Surg Endosc (2013) 27:S504–S527 DOI 10.1007/s00464-013-2878-7

and Other Interventional Techniques

2013 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Baltimore, Maryland, USA, 17–20 April 2013 Video Channel

 Springer Science+Business Media New York 2013

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USE OF INTRAOPERATIVE ROBOTIC ULTRASONOGRAPHY TO CONFIRM LOCALIZATION AND MARGIN CLEARANCE DURING ROBOTIC ASSISTED LAPAROSCOPIC SPLEEN PRESERVING DISTAL PANCREATECTOMY FOR MUCINOUS CYSTIC NEOPLASM OF THE PANCREAS Luca Giordano, MD FACS (presenter) Aria Health, Philadelphia

Incarcerated Diaphragmatic Hernia After Convergent Maze Procedure Tejwant S Datta, MD (presenter), John P Breard, MD, Thomas Guirkin, MD Southside Regional Medical Center

Robotic assisted spleen preserving distal pancreatectomy has been described. The use of intraoperative robotic ultrasonography can help in confirming the localization of the lesions and insuring margin clearance at the time of the resection. This video demonstrates the feasibility of this technique.

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Background: The convergent maze procedure (CMP) is a minimally invasive technique used for the surgical treatment of atrial fibrillation (AF). This technique combines an epicardial and endocardial ablation using radiofrequency energy. The endocardial component is performed via a venous catheter, usually placed in the femoral vein. The epicardial ablation is performed via an abdominal incision and transdiaphragmatic trocar (nContact, Inc., Morrisville, NC). We present a case report of a patient with an incarcerated hernia through the transdiaphragmatic window used for convergent maze procedure. Case: EP is a 65 year-old African American male who presented to the emergency department with acute onset epigastric abdominal pain with nausea. His surgical history is significant for convergent maze procedure (performed at another institution) five months prior to his presentation. He was initially diagnosed with a partial small bowel obstruction and treated conservatively with nasogastric tube decompression and bowel rest. His obstruction resolved, but he developed high fevers and recurrent epigastric symptoms. A repeat CT scan demonstrated pneumopericardium, but was further clarified, showing a diaphragmatic hernia containing transverse colon. EP was taken to the OR for laparoscopic reduction of the hernia with repair using two VentralexTM hernia patches (Bard Davol, Inc. Warwick, RI). EP was uneventfully discharged and was free of symptoms on surgical follow-up. Conclusion: Convergent maze procedure is a relatively new surgical technique used to treat patients with AF. To our knowledge, this is the first reported case of diaphragmatic hernia with bowel incarceration after CMP. More data is required to determine the incidence of diaphragmatic hernia after CMP. Early suspicion and diagnosis is essential to prevent mediastinal sepsis. Laparoscopic repair of incisional diaphragmatic hernias after CMP is feasible.

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Transperitoneal gastroscopy for removal of a gastric foreign body Loren Berman, MD (presenter), David Rothstein, MD Ann & Robert H. Lurie Children’s Hospital of Chicago

LAPAROSCOPIC DISTAL PANCREATECTOMY FOR ADENOCARCINOMA OF THE PANCREATIC BODY Giancarlo Basili, MD (presenter), Nicola Romano, MD, Dario Pietrasanta, MD, Graziano Biondi, MD, Orlando Goletti, MD General Surgery Unit, ‘‘Lotti’’ General Hospital, Pontedera, Pisa, Italy

A 5 year-old girl suffered an esophageal perforation during attempted endoscopic retrieval of a swallowed ring. The perforation healed spontaneously after thoracic drainage and postpyloric feeding. The ring was later removed through a trocar placed under laparoscopic guidance directly into the stomach. This case demonstrates several useful techniques, including placement of transcutaneous holding sutures to maintain traction on the stomach and use of a grasping instrument placed parallel to an endoscopic camera in a single port.

The video presents a case of a 73-year-old female patient affected by an adenocarcinoma of the body of the pancreas. CT-scan and magnetic resonance imaging demonstrated a solid lesion of about 25 mm in diameter. Serum carbohydrate antigen was highly elevated; CEA level was normal. This video demonstrated the technique of a laparoscopic distal splenopancreatectomy which achieves a radical resection with clear circumferential margins. The resection proceeds right to the left to include celiac lymphadenectomy, early division of the splenic artery, splenic vein and the neck of the pancreas. A medial to lateral mobilization of the pancreas is performed to ensure an adequate oncologic clearance.

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Robotic Assisted cortical sparing left adrenalectomy Avishai Meyer, MD, Abhijit Shaligram, MD, Dmitry Oleynikov, MD, Pradeep Pallati, MD (presenter) University of Nebraska Medical Center

COMPLETELY LAPAROSCOPIC TOTAL GASTRECTOMY WITH LINEAR-STAPLED ANASTOMOSIS Hiroshi Okabe, MD (presenter), Kazutaka Obama, MD, Eiji Tanaka, MD, Shigeru Tsunoda, MD, Shigeo Hisamori, MD, Yoshiharu Sakai, MD Department of Surgery, Kyoto University, Japan

Introduction: Laparoscopic adrenalectomy is the standard of care for unilateral adrenal mass with pheochromocytoma. In patients with bilateral disease or with previous adrenalectomy, increasing evidence has shown the feasibility of partial adrenalectomy, which will maintain residual adrenal function so that the patients do not require further hormone replacement therapy. Case Report: Here, we present a case of a 21 year old patient with Von Hippel Lindau syndrome who was diagnosed with right adrenal mass 6 years ago and underwent laparoscopic right adrenalectomy at that time. Now, he presented with recurrent pheochromocytoma and the presence of a nodule on the left adrenal gland. Patient was offered robotic assisted cortical sparing left adrenalectomy. The patient is positioned in right lateral decubitus position. Four ports are placed along the left costal margin. Initial dissection of the adrenal gland is performed laparoscopically including the clipping and division of the adrenal vein. After the gland is mobilized, intraoperative ultrasound is used to locate the tumor and later the standard three-arm da Vinci Surgical System was introduced with hook dissector on the right arm and bipolar dissector on the left arm. With increased stability and three dimensional visualization from the surgical robot, the adrenal mass was then enucleated without difficulty. The patient was discharged the next day after 23-hour observation. At two month follow-up, the patient is on half dose maintenance therapy for steroids. Conclusion: Cortical sparing partial adrenalectomy is feasible. Robotic assistance provides enhanced three-dimensional visualization and minimal manipulation of adjacent normal adrenal tissue.

Introduction: Although number of patients undergoing laparoscopic gastrectomy is rapidly increasing in eastern Asia, laparoscopic total gastrectomy is not popular yet. Difficulty in reconstruction and lymph node dissection in deeper area is a major reason. We established an approach to deep area around the splenic hilum and introduced intracorporeal linearstapled anastomosis to perform completely laparoscopic total gastrectomy securely. Methods and Procedures: (1) The gastrosplenic ligament is divided using a sealing device, while the operation table is tilted to the right. It is important to identify the splenic upper pole to determine the proper dissection line. The gastrophrenic ligament is cut from the caudal side, and then the uppermost branch of the short gastric vessels is divided. (2) After transecting the duodenum, we approach to the space behind the esophagus from the right side (Medial approach). By the blunt dissection between the perigastric fat tissue and the fusion fascia, the fundus is completely mobilized. After the transection of the esophagus and division of the left gastric artery, splenic lymph node dissection is done under a better visualization. (3) Y-anastomosis is performed using linear stapler and hand-sewn closure of the entry hole. Then, the Roux-limb is brought up via an ante-colic route and esophagojejunal anastomosis is performed with functional end-to-end anastomosis using 45 mm linear staplers. The Petersen’s space is closed. Results: Completely laparoscopic total gastrectomy was successfully performed in 114 out of 115 patients. One open conversion was done for splenic bleeding (1.1%). Mean blood loss was 153 g. Mean operation time was 376 min. Extnent of lymphadenectomy was D1 + in 83, D2 in 31 patients. Postoperative complication was observed in 19 patients (16.7%). Mortality was 1.7%. Conclusion: Completely laparoscopic total gastrectomy with linear-stapled anastomosis is technically feasible with excellent short-term outcome.

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REPAIR OF DISTAL ESOPHAGEAL PERFORATION (BOERHAAVE’S SYNDROME) BY LEFT THORACOSCOPY WITH THE PATIENT IN PRONE POSITION Giovanni Dapri, MD FACS FASMBS HonFPALES (presenter), Sergio Carandina, MD, Luisa Brambilla, RN, Leonard Gerard, MD, Etienne Stevens, MD, Alain Roman, MD, Jacques Himpens, MD, Guy-Bernard Cadie`re, MD PhD Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium

ROBOTIC ESOPHAGECTOMY Jagdishwar Gajagowni, MSMch surgical Oncology (presenter) Krishna Institute of Medical Sciences

Background: Boerhaave’s syndrome is an emergency disease related to high risk of mortality and morbidity. Surgical treatment is usually performed by thoracotomy or thoracoscopy with the patient in lateral position. The authors report a patient with a distal esophageal perforation, treated by left thoracoscopy in prone position. Video: A 44-year old male was admitted to emergency room after 14 hours of an episode of vomiting and hematemesis. Preoperative work-up evidenced a perforation of the distal esophagus on the left side, associated to a pneumomediastinum. The patient underwent left thoracoscopy in prone position, after induction of general anesthesia using Carlens double lumen tube. Three trocars of 5-mm, 10-mm, 5-mm, were placed in the 5th, 7th and 10th intercostal spaces respectively. The exploration of the chest cavity showed presence of free liquid and fibrin, without evident esophageal perforation. The latter was however demonstrated after dissection of the mediastinal pleura, and appeared to be 2 cm in length. A nasogastric tube was advanced into the stomach under view, and a supplementary trocarless grasper was placed in the 10th space, to improve exposure. The esophagus perforation was closed using 2/0 silk interrupted sutures, with a reinforcement patch using the inferior pulmonary ligament. The cavity was cleaned and a chest tube replaced the 5-mm trocar in the 10th intercostal space, with its tip close to the suture. Results: Operative time was 90 minutes, and no significant operative bleeding was noted. The patient was hospitalized in the Intensive Care Unit and extubated after 24 hours. A chest tube was placed in the right chest after 10 days for a pleural effusion, and a pericardic drain was placed after 16 days for pericardic tamponade. The gastrograffin swallow at 10 days showed a residual sinus at the site of the perforation, and a repeat gastrograffin swallow at 20 days was negative for leak. The patient was allowed to be discharged after 32 days. Conclusions: Esophageal perforation can be treated in prone position thoracoscopy because the access is advantageous by the effect of gravity on the cardio-pulmonary organs. Success of primary suture depends on the timing between the incidence and the treatment; however the morbidity remains high.

We hereby intend to show in our video presentation a case of robotically assisted total esophagectomy. It was performed in our institute on a 33 yr old lady presenting with a 5 month history of progressive dysphagia. Preoperative workup in terms of a barium swallow and contrast enhanced CT-scan were done, it was suggestive of multiple leiomyomata involving whole of esophagus. Patient was operated in a prone position with two 8 mm robotic ports and an assistant port. We used a zero degree camera through a 12 mm port. With the use of a monopolar scissor and a bipolar grasper the whole of esophagus was mobilised upto the hiatus. The azygous vein was clipped with hemlocks and divided. The reconstruction was done with a mobilised stapled gastric conduit and anastomosed with cervical esophagus in single layer using 3-O PDS. The patient was discharged on 6th postoperative day and oral intake was started on 10th postoperative day. We have been performing robotically assisted total esophageal mobilisation for operable carcinoma esophagus in our institute over last 1 year.

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TRANSUMBILICAL SINGLE-ACCESS LAPAROSCOPIC TOUPET FUNDOPLICATION Giovanni Dapri, MD FACS FASMBS HonFPALES (presenter), Sergio Carandina, MD, Perrine Mathonet, MD, Jacques Himpens, MD, Guy-Bernard Cadie`re, MD PhD Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium

Robot-assisted Laparoscopic Repair of a Giant Paraesophageal Hernia Mario A Masrur, MD (presenter), Gianmarco Contino, MD, Luca Milone, MD, Eduardo Fernandes, MD, Enrique F Elli Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA

Background: Different procedures have been reported to be feasible and safe through single-access laparoscopy (SAL). The authors report a transumbilical SAL Toupet fundoplication. Video: A young lady sought care for gastroesophageal reflux disease associated to grade B esophagitis, hiatal hernia and esophageal dyskinesia. The SAL procedure was performed by the opening of the umbilicus through the Hasson technique. An 11-mm reusable trocar was inserted for a 10-mm, 30 angled, non flexible, and standard length scope. Curved reusable instruments were introduced through the same scar without trocars. The gastroesophageal junction was exposed thanks to the insertion of a millimetrical wire (2 mm) under the xiphoid access. Crura repair and fundoplication were realized by intracorporeal knots, using curved needle-holder. The umbilicus was finally closed in layers. Results: No extraumbilical trocar was necessary, and no peroperative complications were registered. Operative time was 172 minutes and final umbilical scar 15 mm. The postoperative pain was kept minimal, and the patient was allowed to be discharged on the 3rd postoperative day, after a satisfied gastrograffin swallow. Conclusions: Transumbilical SAL Toupet fundoplication is feasible. Use of curved and reusable instruments permits to avoid the conflict between the instruments tips intracorporeally or between the surgeons’ hands externally. Thanks to this technique the cost of SAL is similar to multitrocar laparoscopy.

Introduction: Paraesophageal hernia repair is one of the most challenging procedures in minimally invasive surgery, mostly due to the small space for peri-esophageal dissection. The robotic approach may benefit in the mediastinal dissection and anatomical reconstruction. We present a video of a robot-assisted repair of a paraesophageal hernia reinforcing the hiatus with a matrix biological mesh. Methods: A 72 year old man with a long lasting gastroesophageal reflux and giant paraesophageal hernia underwent robotic-assisted repair of a paraesophageal hernia with a biological mesh. Results: The pneumoperitoneum was achieved and a diagnostic laparoscopy was performed showing a large hernia with almost 70% of the stomach entrapped and slipped into the chest. Once the stomach and the distal esophagus were completely mobilized, closure of the crus was done with interrupted stitches and reinforced with a matrix biological mesh. A Nissen fundoplication was later performed tutored with a 56 Fr bougie. During the procedure an endoscopy was performed to identify the anatomy and indemnity of esophagus and stomach after dissection. The operative time was 220 minutes and blood loss minimal. There was no peri-operative complication and patient was discharged on PO day 2. Conclusions: This video highlights the technical details and issues performing a robotic paraesophageal hernia repair. The robotic system allows for fine dissection and challenging sutures in a narrow space as the mediastinum. The robot may reduce complications such as esophageal perforation, pleural or vascular injury.

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Laparoscopic pancreatic resection for invasive pancreatic ductal adenocarcinoma Akihiro Cho (presenter), Hiroshi Yamamoto, Osamu Kainuma, Yorihiko Muto, SeonJIn Park, Hidehito Arimitsu, Mamoru Sato, Hiroaki Souda, Atsushi Ikeda, Yoshihiro Nabeya, Nobuhiro Takiguchi, Matsuo Nagat Chiba Cancer Center Hospital, Japan

LAPAROSCOPIC CONVERSION OF SLEEVE GASTRECTOMY TO ROUX- EN-Y GASTRIC BYPASS FOR CHRONIC LEAK E Lo Menzo, MD PhD (presenter) Cleveland Clinic Florida

Background: Although recent technological developments and improved endoscopic procedures have further spread the application of laparoscopic pancreatic surgery, laparoscopic pancreatic resection for invasive ductal adenocarcinoma is still not universally accepted as an alternative approach for open surgery. Methods: 20 patients with invasive pancreatic ductal adenocarcinoma (PDAC) underwent laparoscopic pancreatic resection. Surgical technique: We have performed laparoscopic diatal pancreatectomy based on radical antegrade modular pancreatosplenectomy (RAMPS), including distal pancreatectomy with en bloc celiac axis resection, for left-sided PDAC, and laparoscopic pancreaticoduodenectomy with resection of the superior mesenteric arterial plexus for right-sided PDAC. Results: In all patients, laparoscopic pancreatic resection could be successfully performed, as planned. In 16 of 20 patients, the surgical margins were histologically clear (R0 resection). Conclusions: Laparoscopic pancreatic resection is minimally invasive, safe and feasible, and can achieve R0 resection in selected patients with invasive pancreatic ductal adenocarcinoma.

Introduction: LSG is an accepted procedure performed worldwide. The proper management of various surgical complications is still under debate. We present a case of chronic leak after sleeve gastrectomy that required conversion to RYGB. Materials and Methods: A 40 year old female underwent a sleeve gastrectomy for morbid obesity. Post-operatively the patient developed persistent pain, nausea, and vomiting. UGI showed a stricture in the middle of the sleeve, but no leak was seen. Treatments included dilatations, stent placement, and TPN, however no improvement was seen. She underwent a laparoscopic conversion to a RYGB. Intraoperative findings showed chronic leak penetrating posteriorly into the pancreas. The sleeve was dissected of the liver and off of the pancreas. The middle and proximal portion of the sleeve was resected using linear staple. An esophagojejunostomy was created using a side-to-side linear staple technique. Result: The recovery of the patient was uneventful, with a normal UGI on post operative day one without leak or obstruction. Conclusion: The optimal management of leaks after sleeve gastrectomy is still under debate. The different techniques being used include stents, t-tube insertion, oversewing the defect, and some suggest using BioGlue. The ability to convert a sleeve gastrectomy to a Roux-en-Y gastric bypass appears to be a safe option for the treatment of chronic leaks. Keywords: Laparoscopic Sleeve Gastrectomy, Leak, Revision

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Laparoscopic anterior resection with TME for a T4 sigmoid tumor infiltrating the peritoneal refection and the right seminal vesicle using real 3 mm percutaneous surgical instruments with standard 5 mm end-effectors Luigi Boni, MD FACS (presenter), Luisa Giavarini, MD, Elisa Cassinotti, MD, Giulia David, MD, Sabastiano Spampatti, MD, Stefano Rausei, MD Minimally Invasive Surgery Center - University of Insubria

Slipped Band with Necrotic stomach requiring conversion to a Roux En Y esophagojejunostomy Rana C Pullatt, MD FACS (presenter), Shaina Eckhouse, MD Medical University of South Carolina

This video shows our technique for laparoscopic anterior resection with TME for a large sigmoid tumor infiltrating the peritoneal reflection and the right seminal vesicle using real 3 mm percutaneous surgical instruments with standard 5 mm end-effectors as retracting devices. Patients was placed in lithotomic position, one 10 mm trocar (for the optic) was placed in the right flank and a further 12 mm in the right iliac fossa. Further two real 3 mm percutaneous surgical instruments were inserted in the sovrapubic midline and left flank respectively: this new instruments can be assembled intracorporeally with a standard 5 mm end-effectors in order to achieve a good grip and retraction as for standard 5 mm instruments. The procedure started with the dissection of the tumor from the peritoneal reflection on the right side that appeared macroscopically infiltrated by the tumor as for local peritoneal seeding. Isolation of the inferior mesenteric artery and vein was carried out and full mobilization of the left colon completed, the right ureter that identify and isolated, and the local infiltration of the peritoneum was removed ‘‘en-bloc’’ requiring partial resection of the seminal vesicle. Total TME was completed and the rectum transected using surgical stapler flowed by endto-end colo-rectal anastomosis. Laparoscopic anterior resection can be safely performed even advanced tumor; the used of accessory percutaneous microinstruments can help to obtain good traction and contratraction reducing the surgical trauma.

This is a case that highlights the pitfalls of Medical Tourism in Bariatric Surgery. The patient had a band placed in Mexico 5 years ago and had no follow up and minimal weight loss. Patient had never been seen by an accredited Bariatric program in the US. The patient had increasing dysphagia for nearly 2 months and then started having cramping abdominal pain . She was seen by her internist 12 hours after her abdominal pain had started. The patient was then admitted and on work up a CT scan was obtained which showed pneumatosis in the wall of the stomach. Patient was referred to our hospital for emergent surgery. On laparoscopic exploration necrosis of the upper half of the stomach was confirmed from a slipped band. We initially tried to dissect below the left gastric artery to attempt to salvage a small gastric pouch, however it was evident that the stomach had necrosed all the way upto the ge junction. We performed a subtotal gastrectomy and a esophagojejunostomy. The esophagojejunostomy was performed with a hand assist technique using a 25 eea. We also placed a g tube in the remnant distal stomach. The patient did well and has had 45 pound weight loss with no complications 3 months out at the time of submission of this abstract. This case captures what is an increasing problem in this country due to the burgeoning medical tourism industry.

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Remnant Gastrectomy and Hiatal Hernia Repair in a Patient Status Post Gastric Bypass with Recurrent Marginal Ulceration and GERD Due to Gastro-Gastric Fistula Emanuele Lo Menzo, MD PhD (presenter) Cleveland Clinic Florida

Laparoscopic repair of a gastro-small bowel-colonic fistula caused by a gastrostomy tube John A Hagen, MD FRCSC, Eran Shlomovitz, MD FRCPC (presenter) Center for Excellence in Bariatric Surgery, Humber River Regional Hospital Finch Site, University of Toronto, Department of Surgery

Introduction: Marginal ulceration can lead to gastro-gastric fistulas and may necessitate revisional procedures. Materials and Methods: This a 42-years-old woman underwent with a history of gastric bypass approximately 7 years prior, presented with persistent back pain and recurrent anastomotic ulcer. Both the UGI and the EGD showed gastro-gastric fistula. The patient underwent a laparoscopic revision. The gastric remnant is identified and divided distally with the linear stapler. The whole gastric remnant and the fistulous tract are excised en-bloc. The staple lines were oversewn. Then a hiatal was repaired with a knotless suture (QuillTM). Result: The patient tolerates the procedure well. Recovery was uneventful, normal UGI on POD 1 without leak or obstruction. Conclusion: Gastro-gastric fistulas can be a complication of marginal ulceration after RYGB. Reoperation and laparoscopic revision of the gastric pouch as well as resection of the gastric remnant is necessary in most cases. Keywords: Morbid Obesity, Gastric Bypass Revision, Anastomotic Stricture, Laparoscopy, Complication

This video shows the repair of a gastro-small bowel-colonic fistula caused by a gastrostomy tube. The patient had some problems with vomiting after gastric bypass and required gastrostomy tube to help manage her nutrition. Over the course of one year, the gastrostomy tube eroded through the gastric remnant into the roux limb and colon. This video shows how this was repaired laparoscopically.

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LAPAROSCOPIC DIAPHRAGMATIC HERNIA REPAIR WITH MESH - VIDEO PRESENTATION Matthew Benenati, DO (presenter), Alia Abdulla, DO, Linda Szczurek, DO, Adeshola Fakulujo, MD University of Medicine and Dentistry of New Jersey

Combined Laparoscopic & Endoscopic Transgastric Esophageal Stent Retrieval Viet Phuong, MD (presenter), Kevin El-Hayek, MD, Matthew Kroh, MD FACS Cleveland Clinic Foundation

Continuing in the trend of minimally invasive surgery, laparoscopic repair of diaphragmatic hernias is quickly becoming the preferred method. Synthetic mesh was used over a partial primary closure of a rare, rightsided anterior diaphragmatic (Morgagni) hernia.

Management of chronic benign esophageal stricture is challenging. Patients often undergo repeated esophageal dilation & stent changes to alleviate their dysphagia. Esophageal stents can migrate and be difficult to retrieve. The following case highlights the management of this complication. The patient has chronic distal esophageal stricture for refractory candidiasis infection in the setting of AIDS. He has undergone numerous esophageal dilations and stenting to palliate his severe dysphagia. A fully covered stent placed in his esophagus migrated into his stomach, not amenable to endoscopic retrieval. The video demonstrates a combined laparoscopic and endoscopic transgastric stent retrieval technique. The minimally invasive technique demonstrated the benefits of using both laparoscopic and endoscopic visualization to safely remove the migrated stent.

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Laparoscopic management of gastric bypass pouch stricture after paraesophageal hernia repair with mesh Pablo Marin, MD, Miguel Lamota, MD, Abraham Betancourt, MD, Carolina Ampudia, MD, Abraham Abdemur, MD, Emanuele Lo Menzo, MD, Samuel Szmostein, MD, Raul Rosenthal, MD (presenter) Bariatric and Metabolic Institute, Section of Minimally Invasive Surgery, Cleveland Clinic Florida

LAPAROSCOPIC MANAGEMENT OF PORT SITE RICHTER’S HERNIA FOLLOWING GASTRIC BYPASS Michel Gagner, MD, Davit Sargsyan, MD (presenter), Moataz Bashah, Mohammed Al Kuwari, MD, Mohammed Rizwan, MD Hamad General Hospital, Doha, Qatar

Introduction: Laparoscopic paraesophageal hernia repair (LPEHR) is associated with a high recurrence rate. Repair with mesh lowers recurrence but can cause dysphagia and erosion. Materials and Methods: A 55-year-old female presented to our clinic with epigastric abdominal pain and vomiting after laparoscopic Roux-en -Y gastric bypass and paraesophageal hernia repair with non-absorbable mesh in 2005. Preoperative UGI and EGD study showed a stricture in the gastric pouch at the hiatus. The patient underwent to a laparoscopic revision surgery. The intraoperative findings included a large recurrent paraesophageal hernia with dense adhesions with the mesh. The recurrent hernia was reduced and the defect closed with running knotless suture (QuillTM). Intraoperative endoscopy showed complete patency of the pouch. Result: The operative time was 65 minutes, with an estimated blood loss of 50 ml. The recovery of the patient was uneventful. The length of stay was 3 days. Patient is asymptomatic after 3 months of follow up. Conclusion: The current data tend to support the use of prosthetic materials for hiatal repair in large PEHs, however the mesh can produce erosion and stricture. Revisional bariatric surgery is safer when is performed in a high volume center, where the surgeons have the technical skills, knowledge, and experience.

We present a case of port site Richter’s hernia following gastric bypass successfully managed laparoscopically. A 28 year old lady with BMI of 44 without comorbidities underwent laparoscopic Roux-en-Y antecolic gastric bypass with stapled anastomosis performed with EEA 25 mm introduced through the left midclavicular port site. All port sites greater that 10 mm were closed with vicryl 0/0 sutures. Postoperative period was uneventful and patient was discharged on 2nd postop day tolerating fluid diet. Seven days later patient presented to emergency department complaining of fever, pain and purulent discharge from the left midclavicular port. Abdominal CAT scan demonstrated a small bowel loop entrapped in the left port site wound. Patient was taken for laparoscopic exploration which revealed a loop of alimentary limb eventuating through the dehisced left midclavicular port site wound with signs of infection. The loop was bluntly dissected by finger from outside and atraumatic forceps from inside, reduced to the abdomen and found to be viable and non-perforated. The wound was closed by suture passer with interrupted prolene 1/0 stitches. Postoperative period was uneventful and patient was discharged on day 7 with clean and granulating wound. Outpatient follow up on day 21st showed healed wound with no apparent facial defects. Despite port site closure some patients might develop wound dehiscence or hernias especially in presence of infection. Therefore port sites greater than 10 mm should be closed properly and special precautions should be taken at sites of contact with GI staplers and GI specimens.

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Laparoscopic SPIDER sleeve gastrectomy: description of technique Michel Gagner, MD, Davit Sargsyan, MD (presenter), Moataz Bashah, MD, Mohammed Al Kuwari, MD, Mohammed Rizwan Hamad General Hospital, Doha, Qatar

Gastrojejunal revision, Nissen over Bypass for Reflux and Marginal Ulceration Cyrus Moon, MD (presenter), Kelvin Higa, MD FACS FASMBS, Keith Boone, MD FACS FASMBS, Saber Ghiassi, MD MPH FACS Advanced Laparoscopic Surgical Associates

In this video we present a laparoscopic sleeve gastrectomy performed with SPIDER surgical system. SPIDER is a laparoscopic platform of flexible instruments introduced into the abdomen through a single port. We start the procedure with creation of pneumoperitoneum in a conventional open way through a right paraumbilical incision and then introduce the SPIDER system. The system is introduced in a protective plastic shield which is removed afterwards. A small 3 mm stub incision is made in epigastrium for the liver retractor. Left lobe of the liver is retracted laterally and is fixed in this position. Second paraumbilical incision is made on the left side of the umbilicus and additional port for stapler is introduced. Then two flexible manipulating graspers are introduced into the abdomen through 2 articulating flexible ports. We start the procedure with dividing the gastrosplenic ligament with harmonic scalpel. We use long 45 cm harmonic to facilitate the dissection at the angle of His. Short gastric vessels are divided and left diaphragmatic crus is exposed. At this point care must be taken not to injure the spleen and diaphragm. After that fat pad is dissected off thus completely exposing angle of His. Procedure then continued with dissection of gastrocolic ligament. Dissection is continued distally till pylorus is exposed and posterior attachments with pancreas are divided. Once dissection is complete a 38F calibration MidSleeve tube with balloon is introduced into the stomach down to the pylorus. Balloon is inflated with 10 cc of saline and thus fixed in the pylorus. Articulating stapler loaded with buttressed 60 mm green Ethicon or black Covidien cartridge is introduced and placed 4 cm proximal to the pylorus. Stapler is closed and fired. Stomach is transected towards the angle of His by sequential firing of the same size stapler. Once stomach is transected, methylene blue leak test is performed and the calibration tube is taken out. Specimen is extracted through the right paraumbilical incision with the SPIDER system. Wounds are closed with subcuticular absorbable stitches resulting in 2 almost invisible paraumbilical scars. Patients usually don’t require narcotic analgesia and are discharged next day once tolerating fluid diet.

This video outlines the operation performed on a 51F with history of previous RYGB, who had been suffering from chronic reflux symptoms despite maximal medical management and risk factor avoidance. Endoscopy revealed a chronic marginal ulcer. In light of these symptoms and findings, she underwent revision of her gastrojejunostomy, hiatal hernia repair, as well as Nissen over bypass.

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Applications of ICG-fluorescence imaging to identification of HCC and full-thickness cholecystectomy Kiyomi Morita (presenter), Takeaki Ishizawa, MD PhD, Keigo Tani, MD, Nobuhiro Harada, MD, Kazuaki Monden, MD, Hiroko Okinaga, MD, Atsushi Shimizu, MD, Satoshi Yamamoto, MD PhD, Yosuke Inoue, MD PhD, Nobuyuki Takemura, MD, Junichi Kaneko, MD PhD, Sumihito Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, the University of Tokyo

Hybrid SILS Right Colectomy with Intracorporeal Anastomosis Lindsey S Sharp, MD (presenter), Peter Ng, MD, Yale Podnos, MD Rex Healthcare

Recently, a fluorescent imaging technique using indocyanine green (ICG) came to be applied to laparoscopic hepatobiliary surgery, as laparoscopic near-infrared imaging systems became commercially available in 2011. Herein, we present applications of ICG-fluorescent imaging to identification of hepatocellular carcinoma during liver resection and delineation of a boundary between fluorescing liver parenchyma and non-fluorescing subserosa of the gallbladder facilitating full-thickness cholecystectomy for potentially malignant lesions.

The video submitted is that of a hybrid SILS approach to right hemicolectomy with intracorporeal anastomosis. There are several advantages to this technique over standard SILS right hemicolectomy. The case presented is that of a 49 y.o. male found to have a sessile polyp in the ascending colon on routine screening colonoscopy. The polyp was partially removed endoscopically and found to be a villous adenoma with high grade dysplasia. The patient had a BMI of 31 and no previous abdominal surgery. The video demonstrates the use of the Ethicon Single Site Access system placed at the umbilicus with an additional 5 mm port placed at the suprapubic position. A medial to lateral dissection of the mesentery is undertaken and the ileocolic and middle colic vessels are identified. An intracorporeal stapled ileocolic anastomosis is performed via the crotch of the final anastomosis rather than the ends of the stapled bowel. A handsewn closure of the common enterotomy is the shown. The advantages of this hybrid technique include first avoidance of in-line sword fighting with the instruments and return to triangulation of traditional laparoscopy. Suturing is performed without difficulty. Proper orientation of the bowel is maintained without concern for twisting. Additionally, tearing of the mesentery when trying to pull the bowel into the wound for the anastomosis is avoided. The anastomosis is performed in an area of the bowel where the blood supply is not in question when compared to the stapled ends of the colon and ileum, which appear well vascularized, but may not be. We are also able to keep the skin and fascial incisions smaller with this technique, improving cosmesis. The patient did very well postoperatively. He was placed on an Entereg protocol and had return of bowel function on POD#2. He was tolerating soft diet by POD#2 and was discharged home that afternoon, requiring only acetaminophen for pain control.

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Combined Laparoscopic Cholecystectomy and Appendectomy in Patient with Multiple Hepatic Abscesses and Percutaneous Drains Nova Szoka, MD (presenter), Carolyn McCarty, DO, Edward Auyang, MD MS University of New Mexico, Albuquerque, NM

LAPAROSCOPIC SPLEEN-PRESERVING DISTAL PANCREATECTOMY WITH INTRAOPERATIVE VASCULAR REPAIR Xin Wang, MD (presenter), Bing Peng, MD PhD, Yongbin Li, MD West China Hospital, Chengdu, China

This video demonstrates a combined laparoscopic cholecystectomy and appendectomy performed in a patient who underwent placement of 13 percutaneous drains for evacuation of multiple intra-hepatic abscesses. The video shows that the procedure, while technically challenging, is feasible with meticulous dissection and can provide the patient with a successful outcome. Treatment of complex hepatobiliary diseases such as the one demonstrated here also requires a multi-disciplinary collaborative team effort.

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This is a case of a 42-year-old woman who was initially admitted to our hospital, presenting with chronic upper abdominal pain without any other accompanying symptom. Tumor markers test indicated that AFP, CEA, CA19-9 and CA125 were normal, abdominal enhanced CT indicated a cystic mass near the spleen with a 4.7*4.3*3 cm in dimension. All the work-up indicated a benign cystic lesion of the pancrease. A laparoscopic spleen-preserving distal pancreatectomy with intraoperative vascular repair was undertaken using a five-port method.

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Laparoscopic Choledochoduodenostomy After CBD Injury Abraham Krikhely, MD (presenter), Diego Camacho, MD Montefiore Medical Center

Laparoscopic Transduodenal Ampullectomy of Mixed Ampullary Polyp Robert Sung, MD (presenter), Diana J McPhee, MD, Paresh C Shah, MD North Shore LIJ - Lenox Hill Hospital

This is a video presentation of a laparoscopic choledochoduodenostomy after a CBD injury. The injury had occured during a lap cholecystectomy for acute cholecystitis which was performed by another surgeon, and the MIS team (shown on the video) was called in to help out after the injury was discovered. The surgeon in the video is Dr. Diego Camacho. The surgeon is seen making a duodenotomy and performing an end-to-side choledochoduodenostomy with a single row of interrupted sutures with intracorporeal free hand suturing. The surgeon is also seen placing a biliary stent and closed suction drain. The patient remained well during her postop hospital course and office follow-up.

Laparoscopic transduodenal ampullectomy is an uncommon procedure for ampullary neoplasm. We present the case of a 65 year old male with transient obstructive jaundice, nausea and vomiting with a 60 pound weight loss over 4 months. Endoscopy identified a large pedunculated polyp involving the ampulla with extension into the distal duodenum secondary to intussusception. Biospies were consistent with tubulovillous adenoma without invasion. Computed tomography demonstrated no mass effect, a normal pancreatic duct and a dilated common bile duct. In this video we demonstrate our technique for a laparoscopic transduodenal ampullectomy via a longitudinal duodenotomy with reimplantation of the bile duct and transverse duodenal closure. Intra-operative frozen section analysis showed no evidence of invasive cancer. The patient had an uneventful recovery. A gastrograffin upper GI series was performed on post-operative day 5, a liquid diet was commenced and he was discharged the following day. The final pathology showed a mixed adenomatous and hamartomatous polyp surrounded by unremarkable small intestinal mucosa, margins were negative for adenoma.

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Laparoscopic Roux-en-Y cystojejunostomy for pancreatic pseudocyst after laparoscopic removal of pancreatic pseudopapillary tumor Attasit Chokechanachaisakul, MD (presenter), Gustavo Stringel, MD, Dominick A Vitale, MD, Ashutosh Kaul, MD New York Medical College

Transanal Rectal Tumors Resection With a Single Incision Trocar Platform Juan P Toro, MD (presenter), Edward Lin, DO, Nathaniel W Lytle, MD, Ankit D Patel, MD, S. Scott Davis, MD, Jahnavi Srinivasan, MD, Virginia O Shaffer, MD, Patrick S Sullivan, MD Emory University

Pancreatic pseudocyst as a complication after laparoscopic removal of pseudopapillary tumor of uncinate process in pediatric patients is rare and complicated. The location of the cyst, space limitation and significant inflammation around the head of pancreas make the operation more challenging. We report laparoscopic Roux-en-Y cystojejunostomy as the surgical treatment for a 13-year-old girl who developed a 7-cm pancreatic pseudocyst near the head of pancreas after laparoscopic removal of pseudopapillary tumor of uncinate process. The Roux-en-Y cystojejunostomy anastomosis was created using transmesocolic approach at the most dependent part of the cyst. This video highlights the technical issues in enteric drainage of peripancreatic collections.

Transanal resection of rectal tumors is an effective and safe approach for early stage rectal tumors as well as large polyps that are not amenable to endoscopic resection. For such resections, we use a multiport device that is a modified approach of the traditional Transanal Endoscopic Microsurgery (TEM) and the single-site laparoscopy platforms that have been describe by some as the Transanal Minimally Invasive Surgery or TAMIS approach. Preliminary data of this procedure has shown good results. We want to show this technique for rectal tumor resections using uncomplicated set-up and standard laparoscopic methods.

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Transanal Repair of an Anastomotic Defect Using Transanal Minimally Invasive Surgery (TAMIS) Jadd Koury, MD (presenter), Scott Goldstein, MD Thomas Jefferson University

Repair of a non hiatal giant Diaphragmatic hernia- Dual Approach Salman K Alsabah, MD MBA FRCSC (presenter), Ahmed AlMulla, MD FACS, Derar AlShehab, MD FRCSC Al Amiri Hospital Kuwait

Anastomotic leaks resulting from a low anterior resection (LAR) remain a vexing problem. While many leaks will close with time, some leaks require resection and reanastomosis. Resecting a prior low anastomosis is a major undertaking and is best avoided when possible. We offer a novel technique to deal with a chronic anastomotic sinus following a colo-anal anastomosis using transanal minimally invasive surgery.

This video presents the case of an emergency case of an 18 year old male complaining of epigastric pain, vomiting, and dyspnea. Radiographic imaging shows herniation of the stomach, most of the small and large bowel, spleen, and pancreas through a diaphragmatic defect in the left chest. Laparoscopically, we demonstrate an organoaxial gastric volvulus and reduction of the hernia content. After we repaired the defect through the abdomen, we performed a thoracoscopy, due to the difficulty of loss of domain and uncertainty of complete closure of the diaphragm with non absorbable mesh. We then discovered that the kidney herniated to the chest, therefore a thoracotomy was done to reduce the kidney and repair the diaphragm defect.

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Totally Robotic Stapleless Vertical Sleeve Gastrectomy Masoud Rezvani, MD (presenter), Iswanto Sucandy, MD, Gintaras Antanavicius, MD Abington Memorial Hospital

GIST Resection Followed by Gastric Bypass Cyrus R Moon, MD (presenter), Keith Boone, MD FACS FASMBS, Saber Ghiassi, MD MPH FACS, Kelvin Higa, MD FACS FASMBS Advanced Laparoscopic Surgical Associates

Introduction: Bariatric surgery has been reported to be the most effective and durable treatment for morbid obesity and its associated medical comorbidities. Currently, several minimally invasive procedures are available which include vertical sleeve gastrectomy (VSG). During VSG, sequential firing of linear stapler creates a longitudinal gastric sleeve along lesser curvature. We report an alternative approach of totally robotic stapleless VSG and hand sewing gastrostomy in a patient with questionable staple component allergy which prevented us using linear staplers. Surgical technique: A 45 year-old-man with BMI of 44 kg/m2 presented for treatment of morbid obesity. Past medical history was significant for multiple comorbidities including diabetes, hypercholesterinemia, and depression. In addition, he had a questionable allergy to staple component. During elective totally robotic stapleless VSG, 36-French size bougie was used to create the gastric sleeve. Gastric transection and over sewing in two layers by using 3-0 vicryl and 2-0 prolene along longitudinal axis was performed with robot arms. The operation had minimal blood loss (\50 ml). There were no intraoperative or immediate postoperative complications. The patient made an uneventful recovery and was discharged home on postoperative day 3. In 1 week follow-up, he was seen in our bariatric office in a good health and returned to his usual daily activities. Conclusions: A totally robotic approach is safe and technically feasible in VSG. The robotic stapleless approach serves as an alternative to the standard laparoscopic VSG, and can be considered when linear staplers cannot be utilized safely.

This video outlines operative treatment of a 43 year old female that was found to have a submucosal gastric mass below the gastroesophageal junction on preoperative screening endoscopy for bariatric surgery. Due to its location, her operative management consisted of 1st a wedge excision of the mass with preservation of lesser curve vasculature, followed by Roux-Y gastric bypass over a month afterwards. Pathology for the specimen showed negative margins on a benign tumor.

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Revision of Roux Y Gastric Bypass for Bile Reflux: Roux Lengthening and Toupet Fundoplication Daniel Moon, MD (presenter), Cyrus Moon, MD, Ruby Gatschet, MD, Saber Ghiassi, MD, Keith Boone, MD, Kelvin Higa, MD University of California San Francisco - Fresno Medical Education Program. Advanced Laparoscopic Surgery Associates, Fresno, California

LAPAROSCOPIC CHOLECYSTECTOMY AND CHOLEDOCHODUODENOSTOMY AFTER ROUX-EN-Y GASTRIC BYPASS Christopher DuCoin, MD (presenter), Rena Moon, MD, Andre Teixeira, MD, Muhammad Jawad, MD FACS Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando, Florida, USA

45 year old woman status post Roux Y gastric bypass for morbid obesity 6 years prior. Multiple readmissions for abdominal pain, nausea, bilious emesis, reflux symptoms. Imaging non-contributory. EGD showed bile in roux limb only. Manometry grossly normal but some incomplete relaxation. Medical therapy ineffective. Roux limb lengthening and fundoplication agreed on for surgical treatment. Video describes this procedure, and management of intraoperative bleeding episode.

History of Present Illness: 61 year old female who presented to outside hospital with 4 day history of right upper quadrant abdominal pain, right shoulder pain, nausea, vomiting, and low grade fevers. Her past surgical history was significant for gastric bypass surgery in November of 2008. A CT scan of her abdomen showed a dilated gallbladder with wall thickening and surrounding fluid, and an ultrasound showed the same with gallbladder stones and a CBD dilated to 1.1 CM. She was started on IV antibiotics and transferred for definitive care. Procedure: Laparoscopic cholecystectomy, intraoperative cholangiogram, common bile duct exploration, and choledochoduodenostomy were performed. Result: The patient was discharged home on post operative day #2 tolerating regular diet with a JP drain in place near the anastomosis. Final pathology showed acute and chronic cholecystitis with prominent transmural inflammation. The patient has had no biliary pain since that time.

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Overlapping applications of bipolar-radiofrequency energy for tissue coagulation in a robot-assisted hepatic resection Pier C Giulianotti, MD FACS, Mario A Masrur, MD (presenter), Gianmarco Contino, MD, Xiaoying Wang, MD, Eduardo Fernandes, MD, Luca Milone, MD, Subhashini Ayloo, MD FACS University of Illinois at Chicago

Robot-assisted revision of Gastro-Jejunal anastomosis after RYGB Subhashini Ayloo, MD, Young Roh, MD, Mario A Masrur, MD (presenter), Pier C Giulianotti, MD FACS University of Illinois at Chicago

Background: Habib Radiofrequency assisted liver resection allows hepatectomies to be performed with minimal blood loss, a desirable feature in the setting of minimally invasive liver surgery. This video showcases the surgical technique of a minimally invasive left sectionectomy for liver lesion by the use of overlapping fields of Habib radiofrequency and cold blade sectioning. Material and Methods: A 56 year old women presented for symptomatic cholelithiasis. Ultrasound identified a 5 cm left lateral lobe liver mass that was further characterized with MRI imaging. Results: After camera port positioning and assessment of the lesions, two 10-mm trocars on both sides of the umbilicus, two 8-mm trocars in the left-upper quadrant, and one 8-mm size trocar in the right-upper quadrant were placed and the daVinci robot was docked cranially. First, the triangular ligament was dissected and an intraoperative ultrasound confirmed the involvement of the segment II/III. ICG fluorescence evaluation adjuncted the visualization of the limits of the tumor. Habib Radiofrequency was applied in overlapping fields of energy along the section line and a bloodless cold knife sectioning of liver parenchyma was performed with hemostatic prolene suture to control main hepatic pedicels. Blood loss was under 50 cc and postoperative course was uneventful. Pathology examination reported a 6 cm hepatocellular carcinoma with neuroendocrine differentiation with negative margins. Conclusions: Overlapping field of Habib Radiofrequency allows bloodless cold knife parenchymal dissection of the liver and can be incorporated safely in minimally invasive procedures. Use of fluorescence proved useful in identifying safe margins of resection.

Introduction: Anastomotic ulcer at the gastrojejunostomy site after RouxEn-Y gastric bypass operation is a known complication that may usually be associated with a fistula between gastric remnant and gastric pouch of the anastomosis. Surgical management with revision of gastro-jejunal anastomosis is the treatment of choice if they are refractory to medical treatment. Revisional surgery can be challenging, especially with laparoscopy and using the robot may offer some advantages. Methods: A prospective review of two patients who underwent revision of Gastro-Jejunostomy for confirmed anastomotic ulcers after Roux-en-Y gastric bypass for morbid obesity, that are refractory to medical management, was performed in year 2012. Data was collected on patient factors, intra-operative findings and post-operative outcomes. Results: Both patients had confirmed anastomotic ulcers on endoscopy with persistent symptoms that are refractory to medical treatment. Both patients are female with mean age of 42 yrs and BMI of 28 kg/m2. On exploration, both patients found to have extensive adhesions and a fistula between gastric remnant and gastric pouch. In both cases the previous anastomosis along with fistula was resected and revision of gastro-jejunostomy was performed. Both procedures were performed successfully in minimally invasive approach using the robot. Mean operative time is 234 mins (195 and 280 mins) and mean estimated blood loss is 25 ml. Both patients had upper GI series post-operatively and were fed after ruling out anastomotic leak. These patients had uneventful post-operative course and were discharged with mean hospital stay of 4 days. On follow-up, both patients had resolution of their previous symptoms related to the anastomotic ulcers. Conclusions: The use of robot in the revision of gastro-jejunal anastomosis after gastric bypass is feasible and safe with good clinical outcomes.

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Technical considerations for the minimally invasive management of mesenchymal tumors of the stomach Christopher S Armstrong, MD FRCSC (presenter), Ninh T Nguyen, MD FACS, Brian R Smith, MD FACS University of California Irvine Medical Center

LAPAROSCOPIC TOTAL GASTRECTOMY FOR THE TREATMENT OF A CHRONIC FISTULA AFTER SLEEVE GASTRECTOMY: THE LAST RESOURCE Hector Romero-Talamas, MD (presenter), Andrea Zelisko, MD, Kevin El-Hayek, MD, Matthew Kroh, MD FACS Cleveland Clinic

Mesenchymal tumors are uncommon neoplasms of the stomach. Determination of the size and location of these tumors is critical during preoperative planning and for determining the best surgical approach. These lesions are often easily resected using minimally invasive techniques when they present in a favourable location but can be particularly challenging to resect when they present adjacent to the gastroesophageal junction or in the pre-pyloric region. Furthermore, these tumors can also present with concomitant foregut pathology that requires additional surgical management. We present 5 cases of gastric mesenchymal tumors in this video that highlight some of the technical aspects involved in the minimally invasive management of these lesions. Case 1: An exophytic gastric GIST of the anterior wall managed with partial gastrectomy. Case 2: A posteriorly located gastric GIST with concurrent hiatal hernia managed with partial gastrectomy and hiatal hernia repair. Case 3: posteriorly based leiomyoma at the gastroesophageal junction managed with enucleation through an anterior gastrotomy. Case 4: a small leiomyoma immediately adjacent to the gastroesophageal junction managed with laparoendoscopic transgastric enucleation. Case 5: a large leiomyoma of the gastroesophageal junction managed with transmural enucleation.

Endoscopic treatment with the placement of a stent is rapidly becoming the procedure of choice for the management of postoperative fistulas after sleeve gastrectomy. Nonetheless, a small percentage of patients do not respond. The laparoscopic total gastrectomy is a safe and feasible procedure that can be considered an effective last resource in this scenario.

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D2 lymphadenectomy for Gastric Cancer: Technique Video Nathan Lytle, MD (presenter), Juan Toro, MD, Ankit Patel, MD, Scott Davis, MD, Edward Lin, DO Emory University

COMMON BILE DUCT INJURY DURING LAPAROSCOPIC CHOLECYSTECTOMY. FROM DISASTER TO RECONSTRUCTION Guido De Sena, MD, Francesco La Rocca, MD (presenter), Carlo Molino, MD, Francesco Chianese, MD, Antonio Braucci, MD, Rosaria De Ritiis, MD Department Of General Surgery, Cardarelli Hospital – Naples, Italy

D2 lymphadenectomy is still considered a controversial topic in treatment of gastric cancer, but is gaining favor in Western surgical therapy. This is a surgical technique video demonstrating the laparoscopic D2 lymphadenectomy for gastric cancer performed at our institution. All nodal stations are identified and dissected. We believe that the laparoscopic approach provides superior visualization to the traditional open procedure allowing appropriate nodal and oncologic resection.

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Introduction: The aim of the study is to describe and divulgate the surgical errors that must be avoided during laparoscopic cholecystectomy. Methods and Procedures: The movie shows a common bile duct (CBD) injury occurring during a laparoscopic cholecystectomy performed in another hospital and its repair in open surgery done in our department. A high-flow bile fistula (800–1000 ml/24 h) characterized the immediate post-operative course. MRI cholangiography showed a complete lesion of the CBD. On fifth post-operatory day, the patient was transferred to our department. Subsequent diagnostic tests showed a double lesion of the CBD, at the level of the upper-pancreatic tract and at the biliary confluence. The repair consisted of a Roux-en-Y hepaticojejunostomy. Results: The post-operative course was uneventful and the patient was discharged on 14th day. MRI cholangiography performed before the demission showed a complete surgical recovery. Conclusion: The authors show clearly and in detail the chilling path of surgical error and they underline the strategy for preoperative diagnosis and the surgical technique for biliary tract reconstruction. The surgeons perform this technique for over 20 years with excellent results, with no mortality and no long-term postoperative complications. They conclude highlighting the importance of viewing the original video of laparoscopic cholecystectomy to accurately evaluate the damage and decide preoperatively the strategy for biliary tract repair.

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Approach to Laparoscopic Right Hepatectomy Using Seven Common Steps Juan P Toro, MD (presenter), Nathaniel W Lytle, MD, Ankit D Patel, MD, S. Scott Davis, MD, Rachel M Owens, MD, Juan M Sarmiento, MD, Edward Lin, DO Emory University

ELECTIVE REPAIR OF A MASSIVE INTERNAL HERNIA FOLLOWING ROUX-Y GASTRIC BYPASS Amy Neville, MD (presenter), Sebastian Demyttenaere, MD, Nicolas Christou, MD PhD, Olivier Court, MD McGill University Health Centre, Montreal QC, Canada

Several previous series have demonstrated the safety and feasibility of laparoscopy for minor liver resections. However, formal laparoscopic right hepatectomy remains a demanding task even for experienced surgeons because of the vascular dissection for inflow and outflow control. We have performed more than 40 laparoscopic right hepatectomies using a standard approach with a reproducible step-wise technique. We believe this approach in addition to the superior visualization of laparoscopy can be used for instruction and training as well as for process improvement. We deconstructed our technique into 7 major steps that are demonstrated in this video.

The estimated incidence of internal hernia following Roux-Y gastric bypass is 2–5%. Acute incarceration of an internal hernia, a dreaded complication, may result in significant loss of small bowel and carries a mortality of 1–2%. A significant proportion of internal hernias have a chronic, insidious presentation with recurrent symptoms of abdominal pain and cramping. Accurate and timely diagnosis in these patients permits elective repair of the internal hernia prior to developing potentially serious complications. We present the case of a massive internal hernia, containing the patient’s entire small bowel, diagnosed and treated electively. This case highlights the importance of maintaining a high degree of clinical suspicion to permit elective repair whenever possible.

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FEASIBILITY OF LAPAROSCOPIC REPAIR OF SYMPTOMATIC HIATAL HERNIA FOLLOWING ROUX-Y GASTRIC BYPASS Amy Neville, MD (presenter), Olivier Court, MD, Nicolas Christou, MD PhD, Sebastian Demyttenaere, MD McGill University Health Centre, Montreal QC, Canada

Laparoscopic conversion of Gastric Plication to Sleeve Gastrectomy Eric Ahnfeldt, DO (presenter), Monica Dua, MD, Philip Schauer, MD Cleveland Clinic

Obesity is a recognized risk factor for hiatal hernia and an estimated 15% of morbidly obese patients have a symptomatic hiatal hernia. As such, it is not uncommon to encounter a hiatal hernia at the time of bariatric surgery. When hiatal hernia is present during Roux-Y gastric bypass it is considered safe and appropriate to repair the hernia defect at the time of surgery. However, symptomatic hiatal hernia presenting after Roux-Y gastric bypass presents a challenge to the surgeon given the potential difficulties of re-operative upper gastrointestinal tract surgery. We present the case of a patient presenting with a highly symptomatic hiatal hernia following Roux-Y gastric bypass and demonstrate that laparoscopic management is feasible and results in good short term outcomes. To our knowledge, there are no previous descriptions of similar procedures published in the literature.

This video demonstrates an interesting case of laparoscopic conversion of gastric plication to sleeve gastrectomy with the key procedural steps discussed. The patient initially underwent greater curve plication for weight loss, however her BMI reached a plateau and EGD demonstrated dilation of the gastric capacity. She had successful conversion to a sleeve gastrectomy with good post-operative weight loss.

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Laparoscopic repair of foramen of Winslow hernia Peter S Wu, MD (presenter), John R Romanelli, MD Baystate Medical Center

ROBOTIC RESECTION OF GASTRIC INTESTINAL DUPLICATION CYST Michael J Pucci (presenter), Michael Kammerer, Francesco Palazzo, Harish Lavu Thomas Jefferson University

Internal hernias have been gaining attention in recent years in both surgical and radiologic literature, particularly in morbidly obese patients who have undergone the increasingly common laparoscopic Roux-Y gastric bypass. We submit a video of a patient with a history of laparoscopic Roux-Y gastric bypass who presented with a symptomatic foramen of Winslow hernia, a rare internal hernia which occurs as a distinct entity from the more commonly found Petersen’s hernia in this population. It has become apparent that small bowel, colon, and even gallbladder can herniate into the lesser sac through this naturallyoccurring anatomic defect. Even amongst hernia experts, this diagnosis is infrequent enough to preclude agreement on its pathogenesis, natural history, and treatment recommendations. The video demonstrates the relevant preoperative imaging along with the successful laparoscopic reduction and repair of the hernia defect.

In this video, we demonstrate a case of a 38 year-old female who presented with a left upper quadrant cystic lesion that was incidentally discovered. Preoperative work-up raised concern for a mucin-producing cystic neoplasm of the pancreas. Upon robotic operative exploration, the lesion was discovered to be a benign intestinal duplication cyst arising off the posterior stomach. The video shows mobilization and resection of the tumor along with a quick review of a rare lesion.

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MINIMALLY INVASIVE ESOPHAGECTOMY WITH ANTEGRADE ESOPHAGEAL INVERSION Luke M Funk, MD MPH (presenter), Aliyah Kanji, MD, Kyle A Perry, MD, W Scott Melvin, MD The Ohio State University

My Approach of Pancreatic Reconstruction after Laparoscopic Whipple’s Surgery C Palanivelu, MS FACS, P Senthilnathan, MS FACS, R Parthasarathi, MS, P S Rajan, MS, S Rajapandian, MS (presenter), P Praveen Raj, MS, V Vaithiswaran, MS GEM Hospital

Minimally invasive esophagectomy with esophageal inversion has been proposed as an alternative to thoracoscopic-assisted esophagectomy for treatment of patients with high grade dysplasia and distal esophageal cancer. We present the case of a 36 year-old previously healthy female with an adenocarcinoma at the gastro-esophageal junction who underwent a minimally invasive esophagectomy with antegrade esophageal inversion.

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Background: The Principle aim of reconstruction after pancreatic duodenectomy is to minimize pancreatic jejunostomy (PJ) leak which continues to contribute to significant morbidity. The factors that influence the technique anatomists include diameter of pancreatic duct, consistency of pancreas and expertise of surgeon. Methods: Two techniques of PJ anastomosis are performed at our centre – Duct to mucosal anastomosis and modified during with duct to mucosal anastomosis. We perform the modified dunking technique for soft pancreas with minimally duct. For firm pancreas with dilutor duct, a laparoscopic adaptation of Blumghart’s duct to mucosal anastomosis is done. This high definition video will show the technical details of the above two techniques.

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A Multidisciplinary Approach to Small Bowel Disease Centered around Capsule Endoscopy Detection: A Potpourri of Cases Matthew C DeWolf, BS (presenter), Courtney C Sullivan, BA, David Cave, MD PhD, Jason Wong, MD, Nicole Pecquex, MD, James Carroll, MD, Mitchell Cahan, MD, Demetrius Litwin, MD MBA University of Massachusetts Medical School

Combined laparoscopic right colectomy and low anterior resection with intracorporeal anastomosis Francesco Stipa, MD PhD FACS (presenter), Emanuele Soricelli, MD, Antonio Burza, MD, Rosanna Curinga, MD, Piero Delle Site, MD, Ettore Santini, MD Department of Surgery, Colorectal Surgical Unit San Giovanni Hospital, Rome, Italy

This video highlights a multidisciplinary approach and the use of technologies used in the diagnosis and treatment of obscure gastrointestinal bleeding from the small intestines. The specific technologies that are featured include video capsule endoscopy, deep enteroscopy, angiography, and laparoscopic surgery. This is done by describing these techniques as utilized in five different cases. The cases involved are an intussusception, a GIST, two arteriovenous malformations, and NSAID stricture.

The video shows the case of a 60 years old female affected by two synchronous adenocarcinoma of the cecum and of the rectum. She is submitted to a laparoscopic right colectomy and low anterior resection in the same surgical procedure. Both resection and the anastomosis are intracorporeal; the first anastomosis is a side-to-side ileo-colic with linear stapler, while the second is a lateral-to-end colo-rectal with a 31 mm circular stapler, placing the anvil intrabdominally through one of the trocar incisions and introducing it in the descending colon through a colotomy.

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LAPAROSCOPIC RELEASE OF THE MEDIAN ARCUATE LIGAMENT FOR THE TREATMENT OF MEDIAN ARCUATE LIGAMENT SYNDROME (MALS) Charles Thompson III, MD, Mayank Roy, MD MRCS, Carolina Ampudia, MD, Pablo Marin, MD, Emanuele Lo Menzo, MD, Raul Rosenthal, MD (presenter) Cleveland Clinic Florida

Laparoscopic resection T4 splenic angle lesion with involvement of the spleen and tail of pancreas Rafael Garcia-Duperly, MD (presenter), Eduardo London˜o, MD, Javier Carrera, MD, Fernando Arias, MD Fundacion Santa Fe de Bogota

Introduction: This video demonstrates the laparoscopic release of median arcuate ligament to treat the symptoms of MALS, a rare condition characterized by abdominal pain caused by an anatomiacal variance involving a compression of the celiac artery by the median arcuate ligament. Case Report: A 57-year female presented with 4 months history of persistent weight loss, vomiting, and abdominal pain after meals. A preoperative MRI showed narrowing of the celiac trunk at its origin. After informed consent we performed a laparoscopic release of the median arcuate ligament. The abdominal cavity was accessed with a 12 mm optical trocar. Three additional 5 mm trocars were utilized. The left and right crus and posterior vagus nerve were identified and protected. The aortic hiatus was fully dissected, exposing the region of the celiac trunk. Subsequently, the left gastric artery was identified and traced back to the celiac trunk. A band of tissue was easily identified compressing the aorta, and it was released. Immediately, the celiac trunk appeared to resume its normal contour. There was minimal blood loss during the case. The patient was discharged on postoperative day four. On 1-month follow-up, the patient was doing well and tolerating an unrestricted diet without symptoms. Conclusion: Laparoscopic release of the median arcuate ligament is a feasible and safe for the treatment of MALS in the hands of an experienced surgeon.

67 years old lady with a tumor of the splenic flexure of the colon with invasion of the spleen and the tail of the pancreas. Laparoscopic resection was performed, with the tail of the pancreas, the spleen and the colon.

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Laparoscopic cholecystectomy in a patient with congenital atrophy of the right hepatic lobe Lionel van der Westhuizen, MD (presenter), Alfredo M Carbonell, DO, William S Cobb IV, MD Greenville Hospital System University Medical Center

Vertical Banded Gastroplasty to Vertical Sleeve Gastrectomy: Case Report and Description of Technique Brian F Lane, MD (presenter), Chad A Lee, MS, Amy M Biedenbach, PAC, David Hardy, MD, Jeremy A Warren, MD, Michael A Edwards, MD Department of Bariatric and MIDDS, Georgia Health Sciences University, Medical College Georgia

Congenital anomalies of the liver are rare. One of the rarest forms includes agenesis and atresia of the right hepatic lobe. Fewer than 100 cases have been described in the literature. This anomaly is associated with ectopic location of the gallbladder, often high under the right hemidiaphragm, which can present a significant challenge if a cholecystectomy needs to be performed. We present a case demonstrating our surgical approach for a laparoscopic cholecystectomy in a patient with congenital atrophy of the right hepatic lobe.

The patient had undergone VBG in 2002 for morbid obesity and developed progressive severe gastric outlet obstructive symptoms over the past 2 years due to VBG band stricture. Dilation was unsuccessful, and due to continued morbid obesity, the patient underwent revision of VBG to VSG with release of the obstruction utilizing an intra-gastric combine lapendoscopic approach. Operative details and patient outcome are presented.

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ABDOMINAL CYSTS MIMICKING CYSTIC PANCREATIC NEOPLASMS Marc G Mesleh, MD (presenter), Andrew Gratzon, MD, Steven P Bowers, MD, Horacio J Asbun, MD, John A Stauffer Mayo Clinic Florida

Endoluminal Intra-Peritoneal Radical Resection of Rectal Cancer using Transanal Endoscopic Microsurgery Renee Huang, MD (presenter), Cynthia Sulzbach, BS, Dominique McKeever, BA, Joseph L Frenkel, MD, Gerald Marks, MD, John Marks, MD FACS FASCRS Section of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA 19096

Pancreatic cystic lesions are becoming a more frequent indication for surgical resection, especially for symptomatic lesions. This video presents two patients who were found to have abdominal cystic lesions suspected to be of pancreatic origin. The first patient was found to have a retroperitoneal lymphangioma entirely free of the pancreatic parenchyma which was successfully resected. The second patient was found to have a bronchogenic cyst intimately attached to the tail of the pancreas and required a distal pancreatectomy and splenectomy for en bloc removal.

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This video demonstrates a full-thickness hemi-circumferential excision of a uT2 rectal adenocarcinoma, status post neoadjuvant chemoradiation using Transanal Endoscopic Microsurgery in a morbidly obese female. The 3 cm tumor was 10 cm from the anorectal ring, necessitating sizable entrance into the peritoneal cavity to ensure complete full-thickness excision. Though the possible need for a stoma was considered and discussed with the patient, the large defect was closed primarily without proximal diversion. Patient had an uncomplicated post-operative course and was discharged from the hospital on post-operative day seven.

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Totally Laparoscopic Enterolithotomy for Gallstone Ileus Alejandro Rodriguez-Garcia, MD (presenter), Morris E Franklin, MD FACS, Cristopher Salzman, MD, Felice Ferri, MD, Zanndor Del Real-Romo, Mario Rodarte-Shade Texas Endosurgery Institute, Tecnologico de Monterrey

Laparoscopic Mobilization for Resection of a Distal SMA Mycotic Aneurysm Karen Chang, MD (presenter), Eleanor Fallon, BS, Dana Telem, MD, Aurora Pryor, MD Stony Brook Medical Center

Laparoscopic enterolithotomy for the management of gallstone ileus was first reported in 1994. Despite this, to date, experience seems to be limited to a small number of case reports or case series. We will describe our approach in a 59 year-old woman with multiple co-morbidities.

This video depicts the resection of a distal superior mesenteric artery mycotic aneurysm in a 43 year-old man who also presented with a cardiac valvular lesion. After a short course of antibiotics and resection of the cardiac pathology, the procedure was carried out with laparoscopic mobilization. The mesentery was divided distal to the aneurysm with a bipolar sealing device and the resection margins were confirmed with fluorescence perfusion imaging. Final pathology confirmed a sterile aneurysm.

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Sleeve Gastrectomy Complicated by Chronic Gastrocutaneous Fistula, Septic emboli to the Brain and pulmonary embolism Fernando Safdie, MD, Pablo Marin, MD, Carolina Ampudia, MD, Abraham Betancourt, MD, Emanuele Lo Menzo, MD, Samuel Szomstein, MD, Raul Rosenthal, MD (presenter) The Bariatric and Metabolic Institute and the Section of Minimally Invasive and Endoscopic Surgery, Cleveland Clinic Florida

LAPAROSCOPIC REPAIR OF GASTROBRONCHIAL FISTULA AFTER SLEEVE GASTRECTOMY Tushar Samdani, MD (presenter), Pratibha Vemulapalli, MD Montefiore Medical Center

Introduction: Gastrointestinal leaks after bariatric surgery are the primary cause of serious morbidity and mortality nationwide. Enteric leaks can differ in severity, presentation, and management. Materials and Methods: 45Y Female, S/P laparoscopic sleeve gastrectomy in 2008 with revision in 2012 at an outside facility, complicated by leak, abscess, requiring drainage and esophageal stent.

Gastrobronchial fistula is a very rare complication of sleeve gastrectomy. We present an interesting video showing laparoscopic repair of gastrobronchial fistula after sleeve gastrectomy in a 26 year old female. Patient had pneumonia which led to diagnosis of fistula. Patients symptom recurred after conservative management and we had to surgically repair the fistula. We also want to show through our video difficulties encountered while dissecting sleeve of stomach from left crus of diaphragm and subsequent complication of iatrogenic gastrotomy.

A six trocars laparoscopic approach was chosen. Extensive sharp and blunt adhesiolysis performed. The fibrosed right crus was carefully dissected. At the GE junction a cavity was identified an entered. Large amounts of pus and saliva were drained. Her distal esophagus and stomach were transected with the linear stapler, and an antecolic esophagojejunostomy was performed in a side-to-side fashion. Intraoperative leak test was done with air-methylene blue. A tube gastrostomy was placed into the distal stomach. Drains were left in the subhepatic space

Results: The postoperative course was complicated by new intraabdominal collections that required IR drainage and C. Diff colitis which was medically treated. Ultimately she was weaned off TPN, resume on diet and sent home with a PICC line for long term IV Antibiotics Conclusion: Most leaks are successfully managed nonoperatively. Nonetheless revisions still play a role in chronic leaks and gastrocutaneous fistula resection. These are technically challenging procedures and should be only performed by experienced surgeons

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Laparoscopic Conversion from Roux en Y Gastric Bypass to Loop Duodenal Switch for Weight Regain Mitchell Roslin, MD, Brian Mitzman, MD (presenter) North Shore LIJ/Lenox Hill Hospital

LAPAROSCOPIC RESECTION OF OBSTRUCTED CYSTIC DUCT STUMP PRESENTING AS A HILAR CYSTIC MASS Marc G Mesleh, MD (presenter), John A Stauffer, MD, Steven P Bowers, MD, Horacio J Asbun, MD Mayo Clinic Florida

We present a case of an African American female who underwent a laparoscopic Roux En Y gastric bypass nine years previously. She initially went from a weight of 380 pounds down to approximately 200 pounds. She presented to us after regaining a large portion of her weight, now residing at 295 pounds with a BMI of 51. After failing non-operative management, she underwent a laparoscopic conversion to loop duodenal switch. After tolerating the procedure without complication, she has since lost 130 pounds, and is in excellent health.

This is a video presentation concerning a patient undergoing laparoscopic resection of a 7 cm multiloculated cystic lesion in the hepatic hilum. The patient had previously undergone open cholecystectomy 20 years prior. The lesion was found to be a dilated cystic duct remnant due impaction of stones at the insertion of the cystic duct to the common bile duct and was successfully dissected free from the hepatoduodenal ligament. The resultant defect in the bile duct was closed over a t-tube.

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Laparoscopic resection of segment IVB using the intrahepatic Glissonian approach Bestoun Ahmed, MD, Ziad T Awad, MD FACS (presenter), Sunil Sharma, MD University of Florida College of Medicine, Jacksonville

Laparoscopic Posterior Retroperitoneal Adrenalectomy Meena Said, MD (presenter), Andrew S Wu, MD, William B Inabnet, MD, Subhash Kini, MD Mount Sinai School of Medicine

Our case is 64 year old African American female with a solitary liver lesion (colorectal origin) at segment IVB. She underwent laparoscopic intrahepatic Glissonian approach resection of segment IVB. The procedure was done with no complications. The main advantage of the intrahepatic Glissonian procedure is the rapid and precise access to the Glissonian sheath facilitating segment oriented liver resection.

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There are a variety of approaches to adrenalectomies. The laparoscopic retroperitoneal adrenalectomy is a feasible operation with the distinct advantage of obviating the need to enter the abdominal cavity. It is a safe approach that can be applied for smaller adrenal lesions.

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LAPAROSCOPIC CONVERSION OF SLEEVE GASTRECTOMY TO ROUX-EN-Y GASTRIC BYPASS FOR PROXIMAL GASTRIC LEAK Rena Moon, MD, Andre Teixeira, MD (presenter), Muhammad Jawad, MD FACS Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando, Florida, USA

Laparoscopic Paraesophageal Hernia Repair with Gastrointestinal Stromal Tumor Resection Magdy Giurgius, MD (presenter), Archana Ramaswamy, MD University of Missouri

Introduction 34 y/o F s/p LSG 3 months ago for morbid obesity. Presented to the ER with complaints of left shoulder pain and fever. Initial UGI showed a sleeve leak. Placed on abx and TPN. IR consulted for percutaneous drain placement. Materials and Methods Initial treatment was started by placing the patient on TPN and placing sleeve stent. Kept npo for 3 wks. Pt was admitted several times back to the hospital due to severe nausea, emesis and dehydration. Discussed with the patient all the possibility that included surgical intervention by converting a high pressure system sleeve gastrectomy to a low pressure system RYGB. Result Postoperatively the patient did well, UGI done on POD #2 that was negative for any leaks. Discharged home on full liquid diet. Conclusion The most difficult complication to treat from a LSG is the leak. Due to the nature of a high pressure system, it’s very difficult for a leak to close. Some centers have converted sleeve gastrectomies to esophagojejunostomy by performing a gastrectomy of the sleeve. We have proposed to make a high pressure system into a low pressure system.

This is a 62-year-old white male with multiple medical problems who presented with marked weight loss. He had an extensive work up that demonstrated a large paraesophageal hernia and a gastric mass originating from the greater curvature of the stomach. The EUS guided fine needle aspiration of the mass was suggestive of a gastrointestinal stromal tumor. He underwent an uneventful laparoscopic paraesophageal hernia repair and resection of the mass. The final pathology demonstrated a low grade GIST. The patient did well on follow-up.

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SILS PLUS ONE LAPAROSCOPIC RIGHT HEMICOLECTOMY WITH INTRACORPOREAL ANASTOMOSIS Javier Nieto, MD, Madhu Ragupathi, MD, Robert Carman, DO (presenter), Eric M Haas, MD FACS FASCRS, T. Bartley Pickron, MD

REVISION OF SLIPPED NISSEN FUNDOPLICATION WITH PARTIAL GASTRIC VOLVULUS Michael J Pucci, Andrew Brown, Karen A Chojnacki, Ernest L Rosato, Francesco Palazzo (presenter) Thomas Jefferson University

Colorectal Surgical Associates, Ltd, LLP / Minimally Invasive Colon and Rectal Surgery, Department of Surgery, The University of Texas Medical School / Michael E. DeBakey Department of Surgery, Baylor College of Medicine / Houston, TX

In this video, we present a young patient who underwent a prior Nissen fundoplication for severe gastric reflux. He presented with dysphagia and vomiting and was discovered to have a ‘‘slipped’’ Nissen with paraesophageal hernia and partial gastric volvulus. We demonstrate the reduction and reconstruction of this slipped Nissen fundoplication.

Single-Incision Laparoscopic Colectomy has been shown to be a safe and feasible surgical technique for the treatment of benign and malignant diseases. We have performed over 100 single-incision laparoscopic right hemicolectomies since 2009 utilizing an umbilical approach. We have recently adopted a ‘‘Single Plus One’’ technique to improve cosmesis, allow for better instrument ergonomics and decrease the risk of umbilical incisional hernias. This approach utilizes an umbilical 5 mm port and a 2.5 cm Pfannenstiel incision, requiring an intracorporeal anastomosis.

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Laparoscopic Glissonean Approach for Anatomic Central Hepatectomy Long Tran Cong Duy, MD (presenter), Bac Nguyen Hoang, MD PhD, Thuan Nguyen Duc, MD, Dat Le Tien, MD, Viet Dang Quoc, MD HBP Surgery Division, UMC, Vietnam

Laparoscopic Roux-en-Y Double Cyst-Jejunostomy for Pancreatic Head Pseudocysts Bestoun H Ahmed, MD FRCS (presenter), Eric Roberts, DO, Carmine Volpe, MD FACS, Ziad T Awad, MD FACS, Michael Nussbaum, MD FACS University of Florida College of Medicine/ Jacksonville

Vietnam similar to other ASEAN countries, located in the epidemiologic area of HBV infection, as a result, HCC is rather common. Hepatectomy is still the most popular curative treatment for HCC. Open hepatectomy usually leaded to much post-op pain and complications related to the large incision. Minimally invasive surgery may help patients with many benefits. However, laparoscopic surgery encountered several difficulties such as dissection of hepatic pendicles, inlet control, identifying the tumor (satellite) and surgical margin, hemostasis during dividing the parenchyma … and last but not least was the anatomic hepatectomy for better result in terms of the oncological view. Hepatic pedicles dissection for identifying and controlling the Glissoneal pedicles of each segment has been proved effective and beneficial in open hepatectomy for HCC. It’s our aim to evaluate the feasibility of laparoscopic surgery when applying this technique of hepatectomy. So that, we give more evidence for the potential of laparoscopic hepatectomy in HCC treatment. Here, in this video, we present the technique of laparoscopic Glissoneal pedicle dissection for anatomic central hepatectomy. We use 5 ports. Patient position is supine with 2 legs open. Surgeon stand in the right side of patient, the assistant on the left side and camera man between the patient legs. The subumbilical 11 mm port for the scope (45 degree scope). The 12 mm port in the right flank as operating port. One 5 mm port in right subcostal for left hand retraction. Another 5 mm port in epigastric area for suction (assistant). The last 5 mm in left subcostal for liver retraction (assistant). Firstly, the right liver is mobilised. Cholecystectomy is performed. Dissecting Hepatic hilus and exposing the Glissoneal pedicle of the posterior, anterior and the left sector. Temporarily clamping the relevant pedicle of the anterior sector in order to identify the demarcation line on the liver surface. By this way, we determine the anatomic border of the sector as well as the surgical surface. Anatomic hepatectomy along the border between the sector will encounter no large glissoneal pedicle, so we minimize the blood loss and better hemostasis during parenchymal transection. When applying this technique, the resecting sector is complete ischemia. The preserve sectors have good blood supply during the operation. The benefit of this is to avoid postoperative liver failure. The Glissoneal pedicle of the involved sector is controlled at the beginning of the operation and the tumor together with the relevant portal vein (which may be seeding) is removed en bloc. This is more radical in terms of surgical oncology. Patient well and quickly recovered because of benefits of minimally invasive surgery Laparoscopic Glissoneal approach for anatomic liver resection is feasible and show the new trend for advanced laparoscopic liver resection.

A known patient with chronic pancreatitis presented with two symptomatic pancreatic head pseudocysts. He is treated by laparoscopic Roux-en-Y double pancreatic head cyst-gastrostomy. Patient tolerated the procedure well and follow up imaging showed regression of both pseudocysts

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Vascular Injury During Laparoscopic Left Adrenalectomy Ankur Gupta, MD (presenter), Edward H Phillips, MD Cedars Sinai Medical Center

Endoscopic Closure of Colocutaneous Fistula Syed G Husain, MD (presenter), Daniel Eiferman, Dean Mikami Wexner Medical Center at Ohio State University

Objective: Video case presentation of a vascular injury during laparoscopic left adrenalectomy. Background: 25 y.o. female with persistent hypertension and mildly elevated urine normetanephrine levels at 559 was found to have a 1 cm left infero-medial adrenal lesion. The patient was noted to have an abnormal MIBG scan. She was suspected to have a ganglioneuroma given the mildly elevated biochemical markers. Results: A transabdominal laparoscopic left adrenalectomy was performed and the patient was placed in left lateral decubitus position. The adrenal vein was identified and divided. The presumed ganglion was retracted and divided. Bleeding resulted and was controlled using endoloops. The Aorta was dissected from the diaphragmatic hiatus to the left renal artery and revealed a low origination of the celiac artery with transection of the celiac trunk. Post procedure angiogram revealed excellent collateral flow from the superior mesenteric artery. Conclusion: The importance of examining for variant arterial anatomy during left adrenal dissection. Additionally, the ability to control hemorrhage and discern aortic anatomy using laparoscopic techniques is shown.

This is a video demonstration of endoscopic closure of persistent colocutaneous fistula using Overstitch device. To best of our knowledge, this is first reported case of overstitch use in lower GI tract. Patient has remained asymptomatic with a follow-up of three months.

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Single Port Laparoscopic Distal Pancreatectomy Hyung Joon Han, MD (presenter), Tae Jin Song, MD FACS, Sang Yong Choi, MD, Sae Byeol Choi, MD, Wan-Bae Kim, MD, Sung-Ock Suh, MD, Sam Youl Yoon, MD Korea University College of Medicine

Laparoscopic Enucleation of Benign and Low Grade Hepatic Lesions Nicholas N Nissen, MD (presenter), Vichin C Puri, MD, Vijay G Menon, MD Cedars-Sinai Medical Center

Single-port laparoscopic surgery has become popular and widened indications to more various types of minimal invasive surgical field. This report will present our initial experience with distal pancreatectomy technique through a small transumbilical incision using the single-port approach for a cystic tumor of pancreatic tail. The surgery was done using articulating instruments and conventional laparoscopic instruments. The total operative time for this surgery is 230 minutes, and it was completed with a drain via single incision. Patient was discharged from the hospital on the fifth day postoperatively without any event.

Introduction: Enucleation is a technique which can be applied to benign and low grade lesions of the liver. Ideal lesions that are amenable to enucleation include select neuroendocrine tumors, simple cysts, hemangiomas and focal nodular hyperplasia. The benefits of enucleation include the preservation of maximal hepatic parenchyma, as well as the low likelihood that underlying vascular or biliary structures will be compromised. Methods & Results: The application of laparoscopy to the techniques of enucleation allows the patient to benefit both from the advantages of a minimally invasive approach while maximizing hepatic preservation. In addition, laparoscopy allows simultaneous access to multiple regions of the abdomen, and as such is ideal for managing certain tumor scenarios such as the patient with distal pancreatic NET and synchronous liver metastases. Cases illustrating these techniques and principles are presented.

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Endoscopic percutaneous transesophageal gastrostomy, A novel approach for gastric decompression Ajjana Techagumpuch, MD (presenter), Kanokkan Tepmalai, MD, Mahadeven D Tata, MD, Chadin Tharavej, MD, Suppa-ut Pungpapong, MD, Patpong Navicharern, MD, Suthep Udomsawaengsup, MD Chulalongkorn University

SINGLE-INCISION LAPAROSCOPIC GASTRIC BYPASS FOR MORBID OBESITY-USING CONVENTIONAL TROCARS AND INSTRUMENTS C Palanivelu, MS FACS, P Praveen Raj, MS (presenter), P Senthilnathan, MS, R Parthasarthi, MS, N Anand Vijay, MS, Chandra Maliteeswaran, MS, B Vijay, MS GEM Hospital

Introduction: Long term nasogastric tube placement can lead to a lot of complications such as nasal erosion, sinusitis, oral infections and respiratory tract infections. PTEG was first described by H. Oishi in 1994, a method for gastric decompression in patient who are contraindicated for other procedures, by using rupture-free balloon under fluoroscope. Therefore we propose EPTEG as another option for these patients. Method: This is a case series from 2007–2012 in Chulalongkorn University hospital. The decompressive tubes were inserted by using endoscopic and ultrasound guided technique without requiring of any special instrument. (As show in attached video) Results: 22 patients were performed EPTEG successfully without any mortality. There were 12 females and 10 male patients and mean age was 56 years. All patient had advanced stage cancer (Intraabdominal cancer and one case of breast cancer) except for one patient who had recurrent GIST. Average time of procedure was 38 minutes. There were 2 cases with complication, one case had tube displacement and one case had subcutaneous emphysema which can be treated successfully by conservatively. All patients had short post operative hospital stay (Average 3–5 days) and started feeding within 24 hours after procedure. Conclusion: This EPTEG method by using endoscopic and ultrasound guided technique is feasible and safe. It can provides precise view of procedure without requiring any specific commercial instruments which can reduces the cost of the procedure.

Conventional laparoscopic Roux-en-Y gastric bypass (LRYGB) is gold standard for bariatric surgery, but the procedure requires five to seven incisions for placement of multiple trocars and thus may produce less-than-ideal cosmetic results. Recently, single-incision laparoscopic surgery (SILS) has been used for bariatric procedures, and this surgery is considered a type of minimally invasive surgery. When SILS is performed via the transumbilical route, the resultant abdominal wound is hidden and the cosmetic outcome is better. Here we present one of our cases of Single Incision transumbilical Roux en Y gastric bypass Surgery without usage of any commercially available single port systems Video: In this high Definition video, we show a single incision Laparoscopic Roux en Y gastric bypass.

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Step 1 involves creating a transverse umbilical scar and raising umbilical flaps on either side Four trocars (12 mm, two 5 mm and one 10 mm) are inserted directly through the fascia at different sites after creating the pneumoperitoneum the liver was retracted using a novel liver suspension technique of passing polyamide suture through the liver and suspending the liver using a piece of corrugated rubber tube The gastric pouch of 50 ml is created in standard fashion using blue cartridges the gastrocolic omentum is divided in the midline the jejunum was divided at 75 cm and the jejuno-jejunostomy was done with 100 cm Roux limb using linear staplers and intracorporeal sutures The gastrojejunostomy was performed using 30 mm liner staplers and the defect closed with 2-0 PDS with intracorporeal suturing

Conclusion: Single Incision Laparoscopic RYGB though technically challenging is possible and avoids multiple ports in morbidly obese patients.

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NOVEL TECHNIQUE FOR DIRECT ACCESS TRANSGASTRIC ERCP (D.A.T.E.) USING A SINGLE SITE PLATFORM Aaron D Carr, MD (presenter), Gina N Farinholt, MD, Andrew Ingram, MD, Thomas Prindiville, MD, Moahmed R Ali, MD University of California, Davis

LAPAROSCOPIC PARTIAL SPLENECTOMY FOR SPLENIC CYST Nathan G Richards, MD (presenter), Frederick J Brody, MD MBA George Washington University Medical Center

We report our technique for direct access transgastric ERCP (D.A.T.E.) using a single-site platform. The procedure is exemplified by this case of a 54 year old female with a history of Roux-en-Y gastric bypass who presented with persistent right upper quadrant pain after recent laparoscopic cholecystectomy. MRCP revealed choledocholithiasis, but doubleballoon ERCP failed. The patient underwent D.A.T.E. with a modified single-access device, and her choledocholithiasis was successfully cleared. This video illustrates our technique.

Background: Symptomatic splenic cysts, particularly those refractory to drainage, have traditionally been surgically managed via splenectomy. Case Description: An otherwise healthy 31 yo woman presented with a known history of benign splenic cyst of unknown etiology since 2007. In the 4 years since diagnosis, the cyst had nearly doubled in size (to 11 cm) and the patient developed worsening symptoms of early satiety and LUQ pain. Radiologic drainage and phenol injection were unsuccessful and the patient was taken to the operating room for definitive management. This video shows the technique behind a partial splenectomy. Conclusion: Partial splenectomy can be safely and effectively performed. In cases of benign splenic cysts, the cysts can be safely drained intraoperatively to facilitate complete cystic resection. Careful consideration must be made to avoid draining cysts that have a possibility of malignancy or Echinococcus or other infectious etiology.

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A STEP-BY-STEP DEMONSTRATION OF ENDOSCOPIC REMOVAL OF AN ERODED ADJUSTABLE GASTRIC BAND Victor T Wilcox, MD (presenter), Calvin Lyons, MD, Nilson Salas, MD, Luis Benavente, MD, Vadim Sherman, MD, Patrick Reardon, MD, Brian J Dunkin, MD The Methodist Institute for Technology, Innovation and Education (MITIESM), Department of Surgery, The Methodist Hospital, Houston, TX

LONGTERM FOLLOW UP IN 79 PATIENTS FOLLOWING GASTRIC ELECTRICAL STIMULATION Nathan G Richards, MD (presenter), Sara Zettervall, MD, Richard Amdur, PhD, Frederick J Brody, MD MBA George Washington University Medical Center

This video demonstrates a novel endoscopic technique for the removal of an eroded adjustable gastric band using a Soehendra lithotripter and guide wire.

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Introduction: Gastric Electrical Stimulation (GES) has been used to treat medically refractory gastroparesis. Laparoscopic gastric stimulator placement is a well described surgery, however long term outcomes and follow up in patients how have undergone GES have been previously unavailable. Methods and Procedures: 79 patients who underwent GES at out institution were retrospectively analyzed and their symptom severity and frequency scores were statistically analyzed via T-tests and Chi-squared analysis. This video demonstrates our laparoscopic gastric stimulator implantation technique as well as documents our results Results: N = 79. 11 gastrectomies done after GES, 4 unrelated deaths, 4 explantation of gastric stimulators yield new N = 60. 2 pts required reoperation for complications, both small bowel obstructions. 30.4% of patients required another operation after GES. Of these 30.4%, there were 1.83 procedures performed on each patient on average. 9 patients were nutritionally supplemented with either tube feeds or TPN preoperatively, while only 2 needed supplemental nutrition afterwards, a 77.8% reduction. There was a statistically significant reduction in pain and functional symptoms demonstrated in patients who underwent laparoscopic GES. Conclusion: Gastric Electrical Stimulation (GES) can significantly reduce both functional and pain related symptoms of gastroparesis. Patients who undergo GES have a high likelihood of requiring further surgery (30.4%). Patients that do well at 12 month follow up are likely to continue to do well and have further improvement in symptoms.

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Vessel Sealer for Robotic Colectomy Robert K Cleary, MD (presenter), Yu-Hsin Lin, MD St Joseph Mercy Hospital, Ann Arbor

NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES) USING ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD) FOR A LARGE LEFT COLON LESION IN A HIGH-RISK PATIENT I. Emre Gorgun, MD (presenter), Erman Aytac, MD, Feza H Remzi, MD Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio

Objective: The purpose of this study was to determine the effectiveness of the Vessel Sealer when performing robotic colorectal operations. Methods and Procedures: The Vessel Sealer in this video was utilized by the surgeon through the robotic dissecting port (D1) during a robotic sigmoid resection for diverticulitis. Conclusion: The implementation of robotics for colorectal operations provides the advantages of 3D imaging, the ability of the surgeon to use a third arm for fixed retraction, and a stable camera platform under surgeon control. Most colorectal operations mandate the availability of an energy source to effectively provide hemostasis when dissecting and dividing pertinent arteries, veins, and vascular mesentery. Until now, this has been accomplished by way of an assistant through an assistant port or the console surgeon with an instrument lacking articulation. The new Vessel Sealer provides several advantages over similar instruments to date: (1) It is controlled by the surgeon at the surgeon console; (2) It provides complete hemostasis when coagulating and dividing vessels up to 7 mm in diameter; (3) It is controlled with console-based wristed movements and articulation that provide the surgeon strategic angles which allow more effective dissection, limiting blood loss and decreasing operative time; (4) The satisfying audio feedback provided by the system allows for coagulation and cutting to become ‘‘second nature’’ to the surgeon; (5) It allows minimally invasive dissection of complicated tissue planes (phlegmonous diverticular disease adherent to pelvic sidewall) thereby potentially decreasing the need for conversion. The Vessel Sealer is a significant advance in robotic surgical systems, allowing effective coagulation and division of vascular arcades, and effective dissection of tissue planes during robotic colorectal operations.

Introduction: Natural orifice transluminal endoscopic surgery (NOTES) with endoscopic submucosal dissection (ESD) provides en bloc resection of large tumors in the upper gastrointestinal tract. However, this technique can be challenging in the colon due to risk of perforation. In this video, our technique using ESD in a high-risk patient with multiple comorbid conditions who initially was referred for segmental colectomy is presented. Method and procedure: This 88 years old man with past medical history of atrial fibrillation, B cell lymphoma s/p chemotherapy and hypertension underwent en bloc endoscopic submucosal dissection of a large left sided colonic lesion. The lesion was at 70 cm. from the anal verge involving 60 % of the circumference of the lumen. Using dual knife, the lesion was marked circumferentially with 3 mm clear margin. This was followed by submucosal lifting using albumin/indigo carmine solution injection. The dissection was facilitated using distal disposable cap that was attached at the end of the colonoscope. En bloc removal of the lesion was achieved and the specimen measured 3.2 cm. in diameter. Results: Patient was discharged on postoperative day one with no complications. The final pathology revealed tubulovillous adenoma with clear deep and circumferential margins. Conclusion: ESD is a safe and useful technique in carefully selected patients. With increasing experience its use will gradually expand and will more widely be used in large colonic lesions among surgeons.

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Revision of Roux-en-Y Gastric Bypass to Sleeve Gastrectomy and Hiatal Hernia Repair Ruby Gatschet, MD (presenter), Cyrus Moon, MD, Saber Ghiassi, MD MPH, Keith Boone, MD, Kelvin Higa, MD Advanced Laparoscopic Surgery Associates, UCSF Fresno

Left Diaphragm Relaxing Incision for Type IV Paraesophageal Hernia Repair Melanie L Hafford, MD (presenter), Lee Morris, MD, Nabil Tariq, MD, Vadim Sherman, MD, Patrick Reardon, MD, Brian J Dunkin, MD The Methodist Hospital

In this video, we present the conversion of a Roux-en-Y gastric bypass to a sleeve gastrectomy. The patient is a 39 year-old woman who initially underwent laparoscopic Rouxen-Y gastric bypass in 2001. A revision was then performed in 2003 for suboptimal weight loss, where the gastric pouch was revised and a Silastic band was placed to the distal gastric pouch. She then underwent revision to a distal gastric bypass. She developed symptoms of reflux and also had weight recidivism. Endoscopy demonstrated stenosis of the distal gastric pouch at the location of the Silastic band. She was taken to the operation room for conversion sleeve gastrectomy, removal of the Silastic band, and hiatal hernia repair. After entry into the abdomen, attention was first turned to the intestinal anastomosis, which was taken down with primary suture closure of the resulting enterotomy. The retrocolic Roux limb was then dissected just inferior to the transverse mesocolon and divided. Attachments of the proximal Roux limb to the transverse colon mesentery were divided, allowing the Roux limb to be brought superiorly. The jejunal anastomosis was performed using a single layer of absorbable suture. The Silastic band was removed. The Roux limb was dissected from its mesentery and from the gastric pouch. The hiatus was dissected, revealing a hiatal hernia, which was repaired. The short gastric vessels and other attachments were divided so as to free the remnant stomach. A gastrotomy was made in the remnant stomach, and the anastomosis was performed using interrupted Vicryl suture. The gastric sleeve was fashioned using a laparoscopic linear stapler, and the gastrogastrostomy was completed. Endoscopy was performed to visualize the anastomosis and also to perform an air leak test. A drain was left in place alongside the gastrogastrostomy. The patient was started on a clear liquid diet on postoperative day 3 and discharged on postoperative day 4.

Large paraesophageal hernias in which the crura cannot be primarily approximated present a clinical challenge. The purpose of this video, is to demonstrate a left diaphragm relaxing incision as an alternative surgical technique for management of a type IV paraesophageal hernia. A review of current management strategies is included, as well as anatomic landmarks necessary to perform the relaxing incision.

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Laparoscopic Primary Repair of a Morgagni Hernia Samantha Aitchison, MD (presenter), J. Scott Roth, MD University of Kentucky

TRANSANAL REMOVAL OF RECTAL NEUROENDOCRINE TUMOR USING SINGLE PORT ACCESS I. Emre Gorgun, MD (presenter), Erman Aytac, MD, Feza H Remzi, MD Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio

A Morgagni hernia is an uncommon congenital anterior diaphragmatic defect. Repair of Morgagni hernias using laparoscopic technique has been well described. Using three ports, the hernia may be easily reduced and closed primarily with interrupted, pledged prolene sutures. This technique offers a minimally invasive approach of repairing the defect with a tension free closure.

Introduction: Transanal endoscopic surgery using single incision laparoscopic port systems is an emerging technique. Compared to transanal endoscopic microsurgery, this approach can provide better working angles and can be accessible at a fraction of the cost. In this video we present our technique with this approach. Method and procedure: A fifty years old man with a history of rectal neuroendocrine tumor (NET) was referred to department of colorectal surgery, Cleveland Clinic. His past medical history was significant for asthma, his ASA score was 3 and BMI was 28.8 kg/m2. He underwent 8 months ago colonoscopic removal of a 0.5 cm polyp and was found to have NET on the final pathology. All margins were negative on the specimen with no involvement of the muscularis propria. He was advised to undergo surveillance colonoscopy in 6 months. At this time random cold biopsies from the scar revealed again NET and therefore patient was referred for further management of this area. The scar tissue was located anteriorly at 12 cm from the anal verge. Operation was performed under general anesthesia with the patient positioned in prone jack with split legs. A Gelpoint Path (Applied Medical, Rancho Santa Margarita, CA) transanal single port device was inserted into the anal canal. CO2 was used for insufflation. A full thickness excision with 1.5 cm clear margin around the scar tissue was performed. Dissection was performed using monopolar hook cautery. This allowed us to remove 3.5 cm full-thickness rectal wall and part of the mesorectum. Defect on the rectal wall was closed using 2-0 polydioxanone (PDS) sutures in a continuous fashion and was ended using silver bullet. Results: Operating time was 63 minutes and blood loss was 25 milliliters. Patient was discharged home at the same day after surgery. The final pathology did not reveal any signs of remnant neuorendocrine tumor in the specimen. At 4 weeks follow up patient had excellent continence and flexible sigmoidoscopy revealed complete healing of the resection side. Conclusion: Transanal removal of rectal neuroendocrine tumors using single port access device is safe and feasible. Single port transanal surgery is a valuable alternative to transanal endoscopic microsurgery.

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Robotic Assisted Treatment of Bouveret’s Syndrome Brett M Keck, MD (presenter), Stephen G Pereira, MD Hackensack University Medical Center

Laparoscopic transgastric intraluminal cystogastrostomy

Bouveret’s syndrome is a gastric outlet obstruction caused by duodenal impaction of a large gallstone. This occurs usually due to a cholecystogastric or cholecystoduodenal fistula. The following video shows a robotic approach to an 86 year-old female who presents with Bouveret’s syndrome.

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Mario Rodarte-Shade, MD (presenter), Karla Russek, MD, Alexander Richard, MD, Zanndor del Real-Romo, MD, Rene Palomo-Hoil, MD, Alejandro Rodriguez-Garcia, MD, Morris E Franklin Jr, MD Texas Endosurgery Institute - Instituto Tecnologico y de Estudios Superiores de Monterrey, Mexico We present the case of a 41 year old male with past medical history of multiple episodes of gallstone pancreatitis and laparoscopic cholecystectomy. Patient developed a symptomatic pancreatic pseudocyst and was initially treated with ERCP, however, pseudocyst recurred due to a pancreatic duct stenosis. Patient was referred to surgery and a laparoendoscopic transgastric intraluminal cystogastrostomy was performed.

Surg Endosc (2013) 27:S504–S527

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V126 Intragastric approach for submucosal tumor located at zone of Z-line Kyo Young Song, Dr (presenter) Catholic University of Korea A 25 year old female patient was diagnosed as submucosal tumor mass (SMT) located at just near the esophagogastric junction. We performed the ‘‘intragastric’’ resection technique which was consisted of 4 steps. Step I; endoscopic insufflations of the stomach, Step II; insertion 3 trocars into the stomach wall, Step III; enucleation of the SMT lesion and removal, Step IV; intracorporeal suturing of the stomach wall.

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