Faculty Presentations

Obesity Crises in Saudi Arabia
Dr.Naif AlEnazi,MD,MBA,FIC,FEBS
Bariatric and laparoscopic surgeon
Saudi Arabia – Riyadh

Introduction
Obesity is a serious medical condition, because it greatly increases the risk of diabetes, hypertension, hyperlipidaemia, osteoarthritis, coronary artery disease, and certain cancers. Typically, obesity is associated with developed countries, though it is becoming increasingly common in certain developing countries, such as the Kingdom of Saudi Arabia (KSA). In the last few decades, Saudis have become prosperous, this has caused the populace to embrace typical Western lifestyles; in other words, Saudis get little exercise, and eat high-fat and high-calorie diets but few fruits and vegetables. The combined effects of poor diets and low physical activity have led to an obesity crisis in the KSA.

This paper presents a literature review of recent studies on the prevalence of obesity and its health risks in the KSA. It was found that around a quarter to a third of Saudis have body mass indexes greater than 30 kg/m2. This means the KSA has one of the highest obesity rates in the world. Obesity is more prevalent in young men and women and children. This is partly due to lack of exercise. Obesity should not be taken lightly, because it frequently causes heart disease, diabetes and hypertension in the KSA.

Conclusion
Obesity in the KSA is a serious issue, because many obese Saudis die prematurely due to obesity-associated diseases, such as cardiovascular disease. Indeed, heart disease is one of the leading causes of death in the KSA. It is recommended that the Saudi government enact polies to encourage Saudis to exercise and eat healthier diets.


Laparoscopic Approach in Adrenalectomies- First 300 Cases
MirceaBeuran, Mihaela Vartic, Sorin Paun
Emergency Clinical Hospital Bucharest
“Carol Davila” University of Medicine and Pharmacy Bucharest

In the past 20 years laparoscopic adrenalectomies slowly became the gold standard for virtually all adrenal tumors, especially those of size as small as 6 cm.

Material and Method
Since 2003 we have performed 300 adrenalectomies in 288 operations and for 288 patients (12 bilateral adrenalectomies during the same surgery and 12 patients with bilateral tumor operated with interval right/left). All patients have been operated by the same surgical-anesthesical team and the laparoscopic/robotic approach was transperitoneal anterolateral with 4 trocars of 10 mm. The clinical pathology approached laparoscopicaly was from adrenogenital Syndrom (2), neoplasia (3), cyst (4), metastases (4), virilizant tumo (5), Conn Syndrom (21), Cushing Syndrom (30), Cushing Disease (32), Pheochromocytoma (32) to nonsecretant tumour (138).

Results
In our study on patients who underwend laparoscopic approach, we had 200 females and 71 males, with a median age from 46,72 in Cushing Syndrom/Disease to 50,8 in Pheochromocitoma. Median operating time was varried from 89,58 min in nonsecretant tumor and up to 109,9 min in Conn Syndrom, with an average tumour size ranging from 2,82cm in Conn Syndrom to 5,35 in nonsecretant tumour. Moreover, we have accounted for 20 cases conversions to open approach (11 nonsecretant tumour, 4 Pheochromocytoma, 3 Cushing and 2 Conn Syndrom). Postoperative hospital stay had averaged 3,9 days in Conn Syndrom to 4,43 days in Cushing and we had no mortality.

Conclusions
Laparoscopic adrenalectomy can be safely perform for all types of adrenal pathology with all the benefits associated with minimally invasive surgery.


HITERECTOMÍA VAGINAL PRÁCTICA ACTUAL
VAGINAL HYSTERECTOMY CURRENT PRACTICE
Miguel Angel Cáceres, MD

It is well known that vaginal hysterectomy has the property of being a minimal invasion surgery that uses a natural orifice to achieve the goal. It is the original minimally invasive hysterectomy approach. Over the past several years, with current emphasis on cost-effectiveness in the utilization of minimal invasion surgery, this approach is considered the first line approach before the selection of laparoscopy or laparotomy. Reasons for preference for other approaches relates to the sometimes-limited access to working space and the need for special training related to the anatomic approach from the vaginal point of view.

The search for a method that would simplify the procedure, improve the use of space, while remaining cost-effective has been the reason for the development of an alternative technique using a prototype of a kit call VAHYRES (VAGINAL HYSTERECTOMY RESCUE SYSTEM). The goal of this presentation is to compare different techniques for vaginal hysterectomy and present an initial prototype of this method. This technique combines the use of the lines of strength related to retraction, around a specific anatomical point and the use of a system to potentiate the effectiveness of each step. This results in a simplified and more rapid procedure once the bladder is separated and the pouch of Douglas is opened.


Complicated Appendicitis in Pregnancy
Uriel Ovido Cardona, MD

The laparoscopic approach of appendicitis in pregnancy is controversial by maternal-fetal risk. Although low-grade evidence shows that laparoscopic appendectomy is associated with higher rates of fetal loss, benefits of laparoscopic management of complicated appendicitis can also be seen in pregnancy

MATERIALS AND METHODS
We present a series of five pregnant patients with complicated appendicitis with local or generalized peritonitis. Open technique and 3 trocars with harmonic scalpel cauterization of mesoappendix and endo knot- ligation of the base was used.

RESULTS
There was no maternal mortality and fetal loss and average hospital stay was 5 days. Patients were treated with intravenous antibiotics – piperacillin- tazobactam- and underwent fetal monitoring before discharge.

CONCLUSIONS
Laparoscopic approach is feasible in complicated appendicitis in pregnancy. The risk to benefit ratio is difficult to assess because of the small number of patients and requires a wider casuistry.


Manejo quirúrgico en Dolor Pélvico Crónico
Chronic Pelvic Pain: Surgical Treatment
Jorge F. Carrillo, MD
University Of Rochester

Chronic pelvic pain (CPP) is a common condition encountered in the general ObGyn practice, being up to 20-30% of all ObGyn visits and 15-20% of all ER ObGyn visits. Pelvic pain is one of the most common indications for different surgical procedures, including 20-40% of all Gyn laparoscopies, diagnostic or operative laparoscopy and is a frequent indication for hysterectomy as well. To decide when is appropriate to recommend a surgical approach to CPP patients requires first being able to identify conditions causing CPP that are surgical and non surgical, to treat them and to anticipate if performing a surgical procedure in a CPP patient will provide some relief in symptoms. Although surgery is appropriate in several occasions, there are many factors to be considered before, during and after the surgical procedure to provide adequate patient care, including: selecting appropriately patients, counseling, adding alternative medical – psychosocial and non invasive techniques in the treatment, being knowledgeable of which procedures will be adequate for each patient, being technically proficient in performing an adequate intraoperative anatomical survey, being surgically knowledgeable and competent, and very importantly, having a postoperative treatment plan to treat the chronic conditions. The main objectives for this session are to review the aspects to take into account when one suggests or makes the decision to proceed with a surgical treatment in a CPP patient, and to discuss which procedures are done for CPP conditions and their efficacy.


Entrenamiento en cirugía ginecológica minimamente invasiva
Training in Minimally Invasive Gynecologic Surgery (MIGS)
Jorge F Carrillo, MD
University of Rochester

The process of learning minimally invasive surgical techniques is an important part of training in gynecology. The well-known apprenticeship model and graded responsibility system implemented in the US by Doctor William Halsted in 1889 for surgical residencies and used in many countries, is dependent on high patient volume, and might no longer be optimal for the current training environment. As education moves towards a competency based model and patient safety drives primary training into the non-clinical environment, surgical skill acquisition will need to be increasingly developed in the simulated scenario prior to use in the clinical environment and effective methods to assess and evaluate trainees are encouraged to be used. Laparoscopic simulators are available for developing and assessing specific techniques and manual skills. The main objectives for this session are to identify the current challenges we encounter on a daily basis interfering with surgical skills training and to list/explain different validated tools available to help you train and assess the trainee intra-operatively.


Evidence Based Minilaparoscopy – Can Cheaper Really be Better?
Gustavo L. Carvalho MD, PhD. – glcmd1@gmail.com
Oswaldo Cruz University Hospital and UNIPECLIN, Faculty of Medical Sciences, University of Pernambuco – Recife, Brazil

Stigmatized as expensive and time consuming, minilaparoscopy seemed to have no major advantages and did not progress the way industry had imagined. With various advancements in the MINI original technique, several procedures are now being performed where greater results are achieved using simple and more reliable NEW mini LowFriction reusable instruments.

In order to improve movement precision and decrease surgical stress, a no seal and no valve trocar (LowFriction) was developed, minimizing usual friction forces. The special MINI trocar was designed to resemble a long needle, matching the diameter of the corresponding 3mm instruments. Free left lumen is minimal, therefore eliminating the need for sealing to prevent gas loss. The long trocar dilating tip significantly improves cosmesis, while prevents dislocation of the cannula even in thin patients and emphasizes the idea of a less scar, less trauma approach.

In short cheaper is not necessarily worse, and recognized benefits were found in the NEW MINI technique which is a 1-day surgery, safe, with all the advantages of laparoscopy, highly reproducible, cost effective, and with great aesthetic appeal.


HISTERECTOMIA LAPAROSCOPICA EN LATINOAMERICA
LAPAROSCOPIC HYSTERECTOMY IN LATIN AMERICA
Moderador/ Moderator: Jimmy Castañeda • Colombia
Panelistas/ Panelists: Juan Salgado, MD • Puerto Rico, Juan Carlos Ramírez, MD • Colombia, Juan Diego Villegas, MD • Colombia, Miguel Cáceres, MD • Panamá

En este panel se quiere plantear y analizar la situación actual de la Endoscopia Ginecológica en Latinoamérica, con base en el procedimiento más representativo: Histerectomía laparoscópica.

Se van a desarrollar las siguientes preguntas:
1- Que tanta Histerectomía Laparoscópica se está realizando comparativamente con las diferentes vías, en Latinoamérica – Hay datos?
2- Cuáles son las limitantes para la Histerectomía Laparoscópica en Latinoamérica
3- Técnicas de cierre de cúpula vaginal: cuál es su preferencia y porqué?
4- Cuáles son los límites para la Histerectomía laparoscópica, para cada uno de los panelistas

In this panel we want to raise and discuss the current status of Gynaecological Endoscopy in Latin America, based on the most representative method: Laparoscopic hysterectomy.
They will develop the following questions:
1- That much Laparoscopic Hysterectomy is comparatively doing with the different routes in Latin America – there data?
2- What are the limitations for Laparoscopic Hysterectomy in Latin America
3- Technical vaginal cuff closure: what is your preference and why?
4- What are the limits for laparoscopic hysterectomy, for each of the panelists


MIOMECTOMIA Y MORCELACION
MYOMECTOMY AND MORCELATION
Moderador/ Moderator: José D. López Jaramillo, MD • Colombia
Panelistas/ Panelists: Kelmy Jurado, MD • Ecuador, Jimmy Castañeda, MD • Colombia, Juan Carlos Ramírez, MD • Colombia

En este panel se quiere plantear y analizar la situación actual de la Morcelación en Latinoamérica. En los Estados Unidos, y en el resto del mundo ha habido cambios en el ejercicio de la Cirugía mínimamente invasiva, con base en las limitaciones y evidencia que se presenta, con respecto a la morcelación.

Se van a plantear las siguientes preguntas:
1. Impacto de Statement de la FDA en la morcelación en Latinoamérica. Usted está morcelando – si o no- Alternativas a la morcelación eléctrica
2. Está justificado dejar de morcelar?
3. Cómo se puede mitigar el impacto de la declaración de la FDA?

In this panel we want to raise and discuss the current situation in Latin America Morcellation. In the United States, and the rest of the world there have been changes in the performance of minimally invasive surgery, based on the limitations and evidence presented with respect to morcellation.
They are going to ask the following questions:
1. Impact Statement on FDA Morcellation in Latin America. You are using morcellation- whether or not – Alternatives to electricity Morcellation
2. It is justified to stop morcelate?
3. How can mitigate the impact of the statement by the FDA?


Is Surgical Treatment always Necessary for Patients with Endometriosis and LUT?
Maurice K. Chung RPh, MD, FACOG, FPMRS, FACS, ACGE

Endometriosis is one of the more prevalent gynecologic diagnoses among women with CPP, affecting more than half of those patients who receive a diagnosis for their CPP.1,2,5,6,9–11 Symptoms include dyspareunia, cyclic perimenstrual low abdominal pelvic pain, symptom flares after sexual intimacy, and irritative Lower Urinary Tract (LUT) voiding symptoms. In the case of urinary tract involvement.12 A definitive diagnosis of endometriosis requires visual confirmation of the lesion during laparoscopy, and histologic confirmation of the presence of both ectopic endometrial glands and stroma.(12) Interstitial cystitis, or pelvic pain of bladder origin(PBS), isanother disorder that may be associated with CPP.8 The cause of IC is unclear, but it is thought to be multifactorialand progressive, involving bladder epithelial dysfunction,mast cell activation, and bladder sensory nerve upregulation(Figure 1) .13–15 Estimates of the prevalence of IC in the United States range from 10 to 510/100 000 cases.16,17Recent evidence suggests that this condition may, in fact,be much more prevalent than current estimates.14,18The symptoms of IC include urinary urgency/frequencyand/or pelvic pain in the absence of urinary tract infection. Patients may also report dyspareunia and/or cyclicpain in association with the menses.14.19. It can be treated by diet changes and medications. In reality, symptoms existed in both diseases are very similar. Diagnosis of PBS is made through Clinical evaluation and currently, plenty of data are available. Improvement of symptoms relies on diet therapy and medication including physical therapy. Surgical treatment for endometriosis by far is suboptimal and Urinary tract endometriosis is not common. It is therefore very important to treat the two disease simultaneously, and to treat Pelvic pain patients with diet changes and medication first, in the group of patients with LUT, before extensive surgical treatment.


Particularities of Laparoscopic Interventions During Pregnancy
Marius Lucian Craina1,2
1 Department XII – Obstetrics and Gynecology, Neonatology and Perinatal Care,
University of Medicine and Pharmacy “Victor Babeș” Timișoara, Romania
2″Bega” University Clinic of Obstetrics and Gynecology, Timișoara, Romania

Objectives
To critically evaluate the current body of literature regarding the increasingly more common laparoscopic surgeries in pregnant women and draw precise conclusions on their safety and complication rates.

Methods
We analyzed various meta-analyses, articles and clinical studies that assess the contribution of laparoscopic management of surgical cases during pregnancy. In addition, we are presenting a retrospective study on the 7500 interventions conducted in the Laparoscopic Surgery Department of “Bega” University Clinic. Results: 53 laparoscopic surgeries have been performed on pregnant women: 46 cases (86,79%) in the first trimester and 7 cases (13,21%) in the second trimester. Mean age was 28 years. Indications were largely dominated by ovarian cysts – 52 cases, followed by pelvic adhesions – 13, adnexal torsion – 2, and simultaneously extrauterine pregnancy – 1. Transvaginal ultrasound correctly provided the preoperative diagnosis, identified the corpus luteum and assessed the first-trimester pregnancy. Notable particularities: absence of the uterine manipulator, need for corpus luteum conservation and custom anesthesia. Performed laparoscopic surgeries were: cystectomy, partial resection of the ovary, salpingectomy and adhesiolysis. There were no intra- or postoperative complications. Median duration of hospitalization was 72 hours. Conclusions: Laparoscopic surgery for adnexal masses may be safely performed during the first and second trimester of pregnancy, providing satisfactory maternal-fetal outcome. Possible inconveniences may include: injury of the gravid uterus, difficult manipulation caused by its growing mass, decreased uterine blood flow or the risk of carbon dioxide absorption. The surgeon must be a highly skilled expert in advanced laparoscopic procedures.

Keywords
laparoscopy, surgery, pregnancy, adnexal mass


The Surgical Treatment of Ureteral Endometrosis: A Review of the Literature and Our Experience
Claudio P. Crispi Jr MD; Claudio P. Crispi MD; Dirceu Crispi Filho MD; Thiers S. Raymundo MD; Thiago P.Dantas MD.

Abstract
Endometriosis is a multifactorial disease with unclear pathogenesis. Urinary tract endometriosis occurs in about 1% of all endometriotic lesions while isolated ureteral endometriosis (UE) is extremely rare.1

The UE most commonly affects a single distal segment of the ureter, with a left predisposition in most of the patients. Two major pathological types of UE may be distinguished: intrinsic and extrinsic. The symptoms are usually nonspecific and owing to secondary obstruction. The diagnosis starts from physical examination to highly detailed imaging methods. Nowadays, the treatment is usually chosen according to the type of UE, the site lesion and the distance to the ureteral orifice.2

The surgical management of deeply infiltrating endometriosis involving the ureter is a complex procedure that requires an accurate balance between the need for complete excision of endometriotic foci and the need to avoid any morbidity associated with radical surgery.3

Ureterolysis could be used as the initial surgical step for patients with ureteral endometriosis. For patients displaying extended severe ureteral involvement, stenosis, or moderate or severe hydronephrosis with a high risk of having intrinsic ureteral disease, ureteroneocystostomy is likely to be a wiser surgical strategy. 3
This presentation aims to review the literature on this complex topic and discuss our experience with these cases.

References
1 – Papakonstantinou E1, Orfanos F, Mariolis-Sapsakos T, Vlahodimitropoulos D, Kondi-Pafiti A. A rare case of intrinsic ureteral endometriosis causing hydronephrosis in a 40-year-old woman. A case report and literature review. Clin Exp Obstet Gynecol. 2012;39(2):265-8.
2 – Maccagnano C 1 , Pellucchi F , Rocchini L , M Ghezzi , Scattoni V , Montorsi F, et al. Ureteral endometriosis: proposal for a diagnostic and therapeutic algorithm with a reviewof the literature. Urol Int. 2013;91(1):1-9. doi: 10.1159/000345140.
3 – Camanni M, Delpiano EM, Bonino L, Deltetto F. Laparoscopic conservative management of ureteral endometriosis. Curr Opin Obstet Gynecol. 2010 Aug;22(4):309-14.


Inguinal Hernia – Tap Versus Tep Approach
Bogdan Diaconescu, Bogdan Martian, Mircea Beuran
Emergency Clinical Hospital Bucharest
“Carol Davila” University of Medicine and Pharmacy

Hernia repair is one of the most common operations in general surgery worlwide. An estimated total of 15 million working days are lost due to hernia in the United States each year (Memon 1998). Up to now, the trial didn’t report that were important differences between TAP and TEP regarding the length of stay, time to return to usual activity, duration of operation, haematoma or in recurrence of a hernia. It was reported a small increase of the number of hernias developing in port sites and injuries to internal organs were apparent with TAP. TEP is also associated with longer operating times and higher conversion rates. Mesh infections and vascular injuries were rare and there was no obvious difference between the two techniques.

Some meta-analysis comparing TEP with TAP found no significant difference in recurrence rates but did find that TAP was associated with a higher risk of intra-abdominal injury.
Compared with open hernia reapair, TEP and TAP aproach improved clinical outcomes. On the other hand the anatomy in TEP is more complex and is not so familiar. The intraoperative complications, postoperative complications, and cost were similar in both groups. In terms of results, both repair techniques seemed equally effective, but TEP had an edge over TAP.


Uterosacral Vaginal Vault Suspension
Jessica B. Feranec, MD

Pelvic organ prolapse repair may be approached in a variety of ways: transvaginally, laparoscopically, robotically and laparotomically with native tissue, biologic augmentation and permanent mesh. However, surgeon and patient awareness of complications from mesh materials have created a desire to return to more physiologic and native tissue repairs. Uterosacral ligament suspension provides an anatomic repair with good success rates and minimal permanent materials. We will discuss both vaginal and laparoscopic routes with an emphasis on the latter.


Minilaparoscopy Surgery for the Every Day Surgery Pros and Cons
Roberto Gallardo MD
Staff Surgeon at Sanatorio Nuestra Señora del Pilar
Guatemala City, Guatemala C.A.

ABSRACT
In the Minimal Invasive Surgery Era, does Mini Laparoscopy Surgery give the same results in every day surgery that Conventional Laparoscopic Surgery provides???

With this presentation we will try to demonstrate that Mini Laparoscopic is as good as conventional laparoscopy for every day surgery that we have done since the beginning of the laparoscopic surgical era.

This presentation is made to show how Mini Laparoscopic Instruments of 2.8 mm to 3.5 mm wide, can perform easily many procedures that are part of the everyday surgery for all laparoscopic surgeons, with the benefits of performing these surgeries showing how a Mini laparoscopic Surgery could be done with intra corporeal nuts and a very clean technique of dissections with the 2.8 mm instruments; it also shows images and small videos of Mini Laparoscopic Cholecistectomies, Appendectomies, Inguinal Hernia Procedures and Diagnostic Mini Laparoscopys that are done only using these instruments, as well as some images of video diagnostic procedures for endometriosis and possible other minor gynecological procedures. It shows a list of Pros and Cons of the procedures compare to other ways of doing it.

We conclude that Mini Laparoscopic Surgery is secure, effective, and accurate and is proving the same and some times even better results of Conventional Laparoscopic Surgery for the final outcome of the patients.


A Comparison Single Port Surgery vs. Minilaparoscopic Surgery
Roberto A. Gallardo, MD

This will give us a complete definition of what we call Mini Laparoscopic Surgery including the definitions and how it started and what is been going on with it around the glove.

We also we will see the big differences between standard or conventional laparoscopic surgery and Mini or Micro Laparoscopic Surgery that will give a very clear idea why should we try to move on. We will see and analyzed the outcome of Single Port Surgery with a quick view of the important data published.

We will see and learn which are the benefits and details of Mini Laparoscopic Surgery technics with pros and cons when we compared it with Single Port Surgery Technics. We will be looking at some evidence is been written and also will analyzed which technic is has better out comes regarding the ergonomic, triangulations, dexterity, and the aesthetics results; and also and more important we will give reasons on why we should look into the Mini or Micro Laparoscopic era as the next step following Standard or Conventional Laparoscopic Surgery. We will provide enough data and information in order to have any laparoscopic surgeon to be able to make his own conclusions and with enough knowledge to take a decision on which way to go at the end of the day.

Finally there will be a brief discussion on what should be the skills and the characteristics of the surgeons in order to perform this kind of Laparoscopic Surgeries, and what are the ways and the means that should be used to be trained to practice it and the skills to look for in the surgeons who want to make this kind of procedures.


10 Years of Eras in Laparoscopic Colorectal Surgery (Up to 1000
Laparoscopic Procedures)

Authors: Gianluca Garulli, Andrea Lucchi, Pierluigi Berti, Carlo
Gabbianelli, Luca Maria Siani, Franco Vandi, Giuseppe Corbucci Vitolo
Dept. of General and Advanced Laparoscopic Surgery, Ceccarini Hospital, Riccione, Area Vasta Romagna, Italy

Background
Enhanced recovery after surgery (ERAS) colorectal program has been widely adopted in many international centers. It has shown to be successful reducing length of stay, improving perioperative care and decreasing postoperative complications.

Materials and Methods
From 2005 to 2014 we have performed 1647 laparoscopic colon-rectum resections (795 left colectomy, 717 right colectomy, 135 rectum resection). We adopted a fast-track protocol using ERAS guidelines. We analyzed several parameters: percentage of laparoscopic procedures /laparotomy, length of stay, complications according to Clavien-Dindo classification, percentage of readmission.

Results
From 2005 to 2014, the use of laparoscopy increased from 57.4%to 88.8%. Length of stay decreased significantly (6.37 days vs 3.1 days), without an increase in 30-day readmission rate (….). In 2014, 84% of patients are discharged after 2 days. The percentage of complication according to Dindo-Clavien for class 1-2 was 1.8% and for class 2-3 was 2.09% while the overall morbidity was 2.4% and the overall mortality was 1.1%. We had a decrease in wound infections from 0.58% at 0.29%

Conclusions
A two-day hospital stay after laparoscopic colorectal surgery is safe and feasible under an ERAS pathway, without compromising the readmission or complication rate.


10 Years of Eras in Laparoscopic Colorectal Surgery (Up to 1000
Laparoscopic Procedures)
Authors: Gianluca Garulli, Andrea Lucchi, Pierluigi Berti, Carlo
Gabbianelli, Luca Maria Siani, Franco Vandi, Giuseppe Corbucci Vitolo
Dept. of General and Advanced Laparoscopic Surgery, Ceccarini Hospital, Riccione, Area Vasta Romagna, Italy

Background
Enhanced recovery after surgery (ERAS) colorectal program has been widely adopted in many international centers. It has shown to be successful reducing length of stay, improving perioperative care and decreasing postoperative complications.

Materials and Methods
From 2005 to 2014 we have performed 1647 laparoscopic colon-rectum resections (795 left colectomy, 717 right colectomy, 135 rectum resection). We adopted a fast-track protocol using ERAS guidelines. We analyzed several parameters: percentage of laparoscopic procedures /laparotomy, length of stay, complications according to Clavien-Dindo classification, percentage of readmission.

Results
From 2005 to 2014, the use of laparoscopy increased from 57.4%to 88.8%. Length of stay decreased significantly (6.37 days vs 3.1 days), without an increase in 30-day readmission rate (….). In 2014, 84% of patients are discharged after 2 days. The percentage of complication according to Dindo-Clavien for class 1-2 was 1.8% and for class 2-3 was 2.09% while the overall morbidity was 2.4% and the overall mortality was 1.1%. We had a decrease in wound infections from 0.58% at 0.29%

Conclusions
A two-day hospital stay after laparoscopic colorectal surgery is safe and feasible under an ERAS pathway, without compromising the readmission or complication rate.


Experience of the Main Public Center of Bariatric Surgery in Mexico
Francisco Campos, MD, Juan Gonzalez-Machuca, MD, Itzel Fernandez, MD, Diana- Gabriela Maldonado, MD, Luis Zurita, MD, Ary Zarate, MD, MD, Raul Marin, MD.

Mexico is the second country in the world with obesity, and as a public problem of health, the government is trying to decrease the risk of morbi-mortality with different programs, including bariatric surgery.

Bariatric and metabolic Surgery have demonstrated a several benefits that include weight loss, reduction of morbi-mortality, control of associated diseases like DM, hypertension, dyslipidemia, and others.

Dr Francisco Campos is the director of the program and established the Clinic in a public Hospital with the purpose of providing the benefits of bariatric and metabolic surgery for Mexican people without a social security program and lower incomes. Besides the Clinic, a University program was startedfor a Fellowship in Bariatric Surgery with the Universidad Nacional Autonoma de Mexico (UNAM) and Secretaria de Salud del DF with the participation of Dr Armando Ahued (Ministry of Health of Federal District at Mexico City)
Currently over 1000 surgeries have been performed including (the placement of intragastric balloon,) sleeve gastrectomy, SILS sleeve gastrectomy, R-Y gastric bypass, minigastric bypass and Redo; with similar results to those published in the literatura. We present the experience of the Clinic (CLIO)


A Six-year Experience in Robot-assisted Radical Hysterectomy and Open Surgery in the Treatment of Cervical Cancer: Comparative Analysis
Grigor Gorchev, Slavcho Tomov, Latchesar Tantchev
PRESENTED BY: Todor Ivanov Dimitrov, MD
Department of Minimally Invasive Gynecological Surgery, Gynecological Oncology Clinic, Medical University- Pleven, Bulgaria

Objective
To compare the perioperative outcomes of patients with early cancer of the cervix, operated with two operating methods – robot-assisted radical hysterectomy (RARH) and abdominal radical hysterectomy (ARH).

Material and Methods
Over a period of six years (May 2008 – May 2014) in the Department of Minimally Invasive Gynecological Surgery of the Gynecological Clinic of Medical University – Pleven, Bulgaria, were operated 274 patients with carcinoma of the cervix in stage IB1. On 118 (43.06%) of them was performed a RARH and on 156 (56.93%) of them – ARH.

Results
The average operative time of the robotic group was 168±28 min and for the laparotomy group – 170±32 min (p = 0.059). The average hospital stay for patients operated with RARH (4.0±0.8 days) was significantly shorter than that of the patients operated with ARH (9.8±1.1 days) (p = 0.001). A statistically significant difference in the proportion of complications in the two groups of patients was not established (p > 0.05).

Conclusion
RARH is a safe procedure with proven advantages with regard to the operative time and hospital stay of patients with early cervical cancer.


Turkish Experience of Robotic Surgery for Gynecologic Cancers
Mete Gungor, Prof Dr Med
Acibadem University, Department of Obstetrics and Gynecology, Istanbul, Turkey

Introduction
To evaluate the feasibility of integrating robot-assisted technology in the performance of laparoscopic staging of gynecologic malignancies in Turkey
Material and methods: Since 2007, 11 gynecologic cancer centers have robotic technology in Turkey. In those centers, robotic surgery is being used for procedures ranging from hysterectomy with nodal dissection for endometrial cancer to radical hysterectomy for cervical cancer and resection of localized tumor recurrence and complex ovarian masses as a minimally invasive surgical approach.

Conclusion
Robotic surgery for gynecologic cancer appears to be feasible, with acceptable perioperative complication rate, fast recovery time and high patient satisfaction.


Laparoscopic Management of Post-Operative Bleeding in Gynaecology
H F Habeeb M.B, B.ch FRCOG

Objective
To evaluate the role of minimally invasive surgery in the management of post-operative bleeding after hysterectomy.

Methods
A retrospective study of a 7-year period was carried out on 2150 women who underwent hysterectomy using various routes. Twelve women with post-operative bleeding were identified.

Results
The overall incidence of bleeding after hysterectomy in our unit was 0.5% (12 of 2150). The hysterectomy route was abdominal (3 cases), vaginal (6 cases) and laparoscopic (3 cases). The post-operative bleeding was diagnosed clinically from the usual symptoms and signs of hypovolaemia with laboratory confirmation of significant drop in their haemoglobin. Laparoscopic management of the post-operative bleeding was used for those who bled post laparoscopic/ vaginal hysterectomies (9 cases) while those who bled after abdominal hysterectomy underwent laparotomy (3 cases). During the laparoscopic approach, bipolar diathermy was used to control the bleeding points. Generous suction irrigation as well as drainage was also used. All patients received the relevant blood products to replace their blood loss. All patients made a good recovery.

Conclusion
The laparoscopic approach to bleeding after laparoscopic/vaginal hysterectomy is an effective and safe approach with non-significant prolongation in the recovery time.


Surgical Management of Ovarian Endometrioma
Kelmy Jurado, MD, Guillermo Campuzano, MD . Division of Laparoscopic Surgery, Enrique C. Sotomayor Gynecological and Obstetric Hospital, Guayaquil, Ecuador

Ovarian cyst line with endometrioid mucosa (endometriomas) is one of the distinct forms which endometriosis appears in women. The primary indications of ovarian endometrioma surgery treatment are pelvic pain, dyspareunia, and that it could diminish the effectiveness of fertility treatment.

Current laparoscopy is considered an active and proven treatment option due to good tolerance, low morbidity and low total cost, however, the surgical treatment of ovarian endometriomas of less than 3 cm is controversial in women who have the intention of becoming pregnant.

Multiple studies have explored the effect of different surgery techniques in ovarian integrity by evaluating ovarian function. As ovarian reserve cannot be directly measured, the most common approach uses surrogate serum markers such as AMH and follicle stimulating hormone (FSH), sonographic markers as antral follicle count (AFC) and ovarian volume, or clinical markers including response to gonadotropin stimulation during ovulation induction or IVF.

Several alternative laparoscopic techniques have been described for the treatment of ovarian endometrioma. There are cyst wall laser vaporization, drainage and coagulation and stripping.

The correct surgical procedure and quality of treatment is critical to reducing the damage of the residual ovarian tissue and achieving a successful outcome.

Here we review the alternative options of surgical treatment for ovarian endometrioma and identify strategies to avoid ovarian damage.


Long Term Results of Laparoscopic Surgery for Ulcerative Colitis
Lázár György1 DSc, Tajti János jr.1 MD, Simonka Zsolt1 MD, Paszt Attila1 PhD, Ábrahám Szabolcs1 PhD, Molnár Tamás2 PhD,
University of Szeged, Department of Surgery1, 1st Department of Internal Medicine2, Szeged, Hungary

Introduction
For the surgical treatment of ulcerative colitis (UC), laparoscopy is used more widely. The objective of our study is to compare the 3-year follow-up results of patients treated with conventional and minimally invasive surgical methods.
Patients and methods: Between 2005 and 2013 a total of 45 patients received surgery for UC, out of which 16 (35.5%) were emergency (total colectomy with mucous fistula) and 29 (64.5%) were elective cases (proctocolectomy and ileal pouch-anal anastomosis). Laparoscopy was used in 23 (51.1%) and conventional method in 22 (48.9%) cases.

Results
During the follow-up, significantly fewer surgeries were performed in the laparoscopy group because of intestinal obstruction (p=0.005), septic condition (p=0.007) and other complications such as anastomotic stenosis, anal bleeding, and pouch-vaginal fistula (p=0.001). In regard to postoperative hernias, there was no difference between the two groups (p=0.349). There were significantly fewer urgent readmissions in the laparoscopy group (1 vs. 6, p=0.034).

A significant improvement in quality of life was measured in both groups after the surgery, but better cosmetic results were observed in patients treated with laparoscopy.
Conclusion: In UC, laparoscopy can be used for both emergency and elective cases, it provides good quality of life and the long-term rate of complications is low as compared to open surgery.


Laparoscopic Myomectomy
José Duván López Jaramillo, MD

Leiomyomas are the most common benign pelvic tumors in women. Prevalence varies between 12% and 80%. Depending on the size and location may be asymptomatic until presenting a variety of symptoms such as bleeding, pain, pressure and subfertility. When you want to preserve fertility, myomectomy is the procedure of choice. Comparing Laparoscopic myomectomy vs laparotomy, the results show advantages in the first that include shorter hospital stay, faster return to daily activities and less pain. In other variables such as reproductive outcomes and recurrence of fibroids apparently no difference between the two techniques. Surgical time is the only difference in favor of laparotomy.


Laparoscopic Surgery of Colon: A Report of 1000 Cases
Andrea Lucchi, MD

Background
The laparoscopic approach in general and specific to colon cancer has been long proven to have short term benefits and to be oncologically safe. We analyze, in the last 8 years, our series that boasts about 1,000 colorectal procedures, mostly in laparoscopy

Materials and Methods
From 2007 to 2014 we have performed 1065 surgery procedure on colon-rectum. About 706 of these interventions were performed laparoscopically: 377 left colectomy, 294 right colectomy, and 35 rectum resection. We adopted a fast-track protocol. We analyzed several parameters: percentage of laparoscopic procedures, length of stay, complications, percentage of readmission.

Results
77% of patients were discharged on the third postoperative day: in the last two years we have discharged the patients in the second postoperative day. The rate of readmission to hospital is 2%. The epidural catheter was placed in 297 cases (left hemicolectomy and rectum resection) and removed in the third post-operative day (in the last two years in the second day) with the bladder catheter.
The average hospital stay for these patients was 3 days.

The percentage of complication according to Dindo-Clavien for class 1-2 was 1.8% and for class 2-3 was 2.09% while the overall morbidity was 2.4% and the overall mortality was 1.1%.

Conclusions
In our experience, laparoscopic colon surgery resulted in a decrease of hospital stay, less postoperative pain, reduction of wound infections, same oncologic safety, and equivalent long-term outcome compared to open surgery.


WHY Do I Prefer TEP?
Flavio Malcher Oliveira, MD

The laparoscopic repair of inguinal hernia was introduced in the 90s, but only about 15 years ago, the surgical techniques have been definitively established. Today there are two techniques: The transabdominal preperitoneal (TAPP) and the Totally Extraperitonial (TEP). Both have advantages and disadvantages with each other and the TAPP is clearly the most widespread, because the traditional intrabadominal laparoscopic view. The preference for TEP in clinical practice can be defended mainly by non penetration into the abdominal cavity, less need for fixation of the prosthesis (placed in the preperitoneal space limited) and less surgical time. Training needs and especially the knowledge of the pre-peritoneal anatomy is essential.


Robotic Surgery in Mexico: A Hard Labor
Ariel Martinez-Onate, MD, FACS
Facultad Mexicana de Medicina, Universidad La Salle. Mexico City, Mexico.

Although there have been early versions of today´s surgical robots in Mexico it has been difficult to establish a true Robotic Surgery Programme in the country. There were two early attempts at starting a consolidated robotic center that faced some problems due to lack of experience and representation of the robotic companies. With the boom of robotic surgery there is now an interesting mix of state owned, private and even joint venture hospitals that have started robotic surgery programmes. This opens the possibility of applying the benefits of robotic surgery to an increasing segment of the population. The birth of robotic surgery in Mexico hasn´t been much different than in other countries around the world except for the effect of the current economic conditions of the country. It has been a hard labor for sure. This presentation tries to describe the story and numbers in the different surgical specialties that use robotic surgery in my country.


4-Stage Approach of the Gynecologist
M. Marziali*, T.Capazzolo+
*Policlinico Univeritario Tor Vergata Rome
+ Almares center of Infertility Rome

This topic explains the different points of view and approach in the patient with endometriosis between gynecologists and general surgeons where the landmark is the infertility and the pain.
The pain and the function of the organs are very important aspects of the approach from the view of the general surgeon while the approach of the gynecologist is related to fertility and at the same time to pain. Another topic is the fact that winner is the team and not a single man.


Is Endometrioma Surgery by Laparoscopy Still an Option?
Liselotte Mettler, MD, PhD
1 Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Campus Kiel, Germany lmettlere@email.uni-kiel.de

Background
The retrospective cohort study was designed to analyze pre-operative clinical and surgical findings at enucleation of ovarian endometrioma with their impact on recurrence and pregnancy rates.

Material and Methods
550 patients with histologically verified ovarian endometriomas operated endoscopically at the Department of Obstetrics and Gynecology, University Hospital Kiel, Germany were included. Pre-operative data, surgical findings and post-operative outcomes of 289 cases were evaluated.
Results: The average follow-up was 12.9 years. Ovarian endometriomas recurred in 23.9%. Risk factors identified for recurrence of endometriomas were pre-operative pain (p = 0.013), dysmenorrhea (p = 0.013), larger cyst size (> 8 cm), younger age (< 25 years) and pre-operative cyst rupture. Factors associated with post-operative dysmenorrhea were younger age < 25 years (p < 0.001), nulliparity (p = 0.020) and lager cyst size > 8 cm (p = 0.048). Recurrence of pain was influenced by previous surgery of endometrioma (p < 0.05). Laparoscopy had a higher percentage of symptom-free patients than laparotomy (49.0% vs. 33.3%). Additional post-operative hormonal treatment resulted in a higher spontaneous pregnancy rate (41.4% vs. 12.6%; p < 0.001) and a lower recurrence-free interval rate (70.5% vs. 82.6%; p = 0.050) when compared to surgery only.

Conclusions
We identified pre-operative and intra-operative findings associated with higher risk of recurrence of endometrioma, pain and dysmenorrhea. These results suggest that patients desiring pregnancy benefit from post-operative hormone treatment; however no favorable results from combined therapy were observed with regard to recurrence rate.


Current Trends in Laparoscopic Ventral Hernia Repair
Evangelos P. Misiakos, M.D.
University of Athens School of Medicine-Attikon University Hospital, Athens, Greece

Incisional hernias develop in 2-20% of laparotomy incisions. Primary open repair of ventral and incisional hernias with mesh is associated with a recurrence rate of 12-19%. However, open repair is associated with an increased incidence of wound infection, due to the need of larger incision and wide tissue dissection. The laparoscopic approach is based in the principles of the open underlay technique. In the laparoscopic repair special care should be paid during lysis of adhesions and reduction of hernia contents because of the increased risk of bowel injury. Mesh fixation is believed to be more stable if it is done with transfascial sutures and tacks together. The majority of patients develop a seroma postoperatively which is usually absorbed within 3 months. Recurrence rates in laparoscopic series seem to be similar or lower than in open repair series (around 3.5% at 2 years). Laparoscopic ventral hernia repair has yielded an excellent clinical outcome. Meticulous surgical technique and appropriate patient selection are required to obtain the best results.


Transabdominal Preperitoneal (TAPP) Approach in the Management of Obturator Hernia
Radu MOLDOVANU (1)(2), Eugen TARCOVEANU (2), Nutu VLAD (2)
(1) Department of Visceral, Digestive and Oncologic Surgery, “St. Mary” Clinic Cambrai, France
(2) Department of Surgery, University of Medicine and Pharmacy Iasi, Romania

BACKGROUND
Obturator hernia (OH) is a relatively rare disease and its diagnosis is always challenging. In asymptomatic patients the diagnosis is frequently overlooked; the laparoscopic approach for the treatment of groin hernia allows however the diagnosis and repair.

AIM
To evaluate the transabdominal pre-peritoneal (TAPP) procedure for the diagnosis and treatment of obturator hernia.

MATERIAL AND METHODS
A prospective review of 300 patients who underwent TAPP procedure for groin hernia was conducted.

RESULTS
The men / women ratio was 256 / 44. The mean age was 55.29±15.83 years old (17 to 92; median: 57). The mean BMI was 25.44±3.83 kg/sqm (16 to 36.83; median: 25). The hernia was unilateral in 69.3% (n=208) and bilateral in 30.7% (n=92). In 53.26% the contralateral hernia was occult and diagnosed during the procedure. The incidence of OH was 17% (n=51): type I, 92.15% (n=47), type II, 5.88% (n=3) and type III 1.96% (n=1). There is found that OH is associated with female gender (P=0.001; OR: 2.42, 95%CI: 1.45-4.09), bilateral groin hernia (P=0.034; OR: 1.71; 95%CI: 1.04-2.82), femoral hernia (P=0.0001; OR: 4.31; 95%CI: 2.14-8.63) and age over 60 (63.04±13.59 vs 53.70±15.82; P=0.0001). The operation time was 46.17±22.98 minutes (20 to 180; median: 45). The procedure was performed ambulatory in 58% (n=174). The overall postoperative morbidity rate was 5.3% (n=16): seroma in 4% (n=12) and hematoma in 1.3% (n=4). The recurrence rate was 1% (n=3).

CONCLUSIONS
OH is more common than previously and classically reported. TAPP procedure is an effective technique to diagnose and treat OH.


Minilaparoscopy and the Minimally Invasive Hybrid Surgical Techniques
Eduardo Moreno-Paquentin, MD

Reduced-Port Surgery (RPS) has been developed referring to different surgical techniques that are aimed either to utilize the smallest diameter instruments or the fewest trocar sites or to even not produce a skin incision at all. RPS techniques aim to offer other benefits: less postoperative pain and great cosmetic effect due to small, occult or non-existing incisions while keeping comparable safety profile to standard laparoscopic procedures. The most popular RPS techniques today are: Single Incision Laparoscopic Surgery (SILS), Single Port Surgery (SPS), Natural Orifice Translumenal Endoscopic Surgery (NOTES), Minimally Assisted Natural Orifice Surgery (MANOS), and Minilaparoscopy (Mini). Each technique has its own advantages, limitations and drawbacks. Surgeons favoring either one of these new surgical alternatives tend to faithfully defend the features of their preferred technique, wasting the opportunity to fully take advantage of the attributes that the other ones present. The possibility to combine several of these techniques, adds to the armamentarium of the minimally invasive surgeon, enhances the feasibility and dexterity of complex procedures, while preserving safety and effectiveness with an outstanding cosmetic outcome. Minilaparoscopy thanks to its unique features stands as the technique that can assist in a minimally invasive way most of the other RPS surgical alternatives. At the end of this session, minimally invasive surgeons should be able to identify the advantages, limitations and drawbacks of Reduced-Port Surgery, while feeling at ease of combining different RPS techniques with minilaparoscopy to facilitate their minimally invasive surgical procedures in a safer, more effective and cosmetic fashion.


Post-Graduation Course in Laparoscopic Surgery – Eighteen Years of Continuous Experience in Brazil
Miguel Prestes Nácul, MD

The author makes a historical presentation of the evolution of education in laparoscopic surgery in Brazil. The author also analyzes the current situation of education in laparoscopic surgery in the country, with emphasis on training of medical residents. Currently, the available educational alternatives in laparoscopy are intensive and extensive courses, post-graduation courses and medical residency programs. Most of the medical residence programs do not have any kind of experimental training activities, the staking of the problem. The authors conclude that there is great deficiency in terms of quality and quantity of education projects in laparoscopy in Brazil and propose alternatives and solutions.


LAPAROSCOPIC APPROACH IN THE TREATMENT OF COLO-RECTAL CANCER: 15 YEARS EXPERIENCE IN A SINGLE CENTRE OF GENERAL SURGERY
VINCENZO NERI, PROF. DR MED
UNIVERSITY OF FOGGIA

AIM
The laparoscopie surgical technique has mostly concerned the treatment of colo-rectal neoplasms and nowadays it has the role of a procedure widely accepted and diffused. The aim of this study is to show, in a single centre of General Surgery, the evolution from traditional open to laparoscopic approach and to evaluate the details of particular technical problems such as vascular pitfalls in the colo-rectal resections and the management of the anastomosis.

PATIENTS AND METHODS
In our Institution, our global experience (open and laparoscopic approach) on the treatment of the colo-rectal cancer (September 1999- March 2014) includes 555 patients: 204 right colectomy (RC), 196 left colectomy (I.C), 155 anterior resection of rectum (ARR) with mean age 73 year (range 44-90) , male-female ratio 2:1 (370 male, 185 female). First colo-rectal laparoscopic procedures were performed since 2000. Since 2008 we started our laparoscopic experience as first choice: we treated 90 colo-rectal neoplasms: 44 RC, 29 LC, 17 ARR; mean age 67 (range 55-80), male-female ratio 2:1 (61 male, 29 female). We studied the results of open and laparoscopic approach in the treatment of the left colo-rectal neoplasms, comparing the open procedures performed as a first choice (2003-2007) with laparoscopic procedures also performed as a first choice (2008-2014): 79 open LC (2003-2007) versus 29 laparoscopic LC (2008.2014) and 65 open ARR (2003-2007) versus 17 laparoscopic ARR (2008-2014).

RESULTS
The evolution of our experience allows us a not structured comparison between open and laparoscopic approach of left colon and rectal resections: : mean operative time (open: 150′, laparoscopic 210′), resumption of alimentation (open: 5th postoperative day, laparoscopic: 2nd postoperative day), mean hospital stay (open: 12 days, laparoscopic 7 days), anastomosis dehiscence (open: 5%, laparoscopic: 3.5%), bronchopneumonic infiltrates (open: 4.3%, laparoscopic: 2.1%), thrombotic complications (open: 2.3%, laparoscopic: 2.1%), mortatility (open: 0.7%, laparoscopic none), conversion rate 2.1%.

DISCUSSION
Laparoscopic colo-rectal surgery need the step learning curve and the goals of an oncologic resection must be pursued with this procedure. Compared with open colectomy, laparoscopic colectomy has been shown to be associated with decreased postoperative analgesia requirement, faster return of bowel function, earlier resumption of oral intake, shorter hospital stay, and better cosmesis. However, these benefits come at the cost of slightly prolonged operative time and associated expense. In anterior resection of rectum it is in evidence the technical detail of the left colonic artery and Riolano arcade which it’s important to be evaluated for blood perfusion of the anastomosis.

CONCLUSION
The use of minimally invasive approaches in the surgical management of colorectal cancer continues to gain popularity. Laparoscopy has clear advantages and can be performed in a majority of patients at surgical centers with experienced surgeons.


Irreversible Electroporation-Implications for Minimally Invasive Surgery
Gary M. Onik, MD

Irreversible electroporation (IRE) is a new tissue ablation technique in which micro to milli- second electrical pulses are delivered to undesirable tissue to produce cell necrosis through irreversible cell membrane permeabilization. IRE affects only the cell membrane and no other structure in the tissue. Electroporation affects tissue in a way that can be imaged in real time with ultrasound creating a hypoechoic lesion in liver tissue, which should facilitate real time control of electroporation during certain clinical applications. We observed cell ablation to the margin of the treated lesion with several cells thickness resolution. There appears to be complete ablation to the margin of blood vessels without compromising the functionality of the blood vessels, which suggests that IRE is a promising method for treatment of tumors near blood vessels. We show that the structure of bile ducts, blood vessels remains intact and that lesions resolve within two weeks, which is consistent with retention of vasculature. Last, we have shown that mathematical predictions with the Laplace equation can be used in treatment planning. The IRE tissue ablation technique, as characterized in this report, may become an important new tool in the surgeon armamentarium.


Tips and Tricks for Robotic Myomectomy
Mona E. Orady MD, FACOG
Director of Robotic Surgery Education
Women’s Health Institute
Cleveland Clinic

Uterine leiomyoma are the most common type of pelvic tumor in women. Myomatous uteri have an increased number of arterioles and venules which may result in significant blood loss during myomectomy procedures which can exceed 250 ml in cases of multiple or large fibroids. The robotic approach to myomectomy can extend the candidacy for a minimally invasive approach in more complex cases. This presentation will review different methods of reducing blood loss in robotic myomectomy applicable to cases with multiple or large fibroids. Utilization of a uterine artery tourniquet or vascular clamps will be demonstrated. Tips for hemostatic myoma dissection and multilayer closure of uterine artery defect will also be addressed.


The Surgical Check List Help or Hindrance? Are We Missing Something?
Nicholas Pairaudeau, MD
Assistant Professor University of Toronto, Ontario, Canada

The surgical check list came about after many years of trying to promote safe surgery. With the paper by Dr. Hayes et al in the NEJM in 2009, piloting the surgical check list in 4 Canadian Hospitals and 4 American Hospitals, the conclusion was the surgical check list reduced death rates from 1.5% to 0.8%, and reduced complications in inpatients from 11% to 7% over 16 years of age. This resulted in the WHO surgical list being implemented in different ways throughout the world.

From the initial implementation, there were many surgeons, who thought that the surgical check list was cumbersome, and wasted time. Many still to this day feel that the surgical check list is dead. A recent paper from Toronto, NEJM 2014 Dr. David Urbach, attempted to show that over a 3 month period before the surgical check list, and then in 2010 another 3 month period, that there was no improvement in either mortality, or complications in 133 hospitals in Ontario Canada.

I believe that the Surgical check list, far from being dead, is actually a major, and in some respects, revolutionary change in the culture of safety, reduction in complications, team work, efficiency and reassurance to patients having an operation in 2015. Despite the never ending concerns to cameras, and audio in the operating room, citing medico legal issues and confidentiality, in an era of face book, streaming live operating room pictures to the world, these concerns are manageable in the quest for improvements in the operating room.


Emergency Laparoscopic Surgery – Acute Appendicitis – Severe Destructive Forms with Peritonitis
Dalibor Panuska MD, Hospital Zvolen, Department Surgery

There are still some controversies about the role of laparoscopic appendectomy /LA/ in severe destructive forms of appendicitis with peritonitis. There exist a lot of studies on this topic – prospective, randomized, retrospective etc. Despite this there are not clear recommendations. However, some surgical societies present guidelines for these cases.

So this presentation is not only about own experience from our previous study /2008-2010 – presented at Euro-American summit in Orlando 2011 / and recent study /1.1.2012-31.10.2014/. We also present a short reflection about some mentioned EBM, prospective, randomized, retrospective etc. studies that conclusions are not quite uniform.

It is obvious that LA in these advanced destructive forms of appendicitis is at least as feasible and safe as open appendectomy/OA/. In some circumstances comparatively even as cost effective as OA. The same opinion is from our previous and recent study.

Remark
The best method is you can master the best!


Laparoscopic Approach to Benign Ovarian Teratomas
Juan Carlos Ramírez, MD

Dermoid cysts, also known as teratomas, constitute about 10 to 15% of all ovarian tumors. They may become bilateral in nearly 15% of cases and their origin is interesting and unknown. Although many hypotheses regarding their development have been raised, especially related to cell embryonic origin, a definitive theory regarding the etiology is still unresolved. The diagnosis is made easily via pelvic ultrasonography, which often shows very typical features that are unique to dermoid cysts. Identification is important because association with malignancy may be up to 2%. Treatment should ideally be undertaken via a laparoscopic approach, with careful extraction of the cyst itself in younger women with the intent of preserving healthy ovarian tissue for future fertility, although possibility of injury to the surrounding ovarian tissue is still possible. Otherwise oophorectomy may be indicated indicated. In order to reduce peritoneal irritation from spillage of cyst contents as well as the possibility of local implants, the use of Endobags are recommended in addition to copious irrigation of the peritoneal cavity with at least 2000 mL of saline is strongly recommended. Most mature teratomas under 9 cm can thus usually be treated via the laparoscopically taking into account special recommendations and guidelines.


Presentation Title:
Robotic Surgery in Brazil: Cost, Learning, and Future of Robotic Surgery
*Mauricio Rubinstein, M.D.
*Chief of Minimally Invasive Department of Urology – Federal University of the State of Rio de Janeiro, Brazil
*Staff at Samaritano Hospital – Rio de Janeiro, Brazil

Objective: The diagnosis of prostate cancer has been increasing in recent years through public awareness campaigns and the advent of more accurate diagnostic tests. A Robot Assisted Radical Prostatectomy (PRRA) is gaining momentum in Urological scenario in recent years. The presentation shows the steps of the programs developed at Brazil and some issues as costs and learning process about robotic surgery.

Materials and Methods
We will discuss issues as costs and learning process about robotic surgery. Papers addressing the experience in robotic surgery will be evaluated.

Conclusion
Robot surgeries have been gaining prestige in the urological community at Brazil and all South America. With the refinement of minimally invasive technique achieved in recent years the procedure is performed with extreme safety and functional and oncological results encouraging. It requires training of the entire operating room team. The learning curve is steep, involving port placement, availability of the proper instrumentation, use of the correct robotic arms, and proper patient positioning. Defined credentialing for surgeons and cost analysis studies are needed.


Risks and Benefits of the Ultra Low Laparoscopic Rectal Resection
Author: Sakra Lukas, MD, PhD
Co-authors: Flasar J., MD, Siller J. MD, PhD
Surgical Department of the General Hospital Pardubice, Czech Republic

Introduction
With the improvement of rectal resection techniques a whole range of new approaches and procedures which allow to provide continent resection in the cases of very low rectal tumors were introduced.

Objective
The aim of our study was to address and describe these procedures and to compare their functional results.

Methods
The following procedures are performed in the case of the rectal tumor located within 8 cm from the anal verge:
• Transanal minimally invasive surgery (TAMIS) for stage Tis or T1
• Conventional rectal resection
• Intersphinteric resection ISR: total, subtotal, partial
• Combination of TAMIS and ISR
(2-4 can be provided by the laparoscopic or open approach and coloanal anastomosis is performed).

Results
Due to unsatisfactory functional results of conventional ISR we introduced the special technique for resection of lower rectal cancers based on the simultaneous use of TAMIS and IS. The study describes this special method, its tricky points and functional results. The continence acoording to Kirwan classification was monitored.

Video from this procedure will be presented.

Conclusion
The study proves the feasibility and suitability using the TAMIS method for more precise ISR. The combination and simultaneous use of TAMIS and ISR is a less time consuming method, allows more precise location of the right plain of muscles resection and achieves better functional results than conventional ISR. The method requires better equipment and a higher number of surgeons performing this simultaneous procedure.

Key words
laparoscopy – Intersphinteric resection- TAMIS- coloanal anastomosis


Recto-Vaginal Setpum Endometriosis: Diagnostic Approach
Juan Salgado, MD, Universidad Central del Caribe School of Medicine

The rectovaginal septum is a controversial structure, considered by some authors as
a potential space. It is a layer of fibroconnective tissue and muscle fibers between the vagina and the rectum.

This area could be affected by different conditions and endometriosis is one of the most difficult to diagnose and treat. Many gynecologists consider the surgery of the rectovaginal septum affected with endometriosis a greater challenge than even pelvic oncology cases.

The origin of endometriosis that affects the rectovaginal septum has been in debate for many years with theories from the Sampson theory to the HOXA genes. Even though the diagnosis of endometriosis is by laparoscopy and tissue diagnosis, there are different non-invasive modalities for the diagnosis of Deep Infiltrating Endometriosis (DIE) available that can help the surgeon to predict not only laparoscopic findings but the complexity of the surgery. Multiple studies with robust results utilizing modalities such as CT scan, MRI, endorectal sonography and endovaginal sonography have revealed that the diagnosis of DIE can be reliably made. The advantage of the presurgical evaluation and diagnosis is that it allows the patient to undergo a single definitive procedure.


The Fundamentals of Robotic Surgery Curriculum – an Update
Richard M. Satava, MD

The Fundamentals of Robotic Surgery (FRS) Curriculum is an open-source, free curriculum for training basic skills in robotic surgery. It was developed by consensus of 87 participants in clinical, medical education, behavioral psychologists and psychometricians and official representatives of 14 surgical specialties. It is a full life-cycle development curriculum and includes didactic cognitive knowledge, psychomotor skills and team training. The curriculum is the first completely proficiency-based skills course with the entire course tied to objective measures (to benchmark scores set by “experts”). Preliminary data on the FRS Validation Trial will be presented as well.


Robotic vascular surgery, 310 cases.
Petr Štádler
Department of Vascular and Robotic Surgery, Na Homolce Hospital, Prague, Czech Republic

Objectives
The feasibility of laparoscopic aortic surgery has been adequately demonstrated. Our clinical experience with robot-assisted aortoiliac reconstruction for occlusive diseases, aneurysms, endoleak II treatment, robotic median arcuate ligament release and hybrid procedures performed using the robotic system is herein described.

Methods
Between November 2005 and May 2014, we performed 310 robot-assisted vascular procedures. 224 patients were prospectively evaluated for occlusive diseases, 61 patients for abdominal aortic aneurysm, four for a common iliac artery aneurysm, four for a splenic artery aneurysm, one for a internal mammary artery aneurysm five for hybrid procedures, two for median arcuate ligament release and nine for endoleak II treatment post EVAR.

The robotic system was applied to construct the vascular anastomosis, for the thromboendarterectomy, for the aorto-iliac reconstruction with a closure patch, for dissection of the splenic artery, and for the posterior peritoneal suture.

Results
299 cases (96,5%) were successfully completed robotically, one patient’s surgery (0,3%) was discontinued during laparoscopy due to heavy aortic calcification. In ten patients (3,2%) conversion was necessary. The thirty-day mortality rate was 0,3%, and early non-lethal postoperative complications were observed in six patients (1,9%).

Conclusions
Our experience with robot-assisted laparoscopic surgery has demonstrated the feasibility of this technique for occlusive diseases, aneurysms, endoleak II treatment post EVAR, for median arcuate ligament release and hybrid procedures. The robotic system facilitated the creation of the aortic anastomosis, and shortened the aortic clamping time as compared to purely laparoscopic techniques.


Surgical Management of Abdominal Cystic Lymphangioma
Eugen TARCOVEANU (1), Radu MOLDOVANU (1) (2), Nutu VLAD (1)
(1) Department of Surgery, University of Medicine Iasi, Romania
(2) Department of Visceral, Digestive and Oncologic Surgery, “St. Mary” Clinic, Cambrai, France

BACKGRAOUND
Cystic lymphangioma (CL) is a benign rare malformation of lymphatic vessels; in adults it is commonly founded in mesenteric or retroperitoneal areas.
AIM: This study presents the epidemiological, diagnostic difficulties, and therapeutic principles of intra-abdominal cystic lymphangioma in adults.

METHODS
We performed a retrospective study from 2000 until present days; 9 patients who underwent laparoscopic surgical removal were included in the study. The localization, size, and number of cysts have been reported, as well as the surgical intervention used and the postoperative immediate and late complications.

RESULTS
The median age was 45 years old. Abdominal pain was the main symptom and was found in 75%. Physical examination revealed an abdominal mass in about 60%. In three patients, the cystic lymphangioma was incidental. In one case the CL mimicking malignancy. Abdominal CT scan revealed the diagnosis in about 80%. In 2 cases the diagnosis was done postoperatively to pathological exam. The postoperative course was uneventful in all cases.

CONCLUSIONS
The diagnosis of CL is facilitated by modern imaging; however, other diagnoses may be discussed. Complete laparoscopic surgical excision, is the best therapeutic option.


Serious Games as Training Tools in Laparoscopic Surgery
C. Tiu, L.F. Sánchez-Peralta, J.B. Pagador, J.A. Sánchez-Margallo, J.C. Gómez-Blanco, E. Fenyöházi, W. Korb, N. Skarmeas, J. Sándor, G. Wéber, I. Oropesa, E. J. Gómez, G. A. Negoita, F. M. Sánchez-Margallo

Keywords
Minimally invasive training, e-learning, serious gaming, psychomotor skills

The KTS project is proposing to design and validate a serious game dedicated to medical students and surgeons with the purpose of training basic key psychomotor skills in minimally invasive surgery. The main physical skills to be developed are coordination, dexterity, manipulation and speed. The development of those skills is measured in terms of speed, distance, precision, procedures or techniques in execution. The project proposes a game with various levels of difficulty and with different types of surgical tasks that can be practiced and mastered throughout the game. The game will offer the user new levels to be unlocked as one skill is mastered, achievements, and a user friendly graphical design, as well as advices and suggestions from experts.

The user will be able to use mock-up instruments such as laparoscopic grasper, dissector, scissors or needle holder. A camera will be mounted in a training box and computer vision techniques will be used in order to track the laparoscopic instruments, which will be virtually simulated in the computer. The tracking system employs a monoscopic image provided by the camera, to calculate the 3D position and orientation of the surgical tools in the box.

The game will have a background story for the player to be attached to, and will have a long term-goal broken down into separate short-term challenges. The game requires the player to act quickly in certain situations and the difficulty of the game will increase over the course of the long-term goal.


The Impact of Robot-Assisted Surgery on the Treatment of Endometrial Cancer
Slavcho Tomov, Grigor Gorchev
Department of Minimally Invasive Gynecological Surgery, Gynecological Oncology Clinic, Medical University – Pleven, Bulgaria

Based on the literature data and their own experience the authors set as a goal to analyze the current state of robotic surgery in the treatment of endometrial carcinoma and to define the main challenges and trends for its future development.

Nowadays the endometrial carcinoma is one of the most common indications for robotic surgery in gynecologic oncology. Comparative analysis of the perioperative outcome of patients shows that the robotic hysterectomy and robot-assisted staging for endometrial cancer are feasible and safe. The two-year disease-free survival is comparable to that of patients with open surgery. Still, however, there is no published data on long-term oncologic outcome. The technical advantages of the robotic systems give opportunities for reducing the risks in operations of obese and elderly patients. Robot-assisted lymph node yield is comparable to laparoscopy and to laparotomy. Robotic surgical staging helps us to select patients to whom adjuvant therapies can be applied, including novel targeted agents.

In conclusion robotics may overcome some of the challenges with laparoscopy and open surgery. It can give the chance to more women with gynecological oncologic diseases to benefit from the minimally invasive surgery.


Laparoscopic Hepatobiliary Surgery in the Middle of a World Economic Crisis: Does it Make Sense?
Georgios Tsoulfas MD, PhD, FACS
Aristoteleion University of Thessaloniki, Greece

The clinical application of laparoscopic surgery has grown rapidly over the last several years, as a less invasive method that is capable of achieving results similar to those of open surgery in a more patient-friendly manner.

The goal of this presentation is to examine the place of laparoscopic hepatobiliary surgery in today’s health care environment in the middle of a global financial crisis. The significance, cost and value of laparoscopic hepatobiliary procedures will be discussed. Additionally, there will be a comparison between the cost of open vs. laparoscopic hepatobiliary procedures.

Overall, the aim is to examine whether we can achieve a balance between providing up-to-date medical care and doing that in a fiscally conscious manner.


Surgical Education in Europe and the US: Compare and Contrast
Georgios Tsoulfas, MD, PhD, FICS, FACS
Assistant Professor of Surgery, Aristotle University of Thessaloniki, Greece

This presentation will explore differences and similarities between the surgical education systems in Europe and the US, looking at the different levels including medical school, residency and fellowship, as well as research and opportunities for professional placement and advancement. Additionally, this will be examined in the context of an ever-changing environment, given the changing patterns of disease, socio-demographic transition, emerging technologies, changing expectations of consumers, a global financial crisis and a world that is more interconnected on a daily basis. The goal is to identify the common themes and, more importantly, those lessons that can be learnt from each system. When this is achieved then there is the potential for cooperation which will be in the interest of our patients.


Laparoscopic Treatment of Acute Small Bowel Obstruction
Selman Uranues, MD, FACS

Symptoms of obstruction in the intestinal tract involve the small intestine in three quarters of cases and the large intestine in one-quarter. The most common causes of an acute small intestinal obstruction are postoperative adhesions (64.8%) and strangulated hernias (14.8%). The overall incidence of postoperative small bowel obstruction is 4.6%. Because it offers a minimally invasive and targeted means of removing the obstruction, laparoscopy is increasingly used for acute small bowel obstruction. With proper selection of patients, the success rate is high. This work presents the selection criteria, technique and results.

In conclusion, with strict selection, laparoscopic treatment of small intestinal obstruction is a valuable option in visceral acute surgery. Patients with an isolated focal obstruction seem to benefit from laparoscopic surgery on the basis of reduced perioperative morbidity and short hospitalization.


Needlescopic Cholecystectomy
Uranues S., Tomasch G., Popa D.E.

According to the basic idea of minimally invasive surgery, reduction of surgical trauma, the caliber of instruments in needlescopic surgery is reduced to a few millimeters. The reduction in caliber can reduce power transmission to the instruments and impair view and light of the optic, which can cause limitations in its application. This study aimed to analyze the technique and results of needlescopic laparoscopy using the example of cholecystectomy.

Methods
Retrospectively 124 patients underwent needlescopic cholecystectomy were analysed. The trocar sites were always the same as for conventional laparoscopic cholecystectomy, a 10mm trocar is introduced transumbilical for the camera and later for specimen retrieval and a total of three 2mm trocars were used on the epigastrium and the right subcostal space. Intraoperative cholangiography was routine.

Results
All procedures were completed laparoscopically. Three cases (2,4 %) required conversion to conventional laparoscopy. In 11 cases (9%), intraoperative cholangiography could not be performed. In 6 patients (5%), there were intraoperative complications such as opening of the gallbladder. Common bile duct injury never injured and there were no re-operations. There was significantly less need for analgesics in the first 3 days than with conventional laparoscopic cholecystectomy. Patient satisfaction was scored as 10 (very good) on a scale from 1-10 by 117 patients (94%).

Conclusions
In contrast to NOTES and single port surgery, minilaparoscopy adheres to the basic principles of laparoscopy. With selected patients, needlescopic technique reduces postoperative pain, and has a better cosmetic result with higher patient satisfaction.


Robotic Surgery and Health Systems in Countries with Emerging Economies. Is It Possible?
David Valadez-Caballero, MD

Robotic technology is considered one of the most important innovations in minimally invasive surgery over the past decade. Latin America began the process of incorporating robots in surgery later than other countries, but its interest in this area grows in spite of its economic problems. The implementation of new technologies implies during the initial phases high costs, limited security compared with previous technologies and doubts with respect to its operation. The presentation reviews the incorporation of this technology and some of the strategies used by successful projects in Latin America.


Laparoscopic Treatment of Generalized Peritonitis
Valencia S. Juan Carlos, Zuluaga Z Mauricio, Cardona N Uriel, Arenas Carlos
Clinica Farallones de Cali, Clinica SaludCoop Cali Norte

We present a series of 50 cases in which patients developed generalized peritonitis.
These patients received surgical care in two First Leve Clinics of the Cali city, Colombia, in the period between June 2011 and June 2014.

The cause of peritonitis was mostly perforated appendicitis (26 patients, 52%), second, acute cholecystitis (10 patients, 20%) and other miscellaneous causes, including Perforated Peptic Ulcer, Complications of percutaneous gastrostomy, Intestinal anastomosis leaks and other.

In all cases it was possible to make washing the peritoneal cavity by laparoscopy and treatment of the primary cause.

In 36% of cases it was necessary to do more than one review by laparoscopy and only in 14% of cases it was necessary treatment with open surgery after the first draw.

In 66% of cases, a drainage device into the cavity was installed.

All patients survived and the average hospital stay was 9.3 days and ICU stay was 3.7 days.

In conclusion, the laparoscopic approach is feasible and results in the treatment of generalized peritonitis are very satisfactory.


To Cut or Not to Cut
(Or How to See the Future and Deal with Patients with a Bumpy Post-Op?)
Juan Diego Villegas-Echeverri, MD, FACOG

Sometimes doctors ask Why Should a Surgeon Care to Learn about Pain? And the answer is this: Over 51 million inpatient surgical procedures are performed yearly in the USA. And between 10-50% of these patients will have chronic post-surgical pain. No one but surgeons have to change their way dealing with surgical-related pain.

Pain is a universal experience and poor pain control is the number one post-surgical complication. It is also the most frequent reason for poor patient satisfaction and for post-operative visits and phone calls. Post-surgical pain has immense impact on health care systems.

This lecture will try to
• Define Chronic Pain as a diagnosis
• Discuss basic strategies to identify difficult patients
• Contemplate options to deal with post-surgical pain
• Review different approaches to minimize Post-surgical chronic pain
• Consider strategies to improve quality of life
• Raise awareness about the importance of a multidisciplinary approach


Improve the Outcomes for Six Million Surgical Patients – ORReady
Paul Alan Wetter, MD

Over Two Hundred and Thirty Million Operations are performed worldwide each year. Experts estimate that by following a series of safety guidelines, 2-3 % (roughly Six Million surgical patients around the world) could have better surgical outcomes each year. While this may help only a small number of patients in a small local hospital, cumulatively it has the potential of being beneficial to an enormous number of patients worldwide. Research has confirmed that multiple industries benefit by applying the safety steps presented here. When applied in the operating room, these same steps can and do reduce complication rates and improve outcomes for our patients. Top centers, leading surgeons, nurses and OR teams in multiple specialties have adopted various forms of these steps, and have been reducing error rates by 40% and cutting death rates in half. Regrettably, many hospitals and surgeons worldwide have not yet instituted these good-outcome-producing principles. Our goal is to encourage worldwide use of the ORReady Steps in all hospitals within Six Years. Once followed, this could improve the outcomes for 6,000,000 patients worldwide annually.


MIS Hysterectomy Approach Achieved in the Majority of Cases for Benign Gynecology: Vaginal Hysterectomy Revisited and Single-Site Laparoscopic Hysterectomy Advocated. A 5-year Retrospective Study.
Jessica Ybanez Morano, MD, MPH

Background
Minimally invasive surgery (MIS) techniques, such as vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH) are advocated rather than the abdominal approach (TAH). Trends to LH in gynecology have been slowly adapted and the decrease in teaching of the VH has been consequential in maintained high rates of TAH in benign gynecology. In 2003, rates of TAH, VH, and LH were 66%, 22%, and 12% respectively. The combined MIS rate (VH and LH) for 2003 was 34%.

Method
5-yr data from 2009-2013 is reviewed for all hysterectomies 466 (118-2009), (113-2010), (101-2011), (70-2012), (64-2013.) Parameters noted include approach of surgery, age, BMI, specimen weight in gms, EBL in ml, OR time in minutes, complication rates and hospital stay. Trends over the 5 years were compared. LH was performed via reduced-site technique (single-puncture) exclusively from 2010.

Results
The MIS rates (VH & LH) were 76%, 96%, 95%, 93%, and 95% for 2009 through 2013 respectively. Yearly trends are detailed for various parameters. Overall rates for the 5 yrs are 90% MIS approach and 10% open approach. OR times reflects 35 mins (VH), 65 mins (LH) & 74 mins (TAH.) EBL quantified 88ml (VH), 181ml (LH), and 194ml (TAH.)

Conclusions
MIS approaches for hysterectomy are feasible in the majority of benign gynecological cases. Adoption of LH and utilization of VH with faster OR time proves advantageous for shortened patient anesthetic time and cost for OR use. Less blood loss with MIS approaches decreases patient morbidity, improved patient convalescent time, shortened hospital stays and reduced-site laparoscopy improves incisional cosmesis.


Common Laparoscopic Procedures of Pediatric Surgery in an Adult Hospital
N. Zavras, MD, PhD
Assistant Professor of Pediatric Surgery, 3rd Department of Adult Surgery, General University Hospital “ATTIKON”

Introduction
Laparoscopic surgical procedures (LSP) in pediatric population have been rapidly increased over the last decade. Today has becoming the standard of care for many surgical conditions, located either in the thorax or the abdomen, for all ages, even in neonates. We aim to present our experience in LSPs during the last 3 years in an adult teaching hospital.

Subjects and methods
It is a retrospective study from January 2011 to November 2014. We present the various LSPs, the number of patients, complications and conversions of laparoscopic and thoracoscopic procedures.

Results
A total of 32 minimally invasive procedures had been performed over the past 3 years. The mean age of patients was 11.3±2.2 years (range 7-15 years}. Surgeries included: appendectomies (46.8%), cholecystectomies (25%), laparoscopic exploration for undescended testis (9.6%), laparoscopic varicocelectomy (3.1%) excision of omental cyst (3.1%), thoracoscopic excision of bullae (6.2%), and thoracoscopic pleural drainage (6.2%), There were not conversions or postoperative complications.

Conclusion
Although the number of LSPs in children was small, a variety of common LSPs could be performed successfully in an adult teaching hospital. However, adult hospitals do not offer the opportunity in a pediatric surgeon to further expand his skills.