Surg Endosc (2012) 26:S141–S176 DOI 10.1007/s00464-012-2200-0

and Other Interventional Techniques

19th International Congress of the European Association for Endoscopic Surgery (EAES) Torino, Italy, 15–18 June 2011 Video Presentations

Ó Springer Science+Business Media, LLC 2012

EAES VIDEO AWARD SESSION

V001 - Video - Morbid Obesity

V002 - Video - Thoracoscopic Surgery

LAPARO-ROBOTIC GASTRIC BY PASS WITH ‘DOUBLE LOOP’ TECHNIQUE FOR MORBID OBESITY M. Nardi ‘U. Parini’ Regional Hospital, AOSTA (AO), Italy

PORT ACCESS THORACOSCOPIC SEGMENTECTOMY: POSTERIOR SEGMENTECTOMY H. Kato Yamagata University, YAMAGATA, Japan

Laparoscopic gastric by pass (LGBP) is actually worldwide diffused for treatment of morbid obesity. In the General Surgery Unit of Aosta’s Valley (Aosta-Italy) we recently perform the LGBP with roboticassisted technique (Da Vinci IntuitiveTM Robotic System). We present a case of female patient, BMI 50 kg/m2 (sweet and binge eater), in which performed a LGBP with ‘double loop’ technique with 150 cm antecolic alimentary limb and 75 biliopancreatic limb. The gastrojejunal anastomosis was realised with Da Vinci IntuitiveTM Robotic System. Operative time was 180 min; intraoperative and postoperative complications were not observed, hospital stay was 10 days. This early experience suggests that robotic surgery is safe and effective alternative to conventional laparoscopic surgery. We believe that robotic surgery, with its ability to restore the hand-eye coordination and three-dimensional view lost in laparoscopic surgery, will allow us to perform complex procedures with greater precision and better results.

Aim: Recently, the incidence of small-sized lung cancer with groundglass opacity (GGO) has increased. Thus, limited lung resection and minimally invasive surgery are in great demand. We present our technique using port access thoracoscopic lung segmentectomy for patients with small-sized lung cancer as a minimally invasive surgery with curative intent. Case: A 54-year-old woman was admitted to our hospital with a 15 mm GGO on the posterior segment of the right upper lobe that was suspicious of bronchioloalveolar carcinoma. Technique: Port access thoracoscopic lung segmentectomy was performed. One 15-mm flexible port and 3 5-mm ports were used. Vessels were identified pre- or intra-operatively using a contrastenhanced MDCT, 3D volume-rendering method. An ascending artery was ligated and divided using an ultrasonically activated coagulation device, and the posterior bronchus (B2) was dissected. B2 was cut using a stapler after the right lung was inflated to visualize an intersegmental plane for dissecting the anatomical plane. A central vein and its branches (V2a, V2b, V2c) were identified and V2b was ligated; intersegmental veins (V2a and V2c) were preserved based on the 3D image. The parenchyma was dissected along an intersegmental vein, and staplers were used for peripheral lung tissues. The operation took 203 min. Bleeding was only 3 ml. A chest tube was removed on 1 POD and the patient was discharged on 5 POD. Conclusion: Port access thoracoscopic lung segmentectomy can be safely performed using 3D-CT navigational simulation.

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V003 - Video - Oesophageal and Oesophagogastric Junction Disorder SINGLE-INCISION TRANSUMBILICAL LAPAROENDOSCOPIC GASTRIC BENIGN TUMOR RESECTION G. Dapri, L. Casali, P. Carnevali, S. Scomersi, R. Ntounda, J. Himpens, G.B. Cadie`re European School of Laparoscopic Surgery, BRUSSELS, Belgium

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V005 - Video - Liver and Biliary Tract Surgery TRANSVAGINAL HYBRID SCARLESS CHOLECYSTECTOMY WITH RIGID INSTRUMENTS EXPERIENCE WITH 180 CASES H.R. Mofid Israelitisches Krankenhaus, HAMBURG, Germany

Video: A 25 years old man consulted after diagnosis of a 40 9 20 cm endoluminal lesion of the gastric cardia. Preoperative work-up showed a stromal tumor with invasion of the muscular layer. The umbilical scar was incised and, after placement of a purse-string suture, an 11-mm non disposable trocar was inserted for a 10-mm 30° angled scope. Curved and reusable instruments (Karl Storz-Endoskope, Tuttlingen, Germany), and straight ultrasonic shears (Ethicon Endosurgery, Cincinnati, OH) were inserted transumbilically. Peroperative gastroscopy located the lesion on the smaller gastric curvature, 1 cm from the gastroesophageal junction. A stitch was placed in the center of the lesion, and gastroscopic grasper helped in maintaining the limits of the resection. Gastrostomy was closed using two converting absorbable running sutures. Because of the curves of the instruments there was no conflict between the instruments’ tips inside the abdomen, or between the surgeon’s hands outside the abdomen. Leak-test with the gastroscope checked the integrity of the suture. The specimen was retrieved transumbilically in a plastic bag. Results: Operative time was 150 min, and the umbilical incision was less than 15 mm. The patient was discharged after 5 days, and he is doing well 3 months postoperatively. Conclusions: Laparoscopic gastric resection can safely be performed through a single access. Peroperative gastroscopy permits to precise the limits of the resection, and the use of curved and reusable instruments allows surgeon to achieve ergonomic conditions as in classic laparoscopy, without increasing of the laparoscopic cost.

Aim: To demonstrate a safe and feasible NOTES (Natural Orifice Transluminal Endoscopic Surgery) technique which is applicable in the daily routine use. This 7 min long video presents our technique which is in use since nearly 4 years. Method: Operations in the transvaginal technique start with a 5 mm incision deep in the umbilicus, insufflation of the abdomen and diagnostic laparoscopy. A 5 mm dissector and a 10 mm optic both extra long, are inserted in a steep antitrendelenburg position in the posterior fornix of the vagina under laparoscopic control. The optic in the umbilicus is replaced by another dissector. The gallbladder is retracted with the instrument positioned through the vagina, and is then dissected via the umbilicus. When the cystic duct and the cystic artery are identified, they are clipped through the umbilicus with a 5 mm clip device and divided from there. The gallbladder is then mobilized with an electric hook. For removal the 5 mm optic from the umbilicus is used again. A removal bag can be used through the 10 mm vaginal trocar. The gallbladder is then pulled through the 10 mm colpotomy, which can be enlarged bluntly with a clamp if needed. The defects in the vagina are sutured with resorbable thread. Results: The average operation time was 49 min (27–100). Except in one case, all the operations could be performed in this technique. In one case we converted to the standard laparoscopic procedure due to severe inflammation. There was one operative complication: the puncture of the urine bladder in a case after previous hysterectomy. One reoperation was necessary after 3 weeks because of an abscess in the pouch of Douglas. No changes in the sexual intercourses occurred after the operation (interview after at least 3 months). Conclusion: This video demonstrates a feasible and safe method for scarless cholecystectomy. No higher risks compared to the standard method is detectable and the rate of dyspareunie after the vaginal approach is zero.

V004 - Video - Gastroduodenal Diseases

V006 - Video - Liver and Biliary Tract Surgery

LAPAROSCOPIC DISTAL GASTRECTOMY WITH INTRACORPOREAL HAND-SEWN BILLROTH-I ANASTOMOSIS (ICHSA) - NO USE OF AUTOMATIC SUTURING INSTRUMENTS. K. Matsuo1, H. Shimura2, S. Tanaka2, H. Tetsuya2, K. Daibou2, Y. Yamashita2, K. Inoue1, H. Satoh1, A. Inoue1 1 Inoue Hospital, ITOSHIMA, Japan. 2 Fukuoka University School of Medicine, FUKUOKA, Japan

LAPAROSCOPIC LEFT HEPATECTOMY: TOWARDS A NEW STANDARD OF CARE G. Belli, C. Fantini, A. D’Agostino, L. Cioffi, G. Russo, A. Belli, P. Limongelli S.M.Loreto Nuovo Hospital, NAPLES, Italy

Introduction: The authors report the resection of a gastric benign tumor through single-incision laparoscopy, guided by peroperative gastroscopy.

Background: The number of cases of laparoscopic surgery has been increasing in JAPAN. Lymph node dissection has been standardized, and the enlarged view provided by laparoscopes allows for the procedure to carried out successfully entirely within the abdominal cavity, but many cases of reconstruction using the Billroth-I method are performed under direct vision through a small incision. In this study, by placing an anchor thread on a suture line on the lesser curvature of the stomach, we simplified the procedure for hand-sewn anastomosis and safely performed gastroduodenal anastomosis at low cost to obtain good results. Method: From January 2009 to August 2010, we performed hand-sewn gastroduodenal anastomosis in 18 cases. After performing lymph node dissection, the duodenum and the stomach were divided using an automatic suture device. Anchor sutures were placed on the suture line of the lesser curvature. First, the seromuscular layer of the stomach and the seromuscular layer of the duodenum were sutured by performing interrupted suturing using an extracorporeal knot-tying method. With the stomach and the duodenum in a fixed state, the anastomosis area was opened. The thread of the anchor suture was pulled toward the abdominal wall, and then all layers of the stomach and the duodenum at the posterior wall were continuously sutured. Similarly, for the anterior wall, all layers were continuously sutured from the lesser curvature toward the greater curvature. Results: The mean time required for the anastomosis was 64.6 ± 17.1 min, and the estimated blood loss was 53.1 ± 91.0 g. All operation was curative, and the mean number of retrieved lymph node was 27.1 ± 10.8. Postoperative complications included 1 case of a ruptured suture, but this was resolved through a conservative approach. There were no cases of postoperative stenosis. Conclusions: This method is economical, as it does not require the use of machinery for anastomosis, and the duodenal stump is short, and we believe this method, which can be performed in a similar manner even for obese patients, can be used as a standard method of anastomosis.

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Background: Laparoscopic major resections remain a challenge for liver surgeons. So far, no standardized technique for major LHR is yet available This video illustrates, step by step, our laparoscopic technique for left hemi-hepatectomy for a cholangiocarcinoma. Methods: The control of vascular inflow and outflow as well as the division of the left hepatic duct were carried out extraparenchymally before liver transection. Parenchymal transection was performed on a mobilized and devascularized left liver by using CUSA (Cavitron Ultrasonic Surgical Aspirator); major vessels were secured by endoclips. Results: There were no intra-operative complications with no intra-operative or perioperative blood transfusions. A Pringle maneuver was not used. Operating time was 230 min. The patient had an uneventful postoperative course and was discharged on the seventh postoperative day. The surgical resection margin was not invaded and had a width of 4.5 cm. Conclusions: This technique has proved to be safe and easily reproducible if undertaken with proper training in high volume centers, by surgeons with expertise in both liver and advanced laparoscopic surgery.

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V007 - Video - Morbid Obesity PURE TRANSUMBILICAL SINGLE INCISION LAPAROSCOPIC GASTRIC BY-PASS WITH TOTAL INTRACORPOREAL ANASTOMOSIS S. Morales Conde1, M. Socas Macias1, A. Barranco Moreno1, I. Alarcon1, G.L. Sciannamea2, C. Mendez1, M.D. Casado1, V. Gomez1, J. Canete1, H. Cadet1, J. Padillo Ruiz1 1 HUVRocio, SEVILLE, Spain. 2BOLONIA, Italy Background: SPA surgery is considered a new minimally invasive approach wit better cosmetic results and less postoperative pain. Its goals is to preserve the satisfactory results obtained by standard laparoscopy. We present the first pure single port access gastric bypass with intracorporeal anastomosis. Method: Single port access gastric by-pass in a 54-year-old female BMI 40. Results: We performed a transumbilical single port access gastric bypass with no additional trocars and total intracorporeal anastomosis. Both anastomosis were performed using an endostapler and closing the orifice of the staplers with an intracorporeal running suture. The procedure was performed through a 2.4 cm transumbilical incision, without any additional trocar, using a single-port device with two trocars of 5 mm and one of 12 mm placed in the access channels. Surgery was started by performing the side-to-side jejunojejunostomy with a 150-cm alimentary limb, and followed by the transsection of the stomach in order to perform an antegastric and antecolic end to side gastrojejunostomy. In order to have a proper exposition of the stomach, liver was retracted by using one 120 cm-long stitch that was placed in the right cross of the hiatus. The suture was introduced through a 10 cmlong plastic tube, which was introduced in the abdominal cavity through one of the ports. Both sides of the suture were grasped from the outside, at the subxiphoid level, with and endoclose. Once the liver was exposed, traction of the stomach was needed in order to have a proper exposition of the area of transsection. This traction was maintained by using the endograb, which was replaced in different occasion in order to have the proper vision of the area to be transected. The use of a drain was not considered necessary. The umbilical incision was closed with a plug, and the skin was closed with interrupted sutures of a rapid absorbable material. Operative time was 150 min. No intraoperative or postoperative complications were reported. Conclusion: Single port access gastric by-pass with intracorporeal anastomosis without any additional incision is a feasible and safe technique when performed by experienced laparoscopic surgeons.

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V008 - Video - Clinical Practice and Evaluation

V010 - Video - Different Endoscopic Approaches

ACCIDENTALLY DIAGNOSED INTRAABDOMINAL MASS CASTLEMAN DISEASE - LAPAROSCOPIC RESECTION FOLLOWING PREOPERATIVE ARTERIAL EMBOLISATION A. Ba´lint, B. Ro´zsa, M. Ma´te´, Z. Ba´nsa´ghi, E. Bardo´czi, B. Brenner Saint Emeric Hospital, BUDAPEST, Hungary

MINIMALLY INVASIVE ONE-TIME TRIPLE-APPROACH FOR THE TREATMENT OF STAGE IV COLONIC CANCER I. Poves, F. Burdı´o, M. Pera, A. Radosevik, S. Salvans, L. Lorente, L. Grande Hospital del Mar, BARCELONA, Spain

Introduction: Castleman disease is a rare atypical lymph proliferative condition. It can occur as localized or generalized alteration. By histology hyaline-vascular type or plasma cell type of the disease can be defined. The majority of the cases belong to the localized type, occurring in young adults with no or slight atypical clinical symptoms. This subset of patients shows benign course of the disease. In contrary the multicentre variants of the disease often show malignant course with generalized lymphadenomegaly and multiorgan involvement. Case-report: A 60 years old woman had undergone diagnostic work-up because of atypical abdominal complaints. Abdominal ultrasound found a tumor mass in the left lower quadrant. CT scan confirmed the presence of a tumor with size of 41 9 35 mm. Angio CT scan revealed pronounced vascularisation of the mass directly from the inferior mesenteric artery and vein. During the scan the supplying artery was occluded with micro spirals. On the following day the laparoscopic removal of the tumor was performed. The histology of the specimen revealed the hyaline-vascular form of Castleman disease. The intervention was followed by uneventful postoperative period. A thorough diagnostic work up did not reveal tumor mass in any location. Discussion: we decided to present this case because of rarity of Castleman disease furthermore the good example of collaboration of interventional radiology and surgery. The successful occlusion of arterial supply of the mass considerable decreased the risk of intraoperative hemorrhage.

Introduction: Laparoscopic approach for the treatment of colonic cancer (CC) is well established and widely accepted. On the contrary, for hepatic resections due to colorectal liver metastasis (CRLM) is still on debate. Radiofrequency ablation (RFA) is considered a second line treatment for CRLM and especially useful in cases of multiple bilobar metastasis and/or for combining with resective procedures. Simultaneous hepatic and colonic resection for treatment of colonic cancer with synchronous CRLM has been proved to be safe in selected cases requiring minor hepatic resections (two or less segments). Video presentation: In a screening study (positive fecal occult blood test) a 62 years-old man was diagnosed of a CC located 45 cm from the anus. On the staging study were detected two nodules suggestive of CRLM: one of 30 mm on segment II and one of 8 mm on segments VIII. It was decided to perform a triple approach (three procedures) in one time operation: percutaneous RFA and simultaneous laparoscopic left lateral segmentectomy and sigmoidectomy. First, an expert radiologist in interventional procedures performed a percutaneous RFA of the nodule in the segment VIII. It was used a Cool-Tip device (Covidien) during 10 min for achieving a 30 mm of diameter area ablation. The second procedure was to perform a conventional left lateral segmentectomy without hiliar clamping. The parenchymotomy was done using Ligasure V (Covidien). Surface hemostasis was controlled using bipolar graspers. Operative time of the hepatectomy was 114 min. Cholecystectomy was done due to cholelithiasis. The third procedure consisted in performing a standard oncological sigmoidectomy. Inferior mesenteric artery was sectioned at the root of the left colic artery which one was preserved. Both hepatic and colonic specimens were removed through a suprapubic transversal 5 cm incision. Operative time of the colonic procedure was 162 min. Total minimally invasive procedures time was 320 min. Postoperative, haemoglobin was 11.9 g/dl (preoperative 13.9 g/dl). The patient was discharged on 4th postoperative day without any incidence. Conclusions: Multiple simultaneous minimally invasive procedures can be combined in one time for the treatment of stage IV CC.

V009 - Video - Different Endoscopic Approaches

V011 - Video - Different Endoscopic Approaches

SINGLE PORT RIGHT HEMICOLECTOMY R. Smith, A. Day, I.C. Jourdan, T.A. Rockall Minimal Access Therapy Training Unit, GUILDFORD, United Kingdom

LAPAROSCOPIC SINGLE INCISION ASSISTED TECHNIQUE FOR REMOVAL THE GIANT STOMACH TRICHOBEZOAR S.V. Dzhantukhanova, Yu.G. Starkov, K.V. Shishin, I.Yu. Nedoluzhko, M.I. Vyborniy A.V. Vishnevsky Institute of Surgery, MOSCOW, Russia

Aims: Illustrate that right-sided colonic resection is safe and feasible using a single port surgical access technique. Methods: A 74-year-old female patient, ASA 2 underwent an elective right hemicolectomy. Surgical access was achieved using an Ethicon Single Site Laparoscopy (SSL) Access System. Following creation of a pneumoperitoneum, a 30-degree endoscope and a combination of linear and curved 5 mm instruments were used to perform the dissection. Early identification and division of the ileocolic pedicle was performed prior to a medial to lateral dissection. Specimen mobility was assessed before reduction of the pneumoperitoneum, specimen extraction, resection and formation of an extracorporeal ileocolic stapled anastomosis. For completion, correct positioning of the anastomosis was confirmed laparoscopically via the single umbilical port. Postoperative analgesia was administered via spinal anaesthesia and the patient was managed using an established enhanced recovery programme. Results: Total laparoscopic operative time was 39 min. The total midline wound length was 2.5 cm. The patient was discharged on the third postoperative day with no complications. Histological examination of the resected specimen confirmed a tubulovillous adenoma. The patient reported a return to normal activity at clinic review 2 weeks following her surgery during which a follow up colonoscopy was scheduled twelve months later. Conclusions: Single port right-sided colonic resection is technically safe and feasible for appropriately selected patients when performed by an experienced laparoscopic surgeon.

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Currently minimally invasive surgery is marked by an active development of a single port access technique or single incision laparoscopic surgery (SILS). In a period of last 2 years 45 surgical interventions for gallstone disease, GERD, esophageal achalasia, nonparasitic hepatic cysts, liver metastases and pyloric stenosis were performed, using SILS technique. Due to rarity and the lack of similar reports in literature one case of the stomach trichobezoar removal is of interest. A female, aged 21, admitted with a complaint of dense formation presence in the epigastrium, which was found by herself. CT scan and upper GI endoscopy revealed a giant trichobezoar filling almost the entire lumen of the stomach and duodenal bulb. Patient’s life history taking revealed trichophagia in the childhood for several years. Surgery was performed using SILS assisted technique to achieve excellent cosmetic result considering patient’s age. Transverse 2 cm skin incision in suprapubic region for single port system insertion was made (Triport, Olympus). Additional port was introduced at a distance of 3 cm in the suprapubic region. Gastrotomy an approximately 8 cm length was performed using the ultrasonic scissors and suturing device. Trichobezoar was removed from the stomach into EndoCatch. Gastrotomy was closed up by double-rowed interrupted sutures. Given the large size and high density of the foreign body, an incision in the suprapubic region was extended up to 8 cm (Pfannenstiel’s incision) to make an extraction possible. Through a puncture in the right iliac region a drain tube was placed, the wound was closed in layers. The extracted specimen represented a dense compact hair lump up to 25 cm length and up to 10 cm in diameter. The wound was closed up in layers with the cosmetic intradermal suturing. Recovery was uneventful, the patient was discharged on the 6th day after surgery. Follow-up gastroscopy one month later showed the folds convergence in the operation area, no pathological changes. This case shows the feasibility and the superior cosmetic results of SILS assisted technique in removal of large stomach foreign bodies.

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V012 - Video - Different Endoscopic Approaches

V015 - Video - Different Endoscopic Approaches

SINGLE PORT BILLROTH I GASTRECTOMY J.R. Huddy, Y. Soon Royal Surrey County Hospital, GUILDFORD, United Kingdom

SIMULTANEOUS APPENDECTOMY AND CHOLECYSTECTOMY WITH A SINGLE MINIMAL INCISION M. Pawlak, M. Michalik, A. Frask, A. Lehmann Ceynowa Hospital, WEJHEROWO, Poland

Aims: We present our experience of the first reported single port laparoscopic Billroth I Gastrectomy in a 62 year old lady with a 6.2 cm mass in her antrum, abutting her pylorus. Radiologically, this was suspected to be either a lipoma or gastrointestinal stromal tumour. Methods: Single port laparoscopic Billroth I Gastrectomy and Cholecystectomy was performed using a quad-port through a 3 cm transumbilical incision. Straight instruments and a high-definition laparoscope with a 100 degree deflectable tip were used to achieve off axis views. The stomach was mobilised including a limited lymph node dissection of stations 3, 4d, 5 and 6. Kocherisation was not required due to an unusually long first part of duodenum. The stomach was divided at the proximal antrum and the distal resection margin at the duodenum close to the pylorus with flexible tipped laparoscopic staplers. A two layer end-to-end intra-corporal anastomosis was created and this was confirmed endoscopically to be patent with no evidence of leak. In view of her symptomatic gallstone disease a standard single port cholecystectomy was also performed. Results: Post-operatively the patient spent one day in the intensive care unit. She was started on 30 ml of water each hour immediately and was on a full diet six days later. Analgesia was controlled through a patient controlled analgesia pump for 4 days with the patient requiring a total cumulative dose of 58 mg of morphine, then paracetamol for 2 further days. She was discharged on the eighth day. Conclusions: Single port surgery is established in appendicectomy, cholecystectomy and increasingly more complex procedures. However, intra-corporal constructive surgery, such as demonstrated by our reconstruction is rare through this approach. Our unit has recently published a technique for single port subtotal gastrectomy with Polya type gastrojejunal reconstruction. This video demonstrates that single port Billroth I gastrectomy is a technically feasible and safe procedure, without the need for curved instruments, when performed by an experienced single port and oesophago-gastric surgeon. It can offer advantages in terms of cosmesis, reduced analgesic requirements and shorter in-patient hospital stay. However, the extent to which this compares to open and laparoscopic gastrectomy needs investigating further.

Aim: Permanent progress in minimally invasive surgery led to development of the conception of laparo-endoscopic single site (LESS) surgery. At present, LESS surgery is widely accepted in operations of the gallbladder, appendix and abdominal hernias. Simultaneously, multiple reports have appeared on safe and successful LESS application in benign and malignant colorectal lesions, in obesity treatment and spleen resections. The aim of the study was to present a technique of minimally invasive laparoscopic appendectomy and cholecystectomy performed at the same time with a single access surgery via one small transumbilical incision (via the QuadPortTM Access System). While demonstrating the technique we would like to focus on its advantages as well as difficulties and limitations. Methods: The patient was a 25-year-old female with cholelithiasis and chronic appendicitis both confirmed with ultrasound scan, without comorbidities. There was previous history of exploratory laparoscopy in 2009 due to chronic abdominal pain. The operation took place on 18th of January 2011 in the Department General and Vascular Surgery, Ceynowa Hospital, Wejherowo, Poland. Results: The surgery lasted 35 min. There were no perioperative period complications reported and the patient was discharged on the first postoperative day. Conclusions: LESS procedures seem to be another interesting route in the development of surgery and the minimization of surgery-dependent injury.

V014 - Video - Different Endoscopic Approaches

V016 - Video - Different Endoscopic Approaches

STANDARDIZED TECHNIQUE FOR SINGLE INCISION CHOLECYSTECTOMY WITH A NEW SINGLE PORT DEVICE WITH FOUR ACCESSES S. Morales Conde1, M. Socas Macias1, A. Barranco Moreno1, I. Serrano1, I. Alarcon1, M.D. Casado1, G.L. Sciannamea2, J. Canete1, H. Cadet1, J. Padillo Ruiz1 1 HUVRocio, SEVILLE, Spain. 2BOLONIA, Italy

TAILORED APPROACH TO CLOSE THE INCISION DURING SINGLE-PORT SURGERY M. Socas-Macias1, S. Morales Conde1, A. Barranco Moreno1, I. Alarcon del Agua1, G. Sciannamea2, C. Mendez1, MD. Casado1, J. Can˜ete1, H. Cadet1, J. Padillo Ruiz1 1 Hospital Universitario Virgen del Rocio, SEVILLE, Spain. 2H, BOLONIA, Italy

The development of minimally invasive surgical techniques try to search for new methods and approaches to improve cosmetic results, reduce postoperative pain and minimize possible complications associated to laparoscopic approach, trying at the same time to preserve the results so far obtained with the standard laparoscopic procedures. One of the problems associated to single port surgery (SPS) is that the techniques used to perform the different procedures by single port are not standardized. Different instruments have been used in different manners, different optics has been described as necessary, different ways of moving instruments has been used, but basically a simple appendectomy and cholecystectomy has been performed in several ways with longer operating time than standard laparoscopy. Nowadays, the main goal of SPS is to maintain the same degree of safety than standard laparoscopy. In that sense, we should avoid techniques where surgeons works with one hand, while holding the camera with the other hand, those techniques in which the procedures is performed without having traction of the fundus of the gallbladder, and, of course, those in which surgeons perform surgery with their hands crossing. The main problem associated to these approaches is that this surgery could become unsafe, since bleeding is difficult to control and the dissection is recommended to be performed with the non-dominant hand or with an unproper exposition of the surgical field. Three trocar technique for standard laparoscopic cholecystectomy could be performed properly, although the majority of surgeons prefer to use a four trocars technique for standard cholecystectomy, since is faster and safer. Four trocars technique allows a proper exposition of the triangle of Calot to avoid an injury of the common bile duct and offer, on the other hand, the surgeon a important degree of freedom to control bleeding in case it is necessary, since surgeons are able to work with the two hands with the field properly exposed. Based on this principles, we have developed a technique through a four-orifice-multiport-device in order to maintain the principles of safety of this procedure, trying to achieve at the same time similar operating time of standard laparoscopic cholecystectomy.

Introduction: Single-port access (SPA) potentially reduces postoperative pain and improves cosmetic results. However, the umbilicus is considered a physiologic weak area, which needs to be closed properly. Objective: In order to reduce the risk of development a postoperative hernia, we have designed a ‘Protocol to close the SPA’, based on patient’s characteristics and technical difficulty of closing the fascial defect placed under the umbilicus. Method: In patients who underwent a SPA cholecystectomy or inguinal hernioplasty, with a fascial defect of 1.5 cm, we proceed to a direct closure of the defect with single stitches of absorbable suture. In case of SPA hemicolectomy, where the fascial defect needed to be enlarged up to 3 cm, in order to remove the specimen, we proceed to a direct closure of the defect using an absorbable running suture. In case of SPA bariatric surgery, with a fascial defect of 2 cm, due to the technical difficulty of performing a direct closure of the fascia and the higher risk of development an incisional hernia related to the obesity, we proceed to close the fascial defect placing a Ventral PatchÒ mesh, fixed to both sides of the fascial defect with a single stitch of absorbable suture. In case of SPA double crown technique for ventral hernia repair, where the device is placed in the flank of the patient, we also proceed to close the fascial defect placing a Ventral PatchÒ mesh, fixed in the same way. We use a prophylactic mesh in these cases, since the size of the defect is very small (1.5 cm), being more difficult to be closed due to the three layers of muscle. Results: In our series of 99 patients who have been submitted to a SPA procedure (20 cholecystectomies, 14 incisional or groin hernia repairs, 34 colectomies, 3 splenectomy, 16 bariatric surgeries, 8 miscellaneous), with a medium follow up of 10 months, we haven’t had any case of incisional hernia. Conclusion: A tailored approach to close the fascial defect during SP surgery seems to eliminate the risk of development a hernia in the postoperative period.

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V021 - Video - Emergency Surgery

V023 - Video - Endocrine Surgery

LAPAROSCOPIC DIAGNOSIS AND TREATMENT OF A TWISTED, ISCHEMIC HAEMANGIOMA OF THE ILEUM MIMICKING ACUTE APPENDICITIS R. Costi1, A. Le Bian2, J. Lubrano3, J. Thereaux3, M. Leconte3, N. Veyrie3, R. Douard3, C. Smadja2 1 Universita` degli Studi di Parma, PARMA, Italy. 2Be´cle`re Hospital, PARIS, France. 3Cochin Hospital, PARIS, France

ROBOTIC LEFT ADRENALECTOMY W. Petz, P.P. Bianchi, D. Belotti, P. Misitano, B. Andreoni European Institute of Oncology, MILAN, Italy

Background: The laparoscopic approach to patients with suspected acute appendicitis is presently under debate, especially concerning young male patients, where gynaecological affections may not be responsible of the clinical picture. Intraabdominal haemangiomas mostly affect the liver, whereas ileal localisation is unusual. Although mostly asymptomatic, they may cause abdominal pain and septic syndrome if they become ischemic. Methods: We report a case of haemangioma of the ileal mesentery causing an appendicitislike syndrome. An otherwise healthy 16-year-old white, Hispanic male patient presented with one-day history of abdominal pain, associated with hyperpyrexia (38.2°C) and nausea; personal and family history were negative for gastrointestinal diseases. At physical examination, the abdomen was painful in the right iliac fossa and mesogastrium, with rebound tenderness. Laboratory tests showed hyperleukocytosis (14,650 U/ml). CT scan did not identify the appendix, and showed a 3 9 2 cm-hypodense zone surrounded by a hyperdense area among the ileal loops, which was diagnosed as being an intra-abdominal abscess probably due to acute appendicitis. Laparoscopy found a normal appendix and a round inflammatory mass firmly adherent to the ileal loops (video). When adequately dissected, the mass appeared as originating from the ileal mesentery and being twisted on its vascular pedicle by 360°. It was clipped, sectioned and extracted by endobag (video). Results: The outcome was uneventful. The patient had solid food on postoperative day 1, bowel movements on day 2 and was discharged on day 3. Pathological examination confirmed a benign 3 9 2 cm haemangioma of the ileal mesentery with signs of ischemia. The patient is well 10 months postoperatively. Conclusions: An intra-abdominal twisted, ischemic haemangioma may cause general and local signs of inflammation, thus mimicking other more frequent affections, such as appendicitis. Owing to the rarity of this affection and aspecificity of symptoms and CT scan imaging, preoperative diagnosis may be difficult. Differently from a Mc Burney incision, laparoscopy may allow diagnosing and treating rare causes of appendicitis-like clinical picture without the need of a (second) larger laparotomy. Laparoscopy represents the ideal approach to patients with suspected appendicitis, regardless of their sex.

Introduction: Minimally invasive surgery is a standard procedure for the treatment of adrenal glands diseases. Robotic surgery may improve some technical aspects of the operation. The video shows a robotic left adrenalectomy for malignancy. Methods: The patient was a 63 year old woman with a single site left adrenal metastasis from breast cancer. With the patient in right lateral position, three 8 mm robotic trocars along the left subcostal line and 2 standard 12 mm laparoscopic trocars (umbilical and in the left flank) are introduced. After intraoperative ultrasonography, the first step of operation is a complete mobilization of the splenic flexure, spleen and pancreas tail. The adrenal vein is identified, isolated and divided. Adrenal arteries are divided with bipolar cautery. The left adrenal gland dissection is completed with monopolar hook and bipolar grasper and the specimen is removed in a plastic bag. Results: Operating time was 150 min with a blood loss of 100 cc. No intraoperative complications occurred. Oral feeding was reintroduced in first post operative day (POD) and the patient was discharged in second POD without complications. Conclusions: Robotic-assisted adrenal gland surgery is a safe and feasible technique; the robotic system can help in fine dissection of adrenal region, mainly facilitating vascular dissection and control.

V022 - Video - Emergency Surgery

V024 - Video - Endocrine Surgery

LAPAROSCOPIC SURGERY IN ACUTE INTESTINAL OBSTRUCTION S.V. Mosin Russian State Medical University, MOSCOW, Russia

LAPAROSCOPIC SUB-MESOCOLIC LEFT ADRENALECTOMY G. Lezoche Universita` Politecnica delle Marche, ROME, Italy

Materials and methods: From 2005 to 2010, laparoscopic surgery for acute Intestinal Obstruction (IOb) performed in 71 patients, which accounted 24.9% from all operations for IOb. In 2010 they performed in 39.3% of cases. Among the patients 45.1% were male, mean age was 48.2 ± 16.2 years. Early adhesive IOb was observed in 8 patients. In 45 (63.4%) patients the cause of IOb was previous surgery, including the early postoperative IOb - in 8 (11.3%). Strangulated IOb with no prior surgery was observed in 15 (21.1%) patients. Causes of obstructive IOb were gallstones in 2 (2.8%) cases and food ball - in 4 (5.6%). Volvulus of sigmoid colon was found in 4 (5.6%) patients, the Cecum mobile - in 1 (1.4%), small intestine - in 1 (1.4%). In 15 (21.1%) patients the cause of obstruction was not clear, and laparoscopy was primarily used for diagnosis. Results: The ability to perform laparoscopic surgery is evaluated by us both before and during laparoscopy. We refrain from laparoscopic surgery with the expressed enteroparesis, requiring intestinal intubation, or in electrolyte, respiratory or cardiovascular failure. In the presence of adhesive IOb, always follow an open laparoscopy. Rejection of laparoscopic surgery was required in 17 (6.0%) patients, with significant abdominal adhesions or other changes irremovable by laparoscopic surgery. Places of insertion additional 5 mm trocars were chosen individually. Inspection was performed by palpation guts, detection of cause of obstruction and assessment of severity of adhesions. Adhesiolysis produced by a sharp, if necessary we used precision monopolar coagulation. When obstructive small bowel obstruction was performed either displacement of food ball into the colon or removal of gallstones through the minilaparotomy. Revealed volvulus of intestine was treated due detorsion. At early post-operative IOb in 3 patients identified the dynamic enteroparesis, thus avoiding futile laparotomy. In other cases, adhesiolysis was performed. Conversion of laparoscopic surgery was in 7 (9.8%) patients. Passage of intestinal contents was reduced to 2–4 days. Intra-abdominal postoperative complications did not observed. Mortality after laparoscopic surgery was 1.4%. Conclusions: Of the 88 patients who underwent laparoscopy, 64 (72.7%) surgery was completed laparoscopically.

Background: Laparoscopic surgeons usually prefer the ‘flank’ approach introduced by Gagner more than 10 years ago. The authors have investigated an alternative approach to laparoscopic left adrenalectomy.

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Method: From January 2004 to December 2010, 113 left adrenalectomies by sub-mesocolic access were performed (74 females, 39 males, mean age 52.6 years, range 23–81 years). At the beginning, only selected cases were included (no prior abdominal surgery, BMI\25 kg/m2) but after the first 15–20 cases all patients were included (mean BMI 26.1 range 18–45). Results: Conversion occurred in 3 patients (2.6%) for bleeding. Mean operative time was 95 min (range 30–240 min), including the learning curve, 2 patients who underwent bilateral adrenalectomy and 2 patients undergoing associated procedures (cholecystectomy and splenectomy). Mortality was nil. One pancreatic fistula occurred in an old woman and it resolved in 2 months after positioning of a radiological drain and medical therapy. Other minor complications were observed in 3 patient: two patients with fever (T [ 38°C) and one with pleural effusion that resolved with medical therapy. The main advantage of this procedure is a lesser extent of dissection, as compared to other transperitoneal approaches, and the left adrenal vein is readily identified. Conclusions: With adequate experience, the sub-mesocolic approach is a safe procedure for left adrenalectomy and it may a valid alternative to other approaches.

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V025 - Video - Endocrine Surgery

V028 - Video - Gastroduodenal Diseases

CONVERSION FROM OPEN TO LAPAROSCOPIC ADRENALECTOMY: A FEASIBLE SURGICAL ALTERNATIVE FOR SOME PATIENTS S.C. Paun, R.E. Ganescu, M. Vartic, M. Beuran Emergency Hospital, BUCHAREST, Romania

IMPORTANT SUTURE TECHNIQUES FOR INTRACORPOREAL ROUX EN Y RECONSTRUCTION IN LAPAROSCOPIC GASTRECTOMY E. Kanehira, A. Kurita, A. Kamei, K. Shiozawa, M.B. Jin, K. Miyauchi AGEO Central General Hospital, AGEO CITY, Japan

Defined as gold standard, laparoscopic adrenalectomy is the most preferred surgical technique for approaching adrenal pathology. Can it be a real alternative for feasible cases, in which associated pathology increase the difficulty of open adrenal removal? We are presenting two cases - females, NM/51 and SN/46, with adrenal tumors (first patient 4/3/3 cm on right side, hyperplasia; second patient - 4.2/4/3.8 cm on the left side, hyperplasia) and with associated morbidity: obesity (BMI = 38 first patient, BMI = 32 second patient) and recurrent postoperative ventral hernia for the both patients. First case was converted after 90 min from open (median laparotomy and alloplastic repair of the recurrent ventral hernia) to laparoscopy (4 right subcostal trocars anterior transperitoneal approach) due to difficulty to reach the adrenal lodge by hand dissection. Total operating time: 125 min (70 min for hernia repair, 20 min for repositioning the patient and 35 min for laparoscopic right adrenalectomy). Second case was converted after 55 min from open median laparotomy (performed for removal of an old mesh used for primary umbilical hernia followed by 8/6 cm right-side sliding hernia recurrence as well as for right salpingoovariectomy for 3 cm ovarian cyst) to laparoscopy 4 left subcostal trocars anterior transperitoneal approach). Removing the old mesh and surgical repair of the recurrent hernia were the reasons for open approach and easy surgical act for adrenal gland was the reason for conversion to laparoscopy. Total operating time was 90 min: 35 min open procedure, 15 min repositioning the patient, 40 min for left laparoscopic adrenalectomy. No postoperative complications were noticed for both patients. Obesity and abdominal hernia requiring open approach are two co-morbidities for patients with adrenal pathology undergoing laparoscopic surgery, after conversion from open approach.

Herein we precisely present our techniques of intracorporeal Roux en Y anastomosis in laparoscopic total/distal gastrectomy. In distal gastrectomy, the remnant stomach is anastomosed with the jejunum with a linear stapler by side to side fashion. The important tip here is to pre-fix the jejunum to the remnant stomach in two points by suturing. One is the tip of the jejunum onto the posterior wall of the proximal part of the stomach. The other point is the both holes made in the jejunum and the distal tip of the stomach. These stay sutures can control the stapling anastomosis very well. After stapling the common entry hole is closed by continuous running suture. The tip here is the stay suture made at the left corner of the common entry hole, which can control the suture line direction and facilitate the running suture. In total gastrectomy, we apply ‘purse string suture at the stump of the esophagus by hand-sew technique. This technique requires intensive training. Then 25 mm anvil is inserted in the esophagus. The purse string suture is tied to encircle and fix the shaft of the anvil. The body of the circular stapler is inserted in the jejunum and put into the abdominal cavity through the umbilical wound (3.5 mm), which is anastomosed to the esophagus intracorporeally. Since 2003 we have performed the above described totally laparoscopic anastomoses in 81 patients and the results have been excellent. Both of our methods for intracorporeal anastomosis require high level of manual suturing technique. Once a surgeon obtain this suturing ability we believe the laparoscopic gastrojejunostomy or esophogojejunostomy should become considerably stable, which we expect to contribute to better quality of life in the gastrectomy patients.

V026 - Video - Gastroduodenal Diseases

V029 - Video - Gastroduodenal Diseases

LAPAROSCOPIC APPROACH TO AN ACHALASIA PATTERN AFTER ESOPHAGEAL ATRESIA F. Marinello, E. Targarona, C. Balague´, J. Mone´s, M. Trı´as Hospital de la Santa Creu i Sant Pau, BARCELONA, Spain

FEASIBILITY AND MACROSCOPIC EFFECTIVENESS OF TOTALLY LAPAROSCOPIC SUBTOTAL D2 R0 GASTRECTOMY IN ADVANCED GASTRIC CANCER J.J. Sanchez Cano, F. Buils, A. Cabrera, M. Socias, J. Prieto, E. Baeta Hospital Universitari Sant Joan de Reus, REUS, Spain

Aim: The association of Esophageal Atresia (EA) and Achalasia is extremely rare and has been reported scarcely. We present a video of a Laparoscopic approach to a patient with Achalasia with previous repair of EA. Methods: A 30 years old male patient with history of EA with tracheoesophageal fistula to the right superior lobe and bilobectomy of the right median and inferior pulmonary lobes due to severe cystic bronchiectasis. At age 20 he began with episodes of gastroesophageal reflux with regurgitation and bronchial aspiration, being admitted for five episodes of pneumonia. An esophagram showed a sigmoid-shaped esophagus with impaired esophageal clearance. A gastrointestinal endoscopy revealed a dilation of the body of the esophagus with no signs of stenosis of the anastomosis. A manometry revealed a pattern of Achalasia. A Heller-Dor procedure was indicated. Slight difficulties were found to perform the myotomy due to fibrosis. An intraoperative endoscopy proved mucosa integrity. Mean operative time was 90 min. Results: No complications occurred. The patient was discharged on his third post-operative day. Conclusions: The minimally invasive approach for Achalasia keeps being a safe procedure, even with concomitant esophageal disease.

Aims: Although the results of phase III RCTs should be awaited for definitive conclusions, there are scientific expectations that laparoscopic surgery will be proven safe and effective for patients with stage I–III gastric cancer. It is hoped that these results come from high-volume hospitals. However, we must not forget that the great advances in basic laparoscopic surgery have come from medium -low volume hospitals, and hence, greater experience in laparoscopic surgery is from this last type of hospitals. The purpose of this paper is to show how, from a mediumvolume hospital, we perform a totally laparoscopic oncologic gastrectomy. Methods: In our hospital, about 10–15 patients with gastric cancer are treated surgically each year. Since 1993 we applied the Japanese protocol in surgery for these patients, and since 2003 we use laparoscopy as a means to perform this gastrectomy. Results: During this period, we operate over 50 patients by laparoscopy. The video demonstrates how we perform a laparoscopic oncologic gastric surgery after the learning curve with an operating time of 180 min, no postoperative complications and hospital stay of 8 days. Conclusions: After viewing this video clip, we can conclude that, waiting for results of long-term survival, can be performed laparoscopic gastrectomy scrupulously following oncological criteria, and both give the patient the benefits of minimally invasive surgery.

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V030 - Video - Gastroduodenal Diseases

V032 - Video - Gastroduodenal Diseases

LAPAROSCOPIC DUODENOJEJUNOSTOMY FOR SUPERIOR MESENTERIC ARTERY SYNDROME J. Gonzalez Gonzalez1, M. Cea Soraino1, A. Gil Perez1, M. Artes Caselles1, I. Alonso Sebastian1, D. Chaparro Cabezas1, J.L. Lucena de la Poza1, J. Vazquez Echarri2 1 Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain. 2Hospital Universitario Severo Ochoa, LEGANES, MADRID, Spain

POST BALSEY MARK IV ANTIREFLUX OPERATION PYLOIC STENOSIS: LAPAROSCOPIC PYLOROPLASTY IN ADULT: VIDEO PRESENTATION M. Sajid, H. Qandeel, Z. Hanif, L.K.P. Velu, S. Dayal, S. Mahmud Hairmyres Hospital, GLASGOW, United Kingdom

Introduction: Superior mesenteric artery (SMA) syndrome or Wilkie syndrome is an uncommon cause of high intestinal obstruction manifesting with epigastric pain, bilious vomiting and postprandial discomfort resulting from the vascular compression of the third part of the duodenum by the SMA. Various medical and psychiatric conditions may result in the initial rapid weight loss which causes narrowing of the aortomesenteric angle. The vomiting and obstructive syndrome is then self perpetuated regardless of the initiating factors. The young age and non-specific symptoms often lead to a delay in diagnosis. First described by von Rokitansky in 1861, was Wilkie who published a report on duodenojejunostomy for SMA syndrome. Diagnosis and Treatment: The diagnosis of SMA syndrome is difficult and frequently one of exclusion. Current modalities of diagnosis include upper GI study with barium, computerized tomography angioscan and upper GI endoscopy which is necessary to exclude mechanical causes of duodenal obstruction. Conservative measures include nasogastric aspiration and enteral or parenteral nutrition for restoration of the aortomesenteric fatty tissue. Surgery is indicated for chronic cases and failure of conservative management and laparoscopic duodenojejunostomy is usually considered the treatment of choice. Case Report: We present a 30 year-old male patient who had no medical problems and a past surgical history significant for a laparoscopic cholecystectomy. The patient presented a 12 year history of epigastric pain, nausea and bilious vomiting that conditioned a very important weight loss. Diagnosis of SMA syndrome was made using an upper GI study and CT angioscan and the patient was proposed for laparoscopic duodenojejunostomy after a failed period of conservative treatment with nasogastric tube and parenteral nutrition. We performed a side to side mechanical (EndoGIA stapler) laparoscopic duodenojejunostomy. Conclusion: SMA syndrome is a well described entity which must be considered as a cause of vomiting associated with significant weight loss in young adults. Laparoscopic duodenojejunostomy is the procedure of choice and is effective in 90% of patients.

Aim: Accidental Vagotomy is rare complication of antireflux surgery. Post Vagotomy pyloric stenosis is usually easy to treat with therapeutic endoscopy. Laparoscopic pyloroplasty is mainly described in paediatric cases. Pyloroplasty operations for adults are rarely required. We present a video of a Laparoscopic approach in a patient with refractory pyloric stenosis three years after Balsey Mark IV Antireflux Operation resulted in accidental vagal nerve damage through thoracotomy incision. Method: We present a video illustrating this procedure. A 26 years old gentleman had Balsey Mark IV Antireflux operation done by thoracic surgeon. Referred to our Upper GI Surgical Unit for problem of gastric emptying. Isotope gastric emptying study confirmed the diagnosis. Initially treated with multiple pyloric dilatations followed by twice Botox injections. Failed to respond to endoscopic treatment. He was than treated with Laparoscopic Pyloroplasty. Three-port technique was used as will be described with video, liver retraction was done by transcutaneous stitch. Leak and patency test was carried out with perioperative endoscopy. He was done as a day case. Result: Follow up for one year was satisfactory with resolution of symptoms and improved nutritional status. Conclusion: Laparoscopic Pyloroplasty in refractory post vagotomy pyloric stenosis is safe and durable option.

V031 - Video - Gastroduodenal Diseases

V033 - Video - Gastroduodenal Diseases

LAPAROENDOSCOPIC TREATMENT OF GASTRIC GISTS K. Tsimogiannis, D. Tsironis, C. Tsironis, A. Karentzos, A. Manataki, E.C. Tsimoyiannis ‘G.Hatzikosta’ General Hospital of Ioannina, IOANNINA, Greece

SENTINEL NODE MAPPING DURING LAPAROSCOPIC DISTAL GASTRECTOMY FOR GASTRIC CANCER E. Orsenigo, J. Nifosi, E. Viale, C. Canevari, C. Staudacher, P. Gazzetta University Vita-Salute, San Raffaele, MILAN, Italy

Gastric GIST is a mesenchymal neoplasm which constitute only 1–3% of all malignant gastric tumors. GISTs are most commonly found in the stomach (47–60% of all cases) as compared to small bowel (30%) and esophagus and rectum (10%). For small gastric GISTs, wedge resection is adequate, if technically possible. Larger tumors necessitate subtotal or total gastrectomy. Enucleation should be avoided because predicting malignant potential preoperatively is difficult, even in benign-appearing lesions. The laparoscopic approach for these procedures is feasible and safe. We present a video with 3 cases of different laparoendoscopic techniques for treatment of gastric GISTs. In the first case a wedge resection was performed by using linear stapler for simultaneous resection and closure of the gastric opening. In the second case a wedge resection was performed by using ultrasonic energy and the gastric opening was closed by using a linear stapler. In the third case a wedge resection through a gastrotomy was performed using monopolar energy. The small tumor was identified with intraoperative gastroscopy. The closure of gastrotomy was performed by hand sewing. In all cases a R0 resection was achieved and none of the patients was treated with imatinib. No recurrence was presented in a follow-up period of 5–61 months (mean 36 months). In conclusion, the laparoscopic wedge resection of gastric GISTs is a simple, safe, and effective procedure, in experienced hands, for selective patients.

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Objectives: The aim of this video was to demonstrate the feasibility of laparoscopic sentinel node navigation (SLN) in gastric cancer. Methods: A 49-year-old woman with a diagnosis of gastric cancer was admitted ad our Department. The preoperative work-up demonstrated an u T2node negative gastric cancer. The patient was scheduled for laparoscopic distal gastrectomy with SLN. The day before surgery the patient was submitted to endoscopy. During the procedure, the radiotracer (Tc 99) has been injected at four points around the tumor. The operation was performed in Lloyd-Davies position using four trocars. After the opening of the gastrocolonic ligament the patient has been submitted to a intraoperative endoscopy and the blue dye (patent blue) has been injected at four points around the tumor. The lymphatic basin has been identified with the probe and with the blue dye. After then, the sentinel node has been identified. No pick-up technique was used. A standard laparoscopic gastrectomy with intracorporeal anastomosis has been successfully concluded. Through a supraumbilical incision, the specimen was extracted. The sentinel node has been dissected at the bench table at the end of the operation. Results: The post-operative course was uneventful. Conclusions: Sentinel node navigation with double tracer during laparoscopic gastrectomy for gastric cancer is feasible. Nevertheless, it is mandatory to standardize the method of SLN identification in order to increase the diagnosis of lymph node metastases.

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V034 - Video - Gastroduodenal Diseases

V036 - Video - Gastroduodenal Diseases

LAPAROSCOPIC RESECTION OF GASTROINTESTINAL STROMAL TUMOR OF THE DUODENAL- JEJUNAL JUNCTION G. David, G. Ietto, L. Boni, M. Di Giuseppe, F. Cantore, L. Giavarini, S.M. Tenconi, E. Colombo, E. Cassinotti Minimally Invasive Surgery Research Center, University of Insubria, VARESE, Italy

CARDIA GIST RESECTION WITHOUT MECHANICAL SUTURE M.P. Loureiro, P. Trauczynski IJP, CURITIBA, Brazil

This video shows laparoscopic resection of a gastrointestinal stromal tumor (GIST) of duodenum-jejunal junction. GISTs are the most common mesenchymal tumors of the gastrointestinal tract, that can be distinguished from other soft tissue tumors by c-kit protooncogen (CD117) expression. Originated from progenitor cells which differentiate towards Cajal cells, only 3–5% of GISTs are located in the duodenum and they are associated with an increased risk of gastrointestinal bleeding as primary manifestation. A 71-year old asymptomatic woman was referred to our Institute for evaluation of a 26 9 24 9 30 mm paraduodenal mass discovered by abdominal CT performed during oncologic follow-up for renal tumor previously treated by open right nephrectomy in 1989. Ultrasound guided fine needle aspiration on the mass was unsuccessful so a diagnostic laparoscopy was carried out. The patient was placed in supine decubitus and both the main surgeon and the assistant were placed on the left side of the patient. Pneumoperitoneum was induced by open technique through the umbilicus and 10 mm trocar was inserted further 3 trocars (12, 10 and 5 mm) were t inserted in the left lower and left upper quadrants respectively. After mobilization of the transverse colon a 2 9 3 cm lesion was identified on the left side of the duodenumjejunal junction. The duodenal mass was isolated by means of electrocautery and harmonic scalpel and divided from the duodenal wall using a 60 mm endoscopic lineal stapler (Echelon Flex stapler). The suture line was reinforced using re-absorbable interrupted suture. The resected specimen was retrieved in a bag and removed through the umbilicus. A paraduodenal drainage (24 French) was placed in the peritoneal cavity. The postoperative course was uneventful and the patients discharged on post-operative day 7. The pathology report described the lesion as gastro-intestinal stromal tumor, with low mitotic index.

The authors present a movie of a asymptomatic gastrointestinal stromal tumor, discovered by upper endoscopy as part of a routine exam for bariatric surgery. This was presented as a submucosal lesion from cardia to the lesser curve. The patient then underwent laparoscopic resection. It was opted for enucleation of the lesion by gastrotomy, resection and gastrorraphy, observing oncological principles, but avoiding use of staplers, because of the risk for stenosis. This approach also clearly economic, respects the same principles of wedge resection with stapler.

V035 - Video - Gastroduodenal Diseases

V037 - Video - Gastroduodenal Diseases

LAPAROSCOPIC EXCISION OF A PRE-PYLORIC GASTROINTESTINAL STROMAL TUMOUR (GIST) - THE NON-TOUCH TECHNIQUE E. Villatoro, J. Ahmed Royal Derby Hospital, DERBY, United Kingdom

SUBTOTAL GASTRECTOMY EXTENDED TO THE FIRST AND ALMOST DUODENAL PORTION, WITH PRESERVATION OF THE PANCREAS, TOTALLY LAPAROSCOPIC. J.J. Sanchez Cano, F. Buils, A. Cabrera, M. Socias, J. Prieto, E. Baeta Hospital Universitari Sant Joan de Reus, REUS, Spain

Introduction: An 83 year old woman presented to our institution with haematemesis. An OGD showed an ulcerated mass in the pre-pyloric area which was biopsied showing inflammation only. A CT scan was organised which showed a 5 cm tumour in the greater curve of the stomach, with appearances consistent with a GIST. After discussion with the patient she was listed for a laparoscopic resection of GIST. Methods: CT findings were confirmed at laparoscopy and gastroscopy. A gastrostomy was performed and the tumour was everted. Due to the size and position of the tumour it was not possible to use an endoscopic stapling gun for resection. Two stay sutures were placed on the mucosal and serosal surfaces respectively to aid dissection. Harmonic scalpel was used to completely excise the tumour. Reconstruction was carried out with a hand-sewn continuous absorbable suture. Results: The patient had an uneventful recovery. A water-soluble contrast study was obtained 48 h following resection showing no leak. Oral fluids were commenced and normal diet resumed on day 5. Histology confirmed the tumour to be a completely excised (R0) GIST and stratified as low risk. She was reviewed in clinic 3 months post-resection, and she had made a full recovery. Discussion: GIST are becoming more commonly recognised in clinical practice and laparoscopy is being increasingly used as method of resection. Use of stay sutures during dissection is a convenient way of aiding resection, without the need of additional ports or using graspers that might damage the tumour.

Aims: Duodenal adenocarcinoma is a rare tumor which prevents the existence of large series to draw conclusions about diagnosis and treatment. We report a case of oncologic laparoscopic resection with pancreatic preservation in a patient with a duodenal adenocarcinoma. Method: A 77 year old female in study of anemia who was admitted for upper gastrointestinal bleeding. Gastroscopy: extensive proliferative lesion, exophytic, ulcerated and friable at the duodenal bulb. Pathological result: adenocarcinoma. CT Scan: necrotic tumor lesion in duodenal bulb conditioning mechanical occlusion, cleavage plane exists with respect to the liver and pancreas, metastatic disease-free; papilla of Vater in the third duodenal portion. Results: We perform a ‘four trocar’ laparoscopic approach and subtotal gastrectomy extended to the bulb and the first part of the duodenum with pancreatic preservation with Billroth II reconstruction. Operative time was 300 min, requiring transfusion of two red cell concentrates in the perioperative. No postoperative complications, hospital stay 12 days. Histological result: moderate to poorly differentiated duodenal adenocarcinoma, pT3n0 (0/20), radial resection margins and longitudinal unaffected. The patient is alive and disease-free after 18 months. Conclusion: Laparoscopic approach with pancreatic preservation is feasible in first duodenal portion tumors whenever we can ensure oncological resection.

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V038 - Video - Gastroduodenal Diseases

V040 - Video - Intestinal, Colorectal and Anal Disorders

LAPAROSCOPIC ENUCLEATION OF A GASTRIC LIPOMA P. De Nardi, R. Castoldi, N. Pecorelli, C. Staudacher San Raffaele Scientific Institute, MILANO, Italy

RECTUM CANCER. LAPAROSCOPIC RESECTION. M. Carlini, S. Ferretti, D. Spoletini, F. Castaldi S. Eugenio Hospital, ROME, Italy

Aim: Gastric lipomas are rare benign tumors; they are often asymptomatic or may present with upper gastrointestinal hemorrhage or obstruction. Treatment of large symptomatic gastric lipomas often involves gastric resection. We present a video that shows the details of laparoscopic transerosal enucleation of a large symptomatic gastric lipoma. Methods: A 75 year old man, presented with epigastric abdominal pain and iron-deficient anaemia. Endoscopy revealed a large, antral, submucosal lesion. Echoendoscopy and CT scan showed a 6 cm lesion, of fat density, located in the submucosal layer, consistent with the diagnosis of a benign gastric lipoma. Results: The patient underwent elective surgery by laparoscopic approach; with the patient in a prone position, 3 trocars were placed: in the supraumbilical region (10 mm), in the right (5 mm) and left pararectal space (10 mm) and a 30° angled video scope was introduced. A transverse, 4 cm long, gastrotomy was made through the serosa and muscularis layers of the anterior antral wall, just over the lesion. The tumor was dissected and enucleated, without incision of the mucosa. Gastrotomy was closed with a continuous Vicryl suture. Postoperative course was uneventful and the patient was discharged on the fourth postoperative day. Pathological examination confirmed the diagnosis of a benign lipoma. Conclusions: Management of gastric lipomas is debated. For smaller lesions endoscopic resection is a safe and effective option. For larger and symptomatic lipomas partial gastrectomy, with open or laparoscopic approach, has been successfully reported. However morbidity and disturbance of normal physiology are associated with gastric resection. In our patient the large gastric lipoma was enucleated without disruption of gastric anatomy using a mininvasive technique with fast postoperative recovery and maintenance of gastric anatomy and function.

Laparoscopic surgery of colon cancer has been accepted to be oncologically adequate. The role of laparoscopy in rectum cancer is still debated, because complex surgical procedures may specifically influence the long-term outcome. Our experience in laparoscopic colorectal surgery started in 1993 at the National Cancer Institute of Rome and continued, at the S. Eugenio Hospital of Rome where, since 2003, 246 cases of laparoscopic colorectal resections, with 86 cases of laparoscopic rectum resection, were performed. In this video a case of rectum cancer affecting a 61-year-old man is presented. The lesion was located in the anterior wall of the rectum with a longitudinal development, with the proximal limit intraperitoneally and the distal margin in the middle rectum. A rectum resection with total mesorectal excision (TME) was planned. The operation was performed entirely with only three trocars and by a radiofrequency dissector. The first step was the isolation and section of the inferior mesenteric artery and vein. The second step was the mobilization of left colon. The third step was the TME. The section of the rectum was performed with a linear stapler. A left McBurney incision for the removal of the specimen and for the placement of the circular stapler envil was done. A trans-anal TT Knight-Griffen anastomosis with CDH 31 mm was realized. In our opinion, minimally invasive surgery for the treatment of rectum cancer is equivalent to the open surgery and shows advantages of shorter hospitalization and faster recovery. In our experience, in low rectum cancer, the TME, results to be more accurate compare to the open surgery.

V039 - Video - Intestinal, Colorectal and Anal Disorders

V041 - Video - Intestinal, Colorectal and Anal Disorders

LAPAROSCOPIC EXCISION OF RECTO-SIGMOID ENDOMETRIOSIS WITH SPECIMEN EXTRACTION PER VAGINA. A.R. Day, R. Smith, A. Kent, T.A. Rockall MATTU, GUILDFORD, United Kingdom

SINGLE-ACCESS LAPAROSCOPIC COMPLETE MESOCOLIC EXCISION COMBINED WITH EXTRACORPOREAL MAGNETIC RETRACTION D. Uematsu, G. Akiyama, M. Narita, A. Magishi Saku Central Hospital, SAKU CITY, Japan

Aim: Endometriosis can affect up to 10% of women during their reproductive years. Within this group some will be affected by deep invasive endometriosis, which may involve the rectum, sigmoid colon or recto-vaginal septum. Bowel involvement can be treated surgically either with a shave excision, full thickness disc excision or segmental resection of the effected bowel. We present a laparoscopic excision of recto-sigmoid endometriosis with specimen extraction per vagina using a combined approach. Methods: A 45 years old lady presented with pelvic pain secondary to deep invasive endometriosis. Following treatment with Zoladex she underwent a laparoscopic excision of endometriosis including a hysterectomy, bilateral oopherectomy, rectal shave excision and segmental recto-sigmoid resection. The patient was placed in the modified Lloyd-Davies position and two 5 mm and two 12 mm ports were introduced. An area of rectal involvement was treated with a shave excision and the defect closed with vicryl sutures. A secondary area involving the recto-sigmoid required limited segmental resection. The sigmoid colon and upper rectum were mobilised and the vascular pedicle was divided using an ultrasonic scalpel. The colon was divided proximal to the shave excision and the specimen extracted through a vaginal vault incision following the hysterectomy. A stapled end to end colo-rectal anastomosis was fashioned. Results: The patient made an uneventful recovery and was discharged home on day 4 post-op. On follow-up in outpatient clinic she remains well with no complications. Conclusion: Endometriosis involving large bowel can be successfully excised laparoscopically using a variety of techniques. When a hysterectomy is also required, rectal specimen extraction can be performed per vagina. This minimises abdominal wall trauma and can therefore contribute to a rapid postoperative recovery.

Aims: Complete mesocolic excision and central ligation for colonic cancer as lower local recurrence rates and better overall survival was proposed by W. Hohenberger. Single-access laparoscopic colectomy is rapidly widespread from 2008 all over the world. However, triangulation must be lost or instrumental collision must be sustained to compensate for the single-access site. Using a novel multiport device and extracorporeal magnetic retraction can restore traiangulation and avoid instrumental collision. To achieve single-access laparoscopic complete mesocolic excision for advanced colonic cancer more safely and simply, we present radical lymphadenectomy as filleting the fish into 2 pieces. Methods: 50 consecutive patients with advanced colon cancer underwent a curative procedure. Single access to the abdomen was achieved with a 3.0 cm umbilical incision, where a novel multiport device was attached. The vascular forceps grasping the tissue were retracted by an extracorporeal magnetic tool, restoring triangulation. The mesocolon was dissected between the superficial layer of the fat tissue and the deep layer of the vascular sheath along the superior mesenteric artery. After the course of each branch was revealed under the mantle of the vascular sheath, each supplying or draining vessel was transected at its root. Next, the bowel was mobilized and the specimen was retrieved through the small incision. Finally, anastomosis was performed.

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Results: There were no intra-operative complications except for two patients who underwent left hemicolectomy including mobilization of the splenic flexure. The median number of retrieved lymph nodes was 38 (range, 13–52). The median total surgical time was 250 (range, 122–372 min). Surgical blood loss was slight (range, 1–20 mL). The postoperative course was uneventful for all patients except for one patient who had minor leakage of pancreatic juice. Conclusions: Single-access laparoscopic complete mesocolic excision for colonic cancer may compare with conventional laparoscopic colectomy. However, left hemicolectomy including mobilization of the splenic flexure may be necessary for changing the singleaccess site from the umbilicus to the upper midline.

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V042 - Video - Intestinal, Colorectal and Anal Disorders

V044 - Video - Intestinal, Colorectal and Anal Disorders

MALIGNANT COLO-VESICAL FISTULA IS NOT A CONTRAINDICATION FOR LAPAROSCOPIC COLORECTAL RESECTION. N. Naguib, J. Morgan, C.E. Davies, S. Moorhouse, M. AbdelDayem, A.G. Masoud Prince Charles Hospital, MERTHYR TYDFIL, United Kingdom

LAPAROSCOPIC RIGHT HEMICOLECTOMY WITH INTRACORPOREAL ANASTOMOSIS: STANDARDIZATION OF THE TECHNIQUE A. Pisani Ceretti, N. Maroni, E. De Nicola, G. Bislenghi, D. Strada, P. Carnevali, E. Opocher Hospital San Paolo, MILANO, Italy

Aim: As laparoscopic colorectal surgery is expanding worldwide, more challenging cases are considered. We present a DVD of laparoscopic resection of a malignant colovesical fistula sparing the trigone of the urinary bladder. We emphasis the importance of case selection and careful protection of the ureter during dissection. Methods: We present a 61 years old male who presented to the colorectal rapid access clinic complaining of change of bowel habits, urinary frequency and pneumaturia. Investigations revealed a locally advanced recto-sigmoid cancer infiltrating the dome of the urinary bladder. Steps: (i) The operation begins by standard medial to lateral dissection. The left ureter is identified, marked between 2 metal clips and is covered by a tonsil swab. (ii) The inferior mesenteric artery is divided followed by the upper left colic artery and the inferior mesenteric vein. (iii) It is difficult to visualise the ureter on the lateral side as it is obscured by the bulky mass, so lateral mobilisation starts by resection of the dome of the urinary bladder in continuity with the specimen. (iv) Lateral dissection continues by dividing the peritoneum over the external iliac artery. The peritoneum is lifted from left to right to safely visualise the ureter as it crosses over the bifurcation of the common iliac artery. (v) From the medial side, a hemo-lock is applied anterior to the left ureter. Further medial or lateral dissection anterior to this hemo-lock is safe. (vi) The upper rectum is divided using endo-stapler. (vii) The urinary bladder is closed by a continuous vicryl suture. The integrity of the suture line is checked by methylene blue. (viii) Standard cross-stapled colorectal anastomosis using EEA-29. Results: Patient was discharged home with a urinary catheter on day 3. A cystogram performed on day 7 confirmed the integrity of the urinary bladder and the catheter was then removed. Histology confirmed a T4, N1 (2/14 lymph node involved) with free resection margins. Conclusion: Laparoscopic colorectal surgery in malignant colovesical fistula is safe and feasible in selected cases.

Aim: There isn’t a standardization of the technique of the intracorporeal anastomosis in the laparoscopic right hemicolectomy. The aim of this video is to show our technique of the medial to lateral approach to the ileo-colic vessels and the intracorporeal anastomosis. Methods: Since 2005, in our Division, 66 patients underwent laparoscopic right hemicolectomy, with different techniques for the anastomosis, to check the feasibility. We standardizated the technique of the intracorporeal anastomosis and we considered the last 11 consecutive patient operated in the last 6 months (median age 66.7 years). We show the video of one of these surgical operations. We use 5 trocars and 30° camera. Pneumoperitoneum is performed with open technique. The surgeon and assistants stay on the left of the patient. We first cut between clips the ileo-colic and right colic vessels at the origin. So we perform the right hemicolectomy from medial to lateral. We open the gastrocolic ligament, pull down the hepatic flexure and then mobilize the right colon. The section of the colon and the distal ileum is performed with endo-GIA. The transverse colon and ileum are brought together to lie side by side with a Vycril 3-0 stitch, 25 cm length. And then we match the lower part of the anastomosis. These stitches help guide placement of the laparoscopic linear cutting stapler. The bowel is opened with hook and the anastomosis is performed with endo-GIA 60 bleu. We close the hole with double layer, first with Vycril and then monofilament. Then the meso is closed, the specimen is extracted from a Pfannenstiel incision (5 cm) with the wound protector and place a drain. Results: The median operation time was 160 min. There was early return of flatus (2 days). Postoperative pain (with VAS scale) was 3. The median lymphnodes found in the specimen was 30. There was no perioperative mortality and no complications. Conclusions: It is possible to perform a completely laparoscopic right hemicolectomy after an adequate training in advanced laparoscopy. The operation time isn’t longer then the extracorporeal anastomosis. Because of the totally miniinvasivity, this technique allow the application of the ERAS program.

V043 - Video - Intestinal, Colorectal and Anal Disorders

V045 - Video - Intestinal, Colorectal and Anal Disorders

LAPAROSCOPIC RIGHT HEMICOLECTOMY; THE FLEXIBLE APPROACH N. Naguib, A. Saklani, N. Tanner, C.E. Davies, S. Moorhouse, A.G. Masoud Prince Charles Hospital, MERTHYR TYDFIL, United Kingdom

TOTALLY LAPAROSCOPIC LEFT COLONIC RESECTIONS WITH NATURAL ORIFICE SPECIMEN EXTRACTION (NOSE) USING A NEW ENDOSCOPIC PURSTRING DEVICE S.M. Tenconi, G. David, G. Ietto, M. Di Giuseppe, F. Cantore, L. Giavarini, E. Colombo, E. Cassinotti, L. Boni Minimally Invasive Surgery Research Center, University of Insubria, VARESE, Italy

Aim: Laparoscopic right hemicolectomy is indicated for the management of a spectrum of pathological conditions. Flexible surgical approach may be required to accommodate the different surgical indications. Methods: Port placement: Hassan technique to establish an umbilical port and a supra-pubic camera port are required to achieve a good view of the entire right colon. Two additional 5 mm ports in the upper and lower left quadrants of the abdomen. Steps: (1) Standard Medial approach: This is suitable for T1–T3 right colonic tumours. First, the pedicle is divided followed by medial-to-lateral dissection and then mobilisation of the hepatic flexure. (2) Locally advanced tumours: The right ureter is identified and protected by a gauze swab before division of the ileo-colic pedicle. This is followed by medial-to-lateral dissection and then mobilisation of the hepatic flexure. To minimise incision size for specimen delivery, the terminal ileum is delivered first and divided, followed by the transverse colon. The specimen is then delivered by traction on the divided ileal and colonic ends. (3) Caudal approach: This technique is suitable where early division of the pedicle may not be appropriate e.g. for a right iliac fossa mass of uncertain aetiology. Dissection begins posterior to the terminal ileum and continues superiorly lifting the right colon off the duodenum and pancreas followed by lateral and hepatic flexure mobilisation. If malignancy is suspected, extracorporeal high division of the ileocolic pedicle is performed. Pneumoperitoneum can be reestablished if high tie is difficult to achieve. (4) Lateral approach: This technique is suitable if laparoscopic division of the pedicle is unsafe and/or not required e.g. Crohn’s disease with a thickened pedicle. A limited mobilisation of the ileo-caecal junction and the ascending colon is performed to visualise the third and lower aspect of the second part of the duodenum. There is no need for medial or hepatic flexure mobilisation which unnecessarily prolongs the procedure. Results: Over nine years, we performed 49 laparoscopic right hemicolectomy using these approaches. Conversion rate is 8% (4/49). There is no mortality. Anastomotic leak is 2% (1/49). Conclusion: We demonstrate four surgical approaches which can be tailored to different surgical scenarios.

This video describes our experience in natural orifice specimens extraction (NOSE) using a new endoscopic purse string in patients undergone left colonic resections for both benign (endometriosis) and malignant diseases. The pneumoperitoneum is induced using a Verres needle and four trocars are used as in standard laparoscopic left colectomy. In case of malignant diseases we proceed with high ligation of the inferior mesenteric artery and vein followed by full mobilization of the left colon up to 2–3 cm above the peritoneal reflection depending form the site of the lesion. On the contrary, in the procedure is performed for endometriosis, the sigmoid vessels are isolated, clipped and divided according to the level of the resection required, the inferior mesenteric vessels are preserved. Once the left colon is divided distally. A new endoscopic purstring device (Karl Storz, GmbH &CO, Tuttlingen, Germany) is introduced through the 12 mm trocar at the level of left iliac fossa, placed distally and the colon is the transacted with endoscopic scissors and placed into an endobag. At the point, in case of female patients, anterior colpotomy is carried out, specimen removed and the head of an endoscopic circular stapler is introduced. The colpotomy is then closed with interrupted suture. In case of male patients, the distal colon is washed with iodine solution and opened cutting the suture line. At this point endobag is grabbed with a standard forceps, the specimen is removed and the head of the circular stapler introduced. The distal colon is isolated and closed with linear stapler. The head is plased into the distal colon and the purstring tighten with intracorporeal ligature and colo-rectal anastomosis is carried out.

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V046 - Video - Intestinal, Colorectal and Anal Disorders

V048 - Video - Intestinal, Colorectal and Anal Disorders

RIGHT COLON ADVANCED CANCER: TOTALLY LAPAROSCOPIC RIGHT COLECTOMY. M. Carlini, S. Ferretti, D. Spoletini, F. Castaldi, C. Giovannini S. Eugenio Hospital, ROME, Italy

TOTALLY LAPAROSCOPIC RIGHT HEMICOLECTOMY: TECHNIQUE AND RESULTS R. Brachet Contul, M. Fabozzi, P. Millo, M. Nardi, E. Lale-Murix, M. Grivon, R. Allieta Regiona Hospital, AOSTA, Italy

Laparoscopic surgery of colon cancer has been accepted to be oncologically adequate. The role of laparoscopy in rectum cancer is still debated, because complex surgical procedures may specifically influence the long-term outcome. Our experience in laparoscopic colorectal surgery started in 1993 at the National Cancer Institute of Rome and continued, at the S. Eugenio Hospital of Rome where, since 2003, 246 cases of laparoscopic colorectal resections, with 61 cases of laparoscopic right colectomies, were performed. In this video a case of locally advanced right colon cancer affecting a 52-year-old woman is presented. The lesion was extra luminal with an infiltration of the peritoneum. A totally laparoscopic right colectomy was planned. The surgical procedure was performed with three trocars and by a ultrasound device. The first step was the identification, closure and section of the ileocolic vessels and the right branch of the middle colic artery. The complete posterior mobilization of the right colon in the retro peritoneum was achieved by blunt dissection. Then, the peritoneum surrounding the tumor was resected, parietocolic ligament was dissected and the pancreaticduodenal anterior aspect was completely exposed. A linear laparoscopic stapler was employed to transect the ileum and the transverse colon. A latero-lateral mechanical intracorporeal anastomosis was performed. The specimen was delivered in an endo-bag through a small Pfannenstiel incision incision. A paranastomotic drainage was placed, removed after four days. The surgical procedure required 90 min. The post-operative course was uneventful and the patient was discharged in 6th p.o.d. In our experience right laparoscopic colectomy is feasible, effective and reproducible representing a gold standard in surgery.

Aims: Laparoscopic right colectomy for cancer should respect the same oncologic criteria as the open approach including: ‘no-touch isolation technique’, isolation and ligation of the vascular pedicles at the origin, oncologic lymphadenectomy and ‘distal and radial clearance’ of the neoplasm from resection margins. Two major procedures have been described for the treatment of right colon tumors: Video-Assisted (VA) right colectomy, involving vascular ligation and ileocolic mobilization by laparoscopy followed by extracorporeal intestinal resection and anastomosis and Totally Laparoscopic (TL) resection, with the whole procedure performed by laparoscopy. This video shows the technique of TL right colectomy for the treatment of right colon. Methods: From January 2001 to March 2009, we performed 139 laparoscopic right colectomies (of these 16 (11.5%) for benign pathologies and 123 (88.5%) for neoplastic diseases). Of these 66 were Totally Laparoscopic and 73 were Video assisted right colectomies. In the TL colectomy, the sovrapubic minilaparotomy of 6 ± 1 cm is necessary only for the specimen extraction. The procedures were considered curative only when there was no intraoperative evidence of secondary locations. Postoperative recovery was in accordance with Kehlet protocol. They were followed-up until the 4th p.o. year. Results: The mean operative times were 78 ± 25 min. We noted a less p.o. pain associated to a reduction of analgesic consumption and an earlier restoration of digestive function in TL vs VA group. The mean hospital stays were about 5 days. There were no complications either intra or post-operatively and similarly there was no mortality in the TL group. There wasn’t recurrence of the neoplastic disease in both groups after 4 years of follow-up in both group. Conclusions: This study seems demonstrate that TL right colectomy is feasible and safe, with results comparable to open approach but improved post-operative patient’s comfort. The limits of our retrospective comparative study don’t allow us to draw definitive conclusions even if our data remain encouraging for next prospective randomized studies.

V047 - Video - Intestinal, Colorectal and Anal Disorders

V049 - Video - Intestinal, Colorectal and Anal Disorders

TREITZ LAPAROSCOPIC RESECTION WITH INTRACORPOREAL ANASTOMOSIS WITH A NEW BARBED SUTURE M. Scatizzi, E. Lenzi, M. Baraghini, F. Menici, F. Feroci Ospedale Misericordia e Dolce, PRATO, Italy

SURGICAL STRATEGY FOR COMPLEX MULTISEGMENTAL COLO-RECTAL RESECTIONS N. Naguib, P. Mekhail, A. Saklani, M. Farag, J. Morgan, A.G. Masoud Prince Charles Hospital, MERTHYR TYDFIL, United Kingdom

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms of the gastrointestinal tract; life-threatening hemorrhage or intestinal obstruction are the most common presenting symptoms. In the last year we observed four patients affected by GIST of the small bowel presenting with a massive bleeding. After the endoscopic diagnosis, all the neoplasms were ink marked. We present a video showing a Treitz’s GIST treated with a laparoscopic resection, followed by a mechanical latero-lateral intracorporeal anastomosis and enterotomy closure using a new kind of self-anchoring barbed suture (VLoc advanced wound closure device-Covidien, Mansfield, MA).

Aim: Laparoscopic multi-segmental procedures are tedious and time consuming. The mobility of a fully dissected colon makes further retraction and dissection difficult. We aim to simplify this by dividing the colon and removing it in multiple segments. Methods: Colon extraction in three segments: (a) Terminal ileum to Midtransverse colon; (b) mid-transverse to Mid-sigmoid colon and (c) mid-sigmoid to anal canal. Steps: Head-down, left side-up: (a) Left sided medio-lateral approach, extending from the pre-sacral plane to the splenic flexure until entering the lesser sac, (b) high division of IMA and IMV visualising left ureter and gonadal vessels, (c) division of Mid-sigmoid using staples completing the rectal dissection; Flat, right side-up: (a) right colon mobilised medially by dividing the right colic vessels, preserving the duodenum, (b) division of the terminal ileum followed by division of terminal ileal branch and ileo-colic vessels; Head-up, right side-up: (a) transverse colon is lifted up and divided after dividing middle colic vessels, (b) right colon mobilisation is completed, (c) the right colonic segment is kept above the right hepatic lobe; Head-up, left side-up: (a) splenic flexure mobilisation is completed and the left colonic specimen is kept above the left hepatic lobe; Head-down: (a) the small bowel is placed in the upper abdomen with the right and left colonic segments kept side by side in the pelvis, (b) perineal dissection with extraction of all specimens and right iliac fossa end-Ileostomy. Results: We performed this procedure in a 65 years old female with refractory ulcerative colitis who opted for Panproctocolectomy rather than a pouch. Patient was discharged home on day 11 due to social circumstances. No perineal wound or stoma-related complications. Conclusion: Multi-segmental approach to complex operation simplifies surgery and decreases the time taken for this procedure.

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V050 - Video - Intestinal, Colorectal and Anal Disorders

V052 - Video - Intestinal, Colorectal and Anal Disorders

LAPAROSCOPIC APPROACH TO A RETRORECTAL SOLITARY FIBROUS TUMOR F. Marinello, E. Targarona, L. Pallares, C. Martı´nez, P. Herna´ndez, C. Balague´, M. Trı´as Hospital de la Santa Creu i Sant Pau, BARCELONA, Spain

LAPAROSCOPIC TREATMENT OF APPENDICITIS: CAUSES OF CONVERSION TO LAPAROTOMIC APPROACH. S. Condurro, S. Campagna, A. Trunfio, S. Razzi, M. Salval Usl Valle d’Aosta, AOSTA, Italy

Aim: Retrorectal tumors are rare and its histologic origin varies greatly. Total surgical excision is indicated to prevent mass complications or to rule out malignancy. We present a video on a laparoscopic approach to a retrorectal Solitary fibrous tumor. Methods: A 33 years old woman consulted our emergency service with vague low abdominal pain with occasional cramping. An ultrasound visualized a left ovarian cyst along with a pelvic tumor that did not belong to the genital system. A Magnetic Resonance Imaging was performed, finding a 7.5 9 4.4 9 4.4 cm solid cystic mass in the retrorectal space which extended passing the promontory angle. A laparoscopic transabdominal approach was indicated. A dissection of the mass from the mesosigma into the presacral space was realized until final excision from the retrorectal space at S4 level. No bleeding or rectal damaged occured. The tumor was extracted through a mini Phannestiel incision. The total time of the procedure was 180 min. Results: The patient was discharged on her fifth post-operative day with no incidences. On pathological examination a solitary fibrous tumor was reported. Conclusion: The Laparoscopic Approach to retrorectal tumors is feasible and secure.

Aims: Evaluate an identify causes of conversion during laparoscopic treatment of appendicitis. Methods: We collected all operating notes from the 1st of April 2002 up the first of January 2011. Theater data had been computerized starting from January 2007 before that date we used our data record. Part of appendectomies had been automatically divided by ICDM code diagnosis and procedure. Number of conversions and that one treated with starting laparotomic approach had been identified. All the notes had been reviewed, searching for laparotomic conversion ground. Results: from 1/04/2002 to 1/1/2011 we performed 1587 appendectomy. 1397 (87%) laparoscopically. 65 had been converted (4.7%). ICDM computerized diagnosis, had hallowed to divide complicated from non complicated appendicitis, 70/224 (31%).They correspond to acute appendicitis with a generalized peritonitis or peritoneal abscess. These pathologies account for 15% of all cases (35/224); we do convert three times more frequently peritoneal abscess (26%) then acute appendicitis with generalized peritonitis (7%). Conclusion: Number of laparoscopic appendectomies has growth in the first three years to remain stable later on. Review of theatre notes demonstrates conversions in the vast majority of cases due to pathological changes of anatomy and intraoperative complications. One case due to anesthesia problems. Percentage of conversions remained stable during the last 10 years.

V051 - Video - Intestinal, Colorectal and Anal Disorders

V054 - Video - Intestinal, Colorectal and Anal Disorders

LAPAROSCOPIC COLECTOMY WITH ILEO-RECTAL ANASATOMOSIS FOR FAMILIAL ADENOMATOUS POLYPOSIS - TECHNICAL ASPECTS - VIDEO M. Vitellaro, G. Bonfanti, G. Gallino, L. Bertario Fondazione IRCCS Istituto Nazionale dei Tumori, MILANO, Italy

RECTAL SEGMENTAL RESECTION FOR CIRCUMFERENTIAL LESIONS BY TRANSANAL ENDOSCOPIC MICROSURGERY A. Arezzo, M.E. Allaix, F. Cravero, R. Reddavid, M. Morino University of Torino, TORINO, Italy

Aims: Prophylactic surgery is the gold standard for treatment of Familial Adenomatous Polyposis (FAP). The video shows technical aspects of a Total Colectomy (TC) with Ileo-Rectal anastomosis (IRA). Methods: After intubation, a Female patient was placed on the operative table in a modified lithotomy position. Pneumoperitoneum was initiated using carbon dioxide (CO2), through a Veress needle with pressure set up to 14 mmHg. TC with IRA was carried out with four 12 mm cannulas. General abdominal assessment was performed including a check up for liver and peritoneal nodes. Surgical procedure started by dividing the distal gastro-colic ligaments. Transverse and the proximal left colon were mobilized with care to protect the spleen. The mesenteric vein was identified close to the duodenum and divided. The peritoneum was opened between the inferior mesenteric vein and the artery. Left colon was mobilized using medial to lateral approach and care to protect the gonadal vessels and left ureter. The inferior mesenteric artery was divided with protection of the hypogastric nerves. Dissection was completed until the recto-sigmoid junction. The Surgical procedure continued on with the surgeon standing on the left side of the patient. The ileocolic junction was identified and the distal ileum was divided using a 45 mm linear endoscopic stapler. Further, the ileocolic pedicle was divided. The right colon was mobilized medial to lateral, protecting the gonadal vessels and ureter, until duodenum was identified and hepatocolic ligament was dissected and divided. The middle colic vessels were dissected and divided as well. Next, the surgeon comes back to the right side of the patient. Colectomy was completed with finalization of the transverse colon dissection. In TC the upper rectum was divided using a 30 mm Linear stapler through Pfannenstiel incision. The specimen was retrieved after placement of a wound protector. Ileorectal side-to-end anastomosis was performed using a circular stapler. Prior to closing the incisions, the abdomen was checked for haemostasis and a drain tube was placed in pelvis for 48 h. No intraoperative complications were reported. Conclusions: Lap colectomy for prophylactic treatment of FAP appears to be safe, feasible and an appealing alternative to open surgery.

Aims: Transanal Endoscopic Microsurgery (TEM) had revolutionised technique and outcome of transanal surgery, becoming the standard of treatment for large rectal adenomas, and early rectal cancer, also in case of the whole rectal circumference involvement. Materials and Methods: TEM instrumentarium includes a 15 cm rectal tube with 3 working channels (12, 5 and 5 mm) for conventional laparoscopic instruments, plus a 5 mm channel dedicated to a 30° optic. The rectoscope is connected to the operating table via a holding arm consisting of 3 joints and a single screw. The system is used in combination with a standard laparoscopic column: image is projected on a screen, insufflation is obtained by a conventional CO2 thermo-insufflator. Results: The two videos illustrate the technique of dissection of a large neoplasm involving circumferentially the rectal wall, and the following suturing of the rectal defect. The inadvertent opening of the peritoneum is promptly sutured by TEM. In our experience, the conversion rate to abdominal surgery because of peritoneum opening is 0%, and the postoperative course was uneventful. Conclusion: TEM has greatly enlarged its indications to very large rectal neoplasms, without increasing the intraoperative and postoperative complications rates.

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V055 - Video - Intestinal, Colorectal and Anal Disorders

V057 - Video - Intestinal, Colorectal and Anal Disorders

LAPAROSCOPIC NERVE-SPARING TOTAL MESORECTAL EXCISION FOR EXTRAPERITONEAL RECTAL CANCER M.E. Allaix, A. Arezzo, G. Giraudo, M. Morino Digestive Surgery and Center for Minimally Invasive Surgery, University of Turin, TURIN, Italy

SINGLE PORT SUBTOTAL COLECTOMY FOR COLONIC INERTIA S. Morales-Conde, M. Socas, I. Alarco´n, A. Barranco, M.D. Casado, D. Bernal, V. Gomez, I. Serrano, J.M. Can˜ete, C. Caballero, H. Cadet, J. Padillo Hospital Universitario Virgen del Rocio, SEVILLE, Spain

Voiding and sexual dysfunctions are serious complications of rectal surgery for cancer. One of the advantages of laparoscopy is the clear visualization of the smallest structures, including the autonomic nerves. We report four videos concerning laparoscopic nerve-sparing total mesorectal excision for extraperitoneal cancer. The first video shows the inferior mesenteric artery (IMA) dissection and ligation. While the assistant is holding the sigmoid ventrally under traction and to the left, the peritoneal serosa was incised starting at the sacral promontory. Dissection then proceeds to the origin of the IMA, taking care not to injure the sympathetic roots of dorsolumbar origin, which give rise to the superior hypogastric plexus located at the level of the sacral promontory. The IMA is divided 1 cm from the aorta. The second and third videos show the posterior dissection of the mesorectum and preservation the nerves after identification. It is important to locate the avascular cleavage between the parietal layer of the pelvic fascia and the visceral layer that underlines the mesorectum at the level of the sacral promontory. By preserving the parietal layer, one avoids the risk of injuring the superior hypogastric plexus and the left and right hypogastric nerves (sympathetic). The posterior dissection is carried out facilitated by pneumodissection. The peritoneum is then incised along the right side of the pelvis downwards. The incision is completed on the left side of the pelvis where the hypogastric nerve is found as well as the ureter. Finally, the fourth video shows the anterior dissection between the rectum and the posterior vaginal wall. Laterally, descending towards the pelvic floor, the middle rectal artery is sectioned not at its origin but in its intermediate portion to preserve the pelvic plexus. Posteriorly the rectosacral ligament is incised to access the muscular plane of the pelvic floor. Dissection proceeds laterally until circumferential mobilization of the bowel is accomplished.

Introduction: Recently, laparoscopic single incision surgery has became a natural step towards a more minimally invasive surgery due to the potential advantages of this approach over standard laparoscopic surgery, such us better cosmetic results and a reduction of pain and hospital stay. This approach is progressively applied to different procedures such us colonic surgery. Most of the publications related to this colonic single port surgery are related to left and right hemicolectomy, being described in this video its use in subtotal colectomy. Patient and Technique: We present a case of a young female 44 years patient who complains of diffuse abdominal pain and constipation. A redundant colon was the described in the barium enema together with slow transit, being diagnosed of colonic inertia. A single port access was proposed for this case, being performed with a single port device with three orifice through a 2.5 cm transumbilical incision. Surgery was performed with a 5 mm 30° optic, a roticulator grasper and the Ligasure Atlas. The procedures start with the mobilization of the right colon, followed by the transsection of the gastro-colic ligament and the transverse mesocolon, the left colonic flexure and the left colon all the way to the sigmoid colon. Once the colon was mobilized, the specimen was removed from the abdominal cavity through the umbilical incision and the ileo-sigmoid anastomosis was performed extracorporeally. Patient was discharged on day four, being free of symptoms after a follow-up of 10 months. Conclusion: Single port surgery is being used in different fields with similar results than standard laparoscopic surgery, being a safe an effective technique. Surgeons experience in this type of procedures allows increasing the number of indications of this type of access.

V056 - Video - Intestinal, Colorectal and Anal Disorders

V058 - Video - Intestinal, Colorectal and Anal Disorders

SINGLE-PORT LAPAROSCOPIC LEFT HEMICOLECTOMY WITHOUT ADDITIONAL TROCARS SUPPORT. S. Morales-Conde, M. Socas, D.A. Bernal, A. Barranco, C. Me´ndez, G. Scianamea, M.D. Casado, V. Go´mez, I. Alarco´n, J.M. Hisnard, F.J. Padillo University Hospital Virgen del Rocio, SEVILLE, Spain

HYBRID NATURAL ORIFICE TRANSLUMENAL ENDOSCOPIC SURGERY FOR THE TREATMENT OF RECTAL ENDOMETRIOSIS M. Hamada, G. Muraoka, N. Kawakita, K. Oishi, M. Nishi, A. Kouzuki, F. Teraishi, K. Ozaki, T. Nakamura, Y. Fukui, Y. Nishioka, T. Taniki, T. Horimi Kochi Health Sciences Center, KOCHI, Japan

Objective: In order to show to the scientific community a safe and effective alternative to laparoscopic surgical treatment of both benign and malignant left colon were analyzed using a single site accessible through a single incision transumbilical less than 3 cm and without the need assistance of additional dispositions. Method: 55 years old male patient, no personal history of interest and with a BMI of 26.9, a candidate for surgical treatment of colonic diverticulosis. The procedure was carried out through a single incision of 2.8 cm transumbilical and without trocars support. During surgery, we used a single port device with 3 holes (2 of 5 mm and 1 of 12 mm), a 5 mm 30° optic and a roticulator grasper in the left hand. We used the 12 mm hole for the introduction of a straight clamp, different energy sources, such as the Ligasure Advanced and the endostaplers. Surgery was carried out from medial to lateral dissection, coagulating the inferior mesenteric vein and inferior mesenteric artery with the Ligasure. Transsection of the colon at the junction of the sigmoid colon with the rectum was performed using two cartridges of an endostapler. After removal the specimen through the transumbilical incision, the proximal colon was transected and the anastomosis was performed intracorporeally through the anus using a circular stapler. No drain was used. Result: Surgery was performed in 120 min. The patient had no intraoperative or postoperative complications, liquid intake started at day 2, being discharged on day 4. Surgical specimen was 28 cm long. Conclusion: Due to the latest advances in technology, designing and developing different devices for single incision access, left hemicolectomy can be performed safe and with the same results than standard laparoscopic colonic surgery. A careful patient selection, specially those with BMI lees than 28, shows excellent results, similar results than standard laparoscopic surgery, with better cosmetic results and a potential reduction of pain.

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Aims: We present our novel technique of low anterior resection using hybrid natural orifice transluminal endoscopic surgery for rectal endometriosis. Present Case: The patient was a 37-year-old female who had a history of endometriosis with the complaint of constipation and severe lower abdominal pain in relation to her menstrual cycle. Surgical Technique: Under general anesthesia, the patient was placed in a dorsal lithotomy position. Three 12 mm and two 5 mm trocars were used. We used a vagi-pipe to maintain pneumoperitoneum after the vaginal incision. A careful intra-abdominal inspection revealed two separate rectal endometriosis lesions. The first lesion was at the rectosigmoid colon and second was at the rectovaginal pouch. After transection of the rectum at the distal side of the second lesion was performed with an Echelon-flex 60 (Ethicon EndSurgery, Cincinnati, OH). Using a Vagi-pipe (Hakko CO., LTD, Tokyo, Japan), the anvil of the CDH 29 (Ethicon End-Surgery, Cincinnati, OH) was introduced into the abdominal cavity through the vagina. An incision was made at the healthy colon proximal to the first lesion, the length of which was sufficient to introduce the anvil head. After complete introduction of the anvil, transection of the sigmoid colon between the anvil and incised wall was performed with a Echelon Flex 60. After clamping the sigmoid colon, including the anvil, just above the anvil head using the forceps, the tip of the anvil shaft could be detected through the edge of the stapling line. The resected specimens were retrieved into the EZ purse and removed through the vagina. Using CDH 29 mm, the colorectal anastomosis was performed under pneumoperitoneum. Finally, the incised vaginal wall was closed with interrupted suturing. Total amount of the blood loss was under 10 ml and duration of the operation was 4 h 54 min. Postoperative course was uneventful. The patient was discharged on the 7th postoperative day. Pathological diagnosis was rectal endometriosis. She has been free from abdominal symptoms after three postoperative months. Conclusion: Our technique can be an option for the minimally invasive rectal surgery.

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V059 - Video - Intestinal, Colorectal and Anal Disorders

V061 - Video - Intestinal, Colorectal and Anal Disorders

IN LAPAROSCOPIC ULTRA-LOW ANTERIOR RESECTION AND SUTURED COLO-ANAL ANASTOMOSIS, A COLOPLASTY MAY BE MORE SUITABLE FOR THE NARROW MALE PELVIS. N. Naguib, A. Saklani, N. Tanner, M. Farag, C.E. Davies, A.G. Masoud Prince Charles Hospital, MERTHYR TYDFIL, United Kingdom

LAPAROSCOPIC COLECTOMY WITH RADICAL LYMPH NODE DISSECTION FOR LEFT SIDE ADVANCED TRANSVERSE COLON CANCER Y. Fukunaga, M. Ueno, S. Nagayama, Y. Fujimoto, T. Konishi, T. Akiyoshi, K. Yamakawa, T. Sano, S. Tanimura, N. Hiki, A. Saiura, S. Nunobe, R. Koga, K. Yamada, S. Mine, T. Yamaguchi Cancer Institute Hospital, TOKYO, Japan

Aim: Laparoscopic low anterior resection for low rectal cancers in males is restricted by the difficulty to staple low-down in the narrow pelvis. The limited space would make a colonic pouch unsuitable. We recommend a coloplasty and a hand-sewn coloanal anastomosis rather than colonic pouch and a stapled anastomosis. Methods: An 82 years old male presented with an early rectal cancer on the posterior wall 3 cm from the dentate line (MRI staging T1/T2 N0, M0). The operation begins with the perineal approach. Transanal division of the anorectal junction using Lone Star retractor. A cytocidal washout of the rectum is followed by suturing a swab between the tumour and the intended site of incision. After infiltration with saline adrenaline, a circumferential incision is taken 1.5 cm from the dentate line and deepened posteriorly until fat is identified. The dissection is completed anteriorly separating the upper anal canal from the lower part of the prostate. The proximal rectum is closed by a continuous suture to prevent spillage. Laparoscopic low anterior resection: A standard medial to lateral dissection is performed, including mobilisation of the splenic flexure and full rectal mobilisation. During dissection, the end of the previously sutured rectal stump is identified and freed. Through a 5 cm suprapubic incision, the colon and rectum are delivered and transected at the descending-sigmoid junction. The descending colon is used to construct an 8 cm coloplasty. Stay sutures are placed on either end. The terminal ileum is marked to perform a loop ileostomy at the end of the procedure. Colo-anal anastomosis: To maintain pneumoperitoneum and aid mobilisation of the coloplasty into the anal canal, a transanal balloon port is used. The stay stitches on the coloplasty are identified and pulled through by a grasper from the balloon port into the anal canal. An interrupted hand-sewn anastomosis is performed. Results: The patient was discharged home on day 7. Histology revealed T2 N0 adenocarcinoma (0/18 nodes involved). The distal resection margin was 1.5 cm, and the circumferential margin was 8 mm. Conclusion: We believe this technique is more suitable for the male pelvis.

Background and Aim: Even laparoscopic colorectal surgery has been widely spread for these two decades, this procedure for advanced transverse colon cancer especially requiring radical lymph node dissection and mobilization of the splenic flexure is still controversial. We present a laparoscopic left side transverse colectomy for advanced cancer by the video. Procedure: The patient is set at lithotomy position under general anesthesia. Five ports are introduced and CO2 pneumoperitoneum is maintained at 10 mmHg. At first, the transverse mesentery is stretched out by sutured thread that pulling out from the upper right quadrant. After the main feeding artery of the tumor is figured out, its origin was exposed and clipped for dividing. The video showed the feeding artery is independently derived from SMA just behind the pancreas another to left branch of MCA. Dissection is forwarded along the caudal edge of pancreas toward the spleen and the drainage vain is also divided after clipping. Patient is changed to head up position and the procedure is moved on to the caudal to transverse colon. Once the lesser sac is opened, major omentum division is performed toward the lower pole of spleen. When the separation of major omentum is reached to the left edge of lesser sac, descending colon is mobilized from lateral side. Toldt fusion fascia is dissected just on Gerota’s fascia to expose pancreas and the plane is continued to lesser sac. Specimen removal and reconstruction is extracorporeally performed through a 4 cm small skin incision. Results: There was no open conversion in our 18 cases. The mean operation time was 225 min and median blood loss was 75 g. Conclusions: Laparoscopic left side transverse colectomy for advanced colon cancer is feasible when some specific technical knacks were learned.

V060 - Video - Intestinal, Colorectal and Anal Disorders

V064 - Video - Liver and Biliary Tract Surgery

LAPAROSCOPIC MANAGEMENT OF TRANSVERSE COLON CANCER INDUCING OBSTRUCTIONS, WITH D3 LYMPH NODE DISSECTION N. Ueno, A. Arimoto, S. Ueda, H. Nosho, Y. Yamashita, N. Urakawa, T. Yoshikawa, T. Ienaga Takatsuki General Hospital, TAKATSUKI, OSAKA, Japan

LAPAROSCOPIC REDO HEPATICOJEJUNOSTOMY FOR STENOTIC HEPATICOJEJUNOSTOMY M.K.H. Hussein American University of Beirut - Medical Center, BEIRUT, Lebanon

Introduction: It is not too much to say that the laparoscopic approach for colon cancer has been estimated as the standard, due to its higher postoperative QOL. Several clinical guidelines have already recommended its advantage. In our department, 74 colorectal laparoscopic surgeries were performed from April 2009 to December 2010. Among them 18 cases with obstructive tumors were included. In the cases with colonic obstruction, we will perform preoperative bowel decompression with trans-anal for left sided lesions or nasal drainage tube for right sided lesions without temporary stoma as possible. Aim: We report our laparoscopic intervention from a case of the obstructive transverse colon cancer with D3 lymph node dissection. The patient is 67-year-old female who was admitted suffering severe constipation. The plain abdominal CT at the ER revealed dilated large intestine and the tumor at the transverse colon. Colonoscope underwent and a trans-anal drainage tube was inserted over the tumor. After inspections about general status and metastasis, and treatment of the obstructive colitis, laparoscopic surgery was performed 20 days after the admission. Surgical technique: The gastrocolic ligament is opened distally at the gastroepiploic vessel arch, the rear cavity of the greater omentum is accessed and the lower edge of the pancreas identified and the point of insertion of the transverse mesocolon root. After sectioning the splenocolic ligament, the transverse mesocolon is cut below the lower edge of the pancreas. The procedure of D3 lymph node dissection is started with the preparation of the surface of superior mesenteric vessels at the lower edge of the pancreas, and followed by sectioning the middle colic vessels at their root. Conclusion: Laparoscopic curative operation for obstructive transverse colon cancer with D3 lymph node dissection requires surgeons of technique and experience. Preoperative bowel decompression with trans-anal drainage makes it possible without temporary stoma.

I report a case 56 years old post Laparoscopic Whipple procedure done for pancreatic mass that revealed to be chronic pancreatitis. Patient presented 1-year post operation with history of repeated episodes of cholangitis. CT Scan revealed severe stenosis and PTC failed to clear the intra hepatic and extra hepatic biliary tree from impacted biliary stones. This video shows the various steps used through 5 trocars to release the adhesion and explore the Hepaticojejunostomy, division of the Hepaticojejunostomy, stone extraction from the extra hepatic and intra hepatic biliary system through choledochoscope using Dormia basket and Fogarty Catheter number 5, and the redo Anastomosis performed using intracorpeal suturing of 3-0 PDS. Patient had smooth postoperative course and discharged 4 days post operative. Conclusion: Therefore even with most complicated cases can be handled laparoscopically in Advanced Centers of Laparoscopy.

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V065 - Video - Liver and Biliary Tract Surgery

V067 - Video - Liver and Biliary Tract Surgery

ROUVIERE’S SULCUS: A SAFETY LANDMARK FOR LAPAROSCOPIC CHOLECYSTECTOMY M. Zubair1, L. Habib2, M. Yousuf2, M. Khan1, M.R. Mirza2, M.S. Quraishy1 1 Dow University of Health Sciences, KARACHI, Pakistan. 2Hamdard University Hospital, KARACHI, Pakistan

SINGLE PORT APPROACH OF COLECISTO-COLIC FISTULA DURING CHOLECYSTECTOMY S. Morales-Conde, A. Barranco, M. Socas, I. Alarco´n, J.M. Suarez, C. Bernardos, J.M. Can˜ete, I. Serrano, H. Cadet, J. Padillo Hospital Universitario Virgen del Rocio, SEVILLE, Spain Introduction: Single port access has became a real option for different Standard laparoscopic procedures, including laparoscopic cholecystectomy. Since experience is increasing, surgeons are exposed to difficult cases such us chronic cholecystitis, acute cholecystitis and very challenging cholecystectomies, like those presenting a cholecysto-colic or cholecysto-duodenal fistula. Clinical Case: We show a case of a 44 years old female who was scheduled for single port cholecystectomy. The procedure was performed using a single port device with a 5 mm 30° optic. An intense inflammatory process was observed and during the dissection the presence of a cholecysto-colic fistula was detected. The fistula was transected using two blue cartridges of a 60 mm roticulator endoGIA. Cholecystectomy was completed using the single port access in 120 min with no additional trocars, and the patient was discharged from the hospital on day two. Conclusion: Single port cholecystectomy is considered an alternative to standard laparoscopic procedure. New challenging situations related to difficult cases need to be described in order to demonstrate that single port access can be used in similar situations than standard laparoscopic cholecystectomy.

Aim: To determine the frequency of Rouviere’s sulcus in our population. Methods: 335 consecutive patients undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis were included in the study. Frequency and type of Rouviere’s sulcus was documented in operative note. Open type of sulcus was defined as a cleft in which right hepatic pedicle was visualized and the sulcus was open throughout its length. Fused type was defined as one in which the pedicle was not visualized or if the sulcus was open only at its lateral end. Result: Open type of Rouviere’s sulcus was visualized in 109 patients and 117 patients had fused type of sulcus. Hence in a total of 226 (67.5%) patients Rouviere’s sulcus was visualized. Conclusion: Rouviere’s sulcus is an important extra biliary land mark, identifiable in majority of patients either as open or fused variety. Its identification before commencement of Calot’s triangle dissection may help in preventing the bile duct injury.

V066 - Video - Liver and Biliary Tract Surgery

V068 - Video - Liver and Biliary Tract Surgery

TOTALLY LAPAROSCOPIC RIGHT HEPATECTOMY WITH HILIAR DISSECTION I. Poves, M.A. Martı´nez-Serrano, D. Dorcaratto, F. Burdı´o, L. Grande Hospital del Mar, BARCELONA, Spain

TRANSVAGINAL NOTES HYBRID CHOLECYSTECTOMY: OUR OPERATIVE TECHNIQUE C. Copaescu, D. Andrei, G. Eftimie, D. Godoroja St John Hospital, BUCHAREST, Romania

Introduction: Laparoscopic approach for hepatic resections is technically demanding. Left and anterior segments of the liver (II, III, IV, V and VI) are considered ‘favourable’ for laparoscopic approach. In most of the reported series of laparoscopic hepatectomy, the majority of the procedures done are limited non-anatomical resections of one or two ‘favourable’ segments. Until 2010, there have been reported near 250 laparoscopic right hepatectomies (LRH) all over the world, most of them assisted or mixed procedures. Only very few centers perform the LRH as a standard procedure. When done by expert surgeons in both laparoscopic and hepatic surgery, LRH has demonstrated to be as safe and effective than the open procedure. On the video we show our technique for totally LRH with hiliar dissection. Video presentation: We present a case of a 28 years-old woman affected of a 6 cm in diameter adenoma located in segments VII and VIII. In the video are exposed, step by step, all the phases for doing a totally LRH with hiliar dissection: cholecystectomy, dissection of the common biliary duct, hepatic artery (three branches) and right portal vein and portal bifurcation. Right hepatic artery and right hepatic vein are sequentially sectioned and sutured using vascular endostappler. Parenchymotomy was achieved by using a 5 mm LigaSure V (Covidien) device. Surface hepatic hemostasis was done only using bipolar graspers. Biliary duct and right hepatic vein were sectioned and sutured with vascular endostappler. All the procedure was done without hiliar clampling. The specimen was removed, protected in a plastic bag, through a Phannestiel incision. An aspirative drain was left for 2 days. Total operative time was 390 min. No blood transfusion was required. The patient was discharged on 6th postoperative day without any adverse incidence. Conclusions: Totally LRH is not an easy technique and is technically demanding, but it can be done with security in centres with previous experience in other major laparoscopic hepatectomies such bisegmentectomies and non-anatomical resections.

Background: Beside the fact that Natural Orifice Transluminal Endoscopic Surgery (NOTES) has been described for a multitude of procedures (including cholecystectomy) the clinical experience using flexible endoscopes is, however, very limited. Transvaginal cholecystectomy has been demonstrated to be a feasible approach when only rigid instruments are used. Method: In this video we present our surgical techniques for transvaginal cholecystectomy with additional 5/10-mm umbilical trocar using rigid laparoscopic instruments. The patients were placed in French position. Pneumoperitoneum with CO2 was realized with Veress needle through the umbilical scar. A 5 or 10 mm optical trocar was inserted on this site. Under the control of the 5/10 mm telescope the inspection of the peritoneal cavity is performed. The feasibility of NOTES cholecystectomy is appreciated. A uterine manipulator facilitates the transvaginal insertion of 2 canulas (5 and 12 mm). Using a transvaginal view, the cholecystectomy is performed with the help of a grasping forceps inserted through the vaginal canula and the energy device (hook monopolar electrode, LigaSure or Harmonic ACE) inserted through the umbilical port. The Clip Applier was inserted through the umbilical port. The specimen was extracted in a bag, through the vaginal route. The video highlights the important role of the long laparoscopes (50/56 cm), of the long vaginal optical trocar, of the special long instruments and of the accuracy of the surgical technique. We have operated by this method 23 women and we have recorded no major complication. All operations were finished successfully without conversion, with a mean operation time of 55 min. There were no intraoperative or immediately postoperative complications. Patients interviewed 3–12 months after surgery had no abdominal or gynecological complaints including in relation to sexual intercourse. Conclusion: Transvaginal NOTES cholecystectomy with dedicated rigid instruments can be safely and effectively performed.

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V069 - Video - Liver and Biliary Tract Surgery

V072 - Video - Liver and Biliary Tract Surgery

SINGLE-INCISION TRANSUMBILICAL LAPAROSCOPIC GIANT HEPATIC CYST UNROOFING G. Dapri, P. Carnevali, P. Koustas, I. Bessa, L. Casali, J. Himpens, G.B. Cadie`re European School of Laparoscopic Surgery, BRUSSELS, Belgium

LAPAROSCOPIC EXPLORATION AND STONE EXTRACTION OF COMMON BILE DUCT STONES. M.K.H. Hussein American University of Beirut - Medical Center, BEIRUT, Lebanon

Introduction: Large hepatic cysts can be successfully undertaken by laparoscopic unroofing, with a low recurrence rate. Single-incision laparoscopy is of growing interest in the recent years, in an attempt to improve the cosmesis, reduce the postoperative pain, and minimize the abdominal wall trauma. Video: Single-incision transumbilical laparoscopic giant hepatic cyst unroofing, performed in a female with a body mass index of 20.8 kg/m2, is reported here. The patient referred a symptomatic pain in the right-upper-quadrant, and in the preoperative work-up a giant simple hepatic cyst of 15 9 14 cm in diameter was evidenced in the apex of liver segments IV–VII–VIII. An incision was performed in the umbilicus and after placement of a purse-string suture in the fascia, a 11-mm reusable trocar was inserted, and a 10-mm, 30°-angled, rigid, standard-length scope was used. Curved reusable instruments (Karl Storz-Endoskope, Tuttlingen, Germany) were advanced without trocars transumbilically. Thanks to the curves of the instruments, the classic laparoscopic working triangulation was established inside the abdomen permitting surgeon to work in satisfied ergonomic position. The giant hepatic cyst was localized and incised superficially enough to be emptied. The cystic dome was meticulously resected using the curved coagulating hook and curved bipolar scissors. The specimen was removed via the umbilicus in a plastic bag, introduced through the 11-mm trocar. Results: Addition of supplementary trocars or incisions was not necessary. Operative time was 90 min and the final umbilical scar 14 mm. The patient was discharged on 3rd postoperative day. Conclusions: Giant hepatic cyst unroofing can safely be treated by singleincision laparoscopy. The curved instruments permit surgeon to work in ergonomic position similar to standard laparoscopy, without instruments clashing. The incision length is minimal and the cost of the procedure remains similar to the multitrocars laparoscopy.

CBD Stone is a frequent presentation in-patient with cholelithesis and treated in 98% with ERCP, failure of ERCP necessitate surgical intervention. I report 5 cases done at the American University of Beirut Medical Center successfully that were treated by Laparoscopic exploration through 4 trocars and the use of choledochoscope for stone extraction using dormia basket and Fogarty Catheter 5 French and insertion of T-Tube with no complication. The video will show the various steps used for completion of the procedure. Conclusion: Laparoscopic Exploration of CBD for stone extraction is feasible in Advanced Laparoscopic Centers.

V071 - Video - Liver and Biliary Tract Surgery

V073 - Video - Liver and Biliary Tract Surgery

LAPAROSCOPIC CHOLECYSTECTOMY WITH SITUS INVERSUS TOTALIS N. Porte, D.E. Pace Memorial University of Newfoundland, ST. JOHN’S, Canada

CHOLELITHIASIS AND CHOLEDOCHOLITIASIS: ONE STEP RATIONAL TREATMENT F. Furbetta1, S. Gennai1, F. Gragnani1, N. Furbetta2, F. Guidi1 1 Casa di Cura ,,Leonardo‘‘, SOVIGLIANA (FIRENZE), Italy. 2 Medical student, PISA, Italy

Aims: Through a case presentation, we discuss several solutions to the challenge of performing laparoscopic cholecystectomy on patients with situs inversus totalis. Methods/Results: Situs inversus totalis (SIT) is a rare condition where abdominal viscera are a mirror of the normal anatomic position. We briefly review this clinical entity and it features. This case presents a 32-year-old female with known SIT referred with recurrent ‘left-sided’ biliary colic. Cholelithiasis was confirmed by ultrasound and laparoscopic cholecystectomy was performed. According to the literature, at least forty laparoscopic cholecystectomies have been performed on patients with SIT. In this patient population, traditional setups require either left-handed dissection or a modification in technique. Many papers have focused on the latter. We used a mirrored set-up of the standard four-port approach, and demonstrated it to be safe and effective. The technical difficulties of laparoscopic cholecystectomy on patients with SIT are discussed, along with various solutions. We examine approaches presented by others and discuss their benefits and difficulties. Conclusion: By adhering to the basic principles of laparoscopic cholecystectomy, patients with SIT should not be at increased risk of adverse outcome. Laparoscopic cholecystectomy should remain the standard treatment for biliary colic or cholecystitis in patients with SIT. Left-handed dissection is both feasible and safe, and offers familiarity to a situation that few surgeons have encountered.

Aims: The laparoscopic technique is the gold standard approach to cholelithiasis. Diagnosis and treatment of concomitant common bile duct stones (10–15%) is still a motif of debate. The aim of this work is to show how to improve safety and efficacy, saving money and time, combining laparoscopic techniques with endoscopic methods in a single diagnostic and therapeutic act. Methods: 1997–2010: 1748 video-laparo-cholecystectomy (VLC) and 187 contemporary treatment of bile duct stones. Clinical, hematological and echographic (USS) data are the specific pre-operative work-up. Operative strategy: intra-operative cholangiography (IOC) is performed in any suspicious case; bile duct stones are managed by transcystic, endoscopic, laparoscopic or endo-laparoscopic approach. Results: In all cases we achieved clearance of the bile duct with no complications or mortality (post-operatory 2.5 days). In this period we have had a fatal pancreatitis following a wirsungraphy during a non guided cannulation of the papilla. Pre-operative USS and IOC are the most reliable and chip techniques. Efficacy and safety are achieved by coupling endo-laparoscopic technique to avoid risky staged and often unnecessary endoscopic procedures with diagnostic and therapeutic means. Post endoscopic cholangiopancreatography (ERCP) and/or papillotomy (PT) pancreatitis is the most dangerous complication avoided with a procedure accomplished over a trans-papillary guide inserted laparoscopically: intra-operative cholangioscopy is addressed to highly selected patients. Contemporary laparoscopic and endoscopic maneuvers enabled the best clearance and drainage through the papillotomy whenever necessary; in selected case we positioned a naso-biliary drain. We do not use external drain of the bile duct avoiding all the specific, significant related complications. Conclusions: Endo-laparoscopic treatment combined and integrated in one step, permits us to best utilize advanced techniques and technologies. One step procedure saves time, costs and avoids over-treatments. The endoscopic surgeon is the modern surgeon according to the new endoluminal solutions, perspectives and techniques, rationally integrating endoscopic and surgical potentialities. In our country diagnostic and operative endoscopic procedures are mainly demanded to gastroenterologists and there are few expert surgeons in endoscopy: maybe this could explain different approaches to these rational treatment.

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V074 - Video - Morbid Obesity

V076 - Video - Morbid Obesity

LAPAROSCOPIC TRANS GASTRIC REMOVAL OF GASTRO ESOPHAGEAL STENT M.K.H. Hussein American University of Beirut - Medical Center, BEIRUT, Lebanon

LAPAROSCOPIC REDO ROUX-EN-Y GASTRIC BYPASS M.K.H. Hussein American University of Beirut - Medical Center, BEIRUT, Lebanon

This video will show the various steps used for the removal of Gastro esophageal stent done for the treatment of leak post Laparoscopic Sleeve Gastrectomy that was failed to be removed by Endoscopic approach. Though 4 trocars release of adhesion, the stomach was entered at the anterior site and the stent was removed and 2 layers of 2-0 prolene suture used to suture the gastrotomy. Conclusion: Laparoscopic and Endoscopic Complications can be handled successfully by Laparoscopy with low morbidity.

Redo Bariatric Surgery is a complicated procedure, which entail increased morbidity and the high conversion rate to open surgery. This video demonstrates the steps done in a 30 years old lady a known case of Morbid obesity BMI 46 treated previously with Laparoscopic Gastric Band complicated with sleepage, treated by removal followed later by Laparoscopic Gastric Bypass roux-en-y. She presented 1 year later with added weight of 20 kg, and foul smelling stool. Patient had a long alimentary limb 230 cm as reported by her surgeon. Gastrografin swallow revealed Gastro Gastric Fistula. The technical details involve the steps followed to release the adhesions. Identification of the Gastrojejunostomy, identification of the Gastro Gastric Fistula, and division of the fistula with reduction of the pouch using Endo GIA 60 mm, green cartilage, and reanastomosis of the jejunostomy at 150 cm. Patient had smooth postoperative course. Conclusion: Redo Bariatric Surgery can be done safely in Advanced Bariatric Centers.

V075 - Video - Morbid Obesity

V077 - Video - Morbid Obesity

THE LAPAROSCOPIC GREATER CURVATURE PLICATION - A NON COMPLICATION BARIATRIC PROCEDURE? C. Copaescu, D. Andrei, G. Eftimie, D. Godoroja St John Hospital, BUCHAREST, Romania

LAPAROSCOPIC MANAGEMENT OF SLEEVE GASTRECTOMY COMPLICATIONS A. Keidar, A. Chalaileh, S. Abu Gazala Hadassah Hebrew University Hospital, JERUSALEM, Israel

Background: The Laparoscopic Greater Curvature Plication (LGCP) was recently launched as a promising bariatric procedure, presented as a safer and cheaper operation comparing to gastric sleeve resection. Aim: To present the operative technique and the mechanisms of complication occurrence associated with LGCP for morbidly obese patients in our experience (25 pts). Methods: A prospective analysis of the initial 25 patients who underwent LGCP was performed. The first case was operated in July 2010 and the study endpoints included particular technical aspects, but also the operative time, the complication rates, the hospital length of stay, the postoperative evolution of comorbidities and percentage of EWL. The stomach is dissected on the left border, as in the sleeve gastrectomy, and then the greater curvature is invaginated using double continuous rows of nonabsorbable suture over a 36 Fr bougie. Results: There were 16 women and 4 men with a mean age of 42 years (range 32–49). Mean preoperative body mass index of 42.1 kg/m2 (range 32.6–48.6 kg/m2). Mean operative time was 95 min (55–130 min). No patient required conversion. There were no postoperative deaths. There were 4 postoperative laparoscopic explorations for peritonitis due to esophageal fistula (1 pt) and due to a gastric fistula (3 pts). In these video there are presented the possible different mechanisms of producing the postoperative complications associated with our LGCP experience. Also we present our attitude in those particular situations. Conclusions: LGCP can be safely integrated into a bariatric program with good short results in terms of weight loss and co-morbidities but cannot be considered a simple and ‘no complications associated’ procedure. Adequate surgical technique and medical management is required.

Laparoscopic Sleeve Gastrectomy is a commonly performed bariatric operation around the world. Since introduced initially as a first step towards Duodenal Switch, it has grown in popularity as a standalone bariatric procedure. Even though this operation has a low incidence of morbidity and mortality, several complications have been reported intraoperatively and postoperatively, mainly stapler line leakage, bleeding, stapler related technical failure. Management of these complications has been very challenging, especially if performed laparoscopically. We present video compilation of laparoscopic management of different complications during and after sleeve gastrectomy. This includes intraoperative management of bleeding in two patients, management of disrupted stapler line and stapler malfunction in two patients, management of postoperative gastric stapler line leak postoperative day one after surgery in one patient, and management of accidental transection and stapling of thermometer probe. Conclusion: laparoscopic management of sleeve gastrectomy complications is feasible and safe, and requires advanced laparoscopic skills.

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V078 - Video - Morbid Obesity

V080 - Video - Morbid Obesity

POST-TRAUMATIC INTRA-PERICARDIAL DIAPHRAGMATIC HERNIA REPAIR DURING SLEEVE GASTRECTOMY E. Baldini, S. Albertario, C. Grassi, P. Capelli Ospedale ‘G. da Saliceto’, PIACENZA, Italy

SURGICAL MANAGEMENT OF MORBID OBESITY BY LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS M.K.H. Hussein American University of Beirut - Medical Center, BEIRUT, Lebanon

This video shows the technique of a laparoscopic repair of an intra-pericardial posttraumatic diaphragmatic hernia, occasionally found during a sleeve gastrectomy for morbid obesity. The patient was a 52 years old male, affected by morbid obesity; he was operated of laparoscopic cholecystectomy 10 years before and he had a car accident with multiple ribs and pelvis fractures 4 years before. After pneumoperitoneum, four trocars were positioned. A diaphragmatic hernia (about 8 cm in diameter) was discovered, in the left portion of the phrenic center. The great omentum herniated into the thorax was reduced in the abdomen; this made it possible to show a direct communication between pericardial and peritoneal cavity. It was not possible to directly repair the hernia because of the rigidity of the diaphragm, so we performed a prosthetic repair by a Dual-mesh Gore-Tex prosthesis, fixed to the diaphragm by Endo-hernia agraphes. The operation was continued by performing the sleeve gastrectomy. The post-operative period was uneventful. About 1 year after surgery the patient is well and asymptomatic. We considered this diaphragmatic hernia as an acquired post-traumatic laceration because of the medical history regarding a previous severe trauma, and because during a laparoscopic intervention performed before the trauma (cholecystectomy), the lesion was not observed. The Literature describes 86 cases of intrapericardial hernia. About half of the cases were diagnosed at a distance from trauma, as occasional finding or after the onset of symptoms such as wheezing, chest or abdominal pain, cardiac tamponade. The radiological diagnosis is reached by a simple chest x-ray, CT or echocardiography. Regardless of symptoms, intrapericardial hernia should always be repaired. The method of repair is still not clearly defined. Some authors recommended an abdominal approach for acute wounds, for the obvious need to assess and treat possible further abdominal injuries, while a chest approach for chronic wounds in order to better manage any adhesions between herniated viscera and heart or pericardium. Others Authors have demonstrated the feasibility of a laparoscopic approach, for both acute and chronic wounds, because often there are no adhesions with thoracic structures.

The current gold standard for the surgical management of Morbid Obesity is the Laparoscopic Roux-En-Y Gastric Bypass. A total of 327 patients with morbid obesity with average BMI 46, underwent Laparoscopic Gastric Bypass over a period of 14 months. Age range 17–72 years, Male to Female ratio 1:2. All patients were done laparoscopically via 5 trocars with refinement of the technique. The procedure can be performed in 55 min. The Video demonstrates the potential to reduce steps, facilitate stapling, closure of defects and avoid anatomical confusion. The morbidity is 4% including 4 leaks, 3 internal hernias, 2 bleeding and 2 jejunojejunal stenosis and 3 abdominal wall hernias. All treated laparoscopically. Refinement of the technique by the use of 2 Endo GIA 60 mm side-to-side anastomosis resulted in zero incidence of jejunojejunal stenosis in the last 100 cases. Two mortality one due to massive pulmonary embolus and a second due to sepsis. Mean excess weight Loss of 3 months is 45%, 6 months 58%, 1 year is 72%, and 2 years is 70%. Therefore, Laparoscopic Gastric Bypass is effective, safe with excellent weight loss and low morbidity and mortality, minimal discomfort and early return to normal activity.

V079 - Video - Morbid Obesity

V081 - Video - Morbid Obesity

FAILURE OF ROUX-EN-Y GASTRIC BYPASS: WHAT NOW? D. Van Der Fraenen, T. Sablon, M. De Visschere, F. Akin, B. Dillemans AZ Sint Jan, BRUGGE, Belgium

LAPAROSCOPIC CONVERSION OF NISSEN FUNDOPLICATION TO ROUX-EN-Y GASTRIC BYPASS IN MORBID OBESITY PATIENTS. M.K.H. Hussein American University of Beirut - Medical Center, BEIRUT, Lebanon

Aims: As bariatric surgery is gaining interest throughout the globe, the number of redo bariatric interventions, mostly conversions from adjustable banding to Roux-en-Y gastric bypass (RYGB), are growing equally. Even RYGB might not always accomplish sufficient weight-loss, keeping in mind a 15% failure rate (excessive weight-loss less than 50%) after primary RYGB for the superobese. Other patients have an important weight regain years after RYGB. Revisional surgery after failed RYGB poses multiple problems. First of all, it takes a lot of expertise detecting the cause of the failure. Is it dietary related or does it concern a technical deficit? This presentation clearly shows the importance of pre-operative technical investigations. Methods: In this video presentation, we report the case of a 28 year old female who underwent a conversion from a adjustable gastric banding to an open RNY gastric bypass procedure according to Capella for morbid obesity. The preoperative BMI was 35.2 kg/m2. After initial weight loss she had an important regain to a BMI of 34.4 with dysphagia and vomiting. After performing a Barium swallow showing an important pouch-dilatation with stenosis at the neo-pylorus, a laparoscopic pouch reconstruction with lengthening of the alimentary limb was performed. Results: Operative time was 68 min. There was no significant intra-operative blood loss. Patient received prophylactic antibiotics (Cefazolin 4 9 1 g during 24 h). There were no early post-operative complications. Patient was able to leave the hospital after 4 days. Two months after surgery patient has no complaints of dysphagia or vomiting. The BMI at that time was 31.1. Conclusion: This video presentation shows the importance of a decent performed barium swallow in the decision-making process in the case of important weight regain after RYGB. Laparoscopic adjustment of a gastric bypass is a technically feasible and safe procedure even after former open interventions. It is however clear that this technique can only be performed by well trained bariatric surgeons.

The video will demonstrate the various steps that are used in a patient with previous Laparoscopic Nissen Fundoplication done for Gastro esophageal reflux to Roux en y Laparoscopic Gastric to treat her morbid obesity. The technique demonstrate the use of 5 trocars, release of adhesion, and unfolding of the 360 wrap of the fundus followed by partial gastric resection due to Gastric perforation during release of adhesion and creation of small pouch. Patient had smooth postoperative course with no complication. Conclusion: Laparoscopic Conversion of Nissen Fundoplication is feasible in advanced centers is Bariatric surgery without compromising the principle of small pouch creation.

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V082 - Video - Morbid Obesity

V084 - Video - Morbid Obesity

LAPAROSCOPIC ROUX-EN-Y GASTRO-JEJUNOSTOMY FOR STENOSIS AFTER SLEEVE GASTRECTOMY WITH DUODENAL SWITCH S. Abu-Gazala, M. Abu-Gazala, C. Schweiger, A. Keidar Hadassah Hebrew University Medical Center, JERUSALEM, Israel

CONVERSION OF OPEN MAISSON TECHNIQUE TO LAPAROSCOPIC ROUX-EN- Y GASTRIC BYPASS M.K.H. Hussein American University of Beirut - Medical Center, BEIRUT, Lebanon

Background: Sleeve gastrectomy (SG) can be performed either as isolated, or with the malabsorptive procedure of duodenal switch (SG/DS). Among the postoperative complications, stenosis of the SG is relatively rare and only scarcely mentioned in literature. We report a patient presenting a stenosis, previously undergoing endoscopic balloon dilation, and treated by laparoscopic Roux-en-Y gastro-jejunostomy after SG/DS. Methods: A 43 year old healthy patient, undergoing a LSG/DS using a 40Fr. bougie for morbid obesity. His preoperative weight and BMI were 132 kg and 41 kg/m2 respectively. Progressive dysphagia, vomiting and gastro esophageal reflux disease (GERD) symptoms appeared 3 months after the surgery. Barium swallow and gastroscopy showed a functional stenosis at the mid third of the SG. After endoscopic balloon dilatation, only temporary improvement of symptoms was observed. 9 month postoperatively his weight and BMI were 78 kg and 27 kg/m2. Results: The patient underwent a laparoscopic Roux-en-Y gastro-jejunostomy to bypass the stenotic area 9 months after the original surgery. The double layer linear stapled and hand sewn anastomosis was performed at the posterior aspect of the upper third of stomach away from the severe adhesions between the stenotic part of the sleeve and the liver. No transaction of the sleeve was performed. Operative time was 150 min. Post-operatively, the patient developed pneumonia but no other complications. Contrast swallow check at POD 1 demonstrated good passage through the anastomosis. Hospital stay was 7 days. The satisfied patient was able to tolerate a regular diet. Short term result was very favorable. Conclusion: Laparoscopic Roux-en-Y Gastrojejunostomy after SG for stenosis is feasible, and efficient for the treatment of symptomatic dysphagia. Video displaying the surgical technique is presented.

Failed Maisson technique in super obese patients is common due to dehiscence of the stapler line or persistent vomiting secondary to tight stenosis at the ring site. The video will demonstrate the steps followed through 5 trocars insertion to release the adhesions, creation of gastric pouch and Roux en y Gastric Bypass Anastomosis. Therefore, conversion of one Bariatic procedure to other is possible in experienced centers in Morbid Obesity Surgery.

V083 - Video - Morbid Obesity

V085 - Video - Morbid Obesity

LAPAROSCOPIC COLLIS PROCEDURE COMBINED WITH TOUPET FUNDOPLICATION AND GASTRIC BANDING: A REPORT OF 2 CASES E.A. Zorin, V.N. Egiev Medical and Rehabilitation Center, MOSCOW, Russia

SLEEVE GASTRECTOMY PERFORMED THROUGH SINGLE PORT F. Marinello, E. Targarona, C. Balague´, L. Pallares, M. Trı´as Hospital de la Santa Creu i Sant Pau, BARCELONA, Spain

Background: the prevalence of symptomatic hiatal hernias in obese population may reach 40%. In patients with shortened oesophagus laparoscopic Collis gastroplasty combined with fundoplication is commonly indicated. We report 2 cases of laparoscopic Collis procedure combined with Toupet fundoplication and gastric banding in obese patients with symptomatic shortened oesophagus. Methods: 2 male patients of 42 and 38 years old were admitted to our Surgical Department because of excessive weight, with BMI (Body Mass Index) of 33 and 38 kg/m2, respectively. They also reported severe heartburn refractory to medical treatment. Pre-op evaluation revealed giant non-reducible hiatal hernias, complicated with oesophagitis and shortened oesophagus. Laparoscopic Collis gastroplasty alongside with Toupet fundoplication, hiatal mesh closure and adjustable gastric banding were performed. Mesh was used because of huge crural defects about 7 cm in diameter. Results: Operative time has been 75 and 65 min, respectively. No intra- or post-operative complications occurred. Length of hospital stay was 2 days in both cases. At 1 and 2 year follow-up examinations patients reported no dysphagia or heartburn. Barium swallow revealed no hernia recurrence. The percentage of EWL (Excess Weight Loss) at 1 year follow up was 108 and 105%, at 2 year exam 96 and 102%, respectively. Conclusion: simultaneous laparoscopic Collis gastroplasty, Toupet fundoplication and gastric banding may present an acceptable option in obese patients with giant hiatal hernias. The bariatric procedure might improve patients’ quality of life and decrease the risk of hernia recurrence. In our opinion this opportunity justifies further investigation.

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Aim: The continuous progress in minimally invasive surgery has reached to the use of single-port devices. We present a video of a Sleeve Gastrectomy (SG) using this technology. Methods: A 42 years old obese female patient with a Body Mass Index of 40 kg/m2 was admitted for a SG. A single port device was introduced through a 3 cm epigastric incision, between the xifoid appendix and the umbilicus. A 30 degrees laparoscope, a grasper and a harmonic scalpel (UltracisionÒ) were placed through the single port. The dissection started with the release of the gastric greater curvature and upto 2–3 centimeters of the pylorus. After placing a 36F orogastric tube, the sleeve was performed using mechanic suture (Echelon 60Ò) with the assistance of a support device placed on a 2 mm trocar from the left from the left upper quadrant (EndograbÒ). Once finished the section of the stomach, it was extracted through the single-port. The incision was closed with an intraperitoneal mesh. Results: No incidences occurred. The patient was discharged 48 h after surgery. Conclusion: The use of single port devices is feasible and secure in SG.

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V086 - Video - Morbid Obesity

V089

LAPAROSCOPIC SLEEVE GASTRECTOMY STATE OF THE ART TECHNIQUE M.K.H. Hussein American University of Beirut - Medical Center, BEIRUT, Lebanon

THORACOSCOPIC ENUCLEATION OF A LEIOMYOMA OF THE MID-ESOPHAGUS WITH THE PATIENT IN PRONE POSITION C. Staudacher, E. Orsenigo, P. Gazzetta University Vita-Salute San Raffaele, MILAN, Italy

Through 4 trocars in the different quadrants of the abdomen and the patient placed in semi sitting position and the surgeon is between the legs of the patient. The first step is to create a window in the lessen sac 6 cm from the pylorus at the greater curvature. The stomach resection is done after introduction of 36 French catheter using 3 cartilage of Endo GIA Green 60 mm cartilage until the fundus where another 3 cartilage of Endo GIA blue 60 mm cartilage used to complete the Gastric resection till the angle of HIS which is dissected retrogastric. The suture line was reinforced by a continuous layer of 2-0 prolene suture and using the methylene blue test for detection of leak. The last step is the division of the gastric omentum from the resected stomach using ligasure and the resected gastric segment is removed from one of the trocars after extension of the incision to 2 cm. The first fifty cases done by this technique had zero mortality and zero morbidity and 90% of the cases discharged with 24 h. The whole procedure took less than 50 min. The excess weight loss in 1 year is 70%. Therefore, this new technique preserves the blood supply to the remaining stomach and prevents tension at the suture line with no mortality, no morbidity, minimal discomfort and early return to normal activities.

V088 - Video - Morbid Obesity IS THE LAPAROSCOPIC APPROACH AN OPTION IN THE MANAGEMENT OF SMALL BOWEL OBSTRUCTION AFTER BARIATRIC SURGERY? M. Socas-Macias1, S. Morales Conde1, A. Barranco Moreno1, C. Mendez1, M.D. Casado1, I. Alarcon del Agua1, G. Sciannamea2, V. Gomez1, H. Cadet1, J. Padillo Ruiz1 1 Hospital Universitario Virgen del Rocio, SEVILLE, Spain. 2H, BOLONIA, Italy Introduction: The laparoscopic approach has improved the results of bariatric surgery however when a reintervention is needed, in nearly all cases a laparotomy is performed. Objective: The aim of this video is to show how the laparoscopic approach is a safe and effective alternative in the management of small bowel obstruction (SBO) in both the early and late postoperative period after gastric bypass. Case 1: SBO in the early postoperative period. 45 years old woman, BMI 46. Three days after performing a gastric bypass she suffered from biliary vomits, without any other symptomatology. CT-Scan showed a dilatation of both the biliary and the alimentary limb, without signs of ischemia, suspecting a kinking of jejunojejunal anastomosis. After 24 h of conservative management with nasogastric tube, we performed an exploratory laparoscopy, which confirmed the diagnosis and allowed us to solve the problem with a minimum adhesiolysis and a posterior fixation of the common limb to avoid kinking. Case 2: SBO in the late postoperative period. 39 years old woman who had undergone a gastric bypass one year before, with a loss of 50 kg. She had been suffering from abdominal pain in the left hypochondrium for two months, without any other symptomatology. The pain became unbearable in the last 8 h, reason why she came to the hospital. The CT-Scan showed an anomaly in the distribution of the small bowel, placed in the left hypochondrium with a twisted mesenterium, but without signs of ischemia. With the diagnosis of a Petersen’s internal hernia, we performed an exploratory laparoscopy which confirmed the diagnosis, and allowed us to reduce the herniated bowel with a posterior closure of the gap with a non absorbable suture. Results: Both patients were discharged one week after surgery. Conclusion: The laparoscopic management of small bowel obstruction after bariatric surgery is possible, both in the early and late postoperative period. It is essential to have a high rate of suspicion to obtain a successful result, avoiding an important bowel distention which could difficult the laparoscopic management and minimizing the risk of bowel ischemia which could lead to a bowel resection.

Background: Leiomyoma is the most common benign esophageal neoplasm. Different open and minimally invasive approaches have been described. We describe a right thoracoscopic enucleation with the patient in the prone position. Method: A 47-year-old woman consulted us about solid-diet dysphagia without other symptoms. Preoperative work-up showed the presence of 50 9 28-mm leiomyoma of the middle esophagus, without satellite lymph nodes. The patient underwent general anesthesia with a double-lumen endotracheal tube, and subsequently was placed in the prone position. A 30 degrees scope was introduced in the right 7th intercostal space on the posterior axillary line. Two 5-mm trocars were inserted in the right 5th and 9th intercostal spaces on one line with the first one. The operative field was well exposed and the lesion was enucleated without mucosal perforation. A drain was left in the chest cavity. Results: Total operative time was 120 min and blood loss was less than 30 ml. The gastrografin swallow on postoperative day 4 showed good clearance of the esophagus and absence of leak, hence the patient was allowed a liquid diet. Benign pathology was confirmed. Conclusion: Thoracoscopy in the prone position permits the surgeon to reach the esophagus under excellent working conditions, despite an only partially deflated lung. Gravity displaces blood loss eventually, which allows good visualization, and the surgeon can operate in an ergonomic position. This approach allows for fewer trocars which favorably influences the patient’s comfort.

V090 - Video - Oesophageal and Oesophagogastric Junction Disorder THORACOSCOPIC EXCISION OF ESOPHAGEAL LEIOMYOMA IN PRONE POSITION A. Antequera, C. Nevado, D. Acin, L. Carrion, P. Lopez Fernandez, F. Pereira Hospital de Fuenlabrada, FUENLABRADA, Spain Background: Bening tumors of the esophagus are rare lesions that constitute less than 10% of esophageal neoplasms. Leiomyoma accounts for 70% of all benign tumors of the esophagus. open enucleation via thoracotomy has long been the standard procedure, but thoracoscopic and laparoscopic approaches have emerged as procedures of choice. To date, only case reports or very small series of such techniques have been reported. Patients and methods: We describe a patient with esophageal leiomyoma who underwent surgical resection via thoracoscopic approach using a right thoracoscopy in prone position. The patient presented with dysphagia. An upper gastrointestinal endoscopy showed midesophageal narrowing without mucosal irregularity. Perioperative thoraco-abdominal ct showed a 6 9 4.6 mm mass of the middle esophagus. Eus found a submucosal mass and allowed to take a biopsy which was suggestive of leiomyoma. The patient underwent general anesthesia with a double-lumen endotracheal tube, and subsequently was placed in the prone position. A 30° 10 mm scope was introduced in the right 7th intercostal space on the posterior axillary line. The lesion was located bellow the azygos vein. Two 5-mm trocars were inserted in the right 5th and 9th intercostal spaces aligned with the first one. The azygos vein was preserved. The muscular layer of the midesophagus was opened by coagulating hook and harmonic scalpel. The lesion was enucleated without mucosal perforation assessed by postoperative endoscopy. The muscular layer was closed by running 3/0 MonocrylÒ suture. A drain was placed in the chest cavity. The GastrografinÒ swallow on post- operative day 2 showed absence of leak, hence the patient was allowed a liquid diet the postoperative period was uneventful and the patient was discharged on postoperative day 3. Conclusion: Thoracoscopy in the prone position allows a very good esophagus exposure and the surgeon can operate in an ergonomic position. This approach allows the use of fewer trocars and the blood, thanks to the gravity, doesn’t tend to accumulate in the surgical field. Peroperative use of upper endoscopy is not only helpful to locate the lesion but even more to assess the integrity of the esophageal mucosa after the tumor resection.

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V091 - Video - Oesophageal and Oesophagogastric Junction Disorder

V093 - Video - Oesophageal and Oesophagogastric Junction Disorder

LAPAROSCOPIC REMOVAL OF ANGELCHIK PROSTHESIS FOLLOWED BY NISSEN’S FUNDOPLICATION; A TALE OF AN OLD APPLIANCE’S REPLACEMENT BY CONTEMPORARY SURGERY P.I. Mekhail1, O. Jalil2, A. Hassn2, P. Morcous2 1 Aintree University Hospital, LIVERPOOL, United Kingdom. 2 Princess of Wales Hospital, BRIDGEND, United Kingdom

LAPAROSCOPIC MANAGEMENT OF ACUTE PARAESOPHAGEAL HERNIA S. Abu-Gazala, M. Abu-Gazala, M. Faroja, A. Khalaileh, R. Elazary, G. Almogy, A. Rivkind, Y. Mintz Hadassah Hebrew University Medical Center, JERUSALEM, Israel

Aim and Background: Angelchik is a silicone gel-filled prosthesis that was historically placed around the gastroesophageal junction (GOJ) like a horse’s halter for the treatment of gastro-oesophageal reflux disease (GORD). It was first described by Angelchik and Cohen in 1979 following which its usage expanded due to its simplicity and ease of insertion by open surgery. However, the use of this device has largely been abandoned due to numerous complications and a consequent high removal rate. The most common complications cited have been dysphagia, disruption, migration and erosion into the stomach. Whilst many reports of Angelchik prosthesis removal have appeared in the literature, we present the first case of laparoscopic removal of this device which has been inserted 25 years ago, followed immediately by laparoscopic Nissen fundoplication. The main indication for operation was recurrent severe reflux symptoms refractory to medical treatment. Method: Case note review and literature search. Results: There was no intraoperative or post operative complication although the procedure was extremely challenging laparoscopically primarily due to attenuated anatomy and dense adhesions. The patient made an uneventful recovery with subsequent complete resolution of his symptoms. Conclusion: Patients who have severe recurrent GORD symptoms refractory to medical treatment after placement of an Angelchik prosthesis can be successfully treated by laparoscopic removal of the device followed by Nissen fundoplication.

Background: Acute paraesophageal hernia is a surgical emergency presenting with sudden chest or abdominal pain, dysphagia, vomiting, retching or significant anemia. Severe cases can present with respiratory failure or systemic sepsis. This can be due to gastric volvulus, incarceration, strangulation, severe bleeding or perforation. Traditionally this has been treated by laparotomy. We hereby present our experience in five consecutive cases treated by laparoscopy. Methods: A retrospective chart review was performed for patients operated for acute paraesophageal hernia at our institution from 2008 to 2010. Patients admitted with acute symptoms who underwent emergency laparoscopic surgery were included in the study Results: Six patients were identified. One patient was treated by open surgery and five patients underwent successful laparoscopic repair including reduction of the hernia content, excision of the sac, crural closure, and fundoplication.. Diagnosis of all patients was made following high index of suspicion and upper GI series. One patient had necrotic omentum within the incarcerated sac, and one patient had ischemia of the proximal stomach. Mean operating time was 221 min, blood loss was minimal, and mean postoperative hospital stay was 5.7 days. There were no significant perioperative complications. One patient developed post operative fever and a mediastinal seroma which resolved spontaneously. All patients were tolerating regular diet on short-term follow-up. Conclusion: Laparoscopic repair of acute paraesophageal hernia is safe and feasible with low morbidity. It offers all the benefits of minimally invasive surgery without adding risks of damaging the incarcerated organs. Based on our experience, we advocate the laparoscopic technique to repair acute paraesophageal hernias in patients with no obvious perforation or necrosis.

V092 - Video - Oesophageal and Oesophagogastric Junction Disorder

V094 - Video - Oesophageal and Oesophagogastric Junction Disorder

THORACOSCOPIC MANAGEMENT OF MID-ESOPHAGEAL DIVERTICULA: USE OF THE PRONE PATIENT POSITION C. Staudacher, E. Orsenigo, P. Gazzetta University Vita-Salute San Raffaele, MILAN, Italy

THE MECHANISMS OF LEAK PRODUCING AFTER LAPAROSCOPIC SLEEVE GASTRECTOMY C. Copaescu, D. Andrei, G. Eftimie, D. Godoroja St John Hospital, BUCHAREST, Romania

Background: Mid-esophageal diverticula are rare conditions; underlying disorders may be present in case of diverticula. Traditionally, thoracotomy was the preferred route to approach these lesions. Now, more surgeons are using minimally invasive techniques to treat these benign mid-esophageal lesions. Patients and Methods: We present a case of an 86 years old female referred to our surgical department for persistent dysphagia to solid food and weight loss (8 kg in 2 months). She had a good performance status and no past medical history. Our physical evaluation detected severe malnutrition, skin and mucosal dehydration. Blood examination detected moderate hypoalbuminemia, reduction of cholinesterase and retinol binding protein. To evaluate dysphagia, we performed an esophageal endoscopy that revealed the presence of a thoracic diverticulum of 3 cm of the mid-esophagus. No mucosal abnormality was detected. No mediastinal space occupying mass was detected at thoracic CT-scan. An esophageal manometry diagnosed an aspecific esophageal motility disorder (20% of peristaltic contractions were not normally and completely conducted). Systemic and neurologic disorders were excluded (Parkinson disease, myositis, myasthenia, and thyrotoxicosis). The patient was treated with temporary naso-jejunal enteral feeding. After three weeks of enteral feeding and normalization of nutritional markers, surgical treatment was indicated. A thoracoscopic diverticulectomy with prone patient and right access was performed. Thoracic diverticulum was dissected and stapled; muscular layer was sutured with single readsorbable stitches upon endoscopic calibration. Results: the post-operative course was uneventful. Conclusion: In this video, we highlight the use of the prone patient position, the advantages of a right thoracoscopic approach and the value of peroperative endoscopy.

Introduction: Laparoscopic sleeve gastrectomy (LSG) is an increasingly used bariatric surgical procedure. Beside its metabolic efficiency the complications’ rate (especially leaks) is still high, limiting its application. The mechanisms of leak producing are on a worldwide debate. Our experience in LSG is over 1200 pts, the leak rate is low (0.58%) and we have zero mortality but we are very preoccupied by the causes of fistula producing. Method: In this video we present our leak complications after LSG. We have recorded 7 different types of possible mechanisms involved in leaks after LSG. As all the LSG operations were recorded, every situation was analyzed in details, by watching all these videos. Among the causes of leaks identified and presented in this video are: stapled line gap, electric lesions, stapling the esophagus, intra-mediastinal strangulation of the upper part of the sleeve associated with hiatal hernia repair, ischemia produced by ML haemostatic titanium clips or LSG after gastric banding. For all these cases we present our attitude. The conclusions were very important for our team adjusting continuously our surgical technique. Conclusion: LSG is a safe procedure with low morbidity if the complications are prevented or treated in a proper way. The leaks causes may be understood very well and the surgical technique should take into consideration any possibility of preventing the postoperative complications.

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V095 - Video - Oesophageal and Oesophagogastric Junction Disorder

V097 - Video - Oesophageal and Oesophagogastric Junction Disorder

MINIMIZING AGGRESSION DURING ANTIREFLUX SURGERY: MINI-LAPAROSCOPIC NISSEN FUNDOPLICATION WITH 3 TROCARS S. Morales-Conde, A. Barranco, M. Socas, I. Alarco´n, M.D. Casado, D. Bernal, V. Gomez, H. Cadet, J. Padillo Hospital Universitario Virgen del Rocio, SEVILLE, Spain

NON-ELECTROSURGICAL MYOTOMY TECHNIQUE IN LAPAROSCOPIC HELLER-DOR OPERATION FOR OESOPHAGEAL ACHALASIA M. Sajid, H. Qandeel, Z. Hanif, L.K.P. Velu, S. Dayal, S. Mahmud Hairmyres Hospital, GLASGOW, United Kingdom

Introduction: Recently, single incision laparoscopic surgery has became a natural step towards an even more minimally invasive surgery. This surgery has became a good indication in those cases in which it is necessary to remove a specimen, being under discussion the role of single port surgery when a specimen it is not necessary to be removed. For that reason, antireflux surgery is perhaps a good indication for minilaparoscopy together with the idea of reducing the numbers and the size of the trocars. Patients and Methods: We present a case of a patient diagnosed of gastro-esophageal disease with a hiatal hernia less than 3 cm, proposed for antireflux surgery after the different functional studies. The procedure is performed with 3 trocars, one 3 mm trocar, for the left hand of the surgeon, and two 5 mm trocars, one for a 5 mm 30° scope, and one for the right hand of the surgeon. A suture is used to retract the liver. Surgery is performed in 35 min following the basic principles of antireflux surgery with short gastric vessel division. To introduce properly the needle into the abdominal cavity it is necessary to use a 3 mm instrument introduced through the 5 mm trocar. Patient was discharged next day with no stitches at the skin and the postoperative period was similar to standard laparoscopic Nissen fundoplication. Conclusion: Single Port surgery continues being used in different fields with similar results of laparoscopic surgery, but with better cosmetic results and a potential reduction of pain. Surgeries, in which a specimen it is not necessary to be removed, is still under discussion, being our goal in these case to reduce the number and the size of trocars, being mini-laparoscopy a good indication for this procedure. We have standardized the use of mini-laparoscopy with 3 trocars in certain indications of patients suffering of gastro-esophageal disease.

V096 - Video - Oesophageal and Oesophagogastric Junction Disorder LAPAROSCOPIC REPAIR OF GIANT PARAOESOPHAGEAL HERNIA- OUR TECHNIQUE A.K. Shrestha, S. Basu William Harvey Hospital, TWICKENHAM, LONDON, United Kingdom We present a short video of our technique of laparoscopic repair of giant paraoesophageal hernia with biological mesh. This was done in 67 years old lady who presented with dysphagia due to large paraoesophageal hernia confirmed by endoscopy, barium swallow and CT scan. The mesh used is made out of bovine pericardium where we make a TENNIS RACKET incision.

Background: Laparoscopic Heller’s Myotomy (HM) for Achalasia is technically a challenging operation. During myotomy there is bleeding from the cut edges of the oesophageal muscles which obscure the plane between the muscles and oesophageal mucosa. Most of surgeons use diathermy, ligasure or harmonic device to perform myotomy. These all devises generate the heat and cause lateral damage which is not visible at the time of surgery and can lead to delayed perforation of oesophageal mucosa. Aim: Our aim of video presentation is show our experience of HM without use of any electrosurgical device. Method: The port placement is similar as used in Nissan Fundoplication, the video shows that we have used the curved blunt instruments to split the oesophageal muscles and create a plane between the oesophageal muscles and the mucosa and then use endo-shears with out the use of any electrosurgical device. There is always bleeding from the cut edges of the myotomy which is stopped by placing a small swab and pressure without any lateral latent damage of the mucosa. Results: We have performed 13 cases of laparoscopic Heller’s myotomy with this technique with no complication. 6 males and 7 females. Age range (17–75 years); follow up range (4–27 months). Only two patients had mild reflux treated with PPIs successfully. Conclusion: Non-electrosurgical myotomy technique is a feasible and safe technique for Laparoscopic Heller-Dor Myotomy.

V098 - Video - Oesophageal Malignancies A CASE OF LAPAROSCOPIC PROXIMAL GASTRECTOMY WITH TRANSHIATAL RESECTION OF THE DISTAL ESOPHAGUS IN A PATIENT WITH ESOPHAGOGASTRIC JUNCTION CANCER G. Kiguchi, T. Ito, T. Tanaka, T. Nishikawa, T. Soma, Y. Hattori, M. Sugano Sugita Genpaku Memorial Obama Municipal Hospital, OBAMA, Japan Background: Adenocarcinoma of esophagogastric junction shows worldwide an increasing incidence. The optimal approach to resection is still controversial. One of the major disadvantages of radical esophagectomy with open technique is its high rate of morbidity and mortality. Recent advances in minimally invasive surgical technology have allowed surgeons to apply laparoscopy with only abdominal approach to perform resection of the advanced esophagogastric cancer. Patient and Methods: In the video we report the case of a 73 years old man with Siewert? Advanced adenocarcinoma of esophagogastric junction, who was submitted to a minimally invasive proximal gastrectomy with transhiatal resection of the distal esophagus by laparoscopy. The patient was admitted to our hospital with complaints of epigastric pain. Preoperative endoscopy showed an advanced esophagogastric cancer that had invaded the lower esophagus within 2 cm from esophagogastric junction. A biopsy specimen revealed a moderately differentiated adenocarcinoma. Abdominal computed tomography (CT) showed a marked thickening of the wall of the proximal stomach wall. Enlarged lymph nodes were present only around the lesser curvature. The patient was then taken to the operating room. Five ports were used for the abdominal approach. A complete mobilization of the stomach preserving the right gastroepiploic arcade was achieved. The distal esophagus was resected with the autosuture device after splitting of the esophageal hiatus widely and getting a good access to the lower esophagus and lower posterior mediastinum. Lymph nodes of paracardial region, lesser curvatures, left gastric artery towards celiac axis, splenic artery, superior border of the pancreas towards the splenic hilum, and lower posterior mediastinum were also removed. After extraction of the specimen through a small abdominal incision, the stomach was pulled up to the distal esophageal stump, and esophagogastric anastomosis with the double stapling technique was constructed with transhiatal approach. The patient was discharged uneventfully on postoperative day 20. Eleven metastatic lymph nodes/thirty five regional lymph nodes were found. Pathology showed pT3 pN2 adenocarcinoma with R0 resection. Conclusions: The minimally invasive transhiatal approach to adenocarcinoma of esophagogastric junction is feasible and safe.

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V099 - Video - Oesophageal Malignancies

V101 - Video - Oesophageal Malignancies

ROBOT ASSISTED ESOPHAGECTOMY WITH THREEFIELD LYMPHADENECTOMY W. Petz, P.P. Bianchi, G. Veronesi, D. Belotti, B. Andreoni European Institute of Oncology, MILAN, Italy

LAPAROTHORACOSCOPIC IVOR LEWIS ESOPHAGO-GASTRECTOMY WITH INTRA THORACIC ANASTOMOSIS IN PRONE POSITION C. Palanivelu, P. Senthilnathan, P.S. Rajan, V. Vaithiswa, S. Saravanakumar, R. Rohit GEM Hospital, COIMBATORE, India

Introduction: Minimally invasive esophagectomy has been demonstrated to lessen the biologic impact of surgery and potentially reduce pain and trauma. However to date, few centres have embraced this technique. We report a case of combined transthoracic and transabdominal robotic assisted esophagectomy with cervical esophagogastric anastomosis. Methods: A 75 years old man, was diagnosed with a squamous cell carcinoma of the middle esophagus, 5 cm in length with a single periesophageal lymph node of 15 mm. The patient presented cardiac and respiratory comorbidities including ischemic cardiopathy, peripheral vasculopathy and chronic obstructive bronchopneumopathy. Results: The patient, intubated with a double-lumen endotracheal tube, was positioned in the left lateral decubitus. The right arm was positioned over the ear and the operating table was tilted as far anteriorly as possible so that the patient was almost prone. Five trocars were inserted in the right midanterolateral chest. The chest robotic phase was performed first. The intrathoracic esophagus, periesophageal and paratracheal lymph nodes, and thoracic duct were resected. The patient was then rotated into the supine position and 5 laparoscopic trocars were inserted. The stomach was mobilized and a gastric tube was prepared using multiple fires of a linear endostapler. The gastric tube was sutured to the distal end of the esophagus and a feeding jejunostomy tube was placed. The specimen was removed through a left cervicotomy, bringing the gastric tube to the cervical region through the posterior mediastinum. A cervical esophagogastric anastomosis was completed and the neck wound was drained. The operative time was 7 h, estimated blood loss 300 ml. Conclusions: Minimally invasive robotic assisted esophagectomy is a feasible and safe procedure. A less traumatic approach could extend surgical indications of the esophagectomy to patients with comorbidities that otherwise would be excluded from a surgical treatment.

Introduction: Commonest type of Gastro esophageal junction growth in India is Siewert type III with involvement of the cardia. After resection with adequate margin, the length of the stomach tube might not reach the neck. In such situations Ivor-Lewis Esophago-Gastrectomy with intra thoracic anastomosis is a good alternative. Procedure: Laparoscopically the stomach is mobilized preserving the right gastro-epiploic vessels. Lymph nodes along all named vessels are removed. Greater curvature tube is formed ensuring a distal margin of 5 cm. The esophagus is transected 10 cm proximal to the GE junction. The stomach tube is sutured by loose stitch to the hiatus. The specimen is extracted through a Pfannenstiel incision. Patient is then placed in prone position and through a right thoracoscopic approach, the cut end of the esophagus is further mobilised till the azygos vein. Further 5 cm of the esophagus is cut and removed in a endobag through the 12 mm port site. A side to side esophago gastric anastomosis is performed using endo GIA staplers. Conclusion: Laparothoracoscopic Ivor-Lewis Esophago-gastrectomy is an ideal way to approach junctional tumors with cardia involvement which precludes stomach tube formation up to the neck.

V100 - Video - Oesophageal Malignancies

V103 - Video - Pancreas

LAPAROSCOPIC ESOPHAGO GASTRECTOMY WITH COLONIC INTERPOSITION FOR OG JUNCTION TUMOR C. Palanivelu, P.S. Rajan, P. Senthilnathan, P. Praveen Raj, V. Vaithiswa, R. Sathiyamurthy GEM Hospital, COIMBATORE, India

LAPAROSCOPIC SPLEEN-PRESERVING LEFT PANCREATECTOMY WITH SPLENIC VESSELS PRESERVATION: THE DOUBLE-HANGING MANŒUVRE I. Poves, M.A. Martı´nez-Serrano, S. Salvans, F. Burdı´o, L. Lorente, D. Dorcaratto, L. Grande Hospital del Mar, BARCELONA, Spain

Incidence of adenocarcinoma of esophago-gastric junction is increasing rapidly in India. Some of the lesions involve significant lengths of the lower esophagus and the stomach. Laparoscopic Esophago gastrectomy with colonic interposition is a good surgical option in such patients. Procedure: The procedure includes the following steps: (i) Laparoscopic mobilization of stomach and clearance of hepatic, left gastric and celiac nodes; (ii) laparoscopic mobilisation of the colon; (iii) thoracoscopic mobilisation of the esophagus with removal of mediastinal nodes; (iv) mini laparotomy to extract the specimen and prepare colonic conduit and completion of colo-gastric anastomosis; (v) laparoscopic creation of the substernal tunnel and delivery of the colonic conduit to the neck; (vi) sleeve protective sheath is used for colonic pull up; and (vii) completion of the esophago gastric anastomosis. Conclusion: Laparoscopic Esophago gastrectomy with Colonic interposition using combined thoracoscopic and laparoscopic approach is technically feasible and safe alternative to open approach.

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Introduction: When comparing with open approach, laparoscopic left-sided pancreatectomy (LLP) has been associated with less morbidity (same pancreatic fistula rate) and shorter hospital stay. Management of intraductal papillary mucinous neoplasia (IPMN) is controversial. IPMNs larger than 3 cm and/or symptomatics should be resected because of the risk of becoming malignant. When LLP is done for the treatment of benign or pre-malignant tumours, spleen should be preserved. Higher morbidity and late complications are associated when the spleen is preserved without preserving the splenic vessels (Warshaw technique). Video presentation: A 73-years old woman was diagnosed of having a 35 mm polylobulated cystic tumour in the neck of the pancreas. Citology showed cellular atypia (‘borderline’ IPMN). Intracystic CEA was 3227 ng/ml. In the video are exposed, step by step, all the phases for doing a spleen-preserving LLP preserving the splenic vessels. The gastroduodenal and common hepatic artery were identified. The neck of the pancreas was exposed and dissected. A band was placed wrapping the neck of the pancreas (first hanging maneuver). The inferior border of the pancreas was moved from right to left identifying the splenic vein in all its way. In the union of the body and tail another band was placed wrapping the body of the pancreas (second hanging maneuver). Pulling up both bands at one time (double hanging maneuver), the pancreas could be lift up and splenic vessels (artery and vein) easily spared. The neck of the pancreas was divided with endostapler (2.5 mm cartridge) after all the pancreas was completely moved. The stapled line was reinforced using a running suture (Monocryl 2/0). Cholecystectomy because of cholelithiasis was done. Total operative time was 208 min. The specimen was removed, protected in a bag, through a Pfannenstiel incision. The patient was discharged on 4th postoperative day without complications. Definitive diagnosis was IPMS with three small focus of carcinoma (1.5 mm). All pancreatic margins and removed lymph nodes were negatives. Conclusions: Preserving splenic vessels during a spleen-preserving LLP uses to put surgeons in troubles. The described double hanging maneuver can help and facilitate the procedure.

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V104 - Video - Pancreas

V106 - Video - Pancreas

SINGLE INCISION LAPAROSCOPIC SPLEEN PRESERVING DISTAL PANCREATECTOMY - IS IT FEASIBLE? C. Palanivelu, P. Senthilnathan, P.S. Rajan, S. Rajapandian, P. Praveen Raj, V. Vaithiswa, R. Alwar GEM Hospital, COIMBATORE, India

DISTAL ESPLENO-PANCREATECTOMY FOR CYSTIC PANCREATIC TUMOR ASSOCIATED WITH NEUROENDOCRINE TUMOR F.J. Buils Vilalta, J.J. Sanchez Cano, M. Vives Espelta, E. Raga, J. Prieto Amigo´, E. Baeta Capellera Sant Joan Hospital, REUS. TARRAGONA, Spain

Introduction: As innovation continues to move 21st century surgery forward, one of the emerging concepts is single-port or single-incision laparoscopic surgery. The fundamental idea is to have all of the laparoscopic working ports entering the abdominal wall through the same incision. The major drawback to such a surgical approach is that the concept of ‘triangulation’ to which laparoscopic surgeons have grown accustomed in terms of both the instruments and scope is lacking. This, however, seems to be overshadowed by the increasing acceptability of in-line viewing, with the re-emphasis on surgeons performing flexible endoscopy and on newer ideas such as natural orifice translumenal endoscopic surgery Methods: This video describes the step by step approach of single incision multi port technique using conventional laparoscopic instruments for distal pancreatectomy: Step 1: incision and flap rising; step 2: placement of ports; step 3: opening of gastro colic omentum and exposure of pancreas with suture retraction of stomach; step 4: mobilization of the pancreas, attempt to preserve the splenic artery and vein was made by clipligation of the pancreatic branches of the splenic vessels, then the transection of pancreas was done using harmonic and stump closed with 2-0 PDS sutures; step 5: specimen extraction done in endobag through the same incision. Conclusion: Single port spleen preserving distal pancreatectomy is safe and feasible in experienced hands and can be done with conventional instruments.

Aims: Laparoscopy has been introduced in the surgical management of certain pancreatic diseases. Technological advances and the more experience by surgeons in the laparoscopic approach has allowed the treatment of increasingly complex pathologies. We report a case of laparoscopic approach of a cyst lesion of the pancreas tail. Methods: A 59-year-old woman with allergy to iodinated contrast presented right upper quadrant pain of one month’s evolution. MRI: a 3 9 2 cm in cyst tumor of pancreatic body-tail. USE: confirms the cystic lesion with a solid isoechoic nodular pattern image inside, attached to the wall of 8 9 9 mm in size. The study of liquid: marked elevation of amylase, greatly increased Ca 19.9, with no malignant cells. A laparoscopic distal pancreatectomy with esplenectomy was performed. Results: Operating time was 210 min. The postoperatory was uneventful, oral diet was started on 2nd day and was discharged on 8th day after surgery. Histological result: cystic ductal dilatation, chronic pancreatitis, well-differentiated endocrine tumor with benign behaviour (pT1N0) 5 mm distal to the cyst. Radial resection margins and longitudinal not affected. Conclusion: In this case laparoscopic surgery was feasible with less surgical aggression than open surgery, which allowed a quick recovery.

V105 - Video - Pancreas

V107 - Video - Pancreas

SINGLE INCISION LAPAROSCOPIC LATERAL PANCREATICOJEJUNOSTOMY FOR CHRONIC PANCREATITIS C. Palanivelu, P. Senthilnathan, P.S. Rajan, S. Rajapandian, S. Jasmeet, A.P. Manoj Kum, D.A. Pinak GEM Hospital, COIMBATORE, India

TOTALLY LAPAROSCOPIC PANCREATICODUODENECTOMI´A RESECTION J.J. Sanchez Cano, F. Buils, A. Cabrera, M. Socias, J. Prieto, E. Baeta Hospital Universitari Sant Joan de Reus, REUS, Spain

Introduction: Laparoscopic single-site surgery for cholecystectomy and appendectomy are described in the literature. The benefits of these procedures compared with traditional laparoscopic approaches have yet to be determined. To date, no series of Single incision lateral pancreaticojejunostomy has been published or documented. This study is aimed to determine the safety and feasibility of SILS surgery for chronic pancreatitis. Methods: This study describes the technique and results of Single incision lateral pancreatico-jejunostomy in our series of 2 patients. Technique: Incision and flap rising; Placement of ports; Opening of gastro colic omentum and exposure of pancreas with suture retraction of stomach; Creation of roux limb and pancreatico jejunal anastomosis. Results: The average duct diameter was 1.1 cm. The average time taken was 210 min and the average blood loss was 60 ml. Both the cases were completed without any need for additional ports. The immediate (24 and 36 h) post-operative pain score is comparable to our laparoscopic series. The scar score at 7 days is better in single incision surgery compared to laparoscopic group. Conclusion: In our experience, this technique is both feasible and safe for selected patients. Although technical limitations exist that will be improved upon, further studies are needed to compare single incision laparoscopic surgery with traditional laparoscopic technique.

Aims: While laparoscopic surgery of the tail of the pancreas has quickly gained a dominant role, its role in diseases of the head is being debated. This video is about a totally laparoscopic cephalic duodenopancreatectomy (DPC) in one of ours patients, with the aim of showing that the technique can be performed with oncological criteria and, also, possible to do without any associated complications. Method: A 58-year-old female, intermittent jaundice, papillary adenocarcinoma, negative extension study. Introduce the technique of dissection and lymphadenectomy associated and necessary in a classic oncological DPC.

Result: The total operative time was 340 min, no significant blood loss, not requiring blood transfusion in surgery or postoperative period. An vascular anomaly (right hepatic artery from superior mesenteric artery) difficult dissection. The patient stayed the first three days in the intensive care unit and was discharged 10 days after surgery without any complication. Histological result: Papillary adenocarcinoma infiltrating duodenal wall with metastases in 2 of 23 isolated lymph nodes (pT2N1). Conclusion: Of the 11 patients with pancreatic head cancer-periampullary region treated laparoscopically in our unit in the last two years, only five cases have been possible to totally laparoscopic DPC. The patient we have presented is the fifth and only shows that it was possible to perform the technique without complications.

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V108 - Video - Pancreas TOTALLY LAPAROSCOPIC PANCREATICODUODENECTOMY. RECONSTRUCTION J.J. Sanchez Cano, F. Buils, M. Vives, E. Raga, J. Prieto, E. Baeta Hospital Universitari Sant Joan de Reus, REUS, Spain Aim: While laparoscopic surgery of the tail of the pancreas has quickly gained a dominant role, its role in diseases of the head is being debated. This video is about a totally laparoscopic cephalic duodenopancreatectomy (DPC) in one of ours patients, with the aim of showing that the technique can be performed with oncological criteria and, also, possible to do without any associated complications. Method: A 58-year-old female, intermittent jaundice, papillary adenocarcinoma, negative extension study. Introduce the technique of laparoscopic Child reconstruction. Results: The reconstruction was performed on a single intestinal loop. The pancreaticojejunostomy was performed with absorbable suture of interrupted stitches, like the hepaticojejunostomy. The total operative time was 340 min, no significant blood loss, not requiring blood transfusion in surgery, postoperative period. The patient stayed the first three days in the Intensive Care Unit and was discharged 10 days after surgery without any complication. Histological result: papillary adenocarcinoma infiltrating duodenal wall with metastases in 2 of 23 isolated lymph nodes (pT2N1). Conclusion: Of the 11 patients with pancreatic head cancer-periampullary region treated laparoscopically in our unit in the last two years, only five cases have been possible to totally laparoscopic DPC. The patient we have presented is the fifth and only shows that it was possible to perform the technique without incident

V109 - Video - Pancreas LAPAROSCOPIC TRANSGASTRIC CYSTOGASTROSTOMY WITH PANCREATIC NECROSECTOMY: A CASE REPORT K. Hutson1, M. Sajid2, K. Singh1 1 Worthing Hospital, SUSSEX, United Kingdom. 2Hairmyres Hospital, GLASGOW, United Kingdom Aims: Pancreatic necrosis (PN) with or without pancreatic pseudocyst (PP) formation develops in up to 25% of acute pancreatitis episodes, although sterile; secondary infection complicates up to 40% of cases, significantly increasing mortality. PN can be successfully treated by sufficient debridement, adequate drainage and preventing re-accumulation. Laparotomy for PN has been generally superseded by minimally invasive techniques including percutaneous, endoscopic, and laparoscopic methods conferring lower mortality and morbidity. The objective of this video report is to present a case of PN successfully treated by laparoscopic transgastric pancreatic necrosectomy (LTPN). Methods: A 77 year old female was admitted as an emergency with a clinical diagnosis of pancreatitis. Computerised tomography (CT) revealed a 12 cm retrogastric PP associated with gross ([50%) necrosis of the pancreas. She underwent LTPN and cystogastrostomy under general anaesthesia. Pneumoperitoneum was achieved with a verress needle and visiport. Anterior longitudinal gastrostomy was performed; allowing needle aspirate confirmation of PP location and internal posterior gastrostomy formation. Laparoscopic transgastric necrosectomy and drainage was subsequently carried out. The PP cavity was thoroughly irrigated and posterior gastrostomy left open for free drainage. The anterior gastric wall was closed with interrupted 3/0 absorbable stitches. Results: Postoperative recovery of the patient was uneventful and she was discharged home on day 16. A repeat CT scan at two months demonstrated no residual necrosis and a resolving PP. Conclusion: LTPN provides an effective and safe therapeutic option for PN in selected patients. This approach meets all three treatment criteria; facilitating thorough drainage and sufficient exposure for adequate necrosectomy if indicated. The posterior gastrostomy bestows an effective route for continued internal drainage; explaining in part why laparoscopic approaches yield higher primary success rates compared to percutaneous and endoscopic routes.

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V110 - Video - Physiology, Pathophysiology, Immunology SYSTEMIC AND REGIONAL LIVER’S INFLAMMATORY RESPONSE AFTER OPEN AND LAPAROSCOPIC LEFT PARTIAL HEPATECTOMY C.S. Mammas1, G. Kottis2, N. Arkadopoulos2, A. Pafiti2, N. Kavantzas3, I. Donta3, T. Tiniakou3, A. Analytis3, G. Kostopanagiotou2, S. Dourakis4, S. Geropoulos2, D. Voros2 1 Surgical Laboratory C.TOUNTAS, Athens, Greece. 2Aretaieion University Hospital, ATHENS, Greece. 3University of Athens, ATHENS, Greece. 4Ippokrateion University Hospital, ATHENS, Greece Aim: The project compares the impact of the Open Left Partial Hepatectomy (OLPH) and the Laparoscopic Left Partial Hepatectomy (LLPH), on the systemic and regional inflammatory response of the liver, in a porcine model. Materials and Methods: Twenty-nine pigs, weighing (21–32 kg), were randomly allocated into two groups: the open (n = 19) and the laparoscopic (n = 10) and underwent OLPH or LLPH respectively, under general anaesthesia. OLPH was performed by using a knife (A) or a radiofrequency knife (RF) (B), while the laparoscopic ones were performed using a stapler (C), or the combination of a stapler and a sub-cutaneous RF knife (D). Blood samples were taken before operation, after operation, on the 1st and on the 7th PD counting (WBC, Fibrinogen, Cortisol, T3, T4, and CRP). Pairs of histological liver sections from the remnant liver after resection and on the 7th PD, were stained with Eosin-Hematoxylin stain and inflammation and necrosis indexes were calculated. Both parametric and non-parametric methods were applied for statistical comparisons among parameters between the groups (OLPH vs LLPH) and the subgroups (A, B, C, D) on each time-point (a = 5%, P \ .05). Results: Fibrinogen levels were statistically significant elevated on the 1st PD favouring LLPH. The impact of the sub-techniques (A, B) vs (C, D) on the systemic inflammatory response showed the following statistically significant differences: (1) on the levels of Fibrinogen between sub-techniques B and C, favouring B, (B [ C), on the 7th PD, (2) on the levels of serum PLTs between sub-techniques B and D, favouring D (B [ D), as well as between C and D favouring D (C \ D), on the 7th PD, (3) on the levels of serum’s CRP between sub-techniques B and C, favouring B (B [ C), as well as between C and D favouring D (C \ D), on the 7th PD, (4) on the levels of plasma’s Cortisol between sub-techniques C and D, favouring D (C [ D), as well as between B and C favouring B (B \ C), on the 7th PD, (5) on the levels of plasma’s T4 between B and C, favouring B (B [ C), as well as between C and D favouring D (C \ D, P \ .05), on the 7th PD. Conclusion: The impact of OLPH on the systemic inflammatory response of the liver is greater than that of LLPH if the RF-knife is used for a partial liver resection (B).

V111 - Video - Robotics, Telesurgery and Virtual Reality ROBOTIC NEPHRECTOMY IN A 7-YEAR OLD CHILD WITH SECONDARY HYPERTENSION AND ATROPHIC LEFT KIDNEY. REPORT OF A CASE. K.M. Konstantinidis, P. Chrysocheris, S. Hiridis, M. Georgiou Athens Medical Center, ATHENS, Greece Introduction: Laparoscopic nephrectomy in children has proven to be safe and effective with outcome comparable to the open procedure. However, main drawback has been the relatively steep learning curve for the procedure. More recently, robotic-assisted laparoscopic surgery has gained popularity in adult urology and is increasingly being adopted around the world; however, few pediatric urology series have been reported. The robotic approach has several advantages over conventional laparoscopic surgery, with the main advantage being simplification and precision. Aim: We report a case of a seven-year-old male who underwent robotic nephrectomy. Methods: Patient suffered from secondary hypertension (arterial pressure measurements over 230 mmHg) due to congenital renal artery stenosis. He had a history of enterectomy due to necrotizing enterocolitis soon after he was born. An atrophic left kidney was found accidentally during investigations of a previous encephalitis-like syndrome. Results: An open access technique was used for the 12-mm camera port. We placed the camera port in the superior aspect of the umbilicus. The abdomen was insufflated with CO2 at a pressure of 10–15 mmHg. Two additional working 5-mm trocars were inserted. The robotic device was docked from the ipsilateral side, and the robotic arms were engaged. A fourth arm was available for grasping and retraction. We utilized Maryland bipolar forceps as a grasper, and either monopolar hook device or ultracision during dissection. Hilar vessels were secured with clips (hemolocks). Blood loss was minimal. Patient recovery was uneventful. Patient was discharged on the 5th postoperative day. High-blood pressure gradually subsided by the day of the discharge. Conclusion: As described above, robotic-assisted nephrectomy is possible in children with some advantages. It offers promise but expense currently limits its use. There is no report on outcome study of robot-assisted nephrectomy and little information in the literature is available on their pediatric use at the present time.

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V112 - Video - Robotics, Telesurgery and Virtual Reality ROBOTIC SLEEVE GASTRECTOMY FOR THE TREATMENT OF MORBID OBESITY. AN INTERMEDIATE APPROACH TO UNDERGO TOTALLY ROBOTIC GASTRIC BY-PASS R. Vilallonga, J.M. Fort, O. Gonzalez, M. Armengol University Hospital Vall d’Hebron, BARCELONA, Spain Objective: Novel techniques such as laparoscopic sleeve gastrectomy (LSG) is now used for the treatment of morbid obesity. In fact, the only publish article to our knowledge has been in August 2010. There is now enough experience with LSG in our group and we had the possibility to begin robotic sleeve gastrectomy. The application of robotic techniques has been reported for laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding, and more recently for LSG. We report herein our initial experience as a previous step before Robotic Roux-en-Y gastric bypass. Description of the Method: Eighteen consecutive patients underwent LSG with the use of the Da Vinci surgical system by the same surgical team. Surgical techniques followed the principles of standard LSG. We used three 12 mm standard trocars and a 8 mm DaVinci trocar to perform this novel technique. Preparation of the stomach was performed by the console surgeon alone and its division with the staplers by the patientside surgeon. A complete robotic ProleneÒ suture for reinforcement. Also SeamgualdÒ was used as reinforcements. A drain is finally placed next to the sleeve. Preliminary Results: Twenty patients (2 men and 18 women) with a mean age of 44.4 years (17–63) and a mean body mass index (BMI) of 48.0 kg/m2 were operated by Robot. Mean total operative time (including docking time) was 104.1 ± 15.3 min. Mean set-up time was 35 min and mean docking time was 6 min. There were no conversions. Complete robotic ProleneÒ suture for reinforcement was performed in 14 patients. Also SeamgualdÒ was used as reinforcements in 6 patients. Peri-operative morbidity and mortality was zero. Mean time for discharge was 4.16 days. Mean BMI at 3 months post-operatively was 35.8 ± 25.6%. The procedure can be completed with only one assistant and with four trocars instead of five in LSG. Conclusions: Robotic laparoscopic sleeve gastrectomy is feasible and safe. In experienced laparoscopic hands it is still an efficient surgical technique for the treatment of morbid obesity. No added operating time for the procedure has been reported. The application of robotics to this type of surgery might have less obvious advantages than with LRYGBP.

V114 - Video - Robotics, Telesurgery and Virtual Reality ROBOTIC DISTAL PANCREATECTOMY WITH SPLEEN PRESERVATION IN A 61-YEAR OLD WOMAN WITH A PANCREATIC TAIL MASS. CASE PRESENTATION K.M. Konstantinidis, S. Hiridis, P. Chrysocheris, M. Georgiou Athens Medical Center, ATHENS, Greece Background: Minimally invasive distal pancreatectomy with spleen preservation aims to decreased morbidity and comparable efficacy to traditional open approach. Additionally it can reduce the short and long-term risk of postoperative infectious complications. Robotic surgery aims to overcome certain limitations of conventional laparoscopy. There is only scarce literature on its use for distal pancreatectomies. Aim: Presentation of a case in which a robotic distal pancreatectomy was performed with spleen preservation. Patient and Method: We present a 61-year old female patient which reported frequent upper abdominal discomfort with radiation to the back. Her history included an open cholecystectomy and a saphenectomy. A mass in the distal pancreas was accidentally found in upper abdominal CT. Investigation for a neuroendocrine tumor was negative. She underwent a robotic distal pancreatectomy with spleen preservation. Results: Robotic distal pancreatectomy was achieved by a five trocar approach. Dissection of the pancreas and splenic hilum was achieved by means of robotic hook monopolar cautery and bipolar forceps. Pancreatic transection was achieved with vascular endoscopic stapler. The surgical specimen was removed without an additional incision. Operative time was 260 min. Blood loss was minimal, and the patient did not receive a transfusion. The recovery was uneventful, and the patient was discharged on postoperative day 6. Histology showed ectopic spleen inside the tail of the pancreas. Conclusions: Robotic spleen-preserving distal pancreatectomy is feasible and safe for distal pancreatic disease other than adenocarcinoma. The da Vinci robotic system allows for technical refinements of laparoscopic pancreatic resection. Robotic assistance improves the dissection and control of major blood vessels due to the three-dimensional visualization of the operative field and instruments with wrist-type end-effectors. Robotic microdissection is more precise mainly in skeletonizing the splenic vessels. Robotic assistance seems to increases the percentage of spleen preservation.

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V115 - Video - Spleen TREATMENT OF HYDATID SPLENIC CYST BY LAPAROSCOPIC PARTIAL SPLENECTOMY E. Orsenigo, S. Di Palo, FD De Cobelli, C. Staudacher1, P. Gazzetta University Vita-Salute San Raffaele, MILAN, Italy Background: Hydatid splenic cysts are rare. Treatment using splenectomy has the advantage of not presenting recurrence but carries the risk of immunological complications. Treatment through aspiration of the cyst or decapsulation preserves the spleen but with a high rate of recurrence. Optimal treatment is partial splenectomy. A portion of healthy splenic tissue is included that avoids recurrence and preserves the organ. Clinical Case: We report the case of a 36-year-old female with abdominal pain and palpable swelling in the left hypochondrium. With the use of ultrasound and MR, a large ovoid formation (13 9 9 cm) dependent on spleen, lobed, compatible with hydatid cyst was detected. The patient was scheduled for surgical treatment with minimally invasive approach. The surgical intervention was a laparoscopic partial splenectomy; we found a giant splenic hydatid cyst, occupied the left hypochondrium and the left flank; had thick walls, daughter vesicles and clear liquid inside. The cystic lesion was attached to the descending colon, stomach, and left diaphragm. With laparoscopy, a partial splenectomy was performed with endoGEA from the outer cyst. The patient was released in the 3 postoperative day without complications and was followed-up for 6 months. Conclusions: Laparoscopic approach allows resection of splenic hydatid cyst with a margin of healthy tissue without risk of bleeding or recurrence. Patient recovery is rapid, avoiding the morbidity associated with large incisions. Surgeons should keep in mind the possibility of a parasitic cyst when no definitive alternative diagnosis can be made. In the treatment of splenic hydatidosis, benzimidazole therapy is not necessary, although it is crucial to perform splenectomy without rupturing and spilling the cysts.

V117 - Video - Spleen LAPAROSCOPIC SPLENECTOMY FOR A LARGE SPLENIC HAEMANGIOMA S. Kalhan, A. Ali, A. Arora, P. Bhatia, M. Khetan, J. Suviraj Institute of Minimal Access, Metabolic& Bariatric Surgery, NEW DELHI, India Aim: Laparoscopic splenectomy has become the standard of care for the management of many haematological disorders. A very large spleen and dangerous vascularity especially at the hilum, are still considered relative contraindications by many. We present a case of large splenic haemangioma pressing on the splenic hilum, in which a laparoscopic splenectomy was done. Method: A 49 year old female from Nepal presented with pain in left upper quadrant for several months and low grade fever off and on. The spleen was just palpable. The haematological reports were normal except for mild microcytic anaemia. The CECT abdomen revealed a large spleen measuring 15 cm with a 6.5 cm diameter haemangioma encroaching up on the hilum, occupying more than half of the organ. A laparoscopic splenectomy was performed using one 12 mm and three 5 mm ports with pedicle ligation done proximally in the lesser sac. The specimen was removed in an endo bag using finger fracture technique, and a Jackson Pratt drain was left. Post operative recovery was smooth and the patient was discharged on the third postoperative day. Conclusion: With experience in advanced laparoscopic surgery and adequate vision and instrumentation, laparoscopic splenectomy is a better modality than open surgery and can be successfully performed in cases with formidable vascularity and size. There is a significant decrease in the overall morbidity, early ambulation and better cosmesis.

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V118 - Video - Spleen

V120 - Video - Spleen

LAPAROSCOPIC ASSISTED SPLENECTOMY FOR MASSIVE SPLENOMEGALY K.H. Devalia, K. Hutson, K. Singh Worthing Hospital, WORTHING, United Kingdom

TECHNIQUE FOR TRANS-UMBILICAL SINGLE PORT SPLENECTOMY L. Giavarini, M. Di Giuseppe, S.M. Tenconi, G. David, G. Ietto, F. Cantore, E. Colombo, E. Cassinotti, L. Boni Minimally Invasive Surgery Research Center, University of Insubria, VARESE, Italy

Aim: Laparoscopic assisted splenectomy is an established technique for massive splenomegaly. Massive splenomegaly is defined as the splenic weight of 1000 g or more. We discuss our technique in this video presentation. Procedure: The patient is positioned supine with a sandbag under the left loin. CO2 insufflation is carried out using an open technique through an infraumbilical 10 mm port. The port positioning is guided by the size of the spleen. One 10 mm port in right subcostal region in mid clavicular line and the second 10 mm port is in the left iliac fossa. A further 5 mm port is positioned in the left anterior axillary line. The operating steps are: division of short gastrics using an ultrasonic dissector. This gives access to the splenic hilum. The dissection is continued medially in the splenic hilum starting with the inferior pole and inferior pedicle is divided using vascular stapling device. The dissection is then continued to free the inferior pole of its attachments. The main vessels in the splenic hilum are then approached, isolated and divided using a vascular stapling device. Once vascular pedicle is controlled, it is safe to proceed to free the spleen from its lateral and posterior attachments. The specimen is retrieved intact using a retrieval bag through a small transverse incision which is created to the left of the umbilicus. Result: The operating time is approximately 90 min and length of stay is 2 days postoperatively. Conclusion: Laparoscopic splenectomy is a safe procedure with acceptable morbidity. It is feasible and safe even in presence of massive splenomegaly.

This video shows our technique for trans-umbilical single port splenectomy. The patient is placed in right lateral decubitus, the equipe stands on the side of the bed. The pneumoperitoneum is established using a Verres needle inserted in the left flank; a 5 mm longitudinal incision is performed through the umbilicus and a standard trocars inserted. Exploration of the abdominal cavity is carried out to evaluate if a single port procedure is feasible. The umbilical scar is pulled out and the incision is enlarged for up to 3 cm longitudinally: this technique will allow to hide the scar inside umbilicus itself. A size small wound protector is inserted through the incision to protect the abdominal wall as well as to improve the stability of the port system and facilitate its introduction. A reusable single port access system is inserted using a ‘ corkscrew’clockwise movement and thereafter the abdomen is insufflated through the dedicated stopcock on the port. As in standard laparoscopic splenectomy the procedure starts with division of the small vessels of the lower pole of the spleen by means of combination of bipolar electrocautery and harmonic scalpel. The procedure carries on with the isolation of the main splenic artery that can be closed by endoscopic clip or surgical stapler. Once the artery is divided the main vein is dissected gently and then closed and divided with a endoscopic surgical stapler with a vascular cartridge. Division of the short gastric vessels is carried out using the harmonic scalpel and finally the spleen is mobilized by division of the spleno-diaphragmatic, spleno-gastric and spleno-colic ligaments. A large endobag is introduced through the Endocone and the spleen retrieved inside it through the incision in case of enlarged spleens partial morcellation might be requires. The incision is carefully closed with interrupted re-absorbable suture.

V119 - 4 abstracts on 1 dvd

V122 - Video - Spleen

LAPAROSCOPIC SPLENECTOMY. STAPLING TECHNIQUE. S. Ferretti, D. Spoletini, U. Passaro, M. Carlini S. Eugenio Hospital, ROME, Italy

MINIMALLY INVASIVE SPLENECTOMY IN ADULTS AND CHILDREN. ROLE OF ROBOTIC SURGERY. PRESENTATION OF OUR TECHNIQUES K.M. Konstantinidis, S. Hiridis, M. Georgiou, P. Chrysocheris, F. Antonakopoulos Athens Medical Center, ATHENS, Greece

Laparoscopic splenectomy (LS) is a demanding operation which is not yet performed routinely, even though certain surgeons now consider it a standard technique for benign pathologies of the spleen. Compared to other laparoscopic procedures, manipulation of the spleen can be problematic, due to its location and size. Control of bleeding may also be a problem, because of the rich vascularization of the spleen. In our institution we started LS in 2003, with a total of 39 procedures. In the early experience, LS was performed with a ‘classical’ technique, sectioning progressively the ligaments of the spleen and selective approach to the splenic vessels. Over the last 19 cases, however, we used the technique that we called ‘stapling’. As shown in the video, the first operative step, common to both techniques, is to dissect free the splenic flexure and to control the inferior polar vessels which are dissected until the main vessels in the splenic hilum can be seen. This dissection is performed with an ultrasound dissector or with radiofrequency dissector. The second step, is to dissect free the posterior adhesions with the diaphragm deeply to the posterior aspect of the hilar vessels. After that, the spleen can be elevated till verticalization of the vessels allowing to place a stapler, including the gastrosplenic and pancreaticosplenic ligament, in which the splenic vessels are contained. The so called ‘stapling’ technique, reduces the operating time, intraoperative bleeding and surgeon’s stress compared with ‘classical’ technique.

Introduction: Several studies suggest that minimally invasive splenectomy should be the method of choice for treatment of benign hematologic disease not responding to conservative treatment, both in adults and children. Robotic surgery aims in overcoming certain limitations of laparoscopic surgery. Robotic splenectomy seems a good alternative to laparoscopy for very large spleens. Purpose: We present the techniques followed in our clinic for minimally invasive splenectomies (laparoscopic and robotic) in benign hematological disorders or benign masses of the spleen. Methods: We begin with inspection of the peritoneal cavity for accessory spleens or other pathology. Next dissection and ligation of short gastric vessels using ultrasonic shears or bipolar diathermy takes place. In this way the spleen is separated from the stomach. The splenic artery is recognized and ligated with clips (hemolocks). The splenocolic ligament is recognized and divided. The main vascular stalk of the spleen near the hilus is dissected carefully and divided by stapler. Alternatively we may dissect each of the branches separately and ligate them with clips. Mobilization of the spleen is completed after division of the splenorenal and phrenosplenic ligaments. The specimen is placed in a bag introduced through a small extension of the umbilical incision. Drainage tubes are placed in the left subdiaphragmatic region. Results: Indications for surgery include thrombotic thrombocytopenic purpura, autoimmune anemia, spherocytosis and splenic pseudocysts. Parallel operations included distal pancreatectomy, left colectomy, total gastrectomy and cholecystectomy. There were no deaths or major postoperative morbidity. Conclusions: Laparoscopic (and robotic) splenectomy permits an adequate inspection of the abdomen and is associated with shorter hospital stay. It is considered the procedure of choice for benign indications. Robotics may further facilitate removal of larger spleens as well as dissection of the hilar vessels in cases of anatomic variations.

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V123 - Video - Spleen

V125 - Video - Technology

SINGLE INCISION LAPAROSCOPIC SURGERY IN SPLENECTOMY. SUBCOSTAL OR UMBILICAL ACCESS? J. Bellido Luque1, S. Salvador Morales2, J. Guadalajara Jurado1, A. Bellido Luque3, J.M. Suarez Grau1, J. Gomez Menchero1, J. Garcı´a1, I. Dura´n Ferreras1 1 Riotinto hospital, HUELVA, Spain. 2Hospital Virgen del Rocı´o, SEVILLA, Spain. 3Sagrado corazo´n Clinic, SEVILLA, Spain

A NOVEL SPONGE DEVICE AND ITS MODIFICATION FOR THE DISPLACEMENT OF ORGANS DURING ENDOSCOPIC SURGERY S. Tsuchida1, T. Fukumoto1, M. Kido1, I. Matsumotoi1, T. Ajikli1, T. Hamaguchi2, Y. Ku1 1 Kobe University Graduate School of Medicine, KOBE CITY, HYOGO, Japan. 2Kawamoto Corporation, OSAKA, Japan

We present a 53 years old patient, who went to the surgeon because he had a increased left hypocondrium pain for two years. After scanner, a 7 cm intrasplenic mass was diagnosed. Its a capsulated, cistical and septate mass in the middle of this organ. This features make a fine needle aspiration contraindicated, so the patient went to surgery, and single incision laparoscopic surgery was proposed. We started performing a 2.5 cm incision in left hypocondrium, because who thought it was the best place to do the surgery easier. Now we are sure that the umbilical access is better regarding cosmetic results and postoperative pain, but harder than left subcostal approach. The next step is release the posterior attachment of the spleen to the parietal posterior peritoneum using harmonic scalpel, trying to mobilize the spleen to the midline. We prefer using angulated tools avoiding cross movements. Once we have done that step, we have to section the colosplenic and gastrosplenic ligament, taking care of the short vessels. The last step is sectioning the splenic hilum using 2 EndoGIA white cartridge. Is necessary not to damage the pancreas tail. the best way to avoid pancreas injuries is identify the tail before cutting the splenic hilum. The surgery finish taking the spleen out of the abdomen. is necessary to extend the subcostal wound due to the fact that is mandatory for anatomopathologic study the whole splenic mass. The AP showed a Splenic inflammatory pseudotumor, a benign rare splenic mass. In conclusion, Splenectomy using Single Incision laparoscopic Surgery is factible but it must be performed by expert laparoscopic surgeons, to avoid possible bleeding injuries. The best indications for this approach are small tumors in spleen with no more than 15 cm.

Introduction: A major problem during laparoscopic rectal surgery is the descent of the small intestine into the pelvic cavity, which causes interruption of the surgical field. To cope with this problem, patients are usually placed in an extreme headdown position, which results in hemodynamic changes or brachial plexus paralysis. Here we have developed a novel sponge device that can overcome this shortcoming of laparoscopic rectal surgery. Methods and Procedures: A novel device was invented by compressing and drying the sponge into a slender bar (240 9 8 9 8 mm) which will fit to insert through a 12-mm port. The sponge itself has already been approved as general medical device in Japan and possesses the ability to extend its applications to various organs such as pancreas or lung. We also made modified version of the sponge 2, 3, 4, and 5 cm in length to satisfy physical demands. During the surgery, this device was placed at the root of the mesentery and swollen up to 9 times (260 9 8 9 72 mm) by soaking physiological saline to displace the small intestine. Accordingly patient position was returned to horizontal, and descending degree of the small intestine was evaluated. Results: We used this device in 9 cases. In all cases, we could securely complete the surgery in a horizontal or the half of the normal angle head-down position under a good surgical field without a descent of the small intestine. After the surgery, the device could be easily removed from a 4-cm laparotomy incision created to obtain the specimens. No serious complications were observed during the surgery, and all patients discharged with normal postoperative time courses. Conclusions: We developed a useful device to secure a good surgical field without an extremely leaning position. By using this method, we can avoid adverse effects on hemodynamics and complications which occurred during the previous methods. The application of this sponge may extensively benefit endoscopic surgery.

V124 - Video - Technology

V126

SINGLE PORT RIGHT NEPHRECTOMY M. Di Giuseppe, S.M. Tenconi, G. David, G. Ietto, F. Cantore, L. Giavarini, E. Colombo, E. Cassinotti, L. Boni Minimally Invasive Surgery Research Center, University of Insubria, VARESE, Italy

LAPAROSCOPIC RESECTION OF A 5 CM HEPATOCELLULAR CARCINOMA IN THE SEGMENT VII IN A CIRRHOTIC LIVER WITH PORTAL HYPERTENSION USING THE HABIBTM 43 DEVICE I. Poves, F. Burdı´o, S. Salvans, L. Lorente, J.A. Carrion, L. Grande Hospital del Mar, BARCELONA, Spain

Recently SILS has opened a new prospect for mini-invasive surgery. We show our technique for single incision laparoscopic right nephrectomy. The patient, a 62 years old man, undergone to kidney transplant 5 years earlier due to renal failure caused by glomerular nephritis. Native kidney was left in place. Several admission to the infectious disease department for recurrent sepsis were reported. Sepsis was likely caused by a large stone located in the middle part of the right native ureter determining severe hydronephrosis. This is demonstrated by abdominal MRI. The patient is placed in left lateral decubitus. A 3.5 cm umbilical incision is performed and an Endocone (Karl Storz, Germany) single port device is introduced. We begin, like standard laparoscopic right nephrectomy, with the right colon mobilization. The procedure carries on with the ‘kocher manoeuvre’, that allows to expose the right gonadic vessels and the inferior vena cava. The gonadic vein is clipped and divided at the level of the vena cava, than the ureter is dissected distally. Using the ureter as a guide, right renal artery is identified and than divided between clips. Retracting the gallbladder, the right renal vein is exposed, isolated and divided. The procedure continues with the mobilization of the kidney. Finally the stone is identified and the ureter is divided distally using a linear stapler The kidney is introduced into an Endo-bag and removed through the surgical incision used for the Endocone. The surgical field is check for haemostasis. The patient has no postoperative complications and was discharged on postoperative day 4.

Introduction: Surgical resection is the preferred curative option for the treatment of the hepatocellular carcinoma (HCC) when hepatic transplantation is not possible. Radiofrequency (RF) ablation is a good alternative for small HCC less than 2 cm located deep into the liver. Hepatic resection in cirrhotic patients is associated with high rates of morbidity and mortality. Although laparoscopic approach is gaining popularity, there is a risk of major bleeding during hepatectomy in cirrhotic patients. A new bipolar RF device (HabibTM 49, Generator 15009, RITA Medical Systems, Inc. California, USA) has been developed to assist liver resection laparoscopically. It produces controlled RF energy between the electrodes sealing major biliary and blood vessels. Liver parenchyma can be spared with less blood loss and biliary leak. Video presentation: A 70 years-old woman diagnosed of hepatitis C virus cirrhosis was diagnosed of a 5.5 cm HCC located in the segment VII. She had a functional grade A (5 points) score in the Child-Pugh classification. Portal hypertension was documented by oesophageal grade II varices and 44,000 serum platelets. In a multidisciplinary committee it was decided to perform a hepatic resection. It was used the laparoscopic HabibTM 49 device and LigasureTM V (Covidien). All the procedure was done without hiliar clamping. Cholecystectomy was done because of cholelithiasis. The specimen was removed through an enlargement of a recurrent umbilical hernia. Operative blood lost was near 600 ml. Total operative time was 244 min (155 min for the hepatectomy). In the early postoperative course the patient was reoperated due to persistent bleeding through an abdominal drain. A re-laparoscopy was done finding a slow, but persistent bleeding in the retroperitoneal fat around the hepatic flexure of the colon. No bleeding was found in the hepatic section line. The patient had a posterior normal recovery and was discharged on 7th day. Final diagnosis was of 55 mm HCC with free margins of 10 mm. Conclusions: Laparoscopic HabibTM 49 is a very useful device for achieving optimal hemostasis during laparoscopic hepatectomy, specially in those patients with macronodular cirrhosis and portal hypertension.

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V127 - Video - Technology

V130 - Video - Urology

LAPAROSCOPIC SIGMOIDECTOMY WITH TRANS-ANAL SPECIMEN EXTRACTION FOR CORRECTION OF RECTAL PROLAPSE: NATURAL ORIFICE SPECIMEN EXTRACTION (N.O.S.E.) K. Byung Seup, J.W. Kwno, M.J. Kim, S.E. Ahn, B.H. Lee, H.C. Park Hallym University Sacred Heart Hospital, ANYANG, Korea

HYBRID LAPAROENDOSCOPIC SINGLE SITE RADICAL PROSTATECTOMY: A STEP CLOSER TO PURE LESS P.H. Rouse, P. Grange, A. Rao, C. Brown Kings College Hospital, LONDON, United Kingdom

Aims: In the effort to avoid the extension of abdominal incision, woundrelated complication and postoperative pain, transanal specimen extraction techniques have been attempted. Methods: Laparoscopic sigmoidectomy with trans-anal specimen extraction was attempted in consecutive six patients with rectal prolapse. Vascular dissection and bowel mobilization were performed like conventional laparoscopic approach. The proximal colon divided with the laparoscopic linear stapler. And then we dissected the distal mesorectum in two sites. The distance between two sites was about 2 cm. Distal site was true resection margin. We opened the proximal site using vessel-sealing energy device. And we push anal dilator wrapped with camera vinyl through the anus in perineal field. Using laparoscopic babcock, the operator grasped the edges of the opened rectal stump and ends of the camera vinyl together. Leaving the camera vinyl, the anal dilator was retrieved and a long Kelly was inserted through the camera vinyl. The resected specimen was grasped by the long Kelly and retrieved through anus. An anvil was inserted using a long Kelly and the camera vinyl retrieved. The opened rectal stump, to be closed off, was transected using a stapler at the level of prepared distal cutting line. A longitudinal antimesenteric teniae incision of proximal colon was made 2 cm proximal to the transected line using a laparoscopic hook and the anvil was inserted through the enterotomy site. A purse string suture around the anvil was performed using 2/0 prolene intracorporeally. We made knots in the extracorporeal space and pushed it into anvil using knotpusher. An end-to-end colorectal anastomosis was then completed intracorporeally with circular stapler in the usual manner. Results: The mean operation time was 166.7 ± 31.3 min. The postoperative pain was tolerable in all patients. The recovery of patients were uneventful fortunately. Conclusions: Laparoscopic sigmoidectomy with trans-anal specimen extraction for correction of rectal prolapse was feasible. It can decrease wound-related complication and pain.

Introduction and Objectives: A natural advance in minimally invasive surgery has been the use of a single port resulting in laparoendoscopic single-site surgery with better cosmesis for patients. Laparoscopic and Robotic-assisted laparoscopic radical prostatectomy (RP) are the standard of care for surgical management of localised prostate cancer. RP is a complex operation and there are some reports in the literature of RP performed by pure laparoendoscopic single-site surgery. We present our technique of Hybrid laparoendoscopic single-site radical prostatectomy and our oncological and functional outcomes. Methods: Extra-peritoneal access was gained via a sub-umbilical incision. A Triport-or Quadport-OlympusTM as placed. A flexible-tip HD camera (LTF-VP EndoEYE-Video-LaparoscopeTM) and a robotic-camera holder (Freehand, ProsurgicsTM) were used. An additional 5 mm port was placed in the left iliac fossa, to allow hybrid laparoendoscopic single-site surgery. RP was performed by antegrade dissection using a Harmonic ACETM scalpel, a dissector/grasper and a long, curved bariatric suction device. The curvature of these instruments and deflection of the endoscope reduce internal and external clash of instruments. A suture is placed percutaneously through the eye of the Foley catheter, using the Endo-close device, to anteriorly retract the prostate, to aid the dissection of seminal vesicles and vas. Vesico-urethral anastomosis was completed using an extra-corporeal knotting technique using a scissorknot-pusher device to deploy the knots. A 14F drain was placed through the 5 mm port and was usually removed within 24 h. Results: 18 patients under went surgery: mean age 63 years (48–71), BMI 27 (22–32), PSA 8.4 (1.7–14.0) and TRUS volume 58cc (26–176). The mean operative time 233 min (180–310) and average blood loss was 365 ml (50–800). There were no intra-operative complications. Follow-up ranged from 1 to 14 months. 12 patients (66%) were pad free by 3 months post-op and 100% were pad free by 6 months. One patient experienced urinary retention secondary to bladder neck stenosis and required endoscopic incision. Two patients had a positive resection margin. There is no PSA recurrence. Conclusions: Hybrid laparoendoscopic single-site radical prostatectomy is feasible. It has good functional and oncological outcomes in the short-term.

V129 - Video - Thoracoscopic Surgery

V131

THORACIC SYMPATHECTOMY FOR THE TREATMENT OF HYPERHYDOSIS M.K.H. Hussein American University of Beirut - Medical Center, BEIRUT, Lebanon

A NOVEL INTRA-CORPOREAL KNOTTING TECHNIQUE FOR LAPAROENDOSCOPIC SINGLE SITE SURGERY P.H. Rouse1, P. Grange1, A. Rao1, A. Kypke2 1 Kings College Hospital, LONDON, United Kingdom. 2 The UCH Education Centre, LONDON, United Kingdom

The video shows the steps used to the right thoracic Sympathectomy for the treatment of Right Hyperhydosis. Though 3 trocars in a triangular position and the patient position in right lateral position and double lumen intubations with deflation of right lobe. Sympathectomy proceeded from 2nd rib till 4th rib. 12 cases done in this technique at American University of Beirut Medical Center successfully with no complication and resolution of symptoms and hospital stay is 24 h.

Conclusion: Sympathectomy for the treatment of Hyperhydosis is feasible with minimal invasive surgery.

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Introduction: Laparoendoscopic Single Site (LESS) urological procedures are gaining popularity across the globe. Most reported series of reconstructive LESS urological procedures, such as partial nephrectomy and pyeloplasty, describe the use of an additional 2 or 5 mm port to aid dissection and to accomplish intra-corporeal suturing. We have developed a new technique of intra-corporeal suturing that negates the use of an additional port. Methods: Initial proof of concept and competence in performing this knotting technique was perfected in the box trainer model using a commercially available single port device, needle holder and a grasper. Step 1: the needle is grasped with the needle holder and rotated three times in a clockwise direction. Step 2: the needle is then transferred to the grasper. Step 3: the short end of the suture is then grasped with the needle holder. Step 4: the knot is tightened using a push and pull technique. The knot is secured by repeating the above steps in the opposite direction. We have applied this technique in complex LESS reconstructive procedures such as no-clamp partial nephrectomy and pyeloplasty. Results: A video clip demonstrating our novel intra-corporeal suturing technique in the box trainer with the aid of schematic diagrams. A video clip demonstrating the use of this knotting technique to reconstruct the collecting system of a patient following partial nephrectomy. Conclusions: Intra-corporeal suturing can be accomplished in laparoendoscopic single site surgery using this novel knotting technique without the need for an additional port.

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V132 - Video - Vascular Surgery

V134 - Video-Abdominal Cavity and Abdominal Wall

RUPTURED LEFT GASTRIC ARTERY ANEURYSM: LAPAROSCOPIC RESECTION E. Baldini, F. Cattadori, S. Albertario, P. Capelli Ospedale ‘G. da Saliceto’, PIACENZA, Italy

NON-TACKING SINGLE-PORT LAPAROSCOPIC TRANSABDOMINAL PREPERITONEAL INGUINAL HERNIA REPAIR WITH OUR NEWLY DEVELOPED TECHNIQUE N. Kameyama1, M. Tomita1, H. Mitsuhashi1, N. Matsumoto1, T. Obuchi1, Y. Katsuki1, Y. Kitagawa2 1 International Goodwill Hospital, YOKOHAMA, Japan. 2Keio University, TOKYO, Japan

The aim of this video was to show the technique of laparoscopic resection of a ruptured left gastric artery aneurysm, that became clinically evident with an hemoperitoneum. An 84 years old female was admitted to Emergency Room for abdominal pain (in superior abdominal regions) and arterial hypotension. The patient had a chronic cardiac failure and was treated by oral anticoagulants. Abdominal ultrasound and abdominal tomodensitometry showed peritoneal fluid and a 3 cm. left gastric artery aneurysm, who was internally partially thrombosed. After 2 red blood cells units transfusion and crystalloids infusion the patient was haemodynamically stable. A trans-arterial embolization was attempted, but it was not possible to perform, due to an impossibility to cannulate the celiac trunk. One day later, after normalization of coagulation values, the patient was operated in a laparoscopic way. With patient in gynecological (‘French’) position, 4 trocars were placed (1 umbilical for the laparoscope, 1 in right hypochondrium, 2 in left hypochondrium). After lavage of hemoperitoneum and abdominal exploration no other possible cause of hemoperitoneum, neither other abdominal pathologies were found. Aneurysm was dissected and left gastric artery was isolated and sectioned by Ligasure (distally to the aneurysm) and after clips application (proximally to the aneurysm, nearly to emergency from celiac trunk). Postoperative period was uneventful. Abdominal ultrasound performed 1 month after operation were normal. Among splancnic artery aneurysms, gastric arteries aneurysms are 3–4% of cases. While many cases of gastroepiploic arteries aneurysms laparoscopic resection have been reported in literature, only one case of laparoscopic ligation of a left gastric artery aneurysm has been published until now. The majority of cases of splancnic arteries aneurysms are revealed by an hemoperitoneum, with a mortality rate between 25 and 70%. First choice treatment is, in nearly all cases, transarterial embolization. In selected cases laparoscopic treatment can be performed successfully.

Aims: Transabdominal preperitoneal inguinal hernia repair (TAPP), one of the laparoscopic repair procedures for inguinal hernia, enables visualization of the inguinal region on both sides. This procedure allows simultaneous confirmation and pneumoperitoneum-based repair of all hernia orifices. Recently, single-port laparoscopic surgery (SPLS), in particular cholecystectomy and appendectomy, has become widespread. SPLS results in minimal scarring (the so-called invisible scar) providing much better cosmetic outcomes, and higher patient satisfaction. TAPP is suitable for SPLS. This is because the aim of the procedure is to repair the defect without the removal of organs. However, single-port laparoscopic TAPP (SP-TAPP) is not performed frequently because it entails a highly complex technique. Methods: We performed SP-TAPP in patients with symptomatic inguinal hernia by using our newly developed technique. In this report, we will present an overview of transumbilical non-tacking SP-TAPP with an operative video including how to use a self-gripping mesh, running sutures and ligature. Results: Repair of 26 lesions was technically successful and was performed without placement of additional trocars. Two of four cases of recurrent inguinal hernia were excluded from the statistics because in these cases the operating technique was the intraperitoneal onlay mesh method. The average time required for the Loop & LTH ligation technique was 24 min (n = 20), which was lower than the 50 min required for conventional peritoneal repair (n = 4). There were no cases of intraoperative complications or deaths. Postoperative complication was observed in only 1 case (seroma). No recurrence was detected. The Parietex ProGripTM mesh which was used in the all cases contains a self-gripping mechanism and may not require tacking. As a result, complications related to tacking can be avoided. Although the SP-TAPP is a technically difficult procedure, the operative time can be easily reduced by repairing the peritoneal tissue with our Loop & LTH ligation technique. Conclusion: Non-tacking SP-TAPP averts complications related to tacking and requires very few medical devices, reducing the overall cost of the procedure. We believe our Loop & LTH ligation technique is the optimal technique for peritoneal repair with SP-TAPP.

V133 - Video-Abdominal Cavity and Abdominal Wall

V135 - Video-Abdominal Cavity and Abdominal Wall

LAPAROSCOPIC PARACECAL HERNIA REPAIR: A CASE REPORT C. Galatioto1, S. Guadagni1, M. Seccia1, M. Ferrari2, A. Bertolucci2, R. Mancini2, E. Pouli2 1 Azienda Ospedaliera Universitaria Pisana, PISA, Italy. 2Chirurgia Generale e d’Urgenza, PISA, Italy

LAPAROSCOPIC MANAGEMENT OF INTESTINAL OBSTRUCTION FROM A GIANT MORGAGNI’S HERNIA IN A ADULT, A CASE REPORT C. Galatioto, P.V. Lippolis, S. Guadagni, I. Cengeli, C. Lombardo, F. Filidei, M. Seccia Azienda Ospedaliera Universitaria Pisana, PISA, Italy

Introduction: Internal hernias are relatively rare viscous protrusions through a continuous solution in the peritoneal cavity. Paracecal hernia, one of the least common types, is a potentially lethal condition and only with a prompt diagnosis and a surgical intervention we can obtain a change of successful outcome. Minimally invasive surgery for the treatment of paracecal hernia is effective in restoring bowel function and reducing postoperative hospitalization. Case presentation: We present the case of 59 years old man. He was admitted to the department of Emergency Medicine of our hospital for nausea and vomiting. Computer tomography showed diffuse air-fluid levels with the exception of the distal sigmoid colon and associated free fluid in the pelvis and in the right parietocolic space. Because of the failure of the conservative management, laparoscopic surgery was therefore performed for definite diagnosis and treatment of small bowel obstruction. The procedure revealed that same small intestinal loops were protruded through an abdominal hole in the paracecal area. An easy reduction of incarcerated intestinal loop was achieve by gentile traction of intestine. The bowel showed no evidence of non-viability. The orifice was closed with polysorb 4-0 suture laparoscopically. A laparotomy was avoided and the patient experienced an uneventful postoperative course. Conclusion: Laparoscopy can play a role in the treatment of internal hernia causing small bowel obstruction provided that there isn’t any signs of intestinal ischaemia.

Introduction: Congenital retrosternal diaphragmatic hernia rarely presents in adult. Traditionally the best approach was performed by laparotomy, thoracotomy or a combination of both. The advantages of minimally invasive surgery include reduced surgical trauma, less pain after surgical treatment, shorter hospital stay, a more rapid and uneventful recovery and lower morbidity rates. Recently researches have yielded new types of materials for prosthetic patch, especially to reduce the formation of intestinal adhesions with the prosthesis. Case presentation: We report the case of 60 years old man with a clinical picture of intestinal obstruction. We perform a CT scan that had detected a gross anterolateral diaphragmatic hernia with the transposition of the colon, gastric fundus and some small intestine’s loops. He underwent to a laparoscopic repair of the hernia using a combination of simple interrupted suture with intracorporeal knotting technique and placement of a prosthesis fixed to parietal defect with absorbable tacks. We have used a particular type of prosthesis, called Combimesh, that is made with a polypropylene’s monofilament mesh that has a special polyurethane treatment on one of its surfaces. The procedure lasted a total of 150 min. The patient was released from the hospital on the 7th postoperative day without any surgical problems. A upper gastrointestinal tract radiography was obtain after fifteen days from the procedure and it had shown a regular transit of the contrast material in the oesophagus, stomach and duodenum with normal diaphragmatic motility. Conclusion: This case report confirms that the Laparoscopic repair performed, under good conditions, is an effective, safe procedure for Morgagni’s hernia treatment. This procedure presents all the advantages of minimally invasive surgery: namely gentle, easy manipulation of the contents of the sac, reducing surgical trauma so to obtain a rapid and uneventful recovery. The use of a mesh repair technique allows the surgical repair of large defects or muscle weakness.

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V136 - Video-Abdominal Cavity and Abdominal Wall

V139 - Video-Abdominal Cavity and Abdominal Wall

LAPAROSCOPIC LYMPHADENECTOMY IN DIFFERENT TYPES OF ABDOMINAL SURGERY I.E. Khatkov1, V.V. Tsvirkun2, R.E. Izrailov1, K.V. Agapov2, P.S. Tyutyunnik1 1 Moscow State University of Medicine and Dentistry, MOSCOW, Russia. 2Clinical Hospital 119 FMBA, MOSCOW, Russia

VARICOCELECTOMY USING SINGLE INCISION LAPAROSCOPIC SURGERY (SILS) N. Gatsoulis, Th. Zacharouli, K. Nikas, D. Kampouris, M. Theodorou General Hospital of Corfu, CORFU, Greece

Spreading of minimally invasive surgery for abdominal cavity and extra-peritoneal organs cancer treatment is limited by the complexity of performing an adequate lymphadenectomy. Aims: to show possibilities and advantages of totally laparoscopic lymphadenectomy in surgical oncology. Methods: Technical aspects of performing of laparoscopic lymphadenectomy depend on the area of abdominal cavity. In the upper part of abdominal cavity standard lymphadenectomy includes the removal of common hepatic, splenic, splenic hilum, and celiac lymph nodes, sometimes - paraaortic and paracaval lymph nodes, depending on the localization and stage of cancer. Lymphadenectomy in the lower part of abdominal cavity includes the removal of paracolic, epicolic, sigmoid, superior and middle rectal lymph nodes in standard colorectal oncosurgery. In other cases: lateral aortic (lumbar), precaval and postcaval, common iliac lymph nodes, internal iliac, external iliac and obturator pelvic lymph nodes. Results: Laparoscopic approach permits to remove up to 15–20 lymph nodes in each area, what is similar to the results of traditional surgery. Postoperative morbidity and mortality doesn’t grow after laparoscopic procedures. The proper position of trocars suitable for each area and usage of modern instruments (30° camera, soft curved graspers with long brunches, ultrasound scalpel) are key factors for safety of the procedure. Conclusion: Laparoscopic lymphadenectomy is technically feasible procedure for patients with malignant diseases of abdominal cavity and extraperitoneal area. Big series should be studied for understanding possible benefits of laparoscopy in long term results of surgical treatment of oncological patients.

Aims: Varicocele occurs in 15% of male adults and in 40% of infertile men while it is most frequently diagnosed between the 15–30th years of life. A variety of different surgical techniques have been used for the surgical repair of varicocele through the years (Gregorini, Palomo, Marmar e.t.) as well as laparoscopic surgery. We present a video of a case of varicocelectomy using the Single Incision Laparoscopic Surgery (SILS) procedure. Methods: We refer to a 30-year-old male suffering varicocele on the left side with a preoperative ultrasonography verifying the diagnosis. We performed varicocelectomy using the SILS technique. The operative time was 60 min and the patient was discharged of the hospital the same day of the operation (outpatient). Results: There were no postoperative complications, the postoperative pain was minimal and the cosmetic result was excellent (scarless technique). The postoperative ultrasonography confirm the operation’s good outcome results. Conclusion: SILS varicocelectomy is feasible and safe, providing all the advantages of this new technique.

V138 - Video-Abdominal Cavity and Abdominal Wall

V140 - Video-Abdominal Cavity and Abdominal Wall

AN ALTERNATIVE FOR LAPAROSCOPIC REPAIR FOR VENTRAL HERNIA: MAGNETIC ASSISTED SINGLE-PORT LAPAROSCOPIC SURGERY S. Morales Conde1, M. Socas Macias1, A. Barranco Moreno1, G. Dominguez2, I. Alarcon1, J. Canete1, R. Sanchez2, V. Gomez1, H. Cadet1, J. Padillo Ruiz1 1 HUVRocio, SEVILLE, Spain. 2Argentina

LAPAROSCOPIC TREATMENT OF LARGE INCISIONAL HERNIA WITH PARIETEX COMPOSITE MESH M. Nardi ‘U. Parini’ Regional Hospital, AOSTA (AO), Italy

Aim: Laparoscopic approach for ventral hernia repair has reduced local morbidity, provides better visualization of the entire defect, ensuring fixation of the mesh to healthy tissue and has shown low rate (5%) for recurrence. Continuous goal is to minimize de invasiveness of laparoscopy. We use single port access to perform various laparoscopic procedures like cholecystectomy or right hemycolectomy. With a single incision and without the need for complex instruments, we developed the ventral hernia repair trough a single incision with magnetic assistance. Case Report: A 65 year-old woman within the diagnosis of incarcerated Spigelian hernia, was proposed for single-port laparoscopic repair. The Single-Port device with 3 trocars was placed in the left flank of the patient through a 2 cm incision. A magnetic forceps was introduced through the 12 mm port. The TD-magnet grasping the mesh is ‘ called’ by an external magnet. The procedure lasted 40 min. Discussion: Single incision laparoscopic repair of abdominal wall hernias is feasible and reproducible (4). One of the problems related to single port surgery is the lack of triangulation since the instruments are introduced through the same incision. Magnetic forceps has been developed to substitute trocars during laparoscopic surgery offering the surgeon an appropriate exposure with an appropriate management of the mesh, and, moreover, without additional ports.

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The laparoscopic incisional and ventral hernias repair is now widely spread in relationship to the improvement of surgical technique and new materials of mesh. We present a case of large incisional hernia treated laparoscopically with a Parietex Composite mesh.

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V141 - Video-Abdominal Cavity and Abdominal Wall

V143 - Video-Abdominal Cavity and Abdominal Wall

LAPAROSCOPIC MANAGEMENT OF AN UNUSUAL CASE OF LARREY–MORGAGNI HERNIA WITH PARAESOPHAGEAL HERNIA IN ADULT S. Kalhan, A. Ali, P. Bhatia, M. Khetan, J. Suviraj, N. Agnihotri, M.D. Agarwal, V. Bindal Institute of Minimal Access, Metabolic& Bariatric Surgery, NEW DELHI, India

LAPAROSCOPIC MESORECTAL TRANSACTION IN SUBTOTAL TME Z.A.J. Khan The Queen Elizabeth Hospital, KING’S LYNN, United Kingdom

Aims: Morgagni, an Italian anatomist, described in 1769 a rare hernia through a defect in the diaphragm immediately behind the sternum. A hernia through right sternocostal hiatus is termed as Morgagni and one through the left sternocostal hiatus is called Larrey’s hernia. A combined hernia is called Larrey’s–Morgagni hernia. Such combined hernia with paraesophageal hernia is very rare in adults. A 51 years old lady was found to have this rare combination and was repaired laparoscopically. Methods: Patient presented with upper abdominal pain of 3 months duration with acute exacerbations. Her chest x-ray and upper GI endoscopy were normal and CT scan revealed Larrey–Morgagni defect with paraesophageal hernia with transverse colon and transverse mesocolon as contents. Laparoscopic repair using 30°, 10 mm telescope and other conventional laparoscopic instruments was done with reinforcing meshes. Results: Patient recovered well post operatively, was started on liquids next post operative day and discharged the subsequent day. Conclusion: Larrey–Morgagni defect with paraesophageal hernia is very rarely seen and can be dealt with laparoscopically in expert hands, providing all inherent benefits of minimal access surgery to the patient.

This video illustrates laparoscopic mesorectal transaction in subtotal TME in a rectosigmoid carcinoma on a 62 year-old female patient. Rectal dissection is proceeding below the pelvic brim in TME plane. Because of the rectosigmoid location of the cancer, a full TME is not required. Posterior and lateral dissection is carried out with reticulating diathermy scissors and the bulk of the mesorectum is excised with 10 mm ligasure to secure haemostasis. At times, relatively small bites with ligasure ensure avoidance of rectal injury. Following skeletonisation of the rectum at a suitable level, rectal transaction is carried out with Endo GIA using two fires and the specimen extracted through a suprapubic muscle splitting incision using wound protector. The extracted specimen shows 6–7 cm distal clearance. The anastomosis is fashioned with the DST28 using standard technique and tested for air leak. The omentum is brought down to the pelvis before exiting the abdomen.

V142 - Video-Abdominal Cavity and Abdominal Wall

V144 - Video-Abdominal Cavity and Abdominal Wall

LAPAROSCOPIC REPAIR OF RECURRENT MASSIVE VENTRAL HERNIA AFTER OPEN REPAIR WITH LIGHTWEIGHT PROSTHETIC MATERIAL S. Morales-Conde, M. Socas Macı´as, A. Barranco Moreno, S. Can˜eteGo´mez, I. Serrano-Borrero, I. Alarco´n del Agua, V. Go´mez Cabeza de Vaca, H. Cadet Dussort, J. Padillo Ruiz Virgen del Rocı´o Hospital, SEVILLE, Spain

SIMULTANEOUS SINGLE INCISION LAPAROSCOPIC MESH REPAIR OF MORGAGNI–LARREY HERNIA AND CHOLECYSTECTOMY E.A. Zorin, I.V. Shrainer Medical and Rehabilitation Center, MOSCOW, Russia

Laparoscopic repair of ventral hernia is widely accepted in some indications. One of the advantages of laparoscopic repair is the possibility to detect defects not identified by clinical examination, especially in morbidly obese patients. On the other hand, the intrabdominal view also allows detecting previous meshes placed by open approach. For some surgeons, a difficult laparoscopic ventral hernia repair includes those ones previously repaired by open approach using a polypropylene mesh. It has been described an increase of intrabdominal adhesions to previous mesh even if during previous open surgery the mesh has not been placed in contact with the bowel. This video shows how a previous polypropylene meshes placed preperitoneally could produce dense adhesions. It also shown how the use of light-weight meshes in large hernias in obese patients could breaks in the middle, developing a recurrence. This recurrence could be repaired properly by laparoscopy placing a mesh in contact with the bowel following the Double Crown technique. The use of light-weight meshes in very large hernias in morbidly obese patients could become a contraindication for open ventral hernia repair based in experience like ours, since we have detected already three cases in which the lightweight mesh has broken in the middle, developing a recurrence. These recurrences could be repaired properly by laparoscopic approach.

Backgrounds: Morgagni–Larrey hernia is a rare diaphragmatic hernia. We present a case of single-incision laparoscopic mesh repair of Morgagni–Larrey hernia. Methods: A 72 years old woman was admitted to our Department with chronic calculous cholecystitis. Routine chest X-ray revealed no pathology. An elective single-incision cholecystectomy was scheduled. After the trans-umbilical placement of SILSÒ-port (Covidien) an exploration of abdominal cavity was performed. Incidentally a retrosternal defect of the diaphragm sized 10 9 5 cm and containing incarcerated omentum was revealed. After adhesiolysis hernia contents was reduced. First, a typical single-incision cholecystectomy was performed. Regarding the risk of following incarceration, a decision to perform mesh repair. The round and falciform ligaments of liver as well as peritoneum of anterior and posterior rims of diaphragmatic defect was divided using Harmonic scalpel. The hernia sac was excised. To ensure a tension-free repair, a Proceed mesh 15 9 10 cm (Ethicon, Johnson & Johnson Company, Somerville, NJ, USA), was pre-shaped so that it would overlap the edges of the defect for approximately 3 cm. The mesh was introduced in the peritoneal cavity, placed over the defect and secured to the margins of the hernia with 5 mm Protack (Tyco Healthcare, Manseld, MA, USA). No drains were placed. Results: The operation time was approximately 100 min: approach and wound closure - 20 min, cholecystectomy - 40 min, hernia repair - 40 min. The only complaints of the patient post-operatively were mild chest pains without ECG and X-ray changes. The patient was discharged on second day after surgery. Control MRI four weeks after the procedure revealed no recurrence or other abnormalities. Conclusion: To the best of our knowledge, we present the first case of single-incision laparoscopic intraperitoneal mesh repair of Morgagni hernia.

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V145 - Video-Abdominal Cavity and Abdominal Wall

V148 - Video - Morbid Obesity

LAPAROSCOPIC CONSTRUCTION OF LEFT DIAPHRAGM IN ANTERIOR DIAPHRAGMATIC HERNIA M.K.H. Hussein American University of Beirut - Medical Center, BEIRUT, Lebanon

LAPAROSCOPIC ADJUSTABLE BANDED ROUX-EN-Y GASTRIC BYPASS AS A PRIMARY PROCEDURE FOR EXTREME OBESITY D. Van Der Fraenen1, S. Van Cauwenberge2, E. Van Dessel2, J.P. Mulier2, B. Dillemans2 1 AZ Sint Jan Bruges, BRUGES, Belgium. 2AZ Sint Jan, BRUGGE, Belgium

The video will show the various steps used to reduce a huge diaphragmatic hernia in a 55 years old man who presented with Dyspnea on exertion. CT scan revealed the absence of left lung, and all bowels occupying the left chest. The video will demonstrate the various steps used by 5 trocars to reduce the whole bowel inside the abdomen and reconstruction of left diaphragm using composite graft of Vicryl and polyester mesh and protack is used to fix the mesh at the ribs site and prolene sutures to fix the posterior rim of the diaphragm. Patient had smooth postoperative course. Conclusion: Complicated cases can be done safely if done by experienced surgeon in Laparoscopic Surgery.

Aims: Defining the optimal surgical approach for extreme obese patients (Body Mass Index [BMI] [60 kg/m2) has been a challenge for bariatric surgeons. The general bariatric patient has a predictable excess weight loss (EWL) of more than 50–60% after Roux-en-Y gastric bypass (RYGB). However, approximately 15% of the extreme obese patients is not able to achieve a similar weight loss. Moreover, many of the extreme obese patients are still considered medically obese (lowest BMI [35 kg/m2) one year post-RYGB. Several authors have reported the addition of an adjustable gastric band (AGB) as a revisional procedure after failed RYGB. In this presentation the feasibility and short-term results of adding an AGB to a RYGB as a primary bariatric procedure are examined. The technical features of the operation are discussed in detail. Methods: A primary RYGB is performed in an standardized way. A circular stapled gastro-enterostomy is created. After completing the RYGB-construction an AGB is positioned around the gastric pouch, just above the gastro-enterostomy. To prevent slippage, the band is fixed by suturing the gastric remnant to the gastric pouch just above and below the band. Results: Between November 2009 and December 2010, 7 extreme obese patients underwent a laparoscopic adjustable banded Roux-en-Y gastric bypass as a primary bariatric operation. Mean BMI at the time of surgery was 68.1 kg/m2 (range 53.1–73.9 kg/m2). One male patient (21 years, BMI 70 kg/m2) developed a pneumonia postoperatively. No other short-term (4 weeks) postoperative complications were observed. Conclusion: From this small series of patients we can conclude that this combined operation is a feasible and safe procedure with no major early postoperative complications. The working theory behind this intervention is that a sequential mechanism for weight loss can be expected. In the initial phase the well-described effect of the RYGB will induce weight loss to reach a plateau at 12–18 months. After this stadium a gradual filling of the band is performed to create an additional restriction thereby causing further weight loss. We believe that this procedure can be of great value to achieve better results in EWL for the extreme obese patients.

V147 - Video-Abdominal Cavity and Abdominal Wall

V149 - Video - Liver and Biliary Tract Surgery

LAPAROSCOPIC REPAIR OF CHRONIC TRAUMATIC DIAPRAGMATIC HERNIA: VIDEO PRESENTATION E. Altinli, A. Simsek Celik, A. Sumer Ministry of Health, ISTANBUL, Turkey

SINGLE PORT LAPAROSCOPIC SURGERY (SPLS) IN COMBINED CONDITION: SIMULTANEOUS CHOLECYSTECTOMY AND APPENDECTOMY B.J. Choi, S.C. Lee The Catholic University of Korea, DAEJEON, Korea

Aim: Impact of laparoscopic approach for repair of choric diaphragmatic hernia Methods: Traumatic diaphragmatic hernias are an unusual presentation of trauma, and are observed in about 10% of diaphragmatic injuries. The diagnosis is often missed because of non-specific clinical signs, and the absence of additional intraabdominal and thoracic injuries. We present a case of 27-year-old women hospitalized for abdominal pain localized in the left upper quadrant, postprandial distention and vomiting. Her medical history included a blunt trauma (traffic accident) 21 years ago. A chest X-ray showed left diaphragm elevation, and computed tomography revealed that the stomach had been transposed in the hemithorax through a left diaphragmatic rupture. Upper GIS endoscopy revealed herniation of fundus and corpus of the stomach through diaphragm to the left thoracic cavity. Results: The patient underwent laparoscopic diaphragmatic repair, at which time the stomach and greater omentum were reduced back into the abdomen and the diaphragmatic defect was repaired with 15.2 9 10.2 cm dual mesh. Postoperative period was uneventful, and the patient was discharged at postoperative 3 day. Conclusion: Chronic diaphragmatic hernia repair is usually done by open approaches. In recent years thoracoscopic interventions have gained popularity. However, laparoscopic repair of chronic diaphragmatic hernia is a rarely reported procedure, and it could be a choice of treatment in selected cases.

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Purpose: We have experienced combined operation of single port laparoscopic cholecystectomy during single port laparoscopic appendectomy. Herein we would like to introduce our experience with technique. Methods: Between April 2009 and April 2010, 4 patients underwent simultaneous single port laparoscopic cholecystectomy and appendectomy. All the patients were diagnosed with acute appendicitis and asymptomatic gallbladder stone. They were 2 men and 2 women with median age of 55.5 (range: 47–66) years and body mass index of 23.5 (range: 19.7–27.1) kg/m2. This single port laparoscopic surgery (SPLS) was performed 1.5 cm umbilical incision. Single port was made by combination of wound protector with surgical glove. A 10 mm and two 5 mm trocars were applied to 2nd, 3rd, and 5th glove fingers for use. We used conventional straight and rigid type laparoscopic instruments. Cholecystectomy was performed first in all 4 cases. Resected gallbladder and appendix were extracted through the umbilical incision protected by wound retractor within or without Endo-lap bag. Results: Simultaneous single port laparoscopic cholecystectomy and appendectomy was successful in all cases. There was no additional incision for the switching to conventional multiport laparoscopic surgery or conversion to open surgery. The average values were as follows; operative time [90 (range: 70–140) min], hospital stay [3.25 (range: 3–4) days]. And the final 1.5 cm scar would be concealed within umbilicus. Conclusions: In our experience, combined operation of single port laparoscopic cholecystectomy and appendectomy has been demonstrated to be safe and feasible. The benefits or pitfalls of this surgery warrant further investigation and experience.

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V150 - Video-Abdominal Cavity and Abdominal Wall

V152 - Video - Different Endoscopic Approaches

LAPAROSCOPIC REPAIR OF RECURRENT INGUINAL HERNIA FOLLOWING FOUR PREVIOUS OPEN MESH REPAIRS W.D. Beasley1, P. Morcous1, P. Mekhail2 1 Abertawe Bro Morgannwg University Health Board, BRIDGEND, United Kingdom. 2Prince Charles Hospital, MERTHYR TYDFIL, United Kingdom

VIDEO-ASSISTED RETROPERITONEAL NECROSECTOMY: THE STEP-UP APPROACH FOR SEVERE ACUTE NECROTIZING PANCREATITIS I. Poves, F. Burdı´o, M.A. Martı´nez-Serrano, Y. Maestre, M.J. Pons, L. Grande Hospital del Mar, BARCELONA, Spain

Aim: To demonstrate the operative feasibility and technique of laparoscopic recurrent inguinal hernia repair following multiple previous open mesh repairs. Method: A 36 year old man presented with a recurrent right inguinal hernia repair following four previous open mesh repairs within the previous few years. The recurrence was repaired using a trans abdominal laparoscopic approach with mesh. Results: Laparoscopy confirmed medial recurrence and this was successfully repaired using mesh. Following hernia reduction the pre-peritoneal space was successfully dissected despite mesh from previous repairs being present in this anatomical layer. The defect was repaired using mesh secured with tacks. There were no significant early or late surgical complications and the patient remains well without evidence of recurrence at one year post-operatively. Conclusions: This case illustrates the potential for high recurrence rates following open repair of recurrent inguinal hernias and demonstrates that the laparoscopic approach to such recurrent hernias is feasible, safe and robust even after multiple previous attempts at open repair.

Introduction: Severe acute necrotizing pancreatitis (SANP) is a challenging disease for surgeons. Although the indication of surgical debridement can be performed when pancreatic infection is demonstrated, there is enough evidence that the more we can postpone surgical treatment, more definitive is the treatment. Antibiotherapy and percutaneous drains have lead to delay, in some cases, the definitive surgical necrosectomy. The step-up approach is based in these principles. Retroperitoneal approach is a lesser aggressive operative technique than the classical laparotomy, above all if it can be done by video-assisted retroperitoneal approach as it has been described by van Santvoort HC et al. Video presentation: An 82-years old man was referred to our centre with the diagnosis of severe acute biliary pancreatitis. On enhanced-CT it was seen extended pancreatic necrosis ([50%) affecting the body and tail of the pancreas. Antibiotic treatment with Imipenem was administered. On 37th day infected necrosis was diagnosed on CT. A retroperitoneal percutaneous drainage was inserted obtaining purulent liquid. He improved clinically, but 20 days before he presented again abdominal sepsis. At this moment (58th day of admission) it was decided to perform surgical debridement and necrosectomy. It was done a video-assisted retroperitoneal necrosectomy by a 5 cm incision. The previously placed drainage was used as a guide for entering in the correct retroperitoneal space. A great amount of infected necrosis was removed. A huge drain was left in the pancreatic space. The patient was discharged on 45th day after surgical treatment. Total length of stay was 103 days. Conclusions: The step-up approach is a useful strategy for management of patients suffering from severe acute necrotizing pancreatitis. Video-assisted retroperitoneal necrosectomy is a well described technique that can be performed in some patients with well delimited, consistent, localized and evolved infected pancreatic necrosis.

V151 - Video - Liver and Biliary Tract Surgery

V153 - Video-Abdominal Cavity and Abdominal Wall

APPLICATION OF MICROWAVES ABLATION IN THE TREATMENT OF ABDOMINAL TUMOURS M. Barabino, R. Santambrogio, M. Costa, P. Carnevali, M. Conti, A. Cadeo, E. Opocher San Paolo Hospital, MILANO, Italy

TAPP IN A BILATERAL INGUINAL HERNIA F.J. Buils Vilalta, J.J. Sanchez Cano, A. Cabrera Vilanova, M. Socias, J. Prieto Amigo´, E. Baeta Capellera Sant Joan Hospital, REUS. TARRAGONA, Spain

This video explains the role of microwaves ablation (MWA) in the treatment of abdominal tumours. This device represents a technological evolution of the standard radiofrequency termoablation, thus leading to a wider and faster necrosis’ area. We use 14 G antenna for a mean ablation time of 5 min with a 40–50 W of power. Thus microwaves can be used as alternative solution to radiofrequency ablation either in the standard treatment of hepatocellular carcinoma (HCC) or in the care of other selective abdominal tumours. The first case report concerns about MWA’s application in the laparoscopic ablation of an esophytic HCC in segment 3. The next case shows the sequential treatment of a huge HCC close to portal and biliary bifurcation treated with a percutaneous ‘ left-right’ biliary drainage via PTBD, a laparoscopic MWA of the HCC and fulfillment treatment with TACE 1 month later. In the third case report, laparoscopic MWAs have been used in alternative to ‘Habib’ technique to treat an HCC in segment two. In the fourth and fifth case, MWA have been proposed for the laparoscopic care of extrahepatic tumours, the former concerns about a pancreatic neoplasm non suitable to resection for local infiltration, and the latter about a renal tumour via robotic technique. Finally, MWA is an effective and safe tool in the treatment of HCC and of selective abdominal parenchymal tumours in alternative to standard radiofrequency ablation.

Aims: The laparoscopic treatment of inguinal hernias is gaining popularity, is well developed and has already established a technology support. The low recurrence rates compares favourably to other tension-free mesh hernia repairs. Methods: A 23-year-old male with a bilateral hernia, indirect hernia on the left and the right direct. We used the transabdominal technique (TAPP) under general anesthesia. There were two 5 mm and one 11 mm ports. Results: The defect was corrected laparoscopically using a polypropylene meshes. A laparoscopic tacker secured the meshes to abdominal wall. Peritoneum was closed with an absorbable 2-0 running suture. The patient was discharged 24 h after surgery without any complication, having shorter convalescence and a quick return to work. Conclusion: Laparoscopic TAPP hernia repair was an effective and safe technique, especially suited for recurrent and bilateral hernias, with a high degree of patient satisfaction.

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V154 - Video - Liver and Biliary Tract Surgery LAPAROSCOPIC TREATMENT OF A GIANT CIST OF LIVER A. Delitala San Gerardo Hospital, Monza, MONZA, Italy A 70 year old female patient was admitted in our unit presented with persistent upper abdominal pain in known simple hepatic cyst. CT scan showed a large cystic lesion of 12 9 21 9 16.5 cm of volume, occupying the inferior part of the right lobe of the liver, with a slight sepimentation, with regular edge and hydric density as a simple cyst. First we have drained the cyst with a pig-tail percutaneous drainage obtaining a significant reduction of the mass. Then we proceeded with a laparoscopic complete marsupialization. The video shows our technique for the laparoscopic treatment of this giant cyst, which was found to be an hemorrhagic one, in order to obtain the resolution of the pathology without any laparotomic procedures. The patient was discharged 4 days after the surgery without any complications.

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