic guidewire inserted through ascending access, after the execution of the pyelic suture and of the posterior pyeloureteral suture.

Results: Few complications occurred during and after surgery, operating time was reduced, and outcomes were comparable to those of open surgery.

Conclusions: Laparoscopic pyeloplasty is a safe method that offers the advantages of minimum invasiveness. Owing to these considerations, to the few complications during and after surgery and to the functional results comparable to those obtained with open surgery, laparoscopic pyeloplasty, with transperitoneal or retroperitoneal access, can now be considered the “gold standard” for the treatment of UPJO.

8193 Urology
Laparoscopic Ablative Renal Surgery Using a Single Kind of Hem-o-Lok Clips for Global Vascular Control
M. Falsaperla, D. Aleo, A. Saita, F. Marchese, G. Iacona, G. L. Salerno, B. Tomasi, M. Motta, G. Morgia

Objectives: We report our experience with the use of a single size of Hem-o-lok clips during laparoscopic ablative renal surgery for vascular control.

Methods: From May 2003 to October 2007, we performed 36 laparoscopic transperitoneal nephrectomies. The control of the renal vein and artery was obtained in all cases using a single size of Hem-o-lock clips (Large Size: 5 mm to 13 mm vessel size). Our evaluations concern the easiness of loading and clipping, the number of clips used and the safety of their positioning, relative costs, and the transfusion rate.

Results: Vein clipping facilitated raising and stretching the vessel wall through a loop; the mean operative time was 165 minutes (range, 95 to 186). Control of the renal vein and artery was achieved by application of 2 Large Size Hem-o-lok clips on the patient side and 1 on the sample side: in this way, we managed to use only one package of clips in each operation, whose price is 60•. Blood transfusion was only required in 2 patients. The mean hospital stay was 3.3 days.

Conclusions: The safety of Hem-o-lok clips Large Size, also to clip extra-large renal
veins, is strictly connected to the suitable isolation, raising, and tension of the vessel wall and with the check sound (click) of the perfect closing of the device. Therefore, the Hem-o-lock clip Large Size can be considered a safe, reliable, and economical device for global vascular control during laparoscopic ablative renal surgery.

8194 General Surgery
Our Experience with the Laparoscopic Resection of Advanced Low Rectal Cancer with Intraoperative Radiotherapy
Ignazio Massimo Civello, MD, Serafino Vanella, MD, Francesco Brandara, MD, Pasquale Mazzeo, MD, Francesco Giacchi, MD, Anna Crocco, Giuseppe Bianco, Camillo Cavicchioni, MD

Background: Intraoperative radiotherapy (IORT) has been used since the early 1980s. In recent years IORT, has also been used as a boost technique in multimodal approaches using pre- or postoperative radiotherapy in the treatment of locally advanced rectal cancer. Long-term outcomes in patients undergoing laparoscopic resection of colorectal cancer are as good with laparoscopic surgery as with open surgery.

Methods: We describe 14 patients affected by advanced rectal cancer who were treated with neoadjuvant radiochemotherapy and laparoscopic rectal resection combined with total mesorectal excision (TME) and IORT.

Results: Laparoscopic TME was completed successfully in 14 patients, whereas conversion to an open approach was required in 3 cases (21.4%). The overall morbidity rate was 14.3%, with an overall anastomotic leak rate of 7.1%. Average operative time was 301.5 minutes. Low rectal resection was performed in 11 patients, and abdominoperineal resection was performed in 3 patients. Duration of ileus was 3.7 days, and postoperative hospital stay was 8.7 days. All oncological patients are alive at different follow-up periods (3 months to 4 years).

Conclusions: Our preliminary experience shows that laparoscopic rectal resection with IORT is not only feasible but also associates oncologic radical treatment with the important advantages of the laparoscopic approach.

8195 Urology
Comparison of Complete Intracorporeal Construction of an Ileum Neobladder Utilizing Standard Sutured Techniques and Novel Technologies
Gregory W. Hruby, Preston Sprenkle, Dan Lehman, Evren Durak, Franzo Marruffo, Gabriella Mirabile, James McKiernan, Jaime Landman

Objectives:  We compared the surgical efficacy and efficiency of a completely suture-based procedure with a novel enterourethral anastomosis device.

Methods: Two groups of 7 pigs were survived for 8 weeks. In Group 1, neobladder construction was performed using a U-shaped segment of ileum and sealed with an endoGIA. The enterourethral anastomosis was created with a novel sutureless anastomosis device. In Group 2, a completely sutured technique was utilized. Procedure, enteroenteric, ileum neobladder, enteroureteral, and enterourethral anastomotic times were recorded. To evaluate postoperative urinary patency, 2 week and sacrifice cystograms (rating 0-None to 3-Severe leakage) were performed.

Results: In Group 1, the procedure, enteroenteric, ileum neobladder, enteroureteral and enterourethral anastomosis were completed in 285.3, 32.3, 58.8, 54.2, and 5.5, respectively. For Group 2, the procedure, enteroenteric, ileum neobladder, enteroureteral and enterourethral anastomosis were completed in 350.1, 29.9, 139.1, 58.0, and 46.3, minutes, respectively. For both groups the average cystogram ratings at postoperative evaluation were 0.83 and 1.6, and neither group had extravasation at the 2-week and sacrifice screenings. The overall surgical procedure, pouch creation, and enterourethral anastomosis were statistically shorter for group 1 (P=0.036, 0.01, and 0.039, respectively). The average survival time for both groups was 30 (range, 4 to 56) and 41 (range, 1 to 56) days, respectively (P=0.36). All animals developed voiding complications within one week after ureteral and urethra catheters were removed. One neobladder in Group 1 ruptured.

Conclusion: The combination of stapled construction of the ileal neobladder and the enterourethral anastomosis device significantly reduced operative times.

8196 Multispecialty
Content and Face Validity of a Cost-Effective Personal Laparoscopic Trainer Designed for At Home Use
Gregory W. Hruby, Preston C. Sprenkle, Corollos Abdelshehid, Ralph V. Clayman, Elspeth M. McDougall, Jaime Landman

Purpose: To assess the face and content validity of a new portable laparoscopic trainer, the EZ Trainer.

Materials and Methods: The portable, affordable EZ trainer system was conceived, designed, and commissioned by academic surgeons from the Departments of Urology at Columbia University and the University of California – Irvine, with the express purpose of advancing laparoscopic surgical training. Forty-two participants, including general surgeons, obstetricians/gynecologists, urologists, and industry representatives assessed the face and content validity of the EZ Trainer by using a standard questionnaire. Participants were stratified into high-volume laparoscopists (>30 laparoscopic cases/year) and low-volume laparoscopists (<30 cases/year).

Results: Ninety-six percent of the participants rated the EZ Trainer as a realistic laparoscopic training format. Of the high-volume laparoscopists, 81.5% rated the EZ Trainer as comfortable to use, 92.6% found the EZ Trainer to be a realistic practice format, 70.4% would purchase the EZ Trainer for personal use, and 85.2% would recommend the EZ Trainer be made available to surgical residents in their discipline. For low-volume laparoscopists, 87% rated the EZ Trainer as comfortable to use, 93.3% found the EZ Trainer to be a realistic practice format, 73.3% would purchase the EZ Trainer for personal use, and 80% would recommend the EZ trainer be made available to diverse surgical residents.

Conclusions: The EZ Trainer system has both face and content validity as a portable laparoscopic trainer across a broad range of surgical disciplines.

8197 General Surgery
Project REACH: Robotic Expertise Allowing Collaborate Help. A New Paradigm in Postgraduate Surgical Training
Alex Gandsas, MD, Mike Medus, MS, Sergio Cantarelli, MD, Gabriel Egidi, MD

Introduction: An actual feasibility study was recently conducted to test the use of robotic remote presence for distant surgical training. The project code named R.E.A.C.H for Robotic Expertise Allowing Collaborate Help involved the interaction of novice surgeons and their proctor in a virtual environment provided by robotic remote presence technology to master a new surgical procedure.

Methods: The system consists of a robotic unit placed in the operating room that is accessed remotely by the student or proctor using a control station computer. This technology allows both student surgeons and proctors to log into an operating room from their office and experience an individualized, on-site preceptorship of a given surgical procedure. During each session, the user at the control station is able to drive the robot and interact with the environment, emulating an on-site experience.

Results: From September 2006 to December 2006, two laparoscopic surgeons in
Argentina logged into a robot located in an operating room in the USA and experienced customized preceptorships on laparoscopic gastric sleeve. After completing a total of 19 sessions, the surgeons in Argentina were mentored during their first 3 bariatric cases by having the expert surgeon logging in from the United States to another robot located in Argentina. All patients experienced a successful outcome and were discharged on their second postoperative day.

Conclusion: Using robotic remote presence technology as a mobile, real-time telecommunication platform, the surgical education paradigm can be changed to one where actual attendance is replaced by robotic tele-presence.

8199 Gynecology
Preoperative Parameters of Increased Surgical Risk in Patients with Endometriosis
Ilana B. Addis, MD, MPH, Lauren J. Moore, MD, Kenneth D. Hatch, MD

Objective: To identify women with endometriosis at high risk for difficult and complicated surgical treatment.

Methods: Charts were reviewed of patients undergoing surgery for endometriosis by one pelvic surgeon at the University Medical Center in Tucson, Arizona from January 2000 through December 2005. Parameters were analyzed with regards to 3 outcomes: length of surgery, estimated blood loss (EBL), and difficulty of the procedure.

Results: According the above criteria, 88 patients were included in the study. These patients were, on average, 41 years of age with a body mass index (BMI) of 29. The largest group (42%) underwent definitive surgery including hysterectomy and bilateral salpingo-oophorectomy. Eighty-five percent of patients had either stage III or IV disease. Mean operative time was 102 minutes, and median EBL was 100mL with an overall complication rate of 6%. Forty-three percent of cases met criteria as difficult procedures. Multivariate analysis revealed that age greater than 41, the presence of one or more preoperative symptoms, and a history of previous pelvic surgery were significant (P<0.05) with regards to at least one of the outcomes of interest. Elevated CA-125 level and BMI greater than 28, while significant in univariate analysis, did not remain so in the multivariable regression models.

Conclusions: Women with endometriosis requiring surgery for management, over the age of 41, with a BMI >28, and a combination of specific pelvic pain symptoms are at increased risk for difficult or complicated procedures. Consideration could be given to referring these patients to a skilled pelvic surgeon.

8200 Urology
Efficacy and Safety of the Vivostat System for Hemostasis in Laparoscopic Partial Nephrectomy
Luigi Schips, Luca Cindolo, Stefano Gidaro, Katja Lipsky, Richard Zigeuner

Objectives: Hemostasis remains the greatest challenge during laparoscopic partial nephrectomy. We describe the use of the Vivostat system achieving effective hemostasis during laparoscopic partial nephrectomy (LPN).

Methods: Twenty-nine patients underwent LPN. Autologous fibrin sealant was prepared with the Vivostat system and applied to the resection bed. This system is an automated medical device for the preparation of an autologous fibrin sealant, generating up to 5mL of sealant from 120mL of the patient's blood. The clinical and laboratory parameters were evaluated pre- and postoperatively for acute and delayed bleeding.

Results: Mean patient's age was 57.5 years (range, 23 to 76). Hemostasis was immediate in all cases after application of the sealant for 1 minute to 2 minutes to the resection site (mean amount applied, 5.1mL); a Tabotamp bolster was frequently used (80%). Six resections were performed without ilar clamping, whereas the mean warm ischemia time was 26 minutes (range, 16 to 45) for 23 interventions. Mean blood loss was 128cc (range, 20 to 500). Preoperative and postoperative serum hemoglobin did not differ significantly (mean, 14.7 vs 12.5g/dL) and creatinine values (mean, 0.91 vs 1ng/mL). Mean operative time was 131minutes (range, 60 to190). One intraoperative bleeding occurred needing blood transfusion (1 unit). Postoperatively, we observed only 1 perirenal hematoma treated conservatively not requiring blood transfusion.
Conclusions: In this study, immediate hemostasis was achieved and maintained after the kidney reperfusion. These data support the previous finding with the same system and encourage its use in LPN.

8202 General Surgery
Laparoscopic Approach for the Treatment of Huge Hiatus Hernia
Mohammad Alkilani, MD, Salvatore Straci, MD, Elvira Puntorieri, MD

Objective: The laparoscopic approach is the gold standard for the surgical treatment of symptomatic hiatus hernias and GERD because of the technique’s advantages. The laparoscopic procedure should be considered the gold standard for the treatment of huge hiatus hernias, too. We intend to submit a video that highlights the key points of the procedure for treatment of huge hiatus hernias.

Methods: We treated 24 patients for hiatus hernias and GERD by the laparoscopic technique and performed the Nissen procedure. Four of these had huge symptomatic hiatus hernias. Patients had respiratory symptoms because of stomach migration in the thorax, heartburn, and gastroesophageal reflux. Patients underwent the endoscopic procedure, esophagus manometry, and X-ray of the esophagus and stomach. The procedures were performed by the laparoscopic technique with 5 trocars and 30-degree optical scope. The standard operation was the Nissen procedure.

Results: Patients were treated with the Nissen procedure and had a rapid recovery and early return to regular eating, early ambulation, and rapid improvement in symptoms. Patients were discharged within 3 days after surgery. Long-term follow-up confirms the improvement in symptoms and the good quality of life. One patient had transitory dysphagia.

Conclusion: The laparoscopic technique is the gold standard for GERD, hiatus hernias, and the large hiatus hernias. The same consideration is valid for obese patients because the visibility is improved by the laparoscopic technique. Patient outcome after laparoscopy is better, and complications are fewer because no abdominal wall wound is needed.

8204 General Surgery
The Relation of Reduction of Hernial Ring and Reoccurrence Rate in Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair
Zarija Djurovic, MD

Objective: We performed a reduction of hernial rings on many direct and indirect hernias using nonresorbable sutures with care to provide adequate room for vessels and the spermatic cord as well as preventing injury of the urinary bladder.

Methods: Since 1991, we have treated many large direct and indirect hernias with the laparoscopic transabdominal preperitoneal approach using mesh and hernia ring reduction. This technique reduced the effect of intraabdominal pressure on mesh and mesh attachment sites with improved results and a reduction in reoccurrence rates.

Results: Short- and long-term follow-up did not reveal any known reoccurrence in comparison with no-ring reduction.

Conclusion: Laparoscopic transabdominal preperitoneal inguinal hernia repair with hernia ring reduction prior to mesh application further reduces reoccurrence rates.

8205 General Surgery
Primary Omental Torsion, Laparoscopic Approach: Case Report and Literature Review
Luis Salgado, MD, Morris Franklin, MD, Jose A Diaz, MD, Guillermo Portillo, MD

Introduction: Omental torsion is a rare cause of acute abdominal pain; diagnosis is rarely made preoperatively. We present one case of primary omental torsion treated by a laparoscopic approach.

Methods: A 63-year-old man admitted to the emergency department with a 72-hour evolution of right upper quadrant pain. He had bilateral total extraperitoneal inguinal hernia repair 2 years prior to admission. Physical examination revealed moderate tenderness in the right upper quadrant, without peritoneal signs. No laboratory abnormalities were found. Ultrasound showed negative findings for cholecystitis or cholelithiasis. A computed tomography (CT) revealed a focal area suggestive of inflammation in the pericolonic fat, 8cm x 3cm in the axial plane and 6cm cranio-caudad, involving the antimesenteric border at the hepatic flexure: findings suggestive of omental infarction.

Results: The omentum was freed by blunt dissection; a point of torsion was identified. Partial omentectomy was performed, and the specimen was retrieved in a bag. The patient had pain relief and the recovery was uneventful. The patient was discharged on postoperative day 2.
Conclusion: Primary omental torsion is a rare entity that has to be differentiated from acute appendicitis in most cases. The laparoscopic approach allows a transoperative diagnosis if not achieved preoperatively, also allowing resection of the diseased omentum and avoiding a laparotomy.

8206 General Surgery
Laparoscopic Management of Amyand’s Hernia
Dr. P. Bhatia, Dr. S. John, Dr. R. K. Saggu

Objectives: Acute appendicitis in an incarcerated inguinal hernia, called Amyand’s hernia, is an uncommon and rare condition found in approximately 0.13% of cases. Correct preoperative diagnosis is difficult and requires an awareness of this entity. Our emphasis is given to the laparoscopic management and rarity of the disease.

Methods: A 72-year-old female presented with right inguinal swelling for 3 days associated with acute pain and vomiting. On examination, the patient was dehydrated and abdominal examination revealed a tender, erythematous, irreducible right inguinal swelling. A clinical diagnosis of right strangulated inguinal hernia was made. Diagnostic laparoscopy was done, which revealed an incarcerated appendix with perforated tip with purulent fluid in the right hernial sac. The appendix was reduced after raising the flaps as in the transabdominal preperitoneal approach. An appendicectomy was performed. Suture closure of the deep inguinal ring was performed without mesh placement. Peritoneal flaps were approximated.

Results: Postoperative recovery was smooth, and the patient was discharged after 48 hours. Histopathology report suggested acute appendicitis.

Conclusion: Laparoscopic management offers an excellent minimally invasive approach. It has been recommended that repair be done without using a synthetic mesh, as introducing a foreign material into a contaminated field has its own danger.

8207 General Surgery
Prospective, Double-Blind, Randomized, Control Study Evaluating the Outcomes of Laparoscopic Cholecystectomy Without Using an Energy Source, Performed by a Higher Surgical Trainee Versus Consultant
Dr. Brij B. Agarwal, MS, Dip Yoga, FIMSA, Dr. B. K. Sinha, MS, Dr. D. Agarwal, MBBS, Dr. A. Deo, MBBS, Dr. K. C. Mahajan, FRCS

Background: Energy source (ES)-related morbidity remains a concern in laparoscopic cholecystectomy (LC). We use the technique of LC without ES. Training for LC adheres to the technique of dissection with ES. We report the replicability of the technique of LC without ES by the residents at the higher surgical trainee (HST) level.

Methods: Fifty consecutive nonselected candidates for LC were randomized to be operated on by either a consultant (control group) or an HST (study group). No ES was used. The patient was treated while under general anesthesia according to ethics committee approval and gave informed consent. A preoperative anesthesia check up protocol was performed. The operating surgeons were blind to the pre- and postoperative evaluation of the patients who were monitored for preoperative hemodynamic (HD) stability, postseparation hemostasis at the liver bed, vascular/visceral injuries, gallbladder (GB) perforation by dissecting instruments, operative time, conversion or need of blood transfusion (BT) and postoperative HD instability, BT, clinical evidence of biliary/visceral injuries, peritonism/constipation beyond 24 hours, length of stay, rehospitalization, re-exploration, biliary leak, or mortality. An independent doctor analyzed the records.

Results: The control and study groups were similar for demographics, pathology, and preoperative status. No adverse outcomes occurred in either group. The operating time was 45 minutes (range, 30 to 95) in the study group and 35 minutes (range, 25 to 210) in the control group. GB perforation was seen in patients 5 and 3, respectively.

Conclusion: The technique of LC without using ES is easily replicable by HST without any additional skills training or resources.

8208 General Surgery
Single-Port Transaxillary Endoscopic Excision of Benign Breast Lumps: Preliminary Results of a Prospective Study
Dr. Brij B. Agarwal, MS, Dip Yoga, FIMSA, Dr. B. K. Sinha, MS, Dr. D. Agarwal, MBBS, Dr. A. Deo, MBBS, Dr. K. C. Mahajan FRCS,

Background: Absence of scars on the breast appeals to ladies. Based on our technique of transaxillary endoscopic excision of benign breast lumps using 3 ports, we followed the single-port access technique.

Methods: Seven consecutive, nonselected candidates (after a rigid diagnostic evaluation protocol) were enrolled following the ethics, informed consent, and preoperative evaluation for "fast track surgery" module. They were operated on while under general anesthesia. A 10-mm port was advanced from the axilla towards benign breast lumps being excised by telescopic dissection (stabilized with hand externally or a needle) under 12-mm capnosufflation. The lumps were extracted from the port site with marginal enlargement if necessary for larger lumps. End points were technical difficulty, hemostasis, conversion, length of stay, return to activity, bath, commitments, diet, exercise, family life, or clinically evident axillary injury.

Results: Nine lumps (2cm x 2cm to 16cm x 10cm) were excised from all quadrants of 7 breasts without any technical difficulty/conversion as outpatient surgery. Mean operating time was 35 minutes (range, 20 to 210). There were no adverse outcomes for any end point. The ladies returned to activity, bath, commitments, diet, exercise, and family after 48 hours expressing satisfaction and happiness. No clinically evident collection, hematoma, discharge, infection, or injury to axillary structures was reported during the 1-month follow-up.

Conclusion: Endoscopic excision of benign breast lumps by "single-port access" is a technically simple, safe esthetic procedure, not requiring any special instruments. The ladies appreciate it.

8209 General  Surgery
Comparative Study of Single- versus Double-Lumen Endotracheal Tube Anesthesia for Needlescopic Bleb Resection
Hyun Koo Kim, MD, PhD, Heezoo Kim, MD, PhD, Young Ho Choi, MD, PhD, Sang Ho Lim, MD, PhD

Objective: This prospective study was conducted to evaluate feasibility and safety of single-lumen endotracheal tube with low tidal volume anesthesia (SL) compared with double-lumen endotracheal tube anesthesia (DL) for 2-mm sized thoracoscopic (needlescopic) bleb resection.

Methods: The patients with spontaneous pneumothorax underwent bleb resection via 2-mm sized thoracoscope and grasper ports and one 11.5-mm endostapler port. During the operation, tidal volume was set at 4.0mL/kg (SL) and 8.0mL/kg (DL). Respiration rate was set at 23/minute (SL) and 12/minute (DL) at the same FiO2 (50%).

Results: The study included 108 patients (55 patients in SL, 53 in DL). Patient’s age and the number of resected blebs were not different between the 2 groups. Peak airway pressure (6.9±2.52mm Hg in SL vs. 22.3±3.17 in DL, P=0.006) and PO2 (238.3±43.47mm Hg in SL vs. 107.7±29.78 in DL, P=0.000) were significantly different. However, PCO2 (42.8±3.88mm Hg in SL vs. 40.4±5.46 in DL, P=0.104) and end-tidal CO2 (34.1±4.19 in SL vs. 30.6±7.07 in DL, P=0.054) were not significantly different. Operation time was not different between the 2 groups (33.2±19.27 minutes in SL, 30.7±13.51 in DL, P=0.634). However, time duration from anesthesia induction to incision (26.5±6.78 minutes in SL, 39.5±7.57 in DL, P=0.000) and total anesthesia time (70.7±16.56 minutes in SL vs. 93.2±24.52 in DL, P=0.001) were significantly different.

Conclusions: Needlescopic bleb resection using single-lumen endotracheal tube anesthesia with low-tidal volume is technically feasible for thoracic surgeons, makes it easier for anesthesiologists, and is safe for patients.

8210 General Surgery
A Prospective, Randomized, Controlled Study for Effects of Yoga Practice on the "Patient Reported Outcomes" in an Outpatient Minimally Invasive Surgery Practice
Dr. Sneh Agarwal, MS, FIMSA, PGDHHM, Dr. Brij B Agarwal, MS, Dip Yoga, FIMSA,
Ms. Pooja Pant, Dr. A Deo, MBBS, Dr. K. C. Mahajan FRCS,

Background: Patient-reported outcomes are a useful tool for evaluation of perioperative care and results. Minimally invasive surgical skills have improved patient-reported outcomes significantly, making it popular amongst the masses. Yoga is popular in India as an alternative healing therapy and recently has appealed to the global community. We report the results of the study evaluating the impact of yoga in our patients.

Methods: Two hundred fifty consecutive candidates for outpatient surgery were randomized into routine (control) and yoga practice (study) groups, adhering to ethics, informed consent, and a preoperative "outpatient surgery" evaluation protocol. The study group was given yoga training (diet, breathing, yoga exercises) perioperatively. Postoperative pain, analgesic requirement, return to normal bowel habits, and activity and resumption of family/sexual life were the main end points. The data were prospectively collected and analyzed by an independent doctor.

Results: The control and study groups were similar for demographics and type of surgery. Both groups had laparoscopic cholecystectomy, laparoscopic inguinal hernia repair, laparoscopic ventral hernia repair, laparoscopic appendectomy, and stapled hemorrhoidopexy represented similarly. There was a significant reduction in postoperative pain scores and analgesic requirements in the study group. The study group patients reported faster resumption of bowel habits, normal activity, and family/sexual life. They also reported the overall feeling of well-being with yoga practice with improved satisfaction scores.

Conclusion: Yoga improves the feeling of overall well-being and satisfaction. It helps in improving the "patient reported outcomes" in all minimally invasive outpatient surgeries.

8211 Urology
Predication and Implementation Strategies in Laparoscopic Education
Saleem Zafar, MD, Ronney Abaza, MD

Introduction: The ideal method for teaching laparoscopy is unknown. Whether simple independent repetition is a suitable alternative to mentoring by a skilled laparoscopic surgeon has not been investigated in a randomized fashion. Additionally, it is unclear whether a learner's baseline skill can be used to predict whether more intense or different training will be required as compared with a learner with better baseline performance. Finally, the question of whether dry laboratory laparoscopic skill translates into immediate skill on the da Vinci robot has yet to be answered.

Methods: Sixteen fourth-year medical students were tested on 5 validated laparoscopic tasks, ranging from simple to complex. They were then divided into 2 groups; one group received mentoring, and the other was offered a detailed demonstration of the task but practiced independently. Their times before and after instruction were analyzed. Students were then asked to repeat a complex task on the robot without any instruction.

Results: Baseline skill was not predictive of final performance after instruction. Mentored students did not perform better on simple tasks but did on complex tasks, including single (P=0.009) and running (P=0.039) sutures. Additionally, those learners who performed better on complex laparoscopic tasks performed better on the robot.

Conclusion: Baseline skill assessment did not predict performance after laparoscopic instruction. Independent training is effective for the acquisition of simple laparoscopic skills, but mentoring improves performance of complex skills. Acquired dry laboratory laparoscopic skill translates into skill on the da Vinci robot.

8212 General Surgery
Chronic Biloma Ten Years After Laparoscopic Cholecystectomy
Benjamin Clapp MD, Bruce Applebaum MD

Introduction: Late chronic bilomas are rare. Bilomas can occur after laparoscopic cholecystectomy but usually are early in presentation, ranging from 2 days to 3 days to 2 weeks. Late bilomas are rarely described in the literature. We present a case of a biloma 10 years after a laparoscopic cholecystectomy. Our patient presented with chronic right upper quadrant pain. CT scan showed a fluid collection in the gallbladder fossa that had a thick wall and chronic appearance. The patient was worked up by her gastroenterologist who had previously tried to percutaneously drain this fluid collection. Hepatobiliary scan as well as an MRCP showed normal biliary ductal anatomy with no evidence of leak, stricture, or obstruction. The patient was referred for surgical excision.

Description of video: The video begins with a dissection of the thick-walled cyst in the gallbladder fossa. The dissection is carried out bluntly and with electrodissection to remove both the biloma and a rim of liver bed. Once the cyst is dissected, it is retrieved and a drain is placed.

Conclusions: Chronic bilomas are rare but can occur. Any walled off fluid collection in the abdomen after a cholecystectomy should prompt evaluation. This may include a CT scan, ultrasound, hepatobiliary scan, and MRCP. Percutaneous drainage is not likely to work in a thick-walled, chronic biloma.

8213 General Surgery
Laparoscopic Roux-en-Y Gastric Bypass in the Setting of Intestinal Malrotation
George Poulos, DO, Diana Livingston, DO, Tinamarie Juengert, RN, Marc Neff, MD, Louis Balsalma, DO

Background: The laparoscopic Roux-en-Y gastric bypass has been proven to be a safe, effective means of treating morbid obesity. It is rapidly becoming one of the most popular options available for surgical weight loss. Although preoperative screening for bariatric procedures is extensive, intestinal malrotation or other congenital abnormalities of the small bowel and mesenteries may go undiagnosed in asymptomatic adult patients. We present here a case of intestinal malrotation diagnosed intraoperatively, with subsequent successful completion of a Roux-en-Y gastric bypass.

Methods:  The patient was a 42-year-old African American female with a BMI of 44 who had a long-standing history of failed weight loss attempts. After an appropriate preoperative preparatory program, including a UGI that was read as “normal,” she was scheduled for elective laparoscopic Roux-en-Y gastric bypass.

Results:  The patient was taken to the operating room where an exploratory laparoscopy was performed. Upon initial inspection, a malrotation of the small bowel was noted. A laparoscopic Roux-en-Y gastric bypass was performed using an 80-cm Roux limb without difficulty. Anatomic variations in positioning of the small bowel were addressed in creation of the Roux limb and its position related to the colon. The patient was discharged on postoperative day 3 without complications.

Conclusion: Intestinal malrotation may go unrecognized in preoperative testing for patients preparing for surgery for morbid obesity. Although it may increase the technical difficulty of the procedure, it is not a contraindication for the Roux-en-Y procedure.

8214 Gynecology
A Randomized, Controlled Study Comparing Two Standardized Closure Methods of Laparoscopic Port Sites
Kai Chen, MD, Allan Klapper, MD, Hayley Voige, DO, Giuseppe DelPriore, MD, PhD

Objectives: To compare postoperative wound complications of Octyl Cyanoacrylate tissue adhesive (OC) with standard suture technique for the closure of laparoscopic port sites.

Methods: We studied 26 patients. All participates had 2 to 4 low abdominal ports, with one port closed with OC while the opposite port was closed with 4-0 Monocryl suture. An evaluation of the wound was performed 2 weeks to 4 weeks after surgery. The Hollander Wound Evaluation Scale (HWES, including step-off of borders, contour irregularities, margin separation, edge inversion, excessive distortion, and overall appearance) was used for cosmetic evaluation. Complications, such as erythema, warmth, tenderness, drainage, and wound infection, were evaluated. Analysis of complications was performed using the χ² test, and cosmetic evaluation including individual components of the HWES was compared with the t test with P<0.05 considered significant.

Results: In 26 patients, 52 wounds were evaluated. The number of patients with erythema (1/26 vs. 11/26, P<0.05) and tenderness (0/26 vs. 16/26, P<0.05) was lower with OC than that with sutures. Although no difference was noted in the overall HWES for cosmetic evaluation, margin separation (0/26 vs. 5/26, P<0.05) was lower with OC.

Conclusion: Laparoscopic ports closed with OC had fewer early complications, such as wound erythema, tenderness, and margin separation. A larger sample size of longer duration is needed to confirm these results.

8216 General Surgery
Laparoscopic Repair of Postesophagectomy Hiatal Hernia
Thomas Fabian, MD, Jeremiah T. Martin, MD, Alicia A. McKelvey, MD

Background: Postesophagectomy hiatal hernia is a known entity and can occur regardless of the technique used. Generally, these should be repaired when discovered, as the rare occurrence of intrathoracic colon herniation may be associated with other complications such as ischemia and perforation.

Methods: We describe the case of a 60-year-old male who presented 5 months after a minimally invasive esophagectomy with early satiety. A laparoscopic repair was undertaken during which the intrathoracic colon was reduced and confirmed to be viable. The enlarged diaphragmatic hiatus was reapproximated at the level of the left crus and the gastric conduit was pexied to this repair.

Results: The patient underwent a successful repair and was discharged to home within 24 hours of surgery. He has been followed up most recently 9 months postoperatively without any evidence of recurrence.

Conclusion: Intrathoracic colonic herniation is a rare complication of esophagectomy; however, it can be safely and effectively treated with a laparoscopic approach.

8217 General Surgery
Analysis of Operative Indication for TVH and LAVH
Tang Jiasong, MD, Ju Hongshu, MD, Yu Jingping, MD

Objective: To choose the optimal operative method for patients by comparing the different operative indications and effectiveness of transvaginal hysterectomy (TVH) and laparoscopic-assisted vaginal hysterectomy (LAVH) in treatment of patients with nonuterine prolapse.

Method: A retrospective study. Totally 256 patients who underwent TVH and LAVH were analyzed for operation time, blood loss, pre- and postoperative complications, operative indications, and hospital stay from February 2006 to October 2007.

Result: There were no significant differences in blood loss, operative complications, and hospital stay of the 2 groups. The mean operation time for the LAVH group (105.36±27.51 min) was longer than that for the TVH group (83.49±22.18 min), which may be correlated with the more severe pelvic adhesions in the LAVH group. There were more patients with a history of vaginal delivery in the TVH group (171 cases, 86.36%) than those in the LAVH group (36 cases, 62.07%). Patients with a history of abdominal surgery had no or mild pelvic adhesion in the TVH group, while 32 patients had severe pelvic adhesions because of endometriosis in the LAVH group.

Conclusion: Both TVH and LAVH were commonly used minimally invasive surgery methods. TVH is suitable for patients without or with mild pelvic adhesions, while LAVH is more suitable for those with severe pelvic adhesions and stenosis of the vagina and hysterauxesis of more than 16 weeks. We should choose the optimal operative method according to the condition of patients and our operative skills.

8218 Gynecology
A Case of Recurrent Laryngeal Nerve Paralysis After Laparoscopic Surgery
Takashi Yamada, MD

Introduction: Laparoscopic surgery provides benefits, including less visible scarring, less operative pain, a shorter hospital stay, and quicker recovery. We report a case of recurrent laryngeal nerve paralysis after laparoscopic surgery.

Case Report: A 26-year-old nulligravid woman underwent laparoscopic left ovarian cystectomy and uterine myomectomy under general anaesthesia. A few hours later, the patient complained of throat discomfort. On the second postoperative day, she manifested hoarseness, which was attributed to intubation of the trachea. There was no pain, dysphagia, or aspiration. Hoarseness continued, and indirect laryngoscopy showed an immobile left vocal cord on days 7 and 14, suggesting left recurrent laryngeal nerve paralysis. The hoarseness of the patient’s voice interfered with her work. At 4 weeks after the surgery, the patient’s voice was normal. Indirect laryngoscopy 11 months postoperatively revealed normal function of the left vocal cord, and her voice had remained normal.

Conclusion: The exact mechanism by which tracheal intubation may induce recurrent laryngeal nerve paralysis is not known, but this report should alert the clinician to the possibility of complications associated with general anaesthesia during laparoscopic surgery.

8219 Gynecology
Laparoscopic Myomectomy for Large Cervical Fibroids: Repair for the Lacerated Endocervical Mucosa
Tomonori Hada, MD, Masaaki Ando, MD

Objective: Laparoscopic management of cervical fibroids is challenging. We will address how to manage inadvertent laceration of the cervical mucosa during laparoscopic removal of a cervical fibroid. We want to present a repairing strategy for the damaged endocervical mucosa.

Methods: Two patients with large cervical fibroids who experienced laceration of endocervical mucosa are presented. Case 1: 38-year-old, nulliparous, woman with an anterior wall cervical fibroid measuring 95mm, and her cervix was elongated to 11cm. Case 2: 31-year-old, one gravida, woman with a posterior cervical fibroid (60mm) who suffers from secondary infertility. In both cases, the endocervical mucosa was injured during the procedure. The laceration was managed totally laparoscopically by suturing using 4-0 monofilament suture, so as not to cause stenosis to the endocervical canal.
Results: In both cases, there were no complications during or after the surgery, no blood transfusion was needed, and no obstruction or stenosis of the endocervical canal occurred. The Case 2 patient became pregnant, and one year after this procedure had a healthy 2808g baby by scheduled cesarean delivery without trouble.

Conclusion: In the case of cervical fibroids, if we injure the endocervical mucosa during the procedure, we have to approximate the tissue layers precisely to prevent stenosis, infertility, or uterine rupture during a pregnancy. These 2 cases show that with the appropriate repair techniques at hand, it is possible to preserve fertility even in cases of large fibroids.

8220 Multispecialty
Laparoscopic Ultra-radical Parametrectomy (Piver type 5)
Masaaki Andou, MD, Tomonori Hada, MD,

Objective: Super-radical resection has the possibility to rescue patients with advanced or recurrent gynecologic malignancies. Ultra-radical surgery with a wide surgical margin is required, so extensive defects must be compensated for with reconstructive techniques. Laparoscopy stops the delay in recovery and more seriously, the delay of postoperative therapy to expand the radicality for more complete resection while keeping the procedure less invasive.

Methods: We have experienced a number of cases, which have required extensive dissection and reconstruction, and one of those cases is presented. The case is a recurrent endometrial cancer patient who required a radical parametrectomy with partial resection of the bladder and ureter. En-bloc resection of the parametrium, upper vagina, and a part of the bladder along with the pelvic ureter is required to achieve complete removal of the vaginal and parametrial recurrence. Large defects of the urinary tract were compensated for by ileal interposition, using intracorporeal suturing for re-anastomosis. For segmental resection of the ileum, functional end-to-end anastomosis was required.

Results: These reconstructive techniques allowed for a wide surgical margin. No leak, stenosis, or infectious complications occurred postoperatively. Postoperative recovery was quick, and the patient underwent adjuvant chemotherapy 7 days after surgery. The patient is doing well after an observation period of 2 years with no evidence of disease.

Conclusion: Introducing reconstructive techniques makes it possible to reach a new stage in malignancy management by expanding the radicality for advanced and recurrent gynecologic malignancy without increasing the invasiveness.

8221 Urology
Laparoscopic Vascular Injury Repair
Masaaki Andou, MD, Tomonori Hada, MD    

Objective: Because we have to work close to major vessels in oncologic surgery, a risk of vascular injury is present. We have introduced an open vascular suturing technique into the laparoscopic environment creating a total endoscopic repair technique.

Methods: We only applied this vascular suturing technique to clinical cases after training using an animal model. Of 412 patients who underwent radical oncologic surgery including retroperitoneal dissection, 20 underwent intraoperative vascular repair with these techniques. Three of these patients will be presented. Patient 1 suffered an avulsion injury of the IVC during a retroperitoneoscopic para-aortic dissection. Patient 2 suffered deep pelvic bleeding due to the laceration of the posterior aspect of the external iliac vein during a laparoscopic pelvic lymphadenectomy. Patient 3 suffered the accidental partial severing of the external iliac artery by monopolar cautery during a pelvic lymphadenectomy. Vascular clamps and tape and sponge were applied for temporary bleeding control. After these preparations, each perforation was closed completely, totally endoscopically. Intracorporeal suturing proved successful both laparoscopically and retroperitoneoscopically.

Results: All 20 patients were successfully managed intraoperatively without conversion and were able to ambulate and take a regular diet 2 days after surgery. No patients suffered from vascular stenosis or postoperative bleeding or needed a blood transfusion.

Conclusion: For vascular surgery, a blood-free operative field is paramount to precise suture placement. Although technically demanding, mastering the techniques to control bleeding and performing precise suturing are vital.

8222 Multispecialty
Cesarean Delivery Increases the Risk for Development of Interstitial Cystitis but not Other Chronic Pelvic Pain Related Diagnoses
Bradford W. Fenton, MD, PhD, Cheryl Johnson, MD, Eric D. Lindstrom, Robert Flora, MD, James Fanning, DO

Objective: Chronic pelvic pain is a multifactorial disorder with poorly understood antecedents; however, any surgical disruption of the pelvis could reasonably be considered a risk factor. This study evaluates the relationship between the diagnoses found in chronic pelvic pain and a history of previous cesarean delivery (CD). This information could be used to guide patient evaluation or counseling.

Methods: The method of delivery for 245 sequential patients seen during a 2-year period at a chronic pelvic pain referral center was compared using a chi-square test of the primary pelvic pain generating a diagnosis for each patient. These included endometriosis, interstitial cystitis, myofascial pain syndrome, irritable bowel syndrome, pelvic floor tension myalgia, and vulvodynia.

Results: The CD rate in chronic pelvic pain patients was 22.5% compared with a 26% CD rate in routine health care patients in the same office (not significantly different). A history of CD was a significant risk for the development of interstitial cystitis (Relative Risk=1.57; Confidence Interval=1.05-2.36; P=0.036). Other diagnoses were not related to a history of previous CD.
Conclusion: Cesarean delivery does not increase the risk of chronic pelvic pain overall. However, a previous CD does increase the risk for the diagnosis of interstitial cystitis, which should be carefully considered in the evaluation of chronic pelvic pain patients with a history of CD. These results suggest that bladder trauma at the time of cesarean delivery may produce bladder-derived pain in predisposed individuals.

8223 General Surgery
The Evaluation of Endoscopic Therapy in Acute Biliary Pancreatitis
Peng Haifeng, MD, Yan Yukuang, MD, et al.

Objective: To evaluate the therapeutic effect of combined endoscope treatment in acute biliary pancreatitis.

Methods:  From October 2000 to March 2007, 20 cases (group E) of acute biliary pancreatitis were treated with endoscopic retrograde cholangiopancreatography (ERCP), or endoscopic sphincterotomy (EST). Endoscope naso-biliary drainage (ENBD) was performed in all cases. Sixteen patients (group C) underwent conservative treatment or surgical therapy.

Results: The success rate of endoscopic management was 95%. No severe complications or mortalities occurred in group E. The duration of symptoms and hospitalization in the endoscopic group was significantly shorter than that in the control group (P<0.01). The change in serum and urine amylase was not significant between the 2 groups on day 1 after treatment (P<0.05). However, amylase activities in serum and urine in the endoscopic group declined with time, and in the control group on day 2 (P<0.05) and was significantly lower on day 3 after treatment (P<0.01).

Conclusion: Endoscopy treatment can be directed to the pathogen of acute biliary pancreatitis, and it is the best method to relive obstruction of the opening of the cholecystopancreatic duct, clear drainage of cholecystopancreatic juice, and decrease the pressure of the intracholecystopancreatic duct. It is safe, minimally invasive, highly effective, and is a valuable method for treating acute biliary pancreatitis.

8224 Gynecology
The Presence of Endometriosis Increases the Risk for Myofascial Pain and Pelvic Floor Tension Myalgia in Patients with Chronic Pelvic Pain
Bradford W. Fenton, MD, PhD, Thida Nunthirapakorn, MD, Robert Flora, MD, James Fanning, DO

Objective: The occurrence of lower abdominal wall myofascial pain syndrome (MFPS) as a component of chronic pelvic pain is known, but any association between MFPS and endometriosis, as with the association of endometriosis and interstitial cystitis (IC) has not been investigated. If such an association exists, it could alert clinicians to investigate and treat MFPS when evaluating a patient with known endometriosis.

Methods: Over the course of 2 years, 274 consecutive patients seen in a chronic pelvic pain referral center underwent a standardized evaluation to determine their pain generating diagnoses. The presence of endometriosis, as proven by laparoscopy, was then compared using a chi-square test for the presence of MFPS as a primary diagnosis. Chi-squared testing was also used to compare proven endometriosis to pelvic floor tension myalgia (PFTM) and IC.

Results: Endometriosis was present in 36%, and was a significant risk for both MFPS [Relative Risk (RR)=1.82; Confidence interval (CI)=1.29 to 2.59, P<0.001] and PFTM (RR=6.96; CI=2.94 to 16.45, P<0.001). As confirmation of sample validity, endometriosis was also a significant risk for IC (RR=3.5; CI=2.28 to 5.56; P<0.001).

Conclusion: Chronic pelvic pain represents a poorly defined clinical entity that is becoming understood to include pain generation from many sites in the pelvis, rather than being caused by endometriosis alone. Although endometriosis may be present, in many cases muscle-based pain from the abdominal wall and pelvic floor must also be evaluated and treated to provide the patient with an optimal possibility of improvement.

8225 General Surgery
Recurrent Incarcerated Suprapubic Incisional Hernia: Laparoscopic Management
Luis Salgado, MD, Morris Franklin, MD, Jose A. Diaz, MD, Oscar Villegas, MD, Rodrigo Merino, MD

Objective: To present the video of a recurrent incarcerated suprapubic incisional hernia repaired by laparoscopy and to describe the technical aspects of the repair.

Methods: The patient is a 39-year-old female with a past medical history of a desmoid tumor excision in a cesarean delivery incision. She developed an incisional hernia that was repaired with a primary closure and had 2 subsequent recurrences repaired with a tension-free technique, the last repair being 2 days prior to this admission. The patient was admitted through the emergency department with an incarcerated incisional hernia. During the surgical procedure, a diagnostic laparoscopy was performed and an extensive lysis of adhesions, reduction of incarcerated bowel, mesh removal, and an intraperitoneal onlay mesh repair was done.

Results: The patient recovered uneventfully and was discharged on postoperative day 4.
Conclusions: The laparoscopic approach for recurrent incarcerated hernias is a challenging procedure but has excellent postoperative results.

8226 Urology
Laparoscopic Ureteroureterostomy for a Retrocaval Ureter
Hak J. Lee, MD, Aldrin Joseph R. Gamboa, MD, Eric R. Sargent, MD,Elspeth M. McDougall, MD   

Introduction: Embryologically, the retrocaval ureter is the result of persistence of the preureteral vena cava. This vascular anomaly arises from failure of the subcardinal veins to atrophy in their entirety during development. The lumbar component of the subcardinal vein persists as the infrarenal vena cava, crossing anterior to the middle segment of the ureter, and thereby, when it persists, may cause obstruction.

Methods: In this videotape, we present a 24-year-old female with obstruction due to a retrocaval ureter. The epidemiology and embryology of the retrocaval ureter are discussed, followed by a description of the radiographic evaluation of the condition before and after laparoscopic excision of the stenotic area and primary ureteroureterostomy.

Results: The preoperative diuretic renogram confirmed obstruction, and the retrograde pyelogram demonstrated the retrocaval area of the ureter. Laparoscopic ureteroureterostomy entailed mobilization of the ureter above and below the area obstructed by the crossing of the vena cava. The ureter was transected just proximal to the level of obstruction. The retrocaval segment was brought anterior and lateral to the inferior vena cava, and the ureteral stenosis was excised. Continuity of the ureter was re-established by a primary ureteroureterostomy after spatulation of both the proximal and distal surfaces of the ureter, and a 7F stent was placed. The patient’s postoperative course was unremarkable. A diuretic renogram performed 6 weeks later was normal.

Conclusions: Retrocaval ureter is a vascular anomaly that may result in ureteral obstruction. Laparoscopic excision of the retrocaval segment and ureteroureterostomy appears to be a feasible treatment for this condition.

8227 Multispecialty
Hip Arthroscopy for Femoroacetabular Impingement in the Athlete
Dean Matsuda, MD

    Arguably the hottest topic in orthopedic sports medicine surrounds the diagnosis and management of athletes afflicted with femoroacetabular impingement. Until recently, athletic young patients had very limited options (eg, give up sports, wait for eventual total hip replacement). Because of skeletal abnormalities that can occur on both sides of the hip joint, an abutment conflict occurs during flexion and abduction that can lead to labral/chondral damage with resultant pain, mechanical symptoms, and disability. Femoroacetabular impingement is currently thought to be a major cause of "idiopathic" osteoarthritis in young, active individuals. The typical pathway to diagnosis involves a history of groin pain with a positive anterior impingement test (I'll show the exam as taught to me by Dr. Ganz) and radiographs that reveal skeletal deformities, such as a retroverted acetabulum (seen as having a positive cross-over sign) and/or a loss of normal femoral offset (often seen as a cam lesion). Most patients have a combined pincer-cam impingement pattern with acetabular and femoral head-neck junctional pathology. The use of MRI and the current controversy over gadolinium benefits will be discussed. The open formal hip dislocation procedure with acetabular rim trimming, labral refixation (in contrast to repair), and femoral head-neck resection osteoplasty will be shown, followed by the arthroscopic equivalent using professional animations as well as actual edited video segments. Because it is technically challenging, very few surgeons are performing comprehensive arthroscopic management of hip impingement. I will show how I perform this surgery using 2 arthroscopic portals (not the usual 3 to 4) and also show dynamic arthroscopic visualization video of before and after surgery. I will present the early outcome data from this new technology, discuss complications (including a very interesting case that I've presented at the Arthroscopy Association of North America Hip Masters Experience Courses), and end with actual video clips of my own bilateral hip impingement surgeries and the pearls that I've learned along the way.

8228 Urology
Towards a VR Trainer for Laparoscopic Nephrectomy: A Unique Collaboration Between the American Urological Association, Academia, and Industry
Robert M. Sweet, MD, Kishore Ta, MD, David Hananel, Elspeth McDougall, MD

Background: Surgical simulation is finally coming of age. The focus has shifted from a demonstration of technology to a robust educational tool. Combining state-of-the art technologies with proper educational design begs for industry/society/academia collaboration. Until now, that type of collaboration has been elusive. The project we describe, the development of the Laparoscopic Transperitoneal Nephrectomy (LTN)
Learning Module is a major milestone on that path. It began with a defined need within the American Urologic Association (AUA) to train and assess residents as well as practicing urologists in the performance of LTN.

Methods: The team assembled to deliver the final Learning Module represents a professional society (the AUA), the University of Minnesota as the academic partner responsible for building the models, and METI as the industry partner and integrator. The AUA has established the learning objectives, is developing the corresponding metrics, and is creating the didactic content required and will do the validation studies on the final module. The University of Minnesota is using novel advanced modeling techniques to deliver models that look and behave like real tissue with required tissue properties. METI has the responsibility to develop the architecture, provide all simulated scenarios, integrate all aspects of the curriculum into the Learning Module, and bring the product to market.

Results: This collaboration is successfully delivering a VR simulator founded on user-directed educational design, state-of-the-art tissue appearance and behavior, and a strong pathway towards successful commercialization.

8229 General Surgery
Gallstone: A Stone Too Precious To Be Lost
Dr. Tushar Samdani, MS, DNB, Dr. Sophie Helme, MB, ChB, MRCS, Dr. Prakash Sinha, MD, FRCS

Objective: Our case report aims to highlight a fact that if spilled gallstones are not tackled adequately during laparoscopic cholecystectomy, then the subsequent morbidity causes enormous mental trauma to the patient, and they can even refuse further appropriate treatment. Through a literature review, we also aim to discuss various aspects of lost gallstones, such as incidence, causes, presentation, and its ideal management.

Methods: We present the case report of a 77-year-old woman with loin abscess due to a lost gallstone 5 years after laparoscopic cholecystectomy. Intrigued by this case, we performed an extensive literature search of PubMed and Ovid to review papers published on lost gallstones following laparoscopic cholecystectomy.

Results: Delay in diagnosis, a series of errors, and multiple interventions stressed our patient to such an extent that she has refused any further surgical intervention and now has a chronic discharging fistula. Studies have reported the incidence of spilled gallstones during laparoscopic cholecystectomy to be 6% to 40%, and 13% to 32% of these can be “lost.” Many causes of spilled gallstones, varied presentation of lost gallstones, and precautionary measures have been documented in the literature.

Conclusion: Lost gallstones may lead to early or late complications that can prove a diagnostic challenge and cause significant morbidity to the patient. Clear documentation and patient awareness of lost gallstones is of utmost importance because this may enable prompt recognition and intervention of any complications. Although this complication is not common enough to question the efficacy of this novel procedure, it cautions budding surgeons “to be meticulous.”

8230 Gynecology
Fertiloscopic Ovarian Drilling: A Review of 160 Cases
Antoine A. Watrelot, Pr, MD

    If a consensus exists on the first-line treatment for infertility in patients with polycystic ovarian syndrome (PCOS), it is mainly based on diet and clomiphene citrate. In cases of failure, some debate still exists. The medical option using gonadotrophins is often associated with Metformin, and the surgical option is namely ovarian drilling. The medical option is effective to treat infertility but exposes patients to the risks of hyperstimulation syndrome (OHSS). Surgical ovarian drilling is also effective and without the risk of OHSS. Nevertheless, ovarian drilling is rather invasive and exposes patients to the risks of postoperative pelvic adhesions. To be more acceptable, it was important to find a minimally invasive approach. Since our description of fertiloscopy in 1998, Fernandez has proposed drilling the ovaries through fertiloscopy. Results have proven to be as effective as those obtained by laparoscopic drilling, but with some significant advantages, such as mini-invasiveness, safety, and reduced risks of postoperative adhesions. We report a series of 128 fertiloscopic ovarian drillings in patients with a cumulative pregnancy rate of 55% after 6 months. Technique, success, and predictive factors are discussed.

8232 Urology
Efficiency of Lithium Triborate Laser Photoselective Vaporization Prostatectomy (PVP): Kinetic Performance Study
Carson Wong, Massimiliano Spaliviero, Jay B. Page, Motoo Araki

Introduction: Lithium triborate (LBO) laser photoselective vaporization prostatectomy (PVP) is a relatively new technology for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia. Its efficiency for prostate enucleation is unknown.

Methods: We prospectively evaluated our initial single-surgeon experience with LBO laser PVP. All patients had an American Urological Association Symptom Score (AUASS), maximum flow rate (Qmax), and postvoid residual (PVR) determinations. Transurethral PVP was performed using the LBO side-firing laser system. Prostate volume was measured by transrectal ultrasonography (TRUS) before and 12 weeks after surgery. The efficiency of LBO laser PVP was calculated by TRUS volume change divided by laser time or energy usage.

Results: The study included 115 consecutive patients having a mean age of 68±9 years. Prostate size was reduced by 54±14% from 75±44 to 38±29cc 12 weeks after surgery. Mean laser time and energy use were 13±8 minutes and 84±54kJ, respectively. The mean estimated rate of prostate vaporization was 3.5±2.0cc/min and 0.57±0.50cc/kJ. This efficiency was consistent among glands measuring <75cm3 and >75cm3. Mean AUASS decreased from 22 to 9, 7, 6, 5, and 4 (P<0.05) while mean Qmax increased from 10 to 20, 21, 21, 20, and 22cc/sec (P<0.05) at 1, 4, 12, 24, and 52 weeks, respectively.
Conclusions: Our data suggest that LBO laser PVP can efficiently and effectively vaporize human prostate tissue at approximately 3cc to 4cc/min.

8233 Other
Laparoscopic Incisional Hernia Repair in Liver Transplant Patients: Single-Center Experience
Manuel I. Rodriguez-Davalos, MD, Manoj K. Singh, MD, Juan P. Rocca, MD,
Caroline Rochon, MD, Marcelo E. Facciuto, MD, Patricia A. Sheiner, MD

Introduction: The laparoscopic approach is being increasingly used for repair of incisional hernias due to lower morbidity and recurrence rates. There are few reports of this approach being used for liver transplant patients who have a high incidence of incisional hernia and represent a high-risk group. We present a case series of laparoscopic incisional hernia repairs in liver transplant patients.

Method: A retrospective review of all liver transplant patients undergoing laparoscopic incisional hernia repair from January 2007 to January 2008 was performed.

Results: During the study period, 13 laparoscopic incisional hernia repairs were attempted and successfully performed. The median patient age was 55 years (range, 45 to 69) with 10 males and 3 females. The hernia defect size varied from 7.5cm2 to 176cm2, number of defects ranged from 1 to 3. Polyester composite mesh was used in 11 cases and PTFE in 2; the sizes ranged from 28cm2 to 630cm2. Mean operative duration was 167 minutes (range, 90 to 230), and blood loss was 58mL (range, 10 to 200). Median length of stay was 2 days (range, 0 to 18), and 3 postoperative complications occurred. Median follow-up was 8 months with a range of 1 month to 13 months. No recurrences were noted at follow-up.

Conclusion: Our case series indicates that laparoscopic repair of incisional hernia in liver transplant patients is a viable alternative. This complex group of patients can benefit from this intervention without any increased risk of wound infection or recurrence compared with open repair.

8234 Urology
Catheter-Free Lithium Triborate (LBO) Laser Photoselective Vaporization Prostatectomy (PVP)
Massimiliano Spaliviero, Jay B. Page, Motoo Araki, Carson Wong

Introduction and Objective: We evaluated the safety and efficacy of catheter-free LBO laser PVP for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

Methods: We prospectively evaluated our initial LBO laser PVP experience and the need for urethral catheterization.

Results: The study comprised 115 consecutive patients. Sixty-two (54%) were discharged without (C-) and 53 (46%) were discharged with (C+) a catheter. No significant differences existed in preoperative parameters, including age (C-: 66±10 vs. C+: 71±8 years), AUASS (C-: 22±6 vs. C+: 2 ±6), Qmax (C-: 10±4 vs. C+: 9±4cc/sec) PVR (C-: 57±95 vs. C+: 66±81cc), and prostate volume (C-: 71±38 vs. C+: 81±49cm3). No significant differences existed in laser utilization and energy usage. AUASS, Qmax, and PVR values showed significant improvement within each group (P<0.05), but no significant differences existed between the 2 groups. All were outpatient procedures. In C-, 1/62 (1.6%) patient required catheter reinsertion. The overall incidence of adverse events was low and did not differ between the 2 groups.

Conclusions: Our experience suggests that catheter-free LBO laser PVP is safe and effective for the treatment of LUTS secondary to BPH.

8235 General Surgery
Transgastric Endoscopic Bloodless Liver Resection Using Radiofrequency Thermal Energy: An Experimental Study
Konstantinos Tsalis, MD, Emmanuil Christoforidis, MD, Petros Ypsilandis, VM, Konstantinos Blouhos, MD, Konstantinos Vasiliadis, MD, Stavros Kalfadis, MD, Kristalia Moshota, N, Charalampos Lazaridis, MD

Objective: To assess the feasibility and safety of transgastric endoscopic-assisted hepatectomy using percutaneous radiofrequency thermal energy (PRF) in a porcine model.
Methods: Fourteen domestic white male pigs with a mean weight of 17.6kg were used. With the pigs under general anesthesia, a standard upper double-lumen endoscope was advanced perorally into the stomach. A needle-knife was used to make an incision into the anterior wall of the stomach, followed by introduction of a guidewire into the peritoneal cavity. An 18-mm over the wire balloon was used to distend the hole, and the endoscope was pushed into the peritoneal cavity. Pneumoperitoneum was created using the channel of the endoscope. Two 1-cm transverse abdominal incisions were made for the introduction of atraumatic graspers to hold the liver. With the porta hepatis not clamped, the preferred lobe each time was divided using PRF. The resected liver was inserted in a plastic bag and pulled out with the endoscope through the esophagus. Finally, the gastrotomy was closed using 3 to 4 clips. All animals were killed after 1 week.

Results: The procedures performed were 2 wedge resections, 2 left lateral lobectomies, 2 right lateral lobectomies, 2 left medial lobectomies, 2 right medial lobectomies, 2 left hepatectomies, and 2 right hepatectomies. The mean time of the procedures was 135 minutes, and the mean mass of the resected specimen was 90g. No postoperative complications or deaths occurred.

Conclusion: Transgastric endoscopic-assisted hepatectomy using percutaneous radiofrequency is technically feasible and safe in the porcine model.

8236 Multispecialty
Minimally Invasive Surgery Group: Cutting Edge Goes a Cut Above
Dean Matsuda, MD, Kirk Tamaddon, MD, Seth Kivnik, MD, Ashish Parekh, MD,
Adil Farooqui, MD, Apurba Pathak, MD, Benjamin Kim, MD, Charles Plehn, MD,
David Tse, MD, Dong-Joon Lee, MD, Nippon Vadehra, MD, Robert Casillas, MD

    The merits of minimally invasive surgery from multiple and diverse surgical fields has driven the development of the Minimally Invasive Surgery Center at the West Los Angeles campus of Kaiser Permanente. A unique collection of endoscopic and laparoscopic surgeons at one site provides many opportunities that go beyond any marketing hype. With surgeons offering everything from advanced arthroscopic hip surgery to laparoscopic hysterectomy to laparoscopic prostatectomy, the latest technological advances and innovative techniques are harnessed for significant patient benefit. Some of our early outcome data will be presented in light of decreased hospital stays (and many outpatient procedures), minimal blood loss, quicker rehabilitation/recovery, reduced complications (with procedure-specific variation), improved cosmesis, and patient satisfaction. The development process and planning of a comprehensive, multispecialty minimally invasive surgery center will be discussed and the feasibility of this process will be demonstrated. Moreover, the benefits of surgeon cross-education with creative innovation, multidisciplinary camaraderie, improved patient education, and group purchasing power with resultant cost savings will be discussed.

8237 Urology
Does Age Affect the Safety and Efficacy of Lithium Triborate (LBO) Laser Photoselective Vaporization Prostatectomy (PVP)?
Jay Page, Massimiliano Spaliviero, Motoo Araki, Carson Wong

Objective: We evaluated the safety and efficacy of LBO laser PVP for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) in patients of varying age groups.

Methods: We prospectively evaluated our initial LBO laser PVP experience. Patients were stratified into 2 groups: age <70 (group I) and age ≥70 (group II).

Results: The study included 115 consecutive patients (58 group I, 57 group II). Elderly patients (group II) had larger prostate volumes (67cm3 vs. 84cm3, P<0.05). Despite this, comparable laser time (13 vs. 13 minutes, P=NS) and energy utilization (87kJ vs. 81kJ, P=NS) were recorded. American Urological Association Symptom Score (AUASS), maximum flow rate (Qmax), and post void residual (PVR) values showed significant improvement within each group (P<0.05), but were similar between the 2 groups after surgery (P=NS). The incidence of retrograde ejaculation was similar between the 2 groups (29 vs. 19%, P=NS). The incidence of other adverse events was not statistically significant.
Conclusions: Our experience suggests that age has little effect on the safety and efficacy of LBO laser PVP.

8238 Urology
Lithium Triborate (LBO) Laser Photoselective Vaporization Prostatectomy (PVP) for Large-Volume Benign Prostatic Hyperplasia (BPH)
Jay B. Page, Massimiliano Spaliviero, Motoo Araki, Carson Wong 

Objectives: Due to the morbidity associated with transurethral resection of BPH greater than 75cm3, open prostatectomy is recommended. We evaluated the efficacy of LBO laser PVP for treating large-volume BPH.

Methods: We prospectively evaluated our initial LBO laser PVP experience. Only patients who failed either medical or surgical therapy for symptomatic BPH with prostate volumes >75cm3 were included. Transurethral PVP was performed using an LBO side-firing laser system.

Results: Forty-three of 115 consecutive patients were identified, having a mean prostate volume of 120±41cm3. Mean laser time and energy usage were 19±10 minutes and 124±65kJ, respectively. Perioperative serum sodium and hemoglobin did not change significantly. Two patients developed a urinary tract infection. Three patients had persistent hematuria for over one week. One patient developed a bladder neck contracture that required intervention. Two patients had persistent urinary retention requiring clean intermittent catheterization. No urethral strictures or urinary incontinence were noted. All patients were able to discontinue their prostate medications following surgery. Mean American Urological Association Symptom Score decreased significantly from 21 to 9, 7, 5, 4, and 4 (P<0.001) at 1, 4, 12, 24, and 52 weeks, respectively. Mean maximum flow rate and post void residual values also showed significant improvement (P<0.001).

Conclusions: Our initial results demonstrate that LBO laser PVP is safe and effective for the treatment of symptomatic large-volume BPH, obviating open surgery. Continued follow-up is in progress.

8239 Urology
Decreased Efficiency of Lithium Triborate (LBO) Laser Photoselective Vaporization Prostatectomy (PVP) with Long-Term 5α–Reductase Inhibition Therapy: Is It True?
Carson Wong, Massimiliano Spaliviero, Jay B. Page, Motoo Araki

Introduction: 5α-reductase inhibitors reduce angiogenesis in benign prostatic tissue. This has been postulated to affect the efficiency of the LBO laser during PVP, which has hemoglobin as its primary chromophore. We evaluated LBO laser PVP as treatment for benign prostatic hyperplasia (BPH) in patients on long-term 5α-reductase inhibitors.

Methods: We prospectively evaluated our initial LBO laser PVP experience in patients with or without long-term 5α-reductase inhibition.

Results: We identified 115 consecutive patients; 38 were on either finasteride or dutasteride for more than 6 months and 77 were not. Mean prostate volumes were 72±36cm3 and 76±47cm3 (P=0.56), respectively. Mean PSA values were 2.1±2.2 and 2.8±2.7 (P=0.15), respectively. No significant differences existed in the parameters of laser utilization (14±8 and 13±8 minutes, P=0.45) and energy usage (85±56kJ and 84±54kJ, P=0.97). AUASS, Qmax, and PVR values showed significant improvement within each group (P<0.05), but the degree of improvement between the 2 groups was not statistically significant.

Conclusion: Our experience suggests that 5α-reductase inhibitors do not have a detrimental effect on the efficiency and efficacy of LBO laser PVP.

8240 Urology
Does Lithium Triborate (LBO) Laser Photoselective Vaporization Prostatectomy (PVP) Affect Sexual Function?
Massimiliano Spaliviero, Jay B. Page, Motoo Araki, Carson Wong

Objective: We evaluated the impact of LBO laser PVP on sexual function following the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

Methods: We prospectively evaluated our initial single-surgeon experience with LBO laser PVP. Transurethral PVP was performed using an LBO side-firing laser system. American Urological Association Symptom Score (AUASS) and Sexual Health Inventory for Men (SHIM) score were evaluated preoperatively and at 1, 4, 12, 24, and 52 weeks after surgery.

Results: We identified 115 consecutive patients, having a mean age of 68±9 years. The mean prostate volume was 75±44cc. Mean AUASS decreased significantly from 22 to 9, 7, 6, 5, and 4 (P<0.05) at 1, 4, 12, 24, and 52 weeks, respectively. The mean SHIM score changed from 14 to 14, 15, 16, 15, and 14 (P=NS) at 1, 4, 12, 24, and 52 weeks, respectively. Minimum change occurred in SHIM score in 80%, 89%, 80%, 75%, and 70% of patients (0±5); 9%, 3%, 7%, 4%, and 9% of patients had deterioration of erectile function (SHIM score reduction >5); and 11%, 8%, 13%, 21%, and 21% of patients had improvement of erectile function (SHIM score increase >5) during the follow-up period. The incidence of retrograde ejaculation was 28/70 (40%).

Conclusions: Our initial results suggest that sexual function is not compromised following LBO laser PVP.

8241 Urology
120 W Lithium Triborate (LBO) Laser Photoselective Vaporization Prostatectomy (PVP) For Symptomatic Benign Prostatic Hyperplasia (BPH)
Carson Wong, Massimiliano Spaliviero, Jay B. Page, Motoo Araki

Objectives: We review our initial 120 W LBO laser system experience for the treatment of lower urinary tract symptoms (LUTS) secondary to BPH

Methods: We prospectively evaluated our initial experience with 120 W LBO laser PVP.

Results: We identified 115 consecutive patients, having a mean age of 68 (range, 45 to 89) years. The mean prostate volume was 75cm3 (range, 21 to 263). Mean laser time and energy usage were 13 minutes (range, 2 to 47) and 84kJ (range, 11 to 236), respectively. All were outpatient procedures. Ten patients required catheter drainage for one week. Seven patients had persistent urinary retention requiring clean intermittent catheterization. One patient developed a bladder neck contracture requiring intervention. No urethral stricture and urinary incontinence were noted. All patients were able to discontinue their prostate medications following surgery. American Urological Association Symptom Score (AUASS) decreased significantly from 22 to 9, 7, 6, 5, and 4 (P<0.05) at 1, 4, 12, 24, and 52 weeks, respectively. Maximum flow rate increase and prostate size reduction showed statistically significant improvement 3 months postsurgery. The Sexual Health Inventory for Men score was unchanged.

Conclusion: Our initial results demonstrate that 120 W LBO laser PVP is safe and effective for the treatment of LUTS secondary to BPH.

8242 General Surgery
Laparoscopic Lumber Hernia Repair
Keyur Chavda, MD, Sidharth Bhende, MD, Ali Ghellai, MD

    Lumbar hernias are rare defects in the posterolateral abdominal wall that may be congenital. They can occur anywhere between the 12th rib and iliac crest. Many surgical techniques for repair of lumbar hernias have been described including primary repair, local tissue flaps, and conventional open mesh repair. Despite the various available methods, no repair has been adopted as the most favorable surgical approach. The reasons for this include the difficulty in defining the fascial edges of the defect and weakness of surrounding tissue. Furthermore, the boundaries of lumbar hernias inevitably include a bony structure further contributing to the difficulty of the repair. Laparoscopic lumbar hernia repair using a prosthetic mesh has become simple and logical by adopting maneuvers from the laparoscopic ventral hernia repair and modifying the technique to accommodate the anatomy of the lumbar hernia. Laparoscopy has afforded several advantages including reduced postoperative pain, decreased hospital stay, and better cosmesis while accomplishing a complete reconstruction of the area. We present a patient who underwent successful laparoscopic lumbar hernia repair with prosthetic mesh at a rural-based community hospital. The patient had an uneventful postoperative course and was discharged on postoperative day 2. Three-month follow-up reveals the patient to be asymptomatic without any recurrence.

8243 Gynecology
Different Approaches to Identifying the Obturator Nerve during Laparoscopic Pelvic Lymphadenectomy
Connie Liu, MD, Farr Nezhat, MD

Objective: To describe 3 anatomic approaches to identify the obturator nerve during laparoscopic pelvic lymphadenectomy

Methods: Three approaches to identifying the obturator nerve during laparoscopic pelvic lymphadenectomy performed by a single experienced laparoscopic gynecologic oncologist are displayed.

Results: The three approaches illustrated include a medial, lateral, and posterior approach.

Conclusion: When performing laparoscopic pelvic lymphadenectomy, it is essential to know the anatomy, perform a careful dissection, and to be aware of potentially aberrant anatomy. In cases where obturator nerve identification is challenging, these alternate surgical approaches may be implemented to facilitate safe laparoscopic pelvic lymphadenectomy.

8244 Urology
Randomized Prospective Evaluation of the Effect of Patient Positioning on Surgical Outcomes During Laparoscopic Renal and Adrenal Surgery
Chandru P. Sundaram, MD, Amanjot S. Sethi, MD, Carl Gjertson, MD,
Christopher J. Therasse, BS

Objective: Although flexion of the operative table during laparoscopic nephrectomy and adrenalectomy has become standard practice, the effects of such positioning on operative time, ease of exposure, postoperative pain, and complications has not been previously defined. We report a prospective comparison of operative table positioning (ie, flexion or no flexion) and its effect on outcomes in laparoscopic renal and adrenal surgery.

Methods: Twenty-five consecutive patients undergoing laparoscopic nephrectomy or adrenalectomy by a single surgeon (CPS) were randomized to surgery with (FL) or without (NF) a 45-degree flexion of the operative table. A single surgeon (CPS) performed all operations with a transperitoneal pure laparoscopic or hand-assisted approach. Operative parameters, such as ease of bowel mobilization (BM), ease of renal hilar dissection (HD), and overall difficulty of dissection (DD) were recorded on a 10-point Likert scale. Operative time (OT), estimated blood loss (EBL), postoperative pain, and perioperative complications were also recorded prospectively.

Results: There were 12 and 13 patients in the FL and NF groups, respectively. No statistically significant differences occurred in BM, HD, DD, OT, EBL, or postoperative pain. The one complication in the NF group was a minor serosal injury during mobilization of the colon. This was repaired laparoscopically without further sequelae. No complications occurred in the FL group.

Conclusions: Our prospective comparison suggests that there is no benefit to table flexion during laparoscopic renal and adrenal surgery. Surgical exposure, dissection, and outcomes do not appear to be affected by patient positioning in this series.

8245 Gynecology
Robotic-Assisted Laparoscopic Total Pelvic Exenteration
Farr Nezhat, MD, George Hagopian, MD, Dusan Peresic, MD, William Bradley, MD, Connie Liu, MD

Objective: To present a video demonstration of robotic-assisted laparoscopic total pelvic exenteration.
Methods: A 56-year-old with a history of stage IIA cervical cancer status post chemotherapy and radiation presented with a central recurrence.

Results:  Robotic-assisted laparoscopic total pelvic exenteration was performed with paraaortic and pelvic lymphadenectomy, rectosigmoid colon reanastamosis, diverting ileostomy, and Miami pouch reconstruction.

Conclusion: Robotic-assisted laparoscopic total pelvic exenteration is a feasible surgical approach to treat central recurrent cervical cancer.

8246 Gynecology
Robotic-Assisted Ovarian Transposition and Pretreatment Surgical Staging in Cervical Cancer
Farr Nezhat, MD, Connie Liu, MD, George Hagopian, MD, Dimitry Lerner, MD

Objective: To demonstrate the utility of robotic-assisted procedures in ovarian transposition in a case of cervical cancer for pretreatment surgical staging.

Methods: A 28-year-old patient with stage IIA squamous cell carcinoma was counseled to undergo ovarian transposition and paraaortic and pelvic lymph node sampling prior to initiation of chemotherapy and radiation therapy.

Results: Robotic-assisted ovarian transposition and paraaortic and pelvic lymph node sampling was performed without intraoperative or postoperative complications.
Conclusion: The benefits of robotic-assisted procedures are well demonstrated in this procedure.

8247 Gynecology
Consistent Outcomes of Laparoscopic Intraperitoneal Paraaortic Lymphadenectomy Support Incorporation into Fellowship Training Program Curricula
Farr Nezhat, MD, Shaghayegh Moghaddam, MD, M. Shoma Datta, MD, Gazi Yildirim, MD, Jyoti Yadav, MD, Connie Liu, MD, Konstantin Zakashansky, MD

Objective: To compare laparoscopic intraperitoneal paraaortic lymphadenectomy performed during 2 consecutive time periods in a fellowship training program under the supervision of a single attending surgeon.

Methods: All cases of laparoscopic paraaortic lymphadenectomies from April 2000 to September 2007 were retrospectively analyzed and divided into 2 equal, chronologically consecutive groups. Group 1 comprised patients from April 2000 to September 2003, and group 2 from October 2003 to September 2007. Nodal yield, length of hospitalization, and complications were assessed.

Results: During the study period, 90 laparoscopic paraaortic lymphadenectomies were performed by a single gynecologic oncologist and a fellow. Seventy-two patients underwent complete paraaortic dissections, 13 samplings, and 5 biopsies. Forty-seven patients had concurrent bilateral pelvic lymphadenectomy. The groups were comparable in patient characteristics, extent of node dissection, and length of hospitalization (2.8 versus 2.9 days). There was no difference in nodal yield (16.5±1.2 in group 1 versus 13.5±1.1 nodes in group 2, ranges, 7 to 32 and 4 to 30, respectively). No conversions to laparotomy were needed. Overall complication rates were similar. Each group had 2 transfusions, 2 fevers, and 1 cystotomy. Group 1 also had 1 vascular injury, 1 SBO, 1 vulvar lymphedema, and 1 port-site metastasis. Group 2 had 2 lymphoceles, 1 lymphocele cyst, 1 pulmonary embolism, 1 MI, 1 DVT, 1 sigmoid perforation, 1 bilateral leg edema, and 1 port-site hernia.

Conclusion: In our program, time did not impact nodal yield or complications as long as the procedure was performed by an experienced laparoscopic gynecologic oncologist following anatomical guidelines suggested for performing paraaortic lymphadenectomy, supporting incorporation into a gynecologic oncology fellowship program.

8248 Gynecoloy
Outcomes of Retroperitoneal Uterine Artery Ligation during Laparoscopic Hysterectomy: A Retrospective Review of 419 Cases
Ruchi Puri, MD, Rony Abdallah, MD, Michael Sheridan, ScD, Sabine Khoury,Paul Mackoul, MD

Objective: Review of clinical outcomes using retroperitoneal dissection to identify the ureter and ligate the uterine artery when performing laparoscopic hysterectomy.

Methods: This is a retrospective chart review of 419 consecutive patients with preoperative benign disease undergoing laparoscopic hysterectomy between January 2004 and May 2007 by 5 surgeons performing the same technique in a single teaching institution with a resident assistant.

Results: In this retrospective cohort, the mean and 95% Confidence Intervals (CI) for age was 46.4 years (range, 45.6 to 47.2), body mass index (BMI) was 30.1 kg/m2 (range, 29.3 to 30.8), and uterine weight was 437.0g (range, 391.4 to 482.7). Among patients, 62.7% had prior abdominal surgery, and 32% had adhesions. Surgical outcomes included a mean (95% CI) estimated blood loss (EBL) of 204.8mL (range, 183.6 to 226.0), operating room (OR) time including secondary procedures of 92.9 minutes (range, 88.6 to 95.2), and conversion to laparotomy of 0.48% (2 patients). The rate of urinary tract injury was 1.92% (7 cystotomy, 1 fistula), bowel injury was 2.40% (9 serotomy, 1 perforation), and mean hospital stay was 0.88 days (range, 0.81 to 0.94). In separate multivariate models, OR time was slightly increased by uterine weight (P<0.0001) and adhesions (P=0.004), while EBL was increased by uterine weight (P<0.0001). Neither age nor BMI had a significant effect in any adjusted models.

Conclusions: Retroperitoneal dissection is a safe, efficient approach to laparoscopic hysterectomy despite patient age, BMI, or uterine weight. It has a low urinary tract and bowel injury rate, while protecting against ureteral injury and permitting hospital stay of <1day.

8249 Urology
Robotic Pelvic Lymph Node Dissection in Patients Undergoing Radical Cystectomy for Bladder Cancer
Aldrin Joseph R. Gamboa MD, Jennifer L. Young MD, Geoffrey N. Box MD,Atreya Dash MD, Jose Benito A. Abraham MD, Leslie A. Deane MD, Hak J. Lee MD, Ricardo J.S. Santos MD, David K. Ornstein MD

Introduction: Pelvic lymph node dissection (PLND) during radical cystectomy for bladder cancer is critical for accurate staging and may improve oncologic outcomes. Minimally invasive approaches were criticized for limiting extent of PLND. Performances of PLND with robot-assisted laparoscopic radical cystectomy (RARC) were reviewed.

Methods: Data were collected prospectively from 31 patients who underwent RARC with standard PLND. Exclusion criteria were inability to tolerate pneumoperitoneum and subsequent open conversion (n=1), patient factors (n=4), and gross tumor extension (n=3). Entire extirpative procedure was performed using the da Vinci robot (Intuitive Surgical, Sunnyvale, CA). Standard PLND was performed initially, and recently, dissection extended proximally to aortic bifurcation. Port placement was modified by placing ports 2cm to 3cm cephalad from standard placement to facilitate proximal PLND.

Results: There were 22 men and 9 women. Median age was 72 years old (range, 55 to 85). Seventeen ileal conduit and 14 orthotopic neobladders were performed as urinary diversion. Median length of hospital stay was 7 days (range, 5 to 37). Median estimated blood loss was 200mL (range, 50 to 700). Median total operative time was 480 minutes (range, 320 to 805). Median robotic console time was 275 minutes (range, 200 to 311). Median total number of lymph nodes retrieved was 23 (range, 6 to 68). Nodal metastases were 9.6% (3/31). Positive surgical margin rate was 3% (1/31). Intraoperative complications were 2 partial obturator nerve transections, repaired with interrupted sutures and recovered without clinical sequelae. Complications related to lymphadenectomy were 3: clinically significant lymphocele (1) and deep vein thrombosis (2)

Conclusion: Safe performance of adequate PLND during RARC can be accomplished comparable to the open approach. Oncologic efficacy remains to be evaluated with long-term follow-up.

8250 Urology
Robot-Assisted Laparoscopic Radical Cystectomy for Bladder Cancer: An Analysis of Perioperative Surgical Outcomes
Aldrin Joseph R. Gamboa, MD, Jennifer L. Young, MD, Geoffrey N. Box, MD,
Atreya Dash, MD, Jose Benito A. Abraham, MD, Leslie A. Deane, MD, Hak J. Lee, MD,
Ricardo J.S. Santos, MD, David K. Ornstein, MD

Introduction: Advantages of minimally invasive surgery include decreased blood loss, shorter hospital stay, and early return of bowel function. Its efficacy and adherence to standard oncological principles remains unanswered. We report our experience with robot-assisted laparoscopic radical cystectomy (RARC).

Methods: Thirty-nine patients underwent RARC. The entire extirpative procedure was performed using the da Vinci robot (Intuitive Surgical, Sunnyvale, CA). All urinary diversions, except 4 male neobladders, were performed extracorporeally. Data are grouped into 3: ileal conduit female (ICF), ileal conduit male (ICM), and neobladder (NB). Demographics, immediate perioperative, and pathological outcomes were analyzed.

Results: One patient was excluded because of the inability to tolerate pneumoperitoneum. Urinary diversion distributions were 10ICF, 14ICM, and 14NB with median age of 73 years old (range, 55 to 87). Median length of hospital stay was 7.5 days (range, 5 to 37). Median blood loss was 200mL (range, 50 to 700) with blood transfusion unit rate of 0 (range, 0 to 4). Median total operative and console time were 435 minutes (range, 305 to 805) and 255 minutes (range, 200 to 370), respectively. Median total number of lymph nodes harvested was 22.5 (range, 6 to 68). Nodal metastases were 11.42% (4/35). Positive soft tissue margins were 8% (3/38) (2 staged pT4 and one T3b). Intraoperative complication rate was 8% (3/38), ie, obturator nerve injury (n=2; 1NB,1ICF) and inadvertent removal of neobladder catheter requiring small midline incision for reinsertion (n=1,1NB). Twelve postoperative complications in 18% (7/38), ie, ileus (n=3; 2NB, 1ICM); ureteroenteric stricture (n=5; 1ICF,4NB); bowel obstruction (n=1; 1NB); lymphocele collection (n=1; 1NB); and deep vein thrombosis (n=2;2NB).

Conclusions: RARC provides efficacy of minimally invasive surgery. Complication rates compare favorably to those in open series. Longer follow-up determines oncological outcomes to that of  "gold standard" open radical cystectomy.

8252 General Surgery
Repair of Hiatal Hernia and Reinforcement with Bovine Pericardium
Kenneth P. Kleinpeter, MD, Mark Hausmann, MD, V. Keith Rhynes, MD, John Whitaker, MD, Karl LeBlanc, MD

Background: Hiatal hernias have been repaired many ways. Now, with the availability of bioprosthetic materials, the authors have begun to use bovine pericardium to reinforce the hiatal repair.

Methods: The authors undertook a nonrandomized, prospective evaluation of perioperative variables related to this technique in regards to short-term efficacy and potential complications. We selected patients who underwent laparoscopic hiatal hernia repair with bovine pericardium crural reinforcement.

Results: Twenty-one patients underwent laparoscopic repair of hiatal hernia. Time of operation ranged from 64 minutes to 215 minutes. Two of the 21 patients reported persistence of reflux symptoms. Ten of 21 patients had no postoperative dysphagia. Six of 21 patients experienced minimal dysphagia with resolution. Five had persistent dysphagia. Five patients underwent postoperative imaging. Postoperative upper GI studies obtained in 4 of these patients revealed no reflux or stricture. The other documented recurrence of hiatal hernia. The rate of recurrence is 4.8%. There was a single patient death 4 months postoperatively.

Conclusions: Currently, multiple methods of hiatal repair are used for hiatal hernia. We report a method of crural reinforcement with bovine pericardium for large hiatal defects or those with inadequate or friable crura for suture repair. These findings will require longer follow-up to make more definitive recommendations concerning efficacy.

8253 General Surgery
Combined Laparoscopic Paraesophageal Hernia Repair and Sleeve Gastrectomy in a Morbidly Obese Patient
Brian Carmine, MD, Donald Hess, MD, Charles Gruner, MD, Miguel Burch, MD

    Giant paraesophageal hernias present a surgical challenge alone, but in the presence of morbid obesity, short- and long-term outcome can be negatively impacted. Combining a weight loss procedure along with a giant paraesophageal repair would seem ideal; however, until recently there were few attractive options. As a result of esophageal shortening, typical Roux-en-Y gastric bypass creates a situation where tension may be present at the gastrojejunal anastomosis, increasing the risk of short- or long-term anastomotic failure. Additionally, controversy exists over the role of gastric banding especially in the setting where Collis gastroplasty is required for adequate intraabdominal esophageal length. An alternative approach is to perform a sleeve gastrectomy concurrent with repair of the giant paraesophageal hernia. We demonstrate herein a primary repair of a large paraesophageal hernia with sleeve gastrectomy. Our experience shows that this approach is not only a safe alternative to Roux-en-Y gastric bypass, but yields a comparable degree of postoperative weight loss at the same time as significantly decreasing the risk of recurrence of the paraesophageal hernia. Larger studies and long-term evaluation are necessary to determine whether this technique should have a permanent role in obesity surgery, particularly in the setting of complex paraesophageal hernia.

8254 General Surgery
Robotic-Assisted Pelvic Lymph Node Dissection in Melanoma
V. Trisal, MD, C. Garberoglio, MD, B. Paz, MD

Objectives: The purpose of this study was to evaluate the feasibility and surgical outcome of robotic pelvic lymphadenectomy for stage III malignant melanoma using the da Vinci Surgical System.

Methods: A retrospective clinical review was performed of 5 patients with TNM stage IIIa - IIIc malignant melanoma. Patient status was estimated in terms of primary site, operative morbidity, length of surgery, docking time, estimated blood loss, yield of pelvic lymph node, and hospital stay.

Results: Four cutaneous melanomas and one mucosal (vaginal) melanoma were included in the study. Two patients were operated on for bulky nodal disease in the pelvis without any systemic disease. One patient had a positive Cloquet’s node, and the other 2 patients had palpable nodal disease, prompting pelvic nodal dissection. All operations were completed robotically with no conversions to laparotomy. Mean operative time was 125 minutes (range, 105 to 155). Mean docking time was 17 minutes (range, 11 to 28). Mean estimated blood loss for the pelvic lymph node dissection part was 35mL. The average number of pelvic lymph nodes resected was 12 (range, 6 to 16). There were no seromas or wound complications for the pelvic nodal dissection.

Conclusion: Robotic pelvic lymphadenectomy for select patients with stage III malignant melanoma is feasible, promising, and related to low morbidity in this pilot study. Only prospective randomized trials will permit the evaluation of potential benefits associated with this surgical technique.

8256 Other
Single-Port Laparoscopic Colectomy (eNOTES): Ready for Prime Time!
Dan Geisler, MD, Tom Garofalo, MD, Feza Remzi, MD, Jihad Kaouk, MD, Tracy Hull, MD, Ty Garrett, Vic Fazio, MD

Objective: Laparoscopy is quickly becoming the treatment of choice for the majority of colorectal disorders that require an abdominal operation. As the emphasis focuses on minimizing the technique utilized to access the pathology, natural orifice surgery is quickly evolving. While endoscopic approaches are being viewed with much skepticism, the authors explored the realm of utilizing an embryologic natural orifice, the umbilicus, as sole access to the abdomen to perform a complex colorectal procedure.

Methods: A novel approach was used to gain access to the abdomen through a single abdominal incision via the umbilicus - an embryologic natural orifice (eNOTES). A single-port access device was used through a 3.5-cm umbilical incision to perform a hemicolectomy.

Results: After the feasibility of performing a left colectomy through a single 3.5-cm incision was achieved in a pig model, a human cadaveric model was then used to test completeness of resection and efficacy of dissection. The operative procedure was then performed on a live patient with no undue sequelae.

Conclusions: The performance of an advanced colorectal procedure (hemicolectomy) was achievable through a single 3.5-cm umbilical incision. The feasibility has been proven in a live pig model, and the efficacy tested on 2 human cadavers. Using a specialized single-port access technique, the operation has made it to prime time.

8257 Urology
Treatment of Posttransplantation Vesicoureteral Reflux with Injection of Dextranomer/Hyaluronic Acid Copolymer
Ithaar H. Derweesh, MD, Christopher J. DiBlasio, MD, Reza Mehrazin, MD,Hubert S. Swana, MD

Objective: Vesicoureteral reflux and pyelonephritis following renal transplantation may significantly contribute to renal damage and premature graft loss. We evaluated endoscopic correction of reflux using dextranomer/hyaluronic acid copolymer.

Methods: We identified and treated 7 transplant recipients with a diagnosis of posttransplant vesicoureteral reflux and pyelonephritis. All patients had previously undergone Lich-Gregoir ureteroneocystostomy along the ipsilateral anterolateral bladder wall. Postinjection voiding cystourethrogram (VCUG) was performed within 2 months of injection. Patient characteristics, cause of end-stage renal disease, presenting symptoms, serum creatinine, and postoperative results were analyzed.

Results: Four women and 3 men developed pyelonephritis within 2 years of transplantation. The average age was 40.2 years. An average of 1.8mL dextranomer/hyaluronic acid copolymer was used per patient. Average follow-up was 10 months. Preoperative serum creatinine was 1.67mg/dL. Four patients (57%) had resolution of reflux. Three did not. Of the 3 that did not, one had recurrent episodes of pyelonephritis. All 3 underwent open ureteral redo-reimplantation. No patients developed worsening hydronephrosis. Postoperatively, there was no significant increase in serum creatinine, (mean postoperative serum creatinine was 1.74mg/dL).

Conclusion: Injection of dextranomer/hyaluronic acid, while technically challenging, can provide a minimally invasive treatment option for patients with secondary vesicoureteral reflux after transplantation.

8259 Urology
Robotic-Assisted Laparoscopic Radical Prostatectomy for High-Risk Prostate Cancer: Initial Experience and Short-Term Outcomes
Jayant Uberoi, MD, Daniel I. Brison, MD, Matthew S. Hall, MD, Ihor S. Sawczuk, MD, Ravi Munver, MD

Objective: Robotic-assisted laparoscopic radical prostatectomy (RLRP) is gaining popularity as an alternative to the open technique. We report on our experience with RLRP for patients with high-risk adenocarcinoma of the prostate to determine outcomes.

Methods: A retrospective review was performed of patients treated with RLRP with clinical stage T1c and preoperative Gleason score ≥8 or PSA ≥10ng/dL. Postoperative pathology, PSA trends, and adjuvant therapies were analyzed.

Results: Fifty patients were assessed; 31 patients had high PSA levels [mean 15.5ng/dL; range, 10 to 34], and 27 patients had high Gleason scores [GS 8 (n=14); GS 9 (n=12), GS10 (n=1)]. Eight patients had high PSA values and Gleason scores. All patients underwent RLRP with wide resection. Pathology revealed pT2a (n=4), pT2c (n=27), T3a (n=11), and pT3b (n=8). Thirty-two patients (64%) had negative and 18 (36%) had positive surgical margins. Extracapsular extension (ECE) was noted in 38% (n=19) of specimens. Seminal vesicle invasion (SVI) was noted in 16% (n=8). All 18 patients with positive surgical margins received adjuvant radiation therapy and/or hormonal therapy. PSA nadir values of ≤0.1 were achieved in 68% of patients at 3 months.

Conclusions: RLRP is seldom selected as a primary therapeutic option for patients with high-risk prostate cancer. In our experience, early outcomes resulted in negative margins and nadir PSA levels ≤0.1 in a subset of patients; however, a significant number required adjuvant therapy. Long-term follow-up in these patients will allow for further evaluation of RLRP as an option for prostate cancer with high-risk features.

8260 Gynecology
Laparoscopic Colposuspension with Round-Infundibulopelvic Ligament in Procidentia Uteri
Dong-Ho Kim, MD

Objective: To introduce laparoscopic colposuspension with round-infundibulopelvic ligament in procidentia uteri.

Methods: After laparoscopic hysterectomy with or without anterior or posterior colporrhaphy as clinically indicated, a laparoscopic suture was started between both adnexa pedicles (including the round-infundibulopelvic ligament) and cervical stump (dissected vaginal vault in case of a vault prolapse patient). Extracorporeal Röder knot and delicate traction and approximation were done. After traction was completed, 3 to 4 security knots were done. This traction was done from one side to the other side sequentially and bilaterally simultaneously as clinically indicated.

Results: From January 1994 to January 2007, 75 patients with Grades 3 and 4 procidentia uteri were operated on with this method. Mean follow-up was 56.2 months (range, 12 to 144). No recurrence or severe complications occurred in the perioperative and postoperative follow-up periods.

Conclusions: Laparoscopic colposuspension with round-infundibulopelvic ligament is a very safe, effective, and functional operation for treatment of procidentia uteri

8261 Multispecialty
Multidisciplinary Utilization Patterns of Robotic Technology at an Institution with 6 da Vinci Surgical Systems: The Impact of Robotic-Assisted Surgery on Surgical Subspecialties
Jayant Uberoi, MD, Isuru Jayaratna, MD, Garth H. Ballantyne, MD, Jondavid H. Jabush, MD, Arnold Byer, MD, Ihor S. Sawczuk, MD, Ravi Munver, MD

Objective: Robotic-assisted surgery is steadily gaining attention throughout the world. Since its introduction, several surgical specialties have adopted this technology to varying degrees. We report on practice patterns with robotic-assisted surgery and procedural trends at our institution over a 7-year period.

Methods: A retrospective review was conducted of robotic-assisted procedures performed between June 2001 and June 2007 at our institution. Our medical center has acquired 6 da Vinci Surgical Systems: 2 in 2000, 1 in 2002, 1 in 2006, and 2 in 2007. The trends for robotic-assisted procedures across surgical specialties at our institution were analyzed.

Results: In this study, 1312 robotic-assisted procedures were recorded by 26 surgeons in 4 surgical specialties: 1059 (81%) urology, 105 (8%) general surgery, 97 (7%) cardiothoracic, and 51 (4%) gynecology. Urology procedures included radical prostatectomy (93%), pelvic lymph node dissection (5.5%), pyeloplasty (1.3%), and renal/adrenal surgery (0.2%). General surgery procedures included cholecystectomy (67.9%), gastric bypass (14.3%), hemicolectomy (7.9%), Nissen fundoplication (6.4%), Heller myotomy (2.2%), and gastric banding (1.4%). Cardiothoracic procedures included inferior mammary artery harvest (88.7%), thymectomy (8.2%), valve annuloplasty (2.1%), and others (1%). Gynecology procedures included total hysterectomy (33.3%), salpingo-oophorectomy (27.5%), myomectomy (19.6%), supracervical hysterectomy (9.8%), ovarian cystectomy (5.9%), and others (3.9%). The total annual number of robotic-assisted procedures progressively increased from 2001 (n=43) to 2006 (n=418). The percentage of total procedures within each specialty annually shifted over the 7-year period.

Conclusions: The introduction of the da Vinci Surgical System has had a dramatic impact on surgical therapy in many fields. Urology remains the leading discipline in terms of number of procedures; however, adoption of robotic technology in other specialties has resulted in significant changes in the overall distribution of procedures.

8262 General Surgery
Indications for Laparoscopic Sigmoid Resection and End-Colostomy in Spinal Cord Injury Patients
Daniel Wool, MD, Dan Eisenberg, MD, MS

Objective: Approximately 10,000 to 15,000 new cases of spinal cord injury are reported in the United States annually. Neurogenic bowel and chronic perineal pathology often necessitate sigmoid resection with end-colostomy. The objective of this study was to determine the common indications for resection and gastrointestinal diversion in this patient population and to determine whether an immediate benefit exists for a laparoscopic approach.

Methods: A retrospective analysis of a spinal cord injury patient database at a Veteran’s Administration Hospital was performed. Between August 2000 and December 2007, 36 elective colon resections and end-colostomies were performed.
Results: Of 36 resections, 33 were performed laparoscopically. Indications for surgery included colonic inertia (in 63.9%), incontinence (2.8%), sigmoid volvulus (8.3%), perianal sepsis (2.8%), and nonhealing perineal ulcer (22.2%). The mean length of postoperative stay was 7.7 days for open and 4.3 days for laparoscopic resection. However, this difference was not significant based on a paired t test (P=0.067).

Conclusion: Sigmoid resection with end-colostomy is often needed in patients with spinal cord injury. In our study, the most common indication was colonic inertia and constipation. In addition, a laparoscopic approach is feasible and safe and leads to a reduction in postoperative stay, compared with open; however, with our small number of patients, we could not identify a significant difference.

8264 Gynecology
Five-Year Prospective Follow-up of the Results of Roller Ball Endometrial Ablation for Women with Menorrhagia
Atieh Mansouri, MD, Nafiseh Saghafi,  MD, Monireh Pourjavad, MD, Mojgan Gonoodi, MD,
Zahra Kebriae, MD

Objective: To evaluate the outcomes of roller ball endometrial ablation for women with menorrhagia, prospectively for the duration of 5 years.

Methods: Data on the clinical history, operative technique, and follow-up status were obtained prospectively by questionnaire from 50 women undergoing roller ball endometrial ablation from May 2001 to May 2006. Ultrasonography, endometrial biopsy, and cervical cytology did not confirm any pathologic or neoplastic processes. All patients who did not desire future childbearing, after inducing endometrial thinning by using medroxyprogesterone acetate, underwent endometrial ablation by roller ball while under general anesthesia. During a 5-year follow-up period, 8 cases were lost; therefore, data were available on 42 patients.

Results: Of 42 cases, eumenorrhea, hypomenorrhea, and amenorrhea were reported for 19 patients (45.23%), 8 patients (19.04%) and 3 patients (7.14%), respectively. In 10 patients (23.80%), the amount of bleeding was reduced. In 2 patients (4.76%), menorrhagia continued the same as before ablation; one of them underwent hysterectomy 2 years later, and the other was menopausal one year later. Thirty-nine patients (92.85%) had dysmenorrhea before surgery, and in 27 cases (64.28%) dysmenorrhea resolved after surgery. Forty patients (95.23%) were amenorrheic or their bleeding decreased. Thirty-three patients (78.55%) were satisfied. One of the patients conceived 3 years later, and a healthy baby was born. In 30 patients (71.42%), endometrial ablation was successful. No patient had intra- or postoperative complications, such as perforation, hemorrhage, or infection.

Conclusion: Endometrial ablation by roller ball is an effective treatment of menorrhagia and is a good alternative to hysterectomy.

8265 Gynecology
Comparison of Laparoscopic-Assisted Vaginal Hysterectomy with Traditional Hysterectomy at Omolbanin Hospital (January 2005 to September 2007)
M. Pourjavad, A. Mansouri, N. Saghafi, S. Dadgar

Objective: The purpose of this study was to compare intraoperative and postoperative outcomes between laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy among patients who are not candidates for vaginal hysterectomy.
Methods: This cross-sectional clinical trial was conducted in 25 patients who underwent laparoscopic-assisted vaginal hysterectomy, and 26 patients who had traditional total abdominal hysterectomy at Omolbanin Hospital from January 2005 to September 2007. Demographic characteristics and intraoperative and postoperative management was similar for both groups.

Results: Mean operating time was significantly longer for LAVH, but at the end of the project when the team was more skilled, it was nearly the same in the 2 groups (P=0.856). Blood loss was higher in the laparoscopic group (P=0.001). Length of hospital stay between the 2 groups was not statistically significantly different (P=0.537). Need for analgesics was much less in the laparoscopic group than in the traditional group with a statistically significant difference (P=0.001).

Conclusion: For most patients, laparoscopic-assisted vaginal hysterectomy provides a minimally invasive way to accomplish a hysterectomy with shorter convalescence. Therefore, it can be recommended for all patients.

8266 Gynecology
Clinical Comparison of Classic Intrafascial Semm Hysterectomy and Laparoscopically Assisted Vaginal Hysterectomy
Wang Shaojuan, MD, Hou Yulan, MD, Wei Shaoyun, MD, Wei Ping, MD

Objective: To compare the classic intrafascial Semm hysterectomy (CISH) and laparoscopically assisted vaginal hysterectomy (LAVH).

Method: The operation time, blood loss, operative patterns, complications, cause for converting to open surgery, and recovery status were compared between 76 cases of CISH and 47 cases of LAVH performed in the Department of Obstetrics and Gynecology from January 2004 to June 2007.

Results: The success rate for the CISH group was 88.1%, including 9 cases converted to open surgery, because of serious pelvic adhesions, uncommon location of tumors, and the heavy weight of the uterus. The rate of complications was 10.4%. On the contrary, the success rate for the LAVH group was 95.7%, including 2 cases converted to open surgery. No complications occurred. No differences existed in blood loss, operating time, operation cost, complication rate, and length of hospital stay between the 2 kinds of surgery.
Conclusions: Laparoscopic hysterectomy is worth spreading because of its minimal invasion. Therefore, the key of decreasing complications is based on selecting the proper operative approach in view of different situations.

8267 General Surgery
Validity Assessment of a “Serious Game” for Training and Assessing Laparoscopic Suturing
Usman Jaffer, MBBS, BSc (Hons) MSc, MRCS (Eng), Christopher Amos

Introduction: Surgical training globally is under pressure from introduction of working time restrictive legislation and reduced time spent in training. This has lead to serious concerns regarding training opportunities and competency, particularly in laparoscopic surgery. The American College of Surgeons has stipulated that in 2008 all surgical training programs must have simulators on which residents can train in relevant laparoscopic skills. We have developed an affordable “serious game” to train surgeons in difficult to practice and difficult to retain psychomotor skills.

Methods: The “gaming” task involves laparoscopic suturing and knot tying. During the current phase of development, technical issues including control method and look and feel of the game were evaluated for face and construct validity. A cohort of 5 experienced laparoscopic surgeons were introduced to the “serious game,” and their views regarding overall satisfaction with the look and feel of the game were recorded on a Likert scale (1 to 5, 5 being very satisfied).

Results: Overall satisfaction with the laparoscopic serious game was 3.6.
Conclusions: We conclude that this serious game has a good degree of face validity when assessed by experienced laparoscopic surgeons. Further validation studies are being performed to show the ability of the “serious game” to (1) differentiate expert from novice practitioners, (2) improve skills, and (3) demonstrate that improved simulator skill improves real life skill.

8268 Gynecology
Treatment and Survival Analysis of Ovarian Cancer Incidentally Discovered by Laparoscopy
Liu Xiaojun, Liu Yan

Objective: The purpose of this study was to discuss how to deal with ovarian cancers incidentally discovered by laparoscopy and to analyze the prognosis of such cancers.

Methods: Enrolled in the study were 4,550 patients who had routine laparoscopy with negative tumor markers before surgery. Cryosections were performed on all the specimens. Once ovarian cancers were confirmed, patients in stage I-II were operated on with laparoscopy, and patients in late stage cancer were converted to laparotomy. All the patients were followed up for 5 years.

Results: Of the 4,550 patients, 23 who underwent laparoscopy were diagnosed with ovarian cancers incidentally by pathological section. Seventeen of the 23 were in stage I-II, and 6 were in the late stage. The 5-year survival rate in the stage I-II group who underwent laparoscopy (76%, 13/17) and in late stage group transferred to laparotomy (33%, 2/6) was similar to the reported data for those who underwent conventional operations at the same stage (50% to 80%, 30% to 40%, respectively). Two 2 patients who underwent laparoscopy had the complication of puncture-site metastasis.

Conclusions: The application of laparoscopy can avoid a missed diagnosis of ovarian cancers, especially those in the early stage. And the ovarian cancers in the early stage can be treated by laparoscopy and achieve the same 5-year survival rate as conventional operations. But some measures should be taken to avoid puncture-site metastasis.

8270 Urology
Robotic Repair of Access-Related Aortic Injury
Ronney Abaza, MD

Introduction: Robotic surgery is becoming more widespread, but curricula for training residents in robotics have yet to be fully developed. Novice residents involved in robotic procedures expose patients being treated at academic centers to avoidable injuries. A case of major aortic injury during access for robotic radical prostatectomy is presented along with repair and an analysis of factors that contributed to the event.

Case: A 57-year-old male was positioned in a steep Trendelenburg position for robotic prostatectomy. Veress needle insufflation was performed, and all ports were placed under laparoscope guidance. The robot was brought into position and secured to the ports. The 2 left-sided robotic instruments were placed by the attending physician, but during simultaneous placement of the right-sided robotic scissors by a resident, resistance was noted. The instrument was replaced by the attending, but subsequent inspection from the console revealed brisk bleeding from the retroperitoneum.

Result: The source of injury was identified with robotic dissection through the retroperitoneum to the level of the aorta. A polypropylene suture was placed for immediate control and held with the fourth-arm instrument while dissection of the aorta at the injury was performed for controlled suture repair. The patient was admitted for observation with routine robotic prostatectomy performed the following day.

Conclusions: Unexpected major injuries can occur when trainees with inadequate training in robotics are involved in robotic procedures. Root cause analysis of our aortic injury has lessons for surgeons involved in training programs, who should be prepared to handle any potential complications of robotic surgery.

8271 Urology
Laparoscopic Versus Percutaneous Renal Cryoblation: Single-Center Experience and Intermediate-Term Outcomes
Ithaar H. Derweesh, MD, Anthony Patterson, MD, Robert Wake, MD, Robert Gold, MD

Introduction: Cryoablation is a feasible therapeutic option for small renal tumors. We compared our perioperative and intermediate-outcomes of laparoscopic (LAP) versus percutaneous (PERC) renal cryoablation.

Methods: Between September 1998 and February 2007, 34 patients (18 male/16 female) underwent LAP and 26 (19 male/7 female) underwent PERC. LAP was done with ultrasound monitoring. PERC was performed with CT-guidance. Follow-up imaging was obtained at regular intervals.

Results: No significant differences were noted between LAP and PERC for mean age and BMI. Mean tumor size (cm) was 2.9 for LAP and 3.1 for PERC (P=0.432). Anterior tumors comprised 61.8% of LAP and 19.2% of PERC (P<0.001). Mean procedure time (minutes) was 165.7 for LAP and 106.6 for PERC (P<0.001). Hospital stay (hours) was 63.2 for LAP and 44.2 for PERC (P<0.001). Narcotics were required by 82.4% of LAP and 19.2% of PERC patients (P<0.001). Atelectasis developed in 70.6% of LAP and 43.6% of PERC patients (P=0.004). Residual enhancement occurred in 11.5% of PERC and 2.9% of LAP (P=0.192). Complications occurred in 14.7% of LAP and 26.9% of PERC patients (P=0.248). For both groups, 3-year disease-specific survival was 100%. Three-year overall survival was 88.9% for LAP and 71.4% for PERC.

Conclusions: PERC and LAP have similar profiles and intermediate-term outcomes. Most anterior tumors were approached via LAP. PERC offers advantages regarding hospital stay, narcotic requirements, and atelectasis. Longer-term data are required to establish efficacy.

8272 Gynecology
A Novel Technique for Laparoscopic Gastrostomy: A Simple, Safe, and Minimally Invasive Technique
Emad Kandil, MD, Paul Freidlander, MD, Juan Duchesne, MD, Natasha Telusca, Charles Bellows

Background: Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice in the nutritional management of patients requiring gastrostomies. However, PEG tubes are not always feasible. We report herein the first case series of laparoscopic gastrostomy (LG) in an adult population with obstructing pharyngeal or esophageal cancers, severe head trauma, or a history of multiple abdominal surgeries.

Methods: A retrospective chart review of all patients who underwent LG from August 2007 to December 2007 was performed. Demographic and outcome data were abstracted.

Results: Nine patients underwent LG. Seven patients had previous abdominal surgery with an average of 2 previous surgeries (range, 1 to 3) per patient. Three patients had obstructing head/ neck cancer, and 2 patients had severe head trauma. The mean age was 57.8 years (range, 19 to 95); 3 patients were female. The mean operative time was 27 minutes. No conversions to open were necessary. Two ports (5mm and 10mm) were used in the majority of patients (85%); however, up to 4 ports had to be placed (15%) when lysis of adhesions was required. No major complications were observed. Minor complications included 1 tube dislodgement and 3 superficial wound infections. The mean follow-up was 4.1months (range, 2 to 6).

Conclusion: This innovative 2-port laparoscopic technique for G tube placement is safe and effective. It allows for the accurate insertion of the G tube under direct visualization and avoids open techniques in patients where PEG tubes are not feasible.

8273 Urology
Experimental Control of Renovascular Injuries During Laparoscopic Nephrectomy
Saleem Zafar, MD, Ronney Abaza, MD

Introduction: Laparoscopy in urology has become well penetrated, with laparoscopic nephrectomy considered by most to be a standard of care. A major complication that may be encountered during renal surgery is vascular injury with potentially serious hemorrhage. Unfortunately, there are currently no guidelines outlining logical measures to control vascular injury and avoid conversion to open surgery without compromising patient safety. We simulated renovascular injuries during laparoscopic renal surgery to identify which commonly used instruments are helpful in achieving vascular control and which are to be avoided.

Methods: Using a porcine model, we identified the renal hilum and vessels with minimal dissection. We then intentionally caused hemorrhage by creating 5-mm renal arteriotomies and venotomies with laparoscopic scissors. We subsequently attempted to gain vascular control using the following instruments: bipolar forceps, Harmonic scalpel, LigaSure, Gyrus Trisector, titanium clips, and bulldog clamps.

Results: Renal vein hemorrhage was controlled with the Gyrus Trisector, titanium clips, bulldog clamps, and bipolar forceps, but hemostasis could not be achieved with the LigaSure or Harmonic scalpel. Renal arterial hemorrhage was controlled with the bulldog clamps, titanium clips, and bipolar forceps. The Gyrus Trisector, LigaSure, and Harmonic scalpel all failed to control arterial hemorrhage.

Conclusions: A variety of instruments can be used to control vascular injury during laparoscopic nephrectomy. It is imperative that the surgeon be educated on which modalities are successful in controlling hemorrhage from both arteries and veins and which are counterproductive.

8274 Gynecology
Her Option “FOR” Her
Jaswant S. Chaddha, MD

Objective: To evaluate the safety and efficacy of Her Option endometrial ablation using the acronym “FOR” [F (family), O (occupation), and R (recreation)]. Her is an in-office vocal analgesia procedure.

Methods: Global endometrial ablation has been shown to be safe, efficacious, and an alternate treatment for hysterectomy in select patients who present with excessive uterine bleeding. Twenty-five patients from June 2006 to January 2008 had endometrial ablation under ultrasonic guidance in a solo private practice. After obtaining informed consent, the procedure was carried out per protocol. Prior to the procedure, Valium 10mg PO and Toradol 30mg IM were administered to all patients. The first 16 patients were administered 15cc to 20cc local paracervical block with 1% Xylocaine, and the subsequent 9 patients required no local paracervical block. All patients were administered “FOR” Her vocal analgesia. The support staff engaged the patients to divert their mind by discussing their family, occupation, and recreation during the procedure lasting for 12 minutes to 15 minutes. This form of vocal analgesia was very effective as it allowed the staff to easily engage the patient.

Results: Minimal to no discomfort during and immediately after the procedure were noted in all patients and no complications occurred. Twenty-four patients (96%) reported satisfaction with the procedure.

Conclusion: The Her Option in-office procedure is safe, effective, and may be performed using “FOR” as a vocal analgesia alone or in conjunction with local paracervical block analgesia.

8275 General Surgery
From NOTES to Minimally Invasive Surgery: Two-Port Sigmoidectomy
F. Pugin F, MD, Bucher P, MD, Buchs NC, MD, Hagen ME, MD, Morel P, MD

Objective: NOTES is a rapidly evolving technique in visceral surgery; however, some technical progress, especially in terms of instrumentation, still limits its application in clinical practice. The study aim was to evaluate whether perioperative colonoscopy could be used as efficiently as laparoscopic retractors and decrease the number of transabdominal accesses.

Methods: For this preliminary study, 2-port sigmoidectomy was performed in human male cadavers. The 2 laparoscopic ports (10mm and 12mm) were placed in a small McBurney incision. A colonoscope was used perioperatively as a retractor to enable bowel mobilization. A laparoscopic camera and strait laparoscopic instruments and staplers were used for dissection. Colorectal, side to end, anastomosis was performed using a circular stapler.

Results: Sigmoidectomy was performed successfully on the 2 occasions with an operative time of 90 minutes and 60 minutes. Specimen lengths were 36cm and 33cm and included colorectal junction. Anastomoses were checked through endoscopy and were acceptable. The specimens were extracted through the McBurney incision.
Conclusion: Two-port sigmoidectomy is easily feasible using a colonoscope as a retractor. Although NOTES allows surgeons to discover and use endoscopes for transgastric and intestinal surgery, they could primarily help them to reduce the invasiveness of minimally invasive surgery.

8276 General Surgery   
A New Technique for Totally Intracorporeal Laparoscopic Colorectal Anastomosis Using a Circular Stapler
Bucher Pascal, Pugin Francois, Buchs Nicolas, Gervaz Pascal, Morel Philippe

Background: Several surgical techniques for colorectal anastomosis have been described for laparoscopic left-sided colectomies. Due to the complexity of these procedures, open preparation of the proximal bowel for circular stapler anastomosis, through Pfannenstiel incision has become the gold standard. We report a new laparoscopic technique for totally intracorporeal colorectal circular anastomosis (TLCCA) using a circular stapler.

Methods: We report our preliminary experience using TLCCA in 15 patients scheduled for laparoscopic left colectomies (7), sigmoidectomy (7), and low anterior resection (1). Median age of patients was 69 years (range, 51 to 86), and median BMI was 25 (range, 20 to 34).

Results: Side-to-end colorectal anastomosis through TLCCA was feasible in all patients, without conversion to the standard laparoscopic approach or open surgery. Median operative time was 125 minutes (range, 109 to 173). Median time from anvil insertion into abdominal cavity to anastomosis was 12 minutes (range, 10 to 21). Specimen length was 33cm (range, 26 to 52), and number of lymph nodes recovered in cancer patients was 21 (range, 15 to 29). No postoperative complications were recorded, and median hospital stay was 5.5 days (range, 4 to 9).

Conclusion: Side-to-end anastomosis can be easily and safely performed using conventional circular stapler through TLCCA. TLCCA is performed using 4 laparoscopic ports without additional skin incisions (except trocar incisions) and allows retrieval of surgical pieces through a specimen bag.

8277 General Surgery   
Single Midline Working Port for TEP Inguinal and Crural Hernia Repair
Bucher Pascal, Pugin Francois, Ris Frederic, Morel Philippe

Background: The study aim was to evaluate the feasibility of single working port laparoscopic TEP hernia repair and to analyze whether reduced disposable cost is not counterbalanced by longer operative time and indirectly induced cost.

Methods: This was a prospective longitudinal study evaluating the feasibility and validity of single working port for totally extraperitoneal laparoscopic (TEP) groin hernia repair. For single working port TEP, one umbilical optic port and a midline 5-mm port were used. Fifty-two consecutive cases of single working port TEP were compared with the previous standard hernia repair performed by the same surgeon in matched patients. The primary end point evaluated was operative time. Secondary end points were operative cost, per- and postoperative complications, and rate of conversion to standard TEP hernia repair (which happened in 14 additional cases not included with the 52 single working port TEP reported here).

Results: Single working port TEP and conventional TEP repair groups were similar in terms of patient age, unilateral or bilateral hernia, type of hernia (indirect, direct, and crural). A higher number of patients in the single working port group had a previous history of hernia repair or McBurney incisions. Median operative time was 34 minutes (range, 13 to 54) for all single working port TEP repairs and 39 minutes (range, 26 to 69) for the conventional TEP group (P=0.003). Median operative time for unilateral repair was 30 minutes (range, 13 to 46) for single working port TEP compared with 36 minutes (range, 26 to 48) for the conventional TEP group (P=0.002). No per- or postoperative complications were recorded in the single working port group.

Conclusion: Single working port laparoscopic TEP hernia repair is safe and easily performed by surgeons trained for laparoscopic hernia repair. The rate of conversion to standard laparoscopic TEP repair is low (~ 20%). The cost of TEP repair can be reduced because fewer disposable materials are needed, and operative time seems decreased by this approach.

8278 Gynecology   
Profile of Lupron Use for Pelvic Pain in the Community Setting
Sangeeta Senapati, MD, MS, Kristen Pozolo, BS, Frank Tu, MD, MPH

Objective: To examine trends in the use of Lupron in the community setting including, prescribing patterns, duration of use, and tolerance of the medication.

Methods: Retrospective study of patients receiving Lupron in a large community-based multidisciplinary, multihospital network from 2003 to 2007. Descriptive statistics were calculated.

Results: Of 120 patients identified from computerized records, 14 women received Lupron for pelvic pain indications. Mean age was 35, 50% were married, and 64% were nulliparous. None had documented interstitial cystitis, irritable bowel syndrome, fibromyalgia, or anxiety; 93% had surgically documented endometriosis with 71% having pain for >2 years. Documented assessment of comorbid bladder symptoms was absent in 71% of cases, while dyspareunia was only documented in 43%. Prior to Lupron use, 82% of patients were treated with hormonal suppression. Use of narcotics and nonprescription therapies were not well documented. Documented provider counseling did not include alternative treatment options for 43% of women. Mean Lupron use was 5 months, with 31% receiving add-back therapy. Associated hot flashes occurred in 71% of women, and 66% reported an increase in bleeding patterns.

Conclusion: In the community, Lupron was predominantly initiated for pelvic pain patients with documented endometriosis but key related pelvic visceral symptoms and associated conditions are poorly documented by providers, limiting our ability to determine whether comprehensive assessment of these patients is routinely performed. Given the known side effects and limited duration of therapy, Lupron can be used. Prospective long-term follow-up studies with valid assessment tools in this setting are vitally needed.

8279 General Surgery   
Robotic-Assisted Laparoscopic Repair of Paraesophageal Hernia with Mesh + Nissen Fundoplication
Carlos Galvani, MD, Alberto S. Gallo, MD, Maria V. Gorodner, MD,
Francesco M. Bianco, MD

Background: Over the years, the increasing experience gathered with laparoscopic antireflux procedures has made the technique available even for the most technically challenging operations, such as large hiatal hernias. Moreover, with the introduction of the da Vinci robotic system, the technical limitations of such operations have decreased substantially. Herein, we report the robotic-assisted laparoscopic repair of a paraesophageal hernia with mesh and Nissen fundoplication.
Methods: The patient was a 40-year-old woman complaining of dysphagia to solids and liquids, regurgitation, and chest pain for 2 years. Esophagram, endoscopy, and esophageal manometry were performed before surgery.

Results: The esophagram revealed the presence of tertiary contractions, abnormal position and configuration of a slightly dilated stomach with possible diagnosis of organoaxial volvulus vs. large paraesophageal hernia. Endoscopy revealed a large paraesophageal hernia and narrowing of the distal esophagus suggestive of Schatzki's ring. Esophageal manometry demonstrated normal LES pressure with normal relaxation, and ineffective esophageal motility of the esophageal body. The patient underwent robotic-assisted laparoscopic repair of paraesophageal hernia with mesh and Nissen fundoplication. The operative time was 2.5 hours, and the estimated blood loss was 5cc. The hospital stay was 24 hours. No perioperative complications were observed.

Conclusion: The assistance of robotic technology facilitates intramediastinal dissection potentially decreasing blood loss and perioperative morbidity and mortality.

8280 Multispecialty 
Laparoscopic Repair of a Diaphragmatic Injury
Kanayochukwu J. Aluka, MD, Ranjit Pullarkat, MD

Objective: Laparoscopy in the diagnosis and management of penetrating diaphragmatic injuries is an acceptable surgical option.

Methods: We present one case of an 18-year-old male who sustained a penetrating thoracoabdominal injury. In addition to being hemodynamically stable, he had negative radiographs. The patient underwent a diagnostic and therapeutic laparoscopy. In the operating room, he was prepared and sterilely draped. A left tube thoracostomy was placed and secured prior to diagnosis. After trocar placement and instillation of pneumoperitoneum, the abdomen was surveyed. Thorough evaluation of the abdominal cavity failed to reveal any intraabdominal injuries. He was found to have a 2-cm injury located anterior lateral on the left diaphragm. This was repaired with a nonabsorbable suture in an interrupted fashion.

Results: Early ambulation and decreased pain medication requirements were noted during his hospital stay. In addition, his length of stay (3 days) was minimal. Literature search and review has shown a trend toward laparoscopic evaluation of penetrating thoracoabdominal injuries.

Conclusion: Laparoscopic repair of diaphragmatic injuries is a feasible armamentarium in management of penetrating thoracoabdominal injuries.

8281 General Surgery 
Laparoscopic Approach to Abdominal Trauma
Francisco Obregon, MD, Jennifer Marin, MD, Yumaira Hernández, MD,
Carlos Bravo, MD, Salvador Navarrete, A

Introduction: In the 1960s in South Africa, Heleson performed the first diagnostic laparoscopy to evaluate a patient with abdominal trauma. After that, Gazzaniga and Carnevale in 1977 recommended the use of laparoscopy for trauma. Because of the poor technical development in laparoscopy, there was little acceptance at that time. Because our country has an increase in abdominal trauma due a street violence, it is necessary to use this surgical approach to evaluate its benefits.

Methods: From February 2007 until January 2008, 14 patients with penetrating or blunt abdominal trauma have been treated at the Hospital Universitario of Caracas. All of them underwent a diagnostic laparoscopy to avoid laparotomy or to treat the possible injuries.

Results: The average patient age was 36.6 years; 87% were male. Laparotomy was avoided in 71.42% of the patients. Two patients were treated successfully, one with hepatic injury and another with splenic injury. No morbidity or mortality was associated with this procedure.

Conclusion: The use of diagnostic and therapeutic laparoscopy in the management of patients with abdominal trauma avoids unnecessary laparotomy and has the benefits of minimally invasive surgery with possible lower costs, less postoperative pain, wound complications, and reduced length of hospital stay.

8282 General Surgery
NOTES Roux-en-Y Gastric Bypass in Human Cadavers
Ph. Morel, Prof, Dr. Med, F. Pugin, Dr. Med, P. Swain, Prof, Dr. Med, O. Wagner, Dr. Med, P. Bucher, Dr. Med, N. Buchs, Dr. Med, M. Hagen, Dr. Med, MBA

Background: Advantages of a NOTES approach to Roux-en-Y gastric bypass (RYGB) might include easier access to the peritoneal cavity, substantial reduction in number of ports and port-related complications, improved cosmesis, and others. The technical feasibility of a NOTES-RYGB and limitations of available flexible and rigid instrumentation for such a procedure are unknown.

Methods: NOTES hybrid RYGB was performed in 6 human cadavers by using a combination of flexible and rigid instruments. Pouch creation was achieved by needle-knife dissection with a transvaginal flexible gastroscope. Articulated linear staplers transected the stomach. Measurements of limbs were accomplished with flexible and rigid graspers or intralumenally. A 21-mm anvil was introduced through a needle-knife incision into the small intestine and connected to the flexible shaft of a flexible transesophageal stapler to form a gastrojejunostomy. A linear stapler was used for the jejunojejunal anastomosis.

Results: It was feasible to perform bypass surgery in all cadavers. Dissection and pouch creation was easier than expected using flexible instruments to form the pouch. Ordinary rigid instruments were too short for some transvaginal manipulations. Anvil manipulation and docking were difficult using flexible instruments. Combinations of flexible and rigid visualization and manipulation were especially helpful for pouch creation and stapler manipulation. Transabdominal port access number was reduced from 5 to 7 to 1 to 3 translumenal access ports.

Conclusions: Roux-en-Y bypass surgery is technically feasible in human cadavers by using a NOTES hybrid approach. Changes in instrument design are required to improve complex hybrid endosurgical procedures.

8283 General Surgery
Total Robotic Roux-en-Y Gastric Bypass
Ph. Morel, Prof, Dr med, F. Pugin, Dr med, G. Chassot, Dr med, M. Hagen, Dr med, MBA

Background: The gold standard for Roux-en-Y gastric bypass (RYGBP) is currently a laparoscopic approach with stapled anastomoses. This approach is feasible, but associated with a high complication rate. Few centers perform robotic-assisted RYGBP with stapled entero-entero-anastomosis to avoid time-consuming rearrangement of the robot during the procedure. We hypothesize that total robotic RYGBP (1) may be conducted entirely without changing the position of the robot and (2) may result in fewer complications.

Methods: We developed a technique for total robotic RYGBP with robotically sewn gastro-entero and entero-entero-anastomosis without rearrangement of the robot during the procedure. We evaluated prospectively the results concerning complications (regarding anastomoses and overall), duration of suturing of anastomoses, and complete procedure.

Results: To date, we have performed 37 robotic RYGBPs. Duration of anastomoses ranged from 30 minutes to 145 minutes (median, 50) with a rapid learning curve. Duration of operation ranged from 210 minutes to 540 minutes (median, 310). All procedures could be finished robotically without rearrangement of the robot or any technical difficulties. We have not observed any complications, especially no leaks or stenoses of anastomoses. One patient with arterial bleeding from laparoscopic stapling line had to be reoperated on.

Conclusions: The data support the conclusion that total robotic RYGBP is feasible without rearrangement of the robot during the procedure. Robotically sewn gastro-entero and entero-entero-anastomoses seem to be superior compared with stapled anastomoses.

8284 General Surgery
Robotic Surgery Made Cost Effective!
M. Hagen, Dr med, MBA, F. Pugin, Dr med, G. Chassot, Dr med,
Ph. Morel, Prof, Dr med

Background: Due to semi-reusable instrumentation and high operating costs, robotic surgery with the da Vinci Surgical System is supposed to be more expensive than conventional laparoscopy. The authors of this study hypothesize that under certain circumstances (saving of expensive laparoscopic material, such as robotically sewn versus stapled anastomoses in Roux-en-Y gastric bypass), robotic surgery can be carried out more cost effectively than conventional laparoscopy.

Methods: We have prospectively tracked all material used for robotic Roux-en-Y gastric bypass (18 robotically assisted and 10 total robotic cases) and calculated both costs for special robotic material and overall costs. Results were compared with the costs of an average laparoscopic procedure.

Results: Overall costs for a robotic Roux-en-Y gastric bypass was 6041,52 CHF (5113 USD) versus 6619,09 CHF (5604 USD) for the laparoscopic procedure. Robotic material (not needed for conventional laparoscopy) costs 1978,77 CHF (1675 USD). The costs of staplers in laparoscopic Roux-en-Y gastric bypass (versus robotically sewn anastomoses) lead to the differences in overall costs.

Conclusions: Due to the favorable economy of robotically sewn anastomoses, robotic Roux-en-Y gastric bypass can be achieved with fewer costs when compared with the laparoscopic equivalent with stapled anastomoses. This demonstrates that it is generally possible to perform robotic surgery cost effectively. However, initial investment in the robot, maintenance costs, personnel, and many other elements were not considered in this evaluation. Exact analyses of costs, comparing robotic with laparoscopic surgery, remain difficult and subject to further research.

8285 General Surgery
Pure NOTES Repair of Umbilical Hernia in a Human Cadaver
M. Hagen, Dr med, MBA, O. Wagner, Dr med, P. Swain, Dr med, F. Pugin, Dr med,
P. Bucher, Dr med, N. Buchs, Dr med, Ph. Morel, Prof Dr med

Background: A pure NOTES approach to umbilical repair (UHR) might lead to a superior view of the anterior abdominal wall, no need for lateral ports, improved cosmesis, and others. However, feasibility of such a procedure in the human anatomy has not been tested before.

Methods: An umbilical hernia was created in a human male cadaver. A needle-knife incision followed by balloon dilatation over a jagwire allowed transrectal placement of a 15-mm trocar. An IT-knife was used for dissection while retracting with large grasper through a flexible double-channel scope. It was possible to manipulate and dissect by rotating the scope or moving the accessories relative to each other. The flexibility of the scope facilitated different angled views of the hernia and different approaches for adhesiolysis. The hernia mesh was measured and cut according to the size of the hernia. Threads were attached. The mesh was placed intraabdominally in a sterile bag closed by an endoscopic snare. The mesh was then removed with flexible graspers. Sutures were grasped by a sprung hook-needle and pulled outside. All threads were tightened and tied under flexible endoscopic view.

Results: It was feasible to perform the hernia repair by a pure NOTES procedure in the first attempt. Adhesiolysis and retraction were easier than expected using flexible instruments. Vision with the flexible scope was good, and using NOTES for UHR seemed easy.

Conclusions: Pure NOTES approach to UHR is technically feasible in human cadavers and seems an attractive niche procedure for NOTES in patients.

8286 Gynecology
Comparative Evaluation of Tubal Sterilization by Two Methods: Laparoscopy-Filshie Clips and
Minilaparotomy Pomeroy Technique
Saghafi Nafiseh, MD, Mr. Bahman Amirsajjad, Mansouri Atieh, MD, Pour Javad Monireh, MD, Mrs. Bahman Sara

Introduction and Objective: Tubal sterilization is a common method of contraception used worldwide. Many different methods have been used to achieve this end. The purpose of this study was to compare 2 methods: Filshie clips and Pomeroy.

Methods: The study comprised 196 women who desired sterilization. They were randomly assigned into 2 groups: Laparoscopy, Filshie clips (96 cases) and Pomeroy-minilaparotomy (100 cases). We compared the duration of operation, surgical complications, postoperative pain, and infection. We followed patients long term (range, 1 to 4 years) for evaluation of abnormality in menstrual cycles, pelvic pain, and failure rate.

Results: The mean duration of the procedure was shorter for the Filshie clips (P<0.07). Postoperative pain and infection were less with clips (P=0.072). The failure rate was 1.77% for clips and 0% for Pomeroy (P<0.05). Other complications did not show significant differences.

Conclusions: The Filshie clip is an effective and acceptable technique for sterilization, because of its effective design and ease of application.

8289 General Surgery
Superiority of Laparoscopic Resection Over Open Surgery for Rectal Cancer
Andre da Luz Moreira, MD, Isabella Mor, MD, Daniel Geisler, MD, Feza Remzi, MD, Ravi P Kiran, MD

Introduction: There is a dearth of evidence comparing outcomes after laparoscopic (LS) and open surgery (OS) for resection of rectal cancer. We compare early postoperative morbidity and mortality after LS versus OS in rectal cancer patients.

Methods: Retrospective review of prospectively collected data for consecutive patients undergoing elective laparoscopic resection for rectal cancer. LS were matched 1:1 to OS by age, sex, ASA class, BMI, tumor stage, distance from anal verge, neoadjuvant radiotherapy, use of defunctioning stoma, type of anastomosis. Data were analyzed on an intention-to-treat basis, and comparison between groups was performed using chi-squared, Fisher's exact, and Wilcoxon rank-sum tests as appropriate. P<0.05 was considered statistically significant.

Results: Median age for LS (n=91) was 62 years (range, 28 to 91) (59% male). There were 19 open conversions (20%). In addition to comparable matched criteria, LS and OS had similar previous abdominal surgeries (32/35% LS vs.28/30% OS, P=0.5), median tumor size (3.2cm vs.3cm, P=0.7), and lymph node harvest (16 LS vs.16.5 OS, P=0.5). Thirty-day morbidity and mortality were similar except wound infection, which was significantly lower for LS (P=0.02). LS had similar 30-day readmissions (8/9% both groups, P=1) but shorter total length of hospital stay (5 vs.7 days, P<0.01), time to first flatus (3 vs.4.5 days, P=0.001) and time to first bowel movement (4 vs.5 days, P=0.05) when compared with OS.

Conclusion: LS is associated with significantly earlier recovery, reduced length of hospital stay, and reduced risk of postoperative wound infection when compared with carefully matched OS patients.

8290 General Surgery
Gastrojejunal Stapling During Natural Orifice Translumenal Endoscopic Surgery (NOTES) in Human Cadavers: Material, Techniques, and Stapler Modifications
O. J. Wagner, Dr med, M. Hagen, Dr med, MBA, P. Swain, Prof, Dr med, F. Pugin, Dr. med, P. Bucher, Dr med, N. Buchs, Dr med, Ph. Morel, Prof, Dr med

Background: Formation of anastomoses with conventional laparoscopic staplers (CLS) during NOTES is demanding. New methods for translumenal endosurgery would be valuable. CLS are effective at forming anastomoses but are poorly configured for NOTES. Material modifications might ease the application of CLS for NOTES.

Methods: Translumenal gastrojejunostomy was formed in 6 human cadavers either with a flexible, computer-assisted stapler (1), a rigid circular CLS (2), or an articulated linear CLS (3). All material was modified to ease NOTES procedures.

Results: (1) Flexible shaft was introduced transesophageally and anvil through an umbilical incision. Blind transesophageal passage of the flexible stapler shaft was demanding and occasionally caused injuries. Flexible docking was difficult and required laparoscopic graspers. Vicryl loops attached to the anvil eased docking significantly. (2) Rigid circular stapling required transgastric guidewires. Anvils were fixed to the guidewire or a gastric tube before pulling into the stomach. A stapler was introduced transvaginally; docking was conducted with graspers. Modifications for easy anvil release from the tube were designed. (3) For linear anastomosis, linear staplers were inserted transvaginally and small bowel imposed with graspers. The stapler was perforated at the tip to bead a previously introduced guidewire. Staplers were guided by the wire into the stomach, and anastomosis was controlled by an endogastric scope.

Conclusions: This study indicates that stapled anastomoses are feasible with CLS in NOTES procedures, when slightly modified. Flexible staplers allow reverse insertion and make introduction of a rigid shaft into the abdominal cavity dispensable. For pure NOTES procedures, improvements in flexible/rigid instrument interaction, tissue retraction, suturing, and stapler design are needed.

8291 Urology
Long-term Impact of a Laparoscopic Renal Surgery Mini-Residency on Postgraduate Urologic Practice Patterns
Rosanne Santos, Aldrin Joseph R. Gamboa, MD, Michael K. Louie, MD,
Geoffrey N. Box, MD, Kevin H. Sohn, Hung Truong, Rachelle Lin, Amanda Khosravi, Ralph V. Clayman, MD, Elspeth M. McDougall, MD

Introduction and Objective: Laparoscopic renal surgery (LRS) has become a well-accepted approach for surgical management of many renal diseases. However, transfer of these skills to postgraduate surgeons, via a 2- or 3-day hands-on experience has been poor; indeed, the take rate for these courses is only in the 50% to 60% range. Accordingly, at the University of California, Irvine, we have developed a unique 5-day, LRS, mini-residency (M-R) program to assess whether a longer, intense, and more directed experience would result in a more positive impact on postgraduate urologists’ practice patterns.

Methods: One hundred and three urologists underwent laparoscopic ablative (LA) (n=43) and laparoscopic reconstructive (LR) (n=60) renal surgery training. The one-to-two, teacher-to-attendee experience included tutorial sessions, hands-on inanimate and animate skills training, and clinical case observations. Participants were asked to complete a detailed questionnaire 1, 2, and 3 years after the M-R, regarding their laparoscopic practice patterns.

Results:  Response rates 1, 2, and 3 years after the M-R were 69% (71/103), 41% (39/94) and 32% (12/38), respectively. The percentage of participants performing LRS 1, 2, and 3 years after M-R was 79% (56/71), 89% (35/39), and 83% (10/12), respectively. The procedures performed 1, 2, and 3 years after the M-R included radical nephrectomy [75% (42/56), 53% (20/35), 100% (10/10)], nephroureterectomy [43% (24/56), 47% (18/35), 80% (8/10)], pyeloplasty [21% (12/56), 18% (7/35), 30% (3/10)], simple nephrectomy [43% (24/56), 37% (14/35), 60% (6/10)], partial nephrectomy [25% (14/56), 29% (11/35), 50% (5/10)] and cyst decortication [20% (11/56), 18% (7/35), 10% (1/10)], respectively.

Conclusions: A 5-day, intensive LA and LR renal surgery course enabled postgraduate urologists to effectively introduce or expand the volume and breadth of their laparoscopic renal surgery practice.

8292 Urology
Long-term Impact of a Robot-Assisted Laparoscopic Prostatectomy Mini-Residency Training Program on Postgraduate Urologic Practice Patterns
Rosanne Santos, Aldrin Joseph Gamboa, MD, Geoffrey N. Box, MD, Michael K. Louie, MD, Eric Sargent, MD, Ricardo Santos, MD, Kevin H. Sohn, Hung Truong, Rachelle Lin, Amanda Khosravi, David Ornstein, MD, Thomas Ahlering, MD, Ralph Clayman MD, Elspeth McDougall, MD

Introduction: Robot-assisted laparoscopic prostatectomy (RALP) has stimulated a great deal of interest. We evaluated whether a 5-day, focused, mini-residency (M-R) for RALP would enable postgraduate urologists to incorporate the procedure into their clinical practice.

Methods: From July 2003 to June 2006, 47 urologists participated in the M-R RALP. The 5-day course had a 1:2 faculty:M-R attendees ratio; curriculum included lectures/tutorials, inanimate, animate, and cadaveric robotic skills training, and surgical case observation. Questionnaires assessing practice patterns after 1, 2, and 3 years M-R program were analyzed.

Results: One, 2, and 3 years following the M-R, response rates to the questionnaires were 89% (42/47), 91% (32/35), and 88% (21/24), and percentages of participants performing RALP were 70% (33/47), 71% (25/35), and 75%(18/24), respectively. Among the 6 attendees not performing RALP 3 years post M-R, the reasons included lack of a robot (1), other partners performing RALP (1), feeling of insufficient training (1), and unstated (3). The number of RALP being performed per year 1, 2, and 3 years after the M-R were 1 to 10 [61% (20/33), 36% (9/25), 22% (4/18)], 11 to 20 [12% (4/33), 20% (5/25), 17% (3/18)], 21 to 30 [9% (3/33), 16% (4/25), 0%], and >30 [12% (4/33), 24% (6/25) 56% (10/18)], respectively.

Conclusion: A 5-day focused RALP MR enables the majority of urologists to successfully and safely incorporate this procedure into their clinical practice both in the short- and long-term.

8293 Pediactric Surgery
Initiation of a Pediatric Robotic Surgery Program and a Case-Control Analysis of Pediatric Robotic Ureteral Reimplantation
Mathew D. Sorensen, MD, Jeff Bice, Catherine Delostrinos, BS, Richard W. Grady, MD, Byron D. Joyner, MD, Stephen S. Kim, MD, Thomas S. Lendvay, MD 

Introduction/Objective: Robotic surgery may improve patient outcomes in adults but benefits in children remain to be seen. We describe the first 50 robotics cases performed at our institution and report a case-control analysis comparing perioperative performance and postoperative outcomes after ureteral reimplantation for the management of vesicoureteral reflux.

Methods: We retrospectively reviewed patients who underwent robotic surgery at our hospital. For each child who underwent robotic reimplantation, 2 age/sex/ASA class/reflux grade/and laterality-matched open historic controls were compared for nonoperative and operative times, length of stay, EBL, complications, and surgical success.

Results: Fifty patients underwent 14 different robotics procedures over a 20-month period by urology (42 cases, 84%) and general surgery (8 cases, 16%) in 30 males and 20 females. The mean age was 8.6 years (SD, 5.8), and mean weight was 33.1kg (SD, 19.6) with 9 patients under 10kg (18%). There were 5 (10%) complications and 5 (10%) conversions, (3 laparoscopic, 2 open). For ureteral reimplantation (8 unilateral, 5 bilateral), robotic procedures had 51% longer total OR times (P<0.0001) due to longer procedure times. Bilateral repairs averaged 18 minutes longer in the open group, and 138 minutes longer in the robotics group. EBL, length of stay, complications, and surgical success were similar between groups.

Conclusion: Robotic surgery is safe and effective in pediatric patients irrespective of age. Increased operative times can be expected in the infancy of new technology adoption and should be planned for in surgical scheduling. A dedicated support staff is critical for a robotics program’s success.

8294 Pediactric Sugery
Case-Control Analysis of Pediatric Robotic Pyeloplasty and the Impact of Mechanical Failures
Mathew D. Sorensen, MD, Catherine Delostrinos, BS, Jeff Bice, Richard W. Grady, MD, Byron D. Joyner, MD, Thomas S. Lendvay, MD 

Introduction/Objective: Few data compare open and robotic-assisted laparoscopic (RAL) reconstructive surgery in pediatric patients. We performed a case-control analysis of pediatric patients undergoing robotic versus open ureteropelvic junction repair with a focus on perioperative performance and postoperative outcomes and discuss the effect of mechanical failures.

Methods: We retrospectively reviewed 18 patients who underwent RAL pyeloplasty at our institution from April 2006 to November 2007. Each case was paired with 2 age, sex, and ASA class open historic controls. We compared nonoperative and operative times, length of stay, EBL, complications, and surgical success with particular focus on cases with intraoperative mechanical failures.

Results: Eighteen patients, 3 females and 15 males, underwent RAL pyeloplasties with a mean age of 9.5 years (SD 6.2) and mean weight of 39.2 kg (SD 22.0) with 3 patients under 10kg (17%). In comparison to 36 matched open controls, RAL overall OR times were 54% longer than times for open cases (mean, 5.9 hours versus 3.8 hours, respectively). The greatest contributor to longer operative times was primary procedure time. EBL, lengths of stay, complications, and success rates were similar. Three (16%) intraoperative mechanical failures resulted in conversion to laparoscopic procedures with no statistically significant difference in operative times.

Conclusion: RAL pyeloplasty is safe in children and has equivalent success and complication rates as open repairs. Mechanical failures do occur, and thus the surgeon should be capable of performing the procedure laparoscopically. Contrary to other studies, procedure time most heavily influenced operative times, not setup or turnover time.

8296 General Surgery
Minimal Invasive Approach of the Liver Hydatidosis
C. Duta, C. Lazar, F. Lazar

Background: In recent decades, the treatment of liver hydatidosis has changed. Open surgery remains the option for complicated liver hydatid cysts. For simple uncomplicated hydatid cysts, there are very good therapeutic alternatives: medical treatment alone, echo-guided puncture, laparoscopic treatment. The aim of this study was to compare echo-guided puncture with the laparoscopic approach in the treatment of liver echinococcosis.

Methods: Between 1996 and 2005, 214 patients were admitted with liver hydatid cysts. The PAIR (puncture, aspiration, injection, reaspiration) technique was used to treat 138 patients. Twenty-seven patients were treated laparoscopically, and in 49 cases we performed conventional surgery for complicated liver hydatid cysts.

Results: The patients were successfully treated, and the mean follow-up time was 41.7±12.5 months involving ultrasound, computed tomography, and serology tests, which showed no local recurrence or spread of the disease. The patients treated by PAIR were cured in 95.6% of cases, and those treated laparoscopically were cured in 90.5% of cases. In 6 cases from the first lot, it was necessary to perform another puncture up to 2 years later, because the cavity did not disappear. In 3 patients, we performed a classic operation for one hepatic abscess and 2 biliary fistulas. Two patients from the laparoscopic lot developed one subhepatic abscess and one biliary fistula that required open surgery.

Conclusion: Both methods are safe and efficient in the treatment of liver hydatid cysts. However, in difficult localization of the cysts (posterior, superior, central) the echo-guided puncture is the method of choice.

8297 General Surgery
Laparoscopic Type IV Hiatal Hernia Repair with Mesh
J. R. Salameh

Introduction: Paraesophageal hiatal hernias can grow to significant size and may contain the stomach along with other intraabdominal organs (type IV). The repair of such hernias can be technically challenging.

Case Report: An 83-year-old female presented with a long-standing history of epigastric and substernal discomfort, dysphagia, and early satiety. A CT scan revealed a large hiatal hernia containing the entire stomach, small bowel, and the right and transverse colon. Upper gastrointestinal radiographic series confirmed an intrathoracic stomach with organoaxial rotation and an intrathoracic gastroesophageal junction. A laparoscopic repair was performed, and the video of the procedure is presented. The steps of the procedure consisted of (1) reduction of the hernia content, (2) mobilization of the gastric fundus, (3) dissection and resection of the hernia sac, (4) transhiatal esophageal mobilization to establish a 3-cm intraabdominal esophageal length, (5) hiatal hernia repair with sublay ePTFE mesh, and (6) 360-degree fundoplication. The procedure was completed successfully, and the patient made an uneventful recovery. The patient had complete resolution of her symptoms at 2-year follow-up.

Conclusion: Giant type IV hiatal hernias can be successfully corrected laparoscopically. Mesh should be used to achieve a tension-free repair of the hiatal defect.

8298 Multispecialty
Biliary Endoscopic Lithotripsy
Joseph Wyatt, MD, John R. Burns, MD

Background: Calculi in the common bile duct and hepatic ducts are usually treated with endoscopic cholangiopancreatography (ERCP). Using this technique, calculi are trapped within a basket, crushed, and then removed. When calculi are large or difficult to crush, ERCP is no longer an effective treatment. An alternative treatment is transhepatic endoscopy of the common duct and hepatic ducts with holmium laser treatment of the calculi. We have treated 8 of these patients with excellent results.

Methods: All of these patients had a failed attempt at ERCP. In 6 of the patients, a transhepatic catheter had already been placed for drainage. The technique for stone removal involves placement of 2 guide wires followed by placing a 12/14F ureteral access sheath into the common bile duct. A flexible ureteroscope is then passed into the duct, and the calculi are fragmented by a 200-micron holmium fiber or crushed in a nitinol basket. Fragments are then flushed into the small bowel.

Results: Patients are usually treated as outpatients and recover in 1 to 2 days compared with at least one month after open surgery. Calculi in the common bile duct and hepatic ducts can cause severe liver problems including jaundice and infections. Open surgical removal of these calculi is invasive, technically difficult, and sometimes not successful. ERCP is a technique that has been used for many years and is generally very effective.

Conclusion: In cases that fail ERCP, transhepatic endoscopy and lithotripsy can often save the patient extensive surgery. Although transhepatic lithotripsy had been used previously, we believe that combining the miniaturized endoscopic equipment and expertise of urology with the anatomic and management expertise of GI surgery yields superior results.

8299 General Surgery
Laparoscopic Skill Acquisition from a Novel Simulator Curriculum is Independent of Video Gaming Experience and is Maintained After Training
Michael Martinez, AB, Lucian Panait, MD, Kurt E. Roberts, MD, Robert L. Bell, MD, Andrew J. Duffy, MD

Objective: Skills training prior to the operating room is essential for surgical trainees. The LapSim simulator enables customization of training curricula. We previously demonstrated that completing our novel curriculum improves laparoscopic skills in novices. We hypothesize a correlation of surgical skill development with exposure to video games, musical instruments, and sports. We anticipate skill degradation with breaks in simulator training.

Methods: Thirty-two novice medical students were randomly assigned to training schedules. All completed a questionnaire documenting gaming, musical, and sports experience. Subjects were familiarized with laparoscopic instruments. Baseline skill was evaluated with 2 FLS tasks (peg transfer and pattern cutting). Groups trained regularly, attempting to complete the curriculum. FLS tests were repeated monthly. All participants underwent their final skills test at least 30 days after the completion of simulator training. Test score comparisons utilized analysis of covariance with adjustment for baseline scores.

Results: Ten students passed the curriculum and examination, while 15 did not, and 7 withdrew. No statistically significant correlation was found to gaming, instrument, or sports experience between passers and nonpassers. FLS scores showed statistically significant improvement among all subjects (P<0.001). No skill degradation was demonstrated after 30 days; rather, average scores continued to improve. Statistically significant improvement was approached for peg transfer (P=0.069) and reached for pattern cutting (P=0.002).

Conclusions: Experience with video gaming, musical instruments, and sports does not correlate with laparoscopic skill acquisition from our curriculum. All trainees who participate in our virtual-reality training curriculum should develop skills without short-term skill degradation.

8300 General Surgery
Sutureless Ventral Hernia Repair in Obese Patients
Ehab Akkary, MD, Andrew Duffy, MD, Kurt Roberts, MD, Robert Bell, MD, MA

Background: Transfascial sutures are a standard feature of laparoscopic ventral herniorrhaphy. Nevertheless, transfascial sutures contribute to increased postoperative pain and, resultantly, longer hospital stay. Primary abdominal wall hernias are associated with small defects, and in these patients, transfascial sutures may not be necessary. In obese patients, the cosmesis is diminished, and the recurrence rate is increased with primary repair. We hypothesize that obese patients with small abdominal wall hernias would benefit from a laparoscopic repair without transfascial sutures.

Methods: From September 2002 to December 2007, 174 patients underwent laparoscopic incisional hernia repair. Included were 12 patients with a body mass index >30 kg/m2, with small primary abdominal wall hernias. Parietex mesh (Covidien, Norwalk, CT) was implanted, well-overlapped the defect, and was secured to the fascia using only helical tacks. The defect surface area, operative time, and postoperative stay were recorded.

Results: Five patients were female, and 7 patients were male. The mean operative time was 42 minutes, and 11 patients (92%) were discharged home the day of surgery. The defect size ranged from 1.8cm2 to 7.1cm2. There were no infectious or bleeding complications; one patient required chronic pain management. Eight patients (67%) developed palpable seromas that eventually resorbed without intervention. Zero patients had a clinical hernia recurrence at a mean 7-month follow-up.

Conclusion: Laparoscopic ventral hernia repair is feasible and durable without transfascial sutures provided the hernia defect is small. Surgery can be performed as an outpatient procedure with minimal postoperative morbidity, even in obese individuals.

8302 Urology
Robotic and Laparoscopic Partial Nephrectomy without Vascular Clamping and Renal Ischemia
Sijo J. Parekattil, Carl Bischoff, Miranda J. Hardee, Benjamin K. Canales, Chester B. Algood, Charles J. Rosser, Philipp Dahm, Johannes W. Vieweg

Objective: Robotic and laparoscopic partial nephrectomy is a treatment option for small renal masses (<4cm). During these cases, clamping of the renal vessels is required to minimize bleeding. This study presents utilization of hemostatic hydrodissection, bipolar and radio frequency coagulation during these cases to avoid renal vascular clamping and renal ischemia.

Methods: Review of 22 cases from January 2006 to January 2008. Sixteen underwent the procedure without vascular clamping using Hemostatic hydrodissection (Helix HydroJet), bipolar vessel coagulation (Erbe BiClamp Coagulator), and radio frequency coagulation of the margin (RITA Habib probe). Postoperative follow-up ranged from 1 month to 24 months.

Results: None of the 16 cases required vascular clamping. Mean patient age was 60 (range, 37 to 70), mean renal mass size was 2.5cm (range, 1.1 to 3.7), mean estimated blood loss was167cc (range, 20 to 500), and mean operative time was 204 minutes (range, 120 to 300). All resection margins were negative for malignancy. One patient had a horseshoe kidney. Eight patients had a transperitoneal approach, and 8 had a retroperitoneal approach. Mean hospital duration of stay was 3 days (range, 2 to 6). Three delayed urine leaks occurred that were treated conservatively. All patients had no significant change from baseline serum creatinine. Final pathology was as follows: 7 renal cell carcinomas, 3 angiomyolipomas, 1 oncocytoma, and 5 complex hemorrhagic cysts. No tumors have recurred so far.

Conclusions: This new technique for robotic and laparoscopic partial nephrectomy appears to be a safe technique that avoids renal vascular clamping and renal ischemia. Further testing and follow-up will determine longer-term outcomes.

8303 General Surgery
Laparoscopic Sigmoidectomy with Suture Rectopexy for Full-Thickness Rectal Prolapse
Dan Geisler, MD, Tracy Hull, MD

Objective: Surgical approaches for the treatment of rectal prolapse include both abdominal and perineal approaches. Although the abdominal approach has traditionally been met with a higher rate of complications and a lengthier recovery, this approach remains the preferred treatment option for healthy patients because it is related to lower rates of recurrence.

Methods: Using a 3-trocar technique, this video demonstrates a sigmoidectomy with colorectal anastomosis, circumferential dissection to the pelvic floor, and a durable suture rectopexy.

Results: No postoperative complications occurred. The patient reported improvement in all aspects of bowel function and was discharged on postoperative day 3.

Conclusion: The treatment of rectal prolapse continues to evolve. The incorporation of a minimally invasive approach makes an abdominal approach all the more appealing. The authors strongly feel that the use of laparoscopy should not change the critical aspects of the operation, ie, formal resection, circumferential dissection, and durable rectopexy.

8304 Urology
Video Demonstration of Robotic and Laparoscopic Partial Nephrectomy Without Vascular Clamping and Renal Ischemia
Carl Bischoff, Miranda J. Hardee, Benjamin K. Canales, Chester B. Algood, Charles J. Rosser, Philipp Dahm, Johannes W. Vieweg, Sijo J. Parekattil

Objective: Robotic and laparoscopic partial nephrectomy is a treatment option for small renal masses (<4cm). During the procedure, clamping of the renal vessels is required to minimize bleeding. This video presents a technique utilizing hemostatic hydrodissection and bipolar and radio frequency coagulation to avoid renal vascular clamping and renal ischemia.

Methods: Review of 22 cases from January 2006 to October 2007. Fourteen patients underwent hemostatic hydrodissection (Helix HydroJet), bipolar coagulation (Erbe BiClamp Coagulator), and radio frequency coagulation of the margin (RITA Habib RFA probe). Renal hilum was dissected in all cases so that renal vascular clamping could be performed if bleeding was encountered. Postoperative follow-up ranged from 1 month to 21 months.

Results: None of the 14 cases required vascular clamping. Mean patient age was 61 years (range, 37 to 70), mean renal mass size was 2.6cm (range, 1.1 to 3.7), mean estimated blood loss was 162cc (range, 20 to 500), and mean operative time was 198 minutes (range, 120 to 300). All resection margins were negative for malignancy. One patient had a horseshoe kidney. Eight patients had the transperitoneal approach, and 6 had the retroperitoneal approach. Mean hospital duration of stay was 4 days (range, 2 to 6). Two delayed urine leaks occurred that were treated conservatively. All patients had no significant change from baseline serum creatinine. Final pathology was as follows: 6 renal cell carcinomas, 2 angiomylipomas, 1 oncocytoma, and 5 complex hemorrhagic cysts.

Conclusions: This new technique for robotic and laparoscopic partial nephrectomy appears to be a safe technique that avoids renal vascular clamping and renal ischemia. Further testing and follow-up will determine longer-term outcomes.

8305 General Surgery
Laparoscopic Proctosigmoidectomy with Vertical, Double-Stapled Coloanal Anastomosis
Dan Geisler, MD

Objective: Laparoscopy has become readily accepted as a treatment option for cancer of the colon. However, the feasibility of a minimally invasive approach for cancers of the low rectum continues to be a source of debate.

Methods: Using a 3-trocar technique, this video demonstrates a complete proctosigmoidectomy with a vertical, double-stapled coloanal anastomosis for a cancer of the distal 3cm of the rectum.

Results: No postoperative complications occurred. The patient was discharged on postoperative day 2, and the final pathology revealed an intact total mesorectal excision specimen.

Conclusion: The treatment of rectal cancer remains under debate. The incorporation of a minimally invasive approach by a trained surgeon reveals superior results compared with results of conventional surgery for the treatment of rectal cancer.

8306 General Surgery
Laparoscopic Total Proctocolectomy with Vertical, Double-Stapled Ileal-Pouch Anal AnastomosisDan Geisler, MD

Objective: Laparoscopy has become readily accepted as a treatment option for many disorders of the colon. However, the feasibility of a minimally invasive approach for more complex cases continues to be a source of debate.

Methods: This video demonstrates a total proctocolectomy using a 4-trocar technique with a vertical, double-stapled ileal pouch anal anastomosis for ulcerative colitis.

Results: No postoperative complications occurred. The patient was discharged home on postoperative day 3 and was able to have her temporary stoma closed 4 weeks postoperatively.

Conclusion: The use of laparoscopy for more complex cases remains a source of debate. The incorporation of a minimally invasive approach by a trained surgeon is appealing not only for the improved cosmesis and quicker recovery, but also for the ability to restore bowel continuity at a much earlier date and the tremendously decreased rates of bowel obstruction in pouch patients that has been reported to be as high as 80%.

8307 Multispecialty
Cystoscopic Removal of Transvesical Sling with Holmium Laser
Joseph Wyatt, MD, L. Keith Lloyd, MD

Background: Transvesical placement of midurethral slings is a known complication of TVT and TOT that is a challenge for urologists and troubling to patients. We developed a novel technique using equipment universally available to urologists to allow complete cystoscopic removal of the graft material.

Methods: A biopsy forceps is introduced along side the cystoscope through the urethra. It is used to place tension on the graft at the exit site, exposing the injured bladder wall. A 550-micron laser fiber is placed through the deflecting bridge. The Holmium laser set to 0.6 Joules and 6Hz is used to cut the sling and bladder wall. When tension is released, inspection shows no remaining exposed graft. It has retracted deep into the bladder wall. Complete removal of the foreign object is essential. Any remaining exposed graft material is a nidus for infection or stone formation. Only with complete removal deep in the bladder wall as demonstrated can the urothelium heal over the site. The cystoscope is reintroduced, and the injury site is examined. Bugbee electrocautery is sparingly used to stop bleeding vessels. A catheter is kept overnight, and the patient can resume normal activities immediately.

Results: We have followed the results of this technique for over one year without any complications or need for further procedures. Cystoscopic follow-up images are included at the end of the video.

Conclusion: This minimally invasive technique allows for definitive treatment of this complication with no incisions and avoids open excision, allowing the patient immediate return to normal activity.

8308 Urology
Laparoscopic Management of Coexisting Calyceal Diverticulum and Peripelvic Cyst
William J. Badger, MD, Steve Waxman, Sanjeev K. Gupta, MD, Eve D. Clark, MD, Kelli J. Andresen, MD, Howard N. Winfield, MD

Objective: Demonstrate a unique case of a coexisting symptomatic calyceal diverticulum and peripelvic cyst.

Methods: The case was initiated with the retrograde placement of an open-ended catheter into the renal pelvis. Then, utilizing our standard 4-port laparoscopic approach, the monopolar scissors and hook were utilized in reflecting the colon and spleen. After excising the perirenal fat for pathology examination, the cystic lesion was identified and extensively mapped with intraoperative ultrasound. The wall of the diverticulum was excised with the Harmonic scalpel, and retrograde instillation of indigo carmine revealed a pinhole communication with the collecting system. The adjacent peripelvic cyst wall was excised and was demonstrated to have no communication with the collecting system. The wall of the diverticulum was then extensively fulgurated with the Argon Beam Coagulator (ABC). Further hemostasis maintained with Floseal and Surgicel.

Results: No intraoperative complications occurred, and the diverticular wall and cyst wall were benign on pathology examination. The patient did well with resolution of his flank pain.
Conclusion: Calyceal diverticula and peripelvic cysts can be safely and efficiently managed with pure laparoscopic excision.

8309 Urology
Transperitoneal Pure Laparoscopic Partial Nephrectomy: Previous Abdominal Surgery Not a Contraindication
William J. Badger, MD, Steve Waxman, David D. Thiel, MD, Matthew R. Braasch, MD, David M. Kuehn, MD, Howard N. Winfield, MD

Objective: To demonstrate that transperitoneal pure laparoscopic partial nephrectomy for a solid renal mass is safe and feasible even with multiple prior intraabdominal surgeries including bowel resection and colostomy.

Methods: Utilizing our standard 4-port laparoscopic approach, we were able to perform extended lysis of adhesions from previous bowel surgery and complete our standard partial nephrectomy in a transperitoneal approach. The monopolar scissors and hook were utilized in reflecting the colon and spleen, while the hook alone was used in dissecting the renal hilum. After excising the perirenal fat for pathology examination, the lesion was identified and extensively mapped with intraoperative ultrasound. After clamping the hilum, cold scissors were then utilized in excising the mass. Large vessels were then oversewn with the assistance of a single LapraTy. The renal defect was closed with bolsters and sutures.

Results: No intraoperative or postoperative complications occurred for this complex procedure. Pathology examination confirmed renal cell carcinoma with negative surgical margins.

Conclusion: Transperitoneal pure laparoscopic partial nephrectomy for a solid renal mass is safe and feasible even with multiple prior intraabdominal surgeries.

8310 General Surgery
Laparoscopic Ileocecectomy for Malignant Ileocecal Intussusception in an Adult
Dan Geisler, MD

Objective: Laparoscopy has become readily accepted as a treatment option for cancer of the colon. However, the feasibility of a minimally invasive approach in a patient with a chronic intussusception has not been well reported.

Methods: This video demonstrates the 3-trocar technique for an ileocecectomy with en bloc resection of a malignant ileocecal intussusception in an adult patient.

Results: No postoperative complications occurred. The patient was discharged on postoperative day 3, and the final pathology revealed a B-cell lymphoma.

Conclusion: The treatment of B-cell lymphoma is chemotherapy. However, surgery is often required for diagnosis and, occasionally, to treat obstruction. Although a lengthy recovery from conventional surgery can delay the initiation of the ideal treatment of such a malignancy, a minimally invasive approach will often allow the prompt use of chemotherapy in the early postoperative period.

8311 Urology
Decreasing Operative Time with Doppler Identification of Crossing Vessel During Robotic and Laparoscopic Pyeloplasty
Sijo J. Parekattil, Patrick Villicana, Carl Bischoff, Marc S. Cohen, Benjamin K. Canales, Philipp Dahm, Johannes W. Vieweg

Objectives: Robotic and laparoscopic pyeloplasty is a treatment option for uretero-pelvic junction (UPJ) obstruction. A crossing vessel may be the cause for the obstruction. Our goal was to assess whether Doppler ultrasound during the dissection of the renal pelvis would aid in identification of a crossing vessel and whether this would provide any benefit to the surgeon in terms of decreasing the duration of surgery.

Methods: This was a retrospective review of all 22 cases from July 2005 to February 2008. Fifteen of these patients had a crossing vessel. Eleven patients underwent the procedure with the assistance of real-time intraoperative laparoscopic Doppler ultrasound (VTI probe, Vascular Technology) to identify any crossing vessel in the UPJ area. Selection of these patients was randomly based on availability of the Doppler device. Operative duration for all these cases was compared.

Results: Mean duration of a case without Doppler assistance was 223 minutes (range, 90 to 300). Mean duration with Doppler assistance was 168 minutes (range, 60 to 210). This difference was statistically significant, P=0.03. Subjectively, the intraoperative Doppler provided utility for the surgeon to identify where the crossing vessel was located prior to the UPJ dissection and was a useful teaching tool for resident training.

Conclusions: The use of Doppler ultrasound identification of a crossing vessel during robotic and laparoscopic pyeloplasty may provide guidance to surgeons during dissection of the UPJ. The preliminary findings appear to indicate that the use of the intraoperative Doppler decreases operative time. Further testing and evaluation are needed.

8312 Urology
3-Dimensional Visualization During Conventional Laparoscopic and Robotic-Assisted Surgery: A Look Into The Future?
Ravi Munver, MD, Jayant Uberoi, MD, Ruth Ann Miles, MD, George A. Dakwar, MD, Ihor S. Sawczuk, MD

Objective: Implementation of the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) offers the surgeon unparalleled 3-dimensional (3-D) visualization. However, 3-D visualization is limited to the console surgeon, while assistants have a 2-dimensional (2-D) view on flat video screens. Similarly, laparoscopic surgery is faced with the challenge of a 2-D view of the surgical field. We evaluated the EndoSite 3Di Vision System (Viking Systems, San Diego, CA), a high-definition head-mounted 3-D vision system, during laparoscopic and robotic-assisted surgery.

Methods: The 3-D System was used by patient-side assistants during robotic-assisted prostatectomy and by the surgeon and assistants during laparoscopic renal/adrenal procedures. Evaluations were performed by 2 experienced urologists, 1 fellow, and 2 residents, for parameters including visual clarity, learning curve, operative precision, and comfort.

Results: Fifty consecutive laparoscopic and robotic-assisted procedures were evaluated. The 3-D system was rated favorably by all 5 surgeons for exceptional visual clarity, minimal to no learning curve, and subjective improvement in operative precision. Five surgeons noted head/neck fatigue after 1.5 hours and attributed this to the weight (2lbs 6oz) of the head-mounted system. An additional limitation was that the system was only available for use with a bulky 10-mm laparoscope for laparoscopic procedures.

Conclusions: Advantages of the 3Di Vision System include its compatibility with laparoscopic and robotic-assisted procedures. This technology extends 3-D vision to an entire surgical team and may translate into faster learning curves, shorter operative times, and improved performance for novice and experienced surgeons.

8313 General Surgery
Laparoscopic Liver Resection: Our Initial Experience and Results
Manuel I. Rodriguez-Davalos, MD, Edward J. Southard, MD, Juan P. Rocca, MD, Caroline Rochon, MD, Ashutosh Kaul, MD, Michael Marvin, MD, Patricia A. Sheiner, MD, Marcelo E. Facciuto, MD

Background: Advances in minimally invasive surgery (MIS) have revolutionized modalities available to patients and clinicians in performing surgical procedures. However, it is only recently that this technique has been introduced for use in hepatobiliary surgery.

Methods: A retrospective analysis of all patients with potentially resectable liver tumors using minimally invasive techniques (March 2006 to February 2008) was done. Demographics, tumor characteristics, technique, and outcomes were all evaluated.

Results: Over a 2-year period, 9 resections were performed from a group of 11 patients. Two patients underwent intraoperative ultrasound and biopsy. The lesions were benign with no malignant potential, and no resection was performed. Five of 9 were resected for primary hepatocellular carcinoma, 2 for metastases, and 2 for benign disease (one symptomatic and one adenoma). Mean patient age was 57.09 years (range, 25 to 82). Mean blood loss was 375cc (range, 5 to 1500), with 2 patients requiring transfusion. Mean length of stay was 4 days (range, 1 to 13). One patient had to be converted and developed a wound infection in the postoperative course. Four of 9 cases were done using hand-assisted techniques.

Conclusions: Laparoscopic liver resection can be accomplished safely and efficaciously by properly trained surgeons familiar with both laparoscopic and hepatobiliary surgery. Advances in technology make the transection of the parenchyma safer, but there is a learning curve in which hand-assisted techniques may play an important role. Clear understanding of the surgical anatomy of the liver is crucial as is proper utilization of preoperative imaging when planning the resection. As with other MIS, laparoscopic hepatic resection appears to offer some advantages over the open technique in select patients; however, long-term oncologic data need to be obtained.

8314 Urology
Is Sutured Repair Necessary During Laparoscopic Partial Nephrectomy?
Matthew Christman, MD, James L'Esperance, MD, Chong Choe, MD, John Malcolm, MD, Christopher Diblasio, MD, Reza Mehrazin, MD, Brian Auge, MD, Ithaar Derweesh, MD

Objective: We aimed to show that techniques avoiding a completely sutured closure of the renal defect during laparoscopic partial nephrectomy could be safe and effective in a cohort of patients.

Methods: A multi-institutional, retrospective review of patients undergoing laparoscopic partial nephrectomy over a 4-year period was performed. Three groups were established based on the technique used to address the renal defect: Group 1 underwent a sutureless technique, Group 2 a bolster closure, Group 3 a full-sutured closure including deep cortical suturing. Patient and tumor characteristics, intraoperative variables, and outcomes were compared using standard statistics.

Results: A total of 95 partial nephrectomies were performed with a mean follow-up of 16.8 months. The groups were similar with respect to age, laterality of the lesion, and calyceal involvement on preoperative imaging. Significant differences between groups were found for tumor size and location, with Group 3 trending towards larger, more centrally located lesions. Collecting system entry was higher in Group 3. Blood loss, warm ischemia time, and postoperative renal function at 6 months and 12 months significantly favored the sutureless technique over the sutured approach. The complication rate was 17.9% overall and was similar between groups. Two patients were converted to radical nephrectomy intraoperatively. Disease-free survival was 98.8%; negative margins were achieved in 96.6%.

Conclusions: A sutureless approach to the renal defect appears safe and efficacious in appropriately selected patients. Furthermore, elimination of the deep cortical sutures did not increase overall complication rates compared with the standard sutured technique and may be a reasonable alternative for some patients.

8315 General Surgery
Prospective Trial to Compare Postoperative Complications and Length of Stay for Open versus Laparoscopic Methods for Enteric Perforation Repair
Jaideep Singh Chahal, MBBS, MS

Background: The aim of this prospective trial was to determine whether a type of surgical approach (open versus laparoscopic) had an impact on morbidity and postoperative recovery after enteric perforation repair.

Methods: Thirty-five patients diagnosed with enteric perforation were randomized to open or laparoscopic enteric repair. The type of operation was unknown to the patient, and all hospital staff was involved in the postoperative care.

Results: The 2 groups were similar with respect to demographic and clinical characteristics. No significant differences existed in the rate of immediate and delayed postoperative complications and pain score at discharge and length of hospital stay. In 4 patients, a laparoscopic procedure was converted to open repair. Median operating time was 90 minutes (range, 35 to 160) and 80 minutes (range, 45 to 165) in the laparoscopic and open groups, respectively (P=0.040). The median postoperative hospital stay was 3 days for the open procedure and 2.2 days for the laparoscopic group (P=0.011).

Conclusion: Repair for enteric perforation can be performed by either laparoscopic or open techniques without any major clinically relevant differences in postoperative outcome. Both techniques offer low morbidity. Postoperative recovery time was significantly shorter in the laparoscopic group.

8316 Urology
Oncologic Significance of Pathologic T2 Positive Surgical Margin in Robotic-Assisted Laparoscopic Prostatectomy
Zamip Patel, MD, Ardavan Akhavan, MD, Susan L. Rusnack, MD, David B. Samadi, MD

Introduction and Objective: The mechanism and significance of capsular violation may be different between open robotic prostatectomy (RP) and robotic-assisted laparoscopic prostatectomy (RALP). We compared biochemical disease-free survival (BDFS) for RALP patients stratified by margin status.

Methods: A review of consecutive RALPs was performed. No patient received adjuvant therapy without a biochemical recurrence. Patients with positive nodes were excluded.

Results: Inclusion criteria were met by 322 patients. Mean/median follow-up for the entire cohort was 11.1/10.7 months (range, 3.0 to 41.6). Gleason distribution was 5 (<1%), 6 (22%), 7 (67%), 8 (6%), and 9 (5%). Pathologic distribution was pT2 248 (77.0%), pT3a 48 (14.9%), pT3b 15 (4.7%), and pT4 11 (3.4%). Overall, 7.8% experienced biochemical failure
(BF) at a median of 1.5 months. BDFS rates by across pathologic stage were pT2 94.8%, pT3a 87.5%, pT3b 73.3% (11/15), and pT4 80.0% (8/10). Pathologic stage T2 patients with negative margins had the same rate of BF as T2 patients with a PM at mean 13.0 months. In multiple linear regression analysis, preoperative PSA >10ng/mL was the most predictive variable of biochemical failure.

Conclusions: There may be a different mechanism between a positive margin in organ-confined open RP and RALP patients. In our series of RALPs, only 1 of 44 patients who were pT2 with a PM suffered BF during follow-up. At a mean of 13.0 months, BDFS for these patients was 95.5%, and was not significantly different from that in pT2 patients with a negative margin.

8317 Urology
Early Oncologic Outcomes After Robotic-Assisted Laparoscopic Radical Prostatectomy by D’Amico Risk Stratification
Zamip Patel, MD, Ardavan Akhavan, MD, Susan L. Rusnack, MD, David B. Samadi, MD

Introduction and Objective: Little is known about the oncologic outcomes of robotic-assisted laparoscopic prostatectomy (RALP). We performed a prospective analysis of our oncologic outcomes using the risk stratification as proposed by D’Amico.

Methods: We reviewed an IRB-approved database of 751 consecutive patients who underwent RALP between 2001 and 2007 by a single surgeon. Cohort was limited to patients with at least 3 months of follow-up. We stratified patients into low-, intermediate-, and high-risk groups then calculated absolute and actuarial biochemical disease-free survival (BDFS) for each of the risk groups.

Results: Inclusion criteria were met by 322 patients. Mean follow-up was 11.1 months. Mean preoperative PSA was 6.3/5.4 (range, 0.45 to 48.6); median Gleason sum was 6.0. Clinical stages were T1c in 225 (98%) and T2a in 4 (2%). Overall, 8% (25/322) experienced biochemical recurrence at a mean/median of 4.1/1.5 months (range, 0.2 to 15.3). Absolute BDFS for low-, intermediate-, and high-risk groups was 96%, 91%, and 79%, respectively (P=0.0153). Actuarial 21-month survival for the 3 groups was 96%, 85%, and 68%. In a multiple logistic regression model, only preoperative PSA was predictive of biochemical failure (P<0.001).

Conclusion: RALP provides excellent cancer control outcomes for clinically localized prostate cancer at short-term follow-up, with high actuarial biochemical disease-free survival rates at 21 months. We found PSA to be the only predictor of biochemical failure when controlling for other variables.

8318 Urology
Interinstitutional Variations in Robotic Prostatectomy Pathologic Outcomes for a Single Surgeon and Team
David B. Samadi, MD, Zamip Patel, MD, Ardavan Akhavan, MD, Susan L. Rusnack, MD

Introduction and Objective: The pathology report of a radical prostatectomy specimen has critical prognostic significance. To determine an effect of the institution on the pathologic review of specimens, we analyzed the robotic-assisted laparoscopic prostatectomy (RALP) outcomes of a single high-volume surgeon who operated at 2 local institutions using the same technique and robotic team.
Methods: We reviewed the pathologic outcomes in 2 databases for 400 consecutive RALP procedures performed by a single surgeon at 2 local institutions. Multivariate analysis was used to control for preoperative oncologic risk factors.

Results: Between July 2006 and September 2007, 200 RALPs were performed by a single surgeon at each of 2 separate institutions, for a total of 400 cases. Inclusion criteria were met by 384 patients. Preoperative patient characteristics were similar between groups. Median pathologic Gleason grade at both institutions was 4+3. However, I-1 was statistically more likely to upgrade Gleason scores than I-2 (P=0.031). The same institution (I-1) also reported a significantly higher proportion of pT3 tumors (P=0.01), but fewer pT3 positive margins (P<0.001). No differences existed between the institutions in rate of pT2 positive margins (16% vs 11%, respectively, P=0.297).

Conclusions: We present an effect of the institution on pathologic outcomes. Given similar preoperative prostate sizes and PSA values, it is likely that prostate cancer volumes were similar between the cohorts. Institutional differences in methods of pathologic processing may account for some of the differences in reported rates of surgical margins and Gleason scores.

8319 Urology
Extending the Robotic Prostatectomy Learning Curve Beyond 750 Cases with a Single Surgical Team
David B. Samadi, MD, Zamip Patel, MD, Ardavan Akhavan, MD, Susan L. Rusnack, MD

Introduction: The increasing popularity of robotic-assisted laparoscopic prostatectomy (RALP) has triggered a large influx of new robotic surgeons. As more experience is gained, the learning curve is redefined. We present our experiences with a single surgeon and surgical team through 750 cases.

Methods: An IRB-approved RALP outcomes database was reviewed for all patients undergoing RALP by a single surgeon and team. Preoperative and postoperative data were reviewed and analyzed. Multivariate analysis was used to determine significance of variables on outcomes.

Results: Between January 2003 and October 2007, a single surgeon and team performed 750 RALPs. Blood loss (EBL) was 103cc (range, 5 to 900); operating time was 131 minutes (range, 40 to 530); prostate size was 50g (range, 18.5 to 200). Neither patient age, BMI, tumor stage, Gleason score, prostate size, nor positive margins changed significantly over the 750 cases. Length of stay decreased significantly over the first 150 cases (P=0.017) and plateaued around the 150th case. While both operating time and EBL values plateaued briefly between cases 300 and 500, the values continued to drop significantly through the 750th case (P<0.001, 0.015, respectively). Multivariate regression analysis illustrates that neither patient age, BMI, Gleason score, PSA, prostate size, nor margins was associated with EBL or operating time.

Conclusion: Although the learning curve for RALP is steep during the first 100 cases, our data illustrate significant improvements in both operating time and EBL through 750 cases.

8320 General Surgery
Transaxillary Endoscopic Periareolar Approach (TEPA) to Total Thyroidectomy
Titus D. Duncan, MD, Qammar Rashid, MD

    The treatment of many thyroid disease entities remains total thyroidectomy. Although we have successfully performed near total thyroidectomy using an endoscopic transaxillary approach, use of this technique to perform total thyroidectomy has been challenging. We recently explored the feasibility of an approach combining the endoscopic transaxillary technique with a periareolar approach, using the contralateral areola as an access site, to perform endoscopic total thyroidectomy [transaxillary endoscopic periareolar approach (TEPA)]. The addition of contralateral periareolar access to the transaxillary approach permits access to the contralateral thyroid lobe and cervical anatomy. We describe a case report of patients undergoing total thyroidectomy using this approach. In our hands, a pure ipsilateral transaxillary approach to the thyroid limits our ability to safely perform total thyroidectomy using a pure endoscopic ipsilateral approach. This case report shows that total thyroidectomy can be performed using the TEPA approach. Because of the advantages of endoscopic transaxillary thyroidectomy, the TEPA approach warrants further study to assess its viability in patients requiring total thyroidectomy for treatment of their underlying thyroid disease.

8321 General Surgery
Laparoscopic Versus Robotic-Assisted Laparoscopic Roux-en-Y-Gastric Bypass: The da Vinci Robotic System Improves Outcomes?
Subhashini Ayloo, MD, Alberto S. Gallo, MD, Maria V. Gorodner, MD, Fabio Sbrana, MD, Francesco M. Bianco, MD, Pier Cristoforo Guillianotti, MD

Background: Hand-sewn anastomosis for laparoscopic gastric bypass requires highly skilled surgeons. The introduction of the da Vinci robotic system may help facilitate the performance of this operation. Our objective was to compare outcomes between the laparoscopic and robotic-assisted laparoscopic approach.

Methods: Between January 2006 and January 2008, 84 patients underwent gastric bypass surgery and were divided into 2 groups. Group A= the first 44 consecutive patients (3 men) underwent laparoscopic surgery. Group B=40 patients (4 men) underwent gastro j-anastomosis with the da Vinci robotic system. Initial body mass index, age, sex, and perioperative data were analyzed.
Results: Patients in Group A had a greater initial body mass index (kg/m2) than those in group B (48±6 vs. 45±6, P<0.05). No significant sex and age differences existed. The operative time (minutes) and blood loss (mL) for group A vs. B were 226±34 vs. 213±42 (P=NS), and 21±33 vs. 13±18 (P=NS), respectively. Robot mean setup time (minutes) was 13±4 (range, 8 to 22). Length of stay was similar (A=2.5±0.6 vs. B=2.4±0.4, P=NS). In group A, 2 (4.5%) patients developed anastomotic ulcers, 1 (2.2 %) gastro J-anastomosis stricture, and 1 (2.2 %) small bowel obstruction requiring reoperation. No complications occurred in group B.

Conclusions: The use of the da Vinci system may improve performance in gastric bypass surgery, decreasing the operative time and complication rates. From our experience, we note that the da Vinci robotic system improves the surgeon's ergonomics, includes training of fellows and residents, does not need a camera operator because the system is self-sustained.

8322 General Surgery
Single-Incision Laparoscopic Heller Myotomy and Anterior Fundoplication
Sharona B. Ross, MD, Connor Morton, BS, Desiree Villadolid, MPH, Donovan Tapper, MD, Alexander Rosemurgy, MD

Background: Single-incision laparoscopic surgery (SILS) continues the evolutionary arc from “open” to laparoscopic to “minimal scar” surgery, facilitating improved patient recovery and improved cosmesis. Promises of patient acceptance of SILS are high and will drive investment of resources to promptly develop safe and effective SILS procedures for clinical application.

Methods: This video demonstrates SILS Heller myotomy and anterior fundoplication with intraoperative endoscopy in the treatment of achalasia. First, esophagogastroscopy documents the presence of a dilated distal esophagus and a snug gastroesophageal junction. Then, a single 10-mm incision is utilized to place three 5-mm trocars at the umbilicus: one trocar is utilized for liver retraction, another for an articulating laparoscope, and the third as an operating port. Sutures are placed in the fundus and along the lesser curvature to facilitate exposure. Dissection frees the esophagus from the hiatus laterally and along its ventral surface. Longitudinal muscle fibers are divided with hook electrocautery to provide exposure for division of transverse muscle fibers. Repeat esophagogastroscopy is undertaken to document an adequate myotomy: the scope must pass easily through the gastroesophageal junction, the myotomy must be visualized to cross the squamocolumnar junction (ie, the z-line), and no esophagotomy/gastrotomy or submucosal burn should be noted. Anterior fundoplication, covering most of the myotomized esophagus, is constructed to provide optimal control of postoperative gastroesophageal reflux.

Conclusion: Single-incision laparoscopic Heller myotomy and anterior fundoplication will be embraced by patients, and laparoscopic surgeons will need to meet patient demands.

8324 General Surgery
Short-Term Outcomes after Simultaneous Laparoscopic Adjustable Gastric
Banding and Hiatal Hernia Repair
Maria V. Gorodner, Alberto S. Gallo, Federico Moser, Santiago Horgan, Carlos Galvani

Background: The presence of hiatal hernia has been considered a contraindication for laparoscopic adjustable gastric banding (LAGB), because more complications occur. Few data have been reported on simultaneous gastric banding and hiatal hernia repair. We report our experience with gastric banding and hiatal hernia repair.

Methods: Between November 2004 and July 2005, 417 patients underwent gastric banding. Patients were divided into 2 groups: Group A (gastric banding) and Group B (gastric banding + hiatal hernia repair). Hiatal hernia repair consisted of esophageal dissection and crura closure.

Results: Group A included 376 patients (327 women), mean age 40±12 years. Group B included 41 patients (37 women), mean age 45±10. Operative time (min) and length of stay (hours) for group A vs. B was 42±13 vs. 56±19 (P<0.05) and 11±11 vs. 13±12 (P<0.05), respectively. Band slippage and pouch enlargement was 1.6% vs. 0% (P=NS) and 13% vs. 2% (P=NS) for group A and B, respectively. Percentage excess weight loss at 3, 9, and 12 months in group A vs. B was 22±11 vs. 23±10 (P=NS), 38±21 vs. 32±14 (P<0.05), and 41±24 vs. 46±7 (P<0.05), respectively.

Conclusion: These short-term data suggest that patients who had simultaneous hiatal hernia repair demonstrated better weight loss compared with weight loss in group A. Gastric banding and hiatal hernia repair can be safely performed without increasing the complication rate. In contrast, despite not reaching statistical significance, patients in group B showed a trend towards a lower complication rate. Therefore, liberal repair is recommended whenever hiatal hernia is diagnosed.

8325 General Surgery
Laparoscopic-Assisted Percutaneous Gastrostomy Tube Placement: Aiding an Old Technique
Gustavo Lopes, DO, Mark Salcone, DO, Marc Neff, MD 

Background: Percutaneous gastrostomy tube (PEG) placement is commonly used to assist in enteral feeds. Unfortunately, the technique may not always be successful because of prior surgery or inadequate light reflex. We sought to assist in the performance of the procedure with the aid of the laparoscope.

Methods: From August 2006 to February 2008, all patients that were referred for surgical feeding tube placement because of an inability to place a PEG tube by GI were considered for laparoscopic-assisted PEG tube insertion.

Results: Seven patients were taken to the operating room where a laparoscope was inserted via an optical entry. In the majority of cases, adhesions were encountered in the left upper quadrant. One to 3 additional ports were placed to aid in the adhesiolysis and, once the left upper quadrant was free of adhesions, an intraoperative endoscopy was performed. The insufflation pressure was turned down, and the PEG was inserted without difficulty. Average time to performance of the procedure was roughly 30 minutes. Blood loss was minimal. Tube feeds were begun on all PEGs within 48 hours. No postoperative complications occurred.

Conclusion: When PEG tube insertion cannot be performed in the endoscopy suite, a relatively simple maneuver is to take the patient to the operating room and insert a laparoscope. The PEG tube insertion is then completed in the operating room with laparoscopic assistance. This maneuver can save the patient from the operative time or the morbidity of jejunostomy tube insertion, or both.

8326 General Surgery
Laparoscopic Surgery in the Obstetric Patient: A Case Series of Thirteen Patients
Linda Sczcurek, DO, Adair de Berry-Carlisle, DO, Larry Cohen, DO, Marc Neff, MD

Background: Laparoscopic management of the surgical emergencies in the pregnant patient has always been challenging. It is a concern because of difficulty in accessing the abdomen to establish pneumoperitoneum and in the concern of potential triggering preterm labor or early fetal demise, or both. We reviewed the outcomes of 13 patients over a 5-year period.

Methods: Patients from January 2000 to January 2008 who were pregnant
at the time of their nonobstetrical laparoscopic surgery were included in this study. Charts were retrospectively reviewed for indications for surgery, length of operation, length of stay, gestational age, postoperative complications, and preterm labor events/fetal demise.

Results: During the study period, 13 patients were operated on laparoscopically. Three were taken to the operating room for acute cholecystitis, 9 for acute appendicitis, and 1 for an incarcerated hernia. One patient was pregnant with twins. The gestational age ranged from 6 to 20 weeks. The average length of stay was 3 days. No postoperative complications occurred. No preterm labor events or early fetal demises occurred. All children are alive and well to date.

Conclusions: Although laparoscopic surgery can be challenging in obstetrical patients, establishment of pneumoperitoneum and performance of laparoscopic hernia repairs, cholecystectomies, and appendectomies can be performed safely. This should be done in a setting with appropriate obstetrical communication and on-site support.

8327 General Sugery
Laparoscopic Sleeve Gastrectomy Versus Laparoscopic Roux-en-Y Gastric Bypass: A Case Series
Seema Dhorajia, DO, Tinamarie Juengert, RN, Louis Balsama, DO, Marc Neff, MD

Background: The most successful long-term treatment of morbid obesity is surgical intervention. The most popular option is the Roux-en-Y gastric bypass (RYGB). This procedure is recently being challenged by a technique called the sleeve gastrectomy. It is associated with very good results with minimal morbidity and compares favorably to the lap RYGB in other countries. We sought to compare patients undergoing the 2 surgical options.

Methods: A consecutive series of patients were appropriately selected for laparoscopic surgery for morbid obesity. All completed an extensive preoperative preparatory program. The decision on which procedure to perform was left up to the patient with counseling from the nutritionist and surgeon.

Results: From January 2007 to February 2008, 29 patients underwent morbid obesity surgery. The average time of completion was 120 minutes for the sleeve compared with 150 minutes for the bypass. No leaks, obstructions, or stenosis were observed in follow-up of any of the patients. There were 2 infections in each group. In the bypass group, 1 anastomotic ulcer and 1 postoperative bleed occurred. In each group, 1 emergency department visit for dehydration was necessary. In the sleeve group, 1 readmission for dehydration was needed. Postoperative weight loss is still being monitored.

Conclusion: The sleeve gastrectomy is the latest procedure available to patients considering surgery for morbid obesity. It can be performed in patients in a staged or stand-alone fashion. In our sample, the results were very similar between groups with a trend towards higher BMI and shorter operative times.

8329 Urology
Two-Year Follow-Up of Radiofrequency Ablation of Renal Tumor: Dong-A Experience
Gyung Tak Sung, Tae Hyo Kim, Sang Rak Bae

Introduction and Objective: To report short-term outcomes and the safety of nephron-sparing radiofrequency ablation (RFA) of renal tumor.

Methods: Between June 2004 and February 2008, 35 patients underwent radiofrequency ablation of renal tumors. Twenty-eight underwent combined computed tomography (CT) and ultrasonogram-guided percutaneous RFA, and in 7 patients intraoperative ultrasonography guided laparoscopic RFA was performed. Treatment indications were localized, small (<4cm), solid renal masses in elderly patients, those with comorbid conditions, and patient preference. Routine evaluation tests were performed for follow-up. For evaluation of recurrence or remnant tumor, renal biopsy was done at 6 months in 22 patients. The mean follow-up duration was 27.5 months (range, 3 to 42).

Results: All patients underwent successful RFA without any serious events. Seven patients had mild perinephric hematoma on follow-up CT scan, and 3 patients had mild gross hematuria postoperatively. With a mean follow-up of 27.5 months, 2 patients showed residual tumor at 3-month follow-up contrast-enhanced CT after the first tumor ablation. RFA was repeated one more time, and no residual tumor on follow-up computed tomography (CT) was seen. Twenty-two patients with 6-month biopsy of RFA lesions had no recurrent or remnant tumor. Distant metastasis was not found in any cases, and all patients are alive on serial follow-up.

Conclusions: Percutaneous or laparoscopic RFA is considered useful treatment for select patients with small renal masses, and for nephron-sparing. Contrast-enhanced CT/MRI performed serially after ablation was reliable for excluding residual viable tumor. The 6-month postoperative biopsy data of RFA lesions has proved the safety of RFA. The ultimate role of this modality will continue to evolve and warrants further studies.

8330 Urology
Short-Term Outcomes of Laparoscopic Radical Cystectomy with Extracorporeal Ileal Conduit
Tae Hyo Kim, Chan Wook Shin, Sang Rak Bae, Gyung Tak Sung

Introduction and Objective: We analyzed early perioperative and oncological outcomes following radical cystectomy by the laparoscopic method.

Methods: Between January 2003 and October 2007, we performed laparoscopic radical cystectomy (LRC) with extracorporeal ileal conduit for bladder cancer in 32 patients, and the results of the LRC were analyzed. Surgical results, such as the operation time, estimated blood loss (EBL), transfusion rate, hospital stay, and complication rates and the oncological results were reviewed retrospectively.

Results: The pathology reports showed transitional cell type in all cases. The preoperative stage was T1, high grade in 11 cases, T2 in 15, T3 in 6. For the LRC groups, the mean operation time was 189.5 minutes (range, 120 to 340), the EBL was 342.2mL (range, 150 to 800), the transfusion rate was 16.9%, the hospital stay was 10.5 days, the intraoperative complications were 5/32 cases (15.6%). The pathologic surgical margins were all negative.

Conclusions: LRC resulted in less blood loss and transfusion rate and earlier recovery. In our opinion, laparoscopic radical cystectomy with extracorporeal ileal conduit is an acceptable treatment option in patients with muscle invasive bladder tumor.

8331 General Surgery
Laprostop Clinical Evaluations
Mark Surrey, MD, Patrick Diesfeld, MD, Rudy DeWilde, MD, Johan Van Der Wat, MD,
Bruno Van Herendael, MD, Anthony Luciano, MD, William Parker, MD, Charles Koh, MD

Introduction: The clinical evaluations of the Laprostop device were based on 92 patients. The mean age was 34 years of age, and the average length of each case was 70 minutes. The cases were performed entirely by attending physicians with 3.0 trocars; 27.4% of the devices were sutured in place. No complications occurred, and ease of use was noted in all cases. Forty percent of responses indicated the additional benefit of stabilizing the trocar.

Methods: This was a multicenter evaluation during laparoscopic surgery utilizing 5-mm and 10/11-mm trocars for primary and secondary ports. The Laprostop consists of 4 parts: the tightening wrench, the flange, the nut, and the collet. The collet is made from medical-grade flexible vinyl. The other 3 parts are made of medical-grade polycarbonate. All the parts were sterilized using ETO. The wrench measures 4.50mm in length and 2.140mm at its maximum width. The thickness is 0.200mm max. The flange is triangular in shape and has a maximum diameter of 2.380mm. It is 0.570mm high and a thickness of 0.125 at the flange. The nut has a diameter of 0.700mm, a height of 0.550mm, and a minimum wall thickness of 0.160. The entire Laprostop, not including the tightening wrench, measures 2.380mm in diameter and 0.780 in height. The weight of the entire product including the tightening wrench is 1 ounce. When properly tightened, the Laprostop will yield at approximately 30 pounds of force. The collets are designed to fit 2 sizes of trocar with nominal sizes of 5mm and 10/11mm. Other diameters can be easily accommodated.

Results: The clinical evaluations were based on 92 patients. The mean age was 34 years of age, and the average length of each case was 70 minutes. The cases were performed entirely by attending physicians with 3.0 trocars; 27.4% of the devices were sutured in place. No complications occurred, and ease of use was noted in all cases. Sixty percent of responses indicated the additional benefit of stabilizing the trocar.

Conclusion: The Laprostop appears to add a level of security to the trocar insertion process. It effectively limited the depth of penetration of the trocar consistent with the placement location selected by the surgeon. Additionally, when sutured in place, it provides stability, both in the horizontal and vertical planes, making any/all actions directed through the cannula(s) more efficient.

8333 General Surgery
Early Improvement of BDI Score After Gastric Bypass Surgery
Ronak Iqbal, MD, Alberto Gallo, MD, Jennifer Clauson, Melissa Murphy, NP-C, Maryann Holtcamp, RN, Francesco Bianco, MD, Subhashini Ayloo, MD

Objective: Morbid obesity is a serious disease as it is accompanied by substantial comorbidity and mortality. This disease remains largely refractory to diet and drug therapy, but generally responds well to bariatric surgery. This study was conducted to examine the significance of weight loss on depressive symptom using the Beck Depression Inventory II scoring system.

Study Design: Patients who had gastric surgery were prospectively evaluated at the initial visitation and then postoperatively at 2, 4, and 12 weeks. The Beck Depression Inventory II form was completed by each patient. Cut score guidelines Beck Depression Inventory II are as follows: 0 to 13, normal; 14 to 19, mild; 20 to 28, moderate; 29 to 63, severely depressed.

Results: Gastric surgery was performed in 65 patients; 32 patients (29 females, 3 males) completed the Beck Depression Inventory II survey forms and were included in the study. The initial mean age was 43.6±8.7, and mean body mass index was 49.2±6.7kg/m2 (range, 37 to 64). The mean body mass index at 2 weeks and 1 and 3 months was 42.8±6.7, 41.1±5.2, 37.4±12.9, respectively. The initial mean Beck Depression Inventory score was 16.2±13.1 (range, 0 to 4). The mean Beck Depression Inventory score changed to 4.6±2.9 (range, 0 to 9), 3.7±5.3 (range, 0 to 25), and 5.9±10.3 (range, 0 to 36.2) at 2 weeks and 1, 3 months, respectively.

Conclusions: Effective weight loss was achieved in morbidly obese patients after gastric surgery. Surgical treatment of morbid obesity has a profoundly positive impact on patients’ depressive symptoms on the Beck Depression Inventory score.

8335 General Surgery
Application of a Risk Analysis Score to Predict Morbidity/Mortality of Bariatric Surgery in Patients at a VA Medical Center
F. A. Herrera, MD, G. Woods, MD, V. Aroda, MD, C. Gerlan, RN, A. Bryant, RN, S. Horgan, MD, M. K. Savu, MD
 


Objectives: The purpose of our study was to evaluate the postoperative effects of bariatric surgery on comorbid conditions in the veteran patient, as well as determine the accuracy of the Obesity Surgery Mortality Risk Score (OS-MRS) in predicting morbidity in an above-average risk population (veteran) undergoing bariatric surgery.

Methods: We performed a retrospective data analysis of 70 patients undergoing elective bariatric procedures from April 1999 to March 2006. Comorbidities included hypertension (HTN), obstructive sleep apnea (OSA), diabetes (DM), and hyperlipidemia. Postoperatively, comorbidities were measured as resolution, improvement, or no change. The OS-MRS was applied to evaluate its predictive value of complication risk stratification.

Results: Six Lap-Bands and 64 gastric bypasses were performed. Preoperative BMI was 45.1kg/m2 (range, 32 to 74). Average follow-up was 16.5 months with average postoperative BMI of 32kg/m2 (range, 22 to 45). Diabetes resolved/improved in 66%; hyperlipidemia resolved/improved in 82%; HTN resolved/improved in 67%; OSA resolved/improved in 47%. Stratification according to the OS-MRS revealed 10 patients as low risk, 25 patients as intermediate risk, and 37 patients as high risk. Complication rates between the groups included 0/10 (0%) in the low-risk group; 8/25 (30%) in the intermediate-risk group; and 17/37 (46%) among the high-risk group, including 2 deaths. Overall mortality rate was 2.8% and morbidity rate was 33%.

Conclusion: Bariatric surgery results in effective weight loss among veteran patients with significant improvement in obesity-related comorbidities. Application of the OS-MRS appears useful in predicting postoperative complication rates.

8337 Gynecology
Take It or Leave It! A Clinical Outcomes Comparison Between Laparoscopic Supracervical Hysterectomy and Total Laparoscopic Hysterectomy
Amy M. Bruton, MD, Andrea Panting-Kemp, MD, Lorraine Endres, MD, Andrew I. Brill, MD

Objective: To compare the outcomes of total laparoscopic hysterectomy and laparoscopic supracervical hysterectomy.

Methods: This is a retrospective chart review of 133 women who underwent total laparoscopic hysterectomy or laparoscopic supracervical hysterectomy by Dr. Andrew I. Brill between 2/22/2003 and 2/22/2006. Relevant patient information, total operating room time, total specimen weight, estimated blood loss, and related complications over the next year were examined using chi-square and Student t tests.

Results: Laparoscopic supracervical hysterectomy was performed in 111 patients, and total laparoscopic hysterectomy in 22. Average total operating room time was 249 minutes for laparoscopic supracervical hysterectomy and 413 minutes for total laparoscopic hysterectomy (P=0.0005, 95% CI -102.23 to -29.47). Six total complications (5.4%) occurred with laparoscopic supracervical hysterectomy, whereas 9 total complications (40.9%) occurred with total laparoscopic hysterectomy (P=0.00005). Average specimen weights were 176g for total laparoscopic hysterectomy and 293g for laparoscopic supracervical hysterectomy (P=0.023, 95% CI 16.11 to 218.03). Statistically more blood was lost with total laparoscopic hysterectomy (P=0.032), but clinically the difference was only 40mL.

Conclusions: Total operating room time was significantly longer for total laparoscopic hysterectomy, perhaps due to less operator experience with this procedure. There were significantly more complications for total laparoscopic hysterectomy, most from postoperative infection rather than intraoperative complications. This is likely a result of exposure to vaginal flora. Overall, laparoscopic supracervical hysterectomy appears to be a safe alternative and may have some significant benefit over total laparoscopic hysterectomy.

8338 General Surgery
Endoscopic Sclerotherapy Technique for the Treatment of Dilated Gastrojejunal Anastomosis after Roux-en-Y Gastric Bypass
M.L. Simonson, MD, N. Fearing, MD, J. S. Scott, MD, R.A. de la Torre, MD

Background: Dilation of the gastrojejunal anastomosis (GJA) has been shown to reverse the restrictive effects of Roux-en-Y gastric bypass (RYGB). This effect can lead to regain of weight after RYGB.

Methods: The video will demonstrate our technique for sclerotherapy to treat dilatation of the GJA utilizing endoscopy. The video will include the method for measuring the GJA for diagnosis of dilation. The video will provide instruction regarding our technique of injecting the GJA every 1cm in a circumferential manner with injection of 1mL of 5% sodium morrhuate.

Discussion: In one small series, sclerotherapy was shown to narrow the GJA and lead to stabilization of weight or weight loss in 91.6% of patients. Larger studies are needed to show the efficacy of sclerotherapy as a means of definitive treatment of GJA dilatation. Retrospective review and plans for prospective trials regarding the efficacy of sclerotherapy are currently underway at our institution.

8339 Gynecology
Clinical Effects of Laparoscopic Colposuspension with Round-Infundibulopelvic Ligament in High-Grade Procidentia Uteri
Dong-Ho Kim MD

Objective: To evaluate the surgical outcome, complications, and benefits of laparoscopic colposuspension with round-infundibulopelvic ligament in high-grade procidentia uteri.

Methods: Women with Grades 3 and 4 procidentia uteri and vault prolapse underwent laparoscopic colposuspension with round-infundibulopelvic ligament traction suture and ligation. Some patients underwent laparoscopic hysterectomy with or without anterior or posterior colporrhaphy as clinically indicated. Outcomes of the procedures were assessed on postoperative follow-up data.

Results: Between January 1994 and January 2007, 75 patients were operated on. Their mean age was 53 years (range, 32 to 83), average follow-up was 56.2 months (range, 12 to 144), mean operating time was 147 minutes. No conversions were necessary due to anesthetic or surgical difficulties. Follow-up was done by tele research and physical examination. There was 1 case of hematoma, 4 cases of transient urinary retention, 6 cases of transient abdominal discomfort that regressed spontaneously within 3 months, but no recurrence has developed.

Conclusions: Laparoscopic colposuspension with round-infundibulopelvic ligament is a feasible and highly effective technique that offers good long-term results with low complication rates in the correction of procidentia uteri.

8340 Urology
Contribution of Laparoscopic Training To Robotic Proficiency
Michael S. Gomez, MD, Mirza M. Baig, MD, Justin A. Muskovich, Ronney Abaza, MD

Purpose: Robotic technology is being applied in minimally invasive surgery. The benefit of training in laparoscopy prior to use of a surgical robot is unknown. In addition, the question of whether robotic technology allows more precision than standard laparoscopy has not been demonstrated.

Methods: Eight fourth-year medical students with no previous laparoscopic or robotic experience were instructed to incise a 2.5cm2 spiral using the da Vinci robot surgical system. Each student then underwent a validated month-long laparoscopy course. There was no additional robotic teaching. At the end of the course, the students repeated the spiral cutting exercise using the robot as well as standard laparoscopic instruments. Time to cut the spiral and errors (unintentional incisions) were recorded.

Results: On day one, the mean time to incise the spiral robotically was 19:52 minutes (range, 14 to 30) with a mean of 7 errors. After course completion, the mean robotic spiral time fell to 9:52 minutes (range, 6 to 15, P=0.003) with a mean of 4 errors. In comparison, laparoscopic completion of the same task after course completion yielded a mean time of 12:15 minutes with a mean of 7 errors, which was better than the pretraining robotic performance (P=0.004) but no better than the posttraining robotic performance (P=0.11).

Conclusion: Laparoscopic training improved performance of a complicated robotic task. Even with minimal exposure to the modality, the robot produced equal precision in completion of the task as compared with standard laparoscopy after extensive training. Therefore, laparoscopic training may improve proficiency in the actual operation of the robot.

8341 Gynecology
Evaluation of Ninety-Four Patients by Laparoscopy
Gh. Alavi, MD, H. Fattahi, MD, N. Saghafi, MD

Objective: Regarding the importance of pelvic adhesion for infertility, we have evaluated 94 patients with laparoscopy. The purpose of this study was to evaluate the difference in pelvic adhesion for better management in our patients.

Methods: In this retrospective, descriptive study, we evaluated 273 patients by laparoscopy at Ghaem Hospital Mashhad University of Medical Sciences.

Results: Of 273 patients, 94 had pelvic adhesions. Mean-age of patients was 23 years; 85% were suffering from primary infertility, while 15% had secondary infertility. Severe pelvic adhesions were found in 23%. Both tubes were occluded in 29% of patients; the left tube was occluded in 47%, and the right tube was occluded in 24% of patients. Endometriosis was found in 23%, and anovulatory ovaries were found in 31% of patients. Fifty-three percent of patients had both tubal occlusion and endometriosis. Primary infertility was more common than secondary infertility.

Conclusion: This study showed that the most common causes of infertility were tubal occlusions and anovulatory ovaries and endometriosis. Also this study showed lots of patients with multifactorial cases of infertility.

8342 General Surgery
Laparoscopic Cholecystectomy in Cirrhotic Patients
Dr. A. Razaque Shaikh

Objectives: To assess the safety of laparoscopic cholecystectomy (LC) in cirrhotic patients.

Methods: This was a retrospective study conducted from January 2003 to December 2005 at 
Liaquat University of Medical Health and Sciences, Jamshoro, Pakistan. All cirrhotic patients underwent LC.

Results: Of 250 patients who underwent LC, 20 (12.5%) were cirrhotic. Group A included 12 patients (60%) and group B included 8 (40%). Of 20 cases, 2 (10%) were converted to open cholecystectomy. Operating time was 70 minutes to 40 minutes. Cirrhotic patients required more blood than noncirrhotic patients did.

Conclusion: Laparoscopic cholecystectomy is a safe procedure in cirrhotic patients with advantages over open cholecystectomy of lower morbidity rate, reduced hospital stay, and lower risk of infection.

8346 Gynecology
The Comparison of Postoperative Re-Adhesion Formation After Previous Laparoscopic and Laparotomic Adhesiolysis for Stage IV Endometriosis
Sung-Tack Oh, Yong-Taik Lim, Kyu-Sup Lee, Jun-Young Hur, Young-Min Choi

Objective: It is well known that postoperative adhesions occur less after laparoscopic surgery than after laparotomy. However, in stage IV adhesions that are already severe, it is not clear whether laparoscopic adhesiolysis causes less re-adhesion formation than laparotomic adhesiolysis.

Methods: The re-adhesion ratio was compared between 24 laparotomic patients (Group A) and 31 laparoscopic patients (Group B) who underwent laparoscopy due to recurrence of endometriosis. In the first operation, all of both groups received a large amount of lactated Ringer solutions in the abdominal cavity after surgery and Interceed was applied.

Results: The durations of recurrences were 4.2±1.6 in Group A and 5.3±1.8 in Group B (P=NS). All Group A patients had severe re-adhesion formation with the second operation, but 6 of 31 Group B patients (19.4%) had severe re-adhesion and 25 of Group B patients (80.6%) had minimal to mild re-adhesion only (P<0.01).

Conclusions: Therefore, laparoscopic adhesiolysis is essential from the first operation for stage IV endometriosis, especially those who are infertile or unmarried, although it is a very difficult procedure.

8347 General Surgery
Cerebral Gas Embolism Due to Upper Gastrointestinal Endoscopy
M. ter Laan, MD, E. Totte, MD, R. A. van Hulst, MD, PhD, K. van der Linde, MD, PhD, W. van der Kamp, MD, PhD, J. P. E. N. Pierie, MD, PhD

Introduction: Cerebral gas embolism as a result of upper gastrointestinal endoscopy is a rare complication and bares a high morbidity.

Case Report: A patient is presented who underwent an upper endoscopy for evaluation of a gastric-mediastinal fistula after subtotal esophagectomy and gastric tube reconstruction because of esophageal cancer. During the procedure, cerebral gas emboli developed resulting in an acute left-sided hemiparesis. After hyperbaric oxygen therapy, the patient recovered almost completely.

Discussion: The literature concerning cerebral gas embolism associated with upper endoscopy is reviewed.

Conclusion: Once cerebral gas emboli are recognized, patient outcome can be improved by hyperbaric oxygen therapy.

8348 Multispecialty
Magnetic-Assisted Natural Orifice Surgery
Daniel A. Tsin, MD, Guillermo M. Dominguez, MD, Juan M. Alonso Rivera, MD,Ramiro Jesus, MD, Fausto J. Davila Ávila, MD

Objective: To present the feasibility of a transvaginal magnetic-assisted peritoneoscopy for the operation and extraction of a large liver cyst.

Methods: A female patient with abdominal pain, jaundice, and elevated total bilirubin of 9.29, and BILI IND 6.8, ALT/GPT 116, and AST/GOT 85. The patient had a 12-cm diameter liver cyst confirmed by ultrasound and CAT scan. The operation was part of a Natural Orifice Surgery protocol approved by the IRB of the Poza Rica Regional Hospital, Veracruz, Mexico under the direction of Dr. Fausto Davila Avila, principal investigator. The patient underwent a minilaparoscopy assisted transvaginal approach using a gastroscope via a vaginal port and a 5-mm umbilical port. Suction of the cyst was done. A magnet (Imanlap TM) was introduced via a vaginal port to aid in grasping the cyst. After removal of the roof of the cyst, the specimen and magnet were extracted through the vagina. The same port was used to place a catheter for drainage in the right upper flank.

Results: The patient improved rapidly. Thirty-six hours after surgery, her jaundice began to clear, and she had the following: total bilirubin 3.2, BILI IND 1.1, ALT/GPT 59, AST/GOT 24. The patient was discharged the second day after surgery with scanty vaginal drainage.

Conclusions: Natural orifice transvaginal endoscopic surgery could be an option in select cases of liver cyst.

8349 Other
Current Availability of Robotic Vascular Surgery: 110 cases
Petr Štadler, MD, PhD

Introduction: The feasibility of robotically assisted laparoscopic aortic surgery has been adequately demonstrated. The authors report on their clinical experience with aortoiliac reconstruction for occlusive disease, aneurysm, and 2 hybrid procedures performed using the da Vinci system.

Methods: Between November 2005 and April 2008, we performed 110 robot-assisted laparoscopic aortoiliac procedures. Ninety-nine patients were prospectively evaluated for occlusive disease, 7 patients for abdominal aortic aneurysm, 2 for a common iliac artery aneurysm, and 2 for hybrid procedures. Dissection of the aorta and the iliac arteries was performed laparoscopically using a transperitoneal direct approach, and the robotic system was used to construct the vascular anastomosis, for the thromboendarterectomy, for the aorto-iliac reconstruction with the patch closure and for the posterior peritoneal suture.

Results: Success was achieved in 107 cases completed robotically, while 3 were converted. In 3 patients, conversion was necessary, one due to bleeding from an earlier clipped lumbar artery after completion of the anastomosis, the second because difficulties were encountered with the EndoGIA stapler during the exclusion of a common iliac artery aneurysm after completion of the robotic anastomosis, and the last due to bleeding from the robotic anastomosis and the lumbar arteries. Thirty-day survival was 100% and
nonlethal postoperative complications were observed in 2 patients (2.5%).

Conclusion: Our clinical experience with robot-assisted laparoscopic surgery shows that it is a feasible technique for aortoiliac vascular and hybrid procedures.

8350 Gynecology
Comparison of Findings of Hysterosonography Versus Microhysteroscopy
Radha Syed, MD

Objective: To study the clinical efficacy of hysterosonography to target intrauterine pathology in women presenting with abnormal uterine bleeding. 



Methods: Ten patients presenting with a history of abnormal uterine bleeding (premenopausal and postmenopausal) underwent a diagnostic hysterosonogram using an HSG 5 French catheter. Medison 3-D ultrasound model V-10 was used for scanning. The fluid used was sterile saline for injection into the uterine cavity. The balloon of the HSG catheter was inflated with 3cc of air. Saline used varied with patients' uterine cavity size, and their tolerance for uterine distention. The average amount of saline was 12cc. These patients were scheduled subsequently for microhysteroscopy and dilatation and curettage. The findings at hysteroscopy were then compared with hysterosonogram findings and tabulated. Further, histopathology was compared with the preoperative diagnosis from the hysterosonogram. These patient procedures were conducted over a 2-month period between February 2008 and April 2008.

Results: The hysterosonogram findings correlated in approximately 60% of the cases. Additionally, the accuracy of diagnosis was lacking by this modality.

Conclusion: Hysterosonography is a great tool for patients who are unable to undergo operative hysteroscopy and in whom endometrial biopsy alone has to suffice in lieu of hysteroscopic- directed biopsy or excision. This author did not find hysterosonography to be a replacement for hysteroscopy for accuracy of diagnosis. Additionally, hysterosonography fails to address the problem inside the uterine cavity if indeed pathology were present. However, the author agrees that hysterosonogram has a definite place in certain limited clinical situations as a sole modality for diagnosis. 


8351 General Surgery
Reducing Slippage and Erosion Complications in Gastric Banding
Hussam Al Trabulsi, MD

Objective: To evaluate the best approaches for reducing complications in adjustable gastric banding patients in terms of surgical technique (placing the band without using fixation sutures).

Methods: Between 2002 and 2007, 500 patients were operated on for morbid obesity with laparoscopic adjustable gastric banding. Follow-up was from 16 months to 5 years. The same surgical team did the operations and follow-ups in the same surgical facility. We used minimal dissection during surgery, by means of the pars flaccida technique. We leave the band without fixation sutures. The purpose of this is to reduce the intimate contact between the band and the gastric wall in hopes of reducing the erosion rate provided that the band is in its correct position and angle. Follow-up is every 2 months to inflate the band. We get a barium swallow X-ray every 2 sessions or when needed.

Results: In our patient group during the follow-up period, we had 4 (0.8%) cases of erosion and 6 cases of slippage (1.2%).

Conclusion: We recommend our surgical technique and follow-up method for reducing the slippage and erosion complications in laparoscopic adjustable gastric banding.

8352 General Surgery
Comparison of Laparoscopic and Open Methods in the Management of Early Duodenal Ulcer Perforation
Dr. Dheeraj Reddy, MBBS, MS, Dr. Nikita Mehra, MBBS, Dr. Vishwanath M. Pai, MS, DNB

Background: Recently, the laparoscopic approach has been on the rise in the treatment of duodenal ulcer perforation. This study aimed to assess the efficacy and safety of the laparoscopic approach for duodenal perforation compared with the open method.

Methods: A prospective study of patients admitted to Sri Ramachandra Medical College and Research Institute, Chennai, India with the diagnosis of early duodenal ulcer perforation (<24 hours) and who were hemodynamically stable between the periods of April 2006 to April 2008 was done. The rest of the duodenal perforations were excluded. A total of 44 patients were included in the study, 22 of whom underwent laparoscopic repair. Postoperative morbidity, mobilization, initiation of oral feeds, and length of hospital stay were compared between the 2 groups.

Results: The laparoscopic arm had significantly reduced postoperative pain and shortened hospital stay. There was no significant difference in the initiation of oral feeds. The duration of surgery was however a little longer in the laparoscopic approach. Three patients in the open group had wound infection. One patient in the laparoscopic group and one in the open group had pelvic abscesses.

Conclusions: The laparoscopic approach is a safe and efficient alternative for duodenal ulcer perforations albeit only for early perforations.

8355 Multispecialty
Is Performance on a Basic Laparoscopic Skills Set Affected by Differences in Hand-Eye Dominance and Depth Perception?
Rabiya Suleman, MD, Tong Yang, MD, MS, John Paige, MD, Sheila Chauvin, PhD,
Jaime Alleyn, MD, Martha Brewer, MD, Stephen Johnson, Rodney Hoxsey, MD

Objective: The purpose of this study was to determine whether depth perception defects and contralateral vs. ipsilateral hand-eye dominance can affect an individual’s ability to perform laparoscopic skills.

Methods: The study included 105 third-year medical students from Louisiana State University School of Medicine who completed a laparoscopic training session, a questionnaire that included information on handedness, and were tested for eye dominance and depth perception using standardized testing methods. The training session involved an initial recorded performance, a 20-minute practice session, and a final recorded performance. The recorded sessions were randomized and rated using a visual analog scale based on overall performance and depth perception. A general linear model was then used to correlate depth perception defects and hand-eye dominance with assessment scores for overall performance and depth perception performance.

Results: Students who had depth perception defects scored significantly lower than those with normal depth perception. After training, the depth perception defect group still had significantly lower scores. However, after adjusting for pretraining scores, posttraining scores were similar to those of students with normal depth perception. Hand-eye dominance did not significantly affect scores.

Conclusions: Depth perception defects compromise an individual’s essential laparoscopic skill. Individuals with defects can improve their skills by a proportion comparable to those in people with uncompromised depth perception. Differences in hand-eye dominance do not correlate with performance on the laparoscopic skills set. Although further research is necessary, we can conclude that training modules can be tailored to individuals with defects in depth perception to improve laparoscopic performance.

8356 General Surgery
Comparison of Conventional LADG with D2 Lymph Node Dissection with RADG with D2 Lymph Node Dissection for cT2N0M0 Gastric Cancers
W. J. Hyung, J. Song, S. J. Oh, S. H. Choi, S. H. Noh

Background: Robot-assisted surgery has been suggested as an alternative for complex minimally invasive surgeries. However, few studies have analyzed robot-assisted gastrectomy with D2 lymph node dissection (RADGD2), especially for advanced gastric cancer (GC). This study was performed to compare conventional laparoscopic-assisted distal gastrectomy (LADGD2) and RADGD2 for cT2N0M0 GC.

Methods: From July 2005 to December 2007, 22 LADGD2 and 15 RADGD2 were performed on patients who were diagnosed preoperatively as cT2N0M0 GC. The clinicopathological features and surgical outcomes were analyzed.

Results: No conversions were necessary to open in LADGD2 or to open or laparoscopic surgery in RADGD2. Operational mortality was not found in either group. LADG D2 patients (mean, 62 years) were significantly older than RADG patients (mean, 57 years), but no significant differences existed in other characteristics. The mean operative time of RADGD2 (226 minutes) was significantly longer than that of LADGD2 (193 minutes). The numbers of retrieved lymph nodes were similar (35.6 in LADGD2 versus 36.5 in RADGD2). The frequency of using parenteral analgesics had no significant difference between the groups. The day the RADGD2 patients passed flatus (2.6 days) was significantly faster than that of LADGD2 patients (3.2 days), but the day of starting a soft diet and the length of hospital stay were not different between groups. There was one wound complication in each group.

Conclusions: RADGD2 is feasible and safe for the treatment of advanced GC. RADGD2 might be an alternative to LADGD2. However, a prospective study for the long-term surgical outcomes is needed.
Laparoscopic Inguinal Hernia Repair Using a Novel Self-Expanding Rebound HRD Mesh

8357 General Surgery
Laparoscopic Inguinal Hernia Repair Using a Novel Self-Expanding Rebound HRD Mesh
Mr. K. Qureshi, Mr. A. Chopada, Mr. A. Isla

Introduction: Laparoscopic repair of inguinal hernia is now established as a safe and effective way of hernia repair with excellent results. Various meshes are available and have been used for this purpose. We have recently studied a novel self-expanding mesh “Rebound HRD” (MMDI), which is a self-expanding mesh with a nitinol frame. This novel mesh minimizes operation time and eliminates need for mesh fixation.

Method: We randomly selected patients (n=20) with unilateral and bilateral inguinal hernias and randomized them to either a standard Prolene mesh (n=10) or a Rebound HRD mesh (n=10). All of the patients were male. Age range was 25 years to 75 years. Patients underwent laparoscopic repair of their hernia while under general anesthesia, the procedure being performed by experienced surgeons. The operative time and ease of use was recorded for each of these procedures. Postoperatively, patients were assessed for pain levels and mobility.

Results: The average operative time for the standard Prolene mesh group was 22 minutes. The average operative time for the Rebound HRD mesh group was 15 minutes. No fixation clips had to be used for anchoring the Rebound HRD mesh group, unlike with Prolene mesh that required fixation. Use of the mesh needed no special training and could be adapted without any learning curve. Postoperatively, patients in the Rebound HRD mesh group experienced considerably less pain and demonstrated better mobility in the immediate postoperative stage.

Conclusion: Rebound HRD mesh laparoscopic repair of inguinal hernia is a faster and more patient-friendly method that should be used as routine practice.

8358 General Surgery
Single-Port Access (SPA) Colon Resection
Alexander Poor, MD, Erica Podolsky, MD, Stephanie A. King, MD, Paul G. Curcillo, II, MD

Background: We have developed a Single Port Access (SPA) approach for minimal access surgical procedures. Using this technique, we have successfully performed entire procedures through one portal of entry within the umbilicus for all instrumentation.

Methods: We applied our Single Port Access (SPA) technique to 5 colon surgery patients.
One right colon (hepatic flexure tumor), one transverse colon (splenic flexure tumor), and 3 sigmoid (tumor) resections have been accomplished. In all 5 patients, after complete mobilization of the desired portion of the colon and transection of the mesenteric vessels laparoscopically, the colon was delivered through an extension of the initial incision for an extracorporeal resection and anastomosis.

Results: All patients underwent successful colon resections with minimal blood loss. Operative times were similar to times for standard multiport procedures. Nodes removed numbered 12 to 16 and margins of resection were adequate. Patients were discharged within 72 hours of surgery. There were no complications. Two patients spontaneously drained small seromas. Hand-held articulating instruments were used in 2 cases. There have been no umbilical hernias on follow-up at 3 months to 10 months. All incisions were umbilical on completion and were 2.5cm to 5cm in length.

Conclusion: Our initial experience in colon surgery demonstrates successful application of the Single Port Access (SPA) technique. Long-term follow-up of the single-port site is necessary to ensure no added complications compared with standard multiple-port techniques.

8359 General Surgery
Is the Prevalence of Incisional Hernias Changing in the Era of Laparoscopic Surgery?
Usama Qumsieh, MD, Luay Ailabouni, MD, Marek Rudnicki, MD

Objective: Laparoscopic procedures are largely replacing open surgeries nowadays secondary to advancements in laparoscopic technology. As a result, one would assume that the incidence of incisional hernias should decrease given the minimally invasive nature of such procedures.

Methods: Using the ICD-9 code 553.21, we queried the State Inpatient Database (SID) of 4randomly chosen states from the Healthcare Cost and Utilization Project (HCUP) for the prevalence of incisional hernias and their trends from 1997 to 2006. The corresponding state population data from the United States Census database was used to determine prevalence in the general population. The same hospital data were then analyzed by calculating the percentage of patients admitted with a principal diagnosis of incisional hernias compared with the total hospital admissions.

Results: An increase in the total number of patients with the principal diagnosis of incisional hernias was noticed in the hospitals from the 4 analyzed states (from 7962 in 1997 to 9208 in 2006). The prevalence increased from 12.4 to 13.0 hospital admissions per 100 000 population during the study period, peaking at 13.8 in 2004. In 1997, for each 100 000 hospital admissions, 104.9 patients had a diagnosis of incisional hernia versus 112.0 in 2006.

Conclusions: The prevalence of incisional hernias is stable or slightly increasing over the period of observation in the selected states.

8360 Multispecialty
Single Port Access (SPA) Surgery: The First 100 Cases
Paul G. Curcillo, II, MD, Stephanie A. King, MD, Erica R. Podolsky, MD, Steven J. Rottman, MD

Background: Single Port Access (SPA) surgery allows us to perform procedures through one portal of entry for all instrumentation (14mm to 18mm in length). We now report application of this technique to 100 cases in general surgery, gynecology, and urologic surgery.

Methods: Entering through the umbilicus or lateral abdominal wall, an initial 1-cm incision is made. The abdominal cavity is entered in the open technique. A clear 5-mm trocar is inserted for initial insufflation. Lateral skin flaps are raised off the fascia in both directions. Low-profile 5-mm trocars are placed in a triangulated fashion through the same skin incision, but separate fascial sites. Visualization of entry is allowed through the clear trocar with the 300 viewing scope. A combination of instruments can easily be exchanged. For stapling, the central trocar is exchanged for a 12-mm trocar. The initial incision can be slightly lengthened for retrieval of larger organs. The separate fascial incisions may be joined to allow retrieval, and are then securely closed. The intracorporeal portion of the procedure is identical to the standard laparoscopic techniques.

Results: Operative times, results, and outcomes were similar for comparable standard multiport procedures.

Conclusion: We have successfully applied this novel technique to cholecystectomy, colectomy, appendectomy, oophorectomy, hysterectomy, splenectomy, adrenalectomy, ventral hernia repair as well as GE junction procedures. The pliability of the patients’ fascia affords us the “independence of movement” of each trocar, and subsequently of the instrumentation. Long-term follow-up of single surgery sites is necessary to ensure no added complications occur compared with standard multiple-port techniques.

8361 Gynecology
Ruptured Ectopic Pregnancy in Tube and Epiploica
Aimee C. Robinson, MD, Dan C. Martin, MD

Objective: To present the photographs from an ectopic pregnancy found in both the tube and the epiploica. The epiploic mass was immediately adjacent to a recognized site of tubal rupture.

Methods: This presentation includes photographic pictures taken in the routine laparoscopic care of a ruptured tubal pregnancy. The patient had been a candidate for either methotrexate or salpingectomy. Due to the patient’s past history, salpingectomy was chosen. The patient is a 36-year-old, G4P1021, with intermittent right lower quadrant pain and increasing titers after a D&C. Past surgical history is significant for cesarean delivery, multiple laparotomies with myomectomies, and a laparoscopy for a previous ectopic pregnancy. The patient underwent a laparoscopy, lysis of adhesions, right salpingectomy, and excision of a right epiploic mass.

Results: The tube and epiploic mass were both resected. There was a 3-mm area of placental villi in the tube and a 6-mm area of villi in the epiploica.

Conclusions: These pictures and pathology report are compatible with a ruptured ectopic pregnancy with part remaining in the tube and part extruded onto the epiploica. However, it is also possible that this was a twin heterotopic gestation. In either situation, there is concern for both tubal and epiploic components. At surgery, this requires treatment of both the tubal and epiploic segments. Methotrexate could have treated both of these without making a distinction of the site.

8362 Gynecology
Ovarian Remnant Syndrome
Ginny Elisabeth Barton, MD, Dan C. Martin, MD, Todd Tillmanns, MD

Objective: To (1) demonstrate the technique of high ligation of the infundibulopelvic ligament (IPL) containing the ovarian vessels in an area cephalad and lateral to the iliac vasculature, (2) demonstrate tracking the IPL back to a remnant ovary, (3) demonstrate visualization of the ureter through the peritoneum, and (4) to discuss alternate approaches and techniques of identification.

Methods: Pictures were taken in the routine care of a patient with ovarian remnant in the lateral broad ligament. These are presented as the anatomy is readily demonstrated during dissection of the vessels with no adhesions obscuring the view. This dissection is more easily demonstrated than some other dissections as there was also no involvement of the vagina, bladder, or ureter.

Results: The ovarian remnant was resected with no complications under direct visualization.

Conclusions: Beginning the retroperitoneal dissection cephalad and lateral to the pelvic brim and iliac vasculature may be useful in (1) the initial identification of anatomic relationships and (2) decreasing the chance of remnant ovarian tissue along the vascular pedicle, and (3) avoiding ureters in a lateral position. Using the same high-ligation technique for oophorectomy might decrease the chance of remnant ovary.

8363 General Surgery
Laparoscopic Resection of Duodenal Diverticulum: A Case Report and Review of the Literature
Darrin Antonelli, MD, Laura Peterson, MD

Objective: To review the rare cases of duodenal diverticulectomy in the laparoscopic era.
We report the case of a laparoscopic resection of a large-sized symptomatic duodenal diverticulum arising from the fourth portion of the duodenum.

Methods: A 70-year-old female presented with a fluttering sensation in her chest. She also suffered recent weight loss and fear of eating due to her symptoms. She had a cardiac workup that was negative, followed by a CAT scan of her chest. An incidental finding of a large diverticulum was the only noted pathology.

Results: Further study with a GI series showed a diverticulum arising from the fourth portion of the duodenum. Elective laparoscopic surgery revealed an easily dissectible diverticulum approached through the lesser omentum. An endo-GIA linear stapler was used to transect the sac at the base. Postoperative Gastrografin study found no leak or stricture. The patient recovered and was sent home on postoperative day 4. She recovered with no short-term sequelae.

Conclusion: Occurrence of duodenal diverticulum is rare. It can be safely treated laparoscopically.

8364 Gynecology
Single Port Access (SPA) Hysterectomy and Oophorectomy
Stephanie A. King, MD, Ryan Offer, MD, Paul G. Curcillo, II, MD

Background: Single Port Access (SPA) surgery is a technique that allows for laparoscopic procedures to be performed through a single incision concealed within the umbilicus. We compare our series of Single Port Access (SPA) hysterectomy and/or oophorectomy for gynecologic disease, mass, endometriosis, or family history to the outcomes of patients undergoing comparable standard multiport procedures.

Methods: Twenty patients underwent laparoscopic hysterectomy or oophorectomy, or both, using a standard multiport technique. Three to 4 trocars in 3 to 4 separate incisions were used for these procedures in standard fashion. Standard unilateral, bilateral salpingo-oophorectomy, and/or TLH or LAVH were performed. Thirty (30) patients underwent Single Port Access (SPA) salpingo-oophorectomy, TLH, or LAVH. In these patients, the entire procedure is performed through a single (<2cm) incision within the umbilicus. The trocars are all placed within the same skin incision, but through separate fascial incisions in a triangulated fashion. The procedure is then carried out in the same fashion as the standard multiport procedures. Vessel control is obtained with tissue-sealing devices.

Results: Patient populations and surgical indications were similar in both groups. Operative times were comparable, as was blood loss and length of stay postoperatively. Up to 1-year follow-up has demonstrated no additional complications including no increase in umbilical hernia rate.

Conclusion: Our early results comparing Single Port Access (SPA) procedures to standard multiport procedures demonstrate comparable results, but allow us to perform the procedures through a single incision concealed within the umbilicus.

8365 General Surgery
Single Port Access (SPATM) Cholecystectomy: 15 Consecutive SPA Cholecystectomies and One-Year Follow-up
Erica R. Podolsky, MD, Paul G. Curcillo, II, MD

Background: The reduction of trocar sites has been demonstrated in laparoscopic cholecystectomy several times in the past 10 years. Several reports have described single-incision laparoscopic cholecystectomy using additional transabdominal sutures for retraction. We have developed a Single Port Access (SPA) surgical technique that allows for the entire cholecystectomy to be performed through a single incision within the umbilicus while maintaining standard dissection and retraction techniques of currently performed multiport laparoscopic cholecystectomy.

Methods: Fifteen consecutive patients requiring cholecystectomy underwent Single Port Access cholecystectomy. Indications were cholelithiasis, cholecystitis, CBD stones, and biliary akinesia.
SPA cholecystectomy is performed through a single skin incision (<18mm) within the umbilicus. Three trocars are placed in a triangulated fashion within the skin incision, but through separate fascial sites. A fourth instrument for fundal retraction is placed inferiorly, directly into the fascia within the same skin incision. The cholecystectomy is then performed in the standard fashion.  Instrument exchange through the trocars is easily done.

Results: Fourteen patients successfully underwent Single Port Access (SPA) cholecystectomy. One patient required a second 5-mm port site secondary to difficulty with retraction of a large liver. Operative times initially averaged approximately 65 minutes. However, the last 5 have averaged <45 minutes. Blood loss, patient recovery, and outcomes have been comparable to those of standard multiport procedures. No umbilical hernias have been seen 1 year out.

Conclusion: We successfully demonstrate an SPA cholecystectomy with standard instrumentation and trocars performed through a single incision (<18mm) within the umbilicus.

8366 Urology
Laparoscopic Adrenalectomy for a Large Adrenal Mass
Yıldırım Bayazit, MD, Arkun Aytutuldu, MD, Deniz Abat, MD, I. Atilla Aridogan, MD,
Saban Doran, MD

Background: Laparoscopic adrenalectomy has become the technique of choice for the surgical treatment of adrenal tumors. In spite of developments in the era of endoscopic surgery, laparoscopic excision of large adrenal masses is still challenging, and there is a debate on the maximum tumor size suitable for laparoscopy. We present a case of large adrenal mass excised by laparoscopy.

Methods: A 40-year-old man was diagnosed with a 15x10x9-cm right adrenal mass. Transperitoneal right laparoscopic adrenalectomy was performed via three 10-mm and two 5-mm trocars. The adrenal vein was ligated by a LigaSure device. The mass was freed, put into a specimen bag, and extracted through a right lower abdominal incision. A drain was placed through lateral 5-mm trocar incision.

Results: Dissection was difficult due to adhesions to the liver and vena cava. Hemorrhage occurred due to liver injury, and capsular perforation developed on the liver side. A small pleural tear was detected, and a thorax tube was placed. Operative time was 240 minutes. No complication occurred in the early postoperative period. The thorax tube and drain were removed on the second and third postoperative days consecutively, and the patient was discharged on postoperative day 3. Histopathologic examination revealed adrenal cortical carcinoma.

Conclusion: Although laparoscopic adrenalectomy can be performed safely in small adrenal masses, excision of large tumors with a higher incidence of malignancy can be very difficult. Despite surgical skills and experience in laparoscopy, risks of bleeding and other major complications are not low. To avoid complications of laparoscopic adrenalectomy in patients with large adrenal tumors, very careful preoperative judgment is mandatory.

8367 Urology
Early Continence with Novel Restoration of Bladder Neck Anatomy During Robotic Prostatectomy
Gerald Yau Min Tan, MD, Jay K. Jhaveri, MD, Sandhya Rao, MD, Rajiv Yadav, MD, Robert Leung, MPH, E. Darracott Vaughan, MD, Ashutosh K. Tewari, MD, MCh

Objective: We present our integrated approach of anatomic reconstruction of the bladder neck and key periprostatic support structures for delivering early return of continence using the da Vinci robotic platform.

Methods: Between January 1, 2005 and January 30, 2008, a cohort of 1018 patients underwent athermal tri-zonal nerve-sparing robotic prostatectomy by a single experienced surgeon. Patients in 2005 (214) received conventional vesicourethral anastomosis without support. Patients in 2006 (304) received an anterior reconstruction only. Patients in 2007 until January 2008 (500) underwent total anatomic reconstruction. Outcome data were collected using the EPIC and IIEF questionnaires and phone interviews. Patients were followed up at 1-, 6-, 12-, 24-, and 52-week intervals. We defined continence as patients requiring no pads or one small liner for occasional dribble.
Results: Continence rates for patients in the control group are 13%, 35%, 50%, 62%, and 82% at 1-, 6-, 12-, 24-, and 52-week follow-up. Patients receiving anterior reconstruction alone had continence rates of 27%, 59%, 77%, 86%, and 91% for the respective follow-up intervals. Patients receiving total anatomic reconstruction displayed continence rates of 38%, 83%, 91%, and 97% at 1-, 6-, 12-, and 24-week follow-up. Improved continence outcomes in the total reconstruction cohort were statistically significant in all time periods compared with the control and anterior reconstruction cohorts (P<0.01).

Conclusions: Our technique of reconstructing pelvic anatomy and support for the vesicourethral anastomosis following robotic prostatectomy delivers significantly accelerated return of continence, with no added morbidity or prolongation of operative time.

8368 General Surgery
Safety and Efficacy of Laparoscopic Appendectomy in Pregnant Women
Jaideep Singh Chahal, MBBS, MS, Manju Chahal

Background: The most common cause of an acute abdomen in pregnancy is acute appendicitis. But the role of laparoscopic appendectomy in pregnant women is still controversial.

Methods: Clinical data was collected prospectively from May 2004 through October 2007. Twenty-three pregnant women underwent laparoscopic appendectomy at our institution. At the time of surgery, the mean age was 25 years (range, 17 to 41); mean gestational age was 23.5 weeks (range, 12 to 29). Ten patients were in the first trimester, 7 were in the second trimester, and 6 patients were in the third trimester. Perioperative obstetric monitoring was done by fetal ultrasound, Doppler sonography, and cardiotocography.

Results: All patients underwent successful laparoscopic appendectomy. One patient developed wound infection. Mean operation time was 48 minutes (range, 35 to 95). Average length of hospital stay was 4 days (range, 3 to 7). All pregnancies resulted in delivery of healthy infants. The mean gestational age at delivery was 38.4 weeks (range, 34 to 41). Two of 7 third-trimester patients had a preterm delivery at 34 weeks with uncomplicated outcomes, and the other patient underwent cesarean delivery at 39 weeks due to fetal distress.

Conclusions: Laparoscopic appendectomy is a safe and effective method to treat acute appendicitis in pregnant women in the first and second trimesters.

8369 Gynecology
Neutral Argon Plasma in Laparoscopic Management of Endometriosis
Ceana Nezhat, MD, Vadim Morozov, MD

Objective: To describe and demonstrate the use of Plasma technology in the treatment of endometriosis.

Methods: Vaporization and excision of endometriosis with Plasma technology.

Results: Complete removal of the endometriosis lesions. Specimens were sent to pathology for the identification of residual disease after use of Neutral Argon Plasma. No residual endometriosis was identified at the base of the vaporized and excised lesions. Thermal spread was limited to less than 1-mm depth. No complications were observed.

Conclusions: A Neutral Argon Plasma device can be used safely and efficiently to laparoscopically treat endometriosis, especially superficial implants. Minimal thermal spread and the absence of flow of electrical current through the body makes its use especially appealing.

8370 General Surgery
Superior Mesenteric Artery Syndrome after Laparoscopic Gastric Bypass: A Case Series and Review of the Literature
Bruce J. Applebaum, MD, Benjamin L. Clapp, MD

Background and Objectives: As bariatric surgery becomes more widespread, atypical complications will be seen with more frequency. In this cases series, we report on 3 cases of superior mesenteric artery syndrome after gastric bypass and the laparoscopic treatment.

Methods: This is a case series of 3 patients who presented with the persistent postprandial symptoms of pain and nausea after gastric bypass and through extensive workup were eventually diagnosed with superior mesenteric artery syndrome. All 3 patients had dramatic weight loss after laparoscopic Roux-n-y gastric bypass. Gastric remnant distention was not a consistent finding, but persistent postprandial nausea and computed tomography findings of a narrowed angle between the SMA and the aorta were consistently found. Two patients were treated with a laparoscopic gastroduodenal jejunostomy anastomosis, and one patient had a duodenojejunostomy, all with resolution of their symptoms.

Results: A laparoscopic gastroduodenal (or duodeno-) jejunal bypass was performed in each case, which resolved the obstruction caused by the superior mesenteric artery syndrome.

Conclusions: Superior mesenteric artery syndrome can be caused by the dramatic weight loss induced by a gastric bypass. This post weight loss surgery phenomenon may be far more prevalent and underdiagnosed than reported, and should be considered in all patients with greater than average weight loss at one year and who have persistent postprandial nausea. This can be successfully treated by bypassing the obstruction, while maintaining the weight loss induced by the Roux-n-y gastric bypass.

8371 Urology
Real-time Visualization of Periprostatic Neural Architecture Using Multiphoton Microscopy and Second-Harmonic Generation to Improve Potency Outcomes During Nerve-Sparing Radical Prostatectomy: Our Early Results
Gerald Yau Min Tan, Rajiv A. Yadav, Jay Jhaveri, Sushmita Mukherjee, Robert Leung, Sandhya Rao, Frederick R. Maxfield, Watt W Webb, Ashutosh K. Tewari

Objective: Multiphoton microscopy is a novel technology that permits bioimage acquisition using several low-energy photons to induce autofluorescence of cellular components without damaging live tissue. When combined with imaging of a quantum optics phenomenon called second-harmonic generation (SHG), tissue discrimination is considerably enhanced. We report our ex vivo results of this new modality in both rat and fresh human prostatectomy specimen models.

Methods: After obtaining IRB and IACUC approval, the prostate, cavernous nerves, seminal vesicles, and periprostatic tissue were excised from 12 euthanized male Sprague-Dawley rats and imaged under an Olympus X61WI upright fluorescence microscope. A femtosecond pulsed Titanium/sapphire laser at 780nm wavelength was used to excite the cellular tissue. SHG signals were collected at 390nm (±35) and autofluorescence registered at 380nm to 530nm. Bioimages from both sources were merged for improved tissue visualization. Images were similarly obtained using a fresh human prostatectomy specimen. Tissues were labeled and correlated with final images at H&E histopathologic confirmation.

Results: High-resolution images of the prostate capsule, periprostatic neural scaffold, fat, underlying acini, and the individual cells outlining the glands were obtained. Histopathologic confirmation with H&E for harvested tissue was closely congruent with images obtained at MPM.

Conclusions: Multiphoton microscopy with SHG is a feasible real-time imaging modality that delivers high-resolution bioimages without requiring extrinsic labeling agents. Eventual integration of this novel technology with laparoscopic and robotic platforms during nerve-sparing radical prostatectomy may deliver improved potency and cancer clearance outcomes.

8372 General Surgery
Laparoscopic Total Proctocolectomy with Vertical, Double-Stapled Ileal-Pouch Anal Anastomosis
Myles Joyce, MD, Daniel Geisler, MD

Objective: Laparoscopy has become an accepted treatment modality for many disorders of the colon. However, the feasibility of a minimally invasive approach for more complex cases continues to be a source of debate. The objective of this video is to highlight that by using a standard approach a total proctocolectomy (TPC) with ileal pouch anal anastomosis (IPAA) may be safely performed using minimally invasive surgery.

Methods: This video demonstrates our standard laparoscopic approach using a 4-trocar technique for a total proctocolectomy (TPC) with ileal pouch anal anastomosis (IPAA) in a patient with ulcerative colitis and associated dysplasia. The specimen was exteriorized via a 5-cm suprapubic incision.
Results: No postoperative complications occurred. The patient was discharged home on postoperative day 3, and we closed the ileostomy 4 weeks from the indexed surgery.

Conclusion: The above case demonstrates that a laparoscopic approach is feasible for patients requiring a TPC/IPAA. It provides all the benefits of minimally invasive surgery including improved cosmesis, less postoperative pain, and earlier restoration of bowel function. We believe that the reduced incidence of postoperative adhesions allows earlier time to stoma closure. However, we do appreciate that this surgery is associated with a significant learning curve.

8373 General Surgery
Novel Transanal Operation for Rectal Cancer Combining Ultrasonic Dissection, Titanium Knot, and the Storz Rectoscope
Emad Kandil, MD, Verenda Joshi, MD

Background: Transanal endoscopic microsurgery (TEM) allows a precise, full-thickness resection of rectal tumors. However, the standard TEM technique needs complex and expensive equipment, and is associated with bleeding that may be challenging. A modified TEM procedure combining the ultrasonic Harmonic dissection and Titanium Knot quick load via the Storz operation rectoscope has been developed to overcome the limitations of the traditional TEM procedure.

Case Report: A 71-year-old morbidly obese male was referred for surgical management of invasive rectal adenocarcinoma diagnosed on routine colonoscopy. Repeat sigmoidoscopy revealed evidence of 2.5-cm mass 7cm from the anal verge (T1 lesion on endoscopic ultrasound). Combining ultrasonic Harmonic dissection, Titanium Knot quick load system, and the Storz operation rectoscope were used for full-thickness resection. The patient’s postoperative course was uneventful, and he was discharged home the next morning. Pathologic examination of the specimen confirmed negative margins.

Conclusion: Ultrasonic dissection provides a fairly bloodless field. For tumors located up to 20cm from the anal verge, modified transanal operation with the Storz operation rectoscope, Ultrasonic dissection, and Titanium Knot quick load system is feasible, cheaper, and should be considered.

8374 General Surgery
Short-Term Surgical Outcomes of Laparoscopic D2 Lymphadenectomy in Distal Gastric Cancer
Oh Cheong, MD, Young-Kyu Park, MD, Seong-Yeop Ryu, MD

Purpose: With the advancement of laparoscopic surgery, there have been efforts to expand the indication of laparoscopic surgery to advanced gastric cancer. However, little data are available on the feasibility and advantages of LADG with standard radical D2 lymph node dissection.

Patients and Methods: Between February 2007 and August 2007, 22 patients who were preoperatively diagnosed with cT1N0M0 gastric cancer underwent laparoscopic-assisted distal gastrectomy with standard D2 lymphadenectomy. They were compared with patients who underwent conventional open D2 lymphadenectomy, with respect to clinicopathologic features, surgical outcomes, and postoperative course.

Results: The mean operation time took significantly longer in the LADG group than in the ODG group (160±25 vs. 135±21min, P<0.001). However, surgical outcomes, such as surgical margin and retrieved lymph nodes (25.7±11.1 vs. 26.9±9.2, P=ns) were comparable between groups. LADG groups showed quicker postoperative recovery, and both groups showed similar postoperative morbidity and mortality.

Conclusions: LADG with D2 lymphadenectomy is feasible and safe with comparable short-term surgical outcomes with open D2 lymphadenectomy. Further prospective clinical trials will be needed to evaluate the advantages of LADG with D2 lymphadenectomy.

8376 General Surgery
Balloon Retention Facilitates Transgastric Laparoscopic Cysto-gastrostomy in Treatment of Pancreatic Pseudocyst
Todd A. Nickloes, DO, Matt Jones, MD, Craig S. Swafford, MD

Objective: This presentation demonstrates intragastric balloon retention facilitating a transgastric laparoscopic cysto-gastrostomy for pancreatic pseudocyst.

Methods: Via endoscopic and laparoscopic methods, 3 balloon-tipped operating trocars were inserted into the stomach. Transgastric identification of a pancreatic pseudocyst was accomplished with drainage of the pseudocyst via a permanent cysto-gastrostomy, created laparoscopically. Pseudocyst drainage was confirmed endoscopically and laparoscopically, as were the operating gastrostomies after laparoscopic closure.

Results: The patient was discharged home on day 4 after this 3-hour procedure. This is the second of 2 such procedures performed at this institution. The first lasted 3.5 hours, and the patient was discharged on postoperative day 2. Each has been followed for a year postoperatively with an uneventful recovery and full resolution of their pancreatic pseudocysts.

Conclusion: Acute fluid collections occur in 30% to 50% of severe pancreatitis cases. After 4 weeks to 6 weeks, these fluid collections may coalesce into a formal pseudocyst that typically is extrapancreatic and in the lesser sac. Complications of pancreatic pseudocyst include infection evolving into a pancreatic abscess, rupture leading to pancreatic ascites, erosion into the thorax creating a pancreaticopleural fistula, or production of a mass effect with gastric or duodenal obstruction and pain. Various methods of pseudocyst treatment have been described including endoscopic, percutaneous, laparoscopic, open, or combinations of the above. We demonstrate with video and still images a combined technique using an endoscope and the transgastric laparoscope with balloon-retained trocars inside the stomach to improve visualization and facilitate the minimally invasive approach to the pancreatic pseudocyst.

8377 General Surgery
Recurrences After Transanal Endoscopic Microsurgery for Primary Rectal Adenocarcinoma
Jung Wook Huh, MD, Seung-Kook Sohn, MD, PhD

Objective: The role of local excision in treating rectal cancer patients continues to be controversial. The aim of this study was to evaluate the long-term oncological results of transanal endoscopic microsurgery for local excision of early rectal adenocarcinomas and review the outcomes of salvage therapy on rectal cancer patients.

Methods: Between March 1994 and September 2005, 35 consecutive patients with early-stage primary rectal adenocarcinomas were treated with curative intent by transanal endoscopic microsurgery. The mean tumor distance from the anal verge was 5cm (range, 2 to 10).

Results: The median follow-up was 66 months (range, 17 to 161). Pathological examination revealed 23 cases of T1 and 12 cases of T2. Local recurrence had developed in 6 patients (17.1%). Purely extrapelvic recurrence was observed in only 2 (5.7%) patients. Of the 6 patients with local recurrence who underwent surgical salvage, 5 survived with no evidence of disease at the time of this analysis. The 5-year local recurrence-free and disease-free survival rates were 79.6% and 67.9%, respectively.

Conclusions: Local excision alone of early-staged rectal adenocarcinomas, even in the ideal candidate, is followed by a relatively higher local recurrence rate than previously reported. Additional treatment strategies and strict patient selection for local excision are essential. 


17TH SLS ANNUAL MEETING AND ENDO EXPO 2008 GENERAL SESSIONS

OPENING CEREMONY
6:30pm Wednesday, September 17, 2008

SPECIAL PRESENTATION
Virtual World Environments and Their Potential Impact on Surgical Training and Care
James C. “Butch” Rosser, MD

As the sun sets on the real world, Butch Rosser, MD FACS, shines a light into the still-murky dawn of the virtual earth in which our progeny will henceforth live more and more of their lives. In his typical style of aggressively probing the “what if”, he introduces the hypothesis that surgery should leverage the assets of this new medium to enhance surgical care and training. This is not a plea for generations to come, but rather, it is an announcement that the future is ready to happen today

BEST OF LAPAROSCOPY UPDATES
7:30am Thursday, September 18, 2008

UPDATE FERTILOSCOPY/TRANSVAGINAL ENDOSCOPY COMMITTEE
The Current Status of Transvaginal HydroLaparoscopy
Duncan Turner, MD

Approximately seven years ago transvaginal hydrolaparoscopy was introduced to the United States. One particular technique utilized was that of fertiloscopy. This is a procedure involving a transvaginal evaluation of the pelvis, a dye test, and a hysteroscopy in one setting under general or local anesthesia. Although this has not been completely incorporated into the practice of the regular gynecologist, it remains a very interesting technique with some distinct advantages, both in terms of morbidity and financially to the patient. An international multi-center study is about to be embarked upon comparing a fertiloscopy with a hysterosalpingogram for prediction of abnormal pathology. 

UPDATE ROBOTIC SURGERY COMMITTEE
Robotic Surgery: Coming to a Hospital Near YOU Soon
James F. Carter, MD

Over the last 30 years the evolution of Endoscopy has developed to reduce surgical injuries, decrease hospital stays along with reducing postoperative pain. Though laparoscopy could allow better visualization, laparoscopy has continued to work on a 2 D scale that limited to a certain degree tactile feedback and many surgeons fail in their suturing skills. In the last 10 years there has been a plateau of Growth of Laparoscopy with less formalized training, except in residency programs and fear of litigation. Beginning with NASA and the military thinking outside of the box with attempting to work on remote procedures. After initial difficulties, telepresence improving with Cardiac surgeons and Urologists with improving efficacy and lowering mortality. Newer set ups bring surgeon closer to patient, allowing an ergonomic console with 3-D visualization and ultimately bringing together a fully integrated team to effectively dissect laparoscopically returning to the surgeon all six positions of the wrist and making a much easier transition to operative laparoscopy. The ultimate Robotic will allow an organized, validated program to upgrade the skills of the surgeon, cause less pain on even the more challenging patient by restoring the surgeons dexterity and expand the original concept of remote surgery. We will be limited only by our own imagination. What is next?

UPDATE ABDOMINAL/PELVIC PAIN/ADHESIONS COMMITTEE
Pelvic Pain and the Reduction of Adhesions
Dan Martin, MD

Adhesions are a major problem after surgery. Consequences for patients include small bowel obstruction, chronic pelvic pain, infertility and repeat operations. This presentation covers the use of adhesion prevention solutions at laparoscopy.

The results of a FDA approved efficacy study demonstrated that the use of Adept (4% icodextrin) or lactated Ringer's solution at a volume of 1,000 cc decreases reformation of adhesions compared with the literature at volumes of 300 cc and 660 cc. 660 cc of a buffered solution was superior to 300 cc. Adept is a 4% modification of a 7.5% buffered, peritoneal dialysis solution. Adept patients achieved greater clinical success than lactated Ringer's solution in patients with filmy adhesions. Adept and lactated Ringer's were equal in their 50% decreased reformation of dense adhesions.

These solutions are contrasted with normal saline. Normal saline contains sodium and chloride in equal concentration that do not reflect the ratio in human extra cellular fluid. A variety of metabolic and tissue effects are produced by this abnormal ratio. Normal saline may predispose to the formation of peritoneal adhesions and fibrosis of the peritoneum when left in the pelvis. Use of normal saline to wash the peritoneal cavity after chronic peritoneal dialysis appears more likely to produce adhesions than no irrigation at all.

UPDATE INFERTILITY/FERTILITY COMMITTEE
Laparoscopic Update on Infertility/Fertility
Grace Janik, MD

MULTIDISCIPLINARY PLENARY SESSION
8:30am–10:00am, Thursday, September 18, 2008

MULTIDISCIPLINARY APPROACH TO ADHESIONS
Abdominal and Pelvic Adhesions, the GYN Perspective
Charles H. Koh, MD

Adhesions in the Abdomen, the General Surgeon's Dilemma
Phillip Shadduck, MD

Intraabdominal adhesions cause bowel obstruction, chronic abdominal pain, morbidity and mortality.
Approximately 70% of bowel obstructions are caused by adhesions. Adhesive small bowel obstruction alone results in nearly one million hospital days and more than 3 billion dollars of care in the US each year. Approximately 25% to 50% of patients suffering from bowel obstruction will require operative management. Discerning nonoperative from operative obstructions, accurately and timely, is difficult and carries risk. Operations for adhesiolysis can be tedious, difficult, and fraught with postoperative complications. Most adhesiolysis operations are performed open. The laparoscopic approach to adhesiolysis is feasible but requires careful patient selection, advanced laparoscopic skills, and sound surgical judgment, including a low threshold to convert to open when managing distended, thin-walled bowel. Postoperative complications are numerous, sometimes serious, and include prolonged ileus, fluid and electrolyte abnormalities, malnutrition, a variety of infections, enterocutaneous fistulae, recurrent early and late adhesions, and need for further surgery.

Adhesive abdominal pain can be chronic, severe, and frustrating for the patient, the family, and the health care team. Symptoms can be variable and nonspecific. Diagnostic algorithms are imperfect, and diagnostic studies are frequently nonspecific and unsatisfying. Surgery may be required for diagnosis and treatment.  Rates of pain recurrence, even after diagnostic surgery and adhesiolysis, are moderately high.

Safe, effective, cost-effective adhesion prevention is desirable yet seemingly elusive. Anti-adhesion barriers are better now than in decades past, though still with limited success. Opportunities for improved prevention and management of adhesion-induced morbidity and mortality remain.

New Strategies in Prevention and Management of Adhesions: The Research Perspective
Kathleen E. Rodgers, PhD

Adhesions are connections between normally unattached tissues created by surgical injury, infection or foreign body responses. Good surgical technique and minimally invasive surgery reduce the incidence and severity of adhesion formation, but they are not eliminated.

Intraperitoneal adhesion formation can have significant consequences, including small bowel obstruction, infertility, chronic pelvic pain and organ displacement/tethering. The latter can have severe consequences at the time of re-entry at re-operation. Medical devices to reduce adhesion formation have undergone preclinical and clinical development and are currently marketed in the United States, Europe and Japan. Marketed products include Interceed, a bioresorbable knit barrier of oxidized regenerated cellulose; Adept, a 4% solution of icodextrin that provides prolonged hydroflotation / tissue separation during healing; and Intercoat, a gel barrier of carboxymethyl cellulose complexed with polyethylene oxide. Additional therapeutic modalities are undergoing preclinical and clinical development. Pharmaceutical intervention to reduce adhesion formation has a promising future. Sites of intervention under investigation include (1) reduction of inflammation after surgery through prevention of the production of or neutralization of the activity of inflammatory mediators; (2) inhibition of deposition or enhancement of clearance of fibrin which is the scaffold for adhesion formation; and (3) modification of adhesion remodeling. The goal of these efforts is the development of a highly effective, easy to use and safe therapeutic for adhesion prevention.

Prosthetics, Synthetics and Biologicals: Notes from the Laboratory
Raymond J. Lanzafame, MD, MBA

Adhesion formation is part of the normal healing process and has been observed in 90-100% of all abdominal surgeries. Adhesions are a clinically relevant problem with the potential for significant morbidity for the patient. Postsurgical intraabdominal adhesions account for 79% of acute intestinal obstructions and are frequently responsible for chronic abdominal pain and infertility. Mechanical injury to the peritoneum, peritoneal ischemia, manipulation, exposure to foreign materials including powder, gloves and prosthetic materials; and inflammatory diseases and processes have been demonstrated to cause adhesions.

Modern herniorrhaphy techniques utilize mesh bioprostheses in a variety of types and configurations. The ideal material should be chemically inert and noncarcinogenic, should be capable of being fabricated in the form required and be sterilizable, should not be physically modified by tissue fluids, should not excite an inflammatory or foreign body reaction, and should not induce a state of hypersensitivity or allergy (Jenkins SD, et al.: Surgery 1983; 94(2):392-398). Bioincorporation of the mesh material is critical to the success of the repair. Mesh is typically secured with staples or sutures. Clinical use of fibrin glue, other tissue adhesives, and cyanoacrylates for mesh fixation has resulted in strong fibrous reactions and increased inflammatory response locally.

New strategies for mesh fixation, adhesion prevention and tissue reinforcement are being developed from collagen and other biological substrates as well as a number of novel compounds. These novel technologies are demonstrating promising results in experimental models and will likely be made available for clinical use in the near future. This presentation will discuss some of the promising technologies incubating in the laboratory.

SPECIALTY BREAK-OUT CONCURRENT SESSION (GYN)
10:30am–11:30am, Thursday, September 18, 2008

HYSTERECTOMY DEBATE: WITH OR WITHOUT REMOVING THE CERVIX OR OVARIES
Oophorectomy at the Time of Hysterectomy: Pros & Cons
Farr Nezhat, MD

“Prophylactic oophorectomy in women undergoing hysterectomy at age 40 or older would prevent over 1,000 cases of ovarian cancer annually” (Sightler et al 1991). This risk of ovarian cancer must be weighed against the risk of coronary heart disease, hip fracture, and stroke to determine whether oophorectomy should be performed. Additionally, the patient's menopausal status must come under consideration. The current ACOG recommendation for ovarian preservation includes premenopausal status, desire for fertility, impact on sexual function, libido, quality of life, and osteopenia or other risk for osteoporosis. Factors that favor oophorectomy include genetic susceptibility for ovarian cancer, bilateral ovarian neoplasms, severe endometriosis, pelvic inflammatory disease, bilateral tuboovarian abscesses, and postmenopausal status. Among those patients with genetic susceptibility, BRCA and HNPCC mutations are most frequently addressed. This presentation will review the pros and cons of ovarian preservation in the general population as well as those with a genetic predisposition for ovarian cancer.
 
Why Total Hysterectomy and not Supracervical Hysterectomy?
Tommaso Falcone, MD

There is a recent trend towards retention of the cervix at hysterectomy due to the perception that several outcome parameters such as sexual function and pelvic support are better after a supracervical hysterectomy. However three prospective randomized clinical trials as summarized in a recent Cochrane review challenge this perception. These trials included 733 patients with follow up between one to two years. One study was double- blind (patient was not aware if the cervix was removed). There was no evidence to support the concept that leaving the cervix was associated with improved sexual function or lower rates of incontinence or constipation. All of these studies included hysterectomies that were performed by laparotomy. However there is no logical reason to believe that it would have been different by laparoscopy. Blood loss was reduced with supracervical hysterectomy but the transfusion rates were the same. Length of surgery was decreased in the supracervical group. This is the main reason why this approach has become popular with gynecologists. This decreased surgical time is especially the case for laparoscopic hysterectomy where the most difficult part of the surgery is the detachment of the cervix from the lateral ligaments and from the vagina. This is also where most ureteral injuries occur during laparoscopic hysterectomy. However this advantage should be balanced with the potential risk of ongoing cyclic bleeding from the cervix that has been reported to be between 5-20% from the randomized clinical trials and 19% from a prospective observational laparoscopic trial.

Why Supracervical Hysterectomy and not Total Hysterectomy?
Charlie Miller, MD

Prior to the introduction of the Papanicolaou smear in 1958, total hysterectomy was recommended to reduce deaths from cervical cancer. With the advent of “ThinPrep” and HPV testing, the ability to properly evaluate cervical pathology has further improved. Thus, the need to continue to extirpate the non-diseased cervix must be questioned.

In a study by Learman, et al., comparing supracervical hysterectomy and total abdominal hysterectomy, performance of either technique led to statistically significant reductions in most symptoms. Interestingly, although not significant, patients assigned to the supracervical hysterectomy group had more hospital readmissions. No significant differences were noted in the rate of complications, degree of symptom improvement or activity limitation.

In a prospective randomized study comparing surgical complications and clinical outcomes after supracervical versus total laparoscopic hysterectomy for the control of abnormal uterine bleeding or symptomatic uterine fibroids, Morelli, et al. found similar results. Again, significant pain reduction and improvement in stress urinary incontinence were noted in each group. Hospital admissions were again higher in the laparoscopic supracervical hysterectomy group. Once again, no statistical significance was reached in regards to complications, degree of symptom improvement or activity limitation. Though the above does not show a distinct advantage for laparoscopic supracervical hysterectomy, other studies indicate that SLH should be the procedure of choice when the cervix testing is benign and there is no indication of rectovaginal endometriosis. These advantages include the following:

•    Less hospitalization required
•    Faster immediate recovery, including time to intercourse
•    Faster long term recovery

SPECIALTY BREAK-OUT CONCURRENT SESSION (URO)
10:30am–11:30am, Thursday, September 18, 2008

TREATMENT STRATEGIES FOR THE SMALL RENAL MASS
Lap Partial Nephrectomy
Arieh L. Shalhav, MD

Laparoscopic nephron sparing surgery (NSS) is rapidly adopted by urologists that are experienced in urologic laparoscopy. Current laparoscopic NSS ranges from complex, challenging procedures such as laparoscopic partial nephrectomy (LPN) with intracorporeal suturing and the related need for warm ischemia (WI) to simpler laparoscopic needle ablating techniques which do not require WI such as Radiofrequency Ablation (RF) and Cryoablation (Cryo). Though more technically challenging LPN is related to better long term cancer control, however a slight increase in complications compared to RF or Cryo ablation. In experienced hands LPN is currently a standard of care for tumors ≤ 4cm that are not centrally located. Complex LPN defined as tumors >4cm, centrally located or in patients with a single kidney or compromised renal function, should only be performed by surgeons with a vast experience as part of the development curve of the procedure.

The limiting factor for the widespread use of LPN by multiple urologists is the related WI. With the introduction of robotic assisted LPN including 3D vision, increased degrees of instrument freedom and ease of suturing, WI even in less skilled hands will diminish and LPN will be disseminate to urologists with less laparoscopic experience. Initially performing robot assisted LPN for small exophytic tumors and then progress to larger and more centrally located tumors. I believe that as robotic assisted LPN will evolve the relative use of needle ablative procedures for renal tumors will decrease.

Radiofrequency Ablation
J. Kyle Anderson, MD

This presentation will focus on the treatment of renal masses using ablation technologies such as radiofrequency ablation and cryoablation. Success rates, patient selection criteria, and areas for future advances will be discussed.

Active Surveillance of the Small Renal Mass
David Chen, MD

Incidental small renal masses (SRMs) have become a diagnostic dilemma. While the evidence suggests that intervention by excision or ablation are highly effective, the impact these treatments have on the natural history of the disease may be overstated. Data from multiple institutions demonstrate that up to 30% of localized renal tumors under active surveillance demonstrate zero net growth when followed [1],  and that those which do grow show small incremental size increase averaging 3-4 mm per year over a median follow-up period of 34 months [2]. Moreover, active surveillance with delayed management does not appear to raise the risk for stage progression or impact the choice of subsequent minimally-invasive or nephron-sparing treatment options [3]. A recent review and meta-analysis of the data on over 6000 patients undergoing excision, ablation or observation of localized SRMs demonstrates significant limitations in current reports regarding treatment strategies for localized RCC [4]. In a full review of the literature, of 470 reported cases of localized kidney cancer under surveillance just 1.5% developed metastasis and only after a mean interval of 65.4 months [5]. Taken together, these data suggest that the benefit of SRM treatment may be overstated and that active surveillance of these lesions, particularly in the elderly and infirm, may be an appropriate option. This lecture will review the available data on the topic of active surveillance of the SRM.

1. Kunkle DA, Crispen PL, Chen DYT, Greenberg RE, Uzzo RG.: Enhancing renal masses with zero net growth during active surveillance. J Urol., 2007 Mar;177(3):849-53
2. Chawla SN, Crispen PL, Hanlon AL, Greenberg RE, Chen DYT, Uzzo RG:. The natural history of observed enhancing renal masses: meta-analysis and review of the world literature. J Urol., 2006 Feb;175(2):425-31
3. Crispen PL, Viterbo R, Fox EB, Greenberg RE, Chen DYT, Uzzo RG: Delayed intervention of sporadic renal masses undergoing active surveillance. Cancer, 2008 Mar 1;112(5):1051-7.
4. Kunkle DA, Egleston B, Uzzo RG: Excise, ablate or observe: the small renal mass dilemma--a meta-analysis and review. J Urol., 2008 Apr;179(4):1227-33
5. Kunkle DA, Chen DYT, Greenberg RE, Viterbo R, Uzzo RG: Metastatic progression of enhancing renal masses under active surveillance is associated with rapid interval growth of the primary tumor. J Urol., 179 (4):375

Development of a VR Training Module for Lap Renal Skills
Robert M. Sweet, MD

Background: Surgical Simulation is finally coming of age. The focus has shifted from a demonstration of technology to a robust educational tool. Combining state-of-the art technologies with proper educational design begs for industry/society/academia collaboration. Until now that type of collaboration has been elusive. The project we describe, the development of the Laparoscopic Transperitoneal Nephrectomy (LTN) Learning Module is a major milestone on that path. It began with a defined need within the AUA to train and assess residents as well as practicing urologists in the performance of LTN.

Methods: The team assembled to deliver the final Learning Module represents a professional society, (the AUA), the University of Minnesota as the academic partner responsible for building the models, and METI as the industry partner and integrator. The AUA has established the learning objectives, is developing the corresponding metrics and is creating the didactic content required and will do the validation studies on the final module. The University of Minnesota is using novel advanced modeling techniques to deliver models that look and behave like real tissue required tissue properties, and METI has the responsibility to develop the architecture, provide all simulated scenarios, integrate all aspects of the curriculum into the Learning Module and bring the product to market.

Results: This collaboration is successfully delivering a VR simulator founded on user-directed educational design, state-of-the-art tissue appearance and behavior, and a strong pathway towards successful commercialization.

MULTIDISCIPLINARY PLENARY SESSION
7:30am–8:30am, Friday, September 19, 2008

PAY FOR PERFORMANCE (P4P)
Safety, Quality and Improving Operating Room Performance
Gustavo Stringel, MD

Patient safety has always been a priority in medicine. Over the past few years there has been a special focus through transparency and accountability in defining the role of the physician and other health workers in measuring, monitoring, developing and managing health care delivery in order to improve safety and quality of care to ensure desired outcomes. The landmark reports by the Institute of Medicine have raised awareness of the negative impact of medical errors on safety and quality delivery of care that have prompted the creation of new systems to try to prevent harm to the patients and to improve outcomes.

The Institute of Medicine has defined that high quality care should be safe, effective, timely, efficient, evidence based, and equitable. It is the surgeon's responsibility to deliver good quality care and to ensure the safety of the surgical patient. The surgeon is often confronted with hurdles and barriers that interfere with efficiency and performance. One of the main problems is financial constraints; the surgical services of health organizations have been forced to increase patient volume in order to ensure financial viability. The development and acquisition of new technology has significantly increased the cost and complexity of health care. The surgeon needs to learn to function under these new rules and strive to improve safety, quality and performance to improve outcomes.

Improving operating room and overall surgical services performance is essential to cope with the current high volume and technologically advanced modern surgical care. The ultimate measure of quality and performance for surgeons and surgical services is to evaluate and compare outcomes for similar surgical conditions.

Pay for Performance and Transparency
Alex Gandsas, MD

Financial Aspects of Surgical Care. Past, Present and Future
Raymond J. Lanzafame, MD, MBA

Medicine and healthcare are changing rapidly. Aging Baby Boomers and new technology are impacting our ability to provide appropriate care at a reasonable cost. Quality, safety and performance are an integral part of the new healthcare culture. It is incumbent upon the surgeon to acquire a thorough understanding of the financial aspects of surgical care from the perspective of the stakeholders, and the hospital in addition to the view of the provider.

There is a trend on the part of the federal government to mandate more transparency relative to CMS payments to hospitals, ambulatory care centers and providers as a way of providing consumers with cost information in an effort to encourage them to choose the least expensive alternative. It is unclear how the public will respond to this information, or to what degree an individual patient will make decisions based on the cheapest price, particularly since economic responsibility for healthcare is limited at best for most patients. Consumers and other stakeholders are demanding more information and more accountability from providers. Consumers base their decisions on service and satisfaction since they cannot evaluate technical skills. They use word of mouth or service and customer satisfaction attributes when making their healthcare choices, since they cannot evaluate expertise or quality effectively. Patients are willing to trade convenience and speed of access for more comprehensive or ongoing care.

Most healthcare costs are fixed and sunk over any reasonable time horizon. Fixed costs do not vary with the level of patient activity and once sunk they cannot be easily reversed. Once dollars have been invested to acquire a technology, the more frequently it is used, the less expensive its per case cost will be. The variable costs for any disposable items used with the machine would be the same per case. This creates a strong argument for encouraging the use of a technology once it has been acquired.

Many of the least expensive, quickest, and highest return reforms in health care are process rather than technology related. A quality initiative in the State of Kentucky, found that there was no single clinical situation in which safer practices were intrinsically more expensive than those that were less safe in six years of study. Similarly, they found no instances where practices that are more expensive were associated with better outcomes.

Managed care organizations focus on the variable cost of health care delivery and largely neglect capacity decisions. There is little disincentive for the hospital with excess capacity to do additional cases and at reduced capacity there are incentives to increase throughput to increase volume because resource consumption in healthcare is front-loaded. Most of the expenses are incurred on the first day of a patient's stay. Reducing length of stay is important in cases of high capacity utilization, since it frees up capacity and creates opportunities for more admissions. There is very little incentive to reduce length of stay at the extreme condition of low utilization of capacity.

Surgeons have a significant effect on the cost of care. Individual surgeons have statistically and clinically significant differences in their costs and volatility of costs when holding patient factors and procedural complexity constant. Surgeons with similar case mixes can have very different ranges of cost as they treat their patients. There is a dichotomy between what payers pay in professional fees to doctors and what they pay to the hospital. The interaction between the amount of OR time used, the RVUs per case and the number of cases performed per year determine the contribution to the hospital margin by any particular surgeon or surgical service.  The choice of technologies used and the use of disposables rather than reusable instruments can adversely affect the hospital's margin and transform a modestly profitable or break even procedure into an economic loser for the hospital. However, the surgeon is still reimbursed at the usual and customary fee for the procedure.

Previously lucrative surgical services are facing financial challenges as the costs of materials and services continue to rise, while reimbursement remains flat or is decreasing in many cases. Institutions that are positioned to survive these challenges must develop strategies to improve processes, increase efficiency, and lower the costs of care delivery. The surgeon is a key player in the evolving healthcare revolution. Fiscally responsible care is as important as technical skill and excellent outcomes.

FUTURE TECHNOLOGY SESSION
8:00am, Saturday, September 20, 2008

Brace yourself for a vision of the future. Directed by Richard Satava, MD, and featuring an exciting keynote speaker, this session promises to inspire all interested in the future of the medicine.

Richard M. Satava, MD, Director
Leigh R. Hochberg, MD, PhD, Keynote Speaker presents Brain-Computer Interfaces: Frontiers in Restorative Neurotechnology
Orlando Portale, MS, presents Simulated Reality: Exploring the Virtual Hospital of the Future
Kit Parker presents Intracellular Surgery - The Next Surgical Frontier?

BEYOND HUMAN CONTROL
Keynote Address: Brain-Computer Interfaces: Frontiers in Restorative Neurotechnology
Leigh R. Hochberg, MD, PhD

For people with cervical spinal cord injury, brainstem stroke, amyotrophic lateral sclerosis (ALS, Lou Gehrig's disease) and other neurologic illnesses, currently available assistive and rehabilitation technologies are inadequate. In severe brainstem stroke and advanced ALS, both the ability to speak and the ability to move are lost, creating a “locked-in” state of being awake and alert but unable to communicate. Neural interfaces, however, are poised to revolutionize our ability to restore lost function to people with neurologic disease or injury. Over the past decade, technologies to record the individual and simultaneous activities of dozens to hundreds cortical neurons have yielded new understandings of cortical function in movement, vision, cognition, and memory. This preclinical research, generally performed with healthy, neurologically intact non-human primate subjects, has demonstrated that direct neural control of virtual and physical devices can be achieved. Recently, this exciting research has been translated into initial pilot clinical trials (IDE) of an intracortically-based neural interface system, seeking to determine the feasibility of persons with tetraplegia controlling a computer cursor simply by imagining movement of their own hand.  A variety of methods for recording and decoding brain signals are now being tested, with the hope of not only restoring communication, but also providing a control signal for the reanimation of paralyzed limbs.

Simulated Reality: Exploring the Virtual Hospital of the Future
Orlando Portale, MS

Metaverse, Second Life, Machinima, Avatar....what do these terms mean, and how do they relate to healthcare? Find out, as we explore first hand, what the future of high-tech healthcare will look like with an architectural and conceptual simulation of the hospital of the future. Built within Second Life, the on line virtual world with millions of users, the simulation offers a preview of medical, architectural and technical advancements, as visitors are guided along a personalized path to recovery. The virtual hospital simulation includes such as innovations as 3D multi-modality medical imaging, RFID, remote telepresense, acuity adaptable patient rooms and robotic surgery suites. These are just some of the innovations that are being incorporated into the real world $900M hospital that is scheduled to open in 2011. But there is no need to wait, you can experience it all today in the virtual world.

Intracellular Surgery - The Next Surgical Frontier?
Kit Parker

17TH SLS ANNUAL MEETING AND ENDO EXPO 2008 FACULTY INDEX

KEY
*    Nothing to disclose
‡    Disclosed
•    Disclosure not received as of print
#    VIP Moderator

SLS has resolved all potential or perceived conflicts of interest pertaining to this CME activity to the best of its ability prior to the printing of this conference syllabus.

Uchenna C. Acholonu, Jr. MD
72-47 Loubet St, FL 1
Forest Hills NY 11375 USA
Tel: (917) 279-4015
E-Mail: uchenna1@hotmail.com
#
*

Ilana B. Addis MD MPH
1501 N. Campbell Avenue
PO Box 245078
Tucson AZ 85724-5078 USA
Tel: (520) 626-6591
E-Mail: iaddis@email.arizona.edu
‡Speakers Bureau: Merck
Stock Shareholder: Novartis

Arnold P. Advincula MD
L4000 Women's Hospital
1500 East Medical Center Drive
Ann Arbor MI 48109 USA
Tel: (734) 764-8429
Fax: (734) 647-9727
E-Mail: aadvincu@umich.edu
‡Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant Research: Intuitive Surgical
Consultant: Intuitive Surgical, Gyrus ACMI, SurgRx

Ehab El Akkary MD
Dept. of Surgery
P.O. Box 9238
Morgantown WI 26506 USA
Tel: (304) 293-2380
E-Mail: ehabakkary@yahoo.com
‡Discussion of commercial products or services

Kanayochukwu Jacquelyne Aluka MD
8560 2nd Ave, Apt 705
Silver Spring MD 20910 USA
Tel: (301) 520-8732
E-Mail: kanayo02@yahoo.com
*

J. Kyle Anderson MD
467 Portland Ave
Saint Paul MN 55102 USA
Tel: (612) 625-0662
E-Mail: ande1821@umn.edu
‡Discussion of commercial products or services
‡Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant Research: Angiodynamics
Consultant: Boston Scientific
Stock Shareholder: Midwest Stone, Oncostim

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
*

Murali K. Ankem MD
588a M.E.B
1 RWJ Place
New Brunswick NJ 08903 USA
Tel: (732) 235-5642
Fax: (732) 235-8018
E-Mail: ankemmk@umdnj.edu
#
*

Darrin Antonelli MD
610 West Adams St
Black River Falls WI 54615 USA
Tel: (715) 284-1949
Fax: (715) 284-2568
E-Mail: dantonelli@yahoo.com
*

Yasuyuki Asakawa MD PhD
2-17-6 Ohashi
Meguro-ku Tokyo 153-8515 JAPAN
Tel: 81-3-3468-1251
Fax: 81-3-3468-7795
E-Mail: asakawa@i.bekkoame.ne.jp
*

Horacio Asbun MD
365 Lennon Lane
Walnut Creek CA 94598 USA
Tel: (925) 451-1854
E-Mail: asbun@sbcglobal.net
*

Reza Askari MD
127 East 61st, Apt 2F
New York NY 10021 USA
Tel: (310) 200-6811
E-Mail: ucsb2usc@yahoo.com
#
*

Subhashini Ayloo MD
University of Illinois at Chicago
CSB 840 S. Wood Street
Chicago IL 60612 USA
Tel: (312) 355-1493
Fax: (312) 355-1987
E-Mail: ayloosub@uic.edu
*

Ginny Elisabeth Barton MD
1411 Down River Drive
Memphis TN 38103 USA
Tel: (931) 224-8217
Fax: (901) 339-0888
E-Mail: gbarton@utmem.edu
*

Yildirim Bayazit MD
Cukurova University, Faculty of Medicine
Department of Urology
Adana 01330 TURKEY
Tel: 90-322-338-6305
Fax: 90-322-338-7087
E-Mail: bayazit@cukurova.edu.tr
#
*

Tahar Benhidjeb MD
Karower Str 11 / 214
Berlin 13125 GERMANY
Tel: +49 30 9401 2403
Fax: +49 30 9401 2430
E-Mail: tbenhidjeb@nesacademy.org
*

Vivek Bindal MS
75, PG Mens' Hostel, MAMC
New Delhi DE 110002 INDIA
Tel: +91-986-849-5052
E-Mail: bindal.vivek@gmail.com
*

Lawrence C. 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
Speakers Bureau: Covidien

James G. Bittner IV MD
Medical College of Georgia
Department of Surgery
Augusta GA 30912 USA
Tel: (706) 721-1078
E-Mail: jbittner@mcg.edu
‡Discussion of commercial products or services

David Michael Boruta II MD
2350 North Lake Drive
WTMC, Suite 501
Milwaukee WI 53211 USA
Tel: (414) 291-1230
Fax: (414) 291-1270
E-Mail: dboruta@columbia-stmarys.org
*

Joy Brotherton MD
730 Esplanade, #307
Redondo Beach CA 90277 USA
Tel: (310) 968-2882
E-Mail: joy_brotherton@hotmail.com
#
‡Discussion of commercial products or services

James A. Brown MD
1120 15th Street, BA-8408
Augusta GA 30912 USA
Tel: (706) 721-0984
Fax: (706) 721-2548
E-Mail: jimbrown@mcg.edu
#
‡Speakers Bureau: Boehringer-Ingelheim

Amy M. Bruton MD
645 North Main Street
High Point NC 27262 USA
Tel: (336) 882-7700
Fax: (336) 882-6700
E-Mail: brutonam@triad.rr.com
#
*

Kerrey B. Buser MD
1101 Buffalo Bend
Lexington NE 68850 USA
Tel: (308) 324-5660
Fax: (308) 324-5728
E-Mail: kerreyb@hotmail.com
#
*

Arnold Byer MD
Department of Hackensack Univ. Med.
Hackensack NJ 07601 USA
Tel: (201) 996-2626
Fax: (201) 996-2021
E-Mail: abyer@humed.com
*

James F. Carter MD
171 Ashley Avenue
Dept Ob/Gyn; Med Univ of SC
Charleston SC 29425 USA
Tel: (843) 792-4500
Fax: (843) 792-0533
E-Mail: carterja@musc.edu
‡Grant Research: Ethicon in Endoscopy (laparoscopy and hysteroscopy)
Consultant: Ethicon, Boston Scientific, Conceptus
Speakers Bureau: Boston Scientific

Anthony J. Caruso MD
396 E. 17th Place
Lombard IL 60148 USA
Tel: (773) 702-6642
Fax: (630) 629-9665
E-Mail: acaruso@babies.bsd.uchicago.edu
#
*

Jeremy M. Carver SA
2015 E. Newport Ave, Ste. 707
Milwaukee WI 53211 USA
Tel: (414) 289-9668
Fax: (414) 289-0974
E-Mail: jcarver@reproductivecenter.com
*

Jaswant S. Chaddha MD
Atlanta West Women's Center
8697 Hospital Drive
Douglasville GA 30134 USA
Tel: (770) 920-9745
Fax: (770) 920-9760
E-Mail: jchaddha@yahoo.com
‡Speakers Bureau: Duramed and Wyeth Pharmaceuticals for Hormone Therapy

Jaideep Singh Chahal MD
Chahal Hospital
GT Road
Khanna Punjab 141401 INDIA
Tel: 98-1-480-6466
E-Mail: JDSC1970@gmail.com
*

Stefanos Chandakas MD MBA PhD
17 Papadiamanti Str
Paleo Psihiko
Athens 15452 GREECE
Tel: 30-697-444-2000
E-Mail: stefhand@hol.gr
*

Ashfaq Hussain Chandio MBBS, FRCS
8-Cluain Mhor
Clybaun Road
Galway Connacht IRELAND REPUBLIC
Tel: 00353-872635665
E-Mail: chandioashfaq@yahoo.com
*

Keyur A. Chavda MD
323-B Hayden Street
Sayre PA 18840 USA
Tel: (607) 259-0382
E-Mail: kchavda@gmail.com
#
*

David Y.T. Chen MD
Fox Chase Cancer Center
333 Cottman Avenue
Philadelphia PA 19111 USA
Tel: (215) 728-2548
Fax: (215) 214-1734
E-Mail: david.chen@fccc.edu
*

Oh Cheong MD
Department of Surgery
Chonnam National University Hwasun Hospital,
160, Ilsim-ri, Hwasun-eup, Hwasun-gun,
Gwangju Jeollanam-do 519-809 KOREA
Tel: 82-061-379-7646
Fax: 82-061-379-7661
E-Mail: surgeonjeong@yahoo.co.kr
*

Edward H. Chin MD
5 E. 98th St, 15th Floor
Box 1259
New York NY 10029 USA
Tel: (212) 241-7596
Fax: (212) 410-0111
E-Mail: edward.chin@mountsinai.org
#
*

A. Chopada MD
Ealing Hospital NHS Trust
Uxbridge Road
Southall NA UB1 3HW United Kingdom
Tel: 44 (0) 20 8967 5000
E-Mail: sandeep@tarilian-consulting.com
‡Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant Research: Minnesota Medical Development, Inc.

Neil A. Christie MD
5200 Centre Ave
Suite 715
Pittsburg PA 15232 USA
Tel: (412) 623-5379
Fax: (412) 623-0329
E-Mail: stjohnm2@upmc.edu
‡Speakers Bureau: Accuray

Matthew Christman MD
Bldg 3, Suite 200
Dept. of Urology
San Diego CA 92134 USA
Tel: (619) 532-7200
E-Mail: matthew.christman@med.navy.mil
‡Discussion of commercial products or services

Maurice K. Chung RPh MD
310 S. Cable Road
Lima OH 45805 USA
Tel: (419) 228-1000
Fax: (419) 227-3085
E-Mail: endosurgeon85@aol.com
#
‡Speakers Bureau: Ortho McNeil, Astellas, GSK, Pfizer, Novartis

Ignazio Massimo/M Civello Prof Dr Med
Via del Casaletto, 455
Largo A. Gemelli, 8
Rome Lazio 00151 ITALY
Tel: 390-63-015-5398, 390-63-507-2140
Fax: 390-63-015-6091
E-Mail: imcivello@rm.unicatt.it
#
*

Benjamin L. Clapp MD
1700 N. Oregon
Ste 500
El Paso TX 79902 USA
Tel: (915) 351-6020
E-Mail: b_clapp1@hotmail.com
*

Paul G. Curcillo II MD
613 Creek Lane
Flourtown PA 19031 USA
Tel: (215) 880-8203
Fax: (215) 836-9941
E-Mail: paul.curcillo@drexelmed.edu
‡Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Consultant: Novare, Ethicon, Storz
Speakers Bureau: Novare, Ethicon, Storz

Leslie A. Deane MD
840 South Wood St
M/C 955
Chicago IL 60612 USA
Tel: (312) 355-2526
Fax: (312) 413-0495
E-Mail: l.deane@mac.com
*

Ithaar H. Derweesh MD
525 Grey Hill Drive
Cordova TN 38018 USA
Tel: (901) 568-6415
E-Mail: iderweesh@gmail.com
‡Discussion of commercial products or services

Seema Dhorajia DO
2201 Chapel Ave West
Cherry Hill NJ 08002 USA
Tel: (856) 488-6887
Fax: (856) 488-6769
E-Mail: team2451@hotmail.com
*

Zarija Djorovic MD
3172 N. Milwuakee Ave
Chicago IL 60618 USA
Tel: (773) 725-6666
Fax: (773) 725-8404
E-Mail: zdjurovic@aol.com
*

Andrew J. Duffy MD
40 Temple Street
Suite 7B
New Haven CT 06510 USA
Tel: (203) 764-9060
Fax: (203) 764-9066
E-Mail: andrew.duffy@yale.edu
‡Discussion of commercial products or services

Titus D. Duncan MD
315 Boulevard NE
Suite 224
Atlanta GA 30312 USA
Tel: (404) 881-8020
E-Mail: titusduncan@gmail.com
#
‡Grant Research: Ethicon
Consultant: Ethicon
Speakers Bureau: Ethicon

Dan Eisenberg MD
3801 Miranda Avenue
GS 112
Palo Alto CA 94304 USA
Tel: (650) 852-3461
Fax: (650) 852-3430
E-Mail: de1@stanford.edu
‡Consultant: NeoGuide

Mark Erian MD
T & R, Level 6, Ned Hanlon Building
Royal Brisbane & Women's Hospital, Herston
Brisbane Queensland 04029 AUSTRALIA
Tel: 61-07-3365-5207
Fax: 61-07-3398-1491
E-Mail: m.erian@uq.edu.au
#
*

Thomas Fabian MD
330 Orchard Street, Suite 300
New Haven CT 06511 USA
Tel: (203) 787-3488
E-Mail: tfabian1@srhs.org
*

Tommaso Falcone MD
9500 Euclid Avenue, A81
Cleveland OH 44195 USA
Tel: (216) 444-1758
Fax: (216) 445-6325
E-Mail: falcont@ccf.org
*

Bradford W. Fenton MD PhD
75 Arch St, Ste 101
Akron OH 44304 USA
Tel: (330) 375-4810
E-Mail: fentonb@summa-health.org
‡Grant Research: Biomet Inc
Consultant: Ethicon

José M. M. Ferreira-Coelho Prof Dr Med
Avenida Da Republica
No. 45-4º Dto.
Lisbon 1050-187 PORTUGAL
Tel: 351-21-94-30252
Fax: 351-21-43-68417
E-Mail: j.ferreiracoelho@iol.pt
#
‡Grant Research: Univers.Lisbon-Medic.Faculty

Morris E. Franklin, Jr. MD
4242 E Southcross Blvd, Ste 1
San Antonio TX 78222 USA
Tel: (210) 333-7510
Fax: (210) 333-1912
E-Mail: franklin@texasendosurgery.com
‡Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant Research: W.L. Gore, Covidien
Consultant: W.L. Gore, Covidien, Stryker, Ethicon, Cook
Speakers Bureau: W.L. Gore, Covidien, Stryker, Ethicon, Cook

Constantine Frantzides MD PhD
64 Old Orchard Center
Suite 409
Skokie IL 60077 USA
Tel: (847) 676-2200
Fax: (847) 676-1813
E-Mail: cfrantzides@cimis.info
*

Carlos A. Galvani MD
840 S. Wood St. (MC 958)
Chicago IL 60612 USA
Tel: (312) 355- 3007
E-Mail: cgalvani@uic.edu
*

Aldrin Joseph R. Gamboa MD
101 The City Drive Bldg 55, Rm 304
Irvine CA 92868 USA
Tel: (714) 456-7378
Fax: (714) 456-1679
E-Mail: aldringamboa@yahoo.com
‡Grant Research: Astellas Pharma US

Alex Gandsas MD
Sinai Hospital of Baltimore
2435 West Belvedere Ave, #15
Baltimore MD 21215 USA
Tel: (410) 601-4486
E-Mail: webmaster@laparoscopy.com
‡Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant Research: Intouch Health
Consultant: Intouch Health
Stock Shareholder: Intouch Health

William 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
‡Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant Research: Ethicon Endosurgery
Consultant: Ethicon Endosurgery

Dan Geisler MD
9500 Euclid Avenue
Desk A-30
Cleveland OH 44195 USA
Tel: (216) 445-7616
Fax: (216) 445-8627
E-Mail: geisled@ccf.org
‡Discussion of commercial products or services
Grant Research: Ethicon Endosurgery and Covidien
Speakers Bureau: Covidien

Roberta Gelmini Prof Dr Med
Via del Pozzo 71
Modena 41100 ITALY
Tel: 39-059-422-3662
Fax: 39-059-422-4370
E-Mail: gelmini.roberta@unimore.it
#
*

Stefano Gidaro MD
G.S. Pianell 20
Chieti ITALY
Tel: 0039-339-180-6742
E-Mail: s.gidaro@libero.it
‡Discussion of commercial products or services

Herbert A. Goldfarb MD
35 Delwick Lane
Short Hills NJ 07078 USA
Tel: (973) 699-1904
Fax: (973) 467-5175
E-Mail: drhgoldfarb@gmail.com
#
‡Discussion of commercial products or services

Michael S. Gomez MD
3656 Wyckliffe Parkway
Toledo OH 43613 USA
Tel: (419) 509-3410
E-Mail: msgomez2@mac.com
*

Maria V. Gorodner MD
840 S. Wood St (MC 958)
Chicago IL 60612 USA
Tel: (312) 355-3007
E-Mail: vgorodner_72@yahoo.com.ar
*

Tomonori Hada MD
250 Bakuro-Cho
Kurashiki-City Okayama-Pref 710-8522 JAPAN
Tel: 81-86-422-2111
Fax: 81-86-422-4150
E-Mail: hadatomonori@hotmail.com
*

Makoto Hashizume Prof Dr Med
3-1-1 Maidashi, Higashi-ku
Fukuoka City Fukuoka 812-8582 Japan
Tel: 81-92-642-6222
Fax: 81-92-642-6224
E-Mail: mhashi@dem.med.kyushu-u.ac.jp
‡Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational
Grant Research: New Energy and Industrial Technology Development Organization
Other Support: Ministry of Education, Culture, Sports, Science & Technology

Harrith M. Hasson MD
6250 Winter Haven Rd NW
Albuquerque NM 87120 USA
Tel: (505) 792-0240
Fax: (505) 792-0241
E-Mail: drhasson@aol.com
*

Gloria Henao MD
246 Liberty Street
Harrisburg PA 17101 USA
Tel: (717) 599-4392
E-Mail: gloria_henao@yahoo.com
*

B. Todd Heniford MD
1000 Blythe Blvd
MEB 601
Charlotte NC 28203 USA
Tel: (704) 355-3168
Fax: (704) 355-5619
E-Mail: todd.heniford@carolinashealthcare.org
‡Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant Research: Ethicon, Inc, W.L. Gore, Karl Storz, Ethicon Endo-Surgery
Speakers Bureau: Ethicon Endo-Surgery, W.L. Gore, Ethicon, Inc.

Josephine Hidalgo-Tamola MD
1959 NE Pacific Street
Box 356510
Seattle WA 98195-6510 USA
Tel: (206) 543-3640
Fax: (206) 543-3272
E-Mail: jhtamola@u.washington.edu
‡Discussion of commercial products or services
Consultant: Intuitive Surgical Inc

Leigh R. Hochberg MD PhD
MGH Stroke Research Center
175 Cambridge St, Suite 300
Boston MA 02108 USA
Tel: (617) 726-4218
E-Mail: lhochberg@partners.org
‡Discussion of commercial products or services
Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational
Grant Research: Clinical Trial Support: Cyberkinetics Neurotechnology Systems, Inc.
Consultant: G.E. Healthcare

Santiago Horgan MD
200 W. Arbor St
San Diego CA 92103 USA
Tel: (619) 471-0755
E-Mail: shorgan@ucsd.edu
‡Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Consultant: Intuitive Surgical

Fred M. Howard MD MS
601 Elmwood Avenue
Box 668
Rochester NY 14642 USA
Tel: (585) 275-4004
Fax: (585) 276-1956
E-Mail: fred_howard@urmc.rochester.edu
‡Discussion of commercial products or services
Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational
Grant Research: Endometriosis Association
Consultant: Ortho Womens Health & Urology; Ethicon
Speakers Bureau: Ortho Womens Health

Woo Jin Hyung MD PhD
134 Shinchon-dong Seodaemun-gu
Seoul 120-752 KOREA
Tel: 822-2228-2129
Fax: 822-313-8289
E-Mail: wjhyung@yuhs.ac
*

Keith Isaacson MD
34 Hyde Ave
Newton MA 02458 USA
Tel: (617) 571-0808
E-Mail: kisaacson@partners.org
‡Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Consultant: Karl Storz Endoscopy

Volker Jacobs MD PhD MBA
Frauenklinik (OB/GYN) of Tech Univ Munich
Ismaninger Str 22
Munich 81675 GERMANY
Tel: +49-89-4140-5425
E-Mail: volkerjacobs@hotmail.com
#
‡Grant/Research: AMGEN
Consultant: Baxter, Fresenius Biotech
Other Support: Roche, AstraZeneca, Novartis

Garth Jacobsen MD
2S661 Avenue Normandy W
Oak Brook IL 60523 USA
Tel: (858) 784-1898
E-Mail: Garth@robosurgery.com
#
*

Usman Jaffer MB BS
5 Saint Andrew's Road
London NW11 0PH United Kingdom
Tel: 44 (0)796-887-2992
E-Mail: usman.jaffer@doctors.org.uk
#
*

Grace M. Janik MD
2015 E. Newport Avenue
Suite 707
Milwaukee WI 53211 USA
Tel: (414) 289-9668
Fax: (414) 289-0974
E-Mail: drjanik@reproductivecenter.com
#
‡Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant Research: Hologic, Adiana Trial Investigator; Cytyc, Adiana Trial Investigator
Consultant: Storz

T. Matthew Jones MD
1924 Alcoa Highway
Knoxville TN 37920-6969 USA
Tel: (865) 305-6058
E-Mail: tnickloe@utmck.edu
‡Discussion of commercial products or services
Other Support: University of Tennessee Medical Center

Myles Joyce MD
Dept of Colorectal Surgery
9500 Euclid Avenue / A30
Cleveland OH 44195 USA
Tel: (216) 773-9081
E-Mail: mylesjoyce@eircom.net
‡Discussion of commercial products or services

Emad Kandil MD
1430 Tulane Ave, SL-22
Tulane School of Medicine
New Orleans LA 70112 USA
Tel: (504) 988-7407
Fax: (504) 988-4762
E-Mail: ekandil@tulane.edu
*

Michael S. Kavic MD
St. Elizabeth Health Center
1044 Belmont Avenue, PO Box 1790
Youngstown OH 44501-1790 USA
Tel: (330) 480-3124
Fax: (330) 480-3640
E-Mail: michael_kavic@hmis.org
*

William E. Kelley, Jr. MD
8921 Three Chopt Rd.
Richmond VA 23229 USA
Tel: (804) 285-9416
Fax: (804) 285-8257
E-Mail: bill.kelley@earthlink.net
‡Discussion of commercial products or services

Malik Khebbeb Prof Dr Med
62 Rue Verlaine
Bron 69500 FRANCE
Tel: 0033-66-005-5819
E-Mail: drkhebbeb@yahoo.fr
‡Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Consultant: Fertility Focus Ltd

Dong Ho Kim MD
Dept. OBGY Chung-Ang University Hospital
224-1
Heukseok-dong, Dongjak-gu Seoul 156-755 KOREA
Tel: 82-2-6299-1645
E-Mail: dongho23@hanafos.com
*

Hyun Koo Kim MD PhD
97 Guro-Dongkil, Guro-ku
Seoul 152-703 KOREA
Tel: 82-2-2626-1185
E-Mail: kimhyunkoo@korea.ac.kr
*

Stephanie A. King MD
15 South Tower / Gyn Oncology
Hahneman Univ Hospital
Philadelphia PA 19102 USA
Tel: (215) 762-2625
Fax: (215) 762-2642
E-Mail: paul.curcillo@drexelmed.edu
‡Consultant: Ethicon
Speakers Bureau: Novare

Allan Klapper MD
170 William St.
8th Floor
New York NY 10038 USA
Tel: (212) 312-5880
Fax: (212) 312-5878
E-Mail: allan.klapper@downtownhospital.org
#
‡Discussion of commercial products or services
Consultant: Ortho Women's Health, Pfizer
Speakers Bureau: Ortho Women's Health, Pfizer

Kenneth Phillip Kleinpeter MD
1624 Pointer Court
Baton Rouge LA 70808 USA
Tel: (225) 663-6116
E-Mail: kkleinpe@cox.net
‡Discussion of commercial products or services
Consultant: W.L. Gore, Davol, Ethicon, Hyperbranch, Synovis
Speakers Bureau: W.L. Gore, Davol, Ethicon, Synovis

Charles H. Koh MD
2015 E. Newport Ave.
Suite 707
Milwaukee WI 53211 USA
Tel: (414) 289-9668
Fax: (414) 289-0974
E-Mail: drkoh@reproductivecenter.com
#
‡Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Consultant: Fertility Focus
Other Support: STORZ, Patent Royalty; Cooper Surgical, Patent Royalty

Doron Kopelman Prof Dr Med
30 Kanarit St.
Caesarea - 30889 ISRAEL
Tel: 972-54-7390939
E-Mail: kopelmand@bezeqint.net
#
‡Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational
Grant Research: Niti Medical Technologies Ltd, Israel. InSightec Ltd, Israel. Serafix Ltd, Israel. Life-Bond Ltd, Israel. Netania, Israel. Tirat Hacarmel, Israel.
Consultant: Niti Medical Technologies Ltd, Israel. InSightec Ltd, Israel. Serafix Ltd, Israel. Life-Bond Ltd, Israel. Netania, Israel. Tirat Hacarmel, Israel.
Stock Shareholder: Niti Medical Technologies Ltd, Israel. InSightec Ltd, Israel. Serafix Ltd, Israel. Life-Bond Ltd, Israel

Alex Jenny Ky MD
5 East 98th Street
15th Floor
New York, NY 10029 USA
Tel: (212) 241-3547
E-Mail: alex.ky@mountsinai.org
Grant Research: Cook Biotech

Sebastiano Lacitignola MD
S. Francesco da Paola Square
Martina Franca   74015 ITALY
Tel: 39 080 4835282
E-Mail: lacitignola@libero.it
*

Rahim Mo Lang MD
Custidis Str.3-17
Eduardus Hospital
Cologne NRW 50679 GERMANY
Tel: 01149-221-82742298
Fax: 01149-221-82742205
E-Mail: r.lang@eduardus.de
#
*

Raymond J. Lanzafame MD MBA
757 Titus Avenue
Rochester NY 14617-3930 USA
Tel: (585) 266-2159
Fax: (585) 544-8761
E-Mail: ray.lanzafame@viahealth.org
‡Discussion of commercial products or services
Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational
Grant Research: NIDDK #2R44DK62571-03; RGH Foundation
Consultant: Kodak, Carestream Health; CEE

Jude Lee Dr Med
Dept of General Surgery, Alexandra Hospital
378 Alexandra Road
Singapore 159964 SINGAPORE
Tel: 65-9118-0084
E-Mail: jude_lee@alexhosp.com.sg
*

Thomas Sean Lendvay MD
Children's Hospital and Regional Medical Center
4800 Sand Point Way, NE
Seattle WA 98102 USA
Tel: (206) 987-1270
Fax: (206) 987-3925
E-Mail: thomas.lendvay@seattlechildrens.org
‡Discussion of commercial products or services
Consultant: Intuitive Surgical

Carl J. Levinson MD
576 Sand Hill Circle
Menlo Park CA  94025 USA
Tel: (650) 233-0591
Fax: (650) 233-0591
E-Mail: carljmd@yahoo.com
*

Jun Xiao Liu MD
No. 415 FengYang Road
Shanghai 200003 P.R. CHINA
Tel: 86-216-361-0109 X 73823
E-Mail: lxj666@yahoo.com.cn
*

Yan Liu MD
No 415, FengYang Road
Changzheng Hospital
Shanghai 200003 P.R. CHINA
Tel: 86-21-6361-0109 x73481
E-Mail: yliu2004@163.com
*

Gustavo Lopes DO
2201 Chapel Ave West
Cherry Hill NJ 08002 USA
Tel: (856) 488-6887
Fax: (856) 488-6769
E-Mail: gustavo@lopes-usa.net
*

Ali Mallat MD
729 Clubhouse Drive
Ypsilanti MI 48197 USA
Tel: (865) 335-0704
Fax: (413) 280-0683
E-Mail: AliMallat@gmail.com
#
*

Dan C. Martin MD
7945 Wolf River Boulevard
Suite 320
Germantown TN 38138 USA
Tel: (901) 484-4787
Fax: (901) 339-0888
E-Mail: dmarti27@utmem.edu
‡Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational
Speakers Bureau: Baxter Biosurgical

James McCormick DO
4800 Friendship Ave
Department of Surgery, N4
Pittsburgh PA 15224 USA
Tel: (412) 578 3500
E-Mail: jmccorm1@wpahs.org
#
‡Discussion of commercial products or services

Elspeth M. McDougall MD MPH
333 City Blvd West
Orange CA 92868 USA
Tel: (714) 456-3429
Fax: (714) 456-5062
E-Mail: elspethm@uci.edu
#
‡Discussion of commercial products or services
Grant Research: Astellas, Inc.; EndoCare
Other Support: Karl Storz; Intuitive Surgical;  Simbionix; Ethicon Endo-Surgical; Scientific Study

John J. Meehan MD
4300 East Mercer Way
Mercer Island WA 98040 USA
Tel: (206) 947-7793
E-Mail: john.meehan@seattlechildrens.org
‡Discussion of commercial products or services

Liselotte Mettler Prof Dr Med
University Hospitals Schleswig-Holstein, Campus Kiel
Department of Obstetrics and Gynecology
Kiel Schleswig-Holstein 24118 GERMANY
Tel: 0049-431-597-2046
Fax: 0049-431-597-2149
E-Mail: lmettler@email.uni-kiel.de
#
*

Magdy Milad MD MBA
250 East Superior
Suite 5-2177
Chicago IL 60611 USA
Tel: (312) 472-4673
Fax: (312) 472-4687
E-Mail: mmilad@nmh.org
#
‡Discussion of commercial products or services
Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational
Consultant: Terumo Laboratories, Caremark
Stock Shareholder: Da Vinci, Intuitive

Charles E. Miller MD
120 Osler Drive
Naperville IL 60540 USA
Tel: (630) 364-1119
Fax: (866) 477-4910
E-Mail: lmaki@charlesemillermd.org
‡Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant Research: Ferring Pharmaceuticals, Duramed Research, Baxter Healthcare Corporation
Consultant: Ferring Pharmaceuticals, Ethicon (Endo Surgery and Women's Health), Galil Medical, Boston Scientific, Interlace Medical
Speakers Bureau: Ferring Pharmaceuticals, Ethicon (Endo Surgery and Womens Health and Urology), Smith & Nephew

Steven M. Minaglia MD
1319 Punahou St, Suite 824
Honolulu HI 96826 USA
Tel: (808) 371-4205
E-Mail: steven.minaglia@gmail.com
‡Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Speakers Bureau: American Medical Systems

Hossein Mirheydar BS
500 East Grant Street, 1603
Minneapolis MN 55404 USA
Tel: (763) 443-6139
E-Mail: mirhe001@umn.edu
*

Andre L. Moreira MD
1700 East 13th Street, Ap 9VE
Cleveland OH 44114 USA
Tel: (216) 870-1530
E-Mail: moreira@ccf.org
*

Mineto Morita MD
Omori-nishi 6-11-1
Ota-ku Tokyo 143-8541 JAPAN
Tel: 81-3-3762-4151
Fax: 81-3-3765-7671
E-Mail: mmorita@med.toho-u.ac.jp
*

John E. Morrison MD
5404 Hidden Ridge Ln
Baton Rouge LA 70816 USA
Tel: (225) 302-5826
E-Mail: drmorjo@aol.com
*

Ravi Munver MD
360 Essex Street, Suite 403
Department of Urology
Hackensack NJ 07601 USA
Tel: (201) 336-8090
Fax: (201) 336-8221
E-Mail: rmunver@humed.com
#
*

Vincenzo Neri Prof Dr Med
Via G. Murat, 86
Bari BA 70123 ITALY
Tel: (39) 0881-733704
E-Mail: v.neri@unifg.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 Rd.
Suite 276
Atlanta GA 30342 USA
Tel: (404) 255-8778
Fax: (404) 256-5627
E-Mail: ceana@nezhat.com
‡Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Consultant: Covidien, Ethicon, Karl Storz, Viking, PlasmaSurgical, Aragon
Speakers Bureau: Kenwood Therapeutics, Baxter, Covidien, Ethicon, Karl Storz Endoscopy, US Surgical, Viking
Stock Shareholder: Viking, Aragon

Farr R. Nezhat MD
St. Lukes-Roosevelt Hospital Center
University Hospital of Columbia University
College of Physicians and Surgeons
1000 Tenth Avenue, Suite 10-C
New York NY 10019 USA
Tel: (212) 523-7337
Fax: (212) 523-8066
E-Mail: fnezhat@chpnet.org
*

Alfredo Nieves MD
1755 Gunbarrel Rd.
Suite 202
Chattanooga TN 37421 USA
Tel: (423) 490-1136
Fax: (423) 490-1137
E-Mail: anievesmd@pprsc.net
‡Speakers Bureau: Ethicon EndoSurgery, Gynecare, TAP

Francisco A. Obregon MD
Hospital Universitario de Caracas
Piso 5. Servicio de Cirugia 2
Los Chaguaramos
Caracas 01060 VENEZUELA
Tel: 58-212-606-7878
E-Mail: franobre@hotmail.com
‡Grant Research: Hospital Univeristario de Caracas
Consultant: Clinica Santa Sofia- Caracas

Sung-Tack Oh MD PhD
Dept. of Ob/Gyn, Chonnam University Medical School
8 Hakdong
Tongku, Kwangju 0 501-190 KOREA (South)
Tel: 82-62-220-6374
Fax: 82-62-227-1637
E-Mail: ohst@chonnam.ac.kr
#
*

Alexander Onopchenko MD
The Life Center Professional Offices
Building 200
2500 English Creek Ave., Suite 222
Egg Harbor Twp NJ 08234 USA
Tel: (609) 407-2332
Fax: (609) 407-2364
E-Mail: aonopchenko@atlanticare.org
*

Sijo J. Parekattil MD
1600 SW Archer Road, Rm N-217
PO Box 100247
Gainesville FL 32610-0247 USA
Tel: (352) 273-6815
Fax: (352) 392-8846
E-Mail: sijo.parekattil@urology.ufl.edu
‡Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Consultant: ERBE

Kevin Kit Parker PhD
Pierce Hall 321
29 Oxford Street
Cambridge MA 02138 USA
Tel: (617) 835-5920
Fax: (617) 496-1793
E-Mail: kkparker@seas.harvard.edu
*

Dhaval Patel MD
58-Sima Row House,
Ghod-dod Road, Near Krushi Farm
Surat Gujarat 395007 INDIA
Tel: 91-261-987-904-9100
E-Mail: dr_pateldhaval@yahoo.com
Consultant: Lokhat Hospital, Surat, India

Zamip Patel MD
3 E 101st St, #11D
New York NY 10029 USA
Tel: (718) 593-9198
E-Mail: zamip_patel@yahoo.com
*

Haifeng Peng MD
Department of General Surgery
Central Hospital of Longgang
Shenzhen Guangdong 518116 CHINA
Tel: 0086-136-0019-6223
Fax: 0086-755-8481-6979
E-Mail: penghaifeng99@hotmail.com
*

Gaetano Fernando Perego MD
1934 S Prairie Ave, #3
Chicago IL 60616-1312 USA
Tel: (312) 842-7145
E-Mail: gfperego0023556@pol.net
‡Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational

Joseph B. Petelin MD
9119 West 74th St.
Suite 255
Shawnee Mission KS 66204 USA
Tel: (913) 432-5420
Fax: (913) 432-7749
E-Mail: j2pete@mindspring.com
‡Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant Research: Covidien
Consultant: Covidien, Olympus, Intouch Health
Stock Shareholder: Covidien, InTouch Health

Erica R. Podolsky MD
219 North Broad Street
10th Floor
Philadelphia PA 19107 USA
Tel: (215) 762-5577
Fax: (215) 762-5588
E-Mail: paul.curcillo@drexelmed.edu
‡Consultant: Ethicon, Novare
Speakers Bureau: Novare

Orlando Portale MS
11465 Vista Ridge
San Diego CA 92130 USA
Tel: (858) 354-1387
E-Mail: orlando.portale@pph.org
*

Monireh Pourjavad Prof
No.16 Azadi St.
Omolbanin University Hospital
Mashhad Khorasan Razavi 9144663595 IRAN
Tel: 98-511-200-0000
Fax: 98-511-200-0000
E-Mail: mpourjavad@yahoo.com
‡Grant Research: Vice Chancellor for Research

Dana Portenier MD
3116 North Duke St
Suite 209
Durham, NC 27704 USA
Tel: (919) 451-2580
Fax: (919) 660-2256
E-Mail: dana.portenier@duke.edu
‡Consultant: SurgRx, Covidien
Stock Shareholder: SurgRx

Leela M. Prasad MD
1550 N. NW Hwy
S. 107
Park Ridge IL  60068 USA
Tel: (847) 759-1110
E-Mail: leelamprasad@gmail.com
‡Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational
Grant Research: Ethicon, Covidien, Wyeth
Consultant: SurgRx, Applied Medical, Power Medical Interventions, Intuitive
Speakers Bureau: Ethicon, SurgRx, Applied Medical, Covidien

Ruchi Puri MD
13120 Venetian Road
Silver Spring MD 20904 USA
Tel: (301) 367-9951
E-Mail: rpuri77@hotmail.com
‡Other Support: A co-author is an Ethicon sponsored fellow

Usama Qumsieh MD
Advocate Illinois Masonic Medical Center
836W Wellington Avenue
Chicago IL 60657 USA
Tel: (773) 296-7093
E-Mail: uqumsieh@hotmail.com
*

Shaikh Abdul Razaque Prof Dr Med MBBS FCPS
Flat No 208 Tayab Complex Saddar
Hyderabad Sindh 71000 PAKISTAN
Tel: 92-22-2785494
E-Mail: razaque_shaikh@yahoo.com
*

Dheeraj Reddy Dr Med
No 5, Neelakanda Metha Street
T Nagar
Chennai Tamil Nadu 600017 INDIA
Tel: +91 93-8224-4747
E-Mail: dheeraj.doc@gmail.com
*

Harry Reich MD
3 Crestview
Dallas PA 18612 USA
Tel: (570) 675-2023
Fax: (570) 675-6078
E-Mail: hrlscp@aol.com
‡Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational
Stock Shareholder: Encinson, Patton Surgical
Other Support: Royalties, Apple Medical

Troy E. Reihsen MD
MMC 394 / A509 Mayo
420 Delaware St SE
Minneapolis MN 55455 USA
Tel: (612) 624-7466
Fax: (612) 626-3994
E-Mail: reih0005@umn.edu
‡Discussion of commercial products or services

Aimee Claire Robinson MD
234 West Edwin Circle
Memphis TN 38104 USA
Tel: (901) 458-0922
Fax: (901) 339 0888
E-Mail: arobin28@utmem.edu
razaque_shaikh@yahoo.com
*

Kathy Rodgers PhD
1321 N Mission Rd
Room 109
Los Angeles CA 90033 USA
Tel: (323) 222-0089
Fax: (323) 222-0089
E-Mail: krodgers@usc.edu
‡Discussion of commercial products or services
Grant Research: US Biotest
Consultant: FzioMed, Ethicon, ML Labs, Baxter, SyntheMed
Stock Shareholder: Not as an individual

Manuel I. Rodriguez-Davalos MD
Transplant Center BHC-A Wing LL
95 Grasslands Road
Valhalla NY 10595 USA
Tel: (914) 493-2851
Fax: (914) 493-1097
E-Mail: rodriguezmi@wcmc.com
*

Sharona B. Ross MD
University of South Florida
Division of General Surgery
Tampa General Hospital
P.O Box 1289, Suite F145
Tampa FL 33601 USA
Tel: (813) 844-8219
Fax: (813) 844-7396
E-Mail: sross@health.usf.edu
*

James C. Rosser MD
Morehouse School of Medicine
720 Westview Drive, SW
Atlanta GA 30144 USA
Tel: (404) 616-1484
Fax: (404) 616-1417
E-Mail: brosser1@mac.com
*

Ajit K. Sachdeva MD
American College of Surgeons
633 N. Saint Clair Street
Chicago IL 60611 USA
Tel: (312) 202-5405
Fax: (312) 202-5011
E-Mail: asachdeva@facs.org
‡Grant Research: Agency for Healthcare Research and Quality

Ajit K. Sachdeva MD
American College of Surgeons
633 N. Saint Clair Street
Chicago IL 60611 USA
Tel: (312) 202-5405
Fax: (312) 202-5011
E-Mail: asachdeva@facs.org
‡Grant Research: Agency for Healthcare Research and Quality

Nafiseh Saghafi Prof Dr Med
45 Beheshti St
Mashhad Khorasan 91759-4-5435 IRAN
Tel: 0098-511-840-7269
Fax: 0098-511-840-9612
E-Mail: n_saghafi@yahoo.com
*

Lukas Sakra MD PhD
Kyjevska 44
Pardubice 530 02 CZECH REPUBLIC
Tel: 420-46-601-2999
E-Mail: sakra@nem.pce.cz
#
*

Luis E. Salgado MD
Prudencia 402
Col. Prados de Santo Domingo
San Nicolas de los Garza
Nuevo Leon 66436 MEXICO
Tel: 52(81)89949629
E-Mail: salgado.luis@gmail.com
*

David Samadi MD
1 Gustave L Levy Place
New York NY 10029 USA
Tel: (212) 241-8766
E-Mail: robotmd@aol.com
*

Tushar Satish Samdani MS, DNB (General Surgery) MRCS Edinburgh
Princess Royal University Hospital
London Kent BR68ND UNITED KINGDOM
Tel: 44-773-100-0000
E-Mail: drsam771@rediffmail.com
*

Richard M. Satava MD
1959 NE Pacific Street
Box 356410
Seattle WA 98195 USA
Tel: (206) 616-2250
Fax: (206) 616-9138
E-Mail: rsatava@u.washington.edi
#
‡Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Consultant: Karl Storz Endoscopy
Stock Shareholder: Intouch Health

Sangeeta Senapati MD
2650 Ridge Ave
Walgreen Building, Suite 1500
Evanston IL 60201 USA
Tel: (847) 570-2375
E-Mail: ssenapati@enh.org
‡Discussion of commercial products or services
Consultant: Intuitive Surgical

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
#
‡Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Consultant: Closure Medical Corp; Ethicon Inc; JJWM; Ethicon Endosurgery; Bard Davol

Arieh L. Shalhav MD
5841 South Maryland Avenue
MC 6038
Chicago IL 60637 USA
Tel: (773) 834-9889
Fax: (773) 702-1001
E-Mail: ashalhav@uchicago.edu
‡Consultant: Dune Medical

Abraham R. Shashoua MD
3000 North Halsted Street
Suite 405
Chicago IL 60657 USA
Tel: (773) 296-7300
Fax: (773) 296-7390
E-Mail: ashashoua@yahoo.com
*

Jonathan Silberstein MD
4970 Cape May Avenue
San Diego CA 92107 USA
Tel: (315) 345-1023
E-Mail: jsilberstein@ucsd.edu
*

Michael L. Simonson MD
1 Hospital Drive
Department of Surgery; Attn: Gretchen Schultz
Columbia MO 65212 USA
Tel: (573) 884-2000
E-Mail: simonsonml@health.missouri.edu
‡Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational

Jonathan Y. Song MD
4N393 School Rd
St. Charles IL 60175 USA
Tel: (630) 762-9777
Fax: (630) 513-9617
E-Mail: jsong3972@hotmail.com
#
*

Mathew D. Sorensen MD MS
1959 NE Pacific Street
Box 356510
Seattle WA 98195 USA
Tel: (206) 330-8522
Fax: (206) 543-3272
E-Mail: mathews@u.washington.edu
*

Massimiliano Spalivero MD
OUHSC Department of Urology
920 Stanton L Young Blvd WP3150
Oklahoma City OK 73104 USA
Tel: (405) 271-6900
Fax: (405) 271-3118
E-Mail: beverly-shipman@ouhsc.edu
‡Consultant: American Medical Systems, Gyrus, ACMI

Petr Stadler MD PhD
Dept. of Vascular Surgery
Na Homolce Hospital, Roentgenova 2
Praha 5 Czech 15030 CZECH REPUBLIC
Tel: 420257272540
Fax: 420257272969
E-Mail: petr.stadler@homolka.cz
*

Michael Stark MD
The New European Surgical Academy (NESA)
Karower Street 11, House 214
Berlin 13125 GERMANY
Tel: 49 (30) 9401-2403
Fax: 49 (30) 9401-2430
E-Mail: mstark@nesaacademy.org
*

Peter L. Steinberg MD
One West St, Apt 5
Hanover NH 03755 USA
Tel: (585) 576-8374
Fax: (603) 650-4985
E-Mail: peter.steinberg@hitchcock.org
#
‡Grant Research: Dartmouth Hitchcock Medical Center QRGP Grant
Stock Shareholder: Amgen

Gustavo Stringel MD
21 Addison Street
Larchmont NY 10538 USA
Tel: (914) 833-2311
E-Mail: GStringel@aol.com
*

Rabiya Suleman MD
1329 St. Andrew St, Apt 5
New Orleans LA 70130 USA
Tel: (504) 296-1545
E-Mail: rabiyas@gmail.com
‡Grant Research: OBGYN Alliance

Chandru P. Sundaram MD
535 Barnhill Drive
Suite 420
Indianapolis IN 46202 USA
Tel: (317) 278-3098
Fax: (317) 274-0174
E-Mail: sundaram@iupui.edu
#
‡Discussion of commercial products or services
Consultant: Intuitive Surgical, Ethicon Endosurgery, Tyco Healthcare

Mark Surrey MD
450 N. Roxbury Drive
Beverly Hills CA 90210 USA
Tel: (310) 277-2393
E-Mail: msurreymd@aol.com
‡Discussion of commercial products or services
‡Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Stock Shareholder: Innovamed, LLC

Robert M. Sweet MD
420 Delaware Street SE
Mayo Memorial Building A580
Minneapolis MN 55455 USA
Tel: (612) 626-3386
Fax: (612) 626-0428
E-Mail: rsweet@umn.edu
‡Discussion of commercial products or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Grant Research: Gyrus/ACMI, Medical Education Technologies Incorporated, METI
Consultant: Gyrus/ACMI, Medical Education Technologies Incorporated,METI
Stock Shareholder: Red Llama Incorporated

Radha Syed MD
5 Coddington Ave
Staten Island NY 10306 USA
Tel: (718) 351-1350
Fax: (718) 351-1271
E-Mail: radhasyed77@yahoo.com
#
*

Linda Szczurek DO
2201 Chapel Ave West
Cherry Hill NJ 08002 USA
Tel: (856) 488-6887
Fax: (856) 488-6769
E-Mail: lszczurek@hotmail.com
*

Gerald Y. Tan MD
465 Main Street, Apt 16E
Roosevelt Island
New York NY 10044 USA
Tel: (917) 379-5862
E-Mail: gyt2001@med.cornell.edu
‡Grant Research: Prostate Cancer Foundation, New York Academy of Medicine

Vijay Trisal MD
1500 E Duarte Rd
Duarte CA 91010 USA
Tel: (626) 471-7175
Fax: (626) 301-8865
E-Mail: vtrisal@coh.org
‡Discussion of commercial products or services

Daniel A. Tsin MD
25-10 30th Avenue
Long Island City NY 11102 USA
Tel: (718) 899-7878
Fax: (718) 746-4174
E-Mail: LaserGYN@aol.com
#
‡Speakers Bureau: Apple Medical
Stock Shareholder: Imanlap (One co-author only)

Duncan J. Turner MD
219 Nogales Avenue
Suite A
Santa Barbara CA 93105 USA
Tel: (805) 682-6340
Fax: (805) 563-8576
E-Mail: dturnermd@aol.com
*

Amir Vejdan Dr Med
Taleghany st. Immam Reza Hospital
Birjand South Khorasan 97179 IRAN
Tel: 0098-915-161-3885
Fax: 0098-561-442-4285
E-Mail: vejdan_sa@yahoo.com
*

Jeffery Lawrence Walding MD
139 Myrick Drive
Macon GA 31220 USA
Tel: (478) 957-0500
Fax: (478) 633-5153
E-Mail: jlwmd2004@yahoo.com
#
*

Steve Waxman MD
University of Iowa Hospitals and Clinics, Dept Urology
200 Hawkins Drive, RCP 3235
Iowa City IA 52242-1089 USA
Tel: (319) 384-9448
Fax: (319) 356-3900
E-Mail: howard-winfield@uiowa.edu
*

Paul Alan Wetter MD
7330 SW 62 Place
Suite 410
Miami FL 33143 USA
Tel: (305) 665-9959
Fax: (305) 667-4123
E-Mail: Paul@SLS.org
‡Stock Shareholder: Johnson & Johnson

Dave R. Williams MD
50 Charlton Avenue East
Hamilton ON L8N 4A6 CANADA
Tel: (905) 522-1155
E-Mail: willd@mcmaster.ca
*

Howard N. Winfield MD
Univ. of Iowa Hospitals & Clinics
RCP 3235, 200 Hawkins Drive
Iowa City IA 52242 USA
Tel: (319) 384-9183
Fax: (319) 356-3900
E-Mail: howard-winfield@uiowa.edu
#
‡Grant Research: Astellas Pharma
Consultant: Ethicon

Andrew Wright MD
1959 NE Pacific St
Box 356410
Seattle WA 98115 USA
Tel: (206) 359-2287
E-Mail: awright2@u.washington.edu
‡Discussion of commercial products or services
Presentation includes discussion of the use of product(s) for which they are not labeled or are still investigational
Grant Research: Covidien, LifeCell, MetaCure

Joseph Wyatt MD
1105 FOT
1530 3rd Ave S
Birmingham AL 35294 USA
Tel: (205) 996-8765
E-Mail: houseofwyatt@gmail.com
#
*

Takashi Yamada MD PhD
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
#
*

Robert G. Yavrouian MD
500 W. Hospital Rd, #1020
French Camp CA 95231 USA
Tel: (818) 415-6230
E-Mail: ryavrouian@yahoo.com
*

Saleem Zafar MD
2378 Parliament Square
Toledo OH 43617 USA
Tel: (419) 290-4092
E-Mail: saleemzafar1@gmail.com
‡Discussion of commercial products or services

Gregory P. Zagaja MD
5841 S. Maryland Avenue-MC6038
Chicago IL 60637 USA
Tel: (773) 834-4830
Fax: (773) 702-1001
E-Mail: gzagaja@surgery.bsd.uchicago.edu
‡Discussion of commercial products or services
Consultant: Intuitive Surgical

Kevin C. Zorn MD
1730 N. Clark, Apt 2906
Chicago IL 60614 USA
Tel: (773) 702-6105
Fax: (773) 702-1001
E-Mail: kevin.zorn@gmail.com
#
*

Errico Zupi MD
Viale Parioli 12
Rome  00197 ITALY
Tel: 39-33-535-7096
E-Mail: ezupi@libero.it
*

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 or services
Significant for profit relationship with the manufacturer(s) of products or providers of service(s) discussed
Consultant: Ethicon Women's Health and Urology, Conceptus
Speakers Bureau: Ethicon Women's Health and Urology, Conceptus

17TH SLS ANNUAL MEETING AND ENDO EXPO 2008
SCIENTIFIC AWARD WINNERS AND HONORABLE MENTIONS

Award for Honorable Mention Scientific Paper – Urology
Aldrin Gamboa, BS
Long-term Impact of a Laparoscopic Renal Surgery Mini-Residency on Post Graduate Urologic Practice Patterns

Award for Honorable Mention Scientific Paper – Urology
Aldrin Gamboa, BS
Long-term Impact of a Robot Assisted Laparoscopic Prostatectomy Mini-Residency Training Program on Post-Graduate Urologic Practice Patterns

Award for Honorable Mention Scientific Paper – Urology
Aldrin Joseph R. Gamboa, MD
Robotic Pelvic Lymph Node Dissection in Patients Undergoing Radical Cystectomy for Bladder Cancer

Award for Honorable Mention Video – General Surgery
Alex Gandsas, MD
Project REACH: Robotic Expertise Allowing Collaborate Help. A New Paradigm in Post Graduate Surgical Training

Award for Honorable Mention Scientific Paper – Gynecology
Bradford W. Fenton, MD, PhD
The Presence of Endometriosis Increases the Risk for Myofascial Pain and Pelvic Floor Tension Myalgia in Patients with Chronic Pelvic Pain

Award for Honorable Mention Scientific Paper – General Surgery
Ehab El Akkary, MD
Sutureless Laparoscopic Ventral Hernia Repair in Obese Patients

Award for Honorable Mention Video – General Surgery
Emad Kandil, MD
Novel Transanal Operation for Rectal Cancer Combining Ultrasonic Dissection, Titanium Knot and the Storz Rectoscope

Award for Honorable Mention Scientific Paper – General Surgery
Erica R. Podolsky, MD
Single Port Access (SPA™) Cholecystectomy – 15 Consecurive SPA Cholecystectomies and One Year Follow-up

Award for Honorable Mention Scientific Paper – Resident
Erica R. Podolsky, MD
Single Port Access (SPA™) Cholecystectomy – 15 Consecutive SPA Cholecystectomie sand One Year Follow-up

Award for Honorable Mention Video – Gynecology
Farr Nezhat, MD
Robotic Assisted Ovarian Transposition and Pre-Treatment Surgical Staging in Cervical Cancer

Award for Honorable Mention Video – Gynecology
Farr Nezhat, MD
Robotic Assisted Total Pelvic Exenteration

Award for Best Scientific Paper – Urology
Gerald Y. Tan, MD
Real-time Visualization of Periprosatic Neural Architecture Using Multiphoton Microscopy and Second-Harmonic Generation to Improve Potency Outcomes During Nerve-Sparing Radical Prostatectomy: Our Early Results

Award for Best Video – Urology
Gerald Y. Tan, MD
Early Continence with Novel Restoration of Bladder Neck Anatomy During Robotic Prostatectomy

Award for Best Video – Gynecology
Herbert A. Goldfarb, MD
Laparoscopic Assisted Myomectomy Using Mobius Retractor

Award for Honorable Mention Scientific Paper – Urology
Jayant Uberoi, MD
Robotic-Assisted Laparoscopic Radical Prostatectomy for High Risk Prostate Cancer: Initial Experience and Short-Term Outcomes

Award for Honorable Mention Scientific Paper – Resident
Jayant Uberoi, MD
Robotic-Assisted Laparoscoic Radical Prostatectomy for High Risk Prostate Cancer: Initial Experience and Short-Term Outcomes

Award for Honorable Mention Video – Gynecology
Jonathan Y. Song, MD
Laparoscopic Tubal Anastomosis

Award for Honorable Mention Video – MultiSpecialty
Joseph Wyatt, MD
Biliary Endoscopic Lithotripsy

Award for Honorable Mention Resident Video
Joseph Wyatt, MD
Biliary Endoscopic Lithotripsy

Award for Best Scientific Paper – Pediatric Surgery
Kerrey B. Buser, MD
A Call for Raised Awareness and Appropriate Treatment of Symptomatic Gallbladder Disease in the Pediatric Population

Award for Honorable Mention Video – General Surgery
Keyur A. Chavda, MD
Laparoscopic Lumbar Hernia Repair

Award for Honorable Mention Resident Video
Keyur A. Chavda, MD
Laparoscopic Lumbar Hernia Repair

Award for Honorable Mention Video – Gynecology
Masaaki Andou, MD, PhD
Laparoscopic Vascular Injury Repair

Award for Best Video – MultiSpecialty
Masaaki Andou, MD, PhD
Laparoscopic Ultra-radical Parametrectomy (Piver type 5)

Award for Honorable Mention Scientific Paper – Resident
Matthew D. Sorensen, MD, MS
Initiation of a Pediatric Robotic Surgery Program and a Case-Control Analysis of Pediatric Robotic Ureteral Reimplantation

Award for Honorable Mention Scientific Paper – Pediatric Surgery
Matthew D. Sorenson, MD, MS
Initiation of a Pediatric Robotic Surgery Program and a Case-Control Analysis of Pediatric Robotic Ureteral Reimplantation

Award for Honorable Mention Video – General Surgery
Michael L. Simonson, MD
Endoscopic Sclerotherapy Technique for the Treatment of Dilated Gastrojejunal Anastomosis after Roux-en-Y Gastric Bypass

Award for Honorable Mention Resident Video
Michael L. Simonson, MD
Endoscopic Sclerotherapy Technique for the Treatment of Dilated Gastrojejunal Anastomosis after Roux-en-Y Gastric Bypass

Award for Best Scientific Paper – General Surgery
Morris E. Franklin, MD
The Use of Bioabsorbable Staple Line Reinforcement for Circular Stapler (BSG “Seasmguard” in Colorectal Surgery

Award for Honorable Mention Video – General Surgery
Myles Joyce, MD
Laparoscopic Total Proctocolectomy with Vertical, Double-Stapled Ileal-Pouch Anal Anastomosis

Award for Honorable Mention Scientific Paper – MultiSpecialty
Paul G. Curcillo II, MD
Single Port Access (SPA™) Surgery – The First 100 Cases

Award for Best Scientific Paper – MultiSpecialty
Rabiya Suleman, MD
Is Performance on a Basic Laparoscopic Skills Set Affected by Differences in Hand-Eye Dominance and Depth Perception?

Award for Best Resident Scientific Paper
Rabiya Suleman, MD
Is Performance on a Basic Laparoscopic Skills Set Affected by Differences in Hand-Eye Dominance and Depth Perception?

Award for Best Video – General Surgery
Sharona B. Ross, MD
Single Incision Laparoscopic Heller Myotomy and Anterior Fundoplication

Award for Honorable Mention Video – Urology
Sijo J. Parekattil, MD
Video Demonstration of Robotic and Laparoscopic Partial Nephrectomy without Vascular Clamping and Renal Ischemia

Award for Honorable Mention Resident Video
Sijo J. Parekattil, MD
Video Demonstration of Robotic and Laparoscopic Partial Nephrectomy without Vascular clamping and Renal Ischemia

Award for Honorable Mention Scientific Paper – Gynecology
Stefanos Chandakas, MD, MBA, PhD
A New Narrow Band Imaging Endoscopic System for the Detection of Surface Pathology Inclluding Endometriosis: A Series of 75 Patients

Award for Honorable Mention Video – General Surgery
T. Matthew Jones, MD
Balloon Retention Facilitates Laparoscopic Transgastric Cystogastrostomy

Award for Honorable Mention Video – General Surgery
Thomas Fabian, MD
Laparoscopic Repai of Post-esophagectomy Hiatal Hernia

Award for Honorable Mention Resident Video
Thomas Fabian, MD
Laparoscopic Repair of Post-esophagectomy Hiatal Hernia

Award for Honorable Mention Scientific Paper – General Surgery
Titus D. Duncan, MD
Transacillary Endoscopic Periareolar Approach (TEPA) to Total Thyroidectomy

Award for Honorable Mention Video – Gynecology
Tomonori Hada, MD
Laparoscopic Myomectomy for Large Cervical Fibroids – Repair for the Lacerated Endocervical Mucosa

Award for Best Scientific Paper – Gynecology
Yan Liu, MD
The Prognosis of Surgical Treatment Using Laparoscopy in Patients with Endometrial Cancer – The Result of 15 Years’ Follow Up

17TH SLS ANNUAL MEETING AND ENDO EXPO 2008 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 17th SLS Annual Meeting and Endo Expo 2008.

Uchenna Acholonu MD
SUNY-Upstate Medical University
Forest Hills, NY

Kanayochukwu (Kanny) Aluka MD
Howard University Hospital
Washington, DC

Krista Bannon MD
Providency Health Systems
Detroit, MI

Jennifer Benedict MD
Harbor-UCLA Medical Center
Torrance, CA

James Bittner MD
Med College of Georgia School of Medicine
Augusta, GA

Paul Cabral MD
Rochester General Hospital
Rochester, NY

Keyur Chavda MD
Robert Packer Hpspital
Sayre, PA

Damon Cudihy MD
SUNNY Buffalo, Sisters of Charity Hosp.
West Seneca, NY

Michael  Gomez MD
Medical College Of Ohio
Toledo, OH

Josephine Hidalgo-Tamola MD
University of Washington
Seattle, WA

Usman Jaffer MB, BS
Norfolf & Norwich Univ Hospital
Norwich,

Ali  Mallat MD
University Libanaise
Ypsilanti, MI

Michael Martinez Medical Student
Yale School of Medicine
Branford, CT

Nikita Mehra MBBS
Sri Ramachandra University/India
Chennai,

Hossein Mirheydar MD
University of Minnesota School of Medicine
Minneapolis, MN

Vadim Morozov MD
University of Maryland School of Medicine
Baltimore, MD

Ramya Narayanan MD
University of Chicago
Chicago, IL

Zamip Patel MD
Mount Sinai Hospital
New York, NY

Erica Podolsky MD
Drexel University
Moorestown, NJ

Ruchi Puri MD
The George Washington University
Silver Springs, MD

Carlos Roberts MD
York Women's Health Center
York, PA

Aimee Robinson MD
University of Tennessee Health Science Ctr.
Memphis, TN

Jonathan Silberstein MD
University of CA in San Diego
San Diego, CA

Mathew Sorensen MD
University of Washington
Seattle, WA

Peter Steinberg MD
Dartmouth Hitchock Medical Center
Lebanon, NH

Gerald Tan MD
Weill Medical College of Cornell University
New York, NY

Jayant Uberoi MD
Hackensack Medical University
Edgewater, NJ

Sheila Varnadore Nurse/Technician/_Affiliated Personnel
Bariatric & Laparoscopy Center
Ocala, FL

Sumeet Virmani MD
Providence Hospital
Southfield, MI

Jeff Walding MD Resident
University of Alabama School of Medicine
Macon, GA

Steve Waxman MD
University of Iowa
Iowa City, IA

Joseph Wyatt MD
Medical Associates
Pierre, SD

Robert Yavrouian MD
San Joaquin General Hospital
French Camp, CA

Saleem Zafar MD
Medical College of Ohio
Toledo, OH

Scholarships awarded at time of print.

17TH SLS ANNUAL MEETING AND ENDO EXPO 2008 LAPAROSCOPY UPDATES

Abdominal / Pelvic Pain / Adhesions Committee
Update on Adhesion Reduction
Ceana Nezhat, MD

Peritoneal adhesions can cause intestinal obstruction, pelvic pain, and infertility. Intraabdominal adhesions between the abdominal scar and the underlying viscera are a common consequence of laparotomy. Patients undergoing laparoscopy after a previous laparotomy should be considered at risk for the presence of adhesions between the old scar and the bowel and omentum.

Since the development of postoperative adhesions is a major factor in deciding the outcome of fertility-promoting operative procedures, surgeons should understand the mechanism of their formation, use optimal techniques for adhesiolysis, and apply agents or devices to reduce their development.

While significant progress has been made toward understanding the development of postoperative adhesions and their prevention, adjuvants and minimally invasive surgery have not eliminated them. Operative laparoscopy may be more effective than laparotomy in reducing their formation and should be the first procedure in their management.

Although adhesions are not preventable, adhesion reduction materials are available and new materials are being researched. This presentation will give an update on the adhesion reduction methods and materials that are available and a report of what is under investigation.

Bariatrics Committee
Update on Bariatrics
Dana Portenier, MD

Core Competencies Committee
Competencies and the American Board of Surgery
Gustavo Stringel, MD

The six core competencies of Patient Care: Medical Knowledge, Practice-Based learning and improvement, Interpersonal and Communication Skills, Professionalism and Systems Based Practice, were endorsed in 1999 by the Accreditation Council of Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS).

These competencies are now an active part of the education of surgical residents. The general competencies were designed to emphasize educational outcome assessments in residency and in the accreditation process. All residents must develop the competency in all six areas in order to graduate.
The new emphasis of surgical programs is to graduate surgeons who are competent and who are able to provide quality of care in a safe environment to produce the desired outcomes. It is important for the surgeon, not only to obtain desired outcomes comparable to that of others, but also to deliver this care in a confident, empathetic, humane, personal, and respectful manner. The surgeon must also deliver this care in a financially responsible manner. It is especially important for the laparoendoscopic surgeon to be able to work in a technologically advanced environment since many of the procedures performed are technically demanding and equipment dependent.

The American Board of Surgery has incorporated some of the core competencies in the Maintenance of Certification Program (MOC).  The new certification process requires Evidence of Professional Standing, Commitment to Lifelong Learning and Self- Assessment, Cognitive Expertise and Evaluation of Performance in Practice. The surgeon must comply with all these requirements in order to maintain certification in the American Board of Surgery.

Endocrine / Solid Organ Committee
Innovative Endoscopic Thyroid Surgery
Tahar Benhidjeb, MD (NESA)

The technology development of the past two decades in the field of video-assisted surgery has opened up new opportunities, including in thyroid surgery. The first endoscopic thyroid lobectomy was performed in 1996. The technique of minimally invasive video-assisted thyroidectomy (MIVAT) is the method that has so far become most widespread. Limiting factors of this method include the 20mm small cervical incision and consequently the size of the specimen resected. Furthermore, young women in particular consider such cervical scars as disturbing, even when they are quite small and unobtrusive. Several papers describing an access outside the front neck region have been published. Such approaches are chest, axillary, and a combined axillary bilateral breast approach (ABBA). However, these techniques just moved the scars from the front neck region to the axilla or the chest where they are still visible. Furthermore, these approaches do not comply with the use of the term “minimally invasive”, since they are associated with an extensive dissection of the chest and neck region, thus being rather maximally invasive for the patients. In order to achieve at the same time a cosmetically optimal result and a minimally invasive approach, our group has investigated in human cadavers the transoral access, the so-called transoral video-assisted thyroidectomy (TOVAT).

Fibroids / Abdominal Uterine Bleeding Committee
Laparoscopic Myolysis Revisited
Herbert Goldfarb, MD

Fifteen years ago Dr. 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 NdYag laser, subsequent methods have included Bipolar Needles,Cryo probes, Radio frequency probes, MRI guided Laser probe and finally MRI guided high power focused ultrasound. This presentation will review the available techniques used, evaluate efficiency, cost ,success rates and complications.

Multidisciplinary Committee
The Future of Abdominal Surgery —The Natural Orifice Surgery
Michael Stark, MD (NESA)

Most surgical, urological and gynaecological abdominal operations have endoscopic alternatives. In comparison to patients undergoing laparotomies, patients having endoscopic procedures need less postoperative analgesics and have decreased morbidity and shorter hospital stay. Laparoscopic procedures have never proved to be risk less and are usually performed using general anaesthesia with intra-abdominal pressure up to 15 mm Hg and with insertion of up to four trocars.
Next to the recently developed transgastric operations, the use of the Douglas pouch as an entry for different abdominal operations is becoming a subject for experimental as well as clinical use.
The pouch of Douglas has also been used as an entry for infertility work-up, appendicectomy, and cholecystectomy. The New European Surgical Academy is preparing the prerequisites to use the pouch of Douglas as a single entry for abdominal operations in women. The expected advantages of this approach are the following:

1.   The introduction of the instruments can be done under vision and parallel to the major blood vessels, with low CO2 pressure.
2.    The vagina can be easily cleaned and disinfected and repairs without leaving visible scars.
3.    The transdouglas approach improves operation ergonomics.
4.    There is no risk of herniation or eventration.

A multidisciplinary surgical team are joining forces to design transdouglas operations such as cholecystectomies, appendicectomies, hysterectomies and nephrectomies. A multi-channel instrument respecting the pelvic anatomy and enabling to perform operations in the upper and lower abdomen has been designed and will be introduced next to the planned procedures, simulations and first results.

Office and Outpatient Laparoscopy Committee
Office Cosmetic Procedure
Duncan Turner, MD

With the increasing pressure from managed care in conjunction with increasing malpractice cost, the OB/GYN frequently is finding difficulty in maintaining a constant income.  Many physicians are choosing to increase the spectrum of their practice to better serve their patients and one of these areas that is working well for this specialty is cosmetic/elective procedures.

In 2004, the American Society of Plastic Surgeons published a practice advisory on liposuction stating that any board certified surgeon could be trained to perform these procedures within their area of expertise.  They described the training that was thought to be necessary.

Having taken the recommendations of the American Society of Plastic Surgeons in terms of training, I have been involved with both ultrasound and laser-based technologies for body sculpting from the upper abdomen into the mid-thigh. This has been an interesting addition to my practice; patients have been very receptive to this, particularly as these procedures are extremely safe being performed in an office setting entirely under local anesthesia with no IV or conscious sedation.

Pediatric Surgery Committee—Pediatric General Surgery
The Race in Pediatric MIS: Hit the Gas!...But be Ready to Slam on the Brakes
John Meehan, MD

Many advances in MIS have highlighted a great year in pediatric surgery. Although equipment advances in pediatric surgery seem to lag the higher market areas of adult surgery, several new techniques and devices have been developed which have helped pediatric surgeons bring more MIS  procedures to kids around the world. However, certain MIS problems have been discovered, too. Pediatric surgeons need to stay informed as to the latest ideas that work as well as the lessons we learned for things that may not be as good as we thought. This presentation will summarize some of the highlights and new discoveries in MIS pediatric surgery as well as summarize the areas where MIS has failed.

Pediatric Gynecology—Pediatric General Surgery
Robert Zurawin, MD

Pediatric Urology
Thomas Lendvay, MD
The incorporation of pure laparoscopic and robotic-assisted laparoscopic (RAL) techniques in pediatric urologic disease management is an area of rapid growth.  Clinicians are utilizing robotics for the most complex urologic reconstructions and more providers are appreciating the benefits of RAL surgery.  RAL continence procedures are now being adopted in children with complex congenital diseases such as spina bifida.  In addition, we are pushing the envelope on the applications of laparoscopic techniques in children less than 6 kgs.  Others, however, caution on the realities of using robotic techniques in children less than 6 months of age due to size limitations.  In an effort to replicate open renal reconstructive surgery, authors have described the safety and efficacy of RAL retroperitoneopscopic pyeloplasties in children and data is emerging that MIS techniques in children do show a decreased narcotic requirement in the peri-operative period as has been seen for years in the adult MIS literature.  The outcomes have now been published on the largest series of patients undergoing RAL ureteral reimplantation surgery for vesicoureteral reflux and it appears that the success is at least similar to the gold-standard of open ureteral reimplant surgery.  As the demand for decreasing the degree of invasiveness in pediatric urology increases, miniaturization of MIS instrumentation and improved visualization will lessen the technical challenges of MIS in smaller children.  Our sub-specialty must now utilize rigorous prospective evaluations of open and MIS reconstructions in the pediatric population.

Pelvic Reconstructive Surgery / Stress Incontinence Committee
The Use of Mesh for Stress Incontinence and Pelvic Floor Prolapse
Steven Minaglia, MD

Robotic Surgery Committee
New Developments in Robotic Surgery
Andrew Wright, MD

In this session we will review new clinical data in surgical robotics for general surgery, urology, and gynecology. This will include the evolving number of general surgical procedures including gastrectomy, hepatobiliary procedures, and colorectal surgery. In urology we will discuss new multi-center trials of ureteral reimplantation, additional clinical data on robotic prostatectomy, and an extension of robotic techniques into pediatric urology. There has been a rising interest in the gynecologic literature regarding robotic fertility surgery as well as new applications of the robot in gynecologic cancer. We will also discuss exciting new pre-clinical developments in the world of robotic surgery. Featured will be robotic Natural Orifice Transluminal Access Surgery (NOTES), single port access robotic surgery, ultra-miniaturized surgical robots, and semi-autonomous robot behavior. We will also show new innovations in training for surgical robotics, including new VR simulators and the use of standardized training programs for robotics such as adaptations of the Fundamentals of Laparoscopic Surgery.

Thoracic Committee
Minimally Invasive Esophagectomy
Neil A. Christie, MD