Society of Laparoendoscopic Surgeons | MISWeek 2018 Abstracts

MISWeek 2018 Abstracts


A Novel 5-mm Anvil Grasper is Useful for Intra-corporeal Circular stapled Anastomosis During Laparoscopic Colorectal Surgery

Yuen Nakase, MD PhD; Hiroaki Nagata, MD PhD; Kazuto Yamada, MD ; Akira Sougawa, MD; ASatoshi Mochizuki, MD; Shouzou Kitai, MD PhD; Seishirou Inaba, MD PhD

Department of Digestive Surgery, Nara City Hospital

Objective: Traditional anvil graspers have a uniquely shaped jaw that enhances grip force and cannot use by 5-mm trocar, the anvil head cannot be maneuvered delicately in a tight pelvic space. Many surgeons use a grasper designed for holding the bowel or a dissector to hold the anvil during intra-corporeal circular stapled anastomosis during colorectal surgery although it is difficult to connect segments with these instruments due to slipping. We developed a novel 5- mm anvil grasper for more precise and safer anastomosis procedures.

Methods and procedure: The novel anvil grasper has curved blades with tungsten carbide- coated tips, which are curved 15 mm from the tip to create a 6-mm grasping surface that is the same diameter as the anvil stem. This facilitates grasping of the anvil stem at any angle, allowing the surgeon to easily handle the proximal colon and smoothly connect it to the center rod of the circular stapler.

Results: Traditional instruments require more time, depending on the surgeon’s skill, the level of anastomosis (distance from the anal verge), and patient characteristics. However, any surgeon using the novel anvil grasper could perform connections smoothly in any patient with comfortable feeling to use.

Conclusions: By using this grasper, a surgeon can hold the proximal colon in the ideal position and smoothly join segments to perform anastomosis, the most challenging tasks in laparoscopic colorectal surgery. This grasper is a very simple anvil grasper, but should be very helpful in allowing surgeons to perform these procedures safely.


The Usefulness of a Novel Syringe-type Device for Applying Surgical Mesh via a 5-mm Trocar

Hiroaki Nagata, MD PhD; Yuen Nakase, MD, PhD; Kazuto Yamada, MD; Akira Sougawa, MD; Satoshi Mochizuki, MD; Shouzo Kitai, MD; Seishirou Inaba, MD, Phd

Nara City Hospital

Objective: Laparoscopic transabdominal preperitoneal hernia repair (TAPP) with a 5-mm or finer trocar to decrease invasiveness has been increasing, but the procedure for introducing surgical mesh by a 5-mm trocar is complicated and has some problems. To introduce the surgical mesh with a 5-mm trocar, we developed a novel device for applying the mesh.

Methods and procedure: The novel device is a specially ordered precision polypropylene tube. The device resembles a slim, long syringe that has an outer sheath (5.8 mm outer diameter, 5.6mm inner diameter, 2500mm length) with an inner rod. The flat surgical mesh is folded by pulling the suture and inserted into our device using graspers before surgery.

Results: When the surgical mesh applies to reinforce area, a novel device with the mesh through 5-mm trocar and push the inner rod by hand. The folded mesh was extruded smoothly pubis side to lateral side along a curve of inguinal reinforce area and re- expanded easily. We used this device for 216 cases of TAPP, there are no device related complications and mesh infection reported.

Conclusion: The traditional procedure for introducing the surgical mesh during the TAPP without 12mm trocar tend to need additional time and have a risk of contamination. The procedure of mesh applying goes smoothly, comfortably and economically, may reduce the risk of infection with our device.


Laparoscopic Intracorporeal Suturing: Fundamental and Tips & Tricks for New Learners

Jeffrey Woo, MD
Riverside Regional Medical Center

Objective: Medical Students and Residents will be encouraged to use this video to learn laparoscopic intracorporeal knot tying. This is a challenging skill to learn, but once mastered, most other laparoscopic task come with ease.

The outline of the video is as follows: • Introduction • Needle Anatomy • Needle Entrance (proper loading and back-loading) • Needle Handling (Swiveling) • Needle Loading • Throwing a Stitch • Knot-Tying (2 techniques, drop needle and hold needle) • Tips and Tricks/Key Points


Clinical Experience of Mayo 0~IV Tumor Thrombus Treated with Laparoscopic Radical Nephrectomy and Inferior Vena Cava Thrombectomy

Zhuo Liu, MD
Peking University Third Hospital

Objective To investigate the safety and feasibility of radical nephrectomy and Mayo 0~IV venous thrombectomy.

Methods The clinical data of 52 patients with Mayo 0~IV tumor thrombus from February 2015 to January 2017 were analyzed retrospectively. The renal vein tumor thrombus or inferior vena cava tumor thrombus was found in all patients, including type 0 thrombus in 12 cases, typeIthrombus in 11 cases, type IIthrombus in 15 cases, type IIIthrombus in 9 cases, type IV thrombus in 5 cases (Mayo Medical Center classification).

Results All 52 surgeries were completed successfully without intraoperative and perioperative mortality. Open radical nephrectomy and inferior vena cava thrombectomy was underwent in 22 cases. Pure laparoscopic surgery was underwent in 30 cases. Two cases were converted to open surgery. The average surgery time was(333.7±80.1)min. The average blood loss volume was ( 1339.0±508.1)mL. During the operation, the amount of suspended red blood cells transfusion was(761.5±394.8)mL. 7 cases underwent inferior vena cava wall resection because of invasion by tumor thrombus. The average postoperative hospitalization of all 52 cases was (9.7±4.7) d. Among 27 patients, early postoperative complications occurred in 18 cases (34.6%). 44 cases(84.6%) were followed up for 1 to 22 months with a median of 8 months. Postoperative recurrence occurred in 3 cases, and distant metastasis occurred in 9 cases. 9 cases (20.5%) had tumor specific death.Conclusions Our initial clinical results show that radical nephrectomy and inferior vena cava thrombectomy is safe and effective for patients with Mayo 0~IVtumor thrombus.


The Clinical Application of Inferior Vena Cava Segmental Resection in Renal Carcinoma with inferior Vena Cava Tumor Thrombus

Zhuo Liu, MD
Peking University Third Hospital

Objective To investigate the safety and feasibility of inferior vena cava segmental resection in renal carcinoma with inferior vena cava tumor thrombus.

Methods The clinical data of 11 patients with renal carcinoma and inferior vena cava tumor thrombus from January 2016 to June 2017 were analyzed retrospectively. All 11 patients suffered from tumor thrombus invading the inferior vena cava wall and they underwent segmental resection of inferior vena cava. The inferior vena cava tumor thrombus was found in all patients, including type IIthrombus in 6 cases, type IIIthrombus in 4 cases, type IV thrombus in 1 case (Mayo Medical Center classification).

Results All 11 surgeries were completed successfully without intraoperative and perioperative mortality. Open radical nephrectomy and inferior vena cava thrombectomy and segmental resection was underwent in 8 cases. Pure laparoscopic surgery was underwent in 2 case. One case was converted to open surgery. The average surgery time was(388.7±93.5)min(284~556 min ). The average blood loss volume was (1472.7±1080.8)ml(300~4000 ml). The average postoperative hospitalization of all 11 cases was (17.7±9.7) d. Among 11 patients, early postoperative complications occurred in 7 cases. 11 cases were followed up for 2 to 14 months with a median of 8 months. Postoperative distant metastasis occurred in 1 case. 2 cases (18.2%) had tumor specific death.

Conclusions Our initial clinical results show that inferior vena cava segmental resection in renal carcinoma with inferior vena cava tumor thrombus is safe and effective. The surgical resection has the possibility of early postoperative complications, but most can be improved by active treatment.


A Retrospective Study on Breast Cancer Presentation, Risk Factors and Protective Factors in Patients with a Positive Family History of Breast Cancer

Anil Gandhi, MBBS, M.S., FCLS; Liaw YY, MBBS; Loong FS, MBBS; Tan SMQ, MBBS; On SY, MBBS; Khaw ELY, MBBS; Chiew Y, MBBS; Nordin R, MD, PhD

Monash University Malaysia

Women with a positive family history of breast cancer are greatly predisposed to breast cancer development. A retrospective study was conducted at two main hospitals from January 2007 to December 2016.

1101 patients with a histologically confirmed breast cancer were included in the study. Patients are divided into two groups: positive family history and patients without family history. 159 out of 1101 (14.4%) of the patients had a family history of breast cancer. There was no significant difference in the incidence of breast cancer among Malays, Chinese, and Indians. Both patient groups presented at a mean age of about 60 [+FH 60; -FH 61.2 p-value=0.218]. Significantly higher prevalence of history of benign breast disease (11.3%), nulliparity (13.2%), tumor size at presentation of more than 5 cm (47.3%), and bilateral site presentation (3.1%) were noted among respondents with a positive family history of breast cancer compared to those with a negative family history of breast cancer (p<0.05). The odds of having a tumor size larger than 5cm at presentation were almost two times higher in patients with a positive family history as compared to those without a family history (OR=1.786, 95% CI 1.211-2.484 Women in Malaysia, despite having a positive family history of breast cancer, still present late at a mean age of 60 with a large tumor size of more than 5cm, reflecting a lack of awareness. Parity of two or more was marginally significant (p=0.057) and protective (p=0.540) of a positive family history of breast cancer (adjusted OR 0.583, 95% CI 0.334, 1.016). _________________________________________________________________________________ 108MUL

Introduction of Basic Principles of Laparoscopic Surgery in Undergraduate Medical Curriculum

Anil Gandhi, MBBS, MS, FCLS; Chong ALR, MBBS; Loong FS, MBBS
Monash University Malaysia

Introduction: Ever since the first laparoscopic cholecystectomy in 1987, laparoscopic surgery has widely replaced open surgeries. However, no medical schools in Malaysia or most of the countries worldwide includes laparoscopic skills training as part of their undergraduate curriculum which, considering the rapid acceptance of laparoscopic surgery in general surgical practice, would certainly be beneficial.

Aim: To identify the number of laparoscopic procedures in comparison to open surgeries in Malaysia and hence to determine the need for the introduction of a basic laparoscopic surgical skills programme in undergraduate medical curriculum.

Methodology: This study analyzes general surgical operations performed in Hospital Sultanah Aminah. Records of general surgical cases were obtained from the operation theatre involving data on type and nature of surgery. A comparison was done between the years 2010 and 2016 to establish whether an increasing trend is present. R

Results: Preliminary analysis of the data showed that there was a significant increase in percentage of both elective and emergency laparoscopic surgeries. There was an increase in laparoscopic surgeries in elective list from 6% to 18% whereas in emergency the lap surgery showed a increase from 0.8% to 8.6%.T

Conclusion:An increasing number of laparoscopic surgeries are and will be undertaken each year supporting the need for introductory sessions from undergraduate level itself. Establishing this need will instigate measures to design a basic introductory course to be integrated into the final year programme.


A Novel Procedure for Introducing an Absorbable Adhesion Barrier Membrane with a Self- expanding Origami Structure Using a Slim Trocar (Chevron Folding Procedure)

Yuen Nakase, Kazuto Yamada, Akira Sougawa, Hiroaki Nagata, Satoshi Mochizuki, Shouzo Kitai, Seishirou Inaba

Department of Digestive Surgery, Nara City Hospital

Objective: An absorbable adhesion barrier membrane (ABM) is difficult to introduce into a corporeal cavity using a 5-mm trocar. Furthermore, it is necessary not only to introduce but also to secure the applied and expand it on the surgical site. To address these challenges, we developed a novel self-expanding origami structure and devise for introducing ABM into a corporeal cavity with a 5-mm trocar, called the “Chevron Folding Procedure”.

Methods and procedure: A self-expanding origami structure “chevron pleats folding pattern” is modified “Miura-ori” which was developed for folding solar panels on space satellites, and compactly folds a large sheet of material for use with a slim trocar. The ABM (1.5" x 1.25") are formed chevron pleats pattern by novel pressing device which is clamshell type dual silicone sheet and forming a zigzag V-shape with 5-mm width and inserted into a specially ordered precision polypropylene tube. When the surgeon needs ABM, polypropylene tube is set into a 5-mm trocar; then, the 5-mm grasper is used to push it into the corporeal cavity.

Results: We used chevron folding procedure for laparoscopic colorectal surgery (n=30), gastrectomy (n=12), cholecystectomy (n=20), to cover the peritoneal defect. The ABM was securely injected and smoothly expanded in corporeal cavity and completely covered irregular or large peritoneal defects.

Conclusions: This procedure will be useful for introducing several sheet-type surgical materials as well as ABM into a corporeal cavity with a 5-mm trocar and might help ensure efficient and safe laparoscopic surgery.


A Supracervical Hysterectomy In a Woman With Two Uterine Bodies, One Cervix and Two Vaginal Portions of the Cervix (VPCs)

Massimiliano Marziali, MD PhD1; Barbara Borelli, MD2; Francesco Cassanelli, MD2

1Tor Vergata University, Rome ; 2Paideia Clinique, Rome

Objectives: We present the case of a supracervical hysterectomy in a patient with two uterine bodies, one cervix and two vaginal portions of the cervix (VPCs).

Methods: A 48-year-old woman was referred to our Gynecology Service with a magnetic resonance investigation (MRI) showing a plausible hematocolpos measuring mm 50x25. She was completely asymptomatic and reported to be affected by uterine didelphys and right renal agenesis. After gynecological examination (confirming the presence of two VPCs but not showing other abnormalities), it was decided to perform a laparoscopy, in order to drain the blood collection and to understand where it came from. Intraoperatively, they were found two uterine bodies, a single cervix and two VPCs. Between right uterine body (considerably more hypoplastic than the contralateral) and right side portion of the cervix, there was a swelling of the lateral vaginal wall: the hematocolpos observed in MRI. Assuming the existence (confirmed by a contextual hysteroscopy) of a fistula between cervix and right vaginal wall and that the blood collected came from right uterine body, it was decided to perform a supracervical hysterectomy of the right uterus, with uterine hemisection at isthmic level.

Results: Supracervical hysterectomy of the most rudimentary uterine body (which, with menstruation, supplied the fistula) solved our patient’s problem and provided her an almost normal anatomy, with a single, normal-sized uterine body, a cervix and two VPCs.

Conclusions: Uterine malformations are many, varied and, sometimes, difficult to categorize univocally. This, in the absence of real clinical guidelines, recommend an individualized treatment of the affected women.


A Novel Approach of Laparoscopic Sacrospinous Ligament Suspension.

Guangwu Xiong, Prof Dr Med

The Third Affiliated Hospital of Chongqing Medical University

Objective To explore the safety and feasibility of laparoscopic posterior approach sacrospinous ligament suspension (LPASLS) in the treatment of pelvic organ prolapse (POP).

Method The clinical data of 9 patients with symptomatic pelvic organ prolapse treated with LPASLS intraoperatively in the Department of Obstetric and Gynecology, The Third Affiliated Hospital of Chongqing Medical University from Nov. 2016 to Jul. 2017, were analyzed retrospectively. Regular follow-up were provided at 1, 3, 6 months after operation. The subjective cure is defined as: there is no conscious symptom after the operation; the objective cure is defined as: the postoperative pelvic organ prolapse quantification(POP-Q)stage is 0.

Result All the operations were completed successfully. The operative time was 90~140 (117.78±20.01) min,wherein the average time of suspension was about 30 minutes. The intraoperative estimated blood loss was 30~100 (54.9±24.2) ml, intraoperative complications occurred in 1 cases. The postoperative sacrococcygeal pain occurred in 5 cases, and relieved in 3-4 days automatically. After 6.3±2.1 (3-10) months’ follow-up, the subjective and objective cure rate were 100%.

Conclusion LPASLS is safe and feasible, and maybe an alternative approach of the traditional laparoscopic sacrospinous ligament suspension.


Multidisciplinary Minimally Invasive Strategies for Management of Post Cholecystectomy Bile Cuct Injuries. A Part of Egyptian Tertiary Referral Center Experience

Ehab Atef Abdellatif, Ass.Prof, (MD), (MRCS En)1; Ahmad Sultan (MD)2; Ehab elhanafy (MD)2; Ayman Elnakeeb (MD)2

1Mansoura University; 2GISC-Mansoura University

OBJECTIVE: Post cholecystectomy bile duct injuries can cause serious morbidities and should be treated by a specialized multidisciplinary specialists. The aim of this study is to clarify the efficacy of the minimally invasive options in the management of post-cholecystectomy biliary fistula. Z

METHODS & PROCEDURES: A retrospective analysis for the data of 111 patients referred with post cholecystectomy biliary fistula for the ERCP unit, Gastro Intestinal Surgery Center (GISC) Mansoura University during six years. Patients referred directly to surgery were excluded.

RESULTS: Of the 111 patients, 38 (34.2 %) underwent laparoscopic cholecystectomy and 73 (65.8 %) underwent open cholecystectomy. Placement of ultrasound-guided tube drain for intra abdominal collections was used in 39 patients (35%). However surgical exploration and toilet drainage needed in 12 patients(10.8%) endoscopic retrograde cholangiopancreatography (ERCP) diagnosed major bile duct injury (BDI) in 27 patients (38.6 %) in the open cholecystectomy group and in 3 patients (7.9 %) in the laparoscopic cholecystectomy group (P=0.001). ERCP succeeded in stopping the leakage in 93 patients (84%). 77 patients (98.7%) with minor BDI and in 16 patients (53.3%) with major BDI (P<0.001). Failed endoscopic management was encountered in 15 patients (13.5%). CONCLUSION: Major BDI is more common in patients presenting with biliary fistula after open cholecystectomy. ERCP is the first-choice treatment for minor BDI. Surgery plays an important role in major BDI. Magnetic resonance cholangiopancreatogrphy (MRCP) should be used before ERCP in patients with bile leakage following open cholecystectomy or converted laparoscopic cholecystectomy. _________________________________________________________________________________ 113GYN

The Effect of Commercialisation of Gynaecological Surgery

Mark M.S. Erian, Prof Dr Med1; Glenda Mclaren, MD, FRCOG, FRANZCOG2

1University of Queensland, Queensland, Australia; 2Mater Hospital, Queensland, Australia

Objectives: Test the hypothesis that contemporary gynaecological practice and training is largely influenced by commercialization factors.

Setting: Major teaching hospitals affiliated with University of Queensland, Australia.

Methods and Procedures: Observations of gynaecology procedures performed on public and private patients in only one unit of general gynaecology with a special interest in minimally-invasive techniques. With the patients’ safety is the foremost consideration, the trainees performed the operations under close observation of the attending consultant. Each operating session involved at least one trainee and contained Advanced Hysteroscopic/ Laparoscopic /Cystoscopic gynaecological operations. During the time of the study, 1990-2017 (Inclusive), there were 12-18 trainees (registrars) per hospital every year. Only 1-2 registrars were allowed into the operating theatre (OT) at any given list.

Results: During the aforementioned period 15,064 operations were studied with 9464 and 5600 operations of advanced hysteroscopic and laparoscopic procedures, respectively. Over the past 15 years it was noted that there is general decline of economical support, and consequently workshops and infra-structures, for the contemporary endoscopic gynaecological surgery, apart from robotic surgery, so that there was a noticeable decline of manual dexterity, self-confidence and smoothness of operative performance of trainees at advanced endoscopic procedures.

Conclusion: Lack of industry economic support for clinicians resulted in less opportunities for training of Registrars and, consequently, expected competent treatments for tomorrow’s patients.


Laparoscopic Criteria of Common Bile Duct Transection During Laparoscopic Cholecystectomy

Mohamed Ashraf Shawkat, Prof Dr Med

Al Mostaqbal Hospital

Objective: To define criteria for recognition of CBD transection during laparoscopic cholecystectomy.

Methods and procedures: Retrospective study of 11 cases of CBD transections in the last 5 years among more than 1400 cases was done. Reviewing the operative procedures showed that 10 of the 11 transections occurred in what seemed easy straight forward cases. Sessile gallbladders, floating CBD, over confidence and incomplete dissection of the Callot triangle were the main causes.

Results: We observed that dissection of the cystic duct is bloodless, but some bleeding will occur if CBD is being dissected. The clips over the cystic duct always lie transversely, while clips over CBD lie vertical or oblique. Cystic duct is easily divided while during dividing CBD resistance will be encountered. The proximal end of the divided cystic duct is always rounded, while that of the CBD is always rosette in shape. The distal end of the divided cystic duct is small and rounded, while that of the CBD is big and flat.

Conclusion: Unrecognised injuries of the CBD during laparoscopic cholecystectomy will result in bile peritonitis and will always lead to a second difficult surgery. Careful dissection of the triangle of Callot, identifying both cystic and CBD is mandatory. After clipping of the supposed cystic duct and if the clips lie vertically this is mostly the CBD, do not divide and do a cholangiogram to see the anatomy. If rosette appearance appear in the proximal end and flat wide appearance in the distal end mostly you have divided the CBD.


Single Session Laparoscopic Cholecystectomy with Endoscopic Sphincterotomy for Management of Concomitant Gallbladder and Common Bile Duct Stones

Ehab Atef Abdellatif, Ass.PROF, MD ,MRCS En; Ahmed Abdelraof; Ehab Elhanafy; Ayman el Nakeeb; Gamal el Ebeidy

GISC, Mansoura University, Mansoura, Egypt

OBJECTIVE: This study aims at assessment of the outcome of laparoscopic cholecystectomy (LC) combined with intraoperative endoscopic sphincterotomy (IOES) as a single session management option for patients with cholecysto-choledocholithiasis (CCL).

METHODS & PROCEDURES: This is a retrospective analysis of the records and collected data for one hundred patients with CCL who were submitted for LC with IOES. Patients were preoperatively diagnosed by clinical presentation, abdominal ultrasound, laboratory findings, and magnetic resonance cholangiopancreatography (MRCP). IOES was performed by the same operating surgeon in the same setting after adjusting the patient to the left lateral position after completion of LC and closure of ports in most cases.

RESULTS: One hundred patients having combined (LC) and (IOES) for CCL were analyzed. Eighty two patients were females (82%). The mean age was 35.1 years. Mean serum bilirubin level was 7.5 mg/dl. Mean CBD diameter at MRCP was 9.1 mm and the mean CBDS size was 5.1 mm. Mean operation time was 87 minutes. Complete CBD clearance was possible in 94 patients (94%). The mean hospital stay was 3.1 days. There was no procedure related mortality. Complications were reported in 15 patients and included bleeding sphincterotomy in six patients (6%), pancreatitis in seven patients (7%), and minor bile leak in 2 cases (2%). All complications were treated by conservative means.

CONCLUSION: Combining IO-ERCP and sphinctrotomy with LC is a safe and effective single session minimally invasive treatment strategy for patients with CCL that should be available in the hands of the experienced hepatobiliary surgeon.


Robotic- assisted Laparoscopic Cervicovaginal Myomectomy

Pouya Javadian, MD1; Alex Juusela1; Farr Nezhat2

1Newark Beth Israel Medical Center; 2NYU Winthrop Hospital, Weill Cornell Medical College of Cornell University

Objective: Minimally invasive surgery has been the trend in various specialties and continues to evolve as new technology develops. The present study reports the robotic surgery in complicated cervicovaginal fibroid.

Method and Procedures: A 39-year-old woman G0, (body mass index of 23.0 kg/m2) with known cervicovaginal fibroid which in the past underwent uterine artery embolization, presented with recurrence of her severe abnormal vaginal bleeding. She was referred for surgical resection of the mass. Magnetic resonance imaging revealed a 5 cm posterior wall fibroid. Patient desires to preserve reproductive organs. The patient was offered the robotic operation for the first time which was well accepted.

Results: The procedure was performed without any complications. Total robotic procedure was 123 minutes and estimated blood loss was 100 cc. She was discharged uneventfully on the day 0 postoperatively. Pathology result showed 37 grams leiomyoma of uterus. Patient present to 2 weeks’ post-operative visit with no more complaint of vaginal bleeding.

Conclusions: Robot-assisted laparoscopic surgery is a feasible approach for cervicovaginal fibroid with minimal complications.


Teaching Laparoscopic Durgery in Zambia: A Surgical Resident's Experience

Sarah Emily Smith, MD; Steven Heneghan, MD; Theodor Kaufman, MD; Andrew Griffiths, MD

Bassett Medical Center

Objective We hypothesized we would be able to design and initiate an international elective during surgical residency to teach laparoscopic surgery to a group of Zambian surgeons to allow for a sustained laparoscopic program in the country.

Methods & Procedures A team consisting of one fourth year surgical resident and three faculty attendings from Bassett Medical Center obtained ACGME, ABS, and Zambian Department of Health approval to create an international elective to implement a laparoscopic training program. A didactic training program for the surgical team was provided. The surgical training consisted of the Zambian surgeons performing all cases with assistance provided by the American surgical team. Each Zambian surgeon learned to operate, assist, and run the camera. By the end of the fourth week they were performing the surgery without any physical assistance from the American team and with minimal instruction.

Results We performed 20 laparoscopic procedures: 14 laparoscopic cholecystectomies, 4 laparoscopic biopsies (3 liver and 1 mesenteric lymph node), and 2 exploratory laparoscopies. Only one conversion of a diagnostic laparoscopy was necessary to provide exposure. All patients were seen in follow up clinic by the local surgeons and no complications were identified. Since our departure the team has performed 2 laparoscopic liver biopsies and 5 laparoscopic cholecystectomies. They converted to open cholecystectomy on 1 because of insufficient CO2.

Conclusions Our experience demonstrates that laparoscopic surgery can be safely and effectively taught in developing nations such as Zambia.


Repair of Type IV Paraesophageal Hernia with Xenograft Mesh

Yaniv Fenig, MD; Steven J Binenbaum, MD FACS; Frank J Borao, MD FACS; Christopher J Mahrous, BSc; Ratul Bhattacharyya, BSc

Monmouth Medical Center

A massive paraesophageal hernia (PEH) is one in which at least 30% of the stomach is in the chest. A type-IV PEH contains the stomach as well as other peritoneal organs in the chest. The laparoscopic repair of the type-IV PEH is complex, requiring the utilization of a mesh, but the choice of mesh has been a point of contention in the literature. We present a difficult case that was repaired using Xenograft mesh implantation.

G.K., an 82 year-old female, presented with progressive dysphagia and GERD. Surgical history included an open cholecystectomy via a subcostal incision. The patient’s BMI was 45. EGD and CT demonstrated a type-IV PEH with >50% of the stomach and the transverse colon herniated. After obtaining consent, the patient underwent laparoscopic repair with posterior diaphragmatic reconstruction using Xenograft mesh implantation, primary suture repair, and Nissen funduplication.

The repair was confirmed with intra-operative endoscopy. Contrast-enhanced upper gastrointestinal studies demonstrated a patent, appropriately positioned gastroesophageal junction with adequate transition of contrast to the small bowel. Six months post-operatively, the patient remains complication and symptom free.

Laparoscopic PEH repairs are challenging when high volumes of viscera are displaced due to needing expansive mediastinal dissection of the hernia sac to reduce recurrence risk. In studies regarding these repairs in patients over 65, octogenarians are poorly represented. Octogenarians are of particular concern due to the increased co-morbidities and diaphragmatic defect sizes concerning for inferior outcomes. We present a successful repair to encourage further studies evaluating outcomes in octogenarians


Preliminary Result of Laparoscopic Hernia Repair

Enaam H Raboe, MD; Ameen Aksaggaf MD; Alaa Ghallab MD; Yazeed Owiwi MD; Al Zei Elabdeen MD; Mohammed Fayez MD; Ahmed Atta MD; Omer Sindi

King Fahd Armed Forces Hospital

Aim: To compare the outcome of laparoscopic hernia repair and open herniotomy

Patients and methods: Retrospective study conducted between January and June 2017. Forty six patients underwent either laparoscopic surgery or open surgery for pediatric inguinal hernia repair. Outcome was compared. Patients were followed up from 6-12 months. The collected data were analyzed using Statistical Package for Social Science version 22, P value < 0.05 was considered significant Results: Total 46 patients were operated, the majority were male 84.8%. Fifty six % were less than 1 year, 19.6% were between 1-5 years, and 23.9% were 6-13 years old. Twenty seven patients underwent open herniotomy OH, 8 underwent laparoscopic percutaneous internal ring suturing PIRS, 11 laparoscopic sac dissection & intracorporeal suturing SDIS. Mean age is 3.61 years, 1.86 years, and 2.56 years for OR, Lap PIRS and SDIS respectively. For unilateral procedures mean operative time was 36.68 min for OH and 48.80 min for PIRS P=0.12 & 102.16 min for SDIS P< 0.001. For bilateral procedures mean operative time was 37.00 min for OH and 63.33 min for PIRS P=0.12, and 109.00 min for SDIS P< 0.001. Seven CPPV found in laparoscopic surgery. Un-necessary inguinal exploration avoided in one patient. Stitch granuloma developed in one patient underwent SIRS Conclusion: There is no significant difference in the operative time of PIRS and open OR. Although the number of cases is small we could conclude that Lap PIRS is safe with good learning curve and excellent cosmetic result in the treatment of pediatric inguinal hernia _________________________________________________________________________________ 120GS

Endoscopic Submucosal Myotomy of Esophageal Epiphrenic Diverticula: Is It Sufficient?

Diego Laurentino Lima, MD1; Luiz Eduardo Correia Miranda, MD, PhD2; Antonio C. Conrado3; Ana Clara Galindo Miranda2

1Hospital dos Servidores do Estado (state servers Hospital); University of Pernambuco; Hospital da Restauração

Introduction: Esophageal epiphrenic diverticulum (EED) is rare disease of the distal thoracic esophagus and associated with esophageal motility abnormalities. This video case reports the treatment and results of EED using a submucosal tunnelling endoscopic septum division (STESD) technique.

Case report/ Surgical technique: A 52-year-old male referring dysphagia and regurgitation underwent upper endoscopy and esophagogram, both revealing a large diverticulum 10 cm above the cardia. An esophagus manometry showed a hypertonic esophagus. By using a gastroscope with cap, after the submucosal injection of methylene blue solution, a 1 cm transverse mucosal incision was made 3 cm proximal the upper border of diverticula using an electric scalpel. A submucosal tunnel was made by gentle thermoelectric dissection from the initial opening of the esophagus until it reaches the stomach. The muscular septum was dissected along both sides to create an endoscopic window. Thereafter, the diverticular septum was divided along its entire length, and an extensive and complete myotomy was performed from the septum to the stomach. Finally, a rubber band ligature closed the mucosal incision. Ceftriaxone (2g qd i.v.) was continued for 3 days. The patient presented thoracic pain and subcutaneous emphysema in the upper chest and neck that resolved after a few days.“

Conclusions: Despite the complete septum section, imaging revealed an intact diverticulum and severe esophagitis three months after STESD. Endoscopic approach of EED may not be sufficient to dismiss antireflux surgery and/or surgical diverticulectomy


Robot-assisted Laparoscopic Surgery Without Assistant Ports in Children Decreases Morbidity

John G. Van Savage, MD
Jackson Purchase Medical Center

Objective: Robot-assisted laparoscopic surgery (robot surgery) is traditionally performed with ports for the camera, assistant and 2 or more robot arms. The purpose of this study is to investigate the use of robot surgery without the utilization of assistant ports to further diminish the morbidity of robot surgery.

Patients and Procedures: Sixty children (mean age 10 years, range 2-19) underwent robot surgery for urologic conditions. Cases included varicocelectomy (42), pyeloplasty for ureteropelvic junction obstruction (9), nephrectomy (7) and renal cyst marsupialization, orchidopexy for bilateral intraabdominal undescended testes, pyelolithotomy, pelvic cyst excision, ureterolysis and adhesiolysis in 1 each. Total is greater than 60 as some patients had more than 1 procedure.

Results: Fifty-five (92%) of cases were performed without an assistant port. Twelve (71%) of 17 renal cases did not require an assistant port. The instrument in a robot arm was removed by the surgical assistant in order to pass sutures or other items normally passed through the assistant port. Assistant ports were added for bowel retraction in 4 cases (2 pyeloplasties, 2 nephrectomies), and suction in 1 case (large renal cyst marsupialization). There were 3 open conversions in these 5 cases for failure to progress with difficulty in bowel retraction. There were no complications.

Conclusions: Robot surgery can be performed without assistant ports in select cases. This approach obviates the possibility of bleeding or hernia associated with the extra port, decreases the morbidity and pain associated with another incision, decreases the number of scars by 1 and saves on disposable equipment.


Isolated Tubal Torsion in a Premenarchal Female Resulting in Left Salpingectomy

Prapti Singh, DO; Amara Uzoma-Uzo MD; Micah Vaughn MD; John Y Phelps MD, JD, LLM

University of Texas Medical Branch, Galveston

Objective: : Identification and treatment of isolated tubal torsion in a premenarchal female

Procedure: A 10-year-old premenarchal female presented with intermittent left lower quadrant pain present for a month. Patient described pain as dull and had become acute on the day of presentation. Patient had no associated signs and symptoms and vitals were within normal limits. No history of sexual activity or abuse was present. Computed tomography (CT) scan showed a tubular structure in the left adnexum, posterior to the uterus measuring up to 6.3 cm with leftward deviation of the uterus, suggesting possible hydrosalpinx or isolated tubal torsion. Ultrasound (US) showed consistent findings with no free fluid present. We proceeded with diagnostic laparoscopy.

Results: Intraoperatively, left grossly dilated and torsed fallopian tube noted. After torsion was reduced, reperfusion observed, yet tubal torsion returned with repositioning or movements. Left salpingectomy was performed. Right fallopian tube and bilateral ovaries appeared within normal limits . Introitus appeared virginal with no lesions and hymen was intact. Pathology showed edema, ischemic necrosis and hemorrhage consistent with torsion.

Conclusion: Laparoscopy in the benign presentation of isolated tubal torsion in premenarchal females is both diagnostic and therapeutic; salpingectomy is necessary in cases where conservative management with oophoropexy or cyst aspiration does not result in reperfusion or tissue is unsalvageable. Although initially reduced, the persistent torsion with grossly dilated presentation without known secondary cause resulted in unilateral salpingectomy.


The Smart Approach to Surgical Treatment for Gastric and Duodenal GISTs Based on Preoperative EUS-Typing

Seda Dzhantukhanova, MD PhD; Yury Starkov Prof.; Mikhail Vybornyi MD PhD

A. V. Vishnevsky Institute of Surgery

Background. Surgical treatment is the treatment of choice for the resectable GISTs with objective of surgery being complete R0 resection.

Objective. To develop and demonstrate different surgical techniques of laparoscopic or endoscopic resection for GISTs based on classification of EUS-typing for optimal choice of treatment.

Material and methods. The EUS-classification of GISTs was created based on the analysis of treatment of 80 patients with gastric and duodenal GISTs. The EUS-typing includes Type I, Type II, Type III (a,b,c,d) tumors Optimal approach for type I Endoscopic removal of tumor by means of: Endoscopic submucosal dissection (large size) Endoscopic mucosal resection (small size) Type II Endoscopic enucleation of tumor after resection of covering mucosa Endoscopic tunneling dissection Type IIIa Endoscopic tunnneling dissection Type IIIb Laparoscopic atypical resection after gastrotomy (duodenotomy) Endoscopic tunneling dissection (advanced endoscopic surgeon and small tumor size) Laparo-endoscopic hybrid procedures Type IIIc Laparoscopic atypical (wedge) resection Type IIId Laparoscopic enucleation of tumor Laparoscopic atypical stapler resection

Results. Patients with gastric and duodenal GISTs underwent laparoscopic resection – 62, endoscopic intraluminal resections – 18 patients (tunneling resection – 7, endoscopic submucosal dissection or endoscopic enucleation of tumor after resection of covering mucosa – 11) Median operation time was 150 min. Recovery was uneventful and median post-op hospital stay was 5 + 2,4 (2-8) days. The pathology showed R0 resection in all cases.

Conclusion. The classification of GISTs based on EUS-typing allows to select the optimal approach individually for each patient to perform surgery more accurate and less invasive


The Frequency and Common Risk Factors of Dehiscence/ Burst Abdomen in Patients Undergoing Laparotomy.

Saeeda Khan, MBBS,FCPS

Mardan Medical Complex

Total number of patients 177. Males 105 (59.3%) and females 72 (40.7%) with a male to female ratio of 1.45:1. Minimum age was 18 years and maximum age was 80 years with a mean age 38.40. Most frequent age group was 21-30 years (48 cases).

Laparotomy was done as emergency in 144 (81.4%) cases @ electively done in 33 (18.6%) cases. Out of 177 patients, wound dehiscence was observed in 26 (14.7%), all cases divided into group A- patients with wound dehiscence and group B- patients without wound dehiscence. In group A, 15 patients male and 11 patients were female while in group B, 90 patients males and 61 patients were females. In group A, 25 patients were operated as emergency @ 01 patient was operated electively. In group B, 119 patients were operated as emergency 32 patients were operated electively. total 7 (4%) patients were found with diabetes mellitus, 01 in group A and 6 in group B. 41 (23.2%) patients found having anaemia, 20 in group A and 21 in group B. Wound infection observed in 32 (18.1%) cases, 26 in group A and 6 in group B. Post-operative cough developed in 32 (18.1%) patients, 22 in group A and 10 in group B. Presence of wound dehiscence found significantly high (p= <0.05) in patients operated in emergency as compared to elective cases. Diabetes as cause of dehiscence was not established statistically (p= >0.05) anaemia, wound infection and post-operative cough found to be statistically significant (p= <0.05) factors associated with wound dehiscence. _________________________________________________________________________________ 125GYN

Office Hysteroscopy: Many Options, Which Are The Solutions?

Ian Waldman, MD1; Stephanie J. Estes, MD2

1Penn State Milton S. Hershey Medical Center; 2Penn State Health

OBJECTIVE: Compare three different types of office hysteroscopy.

DESIGN: Retrospective cohort

MATERIALS AND METHODS: Office hysteroscopy procedures over 10 years were identified, using the flexible hysteroscope, Truclear, and Endosee. Data was extracted from the EMR and physician charge estimates were obtained. Patient demographics, pre/postoperative diagnosis, completion rate, and pathology were obtained. After the index hysteroscopy, 2nd procedures within 12 months and total charges were calculated. Comparison of the three hysteroscopic methods was performed using exact Pearson’s Chi-Square test or Kruskal-Wallis test.

RESULTS: 411 Flexible, 24 Truclear, and 8 Endosee procedures were identified, of which 90.5% (Flexible), 95.8% (Truclear), and 87.5% (Endosee) were successfully completed. Blind endometrial biopsy was completed for all Endosee procedures; pathology was obtained for 108 (26.3%) of the Flexible and 23 (95.8%) of the Truclear procedures. Return to the operating room was significantly higher for the Endosee (88%) versus the Flexible (22%) or Truclear (0%), and total charges were significantly different between the three groups. The Endosee was more costly than either the Flexible or Truclear hysteroscopes (P=0.004 and P=0.02, respectively).

CONCLUSION: This is the first analysis comparing three different hysteroscopic methods. Our findings demonstrate a higher second procedure rate with Endosee, as well as increased cost. While ease of use is important, appropriate decision making and equipment selection is critical to the optimal use of technology. There continues to be a role for expert hysteroscopists for office procedures and further research is necessary for the evaluation of new hysteroscopic equipment related to the summary outcome of total patient care.


Single Site Natural Orifice Transluminal Endoscopic Surgery In Gynecology With Novel Flexible Robotic System

Ian Waldman, MD; Stephanie J. Estes

Penn State Health

Objective: Perform a single site NOTE surgery through the vaginal and umbilical approach using novel flexible robotic technology.

Design: Experimental cadaveric surgery utilizing a novel flexible robotic platform.

Materials and Methods: Five cadavers were utilized to evaluate feasibility of gynecologic single site flexible robotic surgery. Routine laparoscopic assessment of the pelvis was undertaken to evaluate the reproductive tract. A posterior colpotomy was utilized for entry into the peritoneal cavity. The flexible robot was placed through the vagina into the peritoneal cavity. Within the peritoneal cavity we attempted to visualize key anatomic locations, including the ovaries, fallopian tubes, infraovarian fossa, uterine fundus, bladder peritoneum, posterior cul-de-sac, and anterior abdominal wall.

Results: We were successfully able to enter through a posterior colpotomy and dock the robot. The ovaries, fallopian tubes, and uterine fundus were visualized. We were unable to adequately visualize the posterior cul-de-sac or bladder peritoneum secondary to the robotic arm incompletely rotating 180 degrees, as well as lack of length of the robotic arm. Through the umbilical approach we were able to successfully reach all anatomic locations (4/5 cadavers). Key pelvic measurements were taken including width of colpotomy needed to accommodate introduce (mean 2.75cm), vaginal width (mean 4.07cm), vaginal length (mean 11cm), and internal cervical os to introitus (mean 10cm).

Conclusion: This is the first description of flexible robotic technology as a unique tool to consider for innovative minimally invasive gynecologic surgical technique. Further research and developments may make this a viable alternative to current practice as demonstrated by this initial cadaveric investigation.


Laparoscopic Partial Liver Resection for Posterosuperior Tumors

Hiroki Sunagawa, MD1; Keita Omori2; Takuto Yoshida1; Keigo Hayashi1; Aoi Fujikawa1; Akihiro Kishida1

1St. Luke's international hospital; 2Nakagami Hospital

Background: Laparoscopic partial liver resection is the first step for newly trained surgeons. But it is difficult to establish a resection line in the laparoscopic procedure because in an open partial resection, the resection line is vertical, while in the laparoscopic technique it is horizontal. Thus, the tumor needs to be approached from the bottom to begin liver resection (Bottom first approach). Especially in the posterosuperior liver is most difficult. We present an actual surgical video and report the result.

Methods: We performed 17 laparoscopic partial liver resections for liver tumors in posterosuperior liver between December 2010 and December 2017. In a sagittal view on contrast-enhanced computed tomography images, we measured the distance between a point 2 cm caudal to the subcostal arch with linea medioclavicularis (A) and the tumor (B). The trocar was introduced at point A, through which instruments such as a CUSA is also inserted for liver dissection. A line was drawn from A to a point 5 mm below point B (C) to decide where to begin the resection. When the Glissonian branches was close to the bottom of the tumor, we made it the landmark during hepatic resection.

Results: The conversion rate was nil, median operative time were 230 min (s8) and 327 min (s7), median blood loss was 90 ml (s8) and 192 ml (s7). And resection margins in all cases were negative.

Conclusion: Laparoscopic liver resection for posterosuperior tumors is feasible procedure.



A Comparison between Reduced-Port Robotic Surgery and Multiport Robot-assisted Laparoscopy for Myomectomy

Woo Young Kim, MD PhD1; Jiheum Paek2

1Sungkyunkwan University School of Medicine/Kangbuk Samsug Hospital; 2Ajou University Hospital

Objective: To compare the surgical outcomes between reduced-port robotic surgery (RPRS) using the multi-channel port and conventional multiport robot-assisted laparoscopy for myomectomy.

Methods & Procedures: This prospective study compared and analyzed data from 15 consecutive women who underwent RPRS for myomectomy and 15 consecutive women who underwent multiport robot-assisted laparoscopy to treat symptomatic uterine myoma from January 2016 to September 2016. The patients were treated by two surgeons at two institutions.

Results: The two study groups did not differ demographically. The differences in surgical outcomes, such as docking time, console time, hospital day, estimated blood loss, Hb change, myoma count, and weight, also did not differ between the two groups. On the contrary, the number of port site was only 2 in RPRS compared with 4 to 5 in multiport robot-assisted laparoscopic myomectomy.

Conclusion: RPRS for myomectomy seems technically feasible and safe, with short-term perioperative outcomes similar to those from multiport robot-assisted laparoscopic myomectomy.



Pure Laparoscopic Right Posterior Hepatectomy for Hepatocellular Carcinoma

Deng Feiwen, MD; Chen Huanwei

Affliated Foshan Hospital of Sun Yat-sen University

OBJECTIVE: To explore the safety and efficacy of pure laparoscopic right posterior hepatectomy for hepatocellular carcinoma.

METHODS & PROCEDURES: The clinical data of six patients underwent pure laparoscopic right posterior hepatectomy for hepatocellular carcinoma in the Affiliated Foshan Hospital of Sun Yat-sen University between January 2014 and December 2017 was analyzed retrospectively. Liver resection procedure was by Glissonean pedicle transection method.

RESULTS: All pure laparoscopic right posterior hepatectomy were finished successfully without conversion to open operation. The patients’ age ranged from 33 to 62 years old, median age was 48 years old. All were male. Five cases were hepatitis B virus infected associated hepatocellular carcinoma. All patients were with Child-Pugh class A liver function before operation. The average diameter of the tumor was (5.2±2.3)cm. Five cases were with segment 6 and 7 resection and one with combined segment 6, 7 and 8 resection. The average operation time was (382±42) minutes. The median blood loss introperation was (450±268) ml. All patients recovered very well with 10 days of median hospital stay after surgery. Five cases were with pleural effusion and ascites without intervention after the surgery. After the median 8 months follow up period (ranged 4 months to 58 months), no patient with tumor recurrence.

CONCLUSION: With skillful laparoscopic liver resection technique and selected patient, pure laparoscopic right posterior hepatectomy for hepatocellular carcinoma was safe and efficient. Glissonean pedicle transection method was the key maneuver



Practical Use of Laparoscopic Transient Occlusion of Uterine Srteries (TOUA): Prevention of Intraoperative Bleeding

Jae Young Kwack, MD1; Yong-Soon Kwon, MD, PhD1,2

1Ulsan University Hospital; 2University of Ulsan College of Medicine

Objective Transient occlusion of uterine arteries (TOUA) has previously been reported as a safe and effective method of controlling intraoperative bleeding in laparoscopic myomectomy and adenomyomectomy. We applied this method during other gynecologic procedures: cesarean scar pregnancy, hydatidiform mole, and cervical pregnancy.

Methods and procedures Case 1. A 38-year-old woman, gravida 1 with one previous cesarean section. Cesarean scar pregnancy (amenorrhea 8wks), continuous vaginal bleeding after curettage required a conversion to laparoscopy. Case 2. A 44-year-old woman, gravida1 with one previous cesarean delivery . Cesarean scar molar pregnancy (amenorrhea 4 wks) for vaginal bleeding. Her initial β-hCG count was 450945.9 mlU/ml. Conversion to laparoscopic surgery because transcervical extirpation and medical treatment had been failed. Case 3. A 40-year-old nulliparous woman. Cervical pregnancy (amenorrhea 6 wks). Laparoscopic surgery because transcervical extirpation and medical treatment had been failed.

Results In all three cases, laparoscopic excision was performed successfully by using the TOUA method.

Conclusions Laparoscopic TOUA can be a good method to control intra-operative heavy bleeding during gynecologic surgery with risk of heavy bleeding.



Complete Dissection of Paraaortic Lymph Node by Using 5-port Laparoscopic Approach

Yong-Soon Kwon, MD PhD1,2; Jae Young Kwack, MD2

1Ulsan University Hospital, 2University of Ulsan College of Medicine

Aims In the case of laparoscopic staging of ovarian cancer or endometrial cancer, paraaortic lymphadenectomy is needed for complete staging when there is suspicious lesion. However, great vessel injury during paraaortic lymph node dissection can induce profuse bleeding and it would be increase morbidity of the patients. We devised a method of securing operative field using 5-port laproscopic approach to obtain safety and completeness of paraaortic lymphadenectomy. This video will introduce the technique of paraaortic lymph node dissection in our institute.

Method (Video) Five trocars were needed for the operation. The position of the surgeon was on the lower part of the patient, between the patient’s legs. The surgeon used suprapubic and left trocar and the first assistant used right lower and upper trocars. The first assistant stood on the right side of the patient. The right upper trocar was for the first assistant’s left hand and lower trocar was for the right hand. The second assistant held the videoscope on the left side of the patients.

Results Paraaortic lymphadenectomy was performed completely at the level of inferior mesenteric artery without surgical complications. There was only 2 conversion to laparotomy because of renal vein injury. Mean operation time was 31.5±4.6 minutes and mean number of extracted lymph nodes were 16.6.

Conclusion Laparoscopic 5-port approach paraaortic lyphadenectomy can be a feasible choice for the safe and complete staging operation.



Robotic Procedure Versus Open Surgery for Simultaneous Resection of Colorectal Cancer with Liver Metastases: Short-term Outcomes of a Randomized Controlled Study

Jianmin Xu, MD PhD; Ye Wei, MD; Mi Jian, PhD; Wenju Chang, PhD; Qinghai Ye, MD; Xiaoying Wang, MD; Li Ren, MD; Xinyu Qin, MD

Zhongshan Hospital, Fudan University, Shanghai

OBJECTIVE: Simultaneous resection of both colorectal cancer and liver metastases is a safe and effective surgical procedure for treating colorectal cancer patients with liver metastases (CRCLM). However, the safety and efficacy of robotic simultaneous resection of CRCLM is unclear. The aim of this study was designed to compare robotic procedure with open surgery, and establish robotic surgery indications to identify benefit population of CRCLM.

METHOD & PROCEDURES: CRCLM patients were evaluated and confirmed with surgical indication by multidisciplinary team, and randomized 1:1 to either robotic or open surgery. The primary endpoint is three years disease-free survival, the second endpoints include short-term surgical outcomes and complications.

RESULTS: Sixty patients underwent robotic surgery and 60 patients underwent open surgery from September 2013 to June 2017. Despite longer operating time, patients assigned to robotic surgery had less blood loss (99.3 ml vs. 205.1 ml, P <0.001), shorter time to pass first flatus (63.0 hours vs. 93.6 hours, P <0.001), return to fluid diet, and shorter hospital stay. Furthermore, faster recovery of stress response and liver function were observed in robotic arm, and severe complication was decreased in robotic arm (6.7% vs 20.0%, P=0.032). On analyzing quality of life, postoperative sexual function was better in robotic arm(P<0.001). In addition, we recommended selective CRCLM patients with number of liver metastases<3, and maximal lesions size <5cm. CONCLUSIONS: Selective CRCLM patients were identified and recommended to accept robotic surgery. Robotic surgery results in similar safety as open procedure, with shorter recovery period, decreased complication, and improved sex function. _________________________________________________________________________________ 134GS

Transanal Specimen Extraction of Laparoscopic Radical Resection of Rectal Cancer Without Abdominal Auxiliary Incision

Dexing Chen, Prof Dr Med; Guangyuan Xing,MD

Qianwei Hospital of Jilin Province

Objective: To discuss the application of natural orifice specimen extraction in Laparoscopic radical resection of rectal cancer.

Methods: Retrospective analysis of clinical data of 7 cases of transanal specimen extraction of laparoscopic radical resection of rectal cancer without abdominal auxiliary incision, which our department had carried out during of 1st June 2017 to 30th January 2018.

RESULTS: The operation was completed successfully in all 7 cases, and no one was referred for open surgery. The average operational time was 160 ~ 216mins, with average total blood loss of 20~80ml. The postoperative recovery was well, and complications such as anastomotic bleeding, anastomotic stenosis, anastomotic leakage and abdominal infections were not found. Followed-up for 1~ 6 months after the operation, found no local recurrence, metastasis and incision of tumor.

Conclusion: The application of transanal specimen extraction in laparoscopic rectal cancer resection is safe and feasible, and the short-term effect is satisfactory.



Progress on Transumbilical Laparoendoscopic Single-site Hysterectomy in China

Huiqun Wang, MD1; Xianbo Fu, MD PhD2; Xiaowei Zhang, MD PhD2; Heqiong Li, MD2

1Peking University Third Hospital; 2Chinese Journal of Minimally Invasive Surgery, Peking University Third Hospital

Objective To assess the progress on transumbilical laparoendoscopic single-site hysterectomy in China.

Methods Systematic reviews of transumbilical laparoendoscopic single-site hysterectomy published through February of 2018 were included by searching 3 Chinese electronic databases.

Results Of the 98 non-duplicate papers, 33 studies met the criteria for inclusion, including 525 cases of laparoscopic assisted vaginal hysterectomy in 17 papers, 347 cases of laparoscopic hysterectomy in 13 papers, 28 cases of laparoscopic radical hysterectomy in 2 papers, and 3 cases of laparoscopic staging operation of endometrial carcinoma in 1 paper. The included studies were published between 2010 and 2017. Single port hysterectomy was performed using a transumbilical instrument, such as TriPort (7 papers), QuadPort (2 papers), EndoCone (1 paper), SILS port (1 paper), and some kinds of single-port systems made in China (5 papers). The rest of the papers used 3 trocars all inserted via a 2-3 cm incision around or through the umbilicus. Straight conventional instruments were used in 9 papers, and lengthened or flexional single-port special instruments in 13 papers. Barbed sutures were used to suture vaginal cuff in 4 papers. Of the total of 903 cases, only 8 cases need conversion to traditional 3-port laparoscopy (7 cases) or open surgery (1 case), and 1 case need one auxiliary port. Injury of blood vessel (2 cases) and bladder (1 case) were reported in 1 paper among 27 cases of laparoscopic radical hysterectomy.

Conclusion Transumbilical laparoendoscopic single-site hysterectomy is feasible and safe, and is becoming widely used in China.



Robotic Inferior Vena Cava Tumor Thrombectomy: Initial Series from the University of Missouri

Logan W McGuffey, MD; Lukas Hockman, MD; Alexander Jones, MD; Anna Ali; Naveen Pokala, MD

University of Missouri

Introduction: Renal neoplasms with inferior vena cava tumor thrombus represent a complex surgical challenge. Open surgery has been associated with prolonged recovery, morbidity and peri-operative mortality. Recent published series have described the feasibility and safety of robotic-assisted laparoscopic tumor thrombectomy, which is less invasive and has the potential for faster recovery with fewer complications.

Methods: From 2015 to 2017, four patients underwent intracorporeal robotic caval tumor thrombectomy by a single surgeon. A retrospective chart review was performed on these patients. Data were collected on patient characteristics, tumor and thrombus characteristics, surgical technique, complications, post-operative course and follow up status.

Results: All operations were completed intracorporeally without intraoperative morbidity or mortality. Mean tumor size was 12cm. Mean thrombus length was 4.6cm. According to Mayo Classification, tumor thrombi ranged from level I to III. One patient was a Jehovah’s Witness and refused blood transfusion. Three patients had known metastasis preoperatively and two underwent prior renal embolization. Mean console time was 8.9 hours, mean blood loss was 950cc and mean hospital stay was 8.5 days. Post-operatively, two patients experienced Clavien IIIa complications. At mean follow up of 5.8 months all patients remain alive. Two have experienced disease progression.

Conclusion: Robotic inferior vena cava thrombectomy is feasible and safe with appropriate preoperative planning and patient selection.



Minimally Invasive Right Colectomy with Fully Stapled Intra-Corporeal Anastomosis

Michael Eric Dolberg, MD1; Zachary Snow, BA2; Jeffrey Snow, MD1

1Memorial Healthcare System; 2Nova Southeastern University College of Osteopathic Medicine

Purpose: This video presents a case of a 36 year old female diagnosed with a cecal cancer. A laparoscopic right colectomy with fully stapled intra-corporeal anastomosis (ICA) was performed. A review of the outcomes in the initial sample of 93 patients was completed.

Methods: Retrospective review of 93 minimally invasive right colectomy cases.

Results: 74/93 cases were elective and 19 were either urgent or emergent. The avg. age of the patient population was 68 years. The avg. BMI was 27.52. The lymph node harvest was 23.86. Average operative time was 115 minutes. The avg. length of stay was 4.13 days in the elective group. Complications included: ileus (8); seroma (2); intra-abdominal bleed with return to the OR (1); anastomotic leak with return to the OR (1); abdominal abscess (2).

Conclusions: The LOS in the elective group was 4.13 days. 64% of these patients were discharged by POD 2. We believe that the return of bowel function is faster with ICA due to the fact that the bowel is not pulled up through an incision in order to perform an extra-corporeal anastomosis. The lymph node harvest (23.86) is within the standard of care. Two patients required a return to the OR. There were no wound infections. The use of a pfannenstiel incision combined with negative pressure wound therapy appears to decrease wound complications as well as post-operative pain. In the future, ICA will be compared to a historical group who underwent minimally invasive right colectomy with extra-corporeal anastomosis.



Laparosopic Pancreas-sparing Duodenectomy

Akihiro Cho, MD PhD
Tokyo Joto Hospital

Background: Pancreas-sparing duodenectomy is an attractive surgical procedure for patients with duodenal adenoma, which is difficult to resect endoscopically.

Materials and Methods: Five patients with ampullary disease underwent a totally laparoscopic pancreas-sparing duodenectomy. End-to-side anastomosis between the common duct of the bile and pancreatic ducts and the jejunal limb was performed intracorporeally following the duodenal resection.

Results: Three patients displayed adenoma, while the remaining two had early adenocaricinoma. All lesions were well clear of surgical margins. Mean operative time was 185 minutes, and mean blood loss was 50g. No patients required blood transfusion. One patient developed a biliary leak that resolved spontaneously.

Conclusion: Although there is limited experience and appropriate indications must await future studies, the present cases demonstrate that laparoscopic pancreas-sparing duodenectomy is a feasible, safe, and effective in carefully selected patients.



Transgastric Resection of Paracardial Gastrointestinal Stromal Tumor

Xiaohui Xu, MD; Yushang Cui, MD; Ye Zhang, MD
Peking Union Medical College

Objective: Gastric gastrointestinal stromal tumor (GIST) is a common disease of upper digestive track. Esophageal GIST can be resected through myotomy. Exophytic gastric GIST can be treated with partial gastric resection. But it is really difficult to treat paracardial GIST without gastric resection or injury to cardial structure. We try to find a method of resecting tumors but sparing the stomach.

Method: We present a case of a 60-year-old man in Sep 2014. Gastric endoscopy found an extramucous tumor with size of 5.0 cm X 3.3 cm which was neither exophytic nor endophytic. The tumor located around cadia with 2/3 circle. We make a 5cm incision on anterior gastric wall longitudinally through laporascopy. The tumor was resected after mucosal incision surrounding cardia without injury to cardial muscles. Then we accomplished mucosal suture and stapling incision on gastric wall.

Result: The patient was discharged on 3rd postoperative day uneventfully. The pathology was low grade GIST with Ki-67 2% and free margins. No sign of recurrence was found, and no symptoms of dysphagia or reflux in follow-up of 41 months.

Conclusion: Transgastric approach is a feasible option for paracardial GIST.


Treatment of iIatrogenic Luschka Bile Duct Injury

Dexing Chen, Prof Dr Med; Guangyuan Xing,MD Qianwei Hospital of Jilin Province

The injury of Luschka bile duct in laparoscopic cholecystectomy is often ignored by surgeons.This video introduces the treatment of iatrogenic Luschka bile duct injury by laparoscope in our hospital. For the thicker bile duct, the discontinuous end-to-end anastomosis of Luschka bile duct performed with 3-0 absorbable suture can effectively avoid the chances of cholestasis and biliary fistula.



Comparison of Sleeve Gastrectomy and Roux en Y Gastric Bypass in Weight Loss and Improving Comorbidities: A Five Year Follow Up

Karamollah Toolabi, MD; Mahdieh Golzarand, PhD; Maryam Sarkardeh, MD

Tehran University of Medical Sciences

Background: Bariatric surgeries are an effective approach in treating morbid obesity and its complications in long term period. Laparoscopic Roux en Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG) are the most prevalent bariatric surgery. The aim of this study was to evaluate the rate of weight regain, weight loss and improvement of medical comorbidities in patients with LRYGB and LSG at 1 and 5 years after surgery in Iranian morbidly obese patients.

Methods: In a prospective cohort study, 120 patients who had undergone LRYGB and LSG from 2011 - 2016 were followed up. Weight loss, weight regain, demographic features and remission rate of comorbidities were evaluated.

Result: 56 patients underwent LSG and 64 patients underwent LRYGB. Follow up rate after 5 years was around 82%. After 1 year, EWL% was higher in LSG group: 79.3±25.5% vs. 68.6±18.8% in LRYGB group , but after 5 years, EWL% in LSG group was 70.5 ±27.1% vs. 71.7±30.2%.Weight regain after 5 years of surgery was significantly higher in LSG group 3.1±6.8 kg in comparison with 0.1±8.7 kg in LRYGB group. Some obesity related comorbidities were regressed after bariatric surgery in our study. Prevalence of dyslipidemia decreased from 22.5% to 0% after 1 year of surgery. Also a significant decrease in prevalence of HTN and DM was observed after 1 year of surgery. HTN decreased from 15% to 8% after 1 year and to 7% after 5 years of surgery. DM prevalence decreased from 10% to 4% and 3% after 1 and 5 years.



Endoscopic Pilonidal Sinus Treatment – A Promising Novel Technique in Treatment of Pilonidal Disease

Marko Zelić, Prof Dr Med; Dorian Kršul, MD; Damir Karlović, MD; Đordano Bačić, MD PhD

University Hospital Rijeka

OBJECTIVES: The purpose of this retrospective observational study was to present our results in operative treatment of pilonidal sinuses using endoscopic approach. All operations were performed with EPSiT procedure (Endoscopic Pilonidal Sinus Treatment) using fistuloscope. Our aim was to show that endoscopic treatment can be equally effective or even better than excisional treatment with primary closure.

METHODS AND PROCEDURES: In one year period (April 2016. – April 2017.) 39 patients with pilonidal sinus disease underwent EPSiT procedure and 51 patients underwent excisional procedure with primary closure. Postoperative follow up was up to 6 months. Primary healing was defined as wound closure and lack of secretion 5 weeks postoperatively. To determine statistical significance Fischer’s exact test was used.

RESULTS: Primary healing occurred in 33 cases (84,61%) in EPSiT group, and 32 cases (62,74%) in excisional group, which was shown to be statistically significant (p=0.0318) using Fischer’s exact test. Rest of the patients had secondary wound healing or required reoperation. There was no serious intra and postoperative complications.

CONCLUSION: EPSiT as a novel endoscopic therapeutic procedure has demonstrated healing results that are better than excisional procedures with primary closure. We could argue that it also leaves superior aesthetical results due to smaller wound. Initial promising results require further investigations on a larger group of patients.



Laparoscopic Perforated Peptic Ulcer Repair - Technique and Results

Heitor F.X. Consani, MD1; Yasmine Rebecchi2

1Centro de Cirurgia da Hernia, 2Universidade

OBJECTIVE: Evaluate the results of laparoscopic repair for perforated peptic ulcers. SUMMARY: Laparoscopic repair has been used to treat perforated peptic ulcers since 1990, in our institution we started to use in 2000 and since 2012 it is authors preference.

METHODS: From January 2012 to December 2017, 48 patients with a clinical diagnosis of perforated peptic ulcer were reviewed. Primary outcomes were postoperative complications, mortality, and reoperation. Secondary outcomes were operative time, postoperative pain, postoperative hospital stay, nasogastric tube duration, time to resume diet, and the date of return to normal daily activities.

RESULTS: There were 36 male and 12 female patients recruited, ages 18 to 90 years. The median postoperative stay was 6 days, no complications and death were attributed to laparoscopy and were comparable with the literature

CONCLUSIONS: Laparoscopic repair of perforated peptic ulcer is a safe and reliable procedure.



Minilaparoscopic Cholecystectomy: The Lessons Learned After 18 Years of Experience and More than 2,530 Cases

Diego Laurentino Lima, MD1; Gustavo Henrique Belarmino de Góes (Medical Student) 1; Raquel Nogueira Cordeiro (Medical Student)2; Gustavo Lopes de Carvalho, MD, PhD1

1University of Pernambuco, 2Pernambuco ́s Faculty of Health

Objective: To show the results after 18 years of experience of a single surgical team in the Brazil performing minilaparoscopic cholecystectomy by clipless technique.

Method: A total of 2,536 consecutive patients who underwent MLC were analyzed, from January 2000 to January 2018. Of total, 1973 (77,8%) were women whose age ranged from 6 to 99 years old.

Surgical technique: After performing the pneumoperitoneum at the umbilical site, four trocars were inserted; three of 3.5 mm, and one of 11 mm in diameter, through which a laparoscope was inserted. Neither the 3-mm laparoscope, nor clips, nor manufactured endobags were used. The cystic artery was safely sealed by electrocautery near the gallbladder neck, and the cystic duct was sealed with surgical knots. Removal of the gallbladder was carried out, in an adapted bag, through the 11-mm umbilical site.

Results: The operation video mean time was 24 minutes. There was conversion to LC in 32 cases, which represents 1.261% of total. There was no conversion to open surgery, no bleeding, no bile ducts injury, no bowel lesion, no reoperation or mortality, no important complications in intra and postoperative time. There were just 11 cases (0.433%) of umbilical hernia, which occurred in the first 1,000 surgeries, and 23 cases (0.906%) of minor umbilical infection that was treated with antibiotics. There was great satisfaction of patients regarding postoperative pain and reduced hospital stay.

Conclusion: The clipless MLC shows to be a safe and effective technique, with a lower learning curve when compared to other techniques.



Laparoscopic Hysterectomy in Large Myoma Uteri by Using Lee-Huang Point

Mineto Morita, MD PhD1; Takehiko Tsuchiya, MD2; Yusuke Fukuda, MD2; Tomoko Taniguchi, MD2; Yukiko Katagiri, MD2

1Toho University School of Medicine, 2Toho University

Objective: The Lee–Huang point was developed as the site for insertion of the primary trocar midway between the xiphoid process and the umbilicus. Its location provided the laparoscopist a central anatomical view compatible with the practice of head-to-foot orientation of laparoscopic surgery. Since then, the application of the Lee–Huang point has expanded to various gynecologic laparoscopic surgeries. To present cases of laparoscopic hysterectomy in large myoma uteri by using Lee-Huang point.

Design: Retrospective study

Materials and Methods: In five patients with large myoma uteri, Lee-Huang point was used as primary 12mm trocar. Patients were placed in a dorsal lithotomy position. The arms are tucked at the sides and a foam mattress is situated directly under the patient to prevent sliding during steep Trendelenburg.

Results: The average value of amount of bleeding was 370 ml (120-680 ml). The average of surgical time was 161 minutes (138-198 minutes). The average weight of the specimen was 1125 gram (847-1468 gram). The postoperative course of all patients was good. Pathology anatomy results were fit with leiomyoma.

Conclusions: Lee-Huang point approach offers wide access to abdominal cavity, proper visual angle and increase work space. Lee-Huang Point was very useful in laparoscopic surgery of patients with large myoma uteri.



A Tale of Two Surgeries: Laparoscopic Wedge Resection of Segment II Liver Lesion and Laparoscopic Sleeve Gastrectomy

OBJECTIVE: The objective of this study was to demonstrate the safety and advantage of performing a second procedure, laparoscopic liver haemangioma resection, alongside a laparoscopic sleeve gastrectomy.

METHODS & PROCEDURES: In this case, we performed preoperative imaging and consulted hepatology specialists to ensure the liver mass was a benign haemangioma. The laparoscopic wedge resection of the haemangioma was performed first and immediately following, the laparoscopic sleeve gastrectomy was performed.

RESULTS: The patient tolerated both procedures well without complication. The liver haemangioma was successfully removed and the sleeve gastrectomy was performed without difficulty. There was minimal bleeding encountered on the cut liver edge and haemostasis was easily achieved with a combination of direct pressure of the liver against the diaphragm, electrocautery, haemostatic agent, and fibrin glue. The patient subsequently lost 26 pounds at the three week postoperative visit.

CONCLUSION: In conclusion, there is a benefit to performing laparoscopic wedge resection of a liver haemangioma in patients who are undergoing laparoscopic sleeve gastrectomy. Performing the haemangioma resection prior to the sleeve gastrectomy mitigates the risk of unintentional damage, especially during mobilization of the stomach at the splenic flexure, and allows for haemostasis of the cut liver edge to be obtained in a controlled setting.



Resection of a Hepatic Cyst by a Hybrid Minilaparoscopic Approach

Diego Laurentino Lima, MD; Gustavo Lopes de Carvalho, MD, PhD; Gustavo Henrique Belarmino Góes; Raquel Nogueira Cordeiro; Romenig Profetisa de Oliveira

University of Pernambuco

Case Report: Female patient, 59 years old, with history of abdominal pain in the upper right quadrant and mesogastrium. Ultrasonography was performed, with heterogeneous anechoic hepatic cyst of approximately 13.0 x 6.5 cm. Investigation continued with a nuclear magnetic resonance imaging of the total abdomen, which showed a massive complex cystic expansion, occupying the topography of the left lobe of the liver ( 10.6 x 7.6 x 7.3 cm). A hybrid laparoscopic approach was used to dissect the hepatic cyst. Two 3.5 mm minilaparoscopy trocars were used (one trocar positioned in the left iliac fossa and one in the right iliac fossa) and a trocar of 5.5 mm in the left flank. In the umbilical region, a 10 mm camera was used. The pneumoperitoneum was performed using the open technique under direct vision. A massive cystic mass with thickened walls was found in the segment III of the liver. Due to the possibility of being a malignant neoplasia, the resection of the segment III was considered. However, the surgical team decided to only unroof the cyst which presented a purulent aspect. After unroofing, we used the electrocautery in the edges of the cyst. The piece was removed through the 10 mm trocar. The surgery had no complications, with a total time of 60 minutes. The patient was discharged five days after the surgery, due to the need of intravenous antibiotic.

Conclusion: The Hybrid Minilaparoscopic technique was safe and effective for this procedure. The known advantages of minilaparoscopy - less trauma, better visualization were observed.



Robotic Reconstruction of the Inferior Vena Cava with Bovine Pericardial Patch – Management of Renal Cell Carcinoma with a Level III Tumor Thrombus

Logan W McGuffey, MD; Naveen Pokala, MD; Alexander Jones, MD

University of Missouri

There have been various series describing the feasibility and safety of robotic inferior vena cava thrombectomy. As surgeons continue to improve robotic skills, more complex caval thrombi are being managed laparoscopically. Level III thrombi require more extensive liver dissection, and more frequently require vascular reconstruction.

Methods: We present our experience with a retro-hepatic level III tumor thrombus from renal cell carcinoma with complete intra-corporeal robotic caval thrombectomy, and describe our surgical technique for control of the cava and reconstruction with bovine pericardial patch graft.

Results: This patient underwent robotic level III inferior vena cava thrombectomy for a 12cm right-sided renal cell carcinoma with a thrombus length of 8.7cm. At the time of surgery, no pre-existing metastatic lesions were present. No pre-operative embolization was performed. The console time for the surgery was 11.5 hours with an estimated blood loss of 400cc. Given the extent of cava excised, a bovine pericardial graft was used for cavotomy closure. Pathology included grade 4 clear cell with sarcomatoid features, stage pT3cN0M0. The length of hospital stay was 6 days. There were no intra-operative or post- operative complications. At 3-month follow-up the patient was still alive.

Conclusions: With careful patient selection, surgical planning, and surgical experience level III tumor thrombi can be safely managed robotically.



Laparoscopic Splenic Flexure Mobilization for Sigmoid or Rectal Resections: A Systematic Review and Meta-analysis of Observational Studies

Hanjoo Lee, MD1,2; Alexandra Chudner, MD1; Artem Dyatlov, MD1; Mahir Gachabayov, MD, PhD1; Roberto C Bergamaschi MD, PhD1

1New York Medical College at Westchester Medical Center-2Metropolitan Hospital

OBJECTIVE: The aim was to evaluate the impact of splenic flexure mobilization on anastomotic leak and surgical site infection rates in sigmoid or rectal resections.

METHODS & PROCEDURES: The Scopus, MEDLINE and Pubmed databases were searched. Inclusion criteria were clinical studies comparing laparoscopic SFM to non-SFM during sigmoid or rectal resections. Non-comparative studies and studies comparing open or robotic SFM, and non-clinical studies were excluded. Anastomotic leak and surgical site infection were the primary endpoints Statistical heterogeneity and between-study variance were assessed using I2 and Tau2 statistics, respectively. A random-effects model was used for variables with heterogeneity exceeding 50%.

RESULTS: Six studies with 12,790 patients were analyzed including 5,089 SFM and 7,701 non SFM. The overall bias risk was found to be high. No significant difference was found in anastomotic leak rates when SFM patients were compared to their non-SFM counterparts [OR(95%CI) = 0.96 (0.50-1.82); p=0.903; number needed to treat (NNT)=98]. SFM patients had longer operating time [OR(95%CI) = 4.84 (1.39-16.80); p=0.013] and increased SSI rates when compared to their non-SFM counterparts [OR(95%CI) = 1.21 (1.09-1.35); p<0.001; NNT=29]. Superficial incisional SSI rates were higher in SFM patients [OR (95%CI) = 1.29 (1.14-1.47); p<0.001; NNT=53], whereas there was no difference found in organ/space SSI rates. CONCLUSION: Laparoscopic SFM was not associated with decreased anastomotic leak rates. SSI rates were increased in patients undergoing laparoscopic SFM. This favors individualized decisions rather than routine implementation. _________________________________________________________________________________ 156MUL

Robotic Assisted Sigmoid Resection for Locally Advanced Endometrial Cancer

Gerad A Feuer, MD1; Nisha Lakhi, MD2

1Northside Hospital, 2Richmond University Medical Center, Staten Island, New York

Objective: This video demonstrates a robotic sigmoid resection using a robotic gastrointestinal anastomosis stapler.

Methodology: The patient is a 69 year old, para 0, who presented with symptomatic vaginal bleeding. Endometrial biopsy revealed grade III endometrial cancer. Pre-operative CT scan indicated omental caking with possible involvement of the sigmoid colon. The patient had diagnostic laparoscopy which showed limited disease involving the sigmoid colon. A robotic hysterectomy, bilateral salpingo-oophorectomy, omentectomy, lymph node dissection and a sigmoid resection with end-to-end anastomosis using a robotic gastrointestinal anastomosis stapler, was performed. The patient was debulked to zero residual disease. Final pathology was consistent with clear cell endometrial carcinoma involving the uterus, cervix, omentum, and sigmoid colon. The patient was debulked to zero residual disease.

Conclusion: Given that the disease involving the sigmoid is limited, bowel resection with end-to-end anastomosis is feasible while also achieving optimal debulking outcomes.



Perioperative and Clinical Outcomes in the Management of Cervical Cancer Using a Robot: A Large Case Series Study in a Single Medical Center in China

Yuanguang Meng, Dr Med; Ye Mingxia MD

The Chinese PLA General Hospital

Objective To report the feasibility and efficacy of robotic-assisted management of cervical cancer.

Methods A robotic surgery program was introduced into the gynecologic oncology fellowship program at PLA general hospital in 2008. A database of patients undergoing surgical management of cervical cancer between December 2010 and December 2017 was collected and analyzed.

Results During the study period, 223 patients with cervical cancer (FIGO stages IA1–IIB) met the inclusion criteria and were included in this study. Five patients were at stage Ia1,7 patients were at stage Ia2, 120 patients were at stage Ib1,30 patients were at stage Ib2, 48 patients were at stage IIa1,7 patients were at stage IIa2 and 11 patients were at stage IIb. The mean age was 50 years old (range 27–71) and the mean BMI was24.1 Kg/m2 (range 21.9 – 26.2). The mean operating time was 229 minutes (range100-500ml) and showed a trend of gradually shortened. We identified 223 women, including 175 early stage (FIGO IA2, FIGO IB1 and FIGO IIA1 as Group 1, and 48 local advanced stage (FIGO IB2, FIGO IIA2 an FIGO IIB) as Group 2. No difference was found in the operative time, hospital stay, estimated blood loss, laboratory variables and complication between the two groups.

Conclusion A robotic surgical system is a considerable minimally invasive choice for cervical cancer. However, more long-term follow-up result should be enrolled and additional studies are required.



Laparoscopic Greater Curvature Plication Versus Laparoscopic Sleeve Gastrectomy: A Prospective Study with 5 Years of Follow-up

Yun Ji, MD; Xiaoli Zhan, MD; Jinhui Zhu, MD; Xianming Lin, MD; Yan Chen, MD; Yuedong Wang, MD

Second Affiliated Hospital, Zhejiang University School of Medicine

OBJECTIVE: Laparoscopic greater curvature plication (LGCP) and laparoscopic sleeve gastrectomy (LSG) are two restrictive bariatric procedures. This prospective nonrandomized study was aimed to compare mid-term results between LGCP and LSG.

METHODS & PROCEDURES: From January 2011 to October 2012, a total of 72 patients were assigned by patient choice after informed consent to undergo either LGCP (n = 37) or LSG (n = 35). Data on the operative time, complications, postoperative hospital stay of LGCP and LSG, percent of excess weight loss (%EWL) and improvement of comorbidities were collected during the 5 years’ follow-up.

RESULTS: All procedures were completed laparoscopically. The baseline characteristics of the patients were similar in both groups. No patient needed reoperation due to an early complication. No significant statistical differences were found in operative time and postoperative hospital stay. Five years after surgery, the mean %EWL was 53.6% (n = 32) in the LGCP group and 72.3 % (n = 31) in the LSG group (P < 0.05). At the last follow-up, the comorbidities, including diabetes, sleep apnea and hypertension, were markedly improved in both groups. CONCLUSION: LGCP and LSG are equally safe and effective in improvement of comorbidities, but LGCP is inferior as a restrictive procedure for weight loss after 5 years of follow-up. _________________________________________________________________________________ 159GS

Laparoscopic Plicated Sleeve Gastrectomy: Results in a Series of 58 Patients

Yun Ji, MD; Xiaoli Zhan, MD; Jinhui Zhu, MD; Xianming Lin, MD; Yan Chen, MD; Yuedong Wang, MD

Second Affiliated Hospital, Zhejiang University School of Medicine

OBJECTIVE: Current techniques of laparoscopic sleeve gastrectomy (LSG) usually use a vertical gastrectomy for sleeve-forming. There is no doubt that considerable laparoscopic skills are required to find a suitable size at which the pressure of the sleeve is not excessive and the restriction is sufficient for obtaining good weight-loss effect without increasing the risk of complications. Considerable technical details are required to create a “perfect sleeve”. We introduced our sleeve-forming technique for LSG involving both vertical gastrectomy and plication in 2013, which we have termed “laparoscopic plicated sleeve gastrectomy (LPSG)”. This technique, designed to reduce the technical difficulties in the creation of a “perfect sleeve”, has now been routinely performed for our patients who ask for a LSG procedure. This study aimed to analyze the surgical outcomes.

METHODS & PROCEDURES: Fifty-eight patients who underwent LPSG were enrolled in this study. Patients' demographics and perioperative data, including complications and weight loss, were collected.

RESULTS: All procedures were completed laparoscopically. There were no major complications that needed reoperation. No mortality was recorded. Follow-up at 1 year was 45 patients, and 17 patients reached 3-year follow-up. Excess weight loss at 1 year was 78.7 % and at three years 74.6%.

CONCLUSION: In this present 3-year outcome, LPSG has been proven to be an effective bariatric procedure. Longer follow-up is still needed.



Surgical Outcomes in Patients Undergoing Same-Day Hysterectomy: A Single Institution Experience

Nicole B. Gaulin, MD; Marcia Klein-Patel, MD/PhD; Eileen Segreti, MD; Fredric Price, MD; Thomas Krivak, MD; Stephanie Munns, MD

Western Pennsylvania Allegheny Health Network

Objective: To evaluate the feasibility and safety of same day minimally invasive hysterectomy in gynecologic patients undergoing surgery for benign and malignant indications.

Methods: A retrospective chart review from July 1, 2016-June 30, 2017 was performed of patients who underwent minimally invasive hysterectomy (robotic or laparoscopic) at Western Pennsylvania Hospital. Characteristics, including demographics, diagnosis, pathology, duration of surgery, length of stay and complications were recorded. Patients discharged the same day as surgery were compared to those who were admitted overnight. Subgroups were analyzed and multivariable logistic regression was performed to determine association of characteristics with same day discharge.

Results: 604 patient charts were analyzed. 11% (N=64) of patients were discharged the same day. Medical comorbidities, emergency department visits (9.4% vs 11.7%, p=0.58) and surgical complication rates (3.2% vs 2.3%, p=0.65) were similar between the groups. Within the 213 patients included having surgery for malignancy, 17 (9%) were discharged the same day. BMI was similar between the same day discharge and later discharge groups (33.5 vs. 34.5). Those discharged the same day with malignancy were significantly younger (55.8 vs 61.3 years old, p = 0.045). Emergency room visits (5.9% and 6.6%, p = 1.0) and surgical complications (5.9% and 2.6%, p = 0.40) were similar in the groups.

Conclusions: Same day discharge is a safe and feasible option for some patients undergoing minimally invasive hysterectomy for both benign and oncologic indications. Implementation of a multidisciplinary approach may help optimize the opportunity for same day discharge for a larger patient population.



A Case Report of Complete Small Bowel Obstruction Caused by the Appendix

Varun Krishnan, MD; Roman Grinberg, MD

Lenox Hill Hospital

Background 74 year old male with a medical history of GERD and no past surgical history presented to emergency department with a small bowel obstruction

Summary Our patient presented to the emergency department with a two day history of abdominal pain, distention, nausea and absence of flatus. He reported that the pain became increasingly severe, prompting him to go to an urgent care center, where a CT scan was performed and was suggestive of a small bowel obstruction. He subsequently was sent to our emergency department. He was initially treated non-operatively with nasogastric tube decompression, however, the patient ultimately went to the operating room given his lack of surgical history as well as his persistently high nasogastric tube outputs. Intraoperatively, a diagnostic laparoscopy was performed. The appendix was noted to be wrapped around the terminal ileum and the mesoappendix was noted to be adhered to the mesentery of the small bowel, causing a complete small bowel obstruction. Laparoscopic lysis of adhesions and appendectomy was performed with subsequent resolution of the obstruction.
Conclusion We present an interesting case of a patient with a small bowel obstruction caused by the appendix wrapping around the terminal ileum.



The Design for the Minimally Invasive Laparoscopic Rectopexy and Sacrocolpopexy

Hiroaki Nagata, MD PhD; Yuen Nakase, MD PhD; Kazuto Yamada, MD; Akira Sougawa, MD; Satoshi Mochizuki, MD; Shouzo Kitai, MD; Seishirou Inaba, MD PhD

Nara City Hospital

Objective: Laparoscopic rectopexy and sacrocolpopexy is attractive procedure that provide patients less invasiveness and more satisfaction. The number of laparoscopic rectopexy for the pelvic organ prolapse has been increasing and become mainstream alternative to the open or trans anal approach. We overview our introduction of this procedure in our hospital.

Results: We started this method from 2014 and we have experienced total 11 cases (9 rectopexy and 2 recto and sacrocolpopexy) up to date. There were 91% of women and mean age at surgery was 73.5±19.2 [mean±SD]. Focusing on the rectopexy, the duration has improved as 107.8±22.3 min [mean±SD] in first half of introduction period vs 99.0± 8.6 min in latter half. Comparing the duration by laparoscopic surgery expert to trainee, the former was 91.8±12.8 min vs latter 116.7±15.2min. We performed the procedure using four 5-mm trocar and one 12mm trocar. We use composite mesh for the rectum and vigina fixation. There are no severe complication in all cases. We experienced only one re- prolapse and performed re-operation.

Conclusion: Arrival of the aging society, the number of patient suffering from pelvic organ prolapse will increase. We have to fight to keep up with the demand. So far, we have performed laparoscopic rectopexy and sacrocolpopexy safely. And more, we are exploring novel surgical mesh delivery system using syringe-type device.



Workplace Bullying Faced by Residents in Obstetrics and Gynecology

Belinda J. Nhundu, BA1; Soorin Kim, MD2; Vrunda Desai, MD2

1Yale School of Medicine, 2Yale New Haven Hospital

OBJECTIVE: Mental health in residency training has gained attention in recent years. Bullying defined as exposure to interpersonal aggression and mistreatment has implications on mental health and ultimately patient care. Our objective is to characterize the extent, source and frequency of bullying experienced by resident in Obstetrics and Gynecology.

METHODS : With IRB approval a previously validated survey tool -Negative Acts Questionnaire-Revised (NAQ-R) was distributed to 13 residency programs in the American College of Obstetricians and Gynecologists (ACOG) District 1.

RESULTS : The survey had a response rate of 23.2%. On average respondents cited experiencing 7.1/22 scenarios of bullying. Most respondents were women (79.7%), interns (31.9%) and were from large residency programs (56.5%). Respondents cited more work related bullying scenarios than person related bullying and physical intimidation. The most common sources of bullying came from attendings in the department (31.7%) followed by co-residents (22.5%). Sixty percent of respondents cited having medical opinions ignored weekly (19%) and daily (7.1%).

CONCLUSION: Residents in Obstetrics and Gynecology commonly experience workplace bullying. Addressing the sources of bullying can improve patient care, reduce burnout of residents and increase career satisfaction.



Does Robotic Total Mesorectal Excision Provide Optimal PA

Alexandra Chudner, MD; Mahir Gachabayov, MD; Hanjoo Lee, MD; Artem Dyatlov, MD; Roberto Bergamaschi, MD

Westchester Medical Center

Objective: The aim of this study was to determine whether robotic TME provides optimal pathologic outcome in overweight males with low rectal cancer (MOL).

Methods & Procedures: Prospective data on 890 consecutive patients undergoing robotic TME by six surgeons after neoadjuvant therapy for resectable rectal cancer during an 8 year period were analyzed. Overweight was body mass index >25 kg/m2. Low rectal cancer was within 6 cm from the anal verge. Pathologic outcome included circumferential resection margin (CRM) and TME quality. CRM involvement was identified by pathologist at <1mm. TME quality was macroscopically classified by pathologist as complete, nearly- complete or incomplete. T-student and Chi-squared tests were used to compare continuous and categorical variables, respectively. Results: There were 581 males (65.3%) and 116 (13%) of them were MOL. CRM in MOL patients was significantly narrower compared to all patients (6.8±5.6 vs. 8.3±9.8 mm; p=0.029) and to other males (6.8±5.6 vs. 8.1±9.8 mm; p=0.039). However, CRM involvement in MOL patients did not differ (4.3% vs. 3.5%; p=0.55). TME quality in MOL patients did not differ (84%, 10%, 6% vs. 88%, 9%, 3% (p=0.57) and (86%, 9%, 5% vs. 87%, 9%, 4%; p=0.78). At multivariate logistic regression, MOL patients did not appear to be independent predictors of CRM involvement (p=0.06). Conclusions: This study confirms that robotic TME may provide optimal pathologic outcome in MOL patients. Although CRM was a few mm less in MOL patients, the values were still within the range of uninvolved margins making the statistical difference clinically insignificant. _________________________________________________________________________________ 166GS

Transanal Minimally Invasive Excision of Giant Rectal Adenomas

Fabrizio Luca, MD; Maheswari Senthil, MD; Matthew Selleck, DO; Blake Babcock, MD; Elizabeth Raskin, MD; Mark Reeves, MD PhD; Carlos Garberoglio, MD

Division of Surgical Oncology, Loma Linda University Cancer Center, Loma Linda, CA

Introduction: TAMIS (Transanal Minimally Invasive Surgery) was first described in 2010. The procedure is carried out with a single transanal port and laparoscopic instruments. The rationale for use of TAMIS for giant adenomas is to reduce operative mortality and surgical complications such as: permanent stoma, urinary/sexual dysfunction, incisional hernias, and low anterior resection syndrome.

Methods and Procedure: This video describes the technique of transanal excision of a giant adenoma of the rectum, extending 270 degrees circumferentially and measuring 9 x 4.5 cm. The lesion was resected en bloc and intraoperative frozen sections of the margin were negative. Our experience has provided us with 5 guidelines in treating giant adenomas transanally: (1) marking the lesion circumferentially helps to ensure adequate margins; (2) benign adenomas can be excised following a submucosal plane, but full thickness is preferred if malignancy is suspected; (3) extraperitoneal resections can be left open in cases of a small defect, however, closure of large defects is advisable, even if only partial, to lower the risk of late complications such as stricture and infection; (4) lesions near the anal verge can be treated with a hybrid technique (completing the distal dissection with a conventional transanal excision); (5) peritoneal breach can be successfully treated transanally.

Conclusions: TAMIS should be considered the procedure of choice for giant adenomas. Ergonomic instrumentation and magnified views allow for full thickness excision and en bloc resection. Increased dexterity allows for complications such as peritoneal breach and bleeding to be treated transanally.



Huge Parametrial Endometriotic Lesion Infiltrating the Pelvic Floor Muscles with Histopathological Correlation

Claudio Peixoto Crispi Junior, MD MBA; Claudio Peixoto Crispi MD; Marlon de Freitas Fonseca PhD

Crispi Institute of Minimally Invasive Surgery

OBJECTIVE: Report a case of a patient with deep endometriosis involving multiple structures, who underwent cytoreductive surgery, and the parametrial lesion was infiltrating the pelvic muscles. Also present a systematic review of the literature on endometriosis infiltrating pelvic floor.

METHODS & PROCEDURES: The systematic review was performed by the two authors, using the combination of the terms "endometriosis", "pelvic floor", "pelvic muscles", "ischiococcygeus", "coccygeous", "pubococcygeus" and "puborectal" Medline/Pubmed. We report a case of a 29-year-old woman with deep endometriosis affecting several structures, among them: bladder, rectosigmoid, diaphragm and parametrium. She had low abdominal pain related to menstrual cycle, which intensified at the end of menstrual bleeding, not responsive to hormonal treatment. The nodule painful to palpation was found in the right parametrium. Magnetic resonance imaging showed a large retrocervical nodule with deep extension to the right parametrium. Robotic surgery was the treatment of choice for resection of all endometriotic lesions.

RESULTS: The systematic review found no study demonstrating the presence of deep endometriosis of the pelvic floor musculature. The patient underwent robotic surgery, which resected all lesions, with a multidisciplinary team, without any complication. During the surgical procedure, the right parametrectomy was performed, after nerve sparing and ureterolysis. It was evidenced that the parametrial focus penetrated the pelvic floor musculature. A shaving of the affected muscle was performed. After surgery histopathology confirmed the presence of endometrial glands and stroma in between the muscle fibers of the floor.

CONCLUSION: The parametrial endometriosis can infiltrate the pelvic floor as demonstrated this unprecedented case.



Does Size Matter? Comparing 3 mm Versus 5mm Working Port Sites for Laparoscopic Cholecystectomy

Kristin McCoy, MD; Diane Durgan, MD; Brandon Madris, MD; James Bonheur, MD

Stamford Hospital

Laparoscopic cholecystectomy is one of the most common surgeries performed in the United States with over 300,00 being performed annually. Traditionally this utilizes two 10mm ports and two 5mm working ports. Our study aims to determine if there is an advantage to using 3mm compared to 5mm working ports in terms of pain control and operative length. Thirty patients undergoing laparoscopic cholecystectomy at Stamford Hospital were retrospectively reviewed from 2015 to 2017. Operative records were analyzed to determine the size of the working ports. The post operative data was compared, specifically pain control, length of operation, and length of stay in recovery room. Narcotic medications administered were standardized using a morphine conversion scale. A statisitcal analysis was conducted using a t-test. Our data demonstrated a statistically significant difference in operative time for the 5mm port group (traditional) versus 3mm port group (mini-port), (52 min vs 42 m p = 0.03). Pain scale on arrival to the recovery room was less on average for the mini-port group (3 versus 4). Pain on discharge from the recovery room was less for the mini-port group at 2 versus 3 for the traditional group which approached statistical significance (p=0.08). Narcotic use did not differ between the groups, average being 5mg of morphine for each (p = 0.75) Utilization of 3 mm ports during laparoscopic cholecystectomy is an acceptable technique. The results demonstrate similar operative times and reduced pain upon discharge. Our future investigations will aim to further delineate these outcomes.



Extrahepatic Glissonean Approach in Laparoscopic Anatomical Liver Resection

Akihiro Cho, MD PhD1; Hiroshi Yamamoto, MD2; Osamu Kainuma, MD3; Hiroo Yanagibashi, MD4

1Tokyo Joto Hospital, 2Chiba Sawara Hospital, 3Funabashi Medical Center Hospital, 4Chiba Cancer Center Hospital

Aims: Although recent rapid developments in technological innovations, improved surgical techniques and the accumulation of extensive experience by surgeons have improved the feasibility and safety of laparoscopic liver surgery, laparoscopic anatomical liver resection remains a highly specialized field, as major technical difficulties remain, such as hilar dissection and pedicle control.

Methods: We developed a novel technique by which each Glissonean pedicle could be easily and safely encircled extrahepatically during laparoscopic anatomical liver resection. Subjects comprised 50 patients who underwent laparoscopic anatomical liver resection using an extrahepatic Glissonean pedicle transaction. w

Results: In various types of anatomical liver resections, including right hepatectomy, left hepatectomy, anterior sectonectomy, posterior sectionectomy, medial sectionectomy, and central bi-sectonectomy, Glissonean pedicles, including the right, left, anterior, posterior, and medial pedicles, could be encircled extrahepatically and divided en bloc, as planned. No serious complications, including major bleeding or injury of the portal triad, were encountered during procedures.

Conclusions: The entire length of the primary branches of the Glissonean pedicle and the origin of the secondary branches are located outside the liver and the trunks of the secondary branches, and even more peripheral branches run inside the liver. The right, left, anterior, or posterior Glissonean pedicle can thus be tied and divided en bloc extrahepatically during open anatomical liver resection. Even in laparoscopic procedure, extrahepatic Glissonean approach appears feasible and safe for anatomical resection of the liver.



Parastomal Hernia Repair with Mesh

Mariana Cabral MD1; Morris E. Franklin MD2; Miguel A. Hernandez2

1Technologico de Monterreym 2 Texas Endosurgery Institute

OBJECTIVE: More than 750,000 Americans have an ostomy, and approximately 130,000 new ostomies are created each year in the United States, literature mentions that approximately 50% of all stomas ends up with a parastomal hernia. In our experience 100% of the patients has a parastomal hernia whether is symptomatic or not. We are going to present you a way to repair a hernia laparoscopically for a permanent stoma.

METHODS & PROCEDURES: 51-year-old male with ulcerative colitis who underwent a total colectomy and j-pouch reconstruction 15 years ago, with multiple episodes of intestinal obstruction due to a nonfunctional pouch resulting in a loop ileostomy 2 years ago. Now presenting with a stoma prolapse.

RESULTS: We use 5, 5mm trocars and release the adhesion laparoscopically, then we dismantle the loop ileostomy and convert the loop ileostomy into a terminal one performing a termini-lateral anastomosis with the distal intestine manually, a circumferential hole was made on the biological mesh, and introduce the loop of bowel, next the mesh was fix with staples.

CONCLUSION: There is still not a correct way to repair a parastomal hernia, recurrence rates are high with suture repair and relocation of the stoma; recurrence rates have been lower with mesh repairs, but still the most used techniques have a recurrence rate up to 30%. Using this technique so far we have a 0 recurrence rate.



Emergent Repair of Paraesophageal Hernias and the Argument for Elective Repair

Brian Joseph Shea, MD1; William Boyan, MD1; Jonathan Decker, DO1; Vincent Almagno, BS2; Steven Binenbaum, MD1; Gurdeep Matharoo, MD1; Anthony Squillaro, MD1; Frank Borao, MD1

1Monmouth Medical Center, 2St. George's University School of Medicine

Objective: A feared complication of large paraesophageal hernias is incarceration necessitating emergent repair. According to previous studies, patients that require an emergent operation are subject to increased morbidity when compared to patients undergoing elective operations. In this study, we detail patients that underwent hernia repair emergently, and compare their outcomes with elective patients.

Methods & Procedures: A retrospective analysis was performed of the operations performed between 2010 and 2016. Patients were initially divided into two groups: hernias that were repaired electively and those that were repaired emergently. A third group was created from the elective group to match the age, sex, and comorbidity characteristics of the emergent group. Perioperative complications and follow up data regarding morbidity, mortality and recurrence was also recorded.

Results: 29 patients had hernias repaired emergently and 201 patients underwent elective procedures. Patients undergoing emergent repair were more likely to have a type IV hernia, have a partial gastrectomy or gastrostomy tube insertion as part of their procedure, have a post-operative complication, and have a longer hospital stay. When compared to the age and comorbidity matched group, these findings were no longer statistically significant. Having an emergent operation did not increase a patient’s risk for recurrence.

Conclusion: Though patients that had their hernias repaired emergently suffered complications at similar rates to those in their age and comorbidity matched elective cohort, the complications tended to be of higher grade, leading to a more complicated post-operative course. The authors therefore recommend evaluation of all paraesophageal hernias for elective repair.



Bleeding and Stricture Prevention in Laparoscopic Colorectal Surgery with the Use of a Stapler Line Reinforcement

Mariana Cabral, MD1; Morris E. Franklin2; Jeff L. Glass2; Miguel A. Hernandez2

Texas Endosurgery Institute

Background: Anastomotic leak, bleeding, and stricture are recognized complications with increase morbidity and mortality. The frequency of anastomoses leakage rages from 1% to 24%. The aim of this study is to describe our experience, quality of anastomosis, and the low rate of complications in laparoscopic colorectal anastomosis procedures with stapler line reinforcement, and how it improves the outcomes.

Methods: Retrospective study and collected data of 739 consecutive patients who underwent laparoscopic colorectal resection and primary anastomosis using stapler line reinforcement from 2006 to 2017 were reviewed.

Results: There were no differences in patients’ demographics, surgical procedure, and anesthesia used. 739 patients; (50.3%) female, (49.7%) male. Procedures were: 41%) right hemicolectomy, 30% sigmoidectomy, (19.5%) low anterior resection, (4%) subtotal colectomy, (3.8%) left hemicolectomy, and (1.5%) transverse colon resection. DIagnoses: colorectal cancer (39.5%), diverticulitis (23%), polyps (17.7%), Crohn’s disease (1.5%), dysmotility (0.5%), rectal prolapse (0.3%), ulcerative colitis (1.7%), fistula (3%), ischemic
colitis (1.5%), perforation (3.8%), volvulus (1.9%), and obstruction (6.7%). Median follow-up 7 months. Total intracorporeal anastomosis done in (72%), hand assisted anastomosis in (28%). There were (0.4%) anastomotic leak detected and treated intraoperativelly. No strictures, and no bleeding in follow up.

Conclusion: The use of stapler line reinforcement at the anastomosis site is safe, and seems to show a low rate of stenosis, leaks, bleeding, and better quality of anastomosis.



Single Port Laparoscopic Myomectomy with Uterine Artery Ligation via Retroperitoneal Approach is Feasible for Huge Uterine Myoma

Jihye Kim, MD; Soo Young Cheong, MD; Myeong Seon Kim, MD; Chel Hun Choi, MD, PhD; Jeong-Won Lee, MD, PhD; Byoung-Gie Kim, MD, PhD; Duk-Soo Bae, MD, PhD; Tae-Joong Kim, MD, PhD

Samsung Medical Center, Sungkyunkwan University School of Medicine

Study Objective: To compare operative outcomes of single-port laparoscopic myomectomy with uterine artery ligation via retroperitoneal approach (SP-rLM) versus conventional single-port laparoscopic myomectomy (SPLM) for treatment of symptomatic uterine myomas.

Design: Retrospective cohort study.

Setting: Single institutional medical hospital in Seoul, Korea

Patients: Fifty six women with symptomatic uterine myomas who scheduled for elective single-port laparoscopic myomectomy, from January, 2016 to September, 2016. Twenty four underwent SP-rLM and 32 received conventional SPLM. Patient’s characteristics and properties of myomas were compared between the groups. Also, surgical outcomes, including operation time, estimated blood loss and hemoglobin decrease were evaluated.
Interventions: Ligation of uterine artery via retroperitoneal approach at the beginning of single port laparoscopic myomectomy.

Measurements and Main Results: There were no significant differences in demographic characteristics and properties of myomas including location and type of largest myoma between the groups. There also were no differences innsurgical outcomes, such as operation time, estimated blood loss, and immediate complications, between the 2 groups. And, there was no serious complication in both groups. However, the diameter of longest myoma of SP-rLM group is longer than SPLM group (8.0±1.5 vs. 6.9±1.9, P-value = 0.019).

Conclusion: There were no differences in operative outcomes and complications between the 2 modalities. Therefore, SP-rLM is more feasible for peri-menopause women who have huge myoma compared with SPLM.



Laparoscopic Main Portal Fissure Approach with Parenchymal-sparing Partial Hepatectomy for Deep-seated Metastasis Colorectal Tumor

Keita Omori, MD1; Hiroki Sunagawa2

1Nakagami Hospital, 2St.Luke's International Hospital

Background: The indications for surgery in patients having colorectal liver metastasis (CRLM) are rapidly increasing. Based on recent trends, a 1-mm cancer-free margin involving a parenchymal-sparing hepatectomy (PSH) is accepted as a standard (R0). However, as it is difficult to perform PSH for deep-seated tumors, we attempted a laparoscopic main portal fissure (LPF) approach with PSH for deep-seated CRLM.

Methods: We placed one port at the umbilicus using an open method and four ports below the right rib cage. Using intraoperative ultrasonography, we first investigated the tumor and middle hepatic vein and dissected the main portal fissure to reach the middle hepatic vein, and then resected the tumor hemispherically toward the liver surface. We performed an LPF-PSH in two patients with metastatic liver tumors. Surgical margins were negative, and these patients had an uneventful postoperative course.

Results: LPF-PSH is a safe and feasible procedure for deep-seated CRLM around the main portal fissure.



Metastatic Disease Treatment Confined to the Peritoneum. Pressurized Intraperitoneal Aerosol Chemotherapy - A New Approach

Christos Liakos, MD; Stratoulias Konstantinos; Kalantzis Georgios; Gatos Christos

Athens Medical Center

OBJECTIVE: Peritoneal carcinomatosis is a locoregional disease with relative chemoresistance and bad prognosis.

METHODS & PROCEDURES: Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC). New concept of locoregional and systemic approach for peritoneal metastases.

RESULTS: PIPAC might be proved a palliative salvage intent therapy. It is minimally invasive surgery with no limitation in peritoneal metastasis extent that conserves the quality of patients life.

CONCLUSION: Certainly more studies must be carried out for this new method efficacy. There is already a PIPAC Registry in Europe.



Laparoscopic Interval Debulking Surgery Including Systemic Lymphadenectomy After Neo- adjuvant Chemotherapy in Advanced Ovarian Cancer

Jeong Min Eom, MD PhD; Joong Sub Choi, MD PhD; Jaeman Bae, MD PhD; Won Moo Lee, MD PhD; Un Suk Jung, MD PhD

Department of Obstetrics and Gynecology, Hanyang University College of Medicine

OBJECTIVE: To evaluate feasibility, safety, and operative outcome of laparoscopic interval debulking surgery including systemic lymphadenectomy after neo-adjuvant chemotherapy in advanced ovarian cancer.

METHODS & PROCEDURES: This study was retrospective analysis of ten consecutive cases undergoing laparoscopic interval debulking surgery after neo-adjuvant chemotherapy for advanced ovarian cancer from January 2012 to January 2018.

RESULTS: A total of ten patients were included. Nine patient had clinical complete response and one had partial response after neo-adjuvant chemotherapy according to Gynecologic Cancer Intergroup and Response Evaluation Criteria in Solid Tumors criteria. Surgical procedures included maximal cytoreduction included pelvic and para-aortic lymphadenectomy. Intraoperative and postoperative outcomes were evaluated. Following interval debulking surgery, nine patients had no gross residual tumor and one ended up having a suboptimal debulking. The median operative time was 323 minutes (range 184 - 419) and estimated blood loss was 460 ml (range 50 – 630) during the surgery. Seven among them were given a blood transfusion. There were no significant complications during intraoperative and postoperative state and the median hospital stay was eight days (range 5-21).

CONCLUSION: Laparoscopic interval debulking surgery including systemic pelvic and para- aortic lymphadenectomy after neo-adjuvant chemotherapy in advanced ovarian cancer may be considered feasible and safe. The more cases are needed for evaluation to achieve optimal debulking.



A Case of Laparoendoscopic Reduced-port Nephrectomy for Renal Angiomyolipoma Followed by In-bag Manual Morcellation

Kaori Kawano, MD; Tositaka Shin,MD PhD; Mari Hanada,MD PhD; Kazunori Iwasaki,MD PhD; Mituhiro Mimata,MD PhD

OBJECTIVE: One limitation of using Reduced Port Surgery for nephrectomy is the difficulty of safety extracting specimens through small incisions. Herein, we present a first case of laparoendoscopic reduced-port nephrectomy for renal angiomyolipoma (AML) followed by in- bag manual morcellation.

METHODS AND PROCEDURES: Patient was a 35 year-old woman who had a 6-cm left renal mass. CT scan showed a fat component. Thus, we preoperatively diagnosed as AML. We performed laparoendoscopic reduced-port left nephrectomy. A 3-cm umbilicus incision was made and an access platform was inserted. Two trocars were placed through the access platform, and additional two 3-mm trocars were inserted. Finally, in-bag manual morcellation was performed using laparoscopic scissors within an isolation bag.

RESULTS: The procedure was successfully completed in 219 min, with an estimated blood loss of a small amount. There were no intraoperative or postoperative complications, and the patient was discharged 7 days postoperatively. The umbilical scar was concealed within an umbilical fold, and the scars of 3-mm trocar were almost invisible.

CONCLUSION: Laparoendoscopic reduced-port nephrectomy followed by in-bag manual morcellation is a safe and technically feasible procedure that offers great cosmesis especially for young female patients.



Acellular Dermal Matrix Plug in the Treatment of Primary Transphincteric Anal Fistula: A Prospective Study

Gabriella Giarratano, MD PhD1; Edoardo Toscana, MD1; Claudio Toscana, MD1; Pierpaolo Sileri, MD, PhD, Prof2

1Villa Tiberia Hospital, 2Tor Vergata University

OBJECTIVE We report data of a prospective study designed to evaluate feasibility, early and long- term outcomes of Acellular Dermal Matrix (ADM) plug in the treatment of primary transphincteric anal fistula.

MATERIALS AND METHODS Between January 2014 and December 2017, 27 patients affected by primary transphincteric anal fistula assessed by endoanal ultrasound, were enrolled and treated using ADM plug. A seton was placed for a minimum period of two months before the intervention to all patients and the plug was then surgically positioned through a press-fit technique. The Wexner Incontinence score was administered before and after surgery.

RESULTS Median follow-up was 25,48 months (range 3-40) and the median healing time was 75 days (range 60 – 115). No major complications were observed. Five recurrences were observed (18,51%). The post-operative pain, evaluated with VAS score, ranged between 0 – 3 in 23 patients (85,18%) and 4 – 7 in 4 patients (14,81%). No impairment of continence was observed and no difference reported in Wexner Incontinence score before and after surgery.

CONCLUSIONS The surgical treatment of anal fistula still remains challenging and a sphincter saving procedure is desirable. Our results suggested that ADM-plug could be a simple, safe, not expansive, minimally invasive and potentially effective procedure in the treatment of anal fistula.



Advantage of Laparoscopic Bariatric Surgery in Obese Patients Including a Patient with Renal Transplantation

Wen Yao Yin, MD

Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; College of Medicine, Tzu Chi University, Hualien, Taiwan

Objective In kidney transplantation, obesity is associated with poorer graft survival and patient survival. Bariatric surgery may provide benefit for these patients, not only by inducing weight loss, but also via reduction of diabetes.

Methods & Procedures We report a case of morbid obesity, poorly controlled new-onset diabetes mellitus, and gout after kidney transplantation that was treated with laparoscopic sleeve gastrectomy 3 years after kidney transplantation. We will also collect the data and analyze the outcomes of the surgery with or without “Healthcare Counselling” in 100 consecutive operated cases.

Results After 1 year of follow-up, 76% excessive body weight loss was attained. No complications were noted. The operation also provided total remission of diabetes and gout as well as good graft survival. We find the significant better outcomes of the surgery with “Healthcare Counselling” in 100 consecutive operated cases.

Conclusion Based on our experience, laparoscopic sleeve gastrectomy may be a feasible treatment for obese patients after renal transplantation to help resolve obesity and control new-onset diabetes. However, the timing of operation and the long-term potential for graft and patient survivals with this operation require further study. For better outcomes especially for long term results, Healthcare Counselling after surgery is needed.



Complete Robotic Transabdominal Approach for Pelvic and Diaphragmatic Endometriosis

Jesse Chait, BS1; Andrea Vidali, MD2; Joseph Raccuia, MD2

1NYIT College of Osteopathic Medicine, 2Hoboken University Medical Center

Objective Diaphragm endometriosis is rare and usually asymptomatic necessitating surgical resection. Concomitant pelvic and diaphragm surgery can be approached transabdominally through the same port placement.

Methods & Procedures Complete transabdominal approach can be achieved
robotically through the same port sites. The entire abdomen is explored in every patient prior to docking. Three ports (8 mm) are placed with another port (12 mm). The same port positions were used for both the pelvic and diaphragmatic portions of the operation with only strategic adjustment of the robotic boom with “port hopping” during the same operation.

Results Over a 31-month period, 223 women with an average age of 39 years old (SD = 3; range 33 to 42) were operated for pelvic endometriosis of which 7 (3%) had concomitant diaphragmatic resection. Only 1/7 (14%) had a preoperative diagnosis by previous
laparoscopy. Diaphragm reconstruction was performed primarily in 5/7 (71%) patients while 2/7 (29%) others required biologic mesh reconstruction. Chest tube thoracostomy was needed in 2/7 (29%) cases. There were no complications. Patients were discharged between postoperative day 3 to 5.

Conclusion Surgical resection of endometriosis can be curative. Complete videoscopic exploration of the pelvis and diaphragm is needed in every patient as only 1/7 (14%) had the diagnosis made preoperatively. Once diagnosed, robotic port placement can be tailored so both pelvic and diaphragmatic lesions can be resected through the same port sites.



Study of Pancreatic Duct Leak After Distal Pancreatectomy with Laparoscopic Stapler in Cadaveric and Organ Donors

Wen Yao Yin, MD

Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; College of Medicine, Tzu Chi University, Hualien, Taiwan

Objective Our clinical study showed that transection site (body) and staple sizes (>2.5mm) were key factors contributing to the occurrence of POPF. If we can create a neck (thin pancreas) on the body of the pancreas by slowly compressing before cutting using another clamp (double clamping) to allow optimal situation for 2.5mm staples, then the occurrence of POPF and leakage can be significantly reduced.

Methods & Procedures Seven adult cadavers and three organ donors were used for this study. Each pancreas was cut at multiple sites with laparoscopic staplers: one cut at each neck and tail, and three cuts each on the body of the pancreas. Each cut different staple size ( 2.5 mm and 3.8 mm) and the clamping method (single or double). The leakage was checked by three steps: gross observation, probing with catheter, and methylene blue. The research was also extended onto the organ donors during harvesting surgery (not pancreas donor).

Result Cuts performed with 2.5 mm staple and/or double clamping showed no leakage on both neck and body region. Cuts with both 3.8mm staple and single clamping technique show leakage on body region but no leakage at the neck and tail.

Conclusion The result had supported the hypothesis of double clamping method and/or smaller staple can reduce the risk of leakage especially on gently compressed pancreas. This will be also proven in organ donor patient.



Analysis of the Surgical Performance and Ergonomics Using a New Design of Laparoscopic Instruments with Articulated Handle During Partial Nephrectomy

Juan A. Sánchez-Margallo1; Francisco M. Sánchez-Margallo, PhD1; Rafael Gutiérrez, MSc2; Miguel Rodal2; Mauricio Veloso Brun, PhD3; Kostas Gianikellis. Prof.2

1Minimally Invasive Surgery Centre; 2University of Extremadura, Spain; 3CNPq (308019/2015-6, 200346/2017-2), Brazil

Objectives: To evaluate the surgical performance and surgeon's ergonomics during partial nephrectomy using a new laparoscopic instrument design with an articulated handle.

Methods and procedure: Twelve partial nephrectomies of the caudal pole were carried out in an experimental porcine model, six with conventional laparoscopic instruments and six with the new instruments, organized in a random fashion. For each surgery, complications, execution time of each surgical step, and ischemia time, as well as the surgeon's ergonomics were evaluated.

Results: All procedures were completed without major complications. The surgery time (42.85±8.89 min vs 37.69±4.76 min) and ischemia time (26.09±6.14 min vs 22.86±7.71 min) were significantly shorter with the new instruments. Specifically, surgery time was reduced during the opening the peritoneum and occlusion of the renal artery (10.17±2.57 min vs 6.38±1.64 min) and during the section of the renal parenchyma (8.18±1.94 min vs 4.96±1.42 min). The surgeons did not indicate significant differences between the use of conventional laparoscopic instruments and the new instruments regarding the physical and mental workload. No discomfort or some type of ergonomic alteration in the use of the articulated handle during the surgery was indicated. Objective analysis of muscular ergonomics by means of electromyography revealed an increase of localized muscle fatigue in the deltoid and lower trapezius muscles when using the novel instruments.

Conclusions: The use of the new design of laparoscopic instruments with articulated handle with rings allows surgeons to reduce the surgery time and ischemia time during partial nephrectomy, without compromising the surgical result.



Port-site Metastasis in Laparoscopic Gynecologic Surgery – A Case Report

Danilo Acosta, MD; Camila De Amorim Paiva, MD; Fady Khoury Collado

Objective: We aim to discuss the rare complication of port-site metastasis in a patient who underwent laparoscopy for an adnexal mass.

Methods: Retrospective review of a single case. A 45-year-old female P2002 presented with what appeared to be a non-healing umbilical wound after a laparoscopic left salpingo-ophorectomy and right ovarian cystectomy for a preoperative diagnosis of endometrioma. Intraoperative findings were significant for spontaneous left ovarian cyst rupture prior to surgery. The specimen was removed using an EndoCatch bag through the umbilical incision. Pathology result was consistent with a high grade adenocarcinoma, favoring endometrioid type, arising in a background of an ovarian endometriotic cyst. Postoperative staging CT scan showed a cystic lesion in the umbilicus. After referral to the oncology service, her physical examination was significant for a friable erythematous lesion at the umbilicus. A biopsy of the lesion biopsy showed metastatic carcinoma morphologically similar to the patient’s known primary malignancy.

Results: Patient has received 3 cycles of neoadjuvant chemotherapy with paclitaxel and carboplatin. After her first cycle of chemotherapy, the umbilical lesions showed marked improvement and complete resolution by cycle 3. The patient is currently planned interval debulking surgery.

Conclusion: Port-site metastasis is a rare phenomenon, occurring in less than 1-2% of laparoscopies for gynecological oncologic surgeries. Non-healing appearing lesions at port- sites should prompt providers to think of possible malignant metastasis from a known or unknown malignancy. Chemotherapy followed by surgical excision is usually recommended in cases related to gynecologic malignancies.



Splenic Artery Pseudoaneurysm: A Late Complication of Laparoscopic Roux-en-Y Gastric Bypass

James Sahawneh, MD; Hannah Reavis, BA; Dhiren Patel, MD; Peter Nelson, MD; Geoffrey Chow, MD

University of Oklahoma - Tulsa

OBJECTIVE: Splenic artery pseudoaneurysm (SAP) is a rare occurrence. Common etiologies include pancreatitis, abdominal trauma, and iatrogenic injury. To our knowledge, there has been no published case of SAP resulting as a complication from laparoscopic Roux-en- Y gastric bypass (LRYGB). We describe a SAP in a patient with a late complication after LRYGB.

METHODS & PROCEDURES: 44 year-old female presented as a transfer from a rural hospital with abdominal pain, nausea, vomiting and concerns for a pancreatic process. She denied history of pancreatitis, alcohol abuse, or trauma. Surgical history notable for LRYGB and cholecystectomy. Lipase, triglycerides, calcium, IgG4, CEA, and CA 19-9 were within normal lab limits.

RESULTS: Initial CT revealed a complex lesion suggestive for a pancreatic mass versus pseudocyst, with plans made for outpatient workup. She returned two days later with worsening abdominal pain, and CT revealed active contrast extravasation into the cystic lesion. Angiography revealed a SAP. Splenic artery coil embolization was performed across the pseudoaneurysm. Subsequent MRI was consistent with a SAP abutting the gastric remnant staple line. CONCLUSION: SAP following laparoscopy is a rare diagnosis, making identification challenging. Splenic artery injury in this patient likely occurred during dissection including creation of the gastric pouch or ensuring hemostasis. Once diagnosed, a symptomatic pseudoaneurysm must be intervened on due to risk of rupture. Embolization or surgical options can effectively manage this process. We detail a successfully treated case of SAP as a late complication of LRYGB.



Combined Robotic Sigmoidectomy and Robotic Left Hepatectomy

Allen Chudzinski, MD; Iswanto Sucandy, MD; Michael Musumeci, BS; Timothy Bourdeau

Florida Hospital Tampa

Objective: This is a combined robotic sigmoidectomy and robotic left hepatectomy undertaken in a 56-year-old male with metastatic colonic adenocarcinoma. The patient presented after receiving neoadjuvant chemotherapy.

Methods and Procedures: A CT scan revealed not only a sigmoid colon mass at 45 cm, but also metastatic disease in his liver. The operation was undertaken utilizing 6 ports, one of which was occupied by an airflow/insufflation device and two others were utilized as assistant ports.

Results: To begin, pneumoperitoneum was established, the robot was docked, and the sigmoid colon was lifted and exposed. The inferior mesenteric vessels were ligated with a white robotic stapler. The descending colon was transected with a blue robotic stapler. The specimen was extracorporealized, transected, and anvil placed. A circular EEA stapler was then used for a primary anastomosis. The left lobe of the liver was mobilized and the segment 2 resection was performed with the robotic vessel sealer. A linear vascular stapler was used to divide the vein intrahepatically and the liver segment was removed.

Conclusions: The margin of transection was checked and found to be tumor free. Hemostasis was ensured with a laparoscopic bipolar sealing device. No drain was necessary. This video thus documents that combined robotic sigmoidectomy and robotic left hepatectomy is both safe and efficacious.



Impact of Robotic Learning Curve on Circumferential Margin and Quality of Total Mesorectal Excision in Rectal Cancer

Mahir Gachabayov, MD PhD; Artem Dyatlov, MD; Alexandra Chudner, MD; Hanjoo Lee, MD; Niu Zhang, MD; Roberto Bergamaschi, MD PhD FACS FRCS FASCRS

Westchester Medical Center, New York Medical College

Objective: The aim of this study was to assess how CRM and TME quality are affected by the surgeons’ learning curve.

Methods: Individual patient data of robotic proctectomies for resectable rectal cancer performed by 5 internationally recognized expert surgeons were pooled. Learning curve was defined as the number of cases needed before reaching competency and included learning phase (LP) and plateau phase (PP). CRM was histologically measured by pathologists in mm. TME quality was macroscopically assessed by pathologists and classified as complete, nearly complete or incomplete. Statistical analysis was carried out using statistical analysis software SPSS software (version 18: SPSS Inc., Chicago, IL, US). T-test and Chi-squared tests were used to compare continuous and categorical variables, respectively. P-value less than 0.05 was considered significant.

Results/Outcome(s): Data on 235 patients were available. 83 LP patients were comparable to 152 PP patients for age (p=0.2), gender (67.5% vs. 65.1% males; p=0.72), BMI (p=0.82), ASA score (p=0.86), previous abdominal surgery (p=0.923), stage (p=0.17), neoadjuvant chemoradition (p=0.13), distance of tumor from anal verge (5.8±4.4 vs. 5.5±3.3; p=0.56). TME quality was significantly improved in PP patients as compared to LP patients (73.5%:10.8%:4.8% vs. 92.1%:5.2%:2.6%; p<0.001) (Figure 1A). CRM did not differ (7.7±11.4 mm vs. 8.4±10.3 mm; p=0.62) (Figure 1B). Conclusions/Discussion: While the circumferential resection margin was not affected by the surgeons’ learning curve, the quality of total mesorectal excision significantly improved during the surgeons’ plateau phase. This study confirms that lack of tactile feedback in robotic surgery entails a learning curve. _________________________________________________________________________________ 188GYN

Indocyanine Green for Ureteral Visualization During Robotic Surgery for Pelvic Endometriosis

Jesse Chait, BS1; Andrea Vidali, MD2; Joseph Raccuia, MD2

1NYIT College of Osteopathic Medicine, 2Hoboken University Medical Center

Objective Endometriosis involves varying depths of the pelvic peritoneum and resection is essential for reduced incidence of recurrence. Many of these lesions involve the periureteral peritoneum and intraoperative ureteral localization is indispensable for all pelvic surgery. Indocyanine green (ICG) was used with near infrared imaging to identify the ureters during the robotic procedure.

Methods & Procedures Over 18 months, 192 consecutive women with an average age of 38± 3 years underwent resection of pelvic endometriosis after bilateral ureteral infusion of 5 ml solution of an ICG solution (25 ml ICG/10 ml H2O) with 6 French catheter. Robotic dissection with near infrared imaging (NIR) of the ureters were visualized in real time during the whole procedure.

Results Ureters were visualized in every case and easily identified during the whole procedure. There was decreased visualization over time with longer operations, however, ICG was detected on all cases during the whole procedure. No extravasation or ureteral injury was noted in any patient. There were no adverse effects directly related to the ICG infusion.

Conclusion The use ICG with NIR during robotic pelvic surgery to visualize the ureters is safe and efficacious allowing intermittent visualization of the ureters “a la demande” during the whole procedure. ICG allows real-time identification of the ureters, safe dissection, cauterization and resection of the delicate periureteral tissue. This technology can potentially reduce the incidence of iatrogenic ureter injury.



Incidence and Laparoscopic Presentation of Fallopian Tubes Endometriosis

Shirin Tavakoli Zadeh, MD; Pengfei Wang,MD.PhD; Farr Nezhat ,MD

NYU-Winthrop Hospital

Objective:To identify the incidence and appearance of fallopian-tube endometriosis during laparoscopic evaluation.

Methods and Materials: Limited data is available on incidence and laparoscopic appearance of endometriosis in fallopian-tubes.This is a retrospective of prospective data collection of patients undergoing laparoscopic/robotic-assisted laparoscopic treatment of pelvic endometriosis. All procedures were performed by the senior author (FRN) in different hospitals between Jan 2017-18.The most common indication for surgery was chronic pelvic pain, infertility and/or adnexal masses.

Results: 91 women were included;average age was 43(19±67),G 1,P 0. All had laparoscopic and pathological confirmation of pelvic endometriosis; 9 severe, 1 moderate and 1 mild.11 (12%) women had confirmed laparoscopic appearance and/or pathological diagnosis of fallopian-tube endometriosis. Diagnosis was made after salpingectomy in 10 patients; 4 had endometriosis implants on the ampullary portion of the fallopian-tubes; 3 had either severe adhesion (1) or hydrosalpinx (2); 5 had hydrosalpinx and/or severe adhesion; 2 had normal laparoscopic appearance but pathology confirmed diagnosis of endometriosis.

Conclusion: Fallopian-tube endometriosis is not uncommon in patients with pelvic endometriosis, especially in severe cases. Although typical laparoscopic appearance of endometriosis implants on the fallopian-tubes is not common and most often seen on the ampullary portion, implants may present as hydrosalpinx and/or severe adhesions that can only be diagnosed after salpingectomy. These findings can have implications in treatment of patients with pelvic pain and infertility but also in future prevention of turbo-ovarian malignancies.



Platform for Training and Assistance in Minimally Invasive Urological Surgery Based on Mixed Reality Technology

Francisco M. Sánchez-Margallo, PhD; Juan A. Sánchez-Margallo, PhD; Alejandro Cristo, PhD; Alfonso Rodríguez, MSc; Mario Suárez, MSc

Minimally Invasive Surgery Centre, Spain

Objectives: The main objective of this work is to develop and test a platform for training in anatomy and surgical assistance in urology based on mixed reality technology.

Methods and procedure: A pair of mixed reality smartglasses was used for this project. A platform for training in human anatomy of the pelvis based on interactive holograms that combine the vascular, nervous, muscular, and bone system of the pelvic floor was developed. In addition, the platform also allows access to own interactive theoretical content, 3D anatomical models and medical illustrations. Surgeons used natural user interfaces and voice control to interact with the holograms. The whole system was tested by a group of 6 experienced surgeons in urology, who evaluated different aspects of its usability.

Results: The intuitiveness, the interactivity with the preoperative studies and the clarity and organization of the presented 3D anatomical models were the most highly rated aspects by the surgeons. On the contrary, the comfort of the glasses obtained the lowest score.

Conclusions: The use of the developed platform based on mixed reality technology facilitates anatomical training in urology and its translation to actual medical practice. This technology is potentially useful for planning and assistance during surgical procedures for resection of renal tumors.



LESS Cholecystectomy Undertaken with Epidural Anesthesia in lieu of General Anesthesia

Sharona B Ross, MD; Iswanto Sucandy, MD; Timothy Bourdeau, BS; Michael Musumeci, BS; Alexander Rosemurgy, MD

Florida Hospital Tampa

Objective: This video is of a Laparo Endoscopic Single Site cholecystectomy undertake utilizing epidural anesthesia in lieu of general anesthesia.

Methods and Procedures: A 33 year old women presented with abdominal pain, nausea and vomiting. Abdominal ultra sound demonstrated gallstones. The patient was administered an epidural which consisted of 2% xylocaine with epinephrine. A multitrocar port was utilized. We began the dissection by freeing the gallbladder from the undersurface of the liver then working backwards to then document our critical view. We clipped the cystic artery once distally and twice proximally then divided. The cystic duct is then clipped and divided. The gallbladder is then freed completely from the undersurface of the liver then removed through the umbilical port.

Results: The patient's total hospital time, including the time in the surgical prep unit to the time she left the recovery room, was 4 hours.

Conclusion: The use of epidural anesthesia maintains operative exposure and reduces patients' hospital stay.



Resection of a Gastrointestinal Stromal Tumor in an Older Patient by a Hybrid Minilaparoscopic Approach and Aid of Transoperatory Endoscopy

Diego Laurentino Lima, MD; Gustavo Lopes de Carvalho, MD, PhD; Gustavo Henrique Belarmino Góes (Medical Student); Raquel Nogueira Cordeiro (Medical Student); Romenig Profetisa de Oliveira (Medical Student)

University of Pernambuco

Case Report: We report a 62-year-old male patient, who had had melena for a year. Upper endoscopy with biopsy showed gastrointestinal stromal tumor (GIST) in the stomach. A laparoscopic partial gastrectomy was then proposed. The surgery was performed with the patient in the supine position with open legs. Two 3.5 mm trocars were used, a 5 mm trocar for the ultrasonic scalpel and a 11 mm trocar in the umbilical incision were used. The pneumoperitoneum was created using the open technique under direct vision. Trans- operative upper endoscopy was used to locate the tumor. Initially, the large omentum was released with the ultrasonic scalpel. Then, we performed the resection of the tumor in the body of the stomach. The gastric wall was reinforced with a vicryl 2-0, and the tumor was removed inside an endobag by the 11 mm trocar by the umbilical incision. The surgery had no complications, with a total time of 60 minutes. The patient was discharged four days after the procedure. Histologic study of the tumor showed a GIST with free margins.

Conclusion: The hybrid minilaparoscopic approach was safe and effective for this case. The performance of the intraoperative upper endoscopy also contributed to improve the safety and efficacy of the procedure, allowing a more accurate resection of the GIST, and also to assess the suture at the end of the procedure.



Over 500 Laparo-Endoscopic Single-Site Fundoplications: A Decade of Experience

Sharona B. Ross, MD; Chandler Wilfong, MD; Nicholas Massanet, BS; Gilbert Immanuel; Darrell Downs, BS; Janelle Spence, BA; Iswanto Sucandy, MD; Alexander Rosemurgy, MD

Florida Hospital Tampa

Objective: This study delineates our decade-long experience with over 500 Laparo-Endoscopic Single-Site fundoplications for the treatment of gastroesophageal reflux disease. The Laparo- Endoscopic Single-Site approach offers a beneficial alternative to conventional laparoscopy by providing a ‘scarless’ approach.

Methods and Procedures: With Institutional Review Board approval, 507 patients who have undergone Laparo-Endoscopic Single-Site fundoplications have been prospectively followed since 2008. Patients rated the frequency/severity of their symptoms before and after the operation utilizing a Likert scale (0=never/not bothersome to 10=always/extremely bothersome). In addition, patients were queried about their scar satisfaction (1=revolting to 10=beautiful). Statistical analysis utilized paired Student’s t-tests. Median data are presented.

Results: 64% of patients were women, median age 62 years old, and body mass index 26 kg/m^2. 63% of patients underwent Nissen fundoplication and 37% underwent Toupet fundoplication. Operative time was 135 minutes with minimal blood loss. Preoperative symptoms were frequent and severe (e.g., heartburn=8/7) and decreased in frequency and severity postoperatively (e.g., heartburn=0/0 p < 0.001). 91% of patients indicated they would undergo the operation again knowing what they know now. Patients scored their incisions and scar appearance as 10. Conclusion: A decade of experience undertaking over 500 Laparo-Endoscopic Single-Site fundoplications demonstrates that Laparo-Endoscopic Single-Site fundoplication is a safe and efficacious operation, ameliorating symptoms of gastroesophageal reflux disease with patient satisfaction, in part, because of excellent cosmesis. The application of Laparo-Endoscopic Single-Site fundoplication is encouraged and surgeons should implement this approach into their armamentarium. _________________________________________________________________________________ 194MUL

Principles of New Generation of Training Technology for Medical Education: Combined Hand-manipulating and Information Technologies Master Class

Ospan A. Mynbaev, MD, PhD, ScD; Natalia N. Nadezhkina; Alexei V. Shonenkov; Avinoam Tzabari, MD; Elizaveta A. Nikitina, MD, PhD; Nadezhda S. Zvereva, MD; Elizaveta A. Nikitina; , Nadezhda S. Zvereva; Sergei A. Stepennov; Ilya A. Ryabov;, Maria N. Sysoeva, Michael Stark

The International Bureau of Human Body Design & Biomodeling; Laboratory of Human Physiology; Phystech BioMed School; Faculty of Biological & Medical Physics; Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow Region, Russia

In this new generation of training technology for medical education, combined hand- manipulating and IT master class by the International Bureau of Human Body Design & Biomodeling team will present a state-of-the-art technology giving possibility for participants to increase their hand-manipulating skills by means of a unique training kit, which opens a new way of education for surgeons and doctors. A combination of hand- training tool with IT technology where doctor can gain hand-skills on the real existing model of target organ under his own visual control of his manipulations using real routinely used instruments. Surgeons will see the movement of their instrument inserted into the organ, its movement contour during procedure, injection site of medication in the right place or wrong places with complications. 3D visualization technology was realized by internet connection with our server. Efficiency of training is going to be analyzed by a special program, basing on principles of artificial intelligence development by programmers from department of artificial technology and robotics. Master class can be translated by simultaneous internet connection between the USA and other countries and continents. In conclusion, this combined hand-manipulating and IT master class will give understanding of unique technology principles since the same tools are being developed for gynecology (aesthetic procedures, laparoscopic entering and other surgical technique steps), surgery, anesthesiology, nursery.



Adnexal Masses in Postmenopausal Women: A Review of Cases Undergoing Surgical Management

Belinda J. Nhundu, BA; Vrunda Desai,MD FACOG

Yale School of Medicine

Objective: Women with persistent ovarian masses often undergo surgery for concern of malignant potential and symptom management. ACOG currently does not have definitive recommendations for the extent of surgical management in women who have completed childbearing. We aim to characterize the extent of surgical invention in postmenopausal women with a benign adnexal mass in a single institution.

Design: A retrospective cohort review study of women (Age >51) presenting for surgery of adnexal mass at a single tertiary care university hospital. Patients were excluded if they had a prior hysterectomy or pathology-proven malignancy.

Results: Of 248 potential cases 88 met inclusion criteria. Most patients presented with pain (77.6%). The most common procedure was a unilateral salpingo oophorectomy (45.8%) followed by bilateral salphingo oophorectomy (43.4%). Three patients had a total hysterectomy for a benign adnexal mass.

Conclusion: Larger studies are required to address the need for definitive recommendations for the extent of surgical management in postmenopausal women Future work involves assessing the knowledge, attitudes and practice patterns of gynecologists regarding prophylactic hysterectomy and/or oophorectomy for benign adnexal masses.



Bezoar Management: How to Overcome Difficult Visualization in Per Oral Pyloromyotomy (POP)

Voranaddha Vachrathit, MD; Matthew T Allemang, MD; John Rodriguez, MD; Matthew Kroh, MD; Jeffrey L Ponsky, MD; Kevin El-Hayek, MD

Department of General Surgery, Cleveland Clinic, OH, USA

OBJECTIVE: To discuss how a known gastroparesis related emptying issue, namely, bezoars, influences the management of pre-per oral pyloromyotomy (POP) patients as it relates to the endoscopic intervention and to provide tips on how this is managed at the Cleveland Clinic, OH.

METHODS: This is a case report of an aborted POP due to poor visualization from food bezoars. The patient was kept overnight in the hospital for administration of pro-motility agents and NGT decompression with successful gastric clearance. This allowed for optimal visualization and for the POP procedure to be completed the next day.

RESULTS: Clips from before and after the intervention are demonstrated, with an overview of the steps for a successful POP procedure

CONCLUSION: POPs should be carried out with full visualization of the pylorus for the submucosal tunneling. Should this prove to be challenging due to food bezoars, the stomach can be evacuated overnight with NGT decompression with or without lavage, and the administration of promotility agents.



Implementation of Robotic Hepatectomy for Benign and Malignant Liver Tumors: Initial Experience of the Modern Approach

Iswanto Sucandy, MD; Kenneth Luberice, MS; Niritta Patel; Timothy Bourdeau, BS; Janelle Spence, BA; Darrell Downs, BS; Sharona Ross, MD; Alexander Rosemurgy, MD

Florida Hospital Tampa

Introduction: This study examines the emerging role of robotic hepatectomy in treating both minor and major hepatic disease. Robotic liver resection has the potential to overcome inherent shortcomings of laparoscopy with improved precision, dexterity, visual magnification, as well as decreased surgeon tremor and fatigue.

Methods: With Institutional Review Board approval, 33 patients who underwent robotic hepatectomy between 2012 and 2017 at a tertiary care center were prospectively followed. Patient demographics and perioperative outcomes were collected and analyzed. Data are presented as median (mean ± standard deviation).

Results: The majority of patients were women (67%), age of 58 (58.4±14.5) years, body mass index of 30 (30.9±8.3) kg/m2, and Model for End-Stage Liver Disease score of 15 (13.9±15.5). The most common indications included hepatocellular carcinoma (27%), metastatic colorectal cancer (18%), and benign lesions (30%). 45% of patients underwent left hepatectomy, 49% underwent right hepatectomy, while the remaining 6% underwent central hepatectomy. Operative time was 222 (221.3±114.7) minutes, estimated blood loss was 250 (357.3±354.7) mL, and only two patient were converted to the traditional ‘open’ approach. Length of stay was 3 (4.9±5.2) days. Two patients experienced postoperative complications (enterocutaneous fistula and respiratory failure), with one mortality.

Conclusion: Our data support that robotic hepatectomy is safe and feasible with favorable short-term outcomes not only for minor, but major hepatic disease. Robotic surgical systems facilitate the application of minimally invasive surgery for complex abdominal operation such as hepatectomy.



Laparoscopic Plication of Diaphragmatic Eventration in a 1 Year Old with Bronchial Hyperreactivity and Recurrent Upper Respiratory Tract Infections

Ana Carolina Andaluz , MD; Francisco Sanchez MD

Hospital San Jose Tec de Monterrey

Objective Presentation of a case of congenital eventration presented in a 1 year old girl with frequent upper tract infections and bronchial hyperreactivity and a review on the laparoscopic abdominal repair.

Patient and methods We present a case of a 1 year old female with a congenital diaphragmatic eventration presented with recurrent upper tract respiratory infections along with bronchial hyperrreactivity . TC showed right-sided diaphragmatic elevation. A dynamic fluoroscopy was performed observing paradox diaphragm movement with inspiration.

Procedure Intra abdominal laparoscopic plication was performed with no further complications during post op . A chest x-ray is taken after the procedure, observing both diaphragm at the same level and respiratory symptoms where eradicated after procedure.
Discussion Minimal invasive surgery for infants has been gradually introduced proposing advantages in diverse diseases including congenital diaphragmatic disorders. Small incisions, less recovery time, and a complete evaluation and visualization of intrabdominal organs are some of the advantaged of this approach. Diaphragmatic eventration represent 5 % of diaphragm pathologies, more common in males and classified as congenital or acquired. Symptomatic patients can present recurrent upper track infections is approximately 20 % of cases with a reduce lung function of 20-30% due to compression.
In the management of diaphragmatic repair through laparoscopy instead of thoracoscopic approach avoids placement of thoracostomy tube, selective ventilation, decrease percentage of visceral injury and allows to perform other abdominal procedures in the same intervention.

Conclusions Symptomatic eventration in infants may be considered for laparoscopic intrabdominal plication with good results, improving respiratory track manifestations.



Robot-assisted Repair of Vesico-[Utero]/Cervico-vaginal Fistula

Pengfei Wang, MD PhD; Farr Nezhat, MD; Michael Mesbah, MD; George Lararou, MD; Mathew Wells MD

NYU-Winthrop Hospital

OBJECTIVE: Urogenital fistula in developed countries mostly occurs after gynecologic surgeries, especially hysterectomy. The surgical repair mode mainly is transvaginal or transabdominal. Recently minimally invasive repair of vesico-vaginal fistula and utero- vaginal fistula laparoscopically or robotically were reported and demonstrated significant advantages.

METHODS & PROCEDURES: We presented a complicated large vesico-[utero]/cervico- vaginal fistula (VCVF) after emergent caesarean section. Repair was performed robotic assisted laparoscopically in modified O’Conor style with interposition of omental flap 2 months after injury.

RESULTS: There is no intra-operative complication with minimal blood loss and only one day hospitalization post-operatively. In four months follow up, there is no urine leakage, stress urinary incontinence, frequency or dyspareunia

CONCLUSIONS: Robot platform is an excellent surgical module in repair of complicated urogenital fistula.



Robotic Assisted Debulking of Stage IIIC Bulky Ovarian Cancer Involving the Pelvis and Upper Abdomen

Lauren Ursillo, MD; Pengfei Wang, MD, PhD; Michael Mesbah, MD; Farr Nezhat, MD

NYU-Winthrop Hospital

OBJECTIVE: Laparoscopic or robotic-assisted staging of early ovarian cancer has been well reported but robotic-assisted debulking of advanced stage ovarian cancer is still not common. Here we present our approach of debulking of a patient with stage IIIC ovarian carcinoma with a large complex pelvic mass, ascites, diaphragm metastasis, and omental caking who underwent a robotic-assisted ovarian cancer debulking with the robotic surgical platform

METHODS AND PROCEDURES: The procedure consisted of total hysterectomy, bilateral salpingo- oophorectomy, pelvic mass resection, total omentectomy, bilateral extensive ureterolysis, peritoneal diaphragmatic metastasis resection, enterolysis and appendectomy, cystoscopy, sigmoidoscopy. The four arms of robotic system can turn 180 degrees, therefore the omentectomy was feasible without undocking the robot.

RESULTS: She had optimal debulking. The total procedure took 310 minutes and the estimated blood loss was 200 ml. There were no intra or post-operative complications. The patient was discharged home on post-operative day 1 and had an uncomplicated recovery. Pathology confirmed stage IIIC high grade serous ovarian carcinoma.

CONCLUSION: Our case demonstrated that robotic-assisted optimal debulking is feasible, effective and safe for even complicated late stage ovarian cancer.



Laparoscopic Cesarean Scar Defect Repair Guided with Lightwand

Wonduk Joo, Prof Dr Med

CHA Bundang Medical Center, CHA University

Cesarean Scar Defect (CSD) is the formation of a diverticulum at the site of the old cesarean incision. With a rising cesarean sections being performed, the complications caused by CSDs has attracted more and more attentions. These include conditions such as abnormal bleeding, infertility, scar pregnancy, placenta accreta, placenta previa, and uterine rupture in subsequent pregnancies. Laparoscopic CSD repair is a proper surgical approach treat patients with CSDs. However, it is not easy to identify the exact location of CDS laparoscopically because of the lack of tactile sense. Lightwand, assistant device for tracheal intubation, may be helpful to guide Laparoscopic CSD repair. Transillumination from uterine cervix through endometrial cavity with Lightwand is helpful to find a thin uterine wall, which is the location of CSD. Five cases of laparoscopic CDS repair guided with Lightwand were performed and Lightwand simultaneous assistance during Laparoscopic CDS repair were of great help in identifying the edges of the defect, especially in large cavities and in first cases, in which edges might not be clear otherwise.



Endoscopic Transmural Stents for Resolution of Esophageal and Fundoplication Fistulas Following Failed Laparoscopic Paraesophageal Hernia Repair

Carter C. Lebares, MD; Matthew Y. Lin, MD; Stanley J Rogers


OBJECTIVE: Management of foregut leaks, at the GEJ, within a fundoplication or following delayed recognition, is extremely challenging. Operative intervention remains standard, but carries high morbidity and mortality making endoscopic rescue measures attractive. Unfortunately, such measures often fail due to stent migration, failed apposition, or tissues not amenable to clips or suturing. Endoscopic transmural stents obviate these issues and are described here for resolution of bilateral fistulae after complicated laparoscopic PEHR.

METHODS & PROCEDURES: A 78yo man presented in septic shock, intubated, 10 days post laparoscopic PEHR complicated by gross mediastinal contamination. Following thoracotomy and bilateral chest tube placement, a coated endoscopic self-expanding metal stent was placed but was ineffective against tears that were located in the fundoplication and at the GEJ. A stent-within-stent technique also failed. Due to on-going contamination the patient was catabolic, profoundly malnourished and at high surgical risk, prompting the use of endoscopic transmural pigtail drains for rescue.

RESULTS: Over 4 months, transmural drains were exchanged a total of 6 times, sequentially downsized as the fistulae and adjacent collections collapsed. By 2 months the patient was no longer tracheostomy dependent and tolerated clear liquids. By four months he passed methylene blue and fluoroscopic leak tests and returned home, taking regular food.

CONCLUSION: Endoscopically-placed transmural stents have been effective at healing leaks following sleeve gastrectomy and and were used here to resolve bilateral esophagopleural and gastropleural fistulae, with preservation of esophageal continuity.



Is Percutaneous Treatment Safe Method for Liver Hydatid Cysts?

Ali Uzunkoy, Prof Dr Med

Harran University School of Medicine

Aim: Hydatid cysts are one of the most important problems on the world. Symptomatic liver hydatid cysts can be treated by medical, surgical and percutaneous drainage methods. There is insufficient information about the long-term outcome of this treatment. Long-term results of hydatid cysts treated with the percutaneous method will be presented in this study.

Patients and Methods: Between 1999 and 2015, Gharbi type I, II and some selected type III and IV liver hydatid cysts were treated percutaneously. PAIRD (puncture, aspiration, injection, aspiration and drainage) was used as the percutaneous treatment method. It was performed under ultrasonography guidance. Albendazole was given before and after the percutaneous treatment for the prevention of the abdominal dissemination. Ultrasonography was performed for the control of cyst cavity after treatment at the first, sixth, twelfth months followed by annual follow-up.

Results: Thirty two patients were able to follow up. Average follow-up time is 31 months. The first ultrasonographic control was shown that cystic cavity was reduced and cystic distention was diminished. Recurrence of cyst was shown in one cyst (3.1%) at sixth month and treated secondary percutaneous treatment. Infection of cyst cavity was shown in one cases (3.1%) and treated medically. Anaphylactic shock and mortality were not observed.

Conclusion: The long term results of the percutaneous treatment of liver hydatid cysts were shown that this technique has higher incidence of cure for liver hytadid cysts and it has lower rates of complications and recurrence. This minimally invasive technique can be selected safely and effectively for selected liver hydatid cysts.



Amyand’s Hernia - A Novel Approach to Surgery

Hamish Walker, MBBS; Jignesh Jatania; Kamil Wynne

South Tyneside NHS Foundation Trust

Background Amyand hernia is defined as an appendix within an inguinal hernia which may or may not be inflamed. This may be an incidental finding during elective hernia repair or in the emergency setting as an inflamed appendix within the hernia with or without perforation.

Case Report A 66 year old male presented as an emergency following a 6 day history of a 5x7cm erythematous lump in the right iliac fossa that was painful on movement with erythema, rigors and anorexia. Blood tests revealed that inflammatory markers were raised. Initial impression was that of a possible abscess or an incarcerated hernia. CT scan revealed a right iliac fossa anterior wall abscess with a distended appendix extending up to it. The patient underwent a laparoscopic appendectomy, drainage of abdominal wall abscess and suture repair of hernia. The skin wound was packed and left open.

Conclusions On review of literature, Losanoff et al classified Amyand hernia operations according to degree of complicated appendicitis. This did not include a laparoscopic approach which we have shown is a feasible alternative offering benefits including diagnostic laparoscopy and washout of intraabdominal abscess whilst avoiding muscle cutting incisions. This leads to faster recovery and reduced morbidity.



Bilateral Capnothorax After Laparoscopic Total Extra-peritoneal Bilateral Inguinal Hernia Repair: A Rare Life Threatening Complication

Nicole Christine Marquand, MD; Karim Jreije, DO; Mohammed Salem, MD; Brano Djenic, MD; Ross Goldberg, MD; Paul Del Prado, MD

Maricopa Integrated Health Systems

Capnothorax has previously been reported in laparoscopic inguinal hernia repair. It is a rare but serious complication of the surgery. We report a case of a thirty-nine year old male who presented with respiratory distress and was subsequently diagnosed with symptomatic bilateral capnothorax after laparoscopic bilateral totally extraperitoneal (TEP) inguinal hernia repair. This was managed with bilateral thoracostomy tube placement with subsequent resolution. We recommend considering this differential in patient’s presenting with respiratory symptoms after laparoscopic inguinal hernia repair to aid in early diagnosis, treatment and prevent subsequent complications.



A Case of Robotic Assisted Laparoscopic Resection of a Recurrent Bulky Endometrial Retroperitoneal Pelvic Side Wall Mass

Courtney Griffiths, DO1; Farr Nezhat, MD1,2; Melissa Frey, MD2

1NYU Winthrop; 2Weill Cornell Medical College of Cornell University

Objective: This video demonstrates a complicated robotic assisted laparoscopic resection of a bulky pelvic side wall mass for a patient with recurrent endometrial cancer, involving the retroperitoneal major vessels and ureter with emphasis on surgical techniques and pelvic anatomy.

Methods & Procedures: This patient is a 78 year old female who had undergone a previous hysterectomy and bilateral salpingoophorectomy for Stage 1A endometrial cancer requiring no adjuvant treatment. She presented to the emergency department several years later with complaint of back pain and was found to have a calcified left pelvic side wall mass. She underwent four cycles of neoadjuvant chemotherapy prior to surgical intervention and treatment of pulmonary embolization. The procedure depicted is a robotic assisted laparoscopic resection of pelvic mass, lysis of adhesions, ureterolysis, peritoneal biopsies, and pelvic lymph node dissection. Techniques such as hydrodissection as well as blunt and sharp dissection were utilized to excise a bulky mass from critical retroperitoneal structures while taking great care to protect the ureter as well as external iliac vessels.

Results: Surgical techniques including a combination of blunt as well as hydrodissection prove to be an effective means of adhesiolysis. Careful dissection and focus on pertinent surrounding structures throughout the procedure lead to the successful excision of the pelvic side wall mass.

Conclusion: This case is an example of how robotic assisted laparoscopic surgery can provide significant benefit for the patient in regards to decreased blood loss, postoperative healing and decreased risk of infection as well as postoperative complications.



Natural Orifice Specimen Extraction A Novel Method for Reducing Parietal Morbidity in GI Malignancies

Brij B. Agarwal, MD; Neeraj Dhamija, MD; Varun Pathak, MD; Kiran Muley; Ravi Bhushan, MD

Sir Ganga Ram Hospital

Objectives: Time to start adjuvant therapy is an independent predictor for long-term favorable outcomes after GI malignancies. Delay/ Inability to start adjuvant therapy may result from parietal wound related morbidity. Any reduction in the parietal wound morbidity will result in a sub set of deserving patients with timely institution of Adjuvant Therapy (AdT). With this background we utilized the Natural Orifice Specimen Extraction (NOSE) through Vagina (NOSE-V) in postmenopausal consenting females to evaluate for any added advantages.

Methods & Procedures: Postmenopausal females posted for Minimally Invasive Surgery (MIS) for GI malignancy were counselled for NOSE-V. A total of 5 participants consented for same and were followed up for any deviations from the expected clinical pathways particularly post-operative wound morbidity and time to start AdT.

Results: Postmenopausal females posted for MIS for GI malignancies were included in this study. A total of 5 patients were counselled for NOSE-V, all gave written informed consent for the same. Postoperative data were recorded for all. (Table-1) Total no. of participants-5 Pre operative Diagnosis- Periampullary carcinoma=4, Carcinoma Stomach=1 Post-operative wound morbidity=SSI-Nil, Vaginal Discharge- Nil, Pelvic Abscess-Nil Time to discharge-7.6 days (5-10 Days) Time to start Adjuvant Therapy-22.4 days (18-28 days)

Conclusions: NOSE-V in consenting patients is an option which reduces the parietal wound morbidity and early institution of AdT. More studies with larger case pools are needed for making NOSE-V as a favorable option for specimen extraction.



Modified Dunking Technique for Minimally Invasive Pancreatico-Enteric Anastomosis Post Whipple’s Resection-Initial Experience of 15 Patients at a Tertiary Care Hospital in Delhi, India

Brij B. Agarwal, MD; Neeraj Dhamija, MD; Varun Pathak, MD; Kiran Muley, MD; Ravi Bhushan, MD

Sir Ganga Ram Hospital

Objective: Pancreatico-Enteric Anastomosis (PEA) remains the index predictor of postoperative outcome following Whipples’ [Pancreatic Fistula(PF) @ 2-30%]. Technical innovations in creation of PEA has led to various modifications. We present our experience of innovative 4-layer minimally invasive modified dunking technique for creation of PEA in a case series of 15 patients in a tertiary care hospital in Delhi, India.

Methods and Procedures: 15 Consecutive patients posted for MIS (Laparoscopic & Robotic)-Whipples’ resection were included in this prospective study. Study period- November 2015- March 2018. Technical factors for creation of PEA were evaluated for reproducibility and postoperative PF incidence based on International Study Group for Pancreatic Surgery grading of PF. All patients were followed for a minimum period of 3 months post surgery.

Results: Age (years)-49.28 ( 30-66) SEX -M:F--9:6 Per-operative Blood Loss in ml=360.7(150-1000) Specimen Extraction site-Vaginal-4, Port Site-9, p-fannstiel-2 Total Operative Time in minutes=565 (520-940) Post Operative Bleeding Complication-6.6% [1- PJ site Bleed]-Post Operative Pancreatic Fistula 13.3% [2 (Grade A=1, Grade B=1)] POST OPERATIVE HOSPITAL STAY-9.2 days (4-16) R0 RESECTION-100% LYMPH NODE HARVEST-9 (4—13) 90 DAYS MORTALITY -6.6% (1) 90 DAYS MORBIDITY-20% (3)

Conclusions: Modified dunking technique for creation of PEA is a reproducible technique with acceptable post operative morbidity rates in terms of PF as per our initial experience. Its acceptance as a standard technique will require more studies with larger case pool.



Clinical Analysis of Pin-shaped Bipolar Plasmakinetic Electrode Used in Transurethral En Bloc Resection of Non Muscle-invasive Bladder Urothelial Carcinoma

Wei Wang, MD1, 2, 3; Shan Chen1; Jixiang Wu2
Surgical centre, Beijing Tongren Hospital

1Urology Department, Beijing Tongren Hospital; 2Surgical Centre, Beijing Tongren Hospital; 3Capital Medical University

OBJECTIVE To investigate the surgery procedure of pin-shaped bipolar plasmakinetic transurethral en bloc resection of non muscle-invasive bladder urothelial carcinoma and investigate the clinical outcomes.

METHODS AND PROCEDURES 42 cases of non muscle invasive bladder urothelial carcinoma who received bipolar plasmakinetic transurethral en bloc resection from May 2014 to March 2016 were recruited in this study. Male 29 cases, female 13 cases, average age 50-82 years old. Wide basal tumors were noticed by preoperative cystoscopy , bladder tumors were confirmed by tumor biopsy. Full thickness specimens were obtained in procedures, including tumor, mucosa, lamina propria layer, muscular layer, to accurately assess tumor infiltration depth and staging.

RESULTS All 42 cases were done by this procedure successively. A total of 65 pieces of tumors were excised: 36 in lateral wall, 19 in posterior wall, 10 in bladder triangle. Tumor diameter ranged from 0.5 to 3.5cm, with an average (2.1±0.6cm). Postoperative pathological stages were clear: 16 cases Ta, 49 T1 (of which 32 were T1G3). Intraoperative obturator nerve reflex happened in 2 cases. All cases were Followed up for two years.Tumor recurrence in 3 cases, no progression case.

CONCLUSION Pin-shaped bipolar plasmakinetic transurethral en bloc resection of non muscle-invasive bladder urothelial carcinoma is safe and reliable. It should be recommended in management of non muscel-invasive bladder urothelial carcinoma. Full thickness postoperative specimens can provide accurately judgement of the depth of tumor invasion and pathological staging.



Construct Validity of a Simple Laparoscopic Salpingectomy Model

Shuai Wang, MD; Li Fang Li /MD

Department of Obstetrics and Gynecology People's Hospital of Nanhai Affiliated to Southern Medical University

OBJECTIVE: To determine the construct validity and interrater reliability of a laparoscopic salpingectomy simulator which was designed by clinical data.

METHODS & PROCEDURES: In our Academic teaching hospital ,a simple laparoscopic salpingectomy simulator which could simulate the sense of space in surgery was developed. The design was based on measuring intraoperative data about the relationship between instruments and operating area. A total of 31 gynecology and obstetrics residents were recruited (16 junior residents, postgraduate year PGY 1 and 15 senior residents, PGY 3). Instruction and immediate feedback in our simulation session was given. At the resident skills assessment, each resident received a unique identification number. All levels were recorded with video using this model. Two blinded raters evaluated the video of each resident with the modified Objective Structured Assessment of Technical Skills (5 domains respect for tissue, time and motion, instrument handling, flow of operation and knowledge of specific procedure). An average of the 2 ratings was computed for each domain, and comparisons were made using the Mann-Whitney U test. Interrater reliability was calculated using the Kendall tauβcorrelation coefficient. Construct validity was determined by comparing the rank scores of the junior to senior residents in each domain.

RESULTS: Construct validity and interrater reliability was demonstrated in all of the measured domains.

CONCLUSION: Construct validity discriminating between junior and senior residents was demonstrated using this model. This simple model can be used to teach basic laparoscopic salpingectomy skills.



7-point Technique in Laparoscopic Cholecystectomy to Achieve Critical View of Safety in Complex Acute Calculus Cholecystitis

Madhura Milind Killedar, MS.F.A.C.R.S.I.F.M.A.S1; Dr.Pinky M. Thapar, M.S.DNB,F.I.C.S.FALS,FMAS2; Dr.Vishwanath Masurkar,DNB (General Surgery ) 2; Dr.Roji Philip,MS.DNB.MRCS3; Dr. Muktachand L. Rokade, MD (Radiology)2

1Bharati Vidyapeeth Deemed University Medical College and Hospital, Sangli,Maharashtra,India; 2Jupiter Hospital, Thane ,Maharashtra,India; 3Fortis Hospital,Mulund,Maharashtra,India

Introduction: Complex acute calculus cholecystitis (CACC) results in overwhelming local inflammation with systemic bacterial contamination. Treating such patients with co-morbid conditions poses myriad challenges. We present prospective analysis of 138 patients of CACC managed at Tertiary referral centre from 2008 to 2017. Aim was 1) Grade CACC patients as per Tokyo guidelines 2) Timely intervention 3)Incorporation of 7-point technique to achieve critical view of safety in laparoscopic cholecystectomy (LC) 4)Review literature.

Material and procedure: All patients with CACC were graded and Tokyo II and III cholecystitis included. Radiology guided percutaneous cholecystostomy drainage (PCD) was performed in unfit patients. Co-morbidities were stabilized and early or delayed LC done. 7-point technique of aspiration of tense gall bladder(GB), timely use of 5th port and ultrasonic scissors, flag technique, hydrodissection by hugging GB, avoiding inadvertent posterior cystic artery bleeding, panoramic camera view was incorporated to accomplish critical view of safety which was key point in success.

Results: 38% were > 65 years old. 74% of Type II and 26% were Type III cholecystitis. Findings included empyema (38.8%), gangrenous (27.53%), perforated (10.14%) and dense inflammation (30.43%). 5th port used in 37% and ultrasonic scissors in 84.78%. Delayed LC was done in 23%. Critical view of safety was achieved in 98%. 2 patients required conversion. Bile duct injury was 0% and morbidity of 5% with mortality of 0.72%.

Conclusions: Timely intervention in CACC, unhurried dissection and use of 7-point technique helps to achieve critical view of safety with excellent outcome and also lowers incidence of conversion.



Minimally Invasive Procedure,Transanal Suture Rectopexy (Chivate’s Procedure) for Haemorrhoids. 5 Year Follow Up Study

Madhura Milind Killedar, MS. F.A.C.R.S.I.F.M.A.S1; Dr.Shantikumar Chivate, MS (General Surgery)2; Dr.Laxmikant Ladukar, MS (General Surgery3

1Bharati vidyapeeth Deemed University Medical College and Hospital, Sangli, Maharashtra, India; 2Jivanjyot Hospital, Thane, Maharashtra, India; 3Ladukar Surgical Hospital, Brahmpuri, Nagpur, Maharashtra,India

Objective - This is retrospective study of 1411 patients operated by transanal suture rectopexy for haemorrhoids. Study was conducted for recurrence and incontinence with 5yr follow up. Grade II/ III /IV haemorrhoids with bleeding, prolapse or thrombosis needs surgery with failed conservative treatment. Chivate’s procedure is minimal invasive, painless procedure which deals with such haemorrhoids and is based on principles of circumferential plication of haemorrhoidal vessels at 2 and 4 cm above dentate line and fixing Perks ligament with long acting polygyctide sutures without cutting haemorrhoidal mass, we are performing this procedure since last 10yr.

Material and procedures – 1570 patients operated were telephonically called, 1490 responded to call but 1411 patients visited OPD. History of patients was taken and recurrence was stamped for off and on P/R bleeding within 5 year Follow up and incontinence was classified as uncontrolled passing of flatus, fluid or faeces without notification of patient after 3 months duration of surgery and those not on laxatives. Per rectal examination was done to see haemorrhoidal masses

Results - Of 1411 patients from study, 978 were males and 433 were females, from age group of 25 to 82 yr. 17 (1.2%) patients were having recurrence with off and on P/R bleeding but controlled with conservative treatment and 1 patient had flatus incontinence. Shrinkage of haemorrhoidal mass observed in almost 90% of patients.

Conclusion – Success of haemorrhoidal surgery depends on post op pain, recurrence and evidence of incontinence. With retrospective study results, Chivate’s procedure is better alternative for Grade II/III/IV haemorrhoids.



Resident Bullying in Obstetrics and Gynecology Programs

Belinda Nhundu, BA; Soorin KIm, MD; Vrunda Desai, MD

Yale School of Medicine

Objective: Workplace bullying has been demonstrated to affect mental health especially in high stress environments. Bullying, exposure to interpersonal aggression and mistreatment, has implications on physician mental health and ultimately patient care. Resident physicians are especially vulnerable, given the hierarchy of medicine. Our objective is to characterize the extent, source and frequency of bullying experienced by resident in Obstetrics and Gynecology.

Methods: With IRB approval a previously validated survey tool -Negative Acts Questionnaire-Revised (NAQ-R) was distributed to 13 residency programs in the American College of Obstetricians and Gynecologist (ACOG) District 1, which comprises the Northeast region.

Results: The survey had a response rate of 23.2%. On average respondents cited experiencing 7.1/22 scenarios of bullying. Most respondents were women (79.7%), interns (31.9%) and were from large residency programs (56.5%). Respondents cited more work related bullying scenarios than person related bullying and physical intimidation. The most common sources of bullying came from attending physicians (31.7%) followed by co- residents (22.5%). Sixty percent of respondents cited having medical opinions ignored weekly (19%) and daily (7.1%).

Conclusion: Residents in Obstetrics and Gynecology commonly experience workplace bullying. Addressing the sources of bullying can improve patient care, reduce burnout of residents and increase career satisfaction.



Revision of Nissen to Toupet Fundoplication for the Management of Dysphagia

Salman Alsabah, MD MBA1; Alcides Branco2

1Kuwait University, 2Al-Amiri Hospital

OBJECTIVE: We present the case of a 58 year old female. She had a history of Laparoscopic Nissen Fundoplication and hiatal hernia repair. She did well postoperatively for 6 months. She then presented with dysphagia and reflux and had no response to medical management and balloon dilatation. At 1 year after the initial surgery we did Redo Laparoscopic Nissen to Toupet Fundoplication. The published failure rate for Laparoscopic Nissen Fundoplication is between 2% and 17%. Mechanisms of failure include, trans-diaphragmatic migration, disrupted fundoplication, slipped of misplaced fundoplication, twisted fundoplication or fundoplication being too tight or too long.

METHODS & PROCEDURES: This video illustrates restoring the original anatomy by lysis of adhesions taking down the Nissen fundoplication and mobilizing the esophagus, repairing pleural defect, redo toupet fundoplication utilizing intra-operative endoscopy for verification, correct position of the wrap.

RESULTS: Post-operative patient is doing well, with no symptoms of dysphagia or reflux. Post-operative barium swallow showed no hiatal hernia or reflux.

CONCLUSION: Converting Nissen to Toupet fundoplication is feasible, save and effective. Intra-operative endoscopy is very useful in such cases for better assessment and placement of the wrap. Toupet Fundoplication is a valid option for dysphagia and reflux after failed Nissen fundoplication



Subcutaneous Implant Placement by Means of Mesh for Immediate Breast Reconstruction

Yu Wang, MD; Shan Guan; Jixiang Wu

Beijing Tongren Hospital, Capital Medical University

Objective To explore the application value of subcutaneous implant placement by means of a full titanium-coated polypropylene mesh (TCPM) coverage in immediate breast reconstruction after nipple-sparing mastectomy.

Methods This study is prospective case series studies. Totally 30 cases of primary breast cancer patients who prepared to receive the immediate breast reconstruction after nipple-sparing mastectomy were enrolled in Oncology Center, Beijing TongRen Hospital, Capital Medical University from August 2016 to February 2017. Finally, the operations had been completed successfully in 15 eligible cases. The operation data and the post- operative complications had been evaluated.

Results Operation time (156.67±33.73) minutes, drainage (307.33±51.03) mL, days requiring drains (8.89±1.7), the post-operative pain (2.56±0.73) . There was no nipple and skin flap necrosis, seroma, wound dehiscence, infection and graft reaction were recorded.

Conclusion Immediate reconstructions with TCPM total implant coverage was performed without destroying any muscular dissection. The operative time was reduced, and the relevant complications were not increased compared to submusclar tissue implant placement method. TCPM is a good choice of immediate breast reconstruction after nipple-sparing mastectomy.



Intraoperative Esophageal High-resolution Manometry During Laparoscopic Floppy Nissen Fundoplication for the Treatment of Gastroesophageal Reflux Disease

Shulin Ren, MD; Jixiang Wu, MD

Beijing Tongren Hospital, Capital Medical University

Esophageal high-resolution manometry (HRM) is a useful diagnostic tool for gastroesophageal reflux disease (GERD). Laparoscopic Nissen fundoplication (LNF) is the most common anti-reflux procedure performed for GERD. The use of intraoperative HRM provides real-time estimation of intraluminal esophageal pressures and identifies the exact points of esophageal luminal pressure during laparoscopy. We collected intraoperative manometry data and repeated manometric studies. We conclude that the simultaneous use of HRM during the Laparoscopic Nissen fundoplication may lead to an individualized management of the disease.



Laparoscopic Asssited TAP Block, Randomized Controlled Trial:Posterior vs Lateral TAP Block

Farinaz Seifi, MD1, 2; Masoud Azodi, MD1; Dan-Arin Silasi ,MD1; Joel Messom,MD2

1Yale New Haven, 2Bridgeport Hospital

Objective : To compare the analgesia of laparoscopic-assisted posterior Transversus Abdominis (TAP) block versus lateral approach in patient undergoing laparoscopic gynecology surgery.

Methods : Randomized controlled trial, included 50 patients undergoing major laparoscopic gynecology procedure in each arm . Randomization done through block randomization using software . We used mixed of long acting Bupivacaine and short acting Bupivacaine for TAP block.

Result: To be completed by June 15, 2018 .currently under process.

Conclusion: To conclude which approach , posterior Vs lateral , provides more efficient and longer analgesia for patient.



Psychotechnique Management of Laparoscopic Complications

Antoine A. Watrelot, Prof Dr Med

Hopital Natecia

Even and because laparoscopic complications are infrequent, surgeons are not well trained and prepared to react correctly when such event occurs.
Awareness, teamwork, and adequate psychological attitude are the key to make difference between correct management and surgical disaster. Author through video examples and review of laparoscopic complications demonstrates what should be a good attitude for the surgeon to "keep his brain" in every circumstances



The Result of Laparoscopic Cure of the Ovary Endometriosis

Khusen Baturovich Narzullaev, MD PhD

Centre of Endoscopic Surgery

OBJECTIVE: The laparoscopic treatment of the endometriosis ovary cyst.
METHODS & PROCEDURES: The investigation of the results of laparoscopic treatment of the endometriosis cyst among 200 fertile-aged women.

RESULTS: Centre of Endoscopic Surgery, City Hospital, Samarkand, Uzbekistan. 200 patients, aged 16-47, with the illness of endometriosis ovary cyst. Laparoscopic adnexectomy, ovary resection and the husking of cyst. The laparoscopic adnexectomy was done to 30 of the patients, laparoscopic resection of the ovary was done to 52 and the laparoscopic husking of the cyst was done to 118 patients. In 3 of the cases, a vast commissural process was pointed out in the small pelvis with the involving of the slender bowels and the sigma entrails, in connection with this there was a transition to laparotomy. In two cases, the surgery ended with the extirpation of the uterus and its appendages, in one case it ended with the resection of the slender bowels and the excretion of ileostomy. There were no fatal outcomes. In the post operational period all the patients were recive a hormonal therapy - Dienogest 2 mg 3-6 month.

CONCLUSIONS: Laparoscopy serves as the method of choice in the surgical treatment of the patients with endometriosis lesions of ovary, and it has a number of advantages, compared with laparotomy. After the laparoscopic surgeries the life quality of the patients cures two times faster and more full-grown, compared with laparotomy. This is especially important to the childbearing aged patients.



Minimally Invasive vs. Open Inguinal Lymph Node Dissection (ILND) for Penile Cancer: A Tumor Stage-Specific Outcome Analysis from the National Cancer Database (NCDB)

Shashank S. Pandya, BA1; Zorimar Rivera-Núñez, PhD2; Sinae Kim, PhD3; Nicholas Farber, MD4; Kushan Radadia, MD4; Joshua Sterling, MD4; Eric A. Singer, MD, MA, FACS2; Sammy E. Elsamra, MD2

1Rutgers Robert Wood Johnson Medical School; 2The Cancer Institute of New Jersey; 3Rutgers School of Public Health, Department of Biostatistics; 4Rutgers Robert Wood Johnson Medical School, Department of Surgery, Division of Urology

OBJECTIVES: Inguinal lymph node (LN) involvement in penile cancer is an important predictor of survival. Current NCCN guidelines recommend ILND for any ≥pT1b tumors. Our objective was to measure nodal and survival outcomes for patients who received minimally invasive (robotic(R) or laparoscopic(L)) or open(O) ILND following clinical tumor staging(cT1-4).

METHODS: NCDB was queried (2010-2014) to identify penile cancer patients who received ILND. The following outcomes were analyzed: positive clinical LN(+cLN) vs. positive pathologic LN(+pLN), LN yield, and LN density across surgery types (R/L/OLND) for cT1-T4 tumors. 5-year overall survival(OS) between different tumor stages(cT1-4) were compared for patients who received ILND either ≤or>30days following diagnosis using Kaplan-Meier curves.

RESULTS: LN data were stratified by tumor stage and surgical approach for 1,315 identified patients: 0.30%(4) received RLND (cT1:2, cT2:1, cT4:1); 1.83%(24) received LLND (cT1:11, cT2:12, cT3:1); and 97.87%(1,287) received OLND (cT1:559, cT2:613, cT3:18, cT4:94). Among patients with +cLN (70/1280 examined cLNs), the PPV for +pLN (60/554 examined pLNs) was 85.7%. LN yield by stage and surgical approach (mean): cT1:16.4, cT2:16.0, cT3:12.8, cT4:20.5; RLND:28.0, LLND:10.8, OLND:16.8. LN density by stage and surgical approach (mean): cT1:0.20, cT2:0.20, cT3:0.38, cT4:0.32; RLND:0.35, LLND:0.14, OLND:0.27. Kaplan-Meier curves showed significant improvement in 5-year OS across tumor stages(cT1-T4) for patients who received ILND ≤30days of diagnosis (p=0.004).

CONCLUSION: Minimally invasive ILNDs were rarely performed during the study period. Clinical staging had a PPV of 85.7%. Both LN yield and density were higher for RLND and OLND vs. LLND. Receiving ILND ≤30 days of diagnosis significantly improved 5-year OS.



Assessing Medical Student Learning Experiences During Surgical Missions in Brazil

Yuri Justi Jardim (Medical Student)1; Mauricio Abrao2; Alberto Meyer2; Gustavo Heluani Mesquita2; Nivaldo Alonso2; Guilherme Ribeiro Carvalho2; Fernanda Cotrim2; Jania Ramos1

1Harvard Medical School; 2Sao Paulo University Medical School

Objectives Expedição Cirugica (ECFMUSP) is a University of São Paulo medical student led project to deliver minimally invasive surgeries (MIS) to vulnerable populations in Brazil. In addition to gaining clinical skills, medical students expand their professional and humanistic development through exposure to the challenges of working in rural underserved areas. The aim of this abstract is to describe this novel student led initiative and to evaluate the learning experiences of medical students who participated in the 2017 ECFMUSP.

Methods and Procedures The Shortened Experiences of Teaching and Learning Questionnaire (SETLQ), a validated survey designed to assess students’ learning experiences was applied to the students who participated in the 2017 expedition.

Results: The 2017 student team raised $600,000 in donations, managed 50 health professionals and students to perform 50 surgeries and 330 ultrasounds, transported MIS equipment over 700km and trained 91 laypersons in first aid in an underserved city (Goioerê-PR) of Brazil.100% (18/18) of students responded to the survey. Students identified "to help people, and/or make a difference in the world"(4.8/5) as the main reason for participating in ECFMUSP. They described the experience as important (4.4/5) and interesting (4.6/5). The “experience of teaching and learning” was rated 4.2/5 and “knowledge and learning acquired” 4.1/5.

Conclusion This project can serve as a teaching model for medical missions to provide high-quality academic learning, develop leadership skills and the social awareness of medical students whilst helping vulnerable populations.



Robotic Assisted Excision of Advanced Stage and Deep Infiltrating Endometriosis Tissue Volumes conmpared to Traditional Laparoscopic Resection

Michael T Breen, MD; Ashley Stone

UT Dell School of Medicine Austin

An investigation related to excision of pelvic peritoneal endometriosis contrasting robotic excision verses traditional laparoscopic excision was undertaken . One hundred patients with presumptive endometriosis underwent robotic assisted excision of superficial and deep infiltrating lesions whish were all sent to pathology for evaluation and quantification. The volume of resected tissue was quantified . These volumes (mm squared) were contrasted with traditional resected endometriosis specimens . This retrospective study was not biased by surgeon perspective as the initial resections were done before study design. There were no complications reported in the robotic assisted cases and no re operations . Data was evaluated using T test , ANOVA, and F test were utilized in data analysis .

Findings: While the hypothesis had long been by robotic surgeons a more complete dissection was possible especially in lesions involving ureters, peri-rectum , and the peritoneum overlying the uterine vessel complex this study validated that on average in our Academic affiliated hospital with both robotic and traditional laparoscopic excision of endometriosis the volume of resected tissue trends greater in robotic assisted procedures. Surgeon technique bias as well as inability to control for exact equal endometriosis degree are clear limitations of this study.
Conclusion: Robotic assisted excision of advanced stage and deep infiltrating endometriosis surgery resulted in higher volumes of pathologically confirmed endometriosis than the traditional laparoscopic contrasted procedures.



Minimally Invasive Technique for the Resolution of Pectus Excavatum; A Dozen Year Evaluation

Georgina Eromosele, Dr Med

District Hospital, Ekiadolor

Purpose: This study sought to assess the outcome of a minimally invasive operation that requires neither cartilage incision nor resection for correction of pectus excavatum, over a 12 span.

Methods: 148 patients were evaluated for chest wall deformity. Fifty of 127 patients suffering from pectus excavatum were selected for surgical correction. Eight older patients underwent the Ravitch procedure, and 42 patients under age 15 were treated by the minimally invasive technique.

Results: Of 42 patients who had the minimally invasive procedure, 30 have undergone bar removal. Initial excellent results were maintained in 22, good results in four, fair in two, and poor in two, with mean follow-up since surgery of 4.6 years (range, 1 to 9.2 years). Mean follow-up since bar removal is 2.8 years (range, 6 months to 7 years). Average blood loss was 15 mL. Average length of hospital stay was 4.3 days. Patients returned to full activity after 1 month. Complications were pneumothorax in four patients, requiring thoracostomy in one patient; superficial wound infection in one patient; and displacement of the steel bar requiring revision in two patients.

Conclusions: This minimally invasive technique, which requires neither cartilage incision nor resection, is effective. The upper limits of age for this procedure require further evaluation.



Resection of a Gastrointestinal Stromal Tumor During Sleeve Gastrectomy

Aryan Meknat, MD; Frederick Amog, MD

Brookdale University Hospital and Medical Center

Background: Many patients may have pathology in the proximal GIT that is not clinically evident prior to bariatric surgery. Currently, preoperative endoscopic evaluation of the proximal GIT is not standard of care. (1) Abdominal ultrasounds (ABD US) are routinely done, but assessment of the stomach is not commonly included in routine scanning protocols. ABD US’s have the potential to detect gastric carcinomas or extra luminal lesions if attention is paid to the gastric wall. (2)

Clinical Case: A 53-year-old female had a Laparoscopic Sleeve Gastrectomy done on 12/14/16. Prior to surgery, the patient met all criteria for Bariatric Surgery patient selection. Her pre-operative assessment included an EGD, and she was medically cleared. Intra-operatively a large 5 cm lobulated-exophytic mass was encountered along the posterior aspect of the fundus. Care was taken to dissect away the entire mass with adequate margins, prior to proceeding with the sleeve. The pathology results: 5 cm, spindle cell tumor, mitotic rate - 1/50 HPF, and 1 cm resection margins.

Conclusion: A preoperative EGD can help determine the type of bariatric surgery that is appropriate and to help diagnose nonspecific symptoms or otherwise asymptomatic diseases. This case shows that even if routine EGD’s were routinely done in the pre- operative work-up, there is still potential for extra luminal lesions to be missed altogether. While the appropriate treatment was applied in this case, the question that must be posed to the metabolic surgical community is whether a new focused imaging modality must be added to the pre-operative assessment (e.g. Focused Gastric Ultrasound).



Laparoscopic Liver Resection for Hepatocellular Carcinoma in the Posterior and Superior Segments via 3-port Total Abdominal Approach: A Single Institute Experience

Yen-Chih Chen, MD; Chao-Chuan Wu, MD

Taipei Tzu Chi Hospital

Objective: To evaluate the safety and efficacy of laparoscopic liver resection for hepatocellular carcinoma in posterior and superior segments via 3-port total abdominal approach without assisted transthoracic trocars.

Methods and materials: The study enrolled 34 men and 11 women who suffered from HCC in the posterior segments and received total 50 operations for posterior and superior segments between January 2010 and September 2017. Among them, 16 patients received 20 operations with laparoscopic approach. We analyzed the clinical data of 16 patients (20 operations, n=20) who underwent laparoscopic liver resection with total abdominal approach for hepatocellular carcinoma (HCC) and compared outcomes with patients who underwent open surgery (29 patients and 30 operations, n=30).

Results: There was no significant difference of gender, ASA grading, tumor size between the laparoscopic group and open group. But the age of laparoscopic group was significantly higher than open group (66.7 vs 59.3, p=0.036). There was no significant difference in operation time and blood loss between two groups, but the postoperative hospital stay was significantly lesser in laparoscopic group (5.45 vs 10.03, p<0.001). There were no deaths or major complications in both groups. Two complications occurred in laparoscopic group, which were managed by conservative treatment and antibiotic use. There were no conversions to laparotomy. Conclusion: In our series, laparoscopic resection of liver tumors located in the posterior and superior segments via 3-ports total abdominal approach is technically feasible and safe with short-term result, even in older patients. _________________________________________________________________________________ 233GS

Intestinal Rotation Abnormalities and Bariatric Surgery

Dang Tuan Pham, MD; Osama Shaheen, MD

Sisters of Charity Hospitals of Buffalo

Background: Intestinal rotation abnormalities stand for a broad range of a complex gut anomalies expressing the different stages of premature arrest of embryologic gut rotation. Intestinal rotation abnormalities occurrence beyond the pediatric population has previously being considered an uncommon finding, however more recent studies have indicated increasing recognition of intestinal malrotation in adults. With the growing popularity of bariatric surgery, more bariatric specific studies have identified this occurrence and have described a spectrum of unique challenges and complications.

Objectives: To clarify the incidence, challenges, consequences of IRA in patients undergoing bariatric surgery to potentially help plan the optimal approach.

Methods: We have conducted a systematic English literature search for the articles that described IRA while performing bariatric surgery.

Results: We found that the incidence of reporting IRA in bariatric surgery ranged from 0.025% to 0.5%. 60% of the patients were female. The diagnosis was made intraoperatively in 81% (65% after performing the gastric pouch). Nonrotation was the most common Intestinal Malrotation subtypes (70% of cases) and reported only in 25 % of complication/revision group. The originally planned bariatric procedures were completed successfully in 78% of cases, aborted 13%, and converted into open or different procedure in 9% cases.

Conclusion: While this encounter is very rare, this study was conducted because most surgeons are not aware of this special malformation, its intraoperative challenges, and its unpredictable consequences.



The Clinical Application of Laparoscopic Radical Hysterectomy and Pelvic Lymphadenectomy with Double Orifice Operation (3-Port-Technique) in Treatment of Early-stage Cervical Cancer

Weijie Du, Prof Dr Med

Zhejiang University International Hospital HangZhou

Objective To evaluate the clinical application of laparoscopic radical hysterectomy and pelvic lymphadenectomy with double orifice operation (3-port-technique) in treatment of early-stage cervical cancer.

Methods We retrospectively analyzed the clinical data of 565 cases of early-stage cervical cancer, who underwent laparoscopic hysterectomy and pelvic lymphadanectomy with double orifice operation (3-port-technique) from August 2005 to August 2016.

Results All operations were successfully performed with laparoscopy. The time duration of operation was (165.5±31.5)min, blood loss during operations was (120.1±35.6)ml, the amount of the dissected lymph nodes was (29.5±4.7), the time of the dissected lymph nodes was (58.5±19.3)min. Ureteral injury happened in 3 cases, bladder injury happened in 1 case, and was successfully repaired under laparoscope.Postoperatively urine retention developed in 26 cases.

Conclusion Laparoscopic radical hysterectomy and pelvic lymphadenectomy with double orifice operation (3-port-technique) for early-stage cervical cancer is safe, feasible and of clinical value



Outcome Analysis of Total Extraperitoneal Mesh Repair Vs Lichtenstein Mesh Hernioplasty for Inguinal Hernias

Pawan Sharma, MBBS MS DNB FACS FICS FCLS MNAMS; Vinay Sah, MBBS ; Chandrakant Jakhmola, MBBS MS

Base Hospital Delhi Cantt

Objectives: To compare post-operative clinical outcomes, return to normal activity and complications in laparoscopic total extra peritoneal mesh repair vs Lichtenstein tension free mesh hernioplasty for inguinal hernias.

Methods & Procedures: This was a prospective study conducted at a tertiary care service hospital of the Indian Armed Forces. Fifty consecutive patients of inguinal hernia were included in the study. Twenty five alternate patients underwent open surgery and the remaining underwent total extra peritoneal laparoscopic hernia repair. Statistical analysis was done using descriptive statistics with chi square test, t-test and Mann Whitney U test. The statistical software used for data analysis was SPSS 17.0.

Results: The visual analogue scale score for pain was 14.8% higher for first two days in Lichtenstein tension free mesh hernioplasty. However, there was no significant difference in pain between the two groups after 48 hours. The average hospital stay was considerably less (3.32 days) in total extra peritoneal group as compared to Lichtenstein mesh hernioplasty group (4.52 days). Return to self care (2.56 days) and full work (80 days) was significantly earlier in laparoscopic repair group. There was no significant difference in terms of complications in either groups.

Conclusion: The post operative outcome is definitely better in total extra peritoneal laparoscopic group. Based on findings of this study, it can safely be recommended that probably time has come for total extra peritoneal repair to be considered as a standard of care for groin hernia repair.



Principle and Techniques of Laparoscopic Retroperitoneal Dissection in Large Fibroid Uterus

Farinaz Seifi, MD1,2; Masoud Azodi, MD1; Kelly M. Davis MD2

1Yale New Haven, 2Bridgeport Hospital

Objectives: To demonstarte the techniques for laparoscopic retroperitoneal dissection with large fibroid uterus.

Methods: In this video we demonstrated the techniques for ureterolysis, dissection of avascular spaces and legation of uterine artery at the origin in three different situations: normal size uterus, large fibroid uterus and densely adherent uterus.

Result: The ability of pelvic surgeons to perform ureterolysis and retroperitoneal dissection in order to facilitate the uterine artery ligation is essential to safely perform hysterectomy.

Conclusion: The knowledge of retroperitoneal anatomy and surgical steps are crucial for all expert gynecology surgeons.



Using Exercise to Abate Nerve Pain in Endometriosis Patients

Sallie Sarrel, PT ATC DPT

OBJECTIVE: Endometriosis is a painful disease affecting quality of life in nearly 176 million women worldwide. Even post excision of endometriosis patients may continue to experience pain across multiple systems from gynecological pain to abdominal and musculoskeletal pain. Current best practices leaves women with the disease few options beyond surgery, especially for those suffering with central sensitization and nerve up- regulation due to the long term adaptations of the disease. Pelvic Physical Therapy can be a critical component to mobilize the body post operatively. An exercise prescription designed by a physical therapist may help integrate and quiet long standing nerve patterns thereby returning the woman with endometriosis back to her best possible quality of life.

METHODS: 35 women with endometriosis following excision of endometriosis were given a specific exercise program to help with nerve and pain not reduced by surgery alone. The CHPPS questionnaire was administered at onset of physical therapy and then at the 3 and 9 month mark.

RESULTS: Of the 35 women, 24 reported increases in quality of life, 6 reported changes in pain but no increase in quality of life and 5 did not complete the study either due to compliance.

CONCLUSION: Women with endometriosis experience on average an 8 year diagnostic delay from onset of symptoms to treatment. This delay may increase issues within the central nervous system, additionally the overwhelming pain may cause a patient to become deconditioned. Even after the disease is removed, pain may remain. An exercise prescription by a pelvic physical therapist may help increase quality of life.



Trans-Cystic Exploration of Common Bile Duct - As Multi Modal Approach

Ilayaraja Rajendran, MRCS; Miss Nithya Krishnamohan, Miss Christina Lo, Miss V D Shetty, Mr J B Ward, Mr P D Turner, Dr R Stockwell, Mr R Date

Lancashire Hospital NHS Trust

Objective: ‘Laparoscopic common bile duct exploration’ (LCBDE) performed as a single stage procedure with laparoscopic cholecystectomy (LC) is an viable alternative to ERCP pre-LC. Few case series have demonstrated that ‘Laparoscopic trans-cystic CBD exploration’ (LTCBDE) as an alternative to LCBDE in selective group of patients. Our aim is to assess the viability of LTCBDE performed along with ‘interventional radiologist’(IR) in this group of patients.

Methods and procedures: Retrospective study of prospectively collected hospital database was organised from August, 2015 to February, 2018. The patients (age<50, CBD stone (<5mm) and maximum 2 stones) were included. Whereas patient undergoing LC, LCBDE and LC with ‘on table cholangiogram’(OTC) only were excluded. Total number of stone extraction attempted and number of successful extractions were considered as primary outcome and post LTCBDE ERCP’s were considered as secondary outcome. Results: Some 20 of 21 patients who underwent LTCBDE were included, of which 15% (n=3) were not evaluated further due to failure to cannulate cystic duct, conversion to open and on-table diagnosis of pancreatic cancer. Intra-operatively there were no CBD stones identified in 50 % ( n=10) of patients. LTCBDE exploration was successful in 15 % (n=3) , however 10 % (n=2) required post-operative ERCP. 15% (n=3) of patients had sphincteroplasty as a primary procedure without requiring further ERCP. Conclusion: LTCBDE is a safe and feasible option in a selective group of patients. Performing the procedure along with IR resulted in prompt diagnosis and radiologically guided sphincteroplasty, as required. _________________________________________________________________________________ 244GS

TEP for Incarcerated Inguinal Hernia: Is It Feasible for Experienced Surgeons?

Kayo Augusto Almeida Medeiros, Medical Student1; Bárbara Justo Carvalho, Medical Student2; Yuri Justi Jardim, Medical Student2; Diego Ramos Martines, Medical Student2; Fernanda Nii, Medical Student2; Gustavo Heluani Antunes de Mesquita, Medical Student2;
Leonardo Zumerkorn Pipek, Medical Student2; Alberto Meyer, MD2

1Faculdade de Medicina da Universidade de São Paulo, 2Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo

1. OBJECTIVE: To verify if endoscopic TEP surgery performed by an experienced surgeon is a feasible procedure to manage incarcerated inguinal hernia.

2. METHODS & PROCEDURES: This is a retrospective study in which we analyzed data from patients submitted to TEP endoscopic surgery for treatment of incarcerated and non-incarcerated groin hernia. The surgeries were all performed by a single surgeon. We obtained data about sex, age, ASA score, BMI, hernia location, operating time, hospital discharge time and recurrence rate. The two groups (incarcerated and non-incarcerated) were compared using Chi-squared test and independent Student t test.

3. RESULTS: 322 endoscopic TEP repairs were performed. 27 patients had incarcerated hernia and 9 of them were bilateral. 295 patients had non-incarcerated groin hernias and from these 143 were bilateral. Data from all patients were analyzed, but in what concerned operative info (recurrence rate, operating time and hospital discharge) the first 65 surgeries were excluded for they belonged to the surgeon learning curve (1 incarcerated hernia in this group). Our statistical analysis showed that the patients in the two groups were very similar except for ASA score. We had just three cases of recurrence and also three cases of hospital discharge time >12h. The patients were put in four different groups accordingly to being uni or bilateral and incarcerated or non-incarcerated. Statistically significant difference was observed only between the unilateral/non-incarcerated group and the other groups.

4. CONCLUSION: The endoscopic TEP surgery is a feasible procedure for surgeons that have overcome the technique learning curve.



Ileocolic Intusseption as a Manifestation of MUTYH Associated Polyposis Colorectal Cancer

Gustavo H A Mesquita (Medical Student), Yuri Justi Jardim, Diego Ramos Martines, Fernanda Nii, Bárbara Justo Carvalho, Kayo Augusto de Almeida Medeiros, Leonardo Zumerkorn Pipek, Alberto Meyer

Hospital das Clínicas da Faculdade de Medicina da USP

Introduction: Patients with colorectal cancer may be admitted to the emergency room with complications, such as intussusception. Approximately 5% of all colorectal cancer are attributed to hereditary syndromes, especially MUTYH-associated polyposis (MAP), of an autosomal recessive character. This article purpose is to present the case of a patient diagnosed with MAP after an intestinal intussusception.

Methods: Case Report

Results: A 44-year-old male patient presented a complaint of pain and dyspeptic symptoms at approximately 15 days. He also presented multiple sebaceous cysts. Dyspeptic syndrome hypothesis was made, and complementary exams were requested. After 5 days, the patient reported pain in the lower abdomen and was referred to the emergency room. An abdominal CT-scan revealed intestinal subocclusion by ileocolic invagination. Laparoscopic right colectomy was performed. The anatomo- pathologic piece revealed moderately differentiated mucinous adenocarcinoma, staged T3N0M0. Multiple polyps measuring between 0.2cm and 0.6cm were also found, which led to the suspicion of a genetic syndrome. The genetic analysis revealed biallelic mutations in the MUTYH gene, with MAP being diagnosed.

Conclusion: Our patient presented a MAP with few polyps, multiple sebaceous cysts, and no familial history. The diagnosis of colorectal cancer occurred after a complaint of abdominal discomfort and pain, a rare single manifestation as a CCR presentation. Ileocolic intussuseption, a rare event in adults that is correlated to tumors was present. Our patient is an example of how intussuseption can be a manifestation of colorectal cancer. If genetic syndromes like MUTYH-associated polyposis are suspected, genetic research should be done.



Advanced Modular Manikin: An Open Standards Platform for Simulation

Tony Chen, MD; Jon Keller, MD; David Marko Hananel, PhD; Robert Martin Sweet, MD

University of Washington

1. OBJECTIVE: Simulation technologies are an increasingly integral component of comprehensive medical training. The current state of the commercial simulation industry is characterized by proprietary standards and components that are not non-compatible across platforms. To allow for the continued, sustainable growth in the breadth and depth of simulation models, an open-source unifying standard is necessary. The Advanced Modular Manikin (AMM) system is being created for that purpose.

2. METHODS & PROCEDURES: AMM is designed with a Master Controller central core that houses its state machine, physiology engine, system software and firmware, and power supply which can all be accessed and used by external physical modules via an open standard interface protocol, communication stream, and physical connectors. AMM anatomic structures will have high anatomic and physiologic fidelity, aided by mechanical properties data from human tissue testing. A native fluidics system delivers fluid, air, power, and data seamlessly between peripheral structures and the core.

3. RESULTS: The AMM successfully completed a Phase 1 proof of concept round and begun Phase 2 in 2016 with funding from the Department of Defense (Award #W81XWH- 14-C-0101). Initial scenarios will center around airway management and laparotomy. AMM as a platform will allow for flexible modularity for subspecialized training scenarios, as well as the ability to incorporate future advancements.

4. CONCLUSION: AMM, by creating an open-source, royalty-free simulation platform, will allow for the cost-effective acceleration and expansion of new simulation technology development and implementation in key areas of medical training including minimally invasive surgery.



Combined Extraluminal/Intraluminal Small Bowel Gastrointestinal Stromal Tumor - A Case Report

Marvin Arguello-Angarita, MD1; Adam Rosenstock, MD FACS2; Shreya Patel, BS1

1Rutgers University, New Jersey Medical School; 2Hackensack University Medical Center

Mesenchymal tumors are rare, only composing 1% of all primary gastrointestinal tumors. Gastrointestinal stromal tumors are the most common group of mesenchymal tumors in the GI tract. GISTs may arise in any area of the GI tract, however, intraluminal detection may not be sufficient for jejunoileal GIST tumors, as these tumors are described to be primarily extraluminal. Surgical resection is the standard of treatment for GISTs, but resection has poor long-term outcomes. Laparoscopic resection has been shown to lead to shorter hospital stays and lower morbidity in patients compared to open procedures. The patient is a 84 year old male with a history of longstanding GI bleeding, who was diagnosed with a small bowel lesion through capsule endoscopy. The patient subsequently underwent capsule endoscopy, which revealed and ulcerated lesion in the distal small bowel. Imaging failed to localize the mass. Therefore, the patient underwent a diagnostic laparoscopy, in which a large lesion was identified. The patient had an uncomplicated postoperative course. Usual presentation of intraluminal GISTs is GI bleeding, while extraluminal GISTs present with obstructive symptoms. Patient had multiple negative diagnostic imaging modalities, but a capsule endoscopy positive for an intraluminal ulcerated lesion. Pre-procedure, these findings were suggestive of an isolated intraluminal GIST. A diagnostic laparoscopy was performed to assist in push enteroscopy, in an attempt to identify the location of this tumor. Upon entering the abdominal cavity, a large tumor was immediately evident, confirming that this was a case of combined intraluminal and extraluminal tumor.



Early Experience and Learning Curve for Robotic Inguinal Hernia Repairs

Paul Toomey, MD1, 2, 3; Megan R. McClain, BS1; Nicolas Aguila, BS1; Ali Ahmed

1Florida State University, 2Manatee Memorial Hospital, 3Blake Medical Center

Objective Robotic inguinal hernia repairs are becoming more prevalent in the United States, but data are lacking regarding outcomes. Recent residents and fellows are learning robotic techniques and implementing them after training. We present our early outcomes for a single surgeon immediately following training and his learning curve.

Methods and Procedures Patients undergoing robotic inguinal hernia repairs from July 2015-June 2017 were studied. Patient demographics, perioperative and postoperative data were compared. Median data are presented.

Results Eighty robotic inguinal hernia repairs were undertaken. Twenty-one (26%) patients underwent bilateral inguinal hernia repairs, while 59 (74%) underwent unilateral inguinal hernia repairs. Operative time was 57 minutes. Eight patients had open repairs prior to their robotic repair. There were eight recurrences (10%), three patients with bilateral repairs recurred unilaterally (14%) and 5 patients with unilateral repairs recurred (8%). For the 42 inguinal hernias repairs for the 21 patients with bilateral inguinal hernias, three recurred (7%). For unilateral repairs, the operative time was 60 minutes for the first 20, 54 minutes for the second 20 and 52 minutes for the last 19. Additionally, 5 recurrences occurred within the first 20 patients (1st quartile), no recurrences in the second quartile, two recurrences in the third quartile and one recurrence in the fourth quartile. Median follow-up was 16.9 months. Conclusion The learning curve for a surgeon immediately out of training is short and definable for robotic inguinal hernia repairs. Recurrence rate appears to decline significantly after the first twenty robotic inguinal hernia repairs.



Early Experience for Laparoendoscopic Single-Site (LESS) Cholecystectomy

Paul Toomey, MD1, 2, 3; Megan R. McClain, BS1; Nicolas Aguila, BS1; Ali Ahmed

1Florida State University, 2Manatee Memorial Hospital, 3Blake Medical Center

Objective LESS cholecystectomy is undertaken infrequently in the United States. Surgeons who undertake LESS cholecystectomy typically were laparoscopic surgeons who adopted this advanced technique. There are no studies of the early experience for a young surgeon immediately out of training for LESS cholecystectomy. This study was undertaken to report the early experience for LESS and laparoscopic cholecystectomy for a single surgeon.

Methods Patients underwent a LESS or laparoscopic cholecystectomy during a 2 year period (July 2015-June 2017) were studied. Patient demographics, perioperative, and postoperative data were compared. Median data are presented.

Results A total of 209 patients underwent minimally invasive cholecystectomies. Initial approaches were 76 LESS and 132 laparoscopic cholecystectomies. The diagnoses for patients who underwent LESS cholecystectomy were biliary dyskinesia (54%), symptomatic cholelithiasis (43%), gallbladder polyp (1%) or gallstone pancreatitis (1%). The diagnoses for patients undergoing laparoscopic cholecystectomy were acute cholecystitis (29%), symptomatic cholelithiasis (27%), gallstone pancreatitis with or without choledocholithiasis (18%), biliary dyskinesia (12%), choledocholithiasis (6%) or other (8%). BMI was 32.3 for patients undergoing laparoscopic cholecystectomy and 28.9 for patients undergoing LESS cholecystectomy. Five operations were converted from LESS to laparoscopic. Two conversions were for dome down approaches (one short cystic duct and one dilated cystic duct), one due to poor exposure, one due to adhesions and one due to clashing. There were no complications after LESS cholecystectomy.

Conclusion LESS cholecystectomy can be undertaken safely by surgeons immediately out of residency/fellowship with the appropriate training. Patients who underwent LESS cholecystectomy were more likely to have biliary dyskinesia and a lower BMI.



Comparative Study of Laparoscopically-assisted Differential Access Orchiopexy for Children with Intracanalicular Cryptorchidism

Suolin Li, Prof Dr Med; Yongting Zhang; Xuelai Liu

The 2nd Hospital of Hebei Medical University

Objective: To explore the feasibility and efficacy of different access laparoscopiclly assisted orchiopexy by compairing the outcomes of single-port transcrotal, transumbilical single-site 3-port and conventional 3-port orchiopexy for children with intracanalicular cryptorchidism.

Methods: Between January 2014 and December 2016, a total of 270 cases with undenscended testes in inguingal canal were treated by three different access laparoscopically assisted approaches including 111 cases (3-port group), 84 cases (single- site group), and 75 cases (single-port group). The data of operating time, pneumoperitoneal time, perioperative morbidities and long-term complications were retrospectively reviewed and compaired in three groups.

Results: All of children with intracanalicular cryptorchidism were completed successfully by laparoscopically assisted orchiopexy. No intraoperative complications and conversions were found. The operating time of single-port group (46.12±5.52 min) was significantly shorter than 3-port group (59.71±8.32 min) (P<0.01), and OT of 3-port group was shorter than single-site group (67.30±8.02 min) (P<0.01).The pneumoperitoneal time of single- port group (12.63±1.66 min) was significantly shorter than 3-port group (27.36±4.96 min) and single-site group (31.63±7.87 min) (P<0.01).In postoperative follow-up, no testicular atrophy, malignancies and inguinal hernia or hydrocele formation were observed. Conclusions: Transumbilical single-site 3-port laparoscopic orchiopexy is more laborious and time-consuming for the collision of instruments. With less operating time, less blood loss and better cosmetic effect, single-port laparoscopy combined transcrotal approch orchiopexy can be the optimal access for intracanalicular cryptorchidism. _________________________________________________________________________________ 251GS

Early Experience of the New Robotic System in Colon Cancer

Koo Yong Hahn, MD PhD

Andong Hospital, Department of surgery

Purpose The introduction of robotic system in various surgery, many colorectal cancer surgery is performed by robotic system especially in rectal cancer. The advantages of robotic surgery made easy to conduct pelvic dissection. These days operation of colon cancer with robotic system is increased gradually. I`d like to explain my early experience of colon cancer surgery by new robotic system.

Method From Dec. 20. 2017 to Feb. 28. 2018, the 10 cases of colon cancer surgery were performed by new robotic system. The gender ratio was 6 female and 4 male. Mean age was 69 yrs old. The BMI was below 30 except 1 patient (BMI 32).

Results Tumor location was 2 descending colon, 4 ascending colon, one transverse colon, one distal sigmoid colon and one was recto-sigmoid junction. The procedures were 2 left hemi-colectomies, 4 right hemi-colectomies, two anterior resection and one extended right hemicolectomy. Two were benign diseases (cecal diverticulitis, huge villous adenoma). Mean docking time was 165 minutes. Mean blood loss was below 100 cc. The mean harvested lymph nodes were 28. The stage 2 was 5 and stage 3 was 3. There was no intra-operative complication and conversion.

Discussion The robotic surgery is feasible for colon cancer surgery. The colon cancer surgery is to dissect broad area, nonetheless, this system is approachable to splenic flexure, hepatic flexure, even recto-sigmoid junction dissection with single docking. The large scale study is needed to confirm the oncologic safety compared to conventional laparoscopic surgery.



Mitotically Active Cellular Fibroma of the Ovary: A Case Report and Literature Review

Takashi Yamada, MD PhD

Department of Pathology, Osaka Medical College

Background: The ovarian cellular fibrous tumor with mitotic figure >4 per 10 high power field without moderate to severe atypia is defined as mitotically active cellular fibroma according to the 2014 World Health Organization classification. As this category is new and rare now, we described here a case of mitotically active cellular fibroma and reviewed the literature.

Case: We present a case of mitotically active cellular fibroma of the ovary with 10-year history that was treated with laparoscopic surgery.

Methods: We reviewed the relevant literature using PubMed search system and analyzed the previous cases.

Results: To date, only 5 cases of mitotically active cellular fibroma have been reported. Our patient is the first case of mitotically active cellular fibroma of the ovary treated with laparoscopic surgery.

Conclusion: Mitotically active cellular fibroma of the ovary is a newly defined category and few cases have been reported, while prognostic factors have also not yet been fully characterized. Long-term clinical follow-up is necessary.



Laparoscopic Completion Cholecystectomy and Trans-cystic Exploration of Common Bile Duct Following Gastric Bypass

Ilayaraja Rajendran, MD1; Nitya Krishnamohan, FRCS2; Christina Lo, FRCS2; Vinutha Shetty2; Robert Stockwell2; Ravindra Date2

1Chorley and South Ribble Hospital, 2Lancashire Teaching Hospital

Aim: Common bile duct (CBD) stones are conventionally managed by ERCP. After having a gastric bypass for obesity ERCP using conventional scopes is not possible. Stones in cystic duct remnant makes it even more challenging. Laparoscopic trans-cystic CBD exploration’(LTCBDE) is a good alternative to trans-ductal exploration of CBD, especially for stones<5mm. This video is to share our experience and the challenges one can envisage while performing this procedure Methods: A 63 year old female presented with acute upper abdominal pain. Previously patient had ‘gastric by-pass for weight loss and ‘Laparoscopic Cholecystectomy’(LC). Subsequently patient had ultrasound and MRI scan which confirmed remnant gall bladder and CBD stones. Patient was not suitable for ERCP. Therefore the decision was made to proceed with LTCBDE. Results: The procedure was performed with 4 conventional ports. The left working port of a surgeon was used for the liver retractor. A port for fundic grasper was used as a left hand port istead. There were gross adhesions noted in the infra-hepatic space. Careful dissection was performed to identify the ‘gall bladder’(GB). Subsequently the stones were evacuated from the remnant GB. Trans cystic CBD exploration and balloon sphincteroplasty was performed resulting in expelling of CBD stone into the duodenum. Patient made an uncomplicated post-operative recovery and discharged the next day. Conclusion: We wish to share our experience of this rare case presenting as a complication of what was thought to be a straightforward cholecystectomy. It highlights the importance of careful planning, counselling of patient and teamwork in management of rare difficult cases. _________________________________________________________________________________ 255GS

Laparoscopic Removal of Intraluminally Migrated Adjustable Gastric Band

Jamal L McFarlane, MD; Takintope Akinbiyi, MD; Asha Bale, MD FACS


Laparoscopic adjustable gastric band (LAGB) is the second most commonly performed bariatric operation in the United States. Gastric band erosion is a well described complication of this procedure and has been reported in up to 7% of gastric band cases. Rarely, the band can migrate completely into the stomach lumen. When this occurs, laparoscopic or endoscopic techniques can be used to retrieve the eroded band. In this video, we present a 43 year old female who presented with odynophagia 12 years after LAGB placement, and was found to have a complete band erosion into the lumen of the stomach. We removed her intragastric band using a laparoscopic anterior gastrotomy. Surgical technique of laparoscopic transgastric removal of completely eroded band is illustrated in this video.



Is Laparoscopic Appendectomy Effective in Case of Appendicitis Complicated by Intra-Abdominal Abscess? A Single Centre Experience

Brunella Maria Pirozzi, MD1; Villa Massimo, Prof. MD2; Aniballi Matteo, MD1; Matarangolo Antonio, MD1; Petagna Lorenzo, MD1

1Università di Roma Tor Vergata, 2Policlinico Tor Vergata

Post-appendectomy intra-abdominal abscesses are estimated to complicate up to 4.2% of acute non- perforated appendicitis and between 6.7% and 28% acute perforated appendicitis(1). The aim of our retrospective study was to evaluate the efficacy of laparoscopy in case of complicated appendicitis by an intra-abdominal abscess (CAIA).

METHODS: A retrospective analysis of 148 patients, treated between 2014 and 2017, has been carried out, occurrence of CAIA was shown with the pre-operatory CT scan and/or during surgery. For all patients, treated laparoscopically, peritoneal wash out was performed and one pelvic drainage was positioned. There were three laparotomic conversions due to extensive cecal adhesions.

RESULTS: Six patients developed new abscesses. Four of them were successfully treated with ultrasound guided percutaneous drainage, the other two were drained with a second laparoscopic procedure. Hospitalization time of these patients was 20 +/- 5,6 days. The rest of 141 patients did not present any complications with an hospital stay of 3,1 +/- 2,1 days.

CONCLUSIONS: A laparoscopic approach is generally safe but, according to our knowledge, does not protect against the risk of post-operative abscesses despite the accuracy of the surgical wash out and drainage.
REFERENCES: 1. Coelho A , Sousa C , Marinho AS , Barbosa-Sequeira J , Recaman M , Carvalhao F , [Post-appendectomy intra-abdominal abscesses: six years' experience in a Pediatric Surgery Department.] Cir Pediatr. 2017 Jul 20;30(3):152-155.



The Use of Space Anatomy in Radical Hysterectomy for Cervical Cancer Patients

Song Xu, MD

Hangzhou First People’s Hospital

OBJECTIVE To evaluate the feasibility and safety of sapce anatomy in laparoscopic radical hysterectomy for the treatment of cervical cancer.

METHODS & PROCEDURES Forty-nine patients who underwent laparoscopic radical hysterectomy for the treatment of cervical cancer in our hospital during December 2015 and September 2017. Seven spaces among bladder, uterus and rectum are dissected in the operation. When these potential spaces have been found, we cut off three ligaments surround the uterus to isolate it. These ligaments are cardinal ligaments, uterosacral ligaments and vesicocervical ligaments. Then we correct preserve the pelvic splanchnic nerves and remove the uterus along with 3 centimeters vagina. In this procedure, it is essential to identify the deep uterine vein.

RESULTS The surgical outcomes were analyzed and compared to previous reports. The median operative time was 234 minutes (range,169-312 minutes) and the median intraoperative blood loss was 20 mL (range, 5-50 mL). No patients needed a blood transfusion, conversion to laparotomy, or reoperation. Postoperative complications were observed only in three patients The amount of blood loss and the incidence of complications were less. The operative time in our study was equivalent to previous reports.

CONCLUSION Space anatomy is an attractive surgical approach in laparoscopic radical hysterectomy for early-stage cervical cancer. This procedure can be alternative both in laparoscopy and laparotomy.



The Value of Endoscopic Vascular Clip in Nerve-preserving Radical Hysterectomy for Cervical Cancer Patients

Jinyl Tong

Hangzhou First People’s Hospital

OBJECTIVE: In order to reduce the risk of urinary retention after radical hysterectomy, we chose endoscopic vascular clip to deal with the deep uterine vein instead of bipolar coagulation. The aim of this study was to assess the safety and effectiveness of this method.

METHODS & PROCEDURES: Twenty-six patients who underwent laparoscopic radical hysterectomy in our hospital between January 2017 and December 2017 were equal distributed into two groups: endoscopic vascular clip group and bipolar coagulation group. For the first group, three steps were performed.
Step 1: during the section of paracervix, we separate the deep uterine vein. Step 2: uterine deep vein usually have 3 main branches, we use endoscopic vascular clip to block the distal parts. Step 3: remove the deep vein and protect the bladder nerves.
For the bipolar coagulation group, we use this electrical instrument to coagulate the arteries and veins, then cut them as usual.

RESULTS: The average time of this procedure by vascular clip was a little more than the other group(42±13 vs 27±8 minutes), but the blood loss (15±5 vs 37±17 ml)and the incidence rate of urinary retention (7.7 vs 23.1%) are much less.

CONCLUSION: Direct visualization of the uterine deep vein and treat it with endoscopic vascular clip can reduce the bleeding and perfectly protect the pelvic autonomic nervous system, makes the nerve-sparing approach a safe and feasible procedure.



The Application of Phloroglucinol in the Hysteroscopic Operation of Postmenopausal Women

Feng Xian Fu, MD1; Hua Duan, MD2

1Aerospace Central Hospital (ASCH), 2Beijing Obstetrics and Gynecology Hospital

Objective To investigate the feasibility and safety of the application of phloroglucinol for cervix pretreatment before hysteroscopic surgery for postmenopausal patients.

Methods The clinical data of 110 postmenopausal patients undergoing cervix pretreatment before hysteroscopic surgery in the Department of Obstetrics and Gynecology, Aerospace Central Hospital between January 2017 and January 2018 were analyzed.

Results The cervical entry time of hysteroscopic surgery in 110 cases was (17.8±7.52); In 80 cases (72.7%) of 110 cases, 4.5mm hysteroscopy could enter cervical canal , before the expansion of hegar dilator (No. 4- No. 11); after the application of phloroglucinol for cervix pretreatment, there was no abdominal pain, vaginal bleeding and HR/BP changes before operation. The operation was completed successfully without complications, such as TURP syndrome, uterine perforation, uterine bleeding, infection, venous thrombosis, etc.

Conclusions On a preoperative risk-assessment basis, the efficacy of application of phloroglucinol for cervix pretreatment before hysteroscopic surgery for postmenopausal patients was positive and safe.



Minimally Invasive Surgery Versus Laparotomy for Radical Hysterectomy in the Management of Early-stage Cervical Cancer: Survival Outcomes

Benny Brandt, MD; Vasileios Sioulas, MD; Theresa Kuhn, MD; Katherine LaVigne, MD; Ginger J Gardner, MD; Yukio Sonoda, MD; Nadeem R Abu-Rustum, MD; Mario M. Leitao Jr, MD

Objective: To compare outcomes in patients who underwent minimally invasive surgery (MIS) compared to laparotomy for newly diagnosed early-stage cervical carcinoma at our institution.

Methods & procedures: We performed a retrospective cohort study of all patients who presented at our institution with FIGO stage IA1 to IB1cervical carcinoma from 1/2007-12/2016. Patients undergoing any preoperative therapies were excluded. Only squamous cell carcinomas, adenocarcinomas, or adenosquamous carcinomas were included. Appropriate statistical tests were used.

Results: We identified 193 cases for analysis—111 MIS (98 [88%] robotic) and 82 laparotomy. Two MIS cases (1.8%) were converted to laparotomy. There were no statistically significant differences between cohorts in terms of tumor size, substage, node positivity, margin status, or presence of lymph-vascular space invasion. Median follow-up was 46 months (range, 0.9-117.3) for MIS and 48.4 months (range, 0.5-134.4) for laparotomy (P=0.7). Recurrence occurred in 12/109 (11%) MIS and 6/79 (7.6%) laparotomy cases, respectively (P=0.6). All were FIGO stage IB1. Sites of first recurrence for MIS versus laparotomy were as follows: vaginal (17% vs 0%), pelvis (8% vs 17%), nodal only (17% vs 50%), abdominal (17% vs 0%), extra-abdominal (17% vs 0%), and multiple sites (25% vs 33%) (P=0.4). The 5-year progression-free survival rates were 86.1% (SE 3.9%) for MIS and 89.9% (SE 4%) for laparotomy (P=0.4). The 5-year overall survival rates were 96.1% (SE 2.2%) and 88.0% (SE 4.7%), respectively (P=0.2).

Conclusion: This analysis suggests that MIS does not compromise oncologic outcomes of patients undergoing radical hysterectomy for early-stage cervical carcinoma.



Pre-operative Diagnosis of Uterine Sarcomas on a Continuous Cohort of 3616 Patients Referred for Fibroid Treatment Over 16 Years

Afshin Fazel, MD PhD; Vinciane Place, MD; Françoise Cornelis; Jérémy Sroussi, MD; Matthieu Mezzaddri, MD; Jean-Louis Benifla, MD

APHP- Hôpitallariboisiere

We present a comprehensive strategy to diagnose sarcomas prior to Minimally Invasive Surgery (MIS) among a continuous cohort of 3616 patients of 20 different ethnical origins, referred for fibroid treatment in a University Hospital, between 01.01.2002 and 01.01.2018 Each had a clinical examination, endometrial sampling, office hysteroscopy, pelvic ultrasound, MRI. Patients were treated by Uterine Artery Embolization (UAE), hysteroscopy, laparoscopy, a combined procedure or by laparotomy. Every diagnosis of uterine sarcoma was reviewed by a panel of senior pathologists. Over 70% had a minimally invasive procedure 633 patients were treated by laparoscopy, 268 patients with a vaginal procedure, and 274 patients by UAE. 28 patients had a final diagnosis of sarcoma. None of them was treated by a minimally invasive procedure nor had a uterine morcellation. When a unique uterine mass was assessed by MRI, the Positive and Negative Predictive Value of Malignancy or STUMP was 100% respectively. No hazard due to uterine or myoma morcellation by laparoscopy or vaginal route with an unrecognized sarcoma was reported. The incidence of uterine sarcoma in a continuous population of 3616 patients referred for treatment of fibroids was 0.77%. All sarcomas had a suspected diagnosis of malignancy or cellular fibroid prior to surgery. No hazard was reported due to the morcellation of an unrecognized sarcoma. With unique uterine masses, MRI alone had a PPV and NPV of 100% to diagnose uterine sarcomas or STUMP. The combination of clinical history, MRI, endometrial sampling and hysteroscopy could help in counseling and preventing from accidental morcellation of a malignancy.



Intravenous Leiomyomatosis of the Uterus Extending into Gonadal Vein

Gulden Menderes, MD; Gary Altwerger, MD; Sophie Chung; Dan-Arin Silasi, MD

Yale University School of Medicine

Objective: To demonstrate a surgical video where-in intravenous leiomyomatosis was diagnosed and managed intra-operatively during a robotic-assisted total hysterectomy for leiomyomatous uterus.

Methods/ Procedures: Patient was a 45-year old with bulky leiomyomatous uterus. She was referred to our division for definitive surgical management of her abnormal uterine bleeding secondary to leiomyomas. Pre-operative imaging revealed a ~26-week size enlarged uterus with multiple leiomyomas. Endometrial biopsy was negative for any hyperplasia or malignancy. She was then consented for a robotic-assisted total hysterectomy.
Procedure started with exploration of the peritoneal cavity which revealed bulky leiomyomatous uterus and a significantly enlarged right infundibulopelvic (IP) ligament. Once the ureteroloysis was completed on the right pelvic sidewall, the IP ligament was skeletonized and a vascular clip was attempted to be placed for hemostasis. During the placement of the clip, intravenous leiomyomas were visualized to be protruding through the gonadal vein. The intravenous leiomyomas were then extracted from the vessel by utilizing the robotic graspers. Attention was paid in order not to dislodge the leiomyomas into the vein. Firm and steady pressure was applied during the surgical extraction of the specimen from the right ovarian vein.

Results: The procedure was successfully completed robotically. Patient was discharged home on post-operative day one. Magnetic resonance imaging did not reveal any remaining intravenous leiomyomatosis and echocardiography was negative for any pathology.

Conclusions: Intravenous leiomyomatosis is a rare phenomenon which can occur in patients with leiomyomatous uterus. It can be managed laparoscopically in experienced hands with excellent surgical outcomes.



Minimally Invasive Intrauterine Surgery: Is It Enough to Fertility Recovery?

Vladimir Zuev, Dr Med; Tea Dzhibladze, MD, Prof; Anatoly Ischenko, MD, Prof; Irina Khokhlova, MD; Anna Osipova, MD

Sechenov University

OBJECTIVE: An objective of this study is a hysteroscopic evaluation of main endometrium pathologies those can inhibit implantation and affect pregnancy rate in IVF programs.

METHODS & PROCEDURES: Outcomes of hysteroscopic procedures in 160 patients were retrospectively analyzed, including histology of endometrium biopsy in patients with hysteroscopic findings. Laser minimally invasive surgery was used. Noninvasive Laser fluorescent spectroscopy and photoimmunotherapy was used in 120 patients in to evaluate endometrium quality and activate endometrium regeneration. Group of multiunsuccesfull IVF programs (3-18) formed majority of patients.

RESULTS: Intrauterine pathologies were found in 96 (60 %) patients including intrauterine adhesions 42 (43,8%),submucosal leiomyoma 11 (11,4%), polyps 57 (59,3%), endometrial hyperplasia 17 (17,7%), intrauterine septa 3 (3,1%), atrophy 26 (27,8%), adenomyosis 16 (16,7%), endometritis 57 (59,3 %). Hysteroscopic findings were hystologicalally proved in all cases. The main monitoring technology for regenerate and recover endometrium was office hysteroscopy, laser spectroscopy and photo-therapy.

Results of study: Pregnancy rate in group of multiunsuccesfull IVF programs patients (3- 18) was 68%. " Take baby home" winners were 32,7 % of patients.



Fallopian Tube and Ovary Prolapse After Caesarean Section

Anil Khetarpal, MD; Smita Khetarpal, MD

Khetarpal Hospital

Objective: To report a rare case of fallopian tube and ovary prolapse one month after caesarean section.

Methods & Procedures: Post hysterectomy prolapse of fallopian tube is a known but rare complication. Prolapse of fallopian tube into the vaginal vault have been widely reported after open or laparoscopic hysterectomies. We take this opportunity to report prolapse of a fallopian tube and ovary after a caesarean section and to the best of our knowledge this is the second such case to be reported so far *[1]. A 31-years old woman presented to our hospital with concerns of swelling just adjacent to the left side of scar with minimal discharge. Patient recently had undergone lower segment caesarean section one month back elsewhere. Patient was jointly evaluated by the departments of Obstetrics & Gynaecology and General Surgery and was planned for excision of sinus. Intra-operative findings revealed herniation of left tube and ovary from the abdominal wound. After explaining to the attendants, left adnexa was removed. Post-operative course was uneventful.

Results: Total salpingectomy is recommended as optimal management because recurrent symptoms have been reported after partial salpingectomy.

Conclusion: Any swelling or discharge around the caesarean scar, however trivial, should be thoroughly examined and one should not hesitate to undertake surgical exploration.



To Open or Not to Open Laparoscopic Assisted Vaginal Hysterectomy Post Multiple Open Abdominal Surgeries

Anil Khetarpal, MD; Smita Khetarpal

Khetarpal Hospital

Objectives: To present a case of laparoscopic assisted vaginal hysterectomy after multiple open abdominal surgeries.

Methods & Procedures: 43-year-old woman presented with profuse vaginal bleeding with pain in abdomen from last three months. Patient had history of multiple previous interventions (two lower segment caesarean sections, open appendectomy, open surgery for endometriosis and laparoscopic meshplasty for large abdominal hernia). Patient jointly assessed by departments of General Surgery and Obstetrics-Gynaecology. Ultrasound whole abdomen revealed bulky uterus with adenomyosis. Patient had consulted various doctors for the same complaint and was advised to undergo open hysterectomy. We, however, decided to take up the patient for laparoscopic assisted vaginal hysterectomy after explaining the complications. Consent for open abdominal hysterectomy was taken in view of pelvic adhesions and endometriosis. Intra-operatively, thick adhesions found, adhesiolysis achieved using Ligasure. Utero-Vesico fold was thick, adherent and not well defined. After adhesiolysis & pushing cervix from below, uterus seen approximately 16 weeks size. Left mesosalpinx dissected with tube & ovary which continued till the round ligament. Due to presence of multiple adhesions, another 5mm right lateral port was made at mid axillary line just above the standard position. Using harmonic scalpel, right ovary marsupialized and left behind. Vaginal dissection done, uterus delivered and sent for histopathology.

Results: Post-operative course was uneventful. Patient was discharged in stable condition.

Conclusion: Surgery in patients who have previously undergone multiple open abdominal procedures is always difficult and risk of complications is quite high. Such cases should not be considered as an absolute contraindication for laparoscopic procedures.



Minimally Invasive Treatment of Cesarean Section Diverticulum

Yungui Cao, MD; Juan Deng, MD

Shanghai Jiading District Maternal and Child Health Care Hospital

Background and Objectives: During the past few decades, there has been a significant increase in the number of cesarean deliveries, and thus an increase in the number of complications. A common complication of multiple cesarean deliveries is symptomatic uterine scar dehiscence, for which there are no treatment guidelines available. We report a case of resectoscopic treatment of an IUD embeds in cesarean scar defect and review the literature on this defect.

Case: The patient was a 35-year-old woman, gravida4, para1, complaining of persistent vaginal spotting for the prior 2 years with a history of a cesarean delivery. Ultrasound examination revealed there was an anechoic area in the anterior uterine wall narrow section, and an IUD down to embed in the anechoic area. We use a successful resectoscopic treatment of an IUD embeds in cesarean scar defect.

Conclusion: We describe a repair approach for treating uterine scar diverticula associated with cesarean section. This technique is minimally invasive. Further prospective, large-sample, case- control studies are necessary to confirm the effectiveness of this approach.



Application of Single Port Laparoscopic Gynecologic Operation

Juan Deng, MD, Yungui Cao, MD

Shanghai Jiading District Maternal and Child Health Care Hospital

OBJECTIVE: In recent years, with the development of minimal invasive surgery, abdominal scarless surgeries, including natural orifice transluminal endoscopic surgery (NOTES) and transumbilical endoscopic surgery (TUES) , were highly praised by domestic and international clinicians. The aim of this study is to investigate the application of single hole laparoscopy in gynecological surgery .

METHOD: From September , 2017 to March , 2018, 19 patients (ectopic pregnancy in 15 cases, ovarian cyst in 3 cases, and infertility in 1 case) were operated by transumbilical endoscopic surgery in our hospital.

RESULTS: The operation was completed successfully. There was no transfer of traditional laparoscopy or laparotomy. No complications occurred. 1 cases had persistent ectopic pregnancy after operation.

CONCLUSION: Single port laparoscopic is less invasive and has no wound and beauty in the abdominal wall. It is easy to operate in salpingectomy and adnexal surgery. It is worthy of further clinical research because of its more minimally invasive and beautiful appearance.