Surg Endosc (2012) 26:S249–S430 DOI 10.1007/s00464-012-2203-x

and Other Interventional Techniques

2012 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) San Diego, California, USA, 7–10 March 2012 Poster Presentations

 Springer Science+Business Media, LLC 2012

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DECREASE POST LAPAROSCOPIC SHOULDERS PAIN WITH SLOW DEFLATION OF ABDOMINAL GAS Amir Vejdan, MD, Kataneh Dadashi, RN Immam Reza Hospital Background: Shoulder pain is a common complaint following laparoscopic surgery and the incidence of Shoulder pain is generally about 35% of patients following laparoscopic surgeries, but it is more frequent after some specific type of laparoscopic surgeries like as Nissen fundoplication and laparoscopic adjustable gastric band. This investigation evaluates the role of slow deflation of abdominal gas in decreasing the severity and the incidence of this problem. Patients and Method: 78 patients with uncomplicated gall stone and early phase of acute cholecystitis were randomly divided in two groups. In control group (38 patients), Ports were removed rapidly and gas deflated in less than 10 s, but in main group (40 patients), gas was deflated with a slow rate in 3 min. Patients were followed for 8 weeks after operation and the incidence and severity of pain were evaluated and compared with each other. Results: The incidence of post laparoscopic shoulder pain was 8% and 34% in main group and control groups, respectively (P \ 0.05). Pain score system shows less severity of pain in investigated group that can lead to decrease in analgesic prescription and dosage. Recommendation: Decreasing the speed of abdominal gas deflation at the end of laparoscopic surgeries, can significantly decrease the incidence and severity of post laparoscopic shoulder pain.

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OPTIMIZING WORKING SPACE IN PORCINE LAPAROSCOPY: COMPUTED TOMOGRAPHY MEASUREMENTS OF THE EFFECTS OF INTRAABDOMINAL PRESSURE John Vlot, MD, Rene Wijnen, PhD, Robert Jan Stolker, PhD, Klaas(n) M.a. Bax, PhD Erasmus Medical Centre Rotterdam, Department of Pediatric Surgery and Department of Anesthesiology (R.J. Stolker), PO Box 2060, 3000 CB Rotterdam, The Netherlands Introduction: The effects of CO2 insufflation pressure on cardiorespiratory parameters and laparoscopic working space were analyzed in a porcine laparoscopy model using Computed Tomography (CT) for measuring intra-abdominal volume and distances. Methods and Procedures: Twelve non-starved pigs weighing approximately 20 kg were premedicated with midazolam and ketamine and kept anesthetized with propofol and sufentanil as a continuous intravenous infusion. No neuromuscular blocking agents were used. Ventilation was volume controlled (FiO2 40%, I:E ratio 1:2, tidal volume 10 ml/kg, rate 40/min, PEEP 5 cm H2O). Heart rate, respiratory rate, blood pressure, blood pH and pCO2, peak inspiratory pressure (PIP) and ETCO2 were recorded. End expiratory CT-scans at pneumoperitoneum pressures of 5, 10 and 15 mmHg were made. From reconstructed CT-images we measured intra-abdominal volume of CO2 as well as maximum antero-posterior (AP) distance of the abdominal cavity between the vertebral column and anterior peritoneum, maximum internal width and maximum cranio-caudal distance between the pubic symphysis and diaphragm. For statistical analysis paired T-tests for measurements at different levels of intra-abdominal pressure (IAP) were used. P \ 0.05 was considered significant. Results: One pig died during surgical preparation, leaving data from 11 pigs for analysis. Ventilation rates were adjusted in 3 animals to compensate for hypercapnia. Other cardiorespiratory parameters remained stable except for a statistically significant increase of PIP at an IAP of 15 mmHg. A non-linear increase of volume with increasing IAP was found (Fig. 1). Only the internal AP-distance of the abdominal cavity increased significantly with increasing IAP (Fig. 2). Conclusions: CT-analysis allows measurement of intra-abdominal working space volume and distances in laparoscopy. The gain in working space decreases rapidly at insufflation pressures above 10 mmHg IAP. Moreover, PIP increases significantly above an IAP of 10 mmHg. Only the AP distance increases significantly with increasing IAP. This model allows further investigation of the effects of other interventions aimed at increasing working space e.g. different ventilation strategies, neuromuscular blockade or bowel preparation.

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INVESTIGATING THE EFFECTS OF TENSION ON A STAPLED ANASTOMOSIS Andrew M Miesse, MS, Michael A Stellon, Ross Segan, MD MBA FACS, Emily Miesse, RN, Dwight G Bronson, MS Covidien, Surgical Solutions

Fig. 1 Pressure–volume curve

Introduction: This study was designed to investigate tensile effects on a stapled circular anastomosis. It has been theorized that a high tension anastomosis contributes to the prevalence of anastomotic failure. Ileorectal anastomoses have among the highest leak rates in all intestinal anastomotic leaks (Hyman 2007). Lower colorectal surgeries can be difficult to perform due to access restriction and also the limited mobility of the large intestine. Another factor that affects the difficulty of these surgeries is the quantity of tissue to work with. Since approximately 80% of all intestines are small intestine, when a portion of large intestine must be excised, there is less remaining to reconnect. As a result, these circular anastomoses that reconnect the large intestine, especially ones close to the rectum, are sometimes in tension. This study sought to empirically determine how tension affects the integrity of a circular anastomosis. Methods and Procedures: To test how tension across an anastomosis affects the leak strength of that staple line, a circular anastomosis created in a synthetic media. The artificial media was chosen as a first step to take variability out of the samples being tested. A known strain was applied to the anastomosis and intralumenally pressurized using a custom fixture. The fixture utilized an air piston to apply a linear force axially on the sample, thereby applying a known tension and changing its length. The sample was then clamped at the ends and infused with a fluorescent fluid until a leak was observed against the black contrast of the sample. The leak pressure was then compared with the strain applied. Resultant tensions were calculated in %strain. Strain values were determined using the following equation for and converted to percent with respect to the sample’s initial length.

ke ¼

DL l  L ¼ L L

ð1Þ

Equation 1. Equation used to calculate strain; L = Length / initial Length, l = final length, e = strain. Results: Samples (n = 4/group) were tested at three different % strain values; they were subject to 0, 5 and 10% strain. At 0% strain the average initial leak of the anastomosis = 1.555 PSI. At 5% strain the average initial leak of the anastomosis = 0.725 PSI. At 10% strain the average initial leak of the anastomosis = 0.379 PSI.

Fig. 2 Pressure–distance curves

Graph 1 This graph depicts the decline in leak pressure with increased amounts of strain applied to the anastomosis Conclusions: The results from this study show that even a small amount of strain can have an extensive impact on the leak resistance of a circular anastomosis in synthetic media. The correlation appears to resemble a curve, 1/x, where the leak resistance is reduced by over 50% per 5% additional strain. In artificial tissue tension had a direct and marked impact on strength of an anastomosis. Another phase of this study will use explanted tissue to more closely understand and mimic the effect of tension on a real circular anastomosis.

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P020

METABOLIC PROFILING OF URINE REVEALS DISTINCT PHENOTYPIC CHANGES IN PATIENTS UNDERGOING COLORECTAL EXCISION Sunreet Randhawa, Reza Mirnezami, Beatriz Jimenez, James Kinross, Olaf Beckonert, Claire Merrifield, Elaine Holmes, Jeremy Nicholson, Ara Darzi Section of Biomolecular Medicine and Section of Biosurgery and Surgical Technology, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London SW7 2AZ, UK Introduction: Systems biology has yet to be widely adopted for surgical use however this technology is highly applicable for the development of individualised surgical therapeutics. Colorectal surgery disrupts the gut microbiota and important symbiotic co-metabolic pathways which may be indirectly measured in urine via this approach. This study aimed to determine if a metabolic phenotype exists for the anatomical resection or the invasiveness of surgical approach which accounts for the role of the gut microbiota in mammalian metabolism. Methods and Procedures: 27 colorectal cancer (CRC) patients undergoing open or laparoscopic elective surgery for colorectal cancer (CRC) were recruited prospectively at St Mary’s Hospital, London, UK. Urine sampling was performed preoperatively on the morning of surgery and on the 3rd postoperative day. Samples were frozen at -800C. A metabolic, pharmacological and clinical history was taken and oncological staging and grading data were recorded. Urine samples were analysed by high resolution 1 H NMR spectroscopy using a Bruker 600 MHz Spectrometer. Spectra consisting of 32,000 data points were phase and base line corrected using TopSpin (Bruker BioSpin, Germany). Raw data were exported into SIMCA 12 and Matlab for multivariate analysis by principal component analysis (PCA) and orthogonal partial least squares discriminant analysis (OPLS-DA) models. Water and urea were excluded from the spectra. Results: The median age was 68 (range 47–84) and the male:female ratio was 16:11. There were 11 laparoscopic and 16 open procedures (3 laparoscopic cases were converted to open). Cases comprised: left hemicolectomy (n = 8), right hemicolectomy (n = 8), anterior resection (n = 10) and abdomino-perineal resection (n = 1). Cancers were staged according to UICC criteria as stage 1 (n = 6), stage 2 (n = 8), stage 3 (n = 9) and stage 4 (n = 4). Unsupervised multivariate analysis of pre-operative urine samples revealed significant metabolic variability according to the anatomical site of the tumour (R2 = 0.46). Creatinine statistically correlated with rectal cancer while colonic cancers demonstrated higher levels of hippurate and aromatic compounds strongly identified as gut microbial co-metabolites. OPLS-DA was able to strongly predict the pre- and postoperative states (R2y (cum) = 0.65; Q2 (cum) = 0.63). In addition, postoperative analysis identified markedly differing urinary metabolic profiles between patients undergoing right versus left hemicolectomy (R2y (cum) = 0.65; Q2 (cum) = 0.63, see figure) and rectal versus colonic surgery (R2y (cum) = 0.65; Q2 (cum) = 0.63). Furthermore, we identified statistical variability between laparoscopic and open cases (R2y (cum) = 0.717; Q2 (cum) = 0.22). Conclusion: Urinary metabolic profiling provides a systems overview of the complex response to colorectal surgery and serves as an important scientific platform for the development of personalised surgical therapies. It is able to achieve this in part by noninvasively measuring gut microbial co-metabolic pathways and systems biology is of benefit in determining the beneficial metabolic affects of minimally invasive surgery.

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P021

FACTORS ASSOCIATED WITH REOPERATION, POSTOPERATIVE MORBIDITY AND READMISSION RATES AFTER LAPAROSCOPIC TOTAL ABDOMINAL COLECTOMY FOR ULCERATIVE COLITIS Jinyu Gu, MD, Luca Stocchi, MD, Feza Remzi, MD, Ravi Kiran Cleveland Clinic Foundation Aim: The aim of this study is to evaluate factors affecting postoperative outcomes after laparoscopic total abdominal colectomy (TAC) for ulcerative colitis (UC). Methods: Patients undergoing laparoscopic TAC for severe UC/indeterminate colitis during 1998–2010 in our institution were retrospectively identified. Demographics, disease characteristics and perioperative outcomes were recorded. Associations between short-term outcomes and patient, disease and treatmentrelated variables were assessed using univariable and multivariable logistic regression models. Results: A total of 204 patients (105 males, mean age 38.5 years) were identified. Conversion rate was 4.4%. Median blood loss, operative time and hospital stay were 100 ml, 185 min and 4 days, respectively. Reoperation, postoperative morbidity and readmission rates were 7, 40 and 17%, respectively. Univariable analysis showed that BMI, pancolitis, preoperative anemia and dysproteinemia were associated with reoperation, of which low BMI (P = 0.043) was independently correlated on multivariate analysis. Preoperative treatment with high steroid doses (intravenous or prednisone C40 mg daily) was significantly associated with postoperative morbidity on multivariable analyses (P = 0.011). No specific factor was significantly associated with readmission. Conclusions: Most factors associated with adverse outcomes after laparoscopic abdominal total colectomy for ulcerative colitis are due to preoperative clinical deterioration. An operation performed earlier during the disease course could result in improved outcomes.

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P022

A CASE OF PORTAL VEIN THROMBOSIS AFTER LAPAROSCOPIC LOW ANTERIOR RESECTION OF THE RECTUM Noritsugu Naito, MD, Nobuyasu Kano, MD PhD Kameda Medical Center Introduction: Portal vein thrombosis (PVT) after laparoscopic surgery is a relatively uncommon but potentially lethal complication. There are several reports of PVT after laparoscopic surgery such as laparoscopic splenectomy. There are only a few reports of cases with PVT after laparoscopic colectomy for malignant tumors. However, its true incidence may have been underestimated due to difficulty in making the diagnosis. We report a case of PVT in a patient with no hypercoagulable states and risk factors for thrombosis, who underwent laparoscopy assisted low anterior resection of the rectum. Case: The patient is a 55 year old male with no past medical history. He noticed hematochezia and came to see his family physician. Colonoscopy revealed an early stage rectal cancer. He underwent endoscopic mucosal resection (EMR) for the lesion. The pathological examination showed the mucosal lesion with no positive margin and no vessel invasion. A follow-up colonoscopy showed a recurrent lesion. He undertook laparoscopy assisted low anterior resection for the recurrent rectal cancer. On eleventh day after operation, he noticed abdominal distention. Abdominal CT revealed thrombi in the umbilical portion of the portal vein. His general condition was stable and his symptom disappeared on the next day. We started systemic anticoagulation therapy with Warfarin. The thrombi were not detected on the followup CT four months after the onset. We continued anticoagulation therapy for six months after the follow-up CT. The patient is followed as an outpatient with no signs of recurrence. Result: PVT after laparoscopic surgery is uncommon and difficult to diagnose because of nonspecific signs and symptoms. Its presentation, treatment, and outcomes are poorly understood. Possible etiologic factors are malignant tumors, abdominal inflammatory diseases, alteration in coagulation during pneumoperitoneum, intraoperative damage to the splanchnic endothelium and systemic thrombophilic states. PVT should be diagnosed and treated precisely and promptly, because it can be lethal.

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P023

OUTCOMES OF LAPAROSCOPIC COLORECTAL SURGERY IN THE ELDERLY Giancarlo Basili, MD, Nicola Romano, MD, Dario Pietrasanta, MD, Graziano Biondi, MD, Irene Mosca, MD, Valerio Prosperi, MD, Orlando Goletti, MD, Health Unit 5 Pisa, Pontedera Hospital, General Surgery Unit Introduction: Laparoscopic surgery was demonstrated to be safe and effective for the treatment of colorectal cancer also in elderly patients. Data from National Registries have shown how population is getting older and living longer. Since the incidence of colorectal disease increases with age, a large number of elderly patients will require colorectal surgery. In octogenarians requiring colorectal operations, emergency procedures are more common, blood transfusion, complications and postoperative deaths occur more frequently, and hospital stay is longer. Later-stage disease and comorbid conditions are responsible for the higher incidence of cardiopulmonary complications. Recent reports, however, have recommended applying the standard surgical approach also in the elderly. The advanced age, itself, only minimally increases the operative risk. Octogenarians tolerated elective colorectal surgery as well as younger patients and could potentially benefit from minimally invasive surgery that is associated with less cardiopulmonary stress, early rehabilitation, and faster return to independent status. The aims of our study is to assess the characteristics and perioperative morbidity and mortality in elderly patients submitted to laparoscopic colorectal resection. Methods and Procedures: Between July 2006 and July 2011, a total of 352 patients underwent laparoscopic resection for colorectal cancer. The intention of surgery in all cases was curative if at all possible; no difference in surgical approach was made less than and more than 75 years. Primary outcomes were the evaluation of morbidity and the perioperative death, occurring within 30 days after an operative procedure. The patients and procedural risk factors included sec, age, cancer localization, Dukes’ and TNM classification, blood transfusion and POSSUM score. Morbidity and mortality rates were calculated according to the Kaplan–Meier method. Results: The study consisted of 186 men and 166 women. 77 patients (21.8%) were more than 75 years of age. The more than 75-year age group had tumours that were predominantly right sided in location. Moreover, it appears that the patients more than 75 years of age presented with advanced Dukes’ and TNM stage tumours than those younger than 75 years (63% C or D and 64% stage III or IV, compared with 44 and 43% in the less than 75 years). Although the length of ileus and hospital stay were longer in the elderly group, the difference did not meet statistical significance. Blood transfusions were significantly associated with the elderly and mostly related to preoperative anaemia; two patients required reoperation for postoperative hemoperitoneum. Further analysis among anastomotic leakage showed two documented leakage in the less than 75-year age. In relation to POSSUM mortality score, a median value of 2.3 and 8.5% were registered into the two age-groups. Any post-operative mortality was registered in the elderly. Conclusion: A review of the literature demonstrate a number of short-term advantages of the laparoscopic approach. However long-term results remain unclear. As a results of our experience, minimally invasive colorectal surgery might be a safe and effective solution in elderly patients, provided that a good selection of patients, a tight intraoperative monitoring and an intensive postoperative rehabilitation are planned and followed.

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A SYSTEMATIC REVIEW AND POOLED ANALYSIS OF SINGLE INCISION LAPAROSCOPIC APPENDECTOMY Richdeep S Gill, MD, Xinzhe Shi, MPH, David P Al-adra, MD, Daniel W Birch, MD MSc FRCPS, Shahzeer Karmali, MD FRCPS University of Alberta; Royal Alexandria Hospital Purpose: Acute appendicitis remains the common gastrointestinal emergency in adults. Single incision laparoscopic appendectomy (SILA) has been proposed as the next evolution in minimally invasive surgery. SILA is postulated to reduce post-operative pain and enhance cosmesis, while effectively removing an inflamed appendix. However the efficacy and benefits of SILA compared to conventional laparoscopic appendectomy (CLA) remain to be determined. Our objectives were to systematically review the literature comparing SILA to CLA for acute appendicitis and perform a pooled analysis on the efficacy of SILA. Methods: Published English-language manuscripts were considered for review inclusion. A comprehensive search of electronic databases (e.g., MEDLINE, EMBASE, SCOPUS, BIOSIS Previews and the Cochrane Library) using broad search terms was completed. All comparative studies were included if they incorporated adult patients undergoing appendectomy for acute appendicitis by SILA. The primary outcomes of interest were operative time and length of hospital stay (LOS). Results: From a total of 366 articles, 34 articles were identified. A total of nine comparative studies were included for pooled analysis. There was no significant difference in operative time, LOS, pain scores, conversion or complication rates between SILA and CLA for acute appendicitis. Conclusion: This systematic review and pooled analysis demonstrates that SILA is comparable to CLA for acute appendicitis in adults. However, this review identifies the need for randomized controlled trials to clarify the efficacy of SILA compared to CLA.

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METASTATIC SIGMOID DIVERTICULITIS IN THE ERA OF ADVANCED IMAGING AND HEALTH CARE—A CASE REPORT Arunkumar Baskara, MRCS MD, Stefanie L Saunders, MS Medical Student, Prashanth Ramachandra, MD, Mercy Catholic Medical Center Abstract: Sigmoid diverticular disease is a common disorder and has been dubbed ‘‘the disease of Western civilization’’. Morbidity and mortality associated with diverticular disease is primarily related to acute lower gastrointestinal bleeding, diverticulitis and perforated diverticulum. We present a case report of a patient who had unusual presentation of sigmoid diverticulitis. The clinical presentation and investigations were misleading for sigmoid colon mass with colo-vesical fistula, possible metastasis to the liver and brain. The patient was found to have metastatic sigmoid diverticulitis abscess. The patient made a full recovery after the brain abscess was drained and the sigmoid colon was resected. Our patient, a 54 years old gentleman, presented to the emergency room with acute onset of headache and weakness in the left upper extremity and passing stool in urine. On examination he had mild tenderness in the left lower quadrant with no signs of peritonitis. He was alert, awake and oriented to place, person and time with no focal neurological deficits. His lab investigations were unremarkable except for urine analysis which was positive for nitrite. CT scan of the head showed a cystic appearing lesion within the cortex and subcortical white matter in the right fronto-parietal region. Solid appearing lesions were found in the right centrum semiovale and right frontal white matter suggestive of metastatic tumor, lymphoma or infection. CT abdomen and pelvis showed sigmoid colon mass colo-vesical fistula solitary liver lesion and thrombosis of right branch of the portal vein. CT chest showed chronic obstructive pulmonary disease. His carcinoembryonic antigen level was 2.6. During the hospital stay, he had clonic-tonic seizure. The patient was started on intravenous (IV) anticonvulsants for seizures, IV steroids for brain edema, IV anticoagulation for portal venous thrombosis and IV antibiotics for urinary tract infection. MRI of the brain revealed multiple ring and solid enhancing lesions in the right frontal lobe and right centrum semi ovale. Colonoscopy showed diverticular disease in the left colon, a 6 mm sessile polyp at 40 cm from the anal verge. Snare polypectomy was done using electrocautery and specimen was sent for histopathology. Rigid cystoscopy showed fistula tract with evidence of stool coming from the fistula. There were not tumors or stones in the bladder. Biopsies were taken around the fistula site. In order to obtain tissue diagnosis, neurosurgeons took the patient to the operating room for image guided right parietal craniotomy. Intra-operatively the lesion was visible on the surface and contained purulent material surrounded by a relatively thick and well organized wall which was consistent with an abscess. The specimen was sent to microbiology for aerobic, anaerobic, fungal, tuberculous culture sensitivity. Four days later the patient was taken back to the operating room for resection of sigmoid colon, repair of colo-vesical fistula and end colostomy with hartmann’s pouch. The specimen was sent for histopathology. His pathology report for colon polyp was positive for tubular adenoma with no evidence of high-grade dysplasia and malignancy. The pathology result for resected sigmoid colon was positive for diverticular disease with no malignancy.

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LAPAROSCOPIC COLECTOMY IN AN EMERGENCY SETTING: A CASE-CONTROLLED STUDY COMPARING LAPAROSCOPIC AND OPEN TECHNIQUES Ker-kan Tan, MBBS FRCSEdin, Frederick H Koh, MBBS, Charles B Tsang, FRCS Edin FRCS Glasg, Dean C Koh, FRCS Edin FRCS Glasg National University Health System, Singapore Background: Laparoscopy is being increasingly adopted for elective colorectal resections. Its role in an emergency setting remains controversial. The aim of this study was to compare the outcomes between laparoscopic and open colectomies in acute emergency situations. Methods: A retrospective review of all patients who underwent emergency laparoscopic colectomies for various surgical conditions was performed. These cases were matched for age, surgical diagnosis and type of surgery with patients who underwent emergency open colectomies. Results: Twenty-one emergency laparoscopic colectomies were performed from April 2006 to July 2011 for patients who presented with lower gastrointestinal tract bleeding (5), colonic obstruction (3) and colonic perforation (13). The hand assisted laparoscopic technique was utilized in 13 (61.9%) patients with the remaining patients receiving standard multiport laparoscopic colectomies. A right sided colectomy was performed in 13 (61.9%) patients. There were 4 conversions to the open technique due to dense adhesions. Comparing the two groups, the operative time was longer in the laparoscopic group (175 vs. 145 min, p: 0.06). The duration of hospitalization was shorter in the laparoscopic group (6 vs. 7 days, p: 0.77). The overall post-operative morbidity rate was similar between the two groups (p: 0.82) with only 2 patients in each group requiring post-operative SICU stay or re-operation. There were no mortalities in our series. Conclusions: Emergency laparoscopic colectomy in a carefully selected patient group is safe and feasible in experienced hands. Although the operative time was longer, the various post-operative outcomes were comparable to that of the open technique.

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ECONOMIC IMPACT OF ANASTOMOTIC LEAKS IN COLECTOMY PROCEDURES IN THE USA: 2005–2009 Lobat Hashemi, MS, Nilay Mukherjee, PhD, Michael Morseon, MS, Rhea Sirkar, Covidien Introduction: Colectomy procedures to remove a portion of the large intestine are performed in patients with cancer, diverticulitis, trauma and inflammatory bowel disease. The anastomosis between the joined portions of the large intestine can leak, often with serious consequences for the patient such as peritonitis that can result in prolonged hospital stay and higher complication rates. Methods: We identified a set of colectomy procedures most prone to leaks based on a survey of the literature and consulting with colorectal surgeons. We then developed a work structure for these surgeries as well as additional procedures that need to be done in the event of a post-operative leak. Patient profiles were then created from this information in terms of ICD9 procedure codes that are likely to be associated with patients that leaked versus those that did not leak. The Premier PerspectiveTM Database was used to estimate the incidence and costs of postoperative anastomotic leaks from colectomy procedures, annually, from 2005 to 2009. PPD is the largest hospital-based database in the United States providing detailed resource utilization and cost data. Our study focused on several ICD-9-CM procedures including 45.73 (Open and other right hemicolectomy), 45.76 (Open and other sigmoidectomy), 45.75 (Open and other left hemicolectomy), 48.63 (Other anterior resection of rectum). Results: A total of 46,788 (19.9%) patients with colectomy procedures had ICD9 codes that suggest an anastomotic leak between 2005 and 2009. Table 1 describes the trend in volume, cost, and hospital length of stay (LOS) for colectomy patients with and without anastomotic leak from 2005 through 2009. The percentage of patients with ICD9 codes suggestive of an anastomotic leak increased from 16.2% in 2005 to 22.1% in 2009. The mean cost per discharge for patients with an anastomotic leak was significantly higher than those patients without leaks each year. Patients with anastomotic leaks cost approximately seventeen thousand dollars more than patients without a leak. Average hospital LOS was significantly lower for patients without leaks than patients with leaks, 8.4 days compared to 14.9 days, respectively. Average hospital LOS stayed relatively flat at 15 days for patients with leaks from 2005 to 2009. Average hospital LOS decreased slightly from 8.9 days in 2005 to 8 days in 2009 for patient without anastomotic leaks. Conclusions: Anastomotic leaks present a major clinical problem. Mean cost per discharge and length of stay for patients with an anastomotic leak was significantly higher than the mean cost per discharge for those without a leak. These observations highlight the potential cost advantages of preventing anastomotic leaks for patients undergoing colectomy procedures.

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LAPAROSCOPIC COLECTOMY IN THE ELDERLY ([70 YRS): PERIOPERATIVE OUTCOMES SIMILAR TO THOSE FOR YOUNGER PATIENTS CAN BE ACHIEVED Keith M Baldwin, DO, Luis Suarez, MD, Steven C Katz, MD, Ponnandai Somasundar, MD MPH Roger Williams Medical Center Introduction: Laparoscopic colon resection offers the possibility of decreased length of stay, less pain and faster recovery when compared to open surgery. These benefits may be particularly beneficial in at-risk patient populations such as the elderly. Methods: At a single institution, 103 consecutive laparoscopic colectomies for both benign and malignant disease were examined. All surgeries were performed by the same three surgeons throughout the study period, and hand assisted techniques were not used. Patients were stratified by age (\70 and [70 years). Multiple clinicopathologic variables as well as length of stay, and discharge to home or nursing homes were compared between the groups using non-parametric tests. General fast-track colorectal surgery principles were applied equally to both groups, including early enteral feeding, epidural anesthesia, early catheter removal, but not almivopan. Results: Of 103 patients, 41 (40%) were [ 70 years old. There were no significant differences between the two groups with regards to gender, types of operations performed, lymph node yield, mortality, or major complications including anastomotic leak, pulmonary embolism, major bleeding, enterocutaneous fistula, and post operative bowel obstruction. There were more patients with a diagnosis of cancer in the [ 70 year old group (75.6 vs 58.1%, p = 0.062). Post-operative ileus rates were 5% in both groups. The wound infection rate was 13.6%, with no difference between groups; however there was a higher rate of post-operative urinary tract infection (UTI) in the [ 70 year old group (7.3 vs 1.6%, p = 0.049). Average length of stay (6.1 days), operative time, blood loss and time to return of bowel function (4.2 days) were similar. A higher percentage of patients in the [ 70 year old group required a discharge to skilled nursing (27.5 vs 8.3%, p = 0.011, Mann–Whitney). Conclusions: In this single institution study eliminating surgeon bias, it appears that elderly patients have similar LOS, complication rates, and rates of major complications after laparoscopic colectomy when compared to the younger population. They still have higher rates of post-operative UTI and need of skilled nursing placement, indicating that the special needs of this population are not completely ameliorated by the use of laparoscopy. Further studies evaluating the medium and longer term quality of life after skilled nursing discharge are warranted.

Table 1 Year

With anastomotic leaks N (%)

Mean cost

Without anastomotic leaks Mean LOS (days)

N

Mean cost

p value

Mean LOS (days)

2005

6,944 (16.2)

$30,731

15.1

35,982

$11,822

8.9

\ .001

2006

9,570 (19.4)

$31,204

14.8

39,637

$12,189

8.5

\ .001

2007

9,859 (20.4)

$32,718

14.8

38,538

$12,782

8.4

\ .001

2008

9,529 (21.0)

$35,943

15.0

35,943

$13,259

8.2

\ .001

2009

10,706 (22.1)

$37,042

15.0

37,829

$13,674

8.0

\ .001

All years

46,788 (19.9)

$33,754

14.9

187,870

$12,751

8.4

\ .001

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P030

LAPAROSCOPIC SURGERY AFTER PREOPERATIVE CHEMORADIATION FOR ADVANCED LOWER RECTAL CANCER

SINGLE-INCISION VERSUS CONVENTIONAL LAPAROSCOPIC COLECTOMY : A CASE MATCHED SERIES OF 90 CASES

Shinya Morimoto, MD, Mitsuo Shimada, MD PhD, Nobuhiro Kurita, MD PhD, Hirohiko Sato, MD, Takashi Iwata, MD, Masanori Nishioka, MD, Tomohiko Miyatani, MD, Kozo Yoshikawa, MD, Masakazu Goto, Dr, Hideya Kashihara, Dr, Chie Mikami, Dr University of Tokushima

Goutaro Katsuno, MD PhD, Masaki Fukunaga, MD PhD, Yoshifumi Lee, MD PhD, Masahiko Sugano, MD PhD, Kunihiko Nagakari, MD PhD, Shuichi Sakamoto, MD PhD, Yoshito Iida, MD PhD, Seiichiro Yoshikawa, MD PhD, Yoshitomo Ito, MD PhD, Masakazu Ouchi, MD PhD, Yoshinori Hirasaki, MD PhD, Ayumu Sugai, MD PhD Department of Surgery, Juntendo Urayasu Hospital, Juntendo University

Introduction: Laparoscopic surgery for advanced colon cancer has been widely accepted. A few studies have shown that there are advantages of laparoscopic over open TME surgery for rectal cancer. However, the feasibility of laparoscopic surgery for T3 and T4 rectal cancer has not been clearly defined specifically in cases following preoperative CRT. Preoperative chemoradiation therapy (CRT) for low rectal cancer reduces local recurrence and increases anal sphincter preservation rate. Purpose: The aim of this study was to investigate the feasibility of laparoscopic surgery and the results of anorectal function after preoperative CRT

Background: Single-incision laparoscopic colectomy (SILC) is an emerging modality. Feasibility and safety of SILC has been reported; however, benefits and outcomes are not well defined. We conducted a retrospective matched case-control study to compare the short-term outcomes of Single Incision Laparoscopic Colectomy (SILC) and conventional laparoscopic colectomy (cLAC) for colon cancer.

for advanced lower rectal cancer. Methods and Procedures: Between May 2003 and May 2011, 67 patients who underwent preoperative CRT for lower rectal cancer were identified.

Indications for SILC: The indications for SILC were as follows: (1) tumors located at the cecum, ascending colon, sigmoid colon, or upper rectum; (2) relatively small tumor (less than 4 cm); (3) cSE(-); (4) cN0 or cN1; (5) cP(-); and (6) thick bulky mesorectum/mesocolon(-) (BMI \ 25).

Fifty-three patients with laparoscopic surgery (Lap group) were compared with 14 patients with open surgery (Open group). Wexner scores and stool frequency were checked at six months, one year, two years and three years after closure of ileac stoma on 19 patients.

Study Design/Method: The 100 patients who underwent SILC were matched with 100 patients undergoing cLAC from a database of 1600 patients. The two groups were matched in terms of BMI, age, gender, type of resection, and indication criteria for SILC. The outcomes of the patients in the

Results: All patients underwent complete laparoscopic operations and none were converted to laparotomy. 5 year over all survival rate was 77% in CTR. 5 year disease free survival rate was 60%. Local recurrence rate was 7%, metastatic recurrence rate was 24%. Operating time was longer in the

two groups were then compared. Procedures: A single intraumbilical 25–30 mm incision was made, and the umbilicus was pulled out, exposing the fascia with moderate subcutaneous

Open group (331 vs. 375 min, p \ 0.01). Blood loss during the operation decreased in the Lap group (160 vs. 316 min, p \ 0.01). Lymph node harvest (10 vs. 11) and morbility rate (21 vs. 29) were similar in both groups. No patients had peri-operative mortality associated with surgery after CRT. Postoperative hospital stay was shorter in the Lap group (28 vs. 38 days, p \ 0.01).

exfoliation. Three 5-mm ports or a multi-instrument access port were placed at the umbilical site. The umbilicus was the access point of entry to the abdomen for all patients. SILC was performed using a surgical technique similar to the standard laparoscopic medial-to-lateral approach. The bowel was transected either intracorporeally or extracorporeally with lymph node dissection, and then a stapled anastomosis was performed.

The mean Wexner scores were 8 (6 months after operation), 6 (1 year), 2 (2 years) and 3 (3 years). The mean stool frequency were 10 times per day (6 months after operation), 6 (1 year), 5 (2 years) and 4 (3 years). Wexner scores and stool frequency significantly improved at each time after

Results: Mean operating times were comparable between SILC and cLAC groups (146.3 ± 41.2 vs. 152.7 ± 38.7 min, not significant (NS)). Mean bleeding volumes were comparable between the two groups (27.1 ± 19 vs. 31.6 ± 21 ml, NS). One patient (1%) required conversion to cLAC due to

operation. Conclusion: Laparoscopic surgery after preoperative CRT is a feasible and a safer option for advanced lower rectal cancer compared to conventional

dense adhesions. There was no open conversion case in SILC group. Postoperatively, there was no mortality in either group. In terms of analgesic use, there was no difference between the two groups (1.0 ± 1.3 vs. 1.1 ± 0.8 times, NS). The mean hospital stay was 9.6 ± 1.5 days in the SILC

open surgery.

group and 9.7 ± 1.6 days in the LAC group (NS). The overall rate of postoperative complications was similar in both groups (4.4 vs. 6.7%, NS). The wound infection was infected in 2.2% of patients in each group. The rate of small bowel obstruction was similar. Other postoperative complications included hematochezia in one patient in the SILC group, and enteritis in two patients in the cLAC group. The number of harvested lymph nodes was comparable between the two groups (20.3 ± 4 vs. 19.4 ± 4, NS). Conclusion: This matched case–control study of 90 patients suggested that SILC for colon cancer is feasible and safe in selected patients and can result in good surgical results, with similar postoperative outcomes to cLAC.

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SINGLE INCISION LAPAROSCOPIC OSTOMY SURGERYOUR INITIAL EXPERIENCE Jonathan D Svahn, MD FACS, Dixon R Matthew, MD Kaiser Permanente East Bay-Oakland Campus Single incision laparoscopic surgery (SILS) is becoming more and more popular as surgeons gain experience with this new technique. Single incision laparoscopy provides better cosmetic results and may lead to less post operative pain and a lower incidence of incisional hernias due to the fewer number of incisions. SILS has been utilized for numerous procedures including appendectomy, cholecystectomy, colectomy, Nissen fundoplication, splenectomy, and gastrectomy to name just a few. To date, there has been only one report of single incision colostomy surgery. We report our initial experience with single incision colostomy surgery including both the creation and reversal of ostomies. We performed SILS colostomy creation in five patients (age 44–92, one female, four male, avg blood loss 10 ml, indications: soiling of large perineal wound—3, prior to pelvic exenteration—1, incontinence after treatment for rectal cancer—1) one SILS ileostomy reversal after subtotal colectomy (58 y/o male), and one SILS colostomy (59 y/o female) reversal after perforated sigmoid diverticulitis. In those patients undergoing colostomy creation, the patient was place in supine position. The ostomy site was previously marked on the abdomen in the left mid abdomen. The ostomy defect was created in the standard fashion by removing a circle of skin and then creating a cruciate incision through the fascia allowing passage of two fingers. A small Alexis wound protector is placed into the abdomen through this defect. The wound protector is then covered with a small latex free glove. A 12 mm and two five mm trocars are placed through three alternating fingers of the glove and secured with sterile strips. The abdomen is then insufflated through this device. The abdomen is explored and the sigmoid colon is identified. Mobilization is undertaken to allow sufficient length for the ostomy. The colon is then transected with an endoscopic GIA stapler. The proximal end is grasped with an atraumatic instrument and the distal aspect of the colon is left as a Hartmann’s pouch. The wound protector is removed and the proximal colon is brought out through the fascial defect. The stoma is matured in the standard fashion. For the two ostomy reversals, the procedure is essentially reversed. The patients are placed in modified lithotomy position. The stoma is then mobilized until it is free from the fascia. An appropriately sized EEA anvil is placed in the bowel and then placed in the abdomen. The ‘‘glove port’’ device is created and secured to an Alexis wound protector which has been placed through the stoma site. Adhesiolysis is performed as needed. Under direct vision, an anastomosis is created through the rectum. An air test under saline irrigation is performed. The ostomy site is closed with permanent suture for the fascia and staples for the skin. Single incision laparoscopic surgery is feasible for both the creation and reversal of ostomies. SILS offers all the benefits of laparoscopy while leaving no visible abdominal incision when creating an ostomy and no new incisions when reversing an ostomy.

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SINGLE INCISION LAPAROSCOPIC COLECTOMY USING NEW ACCESS PORT DEVICE (EZ ACCESS) WITH NEEDLESCOPIC INSTRUMENTS FOR cT1 OR cT2 RIGHTSIDED COLON CANCER : A CASE CONTROL ANALYSIS FOR CONVENTIONAL LAPAROSCOPIC COLECTOMY AND REVIEW OF THEIR TECHNICAL ASPECTS Toshimasa Yatsuoka, MD, Yoji Nishimura, MD, Hirohiko Sakamoto, MD, Yoichi Tanaka, MD, Saitama Cancer Center Introduction: With increased clinical experience and advances in technology, single incision laparoscopic colectomy (SILC) has become a safe and feasible approach. Progress in this field has been driven by multiple factors. The recent development of various devices to access into the abdomen and miniaturized laparoscopic instruments of 3-mm diameter or less has caused surgeons worldwide to shift towards performing SILC. We present a case control series of twelve cases of SILC using the new access port device (EZ Access) with needlescopic instruments and conventional laparoscopic right colectomy (LAC). The aim of our report was to analyze the safety, techniques and feasibility of this surgical technique for colon cancer patients. Methods and Procedures: Between December 2009 and September 2011, twelve selected patients whose informed consent was obtained underwent SILC. All cases were cT1 or cT2 right side colon adenocarcinomas (from cecum to hepatic flexure). These cases were matched to an equal number of LAC patients based on 5 matching criteria: age, sex, body mass index (BMI), American Society of Anesthesiologists score (ASA) and pathology. All operations were completed by one Japanese board-certified colon and rectal surgeon. A longitudinal umbilical incision was used for all SILC cases using EZ Access to place three ports through the access port device with standard laparoscopic instruments (non-disposable straight instruments) and needlescopic instruments. Demographic data, intraoperative parameters, and postoperative outcomes were assessed. Results: All cases of SILC procedures were successfully performed with standard and needlescopic laparoscopic instruments through a single umbilical incision. Morbidity was encountered in one patient of twelve patients (0.8%) and one additional trocar was inserted to help to grasp the bowels or pedicle of vessels in 4 cases (33%). No significant intraoperative complications occurred and no patients required conversion to standard laparoscopic approach using 5 ports. All patients recovered without issues. At this time no recurrence was identified. Twelve patients were analyzed in each of two groups (SILC and LAC). The mean age, sex, BMI, ASA score and pathology were similar between the groups. The incision length for SILC (4.1 cm) was smaller than LAC (5.6 cm) groups (p _ 0.006) and length of hospital stay was shorter for the SILC group (10.8 days) than LAC groups (12.5 days) (p _ 0.08). Operative time, estimated blood loss and postoperative surgical site infection were similar between the groups. Conclusions: Our preliminary study suggests that SILC for right side T1 or T2 colon cancer using EZ Access can be feasible and safe with satisfactory hospital stays and reasonable complication rates. The use of additional needlescopic instruments can facilitate SILC procedures more effectively at no extra cost. Although technology in this field is advancing very rapidly, we must have great necessity to practice new minimal access surgical skills to increase benefit of patients. Further follow-up and RCT trials will be necessary to determine its long-term clinical outcomes.

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THE FEASIBLE TECHNIQUE OF MOBILIZING INTERSPHINCTERIC PLANE USING THE PERMEATED HEAD LIGHT THROUGH THE ANAL PROCEDURE IN LAPAROSCOPIC-ASSISTED PER ANUM INTERSPHINCTERIC RECTAL DISSECTION Akiyo Matsumoto, MD, Kaida Arita, MD, Masaki Tashiro, MD, Shigeo Haruki, MD, Shinsuke Usui, MD, Susumu Hiranuma, MD Department of Surgery, Tsuchiura Kyodo General Hospital Purpose: We report the feasible technique in lower rectal surgery. Materials and Methods: In laparoscopic procedure, after dissecting the Waldeyer and Denonvilliers fasciae, the mesorectum is separated along the plane of the total mesorectal excision. On both sides of the rectum, the lateral ligament with identifying pelvic nerve plexsus is divided by laparoscopic coagulating shears to the level of levator ani muscle. The rectum is mobilized to some degree through the intersphincteric plane between the rectum and the levator ani muscle. Thereafter, the surgeon moves to the perineal side. The anal canal is exposed with a retractor, and the lower margin of tumor is identified under direct vision. The rectum is divided, together with the entire width of the internal anal sphincter 1–2 cm distal to the tumor margin. The rectum is mobilized proximally on the intersphincteric plane. After full mobilization of the circumference of the rectum, the cut edge is closed by hand suturing and irrigated with 1000 ml saline solution. Mobilization of the rectum is continued proximally. When connecting the intersphincteric plane that has already been separated through the abdominal procedure, we use the permeated head light (DLX MicroLux Head Light System; Integra Luxtec, Inc. USA) through the anal procedure. The permeated head light shows adequate dissecting line on the intersphincteric plane through the anal procedure. We can mobilize the intersphincteric plane adequately without dissecting into the rectum, the external anal-sphincter muscle and the levator ani muscle in the narrow view of the intersphincteric space between the internal analsphincter muscle and the external anal-sphincter muscle. Result: From January 2011 to the present, this study included 3 patients undergoing laparoscopic per anum intersphincteric rectal dissection for lower rectal cancer, using the permeated head light through the anal procedure, we can safely dissect the intersphincteric plane through the anal procedure in the narrow view of the intersphincteric space. Conclusion: The technique of mobilizing the intersphincteric plane using the permeated head light from the anal procedure is useful for performing laparoscopic per anum intersphincteric rectal dissection.

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PROGNOSTIC FACTORS FOR STAGE IV COLORECTAL CANCER AFTER PRIMARY TUMOR RESECTION—IS LAPAROSCOPIC SURGERY A PROGNOSTIC FACTOR FOR METASTATIC COLORECTAL CANCER? Koya Hida, MD PhD, Suguru Hasegawa, MD PhD, Yousuke Kinjo, MD, Kenichi Yoshimura, PhD, Masafumi Inomata, MD PhD, Masaaki Ito, MD PhD, Yosuke Fukunaga, MD PhD, Akiyoshi Kanazawa, MD PhD, Hitoshi Idani, MD FACS PhD, Yoshiharu Sakai, MD FACS PhD, Masahiko Watanabe, MD FACS PhD Nishi-kobe Medical Center, Kyoto University, Japan Society of Laparoscopic Colorectal Surgery Background: The effect of laparoscopic surgery on metastatic cancer is unclear, and the prognostic factors for patients with metastatic colorectal cancer who have undergone primary tumor resection have not been well examined. This retrospective cohort study was designed to investigate whether the laparoscopic approach has an impact on the prognosis of patients with metastatic colorectal cancer. Methods: Data from patients with incurable metastatic colorectal cancer who underwent primary tumor resection in 41 institutions from January 2006 to December 2007 were collected retrospectively. This cohort was used to investigate the impact of clinical factors (age, gender, ASA-PS, surgical approach, primary tumor location, CEA value, and number of metastatic organs) on overall survival. Patients with no residual tumor were excluded. A logrank test and the Cox proportional hazards regression model were used to analyze the factors. Results: Data from 904 patients were used for analysis. Laparoscopic surgery was performed on 227 patients. Median follow-up time was 30 months, and median survival time for all patients was 24 months. From univariate analysis, ASA-PS, age, CEA value, the number of metastatic organs, and surgical approach (laparoscopic surgery) appeared to have a significant effect on survival. However, multivariate analysis showed that surgical approach was not directly correlated with survival, whereas the other factors were shown to be significant as prognostic factors. Conclusions: Laparoscopic surgery was not an independent prognostic factor. ASA-PS, age, CEA value, and the number of metastatic organs were shown to be independent prognostic factors after primary tumor resection for patients with incurable metastatic colorectal cancer.

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INTRAVENOUS PHENYTOIN: POSSIBLE NEW THERAPY FOR GASTRO-INTESTINAL FISTLAE Saed A Jaber, MD, Hasan A Yami, MD, Basma M Fallatah, MD, Mahmoud Abdelmoeti, MD, King Fahd Medical Military Complex Gastro-Intestinal fistulae are among the most devastating complications after GI surgery. Their subsequent development can be lethal. We report 13 cases of GI fistulas treated with Intravenous phenytoin. Fistula tract healing consists of several processes, including cell migration and the formation of a new extracellular matrix. Multiple studies have shown that phenytoin can promote wound healing and induce faster fibrosis. We postulate that such a positive effect can be used to enhance fibrosis of the fistula tract. We treated 13 patients who had developed GI fistulae as a complication from surgical intervention .Five patients developed external small Intestinal fistulae, 2 colonic, 2 pancreatic, 1 biliary, 3 gastrocutenous fistulas. Patients were started on IV phenytoin in the first 4 day and then switched to oral phenytoin. A Significant drop in output was noticed 3–4 days after treatment. All Fistulae healed in a short period averaging 8 days without the need for a surgical intervention. In conclusion, Intrvenous phenytoin may have a positive effect in the treatment of fistulas. Prospective studies are needed to indicate this possible effect of phenytoin on fistula healing.

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SIMULTANEOUS LAPAROSCOPIC RESECTION OF PRIMARY COLORECTAL CANCER AND METASTATIC LIVER TUMOR Chie Takasu, MD, Mitsuo Shimada, Nobuhiro Kurita, Takashi Iwata, Hirihiko Sato, Masanori Nishioka, Shinya Morimoto, Kozo Yoshikawa, Tomohiko Miyatani, Masakazu Goto, Hideya Kashihara, Tohru Utsunomiya Department of Surgery, The University of Tokushima Objective: Approximately 20–25% of patients with colorectal cancer have synchronous liver metastasis at the time of diagnosis. The optimal strategy for resectable synchronous colorectal liver metastases remains controversial. Simultaneous resection of primary colorectal cancer and metastatic liver tumor is the treatment option, but there is still few reports about laparoscopic simultaneous resection. The aim of this study was to evaluate whether laparoscopic colorectal resection with simultaneous resection of synchronous liver metastases was technically feasible and safe. Methods: We evaluated the 73 patients undergoing surgery from 2004 to 2010. Patients were divided into 3 groups, laparoscopic hepatectomy (A group) (n = 43), simultaneous laparoscopic resection of primary colorectal cancer and metastatic liver tumor (B group) (n = 6), simultaneous open resection of primary colorectal cancer and metastatic liver tumor (C group) (n = 24). A comparison was made to the groups with regard to clinicopathological and perioperative and postoperative factors. Results: The difference was not admitted in the age, sex, body-mass index, chronic disease. The mean operating time was A:B:C = 265 (184–411):508 (430–591):471 (190–764) min. Group A was significantly shorter (p \ 0.05) and there was no difference between group B and C. The mean blood loss was A:B:C = 183 (10–590):165 (10–259):440 (85–820) ml. Group C had significantly higher volume than other two groups (p \ 0.05). There was no surgical mortality, but only one case in A group was converted to open surgery. And postoperative complication rate was significantly higher in C group, A:B:C = 11:16:33%. The most common complication is bile leakage (three cases), and second was bowel obstruction, wound infection and milky fluid (two cases, each). In B group, there were no postoperative complications except for one patient with subcutaneous hemorrhage and melena because of the antiplatelet agent. The mean postoperative hospital stay was A:B:C = 16 (7–46):26 (17–43):34 (17–119) day. Group A was significantly shorter (p \ 0.05), but there was no difference between group B and C. Conclusions: This study shows that simultaneous laparoscopic resection of primary colorectal cancer and liver metastasis is technically feasible and safe and efficiency in selected patients.

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A NOVEL ANVIL GRASPER ‘‘EAGLE’’ IS USEFUL FOR LAPAROSCOPIC INTRA-CORPOREAL CIRCULAR STAPLED ANASTOMOSIS

PREOPERATIVE SIMULATION OF LAPAROSCOPIC LOW ANTERIOR RESECTION FOR RECTAL CANCER BY CT COLONOGRAPHY

Yuen Nakase, MD PhD, Tsuyoshi Takagi, MD PhD, Kanehisa Fukumoto, MD PhD, Takuya Miyagaki, MD PhD Department of Surgery, Nishijin Hospital, Kyoto, Japan

Hiroyuki Fukuda, MD PhD, Kotaro Yoshimura, MD, Hidehito Shibasaki, MD PhD, Takaaki Kaneko, MD PhD, Koya Fushimi, MD PhD, Takashi Senda, MD, Takahito Masuda, MD, Shintaro Kohama, MD, Yangi Mun, MD, Akira Ogata, MD PhD matsudo City Hospital

1. Objective of the Device: Traditional anvil graspers have a uniquely shaped jaw that enhances grip force. They grasp the anvil stem perfectly. Therefore the anvil head cannot be maneuvered delicately in a tight pelvic space. It may be difficult to use for connecting the stem of an anvil to the center rod of a circular stapler. Many surgeons use a grasper designed for holding the bowel or a dissector to hold the anvil during intra-corporeal circular stapled anastomosis during low anterior resection, sigmoidectomy, and left hemicolectomy although it is difficult to connect segments with these instruments due to slipping. Such difficulties may cause operative complications or instrument damage. We developed a novel anvil grasper ‘‘EAGLE’’ (Evolutional Anvil Grasper for LaparoEndoscopic surgery) for more precise and safer anastomosis procedures. 2. Description of the technology: The EAGLE has curved blades with tungsten carbide-coated tips, which are curved 15 mm from the tip to create a 6 mm grasping surface that is the same diameter as the anvil stem. When the stem of the anvil is held by a grasper designed for the bowel or a dissector, the force of the 2 blades act apically and apply the wrong type of force, based on the vector synthesis method. Increasing the force applied to the grasper also increases the apical force. This can cause the stem of the anvil to slip through the grasper. In contrast, the grasping force of the EAGLE does not generate apical force. This facilitates grasping of the anvil stem at any angle, allowing the surgeon to easily handle the proximal colon and smoothly connect it to the center rod of the circular stapler.

Objectives: Laparoscopic low anterior resection for rectal cancer is still technically difficult because the pelvic space is deep and narrow. Furthermore, laparoscopic surgery has a limited two-dimensional display of the operative field, thus, requires a detailed understanding of local anatomy. It is important to assess the many variations in vascular anatomy and adjacent organ, preoperatively. This study was aimed to simulate the laparoscopic low anterior resection for rectal cancer by CT colonography (CTC) with CT angiography. Methods: Eight patients with rectal cancer underwent CTC by 64-MDCT scanner (VCT, GE), using automated device for carbon dioxide (CO2) insufflations. The high concentrate (350 mg I/ml) and high volume (135 ml) contrast agents were rapidly administered intravenously at the dose of 1.8 ml/kg. Arterio-venous phase images, which simultaneously demonstrate the artery and vein in same phase, were obtained by bolus-tracking method. Scanning time of arteriovenous phase was about 55 s after the start of injection. Excretory phase images, which demonstrate the ureters, were obtained 5 min after the injection. The fused three-dimensional (3D) CT images of arteries, veins, ureters, seminal vesicle, skin, pelvis, and CO2-filled colorectum were reconstructed using the volume-rendering technique (advantage workstation ver. 4.3, GE). Surgeons preoperatively simulate the laparoscopic low anterior resection using these fused 3D images. Simulated images can also be observed in the operating room. Results: All eight examinations were successful and diagnostic. The CO2-filled colorectum was totally distended from cecum to lower rectum. Due to the arterio-veous phase, vascular anatomy was clearly identified without divergence. 3D-CT angiogram demonstrated the precise vascular anatomy of the inferior mesenteric artery giving rise to the superior rectal artery, left colic artery, sigmoid artery, and marginal arteries. The inferior mesenteric vein was shown which runs near the left colic artery. Vascular variants of inferior mesenteric artery were clearly identified. Angiogram also revealed the variable branches of internal iliac artery in the pelvis, including the inferior vesical arteries of neurovascular bundles, and middle rectal arteries. Inferior vesical artery was well contrasted suggesting abundant blood flow. Laparoscopic low anterior resection was performed with precise lymph nodes dissection and ligation of vessels in all cases as preoperatively simulated by CTC. Adjacent organs were safely preserved. Conclusion: CT colonography with intravenous contrast agents prior to the laparoscopic low anterior resection for rectal cancer demonstrates the vessels, tumor location, and their position to adjacent organs, which contributed to precise operation including the manipulation of the vessels as well as lymph nodes dissection. Preoperative CTC may reduce the difficulties of laparoscopic low anterior resection for rectal cancer.

3. Preliminary Results: This study included 15 patients undergoing laparoscopic low anterior resection or sigmoidectomy for colorectal cancer using intra-corporeal circular stapler anastomosis. The time required to connect the anvil head to the center rod of the circular stapler using EAGLE vs. other instruments was 18.6 ± 4.3 s versus 35.5 ± 73.6 s (p \ 0.0001). Other instruments require more time, depending on the surgeon’s skill, the level of anastomosis (distance from the anal verge), and patient characteristics (gender, obesity or body frame size, etc.). However, any surgeon using the EAGLE could perform connections smoothly in any patient. All surgeons who used The EAGLE in place of other instruments felt it was comfortable to use and made it easier to connect the anvil to the center rod of the circular stapler. 4. Conclusions: By using the EAGLE, a surgeon can hold the proximal colon in the ideal position and smoothly join segments to perform anastomosis, the most challenging tasks in laparoscopic colorectal surgery. The EAGLE is a very simple anvil grasper, but should be very helpful in allowing surgeons to perform these procedures safely.

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URINARY CONSEQUENCES AND PELVIC FLOOR STABILITY IN WOMEN UNDERGOING STAPLED HEMORRHOIDOPEXY FOR PROLAPSE: IS THIS STILL THE RIGHT PROCEDURE? F A Morfesis, MD FACS, Brian P Rose, BS, Francesca N Morfesis, MA Owen Drive Surgical Clinic of Fayetteville, East Carolina University, Duke University Medical Center Introduction: The use of stapled hemorrhoidopexy or PPH for the treatment of Class III and IV internal hemorrhoids has become standard since its induction. Patients often show superior return to normal activities and are pain free more quickly than the traditional, more invasive open approach. This study aimed to identify pelvic floor stability in women who present with prolapse and elect to undergo stapled hemmorhoidopexy in hopes to assess the validity of this procedure in select population. Methods: Women were selected to undergo stapling based upon prolapse presentation. A validated urologic score endorsed by the American College of Urology was used. Women were assessed both pre-operatively and at 1 month post-surgery. Results: Initial scores in urinary function ranged 0–18 with a maximum score of 20 pre-operatively. This same group reported a 1 month post-operative score ranging from 1 to 15. Patients who reported pre-op difficulty with frequency, sudden urges to urinate, and sleeplessness reported increases in such difficulties post-op. Decreases were seen in spillage of urine during daily routines. Conclusions: This limited case series explores the implications of stapled hemorrhoidopexy in women ages 32–61 for prolapse. The stapling approach is regarded as less invasive compared to traditional open hemorrhoidectomy, but with some remaining consequences in perviously described anal tone and urinary continence. This ultimately begs the question whether or not such procedures should be used in select populations or more attention should be placed into investigating the long term consequences of other treatment modalities.

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LAPAROSCOPIC RIGHT HEMICOLECTOMY WITH MEDIALLY APPROACHED LYMPH NODE DISSECTION ALONG THE SURGICAL TRUNK FOR T3 OR T4 COLON CANCER? Kazuteru Watanabe, Dr PhD, Shoichi Fujii, Dr PhD, Jun Watanabe, Dr PhD, Teni Godai, Dr PhD, Mitsuyoshi Ota, Dr PhD, Chikara Kunisaki, Dr PhD, Yasushi Ichikawa, Dr PhD, Itaru Endo, Dr PhD Yokohama City University Medical Center, Gastroenterological Center, Yokohama, Japan Background: Japan’s 2010 guideline recommends D3 lymph node dissection for T3 or T4 colon cancer. D3 in rightsided colon cancers requires not only mesocolon lymph node resection but also main node removal along the so-called surgical trunk. The aim of this study was to clarify the efficacy of radical lymph node dissection along the surgical trunk (D3) in a cohort of patients undergoing laparoscopic right hemicolectomy for T3 or T4 colon cancer. Methods: We enrolled 258 consecutive patients with right-sided colon cancer (T3 or T4) who underwent potentially curative right hemicolectomy between June 1993 and December 2008. Patients were divided into two groups: laparoscopic-assisted right hemicolectomy (LARH) group (n = 60) and open right hemicolectomy (ORH) group (n = 198). For all patients, patient and tumor characteristics, perioperative findings and long-term results were extracted from the case records retrospectively. Surgical technique: All colic vessels are cut along the surgical trunk using only a medial approach. The pedicle of ileocolic vessels is identified and the mesocolon is dissected between the ileocolic vessels and the periphery of the SMV to expose the second portion of the duodenum. The ileocolic vessels are then cut at their roots. The superior mesenteric vein between the ileocolic vein and the gastrocolic trunk are skeletonized for complete lymph node removal. The right colic vessels and the right branch of the middle colic vessels are cut. Results: The demographic data of the two groups were similar. The mean number of total lymph node harvested and lymph node along the surgical trunk did not differ significantly between the two groups (31.7/4.4 vs. 33.0/4.6). Operation time was similar. The LHRH group had a lower volume of intra-operative bleeding (55.7 vs. 255.9, p \ 0.01) and a shorter post operative hospital stay (9.6 vs. 15.8, p \ 0.01). There was no significant difference in operative complications; wound infection (9.8 vs. 19.2%), anastomotic leakage (0 vs. 3.5%), ileus (3.5 vs. 8.9%). Relapse-free survival (TNM stage 2: 83.4, 3: 62.5 vs. 2: 81.7, 3: 64.4) and overall survival (TNM Stage 2: 96.5, 3: 88.2, vs. 2: 88.2, 3: 69.3) did not differ between two groups. Conclusion: LARH with medially approached radical lymph node dissection along the surgical trunk is a safe and feasible procedure for T3 or T4 right-sided colon cancers.

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ADEQUATE MARGINS OF RESECTION FOR RECTAL AND ANAL CANCERS CAN BE ACHIEVED THROUGH A SINGLE-SITE LAPAROSCOPIC APPROACH David B Stewart, MD, Evangelos Messaris, MDPhD Penn State Hershey Medical Center Background: The adequacy of single-site laparoscopic (SSL) resections for malignancies involving the rectum and anus has not been thoroughly analyzed. The present study assesses the margins of resection for consecutive patients undergoing low anterior and abdominoperineal resections for anorectal malignancies. Methods: Consecutive rectal and anal cancer patients who underwent SSL by a single surgeon in a single institution from January 2011 through August 2011 were identified. Patient demographics, the use of neoadjuvant therapy and operative details were collected, and complications were sought within 30-days of surgery. Pathology reports were also reviewed to assess both the radial and distal margins of resection as well as the pathologist’s evaluation of the mesorectum. Results: A total of 9 patients were identified, of whom 7 (77%) were diagnosed with rectal adenocarcinoma, one (11%) was diagnosed with adenocarcinoma of the anal canal, and one (11%) was diagnosed with anal melanoma. Six (66%) patients underwent neoadjuvant chemoradiation, and all but one rectal cancer was located B 8-cm from the anal verge as measured by rigid proctoscopy. Six (66%) patients underwent a low anterior resection of the rectum with a diverting loop ileostomy, and 3 (33%) patients underwent an abdominoperineal resection. Median patient age was 66 years (range: 44–83) and the median BMI was 30 (range: 24–38), with females comprising 57% of the cohort. Six (66%) patients had Stage III disease, while 3 (33%) patients had Stage IV disease and had undergone neoadjuvant chemotherapy and a previous resection of their hepatic or pulmonary metastases prior to proctectomy. Median operative time was 224 min (range: 170–294 min) and median estimated blood loss was 100 ml (range: 50–200 ml). There were no conversions to standard laparoscopy or laparotomy, and there were no 30-day complications, including mortality. All margins of resection were clear of tumor by histology. The majority of patients had T2 or T3 cancers (88%); median size of the cancer was 25-mm (range: 0–38 mm). A median of 16 lymph nodes were retrieved (range: 8–41), with 3 (33%) patients having mesorectal nodal involvement with cancer. The closest margin of resection was the radial margin (median: 15–mm; range: 12–25 mm), while all distal margins of resection were a minimum length of 2-cm (range: 2–8-cm). Intact mesorectal resections were achieved in each surgery. Conclusions: Single-site laparoscopic resections for rectal and anal cancers can achieve adequate radial and distal margins of resection, even when operating in the distal pelvis and after preoperative radiotherapy. While SSL may potentially develop into a regularly utilized alternative to standard laparoscopy for rectal and anal cancers in the future, larger prospective studies are needed to validate oncologic outcomes for SSL.

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ADAPTATION OF LAPAROSCOPIC SURGERY FOR RIGHT SIDE COLON CANCER—LEARN FROM OPEN COLECTOMY CASES Atsushi Ikeda, title, Atsuko Tsutsui, title, Hirohisa Miura, title, Naoto Ogura, MD, Masanori Naito, MD PhD, Takatoshi Nakamura, MD PhD, Takeo Sato, MD PhD, Masahiko Watanabe, MD PhD Department of Surgery, Kitasato University School of Medicine Background: Laparoscopic colectomy (LAC) has come to be widespread throughout the world. In our institution, the laparoscopic surgery has been introduced since 1995. The initial deployment was intended for early cancer, and now has been expanded gradually adapt to T4a cases. Secure of the surgical field and understanding of the retroperitoneal layer is very important to perform safe laparoscopic surgery. Furthermore, it is important that we understand blood vessels’ anatomy before surgery especially for laparoscopic operations. Currently, there are no rules in clearly nonadaptive in LAC. Insufficient decompression of the bowel, huge tumor, peritoneal dissemination and poor general conditions are generally considered non-adaptive cases of LAC. But in fact, decision about the surgical procedures is decided in individual cases. Purpose: The cases for open colectomy (OC) performed to right-sided colon cancer, a retrospective study reaffirm the difficulty in laparoscopic surgery patients. Objects: From April 2005 to December 2009, all operative patients for colorectal cancer were 730 cases. Surgery for right side colon cancer was performed 141 cases, and 3D-CT was performed among these 119 patients. OC (43 cases) and conversion from LAC to OC (8 cases) a total of 51 cases was included in this study. Examinations: Rate of LAC, conversion rate from LAC to OC, non-indication reasons for LAC, reasons for conversion from LAC to OC. Results: The rate of LAC for right side colon cancer was 57.1% (68/119) and conversion rate was 10.5% (8 / 76). Among the 51 patients, 45 patients underwent OC in patient factors (Conversion from LAC—8 cases). Detailed analysis of patient factors, 12 patients had a previous laparotomy (Upper abdominal operation—6 cases, Appendectomy—5 cases, Sigmoidectomy—1 case), 28 patients had a primary tumor factors (Invasion to other organs—15 cases, Ileus 5 cases, Bulky tumor—6 cases, Total circumference of the transverse colon—5 cases) and 11 cases had a other factors (Other mergers, such as liver metastasis lesions—6 cases, Poor general condition—5 cases). The detail reasons of conversion from LAC to OC, 6 of 8 cases were patient factors (Difficulties of adhesive dissection—2 cases, Multiple organ invasion—4 cases), and only 2 cases were surgeon factors (Bleeding from gastrocolic trunk of Henle, Torsion of mesenterium). Conclusion: Right colon cancer is often found in advanced state with a slow onset of symptoms. Thereby, it is often forced to choose OC. In our cases, the percentage of patients underwent LAC can be low, because it was the most frequent cause of the patients factors (88.2%). Among them, 54.9% was accounted for selection of OC related to the primary tumor factors. We could reduce the conversion rate and surgeon factors by performing adequate preoperative diagnosis and image evaluation using 3D-CT.

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IS SEPRAFILMÒ SLURRY EFFICACIOUS IN PREVENTING SMALL BOWEL OBSTRUCTION? Adit Suresh, MD, Brian G Celso, PhD, Ziad T Awad, MD University of Florida College of Medicine- Jacksonville Seprafilm adhesion barrier is proven to reduce adhesion formation after open abdominal and pelvic operations. We have shown previously that Seprafilm slurry is safe to use in patients undergoing laparoscopic colectomy. The aim of this study is to evaluate the efficacy of Seprafilm slurry with regard to adhesive small bowel obstruction (SBO) in patients who underwent laparoscopic colectomy. Methods: Retrospective review of prospectively collected data from 223 patients who underwent laparoscopic colectomy by a single surgeon was analyzed. In the first group (82 patients): no Seprafilm slurry was used. Seprafilm slurry was used in the second group (141 patients). Group characteristics were evaluated with regard to age, sex, body mass index (BMI), and ASA score. Efficacy of Seprafilm slurry was evaluated by comparing the incidence of adhesive small bowel obstruction between the two groups at 6 month post-operative period. Results: The two groups were similar with regard to race, sex, and BMI. Patients in the Seprafilm slurry group were statistically significantly younger and had a higher ASA score. Three patients in group 1 (no Seprafilm) developed SBO. None resolved with conservative measure and all three needed an operation to alleviate their obstruction. Three patients developed SBO in group 2 (Seprafilm slurry); 2 patients resolved with conservative treatment and one needed surgical intervention. The relative risk of developing a SBO or requiring a re-operation, using 95% confidence intervals, showed no significant difference between the two groups. For the Seprafilm slurry group, the relative risk for developing a SBO was (RR = 0.587, CI = 0.121–2.840) and of re-operation was (RR = 1.031, CI = 0.986–1.078). For the nonslurry group, the relative risk of developing SBO was (RR = 1.016. CI = 0.9671–0.067); and of reoperation was (RR = 0.196, CI = 0.021–1.850). Conclusion: This is the first study in the literature that evaluates the efficacy of Seprafilm slurry. As the RR for the slurry group was almost 59% there was a clinical benefit of reduced risk for SBO although the result was not significant. Because of our small sample size, based upon the available data, the clinical significance was unable to achieve statistic significance in the development of adhesive SBO whether or not patients received Seprafilm slurry. There was also no statistical difference in whether or not patients treated with slurry were more likely to recover with conservative management.

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SINGLE PORT ACCESS LAPAROSCOPIC APPENDECTOMY BY USING MICRO-INSTRUMENTS FOR COMPLICATED ACUTE PERFORATED APPENDICITIS WITH ABSCESS FORMATION: REPORT OF 6 CASE SERIES Yoshiyuki Kawakami, MD PhD, Hidenori Fujii, MD PhD, Toshiharu Aotake, MD PhD, Koji Doi, MD PhD, Makoto Yoshida, MD PhD, Kei Hirose, MD, Riki Ganeko, MD, Hisaya Shirai, MD, Fumie Tanaka, MD, Yuki Hirose, MD PhD Department of Surgery, Japanese Red Cross Fukui Hospital, Fukui, Japan Background: Recently, single port access laparoscopic surgery with transumbilical approach has been widely adopted by emphasizing an excellent cosmetic advantage as innovative features in minimally invasive surgery. We previously reported that transumbilical single port access laparoscopic surgery for appendectomy (TSALS-LA) could be safe and feasible for complicated acute gangrenous appendicitis with some difficult cases with abscess formation. Thus we attempted to introduce modified technique for TSALS-LA that consisted in combining the use of conventional 5 mm trocar in transumbilical single access and newly developed 3 mm micro-instruments with supra-pubic approach. In this case series, we report 6 consecutive cases of modified TSALS-LA and discuss the therapeutic aspects of this entity. Patients and methods: From February to September of 2011, 6 consecutive patients with complicated acute appendicitis with abscess were assigned to undergo modified TSALS-LA at our hospital. We conducted to study our technique using reusable metallic trocar (ENDOTIPTM, 3.5, 6 mm in diameter, 100, 65 mm in length, KARL STORZ GmbH & Co. KG, Tuttlingen, Germany) as a working port. XCELTM (5 mm in diameter, 100 mm in length, ETHICON ENDO-SURGERY, INC., Pittsburgh, PA, USA) was used as a camera port. Straight-type grasping forceps and dissecting forceps (3, 5 mm in diameter) were used both in the parallel setup at umbilical site and in the triangular coaxial setup with supra-pubic puncture. Results: Clinical records of 202 cases of appendectomy for acute appendicitis carried out during this study period (From Jun of 2009 to September of 2011) were analyzed retrospectively in background factors, operative findings, operation time and hospital stay. Of them, 77 patients (38.3%) with 21 abscess cases (13.4%) had the pathological diagnosis of acute gangrenous or perforated appendicitis. Laparoscopic surgery was performed in 35 (8 abscess) cases and open surgery was in 42 (13 abscess). Modified TSALS-LA was in 15 cases (male 6, female 9, average age 47.3 years, range 9–88) with 6 abscess cases (m 2, f 4, 50.8, 9–88). Pure single access (TSALS-LA) was in 10 cases (m 6, f 4, 41.2, 14–71) with 2 abscess (m 2, 59.0, 47–71). 10 had conventional LA (m 6, f 4, 55.0, 20–82) with 6 abscess (m5, f1, 43.0, 20–66) and 42 had open surgery (m 22, f 20, 49.2, 6–88) with 13 abscess (m 8, f 5, 64.1, 34–88). The average body mass index in the modified group was 22.1 kg/m2 (range, 13.4–25.0) as was 22.0 in abscess. The mean operative time in the modified group was 92.2 min (range, 42-178 min) with 118.5 in abscess cases, as was 91.9 (42–123) with 120.0 in the pure single access group. The mean hospital stay in the modified group was 6.2 days (range, 2–19 days) with 8.5 in abscess cases, as was 7.1 (2–28) with 6 in the pure single access group. No major perioperative complications were observed in all cases. Conclusions: Our cases could confirm the safety and the attractive cosmetic advantage of modified TSALS-LA for complicated acute perforated appendicitis with abscess formation as a promising option in managing this condition.

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PATTERND OF THE INFERIOR MESENTERIC ARTERY AND THOSE BRANCHES AND THE CORRELATION OF OTHER MARKS Takuya Sugimoto, title, Makio Mike, title, Nobuyasu Kano, title Kameda Medical Center Introduction: Laparoscopic colorectal surgery has been standard procedure for colorectal cancer. Surgeons, however, often struggle because of the intraabdominal obesity, anomaly, disorientation or other reasons. The preoperative examinations have gotten more and more importance to accomplish operation safely in the era of laparoscopic surgery. Multidetector computed tomography (MDCT) and CT angiography (CTA) provide a lot of information. Method and Procedures: This study from analyzing about 250 cases of MDCT and CTA aimed two purposes, first, the pattern of the inferior mesenteric artery (IMA) and its branches, the left colic artery (LCA) and the first sigmoid artery (S-1), second, the correlation of the other marks, the umbilicus and the bifurcation of aorta. That information is necessary to consider the operative strategy and to make operation safer and easier. Results: As defined that LCA is the first branch of IMA, there are three types. 1. LCA and S-1 branch independently from IMA(49.2%). 2. S-1 branches from LCA (32%). 3. LCA and S-1 co-branch from IMA (18.6%). The distance from the root of IMA to the root of LCA is not correlated with the body height or body mass index (BMI). And the distance from the root of IMA to the bifurcation of aorta or to the level of the iliac crest is not also correlated, either. Conclusion: The frequency of the pattern of IMA and its branches is almost same as previously reported. It is hard to estimate the position of the root of IMA or LCA from the body height, BMI or other marks, such as the umbilicus or the bifurcation of aorta. It is important to use such images and prepare operation case by case preoperatively.

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SINGLE-INCISION LAPAROSCOPIC SURGERY USED TO PERFORM TRANSANAL ENDOSCOPIC MICROSURGERY (SILSTEM): A NEW TECHNIQUE IN THREE CASES Shigeoki Hayashi, PhD MD, Minoru Matsuda, FACS MD, Motoo Yamagata, PhD MD, Ken Hagiwara, MD, Masahito Ikarashi, MD, Tadatoshi Takayama, PhD MD

Department of Digestive Surgery, Nihon University School of Medicine, Tokyo, Japan Introduction: Transanal endoscopic surgery (TEM) was developed by Buess. However, TEM has slowly gained widespread acceptance among colorectal surgeons because of the need for specific training and the high cost of specialized instrumentation. At the other extreme, laparoscopic surgery has rapidly spread throughout the world with the development of improved instruments. Some laparoscopic surgeons have reported single port access surgery using a SILSTM (single-incision laparoscopic surgery) port. We have used this port to perform the procedures such as cholecystectomy, colectomy, appendectomy, and hernioplasty. While using the SILSTM port, we developed a great interest in its shape and soft material and realized that the shape of the SILSTM port resembles that of the anal canal. We therefore considered whether single-incision laparoscopic surgery could be used to perform transanal endoscopic microsurgery (SILSTEM). And we received institutional review board approval for this procedure. We present the clinical application of this technique and its short-term results. SILSTEM is suggested to be an effective technique for the resection of rectal tumors. Methods and Procedures: Between December 2010 and August 2011, three patients underwent SILSTEM. All three operations were performed the same colorectal surgeon. Bowel preparation was done the day before surgery. After spinal anesthesia, the patient was placed in the adequate position. A SILSTM port was gently introduced into the anal canal, and the bowel was extended by carbon dioxide insufflation. A 5-mm laparoscope was set in the port. After a clear view was obtained, indigo carmine was sprinkled around the lesion with the use of an injection-needle to demarcate the border between the tumor and the normal mucosa. A 5-mm safety margin of normal mucosa was defined by coagulation marks. The needle was then introduced into the lower layer of the lesion, and an adequate volume of saline was injected into the submucosa. The tumor rose from the submucosa. The tumor was completely excised from the rectal wall with the use of an ultrasonic surgical scissors. After the defect created by resection was irrigated with saline solution to prevent local recurrence, the defect was closed with the running sutures, using the laparoscopic suturing device and clips. Results: The SILSTEM operations were successfully completed in the three patients without other procedure. The median operation time was 140 (101–284) min, and the blood loss was less than 5 ml in all patients. The three patients had no nausea or abdominal distension during or after the procedure. The median tumor size was 20 (8–48) mm and the final pathological findings were T1 in adenoma, Tis cancer in adenoma and carcinoid. There was no fecal incontinence or soiling during postoperative follow-up. The median postoperative hospital stay was 4 (2–8) days. Conclusion: SILSTEM is a new, useful, well-tolerated technique in our experiences. However, further experience and clinical trials are needed to fully define the advantages, disadvantages, and indications of this procedure. We have no conflict of interest.

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DOES THE NEOADJUVANT CHEMORADIOTHERAPY INCREASE POSTOPERATIVE COMPLICATIONS IN LAPAROSCOPIC LOW ANTERIOR RESECTION?

SHORT-TERM SURGICAL Results OF LAPAROSCOPIC INTERSPHINCTERIC RESECTION FOR LOWER RECTAL MALIGNANT TUMORS

Alejandro G Canelas, MD, Maximiliano E Bun, MD, Esteban E Grzona, MD, Mariano Laporte, MD, Federico Carballo, MD, Nicola´s A Rotholtz, MD Hospital Alema´n, Buenos Aires, Argentina

Seiichiro Yamamoto, MD, Shin Fujita, MD, Takayuki Akasu, MD, Masashi Takawa, MD, Ryo Inada, MD, Yoshihiro Moriya, MD National Cancer Center Hospital

Background: Neoadjuvant radiation and chemoradiotherapy in rectal cancer reduces local recurrence. However, many authors report an increase in the rate of intraoperative and postoperative complications due to local effects generated by the radiation. The aim of this study is to assess whether these preoperative treatment increases the rate of morbidity in patients undergoing laparoscopic low anterior resection. Methods: A retrospective study was performed using a prospective collected database. All patients with rectal cancer who underwent laparoscopic low anterior resection between July 2003 and July 2011 were included. Patients who underwent total proctocolectomy or abdominoperineal resection were excluded. The series was divided into two groups; G1: patients who were operated after diagnosis, and G2: patients who underwent preoperative chemoradiation. Preoperative data and perioperative morbidity were compared between groups by univariate analysis. Results: 66 patients with rectal cancer were included; G1: 50 (76%) y G2: 16 (24%). Preoperative data was homogeneous between the two groups, but G2 presented more advanced stages. G2 had longer surgical time (G1: 227 ± 70 vs. G2: 301 ± 97 min; p \ 0.05), but there were no differences in the rate of intraoperative complications and in the conversion rate. There were no differences in the rate of postoperative complications, return to bowel function and postoperative length of stay. Conclusions: Preoperative neoadjuvant chemoradiotherapy in patients with rectal cancer undergoing laparoscopic low anterior resection does not increase intraoperative and postoperative complications. However it increases operating times.

Introduction: For patients with lower rectal malignant tumor located within 4–5 cm from the anal verge, intersphincteric resection (ISR) was developed to avoid permanent colostomy. However, controversy still persists regarding the appropriateness of laparoscopic surgery (LS) for patients with lower rectal malignant tumor because of concerns over the safety of the procedure and of the uncertainty of the long-term outcome. Laparoscopic rectal excision involves many procedural complexities and technical difficulties, and LS in patients with lower rectal malignant tumor is still technically demanding. The aim of the present study was to evaluate the short-term surgical outcomes of laparoscopic intersphincteric resection (Lap-ISR) for lower rectal malignant tumor. Patients and Methods: A review was performed of a prospective registry of 33 patients who underwent curative LapISR for lower rectal malignant tumor between July 2002 and June 2011. Candidates for Lap-ISR were basically patients who were preoperatively diagnosed with T1N0M0 or T2N0M0. After full mobilization of the left side colon and rectum, the intersphincteric plane between the puborectalis and the internal sphincter was dissected cautiously as caudally as possible under laparoscopic vision. Then, anal canal mucosa and the internal sphincter were circumferentially incised, and the intersphincteric plane was dissected by the anal approach. A per anum handsewn coloanal anastomosis was performed. Patient demographics and outcomes were recorded prospectively. Results: Operations were performed by three consultant surgeons, and all operations were completed laparoscopically in this series. There was no perioperative mortality. Thirty-two patients had lower rectal cancer, and one patient had lower rectal carcinoid tumor. The median follow-up was 22 months. The median operative time was 358 min, and the median blood loss was 108 ml. Liquid and solid foods were started on median postoperative day 1 and 2, respectively. The median postoperative hospital stay was 8 days. Thirteen postoperative complications occurred in 11 patients (33 percent), including subclinical anastomotic leakage in 1 and bowel obstruction in 2. Reoperation was not required in the present series. All the patients underwent ileostomy closure; however, one patient with a past history of esophagectomy for esophageal cancer hoped for a permanent stoma after ileostomy closure, because of diarrhea. The positive margin rate was 0 in the present series. At the end of the study period, cancer recurred in two patients (6.1%). One patient with pathological Stage IIIC developed para-aortic and mediastinum lymph node metastasis 4 years after the initial operation, and another patient with pathological Stage I developed pulmonary metastasis 2 years after the initial operation. Conclusion: Lap-ISR for lower rectal carcinoma is technically feasible and oncologically appropriate for selected patients with lower rectal malignant tumor. It remains unclear, however, whether Lap-ISR is equivalent to conventional open surgery in terms of long-term oncological outcome and functional outcome, and this can only be answered through the accumulation of more patients prospectively, considering the fact that RCT with a sufficient number of patients comparing open and laparoscopic ISR is lacking.

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PERFORATION RISK AND IN-HOSPITAL DELAYS Ck Chang, title, K Cho, title, P Fuchshuber, title, B Eklund Walnut Creek Kaiser Introduction: Risk for perforated appendicitis is related to the duration of inflammation, of which patient related delays are difficult to quantify, however in-hospital interval are more measurable. Methods: A total of 4898 appendectomy were performed in adult patient from January 2008 to December 2010 at 21 Kaiser Permanente medical centers in Northern California. Groups were defined based on time to the operating room after admission (B 12 h, B 9 h and B 6 h) and rate of perforation rate. Results: Overall perforation rate was 16%, with 81% of the appendectomies performed laparoscopic. Mean age was 40 years old with mean length of stay of 1.7 days. Patient over the age of 65 constituted 9% of the total patients studied. Patient over the age of 65 years old, admission to operating room time [9 h and open appendectomies were associated with a higher perforation rate (p \ .05). Admission during regular business hours versus after hours were not associated with an increased perforation rate (p = .16). Mean length of stay was longer in patients with perforations and age greater than 65 years old (3.4 and 2.8 days, respectively). Conclusion: Perforated appendicitis is associated with a higher morbidity and clinical outcome. Admission to operating room time of greater than 9 h has a negative outcome clinically and on hospital length of stay. Patients greater than age 65 were at higher risk for perforation. Delaying surgery more than 9 h should be avoided especially in patients greater than 65 years old.

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SHORT-TERM ASSESSMENT OF CONVERTED CASES IN LAPAROSCOPIC COLORECTAL SURGERY FOR MALIGNANCIES Kazuki Ueda, MD, Fumiaki Sugiura, MD, Koji Daito, MD, Masako Takemoto, MD, Eizaburo Ishimaru, MD, Tadao Tokoro, MD, Jin-ichi Hida, MD, Haruhiko Imamoto, MD, Hitoshi Shiozaki, MD, Kiyotaka Okuno, MD Kinki University School of Medicine Background: Laparoscopic colorectal surgery for malignancies (LAC) has been widely accepted. However, depending on increased cases or expanding indications, converted cases has been experienced. We assessed converted cases comparison to completely performed cases in LAC. Method: All the patients, who underwent LAC between January, 2005 and June, 2011, were entered into a database and several parameters were collected. In these periods, 259 patients underwent LAC. Hand-assisted case and simultaneous surgery were excluded in this study. Results: In 259 patients, hand-assisted cases were performed in 2 patients and simultaneous surgery cases were performed in 4 patients. There were 22 converted cases in 253 patients (8.7%). Reasons for conversion were as follows: severe adhesion/previous open surgery in 11 cases (4.3%), hemorrhage, obesity, and other organ injury in 3 cases, respectively (1.2%), and difficulty of maneuver in 2 cases (0.8%). According to the classified by performed operation, right hemicolectomy was in 7 cases (31.8%), sigmoidectomy and anterior resection were in 5 cases, respectively (22.7%). Comparing conversion cases and completely performed cases, only BMI affected the conversion (24.3 vs. 22.7, p = 0.048). Age and tumor size did not affect the conversion. In perioperative results, the conversion acted on the operative duration (243 vs. 195 min, p = 0.0078), the estimated blood loss (286.5 vs. 57.7 g, p \ 0.0001), and the postoperative hospital stay (15 vs. 12 days, p = 0.009). The anastomotic breakdown was not influenced by the conversion. Conclusion: Severe adhesion/previous open surgery cases consisted half of converted cases. It was thought that expanding indication was the reason. Preoperative decision making will be needed for predicted conversion cases avoiding extended operative duration, unnecessary bleeding and extended hospital stay. High BMI cases will be managed carefully for LAC.

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DISCONTINUATION OF ANTIPLATELET THERAPY FOR COLONOSCOPY AND THE ASSOCIATED THROMBOEMBOLIC RISK

COMPARATIVE STUDY BETWEEN INTRACORPOREAL AND EXTRACORPOREAL ANASTOMOSES IN RIGHT HEMICOLECTOMY

Izi D Obokhare, MD, Jose Cordova, MD, David E Beck, MD FACS, Charles B Whitlow, MD FACS, David, A Margolin, MD FACS Department of Colon and Rectal Surgery Ochsner Medical Center

Christopher W Salzmann, MD, Morris E Franklin, MD FACS, Karla Russek, MD, Ulises Garza, MD Texas Endosurgery Institute

Introduction: Discontinuation of antiplatelet therapy (APT) is associated with a low risk of thromboembolic events. There is a dearth of data to guide the management of antiplatelet therapy in patients undergoing colonoscopy. Current guidelines are based on small trials and expert opinion. The decision to withhold APT in the periendoscopic period is not a trivial one. Methods and procedures: A prospectively collected data base involving 4049 colonoscopies performed in a 10 month period between November 2010 and August 2011 was reviewed. 122 patients on APT were identified. Our current protocol involves checking with prescriber and if safe stopping the clopidogrel for 7 days prior to colonoscopy and restarting immediately after the procedure if no therapeutic maneuvers are performed. If polypectomy is performed we continue to hold the clopidogrel for 3 days. The length of time off clopidogrel prior to and after colonoscopy was recorded. Exclusion criteria included patients who continued clopidogrel use and patients on clopidogrel and coumadin. Patient demographics, and post procedural complications were recorded. The primary endpoint was thromboembolic events and the secondary endpoint was clinically significant hemorrhage within 60 days of clopidogrel interruption. Results: Out of 4049 patients, 122 were eligible for the study, 70% were male and 60% \ 70 years old. 80% of the patients were on aspirin and clopidogrel, while 20% were on clopidogrel only. Of the patient population, 40% had stents and 14% had a history of cerebrovascular event. The mean time off APT prior to colonoscopy was 6 ± 2 days, and after colonoscopy was 2 ± 1.7 days for both groups of patients with thromboembolic events (TE) and without thromboembolic complication (NTE). P = 0.39 and 0.47 respectively. The incidence of all thromboembolic complications was 5.7%, and the incidence of bleeding requiring hospitalization and transfusion of blood products was 4.9%. Comparing the subgroup of patients with a clinically significant hemorrhage with the rest of the cohort, the mean duration of APT was similar: 6 days prior and 1 day post colonoscopy. P = 0.36 and 0.37 respectively. Conclusion(s): Discontinuation of antiplatelet medication can be safely done in patients without any major thromboembolic events such as stroke or pulmonary embolism. Minor thromboembolic events were noted such as NSTEMI and thrombosis of grafts and superficial venous thrombosis. There were no strokes noted in the study population and thromboembolic events were classified as mild. The risk of bleeding in this patient population can be significant requiring hospitalization. Key words: Post polypectomy bleeding, clopidogrel, antiplatelet therapy and colonoscopy.

Introduction: The most common techniques for restoration of intestinal continuity after a laparoscopic right hemicolectomy is an extracorporeal anastomosis, however, an intracorporeal anastomosis is performed routinely by many laparoscopic surgeons. The aim of this paper is to state advantages and disadvantages of an intracorporeal anastomosis compared to an extracorporeal anastomosis, comparing both techniques and with specific focus on complications. Materials and Methods: We reviewed 473 prospectively studied patients who underwent laparoscopic right hemicolectomy from April 1991 to June 2008 at the Texas Endosurgery Institute. 461 patients were included and 12 excluded because they needed to be converted to open surgery. We compared 123 (54 F:69 M) patients who underwent extracorporeal anastomosis with 338 (158 F:180 M) patients with intracorporeal anastomosis. The variables are reported with medians and compared using the U test of Mann–Whitney. Categorical data were evaluated using Fisher’s exact test or the Xi-square (V2). Statistical significance was defined when the p value was less than 0.05. The odds ratios were estimated with 95% confidence intervals to assess the adjusted value of each dependent variable. Results: The operative time (161 vs. 168 min, p = 0.012), surgical bleeding (83 vs. 135 ml, p \ 0.001), hospital stay (4 vs. 7 days, p \ 0.001), perioperative complications (1.2 vs. 4.1%, p = 0.48), minor postoperative complications (7.4 vs 16.3%, p = 0,005) and major postoperative complications rate (2.4 vs. 9.8%, p = 0,001) were lower in the intracorporeal anastomosis group compared to the extracorporeal group. The size of incision (4 vs. 6 cm, p \ 0.001) was lower in the intracorporeal anastomosis group. This had a direct relationship [OR 1.32 CI (0.99–1.78)] in the presence of minor complications, and [OR 1.65 CI (0.11–2.42)] of major complications. Conclusion: In our experience, the main advantages of doing an intracorporeal anastomosis are the operative time, hospital stay and intraoperative bleeding. Postoperative complications mainly have a direct relationship with the size of the incision for specimen extraction and / or creation of the extracorporeal anastomosis, not the location where the anastomosis is performed.

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DELAYED ANASTOMOTIC LEAKS FOLLOWING RIGHT COLECTOMY: A RETROSPECTIVE REVIEW AND CASE SERIES J Koury, MD, P Maxwell, MD, G Isenberg, MD, S Goldstein, MD Thomas Jefferson University Introduction: The reported acceptable incidence of anastomotic leak following a colon resection is reported to be approximately 3–6%. Some authors have noted a 1% leak rate for right colectomy occurring within 30 days of the procedure. While this is the traditional time period during which most leaks occur, clinically significant leaks can occur greater than 30 days post-resection which we refer to as a delayed leak. Although the concept of a delayed leak has been described, data regarding the presentation and timing remains limited. We retrospectively reviewed our database and present patient characteristics and presentation for 3 delayed leaks following right colectomy. Methods: We retrospectively reviewed our database of three colorectal surgeons from February 2010 to March 2011. The incidence of a delayed leak occurring greater than 30 days from an ileocolic anastomosis, time of presentation of leak, and treatment were noted. Leaks were identified using standard radiological methods including but not limited to computed tomography (CT), gastrograffin enema, and plain abdominal films. Results: Upon review of our database over the study period, 3 patients were noted to have delayed anastomotic leaks following a right colectomy. All patients underwent elective formal right colectomy. Two of these colectomies were done in the standard open fashion. All patients underwent a side to side, double layer hand sewn ileotransverse colonic anastomosis. Indications for the procedure included carcinoid tumor of the appendix, adenomatous polyp, and adenocarcinoma of the colon. The average age was 49 (range 34–69) and included one male and two female patients. The diagnosis was made a mean of 189 days postoperatively (range 95–360). The diagnosis was made by CT scan (POD 95), fistulagram (POD 360), and intraoperatively while undergoing laparotomy for pneumoperitoneum (POD 112). The two patients who leaked on POD 95 and 112 were both receiving adjuvant chemotherapy at the time their leaks were diagnosed. One patient (POD 112) required emergent laparotomy and diversion, one (POD 360) underwent an elective anastomotic resection, and one was managed conservatively with a percutaneous drain. There were no mortalities. Conclusions: It is critical to follow patients for longer than 30 days postoperatively as clinically significant leaks can be delayed. Since delayed leaks can occur many months later, surgeons must be diligent in prospective data entry with respect to their leak rate to better understand and characterize this phenomenon. Delayed leaks may present emergently or as nonemergent cutaneous fistulas or intraabdominal collections. Lastly, one must have a high index of suspicion for a delayed leak in patients receiving adjuvant chemotherapy.

References: Hyman, Neil MD, Manchester, T et al. Anastomotic Leaks After Intestinal Anastomosis It’s Later Than You Think. Ann Surg 245(2). Feb 2007. Veyrie, Nicolas MD, Ata, T et. al. Anastomotic Leakage after Elective Right Versus left Colectomy for Cancer : Prevalence and Independent Risk Factors. J Am Coll Surg 205(6):785–793. Dec 2007. Kingham, T Peter MD, Pachter, L MD. Colonic Anastomotic Leak: Risk Factors, Diagnosis, and Treatment. J Am Coll Surg 208(2): 269–278. Feb 2009.

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LAPAROSCOPIC TREATMENT OF DIVERTICULITIS. HAVE WE LEARNED SOMETHING? Christopher W Salzmann, MD, Morris E Franklin, MD FACS, Karla Russek, MD Texas Endosurgery Institute * History -50’s: Lavagae and drainage -60’s: Resection after second episode, 2 stages (Hartmann’s + Resection) -70’s: No changes -80’s: First lap cholecystectomy 90’s: First Lap colon resection *Prevalence -5–10% over 45 years -40% 60 years -80% over 85 years *Modified Hinchey Classification -I: Pericolic abscess -IIA: Distant abscess amenable to percutaneous drainage -IIB: Complex abscess associated with fistula -III: Generalized purulent peritonitis -IV: Fecal peritonitis *Laparoscopic or open resection of diverticular disease may be quite challenging *When to perform surgery? *** all can be performed laparoscopically *** -Drainage of abscess not amendable to CT Drainage -Necessary colonic resection -Large un-resolving phlegmon -Complications of diverticulitis (not responding to medical management) *Chances of converting to open colectomy -4.8% rate in Hinchey I–II, 18.2% rate of conversion for cases of complicated diverticulitis (Hinchey III-IV) -Causes of conversion: Hemorrhage in mesentery, fibrosis, severe inflammation, adhesions, anatomy not defined -Placement of diversion (ileo-colostomy) -Examination and lavage of peritoneal cavity *Conclusions -Laparoscopic colon surgery is a valid alternative for the treatment of acute and chronic diverticulitis. -There is documented success with both laparoscopic colectomy as well as laparoscopic peritoneal lavage and drainage. -The applicability of laparoscopic colonic surgery will remain directly dependent upon the individual surgeon’s laparoscopic skills. -In experienced hands, laparoscopic sigmoid colectomy for diverticulitis is as good or better than open colectomy. -The most common indication for surgery in our practice is patient with chronic refractory disease which summarily interferes with the lifestyle of the patient. -Patients with complicated, perforated (localized) diverticulitis rarely require urgent surgery. -The presence of diverticulitis does not necessary means that surgery is needed immediately or ultimately. -Close followup and patient education…. mandatory!! -Large number of patients, even with perforation can be treated without resection.

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WOUND INFECTION AFTER COLORECTAL SURGERY IN THE LAPAROSCOPIC ERA George Nassif, DO, Diana Ortiz, MD, Joseph Frenkel, MD, Sara Berman, BS, Deborah Keller, MD, Gerald Marks, MD, John Marks, MD Lankenau Medical Center Background: Colon surgery has inherently been associated with significant wound infection rates from 9% to 15%, the highest surgical site infection (SSI) rate for abdominal surgery. Hypothesis: A laparoscopic approach, with less wound surface area and trauma, would result in a decrease in SSI. Methods: From a prospectively maintained database of laparoscopic colorectal resections, 158 consecutive patients operated over a 12 month period, July 2010 to July 2011, were analyzed. All patients were bowel prepped. Surgery was performed using a clean-dirty technique, by a single surgeon (JM). SSI (superficial or deep), space/organ SSI (intraabdominal/pelvic abscess, peritonitis), death and length of postoperative stay were analyzed overall and based on patient age (C 70 vs. \ 70), obesity (BMI C 30 vs. \ 30), length of surgery (C180 vs. \ 180 min), preoperative radiation and colon versus rectal surgery. Results: Of 158 laparoscopic colorectal resections, mean patient age was 61 years (19–94) and 54% (N = 84) were female. The mean patient BMI was 26.9 kg/m2. 34 patients (21.5%) received neoadjuvant radiation. The procedures performed were Anterior Resection (10), APR (11), Right Colectomy (34), Left Colectomy (39), Low Anterior Resection (18), Total Abdominal Colectomy (10), TATA (14), Total Proctocolectomy (3) and other (19) for the following diagnoses: diverticulitis (42), cancer (66), IBD (6), prolapse (10), polyp (20), other (14). Overall conversion rate was 1.9% (to open 0.6%, to lap assisted 1.2%). The mean operating time was 239 min (37–581) and estimated blood loss averaged 172 cc. Patients were discharged post-operatively in a median of 4 days (SD ± 2.62). There was 1 mortality. There were 491 overall abdominal incisions. The average largest incision was 4.3 cm (0.8–19). Follow-up was 4.2 months (0.4–12.1). There were no superficial or deep wound infections. No abdominal wounds were opened. Deep space infections (abdominal/pelvic) were 8, for an overall SSI rate of 5.1%. There was no difference in superficial wound and deep wound infection rate based on BMI C 30 (N = 37), OR time C 180 min (N = 96), patient age C 70 (N = 53), pre-operative radiation (N = 34) or site of surgery colon (N = 119) versus rectal (N = 39). Deep space infections (abdominal or pelvic infections) showed no statistical distance for any group. Conclusion: Laparoscopic colon and rectal resection using a clean and dirty technique and wound protection dramatically reduces wound infections compared to historic controls. We identified no variables associated with increased wound infections.

BHD (p = 0.4823)

OR time (p = 0.4823)

\ 30

C30

\ 180 min

5%

5%

3%

38341

Age (p = 0.4432)

Pre-op XRT (p = 0.3705)

Resection (p = 0.4088)

C180 min

\ 70

C70

Yes

No

Colon

Rectum

6%

4%

8%

3%

5%

4%

8%

P056

COMPARISON OF FOUR Methods OF TRANSECTION AND ANASTOMOSIS IN THE LAPAROSCOPE-ASSISTED ANTERIOR RESECTION OF THE RECTUM Fumihiro Uchikoshi, MD PhD, Tsukasa Oyama, MD PhD, Takahiko Tatsumi, MD PhD, Department of Surgery, Tatsumi clinic & Hospital Background: Even in the up to date laparoscopic surgery of the rectum, we do not have standard method of transection/ anastomosis to avoid post-operative leakage. In fact, in the literatures published after the year of 2005, anastomotic leakage occurred in 6.4–13.5% of the patients. In this study, we chronographically tried four methods to find out the best way to do safe and effective laparoscopic surgery for rectal cancer. Patients and methods: Between April 1993 and September 2011, we operated one hundred and five patients of rectal cancer laparoscopically. Eighteen patients converted to open surgery were excluded from this study. Two colorectal surgeons performed all operations, and all anastomosis were done in DST fashion. During this period, we tried following four methods; A) Transection using staplers designed for open surgery (Access55) under the direct vision from small mid-line incision (8 cases), B) Transection using staplers designed for laparoscopic surgery (ex. Endo-GIA or Endocutter) (49 cases), C) Transection using staplers designed for open surgery (ex. TX30G or TA45) inserted through Lap disk (Hakko, Inc. Tokyo Japan), which was abdominal wall sealing device attached to 5 cm pfannenstiel incision (26 cases). D) Transection using next-generation linear staplers (ex. Endo-GIA Tri-Staple) designed for laparoscopic surgery (4 cases). Results: There was no significant difference in age, gender, operative time and the level of rectal transection between the four groups. We encountered no anastomotic leakage in method A, C and D, but seven cases in method B (14.3%) were suffered from this major complication. The length of hospital stay was the shortest in group C. Conclusion: The advantage of method C seems to be the point that full length stapling of the rectum could be done certainly at once under the magnified view of the laparoscope maintaining pneumoperitoneum. To avoid making an additional wound for inserting staplers, method D might be ideal to perform secure and uniform transection / anastomosis at this moment.

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LAPAROSCOPY IMPACTS OUTCOMES FAVORABLY FOLLOWING COLECTOMY FOR ULCERATIVE COLITIS: A CRITICAL ANALYSIS OF THE ACS-NSQIP DATABASE Marlin W Causey, MD, Derek P Mcvay, MD, Eric K Johnson, MD, Justin A Maykel, MD, Matthew J Martin, MD, David Rivadeneira, MD, Scott R Steele, MD Madigan Healthcare System; University of Massachusetts; St. Catherine of Siena Medical Center Introduction: Varying outcomes have been reported for the numerous surgical approaches for ulcerative colitis (UC). We set out to investigate the outcome of patients undergoing surgery for UC by analyzing a large nationwide database. Methods and Procedures: We queried the American College of Surgeons National Surgical Quality Improvement Program database (ACS-NSQIP, 2005–2008) for all UC patients undergoing colectomy. To analyze by operation, groupings included: partial colectomy (PC; n = 265), total abdominal colectomy (TAC; n = 232), total proctocolectomy with ileostomy (TPC-I; n = 134), and total proctocolectomy with ileal pouch-anal anastomosis (IPAA; n = 446). Risk-adjusted 30-day outcomes were assessed using regression model analysis for patient demographics, steroid use, co-morbidities, and surgical procedure. Results: From 1,077 patients (mean age 44 years; 45% female; 7% emergent), a laparoscopic approach was used in 29.2% with rates increasing 8.5% each year (18.5% in 2005 to 41.3% in 2008, P \ 0.001) and there was no difference in obese patients (P = 0.64 & P = 0.73, respectively). Complications occurred in 29%, and laparoscopy was associated with a lower complication rate (21 vs. 32% open, P \ 0.001). On multivariate regression, postoperative complications increased when patients were not functionally independent (odds ratio (OR) = 2.8), had preoperative sepsis (OR = 2.2) or prior percutaneous coronary intervention (OR = 2.6). Only a laparoscopic approach was associated with a lower complication rate (OR 0.63; 95% CI, 0.46–0.86). When stratified by specific complications, laparoscopy was associated with lower complications including superficial surgical site infections (11.4 vs. 6.7%, P = 0.0011), pneumonia (2.9 vs. 0.6%, P = 0.023), prolonged mechanical ventilation (3.9 vs. 1.3%, P = 0.023), need for transfusions postoperatively (1.6 vs. 0%, P = 0.016), and severe sepsis (2.9 vs. 1.0%, P = 0.039). Laparoscopy was also associated with a lower complication rate in TACs (41.7 vs. 18.8%, P \ 0.0001) and IPAA (29.9 vs. 18.2%, P = 0.005) and had an overall lower mortality rate (0.2 vs 1.7%, P = 0.046). Conclusion(s): Results from a large nationwide database demonstrate that a laparoscopic approach was utilized in a third of UC patients undergoing colectomy, and was associated with lower morbidity and mortality, even in more complex procedures such as TAC and IPAA.

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THE GLOVE TEM PORT Roel Hompes, MD, Frederic Ris, MD, Christopher Cunningham, FRCS, Neil Mortensen, FRCS, Ronan Cahill, MD Department of Colorectal Surgery, John Radcliffe Hospitals, Oxford Objective: The role for Transanal Endoscopic Microsurgery (TEM) in the treatment of rectal tumours is progressing. However, the cost and complex learning curve limit widespread utilisation by colorectal surgeons. Single port laparoscopic tools and principles are transferable to transanal work and various adapted approaches are being reported. Here we describe our initial clinical experience and preliminary data with a new and cost-effective technique for transanal work. Materials and Methods: Between October 2010 and January 2011, all patients eligible for TEM were offered the option to participate in our pilot study. The glove TEM port is constructed on table by using a circular anal dilator (CAD), wound retractor and surgical glove into which standard laparoscopic trocar sleeves and straight rigid instruments are inserted. Results: Initial preliminary work standardised both set-up and application of the apparatus and confirmed it outperformed commercially available counterparts in this application with regard to stability, instrument manoeuvreability and range of movement. With this new access modality, ten consecutive patients underwent resection of benign (n = 6) or malignant (n = 4) rectal tumours. The mean (range) distance from the anal verge and tumour surface area was 5.8 (2–9) cm and 34 (0.3–152) cm2 respectively. One case had to be converted to a conventional TEM procedure because anatomical features prohibited inserting the CAD high enough into the anal canal. All lesions were excised full thickness, however in two patients with very distal lesions (case 1 & 4), the dissection was started as partial thickness (from the dentate line to the top of the puborectal sling). As per the preference of the surgeon, the defect was intraluminally closed by a running suture in six cases. No serious intra-operative complications occurred and mean (range) operating time, measured from injection of the anal block to removal of the CAD, was 84 min (30–120). Seven patients were discharged on the first postoperative day, one patient was discharged on the third postoperative day for social reasons. Postoperative morbidity was low, with only one Clavien grade 1 complication (post-TEM fever, treated with oral antibiotics and discharged on postoperative day 1). After a mean follow up of 5 months, there has been no compromised oncological outcome. The total cost of the glove TEM port was $ 70.40 if used in conjunction with reusable (glove $ 1.29, extra small alexis $ 32.22 and CAD device $ 36.89) or $ 151.59 if disposable ports (12 mm port $ 33.11, 2 x 5 mm sleeves $ 48.08 and glove TEM port $ 70.40) were used. Conclusions: The glove TEM port is a safe, cheap and readily available tool that can be used in combination with regular laparoscopic tools for transanal resection of rectal lesions. It is surgeon friendly, economically attractive and universally applicable.

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A RETROSPECTIVE STUDY OF PROPHYLACTIC DRAINAGE AFTER LAPAROSCOPIC COLECTOMY Hirokazu Suwa, MD, Shigeki Yamaguchi, MD PhD, Takuya Kato, MD, Hiroka Kondou, MD, Ichiro Okada, MD, Jo Tashiro, MD, Toshimasa Ishii, MD PhD, Mitsuo Miyazawa, MD PhD, Isamu Koyama, MD PhD, Nozomi Shinozuka, MD PhD, Saitama Medical University International Medical Center, Gastroenterological Surgery Introduction: In Japan, many surgeons still continue to place a information and prophylactic drainage tube after colectomy. However, some randomized controlled trials have already reported that a prophylactic drainage is unnecessary after colectomy. The aim of this study is to determine the necessity of prophylactic drainage after laparoscopic colectomy retrospectively. Methods and Procedures: Between April 2007 and August 2011, 272 patients who underwent laparoscopic ileocolic resection, right hemicolectomy, and sigmoidectomy were included in this study. Until February 2011, a prophylactic closed suction drainage tube was inserted in all cases. After March 2011, no drainage was performed after coloectomy in principle. Intraoperative factors and short term results were compared between 240 drainage group and 32 no drainage group. Results: Mean operative time of no drainage group was 155 min and shorter than that of drainage group (179 min) (p = 0.007). No statistically significant difference was revealed in postoperative hospital stay (7.5 vs 8.8 days). Anastomotic leakage occurred in only one case of drainage group. There were no complications associated with drainage tube like retrograde infection, pressure necrosis by drainage tube, and incisional hernia. Conclusion: Any significant benefit of routine prophylactic drainage after colectomy did not observed. Therefore it is not necessary for laparoscopic colectmy to place drainage tube.

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INTRACORPOREAL ANASTOMOSIS FOR TRANSVERSE COLON TUMORS Nobuhiro Ito, PhD, Hiroshi Nagata, PhD, Noiku Nakao, PhD, Toshiaki Nonami, PhD Aichi Medical University Background: Recently, laparoscopic surgery for colorectal tumors is widespread, and it seems to be standard operation. However, the operation for transverse colon is not common, because it is difficult to exfoliate a wide area in order to anastomose. In the operation for laparoscopic transverscolectomy we made another wound to anastomose. Here, we report the usefulness of intracorporeal anastomosis for transverse colon tumors. Method: We performed four cases of intracorporal end-to-end anastomosis. We used a 60-mm end-liner stapler, and the entry hole was closed by intracorporal suturing. The operation was done by the three-port method using the umbilical region. At the time of the anastomosis, we added a 5-mm trocar as needed. Results: The procedure was technically successful. Mean operative time was 281 min. Mean operative blood loss was 36 g. One case developed wound infection and ileus as postoperative complications, but they were relieved conservatively. Except for last one case, the postoperative hospitalization was around ten days. Conclusion: Intracorporeal anastomosis for transverse colon tumors is feasible and safe. We did not need another wound to anastomose. No wide exfoliation was needed. Intracorporeal anastomosis may be useful in single-site laparoscopic surgery. Intracorporeal anastomosis can be done with minimal invasiveness.

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LAPAROSCOPIC COMPLETE MESOCOLIC EXCISION FOR RIGHT COLON CANCER—TECHNICAL ASPECT AND CLINICAL RESULTS Shigeki Yamaguchi, MD, Toshimasa Ishii, MD, Jo Tashiro, MD, Hirokazu Suwa, MD, Ichiro Okada, MD, Hiroka Kondo, MD, Mitsuo Miyazawa, MD, Nozomi Shinozuka, MD, Saitama Medical University International Medical Center Purpose: Several studies concluded that oncologic results of laparoscopic colon cancer resection are not inferior to those of open resection. Also complete mesocolic excision (CME) may have a possibility of improving long term results. Regarding right colon cancer, we demonstrate how to perform so-called CME laparoscopically, and accessed postoperative course and meddle term results. Methods: [Laparoscopic CME] First of all, assistant holds ileocolic pedicle and surgeon divides mesentery below the pedicle. The origin of the ileocolic vessels are skeletonized and lymph nodes are removed. Then whole part of right mesocolon is mobilized from Gerota’s fascia by medial to lateral approach. Lateral attachment is divided and right colon becomes completely free. Finally 10 cm distal colon from cancer site is recognized and divides the mesocolon. Major vessels including specimen’s part (right colic, middle colic vessel) are skeletonized around the superior mesenteric vein and lymph nodes are removed. [Clinical data] One hundred fifteen patients underwent laparoscopic right colon cancer resection since 2007 to 2010. Cancer locations were the cecum or the ascending colon and pathological stage was; 0:6, I:37, II:31, III:41. Generally CME was performed for stage II or III patients. Results: Mean operative time (OT) was 130 min for stage 0, 175 min. for Stage I, 174 min. for stage II and 165 min. for stage III. Mean counted blood loss (CBL) was; 5.8, 34.4, 24.9, 18.8 g, mean postoperative hospital stay was; 9.3, 7.9, 7.3, 7.3 days, respectively. Postoperative complications occurred in 2, 4, 4, 3 patients. There was no leak and 6 wound infection and 4 ileus. So far there is no recurrence in stage 0, I, II patients. In 41 stage III patients, 10 recurrences were observed. Those were liver: 2, lung: 1, peritoneum: 2, local: 2, lymph node: 2, and bone: 1. Conclusions: Laparoscopic CME for right colon cancer is safe and oncologic middle term results are satisfactory.

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THE IMPACT OF COMPLIANCE TO COLONOSCOPY SCREENING GUIDELINES ON THE DIAGNOSIS OF COLON AND RECTAL CANCER Rebekah Kim, MD, Joseph T Gallagher, MD, Francisco Itriago, MD, Andrea Ferrara, MD, Jay Macgregor, MD, Kiyanda Baldwin, MD, Paul Williamson, MD, Samuel Dejesus, MD, Renee Mueller, MD Orlando Health, Colon and Rectal Clinic of Orlando Introduction: Our purpose is to correlate compliance to the current recommendations for colonoscopy screening to the diagnosis of colon and rectal cancer. Adherence to colonoscopy screening guidelines is one of the best ways to prevent development of colorectal cancer. However, there is limited research on patients with a diagnosis of cancer and prior compliance to colonoscopy screening. We reviewed patients who were diagnosed with colorectal cancer (CRC) and their adherence to the current colon cancer screening guidelines. Methods: 74 consecutive patients with a diagnosis of cancer were retrospectively reviewed from a colon and rectal surgery practice from 2009 to 2010. All patients underwent surgical resection for colorectal cancer. Analysis of patient’s colonoscopy history was performed examining the following variables: age, indications for colonoscopy, location of tumor, and compliance to colonoscopy screening guidelines according to the American Cancer Society (ACS). Results: 74 charts were reviewed, 46 males (62%), 28 females (38%). Mean and median ages at the diagnosis of cancer were 63.5 and 65 years (range 28–90). The most common indications for colonoscopy were rectal bleeding (68.9%), weight loss (8.1%) and anemia (10.8%). 19 patients (25.7%) developed colon and rectal cancer despite following screening guidelines. The locations of the cancers are shown in the figure. 13 patients (17.6%) developed CRC prior to age of 50 years of age. Two of these patients had a first degree relative with history of CRC. 17 (23%) patients had prior colonoscopy screening prior to diagnosis of colorectal cancer. Six (8.1%) of these patients were compliant with the current recommendations of the ACS guidelines. The remaining 11 patients had a prolonged time interval between colonoscopies in which CRC developed. Conclusions: The majority of patients who developed colorectal cancer were diagnosed due to symptoms rather than screening methods. There is a subset of patients that develop colon and rectal cancer despite following the current recommendations of the ACS. The majority of these patients had distal colorectal cancers. Measures to improve effectiveness in colonoscopy screening needs to be further examined within this group of patients.

Fig Tumor location of patients compliant with colonoscopy screening

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38564

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SEX AND BMI ALONE ARE NOT ADEQUATE PREDICTORS OF OUTCOMES FOLLOWING CURATIVE PROCTECTOMY FOR RECTAL CANCER

FACTORS AFFECTING THE DIFFICULTY OF LAPAROSCOPIC TOTAL MESORECTAL EXCISION FOR RECTAL CANCER

Anjali Kumar, MD MPH, Kirthi Kolli, MBBS, Katherine Khalifeh, MD, James F Fitzgerald, MD, Washington Hospital Center

Cho Tae-ho, MD, Baek Jeong-heum, MD, Lee Won-suk, MD, Lee Woon-kee, MD, Kang Jeong-hyun, MD Department of Surgery, Gachon University of Medicine and Science, Gil Medical Center, Incheon, Korea

Background: When designing investigations to address issues of obesity in rectal cancer patients, it is important to note that obesity is traditionally measured using the metric of body mass index (BMI— weight in kg/height in meters2). BMI, however, may not be the most optimal assessment of obesity as it relates to rectal cancer. Men and women have inherent differences in the distribution of visceral (intraabdominal) versus surface area (extra abdominal) adiposity that contribute greatly to the technical challenges of proctectomy. We sought to investigate the differences in outcomes after resection for rectal cancer by type of operation undertaken, sex, and BMI Methods: We retrospectively reviewed the records of 92 patients (M = 57, F = 35) who had undergone rectal resection for cancer with curative intent (APR = 52, LAR = 40) during a 5-year period (2006–2010) at our institution. Morbid obesity was defined as BMI C 35 and was accurately recorded in 69 patients. We recorded blood loss, operative, peri-operative and postoperative complications. We expected that obesity when factored in with gender would predispose to complications. Data were analysed using STATA10 by chi square and t-test. Results: 13 patients with rectal cancer had a BMI C 35. There was a higher proportion of morbidly obese men than women (5:8). A significantly higher proportion of men underwent APR for rectal cancer than women (37:15, P = 0.04). Males had significantly more blood loss than women (P = 0.05), and this could be explained by a significantly higher operative blood loss in APR procedures than in LAR (p = 0.03). Obesity as measured by BMI did not account for this difference, as blood loss was higher for LAR procedures than for APR among those with BMI C 35. Serious intraoperative complications occured in 4, perioperative morbidity was accounted for in 59 patients, one patient died, and readmissions within 30 days occured in 10 patients. However, between men and women, BMI \ 35, and C35, and APR/LAR procedures, there were no significant differences seen in intra-, peri- or post-operative complications, nor were there for recurrences, regardless of stage of cancer or implementation of neoadjuvant therapy. All patients had resections with adequate margins. Follow up time was an average of 2 years (range 0–62 months). Conclusion: BMI and sex when analyzed independently are not reliable predictors of outcomes in curative resection for rectal cancer. Although visceral-to-subcutaneous fat ratios have been suggested as better predictors, bony pelvic constraints may also contribute, which we aim to investigate using this dataset in future collaborations with radiologists at our institution.

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HOW DO COMMUNITY HOSPITALS COMPARE to UNIVERSITY HOSPITALS in the SURIGICAL MANAGEMENT of PERFORATED APPENDICITIS? Anna L Goldenberg, DO, Robert A Ramirez, DO, Marc Rosen, DO FACOS, James Weese, MD FACS, Roy L Sandau, DO Kennedy University Hospital, NJ Introduction: Appendicitis is the most commonly encountered surgical cause of an acute abdomen. Immediate appendectomy has long been the standard treatment for acute appendicitis because of the known progression to perforation. Perforated appendicitis has a higher rate of complications, which include but are not limited to surgical site infections, abscess, peritonitis, sepsis and death. Laparoscopic appendectomy (LA) is a minimally invasive procedure that offers advantages over the traditional open appendectomy (OA) including smaller incisions, visualization of the peritoneal cavity, and a presumed reduction of recovery time. [10] Methods: A 10 year retrospective analyses of patients who had a diagnosis of perforated appendicitis at Kennedy Memorial Hospitals in Southern New Jersey from January 1998 through December 2008 were analyzed. Patient information was entered into a database. Procedures included laparoscopic, open and laparoscopic converted to open. The information on each patient included age, sex, weight, comorbidities, complications of surgery(s), time of surgery(s), white blood cell count preoperatively (on admission), white blood cell count post-operatively, post-operative complications, additional procedures, readmission and length of hospitalization. Comparisons between the three groups will be made using Microsoft Excel ANOVA single factor analysis for variance and a p \ 0.05 was considered statistical significant. IRB approval was obtained prior to commencing the data collection. An OVID on-line literature review was conducted and our results were then compared to larger tertiary university based hospitals. Results: Preliminary data gathered from January 1998 through December 2008 was performed. A total of 245 medical records met the aforementioned criteria.

•

Laparoscopic treatment reduced the length of hospitalization, rate of overall complication, rate of wound infections, and rate of readmission. P \ 0.05

•

There was no advantage in operative time between laparoscopic versus open groups. However, both were less than converted procedures. P \ 0.05

• •

Laparoscopic treatment did not change the rate of additional procedures; p = 0.13 The rate of intra-abdominal abscess was similar between the laparoscopic and open groups. However, there was less for the converted group. P = 0.69

Conclusion: This study shows that in cases of perforated appendicitis length of hospitalization, overall complication rate, wound infection rate, and rate of readmission is lower in the LA group. There also is no difference in the operative time, rate of intra-abdominal infection or additional procedures. This data supports laparoscopic appendectomy when faced with perforation.

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Keyword: Total mesorectal excision (TME), Pelvic dissection time, Rectal cancer, Degree of difficulty Introduction: The laparoscopic approach for rectal cancer is being performed with increasing frequency worldwide. But its definitive role is controversial due to the technical difficulty. The aim of this study was to evaluate the predictive value of anatomic and clinical features affecting the difficulty of laparoscopic total mesorectal excision (TME). Methods and Procedures: A total of 55 patients who underwent laparoscopic TME for rectal cancer from January 2011 to August 2011 were evaluated. Gender, body mass index (BMI), tumor depth, tumor size, tumor distance from anal verge, preoperative chemoradiotherapy, and 5 pelvic dimensions (pelvic inlet, pelvic outlet, length of sacrum, interspinous distance, intertuborous distance) in pelvic MRI were analysed as potential variables affecting the difficulties of laparoscopic TME. The dependent variable is pelvic dissection time, which was defined as the time required for dissection of rectum from the pelvis. Immediate perioperative outcome (estimated blood loss (EBL), morbidity, hospital stay) were also collected. Results: The series included 41 men and 14 women, with a mean age of 65 years (range, 51–90), Mean pelvic dissection time 45 min, EBL 87 mL morbidity 18.2%, mean hospital stay 10.36 days. Gender, tumor distance from the anal verge, preoperative chemoradiotherapy, interspinous distance, intertuberous distance had significant correlation to pelvic dissection time. Conclusion: Male gender, preoperative chemoradiation, close tumor distance to anal verge, and narrow pelvic cavity seemed factors affecting the difficulty of laparoscopic TME. These factors should be taken into account when planning laparoscopic TME.

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THE USE OF BIOABSORBABLE MESH IN OSTOMY CLOSURE Paravasthu Ramanujam, MD FACS, Hadi Najafian, DO FACS FASCRS, Pedram Motamedi, Sushil Pandey West Valley Colon & Rectal Surgery Center Introduction: The purpose of our study is to compare the incidence of wound complication when ostomy is closed primarily or use of using GORE BIO-A Tissue Reinforcement, an absorbable tissue scaffold . Methods: In this retrospective study, 14 patients with ostomies underwent elective closure with reinforcement using GORE BIO-A Tissue Reinforcement, an absorbable tissue scaffold. This group was compared with 14 other patients who had elective ostomy closures with no reinforcement. All bowel anastomosis were completed with GIA and TA stapler creating a functional end-to-end anastomosis. GORE BIO-A Tissue Reinforcement (W. L. Gore & Associates, Flagstaff, AZ) is an absorbable mesh composed of a 3 dimensional tissue scaffold which is replaced by tissue in about 6 months. In the group where mesh was used, the mesh was placed in the retrorectus space above the posterior fascia and anchored with absorbable sutures to the fascia. The rest of the fascial and skin closures were similar in both groups. Both groups were comparable in terms of age, sex, BMI, nature of ostomy. Mean follow up duration was 24 months. The outcomes parameters were surgical site infection and the incidence of wound hernias. Results: Of the 14 patients who had absorbable mesh reinforcement, 6 had loop ileostomies and 8 had loop colostomies. This is similar to the group of 14 patients where no reinforcement was used. The wound infection rates in both groups were similar, with 2 patients in each group developing wound infection. All patients with wound infection were managed by opening the wound and daily dressing. In all 4 patients, wounds healed satisfactorily. However, in the group with no mesh reinforcement, three patients developed ventral hernia within 6 months. In the group where mesh was used, no patients developed ventral hernia and the mesh was not removed. Conclusions: Even though the number of patients in both groups is small, the use of GORE BIO-A Tissue Reinforcement seems to reduce the incidence of ostomy closure site hernias (ventral hernia). Also when there is a wound infection in this potentially contaminated wound, this mesh seems to resist the infection and help to prevent future hernias. However, prospective studies with a larger number of patients and longer follow-up is needed to establish our preliminary findings.

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TRANSANAL ENDOSCOPIC MICROSURGERY IN A MAJOR URBAN MEDICAL CENTER Claire Graves, Beth Krieger, MD, Alex Ky, MD, Randolph Steinhagen, MD, Sanghyun Kim, MD Mount Sinai School of Medicine, New York, NY Introduction: Transanal Endoscopic Microsurgery (TEM) is a minimally invasive surgical technique for local excision of rectal lesions. The specialized rectoscope and endoscopic instruments improve visualization and dexterity in the rectum, allowing for full-thickness local resection beyond the reach of traditional instruments. Current literature on TEM consists predominately of small case series and retrospective reviews, with results that may not be generalizable to other institutions. The objective of this study is to evaluate Mount Sinai Medical Center’s experience with TEM, investigating indications for its use, demographics of the patient population, operative statistics, and complications.

Methods and Procedures: We performed an IRB-approved retrospective chart review of patients who underwent TEM from January 2007 through July 2011. Outcome measures included patient demographics, indications for TEM, lesion characteristics, duration of procedure, length of hospital stay, pathology, complications, and recurrences. Results: Forty-nine patients were identified from our database as having undergone 50 TEM procedures. Twenty-eight (57%) patients were female, and the mean age was 60 years (range, 33–88 years). Preoperative diagnoses included adenoma (n = 24), carcinoma-in-situ (n = 8), invasive adenocarcinoma (n = 6), carcinoid (n = 5), and others (n = 7). The average tumor size was 2.0 cm (range = 0.2–6.0 cm), and the average distance from the anal verge was 10 cm (range = 3–18). The average duration of surgery was 71 min (range = 8-179 min). Twenty-nine procedures (58%) were ambulatory, while 21 patients (42%) required hospitalization after surgery. Post-TEM pathology led to upstaging of 9 lesions (18%) and downstaging of 5 lesions (10%). Four specimens (8%) demonstrated positive margins. We found two intraoperative complications (4%), both rectal perforations managed with low anterior resection. Two of the procedures (4%) were converted: one, as above, to a low anterior resection due to rectal perforation, and the other to transanal excision with clear plastic anoscope for better visualization. We found 3 post-operative complications (6%): one rectal bleeding on post-operative day 10, one abdominal abscess on post-operative day 19, and one chronic diarrhea for 4 months after TEM. Of the 33 patients available for follow-up, 6 had recurrences (18%): 5 recurrent adenomas at an average of 4.6 months after TEM, and one patient with T2N1 carcinoid was found to have a perirectal nodule and liver metastases 4 months post-operatively. Conclusions: We have found TEM to be a safe and effective technique for local excision of rectal lesions with a low rate of complications. TEM offers the option of local excision at a greater distance from the anal verge than traditional means. In 28% of our cases, TEM was responsible for a change in staging, making it a useful tool for definitive diagnosis before the patient potentially undergoes a more invasive procedure. As a retrospective chart review, this study is limited in its follow-up data. Further prospective studies with long-term follow-up are necessary to better characterize recurrence data and oncologic outcomes.

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Pict 2 Identification of rectal stump (upper left side) with the help of tattoo during Laparoscopic surgery

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A TECHNIQUE OF IDENTIFYING THE RECTAL STUMP IN PATIENT’S WITH HARTMANN POUCH BEFORE CLOSURE, BY TATTOOING WITH INDIA INK (SPOT) Sushil Pandey, MD, Hadi Najafian, DO FACS FASCRS, Pedram Motamedi, Paravasthu Ramanujam, MD FACS West Valley Colon & Rectal Surgery Center Objective: Identification of the rectal stump in a patient during Hartmann closure can be difficult and the dissection can be tedious. Many techniques had been used mark the rectal stump with non-absorbable sutures and even to tack it to the lateral pelvic wall. We describe the simple technique of endoscopy tattooing of the end of the rectal stump with 3–5 cc of India ink to facilitate easy identification both during laparoscopy or open laparotomy. Technique: Patient was status post Hartmann’s procedure presented for reversal of colostomy. Prior to surgery, patient was brought to the endoscopy lab after cleansing the rectal stump with enemas. This technique usually does not need any sedation and can also be done in the office setting. Patient was placed on the left lateral position. The flexible sigmoidoscope was inserted to the rectum through the anus. The rectal stump was intubated and the end of the rectal stump is identified. Using endoscopic sclerotherapy needle, 2–5 cc of India ink, (SPOT) was injected slowly. Once the tattooing was done, the scope is gently withdrawn. Results: In our experience, the identification of rectal stump in both open and laparoscopic reversible of Hartman’s is relatively easy when rectal stump is tattooed pre-operatively. Thus it facilitates the rectal dissection for colorectal anastomosis. Discussion: India ink is commercially available called Spot which is approved by the FDA. During laparoscopy the distinct tattooed end of the rectal stump can be easily seen, facilitating identification and dissection of rectal stump. In open laparotomy, the tattooed rectal stump is clearly visible. This technique of injecting India ink to the end of the rectal stump is simple, safe and significantly facilitates the identification of the rectal stump, thus facilitated rectal dissection and anastomosis.

Pict 3 Identification of rectal stump (center) with the help of tattoo during open surgery

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FACTORS ASSOCIATED WITH SUCCESSFUL EXCISION OF SMALL RECTAL CARCINOID TUMOR Hae Jung Son, MD, Dae Kyung Sohn, MD PhD, Chang Won Hong, MD, Kyung Su Han, MD, Byung Chang Kim, MD, Ji Won Park, MD, Hyo Seong Choi, MD PhD, Hee Jin Chang, MD PhD, Jae Hwan Oh, MD PhD Center for Colorectal cancer, Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, South Korea Introduction: Small rectal carcinoid tumors can be treated by local excision, but complete resection may be difficult because tumors are located in the submucosal layer. We performed this study to find out the risk factors associated with pathologically complete resection of rectal carcinoid tumor. Methods and Procedures: From January 2001 to December 2010, total 299 patients with colorectal carcinoid tumors were treated at the National Cancer Center, South Korea. Among of them, we excluded patients who had metastatic disease (n = 10), who underwent radical operation (n = 33), who were diagnosed in other hospitals (n = 83) and who had colon carcinoid tumors (n = 3). Finally, 170 patients with 175 rectal carcinoid tumors, who treated with local excision including endoscopic resection and surgical resection were enrolled this study. A pathologically complete resection(P-CR) was defined as an en bloc resection with tumor-free lateral and deep margin. Local treatment methods were classified to conventional polypectomy including strip biopsy, snare polypectomy and hot biopsy, advanced endoscopic techniques including endoscopic mucosal resection with cap (EMR-C) and endoscopic submucosal dissection (ESD) and surgical local excision including transanal excision (TAE) and transanal endoscopic microsurgery (TEM). We evaluated the P-CR rate according to treatment method, tumor size, endoscopically initial impression and use of endoscopic ultrasound (EUS) or transrectal ultrasound (TRUS). Results: Mean size of tumors was 5.60 ± 2.41 mm (range from 2 to 18 mm) and all lesions were confined to the submucosal layer. P-CR rate of all lesions was 60.6%. When endoscopic impression was submucosal tumor, P-CR rate increased to 68.1%. P-CR rates according to treatment methods were 31.6, 73.1, 85.7% in conventional polypectomy, advanced endoscopic technique, and surgical local excision, respectively. Because P-CR rates were not significantly different between advanced endoscopic technique and surgical local excision, we performed further analysis with two groups of treatment methods including conventional polypectomy and advanced endoscopic technique or surgical local excision. Univariate analysis showed that treatment method, use of EUS or TRUS and endoscopically initial impression were related to P-CR. On multivariate analysis, treatment method was the only factor associated with P-CR. Conclusions: Advanced endoscopic technique or surgical local excision was more beneficial to achieve pathologically complete resection than conventional polypectomy in local treatment of small rectal carcinoid tumors.

Pict 1 Tattooing of rectal stump preoperatively

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EXPERIENCE OF THE THREE TROCARS Method FOR COLORECTAL LAPAROSCOPIC SURGERY Shuji Kitashiro, Shunichi Okushiba, Yo Kawarada, Takeshi Sasaki, Daisuke Saikawa, Hiroyuki Katoh Tonan hospital Introduction: We introduce our technique of the three trocars method for colorectal cancer. This method means to perform surgery without assistant. It may operative offer many unique advantages, e.g., operator can control the operative view directory, it may diminish human error, enable the operation to progress speedily, and provide significant economic benefits (human assistant in not necessary. And it’s very useful when Single port surgery was introduced, because many points (operative procedure, the way to obtain adequate operative field) are similar to the three trocar method. Method: A total of 460 cases (included 40 Single port surgery) diagnosed with colorectal cancer between 2004 and 2011. Operative, and post operative characteristics including overall survival and surgical complication were analyzed. Result: The 5-years survival rate is 89% in stage II and 70% in stage III. The average surgical time was about 120 min for the colon, 150 min for the rectum and 130 min for single port surgery. In almost all operations, we successfully managed to get an adequate operative field. Only 14 patients were converted to conventional technique, but there were no additional trocar in single port surgery cases. Conclusion: We hereby report on the characteristics and outcomes of the three trocars method in our institute. And feasibility of this method was indicated. We believe that this method will prevail in terms of bringing benefits for single port colorectal cancer surgery.

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INTRAOPERATIVE COLONOSCOPY IN LAPAROSCOPIC ASSISTED COLORECTAL SURGERY FOR THE ASSESSMENT OF ANASTOMOSIS WITH DOUBLE STAPLING TECHNIQUE Chu Matsuda, Hiroshi Tamagawa, Kazuhiro Iwase, Kazuhiro Nishikawa, Takashi Deguchi, Junji Kawata, Yasuhiro Tanaka, Osamu Nishiyama, Takanobu Irie Osaka General Medical Center • Introduction: The aim of our study was to evaluate the use of intraoperative colonoscopy in laparoscopic assisted left-sided colorectal resection for the assessment of anastomosis. • Methods and Procedures: All consecutive laparoscopic assisted left-sided colorectal resections performed at our department between October 2008 and September 2011 were included in this study. After colorectal resection and reanastomosis with double stapling technique, an intraoperative colonoscopy was performed to detect anastomosis risk. • Results: A total of 130 patients were enrolled in this study, and the anastomosis was checked via colonoscopy. Of the 130 patients, 50 (38.5%) underwent a laparoscopic assisted sigmoid resection, 37 (28.5%) a laparoscopic assisted high anterior resection, 43 (33.0%) a laparoscopic assisted low anterior resection. In this study, 2 (1.5%) anastomostic bleeding were detected and endoscopic clipping was performed during surgery. A total of 3 (2.3%) postoperative anastomostic bleeding occurred, but did not required hemostasis. 2(1.5%) anastomostic leakages were detected and oversewn. A total of 6 (4.6%) anastomostic leakage occurred in the early postoperative period. • Conclusions: Intraoperative air leak test using colonoscopy might not predict the possible postoperative anastomotic leakage; however, it is useful for the detection of the unexpectable failure around anastomotic site. The complication rate of anastomosis in laparoscopic-assisted colon resection can be reduced by intraoperative colonoscopy.

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LAPAROSCOPIC COLONIC RESECTIONS WITH INTRACORPOREAL ANASTOMOSIS AND TRANSVAGINAL SPECIMEN EXTRACTION: A PILOT STUDY

TRAINEE LEARNING CURVE IN LAPAROSCOPIC COLORECTAL SURGERY AT A DISTRICT (PERIPHERAL) GENERAL HOSPITAL

Francesco Stipa, MD PhD FACS, Valentina Giaccaglia, MD, Alessio Pigazzi, MD PhD FACS, Ettore Santini, MD, Antonio Burza, MD Department of Surgery, Colorectal Surgical Unit, San Giovanni Hospital, Rome, Italy

Filippos Sagias, MD, Samer Doughan, MD QUEEN ELIZABETH THE QUEEN MOTHER HOSPITAL, KENT, UK

Purpose: Current techniques of laparoscopic colectomy require an abdominal incision for specimen extraction, which may lessen the advantages of laparoscopic surgery. Intracorporeal anastomosis may reduce the extent of colon mobilization and abdominal incision, decreasing postoperative pain and wound related complications. Methods: A series of 10 female and 5 male patients with colon cancer underwent laparoscopic colon resection with intracorporeal anastomosis: 5 right colectomies with latero-lateral ileo-colic anastomosis, 1 transverse resection with hand sewn end-to-end colocolic anastomosis; 6 sigmoidectomies, 5 with a side-to-end stapled and 1 with manual colorectal anastomosis; and 3 low anterior resection with side-to-end stapled colorectal anastomosis. For specimen extraction, in all 10 female patients the natural orifice (NOSE) transvaginal route was used. Results: The patients experienced no intra and post-operative complications, with early return to bowel function (mean 2 days), short time to resumption of oral solid food intake and minimal postoperative pain and narcotic use. The hospital stay was 6 days. Conclusions: Totally laparoscopic colonic resection combining intracorporeal anastomosis and NOSE is safe and feasible. This minimally invasive technique may provide an effective way to reduce postoperative pain and abdominal wall morbidity, with low complication rate.

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Introduction: There are very few studies that analyse the learning curve of colorectal trainees for laparoscopic colorectal resections. Most of the centers that have done so are large academic units. The learning curve of a colorectal trainee at a District General (Peripheral) Hospital has not been established. In our unit there are more than 150 laparoscopic colorectal resections performed each year. The aim of our study was to establish the safety and analyze the outcomes of the initial laparoscopic colorectal resections of a senior registrar that already had some previous advanced laparoscopic experience and was supervised by a single experienced laparoscopic colorectal consultant. Methods: Following multidisciplinary meeting discussions, the first ten suitable patients, median age of 65 (range 61–74, 5 M:5 F), were identified and subsequently underwent laparoscopic resections. Six patients (60%) underwent a left-sided resection and four patients (40%) underwent a right hemicolectomy. The ASA grade was 2 (10/10). Results: The registrar performed 75–95% of each operation. There were no intra-operative or postoperative complications. There was minimal blood loss and blood transfusion was not required for any of the cases. None of the cases required conversion to open. The median in-hospital stay was four days (range 3–6). One patient was readmitted to hospital after two weeks with abdominal pain which settled within 48 h. There were no mortalities (0/10). The mean lymph node harvesting was 16 (range 11–26). Histopathology confirmed adenocarcinoma in seven patients (70%) and the other 3 patients (30%) had benign disease. Conclusion: The initial learning curve of a senior registrar for laparoscopic colorectal resections at a District General (Peripheral) Hospital with a high volume of cases is safe and the outcomes can be equivalent to those of the senior mentor. It is crucial to select the patients appropriately during a multidisciplinary meeting discussion.

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LAPAROSCOPIC RECTAL SURGERY—HOW DO WE TEACH?

SINGLE INCISION LAPAROSCOPIC COLECTOMIES WITH CONVENTIONAL INSTRUMENTATION- OUR EXPERIENCE

Akiyoshi Kanazawa, MD PhD FACS, Tadayoshi Yamaura, MD, Hisahiro Hosogi, MD PhD, Akio Nakajima, MD PhD, Seiichiro Kanaya, MD PhD FACS, Yukihiro Kohno, MD PhD Department of Surgery, Osaka Red Cross Hospital

C Palanivelu, P Senthilnathan, P Praveen Raj, R Parthasarthi, S Rajapandian, Anirudh Vij, S Saravanakumar GEM Hospital & Research Centre

Introduction: A correct surgical procedure to rectal cancer has to make due allowance for both improved overall survival with local control of disease and preservation of the sphincter and urinary functions. Laparoscopic approach for rectal cancer has good operative view that has obvious advantage for improvement of operative procedure and education. On the other hand, we also need to teach the trouble shooting in this procedure. In this presentation, I would like to present how we teach the trainee and what we need to teach the procedure. Procedures: For the reproducible operation, the important points are as follows: 1) symmetrical five-port system 2) making premeditated operative field with same instruments and view angle, 3) precise role of assistant, 4) enough rectal mobilization of rectum for cutting distal side of tumor. There is not objective guideline to be a operator in our department, but when instructor judge it by talking with trainee when the understanding for the procedure is enough, instructor allow trainee to perform the surgery as a operator. Results: Between January 2007 and December 2010, 233 cases laparoscopic resection for rectal cancer was performed in our hospital. laparoscopic low anterior resection: 202 cases, Laparoscopic intersphincteric resection: 15 cases, laparoscopic abdominoperineal resection: 16 cases were performed. Two cases of anastomotic leakage were observed. All patients could retain urinary function without catheterization. There was no postoperative mortality in all cases. Trainee with instruction performed 63% of this procedure. But there is no significant difference in mobility and mortality between trainee operated case and instructor operated case. There is significant difference only in operation time. Conclusion: Laparoscopic rectal surgery still is not standard. For effective education, we should establish the standardized operative view and more simplified technique of laparoscopic rectal surgery.

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Introduction: A prospective case series of single incision multiport laparoscopic colorectal resections for malignancy using conventional laparoscopic trocars and instruments is described. Methods: Eleven patients (7 men and 4 women) with colonic or rectal pathology underwent single incision multiport laparoscopic colectomy/rectal resection from July till December 2010. Four trocars were placed in a single transumbilical incision. The bowel was mobilized laparoscopically and vessels controlled intracorporeally with either intra or extracorporeal anastomosis. Results: Three patients had carcinoma in the caecum, one in the ascending colon, two in the sigmoid colon, one in the descending colon, two in the rectum and two had ulcerative pancolitis (one with high grade dysplasia and another with carcinoma rectum). There was no conversion to standard multiport laparoscopy or open surgery. The median age was 52 years (range 24–78 years). The average operating time was 130 min (range 90–210 min). The average incision length was 3.2 cm (2.5–4.0 cm). There were no postoperative complications. The average length of stay was 4.5 days (range 3–8 days). Histopathology showed adequate proximal and distal resection margins with an average lymph node yield of 25 nodes (range 16–30 nodes). Conclusion: Single incision multiport laparoscopic colorectal surgery for malignancy is feasible without extra cost or specialized ports/instrumentation. It does not compromise the oncological radicality of resection. Long term results are awaited.

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LAPAROSCOPIC SURGERY FOR COLORECTAL CANCER WITH THE HIGH LIGATION USING AUTOMATIC STAPLING DEVICE: THE EXAMINATION OF ONCOLOGIC VALIDITY AND TECHNICALLY SAFETY

A NOVEL APPROACH TO WOUND HEALING AND HERNIA PREVENTION FOLLOWING LAPAROSCOPICALLY ASSISTED LEVATOR-CUFF ABDOMINOPERINEAL RESECTION (APR) OF THE RECTUM

Masanori Naito, PhD MD, Masahiko Watanabe, PhD MD, Takeo Sato, PhD MD, Atsushi Ikeda, PhD MD, Naoto Ogura, MD Kitasato University School of Medicine, Department of Surgery

Christopher Wright, Mr, Matthew Tutton, Mr Department of Colorectal Surgery, Colchester General Hospital

Introduction: Laparoscopic surgery for colorectal cancer is excellent in cosmetic and minimally invasive procedure, but is the need for skillful technique. We performed laparoscopic colorectal surgery with the high ligation using automatic stapling device for the purpose of being technically easily. Here we examined oncologic validity and technically safety of laparoscopic surgery for colorectal cancer with the high ligation using automatic stapling device. Methods: There were 104 patients (median age, 68 years, range 43–88) who underwent laparoscopic colectomy for cecum cancer, ascending colon cancer, sigmoid colon cancer and recto-sigmoid colon cancer from January 2006 to December 2010. Furthermore, there were 35 patients (median age, 66 years, range 29–84) who were performed laparoscopic rectectomy for rectal cancer at the same time. We examined operation times, the amount of bleeding and complications between the high ligation technique using automatic stapling device (instrument technique) and conventional technique by the high ligation using clip or ligature (conventional technique). Results: As for colon cancer, the procedure was underwent the instrument technique to 68 patients and the conventional technique to 36 patients. In the instrument technique, the median number of dissected lymph nodes was 13 (range 0–40). The median operation time and the median amount of bleeding were 155 min (range 93–280) and 35 ml (range 5–510) in right side colectomy, and 210 min (range 105–340) and 10 ml (range 5–70) in left side colectomy, respectively. In the conventional technique, the median number of dissected lymph nodes was 13 (range 0–58). The median operation time and the median amount of bleeding were 170 min (range 95–270) and 5 ml (range 5–80) in right side colectomy, and 197 min (range 136–360) and 20 ml (range 5–245) in left side colectomy, respectively. Post-operative complications occurred in 13 patients (16.2%) of the instrument technique and 7 patients (19.4%) of the conventional technique. Whereas as for rectal cancer, the procedure was underwent the instrument technique to 27 patients and the conventional technique to 8 patients. The median number of dissected lymph nodes was 8 (range 2–22) in the instrument technique and 5 (range 2–17) in the conventional technique. In the instrument technique, the median operation time and the median amount of bleeding were 267 min (range 170–342) and 40 ml (range 5–110), respectively. In the conventional technique, the median operation time and the median amount of bleeding were 261.5 min (range 220–334) and 32.5 ml (range 5–120), respectively. Conclusions: In this examination, we have shown that laparoscopic surgery for colorectal cancer with the high ligation using automatic stapling device is oncologic validity and technically safety.

Introduction: This is the first description of primary use of biological mesh for both pelvic floor and parastomal region during APR. Poor perineal wound healing and parastomal hernias following abdominoperineal resection (APR) causes significant morbidity. The risk of parastomal hernias is up to 70% in the literature. Many authors have looked at prevention of both parastomal and pelvic floor hernias with mesh. Due to the complications of synthetic mesh there has been an interest in the use of biological mesh for both of these problems. Method: A retrospective study of all patients undergoing laparoscopically assisted levator-cuff APR with biological mesh was undertaken from a prospectively collected database. Mesh was inserted in both the pelvic floor reconstruction and laparoscopically as a ‘‘key-hole’’ sublay repair at the stoma site. Primary endpoints were perineal wound healing, wound infection, mesh survival and occurrence of parastomal hernias. A costbenefit analysis was also performed. Results: 6 consecutive patients were included in the series. 4 patients had undergone preoperative long course chemoradiotherapy (2 for anal squamous carcinoma and 2 for low rectal adenocarcinoma). One patient had a perineal wound infection (16.7%), however, there were no cases of mesh loss and primary healing occurred in all six patients. With a mean follow-up of 10.2 months (±3.5 S.E), there have been no stoma complications, parastomal or perineal hernias and no cases of local disease recurrence. The cost of the biological mesh is $2700 per patient with very little increase in operative time for mesh placement. If just half of patients with parastomal hernias were repaired at a cost of approximately $4500, the biological mesh is cost effective and even more so if costs through lost income, input of stoma care nursing staff, use of hernia belts, or removal of infected prosthetic mesh are included in the equation. Conclusions: Whilst expensive, the use of biological mesh may well offer significant advantages for patients undergoing APR both in terms of perineal wound healing and prevention of hernias. This approach is likely to be cost-effective when considering all costs from treatment of related complications and may improve patient satisfaction. Although these are preliminary results of a small series it highlights an exciting new approach for the improved healing of perineal wounds and hernia prevention following APR.

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23-h DISCHARGE FOR MASSIVE RECTAL ADENOMAS TREATED WITH TRANSANAL ENDOSCOPIC MICROSURGERY Christopher Wright, Mr, Matthew Tutton, Mr Department of Colorectal Surgery, Colchester General Hospital Introduction: Transanal endoscopic microsurgery (TEM) provides a local treatment for rectal tumours instead of radical surgery. Although introduced in the 1980s, little has been reported about tumour size or massive adenomas over 4 cm in size in relation to early discharge. This series confirms that larger adenomas can be safely removed by TEM, without affecting the prospect of early discharge. Method: All patients undergoing TEM procedures performed in a 3-year period between 2008-2011 were included in the study. Data was taken from a prospectively compiled database including demographics, hospital stay data and histology reports. Results: 64 patients were identified. The mean age was 64 years (range 28–87). The maximum tumour diameter was 4.6 cm (±0.38 cm (standard error)). 36 tumours (56%) were massive adenomas and 6 were circumferential tumours. The median hospital stay was 1 day (range 1–31), with 77.3% being discharged on a 23 h basis. There was no correlation between size of tumour and hospital stay (p = 0.187 (regression analysis)). In particular there was no significant difference in the median hospital stay for tumours \ 4 cm compared with C4 cm (both 1 day). 6 patients had complications (7.6%) with no relation to tumour size. With a mean follow-up of 19.8 months (±3.2) there were 3 recurrences (4.7%), 2 in the massive adenoma group (p = 0.71 (Fishers exact)). Conclusion: TEM is an ideal method for resection of large rectal adenomas without the morbidity or radical surgery. The majority of massive rectal adenomas treated by TEM are suitable for 23 h discharge and this does not increase the risk of complications. Whilst other local treatments report a high recurrence risk with large adenomas TEM provides a safe and effective means of treatment.

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SINGLE PORT LAPAROSCOPIC COLECTOMY: LONG TERM OUTCOME Ovunc Bardakcioglu, MD FACS Saint Louis University Introduction: Single port laparoscopic colectomy is described as a new technique in colorectal surgery. These initial case reports and series show the feasibility and short term outcome only. We report our long term outcome for the initial 20 single port laparoscopic right hemicolectomies without selection bias. Methods: Between July 2009 and September 2010 20 patients with the indication for a right hemicolectomy underwent a single port laparoscopic approach without selection bias. The only exclusion criterium was a prior midline laparotomy. The patients were followed for a median of 24 months (range 12–33 months). Results: The median age was 65 (range 59–88). 90% of patients were male. The median BMI was 28 (range 20–35). 75% of patients had significant co-morbidities with an ASA class of 3 and 4. The estimated blood loss was 25 cc (range 25–250). The median number of pathologic lymph nodes for patients diagnosed with adenocarcinoma was 16 (range 8–23). There was one conversion to handassisted laparoscopic (case 6) and one to open colectomy (case 9) due to the inability of safe vessel ligation. The median hospital stay was 4.5 days (range 3–7). The mean operative time for the first 10 cases was 198 min (range 148–272) and for the following 10 cases 123 min (range 98–150 min). There were no significant postoperative complications within 30 days. At a median follow up of 24 months there were no patients with local recurrence or distant metastases. One patient died 17 months after resection from a myocardial infarction. Two patients developed an incisional hernia with one requiring a laparoscopic incisional hernia repair. Conclusion(s): Single port laparoscopic right hemicolectomy can be safely performed for patients who were candidates for conventional laparoscopic right hemicolectomy with a very low postoperative complication rate and comparable long term outcome.

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ROBOTIC VERSUS OPEN RECTAL RESECTION FOR CANCER: A COMPARATIVE ANALYSIS OF ONCOLOGICAL SAFETY AND SHORT-TERM OUTCOMES IN 164 PATIENTS Paolo Pietro Bianchi, MD, Wanda Petz, MD, Bruno Andreoni*, Pr, Antonio Chiappa*, MD, Emilio Bertani*, MD, Lorenzo Casali, MD, Daniele Belotti, MD, Matias Parodi, MD Unit of Minimally-Invasive Surgery, * Division of General Surgery, European Institute of Oncology Introduction: Minimally invasive surgery of the rectum for cancer has not still become a standard of care. We assessed feasibility, short-term oncologic safety and short-term outcomes in robotic rectal resection (RR) for cancer compared with open rectal resection (OR) in two homogenous groups of patients treated in the same surgical division. Patients and methods: From February 2008 to September 2011 164 patients were retrospectively studied from a prospective data base, 80 patients underwent OR and 84 patients underwent RR. In patients with locally-advanced non metastatic tumor pre operative chemo-radiotherapy was administered. Sphincter preservation was realized every time the lesion was localized at least 3 cm above the anal verge. The robot utilized was a 4 arms DaVinci surgical system (Intuitive Surgical, Sunnyvale, CA, USA). Results: Patients in the two groups were comparable in terms of mean age (65 years in OR and 65 in RR), mean body mass index (26 kg/m2 in OR and 25 kg/m2 in RR) and cancer stage. Seventeen abdomino-perineal resection were performed in OR group and 16 in RR group; mean surgical time was 200 min in OR and 274 min in RR (p: 0.001), mean blood loss was 216 ml in OR and 88 ml in RR (p: 0.02). One conversion to open surgery was necessary in the RR. Mean hospitalisation time was 11 days in OR group and 7 days RR group (p: 0.001). Postoperative complications were 31% in OR and 15% in RR (p: 0.007) and the surgical site infections were 13 and 1% respectively (p: 0.001). Mean number of harvested lymph nodes per patient was 18 OR and 22 in RR, mean distal resection margin was 2.9 and 4.3 cm respectively. Conclusions: Robotic rectal resection for cancer is a feasible and safe operation with short-term oncologic outcomes similar to those of OR but with a significant less incidence of postoperative complications and hospital stay. Further studies are necessary to address more systematically advantages of robotic surgery in rectal cancer.

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COMPARATIVE ANALYSIS OF OPEN AND LAPAROSCOPIC COLECTOMY FOR MALIGNANCY IN A DEVELOPING COUNTRY Pierre-anthony Leake, MD, Kristen B Pitzul, MSc, Patrick O Roberts, MD, Joseph M Plummer, MD University of the West Indies (Mona Campus), Kingston, Jamaica, West Indies Introduction: Despite the various factors limiting the widespread use of laparoscopic colectomy for colorectal cancer in developing countries, short term and oncologic outcomes similar to those noted in large prospective studies can be achieved in these environments. Previous studies have demonstrated laparoscopic colectomy to be a safe and feasible approach to colonic neoplasms in developing countries. Demonstrating outcomes similar to those achieved in the developed world will further support the continued growth of laparoscopy in the developing world. Methods and Procedures: The records for patients who underwent elective open and laparoscopic colectomies for cancer at the University Hospital of the West Indies between January 1, 2005 and December 31, 2010 were retrospectively reviewed. One hundred and four charts were grouped according to intention-to-treat for colonic resections. Emergency procedures and rectal resections were excluded. Demographic, peri-operative, post-operative and oncologic data were collected for each patient. Fisher’s exact, Mann–Whitney, and binary logistic regression tests were used for analysis. Significance level was set at P \ 0.05. Results: There were 87 cases for open colectomy (OC) and 17 cases for laparoscopic colectomy (LC). Demographics such as gender, age, and Charlson comorbidity index score (CCI) did not significantly differ between OC and LC groups (Pgender = 0.429; Page \ 0.363; Pcci = 0.501). Only 1 laparoscopic case was converted. Intra-operative blood loss and number of post-operative parental narcotic doses did not significantly differ between groups (Pblood \ 0.512; Pnarcotics \ 0.176). There was a trend towards longer operating times in the OC group (P \ 0.075). Controlling for potential confounding variables, there was a trend towards shorter length of hospital stay in the LC group (P \ 0.083). Lymph node yield (P \ 0.619), proximal (P \ 0.353) and distal (P \ 0.57) resection margin distance and circumferential margin involvement (P = 0.348) did not significantly differ between groups. Thirtyday morbidity was equivalent between groups (P = 0.774). There were 6 deaths within 30 days of initial procedure, all in the OCR group (6.9%). Conclusion: Laparoscopic colectomy in the developing world is oncologically safe and represents a viable option for colectomy for cancer in these regions. It provides short-term outcomes at least equivalent to open colectomy. Continued experience with laparoscopy in these settings will serve to more clearly demonstrate the wellestablished benefits of this operative approach.

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DUPLICATE APPENDIX WITH ACUTE RUPTURED APPENDICITIS- CASE REPORT Sharique Nazir, MD, Ibrahim I Jabbour, MD MPH, Larry Griffith, MD FACS, Armand Asarian, MD FACS, Peter J Pappas, MD FACS The Brooklyn Hospital Center Introduction: Acute appendicitis is the most common cause of emergent abdominal surgery in the United States (US). Less than 100 appendiceal duplications have been documented in the literature to date, of which less than 10 are cases of appendiceal duplication complicating acute appendicitis including this case. Case Report: A 33 year-old female presented with migratory right lower quadrant pain of four days duration with nausea and vomiting. She was febrile and had a tender right lower quadrant with rebound tenderness and guarding. Her white blood cell count was elevated with neutrophilia. CT Scan showed possible acute appendicitis with perforation and fluid collection in the pelvis. Diagnostic laparoscopy prior revealed two appendices attached via separate bases to one cecum. The anterior appendix was inflamed with a gangrenous tip while the posterior appendix was grossly normal. Both appendices were located on the taenia-coli and a single cecum was present. Laparoscopy did not reveal any other associated intra-abdominal anomalies. The patient underwent emergent laparoscopic appendectomy. Histology confirmed normal appendicular tissue in one specimen and severe acute transmural appendicitis in the other. There were no post-operative complications. The patient was discharged home in stable condition after three days. Discussion: In 1962 Wallbridge and Waugh contributed a classification system for appendiceal duplication which recognizes three major types of anomalies: Types A, B, and C. Coker et al suggested the embryological etiology for each of these etiologies Based on the above classification the case presented here can be classified as Type B2 due to two separate appendices attached via separate bases onto the cecum and are located over taeni-coli. Type B2 is the most frequently reported duplication. Suspicion of a duplicated appendix should prompt further investigation into the possibility of other congenital anomalies, including duplications or anomalies of the gastrointestinal or genitourinary tracts, gastroschisis, and vertebral anomalies. Type B2 duplication is not known to be associated with any other congenital anomalies Based on the different types appendiceal duplication the clinical presentation of acute appendicitis could vary extensively. It is likely that the lack of reported acute appendicitis in appendiceal duplication is most likely due to failure to diagnose the anatomical anomaly. This is most certainly the case when the clinical presentation mimics other conditions, such as adenocarcinoma of the colon or intussusception. In cases where appendiceal duplication is suspected, differential diagnoses such as appendiceal diverticulosis, solitary cecal diverticulum, triple appendix, and horseshoe appendix (Type D) must be ruled out. Histopathological examination can distinguish duplicate appendix. The potential complication of missing a second or third normal appendix could make evaluation of right lower quadrant pain difficult, hence although the incidence of appendiceal duplication is 0.004% a thorough laparoscopic examination is recommended to rule out any anatomical anomalies. Although appendiceal duplication occurs very rarely, awareness of this congenital anomaly and thorough intra-operative inspection are critical to avoid the potential consequences of missing a second appendix, as well as any associated congenital anomalies, and to minimize confusion with other intraabdominal structures.

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COMPARISON OF OPEN, LAPAROSCOPIC ASSISTED, AND TOTALLY LAPAROSCOPIC RIGHT HEMICOLECTOMY Gideon Sroka, MD MSc, Tal Kopelman, MD, Dan Shteinberg, MD, Nadav Slijper, MD, Husam Mady, MD, Ibrahim Mattar, MD Bnai-Zion Medical Center, Technion—Israel Institute of Technology, Haifa, Israel Background: Totally laparoscopic right hemicolectomy with intracorporeal anastomosis has recently been described. The purpose of this study was to assess the advantages of this technique in comparison with laparoscopic assisted and open surgery. Methods: We retrospectively analyzed all patients who went through elective right hemicolectomy in our department between 2007-2010. Patients were divided into three groups: open (ORH), laparoscopic Assisted with extracorporeal anastomosis (LAC), and totally laparoscopic with intracorporal anastomosis (TLC). Demographic, perioperative and oncologic data were compared. Results: 119 patients who were operated. 41 underwent ORH (15 male), 44 underwent LAC (19 male) and 34 underwent TLC (15 male). Age and BMI were the same. Average length of stay was 6 ± 2 days for TLC, 7 ± 3 for LAC and 9 ± 3 for ORH. Operative duration was 136 min in TLC, 115 min in LAC and 105 min in ORH. 5 patients (14%) had minor complications in TLC, LAC had 8 (18%) post operative complications out of which 3 were intra-abdominal collections, and ORH had 12 complications (29%), 5 of which were anastomosis related. Tumors tend to be more advanced in the ORH. There was no difference in number of lymph nodes harvested in the three groups. There were 8 incisional hernias in the LAC and not even one in TLC. Conclusions: Totally laparoscopic right hemicolectomy offers better short-term outcome with less intraabdominal and wound complications and with no oncologic compromise.

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LOW ANTERIOR RESECTION SYNDROME: A NOT UNCOMMON COMPLICATION OF TRANSANAL ENDOSCOPIC MICROSURGERY Michael F Horaist, MD, Philip A Cole Ii, MD, Andrew M Werner, MD FACS, Michael D Stratton, MD FACS, W Reid Grimes, MD FACS, Philip A Cole, MD FACS LSU Health Shreveport Introduction: Transanal Endoscopic Microsurgery (TEM) allows for excision of middle and high rectal lesions utilizing a minimally-invasive technique. Low anterior resection syndrome (LARS) includes a constellation of symptoms that typically follows colorectal/coloanal anastomosis. The most pronounced symptoms include frequency, urgency, and/or incontinence. The goal of this study was to review our TEM experience for the treatment of rectal neoplasia and monitor the subsequent development of LARS. Methods: 100 patients underwent TEM from August 2005 to July 2011 after receiving 2 Fleets enemas on the morning of surgery. All patients were admitted overnight, given clear liquids post-op, and discharged the following morning once tolerating a diet and voiding. Results: The average follow-up of these 100 patients was 19.2 months. Complications following this minimally-invasive procedure (including frequency, urgency, bleeding, infection, incontinence, and recurrence) occurred in 16 out of 100 patients. The positive margin rate was 5% leading to an equivalent recurrence rate. LARS occurred in 11/100 patients. Discussion: Although better tolerated than more extensive resections, TEM is associated with a risk of functional complications. LARS has traditionally followed resection with low anastomosis; however, TEM has led to similar symptomatology in 16% of our patients. Improvement within one year was noted in 91% of those patients.

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LAPAROSCOPIC TOTAL COLECTOMY FOR PATIENTS WITH SEVERE ULCERATIVE COLITIS. CAN WE IMPROVE THE Results? Alejandro G Canelas, MD, Maximiliano E Bun, MD, Esteban Grzona, MD, Mariano Laporte, MD, Federico Carballo, MD, Nicola´s A Rotholtz, MD Hospital Alema´n, Buenos Aires, Argentina Background: The surgical treatment of patients with ulcerative colitis (UC) is total proctocolectomy with ileal pouch-anal anastomosis. This surgery can be performed by laparoscopy with excellent results. It is not clear which is the impact of this approach in the management of patients with severe colitis who require emergency surgery. There is scarce data showing that laparoscopic approach has lower morbidity and hospital stay compared with the conventional approach, but has longer surgical time and morbidity during the learning curve. The aim of this study is to assess if the acquisition of experience by the surgical team can improve the outcomes of laparoscopic total colectomy in severe ulcerative colitis. Methods: A retrospective study was performed using a prospective collected database. All patients with severe ulcerative colitis who underwent urgent laparoscopic total colectomy between August 2003 and July 2011 were included. The severity of the colitis was graded by clinical evaluation, using the Truelove and Witts Ulcerative index, and colonoscopy. The series was divided into two groups: the first 20 surgeries (G1); and the last 15 surgeries (G2). Perioperative outcomes of the two groups were compared by univariate analysis. Results: There were no differences in the demographic data between the two groups. G2 had shorter surgical time (G1: 199 ± 39 vs. G2: 170 ± 29 min; p \ 0.05). There were no differences in the rate of intraoperative complications and in the conversion rate, but the only patient who was converted to laparotomy belonged to G1. There were no differences in the postoperative complication rate, return to bowel function, postoperative length of stay and in the time to complete proctectomy with ileo-anal pouch. Conclusions: The acquisition of experience by the surgical team in laparoscopic total colectomy for patients with severe UC decreases the surgical time and shows a tendency to decrease the conversion rate.

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Surg Endosc (2012) 26:S249–S430

P086

MCKITTRICK-WHEELOCK SYNDROME TREATED BY TEM/TEO:REPORT OF TWO CASES Mikel Prieto, Hector Marin, Jose Maria Garcia, In˜aki Marinez, Alberto Lamiquiz, Tamara Moreno, Eduardo Ayestaran, Iratxe Roden˜o Alberto Colina Cruces University Hospital Introduction: The McKittrick-Wheelock syndrome (MW) is characterized by severe dehydration, hyponatremia, hypokaliemia and metabolic acidosis caused by hypersecretant colorectal tumor. We Present two cases of MW treated by TEM/TEO, being the only two published cases by endoscopic endoanal surgery. Clinical Case 1: Women of 64 years, who refers rectal bleeding and deezing. Exploration: pain in right iliac fosse and a rectal polyp 5 cm from anal verge. Blood test: leucocytosis, acute renal failure, hyponatremia and hypokaliemia. Colonoscopy: polypoid lesion that occupied the 80% of the circumference 6 cm from anal verge (Pathologic anatomy (PA): Adenoma with moderate dysplasia). Echoendoscopy: mucosal lesion. TEM was performed and a villous lesion in posterior face was located (PA: Adenoma with moderate dysplasia).12 months later local disease recurrence was observed, and a small polyp lesion 4 cm from anal margin was removed by colonoscopy. Clinical Case 2: 74 year old man who refers dizziness associated with long standing mucous diarrhea and weight loss. Exploration:hypotension and tumor to 2 cm from anal margin. Blood test: acute renal failure, hyponatremia, and hypokalemia. Echoendoscopy: mucosal lesion 2 cm of anal verge 10 cm in length that occupied the entire circumference. MRI: 3 cm of the anal margin a polypoid lesion of 8 cm. length. TEO was performed in prone position demonstrating a villous anterior lesion of 3 quadrants, (PA: Adenoma with moderate dysplasia). No acute surgical complication was observed, being asymptomatic at the present time. Discussion: The initial treatment of MW is electrolyte recovery, surgery being the definitive treatment. Indomethacin is recommended prior to surgery. When endoscopic resection is not possible, there are two options: conventional surgery or TEM/TEO, according to location and PA. Although local recurrence, we recommend this surgical approach in cases of appropriate location and PA.

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SELF-EXPANDING METAL STENTS IN THE CONTEXT OF COLONIC OBSTRUCTION: A RETROSPECTIVE ANALYSIS FROM 45 CASES Hector Marin, Mikel Prieto, Laura Buendia, Alberto Lamiquiz, Aingeru Sarriugarte, Jose Maria Garcia, Andoni Larzabal, Tamara Moreno, Alberto Colina Cruces University Hospital Objectives: Colonic stents have been increasingly used as a non-surgical choice to relieve colonic obstruction, most frequently in cases of advanced colorectal cancer. This approach could provide the opportunity of performing a one-stage elective procedure with primary anastomosis, instead of an emergent operation with the necessity of a diverting colostomy. Our objective was to assess the results of colonic stent placement for benign and malignant disease in our center. Methods: Forty five cases of colonic stent placement carried out in our center from January 2010 to April 2011 where analyzed. These included 42 cases of advanced colorectal cancer, and 3 cases of obstruction due to benign conditions (one postsurgical anastomosis stricture and two extrinsic compressions from endometriosis and ovarian cancer). Results: Technical success rate of the procedure was very high (97, 8%), with only one case of impossibility to place the stent. Clinical success defined as obtainment of an effective long-term palliative decompression or until an elective procedure was carried out was obtained in 29 cases (64, 4%). In other 3 cases (6, 7%) decompression was finally achieved after the placement of another stent, and other 2 cases (4, 4%) finally needed a diverting colostomy. The objective of stent placement for temporal decompression as a bridge to surgery was established for 11 patients, and in 9 of them (81, 8%) this objective was achieved. Perforation occurred in 7 cases (15, 5%), with delayed perforation being the most common (6 out of 7 cases), mainly in the site of the stent placement, but in 2 cases it was located in proximal colonic segments. Stent migration, which required repetition of the procedure, was described in 3 patients (6, 7%). Minor complications, such as occasional bleeding or abdominal pain were not considered. Conclusion: The use of stents for managing colonic obstruction is feasible and effective, despite potential complications, allowing the practice of one-stage procedures and reduced morbidity in many cases, and providing effective palliation in others.

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THE EFFECT OF CO2 PNEUMOPERITONEUM FOR OCTOGENARIAN DURING LAPAROSCOPIC RECTAL SURGERY Chang Sheng-chi, MD, Ke De-wei, MD, William Tzu-liang Chen, MD, China Medical University Hospital, Taichung, Taiwan Purpose: Laparoscopic surgery, especially rectal surgery, requests a relative long time and it may cause adverse impact on circulation, respiration and renal function due to CO2 absorption and high intraabdominal pressure. This kind of phenomenon was more obvious in patients of old age. The aim of this study is to compare the anesthetic results between octogenarian and younger patients undergoing laparoscopic rectal surgery perioperatively and to evaluate the effect of pneumoperitoneum in elderly. Materials and Methods: Since Jun 2009 to Jun 2011, patients undergoing elective laparoscopic rectal surgery were enrolled in this study, except age from 60 to 80 years old. Patients were divided into two groups, octogenarian ([80 y/o, group O) and younger (\60 y/o, group Y) group. The parameters were recorded prospectively, including mean blood pressure (MBP), heart rate (HR), cardiac output index (COI), stroke volume index (SVI) and stroke volume variation (SVV), central venous pressure (CVP), end-tidal CO2 (EtCO2), air-way pressure (PAW) and urine output (UO) during anesthesia and pneumoperitoneum. We also compared the perioperative surgical outcome between group O and group Y, including operative time, blood loss, length of first flatus passage, hospital stay, surgical complication and mortality. Results: In this period, a total of 70 patients were included in this study, 30 octogenarian and 40 younger patients. All patients accept laparoscopic rectal surgery for rectal cancer in the same institute. Although group O had higher ASA degree, the perioperative circulatory parameter seems like similar in both groups. At timing of pneumoperitoneum, the group O had significant increased in CVP level. The short-term surgical results had no significant difference between the two group. Conclusion: CO2 pneumoperitoneum is safe to octogenarian during laparoscopic rectal surgery and not increase the medical or surgical morbidity after surgery.

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OUTCOME IN 23 PATIENTS UNDERGOING LAPAROSCOPIC POSTERIOR RECTOPEXY WITH SHALLOW REPERITONIZATION FOR FULL-THICKNESS RECTAL PROLAPSE Koji Masumori, Assistant Professor MD, Koutarou Maeda, Professor, Tsunekazu Hanai, Associate Professor, Haruyosihi Sato, Associate Professor, Hiroshi Matsuoka, Assistant Professor Department of Surgery, School of Medicine, Fujita Health University Introduction: For full-thickness rectal prolapse, transanal and transabdominal procedure have been performed in our hospital, depending on the patient’s age and total condition. Currently, laparoscopic surgery with it radical and less invasive procedure has been for several diseases. We laparoscopically added pelvic peritonizatin repair to the fixation of the rectum to the sacrum with prothetic material by Nicolas and Bass. The procedure and outcomes of the laparoscopic surgery were described. Patient and Methods: All patients were assessed preoperatively by clinical examination, defecography, anal manometry and endoscopy, transit study with sitzmarks. Dis indications for Laparoscopic surgery were in performance status 2 and above, were unable to have general anesthesia or have the last open surgery or severe mental sickness. Laparoscopic operative technique: A total of 5 port sites (using three 12 mm ports and two 5 mm ports) are placed at the umbilicus and the other lower abdomen. The sigmoid colon and the rectum are dissected posteriorly and laterally from the autonomic nerves with forceps and electric diathermy. The rectovaginal septum is dissected anteriorly. Using the rolling tape, the rectum is retracted, and the rectum is mobilized down to the levator muscles. A rectangular polypropylene mesh (width; 3 quarters of the rectum, length; about 5 cm) is inserted and fixed to the sacral concavity using a Endo-Hernia staplar. Reperitonization was performed by hand sewn method to shallow the peritoneal reflection. Result: This procedure was performed in twenty three patients from May 1996 to December 2010. Median Operating time and blood loss were 169 (range 89–248) min and 13 (range 2–57) g respectively. Postoperatively, slight soiling was observed in 5 patients with acceptable bowel moments. Intraoperative complication was 1 case (bleeding of the middle rectal artery). And postoperative complication was 1 case with port site hernia. Median following time was 23 (range 2–145) months, there were no recurrence case. Conclusion: This laparoscopic procedure is feasible for full thickness rectal prolapse with favorable short term functional results.

Surg Endosc (2012) 26:S249–S430

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EFFICACY OF INTRACOLONIC WASHOUT IN PATIENTS WITH ANASTOMOTIC LEAK Sohyun Kim, MD, Sanghun Jung, MD PhD, Jae Hwang Kim, MD PhD, Yeungnam University Hospital Introduction: One of the most important causes of anastomotic stricture is local sepsis due to leakage. Even though it is defunctioned with stoma formation, sometimes fibrotic stricture remains. We added intracolonic wash out procedure to the conventional procedures for anastomotic leakage in order to reduce the source of sepsis. The aim of this study is to identify the effect of added colonic washout procedure. Methods and Procedures: A prospective randomized study was conducted in rectal cancer cases with extraperitoneal anastomosis and the subsequent postoperative leakage from January 2004 to December 2010. Exclusion criteria were neo-adjuvant radiotherapy with or without chemotherapy, synchronous formation of defunctioning stoma in cancer surgery and postoperative mortality. The patients were divided into two groups; the control group (CG) underwent conventional procedure; defunctioning stoma and intraperitoneal irrigation. The colonic washout group (WG) underwent intracolonic washout procedure in addition to conventional procedure. Colonic washout procedure in this study was cleansing the colon from the stoma to anus with tepid saline. Patients were evaluated with contrast study, MRI and digital rectal exam to confirm the status of anastomotic area during follow-up period before and after reduction of stoma. The stricture defined in this study means prominent clinical defecation difficulty proved in digital rectal examination, barium enema and MRI. The result of each group was assessed using Fisher’s exact test and Mann–Whitney U-test. P \ 0.05 was regarded as statistically significant. Results: A total of 656 patients experienced extraperitoneal anastomosis after rectal cancer resection. Two hundred and sixty four patients underwent neo-adjuvant radiotherapy. Seventy one out of the remaining 392 patients got defunctioning stoma at the time of rectal surgery. Twenty-two patients (6.9%) out of remaining 321 were included in this study. These patients were randomly divided in two groups; Eleven patients per each group. There was no stricture complication in WG, however, three patients (27%) in CG experienced anastomotic stricture after stoma reduction (p = 0.214). The patients with anastomotic stricture needed conservative treatment with Hegar dilator to minimize defecation difficulty. Eventually one out of the 3 patient experienced stricturoplasty with general anesthesia. The stoma were reduced in all patient included in this study. The mean time to reduce the stoma was 151 days in CG and 114 days in WG (p = 0.212). Conclusion: In this study, colonic washout procedure added to conventional procedure for anastomotic leakage had reduced the anastomotic complication even though there was no statistical significance. Further trials are needed to confirm the efficacy and the role of this additional colonic washout procedure.

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TWO-PORT LAPAROSCOPIC APPENDECTOMY: MAXIMALLY VERSATILE MINIMALLY INVASIVE SURGERY R S Brooks, MD RVT St. Mary’s Hospital and Community Hospital Grand Junction, CO Background: Conventional laparoscopic appendectomy (LA) is performed via 3-port laparoscopic methods. Novel 2 and single port LA have gained increasing interest. Objective: A retrospective study of 2-port LA is presented to assess safety, outcomes, complications and potential advantages. Materials/Methods: During the study interval of 2005–2011, 86 consecutive patients with clinical and imaging findings of appendicitis were identified. The intent to treat was 2-port LA in all cases. Pregnant patients were excluded, 2 cases were recommended for open surgery secondary to very young age and prior multiple surgical procedures. 2 elderly patients with delay in presentation, abcess and extensive phlegmon were definitively treated with CT-guided pig-tail catheter drainage and antibiotics. No other exclusions were made, the study population included complicated appendicitis with gangrene, abcess, phlegmon and comorbidity such as BMI 50. The 2-port method included a 12 mm periumbilical port, 15 mm suprapubic port, 10 mm operating laparoscope, 2.5 9 12 and 3.5 9 12 mm articulating endo GIA staplers. Results: 2-port LA was successful in 80 patients, (93%) 2 patients required conversion to open secondary to extensive phlegmon formation. No major morbidity was encountered, including no infectious complications, surgical site infection, abcess or fistula. One patient sustained a periumbilical port site hernia requiring surgical revision. Conclusions: 2-port LA is a safe, efficient, versatile method with a high success rate, including complicated appendicitis. 2 working ports allow port selection for optimal stapler orientation, the 15 mm suprapubic port allows retrieval of enlarged appendix and mesoappendix tissue without risk of fragmentation or contamination. 2-port LA may be associated with less post-procedural pain and is cosmetically appealing.

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LAPAROSCOPIC MESH POSTERIOR RECTOPEXY FOR THE TREATMENT OF FULL THICKNESS RECTAL PROLAPSE Hitoshi Idani, MD, Satoshi Komoto, MD, Kanyu Nakano, MD, Shinichiro Kubo, MD, Yohei Kurose, MD, Shinya Asami, MD, Tetsushi Kubota, MD, Yasushi Ohmura, MD, Hiroshi Sasaki, MD, Katsuyoshi Hioki, MD, Hiroki Nojima, MD, Takashi Yoshioka, MD, Masahiko Muro, MD, Hitoshi Kin, MD, Norihisa Takakura, MD Department of Surgery, Fukuyama City Hospital, Department of Gastrointestinal surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Background: The best surgical procedure for the management of full thickness rectum prolapse remains unknown. It has been reported that abdominal procedures have a lower recurrence rate than perineal ones, however, those are associated with larger surgical stress and higher rates of morbidity. Laparoscopic rectopexy has been introduced in these past ten years offering lower recurrence rate with less invasion and lower morbidity. We report our surgical procedure and outcome of laparoscopic posterior mesh rectopexy. Surgical Procedure: Under 10 mmHg pneumoperitoneum, the sigmoid colon and the rectum were fully mobilized. 10 9 6 cm polypropylene mesh or Parietex mesh was fixed to the presacral fascia with absorbable tacks. The rectum was wrapped 4/5 around with the mesh and fixed with 4-0 absorbable suture materials. Peritoneum was repaired by 3-0 absorbable suture materials. Patients and Methods: From January 2004 to June 2011, 10 patients with full thickness rectal prolapse underwent laparoscopic posterior mesh rectopexy in our hospital. Operative time, blood loss, length of hospital stay, morbidity and recurrence rate were evaluated. Result: Patients consisted of 7 women and 3 men with a mean age of 74 ± 11.7 years. ASA score was 2.2 ± 0.75. Polypropylene Mesh was used on 6 patients and Parietex Mesh was used on 4 patients. Operative time was 137 ± 49.8 min and the amount of blood loss was negligible. Mean length of hospital stay was 6.8 ± 2.4 POD. Constipation occurred in 3 patients, and diarrhea in 1 patient. No perioperative complication was marked. During the median follow up period of 46 months, there has been no sign of recurrence. Conclusions: Laparoscopic mesh posterior rectopexy is safe and effective procedure for the treatment of full thickness rectal prolapse.

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NATIONAL UTILIZATION OF MINIMALLY INVASIVE SURGERY FOR COLON RESECTION: AN ANALYSIS OF RECENT TRENDS Allyson H Stone, MD MS, Stefan Holubar, MD MPH, Samuel Finlayson, MD MPH, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA Introduction: A relatively slow rate of rise in the proportion of elective colon resections performed laparoscopically prior to 2005 was shown in a prior study of national inpatient data. Since 2004, several published studies showed significant benefits of laparoscopic colectomy, and the COST trial demonstrated that laparoscopic colectomy is oncologically sound, but to what degree these studies have accelerated the adoption of laparoscopic colectomy nationally is unknown. The objective of the present study was to examine recent nationwide trends in the adoption of laparoscopy for elective colon resections since 2004. Methods: Using the Nationwide Inpatient Sample, which includes national data for a 20% sample of non-federal hospitals across the United States, we retrospectively identified all laparoscopic colon resection procedures performed on adults between January 1, 2005 and December 31, 2009. We used sampling weights to estimate national procedure totals and calculated proportions performed laparoscopically, stratified by procedure type, indication, hospital characteristics, and geographic region. Pearson chi square tests were used to assess the statistical significance of trends observed over time. Results: From 2005 to 2009, the proportion of colectomy procedures performed laparoscopically increased 5.6 times, from 8.2% to 40.1%. The rise in use of laparoscopy was greatest for right hemicolectomy procedures (8.6–48.0%). Abdominoperineal resection of the rectum (APR) remained the procedure least likely to be performed laparoscopically (2.11–3.38%). By indication, the greatest increase was observed for colon cancer (5.9 times, from 5.75 to 34%), and smallest increase was observed for inflammatory bowel disease (3.5 times, from 5.7 to 19.8%). All trends over time were statistically significant (p \ 0.0001). The proportion of procedures performed laparoscopically was highest in the Northeast region (44% in 2009) and in urban hospitals (42% in 2009). While in earlier years urban teaching hospitals performed a higher proportion of colectomies laparoscopically, by 2009 rates were similar at urban teaching vs. non-teaching hospitals (41.7 vs 41.5%).

Conclusion: There has been a significant rise in use of laparoscopy for colon resections since 2005. This rise has been most dramatic for cancer patients. Possible explanations for this trend towards more widespread acceptance of laparoscopy as a viable alternative to open colon resection include the impact of clinical studies such as the COST trial, dissemination of technical skills, and increased patient awareness and demand for minimally invasive procedures.

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P094

SINGLE-PORT LAPAROSCOPIC ABDOMINO-PERINEAL RESECTION (SPLS-APR) THROUGH THE COLOSTOMY SITE Hyung-jin Kim, MD, Sang-chul Lee, MD, Yoon-suk Lee, MD, Hyeon-min Cho, MD, Jun-gi Kim, MD, Department of Surgery, The Catholic University of Korea Introduction: Laparoscopic surgery has been proven to be feasible and beneficial for the treatment of colorectal cancer. Single-port laparoscopic surgery (SPLS), which is performed via a small incision, may magnify the advantages of minimally invasive surgery, especially for the cosmetic results. We present our initial experience and a novel technique of single-port laparoscopic abdomino-perineal resection (SPLSAPR) through the colostomy site for low rectal cancer. Methods: From May 2009 to March 2010, we have performed SPLS-APR through the colostomy site in 6 patients. The mean age was 67.5 years old, the mean BMI was 23.5 kg/m2. A 2.3 cm incision was made at the left lower quadrant abdomen for the colostomy. The single port procedure was conducted with a wound retractor and a surgical glove. We used conventional straight and rigid type laparoscopic instruments, and there was no difference in intracorporeal procedures and range of operation as compare to the laparoscopic APR. Following TME by laparoscopic procedure to the pelvic floor muscles, specimen retrieval was done by a perineal approach. Proximal stump was pulled out and maturated through a preset colostomy site. Results: The mean incision length was 2.3 cm, and the mean operating time was 238 min. Oral diet was started at 2.3 days after the operation and discharged 6.8 days after the operation. The mean specimen length was 30 cm with 21 harvested lymph nodes. There were no perioperative complications. The patients had a virtually scarless abdomen, other than the site of colostomy. Conclusion: SPLS-APR can be applied for low rectal cancer with the result of a virtually scarless abdomen, except at the site of t colostomy.

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EARLY EXPERIENCE OF SINGLE-PORT LAPAROSCOPIC ANTERIOR RESECTION FOR COLON CANCER Hyung-jin Kim, MD, Sang-chul Lee, MD, Bong-hyung Kye, MD, Inkyu Lee, MD, Hyeon-min Cho, MD, Seong-taek Oh, MD, Jun-gi Kim, MD, Department of Surgery, College of Medicine, The Catholic University of Korea Introduction: Single-port laparoscopic surgery (SPLS) has recently emerged as a method to improve cosmetic benefit of conventional laparoscopic surgery. Herein, we describe our experience with SPLS for anterior resection (AR). The results of a prospective series of single-port laparoscopic anterior resection procedures are presented. Methods: From March 2009 and March 2010, sixteen patients were undergone anterior resections by a single-port laparoscopic technique. Surgical and oncologic outcomes were recorded in a prospective database. Results: Sixteen unselected consecutive patients (eight males, eight females) aged 43–82 years (median, 66.5 years) underwent SPLS anterior resection. Operative time ranged from 150–415 min (median 242 min) and median wound incision length was 2.4 cm (range 1.5–4.0 cm). The median length of hospital stay was 7.5 days. Pathological reports from resected specimens showed adenocarcinoma in 15 patients and mucinous carcinoma in one. There was one case of anastomotic leak that required reoperation. There were no hospital death. The median number of harvested lymph nodes was 27.5 (range 10–56). Conclusion: SPLS is a possible approach to anterior resection with potential for minimal access advantages. SPLS anterior resection is feasible and safe when performed by an experienced laparoscopic surgeon and team. However, the technique and oncologic safety warrants further experience and prospective randomized studies.

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RARE COMPLICATIONS DURING THE PLACEMENT OF SELF-EXPANDABLE METALLIC STENT FOR COLON CANCER OBSTRUCTION Hyung-jin Kim, MD, Bong-hyeon Kye, MD, Hyeon-min Cho, MD, Jae-im Lee, MD, Jong-kyung Park, MD, Jun-gi Kim, MD Department of Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea Self-expandable metallic stent (SEMS) is widely used for the colon cancer obstructions in palliative treatment or as a bridge to elective surgery. The technical and clinical success rates for SEMS placement are 75–100% and 84–100%, respectively. But the complications of SEMS placement such as perforation, stent migration, re-occlusion, bleeding and pain may happen. We are trying to present two cases of rare complications during the placement of SEMS. Case 1. A sixty-six female patient visited our hospital for low abdominal pain and the CT scan showed concentric wall thickening in the distal sigmoid colon with proximal dilatation of colon and small intestines. A SEMS was introduced under endoscopic and fluoroscopic guidance. The chest PA showed pneumoperitoneum, after the SEMS insertion. Emergency operation was performed and the stent perforation through the tumor was noted. Case 2. A eighty-five male patient visited our hospital for the sigmoid colon cancer obstruction with multiple liver metastases. For palliative treatment, A SEMS was tried under endoscopic and fluoroscopic guidance. But a guidewire was kinked and it couldn’t be removed. So an emergency Hartmann’s procedure was performed. During the operation, colotomy was performed and a guidewire was cutted. In most cases, SEMS can be performed safely with low morbidity, but some complications associated with the placement of SEMS may happen. So we must aware and prepare for the potential complications of the placement of SEMS.

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P097

APPENDICEAL PHLEGMON; A LAPAROSCOPICALLY DEFEATED FOE Hani H Haider, MD, Dalal F Al-aradi, MD, Ramla T Juma, MD, Waleed Al-herz, MD, Talib Juma, MD Department of Surgery, Amiri Hospital, Kuwait Introduction: It is not clearly documented in the literature whether laparoscopic appendectomy for phlegmons is destined to a high rate of conversion to open surgery or not. The aim of this study is to concentrate on the rate of conversion, and the factors that contributes to it. Methods and Procedures: A retrospective analysis of a prospectively collected data in a major governmental hospital from year 2000 till April 2011. We identified 125 cases of appendiceal masses out of 2358 laparoscopic appendectomies performed during the study period (5%). One patient was excluded from the study because of concurrent pregnancy. Statistical analysis used included Pearson’s chi-square and student’s t test. Results: There were 76 males (61%) and 48 females (39%) in our study patients with an average age of 34 years (9–78 years). Twenty three percent of the patients had pre-existing medical comorbidities. Average onset of pain at presentation was 2.3 days (1–10 days), while surgery was performed on an average 2.7 days (1–11 days) from onset of pain. In 10% of the cases a mass was identified on imaging studies (US or CT), while it was negative in 42%, and the remaining patients (48%) were not imaged before surgery. A mass was felt in only 5% of the cases on physical exam. When onset of pain was 3 days or more, senior surgeons were involved more in the surgery than junior surgeons (65 vs. 28%, P = 0.001). Average surgery time was 72 min (20–150 min). 19 patients needed conversion out of 124 (15%), (14 difficult dissection, 4 bleeding, and 1 due to injury to ileum). Conversion was highest when onset of pain was 3 days or more (32 vs. 5%, P = 0.001). Conversion to midline incision was in 21%, and the remaining through incision at McBurney’s point. Post-operative complications developed in 8% of patients after laparoscopy and 29% after open surgery (P = 0.02), and developed more in patients with preexisting medical comorbidities (28 vs. 6%, P = 0.003) (Ileus 42%, Pneumonia 25%, myocardial infarction 8%, pulmonary embolism 8%, Wound infection 8%, pelvic abscess 8%, and no case of surgical site infection, leak, or post-operative bleeding). Post-op diet was started later when patients developed post-operative complications (4 vs. 2 days P = 0.00). Average hospital stay after laparoscopy was 4 days while that after open 6 days (P = 0.02). Conclusions: Laparoscopic appendectomy can be successfully performed in 85% of the cases of appendiceal phlegmons. There was a higher chance of conversion to open when onset of pain was 3 days or more. Laparoscopy significantly decreased post-operative complications and hospital stay. The reason for the low conversion rate in our study could be attributed to the more involvement of senior surgeons in this kind of cases.

Surg Endosc (2012) 26:S249–S430

39269

S271

P098

SINGLE UMBILICAL INCISION LAPAROSCOPIC COLECTOMY WITH AN ADDITIONAL PORT FOR COLORECTAL CANCER Sang Woo Lim, MD PhD, Hun Jin Kim, MD, Chang Hyun Kim, MD, Jung Wook Huh, MD PhD, Young Jin Kim, MD PhD, Hyeong Rok Kim, MD PhD, Department of Colon and Rectal Surgery, Chonnam National University Hwasun Hospital

39340

P100

TOTALLY ROBOTIC COLORECTAL SURGERY IN SINGAPORE: OUR INITIAL EXPERIENCE OVER 3 YEARS Kuok-chung Lee, Ker-kan Tan, Seon Hahn Kim, Charles B Tsang, Dean C Koh, National University Health System

Introduction: The aim of our study was to compare outcomes for single umbilical incision laparoscopic colectomy with an additional port (SULAP) and conventional laparoscopic colectomy. Materials and Methods: One hundred sixty-three patients with colorectal adenocarcinoma were received laparoscopic colectomy between February 2011 and August 2011. Forty patients of SULAP group were compared with 123 patients of conventional laparoscopic surgery group. Demographic, intraoperative, and postoperative data were analyzed. Results: Demographic data of age, gender, body mass index were similar in both groups. Conventional laparoscopic surgery group had more previous operation history (0/40 vs. 12/123, p = 0.040). Operation time was longer in SULAP group than in conventional group (225.5 vs. 144.6 min, p = 0.000). One conversion to open surgery due to distant metastasis in SULAP group and another conversion with adhesion in conventional group were noted (1/40 vs. 1.123, p = 0.40). Tumor size (3.9 vs. 4.1 cm, p = 0.455), harvested lymph nodes (25.3 vs. 28.3, p = 0.203), and distal resection margins (5.7 vs. 7.0 cm, p = 0.151) were not different significantly between SULAP and conventional group. SULAP and conventional group were similar in estimated blood loss (183.4 vs. 170.8 ml, p = 0.260), transfusion (p = 0.841), and hospital stay (7.7 vs. 7.8 day, p = 0.862). Postoperative morbidity were similar in both groups (5/40 vs. 18/123, p = 0.736). Conclusion: Umbilical incision laparoscopic colorectal cancer surgery with an additional port is a feasible and safe approach, although it takes more time than conventional laparoscopic colectomy.

Background: Totally robotic colorectal surgery is not widely practiced in view of its technical difficulty and availability of required resources. The aim of this study is to determine the feasibility and short-term outcomes of our initial experience. Methods: A retrospective review of all patients who underwent robotic colorectal resection from August 2008 to August 2011 was performed. Only totally robotic colorectal technique was adopted in our institution. The standard da Vinci Surgical System was used until December 2009 and was replaced by the Si model thereafter. Results: A total of 47 (31 males, 66.0%) patients with a median age of 62 (range, 21–92) years underwent various elective procedures. The majority of the cases (n = 45, 95.7%) were operated for malignant conditions, of which rectal cancer comprised 25 (57.4%) of them. The remaining two benign conditions were for colovesical fistula from diverticulitis and rectal prolapse. Eight (17.0%) patients had a history of previous abdominal surgery. There were 45 (95.7%) left sided and 2 (4.3%) right sided colonic resections. The median operative and docking times were 315 (range, 163–771) min and 10 (3–34) min, respectively. There was one patient who required conversion to conventional laparoscopy surgery for a small bowel serosal tear. The median number of lymph nodes harvested was 16 (range, 4–45). There were 2 patients with anastomotic leakage while another had significant post-operative haemorrhage from a bleeding mesenteric vessel necessitating a laparotomy. Two other patients also had brachial plexus neuropraxia that resolved with conservative management. The median length of stay was 5 (3–21) days. Conclusions: Totally robotic colonic resection using is technically feasible and short-term outcomes are comparable to those of conventional laparoscopic approach.

39301

39342

P099

P101

REDUCED PORT SURGERY FOR COLORECTAL CANCER Jun-ichi Tanaka, MD FACS, Tomokatsu Omoto, MD, Shunpei Mukai, MD, Kenta Nakahara, MD, Chiyo Maeda, MD, Yusuke Takehara, MD, Daisuke Takayanagi, MD, Eiji Hidaka, MD, Shungo Endo, MD, Fumio Ishida, MD, Sin-ei Kudo, MD Digestive Disease Center Showa University Northern Yokohama Hospital

LAPAROSCOPIC INTERSPHINCTERIC RESECTION FOR LOW RECTAL CANCER Sang Woo Lim, MD PhD, Chang Hyun Kim, MD, Hun Jin Kim, MD, Jung Wook Huh, MD PhD, Young Jin Kim, MD PhD, Hyeong Rok Kim, MD PhD Department of Colon and Rectal Surgery, Chonnam National University Hwasun Hospital

Introduction: Needlescopic surgery (NSS) and single port surgery (SPS) have been applied in various diseases from the viewpoint of cosmetic outcomes as well as minimal invasiveness, so we have applied these procedures to colorectal cancer (CRC) as reduced port surgery (RPS). We report our initial experience of RPS for CRC to elucidate the technical feasibility of these procedures. Introduction: The size of skin incision on the umbilicus was ranging 2.5 to 3.5 cm, and a single multi-channel port (SILSTM port), a single access platform (EZTM port) or three 5 mm trocars directly inserted through the single skin incision were used in SPS. A puncture or a port with 1.8–3.0 mm was used in NSS. Sixty patients with CRC (up to T2 N1 M0) were proposed and underwent RPS including 25 cases of right colectomy, 23 of sigmoidectomy and 12 of rectal resection instead of conventional laparoscope-assisted colorectal resection (LAC). Procedures were medial approach as well as conventional LAC, by parallel method with straight instruments or combined method with articulated instruments and energy devices such as ultrasonic coagulation shears or tissue sealing system. Endoscopic linear stapler or circular stapler also could be used for resection and reconstruction of bowels. Wound protectors such as Wound RetractorTM or Lap ProtectorTM were used in order to prevent port site recurrence during extraction of bowel specimen. Results: PRS in all patients were carried out successfully except for one case of conversion to conventional LAC due to serious intra-abdominal adhesion. Operating time was longer in RPS procedure for 30 to 40 min compared to conventional LAC, however postoperative hospital stay of patients with RPS was not longer than that of patients with conventional LAC. Most patients were satisfied to better cosmetic outcomes. Conclusion: RPS including NSS and SPS for selected colorectal cancer was feasible with better cosmetic results.

Introduction: The aim of current study is to compare the outcomes of laparoscopic intersphincteric resection (ISR) with laparoscopic abdominoperineal resection (APR) in patients with low rectal cancer. Methods and Procedures: From July 2004 to December 2009, patients with rectal cancer below 6 cm from anal verge treated by laparoscopic curative intersphincteric resection and abdominoperineal resection were included in a retrospective comparative study. Neoadjuvant chemoradiation was given to patients with T3–4 or N+ tumors. Recurrence and survival were evaluated by the Kaplan Meier methods and compared using the Log rank test. Results: Laparoscopic intersphincteric resection was performed in 124 patients with low rectal cancer, and 55 patients were performed laparoscopic abdominoperineal resection. The median follow up period was 31.2 months (range, 2–75). Demographic data of age (60.2 vs. 61.3 years, p = 0.58), body mass index (kg/m2, 23.6 vs. 22.7, p = 0.17), ASA score (p = 0.87), tumor stage (p = 0.11) were similar in laparoscopic ISR and APR group. Tumor location is lower (3.9 vs. 2.3 cm, p = 0.04), and tumor size were larger (2.7 vs. 3.3 cm, p = 0.02) in APR group. Preoperative chemoradiation were performed in 114 patients (91.9%) in laparoscopic ISR group and 19 patients (34.5%) in APR group (p = 0.00). Operation time was longer in ISR group (227.6 vs. 183.4 min, p = 0.01). Conversion to open surgery was found in 2 ISR and 1 APR (p = 0.37). Distal resection margin was 2.1 cm in ISR and 3.1 cm in APR (p = 0.02). Harvested lymph nodes were similar in both group (13.6 vs. 13.9, p = 0.94). Postoperative morbidity and hospital stay were similar in both groups. The survival rate of ISR was higher than APR in 3-year overall survival (90.1 vs. 75.9%, p = 0.021), and 3-year disease-free survival (72.5 vs. 56.7%, p = 0.062). The recurrence rate was lower in ISR group in overall recurrence (14.6 vs. 29.1%, p = 0.006), systemic recurrence (15.4 vs. 32.7%, p = 0.001), and local recurrence (4.9 vs. 12.7%, p = 0.030). Conclusions: Sphincter preservation in low rectal cancer can be facilitated by laparoscopic intersphincteric resection after preoperative chemoradiation.

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Surg Endosc (2012) 26:S249–S430

39351

P102

TRAINING LEVELS OF SURGEONS DO NOT IMPACT SHORT- AND LONG-TERM COLORECTAL CANCER OUTCOMES AFTER SUPERVISED LAPAROSCOPIC SURGERY Danilo Miskovic, MD, Najaf Siddiqi, Dilan Dabare, John Conti, PhD, Karen Fleshman, Jim Khan, MD, Amjad Parvaiz, MD Queen Alexandra Hospital, Portsmouth/UK Introduction: There is evidence that short-term outcomes do not differ between experienced and inexperienced laparoscopic colorectal surgeons as long as they are closely supervised during their training. The aim of this study was to investigate if the experience level of the surgeons influences the long-term survival of colorectal cancer patients. Methods: Prospectively collected data since the introduction of a laparoscopic colorectal service in 2006 was used for analysis. A majority of all resectable colorectal cancers were approached laparoscopically. Two laparoscopic surgeons trained 15 fellows (group A) and 13 senior colorectal surgeons (group B) and performed a number of cases as primary surgeons (group C). For short-term outcomes complications (minor and major), conversions, mortality, readmissions and reoperations were analyzed For long-term results overall survival and disease free survival were analyzed using Kaplan-Meier curves and Cox regression. Results: 537 cases were included in the analysis (A: 141, B: 162, C: 234). There was no difference for patient age, gender and ASA status and tumor stages were distributed equally among the groups. There was a higher proportion of rectal cancer for group C (A: 30.2, B: 29.8%, C: 50.4%, p \ 0.001). There was no intergroup difference for most short-term outcomes, but there was a slightly higher conversion rate in the expert group (see table). Median follow-up was 652 days. Overall, 3-year-survival was 81.9%; for both groups A and B it was 83.4% and for group C 79.9%. After adjustment for tumor stage and rectal cancer, there was no difference between the groups (Cox regression p = 0.620).

Outcome

Group A (%)

Group B (%)

Group C (%)

p value

Conversions

0.6

0

3.4

0.020

Complications (all)

29.6

34

35.4

0.469

Mortality

1.2

0

1.3

0.407

Readmission

16.5

11.9

18.8

0.373

Reoperations

1.25

3.7

4.5

0.226

Conclusion: Laparoscopic colorectal training is not only safe for short-term, but also for long-term oncological outcomes in a supervised and structured training environment. The slightly higher conversion rate in group C may represent a group of technically challenging cases.

39371

P104

GETTING MORE FOR YOUR MONEY: LAPAROSCOPIC RECTAL SURGERY PROVIDES SIMILAR SHORT TERM OUTCOMES AND SHORTER LENGTH OF STAY AT COMPARABLE COSTS TO OPEN SURGERY Krista Hardy, MSc MD, Josephine Kwong, BScH MPA, Kristen Pitzul, BScH MSc, Ashley Vergis, MD MMed, Timothy Jackson, MD MPH, David Urbach, MD MSc, Allan Okrainec, MD MHPE University of Manitoba, Winnipeg, Man., Department of General Surgery, University Health Network, University of Toronto, Toronto, Ont., Canada Introduction: The benefits of laparoscopic surgery in the management of colon cancer have been well established. Controversy remains in the application of this technique in rectal cancer. The objective of this study was to compare the early outcomes and total hospital cost of laparoscopic (lap) and open rectal surgery. Methods and Procedures: Patients undergoing elective lap or open rectal resection at the University Health Network, University of Toronto from April 2004 – March 2009 were included. Patient demographic, operative (OR) and outcome data was obtained from electronic hospital records. Cost data was determined from the hospital case costing system and median costs were compared using the Mann–Whitney U Test. Conversions to open surgery were analyzed on an intention-to-treat basis. Binary logistic regression analysis was used to compare differences in baseline patient characteristics. Pathology reports were reviewed for tumor status, nodal harvest and resection margins. The relationship between length of stay and cost was determined with analysis of covariance. Results: There were 68 (26%) lap and 191 (74%) open rectal resections. The rate of conversion to open surgery was 28.8%. There was no difference in preoperative body mass index, gender, American Society of Anesthesiology score or Charlson Index. Open patients were more likely to have a previous laparotomy (40.8 vs 17.6%, open vs lap, p = 0.001). Most patients had a final pathologic diagnosis of invasive cancer (85.1 vs 81.7, lap vs open, p = 0.525). Median operative time was slightly longer for lap surgery (291 vs 254 min, lap vs open, p = 0.005), while median length of stay was less for lap surgery (6 vs 8 days, lap vs open, p = 0.000). Rates of neoadjuvant therapy were similar for invasive cancers. There was no difference in T status, N status, number of nodes resected or margin status (Table). Complication rates were similar (21.2 vs 22.0%, lap vs open, p = 1.000). There were no differences in ICU admissions, reoperations, 30-day readmissions or emergency room visits. Lap surgery was associated with higher operative cost ($4 656.56 vs $4 292.79, lap vs open, p = 0.014) but lower ward cost ($4 050.96 vs $5 222.61, lap vs open, p = 0.003). Total hospital cost was similar for lap and open surgery ($11 661.79 vs $12 449.34, lap vs open, p = 0.097) Length of stay was a significant predictor of cost (p = 0.001).

Laparoscopic

Open

All

P value

16 (12–21)

14 (12–19)

15 (12–20)

0.314

Uninvolved

95.3 (41)

93.2 (136)

93.7 (177)

0.737

Involved

4.7 (2)

6.8 (10)

6.3 (12)

Median number of nodes resected (cm) (25Q-75Q) Radial Margin Status

Conclusion: The laparoscopic approach was associated with similar short term outcomes and shorter length of stay. Examination of costs revealed a similar total hospital cost for both procedures with higher operative and lower ward costs associated with laparoscopic approach. This study is consistent with previous literature supporting the short term benefits of laparoscopy and furthermore demonstrates comparable costs between procedures.

39368

P103

RATE OF UTILIZATION OF HAND-ASSISTED LAPAROSCOPIC Methods IS DIRECTLY PROPORTIONAL TO BMI Elizabeth A Myers, DO, Daniel L Feingold, MD, Tracey D Arnell, MD, Linda Njoh, MSc, Vesna Cekic, RN, Joon Ho Jang, MD, Daniel D Kirchoff, MD, Samer Naffouje, MD, Sonali Herath, BS, Jon Kluft, BS, Richard L Whelan, MD St. Luke’s Roosevelt Hospital Center, New York, NY, USA; College of Physicians and Surgeons, Columbia University, New York, NY, USA Introduction: Some MIS surgeons believe the use of hand-assisted (HA) laparoscopic methods will lead to decreased use of laparoscopic-assisted (LA) methods. Another opinion is that the incision length (IL) will always be shorter for LA vs. HA methods. The impact of BMI on the choice of MIS method and the overall IL has not been studied. This study assessed the utilization of HA and LA methods in regards to BMI by a group of 3 colorectal surgeons who primarily used MIS techniques. A second purpose was to determine the relationship between surgical method and IL in the setting of colorectal resection (CR). Methods: A retrospective analysis of 1122 patients who underwent CR during an 11 year period was performed. Patients were placed in 1 of 3 categories: LA, hand-assisted or hybrid laparoscopic (HHL), or open. Both laparoscopic and open methods are used in hybrid resections (incision length usually \ 11 cm). Because of the similarity in IL of Hand and Hybrid cases (difference B 1 cm) these cases were grouped together. Overall and BMI specific utilization rates and mean incision sizes were determined and the results compared. Results: Overall, the utilization rate for each surgical method was: LA, 60%; HHL, 25% (Hybrid 17 pts/Hand 263 pts), and open, 15%. The mean BMI of patients was significantly higher in the HHL vs. LAP group (P \ 0.0001). The utilization rate for HHL methods was directly proportional to BMI: BMI \ 18.5, 9.7%; BMI 18.5–24.9, 22%; BMI 25–29.9, 29%; BMI 30–34.9, 36%; BMI 35–39.9, 41%, and BMI C 40, 58%. Except for patients with BMI C35, HHL methods were rarely used for right/transverse CR’s. In contrast, HHL methods were used for 54% of sigmoid and rectosigmoid CR’s, and 40% of LAR’s and APR’s. IL was directly proportional to BMI for all surgical methods: the most dramatic difference was noted in the LA group (BMI \ 18.5, 4.57 cm vs. BMI C 40, 11.45 cm) whereas lesser differences were noted for the HHL (BMI \ 18.5, 8.33 cm vs. BMI C 40, 11.14). For patients with BMI C40, no difference in IL was noted between HHL vs. LAP methods (P = 0.85), whereas IL was significantly greater using HHL when the BMI was \ 40 (P \ 0.0001). The mean difference in IL between the HHL and LA methods was 4.3 cm when BMI \ 40. The mean LOS was 1 day longer for the HHL vs. LA group (p = 0.11). Conclusions: The use of both HHL and LA methods was associated with an overall MIS utilization rate of 85%. Most cases were done with LA methods. HHL methods were used primarily for sigmoid/LAR cases and the rate of use increased with rising BMI. For both methods, IL increased with BMI. At BMI C40 there was no difference in mean IL’s for HHL and LA cases. The mean IL difference between methods was 4 cm. LOS was 1 day longer for HHL. HHL and LA methods are not mutually exclusive. Together, they may increase the number of MIS cases done. HHL methods may facilitate MIS in high BMI patients.

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P105

SURGICAL OUTCOME AFTER LAPAROSCOPIC SURGERY IN PATIENTS WITH COLONIC ADENOMATOUS POLYPOSIS SYNDROMES Francisco Lopez-kostner, MD, Alejandro J Zarate, MD, Udo Kronberg, MD, Claudio Wainstein, MD, Katya Carrillo, MD Colorectal Unit, Clinica las Condes Introduction: Colonic adenomatous poliposis (CAP) syndromes include classical FAP and attenuated polyposis and are associated to a higher risk to develop colorectal cancer. Surgical treatment includes complete removal of the colon and sometimes the rectum followed by ileorectal anastomosis or ileoanal pouch anastomosis, respectively. Laparoscopic surgery is a standard procedure in partial colectomy; however few publications have analyzed its role in colonic adenomatous polyposis. Objective: To analyze surgical outcomes in patients with CAP who underwent laparoscopic total colectomy followed by IRA and restorative proctocolectomy. Patients and Methods: From the prospective laparoscopic colorectal surgery database (2002–2011) patients with diagnosis of CAP were included. Demographic clinical data was analyzed such as type of surgery, operating time, time to oral feeding, complications and length of hospital stay. Results: Thirty-eight patients were included, 17 of the female with an average age of 40.2 years. A total of 25 total colectomies with ileorectal anastomosis were performed (TC), 11 proctocolectomies with ileal-pouch anal anastomosis (IPAA) and 2 proctectomies with ileal-pouch (PT). Mean operating time was 249, 324 year 235 min for TC, IPAA and PT groups, respectively. Mean time to oral feeding was 2.5, 2.6 and 2 days for TC, IPAA and PT groups, respectively. Postoperative surgical complications occurred in 6, 2 y 1 for patients in TC, IPAA and PT groups, respectively. The mean length of hospital stay was 6.4, 6.9 and 15 days, for TC, IPAA and PT groups, respectively. In summary, surgery for FAP and attenuated FAP is feasible by laparoscopic approach, with early oral feeding and less than a week of total hospital stay.

Surg Endosc (2012) 26:S249–S430

S273

39389

P106

COST-EFFICIENCY OF SINGLE-PORT WHEN COMPARED TO CONVENTIONAL LAPAROSCOPIC COLECTOMY Barlas Sulu, MD, Hasan T Kirat, MD, Meagan Costedio, MD, Emre Gorgun, MD, Ravi P Kiran, MD Cleveland Clinic Foundation Background: The aim of this study is to investigate whether single-port laparoscopic colectomy is associated with increased costs when compared with conventional laparoscopic colectomy Methods: Patients undergoing single-port laparoscopic colectomy between 2007 and 2010 with available cost data (Group SPL) were matched to those with conventional laparoscopic colectomy (Group CL) for age (within 10 years), gender, American Society of Anesthesiologists class, body mass index (within 5 kg/m2), operation type and year (within 3 years). Direct costs for the two groups were compared using appropriate statistical tests. Results: There were 90 patients in SPL group and 90 patients in CL group. Age (48.7 ± 18.2 vs. 48.1 ± 18.1, p = 0.79), gender (male gender, n = 46, 51.1% vs. n = 45, 50%, p = 0.88), body mass index (kg/m2 25.8 ± 5 vs. 25.6 ± 5.2, p = 0.82), American Society of Anesthesiologists class (class II, n = 66, 73.3% vs. n = 66, 73.3%, p = 1) and diagnosis (benign, n = 71, 78.9% vs. n = 72, 80%, p = 0.85) were similar in groups SPL and CL. Type of surgery, estimated blood loss and length of hospital stay were also similar (Table). Operation time was significantly shorter for Group SPL (min, 136.1 ± 178.6 vs. 217.9 ± 91.2, p B 0.001), hence anesthesia cost was significantly lower for Group SPL (p = 0.003). Total direct costs (p = 0.5), operating room (p = 0.65), nursing, (p = 0.13), pharmacy (p = 0.6), radiology (p = 0.27), professional (p = 0.38) and pathology/laboratory (p = 0.46) costs were however similar between groups Conclusions: Single-port laparoscopic colectomy can be performed with comparative costs to conventional laparoscopic colectomy thus confirming the feasibility and safety of the technique. The additional finding that operating time can be reduced when the

Table Variable

Group SPL (n = 90)

Group CL (n = 90)

26 (28.9%)

26 (28.9%)

Type of operation Right hemicolectomy

P value

1

Total abdominal colectomy with EI

23 (25.6%)

23 (25.6%)

Sigmoid colectomy

12 (13.3%)

12 (13.3%)

Total proctocolectomy with IPAA

12 (13.3%)

12 (13.3%)

Ileocecal resection

10 (11.1%)

10 (11.1%)

Total abdominal colectomy with IRA

3 (3.3%)

3 (3.3%)

Low anterior resection

2 (2.2%)

2 (2.2%)

Left hemicolectomy

2 (2.2%)

2 (2.2%)

Estimated blood loss, ml

124.4 ± 108.4

157.2 ± 154.5

Operation time (min)

136.1 ± 178.6

217.9 ± 91.2

Length of hospital stay, days (mean)

6.5 ± 4.7

7.6 ± 6

0.17 \ 0.001 0.06

EI end ileostomy, IRA ileorectal anastomosis, IPAA ileal pouch-anal anastomosis single-port technique is adopted by surgeons already facile with the conventional laparoscopic technique, suggests that increasing experience may be associated with reduced costs when compared to conventional laparoscopic colectomy.

39404

P107

39417

P108

MINIMALLY INVASIVE COLORECTAL RESECTION FOR BENIGN PATHOLOGY IS ASSOCIATED WITH PROANGIOGENIC PLASMA COMPOSITIONAL CHANGES; POSTOPERATIVE PLASMA STIMULATES IN VITRO ENDOTHELIAL CELL GROWTH, INVASION, AND MIGRATION DURING WEEK 2 AND 3 AFTER SURGERY Hmc Shantha Kumara, PhD, Samer A Naffouje, MD, Elizabeth A Myers, DO, Sonali A Herath, BS, Joon Jang, MD, Linda Njoh, MS, Daniel Kirchoff, MD, Xiaohong Yan, MDPhD, Vesna Cekic, RN, Nadav Dujovny, MD, Richard L Whelan, MD (1)Division of Colon and Rectal Surgery, Department of Surgery, St Luke-Roosevelt Hospital Center, Suite 7B, 425 West, 59th Street, New York, NY 10019, (2)Ferguson Clinic, Spectrum Health Medical Group, 4100 Lake Drive 205, Grand Rapids, MI 49546, USA Introduction: Minimally invasive colorectal resection (MICR) in cancer patients is associated with persistently increased plasma levels of the following proangiogenic proteins: VEGF, Angiopoetin-2, Placental growth factor, and sVCAM. Prior studies have shown that plasma from the 2nd and 3rd weeks after MICR and open colorectal resection for cancer stimulates in vitro endothelial cell (EC) proliferation, migration, and invasion which are critical for new blood vessel formation. The purpose of this study is to investigate the impact of postoperative (PostOp) plasma from patients undergoing MICR for benign indications on EC proliferation (branch point formation [BP]), migration (MIG), and invasion (INV). The overall goal is to determine if the proangiogenic effects noted after MICR for cancer also occur in the benign disease setting. Method: Patients in an IRB approved data/plasma bank who underwent elective MICR for benign colorectal problems for whom adequate plasma samples were available were included. Blood samples were collected Preoperatively (PreOp) and at a variety of Postop time points. Plasma was isolated and stored at -80C. Only patients for whom a PreOp and at least one Postop sample between POD 7–33 were available were included. Late samples were bundled into 7–14 day blocks and considered as single time points. In-vitro human umbilical venous endothelial cell (HUVEC) cultures were used for BP, INV and MIG assays; the time points assessed were PreOp, POD7–13, POD14–20 and POD21–33 (n = 30 for each postop time point). Data were analyzed by paired t test and reposted as mean and ± SD for each parameter at each time point (significance p \ 0.05). Results: Plasma samples from 77 MICR patients were assessed (mean age: 58.8 ± 12.9 years; 37 male, 40 female). Indications for surgery were diverticulitis (n = 25), benign neoplasm (n = 50) and other (n = 2). The mean incision length was 4.8 ± 1.5 cm, mean operative time, 224.9 ± 89.9 min, and mean length of stay, 4.4 ± 1.5 days. Each Postop assay result was compared the PreOp outcome for each parameter. The mean BP results for the POD7-13 (46.6 ± 7.8) and POD14-20 (46.2 ± 5.5) time points were significantly greater than the PreOp results (36.6 ± 4.4 and 40.1 ± 4.9 respectively, p \ 0.001). Similarly, the INV results for the POD7-13 (59.0 ± 7.3) and POD14-20 (49.1 ± 6.1) time points were significantly greater than the PreOp results (43.9 ± 7.8 and 41.3 ± 4.4 respectively, p \ 0.001). Lastly, the MIG results for the POD7-13 (80.4 ± 23.6) and POD14-20 (60.1 ± 17.3) time points were significantly greater than the PreOp results (63.1 ± 22.5 and 50.7 ± 12.1, p \ 0.001). There were no differences noted for the POD21-33 vs PreOp comparisons. Conclusion: Postop plasma from the 2nd and 3rd but not the 4th/5th weeks after MICR for benign pathology significantly stimulates in-vitro EC proliferation, invasion and migration which are critical to angiogenesis. These results are similar to those noted with plasma from cancer patients who had MICR and Open resection. This study confirms that surgery induced proangiogenic plasma alterations are procedure related and not dependent on the surgical indication. Further studies are underway to determine which specific proteins are responsible for these effects in the benign population.

39430

P109

ENHANCED RECOVERY PATHWAYS DECREASE LENGTH OF STAY FOLLOWING COLORECTAL SURGERY BUT HOW QUICKLY DO PATIENTS ACTUALLY RECOVER? A Neville, MD, A S Liberman, MD, P Charlebois, MD, B Stein, MD, A Ncuti, BSc, M C Vassiliou, MD, G M Fried, MD, L S Feldman, MD McGill University Health Center

USE OF LAPAROSCOPIC COLORECTAL RESECTION FOR CANCER AND SHORT-TERM OUTCOME AMONG ELDERLY PATIENTS IN URBAN COMMUNITY HOSPITAL Karmina Choi, MD, Vadim Nakhamiyayev, MD, Justin Mann, Aamisha Gupta New York Methodist Hospital

Background: Enhanced recovery pathways (ERP) are associated with decreased complications and shorter hospital stay after colorectal surgery. While many studies evaluating recovery report length of stay as the primary outcome, duration of hospitalization does not necessarily reflect the patients’ process of recovery to their baseline level of function following the physiologic stress of surgery. The purpose of this study was to evaluate recovery following colorectal surgery within an ERP using a physical activity questionnaire (The Community Health Activities Model Program for Seniors [CHAMPS]). Methods: CHAMPS, a validated measure of postoperative recovery, is a questionnaire where patients report time spent doing physical activity over the course of a week. Responses are converted into caloric expenditure (kcal/kg/wk). A 3 kcal/kg/wk difference is equivalent to 1 h of moderate intensity activity. This questionnaire was administered preoperatively and 6 weeks post-operatively to patients undergoing elective colorectal surgery within the framework of a multimodal ERP between September 2009 and February 2011. Data are presented as mean (sd) or median [25th, 75th percentile]. Statistical significance was defined as p \ 0.05. Results: Fifty-four patients with complete follow-up data were analysed. Of these patients 54.0% were male and the mean age was 59.0 (17.9) years. The mean BMI was 26.2 (5.7) kg/m2 and 77.4% of patients underwent surgery for neoplastic disease. All patients received perioperative care within the framework of an ERP; 75.9% of procedures were performed laparoscopically. The median length of stay was 4[3,7] days. Physical activity decreased from a median of 30.7 [17.5, 60.8] kcal/kg/wk preoperatively to a median of 25.2 [16.9, 44.8] kcal/kg/wk at 6 weeks postoperatively (p = 0.03). Overall, only 53.7% of patients were back to or above baseline physical activities at 6 weeks. Length of stay was not significantly correlated with physical activity at 6 weeks (Spearman correlation coefficient = -0.23). However, more patients who left the hospital on or before postoperative day 4 were more likely to have recovered to baseline physical activity at 6 weeks than those who left after postoperative day 4 (67.7 vs 34.8%, p = 0.03). Conclusion: This study highlights the limitations of using length of stay as a primary outcome measure when evaluating recovery within an ERP. While length of stay was short, a significant proportion of patients were not fully recovered at 6 weeks postoperatively. In order to assess post-discharge outcomes, novel measures such as physical activity should be considered in the assessment of innovations aimed at improving recovery.

Introduction: Emerging data suggest that laparoscopic colorectal resection for cancerous and precancerous lesions has oncologic outcome comparable to the open approach, with the advantage of earlier postoperative recovery and lower complication rate. The aim of this study was to examine the pattern of its use among patients of advanced age in urban community hospital and the short-term perioperative outcome. Methods and Procedures: We performed a retrospective chart review of all patients who had undergone colorectal resection for cancerous and precancerous lesions between 1/1/2005 and 12/31/2010 in a single urban community hospital in New York. Patients were stratified into 3 groups: age \ 65, age 65–79 and age C80. Comparisons were made between laparoscopic and open cases among and across each age group. Variables thought to influence the choice of laparoscopic vs open technique were examined including ASA class, BMI, and preoperative diagnosis. Short-term outcome measures included length of stay (LOS), surgical site infection (SSI), cardiopulmonary complications, requirement for transfusion, sepsis or septic shock, and 30-day mortality, readmission, or reoperation. Results: 455 patients were identified among which 269 (59.1%) were female. 163 (35.8%) patients were age \ 65, 162 (35.6%) patients were age 65–79, and 130 (28.6%) patients were age 80 or above. Laparoscopic resection were performed less frequently in older age groups (58.3% in age \ 65, 32.7% in age 65–79, and 22.3% in age C80). Patients of advanced age were of higher ASA class (ASA III or IV) (28.8% in age \ 65, 50% in age 65–79 and 76.9% in age C80; p \ 0.0001) and were more likely to have advanced disease at time of surgery (26.6% with stage III/IV cancer in age \ 65 vs 40% in age C80; p \ 0.04). These were not significantly different between patients who underwent laparoscopic vs open surgery in each age category. Among patients age C80, those who underwent laparoscopic surgery had shorter LOS (10.4 vs 14.9 days; p \ 0.01) and lower 30-day combined readmission, reoperation and mortality rates (10.3 vs 26.7%; p \ 0.005) than those who had open surgery. Rate of complications between laparoscopic and open group were not significantly different. Most common postoperative complications were related to cardiopulmonary (24 and 28.7% in laparoscopic open groups respectively). Conclusion: Patients of more advanced age who underwent colorectal resection of cancerous and precancerous lesions were of higher ASA class and had more advanced disease. While these patient characteristics remain comparable between the laparoscopic and open surgical group, the short-term postoperative outcome was superior in those who underwent laparoscopic resection as evidenced by shorter LOS and lower readmission, reoperation and mortality within 30 days postop. Laparoscopic colorectal resection for cancer should be considered more often in elderly patients.

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PLASMA LEVELS OF MONOCYTE CHEMOTACTIC PROTEIN-1 (MCP-1), A PROANGIOGENIC PROTEIN, ARE PERSISTENTLY ELEVATED DURING THE FIRST MONTH AFTER MINIMALLY INVASIVE COLORECTAL CANCER RESECTION Hmc Shantha Kumara, PhD, Samer A Naffouje, MD, Sonali A Herath, BS, Elizabeth A Myers, DO, Joon Jang, MD, Linda Njoh, MS, Xiaohong Yan, MDPhD, Daniel Kirchoff, MD, Vesna Cekic, RN, Martin Luchtefeld, MD, Richard L Whelan, MD (1)Division of Colon and Rectal Surgery, Department of Surgery, St Luke-Roosevelt Hospital Center, Suite 7B, 425 West, 59th Street, New York, NY 10019, USA; (2)Spectrum Health, 25, Michigan Ave SE, Suite 4300, MC 038, Grand Rapids, MI 49503, USA Introduction: Minimally invasive colorectal resection (MICR) of cancer is associated with persistently elevated plasma levels of VEGF, Angiopoetin 2, sVCAM, and other proangiogenic proteins. Further, plasma from the 2nd and 3rd weeks after MICR has been shown to promote endothelial cell (EC) proliferation, migration and invasion in-vitro which are necessary for neovascularization. This persistent proangiogenic blood composition may stimulate the growth of residual cancer. Monocyte Chemotactic Protein-1 (MCP-1) is a direct mediator of angiogenesis and induces in-vitro EC migration and budding. MCP-1 is produced by EC’s, fibroblasts, and monocytes; MCP-1 expression has also been documented in bladder, prostate and breast malignancies as well as hepatic colorectal metastases. The MCP-1 receptor CCR2 is expressed on the surface of EC’s and is upregulated by inflammatory cytokines; during wound repair it is responsible for endothelial regeneration and vascular remodeling. The impact of colorectal cancer (CRC) resection on blood levels of MCP-1 is unknown. The goal of this study is to evaluate plasma MCP-1 levels during the first month after MICR for CRC. Method: CRC patients who underwent MICR were eligible. Plasma was obtained from an IRB approved perioperative plasma and data bank. The clinical, demographic and pathologic data was prospectively gathered. Blood samples were obtained PreOp and at varying postop time points and were stored at -80C. Because the timing of late specimens varied and since fewer late specimens were taken, plasma samples for 7–14 day blocks were bundled and considered as single time points. MCP-1 levels were determined in duplicate via ELISA and results reported as mean ± SD. The paired t test was used for analysis (significance p \ 0.01 after Bonferroni’s correction) Results: Preop and, at least, 1 late postoperative plasma sample were available for 102 MICR cancer patients (colonic, 71%; rectal 39%; 59 male /43 female, mean age 67.1 ± 12.3 years). The mean incision length was 7.1 ± 2.8 cm, mean operative time 266.5 ± 113 min, and mean length of stay was 5.9 ± 2.3 days. The final cancer staging breakdown was; Stage I, 30%, Stage II, 30%, stage III, 37% and stage IV, 2%. The mean PreOp MCP-1 level was 286.2 ± 108.3 pg/ml (n = 102). When compared to PreOp levels significantly elevated (p \ 0.001) mean MCP-1 plasma levels (pg/ml) were detected on POD1 (496.6 ± 244.3; n = 102), POD 3 (394.0 ± 224.7, n = 100), POD7-13 (356.6 ± 132.2, n = 61), POD14-20 (366.1 ± 99.7,n = 27), and POD 21-27 (332.9 ± 78.1,n = 28, p = .003). Conclusion: Plasma MCP-1 levels are significantly elevated over baseline for at least 1 month after MICR. The etiology of this change is unclear. Transient surgery-related increases in inflammatory cytokines may account for MCP-1 elevations during the first week after MICR. Likewise, the persistent late elevations during weeks 2 and 3 may be related to systemic changes associated with wound healing. Elevated MCP-1 levels after MICR and may stimulate the growth of residual tumor or facilitate metastasis formation. Further studies are warranted.

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PREDICTIVE FACTORS OF POSTOPERATIVE ILEUS AFTER LAPAROSCOPIC COLORECTAL SURGERY E Grzona, MD, F Carballo, MD, M Bun, A Canelas, MD, L Pereyra, MD, N Rotholtz, MD Hospital Alema´n de Buenos Aires Background: Postoperative ileus (PI) is defined as an interruption of bowel function after surgery. It is the most important determinant of length of stay (LOS) after abdominal surgery, and thus has significant implications in hospital resource utilization. The pathogenesis is multifactorial. Predictive factors are not fully known. Although laparoscopic surgery reduces the recovery time of bowel transit it has also recorded PI rates. Objective: To evaluate the incidence and analyze predictive factors of PI after laparoscopic colorectal surgery. Methods: A retrospective study was performed using a prospective collected database of all patients who underwent a laparoscopic colorectal procedure between March 2000 and June 2011. PI was defined as a delay of the postoperative recovery time and bowel transit without a secondary etiology. The patients were divided in two groups: normal recovery (G1) and patients with PI (G2). As potential predictive factors for PI, demographic characteristics, surgeryrelated variables and disease-related variables were considered. Univariate analysis was performed to identify individual predictive risk factors for PI. Factors with p values below 0.05 were included in a regression model. The results were expressed as odds ratio (OR) and their 95% confidence intervals (CI). Results: A total of 869 patients were evaluated. 23 patients were excluded for secondary ileus. Median age was 58.7 (15–92) years. 55.1% were men. The indications for surgery were: colorectal cancer 31.5%, diverticular disease 28.1%, polyps 19.6%, inflammatory bowel disease 13%, others 7.8%. The procedures performed were: 399 (40%) left colectomies, 169 (20%) right colectomies, 120 (14.2%) proctectomies, 33 (3.9%) subtotal colectomies, 32 (3.7%) proctocolectomies, 25 (2.95%) total colectomies, 18 (2.1%) segmentary colectomies, 16 (1.89%), Hartmann’s reversal, 15 (1.8%) ileocecal resections, 10 (1.2%) abdominoperineal resections and 3 (0.35%) Hartmann’s procedures. 6% from all patients presented PI. There were no differences in demographics data between the groups (G1: 795; and G2: 51). Recovery parameters of bowel function were significantly shorter in G1 [Bowel sounds: 0.85 vs. 1.4 days (p \ 0.05), flatus 1.57 vs. 2.8 days (p \ 0.05), liquids intake 1.1 vs. 5.9 days, (p \ 0.05) solid intake 2.1 vs. 7.2 (p \ 0.05) days] and LOS [3.9 (2–8) vs. 9.43 (3–20) days (p \ 0.05)]. Surgical time [ 180 min [G1: 308/795 (38.7%) vs. G2: 28/51 (54.9%) OR 1.85 (CI: 1.05–3.25, p \ 0.05)], Conversion [G1: 73/795 (9.1%) vs. G2: 14/51 (27.45%) OR: 10.95 (CI 5.24–16.66, p \ 0.01)], left colectomy [G1: 386/795 (48.5%) vs. G2: 13/51 (25.5%) OR (5.24) (CI: (-1.87)–(-8.61), p \ 0.01)] and total colectomy [G1: 20/795 (2.51%) vs. G2: 5/51 (9.8%), OR: 14.4 (CI: 3.33–25 .47, p \ 0.05)] showed association with PI in univariate analysis. In multivariate analysis, significant predictors of PI were total colectomy [OR: 13.5 (CI: 2.18–10.47)] and the conversion [OR: 3.84 (CI: 1.84–8.04)]; whereas left colectomy are a protector variable of PI [OR: 0.37 (CI: 18–75)]. Conclusion: Conversion to open surgery and total colectomy were independent predictive factors of PI, while left colectomy appears as an independent protective factor.

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SINGLE INCISION LAPAROSCOPIC COLORECTAL SURGERY FOR INFLAMMATORY DISEASE Dan Geisler, MD Associate Staff West Penn Allegheny Health System Compared to open surgery, the benefits afforded to a patient from a minimally invasive approach for colorectal surgical resections are very well documented. With heightened interest in even less invasive surgery, single incision laparoscopic colorectal surgery is quickly gaining acceptance. While the access technique was first described in 2007 for colorectal resective procedures, large series and indications for its application are lacking. Between January 2009 and December 2010, all patients undergoing single incision colorectal procedures by a single surgeon were prospectively entered into an IRB-approved database and studied with regards to perioperative and postoperative events, morbidity and mortality. 58 consecutive patients (Age 19–83) underwent single incision laparoscopic colorectal procedures for inflammatory disease. There was one conversion (1.7%) to an open operation due to unclear anatomy from intra-abdominal adhesions. 29 patients (50%) had previous abdominal surgery and the average BMI was 25.4 (15–36). Ten patients (17%) required placement of additional ports (1: N = 7; 2: N = 1; 3: N = 2). Primary diagnosis included ulcerative colitis (N = 40), Crohn’s disease (N = 9), and diverticulitis (N = 9). The average operating room time was 110 min (13–222) and mean length of incision was 2.98 cm (1.2–7.8). Estimated blood loss was 121 mL (0–700). Procedures performed included total abdominal colectomy (16), total proctocolectomy with J-pouch (11), small bowel resection (9), completion proctectomy with J-pouch (7) and loop ileostomy (1). There was no mortality. Overall morbidity was 38%. Average length of stay was 5.6 days (2–18). No patients required reoperation. With proper patient selection and laparoscopic experience, single incision laparoscopic surgery can be performed safely for even the most complex and inflammatory of colorectal disorders.

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LAPAROSCOPIC APPENDECTOMIES: DOES TECHNIQUE MATTER? T J Hufford, BA, Ronald Markart, PhD, Jonathan M Saxe, MD Wright State University Cost for health care has become an increasing concern for health care providers and hospitals. Even seemingly routine procedures can impact the cost of care in a appreciable manner. In our large community hospital we noticed two consistent ways of performing laparoscopic appendectomy. The first methods utilized the endostapler and endocatch bag to remove the appendix, and the second method employed the harmonic scalpel and an endoloop. The purpose of this retrospective study was to evaluate the differences in both outcome and cost in the two techniques. Methods: A retrospective chart review for a period of 6 months from January 2011 to July 2011 identified 114 eligible patients (n = 81 for endostapler; n = 33 for endoloop). Data collected included clinical data: age, race, sex, comorbid factors, BMI, pathology, and post operative complications as well as non-fixed financial data: charges for OR time, disposables. Statistical analysis was performed utilizing the Students T-test with Bonferonni correction and the Chi-Square analysis where appropriate. IRB approval was obtained prior to data collection. Results: The two methods did not differ on abscess (endoloop = 12%, endostapler = 9%, p = .73), return for complications (12 vs. 17%, p = .49), and length of stay following surgery (41 vs. 51 h, p = .37). The endoloop method was less costly for both total operative charges ($16,126 vs. $11,699) and operating room charges ($10,798 vs. $14,172). The endoloop method also required less total operative time (43 vs. 60 min) and less operating room time (71 vs. 93 min) [all comparisons p \ .001]. The mean savings per patient were $4,427 and $3,374 for total operative and operating room charges, respectively. The lower cost for the endoloop method was due to less total operative and operating room time, 17 and 22 min, respectively. Conclusion: endoloop and endostapler methods do not differ in clinical outcomes, but the endoloop is notably less costly.

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ABDOMINAL WALL NECROTIZING FACIITIS-A RARE COMPLICATION OF PERFORATED APPENDICITIS-CASE REPORT Sharique Nazir, MD, Timothy S Kuwada, MD FACS FASMBS Division Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte

THE USE OF MINIMALLY INVASIVE SURGERY AS A TREATMENT FOR COLOCUTANEOUS FISTULA CASE REPORT Ahmed Hammad, MR, Hitham Qandeel, FRCS, Hitham Abudeep, MR, Arijit Mukherjee, FRCS, Ali Amin, Mr, C Murch, Dr General Surgery Department Hairmyres Hospital, Glasgow

Introduction: Acute appendicitis is relatively common and can present with a myriad of abdominal and systemic symptoms. If diagnosed early, surgery is an effective treatment and most patients have a rapid recovery. However, once appendicitis progresses to perforation of the appendix, treatment and recovery becomes more complex. Complications of perforated appendicitis include phlegmon, abscess, and bowel obstruction. However necrotizing fasciitis is an extremely rare complication of advanced perforation. Case Report: We present a case of abdominal wall necrotizing fasciitis secondary to a perforated appendix. A 72 year old African American, immunocompetent female presented to our emergency department with a 4 day history of dull, diffuse right sided abdominal pain associated with nausea and diarrhea. She denied any fevers. Her medical history was significant for chronic atrial fibrillation for which she took Coumadin. She had a remote abdominal procedure after a motor vehicle accident (right lower quadrant scar). She had undergone a normal, uncomplicated colonoscopy the week prior at an outside hospital. On exam she was afebrile with a heart rate of 110 and a systolic pressure in the 90’s. She was alert, in no distress and did not appear ‘‘toxic’’. She was focally tender in the right lower quadrant and flank with no subcutaneous crepitus. WBC was 9,000. CT scan revealed air throughout the right retroperitoneum extending through the lateral side wall into the subcutaneous tissue. The patient was taken to the OR for a diagnostic laparoscopy with a presumptive diagnosis of a perforated viscus vs. appendicitis. Intraoperative findings were notable for a gangrenous, retrocecal appendix. The retroperitoneum had copious amounts of purulent fluid with obvious erosion into the right side wall. There was no intra-peritoneal contamination. There was extensive peri-cecal inflammation that precluded a simple appendectomy. A laparoscopic hand assisted ileocecoctomy with end ileostomy was performed in less than an hour. The ileostomy was positioned in the left abdomen. Incision of the right flank revealed necrotic deep fascia. The patient was then placed in the lateral decubitus position and an extensive right abdominal wall and flank myofascial debridement (100 9 80 cm) was undertaken. The patient was hemodynamically unstable for 48 h, requiring three pressors. Wound exploration 48 h after surgery revealed viable tissue with no evidence of progression of the necrotizing process. She rapidly improved and was extubated 1 week after surgery. Wound cultures grew out Streptococcus constellatus and two different strains of E. coli. She was treated with Piperacillin-Tazobactam and Ciprofloxacin. Her large wound is currently being managed with a VAC with plans for a skin graft in the near future. Discussion: Necrotizing fasciitis is a serious soft tissue infection that is lethal if it is not treated early with aggressive debridement and hemodynamic support. Although rare, intra-abdominal infections such as appendicitis can progress to abdominal wall necrotizing facilities. Immunosuppressed and elderly patients with appendicitis are particularly susceptible to complicated appendicitis due to their often atypical presentation which can delay diagnosis and treatment.

Aim: We report a case of successful management of a benign colocutaneous fistula following an anastamotic stricture treated by repeated endoscopic dilatation, placement of self-expandable metal stents (SEMS) and percutaneous ethanol injection (PEI). Case presentation: 54 year white lady developed a colocutaneous fistula at the anastamotic stricture site following reversal of Hartmann’s procedure for diverticular disease. Given the fact that the patient was not keen on surgery and having another stoma, in addition to her morbid obesity, a decision was made to manage her conservatively in the form of repeated flexible sigmoidoscopy and balloon dilation. The patient improved symptomatically but the fistula was persistent. A decision was made to place SEMS endoscopically and at the same time ethanol was injected percutaneously through the fistulous tract with continuous rectal saline irrigation. The procedure was done without complications. A month later, the fistula healed which was confirmed on contrast study. One year follow up did not show any clinical symptoms or signs of recurrence. Conclusion: To our knowledge, this is the first case demonstrating SEMS combined with PEI as a curative and potentially permanent alternative for benign postoperative fistulae. This approach is very attractive for patients unfit for surgery, although a longer follow up and further studies will be needed

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OPEN VERSUS LAPAROSCOPIC COLECTOMY FOR PATIENTS WITH ENDOSCOPICALLY UNRESECTABLE POLYPS. THE EFFECT OF CONVERSION Nawar A Alkhamesi, MD PhD FRCSGenSurg FRCS FRCSEd, Micheal V Lebenbaum, MSc, Sisira Sarma, PhD, Janet Martin, PhD, Christpher M Schlachta, BSc MD CM FRCSC FACS Department of Surgery and Department of Epidemiology & Biostatistics, Schulich School of Medicine, University of Western Ontario Objective: Cost analysis of elective laparoscopic versus open colon resection in patients with endoscopically unresectable polyps was performed to evaluate relative costs of both surgeries. A decision tree incorporating parameters from this patient sample was created to examine the possible effects of including disability related costs and to determine which variables the costs were most sensitive to. Method: Retrospective review of elective laparoscopic and open segmental colectomies between January 2005 and April 2010 for patients with unresectable polyps was performed. Combined cases and procedures carried out on inpatients were excluded to minimize cost variables. The hospital case costing system was used to calculate capital and hospital stay cost. The cost of disposable equipment was calculated manually. Examination of the possible effects of including disability related costs was done by applying partial and full recovery times derived from the literature in a decision tree. Estimation of costs was conducted by applying full-time wage rate for time until partial recovery and part-time wage rate to the remaining time until full recovery. Result: Total sample size was 79 (34 laparoscopic, 45 open colectomy). Median operating room time was longer for laparoscopic than open (169 vs. 133 min; p = 0.004). Mean disposable costs were greater for laparoscopic than for open ($1777.56 vs. $1028.37). Overall direct surgical costs were greater for laparoscopic than open surgery ($5407.63 vs. $3741.45; p \ 0.0001 for median). Complication risk was similar (35.3% vs. 33.3%; p = 0.8). In total, 23.5% of laparoscopic surgeries were converted to open. Median hospital stay during index admission was shorter after laparoscopy versus open (5 vs. 6 days; p = 0.02); however, due to readmissions for complications, the mean cost of hospital stay throughout the study period was higher for laparoscopic vs. open ($5412.71 vs. $4615.00). Mean total hospital cost including supplies, index admission cost, and readmission cost was greater for laparoscopy than for open ($11703.66 vs. $8597.85), although median costs were not significantly different (p = 0.23). Conclusions regarding total costs remained robust after post-hoc sub analysis for right versus left colectomy. After inclusion of disability costs, laparoscopic surgery remained more costly than open surgery ($14801 vs. $12737). There was one far outlier in the laparoscopy group, and its exclusion reduced the estimate of total cost to $13912. With this exclusion, one way sensitivity analyses suggested that costs were only sensitive to conversions. A 10% decrease in conversions would reduce the probability of readmission, and would bring costs of laparoscopy in line with open surgery or cheaper. Conclusion: This analysis shows that costs were higher in the laparoscopic group and are sensitive to conversions. Due to the small sample size, outliers had strong effects on the results. In addition, the non-randomized nature of the study makes it difficult to draw definitive conclusions from the sample. RCTs with larger sample sizes may clarify this decision in this particular patient population.

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SINGLE INCISION LAPAROSCOPIC COLORECTAL RESECTIONS Elie K Chouillard, MD PhD, Andrew Gumbs, MD FACS On behalf of the Intercontinental Society of Natural Orifice, Endoscopic, and Laparoscopic Surgery (i-NOELS), Poissy, France Aim: Natural Orifice Translumenal Endoscopic Surgery (NOTES) is an emerging concept in surgical ideology. Many variants have been described including « pure » NOTES, « Hybrid » NOTES, or even endoscopic surgery. Single Incision Laparoscopic Surgery (SILS) has been inspired by the potential advantages of NOTES including less abdominal wall complications, less postoperative pain, faster return to activity, and better cosmesis. This study analyzed the results of our preliminary experience with these new techniques in colorectal surgery. Methods: All patients were prospectively included after a written informed consent. The Ethical Board of the Hospital approved the study. A single 25 to 35-mm diameter, umbilical (or right lower quadrant) incision was used. Three 5-mm ports (or two 5-mm and one 12-mm) were inserted through a special platform device. Patients: From January 2009 to December 2010, SILS or NOTES (either hybrid or pure) was attempted in 39 patients. Exclusion criteria comprised mainly prior open abdominal surgery, ASA III status, organ insufficiency, and hemostasis disorders. Results: The success rate without conversion to laparotomy or additional port sites was 89.7% (35 patients). Additional procedures included cholecystectomy (5), oophorectomy (4), intraperitoneal chemohyperthermia (2), duodenal resection (1), hysterectomy (1), and atypical liver resection (1). Mortality rate was nil. The overall morbidity rate (mainly minor complications) was 12.8% (7 complications in 5 patients). One leak occurred after a sigmoidectomy. Conclusions: SILS and NOTES procedures are safe and feasible in selected patients with colorectal disease, either benign or malignant. Advantages regarding postoperative pain and length of hospital stay could be demonstrated. However, larger scale, studies are needed for further evidence-based analysis, especially regarding oncological outcome.

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FEASIBILITY OF LAPAROSCOPIC REOPERATION FOR EARLY COMPLICATIONS AFTER LAPAROSCOPIC COLORECTAL RESECTIONS Rodrigo A Pinto, MD, Fa´bio G Campos, PhD, Se´rgio A Arau´jo, MD, Jaime P Kruger, MD, Guilherme N Namur, MD, Se´rgio C Nahas, PhD Ivan Cecconello University of Sa˚o Paulo School of Medicine Background: Recently, growing experience with the performance of minimally invasive procedures for the management of colorectal disorders allowed to extend the indication of laparoscopy for the handling of various early and late postoperative complications. However, experience with this type of approach during reoperations is still restricted. Objective: To present the experience of our colorectal group with laparoscopic reoperations for early complications after laparoscopic colorectal resections. Methods: A retrospective study of prospectively collected database of patients undergoing laparoscopic colorectal resections that presented postoperative surgical complications that were approached laparoscopically. The patients selected for laparoscopic approach were those with early diagnosis of complications, hemodynamic stability without significant abdominal distention and without clinical comorbidities that would preclude the procedure. Results: In the last two years, 9 of 240 (3.75%) patients who underwent laparoscopic colorectal resections were reapproached laparoscopically. There were 5 female patients. The mean age was 40.67 years. Diagnoses of primary disease included adenocarcinoma (3), familial adenomatous polyposis (3), ulcerative colitis (1), colonic inertia (1) and Chaga´ssic Megacolon (1). Initial procedures included 4 total proctocolectomy with ileal pouch anal anastomosis, 3 anterior resections, a completion of total colectomy and a right hemicolectomy. Anastomotic dehiscence was the most common complication that resulted in reoperations (6). An accidental lesion of the ileum, an omental bleeding vessel and a small bowel obstruction were other reasons for reoperation. In two cases, assisting incision had were utilized, one for cleaning the cavity, rectal stump closure and exteriorization of an end colostomy, and another for suture of injured ileum. The other cases were completely laparoscopic, including suture anastomotic dehiscences, and cleaning the cavity with drainage. There was only one case of an unfavorable outcome, with death on the 40th day of the first approach, after consecutive complications and reoperations by 4 other open procedures. The remaining cases had favorable outcome with an average hospital discharge of 14.6 days after the first operation and 9.9 days after reoperation. Conclusion: In selected cases, laparoscopic access may be a safe and minimally invasive approach for complications of colorectal resection. However, laparoscopic reoperation must be cautiously selected, considering the type of complication, patient’s clinical condition and experience of the surgical team.

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SINGLE INCISION LAPAROSCOPIC RECTAL RESECTION FOR CANCER: A PRELIMINARY STUDY Elie K Chouillard, MD PhD, Nelson Trelles, MD, Andrew Gumbs, MD FACS On behalf of the Intercontinental Society of Natural Orifice, Endoscopic, and Laparoscopic Surgery (i-NOELS), Poissy, France Aim: Natural Orifice Translumenal Endoscopic Surgery (NOTES) is an emerging concept in surgical ideology. Many variants have been described including « pure » NOTES, « Hybrid » NOTES, or even endoscopic surgery. Single Incision Laparoscopic Surgery (SILS) has been inspired by the potential advantages of NOTES including less abdominal wall complications, less postoperative pain, faster return to activity, and better cosmesis. This study analyzed the results of our preliminary experience with these new techniques in patients with rectal cancer. Methods: All patients were prospectively included after a written informed consent. The Ethical Board of the Hospital approved the study. All patients with resectable rectal or low sigmoid cancer could be theoretically included. A single 25 to 35-mm diameter, umbilical incision was used. Three 5-mm ports were inserted through a special platform device. Patients: From January 2009 to April 2011, SILS or NOTES (either hybrid or pure) was attempted in 31 patients. Preoperative radiochemotherapy was performed in 17 patients (54.8%). Exclusion criteria comprised mainly prior open abdominal surgery, ASA III status, organ insufficiency, and hemostasis disorders. Results: The success rate without conversion to laparotomy or additional port sites was 90.3% (28 patients). Additional procedures included oophorectomy (4), hysterectomy (2), intraperitoneal chemohyperthermia (2), bladder resection (1), appendectomy (1), and atypical liver resection (1). 21 patients had rectal resection with sphincter preservation (coloanal anastomosis) and 10 patients had abdominoperineal resection. Mortality rate was nil. The overall morbidity rate (mainly minor complications) was 19.6% (8 complications in 6 patients). Two patients (9.5%) had leaks (including one diagnosed only radiologically 6 weeks later) and no reoperation occurred. One year survival rate is 96.8% Conclusions: SILS and NOTES procedures are safe and feasible in selected patients with rectal cancer. Advantages regarding postoperative pain and length of hospital stay could be demonstrated. However, larger scale studies are needed for further evidence-based analysis, especially regarding oncological outcome.

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COMBINED ABDOMINAL AND TRANSANAL NOTESINSPIRED APPROACH TO THE TOTAL MESORECTUM EXCISION (TME): A PRELIMINARY STUDY Elie K Chouillard, MD PhD, Vincenzo J Greco, MD, Andrew Gumbs, MD FACS On behalf of the Intercontinental Society of Natural Orifice, Endoscopic, and Laparoscopic Surgery (i-NOELS), Poissy, France Aim: Natural Orifice Translumenal Endoscopic Surgery (NOTES) is an emerging concept in surgical ideology. Many variants have been described including « pure » NOTES, « Hybrid » NOTES, or even endoscopic surgery. Single Incision Laparoscopic Surgery (SILS) has been inspired by the potential advantages of NOTES including less abdominal wall complications, less postoperative pain, faster return to activity, and better cosmesis. This study analyzed the results of our combined, abdominal and transanal approach to total mesorectum excision (TME) in patients with low rectal cancer. Methods: All patients were prospectively included after a written informed consent. The Ethical Board of the Hospital approved the study. Patients with resectable mid or low rectal cancer were considered candidates for a single incision approach to surgery. A single 25-mm diameter, umbilical incision was used. Three 5-mm ports were inserted through a special platform device. The lower part of the mesorectum was dissected through a transanal approach using a second type of platform device with laparoscopic instruments inserted through the anus (video). Patients: From December 2009 to June 2011, this technique was attempted in 13 patients. Exclusion criteria comprised mainly prior open abdominal surgery, ASA III status, organ insufficiency, and hemostasis disorders. Results: The success rate without conversion to laparotomy or additional port sites was 92.3% (12 patients). Nine patients had rectal resection with sphincter preservation (coloanal anastomosis) and 4 patients had abdominoperineal resection. Mortality rate was nil. The overall morbidity rate (mainly minor complications) was 15.4%. Pathological analysis of the specimen showed the margins were negative in all patients. Mean number of harvested lymph nodes was 17 (10–41). Conclusions: SILS and NOTES procedures are safe and feasible in selected patients with rectal cancer. Advantages regarding postoperative pain and length of hospital stay could be demonstrated. However, larger scale studies are needed for further evidence-based analysis, especially regarding oncological outcome.

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INFLUENCE OF ANASTOMOTIC LEAKAGE IN THE LONGTERM Results OF LAPAROSCOPIC TREATMENT OF CURATIVE RECTAL CANCER Cedric Adelsdorfer, MD, Salvadora Delgado, MD, Waldemar Adelsdorfer, MD, Rau´l Almenara, MD, David Saavedra, MD, Mihai Pavel, MD, Nils Hidalgo, MD, Antonio M Lacy, MD PhD Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases (ICMDM), Hospital Clı´nic of Barcelona Objective: Assess the impact of AL in local and distance recurrence, and overall and cancer-specific survival, in patients undergoing laparoscopic anterior resection (AR) for rectal cancer. Methods: Prospective study of patients undergoing laparoscopic rectal AR, in the period from 1998 to September 2010. Differences in long-term oncological results were obtained by multivariate analysis (Cox regression). Results: 390 patients included. AL in 11.5% (45/390). No differences were found between AL patients and those who did not, in local recurrence: 4.4 vs 3.8%, p = 0.607; metastasis: 15.5 vs 15.1%, p = 0.652, overall recurrence: 17.8 vs 17.6%, p = 0.845. Overall 5 years survival in both groups was 65%. Cancer specific survival in the AL was 85% and 82% in the without dehiscence group, (p = 0.516). In multivariate analysis the AL did not prove a risk factor for recurrence and worse survival. Have proven to be risk factors for local recurrence: compromise of the circumferential margin (p \ 0.001, HR 5.3 CI 95% 2.6–11.1) and pT3–4 (p = 0.002, HR 2.7 CI 95% 1:4–5). Influenced a worse survival, pTNM III-IV (p = 0.005; HR 2.2 95% CI 1.2–3.8). Conclusions: Anastomotic leakage has not proven to be a risk factor for worse long-term oncological outcome in laparoscopic surgery series presented. A higher local recurrence would be associated with the compromise of circumferential margin and pT3–4. pTNM stage III-IV is associated with poor 5 years survival.

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THE CURRENT STATUS OF LAPAROSCOPIC VERSUS OPEN COLECTOMY: INCIDENCE AND SHORT TERM OUTCOMES IN A COHORT OF 59,000 PATIENTS Rodrigo Pedraza, MD, Javier Nieto, MD, Victor Malave, MD, Eric M Haas, MD FACS FASCRS Division of Elective Minimally Invasive Colon and Rectal Surgery, Department of Surgery, The University of Texas Medical School at Houston Introduction: Despite research outcomes, there remain doubts regarding the short-term benefits of laparoscopic colectomy (LC) over open colectomy (OC). As such, many surgeons remain hesitant to take the necessary commitment and resources to introduce this highly technical procedure into their routine practice. In part, the lack of uniform acceptance of the benefits of LC has retarded its widespread utilization and implementation. The purpose of this retrospective study was to identify the current utilization of laparoscopic colectomy and to evaluate short-term comparative outcomes in a large cohort of patient presenting for elective and emergent colectomy. Methods: The authors queried the de-identified Premier PerspectiveTM database for the data acquisition. This database provided information of discharge files from 348 health care facilities including urban or rural and teaching or non-teaching hospitals. Data analysis criteria included patients 18 years of age and older who underwent OC or LC between September 2008 and August 2010. The ICD-9 procedure codes were utilized to obtain the information of patients who had OC (codes: 17.31-17.39 and 45.81–45.83) or LC (codes: 45.71–45.79 and 45.82). Analyzed data included age, gender, diagnosis (benign or malignant disease), severity of illness utilizing the 3MTM APRTM-DRG analysis, type of admission (emergency, urgent, elective or trauma), type of procedure and operative time. Outcomes following colectomy including length of stay, total hospital costs, and readmission rates within 30 days following discharge were evaluated. Results: There were a total of 59,912 patients that underwent colonic resection from September 2008 to August 2010 with a mean age of 63.9 ± 15.8 years in OC group and 61.6 ± 14.9 years in the LC group. An open approach was utilized in 68.1% of the colectomies and a laparoscopic approach was utilized in 31.9%. Surgery was indicated for malignant cases in 22.2% of OC patients and in 26.3% of LC group. In the OC group the severity of illness was 17.3% minor, 32.0% moderate, 28.3% major, and 22.4% extreme severity. In patients who underwent LC the severity evaluation resulted in 43.7% minor, 37.8% moderate, 14.1% major, and 4.3% extreme. In the OC group, just under half of the procedures were classified as elective (45.3%), whereas in the LC group, the majority were elective admissions (79.2%). The mean operative time was similar between the two groups (3.3 ± 1.9 vs. 3.4 ± 1.6 h); nonetheless, the LOS was nearly twice as long in the OC group (11.2 ± 10.7 days) compared to the LC cases (6.3 ± 5.8 days). There was also a higher readmission rate in the OC group (15.5%) versus the LC group (9.1%). The total hospital costs was approximately $10,000 more in the OC group ($26,324.9 ± 29,788.1) versus the LC ($16,171.8 ± 16,548.6). Conclusions: In spite of its safety, feasibility, and published benefits, we present current data indicating that LC remains underutilized in the United States, accounting for only one third of colon resections. The majority of LC procedures are performed for elective procedures involving patients of lower illness severity and results in shorter LOS, lower readmission rate and lower total hospital costs.

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COLONOSCOPIC PERFORATION MANAGEMENT IN THE ERA OF LAPAROENDOSCOPY; A SIMPLE ALGORITHM Tafadzwa P Makarawo, MD, Edward Itawi, MD, Amir Damadi, MD, Gurteshwar Rana, MD, Vijay K Mittal, MD Providence Hospital Medical Centers Introduction: The role of laparoscopy in the management of iatrogenic colonoscopic injuries has increased as more reports of successful treatments have emerged. Iatrogenic colonoscopic perforations have a varied presentation. Perforations are defined by colonic location, length and degree of tear, time to presentation, and mechanism of injury. Laparoscopic surgeons have differing levels of skill and institutional resources when faced with this complication. Drawing from the experiences of previously documented literature and that of our own institution, we have formulated a simple algorithm that guides laparoscopic surgeons with varied means in treating colonoscopic perforations. Methods and Procedures: A retrospective review of four patients admitted to our institution following iatrogenic colonic perforation over the course of 2 years was undertaken. For each patient, the initial clinical assessment, resuscitation, surgical management and post-operative recovery was carefully studied and recorded. A medline search was performed of previous literature on the subject incorporating primarily the search words ‘‘colonoscopy’’, ‘‘perforation’’ and ‘‘laparoscopy’’. Twenty articles involving 95 patients were identified and reviewed focusing on patient clinical presentation, laparoscopic interventions and outcomes. From this and our own experiences, we formulated our algorithm. Results: Between May of 2009 and May 2011, four patients with colonoscopic perforations underwent laparoscopic surgical repair by two attendings. Their presentations and outcomes are summarized below. There were no postoperative complications. Patient

Age

Sex

Perforation location

Operation

Hospital stay

A

59

F

Rectum

Laparoscopic assisted low anterior resection & loop ileostomy

4

B

51

M

Descending colon

Laparoscopic linear stapler repair

7

C

51

F

Descending colon

Laparoscopic intracorporeal suturing

2

D

80

F

Cecum

Laparoscopic intracorporeal suturing

4

*All patients underwent laparoendoscopy prior to their definitive procedure

ALGORITHM:

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SINGLE INCISION LAPAROSCOPIC COLORECTAL SURGERY FOR NEOPLASIA Dan Geisler, MD Associate Staff West Penn Allegheny Health System Compared to open surgery, the benefits afforded to a patient from a minimally invasive approach for colorectal surgical resections are very well documented. The oncologic outcomes of a minimally invasive approach for the treatment of colorectal cancer have been shown to be at least equivalent to that of an open operation. With heightened interest in even less invasive surgery, single incision laparoscopic colorectal surgery is quickly gaining acceptance. While this access technique was first described in 2007 for colorectal resective procedures, large series and indications for its application are lacking. Between January 2009 and December 2010, all patients undergoing single incision colorectal surgery by a single surgeon were prospectively entered into an IRB-approved database and studied with regards to perioperative and postoperative events, morbidity and mortality. 27 consecutive patients (Age 13-93) underwent single incision laparoscopic colorectal procedures for neoplasia. There were no conversions to an open operation. 7 patients (26%) had previous abdominal surgery and the average BMI was 26.1 (15-38). Five patients (19%) required placement of additional ports (1: N = 4; 3: N = 1). Primary diagnoses included colon cancer (9), adenoma (8), ulcerative colitis with dysplasia (7), familial adenomatous polyposis (1), rectal cancer (1) and submucosal mass (1). The average operating room time was 100 min (46–245) and mean length of incision was 3.7 cm (1.2–7.4). Estimated blood loss was 135 mL (10–400). One patient required a peri-operative blood transfusion. Procedures performed included right colectomy (15), total colectomy (5), total proctocolectomy with j-pouch (5), and left colectomy/anterior resection (2). There was no mortality. Overall morbidity was 55%: wound infection (6), ileus (4), atelectasis (4) and urinary retention 1. There were no anastomotic leaks. The mean length of stay was 6 days (3–24). No patients required reoperation. In patients with known cancers, an average of 33 lymph nodes (Range = 13–132) were examined. There were no involved margins. With proper patient selection and laparoscopic experience, single incision laparoscopic surgery can be performed safely and effectively for neoplasia of the colon and rectum.

* Secondary to previous medical or surgical comorbidities Conclusion: Traditionally laparotomy has been the standard of care for treating colonoscopic perforations when conservative management is deemed inappropriate. Our initial experience reinforces previous views that laparoendoscopic surgery is a safe and effective alternative to managing this complication. We have formulated a simple algorithm that we have found helpful to the surgeon considering a laparoscopic approach to managing this condition.

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CLINICAL Results OF LESS INVASIVE LAPAROSCOPIC ISR BY USING NEEDLE DEVICES AND SURGICAL CLIPS Masaaki Ito, MD PhD, Yusuke Nishizawa, MD PhD, Akihiro Kobayashi, MD PhD, Masanori Sugito, MD PhD, Norio Saito, MD PhD National Cancer Center Hospital East

EARLY LAPAROSCOPIC SINGLE-STAGE RESECTION FOR THE TREATMENT OF ACUTE DIVERTICULITIS Seema Izfar, MD, Teresa H. Debeche-adams, MD, Sam Atallah, MD, Matthew R Albert, MD, James Clancy, ARNP, Karla Miller, Omar Felix, MBBS, Sergio W Larach, MD Florida Hospital

Objective: The aim of this study was to create surgical techniques by using needle forceps and surgical clips in laparoscopic intersphincteric resection (New Lap ISR) and to clarify the short-term results of the less invasive laparoscopic procedure for very low rectal cancer near the anus. Methods: We performed New Lap ISR for 12 patients with very low rectal cancer of stage 1. Instead of 5 mm surgical forceps generally used in conventional Lap ISR, we used needle forceps of 2 or 3 mm in length. To reinforce the traction by the needle devices, new clips were developed for special use of New Lap ISR. The clips were inserted through a 10 mm camera-port sited in the umbilicus and attached by nylon sutures which were pulled out through the abdominal wall. We could grasped tissues by them and control the traction of the surgical clips by pulling the sutures through the external wall of the abdomen. We assessed perioperative clinical results of the surgical procedures. Results: Two needle devices and 3 clips were generally used in New Lap ISR. We have not experienced conversion to open and complication during surgery in all patients. Median operative time was 344 min and blood loss was 160 ml in this series which showed the statistically better than one in conventional Lap ISR (p \ 0.05). We had one postoperative reoperation due to the anastomotic leakage. The rates of anastomotic leakage were found in 8%. R0 operation was achieved in all patients. Total length of the wound was 21 mm on an average. Fecal incontinence score was 9 points, and the anal function in New Lap ISR was comparable to one in conventional Lap ISR. Of 12 patients, diverting stoma was not created in 9 patients who showed only scars on surgical sites of the abdomen. Conclusion: The short-term results of New Lap ISR were clinically acceptable and comparable to conventional Lap ISR. The new technique by using needles and clips enabled us to accomplish a less invasive laparoscopic ISR and will be considered as one of the new options in reduced port surgery.

Introduction: Recent literature regarding the treatment of acute diverticulitis has supported non-operative management or delayed operative management in the setting of acute disease. This can result in longer hospital stays and indolent symptomatic disease that can be both morbid and costly to the patient. The purpose of this study is to determine the incidence of operative complications and peri-operative morbidity related to laparoscopic single-stage resection in treatment of acute sigmoid diverticulitis with or without local perforation (Hinchey classification I/II). Methods: Retrospective chart review was performed from March 2009 to July 2011 of all patients undergoing laparoscopic single-stage resection for acute sigmoid diverticulitis. Patients with either CT-proven diverticulitis or clinical symptoms consistent with recurrent diverticulitis who underwent operative intervention within two weeks of presentation were selected for chart review. Patients without physician documentation or imaging consistent with acute diverticulitis and patients with findings consistent with peritonitis (Hinchey classification III/IV) were excluded. All patients underwent laparoscopic resection, with or without hand-assistance. Intra-operative complications, operative times, post-operative morbidity, and length of stay were documented. Additionally, pathology reports were examined for confirmation of acute diverticulitis and evidence of local perforation or abscess formation. Results: Sixty-two patients (35 male, 27 female) were identified to have undergone laparoscopic operative intervention for treatment of acute diverticulitis. Of these 62 patients, all were confirmed to have evidence of acute diverticulitis on formal pathology and 24 were found to have evidence of perforation or pericolonic abscess formation (38%). There were no intra-operative complications reported and no intra-operative blood transfusions. One patient was converted to open (1.6%). Average operative time was 121 min (64–232 min). There were two contained anastomotic leaks reported (3.2%), one of which was treated with a Hartmann’s resection, and the other treated with a revision of end-toend anastomosis. Post-operative morbidity overall was 16% (10 patients). Morbidities included acute renal insufficiency (3.2%), post-operative hemorrhage requiring blood transfusion (3.2%) post-operative ileus requiring readmission (1.6%), Clostridium dificile colitis (1.6%), pulmonary embolism (1.6%), and respiratory failure requiring reintubation (1.6%). Average post-operative length of stay was 4.37 days (2–22 days). Conclusion: Laparoscopic single-stage resection in the setting of acute sigmoid diverticulitis is a safe modality of treatment for recurrent and refractory diverticulitis in well-selected patients. In our study, we have shown results comparable to elective resection after delayed management with antibiotics. Though operative intervention in the setting of acute diverticulitis may still result in postoperative morbidity and longer operative times, in well-selected patients, there should be no higher incidence of operative morbidity or stoma formation even in the presence of local perforation and abscess. Judicious patient selection for early operative intervention in the hands of experienced laparoscopic surgeons may benefit patients with complicated or refractory diverticulitis.

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ACUTE SOLITARY TRANSVERSE COLON DIVERTICULITIS IN A 27 YEAR OLD FEMALE Negar M Salehomoum, MD, Georg N Herlitz, MD JD, Mark R Schwartz, MD FACS Robert Wood Johnson Medical School; Jersey Shore University Medical Center Introduction: We report an unusual case of solitary transverse colon diverticulitis in a young woman, presenting as right-sided abdominal pain. Methods and Procedures: A 27 year old female presented to our emergency department complaining of right-sided abdominal pain of two days duration. She complained of anorexia, but denied fevers, chills, nausea, diarrhea or constipation. Her physical examination was significant for right-sided abdominal tenderness to palpation with voluntary guarding but without evidence of peritonitis. Laboratory studies revealed a leukocytosis of 12,100/uL, a normal hepatic function panel, and a negative pregnancy test. A computed tomography scan was performed to evaluate for possible appendicitis. Although the appendix was well-visualized and normal there was a thickened blind-ending tubular structure in the right lower quadrant. The radiologic diagnosis was presumed Meckel’s diverticulitis, but we noted that the inflamed mass appeared to be arising from the colon and did not appear to be connected to the umbilicus by any discernible structure. The patient was admitted and placed on intravenous antibiotics and bowel rest. Diagnostic laparoscopy on hospital day number three demonstrated no mass connected to the umbilicus, thereby ruling out a Meckel’s diverticulum. Upon conversion to midline laparotomy we identified a small mass in the proximal transverse colon which arose from either the mesentery or the bowel wall. We performed a segmental resection of this segment with a stapled side-to-side functional end-to-end anastomosis. Frozen section was negative for evidence of malignancy. The patient recovered uneventfully and was discharged home on post-operative day five. The final pathologic evaluation revealed acute inflammation of a solitary and proximal transverse colon diverticulum. Conclusions: Acute diverticulitis should remain on the differential for right-sided abdominal pain. Diverticulitis occurs most commonly in the left colon with solitary diverticula occurring occasionally in the right colon, and rarely in the transverse colon. Solitary right-sided colonic diverticula are usually congenital, in contrast to the more common acquired left-sided diverticula. Consideration of this possible diagnosis in our patient might have prevented unnecessary operation by allowing treatment with intravenous antibiotics only. However, this entity is so rare that its natural course is poorly understood; consequently, segmental colon resection is an appropriate treatment and may likely be the least morbid approach to prevent future complications in a young patient such as ours.

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COMPARISON OF Results AND COMPLICATIONS OF STAPLED HEMORRHOIDOPEXY PERFORMED WITH THE ETHICON AND COVIDIEN STAPLERS Rebekah Kim, MD, Andrea Ferrara, Mark Soliman, Robert Stevens, Samuel Dejesus, Paul Williamson, Joseph Gallagher, Jay Macgregor Kiyanda Baldwin Colon and Rectal Clinic of Orlando, Orlando Health Purpose: Two staplers (Ethicon Proximate Hemorrhoidal Circular Stapler and Covidien EEA Hemorrhoid & Prolapse Stapler Set) are currently available for stapled hemorrhoidectomy in the United States. Our aim was to compare the results of both devices by experienced Colon and Rectal Surgeons. Methods: Retrospective analysis of the initial forty consecutive patients that underwent Ethicon hemorroidopexy in 2003 were compared to our initial experience using the Covidien device in 2010. In addition, forty patients who underwent hemorrhoidopexy with the Ethicon device in 2010 were studied due to the learning curve when the procedure was first introduced. All operations were performed by 5 board certified Colon and Rectal Surgeons. Complications were characterized into early (\2 weeks), and late ([2 weeks) after the initial surgery. Data regarding readmission, hemorrhoid grade, patient age and sex, as well as ancillary procedures at the time of stapled hemorrhoidopexy were compared. Results : One hundred and twenty charts were reviewed (74 male [63%], 46 female [37%], mean age 48.7 [21–82]). Eleven (9%) had Grade II, 108 patients (90%) had Grade III, and 1 (0.8%) had Grade IV internal hemorrhoids. Early complications (\2 weeks) and ancillary procedures are listed (Table). Two weeks after surgery, 1 patient (2.5%) in each of the groups complained of anal pain. In the early Ethicon group 1 patient (2.5%) complained of fecal incontinence, and 4 (10%) presented with fissure-in-ano. In the late Ethicon group, 1 patient (2.5%) presented with a fissure-in-ano, and 2 (5%) presented with a thrombosed external hemorrhoid requiring excision. The early Covidien group had 1 patient (2.5%) with complaints of constipation, and 1 (2.5%) with a thrombosed external hemorrhoid requiring excision. The late Ethicon and Early Covidien groups both had ancillary procedures such as excision of anal skin tags in addition to the stapled hemorrhoidopexy at time of surgery.

Table Early Ethicon (n = 40)

Late Ethicon (n = 40)

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SINGLE INCISION COLECTOMY: THE REALITY OF ADOPTION INTO PRACTICE Deborah Nagle, MD, Vitaliy Poylin, MD, Steven Tizio, MD Beth Israel Deaconess Medical Center Introduction: Single incision or reduced port surgery is a newer development in colon and rectal surgery but is technically demanding. Our aim is to evaluate the uptake of single incision colectomy in a colon and rectal surgery practice focused on minimally invasive surgery. Methods: Retrospective review of a prospectively collected, IRB approved database. Data from 60 consecutive, planned single incision colorectal surgical cases from September 2008 to September 2011 are reported. Results: Sixty (N = 60) patients underwent SIL colorectal surgery by two surgeons at our institution. Cases included: small bowel resection (N = 4), appendectomy/partial cecectomy (N = 9), ileocectomy and right colectomy (N = 27), sigmoid or left colectomy (n = 7), transverse colectomy (N = 2), total abdominal colectomy (N = 4), takedown of Hartman’s pouch (N = 1), sigmoid colostomy (N = 1) and a J-pouch (N = 5). There were 40 female patients and 20 male patients. Mean age was 57.2 years (21–86 years). Mean BMI was 25.2 (range 18–41.8), but the average selected patient BMI per year dropped slightly from 25.7 to 25.4 to 24.1. Of the planned SILC cases, (85%) were successfully completed by single port technique. Six (10%) cases were completed by reduced port technique and three (5%) were converted to open laparotomy. The converted cases all had previous abdominal surgery. The mean operative time for all SIL colorectal cases was 140 min (range 39–313 min), clearly varying with case complexity. Case times were comparable to our multiport cases. Case times did not decrease significantly after the learning curve was achieved. Residents of Postgraduate Year 5 and 6 participated in most all cases but essentially only the PGY6 physicians were able to operate rather than assist. The median length of stay for all SIL colorectal cases was 3.98 days (range 0–29). However, 22% (13/60) of patients were discharged on the first postoperative day, and 50% of patients were discharged within 2 days of surgery. There were 3 significant complications (5%), including one death after hospital discharge (1.6%). Conclusions: Single incision colorectal surgery is feasible, with acceptable complication rates and operative times. However, barriers to uptake include: technical complexity, decreased resident case participation, obese patients and previous abdominal surgery. Shorter hospital length of stay may compensate for some of these factors. Over time, our practice pattern migrated to use single incision laparoscopic colectomy for right sided cases, patients with BMI under 30 and younger females. With evolving selection parameters, our reduced port case volume actually decreased, rather than increased, on a yearly basis. Further study and trials will help to identify the optimal patients for this technique.

Early Covidien (n = 40)

Early (\2 weeks) Stapler misfire

0

0

0

Bleeding

1 (2.5%)

1 (2.5%)

0

Urinary retention

3 (7.5%)

0

2 (5%)

Excessive pain

5 (12.5%)

1 (2.5%)

3 (7.5%)

Thrombosed ext hemorrhoids

2 (5%)

0

2 (5%)

Abscess/fistula

0

1 (2.5%)

0

Fissure-in-ano Total Ancillary procedures (AP) Excision of skin tag

1 (2.5%)

0

0

12 (30%)

3 (15%)

5 (20%)

0

12 (30%)

15 (37.5%)

-

8 (20%)

7 (17.5%)

External hemorrhoidectomy

-

3 (7.5%)

5 (12.5%)

Fissure cauterization

-

0

1 (2.5%)

Excision of papilla Number of patients with ancillary procedures

-

1 (2.5%)

2 (5%)

N/A

0

5 (12.5%)

Conclusions: In our initial experience with both the Ethicon and Covidien devices, the rates of early and late complications are similar. The rates of complications in the early and late Ethicon groups show a slightly decreased rate of urinary retention and pain requiring readmission among patients, however neither were statistically significant. The increasing excision of skin tags and external hemorrhoids during stapled hemorrhoidopexy may decrease the rate of recurrence.

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LONG-TERM OUTCOME FOLLOWING SURGERY FOR COLORECTAL CANCERS IN OCTOGENARIANS: A SINGLE INSTITUTION’S EXPERIENCE OF 204 PATIENTS Ker-kan Tan, FRCS Edin, Frederick H Koh, MBBS, Yan-yuan Tan, MBBS, Jody Z Liu, MRCS Edin, Richard Sim, FRCS Tan Tock Seng Hospital Background: The incidence of colorectal cancer in elderly patients is likely to increase with an aging population. The aims of this study are to review our experience in the surgical management of octogenarians with colorectal cancers and to identify factors that influence the short- and long-term outcomes. Methods: A retrospective review of all octogenarians who underwent surgery for colorectal cancer from December 2002 to October 2008 was performed. Results: We identified 204 patients with a median age 84 (range, 80–97) years. The majority of patients had an ASA score C3 (n = 142, 69.6%) and a Charlson Comorbidity Index of B3 (n = 128, 62.7%). Emergency surgery was performed in 83 (40.7%) patients. Left sided malignancy was seen in 138 patients (67.6%). Most of the patients had either stage II (n = 75, 36.8%) or III (n = 69, 33.8%) diseases. The 30-day mortality rate was 16.2% (n = 33). Factors associated with mortality included emergency surgery and renal impairment. After multivariate analysis, the independent variables predicting worse peri-operative complications were age [ 85 years old and Charlson Comorbidity Index [ 3. The median follow up for the 171 remaining patients was 27 (2–92) months. Thirty-one (21.2%) of 146 patients who survived curative surgery developed recurrent disease. Seventy (34.3%) patients died from various aetiologies (60% cancer specific and 40% non-cancer mortality). Disease free and overall survivals were both adversely affected in patients with advanced malignancy and in those with severe peri-operative complications. Conclusions: Surgery for octogenarians with colorectal cancers is associated with significant morbidity and mortality rates. Some of the factors predicting worse peri-operative outcomes included emergency surgery, increasing age and Charlson Comorbidity Index [ 3. Long term survival is dependent on the stage of the malignancy and the presence of severe peri-operative complications.

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OBESITY INCREASES RISK OF COMPLICATIONS OF DIVERTICULAR DISEASE IN A VA PATIENT POPULATION Michelle K Savu, MD, G. Abourjaily, MD, A Logue, MD, J Mayoral, MD, Ej Ledesma, MD, W.b. Perry, MD, Kareem Eid, MD South Texas VA HCS/University of Texas Health Science Center, San Antonio, TX Objective: Obesity has been implicated in some research studies to affect the severity of the presentation of diverticular disease. Our objective was to study the relationship between obesity and diverticular disease presentation and treatment in a VA patient population. Methods: We performed a retrospective study using a computerized patient medical record database (CPRS) in the VA system based on CPT codes for diverticular disease and obesity for patients with the diagnosis between 2009–2010. Obesity was defined as a BMI C 30 kg/m2. Results: Fifty five patients were admitted with the diagnosis of diverticulitis or diverticular disease during this timeframe. The average age of all patients was 67 (range 40–91) and the average BMI was 28.9 ± 6 kg/m2. Forty four percent (24/55) of patients diagnosed with diverticular disease were obese. 10 patients had complications requiring surgical intervention (3 perforations, 4 colovesicle fistulas and 3 elective surgeries for recurrent diverticulitis). Of the patients requiring surgery 7 were obese. A significantly higher percentage of obese patients with diverticular disease [7/24 (29%)] versus nonobese patients with diverticular disease [3/31 (9.7%)] had complications requiring surgery (p \ 0.05). The average age and BMI of obese patients requiring surgery were significantly higher than the nonobese patients requiring surgery 61 ± 3 years and 34.3 kg/m2 vs 73 ± 4 years and 24.5 kg/m2 respectively (p \ 0.05) Conclusions: Our data support that obese patients with diverticular disease have a significantly increased risk of developing complications requiring surgical intervention than nonobese patients with diverticular disease. In addition, these complications are more likely to occur at an earlier age. These data would support consideration of earlier elective surgical intervention for obese patients with presenting symptoms of diverticular disease.

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SINGLE PORT LAPAROSCOPIC TOTAL COLECTOMY WITH END ILEOSTOMY IN THE ACUTE SETTING Mohamed Moftah, Dr, Ronan A Cahill, Dr Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland Introduction: Proponents of single port laparoscopy tend to claim improved cosmesis in elective operations as its major rationale. However minimizing abdominal wounding is especially important in debilitated patients who need acute operative intervention for acute severe pancolitis recalcitrant to medical therapy. In addition to malnutrition, systemic toxemia and iatrogenic immunosuppression, their early convalescence must include stoma education while further surgery (whether ileoanal pouch formation/proctectomy for those with ulcerative colitis or ileorectal reanastomosis/ other reoperation for those with Crohn’s disease) is often needed in the intermediate term. Methods: Having previously developed and standardized the procedure in the semi-elective setting, we have now the departmental expertise and confidence to provide the approach on-call. In short, the operation involves placement of the single port access device at the site intended for end ileostomy formation as the sole transabdominal access. For this, we favor the Surgical Glove Port as the most ergonomically and economically advantageous device currently available. This access device is constructed table-side by inserting standard trocar sleeves into the finger tips of a sterile surgical glove. The glove cuff is then stretched over the outer ring of a standard wound protector-retractor (ALEXIS, Applied Medical) in situ at the ileostomy site trephine. Standard straight rigid laparoscopic instruments and a 30 lens camera are used. The operation is commenced distally with early rectosigmoid transection and then proceeds distal to proximal in a close pericolic plane using an energy sealer/divider device (Liagsure, Covidien). A transanal catheter is left in situ for 72 h postoperatively. As it needs no specialized equipment and only two members of the expert surgical team regardless of which theatre suite is available, out-of-hours service is facilitated. Results: This approach has been considered in every patient requiring acute colectomy for pancolitis since January 2011. Of ten such patients, three had standard multiport laparoscopy (due to morbid obesity, colitic perforation with peritonitis and unstable critical systemic illness). Six patients (two females, one with Crohn’s pancolitis and five with ulcerative colitis) had their entire procedure completed by the single port approach. One other patient with ulcerative colitis needed three additional 5 mm ports in addition to the stoma site single port inserted to facilitate adhesiolysis of dense adhesions (prior midline laparotomy with right nephrectomy for trauma). The mean (range) age of the patients was 43 (36–59) years while mean (range) BMI was 27 (21–28) kg/m2. All were on significant immunosuppressant/ biological therapies. None had antegrade mechanical bowel preparation preoperatively. Mean (range) length of theatre time from patient entry to exit was 190 (165–210) min. There were no significant intraoperative complications and only two minor (Clavien Class One) postoperative problems. Modal (range) postoperative day of discharge was 4 (3–6). As only trocar sleeves are used with the glove port construct, laparoscopic access costs were reduced by 60%. Conclusions: Single port laparoscopic total colectomy is not only feasible and effective but appears useful and beneficial for patients. In-theatre costs are not increased (in fact can be reduced versus conventional laparoscopy) and postoperative hospital stays are short.

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SINGLE PORT ACCESS LAPAROSCOPY VIA THE GLOVE PORT FOR PLANNED AND URGENT COLORECTAL SURGERY Mohamed Moftah, Dr, Ronan A Cahill, Dr Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland

EFFECTS OF EARLY ENTERAL NUTRITION ON POSTOPERATIVE COMPLICATIONS AFTER GASTROINTESTINAL ANASTOMOSIS Ali Uzunkoy, Prof Dr Harran University School of Medicine Department of General Surgery

Introduction: Single access laparoscopic surgery is a recent compliment to the field of minimally invasive colorectal surgery. While selected series have indicated feasibility, we have prospectively examined its usefulness across the full spectrum of elective and urgent colorectal procedures over the past twelve months including its use in a consecutive ‘‘all comers’ series of segmental proximal colonic resection. Procedural familiarity and expertise has been enabled and greatly advanced by our employment of the most ergonomically and economically favorable access device, the ‘‘Surgical Glove Port’’. Methods: All patients undergoing laparoscopic colorectal resection over the study period were considered for a single access approach by a single surgical team in a university hospital. The ‘Glove’ port is constructed by snapping the cuff of a standard sterile surgical glove onto the outer ring of a conventional wound protector/retractor (ALEXIS, Applied Medical) placed via a 3-5 cm transumbilical or stomal site incision. Standard trocars and normal rigid laparoscopic instrumentation are used to complete the procedure. Results: Of 90 planned laparoscopic colorectal procedures over the last 12 months, 40 (44%) were performed by this single incision laparoscopic modality without disruption of theatre list efficiency or surgical training obligations. These included 31 consecutive pure colonic resections comprising 15 right hemicolectomies (14 for neoplasia, 1 for volvulus), 8 total colectomies (including 7 urgent operations for either ulcerative colitis or Crohn’s disease), 6 ileocecal resections (five for Crohn’s disease) and 2 transverse colectomies. The remaining nine cases were diagnostic mesenteric or peritoneal biopsies (n = 2), ileal resections (n = 2), laparoscopic-assisted polypectomy (n = 2), construction of defunctioning stoma (n = 2, one loop ileostomy, one loop colostomy) and one anterior resection. In addition, four other patients undergoing emergency surgery had their operation commenced and partially completed via a single port approach before conversion to a limited midline laparotomy encompassing extension of the same incision. The mean (range) age and BMI of the single access patient group was 58 (22–82) years and 23.9 (18.6–36.2) kg/m2 respectively. One extra port was required in two cases. There were no unexpected conversions to open surgery. Four patients did need extension of the incision site beyond 3 cm however to facilitate specimen extraction due to either a bulky tumor or adhesions along the distal transverse colon due to previous laparotomy. The modal postoperative day of discharge was 4. For right sided resections, the mean (range) post-op stay in those undergoing surgery for benign disease (n = 7, mean age 32 years) was 4, while for those undergoing operation for neoplasia (n = 14, mean age 71 years) it was 5.8 days. The average lymph node harvest for oncological resections was 13. Use of the glove port reduced trocar cost by 58% (€60) by allowing use of trocar sleeves alone without obturators. Conclusion: Single incision laparoscopic surgery is an effective option for abdominal surgery and seems especially suited for laparoscopic-assisted right-sided colonic resections. The Glove port technique facilitates procedural frequency and familiarity. Its use together with avoidance of specialised instrumentation prevents cost inflation undermining this access modality.

Background: The patient’s nutritional status is one of the most important factors for postoperative complications. Morbidity and mortality is increased in the cases with poor nutritional status. Recently, there are some reports about the benefits of early enteral nutrition. However, there is some debate about early enteral nutrition for the patients with gastrointestinal anastomosis. In this study, it was aimed that the effects of early enteral nutrition on postoperative surgical complications in the patients with gastrointestinal anastomosis. Patients and methods: Forty-eight cases that underwent colonic anastomosis were prospectively randomized into two groups. In the group one (the group of early enteral nutrition), oral feeding was started at the 24th hours after operation. In the second group, oral feeding was started after bowel movement or passage of flatus. Nutritional status, appropriate dietary regimen, tolerance of enteral nutrition, abdominal pain, nausea, vomiting, postoperative ileus, postoperative complications, and hospitalization time and satisfactory of patients were evaluated. Results: Three cases could not tolerate early postoperative feeding. However there was no difference about the tolerance of early enteral nutrition, abdominal pain, nausea, vomiting and postoperative ileus between the groups (p [ 0.05). In the early enteral nutrition group, bowel movement returned early (p \ 0.05). Surgical site infection was significantly lower in the early enteral nutrition group (p \ 0.05). Hospitalization time was shorter in the early enteral nutrition group (p \ 0.05). Conclusion: Postoperative early enteral nutrition in the patients with gastrointestinal anastomosis is well tolerated after elective surgery. Also, it has some advantages in certain situations such as preventing surgical site infections, returning early bowel function and shorter hospitalization time.

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PREVENTION OF STOMA SITE HERNIA AFTER LAPAROSCOPIC REVERSAL OF HARTMANN’S PROCEDURE FOR PERFORATED DIVERTICULITIS Morris E Franklin, Jr, MD FACS, Song Liang, MD PHD The Texas Endosurgery Institute Background and Objectives: The rate of hernia at stoma site has been reported as 32% following colostomy reversal. This prospective study focused on the patients who underwent laparoscopic colostomy closure after laparoscopic Hartmann’s for severe diverticulitis, and was specifically aimed at investigating if mesh placement could be accepted as a safe and effective strategy of tissue reinforcement for prevent the stoma site from developing a hernia. Methods: A prospective database involving three surgeons in our institute was mined to identify a consecutive series of patients from April 1991 to May 2011, who underwent laparoscopic colostomy closure after the laparoscopic Hartmann’s for emergently managing severe diverticulitis at the Texas Endosurgery Institute. All the perioperative information was processed by SSPS. Results: Among 41 patients with laparoscopic Hartmann’s for the perforated diverticulitis, 33 had the procedure of laparoscopic colostomy reversal with the rate of 80.5%. Of these 33 stomas, 29 were reinforced with Paritex Composite mesh. The operating time (OR) was 124.8 ± 66.6 min including laparoscopical colostomy takedown, intraoperative colonoscopy, as well as reestablishment of intestinal continuity. Blood loss during the operation was 86.3 ± 72.9 ml. Postoperatively none of the patients developed any major or minor complications, and length of hospital stay is 5.1 ± 3.3 days. Lastly in the oneyear follow-up, one patients was diagnosed as anastomotic stenosis while no one was found to develop either hernia or wound infection at the stoma site. Conclusions: Laparoscopic colostomy reversal can be safely performed in the restoration of colonic continuity with low postoperative morbidity and short hospital stay. Moreover, application of mesh such as Paritex Composite to the stoma site has been effectively prevent from the developing the stoma hernia and did not cause gross wound infection at the stoma site.

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VARIABILITY OF THE IMPACT OF RISK FACTORS ON CARDIAC OUTCOMES BETWEEN OPEN AND LAPAROSCOPIC COLECTOMY—Results FROM A NSQIP DATABASE STUDY Shankar R Raman, MD MRCS, Ilan Rubinfeld, MD FACS, Craig A Reickert, MD FACS FASCRS Henry Ford Hospital, Detroit, MI Introduction: Laparoscopic colectomy is known to be associated with decreased overall complications when compared to open colectomy. The role of cardiac risk factors for complications as defined by the American Heart Association (AHA), in the setting of colectomy is not clear. We sought to examine and compare the risk factors for cardiac complications after laparoscopic and open colectomy based on the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database. Methods: Using the ACS-NSQIP Participant Use File database, all patients undergoing both open and laparoscopic colectomy between 2005–2009 were identified based on CPT code. AHA Cardiac risk factors were mapped to existing NSQIP comorbidities such as history of ischemic heart disease, compensated or prior heart failure, cerebrovascular disease, diabetes mellitus and renal insufficiency were studied in both the laparoscopic and open group. Cardiac specific outcomes that were studied included myocardial infarction (postoperative and intraoperative), cardiac arrest (Intra-op and post op), congestive heart failure as well as death. Statistical analysis was done using SPSS 19 (IBM, NY). Chi square tests, univariate and multivariate logistic regression models were used to study the impact of variables on outcome. Results: 58448 colectomy patients were identified from the NSQIP database, of which 19062 (32.6%) underwent laparoscopic resections. 951 (1.6%) patients developed cardiac complications (101/19062 lap vs. 850/39386 open; Odds ratio 4.14, p \ 0.001). Emergency colectomy was performed in 10732 patients (672 laparoscopic). Incidence of cardiac complications among emergency colectomy (476; 4.4%) was significantly higher when compared to nonemergent cases (475; 1.0%) with odds ratio 4.6, p \ .001 Increasing number of cardiac specific risk factors was significantly associated with worse outcomes from a cardiac standpoint (p \ 0.001) in both open and laparoscopic groups. Using regression models, the factors that were significantly associated with any cardiac complications were AHA risk factors, advanced age, male sex, emergency surgery, ASA class 4 or more, wound classification. In the laparoscopic colectomy group, emergency surgery and ASA class did not affect outcome whereas in the open group, only wound class was not significant. Odds ratio and p values for variables impacting cardiac outcome Variable

All colectomy odds ratio (p)

lap colectomy odds ratio (p)

Open colectomy odds ratio (p)

AHA Risk Count

1.466 (\0.001)

2.083 (\0.001)

1.791 (\0.001)

Age [ 70 years

1.029 (\0.001)

1.047 (\0.001)

1.025 (\0.001)

Male

1.357 (\0.001)

1.838 (\0.005)

1.307 (\0.001)

Emergency

2.051 (\0.001)

1.021 (0.962)

1.897 (\0.001)

ASA 4 or more

2.576 (\0.001)

1.366 (0.362)

2.745 (\0.001)

Wound class

P \ 0.002

P = 0.027

P = 0.131

Conclusion: Based on this large database study, the risk factors for cardiac complications after open colectomy and laparoscopic colectomy are different. Different mechanisms of pathophysiology may underlie this difference between open and laparoscopic colectomy. The risk factors as defined by AHA, advanced age, male sex are consistently associated with worse cardiac outcomes in both laparoscopic and open colectomy groups.

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ALVIMOPAN AS ADJUNCT TO FAST-TRACK MANAGEMENT TO FURTHER REDUCE POSTOPERATIVE ILEUS AND HOSPITAL LENGTH STAY IN OPEN VERSUS LAPAROSCOPIC COLECTOMY Alia Abdulla, DO, Gretchen Aquilina, DO, Devin Flaherty, DO, Roy Sandau, DO, Larry Cohen, DO, Marc Neff, MD UMDNJSOM Introduction: Post-Operative Ileus (POI) is a common complication of abdominal surgeries leading to increased hospital stay and healthcare costs. Fast-track management has been employed to avert this complication and can aid in reduction of these costs. Alvimopan is a novel agent in which competitively binds to peripheral mu-opioid receptor in the gastrointestinal tract. Following oral administration, alvimopan antagonizes the peripheral effects of opioids on gastrointestinal motility. Use of this drug during laparoscopic colon surgery may shorten hospital length stay by reducing the incidence of POI. Methods: A retrospective review was conducted to evaluate the effectiveness of using alvimopan and comparing the return of bowel function in open versus laparoscopic colon surgery. Alvimopan (12 mg) was administered to patients at least 30 min prior to undergoing colon surgery and the drug was continued during the hospital stay (12 mg twice daily). The postoperative course was followed and return of bowel function and length of stay was recorded. Results: One-hundred and sixteen patients underwent laparoscopic colon surgery and received alvimopan during the period of Jan 1 2009 to December 31, 2010. BMI ranged from 25 to 40. The patients received one of four colon surgeries (laparoscopic low anterior resection, laparoscopic right hemicolectomy, laparoscopic sigmoid resection, or laparoscopic colostomy reversal). The return of bowel function with regards to passage of flatus was 1–5 days (ave 2.2 days). The full resolution of ileus with passage of stool was 1–6 days (ave 3.7 days). The length of stay was 1–6 days (ave 3.2 days). Conclusion: Alvimopan can be employed as an adjunct to fast-track management in order to significantly reduce the incidence of POI with return of bowel function as quickly as postoperative day 1 in open versus laparoscopic colon surgery. This in turn reduces length of stay in the hospital. It should be considered additive to the reduction in postoperative ileus seen with fast-track management and laparoscopic surgery.

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EYE TRACKING AS A TOOL FOR EVALUATING COLONOSCOPIC POLYPECTOMY SKILL: A FEASIBILITY STUDY Kazuhiko Shinohara, MD PhD, Yasushi Yamauchi, PhD School of Health Sciences, Tokyo University of Technology Background and Objective: Analysis of eye movement has the potential to improve educational efficiency because tracking gaze can be used to determined the areas on which operators concentrate their attention. Since few studies have focused on eye movement during endoscopic polypectomy, we tracked the eye movement of both experienced and novice endoscopists while they observed short videos on polypectomy. We evaluated gaze points and gaze duration of the subjects, especially when observing procedures for polyps. This feasibility study investigated whether eye tracking during endoscopic polypectomy is an effective tool for objectively evaluating skill. Materials and Methods: Two short videos (120 s, 3600 frames each) were prepared from a video of a colonoscopic polypectomy by an expert endoscopist. Video 1 showed the task of locating a polyp and Video 2 showed the task of endoscopic polypectomy using a snare. Study subjects were 1 expert endoscopist and 8 novices. Subjects were not informed about the position of the polyps before the observation and simply sat and watched the videos on a 32-in. LCD monitor. An eye-tracking system was used to detect the movement of both eyes at 30 Hz using two infrared cameras and displayed the position of the gaze point on an image of the visual field. Eye position relative to scene content was classified for each frame (1/30 s) as follows: polyp, snare loop, snare sheath, or other. Results: Video 1: The target polyp appeared in 308 frames (10.3 s). The expert gazed at the polyp in 267/308 frames (86.7%), whereas on average, the novices gazed at the polyp in 94/308 frames (30.6%) (SD = 18.8%). Video 2: The expert gazed at the polyp and the snare loop in 59.2% and 12.0% of the frames, respectively. On average, the novices gazed at the polyp in 44.0% (SD = 7.5%) of the frames and at the snare loop in 22.0% of the frames (SD = 8.1%). Discussion and Conclusion: The expert found the target polyp earlier than the novices and did not look away from it. The expert also gazed at the polyp for about three times longer than the novices. The novices looked away from the polyp for longer periods than the expert. These results indicate that experts concentrate their attention more than novices on the target. This preliminary study revealed that eye tracking can provide a feasible tool for objective evaluation of endoscopic skill, and therefore, can be used to assess the diagnostic and attentive ability during endoscopic procedures, which can affect eye movement during colonoscopy.

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BASIC LAPAROSCOPIC SKILLS TRAINING USING FRESH FROZEN HUMAN CADAVER; A RANDOMISED CONTROLLED TRIAL Mitesh Sharma, MBBS MS MRCS, David Macafee, MADM FRCS, Alan Horgan, MD FRCS Newcastle Surgical Training Centre, Freeman Hospital NHS Trust Introduction: The study was aimed to determine if training on Fresh Frozen Human Cadavers (FFC) improves the laparoscopic skills performance of novices and whether the acquired skills are transferable to another valid training modality i.e. a virtual reality simulator. Methods and Procedures: Junior surgical trainees (\3 laparoscopic procedure performed) were randomised into control (Group A) and practise (Group B) groups. Group B performed 10 repetitions of a set of structured laparoscopic tasks on FFC, improvised from ‘Fundamentals of Laparoscopic Skills’ technical curriculum. Performance on FFC was scored using a validated, objective ‘Global Operative Assessment of Laparoscopic Skills (GOALS)’ scale by expert assessors, blinded to the order of repetition and identity of the performer. The baseline technical ability of two groups and any transfer of skills from FFC was measured using a full procedural laparoscopic cholecystectomy task on LAP MentorTM, a virtual reality simulator, before and after practise on FFC respectively. The data were analysed with SPSS version 17. Demographics were compared using Fischer’s exact and Mann– Whitney U test as appropriate. Mann–Whitney U test was also used to compare performances of control and practise groups. The learning curve data on FFC were analysed by Friedman test (non-parametric repeated measures ANOVA). Inter-rater reliability was assessed using Kendall’s tau_b and Spearman’s rho tests. P \ 0.05 was considered statistically significant. Results: Twenty candidates were randomised, of whom one withdrew before the study commenced and 19 were analyzed (Group A, n = 9; Group B; n = 10). Four out of five tasks (non dominant to dominant hand transfer; simulated appendicectomy; intra-corporeal and extra-corporeal knot tying) on FFC showed significant improvement within 10 repetitions on learning curve analysis (p \ 0.05). Post-training significant improvement was ‘shown for safety of cautery’ (p = 0.040) and ‘left arm path length’ (p = 0.047) on LAP MentorTM by the practise group. Interrater reliability was confirmed (Kendall’s W = 0.478–1.000; p \ 0.001; Spearman’s rho = 0.585; p \ 0.001). Conclusions: Training on fresh human cadaver significantly improves basic laparoscopic skills and can improve full procedural performance. Transfer of skills is possible between cadaver and virtual reality simulator suggesting concurrent validity.

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ENDOSCOPIC SURGICAL SKILL QUALIFICATION SYSTEM IN JAPAN. AN ANALYSIS OF COMPLICATION RATE, OR TIME, AND EBL IN ACCUMULATED 1895 SURGEONS WHO APPLIED TO THIS SYSTEM FOR 7 YEARS Toshiyuki Mori, MD, Fumio Konishi, MD, Taizo Kimura, MD, Seigo Kitano, MD The committee for Endoscopic Surgical Skill Qualification System. Japan Society for Endoscopic Surgery Purpose and Method Japan Society of Endoscopic Surgery started surgical skill accreditation in 2004, as reported previously in this meeting. Comprehensive analysis of surgical skill and instructive ability was possible with this system. It is 7 years since its start, and a total of 1895 surgeons applied to this system. The purpose of this study is 1. to validate the system, 2. to delineate the appropriate procedure to assess the laparoscopic surgical skill. The perioperative parameters including the complication rate, OR time, and estimated blood loss (EBL) were collectively analyzed and compared in the qualified and non-qualified groups. The age of the applicants were also analyzed. The same analysis was performed for the subgroups of Lap Chole (LC:n = 693), gastrectomy (Gas:n = 440), and colectomy (Col:n = 552). Results are also compared in-between these subgroups. Results A total of 835 surgeons were qualified, yielding 44% of total qualification rate. In total, statistically significant differences were calculated for complication rate between the qualified and non-qualified groups, total complication rate (4.8 vs. 7.8%, p \ .01), OR time (161 vs. 178 min, p \ .01), EBL (25.6 vs. 35.2 p = .019), and post operative hospital stay (PHS: 8.8 vs. 9.7 days, p = 0.02), respectively. Differences in OR time, EBL and PHS are more prominent in the Gas and Col groups, but not found in LC group. The difference in complication rate was most prominent in the Col group (3.0 v. 7.4%, p = .03) and marginal in the Gas group (6.7 vs. 8.2%, p = .06), and not found in the LC group (4.5 vs. 5.0%) The mean age of applicants in the qualified group is significantly younger when compared to those in non-qualified group (42 vs. 43 years, p = .001). This difference in the mean age of qualified and non-qualified surgeons were more prominent in Gas (41 vs. 43, p = .01) and Col groups (41 vs. 43, p = .001), but not found in the LC group (42 vs. 42). Conclusions Standardized procedures with appropriate complexity, such as LADG or lap. colectomy, may be suitable procedures to assess the laparoscopic surgeon’s skill. Laparoscopic cholecystectomy may be too simple to be a qualification tool for this kind of systems. Our accreditation system may be a useful tool to identify the group of surgeons who can offer better laparoscopic surgery for the stomach and colon. There might be suitable age of surgeons to be more effectively trained in laparoscopic surgery.

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EVALUATING THE INFORMED CONSENT PERFORMED BY RESIDENTS FOR ENDOSCOPIC PROCEDURES William W Hope, MD, W. Borden Hooks, MD, Cyrus A Kotwall, MD, Thomas V Clancy, MD New Hanover Regional Medical Center The informed consent may be one of the most important dialogues that a surgeon has with the patient. Despite its importance, it is something that is not well taught or stressed in residency training. The purpose of this project was to evaluate the patient’s impression of the informed consent given by surgical residents for endoscopic procedures. Patients in the surgical resident clinic were asked to take part in a study evaluating the resident’s ability in performing the informed consent. A questionnaire was given to all consenting patients asking about the thoroughness and appropriateness of the consent highlighting specific complications relating to endoscopic procedures. An overall impression and additional comments were also solicited. The questionnaire was given by one surgical faculty that periodically covers the clinic and the residents were blinded to this process Twenty nine patients consented to evaluating the informed consent given by residents. Residents in all levels (1–5) of training were evaluated with 3rd year residents being the most common at 35%. In 97% of cases the patient stated the resident adequately explained the procedure to them and in only 4% had additional questions for the attending. In 90% of the time, the patient stated that the resident explained about the possibility of perforation and in 86% of the time the resident fully explained the implication of this complication. In 86% of the patients, the resident explained the potential for bleeding complications. In 93% of the patients, the resident discussed the benefits of the procedure and in 69% the alternatives to the procedure. Residents got an overall grade of excellent by 79% of patients and good in the remaining 21%. Overall, patients are well pleased with the informed consent given by residents for endoscopic procedures. In the vast majority of patients, an appropriate consent relating to endoscopic procedure was given to the patient and able to be understood.

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ASSESSING COMPETENCY AND TRAINING OF COLONOSCOPY IN A GENERAL SURGERY RESIDENCY PROGRAM William W Hope, MD, W. Borden Hooks, MD, S. Nicole Kilbourne, Cyrus A Kotwall, MD, Thomas V Clancy, MD New Hanover Regional Medical Center Recently, the adequacy of training for endoscopy in general surgery residency programs has been questioned. Efforts to improve residency education in endoscopy as well as judging competency are ongoing but are not well studied. The purpose of this study was to assess resident competency and assessment tools in colonoscopy in a general surgery residency program. Prospectively collected data was reviewed from consecutive colonoscopies from a single surgeon from 9/2008 to 6/2011. Colonoscopies performed without residents were excluded. Data included demographic information, procedural data, and outcomes. Following the colonoscopy, residents were graded by the attending surgeon using up two different assessment tools. Descriptive statistics were calculated. Colonoscopies were performed by residents in 100 patients. Average age was 52 years (range 22–79 years). Female patients made up 66% of patients and 63% were Caucasian. Colonoscopies were performed by PGY-3 level residents in 72% of cases. Average resident participation was 73% of the procedure. Biopsies were performed in 35% with adenomatous polyps found in 17% and an invasive cancer in 1%. Bowel preparation was deemed good in 76% of patients. Colonoscopy was completed in 90% of patients with reasons for incomplete exam being technical in 7 patients, inability to pass a stricture in 2 patients, and poor prep in 1 patient. For completed full colonoscopies, average time to reach the cecum was 22 min and withdrawal time was 13 min. Resident assessment was performed in 89 of the colonoscopies with 2 separate assessment tools. There were no mortalities with a morbidity rate of 3%. Morbidities included a perforation related to a biopsy requiring surgery and partial colectomy, a postpolypectomy bleed requiring repeat colonoscopy with clipping of the bleeding vessel, and a patient with transient bradycardia requiring atropine during the procedure. Residents can perform basic colonoscopy safely with appropriate supervision. Methods to assess competency continue to evolve and should be an area of active research in the future.

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TEACHING CHOLANGIOGRAPHY IN A SURGICAL RESIDENCY PROGRAM Lindsay M Bools, W. Borden Hooks, MD, Ashley Adams, BA, Thomas V Clancy, MD, William W Hope, MD New Hanover Regional Medical Center Although indications for the procedure are debated, cholangiography remains a vital tool for the surgeon performing cholecystectomies. One potentially viable argument against routine cholangiography relates to the associated increase in time and money associated with this procedure. The purpose of this study was to evaluate the time associated with routine cholangiography in a residency teaching program. A retrospective review of all patients undergoing laparoscopic cholecystectomy with intraoperative cholangiography from a single surgeon was reviewed from 4/2010 to 9/2011. Cases performed without a resident and cases where laparoscopic common bile duct explorations were performed were excluded. Cholangiogram times, deemed as time from initial placement of a clip on the cystic duct until removal of the clip after the cholangiogram was performed, were collected prospectively by the attending surgeon. Demographic information and operative information were documented and factors associated with increased cholangiogram times were compared with a p value of \ 0.05 considered significant. Laparoscopic cholecystecomy with intraoperative cholangiography was performed in 54 cases. Average age of the sample was 43 years with 69% Caucasian and 74% female. Cholangiography was successful in 96% of patients. Residents from each level of training were evaluated with the most common being 3rd year residents at 48%. Average total time for cholangiograms performed by residents was 11 min (range 6–22 min) with an average operating room time of 68 min (range 32–103 min). The average percentage of the case taken up by cholangiography was 17% (range 9–63%). Minor technical complications relating to cholangiograms occurred in 37% with the most common being difficulty with clipping the catheter occurring in 20%. There was no significant difference in completion rate or cholangiogram time based on resident level of experience (p [ 0.05). Intraoperative cholangiogram can be safely performed by residents at every level during laparoscopic cholecystectomy without adding significant time to the operation.

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IS SINGLE PORT SURGERY IS DIFFICULT ?—AN EXPERIMENTAL SUTURING MODEL IN DRY BOX Yasuhiro Ishiyama, Noriyuki Inaki, Masashi Matunaga, Hirotaka Kitamura, Michihiro Yamamoto, Masanori Kotake, Masaru Kurokawa, Hiroyuki Bando Tetuji Yamada Ishikawa Prefectural Central Hospital Introduction: Single port surgery (SPS) has been explosively spreading. SPS is sometimes demanded, and it seems to be more difficult than under conventional laparoscopic surgery. However, there has been no report which evaluate the difficulty of SPS in objective or subjective way, yet. The aim of this study is to assess the difficulty of SPS, using and experimental suturing model in dry box. Materials and Methods: Subjects were divided for 3 groups; 7 experienced laparoscopic surgeons (Group A) and 7 surgical residents (Group B) and 7 interns (Group C). An experimental suturing model is developed and working angle was set from 0 to 90. Task was specified to be making one stitch and square knot. Subjects performed the intracorporeal suturing task in dry box for three times in each angle; 0, 30, 45, 60, and 90. The completion rate, the execution time, the precision, and the stress in each angle and each group were statistically evaluated. Results: The completion rate in 0 was significantly lower than that in the other angles (p \ 0.05). There was no significant difference between 30 and 90 (p [ 0.05). Completion rate of group A was higher than that of the other groups (A: 42.8%, B: 14.2%, C: 0%). There was no significant difference in the execution time of each angles (p [ 0.05). Group A completed the suturing task significantly shorter than group B and group C in each angle (90; p = 0.002, 60; p = 0.0015, 45; p = 0.0001, 30; p = 0.01, 0; p = 0.04). Precision of task in 30 and 45 were significantly higher than that in 0 (p = 0.018), and there was no significant difference between tasks in 30 and 90 (P [ 0.05). Precision of task in group A was significantly higher than that of group B and group C in 0, 60, and 90 (90; p = 0.014, 60; p = 0.01, 0; p = 0.001). In precision of task in 45, there is no significant difference between each group (p [ 0.05). Stress score in 0 were significantly higher than that in the other angles (p \ 005), and there was no significant difference between each group (p [ 0.05). Conclusion: Our study demonstrated that SPS seems to be more difficult than conventional laparoscopic surgery. Experienced laparoscopic surgeon can keep the quality of procedure, although they feel stress during procedure. Our data should be taken under consideration for introduction of SPS.

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THE IMPACT OF A FUNDAMENTALS OF LAPAROSCOPIC SURGERY AND VIRTUAL REALITY TRAINING PROGRAM ON SURGICAL PERFORMANCE, A BLINDED RANDOMIZED VALIDATION TRIAL S B Goldin, MD PhD, H Lomas Iv, MPAS PAC MSIV, R E Heithaus, MS MSIV, D Molloy, MS MSIV, J R Williams, MD, D Donohue, MS MSIV, J Groundland, PT MSIV, S Schnaus, MS MSII, JJ Mateka, MS MSII, R Singh, MD, M T Brannick, PhD The University of South Florida College of Medicine, Tampa FL Introduction: Simulation is increasingly used in surgical training. Virtual reality trainers have advantages in data collection and information presentation over inexpensive box trainers for the development of perceptual and motor skills required for laparoscopic surgery. Our aim was to determine whether VR training was superior to box trainers in training novice laparoscopists. Methods: We compared the performance of those randomly assigned to box training in ten 2-h sessions or to a box trainer in five 2-h sessions, augmented by a virtual reality trainer for an additional five 2-h sessions. All participants completed a laparoscopic cholecystectomy on a porcine liver-gallbladder prosection before training and again after training. All operations were video recorded. Skill was evaluated using the GOALS scoring system rated by a blinded expert. Of the 39 participants who completed the training, 7 were fourth year medical students, 32 were 1st-year surgical residents, and 36 were right handed. None had prior experience as an operative surgeon for laparoscopic cholecystectomy and none had any significant prior laparoscopic experience. No participant had any prior simulation experience. Results: Analysis of covariance was used to test whether there was a difference on the posttest by training condition using the pretest as a covariate. Neither the training effect nor the covariate was significant for the analysis of covariance. Therefore, the two training groups were combined, and a dependent t-test was used to compare the means from pretest to posttest. Results showed a statistically and practically significant improvement in surgical performance after training (t = 4.17, p \ .01, d = .67). Conclusions: The VR trainer did not produce a detectable amount of augmented skill over the box trainer under the conditions of this study. Both training methods were effective in improving surgical skill as measured by prosection, and therefore the box trainer continues to be a useful and inexpensive tool for developing perceptual and motor skills.

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THE UTILITY OF STANDARDIZATION OF LAPAROSCOPY ASSISTED GASTRECTOMY AND Introduction OF TELESURGERY MENTORING SYSTEM Nobuhiro Kurita, MD PhD, Mitsuo Shimada, MD PhD, Takashi Iwata, MD PhD, Hirohiko Sato, MD PhD, Masanori Nishioka, MD PhD, Shinya Morimoto, MD PhD, Kozo Yoshikawa, MD PhD, Tomohiko Miyatani, MD, Masakazu Goto, MD, Hideya Kashihara, MD, Chie Mikami, MD Department of Surgery, the University of Tokushima Introduction: The complexity in the procedures laparoscopy assisted gastrectomy (LAG) for gastric cancer disturbs the smooth spread. The utility of standardization of the procedures and telesurgical mentoring system using internet connection of the plural hospitals for the education of LAG were evaluated. Patients and Methods: Study 1 Utility of standardization of the procedures: In the 110 cases undergoing LADG which procedures were standardized, Certified surgeon (CS) by Japanese Society for Endoscopic Surgery: operator + Resident: assistant (Group A: n = 33), Resident I: operator + CS: assistant (Group B: n = 26), Resident II: operator + CS: assistant (Group C: n = 5) and CS: operator + assistant (Group D: n = 33) were compared in operation time, estimated blood loss, number of retrieved lymph nodes. The 41 cases undergoing LATG were evaluated after division into A-D group similarly. Study 2 Introduction of telementoring system: After Telementoring system using internet connection was introduced between the University of Tokushima and another hospital which distance was approximately 70 km, CS: operator + Resident in the another hospital: assistant performed 6 cases of LADG and the outcomes were compared with the cases in the University of Tokushima. The utility of telementoring system was evaluated by 20 students, 5 residents and 10 surgeons below 35 years old using questionnaire survey. Results Study 1: LADG: Mean operation time was 296\323\329[285 min in Group A, B, C and D, respectively. Operation time in Group D is significantly shorter than those in Group B and C and there were no significant differences among the Group A, B and C. There were also no significant differences in estimated blood loss and retrieved lymph nodes among four groups. LATG: Mean operation time in Group D was 352 min and shorter than those of other groups. There were also no significant differences in estimated blood loss and retrieved lymph nodes among four groups. Study 2: Mean operation time in 6 cases undergoing LADG was 310 min and no significant difference was found compared with that of group A in the University of Tokushima. There were no significant differences in estimated blood loss and retrieved lymph nodes. 50% of residents and students answered that telementoring system was not useful, however, almost all surgeons felt the utility of this system in medical aid. Conclusion: Standardization of the procedures was essential for education of LAG and telesurgical mentoring system could contribute medical aid and education, which leads to findings of human resources.

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THE EFFECT OF SIMULATION IN IMPROVING STUDENTS’ PERFORMANCE IN LAPAROSCOPIC SURGERY: A META-ANALYSIS Azzam S Al-kadi, MD FRCSC, Tyrone Donnon, PhD, Elizabeth Oddone Paolucci, PhD, Philip Mitchell, MD FRCSC, Estifanos Debru, MD FRCSC, Neal Church, MD FRCSC Department of Surgery, Faculty of Medicine, Qassim University, Saudi Arabia. Department of Upper GI and Laparoscopic Surgery, Peter Lougheed Center, Calgary, and Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Canada. Background: There is increasing interest in using simulators for laparoscopic surgery training, and simulators have rapidly become an integral part of surgical education. Methods: We searched MEDLINE, EMBASE, Cochrane Library, and Google Scholar for randomized controlled studies that compared the use of different types of simulators. Criteria for inclusion in our meta-analysis included all peer-reviewed published randomized clinical trials comparing simulators versus standard apprenticeship surgical training (no simulation) among surgical trainees with little or no prior laparoscopic experience. Of 551 relevant studies, 17 trials fulfilled all inclusion criteria. The effect sizes (ES) with 95% confidence intervals [CI] were calculated for multiple psychometric skill outcome measures. Results: Data was combined by means of both fixed and random-effects models. Meta-analytic combined effect size estimates showed that novice students who trained on simulators were superior in their performance and skill scores (d = 1.73, 95% CI: 1.15–2.31; P \ 0.01), were more careful in handling various body tissue (d = 1.08, 95% CI: 0.36–1.80; P \ 0.01), and had a higher accuracy score in conducting laparoscopic tasks (d = 1.38, 95% CI: 0.30–2.47; P \ 0.05). Conclusion: Simulators have been shown to provide better laparoscopic surgery skills training for trainees than those that receive only a traditional standard apprenticeship approach to skill development. Surgical residency programs are highly encouraged to adopt the use of simulators in teaching laparoscopic surgery skills to novice students.

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GLOBALIZATION OF UNDERGRADUATE SURGICAL EDUCATION: A UNIQUE EDUCATIONAL EXPERIENCE AT THE IRCAD FRANCE Vivian De Ruijter, Michele Diana, MD, Silvana Perretta, MD, Luc Soler, PhD, James Wall, MD, Susana Maia, MD, Thomas Parent, Didier Mutter, MD PhD FACS, Bernard Dallemagne, MD, Jacques Marescaux, MD Hon FRCS FACS JSES IRCAD University of Strasbourg, France Introduction: Undergraduate medical students across the world have expressed the need for an early contact with Minimally Invasive Surgery (MIS). In this pilot study, we explored how interested medical students were in MIS educational programs by providing online charge-free interactive educational contents and a competency-focused strategy based on skill improvement in MIS. Materials and Methods: A 2-h web-based, charge-free course and a 5-day charge-free MIS boot camp took place at the Research Institute against Digestive Cancer (IRCAD, France). The courses were advertised through the mailing list of the educational website (WeBSurg). During the web-based course, live lectures were given by internationally renowned experts and an online chat was established for questions. The program of the MIS boot camp included lectures, workshops, and hands-on training on pelvic trainers and pig models. The training was inspired on the FLS and LASTT. A 1-to-5 Likert scale satisfaction survey was sent to all participating students. A pre- and post-course assessment was also submitted to boot camp participants. Results: One hundred thirty-four participants (mean age: 24.6; SD: 4.9) from 47 countries attended the 2-h web-based course. Eighty-seven attendees used the online chat at least once, producing 523 messages in total. The post-course survey had a response rate of 45% with a course satisfaction rate of 4.37 (SD: 0.58) among the attendees. All expressed their interest to attend a similar educational event for a second time. Sixty-eight students (mean age: 24.6; SD: 1.41) from 28 countries applied to participate at the MIS boot camp. Fifteen participants from 10 different countries were selected. A satisfaction rate of 4.75 (SD 0.5) was awarded to the boot camp by the participants. Conclusion: The interactive web-based course and MIS boot camp pilot study was well received among medical students. This format could be used to educate and inspire students worldwide, allowing for a high quality global distribution of surgical education. This format meets the demands and profiles of today’s students as well as the interest of the younger student generation. These results have led to incorporate a structural educational concept at our institute combining charge-free, web-based interactive teaching and clinical skills laboratory programs in MIS for international undergraduate medical students.

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A COMPARISON OF THE MINI-GASTRIC BYPASS, COMMERCIAL DIET PLAN AND STANDARD CARE FOR OBESE PATIENTS R Rutledge, MD The Center for Laparoscopic Obesity Surgery Recently ‘‘Weight Watchers’’ funded a multi-institutional trial comparing a free access to ‘‘Weight Watcher’s’’ Commercial plan to ‘‘standard care’’ as recommended by patients’ local physician. The purpose of this study was to include similarly sized patients who underwent Mini-Gastric Bypass (MGB) as a comparison to this published trial of a commercial weight loss diet and exercise program. Materials and Methods: Patients in the reported commercial plan were 86-88% female, weight 87 kg, height 1.66 m, BMI 31. 196 MGB patients were selected with similar demographics and the outcomes were compared. For purposes of this study BMI of 19 to 25 classified as ‘‘healthy weight.’’ BMI is 25.1 to 29 classified as ‘‘overweight’’ and may incur moderate health risks. BMI is 30 or more considered to be obese and linked to increased risk of serious health problems. Results: The MGB patients were heavier at 99 kg and BMI was greater at 36. Almost half of both diet programs dropped out (39 and 46%). It can be assumed from other reports, that they returned to their pre treatment weight or more. Weight lost at one year was -5 and -2.3 kg in commercial and ‘‘standard care’’ groups respectively. The starting–end BMI was: 31–30, 31–31 respectively. All patients were ‘‘Obese’’ both before and after 1 year of nonsurgical therapy. If we include the roughly 50% drop out rate the mean weight loss for the commercial group and standard groups drops to 3 kg and 1.5 kg or less. The estimated time spent per year for the commercial plan was a weekly meeting for 2 h with 1 h pre and post meeting travel and preparation time. For one year the time would be 156 h. In contrast MGB patients went from a mean of 99 kg to 68 kg and BMI dropped from 36.1 (Obese) to 24.9 (Healthy weight). Conclusion: 156 h and 1 year in a commercial program, offered for free; resulted in a mean weight loss of 3–5 kg, and a change in 1 point of BMI and patients remained obese and at risk for the serious consequences of obesity. On the other hand in this low risk group MGB resulted in major weight loss, 31 kg, and BMI moved form Obese to a healthy weight classification. Although reported as having ‘‘twice the weight loss’’ of standard therapy, this commercial program makes very little or no impact on the calculated health risks of these patients. Commercial diet programs and standard therapy fail to get participants to a Healthy weight and instead use up hundreds of hours of effort for little gain. On the other hand the Mini-Gastric Bypass is a short simple operative procedure that lasts only 30 min and successfully converts obese patients into health weight patients.

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LAPAROSCOPIC MEASUREMENT OF INTESTINAL LENGTH: HOW ACCURATE ARE WE? Ryan Lussenden, MD, David Brams, MD, Lee Sillin, MD, Dmitry Nepomnayshy, MD Lahey Clinic Introduction: Many laparoscopic operations require accurate measurement of small bowel length. For example, during a laparoscopic Roux-en-Y gastric bypass, an accurate measurement of the alimentary limb should be done to prevent bile reflux or short gut. This skill must also be used during a laparoscopic exploration when using distance markers to describe the location of intra-operative findings, and also when measuring for short gut syndrome. There are many methods to measure small bowel, and it is unknown what method, if any, is most accurate. We wanted to evaluate the accuracy and investigate the current laparoscopic methods of measuring small bowel. Methods and Procedures: Approximately 500 cm of porcine intestine were cleaned and placed in a laparoscopic trainer. 10 Residents and 4 attendings used 2 graspers to measure 100 cm small bowel laparoscopically. They were told to use their standard intra-operative methods. Their chosen incremental method that they measured the bowel was recorded. Their best approximation of 100 cm small bowel length was then more precisely measured with a string placed along the mesenteric side. Unpaired student t test was used to determine if there was a difference with p \ 0.05 between attendings and residents and between the methods of measurement (5 vs. 10 cm increments). Results: The residents and attendings both averaged 24 cm away from the 100 cm goal. (SD for residents was 18.5, for attendings was 17.4; p = 1.0) The bowel length range was 72 cm to 164 cm for residents, and 60 cm to 138 cm for attendings. There were no serosal tears or bowel injuries. There was a statistical difference (p = 0.042) for the doctors’ chosen measurement method. 6 doctors (3 attendings, 3 residents) measured using 10 cm increments, 7 doctors (1 attending, 6 residents) measured using 5 cm increments, and 1 doctor measured using 3 cm increments. The 5 cm technique averaged 33.57 cm away (SD 17.2) from the chosen length, while the 10 cm technique averaged 13.67 cm away (SD 13.2). Conclusion(s): There is a wide variability in how well both general surgery residents and attendings can laparoscopically measure small bowel. This could have clinical consequences, for example, bile reflux or short gut syndrome. Both residents and attendings should be educated and prepared to accurately run small bowel, perhaps best taught and practiced in a simulation environment. Better techniques to run small bowel accurately need to be explored. A future randomized simulation study should be done to evaluate the most accurate method to measure small bowel, for instance, between the 5 cm and 10 cm techniques.

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FUNDAMENTALS OF ROBOTIC SURGERY Jay M Macgregor, MD, Rebekah S Kim, MD, Joseph T Gallagher, MD, Mark K Soliman, MD, Andrea Ferrara, MD, Kiyanda Baldwin, MD, Rudolfo Pigalarga, MD, Carlos Glanville, MD Orlando Health, Colon and Rectal Clinic of Orlando Introduction: Our objective was to create a simulation-based training curriculum for robotic surgery analogous to the curriculum that exists for Fundamentals of Laparoscopic Surgery (FLS). While FLS provides a useful introduction to minimally invasive surgical skills, there are no structured teaching and skills assessment specific for robotic surgery. The FLS curriculum resulted from the need to safely introduce laparoscopic techniques into clinical practice. The FLS program has been rigorously validated and is now a core component of surgical education. Robotic surgery was first reported in 1985 and has continued to rapidly evolve over the past two decades. Despite its increasing use in surgical practice, no formal certification exists to show competency in robotic surgery. The purpose of this study is to determine the feasibility of developing a Fundamentals of Robotic Surgery (FRS) program using available simulation technology. Methods: A literature review was performed regarding the creation of FLS and robotic surgery education. A commercially available robotic simulator (Skills Simulator for da Vinc SI, Intuitive Surgical) at a minimally invasive academic center of excellence was studied for core robotic skills. Results: Five tasks were selected which represent robotic competencies as outlined in the table.

Tasks and skills tested for fundamentals of robotic surgery Task

Skills tested

Peg board (Fig. 1)

Tests camera control and manual dexterity.

Camera targeting (Fig. 2)

Tests depth perception, camera control and operating within limits of the robotic view

Ring Walk (Fig. 3)

Tests tissue handling, manual dexterity and ability to change between camera control and manipulation of instruments.

Energy dissection (Fig. 4)

Tests use of energy device, manual dexterity and use of both hands in a complimentary manner.

Suture sponge (Fig. 5)

Tests accuracy of movements with needle control and needle driving. Tests clutching of robotic instruments.

Fig. 2 Camera targeting

Fig. 3 Ring walk

Fig. 1 Peg board

Fig. 4 Energy dissection

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VALIDATING A PROCEDURE-SPECIFIC RATING SCALE FOR SINGLE INCISION LAPAROSCOPIC CHOLECYSTECTOMY Richard M Kwasnicki, Trystan M Lewis, Sanjay Purkayastha, Rajesh Aggarwal, Alexandra Shepherd, Aimee N Di Marco, Ara Darzi, Paraskevas A Paraskeva Imperial College London

Fig. 5 Suture sponge

Conclusion: Simulation is a safe and accessible way to improve surgical technique. Currently there are 169 Skills Simulators for da Vinc SI robots in use worldwide, with 156 of these in the United Sates. Simulated tasks, such as those used in FLS, allow for a validated, objective assessment of technical skill. Current robotic simulation provides objective measurement of multiple parameters including economy of motion and excessive instrument force. Transfer of skills acquired through simulation training can improve performance in the operating room. Robotic surgery is currently utilized across numerous surgical specialties with 1,411 daVinci Surgical System robots in the United States. There is a need to develop a program to assess technical skills specific to basic robotic surgery thereby enhancing surgical education and improving patient safety.

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BEST TRAINING IMPROVES THE UNDERSTANDING AND SAFETY OF ELECTROSURGERY USE IN THE OPERATING ROOM Catherine E Beck, MD, Jeffrey L Eakin, MD, Dean Mikami, MD The Ohio State University Background: In 1928 Drs. Cushing and Bovie invented the standard electrocautery pencil known as the bovie. Since then, great advances have been made in electrosurgical technology generating an abundance of diverse devices and electrosurgical principles, which are used in the majority of surgical procedures today. Nonetheless, standardized training to ensure proper use and safety does not exist. The Basics of Electro Surgery Training (BEST) is a course created at The Ohio State University to provide General Surgery Residents proficiency-based skills training in electrosurgery. BEST provides a standardized learning environment for surgical residents, to ensure a standard assessment of knowledge on the safe use of electrosurgery to ultimately increase patient safety in the operating room. Methods: First and third year General Surgery Residents at The Ohio State University Medical Center have been completing BEST since 2004 using a standardized format. After completing a pre-test followed by a lecture regarding the science and safety of electrosurgery and discussion of clinical scenarios, the residents participate in an animal lab session to use monopolar, bipolar, ultrasonic and advanced bipolar energy devices. The course is concluded with a post-test assessment. We evaluated the proficiency and course efficacy by comparing pre and post-test scores over a 3 year period. Results: Interns and third year residents over three years were taken through this course, taking a standardized pre- and post-test to assess the knowledge gained through this course. Over three years, 37 residents participated in the course. The mean of the pre-test scores were 57.29% (Standard Deviation of 13.66) with a 95% confidence interval of (51.53, 63.060). The mean of the post-test scores was 77.67% (Standard Deviation of 12.45) with a 95% confidence interval of (72.41, 82.92). The mean difference of the scores was 20.38% (Standard Deviation of 24.79) with a 95% confidence interval of (15.25, 25.50). The post test scores were significantly greater than the pre-test scores by 20.375% on average (p-value \ 0.0001). Conclusions: The BEST course provides an effective standard learning environment for the safe and proper use of electrosurgery in general surgery residents as demonstrated by the post course assessment values. This will help ensure safe, standard practices of these devices in board eligible residents.

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Introduction: The prevalence of Single Incision Laparoscopic Surgery (SILS) in clinical practice is increasing. However, there is currently a lack of validated assessment tools available to assess SILS operative performance. This study aims to devise and validate a procedure-specific rating scale (PSRS) for SILS cholecystectomy, to facilitate objective technical skills assessment of SILS. Methods and Materials: Ten medical students (NOV), and two experienced SILS surgeons (EXP) were recruited. All medical students initially completed a comprehensive cognitive module in laparoscopic surgery, gallbladder anatomy and SILS cholecystectomy technique described by an expert SILS surgeon. All subjects performed two cadaveric porcine SILS cholecystectomies. A new PSRS was developed by two expert SILS surgeons using the cognitive task analysis technique. Video assessment was carried out by two independent raters using the new PSRS and a modified Global Rating Scale (mGRS). Results: Construct validity was established with significant differences in performance demonstrated between the NOV and EXP group in all examined aspects of the new SILS cholecystectomy rating scale (median 9.25 vs. 23.5, P \ 0.001). The NOV group also had a significantly lower mGRS score than the EXP group (6 vs. 18.5, P \ 0.001). Concurrent validity was established with a significant correlation demonstrated between PSRS and mGRS (inter-test correlation was 0.827). The inter-rater reliability of the assessments was 0.911. Discussion: There are currently no methods for assessing technical performance in SILS. This study has developed and validated a new PSRS, which can be used as an objective assessment tool for SILS cholecystectomy. This tool could be used to assess the development of SILS technical skills as part of a structured SILS training curriculum.

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TEACHING TECHNICAL SKILLS FOR SURGERY—HOW CAN WE IMPROVE? Trystan M Lewis, Mr, Rajesh Aggarwal, Mr, Ara Darzi, Professor Imperial College London Introduction: Teaching technical skills is an obligation of all surgical trainers. It is vital that technical skills’ teaching is performed appropriately and effectively. However, it is not certain which methods are most effective for skills teaching, as it is difficult to objectively assess the quality. This study aims to evaluate the optimum methods for technical skills teaching, and develop a new assessment tool that allows objective assessment of teaching methods by surgical trainers. Methods and Procedures: The technical skills teaching methods of ten experienced surgical trainers were evaluated during a bariatric and a colorectal surgical masterclass using live porcine models. Teaching methods were assessed in three ways; by faculty self-assessment questionnaires, trainee assessment of faculty questionnaires and a new structured assessment tool developed to objectively assess the quality of teaching skills during practical sessions. Assessments were divided into knowledge, skill and attitude parameters and measured using a five point Likert scale. Results: Teaching methods were assessed during one colorectal and one bariatric masterclass. Each masterclass contained five faculty members and thirty trainees. There were no significant differences in quality of teaching for any parameter between the colorectal and bariatric faculty (p [ 0.05). The colorectal faculty rated their performance significantly better than the trainees rated the faculty for explanation of technical skills (median 5 vs 4, p = 0.037), length of time giving advice (median 4 vs 3, p = 0.014) and length of supervision during the procedure (median 4 vs 3, p = 0.048). All other parameters demonstrated no significant difference between faculty self-assessment and trainee assessment of faculty (p [ 0.05) The bariatric faculty rated their performance significantly better than the trainees rated the faculty for demonstration of technical skills (median 5 vs 4, p = 0.016), time spent giving advice (median 5 vs 4, p = 0.003) and time spent supervising (median 5 vs 4, p = 0.011). All other parameters demonstrated no significant difference between faculty self-assessment and trainee assessment of faculty (p [ 0.05) Conclusions: The ability to teach technical skills is a vital quality required by surgical trainers. It has previously not been clear which methods are most effective for teaching technical skills. This study demonstrates areas of technical skills teaching that could be improved. Quality of skills teaching can now be evaluated objectively, following the development of a new structured assessment tool for skills teaching.

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ENERGY EXPENDITURE DURING LAPAROSCOPIC CHOLECYSTECTOMY EVALUATED USING THE TELEMETRIC HEART RATE MEASUREMENT Miroslaw Szura, MD PhD, Jan M Krzak, MD, Senka Stojanovic, MD IST DEPARTMENT OF GENERAL SURGERY JAGIELLONIAN UNIVERSITY KRAKOW POLAND, SYGEHUS LILLEBAELT KOLDING DENMARK Introduction: Evaluating the work of a surgeon is a difficult task, on one hand being influenced by the physical demands related to work in a standing position without any possibility of rest, and on the other hand by the stress related to the necessity of decision-making during the procedure. The method of evaluating the strain by using the heart rate measurement can be applied in easy tasks or moderately difficult ones, on the basis of oxygen consumption and energy expenditure, but at the same time in those requiring considerable static power or those involving limited, well-defined group of muscles. Increase in heart rate in such cases signifies the increase in tiredness, and the stress related to the course of the procedure additionally increases the energy given off. The aim of this study is to evaluate the energy expenditure of an experienced surgeon during the basic laparoscopic procedure. Materials and Methods: Involved in this study are two experienced surgeons who independently performed or assisted residents during laparoscopic cholecystectomy. Fifty cholecystectomies were analyzed, in which the experienced surgeon was randomized into one of the two roles—that of the operator (group I) and that of the assistant (group II). Eliminated from the analysis were those procedures involving conversions to laparotomy, and those in which the experienced surgeon took over the role of the operator mid-procedure. Heart rate was measured telemetrically, continuously recording the fluctuations of the heart rate, mean heart rate and total calorie burnt. Based on the data gathered, the metabolic unit of energy expenditure was calculated to kcal/kg/h. Results: Mean heart rate of the surgeon in group I was 86/min (76–93), and in group II 88/min (71–100). Maximum value of heart rate in group I was 106/min, and in group II 118/min (p = 0,001). Converted to the metabolic unit, the mean energy expenditure in group I was 3,27 kcal/min, and in group II 3,17 kcal/min (p [ 0,05). Conclusions: Experienced surgeon has greater heart rate fluctuations during laparoscopic cholecystectomies in which he is assisting the resident, however, the energy expenditure was similar regardless of whether he is assisting or operating independently.

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TRAINING TRANSANAL ENDOSCOPIC MICROSURGERY (TEM): FEASIBILITY OF A NEW SIMPLE AND ECONOMIC SURGICAL SIMULATOR Gustavo L Carvalho, MD PhD, Marcos Lyra, MD, Sergio E Araujo, MD PhD, Eduardo A Bonin, MD MSc, Diego L Lima, Student Oswaldo Cruz University Hospital and UNIPECLIN, Faculty of Medical Sciences, University of Pernambuco, Recife, Brazil. Background: TEM is a safe, feasible and efficacious minimally invasive surgical approach for the treatment of benign adenomas and early-stage carcinomas of the rectum. TEM enables proper en bloc tumor resection while providing enhanced visualization. TEM results in reduced hospital stay and morbidity when compared to anterior resection or abdominoperineal operation. Although advantageous in many ways, TEM techniques are not yet performed in a widespread fashion as expected at many institutions, since it is still considered a technically demanding procedure. Extensive training is deemed required to master the technique. Cadaveric and live animal models represent the current available options for simulation. However, they might be considered laborious and raise ethical concern. Furthermore, these models are expensive and require complex settings which are not easily accessible in all institutions. In order to overcome these limitations, a newly developed, simple and user friendly surgical TEM simulator model using an artificial low cost synthetic tissue called Neoderma is presented. Method: Neoderma is a material that offers color, touch, consistency and texture similar to the Human tissues. A TEM Neoderma trainer was engineered to simulate a pathologic rectum with several sessil tumors. Every TEM trainer is a cylinder 30 cm- long, 4 cm-wide, naturally self-expanded and closed at one end, simulating a gas-insufflated rectum. It simulates all rectum wall layers including mucosa, muscularis propria and the surrounding fat tissue (mesorectum). Each layer was engineered in a different color and this resource is used to help the identification of surgical dissection plans. The actual surgical model is manufactured with 3 polypoid 2 cm-sized tumors. The TEO device is firmly inserted in the open end of the model keeping it securely attached. A 5 mm laparoscope and usual 5 mm grasping forceps, scissors and needle holder completes the setting. The device was used by two experienced surgeons for performing endoluminal full-thickness resection of polypoid tumors to evaluate its feasibility. Results: Preliminary results with the use of the simulator indicate that it is a reliable tool. Experienced surgeons demonstrated a good acceptance by successfully completing the proposed tasks. A total of 3 polypectomies and 5 endoluminal sutures were performed. Apart from usual TEM instruments, a harmonic scalpel device was successfully used. Both surgeons agreed that the TEO simulator offers a good model for mastering transanal resection and suturing superficial rectal tumors. Conclusions: TEM Neoderma trainer offers a simple, practical and cost effective solution for training the surgeon to perform the complex TEM procedures. The number of lesions to be resected with this model to master the ex-vivo technique and its correlation with in vivo procedures is currently under evaluation. Due to exemption of human cadavers and laboratory animals, significant cost saving associated to TEM pre clinical practice may be anticipated.

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EVALUATING VIRTUAL REALITY SIMULATOR TRAINING ON SURGICAL RESIDENTS PERCEPTIONS OF STRESS: A RANDOMIZED CONTROLLED TRIAL Kamran Samakar, MD, J Andres Astudillo, MD, Mallika Moussavy, MA, Joanne Baerg, MD, Mark Reeves, MD, Carlos Garberoglio, MD Loma Linda University Medical Center Background: Standardized curriculum and educational models such as the Fundamentals of Laparoscopic Surgery (FLS) have provided a means to teach, practice, and test surgical trainees. Virtual reality simulation (VRS) and training boxes have augmented operative teaching opportunities. At our institution, we implemented a laparoscopic curriculum for surgical residents to progress between post-graduate years. The curriculum consists of graduated skill acquisition through online study, box training, VRS, objective structured assessment of technical skills (OSATS) evaluation, and ultimately FLS certification. Evaluation of our education curriculum was carried out through a number of objective measures as well as reports of subjective experiences by trainees. We hypothesized that VRS training would attenuate surgical trainees stress related to laparoscopic surgery. We report the results of resident performance on VRS and their subjective experiences of self-efficacy and task-specific stress associated with laparoscopic surgery. Methods: After Institutional Review Board approval, a prospective, randomized controlled study was designed for surgical residents in their second, third, and fourth year of clinical training (n = 19). Participants in the experimental group underwent virtual reality simulator (VRS) training composed of 5 training modules culminating in the completion of a VR laparoscopic cholecystectomy during a 60 period. Objective measurements, including total operative time, efficiency, and complications were recorded by the simulator and subsequently analyzed for residents in the experimental group. The control group did not undergo VRS training. All study participants were then asked to complete the State Trait Anxiety Inventory (STAI) questionnaire to measure subjective levels of task-specific stress prior to performance of a laparoscopic cholecystectomy on a human patient. Subjective experience of stress was calculated using the validated STAI questionnaire. Stress scores were quantified on a scale from 20-80, with higher scores indicative of greater subjective stress levels. Results from the STAI questionnaire were compared by Pearson chi-square test and p \ 0.05 achieved significance. Results: Average STAI score in the experimental group was 36.2 with a SD of 10.8 (n = 8). Average STAI score in the control group was 35.5 with a SD of 11.3 (n = 11). Average operative time for a VR laparoscopic cholecystectomy was 15.5 min with a SD of 8.7. No significant difference was observed between the two groups in subjective stress scores (P = 0.91). High stress scores were associated with lower performance on VRS as measured by objective indices. Conclusion: Practice in a Virtual Reality Simulator may not significantly reduce the stress experienced by trainees prior to performance in a real laparoscopic cholecystectomy. Evaluating an educational curriculum will require objective measurements and an understanding of the subjective perceptions of trainees. Ongoing studies on the transition from trainee practice to actual performance and competency will inform future educational modalities.

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THE ESTABLISHMENT OF A TRAINING SYSTEM FOR SINGLE PORT SURGERY (SPS) USING A TISSUE LABORATORY MODEL Hitoshi Idani, MD, Masahiko Nishizaki, MD, Madoka Hamada, MD, Toshiyoshi Fujiwara, MD Department of Surgery, Fukuyama City Hospital, Department of gastrointestinal surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Objectives: Single incision laparoscopic surgery has widely accepted in various abdominal surgeries. However, there had been few training system for SILS. We have established and evaluated a tissue laboratory model for SILS. Methods: Training tasks included SILS cholecystectomy using a training box provided with a porcine liver with the gallbladder and ligation by cross over technique using articulating graspers. Between September 2009 and August 2010, we held SILS training course three times. Useful ness of the training course was evaluated by questionnaire after the course and the situation of the induction of SILS surgery was evaluated 6 months after the course. The time for ligation was also evaluated pre and post training course. A total of 43 surgeons from 13 hospitals who had no or little experience with SILS attended our training course. Each surgeon completed SILS cholecystectomy during the course. All participants satisfied with the training course. SILS was introduced in 9 hospitals (62.9%) 6 months after the training. More than 10 SILS cases was performed I n 5 hospitals. Most of the surgery was cholecystectomy, however, appendectomy, colectomy and groin hernia were also performed in a few hospitals. Ligation time was significantly improved after the training (from 94 ± 15 to 40 ± 5 s: p = 0.0013). Cost for our tissue laboratory system was 200,000 Japanese yen, which was less than 1/10 of animal laboratory model for SILS. Conclusion: Our training system for SILS is useful for introduction SILS and also cost effective.

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DEVELOPMENT OF A VIRTUAL REALITY NOTES SIMULATOR Kai Matthes, MD PhD, Ganesh Sankaranarayanan, PhD, Arun Nemani, BS, Woojin Ahn, PhD, Masayuki Kato, MD PhD, Daniel B Jones, MD, Steven Schwaitzberg, MD, Suvranu De, ScD Harvard Medical School, Boston, MA and Center for Modeling, Simulation and Imaging in Medicine, Rensselaer Polytechnic Institute, Troy, NY Introduction: Virtual reality (VR) simulation has been beneficial for the training in interventional endoscopy and minimally invasive surgery. Ex-vivo tissue simulators have been developed for the simulation of Natural Orifice Translumenal Endoscopic Surgery (NOTES). The aim of our study was to perform a structured needs analysis to identify critical design parameters for a virtual reality NOTES simulator. Methods and Procedures: After securing IRB exemption, we distributed a 30-point questionnaire at the 2011 Annual Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR). The questions covered a variety of topics: procedures, devices, endoscopic equipment, and training. A total of 22 NOTES experts completed our survey (17 surgeons, 4 gastroenterologists, 1 thoracic surgeon). Statistical analysis was performed using the Wilcoxon rank sum test. Results: Among those surveyed, the most commonly performed NOTES procedure in humans is currently cholecystectomy followed by colectomy and appendectomy. When given a choice of procedures to be simulated in the VR environment, the majority of participants chose cholecystectomy (CE, 68%) followed by appendectomy (AE, 63%) (CE vs. AE, p = 0.0521). For NOTES appendectomy, participants would prefer to perform the surgery using flexible instruments (FL, 47%) or as a hybrid procedure (HY, 47%) using only rigid instruments (RI, 6%) (FL vs. RI, HY vs. RI, both p \ 0.001). As preferred access route for NOTES appendectomy, 65% of the participants chose the transvaginal (TV) followed by the transgastric (TG, 35%) approach (TV vs TG: p = 0.52). There was no preference for the brand of endoscope for the VR-NOTES simulator (85%, p \ 0.001), Although most of the participants preferred a two channel endoscope (2C, 65%) as opposed to single channel (1C, 17%) and three or more channels (3C, 17%) (2C vs. 1C and 2C vs. 3C, both p \ 0.001). On a five-point Likert scale, participants rated force feedback and torque as important (Table 1).

Table 1 Results from a NOTES expert need analysis using a 5-point Likert scale

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SINGLE INCISION LAPAROSCOPIC CHOLECYSTECTOMY PERFORMED BY RESIDENTS Elizabeth Hooper, MD, Jonathan Myers, MD, Keith Millikan, MD, Minh Luu, MD Rush University Medical Center Background: Single incision laparoscopic cholecystectomy (SILC) is a feasible and safe technique that is gaining popularity. SILC is technically demanding. Initial concerns regarding safety have limited its wide acceptance. Slowly, SILC techniques are now taught to fellows and residents in training. We report our early experience in teaching residents SILC and compare to matched LC cases. Methods and Procedures: A retrospective review of a single institution experience in teaching upper level residents SILC is studied. Resident performed SILC were compared to junior and senior resident level performed LC. Patient (age, BMI) and operative measures (OR time, complications, stay) were compared. Patients with acute cholecystitis were excluded from the study. LC involves four trocars: umbilical, subxiphoid and two in the right abdomen. SILC involves three periumbilical 5 mm trocars and one right upper quadrant percutaneous suture retraction of the fundus. In both techniques, the lower one third of the gallbladder is dissected from the liver using a hook with electrocautery or using blunt dissection. The cystic duct and artery are then dissected and clearly seen entering the infundibulum. The ‘‘critical view’’ of safety is met when the preceding steps are completed. Results: Over a period of 15 months, 20 SILC and 40 LC cases were identified and compared. The LC group was separated into junior and senior residents, summarized in Tables 1 and 2.

Table 1

Number

Jr

SILC

20

20

p

Age

42

30

0.001

BMI (kg/m2)

34

29

0.05 0.72

Time

68

70

Question

Mean ± SD

EBL

Min

Min

Importance of realistic interface and force feedback

3.85 ± 1.06

Complications

None

None

4.0 ± 1.06

Stay

0.9

0.9

1

Importance of having multiple views

3.59 ± 1.09

PGY

2.6

4.8

0.001

Importance of VR testbed for training and developing in new procedures for NOTES

4.04 ± 0.99

Importance of feeling torque

Importance of designing/testing new instruments for the NOTES procedure in VR-NOTES

4.0 ± 1.11

Conclusions: Our analysis reinforced the importance of developing a VR simulation environment for NOTES. The VR platform should simulate cholecystectomy and appendectomy using both flexible and rigid instruments. The results of this analysis will direct our initial development of a VR NOTES platform. The ideal VR-NOTES simulator will ultimately promote training, assessment of surgical approaches and design of novel instrumentation.

Table 2

Number

Sr

SILC

20

20

p

Age

51

30

0.001

BMI (kg/m2)

31

29

0.05

Time

66

70

0.69

EBL

Min

Min

Complications

None

None

Stay

0.8

0.9

0.24

PGY

3.9

4.8

0.001

Table 1 summarizes the junior group. The patients in LC were older and more obese. The mean operative time was lower for LC but not significant. The LC group had an average OR time of 68 min (range 34–105 min) and the SILC group had an average OR time of 70 min (range 39–103 min). Blood loss was minimal and there were no perioperative complications for either group. The length of stay was just under one day for both groups. The resident level was higher for the SILC group by two post graduate year (PGY) levels. Table 2 summarizes senior residents completing traditional LC compared to SILC. The patient age remained different between the two groups. BMI became non significant, and OR time remained similar, 66 compared to 70 min. The resident cohort was more advanced in training, however significant difference remained from the SILC group. Conclusions: The results of SILC performed by upper level residents are comparable to LC performed by junior and senior level residents. Based upon our early experience, SILC techniques can be safely taught to upper level residents. Further study is needed to assess the minimum level of experience in traditional LC that allows for efficient and safe acquisition of SILC techniques.

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DOES A SURGICAL OPERATING PLATFORM SHORTEN THE LEARNING CURVE FOR SINGLE-INCISIONLAPAROSCOPY? Erwin Rieder, MD, Matthew Breen, BS, Maria A Cassera, BS, Danny V Martinec, BS, Chet W Hammill, MD, Lee L Swanstrom, MD MIS Program, Legacy Health, Portland, OR; Gastrointestinal and Minimally Invasive Surgery, The Oregon Clinic, Portland, OR Objective: In single-incision-laparoscopy (SIL), crossed instruments together with the proximity of the endoscope inevitably interferes with smooth movements, and has been shown to be more mentally demanding than the standard laparoscopic approach (SL). Novel developments such as triangulating operating platforms, aim to overcome these drawbacks and provide true right/left manipulation. However, due to the novelty of this surgical approach, the required learning curve to reach proficiency might be even more challenging. The aim of this study was to compare the early learning curve of a single-port surgical-platform (SPSP) with that of SIL and SL. Methods and procedures: Six participants with different laparoscopic experience levels (naı¨ve, intermediate, expert) were tested with a validated intracorporeal suturing task (FLS) performed with either a SPSP (Spider-System), or a SIL-approach with crossed/articulating instruments. SL served as the control. During a 4-week training period (two sessions/week), suture performances with the three different techniques were assessed. All sutures were evaluated using FLS-scoring methods for suturing. A previously defined level of proficiency (two consecutive proficient suture scores at or above 93.7, followed by 10 non-consecutive proficient sutures) was used. After each individual session, participants rated their related subjective mental workload by a validated tool (NASA-TLX). Results: Within the four-week training period it was observed that, compared to the SIL approach, a significantly higher number of proficient sutures were achieved with the SPSP (9.7% vs. 18.0%, p = 0.041). However, both were significantly lower than the number achieved with SL (87.5%; p \ 0.01). No participant obtained the pre-defined level of proficiency with the SPSP or SIL. The experts, who were proficient in laparoscopic suturing, achieved a median of 9 sutures (37.5%) with the SPSP, at or above the proficiency score. Only a median of 5 sutures at this level were accomplished with the SIL approach (21%). Although the intermediate group was also found to be proficient in standard laparoscopic suturing, each participant achieved only 2 successful attempts with SIL and a median of 2.5 (range: 0–5) proficient sutures with the SPSP. None of the novices accomplished a proficiency score C93.7 with the SIL approach. With the SPSP, one naı¨ve participant achieved three proficient sutures. Interestingly, even without any previous surgical experience, naı¨ve participants easily achieved proficiency with SL during the 4 weeks. Evaluating the best individual scores achieved with the SPSP and SIL, a residual median performance gap of 15% (range: 9% to 25%) to SL was observed. Mental workload of the experts decreased during the SPSP and SIL training and were finally comparable to the level of SL (score of less then 30). On the other hand, the less experienced participants still indicated a higher mental workload for SPSP and SIL. Conclusion: Compared to SIL with crossed instruments, a surgical operating platform appears to be beneficial in shortening the early learning curve of single port surgery. However, performance with SPSP or SIL seems to be significantly less intuitive than SL. Additionally, after the 4-week training-period a performance gap to SL remained when a SPSP- or SIL-approach was used.

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MODELS FOR TRAINING AND EVALUATION OF FLEXIBLE ENDOSCOPIC SKILLS USING THE STEP PROGRAM D. Berger-Richardson, Y. Kurashima, MD, P. Kaneva, MSc, L. S Feldman, MD, G. M Fried, MD, M. C Vassiliou, MD Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, and The Arnold and Blema Steinberg Medical Simulation Centre, McGill University Objective: Flexible endoscopy is an increasingly important skill for gastrointestinal surgeons, but training opportunities are limited. Simulation may have a role to play, however, existing virtual reality models are criticized for their high cost and metrics that are difficult to interpret. The SAGES STEP (Surgeons Training Endoscopic Proficiency) program provides a complete flexible endoscopy setup to qualifying institutions for resident education. The purpose of this study was to create and validate tasks using the STEP program for training and evaluation of the basic skills required for flexible endoscopy. Methods: Learning objectives were retroflexion, instrument targeting, navigation, loop reduction and mucosal inspection. Models were created using low cost, readily available materials such as fabric, paper and wood. Metrics were developed to value both efficiency and precision. (1) Retroflexion Model: A box containing various symbols scattered throughout 6 inner walls and 3 lumens. The trainee enters the endoscope into the box through a lumen and must identify the symbols using retroflexion. (2) Targeting Model: A hollow tube in which two metal targets are placed in close proximity. The trainee must position open biopsy forceps to touch both metal targets simultaneously to complete an open electrical circuit, sounding a buzzer. (3) Navigation and loop reduction Model: A ‘‘Slinky’’ (Poof-Slinky Inc., Plymouth, MI) covered with fabric is secured to the bottom of a cardboard box. Trainees must navigate the curves of the slinky, which is prone to formation of loops, thus creating opportunities for loop reduction. (4) Mucosal evaluation The same ‘‘Slinky’’ model is used to develop the skills of mucosal evaluation. Within folds of the lumen, there are stud earrings that the trainee must identify. Four novices (NE) and 4 experienced endoscopists (EE) were evaluated during performance of these tasks using the STEP gastroscope setup. Scores were compared using independent T-tests (Statistical Software SAS 9.2). Results: (1) Retroflexion: In the time allotted, NE identified a mean of 10.8 (±5.1) symbols, while EE identified 21.3 (±2.5; p = 0.01). (2) Targeting: In the NE group, 0/4 participants successfully completed 4 biopsies. In the EE group, 3/4 participants completed the task in the allotted time. (3) Navigation and loop reduction: In the NE group, 1/4 completed the task. In the EE group, all 4 participants reached the end of the lumen within the allotted time. (4) Mucosal evaluation: In the NE group, a mean of 5.3 (±1.0) targets were identified compared to 7.8 (±1.7) in the EE group (p = 0.04). Conclusion: This pilot study describes the creation of a new set of tasks to model the basic skills of flexible endoscopy that can be used in conjunction with the STEP program. The metrics discriminate between NE and EE. This low cost simulator may be a useful tool for training and evaluation of the skills fundamental to flexible endoscopy.

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TRAINING THE TRAINERS—SURGICAL STYLE Susannah M Wyles, MSc MRCS, Chee Wan Lai, MBBS MRCS, Melody Ni, PhD, Nader Francis, PhD FRCS, John T Jenkins, FRCS, Amjad Parvaiz, MD FRCS, Tom Cecil, MD FRCS, Roland Valori, MD FRCP, George Hanna, PhD FRCS, Mark G Coleman, MD FRCS Imperial College London, Derriford Hospital, Yeovil Hospital, St Marks Hospital Harrow, Queen Alexandra Hospital Portsmouth, Basingstoke and North Hampshire Hospital, Gloucester Hospital Introduction: The aim of this study was to design, role out and assess a surgical teaching training course to ensure, and if necessary improve, the skills of laparoscopic colorectal surgery (LCS) trainers within the English National Training Programme (Lapco). Methods and Procedures: A training committee of five expert surgeons (performing LCS [ 10 years) and three educationalists developed and piloted a two day course. Participants were Lapco trainers, with 6–8 within a group. Day one of the course consisted of educational theory interspersed with role-play and laboratory-based practical sessions. Live-operating took place on the second day, with each course participant (trainer) training a trainee surgeon on LCS resection, whilst being observed directly by another course member and a faculty member. The trainers were concurrently observed indirectly by the remainder of the course participants and experts via a video-link. After a 20 min training episode the trainer stopped teaching and received extensive feedback from both the trainee, the observer (course member) and the expert. There was also an opportunity for further discussion with the others. Course participants gave their opinion about the course through a standardised anonymised questionnaire with a 5-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = undecided, 4 = agree, 5 = strongly agree). Before and after the course trainers were assessed by their trainees using the Structured Training Trainer Assessment Report (miniSTTAR) in the clinical setting to determine the impact of the course. This is a 24-point validated assessment that enables the trainee to give their opinion regarding their trainer’s training through a 5-point Likert scale. Data were analysed using SPSS, Kruskal–Wallis and Mann Whitney tests. Mean scores are quoted and a p value of \0.05 was considered to be significant. Results: Over a twelve month period (June 2010–June 2011), four courses ran, attended by 27 trainers (26 male, 1 female), aged 45.1 (range 34–53) with between 5–10 years experience in LCS. From January 2011 the mini-STTAR assessments were introduced into Lapco and were completed after each training episode in the clinical setting. Trainers agreed that after the course they had a greater understanding of educational theory (4.54 (4–5)), that the coaching practical sessions were interesting(4.48 (4–5)), that they were aware of a variety of coaching techniques for LCS (4.23 (3–5)) and that the course was well structured and organised (4.4 (4–5)). With regard to the scores on the mini-STTAR, the experts scored most highly (3.59 ± 0.45), followed by those who had not been on the course (3.54 ± 0.37) then by those who had attended (3.49 ± 0.46). However Kruskal–Wallis tests found no significant differences among the groups (p = 0.524). Mann–Whitney test found no significant difference in the trainers scores before and after the course (p = 0.788). Conclusion: Overall the course was found to be well designed and educational. The quality of trainers was uniformly high throughout the programme training centres. The next step would be to open the course to other surgeons outside of the programme where it is more likely to have a significant impact on their training.

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TEACHING AND GOOD Results CAN GO HAND IN HAND IN BARIATRIC SURGERY: 1733 CONSECUTIVE LAPAROSCOPIC GASTRIC BYPASS CASES AT A TEACHING CENTER WITHOUT GASTROJEJUNOSTOMY LEAK Ashutosh Kaul, MD FRCS FACS, Anthony Maffei, MD FACS, Thomas Sullivan, BS, Edward Yatco, MD FACS, Thomas Cerabona, MD FACS, Niu Zhang, MD New York Medical College Aim of this presentation is to communicate our series of 1733 consecutive laparoscopic gastric bypasses done at a teaching center without any leak from the gastro-jejunostomy and to highlight the fact that both teaching and good results in bariatric surgery can go hand in hand . This is a retrospective analysis of prospectively maintained data from a tertiary care center. Data was analyzed from January 2001 till June 2011. Redo cases, sleeve gastrectomies, lap band placement and biliopancreatic diversions were excluded. All cases were done by four bariatric surgeons and by fellowship trainees under their guidance. Our technique in creation of the gastrojejunostomy is a four layered hand sutured gastrojejunostomy sized over an 18 French nasogatric tube. We bring our roux limb up in a retro-colic retrogastric transmesocolic route. The nasogastric tube is removed after intraoperative testing of the anastamosis by injecting air through the tube while compressing the jejunum. A gastrografin upper-gastrointestinal series was also performed in all patients on the morning of postoperative day 1, and then the patient was started on a liquid diet. Care is taken to ensure that there is no tension at the anastamosis, or narrowing at the transmesocolic or jejunojejunostomy and to maintain good blood supply. 1733 cases were attempted laparoscopically in this period. We converted 3 cases from laparoscopic to open (2 due to extensive adhesions and one due to lack of working space). 81 of these gastrojejunostomy were done with Da Vinci robotic assistance while the rest were done by hand sutured technique. BMI of patients ranged from 35 to 90 kg/m2 (average BMI 47.9 kg/m2) and age from 16 to 75 years (mean 41 years). There were three mortalities in this period (one in a patient with arrythmias who threw an emboli to the small bowel, one with pulmonary embolism at about 27 days after surgery, and third with aspiration pneumonia at about 29 days). Three patients developed a leak from the staple-line in the divided gastric pouch (0.19%). During the study period, 7 patients were diagnosed with an anastomotic stricture (0.4%), and were all corrected with endoscopic dilation. Marginal ulcer and wound infection rates are both under 1%. Average length of stay was 2.7 days. 30 day readmission rate was 6.9% while 90 day readmission rate was 9.3%. Majority of the gastrojejunostomy were done by the fellows while being actively supervised by the attending surgeons. Though technically challenging, hand sutured gastrojejunostomy seems to have excellent results and is a technique which can be learned by fellows during training under close supervision. Good results in bariatric surgery can go together with hands on teaching during the fellowship year.

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PREOPERATIVE TRAINING AND PLANNING Methods FOR A SINGLE-INCISION LAPAROSCOPIC CHOLECYSTECTOMY FOR SITUS INTREVSUS TOTALIS (SIT) Hisashi Ikoma, PhD, Yukihito Kokuba, PhD, Yusuke Yamamoto, PhD, Ryou Morimura, PhD, Yastutoshi Murayama, PhD, Syuuhei Komatsu, PhD, Atsushi Shiozaki, PhD, Yoshiaki Kuriu, PhD, Masayoshi Nakanishi, PhD, Daisuke Ichikawa, PhD, Hitoshi Fujiwara, PhD, Kazuma Okamoto, PhD, Toshiya Ochiai, PhD, Eigo Otsuji, PhD Department of Digestive Surgery, Kyoto Prefectural University of Medicine 1. Objective of technique: A single-incision laparoscopic cholecystectomy, which is performed by making an incision into the umbilical region, is expected to lead to reduced pain and scarring and a shortened time required for recovery, and this procedure is now becoming more widely used. Although laparoscopic cholecystectomy for situs intrevsus totalis (SIT) has been previously reported, there have been a few previous reports of a single-incision laparoscopic cholecystectomy. We herein introduce the preoperative training and planning methods for a single-incision laparoscopic cholecystectomy for situs intrevsus totalis (SIT). These methods could decrease difficulty, and improve safety. 2. Description of the methods: 1 We made a hepato-biliary model of SIT using wheat clay. When the model was put in a dry box, preoperative simulation was performed. 2. A movie about the mirror image laparoscopic cholecystectomy was made using ‘Quick Time 7’. 3. A Virtual Reality image made using the Work Station and multi-detector computed tomography. 3. Preliminary results: A single-incision laparoscopic cholecystectomy in a 49-year-old female with SIT, who was diagnosed cholelithiasis, was safely performed. Our initial concerns about this procedure were the increased difficulty, and concerns about patient safety. We enhanced our preoperative training and planning to address each of these concerns. In particular, we made a hepatobilliary model of SIT using wheat clay. When the model was put in a dry box, preoperative simulation was performed, and both the multitrocar access using the French technique and the single port access, which were carried out in symmetrical fashion with respect to their situation in orthotopic patients, were tried to estimate the difficulties in performing this procedure using the single port access. During the above simulation, the difficulty using the instruments read to single port access was observed regarding multitrocal access, because it was noticed that the angle crossing by both instruments in the single port access for SIT was similar to that made in orthotopic patients. During the surgical procedure, it was necessary to apply counter-traction between the gallbladder and the adipose tissue surrounding the gallbladder by retracting both instruments either up or down, rather than in the lateral direction, which allowed for good tension. A movie about the mirror image laparoscopic cholecystectomy was made using ‘Quick Time 7’. The movie allowed us to become used to the mirror image, and made it easier to imagine the actual surgical site. This technique was very easy and inexpensive. This method is also considered to be applicable to another types of endoscopic surgery for SIT. One more approach was used to familiarize the surgical team to the mirror image, which was a Virtual Reality image made using the Work Station from the voxel data obtained by multi-detector computed tomography. This image presented the detailed anatomical features of the patient 4. Conclusions: These three methods of preoperative training allowed for a rapid, successful and safe operation, and allowed the surgeon to maintain a safe dissection and attention to the safety aspects of laparoscopy.

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SHORT-TERM USE OF A LAPAROSCOPIC VIRTUAL REALITY SIMULATOR IN ONE SURGICAL RESIDENCY PROGRAM: A SURVEY OF RESIDENTS Eric Changchien, MD, Dahlia Tawfik, MD, Sachin Kukreja, MD MOUNT SINAI HOSPITAL, CHICAGO, IL Introduction: The quality, accessibility, and utilization of laparoscopic training labs and laparoscopic virtual reality (VR) simulators are varied amongst surgical training programs in the country. We surveyed residents in one surgical residency program to assess the satisfaction of their laparoscopic training resources and the perceived utility of adding a laparoscopic VR simulator. Methods: Surgical residents from one residency program were given the use of a laparoscopic VR simulator (Simbionix Lap Mentor) for two weeks. Each resident was administered pre- and post-simulator surveys to determine if the simulator met their expectations and would promote more use of the simulation lab if such a machine were purchased for the institution. Results: Fifteen residents (PGY1-5) used the laparoscopic simulator an average of 95 ± 23.2 min; 10 residents completed both pre- and post-simulator surveys. On a 5-point Likert-scale, the residents in aggregate were dissatisfied with the current laparoscopic training tools (2.27 ± 1.09). The majority of respondents (66.7%) said the primary asset of the laparoscopic VR simulator was the ability to perform actual cases compared to traditional trainers, while the primary limitation after using it was the lack of tactile feedback (90%). After using the VR simulator, its apparent usefulness in promoting greater lab utilization was unchanged from 3.60 ± 0.84 to 3.67 ± 1.12, p = 0.71. However, resident’s perception that the VR simulator would add to their laparoscopic simulation experience decreased from 3.30 ± 0.67 to 2.60 ± 1.17, p = 0.04. Conclusion: Residents may anticipate a benefit from adding a laparoscopic VR simulator to their lab; however, after using it for a brief period they find it to be less useful than expected, at least in part due to its lack of tactile feedback. Despite this, the VR simulator could still potentially promote greater utilization of the simulation lab.

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SIMULATION AND PERFORMANCE OF SINGLE SITE SURGERY Pamela Burgess, MD, Joel Brockmeyer, MD, Byron Faler, MD, Yong Choi, MD Dwight D. Eisenhower Army Medical Center

BIO-TEXTURE MODELING BY MULTIMATERIAL 3D PRINTING SYSTEM FOR LAPAROSCOPIC SURGICAL SIMULATION AND NAVIGATION Maki Sugimoto, title, Takeshi Azuma, title Kobe University Graduate School of Medicine

Introduction: Interest in Laparoendoscopic Single Site (LESS) surgery has been increasing in the past several years. While the benefits of LESS surgery are limited to cosmesis at this time, a recent survey performed at a meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) indicated that a majority of participants anticipated widespread acceptance of LESS surgery as a commonly used modality in the future. Citing improved cosmesis, theoretical reduced pain, and quicker return to work, more surgeons are offering this to patients. Despite definite benefits, LESS has been demonstrated to be safe in small studies. Laparoscopic simulation has become a necessity in training general surgeons. Studies have shown consistently that the more frequently a surgeon performs a procedure, the better they become. Much study has been done demonstrating that practice in a simulation lab can improve scores of set levels of skill which can be transferred to the operating room. Fundamental Laparoscopic Skills (FLS) has positioned conventional laparoscopy (LAP) within the general surgery curriculum by requiring graduating residents to be proficient with skills that have been validated as objective measures. We hypothesize that simulation training with LESS trainers will improve scores on the PEG transfer portion of FLS more than training on a conventional laparoscopic simulation trainers. Methods: Medical students were recruited and randomized to practice with a (LESS) surgery trainer or the standard FLS trainer. (LESS) training was performed with standard straight laparoscopic instruments using the GELPoint system (Applied Medical). Data was collected regarding gender, handedness, video game systems owned and hours played per week, as well as varsity sports played. They were given a brief introduction and allowed to practice for 15 min during which each completed [ 5 repetitions of transfer. They were then tested in the PEG transfer on the (LESS) surgery trainer. Results: 14 students were recruited for participation, 6 females and 8 males. The subjects were randomized into the two groups with seven subjects per group. All subjects were right handed. No difference was identified between groups in regards to age or gender. Mean score between the groups was 141 and 98 in the LAP and LESS groups respectively (p = 0.143). On regression analysis, varsity sports played and number of gaming systems owned were not significant. Female gender was found to be an independent predictor of a higher score, correlation coefficient of 58.530 (p = 0.045), as well as number of gaming systems owned, 29.359 (p = 0.026). Discussion: LESS surgery is on the forefront of surgical innovation with new technology constantly in development. While new technologies are intuitive, they have yet to show true utility and their learning curve has been prohibitive. This study, while small in number, demonstrates that after a single session there is no statistical difference between scores regardless of simulation system. An improvement in laparoscopic skills based on video gaming skills has been shown recently and is shown again in this study. The unexpected difference in scores between genders is interesting and requires further investigation.

Background: 3D printing technologies have been used for manufacturing patient-specific models used for planning surgical procedures. However the initial method has been simply printed out by one material. Our new technique of bio-texture modeling by multimaterial 3D printing system enabled simultaneous jetting of different types of model materials enabling the simultaneous use of two different rigid materials, two flexible materials, one of each type, any combination with transparent material, or two jets of the same material to form 3D organ textures and structures. We evaluate an anatomical 3D rapid prototyping modeling to facilitate planning and execution of the laparoscopic surgical procedure and educational aspects. Method: Based on CT and MRI images, regions of interest were segmented using OsiriX software. After generating an STL-file out of the patient’s data set, the inkjet 3D printer created a 3D multimaterial organ model. The patient individual 3D printed models were used to plan and guide the successful laparoscopic hepatobiliary surgery. The 3D objects using combination of transparent and soft materials allowed creation of translucent medical models that show visceral organs and other details that can be handled, overcome the limitation of the conventional imageguided navigation. The gel-like support material, which is specially designed to support complicated geometries, is easily removed by hand and water jetting. This enabled each composite material to provide specific values of biotexture for tensile strength and elongation to break. Discussion: These futuristic technologies provide better anatomical reference tool as a tailor-made laparoscopic surgical simulation and navigation, and contribute to medical safety/accuracy, less-invasiveness and improvement of the medical education for students and trainees. We applied its in robot-assisted laparoscopic surgery. The automation of robotic surgery would be possible by recording robotic surgical procedure using such 3D modeling. Conclusion: The bio-texture modeling by multimaterial 3D printing system combines the advantages of conventional 3D modeling, precise virtual 3D planning in laparoscopic surgery.

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NEW MINIMALLY INVASIVE SURGICAL APPROACHES— NOTES, LESS MINI: WHICH IS THE PREFERRED AMONG PATIENTS? Gustavo L Carvalho, PhD, Diego L Lima, Student, Adriano C Sales, Student, Rafaela L Gouveia, Student, Rebeca G Rocha, Student, Eduardo F Chaves, Student, Jose´ Se´rgio N Silva, MD Oswaldo Cruz University Hospital, University of Pernambuco, Faculty of Medical Sciences Background: The recent advances in laparoscopic surgery developed new technologies that can be established soon. However, it is difficult to find in medical literature articles considering the patient’s preferences regarding these new surgical accesses. Objective: Identify patient’s preferences among the new approaches. Methods: A questionnaire was applied to medical students. At first there was brief information about the techniques (Open Surgery, Laparoscopy, Minilaparoscopy, LESS and NOTES). Hypothetically, the participant would be submitted to a cholecystectomy. The first question was related to the opting for the open method. The second asked if they would consider LESS and NOTES despite these techniques are not totally safe yet. At the third, they rank in order of their preferences the different methods. The fourth asked which was the preferred among the new surgical approaches. The fifth was about the choice of a route for NOTES. At the sixth they must choose between LESS and Minilaparoscopy. The last asked which is the most important factor related to the decision among the approaches. Results: Two hundred thirty-eight questionnaires were answered. There were 135 female and 103 male respondents. The majority of the persons (83%) was between twenty and twenty-nine years old. Overall, 95 participants would consider the open surgery despite the four others options (LESS, NOTES, Laparoscopic and Minilaparoscopy). Among the new approaches (LESS, NOTES and Minilaparoscopy), the most popular as first option to the procedure was Minilaparoscopy which had the preference of ninety-two persons (39%). After that was LESS with 69 and in third place was NOTES with fifty-five. If only NOTES, LESS and Minilaparoscopy were offered, the participants0 preference was the same with to Minilaparoscopy (a hundred sixty-three). When only LESS and Mini were possible, 69% would prefer Minilaparoscopy. The overall preference for the route of NOTES was the oral (61%). The majority of the participants (85%) chose the safety as the most important factor to make a decision. And a hundred ninety-three respondents would not consider NOTES and LESS as therapeutics choices unless these procedures have proved its safety and effectiveness. Conclusion: Minilaparoscopy has been preferred for the patients who considered the safety the most important aspect, what makes to infer that this patients consider Minilaparoscopy as the safer technique.

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YOU HAVE A MESSAGE! SOCIAL NETWORKING AS A MOTIVATOR FOR FLS TRAINING Andrea M Petrucci, MD, Pepa Kaneva, MSc, Ekaterina Lebedeva, MLIS, Liane S Feldman, MD, Gerald M Fried, MD, Melina C Vassiliou, MD McGill University Health Center Introduction: Despite evidence supporting the value of FLS, surgical educators still find it challenging to motivate residents to practice. Web 2.0 technologies allow users to interact with, and contribute to material online. Examples include social networking and collaboration websites, and many learners are accustomed to these new communication platforms. Wiggio (W-I-G stands for Working In Groups) is an online tool that allows learners to track performance, see what their peers are doing and send and receive updates by email or SMS. The purpose of this study was to assess whether using Wiggio impacts practice patterns and performance of the FLS manual skills. Methods and Procedures: After baseline FLS testing, PGY-1 and PGY-2 general surgery residents were randomized into control (C) and Wiggio (W) groups. Online tutorials and logsheets were distributed to all participants to track practice events, time spent practicing and best scores. Each group practiced without proctoring. Residents in the Wiggio group interacted with each other via the Wiggio website. The website moderator sent motivational messages, calendar reminders and FLSrelated articles. Best times and progress graphs for each resident were also posted online. After 4 weeks, all residents underwent final FLS testing. Data are presented as means (SD) and compared using t-tests and nonparametric tests. Results: Fourteen residents were enrolled in the study, 7 in each group. During the study period, twice as many residents in the Wiggio group practiced compared to the control group (4 vs 2), had more practice events than the control group (14 vs 4) and spent more time practicing in the lab (1035 vs 480 min), although these results did not reach statistical significance. During practice sessions, proficiency scores were achieved for 40% of the tasks in the Wiggio group compared to 8.6% in the control group however, this difference was also not significant. FLS scores were similar at baseline (C 56.9 (SD); W 57. 6(SD) p = 0.93). Final scores in both groups improved compared to baseline, yet final scores in the Wiggio group were not better than the control group(C 76.5 (SD), W 73.3 (SD); p = 0.73). The moderator spent an average of 6.5 min per day sending messages and managing the Wiggio website. Conclusion: Participation in Wiggio seems to increase practice events and time spent in the lab for FLS training, however, further research with more subjects is needed to confirm these findings. Social networking can play a role in surgical education and learner motivation; the optimal use of Web 2.0 tools into resident education remains to be explored.

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CONCURRENT PERFORMANCE IN VIRTUAL REALITY AND CLINICAL ENDOSCOPY Mazen R Al-mansour, MD, Kelly M Tyler, MD, Ziad N Kutayli, MD, Angelica C Belo, MD, Paul F Visintainer, PhD, Neal E Seymour, MD Baystate Medical Center Introduction: The aim of the current study is to characterize concurrent performance of colonoscopy on a virtual reality (VR) simulator and in clinical endoscopy, and to determine if skills assessment results correlate in these two settings. Methods: Participants in the study were PGY 1–5 surgical residents (RES) and expert (EXP) endoscopists. Each participant performed a VR colonoscopy case on the Simbionix GI mentor II endoscopy simulator and an actual colonoscopy during a 2-week period. Built-in software-based measurements in the VR endoscopy simulator were used to evaluate performance on the simulator. The GAGES-C scale (Vassiliou, et al.) was used to evaluate clinical performance. Separate GAGES-C assessments were done by supervising attendings and by the resident performing the procedure (self-assessment). Data comparisons were performed by unmatched T-test. Cronbach’s alpha and intraclass correlation (ICC) were used to assess internal consistency and interrater reliability (IRR) of GAGES-C results, respectively. Pearson correlation was used to evaluate correlation of performance in VR and clinical colonoscopy. Results: The RES group (n = 9) consisted of 4 males and 5 females, mean age 28 ± 2 years, with prior endoscopy experience ranging between 0-35 upper endoscopies and 0-60 colonoscopies. EXP group (n = 6) consisted of 4 gastroenterologists and 2 colorectal surgeons, 4 male and 2 female, mean age 42 ± 7.0, with prior endoscopy experience ranging between 25-10,000 upper endoscopies and 300-5,000 colonoscopies. Mean GAGES-C scores for RES group performance on attending evaluation (2.5 ± 1.0) did not differ significantly from resident self-assessment (2.8 ± 1.2; p = 0.59). IRR was good with ICC = 0.78 (95% CI: 0.08–0.95) and internal consistency was excellent (Cronbach’s alpha = 0.94). Mean GAGES-C scores for residents were significantly lower than for experts for both EXP assessment and RES self-assessment (2.8 ± 1.2 versus 5 ± 0.0; p \ 0.005). On VR endoscopy mean time to reach the cecum was significantly less for EXP than RES group (4.12 ± 1.27 vs. 12.5 ± 10.25 min; p = 0.04), as was calculated mean sum of errors (7.9 ± 6.6 vs. 1.8 ± 2.0, p = 0.03). Efficiency of screening and time with clear view were not significantly different between groups. No significant correlation between VR endoscopy measures and GAGES-C scores could be demonstrated. Conclusion: Mean GAGES-C scores for measurement of performance in clinical colonoscopy demonstrated good IRR and excellent internal consistency. Expert endoscopists performed better than residents in concurrently performed VR and actual colonoscopies, confirming construct validity of the assessment systems employed. However, correlation of VR measures and GAGES-C scores could not be shown. We suspect that small sample size and vagaries of the nonstandardized clinical task versus highly standardized VR task are likely contributors to this finding.

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DEVELOPING A NEEDS ASSESSMENT FOR STANDARDIZED SURGICAL RESIDENT TRAINING IN BASIC ELECTROSURGICAL PRINCIPLES Jeffrey L Eakin, MD, Catherine E Beck, MD, Rebecca Detorre, Dean J Mikami, MD The Ohio State University Medical Center Introduction: Unintended electrosurgical injuries are preventable complications that may be a direct result of an insufficient fund of knowledge pertaining to electrophysics and electrosurgical equipment. In fact, some studies estimate that electrosurgical injuries may be responsible for 3 to 5 injuries per 1000 cases in varying surgical specialties. Currently, there is no standard in General Surgery training or proficiency requirement for electrosurgical principles. We performed a survey of General Surgery Residents at The Ohio State University who have been undergoing the Basics of Electro Surgery Training at The Ohio State University, to provide a needs assessment of proficiencies or deficiencies that exist, as perceived by current resident trainees. Methods: After receiving approval from the Institutional Review Board at Ohio State University, we performed an anonymous survey of current categorical and preliminary General Surgery Residents at The Ohio State University utilizing Google Forms. Statistical analysis was performed using Microsoft Excel 2008 for Macintosh. Results: Our survey response rate was 60% and included trainees in Post-Graduate Year (PGY) 1 through 6. Ninetytwo percent (92%) of residents claimed they never received electrosurgical training during medical school while 40% felt they had inadequate training during residency. Fifteen percent (15%) of residents felt they had been involved in a case where the improper use of electrosurgery caused a direct complication to the patient. Sixty-five percent (65%) of residents felt that a training course in electrosurgery would be most helpful during the PGY-2 or PGY-3 years. The other 35% indicated a training course would be most helpful during their PGY-1 year, and 35% overall felt they need an annual refresher course. Moreover, 65% of residents felt they were rarely to never taught electrosurgical principles in the operating room. When polled on how well they felt their attending physician understood basic electrosurgical principles, residents gave their attending physician an average of 3.5 on a 5-point scale. Similarly, they felt their peers’ general knowledge of electrosurgery was a 2.8 on a 5-point scale. Finally, 25 out of 26 (96%) residents felt a course in electrosurgery should be a necessary component of a general surgery residency. Discussion: Injuries related to the improper use of electrosurgery may be the direct result of inadequate to no preresidency education in the basics of electrophysics and inadequate training in electrosurgical techniques and equipment during training. Injuries related to electrosurgery could possibly be reduced by providing standardized training in electrosurgery during PGY 1 through 3 years of General Surgery residency with annual refresher courses, as well as increased efforts to teach basic electrosurgical principles, techniques and technologies to trainees in the operating room.

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Results: Objectives

WHICH SKILLS REALLY MATTER? PROVING FACE, CONTENT, AND CONSTRUCT VALIDITY FOR A COMMERCIAL ROBOTIC SIMULATOR Calvin Lyons, MD, David Goldfarb, MD, Brian Miles, MD, Rohan Joseph, MD, Richard Link, MD, Barbara L Bass, MD, Brian J Dunkin, MD The Methodist Institute for Technology, Innovation, and Education Background: A novel computer simulator is commercially available for robotic surgery. Initial validation studies have been limited due to a lack of understanding of which of the many provided skills modules and metrics are useful for evaluation. Construct validation studies are further limited in that medical students are used as a ‘‘novice’’ group – a clinically irrelevant cohort given the complexity of robotic surgery. This study systematically evaluated the simulator’s skills modules and metrics and investigated its face, content and construct validity using a relevant novice group. Methods: Expert surgeons deconstructed robotic surgery into eight separate skills. The content of the 33 modules on the da Vinci Skills Simulator (Intuitive Surgical) were evaluated for these eight skills and eight of the 33 determined to be unique. These eight tasks were then used to evaluate the performance of 46 surgeons and trainees (25 novices, 8 intermediate and 13 experts). Novice surgeons were mid-level general surgery and urology residents or practicing surgeons with clinical experience in open and laparoscopic surgery, but limited exposure to robotics. Results: Face and content validity were confirmed using global rating scales. Of the 85 metrics provided by the simulator, 11 were found to be unique. Experts performed significantly better than novices in all 8 tasks and for nearly every metric. Intermediates were inconsistently better than novices with only four metrics showing a significant difference in performance. Intermediate and expert performance did not differ significantly. Results for the ‘‘overall score’’—one of 11 metrics that performed well—are shown.

VR simulator

STEP simulator

Before endoscopy rotation (n = 35)

After endoscopy rotation (n = 34)

Before endoscopy rotation (n = 35)

After endoscopy rotation (n = 34)

Basic scope operation

3.2 (±0.5)*

2.2 (±0.7)

4.8 (±0.2)*

4.9 (±0.3)*

Scope setup & troubleshooting

1.2 (±0.3)*

1.1 (±0.2)*

4.7 (±0.2)*

4.9 (±0.1)*

Scope navigation

3.8 (±0.3)

3.2 (±0.1)

4.0 (±0.2)

3.7 (±0.3)

Visualization of colonic mucosa

4.4 (±0.2)

3.9 (±0.2)

3.8 (±0.4)

3.4 (±0.3)

Endoscopic biopsy

3.3 (±0.4)*

2.6 (±0.5)*

4.8 (±0.1)*

4.6 (±0.2)*

1 strongIy disagree, 3 neutral, 5 strongly agree mean (±SD) is shown. * Significance p \ 0.05

Conclusions: Trainees perceived the STEP simulator to be equivalent or better than the more expensive VR simulator for all five training objectives. The differences were particularly pronounced for the basic scope operation, scope setup/troubleshooting, and biopsy objectives. These were objectives for which having an actual scope, similar to that used during the endoscopy rotation, was perceived as most beneficial. The STEP program may enable training programs to achieve their stated goals for basic diagnostic colonoscopy training with low-cost alternatives to expensive commercial simulators.

Median [95% CI] Overall score

Novice

Intermed

Expert

Novice vs. expert

Novice vs. intermed

Intermed vs. expert

Energy

68 [63–74]

79 [70–91]

83 [76–86]

p = 0.004

p = 0.046

p = 0.726

Match board 3

34 [29–42]

41 [34–44]

55 [42–59]

p = 0.005

p = 0.139

p = 0.192

Peg 1

78 [66–79]

83 [75–92]

87 [81–92]

p = 0.006

p = 0.085

p = 0.612

Peg 2

82 [66–84]

94 [88–98]

93 [89–96]

p = 0.001

p = 0.006

p = 0.885

Ring walk 3

44 [29–49]

59 [38–70]

63 [56–70]

p = 0.001

p = 0.049

p = 0.190

Ring rail 2

43 [34–50]

79 [66–86]

75 [63–80]

p \ 0.001

p \ 0.001

p = 0.096

Suture sponge

40 [35–51]

66 [55–86]

68 [59–78]

p = 0.001

p = 0.003

p = 0.929

Tubes

50 [45–56]

73 [54–80]

71 [63–78]

p \ 0.001

p = .015

p = 0.447

Conclusion: This study systematically determined the important modules and metrics on the da Vinci Simulator and used them to demonstrate face, content, and construct validity with clinically relevant novice, intermediate, and expert groups. The results will be used to develop proficiency-based training programs and to investigate predictive validity.

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REALITY vs. VIRTUAL REALITY—A COMPARISON OF COLONOSCOPY SIMULATORS James Bittner, MD, Debra Tiemann, RN, Angelia Declue, Michael M Awad, MD PhD Washington University in St. Louis School of Medicine Introduction: In this era of proficiency-based training and limited duty hours, the role of simulation in medical education is becoming increasingly important. However, virtual reality (VR) simulators are often out of reach for most education centers because of their expense. In this study, we sought to compare the utility of a high-fidelity VR colonoscopy simulator to that of a low-fidelity plastic simulator and colonoscope received as part of the SAGES/ Olympus Surgeons Training Endoscopic Proficiency (STEP) program. Methods: From 2009–2011, 35 PGY-2 and -3 surgical residents participated in 2-h endoscopy training sessions, during which they performed simulated colonoscopy, then completed their formal endoscopy rotation. The objectives of the session were to learn (1) basic scope operation, (2) scope setup and troubleshooting, (3) scope navigation, (4) visualization of colonic mucosa, and (5) endoscopic biopsy. Residents trained for 1 h each using a VR colonoscopy simulator (*$20,000; Immersion Medical, Inc.) and the STEP colonoscope (CF-H160, Olympus America, Inc.). For the VR simulator, trainees performed the basic scope navigation, advanced scope navigation, and biopsy modules. For the STEP simulator, trainees were first given instruction regarding assembling and disassembling the scope/tower and then were asked to navigate through a custom-developed simulator made of hamster tubing based on a model from Southern Illinois University ($57.80). Within this model are numbered stickers, a pool of fluid for suctioning, and a simulated sessile polyp made of putty. After the training session, residents completed a survey rating the extent to which the five stated objectives were accomplished by each of the simulators (1 = Strongly disagree, 5 = Strongly Agree). At the conclusion of the four-week endoscopy rotation, trainees once again were asked to complete the same survey. Student’s t-test was used to compare survey responses between training groups (a = .05).

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TEACHING LAPAROSCOPIC SKILLS TO QUALIFIED SURGEONS WITH LIMITED LAPAROSCOPIC EXPERIENCE Muhammad F Murad, MBBS MCPS FCPS, Tariq Nawaz, MBBS FCPS, Qasim Ali, MBBS MCPS FCPS, Farhat Jehan, MBBS, Asif Zafar, FCPS FRCS Holy Family hospital Introduction: In most of the developed countries, laparoscopic surgery is part of resident training program which enables them to learn this technique when the surgical teaching is going side by side. In developing countries like Pakistan, laparoscopic surgery is still not widely practiced because of multiple factors and so it is not integral component of surgical resident training. In this case surgeons often acquire this skill after completion of their surgical training program. This is a different avenue of teaching laparoscopy to trained surgeons. This study is the experience of teaching laparoscopic skills to the trained surgeons and gynecologists in time specific curriculum. .Materials and Methods: Virtual Trainer Lab has been established at Holy Family Hospital Rawalpindi, Pakistan in collaboration with Virginia Commonwealth University, USA as part of PAK-US science and technology cooperation program. This is equipped with laparoscopic surgery training tools. Qualified surgeons and Gynecologists were randomly identified from all over the country. They were divided in beginners, basics, intermediate and expert level based on their practice of laparoscopy. Four days of structured training workshops have been arranged. This workshop included orientation and practice of 8 basic laparoscopic surgery skills in the lab followed by observer ship and assisting the basic laparoscopic procedures in the OR. Results: 107 surgeons and gynecologists from all over Pakistan have completed their basic laparoscopic training in 10 structured workshops. The mean post graduate experience of group in surgery was 12.7 yrs. (SD 6.9). Most of the training group was at basic level of laparoscopic skills. Improving the depth perception and equal utilization of both hands were most time taking skills during training of this group. There was significant improvement in the skills of trainees during four days enabling them to gain more confidence in introducing laparoscopy to their surgical practice. Conclusion: Structured workshops for teaching laparoscopic skills to qualified surgeons and gynaecologists in developing countries significantly improves the laparoscopic practice. The curriculum has to be revised to cater the needs of qualified surgeons having little or no experience of laparoscopy in the past.

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ENDOSCOPIC RECTUS ABDOMINIS MUSCLE HARVESTING—EXPERIMENTAL STUDY Alexandru I Blidisel, Assistant Professor MD PHD, Lucian P Jiga, Associated Professor MD PHD, Octavian Cretu, Professor, Razvan Tirziu, MD Phd, Mihai Ionac, Professor University Of Medicine and Pharmacy from Timisoara, Romania

MINIMALLY INVASIVE MANAGEMENT OF BLEEDING OBSCURE ORIGIN. EXPERIENCE LEVEL IV IN TWO INSTITUTIONS IN COLOMBIA Evelyn Dorado, MD, Jorge Bernal, MD Clinica Las Americas.CES University, Hospital Universitario San Ignacio Universidad Javeriana

Aim: The rectus abdominis muscle is one of the most frequent used free flaps in reconstructive surgery. Endoscopic harvesting of free flaps is increasingly used in reconstructive surgery due to minimal donor site morbidity. The present study aims in establishing a comparison between the experimental model of the rectus abdominis muscle endoscopic harvesting technique and the open harvesting technique in pigs. Material and Method: The study was conducted on 10 pigs with an average weight of 25-30 kg. 5 muscle were harvested by endoscopic technique and 5 muscle through the open technique After orotracheal intubation and anesthesia, a 4-5 cm incision is made in the inguinal plica and prolonged to the lateral margin of the caudal segment of the rectus abdominis muscle. Laparoscopic surgery instruments were used along with the Emory retractor The anterior and posterior side of the muscle is dissected using a forceps and a Hook. After the muscle is sectioned using the hook, the pedicle is isolated and clipped on the desired length. The work chamber is created using Emory retractors. Results: Operating time was 110 min for the open technique and 150 min with the endoscopic technique. During the study, the rate of conversion, bleeding, surgery duration, flap viability, length and aspect of the pedicle and moment of mobilization were followed. One pedicle was damaged during endoscopic surgery with following seroma development. Morbidity was lesser in animals where endoscopic harvesting was performed. Conclusions: Endoscopic harvesting of the rectus abdominis muscle leads to minimal donor site complications. At the same time, this techniques represents an excellent training model for developing endoscopic and open flap harvesting skills.

Introduction: The stromal Tumors are rare neoplasms of the gastrointestinal tract. It has an incidence of 4 per million people. They are derived from cells of Cajal located in the myenteric plexus and are related to intestinal motility. This type of neoplasm present with bleeding from obscure, unexplained anemia. Studies ordered for this type of pathology double balloon enteroscopy, videocapsula, endoscopy and colonoscopy to determine the site of bleeding. Main: Describe the minimally invasive management of patients with GIST of the small intestine studied as obscure bleeding . Methods: Retrospective descriptive. A sample of 3 patients over a period of one year July 2010–July 2011 with a history of anemia, blood transfusions for bleeding from obscure origen. In two cases detected by enterescopia, 1 case with enteroscopy assisted by laparoscopy but the mass was seen in the laparoscopy. Results: All three patients are carried by laparoscopy two with evidence of the injury site by the enteroscopy and videocapsula, and another with laparoscopic visualization of the mass. patient deserves a enteroscopy laparoscopically assisted . In all three cases were mass-dependent vascular proximal jejunum (3 cm ligament of Treitz) and distal jejunum in communication with the lumen of the gut and stigma of bleeding. Bowel resection was performed and stapled, anastomosis laterolateral, and closed handsaw, operative time 200 min, 100 cc bleeding, a patient being left with drain for the anastomosis 3 cm from Treitz, oral intake at 48 h, 4 days hospitalization, no complications from the procedure. Pathology report: Stromal tumors of low grade, less than 4 cm, with low mitosis. Conclusion: The small intestinal stromal tumors are rare, present with bleeding of obscure origin. Minimally invasive management is effective in both the oncology and in the speedy recovery of the patient, little need for pain medications and early discharge. All this can be guaranteed training in advanced laparoscopy The realization of laparoscopically assisted enteroscopy is easy to perform a comprehensive assessment helps when there is doubt the site of bleeding.

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GASTRODUODENAL INTUSSUSCEPTION—A RARE INTERESTING CASE REPORT Choden Norbu, MS, J S Basunia, MS, K Khan, MD, D Bagchi, MS, N Pandit, MD, A N Sarkar, MS, Jamyang Gyatsho, MS North Bengal Medical College and Hospital, Sushrutanagar, Darjeeling, West Bengal, India

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EFFECTS OF ORALLY DISINTEGRATED METOCLOPRAMIDE (ODM) IN OPTIMIZING LATE OUTPATIENT ENDOSCOPY: A RANDOMIZED DOUBLEBLIND PLACEBO-CONTROLLED CLINICAL TRIAL P Patrick Basu, MD MRCP MACG AGAF, Niraj James Shah, MD, Hemanth Hampole, MD, Thankam Nair, MD, Nithya V Krishnaswamy, MD, S Farhat, MD Columbia College of Physicians and Surgeons, NY, North Shore University Hospital at Forest Hills, NY

Gastroduodenal intussusception is by far a very rare clinical entity reported in the literature. We present a rare case in a 10 year old boy who presented to us with features of subacute gastrointestinal obstruction. A presumptive diagnosis of gastroduodenal intussusception was made which was later confirmed on Ultrasonography, Barium Meal study and Computed Tomogram of the Abdomen. At Laporotomy the distal part of the stomach and duodenum upto the 2nd part was poorly delineated and a hard mass was observed at the corresponding place. Multiple lymph nodes were observed interspersed throughout the entire gastrointestinal tract and the mesentery. Minimal free fluid was present. Manipulation of the mass for reduction was not possible as it was adherent. Hence a longitudinal incision over the mass was given extending from the anterior wall of the distal stomach, pylorus upto the duodenum. On opening and exposing the anterior wall of the stomach a chronic indurated mass was seen obliterating the lumen. Fine dissection was not possible and thus removed piece meal. The post wall of the stomach was left in situ as it was poorly defined. Duodenum was divided and closed. Partial gastrectomy with gastrojejunostomy and roux en Y jejunojejunostomy was constructed. Mesenteric lymph nodes were sent for biopsy and fluid sent for biochemical analysis. Our presumptive diagnosis intraoperatively was on the lines of a gastroduodenal intussusception secondary to a tubercular lymphadenitis or a lymphoproliferative disorder. The Ascitic Fluid analysis report documented an increased ADA level of 162 IU/L. The Histopathological Report of the lymph node that arrived subsequently came to a diagnosis of Non Hodgkins Lymphoma. On Immunohistocytochemistry the tumour cells showed strong immunoreactivity for CD 45 (Leucocyte common antigen) and B-cell marker CD 20. Moderate and weak immunoreactivity was noted for CD 10 and CD 30 respectively in the atypical tumour cells. These cells were also negative for CD 5 and CD 3. Hence, immunohistochemistry favored a diagnosis of Non Hodgkin Lymphoma, Diffuse large B cell type, germinal center subtype. Post operatively the patient was recovering well on his last visit and we have now referred him to a Medical Specialist for initiation of chemotherapy. Gastroduodenal intussusception is by far very rare and there have been very few case reports on this clinical entity. To the best of our knowledge Gastroduodenal intususception secondary to a Non Hodgkins Lymphoma has never ever been reported. Suprisingly we also observed that this patient had no systemic features suggestive of a lymphoid malignancy. It was only on histopathological and immunohistochemistry examination of the lymph nodes that the diagnosis was ascertained. The reporting of this case thus holds importance on three counts. First because it adds to the literature of the very few cases of gastroduodenal intussusception reported so far. Secondly, a Gastroduodenal intussusceptions secondary to a Non Hodgkins lymphoma has never ever been reported and finally for the fact that this Lymphoid malignancy could present as a gastroduodenal intussusception as the initial clinical manifesting feature, as was the case in our patient.

Introduction: Outpatient endoscopy is a standard procedure with one million procedures done every year. Approximately 320$ are lost for every days work lost both to the employer and the employee. Total 320 million dollars being lost every year. Six hours fasting for solids and 2 h for liquids are standard anesthesia guidelines prior to sedation. This study evaluates the beneficial effects of Orally Disintegrated Metoclopramide(ODM), a pro-motility agent, given 20 min prior to the procedure in the late afternoon with 5 h post lunch interval. Methods: 517 patients (age: 25–75 years) were randomized into three arms. Arm A (n = 172): ODM 10 mg, 20 min before endoscopy in the late afternoon; Arm B (n = 172): oral Metoclopramide 10 mg, 30 min before endoscopy; Arm C (N = 173): the placebo. The last solid meal was given at noon (one oz. of either chicken, turkey, or tuna with half an oz. of potato or fruits salads, without mayonnaise or dairy products, and 12 oz. of water) 5 h before endoscopy. The Anesthesiologist administered routine IV Propofol with documented pre- and post-sedation time. The total time of pan endoscopy with six biopsies and recovery time were evaluated. Exclusions: active GI bleeding, DM, BMI [ 33, neuromuscular diseases, known gastric motility disorders, gastric malignancy, and drugs altering GI motility. Results: The total sedation time was similar (p = 0.91) between the ODM (5.1 ± 0.9 min; mean ± SD) and oral Metoclopramide (5.6 ± 1.4 min) groups; both groups were significantly shorter (p \ 0.001) than the placebo (12.6 ± 3.4 min; p \ 0.001, one-way ANOVA). Likewise, the recovery time was comparable(p = 0.75) between the ODM (11.7 ± 4.3 min) and oral Metoclopramide (10.9 ± 4.4 min) groups, with both being significantly shorter (p \ 0.001) than the placebo (27.9 ± 6.5 min; p \ 0.001, one-way ANOVA). No major side effects were observed in the ODM group, while dizziness and confusion occurred in both the oral Metoclopramide (n = 11 and 7) and placebo (n = 20 and 12) groups. Conclusions: The use of ODM in outpatient endoscopy is beneficial over standard endoscopy with reduced amount of sedation, prompt recovery, a wider safety profile and immense cost benefits both to the employer and the employee. A multicenter trial is needed to validate these findings.

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HYBRID ENDOSCOPIC AND LAPAROSCOPIC GIST RESECTION Hoylan Fernandez, MD MPH, Ross Bremner, MD, Elbert Kuo, MD MPH St. Joseph’s Hospital and Medical Center Objective: Several novel approaches have been described for resection of gastric masses through minimally invasive surgical intervention. However, lesions in the cardia near the gastroesophageal junction still pose a surgical challenge. These lesions historically have been resected with a distal esophagectomy or proximal gastrectomy, or with an open operation with consideration of fundoplication. The following case reports describe an innovative surgical technique of endo-laparoscopically assisted gastric resection for lesions in close proximity to the gastroesophageal junction. Description of Methods: Intraoperative endoscopy was performed to locate the mass and ‘‘stent’’ the lower esophageal sphincter area. The mass of both patients reported, was located endoscopically and laparoscopically, in juxtaposition to the LES on the gastric side. Laparoscopy was performed and sutures were placed on either side of the anterior wall of the stomach and the stomach was opened with the Harmonic scalpel. The gastrotomy was kept open with the gastric retraction sutures passed through the anterior abdominal wall. A suture was placed through the mass for retraction. The laparoscope was introduced into the gastric lumen and an endoscopic stapler was passed around the base of the lesion. Serial firings were used transgastrically to remove the mass from the interior/mucosal aspect of the stomach. The mass was then placed in an endo catch bag and brought out through the umbilical incision. The gastrotomy was closed with a running 2-0 Vicryl suture and 2-0 silk sutures were used to imbricate the suture line in a Lembert fashion. Intraoperative endoscopy was subsequently performed to assess the lower esophageal sphincter and to assess for leak. The GE junction appeared intact with no eructation of air. In one of the patients, a Dor fundoplication was performed, given the proximity of the resection. Conclusions: The gold standard for treatment of gastric subepithelial tumors has been surgical resection. However, developments in the realm of endoscopy and laparoscopy have revealed the potential for novel surgical and cooperative approaches to gastric resection. Endoscopic submucosal dissection and laparoscopic and endoscopic cooperative surgery have developed various approaches to resection of gastric lesions. While endoscopic dissection techniques have made many advances in performance of minimally invasive gastric resections, the depth of invasion and proximity to the GE junction may necessitate further surgical intervention, which cannot be addressed with currently described techniques. In the past, these lesions have commonly been resected through the use of total or partial gastrectomy, transgastric enucleation, or wedge resection, and may interfere with LES function. Care must be taken to prevent stricture, vagal nerve injury, and reflux. The described novel surgical technique potentially permits further minimally invasive intervention, without disruption of the GE junction. Small to moderate sized gastric lesions such as these are amenable to resection with minimally invasive techniques. The method described in this case series eliminates the risk of perforation, and introduces new possibilities in the surgical intervention of early, small to moderate sized, or subepithelial gastric tumors near the GE-junction.

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SURGICAL OUTCOME OF LAPAROSCOPIC HELLER-DOR PROCEDURE FOR YOUNG PATIENTS WITH ACHALASIA Kazuto Tsuboi, MD, Nobuo Omura, MD, Fumiaki Yano, MD, Masato Hoshino, MD, Se Ryung Yamamoto, MD, Shunsuke Akimoto, MD, Hideyuki Kashiwagi, MD, Katsuhiko Yanaga, MD Department of Surgery, Jikei University School of Medicine, Tokyo, JAPAN Back ground: Endoscopic balloon dilation (EBD) and laparoscopic Heller-Dor operation (LHD) have been considered effective treatments for achalasia. Although most young patients require surgical intervention after repeated EBDs, these patients in Japan traditionally undergo EBD as a primary treatment because of minimally invasive nature of EBD as compared to LHD. The aim of this study is to evaluate surgical outcome of LHD for young patients with achalasia. Material and Method: The patients under 30 years of age who underwent LHD in our institution were extracted from the database. We analyzed patients’ background, pre- and post-operative symptom scores, and surgical outcome. Moreover, the surgical outcome of these patients were compared to those of patients equal to or over 30 years of age during the same study period. Results: Fifty-six patients met our inclusion criteria (male; 30, female; 26). As compared to older patients, preoperative body mass index in younger patients was significantly lower (19.1 vs. 20.8, p \ 0.001) but there were no significant differences in preoperative symptom scores except for chest pain. There were also no differences in surgical outcome such as operative time, blood loss, occurrence of perioperative complications, and postoperative course between the two groups. In younger patients, although frequency and severity of chest pain were improved postoperatively, these symptom scores were significantly higher than those of older patients (0.8 vs. 0.5, p = 0.009, and 1.4 vs. 0.8, p = 0.004, respectively). However patient satisfaction was comparable between the two groups. Conclusion: LHD obtained excellent patient satisfaction even in patients under 30 years of age, which might replace EBD as a primary procedure in such patients. Sensitivity of the distal esophagus may be retained in young patient with achalasia.

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BODY MASS INDEX DOES NOT AFFECT THE SURGICAL OUTCOME OF LAPAROSCOPIC HELLER-DOR SURGERY FOR ACHALASIA PATIENTS Kazuto Tsuboi, MD, Nobuo Omura, MD, Fumiaki Yano, MD, Masato Hoshino, MD, Se Ryung Yamamoto, MD, Shunsuke Akimoto, MD, Hideyuki Kashiwagi, MD, Katsuhiko Yanaga, MD Department of Surgery, Jikei University School of Medicine, Tokyo, JAPAN Back ground: Laparoscopic Heller-Dor surgery (LHD) is widely performed as the gold standard treatment for patients with achalasia. The most patients with achalasia suffer from body weight loss since dysphagia, the chief compliant of this disease is associated with disturbed oral intake. According by, the analyses of surgical outcome for LHD in view of body mass index are rare. The aim of this study is to clarify the effect of body weight on the surgical outcome of LHD. Material and Method: Between August 1994 and February 2011, 291 patients who underwent LHD in our institution. Of these, 7 redo patients and 53 patients whose follow up periods are less than one year were excluded, and the remaining 231 patients (age 43.8 ± 14.7 years, 107 women) were studied. Patients were divided into three groups by body mass index (BMI); group A, BMI \ 20 (n = 112); group B, BMI = 20-25 (n = 106), group C; BMI? 25 (n = 13). Surgical results, patients’ post-operative symptom scores, patients’ satisfaction, and post-operative course were compared. Results: The average age was 43.8 ± 14.7 and mean BMI was 20.3 ± 3.1 in our patients. Average BMI was 18.0 ± 1.5 in group A, 21.8 ± 1.3 in group B, and 28.2 ± 4.0 in group C. Group A was significantly younger (p = 0.026) and had significantly greater proportion of female gender than the other two groups (p = 0.002). There were no differences in operation time, blood loss, and the rate of mucosal injury between the three groups. Also, the post-operative symptom score and the satisfaction score were comparable. In addition, the occurrence of reflux esophagitis after surgery was not significantly different between the three groups. Conclusion: The surgical outcome of LHD and post-operative symptoms in patients with achalasia were not affected by body mass index (BMI).

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SURMOUNTING THE LEARNING CURVE OF THREEFIELD MIE: ONE INSTITUTION’S EXPERIENCE Jeffrey S Fronza, MD, Brett C Sheppard, MD, Paul H Schipper, MD, Brian Diggs, PhD, Miriam A Douthit, MA, John G Hunter, MD Oregon Health and Sciences University Introduction: Minimally-invasive esophagectomy (MIE) is a technically demanding operation and expertise is concentrated in a small number of high volume centers. Our institution has performed MIE for 10 years utilizing IvorLewis, transhiatal, and 3-field techniques. Three-field has only supplanted transhiatal as our preferred approach since 2009. In this study we report our entire experience with 3-field MIE in order to better understand its learning curve at an established center of esophageal surgery. Methods: The Natural History of Esophageal Cancer and Related Diseases database has prospectively accrued perioperative and long-term follow-up data on over 350 patients since 2004. After querying this database, 73 patients were identified as having undergone 3-field MIE between Oct 2005 and June 2011. This cohort was divided into an early and late group in terms of our experience with 3-field MIE. We hypothesized, based on existing esophagectomy literature, that a year in which greater than 20 3-field MIE were performed was necessary to surmount its learning curve. Thus the 35 patients who underwent 3-field MIE during the last 1.5 years of our experience were compared to the 38 patients who underwent MIE during previous years. Of specific interest were surgical morbidity, in-hospital mortality, and oncologic outcome. Results: The groups were similar in all preoperative factors except ASA class (84% ASA III in early vs. 31% in late [p \ .001]). Ninety-six percent underwent 3-field MIE for cancer, and 80% had adenocarcinoma or dysplasia of the gastroesophageal junction. Ninety-three percent of our cancer patients underwent neoadjuvant therapy. Complications occurred in 77% of patients (90% early vs. 63% late [p = .007]). All 7 conversions and all 3 mortalities were in the early group. There were 5 reoperations in the chest or abdomen, and all but one was in the early group. Anastomotic leak rate was 16% (26% early vs. 6% late [p = .018]). Two patients, both in the early group, required takedown of their conduit and cervical esophagostomy. Recurrent laryngeal nerve palsy occurred in 11% (18% early vs. 3% late [p = .033]). Chylothorax occurred in two patients in the late group, one of whom was successfully managed with IR coil embolization while the other required thoractomy. Pneumonia occurred in 37% of the early group and in only 14% of patients in the late group (p = .028). Atrial fibrillation was the most common complication in both groups (53% early vs. 23% late (p = .009). Median LOS was 13.5 in the early group vs. 9 in the late (p \ .001). An R1 resection was done on 5 patients in the early group, while only once in the late group. Median lymph node harvest was significantly better in the late group (16 early vs. 19 late [p = .014]). Conclusion: Three-field MIE remains a challenging operation, even in a high volume center. An institutional experience of one year with greater than 20 cases is needed to surmount the severe learning-curve, and subsequently results significantly improve. It appears prudent for these cases to be performed at institutions with a significant commitment to esophageal surgery as volume does matter.

Surg Endosc (2012) 26:S249–S430

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PERSISTENT GERD: DIFFERENT APPROACH Alaa Eldin Badawy, consultant of surgery, Ahmed Talha, Lecturer of surgery, Amani El-bana, Lecturer of Medicine, Ahmed Hemimi Assistant professor of radiology Alexandria university hospitals, Alexandria Medical research institute and faculty of medicine Objective: To evaluate the intra-abdominal esophageal length (IAEL) in GERD by MRI or multi-slice CT after upper GIT endoscopy in relation to GERD Q-questionnaire, also to see if this has an impact on the clinical course of the patient and response to medical or surgical therapy. Methods: Seventy patients presented by symptomatic reflux disease according to GERD Q-questionnaire. Investigations included upper gastrointestinal endoscopy (excluding hiatal hernia cases), esophageal manometry, Multi-slice CT and/or MRI for the lower esophagus. Basically all patients were treated medically, only cases of failed or poor response to medical treatment were converted to (group B) for surgery, rendering patients with good medical response as (group A). The esophageal intra-abdominal length was compared in both groups. Again GERD Q-questionnaire was used to assess the response to surgery weather Toupet fundoplication or 180 posterior fundoplication plus anterior truncal vagotomy after crural repair in both groups. Results: Medical treatment in the form of proton pump inhibitor and gastric prokinetic was successful in 50 cases (group A) with IAEL of 2 cm or more (mean 2.9 ± 1.8 cm) whole esophageal length (mean 38.5 ± 1.8 cm). Surgical treatment was done for 20 cases (group B) not well responding to medical treatment, IAEL was less than 2 cm (mean 1.4 ± 1.5 cm), whole esophageal length (mean 37.3 ± 1.5 cm). Upper gastro-intestinal endoscopy demonstrated negative endoscopy reflux disease–NERD-cases to be 31 (7 of them were in group B). There was a statistically significant difference between both groups for the whole esophageal length using the independent groups T-test (‘‘T’’ value of 2.6347, P = 0.0104), similarly the IAEL was very statistically significantly shorter in group B (‘‘T’’ value of 3.2934, P = 0.0016). GERD Q-questionnaire score in Group A had a mean of 10.3 ± 1.7, while Group B had a mean of 14.6 ± 1.6 that dropped postoperatively to 12.4 ± 1.1 for Toupet group-10 cases- (extremely statistically significant drop T = 3.8957, P = 0.0006) and to 10.8 ± 1.5 for the group where anterior truncal vagotomy was added (10 cases), with cessation of post-operative prokinetics and proton pump inhibitors in both surgical groups. There is still a statistically significant drop of the score between the two surgical techniques (T = 2.72, P = 0.014) with much improvement in symptoms and no significant side effects for adding anterior truncal vagotomy. Conclusion: In view of evidence based medicine IAEL of approximately 1 cm. in symptomatic GERD responded better to antireflux surgery with cessation of postoperative medication, results were enhanced if anterior truncal vagotomy was added to the partial posterior anti-reflux procedure. Though non-invasive, multi-slice CT and MRI can plan GERD management.

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ASSESSMENT OF OUTCOMES AFTER GASTRECTOMY OF GASTRIC CANCER IN THE UNITED STATES Mingwei Ni, MD PhD, Omar Bellorin-marin, MD, Alexander Kraev, MD, Kadar Oak, James Turner, MD, Litong Du, MD PhD New York Hospital Medical Center of Queens Introduction: Gastric cancer is one of the most common cancer globally, particular in Asia such as China, Japan and Korea. Although the prevalence of gastric cancer is not nearly as high in the United States as in Asia, the U.S. population tends to present with more advanced disease and have a worse prognosis than the Asian counterparts. The treatment armamentarium indeed differs widely between regions. Currently, gastrectomy remains the standard of care in the treatment of gastric cancer. While the natural history of gastric cancer in the U.S. markedly differs from that seen in Asia, the U.S. experience with gastrectomy techniques is beginning to parallel with those seen in Asian countries. This study investigates the outcomes after gastrectomy of gastric cancer in the U.S., including preoperative risk factors, morbidity and mortality rates. Methods: Patients undergoing gastrectomy in the U.S. from 2005 to 2009 were identified from the American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP). Using multivariate analysis of variance (ANOVA) and logistic regression, multiple comorbidity variables were analyzed to ascertain preoperative risk factors affecting gastrectomy outcomes. Post-operative morbidity such as re-operation, pneumonia, sepsis, re-intubation, deep venous thrombosis (DVT), transfusion, stroke and myocardial infarction, etc. were further studied to in this project. Results: Total of 2301 patients were recruited in the current study. The morbidity and mortality was 22.38% and 3.78%, respectively. The mean operative time was 219 ± 100 min. The mean length of hospital stays (LOS) was 11 ± 10 days. Current study has identified multiple risk factors associated with increased LOS. For example, compared with independent status, dependent functional status was associated with a 3.081-day increase in LOS (p = 0.005). Preoperative CHF was also associated with a 4.209- day increase in LOS (p = 0.0196). American Society of Anesthesiology (ASA) class 4 patients had a longest LOS. Compared to class 1 patients, class 4 patients was associated with a 7.52- day increase in LOS (p \ 0.001). Conclusion: Multiple factors were associated with increased post operative morbidity. These risk factors include acute renal failure, dialysis, sepsis, smoking, dyspnea and etc. Neoadjuvant radiation therapy and weight loss [ 10% were associated with increased operative time, whereas neoadjuvant chemotherapy, emergency case, HTN and stroke were associated with decreased operative time. Among all factors affecting LOS, the most strong factors are weight loss [ 10%, preoperative sepsis and ASA class 3 and 4.

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LONG-TERM OUTCOME OF LAPAROSCOPIC FUNDOPLICATION FOR GASTROESOPHAGEAL REFLUX DISEASE IN JAPANESE PATIENTS Fumiaki Yano, MD, Nobuo Omura, MD, Kazuto Tsuboi, MD, Masato Hoshino, MD, Yoshio Ishibashi, MD, Katsunori Nishikawa, MD, Yujiro Tanaka, MD, Hideyuki Kashiwagi, MD, Katsuhiko Yanaga, MD Department of Surgery, Jikei University School of Medicine Introduction: Laparoscopic fundoplication (LF) is an established surgical treatment for gastroesophageal reflux disease (GERD). However, since the number of surgeries in Japan is much lower than that in western countries, reports on the long-term outcome of surgical treatment are limited. In this study, long-term outcomes of LF for GERD at a single institution in Japan was evaluated. Methods: Three-hundred and fifty patients underwent LF for GERD to date. Among them, 112 patients who have been followed-up for more than 10 years were studied. There were 64 men (57%) and 48 women (43%). Their mean age was 53.3 (range, 18-85) years. Their clinical data were collected in a prospectively fashion and retrospectively reviewed. Long-term outcome was assessed in terms of operative procedure, peri- and post-operative complications, and recurrence rate after surgery. Recurrence was defined as post-operative recurrence of erosive esophagitis and/or evident hiatal hernia. Results: No operative mortality occurred. The mean follow-up period was 143.7 (range 120-198) months. Nissen procedure was performed for 62 patients (55%), Toupet procedure for 48 patients (43%), and the others 2 (2%) underwent Collis-Nissen procedure. A total of 20 peri-operative complications were observed in 20 patients (18%), consisting of bleeding mainly from the spleen (10%), and injuries of the vagus nerve (2%), stomach (2%), crus of the diaphragm (2%), esophagus (1%), or mediastinal pleura (1%), but no one required conversion to open surgery. Post-operatively, 11 patients (10%) complained of moderate to severe post-operative dysphagia and 2 patient (2%) required re-do surgery (Nissen to Toupet). Recurrence was diagnosed in 12 patients (11%), and 3 of them (3%) required re-do surgery. The other 9 patients (8%) were treatable with acid suppressive medications. The mean time to recurrence was 67.0 ± 54.0 (range 10-158) months. Three patients each recurred by 2 years, 2 to 5 years, and 5 to 10 years, respectively, while 2 patients recurred more than 10 years after surgery. As patterns of recurrences, 7 patients had sliding hiatal hernia with erosive esophagitis, 3 patients had a disrupted fundoplication, and 2 patients had paraesophageal hiatal hernia. Conclusion: Long-term non-recurrence rate of LF were 89%. LF is a safe and secure procedure for treatment of GERD.

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ESOPHAGEAL PERFORATION: ETIOLOGY, OUTCOMES AND COST ANALYSIS OVER A DECADE IN A COMMUNITY TEACHING HOSPITAL Tolutope Oyasiji, MD MRCS, Marko Lujic, MD MPH, Luis Suarez, MD, John Federico, MD FACS, Mario Katigbak, MD FACS Thoracic Surgery Section, Dept. of Surgery, Hospital of Saint Raphael, New Haven, CT 06511 Introduction: The study aims to assess if any difference in etiology, outcomes and treatment costs between the first 5-year and the second 5-year periods of the study. We hypothesize that length of hospital stay, hospital charges and mortality are decreased in the last 5 years of the study period to reflect advances in management of this condition. Perforation of the esophagus remains a rare but challenging clinical problem with significant mortality. Despite the many advances in thoracic surgery, the management of patients with esophageal perforation remains controversial. Practice standards are based primarily on retrospective reviews and expert opinions. Methods: An IRB approved retrospective review of 30 consecutive cases of esophageal perforation managed during the study period of Jan 2001–Dec 2010 was performed. Data analysis was done using parametric and non-parametric tests as appropriate. Results:

Jan 2001–Dec 2005 N = 14

Jan 2006–Dec 2010 N = 16

Mean age

71.7 year

70.2 year

Gender distribution

M = 8, F = 6

M = 7, F = 9

Mean no of comorbidities

0.71

0.75

Site of perforation

Proximal = 2, distal = 12

Prox = 2, distal = 14

Time to treatment

\ 24 h = 10, [24 h = 4

\24 h = 10 , [24 h = 6

Operative vs non operative

Op. = 11, non op = 3

Op. = 10, non op. = 6

Etiology

Spont. = 1, Iatrogenic = 12, FB = 1

Spont. = 1, Iatrogenic = 10, FB = 5

Mean LOS

22.8 days

14.3 days

Mean hospital charges

$132,134

$113,312

Mortality

3 [18.7%]

2 [12.5%]

Pneumonia

3 [18.7%]

2 [12.5%]

SSI [operative cases]

1

1

Mediastinal abscess

2

2

P value

0.80 0.72 0.98 1.00 0.71 0.44 0.26 0.43 0.76 0.64 1.00 1.00 1.00

Spont. spontaneous, FB foreign body

Conclusion: Both groups are comparable in terms of demographics, etiology of perforation & pattern of management. Outcomes like mean length of stay, mean hospital charges and mortality improved in the last 5 years but fail to achieve statistical significance. This argues for a prospective randomized clinical trial to further examine the hypothesis.

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PRIMARY COLONIC TYPE ADENOCARCINOMA OF THE CECAL APPENDIX: A RARE CAUSE OF CONVERSION IN LAPAROSCOPIC APPENDECTOMY Alexander Ramirez Valderrama, MD, Armando Castro, MD FACS New York Hospital Queens Appendix tumors are unusual, accounting for 0.4% of all of the gastrointestinal tract malignancies. Approximately 66% of all appendix tumors are carcinoid tumors; mucinous cystadenocarcinoma is the most common non-carcinoid appendix tumor and accounts for about 20% of appendix cancer cases, colonic-type adenocarcinoma accounts for about 10% of appendix tumors and usually occurs at the base of the appendix. This type of tumor looks and behaves like the most common type of colorectal cancer. It often goes unnoticed, and diagnosis is frequently made during or after surgery for appendicitis. We present a case of a 60-year-old female with abdominal pain for about 2 weeks, with right lower quadrant tenderness, without nauseas, vomiting, fever or chills. Initial work up shows elevated wbc (13.4), normal urinalysis, and abdominal CT scan with dilated appendix with wall thickening of the ileum with adjacent inflammation. Patient underwent to laparoscopic appendectomy, with findings of right lower quadrant phlegmon with difficult safe dissection, and the procedure was converted to open. During the procedure a pelvic collection of 20 cc of pus was drained, a distal ileocecostomy was performed and a JP drain was left on place. Patient had an uneventful recovery and was discharged home on postoperative day seven. Pathology report shows a well-differentiated adenocarcinoma at the appendix base with muscular infiltration to subserosa (T3) with 4 centimeters negative distal margin and eight lymph nodes all negative for malignancy. The case was presented on multidisciplinary tumor board conference and the decision was not perform any additional treatment and continues with a close follow up and colonoscopy.

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LAPAROSCOPIC TREATMENT OF BLEEDING DUODENAL ULCER Kamran Samakar, MD, Jose Tschen, MD, J Andres Astudillo, MD, Jason Wallen, MD, Carlos Garberoglio, MD Loma Linda University Medical Center Introduction: A 72 year old male presented to our tertiary care facility with a one day history of hematemesis and coffee-ground stools. The patient underwent initial resuscitation efforts, blood transfusion, and upper endoscopy. Endoscopy revealed a large posterior ulceration in the duodenal bulb with signs of slow bleeding and difficult visualization secondary to a large amount of blood clot burden. Attempts at endoscopic intervention were ultimately aborted due to limited visibility and procedure related respiratory decompensation. Subsequently the patient was taken to the operating room for surgical intervention. Objective: Presentation of a rare case along with a description of the procedure and accompanying images. A discussion of the role for laparoscopic surgery in the management of complications from peptic ulcer disease. Results: The decision to attempt laparoscopic treatment of this patients bleeding duodenal ulcer was based largely on his clinical presentation. His initial hemoglobin upon admission was 7.9 (gm/dl) and improved to 9.6 (gm/dl) after two units of packed red blood cells. While he continued to demonstrate signs of slow bleeding requiring blood products, the patient remained remarkably stable from a hemodynamic standpoint. Initial laparoscopic intervention was undertaken with the understanding that conversion to open repair would require haste if necessary. The patient underwent laparoscopic pylorplasty, oversewing of the gastroduodenal and transverse pancreatic arteries, truncal vagotomy, and placement of a feeding jejunostomy tube. The patient tolerated the procedure well and after a short stay in the ICU was ultimately transferred to the ward and subsequently discharged from the hospital. Discussion: Treatment of bleeding duodenal ulcers, including the management of hemorrhage and perforation, pyloroplasty, and vagotomy may be feasibly accomplished with the use of minimally invasive techniques. While case series and descriptions of minimally invasive techniques can be found in the literature, laparoscopic approach is usually not performed for acute hemorrhage due to difficulties with visualization and control of bleeding. In select, hemodynamically stable patients, the role of laparoscopic surgery in the treatment of complications from peptic ulcer disease has been advocated as both safe and effective. We report here a description of a laparoscopically treated bleeding peptic ulcer with accompanying intraoperative images and a discussion of the current literature on the use of minimally invasive techniques in this setting.

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LAPAROSCOPIC REPAIR FOR LARGE HIATAL HERNIA USING COMPOSITE MESH AND TEMPORARY ATTACHMENT TECHNIQUE Tatsushi Suwa, MD PhD, Kazuhiro Karikomi, MD, Naoki Asakage, MD PhD, Eishi Totsuka, MD PhD, Naokazu Nakamura, MD PhD, Keigo Okada, MD, Tomonori Matsumura, MD Kashiwa Kousei General Hospital Introduction: Recently elderly people has become majority and hiatal hernia also has become one of common diseases in many countries. Surgical treatment for the disease is sometimes needed. Primary repair of large hiatal hernia is associated with a high recurrence rate. Reportedly, the use of mesh reduces this recurrence rate. The indication for mesh use, the type of mesh to use, and the placement technique are controversial. We report our standard method in laparoscopic repair for large hiatal hernia using composite mesh and temporary attachment technique. Surgical Procedure Setting Our 5-trocar setting with patients in the reverse Trendelenburg’s position is as follows. A 12 mm trocar was inserted just below the navel for a laparoscope. A 5 mm trocar was inserted in the upper right abdomen for a snake-retractor to pull up lateral segment of the liver, and a holder was used for a snake-retractor. A 5 mm trocar was inserted in the upper abdomen for operator’s left hand. A 12 mm trocar was inserted in the upper left abdomen. A 12 mm trocar was inserted in the middle left abdomen. The operator is positioned between the patient’s legs. Step 1: Under laparoscopic view, repositioning of hernial contents was performed at first and the dissection of adhesion was often needed in this step. Step 2: We usually do not remove hernia sac from outside of the abdominal cavity especially in the large hiatal hernia cases. We cut the peritoneum to expose the hiatus and separate hernia sac. The bilateral crura have been dissected free, and the esophagus is being recognized. Step 3: The crura of the diaphragm were widely open and seemed difficult to be approximated with direct suturing. The defect was reinforced with Bard Composix E/X mesh (10 9 15 cm) which had two distinctly different sides, polypropylene mesh on one side to promote tissue ingrowth and sub-micronic ePTFE (polytetrafluoroethylene) on the other side to minimize adhesions to the prosthesis. The mesh shape was prepared by hands to be fit nicely to the defect. We used an absorbable tack fixation device for temporary attachment of mesh to the diaphragma. After the temporary fixation, the suturing could be performed very easily. Using nonabsorbable braided suture, stitches are placed between the mesh and the hiatus. The characteristic features of our procedure 1. Use of composite mesh 2. No removal of the hernial sac 3. Temporary attachment technique before suturing Results: This procedure needs 2 surgeons (the operator and the assistant (scopist)). A favorable outcome was assessed by radiograms performed during the hospital stay. There was no recurrence or abdominal symptoms during the followup period in all cases. Discussion: We think that the selection of mesh and the placement technique are important to avoid recurrence of hernia or mesh migration.

THE CHARACTERISTICS OF OUR PROCEDURES IN ANTIREFLUX SURGERY FOR GERD PATIENTS Tatsushi Suwa, MD PhD, Kazuhiro Karikomi, MD, Naoki Asakage, MD PhD, Eishi Totsuka, MD PhD, Naokazu Nakamura, MD PhD, Keigo Okada, MD, Tomonori Matsumura, MD Kashiwa Kousei General Hospital Introduction: Anti-reflux surgery is not as popular as medication. One of the reasons might be that laparoscopic techniques in the procedure are considered complicated by many surgeons, so we have simplified it and established a simple and practical procedure. Surgical Procedure Setting Our 5-trocar setting with patients in the reverse Trendelenburg’s position for laparoscopic Nissen fundoplication is as follows. A 12 mm trocar was inserted just below the navel for a laparoscope (A). A 5 mm trocar was inserted in the upper right abdomen for a snake-retractor to pull up lateral segment of the liver, and a holder was used for a snakeretractor. A 5 mm trocar was inserted in the upper abdomen for operator’s left hand. A 12 mm trocar was inserted in the upper left abdomen (B). A 12 mm trocar was inserted in the middle left abdomen (C). The operator is positioned between the patient’s legs. Step 1: Under laparoscopic view, left part of the lesser omentum was cut with preserving the hepatic branch of vagus nerve. The right crus has been dissected free, and the esophagus is being recognized. The soft tissue at the posterior side of the abdominal esophagus was carefully dissected. Then the left crus of the diaphragma was recognized from the right side. In this part of the procedure, laparoscope uses 12 mm trocar (A), the assistant uses 12 mm trocar (B) to pull the stomach to left lower side and the operator’s right hand uses 12 mm trocar (C). Step 2: The branches of left gastroepiploic vessels and the short gastric vessels were divided with LCS. The left crus of the diaphragma was exposed and the window at the posterior side of the abdominal esophagus was widely opened. In this part of the procedure, laparoscope uses 12 mm trocar (A) at the beginning of dividing left gastroepiploic vessels, 12 mm trocar (C) when dividing short gastric vessels and 12 mm trocar (B) at the last part of opening the window at the posterior side of the abdominal esophagus. The assistant uses 12 mm trocar (B-C-A) to pull the stomach. Step 3: The right and left crura are sutured with interrupted stitches to reduce the hiatus. From the right side, the stomach is grasped from behind the esophagus. Then the fornix of the stomach is pulled to obtain a 360 ‘‘stomachwrap’’ around the esophagus (fundoplication). Such as taping technique is not needed. Using nonabsorbable braided suture, stitches are placed between both gastric flaps. The characteristic features of our procedure 1. Floppy Nissen fundoplication 2. No use of bougie device or taping technique for esophagus 3. Rotation of scope site Results: This procedure needs 2 surgeons (the operator and the assistant (scopist)). The mean operation time was about 60 min. A favorable outcome was assessed by radiograms performed during hospital stay. Resolution of the symptoms was noted at follow-up 1 month postoperatively in mostly all cases.

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RETROGASTRIC HERNIA: AN UNUSUAL CAUSE OF INTESTINAL OBSTRUCTION Alexander Ramirez Valderrama, MD, Litong Du, MD FACS NEW YORK HOSPITAL QUEENS Internal herniation is an unusual cause of intestinal obstruction. Herniation of the intestine may be through a normal anatomical apertura or an abnormal structure. The incidence of internal hernia trough the lesser sac is very unusual, there are few reports on the literature. We present a case of a 53 year-old male with no significant past medical history who presented to emergency department for one day history of abdominal pain associated with nauseas and vomiting. The pain was severe and localized on the epigastrium and left upper quadrant. The patient got a abdominal CT scan that was consistent with small bowel obstruction and possible bowel ischemia. patient underwent to diagnostic laparoscopy and a large amount of ascitis and also necrotic bowel was noted in the left upper quadrant. at this time the procedure was converted to esploratory laparotomy and it was noted that the small bowel was incarcerated trough the lesser sac behind the stomach and necrotic small bowel was identified and resected. A primary anastomosis was done and the mesentery defect was closed with 3-0 vicryl. The patient had an uneventful recovery from the procedure and the patient was discharge home without any complications.

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LAPAROSCOPIC PYLORUS-PRESERVING GASTRECTOMY WITH INTRACORPOREAL DELTA-SHAPED ANASTOMOSIS Shinya Tanimura, PhD, Naoki Hiki, PhD, Soya Nunobe, PhD, Sayuri Sekikawa, Dr, Takehiro Chiba, Dr, Toshiyuki Kosuga, Dr, Takafumi Sato, Dr, Yoshikazu Hashimoto, Dr, Yohei Watanabe, Dr, Koshi Kumagai, Dr, Susumu Aiko, Dr, Takeshi Kubota, PhD, Takeshi Sano, PhD, Toshiharu Yamaguchi, PhD Cancer Institute Hospital, Japan Foundation for Cancer Research Aim: Recently, pylorus-preserving gastrectomy has been recognized a safe and feasible procedure as an option of the treatment for early gastric cancer in the middle third of the stomach. On the other hand, laparoscopic gastrectomy followed by intracorporeal reconstruction of the digestive tract has become popular according to the advance of laparoscopic technique. Here, we present the procedure and the shortterm outcomes of laparoscopic pylorus-preserving gastrectomy (LPPG) followed by intracorporeal anastomosis using linear staplers for early gastric cancer. Patients and Methods: As a general rule, the inclusion criteria of this procedure should be employed for early gastric cancer in the middle third of the stomach, more than 4 cm apart from the pyloric ring, without lymph node metastases in the preoperative examination, such as computed tomography and endoscopic ultrasonography. The mobilization of the stomach and the dissection of the regional lymph nodes are performed with almost a same method of the conventional gastrectomy, except for preservation of the infrapyloric artery and omission of the suprapyloric lymph node dissection. Intracorporeal gastrogastrostomy is undertaken by a functional end-to-end anastomosis using linear staplers between both posterior walls of the proximal and distal gastric remnants, which called ‘delta-shaped anastomosis. Results: Between August 2010 and March 2011, we carried out this procedure for 36 cases of early gastric cancer. The patients had uneventful postoperative courses except one patient, who suffered from minor pancreatic fistula treated conservatively. Conclusion: Laparoscopic pylorus-preserving gastrectomy with intracorporeal deltashaped anastomosis is a useful procedure with regard to treatment for early gastric cancer in the middle portion of the stomach.

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A CASE OF LAPAROSCOPIC BYPASS BETWEEN THE RESIDUAL STOMACH AND JEJUNUM BYPASS FOR ANASTOMOTIC RECURRENCE AFTER OPEN DISTAL GASTRECTOMY Yuichiro Tanishima, MD PhD, Norio Mitsumori, MD PhD, Masami Yuda, MD, Seryong Yamamoto, MD, Hiroaki Aoki, MD PhD, Toshiyuki Sasaki, MD, Katsunori Nishikawa, MD PhD, Nobuo Omura, MD PhD, Yoshio Ishibashi, MD PhD, Koji Nakada, MD PhD, Hideyuki Kashiwagi, MD PhD, Katsuhiko Yanaga, MD PhD Department of Surgery, Jikei University School of Medicine A 75-year-old man with advanced gastric cancer underwent open distal gastrectomy (Roux-Y). Postoperatively the proximal margin was judged cancer positive by pathological report. Two years after operation, he was admitted urgently with severe abdominal pain and vomiting. Computed Tomography showed dilation of the residual stomach, while the roux limb of the jejunum was not dilated, for which anastomotic stenosis by recurrence was suspected. He underwent exploratory laparoscopy, and such a diagnosis was confirmed. He underwent laparoscopic side-to-side anastomosis between the residual stomach and the Roux limb of the jejunum 10 cm anal side of the anastomosis. His postoperative course was uneventful, and oral intake was resumed on postoperative day 4. Laparoscopic bypass between the residual stomach and jejunum bypass is a rare surgical procedure, and herein we report such a case and review the literature.

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NON-OPERATIVE MANAGEMENT OF DELAYED ESOPHAGOJEJUNOSTOMY ANASTOMOTIC LEAK WITH ENDOSCOPICALLY PLACED STENT Richard Y Greco, DO, Dennis Bordan, MD FACS, Sohail Shaikh, MD, Erwin Douyon, MD St. Joseph’s Regional Medical Center Introduction: Gastric ischemia secondary to volvulus is an uncommon entity that is a life-threatening surgical emergency and carries a high morbidity and mortality rate. It typically involves a hiatal hernia. The repair consists of operative reduction with likely resection and esophagojejunostomy anastomosis. Post-operatively, these patients can develop anastomotic leaks, usually because of ischemia. Discussion: Esophageal anastomotic leaks typically have been managed surgically with multiple staged surgeries and have carried a high morbidity and mortality. Advances in technology and endoscopy have now permitted management of these leaks with fibrin glue, clips, and stents. This is being done with great success and allows non-operative management of these complications. Conclusion: Prior management of esophageal anastomotic leaks has typically been done surgically with multiple staged operations with high morbidity and mortality. New innovations permit the non-operative management of these complications with little morbidity or complications. Surgeons should be aware of these options and if this is not available to them, great consideration should be made to transferring the patient to an institution that has this technology. In the future, this technology should be made available to institutions that perform esophageal or gastric surgery.

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MODERN MANAGEMENT OF ESOPHAGEAL DIVERTICULA Armando Rosales-velderrain, MD, Steven P Bowers, MD, Ross F Goldberg, MD, Tatyan M Clarke, MD, Lauren M Olsen, Mauricia A Buchanan, RN, John A Stauffer, MD, Horacio J Asbun, MD, C D Smith, MD Mayo Clinic in Florida

COMPLETE LAPAROSCOPIC R-Y RECONSTRUCTION WITH HUNT-LAURENCE POUCH IN TOTAL GASTRECTOMY Koji Hattori, MDPhD, Kazunao Watanabe, MD, Hidemitsu Ogino, MD, Rai Shimoyama, MD, Jun Kawachi, MD, Hiromitsu Takeyama, MDPhD Shonan Kamakura General Hospital

Introduction: Esophageal diverticula are rare, with the largest series in the literature including less than 25 patients. Esophageal diverticula (ED) are typically characterized as either pulsion diverticula (PD), which result from an increased intraesophageal pressure, or traction diverticula (TD) that are associated to periesophageal chronic inflammation. Typically PD are epiphrenic, and TD midthoracic, but each can occur variably in location. When ED are large and/or symptomatic surgical management is indicated. Herein we report our experience with the surgical management of ED since applying minimally invasive surgical (MIS) approaches to this condition, which to the authors’ knowledge this represents the largest case series. Methods: Between 1997 and 2011, 36 patients underwent surgical management of symptomatic ED [17 men and 19 women, aged 67 ± 12 years, BMI 27 ± 4 kg/m2]. We retrospectively reviewed these patients’ records specifically looking operative approach, perioperative and long-term outcomes. Of the 36 patients, 31 had a PD (29 epiphrenic and 2 midthoracic), and 5 had a TD (1 epiphrenic and 4 midthoracic). Eleven patients had undergone a prior foregut operation for GERD or hiatal hernia (6), esophageal diverticulectomy (3), closure of an esophagobronchial fistula (1), and gastrojejunostomy with vagotomy (1). An esophageal motility disorder was present in 22 patients (PD, 21 and TD, 1). Three patients with a PD had an esophageal stricture. Results: A MIS approach was attempted in 29 patients, and completed in 26 patients [laparoscopic (Lap); 20 PD and 1 TD, video assisted thoracoscopy (VATS); 1 PD and 1 TD or (VATS-Lap); 2 PD and 1 TD]. Three patients were converted to an open approach, and another 7 patients underwent a primary open approach. Stapled diverticulectomy was performed in 30 patients (MIS, 21 and open, 9), 4 patients with PD underwent a diverticulum imbrication. An esophagogastric myotomy was performed in 29 patients (PD, 26 and TD, 3), and fundoplication in 23 patients (PD, 21 and TD, 2). During intraoperative endoscopy two staple line leaks were detected and oversewn. Perioperatively 6 patients developed complications, with 4 staple line leaks. None were in patients who had leaks identified intraoperatively. In 2 patients with postoperative leaks no myotomy was performed. The median hospital stay was 3 and 6 days for the MIS and open procedure, respectively. There were no perioperative deaths. During a median follow-up of 4 weeks (235), 2 patients developed recurrent diverticula; 1 had not undergone a myotomy. Only 1 patient who underwent resection and myotomy with fundoplication remained symptomatic. Conclusions: This large series of esophageal diverticula managed by MIS approach(s) confirms that the procedure is safe and relieves symptoms in the majority of patients. Leaks can occur and when found intraoperatively can be managed. Postoperative leaks were associated with prior diverticulectomy and not performing a myotomy at the time of diverticulectomy. An MIS approach should be offered when appropriate.

Objectives: Since 2004, after open total gastrectomy(OTG), we have included a HuntLawrence pouch formation in Roux en Y reconstruction protocol (PRY), in order to increase the amount of meal to be taken once. And since 2007, we had performed the PRY in laparoscopically assisted total gastrectomy(LATG) in 16 cases and we presented these reconstruction method and these results. However, at this point, the LATG-PRY method took longer operation time and had to make a mini open incision of 6 cm long and made many staplers. So, in order to resolve these problems, since 2009 we tried to improve our LATG-PRY method in 8 cases and reduced reconstruction time by the complete laparoscopic reconstruction. In the present study, we propose a protocol to overcome the technical weak points encountered during the former PRY procedures in LATG. Furthermore, some comparisons were made with those in case of former LATG-PRY and LATG-RY. Methods: The former procedures of PRY : Skin incision of 6 cm-length was made at the midline of epigastric region. Jejunum was pull out through incision, formed an inverted J-shaped pouch of 15 cm-long or a Y-shaped anastomosis, and then it was placed back into the abdominal cavity each other. The pouch was anastomosed with a circular stapler to the esophagus under direct vision through the 6 cm midline incision. The new procedures of PRY: All reconstructive procedures were performed under laparoscope. At the first the transverse mesocolon was opened in order to pull out the jejunum through the hole. The jejunum at 30 cm from Treitz lig was cut. The Y-shaped anastomosis was formed with a linear stapler and its entry hole was closed by suture. An inverted J-shaped pouch of 15 cm-long was formed and was anastomosed to the esophagus with a linear stapler and its entry hole was closed by suture. Results: Operation time: Average operation time of the former procedures(16 cases) was 78 min and one of the new procedures(8 cases) was 65 min. Hospital stay: The average length of hospital stay after surgeries was 6.0 days in the former procedures and 6.1 days in the new procedures. Amount of meals: The average amount of meals the patients could take per once in six months after the surgeries were 78.0% in the former procedures and 75.0% in the new procedures. So between the former procedures and the new ones, there were no differences in amount. The amount of meals the patient of both pouch methods could take were twice as much the patient of LATG-RY method(37.5%) could take. In the methods presented here, no severe complications such as anastomotic stenosis or leakage were encountered, indicating that these methods are safe and practical. Conclusion/Perspective: With the new procedures of LATG-PRY we had no handles through the mini-open incision. Therefore we had less stress under these operations and could reduce the average operation time by 13 min.

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LAPAROSCOPIC GASTRIC WEDGE RESECTION WITH PROPHYLACTIC FUNDOPLICATION FOR SUBMUCOSAL TUMOR AT GASTROESOPHAGEAL JUNCTION Jin-jo Kim, MD, Jung-sun Lee, MD Incheon St. Mary’s Hospital, The Catholic University of Korea Objective: Laparoscopic gastric wedge resection (LGWR) for a gastric submucosal tumor (SMT) which involved gastroesophageal junction (GEJ) is technically challenging because of difficulty in reconstruction of GEJ after resection and resultant damaged function of lower esophageal sphincter (LES). We report our surgical results of LGWR with prophylactic fundoplication in order to evaluate its clinical usefulness. Method: Four consecutive patients who underwent LGWR with prophylactic fundoplication at our institution from February, 2011 to September, 2011 were enrolled into this study. There were 2 male patients and 2 female patients with mean age of 62. The peripheral margin of SMT of the patients involved GEJ, except for that of one patient. The SMT of this patient was located at 1 cm beside the angle of His and the patient has suffered from gastroesophageal reflux disease (GERD) with her hiatal hernia. None of the rest had suffered from GERD, preoperatively. All SMT’s of the patients were suspected as a gastrointestinal stromal tumor (GIST) in preoperative study. After resection of tumor, GEJ was reconstructed with 2-layered interrupted or continuous intracorporeal suturing or both. After reconstruction of GEJ, crural repair and partial or total fundoplication (2 Dor, 1 Toupet, 1 Collis-Nissen) were performed. Results: The average size of the SMT was 4 cm and the pathologic results were GIST in 3 patients and leiomyoma in 1 patient. The mean operation time was 244 min and oral feeding was started at 3rd postoperative day. The mean postoperative hospital stay was 7 days. There were no postoperative morbidity nor mortality. During the mean 5 months of postoperative follow up, all patients eat very well without any difficulty of swallowing, without symptom of GERD. Conclusion: LGWR with prophylactic fundoplication for SMT at GEJ was safe and clinically useful. It can be a good surgical option for those patients instead of total or proximal gastrectomy.

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UNCUT ROUX-EN-Y RECONSTRUCTION AFTER LAPAROSCOPIC DISTAL GASTRECTOMY Yong Jin Kim, MD PhD SCH Hospital Roux-en-Y gastrojejunostomy is one of the reconstruction methods for the prevention of alkaline reflux gastritis, esophagitis, dumping syndrome, and carcinogenesis of the gastric remnant. However, some patients who receive Roux-en-Y gastrojejunostomy suffer from the Roux stasis syndrome. To prevent this syndrome, a new type of reconstruction, called the uncut Roux-en-Y technique, has been reported. We successfully performed 24 uncut Rouxen-Y gastrojejunostomies after laparoscopic distal gastrectomy. Here we describe our technique and the initial outcome.

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EXPERIENCE OF DUAL INCISION LAPAROSCOPYASSISTED DISTAL GASTRECTOMY (DI-LADG) FOR PATIENTS WITH GASTRIC CANCER Hidenori Fujii, MD PhD, Yoshiyuki Kawakami, MD PhD, Toshiharu Aotake, MD PhD, Koji Doi, MD PhD, Makoto Yoshida, MD, Kei Hirose, MD, Hisaya Shirai, Riki Ganeko, MD, Fumie Tanaka, MD, Yuki Hirose, MD PhD Department of Surgery, Fukui Red Cross Hospital Introduction: Since laparoscopic assisted distal gastrectomy (LADG) is less invasive, it has been extensively used and its safety has been being recognized. On the other hand, reduced port surgery has been considered as a next step in minimal access surgery. We introduced Dual Incision Laparoscopy-Assisted Distal Gastrectomy (DI-LADG) using the technique of transumbilical single incision laparoscopic surgery. Surgical Technique: A 2.5-cm longitudinal skin incision was made at the umbilicus and subcutaneous tissue was dissected. A 100-mm XCEL trocar 12 mm in diameter was inserted from the center of the area without fascia and an oblique-viewing endoscope 10 mm in diameter was used. A 65-mm Endo tip cannula (ETC) 6 mm in diameter was inserted from the right of the umbilicus to observe the peritoneal cavity and the location of the duodenum was confirmed. XCELs 12 mm in diameter were inserted at both ends of a small incision (5 cm) that was planned to make just above the duodenum in the epigastrium, and an ETC was inserted at the left of the umbilicus under endoscopic observation via the port at the epigastrium. Devices were controlled intraperitoneally in LADG through these five ports. A surgeon, standing between the legs of the patient, was in charge of the port at the umbilicus, while an assistant, standing on the left of the patient, used ports at the epigastrium at the beginning of surgery. According to the site of lymphadenectomy, it was possible to adjust the line of lymphadenectomy during surgery by switching the positions of the surgeon and the assistant, which would shorten the operation time. When the duodenum was resected, a 30-mm oblique-viewing endoscope 5.5 mm in diameter was inserted from the ETC and a linear stapler was inserted from the XCEL trocar at the umbilicus. After completion of the intraoperative maneuver for duodenal resection, gastric resection and gastrointestinal reconstruction were carried out through the 5-cm small incision that was made between the sites where two ports were created at the epigastrium. Taken together, dual incisions, consisted of a single incision at the umbilicus generally for single incision laparoscopic surgery and a transverse incision at the epigastrium, were made and the wound scar at the umbilicus was inconspicuous. No special access port or flexible forceps was required in this method and some pairs of conventional straight forceps were used. Therefore, the method was economical. Results: DI-LADG was performed in 12 cases. No additional port was required in any case and lymphadenectomy of D1 + lymph node number 7, 8a, and 9 (around the left gastric artery, common hepatic artery, and celiac artery) was possible. Compared with the conventional LADG, operation time was longer but there was no significant difference in the amount of bleeding and the number of resected lymph nodes. Conclusions: From the point of view of reduced port surgery, DI-LADG was considered an option for laparoscopic surgery.

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LAPAROSCOPIC WEDGE RESECTION OF THE STOMACH FOR EARLY GASTRIC CANCER Tsutomu Sato, Yasushi Rino, Koichiro Yamaoku, Hirohito Fujikawa, Daisuke Inagaki, Roppei Yamada, Takashi Oshima, Norio Yukawa, Toshio Imada, Munetaka Masuda Department of surgery, Yokohama City University, School of Medicine Background: Sentinel lymph nodes (SLNs) mapping has been recently introduced to the field of gastric cancer. The aim of the present study was to evaluate laparoscopic wedge resection of the stomach for early gastric cancer with lymphatic basin resection. Methods: Eleven patients with cT1N0M0 gastric cancer were enrolled. Endoscopic injection of patent blue dye was performed during operation. Laparoscopic wedge resection of the stomach with lymphatic basin resection was performed in all patients. Dissected nodes were evaluated by pathologic examination(HE stain). Results: The mean operation time and bleeding blood loss was 271.0 min, 131.7 ml. SLNs were identified successfully in all cases. The mean number of identified SLNs per case was 3.9, and dissected lymph nodes per case was 10.5. There was no postoperative complication. The mean postoperative hospital stay was 10.8 days. With a median followup of 45 months, no recurrent case was observed. Conclusions: Laparoscopic wedge resection of the stomach with lymphatic basin resection may be an acceptable option for patients with early-stage gastric cancer. We plan to study this operative method further in gastric cancer with cT1N0.

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SINGLE INCISION LAPAROSCOPIC NISSEN FUNDOPLICATION IN 11 PATIENTS WITH GERD Kazuo Tanoue, MD PhD FACS, Hidenobu Okino, MD PhD, Yasuhiro Nozoe, MD PhD, Masamitsu Kanazawa, MD PhD, Kiichiro Ueno, MD PhD Ueno Hospital, Fukuoka, Japan Background: Laparoscopic Nissen fundoplication has been recognized as the standard procedure for gastroesophageal reflux disease (GERD). Single incision laparoscopic surgery (SILS) is one of the newest branches of advanced laparoscopy, and its indication has been spread to not only simple surgery such as cholecystectomy, but also complex digestive surgery. Patients and Methods: We performed single incisional laparoscopic Nissen fundoplication (SILN) for GERD in 11 patients during April 2010 to August 2011. Pure SILN (P-SILN) was performed in the former 6 patients, and SILN plus one puncture of a thin instrument (SILN+1) was performed in the later 5 patients. Establishment of the ports: A 25-mm vertical intra-umbilical incision is made for port access. One 5-mm optical port and two 5-mm ports were placed side-by-side through the umbilical scar. An additional instrument (RoticulatorTM, Covidien, Tokyo, Japan) for liver retraction was placed through the umbilical scar for P-SILN, or an additional 3-mm grasper instrument for assistance was directly inserted through the upper left abdominal wall for SILN+1. Original method of Liver Retraction: PDS loop suture (PDSII, a needle 48 mm, thread 150 cm in length; Ethicon) and a 2-0 silk thread which was passed in the loop were prepared. The PDSII was directly inserted into the peritoneal cavity through the abdominal wall. After suturing the muscle around the hiatus of the esophagus, the PDS loop was tightened at sutured place. The loop was cut and these PDS threads were taken out of appropriate places using the percutaneous suture-passing device (Lapa-Her-ClosureTM, Hakko, Tokyo, Japan), and fixed above the skin with clamps. Finally, the left lateral segment of the liver can be retracted with three threads (Two PDS and one silk thread) of the different direction. Surgical Procedure: The procedure was carried out in the conventional fashion with dissection of the esophagus and the cardia of the stomach, which was brought down below the esophageal hiatus with adequate length and without tension. The crura were identified and dissected, and short gastric vessels were divided to mobilize the gastric fundus. Closure of the crura and a floppy Nissen fundoplication were performed with 2-0 polypropylene (Prolene, Ethicon, Tokyo, Japan) sutures tied extra-corporeally with the pre-tied knot technique. Results: There was no conversion to the open surgery, and no intra-operative complication. The preoperative complaint improved after surgery in all patients. There was no significant difference in the operative time and the blood loss between P-SILN and SILN+1 (221.7 ± 24 vs 207 ± 45.4 min, 18.2 ± 25.6 vs 19 ± 23.8 g, respectively). The conversion rate to the conventional surgery in P-SILN was 33.3% (2/6), and that in SILN+1 was 0% (0/5). There was no significant difference in sex, age, BMI, post-operative stay, and post-operative complication. Discussion: Our results suggest that SILN is a safe and feasible method. Although P-SILN was excellent in cosmetics, the conversion rate to the conventional surgery was high. Since SILN+1 can be performed entirely same as the conventional fashion and its cosmetic outcome is permissible, it seems that SILN+1 is superior to P-SILN.

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META-ANALYSIS OF STAGING LAPAROSCOPY VERSUS COMPUTED TOMOGRAPHY IN OESOPHAGOGASTRIC CANCER STAGING Matthew F Leeman, MBChB MSc MRCS Department of Surgery, Royal Infirmary of Edinburgh, UK Introduction: Accurate staging before potentially curative resection is essential in patients with oesophagogastric (OG) cancer. The aim of this study was to review the evidence for Staging Laparoscopy (SL) and Computed Tomography (CT) in OG cancer, with particular reference to peritoneal metastases (PM). Methods and Procedures: Medline, EMBASE and the Cochrane library were searched for relevant studies and the results reviewed systematically. Pooled sensitivity, specificity and area under curve (AUC) for receiver operating characteristic curves were calculated. Results: 133 studies were reviewed and 43 studies were accepted for meta-analysis. Random-effects pooled sensitivity and specificity of SL for overall resectability were 77.1% (95% CI 74.8–79.2) and 99.9% (99.6–1.00); for CT, sensitivity and specificity were 39.7% (28.5–51.9) and 97.2% (92.2–99.4). Resectability AUC of SL and CT were 0.9843 (Standard error 0.0029) and 0.8614 (0.0592), respectively. For PM detection, the sensitivity and specificity were 86.5% (82.0–90.2) and 98.5% (97.5–99.2) for SL and 29.1% (19.8–39.9) and 100% (98.4–100) for CT. AUC of SL and CT for PM were 0.9815 (0.0066) and 0.9257 (0.0391), respectively. Conclusion: SL is an important tool in confirming the resectability of OG cancer, particularly with respect to the detection of PM.

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THE DIAGNOSTIC ACCURACY OF MULTI-DETECTOR CT VERSUS STAGING LAPAROSCOPY IN OESOPHAGOGASTRIC CANCER PERITONEAL METASTASES Matthew F Leeman, MBChB MSc MRCS, Patel Dilip, FRCR, Anderson Judith, FRCR, Simon Paterson-brown, MBBS MPhil MS FRCSEd FRCSEng Department of Surgery, Royal Infirmary of Edinburgh, UK Introduction: Accurate staging before potentially curative resection is essential in patients with oesophagogastric (OG) cancer. Staging Laparoscopy (SL) is the current gold standard investigation for detecting peritoneal metastases (PM) but Computed Tomography (CT) technology is undergoing rapid improvements. The aim of this study was to investigate whether multi-detector CT can replace SL. Methods and Procedures: The operation notes of SL performed in Edinburgh between January 2008 and December 2009 were reviewed for the detection of PM. Corresponding CT scans were re-assessed by two experienced gastrointestinal radiologists. Results were compared with findings at subsequent resection or biopsies with histological confirmation of PM. Results: 63 SL were included in the study. The sensitivity and specificity of SL for PM were 90% (95% CI 54.1–99.5) and 100% (90.4–100). CT review by radiologist 1 yielded sensitivity and specificity of 30% (8.1–64.6) and 91.3% (78.3–97.2). For radiologist 2 the sensitivity and specificity were 66.7% (30.9–91.0) and 88.9% (75.2–95.8). Crosstabulation yielded substantial agreement (Kappa 0.663). Conclusion: SL remains the gold standard staging investigation for PM in OG cancer. At present CT cannot replace SL for the detection of PM in OG cancer staging.

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LAPAROSCOPIC HAND-SEWN ESOPHAGOJEJUNAL ANASTOMOSIS AFTER LAPAROSCOPIC TOTAL GASTRECTOMY FOR GASTRIC CANCER Susumu Inamine, MD, Yasuaki Mayama, MD, Tomofumi Orokawa, MD, Osamu Kakazu, MD, Hiroki Sunagawa, MD, Tetsuo Toyama, MD, Hisamitsu Zaha, MD Nakagami General Hospital Background: In Japan, laparoscopic distal gastrectomy (LDG) has been widely accepted for the treatment of early gastric cancer. However, laparoscopic total gastrectomy (LTG) is not widely accepted because of the difficulty of reconstruction after total gastrectomy. In particular, making an esopagojejunal anastomosis under laparoscopy is very challenging. Several techniques using circular staplers or a linear stapler for the anastomosis have been reported, but the methods using staplers are not easy enough to perform safely. Therefore, we developed a hand-sewn esophagojenunal anastomosis technique under laparoscopically without the need for a mini laparotomy. To date, we have performed 14 laparoscopic hand-sewn esophagojejunal anastomosis procedures. The aim of this study was to confirm the technical feasibility and short term safety of the novel technique. Materials and Methods: From June 2010 to May 2011, 14 consecutive patients (8 male and 6 female) diagnosed with early gastric cancer underwent laparoscopic total gastrectomy by a single surgeon at our institution. After radical lymph node dissection, the abdominal esophagus was mobilized and transected with an endolinear stapler. The specimens were retrieved from an umbilical port extended to 3 cm. Reconstruction was made in the Roux en Y manner via the ante- or retrocolic route. First, the jujunojejunostomy was made laparoscopically with the endolinear stapler mixed with hand suturing. The cut end of the abdominal esophagus was opened with laparoscopic coagulating shears (LCS), and a 2.5 cm hole was made at antemesenteric side of the jejunum for anastomosis using the LCS. Finally, an end-to-side esophagojejunal anastomosis was made with hand-sewn single layer interrupted sutures using 3-0 absorbable sutures. After completion of the anastomosis, a leak test was performed for all patients. There were no cases with leaks. Results: The totally laparoscopic Roux en Y reconstructions with hand-sewn esophagojejunostomies were performed successfully in all of the patients. There were no cases that had to be converted to open surgery. The median suturing time for the hand-sewn esophagojejunal anastomosis was 51.5 min (range, 34–85 min), and the median number of stitches was 16.5 (range, 14–24). No anastomotic leakage occurred. All patients were discharged within 2 weeks without any perioperative complications. Endoscopic studies revealed only two cases of anastomotic stenosis. The periods when the anastomotic stenosis at the esophagojejunostomy developed were at 5 weeks and at 3 months after surgery. One patient was under hemodialysis for chronic renal failure, and the another was complicated with polycythemia. Both patients were successfully treated with endoscopic balloon dilatation.

Conclusions: Laparoscopic hand-sewn esophagojejunal anastomosis during laparoscopic total gastrectomy for early gastric cancer is feasible and safe. So far, the most common drawback to this novel technique is anastomotic stenosis.

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EFFICACY OF LAPAROSCOPIC GASTRIC MOBILIZATION FOR ESOPHAGECTOMY: COMPARISON WITH OPEN THORACO-ABDOMINAL APPROACH Hiroyuki Kitagawa, Tsutomu Namikawa, Jun Iwabu, Michiya Kobayashi, Kazuhiro Hanazaki Kochi Medical School Background: Less invasive esophagectomy using laparoscopic or thoracoscopic surgery has been reported better than conventional open thoraco-abdominal approach. But few report directly compared laparoscopic gastric mobilization (LGM) and thoracotmy with laparotomy and thoracotomy. The aim of this study was to investigate the efficacy of LGM compared with open thoraco-abdominal esophagectomy (OE) on thoracic esophageal cancer. Methods: We retrospectively reviewed 92 consecutive patients underwent esophagectomy by OE (n = 47) or LGM (n = 45) between 1999 and 2009 at Kochi Medical School to analyze the surgical outcomes. Results: Patients underwent LGM had significantly lower intraoperative blood loss (430 vs. 1060 ml, P \ 0.001), lower rate of postoperative infections (POI) (33.3 vs. 55.3%, P = 0.034), shorter length of ICU stay (1 vs. 3 days, P \ 0.001), and hospital stay (35 vs. 46 days, P = 0.003). Conclusions: The current study demonstrated that LGM was of clinical benefit for patients with resectable esophageal cancer and safer procedure compared to OE. Our results suggested that LGM for esophageal cancer reduced the POI and shorten the duration of hospital stay compared with OE.

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LAPAROSCOPIC MANAGEMENT OF BOWEL OBSTRUCTION, THE ALL INCLUSIVE APPROACH, IMPROVES OUTCOMES Christopher W Salzmann, MD, Morris E Franklin, MD FACS, Karla Russek, MD Texas Endosurgery Institute Background: Multiple series on laparoscopic management of Bowel obstruction have been published. Most are limited to likely cases of adhesive Small Bowel Obstruction and exclude patients with hernias and/or Colon Obstruction. We present our series on the ‘‘all inclusive approach’’ to laparoscopic treatment of bowel obstruction. Methods: From 1991 to 2010, 448 patients underwent laparoscopy for Bowel Obstruction. Results: Laparoscopic management was successful in 74.5%. There were 62 enterotomies (13.8%). Mean length of stay was 10.4 days. Mortality was 1.7%. Significant differences were found between the Laparoscopic and Converted patients in enterotomies (6.4% vs 40%), Mean ASA score (2.47 vs. 2.94), Blood loss (49.183 vs. 177.35 cc), Length of surgery (94 vs. 166 min.), length of stay 9.485 and 14.714 (p value 0.008) and in the Nonenterotomy and Enterotomy length of surgery (94 vs. 149 min.) and Blood loss (64 vs. 127 cc). Linear regression showed a relation between ASA score and Length of Stay (p value 0.0001). Conclusion: Bowel Obstruction can be managed by laparoscopy in 74.5% of cases. Conversion is associated with a significant increase in blood loss, operating time, a greater number of enterotomies and increased length of stay, with the latter being related to patient co-morbidites.

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A SURVEY OF PEDIATRIC SURGEONS’ EXPERIENCE WITH LAPAROSCOPIC PYLOROMYOTOMY Charles W Hartin, M A Escobar, S T Lau, S Z Yamout, Michael G Caty, Y H Lee Women and Children’s Hospital of Buffalo, State University of New York at Buffalo, Mary Bridge Children’s Hospital & Health Center, Kaiser Permanente Los Angeles Medical Center, University of Rochester Medical Center Purpose: The purpose of this study is to survey practicing pediatric surgeons about their preferred technique for pyloromyotomy (laparoscopic versus open), and, if experienced, their management of mucosal perforation. Methods: An IRB approved survey was sent to the 889 members of the American Pediatric Surgical Association and the Canadian Association of Paediatric Surgeons. Data collected included surgeon demographics, preferred pyloromyotomy technique, experience with mucosal perforation, and repair methods. Results: 401/889 (45%) surgeons responded. Most report performing an open pyloromyotomy (55%) over a laparoscopic approach (32%). 12% use both approaches routinely. More surgeons reported having a perforation during an open pyloromyotomy (61%) than during laparoscopy (26%). Of those experiencing a mucosal perforation, 97% recognized the perforation intraoperatively during an open procedure versus 86% during laparoscopy. Most surgeons (85%) converted to an open procedure for repair when encountering a mucosal perforation during laparoscopy. Primary mucosal repairs with Graham patch was the most common repair technique reported. Conclusions: Of the pediatric surgeons surveyed, more performed open pyloromyotomy. More surgeons experienced a mucosal perforation during an open procedure compared to a laparoscopic procedure. Graham patch was the repair of choice. Mucosal perforations were less likely to be recognized during laparoscopy than during open repair.

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LAPAROSCOPIC LIMITED GASTRECTOMY WITH SENTINEL NODE NAVIGATION FOR GASTRIC CANCER Ju-hee Lee, MD, Sang Hoon Ahn, MD, Do Joong Park, MDPhD, Hyung-ho Kim, MDPhD, Hye Seung Lee, MDPhD Seoul National University Bundang Hospital Introduction: The aim of this study was to evaluate the feasibility of laparoscopic limited gastrectomy with sentinel basin(SB) dissection for gastric cancer in phase II clinical setting. Methods: Forty-five patients were enrolled who had been diagnosed with cT1–T2a and cN0 stage gastric cancers \ 4 cm from July 2010 to August 2011. After detection of SBs using endoscopic ICG and 99mTc-ASC injection during operation, SB dissection was laparoscopically performed. When the sentinel node(SN) biopsy by frozen section (hematoxylin and eosin staining and immunohistochemistry for cytokeratin.) was negative, limited gastrectomy was performed. Results: We failed to complete this procedure in two patients because of intraperitoneal leakage of dye and isotope and obesity. SNs were identified in 42 of the 43 patients (97.67%; mean 5.5 per patient). Ten patients (23.26%) with positive SN biopsy underwent laparoscopic assisted distal gastrectomy with D2 lymph node dissection, 33 with negative SN biopsy underwent limited gastrectomy with SB dissection; endoscopic resection in 10, wedge resection in 7 and segmental gastrectomy in 16. Mean operation time was 192.6 min for patients with negative SN biopsy and 267.0 min for those with positive SN biopsy. Complications were occurred in 4 patients (9.3%). Postoperative morbidity included one gastric stasis, one ulcer bleeding and one minor perforation after endoscopic resection and one postoperative bleeding. Conclusion: Limited gastrectomy with SB dissection for gastric cancer was considered safe and acceptable although long-term follow-up is mandatory.

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LAPAROSCOPY ASSISTED PROXIMAL GASTRECTOMY IN GASTRIC CANCER : SHORT TERM CLINICAL OUTCOME AND FUNCTIONAL STUDY Tomotaka Shibata, Shinichi Sakuramoto, Hiroaki Mieno, Masayuki Nemoto, Nobue Futawatari, Keishi Yamashita, Natsuya Katada, Shirou Kikuchi Masahiko Watanabe Department of Surgery Kitasato University Background: Laparoscopy assisted proximal gastrectomy (LAPG) has become prevalent for early gastric cancer (EGC) located in the upper stomach in Japan. However, standard reconstruction method is not defined. Patients: From May 2006 through June 2011, LAPG was performed for 50 EGC patients. Esophagogastrostomy with Liner stapler (LS) was performed in the initial 25 patients and the 25 remaining patients underwent that with circular stapler (CS). Postoperative esophago-gastro-reflux was assessed by 24 h pH monitoring (n = 25) and/or multichannel intraluminal impedance (MII/pH)(n = 11). Esophago-gastrostomy: Esophagus was laparoscopically dissected and both right and left crura of the diagram were exposed. Upper 3rd of the stomach was resected extra-corporeally with 5 cm minilaparotomy. Esophago-jejunostomy was made by either LS or CS. (1) For LS group, esophagogastrostomy was made using the ETS Flex stapler (Ethicon Endo-Surgery). After making small hole in the anterior wall of the stomach, the gastric remnant was returned to the abdomen with linear stapler inserted, where small hole was afterward added in the posterior wall of the esophagus to allow insertion of the linear stapler. The entry hole was sewn by hand. Toupet like partial fundoplication was added, if remnant stomach is large. (2)For CS group, the esophagogastrostomy was performed using an Orvil package (Covidien) consisting of 25 mm anvil with the head pretiled and the tip attached to an 18 Fr orogastric tube. Through the hole for cartridge insertion, circular stapler was introduced into the intra-stomach and allowed the spike to exit anterior proximal side proximally, and the circular stapler was closed. The entry hole was sewn by hand. Results

(1)

The mean operation time was 292 ± 72 min. The mean estimated blood loss was 103 ± 98 ml. The mean total number of dissected lymph nodes were 24 ± 12. There are no differences between LS and CS groups. Two patients with LS group had anastomotic leakage, but CS group had no leakage. On the other hand, patients with CS group had anastomotic stenosis, while LS group had no stenosis. All stenosis was successfully treated by pneumatic balloon dilatation endoscopically.

(2)

24 h pH monitoring or multichannel intraluminal impedance (MII/pH). Twenty eight percentage (7/25) of patens still sustained for secretion of acid gastric juice (% time pH \4 was above 50%). Pre operative esophageal % time \4 was 1.8 ± 4.1 and post operative esophageal % time \4 was 5.7 ± 9.5 (no significant difference). There were no differences between acid reflux in pre and post operation, but non-acid reflux was increasing in post operation.

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LAPAROSCOPIC PARAESOPHAGEAL HERNIA REPAIR WITH ANTERIOR GASTROPEXY DOES NOT WORSEN REFLUX AND IMPROVES DYSPHAGIA; AN INSTITUTIONAL SERIES Toms Augustin, MD MPH, Jonathan M Tomasko, MD, Gustavo E Bello, MD, Randy S Haluck, MD FACS, Ann M Rogers, MD FACS, Jerome R Lynsue, MD FACS Milton S. Hershey Penn State Medical Center Aim: The course of reflux and dysphagia in patients undergoing paraesophageal hernia (PEH) repair with anterior gastropexy without an antireflux procedure in not established. We studied the prevalence of symptomatic reflux and dysphagia in patients undergoing laparoscopic PEH repair with anterior gastropexies not undergoing fundoplication. Methods and Procedures: Retrospective review of patients who underwent laparoscopic PEH repair and anterior gastropexy at the Penn State Hershey Medical Center. Electronic charts were reviewed and telephone interviews were conducted by a surgeon. The scale for assessment of GERD and dysphagia symptoms (Swanstro¨m et al) was administered. Results: 20 patients underwent laparoscopic PEH repair with mesh and suture posterior cruroplasty and anterior gastropexy or percutaneous gastrostomy. The mean age was 73 years (range: 35 to 93 years). 80% (16) of the patients had reflux symptoms preoperatively and four had that as their chief compliant. Out of these, 80% (13) were on acid reducing medications preoperatively. 60% (12) of the patents had dysphagia. Other preoperative symptoms included post prandial abdominal/chest pain (45%, 9 patients), nausea and vomiting (50%, 10), abdominal distention and bloating (40%, 8), and shortness of breath (40%, 8). Two patients presented with acute gastric volvulus. On imaging type III hiatal hernia was noted in 75% (15/20), followed by type IV (3/20; 15%) and II (2/20; 10%). Interestingly, 8 patients were noted to have a chronic volvulus, most commonly organoaxial. Seven patients had preoperative endoscopy and one had esophagitis. 75% of the patients had a diagnosis of gastroesophageal reflux disease preoperatively. Other comorbidities included obesity (60%), hypertension (50%), and history of coronary artery disease (25%). All patients underwent laparoscopic PEH repair with suture posterior cruroplasty and placement of mesh. Ten patients additionally underwent suture anterior gastropexy and the remaining ten underwent percutaneous gastrostomy. The mean OR time was 105 min (range: 70 to 164). The median length of stay was 3 days (range 1 to 11 days). There were no operative mortalities. The mean follow up was 11 months (range; 1 to 33 months). Post operatively seven patients continued to have reflux. Only one of these had daily symptoms but notably was not on acid reducing medications. Dysphagia improved in all but one patient. Overall there was a 55% decrease in the percentage of patients with reflux and 91% decrease in percentage of patients with dysphagia. Conclusion: There was no significant worsening of reflux or dysphagia symptoms in patients undergoing laparoscopic PEH repair with gastropexy. A considerable decrease in the percentage of patients with these symptoms suggests etiology to be related to the abnormal anatomy. Prospective studies with larger number of patients would help clarify whether these clinically relevant results gain statistical significance.

Conclusions: Esophagogastrostomy with LS or CS could be a simple and useful technique for reconstruction after LAPG. Concerned issues were GERD for LS, and stenosis for CS.

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LAPAROSCOPY-ASSISTED GASTRECTOMY AS ADDITIONAL TREATMENT AFTER ENDOSCOPIC SUBMUCOSAL DISSECTION FOR EARLY GASTRIC CANCER H Mieno, S Sakuramoto, T Shibata, M Nemoto, K Yamashita, N Katada, S Kikuchi, M Watanabe Department of Surgery, Kitasato University School of Medicine Background: Recently, endoscopic submucosal dissection (ESD) has been aggressively used to treat early gastric cancer. The growing number of patients undergoing ESD has been accompanied by an increasing number of lesions for which ESD is found not to be indicated on histopathological examination. Laparoscopy-assisted gastrectomy (LAG) has thus assumed new importance as salvage surgery. Objective: To study the safety and problems of LAG as additional treatment after ESD for early gastric cancer. Methods: We studied 53 patients who underwent LAG as additional treatment after ESD for early gastric cancer from March 2003 through August 2009. Results: The reasons for additional treatment were as follows: positive resection margin in 11 patients, cancer invading the second layer of the submucosa (sm2) in 26, vascular invasion in 19, presence of poorly differentiated components in 14, recurrence in 2, and passage disorder in 2. The surgical procedures were as follows: laparoscopy-assisted distal gastrectomy (LADG) in 33 patients, laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) in 7, laparoscopyassisted total gastrectomy (LATG) in 4, and laparoscopy-assisted proximal gastrectomy (LAPG) in 9. Two patients had histopathological evidence of residual cancer. Lymph-node metastasis was diagnosed in 4 patients (7.5%), all of whom had differentiated sm2 cancer. Intramucosal microcancers not detected before surgery were found in 6 patients (11.3%). The operation times for LADG/LAPPG were 256.3 min. The bleeding volume was 98.5 mL, the postoperative hospital stay was 10.9 days, and the postoperative incidence of complications was 7.5%. For LATG/LAPG, the operation time was 328.9 min, the bleeding volume was 139.6 mL, the postoperative hospital stay was 14.1 days, and the postoperative incidence of complications was 14.4%. There was no postoperative recurrence. Conclusions: After ESD, 15% of patients with sm2 cancer had lymph-node metastasis. Salvage surgery should be performed without hesitation in such patients. LAG was performed safely as additional treatment and may be the procedure of first choice for salvage surgery after ESD.

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TWO-LUNG VENTILATION TECHNIQUE FOR THORACOLAPAROSCOPIC ESOPHAGECTOMY IN PRONE POSITION Daisuke Saikawa, MD, Shunichi Okushiba, MD PhD, Saseem Puedel, MD, Takanobu Onoda, MD, Takeshi Sasaki, MD PhD, Yuma Ebihara, MD PhD, Yo Kawarada, MD PhD, Shuji Kitashiro, MD PhD, Hiroyuki Kato, MD PhD Tonan Hospital Thoracolaparoscopic esophagectomy (TLE) in prone position has become common because of better visibility and operability. Implementing the technique of TLE in prone position requires some special skills and knowledge beside surgical technique especially anesthesia management. One side ventilation is common in TLE in prone position, but it makes the anesthesia induction and management cumbersome and complicated. Since 2008, we have been performing esophagectomy with single-lumen endotracheal tube with possible two-lung ventilation. And we use artificial pneumothorax by carbon dioxide to deflate the right lung and keep the surgical field clear. This technique does not mean only simplicity of anesthesia but also an excellent surgical field because of tracheal mobility due to single lumen endotracheal tube intubation. Now we are going to present the unique surgical approach that strips off the ventral side of esophagus first. We have also researched respiration and circulation dynamics under the two lung ventilation with artificial pneumothorax in prone position using FloTrac System (Edwards lifesciences). 8 patients were treated and the result is that as follows: mean cardiac index is 2.6 L/min/m2, mean central venous pressure is 10.4 cmH2O, and mean usage of dopamine agonist is 0.8 c under the artifical pneumothrax with 8 cmH2O carbon dioxide. On the other hand, respiratory condition is this : the peak airway pressure of 8 patient average is 20.4 cmH2O, and mean PaO2/FiO2 ratio is 267. When left side pleura is injured and both side artifical pneumothrax is induced, we observe an increased airway pressure and decreased tidal volume, but circulation dynamics is unchanged. Although this data is not enough number, we consider two-lung ventilation technique is feasible and has many advantages.

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A CLINICAL STUDY ON POSTOPERATIVE ENDOSCOPIC APPEARANCE OF ANASTOMOSIS EARLY AFTER ESOPHAGECTOMY Yujiro Tanaka, MD, Katsunori Nishikawa, MD, Fumiaki Yano, MD, Jun Asakura, MD, Tomoyoshi Okamoto, MD, Hideyuki Kashiwagi, MD, Katsuhiko Yanaga, MD Dept. of Surgery, Daisan Hospital, Jikei University School of Medicine?, Tokyo, Japan Background and Aim: Esophagectomy and esophagogastrectomy are major operations with high mortality and morbidity, for which anastomotic leakage of esophageal substitute is a serious and potentially fatal complication. The purpose of this study was to verify the significance of postoperative endoscopy early after esophagectomy. Patient and Methods: The median age was 67 (range 59 to 75) years. All patients underwent transthoracic esophagectomy with a gastric tube reconstruction for thoracic esophageal cancer. Anastomoses were all performed in an endto-side fashion using a circular stapling device. The gastric tube was pulled up through the retrosternal route in four patients and through the posterior mediastinal route in another patient. Postoperative endoscopy was performed around 2 weeks after operation to evaluate the esophagogastric anastomosis. Results: One patient developed anastomotic leakage, for whom postoperative endoscopy demonstrated thick yellow necrotic tissue, not in the anastomotic site but at the stump of the gastric tube, which was suspected as the point of leakage. In other cases, small necrotic tissue was identified, while the anastomosis remained intact. Discussion: The reason for anastomotic leakage was considered as the lack of blood flow at the stump of the gastric tube. The incidence of anastomotic leakage might be reduced by choosing end-to-end anastomosis, provided that the anastomosis is performed at the same point.

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COLLABORATING LAPAROSCOPIC AND ENDOSCOPIC Method FOR GASTRIC SUBMUCOSAL TUMORS: OUR EXPERIENCE Saseem Poudel, MD, Yuma Ebihara, PhD MD, Daisuke Saikawa, MD, Takanobu Onoda, MD, Takeshi Sasaki, MD PhD, Yo Kawarada, MD PhD, Shuji Kitashiro, MD PhD, Syunichi Okusiba, MD PhD, Hiroyuki Katoh, MD PhD, Tetsuya Sumiyoshi, MD KKR Sapporo Medical Center, Tonan Hospital Introduction: Laparoscopically, exact border of the gastric submucosal tumor is hard to determine. This makes laparoscopic wedge resection of these tumors difficult. This often leads to resection of larger gastric area then necessary, which can lead to gastric dysfunction and stenosis postoperatively. To overcome this Hiki et al proposed a method called Laparoscopic Endoscopic Cooperative Surgery (LECS) in 2007, which combined intraluminal endoscopy and laparoscopic method for resection of the submucosal tumors, and has been gaining popularity in Japan. Our center has been routinely applying this method for gastric submucosal tumors since May 2010. We would like to share our experience on this procedure. Methods and Procedures: The location of the tumor is confirmed laparoscopically and endoscopically. Blood vessels and other tissues near the tumors are then dissected laparoscopically. Once the tumor area is skeletonized, endoscopist mark the mucous layer around the tumor using needle knife. Glycerine dyed with ink is then injected in submucosal layer. Then IT knife is used to dissect the mucous layer around the tumor. After this, IT knife is used to cut through the whole layer of gastric wall from the caudal side of the tumor along the cut edge of mucosa. This procedure is assisted laparoscopically and is continued until the tumor can be overturned into abdominal cavity. Rest of the gastric wall around the tumor is dissected using ultrasonic coagulating shears and the tumor is placed in the collection bag. The defect area is generally closed by intracorporeal continuous suture using absorbable sutures for the mucosal layer and interrupted suture of non-absorbable sutures for serous and muscular layer. In the case of GIST with ulcerative lesions, we apply modified version, taking in consideration the risk of dissemination. After the location of tumor is confirmed, glycerin dyed with ink is injected endoscopically in the submucosal layer of the. Serous and muscular layer around the tumor is dissected laparoscopically until we reach the submucosal layer. Once submucosal layer is exposed all around the tumor, the tumor is pulled outwards towards the intraabdominal cavity and the mucosa around the tumor is closed using the stapler. We add interrupted sutures in serosal and muscular layer if not closed by the stapler. In each case endoscopy is performed after the closure to confirm that there is no bleeding or leakage of the closure site or stenosis of stomach. We finish the procedure after confirming that there is no bleeding intra-abdominally. Results: We have so far done 9 such procedures in our hospital. The mean age of the patients being 67, with the mean maximum diameter of the tumor being 35 mm. The procedure took average of 168 mins and done with negligible blood loss. Post-operative course of the patients were uneventful.) Conclusion: By collaboration of endoscopy and laparoscopy we have been able to do minimally invasive surgery to resect gastric submucosal tumors with minimum possible margin safely and have been able to preserve the function of stomach.

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LAPAROSCOPIC SINGLE-PORT GASTRECTOMY FOR A GASTRIC GASTROINTESTINAL STROMAL TUMOR Norimasa Koide, MD, Takao Kunou, MD Kenji Kato Inazawa City Hospital Objectives: Laparoscopic resection of gastric gastrointestinal stromal tumor (GIST) had has been widely accepted as a safe and feasible approach. Laparoscopic single-port surgery is currently emerging as the next evolution in noninvasive surgery. We present our first experience of single-port laparoscopic gastric wedge resection for an extramural gastric GIST via a single umbilical incision. Methods: A 75-year-old female was planned for a resection of a gastric GIST, 5 cm in diameter which was located in the lesser curvature of corpus of the stomach. A wound retractor and surgical glove as the single-port device was placed through a 3-cm umbilical incision. A combined method was applied using both straight and reticulated instruments. Wedge resection was carried out by using single endoscopic staple. The procedure was completed successfully without any perioperative complications. Results: Total operative time was 129 min, and estimated blood loss was less than 10 ml. Postoperative course was uneventful and the length of hospital stay was 5 days. Final pathological diagnosis was gastric GIST. Conclusions: We demonstrated the technical feasibility of laparoscopic single-port gastric wedge resection and we emphasize that the extramural gastric GIST is a good indication for this procedure.

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THE ADVANTAGE OF TOTALLY LAPAROSCOPIC TOTAL GASTRECTOMY (TLTG), LESS INVASIVENESS, APPLICATION EASINESS AND COST EFFECTIVENESS: IN A SINGLE-INSTITUTION EXPERIENCE OF OVER 140 CASES Hitoshi Satodate, Haruhiro Inoue, Shin-ei Kudo Showa University Northern Yokohama Hospital Introduction: Although laparoscopy-assisted distal gastrectomy for gastric cancer is becoming popular procedure especially in Japan and Korea, laparoscopy-assisted total gastrectomy is less common operative procedure. One of the major problems is difficulty of intracorporeal reconstruction, especially intracorporeal esophagojejunostomy. And another problem is cost. Some article reported laparoscopy-assisted gastrectomy was associated with decreased hospital profit, due to much use of the disposable instruments. We developed TLTG procedures that requirement of disposable instruments is minimal, within the coverage of Japanese insurance system. Method: A 12-mm trocar is placed through umbilical incision, and four additional trocars are placed. Only two 12-mm trocar incisions and three 5-mm trocar incisions, including for the camera, are created for this procedure. After thorough mobilization of the abdominal esophagus, the esophagus is divided with stapler, and Orvil is inserted per orally, and the anvil is loaded into the esophageal stump. Then the handpiece of EEA stapler is introduced from the umbilical port incision, and the jejunojejunal anastomosis is also created from the umbilical port incision. Results: We have performed 142 cases of the TLTG with this procedure, and have experienced only one minor anastomotic leakage. No other major problems had occurred. Mean operation time is 230 min. And the mean time for the whole procedures for reconstruction including creation of Roux-en-Y jejunojejunal anastomosis is 54 min. Conclusion: Two clear advantages can be mentioned with this method, compare with other techniques. First, this technique can be relatively easily applied for the cancer of the cardia. Second, minimize the use of disposable instruments. Only two linear staplers and one circular stapler are needed, and these are completely covered by insurance. This technique could become the standard methods for reconstruction after TLTG, and facilitate the acceptance of TLTG. And also lead to the hospital benefit. We will show our clinical practice.

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CAUSTIC AGENT INGESTION OUTCOMES FROM ONE INSTITUTION IN THAILAND WITH MEAN 6 YEARS FOLLOW UP Orapich Kayunkid, MD, Panot Yimchareon, MD, Vibul Trakulhun, MD Department of Surgery Bhumibol Adulyadej Hospital, Bangkok, Thailand Background: The ingestion of caustic substances is a common condition which may result in serious injury of the upper gastrointestinal system. Esophagogastroduodenoscopy (EGD) is the gold standard of assessing depth, extent of injury. Objective: The purpose of this study to determine the main caustic substance ingested and the lesion on the esophageal mucosa from EGD within 24 h after injury. Find out incidence of esophageal stricture of these patients and long term follow up after management at our hospital. Design: Caustic agent ingestion patients at our hospital were studied. Reasons for ingestion, symptoms, physical findings, endoscopic findings, operative findings and procedures were reviewed from medical record of patients. Nearly all patients were performed esophagogram at 6 weeks after ingestion and long term follow up at least 6 years. Data were analyzed by using the descriptive statistical method. Results: From July 2004–July 2011, 131 patients (81 female, 50 male) who ingested a caustic agent, had mean age 27.6+ 10.63 years. The caustic substance ingested were 15% hydrochloric acid 110 patients (84%), sodium hydroxide 5 patients (3.8%), caustic soda 1 patient and undetermined agent 15 patients .The mean volume of caustic substance was 36.2 + 18.3 ml . The reasons for ingestion were a family conflict 83 patients (63.4%), study problem 20 patients (15.2%) work and business problem 15 patients (11.5%), accident 7 patients (5.3%), psychiatric problems 6 patients (4.6%) . The signs and symptoms of these patients when they were admitted into our hospital were oropharyngeal burn 57.5%, drooling 52.5%, dysphagia 32.3% chest pain 16.6%, epigastrium pain 70.8%, stridor 2.5% and diarrhea 0.83% . 125 of 131 underwent endoscopy and lesions found were normal 11 patients, grade I 42 patients, grade II 60 patients and grade III 12 patients and 8 of 131 went to surgery because of peritonitis and mediastinitis. The others who did not show sign of peritonitis were treated by conservatively. The mean follow-up period was 77.3+6.6 months. During this period, esophageal strictures were developed 14.2% in 2nd degree burn and 100% in 3rd degree burn patient. Fifteen patients of 2nd and 3rd degree burn underwent endoscopic dilation but only 7 patients were successful and other underwent surgery. Conclusions: Hydrochloric acid is the most frequently ingested caustic substance. Family conflicts are the most frequent stated reason for caustic ingestion. Clinical symptoms are variety. Clinical symptom of dysphagia and early endoscopic evaluation may predict morbidity outcomes .No esophageal strictures developed in first degree burn patients. Second degree burn patients should be followed up by esophagogram at 6 weeks after ingestion or when dysphagia occurred for early detection of esophageal stricture complication.

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PRESERVATION OF VAGUS NERVE TECHNIQUE USING LEFT-SIDED APPROACH IN LAPAROSCOPIC GASTRECTOMY Tetsu Fukunaga, PhD MD, Shinya Mikami, PhD MD, Takehito Ohtsubo, PhD MD, Nobuyoshi Miyajima, PhD MD St. Marianna University School of Medicine Laparoscopic gastrectomy is mainly performed for early gastric cancer, and it is preferable to perform the vagus nerve preserving operation to maintain long-term quality of life. In preservation of vagus nerve, celiac branch and hepatic branch are generally preserved, but in conventional laparoscopic surgery, preservation of celiac branch has been so demanding. Then, we developed a surgical procedure to easily preserve celiac branch. With the use of left-sided approach for left gastropancreatic fold we had developed in 2005, celiac branch is identified at the root of the left gastric artery, and from there, celiac branch is followed and persevered toward its center in our method. By using this procedure, preservation was surely conducted in all cases undergoing vagus-nerve preserving gastrectomy. Here, we describe our technique.

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A LESS INVASIVE THERAPY BY DIAGNOSTIC DOUBLE BALOON INTESTINAL ENDOSCOPY (DBE) AND LAPAROSCOPIC SALVAGE SURGERY (LSS) Shigehiko Yagi, Fumiki Kushihata, Riki Ohno, Hideshi Yamamoto, Hirotsugu Yoshiyama, Hidenori Takatsuki, Yasutsugu Takada DEPARTMENT OF SURGERY, Ehime Prefectural Imabari Hospital Background: Double-balloon endoscopy (DBE) is a new method that allows visualization, tissue sampling, and therapeutic intervention of a variety of pathologies throughout the small-intestinal tract.?Objectives: we evaluated an efficacy of the new combinational strategy of DBE and less invasive laparoscopic surgery (LSS) and its impact on treatment and clinical outcome of patients with small intestinal diseases. Methods: We present here five typical cases of this new strategy. Results: Case 1; Due to disadvantage of invasive open laparotomy for intra-abdominal huge mass 9 cm in diameter, diagnostic DBE revealed a full circumferential ulceration of jejunum and B cell lymphoma was confirmed. Following chemotherapy with R-CHOP regimen of four sessions successfully resulted in a remarkable tumor reduction with a stricture of jejunum. Following less invasive laparoscopic-assisted jejunostomy disclosed no residual variable lymphoma cells and resulted in no additional chemotherapy. Case 2, 3; Due to overt-on going GI bleeding and ileus, DBE showed a irregular ulceration of proximal jejunum and confirmed well differentiated adenocarcinoma. Laparoscopic-assisted jejunostomy was done with radical lymphnodes resection along with superior mesenteric artery preserving first branch of jejunal artery. Pathological depth of invasion was subserosa with no lymphnode metastasis. Pts were doing well and underwent following adjuvant chemotherapy using TS-1. Case 4, 5 DBE are also quite useful tool for diagnosis following benign cases such as IBD and Meckel’s diverticulum? We exfoliated the adhesion of the Meckel’s diverticulum tip by laparoscopically. Crohn disease with stricture and longitudinal ulceration of the small intestine was diagnosed by DBE, small intestine partial resection and intestinal stricture plasty using laparoscopy was done due to failure of TNF a antibody therapy. This new strategy leads us to more accurate and less invasive strategy to intestinal diseases. Conclusion: A shift in the diagnostic and therapeutic algorithm was noticed in the combination strategy with DBE and SLS now taking the lead.

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THE FEASIBILITY AND SAFETY OF LAPAROSCOPIC DISTAL PANCREATECTOMY FOR PANCREATIC TUMOR Long Vo Duy, Ms, Bac Nguyen Hoang, Prof PhD, Tuan Le Quan Anh, Ms University Medical Center, Hochiminh city, Vietnam Background: Distal pancreatectomy is performed for a range of benign and malignant lesions of the left pancreas. Laparoscopic distal pancreatectomy is increasingly performed for lesions of the body and tail of the pancreas. The aim of this study is to evaluate the technical procedures, the feasibility and the safety of laparoscopic distal pancreatic resections for solid and cystic tumors of the distal pancreas. Methods: This was a prospective, case- series with a total of 18 patients affected by solid and cystic tumors were underwent laparoscopic distal pancreatectomy at University Medical Center, Hochiminh city, Vietnam between March 2007 and August 2011. Clinical characteristics as well as diagnostic preoperative assessment and intra- and postoperative data were prospectively recorded. Results: There were 10 women and 8 men with a mean age of 50 years. All procedures were successfully performed laparoscopically. The median tumor size was 40 mm (range, 20–100 mm). The mean operative time was 156 ± 32 min. The estimated intraoperative blood loss was 90 ± 12 ml and no patient required blood transfusion. Spleen preservation was done in 4 patients (22.2%). There were no mortalities. The median length of hospital stay was 6 days. No patients developed in postoperative pancreatic fistula. The overall morbidity rate was 16.7% (3 patients) including fluid collections in 2 patients which were asymptomatic and resolved spontaneously and wound infections in 1 patient but no patient required reoperation. The final pathologic diagnoses consisted of primary adenocarcinoma (n = 5), and others benign lesions including serous cystadenoma (n = 5), solid pseudopapillary tumor (n = 4) and mucinous cystadenoma (n = 4). All 5 patients of adenocarcinoma had negative resection margins. The median number of nodes in the specimens was 6 with none of them had positive metastasis. All the patients with adenocarcinoma are alive and free from disease at a median follow-up of 18 months (range, 4–38 months). Conclusions: Laparoscopic distal pancreatectomy is feasible and safe. Solid and cystic tumors of the distal pancreas represent a good indication for laparoscopic resection whenever possible.

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Results: Tumour staging (T) by EUS and CT scan compared with operative pathology: Operative pathology stage

SUB-TOTAL LAPAROSCOPIC GASTRECTOMY PROVIDES AN APPROPRIATE ONCOLOGIC PROCEDURE IN SELECTED PATIENTS WITH ANTRAL ADENOCARCINOMA Samantha Benlolo, Jonathan Cools-lartigue, MD, Victoria Marcus, MD, Lorenzo Ferri, MD PhD Department of Surgery McGill University Health Center, Department of Pathology McGill University Health Center, Steinberg-Bernstein Center for Minimally Invasive Surgery Introduction: Laparoscopic gastrectomy (LG) is being employed with increasing frequency in the management of gastric cancer. However, the short-term benefit and oncologic adequacy of this approach remains incompletely characterized, precluding its routine employment in many institutions. Accordingly, we sought to evaluate the results of LG in patients with distal gastric adenocarcinoma compared to those undergoing open surgery? Methods: All patients undergoing gastrectomy from 2005-11 at a North American university hospital were identified from a prospectively collected database. In an attempt to limit confounding factors, we elected to study only patients undergoing resection of distal gastric adenocarcinoma. Patients undergoing subtotal gastrectomy for antral adenocarcinoma were divided into two groups depending on the surgical approach (laparoscopic gastrectomy LG vs open gastrectomy OG). LG and OG were compared in terms of patient demographics, histologic tumor type, tumor size, adequacy of oncologic resection (lymphadenectomy and R0 resection), AJCC stage, incidence and severity of postoperative complications, and hospital length of stay. Post-operative complications were classified according to the scale proposed by Clavien (0 = none; 1–2 = minor; 3–5 = major). Data are presented as median (range). Mann– Whitney U and Fischer’s exact test were used to determine significance (*p \ 0.05). Results: One hundred and seven patients underwent gastrectomy over the study period, of which 37 were subtotal gastrectomies for antral adenocarcinoma (LG = 17: OG = 20). Patient age (LG = 75 years (52–86): OG = 76 years (49–87)) and sex (LG = 12/17 male: OG 11/20 male) did not differ between the two groups. Tumor size was similar (LG = 4 cm (1–6.5):OG = 4 cm (1.5–10), but there were more stage I cancers in the LG group (11/17 vs 3/20)*. No difference was observed in those who achieved R0 resection (LG = 15/17(88%):OG = 18/20(90%)). There was no difference in lymph node retrieval (LN = 26 (12–84): OG = 27 (12–89)) between the two groups, but more OG patients received a formal D2 dissection (LG = 10/17 (59%): OG = 16/20 (80%)) NS. Patients in the OG group were more likely to harbor positive lymph nodes and in greater numbers than patients in the LG group (LG = 0 (0–19): OG = 2 (0–14))*. There was a trend for decreased rate, and severity of complications (none/minor/major), in patients undergoing laparoscopic resection (LG 10/5/2 : OG 8/7/5). This translated into more LG patients that were discharged by post-operative day 5 than OG (6/17 (35%) vs 0/20)*? Conclusions: In selected patients, laparoscopic gastrectomy is associated with improved short-term outcomes, and provides an appropriate oncologic resection compared to the open approach. Additional prospective randomized studies are required to further define the role of laparoscopy in the resection of gastric cancer

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ROLE OF ENDOSCOPIC ULTRASONOGRAPHY (EUS) VERSUS COMPUTERISED TOMOGRAPHY(CT) SCAN IN STAGING OF GASTRIC MALIGNANCY Ahmed Hammad, Mr, Mohamed Shams, Mr, Mohamed Gamil, PhD, Reda Tabash, PhD, Ali Amin, Mr National Cancer Institute, Cairo University, Cairo, Egypt Objective of the study: Evaluation of the practical application of EUS compared to CT scan in staging of gastric malignancy. Methods and procedures: Patients diagnosed or clinically suspected to have gastric tumour were subjected to upper gastrointestinal scope and EUS at the same time. Forty patients were involved in the study over two year period. Number of patients (n)

Pathological diagnosis

27

Adenocarcinoma

10

Gastric lymphoma

2

Left lobe hepatocellular carcinoma, pancreatic head tumour invading the stomach

1

Benign peptic ulcer

Last three cases were excluded from the study as the diagnosis was not primary gastric malignancy and five patients were excluded as they did not undergo operation and no operative pathology obtained. All patients had staging CT chest abdomen and pelvis (cap).

123

n

EUS Tx

EUS T1

EUS T2

T1

1

T2

4

4

T3

15

1

T4

12

T with no operative pathology Total

EUS T3

EUS T4

CT Tx

1

CT T1/2

1

37

2

CT T4

1 3 12

2

2

12

5

CT T3

5

2

2

1

14

16

1

1 8

5

5

7

4 6

18

12

Total accuracy of EUS staging was 29 out of 32 lesions 91% with one lesion under staged 6% and two lesions over staged 13%, the 95% confidence interval (C.I) was (79–100%) with p value (p = 0.0005) The total accuracy of CT was 19 out of 32 lesions 60% with seven lesion under staged 22% and six lesions over staged 18%, the 95% confidence interval (C.I) was (24–76%) with p value (p = 0.38) Conclusion: EUS is a non invasive safe and superior to CT scan in T staining of gastric malignancy and should be one of the pre-therapeutic methods in staging before considering different treatment modalities.

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LAPAROSCOPIC IMPLANTATION OF GASTRIC STIMULATOR AS AN EFFECTIVE TREATMENT MODALITY FOR GASTROPARESIS Lee A Farber, DO, David B Earle, MD Baystate Medical Center Objective: Gastroparesis is a motility disorder of the stomach characterized by delayed passage of liquid and/or food boluses without a widely accepted effective treatment thus far. Our aim is to evaluate the effectiveness of an implantable gastric electrical stimulator device (Enterra; Medtronic; Minneapolis, MN) in patients with diabetic or idiopathic gastroparesis as measured by patient estimate of the percentage improvement in their symptoms postoperatively. Methods: Retrospective review of 23 patients with implantation of gastric stimulator between 2005 and 2011. Inclusion criteria were symptoms consistent with gastroparesis, abnormal nuclear medicine gastric emptying study and no evidence of an anatomic gastric outlet obstruction. All patients underwent laparoscopic implantation of the device with simultaneous upper endoscopy. Two leads were secured parallel to each other, 10 cm proximal to the pylorus near the greater curvature of the stomach. All cases were successful, and had the stimulator turned on in the operating room. Patient responses concerning their percentage improvement over preoperative symptoms, demographics, and known complications were analyzed. Results: Two patients were lost to follow-up. Two patients had their stimulator removed due to infection or pain within six months, and one patient died of unrelated causes within one year. The remaining 18 (78%) patients were analyzed for symptom relief with a mean f/u of 22 months (0.5–71 months). Gender was male (n = 7) and female (n = 11), with a mean age of 47 years (22 to 69). Etiology was diabetes (61%) and idiopathic (39%). Preoperative symptoms were vomiting (n = 17), nausea (n = 16), hospital admission related to gastroparesis (n = 12), abdominal pain (n = 11), weight loss (n = 11), and early satiety (n = 3). All patients were refractory or intolerant to medical treatment. The mean overall symptom improvement was 62.2% (0–100%), with a median of 75%. 16 of 18 patients followed up beyond their initial postoperative visit (mean 25 months). Two patients were 0–10% improved, 4 were 50–70% improved, and 9 were 80–100% improved. Only 6 patients showed a decrease of 43% (5–90%) of initial symptom improvement during the subsequent follow up period. Conclusions: Laparoscopic gastric stimulator implantation effectively relieves symptoms related to gastroparesis in patients with idiopathic or diabetic gastroparesis, and an abnormal gastric emptying study. While some complications occurred and results varied, but almost always met the goals and objectives of the patients, who had no other treatment alternative and would generally accept even a small improvement in symptoms. This modality should be considered in all medically refractory or medically intolerant patients with symptomatic gastroparesis.

Surg Endosc (2012) 26:S249–S430

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OUR EXPERIENCE WITH LAPAROSCOPIC NISSEN FUNDOPLICATION IN PATIENTS WITH GASTROESOPHAGEAL REFLUX M.tahir Oruc, MD, M. Umit Ugurlu, MD, H. Taner Turgut, MD, Emel Canbey, MD, Mehmet Ozyildiz, MD, Zehra Boyacioglu, MD Kocaeli Derince Teaching And Research Hospital General Surgery Clinic, Kocaeli, Turkey

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LAPAROSCOPIC GASTRECTOMIES IN GASTRIC CANCER PATIENTS: A SINGAPORE’S INSTITUTION INITIAL EXPERIENCE Aung M Oo, MD, V Shelat, MD, K H Lim, MD, A Koura, MD, J Rao, MD Tan Tock Seng Hospital, Singapore

Background: Laparoscopic Fundoplication for gastroesophageal reflux disease (GERD) is common performed procedure in worldwide. We analyzed our laparoscopic Nissen Fundoplication (LNF) procedures performed in our clinic. Methods: LNF was performed in 36 patients between January 2009- August 2011 in Kocaeli Derince Teaching and Research Hospital. Patients’ characteristics, operative and postoperative data were analyzed. Patients with GERD were reanalyzed with endoscopy and pH monitorization post-operatively in one month. Results: Thirty-seven patients aged 42 ± 9.4 (26–63) years old were enrolled the study 13 (35%) men and 24 (65%) women). The mean of body mass index was 26 ± 3, and mean De Meester score of the patients was 53 ± 39 (15–190). Mean duration of complaints for GERD was 4.7 ± 3.9 (1–20) years. LNF were completed successfully in 33 (92%) of these patients. LNF alone was performed in 15 (43%) patients, whereas in 11 (30%) patients LNF and cruroplasty and in 10 patients LNF-cruroplasty with mesh repair were performed. Mean operation time was 64 ± 18.2 (35–130) min. In 2 patients (5.4%) laparoscopic approaches were turned into open procedure due to peroperative complications as esophageal perforation in one, subcutaneous emphysema and pneumothorax in another. These cases were within the first 10 surgeries and occurred in learning phase. Average time to discharge post-fundoplication was 2.6 days. Conclusion: LNF is safe and effective in treatment of GERD. Other approaches such as cruroplasty and mesh repair might be added to LNF procedure due to concomitant pathologies to GERD. The clinical results show decrease in morbidity and hospitalization time. Our results are comparable to the published results and our clinic is one of the executive centers for LNF.

Introduction: Cancer of the stomach is the fifth most common cancer in men and the seventh most common cancer in women in Singapore. Gastrectomy with D2 lymphadenectomy has been proven to be the gold standard for the treatment of gastric cancer. Laparoscopic or minimally invasive gastrectomy has become more and more popular nowadays since its introduction by Kitano et al in 1994. Laparoscopic gastrectomy with D2 lymphadenectomy has been shown to be a safe and feasible procedure for the gastric cancer patients. The objective of this study is to review the initial series of laparoscopic gastrectomies done in Tan Tock Seng Hospital, Singapore’s second largest acute care general hospital with 1,400 beds. Methods and Procedures: A retrospective review of patients who underwent laparoscopic gastrectomies for stomach cancer from July 2008 to August 2011 was done using a prospectively collected gastric cancer data base and medical records. Results: A total number of 34 patients underwent laparoscopic gastrectomies for stomach cancer from July 2008 to August 2011. All the cases were done laparoscopically and there was no conversion to open surgery. 59% (n = 20) were male and 41% (n = 14) were female. The mean age of the patients was 64 years old. The median ASA score of the patients was 2 and average length of stay was 11 days. Among 34 patients, 5.88% (n = 2) had proximal gastrectomies, 14.72% (n = 5) had total gastrectomies and 79.4% (n = 27) had distal/ subtotal gastrectomies. Mean operative time was 251 min. The mean number of total lymph nodes dissected was 20. All patients had R0 resection and resection margins were all clear. 30 days perioperative mortality rate was 0%. 2.94% (n = 1) had anastomotic leak and thus unplanned return to OT rate was 2.94% (n = 1). Conclusions: Our initial series showed that laparoscopic gastrectomies are safe and feasible. The oncological clearance, morbidity and mortality rates are comparable to that of open surgeries in the experienced hands.

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A SYSTEMATIC REVIEW OF PAIN AFTER ANTI-REFLUX SURGERY David Bunting, Mr, Lukasz Szczebiot, Dr, Paul Peyser, Mr The Royal Cornwall Hospital, Truro, Cornwall, UK. Introduction: The benefits of anti-reflux surgery are well established. Laparoscopic techniques have been shown to be generally safe and effective. Whilst some postoperative discomfort is common, a small percentage of patients suffer persistent and severe pain after anti-reflux surgery. There is limited discussion of this in the literature, no established scheme for managing these patients and little is known about the cause of the pain. This study reviews the literature on pain following laparoscopic anti-reflux surgery. An algorithm for its investigation and treatment is constructed. The authors present two cases previously undescribed of postoperative pain following laparoscopic fundoplication caused by traumatic neuromas. Methods and procedures: A systematic review of the literature without date restriction using the PubMed database was conducted to identify all studies reporting pain after anti-reflux surgery. Other important studies were identified by cross-checking reference lists and using the related articles feature. Studies were included for the main analysis if they contained at least 30 patients operated on for gastro-esophageal reflux disease. Operations in children, Collis gastroplasty procedures, endoluminal fundoplication and surgery for paraoesophageal hernias were excluded. The frequency, severity, cause, duration, investigation and treatment of post-operative pain are discussed. An algorithm for the investigation and management of patients with pain following laparoscopic fundoplication is presented. Results: 256 individual studies were identified through the initial search. After the application of specified criteria, 18 studies were included in the main analysis containing a total of 2769 patients. The frequency of abdominal pain following fundoplication ranged from 1% to 58% (mean 24.0%). Chest pain occurred in 2.4% to 41% (mean 19.5%) of patients. Frequency of pain did not correlate with follow up length (p = 0.24) and was not associated with operation type. Meta-analysis was not possible due to the heterogeneity of studies and the small number of comparative studies. Pain was mild or moderate in the majority and severe in 4% of patients who underwent surgery. In the group of patients with severe pain, there was often limited further investigation and no diagnosis made. The authors present two cases of persistent, severe epigastric pain following laparoscopic anterior fundoplication. Initial investigations failed to identify any cause. Laparoscopy in each case demonstrated a small, pale nodule associated with a gastric fundal suture. Pain was alleviated by excising the nodules. Histopathological analysis of both lesions proved them to be neuromas. Conclusions: Pain following anti-reflux surgery is poorly reported in many trials but occurs in almost one quarter of patients. Most of these will have mild to moderate pain with minimal effect on quality of life. Some will have an obvious complication or a diagnosis made through routine investigation. In a smaller proportion of patients, pain is severe, persistent and can be disabling. In this group, diagnosis is more difficult but systematic investigation can be rewarding and enable appropriate and successful treatment. Imaging, endoscopy, pH testing and manometry can be useful but in the absence of a diagnosis, repeat laparoscopy with or without revision surgery has been shown to be of benefit.

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INITIAL EXPERIENCE OF PROSTHETIC MESH IN LAPAROSCOPIC REPAIR OF GIANT PARAESOPHAGEAL HIATUS HERNIA H Poon, MD MRCS, A Patel, MD MRCS, A S Perry, MD FRCS, M S Wadley, MD FRCS Department of Upper GI Surgery, Worcestershire Royal Hospital, Worcester, UK Introduction: Paraesophageal hiatus hernias (PHH) can present with disabling symptoms and may result in lifethreatening complications. Laparoscopic repair is now considered routine in many centres although a number of studies have reported high recurrence rates. Tension free repair with prosthetic mesh reinforcement of the crura has been advocated and reported to result in significantly lower rates of recurrence. This technique however has the potential to result in significant complications including mesh erosion. Our study aimed to assess the outcome and complications of the use of prosthetic mesh in the repair of giant PHH. Methods: All patients undergoing laparoscopic repair of giant PHH by two surgeons in a UK district general hospital from 2005 to 2011 were studied. Only patients who underwent repair using PTFE mesh (Bard Crurasoft patch) were included. Surgery involved reduction of hernia contents and complete reduction of the sac. The crural defect was repaired using interrupted sutures buttressed with a PTFE mesh. Basic demographics, length of stay, complications, recurrence and follow up details were noted. Results: 36 patients were included [M:F 17:19, median age 64 years (range 53–79 years)]. There were 5 (15%) emergency cases. Median post-operative length of stay was 3 days (range 1–5 days). There were no significant intra-operative complications or conversions to open surgery. One patient developed early in-hospital recurrence requiring redo laparoscopic surgery. After median follow-up 40 months (range 9–68 months), 8 patients (22%) developed symptoms requiring further investigation (5 diarrhoea, 3 reflux symptoms, 1 port site hernia). In these patients endoscopy and upper GI series revealed no evidence of hiatal hernia recurrence, mesh erosion or migration. Conclusions: Use of prosthetic mesh in the repair of large PHH appears safe with an acceptable complication rate and low incidence of recurrence with medium-term follow up. Longer follow up of our patients is needed and further studies should be commissioned to assess the long-term impact of prosthetic materials in the repair of these challenging hernias.

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DO ROUTINE POSTOPERATIVE UPPER GASTROINTESTINAL STUDIES FOLLOWING LAPAROSCOPIC GASTRIC BYPASS AFFECT CLINICAL OUTCOMES? A COMMUNITY HOSPITAL EXPERIENCE Salim Abunnaja, MD, Lucian Panait, MD, Aziz Richi, MDFACS, Shady Macaron, MDFACS, Ankit Dhamija, MS, Binh Nguyen, MS, Alexander Palesty, MDFACS Saint Mary’s Hospital Introduction: Many institutions routinely perform upper gastrointestinal studies (UGIS) following laparoscopic Roux-en-Y gastric bypass (LRYGBP) for the potential advantage of early identification of anastomotic complications. Alternatively, UGIS may be used selectively, if early post-operative anastomotic complications are suspected. Intraoperative air leak test may be used solely or in conjunction with UGIS to rule out an anastomotic leak. Methods: A retrospective chart review of 75 LRYGB cases was performed at our institution from January 2009 to July 2010. In 55 cases an UGIS was performed routinely on post operative day one (group 1). In 20 cases an intraoperative air leak test was performed to rule out any leak and a postoperative UGIS was only obtained selectively in the presence of clinical indicators (group 2). Results: A postoperative UGI study was obtained in 58 patients (55 patients from group 1 and 3 patients from group 2). No obstructions or leaks were found in any of those 58 patients. 17 Patients were discharged without an UGIS and did well without any leak or obstruction. Post operative complications included anastomotic stricture (1 patient from group 1, and 2 from group 2) and internal hernia (2 patients from group 1). No statistical significant differences were found between the 2 groups. Conclusion(c): The results of our study suggest that routine UGIS after LRYGB do not contribute significantly to patient care. Intraoperative air leak test may be a good substitution since it is cheap, easy to perform and gives the opportunity to repair any detected leak at the initial operation.

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LAPAROSCOPIC REPAIR OF PARAESOPHAGEAL HERNIAS: THE LAST TEN YEARS Michael Latzko, MD, Frank Borao, MD FACS, Anthony Squillaro, MD FACS, Jonas Mansson, MD, William Barker, MD Thomas Baker Monmouth Medical Center Background: Laparoscopy has quickly become the standard surgical approach to repair paraesophageal hernias (PEH). Although many centers routinely perform this procedure, relatively high recurrence rates have led many to question this approach. We sought to evaluate outcomes in our cohort of patients with emphasis on recurrence rates, symptom improvement and its correlation with true radiologic recurrence seen on contrast imaging. Methods: We retrospectively identified 126 consecutive patients who underwent laparoscopic repair of a large PEH between 2000 and 2010. Clinical outcomes were reviewed, and data was collected regarding operative details, peri-operative and post-operative complications, symptoms, and follow-up imaging. Radiologic evidence of any size hiatal hernia of was considered to be a recurrence. Results: There were 95 female and 31 male patients with a mean (±SD) age of 71 ± 14 years. Laparoscopic repair was completed successfully in 120/126 patients with 6 operations converted to open procedures. 126 patients (79%) received crural reinforcement with mesh, and 13 patients (11%) had a Collis gastroplasty performed. Fundoplications were performed in 113 patients (89%); Nissen (111), Dor (1), and Toupet (1). Radiographic surveillance was available for 89 patients (71%), obtained at mean time interval of 23 months post-operatively. Radiographic evidence of a recurrence was present in 19/81 patients (21%) with available imaging. Re-operation was necessary in six patients (5%); five for symptomatic recurrence (4%), and one for dysphagia (1%). Median length of stay was 4 days. Conclusion: Laparoscopic PEH repair results in excellent outcome with short length of stay when performed at an experienced center. Radiologic recurrence is observed relatively frequently with routine surveillance, however many of these recurrences are small and few patients require correction of the recurrence. Furthermore, these small recurrent hernias are often asymptomatic and do not seem to be associated with the same risk for developing severe complications as the initial PEH.

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LONG-TERM SYMPTOMATIC OUTCOMES IN PATIENTS UNDERGOING RE-OPERATIVE FUNDOPLICATION Masato Hoshino, Ananth Srinivasan, Amith V Reddy, Tommy H Lee, Sumeet K Mittal Creighton University Medical Center Introduction: Re-do fundoplication is a viable and safe option in the management of the symptomatic post-fundoplication patients. The purpose of this study was to evaluate subjective outcomes and satisfaction of redo-fundoplication more than 3 years after surgery. Methods and Procedures: After IRB approval, a prospectively maintained database was retrospectively reviewed to identify patients who underwent a redo-fundoplication with 3 years or greater follow. Data was analyzed for manometry, 24 h pH study, surgical approach and procedure, peri-operative findings, complications and pre and post symptom (heartburn, regurgitation, dysphagia and chest pain) scores (scale 0–3), along with patients’ satisfaction score (scale 1–10). Patients with grade 2 and 3 were considered to have severe symptoms. All data was expressed as median (IQR). Chi-square test was used to compare categorical variables. Mann–Whitney’s U test and Wilcoxon test were used to compare continuous variables. A p-value \ 0.05 was considered statistically significant. Results: We identified 104 consecutive patients [70 (67%) females, 57.5 (45.5–66) years]. The majority of surgical approach was laparoscopic (66%) (Conversion rate was 7%). 16% patients with short esophagus underwent collis-fundoplication. Overall complication rate was 21% with no-peri-operative mortality. The median follow up of 50 (range: 37–91) months was available in 73 (70%) patients. There was significant decline in number of patients reporting significant regurgitation (p = 0.035), dysphagia (p \ 0.001), chest pain (p \ 0.001). 27% postoperative reported taking PPI or/and H2 blocker compared to preoperative 46% patients (p = 0.012) and the 70% reported excellent to high satisfaction with outcome (8 or higher on a scale 1–10). Conclusion: Patients undergoing redo-fundoplication can expect durable improvement of symptoms and high satisfaction more than four years after surgery.

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EVALUATION OF ESOPHAGOGASTROSTOMY USING A CIRCULAR STAPLER IN LAPAROSCOPY-ASSISTED PROXIMAL GASTRECTOMY Daisuke Ichikawa, MD, Shuhei Komatsu, MD, Kazuma Okamoto, MD, Atsushi Shiozaki, MD, Hitoshi Fujiwara, MD, Yasutoshi Murayama, MD, Yoshiaki Kuriu, MD, Hisashi Ikoma, MD, Masayoshi Nakanishi, MD, Toshiya Ochiai, MD, Yukihito Kokuba, MD, Eigo Otsuji, MD Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine Purpose: Recently, the frequency of early gastric cancer in the upper third of the stomach has especially increased. We have improved the esophagogastrostomy procedure to maximize the preservation of physiologic functions. Methods: Fourteen patients were reconstructed by esophagogastrostomy with an incision in the left abdomen after limited proximal gastrectomy. We presented here the details of this reconstructive method, and demonstrated the results of postoperative evaluations of the lower esophagus and the remaining stomach. We also assessed quality of life in these patients using questionnaires, based on comparisons with that of patients underwent open limited proximal gastrectomy. Results: Median surgical duration and blood loss was 315 min and 31 ml for this procedure. The approach using circular stapler from the left side allowed a good laparoscopic visual field to be obtained for plane of the esophagogastrostomy. The reconstructive procedure was successfully performed without intra-operative complications. There were no anastomosis-related postoperative complications encountered in ten patients, but delayed anastomotic stenosis occurred in one patient. This technique preserved the lower esophageal sphincter as well as peristalsis of the lower stomach, and also allowed the greater curvature near the top of the stomach to function as a new fundus. The incidence of reflux esophagitis on endoscopic examination was limited. There was no significant difference in the frequency of postoperative abdominal symptoms between the laparoscopic and open groups on the Gastrointestinal Symptom Rating Scale questionnaire. Conclusions: This approach for esophagogastrostomy with an incision in the left abdomen could be a simple, easy and safe reconstructive technique after laparoscopy-assisted proximal gastrectomy with preservation of maximal physiologic function of the remnant stomach.

Surg Endosc (2012) 26:S249–S430

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LEIOMYOMA REMOVED DURING LAPAROSCOPIC GASTRIC BYPASS Daniel J Mullins, MD, Sean Orenstein, MD, Nissin Nahmias, MD University of Connecticut Introduction: Pre-operative upper endoscopy is not uniformly performed prior to Roux-en-Y gastric bypass surgery, the most common weight loss surgery performed worldwide. Current literature has shown that upper endoscopy is important if the patient has symptoms involving potential pathology in the upper intestinal tract. However, data regarding the routine use of upper endoscopy prior to surgery is lacking. It is of utmost importance to routinely perform upper endoscopy to look for abnormal anatomy which may be difficult to assess post-operatively, especially involving the distal stomach and proximal small bowel. Previous studies have shown that abnormal endoscopies may be found in 46% of patients. We report the case of a 54 year old female who was found to have a gastrointestinal stromal tumor during an upper endoscopy prior to her planned laparoscopic roux-en-y gastric bypass. Methods: A retrospective chart review was performed on a patient who was found to have a mass in the gastric fundus during a pre-operative endoscopy. The entire operative and hospital course was reviewed and presented. An intraoperative video was also recorded reflecting the changes needed to successfully remove the tumor during the gastric bypass procedure. A literature review using PubMed to search MEDLINE searching for articles involving ‘‘gastric bypass surgery’’ and ‘‘upper endoscopy’’ was done and presented as a literature review. Results: We present the case of a 54 year old female with a pre-operative body mass index of 46 and a history of hypertension, coronary artery disease status post myocardial infarction, gastroesophageal reflux disease, hyperlipidemia, obstructive sleep apnea, ovarian cysts, and degenerative joint disease. The patient had a previous endoscopy prior to referral to a bariatric surgeon which showed 1.2 a mass in the gastric fundus. A mucosal endoscopic biopsy was done and showed no evidence of malignancy. She was referred to a bariatric surgeon for a combined surgical approach that would lead to weight loss to improve her medical problems and for surgical removal of the potential tumor. The bariatric surgeon performed a repeat endoscopy on the day of surgery to localize the tumor with isosulfan blue dye. The procedure was performed in the standard fashion, with the exception of a larger gastric pouch encompassing roughly 70% of the posterior portion of the stomach with definitive visualization by intraoperative endoscopy. The mass was excluded via wedge resection and sequential firings of an endoGIA stapler with blue cartridges. The specimen was removed via an endoscopic retrieval bag. The final pathology was a leiomyoma. Conclusion: Pre-operative endoscopy should become the standard of care prior to performing gastric bypass surgery in order to identify abnormal pathology which may be missed after surgery. Although rare, benign gastric tumors including leiomyomas and gastrointestinal stromal tumors have the potential for malignant transformation. The laparoscopic approach for removal of both benign and malignant variants of these tumors has already been described in the literature and accepted as a feasible option. Post-operative care will be complicated by the inability to adequately visualize the stomach remnant.

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COMBINED ENDOSCOPIC AND LAPAROSCOPIC INTRAGASTRIC TUMOR REMOVAL: AN APPLIED TECHNIQUE TO MANAGE SUBMUCOSAL GASTRIC TUMOR LOCATED NEXT TO THE EJ JUNCTION Suriya Punchai, MD, Suppa-ut Pungpapong, MD, Chadin Tharavej, MD, Patpong Navicharern, MD, Suthep Udomsawaengsup, MD Chula Minimally Invasive Surgery Center Chulalongkorn University, Bangkok, Thailand Introduction: Gastric submucosal tumor is arising from deeper layers of the stomach wall. Overlying mucosa is not involved and gastric biopsy provides less yields. Endoscopy and also endoscopic ultrasonography are complementary to make a diagnosis. Treatment of these tumors is depending on its location. Laparoscopic resection is usually applied but in some specific areas such as lesions located next to the EG junction, the management is challenging. The combined endoscopic and laparoscopic intragastric tumor resection is theoretically benefited to manage this specific situation. Material and methods: The procedure started with the completing diagnostic endoscopy. Tumor was located and CRE dilator was then applied to occlude the pylorus to allow gastric inflation. Laparoscopic part was followed in step. Fivemm. blunt tip trocar was carefully inserted directly into the gastric lumen using a safe track technique. Follow by the introduction of another two 5-mm trocars into the intragastric cavity. Five-mm, 30 laparoscope; laparoscopic dissector forceps and Halmonic scalpel were applied to conduct the resection. Cure was to keep the tumor intact with free margin. Bleeding was secured and intragastric suturing was deployed. Tumor was then retrieved endoscopically. Finally, trocars were reduced into the peritoneal cavity and gastric defects were repaired laparoscopically. Outcomes were analyzed. Results: From March 2010 to March 2011, there were 7 patients presented with submucosal gastric tumor that located next to the EG junction underwent combined Endoscopic and Laparoscopic intragastric tumor resection. Five were female. Mean age was 59 years (46–82). All patients were successfully done with the procedures. Operative time was 120 min (95–180). Operative blood loss was 70 ml (10–200). Tumor size was 1.9 cm (1–-2.5). Pain score on the first operative date was 3.8 (2–5). Mean hospital stay was 4.4 days (range; 3–6). Pathologically, there were 4 GISTs, 2 leiomyomas and one carcinoid . The recovery was uneventful. There was no operative morbidity and mortality. Conclusion: Combined endoscopic and laparoscopic intragastric submucosal resection is feasible and safe for management of submucosal tumor of stomach located next to the esophagogastric junction

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RETROSPECTIVE ANALYSIS OF LAPAROSCOPIC APPROACH IN INTESTINAL OBSTRUCTION Masaru Matsumura, MD, Tomoaki Okada, MD, Yoshitomo Ueno, MD, Kei Tamura, MD, Tetsuya Mizumoto, MD, Naoki Ishida, MD, Yoshinori Imai, MD, Taro Nakamura, MD, Hidenori Kiyochi, MD, Kenzo Okada, MD, Toshihiko Sakao, MD, Shinsuke Kajiwara, MD Uwajima city hospital Introduction: Laparoscopic approach for intestinal obstruction is controversial because of obstacles including dilated loops of bowel, a limited working space and postoperative adhesion. The aim of this retrospective study was to verify the benefit of laparoscopic approach for intestinal obstruction. Methods and Procedures: Surgical treatment for intestinal obstruction was undertaken in 40 cases between January 2010 and September 2011 at our department. These consisted of 23 open approach cases (OA) and 17 laparoscopic approach cases (LA). We accessed these outcomes and compared LA with OA. Results: LA resulted in fewer blood loss (58 ± 35.5 g for LA versus 228 ± 85.0 g for OA mean, p = 0.03) and earlier oral intake (2.3 ± 0.25 days for LA versus 3.7 ± 0.51 days for OA mean, p = 0.02). There was a trend toward a shorter operating time in LA(84 ± 12.7 min for LA versus 96 ± 9.6 min for OA mean, p = 0.02). Postoperative complications within 30-days included 6 patients in OA (5 surgical site infections and 1 aspiration pneumonia) and no patient in LA. OA included 1 death due to aspiration pneumonia. One recurrence was found in OA and 2 recurrences were found in LA. Conclusions: It suggests that laparoscopic approach for intestinal obstruction is less invasive and results in fewer complications than open approach. A relatively high recurrence rate was observed in laparoscopic approach cases.

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ENDOFLIP HIATAL CALIBRATION DURING ANTERIOR PARTIAL FUNDOPLICATION—EARLY OUTCOMES Leslie Nathanson, Dr Wesley Hospital, Brisbane Methods: Thirty one male and 57 female patients of mean age 54 year undergoing Anterior Partial Fundoplication had documentation of symptom score, Endoscopy and Oesophageal pH. EndoFLIP assessment of the compliance of the hiatus was undertaken using the EF-325 catheter with 30 ml fill. Baseline readings prior to repair were compared to control patients and intraoperative suturing calibrated using a variety of parameters (minimum diameter, cross sectional area (CSA) and distension index (Dind)). At six months follow up re-evaluation was undertaken with EndoFLIP assessment and oesopageal pH study, in addition to symptom score and Endoscopy. A detailed presentation of the intra-operative deployment of the EndoFLIP catheter will highlight its accuracy and utility for evaluating hiatal compliance. Results: Hiatal EndoFLIP assessment of CSA was 58 mm2 vs control 37 mm2 (p \ 0.0001) and Dind 2.8 vs control 1.3. After intraoperative calibration to CSA 20 mm2 and Dind of 0.8, six month follow up revealed CSA 37 mm2 (22–51) and Dind 1.4 (1.1–2.8). At six months 24 h distal oesophageal pH of 0.2% (Normal \ 4) with Demeester score of 1.2 (Normal \ 14) Conclusions: These data confirm the limited published information confirming increased hiatal compliance in patients with pathologic oesophageal reflux. In addition realtime EndoFLIP intraoperative monitoring of the hiatal repair and follow up data at 6 months gives a glimpse of the impact of the effect of healing. This tool shows promise for evaluating and standardising hiatal repair techniques.

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COSMETIC OUTCOME AFTER SINGLE INCISION LAPAROSCOPIC CHOLECYSTECTOMY AND CONVENTIONAL LAPAROSCOPIC CHOLECYSTECTOMY: AN Objective COMPARISON Pankaj Garg, MBBS MS, Vikas Gupta, MBBS MS MCH, Jai D Thakur, MBBS 1. Fortis Super Speciality Hospital, Mohali, India, 1. MMIMS, Mullana, India 2. Post Graduate Institute of Medical Sciences & Research, Chandigarh, India, 3. Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA

COMPARISON OF SINGLE INCISION LAPAROSCOPIC CHOLECYSTECTOMY AND CONVENTIONAL LAPAROSCOPIC CHOLECYSTECTOMY: A METAANALYSIS OF RANDOMIZED CONTROLLED TRIALS Pankaj Garg, MBBS MS, Vikas Gupta, MBBS MS MCH, Jai D Thakur, MBBS, Geetha R Menon, PhD 1. Fortis Super Speciality Hospital, Mohali, India & MMIMS, Mullana, India, 2. PGIMER, Chandigarh, India, 3. Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA, 4. ICMR, New Delhi, India

Background: Single incision laparoscopic cholecystectomy (SILC) has been projected to have better cosmetic outcome as compared to conventional laparoscopic cholecystectomy (CLC). However, there is scarce data that has objectively compared the patient’s perception of cosmetic outcome after SILC & CLC. Methods: The SILC & CLC patients, who were operated in the last two years, were personally interviewed and assessed using the Patient Scar Assessment Questionnaire. The patient scar questionnaire was divided into the following five categories (with possible scores in parentheses): appearance (1–5), symptoms (1–5), scar consciousness (1–4), satisfaction with appearance (1–4), and satisfaction with symptoms (1–4). Each category question could have five or four possible responses (First two questions had 5 and the next three questions could have four possible responses). A lower score indicates a favorable cosmetic outcome. Results: 52 patients were included in the study, (SILC = 25, CLC = 27). The age, sex distribution and BMI were similar in both the groups. The scores of different parameters assessed as per Patient Scar Assessment Questionnaire— appearance (SILC—1.08 ± 0.4, CLC—1.14 ± 0.5, p = 0.57, not significant, two-sided t-test), symptoms (SILC— 1.16 ± 0.5, CLC—1.18 ± 0.4, p = 0.83, not significant, two-sided t-test), scar consciousness (SILC—1.04 ± 0.2, CLC—1.07 ± 0.3, P = 0.6, not significant, two-sided t-test), satisfaction with symptoms (SILC—1.12 ± 0.3, CLC— 1.18 ± 0.4, P = 0.52, not significant, two-sided t-test) and satisfaction with appearance (SILC—1.04 ± 0.2, CLC— 1.11 ± 0.3, P = 0.34, not significant, two-sided t-test) - were similar in both the groups. The overall satisfaction scores were also statistically similar in both the groups (SILC—5.44 ± 1.4, CLC—5.70 ± 1.7, P = 0.54, not significant, twosided t-test). Overall, a majority of patients ([80%) in both the groups gave least score (1), indicating maximum satisfaction, in all the categories. Conclusions: The patient perception regarding cosmetic outcome after single incision laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy was similar in both the groups. Single incision laparoscopic cholecystectomy doesn’t seem to offer any significant cosmetic advantage over conventional laparoscopic cholecystectomy. This finding is significant because cosmetic benefits are one of the major projected advantages of SILS over CLC. In case this is not so, then the case in favor of SILS would not remain strong considering the complexity associated with SILS, namely technically difficulty, higher risk of complications especially in patients with BMI [ 33, increased operating time, need for sophisticated instruments, no improvement in postoperative pain scores as compared to CLC and lack of long term data. This point needs to be assessed in detail by larger studies, as cosmetic benefit is projected as one of the major advantages of single incision surgery.

Background: Single incision laparoscopic cholecystectomy (SILC) has been developed as a step forward in minimal access surgery. The principal benefit of SILC is supposed to be better cosmesis and reduced pain. The purpose of this study was to compare different morbidity parameters between SILC and conventional laparoscopic cholecystectomy (CLC). Methods: The databases- Pubmed, Ovid, Embase SCI database, Cochrane & Google Scholar were searched for single incision laparoscopic cholecystectomy and all related terms. The studies between 1995 to September, 2011 were extracted by two independent reviewers. Out of 2057 yielded studies, 14 studies comparing SILC & CLC were extracted and out of these, 5 randomized controlled trials (RCT) were selected for meta-analysis. The assessment of risk of bias in the trials was based on adequate sequence generation, allocation concealment, blinding, whether incomplete outcome data was addressed and selective outcome reporting. For continuous variables, statistical analysis was carried out using the weighted mean difference(WMD) as the summary statistic and for categorical variables, odds ratio was used as the summary statistic. The primary endpoint analyzed was pain at 24 h after the operation and the secondary end points were cosmetic satisfaction, operating time, hospital stay and incidence of post operative complications namely bile leak, hernia formation and wound infection. Results: A total of 287 patients (SILC-150, CLC-137) were analyzed from 5 randomized controlled trials (RCT). The operating time was significantly longer in SILC (mean difference = 15.54, 95% CI: 11.01 to 20.08, p \ 0.00001). The objective post operative pain scores at 24 h, though less in SILC group, was not statistically different between the two groups (mean difference = 0.27, 95% CI: -0.55 to 0.01, p = 0.06, not significant). SILC group had significantly favorable cosmetic scoring compared to CLC (mean difference-1.16, 95% CI: 0.75 to 1.56, p \ 0.00001). The hospital stay was similar in both the group (mean difference = -0.15, 95% CI: -0.35 to 0.05, p = 0.15). All the post operative complications, though higher in SILC group, were statistically comparable in both the groups- bile leak (RR = 1.17, 95% CI: 0.37 to 3.75, p = 0.79, not significant), wound infection (RR = 1.49, 95% CI: 0.29 to 7.63, p = 0.63, not significant) & hernia formation (RR = 2.58, 95% CI: 0.26 to 25.60, p = 0.42, not significant). Conclusions: Single incision laparoscopic cholecystectomy(SILC) has cosmetic benefit over conventional laparoscopic cholecystectomy (CLC). SILC had significantly longer operating time which is perhaps due to the learning curve. However, there is no difference between other morbidity parameters such as post operative pain at 24 h, and the hospital stay. Post operative complications such as bile leak, wound infection and hernia formation, though higher in SILC, were statistically similar in both the groups. Though SILS has cosmetic benefit over CLC, studies have demonstrated that cosmesis after CLC is also remarkable and acceptable. Against this background, the future of SILC depends on the long term safety of SILC especially the hernia formation and biliary injuries.

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POSTOPERATIVE OUTCOMES OF ROUX-EN Y RECONSTRUCTION WITH DOUBLE STAPLING AND INTRACORPOREAL SUTURES; IN A TOTALLY LAPAROSCOPIC DISTAL GASTRECTOMY Jung Ho Shim, MD, Kyo Young Song Department of Surgery, College of Medicine, The Catholic University of Korea Background: This study was designed to evaluate the feasibility and clinical outcomes of a Roux-en Y reconstruction in a totally laparoscopic distal gastrectomy (TLDG). Methods: Between January 2011 and August 2011, we had performed 84 totally laparoscopic distal gastrectomies. Of these, thirty sevens totally laparoscopic distal gastrectomies with Roux-en Y reconstructions were reviewed. And we evaluated the clinical data, including age, gender, BMI, operation time, hospital stay, co-morbidity, postoperative complication rates, and pathologic stages in those patients. Results: Of 37 patients who underwent TLDG, there is no intraoperative complication or conversion to open surgery. In all cases, we used laparoscopic staplers and intracorporeal suture techniques to close the entry site of the linear staplers. The mean operation time was 135 ± 24.9 min, and the mean anastomosis time was 26.2 ± 3.5 min. There were 4 cases of Roux stasis, one duodenal stump leakage, and one patient was required to have reoperation due to the internal herniation with afferent loop obstruction. But there is no operation related mortality. Postoperative fluorography revealed no anastomosis leakage or stenosis in any of the patients. Patients resumed an oral liquid diet on postoperative day 4.3 ± 1.75 days. Conclusion: In this study, we have successfully performed TLDG with Roux-en Y reconstruction using our technique in 37 patients. This is a feasible and safe operative management on patients with distal gastric cancers.

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ENHANCED RECOVERY PROGRAM IN LAPAROSCOPIC RADICAL GASTRECTOMY FOR GASTRIC CANCER PATIENTS Chung-wei Lin, MD, Tzu-jung Tsai, MD, Tsung-yen Cheng, MD, Hung-kuang Wei, MD, Chii-ming Chen, MD Koo Foundation Sun Yat-Sen Cancer Center Introduction: Laparoscopic gastrectomy for gastric cancer is technically feasible. The oncologic outcome is comparative with standard surgery and the postoperative recovery is better. The aim of this study is to establish the improvement of postoperative care by applying the Enhanced Recovery Program (ERP) in gastric cancer patients undergo laparoscopic gastrectomy. Methods and Procedures: From August 2008 to August 2011, 47 consecutive gastric cancer patients who received laparoscopic radical gastrectomy with D2 lymph nodes dissection were included. The ERP includes : no epidural or patient controlled analgesic device used, early removal of nasogastric tube on the first postoperative day and then sip water, early mobilization, early resume of regular diet right after flatus passage. Patient characteristics, operative data, and post-operative outcomes were prospectively collected and analyzed. Results: There were 18 females and 29 males, the mean age was 57 years. The mean operative time was 326 min and mean blood loss was 68 ml. The time to first flatus passage was 2.8 days. The mean hospital stay was 6.6 days (range, 5–12). Failure of ERP is defined as need for re-insertion of nasogastric tube, slow progression of resume oral intake and admission longer than 8 days. The failure rate in this 3 years study was 6.4%. Four patients experienced delayed the resume of oral intake because of gastroparesis or ileus in the postoperative period. All of them were treated successfully with conservative method. One patient developed afferent loop syndrome 28 months after operation and managed with emergent exploration. The morbidity and mortality rate was 12.8% and 0%. There was no anastomosis leakage. Median follow-up was 17 months (range, 2–36). There was no cancer recurrence nor disease related death in the follow up period. Conclusion: The application of Enhanced Recovery Program after laparoscopic gastrectomy for gastric cancer is feasible with favorable outcome.

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EARLY REFERRAL FOR 24-h ESOPHAGEAL pH MONITORING MAY PREVENT UNNECESSARY TREATMENT WITH ACID-REDUCING THERAPY David A Kleiman, MD, Matthew J Sporn, BS, Toni Beninato, MD, Thomas J Fahey, Iii, MD, Rasa Zarnegar, MD New York Presbyterian Hospital - Weill Cornell Medical College Introduction: Gastroesophageal reflux disease (GERD) affects nearly 25% of adults, however an objective diagnosis is rarely established. We hypothesized that delayed referral for 24-h pH monitoring (current ‘‘gold-standard’’ for diagnosis) may result in lengthy courses of unnecessary acid-reducing therapy for select patients. Methods and Procedures: A retrospective chart review was performed of all 24-h esophageal pH monitoring studies performed at our institution between 2004 and 2011. Patients whose medical records lacked adequate historical information were excluded. The records were reviewed for patient age, gender, type of GERD symptoms, and duration/response to prior acid-reducing medications. Patients were labeled ‘‘no GERD’’ if there was a low index of suspicion, ‘‘typical GERD’’ if descriptors such as regurgitation, ‘‘heartburn,’’ and dysphagia were reported, and ‘‘atypical GERD’’ if symptoms such as hoarseness, voice changes, post-nasal drip, or sinusitis were used. Patients were grouped by history of GERD and then also by response to acid-reducing therapy prior to testing. pH monitoring was considered diagnostic of pathological GERD if the DeMeester score was C14.7. Statistical analysis was performed using STATA 12.0 (College Station, TX). Results: 115 patients were included in this study. 68.7% of the patients had a history of typical GERD, 22.6% had a history of atypical GERD, and 8.7% had no history of GERD. Patients who tested positive for GERD on 24-h pH monitoring were well-matched compared to those who tested negative except the positive group was significantly older than the negative group (52.5 ± 15.1 years vs. 45.4 ± 15.8, p = 0.023). When grouped according to type of GERD history, there were no significant differences in the outcome of the test, DeMeester score, or duration of PPI use prior to testing (Table 1). When grouped according to response to anti-reflux therapy, there were no significant differences in DeMeester scores or test outcomes between the groups. However, there was a significant step-wise increase in duration of anti-reflux therapy prior to testing. Patients with no response to treatment were referred earliest and patients with an initial response but subsequent relapse of symptoms were referred the latest (median 1.3 years vs. 6.0 years, p = 0.012) (Table 1). 42.9% of the patients who had a relapse of symptoms had no evidence of GERD on pH monitoring (Table 1).

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FEASIBILITY OF MINIMALLY INVASIVE ESOPHAGECTOMY AFTER NEOADJUVANT CHEMORADIATION Charles Bakhos, MD, Tolutope Oyasiji, MD, Michael Kent, MD, Sidhu Gangadharan, MD, Jonathan Critchlow, MD, Tom Fabian, MD Albany Medical Center (Albany NY), Beth Israel Deaconess Medical Center (Boston, MA) Introduction: The impact of neoadjuvant chemo-radiation (NCR) on outcomes after esophagectomy is still debated. The choice of surgical approach can also be influenced by this treatment modality, including the performance of minimally invasive esophagectomy (MIE), a technically demanding procedure. We sought to inquire the outcomes of MIE after NCR. Methods and Procedures: We conducted a retrospective analysis of consecutive MIEs performed at two institutions from January 2002 to January 2009. We analyzed the effect of NCR on peri-operative results including pulmonary complications, oncological outcomes, length of stay (LOS) and mortality. Results: A total of 105 patients were eligible for the study. Six patients (5.7%) were converted from MIE to an open approach and were excluded from the analysis. The causes for conversions were: bleeding (3), significant adhesions (2) and inadequate conduit length (1). Out of the 99 patients, 79 were male (80%), mean age was 63 ± 12 years (range 26-88) and 45 underwent NCR (46%, group 1). Anastomoses were performed in the neck in 79 patients (80%). Comparing both groups, the incidence of pneumonia (7 vs. 11), pleural effusions including chylothorax (7 vs. 3) and number of harvested lymph nodes (16 ± 9 vs. 19 ± 9) was comparable (group 1 vs. group 2, respectively, p = NS). More anastomotic leaks occurred in patients who did not undergo NCR (group 2, 1 vs. 8, p = 0.04). Median LOS was also comparable between both groups (10 ± 10 vs. 11 ± 8 days). Overall, there were 3 patients (3%) with an R1 resection margin and 3 operative deaths (both exclusively in group 1, p = NS). Conclusion: MIE can be safely performed after NCR in the management of esophageal cancer, with a low conversion rate. Outcomes seem comparable regardless of pre-operative NCR. Number of words: 287

Table 1 Negative DeMeester scorea p-valueb 24-h esophageal pH study (%)

Duration of prior acid-reducing therapy (years)a

p-valueb

1.0 (0–2.0)

0.123

History of gerd None (N = 10)

60.0

11.4 (0.3–57.5)

Typical (N = 79)

35.4

23.6 (0.3–207.4)

3.0 (0.1–20.0)

Atypical (N = 26)

73.1

17.6 (1.4–94.8)

2.0 (0.3–25.0)

0.105

Response to acid-reducing therapy None (N = 43)

34.9

18.8 (0.3–94.8)

Partial (N = 28)

32.1

20.4 (0.5–25.3)

3.5 (0.3–25.0)

Complete (N = 3)

0

30.2 (24.0–38.3)

4.5 (1.0–8.0)

Relapse (N = 7)

42.9

27.6 (0.5–57.1)

6.0 (3.0–20.0)

0.826

1.3 (0.1–16.0) 0.012

a

Values not normally distributed reported as median (range),

b

Kruskal–Wallis rank test

Conclusion: Delayed referral for esophageal pH monitoring occasionally results in lengthy periods of unnecessary treatment with acid-reducing therapy with no therapeutic benefit. Early referral for 24-h esophageal pH monitoring could potentially avoid unnecessary side effects and expenses for these patients.

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LONG-TERM SYMPTOM CONTROL AND SATISFACTION SCORES IN PATIENTS UNDERGOING PRIMARY ANTIREFLUX SURGERY Ananth Srinivasan, Masato Hoshino, Amith V Reddy, Tommy H Lee Sumeet K Mittal Creighton University Medical Center Background: Aim of this study was to evaluate the long-term outcomes of Primary Anti-Reflux Surgery (ARS). Methods: After IRB approval, a retrospective review of prospectively maintained database was done to identify patients who underwent a primary ARS by the senior author with 5 years or greater follow up. Symptoms included heartburn, regurgitation, dysphagia and chest pain. Significant symptoms were defined to have a grade of 2 or 3. All data was expressed as median (IQR) or mean (range). Chi-square test was used to compare categorical variables. Mann–Whitney’s U test and Wilcoxon test were used to compare continuous variables. A p-value \0.05 was considered statistically significant. Results: A total of 207 patients underwent ARS from September 2003 to September 2006. There were 125 (60%) females and the median age of the entire group was 53 (IQR: 43–77). 198 surgeries (95.6%) were completed laparoscopically while 1 (0.5%) and 8 (3.9%) were performed via laparotomy and left thoracotomy respectively. A Nissen fundoplication was performed in 175 (84.5%) patients. A Collis gastroplasty was required in 5.8% of the patients to complete the fundoplication. A follow up on 115 (56%) was obtained and the mean follow up time was 70.4 months (60–89). There was significant differences between the mean scores of heartburn (1.36 vs 0.4; p \ 0.001), regurgitation (0.82 vs 0.12; p \ 0.001) and chest pain (0.52 vs 0.3; p = 0.024). There was also a statistically significant proportion of patients reporting a decrease in significantly severe (defined as a score of 2 or 3) symptoms for heartburn (60% vs 7%; p \ 0.001), regurgitation (33% vs 2%; p \ 0.001), dysphagia (18% vs 7%; p = 0.005) and chest pain (24% vs 6%; p \ 0.001). The mean satisfaction score was 8.67 with 79% of the patients queried reporting excellent satisfaction scores (8 or greater). A good percentage (84%) of the patients responded positively when asked if they would recommend their procedure to someone. 31.2% reported continuation of some form of medication for reflux (22.6% PPI, 4.3% H2 blockers & 4.3%% antacids). Conclusion: Long-term follow up of patients who underwent primary ARS has shown very good outcomes as measured by significant improvement in severity of symptoms and patient satisfaction scores.

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SWALLOW SYNCOPE AFTER LAPAROSCOPIC VERTICAL SLEEVE GASTRECTOMY: FIRST REPORTED CASE Sergio G Casillas, MD, Gintaras Antanavicius, MD FACS Abington Memorial Hospital, Department of Surgery Introduction: Vasovagal arrhythmias are well documented in the general population, especially in patients with primary cardiac disorders, such as hypertensive heart disease, congestive heart failure and ischemic cardiomyopathy. The presence of arrhythmias related to gastrointestinal disorders is rare. We present the case of complete atrioventricular block that resulted in syncope secondary to swallowing after a laparoscopic vertical sleeve gastrectomy (LVSG) in a patient with no previous history of heart disease. Previously reported cases were collected and reviewed. Report: A 51-year-old female patient underwent elective LVSG in the treatment of her morbid obesity. Her past medical history was significant for hypertension, obesity, gastroesophageal reflux disease, osteoarthritis and gout. Preoperative cardiac and pulmonary workup included a chest X ray, EKG, polysomnography and stress test that were all normal. Abdominal ultrasound, esophagogastroduodenoscopy and colonoscopy were performed and were normal. Cardiologic and pulmonary consultations granted clearance for her operation. A routine LVSG was performed successfully and no intraoperative complications were observed. On postoperative day # 1, she was started on a restricted clear liquid diet, but then developed a syncopal episode while having her first meal. She was given bedrest, IV fluids and oxygen and recovered immediately. A full cardiac work-up looking for arrhythmias and ischemic changes was performed, serum markers for cardiac ischemia were all negative, EKG tracings revealed normal sinus rhythm. She was transferred to the ICU where she developed a witnessed symptomatic atrioventricular block while having a clear liquid swallow trial; the block was reversed with atropine. Several episodes of self-limited atrioventricular blockages were observed during her hospital stay, persistently, while the patient was eating. No syncopal episodes were reported after the first one and she was discharged home stable and tolerating oral intake. No permanent pacemaker was required. Patient’s symptoms have gradually diminished without any specific treatment. Conclusions: To our knowledge, the presence of vasovagal reflexes that translate into atrioventricular blockage after LVSG is previously undocumented. We theorize that perigastric manipulation stimulated and irritated the visceral roots of the vagus nerve, leading to hyperexcitabilty and efferent stimulation of the posterior nucleus of the vagus nerve with resultant afferent cardiac response manifested as bradycardia or atrioventricular block. Close monitoring is mandatory and future considerations for patients undergoing gastric surgery must be taken into account to prevent or detect these arrhythmias.

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THE SURGICAL OUTCOMES OF LAPAROSCOPIC ASSISTED TOTAL GASTRECTOMY WITH UPPER MEDIAN SMALL INCISION Nobuhiro Takiguchi, MD PhD, Matsuo Nagata, MD, Yoshihiro Nabeya, MD, Atsushi Ikeda, MD, Osamu Kainuma, MD, Hiroaki Soda, MD, Akihiro Cho, MD, Takumi Ota, MD, Sjonjin Park, MD, Hiroshi Yamamoto, MD Division of Gastroenterology, Chiba Cancer Center Introduction: The laparoscopic assisted total gastrectomy (LATG) is not accepted for standard operation because of the difficulty of the esophago-jejunostomy. Methods of esophago-jejunostomy have been proposed by using a circular stapler or by using linear staplers. Our procedure of esophago-jejunostomy by circular stapler is performed with upper median small incision. The purpose of this study is to evaluate the indication and short and long term surgical outcomes of LATG by our procedure. Methods: Our indication for LATG is gastric cancer under cT2 and cN1. The D1+b dissection is carried out laparoscopically. After the lymph nodes dissection and cutting off the duodenum by laparoscopic linear stapler, upper median mini-laparotomy is performed with an incision about 6 cm. I. Making of working space; Two gauze mass are inserted in order to keep the good vision of the field of esophagus circumference and wide working space. II. The insertion of Anvil; Abdominal esophagus is transected using a purse string suture instrument (PSI) with 35 mm width and 3-0 proline straight needle (EH7921). Esophagus is grasped by 3 Babcock forceps and anvil head of circular stapler (CDH 25 mm) is inserted into the jejunal stump . III. Y limb anastomosis; Jejuno-jejunostomy is performed by hand sewn and mesentery is sewn under direct vision. IV. Esophago-jejunum end to side anastomosis; The jejunum is lifted by antecolic route. Esophago-jejunum end to side anastomosis is performed by CDH 25 mm introduced through the jejunal stump. Jejunal stump was closed by laparoscopic linear cutter. Results: Forty one gastric cancer patients (32 males and 9 females) underwent LATG. Median follow up period was 22 months. Ten cases were advanced gastric cancer, and seven patients received adjuvant chemotherapy. The short term results of LATG was following; Operating time, blood loss, and post-operative hospital stay were 224.9 ± 34 min, 141.4 ± 124.9 ml, and 13.7 days, respectively. Perioperative complications were one esophago-jejunal leakage, one intra-peritoneal abscess, and two Y limb passage disorders. Five-year cumulative survival rate was 97%. One patient with pStageIIIA died due to the peritoneal recurrence. One emergency operation was performed because of the esophago-jejunal leakage. Conclusion: The point of LATG reconstruction is to make the complete esophago-jejunostomy by avoiding the excessive traction of esophagus in narrow working space. LATG using CDH with small upper median incision is a useful technique for gastric cancer in the confined indication from the point of short and long term results.

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THE EFFECT OF VESSEL SEALING SYSTEM ON THE OUTCOME OF LAPAROSCOPIC GASTRECTOMY Kengo Kanetaka, PhD, Shinichiro Ito, MD, Kosho Yamanouchi, PhD, Fumihiko Fujita, PhD, Mitsuhisa Takatsuki, PhD, Tamotsu Kuroki, PhD, Susumu Eguchi, PhD Nagasaki University Graduate School of Biomedical Sciences Introduction: With the advances in technology in recent years, laparoscopic procedures have gained popularity for gastrointestinal surgery. In Japan, laparoscopic distal gastrectomy has been frequently used for the resection of gastric cancer, especially in early phase. However, to make this procedure a standardized treatment, it is important to ensure that this complicated method can be performed in a safe and easy manner. For this purpose, co-ordination between the surgeon and assistants, appropriate surgical fields, and the use of the appropriate laparoscopic instruments in the correct place are crucial. So far, many useful energy devices for sealing vessels and reducing intraoperative blood loss have been developed in this field, such as vessel sealing systems and ultrasonically- activated devices. As each of these devices has unique advantages and disadvantages, the choice of the best instrument according to the intraoperative situation and site for dissection are important. We herein provide the first description of our techniques of comprising the combined use of a vessel sealing system and an ultrasonically-activated device. We also investigated the efficacy of the combined use of these two instruments in laparoscopic distal gastrectomy. Procedures: We introduced laparoscopic gastrectomy to our institution in 2007. During the early period, we had mainly used an ultrasonically-activated device for all operations. However, beginning in September 2010, in addition to the ultrasonically-activated device, we introduced a vessel sealing system. Briefly, to dissect thick fatty tissue, such as the gastrocolic ligament, we use the vessel sealing system. On the other hand, to divide relatively small vessels and to dissect the connective tissues around large arteries, the ultrasonically-activated device is used. We compared the surgical data between two groups, that comprising patients treated exclusively using the ultrasonically-activated device group (USAD) and that where patients were treated with the combined use of the ultrasonically-device and the vessel sealing device (COMB) In addition, we investigated the data according to the body mass index of the patients. Results: Between February 2007 and September 2011, 74 consecutive patients who underwent laparoscopic distal gastrectomy were included in this retrospective study (the USAD group included 53 patients and the COMB group included 20). There were no significant differences in the clinicopathological parameters, such as blood loss, length of the operation, postoperative morbidity, and the number of harvested lymph nodes between the groups. When analyzed in patients with a body mass index of 24.0 and over, there was a trend for there to be less blood loss (294.9 ml vs. 204.5 ml, p = 0.20) and a shorter length of the operation in the COMB group compared with the USAD group (420.6 min vs. 362.4 min, p = 0.17). Conclusion: Our results showed that the use of both the vessel sealing system and the ultrasonically-activated device caused no significant difference in terms of blood loss or the length of the operation. However, for the patients with a BMI 24 or over, the combined use of these instruments appeared to reduce both the bleeding and the length of the operation.

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DOES SIMULTANEOUS HIATAL HERNIA REPAIR WITH LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS EFFECT OUTCOMES? Kunoor Jain-spangler, MD, Jin Yoo, MD, Alfonso Torquati, MD MSci, Dana Portenier, MD, Ranjan Sudan, MD, Aurora D Pryor, MD Duke University Medical Center; Stony Brook University Medical Center Objective: The purpose of this study was to identify differences in outcomes for patients undergoing laparoscopic Roux-en-Y Gastric Bypass (LRYGB) with simultaneous hiatal hernia repair (HHR) as compared with a matched cohort of patients undergoing LRYGB alone. Patients presenting for LRYGB often have hiatal hernias, either known or incidentally discovered. We feel the hernia should be repaired for appropriate pouch sizing and to minimize longterm complications due to an incompetent GE junction or sliding hernia. Furthermore, from the acute postoperative standpoint, HHR helps minimize tension on the gastrojejunal anastomosis, potentially reducing leak risk. Methods and Procedures: A retrospective cohort review was performed of MetaBarR (IRB Pro00003715), a secure bariatric database created and maintained by the Duke University Metabolic and Weight Loss Surgery Center, in which anthropometric data is collected prospectively. We compared data and outcomes for 59 patients from July 2009 to July 2011 who had LRYGB with simultaneous HHR with a matched cohort of patients in the same time period who had standard LRYGB with no additional procedure. Patients were matched by preoperative BMI, ASA class, age, sex and race. When performed, HHR began with circumferential crural dissection and utilized interrupted permanent sutures for primary cruroplasty. Biologic mesh was placed in 11 patients with larger defects, including large paraesophageal hernia, in addition to primary repair. Data were analyzed using student’s t-test. Results: As shown in Table 1, patients undergoing LRYGB with HHR who are demographically similar to patients undergoing LRYGB alone demonstrated no significant differences in estimated blood loss, hospital stay or weight loss. Operative time was significantly longer (p = 0.03). Gastrojejunal leak rate was 0% in both groups, however the incidence of marginal ulcer was higher in the control group (3 vs. 0) without reaching statistical significance. The addition of mesh, which is indicative of larger hernia in our practice, was not significantly different than the no mesh group.

Table 1 Patient demographics and outcomes Control

LRYGB+HHR

P Value

Age

49.3 ± 11.3

49.4 ± 11.7

0.95

Gender (M/F)

11/48

11/48

1.0

ASA Classification

2.8 ± 0.4

2.8 ± 0.4

0.82

Preop BMI

46.7 ± 6.2

46 ± 6.7

0.64

Operative Time (min)

111 ± 36.4

126 ± 37.9

0.03*

Hospital Length of Stay

1.95 ± 1.8

1.63 ± 0.8

0.22

Estimated Blood Loss

27.3 ± 14.2

30 ± 17.6

0.29

3 week %EWL

16.5 ± 4.3

16.5 ± 5.3

0.98

3 month %EWL

34.7 ± 7.1

34.7 ± 10.9

0.98

6 months %EWL

48.7 ± 12.2

50.4 ± 15.9

0.66

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PARAESOPHAGEAL HERNIA REPAIR IN THE ELDERLY PATIENT Isabelle Raiche, MD FRCSC, Fatima Haggar, MPH, Joseph Mamazza, MDCM FRCSC, Husein Moloo, MD FRCSC MSc, Guillaume Martel, MD FRCSC, Eric C Poulin, MD MSc FRCS C, James Masters, MD, Christopher Smith, MD FRCSC, Balpreet Brar, MD FRCSC The Minimally Invasive Surgery Research Group, The Ottawa Hospital, University of Ottawa Background: The elderly population often presents an increased surgical risk. The potential risk of surgical complications is always balanced against the risk of the primary disease. Paraesophageal hernias in the elderly present a unique challenge to the clinicians. The aim of this study was to 1) compare the short-term postoperative outcomes between the different surgical approaches (laparoscopy, laparotomy and thoracotomy) for paraesophageal hernia (PEH) repair in elderly patients; and 2) evaluate the short-term postoperative outcomes following emergency and elective PEH procedures in elderly patients. Methods: Data was obtained on patients 70 years of age or older who underwent PEH repair from a prospective database. This database included patients who underwent surgical hernia repair by laparoscopy, laparotomy or thoracotomy between July 2005 and December 2010 at a single academic center. The surgical approach was left to the surgeon discretion. Length of stay (LOS), postoperative morbidity and mortality were analysed. Results: Ninety-five patients (27 males, 68 females) with a median age of 77 years (interquartile range, IQR: 9 years) undergoing laparoscopy (n = 52, 54.7%), laparotomy (n = 30, 31.6%) and thoracotomy (n = 13, 13.7%) were included. In the thoracotomy group, 8 patients had a Collis gastroplasty. A majority of included patients had ASA score of II (31.6%), III (46.3%) or IV (14.7%). The most frequent diagnosis was type III PEH (n = 72, 75.8%), 17 patients had type IV (17.9%) and 6 patients had type II (6.3%). In the patients undergoing elective surgery (n = 71, 74.7%), the median LOS was 6.0 days (IQR: 5 days). For this group, the median LOS for patients undergoing laparoscopy was 4.8 days, which was significantly shorter than for patients undergoing laparotomy (9.2 days, p = 0.02) and thoracotomy (14.2 days, p B 0.0001). The post-operative complication rate for the laparoscopy group was 34.0% (n = 16), 57.1% for the laparotomy group (n = 8) and 70.0% for the thoracotomy group (n = 7); the difference was statistically significant only between the thoracotomy group and the laparoscopy group (p = 0.02). The overall mortality rate was 2.8% (n = 2) without significant difference between the approach. Twenty-five percent of the cases (n = 24) were emergencies, 19 patients for type III PEH (79.2%) and 5 patients for type IV (20.8%). The most frequent procedure performed was a laparotomy, crural repair and tube gastrostomy (n = 16, 66.7%). Three patients had a fundoplication (12.5%). Only one patient needed a gastrectomy. Patients undergoing emergency procedures on average stayed in hospital significantly longer than patients undergoing elective procedures (6.3 vs. 44.1 days, p = 0.02). Elderly patients undergoing emergency PEH surgery experienced 3 times higher odds of postoperative complications (odds ratio (OR) 3.13, 95% confidence interval (CI); 1.16, 8.47, p = 0.025) and nine (9) times higher odds of death (OR 9,09, 95% CI; 1.63, 50 p = 0.012) compared with those undergoing an elective procedure. Conclusions: Despite underlying comorbidities, individuals older than 70 years of age tolerate elective laparoscopic PEH surgery relatively well. Emergency procedures for PEH are associated with an increased risk of serious adverse events or fatality. Referring practitioners need to be informed of the potential risk and encouraged to refer patients earlier.

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EWL estimated weight loss; *denotes statistically significant value Conclusions: Data concerning simultaneous LRYGB and HH repair is sparse and consists primarily of case reports and series. The data we present here show the safety of performing these procedures together in appropriately selected patients, even with large paraesophageal hernia. The trend towards decreased marginal ulcers may be due to smaller pouch size in hernia repair patients.

PARTIAL LONGITUDINAL GASTRECTOMY: A NOVEL CURATIVE APPROACH FOR GASTROPARESIS Avishai Meyer, MD, Pradeep Pallati, MD, Abhijit Shaligram, MBBS, Dmitry Oleynikov, MD, Matthew Goede, MD University of Nebraska Medical Center Background: Gastroparesis is a disorder that affects thousands of worldwide. It is marked by a stomach’s inability to properly empty its contents. The mainstay of treatment to date has been pharmaco-therapeutic in nature (e.g. prokinetic agents, diabetes management, etc). Surgical intervention is usually reserved for recalcitrant cases. The aim of this initial study was to determine whether partial longitudinal gastrectomy without anastomosis (sleeve gastrectomy) could significantly improve gastric emptying. Study Design: Nine morbidly obese patients (8 female, 1 male) diagnosed with gastroparesis were prospectively followed after undergoing sleeve gastrectomy. All patients were preoperatively evaluated by radionuclide gastric emptying studies. Pre and postoperative BMIs and symptoms were assessed. Two surgeons performed all operations in a standardized fashion with EGD evaluation. Postoperatively, weight loss was calculated. There were no operative complications. Results: All nine patients reported improved symptoms following longitudinal gastrectomy (mean followup 8 months). Average preoperative BMI was 39.2. Postoperatively, BMI decreased to 36.2 with an average weight loss of 12.3 kg. All patients reported resolution of their pre-operative abdominal pain and distension. The most common post-operative symptom noted was vomiting (3/9). One patient remains on prokinetics (metoclopramide). Four patients had postoperative radionuclide gastric emptying studies, of which three now show normal gastric emptying. Conclusions: A novel technique of partial longitudinal gastrectomy without anastomosis has been proposed as a treatment for patients with gastroparesis. Beyond the improvement in gastric emptying, hormonal changes from the removal of the gastric fundus may make diabetic control easier. Larger studies with a longer follow up are needed, in both morbidly obese and non-morbidly obese patients, to evaluate if this type of gastrectomy leads to a durable resolution of symptoms.

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IMPACT OF TRANSORAL INCISIONLESS FUNDOPLICATION ON SUBJECTIVE AND Objective GERD INDICES: A META-ANALYSIS OF THE PUBLISHED LITERATURE Mark R Wendling, MD, W. Scott Melvin, MD, Kyle A Perry, MD Center for Minimally Invasive Surgery, The Ohio State University, Columbus, OH Introduction: Since 2007, transoral incisionless fundoplication (TIF) has been employed for endoscopic treatment of gastroesophageal reflux disease (GERD). Full thickness polypropylene H-fasteners create a serosa to serosa gastroesophageal plication to create a mechanical barrier to reflux. Multiple cohort studies in the United States and Europe have examined the effect of TIF on subjective and objective measures of gastroesophageal reflux. The aim of this meta-analysis was to evaluate the worldwide experience with TIF to date and to assess the effect of this procedure on patient symptoms and esophageal acid exposure. Methods: A systematic search of the literature, published to date in English and indexed in MEDLINE and PubMed, was carried out in August 2011 using the following keywords: GERD + endoluminal treatment, ELF, TIF, Esophyx, endoscopic fundoplication, reflux + endoluminal treatment, incisionless fundoplication. Studies were selected on the basis of availability of data on at least two of the following parameters: esophageal manometry, pH study, symptom scores, and medication usage. Statistical analysis was performed on the results from twelve cohort studies. With average pre- and post-EsophyX scores for each study available, statistical evaluation was performed using a weighted paired t-test. When more than one post-treatment score was obtained, the last measurement was included in this analysis. Statistical significance was defined as p \ 0.05. Results: The literature search yielded 12 cohort studies containing 358 unique patients with a mean follow-up interval of 8.7 (±5.1) months. No randomized controlled trials of TIF have been published to date. The subjective and objective outcome data are summarized in the Table 1 below. The major complication rate was 3.9%. Also, 9.4% of patients required further treatment with either a second TIF procedure or laparoscopic Nissen fundoplication. TIF significantly improved GERD health related quality of life score (GERD-HRQL) and 75% of patients did not require PPI therapy after 9 months. While TIF appears to decrease esophageal acid exposure and increase LES pressure, these differences did not reach statistical significance.

Measurement

No. Total studies patients

Average decrease

GERD-HRQL score

9

325

20.6

8.2

0.0001

RSI score

2

133

23.3

6.8

0.1026

Continued PPI use

9

320

25.4%

9.2

0.0001

Hiatal hernia incidence

3

63

36.0%

7.5

0.2423

Mean LES pressure

3

103

-5.0 mmHg

10.1

0.0762

Esophageal acid exposure time (% time pH \ 4)

3

99

2.8%

10.0

0.2027

DeMeester score

3

107

7.7

10.0

0.2008

61

22.1

6.7

0.3066

4

Mean F/U P(months) value

Conclusions: TIF improves typical GERD symptoms as measured by GERD-HRQL and eliminates the need for PPI therapy in a significant number of patients at short term follow-up. There is insufficient data to demonstrate that these symptomatic improvements are associated with significant changes in esophageal acid exposure or changes in esophageal sphincter pressure. TIF may provide symptomatic improvement in select patients. Prospective randomized controlled trials and cohort studies with long term follow-up are required to provide further assessment of the efficacy and durability of this procedure.

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LAPAROSCOPIC MANAGEMENT OF SMALL BOWEL OBSTRUCTION DUE TO MECKEL’S DIVERTICULUM IN THE ADULT Alex Gandsas, MD, Adeshola Fakulujo, MD, Wanda Good, DO, Sohail Mamdani, DO, Abier Abdelnaby, MD UMDNJ-SOM Introduction: Small bowel obstruction in the adult as a result of a Meckel’s diverticulum is an uncommon surgical condition that carries high morbidity if treatment is not rendered in a timely fashion. Case presentations and Methods: We report a case of a 39-year-old male who was admitted to the emergency room with a 3 day history of left lower abdominal pain. Physical exam, as well as images, was consistent with small bowel obstruction. A diagnostic laparoscopy demonstrated a Meckel’s diverticulum acting as a fixed point strangulating the ileum, thus, compromising the blood supply of the affected segment. A diverticulectomy was carried out and conservative approach was chosen regarding the affected small bowel. Results: Patient recovered with no complications and was discharged on the second post operative day. Conclusion: This video presentation underscores the importance of including a complication of a Meckel’s diverticulum as part of a differential diagnosis of bowel obstruction in a male adult with no previous history of abdominal surgery.

39669

Table 1 Subjective and objective measures of GERD indices after TIF

Number of acid refluxes

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MARKED INCREASE IN INTRACRANIAL PRESSURE WITH LAPAROSCOPY: CASE REPORT Tovy H Kamine, MD, Efstathios Papavassiliou, MD, Benjamin E Schneider, MD Beth Israel Deaconess Medical Center Introduction: Diagnostic laparoscopy has recently emerged as an alternative to laparotomy in trauma patients. However, the impact of abdominal insufflation on intracranial pressure is not well described outside animal models. We present a case report of a patient who underwent a laparoscopic assisted ventriculoperitoneal shunt placement (lap VPS), with intracranial pressure (ICP) measurements. Methods: The patient had a lap VPS placement performed at BIDMC. Abdominal insufflation was performed using CO2. The intracranial pressure was measured through the ventricular catheter with a simple manometer with insufflation and desufflation. Results: The patient is a 75 year old man with history of normal pressure hydrocephalus who presented for laparoscopic VP shunt placement. A Hasson trocar was placed under direct visualization and the abdomen was insufflated with CO2 to a pressure of 15 mmHg. Concurrently, the intraventricular catheter was placed and the ICP measured to be 8–12 cmH2O with respiratory variation. The abdomen was then desufflated and the ICP was measured to be 0–1 cmH2O. The rest of the operation was performed without complication. Discussion: Intracranial pressure in this patient was markedly elevated with laparoscopy up to 12 cmH2O above the desufflated baseline. Increased ICP is associated with cerebral ischemia and even herniation at levels [20 mmHg. This case suggests that further research is needed on the association between laparoscopic insufflation, ICP and cerebral perfusion pressures. Laparoscopy should be used cautiously in patients with a baseline elevated ICP or head trauma.

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LAPAROSCOPIC RESECTION OF GASTROINTESTINAL STROMAL TUMORS (GIST)—REPORT OF 62 CASES AND COMPARISON TO OPEN RESECTION Michael J Pucci, MD, Francesco Palazzo, MD, Bernadette C Profeta, MD, Pei-wen Lim, BS, Karen A Chojnacki, MD, Ernest L Rosato, MD, Adam C Berger, MD Thomas Jefferson University Hospital, Department of Surgery, Philadelphia, PA, USA

LAPAROSCOPIC ANTIREFLUX PROCEDURES WITH HEPATIC SHOULDER TECHNIQUE FOR THE SURGICAL MANAGEMENT OF LARGE PARAESOPHAGEAL HERNIAS AND REFRACTORY GASTROESOPHAGEAL REFLUX DISEASE Philippe J Quilici, MD FACS, Carie Mcvay, MD, Alexander Tovar, MD Dept. of Surgery, Providence St. Joseph Medical Center, Burbank CA

Background: As advanced techniques in laparoscopy improve, laparoscopic resection of GISTs is becoming more common. We reviewed our large, single-institution experience with laparoscopic resection of GISTs to determine safety and efficacy. Methods: Between January 2003 and July 2011, 62 patients underwent laparoscopic resection of GISTs (57 gastric, 5 other). Using an IRB-approved prospectively maintained database, data on sex, age, tumor size, location, symptoms, margin status, operative time, blood loss (EBL), length of stay, and complications were collected. This data was compared to a contemporary series of 54 patients, who underwent open resection (47 gastric, 7 other). Results: The average age of patients in the laparoscopic group was 61 years (range = 22 to 89) compared to 64 (range = 27 to 87) in the open group. The mean tumor size was significantly lower in the laparoscopic group (3.8 vs. 9.0 cm, p \ 0.001). The average blood loss (39 vs. 462 ml, p \ 0.0001) and median length of stay (4.2 vs. 11.1 days, p \ 0.0001) were significantly decreased in the laparoscopic cohort. There was a 6% major complications in the laparoscopic group compared to 35% major complication rate in the open group (p \ 0.0001). In terms of oncologic efficacy, 95% of the cases in the laparoscopic series achieved a R0 resection compared to 93% in the open group. Conclusions: Laparoscopic resection is safe and efficacious in treating gastric GISTs. Small and medium-sized GISTs lend themselves to laparoscopic resections. Given the advantages of laparoscopic surgery, a minimally invasive approach should be the preferred treatment in patients with small and medium-sized gastric GISTs.

Background: A novel laparoscopic approach to manage patients diagnosed with large, paraesophageal hernias was initially reported in 2009 and gastroesophageal reflux disease [GERD} symptomatology was presented in 2009. This technique was later used in patients with refractory GERD. A larger series of these cases is now presented. Methods: All procedures were performed via laparoscopy. 39 patients underwent a reduction of the paraesophageal hernia with a Nissen fundoplication and two with Collis-Nissen fundoplication. Standard crural closure was performed over a #60 Fr Bougie in 34 patients, and five patients did not undergo a cruroplasty. In all patients, the left hepatic lobe was freed, repositioned, and anchored under and inferior to the gastroesophageal junction, propping the gastroesophageal junction anteriorly. This maneuver entirely covers and closes the diaphragmatic defect. Results: Postoperatively, all patients did well without notable, unusual complaints. Average length of stay was 1.9 days. One patient was reexplored for possible intra-abdominal sepsis and had a negative exploration. The longest follow-up was 4.2 years. To date, all patients had no recurrence of symptoms or of their paraesophageal hernia. Conclusion: In selected patients, large paraesophageal hernias and patients with refractory GERD can safely be managed via a laparoscopic antireflux procedure with the hepatic shoulder technique. Although no long-term followup is available, this technique continues to show solid postoperative results and may be used as an alternative to a laparoscopic Mesh reinforced fundoplication or difficult crural closure.

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ROLE OF LAPAROSCOPIC SURGERY IN PALLIATIVE GASTRIC CANCER MANAGEMENT Cedric Adelsdorfer, MD, Waldemar Adelsdorfer, MD, Elizabeth Pando, MD, Dulce Mombla´n, MD, Antonio M Lacy, MD PhD Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases (ICMDM), Hospital Clı´nic of Barcelona

PNEUMATIC BALLOON DILATION HAS LIMITED EFFECTIVENESS IN PATIENTS AFTER FOREGUT SURGERY Alla Zemlyak, MD, Sofiane El-djouzi, MD, Paul D Colavita, MD, Dimitrios Stefanidis, MD, Brant T Heniford, MD Carolinas Medical Center

Introduction: There are few reports about the value of surgery in palliative gastric cancer, even less with the laparoscopic approach, which is proving to be superimposable results to open surgery in early cancer. Objective: Assess the immediate and medium term in the series of patients undergoing laparoscopic surgery with palliative gastric adenocarcinoma in our institution. Material and Methods: Prospective study of consecutive patients undergoing laparoscopic surgery for palliative adenocarcinoma between January 2005 and October 2010. Demographic variables are analyzed, short-term results and survival. Results: 48 patients were operated. Exploratory laparoscopy was performed only in 25% (12/48), or gastro jejunostomy in 10.4% (5/48), gastro-jejunal anastomosis in 29.2% (14/48) and resective surgery in 35.4% (17/48). The average age was 71 ± 9 (50-88), 34 male predominance (70.8%). TNM stages are: 4.2% (2/48) IIB, 10.4% (5/48) IIIA, 12.5% (6/48) IIIB, 12.5% (6/48) IIIC and 60.4% (29/48) stage IV. The operating time of the resected patients was 230 ± 67 min, significantly higher than in the other interventions (p \ 0.001). The conversion rate in the resected was 17.6% (3/17), all due to technical difficulties in mobilizing the tumor. The overall postoperative morbidity was 25% (12/48), being higher in the resected group with 40% (p = 0.283). 1 patient in the resected group showed no mortality suture failure, requiring reoperation. Postoperative mortality was 6.3% (3/48), 1 in resected group with intraabdominal complication without proof of leakage, the other two with a medical cause. The average follow-up 11 ± 8 months (1–33). Overall survival at 24 months was 24.3%. The Kaplan–Meier analysis showed a significantly better survival in cases resected and adjuvant therapy (log-rank test, p = 0.034), with a median survival of 25 months (95% CI 14-36.8). Conclusions: Laparoscopic approach for palliative gastric cancer is a feasible, the rate of morbidity and mortality in resected patients was similar to healing. Palliative resection may increase survival in selected patients.

Introduction: Pneumatic balloon dilation has been used successfully for the treatment of esophageal pathology. Our objective was to analyze the outcomes of pneumatic balloon dilation after foregut procedures. Methods and Procedures: Prospectively collected data between 2007–2010 on pneumatic balloon dilations after foregut surgery were reviewed at a single institution. Patients after esophagectomy, fundoplication, vertical banded gastroplasty, or gastric bypass were included in the analysis. Patient demographics, presenting symptoms, surgical procedure, number of endoscopies, number of dilations and other endoscopic treatments were recorded. Results: Twenty seven patients underwent pneumatic balloon dilation following surgery. Eight patients had esophagectomy, 4 patients had gastric bypass, 2 had prior vertical banded gastroplasty, and 13 patients had a fundoplication (12 Nissen, 1 Toupet). Of the anti-reflux procedures, 7 were referred from an outside hospital. Average patient age was 59 (24–91) with 63% women. The major presenting symptoms were dysphagia and vomiting. Five patients had their first dilation within the first post-operative year and 8 patients were 3 or more years out from surgery. The total number of dilations per patient ranged from 1 to 9. The timing of dilation after the surgery did not affect the outcomes. Mean follow up was 18.5 (1–46) months. In the esophagectomy group the number of anastomotic balloon dilations per patient ranged between 1 and 9; the patient with 9 dilations eventually underwent esophageal stent placement. Only one patient reported relief of symptoms at follow up. Out of 4 gastric bypass patients, only one had complete relief of nausea and vomiting after dilation while one did not improve even after seven balloon dilations. Two vertical band gastroplasty patients had 3 and 5 gastric dilations each with no relief; one eventually had a stent placed. Two Nissen patients reported significant relief of dysphagia after single balloon dilation of the GE junction while the rest did not improve after a single or multiple dilations (1–9). In summary, only 4 of 27 postsurgical patients (14.8%) had symptomatic relief of dysphagia or vomiting after pneumatic balloon dilation. Three of the successfully treated patients improved after their first dilation and one improved after the second one while the rest underwent a total of 60 dilations without symptom relief. There were no procedure related complications. Conclusion: Pneumatic balloon dilation after foregut surgery has limited effectiveness for the treatment of postoperative dysphagia and vomiting. Our data suggests that in the absence of symptom relief after the initial dilation, repeat dilations are unlikely to be effective, are costly, likely delay effective operative intervention, and should be avoided.

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SURVIVAL AND SURGICAL OUTCOMES AFTER LAPAROSCOPY-ASSISTED TOTAL GASTRECTOMY FOR GASTRIC CANCER: CASE CONTROL STUDY Young-woo Kim, Bang Wool Eom, Sang Eok Lee, Keun Won Ryu, Jun Ho Lee, Hong Man Yoon, Soo-jeong Cho, Myeong-cherl Kook Soo Jin Kim Gastric Cancer Branch, Research Institute & Hospital, National Cancer Center Background: Few Long-term survival data of laparoscopy assisted total gastrectomy (LATG) was reported. Purpose of this study was to investigate the feasibility of laparoscopy-assisted total gastrectomy (LATG) in terms of long term survival and morbidities Methods: Case–control study was done for 100 cases of LATG and 348 cases of open total gastrectomy (OTG) for clinical T1N0, T1N1, and T2N0 gastric cancer from August 2003 to December 2008, at the National Cancer Center, Korea. Clinicopathological characteristics, surgical outcomes, complications were compared between LATG and OTG groups. Overall survival and disease-free survival were analyzed using Cox proportional hazard model for multivariate analysis. Results: The rate of postoperative complication was 27%, and the most common complication was anastomotic stenosis in LATG (9%). There was no significant difference of surgical outcomes and complications between LATG and OTG groups except longer operating time in LATG. Survivals were also similar between groups; the hazard ratio of LATG vs OTG was 0.51 (95% confidence intervals, 0.18-1.46; p = 0.212) for overall survival, and 0.19 (95% confidence intervals, 0.03-1.40; p = 0.102) for disease-free survival. Conclusion: LATG for gastric cancer might be a feasible procedure with acceptable complications and long term survival.

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P258

LETHAL ACUTE GASTRIC VOLVULUS MASQUERADING IN THE MEDICAL UNIT IS MANAGABLE WITH A LAPAROSCOPIC APPROACH Michael L Hibbard, MD, Giovanni Begossi, MD, Paul Suding, MD, Teresa Kim, MD, Greg Broderick-villa, MD, Rupert Horoupian, MD, Steven Stanten, MD, Ajay Upadhyay, MD First Surgical Consultants, Alta Bates Summit Medical Center, Oakland, California, U.S.A. and St. Rose Hospital, Hayward, California, U.S.A. Purpose: Acute gastric volvulus associated with a large paraesophageal hernia is an uncommon entity but can be potentially serious and life threatening. The widely quoted classic diagnostic triad of Borchardt: (1) inability to vomit with retching; (2) upper abdominal distension; (3) inability to pass a tube into the stomach, may not be the presenting symptoms in all cases. Dramatic variations of atypical presentations (chest pain, shortness of breath, gastrointestinal bleeding) mimicking a medical condition have been described. This can lead to diagnostic delay and deleterious delay in surgical intervention. We describe the clinical presentation of patients with acute gastric volvulus associated with a large paraesophageal hernia presenting to a medical unit (medical floor, medical intensive care unit or coronary care unit) that subsequently required emergent surgical intervention. Methods: Review of our series of elderly patients initially admitted to a medical unit with atypical symptoms who subsequently required emergent surgery for acute gastric volvulus in a large paraesophageal hernia between 2002 and 2011. Laparoscopic derotation of the stomach with cruroplasty was performed. Fundoplication and/or anterior gastrorrhaphy were used in select cases. Results: Nine elderly patients (three females and six males) were initially admitted to a medical unit. Five patients (56%) had presented with chest pain as the predominant symptom. Four (44%) patients presented with gastrointestinal bleed. Abdominal discomfort or pain was a presenting symptom noted on the emergency room admission notes in four (44%) patients but was not considered significant by the admitting physician. Aspiration pneumonia was the admitting diagnosis in two (22%) patients. Sepsis with hypotension was present in three (33%) patients. An acute coronary event was suspected and ruled out in four (44%) patients prior to surgical consultation. A laparoscopic approach was used for derotation of the stomach, followed by cruroplasty in seven (78%) cases. One patient with morbid obesity and ischemic stomach underwent a laparoscopic vertical sleeve gastrectomy. One patient in septic shock with a preoperative diagnosis of gastric perforation underwent an open approach, and a gastrectomy was performed. She subsequently expired on the 30th post operative day from multiple organ failure. This was the only mortality in our series. Conclusions: A variety of unusual case presentations of acute gastric volvulus leading to delay in the diagnosis have been reported. Though patients presenting with atypical symptoms must be ruled out for life-threatening cardiopulmonary diseases, in the setting of a large paraesophageal hernia, acute gastric volvulus must be considered in the differential diagnosis. The medical practitioner must keep an especially high index of suspicion for acute gastric volvulus in the setting a negative cardiac work-up in order for a timely diagnosis and prompt surgical consultation. Despite the predominantly advanced ages and multiple co-morbidities seen in our patients, a laparoscopic approach was feasible.

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PEG PLACEMENT OUTCOMES IN THE OBESE PATIENT POPULATION Onur C Kutlu, MD, Diana Vega-burgueno, MD, Ari Halldorsson, MD, Sharmila Dissanaike, MD Texas Tech University, Department of General Surgery Obesity has reached a state of a global epidemic. No society therefore no health system is spared from the effects of the disease. Percutaneous Endoscopic Gastrostomy (PEG) tube is frequently used in patients with swallowing dysfunction. Each year more than one hundred thousand PEG placement procedures are performed in the United States. Despite the frequent use of the technique and the ever increasing prevalence of obesity we could only find four papers in the medical literature on PEG placement and obesity. Our search of National Library of Medicine revealed only one article published on outcomes of obese patients undergone PEG placement. In this study we would like to present our experience on PEG placement on the obese patient at an Academic Medical Center. Patients and Methods: All patients undergone PEG placement between 2006-2010 were retrospectively analyzed based on gender, body mass index, type of pathology, indication for PEG placement outcome, type of complication encountered and hospital stay. Patients who had a BMI over 30 kg/m2 were compared to normal BMI group in terms of complications. We later further analyzed the type and frequency of the complications encountered. Results: 341 patient underwent PEG placement at our institution between 2006 and 2010. 76 were obese (BMI [ 30kg/m2). Indications were dysphagia 50%, intracranial tumor 13.9%, gastrointestinal tumors 1.4%, head and neck cancer 5.6%, cerebrovascular accident 18.1%, anoxic brain injury in 5.6%, dementia 1.4%. 25.8% of the patients were admitted due to trauma and 13.9% suffered burns. The complication rate was 28% in the obese patient group vs. 27% in the normal BMI group. Overall complication rate was 27.6%. Chi square statistical analyses showed no significant difference between two groups. Types of complications encountered in the obese group were ileus 4.1%, Peristomal infection in 6.8%, buried bumper in 2.7%, gastric ulcer in 1.6%, inadvertent removal in 14%, aspiration in 6.8%, hemorrhage in 1.4%, 11% of patients died within 30 days. Conclusion: The reported complication rate for PEG placement in literature varies between 10% in selected patients up to 42% in the terminally ill oncological patient. The reported 30 day mortality rate after PEG placement varies between 2% to 12%. The mortality and complication rates in our series falls within the reported ranges of different authors. Analyzing indications, comorbidies and outcomes, we have observed that PEG placement has a similar safety profile in the obese patient group compared to the normal BMI patients. Despite the procedural challenges due to body habitus, we believe that PEG placement can be utilized as a safe technique to be used in the obese population requiring long term nutritional support.

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A NOVEL BIOLOGIC MESH AS REINFORCEMENT OF HIATAL CLOSURE DURING LAPAROSCOPIC PARAESOPHAGEAL HERNIA REPAIR Eelco B Wassenaar, MD PhD, Carlos A Pellegrini, MD, Brant K Oelschlager, MD University of Washington Introduction: Primary laparoscopic paraesophageal hernia repair (LPEHR) is associated with a very high recurrent hernia rate. Biologic mesh has been shown to reduce (but not eliminate) this recurrence rate in the short run (6 months) but its durability is questioned. Outcomes for the spectrum of biologic materials is limited, therefore, we performed a study to assess the short-term efficacy of a bovine pericardium mesh (BP) (Veritas collagen matrix, Synovis, St. Paul MN) in these repairs. Methods and Procedures: Twenty patients with a paraesophageal hernia ([5 cm) were included in the study. A LPEHR was performed and the hiatus buttressed with BP. A Nissen fundoplication was performed in all patients. A standardized questionnaire and a short-form 36 quality of life score were filled out by all patients before and 6 months after the operation. Six months post-operatively an UGI study was performed. Results: Median age was 66 years (range 47–89), median BMI was 28.7 kg/m2 (21.9–40.2) and there were 4 men. One patient died of a cause unrelated to the operation. Nineteen patients filled out the post-operative questionnaire and 16 patients had an UGI. Four of 16 patients (25%) were found to have a recurrence (C2 cm) on UGI. There was a significant improvement in heartburn, regurgitation, and chest pain after LPEHR. Improvement was reported for heartburn in 15 of 16 (94%) patients and of regurgitation in 11 of 15 (73%) patients. Though median dysphagia scores improved, two patients reported worse dysphagia one of which required a dilatation. Overall quality of life improved post-operatively and this improvement was not influenced by having a recurrence or not. Patients with a recurrent hernia were not more likely to have persistent heartburn, regurgitation, dysphagia or chest pain post-operatively. Conclusions: Recurrence rate at 6 months after LPEHR using BP mesh was 25%, but recurrence didn’t appear to affect the positive impact of LPEHR. This rate is not lower than expected based on reported biologic mesh repairs, thus can’t recommend this over existing biomaterials.

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DELAY IN THE REPAIR OF OBSTRUCTED PARAESOPHAGEAL HERNIAS INCREASES POSTOPERATIVE SEPTIC COMPLICATIONS Neil H Bhayani, MD MHS, Ashwin A Kurian, MBBS, Kevin M Reavis, MD, Christy M Dunst, MD, Lee L Swanstrom, MD The Orgeon Clinic

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SINGLE INCISION LAPAROSCOPIC SURGERY FOR SURGICAL LIVER DISEASE Jonathan D Svahn, MD FACS, Austin L Spitzer, MD, Christine Henneberg, BS, Matthew R Dixon, MD Kaiser Permanente East Bay, Oakland Campus

Introduction: Incarceration and obstruction of an intra-thoracic stomach are complications of paraesophageal hernias (PEH). Emergent surgery for PEH is considered to have worse outcomes when compared to elective repair. Gastric decompression and resuscitation are important elements of preoperative management of acutely obstructed PEH. The optimal time for surgical repair after decompression is unknown. We hypothesized that in obstructed patients, early surgery may not improve outcomes compared to initial non-operative management followed by same admission surgery. Methods: The National Surgical Quality Improvement Project (NSQIP) database was queried by current procedural terminology (CPT) codes for PEH repair from 2005- 2009; we included only patients with a post-operative diagnosis code for obstructed PEH. Patients were divided into having surgery within 1 day of admission (EARLY) or more than 1 day (DELAYED). Primary outcomes were rates of mortality & any morbidity. Secondary outcomes were pulmonary, wound, and thromboembolic (VTE) complications. Multivariable analysis controlled for age and cardio-pulmonary co-morbidities Results: There were 224 patients with obstruction and PEH, of these 149 (67%) underwent surgery within 1 day (EARLY) and 75 (33%) had surgery after 1 day (DELAYED), mean 3.6 days (standard deviation 2.8 days). Patients were a median of 70.5 years old and 63% were female. Repairs were 89% trans-abdominal, 9% included a fundoplication, and 18% a gastrostomy. The EARLY and DELAYED patients experienced similar overall morbidity 23% v. 31% (p = 0.2) and mortality 5.4% vs. 4.0% (p = 0.7). There were no differences in post-operative pulmonary, wound, or VTE complications. Post-operative sepsis was less common (2.7% vs. 13%, p = 0.002) and length of stay was shorter (5 vs. 11 days, p \ 0.001) for EARLY patients compared to INTERVAL patients. On adjusted analysis, patients in the EARLY group had an 80% reduction in odds of post-operative sepsis (95% CI 0.05—0.6, p = 0.005). Odds of overall or other morbidity, or mortality were statistically similar between groups. Conclusions: Increased morbidity and mortality has been well documented for patients undergoing emergency surgery for PEH repair compared to elective repair. Presumably, patients requiring emergency surgery for PEH have diseased complicated by strangulation, perforation, bleeding or sepsis. In our analysis, patients with an obstructed PEH had less postoperative sepsis and fewer days in the hospital if surgery was performed within the 1st hospital day. There was no difference in mortality or other major morbidities. While deferring surgery for resuscitation permits patient optimization, prolonged delay in surgical repair may result in worse patient outcomes.

Over the last two decades minimally invasive surgery has become more prevalent in digestive surgery. The feasibility of advanced hepato-biliary procedures using minimally invasive techniques has been well documented. More recently there have been reports of single incision laparoscopic surgery undertaken in individuals with both benign and malignant liver disease. We report our experience with single incision laparoscopic surgery in four patients with surgical liver disease. Three individuals (age range: 62–81, two female, one male) were referred to the surgical department for management of suspected benign simple liver cysts. Lesions were located in the left lobe in two patients and in the right lobe in one patient. They ranged in size from 9 cm to 25 centimeters in maximum dimension. A fourth patient (59 year old female) with advanced cirrhosis was referred for management of a single peripheral hepatocellular carcinoma (HCC) in immediate proximity to her gallbladder. In each patient, CT imaging was used to establish the extent, character, and surrounding architecture of the lesion(s). Our technique has been previously reported and involves the use of a home made single port device. Our ‘‘gloveport’’ is created using a small latex free glove and one 12 mm trocar. The trocar is placed through the thumb of the glove and secured with steri-strips. Similarly, a five mm 30 laparoscope and a five mm atraumatic grasper are secured through alternating fingers of the glove. A vertical incision is made through the base of the umbilicus and the fascia is divided sharply under direct vision. A small wound protector is introduced into the abdomen and rolled until it is secure. The gloveport is then secured around the external portion of the wound protector. In each of the cyst resections the cyst was aspirated and then unroofed using a Ligasure device (Covidien. Norwalk, CT). The cyst wall was removed and sent for pathologic examination to confirm the benign nature of the cyst. The exposed intrahepatic surface of the cyst was then coagulated with argon beam energy source. For the HCC, the gallbladder was first removed with the assistance of transabdominal retraction sutures. Ablation of the nearby HCC was accomplished under laparoscopic ultrasound guidance with real time imaging. In each case, after homeostasis was confirmed, the gloveport and wound protector were removed. The fascia was closed with interrupted sutures and a running subcutaneous stitch was used for the skin. The patients all did well and were discharged without event. At follow up, the three patients status post cyst resection are all symptom free and have had no evidence of recurrence based on ultrasound evaluation. The fourth patient continues to do well and is currently being followed for HCC recurrence. Our initial experience will single incision laparoscopic surgery for surgical liver disease has been promising. Larger scale studies are warranted to determine if this application of single incision laparoscopic surgery is truly safe and provides similar or improved outcomes compared to open and standard laparoscopic liver surgery.

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SINGLE PORT LAPAROSCOPIC SURGERY FOR ACHALASIA—A CASE REPORT Hisae Aoki, MD, Toshiyuki Mori, MD, Nobutsugu Abe, MD, Osamu Yamagida, MD, Tadahiko Masaki, MD, Masanori Sugiyama, MD Department of Surgery, Kyorin University

SINGLE ACCESS LAPAROSCOPIC SURGERY (SALS) FOR ILEAL DISEASE Mohamed Moftah, Dr, John Burke, Dr, Ronan A Cahill, Dr Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland

Background & Object: Recently Single port surgery (SPS) has been widely accepted worldwide. Indication of SPS started with appendectomy and cholecystectomy, extending the stomach surgery, colon surgery and liver surgery. Laparoscopic operation is undoubtedly the gold standard treatment for GERD and achalasia. Laparoscopic Heller myotomy and Dor fundoplication usually required 5 ports. It may be performed with single port surgery or single port surgery + an additional port, namely reduced port surgery. Methods: We present a case of patients with achalasia. a 81 year-old male, was diagnosed as achalasia. For umbilical access, a 4 cm vertical incision was made at the umbilicus and an EZ access port was placed.The scope, two working ports for forceps were inserted through the EZ access. An additional port was then inserted in the left upper quadrant. The scope was 30 oblique view scope. Dissection was performed using two instrument from EZ access port.When making fundoplication, suturing and knot tying was needed. At the time of suturing, instrument through the additional port was manipulated by right hand. The instrument through EZ access was manipulated by left hand. Result: The operation was concluded safely. Operating time was 2 h 51 min and blood loss was negligible. The postoperative course was uneventful. Discussion: Dissection around the esophagus was easy and was entirely possible with single port surgery. The technique becomes demanding for suturing and knot tying for fundoplication. To cope with this difficulty additional port was good option, restoring triangular formation. Conclusion: Single port surgery with one additional port (reduced port approach) could be the method of choice for benign esophageal disorders.

Introduction: To show the effectiveness and usefulness of Single Access Laparoscopic Surgery (SALS) in the management of benign and malignant diseases of the ileum in both the elective and urgent care setting. Patients and Methods: Consecutive, non-selected patients (one male and seven females) with ileal disease requiring surgery in our university hospital between October 2011 and July 2011. All had a computerised tomogram of abdomen and pelvis preoperatively as well as standard perioperative management (including thromboembolic prophylaxis and intravenous antibiotics). SALS operative access to the peritoneum was achieved via a single trans-umbilical incision and therefore a ‘surgical glove port’ constructed as our preferred single port device (this is created by the insertion of conventional disposable laparoscopic trocar sleeves into the fingers of a sterile surgical glove that has been stretched onto the outer ring of a standard wound protector-retractor). With the pneumoperitoneum established, a 30 10 mm laparoscope was introduced to inspect the abdominal cavity along with two or three conventional straight rigid laparoscopic instruments. The relevant ileal loop was located, its mobility assessed and the procedure performed. For ileal resection or enterotomy, an extracorporeal anastomosis was performed after the site of pathology was withdrawn up to and through the wound protector in the incision. After anastomosis or closure of the enterotomy, the bowel is replaced into abdominal cavity, wound protector removed and layered closure of fascia and skin is performed. Results: Eight patients (seven males) had surgery by this access modality. The median (range) age of the patients was 53.5 (22–78) years and the median (range) body mass index was 26 (20.2–28) kg/m2. One patient had previously had open abdominal surgery. Procedures included ileal (n = 3) or ileocaecal resection (n = 2) (for Crohn’s disease, n = 3, tuberculosis, n = 1, and B-cell lymphoma, n = 1) and ileal opening (for the purposes of loop ileostomy formation and ileotomy for extraction of an impacted gallstone ileus) as well as a tru-cut biopsy of ileal mesenteric mass (subsequently proven desmoid tumor). The median (range) operating room time was 65 (35–115) min and blood loss was minimal in each case. The median (range) hospital stay was 4 (2–7) days. The mean (range) incision length was 3 (2–5) cm. There were no difficulties in maintaining pneumoperitoneum throughout the procedure and there was no need for additional or converted access. After a mean follow-up of 8 there have been no wound infections, hernias or other postoperative complications. Conclusions: These preliminary results showed that SALS is an efficient and safe modality for management of ileal disease with all the advantages of minimally access surgery without significant increase in operation time, theatre resource or patient morbidity.

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PROSPECTIVE RANDOMIZED TRIAL COMPARING LAPAROSCOPIC TRANSABDOMINAL PREPERITONEAL (TAPP) AND LAPAROSCOPIC TOTALLY EXTRA PERITONEAL (TEP) APPROACH FOR BILATERAL INGUINAL HERNIA Deborshi Sharma, MS MRCSEdin FMAS, Kamal Yadav, MBBS MS, Nikhil Gupta, MS MRCSEdin FMAS, Romesh Lal, MS DNB Lady Hardinge Medical College & Associated Dr RML Hospital, New Delhi Introduction: Laparoscopic inguinal hernia repair (LIHR) is an accepted technique for bilateral inguinal hernia. The two most common laparoscopic techniques for inguinal hernia repair are transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair. Lot of controversy exists between the choices of procedure. Till date no randomized study is available comparing the two procedures in bilateral inguinal hernias. Aim of the Study: To compare the clinical effectiveness and relative efficacy of laparoscopic TAPP and laparoscopic TEP for bilateral inguinal hernia repair in terms of intraoperative difficulties, post-operative problems, complications and early recurrence. Materials and Methods: All consecutive patients with uncomplicated symptomatic bilateral inguinal hernia diagnosed clinically, attending the surgery out patient department at Lady Hardinge Medical College was included and were operated by a single surgeon. Exclusion criteria: Patient unfit for general anaesthesia, Below 18 years and above 70 years, Previous lower abdominal surgery, Pregnancy, Past history of malignancy, Complicated Hernia, Severe LUTS, Morbid Obesity, Uncorrected coagulopathy. Sample Size: A convenient sample size (30 in each group) was taken Results: TEP took longer time but consumption of tacks was more in TEP compared to TAPP. There was no significant difference between blood loss, inferior epigastric artery injury, post operative pain scores, hospital stay and wound infection. Their was no recurrence in either group. Conclusion: Both procedures are safe with similar incidence of intra & post operative complications. Surgeons should choose the procedure according to his competence and expertise.

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SYMPTOMATIC PARA ESOPHAGEAL AND INCISIONAL HERNIA: SIMULTANEOUS OR SEQUENTIAL REPAIR? Osama Hamed, MBBS, Stephen Kavic, MD, Adrian Park, MD Department of Surgery University of Maryland School of Medicine Baltimore, MD. Department of Surgery, University of Dalhousie, Halifax NS Canada Objective: Paraesophageal (PEH) may represent a significant challenge for the minimally invasive surgeon. Increasingly, we are finding this condition in patients who also have an incisional hernia (IH). The patient may rightly expect a minimally invasive approach to either condition, but the combination of conditions makes a single operation substantially more difficult to perform. Surprisingly, there are few reports in the literature available to address this problem and guide clinical decision making. We present here our recent experience with sequential repair of symptomatic PEH and IH in two patients. Methods: We present two patients with combined symptomatic PEH and large IH. The main symptoms from the PEH were dysphagia and chest discomfort, and the IH symptoms were abdominal pain. Interestingly, both patients were more affected by their IH than by their PEH symptoms. Results: These patients presented electively with the expectations for simultaneous laparoscopic repair of both hernias. Although simultaneous repair is technically feasible, we choose a sequential approach starting with the laparoscopic PEH repair first, and interval laparoscopic IH repair. Our choice was based on: 1, the risk of increased tension (and therefore recurrence) on the tenuous PEH primary repair; 2, to avoid prolonged operative time and compromised port placement; 3, the potential for mesh contamination during PEH repair; and 4, to facilitate laparoscopic IH repair by the post operative weight loss associated with PEH repair. Both patients recovered uneventfully from their procedures with no evidence of recurrence of either hernia to date, at approximately one year follow-up. Conclusion: Combined symptomatic (PEH) and incisional hernias (IH) represent a significant challenge when present in the same patient. Although simultaneous laparoscopic repair of PEH and IH may be technically feasible, we recommend sequential repair.

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TAPP REPAIR OF SPIGELIAN HERNIA AND INCIDENTALLY FOUND INDIRECT INGUINAL AND FEMORAL HERNIA: A CASE REPORT Amy L Hiuser, MD, John Bach, MD, Timothy Barnett, MD, Cleveland Clinic Foundation We are reporting a case of an 84 year-old female who presented to outpatient surgery clinic with complaints of a right-sided abdominal bulge. Upon physical examination patient was found to have a bulge at the lateral border of the rectus muscle at the level of the semilunar line; subsequently was diagnosed with a spigelian hernia. The patient elected to undergo laparoscopic surgical repair with a Trans-abdominal preperitoneal approach. At the time of surgery patient was found to have two incidental hernias: a right indirect inguinal as well as a right femoral hernia, neither of which were appreciable upon pre-operative physical examination. Repair was conducted using a single Proceed mesh 15 9 20 cm and carried out in the pre-peritoneal plane. The patient had an uneventful post operative course and was discharged home on post operative day 3

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CLINICAL APPLIED STUDY OF TENSION-FREE HERNIA REPAIR TECHNIQUES FOR INGUINAL HERNIA Ke Gong, MD, Zhanzhi Zhang, MD, Dexiao Du, MD, Xingbiao Wang, MD, Yankai Zhang, MD, Beijing Shijitan Hospital affiliated to Capital Medical University Objective: The aim of this study was to improve the application of tension-free inguinal hernia repair . Methods: We retrospectively reviewed 226 patients diagnosed with inguinal hernia who undertook laparoscopic tension-free inguinal hernia repair (LTIHR group)or open tension-free hernia repair (Open group) in general surgical department of Beijing Shijitan Hospital during April 2008 to April 2010 and collected the clinical data. The clinical data in two groups were compared. Results: A total of 226 patients with inguinal hernia underwent tension-free inguinal hernia repair successfully. The patients were followed up for a mean time of (24 ± 6) months. No major complications and recurrence was found in all patients. The average operating time for the patients in the open group was significantly shorter compared to the LTIHR group (t = 7.114,P = 0.000) and the cost involved in the open group was also significantly lower than the LIHR group (t = 10.67,P = 0.000). However, the hospital stay was significantly longer in the open group (t = 3.76,P = 0.000) compared to the LIHR group. Among 226 patients, 16 patients with abnormal blood coagulation mechanism were successfully underwent open tension-free hernia repair under local anesthesia, 6 patients with chronic pulmonary diseases who are intolerance of general anesthesia were also undertook TEP under spinal canal anesthesia. Conclusion: This study demonstrated the application of tension-free inguinal hernia repair will be accepted widely by choosing a suitable anesthesia and a surgical procedure as well as decreasing the cost.

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LAPAROSCOPIC PARASTOMAL HERNIA REPAIR AND REOSTOMY, A TOTALLY NEW LAP-RE-DO TECHNIQUE Yao Qiyuan, Huashan Hospital, Shanghai Medical Collage, Fudan University Background: Paracolostomal hernia is a common postoperative complication of colostomies. Laparoscopic paracolostomal hernia repairs have been reported for at least five techniques so far with variable and unsatisfactory follow-up results, especially for the high incident rate of postoperative recurrence. Herein we developed and applied a totally new Lap-re-Do technique to laparoscopic paracolostomal hernia repair to reduce the postoperative complications, with the quietly different idea from current laparoscopic procedures. Methods: We applied the Lap-re-Do technique to laparoscopic paracolostomal hernia repairs on 26 patients with PVDF mesh from May 2009 to June 2011, including 2 single-incision laparoscopic surgical (SILS) procedures. The demographic, perioperative, and early follow-up data prospectively collected for these patients are presented in this report. Results: All the 26 operations were performed successfully, including 19 patients under routine laparoscopic procedures (median operative time, 100.5 min), 4 patients detected with incisional hernia being repaired simultaneously (median operative time, 132.5 min), 1 patient with recurrent paracolostomal hernia (operative time, 160 min) and 2 patients under SILS procedures (median operative time, 122.5 min). No in-hospital mortality occurred. Postoperative recovery was uneventful for all the 21 patients (80.8%), who had a median hospital stay of 6.1 days. Surgical and nonsurgical complications occurred, respectively, for one patient with mild stoma collapse (3.8%), one patient with arrhythmia (3.8%), one patient with mild seroma (3.8%), one patient with accidental enterotomy detected and reoperated in 2 days after the primary operation without removal of PVDF mesh (3.8%), and two patients with postoperative ileus and recovery of conservative treatments (7.7%). In 8 weeks after discharge from hospital, all the patients were reexamined by physical examination and computerized tomography scan, and the follow-up results (median follow-up time, 12.5 months) indicated no recurrence, no severe seroma, no intractable pain, none complications of mesh-related infection and no dysfunction of defecation. Conclusions: Laparoscopic paracolostomal hernia repair with Lap-re-Do technique is effective and feasible.

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PATTERN OF RECURRENCE, READMISSION AND WOUND INFECTION FOLLOWING EMERGENT VENTRAL HERNIA REPAIR Tolutope O Oyasiji, MD MRCS, Scott W Helton, MD FACS, Department of Surgery, Hospital of Saint Raphael, New Haven, CT 06511 Introduction: The study aims to investigate if surgical technique, wound contamination or interaction between both are predictive of adverse outcomes following emergent ventral hernia repair. We hypothesize that patients repaired with permanent mesh or no mesh would have higher incidence of wound infection, readmission to hospital and recurrent hernia when compared to patients repaired with biologic mesh. There is uncertainty as to how patients with emergent ventral hernia repair are optimally managed. Concern for infection has resulted in some surgeons performing only primary repair while others chose to use biologic mesh. Some surgeons also use permanent mesh despite higher risk for infection. Method(s): An IRB approved retrospective review of 176 consecutive patients operated upon emergently for ventral hernia in a community teaching hospital between 2005 and 2010 was performed. Presence of infection, readmission to hospital over 5 years, and recurrent hernia were recorded. Differences in the incidence of these outcomes were compared using 2-way ANOVA Results:

Primary repair

Synthetic

Biologic

P value [2-way ANOVA]

Contaminated

4/28 [14.2%]

2/8 [25%]

2/16 [12.5%]

0.3 [type of repair]

Non contaminated

9/36 [25.0%]

5/77 [6.5%]

0/11 [0%]

0.4 [contamination]

Contaminated

6/28 [21.4%]

3/8 [37.5%]

4/16 [25.0%]

0.4 [type of repair]

Non contaminated

8/36 [22.2%]

6/77 [7.7%]

0/11 [0%]

0.9 [contamination]

Contaminated

2/28 [7.1%]

2/8 [25%]

2/16 [12.5%]

0.5 [type of repair]

Non contaminated

1/36 [2.8%]

8/77 [10.4%]

0/11 [0%]

0.7 [contamination]

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LAPAROSCOPIC HERNIA REPAIR IN A TERTIARY CARE CENTRE: A SINGLE INSTITUTION EXPERIENCE Franc¸ois Julien, MD, Jean-pierre Gagne´, MD, Que´bec Centre for Minimally Invasive Surgery. Centre Hospitalier Universitaire de Que´bec This study evaluates the peri-operative outcomes of laparoscopic ventral hernia repair (LVHR) done by one surgeon in a tertiary care centre over a six-year period. This is a retrospective study of 99 consecutive cases of LVHR performed between August 2005 and July 2011. Data included patients’ demographics, BMI, ASA classification, hernia size, operative time, length of stay, conversion and complication rates. Of the 99 patients, 46 were men. Median age was 65 (28–88). Median BMI was 30 (22–46). Eleven patients had recurrent hernias while 8 presented with incarceration. Most patients (69/99) were classified as moderate surgical risk according to ASA classification (category 2–3). Median hernia size was 120 cm2 (9–560). Median operative time was 150 min (30–720). Median hospital stay was 4 days (1–210). Conversion rate was 8%. Most for conversions were due to adhesions (7/8). In that subgroup of 8 patients, median operative time was 260 (180–720) min and median hospital stay 6 days. Complications occurred in 22 patients. There was one death. There was no early post-operative infection. There were two enterotomies, one of which was recognized 1 week post-operatively, resulting in peritonitis, stoma creation and a prolonged hospital stay. LVHR can be considered as a safe procedure providing excellent immediate results and short hospital stay; the infection rate in this study is much lower than most reported series of open approach. However, the most feared complication is a missed enterotomy; thus, a low conversion threshold might be the best way to avoid such catastrophic events.

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LIGHTWEIGHT VERSUS HEAVYWEIGHT MESH IN LAPAROSCOPIC INGUINAL HERNIA REPAIR: A METAANALYSIS A Currie, MRCS, H Andrew, MRCS, A Tonsi, MRCS, P R Hurley, MS FRCS, S Taribagil, FRCS, Croydon University Hospital Background: Prosthetic mesh reinforcement is standard practice for inguinal hernia repair but can cause considerable pain and stiffness around the groin and affect physical functioning. This has led to various types of mesh being engineered, with a growing interest in a lighter weight mesh. Minimally invasive approaches have also significantly reduced post-operative recovery from inguinal hernia repair. The aim of this systematic review was to compare the outcomes after laparoscopic inguinal repair using newer lightweight and traditional heavyweight mesh in published randomised controlled trials. Methods: Medline, Embase, trial registries, conference proceedings and reference lists were searched for controlled trials of heavyweight versus lightweight mesh for laparoscopic repair of inguinal hernia. The primary outcomes were recurrence and chronic pain. Secondary outcomes were visual analogue pain score at seven days post-operatively, seroma formation and time to return to work. Risk differences were calculated for categorical outcomes and standardised mean differences for continuous outcomes. Results: Eight trials were included in the analysis of 1667 hernias in 1592 patients. Mean study follow-up was between 2 and 60 months. There was no effect on recurrence (pooled analysis risk difference: 0.00 (95% CI: -0.01 to 0.01); p = 0.86) or chronic pain (pooled analysis risk difference: -0.02 (95% CIs -0.04 to 0.00); p = 0.1). Lightweight and heavyweight mesh repair had similar outcomes with regard to postoperative pain, seroma development and time to return to work. Conclusion: Both mesh options appear to result in similar long- and short-term post-operative outcomes. Further long term analysis may guide surgeon selection in mesh weight for laparoscopic inguinal hernia repair.

Recurrence:

Readmission:

Wound infection:

Conclusion(s): The use of biologic mesh was associated with reduced incidence of readmission, recurrence and wound infection following emergent ventral hernia repair. Contamination increased the risk for these adverse events. These differences, however, were not statistically significant. These data argue that a prospective randomized control trial is justified to test this hypothesis.

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THE MEANDERING ILIAC ARTERY: A VASCULAR ABNORMALITY COMMONLY ENCOUNTERED DURING LAPAROSCOPIC INGUINAL HERNIA REPAIR Jonathan P Pearl, MD, Tiffany C Cox, MD, Kristen Trinca, MD, Gary Wind, MD, E. Matthew Ritter, MD, National Military Medical Center, Bethesda Vascular anomalies encountered during laparoscopic inguinal hernia repair could be a source of significant hemorrhage. The external iliac artery normally resides within the Triangle of Doom and its injury is avoided by limiting dissection in the triangle. When the artery courses beyond the confines of the triangle it is subject to injury by injudicious dissection. We describe a series of meandering external iliac arteries discovered during laparoscopic inguinal hernia repair. Methods: A retrospective review of all laparoscopic inguinal hernia cases completed by 2 surgeons was performed. Results: 356 inguinal hernias were repaired laparoscopically over 5 years. All but 9 cases were totally extraperitoneal. During the dissection of the preperitoneal space 7 meandering iliac arteries were encountered. In 2 cases the internal iliac artery coursed medial to the Triangle of Doom and in 5 cases the artery coursed lateral to the triangle. No vascular injuries occurred and the vascular irregularity did not impede placement of the mesh prosthesis. Conclusion: A meandering iliac artery may be commonly encountered during laparoscopic inguinal hernia. Knowledge of this vascular abnormality may help the surgeon avoid its injury.

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LOW INCIDENCE OF SURGICAL SITE INFECTION IN LAPAROSCOPIC INGUINAL HERNIORRHAPHY Maris S Jones, MD, Charles St Hill, MD, Shawn Tsuda, MD, University of Nevada School of Medicine Introduction: The objective of this study is to evaluate the incidence of surgical site infection in laparoscopic (TEP) versus open inguinal hernia repair. Data is equivocal for antibiotic prophylaxis in open inguinal hernia repair for a reduction of surgical site infections. There is a paucity of data regarding surgical site infection in laparoscopic inguinal hernia repair. The primary outcome of this study is the incidence of surgical site infections in inguinal herniorrhaphy (laparoscopic versus open) leading to mesh infection. All patients received single-dose prophylactic antibiotics in an academic medical center. The secondary outcome under investigation is the incidence of surgical site infection. Methods and Procedures: A single institution, retrospective chart review was performed on 222 adult patients who underwent consecutive elective inguinal herniorrhaphy from 2008–2011. Surgical site infections were recorded in each group utilizing the definition from the Centers for Disease Control. Mesh infection was defined as any surgical site infection that led to mesh removal. Both mesh and surgical site infections were included in the data set if they occurred within 90 days of surgery. Both groups received single-dose antibiotic prophylaxis. Fisher exact and student’s t-test were utilized to analyze the results, with statistical significance of p \ 0.05. Results: A total of 222 patients were evaluated. The rate of surgical site infections that lead to mesh infection in laparoscopic inguinal hernia repairs was 0% (0/97). The rate of surgical site infection that lead to mesh infection in open inguinal hernia repairs was also 0% (0/125); p = 1.00. The surgical site infection rate for the laparoscopic inguinal hernia repair group was 1.0% (1/97) compared to a 4.8%(6/125) infection rate in the open inguinal herniorrhapy group (p = 0.05). Conclusion: The rate of surgical site infection after laparoscopic inguinal herniorrhaphy is lower than that for open inguinal herniorrhaphy in this series. No infections lead to mesh removal. Routine antibiotic prophylaxis for prevention of surgical site infection may not be necessary for laparoscopic inguinal herniorraphy given the low incidence of mesh or surgical site infection.

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OVERLAYING THERAPY USING COLLAGEN SPINCOATED PLLA NANOSHEET FOR FIXATION OF POLYPROPYLENE MESH Keiichi Fujino, MD PhD, Manabu Kinoshita, MD PhD, Hiroki Haniuda, Hidekazu Yano, MD, Akihiro Saitoh, PhD, Toshinori Fujie, PhD, Kahoko Nishikawa, PhD, Keiichi Iwaya, MD PhD, Shinji Takeoka, PhD, Daizoh Saitoh, MD PhD, Yuji Tanaka, MD PhD, Department of General Medicine, National Defense Medical College Introduction We have recently developed a biocompatible poly L-lactic acid (PLLA) nanosheet and demonstrated its anti-adhesive properties in intraperitoneal polypropylene mesh (PPM).We herein investigated the fixative effect of collagen spincoated on a PLLA nanosheet (Col-Spin-PLLA) on a rabbit model. Materials & Methods We prepared a hetero-functional freestanding PLLA nanosheet with a spin-coated collagen side and an uncoated side (J Biomater Appl; 2011, DOI: 10.1177/0885328210394470). Nanosheet was scooped up with wire frame and held in air. Expt. 1: Two pieces of mesh were implanted on each side of injured peritoneal side apart from the midline incision. The mesh was overlaid with PLLA (n = 12) or Col-Spin-PLLA (n = 14) without a fixed suture. Expt. 2: Two pieces of mesh were implanted into each side of extraperitoneal spaces (TAPP model). The insertion region was overlaid with PLLA (n = 6) or Col-Spin-PLLA (n = 14) without a fixed suture. After 3 weeks, the degree of adhesion tenacity and the fixation rate were assessed histologically. Results Nanosheet scooped up with wire frame was good handling. Expt. 1: The fixation rate was higher in the Col-Spin-PLLA group than in the PLLA group (64% vs. 33%). Expt. 2: The insertion regions showed good wound healing in the ColSpin-PLLA group. The numbers of neovascularity and fibroblast proliferation were significantly larger in the Col-Spin-PLLA group than in the PLLA group. The adhesion rate was rarely. Conclusion We have succeeded in developing a hetero-functional nanosheet comprising a collagen modified side. PLLA side acts as an adhesion barrier. Collagencoated side acts as a scaffold and thereby may enhance mesh fixation.

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DEVELOPMENT OF NOVEL ELECTROSPUN ABSORBABLE POLYCAPROLACTONE (PCL) SCAFFOLDS FOR HERNIA REPAIR APPLICATIONS Gregory C Ebersole, MS MS, Evan G Buettmann, Matthew R Macewan, BSE, Michael E Tang, BS, Margaret M Frisella, RN, Brent D Matthews, MD, Corey R Deeken, PhD, Washington University in St. Louis Introduction: Permanent hernia repair materials rely on pro-fibrotic wound healing. As a result, repair sites are commonly composed of disorganized fibrotic tissue, resulting in greater risk of re-herniation. Electrospun scaffolds are a novel class of biomaterials which may provide a unique platform for the design of increasingly advanced soft tissue repair materials. These scaffolds are simple, inexpensive, non-woven materials composed of micro- or nano-scale polymer fibers which readily mimic structural elements of the natural extracellular matrix. Unlike currently available permanent meshes, absorbable electrospun scaffolds possess the ability to direct cellular orientation through the presentation of ordered topographical cues and to prevent chronic foreign body response through resorption of the scaffold. However, the mechanical properties of electrospun scaffolds are currently unknown. Thus, the primary aim of the present study was to evaluate the physiomechanical properties of several novel scaffold designs and to determine their suitability for hernia repair applications. Based on prior experimentation, scaffolds possessing at least 20 N suture retention strength, 20 N tear resistance, and 50 N/cm tensile strength will be appropriate for hernia repair applications. Methods: Six novel scaffolds were designed, fabricated, and tested in our laboratory. The scaffolds were fabricated using various combinations of polymer concentration (10–12%) and flow rate (3.5–10 mL/h). Briefly, poly(e-caprolactone) (PCL) was dissolved in a solvent mixture, loaded into a syringe, and electrospun onto a planar metal collector, yielding scaffolds with randomly oriented fibers. Physiomechanical properties of each scaffold were subsequently evaluated through scanning electron microscopy, laser micrometry, and mechanical testing (suture retention, tear resistance, and ball burst testing). Results: Scanning electron micrographs revealed fiber diameters ranging from 1.0 ± 0.1 lm (10% PCL, 3.5 mL/h) to 1.5 ± 0.2 lm (12% PCL, 4 mL/h). Laser micrometry showed thicknesses ranging from 0.72 ± 0.07 mm (12% PCL, 10 mL/h) to 0.91 ± 0.05 mm (10% PCL, 3.5 mL/h). Only 2 designs achieved suture retention values above 20 N (12% PCL, 10 mL/h and 12% PCL, 6 mL/h), and none of the designs achieved tear resistance values above 20 N (range: 4.7 ± 0.9 N to 10.6 ± 1.8 N). Tensile strengths ranged from 35.27 ± 2.08 N/cm (10% PCL, 3.5 mL/h) to 81.76 ± 15.85 N/cm (12% PCL, 4 mL/h), with 3 out of 6 designs achieving strengths above 50N/cm (12% PCL, 10 mL/h; 12% PCL, 6 mL/h; 12% PCL, 4 mL/h). Conclusions: Two scaffold designs (12% PCL, 10 mL/h and 12% PCL, 6 mL/h) possessed suture retention and tensile strengths appropriate for hernia repair applications. The incorporation of aligned fibers or other patterned designs may improve tear resistance values of the 12% PCL, 10 mL/h and 12% PCL, 6 mL/h scaffold designs for preclinical testing in a hernia repair model.

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STAGED APPROACH TO INFECTED SYNTHETIC MESH: OUTCOMES FOLLOWING ABDOMINAL WALL RECONSTRUCTION WITH STRATTICE BIOLOGICAL MATRIX Sujata Sofat, MD, Ketan Patel, MD, Frank Albino, MD, Maurice Nahabedian, MD, Parag Bhanot, MD, Georgetown University Hospital Departments of General Surgery and Plastics Surgery Background: Infection of synthetic mesh following abdominal wall hernia repair is a complex problem. Management can be difficult resulting in multiple operations with significant morbidity. The majority of cases involve mesh explantation necessitating definitive abdominal wall reconstruction. Strattice, a porcine-derived acellular dermal matrix, may provide a solution by providing a scaffold for native tissue regeneration and incorporation. Our study analyzed patients who had infected mesh requiring removal and placement of Strattice in a staged setting. Methods: The authors performed a retrospective review of all patients who underwent complex AWR with Strattice placement by the senior author (P.B.) from 2007–2010 in the setting of infected mesh. Eligible patients presented with open wounds with infected mesh in the setting of previously repaired hernia with synthetic mesh. All patients underwent staged hernia repair; first stage was mesh explantation and debridement followed by VAC therapy/dressing changes. The second stage entailed formal hernia repair with Strattice reinforcement. Demographic, perioperative, and follow-up information were reviewed. Results: 78 patients were identified as having Strattice implanted during the study period. 13 patients met the study criteria. Average patient age was 55 years with a BMI of 35.6. Average follow-up was 332.7 days. Co-morbidities include diabetes 5/13 (38.5%), coronary artery disease 2/15 (13.3%), and COPD 1/13 (7.7%). Recurrent/complex hernia was present in all patients. Mesh explantation occurred in all patients. Previous history of an enterocutaneous fistula was present in 3/13 (23.1%). Mean diameter of defect was 13.4 cm. Pathogen culture positivity included MRSA (26.3%), Pseudomonas (21.1%), MSSA (15.8%), E. faecalis (10.5%), Proteus (5.3%), Corynebacterium (5.3%), E. coli (5.3%), and Enterobacter (5.3%). Average time between stages was 4 days. Primary fascial closure was achieved with/ without component separation in 9/13 (69.2%) patients. Average hospital stay following repair was 8.2 days. Wound related complications occurred in 5/13 (38.5%) patients. Soft tissue infection with exposure of Strattice occurred in 2/13 (15.4%), but did not require removal. At an average of 4 weeks follow-up, all of the midline incisions had completely healed utilizing dressing changes and debridement when necessary. Conclusion: Management of infected synthetic mesh is a challenging problem. A staged approach to abdominal wall reconstruction with Strattice appears to provide a safe and effective solution. Wound related complications do not require removal of Strattice limiting significant morbidity in these high-risk patients.

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CRITICAL ANALYSIS OF STRATTICE PERFORMANCE IN COMPLEX ABDOMINAL WALL RECONSTRUCTION: INTERMEDIATE RISK PATIENTS AND EARLY COMPLICATIONS Sujata Sofat, MD, Ketan Patel, MD, Frank Albino, MD, Maurice Nahabedian, MD, Parag Bhanot, MD, Georgetown University Hospital Departments of General Surgery and Plastics Surgery Background: Indications and outcomes following abdominal wall reconstruction (AWR) are variable based on a variety of factors. Patient factors include hernia stage and co-morbidities, while surgeon factors include the method of hernia repair. Various strategies have been devised to improve outcomes in the intermediate and high risk patients that include specific operative techniques and biologic materials. The purpose of this study is to analyze the performance of a porcine acellular dermal matrix (Strattice) in a subset of patients who are at increased risk for peri-operative complications. Study Design: The authors reviewed all patients that had complex AWR with Strattice underlay/reinforcement from 2007-2010. Intermediate risk patients were defined as having multiple co-morbidities without abdominal infection. Strattice was used as an underlay graft in all patients. Results: Strattice was used in 69 patients of which 41 met the inclusion criteria. Average patient age was 60 years and the average BMI was 35.5. Co-morbidities included coronary artery disease (63.4%), diabetes mellitus (36.6%), and COPD (17.1%). A recurrent hernia was present in 78%. Mean defect diameter was 13.7 cm. Fascial closure was achieved with/without component separation in 40/41 (97.6%) patients. Panniculectomy was performed in 6/41 (14.6%). Average hospitalization was 6.4 days (range 1-24 days). Complications included seroma (3/41; 7.3%), wound dehiscence/skin breakdown with Strattice exposure (2/41; 4.9%), cellulitis (1/41; 2.4%), and hematoma (1/41; 2.4%). Strattice removal was not required in any patients. Two patients had medical-related complications requiring intervention. Conclusions: Patients with abdominal hernias who are at intermediate risk for complications appear to have fewer complications when Strattice is used. Post-operative skin and soft tissue infections can be managed without explantation of mesh. Strattice should be considered in AWR for intermediate risk patients.

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TOTALLY EXTRAPERITONEAL SINGLE INCISION LAPAROSCOPIC INGUINAL HERNIA REPAIR Nicole Sharp, MD, Justin Fried, BS, Rob Watson, MD, John F Eckford, MD, F. Paul Buckley, MD, Stephen Abernathy, MD, Richard Frazee, MD, Scott & White Introduction: Several options exist for the surgical management of inguinal hernias. Laparoscopic inguinal hernia repair has been demonstrated to produce less postoperative pain compared to open inguinal hernia repair. Single incision laparoscopic surgery (SILS) inguinal herniorapphy offers a less invasive method for inguinal hernia repair. We present our initial results with SILS total extraperitoneal (TEP) inguinal herniorapphy in 86 patients. Methods and Procedures: An IRB approved retrospective review of SILS TEP inguinal herniorapphy at our two sister institutions was performed. SILS herniorapphy was performed through a 1.5 cm infraumbilical incision and a planned preperitoneal approach. Operating time, need for admission, perioperative morbidity, and recurrence at time of followup were determined. Results: 81 men and 5 women, age 17–85 years (mean age 55.5 years) underwent SILS inguinal herniorapphy between Oct 2009 and August 2011. BMI ranged from 17.6–36.9 kg/m2 (mean 25.5 kg/m2). Mesh fixation was performed with 3 or fewer hernia tacks in 96% of patients. Operating time ranged from 31–206 min (mean 74.9 min). 7 patients underwent additional unrelated surgical procedures including breast augmentation, cystocele repair, rectocele repair, incisional hernia repair, and groin mass excision. Excluding patients that underwent additional procedures, average operative time ranged from 31 to 129 min (mean 71.5 min). 9 patients (10%) required conversion to a SILS transabdominal pre-peritoneal (TAPP) approach. There were no conversions to standard laparoscopic or open procedures. 84 procedures were performed as outpatients and 2 procedures were admitted for 2-3 days. Postoperative complications occurred in 13 patients and included urinary retention (4), seroma (4), bladder injury (1), stitch abscess (1), prostatis (2) groin hematoma requiring re-exploration (1). Follow-up is brief, but to date, there has been one recurrence. Conclusions: SILS inguinal herniorapphy is another viable option for inguinal hernia repair and has comparable results to other techniques in the literature. It offers the advantages of the laparoscopic preperitoneal approach, is technically feasible, and minimizes incisional discomfort and scarring.

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LAPAROSCOPIC HERNIA REPAIR UNDER LOCAL ANESTHESIA Norihito Wada, MD PhD, Toshiharu Furukawa, MD PhD, Yuko Kitagawa, MD PhD, Department of Surgery, School of Medicine, Keio University Background: Laparoscopic hernia repair is considered to be a minimally invasive surgery for inguinal hernia. Pneumoperitoneum during laparoscopic surgery, however, requires muscle relaxation and general anesthesia which needs preoperative preparation and post-operative recovery process. On the other hand, open surgery with anterior approaches, such as open Lichtenstein repair, can be safely performed under local anesthesia and ensures early recovery and safety especially for patients with comorbidity. We developed a novel technique for single-incision laparoscopic totally extraperitoneal (TEP) inguinal hernioplasty feasible even under local anesthesia. Here we show the short-term outcome of this successful procedure. Patients and Methods: From January to September 2011, a consecutive group of 28 adult patients with bilateral inguinal hernia was included in this study. Patients with obesity, inguinoscrotal hernia, irreducible hernia or coagulopathy were excluded from this study. Short-term outcomes were determined via a retrospective review of available medical records. No preoperative bowel preparation or urinary catheterization was needed. Under conscious sedation and local anesthesia, single incision of 30 mm in the lower abdomen was made and a wound protector with sealing silicon cap was placed. Two 5 mm and a 12 mm trocars were inserted. The preperitoneal space was inflated with carbon dioxide gas at 8 mmHg constant pressure. A flat self-fixating mesh with resorbable microgrip (Parietex ProGrip; Covidien, Inc., Norwalk, CT, USA) was installed through the 12 mm trocar. No tacking devices were required. Results: The mean age was 64.4 (SD = 9.6) and male sex was 95%. Median operating time was 136 min. Intraoperative and immediate postoperative complications were not observed. Pneumoperitoneum due to peritoneal injury was occurred in 4 cases (14.3%) and managed by inserting a flat silicon disk to keep a preperitoneal space. We observed 11 seromas (39.3%) at 2 weeks after surgery. During median follow-up of 5 months, we had one hernia recurrence (3.6%), in which unilateral indirect hernia was developed after direct hernia repair. Conclusions: Short term outcomes of single-incision laparoscopic TEP inguinal hernioplasty under local anesthesia were similar to those of conventional TEP or open hernia repair. This novel procedure is a promising strategy to reduce the invasiveness of hernia repair not only surgically but also anesthesiologically.

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A SYSTEMATIC REVIEW OF THE ASSOCIATION BETWEEN OBESITY AND INGUINAL HERNIAS Kourosh Sarkhosh, MD MSc FRCSC, Richdeep S Gill, MD, Daniel W Birch, MD MSc FRCSC, Xinzhe Shi, MPH, Shahzeer Karmali, BSc MD FRCSC, University of Alberta Background: The prevalence of obesity continues to increase and is associated with increased abdominal girth and pressure. Inguinal hernia incidence has previously been associated with increased intra-abdominal pressures. Inguinal hernia repair is also a common operation performed in North America. The objective of this study is to systematically review the incidence of inguinal hernia and outcomes following inguinal hernia repair in the obese patients. Methods: A comprehensive electronic data search of MEDLINE, PubMed, Embase, Scopus, Dare, Clinical Evidence, TRIP, Health Technology Database, Conference abstracts, clinical trials, and the Cochrane Library was completed. All English studies, with no date restrictions were included. All studies assessing either incidence of inguinal hernia in obese patients or inguinal hernia repair outcomes in obese patients were included. The primary outcome of interest was incidence of inguinal hernia in obese patients. Results: After an initial screen of 3672 titles, 161 abstracts were reviewed, and 18 studies met the inclusion criteria. Following full-manuscript review, 8 studies were excluded. A total of 10 studies were included with a total of 70,730 patients. This included 4 case-control studies, 2 prospective registry reviews, 2 surveys, and 1 case series and 1 retrospective registry review. The incidence of hernia was lower in obese patients (BMI [ 30), compared to non-obese patients (8.3% vs. 15.6%, respectively). Complication rates ranged from 3.9 to 10.3% in the obese patients, compared to 2.7 to 7.1% in the nonobese patients. Average length of hospital stay was 4.8 days in the obese, compared to 2.8 days in the non-obese group. While there was a higher incidence of femoral hernias in thin (BMI \ 20) patients, the incidence of direct, indirect and femoral hernias was identical between obese and non-obese patients. The recurrence rate seems to be similar between the obese and non-obese patients (1.5 and 1.2%, respectively). Conclusion: Overall, incidence of inguinal hernias seems to be lower in obese patients. There seems to be a trend towards higher risk of complications and hospital stay in the obese patients following inguinal hernia repair, with no significant difference in the types of hernia, and in recurrence rates. Further research is needed to clarify the association between obesity and inguinal hernia occurrence.

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LAPAROSCOPIC REPAIR FOR A BOCHDALEK HERNIA IN YOUNG PERSON—REPORT OF A CASE Atsushi Iida, MD PhD FACS, Katsusji Sawai, MDPhD, Mitsuhiro Morikawa, MD PhD, Takanori Goi, MD PhD, Kanji Katayama, MD PhD, Akio Yamaguchi, MD PhD, Gastroenterological surgery, University of Fukui 16-year-old female consulted our hospital by complaining continuous upper abdominal pain after her gymnastic activity. CT scan showed the protruded stomach and spleen to the left thoracic cavity by Bochdalek hernia. Emergent laparoscopic surgery was performed for the hernia. Operative procedures: We set the trocar at the umbilicus for the scope and two trocars at upper abdomen for the surgeon. Nathason’s liver retractor was used for the liver retraction. The surgeon was standing between the legs of the patient, and the bed was tilted on head up position. There were protruded spleen, stomach and omentum into the left thoracic cavity seen through the hernia site by laparoscope. All surgical procedures were completed under laparoscopy that were the returning the protruded organs and the repairing the orifice of the hernia by sutures. The shrunken left lung was inflated just before the last suture for closing hernia site. There was no drain. Results: The post-operative course was uneventful and the patient started to walk and to eat from the next day of the operation. The hospital stay was seven days. Discussion and conclusion: The cases of Bochdalek hernia in adult were rarely reported. The reported severe cases with bowel obstruction or perforation were resulted in open surgery. Recent reports including our case indicate laparoscopic repair could be the good indication for the patients with Bochdalek hernia in the onset on adult. CT scan was useful to diagnose the Bochdalek hernia.

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HIGH INCIDENCE OF SYMPTOMATIC INCISIONAL HERNIA AFTER MIDLINE EXTRACTION IN LAPAROSCOPIC COLON RESECTION Lawrence Lee, MD, Benjamin Mappin-kasirer, Chao Li, MD, Pepa Kaneva, MSc, Barry Stein, MD, Patrick Charlebois, MD, Sender Liberman, MD, Melina Vassiliou, MD, Gerald M Fried, MD, Liane S Feldman, MD, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, QC, Canada Background: The incidence of incisional hernia (IH) has not decreased despite the use of laparoscopy for colon resections. After open abdominal surgery, off-midline incisions may result in fewer IH compared to midline laparotomy. The purpose of this study was to estimate the impact of the location of the incision used for specimen extraction on the incidence of IH after laparoscopic colon resection. Methods: All laparoscopic segmental colectomies performed at a single university centre between 2005 and 2010 were identified from the operating room database and the medical records were reviewed. Cases involving the creation or reversal of a stoma were excluded. Patients were contacted by telephone for participation (IRB no. 10-183-SDR). Consenting patients completed the Body Image Questionnaire and were examined for specimen extraction site incisional hernia by a single surgeon who was not involved in the initial operation. Specimen extraction incisions were classified into midline, transverse and Pfannenstiel groups. Univariate analysis was performed using the V2 and Fisher’s exact tests. A p \0.05 was considered significant. Results: Out of a total of 251 patients, 99 patients agreed to participate (68 midline, 7 transverse, and 24 Pfannenstiel), while 73 patients refused consent and 79 patients could not be contacted. Patients who refused consent were older (69.8 vs. 62.4 years, p = 0.001), but otherwise were similar to participants with respect to gender, malignant disease, postoperative complications and extraction site. Mean length of follow-up was 37.0 months in participants. Overall, 21% (21/99) of patients were diagnosed with an IH; 29% (20/68) of patients in the midline group developed an IH compared to 14% (1/7) in the transverse group and 0% (0/24) in the Pfannenstiel group (p = 0.002). 47% (10/21) of patients with IH (IH+) were symptomatic. The IH+ group had a lower cosmetic score (14.4 vs. 17.7, p = 0.02) compared to the IHgroup, but no difference in body image score. There were no differences in body image and cosmetic scores between midline, transverse and Pfannenstiel groups. Conclusions: There is a high incidence of symptomatic IH after midline specimen extraction in laparoscopic colectomy. Cosmesis is negatively impacted by the presence of IH. The rate of IH may be lower with the use of a transverse or Pfannenstiel incision for specimen extraction.

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ASSESSING POSTOPERATIVE URINARY SYMPTOMS IN LAPAROSCOPIC CHOLECYSTECTOMY AND TAPP INGUINAL HERNIA REPAIR USING THE AMERICAN UROLOGICAL ASSOCIATION SYMPTOM SCORE FOR BPH Robert Mckay, MD, Ellis Hospital Introduction: Urinary retention requiring catheterization occurs in 2% to 7% of patients undergoing laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair and in less than 2% of patients undergoing laparoscopic cholecystectomies (LC). Urinary symptoms post laparoscopic surgery have been poorly quantified. The American Urological Association Symptom Score (AUASS) for benign prostatic hypertrophy was used to compare the change in urinary symptoms from preoperative to 24- and 48-h postoperative with these two procedures. Methods and Procedures: Men undergoing an elective TAPP inguinal hernia repair (n = 134) were enrolled. A comparative group, LC (n = 54) were also enrolled. The average age for TAPP hernia repair patients was 48.8 years (range, 20–87) and LC 54.7 years (range, 29–86) (p = .0091). All patients received inhalational general anesthesia with minimal variation in the anesthetic agents. One surgeon performed all procedures. Preoperative and postoperative 24- and 48-h AUASS were obtained. The 24- and 48-h AUASS were each compared to the respective preoperative baseline. AUASS was recorded as 1–7 mild, 8–19 moderate, or 20–35 severe. Descriptive statistics, Student’s t- test, multiple regression, and repeated measures were used to compare outcomes. Results: At 24 h post surgery, AUASS increased significantly in both groups, indicating an overall worsening of urinary symptoms. At 48 h, in the TAPP Inguinal hernia repair group, AUASS decreased or improved significantly from baseline, from moderate to mild (p = .0332). In the LC group, AUASS returned to baseline at 48 h (Table 1). AUASS change at 24- and 48-hr between TAPP inguinal hernia and LC were not significantly different. No patient developed urinary retention.

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INTERNAL HERNIA WITH SMALL BOWEL INCARCERATION DUE TO MECKEL’S DIVERTICULUM Ming-li Wang*, MD, Scott Bloom, MD, Staten Island University Hospital, Yale New Haven Hospital* Objective: We report an unusual case of small bowel incarceration due to a Meckel’s diverticulum causing an internal hernia. CT demonstrated several loops of dilated fluid-filled bowel with a twisting of the bowel in the region of the terminal ileum. This case highlights the feasibility of computed tomography in contributing to a prompt preoperative diagnosis and early surgical intervention. Introduction: Meckel diverticulum(MD) is a common congenital anomaly of the gastrointestinal tract that occurs in about 2% of the general population. The majority of the patients are asymptomatic but 17–22% may manifest symptoms of bleeding, abdominal pain and intestinal obstruction. In adults, small bowel obstruction (SBO) is the predominate presentation and is frequently due to intussusception, volvulus around an associated fibrous or omphalo-mesenteric band, adhesions from an inflammatory process, or incarceration within a hernia sac. We present a rare case of an acute small bowel obstruction due to MD. Method: A healthy 26 year old male presented with two day history of right-sided abdominal pain associated with obstipation. On examination, his abdomen was mildly distended with right-sided tenderness and guarding. Rectal examination was unremarkable. WBC was 17300/mm3. An abdominal CT showed multiple dilated fluid-filled loops of small bowel, with twisting of the bowel in the region of the terminal ileum (Fig. 1). Findings were consistent with (SBO) suggestive of a volvulus of the small bowel in the right lower quadrant (Fig. 2).

Table 1 Baseline

24 h

p (base to D 24 48 h 24 h) h

p (base to D 48 48 h) h

TAPP 8.2 ± 6.6 10.8 ± 8.0 hernia moderate moderate

0.0008

2.6

6.9 ± 7.2 mild

0.0332

LC

0.0014

3.8

7.9 ± 7.7 mild

0.715

7.6 ± 6.5 mild

11.4 ± 8.8 moderate

-1.3

0.3

Multiple regression analysis did not show any significant relationship of age, procedure, or change in AUASS at 48-h compared with baseline. Repeated measures analysis did not show any difference between AUASS and type of surgery but there is a significant difference over time with 24-h being greater than baseline or 48-h, which are not significantly different. Conclusions: AUASS provided a sensitive and accurate scoring method to assess urinary symptoms in LC and TAPP inguinal hernia repair. Symptoms significantly increased in both LC and TAPP inguinal hernia repair in the first 24 h postoperatively. Scores returned to baseline in the LC group and significantly improved, from moderate to mild, in the TAPP inguinal hernia group.

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LAPAROSCOPIC HERNIA REPAIR WITH C-QUR EDGE—A REPORT OF THREE CASES Roppei Yamada, MD PhD, Yasushi Rino, MD PhD, Norio Yukawa, MD PhD, Tsutomu Sato, MD, Hirohito Fujikawa, MD, Koichiro Yamaoku, MD, Daisuke Inagaki, MD, Teni Godai, MD, Shinichi Hasegawa, MD PhD, Takashi Oshima, MD PhD, Munetaka Masuda, MD PhD, Department of Surgery, Yokohama City University School of Medicine

Fig. 1

Aim: We report three incisional ventral abdominal wall hernias were repaired by placing a 20 9 25 cm New Bio-Absorbable Mesh Prosthesis (C-QUR Edge) by laparoscopic hernia repair. Methods: All three cases had previous operations and presented with giant incisional defects clinically. The defects were repaired laparoscopically with the placement of a C-QUR Edge of 20 9 25 cm. Absorba-Tac technique was used in all of the cases to secure the mesh to the anterior abdominal wall. Results: The mean operation time was 120 min. The patients were mobilized and led for oral intake at the first postoperative day. No morbidity occurred. Conclusion: Abdominal incisional hernias can be repaired by laparoscopic surgery with a mesh application in experienced centers.

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Fig. 4

Fig. 2

At emergency laparotomy, a MD was identified approximately 20 cm away from the ileocecal valve with its tip adherent to the adjacent mesentery (Fig. 3). The MD formed a bride-like lesion causing an internal hernia of ileal loop of bowel with incarceration (Fig. 4). The incarcerated small bowel was successfully reduced and the MD was resected. Pathology showed a MD without gastric tissue or necrosis. The patient recovered uneventfully and was discharged without any complications. Results/Discussion: Since originally reported in 1598 by Hildanus and then described in 1809 by

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A CASE OF LARGE PARAESOPHAGEAL HIATAL HERNIA SUCCESSFULLY TREATED BY LAPAROSCOPIC TENSIONFREE REPAIR Hirohito Fujikawa, Yasushi Rino, Kenji Inafuku, Koichiro Yamaoku, Daisuke Inagaki, Nobuhiro Sugano, Tsutomu Sato, Roppei Yamada, Norio Yukawa, Munetaka Masuda, Toshio Imada Yokohama City University Hospital

Fig. 3

Johann Meckel, MD is the most commonly encountered anomaly of the small intestine recognized to have clinical significance. Its clinical feature is typically described by ‘‘the rule of two’s’’. In adults, the most common presenting symptoms of MD are inflammation and intestinal obstruction, which may occur as a result of a volvulus of the small bowel around a diverticulum associated with a fibrous band, intussusception or inclusion of the diverticulum in an inguinal hernia. In the setting of SBO, the diagnosis of a symptomatic complicated MD may be difficult in adults. The efficacy of using CT to detect complicated MD has been controversial. Although CT diagnosis of SBO has high sensitivities of 81-96% with up to 96% specificity and 95% accuracy, accurate identification of MD as the cause of SBO is difficult. In our case, CT aided in diagnosing the rare etiology of a MD in incarcerated small intestine. Our case illustrates the utility and feasible of CT, especially in the emergent setting. The early diagnosis allowed early surgical intervention which ultimately resulted in a positive outcome in our patient.

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Paraesophageal type of hernias accounts for a very small percentage of hiatus hernias. Moreover, cases involving protrusion of the colon and the stomach are extremely rare. Here we report positive results achieved from a reparative laparoscopic surgery using a mesh for a paraesophageal hiatal hernia with protrusion of the stomach and colon. A 66-year-old woman, eight years back, the subject consulted a physician, complaining of abdominal distension and nausea and was diagnosed with an esophageal hiatal hernia by an upper GI tract contrast study. The patient was also diagnosed with GERD and was treated conservatively with oral proton pump inhibitors (PPI) since then. Although the subject’s symptoms temporarily improved, she began to experience recurrent exacerbation and remission, and also experienced frequent postprandial vomiting from May 2010, losing about 6 kg weight during the ensuing two months. This was thought to be caused due to an obstruction accompanying esophageal hiatal hernia. A GI tract contrast study and CT imaging revealed a paraesophageal hiatal hernia with protrusion of the gastric corpus and antrum, as well as transverse colon. A course of laparoscopic surgery was decided. Trocars were inserted into the umbilicus, the left and right epigastric region, the left and right lateral abdomen, and below the xiphoid. Intraperitoneal observation revealed protrusion of the stomach and transverse colon into the mediastinum. No adhesions were observed on the hernial sac, and the organs were returned to the peritoneal cavity. When an incision was made in the lesser omentum, a hernial orifice, 6 cm in diameter, formed by the dilated esophageal hiatus on the right side of the esophagogastric junction became evident. No malposition of the esophagogastric junction and sliding-type complications were observed. The esophagus was taped and pulled to the left, and a 6 x 6 cm surgical mesh was sutured and fixed to the diaphragm and the phrenico-oesophageal ligament to close the hernial orifice. An intraoperative endoscopy was performed, which confirmed the absence of esophageal stricture. The patient showed a favorable postoperative course and began eating on the second day after surgery. She was discharged on the fifth day postsurgery as reflux symptoms were not observed. Stricture due to adhesion and granulation is a possible, but rare, complication of mesh usage. There are reports suggesting migration to the thoracic region and the pericardium. Careful follow-up is required in the future for a long-term prognosis.

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IMMEDIATE POSTOPERATIVE PAIN MEDICATION USE AFTER LAPAROSCOPIC VENTRAL HERNIA REPAIR Maureen M Tedesco, MD, Dan Eisenberg, MD MS, Stanford University Medical Center and Palo Alto VA HCS Introduction: Immediate postoperative pain control is an important, and at times, difficult aspect in laparoscopic ventral hernia repair. In this study we examined whether placement of larger mesh, with a greater number of tacks, is associated with a greater usage of pain medication after surgery. Methods: A prospective database of laparoscopic ventral hernia repairs performed at a single institution was retrospectively reviewed. Mesh fixation was accomplished with circumferential spiral tacks (ProTack, Covidien, North Haven, CT) and 4–6 trans-fascial sutures. Mesh sizes were recorded in each case, and mesh perimeters were calculated as a surrogate measure of the number of tacks placed. Narcotic usage in the recovery room was documented and morphine equivalents calculated. Results: Between September 2007 and September 2011, 94 patients underwent a laparoscopic ventral hernia repair with Parietex composite mesh (Covidien, North Haven, CT) (52 incisional, 39 umbilical, 2 epigastric, 1 spigellian). The average mesh perimeter was 47.6 ± 20.0 cm (range 21.98-110 cm). The average narcotic use in the recovery room corresponded to a morphine dose of 6.91 ± 7.29 mg. there was no correlation between mesh perimeter and morphine dose (correlation coefficient = -0.09). However, when the cohort was divided into small mesh (\50 cm perimeter) and large mesh ([50 cm perimeter), there was a significant difference in morphine usage. Patients with small mesh required significantly more morphine compared to those with large mesh (8.07 mg vs. 5.22 mg, p = 0.03). Conclusion: The number of tacks used to secure the mesh in a laparoscopic ventral hernia repair does not significantly influence immediate postoperative narcotic pain medication requirements. Pain medication requirements are not decreased when smaller mesh and fewer tacks are used.

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HIATAL HERNIA AFTER THE ESOPHAGECTOMY REPAIRED BY LAPAROSCOPIC SURGERY Jun Iwabu, Hiroyuki Kitagawa, Tsutomu Namikawa, Michiya Kobayashi, Kazuhiro Hanazaki Kochi Medical School Introduction: Laparoscopic surgery has an advantage at the point of less abdominal adhesion compared with open laparotomy. Since 2005, we had introduced the total laparoscopic gastric mobilization (TLGM) for esophagectomy as a less invasive surgery, and experienced a case of incarcerated hiatal hernia after the esophagectomy. Case report: A 80-years old woman was admitted with acute abdominal pain and vomit. She had a history of the esophagectomy with TLGM for esophageal cancer 5 years ago. The computed tomography confirmed the incarcerated small bowel in the right thoracic cavity through the hiatus, and collapse of the right lung. Under the diagnosis as the incarcerated hiatal hernia of the small bowel, the emerging laparoscopic surgery was performed. Result: There was no adhesion in the abdominal cavity, and the small intestine fell into the right thoracic cavity through the hiatus. Following small bowel returning, neither the ischemia nor the necrosis was observed. The hiatus was directly repaired without graft. Her postoperative course was uneventful. Conclusion: The hiatal hernia is an unusual complication after the esophagectomy. It might be due to excessive hiatal enlargement and less adhesion by TLGM. The laparoscopic approach is feasible option of repair of this complication.

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EVALUATION OF ABDOMINAL WALL REMODELING FOLLOWING VENTRAL HERNIA FORMATION IN A RODENT MODEL David M Krpata, MD, Karem C Harth, MD, Jeffrey A Blatnik, MD, Michael J Rosen, MD, Case Comprehensive Hernia Center, University Hospitals Case Medical Center Introduction: Mediating abdominal wall function, the linea alba is a major tendinous insertion for abdominal wall musculature. When tendons are severed in limb muscles, changes classic for disuse atrophy appear. Similarly, when a ventral hernia occurs, particularly following a midline laparotomy, the linea alba attachment is lost and abdominal wall muscles may laterally retract and potentially undergo disuse atrophic changes. The objective of this study was to evaluate in a rat model the abdominal wall remodeling that occurs after the unloading of the core abdominal wall musculature with ventral hernia formation. Methods: The linea alba of Sprague-Dawley rats were incised and rats were survived for 30 days to represent a model of chronic ventral hernia. At 30 days, abdominal wall samples were evaluated for changes in muscle fiber type and size with histologic analysis, changes in muscle biomechanics and changes in gene expression with Affymetrix GeneChips to potentially associate downstream effects of ventral hernias with abdominal wall remodeling. Results: In total, 10 Sprague-Dalwey rats underwent hernia formation (Hernia) and were compared 10 Sprague Dawley normal abdominal walls (Control). Mean size of the hernia defects at 30 days was 4.52 cm2 (range 2.5–6 cm2). On histologic analysis, there was no significant difference in number of Type I muscle fibers or Type I fiber total percent area in either the external abdominal oblique muscles (Control: 413 fibers ± 216; 4.62% ± 1.29: Hernia: 481 ± 297 fibers; 5.11% ± 1.56) (p = 0.30; p = 0.18) or internal abdominal oblique muscles (Control: 311 fibers ± 241, 5.96% ± 1.25; Hernia: 442 fibers ± 231, 6.03 ± 1.90) (p = 0.06, p = 0.88). The biomechanical properties of unloaded and normal abdominal walls were similar in tensile strength (Control: 1.90 N/mm2 ± 0.72; Hernia: 1.82 N/mm2 ± 0.38) (p = 0.71), toughness (Control: 126.37 J ± 48.18; Hernia: 105.89 J ± 25.37) (p = 0.16), and stiffness (Controls: 1.05 N/mm ± 0.5; Hernia: 1.00 N/mm ± 0.30) (p = 0.77). After RNA isolation, gene expression was significantly different in only a single gene out of the over 30,000 genes analyzed. Conclusions: Abdominal musculature of Sprague Dawley rats at 30 days following ventral hernia formation does not show significant changes in muscle typing, biomechanical properties or gene expression as would be expected with abdominal wall remodeling. Although literature supports a rat model to investigate the disuse atrophy associated with limb muscle unloading, this does not appear to hold consistent with abdominal wall musculature. Additional models should be investigated to evaluate the abdominal wall remodeling likely associated with functional changes seen in humans who have developed ventral hernias.

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INITIAL OUTCOMES FOR LAPAROSCOPIC INGUINAL HERNIA REPAIR WITH PARTIALLY ABSORBABLE POLYPROPYLENE/POLYGLECAPRONE-25 MESH Edward Samourjian, MD, Shawn Tsuda, MD, University of Nevada School of Medicine Department of Surgery Introduction: This study reports the short-term outcomes for the use of a partially absorbable polypropylene/polyglecarpone-25 mesh (PhysiomeshTM, Ethicon, Cincinatti, OH) in laparoscopic total extraperitoneal (TEP) inguinal hernia repair. Physiomesh is a composite mesh composed of nonabsorbable polypropylene mesh laminated between two layers of polyglecaprone-25 film (monocryl). The purpose of the monocryl film is to prevent contact of the nonabsorbable polypropylene mesh with the intra-abdominal visceral contents during the initial phases of the inflammatory cascade. This is purported to aid in the reduction of adhesion to the mesh. However, tissue ingrowth begins forming following the initial phase. Physiomesh was launched for usage in August of 2010. In our institution, present initial outcomes using Physiomesh for TEP laparoscopic inguinal hernia repair. Methods and Procedures: The 15 9 15 cm partially absorbable polypropylene/polyglecarpone-25 mesh was FDA approved for hernia repair in August 2010. Consecutive laparoscopic inguinal TEP repairs were performed between August 2010–August 2011 at a single institution and a retrospective analysis of records performed with IRB approval. The mesh was fashioned to 15 9 13 cm and a three port technique with a Stoppa-like repair was used to place the mesh, and two absorbable tacks in the Cooper’s ligament were used to secure it. Specific outcome measures investigated were recurrence, seroma/hematoma, small bowel infection, unplanned return to the OR, infection, and mortality. A student’s T-test was used to compare outcomes to published meta-analyses. Results: Data collection included all cases from August 2010 until August 2011. A total of 68 inguinal hernias were repaired with TEP in 51 patients. Over the course of the data collection period, we did not observe any hernia recurrences, wound infections, reoperations, readmissions, bowel obstructions or deaths. Range of follow up was 2-16 weeks. We did observe 14/68 (20.5%) seromas post-operatively, none requiring intervention. This was non-significant compared to recent meta-analyses (11.9%, p = 0.22%). Conclusion: The use of a partially absorbable polypropylene/polyglecarpone-25 mesh in laparoscopic inguinal hernia repair is feasible with acceptable short-term outcomes. A partially absorbable mesh with a light-weight polypropylene component may be technically advantageous with handling and reduce foreign-body response. Long-term outcomes in a randomized setting may be required to establish efficacy.

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SACCULAR AND INTRA-SACCULAR NEOPLASMS OF THE HERNIA SAC—A CASE SERIES Ambar Banerjee, MD, Randy Tashjian, MD, Robert D Danforth, MD, John E Boccaccio, MD, DEPARTMENT OF SURGERY, DEPARTMENT OF PATHOLOGY, ST JOHN HOSPITAL AND MEDICAL CENTER, DETROIT, MI Introduction: The presence of a saccular or an intra-saccular neoplasm is a rare occurrence with a reported incidence of less than 0.5% in the literature. Despite numerous case reports, there is a dearth of case series on such lesions. We retrospectively reviewed the cases of inguinal, incisional and umbilical hernia repairs, performed at our institution, to present our experience with such unusual hernia contents. Methods: After obtaining Institutional Review Board (IRB) approval, a search of the institutional pathology database was conducted for patients who were treated with inguinal, incisional or umbilical hernia repair along with excision of respective sacs from January 2007 through September 2011 at St. John Hospital and Medical Center (SJHMC). A retrospective evaluation of histopathology reports of the selected patients was performed. Patient demographics, forms of herniation and their concomitant repair procedures, types of malignancy in the hernia sacs and other associated features were noted. The pertinent patient variables were analyzed with descriptive statistics. Results: Nine of 1801 patients (0.49%), with a mean age of 59.9 years (SD 19.9; range = 17, 83), were found to have neoplastic contents in their hernia sacs following inguinal (N = 6), incisional (N = 2) and umbilical (N = 1) hernia repairs. Six of nine patients (66.7%) were male. 55.6% of the patients were not known to have intra-abdominal malignancies prior to herniorrhaphy. All patients were treated with open hernia surgeries. The attached table elaborates the various neoplasms encountered in the hernia sacs at our institution. Table Demonstrating the different types of neoplasms in the hernia sac Subject Type of hernia

Type of neoplasm

1

Inguinal

Liposarcoma of the cord

2

Inguinal

Metastatic adenocarcinoma of recto-sigmoid junction

3

Inguinal

Seminoma of right testicle

4

Incisional

Metastatic mucinous adenocarcinoma of ascending colon

5

Umbilical

Metastatic ovarian serous carcinoma

6

Inguinal

Metastatic ovarian serous carcinoma

7

Inguinal

Liposarcoma of the cord

8

Incisional

Metastatic malignant mixed mullerian tumor of the ovary

9

Inguinal

Metastatic prostatic adenocarcinoma

Conclusion: Peritoneal carcinomatosis is the most common cause of saccular neoplasms in our study population, with liposarcoma of the cord being most common in the intra-saccular subgroup. Our study highlights the importance of routine pathological evaluation of hernia sacs, which may aid in the diagnosis, and guide eventual management of unknown malignancies in the afflicted patients.

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A MODIFIED ACCESS TECHNIQUE COMBINING TAPP AND TEP TO FACILITATE EXTRAPERITONEAL INGUINAL HERNIA REPAIR USING MINI-INSTRUMENTS Gustavo L Carvalho, MD PhD, Marcelo P Loureiro, MD PhD, Eduardo A Bonim, MD MSc, Christiano P Claus, MD MSc, Frederico W Silva, MD, Antonio M Cury, MD, Flavio A Fernandes Jr., MD, Adriano C Sales, Student Oswaldo Cruz University Hospital and UNIPECLIN, Faculty of Medical Sciences, University of Pernambuco - Recife and Positivo University - Curitiba, Brazil Introduction: Endoscopic surgical repair of inguinal hernia is currently represented by two techniques: the totally extraperitoneal (TEP) and the transabdominal (TAPP) hernia repair. Although technically advantageous because of the option of no mesh fixation and no need for creation of peritoneal flap resulting in less postoperative pain and faster recovery, TEP has not achieved the popularity it deserves because of its complexity and longer learning curve. Minilaparoscopy (MINI) is a natural advancement of laparoscopy, which proposes to diminish surgical trauma by reducing the diameter of the standard laparoscopic instruments. With the advent of new low-friction trocars, precisely engineered for low friction forces between the trocar and the mini instruments, improvement was found in surgical precision during dynamic tasks (e.g. dissection of hernia sac), resulting in less stress and higher effectivity. Trocar dislocation and skin reinsertions were significantly diminished, consequently reducing skin trauma, resulting in improved aesthetics By combining established advantages of TEP and TAPP associated with the precision and cosmetics of minilaparoscopy, in this study, a hybrid technique to potentially become the gold standard of minimally invasive inguinal hernia surgery has been proposed. Method: Between January and September 2011, 22 male and one female patients were operated. Three patients had bilateral hernias, two of them discovered intraoperatively. Among the total, 5 were recurrent, and 3 were incarcerated. After local anesthesia infiltration, a vertical transumbilical incision is done. A 10 mm trocar was gently inserted after blunt dilation of the aponeurotic umbilical orifice. A 10 mm 30 laparoscope was used throughout the procedure. The combined technique began with TAPP inspection and direct visualization of a minilaparoscopic trocar dissection of preperitoneum space. It continued with a 10 mm trocar placement inside the already partially dissected preperitoneal space, using the same umbilical TAPP skin incision. Minilaparoscopic retroperitoneal dissection was continued and at the end of this TEP procedure, the operation was completed with intraperitoneal review and eventual correction of the preperitoneal work. Results: The mean operative time was 41 min. There were no conversions and no intraoperative complications. There were 2 accidental peritoneal perforations and 6 hernia sacs needed to be transected. Those defects were sutured laparoscopically at the end of the procedure, after proper TEP mesh accommodation. Small clinical irrelevant hematomas were found in 5 patients. One patient developed asymptomatic small hydrocele, partially regressed after 1 month. All patients were discharged within 19 h, with analgesics on demand. No patient used analgesics for more than 5 days and no pain was referred for more than a week. No infection or recurrence was observed. All patients were very satisfied with the procedure and all returned to their activities from 3 days to 2 weeks. Conclusions: The minilaparoscopic TEP-TAPP combined approach for inguinal hernia is feasible, safe and contributes for a simpler endoscopic hernia repair. This is achieved by combining features and advantages of both TAPP and TEP techniques using thinner and more precise MINI instruments. Minilaparoscopic preperitoneal dissection allows faster and easier creation of the preperitoneal space for the TEP component of the procedure.

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PARASTOMAL HERNIA AFTER LAPAROSCOPIC ABDOMINOPERINEAL RESECTION CAN BE PREVENTED BY CREATING END SIGMOID COLOSTOMY THROUGH THE EXTRAPERITONEAL ROUTE Madoka Hamada, MD, Genya Muraoka, MD, Naoya Kawakita, MD, Kazuhide Ozaki, MD, Yasuo Fukui, MD, Yutaka Nishioka, MD, Toshitatsu Taniki, MD, Tadashi Horimi, MD, Kochi Health Sciences Center Purpose: The prevalence of a paracolostomy hernia has been reported to be from 10% to 50%, with serious impairment of the quality of life and sometimes life-threatening morbidity in some cases. Most essential in avoiding the need for further treatment of an end sigmoid colostomy is prevention of a parastomal hernia. We examined the effects of the extraperitoneal route for stoma creation to prevent parastomal hernia after laparoscopic abdominoperineal resection (APR) for rectal neoplasms. Patients and Methods: Data on a total 37 consecutive patients who underwent APR from March 2005 to December 2010 in Kochi Health Sciences Center were examined retrospectively in this study. Group A included 22 patients whose stoma was created through the extraperitoneal route and Group B included 15 patients whose stoma was created through the transperitoneal route. We compared the incidence of parastomal hernia determined through CT and clinical examinations between the two groups. Results: In Group A, one case was diagnosed as having a parastomal hernia, while in Group B, 6 cases were diagnosed by CT examination as having a parastomal hernia with CT examination; the difference in incidence between the two groups was significant (p \ 0.001). Furthermore, median duration of the follow-up period between the latest CT examination and the primary operation was 722 days in Group A, which was significantly longer than that in Group B (442 days) (p = 0.001). Group B developed parastomal hernia more frequently within a significantly shorter period. Conclusion: A permanent sigmoid colostomy created through the extraperitoneal route can prevent incidence of the parastomal hernia after laparoscopic APR. Our results support Sugarbaker technique for the treatment of parastomal hernia at the end sigmoid colostomy.

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LAPAROSCOPIC VENTRAL HERNIA REPAIR & BODY MASS INDEX Mohamed I Dahman, MD, Damien J Lapar, MD, Bruce D Schirmer, MD, Peter T Hallowell, MD, Department of Surgery, University of Virginia, PO Box 800709, Charlottesville, VA 22908, USA Introduction: With obesity on the rise, more patients with a higher body mass index (BMI) are likely to require incisional hernia repairs. The aim of this study is to evaluate the impact of BMI on outcomes of laparoscopic ventral hernia repair. Methods: We retrospectively reviewed the laparoscopic ventral hernia repairs performed from 2002 to 2009 at a single institution. We divided the patients into two groups; BMI B 30 kg/m2 and BMI [ 30 kg/m2. We looked at demographics, operative time, whether the hernia was an initial or a recurrent hernia, morbidity, and mortality. Results: We had a total of 308 cases who qualified for this study.

2

BMI B 30 Kg/m2

BMI [ 30 kg/m2

p-value

N

123

185

–

Initial hernia

101

134

p = 0.05

Recurrent hernia

22

51

p = 0.05

Male /female

56/67

75/110

p = 0.38

Age

57 (22–85)

51 (22–84)

p \ 0.001

BMI

25.8 (17–30)

36.4 (31–73)

p = 0.84

Operative time

110 min

118 min

p = 0.20

Hospital stay

1.13 days

0.97 days

p = 0.41

Morbidities

14 (11.4%)

27 (14.6%)

p = 0.21

Mortalities

1 (0.8%)

0 (0%)

p = 0.44

Recurrence

6 (4.9%)

13 (7%)

p = 0.44

Seroma

2 (1.6%)

11 (5.9%)

p = 0.65

Wound infection

2 (1.6%)

2 (1.1%)

p = 0.67

Mesh infection

4 (3.3%)

4 (2.2%)

p = 0.55

Bowel injury

3 (2.4%)

0 (0%)

p = 0.03

Small bowel obstruction

1 (0.8%)

1 (0.5%)

p = 0.77

Re-intubate

0 (0%)

1 (0.5%)

p = 0.41

Urinary problems

2 (1.6%)

1 (0.5%)

p = 0.34

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A PROSPECTIVE COMPARISON OF TACKS AND GLUE FOR MESH FIXATION IN LAPAROSCOPIC REPAIR OF INGUINAL HERNIA Francesco Stipa, MD PhD FACS, Valentina Giaccaglia, MD, Alessio Pigazzi, MD FACS, Ettore Santini, MD, Antonio Burza, MD, Department of Surgery, San Giovanni Hospital, Rome, Italy Background: Chronic pain after laparoscopic repair of inguinal hernia is relatively common and may be invalidating. This is often due to nerve injury by penetrating mesh fixation devices. In several studies on open hernioplasty, atraumatic mesh fixation proved to be efficient. The aim of this study was to compare the effect on pain, complications and recurrence rate of two laparoscopic mesh fixation: with tacks (T) or with glue (G), to define whether one technique is superior. Methods: Between January 2010 and September 2011 we operated on 40 patients either with bilateral or recurrent inguinal hernia, performing laparoscopic transabdominal preperitoneal repair (TAPP) and polypropylene mesh fixation either with titanium taks (ProTack, Covidien; group T, n = 20) or synthetic glue (Glubran-2, GEM; group G, n = 20). The mean follow up was 9 months. Results: Postoperative pain measured by visual analogue score (VAS) in the T and G groups were respectively: 4.5 vs 3.2 on day 1, 2.9 vs 2.1 on day 2 and 0.7 and 0.3 on day 7. We did not experience postoperative complications in both groups except one bleeding from trocar site on group G which resolved spontaneously. Mean hospital stay was 1.5 days. Four patients (20%) in group T complained about chronic pain, whereas no patients in group G complained it. We had no recurrences at 1, 2, 6 and 9 months follow-ups in both groups. Conclusions: In our experience atraumatic mesh fixation with synthetic glue significantly reduces postoperative and chronic pain with the same recurrence rate compared to taks fixation. A longer follow up is necessary to confirm these results over a longer period of time. Atraumatic mesh fixation with glue for TAPP may become the standard in the future.

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PROSPECTIVE EVALUATION OF THE ECONOMIC BENEFIT OF LAPAROSCOPIC TRANSABDOMINAL PREPERITONEAL (TAPP) HERNIA REPAIR IN THE DETECTION OF OCCULT BILATERAL INGUINAL HERNIAS A Patel, MD MRCS, D Vandellen, MD FRCS, M S Wadley, MD FRCS, Department of Surgery, Worcestershire Royal Hospital, Worcester, UK Introduction: The aim of our study was to determine the incidence and the potential economic benefit of the detection of occult bilateral hernias during laparoscopic inguinal hernia repair. In the UK many authorities recommend laparoscopic repair for bilateral and recurrent inguinal hernias only with TEP being the preferred approach in many centres. The TAPP approach however enables detection and simultaneous treatment of occult bilateral hernias undiagnosed in the outpatient setting. Methods: This is a prospective review of patients undergoing TAPP hernia repair by a single surgeon from October 2002 to May 2011. Patient demographics, intra-operative findings, length of hospital stay and details of post-operative follow-up were recorded. Routine laparoscopic TAPP repair was performed with mesh fixation. Consent was obtained prior to the procedure for the repair of contralateral hernias if detected intra-operatively. Results: 329 TAPP repairs (183 unilateral; 73 bilateral; 34 recurrent) were performed in 254 patients (248 male; 6 female; median age 55 yrs; range 17–90). In 31 (14%) patients listed with unilateral hernias, occult bilateral hernias were diagnosed. The median operating time for unilateral hernias was 38 min (range 18–67) and 55 min (range 32–90) for bilateral hernias. Extrapolating savings based on patient numbers, theatre costs and hospital stay this amounts to a potential annual saving for the local health economy of £70,000 ($110,000). Conclusions: TAPP repair offers advantages over the TEP/open approach as it enables detection of occult hernias without further dissection of tissue planes. It avoids the potential risks and additional costs of further surgery and we recommend it also be considered for unilateral inguinal hernia repair.

Conclusions: Laparoscopic ventral hernia repair can be successfully performed in the obese population with increases in complication and recurrence rate, that were not significantly different based on this sample size.

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LAPAROSCOPIC REPAIR OF COEXISTING PREVASCULAR AND OBTURATOR HERNIAS David Bunting, Mr, Ian Finlay, Mr, The Royal Cornwall Hospital, Truro, Cornwall, UK Introduction: A prevascular hernia is a rare type of femoral hernia in which the neck lies anterior to the femoral vessels rather than medial to them in the femoral canal. They are thought to account for less than 1.5% per cent of all femoral hernias and usually present as a painful lump in the groin. The diagnosis is often only made at the time of operation. Obturator hernias are uncommon, accounting for between 0.05% and 1.4% of all hernias. They present routinely with pain in the groin or medial thigh and as emergencies with small bowel obstruction when they are often discovered at laparotomy. This article summarises the literature on prevascular and obturator hernias. It also reports the first case in the literature of a patient with a prevascular femoral hernia treated successfully by laparoscopic pre-peritoneal mesh repair in a rare case associated with ipsilateral obturator and classical femoral hernias. Case Report: A 30-year old female presented as an emergency with a lump in the right groin. She complained of severe pain at the site of the lump and radiating to the medial thigh. The patient had previously undergone open repair of a prevascular femoral hernia using a mesh plug through a low anterior groin incision. Clinical examination revealed a non-reducible, tender lump in the right groin. Urgent laparoscopy was performed via the trans-abdominal, preperitoneal approach. A recurrent, right prevascular femoral hernia was identified with its neck situated directly anterior to the femoral vessels. After mobilisation and retraction of the peritoneum, a classical femoral hernia and an obturator hernia were identified on the ipsilateral side. All three hernias were reduced and successfully repaired using a preperitoneal polypropylene mesh. The peritoneum was closed with a continuous suture. The patient made a routine recovery and was discharged on post-operative day two. At seven months after surgery the patient had no clinical signs of recurrence or other complications. Discussion: Prevascular hernias pose a unique difficulty in treatment due to the lack of a posterior ligamentous structure for suture placement. Various approaches have been attempted, including infra-inguinal, trans-inguinal and preperitoneal dissections. Mesh plugs, flat-profile meshes and suture/tissue reconstructions have all been tried. Despite the range of techniques used, no consensus on a preferred method has been reached. The difficulty in diagnosis and problems suturing the defect or securing mesh from below suggest that prevascular hernias would be ideally suited to laparoscopic repair with a pre-peritoneal mesh. Obturator hernias can be repaired successfully via a range of approaches depending upon the clinical setting. Emergency presentations with intestinal obstruction usually undergo laparotomy regardless of whether the diagnosis has been made preoperatively. Successful laparoscopic repair of irreducible obturator hernias has been reported when there is no compromise in viability of the small bowel, however most are still treated by laparotomy. Conclusion: Prevascular femoral hernias are rare, coexist with other variants of groin hernia, they are potentially difficult to treat and are ideally suited to investigation and repair by laparoscopic means.

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LAPAROSCOPIC SUBCUTANEOUS DIRECT SUTURE CLOSURE FOR A CASE OF HERNIA IN THE LINEA ALBA Masanobu Hagiike, MD, Norikatsu Maeda, MD, Jun Uemura, MD, Seiji Noge, MD, Minoru Oshima, MD, Hirotaka Kashiwagi, MD, Naoki Yamamoto, MD, Shintaro Akamoto, MD, Masao Fujiwara, MD, Shinichi Yachida, MD, Takehiro Takama, MD, Keiichi Okano, MD, Hisashi Usuki, MD, Yasuyuki Suzuki, MD, Department of Gastroenterological Surgery, Kagawa University, Japan Laparoscopic hernia repair is now widespread. Many report recommended prosthetic mesh repair. There are several advantages, which are reduction in postoperative pain and recurrence, and disadvantage which is infection. We report a case of hernia in the linea alba, which was treated by laparoscopic direct suture closure in young female patient. A 25-year old lady visited our hospital because of occasional abdominal mass in the upper midline when patient was exercising. We examined by ultrasonography and computed tomography. Defect of the linea alba, which size was 7 mm, was detected by only ultrasonography. There is only adipose tissue in this defect. The laparoscopic operation was performed. We put three trocars in the lower abdominal area which was covered by under wear. We dissected hepatic ligament and detected small defect of linea alba which was the same area marked before operation by ultrasonography. Three subcutaneous direct suture were made by intracorporal from inside without skin incision. Bleeding was minimum and operating time was 135 min. Patient recovered rapidly and returned to unrestricted activity quickly. There have been no sign of recurrence up to now. Most of laparoscopic hernia repair cases use prosthetic mesh right now. But laparoscopic direct suture closure is also good procedure for small defect of linea alba in young patient, especially young lady who has a possibility of pregnant and other disease of abdominal organ.

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LAPAROSCOPIC HERNIA REPAIR—WHEN IS A HERNIA NOT A HERNIA? David Bunting, Mr, Lukasz Szczebiot, Dr, Alwyn Cota, Mr, The Royal Cornwall Hospital, Truro, Cornwall, UK

LAPAROSCOPIC VENTRAL HERNIA REPAIR WITH NEW TYPE OF MESH V.v. Grubnik, Prof, N.d. Parphentyeva, K.o. Vorotyntseva, Odessa national medical university

Introduction: A wide range of diagnoses can present as inguinal hernia and there are published reviews summarising these findings at open hernia repair. Laparoscopic techniques are being used increasingly in the repair of inguinal hernias. Aside from confirming the primary hernia and finding additional unsuspected hernias, laparoscopy offers the advantage of identifying other pathology. The authors review the literature on unusual findings at laparoscopy for hernia repair and present a rare case concerning laparoscopic identification of a Hydrocele of the canal of Nuck, initially thought to represent an inguinal hernia. Case Report: A 42-year-old female presented to the outpatient department with a one month history of a painless groin swelling. It was more prominent during activity, improving at rest and disappeared on lying supine. She had a history of laparoscopic cholecystectomy but no other significant medical history. Examination revealed a reducible, nontender, left groin swelling which was more prominent standing and demonstrated a positive cough reflex. Clinical diagnosis of a left inguinal hernia was made. Due to the risk of strangulation and because in women a femoral hernia must be excluded, the patient was scheduled for a routine laparoscopic hernia repair via the trans-abdominal preperitoneal (TAPP) approach. At operation, a cystic swelling which appeared to have a pulsation was found at the left deep inguinal ring. No therapeutic procedure was performed because of concern that there may have been an underlying arteriovenous fistula. Postoperatively, an ultrasound scan demonstrated a discreet fluid-filled cavity extending from the labia majora externally through the inguinal canal into the pelvis. Magnetic resonance imaging (MRI) scan of the area confirmed the diagnosis of a large hydrocele of the Canal of Nuck. Due to the exclusion of a hernia and minimal ongoing symptoms, the patient declined any further treatment and underwent no further surgery. Results: Previously, diagnoses such as diverticular abscess, Meckel’s diverticulum, perforated appendix, pancreatic pseudocyst, scrotal lipoma and liposarcoma of the cord amongst many have been made at operation for inguinal hernia repair. These have all been identified through open surgery. Laparoscopic approach to the preperitoneal space and particularly trans-abdominal laparoscopy expand the range findings when operating for a suspected hernia. In addition to the presenting hernia, concurrent hernias on the ipsilateral side may be identified and are present in 15.4% and 18% patients with inguinal hernias when assessed by open groin dissection or laparoscopy (TAPP) respectively. Concurrent contralateral hernias are identified by laparoscopy in 13% of patients with a suspected unilateral hernia. There are no previously reported cases in the literature of a Hydrocele of the canal of Nuck being identified through laparoscopy. Conclusion: Laparoscopic approaches to hernia repair offer the opportunity to confirm the diagnosis of suspected hernias, identify additional hernias (ipsilateral and contralateral), they can demonstrate other causes of a lump and allow the possibility of incidental findings. The authors suggest that in patients with atypical presenting features of a hernia, the TAPP rather than totally extra-peritoneal (TEP) approach to groin hernia repair should be considered because of the greater diagnostic potential.

Introduction: Laparoscopic operations are being used increasingly in the repair of ventral hernias. Results and rate of complications after laparoscopic hernia repair depend on type of mesh and methods of mesh fixation. The aim of the study was to compare new type of mesh for laparoscopic ventral hernia repair with standard composite mesh. Materials and methods: Prospective randomized study was conducted from January 2009 to September 2011. Study group consisted of 72 patients (men—31, women—41) with a mean age 56.4 ± 11.5 years (range, 28–79 years). Umbilical hernias were in 19 patients, paraumbilical hernias were in 12 patients and ventral postoperative hernias were in 41 patients. 33 patients (group I) were operated laparoscopically with the use of PTFEe mesh Gore–Tex, which was fixed to the abdominal wall with double row of spiral tackers. 39 patients (group II) were operated laparoscopically with MMDI mesh (new generation of mesh, made from lightweight PTFEe mesh strain on the nitinol framework). These meshes were adequately fixed to the abdominal wall using only 3–4 transfascial sutures. Results: The patients in the two groups were comparable at baseline in terms of sex, size of hernia defects, presenting complains and comorbidity conditions. The mean surgery duration was 117 min for the patients of the group I and 72 min for the patients of the group II (p \ 0.05). The pain score was significantly less at 24 and 48 h in the patients of group II (mean visual analog scale score, 2.74 vs. 3.82, p \ 0.01). There were fewer complications among the patients of group II (7.5% vs. 37%, p \ 0.01). Mean follow-up time was 23 months. Recurrence of hernia was detected in 2 patients of the group I, and no recurrence among the patients of the group II. Conclusion: Meshes of new generation with nitinol framework can significantly improve laparoscopic ventral hernia repair. The fixation of these meshes is very simple using 3-4 transfascial sutures. The absence of shrinkage of these meshes makes the probability of recurrence minimal. Absences of takers allow avoiding the postoperative pain. We consider that these new meshes can significantly improve laparoscopic ventral hernia repair.

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A CASE OF INCARCERATED HERNIA AT THE 5 mm PORT SITE AFTER REMOVAL OF TUBE DRAIN Takayuki Iino, MD, Hideto Oishi, MD PhD, Takao Yamane, MD, Eiichi Hirai, MD PhD, Shingo Kameoka, MD PhD, Masaki Fukunaga, YACHIYO MEDICAL CENTER, TOKYO WOMEN’S UNIVERSITY Introduction: Laparoscopy became a popular tool in gastrointestinal surgery. Laparoscopic operations offer an advantages of post-operative recovery and applications of this technique is still expanding. Parallel to the development of new technique, it will also expose patients to new complications. Port site hernia is one of new complications and several cases have been reported, recently. To prevent hernias, trocar sites 10 mm or greater in size are recommended to close at the fascial level and 5 mm trocar sites are usually closed only at the subcutaneous level because of the difficulty of exposing the fascia through the small skin incision and the rarity of herniation through these trocar sites. We herein report a rare case of an incarcerated hernia through a 5 mm laparoscopic wound. Case Report:: A 86-year-old lady underwent laparoscopic-assisted left hemi-colectomy due to descending colon cancer. Five ports were used for carrying out the procedure, of which two were 10 mm, two were 5 mm, and 12 mm for camera port. During closing, an 8 Fr tube drain was placed through the 5 mm port at the upper left quadrant trocar site. On the fourth post-operative day, tube drain was removed. After 5 h, the patient felt slight pain at the upper left quadrant and had small bulge without inflammation by the trocar site. USG abdomen and CT scan revealed a viable herniating loop of small bowel with tight constriction at its neck. She was taken up for emergency operation. The port site incision that had been made on the left lower quadrant was transversely extended to about 5 cm long. The length of incarcerated small bowel was about 10 cm long and found to be viable. The small intestine was carefully placed back manually and hernia site were closed with absorbable polydioxanone 3-0 suture. After the operation, the patient made an uneventful recovery. Discussion: Port site hernia is a rare complication following laparoscopic surgery. The incidence of trocar site hernia is estimated to be between 0.65-2.80%. Tonouchi et al, suggested a classification in which these hernias were classified into three types. The early-onset type occurs immediately after the operation, the late-onset type develops after several months and the special-type presents as dehiscence of the whole abdominal wall. Factors associated trocar site hernia development include intra-abdominal pressure overwhelming abdominal wall strength, 10 mm (86%) trocar size, imcomplete closure of fascia at the trocar site, midline trocars, trocar site fascial extension, obesity and aggressive manipulation and post-operative wound infection. Prevention is the key, with all trocar sites more than 10 mm at the fascia level and sites less than 5 mm in infants requiring closure. In our case, peritoneal defect and fascial defect was lined straight due to placement of tube drain and weak fascia due to high age enlarged the defect and made possible for intestine to herniate. Conclusion: Hernia at 5 mm laparoscopic port site is extremely rare, but attention should be paid to a possible occurrence of the hernia. Every effort should be done to repair the fascial and peritoneal defects to prevent the port site hernia.

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INCIDENCE OF INCISIONAL HERNIAS INCREASE WITH SINGLE PORT LAPAROSCOPIC TECHNIQUE Cici Zhang, Bruce Robb, MD, Joshua Waters, MD, Don Selzer, MD, Eric Wiebke, MD, Virgilio George, MD, Indiana University School of Medicine Introduction: Single port laparoscopic surgery (SPLS) has gained popularity albeit remaining a controversial topic. SPLS allows the surgeon to complete entire surgical procedure, like partial colectomy, through a peri-umbilical incision. Modifications of operative technique can allow the performance of colectomies using a single port, without additional access sites and without mini-laparotomy. An optimal indication for SPLS procedure could be the laparoscopic assisted right hemicolectomy—where the planned extracted site also serves as the site of the single port device. Proliferation in publications of SPLS has occurred since 2007. However, since the inception of SPLS, there has been limited evidentiary support asserting its benefits on incisional hernias. Through retrospective investigation of incisional hernia occurrences and numerous possible associated comorbidities, we propose a higher incidence of incisional hernias associated with SPLS right colectomies. Methods: A retrospective review of SPLS right colectomies (SPLSRC) was conducted from January of 2009 to June of 2011. We performed sixty-eight single port laparoscopic right colectomies during the study period. Thirteen patients were excluded due to inadequate follow-up. We collected the following data from all patients: age, surgical indication, prior abdominal surgery, surgery duration, estimated blood loss, length of stay, intra-operative complication, post operative complication, ASA classification, specimen length, BMI, prior hernias, incision length, lung disease, tobacco use, coronary disease, diabetes, hypertension, steroid use, and preoperative albumin. All surgeries were performed using a single port trocar. Vascular pedicles were ligated with energy intracorporally and anastomoses were created extracorporeally. The data was analyzed using Student’s t Test and Fisher’s Exact Test. Results: Of the fifty-five patients included, incisional hernias were found in nine patients. Three patients had large hernias that were symptomatic, and one required repair. Incision length is significantly associated with an increased incidence of incisional hernias (p = 0.01). The mean incision length is 4.4 cm in the hernia group and 3.29 in the no hernia group. Conclusion: There was no significant association between the incidence of incisional hernias after SPLSRC and the risk factors identified. Further study with long-term follow-up and larger sample size is warranted to better assess the risk factors for incisional hernias in single incision surgery.

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LAPAROSCOPIC REPAIR OF PARASTOMAL HERNIAS OF ILEAL CONDUITS: A CASE SERIES Philip J Davis, MD, Denis R Klassen, MD, Dalhousie University Background: In recent years laparoscopic repair of parastomal hernias of ileal conduits has evolved. To date, relatively little outcome data has been published on this repair. Here we present our experience with this repair over a five-year period. Methods: From July 2005 thru October 2010, eleven repairs of parastomal hernias of ileal conduits were preformed by a single surgeon (DK). Charts were reviewed in order to determine patient demographics (age, sex and BMI), operative details (operative time, conversion, satellite defect repair, and blood loss), and post-operative outcomes (length of stay, complications and recurrence). Results: In the 11 repairs, 8 were successfully completed laparoscopically, while 3 required conversion to laparotomy. Mean age was 63.9 years (range 49–79); mean BMI was 26.7 kg/m2 (range 22.4–30.8), with a 63.6% female preponderance. Average operating time was 189.1 min (range 140–350), with an average blood loss of 53.6 cc (range 20–100). Average length of stay was 6.3 days (range 1–12 days). Average follow-up was 19.1 months (range 1–62), with 3 patients developing a recurrent parastomal hernia. One recurrence was secondary to a mesh infection necessitating removal and repair with a biologic mesh. All recurrences have undergone subsequent repair. Conclusions: Laparoscopic repair of parastomal hernias of ileal conduits appears safe and is an evolving technique.

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SAFETY AND EFFICACY OF COMMON LAPAROSCOPIC PROCEDURES IN PATIENTS WITH CIRRHOSIS—A LARGE RETROSPECTIVE MULTI-CENTER STUDY Abhijit Shaligram, MBBS, Anton Simorov, MD, Vishal Kothari, MD, Matthew Goede, MD, Dmitry Oleynikov, MD, University of Nebraska Medical Center Background: Patients with cirrhosis of the liver have been shown to carry significant risk of adverse outcome after common abdominal surgical procedures. With recent advances, laparoscopy is being increasingly utilized in management of these patients who need surgical intervention. This study aims to examine the safety and efficacy of common laparoscopic procedures in patients with cirrhosis of the liver and compare them with open procedures. Method: This study is a multi-center, retrospective analysis utilizing a large administrative database. The University HealthSystem (UHC) Consortium is an alliance of over 200 academic medical centers and affiliate hospitals. The UHC database was accessed for all adult patients ([18 years old) discharged between October 2007 and September 2011 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD 9th CM) codes for cirrhosis of liver, cholecystectomy, appendectomy, groin, umbilical and incisional hernia repairs. The data on the following surgical outcome variables was obtained and analyzed: mortality, overall morbidity, hospital Length of stay (LOS), Intensive Care Unit (ICU) admission rate, 30-day readmission rate and hospital costs. Results: A total of 3131 patients with cirrhosis underwent abdominal and groin hernia repair between October 2007 and September 2011. 1678 patients underwent open repair and 1453 were treated by laparoscopic technique. Both the groups were comparable in regards to their demographics, comorbidities and admission severity of illness. Compared to open procedure, laparoscopic procedures showed lower mortality (1.72% vs. 4.05%, p = 0.0001), morbidity (7.63% vs. 11.9%, p = 0.0001), hospital LOS (days) (5.88 ± 6.38 vs. 7.44 ± 8.87, p = 0.0001), ICU admission rate (15.75% vs. 27.19%, p \ 0.0001), 30 day readmission rate (4.64% vs. 7.09%, p = 0.0083) and significantly lower hospital costs ($) (11987 ± 21054 vs. 15407 ± 12446, p = 0.0001). Conclusion: Laparoscopy is safe and feasible in patients with cirrhosis of the liver who require common abdominal surgery. Overall laparoscopic procedures had better outcomes than open procedures resulting in significantly lower hospital costs. When feasible, a laparoscopic approach should be the standard of care in patients with cirrhosis.

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Is peritoneal closure required in TEP procedure Bojan m Radovanovic, md, Miodrag m Cudomirovic, md, Nenad m Davidovic, md, General hospital Pozarevac Introduction: In the literature and in guidelines (IEHS), closure of peritoneum is recommended in laparoscopic TEP procedure. Most of papers about postoperative ileus, caused by unclosed peritoneum, are case reports. Material and Method: In last seven years we operated 652 patients with TEP technique. 23% were bilateral hernias. All operations were performed by three surgeons, with same technique. The age of patients was between 19 and 78 years. Operation technique were standard with two working 5 mm trocars, one in midline and one lateral. One or two meshes 10 x 15 cm were used. In some cases (only big direct hernias) we fixed them with tucker or glue. We had small opening of peritoneum in 80% of cases. There were big opening (2 cm or more) in 35% of them. Results: We never closed peritoneum besides dimension of peritoneal gap. During exsufflation of gas we hold the peritoneum edge and approximate defect. Among all other complications we don’t have any case of postoperative ileus. The average follow up of the patients are two and the half years. Conclusion: This is a small number of patients, but it seems that if we pay attention et the end of operation we can avoid suturing of peritoneum, which is time consuming. After the exsufflation of gas there is no possibility of bowel interposition. But there is still a chance of the late ileus caused by adhesion between uncovered mesh and bowel.

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THE INCREASING UTILIZATION OF COMPONENT SEPARATION TECHNIQUE DURING VENTRAL HERNIA REPAIR: ASSOCIATION OF PATIENT, PAYOR, AND COMMUNITY DEMOGRAPHICS Tatyan M Clarke, MD, Ross F Goldberg, MD, Jillian M Lloyd, MD, Armando Rosales-velderrain, MD, Steven P Bowers, MD, Mayo Clinic, Florida Introduction: Component separation for rectus abdominis myofascial advancement (CST) during ventral incisional hernia repair (VIHR) is a technique associated with higher complexity of operation and postoperative complications than traditional mesh repairs. Despite a lack of new evidence demonstrating an improvement in longterm efficacy, there remains great interest in CST and published reports of open and endoscopic CST are increasing in frequency. We hypothesized that the utilization of CST in the United States is likewise increasing, and we sought to determine whether this increase was associated with any patient, payor, or community demographics. Methods: The Nationwide Inpatient Sample (NIS) database from 2003–2008 was queried to identify patients having undergone VIHR using ICD-9-CM diagnosis codes consistent with ventral abdominal wall hernias (553.20, 553.21, 553.29) and procedure codes for the abdominal wall hernia repair (53.51, 53.59, 53.61, 53.69). The CST group was defined as cases having the above criteria, combined with ICD9-CM procedure code for myofascial or myocutaneous advancement flap (86.70, 86.72, 86.74). The annual incidence of utilization, cost, outcomes, and length of stay (LOS) for VIHR vs CST were compared over the time course of the study. Patient demographics (age, gender, race), payor status (Medicaid, Medicare, private insurance, self pay), and community economic status (average yearly salary by zip code) of the CST group were compared to the VIHR group. Results: A highly significant increase in the utilization of CST was observed over the time course of the study, while VIHR volume remained stable (Fig. 1). Patients undergoing CST in all years of study were significantly (p \ 0.0001) more likely to be younger, male, white, and reside in a high-income zip code. CST groups were less likely to have Medicare or Medicaid as a payor. Length of stay and hospital charges were significantly higher in all years of the study for CST cases, but the rates of increase in hospital charges over time were comparable in both groups. The differences observed in patient and payor demographics between the two groups remained stable over time. Conclusion: Data derived from the NIS database indicate there has been a significant increase in the utilization of CST with VIHR over the years 2003–2008. Over this time course, the patient, payor, and community demographics have consistently implied a bias toward specific subgroups, but this discrepancy, while still significant, has not become more exaggerated with the increased utilization we observed.

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Fig. 1 Annual incidence of CST among patients indergoing VIHR. p \ 0.0001 by Fisher’s exact test for 2008 compared with each year 2003–2007

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A META-ANALYSIS OF TRIALS COMPARING THE EFFECTIVENESS OF USE OF MESH IN LAPAROSCOPIC REPAIR OF PARAESOPHAGEAL HERNIAS Katherine G Lamond, MS MD, Miloslawa Stem, MS, Michael A Schweitzer, MD, Kimberley E Steele, MD, Anne O Lidor, MD MPH, Department of Surgery, Johns Hopkins Hospital Objective: Hiatal hernias are commonly and safely repaired via a laparoscopic approach, typically with a posterior cruroplasty followed by an anti-reflux operation. Unfortunately, there is a relatively high rate of recurrent hiatal herniation reported postoperatively. Our objective was to determine a consensus for effective use of mesh in repair of diaphragmatic hernias using meta-analysis methodology. Methods: A systematic literature search (Medline, Embase, Cochrane Library, and Pub of Med) was performed to identify all eligible articles. Randomized controlled trials (RCT) and prospective cohort studies (PCS) comparing use of mesh (biologic and prosthetic) versus primary suture repair were reviewed and the methodologic quality of included studies was evaluated independently by 2 authors. Pooled estimates of relative risk of recurrences were calculated using a random effects model to account for heterogeneity in study designs. Results: In total, 294 abstracts were reviewed and assessed for eligibility, with 3 RCT and 3 PCS identified. A total of 408 patients were analyzed. Mesh closure was not associated with reduced risk of recurrence compared to primary suture repair when stratified by study design type for RCT (Relative Risk (RR) = 0.39, 95% CI 0.09 to 1.67, p = 0.205), for PCS (RR = 0.77, 95% CI 0.26 to 2.34, p = 0.651), and overall (RR = 0.54, 95% CI 0.24 to 1.23, p = 0.141). There were no reports of mesh erosion in any study. Conclusion: In pooled analysis, the use of mesh does not seem to offer an advantage over hernia recurrence when compared to primary suture closure in laparoscopic repair of paraesophageal hernia. Our evaluation of multiple studies analyzed a variety of hernia repair techniques, as well as multiple different types of mesh. Further prospective randomized studies are certainly warranted in an effort to discover the most durable repair for hiatal hernia.

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REPAIR OF A GIANT INGUINAL HERNIA WITHOUT LOSS OF INTRA-ABDOMINAL DOMAIN Gretchen Aquilina, DO, Roy Sandau, DO, Alia Abdulla, DO, UMDNJ-SOM Objectives: While minimally invasive techniques are now favored by many surgeons and requested by many patients, there is still great importance of knowing the foundation of open surgical techniques. A 60 year old male with an impressive giant incarcerated inguinal hernia requested elective repair. The scrotum had multiple weeping ulcers, was larger than a basketball and extended down to the level of the patients knees. A pre-operative CT scan revealed the hernia contained colon and omentum compromising a large portion of his intra-abdominal domain. A successful repair of the hernia and restoration of the abdominal contents into their normal anatomic location is presented. Methods: The hernia repair was completed following a transverse left inguinal incision. First a large hydrocele was drained. Careful dissection freed the hernia sac which contained segments of sigmoid colon and a large amount of omentum. Lysis of adhesions allowed the colon to be reduced back into the abdomen without bowel resection. A partial omentectomy was performed and redundant hernia sac amputated. The testicles were identified and preserved. The hernia was then repaired with biologic mesh in a tension free manner. Conclusions: By instituting the classic techniques of open hernia repair, a giant inguinal hernia was successfully repaired with restoration of the colon into the abdomen cavity. The patient suffered no post-operative complications and did not require any scrotoplasty.

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TOTAL PREPERITONEAL BIOLOGICAL PATCH INDIRECT INGUINAL HERNIOPLASTY Andrew Dobradin, MD PhD, Winter Park Memorial Hospital, University of Central Florida The mesh repair of the inguinal hernia is consider as a standard of care in the contemporary surgery. The commonly use material is polypropylene. Tension-free repair with the use of reinforcement mesh provides best results in the area of recurrence, pain control, return to routine daily activity. Newly available biological mesh material provides possibility of treating different type of hernias without necessity of leaving artificial material in the site of operation that might lead to neuralgia, excessive scarring, difficulty in the future surgical access to the operated area. Between March and September 2011, 11 patients had TEP procedure for the indirect inguinal hernia repair performed with the use of Veritas patch. One patient underwent transperitoneal repair of the recurrent indirect inguinal hernia. Unilateral hernia repair was done on 10 patients (including two patients with bilateral inguinal hernia when for the other site hernia 3DMax mesh was used). Two patients had bilateral inguinal hernia repaired with the bovine pericardium patches. In every case the patch was secured with the use of the absorbable tacks. The placement of the patch did not complicated the procedure despite it soft texture and need for fixation with standard laparoscopic technique. All cases were performed as a same day surgery. There were no immediate postoperative complications and patients not required any additional interventions related to the pain control, hematoma or seroma formation. Early results of the TEP biological patch repair shows no evidence of short time recurrence or complications. Veritas patch might provide adequate reinforcement of the groin for indirect inguinal hernia repair. Long term study is necessary to validate the outcome. Research for less expensive biological grafts might be beneficial in application of this technique.

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INGUINAL HERNIA REPAIR WITH BIOLOGIC MESH: EARLY SERIES OUTCOMES Alla Zemlyak, MD, Paul Colavita, MD, Victor B Tsirline, MD, Brant T Heniford , Carolinas Medical Center Introduction: Biologic meshes have been used for repair of complex abdominal wall defects. However, there is little evidence for using them in the repair of inguinal hernias. This study describes a single center experience with biologic prostheses in the inguinal region. Methods: A retrospective chart review of the patients who underwent inguinal hernia repair with biologic mesh between 2009-2011 was performed. Patients’ demographics, details of surgical procedures and post-operative outcomes have been recorded. Results: There were 7 patients whose inguinal hernias were repaired with biologic mesh between 2009 and 2011. Their average age was 63 (46–88); 2 were females. Average BMI was 28.4 (20.5–38.2). Four patients had concomitant, resectional GI procedures at the time of repair, 2 had strangulated hernias and 1 had biologic mesh placed in infected field. Mesh implants included Alloderm, FlexHD, Permacol and Strattice. Three hernias were repaired with Lichtenstein technique, two were laparoscopic and two were repaired with a combined approach. Average follow up was 4 months. One patient developed a small seroma that was treated expectantly. One patient recurred and developed chronic groin pain and had his mesh removed. No infectious complications were noted. Conclusions: This small series demonstrates that biologic mesh is a reasonable option for repair of inguinal hernias in the presence of contamination. No mesh related infections occurred, but one patient required a reoperation with shortterm follow up. Given the complicated nature of the repairs a definitive conclusion can not be drawn, but biologic grafts do not appear to offer an advantage over synthetic mesh in terms of chronic groin discomfort.

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EARLY CLINICAL OUTCOMES OF HERNIA REPAIR WITH PHYSIOMESH Alla Zemlyak, MD, Victor Tsirline, MD, Paul Colavita, MD, Amy Lincourt, PhD, Brant T Heniford, MD, Carolinas Medical Center Introduction: Physiomesh is a flexible, composite, large pore partially absorbable, polypropylene mesh that was designed to match the compliance of the abdominal wall. This study examines the short term outcomes, including quality of life (QOL), of patients undergoing hernia repair using Physiomesh. Methods: The prospectively collected International Hernia Mesh Registry (IHMR) was queried for patients who underwent ventral (VHR) and inguinal hernia repair (IHR) with Physiomesh between 2010-2011. Demographics, comorbidities, operative details, post-operative complications and Carolinas Comfort Scale (CCS) scores were recorded. Results: Sixty two patients with Physiomesh repair were identified, 33 VHR and 29 IHR (41% bilateral). Average age was 56.4 ± 14.3, BMI 29.5 ± 6.4 kg/m2; 19.4% were females; 14.5% had previous repairs. Mean follow up was 6 months (range 1–12 months). Smokers constituted 22.2% of patients; 1.6% of patients were on steroids, and 11.3% required anticoagulation. Average VHR defect size was 98.6 cm2 (range: 4–300 cm2), mesh sizes ranged from 150 to 875 cm2. A laparoscopic repair was performed in 91%, using tacks and transfascial sutures in all cases. All IHR were laparoscopic and used tacks, with mesh sizes 150 to 300 cm2. No complications were reported after IHR. Pre-operative pain (CCS [ 2) was present in 43% of IHR patients. Post-operatively, only 12.5% had a CCS [ 2. One patient died in VHR group ([30 days post-op); one developed a hematoma but did not require intervention. There was 3% incidence of superficial surgical site infection and 15.2% incidence of seroma. No early recurrences or reoperations were reported. Pain was reported by 58% VHR patients pre-operatively, while only 4% had a CCS [ 2 six months postoperatively. Conclusion: Physiomesh is well tolerated by patients undergoing VHR and IHR and is associated with a low rate of complications and favorable quality of life outcomes. No recurrences were observed at 6 months of follow up.

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A CHEAP METHOD OF SINGLE INCISION LAPAROSCOPIC SURGERY IN TOTAL EXTRAPERITONEAL APPROACH FOR INGUINAL HERNIA Hayashi Nobuyasu, PhD, Ichihara Takao, PhD, Oka Yoshio, PhD, Sakon Masato, PhD, Nishinomiya Municipal Hospital Introduction: With technical advancements and the increasing demand for more minimally invasive surgery, single incision laparoscopic surgery (SILS) has recently been deployed in certain surgical procedures including inguinal hernia surgery. Currently, SILS can usually be performed with the use of several novel multichannel single port devices. It is well known that these specialized ports and instruments are too expensive and ecologically wasteful. To our knowledge, no report in the literature has described SILS TEP for inguinal hernia using the glove port technique. We will demonstrate our initial experiences with SILS-TEP using a homemade single-port device with a surgical glove and cheap instruments, assessing the safety and feasibility of this technique. Material and Surgical Technique: From August to December 2011, a total of 10 indirect inguinal hernia cases under went SILS TEP performed by a single surgeon at our hospital with this technique. The single port was made with a sterile 6.0 inch surgical glove, three 5 mm laparoscopic reusable standard trocars for reusable forceps and a laparoscopy. A Lap Protector for 2–4 cm skin incision was installed in position through the incision with the bottom ring between the rectus muscle and the posterior layer of rectus sheath, followed by the placement of a single-port device using the surgical glove. No DPP balloon was used to dissect the peritoneum space. TEP procedure was almost the same as the conventional laparoscopic one, except for slight discomfort with visualization and retraction due to collision of the instruments. Results: We successfully performed SILS-TEP for 10 patients with unilateral inguinal hernia using this port. All procedures were completed without any intraoperative or postoperative complications without the need for any conversion to standard laparoscopic or open surgery. The mean operative time was 82.3 min (range, 65–120 min). No perioperative or postoperative complications or accidents were recorded in association with the use of a homemade single-port device during the surgery. All hospitalization duration was less than 24 h after each operation. Mean visual analogue pain scales on the operative day, 1, 3 and 6 h after surgery and the first postoperative day were 6.3/10, 5.3/10, 5.1/10 and 2.1/10, respectively. These scores were comparatively lower than those obtained from conventional TEP or open methods, such as Mesh Plug procedures. Our port was more cost-effective than those commercial single port access systems, because our port consists of conventional reusable instruments. Another merit in our port system was its feasibility in the movement of forceps for SILS. We could preoperatively alter the choices of trocar placement in staggered position to prevent the interference. In addition, the surgical rubber glove was flexible enough to manipulate the forceps three dimensionally, minimizing the conflict. Conclusion: This homemade single port device reported in this study provides a simple, cost effective and flexible approach to carry out SILS-TEP. This port device might be an alternative for current commercial expensive port devices designed for SILS technique.

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LAPAROENDOSCOPIC SINGLE SITE HERNIA REPAIR USING CONVENTIONAL TROCARS AND INSTRUMENTS : INITIAL EXPERIENCE C Palanivelu, P Senthilnathan, P Praveen Raj, S Rajapandian, S Sathiyamurthy, Anirudh Vij GEM Hospital & Research Centre Background: The tremendous advancements in single incision laparoscopic surgery has prompted us to perform laparoscopic single incision hernia repair. Methods: A total of 10 patients (8 men and two women) underwent laparoscopic single incision hernia repair between June 2010 and January 2011. The mean age of the patients was 48.2 years (21–74 years). Five patients had unilateral inguinal hernia, three patients had bilateral inguinal hernias and two patients had femoral hernias one of which was obstructed. One patient had history of previous hysterectomy. Recurrent hernias were excluded from our study. Initial 5 cases were operated via single incision TAPP approach while the latter 5 cases underwent single incision TEP repair. All patients were operated via a 2 cm transverse subumbilical incision through which 3 conventional trocars were placed. Dissection was done using standard straight instruments as in conventional laparoscopy followed by placement of 15 X 12 cm prolene mesh unilaterally or bilaterally. Results: No patient in the study underwent conversion to multiport laparoscopy and all procedures were completed by the initially selected approach. The mean operative time was 68.4 min. One patient developed urinary retention in the immediate post operative period necessitating catheterization and one developed seroma two weeks postop for which aspiration was done. The mean hospital stay was 1.2 days. There has been no recurrence so far in short term follow up of 6 months. Conclusion: Based on our experience, LESS hernia repair is both feasible and safe in hands of experienced laparoscopic surgeons with a superior cosmetic outcome as compared to conventional laparoscopy. The technical difficulty of the procedure leading to possible intraoperative complications and the long term outcomes are yet to be determined.

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LAPAROSCOPIC MINOR PANCREATIC RESECTIONS (ENUCLEATIONS/ATYPICAL RESECTIONS). A LONGTERM APPRAISAL OF A SUPPOSED MINI-INVASIVE APPROACH Renato Costi, MD PhD, Bruto Randone, MD PhD, Fre´de´ric Mal, MD, Silvia Basato, MD, Hugues Levard, MD, Vincenzo Violi, MD, Brice Gayet, MD, De´partement de Pathologie Digestive, Institut Mutualiste Montsouris, Paris, France; 2 Dipartimento di Scienze Chirurgiche, Universita` degli Studi di Parma, Parma, Italia Introduction: Laparoscopic pancreatic enucleation is increasingly performed worldwide. Few retrospective, smallsized studies show encouraging results (at least for procedures performed outside the pancreatic head), but do not allow for an evaluation of laparoscopic enucleations feasibility and effectiveness. The objective of this retrospective study is to assess the short- and long-term outcome of laparoscopic minor pancreatectomy, including enucleation and atypical resection. Methods and Procedures: A retrospective analysis of short- and long-term outcome of laparoscopic pancreatic enucleations (and atypical resections) is performed by the analysis of prospectively collected preoperative and intraoperative parameters (operative time, blood loss, conversion to laparotomy, perioperative morbidity, hospital stay and late outcome) both in the whole series (including patients undergoing atypical resections and synchronous major procedures), and the subgroup of patients undergoing simple enucleations. An in-depth analysis of the relationship between the occurrence of pancreatic fistula and 1) type of resection (enucleation vs. atypical resection), 2) modality of section of pancreatic parenchyma (use of harmonic scalpel), 3) management of pancreatic enucleated surface after tumor extirpation (including running suture, omentoplasty and the local administration of various products), 4) use of somatostatine analogue, is also performed. Results: Since 1996, 33 patients (22 females) underwent laparoscopic minor pancreatic resection (29 enucleations and 4 atypical resections) for various affections, including malignancy (9 patients). Overall, seven procedures (21%) were converted to laparotomy; of them, 5 occurred among the first six procedures performed. Overall, mean operative time was 189 min, and mean blood loss was 133 ml. Within the subgroup of patients undergoing simple enucleations, conversion rate was 9% (2/22), mean operative time 144 min and blood loss 112 ml. Histology showed infiltrated margins in 1 case. Overall, morbidity was 60% (20/33 patients) and 10 patients (30%) presented a pancreatic fistula. Pancreatic fistula was independent from type of resection, technique of transection, management of enucleated surface and use of somatostatine’s analogue. Median hospital stay of simple enucleations was 18 days (4–64). Conclusions: The laparoscopic enucleation of pancreatic tumors is feasible and safe, including procedures performed for tumors harbouring in the head and the uncus, with no mortality, no longer operative time, high success-rate and, in some cases, short hospitalisation; conversely, the laparoscopic enucleation does not imply a reduction of complications, pancreatic fistula, and overall hospital stay. Feasibility of laparoscopic atypical pancreatic resection is still to be confirmed, as well as that of procedures performed for malignant disease. Only technologic upgrades in pancreas section/management will allow for the reduction of perioperative morbidity and hospital stay, so maximizing the potential advantages of laparoscopy.

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ACUTE PANCREATITIS: A RARE COMPLICATION FROM A MIGRATED GASTROSTOMY TUBE Dan Enger Ruiz, MD, Mingwei Ni, MD PHD, Rajkumar Jeganatan, MD, New York Hospital Queens Percutaneous endoscopic gastrostomy (PEG) is a common modality used for primary and supplemental feeding for long-term external access. It is generally a safe procedure, however can be associated with many potential complications. Migration of the tube is one of the complications, rarely obstruction of the pancreatic duct is seen. We report a case of a 63 year old female nursing home resident, bed bound from severe Parkinson’s disease who had a (PEG) placed months previously and was send to the Emergency Department with abdominal pain, nausea and vomiting for the last 5 days. Serum Lipase was 5000 U/L. Imaging studies showed the tip of PEG tube with the inflated balloon in the second portion of the duodenum, causing occlusion of pancreatic duct and resultant pancreatitis. At her hospitalization she was placed NPO, the balloon was deflated and changed to a shorter PEG tube. The patient improved shortly after. Our case suggests that it is very important to secure PEG-tube at the level of skin and once the tract is well formed the balloon can be deflated. The migration of percutaneous endoscopic gastrostomy tube (PEG) causing gastrointestinal obstruction is well known. Minor clinical manifestations of gastrotomy tube migration include nausea, vomiting, gastrointestinal bleeding, sudden increased perigastrostomy tube leakage and aspiration pneumonia [1–6]. Gastrostomy tube can migrate to distal organs such as kidney [7]. Among these complications, obstruction of duodenum is very rare, but has higher mortality if the initial diagnosis is missed [8]. Connar and his colleagues [9] reported two gastrointestinal obstruction cases in 125 gastrostomy patients; one of them was fatal secondary to duodenal obstruction. Haws [10] also observed one death in five cases of duodenal obstruction after reviewing complications in 240 gastrostomy tube cases. A case of acute pancreatitis caused by migration of inflated balloon of percutaneous endoscopic gastrostomy tube (PEG) into secondary portion of duodenum is presented. To the authors’ knowledge, this complication with percutaneous endoscopic gastrostomy tube (PEG) has not been described before.

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SINGLE USE OF ROMIPLOSTIM THROMBOPOIETIN ANALOGUE(TPO) IN SEVERE THROMBOCYTOPENIA FOR OUTPATIENT PERCUTANEOUS LIVER BIOPSY IN PATIENTS WITH CHRONIC LIVER DISEASE (CLD)—A RANDOMIZED DOUBLE BLINDED PROSPECTIVE CLINICAL PILOT TRIAL P Patrick Basu, MD MRCP MACG AGAF, Thankam J Nair, MD, Nithya V Krishnaswamy, MD, Niraj James Shah, MD, Robert S Brown Jr, MD MPH, Columbia College of Physicians and Surgeons, NY, North Shore University Hospital at Forest Hills, NY Introduction: Thrombocytopenia is a common entity in Chronic Liver Disease (CLD) with or without cirrhosis. Liver biopsy is the gold standard for diagnosis and prognosis of CLD. Platelet count is imperative before percutaneous liver biopsy. Platelet transfusion requires over night hospitalization with transfusion associated morbidities and cost burden. Romiplostim, a fusion protein- Romiplostim Thrombopoietin Analogue (TPO), is a hormone that regulates platelet production approved in idiopathic thrombocytopenic purpura(ITP). This study evaluates single use of Romiplostim 2 week prior to liver biopsy to avoid biopsy related morbidity and mortality. Methods: Sixty-five patients(n = 65), (mean age:56 years; M:F—2:1) with Hepatitis C: 37/65(57%); hepatitis B(HBV) 7(15.5%), Alcoholic Cirrhosis 10(15%); Non-Alcoholic steato-hepatitis(NASH) 3(5%), Primary biliary cirrhosis(PBC) 6(9%) with pre-biopsy mean platelet count 77k; Mean MELD score 20, mode fibrotic score F4 were randomized in blinded fashion into three groups: Group A(n = 18), received 7 units of platelet transfusion at night for the morning procedure. Group B(n = 23) received Romiplostim 500mcg sc given two weeks prior to the procedure, and Group C(n = 24) Elthrombopag orally 75 mg/day for two weeks. Platelet count was repeated 2 hour prior and Post-biopsy in four weeks in all groups. Inclusion criteria:CLD with thrombocytopenia. Exclusion Criteria: ITP, drug induced thrombocytopenia, HIV, Hepatocellular carcinoma, Hemangioma, Auto-immune thrombocytopenia, use of steroids, Myelodysplastic syndrome. Side Effects: Nausea 4 (8.8%), vomiting 2 (4%), dry mouth 2 (4%), headache 6 (13%), Insomnia 3 (6.6%), irritability 3 (6.6%), local skin rash 9 (20%), shortness of breath 1(2%), myalgia 11 (24%) arthralgia (15%) Erythema (9%) in post-biopsy and 39% post-Injection site. No post-biopsy bleeding or hematoma was recorded. Results: Single use TPO showed a higher platelet count pre-operatively as well as on follow through (4 week platelet count after the procedure) as compared to platelet transfusion or Elthrombopag. The findings were statistically significant with the p-values of TPO versus platelet transfusion being \0.001 while that of Elthrombopag versus platelet transfusion being \0.05. The cost of TPO was the least (2,284 $) compared to Elthrombopag (2,991 $) or Platelet transfusion (7,500 $). Conclusions: This pilot study demonstrates that single use of Romiplostim is efficacious, cost-effective, and safe without side effects for liver biopsy with severe thrombocytopenia. Single use of Romiplostim should be considered before Trans jugular intra-hepatic porto-systemic shunts or portal hemodynamic procedures and prior to surgical interventions with severe thrombocytopenia. A large randomized clinical trial is needed for further validation.

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PRACTICE PATTERNS FOR GALLSTONE PANCREATITIS: A 5-YEAR EXPERIENCE AT A COMMUNITY-BASED TEACHING HOSPITAL John Compoginis, MD, Tiffany Wu, MD, Gabriel Akopian, MD, Huntington Hospital Objective: To assess the practice patterns applied to patients with gallstone pancreatitis (GSP) who presented to the emergency department at large, community-based hospital and clarify factors influencing the type of intervention chosen. Methods: A retrospective review of medical records was performed over a 5-year period. Ninth edition international statistical classifications of diseases (ICD-9) codes for GSP were used to identify a large pool of consecutive patients. Medical records were reviewed to confirm the diagnosis of GSP using the following criteria: 1) Abdominal pain on admission, 2) a serum amylase or lipase level greater than 2 times the upper limit of normal (236 U/L and 120 U/L respectively) and 3) radiologic evidence for gallstones documented before or during the hospitalization. History and physicals were reviewed to insure the absence of other possible causes of pancreatitis. Patients with a history of cholecystectomy were excluded. Results: Two hundred seventy two patients met the inclusion criteria. Fifty-six percent of patients had at least one intervention (laparoscopic cholecystectomy, endoscopic retrograde cholangiopancreatography or both) while 44% had no intervention during hospitalization. Patients who underwent interventions were younger (p = 0.034), had longer lengths of stay (p = 0.001), had higher BMIs (p = 0.018), serum bilirubin levels (p = 0.001) and liver enzymes (p \ 0.01). They were also more likely to be started on antibiotics on admission (p \ 0.01). Patients who received a CT scan on presentation were less likely to undergo an intervention (p = 0.018). Of patients who underwent interventions, 37% had a laparoscopic cholecystectomy (LC) only, 33% percent had ERCP only and 30% had both an ERCP and LC. Patients with higher BMIs were more likely to have an ERCP (p = 0.043) and those with higher serum bilirubin, alkaline phosphatase, AST and ALT levels were more likely to undergo both an ERCP and LC (p \ 0.05). Patients presenting with leukocytosis tended to have LC only during their hospitalization (p = 0.005). CT scan on admission was associated with ERCP only (p = 0.013). Of patients who had either a LC only or LC followed by ERCP- 56% had cholangiograms and 14 of 38 cholangiograms were positive. Of those, 4 had no further intervention. This included 2 successful common bile duct explorations (CBDE). The other 10 patients went on to have ERCPs- with only one patient having had a failed CBDE attempt. Only 21% of positive IOC resulted in CBDE. Conclusions: Of patients with gallstone pancreatitis presenting to our institution, those more likely to undergo intervention tend to be younger with higher BMIs and higher serum total bilirubin, AST, and ALT levels. Those without a CT scan on admission were less likely to have an intervention. Patients with higher BMIs were most likely to have an ERCP, while patients with higher serum bilirubin, alkaline phosphatase, AST and ALT levels were more likely to undergo both an ERCP and LC. CBDE is infrequently performed despite positive cholangiograms.

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SINGLE INCISION LAPAROSCOPIC CHOLECYSTECTOMY Nihat Yavuz, MD, Serkan Teksoz, MD, Engin Hatipoglu, MD, Sabri Erguney, MD, Osman Tortum, MD, Tuna Yildirim, MD, Sirri Ozkan, MD, Istanbul University, Cerrahpasa Medical School, General Surgery Department and Acibadem Kadikoy Hospital, General Surgery Department Introduction: Thanks to technological advances, laparoscopic surgery continues to evolve. One recent advance in this field is laparoscopy performed through a single incision.In this study we present our experiences concerning cholecystectomy through a single incision. Materials and Methods: Between November 2009 and August 2011 we performed single incision laparoscopic cholecystectomy in 185 patients. 124 of the patients were female, 61 were male. The mean age was 45 years (range: 21–79 years). 18 patients presented with acute cholecystitis,others with cholelithiasis. In 7 cases an ERCP had been performed preoperatively. The procedures were realized using a SILS portTM (COVIDIEN), flexible and articulated instruments (COVIDIEN) and 5 mm endoclip as the ligation device (COVIDIEN) and electrocautery as the energy source Results: Average operative time was 37 min (20–240 min). An additional trocar was inserted in five cases, because of difficulty at exploration in two, for bleeding control in two and because of a choledocal cyst in one other case. An abdominal drain was used in nine cases, which had been removed the following day. No any postoperative complication had been encountered. Nonsteroid antiinflammatory agents had been used for postoperative analgesia.Mean hospital stay was 1.04 day (range: 1–3 days). Conclusion: With its superiority of scarlessness, single port laparoscopic cholecystectomy may be admitted as an alternative method to its multiport counterpart

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LAPAROSCOPIC CHOLECYSTECTOMY: A RETROSPECTIVE ANALYSIS OF HOSPITAL COSTS AND CLINICAL OUTCOMES IN PATIENTS UNDERGOING CONVENTIONAL, SINGLE PORT, AND MICROLAPAROSCOPIC SURGERY Edward Chekan, MD FACS, Mathew Moore, MHA, Tina Hunter, PhD, Candace Gunnarsson, EdD, Ethicon Endo-Surgery, Inc Cincinnati, Ohio; S2 Statistical Solutions, Inc Cincinnati, Ohio Introduction: This study compares hospital costs and clinical outcomes for traditional laparoscopic (LC), single port surgery (SPS) and micro-laparoscopic (MLC) cholecystectomy procedures from Premier hospitals across the United States. Methods: Eligible patients were those of any age undergoing LC in the Premier hospital database for the years 2009 Q2 2010. Patients were categorized into three groups: LC, SPS or MLC, based on ICD-9 codes and hospital charge descriptions for the surgical tools utilized. A procedure was considered to be MLC if: no SPS products were identified in the charge master descriptions; the patient had a record of at least one product \ 5 mm used; there was not more than one product [ 5 mm used and any other products identified were = 5 mm. Summary statistics were generated for all three groups. Multivariable analyses were performed for outpatient procedures on hospital costs and clinical outcomes. All multivariable models were adjusted for patient demographics, patient severity, comorbid conditions, and hospital characteristics. Results: In the outpatient setting, when SPS was utilized, hospital costs were approximately $834 more than MLC and $964 more than LC (p \ 0.0001). Adverse events were significantly higher (p \ 0.0001) for SPS compared to MLC [95% CI for odds ratio (1.38–2.68)] and SPS compared to LC [95% CI for odds ratio (1.37 to 2.35)]. MLC hospital costs were statistically significantly (p \ 0.0001) lower than LC by $211 and there were no significant differences in adverse events. Conclusions: In the outpatient setting, single port surgery costs approximately 22% more and has higher adverse events than micro-laparoscopic and traditional laparoscopy. Micro-laparoscopic costs approximately 5% less than traditional laparoscopy with no differences in adverse events. These findings could influence technique choice for patients requiring cholecystectomy.

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LAPAROSCOPIC PANCREATECTOMY FOR BENIGN/LOWMALIGNANT LESIONS T Misawa, MD PhD, K Furukawa, MD PhD, H Kitamura, MD, F Suzuki, MD, R Ito, MD, T Gocho, MD, H Shiba, MD PhD, Y Futagawa, MD, S Wakiyama, MD, Y Ishida, MD PhD, K Yanaga, MD, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan Objective: We present the technical refinements of our laparoscopic pancreatectomy including distal pancreatectomy and enucleation by pure laparoscopic (PL), hand-assisted laparoscopic (HL), and single-incision laparoscopic (SL) settings. Patients: From May 2005, we performed a total of 33 laparoscopic pancreatectomies (distal pancreatectomy in 32, enucleation in 1). Indications were mucinous cystic neoplasm (MCN) in 8, neuroendocrine tumor (NET) in 7, intraductal papillary mucinous neoplasm (IPMN) in 6, serous cystic neoplasm in 4, solid and pseudopapillary tumor (SPT) in 1, non-neoplastic pancreatic cyst in 3, and splenic diseases in 4 patients. In 15 (45%) patients, the spleen was preserved. Methods: In HL, a 7-cm midline laparotomy was made for the operator’s left hand, and then three trocars were inserted. In PL, 4 trocars were used. In SL, SILS Port was placed in the umbilicus for articulating instruments and a 5-mm flexible scope. In all distal pancreatectomies, the pancreas was resected using a liner stapler. In enucleation for NET, harmonic scalpel was employed for pancreatic resection. For splenic preservation, both the splenic artery and vein were isolated and preserved in 14, and Warshaw technique was performed in one. In SL, technical refinements such as gastric suspension with stitches and splenic hilum hanging maneuver with a cloth tape were applied. Results: There was no conversion to open surgery. The mean operative time, blood loss, and postoperative hospital stay were 261 ± 87 min, 56 ± 147 mL, and 9 ± 3.5 days, respectively. Only one (3%) patient developed clinically significant (grade B) pancreatic fistula. In comparison between spleen-preserved group and splenectomy group, there was no statistical difference in operative time, blood loss, postoperative stay, frequency of pancreatic fistula, and preoperative platelet count. However, postoperative platelet count was significantly higher in splenectomy group (225 ± 38 vs. 354 ± 1339103/ll, p \ 0.005). Postoperative pathological study revealed that two patients with preoperative diagnoses of MCN and IPMN, respectively, had non-invasive carcinoma. Another patient with SPT was also found to have limited micro-invasive lesion within the pancreatic parenchyma, thus diagnosed as carcinoma. These three patients are now under close observation. Conclusions: Though laparoscopic distal pancreatectomy is a safe and optimal procedure for benign/low-malignant lesion in the pancreas, special attention should be paid to their malignant potential.

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LAPAROSCOPIC LIVER RESECTION WITH SELECTIVE PRIOR VASCULAR CONTROL Hadrien Tranchart, MD, Giuseppe Di Giuro, MD, Panagiotis Lainas, MD, Guillaume Pourcher, MD, Gabriel Perlemuter, MD PhD, Dominique Franco, MD, Ibrahim Dagher Department of General Surgery, Antoine Be´cle`re Hospital, AP-HP, Clamart Introduction: Vascular inflow control in laparoscopic liver resections can reduce blood loss and transfusion rates. Selective clamping, in contrast to hepatic pedicle clamping, does not cause ischemic injury to the remnant liver and may be particularly efficient in laparoscopy. The aim of our study was to evaluate the effect of selective prior vascular control (PVC) in patients undergoing laparoscopic liver resections (LLR). Methods and Procedures: Between 1999 and 2008, anatomic LLRs were performed with PVC whenever possible. Fifty-two patients underwent LLR with PVC with prospective data collection and were compared with patients undergoing open liver resections (OLR) with PVC selected from our liver resection database, in a case-match analysis. Variables evaluated were: duration of intervention, blood loss, transfusion rate, resection margin, specific and overall morbidity, perioperative mortality and length of hospital stay. Results: There was no difference in operative time between the two groups (309 min vs. 295 min in the laparoscopy and laparotomy groups, respectively; p = 0.75). Blood loss and transfusion rates were lower in LLR (367 ml vs. 589 ml, p = 0.001; transfusions: 3.8% vs. 17.3%, p = 0.05). Surgical margins were similar. Specific and general morbidity did not differ significantly between the two groups (specific: 1.9% vs. 11.5%, p = 0.11 and general: 13.3% vs. 13.3% in LLR and OLR, respectively; p = 1.00). Hospital stay was longer in the OLR group (11.0 days vs. 7.4 days, p = 0.001). Conclusions: PVC during LLR was feasible and improved intra-operative and post-operative results when compared to OLR. Selective PVC should be obtained in LLR whenever possible.

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A RETROSPECTIVE ANALYSIS OF THE SAFETY OF OUTPATIENT PERCUTANEOUS LIVER BIOPSY IN PATIENTS WITH VON WILLEBRAND DISEASE P Patrick Basu, MD MRCP MACG AGAF, Krishna Rayapudi, MD, Niraj James Shah, MD, Nithya Krishnaswamy, MD, Thankam Nair, MD, Sakina Farhat, MD, Robert Brown, MD MPH, Columbia College of Physicians and Surgeons, NY, North Shore University Hospital at Forest Hills, NY Introduction: Liver biopsy remains the gold standard for the diagnosis of chronic liver diseases. Outpatient percutaneous biopsy is generally safe with a mortality rate of 0.17% and hospitalization rate for bleeding of 3%. Von Willebrand Disease (VWD) is the most common inherited hematological disorder with a prevalence of 1–3% globally. There are 3 major types of VWD—type 1 (low levels of VW factor), type 2 (several qualitative abnormalities of VWF) and type 3 (extremely reduced or undetectable levels of VWF with low concentration of factor VIII). Type 1 is the mildest and most common form of VWD, while type 3 is the most serious, but very rare. Whether VWD increases the risk of bleeding in invasive procedures is not known. The purpose of this review is to determine the safety of outpatient percutaneous liver biopsies in patients with VWD. Methods: 120 patients who underwent outpatient percutaneous liver biopsies from 1997 to 2010 were included in the study. Demographics, PT/INR, platelet count, VW factor antigen, VW factor ristocetin cofactor, Factor VIII activity, and VW factor multimers were collected. Patients had not received salicylates, NSAIDs or anticoagulants for at least 5 days prior to biopsy. Exclusions included prior known coagulation diathesis, familial bleeding history, arteriovenous malformations, collagen vascular diseases and congestive heart failure. Results: Of the 120 patients biopsied, 66 (55%) had hepatitis C, 24 (20%) hepatitis B, 10 (8.3%) alcoholic hepatitis, 20 (16%) other diagnoses. Overall, 30 (25%) had minor local bleeding that resolved with pressure and 53 (48%) had biopsy site ecchymosis after 24 h. Twelve (10%) patients were diagnosed with VW factor deficiency, of these 5 (41%), 7 (56%), and 0 had type 1, 2 and 3 respectively. No VWD patients had major bleeding that required transfusion, hospitalization or surgery but 9 (75%) had minor local bleeding and all had ecchymoses, which resolved spontaneously within a week. Conclusion: Patients with VWD types 1 and 2 without prior bleeding diathesis can undergo percutaneous liver biopsy without major bleeding. Minor bleeding may occur at a slightly higher rate. VWD type 1 and type 2 does not appear to be a contraindication to percutaneous liver biopsy. The safety of percutaneous biopsy in VWD type 3 patients is unknown. We concur with the AGA guideline that outpatient percutaneous liver biopsy is safe and non-threatening in the setting of concomitant minor inherited bleeding diathesis without prior history of excessive bleeding. Routine screening for undiagnosed VW syndrome is not recommended.

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COMMUNITY HOSPITAL EXPERIENCE WITH SILS CHOLECYSTECTOMY Kimberly N Weaver, MS, James W Valuska, MD, Thomas V Lheureau, MD, Pablo G Giuseppucci, MD, Miles L Weaver, MD, UPMC Passavant and UPMC Horizon

LAPAROSCOPIC PANCREATIC SURGERY Nobumi Tagaya, PhD, Yawara Kubota, MD, Asami Suzuki, MD, Yoshitake Sugamata, PhD, Hidemaro Yoshiba, PhD, Masatoshi Oya, PhD, First Department of Surgery, Dokkyo Medical University Koshigaya Hospital

Background: This is a report of a community hospital group practice experience with single-incision laparoscopic cholecystectomy. Patients and methods: From July 2009 to August 2011, 300 patients (225 female and 75 male) underwent SILS cholecystectomy for biliary tract disease. No patients were excluded based upon BMI, age, prior abdominal operation, or pre-operative diagnosis including acute cholecystitis. Questionnaires were sent to patients to evaluate pain, return to normal activities, as well as overall satisfaction with the procedure. Results: A significant learning curve was observed for this procedure. Median operative time overall was 49 min. The first 50 cases and last 50 cases had median operative times of 53 and 41 min. Ninety-one percent of cases were performed on an outpatient basis. There were no conversions to open cholecystectomy. One patient was converted to traditional laparoscopic cholecystectomy, while another required placement of a single additional trocar. Ninety-three percent of patients had documented cholelithiasis/chronic cholecystitis on pathology. Five percent of the procedures were performed for acute cholecystitis. The cost of SILS cholecystectomy was equivalent to traditional laparoscopic cholecystectomy. Eighty-five percent of patients described less or equivalent pain when compared to previous operations. Ninety-nine percent were pleased with the cosmetic aspect of the incision. Patients returned to normal activities within a week of operation. Ninety-five percent described complete resolution of symptoms. Conclusion: SILS cholecystectomy is an equivalent technique to traditional laparoscopic cholecystectomy in addressing symptomatic gallbladder disease and may emerge as treatment of choice as it offers improved cosmesis and decreased post-operative pain.

Background: Laparoscopic pancreatic surgery for pancreatic disorders includes enucleation, distal pancreatectomy, pancreatoduodenectomy, and cystgastrostomy. However, these procedures are still uncommon, with limited indications. If postoperative complications such as a pancreatic leakage occur, they can be potentially serious. We evaluated our experience of laparoscopic pancreatic surgery. Patients and Methods: We experienced seven consecutive laparoscopic pancreatic surgeries. Preoperative diagnoses are islet cell tumors in 3 patients, cystic tumor in 2, mucinous cystic disease and pseudopancreatic cyst in each one. The mean age was 49 years (range: 27–73), they were 3 men and 4 women, and the pancreatic tumor located in body in 3 patients and tail in 4. Under general anesthesia, the patient had a supine or right semilateral position with 4 or 5 ports. In cystgastrostomy, anastomosis was created by an intragastric procedure using Endo-GIA stapler. Results: Laparoscopic surgeries were successfully completed in all patients. Laparoscopic procedures consisted of distal pancreatectomy in 5 patients with the preservation of the spleen in 4, tumor enucleation and cystgastrostomy in each one. For the distal pancreatectomies, the splenic artery and vein were preserved in 2 patients, and divided in the other. The mean size of tumor was 3.9 cm (range: 1–10), the mean operation time was 202 min (range: 150–330), and the mean blood loss was 130 ml (range: 30–450). There was a splenic infarction in one patient without any treatments. Conclusions: Laparoscopic pancreatic surgeries are feasible and safe when conducted by experienced laparoscopic surgeons in selected patients. However, further improvement of laparoscopic skills and innovation of laparoscopic instruments will be required to obtain successful outcomes of laparoscopic pancreatic surgery for a wider range of patients.

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THE APPROACH FOR STANDARDIZATION OF PURE LAPAROSCOPIC HEPATECTOMY ‘‘STANDARDIZATION OF PURE LAPAROSCOPIC AND SINGLE PORT LATERAL SECTIONECTOMY’’ F Hirokawa, M Hayashi, Y Miyamoto, M Asakuma, K Komeda, Y Inoue, Department of General and Gastroenterological Surgery Osaka Medical College Introduction: Recently, pure laparoscopic hepatectomy (PLH) has been spreading explosively. But the level of difficulty is various according to the tumor location. On the other hand, single port hepatectomy has been introduced recently. This presentation expresses the approach for laparoscopic hepatectomy at our institution. Material and Methods: Laparoscopic hepatectomy has been performed in 74 patients at our institutions. Nine patients were hemihepatectomy, 2 patients were posterior segmentectomy, 17 patients were lateral sectionectomy and 46 patients were partial hepatectomy. 40 patients were performed PLH and 34 patients were laparoscopy-assisted hepatectomy. Furthermore, single port hepatectomy(SPH) was performed at 8 patients. Results: The mean operative time and bleeding are 266 min and 242 ml. There were no post-operative complications in all the case, except 1 case of biliary fistula after pure laparoscopic S5 resection. Discussion: However, not all the cases can be a good indication for laparoscopic approach. If the tumor is located on the edge or surface of the inferolateral segments (Segments II, III, IVa, V and VI), the partial resection is relatively easy. But in the posterosuperior segments (Segment IVb, ? and ?), the resection is difficult and in selected cases, it requires the small incision so-called ‘‘the with handport conversion’’. Furthermore, it is hard to say that PLH has been established as standard operation, especially for the anatomical resection, such as hemihepatectomy, anterior and posterior sectionectomy. On contrary, for the lateral sectionectomy, procedure is simplified using the endo-lineal stapling device, unless the surgeons are not obsessive to expose the hepatic vein and Glisson’s pedicles just like open hepatectomy. Surgical time was around 90 min and there were no complications, we consider, this approach will be a standard. In addition, we perform the single port surgery using the surgical glove and the semi-flexible laparoscopic camera from June 2009. If the cutting line is straight, single port hepatectomy (SPH) is feasible and useful with a little ingenuity. As a result, surgical time was around 150 min and no post-operative complications. Finally, we present the knacks of liver parenchymal transection. We generally transect the parenchyma by Laparoscopic Coagulation Shears (LCS) within 2 cm from liver surface and more deeply we normally use Cavitron Ultrasonic Surgical Aspirator (CUSA). Bleeding is managed by the soft coagulation system(VIO300D; ERBE Elektromedizin, Tu¨bingen, Germany) and occasionally, clump crushing method with Biclamp? is used. The Pringle maneuver can be easily performed only to insert the laparoscopic forceps from right lower lateral port to under the hepatoduodenal ligament. And selective hemihepatic vascular occlusion is performed between the hepatic parenchyma and the Glissonean sheath at the bifurcation in the hepatic hilum, then the Glissonean pedicle is encircled using the Endo Retract Maxi? Conclusions: The lateral sectionectomy has been already standardized and the other PLH will also become standardized operation with the various approaches in the near future.

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EXPERIENCE WITH REAL-TIME FLUORESCENCE IMAGING OF BILIARY ANATOMY DURING SINGLEINCISION LAPAROSCOPIC CHOLECYSTECTOMY Nobumi Tagaya, PhD, Yawara Kubota, MD, Asami Suzuki, MD, Nana Makino, MD, Kosuke Hirano, MD, Shinichiro Kouketsu, PhD, Emiko Takeshita, PhD, Yoshitake Sugamata, PhD, Hidemaro Yoshiba, PhD, Shinichi Sameshima, PhD, Masatoshi Oya, PhD, First Department of Surgery, Dokkyo Medical University Koshigaya Hospital Background: We evaluate the real-time fluorescence imaging of biliary anatomy using indocyanine green (ICG) during single-incision laparoscopic cholecystectomy. Patients and Methods: This study enrolled 7 patients who underwent single-incision laparoscopic cholecystectomy. ICG was injected 4 h before exploration. Under general anesthesia, we observed biliary tract under the guidance of real-time fluorescence imaging producing by prototype 10-mm laparoscope. The flow of the cystic artery after reinjection of ICG was also observed by the same laparoscope. Laparoscopic cholecystectomy was performed by a standard manner Results: We obtained the clear vision of biliary tract in all patients. The cystic artery was also identified approximately 10 seconds after re-injection of ICG. There were no particular perioperative complications related with an intravenous injection of ICG. After obtaining the critical view, cystic duct and artery were clearly identified by ICG fluorescence imaging. Conclusion: The advantages of this method are no cannulation manner into cystic duct, no arrangement of X-ray equipment and no radioactivity. ICG fluorescence imaging is a safe and useful tool for the navigation of biliary anatomy during single-incision laparoscopic cholecystectomy.

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EXPERIENCE WITH NEEDLESCOPIC CHOLECYSTECTOMY IN 160 PATIENTS Nobumi Tagaya, PhD, Yawara Kubota, MD, Asami Suzuki, MD, Nana Makino, MD, Kosuke Hirano, MD, Shinichiro Kouketsu, PhD, Emiko Takeshita, PhD, Yoshitake Sugamata, PhD, Hidemaro Yoshiba, PhD, Shinichi Sameshima, PhD, Masatoshi Oya, PhD, First Department of Surgery, Dokkyo Medical University Koshigaya Hospital Background: Laparoscopic cholecystectomy with needlescopic instruments has been progressed. However, this refinement has several limitations to perform surgical procedure. We performed a consecutive study to evaluate the feasibility and safety of needlescopic cholecystectomy. Patients and Methods: Recent 10 years we performed needlescopic cholecystectomy in 160 patients. They were 63 men and 96 women with mean age of 51.6 years (range: 27–79). After creation of pneumoperitoneum, the port sites consisted of three 2-mm or 3-mm ports at the right upper quadrant and one 12-mm port at the umbilicus. The operation was divided into two procedures. The operator manipulated dissecting forceps, electrocautery, clipping, cutting and intraoperative cholangiography (IOC) in the left hand and 2-mm needlescope in the right hand during all procedures. The assistant manipulated two grasping forceps form the right subcostal ports. In the other, the operator manipulated two dissecting or grasping forceps under 10-mm laparoscope. The assistant manipulated grasping forceps from the right subcostal port and 10-mm laparoscope from the umbilical port. When performing clipping or cutting of cystic duct and artery, IOC and removal of gallbladder, 2-mm needlescope is moved from the umbilical port to the epigastric port. Results: IOC was successfully performed in selected patients. The conversion to standard laparoscopic cholecystectomy was required in 8 patients (5.0%) due to the difficulty of continuing procedure. The mean operative time was 84 min (range: 45–195 min) and postoperative hospital stay was 3.4 days (range: 2–10 days). Postoperative complications were intra-abdominal abscess in one patient, wound infection in one, respectively. There were no major intra or postoperative complications. Conclusion: The use of needlescope and needlescopic instruments was feasible and safe to perform laparoscopic cholecystectomies with low morbidity and no mortality.

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SINGLE-INCISION NEEDLESCOPIC CHOLECYSTECTOMY Nana Makino, MD, Nobumi Tagaya, PhD, Yawara Kubota, MD, Asami Suzuki, MD, Kousuke Hirano, MD, Shinichiro Kouketsu, PhD, Emiko Takeshita, PhD, Yoshitake Sugamata, PhD, Hidemaro Yoshiba, PhD, Shinichi Sameshima, PhD, Masatoshi Oya, PhD, First Department of Surgery, Dokkyo Medical University Koshigaya Hospital Background: In single-incision laparoscopic cholecystectomy (SILC), the additional needlescopic instrument was often inserted at right subcostal region to improve the transumbilical manipulability between laparoscope and surgical instruments. We applied 3.3-mm needlescope with a zoom function into the additional port to obtain further improvement in SILC. Materials and methods: Recent 6 months, we performed single-incision needlescopic cholecystectomy (SINC) in 10 patients. Under general anesthesia, 2-cm transumbilical skin incision was made. Lap-protector was applied and covered by glove. Two 5-mm ports and one 2-mm needlescopic instrument were inserted into the peritoneal cavity through the glove. A 3.3-mm needlescope was inserted through the right subcostal needle port. After obtaining the critical view, the cystic artery was divided using laparoscopic coagulating shears and the cystic duct was also divided after clipping. The gallbladder was freed from the liver bed and retrieved through the umbilicus. Results: A 3.3-mm needlescope had a higher quality image than the previous one and equipped a zoom function to realize a precise observation. The crushing between the laparoscope and 5-mm instruments was reduced by the change of insertion site of needlescope in SINC. Conclusion: SINC is feasible and safe to perform laparoscopic cholecystectomy. The introduction of 3.3-mm needlescope through the right subcostal port will attribute the improvement of single-incision surgery.

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LAPAROSCOPIC HEPATIC RESECTION FOR HEPATOCELLULAR CARCINOMA: COMPARATIVE ANALYSIS OF SHORT AND LONG TERM Results Satoru Imura, MD, Mitsuo Shimada, MD PhD, Tohru Utsunomiya, MD PhD, Yuji Morine, MD, Tetsuya Ikemoto, MD, Hiroki Mori, MD, Jun Hanaoka, MD, Mami Kanamoto, MD, Koji Sugimoto, MD, Hidenori Miyake, MD PhD, Tokushima University Introduction: With progress of surgical technique and devices, laparoscopic hepatectomy (LH) became a realizable option for patients with hepatocellular carcinoma (HCC). However, the feasibility of LH for HCC should be guaranteed also oncologically. Herein, we evaluate the short and long term outcome of LH compared with open hepatectomy (OH) for HCC patients by matched pair analysis. Methods and Procedures: From January 2007, 23 consecutive HCC patients who underwent LH were compared in a retrospective analysis with a historic group of 23 patients who underwent OH. The two groups were well matched for age, gender, tumor location and size, type of hepatic resection, and severity of cirrhosis. The selection criteria of HCC for both groups specified a small (size \ 6 cm), in the left or peripheral right segments of the liver (Couinaud’s segment: II-VI, VIII). The patients less than 80-year and without severe cirrhosis were included in this study. Results: The mean age was similar in both groups (LH: 64 year [40–77], OH: 62 year [49–78]). All patients were Child-Pugh A, except 1 patient in LH group. The mean operative time was similar in both groups (LH: 288 min [198–411], OH: 322 min [159–470]). The mean blood loss in the LH group was significantly less than OH group (149 ml [28–429] vs 244 ml [45–620], p \ 0.05). The mean hospital stay in the LH group was significantly shorter than OH group (15 days vs. 22 days, p \ 0.05). There was no significant difference in the incidence of postoperative complication. Critical complication was not observed except 1 case of gas embolism in the LH group (emergent conversion to laparotomy). Overall survival rate was 96% at 1-year, 85% at 3-year in LH group and 91% at 1-year, 80% at 3-year in OH group. Disease-free survival rate was 77% at 1-year, 71% at 3-year in LH group and 62% at 1-year, 58% at 3-year in OH group. There was no significant difference in overall and disease-free survival between the two groups. Conclusion: LH is safe and feasible option for selected HCC patients. The short and long term outcome of LH is also considered to be acceptable.

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LAPAROSCOPE-ASSISTED HEPATIC RESECTION FOR GALLBLADDER CANCER Masato Yoshikawa, Mitsuo Shimada, MD PhD, Tohru Utsunomiya, MD PhD, Satoru Imura, MD, Yuji Morine, MD, Tetsuya Ikemoto, MD, Hiroki Mori, MD, Jun Hanaoka, MD, Mami Kanamoto, MD, Hidenori Miyake, MD PhD, Tokushima University Introduction: The majority of early gallbladder cancers are diagnosed at the final pathology after laparoscopic cholecystectomy. However, when the preoperative diagnosis of gallbladder cancer is acquired from the imaging modalities, laparoscopic approach is controversial. We investigated the short-term outcome of laparoscope-assisted surgery for preoperatively diagnosed gallbladder cancers. Methods and Procedures: Three patients who diagnosed as non-invasive gallbladder cancer underwent laparoscopeassisted hepatic resection. Surgical procedure is anatomical hepatic resection of segment 4a plus 5 with hepatoduodenal lymphadenectomy. Extrahepatic bile duct was not resected in all cases. Short-term outcome of the three patients was investigated. Median follow-up period after operation was 8.9 months (range, 6.1–20.8). Results: The average number of lymph nodes retrieved was 4 (range, 1–6). The average estimated blood loss was 149 ml (range, 90–186 ml) and average operative time was 260 min (range, 251–273 min). The average hospital length of stay was 18 days (range, 13–29 days). No morbidity or mortality was observed during 3 months of follow-up for each patient. Local recurrence was not observed for 6 months after operation. Conclusion: The minimally invasive approach to gallbladder cancer is feasible and safe. However, larger trials are needed to determine whether either the laparoscopic or open approach offers any advantage.

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HOW TO OVERCOME THE LEARNING CURVE OF SINGLE-INCISION LAPAROSCOPIC CHOLECYSTECTOMY Stephen Ky Chang, FRCS, Chee Wei Tay, MRCSEd, Iyer Shridhar Ganpathi, FRCS, Victor Tswen Wen Lee, FRCS, Krishnakumar Madhavan, FRCS, National University Health System, Singapore Introduction: Single-incision laparoscopic cholecystectomy (SILC) has been increasingly performed for benign gallbladder disease over the last few years with comparable operative results with conventional 4 ports laparoscopic cholecystectomy (CLC). As SILC is a relatively new approach to gallbladder disease, many aspects of this new technique have not been studied in detail. Majority of the concern from most surgeons are the learning curve of SILC and its potential problem and longer operating time. Some publications suggested that learning curve of SILC by an experience HPB laparoscopic surgeon is 5–10 cases, however other publications concluded that SILC learning curve is independent of CLC experience. In this study, we report the SILC learning experience of a HPB unit in a university hospital. Operating time, potential problems, and ways to overcome them as well as surgical technique were included in this report. Our paper aims to facilitate other surgeons especially those who are starting to perform SILC or facing difficulty in SILC to smoothen their learning curve. Methods and Procedures: 81 patients who underwent SILC by 3 HPB surgeons who routinely perform laparoscopic cholecystectomy for all benign gallbladder disease in a university hospital were studied retrospectively. Operating time, conversion rate and reason and technical problems were recorded. Conversion is defined as adding additional port(s) at other part of the abdomen or mini-laparotomy. Results: 81 patients who underwent SILC by 3 HPB surgeons during the period of April 2009 to March 2011 were included, 66 cases were performed by surgeon A, 9 cases were performed by surgeon B, and 6 cases were performed by surgeon C. 6 (9%) cases were acute cholecystitis, and 61 (91%) were chronic cholecystitis. We subdivided surgeon A’s 66 cases into 4 groups in chronological order (16 cases each group). Mean opeative time of all surgeon A’s cases is 72 min (25–135, SD ± 28). Mean operative time of first, second, third and forth 16 cases was 93 min (64–135, SD ± 22), 80 min (43–134, SD ± 27), 63 min (39–128, SD ± 22), 53 min (26–94, SD ± 28) respectively. 5 (7.6%) cases need additional ports to complete the surgery. Surgeon B has performed 9 cases with mean operative time of 120 min (51–182, SD ± 50), with 1 conversion. Surgeon C has done 6 cases with mean operative time of 101 min (63–138, SD ± 25) with no conversion. No open conversion or mini laparotomy was necessary in our study. Conclusions: SILC is a feasible procedure for benign gallbladder condition. About 20 cases are needed to overcome the learning curve, no significant conversion rate or longer operating time were observed after learning curve is overcome. CLC experience does not shorten the learning curve of SILC. Careful patient selection, role of assistant and appropriate equipment and technique are important at the beginning stage of performing SILC.

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LAPAROSCOPIC SPLENECTOMY PLUS PREOPERATIVE SPLENIC ARTERY EMBOLIZATION VERSUS LAPAROSCOPIC SPLENECTOMY ALONE FOR MASSIVE SPLENOMEGALY: COMPARISON OF TREATMENT OUTCOME AND LITERATURE REVIEW Zhong W, Jin Zhou, Bing Peng W Abstract: Introduction: Although laparoscopic splenectomy has been gradually regarded as an acceptable therapeutic approach in patients with massive splenomegaly, intraoperative blood loss remains an important complication. In an effect to reduce this risk, we evaluate the clinical outcome of a combined treatment of preoperative splenic artery embolization plus laparoscopic splenectomy. Methods: Between October 2009 and August 2011, 20 patients with massive splenomegaly underwent a combined treatment of preoperative splenic artery embolization and laparoscopic splenectomy (group 1). For comparison, we enrolled another 30 age- and gender-matched case controls undergoing same operations during the same period (group 2). Patient demographics, perioperative data, clinical outcome and hematological changes were analysed. Results: Preoperative splenic artery embolization plus laparoscopic splenectomy was successfully performed in all patients in group 1. One patient in group 2 required an intraoperative conversion to traditional open splenectomy because of severe blood loss. Significantly shorter operating time, less intraoperative blood loss and shorter postoperative hospital stay were noted in group 1 compared with group 2. No significant differences were found in postoperative complication rate. There was marked improvement in platelet count and white blood count in both groups during the follow-up period. Conclusion: Preoperative splenic artery embolization with laparoscopic splenectomy reduced the operating time and decreased the intraoperative blood loss when compared with laparoscopic splenectomy procedure alone. Splenic artery embolization is a useful intraoperative adjunctive procedure for patients with splenomegaly because of benefit of perioperative outcomes.

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THE EFFICACY AND SAFETY OF URGENT LAPAROSCOPIC COMMON BILE DUCT EXPLORATION (LCBDE) USING C-TUBE FOR CRITICAL ABDOMINAL CONDITIONS Yoshihide Chino, PhD, Masaki Fujimura, PhD, Isao Sato, MD, Seiji Masuda, MD, Makoto Mizutani, PhD, Tomotake Tabata, MD, Atsushi Okita, PhD, Reina Shimoshiro, MD, Minoru Iida, PhD, Daiichi Towakai Hospital Endoscopic Surgery Center Introduction: The laparoscopic management of common bile duct exploration (LCBDE) is widely accepted throughout the medical world. However, urgent LCBDE within the first 48 h for critical abdominal conditions has not been extensively evaluated. One of the serious complications of LCBDE is bile leakage. To prevent this, we inserted a bile drainage tube (C-tube) into the CBD via the cystic duct, and reported on the efficacy of this technique at this meeting last year. The aim of the current study was to evaluate the efficacy and safety of urgent LCBDE using C-tube for critical abdominal conditions. Methods: Between 2004 and 2010, 194 patients underwent LCBDE in our hospital. Intra-operative and postoperative cholangiographies via C-tube were performed routinely. 27 patients who underwent urgent LCBDE (group A) were retrospectively reviewed. The points evaluated were: operation time, post operative day of C-tube removal, length of hospital stays, CBD stone clearance rate, morbidity and mortality. These were statistically compared with another 167 patients who underwent scheduled LCBDE (group B). Results: There were 11 male patients and 16 female patients in group A, and 87 males and 80 females in group B. Their mean age was 67 ± 16 years in group A, and 71.6 ± 12 in group B. The reasons for urgent treatment consisted of acute cholecystitis (81.5%), and acute cholangitis (18.5%). ERCP for preoperative drainage had failed in 2 patients. The median serum bilirubin level was 2.3 mg/dl (range: 0.1–9.2). The CBD stones were diagnosed with preoperative CT (32.4%), preoperative MRCP (35.3%), intra-operative cholangiography (20.6%), ENBD or PTCD (8.8%). CBD stones were cleared with choledochotomy (96%) or transcystic exploration (3.7%). Mean operation times, postoperative C-tube removal times and hospital stays in groups A and B were 197 ± 55 min and 200 ± 56 min, 5.6 ± 2.6 days and 5.4 ± 2.6 days, 9.0 ± 4.0 days and 10.5 ± 9.5 days, respectively. There were no significant statistical differences between the two groups. The CBD clearance rate was 100% in group A and 95.2% in group B. There were no major morbidities such as bile leakage, common duct stricture, bile originated peritonitis, and postoperative pancreatitis. There was no mortality in group A, but one patient (0.5%) in group B died of acute myocardial infarction. Conclusion: Intraoperative cholangiographies via C-tube played an important role in detecting the CBD stones. Urgent LCBDE using C-tube was a safe and feasible procedure for critical abdominal conditions.

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EFFECT OF NORMAL SALINE IRRIGATION ON ATTENUATION OF SHOULDER TIP PAIN AND CHANGE OF BETA-ENDORPHIN AFTER LAPAROSCOPIC CHOLECYSTECTOMY Tae Kyung Ha, PhD, Youn Kyoung Seo, PhD, Kyeong Geun Lee, PhD, Department of Surgery, College of Medicine, Hanyang University Aim: The purpose of this study is to evaluate the effect of saline washout under diaphragm on postoperative shoulder tip pain (STP) and beta-endorphin (BE) level in patients who have undergone laparoscopic cholecystectomy Methods: Between December 2010 and March 2011, 50 patients requiring cholecystectomy for benign gallbladder disease were enrolled in this study. Twenty-five patients (Group 1) had undergone laparoscopic cholecystectomy (LC), while the other 25 were operated on with saline irrigation (30 ml/kg) under the diaphragm (Group 2). The obtained plasma level of BE was measured at the beginning and end of the operation. The degree of STP following LC was assessed using a visual analogue pain scale (VAS) at 6, 12, and 24 postoperative hours. Results: Eight patients in group 1 (32.0%) and seven patients in group 2 (28.0%) complained of STP. There was no significant difference in operation time, postoperative hospital length, postoperative BE, dose of analgesics or VAS at 6, 12 and 24 h after surgery between the two groups. The intensity of abdominal pain (AP) was significantly higher than for STP. Postoperatively, significantly elevated levels (11.3 5.1 pg/ml) of BE were observed when compared to preoperative levels (9.7 5.2 pg/ml) of BE (P = 0.02). Conclusion: Normal saline irrigation under diaphragm does not reduce postoperative STP after LC, as denoted by no significant difference in VAS and BE. Ancillary techniques to reduce AP along with STP should be considered during LC.

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LAPAROSCOPIC CHOLECYSTECTOMY IN SITUS INVERSUS TOTALIS: FEASIBILITY AND REVIEW OF LITERATURE Ibrahim A Sslama, MD, Mohammed H Abdullah, MD, Mohammed a Houseni, MD, Department of Hepatobilary Surgery (1), Department of Anesthesia (2), Department of Radiology (3) National Liver Institute, Menophyia University, Shiben Elkom, Egypt Abstract: Situs inversus is a rare anomaly characterized by transposition of organs to the opposite site of the body. Laparoscopic cholecystectomy in these patients is technically more demanding and needs reorientation of visumotor skills to left upper quadrant. Herein, we report on a patient with situs inversus totalis underwent laparoscopic cholecystectomy for cholelithiasis. Feasibility and technical difficulty in diagnosis and operation are discussed in the context of the available literature. Difficulty is encountered in skelatonizing the structures in Cabot’s triangle, which consume extra time than normally located gall bladder. A summary of additional 50 similar cases reported up to date in the medical literature is also presented. Key Words: Situs inversus totalis-cholelithiasis- laparoscopic cholecystectomy.

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ROLE OF THE USE OF OMENTAL FLAP IN PROGNOSIS OF CASES WITH INDUCED ACUTE PANCREATITIS IN EXPERIMENTAL DOGS Mohamed H Fahmy, title, Engie T Hefnawy, title, Karim A Hoseny, title, Ashraf Seeda, MD, Hisham M Elsharkawy, MD, Nader Shaaban, MD, Reem Jan, MD, Mustafa Khodeir, PhD, Mohamed Hassan M.D.*, Engie T. Hefnawy M.D.*, Karim A. Hosny M.D.*, Hisham M. ElSharkawy M.D.*, Ashraf Seeda M.D.**, Nader Shaaban M.D.***, Reem Jan M.D.****, Mustafa Khodeir M.D.***** *Dept of Surgery, Faculty of Medicine, Cairo University, **Faculty of Veterinary Medicine, Cairo University, ***Dept of Surgery, Faculty of Medicine, Fayoum University, ****Dept of Clinical Pathology, Faculty of Medicine, Cairo University, *****Dept of Pathology, Faculty of Medicine, Cairo University, Faculty of Medicine, Cairo University Role of the use of omental flap in prognosis of cases with induced acute pancreatitis in experimental dogs Acute pancreatitis is an acute inflammatory process of the pancreas that frequently involves peripancreatic tissues and at times remote organ systems. Approximately 20% of patients with acute pancreatitis develop a severe disease associated with complications and high risk of mortality (1) . Acute pancreatitis was experimentally induced in dogs by oleic acid injection in the pancreatic duct after permission and supervision of the Eyptian Animal Friend Society. The research was conducted in animal lab. In faculty of veterinary medicine on 10 dogs divided into 2 groups; Omental flap was used to wrap the pancreas in one group of dogs after injection of oleic acid in the pancreatic duct. The animals were followed up with biochemical markers, abdominal ultrasonography . Dogs were re-explored after 45 days and pathological examination was done for the pancreatic tissue as regards the extent of interstitial edema-leukocytic infiltration, acinar cell necrosis and hemorrhage and the Schmidt Scoring system was used to determine the degree of severity of pancreatitis. In conclusion, there was a marked difference between the two groups in favour of the omental flap as regards levels of LDH and serum amylase. also pathological examination was in favour of the group with the omental flap.

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LAPAROSCOPIC AND OPEN SPLENECTOMY FOR SPLENOMEGALY SECONDARY TO LIVER CIRRHOSIS: AN EVALUATION OF IMMUNITY Bing Peng, PhD, Zhong Wu, MD, Jin Zhou, MD, West China Hospital, Sichuan University Abstract: Objective: To investigate the perioperative inflammatory response and immunological effects of patients with splenomegaly due to portal hypertension who underwent laparoscopic (LS) or open splenectomy (OS). Methods: Between May 2009 and September 2010, a total of 34 patients with splenomegaly due to portal hypertension underwent either laparoscopic (n = 18) or open splenectomy (n = 16) in this prospective study. Peripheral venous blood samples were taken from these patients prior to surgery as well as on postoperative days (POD) 1, 3 and 7. The perioperative clinical outcomes and immune function results were analyzed and compared within each surgical group. Results: No difference was found in the demographic data between the two groups. Patients in the LS group had more operating time, less intraoperative blood loss, an earlier resumption of diet and shorter postoperative hospital stay. On POD 1 and 3, there were statistically significant differences in IL-6 and C-reactive protein levels, as well as in total lymphocytes, CD4 T cells and NK cells compared with presplenectomy in both the open and the laparoscopic group. The immune responses in the LS group were significantly less than those in the OS group. On POD 7, the LS group had a better preserved cellular immune response than the OS group, in addition to a faster recovery. Conclusions: The study demonstrated that there are significant differences in the immune response depending on whether LS or OS was performed by examination of the inflammatory reaction and cellular immune response. Further human studies are required to determine the permanent effects on immune function following splenectomy.

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FEASIBILITY OF LAPAROSCOPIC HEPATECTOMY FOR INTRAHEPATIC CHOLANGIOCARCINOMA Mitsuo Shimada, MD FACS, Toru Utsunomiya, MD FACS, Yuji Morine, MD, Satoru Imura, MD, Tetsuya Ikemoto, MD, Jun Hanaoka, MD, Hidenori Miyake, MD, Department of Surgery, The University of Tokushima Introduction: Laparoscopic hepatectomy (Lap-Hx) has been established as an important treatment choice for liver cancers, especially hepatocellular carcinoma. However, role of Lap-Hx on short- and long-term outcomes remains unclear for intrahepatic cholangiocarcinoma (IHCC). The aim of this study was to clarify feasibility of Lap-Hx for IHCC. Patients and Methods: IHCC of less than 10 cm in diameter, which located in the left lobe and had no macroscopic vascular invasion, is indicated for Lap-Hx including hybrid method. Lymph node dissection was basically performed in case of hilar type IHCC or lymph node swelling in the hepatic hilum. Four patients with IHCC who underwent laparoscopic left hepatectomy (LHx) or left lateral segmentectomy (LLSx) were studied. All were male, and age ranged from 52 to 76 years. Those short- and long-term outcomes of those four patients (Lap group) were compared with ten patients with IHCC who underwent open LHx or LLSx (Open group) in our institution. Results: In Lap group, operative procedures consisted of LHx in one and LLSx in 3, and lymph node dissection was done in 2 patients. Median values of operative time, blood loss and hospital stay were 317 min., 246 ml, and 16.5 days, respectively. 5-year overall survival (OS) and disease-free survival rate (DFS) were 75% and 38%. Regarding the background variables, age in Lap group tended to be younger, and ICGR15 value in Lap group tended to be lower than those in Open group. Incidence of intrahepatic metastasis in Lap group tended to be higher than that in Open group. In respect to operative variables, rate of left hepatectomy in Lap group tended to be lower, however, no difference was observed in operative time, blood loss, and rate of lymph node dissection. Postoperative hospital stay in Lap group (median 16.5 days) tended to be shorter than that in Open group (34.5 days). Regarding the long-term outcome, 5-year OS and DFS in Lap group tended to be better than that in Open group, (OS: 75% vs. 30%, DFS: 38% vs 20%). In Lap group, one patient is alive without recurrence over 10 years after operation. Conclusions: Lap-Hx could be justifiable in selected patients with IHCC from viewpoint of short-and long-term outcomes.

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ANALYSIS OF INTRAOPERATIVE FINDINGS DURING SINGLE PORT LAPAROSCOPIC CHOLECYSTECTOMY Hyung Joon Han, MD, Sae Byeol Chi, MD, Jin-suk Lee, MD, Young Dong Yu, MD, Cheol Woong Jung, MD FACS, Wan-bae Kim, MD, Dong-sik Kim, MD, Tae Jin Song, MD FACS, Sung Ock Suh, MD, Sang Yong Choi, MD, Korea University Medical Center

ROLE OF LAPAROSCOPY AND MINI-INCISION IN MANAGEMENT OF COMPLICATED FORMS OF CHOLELITHIASIS *,**abdulkadir Yakubu, MD MSc PhD, *viktor N Chernov, Prof , *Rostov State Medical University, Russia,** Kazaure General hospital, Jigawa state, nigeria

Background: Single Port Laparoscopic Cholecystectomy displays substantial progresses in minimally invasive surgery and recent randomized controlled studies of this novel technique have challenged the conventional laparoscopic cholecystectomy as the gold standard treatment in benign gallbladder disease. Herein, we analyze our clinical outcomes and operative findings of single port laparoscopic cholecystectomy in order to give some better opinions about selecting patients who will undergo single port laparoscopic cholecystectomy. Methods: We analyzed the operative findings and clinical parameters patients who underwent single port laparoscopic cholecystectomy using logistic regression method to find significant variables of influencing postoperative results. Results: Between Jan 2009 and Sep 2011, 203 patients were underwent single port laparoscopic cholecystectomy. The patients with higher body mass index ([25 kg/ m2; p = 0.026; odd ratio, 3.451; 95% confidence interval, 1.161–10.256) and acute cholecystitis (p = 0.050; OR, 5.437; 95% CI, 0.948–31.190) have higher complication rates. Longer operation time was observed in patients with intraoperative bile leakage (p = 0.034; OR, 1.010; 95% CI, 1.001–1.020) and adhesions around gallbladder (p = 0.019; OR, 1.014; 95% CI 1.002–1.027). Single port laparoscopic cholecystectomies using four instruments were frequently performed in patients with gallbladder distention (p = 0.018; OR, 5.920; 95% CI, 1.351–25.928) and adhesions (p = 0.005; OR, 8.448; 95% CI, 1.888–37.802). Conclusion: Single port laparoscopic cholecystectomy is feasible and safe in selected patients. We recommend avoiding the patients with higher body mass index, acute cholecystitis, bile leakage, gallbladder distention or adhesions around gallbladder.

Background: To demonstrate the capability of laparoscopic and mini-incision in management of complicated gallstones Methods and materials: Three hundred and nine two patients with different complications of calculous cholecystitis were evaluated prospectively and managed using a designed algorithm. Only patients with acute cholangitis were included. All patients had cholecystectomy with or without other surgical interventions. They were divided into 3 groups based on the approach used. Demographic information, Demographic information, clinical characteristics, types of surgery, operation time, hospital stay, complications and conversion rate were analyzed. Results: Acute pyogenic cholangitis was revealed in 27 (6.8%) subjects from the 392 evaluated. It occurred in 26 patients (88.9%) with mechanical jaundice, 22 patients (81.5%) with choledocholythias, 7 patients (25.9%) with biliary pancreatitis, 5 patients (18.5%) with common bile duct strictures, 4 patients (14.8%) with pericholecystic fibrotic mass and 3 patients (11.1%) with empyema. Eleven patients (40.7%) were included in the LC group, 11 (40.7%) had MC while the remaining 5 (18.5%) patients underwent open conventional laparotomy. A single surgical procedure was performed in 3 patients (11.1%); 2 patients (7.4%) had MC and 1 patient (3.7%) had LC. The remaining 24 patients (88.9%) were exposed to two or more procedures. The average duration of surgery in LC was 72 ± 9 min and 55 ± 2 min in MC group. Hospital days were comparatively less in the LC group. There was no mortality in this study. Conclusion: The designed diagnostic–therapeutic algorithm has clearly demonstrated the possibility of one stage management of complicated forms of cholelithiasis using MC.

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COMPARISON OF PAIN AND INFLAMMATORY RESPONSE BETWEEN SINGLE PORT AND LAPAROSCOPIC CHOLECYSTECTOMY—A PROSPECTIVE STUDY Renato A Luna, MD, Daniel B Nogueira, MD, Pablo S Varella, MD, Eduardo O Rodrigues Neto, MD, Maria Julia R Norton, MD, Luciana Do Carmo B Ribeiro, MD, Agatha M Peixoto, MD, Isidro Bendet, MD, Rossano Fiorelli, MD MS PhD, James P Dolan, MD, Servidores do Estado do Rio de Janeiro Hospital and Oregon Health and Science University

THE ROLE OF THE PREOPERATIVE ENDOSCOPIC DRAINAGE IN THE MALIGNANT OBSTRUCTIVE JAUNDICE Constantinos S. Mammas, MD MSC PhD, Andreas Polydorou, Associate Professor, Nikolaos Arkadopoulos, Assistant Professor, Dimitrios Lappas, Assistant Professor, Vasileios Smyrniotis, Professor, National and Kapodistrian University of Athens, Aretaieion University Hospital, Surgical Experimental Unit ‘K.TOUNTAS’

Introduction: The aim of this study was to compare the perioperative and postoperative inflammatory response and severity of pain between single incision laparoscopic surgery (SILS) cholecystectomy and conventional laparoscopic cholecystectomy. Methods and Procedures: Two groups of 20 patients were prospectively randomized to either conventional laparoscopic cholecystectomy (LC) or SILS cholecystectomy. Serum interleukin-6 (IL-6) levels were assayed prior to surgery and then 4–6 h and 18–24 h after the procedure. Serum C-reactive protein (CRP) levels were also assayed at 18–24 h after surgery. Pain was measured at three points after surgery using the visual analogue scale (VAS) and the number of analgesic doses administered in the post-operative period was recorded during first 24 h after the procedure. Student’s t-test and the Mann–Whitney test were used when appropriate. P values \ 0,05 were considered significant. Results: The groups had equivalent BMI, age and comorbidity distribution. The peak of IL-6 levels occurred 4–6 h after surgery and the median level was 8.9 pg/ml in the SILS group and 12.8 pg/ml in LC group (p = 0.495). The median CRP level before discharge was 1.6 mg/dl in LC group and 1.9 mg/dl in SILS group (p = 0.383). In addition, no difference in pain intensity according VAS measures or analgesic use was found between the two groups (p = 0.723). The length of the surgical procedure was significantly longer in the SILS group (p \ 0.001). No intra operative complications occurred in any group. Conclusion: SILS does not significantly reduce systemic inflammatory response, post-operative pain or analgesic use when compared to laparoscopic cholecystectomy.

Background: Preoperative biliary drainage (PBD) in Malignant Obstructive Jaundice (MOJ) remains controversial. Aim: This project is a meta-analysis that compares the impact of PBD and Surgery (DS = S: pancreatectomy and/or hepatobiliary resection) in the formation of morbidity and mortality after PBD+S. Material and Methods: The impact of PBD on morbidity and mortality in MOJ treatment was assessed by: 1. Systematic referencing in the medical databases (HSR/ PUBMED) 2. Typing the key words ‘’obstructive jaundice, biliary drainage, liver surgery, complications, morbidity, mortality’’ under selection criteria: a) that articles were published between 2000-10, b) all or the majority of data were collected between 2000-10, c) MOJ patients undertook pancreatic, biliary and/or hepatic therapeutical resection, d) MOJ patients undertook endoscopic PBD preoperatively. Five final articles fulfilled the stated criteria consisting of 386 MOJ patients (114 underwent pancreaticoduodenectomy, 51 hepatobiliary resections, 102 PBD). Results: 1. There is no significant difference in the mortality rate between DS and PBD+S (OR = 0.39, 95% CI: (0.10–1.57), 2. Patients treated with PBD+S demonstrated no significant difference in the morbidity rate compared to those treated only with DS (OR = 3.75, 95%, CI:(0.76–18.51), 3. Comparison of the morbidity rate between PBD and S showed a significant difference favouring the second . (OR = 0.04, 95%, Cl: (0.00–0.37). Conclusion: There is no significant difference in the mortality rate between S and PBD+S. The morbidity rate of surgery for MOJ is significantly higher than that of PBD. Consequently, surgery seems to be the decisive factor that finally forms the morbidity rate after PBD+S. Thus, it is documented the need for stratified and prospective research protocols on the role of PBD in MOJ.

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REDUCED PORT CHOLECYSTECTOMY—A STEP FORWARD IN MINIMIZING ACCESS IN LAPAROSCOPIC SURGERY Asfar Ali, MS MRCS FNB FIAGES, Parveen Bhatia, MS FRCS FACS, Sudhir Kalhan, MS, Mukund Khetan, MS, Suviraj John, MS MRCS DNB FNB, Institute of Minimal Access, Metabolic & Bariatric Surgery, Sir Ganga Ram Hospital Background: Various innovations have been described in reducing access in laparoscopic surgery. Most of these are either complex or costly. We describe our technique of Reduced Port Surgery in an effort to overcome these problems. Methods: In this study, 210 patients underwent Reduced Port Laparoscopic Cholecystectomy. This involved placing the patient in modified lithotomy position with surgeon between the legs and camera assistant sitting on patient’s left. A 12 mm Optiview (Endopath XCELTM) and a 5 mm low-profile trocars were inserted through a 1.8 cm incision at umbilicus. A 2.3 mm Alligator Grasper (Stryker MiniLap, USA) passed through right hypochondrium allowed a biplanar manipulation of gall bladder. Hepato-cystic triangle was adequately dissected to obtain the critical view of safety before clipping the cystic duct and artery. Specimen was retrieved in endobag and 12 mm port closed. Results: All cases were completed laparoscopically. Additional 5 mm ports were placed in 4 patients. One out of the four procedures performed by Fellows in laparoscopic training was converted to conventional four-port laparoscopic cholecystectomy. Overall, mean operative time was 59.4 min. Post operative pain scores were similar to conventional laparoscopic cholecystectomy and most patients were discharged on the first postoperative day. The cosmetic results and patient satisfaction was significantly better with this technique. Conclusions: Reduced Port Surgery is a valid, useful and a more easily learnt technique to minimize access in laparoscopic surgery providing excellent cosmetic outcome without increasing the cost.

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CLINICAL OUTCOMES COMPARED BETWEEN LAPAROSCOPIC AND OPEN DISTAL PANCREATECTOMY: A RETROSPECTIVE COHORT STUDY Takanori Morikawa, MD, Takeshi Naitoh, MD FACS, Masayuki Kakyo, MD, Naoki Tanaka, MD, Kazuhiro Watanabe, MD, Tohru Onogawa, MD, Fuyuhiko Motoi, MD, Toshiki Rikiyama, MD, Yu Katayose, MD, Chikashi Shibata, MD, Shinichi Egawa, MD FACS, Michiaki Unno, MD, Tohoku University Hospital, Department of Surgery Objective: Laparoscopic surgery for pancreatic disease has gained increasing popularity and a laparoscopic distal pancreatectomy (LDP) has been used in many centers because of the simplicity of technical aspect. However, actual comparative data between open distal pancreatectomy (ODP) and LDP is limited. The aim of this study is to evaluate clinical outcomes of LDP and ODP for benign pancreatic disease. Patents and Methods: From January 2008 and June 2010, 35 consecutive patients who had presumptive diagnoses of benign pancreatic disease underwent distal pancreatectomy at the Department of Hepatobiliary Pancreatic Surgery in Tohoku University Hospital. Data including patient demographics, pancreatic pathology, intraoperative blood loss, operation time, postoperative complication, pancreatic fistula, postoperative hospitalization, and mortality were retrospectively analyzed. Results: There was no mortality in all cases. Eleven patients underwent LDP and no patient was converted to an open procedure. Patients in the LDP group did not differ from those in the ODP group in age (57.7 vs 57.2 years; p = 0.93), gender (90.9% vs 54.1% female; p = 0.055), tumor size (27.4 vs 48.0 mm; p = 0.068), body mass index (22.1 vs 21.5; p = 0.57), and operation time (208 vs 239 min; p = 0.57). However, LDP was associated with smaller amount of intraoperative blood loss (94 ml vs 421 ml; p \ 0.001). There were no differences between LDP and ODP groups in overall postoperative complications (63.6% vs 62.5%; p = 0.94), rate of pancreatic fistula (63.6% vs 37.5%; p = 0.14), rate of Grade BC pancreatic fistula (9.0% vs 16.6%; p = 0.55), and duration of postoperative hospital stay (15.3 vs 19.7 days; p = 0.23). Rate of complications excluding pancreatic fistula was significantly lower in LDP group than in ODP group (9.0% vs 45.8%; p = 0.03). Conclusions: LDP is feasible and safe, however, pancreatic fistula rates appear similar to ODP. Further study is necessary to reduce pancreatic fistula after LDP for the development of minimally invasive pancreatic surgery.

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PRIMARY NEUROENDOCRINE TUMOR OF THE LEFT HEPATIC DUCT—A CASE REPORT WITH REVIEW OF LITERATURE Jaydeep H Palep, MS, Ajay H Bhandarwar, MS, Aditya Mandke, MD, Grant Medical College & Sir J. J. Group of Hospitals, Mumbai, INDIA Primary Biliary Tract Neuroendocrine tumors (NET) are extremely rare tumors with only 59 cases reported in the literature till now. We describe a case of a Left Hepatic Duct NET and review the literature for this rare malignancy. To the best of our knowledge the present case is the first reported case of a Left Hepatic Duct NET in the literature. In spite of availability of advanced diagnostic tools like Computerized Tomography(CT) Scan and Endoscopic Retrograde Cholangio Pancreaticography (ERCP) a definitive diagnosis of these tumors is possible only after an accurate histopathologic diagnosis of operative specimens with immunohistochemistry and electron microscopy.

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A NEW INNOVATIVE TECHNIQUE TO PRESERVE GALLBLADDER FOR THE POLYPOID LESIONS OF THE GALLBLADDER Zhen-ling Ji, MD PhD, Department of General Surgery, Zhongda Hospital, Southeast Univerisity Medical College, Nanjing, China Abstract Aim: Gallbladder polyps are frequently discovered in recent year. If polyps are benign, and the gallbladder has a good function, it is not an absolute indication for cholecystectomy. For this reason percutaneous cholecystoscopic polypectomy of the gallbladder polyps were developed and applied. Methods: 100 patients with gallbladder polyps who were to undergo percutaneous endoscopic polypectomy of the gallbladder were studied. Under the epidural or general anesthesia, a mini laparotomy (2.5 to 3.0 cm) was performed subcostly in the right upper quadrant and the gallbladder fundus was then pulled out of the abdominal cavity with a grasping forceps. A rigid or flexible cholecystoscope was introduced into the gallbladder. The polyp stalk or basement mucosa of the polyps was coagulated by self-made microwave coagulator and then removed for histopathological evaluation. The preserved gallbladder was followed up to evaluate the efficacy of this innovative technique. Results: All procedures were uneventful with a mean operation time of 1 h. 87 patients were followed-up for a mean of 5.5-year (1 to 11 years). The results showed that 74 patients were symptom free and their gallbladder function was found to be well preserved without recurrence of polyps and occurrence of gallstones on ultrasonography. The other 13 had mild upper abdominal discomfort and 3 of them their gallbladder function was proved insufficient with gallstone formation, the gallbladders were removed laparoscopically. Conclusion: The procedure reported is a reliable, simple, applicable and minimally invasive technique to remove gallbladder polyps and to preserve gallbladder function for the patients who have benign gallbladder polyps. This technique need to be multicentral clinical trial.

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PROSPECTIVE COMPARISON BETWEEN SINGLE INCISION LAPAROSCOPIC CHOLECYSTECTOMY AND NEEDLESCOPIC CHOLECYSTECTOMY Koji Hattori, MDPhD, Kazunao Watanabe, MD, Hidemitsu Ogino, MD, Rai Shimoyama, MD, Jun Kawachi, MD, Hiromitsu Takeyama, MDPhD, Shonan Kamakura General Hospital Background: Since 2009 we had performed Single Incision Laparoscopic Cholecystectomy(SILC) in 110 cases. We recognize this procedure for patients to prefer to. But SILC have several problems for example difficult handling under laparoscope and high cost. Then we had constructed the new procedure(Needlescopic Cholecystectomy:NC) to use the B.J. needle (2.1 mm thin forceps) in order to operate by easy handling and in low cost. So, we compared SILC procedure with NC procedure in the prospective study. Methods: The study enrolled 30 patients who had biliary colic and documented gallstones or polyps and would like to undergo so-called single incision laparoscopic cholecystectomy from April 2011 to August 2011 in the day surgery center of our hospital. They randomly assigned them to one of two groups (SILC: n = 15 or NC: n = 15). Data measures were operative time, estimated blood loss, length of hospital stay, adverse events, and conversion to 4 port laparoscopic cholecystectomy or laparotomy. Additionally, pain, satisfaction and cosmetic scoring was performed by the patient over the 1 month follow-up. Operative procedure: SILC: Through a vertical 20 mm navel incision a SILS port was set up. A scope, a straight forceps and a bended forceps were inserted into the abdominal cavity through the navel port. And via right upper abdominal skin with a needle device the bottom of gallbladder was lifted up. NC: Through a vertical 15 mm navel incision a scope and a 5 mm straight forceps were inserted. And the B.J. needle forceps (2.1 mm) was inserted through the right upper abdominal wall. So under triangular formation we could operate. Via other right upper abdominal wall a needle device was inserted to lift the gallbladder. Results: No cases in the both groups had adverse events and were converted to other laparoscopic approaches or laparotomy. The two study groups did not differ in terms of patient demographics. The SILC group had a statistically significant longer operative time than the NC group (70 vs 58 min), but no difference in operative blood loss and hospital stay. And there was no difference in the pain score, satisfaction, the cosmetic score. The SILC group was higher cost to use siposable goods than NC group (128000 vs 76200 JPY). Conclusion/Perspective: Compared with SILC, NC is a feasible approach with comparable operative outcomes. NC is shorter operative time than SILC because of more natural handling and is lower cost. So NC offers a safe alternative to SILC.

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THE USEFULNESS OF LAPAROSCOPY-ASSISTED HEPATECTOMY FOR METASTATIC LIVER TUMOR AND HEPATOCELLULAR CARCINOMA Go Oshima, MD, Osamu Itano, MD, Yoshiaki Shoji, MD, Shingo Maeda, MD, Yasumasa Koyama, MD, Satoshi Aiko, MD, Yuko Kitagawa, Prof, Eiju General Hospital Background and Aims: In this decade, laparoscopy-assisted hepatectomy has been rapidly spreading because of its less-invasiveness. Because metastatic liver tumor and hepatocellular carcinoma (HCC) often need repeated operation, minimally-invasive laparoscopy-assisted hepatectomy have a number of advantages to keep the damage and the period for subsequent therapy at a minimum. Herein we present our experiences of laparoscopy-assisted hepatectomy for the treatment of metastatic liver tumor and HCC and evaluate its usefulness. Methods: We retrospectively analyzed the clinical outcomes of 41 patients who had undergone laparoscopy-assisted hepatic resection for metastatic liver tumor and HCC from January 2006 to March 2011 at Eiju General Hospital. We adopted laparoscopy-assisted hepatectomy appropriately, in consideration of adhesion due to surgery for primary disease or incision for simultaneous resection of primary disease. Results: Twenty three and 18 laparoscopy-assisted hepatectomy for treatment of metastatic liver tumor and HCC were carried out. Metastatic liver tumors included 15 metastases of colon cancer, 1 metastasis of ovarian carcinoma, 1 metastasis of gastrointestinal stromal tumor of jejunum, 1 metastasis of breast cancer. The patients were composed of 25 men and 16 women. The patients’ mean age was 67.7 ± 9.9 years. Tumor mean size was 3.7 cm (range: 1.0 cm to 10 cm). There were 21 partial hepatectomy, 3 lateral sectionectomy, 3 anterior sectionectomy, 3 posterior sectionectomy, 2 left hepatectomy and 9 right hepatectomy. The operation consisted of laparoscopic mobilization of the target liver lobe, followed by open liver resection through a 8–12 cm extraction site. The mean operative time was 390 ± 124 min and 3 patient had blood transfusion. There were no intraoperative complications and no conversion to conventional open method. Mean postoperative hospital stay was 16 ± 13 days. There were no critical postoperative complications which need intensive therapy and no postoperative mortality. Conclusion: Our experiences indicated that laparoscopy-assisted hepatectomy was a safe and useful option in the treatment of metastatic liver tumor and HCC. More accumulation of data may be needed for evaluation of long-term outcome.

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FIRST EXPERIENCES WITH SINGLE PORT CHOLECYSTECTOMIES D A Van Dam, MD, M A Cuesta, MD PhD, S S Gisbertz, MD PhD, W J Meijerink, MD PhD, VU University Medical Centre Amsterdam Introduction: Although the laparoscopic approach has been well accepted for symptomatic cholecystolithiasis, the introduction of NOTES has put the minimal invasive character of laparoscopic surgery to a new perspective. Transumbilical single port surgery could be a safe and scarless way to improve laparoscopic surgery without the pitfalls and challenges that NOTES still hold today. The authors report the first experiences with a single port device in combination with flexible angulated and fixed curved instruments for elective cholecystectomies in The Netherlands. Methods and Procedures: Transumbilical single port cholecystectomies were performed in 23 patients with symptomatic cholecystolithiasis or episodes of cholecystitis. The umbilicus was used as single access point for a single port device (Triport or Triport+, Olympus Hamburg Germany) and a combination of angulated (AutonomyTM LaparoAngleTM, CambridgeEndo Framingham, MA, USA), fixed curved instruments (HiQ LS line, Olympus, Hamburg Germany) and conventional laparoscopic instruments. For adequate triangulation a transabdominal suture was used in most cases for traction on the gallbladder. Results: Data was prospectively collected. No major intra- or post-operative complications occurred. 8 inadvertent gallbladder perforations were noted, without clinical consequences. Mean operating time was 78 min (range: 47–135), and Pearson’s coefficient showed a significant negative correlation of -0.491 (P = 0.033) between the decrease in operating times and growing experience. Two pregnant patients were safely operated at 15 and 16 weeks of gestation respectively, and remained intact and uneventful at time of follow-up. Mean admission time of surgical admission (excluding 3 days of gynaecologic admission) was 1.1 days (range: \12 h to 6 days), with 83% of patients admitted for 24 h or less. At inspection of the umbilical site, 2/23 patients had an wound infection at the umbilical incision site, both resolved completely with conservative treatment. One patient had a skin defect at the umbilical site without signs of infection. In the remaining 20/23 patients, the umbilical site was healed completely. Conclusions: We successfully and safely performed the first series of single port cholecystectomies with flexible angulated and fixed curved instruments with aid of a single port device. Transumbilical single port surgery seem a safe and applicable step toward ‘‘scarless’’ surgery without the risks associated with NOTES. In the first 3 patients of our series, we placed an additional transabdominal trocart for traction and triangulation of the galbladder, which was later replaced by transabdominal sutures. The Triport+ (Olympus, Hamburg Germany), which is provided with an additional working channel, prevented the need for a transcutane stitch, that was used during the earlier patients with the aid of the Triport. The fixed curved instruments effectively prevented cross-over of and clashing of instruments that frequently occurred with the flexible, angulated and conventional instruments. Randomized and substantial trials are required to validate the advantages that single port cholecystectomy holds over the conventional laparoscopic approach in order to implement this step forward in minimal invasive surgery.

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VISUALISATION OF THE COMMON BILE DUCT AND CYSTIC DUCT WITH A NOVEL NEAR-INFRA RED CAMERA AND INDOCYANINE GREEN DURING LAPAROSCOPIC CHOLECYSTECTOMY D A Van Dam, MD, M Ankersmit, M H Van Der Pas, MD, W J Meijerink, MD PhD, VU University Medical Centre Amsterdam Introduction: We present a novel technology to visualize the common bile duct (CBD) and cystic duct (CD) in patients. Injuries to the CBD are rare but serious complications with need for re-intervention, risk of permanent disability and prolonged hospital stay, and occur most often in presence of unclear or anatomic variations. An intraoperative cholangiogram requires additional operating time, a X-ray machine with trained personnel, and the bile ducts need to be perforated or cannulated to administer the contrast fluid to the biliary structures. Indocyanine Green (ICG) is a well used green contrast fluid, and with the recent introduction of a near-infrared (NIR) camera (Olympus, Hamburg Germany) ICG can also be used for its fluorescent qualities. After intravenous administration ICG is exclusively cleared by the liver and secreted into the bile, where it can be visualised with the near-infrared camera. Aim: A new method of early visualisation of the CBD and CD during laparoscopic cholecystectomy and prevention of injuries to biliary structures. Methods and Procedures: Patients eligible for elective laparoscopic cholecystectomy diagnosed with uncomplicated cholecystolithasis are included in the study after oral and written consent. A single intravenous injection of ICG is administered after induction of general anaesthesia, before the start of surgery. During standard laparoscopic cholecystectomy, the specially build NIR camera to is used to visualise the biliary structures. Time of administration of the ICG and assessment of visible structures with both NIR and conventional camera is noted, and procedures are recorded . Post-operatively patients are admitted to the day-care centre and are discharged at the day of surgery conform standard surgical procedures. In total 30 patients are required to obtain 90% power for significant results in regard of early visualisation of the CBD and CD with the NIR camera compared to conventional camera imaging. The power calculation was based on the pilot series of 7 patients. Premilinary Results: In the first 19 patients, no per- or postoperative complications due to the administration of ICG or the laparoscopic cholecystectomy occurred. ICG in the liver, CBD and CD could be detected as early as 20-30 min after intravenous administration. In 18/19 patients, the CBD could be visualised with the NIR before identification of the CBD on conventional camera was possible. Early identification with ICG-NIR of the CD was successful in 6/19 patients. 4 anatomic variations were detected during laparoscopic cholecystectomy, and in 2 patients the use of ICGNIR could prevent conversion to open surgery when Critical View of Safety could not be confirmed. In fall 2011 the inclusion of patients will be finished and final results with sufficient power will be presented at the SAGES meeting, with video material of this new technique.

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REVISITING VASCULAR PATENCY FOLLOWING SPLEENPRESERVING LAPAROSCOPIC DISTAL PANCREATECTOMY WITH CONSERVATION OF SPLENIC VESSELS Ho Kyoung Hwang, MD, Chang Moo Kang, MD, Woo Jung Lee, Yonsei University College of Medicine Introduction: We evaluated vascular patency and potential changes in preserved spleens after laparoscopic spleenpreserving distal pancreatectomy (SPDP) with conservation of both splenic vessels. Methods and Procedures: We retrospectively analyzed the patency of conserved splenic vessels in patients who underwent laparoscopic or robotic splenic vessel-conserving SPDP from January 2006 to August 2010. The patency of the conserved splenic vessels was evaluated by abdominal computed tomography and classified into three grades according to the degree of severity. Results: Among 30 patients with splenic vessel-conserving laparoscopic SPDP, 29 patients with complete follow-up data were included in this study. During the follow-up period (median: 13.2 months), Grade 1 and 2 splenic arterial obliteration was observed in one patient each. A total of five patients (17.2%) showed grade 1 or 2 obliteration in conserved splenic veins. Most patients (82.8%) had patent conserved splenic vein. Four patients (13.8%) eventually developed collateral venous vessels around gastric fundus and reserved spleen, but no spleen infarction was found, and none presented clinical relevant symptoms, such as variceal bleeding. There was no statistical difference in vascular patency between the laparoscopic and robotic groups (p [ 0.05). Conclusion: Most patients showed intact vascular patency in conserved splenic vessels and no secondary changes in the preserved spleen after laparoscopic splenic vessel-conserving SPDP.

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RE-DO LAPAROSCOPIC LONGITUDINAL PANCREATICOJEJUNOSTOMY IN A PATIENT WITH CHRONIC PANCREATITIS AND FAILED OPEN PEUSTOW’S PROCEDURE Srikanth Gadiyaram, MS MCh, Neel Shetty, DNB, Sunil Alur, DNB, Ganesh Shenoy, MS, Institute of Gastroenterology, BGS Global Hospitals, Bangalore We here present a 20 years old female patient who had undergone open pancreatico-jejunostomy for chronic calculous pancreatitis 2 years ago. Patient continued to have recurrent episodes of upper abdominal pain radiating to back and weight loss after the surgery. She doesn’t have any history suggestive of pancreatic exocrine/ endocrine insufficiency. On evaluation, CECT-abdomen showed atrophic pancreas with stones in head, body and tail region of pancreas; largest measuring 13 mm. calculi were seen clustered in the head and tail region. There was no peripancreatic collection or mass lesion. After basic haematological and biochemistry work-up she underwent laparoscopic lateral pancreatico-jejunostomy. Pnueumoperitoneum was created by Hassan’s open method. A four-port technique was used. After an initial diagnostic laparoscopy and adhesiolysis, lesser sac was entered and a wide exposure of lesser sac was achieved by aided gastric traction sutures. The Roux-loop of jejunum created during the previous surgery was identified and defined. Pancreatic duct was widely opened along its entire extent. All stones were cleared. Pancreatic duct was anastomosed to subjacent lying jejuna Roux-limb with interrupted sutures of no. 2-0 monocryl sutures. Abdominal drain was placed and anchored. Umbilical port was closed with no. 1-0 vicryl suture and skin of ports site closed with no. 3-0 monocryl, subcuticular sutures. She was allowed oral clear liquids on post-op day 1 and liquid diet on post-op day 2. She made an uneventful postoperative recovery. At three month follow-up she had complete relief of abdominal pain and weight gain of 8 kg.

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LAPAROSCOPIC LATERAL PANCREATICOJEJUNOSTOMY IN CHRONIC PANCREATITIS Srikanth Gadiyaram, MCh, Neel Shetty, DNB, Ganesh Shenoy, MS, Sunil Alur, DNB, Institute of Gastroenterology, BGS Global Hospitals, Bangalore Background: Laparoscopic lateral pancreatico-jejunostomy has been reported by few groups previously. We herein present our experience with laparoscopic management of chronic pancreatitis (CP). Material and method: Retrospective review of patients who underwent laparoscopic management for chronic pancreatitis during April 2011 to June 2011 were studied from a prospective database The clinical profile, imaging characteristics, operative details and postoperative outcomes were studied. Results: Four patients (3 female and 1 male), age ranging from 20 to 46 yrs presented to the Department of Surgical Gastroenterology. All four patients presented with recurrent episodes of intermittent upper abdominal pain for 2–4 years duration. All 4 patients underwent basic biochemical evaluation and contrast-enhanced CT scan of abdomen. 3 patients had chronic calculous pancreatitis with duct dilatation of 15 mm, and 1 had alcoholic chronic pancreatitis with large pseudocyst. Among the 3 chronic calculous pancreatitis patients 1 had already undergone an open pancreaticojejunostomy previously. Among the 4 CP patients, 3 chronic calculous pancreatitis patients underwent laparoscopic lateral pancreaticojejunostomy and 1 alcoholic pancreatitis patient underwent laparoscopic cysto-jejunostomy. The median operating time in these patients was 280 min (range 250–360 min). The diameter of pancreatic duct in chronic calculous pancreatitis was 15 mm with stone load in head, body, tail and uncinate regions of pancreas. The average stay in the hospital was 6.6 days. A four- port technique was used, all surgeries were accomplished laparoscopically without any conversion to open surgery. Post-operatively all 4 patients faired well. There were 2 morbidities 1 had a low pancreatic fistula from the drain site which was managed conservatively and another had DVT which was managed appropriately by anticoagulation. There were no mortality. On follow-up all 4 patients had complete pain relief and all of them had weight gain. Conclusion: Laparoscopic lateral pancreatico-jejunostomy is technically challenging but is feasible in CP patients with atrophic gland, large duct and no stone load in uncinate process. We demonstrated the feasibility of a re-do laparoscopic lateral pancreatico-jejunostomy in a carefully selected patient with previous failed open LPJ.

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LAPAROSCOPIC DISTAL PANCREATECTOMY WITH SPLENECTOMY FOR SEROUS CYSTIC TUMOR IN PROXIMAL BODY OF PANCREAS Srikanth Gadiyaram, MCh, Neel Shetty, DNB, Sunil Alur, DNB, Jayanth Reddy, MCh, Institute of Gastroenterology, BGS Global Hospitals, Bangalore Laparoscopic distal pancreatic resection is becoming the preferred approach in patients with cystic tumors in the body and tail of pancreas. We herein present an operative video of a patient with a serous cystic neoplasm in the proximal body of pancreas who underwent distal pancreato-splenectomy. Case report: 69 year old male patient presented with pain in the mid-epigastrium of 3 months duration. His laboratory tests including Ca 19-9 were within normal limits. Multi detector computerized tomography of the abdomen revealed a cystic neoplasm in the proximal body of pancreas. The posterior surface of the tumor was seen abutting the splenoportal confluence with the medial end reaching the neck of pancreas. Patient received prophylactic vaccination against pneumococccus, meningococcus and hemophilus influenza two weeks prior to surgery. A laparoscopic distal pancreatectomy with splenectomy was performed utilizing 5 ports. Operative procedure was performed in seven steps. Step 1: Lesser sac was entered by dividing gastrocolic omentum. Step 2: Defining inferior border of pancreas. Step 3: Dissection of retropancreatic tunnel in an avascular plane anterior to the portal vein behind the neck of pancreas . Step 4: Endo GIA staple transaction of neck of pancreas. Step 5: Clipping and division of splenic vessels. Step 6: Dissection of distal pancreas and spleen in an avascular plane from retroperitoneum . Step 7: Bagging the specimen and retrieval by enlarging the umbilical port site. Operative video is presented.

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LAPAROSCOPIC RESECTION OF GIANT LIVER HEMANGIOMA USING LAPAROSCOPIC HABIB PROBE FOR PARENCHYMAL TRANSECTION Srikanth Gadiyaram, MCh, Neel Shetty, DNB, Ganesh Shenoy, MS, Sunil Alur, DNB, Jagannath H, MS, Institute of Gastroenterology, BGS Global Hospitals, Bangalore Background: Experience with laparoscopic liver resections is limited. Laparoscopic resection of a variety of liver lesions has been reported and is considered appropriate for lesions in the left lateral segment and inferior segments of right lobe. Herein, we report a 37-year-old male patient who underwent a laparoscopic resection of giant liver hemangioma with the use of laparoscopic 4X Habib probe. Case Report: 37-year-old male patient presented with abdominal pain of 3 months duration. MDCT imaging revealed a giant hemangioma arising from the segments, 5 and 6 of liver with feeding artery from right anterior hepatic artery. He underwent a laparoscopic resection of the giant hemangioma. Surgery was performed in the following five steps. Step 1—Calot’s dissection. Step 2—Dissection of right hepatic artery(RHA) and occlusion of RHA with Bulldog clamp. Step 3—Developing enucleation plane in the medial aspect of the hemangioma. Step 4—Liver parenchymal transection in a transverse plane cranial to the hemangioma with laparoscopic Habib probe (to minimize the transection surface). Step 5—Hemostasis and Specimen retrieval. Operative video demonstrating these steps is presented.

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ACUTE AND CHRONIC CALCULOSE CHOLECYSTITIS AS ONE DAY SURGERY TREATMENT Vladimir Zivanovic, MsC MD, Goran Vasic, MD, Radoslav Perunovic, PhD MD, Predrag Stevanovic, PhD MD, Radisav Scepanovic, PhD MD KBC, Dr D. Misovic University Hospital Laparoscopic cholecystectomie as one day procedure, we start in December 2009 and we perform 1805 operations until the end of September 2011. Out of 1805 cholecystectomies 172 was performed for acute inflamation. All patient was released next day after control US examination and blood sample for bilirubin, so they spent less than 24 h in hospital bed. Oldest patient was 81 year old. At the department of surgery ‘‘Dr D. Misˇovic’’ hospital in Belgrade, After a fire in our surgical department with 120 bads we have to close department. After a month we rearrange in near by bilding with urology department 6 bads for laparoscopic one day surgery. We have to rearrange ambulatory preparing of patients sutiable for one day surgery. We do all necessary preparation including prehospital bowel preparation and DVT prophylaxis, so patient came to hospital only 1 h before the operation. Cholecystectomy performed as emergency procedures was organised through emergency department. After examination of the patient with US and neccesary laboratory test with decision for imediate surgery and anesteziology consultation for fitting the one day surgery, patient was taken to the OR and performed emergency surgery for acute cholecystitis. After thorough rinsing of abdominal cavity et the end of procedure and one protective shot of antibiotic other outcome is same as in elective surgery. We use drainage tube in one case and their removal was next day before discharge from hospital. Using ultrasound hook and water dissection reveal itself as an adequate tool. In same manner ultrasound dissection shorten operation time because we can dissect tissue without losing time on changing instrument. In conclusion we can advocate one day surgery in patients with acute and chronic cholecystitis.

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SAFETY OF LAPAROSCOPIC CHOLECYSTECTOMY WITH SELECTIVE USE OF INTRAOPERATIVE CHOLANGIOGRAPHY IN MANAGEMENT OF GALLBLADDER DISEASE Aileen Murphy, MA DO, Satbir Dhillon, BS, Maureen Martin, MD FACS FRCSC, Department of Surgery, Kern Medical Center, Bakersfield, Ca Introduction: Our center has adopted a policy of selective intraoperative cholangiography (SIOC) during laparoscopic cholecystectomy (LC). This study aimed to evaluate the incidence and management of choledocholithiasis, extrahepatic bile duct injuries, and other findings potentially affected by intraoperative cholangiogram (IOC). Methods and Procedures: Medical records were reviewed of patients undergoing cholecystectomy at our institution from July 2005 to July 2011. Dissection with the goal to achieve the critical view of safety was the standard operative technique for our patients. Results: Nine hundred and fifty (950) patients underwent LC. Eleven (11) patients (1.2%) required conversion to open cholecystectomy. One (1) patient died as a result of an unrecognized duodenal thermal injury. Eight hundred and seventy five (875) patients received SIOC (92.1%), while sixty-nine (69) patients received IOC (7.3%) and six (6) patients had attempted IOC (0.6%). The rate of major bile duct injury was 1/875 (0.11%) in the SIOC group, and 1/69 (1.4%) in the IOC group, p = 0.14. Perioperative ERCP was performed in 95 patients. Findings included 13 patients with retained stones, all 13 in the SIOC group (1.5%); 10 patients with cystic duct leak, 9 SIOC (1%), 1 IOC (1.4%); and 72 patients with normal ductal findings. Retained stones passed incidentally or were treated with endoscopic sphincterotomy when indicated. Conclusions: SIOC during LC is a safe practice when the critical view of safety technique is utilized and in the absence of laboratory or clinical evidence of common bile duct abnormalities. Symptomatic retained common bile duct stones will be few, and bile duct injuries rare when IOC is performed for well established indications.

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LAPAROSCOPIC RESECTION OF BILIARY MALIGNANCIES Osamu Itano, MD PhD, Go Oshima, MD, Minoru Tanabe, MD PhD, Shigeyuki Kawachi, MD PhD, Masahiro Shinoda, MD PhD, Minoru Kitagou, MD PhD, Ryo Nishiyama, MD, Hiroto Fujisaki, MD, Kysho Mihara, MD, Tomonori Fujimura, MD, Yoshie Kadota, MD, Shigenori Ei, MD, Yusuke Katsuki, MD, Masanori Odaira, MD, Masayuki Tanaka, MD, Satoshi Aikou, MD PhD, Yuko Kitagawa, MD PhD, Department of Surgery, Keio University, School of Medicine, Tokyo, Japan; and Department of Surgery, Eiju General Hospital, Tokyo, Japan Purpose: The purpose of this study was to evaluate short term results of the laparoscopic resection of biliary malignancies Methods and Procedures: From May 2007 to September 2011, there were 20 laparoscopic surgeries for biliary malignancies carried out at our hospital. Laparoscopic-assisted pylorus preserving pancreaticoduodenectomy was performed for one ampulla vater carcinoma and four common bile duct carcinomas. Two laparoscopic-assisted extended left hemihepatectomy and 3 laparoscopic-assisted extended right hemihepatectomies were performed for 5 hilar cholangiocarcinomas. Seven laparoscopic extended cholecystectomy (one with Roux-en-Y choledochojejunostomy), 2 laparoscopic-assisted liver S4aS5 subsegmentectomies, and 1 laparoscopic-assisted left hemihepatectomy were performed for 10 gallbladder cancers. Laparoscopic-assisted procedures consisted of laparoscopic mobilization of the target organs, followed by open resection and reconstruction through an 8-12 cm extraction site. Results: For laparoscopic-assisted pylorus preserving pancreaticoduodenectomy, the mean operative time was 693 ± 77 min. The mean blood loss was 1157 ± 477 ml. There were no intraoperative complications. Postoperative complications developed in 2 patient (pancreatic fistula), which resolved with conservative management. The mean postoperative hospital stay was 19.8 ± 9.4 days. For hilar cholangiocarcinoma, the mean operative time was 701 ± 105 min. The mean blood loss was 1132 ± 617 ml. There were no intraoperative complications. One patient died of postoperative liver dysfunction. For gallbladder cancers, the mean operative time was 367 ± 173 min and the mean blood loss was 270 ± 338 ml. There were no intraoperative or postoperative complications. The mean postoperative hospital stay was 6.7 ± 1.6 days. Pathological examination showed R0 resections in all cases. Recurrence was detected in 2 cases (liver metastasis in one hilar cholangiocarcinoma case and lymph node metastasis in one gallbladder carcinoma case), but no port site metastasis or peritoneal dissemination was observed. Conclusion: Laparoscopic surgery for biliary tract cancer is feasible and safe, but more data may be needed for evaluation of long-term outcome.

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IS IT SUITABLE LAPROSCOPIC TRANSDUODENAL AMPULLECTOMY FOR THE TREATMENT OF LARGE AMPULLARY TUMORS WITH HIGH-GRADE DYSPLASIA? Ki Byung Song, MD, Song Cheol Kim, PhD, Duck Jong Han, PhD, Jae Berm Park, MD, Young Hoon Kim, MD, Young Soo Jung, MD, Depetment of surgery, Ulsan University College of Medicine and Asan Medical Center Aim: Transduodenal ampullectomy (TDA) can be performed for periampullary tumors. However, the laparoscopic approach has rarely been attempted. This study evaluated the safety and efficacy of laparoscopic TDA (L-TDA). Material and Methods: From April 2009 to March 2011, 4 patietns with diagnosis of ampullary tumors, were unable to treated using endoscopic resection because of large size and evidence of malignancy based on endoscopic appearance, underwent L-TDA. We retrospectively reviewed the demographics, pathologic findings, and outcomes. Result: Four patients underwent L-TDA in our center. The mean age of the patients was 51.8 ± 18.8 year old. There were 2 men and 2 women. Final pathology showed 2 tubular adenoma with high-grade dysplasia, 2 tubulovillous adenoma including 1 with high-grade dysplasia. The mean size of tumors was 3.8 ± 1.8 cm. The resection margin of all tumors was negative. Mean operative time was 197 ± 47.9 min and mean postoperative hospital stay was 12.5 ± 2.4 days. There were no recurrence and complications during 14.8 ± 9.9 months, mean follow up time. No.

Sex

Age (years)

OP time (min)

HS (days)

Diagnosis

Tumor (cm)

1

M

51

214

14

TA(HGD)

2

M

50

252

11

TA(HGD)

3

F

30

139

15

4

F

76

183

10

size

Resection margin

F/U time (months)

1.2

Negative

29.1

5

Negative

12.3

TVA

5

Negative

11.7

TVA(HGD)

4

Negative

6.0

Conclusion: L-TDA was feasible and safe for the treatment of ampullary tumors, especillay unsuitable for endoscopic resection. We must consider L-TDA as treatment option in ampullary tumors.

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SCLEROSING ANGIOMATOID NODULAR TRANSFORMATION OF THE SPLEEN DIAGNOSED AFTER LAPAROSCOPIC SPLENECTOMY Young Hoe Hur, MD, Ho Hyun Kim, MD, Hee Joon Kim, MD, Byung Gwan Choi, MD, Eun Kyu Park, MD, Yang Seok Koh, PhD, Jung Chul Kim, PhD, Chol Kyoon Cho, PhD, Hyun Jong Kim, PhD, Department of Surgery, Chonnam National University Medical School Introduction: Vascular tumor or tumor like lesion of the spleen are rare and mainly incidentally on radiologic studies. Among them, sclerosing angiomatoid nodular transformation (SANT) of the spleen is a benign vascular splenic mass, which has been reported in less than 100 cases since it was first described by Martel et al. in 2004. Specifically, SANT is a vascular lesion of the red pulp of the spleen. Here, we report on a case of SANT of the spleen, which was diagnosed after laparoscopic splenectomy. Methods: A 51-year-old woman visited our hospital complaining of abdominal pain. Abdominal computed tomography revealed a 5.1 9 4.6 cm well-defined heterogenously enhanced nodular mass in the spleen. The laboratory data revealed that liver and renal function were within normal limits, and tumor markers including CEA and CA 19-9 were normal. The initial impression was benign lesion such as hamartoma or hemangioma. Laparoscopic splenectomy was performed. Result: The macroscopic examination of the specimen showed a 4 9 4-cm tumor with red-brown multi-nodular surface. Microscopically, the tumor was composed of multiple vascular structures separated by fibrous connective tissue. An immunohistochemical examination showed positive staining for CD31, CD34, factor VIII (\1%), and IgG4 (\1%). Based on these results, the tumor was diagnosed as SANT of the spleen. The patient had an uneventful postoperative course. Conclusion: Although the etiology and pathogenesis of SANT is still known, some report about the connection SANT to IgG4-related sclerosing disease. In our case, immunohistochemical staining for IgG4 was positive. Thus, our data support the possibility that SANT is connected to IgG4-related sclerosing disease. But further studies based on large populations are necessary to clarify its pathogenesis. Here, we present a case of SANT of the spleen treated with surgical resection.

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REDUCED PORT NEEDLESCOPIC CHOLECYSTECTOMY Selman Uranues, MD FACS, Gordana Tomasch, MD, Department of Surgery, Medical University of Graz, Graz, Austria Background: Thanks to its potentially better cosmetic results and reduced pain, single port surgery (SILS) has been increasingly advocated for various abdominal procedures, among them removal of the gallbladder. Due to the intraoperative limitations of SILS and the potentially increased rate of subsequent incisional umbilical hernia, needlescopic cholecystectomy (NC) with its reduced port retains its importance. The aim of this study was to investigate the results of minilaparoscopy in terms of safety and patients’ satisfaction. Methods: This clinical study was performed between January 2006 and December 2010 in a consecutive series of 650 patients with symptomatic gallbladder diseases (GB). All data were collected prospectively. The patients’ satisfaction and their opinion on the cosmetic result were obtained with a questionnaire (GIQLI GB). The patients were divided into 3 groups: open access (OA), laparoscopic (LC) and NC. Intraoperative cholangiography was always performed. Results: The GIQLI GB was sent 3 months postoperatively to all patients. The study included the 305 of 650 patients who replied and completed the questionnaire. The groups comprised 61 OA, 130 LC and 84 NC patients. There were 3 cases of conversion from needlescopic to conventional LC, and 3 of conversion to open technique. There were no intraoperative complications. No drains were used and patients were discharged between the second and fourth postoperative day except for those with conversion to LC, who were discharged on the fifth day. The health insurance system does not foresee an earlier discharge. All patients with NC scored highly satisfactory; LC scores satisfactory/ highly satisfactory, and open access satisfactory/ not satisfactory. Conclusion: Reduced port needlescopic cholecystectomy has the same advantages as SILS but because the technique adheres to the basic principles of laparoscopic surgery, it is safer and easier to perform.

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MINIMALLY INVASIVE (LAPAROSCOPIC + ROBOTIC) SPLEEN-PRESERVING SUBTOTAL LEFT-SIDED PANCREATECTOMY Lim Jin Hong, MD, Whang Ho Kyung, MD, Kim Sung Hoon, MD, Choi Sung Hoon, MD, Lee Woo Jung, MD, Kang Chang Moo, MD, Division of hepatobiliary and pancreas, department of surgery, Yonsei University College of Medicine Purpose: Laparoscopic distal pancreatectomy (LDP) has been regarded as safe and effective treatment option in benign and borderline malignant tumors in left-sided pancreas. With the emphasizing role of spleen increased, spleenpreserving LDP (Sp-LDP) has been widely applied. However, Sp-LDP with division of pancreatic neck (Sp-subtotal LDP) is rarely reported. Methods: From January 2006 to June 2011, consecutive 43 patients underwent Sp-LDP for pancreatic benign and borderline malignant tumors. Patients were divided into two groups; Sp- LDP (N = 27) vs. Sp-subtotal LDP (N = 16). Patients’ characteristics and perioperative surgical outcomes were compared between two groups. Results: Splenic vessel-conserving Sp-subtotal LDP was performed in 10 patients and splenic vessels-sacrificing Spsubtotal LDP in 6 patients. Patients’ characteristics (age, sex, BMI, disease type and comorbidities), intraoperative bleeding, lengths of hospital stay, post-op complication did not differ between two group (p [ 0.05). However, length of resected pancreas was longer in Sp-subtotal LDP group (Sp-LDP:Sp-subtotal LDP = 7.74 cm:10.70 cm, p \ 0.01), and Sp-LDP group required more operative time than Sp-subtotal LDP group (Sp-LDP:Sp-subtotal LDP = 361.96 min:273.31 min, p = 0.038), but time difference seemed not clinical significant. Conclusions: Sp-subtotal LDP is also feasible and safe for benign and borderline malignant disease at the pancreas neck lesion. Both splenic vessels also can be safely resected for spleen preservation in selected cases.

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A CASE OF GASTRIC HETEROTOPIC PANCREAS Kenneth Juenger, MD, Leandra H Burke, BS, Elizabeth A Steensma, MD, Christian W Ertl, MD FACS FACCWS, Michigan State University / Kalamazoo Center for Medical Studies Introduction: First described by Schultz in 1729, the condition of heterotopic pancreas is an infrequently occurring anomaly1. Although typically asymptomatic, this condition can present as a submucosal heterotopic mass or as symptoms of chronic pancreatitis and abdominal pain. Currently, resection is indicated when symptoms are persistent and underlying malignant process cannot be ruled out2. Here we describe the surgical management of heterotopic pancreas in a 48 year-old man. Case Presentation: A 48-year-old man with a past medical history significant for alcohol abuse, anemia, and chronic abdominal pain, presented to our institution with worsening abdominal symptoms. Laboratory studies showed a mildly elevated lipase and a CT scan demonstrated pancreatitis with a mass-like lesion in the stomach. An EGD was performed which confirmed the presence of a submucosal mass. Subsequent mucosal biopsies were unremarkable. Given the inability to rule out an underlying neoplasm, the patient underwent a partial gastrectomy with Billroth I reconstruction. At one month post operation, the patient was doing well and was not experiencing significant pain. A segment of the stomach and attached perigastric adipose tissue was obtained intraoperatively for pathology evaluation. The stomach fragment contained a polyploid mass measuring 3 cm in diameter, which was gray-white in color and had a soft texture. A frozen section of this sample revealed heterotopic rests and mucosal hyperplasia. Final pathology demonstrated polyploid pancreatic heterotopia with acute and chronic inflammation and abscess formation. Fortunately, no evidence of malignancy was present. Discussion: Heterotopic pancreatic tissue is frequently found throughout the upper gastrointestinal tract with a propensity to be located within the stomach, duodenum and jejunum3. Most cases are discovered incidentally, as heterotopic pancreatic tissue is typically asymptomatic2. Although heterotopic pancreas can present at any age, it is usually discovered in the fifth to sixth decade, and is three times more likely to occur in men than women4,5. Within the stomach, pancreatic rests may present with chronic abdominal pain, gastrointestinal bleeding, abscesses and chronic pancreatitis6. Our patient presented with all of these symptoms, and the final pathology confirmed that there were acute and chronic forms in the gastric rest, indicating that he may have had prior episodes of ‘‘gastric pancreatitis’’. Since the patient was symptomatic, and an intraoperative pathological consultation could not rule out malignancy, the patient elected to undergo surgery to remove the polyp.

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SIXTY-TWO CONSECUTIVE LAPAROSCOPIC MINOR LIVER RESECTIONS OF THE POSTERO-SUPERIOR SEGMENTS. A SHORT-TERM OUTCOME ANALYSIS Bruto Randone, MD PhD, Renato Costi, MD PhD, Oriana Ciacio, MD, Vishal Gupta, MD, Brice Gayet, MD, De´partement de Pathologie Digestive, Institut Mutualiste Montsouris, Universite´ Paris Descartes, Paris, France; Dipartimento di Scienze Chirurgiche, Universita` degli Studi di Parma, Parma, Italia Introduction: Despite the recent diffusion of laparoscopic liver minor resections (‘‘wedge’’ and segmentectomy), their feasibility in the case of lesions located in the postero-superior liver segments (I, IVa, VII, VIII) is still under debate. In fact, recent articles suggest that major resections should be preferable in those cases. Methods and Procedures: In order to assess feasibility and short-term outcome of laparoscopic elective minor hepatic resections of postero-superior segments, a retrospective analysis of a prospectively maintained database including all consecutive patients undergoing such procedures until 2008 was performed. Results: From January 1996 to December 2008, 62 laparoscopic elective minor liver resections of lesions located in the postero-superior segments were performed in 53 patients (27:26 male:female ratio). Nine-teen patients underwent preoperative chemiotherapy (17 colorectal cancer metastases, 2 gastric GISTs). Mean age was 62 ± 13 years (range 23-89). The series included 14 resections performed in liver segment I, 13 in segment IVa, 19 in segment VII, 16 in segment VIII. Indications for surgical resection were: metastases (41 patients), benign tumors (8) and hepato-cellular carcinoma (4). Mean tumor size and surgical margin were 37.6 ± 11.1 mm and 4.4 ± 1.2 mm, respectively. Mean operative time was 187 min (range 60-420). Mean blood loss was 370 ml (range 10-1800). Intraoperative transfusion was needed in 4 patients (7.5%). Seven procedures (13%) were converted to an open access; reason for conversion was bleeding (4 patients), adhesions (1), difficulty in tumor localisation (1), preoperatively misdiagnosed synchronous metastases (1). Mean intensive care unit stay and hospital stay were 0.5 and 11 days, respectively. Perioperative morbidity rate was 26% (14 patients). Four patients (7.5%) required further surgery owing to perioperative complications, including bleeding (2 patients), intestinal obstruction (1), biliary leakage (1). There was no perioperative mortality. Conclusions: Elective laparoscopic minor resections of tumors located in the postero-superior segments of the liver are safe, with no perioperative mortality, a 26% morbidity rate and a 7.5% re-operation rate. Moreover, although they may sporadically be time-consuming, they seem technically feasible, as conversion rate is 13%. Our results discourage performing systematic major liver resections for lesions located in postero-superior liver segments, whenever it is not deemed necessary for oncological reasons.

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ANOTHER CAUSE OF ABSCESS: DROPPED GALLSTONES Vinayak Sreenivas, MD, Vinay Singhal, MD, Amir R Azar, MD, Daniel Farkas, MD, Bronx Lebanon Medical Centre Introduction: Approximately one third of laparoscopic cholecystectomies are reported to have dropped or lost gallstones during dissection. Complications like infection, inflammation, fibrosis, adhesion, cutaneous sinus formation, and abscesses; though uncommon, can be dangerous. Surgeons and radiologists should be aware of these complications and the related morbidity. We present a case of intra-peritoneal abscess with subcutaneous extension caused by dropped stones during laparoscopic cholecystectomy. Case Report: A 75 year old lady who had undergone laparoscopic cholecystectomy ten months prior presented to the emergency room with fever, nausea, vomiting and abdominal mass. She had a similar abscess drained percutaneously 6 months after surgery. She was diagnosed following CT scan of the abdomen with intraperitoneal abscess with subcutaneous extension. Two radio-opaque foreign bodies, possibly dropped stones, were observed in the right subdiaphragmatic recess. Patient underwent open drainage of the abscess with retrieval of stones. Conclusion: There are several reports of spilled gallstones causing abscess and a few causing abdominal wall abscess including port site abscess after ‘dropped’ gallstones. Open drainage and retrieval of stones instead of just draining the abscess percutaneously avoids recurrence and attendant morbidity. Also, considerable care should be taken to retrieve spilled gallstones and avoid gallbladder perforation.

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SUCCESSFUL LAPAROSCOPIC COMMON BILE DUCT EXPLORATION Christopher W Salzmann, MD, Morris E Franklin, MD FACS, Karla Russek, MD, Texas Endosurgery Institute * The routine use of intraoperative cholangiogram (IOC) performed by some surgeons at the time of laparoscopic cholecystectomy, also leads to identification of patients with totally unsuspected choledocholithiasis. *Sequential Technique -Intraoperative cholangiogram: Road map of the biliary system, ID of biliary stones -Anterior dissection of common bile duct: Stay sutures, traction on cystic duct -Choledochotomy -Flushing the duct: This maneuver will frequently suffice to clear stones -Choledochoscopy: Direct visualization of the biliary system and stones, stone retrieval with basket, trans-scope cholangiogram -Placement of T-tube: T-tube tailoring, pre-tied sutures, suture technique -T-tube cholangiogram -Completion of cholecystectomy -Extraction of specimen and stones -Drain placement *Conclusions -Laparoscopic CBDE is a safe technique that allows the surgeon a successful exploration of the common bile duct and clearance of stones. -Systematic, stepwise technique is advised. -Two-handed laparoscopic suturing techniques are essential

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TRANSUMBILICAL SINGLE SITE CHOLECYSTECTOMY VERSUS STANDARD LAPAROSCOPIC CHOLECYSTECTOMY: Results OF A PILOT TRIAL M. Umit Ugurlu, MD, M. Tahir Oruc, MD, Zehra Boyacioglu, MD, H. Taner Turgut, MD, Mehmet Ozyilmaz, MD, S. Yigit Yildiz, MD, KOCAELI DERINCE TEACHING AND RESEARCH HOSPITAL GENERAL SURGERY CLINIC, KOCAELI, TURKEY Introduction: The potential benefits of single incision laparoscopic cholecystectomy (SILC) may include scarless surgery, reduced postoperative pain, reduced postoperative length of stay, and improved postoperative quality of life. Usage of commercially available SILC access devices and hand instruments has some disadvantages. This study aimed to compare the outcomes of trans-umbilical single site cholecystectomy (TUMP-LC) using standard laparoscopic instruments versus conventional 4-port laparoscopic cholecystectomy (4PLC). Methods: Patients with symptomatic gallstones were randomized to TUMP-LC (n: 25) or 4PLC (n: 25). The surgical outcomes such as length of stay, complications perioperative morbidity, operative time and conversion were analyzed. For evaluation of surgical stress preoperative and postoperative CRP values at 6 h and 24 h were measured. Postoperative pain was evaluated using a standard 10-point visual analogue scale (VAS). Results: Mean age was 47.7 vs. 51.2, mean BMI of the patients was 28.6 vs. 27.9 kg/m2, mean surgical time (44.56 vs 46.5 min) and mean hospital stay (1.5 vs 1.8 day) were similar for both the TUMP-LC and 4PLC group. There were no open conversions and no major complications. The mean total wound length of the TUMP-LC group was significantly shorter (2 vs. 3.75 cm). Mean pain scores post-operatively at 4, 12 h were significantly higher in 4PLC group than the TUMP-LC group (6 ± 2.23 vs. 4 ± 1.19 and 5.47 ± 1.14 vs. 3.64 ± 1.03; p \ 0.05). Plasma CRP values were significantly higher at 6 h and 24 h of surgery in 4PLC group than the TUMP-LC group (17.2 vs. 25.3 and 33.2 vs. 4.7; p \ 0.05). None of the cases were converted to open and no major complications occurred. Discussion: TUMP-LC using standard laparoscopic instrumentation without an access device is an effective alternative to standard four-incision laparoscopic cholecystectomy. Lower pain scores and surgical stress values shows that TUMP-LC is feasible and safe for properly selected patients in experienced hands.

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TRANSUMBILICAL MULTIPLE-PORT LAPAROSCOPIC CHOLECYSTECTOMY USING STANDARD LAPAROSCOPIC INSTRUMENTS M. Tahir Oruc, MD, M. Umit Ugurlu, MD, Zehra Boyacioglu, MD, Kocaeli Derince Teaching and Research Hospital General Surgery Clinic

NOVEL END-TO-END SUPRA-AND INFRA-HEPATIC CAVAL ANSTOMOSIS FOR ORTHOTOPIC LIVER TRANSPLANTATION WITH A 21 mm CIRCULAR STAPLER. Muhammad S Ikram, MD, John Ham, MD, Shawn Tsuda, MD, University of Nevada Las Vegas, University Medical Center, Las Vegas, Nevada

Introduction: As a complement to standard laparoscopy, SILS is gaining popularity. We reported our technique and our initial experience with TUMP-LC without an access device using standard laparoscopic instruments, together with its clinical outcomes. Material and Methods: Twenty-five (23 F:2 M) consecutive patients with symptomatic cholelithiasis were involved. The surgical outcomes such as length of stay, complications and perioperative morbidity were analyzed. For evaluation of surgical stress preoperative and postoperative CRP values at 6 h and 24 h were measured. Postoperative pain was evaluated using a standard 10-point visual analogue scale (VAS). Results: The mean age of the patients was 47.72 years (range, 22–72); mean BMI of the patients was 28.64 kg/m2 (range, 19.5–39.6). Mean duration of the surgery was 44.56 min (range, 18–110). Additional trocars were needed in 2 (8%) cases. Mean pain scores post-operatively at 4 h, 12 h and 24 h were 4 ± 1.19, 3.64 ± 1.03 and 2.24 ± 0.96, respectively (p \ 0.0001). Plasma CRP values increased at 6 h and started to decrease at 24 h (p \ 0.0001). None of the cases were converted to open and no major complications occurred. Discussion: TUMP-LC using standard laparoscopic instrumentation without an access device is an effective alternative to standard four-incision laparoscopic cholecystectomy. Our technique maintains the principles of conventional procedure and the instrumentation, but also improves the access.

Background: The potential advantages of using veno-veno bypass during recipient hepatectomy in orthotopic liver transplantation (OLT) are to reduced the amount of hemorrhage, improve cardiac stability, preserved renal perfusion, and avoid bowel edema during the bicaval anastomosis. Most centers use veno-veno bypass on a selective basis for patients who are intolerant of suprahepatic cross-clamping. In those patients time is essential and bicaval anastomosis needs to be performed efficiently. The average time for liver perfusion after supra, infra, and portal anastomosis is 35–45 min. The operative course of bicaval anastomosis may be shortened by using a 21-mm circular stapler in order to reduce bypass time and improve warm ischemia time during the transplantation. Objective: The objective of this study is to demonstrate a supra- and infra-hepatic caval anastomosis for OLT using a 21 mm circular stapler device in an animal model. Methods: This procedure was performed in a live pig model. A midline incision was made, fixed retractors placed, and the duodenum was mobilized medially. The infra-hepatic cava was isolated and the hepatic artery and portal vein were divided. The supra-hepatic cava was isolated at the diaphragm by taking down the falciform ligament. Two clamps 1 cm apart were applied to the supra- and infra-hepatic cava and divided with a linear stapler. A 21 mm circular stapler (Ethicon, Cincinatti) was then introduced via a venotomy in the suprahepatic caval stump to the infra-hepatic staple line. The stapler anvil was placed in the proximal portion of the divided infra hepatic cava and secured with a purse sting suture and the anastomosis created. The supra-hepatic venotomy was then. closed with a linear stapler. The circular stapler was then introduced through a venotomy in the infrahepatic cava until it reached the supra hepatic staple line. The anvil was placed in the distal portion of the divided supra-hepatic cava and mated with the stapler to create the anastomosis. Then venotomy site was closed with a running prolene suture. Results: Bi-Caval anastomoses with a 21 mm circular stapler was performed in 2 live pigs. Total procedure time was under 30 min. No staple-line bleeding was identified post anastomosis. Conclusion: Bicaval anastomosis can be performed in a veno-veno bypass patient with a circular stapling device with a 21 mm outer diameter. This is the first demonstration of an end-to-end circular anastomsis for Bi-Caval anatomosis. This technique may help to improve perfusion time by decreasing warm ischemia during an hepatic phase of the procedure.

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OUTPATIENT SINGLE INCISION LAPAROSCOPIC CHOLECYSTECTOMY WITH ROUTINE INTRAOPERATIVE CHOLANGIOGRAM B Pellini, MD, S Smith, MD, B O’connell, MD, I Daoud, MD FACS, St Francis Hospital and Medical Center, Hartford, CT

PANCREATICOGASTROSTOMY DURING LAPAROSCOPIC PANCREATICODUODENECTOMY; A VIABLE ALTERNATIVE TO PANCREATICOJEJUNOSTOMY? E M True, MD, J R Debord, MD, J S Marshall, MD, University of Illinois College of Medicine - Peoria, Department of Surgery

Introduction: While a number of studies have demonstrated the feasibility and early outcomes pertaining to single incision laparoscopic (SILS) cholecystectomy there is very limited published data concerning use of routine cholangiography during this procedure. Presented is the initial outpatient elective operative experience of a single surgeon’s SILS cholecystectomy with routine cholangiogram. Methods: Data was gathered from a prospectively maintained single incision laparoscopic database consisting of a single surgeons experience from a community teaching hospital. All SILS cholecystectomy operations were then extracted from this database and analyzed for descriptive statistical analysis. As a general surgical approach in this practice, routine identification of the critical view of safety followed by intraoperative cholangiogram using an Olsen Cholangiogram Clamp is attempted for all SILS cholecystectomy. Results: SILS patient data was analyzed from November 2008 through May 2011. 112 patients identified in the SILS database underwent cholecystectomy during this time. The average age was 46.2 years old (range 18–84) with an average BMI of 27.7, and 78% were female patients. Routine cholangiogram was successfully completed in 95.5% of these cases (n = 107), which required on average an additional 7 min of operative time to the case. There were no surgical complications identified attributed either to an attempted or completed cholangiogram. While no additional ports were required specifically to perform cholangiogram, at least a single additional port was required for cholecystectomy in 35 patients (31%). There were no open conversions identified and only 2 (1.7%) patients required conversion to standard 4 port laparoscopic cholecystectomy. All patients were operated on in same day surgery with all except 2 (1.7%) being discharge home immediately following recovery from anesthesia. One admission was due to choledocholithiasis requiring further treatment, the other due to conversion to standard laparoscopic cholecystectomy secondary to local inflammation and adhesions. In addition, there were no SILS cholecystectomy mortalities and review of office follow up reveals no initial wound complications. Conclusion: New innovative approaches to common surgical procedures must continue to demonstrate that they maintain sound surgical principles and safety in addition to equivalent to superior outcomes in comparison to the current standard of care. The results presented demonstrate that routine cholangiogram, an important tool in the general surgeon’s armamentarium for confirmation of biliary anatomy, is not sacrificed in any manner during SILS cholecystectomy. What’s more, it required little additional operative time to complete the procedure and had no associated complications.

Introduction: Laparoscopy has changed the approach to many operative interventions. Due to its complexity, minimally invasive surgeons have been slow to adopt laparoscopic pancreaticoduodenectomy (PD). Since the early 1990s, there have been reports of the success and feasibility of laparoscopic PD. Differing methods to perform laparoscopic PD are emerging with increasing experience in the surgical community. In the case of pancreatico-enteric anatomosis, pancreaticogastrostomy (PG) is a viable option compared to pancreaticojejunostomy (PJ) in open PD. This series is the first reported of completely laparoscopic PD performed with a PG rather than a PJ. Methods: A retrospective chart review was performed from 9/2008 to 9/2011. 19 patients were identified as candidates for laparoscopic PD after pre-operative evaluation. Patients then underwent attempted laparoscopic PD. PG was performed totally laparoscopically using a single layer, mattress technique. Outcomes of operative time, estimated blood loss (EBL), length of hospital stay (LOS), peri-operative (30 day) mortality, number of retrieved lymph nodes, rate of pancreatic fistula, and rate of conversion to open procedure were analyzed. These were compared to the current literature. Results: The patient group was predominantly male (74%) with a mean age of 68.9 years. Conversion to an open procedure occurred in 4 cases (21%). In the 15 cases without conversion; mean operative time was 354 min, mean EBL was 430 mL, and the mean length of stay was 13.6 days. One mortality was observed in the peri-operative period (6.7%). The mean number of lymph nodes removed was 12.5. Two patients (13.3%) were diagnosed with a pancreatic fistula. These resolved spontaneously with conservative, medical management. Conclusion: Operative time (355 min vs 378 min) and rate of pancreatic fistula (13.3% vs 15%) were lower than an average of other published series. LOS (13.6 days vs 12 days), EBL (430 mL vs 189 mL), rate of conversion to open (21% vs 9%), and peri-operative mortality were higher (6.7% vs 2%). Number of lymph nodes removed (12.5 vs 15) was lower. Results are comparable to prior series of similar size. The possibility of decreased operative time and rate of pancreatic fistula could positively impact morbidity after PD. This makes PG during laparoscopic PD a technique worthy of further investigation. Larger, randomized trials are warranted to determine statistical significance.

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WHEN IS THE OPTIMAL TIME FOR LAPAROSCOPIC CHOLECYSTECTOMY IN GALLBALDDER EMPYEMA? Yong Jin Kwon, BS, Hwon Gyeom Park, MD, Kwang Soo Lee, MD, Kyeong Geun Lee, MD, Department of Surgery, College of Medicine, Hanyang University

INTRA-OPERATIVE CHOLANGIOGRAPHY FOR PREVENTION OF ‘MAJOR’ BILE DUCT INJURY DURING LAPAROSCOPIC CHOLECYSTECTOMY Jai Bikhchandani, MD, Xiang Fang, PhD, Robert J Fitzgibbons, MD, Creighton University Medical Center

Purpose: With increasing experience in laparoscopic surgery, early laparoscopic cholecystectomy (LC) is increasingly offered for acute cholecystitis. But early LC without percutaneous transhepatic gallbladder drainage (PTGBD) for gallbladder empyema is believed to be still unsafe. The aim of the present study is to determine optimal time for laparoscopic cholecystectomy in gallbladder empyema. Methods: A retrospective analysis was made of patients who underwent LC without PTGBD between August 2007 and December 2010 for gallbladder empyema. All cases were confirmed by biopsy. Based on 72 h, patients were divided into two groups. Results: LC for gallbladder empyema was performed without PTGBD in 61 patients during the study period. The overall conversion rate was 6.6%. Based on 72 h, there were 33 patients in the early group and 28 in the delayed group. Comparing patients who underwent early and delayed LC, no significant differences in the rate of operative time (75.5 vs 71.4 min, P = 0.537), postoperative hospital stay (4.2 vs 3.3 days, P = 0.109), conversion rate (12.1% vs 0%, P = 0.118), complication rate (12.1% vs 3.6%, P = 0.363) were found between groups. However, the early group had significantly shorter total hospital stay (5.3 vs 8.7 days, P = 0.001). Conclusions: Early LC without PTGBD is safe and feasible for gallbladder empyema and associated with low conversion rate. Delayed LC for gallbladder empyema has no advantages, resulting in longer hospital stay. LC should be performed as soon as possible within 72 h after admission, to decrease the hospital stay.

Introduction: The incidence of Bile duct injury (BDI) during laparoscopic cholecystectomy (LC) ranges from 0.5–1.4%. Roughly half of these have been reported to be major BDIs. Although studies have shown that the overall incidence of BDI does not change with the routine use of intra-operative cholangiogram (IOC), the question about the severity of the injury being limited by routine IOC has not been settled. Methods: Beginning in 1989, all patients who had laparoscopic cholecystectomies performed by a single surgeon (RJF) were enrolled in a prospectively maintained database of consecutive LCs. Following IRB approval, this database was queried for information on patient demographics, clinical presentation, intra-operative findings and operative complications. Statistical software SAS 9.2 was used to analyze the data. Results: A total of 2360 patients, with a mean age of 46, BMI of 30.6 and a gender ratio of 1:2.6 (M:F) had LC. Before 1996, IOC was done selectively. After that a policy of routine IOC for all patients was adopted. The result was that 1910 of the 2360 patients underwent IOC. The overall surgical complication rate was 2.2% (52 of 2360 patients), including both minor and major events. Five patients (0.2%) had biliary complications after the operation; all were Strasberg type A—BDIs i.e. minor ductal injury due to cystic duct leaks or leaks from small ducts in the liver bed. Two of these BDIs were recognized at surgery and were treated by repair and T-tube drainage. One patient had a postoperative ERCP with a biliary stent. Percutaneous drainage resolved the leak in another patient. The last patient presented with severe abdominal pain 5 days post-operatively and was explored with a washout and drainage. There were no major bile duct injuries seen in our patient cohort. Conclusion: In our experience, routine IOC has been shown to be helpful in preventing major BDIs during laparoscopic cholecystectomy. There was however, no difference seen in the incidence of minor biliary complications in the patients who had routine versus selective IOC.

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FESIBILITY OF TWO-STAGE LAPAROSCOPIC HEPATECTOMY FOR BILOBAR METASTATIC LIVER TUMORS. Hitoshi Inagaki, MD, Gifu Chuo Hospital, Japan Introduction: The progress of the systemic chemotherapy for colorectal cancer had revolutionized the therapy for metastatic liver tumors. It is found that there is the prognostic prolongation by hepatectomy after chemotherapy. On the other hand, it is found that there is high morbidity rate of hepatectomy after chemotherapy. Aims and Methods: We report our experiences in laparoscopic two step hepatectomy. We have 107 cases of laparoscopic hepatectomy, and in 107 cases, we have one case of pure laparoscopic two step hepatectomy, and two cases of laparoscopic right portal vein ligation prior major hepatectomy. A 64-year-woman with multiple liver metastasis underwent chemotherapy by XELOX+ cetuximab, then we performed laparoscopic right posterior portal vein ligation and partial hepatectomies in left lobe of the liver. At 21st day after first operation, we performed laparoscopic extra posterior segmentectomy. Results: Operation time was 272 min and blood loss was 519 g. A little pleural effusion and abscess of hepatic aspect occurred and both morbidities relieved conservatively. The hospital stay after second operation was 20 days. Conclusions: There is higher complication rate of hepatectomy after chemotherapy than hepatectomy without chemotherapy, so we expect pure laparoscopic two step hepatectomy is one of strategies for colorectal liver metastasis. Furthermore, in the therapy of colorectal metastasis to be possible to require polysurgery, it is useful of laparoscopic surgery which benefit has a little abdominal wall destruction

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LAPAROSCOPIC ASSISTED PANCREATICODUODENECTOMY: FEASIBILITY AND OUTCOME STUDY Raymund Andrew G Ong, MD FPCS FPALES, Winston S Vequilla, MD DPBS, Jeremy J Tan, MD, Department of Surgery, FEU-NRMF Medical Center, Philippines Objective: To assess the feasibility of laparoscopic pancreaticoduodenectomy in patients with pancreatic tumor performed by the same surgical team. Method: A consecutive series of patients affected by solid and cystic tumors were selected prospectively to undergo laparoscopic pancreaticoduodenectomy performed by the same surgical team. Main outcome measures are the following: blood loss, operative time, postoperative morbidity, and length of hospital stay. Results: Three patients underwent laparoscopic resection for tumors of the head of the pancreas. All procedures were successfully performed laparoscopically, and no patient required intraoperative blood transfusion. There were no mortalities. The overall median hospital stay was 8 days, median operative time was 380 mins and overall median blood loss was 250 mL. Perioperative complication occurred only in one patient, which was pneumonia. No port-site recurrences were identified in any patient during the observation period. Conclusion: Our experience with 5 consecutive patients proved that Laparoscopic Assisted Pancreaticoduodenectomy is feasible, safe and effective for preoperatively assessed resectable pancreatic tumors, and a one-stage option for patients requiring staging diagnostic laparoscopy. Outcomes are comparable with those via the open approach; however, controlled trials are needed.

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METHODS OF VENOUS HEMOSTASIS FOR THE STANDARDIZATION OF TOTAL LAPAROSCOPIC HEPATECTOMY Mitsuo Miyazawa, MD FACS, Masayasu Aikawa, MD, Katsuya Okada, MD, Kojun Okamoto, MD, Yasuko Toshimitsu, MD, Shigeki Yamaguchi, MD, Isamu Koyama, MD, Saitama Medical University International Medical Center In order to standardize total laparoscopic hepatectomy, it is necessary to establish a method for controlling venous hemorrhage, which impairs treatment and is the most common intra-operative complication. We investigated what types of techniques were useful in controlling hemorrhage during total laparoscopic hepatectomies conducted at our hospital. Methods: Total laparoscopic hepatectomy was conducted on 42 patients between January 2008 and May 2011 at Saitama Medical University International Medical Center, Department of Gastrointestinal Surgery. Our subjects comprised 9 of these patients whose intra-operative hemorrhage volume was 100 ml or more (3 cases [5 nodules] of hepatocellular carcinoma, 3 cases [8 nodules] of hepatic metastasis, 1 case of intrahepatic cholangiocarcinoma, 1 case of hepatic hemangioma, and 1 case of other hepatic tumor). We investigated the cause of hemorrhaging, useful hemostatic methods and clinicopathological features of the tumors. Results: None of the patients who underwent total laparoscopic hepatectomies during this period required conversion to laparotomy because of hemorrhaging. Increased hemorrhaging was observed in tumors localized to the S6, S7 peripheries, tumors with large diameter and, in one case, multiple nodules. Conclusions and Discussion: During total laparoscopic hepatectomy, it is difficult to conduct hemostasis on hemorrhaging in tumors, localized in S6, S7 peripheries because of the limited insertion angle for instruments used in hemostasis. Monopolar soft coagulation (under irrigation) was useful when there was a small amount of venous hemorrhaging (and the hole in the vein could be located). Bipolar soft coagulation with BiClamp was useful when the vein was narrow (a narrow vein had been torn). When difficulties are encountered with monopolar soft coagulation and bipolar soft coagulation, temporary pressure hemostasis using gauze and dissecting the area around the site of hemorrhaging before carefully examining the site and conducting hemostasis with clips and BiClamp was found to ensure no increased hemorrhaging.

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THE IMPROVEMENT OF THE PATIENTS WITH ACUTE DESTRUCTIVE PANCREATITIS SURGICAL TREATMENT Vladimir M Demidov, PhD DSci Medicine, Sergei M Demidov, PhD, Medicine Odessa National Medical University, Ukraine The number of the patients with the acute pancreatic gland parenchyma inflammation constantly increases due to the different environmental, feeding and other related pathological processes. Despite the intensive conservative and operative treatment in the 40–70% of the acute pancreatitis (AP) patients received destructive manifestation that makes more complex and difficult the forthcoming curing efforts. The fundamental physiological and pathological disciplines stated that pancreatic parenchyma can’t absorb the pharmacological compounds during the first 3–5 days of the inflammation. Correspondently, in our daily practice we use the following approach that intensive pharmacological treatment we started from the 5th day after the disease onset while administering drugs with pacnreatoprotective functions through the catheter inserted into bursa omentalis. 28 patients with acute destructive pancreatitis were treated in the surgical department of the Odessa Municipal Hospital N10 during the last 3 years. The treatment was aimed to pancreatic gland edema diminishing, extrahepatic bile tracts decompression, usual desintoxicative and pancreatoprotective compounds administration etc. Abdominal cavity laparoscopic drainage was performed to 23 patients. Ten patients were treated traditionally with the very first days of the input to the department. 13 patients constituted the group of the patients to whom we gave the Sandostatin (Novartis Pharma Stein AG, Switzerland) and Deltaran (Russia). Traditional AP treatment resulted in the certain improvement of the disease manifestation. Besides, the patients with the additional intrabursal Sandostatin and Deltaran administration started after the 5th day of the disease onset showed more progressive clinical condition improvement. There were no cases of the pancreonecrosis development in this group of patients (2 patients out of 10 with the traditional AP treatment had pancreonecrosis). We didn’t observe any cases of complication among the 13 patients treated with Sandostatin and Deltaran (2 complications were in 10 patients with the traditional AP treatment). The average time of patients treated traditionally days-in the hospital equal to 9–14 days. The average time of patients who received Sandostatin and Deltaran days-in the hospital was 4–7 days shorter comparing with the same index in the traditionally treated patients. Hence, we can conclude that intrabursal pharmacons with the potent pancreatoprotective properties administration in patients with destructive AP has some important advantages. There are less cases of disease progression, less cases of complications and the quicker improvement of the patient. The very important idea we worked with is that intrabursal drugs administration we stared 5 days later waiting for the termination of the initial stage of pancreatic gland inflammation.

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THE INTRODUCTION OF LAPAROSCOPIC DISTAL PANCREATECTOMY AT OUR INSTITUTION Hisashi Ikoma, PhD, Yukihito Kokuba, PhD, Yusuke Yamamoto, PhD, Ryou Morimura, PhD, Yastutoshi Murayama, PhD, Syuuhei Komatsu, PhD, Atsushi Shiozaki, PhD, Yoshiaki Kuriu, PhD, Masayoshi Nakanishi, PhD, Daisuke Ichikawa, PhD, Hitoshi Fujiwara, PhD, Kazuma Okamoto, PhD, Toshiya Ochiai, PhD, Eigo Otsuji, PhD, Department of Digestive Surgery, Kyoto Prefectural University of Medicine Currently, laparoscopic distal pancreatectomy (Lap-DP) is treated as an advanced medical technology, and yet, there has been an increase in the number of institutions using this procedure. However, cases requiring Lap-DP are far fewer than for other digestive laparoscopic surgeries. Therefore, it is difficult to introduce Lap-DP in the same way as laparoscopic gastrectomy, colectomy and cholecystectomy, for which there are many candidates. Therefore, it is difficult to safely and efficiently introduce Lap-DP. At our institution, we introduced Lap-DP by applying the surgical technique of laparoscopic colectomy to this procedure under the mentorship of a Japan Society for Endoscopic Surgery-certified surgeon who also has experience with a large number of laparoscopic colectomy. At our institution, we have also adopted this surgical technique and are safely operating and implementing this technique, and we herein report the conditions associated therewith and describe the adjustments made regarding this treatment modality. Laparoscopic colectomy was determined to be useful based on detailed membrane anatomy and in order to maintain a good surgical view. When introducing new laparoscopic surgery techniques, it is helpful to find common ground with prevailing laparoscopic surgery methods and to apply these known techniques to the new procedure.

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ADOPTION OF A SINGLE-INCISION LAPAROSCOPIC CHOLECYSTECTOMY Hisashi Ikoma, PhD, Yukihito Kokuba, PhD, Yusuke Yamamoto, PhD, Ryou Morimura, PhD, Yastutoshi Murayama, PhD, Syuuhei Komatsu, PhD, Atsushi Shiozaki, PhD, Yoshiaki Kuriu, PhD, Masayoshi Nakanishi, PhD, Daisuke Ichikawa, PhD, Hitoshi Fujiwara, PhD, Kazuma Okamoto, PhD, Toshiya Ochiai, PhD, Eigo Otsuji, PhD, Department of Digestive Surgery, Kyoto Prefectural University of Medicine Background: A single-incision laparoscopic cholecystectomy, which is performed by making an incision into the belly button, is expected to lead to reduced pain and scarring and a shortened time required for recovery and it is now becoming more widely used. Method: Since July 2009, we performed single-incision laparoscopic cholecystectomy for 52 patients with Cholelithiasis patients or cystic adenomyosis patients with no history of fever, jaundice, or colic attacks. Results: The cases comprised 52 patients, including 21 male and 31 females, wherein the average surgery time was 103 min, the average amount of bleeding was low, and there were no cases involving the addition of ports, cases shifted to laparotomy, or cases involving intraoperative gallbladder perforations and there were no postoperative complications without one SSI . Conclusions: We safely adopted the surgical technique known as single-incision laparoscopic cholecystectomy. With a single-incision laparoscopic cholecystectomy of the umbilical region, it was possible to secure a field of view comparable with that obtained in a conventional laparoscopic cholecystectomy using four incisional wounds. Moreover, no special forceps or procedures are required and the surgery can be performed safely.

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INITIAL RESULT AND FEASIBILITY OF LAPAROSCOPIC HEPATECTOMY Fumiki Kushihata, title, Hitoshi Inoue, title, Yoshikuni Yonenaga, title, Jota Watanabe, Akifumi Miyoshi, Taiji Toyama, Yasutsugu Takada Surgery, Ehime University School of Medicine Purpose: We examined initial results and the effectiveness of the laparoscopic hepatectomy (LH). Object, Method: 19 Hepatocellular carcinoma (HCC), 6 metastatic liver cancer, others 4 cases. 3 Re-hepatectomy cases are 2 HCC recurrence and one gastric cancer metastasis. As for liver dysfunction cases with high ICG ([30%), one HCC explosion in 2 cases. 18 pure laparoscopic hepatectomy and 11 hybrid hepatectomy cases are enrolled. A procedure of pure laparoscopic hepatectomy is as following; VSS (vessel sealing system) is adapted for surface hepatectomy, and CUSA for deep layer without Pringle maneuver and precagulation. Hybrid hepatectomy: We took cholecystectomy / liver mobilization in laparoscopy and performed hepatectomy by CUSA. Result: 4 lateral segmentectomy, 3 subsegmentectomy, 22 partial hepatectomy cases. For average tumor diameter 3.1 cm, operation time 262 min, bleeding 306 ml, postoperative hospitalization 13 days. There is no postoperative complication. Conclusion 1. Hybrid procedure was suitable for right sided hepatectomy, otherwise pure laparoscopic hepatectomy for left sided hepatectomy. 2. Re-hepatectomy and the high ICG hepatectomy are safely undertaken by LH.

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SINGLE INCISION CHOLECYSTECTOMY WITH NEEDLESCOPIC INFUNDIBULAR RETRACTION; INITIAL EXPERIENCE Kee-hwan Kim, MD PhD, Young-kyung You, MD PhD, Changhyeok An, MD PhD, Jeong-soo Kim, MD PhD, Il-young Park, MD PhD, Dong-gu Kim, MD PhD, Uijeongbu St. Mary’s Hospital, Uijeongbu, Korea Introduction: Single incision LC has been reported to be safe and feasible in various clinical experiences. But limited retraction has been an obstacle in the advancement of pure single incision cholecystectomy. Adequate retraction is necessary to perform a safe cholecystectomy. We reviewed the results of a single institution with respect of single incision cholecystectomy with a single 2 mm needlescopic instrument for retraction of gallbladder infundibulum to aid in obtaining a critical view of safety. Methods and Procedures: From October 2010 to Sep 2011, 85 patients with a mean age 45,3 years (range 14 to 76) were identified. Single port device was placed through umbilicus. A (2 mm) needlescopic retractor was placed in the right flank region directly through the abdominal wall for retraction of the gallbladder infundibulum in an anterior and cephalad direction. Results: Patient all had a pathologic diagnosis of acute and chronic cholecystitis. ASA class averaged 1.62 (range 1 to 2). Operative times averaged 46.2 min (range 28 to 86 min). Postoperative hospital stays averaged 2.4 days. Conclusions: Operative times and incidence of complications for Single incision cholecystectomy with a single needlescopic instrument are within acceptable range and safe for both acute and chronic gallbladder disease. Thus, it can be recommended as a safe alternative procedure in elective LC

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THE PURE LAPAROSCOPIC HEPATECTOMY INDUCTION IN THE LOW-VOLUME CENTER Shinjiro Tomiyasu, MD PhD, Kazutoshi Okabe, MD PhD, Toru Beppu, MD PhD, Osamu Sano, MD PhD, Tsuyoshi Yamanaka, MD PhD, Akira Chikamoto, MD PhD, Kouichi Doi, MD PhD, Masatoshi Ishiko, MD PhD, Keiichiro Kanemitsu, MD PhD, Hideo Baba, MD PhD, NTT West Kyusyu Hospital, Saiseikai Kumamoto Hospital and Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University Introduction: Laparoscopic hepatectomy (LH) was published insurance by partial resection and left lateral segmentectomy in Japan. The progress of surgical tools and the improvement of surgical procedure cased LH spread out in the world. Our hospital: low-volume center in HCC, started pure laparoscopic hepatecomy in this year. Aim: To examine pure laparoscopic hepatectomy (Pure-Lap) and laparoscopic assisted hepatectomy (Hybrid) in this hospital. Patients and Methods: Patients (n = 17) who underwent laparoscopic hepatectomy from 2008. These 17 patients are 15 men and 2 female. The age is 51-85 years old. The disease was 15-hepatocellular carcinoma (HCC) and 2 metastatic liver cancers. As for the preoperative liver function, is liver damage degree A 15, B two and one rehepatectomy. Indication for LH is 5 cm or less in tumor diameter, the surface area of the liver except of left lateral segment, and not invasion to a surrounding tissue. The Hybrid method performed in 12 patients, mobilization under a laparoscope and performed a hepatectomy from a small laparotomy wound. By the Pure-Lap method performed in five patients, we gradually raised intraabdominal pressure in 12 cmHg, used CUSA for transection of the liver parenchyma after coagulation by BiClamp. A vessel and the Glisson’s capsule used a clip, ligation or linear staples. The Pure-Lap compared to Hybrid about HCC in bleeding, operative time, an SIRS rate until day 3 after surgery, a CRP level on the postoperative third day and postoperative hospitalization. Results: The bleeding, operative time, an SIRS rate until day 3 after surgery, a CRP level on the postoperative third day, postoperative hospitalization against the Hybrid method by the Pure-Lap method in HCC were not the difference in both groups. Conclusions: In low-volume center in HCC, after the experience of Hybrid method, to introduce the Pure-Lap method is capable and safe.

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NEEDLE-ASSISTED SINGLE-INCISION LAPAROSCOPIC (NASLAP) LIVER SURGERY Minoru Tanabe, MD PhD, Shigeyuki Kawachi, MD PhD, Osamu Itano, MD PhD, Masahiro Shinoda, MD PhD, Minoru Kitago, MD PhD, Norihito Wada, MD PhD, Yuko Kitagawa, MD PhD, Department of Surgery, Keio University School of Medicine Introduction: Single-incision laparoscopic surgery is becoming more common for a multitude of laparoscopic procedures. However, there are few reports about liver surgery so far. In this session, we present our initial experience of needle-assisted single-incision laparoscopic (NASLAP) liver surgery. The concept of this method is to assist singleincision laparoscopic surgery by using needle devices such as RFA/microwave coagulator and/or our original needle devices. We developed two types of novel needle device; one is for retracting organs, which is assembled inside the abdominal cavity, and the other is for water dripping for bipolar coagulation. Methods: A intraumbilical vertical 2.5 cm-incision was made and the SILS port (Covidien, Norwalk, CT, USA) was introduced into the abdomen. One 12 mm and two 5 mm trocars were put through the port and the pneumoperitoneum was induced at 8 mmHg. A 5 mm flexible fiberscope was used in all operations. \ NASLAP hepatectomy [ The transection plane was precoagulated using a flexible microwave probe or bipolar coagulation device for laparoscopic surgery. Parenchymal transection was accomplished with the ultrasonic coagulating shears and the ultrasonic aspirator. The original needle retractors inserted through the upper abdominal wall were used to control the direction of transection. This needle device is assembled inside the abdominal cavity. Water dripping needle was also inserted through upper abdominal wall, in order to moisturize cutting surface of the liver when bipolar coagulation is used for hemostasis. The indication of NASLAP hepatectomy includes the tumors in the lower peripheral part of the right anterior, and left medial/lateral segments of the liver. \ NASLAP ablation therapy [ A laparoscopic ultrasonography probe and a forceps as a retractor were introduced into the abdomen through the SILS port. The Ablation needle (radiofrequency or microwave energy device) was inserted through the best point of the abdominal wall according to the location of the tumor. The indication of NASLAP ablation therapy includes the tumors adjacent to gastrointestinal tract, because heat injury can be avoided by retracting gastrointestinal tract by this operation. In addition, another candidate for this operation is the tumors undetectable by preoperative extracorporeal ultrasonography, because clearer image of the tumors can be obtained by laparoscopic ultrasonography. Results: From April 2009 to September 2011, there were 9 limited hepatectomy and 6 ablation therapy were carried out at our hospital using NASLAP technique. There were no conversion and no intraoperative complications. The postoperative courses of all patients were uneventful. Conclusion: Needle devices expand the possibility of single-incision laparoscopic liver surgery. NASLAP procedure for liver tumors is feasible and safe for highly selected patients.

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CRITICAL VIEW EXPOSURE USING THE ‘‘FRENCH’’ TECHNIQUE ENSURES PATIENT SAFETY DURING LAPAROSCOPIC CHOLECYSTECTOMY Shin-ichirou Mori, MD, Kenji Baba, MD, Tsutomu Kozono, MD, Kuniaki Aridome, MD, Kousei Maemura, MD, Shouji Natsugoe, MD, Department of Digestive Surgery, Breast and Thyroid Surgery

ONE-STAGE LAPAROSCOPIC CHOLECISTECTOMY AND CBD EXPLORATION WITH PRIMARY CLOSURE Gintaras Antanavicius, MD FACS, Carlos A Cutini Cingozoglu, MD, Patricio E Donnelly, MD, Rodolfo H Scaravonati, MD, Rodrigo Moran Azzi, MD, Roberto P Munin, MD, Victor H Serafini, MD FACS, Sanatorio Gu¨emes, Argentina, Abington Health, USA

Objective: Applying the critical view exposure of Calot’s triangle as described by Strasberg can avoid bile duct injury, which is a serious surgical complication of laparoscopic cholecystectomy (LC). We performed LC using this procedure according to the ‘‘French’’ technique, in which the surgeon stands between the patient’s legs. The present study assessed the feasibility and safety of critical view exposure according to the ‘‘French’’ technique during LC. Methods: Sixty five patients (mean age, 60 years) underwent complete LC with critical view exposure according to the ‘‘French’’ technique between January 2008 and July 2011. Results: The triangle of Calot was easily and extensively dissected according to the ‘‘French’’ technique, which allows a wide working area. No conversion occurred and no blood vessels were damaged during the procedure. Twogallbladder became perforated, but no complications were associated with the extrahepatic biliary duct. Postoperative complications occurred in two cases including a bleeding and a cerebral infarction. No deaths were associated with the procedure. Conclusion: Critical view exposure, which allows extensive dissection of the triangle of Calot according to the ‘‘French’’ technique, ensures patient safety during LC.

Introduction: There are several approaches for choledocolithiasis and current data do not suggest clear superiority of any approach; decision regarding treatment is based on surgeons preferences, experience and equipment disponibility. When trancistic common bile duct (CBD) exploration fails, choledochotomy is an option. The open bile duct may be done with closure on a T-tube or primary closure. We report the result for one-stage laparoscopic cholecistectomy and CBD exploration with primary closure. Methods: Retrospective analysis from a prospectively collected database. We include all laparoscopic cholecistectomy with intraoperative finding of common bile duct stones. Inclusion Criteria: Failure of trancistic exploration Dilated CBD Complete ductal clearance after CBD exploration Result: Between August 2007 and May 2011, we performed 8 laparoscopic cholecistectomy with CBD exploration and primary closure (1male, 7 female). The average age was 46 years old (range 21–62 years).12.5% were elective procedures and 87.5% of patients were performed in the emergency settings. The presence of CBD stone was suspected preoperatively in 7 cases and in one case was an incidental finding. The rate of convertion was 12.5% (n = 1). The operative time was about 153 min (range 105–225 min). None of the patients required post operative ERCP (Endoscopic Retrograde Cholangiopancreatography). In one case we performed an intraoperative choledocoscopy. The average post operative stay was 4 days (range 2–8 days). There was no mortality and the morbidity was 12.5% (Bilirragia that resumed in five days). Conclusion: Laparoscopic common bile duct exploration with primary closure is safe and effective for selected patients. Future experience is needed for further study on the sistematic or elective use of choledocoscopy.

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SINGLE-PORT LAPAROSCOPIC HEPATECTOMY: TECHNIQUE, SAFETY, AND FEASIBILITY IN A CLINICAL CASE SERIES Masayasu Aikawa, MD, Mitsuo Miyazawa, MD, Katsuya Okada, MD, Yasuko Toshimitsu, MD, Kojun Okamoto, MD, Shigeki Yamaguchi, MD, Isamu Koyama, MD, Saitama Medical University International Medical Center Background: The recent use of single-port access surgery in cholecystectomy and other abdominal surgeries has confirmed its safety and validity as a treatment option. However, there are few reports regarding the use of complete single-port access surgeries in hepatectomy for neoplasms. Method: Between January 2008 and March 2011, 40 LHs were performed in our hospital (Saitama Medical University International Medical Center, Saitama, Japan). We performed single-port laparoscopic hepatectomy (SLH) in 8 patients, among whom 5 patients had hepatocellular carcinoma, 1 had metastatic liver tumor, 1 had endocrine liver tumor, and 1 had hemangioma. Further, 5 patients were classified in the Child-Pugh category A, 2 were in category B, and 1 was in category C. The tumors were located in the S2 in 1 patient, S3 in 2 patients, S4 in 2 patients, S5 in 1 patient, and S8 in 2 patients. The patients were eligible for SLH if they had solitary tumors measuring 3 cm or less on the caudal surface of the liver. In an abdominal approach, a SILSTM Port (Covidien, Mansfield, MA, USA) was inserted through a 20-mm incision on the upper median umbilical site. In hepatectomy, 2 devices are typically used in order to shorten the operative time. The parallel approach method is used to operate these devices. One device is the Bipolar LAP forceps unit (Erbe Elektromedizin GmbH, Tuebingen, Germany), which is connected to the electrosurgical unit VIO300D (Erbe Elektromedizin GmbH, Tuebingen, Germany) for low-voltage coagulation. The other device is the disposable suction irrigation system LAGIS (Lagis Enterprise Co., Ltd, Taichung, Taiwan), which is useful for irrigation, suction, and retraction of the liver . Results: No patient developed intraoperative complications that required additional port access and conversion to laparotomy. Operative time was 148 min (141–235 min). The postoperative course of the patients was uneventful, and they were discharged at an average of 6.2 days (3–11 days) after the operation. Approximately 2 weeks after discharge, the patients did not experience wound pain or liver dysfunction. Conclusion: SLH is a safe and feasible procedure for a specific group of candidates, including patients with high-grade liver dysfunction.

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SILS CHOLECYSTECTOMY Adrian M Maghiar, MD PhD, Pravish R Sookha, MD PhD, George E Dejeu, MD, Pelican Hospital Oradea Romania Aim: Performing single incision laparoscopic cholecystectomy in a safe and feasible way in a more public approach. Methods: Between August 2009 till September 2011 the surgical teams, taking in consideration ultrasonographic thickness of gallbladder wall, previous surgery on superior abdominal wall, and no signs of acute inflammation, reviewed all patients admitted in the surgery department in Pelican hospital in Oradea, Romania, once more. Patients who passed these tests were proposed for single incision laparoscopic cholecystectomy. We had 715 patients admitted for cholecystectomies, out of which 180 were proposed SILS cholecystectomy. Only 132 patients agreed, and a SILS cholecystectomy was tried in all cases. Our technique involves a 2 cm transumbilical incision, through which we introduce our first 10 mm trocar and perform a exploratory laparoscopy. If the case seems feasible for SILS cholecystectomy, we continue by placing a second trocar, a 10 mm one, just lateral to the first one. The first trocar is used for the optics, and the second one is used for dissector, hook cautery, scissors, needle holder and clip applicator. After placing the trocars we introduce 3 transcutaneous sutures, used to retract the gallbladder in different positions. The first suture is place in the last intercoastal space in the midclaviculary line and retracts the gallbladder fundus. The second and third sutures are place in the sides and are used to move the gallbladder from side to side. The cholecystectomy is performed the same as in classic laparoscopic cases. From January 2011 we started using the double curved Dapri-Stroz forceps for SILS cholecystectomies, thus elimination the need for the 2 transcutaneous sutures on the sides used to move the gallbladder form side to side. Results: We had 3 conversions from SILS to classic laparoscopic cholecystectomy. 2 of these cases were in our first seven cases, both for bleeding difficult to control through the SILS technique, the last one in our first 70 cases for the same problem. In the whole 132 lot we never had conversions to cholecystectomy by laparotomy and in the same time we had no major intra or postoperative incidents or accidents. Our mean surgery time was 1 h 13 min during our first seven cases, but it decreased gradually, showing a very lean learning curve, and the end of the 132 cases our mean surgery time was 31 min. All patients were discharged 48 h postoperative. Conclusions: SILS cholecystectomy is feasible according to us, and of course more trials in larger scale should be performed. Single incision laparoscopic surgeries is still a new concept, and it is growing fast, and will definitely be in great demand in the future. The puppeteer technique is a relatively economic way of performing SILS cholecystectomy and can be performed in all surgery clinics that are performing laparoscopic procedures. The introduction of curved instruments, although more expensive, comes in the aid of both surgeons ergonomics and shortening the operating time without the sacrifice of patient safety.

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MINIMALLY INVASIVE DISTAL PANCREATECTOMY IMPROVES OUTCOMES COMPARED TO OPEN AT A RURAL TERTIARY CARE CENTER Horatiu C Dancea, MD, Vladan N Obradovic, MD, Nicole L Woll, PhD, Mohsen M Shabahang, MD PhD, Joseph A Blansfield, MD, Geisinger Medical Center, Danville, PA Background: As surgeons become more adept at minimally invasive techniques, more surgeries are being tackled laparoscopically. Laparoscopic pancreatic surgery requires considerable expertise in both pancreatic and laparoscopic surgery; therefore laparoscopic pancreatic resections have been less common than other surgical techniques. Most reports of laparoscopic pancreatic resection have come from major academic centers. Our goal is to investigate clinical outcomes of laparoscopic distal pancreatectomy (LDP) compared to open distal pancreatectomy (ODP) at our institution. Methods: We reviewed all patients who underwent distal pancreatectomy from 1999 to 2011 at our institution. Results: Sixty six patients underwent distal pancreatectomy at our institution during this time period. Thirty-five patients had ODP and 31 underwent LDP. The average age in our total population was 60 years. The average BMI in our patient population was 29.7 kg/m2. The majority of our patients were women (38 patients, 58%). The groups were evenly matched in terms of age, gender and BMI. The majority of patients undergoing distal pancreatectomy had benign lesions. There was no significant difference in the histology between the groups. Fourteen patients had pancreatic adenocarcinoma, 4 in the laparoscopic and 10 in the open group (P = 0.14). Of those, only one patient had a positive margin on pathology. That patient was in the open group. For patients who had neoplastic lesions, average tumor size was 4.3 cm. The average tumor size was larger in the laparoscopic group but this difference was not significant (5.2 cm versus 3.85 cm, p = 0.25). Operative times were significantly shorter for LDP (246 min versus 309; p = 0.02). Blood loss was significantly higher in the open group (438 versus 208 ml; p = 0.02). There were no conversions from laparoscopic to open procedure. The most common complication in our patients was intra-abdominal fluid collection or abscess in 10 patients, 6 in the LDP group and 4 in the ODP group. Pancreatic fistula rates for our total population was 11% and was slightly higher in the open versus the laparoscopic group (5/35 (14%) versus 2/31 (6%), p = 0.43). Hospital stay was shorter in LDP group but this did not reach statistical significance (6.4 versus 8 days; p = 0.08). There was no 30 day mortality. Conclusions: Complication rates after open and laparoscopic pancreatectomy in our series are equivalent, similar to those reported from major academic centers, with pancreatic leak continuing to be the most significant factor. While achieving similar outcomes, laparoscopic approach does lead to decreased operative time and blood loss, shorter hospital stay and less wound complications. Laparoscopic distal pancreatectomy is safe when performed at a rural tertiary care center.

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SURGICAL VERSUS PERCUTANEOUS DRAINAGE FOR PANCREATIC PSEUDOCYSTS: PATIENT, DISEASE AND PROCEDURE CHARACTERISTICS Justin Lee, MD, Romie Mundy, MD, Neal E Seymour, MD, St. Elizabeth Medical Center, Baystate Medical Center, Tufts University School of Medicine Introduction: The objectives of this study were to use population-based data to 1) compare recent use of percutaneous and surgical drainage procedures, 2) quantify utilization of laparoscopy for pseudocyst, and 3) define patient and disease characteristics pertaining to use of specific drainage methods. Methods: Hospitalizations for pancreatic pseudocyst-related drainage procedures were identified in the National Inpatient Sample (NIS) database from 2001 to 2008. Patient demographics, associated diagnoses, and procedures during these hospitalizations were identified. Percutaneous and surgical drainage procedures were quantified and compared for mortality, length of stay, and total hospital charges. Frequency of use of laparoscopy relative to other treatment methods was defined for the study period. Categorical and continuous variables were analyzed using the chi square and Student’s T-test respectively. Results: The NIS search identified 23,832 hospitalizations for pancreatic pseudocyst drainage procedures. Patients characteristics included: Age 50.7 ± 16.4 years, 59.4% male, 43.8% private insurance, 26.4% Medicare, and 72.5% urban metropolitan area residence. 13,511 (56.7%) underwent percutaneous drainage and 10,321 (43.3%) underwent surgical drainage. Utilization of laparoscopy with surgical drainage increased near four-fold from 1.0% to 3.9% (P \ 0.001) during the period of study. Surgical drainage was associated with decreased inpatient mortality (1.3% versus 3.4%, P \ 0.001), shorter mean length of stay (15.25 days vs. 20.34 days, P \ 0.001) and lower mean total hospital charges ($75,265.78 vs. $104,936.73, P \ 0.001). Overall, 65.2% were associated with acute pancreatitis and 25.1% were associated with chronic pancreatitis. Acute pancreatitis was managed with surgical drainage in 37.1%, whereas chronic pancreatitis was managed with surgical drainage in 49.9% (P \ 0.001). Multivariate logistic regression analysis of gender, insurance status, urban location, and associated pancreatitis identified chronic pancreatitis as the most statistically significant factor associated with increased utilization of surgical drainage (OR 2.36, CI 2.18-2.56, P \ 0.001). Conclusions: Surgical treatment of pancreatic pseudocyst was associated with significantly more favorable mortality, length of stay, and total hospital charge outcomes. Chronic pancreatitis appears to be a significant clinical factor in the selection of surgical drainage as a treatment modality. Use of laparoscopy increased during the study period, but further studies are needed to identify both barriers and specific clinical circumstances where laparoscopy might offer benefit.

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FLUORESCENCE CHOLANGIOGRAPHY FACILITATES IDENTIFICATION OF BILIARY ANATOMY Cristina A Metildi, MD, Sharmeela Kaushal, PhD, Santiago Horgan, MD, Mark A Talamini, MD, Robert M Hoffman, PhD, Michael Bouvet, MD, University of California San Diego Department of Surgery; AntiCancer, Inc., San Diego Introduction: The aim of this study was to evaluate the autofluorescent properties of bile and the subsequent utility of fluorescence cholangiography to facilitate intraoperative identification of biliary anatomy in mice. Methods: Diagnostic laparoscopy was performed on four to 6 week old athymic mice under bright and fluorescence light. Standard bright light laparoscopy (BL) was achieved with a Stryker X8000 xenon light source. Fluorescence laparoscopy (FL) was achieved by placing a 495-nm emission filter between the Stryker L9000 LED light source and a Stryker 1288 HD camera. To achieve mouse laparoscopy, a 2.7 mm 0 laparoscope was inserted through a 3 mm trocar mid-abdomen and secured with a purse string suture. Insufflation was set to a pressure of 2 mm Hg, which permitted sufficient pneumoperitoneum for adequate visualization and manipulation of the laparoscope within the abdominal cavity. Post laparoscopy, the mice were sacrificed and their abdomens exposed for intravital imaging with the OV-100 Small Animal Imaging System to serve as a visualization control. The parameters measured were time to distinguish the common bile duct (CBD) from the cystic duct and the subject’s ability to correctly identify additional biliary anatomy. Results: Utilizing the autofluorescence of bile in the mouse model improved the subjects’ ability to identify the cystic duct, decreasing the mean time from 37.3 s under bright light to 7.6 s under fluorescence light (p \ 0.001). More importantly, time to distinguish the cystic duct from the CBD was also significantly decreased with fluorescence cholangiography (41.4 s under bright light vs. 10.3 s under fluorescence light, p \ 0.001). Additionally, fluorescence cholangiography afforded the subjects greater ease in further identifying multiple hepatic ducts. While only 36% of additional biliary anatomy was correctly identified under BL, fluorescence cholangiography permitted proper identification of 80% of biliary anatomy (p \ 0.001). Overall, fluorescence cholangiography was significantly associated with accurate identification and localization of complete biliary anatomy among all subjects (p = 0.014). Conclusions: The autofluorescence of bile facilitated real-time identification of biliary anatomy in mice during laparoscopy. Fluorescence cholangiography could improve real-time intraoperative identification of biliary anatomy during laparoscopic procedures without additional need for an intraoperative cholangiogram. This technique has potential to decrease the incidence of iatrogenic biliary tract injuries during laparoscopic cholecystectomy without significantly adding to operative time.

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LAPAROSCOPIC HEPATOBILIARY SURGERY FOR BENIGN AND MALIGNANT LESIONS—BRINGING NEW PARADIGM INTO PRACTICE Daniel Tuvin, Manuel I Rodriguez-davalos, Marcelo E Facciuto, Ashutosh Kaul, Patricia A Sheiner, Michael R Marvin, Sukru Emre Yale University, Recanati-Miller Transplantation Institute/Mount Sinai NY, New York Medical College Background: Advances in minimally invasive surgery (MIS) have revolutionized modalities available to patients and clinicians in performing surgical procedures. However, it is only recently that this technique has been introduced for use in hepatobiliary surgery. Laparoscopic liver resections are used for treatment of benign and malignant tumors in many hepatobiliary centers, with growing demand for minimally invasive liver surgery. Evidence on safety and upfront benefits of laparoscopic approach is emerging. Operative time for laparoscopic procedures has been shown to be approaching open ones. Learning curve is described as steep, associated with improving OR time with increased experience. Methods: A retrospective analysis of patients with potentially resectable liver lesions using minimally invasive techniques (January 2003 to December 2010) was done. Demographics, tumor characteristics, resection technique, and outcomes were evaluated. Results: 19 laparoscopic liver resections and 20 cyst fenestrations were performed in a group of 39 (30 female, 9 male) patients. All of the mass lesions patients underwent intraoperative ultrasound and biopsy. Two lesions were benign with no malignant potential, and no resection was performed. 7 of 19 were resected for primary hepatocellular carcinoma, 2 for metastases, 2 for hepatic adenoma and 8 for symptomatic benign disease. Mean patient age was 52.1 years (range, 14 to 82). Fifteen of 19 cases were done using hand-assisted techniques. Mean blood loss in liver resection group was 289.8 ml (range, 5 to 1500), with 2 patients requiring transfusion. Mean length of stay was 4 days (range, 1 to 13). One patient had to be converted and developed a wound infection in the postoperative course. 5 of 39 patients underwent robotic-assisted procedure. Conclusions: Laparoscopic hepatic procedures can be accomplished safely and efficaciously by properly trained surgeons familiar with both laparoscopic and hepatobiliary surgery. Advances in technology make the transection of the parenchyma safer, but there is a learning curve in which hand-assisted techniques and robots application may play an important role. Clear understanding of the surgical anatomy of the liver is crucial as is proper utilization of pre- and intraoperative imaging when planning the resection. As with other MIS, laparoscopic hepatic procedures appears to be advantageous over the open technique in select patients; however, further exploration and comparative analysis of new methods is warranted.

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INCIDENCE OF UNSUSPECTED STONES IN THE COMMON BILE DUCT DURING ELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY: A WORD OF CAUTION Gintaras Antanavicius, MD FACS, Rodolfo H Scaravonati, MD, Carlos A Cutini Cingozoglu, MD, Patricio E Donnelly, MD, Mariano Irigoyen, MD, Rodrigo Moran Azzi, MD, Victor H Serafini, MD FACS, Sanatorio Guemes; Abington Health Introduction: the incidence of unsuspected stones in the common bile duct (CBD) is about 5%. When a stone in the CBD during elective cholecystectomy is found fortuitously, the appropriate strategy to carry out is still uncertain. The risk of a potentially life-threatening complication, justified systematic extraction of all stones in the CBD, whether symptomatic or not. With adapted equipment and a well trained surgeon, this can be done during the same operation. We have analyzed a group of patients, who underwent elective laparoscopic cholecystectomy, without preoperative suspicion of ductal stone to determinate the incidence and morbility in a University Hospital. Methods: Retrospective analysis from a prospectively collected database. Inclusion Criteria: Elective laparoscopic cholecystectomy with intraoperative CBD stone found during transcystic cholangiography. Result: Between March 2008 and August 2011, a total of 2471 laparoscopic cholecystectomy operations were perfomed. Of these, 1453 were elective procedures. Unsuspected lithiasis in the CBD were diagnosed in 3.16% patients (n = 44) during the intraoperative cholangiography (34 females, 10 males). All cases were initially treated by transcystic exploration. The rate of conversion was 2.5% (n = 2), 9% required choledochotomy and closure on a T Tube (n = 4). In one case primary closure was performed. The average post operative stay was 1.4 days (range 1–10 days). None of the patients required post operative ERCP (Endoscopic Retrograde Cholangiopancreatography) neither second procedure. The morbidity was 6.8% (n = 3) and there was no mortality. Conclusion: Our incidence of unsuspected CBD stone was similar to global rates (3.16%). Most of the cases (80%) were resolved it successfully by transcystic exploration without biliary duct injury, and in the remainder, CBD was clear with a choledochotomy in the same procedure. We conclude that systematic transcystic exploration should be done in every procedure, even in patients without preoperative suspicion of ductal stone.

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ROBOTIC MAJOR LIVER RESECTIONS. ANALYSIS OF TECHNIQUE AND INTRAOPERATIVE HEMODYNAMICS. David Calatayud, MD PhD, Stefano D’ugo, MD, Francesco Coratti, MD, Paolo Raimondi, MD, Federico Gheza, MD, Mario Masrur, MD, Enrique F Elli, MD, Francesco M Bianco, MD, Subashini Ayloo, MD, Pier C Giulianotti, MD FACS University of Illinois at Chicago Medical Center Introduction: Open surgery is the standard approach for major liver resections. Laparoscopic approach is limited to few hepatic transactions. Robotic surgery allows the surgeon to perform complex procedures in the liver, including major resections. This study presents a series of major liver resections performed by the robotic approach, focusing in the intraoperative data concerning the technical surgical aspects, as well as the hemodynamic management. Methods and Procedures: This study is a single-surgeon series, which included all major hepatic resections performed by robotic approach. Major liver resection is defined by a resection of 3 or more liver segments. We have analyzed intraoperative surgical aspects, as the devices used for the liver transection, or the need of Pringle maneuver. The intraoperative anesthetic management of the hemodynamic status of the patient has been evaluated, focusing on the central venous pressure (CVP) during the transection, the main blood pressure, and the resulting blood loss and requirements for transfusion. The statistical analysis is performed by the IBM SPSS StatisticsTM software version 19. Results: From November 2003 to July 2011, 47 major liver resections have been performed in 3 different centers (male/female: 24/23). The mean age of the patients was 57.01 ± 14.98 (SD), with a mean BMI of 27.63 kg/m2 ± 6.8. The indication of the surgery was a malignant lesion in 34 patients (72.3%). Procedures were: Right hepatectomy (n = 31), left hepatectomy (n = 5), extended right hepatectomy (n = 4), extended left hepatectomy (n = 3), trisegmentectomy or multiple ([3) liver segment resection (n = 4). Pringle maneuver was used in 1 case. The device most frequently used during the parenchymal transection was the harmonic scalpel, in 95.7% of the cases, and the bipolar device was the coagulation device of choice in 70.6% of the cases. Median blood loss was 600 mL, and intraoperative transfusion was needed in 9 cases (19.1%). During the liver transection, mean CVP and blood pressure were 7.75 and 81.95 mmHg respectively. The mean operation time was 391 min ± 137. Conversion rate was 12.8% (n = 6). Postoperative bile leak was detected in 1 patient, treated endoscopically with an ERCP. The median hospital length of stay was 6 days ± 4.34. Conclusion: Robot assisted major liver resections seem to be feasible and to have good outcomes. Morbility and tranfusion rate are low. Technical details are discussed . The robotic technology could expand the role of the minimally invasive approach in hepatobiliary surgery.

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FLUORESCENCE GUIDANCE FOR IDENTIFICATION OF THE CYSTIC DUCT—COMMON BILE DUCT JUNCTION. FIRST EXPERIENCE IN ROBOTIC SURGERY Pier C Giulianotti, MD FACS, David Calatayud, MD PhD, Luca Milone, MD, Stefano D’ugo, MD, Paolo Raimondi, MD, Mario Masrur, MD, Federico Gheza, MD, Enrique F Elli, MD, Francesco M Bianco, MD, Subashini Ayloo, MD, Enrico Benedetti, MD FACS, University of Illinois at Chicago Medical Center Introduction: An adequate identification of the cystic duct—common bile duct (CBD) junction is the main surgical landmark in gallbladder surgeries. Bile duct injury (BDI) is a rare but serious complication of laparoscopic cholecystectomy, with an incidence about 0.3–0.7%. To reduce the risk of BDI during cholecystectomy the intraoperative cholangiography (IOC) is done in many centers, with some advantages, but some has some disadvantages related to the technique. In the last years, Indocyanine green (ICG) has been used as a fluorescent agent by means the near-infrared light (NIR) technique to visualize blood flow and related tissue perfusion. ICG is a synthetic anion, administered intravenously and excreted exclusively into the bile. During its excretion ICG emits light when illuminated with NIR, obtaining the fluorescence imaging. This imaging has the advantage to identify biliary anatomy even before starting the surgical dissection of the gallbladder hilum, without imposing an additional risk to the patient. Methods and Procedures: From July, 26th until September, 20th 2011, all the patients undergoing a robotic cholecystectomy were included in this study. Exclusion criteria were patients 16 years old or less, and to have a proved allergy to contrast iodide. Seven different surgical biliary landmarks were analyzed for the fluorescence visualization, and most importantly the cystic duct-CBD junction. Biliary anomalies also were analyzed. The liver function was assessed to correlate with the ICG biliary excretion. Results: During this period, 25 robotic cholecystectomies using the NIR technique have been performed in our center. The period range from the intravenous injection of ICG until the first NIR visualization varies from 20 min, up to more than 6 h. In all but 2 cases there was a positive visualization of the junction between the cystic duct and the common bile duct. Three biliary anomalies were detected. Two of them consisting in right aberrant canaliculus from segment VI to the CHD in both cases, and in another case it was an anterior implantation of the cystic duct in the CBD. Conclusion: Fluorescence during Robotic Surgery, as part of a new generation of real time implemented imaging, it is a very promising development. The identification of the cystic duct junction in particular can contribute to make the cholecystectomy safer in minimally-invasive biliary surgery.

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A CASE OF PSEUDOLYMPHOMA OF THE LIVER OPERATED WITH LAPAROSCOPIC SURGERY Hiroki Kamata, Kenichiro Ishii, Hiroshi Tajima, Hiroyuki Katagiri, Kazunori Huruta, Yusuke Kumamoto, Masahiko Watanabe, Department of Surgery, Kitasato University School of Medicine Hepatic pseudolymphoma (HPL) and primary hepatic marginal zone B cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) are rare diseases and the differential diagnosis between these two entities is sometimes difficult. Here we experienced a case which was diagnosed for HPL by laparoscopic liver resection. The patient was a 56-year-old woman. She was pointed out SMT of the stomach in 1996. She visited our hospital for investigation. Ultrasonography revealed the SMT was exclusion of liver itself and high echoic tumor which size was 9 mm was detected in the left lateral segment of the liver. As serology examinations for hepatitis C viruses was positive, she was followed in outpatient. Magnetic resonance imaging performed in 2008 suggested the lesion was suspected for hepatocellular carcinoma. She didn‘t hope further treatment at that time. In 2011, imaging study using computed tomography and magnetic resonance imaging showed tumor margin was enhanced in early phase, but was low signal in delayed phase. Under a diagnosis of well differentiated hepatocellular carcinoma, laparoscopic lateral segmentectomy was performed. The lesion was white and hard with clear margins. Histopathological examination showed Lymph follicles with germinal centers were well formed and lymphocytic infiltration was extended along portal tracts. Immunostainings for CD3, CD20, and CD79 revealed regularly distributed T cells and B cells. In situ hybridization for immunoglobulin light chains was performed because it is one of the useful tools to discriminate between reactive lymphoid lesions and MALToma. In situ hybridization revealed no significant difference between the numbers of cells positive for kappa-chain and lambda-chain. Based on these histological features, the lesion was diagnosed as pseudolymphoma of the liver. Surgical margin was negative. The postoperative course was uneventful, she was discharged on POD 8. We experienced a case of Pseudolymphoma of the liver which was operated after 15 years follow up.

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ATYPICAL LAPAROSCOPIC RIGHT ANTERIEUR BISEGMENTECTOMY FOR SINGLE TUMOR Ludmil M Veltchev, MD PhD, Manol A Kalniev, MD PhD, Department of Abdominal surgery

Controversy remains as to the optimal indications for resection of cystic pancreatic neoplasms. Minimally invasive pancreatic surgery is being more widely adopted. The risk/benefit decision for resection of cystic pancreatic neoplasms needs to consider the morbidity and mortality of the surgical procedures. We chose to evaluate our experience with minimally invasive pancreatic resection for cystic neoplasms. Methods: A retrospective review was conducted on all patients undergoing minimally invasive pancreatic resection for cystic lesions from 1/2005 to 9/2011. Results: 41 minimally invasive pancreatic resections were performed for cystic lesions by preoperative imaging. Pathologies are listed in Table 1. There were 3 total pancreatectomies, 5 pancreatico-duodenectomies(PD), and 33 distal resections. Length of stay (LOS) was 6 ± 1, 12.5 ± 11.7, and 3.1 ± 1.7 days for total, PD, and distal resections respectively. Blood loss and operative times are displayed in Fig. 1. A single mortality (2.4%) occurred in the PD group from stroke. Morbidity for total, PD, and distal was 0, 60, and 15% respectively. No pancreatic fistulae occurred in the distal resection group. Conclusions: Minimally invasive pancreatic resection for cystic neoplasms can be performed with similar morbidity and mortality to open procedures. Distal resections may offer lower morbidity than open procedures. Further evaluation is necessary for the indications for distal resection for cystic neoplasms.

Table 1 IPMN Serouscystadenoma Mucinous cystic neoplasm Solid pseudopapillary Lymphoepithelial cyst Pancreatitis Pancreatic cancer Neuroendocrine

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IS THERE ROOM FOR IMPROVEMENT IN THE DIAGNOSTIC ACCURACY OF INTRAOPERATIVE CHOLANGIOGRAM? S El Djouzi, MD, A Y Zemlyak, MD, V B Tsirline, MD, B Hammond, Michael T Lavelle, MD, Amanda Walters, MS, D Stefanidis, MD PhD, T B Heniford, MD, Carolinas Medical Center Background: Post-cholecystectomy ERCP is commonly performed for abnormal findings of the intraoperative cholangiogram (IOC) interpreted by the operating surgeons. Our objective was to assess the accuracy of IOC for diagnosing choledocholithiasis and predicting the need for post-operative ERCP. Methods: A retrospective review of patients who underwent postoperative ERCP for the identification of a filling defect during IOC at an academic institution between 2006 and 2011 was performed. Patient demographics, IOC and ERCP findings were recorded. The surgeons’ interpretation of the IOC was compared to that of the radiologist’s and to the findings of the ERCP to determine the accuracy of intraoperative and radiographic interpretation. Results: Ninety-seven cases that had an abnormal filling defect during IOC and a postoperative ERCP were identified and reviewed. Patient age was 42 ± 16 years, BMI was 30.5 ± 7.5 kg/m2, 74% were females, and 55% Caucasians. Conversion rate was 1% and length of stay 4.6 ± 2.9 days. All IOCs were reviewed by a radiologist who confirmed a filling defect in only 55% of patients. Subsequent ERCP revealed stones in 52.5%, sludge in 18%, ampullary stenosis in 8%, and no abnormal findings in 22%. The accuracy of the surgeon’s interpretation of IOC was 73% and that of the radiologist 78% (p [ 0.05). In cases where glucagon was used (N = 25), the accuracy was improved (88.4% versus 67%; p = 0.04). Unsuccessful CBD exploration requiring postoperative ERCP was performed in 12 patients; challenging anatomy, inability to access the CBD due to tortuosity of the cystic duct, or inability to retrieve the stones through the cystic duct were reasons for failure. The subsequent ERCP revealed stones in 2 patients, sludge in 1 patient, and normal findings in 9 patients. CBD dilatation (size [ 6 mm) was seen in 59.2% of the entire sample, whereas 79.6% of the patients with abnormal ERCP (stones, sludge, or stenosis) had a dilated CBD. The CBD was dilated in 64.7% of ERCPs with stones, in 37.5% of ERCPs with ampulla stenosis, and in 23% of the ERCPs with sludge. Conclusion: The accuracy of IOC as interpreted by the operating surgeon during cholecystectomy approached 80% and was not significantly different than that of the radiologist and may be increased by using glucagon. The use of transcystic duct exploration, intra-operative ultrasound, or post-operative MRCP as an adjunct to IOC prior to ERCP needs to be studied and may reduce the incidence of negative ERCPs.

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MINIMALLY INVASIVE PANCREATIC RESECTION FOR CYSTIC NEOPLASMS Philip Q Bao, MD, Kevin T Watkins, MD, Stony Brook University Medical Center

Anterior right sectorial resection or bisegmentectomy 5–8 is an indication for primary malign liver tumors or single metastasis. Anatomical disposition of this sector between hilar portal arterial inflow and venous outflow is making its resection very difficult without the sacrifice of the intact blood flow to right posterior segments. Gold standard procedure is wedge liver resection under intraoperative ultrasound and blood control by clamping of the right hepatic artery. Introduction of laparoscopic manipulations on the liver permits performance of typical major liver resections under Pringle maneuver and in selected cases hilar plate dissection and blood control proximally to divergence of hepatic artery. It is difficult in this antegrad methodology to find exact borders between right anterior sector and right posterior sector. Our method for save laparoscopic bisegmentoctomy 5-8 includes the following steps: 1. Pneumoperitoine 2. 308 camera insertion 3. Laparoscopic cholecystectomy 4. The hepatoduodenale ligament dissection and insertion of elastic tape for Pringle maneuver, exteriorized by 5 mm hard tube for security. 5. Determination of the place for minimal liver dissection of the gall bladder bed to find and clipping of the right anterior artery branch. Avascularization of the anterior sector. We found the right anterior branch at the point where projection of right hepatic artery crosses the sagital line of the gallbladder bed and 1.5–2 cm superior-posterior intrahepataly. 6. Wedge resection of unvascularized area of segments 5–8 using bipolar instrument and clips. 7. Minilaparotomy for evacuation of specimen. Advantages: - No rick for blood lost - Absolutely demarcation of resection lines - No rick for damage of right and middle hepatic veins if follow demarcation. Disadvantages: - Difficult to find right anterior branch using gallbladder bed: need to follow the right hepatic artery from liver hilar just to division to anterior and posterior branch and clipping. It my have parenchymal phase.

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IMPACT OF Introduction OF LAPAROSCOPIC SURGERY ON MANAGEMENT OF UNRESOLVED INTRAABDOMINAL MALIGNANCIES IN A SEMI-URBAN NIGERIAN HOSPITAL Adewale O Adisa, MBChB FWACS FMCSNig DMAS, Oladejo O Lawal, MBBS FMCSNig FWACS, Obafemi Awolowo University, Ile-Ife, Nigeria Introduction: With limited access to modern imaging techniques, intra-abdominal malignancies often pose diagnostic challenges to surgeons in poor resource settings. This article describes initial experience with laparoscopic surgery for advanced intra-abdominal malignancies in a Nigerian hospital. Methods and procedures: A prospective study was carried out from January 2009 through December 2010. Patients preoperative, intraoperative and postoperative data were recorded and evaluated. Results: Thirty-six patients with previously unresolved intra-abdominal tumours were studied. Fifteen (41.7%) had masses detected by Computerized Tomography (CT) without a clear diagnosis while 21(58.3%) could not afford the CT scan. On diagnostic laparoscopy, 12(33.3%) had ascites. Anatomic diagnosis were made and tissue biopsies taken in all patients leading to histopathological diagnoses such as abdominal tuberculosis, lymphoma, pancreatic carcinoma, hepatic malignancies, carcinoid tumour, and Kaposi’s sarcoma in an HIV positive patient. One operation was converted to open due to significant bleeding from hepatic biopsy site. No mortality was recorded. With local adaptation and improvisations, the local cost of the procedure was about 30% the cost of abdominal CT scan in our setting. Conclusion: Laparoscopic surgery provided an affordable and safe aid for clinical and histopathologic diagnosis for patients in a resource limited setting. Key words: Laparoscopic surgery, intra-abdominal malignancies, Nigeria.

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THORACOSCOPIC ESOPHAGECTOMY IN THE PRONE POSITION Hidehito Shibasaki, MD PhD, Takahiro Kinoshita, MD PhD, Akira Ogata, MD PhD, Masaru Miyazaki, Prof, Matsudo City Hospital, Department of Surgery Thoracoscopic esophagectomy performed with the patient in the left lateral position has been occasionally reported since the 1990s, but it has not been established as a standard procedure. This may be because the success of this procedure largely depends on the technical competence of an assistant to secure an adequate field of view during the procedure. Thoracoscopic esophagectomy with the patient in the prone position has recently been introduced and has been consistently shown to be useful. Compared with left lateral thoracoscopic esophagectomy, prone thoracoscopic esophagectomy requires less assistance in exposing the operative field, and it is relatively easy to obtain a satisfactory field of view. We performed prone thoracoscopic esophagectomy on 20 patients and were successful in achieving a wide field of view. The postoperative course was remarkably favorable in all patients, and the procedure is considered promising for standard thoracoscopic esophagectomy. There are few detailed reports of this procedure; herein, we describe the procedure of prone thoracoscopic esophagectomy employed at our hospital. Outcomes of 20 patients who underwent thoracoscopic esophagectomy in the prone position Age (years)

68.6 (49–81)

Male/female

15/5

Operation time (min)

554.2 ± 27.8 (450–680)

Blood loss (mL)

194 ± 114 (84–350)

Time of extubation (days)

0.70 (0–1)

Start of oral intake (days)

3.3 (1–7)

Length of postoperative hospital stay (days)

17.8 (10–74)

Postoperative complications in 20 patients who underwent thoracoscopic esophagectomy in the prone position Complications Anastomotic failure Hoarseness Ileus Pneumonia aspiration Chylothorax

Number (%)

1 (5.0) 8 (40.0) 1 (5.0) 2 (10) 2 (10)

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SURGEONS’ ESTIMATED STANDARD METABOLIC EQUIVALENT, A PILOT STUDY Miroslaw Szura, MD PhD, Jan M Krzak, MD, Poul Bak Thorsen, Ist Department of General Surgery Jagiellonian University, Krakow, Poland & Sygehus Lillebaelt, Kolding, Denmark

THE NEW FLEXIBLE TROCAR FOR SINGLE PORT SURGERY M. Yamagata, title, M. Matsuda, title, S. Hayashi, title, K. Hagiwara, MD, T. Takayama, PhD, Department of digestive surgery, Nihon University

Introduction: To estimate surgeons’ estimated standard metabolic equivalent (MET) in a pilot study from established METs. From 70 observations including skiing, running, bicycling, consultations in outpatient clinic, cholecystectomy, endoscopy, and endoscopic retrograde cholangio-pancreatography, energy used related to each of the physical activities to be calculated and from the results to estimate standard metabolic equivalent for an average surgeons’ work related activities from the METS for skiing, running, and bicycling. A Garmin Forerunner XT310 was used for energy monitoring. Results: The mean Kcal per minute for all physical activities, skiing, running, and bicycling, were statistically significantly higher than the energy used for carrying out the surgeons work related activities. The means of energy used for the surgeons work related activities were one fourth of the physical activities; values were 2.437 Kcal per minute (40 observations) and 10.517 Kcal per minute (30 observations), respectively. Estimated METs for a surgeons work can thus be calculated from METs agreed upon for skiing, running, and bicycling (2011 Compendium of Physical Activities). Conclusion: Surgeons’ standard metabolic equivalent is in average one fourth of physical activities such as skiing, running, and bicycling. Details of calculations will be presented.

SPG spreads explosively now. However, maximal problem is in single port surgery that all of the operation is performed from an isologues direction and operative degree of difficulty increase with distance between navel and target organ. for example, Appendectomy and colostomy were comparatively easy for short distance from navel, but operation for esophagus, stomach and gall bladder were more difficult because in these operation comparatively had a long distance from a navel, If the operation will be performed from an isologues direction, pre-bend instruments will be necessary for changing vector of dissection and traction. In the present time, disposable flexible forceps were already derived but these instruments were more expensive, and Flexibility of Energy device is not satisfactorily. In Second generation of Single port surgery, Flexible instruments or flexible trocar is crucial factors. By change way of thinking, we developed the specific structural flexible trocar made by silicon and wire. All kinds of this trocar are disposable. Types of trocar are 2 type. First type has no air inlet with cock, other type has side cock. And diameters of trocar were 5 mm, 10 mm, 15 mm, respectively, and lengths of trocar were 60 mm, 100 mm, 150 mm respectively. In insertion of second or third trocar, it is very difficult to confirm tip of trocar, by endoscopy, so dangerous blind insertion was sometimes performed. The insertion of this trocar to peritoneal cavity uses Seldinger’s method which use by angiography, it is for prevent injury of peritoneal organ, so this method of insertion to peritoneal cavity is become to more safety compared with direct insertion. As other characteristics of this trocar, we can insert any shape of flexural forceps to peritoneal cavity by using this trocar. An operator can set any Vector of manipulation and traction by using this trocar with pre-bend instruments. And dissection of Vessel and Duct will become easy, so stress of an operator will be relieved. It is necessary enough training, the first Step of training is dry lab. for making image of movements in pre-bend instruments. And second step is simulation by wet lab, because movement of pre-bend instruments were extremely different compared with normal procedure. Finally, Our trocar have benefits that, we can use reusable pre-bend instruments, as a result, opportunity of using disposable flexible instruments will be decreased, so that cost performance will be improved. In addition, we could apply this trocar with flexural forceps to even normal procedure and reduced port surgery.

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EVOLUTION OF HEPATIC ENDO-RETRACTORS IN INCISION REDUCTION ANTI-REFLUX SURGERY Fausto J Da´vila, MD, Daniel Tsin, MD, Guillermo Domı´nguez, MD, Martha R Da´vila, MD, Jose Lemus, MD, Ramiro Jesus, MD, Hosp Regional de Poza Rica, Ver. Mex. Mount Sinai Hospital Queens, NY .USA Fundacio´n Hospitalaria. Buenos Aires. Arg. Hosp Gral Dr. Manuel Gea Gonzalez. DF, Mex. Hosp Reg Zona PEMEX. Poza Rica, Ver Mex Universidad Nacional Autonoma de Mexico. DF. M The objective of this work is to show different forms of liver retraction by avoiding the use of additional ports and instruments thus reducing abdominal trauma as well as improving the cosmetic results, beyond traditional laparoscopy. Material and Methods: From July 2004 to July 2010 we conducted a retrospective study that included 32 patients, 8 men and 24 women in need of anti-reflux surgery. Patients with a BMI [ 30 were excluded. The instruments used for liver retraction are from 0.5 to 2 mm in diameter, developed specifically for this purpose. A 2 mm angled rod was used in 6 cases, a needle hook in 14, a retraction alligator also known as secured independent tool in 2, a laparoscopy rein (hereinafter referred to as ‘‘endolifter’’) in 7, and a double needle endolifter in 3. All surgeries were successfully done with no complications. Conclusion: The above described mini liver retractors have the advantage of reducing abdominal trauma, with good cosmetic results and low cost. More cases are needed to validate these results.

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DEVELOPMENT OF THE HYPEREYE MEDICAL SYSTEM FOR ENDOSCOPIC SURGERY Michiya Kobayashi, MD PhD, Takayuki Sato, MD PhD, Takeki Sugimoto, MD PhD, Ken Okamoto, MD PhD, Ken Dabanaka, MD, Tsutomu Namikawa, MD PhD, Takehiro Okabayashi, MD PhD, Kazuhiro Hanazaki, MD PhD, Department of Human Health and Medical Sciences, Hospital Administration Section, Department of Cardiovascular Control, and Department of Surgery, Kochi Medical School Introduction: We developed a new imaging system (HyperEye Medical System, HEMS) for simultaneously capturing nearinfrared (NIR) fluorescence of indocyanine green (ICG) and visible light through a unique, high-sensitive, charge-coupled device (CCD) area sensor coated with arrays of red-, green-, blue-, and NIR-specific filters. Unlike multiple-sensor systems, HEMS enables real-time color-NIR imaging in ICG fluorescence-guided endoscopic surgery without the need for special video data laparoscope processing to superimpose the NIR signal on color images. We have developed a prototype that captures NIR fluorescence of ICG (HEMS-E) and carried out preliminary evaluation of the system in laparoscopic colon surgery. Methods and Procedure: To label a site of interest, we injected 0.2 ml of ICG solution (1 mg/ml) and 0.2 ml of Indian ink into the submucosal layer adjacent to the tumor to be resected. While ICG was excited with a custom-made xeon fiber illumination system, NIR fluorescence and color images were visualized with HEMS through the NIR-compatible endoscope. Results: The resolution of our new endoscopic imaging is still insufficient for surgical procedures. However, our new HEMS-E imaging system could detect the fluorescence of ICG even in cases where the Indian ink was not visible by conventional laparoscopy (HD Endoeye LTF-VHTM, Olympus, Japan). Conclusions: The resolution of HEMS-E should be improved to satisfy the needs of laparoscopic surgery using this system. However, the detection limits for tumor sites during laparoscopic surgery by HEMS-E is superior to that provided by a standard laparoscope using Indian ink. Further development of HEMS-E is going to meet the needs of the surgeon.

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STERILISATION AND DISINFECTION ACCEPTATION TEST OF REUSABLE SINGLE PORT AND MINIPORT LAPAROSCOPIC INSTRUMENTS D A Van Dam, MD, S Beeksma, W J Meijerink, MD PhD, VU University Medical Centre Amsterdam Objective: to determine if newly designed reusable laparoscopic HiQ LS (Olympus, Hamburg Germany) for single port surgery and AdTechmini (BBraun, Melsungen Germany) miniport instruments meet the disinfections and sterilisation standards used in the VU university medical centre, Amsterdam The Netherlands. The HiQ instrument line has distinctively fixed, curved shafts with undetachable rotating parts that remaining covered during cleaning procedures. The AdTechmini instruments are detachable to individual parts with accessible rotating parts and is similar in shape compared to the conventional rigid laparoscopic instruments. However, the characteristic small diameter (3.5 -4.5 mm) of these miniport instruments could compromise the cleaning procedures. Design and methods: an acceptation test including multiple cycles of soil and cleaning following standard VU University Medical Centre procedures was performed on the new instruments. Cleaning procedure consists of intensive cleaning by hand with alkaline agent and ultrasonic cleaning followed by mechanical cleaning. Cleaned instruments are subjected to visual inspection and protein testing. Results are digitally recorded. Results: multiple different types of instruments of both instrument lines were subjected to the acceptation test. One instrument of the HiQ line had mechanical failure after the 2nd test cycle and the acceptation test was ended. A second HiQ instrument was opened after the 4th test cycle for additional visual inspection, and opened further after the 5th cycle. A third HiQ instrument received only mechanical cleaning in the first test cycle to control for the effect of the hand-cleaning before the mechanical washing. With the exception of the instrument receiving only mechanical washing, all instruments were clean. The opened instrument showed no internal residue of the test agent. No contamination was found at evaluation after the first 10 clinical cases. Conclusion: the newly designed laparoscopic HiQ LS and AdTechmini miniport instruments can be reused when following the standard VU university medical centre protocol for disinfection and sterilisation as stated for laparoscopic instruments. It is mandatory to perform the pre-mechanical hand wash to guarantee sterilisation. Reusability of specialized laparoscopic instruments after standard cleaning protocols could be crucial for the future use and development of the minimal invasive surgery. Additional costs for extended or repeated cleaning procedures, or purchase of specialized sterilisation equipment could neutralize any financial advantage that single port surgery could have over conventional laparoscopic instruments.

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FIRST CASE SERIES OF MICROLAPAROSCOPIC ADJUSTABLE GASTRIC BANDING: MAINTAINING ERGONOMICS AND LAPAROSCOPIC PRINICPLES OF TRIANGULATION WHILE REDUCING SCARS Emma J Patterson, MD, Jamie Laut, MEd, Oregon Weight Loss Surgery LLC, Portland OR; Legacy Good Samaritan Medical Center, Portland OR; Wilshire Surgery Center, Portland OR Introduction: Many recent potential advances such as single incision laparoscopic surgery (SILS) require additional (often disposable) devices or for the surgeon to employ a less ergonomic approach. Microlaparoscopic Adjustable Gastric Banding (MLAGB) is a novel modification that utilizes smaller, reusable instruments resulting in tiny scars, and yet maintains the basic laparoscopic principle of triangulation. This is a pilot study to assess the feasibility and safety of MLAGB. Methods and Procedures: Between March and September of 2011, 10 of 49 consecutive adult patients undergoing banding by a single surgeon were offered the MLAGB approach. Inclusion criteria were: relatively young and healthy; lower BMI; and a short, thin upper abdomen that was scar-free preoperatively. A 15 mm trocar was placed at the umbilicus, and three or four 2.9 mm cannulas in the upper abdomen. The 2.7 mm microlaparoscopic instruments are made from a ceramic-titanium alloy (TransEnterix, Research Triangle, NC). Data was collected prospectively in an IRB-approved registry. Results: MLAGB was performed successfully on all patients, and two had concurrent hiatal hernia repairs. They were 90% female, had a median age of 35 years (range 22 to 46 years), and a median body max index (BMI) 39.4 kg/m2 (range 34.3 to 44.6). Median operative time was 56.5 min (range 52 to 76 min). None of the patients have had complications. Four graspers were broken while attempting to lock the buckle of the band. This step is now performed with one micro grasper in the right upper quadrant and one regular bariatric needle driver through the umbilical trocar. Conclusions: This early experience with MLAGB suggests that the instruments are strong enough to perform gastric banding surgery safely on some highly selected bariatric patients, but not strong enough to lock the band. MLAGB may appeal to patients due to the tiny scars, which help protect their privacy about surgery, and may appeal to surgeons due to the maintenance of ergonomic and laparoscopic principles.

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SINGLE PORT ACCESS (SPA) LAPAROSCOPIC CHOLECYSTECTOMY VERSUS THREE-PORT LAPAROSCOPIC CHOLECYSTECTOMY: A Prospective Randomized Study Raymund Andrew G Ong, MD FPCS FPALES, Winston S Vequilla, MD DPBS, Department of Surgery, FEU-NRMF Medical Center, Philippines Objectives: Laparoscopic cholecystectomy has replaced open cholecystectomy as the standard procedure for gallbladder removal whenever possible. Recent developments regarding laparoscopic cholecystectomy have been directed toward reducing the size or number of ports to achieve the goal of minimally invasive surgery. The first successful case of single port access (SPA) Laparoscopic Cholecystectomy in the Philippines was done at FEU-NRMF Medical Center in August 2008 and became almost the standard in the surgery of the gallbladder. The goal of this prospective randomized controlled clinical study is to evaluate the real benefit of single port access as compared to standard threeport technique without compromising the safety in cases of laparoscopic cholecystectomy in terms of pain, recovery, and patient satisfaction. Methods: Seventy-five consecutive patients who underwent elective laparoscopic cholecystectomy were randomized to undergo either the SPA or the standard 3-port technique. Three surgical tapes were applied to standard 3-port sites in both groups at the end of the operation. All dressings were kept intact until the first follow-up 1 week after surgery. Postoperative pain at the 3 sites was assessed on the first day after surgery by using a 10-cm unscaled visual analog scale (VAS). Other outcome measures included analgesia requirements, length of the operation, postoperative stay, and patient satisfaction score on surgery and scars. Results: Demographic data were comparable for both groups. Patients in the standard threee-port group had shorter mean operative time (47.3 ± 29.8 min vs 60.8 ± 32.3 min) for the SPA group (P = 0.04). SPA group had less pain at port sites on 12 post-op (mean score using 10-cm unscaled VAS: (2.19 ± 1.06 vs 2.91 ± 1.20 P = 0.02). Overall pain score, analgesia requirements, hospital stay, and patient satisfaction score on surgery and scars were similar between the 2 groups. Conclusion: The study showed that single port access (SPA) laparoscopic cholecystectomy is comparable and has similar clinical outcomes to the standard three port laparoscopic cholecystectomy in the surgical treatment of cholecystitits. Added advantages are reduced need for analgesics and a virtually scar-less surgery.

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DEVELOPMENT OF AN ERGONOMIC INSTRUMENT FOR LAPAROSCOPIC AND LESS SURGERY Jakeb D Riggle, Adam E De Laveaga, Jake Kaufman, Chad A Lagrange, MD, Dmitry Oleynikov, MD FACS, M Susan Hallbeck, PhD PE CPE, University of Nebraska—Lincoln and University of Nebraska Medical Center

COMPARING THE BIOMECHANICAL CHARACTERISTICS OF MANUAL AND POWERED LAPAROSCOPIC STAPLER DESIGNS Donald R Peterson, PhD, Drew R Seils, BS, Tarek Tantawy, BS, Angela S Kueck, MD, M Kurt E Roberts, MD, University of Connecticut Health Center, Yale University

The most common laparoscopic surgical tools in use have been shown to be detrimental to surgeons’ health, causing hand and finger pain potentially leading to nerve lesions and numbness. In an effort to reduce the pain and awkward postures surgeons endure during laparoscopic surgery, a new laparoscopic tool was developed starting with direct observation of minimally invasive surgery (MIS), surgeon input, and basic ergonomic design. The objective of this design was to reduce surgeon discomfort during surgery, potentially reducing surgical errors caused by discomfort and awkward postures, and to improve performance of certain tasks during laparoscopic surgery. Basic design of the instrument began with contextual inquiry interviews of surgeons in the operating room to examine the cause of discomfort and pain during surgery as well as the use of current instruments. This ethnographic approach opened lines of communication between the researchers and the surgeons, enabling a true user-centered design process. The size of the instrument was fashioned to comfortably fit a 5th percentile woman and a 95th percentile man using an adjustable mock handle. The shape of the handle was created to reduce abduction of the arm, reduce radial deviation of the wrist during surgery, and decrease actuation grip strength. Functional characteristics such as an articulating end effector with 360 circumduction and 60 flexion and extension were developed using surgeon feedback through interviews and surveys. This unique articulation would give the instrument the ability to overcome the lack of triangulation present in laparoendoscopic single-site surgery (LESS). Usability testing showed that use of the prototype ergonomically-designed tool improved performance on select Fundamentals of Laparoscopic Surgery (FLS) training tasks and reduced harmful arm and wrist angles adopted during laparoscopic surgery. Further usability testing and surveys confirmed that both experienced surgeons and novice users preferred the prototype instrument to a common scissorstype laparoscopic instrument. Despite high marks and praise from nearly all users tested, the ergonomically-designed laparoscopic instrument encountered muted interest when presented to industry instrument manufacturers. The complex control mechanisms were deemed difficult to manufacture and prone to failure after extended use. The usercentered design process resulted in a surgeon-friendly instrument that was not feasible to manufacture, prompting researchers to reevaluate the functional characteristics and mechanical design of the tool. Novel functions were weighed against reliability and ergonomics to determine what features could be modified to maintain the instrument’s ergonomic advantage over current instruments and improved usability in the operating room. The final iteration of the redesign process has yielded an ergonomic and universally fitting instrument with an articulating end grasper capable of 360 circumduction, ideal for use in both laparoscopic and LESS surgeries. Additionally, the new design is able to withstand the forces and environment encountered during MIS, giving the instrument the capabilities to perform most laparoscopic surgical tasks, including needle driving. The end result is a fully functional, unique ergonomic laparoscopic instrument.

Introduction: The incidence of musculoskeletal disorders among laparoscopic surgeons is increasing and may be a result of an increase in surgical procedures performed and the biomechanical risks associated with manually-operated laparoscopic instrument use. The introduction of battery-powered surgical instruments may alleviate some of the biomechanical stressors experienced with their manual counterparts and provide an increase in surgical accuracy and efficiency. To better understand and compare the biomechanical risks associated with the use of manual and powered laparoscopic surgical staplers, the physical characteristics and the forces required to activate the various functions of a stapler, including staple firing and blade retraction, were measured for two manual designs (Covidien Endo GIA Ultra, Ethicon Echelon Flex 60) and one powered design (Covidien iDrive Ultra). Measurements included the identification of key ergonomic features such as handle shape and contour, handle angle, hand and finger reach, and grip spans. Methods and Procedures: All physical dimensions were measured using precision calipers and an image analysis software protocol, configured for linear and angular metrics, was used to characterize high-resolution photographs taken of each stapler from various perspectives. The forces required to activate the various functions of the stapler were measured using strain gage force transducers. Four stacked layers of 4 mm thick foam were used as a tissue surrogate for all clamping and firing operations. Results: The physical dimensions varied between staplers and direct correlations were difficult because of the inherent differences in design and functionality. Except for the finger reach associated with staple firing for the Echelon, the dimensions of each stapler were observed to fall within published anthropometric limits for males and females. The clamping lever motion of the two manual staplers favorably traverses a grip span ranging from 2 to 4.5 inches, which allows for the greatest use of grip strength in both male and female users. The activation forces for each of the stapler components also varied and considerable differences in force levels were observed between the stapler designs. Both manual staplers subject its users to repeated grip forces in excess of 20 pounds during staple firing and blade retraction functions, while published literature indicates that maximum grip force levels should not exceed 25 pounds when designing a hand tool for use by 95 percent of the female population. Conclusion: Although the physical characteristics of the three stapler designs were generally within the recommended anthropometric limits for males and females, the dimensions of the manual staplers are not adequately suited for use by male or female surgeons having a glove size less than 6.5, as reported in the literature. The presence of high activation force levels generates significant biomechanical risks to the surgeon, especially if coupled with awkward postures, strained movements, and/or one-handed operations. The slightly-heavier powered stapler demonstrated negligible staple firing and blade retraction forces when compared to the manual staplers, which may increase instrument stability and decrease surgeon fatigue. If properly designed, powered instruments may help to control, and possibly eliminate, some of the musculoskeletal issues inherent to minimally-invasive surgeries.

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REVIEW OF SURGICAL ERGONOMICS RESEARCH ASSOCIATED WITH MINIMALLY INVASIVE SURGERY Donald R Peterson, PhD, Tarek Tantawy, BS, Drew R Seils, BS, Angela S Kueck, MD, M Kurt E Roberts, MD, University of Connecticut Health Center, Yale University

30-30 CUT/COAG—IS ELECTROSURGICAL MONOPOLAR ENERGY TECHNOLOGY UNDERUSED? Paul N Montero, MD, Matthew Fox, MD, Thomas Robinson, MD, Gregory V Stiegmann, MD, University of Colorado School of Medicine

Introduction: The widespread acceptance of minimally invasive surgical procedures has led to an increase in its popularity and demand. The growing number of surgical procedures performed coupled with the high physical demand of the laparoscopic tasks has resulted in a significant rise in occurrence of neuromuscular disorders among surgeons. According to a 1999 SAGES survey, 8% to 12% of 149 surgeons reported frequent pain or numbness in arms, wrists, or hands following laparoscopic surgeries. In 2007, the University of Chicago estimated that 30% of 73 urologists sustain neuromuscular or arthritic injury from laparoscopic surgeries. The prevalence of these conditions has prompted ergonomics researchers to evaluate the environment of the operating room and the instruments involved, particularly those in standard laparoscopy. Methods and Procedures: An extensive review of the published literature was conducted in the PubMed database for articles published between January 1998 and March 2011 using keywords such as surgical ergonomics, minimally invasive surgery, laparoscopic tools, laparoscopic instruments and hand sizing, laparoscopic stapling, laparoscopic trainers, laparoscopic training simulations, hand assisted laparoscopy, laparoscopic handle, hand tool grip, grip forces, grip span, and other various combinations of these keywords. The relevant articles were saved and organized into a database that categorizes them according to their type, objectives, and outcomes, and included literature reviews, clinical observations, surveys, discussions, simulated tasks, and virtual reality simulations for gastrointestinal, urological, hernia repair, and other endoscopic procedures. Results: Of the 47 relevant publications found, 27 employed qualitative methodologies, such as surveys, visual observations, and literature reviews, for evaluating the ergonomics of the surgical tasks and instruments. Twelve quantitative studies were found and were limited primarily to analyses of upper extremity effort using surface electromyography and, in two cases, opto-electronic motion capture. The eight remaining studies incorporated both qualitative and quantitative methodologies. Four of the 47 studies, three qualitative and one quantitative, were found to specifically address the issues associated with workplace design and equipment distribution, including monitor placement and operating table height. In total, 1,407 surgeons were found to be studied with the results from two of the studies suggesting that at least 85% of surgeons experience discomfort in the shoulders and upper extremities from laparoscopic surgery. It was evident that a significant amount of information has been generated but was limited to suturing and grasping tasks and the related surgical instruments, such as laparoscopic needle drivers and articulating graspers. The review also demonstrated a lack of information regarding other laparoscopic procedures, such as tissue resection and vessel ligation, and other related devices, such as laparoscopic surgical staplers and trocars. Conclusions: In order to better understand the pathophysiological risks and injuries (e.g. repetitive strain injuries, carpal tunnel syndrome) associated with laparoscopic surgical instrument use, it is clear from the published literature that comprehensive biomechanical performance measurements are needed. Such measurements would allow for an integrated characterization of the primary biomechanical stressors (e.g., awkward postures, dynamic/static posture ratios, repetition, force, actual stressor durations, etc.) throughout complex and rapid sets of movements as a basis for laparoscopic instrument design.

Objective: Our hypothesis is that monopolar electrosurgery technology is underused, and that the ‘‘standard’’ setting of Coag 30 remains the most commonly used generator setting. Despite advances in monopolar elecrosurgical energy devices, surgeons routinely use generator settings they are most familiar with or that they used in training. Methods: Monopolar energy activation data were downloaded from electrosurgery generators at an academic hospital. The following information was collected: number of monopolar activations, generator mode, generator power setting, and type of case performed. Data included an activation histogram detailing the generator modes used for monopolar activations and an event log surveying the generator power setting and mode for a subset of activations. Results: Seven generators were interrogated from operating rooms where general surgery, vascular, cardiovascular, orthopedic, and otolaryngology cases took place. Of 113,867 monopolar activations, Coag mode was more commonly used in comparison to Cut mode (91.2% versus 8.8%; p \ 0.0001). For Coag activations, the Fulguration setting was used more commonly than the Spray setting (97.2% versus 2.8%, p \ 0.0001). For Cut activations, Pure mode was used more frequently than the Blend mode (80.7% versus 19.3%; p \ 0.0001). Of 1152 activations analyzed for power setting, Coag mode was used 97.9% of the time with a wattage range of 20 to 60 (Table 1).

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Table 1 Monopolar activations, modes and power settings from event log data Coag Power setting Activations % (Watts)

Cut Power setting Activations % (Watts)

20

178

15.8

30

9

37.5

30

401*

35.5

35

3

12.5

35

160

14.2

40

10

41.7

40

229

20.3

50

2

8.3

60

160

14.2

* p \ 0.0001 versus all others Conclusions: Coag 30 is the most commonly used setting for surgeons. Cut mode is infrequently used. This suggests that innovative technology in electrosurgical monopolar devices is underused and perhaps poorly understood by surgeons. Further education on these complex instruments may benefit surgeons and surgical trainees.

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A COMPARITIVE STUDY OF GASTROJEJUNAL STRICTURES AFTER ROUX-EN-Y GASTRIC BYPASS IN 3200 CONSECUTIVE PATIENTS WITH A USE OF 21-MM VS 25 mm CIRCULAR STAPLER Atif Iqbal, MD, Mir Ali, MD, Kelly Frances, MD, Phillip Chin, MD, Peter Leport, MD, Leport Surgical Associates, Orange Coast Memorial Medical Center and Fountain Valley Hospital, Fountain Valley, CA Introduction: Gastrojejunal anastomotic strictures remains the most common late complication after Laparoscopic gastric bypass. This is relatively more common with circular –stapled gastrojejunostomy. The objective of this study was to report the incidence of these strictures with the use of 21-mm vs. 25 mm circular stapler. We analyzed outcomes of a transabdominal circular-stapled (RYGBP) with evaluation of short and long-term anastomotic complications. Methods: Three thousand two hundred consecutive laparoscopic RYGBP using circular-stapled technique were performed between January 2005 and December 2010 at two community hospitals. A retrospective comparison was made involving the work of four surgeons. Two used 21-mm (A) and other two used 25-mm (B) circular stapler for their gastrojejunostomy anastomosis. Group A reinforced the anastomosis with 3.0 vicryl running stitch, where as Group B used circular seamguards. Our mean follow up was six months. Results: Between January 2005 to December 2010, 3200 patients underwent Trans abdominal circular-stapled RYGBP. Thirty five patients (1.7%) developed stricture at the gastrojejunostomy site in group A with the use of 21 mm circular stapler. The total number of patients in that group was 2046. Fourteen patients (1.2%) in group B with 25 mm circular stapler had strictures out of the total 1145. Six patients (0.2%) in group A had recurrent ulcers and two patients (0.09%) underwent surgical repair. Three patient (0.26%) in group B had recurrent ulcers and one patient (0.08%) underwent surgical repair. The p value was calculated by using Chi square and Fisher’s test (P = 0.3). Conclusion: Symptomatic anastomotic strictures developed in both groups with slightly more stricture rate with 21 mm circular stapler vs 25 mm, although it was not of any significant statistical value.

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WEIGHT REGAIN AND REMISSION OF DIABETES AFTER ROUX-EN-Y GASTRIC BYPASS Andrew A Taitano, MD, Tejinder P Singh, MD, AMC Bariatric Surgery Group, Albany Medical Center Introduction: The surgical treatment of morbid obesity leads to weight loss and remission of diabetes in most patients with type 2 diabetes mellitus (T2DM). However, little is known regarding whether patients who regain weight after surgery will maintain remission of their diabetes. Our purpose was to investigate the rate of remission of T2DM (defined as maintaining a normal hemoglobin A1C without the use of diabetes medication) and the association with factors such as weight loss and weight regain in patients after gastric bypass surgery. Methods: We evaluated pre- and post-operative data, including demographics, weight at all follow-up encounters, Hemoglobin A1C levels, and medication lists of patients undergoing laparoscopic roux-en-y gastric bypass (LRYGBP) between April 2003 and May 2009. Results: 344 Patients underwent LRYGBP, of whom 22.4% had T2DM. Follow-up was possible in 77.8% and averaged 3.1 years. Patients with T2DM achieved 74.5% excess BMI loss compared to 82.7% in patients without T2DM. Patients with T2DM experienced less weight regain than patients without T2DM (13.3% vs 19.5%). At last follow-up, 80.3% of patients with T2DM achieved remission and 91.8% of patients with T2DM experienced remission or improvement of their disease. Patients taking oral medications for T2DM were more likely to achieve remission than patients taking insulin or insulin and oral medications (91.3% vs 46.7%), RR 1.96 (1.13 to 3.39, 95% CI). Patients with greater than average weight loss did not achieve remission more frequently than patients with less than average weight loss (80.0% vs 80.5%). There was no statistical difference in rates of remission between patients who regained more weight compared to those who regained less weight (77.4% vs 83.3%). There was a trend towards higher rates of remission with higher BMI at the time of surgery (89.5% for BMI 50–70, 80% for BMI 40–50, and 66.7% for BMI 33–40), but these results did not achieve statistical significance. Conclusions: LRYGBP resulted in significant maximum excess BMI loss (74.5%) and remission of T2DM (80.3%) at 3.1 years average follow-up. Remission rates were higher in patients taking oral medications for diabetes. There was a trend toward higher rates of remission with higher BMI at the time of surgery. Despite significant weight regain, patients with T2DM achieved high rates of remission.

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MALIGNANT HYPERTHERMIA DURING LAPAROSCOPIC ADJUSTED GASTRIC BANDING: A CASE REPORT Josue Chery, MD, Chiba Shintaro, Ambibola Pratt, MD, Ronell Kirkley, DNP CRNA, Barbara Hearne, RN, Andrew Beyzman, MD, Piotr Gorecki, MD, New York Methodist Hospital

EFFECTIVE USE OF INFERIOR VENA CAVA FILTERS IN HIGH-RISK MORBIDLY OBESE PATIENTS UNDERGOING BARIATRIC SURGERY Tec Chong, MD FACS, Suma Sangisetty, MD, Siva Vithianathan, MD FACS, Brown Alpert School of Medicine

Introduction: Laparoscopic adjustable gastric banding (LAGB) is the least invasive form of bariatric surgery. It is increasingly performed on an outpatient basis. Malignant hyperthermia (MH) is a rare but life-threatening complication that can occur from administration of inhalation anesthetics. Desflurane is favored in bariatric surgery because of its facilitation of post-operative recovery. Here, we report a case of MH during LAGB, with Desflurane as the maintenance anesthetic agent. Review of the literature reveals one reported case of MH during LAGB. The use of anesthesia team familiar with the biochemical and metabolic derangements associated with MH will afford timely diagnosis and treatment of the disorder, thus reducing morbidity and potential mortality. Case Presentation: A 32-year old woman with a BMI 41kg/m2, presented for bariatric consultation. Her past medical and surgical history included asthma, hyperlipidemia, infertility and arthroscopy performed under general anesthesia. Preoperative evaluation revealed no personal or family history of adverse reaction to anesthetics. The patient underwent LAGB. Anesthesia was induced with Propofol, Rocuronium and Fentanyl. Desflurane was used for maintenance. Towards the end of the laparoscopic portion of the operation, she experienced rapid physiologic changes consistent with MH. Her end tidal carbon dioxide (ETCo2) increased from 32 mmHg to a peak of 115 mmHg, pulse of 129 bpm and temperature increase from 35.8C to 37.5C. Her urine was color was ‘‘cola’’-colored with a redtinge. The volatile anesthetic was immediately discontinued and intravenous Dantrolene was initiated. She responded to the treatment, with a decrease ETCo2 (115 mmHG to 31 mmHg) pulse (129 bpm to 80 bpm) and temperature (37.5C to 36.0C). The surgery was completed uneventfully with a total operative time of 63 min. CKMB and creatine kinase measured post-operatively were 84.2 ng/ml and 22,233 u/l respectively. Both CKMB and creatine kinase reached a maximum level on postoperative day one at 91.1 ng/ml and 49220 u/l, respectively. Post-operative management with intravenous Dantrolene continued for an additional 36 h. The patient remained hemodynamically stable. All her metabolic and biochemical derangements progressively improved to normal values. She underwent physical therapy for mild muscle weakness. The patient was discharged home on post-operative day 8 in good condition. Conclusion: We present a rare but potentially life threatening intra-operative, anesthesia related complication of bariatric surgery. Bariatric surgeons, anesthesiologists and all medical personnel involved in peri-operative care of bariatric patients should be aware of early sings of malignant hyperthermia since its early recognition and prompt treatment reduce morbidity and potential mortality of this serious complication.

Purpose: Obesity is an independent risk factor for venous thromboemolic events (VTE), including pulmonary embolism (PE), which is the leading cause of death postoperatively from bariatric surgery. Retrievable inferior vena cava (IVC) filters have been shown to prevent VTE, and have a low morbidity profile when retrieved. We developed a protocol for placement of IVC filters in high-risk morbidly obese patients undergoing bariatric surgery and postoperative retrieval of the IVC filter. Methods: Patients undergoing bariatric surgery were chosen for IVC filter placement based on the presence of one or more high-risk characteristics for VTE; BMI [ 50, non-ambulatory or impaired ambulatory status, prior history or family history of VTE, pulmonary hypertension, and hypercoagulable state. Retrievable IVC filters were inserted within 14 days of bariatric surgery. IVC filters were retrieved at 4 to 6 weeks after bariatric surgery or when the patient was fully ambulating. Results: IVC filter placement was performed in 21 patients. Their average BMI was 51 ± 7.6. Route of insertion of the IVC filters was right internal jugular vein in 10 patients, right common femoral vein in 10 patients and left common femoral vein in one patient. Average indwelling time for the filters was 64 ± 22 days. 16 patients had their IVC filters removed postoperatively (76%). Two patients were lost to follow-up. One patient requires increased mobility and one patient is awaiting filter removal. No patients had a venous thromboembolic event. Conclusion: IVC filter placement in high-risk morbidly obese patients undergoing bariatric surgery is a safe and effective form of prophylaxis against VTE.

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LAPAROSCOPIC BARIATRIC PROCEDURES IN COMMUNITY TEACHING HOSPITAL—HOW FAR ARE WE INTO TEACHING SURGICAL RESIDENTS? Arunkumar Baskara, MRCS MD, Stefanie L Saunders, MS, Brendan O Connell, MD, Prashanth Ramachandra, MD, Mercy Catholic Medical Center

TRANSVERSUS ABDOMINUS PLANE BLOCK + SINGLE PORT OPERATION 5 ALMOST SCARLESS AND ALMOST PAINLESS SURGERY: A PILOT STUDY ON SINGLE-PORT SLEEVE GASTRECTOMY David Y Lee, MD, Ronald Ross, MBBS, Michael Wassef, MD, Jun Levine, MD, Julio Teixeira, MD, St. Luke’s Roosevelt Hospital

Abstract Background: Laparoscopic Bariatric Surgery is being done in several Community Teaching hospitals. Most hospitals don’t have formal fellowship training and surgical residents play a key role in assisting the Surgeon for these procedures and in most centers, major part of the procedure are being done by the attending Surgeon and residents do minor share of it as these procedures are considered as advanced laparoscopic procedures. We developed a systematic training program that enables resident surgeons to perform laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding and evaluated the safety and feasibility of this training program. Methods: A retrospective study of 215 patients was performed who underwent Laparoscopic Roux-en-Y bypass and Laparoscopic Adjustable Gastric Banding, with active surgical resident involvement, from August 2007 to December 2009. Surgical candidates have an average BMI of 44.1 in the band group and 51.1 in the bypass group with history of failed diet and exercise programs. 54.5% of our patients in bypass group and 14.78% of patients in band group were super obese (BMI [ 50). All the procedures were done by single board certified general surgeon at community teaching hospital. Patients were assessed by their age, gender, BMI, average weight of the patient pre-operatively. We compared the early surgical and functional outcomes, like early post -operative and late post-operative complications, average weight loss, conversion rate, average hospital stay, of bariatric procedures performed by expert surgeon with those of procedures performed by resident surgeons. All analyses were performed on an intention-to-treat basis. Results: A total of 225 patients were included in this study of whom 115 (51.1%) patients underwent Laparoscopic Gastric adjustable banding procedure and 110 (48.9%) patients underwent Laparoscopic Roux-en-Y bypass procedure. Of the 110 bypass procedures 60 were performed by expert surgeon and 50 by resident surgeons at year 5. Of the 115 gastric band group 45 were performed by expert surgeon and 70 were performed by resident surgeons at year 4 & 5. The average BMI in band and bypass patients are 44.1 and 51.1 respectively. 60 patients (54.5%) in our bypass group were super obese (BMI [ 50). Our maximum BMI in the bypass group is 79.9. The average length of hospital stay for band patients was 1 and for bypass patients was 3.72. The operative time was longer in the resident surgeons group than in the expert surgeon. The other outcomes like conversion rate, anastomotic leakage, bleed, stricture, ulcer were similar in both the groups. Conclusion: Our systematic training program on Laparoscopic Bariatric procedures which include Roux-en-Y bypass and adjustable gastric banding enables senior level resident surgeons to perform these procedures safely during residency with acceptable outcomes.

Introduction: Single-port laparoscopy is a relatively new modality in abdominal surgery which offers improved cosmesis. Although studies to date have not been able to demonstrate that single-port laparoscopy achieves superior outcomes for postoperative pain compared to the conventional multiport technique, the single port technique may be more amenable to regional anesthetic interventions. In this pilot study, we evaluated the analgesic utility of Transversus Abdominal Plane (TAP) block in patients undergoing laparoscopic single-port sleeve gastrectomy (SPSG). Methods: All patients undergoing laparoscopic sleeve gastrectomy were followed prospectively to evaluate postoperative pain utilizing the Visual Analog Scale (VAS). Patients received Patient-Controlled Analgesia (PCA) with intravenous hydromorphone postoperatively. Patients with VAS score [3 during the first 60 min postoperatively were offered a bilateral ultrasound-guided TAP block (2 x 30 ml of 0.2% ropivacaine). The resulting VAS scores, opioid usage, and length of stay (LOS) were compared between patients who underwent SPSG that did and did not accept the TAP block, and patients who underwent multiport sleeve gastrectomy (MPSG). Results: Within 30 min of administration, the mean pain score of patients receiving the TAP block decreased from 8.0 to 4.0 (p = 0.037) (Fig. 1). These patients also had the lowest average pain scores at all time points compared to other groups. This reached statistical significance at postoperative hours 1 and 12 (Table 1). Overall opioid usage and LOS were lower for patients who underwent SPSG versus MPSG but this did not reach statistical significance in our preliminary series. Administration of TAP blocks required 5-10 min of intervention time and was not associated with any complications.

Fig. 1 Vas scores post TAP block Table 1 Comparison of patients undergoing laparoscopic sleeve gastrectomy SPSG + TAP SPSG (n = 10) (n = 25)

MPSG (n = 13)

p value

Mean Age (year)

43.1 ± 11.8

46.8 ± 13.3 45.4 ± 12.9 0.739

Mean BMI (kg/m2)

42.2 ± 3.9

47.1 ± 6.6

4.0 ± 3.6

2.6 ± 3.9

50.9 ± 15.4 0.106

Mean postoperative pain score 0h

3.3 ± 4.2

0.638

1h

2.7 ± 2.4

3.6 ± 2.9

6.2 ± 2.1

0.004

6h

0.3 ± 1.0

1.8 ± 2.4

1.9 ± 2.3

0.156

12 h

0.1 ± 0.3

1.2 ± 1.5

0.6 ± 1.0

0.038

24 h

0.4 ± 1.3

0.6 ± 1.0

0.7 ± 1.7

0.844

5.9 ± 2.3

5.6 ± 2.9

6.9 ± 2.2

0.393

Mean duration of patient controlled 43.0 ± 9.3 analgesia (h)

43.0 ± 16.0 43.8 ± 6.5

0.985

Mean legnth of stay (h)

59.1 ± 17.1 65.0 ± 16.9 0.790

Mean dose of patient controlled anlgesia (mg hydromorphone)

56.3 ± 6.6

Conclusion: Administration of TAP block significantly decreases postoperative the pain up to 12 h after SPSG. Ultrasound guidance allowed for a reproducible and time-efficient analgesic benefit in the bariatric population. The combination of a single-port laparoscopic operation with TAP block may enhance postoperative pain control due to the block’s efficacy in covering the dermatomal distribution of the mid-abdomen. Future studies should evaluate the impact of preoperative administration of the block.

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LAPAROSCOPIC SLEEVE GASTRECTOMY WITH STAPLE LINE BUTTRESS REINFORCEMENT IN 116 CONSECUTIVE MORBIDLY OBESE PATIENTS: A CANADIAN EXPERIENCE Richdeep S Gill, MD, Noah Switzer, Mike Driedger, Xinzhe Shi, MPH, Arya M Sharma, MD, Daniel W Birch, MD MSc, Shahzeer Karmali, MD, University of Alberta; Royal Alexandria Hospital

CORRELATION BETWEEN INTRAOPERATIVE DEXAMETHASONE ADMINISTRATION AND LEUKOCYTE COUNT ON POST-OPERATIVE DAY NUMBER ONE IN LAPAROSCOPIC GASTRIC BYPASS PATIENTS David R Donahue, DO, Kevan E Mann, MD, Naval Medical Center Portsmouth

Introduction: Obesity rates have reached epidemic levels with over 300 million obese individuals worldwide. Laparoscopic sleeve gastrectomy (LSG) as a primarily restrictive bariatric surgical procedure has been shown to be effective in producing marked weight loss. However, LSG associated gastric leakage and hemorrhage remain the most important challenges postoperatively. Staple line buttress reinforcement has been suggested to reduce these postoperative complications. Objectives: Our objective was to assess staple line buttress reinforcement via the DuetTM tissue reinforcement stapler system in morbidly obese patients undergoing LSG as part of a comprehensive weight management strategy, focusing on postoperative complications. Methods: Between January 2008 and April 2011, we retrospectively reviewed the medical records of 116 consecutive patients that underwent LSG with staple line buttress reinforcement through the Weight Wise Program. Results: The mean age of patients was 44.3 ± 9.5 years, with mean preoperative BMI of 44 ± 7 kg/m2. The mean operative time to perform LSG was 96 ± 25 min. Postoperative weight was significantly lower following LSG at 1-year follow-up compared to baseline (104 ± 25 kg vs. 125 ± 27 kg, P \ 0.05). There were no postoperative gastric leaks observed. Postoperative bleeding from the gastric staple line occurred in one patient (0.9%) and was treated with conservative management. Conclusion: In LSG, staple line buttress reinforcement limits postoperative gastric leakage and bleeding in morbidly obese patients.

Background: We hypothesize that a single dose of perioperative steroids cause a leukocytosis on post-operative day one in laparoscopic gastric bypass patients. One of the most recognized uses of perioperative dexamethasone is for the prevention of postoperative nausea and vomiting. One of the most feared complications in bariatric surgery is that of an anastomotic leak. In our bariatric patient population, intraoperative steroids are often given to help control post-operative nausea and vomiting. These patients follow a very regimented protocol after surgery with discharge typically occurring on postoperative day two. A leukocytosis could cause a delay in this protocol while searching for a complication such as anastomotic leak. Methods: We performed a retrospective chart review of all patients who underwent a laparoscopic gastric bypass in the period of 1/2008 through 8/2009 with documentation of whether dexamethasone was administered and the dose given. We then performed a computed t-test to evaluate if a correlation exists between administration of medication and elevated white count on post-operative day one. We also determined if there was a correlation between dose given and elevation of white count. Results: The results show a statistically significant difference in WBC count between those who received dexamethasone and those who did not. The mean count in those who received a dose was 11.6 versus 10.7 in those who did not receive dexamethasone (p = .036). There was no correlation between dose of dexamethasone and white blood cell count (p = .317). Conclusions: We hypothesized that a single dose of intraoperative steroids cause a leukocytosis in the post-operative period. Our data shows that there is a statistically significant elevation in leukocyte count in patients who receive dexamethasone intraoperatively. This needs to be taken into account when determining the cause of a leukocytosis since the post-operative course may be altered unnecessarily searching for a complication.

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EARLY EXPERIENCE OF BARIATRIC SURGERY AT DAYANAND MEDICAL COLLEGE & HOSPITAL, LUDHIANA (PUNJAB) INDIA Ashish Ahuja, MS, Prabhdeep Nain, MS, Satpal Singh Virk, Mch, Dayanand Medical College & hospital, Ludhiana, (Punjab) INDIA Introduction: Obesity is a rapidly progressing worldwide epidemic which rates among the top 10 causes of illhealth worldwide. In India, Punjab is the no. 1 state as far as obesity is concerned & is rapidly growing. We present our early experience of 80 bariatric surgery in our centre over one & half years. Methods: The study was conducted on 80 bariatric surgery patients (operated), age ranging from 20–64 years, 72 female (90%), 8 males (10%). There pre operative comorbid conditions, early as well as late complications with post operative resolution of co-morbid conditions was reviewed. Three bariatric surgery procedures. Laparoscopic adjustable gastric banding (LAGB),Laparoscopic sleeve gastrectomy, Roux-en-Y gastric bypass (Rgb) were done. Results: The overall weight loss in Laparoscopic sleeve gastrectomy was more than 60% excess body weight, 40% in LAGB, & Rgb patient more than 40%. Two (2) patients of sleeve gastrectomy has post operative leak were treated conservatively for 6 to 8 weeks & healed, one (1) patient of LAGB presented with deep vein thrombosis after 2 days, one (1) LAGB patient had severe band port site infection for which port had to be removed. 60% (48) patients had resolution of hypertension for which they were taking antihypertensives, 30% (24) patients were cured of type 2 diabetes mellitus. 2 patients were converted to laparotomy,one had oesophageal injury while clearing the adhesions & other was converted after injury from the nathansons liver retractar at the gall bladder fossa resulting in profuse haemorrhage & liver tear, 60% patients had hair loss after 6 months of surgery treated conservatively. Conclusion: Bariatric surgery should be considered in all patients who have failed medical as well as dietary management to loose weight. In new centres bariatric surgery patient management involves lot of intraoperative & postoperative challenges in terms of surgical technique & Anaesthesia management. The results in terms of weight loss,resolution of co-morbid conditions & patient satisfaction with Laparoscopic Sleeve gastectomy were excellant as compared to other procedures which required aggressive follow up & adjustments.

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STAPLER MISFIRE DURING SLEEVE GASTRECTOMY: CAUTION WITH BUTTRESS USE David Nguyen, MD, Bahar Moheban, Amir Mehran, MD, UCLA Department of Surgery Introduction: The use of staple line buttressing during vertical sleeve gastrectomy (VSG) has been advocated by some authors as a method to reduce the incidence of bleeding, leak, or strictures. The surgical literature, however, does contain reports of complications attributed to their use. We reviewed our experience with buttressed sleeve gastrectomies to identify such cases. Methods and materials: Retrospective review of a prospectively collected IRB approved database of bariatric surgery cases performed at our institution. Results: From 2006–2009, 182 VSG cases were performed. Six cases were identified where the stapler misfired due to buttress use, requiring additional sutured staple line repair. There were no long term consequences. A horizontally embedded staple at the ‘crotch’ was identified as the culprit. No further misfires were noted once that area was routinely divided with endoscissors Conclusion: Whereas staple line reinforcement with buttress material is generally safe, surgeons should be aware of possible stapler misfiring due to their use. Slow firing and careful monitoring of the surgical field will help identify the problem rapidly and avoid major consequences.

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DIFFERENCE IN QUALITY OF LIFE IN MORBIDLY OBESE PATIENTS AFTER BARIATRIC SURGERY Ravinder Singh Bal, MS, Ashish Ahuja, MS, Satpal Singh Virk, Mch, Dayanand Medical College & Hospital, Ludhiana, (Punjab) INDIA Introduction: The difference in quality of life of morbidly obese patients was investigated in a controlled cross sectional study. The present study investigates the predictive value of various parameters such as age, gender, weight loss and pre operative psychiatric disorders with regard to quality of life (QOL) after performing bariatric surgery & the improvement in QOL after weight loss. Methods: A post operative Bariatric surgery group of 40 patients (Group A) was compared with another group of 40 patients (Group B) of morbid obesity pre operatively using health, wellness and quality of life questionnaire. The questionnaire was completed by 50 patients (62.8%). The bariatric surgical procedure done in both groups was Laparoscopic adjustable gastric banding (LAGB) & Laparoscopic vertical sleeve gastrectomy (LVSG). Results: Average weight loss in both groups was more than 60% over two years time. No differences were seen in satisfaction of weight loss in post operative patients. Drastic correlations in amount of weight loss and QOL scores in females as compared to the males. Greater weight loss showed statistically significant positive correlation with improved self esteem, physical activity, social relations, personal hygiene and eating patterns which were much better than pre operative groups. Conclusion: The results of this study show that QOL is better after surgically induced weight loss and is not related to type of surgical procedure performed. Some obese patients who had pre operative psychiatric or personality disorders counseling strategies post operatively.

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LENGTH OF STAY IS A PREDICTOR OF WEIGHT LOSS IN PATIENTS WITH GASTRIC BYPASS Lucian Panait, MD, Graeme Rosenberg, Andrew J Duffy, MD, Kurt E Roberts, MD, Robert L Bell, MD, Yale School of Medicine Introduction: Substantial and lasting weight loss is the major goal of bariatric surgery. A target of 50% excess weight loss (EWL) or more is considered successful if sustained. The EWL after laparoscopic Roux-Y gastric bypass (LRYGB) depends on several variables, specifically compliance with diet and exercise. We hypothesize that the length of hospital stay (LOS) following LRYGB reflects patient motivation and thus correlates with EWL at 1 year. Methods: We reviewed longitudinally collected data regarding patients who underwent LRYGB by a single surgeon at our institution between August 2002 and August 2010. Follow-up data at 1 year were available for 564 patients. The EWL at 1 year was correlated with the LOS. Results: Patients had an average age of 42.7 years and an average BMI of 50.7. Length of stay was 1 day in 43 patients, 2 days in 344 patients, 3 days in 109 patients and 4 days or more in 66 patients. The EWL at 1 year decreased as LOS increased as illustrated in Table 1. Statistical significance was achieved when comparing the EWL of the groups with LOS of 3 days vs. 2 days and LOS of 4 days vs. 3 days respectively (p \ 0.05).

Table 1 Correlation between LOS and EWL at 1 year LOS (days)

EWL at 1 year (%)

1

69.5 ± 15.8

2

66.7 ± 16.3

3

61.9 ± 15.3*

4 or more

55.4 ± 17.4*

* p \ 0.05 Conclusion: Length of hospital stay is an early predictor of EWL at 1 year. Timely intervention in the patients whose LOS is longer may lead to increasing success in achieving optimal weight loss.

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ANALYZING EARLY OUTCOMES OF ROUX-EN-Y GASTRIC BYPASS IN A PUBLICALLY FUNDED CANADIAN OBESITY PROGRAM Kevin Whitlock, BSc, Daniel W Birch, MD MSc, Richdeep S Gill, MD, Shahzeer Karmali, MD, Center for the Advancement of Minimally Invasive Surgery (CAMIS) Introduction: The purpose of this study was to determine the outcomes of laparoscopic roux-en-Y gastric bypass (RYGB) surgery performed since the inception of an obesity program in a publically funded, Canadian teaching hospital. Methods and Procedures: A retrospective study identified 265 patients who underwent laparoscopic RYGB since the inception of a bariatric program (2005–2010). The hospital was a publically funded, level 2 trauma center with 678 beds and an advanced minimally invasive surgery (MIS) bariatric program. All patients attempted weight loss with the program before being selected for surgery. A total of three different surgeons performed all procedures and they were not dedicated bariatric surgeons. Results: The average age at surgery was 41.5 years, 81% of the patients were female, and the mean preoperative BMI was 51.8 ± 9.5 kg/m2. The average operative time was 162.7 ± 46.7 min and the majority of surgeries were teaching cases. The median in hospital stay was 3 days and the median postoperative follow-up was 12 months. At 1 year 76% of the patients followed up with the clinic and the average BMI was 36.0 ± 8.6 kg/m2, which was an excess weight loss of 63.5 ± 20.3%. This corresponds to a statistically significant 31.6 ± 8.8% decrease in total weight from preoperative levels and a 35.5% ± 8.6% decrease from their first visit with the program. After 159 surgeries with a hand sewn GJ anastomosis, the surgeons changed to using a circular Orville stapler. There were 9 leaks in hospital (5.7%) and 3 leaks within 6 months of surgery (2.6%) after hand sewing the GJ anastomosis. This is compared to no leaks after using the circular Orville stapler. Additionally within one year of surgery, 13 patients (11.7%) developed GJ anastomotic strictures after hand sewing, in comparison to 5 patients (5.8%) after stapling. The positioning of the roux limb was either retrocolic (159 patients) or antecolic (106 patients). After one year, there were 10 bowel obstructions (6.4%) after retrocolic positioning, in comparison to 2 bowel obstructions (2.3%) after antecolic positioning. Postoperative complications also included gastric staple line bleeds (0.4%) and abdominal hematomas (2.6%). There were 3 (1.1%) postoperative deaths and 18 patients (6.8%) underwent surgical revision. Preoperatively 29.1% of the patients had type 2 diabetes mellitus. Postoperatively, 51.3% had complete resolution and 65.4% had improvement or resolution of their diabetes after a median follow-up of 3 months. Also, 48.9% of the patients had preoperative hypertension. Postoperatively, 37.4% had complete resolution and 50.4% had improvement or resolution of their hypertension after a median follow-up of 6 months. Conclusion: Our obesity program, in a publically funded teaching hospital without dedicated bariatric surgeons, was able to achieve significant weight loss and improve the comorbidities of our morbidly obese patients. Therefore, even in an unconventional setting for an obesity program, we show that bariatric surgery with appropriate follow-up support can be effective for treating obesity.

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A SYSTEMATIC REVIEW OF STAPLE LINE REINFORCEMENT DURING LAPAROSCOPIC SLEEVE GASTRECTOMY Jean Knapps, MD, Maher Ghanem, MD, John Clements, MPA, Aziz Merchant, MD, Synergy Medical Education Alliance

EARLY SINGLE STAGE OPERATIVE MANAGEMENT OF SLEEVE GASTRECTOMY LEAKS WITHOUT ENDOSCOPIC STENT PLACEMENT Abdelrahman A Nimeri, MD, Maria Margarita, MD, Mohammed B Al Hadad, RN SKMC, Managed by Cleveland Clinic

Background: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a primary or revisional bariatric procedure with outcomes similar to the more commonly performed gastric band and gastric bypass. Staple line disruption and leakage after LSG is a significant source of morbidity and mortality. Surgeon practice with respect to staple line reinforcement varies considerably. The aim of this study is to retrospectively evaluate the effect of staple-line reinforcement on the gastric leak rate, overall morbidity, and mortality. Methods: We conducted a systematic review of the literature analyzing outcomes after LSG with or without various staple-line reinforcement methods. A major database (Pubmed) was searched using the key words ‘‘Sleeve Gastrectomy’’ within the title, and articles were assessed by 4 reviewers. Inclusion criteria included operative technique description, and documentation of postoperative outcomes, especially staple line leak. Two groups were identified: LSG with staple-line reinforcement (Group A) and LSG without staple-line reinforcement (Group B). After determining heterogeneity of our variables, we calculated pooled event rates and 95% confidence intervals using fixed effects modeling to determine significant differences in rates between our two treatment groups. Variables analyzed included leak rate, bleeding, surgical site infection, reintervention, readmission, and mortality. Results: A total of three-hundred and ninety articles were identified, of which 34 articles, with 4830 patients, met inclusion criteria. Group A had 3342 patients and Group B had 1488 patients, with an overall 3:1 female to male ratio. The BMI ranged from 30 to 85 for group A and 32 to 103 for group B. The ranges for estimated weight loss (EWL) after 12 months follow up were 30.6% to 81.1% for group A and 47.2% to 81.1% in group B. After heterogeneity calculations, nine total variables met criteria to be analyzed further, including the leak rate and mortality. The leak rate was 3.9% (CI, 2.9% to 5.5%) in group A and 3.2% (CI, 2.8% to 4.1%) in group B, indicating a lack of statistical difference in the pooled rate. In addition, mortality was 0.8% (CI, 0.4% to 1.5%) in group A and 0.7% (CI, 0.4% to 1.1%) in Group B, again indicating a lack of statistical difference in the pooled rate. Our results also revealed no statistical difference in the pooled rate of any of our other seven outcome variables.

Sleeve gastrectomy is considered a primary treatment for morbid obesity. Leaks following sleeve gastrectomy are not uncommon, and may lead to major morbidity, and prolonged hospital stay. 2 The leak rate from gastric staple line ranges from 1.4 to 20% Endoscopic stent placement is a potential management strategy. However, it requires expertise, may not heal the leak, lead to stent migration, or significant dysphagia in some patients. A standard method of managing leaks following sleeve gastrectomy has not been established. Objective: To evaluate the outcomes of consecutive patients with leaks following laparoscopic sleeve gastrectomy managed at BMI Abu Dhabi. Methods: We performed a retrospective analysis of our prospectively maintained data base of consecutive patients with leaks after laparoscopic sleeve gastrectomy managed at BMI Abu Dhabi utilizing a standardized operative management strategy without the use of endoscopic stenting between April 2010 and April 2011. All patients were optimized, and resuscitated adequately before surgery. Data was obtained from the hospital medical record, and IRB approval was obtained. Results: All patients were referred to BMI Abu Dhabi; during the same time period we performed 34 laparoscopic sleeve gastrectomies without a leak. We identified a total of four patients. Two patients were done at a private hospital in the UAE, one done in Jordan, and one in Egypt. All patients were referred for higher level of care. All patients were optimized, and resuscitated adequately before surgery. Intraoperatively, all patients had endoscopy and a T tube was placed into the leak if identified clearly; Otherwise, the area of the leak was drained adequately and a jejunostomy tube was inserted in a standard fashion. No attempts were made at suturing the leak site. All leaks healed following an initial period of inpatient hospital stay, followed by an outpatient period on jejunostomy tube feeding and Nil Per Os (NPO). All Leaks healed without the need for endoscopic stent placement. Conclusion: Early single stage operative management of leaks after laparoscopic sleeve gastrectomy utilizing a standardized operative strategy without the use of endoscopic stenting is both safe and effective.

Conclusion: Our systematic review reveals lack of statistical difference for staple line leak in LSG with or without staple line reinforcement as well as other major complications. Due to retrospective bias and heterogeneity of studies and outcome variables, we also propose that strong, Level 1, prospective trials are needed to determine the true effect of staple line reinforcement on leak rates and overall morbidity in LSG.

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ENDOSCOPIC MANAGEMENT OF POST-GASTRIC BYPASS ANASTOMOTIC STRICTURES WITH BALLOON DILATIONS AND ENDOLUMINAL STENTS Eric Marcotte, MD MSc, Emilie Comeau, MD FRSCS, Anne Meziatburdin, MD, Charles Me´nard, MD FRCPC, George Rateb, MD, Centre Hospitalier Universitaire de Sherbrooke Introduction: Laparoscopic Roux-en-Y gastric bypass (RYGB) is well recognized for its efficiency in terms of weight loss for morbidly obese patients. Anastomotic strictures present in 5–15% of cases and have a significant impact on the patient’s quality of life. The aim of this study was to evaluate the frequency of anastomotic stricture in our center and report our experience in treating refractory cases. Methods: Data from all patients presenting with a post-RYGB anastomotic stricture were retrospectively collected and analyzed. The first step in their management was endoscopic balloon dilation. Refractory cases underwent endoscopic placement of fully covered esophageal stents. Results: Eighty-seven patients underwent LRYGB in our center between September 2005 and January 2011. Eleven patients (12.6%) presented a gastrojejunal anastomotic stenosis, a mean of 6 weeks post-LRYGB, of which 6 patients (55%) had a marginal ulcer. One to three dilations were necessary for the majority of patients, but 2 patients were still unable to feed after five interventions. A sub-phrenic abscess was the only major complication of pneumatic dilations. For the 2 refractory patients, stents migrated early. The first patient underwent surgical revision of the anastomosis. After failure of placement of a second stent, the other patient was successfully dilated and the site of the stricture was locally injected with triamcinolone acetonide, which prevented further recurrence of the stenosis. Conclusions: The majority of patients with RYGB gastrojejunal anastomotic stricture respond favorably to endoscopic pneumatic dilations. Refractory cases are challenging. Stents are aimed at preventing a complex surgical reintervention but are not yet designed for that use. Local infiltration of corticosteroids at the time of dilation seems to prevent recurrence of the stenosis.

Preoperative data

Age Sex Time to presentation to BMI Abu Dhabi

Initial operation

Time to Operative Surgery strategy

49

F

6 weeks

Revision of LAGB to sleeve

7 weeks

Open SB resection, ECF resection, J tube

35

M

4 weeks

Revision of LAGB to sleeve

1 weeks

Open G tube, J tube

27

F

5 weeks

Revision of LAGB to sleeve

5 weeks

Lap T Tube & J tube, drains

36

F

4 weeks

Primary Sleeve

4 weeks

Lap J tube & drain

Postoperative data Radiological drainage

Reoperation

LOS

Time to leak closure

Outcome

None

None

26 weeks

16 weeks

Healed

None

None

4 weeks

4 weeks

Healed

Pre and post surgery

None

4 weeks

8 weeks

Healed

Pre surgery only

None

4 weeks

8 weeks

Healed

Patient referred to our unit in acute renal failure on dialysis, intubated, septic with a high output enterocutaneous fistula, a gastrocutaneous fistula, pancytopenia, and severe malnutrition

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INTERNAL HERNIA AFTER LAPAROSCOPIC ANTECOLIC ROUX-EN-Y GASTRIC BYPASS Mazen R Al-mansour, MD, John R Romanelli, MD FACS, Jay N Kuhn, MD FACS, Baystate medical Center Introduction: Internal hernia (IH) after Roux-en-Y Gastric Bypass (RYGB) is an important cause of small bowel obstruction. We aimed to evaluate the incidence and patterns of presentation of internal hernia after laparoscopic antecolic RYGB at Baystate Medical Center. Methods: We retrospectively reviewed the records of 29 patients who underwent laparoscopic antecolic RYGB at Baystate Medical Center between December 2004 & December 2010 who developed symptomatic IH requiring operative intervention. Median age of the patients was 32 (±8.5) years and 25/29 (86.2%) were women. Median BMI preoperatively was 43.7 (±3.9) Kg/m2. Results: We identified 578 patients who underwent laparoscopic antecolic RYGB in our institution during the study time period. 29 patients developed 30 IH (5.19%) requiring surgical intervention. The median time of presentation after their RYGB procedure was 23.5 months (range 3 to 47 months). The mean % excess body weight loss (EBWL%) at the time of presentation of the hernia was 55.3% (±12.4). In 22/30 of IH (73.3%) the hernia occurred at Petersen’s space, while in 7/30 IH (23.3%) occured at the jejunojejunostomy and one patient was found to have a hernia at both locations. In 29/30 of cases computed tomography scan (CT) was obtained. Swirling of the mesentery was the most common CT finding 17/29 (58.6%). Patients presented with different degrees of acuity: 6/30 (20%) electively with chronic abdominal pain, 24/30 (80%) presented to the hospital with acute abdominal pain. Bowel necrosis was found in 3/30 (10%). Conclusion: Internal hernia is a serious and potentially fatal complication of RYGB. Patients present with different degrees of acuity ranging from chronic abdominal pain to peritonitis with bowel necrosis. CT is helpful in providing diagnosis; however, careful attention should be made the specific signs of small bowel vovulus such as mesenteric swirl sign. It is important for surgeons to keep this diagnosis under consideration for RYGB patients who present even with vague symptoms. Although not reflected in this series, closure of the mesenteric defects at the time of the index operation may help to lessen the rate of this complication.

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LAPAROSCOPIC ROUX-Y-GASTRIC BYPASS ACHIEVES SUPERIOR WEIGHT LOSS IN ADOLESCENTS COMPARED TO LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING David Y Lee, MD, Hamza Guend, MD, Ronald E Ross, MBBS, Malcom Reid, BS, Jun Levine, MD, Julio Teixeira, MD, St. LukesRoosevelt Hospital Center Introduction: Laparoscopic Roux-en-Y gastric bypass (LRYGB) achieves superior weight loss compared to laparoscopic adjustable gastric banding (LAGB) in adults. Whether this holds true for adolescents is not well established. An increasing number of adolescents are undergoing LAGB compared to LRYGB since the long-term effects of LRYGB on this population is still under investigation. The goal of this study was to compare weight loss achieved with LAGB versus LRYGB in adolescents. Methods: We performed a retrospective review of all adolescents between 12 to 18 years of age who underwent LAGB or LRYGB at our institution from 2003 to 2011. Postsurgical weight loss at 1, 3, 6, 12, 18 and 24 months was noted and expressed as percent excess body weight loss (%EBWL). Results: Seventeen patients underwent LAGB and 13 underwent LRYGBP. Mean Body Mass Index (BMI), gender composition, and ethnicities of the two groups were similar. The %EBWL was significantly superior in the LRYGB group compared to LAGB group at all time points (Table 1). Two patients who underwent LAGB required revision of band for slippage and one patient elected to have the band removed. One patient who underwent LRYGB was readmitted to the hospital for dehydration. Conclusion: In adolescents, LRYGB achieved significantly superior weight loss compared to LAGB in

Table 1 Preoperative patient profile and weight loss during follow-up LAGB (n = 17)

LRYGB (n = 13)

p value

Mean age (year)

16.2 ± 1.5

17.9 ± 0.3

\ 0.05

Male Female BMI (kg/m2) %EBWL 1 month 3 months 6 months 12 months 18 months 24 months

5 12 47.5 ± 5.6

3 10 50.6 ± 6.8

16.2 18.7 25.9 26.3 32.6 34.6

21.6 33.3 59.4 74.0 62.5 93.4

± ± ± ± ± ±

4.8 (n = 14) 12.4 (n = 12) 15.1 (n = 8) 14.8 (n = 9) 13.9 (n = 6) 19.0 (n = 5)

± ± ± ± ± ±

7.2 (n = 12) 6.6 (n = 8) 20.5 (n = 7) 22.2 (n = 5) 15.6 (n = 3) 18.8 (n = 3)

0.198 0.031 0.007 0.003 \ 0.001 0.022 0.005

the short to intermediate follow-up period. The complication rate for LAGB was higher than for LRYGB. Although LAGB is currently not FDA-approved for use in adolescents, its off-label use in this population is on the rise. Mores studies are needed to monitor the long-term effects of these operations on adolescents before definitive recommendations can be made.

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Comparison of Laparoscopic Versus Robotic assisted Longitudinal Sleeve Gastrectomy Nathan Miller, Erik Wilson, Brad Snyder, Phil Leggett, Terive Duperier, Terive Duperier, Todd Wilson, Kulvinder Bajwa, Nick Brown, Ben Dubois, Rachel Reeder, Sheilindra Mehta, Rich Engelhardt UT, Houston, Bariatric Medical Institute of Texas, Houston Northwest MIS Fellowship Introduction: The purpose of the study was to determine the best modality to perform longitudinal sleeve gastrectomies (LSG). The number of LSG is increasing each year because of the related relative simplicity and satisfactory weight loss. The LSG is currently being performed laparoscopically, with robotic assistance, and as a single incision procedure. Currently, there has been no comparison of these different techniques to show an advantages or disadvantages when analyzed in comparison. Method: A multicenter, retrospective review was performed for patients who underwent laparoscopic and robotic gastric LSG between 2005 and 2011. Comparisons were made of the incidence of complications within the 90 day global period, length of operative time, and length of hospital stay for each respective procedure. Results: A total of 317 gastric sleeves where data was available were included in our review. 277 laparoscopic and 40 robotic assisted LSG) were performed in our consortium from 2005-2011. Overall mean operative time for all procedures was 94 min. Specifically, mean operative time for lap sleeve was 91 min vs. 113 min for the robot (p = .002). Overall mean hospital stay for all procedures was 2.4 days. Specifically, mean hospital stay for lap sleeve was 2.4 days, vs. 2.5 days for the robot (p = 0.86). Overall mean 90 day complications requiring readmission was 11%. Individually, it was 12.3% for laparoscopic, and 5% in the robot assisted LSG (p B .001). Conclusions: Robotic assisted LSG sleeves took significantly longer than the laparoscopic technique; whereas robotic sleeves elicited fewer complications. There was no significant difference in hospital length of stay between techniques.

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WEIGHT LOSS AFTER MAJOR REOPERATIONS FOR ADJUSTABLE GASTRIC BANDING Melissa M Beitner, MBBS, Christine J Ren-fielding, MD, Marina S Kurian, MD, Bradley F Schwack, MD, Andrew H Kaye, MBBS MD, Anita R Skandarajah, MBBS MD, Benjamin N Thomson, MBBS PhD, George A Fielding, MD NYU, Langone Medical Center and University of Melbourne Introduction: Long term complications requiring reoperation after laparoscopic adjustable gastric banding (LAGB) occur with relative frequency. Little is known about the impact of revisional surgery on patients’ weight, an essential consideration when deciding to reoperate and choosing a revisional procedure. This study aims to assess the weight of patients who have had a major reoperation after LAGB with 1 and 2 year follow up. Methods and Procedures: All patients who underwent LAGB as a primary bariatric procedure and subsequently underwent one major reoperation before 31 December 2010 were retrieved from a prospectively collected bariatric database. Major reoperations were defined as band repositioning, band replacement and hiatal hernia repair. Demographic data, weight as Body Mass Index (BMI) and percentage excess weight loss (%EWL), surgical indications and operative details were recorded. Weights at 12 and 24 month post revision were recorded and compared with initial weight and weight before reoperation. Data were described using the mean and range and in the study of outcomes, changes in %EWL were compared using the paired T-test with a 95% confidence interval. Results: 423 patients were included. Age at primary banding was 40.4 years, initial weight was 122.8 kg (range 69.9–220.4 kg) and BMI 44.2 kg/m2 (27.0–69.0 kg/m2). Reoperation occurred 34.8 months after primary LAGB. Age at reoperation was 43.3 years, weight and BMI had decreased to 91.9 kg (44.5–177.3 kg) and 33.0 kg/m2 (18.9–57.7 kg/m2) and %EWL was 50.3 (-13.0 to 127.0). Weight, BMI and %EWL at 12 and 24 months after reoperation was 92.5 kg (49.0–163.7 kg), 33.4 kg/m2 (19.0–60.6 kg/m2) and 47.8 (-41.0 to 114.0) and 92.8 kg (47.6–166.8 kg), 33.6 kg/m2 (19.8–54.1 kg/m2) and 48.1 (-12.0 to 115). The change in %EWL for the entire study population was -3.9 from reoperation to 12 months and -4.1 from reoperation to 24 months. Theses changes in %EWL are statistically significant P B 0.001 (to 12 months) and P = 0.001 (to 24 months).

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METABOLIC OUTCOMES OF BARIATRIC SURGERY: THE RESULT OF THAI SUBJECTS Suthep Udomsawaengsup, MD, Amarit Tansawet, MD, Poochong Timratana, MD, Suriya Punchai, MD, Warit Utanwutipong, MD, Komdej Thanavachirasin, MD, Suppa-ut Pungpapong, MD, Chadin Tharavej, MD, Patpong Navicharern, MD, Chula Minimally Invasive Surgery Center, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand Background: Obesity and its co-morbidities become to be one of the most important health care problems. Thailand and other Asian counties are not excluded. Weight loss surgery has been proved as the most effective and sustainable method to obtain long term weight control and to achieve improvement of metabolic disorders. We reviewed outcomes of surgical treatment for morbidly obese in Thai patients in our institute. Methods: Data from all patients who underwent bariatric surgery by Chula Minimally Invasive Surgery Center, Chulalongkorn University were collected and outcomes were reviewed. Results: From Jan 2003 to May 2005 and July 2007 to August 2011. Eighty consecutive Thai patients underwent bariatric surgery by Chula Minimally Invasive Surgery Center, Chulalongkorn University. The mean age was 36.2 (18-57) years. Fifty one of 80 (51.3%) were men. The initial BMI was 51.1(35–81.3) kg/m2 Roux en Y Gastric bypass was the most common procedure (68.8%). In RYGB group showed mean EWL of 64.2% at 2 years. Nineteen (23.8%) were type II diabetic, all of them were getting improvement post operatively; of which, 81.8% were completely resolved and 18.2% were able to decrease dosage of hypoglycemic drugs. Thirty four (42.5%) were hypertensive, 46.7% of them were able to discontinue antihypertensive drugs and 46.7% were decreasing dosage. Twenty one (26.3%) were dyslipidemia; 60% were resolved and 40% were improved. Conclusion: Metabolic results in Thai patients undergoing bariatric surgery are excellent. This initial data from part of Asia reflects a comparable result worldwide.

Weight after reoperation by procedure Initial

Reoperation

No. of patients

Weight (kg)

BMI (kg/m2)

Weight

BMI

%EWL

Repositioned

234a

118.8

43.4

85.7

31.2

56.1

Replaced

162b

127.4

44.9

99.9

35.2

42.7

27

130.3

45.8

99.7

35.2

44.4

HHR

37806

12 months No. of patients

24 months Weight

BMI

%EWL

No. of patients

Weight

BMI

%EWL

87.4

32.0

51.8

130

88.4

32.4

51.2

Repositioned

198

Replaced

125

98.8

35.1

42.6

79

100.0

35.5

41.6

23

101.2

35.8

40.7

14

93.6

33.6

55.6

HHR a

160 of these patients had concurrent HHR

b

95 of these patients had concurrent HHR

Conclusions: Overall, weight loss after all major reoperations for LAGB is maintained at 12 and 24 months. Despite variability in procedures, indications and starting weights, surgeons and patients can feel assured that weight maintenance with adequate follow up is possible after reoperation for LAGB.

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PERIODICALLY EMPTYING OF THE GASTRIC BAND SYSTEM REDUCES LATE COMPLICATIONS Brane Breznikar, MD, Dejan Dinevski, PhD Prof, Grega Kunst, MD, Barbara Rozej, MD, General Hospital Slovenj Gradec Introduction: We analyzed our first five years of performing gastric bandings. We were monitoring comorbidities and results regarding participation the support group and emptying of the system. Based on our experiences, gastric banding is successful only with thorough assessment and treatment before the operation, as well as methodical professional support after it. Those who had participated the support group more often had better results than those who were present less frequent. Based on our retrospective study periodically emptying reduces late complications. Prospective study is performing from January 2009. Patients and methods: From May 2005 to May 2010 we have performed 264 gastric bandings (66.5% of all procedures). Patients were 41.0 years old and had BMI of 42.4 kg/m2 on average. There were 224 female (84.8%). 155 patients (80.7%) were evaluated for BAROS. Results: 1st, 2nd and 3rd year they lost 23.4, 31.4 and 33.7 kg on average respectively (EWL 50.3, 65.6 and 69.8% on average respectively). We monitored the resolution of comorbidities and complications. BAROS quality of life scale was evaluated with grade good in both ‘‘comorbidity’’ and ‘‘without comorbidity’’ group (4.85 and 2.64 respectively). Retrospective study of 182 patients from May 2005 to January 2009 presented 10 slippages and 1 migration among those we did not empty the system. One slippage was among those we have emptied the system at least once a year. Prospective study from January 2009 to October 2011 presented 2 slippages in the group we did not empty. Conclusions: The results are better when patients participate the support group and when we empty the system periodically.

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LAPAROSCOPIC SLEEVE GASTRECTOMY WITH HIATAL HERNIA REPAIR: A RETROSPECTIVE CASE SERIES AND REVIEW OR LITERATURE Anna Goldenberg-sandau, DO, Wanda Good, DO, Lisa Shaw, RN, Marc Neff, MD, University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine(Kennedy University Health System), Department of Surgery. University of Medicine and Dentistry and Medicine of New Jersey, Kennedy University Hospital Background: In current literature laparoscopic sleeve gastrectomy (LSG) for morbid obesity is gaining increasing popularity among both surgeons as well as patients. To date there is little research on combination sleeve gastrectomy with hiatal hernia repair(HHR) even thought symptoms of gastroesophageal reflux disease(GERD) and hiatal hernia(HH) is significantly increased with morbid obesity to a prevalence as high as 50%. In fact, obesity is considered an independent risk factor for hiatal hernia and symptoms of chronic esophagitis. Methods: From January 2010 to June 2011, eleven patients underwent LSG and HHR. Retrospective chart review was conducted. Clinical evaluation included average weight loss and resolution of GERD symptoms including discontinuation of anti-reflux medications. We perform a comprehensive literature review(Pubmed, Cochrane, Ovid 1990–current) of the current trends in surgical management of morbid obesity with LSG and HHR. Results: Retrospective chart review was conducted with a mean follow up of 4 months. Average weight loss was 6.4 kg/month. The mean weight was 275.9 lbs. with a BMI is 44.75. Ten of of eleven patients had pre-operative diagnosis of symptomatic HH with GERD symptoms. One patient without symptoms showed no evidence of HH on UGI and did not have a pre-operative EGD but a HH was identified intraoperatively. Five patient had evidence of chronic gastritis on EGD with confirmed tissue biopsy and one positive for H. pylori was treated pre-operatively with confirmed eradication. Crural closure was performed in all cases with HH size ranging from 2 cm to 5 cm. There were no intra-operative or postoperative complications. Eight of eleven (73%) patients reported cessation of reflux symptoms postoperatively. Four of six patient taking anti-reflux medication (67%) patients discontinued all anti-reflux medication. The two patients, although reported decrease in symptoms still continued to take proton pump inhibitors. Conclusion: With the increase risk of reflux before weight loss surgery as well as after LSG, patients with HH identified pre-operative and intra-operatively should be considered for repair. Combination LSG with HHR is safe and provides good outcomes for patients with morbid obesity and GERD.

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COMPARATIVE OUTCOMES OF WEIGHT LOSS AND PERIOPERATIVE COMPLICATIONS IN MORBIDLY OBESE POPULATION UNDERGOING BILIOPANCREATIC DIVERSION BASED ON AGE Iswanto Sucandy, MD, Gintaras Antanavicius, MD FACS, Abington Memorial Hospital, Abington, Pennsylvania Introduction: Although many risk factors affecting outcomes of bariatric procedures have been identified, the effect of age on weight loss and perioperative complications was not adequately investigated. Previous studies have reported that increasing age and preoperative BMI are independently associated with an increased risk of complications. Therefore, many surgeons are hesitant to offer bariatric surgery to older patients with significantly higher BMI because of considerably greater medical comorbidities, and less weight-control efficacy. In this study, we compare the weight loss outcome and perioperative complications following biliopancreatic diversion in high-BMI morbidly obese population stratified by age. Methods: Review of a prospectively maintained database was conducted in all patients who underwent robotically assisted laparoscopic biliopancreatic diversion with duodenal switch (R-LBPD/DS) between December 2008 and July 2011. Data assessed included age, gender, preoperative and postoperative weight at 1-, 3-, 6-, 9-, 12-, 18-month intervals, operative time, conversion rate, perioperative complications, length of stay (LOS), and readmission rates. Variables were compared based on the patients age (age 20–35, n = 26 (group A), age 36–50, n = 45 (group B), and age 51–72, n = 36 (group C)). Statistical analysis was conducted using T-test and analysis of variance (Anova). Results: A total of 107 consecutive patients (F:M = 83:24) were included in this study, with no significant differences in gender distribution (p = 0.39), preoperative weight (p = 0.52), and body mass index (BMI) (p = 0.84) among groups. The oldest group (C) had a statistically significant higher number of preoperative comorbidities (7.3) compared with those in groups A (5.4) and B (6.3) (p = 0.0034). No statistically significant difference was found in the mean operative time (A = 274, B = 266, C = 294 min, p = 0.074), or length of stay (A = 3.0, B = 2.7, C = 3.3 days, p = 0.16). All cases were successfully completed using minimally invasive approach. There were no intraoperative or 30-day major postoperative complications (ie; anastomotic leak, hemorrhage, intestinal obstruction, inadvertent intraabdominal organ injury, and thromboembolic event). Three patients developed minor complications : one in group C developed incarcerated umbilical hernia requiring laparoscopic repair, one in group A developed postoperative carpal tunnel syndrome exacerbation and another in group C had to return to the operating room for port site infection. Percentage of excess body weight loss (EBWL) at 1, 3, 6, 9, 12, and 18 months are comparable among groups, although group B trended toward higher weight loss outcome at 18 months compared with that in groups A and C (88% versus 81% and 80.3%, respectively, p = 0.27). No mortality occurred in this series. Conclusions: Despite a higher number of preoperative medical comorbidities that translated into a higher perioperative risk, older patients perform as well as their younger counterparts with respect to operative time, conversion rate, perioperative complications, length of stay, and weight loss outcome.

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LAPAROSCOPIC BARIATRIC SURGERY FOR THE TREATMENT OF SEVERE HYPERTRIGLYCERIDEMIA Wei-jei Lee, MD PhD, Jung-chien Chen, MD, Kong-han Ser, MD, Jun-juin Tsou, SPN, Yi-chih Lee, MHA, Min-Sheng General Hospital, National Taiwan University, Taiwan Background: Severe hypertriglyceridemia is an established cause of pancreatitis. Medical treatment for patients with severe hypertriglyceridemia and repeat pancreatitis attacks are not satisfactory. Methods: A review of 20 morbid obese patients with severe hypertriglyceridemia (a triglyceride level of more than 1000 mg/dl) who received laparoscopic bariatric surgery was performed. The series consisted of 14 males and 6 females, with an average of 35.0 years (from 24 to 52) and the mean BMI was 38.2 (from 25 to 53). The preoperative mean plasma triglyceride was 1782.7 mg/dl (from 1043 to 3884). Four patients had a history of hypertriglyceridemic pancreatitis and 13 had associated diabetes. Results: Of the 20 patients, 17 (85%) received gastric bypass, 3 (15%) received restrictive type surgery. Laparoscopic access was used in all the patients. Hypertriglyceridemia in morbid obese patients were associated with male gender and a not well controlled diabetes state. The mean BMI decreased to 28.7 (24.9% reduction) one year after surgery with a great improvement in diabetes control. The markedly elevated plasma triglyceride levels decreased to 254 mg/dl (from 153 to 519) at one month after surgery and to 192 mg/dl (from 73 to 385) at one year. One patient developed acute pancreatitis at peri-operative period but none of the patient has had an episode of pancreatitis at follow-up (from 6 months to 13 years). Conclusions: Bariatric surgery can be used as a metabolic surgery in severe hypertriglyceridemia patients at risk of acute pancreatitis. Control of hypertriglyceridemia before bariatric surgery is indicated.

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EARLY EXPERIENCE WITH NATURAL ORIFICE TRANSUMBILICAL SURGERY GASTRIC BYPASS(NOTUS) USING NEEDLESCOPIC INSTRUMENTS Arif Ahmad, MD FACS FRCS, Ashish Agarwala, DO John T. Mather, Memorial Hospital, Stony Brook University Medical Center We present our early data on NOTUS gastric bypass using needlescopic instruments and compare it to the traditional 5 port laparoscopic gastric bypass. Prospective trial in which 20 morbidly obese patients after undergoing workup as per the NIH criteria were enrolled for NOTUS gastric bypass. Data collected included operative time, blood loss, hospital stay, perioperative complications, cosmetic appearance of incisions and patient satifaction surveys. This was compared with our own data of traditional 5 port laparoscopic gastric bypass. In brief NOTUS gastric bypass is performed by placing one 12 mm and one 5 mm trocar through a single transumbilical incision followed by three needlescopic 2.3 mm instruments introduced percutaneously in the left and right upper quadrants. There were no differences between the two groups in terms of blood loss or hospital stay. There were no perioperative complications in either group. The operative times were slightly longer in the NOTUS group. Cosmesis was markedly improved in the NOTUS group. Patient satisfaction survey scores were also higher in the NOTUS group. In summary, NOTUS gastric bypass is a technically feasible procedure producing equivalent results as the traditional gastric bypass while achieving the cosmetic benefits desired of SILS. Unlike SILS, it does not compromise the basic surgical tenets of precision and safety while still offering a potentially scarless operation.

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A NOVEL APPROACH FOR CONVERSION OF ROUX-EN-Y GASTRIC BYPASS TO BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH Philippe Topart, MD, Guillaume Becouarn, MD, Carine Phocas, RN, Societe de Chirurgie Viscerale, Clinique de l’Anjou, Angers, FRANCE Objectives: Roux-en-Y gastric bypass (RYGB) is now one of the most used bariatric procedures. Although an efficient one, weight regain appears to be frequent and in approximately 20% of the cases will eventually lead to poor weight loss results. Besides applying further restriction to a basically mostly restrictive procedure in case of weight loss failure, conversion to a more malabsorptive procedure has been proposed. In addition to the modification of the proximal RYGB to a distal gastric bypass (D-RYGB), conversion to a biliopancreatic diversion with or without duodenal switch (BPD-DS)) has been described. Conversion to BPD-DS is by far the most complex as it implies the take down of the gastrojejunal anastomosis and restoration of the gastric continuity before performing the BPD-DS itself. As a result, only half of the procedures could be completed in 1 stage in the few published reports. Methods and Procedures: A 1 stage procedure was designed, keeping the gastric pouch of the RYGB as well as the gastrojejunal (GJ) anastomosis. The alimentary limb was divided 10 cm below the GJ and the fundus of the remnant stomach resected, leaving only the antrum. An anastomosis between the short segment of alimentary limb and the antrum was performed, thus constructing a ‘‘hybrid’’ sleeve gastrectomy. The remaining alimentary limb was reconnected to the biliopancreatic limb of the RYGB. A new 150 cm alimentary limb with a 100 cm common channel using the ileum was measured and the ileo-ileal anastomosis performed 100 cm distal to the ileo- caecal valve. An end to side duodeo-ileal anstomosis was performed with a 21 mm circular stapler after dividing and stapling the duodenum 3-4 cm distal from the pylorus. Results: 4 patients with weight loss failure had their RYGB converted to BPD-DS using this technique. Their initial BMI was 45, 56, 61 and 70. Their respective BMI at the time of the conversion was 45, 52, 44 and 50. One procedure was done open because of an incisional hernia and the 3 others were done laparoscopically. One patient with a retro-colic, retro-gastric RYGB had to be converted to an open procedure to locate the alimentary limb. The surgery duration was 4 h. No death occured and 1 patient with an open procedure had to be reoperated on for an abdominal abscess. 6 to 18 months postoperatively, the weight loss experienced ranged from 10 to 38 Kg. Conclusion: Although remaining complex, this procedure of conversion from RYGB to BPD-DS can always be done as 1 stage. Laparoscopy is feasible providing the RYGB has been done ante-colic, ante-gastric. The long term benefit on weight loss needs to be further assessed.

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ADJUSTING THE GASTRIC BAND DURING SURGERY—IS TIGHTER BETTER ? John O’dea, BE MED PhD, Robert G Snow, DO FACOS NUI, Galway, Ireland; Specialty Surgery Center of Fort Worth, TX Objective: We have previously demonstrated that intra-operative adjustment of a gastric band to a stoma size of 6.5 mm appears to confer an advantage of approximately 5%EWL in the period 4–6 weeks after surgery [1], such adjustment being well tolerated by patients. We sought to assess how adjusting the band more tightly, setting the stoma size to 5.5 mm during surgery, would be tolerated, and whether it would improve early post-operative weight loss. Methods: The EndoFLIPTM system (Crospon, Galway, Ireland) and BF-325 balloon catheter were used to intra-operatively set the stoma size in the APS (Small, S) and APL (Large, L) Model Lap-Bands (Allergan Inc., Irvine, CA) in 50 consecutive patients, and %EWL was measured at the first follow-up visit in the period 4–6 weeks after surgery. %EWL was compared (a) against a group of historic control patients who did not have intra-operative band adjustment and (b) a group of patients who previously had intra-operative band adjustment to a stoma size of 6.5 mm. Results: The following were the demographics and %EWL results for the three groups (mean (SD)) : D% EWLa

P

14.6 (9.6)

-6.1

0.03

15.6 (8.9)

-5.2

0.11

Group

N

Age (year)

Weight (lb)

BMI

Sex (F:M)

%EWL

6.5 mm

23

45.8 (10.8)

266 (57)

41.7 (8.1)

20:3

20.8 (10.8)

5.5 mm

50

47.0 (10.5)

256 (52)

41.8 (7.0)

44:6

No adjust

39

41.8 (12.2)

283 (62)

45.0 (8.0)

28:11

a

Compared with 6.5 mm group

Patients tolerated the 5.5 mm intra-operative adjustment comfortably. The difference in %EWL between the 5.5 mm adjusted group and the historic controls was not significant (D%EWL = 0.97, p = 0.88).

Conclusions: Tightening the band to 5.5 mm did not improve %EWL in the 4–6 week post-operative period versus historic controls. This supports previous observations [2] that a stoma size reduction of 1 mm could potentially move a patient from the green zone (6.5 mm stoma size) to the red zone (5.5 mm stoma size), potentially leading to maladaptive eating behavior. References 1. Snow RG, O’Dea J Intra-operative Band Stoma Adjustment Improves Early PostOperative Weight Loss. Obesity Surgery Vol. 20 No. 8 969-1077, July 2010 2. Snow RG, O’Dea J Is there an optimal gastric band stoma size. Surgical Endoscopy Vol. 24 Supp. 1, S318, Apr 2010

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VIDEO GUIDE TO THE PERFORMANCE OF THE MINIGASTRIC BYPASS R Rutledge, MD, Centers for Laparoscopic Obesity Surgery Introduction: There is a growing body of evidence showing that the Mini-Gastric Bypass (MGB) is a safe and effective alternative to other bariatric surgical operations. Repeated randomized controlled trials show the MGB outperforms comparable bariatric procedures. This video describes the technique of performance of the MGB. Methods: A video demonstration of the steps in performance of the MGB. The surgery is simple and requires only 2 people the surgeon and the scrub tech. Results: The average operative time was 39 min, and the median length of stay was 1 day. Procedure: Port placement: 5 ports, 4.12 mm ports and 1.5 mm ports. Retraction of the liver is followed by skeletonization of the lesser curvature of the stomach at the Crow’s foot, the junction of the body and the antrum of the stomach. Beginning on the lesser curvature at the Crow’s foot two staplers (30 mm and 45 mm) fired perpendicular to the lesser curvature. A 28 French ‘‘guide tube’’ is placed along the lesser curvature to ‘‘size’’ the gastric pouch. Parallel to the lesser curvature a staple line is extended from the Crow’s foot to the esophago-gastric junction. Then attention turns to the bypass portion of the case. The transverse colon is retracted cephalad. The ligament of Trietz is identified and the bowel is run in 1.2 inch steps to bypass between 3 to 8 feet of small bowel based upon the patient’s starting weight. The gastro-jejunostomy (GJ) anastomosis is begun. A gastrotomy and jejunostomy are created. An Endo-GIA is passed into the stomach and small bowel. The gastro-jejunosotmy is formed firing the Endo-GIA. The ‘‘guide tube’’ is advanced across the anastomosis to act as a stent and help avoid a stricture. Four stay sutures are placed to pull the gastric and jejunal tissue up into the jaws of the stapler the EndoGIA is fired to close the GJ. A corner stitch is placed at the lateral corner of the GJ The GJ is flipped and a continuous suture is run around the GJ reinforcing the anastomosis. The operation is now completed and the ports removed and the skin is closed with clips Conclusions: Several randomized controlled prospective trials confirms that the MGB out performs comparable bariatric procedures. The MGB is safe, reversible and revisable, results in a marked decrease in perceived hunger and increased satiety with major weight loss, it has a short operating-time, and a significantly shorter hospital stay than the RNY. The MGB appears to meet many of the criteria of an ‘‘ideal’’ weight loss operation.

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MORBIDLY OBESE MEN SHOWED DECREASED TESTOSTERONE LEVELS AND SEXUAL QUALITY OF LIFE COMPARED WITH AGE ADJUSTED MEN IN THE COMMUNITY Taehee Kwak, MD, Homayoun Pournik, MD, Krystyna Kabata, RPAC, Anthony Tortolani, MD, Piotr Gorecki, MD, New York Methodist Hospital, Brooklyn, NY, USA Background: Previous studies have indicated that morbidly obese males have decreased testosterone levels and sexual function related quality of life.

Objective: The purpose of this study was to quantify decreased sexual quality of life in morbidly obese men using a previously validated questionnaire, to compare their reported sexual quality of life with that of a previously reported age-related normative sample of men and to examine the association between sexual quality of life and testosterone levels. Methods: Sixty-three morbidly obese men who were scheduled for bariatric surgery participated in this study. Serum testosterone levels and sexual quality of life were measured before any bariatric surgery performed. In order to evaluate sexual function, the previously validated Brief Male Sexual Function Inventory (BSFI) questionnaire was administered. The questionnaire has 11 questions measuring 5 different categories of sexual function including sexual drive (two questions), erectile function (three), ejaculatory function (two), problem assessment (three), and overall satisfaction (one). To assess the degree of decreased sexual quality of life in morbidly obese men, their baseline data were compared with age adjusted normative data from the literature. Pearson correlation coefficients were computed between BMI, free and total testosterone levels, and scores in each category of the BSFI questionnaire. Results: The mean age was 41.4 ± 11.2 year, weight was 316.3 ± 43.8 lb, BMI was 45.2 ± 5.3 Kg/m2, free testosterone was 50.6 ± 21.3 pg/ml, and total testosterone was 288.2 ± 103.4 ng/dl. 58% (23 out of 40 men who had baseline free testosterone level) of morbidly obese men had low free testosterone level (\50 pg/ml). 38% (20 out of 54) of the men showed low total testosterone level (\250 ng/dl). There were no statistically significant correlations between BMI and scores on BSFI. Scores on BSFI Sexual Drive were correlated positively with both free testosterone and total testosterone level (r = 0.58, p = 0.02 and r = 0.52, p = 0.02 respectively). There was no significant correlation between testosterone levels and other categories of sexual function in the questionnaire. The percentage of morbidly obese men with at least one BSFI score below the normative mean for men in the same age group was as follows: 20–29 (70%); 30–39 (80%); 40–49 (80%); 50–59 (80%); 60 and older (40%). Conclusions: This study supports previous studies demonstrating decreased testosterone levels and sexual quality of life in morbidly obese men. Based on responses to a previously validated questionnaire, the vast majority of morbidly obese men, under the age of 60, indicated a level of sexual function below that of a large normative sample of men of similar age. Our results provide important evidence that will enable better understanding of sexual function related quality of life in morbidly obese men undergoing bariatric surgery.

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LAPAROSCOPIC SLEEVE GASTRECTOMY DOES NOT WORSEN GASTROESOPHAGEAL REFLUX DISEASE SYMPTOMS IN MORBIDLY OBESE PATIENTS Joshua A Scott, MD, Joel R Brockmeyer, MD, Rebekah J Johnson, MD, Yong U Choi, MD, D.D. Eisenhower, Army Medical Center Introduction: Those with morbid obesity are at increased risk for having gastroesophageal reflux disease (GERD) symptoms. Currently, treatment for GERD in these patients is either gastric fundoplication or bariatric surgery. Gastric bypass has shown to decrease GERD symptoms, however, the data are less clear on the resolution or worsening of GERD symptoms in patients who have undergone laparoscopic sleeve gastrectomy (LSG). This study investigates whether patients who have undergone LSG have improved GERD symptoms and decreased use of anti-reflux medication compared to those who have had laparoscopic gastric bypass (LGB). Methods: Forty three patients who underwent LSG and 35 patients who underwent LGB at a single institution by four surgeons over 19 months were interviewed by telephone and their medical charts were retrospectively reviewed. Upon interview, GERD symptoms were recorded based on a GERD symptom severity scale. Patient age, gender, loss of excess body weight (EBW) one year after surgery, and medication use were also collected. Results: There was no difference in overall post-operative GERD symptoms between patients who had LSG or LGB per patient report (21% versus 8.6%, p = 0.243). Patients who had LGB lost significantly more EBW (p \ 0.001) than those who had LSG after one year, however, both groups lost at least 50% on average of EBW. Patients who had LSG reported having to change their diets due to GERD symptoms (p = 0.019) and had significantly more bothersome GERD symptoms when lying down (p = 0.02) and after meals (p = 0.022) compared to those who had LGB. There was no difference in the use of anti-reflux medication between the groups. Conclusions: Overall GERD symptoms are not more common in patients who have had LSG versus LGB, however, those who have had LSG reported having worsened GERD symptoms when lying down, after meals, and reported to have to change their diets in order to prevent GERD symptoms. Further trials with longer term follow up is required to truly identify if LSG does not worsen GERD, however, initial data is promising.

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PRESENTATION AND MANAGEMENT OF GASTROGASTRIC FISTULA AFTER ROUX-EN-Y GASTRIC BYPASS Saber Ghiassi, MD MPH, Ruby Gatschet, MD, Daniel Moon, MD, Keith Boone, MD FACS, Kelvin Higa, MD FACS, University of California, San Francisco, Fresno Introduction: Gastrogastric fistula (GGF), a communication between the gastric pouch and gastric remnant, is a rare but important complication of Roux-en-Y gastric bypass (RYGB) that can lead to weight recidivism and marginal ulcer. We describe our experience with the presentation and management of this complication. Methods: We performed a retrospective chart review of patients who had undergone treatment of GGF from 2007 to 2011. Presentation, diagnostic and therapeutic modalities, and complications were noted. Weight loss before and after treatment of GGF was compared using the Student’s paired t-test. Results: Eighteen patients with GGF were identified. They had undergone 6 open RYGB and 12 laparoscopic RYGB. Five were complicated by leak. Eight were referred from outside institutions. Average interval between RYGB and presentation was 6 ± 1 years. Most common presentation was abdominal pain (67%), followed by weight recidivism (56%) and ulcer (44%). Sixteen endoscopies and 7 out of 10 upper GI studies were diagnostic. One patient was successfully treated with endoscopic selfexpanding stent. Three patients failed endoscopic management with Endoclips. Seventeen patients underwent remnant gastrectomy, 9 patients also underwent pouch gastroplasty, and an additional 8 patients underwent revision of gastrojejunostomy. Postoperative complication rate was 17%. One postoperative leak was treated with image-guided drainage and another with endoscopic self-expanding stent. One patient underwent endoscopic balloon dilatation of gastrojejunostomy. Mean follow-up was 10 ± 3 months. Mean percent excess weight loss was 46% ± 8 at the time of surgery for GGF vs. 64% ± 5 at follow-up (p = 0.005). Conclusion: Gastrogastric fistula is a rare complication of RYGB that can lead to weight regain and marginal ulcer. Etiologies include anastomotic leak, incomplete gastric division, marginal ulcers, distal obstruction, and erosion of foreign body. Endoscopy is diagnostic but its therapeutic efficacy is very low. Surgery, including remnant gastrectomy, is the definitive treatment with acceptable complication rate. Treatment of GGF results in resolution of symptoms and improved weight loss.

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PROPHYLACTIC MANAGEMENT OF CHOLELITHIASIS IN BARIATRIC PATIENTS - IS ROUTINE CHOLECYSTECTOMY WARRANTED? Chris G Smith, Dr, Balpreet Brar, Dr, Fatima Haggar, Ms, Joseph Mamazza, Dr, Robert Dent, Dr, Jean Denis Yelle, Dr, Husein Moloo, Dr, Isabelle Raiche, Dr the Ottawa Hospital Introduction: The role of prophylactic cholecystectomy and the usefulness of preoperative ultrasound in patients undergoing bariatric surgery is unclear. The objective of this study was to examine the rates of laparoscopic cholecystectomy in patients participating in a weight loss program and to identify risk factors for the development of symptomatic gallstones requiring cholecystectomy. Methods and Procedures: We prospectively studied 176 (97 females and 33 males) consecutive bariatric patients who were enrolled in an intensive weight loss program. Data from 166 patients who had a transabdominal ultrasound on week 1 of the program were analysed. Logistic regression was used to model the risk of laparoscopic cholecystectomy due to development of symptoms of biliary disease after enrolment into the program. Risk factors associated with cholelithiasis including, sex, age, BMI, % weight loss, fatty liver, diabetes mellitus and cholesterol lowering drugs were included in the regression model. Results: Gallbladder disease, as indicated by presence of gallstones on ultrasound, or previous cholecystectomy, were found in 16.3% (n = 27) and 21.7% (n = 36) of patients, respectively. Of the 27 who had positive ultrasound findings, 25.9% (n = 7) developed delayed symptoms related to biliary disease and underwent laparoscopic cholecystectomy. In contrast, of the 105 patients who had a negative ultrasound, 8.6% (n = 9) underwent cholecystectomy. Median time to surgery was 6.2 years (interquartile range: 8.75 years). There were no post-operative complications due to cholecystectomy. Logistic regression analysis, adjusted for known risk factors of gallstones formation, revealed that patients with identified gallstones were significantly more likely to undergo laparoscopic cholecystectomy compared with those with no gallstones at the start of the program (Odds Ratio 4.6, 95% confidence interval (CI) 1.6–12.4, p value = 0.003). Discovery of cholelithiasis after starting the program was highly associated with the development of symptoms requiring cholecystectomy (Odds Ratio 5.2, 95% confidence interval (CI) 3.16–8.4, p value \ 0.001). Conclusion: The presence of gallstones during rapid weight loss is associated with an increased risk of developing symptoms requiring cholecystectomy. Routine preoperative ultrasound and concomitant cholecystectomy at the time of gastric bypass surgery may be indicated given this increased risk. However, the value of prophylactic cholecystectomy in the absence of symptomatic gallstones has yet to be demonstrated.

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THE MINI-GASTRIC BYPASS: 15 YEARS LATER R Rutledge, MD, Center for Laparoscopic Obesity Surgery Introduction: There is a growing body of evidence showing that the Mini-Gastric Bypass (MGB) is a safe and effective alternative to other bariatric surgical operations. This study reports on the results of a consecutive cohort of 6,000 patients undergoing the MGB. Methods: A prospective database was used to continuously assess the results in 2,410 MGB patients treated from September 1997 to 2010. Results: The average operative time was 44 min, and the median length of stay was 1 day. The 30-day mortality and complication rates were 0.05% and 5.1% respectively. The leak rate was 0.96%. Average weight loss at 1 year was 64 kg (81% of excess body weight). The most frequent long-term complications remain as previously reported: dyspepsia and ulcers (5%) and iron deficiency anemia (5%.) Excessive weight loss with malnutrition occurred in 1.0%. Weight loss was well maintained over 15 years, with \7% patients regaining more than 10 kg. Conclusions: As shown in previous studies, the MGB is very safe initially and in the long-term. It has reliable weight loss and complications similar to other forms of gastric bypass.

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PULL TECHNIQUE FOR INTRODUCING THE ANVIL DURING GASTRIC POUCH-JEJUNAL LIMB ANASTOMOSIS IN LRYGB Amarit Tansawet, MD, Suphakarn Techapongsatorn, MD, Sopon Lerdsirisopon, MD, Wisit Kasetsermwiriya, MD, Vajira Minimally Invasive Surgery Unit, Department of Surgery, Faculty of Medicine Vajira Hospital, University of Bangkok Metropolis Objective of Technique: To help us perform the gastric pouch-jejunal limb anastomosis more easier.

Description of Methods: The gastric pouch-jejunal limb anastomosis is usually done by circular staple in our institute. We use the instruments from commercial PEG set to facilitate the procedure. Under direct vision from the endoscope inside the pouch, The tiny hole is create by cautery from outside. The snare is passed through this hole into peritoneal cavity to retrieve the nilon loop which insert via the laparoscopic port. After the loop is bought out from the patient’s mouth, the anvil of the staple is fixed to this loop. The loop is drawn backward, so the anvil is introduced into the gastric pouch. The EEA staple shaft is inserted into peritoneal cavity via the extended port incision. The anvil is attached and approximated to the shaft, then the staple is fired. The completeness of the anastomosis is ensured. Conclusion: We found that our technique help us save the time in doing the gastric pouch-jejunal limb anastomosis.

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ROUX-LIMB LENGTH DOES NOT PREDICT REMISSION OF DIABETES AFTER ROUX-EN-Y GASTRIC BYPASS Andrew A Taitano, MD, Tejinder P Singh, MD AMC, Bariatric Surgery Group, Albany Medical Center Introduction: The surgical treatment of morbid obesity leads to weight loss and remission of diabetes in most patients with type 2 diabetes mellitus (T2DM). However, it is unknown whether technical factors such as the length of the roux-limb have an impact on remission of diabetes. Our purpose was to investigate the relationship between the length of the roux-limb in gastric bypass patients and remission of T2DM. Methods: We evaluated pre- and post-operative data, including demographics, weight at all follow-up encounters, Hemoglobin A1C levels, medication lists, and the length of the roux-limb of patients undergoing laparoscopic roux-en-y gastric bypass (LRYGBP) between March 2003 and December 2009. Results: 551 patients underwent LRYGBP, of whom 162 (29.4%) had T2DM. Follow-up was possible in 77.8% and averaged 2.4 years. At last follow-up, patients with T2DM achieved 67.2% excess BMI loss and had regained 12.9% of their postoperative weight loss. Average BMI was 47.7 at the time of surgery and 34.1 at last follow-up. 82.5% of patients achieved remission of T2DM. Comparing patients with remission and those without, there were no significant differences for average age, roux-limb length, BMI at the time of surgery or at last follow-up, percent excess BMI loss, or percent weight regain. Rates of remission from T2DM did not significantly vary based on the length of the roux-limb (81.3% for 140–150 cm, 84.9% for 120–125 cm, and 75.0% for 100–110 cm). Subgroup analysis did not reveal any further differences between patients who achieved remission and those who did not. Conclusion: LRYGBP resulted in significant excess BMI loss (67.2%) and remission of T2DM (82.5%) at 2.4 years average follow-up. The length of the roux-limb in LRYGBP does not appear to have a significant effect on remission of T2DM. Prospective studies are needed to determine the optimal rouxlimb length for LRYGBP.

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MORBIDLY OBESE ACHONDROPLASIC AND BARIATRIC SURGERY Venkata S Kanthimathinathan, MD, John Dockins, MD, Norbert Richardson, MD, Daniel Hoernschemeyer, MD, Archana Ramaswamy, MD, Natalie Suttmoeller, RN CCRN CBN, Roger De La Torre, MD, University of Missouri Health Care Introduction: Obesity is a significant and potentially serious health problem in achondroplasia with an incidence of 13 to 43%. Long-term studies show that bariatric surgery in non-achondroplasia patients cause significant loss of weight, better control of diabetes, improvement in cardiovascular risk factors, and a reduction in mortality of 23% from 40%. For the first time, we report a case series of laparoscopic bariatric surgery in morbidly obese achondroplasia patients. Objective: Our aim was to determine whether laparoscopic bariatric surgery improves the quality of life and co-morbidities seen in morbidly obese achondroplasia patients. Methods: Two achondroplasia patients with morbid obesity were studied. Patient A was a 42-year-old female, BMI of 57, height of 58 inches, weight of 272 pounds, associated comorbidities include asthma, sleep apnea, dyspnea on exertion, gastro esophageal reflux disease, hypertension, back pain, stress incontinence, hypercholesterolemia, osteoarthritis and depression. She underwent laparoscopic gastric bypass. Patient B was a 28-year-old female, BMI of 65, height of 47 inches, weight of 205 pounds; associated co-morbidities include back pain and obstructive sleep apnea. She underwent laparoscopic gastric band. Results: At 1 year follow-up, patient A’s BMI was 38, weight was 186 pounds. Significant resolution of co-morbidities was seen with regards to hypertension, hypercholesterolemia, back pain, and depression. She has noticed significant improvement in exertional dyspnea and her quality of life. At 2 year follow-up, patient B’s BMI was 52 and weight was 164 pounds. She has noticed significant improvement in back pain and her quality of life. Conclusion: Obesity in achondroplasia is associated with a higher prevalence of musculoskeletal dysfunctions that interfere with quality of life. So far, very limited data has been published on open bariatric surgery in achondroplasia patients and no data has been published on laparoscopic bariatric surgery on achondroplasics. We did laparoscopic gastric bypass surgery on one patient and laparoscopic gastric banding on the other patient. In our patients, laparoscopic bariatric surgery resulted in resolution of co-morbidities such as hypertension, hypercholesterolemia, back pain, depression and has shown significant improvement in exertional dyspnea and quality of life.

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SLEEVE GASTRECTOMY VERSUS ROUX-EN-Y GASTRIC BYPASS: A RETROSPECTIVE REVIEW OF WEIGHT-LOSS AND RESOLUTION OF CO-MORBIDITIES Alisha Skinner, BA, Brent Tatsuno, BS, Yosuke Mitsugi, MD, Edwin A Takahashi, BS, Michael Tom, BA, James Davis, PhD, Daniel Murariu, MD MPH, Racquel S Bueno, MD FACS, Cedric S Lorenzo, MD, University of Hawaii John A. Burns School of Medicine, University of Hawaii Department of Surgery, Kuakini Medical Center, The Queen’s Medical Center, Honolulu, Hawaii, United States of America Background: The outcomes for laparoscopic roux-en-y gastric bypass surgery versus laparoscopic sleeve gastrectomy for weight loss and co-morbidities resolution were compared. Laparoscopic roux-en-y gastric bypass surgery (LRYGB) has become the leading procedure for weight loss in the morbidly obese. Multiple obesity related co-morbidities including type 2 diabetes mellitus (T2DM), hypertension (HTN), obstructive sleep apnea (OSA) and gastroesophageal reflux disease (GERD) improve or resolve following these operations. LRYGB has been the primary surgery offered to bariatric patients, but the laparoscopic sleeve gastrectomy (LSG) is an increasingly popular alternative procedure. Methods: A retrospective chart review at a bariatric center associated with a tertiary medical center was conducted to analyze the quantity of excess weight loss (EWL) and the resolution of T2DM, HTN, OSA, and GERD in 26 patients undergoing LRYGB and 26 patients undergoing LSG between 01/01/2008 and 2/8/2010. Subjects were matched primarily based on age, gender, pre-operative weight and BMI, and secondarily on co-morbidities. Statistical analysis was performed using McNemar’s test for categorical variables and paired t test for continuous variables. Results: At one year after surgery, the LRYGB operative subjects had an EWL of 84.2% compared to 66.1% for the LSG group (p \ 0.01). T2DM had resolved respectively in 93% and 75% of LRYGB and LSG patients (p = 0.53). HTN had resolved respectively in 45% and 56% of LRYGB and LSG patients (p = 0.74). CPAP use for OSA had resolved respectively in 77% and 62% of LRYGB and LSG patients (p = 0.67), while the diagnosis of GERD had resolved in 56% and 56% (p = 1.00). Conclusions: Our data shows a significantly greater percentage of EWL at one year in patients undergoing LRYGB compared to LSG. There was a significant resolution of co-morbidities associated with obesity in both groups, but without a significant difference between them. Our results confirm that LSG is a viable alternative to LRYGB in the resolution of obesity related comorbidities, despite greater weight loss obtained in the LRYGB group.

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TRANS-UMBILICAL TWO-SITE LAPAROSCOPIC ROUXEN-Y GASTRIC BYPASS: RESULTS IN 500 PATIENTS Wei-jei Lee, MD PhD, Jung-chien Chen, MD, Kong-han Ser, MD, Jun-juin Tsou, SPN, Yi-chih Lee, MHA, Min-Sheng General Hospital, National Taiwan University, Taiwan Background: Single-incision laparoscopic surgery (SILS) has emerged recently but is difficult to be applied in more complicated gastric bypass surgery. According to the thought of SILX, we developed a modified technique (two-site technique) to perform laparoscopic Roux-en-Y gastric bypass (TS-LRYGBP). Methods: A retrospective analysis from prospective collected data was performed. Patients who underwent TS-LRYGBP were included. Two small skin incision (17 mm and 5 mm) with the subxyphoid skin puncture wounds were made for all patients. Demographics, operative time, length of stay (LOS), weight loss, effect on co-morbidity and mortality were evaluated.

Results: Between February 2009 and August 2011, a total of 500 underwent TSLRYGBP at our institute. 60% were female, initial mean BMI 40.5 (30.1–60) Kg/m2. All procedures were completed by laparoscopic surgery but 18% of them required one to two more 5 mm ports to complete the procedure. For the first 100 patients, operative time was 170.9 + 30 min which was gradually decreasing to 140 + 14 min. The mean LOS was 4.1 days at beginning and decreased to 3.5 days. Weight loss was 25% at 1 year and 30% at 2 years. Major complication rate was 4% with one mortality case (0.2%). The patient’s satisfaction was higher than convention LRYGBP. Conclusions: TS-LRYGBP is a safe and reproducible modified SILS bariatric procedure. This technique might generate minimal pain and achieve an excellent cosmetic satisfaction.

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MANAGEMENT OF A DIFFICULT: GASTROSPLENIC FISTULA AFTER LAPAROSCOPIC SLEEVE GASTRECTOMY Flavia C Soto, MD, Wayne J English, MD FACS, Marquette General Hospital Introduction: Gastrosplenic fistulas are a rare event and mainly related to gastric and splenic malignancies and associated chemotherapy, Crohn’s disease, peptic ulcer disease and trauma. We present a patient who underwent a laparoscopic sleeve gastrectomy and developed a gastrosplenic fistula that was difficult to manage. Methods and procedure: A 33 year old female with BMI 53 and multiple comorbidities underwent an uneventful laparoscopic sleeve gastrectomy (LSG). Twenty four days after surgery, she presented with fever and tachycardia. The CT scan evidenced a questionable leak and inflammatory changes in the superior medial aspect of the spleen. Patient underwent exploratory laparoscopy. A peritoneal lavage was performed, multiple drains were placed and a feeding jejunostomy was inserted. No leak site was identified intraoperatively using the air insufflation test. The patient was discharge home eight days later. Eighteen days after that event, the patient returned with the same symptoms. A CT scan revealed a gastrosplenic fistula and pneumatosis in the portal system. The patient underwent a second exploratory laparoscopy. Dense adhesions between the gastric sleeve and the spleen were encountered and a splenectomy was performed; no abscess or fluid collection was present and there was no evidence of gastric sleeve leak with air insufflation leak test. Eleven days later, the patient developed an intraabdominal abscess that required drainage. A stent was also positioned within the gastric sleeve and was left in place for 5 weeks. Results: The patient remained nil per os (NPO), received enteral feeds via the feeding jejunostomy tube and antibiotics for 6 weeks. A follow up CT scan suggested a contained leak, but this could not be identified on endoscopy. Despite this, the patient remained NPO and on tube feed for an additional 6 weeks. A follow up CT scan and upper gastrointestinal contrast study did not demonstrate the presence of a leak or collection. Oral intake was resumed and the patient remains asymptomatic 15 months after the original bariatric procedure. Conclusions: There is no previous report in the literature of gastrosplenic fistula related to laparoscopic sleeve gastrectomy. Sepsis control and nutritional optimization are the cornerstone of treatment. The surgical management should be tailored to each patient.

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THE UTILITY OF RADIOLOGY AND ENDOSCOPY IN THE EVALUATION OF VBG FAILURES Amanda Parker, MD, Michele Riordon, MD, Patrick Reardon, MD, Vadim Sherman, MD, The Methodist Hospital Introduction: Patients with a history of vertical banded gastroplasty (VBG) have a long-term complication rate of 30–55%. The majority of complications are related to the band and result in proximal gastric outlet obstruction. Symptoms of proximal gastric outlet obstruction include reflux, vomiting, and solid intolerance. These symptoms may result in poor nutrition. Alternatively, they may lead to a change in diet that results in weight regain. The purpose of this study was to assess the utility of UGI and EGD in the evaluation of VBG failures. Methods and Procedures: This is a retrospective study of all VBG patients that presented between March 2007 and June 2011. There were 82 patients total. All patients were specifically questioned regarding symptomatology. They all underwent EGD and UGI as part of their diagnostic work up. Results: Patients most often presented with symptoms of reflux (66%), solid intolerance (61%), and vomiting (44%). On EGD, 68% displayed gastric outlet obstruction or stricture at the band site, 26% had dilation of the pouch, 24% had band erosion. Hiatal hernia, staple line breakdown, gastritis, and esophagitis occurred less frequently. On UGI, reflux was found in 38% of the patients, while slow transit of contrast and stricture were found only in 21%. Hiatal hernia and staple line breakdown were seen less frequently. Conclusion: Although UGI may provide information regarding reflux and anatomical changes to the stomach, it does not correlate well with extent of obstruction at the band site. While EGD demonstrated that 68% of patients had gastric outlet obstruction or stricture, UGI only showed 21% with either slow transit of contrast or stricture. Moreover, when 66% of patients presented with reflux symptoms, UGI only documented 38% with reflux. EGD, on the other hand, provides an accurate diagnosis of the degree of proximal gastric outlet obstruction, as well as the option for therapeutic intervention should there be an eroded band.

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MARGINAL ULCER IN THE MINI-GASTRIC BYPASS; A COMPARISON WITH MARGINAL ULCER REPORTED IN BILLROTH II PATIENTS OPERATED BETWEEN 1920 AND 1980 AND WITH MARGINAL ULCER IN ROUX-EN-Y GASTRIC BYPASS Robert Rutledge, MD, Robert Rutledge, Mr, Robert Rutledge, Mr, Center for Laparoscopic Obesity Surgery Introduction: The Mini-Gastric Bypass has been shown to be more effective than the RNY, the Band or the Sleeve with lower complication rates than the Biliopancreatic diversion. Surgeons who do not recall the past experience in peptic ulcer disease (PUD) surgery criticize the MGB because of a fear of bile reflux causing gastritis and marginal ulcer. The purpose of this paper is twofold: one to remind surgeons of the past experiences with the Billroth II and marginal ulcer and two: to compare the incidence of marginal ulcer in the Mini-Gastric Bypass with the reported rates of marginal ulcer after RNY. Methods: Surgery for PUD was common and the experience with marginal ulcer and its management was clear prior to the development of H2 blockers and Proton Pump Inhibitors (PPI). Articles on marginal ulcer after peptic ulcer disease surgery from the 1920s through the 1980s and articles on marginal ulcer after RNY gastric bypass were reviewed. Experience with the MGB in 6,185 patients and the incidence of dyspepsia, marginal ulcer and therapy was reviewed. Results: The literature from 1920 through 1980s is clear; the Billroth II was the most common form of therapy for PUD and marginal ulcer was an uncommon but well recognized complication. The cause of marginal ulcer was well known (excess ACID) and the treatment was also well known (Acid control operations such as (re)-vagotomy or (re)-resection, see Erdmann 1921, Passaro 1976, Schirmer 1981.) Marginal ulceration after Roux-en-Y gastric bypass (RYGB) is diagnosed in 1% to 16% with an estimated actual rate of 5-7%. In a series of 6,185 MGB patients complaints of dyspepsia occur in 5.4%/year. The overall rates of marginal ulcer followed for a mean of 6 years is 4.8% with a rate of perforated ulcer of 0.27% (17). Conclusion: The rate of marginal ulcer formation in the Mini-Gastric Bypass is essentially the same as that reported for the RNY bypass. The etiology is the same, Acid Peptic Disease, with or without H. pylori infection. Also; the treatment is the same; Anti-Acid Rx with bile not playing a significant role. Fear of bile reflux gastritis and marginal ulcer are not supported by historical data or by comparison of marginal ulcer rates in RNY and BII gastric bypass. In this series of over 6,000 patients followed between 2 and 14 years, bile appears to play an insignificant role as the cause of marginal ulcer.

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INSURANCE STATUS AND OUTCOMES IN LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING (LAGB) Paul R Balash, MD, Nicholas E Bruns, BA, Minh B Luu, MD, Amanda Francescatti, BA, Khristi M Autajay, RD, Jonathan A Myers, MD, Rush University Medical Center Introduction: In the ongoing battle against the obesity crisis in the United States, surgical treatment has been shown to be superior to medical management. Laparoscopic adjustable gastric banding (LAGB) is a safe, effective and accepted procedure for weight loss. For patients without health insurance or for those who don’t qualify for LAGB under their healthcare policy, the only option is to self-finance the procedure. The aim of this study was to evaluate the effectiveness of LAGB in terms of overall excess weight loss, perioperative outcomes and complications between selffinanced and insured patients. Methods and Procedures: A total of 108 patient underwent LAGB from January 2007 to December 2008 at one surgical center by a single surgeon (JM). There were 61 patients whose procedure was covered by their insurance provider (INS) and 47 patients whose procedure was self-financed (SF). The patient demographics such as age, gender, race, BMI, and co-morbidities were tabulated and compared. Excess weight loss was calculated at 6 months, 12 months, and 18 months. Weight loss was expressed as the percent of excess weight loss (EWL). Statistical analysis was performed using SPSS version 11.5. Results: Women comprised 81.5% of the patients. Mean age was 40.5 ± 11.0 years and mean BMI was 43.1 ± 5.9 kg/m2. Patients from the INS and SF groups were similar in age, gender, race, and co-morbidities. The mean BMI was higher in the INS group compared to the SF group (44.1 ± 5.17 vs. 41.9 ± 6.56 kg/m2, respectively, P = 0.049). At 6 months, the EWL was 23.4 ± 11.6% for the insured group and 24.0 ± 11.8% for the self-pay group. At 12 months, the EWL was 38.3 ± 19.0% for the insured group and 39.5 ± 18.3% for the self-pay group. At 18 months, the EWL was 44.2 ± 19.1% for the insured group and 48.2 ± 19.6% for the self-pay group. There was no significant difference between the groups at 6 months, 12 months, or 18 months. Conclusions: Our original hypothesis was that self-financed patients would be more motivated, leading to an increase in excess weight loss compared to insured patients. However, the data has shown that there is no significant difference in excess weight loss between self-financed and insured patients.

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PERI-OPERATIVE OUTCOMES OF LAPAROSCOPIC SLEEVE GASTRECTOMY AND EFFECTIVENESS SHORT TO MEDIUM TERM WEIGHT LOSS AND IMPROVEMENT OF DIABETES MELLITUS C M Hoogerboord, MBChB MMed FCSSA FRCSC, S Wiebe, MD FRCSC, D Klassen, MD FRCSC, D Lawlor, NP, J Ellsmere, MD MSc FRCSC, Department of Surgery, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada Introduction: Laparoscopic Sleeve Gastrectomy (SG) is increasingly being performed as a one stage procedure with short and medium term weight loss and improvement in obesity associated co-morbidities comparable to Roux-en-Y Gastric Bypass (RYGB). The aim of our study was to evaluate our experience with SG in terms of peri-operative outcomes and improvement of glucose control and decrease in hypoglycemic medication use over the short to medium term. Methods and Procedure: A retrospective review of all SGs performed at a university teaching hospital was conducted. A six port technique was used. A 15 mm optical trochar was placed in the left upper quadrant (LUQ) for insufflation. The distal transection point was 5 cm from the pylorus. A 42 F bougie was used to size the sleeve. At the gastroesophageal junction (GEJ), 1 cm of fundus was preserved. Routine buttress material was not used. Selective clipping and suturing was performed for staple line bleeding with routine endoscopy to assess for luminal bleeding and extraluminal leaks. Results Between September 2007 to July 2011, 166 consecutive patients underwent SG. The majority of patients were female (82%), mean age was 44 years (16–68, range). Mean pre-operative BMI was 49.6 kg/m2 (29.3–73.5, range). Most patients had previous abdominal operations (63%). Median operative time was 93 min (56–232, range). One case (0.6%) was converted to an open operation. Mean hospital stay was 2 days. There was no deaths. Intra-operative blood loss was negligible except for four cases, two of which were managed nonoperatively. Two patients (1.2%) required intervention; one patient returned to OR the day of surgery and was managed laparoscopically, one returned on day one, requiring laparotomy and splenectomy. A water soluble contrast study was performed in all patients on post op day one. There were no early staple line leaks. One patient (0.6%) presented with a delayed leak 7 days post op and required surgical drainage of an abscess. Early complications (within 30 days post op) included three cases (1.8%) of superficial site infections, one patient developed a urinary tract infection (UTI). There were two cases of gluteal nerve neuropraxia. One patient was re-admitted with dehydration secondary to vomiting. Follow up was 98% (158/162) at 1 month, 64% (90/140) at 6 months, 38% (41/109) at 12 months, 13% (10/78) at 18 months and 11% (5/44) at 24 months. Mean BMI and percent excess weight loss (%EWL) were 43.6 (27–68, range) and 25.3% (0.34–45.9, range) at 1 month, 38.0 (26–57.7, range) and 49.3% (18.9–92.4, range) at 6 months, 36.0 (26.0–48.5, range) and 54.2% (21.7–95.9, range) at 12 months, 36 (26–50 range) and 60% (42–95 range) at 18 months and 37 (29–51 range) and 64.4% (38.3–101 range) at 24 months. Of the study group, 87 (52%) had diabetes mellitus. Glucose control improved in 79 (91%) patients and hypoglycemic medications were either stopped or significantly decreased in 66 (77%) patients.

Conclusions SG is a safe and effective primary weight loss procedure with improvement of diabetes mellitus up to one year. A national bariatric surgery data registry would improve long term follow-up.

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Table 1 Excess BMI loss after revisional laparoscopic sleeve gastrectomy Median BMI

ENDOSCOPIC CLIPPING FOR THE TREATMENT OF SLEEVE GASTRECTOMY LEAKS: IT WORKS! Ali Almontashery, MD, Yaser Dahlan, MD, Khalid Alshahrani, MD, Adel Bakhsh, MD, King Abdualaziz Medical City, Jeddah, Saudi Arabia Background: The purpose of this study is to present our experience in the management of persistent staple line leaks post LSG using endoscopic clipping. Methods: Four patients presented with clinical and radiological evidence of a leak post LSG. All Patients underwent a diagnostic exploration with oversewing of the staple line, wide local drainage, and insertion of a feeding jejunostomy tube. Four weeks post operatively upper GI studies showed a persistent leak at the esophagogastric junction. Upper GI endoscopy and clipping was then used to close the gastric leak. Results: This approach achieved adequate control of the leak in 3 patients and failed in one patient due to anatomical difficulties. After negative radiological studies oral diet was commenced 3 days post clipping and the patients were successfully discharged home. Conclusion: Endoscopic clipping is a safe and a feasible therapeutic option in the treatment of staple line leaks post LSG. Its value compared to the other treatment options for refractory leaks will need to be evaluated in a prospective comparative study.

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Median percentage excess BMI loss

Timeline

LAGB(n)

Redo(n)

LAGB (%)

Redo (%)

Baseline

49.6 (20)

41.6 (20)

3 Months

42.8 (10)

6 Months

39.9 (13)

40.6 (13)

24.1

29.9

35.9 (14)

32.5

12 Months

48.6

38.0 (15)

32.7 (10)

31.0

24 Months

65.3

43.7 (11)

29.8 (6)

22.7

69.2

LAGB laparoscopic adjustable gastric banding, Redo laparoscopic removal of gastric banding with concomitant sleeve gastrectomy

Conclusion: Laparoscopic removal of gastric banding with concomitant sleeve gastrectomy is a safe and effective procedure, with higher excess BMI loss and fewer complications compared with LABG. LSG can be recommended as a revisional procedure for poor-outcome gastric banding.

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LAPAROSCOPIC REMOVAL OF POOR-OUTCOME GASTRIC BANDING WITH CONCOMITANT SLEEVE GASTRECTOMY AS A REOPERATIVE PROCEDURE Aayed R Alqahtani, FRCSC FACS, Mohamed Elahmedi, MD, Hussam Alamri, MD, King Saud University, College of Medicine, Department of Surgery

INPATIENT WEIGHT LOSS AS A PRECURSOR TO BARIATRIC SURGERY FOR ADOLESCENTS WITH EXTREME OBESITY Evan P Nadler, MD, Faisal G Qureshi, MD, Leah C Barefoot, MSN CPNP, Daniel Davidow, MD, Children’s National Medical Center, Cumberland Hospital for Children and Adolescents

Introduction: Several studies questioned the long-term safety and efficacy of laparoscopic adjustable gastric banding (LAGB), primarily due to inadequate weight loss, weight regain, and bandrelated complications. The percentage of reoperations varies greatly, ranging from 2% to 80%. Although there is no consensus regarding which alternative surgical solution to perform, removal of the band, rebanding, conversion to gastric bypass, biliopancreatic diversion, and laparoscopic sleeve gastrectomy (LSG) have all been investigated as reoperative procedures, with varying degrees of success. We conducted a retrospective review evaluating the feasibility of performing LSG at the time of band removal and assessing its safety and efficacy as a reoperative (Redo) solution. Methods and Procedures: A retrospective review of patients who underwent LSG for poor outcome LAGB performed by a single surgeon between November 2007 and June 2011 was conducted. Data collection included patient demographics, weight and height at the time of banding and at 3, 6, 12, and 24 months post-gastric banding, complications, indication for revision, time interval between banding and Redo, weight and height at the day of reoperation, and at 3, 6, 12 and 24 months postRedo. Hospital stay, operative time, and postoperative complications were also evaluated. Results: Twenty patients underwent LABG Redo during the study interval, of whom 13 were female (65%), with an average age of 28.3 ± 10.9 years . Median BMI was 49.6 kg/m2 (range 29.6–57.3) before band placement, and 41.6 kg/m2 (range 30.8–61.7) at the time of the revisional procedure, performed at an average of 3 years 5 months ± 1 year postoperative. After gastric banding, 1 patient had gastric outlet obstruction secondary to band slippage, 4 had severe dysphagia, and 3 had intolerable reflux esophagitis. At 3, 6, 12, and 24 months post-gastric banding, patients had an excess BMI loss of 24.1%, 32.5%, 31.0%, and 22.7%, respectively. Nineteen patients (95%) had weight regain. After revisional surgery, excess BMI loss was 29.9%, 48.6%, 65.3%, and 69.2% at 3, 6, 12, and 24 months, respectively. Mean operative time for the Redo surgery was 2 h 25 min ± 36 min, and mean hospital stay was 2.6 ± 1.1 days. Following the Redo procedure, 1 patient had postoperative pneumonia with an uneventful recovery.

Background: As the obesity epidemic continues to take its toll on both the patients who are stricken with the disease and our healthcare system debate continues regarding the optimal utilization of weight loss surgery and its long-term consequences, especially for adolescents. One subset of patients where the controversy may be even more pronounced is adolescents with massive or extreme obesity (BMI [ 60), as risk of complications in this weight category is higher than for others undergoing bariatric surgery. Several strategies have been suggested for this patient group including staged-operations, combined operations, intragastric balloon use, and endoluminal sleeve placement. However the device options are often not available to adolescents, and there are no data regarding staged or combined procedures in this age group. Here we report 3 adolescents who underwent inpatient weight loss followed by laparoscopic sleeve gastrectomy. Methods: All adolescents with BMI [60 who were referred to our program were evaluated for inpatient medical weight loss prior to laparoscopic sleeve gastrectomy. The medical weight loss program utilizes a multidisciplinary approach with a protein sparing-modified fast diet, exercise, and behavioral modification as its pillars. Three such patients have completed pre-operative medical weight loss at a sub-acute facility and subsequently undergone laparoscopic sleeve gastrectomy at our institution. Results: Two African-American males and one African-American female were referred to our surgical weight loss program with BMI [60. All 3 patients were 18 years of age at the time of referral. The first male weighed 197 kg with a BMI of 62. His pre-operative weight loss was 16 kg (13% Excess Weight Loss or EWL) and post-operative weight loss now 18 months after surgery is an additional 50 kg (46% EWL) for a total weight loss of 66 kg (59% EWL). The second male weighed 220 kg with a BMI of 61. His pre-operative weight loss was 33 kg (24% EWL) and postoperative weight loss now 6 months after surgery is an additional 24 kg (23% EWL) for a total weight loss of 57 kg (47% EWL). The female patient weighed 238 kg with a BMI of 96. Her pre-operative weight loss was 56 kg (31% EWL) and postoperative weight loss now 9 months after surgery is an additional 17 kg (14% EWL) for a total weight loss of 73 kg (45% EWL). The BMI for each patient at their most recent follow up was 41, 45, and 62 respectively. No complications occurred at any point in their care. Conclusions: Pre-surgical weight loss via an inpatient program for adolescents with a BMI [60 results in total weight loss comparable to a primary surgical procedure alone, with the benefit of decreasing the peri-operative risk. We recommend this practice as an ideal algorithm for adolescents suffering from extreme obesity.

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IMPLEMENTATION OF A STANDARDIZED BARIATRIC QUALITY OF CARE PROGRAM IN ONTARIO, CANADA R Nenshi, BA MD MSc FRCSC, S A Glazer, MD FRCPC FCCP, J Patel, RN MScN CNN, Q Huynh, MD FRCS, L Klein, MD MSc FRCS, J Hagen, MD FRCS, Humber River Regional Hospital, Toronto, Ontario Introduction: The first comprehensive bariatric program in Ontario was established in Feb 2007 at Humber River Regional Hospital. Over a four year period, case volumes increased from 48 cases per year to approximately 450 cases per year and are completed by 5 surgeons. In April of 2011, a series of unexpected mortalities occurred at our site over a 6 month period. Active support was provided by senior hospital administration and a comprehensive internal and external review of the program was undertaken. This led to the creation of standardized pre-operative and post-operative pathways designed to improve the quality of care. This paper describes the programmatic changes made and the effect it has had on outcomes. We also describe pre and post implementation compliance to pre-established program measures via chart audits. Methods: Directed by a literature review and expert opinion, our group prioritized several areas of improvement. In the realm of pre-operative care this included: Mandatory consultation with an internist prior to surgery, final collaborative chart sign-off by Nursing, Medical and Surgical Directors prior to bariatric procedures, and the creation of standardized pre-printed order sets and prescriptions including extended VTE and reflux prophylaxis and lab work. During the operative course, we implemented guidelines including: complex bariatric patients to have 2 bariatric surgeons involved in the OR, post-operative tachycardia to be reported to bariatric surgeon on-call immediately, twice daily rounds on all bariatric patients (at least once daily by bariatric dedicated internist) and all bariatric patients to be placed on continuous post-operative pulse oximetry for 48 h with vitals every 2 h for the first 8 h post-procedure. Predischarge medication reconciliation was undertaken as well as predischarge dietary reassessment. Following discharge, patients were contacted within 48–72 h by phone by a nurse from the bariatric team and all bariatric patients presenting to our emergency department were designated as direct patient to the bariatric surgeon on call. The pre-program period was April 2009–March 2010. During this time, 457 bariatric procedures were completed. Post-implementation (April 2010–March 2011), 506 cases were completed. To perform our audit, we retrospectively reviewed a random sample of charts before and after implementation of our program. Results: Our programs overall mortality rate is 0.4%. Pre-program annual mortality was 1% and post-program annual mortality was 0% (P = 0.024). Our 30-day morbidity rates also decreased from 18.44% pre-program to 14.25% following implementation, Readmission rates also decreased from 7.25% to 5.4%. Compliance to our program parameters are summarized in Table 1.

Table 1 Program guideline

Compliance (%)

2 surgeons present for complex cases Tachycardia notification Monitored bed 2 notes per day by surgeon Blood work as per standardized orders ER notification directly to surgeon

92 85 97.5 98 99 80

Conclusions: We have successfully implemented a standardized bariatric quality of care program at our centre. Pre and post implementation mortality and morbidity rates show a significant improvement. We report C80% compliance with our program measures.

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EFFICACY OF ROUX-EN-Y GASTRIC BYPASS SURGERY IN ACHONDROPLASTIC PATIENT: A CASE REPORT Akeel M Merchant, BS, Eyad M Wohaibi, MD, Tejinder P Singh, MD, Albany Medical Center Introduction: Patients with achondroplasia fall under the category of atypically morbid obese individuals in whom correction of obesity via lifestyle modification becomes of limited use given their body disposition and co-morbidities. Case report: This paper reports a 30 year old morbidly obese achondroplastic patient in whom correction of obesity was achieved using laparoscopic Roux-en-Y gastric bypass (RYGB) surgery. Her BMI dropped significantly from 65.2 preoperatively to 26.7 twenty months after the operation. Although the patient developed stenosis of gastrojejunostomy and a perforated gastrojejunal ulcer status post RYGB, these were not likely due to her achondroplasia. Rather, they were a complication of the procedure itself. Discussion/Conclusion: Achondroplasia is a mutation of fibroblast growth factor receptor 3 (FGFR3) gene which leads to shortened limbs with normal axial length. With the growing popularity of bariatric surgery, this modality can be a resourceful option in this population. This is the first reported case of a successful laparascopic RYGB in an achondroplastic patient, and the first reported case following the post operative course of an achondroplastic patient following RYGB. Further clinical studies will need to be performed to assess the efficacy of bariatric surgery in this patient population.

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COMPARATIVE STUDY OF SINGLE INCISION, ROBOTIC, AND STANDARD LAPAROSCOPIC SLEEVE GASTRECTOMY Harvey C Rainville, MD, Kulmeet Sandhu, MD, Brad Snyder, MD, Pratibha Vemulapali, MD, Emmanuel Agaba, MD, Diego Camacho, MD, Montefiore Medical Center, University of Texas Health Science Center Introduction: Advanced minimally invasive techniques including robotic and single incision laparoscopic surgery (SILS) are being increasingly utilized in the field of Bariatric Surgery. These techniques appear to be effective alternatives to the standard laparoscopic sleeve gastrectomy, currently one of the most commonly performed bariatric operations. We were interested in comparing these techniques to one another and to the standard laparoscopic sleeve gastrectomy in terms of perioperative complications, operative time, and length of stay. Methods: We performed a multi-institution retrospective study comparing the use of robotic and SILS techniques to the standard laparoscopic sleeve gastrectomy. The study included 20 SILS, 11 robotic, and 50 traditional laparoscopic sleeve gastrectomies. The patients demographics and comorbidities were standardized with respect to the traditional laparoscopic group. We then focused on comparing operative time, perioperative complications, conversion rates and length of stay. Results: All of the operations performed using the advanced techniques were performed successfully without the need for conversion. There were two patients who required the placement of an additional port in the SILS group. The operative times were increased for both the SILS and robotic groups. There was no increase in operative blood loss, length of stay or perioperative complications in the hospital or at the initial follow up. Conclusion: The use of robotic and SILS techniques to perform sleeve gastrectomies are safe and comparable alternatives to the standard laparoscopic technique.

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THE ROLE OF DUMPING SYNDROME IN WEIGHT LOSS AFTER GASTRIC BYPASS SURGERY Ambar Banerjee, MD, Yi Ding, BS, Nilay Shah, MD, Dean J Mikami, MD, Bradley J Needleman, MD, Center for Minimally Invasive Surgery, Division of General and Gastrointestinal Surgery, The Ohio State University, Columbus, Ohio Background: Roux-en-Y gastric bypass (RNYGB) is the most commonly performed operation for the treatment of morbid obesity in the US. Dumping syndrome is an expected side effect that may be desirable as part of the behavior modification caused by gastric bypass surgery, which can deter patients from consuming energy-dense food. In this study, we assessed the role dumping has in weight loss and its relationship with the patient’s eating behavior. Methods: After obtaining Institutional Review Board approval, fifty patients who underwent gastric bypass between January 2008 and June 2008 were enrolled. Two questionnaires, the dumping syndrome questionnaire and the revised Three-Factor Eating Questionnaire (TFEQ-R18), were administered to the patients. The diagnosis of dumping syndrome was based on the Sigstad scoring system where a score of 7 and above was considered positive. TFEQ-R18 evaluated the patients’ eating behavior under three scales—Cognitive restraint, Uncontrolled eating and Emotional eating. The patients were asked about dumping syndrome symptoms, usually following sweet ingestion, at three points in time—preoperative, immediate postoperative, and 2 years post surgery. TFEQ-R18 was completed on the basis of their diet at the time of execution of the questionnaire. The medical records of the enrolled patients were reviewed to collect pertinent data on demographics including their body weights and body mass index (BMI). BMI loss was calculated at 1 month, 6 months, 1 year and at 2 years post surgery. The results were analyzed with descriptive and parametric statistics, where applicable. Results: The prevalence of dumping syndrome in our study population was 42%. Twelve of these 21 patients (57.1%) complained of early dumping only, while 9 patients experienced symptoms of both early and late dumping. All of the patients experienced resolution of the symptoms between 1 and 2 years post RNYGB. At one month post RNYGB, the dumpers lost an average of 4.1 kg/m2 in their BMI compared to 3.3 kg/m2 in non-dumpers. (p = 0.29) However, at the remaining points of observation, the non-dumpers were observed to suffer a greater decrease in BMI than the dumpers: 13.8 kg/m2 vs 12.5 kg/m2 at 6 months (p = 0.39), 18.5 kg/m2 vs 14.4 kg/m2 at 1 year (p = 0.57) and 17.8 kg/m2 vs 13.7 kg/m2 at 2 years post surgery (p = 0.39). There was no definite relationship between the presence of dumping syndrome and the eating behavior of the patient. However, patients with cognitive restraint scores greater than 80% were associated with an average decrease in BMI of 19 & 20.8 kg/m2 at 1 & 2 years compared with 14.6 & 12.4 kg/m2 in those with scores less than 80%. (p = 0.01 & p = 0.03 respectively) Similarly, those who showed low uncontrolled eating scores (\10) experienced greater decrease in their BMI at 6 months (15.7 vs. 12.4, p = 0.01) and 1 year (20.9 vs 15.1, p = 0.003). Conclusion: The presence of dumping syndrome after RNYGB does not influence weight loss. However, eating behaviors, as measured by the TFEQ-R18, may directly influence weight loss. Modification of individual eating behavior appears to be the biggest predictor of continued long term weight loss.

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SHOULD SURGEONS ACCEPT LIVER BIOPSY AS A STANDARD PRACTICE WHEN PERFORMING BARIATRIC SURGERY? Manpreet K Kohli, MD, Frank Borao, MD, Steven Binenbaum, Jurek Kocik Monmouth Medical Center, Long Branch, NJ Introduction: We explore one center’s experience in performing liver biopsies routinely with bariatric surgery in the aim of detecting Nonalcoholic Fatty Liver Diseases (NAFLD). Methods and Procedures: A retrospective review of 142 cases between January 1, 2007 through October 15, 2010 in which liver biopsies were performed with a variety of bariatric prodecures. Comparisons were made between patient populations with specific comorbidities and incidence of Nonalcoholic Steatohepatitis (NASH). Results: Of 142 patients studies 93% were found to have a pathological diagnosis of one of the Nonalcoholic Fatty Liver Diseases. Seventy six percent of the population was found to have Steatosis on liver biopsy and 17% had the pre-cirrhotic stage Nonalcoholic Steatohepatitis. Comorbidities most frequently associated with NASH were hypertension, gastroesophageal incompetence, and diabetes mellitus. Conclusions: Our series reports a lower incidence of NASH than comparable studies and a high overall incidence of NAFLD in the population studied. Early detection of NAFLD by liver biopsy during bariatric surgery can help identify patients who will require surveillance and prevent progression from Steatosis to Steatohepatitis. Our experience demonstrates that liver biopsy is a safe and effective diagnostic tool that should be routinely utilized in all bariatric procedures.

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VENTRAL HERNIA AT THE TIME OF LAPAROSCOPIC GASTRIC BYPASS SURGERY: SHOULD IT BE REPAIRED? Isabelle Raiche, MD FRCSC, Fatima Haggar, MPH, Joseph Mamazza, MD FRCSC, Husein Moloo, MD MSc FRCSC, Eric C Poulin, MD MSc FRCS C, Guillaume Martel, MD FRCSC, Jeandenis Yelle, BA MD FRCSC FACS, The Minimally Invasive Surgery Research Group, The Ottawa Hospital, University of Ottawa Objective: Despite the relatively high prevalence of ventral hernias in the morbidly obese population, there is no clear consensus regarding the optimal treatment for patients with ventral hernias who present for gastric bypass. The objective of this study was to conduct a systematic review of the current evidence to determine the most appropriate surgical management of patients found to have a ventral hernia at the time of a laparoscopic gastric bypass (LGB). Method: Medline, Embase and Cochrane databases were searched from January 1995 to September 2010. The search strategy, prepared with experienced systematic reviewers and a librarian, included the following MESH terms: ventral hernia, abdominal hernia, laparoscopy, minimally invasive surgery, bariatric surgery, Roux en Y, and gastric bypass. The reference lists of pertinent articles were manually reviewed to ensure that no published data was missed. Outcomes of interest included post-operative bowel obstructions secondary to ventral hernia, recurrence of ventral hernia and mesh infection. Data pertaining to relevant articles were abstracted and synthesized according to accepted methods. Results: The search identified 534 articles. After duplicate records and irrelevant studies were removed, 83 potentially relevant articles were reviewed (4 systematic reviews, 3 randomized controlled trials, 59 observational studies, 17 narrative reviews). After exclusion of reviews, case reports and any study in which fewer than 50% of patients underwent laparoscopic gastric bypass, 3 retrospective articles, with a total of 123 patients reporting on the management of ventral hernias at the time of LGB were included. Eight percent of patients undergoing LGB presented with a ventral hernia. Three management strategies were reported: deferred treatment of the hernia, primary repair or repair with biological or synthetic mesh. Up to 35.7% of patients in whom the treatment was deferred presented with SBO within 150 days. Recurrence after primary repair of the hernia varied from 22-100%. No recurrence was found in the group using biologic mesh after a follow-up of 13 months. In the group using synthetic mesh, the recurrence varied from 0-9% with a mean follow-up of 14 months. No mesh infection was reported. Conclusion: Ventral hernia in patients considered for LGB is a complex problem. There is a paucity of high level evidence to guide clinical decisions. The available information suggests that mesh repair of the hernia at the time of bypass may be a safe and appropriate treatment option for preventing an obstruction in the perioperative period.

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SLEEVE GASTRECTOMY: PRELIMINARY RESULTS FROM BARIATRIC OUTCOME LONGITUDINAL DATABASE (BOLD) Jyoti Sharma, MD, Debbie Winegar, PhD, Donald Risucci, PhD, Anthony Maffei, MD FACS, Thomas Cerabona, MD FACS, Ashutosh Kaul, MD FRCS FACS, New York Medical College Introduction: Sleeve gastrectomy (SG) has in the last decade emerged as an increasingly utilized procedure for weight loss. Laparoscopic SG (LSG) is gaining popularity as a definite, isolated bariatric procedure for morbid obesity due to satisfactory weight loss and resolution of co-morbidities. This study examines preoperative, operative and postoperative outcomes after LSG in the largest longitudinal bariatric database in the world, the Bariatric Outcomes Longitudinal Database (BOLD). Methods: BOLD was queried for data on adult patients (age [ 18 years) who had SG between June 2007 and March 2, 2010. Variables of interest included demographic characteristics, co-morbidities, medications, functional status, additional procedures performed, operative/anesthesia length, estimated blood loss, blood transfusions, American Society of Anesthesiologists (ASA) class, intra-operative complications, postoperative complications, intervention for postoperative complication and length of stay. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) Version 19. Results: Of the 112,337 research-consented bariatric surgery patients with data entered into BOLD, 3448 (3.1%) had undergone SG. With an average age (Mean + Standard Deviation) of 46.0 ± 11.8 and a body mass index (BMI) of 48.2 ± 10.2, most patients were female (72.7%), white (80.7%), worked full time (54.6%), and had no functional status impairments (94.8%). Preoperative co-morbidities included the following: 47.4% had diagnosed hypertension; 26.3% had obstructive sleep apnea; 25.9% had diabetes mellitus; 23.0% were on medication for gastroesophageal reflux disease (GERD) and 22.2% had dyslipidemia. Almost all patients underwent LSG (96.6%) with a majority in ASA Class IV (63.6%). Mean operative time was 100.4 min and average length of stay was 2.4 days. Postoperatively, 4.1% had at least 1 readmission and 2.6% needed re-operation within the first 30 days. The 30- and 60-day mortality was 0.1% with most of the deaths in patients with ASA Class III. The most common adverse events reported were nausea/vomiting 3.5%, dehydration 1.1%, electrolyte imbalance 1%, stricture 0.8%, intraabdominal bleeding/hemorrhage 0.8% and leak 0.8%. Patients had lost an average of 73.2 lbs, 96.0 lbs, and 78.3 lbs at 6, 12, and 18 months respectively. Complete resolution of co-morbidities at 12 months occurred in 60.9% with diabetes mellitus, 44.9% with hypertension, 33.6% with dyslipidemia, and 38.7% with GERD patients. Conclusion: SG is an increasingly performed bariatric procedure with significant weight loss at 1 year follow up and low mortality and morbidity. Co-morbidity reduction, weight loss and postoperative complications compare favorably to other commonly performed bariatric surgery procedures. Larger studies are needed especially with longer follow-up times to better assess its utility. Moreover, risk stratification of SG patients is recommended to optimize patient selection for prevention of complications.

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ADJUSTABLE GASTRIC BANDING: A SINGLE INSTITUTION RETROSPECTIVE REVIEW OF SINGLE INCISION VERSUS STANDARD LAPAROSCOPY Anthony M Gonzalez, MD FACS FASMBS, Jorge R Rabaza, MD FACS FASMBS, Carmen Rodriguez, RN MSHSA, Maria Fuego, RN BSN, South Miami Hospital, Baptist Health South Florida, South Miami, Florida Adjustable gastric banding has shown to be an effective modality for the treatment of morbid obesity and its co-morbidities with demonstrated long-term weight loss (Saber and El-Ghazaly, 2009). With progression of minimally invasive surgery (MIS), single incision laparoscopic surgery (SILS) has also shown to be successful in procedures such as cholecystectomy (Joseph et al., 2009). A retrospective review of the data, in a single institution, was performed to compare adjustable gastric banding via the innovative approach of SILS versus standard laparoscopic placement (multi port). A total of 94 adjustable band cases (Lapband & Realize) were performed since 2007 and retrospectively reviewed to compare age, sex, body mass index (BMI), length of stay (LOS), band type, operative times, and complications. There were 56 SILS and 38 standard laparoscopic placements. Independent t-tests comparing age (t(92) = –.589,p = .557), BMI (t(92) = .284,p = .777) and chi-square analysis comparing sex (V2 (1, n = 94) = .00, p = .998), band type (V2 (1, n = 94) = 1.94, p = .164) were not statistically significant suggesting comparable groups. There was a statistically significant difference in surgical time for SILS (Md = 40.00, n = 56) versus standard laparoscopic (Md = 45.50, n = 38); (U = 657.00, z = -3.139, p = .002, r = .32). There were only 3 cases with complications; all within the SILS group. These complications included intraoperative bleeding, over medication of narcotics, and tightness of band caused by fluid in band. As demonstrated, SILS is a safe approach to gastric banding with acceptable operative times. It can be argued that, the reviewed complications in the SILS group were related to variables beyond procedure type.

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SHOULD ADJUSTABLE GASTRIC BANDS BE DONE ONLY IN SPECIALIZED BANDING CENTERS? Ashutosh Kaul, MD FRCS FACS, Thomas Sullivan, BS, Pawandeep Hunjan, MD, Anthony Maffei, MD FACS, Thomas Cerabona, MD FACS, New York Medical College Adjustable gastric bands outcomes for weight loss have shown wide variations with some specialized centers showing excellent weight loss while others have shown poor outcomes in comparison to other weight loss procedures. The aim of this presentation was to compare the results of three commonly performed bariatric surgery procedures in a center of excellence fellowship training academic hospital. This is a retrospective analysis of prospectively maintained data from April 2008 till April 2011. All cases were done by four bariatric surgeons and by fellowship trainees under their guidance. During this period 874 bariatric surgery cases were done. 382 cases were laparoscopic roux-en-Y gastric Bypass (LRYGB), 270 were adjustable gastric banding (AGB) and 207 were laparoscopic sleeve gastrectomies (LSG) while the rest were Revisional cases and were excluded from further analysis. All cases were completed laparoscopically. The preoperative BMI were comparable (LRYGB = 46.1 kg/m2, AGB = 42.7 kg/m2, LSG = 47.8 kg/m2). Weight loss after surgery showed significant dichotomy in our series with AGB showing significantly poorer results compared to both LRYGB and LSG at 6 months, 1 year and 2 year follow up in our series. The mean % weight loss in different procedures at 6 months was LRYGB = 53.4%, AGB = 27.3%, LSG = 46.7%, at one year was LRYGB = 73%, AGB = 30.9%, LSG = 61.9%, and at 2 years was LRYGB = 73.8%, AGB = 36.8%, LSG = 64.2%. Our results seem to suggest that in our hands LSG and LRYGB have better weight loss results compared to patients undergoing AGB. Specialized centers doing mainly AGB have presented great results while centers doing smaller percentage of AGB in comparison have shown poorer results. This may suggest that AGB results may be better in specialized centers doing mainly bands. Factors which may play a role will be discussed.

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INFORMING INFORMED CONSENT IN BARIATRIC SURGERY: DEVELOPMENT OF AN ONLINE RISK/BENEFIT CALCULATOR FROM THE AMERICAN COLLEGE OF SURGEONS BARIATRIC SURGERY CENTER NETWORK (ACS-BSCN) Timothy D Jackson, MD MPH, Matthew M Hutter, MD MPH, Codman Center for Clinical Effectiveness, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA & Department of Surgery, University of Toronto, University Health Network, Toronto, ON, Canada Introduction: Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG) and laparoscopic adjustable banding (LAGB) each have unique risk/benefit profiles and are all considered acceptable surgical options for the treatment of morbid obesity. The choice of procedure is a shared decision between both patient and providers. The application of current outcomes data to generate a risk/benefit display on a webbased platform has the potential to better inform the informed consent process. The objective of the present study is to develop a clinical predictive model to better define the expected risk/benefits profiles across these three procedures for a given patient to facilitate decision-making in the clinical setting.

Fig. 1

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Methods: The ACS-BSCN accreditation program maintains a large prospective, multi-institutional, observational database that collects clinically rich data using trained reviewers and standardized definitions. The study cohort will include an updated dataset of patients undergoing RYGB, SG, and LAGB from July 2007. A risk-adjusted analysis will identify patient factors predictive of bariatric specific end points for each procedure type. The feasibility of this methodology within this dataset has recently been demonstrated by Hutter et al (Ann Surg, 2011). Model design will allow for the incorporation of updated datasets from the ACS-BSCN centers. The predictive model will be assessed for performance, validated and implemented on a web-based format for widespread use. Results: This will be an interim report of the study funded by the 2010 SAGES Career Development Award and we anticipate our findings to be available at the time of the meeting. Based on entered patient characteristics identified in the model, reports provide current risk estimates of mortality, morbidity, medical and surgical complications, conversion to open, reoperation, and length of stay. Estimates of expected benefits are reported as change in BMI, % excess body weight loss and resolution of comorbidities (diabetes, hypertension, hyperlipidemia, sleep apnea, gastroesophageal reflux) up to one year. Preliminary design is depicted in Fig. 1. Conclusions: The development and implementation of a risk/benefit calculator based on high quality, ‘‘real world’’ data from the ACS-BSCN has the potential to better inform the consent process, aid in the selection of procedure type, and help further optimize outcomes from bariatric surgery. Availability of this model in a web-based format will enable widespread application in the clinical setting. Further evaluation will investigate the utility of this tool in the procedure selection process.

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POST OPERATIVE SWALLOW STUDY AS A PREDICTOR OF INTERMEDIATE WEIGHT LOSS AFTER SLEEVE GASTRECTOMY Alex Zendel, MD, Gali Westrich, MD, Moshe Rubin, MD, David Goitein, MD, Sheba Medical Center Introduction: Laparoscopic sleeve gastrectomy (LSG) is an accepted bariatric procedure, either as a first step for biliopancreatic diversion or gastric bypass, or as a standalone option for selected patients. Swallow studies (SS) after LSG are not uniform and display different patterns with regard to contrast passage through the gastric sleeve. The impact of immediate postoperative contrast transit time on weight loss after surgery has not been studied. The influence of immediate fluid tolerance on weight loss after LSG is herein reported.

Methods: 99 patients after LSG were included. There were 67 females, mean age 41 (range 17–67), mean BMI 44.4 (range 37–75). A routine SS was performed on post operative day (POD) 1. Pattern of contrast transit was noted. Patients were followed up in our bariatric clinic. Results: Percent excess weight loss (%EWL) was significantly lower in the patients with rapid contrast passage (Group 1, n = 50) than those with delayed passage (Group 2, n = 49). Group 1 achieved 62%, 58% and 53% at 1, 2 and 3 years, respectively, while group 2 attained 69%, 74% and 75% at the same time points (p = 0.05, 0.001 and 0.04, respectively). Group 1 patients displayed a negative weight-loss trend after 1 year whereas group 2 patients reached a plateau after 2 years. Conclusions: Tolerance of fluid intake after LSG is crucial for patient recovery and discharge. Distinct radiologic appearance on POD 1 helps predict this behavior. Mid-term weight loss after LSG appears to be dependant on immediate postoperative contrast transit time, whereas patients with slow contrast passage tend to lose more weight. Long-term follow up will reveal whether this finding will hold true.

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INDICATIONS FOR PROPHYLACTIC ANTIBIOTICS BASED ON CULTURES TAKEN DURING ELECTIVE LAPAROSCOPIC SLEEVE GASTRECTOMY Katherine E Hansen, DO, Marc Neff, MD, UMDNJ-SOM Abstract: The evidence to support prophylactic antibiotics in a clean-contaminated case are limited especially in regards to sleeve gastrectomy patients. To evaluate the necessity of prophylactic antibiotics, peritoneal fluid cultures were taken in ten laparoscopic sleeve gastrectomy cases after the transaction of the greater curvature of the stomach was complete. Both anaerobic and aerobic fluid cultures were obtained in these patients to determine if contamination occurred after the stapling procedure. Nine of the ten bariatric patients tested had negative cultures and one patient grew Methicillin resistant Staphylococcus aureus despite using the same methods and materials during the operative case. Despite the small sample size of patients in this study, there seems to be an indication to continue the use of prophylactic antibiotics during elective bariatric and other clean-contaminated surgeries.

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CT SCANS SHOW LOW INCIDENCE OF TROCAR SITE FASCIAL DEFECTS AFTER LAPAROSCOPIC ROUX -EN-Y GASTRIC BYPASS Gustavo E Bello, MD, Toms Augustin, MD, Jonathan M Tomasko, MD, Jerome R Lyn-sue, MBBS, Randy S Haluck, MD, Ann M Rogers, MD, Penn State Hershey Medical Center Introduction: Incidence of clinically evident abdominal wall trocar site hernias is known to be between 0.5 to 2% depending on type of surgery, port size, and type of port. The vast majority of these hernias occur at trocar sites of 10 mm or larger; thus many authors recommend routine closure of these defects. To our knowledge there is no study in the literature characterizing abdominal wall defects on computed tomography (CT) scans after laparoscopic roux-en-Y gastric bypass (LRNYGBP). Methods: A retrospective chart review was performed of all patients undergoing LRNYGBP between 2005 and 2010 at one institution who had undergone a CT scan of the abdomen postoperatively for any reason. Port sites are in the upper abdomen as the surgeon stands between the legs of the patient. Dilating trocars were used for all cases (Endopath Xcel, Ethicon, Cincinnati, OH) It is our practice not to close any defect in the fascia which includes one 11 mm port, two 12 mm ports, one 5 mm port, and a 5 mm puncture for a liver retractor. Patients were excluded if they had undergone any abdominal surgery other than the LRNYGB prior to the CT scan. Records were searched for evidence of incisional hernia existence or repair. The location and the size of the defects seen on CT scan were documented. Results: 828 LRNYGBP were performed. Of these, 152 patients had CT scans for review for a total of 456 trocar sites from 11–12 mm ports. The mean age of the population was 44 years (range: 22 to 67). The mean weight was 288 pounds (range: 187 to 428) and the mean body mass index was 48 (range: 35.2 to 64). The population was mostly female (87%) and Caucasian (89%). The mean time from the day of surgery to CT scan was 350 days (range: 1 day to 1836 days). On review of the CT scans only two defects (0.4%) were identified in two separate patients (1.3%). One had an early symptomatic trocar site hernia requiring re-operation on postoperative day 6 suggesting a technical issue. The second was noted to have a 6 mm defect in the posterior fascia without an associated hernia. Interestingly there were no persistent abdominal wall defects noted on the 58 patients who had CT scans done within the first 30 days and the 39 patients underwent CT scan within the first week of bypass. Incidentally 34% of patients were noted to have umbilical hernias. Conclusion: Trocar site hernias and persistent defects in the fascia are low after LRNYGB. This phenomenon may be partly due to rapid weight loss in the immediate pre- and postoperative periods. Additionally the absence of defects on CT seen within the first month of the bypass suggests the presence of different mechanisms like shearing forces (shutter mechanism) assisting with early closure of these trocar site defects. Our data suggest that routine closure of non-bladed trocar sites in the upper abdomen up to 12 mm for bariatric surgery is not necessary.

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ANASTOMOTIC STENOSIS AND THE KEY ROLE OF THERAPEUTIC ENDOSCOPY AFTER LAPAROSCOPIC BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH (LBPD-DS) SURGERY Fady Moustarah, MD MPH, Ste´fane Lebel, MD, Simon Marceau, MD, Laurent Beirtho, MD, Fre´de´ric-simon Hould, MD, Odette Lescelleur, MD, Simon Biron, MD, Institut Universitaire de Cardiologie et de Pneumologie de Que´bec (IUCPQ), Universite´ Laval

SMOKING CESSATION AFTER INTRA-GASTRIC BALLOONS PLACEMENT: AN INTERESTING SIDEEFFECT FOR SMOKER PATIENTS: PRELIMINARY REPORT Gustavo L Carvalho, PhD, Diego L Lima, Student, Adriano C Sales, Student, Rafaela L Gouveia, Student, Rebeca G Rocha, Student, Flavio A Fernandes Junior, MD, Masaichi Okazaki, MD, University of Pernambuco - Faculty of Medical Sciences

Background: Stenosis at the duodeno-ileal anastomosis has been observed after LBPD-DS, and it can be managed surgically or endoscopically with balloon dilatation. We reviewed the incidence of duodeno-ileal stenosis (DIS) in our cohort of patients who had LBPD-DS and evaluated the role of therapeutic endoscopy in our treatment algorithm. Methods: We queried our prospectively maintained bariatric surgery clinical database to identify a consecutive series of all patients who underwent laparoscopic BPD-DS procedure at our institution. Data was extracted from the electronic database and the patients’ paper medical records. An electronic spreadsheet was used to analyze the data. Continuous variables are reported as means ± s.e. Results: Between Nov 2006 and Dec 2010, 315 patients (264 F:51 M) underwent a complete LBPD-DS using a circular stapler to fashion an end-to-side duodeno-ileal anastomosis. Video of the technique is available. Females represent 83.8% of our sample. The mean age at the time of surgery is 40 years (range: 16 to 67 years). The mean preoperative BMI is 47.7 ± 2.7 Kg/m2 (range: 34.1–83.2 Kg/m2). Gastroscopy was used to evaluate symptomatic postoperative patients, and the incidence of duodeno-ileal stenosis was 12% (37 patients). The majority of stenosis (79%) occurred in the first three months after surgery. Endoscopic balloon dilatation was employed as the treatment of choice for DIS, and it proved helpful in 76% (28/37) of cases. Multiple dilatation sessions were needed in 57% (22/37) of cases. Dilatation related perforation occurred in 7 patients. Patients requiring multiple dilatation sessions were not at higher risk of perforation than those having had only one session, RR = 1.02 and 95% CI [0.26, 3.91]. Surgery to definitively resolve persistent severe stenosis or treat perforation post dilatation was needed in 24% (9/37) of cases. Endoscopic or surgical treatment for stenosis was associated with no mortality.

Introduction: Obesity is a major health problem with substantial morbidity and mortality. The use of intra-gastric balloons for obesity and non-obese patients has been reported with success to weight loss. Different types of treatment for stop smoking have been created over years, but the smoking cessation in addicted patients who underwent gastric balloon placement has never been reported. Method: From June 2006 to January 2011, 221 patients with pre-treatment BMI between 25.1 and 63.5 were submitted to treatment with Silimed Intra-gastric Balloons (SIB). Smoker patients were selected for evaluation of smoke intolerance during the SIB treatment. This study included 19 patients (18 women), with mean age of 40.0 years (23 to 55 years). They comprised two groups of pre-obese and obese patients who failed to respond to previous clinical treatment for weight loss. Their pretreatment mean weight was 90.1 ± 22.5 kg (58.3 to 207 kg), mean BMI was 34.21 ± 5.2 kg/m2 (25.6 to 63.5 kg/m2). During their intra-gastric balloon treatment, they reported to our team an unusual smoke intolerance which was classified in three groups: tolerance or small intolerance, partial intolerance and total intolerance. Patients classified as small intolerance presented an initial intolerance but started smoking again less than 1 month after the beginning of the balloon placement or didn0 t present any intolerance. Patients classified as partial intolerance stopped smoking for at least 3 months. And patients classified as total intolerance stopped smoking completely. Those patients were followed after the balloon removal regarding the continuity of smoke intolerance. Results: 3 of 19 patients (15.78%) were placed in the small intolerance group. Also 3 of 19 patients (15.78%) composed the partial intolerance group. And 13 patients (68.44%) stopped smoking completely, compounding the total intolerance group. After the balloon treatment (6 months) the patients were accompanied for both weight loss and smoking intolerance. All patients in the small tolerance group and partial intolerance group didn0 t stop smoking. 6 of 13 patients (46.15%) located in the total intolerance group stop smoking and didn0 t start again after the end of the balloon treatment. Conclusions: SIB is a useful and safe treatment for obesity patients. At this moment SIB can not be proposed as a new treatment for stop smoking and proper investigation of this interesting and comon side effect still needed to be pursued.

Conclusion: Therapeutic gastroscopy with balloon dilatation played a critical role in the management of anastomotic duodeno-ileal stenosis found in patients presenting with upper gastrointestinal symptoms after a primary LBPD-DS. It limited surgical intervention for stenosis to less than a quarter of patients in our cohort. In addition, our observed rate of stenosis prompted innovation and refinement of our surgical technique with very favorable results emerging for presentation.

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IS SWIMMING A BETTER PREOPERATIVE Method OF EXERCISE FOR POST OPERATIVE WEIGHT LOSS? Abraham J Frech, MD, Arpan Goel, MD, Tovy H Kamine, MD, Benjamin E Schneider, MD, Daniel B Jones, MD, Robert A Andrews, MD, Beth Israel Deaconess Medical Center/Harvard Medical School Introduction: Much emphasis has been given to the importance of exercise prior to weight loss surgery. Swimming in particular has been suggested as a superior form of exercise given the prevalence of musculoskeletal disability in the morbidly obese population. The aim of our study was to determine if swimming more positively affected post operative outcomes than other forms of exercise. Methods and Procedures: Between September and December 2010, 108 surveys were collected from postoperative weight loss surgery patients at an academic medical center. Patients included in the survey underwent either Roux-en-Y gastric bypass or adjustable gastric band. Of the 108 collected surveys, 22 were excluded as incomplete. The 86 included surveys of patient who underwent either gastric banding or gastric RNY bypass. The patients recorded their type of preoperative exercise and their postoperative weight lost. We divided patients into two groups based on their method of exercise in the preoperative period, non-swimmers (78) and swimmers (8). Results: Percentage (number) of non-swimmers and swimmers reaching weight loss cut offs at various post-operative time points and p values from fisher exact test Time

Weight cut off %

1 month

[20 lbs

1 year

[40 lbs

2 years

[100 lbs

Non-swimmers (#)

Swimmers (#)

P value

43.6% (34/78)

37.5% (3/8)

1.00

64.0% (32/50)

80.0% (4/5)

0.65

14.7% (5/34)

100% (2/2)

0.03

At one month, 43.6% (34/78) of non-swimmers and 37.5% (3/8) of swimmers had a greater than 20 pounds weight loss (p = 1.00) At 1 year, 64.0% (32/50) of non-swimmers and 80.0% (4/5) of swimmers had a greater than 40 pound weight loss (p = 0.65) At 2 years, 14.7% (5/34) of non-swimmers and 100% (2/2) of swimmers had a greater than 100 pound weight loss (p = 0.03) Conclusion: While swimmers had no significant differences in short term weight loss (one month and 1 year) compared to non-swimmers, swimmers did show significantly higher weight loss at a longer term time point (2 years). Swimming may be an excellent method of exercise for the morbidly obese post surgical population in that it is low impact, and may be correlated with better surgical outcomes; however, further studies and longer term followup may be necessary.

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LAPAROSCOPIC GASTRIC BAND REMOVAL—SINGLE INSTITUTION EXPERIENCE Emilia Krol, MD, Keith Zuccala, MD, Laura Choi, MD, Danbury Hospital Introduction: Laparoscopic gastric band placement is an effective method for the treatment of morbid obesity. Placement of a gastric band via minimally invasive surgical technique contributed to an increasing number of patients who select and undergo this procedure as opposed to gastric bypass. Accumulated experience with gastric band placement has revealed that a subset of patients require revision or removal of the device for multiple reasons, including patients’ dissatisfaction with results and a variety of device-related complications. Because the true rate of gastric band removal is an important part of the preoperative patient preparation and informed consent discussion, the aim of this review is to identify the true rate of gastric band removal in our institution. Methods: This study is an IRB approved retrospective chart review inclusive of all gastric band placement, removal and revision procedures that were performed in our institution from January 2005 to July 2010. From this data base, a group of patients who underwent both gastric band placement and subsequent removal were identified. Their metrics include: gender, age, pre-operative weight and BMI, weight loss until band removal, time interval between placement and removal of the band, and the documented reason for removal. Results: Four hundred and three laparoscopic gastric band placement procedures were performed at our institution from January 2005 to July 2010 (66 months).Thirty three gastric bands (8%) that were placed, were subsequently removed. Of these 33 patients, 25 were women and 8 were men with mean age of 52 years (range: 23–72), mean preoperative weight of 278.6 and BMI of 46. Mean weight at time of removal was 238 lbs and BMI of 38.2. Patient lost the average of 43 lbs (range: 178 to +30 lbs). Mean time interval from placement to removal was 21 months (range: 2 days to 54 months). Ten (30%) patients underwent elective removal of the device—due to diet intolerance (3 patients—9%) or inadequate weight loss (7 patients—21.5%). The remaining 23 patients had the device removed due to surgical complications: slipped band (17 patients—51.5%), infection (3 patients—9%), gastric erosion (2 patients— 6%), and chronic inflammation around the band (1 patient—3%). Two patients underwent a second gastric band placement at a later time (4 and 20 months, respectively). Conclusions: Laparoscopic placement of a gastric band remains an accepted method for the surgical treatment of morbid obesity. Any event leading to the loss of the device significantly affects the goal of weight loss, and, thereby, the intended long-term outcome. Gastric band explant rates are currently not well defined in the literature. This leads to difficulty in education and lack of clarity in advising patients who are considering weight loss surgery. The risk of explantation, along with the risks of device-related complications and failure of intended weight loss must be discussed with patients who consider multiple surgical options for weight management.

Surg Endosc (2012) 26:S249–S430

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IS EARLY DISCHARGE OF PATIENTS POST LAPAROSCOPIC ROUX EN Y GASTRIC BYPASS SAFE? B S Brar, MD FRCSC, C Smith, MD FRCSC, I Raiche, MD FRCSC, Jd Yelle, MD FRCSC, J Mamazza, MD FRCSC, University of Ottawa Introduction: Worldwide obesity rates have been increasing exponentially and bariatric surgery rates have similarly increased to combat this growing epidemic. Previous studies have shown that bariatric surgery can be preformed in a safe manner with low patient morbidity and mortality. What is unclear is the safety and feasibility of early discharge of patients undergoing laparoscopic Roux en Y Gastric Bypass (RYGB). The objective of this study was to examine the impact of early hospital discharge on short-term outcomes of bariatric patients undergoing laparoscopic RYGB. Methods and Procedure: Retrospective review of patients from November 2007 to July 2011 who had undergone laparoscopic RYGB at the Ottawa Hospital and discharged within the first 3 post operative days. Patients were excluded if there wasn’t sufficient peri-operative data. Discharge readiness was determined by adequate analgesia achieved with PO medication, patients tolerating fluids, voiding well and ambulating without assistance. Fischer exact tests was used to determine if there were any differences between patients discharged on post operative day 1 and those discharged on post operative days 2 or 3. Results: 349 patients (280 females and 69 males) in total were included. 23 were discharged on post operative day 1 (early discharge) with 283 discharged on day 2 and 43 discharged on post operative day 3 (normal discharge). The two groups were similar in terms of mean age (45.5 versus 46.0, p = 0.83), mean BMI (47.6 versus 47.6, p = 0.98), presence of co morbidities (hypertension, type 1 and 2 diabetes mellitus, obstructive sleep apnea, coronary artery disease, dyslipidemia, gastroesophageal reflux, asthma or COPD). The early discharge group did differ from the normal discharge group in terms of shorter mean operative (139.4 versus 152.7 min, p = 0.01) and having a significantly greater proportion of patients living within the greater Ottawa area (within 1 h of travel time to the weight management clinic) (76.3% vs. 45.8%, p = 0.004). Overall there were 51 peri-operative complications for a proportion of 14.6%. The rate was lower (8.7%) in the early discharge group versus the later discharge group (15.0%) but this was not statistically significant (p = 0.43). The early discharge group only had 2 complications, 2 surgical site infections. The normal discharge group had 49 complications: 32 surgical site infections, 3 post operative bleeds (1 observed, 2 requiring blood products), 2 renal complications (acute renal failure-no dialysis needed) and 2 respiratory complications (2 pneumonias). Six patients (all in the normal discharge group) had a major complication requiring reoperation (4 for anastomotic leak, 1 for anastomotic stricture and 1 for intestinal obstruction from port site herniation). There were no deaths in our series. Conclusion: Early discharge from hospital within 1 day after laparoscopic RYGB appears to be safe. Early discharge may result in significant hospital cost savings and a reduction in waiting lists, without increasing complications or mortality.

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LAPAROSCOPIC REPAIR OF PERFORATED MARGINAL ULCERS CAN BE DONE WITH SUPERIOR OUTCOMES COMPARED WITH OPEN REPAIR Girish Luthra, MD, Vladan N Obradovic, MD, Aamir Akmal, MD, Eliah M Malka, Corrine Blumling, MD, Lindsey Stratchko, MSIII, Mathew E Plank, PAC, Andrea L Plank, Nicole Woll, PhD, Jon D Gabrielsen, MD FACS, Chad Lee, Anthony T Petrick, MD FACS, Geisinger Medical Center, Danville, Pennsylvania Introduction: Perforated marginal ulcers represent a rare, but serious complication after RYGB almost invariably requiring operative management. We hypothesize that laparoscopic repair (LR) of perforated marginal ulcers after RYGB is feasible and can be done in experienced centers with lower morbidity when compared to open repair (OR). Methods: A review of the institutional database of patients with a previous RYGB for the treatment of morbid obesity was carried out to identify those diagnosed with perforated marginal ulcers between March 2001 and July 2011. 24 records were identified and retrospectively reviewed. Of these, 19 patients had undergone LR and 5 patients OR. These groups were also analyzed with respect to their clinical presentation, age and BMI at presentation with the ulcer, presence of peritoneal contamination, and mean follow up. The primary outcome measure was the incidence of postoperative complications in these two groups with secondary outcome measures including OR times, EBL, LOS, and ICU stay. Statistical analysis was performed using Fisher’s exact and unpaired t tests. Results: The average age of the patients was 46.9 years in the laparoscopic and 54.0 years in the open group, though this did not reach statistical significance. The average BMI at presentation was significantly higher in the open group (48.1 vs 29.6; p = 0.024). Of the 19 patients with LR, 10 presented with an acute free perforation. The remaining 9 patients presented with intractable symptoms (pain, nausea, vomiting, poor oral intake, weight loss) or bleeding and were found to have a chronic, walled-off perforation at surgery. Of the 5 patients with OR, 1 had a free perforation and 4 presented with intractable symptoms. 9 patients had generalized peritoneal contamination in the LR group, 1 had localized contamination and 9 had completely contained perforations. In the open group, 1 had generalized contamination whilst the other 4 had completely contained perforations. Our mean follow up in the LR group was 18 months and in the OR group 35 months. There was a trend toward a higher complication rate in the OR group (60% vs 32%). No statistically significant difference in operative time was noted between groups (162 min. LR, 212 min. OR); however, blood loss (46.7 ml vs 166 ml; p = .004), length of stay (3 days vs 12.2 days; p = 0.004), and percentage of patients requiring ICU stays (11% vs 60%; p = 0.04) were significantly lower in patients undergoing LR. Conclusions: Laparoscopic repair of a perforated marginal ulcer is feasible and compared favorably to open repair in our series. LR was associated with lower blood loss, shorter length of stay, and fewer patients requiring ICU admission compared to open repair. Although the groups are small, the laparoscopic approach to perforated marginal ulcers seems preferable when undertaken by surgeons experienced in revisional laparoscopic bariatric surgery.

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LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS FOR TREATMENT OF SYMPTOMATIC PARAESOPHAGEAL HERNIA IN THE MORBIDLY OBESE Brendan M Marr, MD, Mark R Wendling, MD, Dean J Mikami, MD, Bradley J Needleman, MD, Scott Melvin, MD, Kyle A Perry, MD, Ohio State University Background: Laparoscopic paraesophageal hernia (PEH) repair with complete or partial fundoplication has become the procedure of choice in specialized centers for the treatment of symptomatic paraesophageal hernias. While obesity increases the risk of GERD and hiatal hernia, the ideal surgical approach for the treatment of symptomatic PEH in morbidly obese patients is unclear. The aim of this study was to review our experience with laparoscopic PEH repair and concomitant Roux-en-Y gastric bypass (RYGB) for the management of symptomatic PEH in morbidly obese patients. Methods: Patients undergoing laparoscopic PEH repair between 2006 and 2011 (n = 181) were reviewed. Fourteen patients with morbid obesity and symptomatic PEH underwent laparoscopic PEH repair with RYGB. In all cases, the PEH repair consisted of reduction of the hernia and hernia sac followed by primary posterior cruroplasty without mesh reinforcement. A standard RYGB was then performed with a circular stapled gastrojejunostomy. Outcomes of interest included operative time, body mass index, estimated blood loss, complications, and symptomatic recurrence. Results: Fourteen patients underwent simultaneous PEH repair with laparoscopic RYGB . Eleven patients (79%) were female and the mean age was 50 ± 10.8 years. Preoperative BMI was 46 ± 9.5 kg/m2. Laparoscopic PEH repair with RYGB required 176 ± 43.7 min and was associated with operative blood loss of 48 ± 25.6 ml. One patient developed a minor gastrojejunostomy leak that resolved with conservative management, and postoperative anastomotic stricture requiring endoscopic dilation occurred in 2 patients (14%). Another patient developed C. difficile colitis that resolved with antibiotics. To date, none of these patients have developed a symptomatic hiatal hernia recurrence. Conclusions: Symptomatic PEH in the morbidly obese population presents a challenging therapeutic dilemma with a high risk of recurrent hernia. This series demonstrates that laparoscopic PEH repair with concomitant RYGB can be safely performed and provides good short term symptoms relief. Longer-term follow-up of these patients is required to assess the radiographic and symptomatic recurrent PEH rates following this procedure

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LAPAROSCOPIC CHOLECYSTECTOMY IN THE SUPER MORBIDLY OBESE PATIENTS Muhammad Asad Khan, MD, Roman Grinberg, MD, Stelin Johnson, RPAC, John N Afthinos, MD, Karen E Gibbs, MD, Staten Island University Hospital Objective: Laparoscopic cholecystectomy has been the accepted standard of care for the treatment of acute cholecystitis for over a decade. There is ongoing debate whether it is safe in the super morbidly obese patient with BMI C 50 kg/m2. The current study compared the outcomes of super-obese (BMI C 50 kg/m2) patients undergoing open vs. laparoscopic cholecystectomy. Methods: We obtained data from the American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) on 1062 super-obese patients with a BMI C50 kg/m2 who underwent open and laparoscopic cholecystectomy between 2007 and 2009. The parameters analyzed included age, gender, co-morbid conditions, American Society of Anesthesiologists classification score, operative time, postoperative complications, re-operation, length of hospital stay and mortality. Results: Among 1062 patients, 912 (85.9%) underwent laparoscopic cholecystectomy while 150 (14.1%) had open cholecystectomy. Mean age of the study population was 43.1 years and 80% were female. Among two groups, patients underwent laparoscopic procedures had significantly lower incidence of diabetes (20% vs. 36%), COPD (2.2% vs. 5.3%), HTN (44% vs. 66%) and bleeding disorder (2.9% vs. 20%). Operative time and length of hospital stay was significantly shorter in laparoscopic group as compared to open group (81 ± 40 min vs. 145 ± 68 min and 1.7 ± 3.2 days vs. 9.2 ± 15.5 days, respectively). Nine patients (6%) in open cholecystectomy group underwent return to OR compare to only 1% patients in laparoscopic group. Similarly superficial, deep, organ space infection and wound dehiscence was significantly higher in open group, Patients in open cholecystectomy group had higher incidence of pneumonia, re-intubation, failure to wean, UTI, MI, cardiac arrest, sepsis and septic shock. Perioperative mortality was 3.3% in open cholecystectomy patients as compared to 0.2% in laparoscopic patients (p \ 0.01). Conclusion: Laparoscopic cholecystectomy is a safer option for super-obese patients and should be attempted in order to potentially avoid significant peri-operative complications in this high risk group. Perioperative complications Complications

Open cholecystectomy N = 150 (%)

Laparoscopic cholecystectomy (%)

P

Reintubation

8 (5.3)

4 (0.4)

.001

Failure to wean

11 (7.3)

3 (0.3)

\.001

Progressive renal failure

7 (4.7)

2 (0.2)

\.001

Urinary tract infection

4 (2.7)

5 (0.5)

.027

Cardiac arrest

3 (2)

0 (0)

.003

Myocardial infarction

2 (1.3)

1 (0.1)

.054

Sepsis

6 (4)

1 (0.1)

\.001

Septic shock

10 (6.7)

2 (0.2)

\.001

Pneumonia

8 (5.3)

4 (0.4)

\.001

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SYSTEMATIC REMOVAL OF MORE THAN 50% OF FLUID IN PATIENTS WITH CLINICALLY SIGNIFICANT REFLUX OR SLIPPAGE-LIKE COMPLICATIONS OF ADJUSTABLE GASTRIC BANDING IS AN EFFECTIVE TREATMENT OPTION Andrea S Bedrosian, MD, Nabeel R Obeid, MD, Bradley F Schwack, MD, Heekoung Youn, RN MA, Christine J Ren Fielding, MD, George A Fielding, MD, Marina S Kurian, MD, New York University Langone Medical Center

RELATIVE FREQUENCY OF OBESITY IN NEW BARIATRIC CENTRE IN THE INTERIOR OF PORTUGAL Jose´-eduardo Santos, FCSSA FRCSEd MMEDWits SA, Miguel Freitas, MScPhysics Univ Coimbra Portugal, Ana Monteiro, LNutrit Univ Porto Portugal, Manuel R Fanfa, MD, Miguel Castelo-branco, PhDMed, Univ Beira Interior Portugal Faculty of Health Sciences, University of Beira Interior; CICS-UBI-Health Sciences Research Centre, University of Beira Interior; Centro Hospitalar Cova da Beira; Av. Infante D. Henrique, 6200-506 Covilha, Portugal

Introduction: As the patient population with laparoscopic adjustable gastric banding (LAGB) becomes more prevalent, and with it several known clinical complications, we investigated whether systematic loosening for specific bandrelated problems can prevent re-operation. We hypothesized that removing all fluid in patients with documented band slip, esophageal dilatation, pouch dilatation, or clinically significant reflux may be a sufficient therapeutic intervention, thereby avoiding the risks and cost associated with surgical revision of the band. Methods and Procedures: We conducted a single-institution retrospective review of 273 patients who had LAGB with Allergan AP-Standard bands performed between June 2006 and July 2011, were at least 120 days from initial surgery with C5 mL of fluid in the band, and had C50% fluid removed for various reasons. Justification for fluid removal was divided into band-related clinical complications (documented slip, esophageal dilatation, pouch dilatation, or reflux) and non-band related issues (e.g., pre-procedure fluid removal, patient request, etc.), and the percent of fluid removed was largely provider-dependent. We analyzed rate of re-operation for band-related complications, as well as categorization of documented resolution for those not undergoing surgical revision. Data points studied included demographic information, time from band loosening to re-operation, number of adjustments following band loosening, and weight change. Results: 113 of the original 273 patients had a band-related clinical complication justifying fluid removal of C50%: 34.5% had slippage, 28.3% reflux, 23.9% pouch dilatation, and 13.3% esophageal dilatation. Of these, 71.7% had documented resolution of the complication without surgery following fluid removal of C50%, while 25.7% underwent re-operation. Resolution was defined as complete alleviation of symptoms or normal follow-up imaging studies, such that the band could be refilled. Overall, 51.7% of patients with band slips had resolution without surgical revision, compared to 81.5% of patients with pouch dilatation, 81.3% with reflux, and 86.7% with esophageal dilatation. Three adjustment groups of fluid removal were selected: 50%, 51–75%, and C76%. Of the 10 patients who had 50% of fluid removed, none required band revision. For the 31 patients with 51–75% of fluid removed, 22.6% required band revision. For the 72 patients with [75% of fluid removed, 25% required band revision. In each adjustment group in those not requiring re-operation, an average of 4 adjustments was needed to reach the band’s original fill volume. Patients not requiring surgical revision saw an average of +7.6% change in weight, and weight gain was similar across all adjustment groups. Conclusions: We found that simple fluid removal of C50% in LAGB patients is a good therapeutic option with [71% overall success. Over 80% of patients presenting with pouch dilatation, esophageal dilatation, or reflux had resolution without surgical re-intervention. Even in those with esophagram-proven slips, over 50% did not require re-operation. The small number of office visits to refill the band and \8% weight gain are acceptable when compared to additional surgery.

The prevalence of obesity has steadily risen in North America and Western Europe over the past 25 years. This has been linked to a parallel rise in all associated illnesses, mainly type II diabetes, hypertension, sleep apnoea, musculoskeletal disorders, respiratory and cardiovascular diseases. To adequately serve the purposes of prevention and treatment of obesity and its related diseases multidisciplinary Bariatric centres, ideally linked to Academic Centres are extremely important. Portugal has a scarcity of specialist Medical care in the interior of the country. In spite of the lack of published statistics it is estimated that the prevalence of obesity in these interior regions is at least as high as it is in the coastal areas where the main Medical Centres and the Classical Universities are located. To provide adequate care to the increasing obese population of this region a new multidisciplinary Bariatric Centre has been established in an area of the interior, connected to the Academic Hospital that is adjacent to the newly created Medical School of the University of Beira Interior. The population served by this area, designated as Cova da Beira is estimated as being 93,579. An analysis of the bariatric patients that presented at this Academic Hospital for the period between February and July 2011 was done. An assessment of the relative frequency of the types of obesity and its associated comorbidities was done. A total of 412 patients were evaluated, 289 females and 123 males. These included 19 patients from the paediatric age group. Their age ranges were from 6 to 83 years.

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SAFETY OF ADOLESCENT ROUX-EN-Y GASTRIC BYPASS AT AN ADULT BARIATRIC CENTER OF EXCELLENCE James V Siatras, DO, Kate Ziegler, MD, Anna Ibele, MD, Daniel Mwanza, DO, Christopher Evanson, MD, John Ditslear, MD, Samer G Mattar, MD, Department of General Surgery, Indiana University School of Medicine, Indianapolis, IN Background: While major pediatric surgery referral centers are publishing adolescent outcomes, there is little published data from adult centers of excellence which incorporate adolescents into their established bariatric programs. We propose to review the outcomes all adolescent patients between the ages of 13 and 21 who underwent laparoscopic roux en y gastric bypass (LRYGBP) at our center. Methods: A retrospective chart analysis of all adolescents who had undergone LRYGBP from 2006-2011 and had at least a 12 month follow-up was done. Demographic information, % excess weight loss (%EWL), BMI loss, and complication rates were reviewed from patient charts and telephone interviews. Results: Seven patients met our follow-up criteria (5 females and 2 males). Mean age was 19 years old (range 17–21 years old). The mean follow-up was 22 months (range of 12–36 months). Our patient population had a mean %EWL of 49%. Mean body mass index fell 32% (from 59 preoperatively to 40). Four patients had complications from surgery, 3 of which were minor, while one patient required readmission for small bowel obstruction requiring lysis of adhesions. There were no deaths. Conclusion: In our study, gastric bypass was safely performed and resulted in dramatic decrease in BMI. Our results show that adolescent bariatric surgery can be safely delivered in an adult bariatric center of excellence.

Of the 412 patients that were evaluated there were 124 patients that were classified as overweight (BMI 25–29.9), 181 patients were class I obese (BMI 30.0–34.9), 65 patients as class II obese and 42 as severely or class III obese, as displayed in the following chart.

Out of the total of 412 patients evaluated during the 6 month study period 89 patients had Type II diabetes. Twenty five of them were overweight, 42 class I obesity, 15 class II obesity and 7 were class III obese, as shown in the adjacent chart. The emphasis of treatment is primarily based on lifestyle modification with combined caloric intake control (following the principles of small frequent meals) with

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FACTORS INFLUENCING CHOICE OF OPERATION AMONG PROSPECTIVE BARIATRIC PATIENTS Stelin Johnson, RPAC, Roman Grinberg, MD, John N Afthinos, MD, Karen E Gibbs, MD, Staten Island University Hospital

increased caloric expenditure. Positive motivational techniques and the aid of aerobic minimally weight bearing exercise techniques being used. On the interventional procedure side the principle of downgrading risk potential is used for patients that are considered high risk (class III obese or class II with comorbidities). As such the use of the intra-gastric balloon is favoured before either sleeve gastrectomy (presently the favoured surgical procedure) or Lap-Band.

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THROMBOEMBOLIC EVENTS AFTER LAPAROSCOPIC GASTRIC BYPASS: IDENTIFICATION OF HIGH-RISK FACTORS C Gonczy, MD, V Advani, MD, S Markwell, MA, S Ahad, MD, I Hassan, MD, Southern Illinois University School of Medicine Introduction: In-hospital prophylaxis against thromboembolic events (TE) is considered routine for patients after laparoscopic roux-en-Y gastric bypass surgery (LGB) for morbid obesity. However, there is a paucity of data regarding the utility of extending prophylaxis beyond discharge. Utilizing the American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database, we analyzed patients undergoing LGB to determine the incidence of pre- and postdischarge TE and associated risk factors. Methods: Patients undergoing LGB between 2005 and 2009, were identified from the public use file of the ACS-NSQIP database using the Current Procedural Terminology code for LGB. Univariate comparison and regression analysis of demographics and comorbidities of patients with and without TE were performed to determine independent risk factors for the development of TE. Results: During the study period, 28,427 patients underwent LGB, of whom 123 (0.43%) developed a TE within 30 days of surgery. Seventy-seven percent of the pulmonary embolisms and 82% of the deep venous thromboses were diagnosed after discharge. On regression analysis several patient characteristics, medical comorbidities and postoperative complications were independently associated with increased risk of TE (Table)

Introduction: It is currently unclear what factors patients wishing to undergo weight loss surgery use in their selection of an operation. In our practice we have noticed an apparent disparity between the information presented to our bariatric patients regarding the different bariatric procedures during an information session and the choice that is ultimately made. For example, it is known that the gastric bypass is superior in terms of diabetes remission rates relative to gastric banding, yet a higher percentage of patients with diabetes select gastric banding. We conducted this study to elucidate which factors patients use in their decision making process. Methods: Our bariatric surgery program is structured such that patients are required to attend an information session and an education session prior to their surgical consultation. A survey was administered to a random subset of patients who were established members of our practice and to new patients who were still deciding on which operation to pursue. The survey asked which source was considered most informative among the program, another patient, friends or family, primary care physician, media outlets or others. The patients were then asked to state the most important factor in selecting an operation from the same choices. Additionally, it also asked how long patients were contemplating surgery before they finally had their choice of procedure done. Results: Two hundred patients completed the survey with 34 patients (17%) being pre-operative candidates. The most informative source were found to be the bariatric surgery team itself (64%), a prior bariatric surgery patient (13%), friends or family (8%) and the primary care doctor (7%). The most important factors for decision were listed as the bariatric surgery team (34%), friends or family (27%), the primary care doctor (11%) and a prior bariatric surgery patent (9%). The average time patients considered surgery was 19 months (range 2 to 120 months), with the most common time frames being 12 (43%), 24 (25%) and 6 (13%) months before their operation. Conclusion: It appears that although the bariatric surgery team is most informative and important, a significant number of patients will also include friend and family input in their decision. It is unclear how many of our patients had sat through other sessions at other institutions. It is also unclear what type or how valid the information they received from friends and family. This suggests that information sessions should potentially be expanded to include friends and family since they are such a major factor in the patients’ decision making process.

Risk factors for thromboembolic events after laparoscopic gastric bypass Risk factor

Odds ratio

P-value

Age C 40 years

1.98

0.0036

OR time C 180 min

2.00

0.0003

BMI C 45

1.72

0.0059

Male gender

1.66

0.0104

Non-independent functional status

4.62

0.0006

History of CHF

24.15

0.0001

Bleeding disorder

2.72

0.0088

Infection complication

2.25

0.0228

Sepsis complication

5.65

0.0001

Conclusion: The 30-day incidence of thromboembolic events after LGB in ACSNSQIP hospitals is low, although the majority of these events occur following discharge. Certain patients are at higher risk for TE, and may represent a cohort that would benefit from extended post-operative prophylaxis.

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39727

P487

39746

P488

LAPAROSCOPIC VS. OPEN APPENDECTOMY IN OBESE PATIENTS Muhammad Asad Khan, MD, Roman Grinber, MD, Stelin Johnson, RPAC, Johan N Afthinos, MD, Karen E Gibbs, MD, Staten Island University hospitals

PREDICTORS OF OUTCOMES FOLLOWING ROUX EN Y GASTRIC BYPASS SURGERY AT THE OTTAWA HOSPITAL Chris G Smith, Dr, Balpreet G Brar, Dr, Joseph Mamazza, Dr, Husein Moloo, Dr, Haggar Fatima, Ms, Jean Denis Yelle, Dr, Robert Dent, Dr, Isabelle Raiche, Dr, The Ottawa Hospital

Introduction: Prevalence of obesity in adults older than 20 years of age is 34%. Although laparoscopic surgery has been widely adapted as the standard of the care, it is still unclear if it is superior to the open approach in obese (BMI C 30) patients. Information from administrative databases and single institutions are available but have inherent deficiencies. The aim of our study is to assess the risk profile of contemporary patients being treated with open repair and to compare outcomes among open vs. laparoscopic appendectomy patients. Methods: Patients who underwent appendectomy for non-perforated appendicitis between 2007 and 2009 were identified from ACS-NSQIP, which is a multicenter, comprehensive, prospectively maintained database with more than 180 participating hospitals. Laparoscopic and open techniques were compared. Preoperative comorbidities, operative duration, and 30-day outcomes were evaluated using t-tests or chisquared test as appropriate. Results: A total of 12,532 patients were identified and 2,057 (16.4%) patients underwent open repair. The mean age of the study population was 41.6 ± 15 years. The open repair group had a higher risk profile in terms of increased frequency of diabetes (11.5% vs. 8.5%), chronic pulmonary disease (2% vs. 1%), chronic heart failure (0.5% vs. 1%), history of percutaneous cardiac revascularization (4.3% vs. 2.0%), hypertension (32.3% vs. 26.5%) and symptomatic peripheral vascular disease (0.6 vs. 0.2%) compared to the laparoscopic group. Operative time and length of hospitalization were significantly greater in the open group (67.8 ± 39 min vs. 55.1 ± 28 min and 3.3 ± 4.8 days vs. 1.6 ± 2.2 days). Thirty day mortality was higher in the open group (0.3% vs. 0.1%) and more patients required re-operation (2.5% vs. 1.3%). The rate of surgical site infection including superficial, deep and surgical wound dehiscence was higher in the open group. More patients in the open group had significant postoperative morbidity including pneumonia, ARF, failure to wean from the ventilator, re-intubation, DVT, sepsis, septic shock and cardiac arrest (Table).

Introduction: Despite a low complication rate, the consequences of complications from bariatric surgery can be devastating. The purpose of this study was to identify predictors of outcomes in patients undergoing laparoscopic roux en y gastric bypass. Methods and Procedures: Prospective analysis of patients undergoing roux en y gastric bypass at an academic center from November 2007 to July 2011. Exclusion criteria were: patients who underwent revisional surgery, those who had surgery at another center, and those who had incomplete follow up. Primary outcome measure was incidence of complications including: anastomotic leak, abscess, pulmonary or cardiac complications, internal hernia, stricture, renal failure and wound infection. Complications were pooled to create a single binary variable. Multiple logistic regression was used to identify predictors of post operative complications as well as length of stay. Linear regression was used to explore factors predictive of weight loss. Surgeon factors such as OR time and Patient factors including: age, BMI, comorbidities, distance from bariatric center, percent excess weight loss, and number of visits with the nurse practitioner and behaviourist preoperatively were explored. Results: Data on 377 patients was analyzed with a complication rate of 18.7%. Mean duration of follow up was 7.2 months. The mean age, BMI, and OR time were 46.1 ± 10.3 years, 47.9 ± 6.8, and 154.6 ± 38.2 min respectively. Mean excess weight loss was 82.2%. Univariate analysis identified BMI (odds ratio [OR] 1.058, 95% CI 1.019–1.098) and history of hypertension (OR 2.086, 95% CI 1.231–3.536) as being significantly associated with the incidence of complications. Multivariate analysis with forward selection showed that BMI alone (OR 1.043, 95% CI 1.000–1.088) was significantly associated with an increased risk of developing complications. Separate logistic models were used to analyze each complication type as a response variable. This identified hypertension (OR 2.027, 95% CI 1.034–3.973) as being significantly linked to the incidence of wound infection. Number of visits with the behaviourist preoperatively (OR 2.375, 95% CI 1.289–4.375) was associated with a higher number of complications occurring greater than 90 days after surgery. When looking at length of stay as the response variable, only type 2 diabetes mellitus was shown to be significantly related (p = 0.0064). Linear regression analysis showed that increased BMI was negatively associated with excess weight loss (parameter estimate -1.43, p = 0.0003). Conclusion: In our experience, BMI, hypertension, and number of visits to the behaviourist preoperatively were shown to be associated with a higher risk of complications post laparoscopic roux en y gastric bypass for morbid obesity. History of diabetes was predictive of increased length of stay while increased BMI was associated with decreased excess weight loss. These factors may be important when counselling patients considering bariatric surgery.

Perioperative complications Complications Open appendectomy Laparoscopic appendectomy P value N = 2057 (%) N = 10475 (%) Pneumonia

16 (0.8)

41 (0.4)

\.001

Failure to wean

21 (1.0)

19 (0.2)

\.001

Reintubation

18 (0.9)

28 (0.3)

\.001

Acute renal failure

6 (0.3)

6 (0.1)

.007

Urinary tract infection

22 (1.1)

0 (0.5)

.003

Cardiac arrest

4 (0.2)

5 (0.04)

.046

DVT

8 (0.4)

9 (0.1)

.001

Sepsis

38 (1.8)

112 (1.1)

.004

Septic shock

11 (0.5)

19 (0.2)

.006

Conclusion: Open appendectomy in patients with BMI [30 is associated with significantly higher morbidity and mortality. Laparoscopic appendectomy offers significant benefits and should be employed in this population.

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39759

S383

P489

BARIATRIC SURGERY INCREASES TESTOSTERONE AND IMPROVES MALE SEXUAL FUNCTION. A PILOT STUDY OF THIRTEEN MORBIDLY OBESE MEN Taehee Kwak, MD, Homayoun Pournik, MD, Krystyna Kabata, RPAC, Anthony Tortolani, MD, Piotr Gorecki, MD, New York Methodist Hospital, Brooklyn, NY, USA Background: The effect of bariatric surgery on sex hormones and sexual function of morbidly obese men has not been well studied. Objective: The purpose of this study was to examine the effect of bariatric surgery induced weight loss on testosterone level and sexual function in morbidly obese men. Methods: Thirteen morbidly obese men who underwent bariatric surgery were followed for 1 year. All operations were performed by the same surgeon (PG) at a single institution. Total testosterone level and sexual quality of life were measured before and 1 year after the surgery. The previously validated Brief Male Sexual Function Inventory (BSFI) questionnaire was administered to evaluate sexual function. The questionnaire has 11 questions measuring: 1) sexual drive, 2) erectile function, 3) ejaculatory function, 4) assessment of problems with sexual drive, erection, or ejaculation, and 5) overall satisfaction with sex life. Each question is scored on a scale of 0-4, with higher scores indicating better functioning. Pearson correlation coefficients were computed between BMI, serum testosterone levels, and scores in each category of the BSFI questionnaire, as well as the changes after 1 year in each of these parameters. Results: The mean age was 45.2 ± 14.2 year. At baseline, mean weight was 307.4 ± 45.9 lb, BMI was 44.9 ± 4.5 Kg/m2, and serum total testosterone level was 311.6 ± 130.7 ng/dl. 77% (10 out of 13) of the men underwent laparoscopic adjustable gastric banding and 23% (3 out of 13) underwent laparoscopic Roux-en-Y gastric bypass. At 1 year follow-up, mean weight was 253.8 ± 45.93 lb (mean decrease: 53.6 ± 34.18 lb), BMI was 36.7 ± 5.2 Kg/m2 (mean decrease: 8.2 ± 4 Kg/m2), and total testosterone level was 458.2 ± 179.6 ng/dl (mean increase: 146.9 ± 142 ng/dl). Six men answered the questionnaire both before and after surgery, and their baseline mean scores (±S.D.) for sexual drive, erection, ejaculation, problem assessment, and overall satisfaction were 2.3 (±0.9), 2.6 (±0.9), 3.6 (±0.5), 3.2 (±0.9), and 2.7 (±1.0), respectively. At 1 year, mean scores were 3.1 (±0.8), 3.2 (±0.9), 3.8 (±0.4), 3.4 (±0.8), and 3.0 (±0.9), respectively, and all increased. Increases in four categories (sexual drive, erection, problem assessment, and overall satisfaction) were statistically significant (p \ 0.05). Correlation coefficients calculated between decreases in BMI, increases in testosterone level, and changes in questionnaire scores were all in the expected direction but not statistically significant, likely due to the currently small sample size in this ongoing study. Conclusions: Our results demonstrate that testosterone level and sexual quality of life in morbidly obese men were significantly improved after bariatric surgery. While a limited number of men have completed the questionnaire to date, this pilot study suggests potential effects of bariatric surgery on improving sexual function related quality of life in morbidly obese men.

39775

P490

LAPAROSCOPIC VS. OPEN APPENDECTOMY IN MORBIDLY OBESE PATIENTS (BMI [ 40): A NSQIP ANALYSIS Muhammad Asad Khan, MD, Roman Grinberg, MD, Stelin Johnson, RPAC, John N Afthinos, MD, Karen E Gibbs, MD, Staten Island University Hospital Background: Morbid obesity has become a major global health problem and, as such, treating common surgical problems must factor this into determining best care practices. Laparoscopic appendectomy is commonly employed as a treatment modality for acute appendicitis and offers potentially decreased morbidity and mortality in single institution studies. However, there is still an ongoing debate whether laparoscopic appendectomy offers any benefits in morbidly obese patients. The aim of this study is to compare the outcomes of this subset of patients undergoing open versus laparoscopic appendectomy. Method: Morbidly obese patients (BMI C 40 kg/m2) undergoing open and laparoscopic appendectomy for non-ruptured appendicitis were identified from American College of Surgery—National Surgical Quality Improvement program (ACSNSQIP) database using CPT-codes. Preoperative co-morbidities, operative time, length of hospitalization and perioperative mortality and morbidity were compared between the two groups using chi-square and independent t-test as appropriate. A p-value of 0.05 or less was considered statistically significant. Results: A total of 1,976 patients were identified between the year 2007 and 2009 with a mean age of 40 ± 14 years with 61% being female. A laparoscopic appendectomy was performed on 1,643 (83.1%) patients. The patients in the laparoscopic group were younger (40 ± 14 years vs. 43 ± 14 years, p \ .001), had a lower prevalence of hypertension (35% vs. 43%), diabetes (14.7% vs. 21.3%) and have had fewer percutaneous coronary revascularizations (1.7% vs. 4.2%). The operative time in laparoscopic group was 61 ± 34 min which was significantly shorter than the open group (81.6 ± 45 min). The length of stay was also shorter in the laparoscopic group (2.1 ± 2.7 days vs. 4.2 ± 5.4 days). The laparoscopic group had fewer postoperative superficial and deep surgical wound infections and a lower rate of pulmonary complications including a decreased need for reintubation and failure to wean from the ventilator (Table). There was no difference in mortality between the two groups. Conclusion: Open appendectomy in morbidly obese patients is associated with significantly increased risk of surgical wound infections and respiratory complications. Laparoscopic appendectomy should be attempted in all morbidly obese patients to potentially avoid these complications.

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P491

39865

P493

WEIGHT LOSS AFTER LAPAROSCOPIC SLEEVE GASTRECTOMY: DOES SIZE MATTER? Scharf Keith, MD, Nayna Lodhia, BS, Anit Kaushal, PhD, Homero Rivas, MD, John M Morton, MD MPH, Stanford School of Medicine

DOES GASTRO-INTESTINAL QUALITY OF LIFE IMPROVE AFTER GASTRIC BYPASS? Nayna Lodhia, BS, Jaffer Kattan, BS, Adam Eltorai, BS, Homero Rivas, MD, John M Morton, MD MPH, Stanford

Background: Sleeve gastrectomy is a successful weight loss procedure. However; there are still technical variations in creating the sleeve including what size bougie or endoscope should be employed in sizing. We sought to objectively determine if a certain gastric volume removed resulted in adequate excess body weight loss. Methods: We retrospectively analyzed data from 100 patients who underwent sleeve gastrectomy from 2007-2011. Data analyzed included age, gender, BMI, weight and volume of gastric specimen removed, and percent excess weight loss (%EWL) at 3, 6, and 12 months postoperatively. Volumes were calculated by multiplying length, width, and height of pathology specimens. Results: Median volume of stomach removed was 245 cubic centimeters (cc) with a range of 103 cc to 729 cc. Volume removed was not found to be correlated to age, initial BMI, sex, or race. For all subjects, we compared volume of stomach removed to absolute weight lost and percent excess weight loss at 3, 6, and 12 months. The only significant relationship with volume occurred at 12 months, with absolute volume of stomach removed. Using logistic regression, we determined that at volumes of approximately 200 cc, patients are more likely to have EWL of 60% or greater while below this volume they are more likely to have EWL 40% or less. With a volume of 300 cc removed, there is an 80% chance that patients will have EWL 60% or greater. Conclusion: One year percent excess weight loss had a statistically significant correlation to gastric volume removed. It appears that gastric volume removed [200 cc correlates to acceptable excess weight loss and could be a quality metric in determining an adequate resection volume in patients undergoing sleeve gastrectomy.

Introduction: Morbid obesity is the leading public health crisis in the United States and laparoscopic Roux-en-Y-gastric Bypass (LRYGB) is an effective and enduring weight-loss intervention. The purpose of this study was to analyze changes in quality of life of patients using the Gastrointestinal Quality of Life Questionnaire (GI-QoL). Methods and Procedures: Demographic, preoperative, three, six and twelve month postoperative data were prospectively obtained for 196 consecutive laparoscopic RNYGB patients at a single academic institution. At each clinic visit, patients completed the GI-QoL, a 36 item questionnaire that analyzes GI symptoms, emotional status, physical and social performance, and stress of medical treatment with higher scores indicating better quality of life. Patients were compared on the basis of gender and body-mass index (BMI). Demographic, preoperative, and postoperative data were compared with GI-QoL scores with a one way ANOVA for continuous variables and chi-squared analysis for dichotomous variables using Stata/IC 11.1 software. Results: 129 patients had 12 month postop data. Patient demographics included an average BMI 47, age 47, 67% white, income $62,000, 79% with private insurance, and 4 total preoperative comorbidities. Major comorbidities were diabetes (42%), hypertension (70%), hyperlipidemia (53%), GERD (43%), sleep apnea (48%), and depression (39%). Patients with depression had a lower overall preoperative GI-QoL score (p \ 0.001) compared to those without depression; however, the twelve month postoperative total GI-QoL had a less significant difference between those with and without depression (p \ 0.07). Men had significantly better results in nearly all preoperative GI-QoL categories: emotional status QoL (p = 0.04), physical symptoms (p = 0.003), medical treatment stress (p = 0.02), disease specific stress (p = 0.01), digestive health (p = 0.023) and total score (p = 0.002). However; these differences were not significant twelve months postoperative. A preoperative BMI above 50 trended towards a lower preoperative total QoL score (p = 0.096), and a significantly lower depression sub-score (p = 0.055); however these trends were not apparent at 12 months. Patients with surgical complications had a significantly lower preoperative and three month total GI-QoL score than those without surgical complications (p = 0.02 and p \ 0.001, respectively). At 6 months there was a trend for lower quality of life in these patients (p = 0.07), and by 12 months there was no significant GI-QoL difference in patients with surgical complications. Total GI-QoL scores increased postoperatively; however, the most significant increase was seen between preoperative and three month postoperative values (p \ 0.001), with less significant changes at six and twelve months. Conclusions: This study demonstrates that LRYGB increases the overall gastrointestinal quality of life almost immediately after surgery. Furthermore, LRYGB results in comparable total quality of life at 12 months postop in patients regardless of their gender, preoperative depression diagnosis, surgical complications and BMI. A low initial total GI-QoL score may be predictive of a risk for surgical complication and further study is required.

39828

P492

IMPROVEMENT IN ESTIMATED GLOMERULAR FILTRATION RATE AFTER BARIATRIC SURGERY: A NEW APPLICATION FOR BARIATRIC SURGERY ON THE HORIZON? Michael L Hibbard, MD, Andrea R Giovanelli, Megan Palsa, PAC, Teresa Kim, MD, Gregory Broderick-villa, MD, Ajay Upadhyay, MD, First Surgical Consultants, Alta Bates Summit Medical Center, Oakland, California, U.S.A Introduction: Bariatric surgery has been shown to improve multiple conditions that are known risk factors for renal disease. Despite this, there remains a paucity of evidence to support the benefits of bariatric surgery on renal function. We hypothesized that a demonstrable improvement in estimated glomerular filtration rate would be seen in our bariatric surgery patients. Methods and Procedures: A retrospective review of prospectively collected data of 186 patients who underwent minimally invasive bariatric surgery as treatment for morbid obesity from Jan 2009 through Dec 2009. Demographic and laboratory data was collected and used to calculate estimated glomerular filtration rate (eGFR) using the 6 variable modification of diet in renal disease formula. Significance was then determined using the paired t-test. Results: A laparoscopic adjustable band system was used in 48 patients, 7 patients underwent laparoscopic sleeve gastrectomy, and 131 underwent laparoscopic gastric bypass with roux-en-y reconstruction. The mean eGFR showed significant improvement from 86.89 ml/min/1.73m2 pre-operatively to 98.03 ml/min/1.73m2 by 6 month follow-up (p = 0.01) with a mean percent excess body weight (%EBW) loss of 42.98 pounds. At 1 year follow-up, the improvement in mean eGFR remained significant at 95.87 ml/min/1.73m2 (p = 0.001) with %EBW loss of 51.76. Conclusion: Our data suggest a clear improvement in renal function as calculated by eGFR. Though significance in eGFR was apparent by 6 months and held through 1 year follow-up, longer follow-up and prospective analysis is needed. Whether improvement in renal function is due to direct effects of weight loss or by the indirect effects of modification of risk factors has yet to be determined. If progression of renal dysfunction can be slowed or reversed with weight loss surgery, the extensive financial and lifestyle burden of dialysis may be delayed or avoided.

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39870

P494

BARIATRIC SURGERY IN PATIENTS WITH BMI LESS THAN 35. EXPERIENCE IN 895 PATIENTS Salinas Jose´, MD, Rodrigo Fernandez, MD, Ce´sar Mun˜oz, MD, Julio Cerda, MS, Luis Iba´n˜ez, MD, Fernando Crovari, MD, Gustavo Pe´rez, MD, Ricardo Funke, MD, Camilo Boza, MD , Department of Digestive Surgery, Hospital Clı´nico P, Universidad Cato´lica de Chile Introduction: Patients with BMI 30-35 kg/m2 and comorbidities that are refractory to intensive medical therapy are excluded from classic NIH Bariatric Surgery guidelines. The aim of this study is to compare Laparoscopic Sleeve Gastrectomy (LSG) to Laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients with a preoperative BMI between 30-35 kg/m2 in terms of complication and weight loss Methods and Procedures: All cases were approved by a multidisciplinary team. All patients had at least one obesityrelated comorbidity and several documented failed medical weight-loss treatment attempts. A review of our prospective electronic database between December 2002 and December 2010. Data is expressed as mean ± standard deviation or median (interquantile range) when appropriate. Results: A total of 370 LRYGB and 525 LSG cases were performed. There were 76.8% and 85.3% of females in LRYGB and LSG respectively (p \ 0.05). Preoperative age was 42 (33–50) and 37 (28–45) years for LRYGB and LSG respectively (p \ 0.05). Preoperative BMI was 33.1 ± 1.6 and 32.9 ± 1.4 years for LRYGB and LSG respectively (p = ns). Obesity-related comorbidities were arterial hypertension (36.2%), type 2 diabetes (17.8%), dyslipidemia (84.6%), insulin resistance (80.8%), obstructive sleep apnea (6.5%) and osteomuscular disorder (26.2%). Operative time was 105 (85–155) and 70 (60–115) min for LRYGB and LSG respectively (p \ 0.0001). Conversion occurred in one case in each arm. Hospital stay was 3 (2–4) and 2 (2–3) days for LRYGB and LSG respectively. There was no mortality during follow-up. Early complications occurred in 6.5% and 2.3% after LRYGB and LSG respectively (p \ 0.001). BMI evolution was as follow (LRYGB vs LSG): Month3 26.6 ± 3.8 vs 27.5 ± 1.4, Month6 25.3 ± 2.3 vs 25.8 ± 1.7, Year1 23.9 ± 2.3 vs 25.2 ± 2.5, Year2 23.8 ± 2.4 vs 25.6 ± 2.3 and Year3 24.2 ± 2.3 vs 25.4 ± 2.1. Comorbidities were improved or resolved in almost all cases. Conclusion: Metabolic surgery for patients with a BMI between 30–35 kg/m2 was safe and effective in our series. LSG was safer than LRYGB. LRYGB was superior to LSG in terms to weight loss, however, both procedures achieved a mean normal weight during follow-up. Bariatric surgery guidelines should be updated and expanded.

39876

P495

WEIGHT LOSS IN LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING WITH SINGLE INCISION LAPAROSCOPIC SURGERY VERSUS CONVENTIONAL TECHNIQUE Jennifer Jolley, MD, Nida Ahmed, Minh Luu, MD, Amanda Francescatti, Khristi Autajay, Jonathan A Myers, MD, Rush University Medical Center Abstract Background: Laparoscopic adjustable gastric banding (LAGB) is an effective and commonly used bariatric surgery for weight loss in obese patients. Traditional LAGB generally involves the placement of up to five incisions. However, the advancement of surgical instrumentation and training has allowed for the development of a more minimally invasive surgical technique with single-incision LAGB (SILS LAGB). In this study, we seek to compare a cohort of conventional LAGB and SILS LAGB with regard to weight loss and complication rates in demographically similar patients. Methods: From February 2009 to February 2010, fifty-nine patients underwent LAGB by one surgeon at an outpatient surgery center. All patients were compared by age, gender, preoperative body mass index (BMI), 30-day complication rates, and excess weight loss (EWL). Thirty-seven of the operations were performed in a conventional, five-incision LAGB technique. Twenty-two patients had SILS LAGB, via an incision placed either in the left upper abdominal quadrant or periumbilical region. We retrospectively assessed the success rates of these different techniques with regard to general rates of complications and average percentage EWL in six-month follow-up intervals. Results: Thirty-seven patients underwent conventional LAGB (27 females, 10 males) with an average age of 41.2 years, and an average preoperative BMI of 48.2 kg/m2. The 22 patients in the SILS group (21 females, 1 male) had an average age of 43.9 years, and an average preoperative BMI of 40.3 kg/m2. The mean operative time in the SILS group was longer than the conventional LAGB group, 47.1 min versus the 37.4 min, p value of 0.0027. EWL comparisons for each group are listed below: Follow-up 0–6 months 7–12 months 13–18 months

LAGB

SILS LAGB

P value

17.0

18.3

0.3008

30.9

28.7

0.7317

44.6

44.2

0.9645

39901

P496

THE OPTIMAL TECHNIQUE OF GASTROJEJUNOSTOMY IN LAPAROSCOPIC GASTRIC BYPASS MAY BE A HAND SEWN ANASTOMOSIS. COMPARISON OF OUTCOMES AND COSTS Piotr Gorecki, MD FACS, Krystyna Kabata, PA, Srikanth Eathiraju, MD, Suraj Parekh, MD, Anthony Tortolani, MD, New York Methodist Hospital Introduction: Creation of gastrojejunostomy during laparoscopic gastric bypass remains technically challenging part of the procedure. The techniques utilized include: circular stapled anastomosis (CSA), linear stapled anastomosis (LSA), and hand sewn anastomosis (HSA). No consensus on optimal technique exists and individual surgeon’s training and personal preferences are main determinants behind the choice of method. Methods: We compare the outcomes of 434 consecutive patients who underwent a CSA with 218 consecutive patients who underwent HSA. All patients were approached with laparoscopic technique and were performed by the same surgeon (PG) at a single institution (NYMH). All patients followed the same clinical pathways for perioperative care. All data were collected and entered into the data base prospectively. The two groups were compared for the following patient variables: mean preoperative weight, BMI, age, sex, insurance status and number of comorbidities. Main outcome measures: Perioperative outcomes included: operative times, intra-operative blood loss, length of hospital stay and utilization of post discharge prescription pain medications. Complications included mortalities, anastomotic leaks, wound infections, incisional hernias, GI bleeding, 30-day reoperations and anastomotic strictures. Hospital costs were calculated based on a sample of the most recent 100 consecutive patients in each technique group. Financial information included: costs of disposable instrumentation, total hospital charges and hospital charges to reimbursement ratio. The dynamics of postoperative weight and BMI loss were also evaluated. Pearson Chi-Square and t-test were utilized for statistical analysis. Results: Groups were comparable preoperatively (mean BMI in CSA group 48.34 vs. 47.61 in HSA group, p = 0.178). All operations were completed laparoscopically and there were no major intraoperative complications and no intraoperative blood transfusions in either group. There was a shorter operating time in the HSA group (HSA group, 150.87 min vs. CSA group, 179.89 min, p \ 0.001) and less blood loss in the HSA group (17.19 cc vs. 44.95 cc). Patients in the HSA group had shorter mean hospital stay (2.47 vs.3.45 days, p \ 0.001) and less utilization of prescription pain medications (2.84 vs. 7.43 days, p \ 0.001). There was no postoperative mortality and no leaks in the HSA group (3 leaks in CSA group). There were no wound infections in HSA group (HSA 0% vs. CSA, 17 patients, 3.92%), and no postoperative GI hemorrhage in HSA group (0% vs.3.7%). There were 8 (1.84%) 30-day reoperations in CSA group (5-laprotomy, 3- laparoscopy, 7 potentially related to utilization of staple products) and 3 reoperations (1.36%) in the HSA group (all 3 - laparoscopy, none related to HSA technique). The incidence of anastomotic strictures was similar in both groups (HSA 5.5% vs. 6.9% in CSA group). HSA provided significant costs saving ($1004.03 saving in disposable instrumentation per patient) and 33.06% improvement in hospital charges to reimbursement ratio. The dynamics of weight loss, and 1-year excess weight loss were similar in both groups (1 year BMI 31.27 in CSA vs. BMI 31.69 in HSA, p = 0.483) Conclusions: HSA appears to be a less expensive and safer method as compared to CSA and therefore may be the preferred technique of laparoscopic gastrojejunostomy during laparoscopic gastric bypass.

39907

P497

LAPAROSCOPIC GASTRIC PLICATION AS A REVISIONAL PROCEDURE AFTER FAILED ADJUSTABLE GASTRIC BAND John H Rodriguez, MD, Stacy Brethauer, MD, Matthew Kroh, MD, Cleveland Clinic Foundation Introduction: Laparoscopic adjustable gastric banding (LAGB) is one of the most common weight loss operations performed. Despite it’s popularity, well known complications requiring re-operation are frequently encountered. Revision of the band or conversion to other procedures including Roux en-Y gastric bypass and sleeve gastrectomy are well described. More recently, laparoscopic gastric plication has been introduced as a safe and effective restrictive weight loss procedure. We present two cases of failed LAGB conversion to gastric plication. Case Report: Two patients developed band-related complications requiring re-operation. Both declined or were ineligible for conversion to bypass or sleeve gastrectomy. Case #1 is a 41 y/o female who developed intractable dysphagia following LAGB and primary failure of weight loss. Case #2 is a 29 y/o female with band erosion. Both patients required operation for band removal. After band removal, greater curvature plication was performed as a revisional bariatric salvage procedure. Both cases were successfully completed laparoscopically. Both patients experienced satisfactory outcomes regarding post-operative recovery and weight loss. Conclusion: Laparoscopic greater curvature plication is an optional procedure for patients presenting with LAGB complications requiring revisional surgery. As we gain experience with this novel procedure, application and results need to be carefully examined.

The overall percentage EWL was not statistically different between the two groups for each follow-up period. There were no complications or mortalities in either group. Conclusions: While patients undergoing bariatric surgery may choose SILS LAGB for cosmetic purposes, this retrospective review comparing SILS LAGB to conventional LAGB demonstrates that it is just as effective in helping these patients to achieve weight loss without any added morbidity.

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P498

LAPAROSCOPIC GASTRIC BYPASS IN ADOLESCENTS: A PROSPECTIVE ANALYSIS OF DYNAMIC OF WEIGHT LOSS Piotr Gorecki, MD, Alok Aggarwal, MD, Elizabeth Lax, MD, Anthony Tortolani, MD, Wojciech Gorecki, MD, Department of Surgery, New York Methodist Hospital, Brooklyn, NY Introduction: With an epidemic of obesity among American children and adolescents, and growing popularity of bariatric surgery in adults, little data focusing on dynamics of weight loss and potential outcome differences in these groups of bariatric patients is available. Objective: The purpose of this study is to evaluate the dynamic of weight loss in adolescent patients (AP) undergoing laparoscopic Roux-Y gastric bypass (LRYGB) and compare the results with the older patient (OP) population undergoing the same procedure. Materials and Methods: We present our experience with 41 adolescent (18 to 21 years of age) patients who underwent LRYGB at our institution between August 2001 and August of 2011. All patients met the NIH criteria for bariatric surgery and were operated by a single surgeon (PG). All patients were evaluated preoperatively in the multidisciplinary setting that included pediatrician. The data were collected prospectively. The weight loss patterns for both groups were measured at the following intervals: excess weight loss at one week, 1, 3, 6, 9, and 12 months, and 2, 3, 4 and 5 years. In addition, age groups were compared in regard to distribution of weight loss (percent of excess BMI loss at 1-year—EBMI) in 5 distribution groups. Group I included patients with EBMI loss of \25%, group II—between 26 and 50 EBMI%, group III—51–75% of EBMI loss, group IV—75–100% EBMI loss and group V [100% EBMI loss. Results: Out of 652 patients who underwent LRYGB, 41 were between ages of 18 and 21 (6.72%, mean age 19.75). There were 31 females (76%) and 10 males (24%) with an average body mass index (BMI) of 49.86 kg/m2 (range 41–64). All operations were completed laparoscopicaly with no intraoperative complications. Mean length of hospital stay was similar for the two groups (2.89 days for AP vs. 3,1 days for OP, p = 0.585). There was one (3.2%) major postoperative complication an 3 minor complications in the AP group. There were no long-term disabilities and no mortalities in either group. At 1-year follow up, the EBMI loss was 72.67% for AP and 75.36% for OP group and was similar (p = 0.51). In addition, at one year follow up, the distribution of weight loss in both patient population was as follow: Group I contained 4.2% AP vs. 0% OP patients, group II—12.5% vs. 9.6%, group II 37.5% vs. 43.6%, group IV 33.3% vs. 38.0% and Group V 12.5% vs. 8.8%. There was no significant differences in weight loss patterns in the two groups (p = 0.798). Comparable weight loss pattern extended up to 5 years after surgery with 5-year follow up BMI 32.67 for AP and 30.38 for OP (P = 0.492). Conclusion: The dynamic distribution of the pattern of weight loss up to 5 year after LRYGB was similar in both groups. The results of bariatric surgery in adolescent patients appear to parallel those in adult population.

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HIATAL HERNIA REPAIR IN LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS SIGNIFICANTLY IMPROVES REFLUX BUT NOT WEIGHT LOSS Daniel Moon, MD, Ahmad Bashir, MD, Jennifer Higa, BS MPH, Saber Ghiassi, MD MPH, Tienchin Ho, MD FACS, Keith Boone, MD FACS, Kelvin Higa, MD FACS, Department of Surgery, UCSFFresno Medical Education Program Introduction: Hiatal hernia repair during laparoscopic adjustable gastric banding has been shown to improve outcomes and surgical reoperations. We questioned if hiatal hernia repair during laparoscopic Roux-en-Y gastric bypass (LRYGB) had the same effect. Methods: We compared a 2006 cohort without routine hiatus dissection (Group 1) to a 2008 cohort with routine dissection (Group 2) for weight loss and reflux symptoms. All procedures were performed by a single surgeon. Hiatal dissections were complete and hiatal hernias, when present, were repaired by posterior crural approximation. Weight loss data was obtained from measurements at post-op office visits and analyzed using Student’s t-test. Reflux data was obtained from a mailed survey and analyzed using Chi-squared test. Results: There were a total of 385 patients from Group 1 and 369 patients from Group 2 available for study. Weight loss data was available on 136 patients at two years and 92 patients at three years post-op for Group 1, and for 105 patients at two years and 20 patients at three years post-op for Group 2. Percent excess weight loss did not differ between groups (Table 1). Return percentage for GERD Survey was 26% from Group 1, and 33% from Group 2. Reflux was reported in more Group 1 patients than Group 2 patients, though daily reflux medication use was similar (Table 2). Table 1 Average percent excess weight loss Group 1

Group 2

Year 2

69.2% (n = 120)

68.0% (n = 105)

Year 3

64.4% (n = 92)

58.1% (n = 20)

p 0.61 0.24

Table 2 Reflux symptom survey results Group 1 (n = 100)

Group 2 (n = 120) p

Reported Reflux

31%

18%

B0.05

Medication Use

18%

16%

0.67

Conclusions: Excess weight loss at 2 and 3 years is unchanged by the addition of routine hiatus dissection to LRYGB, however, GERD symptoms were improved by addition of this practice.

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SINGLE INCISION LAPAROSCOPIC GASTRIC BYPASS SURGERY: A STUDY OF 55 SINGLE INCISION LAPAROSCOPIC GASTRIC BYPASS SURGERY BY A SINGLE SURGEON Keyur Chavda, MD, Sunil Sharma, MD, Ziad Awad, MD FACS, University of Florida, Jacksonville Introduction : Laparoscopic Roux en Y gastric bypass is one of the most commonly performed weight loss surgery in United States. This complex reconstructive surgery requires high level of expertise with little room for error. Single Incision Laparoscopic Surgery (SILS) is a new approach where by the whole surgery is performed using a small incision and inserting multiple ports through it. Better cosmetics, less pain and faster recovery are potential advantages of this approach. Inadequate visualization, lack of space, expensive equipments, long operative time and being potentially unsafe are often criticism. SILS has been successfully performed and reported for cholecystectomy, sleeve gastrectomy and lap band surgery. For the first time we are reporting our successful technique for performing Single Incision Laparoscopic Surgery for Roux en Y Gastric Bypass using end-to-end anastomosis (EEA) stapler technique and extracorporeal small bowel anastomosis. Material and Method: retrospective analysis of first 55 patients who underwent SILS LGBP over a period of 18 months. Selection criteria included body mass index (BMI) of 33–60, no prior major abdominal surgery and patient consenting for this approach. Results: Attempted in 55 patients. 7 patients required additional single 5 mm port. Average operative time was 110 min with minimal blood loss. No major complication. One patient had anastomotic leak secondary to EEA stapler malfunction. Average hospital stay was between 24 and 36 h. 4 patients developed small seroma which required drainage but no hospitalization.

Conclusion: SILS LGBP is a reasonable option for selected patients. The procedure is safe, technically feasible and can be performed in a reasonable time with a potential of faster recovery.

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´ STRICA VARIANTE STRACHAN A LA MANGA GA Ivan Strachan, Gianna Ramos, Bariatric Surgeon CIPLA y Centro Me´dico Dominico Cubano Introduction: The sleeve gastrectomy has become one of the most used in the treatment of obesity. The risk of leak and difficult to manage is its most feared complication, also the high incidence of gastroesophageal reflux and hiatal hernia development makes many surgeons still prefer the gastric-bypass. This study aims to demonstrate that the Strachan variant significantly reduces leaks and reflux. Material and Methods: We performed a prospective descriptive study of the first 100 patients with the technique of Strachan. Our technique is based on a thorough and systematic dissection of the esophageal hiatus. Section of the stomach from 4 cm from the pylorus on 36 F catheter with suture reinforcement of the staple line and pexia the esophageal hiatus. Results: We operated and followed the first 100 patients with the technique of Strachan. The distribution of patients were 61 females and 39 males. The mean age was 37 years and BMI of 41. Barium upper gastrointestinal series were performed preoperatively after a month and three months after surgery. There were no bleeding complications or leakage and corrected and improved episodes of reflux. No hiatal hernia is presented. Conclusion: We believe that the variant Strachan to the sleeve gastrectomy is an acceptable option for improving the performance of the gastric sleeve in the treatment of obesity.

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ENDOSCOPIC STENTS (ES) AS DEFINITIVE TREATMENT FOR POSTOPERATIVE LEAKS IN BARIATRIC SURGERY Ce´sar Mun˜oz, MD, Jose´ Salinas, MD, Camilo Boza, MD, Fernando Crovari, MD, Ricardo Funke, MD, Alejandro Raddatz, MD, Allan Sharp, MD, Alex Escalona, MD, Fernando Pimentel, MD, Digestive Surgery Department, Hospital Clı´nico P. Universidad Cato´lica de Chile Introduction: Obesity surgery is the most effective treatment for severe obesity. However surgery is associated with complications like postoperative leaks. This complication has difficult treatments and can be potentially severe. The endoscopic stent (ES) is a useful tool in the treatment of other complications and diseases in gastrointestinal surgery but the experience in the treatment of postoperative leaks in bariatric surgery is still reduced. Our aim is to present and describe the results in patients with postoperative bariatric surgery leaks managed with ES in a high volume center of bariatric surgery. Methods and Procedures: Design: Descriptive study. Date: From January 2007 to March 2011. Inclusion criteria: All patients with a postoperative bariatric surgery leak with ES as treatment for closure of defect. Maneuver: A retrospective review of clinical files was done for patients with ES treatment for postoperative leaks from bariatric surgery. Measures variables: Biodemographic, weight, antropometric measures, type of surgery, time of postoperative leaks, methods for diagnosis, time since surgery to ES procedure, rate and time to complete resolution of leaks. Statistical analysis: We use descriptive statistical with central tendency measures and dispertion. The Stata 10.0 software was used for this purpose. Results: Nineteen patients with postoperative leaks have been treated with ES during the study period. Fifty seven percent were femenine with and median age of 35 years. Median BMI was 39,5 kg/m2. In 57% the primary procedure was done in our center. The median time from sugerı´ to leaks diagnosis was 10 days. Sleeve gastrectomy (42%) was the most frequent surgery in which it was necessary to install a ES. Seventy nine percent had undergone a previous surgery for the treatment of leaks. The median time between the first surgery and the time to install the ES was 25 days. Ninety five percent have the ES was the definitive treatment for leaks and one patients have unscheduled removal for spontaneus expulsion. The median time for removal ES was 85 days and only 1 patients required a new ES for a refistulae. Conclusions: The ES in the treatment of postoperative leaks after bariatric surgery is an effective treatment, even when the procedure is frequently done late, because other treatment have failed previously. An early use of ES in patients with diagnosis of leak should result in even quickly reassumption of oral feeding in this patients.

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WHAT ARE THE INCIDENCE AND TIMING OF CHOLECYSTECTOMY AFTER BARIATRIC SURGERY? Z M Keilani, MD, S El Djouzi, MD, T S Kuwada, MD, K Gersin, MD, C Simms, RN, D Stefanidis, MD PhD, Carolinas Medical Center Background: Obesity and rapid weight loss are major risk factors for the development of cholelithiasis. Patients after bariatric surgery are at increased risk for gallstone formation and subsequent cholecystectomy. Our objective was to assess the incidence of cholecystectomy after different bariatric procedures and the timing it occurs after surgery. Methods: Patients who underwent cholecystectomy after bariatric surgery at a center of excellence between 2005 and 2011 were identified and their data reviewed. Age, body mass index (BMI), gender, pathologic diagnosis, and the time interval between the bariatric procedure and the cholecystectomy were recorded. The incidence of cholecystectomy after each procedure was calculated and compared using chi square. Data are presented as mean ± s.d. A p-value \0.05 was considered significant. Results: The records of 1751 patients after bariatric surgery were reviewed; 1271 (72%) had prior laparoscopic Rouxen-Y gastric bypass (LRYGB), 349 (20%) laparoscopic adjustable gastric banding (LAGB), and 131 (8%) laparoscopic sleeve gastrectomy (LSG). Seventy four (4.2%) of these patients required laparoscopic cholecystectomy during follow up that ranged between 2 weeks and 68 months. There were no conversions and no major complications. 89% were females and 59% Caucasians, with an average age of 40 ± 10 years. At the time of cholecystectomy, BMI had decreased to 36 ± 8 kg/m2 from a preoperative value of 45 ± 7 kg/m2. Sixty eight patients had undergone LRYGB (5.3% incidence), 4 LAGB (1% incidence), and 2 LSG (1.5% incidence) (p \ 0.001). The pathology of the gallbladder specimen showed cholelithiasis without prominent inflammation in 32%, chronic cholecystitis in 30%, acute cholecystitis in 8%, and was normal in 30% (dyskinesia). Cholecystectomy rates declined over time (incidence of 55.4%, 21.6%, 14.9%, 5.4%, and 2.7% at 1, 2, 3, 4, and 5 years follow-up respectively) and were highest during the first 6 months after surgery (33.8% versus 21.6% for the next 6 months postoperatively). Conclusion: The incidence of cholecystectomy is highest during the first 6 months after bariatric surgery but is overall low at 4%. Gastric bypass patients are more likely to require cholecystectomy compared to band and sleeve patients. Few patients have their gallbladders removed due to acute cholecystitis and one in three have it for biliary dyskinesia. These findings may have important implications for preoperative counseling of patients undergoing bariatric surgery.

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MORBIDY AND MORTALITY AFTER 5000 CONSECUTIVE LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASSES PERFORMED BY A SINGLE GROUP IN ARGENTINA Oscar E Brasesco, Mario A Corengia, Gaston L Borlle, Juan M Riganti, Jose M Cabrera, Gabriel Menaldi, Guillermo Premoli, Jorge Bella, Guillermo Muzio, Pedro Martinez Duartez, Fundacion Favaloro & Hospital Universitario Austral, Buenos Aires, ARGENTINA Introduction: long term weight loss and resolution of comorbidities make laparoscopic Roux -en-Y gastric bypass (LRYGB) an excellent alternative for the treatment for morbid obesity. However it is still considered a technically challenging operation and it is usually associated with a long learning curve. Methods: retrospective analysis from prospective collected data base was performed. Patients who underwent LRYGB were included. Demographics, operative time, length of stay (LOS), weight loss, morbidity and mortality were evaluated. Data are expressed as average ± standard deviation. Results: between 4/2003 and 9/2011, a total of 5000 underwent LRYGB at our institution; 64% were female, age 43 ± 11, initial weight 133 ± 28 kg, initial BMI 48 ± 9 kg/m2. For the first 150 patients operative time was 180 ± 21 min. which was gradually decreasing to 102 ± 14. LOS was 48 ± 56 h. Percentage excess weight loss (%EWL) was 49 ± 13, 64 ± 16, 78 ± 19, 79 ± 20, 73 ± 20, 69 ± 22, 65 ± 24, 57 ± 23% at 3, 6, 12, 24, 36 months, 4, 5 y 6 years respectively; 30-day mortality was 0.1% and mortality after that period was 0.26%. Complication rate was 3.5% and 15% for early and late complications respectively. Conclusion: LRYGB offers an effective alternative for the treatment of morbid obesity. LRYGB has demonstrated to be safe given its low morbi-mortality when performed by an experienced group with high volume of surgeries.

40150

LAPAROSCOPIC ILEAL INTERPOSITION (II) WITH DIVERTED SLEEVE GASTRECTOMY (DSG) IS VERY EFFECTIVE FOR METABOLIC DISORDERS Surendra Ugale, MS, Neeraj Gupta, MBBS, Vishwas Naik, MS, Kd Modi, MD, Sunil Kota, DNB, Kirloskar Hospital and Medwin Hospitals, Hyderabad, Andhra Pradesh, India Aim: To evaluate the results of Laparoscopic Ileal Interposition (II) with diverted sleeve gastrectomy (DSG) (II+DSG) for control of type 2 diabetes (T2DM) and related metabolic abnormalities, with weight reduction without causing malabsorption. Methods: Sixteen (M:F = 11:5) patients were selectively subjected to II+DSG, based on their adverse baseline clinical profiles like duration of diabetes [5–10 years, lower BMIs, poorer basal and stimulated C-peptide response, strong family history of T2DM, requirement of maximum dosages C3 OHAs and/or Insulin, presence of end organ impairment. Patients had mean age of 50.9 ± 8.3 years (range 34–64 years), duration of diabetes 15.1 ± 5.8 years (range: 9 to 32 years). All had poorly controlled T2DM (mean HbA1c: 10.1 ± 2.8%) despite medication. 7 (44%) patients had hypertension, 6 (37%) had dyslipidemia and 6 (37%) had microalbuminuria. The primary outcome was remission of diabetes (HbA1C \ 6.5% without OHAs/ Insulin) and secondary outcomes were changes in OHA requirement and components of metabolic syndrome. Results: Table 1 shows results of II+DSG. Mean follow up was 8.5 ± 5.5 months (range: 1-18 months). Results are in Table 1. 11 patients (69%) had remission in diabetes and others showed significant reduction in medication. 6 patients (85.7%) had remission in hypertension. There was a significantly declining trend in both lipids and microalbuminuria.

Table 1 Postoperative follow up data of 16 patients Parameter Months

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PREDICTING REMISSION OF TYPE-2 DIABETES WITH ILEAL INTERPOSITION WITH SLEEVE GASTRECTOMY Surendra Ugale, MS, Neeraj Gupta, MBBS, Vishwas Naik, MS, Kd Modi, MD, Sunil Kota Kirloskar Hospital and Medwin Hospitals, Hyderabad, Andhra Pradesh, India Aim: Combination of Laparoscopic Ileal Interposition with sleeve gastrectomy offers good metabolic improvement and weight reduction without causing significant malabsorption. In a country with more than 62 million diabetics, India can soften the impact of rising healthcare costs in an environment of good economic growth, if resources are focused on selected group of patients, with impending complications of nephropathy, retinopathy or cardiac disease, by using factors predicting successful outcomes after Ileal Interposition Methods: The II&SG was performed in 43 patients (M:F = 26:17) from January 2008. Participants had mean age of 47.53 ± 8.82 years (range 29–64 years), mean duration of diabetes 9.75 ± 8.82 years (range 1 to 32 years) and mean preoperative BMI 32.05 ± 7.5 kg/m2. All patients had poorly controlled type 2 diabetes mellitus (mean HbA1C 9.57 ± 2%) despite use of oral hypoglycemic agents (OHA) and/or Insulin. Thirty (70%) patients had hypertension, 19 (44%) had dyslipidemia and 19 (44%) had significant microalbuminuria. Results: Mean follow up was 11.3 ± 9 months (range: 1–32 months). Postoperatively glycemic parameters (FBS, PLBS, HbA1C) improved in all patients (p \ 0.05) at all intervals. Eighteen patients (45%) had remission in diabetes and the remaining patients showed significant reduction in AHA dosage. significantly decreased OHA requirement. All patients had weight loss between 15–30% (p \ 0.05). Twenty seven patients (90%) had remission in hypertension. At 2 years mean fall in HbA1C (36%) was more than reduction in BMI(20%). There was a declining trend in lipids and microalbuminuria postoperatively. Remission of diabetes and Hypertension and metabolic improvement was clearly more in patients with BMI [27 kg/ m2, duration of diabetes B10 years and stimulated C-peptide [4 ng/ml.

Conclusions: Laparoscopic Ileal Interposition with sleeve gastrectomy, based on the principle of neuroendocrine brake, appears to be safe and a potentially effective option for remission of type 2 diabetes. Hypertension is a major risk factor for cardiovascular disease and micro vascular complications such as retinopathy and nephropathy. Seventy five percent of our patients (30/43) had hypertension. In majority of them i.e. 27/30 (90%) hypertension subsided after surgery Patients with shorter duration of diabetes, higher BMI and higher stimulated C-peptide values would respond better, enabling a focused utilization of scarce resources, to prevent major complications like nephropathy, retinopathy & cardiac events, to avoid the large financial drain on the country’s economy. Postoperative glycemic improvement (HbA1C) in patients classified as per their preoperative bmi, duration of diabetes and stimulated c-peptide levels

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BMI (kg/m2)

FBS (mg%)

PLBS (mg%)

HbA1C (%)

Total cholest(mg%)

Pre-op

28.8 ± 7.5

243.2 ± 92.5

310.8 ± 133.1

10.1 ± 1.9

175. 2 ± 47.3

3 months

23.7 ± 3.5*

100.6 ± 37.8*

156.5 ± 34.6*

7.4 ± 0.5*

151.6 ± 14.7*

6 months

22.1 ± 3.8*

147.4 ± 28.4*

136 ± 32.4*

6.9 ± 0.5*

145.5 ± 40.5*

12 months

21.4 ± 2.4*

99.4 ± 17.8*

138.4 ± 38.9*

6.5 ± 0.6*

134.7 ± 28.2*

18 months

–

114#

134#

6.4#

180#

LDL-Chol (mg%)

HDL-Chol

Parameter Months

TriGly (mg%)

Micralb.(mg/24–h)

Pre-op

107 ± 36.9

40.3 ± 7.9

195.3 ± 87.5

40.2 ± 23.9

3 months

93.5 ± 15.8*

44.3 ± 2.5*

140.3 ± 13.2*

28.3 ± 16.8*

6 months

85 ± 35.8 *

42.5 ± 5.2*

98.2 ± 41.3*

32.9 ± 52.5*

12 months

85.6 ± 15.2*

47.7 ± 5.9*

85.6 ± 15.1*

17.5 ± 7.7*

18 months

94#

46#

130#

10#

Data expressed as Mean ± SD *P \ 0.05, statistically significant # Only single patient has completed 18 months follow up, so no SD could be calculated

Conclusions: Laparoscopic II+DSG seems to be a very promising procedure for control of Type 2 DM. Amongst the Baraitric operations which are now finding their use in remission of diabetes, Ileal interposition stands alone as a procedure devised specifically for remission of Diabetes. This procedure is especially meant for bringing about remissions in patients with low C-Peptides, Strong family history of diabetes, rapidly increasing insulin requirements, Microalbuminuria and Dyslipidemia. This is achieved without significant issues of nutrient malabsorption, post operative dumping, intractable hypoglycemia and pancreatic exhaustion.

Surg Endosc (2012) 26:S249–S430

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COMPLICATION AND OUTCOME OF LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING (LAGB) Karamollah Toolabi, Saeed Arefanian, Tehran University of Medical Sciences Obesity has many co-morbidities. Commercial and pharmacologic assisted diets show little success in severely obese patients. Several surgical procedures (Jejunoileal bypass, vertical and horizontal banded gastroplasty, gastric bypass, biliopancreatic diversion and gastric banding) developed in order to reach more acceptable long-term outcomes. Therefore we perform this study to evaluate outcomes and complications of a low pressure band (MID-BAND) in LAGB technique. Eighty patients were operated by LAGB from May 2003 to June 2007 with BMI of more than 40 kg/m2 or more than 35 kg/m2 with at least one co-morbidity of obesity. Mean BMI was 44.8 ± 7.1 kg/m2. We used Pars Flaccida procedure with five trocars including three 5 mm, one 10 mm and one 12 mm with reverse trendelenburg position. Bands were adjusted 4 to 6 weeks after operation for the first time with Ultravis inflation. Patients follow up was performed monthly up to 3 months, in months 6, 12, and then annually. Seventy seven patients (66 women and 11 men) with a mean preoperative age of 33.6 ± 10.6 years (range, 19–56) have been followed since 2003. The mean %EWL in the first and second year follow up was 62 ± 3.1% (range, 34–95%) and 54.5 ± 2.6% (range, 21–90%), respectively. Early complication rate was 5% (n = 4) consisting of dysphagia and halothane induced hepatotoxicity and late complication rate was 53.2% (n = 41) with band migration/ gastric erosion the most common one (19.4%, n = 15). Twenty six laparoscopic reoperations were performed for purposes such as port position correction, collection drainage, and band extraction. The high rate of gastric erosion (19.4%) and reoperation in this study imply that low pressure bands cause more gastric erosion than reported for high pressure bands. In our practice, we do not consider that LAGB has low rate of major complications. We prefer other methods of bariatric surgery such as LRYGBP and Sleeve gastrectomy for morbid obesity.

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SURGICAL SITE INFECTION IN N.O.T.E.S. SURGERY Jose´ F Noguera, PhD MD, Angel Cuadrado, PhD MD, Juan C Garcı´a, MD, Jose´ M Olea, MD, Rafael Morales, MD, Hospital Son Lla`tzer. IUNICS Introduction: NOTES surgery in a new modality of minimally invasive surgery. Transvaginal approach is the most used one to perform intraabdominal human procedures. We must know if this new approach is better of laparoscopic surgery in some questions, like the surgical site infection. Material and methods: Prospective non-randomized clinical series of 50 patients with elective cholecystectomy for gallstones. 25 patients with transvaginal hybrid NOTES surgery and 25 with a conventional laparoscopic approach. Surgical infection in both groups was evaluated: general infections, surgical site infections and intraabdominal infections. Results: We found an urinary infection in one case with transvaginal approach (the eiggth case: we performed rutinary urethral catheterization in the first ten cases) and one umbilical site infection in laparoscopic group. No intraabdominal infections were found in the study. Conclusions: Transvaginal hybrid NOTES for cholecystectomy is a safe approach in relation to the surgical infections. According to the minor abdominal trauma in transvaginal NOTES we can expect less abdominal complications (infections, ventral hernia). The elective urethral catheterization must be avoided and only used if urinary bladder difficult the transvaginal approach. Transvaginal NOTES approach is as safe as laparoscopy in terms of surgical infection.

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TRANSUMBILICAL HIDDEN SCAR SURGERY USING GELPOINT THROUGH AN UMBILICAL ZIGZAG SKIN INCISION Takehiro Hachisuka, M D, Takashi Kinosita, M D, Nobuhiko Kurata, MD, Masayuki Tsutsuyama, MD, Shinnichi Umeda, MD, Akinaga Yaraita, MD, Seisaku Tokunaga, MD, Masahiro Shibata, MD, Toshio Shikano, MD, Keisuke Hattori, MD, Toshihiro Mori, MD, Masahiko Shinohara, MD, Tomomi Yamakawa, MD, Masayuki Miyauchi, MD, Department of Surgery and Plastic Surgery, Yokkaichi Municipal Hospital Introduction: Hidden scar surgery is a new way in which surgeons perform abdominal operations through one incision made in the patient’s folds of umbilicus. The hidden scar approach is the latest advancement in minimally invasive surgery. However, with a straight incision of the umbilicus, the opening of fascia is maximally 2 cm. The 2-cm fascial opening is not enough to keep the triangulation of instruments, remove specimens and do anastomosis, particularly in gastrectomy and colectomy. To overcome this problem, we developed an umbilical zigzag skin incision with a 6-cm opening of fascia and peritoneum in collaboration with plastic surgeons and used Gelport to keep pneumoperitoneum, which finally resulted in scarless wound1) This technique is a modification of umbilicoplasties for umbilical deformities by plastic surgeons2,3). We have already experienced 24 abdominal operations including 1 total gastrectomy, 1 distal gastrectomy, 3 gastric local resections, 5 right hemicolectomies, 3 high anterior resections, 4 cholecystectomies, and 7 transabdominal preperitoneal hernioplasties (TAPP) . Meanwhile, for hidden scar surgery, GelPOINT (Applied Medical, Rancho Santa Margarita, CA, USA), was developed to maintain triangulation, fulcrum and pneumoperitoneum during the laparoscopic procedure. The product was available in Japan this year and used to many procedures through our umbilical zigzag incision in our institution. We report herein our new method of transumbilical laparoscopic surgery (TULS) using GelPOINT through an umbilical zigzag skin incision. Methods and Procedures) After marking a zigzag skin incision in the umbilical region, the skin was incised along this line. Then, a GelPOINT ’s double-ring wound retractor was inserted through the incision, which enlarged the diameter of the fascial opening to 6 cm. Its GelSeal cap was latched on the wound retractor ring, following inflation of the pneumoperitoneum by CO2. One or more additional ports were inserted as necessary. All operations were performed in the standard fashion. The specimen was easily extracted from the abdomen through the umbilical incision, and anastomosis was performed. Results) Using the above method, we performed the following: 1 right hemicolectomy, 1 high anterior resection, 2 cholecystectomies, and 2 transabdominal preperitoneal hernioplasties (TAPP). All cases were accomplished by this method without any complications. The wounds of the umbilical region were almost ‘‘scarless’’ in all cases. Discussion) We developed an umbilical zigzag skin incision technique to perform abdominal laparoscopic operations using GelPOINT with a minimal number of skin incisions. We consider that our method is one new way to lessen the technical difficulties of ‘‘hidden scar’’ laparoscopic surgery and keep cosmesis for scarless wounds. References 1. Hachisuka T, Kinoshita T, Yamakawa T et al. Transumbilical laparoscopic surgery (TULS) using Gelport through an umbilical zigzag skin incision. Asian Journal of Endoscopic Surgery, in press 2. Kajikawa A, Ueda K, Sakaba T et al. (2010) Umbilicoplasty for type of umbilical deformities. Plast Reconstr Surg 125(6):263e-264e 3. Bruekers SE, van der Lei B, Tan TL, Luijendijk RW, Stevens HP (2009) ‘‘Scarless’’ umbilicoplasty: a new umbilicoplasty technique and a review of the English language literature. Ann Plast Surg 63(1):15-20

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NOTES SIMULATOR : QKO SAJOR Sergio Rojas-ortega, MD, Gerardo Reed, MD, Octavio Gomezescudero, MD, Eduardo Marin, MD, Hospital ANGELES / Puebla Surgery is always changing and the new technologies demands proper training before we can perform surgery in humans. Today it has become indispensable to retrain surgeons who are willing to embrace the new techniques. NOTES is becoming the new era in minimally invasive surgery, but it is a high demanding technique. We decided to create a NOTES simulator: QKO SAJOR so that the common surgeon can learn to use the flexible endoscope in a simple manner before starting to practice in the laboratory with live animals. Material: We designed an acrylic box with two entrances to resemble the natural orifice technique. Inside the box we adapted a tube an a plastic bag to resemble the esophagus and the stomach. With an standard flexible endoscope we challenged 5 different groups. A: Medical students (9), B: Nurses (2), C: Surgical assistants (2), D: Gastroenterologist (3), E: Surgeons (2). The easy challenge consisted in finding a spot inside the bag (plastic stomach) and we recorded the time in each performance. Then the second challenge consisted in finding a star inside the bag between three other different figures (difficult task) and again we measured the time to perform in each individual and compared the time to succcess. Results: At the beginning of the practice we found that only the gastroenterologist knew how to use the flexible endoscope, and only one surgeon had a basic knowledge. The other groups had to practice with the flexible endoscope before trying the QKO SAJOR simulator. In the first practice (easy challenge) we found the following times in seconds: Group A: 60.1, B: 127.5, C: 31.0, D: 109, E: 40.4. In the second challenge the time/seconds was: Group A: 42.7, B: 46.0, C: 35.1, D:13.18, E: 18.0. Comparing the different scores we found that gastroenterologist and surgeons were equal in performing endoscopy at the simulator, but better comparing with the other groups (p 0.09) Conclusion: We found that performance of flexible endoscopy can be learned in this simple simulator. The difference found in time/sec to perform the easy task is similar between medical students, nurses, surgeons and gastroenterologist. Only the difficult tasks is performed better by gastroenterologist and surgeons (p 0.09).. We conclude that the surgeon have to train in this type of simulator to acquire skills that are indispensable before trying any NOTES procedure in live animals.

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PORCINE ESOPHAGEAL-GASTRIC EXPLANTS: A FEASIBLE TRAINING MODEL FOR PERORAL ENDOSCOPIC MYOTOMY (POEM) Whalen Clark, MD, Vic Velanovich, MD, University of South Florida Department of Surgery Introduction: Peroral endoscopic myotomy (POEM) has been applied and is emerging as a less invasive outpatient procedure for the definitive treatment of achalasia. Very few surgeons have gained competency with POEM, and there are almost no available training opportunities. Our objective was to evaluate the feasibility of a porcine esophagogastic explant for training surgeons to complete the technique of POEM. Methods: En bloc esophageal-gastric porcine explants measuring approximately 20 cm long by 2 cm wide were acquired and secured in place using prolene sutures (Image 1). The porcine esophagus required an initial predilation step before the endoscope would pass freely into the stomach. Using a 10 mm GIF-160 gastroscope equipped with an injection needle (Olympus), saline was injected into the submucosal layer of the distal-anterior esophagus. The needle knife was then used to create an approximately 2 cm longitudinal mucosotomy. Next, a combination of blunt dissection facilitated by a cap on the scope and the blunt tip of the triangle tip bovie (Olympus) was used to develop a plane between the mucosa and underlying muscle layers. Remaining adherent bands were cauterized using the triangle tip bovie. A key maneuver at this point was to twist the scope to access the submucosal plane where dissection could be continued distally onto the stomach. The triangle tip bovie was then used to create a myotomy in the circular muscle fibers of the esophagus which could clearly be visualized. Extending the myotomy required longitudinal pushing of the bovie to effectively and completely divide the fibers(Image 2).

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ECTOPIC PANCREAS IN THE STOMACH PRESENTING AS AN INFLAMMATORY ABDOMINAL MASS Takayuki Tokutsu, MD, Toshiyuki Mori, MD, Noritsugu Abe, MD, Tomokazu Kishiki, MD, Hirohisa Takeuchi, MD, Hiroyoshi Matsuoka, MD, Masanori Sugiyama, MD, Yutaka Atomi, MD, Kyorin University, School of Medicine

Image 1

A 32-year-old woman with ectopic pancreas in the stomach, presenting as inflammatory mass, is presented. A computed tomographic (CT) scan demonstrated a mass adjacent to the gastric antrum, which was diagnosed inflammatory mass lying near the gastric antrum. Gastric endoscopy demonstrated a submucosal mass (2 cm in size) with a central pit. Blood chemistry was suggestive for inflammation and ectopic pancreas with abscess formation was suspected. Antibiotics was administrated and the size of mass decreased and symptom was improved. The similar symptom due to ectopic pancreas relapsed later a couple of times. Then surgery was indicated and hyblid NOTES(Natural Orifice Translumenal Endoscopic Surger)was selected for removal to reduce invasiveness. Resected specimen measured 33 9 25 mm. Histological examination revealed an ectopic pancreas with abscess formation.

From a review of the English and Japanese literatures, we believe that our case is the second report of an ectopic pancreas, presenting as an inflammatory abdominal mass.

Image 2 Results: To competently complete POEM using this model, approximately 5 specimens were required. After the myotomy is made, inspection of the outer muscle layers can easily be made and similarly the gastric mucosa can be inspected using retroflexion with the gastroscope. Circular myotomies starting above the gastroesophageal junction and extending 2 cm onto the stomach were successfully achieved. Conclusions: A porcine explant model is a feasible, affordable model for training surgeons how to undertake POEM. This model provides to opportunity to practice key maneuvers before risking perforation and esophageal damage in a live animal model and should be applied as initial training. POEM and other endoscopic procedures will be increasingly embraced and this model might be useful for other endoscopic applications.

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SINGLE-INCISION MULTIPORT LAPAROENDOSCOPIC CHOLECYSTECTOMY USING A NEWLY DEVELOPED SHORT-TYPE FLEXIBLE ENDOSCOPE: A COMBINED PROCEDURE OF FLEXIBLE ENDOSCOPIC AND LAPAROSCOPIC SURGERY Nobutsugu Abe, MD PhD, Hirohisa Takeuchi, MD, Atsuko Ooki, MD PhD, Toshiyuki Mori, MD PhD, Masanori Sugiyama, MD PhD, Kyorin University School of Medicine, Department of Surgery Objective: We hypothesized that using a flexible endoscope as a working scope might provide many merits with single-port surgery (SPS). To this end, a short-type flexible endoscope with a working length of 60 cm was developed. The aim of this study was to evaluate the technical feasibility of our new approach, single-incision multiport laparoendoscopic (SIMPLE) cholecystectomy, using this endoscope. Methods: Eight pigs were subjected to SIMPLE cholecystectomy. The endoscope was inserted through a 12-mm trocar in a SILSTM Port followed by the insertion of two additional 5-mm trocars in the SILSTM Port. Encirculation and ligation of the pedicle of the cystic artery and duct were carried out using laparoscopic instruments through the 5-mm trocars, while the dissection of the gallbladder from the infrahepatic fossa was predominantly performed using a cutting device (Mucosectome, a device for endoscopic submucosal dissection) through the endoscope. Results: The mean operating time was 58 min (range, 34 to 78 min). A complete gallbladder excision, with complete encirculation and ligation of the pedicle, was achieved in all pigs. The endoscope provided an excellent view of the operating field. Dissection of the gallbladder using the cutting device through the endoscope was easier than that using the laparoscopic device, because the articulating instruments together with the endoscope enabled operation with triangulation. The water-jet and suctioning functions and the self-cleaning lens capability of the endoscope served well for the SPS.

Conclusions: SIMPLE cholecystectomy using the short-type flexible endoscope is a technically feasible procedure. Letting this flexible endoscope do various works, such as resection, suctioning, and smoke evacuation, can make the surgical procedures easier.

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RIGID AND FLEXIBLE ENDOSCOPIC RENDEZVOUS IN SPATIUM PERITONEALIS MAY BE AN EFFECTIVE TACTIC FOR LAPAROSCOPIC MEGASPLENECTOMY: SIGNIFICANT IMPLICATIONS FOR PURE NOTES Morimasa Tomikawa, MD PhD FACS, Tomohiko Akahoshi, MD PhD, Yoshihiro Nagao, MD PhD, Makoto Hashizume, MD PhD FACS, Department of Advanced Medicine and Innovative Technology, Kyushu University Hospital Introduction: We recently experienced 10 cirrhotic patients who had undergone laparoscopic splenectomy, in part of which dissection with flexible endoscope in peritoneal cavity had been performed. This pilot study mainly focuses on the technical aspects and the immediate results. Methods and Procedures: From November 2009 to September 2010, 10 cirrhotic patients with hypersplenism were entered in this pilot study. They were indicated to undergo laparoscopic splenectomy to treat portal hypertension and to facilitate initiation and completion of either interferon therapy for liver cirrhosis or anti-cancer therapy for hepatocellular carcinoma. To dissect the marginal region between the left diaphragma and the upper pole of the spleen and to dissect the upper end of the gastrosplenic ligament, a flexible single-channel endoscope was introduced into the peritoneal cavity simultaneously with the use of a rigid laparoscope. The dissection with flexible endoscope in the peritoneal cavity was performed using an insulation-tipped electrosurgical knife through the channel of the flexible endoscope. Results: The flexible endoscope offered a magnified operative view, a water-jet lens cleaner and a powerful lavage/suction capability. The marginal region between the left diaphragma and the upper pole of the spleen, and the upper end of the gastrosplenic ligament could be easily seen and the dissection of those critical regions could be smoothly conducted with the tip articulation of the flexible endoscope even in the patients with megaspleen. No patient experienced major intraoperative complications and required a conversion to open surgery. Considering feasibility of pure natural orifice translumenal endoscopic surgery (NOTES) from this pilot study, the loss of orientation, the narrow view angle of a flexible endoscope, unpreparedness for unexpected hemorrhage, and the impossibility to acquire a good operative view would be the problems that should be overcome in the future. Conclusion: Dissection with flexible endoscope in peritoneal cavity may be an effective tactic for laparoscopic megasplenectomy and significant implications for pure NOTES have been raised. While future randomized controlled prospective studies are needed to confirm these findings, surgeons might find a typical example of the high-risk patient strategy.

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ENDOSCOPIC FULL-THICKNESS OR PARTIALTHICKNESS MYOTOMY USING SUBMUCOSAL ENDOSCOPY WITH MUCOSAL SAFETY FLAP (SEMF) TECHNIQUE: A COMPARATIVE STUDY IN SWINE Eduardo Aimore Bonin, MD, Erica Moran, MD, Juliane Bingener, MD, Mary Knipschield, Kohei Takizawa, MD, Christopher Gostout, MD, Mayo Clinic Background: Esophageal myotomy using submucosal endoscopy with mucosal safety flap (SEMF) has been proposed as a new treatment of achalasia. In this technique, a partial-thickness myotomy (PTM) preserving the longitudinal outer esophageal muscular layer is advocated, which is different from the usual full-thickness myotomy (FTM) performed surgically. The aim of this study was to compare endoscopic FTM and PTM analyzing the outcomes of each method after a 4-week survival period. Materials and methods: Twenty-four pigs were randomly assigned into Group A (FTM, 12 animals) and Group B (PTM) to undergo endoscopic myotomy. Lower esophageal sphincter (LES) pressure was assessed using pull-through manometry. For statistical analysis we compared the average esophageal sphincter pressure values at baseline, after 2 weeks and after 4 weeks between groups A and B. The p value was set as \0.05 for significance. Results: Eighteen animals were included for statistical analysis. Mean (SD) LES pressures were similar between groups A and B (9 animals each) at baseline (group A = 23 (10.4) mmHg; group B = 20.7 (8.7) mmHg; p = 0.79), after 2 weeks (group A = 19 (7.7) mmHg; group B = 21.8 (8.4) mmHg; p = 0.79) and after 4 weeks (group A = 22.6 (10.2) mmHg; group B = 20.7 (9) mmHg; p = 0.82). LES pressures were significantly reduced in three animals after 4 weeks: one animal (1%) in group A and 2 animals (2.5%) in group B. An extended myotomy (3 cm below the cardia) was achieved in 3 animals, and responsible for the significant drop in LES pressure seen in the two animals from group B. Conclusion: Esophageal myotomy using SEMF is a feasible yet challenging procedure in pigs. Full-thickness myotomy does not seem to be superior to partial-thickness myotomy as demonstrated by pull-through manometry. Endoscopic esophageal myotomy results are greatly influenced by obtaining adequate myotomy extension into the gastric cardia.

Keywords: Achalasia, Endoscopy, Minimal Access Surgical Procedures, Operative Therapy, Swine.

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EVALUATION OF BACTERIAL CONTAMINATION AFTER TOTALLY TRANSVAGINAL NOTES ACCESS FOR PERITONEOSCOPY AND LIVER BIOPSY IN SWINE: A COMPARATIVE STUDY WITH LAPAROSCOPY Eduardo Aimore Bonin, MSc, Christiano Marlo Paggi Claus, MSc, Maria F Torres, Veterinarian, Antonio C Campos, PhD, Marcelo De Paula Loureiro, PhD, Antonio Moris Cury Filho, MSc, Gustavo Lopes Carvalho, PhD, Instituto Jacques Perissat (IJP) - Universidade Positivo, Curitiba, Brazil Introduction: For not having skin incisions, totally (or pure) NOTES (natural orifice translumenal endoscopic surgery) has aesthetic advantages and probably less risk of wound complications when compared to conventional laparoscopy. However, bacterial contamination from viscerotomy are potential barriers to NOTES. The aim of this study is to evaluate totally transvaginal NOTES compared to laparoscopic surgery for bacterial contamination, in addition to postoperative outcome. Method: Twelve adult female pigs underwent liver and peritoneal biopsies, either using laparoscopy access (Glap – 6 animals), or totally transvaginal access (GNotes), and survived for 7 days. In all animals, blood cultures were taken at baseline, after 24 h and 7 days postoperatively. Swab cultures from vagina (Gnotes) and skin (Glap) were obtained before and after antisepsis. Peritoneal fluid culture was obtained at necropsy. For statistical analysis, Fisher‘s test was applied with the level of significance set at p \ 0,05. Results: All animals had good postoperative outcome. Only one animal had a transient peroperative bleeding, from a transvaginal access. All animals from GNotes and Glap presented with mixed flora pre-antisepsis. After antisepsis, only one animal at GNotes presented with a positive vaginal swab culture (a single bacterial strain was identified). There were no positive skin swab culture at Glap. There were no intra-abdominal abnormalities at necropsy. In two animals, one from GLap and another from GNotes, intra-abdominal culture was positive for Corynebacterium spp and Escherichia coli, respectively. There was no correlation between the bacterial flora found at the access site and at the peritoneal cultures. Two animals in GLap and one in GNotes had positive blood cultures after the procedure, and were considered contaminations of the samples. Conclusion: Transvaginal peritoneoscopy is feasible and not associated with increased bacterial contamination compared to laparoscopy in swine. Preoperative antisepsis provided significant reduction on bacterial flora prior to transvaginal and laparoscopic peritoneoscopy.

Key words: Natural orifice translumenal endoscopic surgery, infection, laparoscopy, complications, swine.

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TRANSVAGINAL CHOLECYSTECTOMY: A HYBRID APPROACH USING OUR EXPERIENCE WITH NOTES AND SILS K A Zuberi, MD, J W Hazey, MD, D B Renton, MD, J T Rohl, MD, V K Narula, MD, The Ohio State University Medical Center: Center for Minimally Invasive Surgery, Columbus, OH, USA Introduction: The idea of using a natural orifice as a means for accessing the abdomen has resulted in novel solutions to common general surgical issues. Hybrid NOTES procedures have proven to be safe and feasible. With a combined flexible endoscopic-mini-laparoscopic approach, a safe and effective method of operative intervention can provide patients with an operation that is less painful and associated with a quicker return to function. Methods and Procedures: Approval for this trial was granted by The Ohio State University IRB and data was collected prospectively from a total of 3 patients since 2009. Informed consent was obtained. Preoperative workup included liver function tests and a right upper quadrant ultrasound. Colpotomy was initially made in lithotomy, by a board certified gynecologist. A SILS Triport (Olympus Corp.) was then placed within the colpotomy for instrument access. The cholecystectomy was performed by a board certified general surgeon. A standard 5 mm laparoscope was utilized to provide a pneumoperitoneum and visualization of instruments into the peritoneal cavity via the colpotomy. Dissection and removal of the gallbladder was completed with standard laparoscopic instrumentation and a 9 mm esophagogastroduodenoscope. Postoperatively, all patients were admitted overnight for observation. Data was collected preoperatively, and on postoperative days 1, 14, at 4–6 weeks, and at 3 months. Results: The indication in all patients for the procedure was symptomatic cholelithiasis. The mean time to introduction of a transvaginal flexible endoscope after the official recorded start time was 30.33 min. The mean time to transvaginal gallbladder removal was 52.67 min after the start of the dissection. The average time for the entire procedure was 91 min. Dyspareunia has not been reported as a complication after 3 month follow up in 2 of the 3 patients. Pathology results were consistent amongst all patients, revealing chronic cholecystitis and cholelithiasis. Conclusion(s): Our data set shows that the use of a flexible endoscope does not substantially increase operative times in cholecystectomy compared to the national average. Furthermore, this hybrid approach is a feasible technique for peritoneal access, with the endoscope being used with instrumentation and as the only source of visualization after initial laparoscopic access.

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PRELIMINARY Results OF NEW MINIMALLY INVASIVE TECHNIQUE IN PERIPHERAL VASCULAR DISEASES: INTRAMUSCULAR INJECTION OF EXTRACTS OF LAPAROSCOPICALLY HARVESTED OMENTUM IN LIMBS OF PATIENTS WITH BUERGER’S DISEASE Ali Aminian, MD, Rasoul Mirsharifi, MD, Tehran University of Medical Sciences Introduction: Salvage of limbs affected by Buerger’s disease has been a dilemma for surgeons. Reconstructive procedures are usually not possible and sympathectomy relieves vasospasm only in the early stages. Limb amputation often is the only available management option. Previous reports demonstrated acceptable results with pedicled omental transfer (omentopexy). The purposed mechanism is that omentum has angiogenic activity that may stimulate neovascularization in ischemic tissues. We used the intramuscular injection of omental extract to salvage these limbs. Methods and Procedures: This procedure was performed in five patients with sympathectomy failure in end-stage Buerger’s disease. The surgeon positioned between the patient’s legs. Laparoscopic omentectomy was performed through three ports with help of LigaSure. The omentum was cut into small pieces, which were placed in a blender containing 100 ml normal saline. The homogenate was filtered to separate solid particles from liquid. The liquid extract was injected in to the muscles of affected limb. Preliminary Results: Five male patients with mean age of 36 ± 1 years were studied. The mean operating time was 120 min. About 200 ml of extract was injected in affected limb. Patients were followed for a mean of 1.5 (1-2.5) years. Postoperatively there was relief of pain and coldness in all, with increase in claudication distance. No major amputation needed in these hopeless legs. One Syme and one transmetatarsal amputation were performed for gangrene (Fig. 1).

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SINGLE INCISION LAPAROSCOPIC SURGERY (SILS) AND NOTES IN BARIATRICS Elie K Chouillard, MD PhD, Nelson Trelles, MD, Andrew Gumbs, MD FACS, On behalf of the Intercontinental Society of Natural Orifice, Endoscopic, and Laparoscopic Surgery (INOELS) Centre Hospitalier Intercommunal, Poissy, France Background: Natural Orifice Translumenal Endoscopic Surgery (NOTES) is an evolving concept. Many variants have been described including « pure » NOTES, « Hybrid » NOTES, single incision laparoscopic surgery (SILS), or even NOTES-inspired endoscopic surgery. The potential advantages of such techniques may include less postoperative pain, less abdominal wall complications, faster return to activity, and better cosmesis. Methods: All patients were prospectively included after a written informed consent. The Ethical Board of the Hospital approved the study. All types of bariatric procedures could be theoretically included. Patients: From April 2008 to March 2011, SILS or NOTES was attempted in 89 selected bariatric patients. Exclusion criteria comprised mainly prior open abdominal surgery, more than 55 Kg/m2 BMI, ASA III status, organ insufficiency, hemostasis disorders. The success rate without conversion to laparoscopy or laparotomy was 86.5% (77 patients). Procedures included Sleeve gastrectomy, adjustable band gastroplasty, adjustable band retrieval, gastric bypass, Stomaphy 9 endoplication, Gastric plication, and miscellaneous. Results: Mortality rate was nil. The overall complications (mainly minor) rate was 8.9%. Two patients (2.2%) were reoperated for bleeding. The median length of stay was 2.9 days (as compared to 4.1 days in a matched series of patients operated by standard laparoscopic techniques) (p \ 0.05). Conclusions: SILS and NOTES procedures are safe and feasible in selected patients with morbid obesity. Advantages regarding postoperative pain and length of hospital stay could be demonstrated. However, larger scale, prospective, controlled, randomized studies are needed for further evidence-based analysis.

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Fig. 1 Conclusion: This minimally invasive approach of laparoscopically harvested omentum and intramuscular injection of its extract may be an effective new surgical management toward patients with unreconstructable peripheral vascular diseases including Buerger’s disease. However, the true role of it awaits larger studies with long-term results.

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LAPAROSCOPIC RETRIEVAL OF NON EXCRETED CAPSULE ENDOSCOPY Thuan Ho, MD, Praneetha Narahari, MD, Community regional Medical Center/UCSF Fresno MEP, Fresno, CA Capsule Endoscopy is used as an adjunct to study small bowel pathology. Non excretion of the capsule has been reported in Crohn’s disease and strictures. Enteroscopy or surgical intervention is needed when the capsule is retained. I report a case where adhesions prevented excretion of the capsule. It was retrieved with Laparoscopy. A 65 year old with prior hysterectomy underwent capsule endoscopy for iron deficiency anemia. The capsule did not progress after 3 h of study. Enteroscopy was attempted at 6 weeks but scope could not be advanced as the bowel was dilated. CT scan confirmed the device in the small bowel. Laparoscopy was performed with 3 ports (12 mm and 5 mm 9 2). An adhesion from the anterior abdominal wall to the small bowel mesentery was noted. The bowel that was trapped under the adhesion was released with sharp adhesionolysis. The device was identified in the proximal vicinity and an enterotomy was made. A Lap sac was introduced and the device was retrieved. The enterotomy was closed in 2 layers with laparoscopic suturing. Patient was discharged on POD 3 and is currently doing well on iron supplements. Technological advances lead to implementation and widespread use of new devices. Complications are often not apparent immediately. Awareness and the ability to deal with complications with minimal side effects will ensure their continued use. Laparotomy is viewed as a morbid procedure to retrieve a capsule. Laparoscopy on the other hand offers a minimally invasive approach with smaller incisions, less pain, quicker recovery in the short term, and less risk of adhesions and hernia in the long term. Small bowel is a difficult area to study due to access. Capsule endoscopy had recently emerged as a novel technique to study small bowel pathology. Laparoscopy can be viewed as an emerging technology, as its indications are ever expanding and it is used in various novel procedures. This case exemplifies the use of laparoscopy as an emerging procedure for retrieval of a device that is retained as a complication of capsule endoscopy that had recently gained widespread acceptance.

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LAPAROSCOPIC SLEEVE GASTRECTOMY FOR GASTRIC LIEOMYOSACROMA IN MORBIDLY OBESE PATIENT: A CASE FOR COLLABORATION Osama Hamed, MBBS, Ajay Jain, MD, Mark Kligman, MD, Department of General Surgery, University of Maryland School of Medicine, Baltimore MD Objective: Minimally Invasive Surgery (MIS) for Gastrointestinal (GI) malignancies had gained large attention recently, the plethora of information available on the internet resulted in patients expectation to have their elective cancer surgery done laparoscopically. MIS for GI malignancy require advanced laparoscopic skills mastered by Minimally Invasive Surgeons, at the same time adherent to the principles of surgical oncology and multidisciplinary approach mastered by Surgical Oncologists. Methods: 49 year old male, presented with epigastric pain of several months duration. Upper GI endoscopy showed an ulcerated mass in the Gastric Fundus within 3 4 cm of the Gastroesophageal Junction. Biopsy demonstrated Gastric Leiomyosarcoma. The patient was morbidly obese with BMI of 44.2 kg/m2. Multidisciplinary oncology team decision made for resection with negative margin as the best treatment option. Patient seen by surgical oncology and requested surgery to be done laparoscopically. Due to patient body habitus, complex nature of the procedure and the possible need for complex laparoscopic GI reconstruction, patient was referred to MIS/Bariatric surgery team for evaluation, preoperative planning and collaboration. During this evaluation the patient expressed a desire for weight loss; sleeve gastrectomy was determined to be the best option to achieve the patient’s goal of weight loss while still maintaining the oncologic principles. Results: Laparoscopic exploration in the presence of both the MIS and the surgical oncologist, confirmed that sleeve gastrectomy was an adequate procedure to provide the desired negative margin. The procedure was completed without complication. Patient was discharged home on post operative day 1. Pathology showed high grade gastric Leiomyosarcoma, 3.8 cm margin from the staple line. The patient had a 44% excess weight loss (67 Ibs) 5 months post operatively. Multidisciplinary oncology decision made for close follow up with no need for adjuvant therapy. Patient was greatly satisfied with the surgical approach and the outcomes. Conclusion: Minimally invasive management of GI malignancies represents a challenge for both surgical oncologist and MIS as individual surgeon. Collaboration among the two specialties needed to provide the optimal care for patients.

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LAPAROSCOPIC TECHNIQUE FOR THE TREATMENT OF HEMATOCOLPOS DUE TO AN OBSTRUCTED UTERINE HORN Alexey Markelov, MD, Holy Hedrick, MD FAAP FACS, Easton Hospital, Drexel University School of Medicine and Children’s Hospital of Philadelphia A uterine malformation is a type of female genital malformation resulting from an abnormal development of the Mullerian ducts during embryogenesis. The prevalence of uterine malformation is estimated to be 0.4% in the general population. Young females, with Mullerian duct obstruction may present with abdominal pain, palpable mass and dysmenorrhea. If the patient is not treated in a timely fashion, the consequences can be severe, extending even to infertility. We present a case of 14-yearold female who initially presented with an abdominal pain and was found to have fluid filled uterine horn on the abdominal ultrasound. MRI showed an obstructed functional right uterine horn containing blood degradation products with no communication with the cavity of the normal left uterine horn. Surgical treatment with laparoscopic removal of the obstructed uterine horn was performed without any complications. In this case report, we discuss diagnosis and classification of Mullerian duct anomalies and describe laparoscopic technique for the treatment of hematocolpos due to an obstructed uterine horn.

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THE QUALITY OF ENDOSCOPIC SURGICAL SKILL QUALIFICATION IN JAPAN IN THE SECTION OF LAPAROSCOPIC CHOLECYSTECTOMY Sumio Matsumoto, PhD, Hiromi Tokumura, Dr, Yuichi Yamashita, Professor, Taizo Kimura, DMsc, Toshiyuki Mori, Professor, Fumio Konishi, Professor, Seigo Kitano, Professor, Masaki Kitajima, Professor ESSQS, Committee of the Japan Society for Endoscopic Surgery Purpose: The Japan Society for Endoscopic Surgery (JSES) started Endoscopic Surgical Skill Qualification (ESSQS) in 2004, and carried out seven examinations up to 2010. We reported these results and consideration as to consensus meeting needed. Methods: Assessment was performed by reviewing documents, laparoscopic surgery experiences, and qualifying unedited video tape by two independent referees. We adopted two criteria to evaluate surgical skills, as common and procedure-specific criteria to each gastrointestinal organ. Common criteria were given 60 points regarding basic endoscopic practice, and procedure-specific criteria were given 40 points to evaluate specialized skills of the practice. A score of 70 points is designated as the passing mark. Laparoscopic cholecystectomy was evaluated by ten practice steps and degree of difficulty in completion. The proper skill evaluation was by the following items, elevating gall bladder (GB), retracting duodenum and transverse colon, exposing layer around cystic duct, identifying cystic artery and right hepatic artery, identifying common bile duct, transecting cystic duct, layer of dissecting from liver bed, bleeding control at liver bed and retrieval of GB. Each step was given three points respectively, and further points were added by referee, from neither for easy case to 10 points for difficult case according to the difficulty to complete. As for critical view of safety, it was regarded as the most important among procedures. Results: In 2004, 110 surgeons were qualified among 175 candidates (63%). In 2005, 62 surgeons were qualified among 139 candidates (45%). In 2006, 36 surgeons were qualified among 101 candidates (36%). In 2007, 32 surgeons were qualified among 82 candidates (39%). In 2008, 37 surgeons were qualified among 86 candidates (43%). In 2009, 23 surgeons were qualified among 58 candidates (40%). In 2010, 38 surgeons were qualified among 82 candidates (46%). To assess interrater agreement between referees, Cohen’s weighted kappa value was calculated. It was 0.18 in 2004, 0.32 in 2005, 0.29 in 2006, 0.20 in 2007, 0.25 in 2008, 0.23 in 2009, and up to 0.31 in 2010.

Discussion: The result of 2007 was unexpected in spite of adding the figure showing critical view of safety which consisted of complete exposure around Calot’s triangle in judge sheet. We should explore the reason of disagreement between the two judges crossing 70 points. These mismatches might be induced by different favorite understanding, what is good laparoscopic view, or what are safe skills to dissect layer to expose the biliary tract and cystic artery. Conclusion: These could be influenced by the education in different district or institute which should be overcome by frequent consensus meetings to obtain standard agreement. We should also discuss regarding new procedure, single incision laparoscopic cholecystectomy or reduced port access.

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REDUCED PORT CHOLECYSTECTOMY vs LAPAROSCOPIC CHOLECYSTECTOMY: A COMPARISON STUDY Andreas Kiriakopoulos, MD, Dimitrios Tsakayannis, MD, Dimitrios Linos, MD, Department of Surgery, Hygeia Hospital, Athens, Greece Background: Reduced port cholecystectomy either as needlescopic or hybrid-SILS cholecystectomy challenges the classic laparoscopic approach since it holds the promise of a smaller footprint and perhaps improved patient outcome. We present our comparative results, retrospectively, between these different operative techniques. Patients and Methods: From January 2009 to August 2011, a total of 180 (one hundred and eighty) patients with cholecystitis underwent either needlescopic cholecystectomy (NC), hybrid-SILS cholecystectomy (HSC) or laparoscopic cholecystectomy (LC). NC includes use of a 5 mm camera at the umbilicus, a 5 mm port at the subxiphoid position and two 2 mm instruments at the right upper quadrant. Hybrid SILS technique involves use of these two mini-instruments at the right upper quadrant along with use of a SILSTM port. This arrangement provides excellent exposure and avoidance of instrument clashing, overcoming the technical pitfalls of pure SILS. We excluded all cases with gangrenous cholecystitis and all patients with extreme obesity (BMI [ 40) or ASA score [3. Operative time, hospital stay, postoperative pain (VAS score on days 1 and 3) and complication rates are presented. Statistical analysis was performed. Results: NC was applied in 52 patients (15 males and 37 females, mean age 44.8 yrs (23–66), HSC in 42 patients (13 males and 29 females, mean age: 47.3 (22–70), whereas LC was performed in 86 patients (37 males and 49 females, mean age 53.2 (27–84). Median operative time was 70 min (45–100) for the NC patients, 85 min (60–110) for the HSC and 70 min (35–105) for the LC patients (p [ 0.05). There was no difference in the median hospital stay among all groups, which was 2 days. Median postoperative pain on day 1 was 1.5 (1–2) for the NC group, 2 (1–3) for the HSC group and 2 (1–3) for the LC group (p [ 0.05). On postoperative day 3, median pain score was 0 in all groups. Other than two cases of seromas at the umbilicus for the HSC cases, there were no other noteworthy complications. Conclusion: In this series of patients that underwent cholecystectomy we have seen no significant differences among the three different operative techniques applied. Therefore, reduced port cholecystectomy either as needlescopic or in combination with SILS is equivalent to the existing laparoscopic approach.

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THORACOSCOPIC ESOPHAGECTOMY FOR ESOPHAGEAL CANCER IN SEMI-PRONE POSITION Naoshi Kubo, Katsunobu Sakurai, Hiroaki Tanaka, Kazuya Muguruma, Hitoshi Nagahara, Eiji Noda, Kiyoshi Maeda, Masakazu Yashiro, Nobuya Yamada, Masaichi Ohira, Kosei Hirakawa, Department of Surgical Oncology, Graduate school of medicine, Osaka-City University Background: The thoracoscopic esopagectomy for esophageal cancer has been reported as minimally invasive with regard to less thoracic wall injury and decreased respiratory function. We had inducted thoracoscopic esophagectomy with minithoracotomy at left lateral position (TEL) in September 1999 and TEL were consecutively performed in about 100 cases. Additionally, thoracoscopic esophagectomy in semi prone position (TEP) was conducted in April 2010. This procedures included upper mediastinum lymph-adenectomy in left decubitus position and lower mediastinum lymph-adenectmy in prone position. Patients was placed on the surgical table in left lateral-prone position. Surgical table can be tilted to prone or lateral position immediately . The CO2 insufflation at a pressure of 7 mmHg was established during operation and good surgical exposure was obtained because of gravity and lung collapse. We retrospectively compared surgical outcomes in 15 TEP cases to those of 28 TEL cases as a historical control. Result: There were no differences between the two groups in patients background (age, gender, tumor stage, tumor location). The mean blood loss during thoracoscopic portion were significantly lesser in TEP than TEL (123 versus 285 min, p = 0.02). The incidence of pulmonary complication was significantly lesser in TEP than in TEL. The levels of C reactive protein on postoperative day 1 and 2 were significantly lower in TEP patients than TEL patients. conclusion: TEP was less invasive procedure compared to TEL.

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EFFICIENCY OF ABSCESS PATHWAY Aliasger Amin, Anil Reddy, Madan Jha, Ahmed Hammad, James Cook University Hospital Objective: Conventionally, patients with abscess admitted under surgery were operated according to the availability of emergency operation theatres. Other emergency procedures took priority, delaying the incision and drainage of abscess. This resulted in long waiting time and unnecessary overnight stay and costing National Health Service approximately 250 pounds a day. The aim of the study was to develop a pathway for increasing efficacy and evaluating it. Methods and Procedures: An abscess pathway was developed wherein a special slot was created in operating theatres for incision and drainage (I&D) of abscess at a set time. Patients presenting with an abscess, without significant medical comorbidities, were assessed, consented and then allowed to go home. They were given appropriate preoperative instructions and then admitted to the surgical day unit at the specified time for I&D. The length of stay of 30 patients, who had I&D, before the abscess pathway was introduced (data collected retrospectively), was compared with that of 30 patients, after the abscess pathway was introduced (data collected prospectively). Results: The average length of stay of 30 patients before the introduction of abscess pathway was 33 h and 19 of those patients had I&D done on the next day of admission. Average length of stay of 30 patients after the introduction of abscess pathway was 16 h and all of them had the procedure done on the day of admission. Conclusion: Abscess pathway decreased the hospital stay of medically fit patients after I&D, by half, improving efficiency and cutting costs. These patients were admitted in surgical day unit leading to release of acute surgical inpatient beds for managing other emergencies. The specific slot in theatres for I&D provided a training opportunity for junior doctors.

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LAPAROENDOSCOPIC SINGLE SITE CHOLECYSTECTOMY USING A NOVEL OVAL-SHAPED PORT DEVICE Kazunori Shibao, MD PhD, Aiichiro Higure, MD PhD, Noritaka Minagawa, MD PhD, Koji Yamaguchi, MD PhD, Dept of Surgery I, University of Occupational and Environmental Health Objective: To evaluate the usefulness of oval-shaped port devices compared to round-shaped port devices in laparoendoscopic single site (LESS) surgery, and to report an initial clinical case series of LESS cholecystectomy using this oval-shaped port device. Methods: The LAPPROTECTOR series (Hakko, Japan) is a wound retractor/protector made from a silicon rubber membrane with a flexible shape-memory frame. The EZ ACCESS Round type (Hakko, Japan) is a silicon rubber cap that is designed for the LAPPROTECTOR Round type device to create a tight seal, and was introduced for LESS surgery. As the EZ ACCESS Round type device has no fixed channel, surgeons can select the best trocar placement to maintain maximum trocar separation for each surgery. We recently developed an oval-shaped EZ ACCESS device, which we named the EZ ACCESS Oval type, which is designed exclusively for the LAPPROTECTOR Oval type device, and compared the trocar separation to procedures using the conventional round-shaped EZ ACCESS/LAPPROTECTOR in five patients with cholecystolithiasis. Both devices were placed through a single 25 mm umbilical incision. The scope trocar was introduced at the caudal side of the device center. Two other trocars for working instruments were inserted through both sides of the device. The lengths between the working-ports were measured and compared. After measuring the trocar separation for both devices, the LESS cholecystectomy with the oval-shaped device was performed. Another 3 mm grasper was directly inserted into the peritoneal cavity through the device for cephalad retraction of the gallbladder. Only standard straight instruments were used throughout the procedures. Results: The average distance between the right and left trocars for the oval- and round –shaped devices with a 2.5 cm umbilical incision were 34 ± 0.67 mm and 27 ± 1 mm, respectively. The wider trocar separation achieved using the oval-shaped device made the surgical procedures easier. Frequent instrument changes during the surgery did not affect the seal. Conversion from 5 mm to 12 mm trocars, and replacement of trocars were performed easily without air leakage. The direct insertion of a 3 mm grasper through the device for cephalad retraction of the gallbladder allowed a good surgical view to be maintained without air leakage or touching of instruments. The novel port cap allowed for safe and quick retrieval of the gallbladder with the cap off the device. Re-pneumoperitoneum was easily achieved by recapping the device. All procedures were completed uneventfully. The total length of the operation was 70 ± 12.3 min, and intraoperative blood loss was less than 5 grams in all five patients. There were no perioperative port-related or surgical complications. Conclusions: LESS cholecystectomy using the EZ ACCESS Oval type device was found to be technically feasible. The oval type device appears to provide wider trocar separation, thereby reducing the surgeon’s stress, and ensuring patient safety with cosmetic benefits. Further investigations will need to be performed to confirm the efficacy and safety of using such oval-shaped LESS port devices.

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KEY POINTS AND SURGICAL OUTCOME OF CHOLECYSTECTOMY USING SILS WITH 2 mm FORCEPS Hideaki Tsutsumida, MD, Mitsunobu Uto, MD, Mari Kamimura, MD, Toshiro Kamimura, MD, Kamimura Hospital Single incision laparoscopic surgery (SILS) for cholecystectomy was introduced into our hospital in February 2011, with the goal of using the conventional technique but reducing surgical time. A 2-mm diameter forceps was also used in the right flank to achieve this objective. Our hospital policy includes a ‘‘Final Critical View of Safety’’ approach in cholecystectomy, in which flow of the cystic duct and artery into the gallbladder after dissection from the liver is confirmed prior to complete separation of the organs. This approach is used to avoid misidentification of the common bile duct and the hepatic artery and resulting damage to these organs. Before SILS was introduced, latest 50 patients, except two groups of difficult cases (previous upper abdominal surgery or poor visualization of cystic duct with pre-operative drip infusion cholecystocholangiography – computerized axial tomography scan), have had a mean surgical time of 39 min and none have had bile duct injuries or required conversion to laparotomy. Since introduction of SILS, the number of ports was changed in 30 patients depending on the severity. The mean surgical time was 40 min in patients except difficult cases and performed with SILS +2 mm forceps. None have had bile duct injuries or required conversion to laparotomy in all patients. These results show that prolongation of surgery can be avoided even in procedure of SILS + 2 mm forceps. Here, we show and discuss the significance of the ‘‘Final Critical View of Safety’’ approach and the benefits of SILS + 2 mm forceps for safe and timely performance of cholecystectomy.

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THE FEASIBILITY OF SINGLE INCISION THORACOSCOPIC SURGERY FOR PRIMARY SPONTANEOUS PNEUMOTHORAX USING A SINGLEINCISION LAPAROSCOPIC SURGERY PORT UNDER SINGLE-LUMEN ENDOTRACHEAL TUBE INTUBATION WITH CO2 GAS INSUFFLATION Hyun Koo Kim, MD PhD, Ho Kyung Sung, MD, Hyun Joo Lee, RN, Jiae Min, RN, Young Ho Choi, MD PhD, College of Medicine, Korea University Guro Hospital Background: Single incision laparoscopic surgery (SILS) has recently been used by general surgeons to perform cholecystectomy and pre-peritoneal hernia repair. The SILS approach with SILS port had the potential merits of decreasing the duration of anesthesia by using single-lumen endotracheal tube intubation with CO2 gas insufflation. We performed single incision thracoscopic surgery for primary spontaneous pneumothorax using a SILS port with CO2 gas insufflation and evaluated the feasibility and safety of this procedure. Methods: Thirty patients with primary spontaneous pneumothorax underwent bleb resection with chemical and mechanical pleurodesis in our clinic, from October 2010 to August 2011. Singlelumen endotracheal tube with CO2 gas insufflation was used for obtaining the optimal surgical field. An incision of 2.5 cm was made at the previous closed thoracotomy site. A single flexible port (SILS port) was placed to access the thoracic cavity, and a 5 mm thoracoscopy, articulating gasper and endoGIA stapler were introduced through port channels. Results: Thirty-one male patients (mean age 21.2 ± 7.79 years) were enrolled in this study. The mean time from endotracheal intubation to the incision was 15.2 ± 5.28 min (range 9–25 min), the mean operation time was 33.2 ± 15.38 min (range 13–77 min) and the total time under anesthesia was 59.3 ± 13.16 min (range 41–95 min). There were no wound infections, early recurrences or readmissions. The chest tube was removed on average at postoperative day 3.6 ± 1.3 (range 2–5 days) and patients were discharged from the hospital without complications on average at postoperative day 4.5 ± 1.3 (range 3–6 days). During the mean follow-up period of 4.9 ± 3.15 months (range 0.6–10.4 months), there was no recurrence on the side that underwent surgery. Conclusions: Single incision thracoscopic surgery for primary spontaneous pneumothorax using a SILS port under single-lumen endotracheal tube intubation with CO2 gas insufflation was technically feasible. Further work and development of a specific thoracic single port are needed to refine the use and advantages of this procedure.

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SINGLE-INCISION LAPAROSCOPIC SURGERY: THE EXPERIENCE OF OUR FIRST 165 CASES: PEARLS AND PITFALLS Akram M Alashari, MD, Nissin Nahmias, MD, Bruce Bernstein, PhD, Stanton Smith, MD, Brian Pellini, MD, Justin Lee, MD, Ibrahim Daoud, MD, Division of Minimally Invasive Surgery St. Francis Hospital and Medical Center, Hartford, CT Introduction: Single-incision laparoscopic surgery is being increasingly used and emerging as a common alternative to standard multiport laparoscopic surgery. A wide variety of general surgery procedures are being performed using this relatively new single-port access technique. Methods: This is a retrospective review from November, 2008 to July 2011 of a wide variety of 165 single-incision laparoscopic cases, including cholecystectomies with and without intraoperative cholangiography, gastric banding, appendectomies, hiatal hernia repair, colon resection, adhesiolysis, and inguinal hernia repair. Patients included 126 females and 39 males, ranging in age from 18 to 70 years of age, and ranging in BMI from 20 to 40 kg/m2. Results: Over the course of our retrospective review, our experience shows that a wide variety of general surgery intraabdominal procedures that have long been performed by standard multiport laparoscopic surgery are amenable to single-port access surgery as well. As our operative experience grew larger, operative times decreased. Overall cosmetic outcome was superior to that of standard multiport laparoscopy. Conclusion: Our experience shows that a wide variety of intra-abdominal procedures that are regularly being performed with standard multi-port laparoscopic surgery are feasible with singleport access techniques. We have found that this variety of procedures can also be done for a variety of pathologies as well. Our study shows that differences in patient age, gender, and BMI did not hinder the applicability of single-incision laparoscopy. In addition, we felt that patients had equal overall outcome compared with standard laparoscopy with the benefit of a superior cosmetic outcome.

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A RARE CASE OF SOLITARY NEUROFIBROMA OF THE THORACIC ESOPHAGUS Katsunori Nishikawa, MD, Noburo Omura, MD, Masami Yuda, MD, Yujiro Tanaka, MD, Akira Matsumoto, MD, Yuichiro Tanishima, MD, Toshiyuki Sasaki, MD, Yoshiro Ishibashi, MD, Kouji Nakada, MD, Norio Mitsumori, MD, Hideyuki Kashiwagi, MD, Katsuhiko Yanaga, MD, The Jikei University School of Medicine Department of Surgery Benign esophageal tumors are rare disease, of which leiomyomas account for the majority of disease, while uncommon tumors include papilloma(s), hemangioma, granular cell tumor, neurofibroma, and myxofibroma(s). We present a case of a 56-year-old woman with the diagnosis of esophageal submucosal tumor (SMT) in mid-portion of the thoracic esophagus. The SMT was 3 cm in diameter, and MRI suggested the diagnosis of esophageal leiomyoma or neurofibroma. The operation was performed by video-assisted thoracoscopic surgery (VATS). In order to protrude SMT outward from the esophagus for easy access, a Sengstaken-Brakemore tube was inflated in the esophageal lumen at the level of the tumor. The tumor was gently enucleated from the esophageal wall by splitting esophageal muscle layers without mucosal injury. Her postoperative course was uneventful and the patient was discharged on postoperative day 8, and she remains asymptomatic to date. Histrogical diagnosis of the tumor was esophageal neurofibroma. To our knowledge, this is the first report of such a tumor in the esophagus treated by VATS.

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VIDEO-ASSISTED THORACOSCOPIC SURGERY FOR CHILDREN’S GENERAL THORACIC DISEASE Masahide Murasugi, MD PhD, Masato Kanzaki, MD PhD, Takuma Kikkawa, MD, Tamami Isaka, MD PhD, Hideyuki Maeda, MD, Takamasa Onuki, MD PhD, Osamu Segawa, MD PhD, Ryuji Yoshida, MD PhD, Department of Surgery, Division of General Thoracic Surgery*, Division of Pediatric Surgery**, Tokyo Women’s Medical University Background: An operation case of children’s general thoracic surgery increases by progress such as an imaging, prenatal diagnosis. A minimally invasive thoracoscopic surgery offers several options in diagnosis and surgical treatment in pediatric surgery. We would like to review our surgical experience during thoracoscopic surgery for children’s respiratory disease in our institute. Patients and Methods: From November 1993 to August 2011, 49 patients (50 times) underwent thoracoscopic surgery for thoracic diseases, except pectus excavatum and pigeon chest. Age ranged from 9 months to 15 years old (an average of 12.6 years old). The patients were positioned in a modified prone or supine position, and single lung ventilation was performed on the contra lateral side. Video-assisted thorasoscopic surgery was performed through a small chest incision (minithoracotomy) with two or three trocar ports with 3 and 5-mm instrumentation. Thirty degrees thoracoscopy of 5 or 10-mm was used. Anomalous blood vessels were clipped, stapling, ultrasonic vessel sealing system and/or ligated. Results: There was no morbidity or mortality associated with the video assisted thoracoscopic surgical procedures. None of the patients required a conversion to standard thoracotomy. The thoracoscopic surgical procedures were feasible in 49 children with thoracic diseases including 29 spontaneous pneumothorax, 10 mediastinal tumors (including 4 Myasthenia Gravis), 4 congenital cystic adenomatoid malformation (CCAM), 2 pulmonary sequestration, 1 pulmonary nodule, 1 pulmonary A-V malformation (bilateral and two times), 1 hemopneumothorax and 1 empyema. Single lung ventilation was insufficient in 3 cases under 2 years old. Video-assisted thoracosopic surgery was effective in these cases. Conclusions: We considered that video-assisted thoracosopic approach is surgical treatment of children. Cosmetic benefits were also obtained for girls. However, the most important consideration is the decision on a treatment strategy made by both pediatrician and thoracic surgeon.

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MINILAPAROSCOPIC APPROACH WITH HIDDEN SCARS FOR USUAL LAPAROSCOPIC PROCEDURES Isaac Baley Spindel, MD, Karla Susana Martin Tellez, MD, Angel Martinez Munive, MD, Jorge Cueto Garcia, MD, Fernando Quijano Orvan˜anos, MD, American British Cowdray Medical Center, Mexico City Introduction: About 25 years ago laparoscopic surgery emerged as a novel, minimally invasive technique for treatment of common surgical pathologies. In the last 5 years, techniques and instruments evolved looking to reduce morbidity while improving cosmetic outcomes. Such techniques include single incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES), however equipment is usually expensive and a new learning curve required for most surgeons. We propose a 3 or 4 port minilaparoscopic approach with hidden scars for usual laparoscopic procedures using standard laparoscopic instrumentation and techniques. Methods: All appendectomies since 1998 and all cholecystectomies since 2005 were reviewed in terms of complications, postoperative pain, and cosmetic results, with a mean follow of at least 1 month. Results were compared against data published in international literature. Appendectomy is performed with a 10 mm umbilical port and two 3 or 5 mm suprapubic ports. A 10 mm scope is introduced through the umbilical port and, working from the suprapubic ports, dissection is carried out in the usual fashion. A 5 mm harmonic scalpel or 3 mm pulsated bipolar coagulator is used to ligate the appendicular artery. The appendix is tied with Endoloop sutures and transected with scissors. We then switch to a 3 or 5 mm scope and extract the appendix with a laparoscopic retrieval bag. For cholecystectomy, ports are placed in the same manner and an additional 3 mm port is introduced in subxiphoideal position. The right suprapubic port is used for fundus retraction, left suprapubic and subxiphoideal ports for dissection. The cystic duct is ligated either with intracorporeal suture or with clips (introduced through the 10 mm port and switching to 3 or 5 mm optics), a 3 mm pulsated bipolar electrocautery is used for cystic artery ligation, again, this can be performed with other methods. The gallbladder is extracted through the umbilical port using a laparoscopic retrieval bag. Results: No statistically significant difference in complications was found as compared to rates reported in worldwide literature, nor was operative time increased. Postoperative stay was 12–24 h. For cholecystectomies, five transcystic cholangiographies and 2 common bile duct explorations were performed; mean operative time was 45 min. No conversion to open surgery or extra trocars were needed. Discussion: Back in 1998 we started to perform a hidden scar appendectomy using a 10 mm umbilical port and two 3 or 5 mm suprapubic ports. In 2005, upon realization that the gallbladder could be reached from the suprapubic ports, we added a 3 mm subxiphoideal trocar and began to perform cholecystectomies, at first on selected patients, today we do it standard, including complicated gallbladder disease. The technique is suitable for all kind of patients, including the very tall and obese. We have found no increase in complication rates or operative time. Moreover, postoperative pain is decreased, ergonomics improved, there is practically no learning curve for laparoscopic surgeons and costs are not increased. Lately we performed 10 gynecologic procedures using the same approach and a laparoscopic fundoplication with only one 5 mm and one 10 mm visible ports.

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ANESTHESIA MANAGEMENT FOR BARIATRIC SURGERY R Rutledge, MD, Center for Laparoscopic Obesity’s Introduction: The goals of anesthesia of obese patients include relaxation during surgery with no weakness post op; no drug induced bleeding and excellent anesthesia and analgesia without respiratory depression or nausea and vomiting post op. The present study documents a new anesthetic technique that aggressively utilizes exclusion of inhalational anesthetics and minimization of narcotic administration via foundation of Total Intravenous Anesthesia (TIVA) and concomitant use of Opioid Analgesia and Anesthesia (OAA). Materials and Methods: Anesthesia has been modified in a continuous improvement process to manage patients undergoing the Mini-Gastric Bypass. The MGB is relatively unique because of several features: abdominal, laparoscopic, very short operating time (20 to 60 min), minimal bleeding, and very short hospital stay (less than 24 h). This unique surgery requires a tailored approach to anesthesia and post operative management. Results: Over a period of 15 years the anesthetic management has been modified from a gas and narcotic based traditional technique to one much more akin to out patient or conscious sedation techniques. Premeds the day and night morning of surgery include the use of a gabapentin and melatonin. A drip of Propofol and Remifentanil is used and patients are treated preoperatively with a graded low dose of Ketamine and a loading dose of Dexmedetomidine. Narcotic use was decreased and need for antiemetic was also minimized. Mean respiratory rate in the recovery room increased with the lesser use of narcotics and antiemetic (mean 8 to mean of 12 respirations/min). Patient satisfaction was high and need for ICU admission for respiratory support was present in 2 patients who recovered quickly. Hospital stay was less than 24 h in 93% of patients. Conclusions: Newer anesthetic techniques can match newer mini surgical procedures. Elimination of inhalational agents, rare use of paralysis, TIVA and opioid sparing techniques can lead to safe management rapid recovery of independent respiratory status and rapid discharge.

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LAPAROSCOPIC TREATMENT FOR URACHAL REMNANT—A REPORT OF TWO CASES Roppei Yamada, MD PhD, Yasushi Rino, MD PhD, Norio Yukawa, MD PhD, Tsutomu Sato, MD, Hirohito Fujikawa, MD, Nobuhiro Sugano, MD, Koichiro Yamaoku, MD, Daisuke Inagaki, MD, Teni Godai, MD, Shinichi Hasegawa, MD PhD, Takashi Oshima, MD PhD, Munetaka Masuda, MD PhD, Department of Surgery, Yokohama City University School of Medicine Objective: To report our experience with a laparoscopic approach to managing symptomatic urachal remnant. Patients and Methods: Two patients (19 year-old man and 23 year-old woman) had a laparoscopic excision of a complicated urachal remnant in 2011. Three ports were routinely used, although their positioning varied as our technique developed with experience. The urachal remnant was dissected from the umbilicus to the bladder dome and then removed intact. Results: All two operations had no complications and minimal blood loss (5 ml and 10 ml) with short duration of operation time (134 min and 201 min). Conclusions: The laparoscopic approach appears to be a safe and effective alternative to open surgery for this condition. The reduced morbidity of this procedure and better cosmetic result would appear advantageous.

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INTRA-OPERATIVE SMALL BOWEL LENGTH MEASUREMENTS Ezra Teitelbaum, MD, Khashayar Vaziri, MD, Sara Zettervall, MD, Richard L Amdur, PhD, Bruce A Orkin, MD, George Washington University Introduction: Few studies have measured small bowel length (SBL) in live humans and most surgery texts base their ‘‘normal’’ anatomic lengths on cadaver data. Here we present a single-surgeon series of intra-operative SBL measurements and analyze potential demographic predictors of increased length. Methods: From May 1997 to December 2008, SBL (jenunum and ileum) was measured in 240 patients undergoing laparotomy for colorectal resections. The intestine was measured from the ligament of Treitz to the ileocecal value along its anti-mesenteric border with an umbilical tape immediately upon entering the peritoneal cavity. Patients with Crohn’s disease and those who had undergone prior bowel resections were excluded. Univariate Pearson’s correlation analysis was used to check individual associations of height, weight, and age with SBL. An unpaired t-test was used to compare SBL in men and women. A multivariate linear regression analysis was performed to evaluate whether patient gender, height, weight and age were predictive of increased SBL. Separate analyses were then performed within each gender subgroup. Results: Of 240 patients, 127 (53%) were women. Mean age was 55 ± 15 (range 20–86) years, mean height was 169 ± 10 (range 138–196) cm, and mean weight was 77 ± 19 (range 41–175) kg. Mean SBL from ligament of Treitz to ileocecal valve was 506 ± 105 (range 285–845) cm. On univariate analysis, height was associated with increased SBL (p \ .001) and men had a longer mean SBL than women (533 ± 105 vs. 482 ± 99; p \ .001). A multivariate linear regression model using patient gender, age, height and weight was significant (p = .001) and the predictors explained 8% of the variance in SBL. In this model, only height was independently predictive of increased SBL (p \ .05). Correlation results differed between genders. In men, height correlated with increased SBL (r = .20; p \ .05), whereas in women it did not (r = .06; p = .51). In men, age did not correlate with SBL (r = .17; p = .08), whereas in women age had a negative correlation with SBL (r = -.18; p \ .05). Conclusions: This study describes the largest data set of in vivo SBL measurements in a non-bariatric patient population. We found a mean SBL of 506 cm in live patients as compared with the 600–700 cm range derived from cadaver measurements quoted by most surgical textbooks. Men had longer mean SBL than women and height was independently predictive of increased SBL. SBL may decrease with age in women but not in men. This surprising gender difference will need to be validated in future studies.

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INTERVAL LAPAROSCOPIC MANAGEMENT OF MECKEL’S DIVERTICULITIS Vinay Singhal, MD, Vinayak Sreenivas, MD, S Sainathan, MD, Kamal Nagpal, MD PhD, Daniel Farkas, MD, Bronx Lebanon hospital centre Background: Meckel’s diverticulum is a rare entity. A high degree of suspicion is needed for opportune diagnosis and management. Traditionally patients diagnosed with this entity underwent laparotomy with diverticulectomy or resection of the small intestine. We present a case of meckel’s diverticulitis treated conservatively initially and with interval laparoscopic small bowel resection and intra-corporeal anastamosis. Case Report: A 64 year old lady presented to the emergency room with right lower quadrant pain, nausea and vomiting. CT scan of the abdomen showed an inflammatory mass in the mid-abdomen with a normal appendix. Meckel’s diverticulitis was suspected. She was treated conservatively with antibiotics. Meckel’s scan and small bowel series done later were suspicious of Meckel’s diverticulum. Patient underwent elective diagnostic laparoscopy and laparoscopic resection of the small bowel with anastamosis. Post- operative course was uneventful and she was discharged on second post-operative day. Laparoscopic resection at the time of initial admission would have been difficult and may have ended up in laparotomy and large resection of multiple involved bowel loops. Interval resection was successfully performed laparoscopically, was small and easy to do with good clinical results. Conclusion: Interval surgery for meckel’s diverticulitis after management with antibiotics may help avoid laparotomy and may allow the resection to be performed laparoscopically with the attendant benefits of rapid post- operative recovery and reduced morbidity.

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THE NOVEL APPLICATION FOR COLORECTAL STENTING AFTER ANASTOMOTIC LEAK Kanika A Bowen, MD MMS, Stephen W Abernathy, MD, Richard C Frazee, MD, Texas A&M University, Scott & White Hospital Introduction:- The endoscopic use of stents in the gastrointestinal tract has been instrumental in the treatment of unresectable esophageal cancer, esophageal leak, and the temporary relief of colonic obstruction. The current use of colorectal stenting has mainly been targeted to the temporary relief of obstruction. Our group will describe the success and novel application for colorectal stenting after anastamotic leak. Methods and Procedures:- Two patients at our institution were treated with a covered esophageal stent after anastamotic leak. Both patients agreed to the off-label use of the stents after an informed, detailed discussion. One patient had a delayed presentation with a pelvic abscess two weeks after his elective colostomy takedown with primary anastamosis. At abdominal exploration the area of leak was drained externally. Colonoscopy revealed disruption of one-third of the anastamotic circumference. A 23 mm 9 18 cm covered stent was placed endoscopically using fluoroscopic guidance. Another patient developed an anastamotic bleed and subsequent anastamotic leak after elective sigmoidectomy in the early postoperative period. In this case, re-exploration revealed minimal intra-abdominal contamination and a 23 mm 9 18 cm covered stent was placed across the anastamosis. Results: In both patients a covered removable stent was placed to protect the anastamosis and allow for adequate healing time. Both patients passed the colonic stents at home without any squealae and on routine follow-up have had return of normal bowel function with no further anastamotic complications to date. The patient that presented with a delayed anastamotic leak underwent colonoscopy one month after stent placement. This patient had complete, intact mucosal integrity and no evidence of stricture. Conclusion: Anastamotic leak is one of the dreaded complications of colorectal anastamoses and treatment strategies have mainly been directed at drainage and diversion. We report the use of covered stents in the successful management of anastamotic leaks in two patients. We feel the use of covered stents in carefully selected patients allows for anastamotic healing without proximal diversion.

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NEW MODIFICATION OF LAPAROSCOPIC COLECTOMY BY NOSE AND SILS WITH VIRTUAL PORTS Hwei-ming Wang, MD, Feng Fan Chiang, Taichung Veterans General Hospital Introduction: The NOTES (natural orifice transluminal endoscopic surgery) and SILS (single incision laparoscopic surgery) were two recent progresses in minimally invasive surgery. The effort of NOTES and SILS was try to decrease the numbers of ports and minimized the size of incision in laparoscopic surgery and give patient better cosmetics, less pain and quickly recovery. However, there were critics of NOTES and SILS such as little true patient benefit, increased complexity of technique and increased extra-cost compared with conventional multi-port laparoscopic surgery. So far, in conventional laparoscopic colectomy, an abdominal mini-incision was always needed for removal of specimen. How I do it: SILS with virtual ports — During SILS, I use a new devices, the endograsp which was inserted via 5 mm port and act as virtual assistant. The endo-grasp make good exposure of operative filed by excellent counter-traction and fascinating the SILS procedures: Natural Orifice Specimen Extraction (NOSE) - removal of specimen via anus or vagina without abdominal incision in laparoscopic colectomy. 1.NOSE via anus The mobilization of splenic flexure was always needed. After high ligation of inferior mesenteric artery and vein, the left side colon was fully mobilized. Tran section of colon or rectum was done by endo-GIA. A TEM scope (20 cm in length) was inserted into rectal stump and the stump was open. The specimen was pulling out of anus via TEM scope. Resection of specimen was done and purse string suture was completed with insertion of anvil extra-corporeally. The anvil was put back into peritoneal cavity and rectal stump was re-closed by endo-GIA. The end-to end anastomosis was achieved by double stapling technique. 2. NOSE via vagina In female patients, the TEM scope was inserted in vagina and posterior vagina wall was open. The specimen was pulling out of vagina via TEM scope. The rest procedures were same as above. Preliminary result: The SILS + virtual ports had been done in 10 patients with benign diseases or early cancer. No conversion and any major complications. The NOSE had been done in 26 patients. Only one anastomotic leakage occurred (3.8%) and no other major complications noted. All patients recovered very quickly, could walk and water intake in the 1st postoperative day and the cosmetic was extreme good.. Conclusion: The NOSE and SILS + virtual ports approach were feasible and the learning curve was not so difficult. In near future, for improvement of NOSE, there are new technologies needed to do intra-corporeal anastomosis. I expected a collaborative clinical trial to test the true value of NOSE procedure.

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MINIMALLY INVASIVE SURGERY ADOPTION INTO AN ESTABLISHED SURGICAL PRACTICE Edward P Dominguez, MD, Cory D Barrat, MD, Ryan Gruner, BS, Donald Whisler, BS, Lynn Shaffer, PhD, Riverside Methodist Hospital, Minimally Invasive Surgery, Columbus, OH Introduction: We compared the rate of adoption of laparoscopic techniques by general surgeons before and after the introduction of a MIS fellowship trained colleague to an established practice. The advancement of minimally invasive surgery techniques has changed the practice of general surgery. Practicing general surgeons actively adopt new techniques often without the benefit of established training resources. Training opportunities such as weekend courses, video libraries, hands-on conferences, and traveling proctors have been used with varying success. None of these methods allow for comprehensive teaching and follow-through during the surgeon’s learning curve. Integrating a fellowship trained surgeon into an established practice may optimize the safe and efficient adoption of MIS by the other colleagues. Our secondary objective explored the barriers and drivers behind adopting these new MIS techniques. Methods and Procedures: A retrospective review of operative reports from July 2004 through June 2008 obtained the number of laparoscopic and open appendectomies, colectomies, ventral/incisional hernias, and inguinal hernias performed by the five surgeons of Riverside Surgical Associates. All operations were performed at Riverside Methodist Hospital and Knightsbridge Surgery Center in Columbus, OH. Three time intervals were formed: (A) 18 months before arrival of the MIS trained surgeon, (B) the 12 month ‘‘transition period,’’ representing 6 months before and 6 months after arrival of the MIS trained surgeon, and (C) 18 months following the transition period. The proportion of total cases classified as laparoscopic was calculated by procedure type and time period. Only cases performed by the five partners, and not by the MIS trained surgeon, were included in the analysis. In addition, a survey elicited the opinions of the five surgeons on various aspects of the transition, including barriers to adopting MIS techniques and effectiveness of different methods for learning MIS techniques. Results: A total of 4,016 cases were reviewed (1693 in period A, 964 in period B, and 1359 in period C). The percentage of total cases performed laparoscopically increased across time periods, from 12.1% in period A, 27.5% in period B, to 48.3% in period C. Laparoscopic appendectomies (LA) significantly increased across time periods from 19% in period A to 80% in period C (p \ 0.0001). Adoption of laparoscopic ventral/incisional and inguinal hernias accelerated after the transition period compared to before: increase in laparoscopic ventral/incision procedures before transition was 4.8% vs. 20.1% after (p = 0.0322); comparable figures for inguinal hernias are 0.6% before transition vs. 31.1% after (p \ 0.0001). Finally, laparoscopic colectomies significantly increased from 25% in period A to 52% in period C (p \ .0001). Survey responses indicated that ‘‘mentoring by a colleague with MIS training’’ was superior to other methods for learning MIS procedures (p = 0.0327 to p = 0.0516). Conclusions: The integration of a fellowship-trained MIS colleague into a general surgery practice resulted in a 300% increase in the proportion of appendectomies, ventral hernias, inguinal hernias, and colectomies performed laparoscopically by the other members of the practice. When surveyed, the surgeons felt that mentoring by a colleague with MIS training was the most effective method for adopting MIS procedures into their practice.

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P541

NEEDLESCOPIC SURGERY IN PATIENTS WITH ACUTE ABDOMEN Efthymios Poulios, MD, Konstantinos P Economopoulos, MD, Dimitrios Tsakayannis, MD, Andreas Kiriakopoulos, MD, Dimitrios Tranoudakis, MD, Dimitrios Linos, MD FACS, Department of Surgery, ‘‘Hygeia’’ Hospital, Athens, Greece University of Athens, School of Medicine, Athens, Greece Introduction: The needlescopic laparoscopic procedures provide minimal scars, minimal tissue injury, probably less postoperative pain, and analogous to conventional laparoscopic approach postoperative results in selected patients with acute abdomen. The aim of this study was to retrospectively analyze patients with acute abdomen who underwent a needlescopic laparoscopic surgery in a tertiary hospital. Methods and Procedures: A cohort of patients underwent needlescopic laparoscopic surgery from September 2009 to May 2011 was retrospectively analyzed. Demographic data, pathology reports, duration of the procedure, complication rates, conversion rates, postoperative pain on days 1 and 3 (VSA score), duration of hospital stay and cosmetic results were examined. Preoperative evaluation was done with U/S, CT scan and laboratory work-up. All procedures were performed under general anesthesia with the introduction of a 10-mm or 12-mm trocar through the umbilicus, one or two 2-mm needlescopic instruments and one 5-mm trocar, if there was a need for an energy device. The specimen was retrieved via the umbilical incision using a plastic bag. Results: 72 patients (61 females/13 males), with a mean age of 44.8 years (range, 23–66 years) and mean BMI of 25.1 (range, 18–-33), underwent needlescopic laparoscopic surgery. 52 patients presented with acute cholecystitis, 16 patients suffered from acute appendicitis, 4 had ovarian cyst rupture and 3 patients had no preoperative established diagnosis and they underwent diagnostic laparoscopy. The mean operative time was 70 min for cholecystectomies (range, 45–100 min), 45 min for appendectomies (range, 43–76 min), 55 min for the ovarian cyst excisions (range, 40–116 min) and 42 min for the diagnostic laparoscopies (range, 30–80 min). The mean postoperative hospital stay was 2 days after cholecystitis, 1.8 days after appendicitis, 1.7 days after ovarian cyst excision and 1 day after diagnostic laparoscopy. No intraoperative complications were encountered. 5 operations (3 cholecystectomies, 2 appendectomies) converted to conventional laparoscopic approach via replacing the needlescopic instrumentation with 5-mm trocars due to difficulties in organ manipulation and unclear anatomical orientation. Mean hospital stay for patients underwent a conversion was 1.8 days (range, 1–3 days). Mean postoperative pain score on day 1 was 1.5 for needlescopic cholecystectomy and laparoscopy and 1.8 for needlescopic appendectomy and needlescopic oophorectomy. Mean postoperative pain scores on day 3 was 0 for all groups. Cosmetic results were excellent in all cases. Conclusions: Needlescopic surgery is a safe and feasible procedure. Minimal instruments allow experienced surgeons to perform minimally invasive operations in patients with acute abdomen with low morbidity. Needlescopic surgery is associated with excellent cosmetic results and improvement of postoperative quality of life.

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OVERNIGHT-STAY BILATERAL THORACOSOPIC SYMPATHECTOMY IN PATIENTS WITH PALMAR HYPERHIDROSIS Avinash N Katara, MS DNB MRCSEd, Ramya Behera, MS, Deepraj S Bhandarkar, MS FRFACS FICS FAIS FIAGES, Tehemton E Udwadia, MS FCPS FRCSEng FRCSEdin FICS PD, Hinduja National Hospital & Medical Research Centre, Mumbai Introduction: Thoracoscopic sympathectomy is the gold standard for treatment of patients with primary palmar hyperhidrosis. This study assesses the feasibility of thoracoscopic sympathectomy as an overnight-stay procedure in the treatment of primary palmar hyperhidrosis and its efficacy. Material and procedures: The data on 60 patients undergoing thoracoscopic sympathectomy on an overnight-stay basis (\24 h) were prospectively collected and retrospectively analysed. All procedures were performed under general, double-lumen endotracheal anaesthesia with the patient in supine position. Two 5-mm ports under the axillary fold were used on each side. The sympathetic chain was identified and transected at T2 and T3 levels using diathermy. In case of severe axillary hyperhidrosis, the T4 level was also ablated. Intercostal drains were not used routinely. A chest x-ray was obtained 4 h after surgery. Results: There were 60 patients (M:F = 3:2) with a mean age of 28 years (range = 16 to 61 years). In addition to the palmar hyperhidrosis all had plantar and 11 complained of axillary hyperhidrosis. All but one patient were discharged within 24 h of surgery. At a mean follow up of 72 weeks (range 7-90 weeks) the palmar sweating stayed resolved in all patients. Fifty-nine out of 60 patients also had a complete resolution of their plantar hyperhidrosis while in 1 patient it was significantly better. All 8 patients with axillary hyperhidrosis had complete relief. Complications included minor injury to lung parenchyma requiring post-operative chest drain in 1 patient (resulting in a 2-day hospital stay) and a temporary paraesthesia in the left axilla in another. One patient experienced bothersome compensatory hyperhidrosis of the trunk and lower limbs. Conclusion: Thoracoscopic sympathectomy at T2 and T3 levels can be safely and effectively carried out as an overnight-stay procedure in patients with palmar hyperhidrosis. It carries minimal morbidity and a small risk of compensatory sweating.

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VIDEO ASSISTED ESOPHAGECTOMY WITH EXTENSIVE LYMPHADENECTOMY FOR THORACIC ESOPHAGEAL CANCER Toshiaki Shichinohe, MD PhD, Kentaro Kato, MD PhD, Akihiro Matsunaga, MD PhD, Satoshi Hayama, MD PhD, Takahiro Tsuchikawa, MD PhD, Joe Matsumoto, MD PhD, Takehiro Noji, MD PhD, Norihiro Takemoto, MD PhD, Yoshinori Suzuki, MD PhD, Hiroyuki Kaneko, MD PhD, Eiichi Tanaka, MD PhD, Satoshi Hirano, MD PhD, Gastrointestinal Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan. Introduction: Video assisted thoracoscopic surgery (VATS) for thoracic esophageal cancer is an advanced surgical technique. To accomplish extensive lymphadenectomy of paraesophageal and paratracheal lymph nodes as well as esophageal removal, we apply two different operation procedures; Hand assisted thoracoscopic surgery (HATS) is our standard procedure for thoracic esophageal cancer which is substitute for conventional open thoracotomy; Prone position esophagectomy (Prone) is newly applied operative procedure especially for the lower thoracic esophageal cancer cases. By applying these two operative procedures, over 90% of operation cases of esophageal cancer are able to be completed thoracoscopically. Methods and Procedures: VATS three-stage esophagectomy with extensive lymphadenectomy was performed by HATS or Prone procedure with gastric tube reconstruction and the cervical anastomosis. HATS: The left lateral decubitus position is used for HATS. Assistant surgeon inserts his left hand into the right thoracic cavity from the abdominal incision through the anterior phreno-mediastial route. Retraction of the lung and trachea are thus done manually with the hand of the assistant. The abdominal incision is then used for hand assisted laparoscopic surgery (HALS). The advantage of HATS is the gentle retraction of the lung from the caudal side of the thorax, thus obviating the need for lung retractors. Furthermore, this procedure allows the surgeon’s hand to use its sense of touch within the thoracic cavity, which can also confirm whether or not the tumor has invaded the surrounding organs such as the trachea. Prone: Patient placed by the prone position. By this positioning with positive CO2 pressure to the thoracic cavity, the right lung falls away from the operative field both by gravity and the artificial pneumothorax, a good visual exposure of the esophagus without assistant’s help. The advantage of this procedure is the superior visualization of the lower mediastinum. Thus, lower esophageal cancer case is the good applicant for this operation. Results: Since 1996, we experienced 134 cases of VATS esophagectomy, which includes 103 cases of HATS and 7 cases of Prone. The average of the amount of blood loss was 840 mL, and the operation time of thoracic approach was 252 min. In hospital mortality rate was 1.5%. Conclusion: Video assisted esophagectomy with extensive lymphadenectomy for thoracic esophageal cancer is feasible procedure in term of the less invasive surgery.

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READMISSION AFTER MINOR SURGERY Aliasger Amin, Mr, Anil Reddy, Mr, Madan Jha, Mr, James Cook University Hospital Aim: Repair of hernia and laparoscopic cholecystectomy are minor procedures and can be done as day case. Complications in the postoperative period are considered rare and hence they are not followed up routinely. The aim of this study was to highlight the readmission rates for these patients, cause of readmissions and the resources used. Materials and Methods: Those patients who were readmitted within 30 days of hernia repair or laparoscopic cholecystectomy were looked at over one year period in a university teaching hospital. Data pertaining to the cause of readmission, radiological investigation performed and the outcome was collected retrospectively. Results:

Discussion: Majority of the readmissions following laparoscopic cholecystectomy could have been managed as an outpatient as they were admitted to have an inpatient USS. Similarly readmissions following inguinal hernia repair having seroma or wound infection could have been managed without a hospital admission. We propose an alternative for reducing readmissions such as ambulatory clinics, USS slots for post op patients presenting with pain and telephonic consultation. This in turn could be cost effective to the healthcare trust.

Surg Endosc (2012) 26:S249–S430

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GASTROINTESTINAL NEUROENDOCRINE TUMOUR: CASE SERIES A Amin, Mr, Anil Reddy, Mr, Ahmed Hammad, Mr, M Jha, Mr, Prasad Kolanu, Dr, James Cook University Hospital Introduction: Over 60% of all neuroendocrine tumours are found in the gastrointestinal tract. Gastrointestinal neuroendocrine tumours are rare and constitute \ 2% of all gastrointestinal cancers. Most tumours are slow growing and asymptomatic, although metastatic lesion may be the presenting feature in some patients. Material and Methods: Data was collected retrospectively over a 10 year period from 2001 to 2010. All patients with proven histopathology of neuroendocrine tumour were included. Results: There were 74 patients with histopathology positive of neuroendocrine tumour. 39 males and 35 females with the age range of 8–88 years. The commonest presenting symptoms were anaemia, diarrhoea, weight loss and abdominal pain. The duration of symptoms before the diagnosis was made ranged between 2 months and 5 years.

Site of tumor

Number

Incidental

Non incidental

Appendix

27

23

4

Duodenum

6

4

2

Terminal ileum

12

3

9

Stomach

14

5

9

Oesophagus

2

0

2

Rectum

3

2

1

Meckel’s

1

0

1

Caecum

2

0

2

Sigmoid

2

0

2

Small bowel

2

0

2

Pancreas

1

0

1

Colon

1

1

0

Liver (primary unknown)

1

0

1

12 out of the 74 (16%) patients with neuroendocrine tumour presented with distant metastases. 44 patients were followed up for 5 years after the initial diagnosis. Local recurrence occurred in 1 patient and 6 patients developed distant metastases on follow up. 5 year survival was 22/44 (50%). None of the patients who presented with metastases in the first place survived for 5 years. Conclusion: Neuroendocrine tumours can present at any age. Delay in diagnosis is usually because of the indolent nature of the disease. More than 50% of the patients presented with a coincidental finding of neuroendocrine tumour. Though neuroendocrine tumour is considered to be a slow growing tumour, our study showed a 5 year survival rate of only 50% with 16% of patients presenting initially with metastases.

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LAPAROSCOPIC VERSUS OPEN APPROACH IN THE MANAGEMENT OF APPENDICITIS COMPLICATED WITH PERITONITIS Felipe Quezada, MD, Ricardo Mejia, MD, Nicolas Quezada, MD, Oslando Padilla, Alex Escalona, MD, Nicolas Jarufe, MD, Fernando Pimentel, MD, Department of Digestive Surgery, School of Medicine, Pontificia Universidad Cato´lica de Chile, Santiago, Chile Introduction: In the last few years, laparoscopy has become the standard of care in most of abdominal surgical pathologies. Laparoscopic appendectomy (LA) has demonstrated to be a safe approach in cases of non-complicated appendicitis; however, controversial evidence exists regarding the laparoscopic management of patients with ongoing appendicitis complicated with peritonitis (ACP). The aim of the present study was to compare short and long term post-operatory outcomes in patients with ACP managed with LA or open appendectomy (OA) in our institution. Materials and Methods: We conducted a retrospective analysis of the clinical records of patients with ACP operated from January 2003 until July 2011 in our center. Demographic data, comorbidities, intra-operative variables, length of stay, surgical complications, operative mortality, readmissions and reoperations were recorded. Analysis was made using IBM SPSS Statistics v.19.0. Results: A total of 160 patients were identified: 63,1% were males, mean age 38 ± 17,2 years (range from 12 to 85 years) and 33,1% had associated comorbidities. Forty-four patients (27.5%) underwent LA, 11 (25%) of which were converted to OA. There were a total of 58 patients (36.3%) with diffuse peritonitis: 43.2% in the LA group and 33.6% in the OA group (p = NS). LA was associated to a longer operative time (LA: 93 ± 43.8 vs OA: 68,4 ± 30.3 min p = 0,005). No differences were recorded in length of hospital stay (LA: 4.9 ± 2.8 days vs OA: 5.6 ± 4.5 days, p = 0,34). A total of 33 patients (20,6%) presented a postoperative complication. There were no differences in the rate of surgical site infections (LA: 4.5% vs OA: 6%, p = NS), prolonged post-operatory ileus (LA: 2.3% vs OA: 6%, p = 0,44), or postoperative intra-abdominal abscesses (IAA) (LA: 6.8% vs OA: 1.7%, p = 0,13). Two patients with IAA in the LA group were managed laparoscopically. There were 6 hospital readmissions in the OA group, all of them required a surgical intervention: 3 mechanical ileus, 2 incisional hernias and 1 evisceration. No readmissions were found in the LA group. Two patients (1.3%) died during hospitalization due to abdominal septic shock, both in the OA group. Conclusions: In our study a trend to higher late postoperative complications as readmissions and reoperations was seen in the OA group, while LA tended to have more IAA. Overall, LA showed comparable postoperatory outcomes to OA in the management of ACP.

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HIGH-RESOLUTION MANOMETRY FINDINGS IN HEALTHY VOLUNTEERS WITH BIOVIEWÒ SOFTWARE Masato Hoshino, Ananth Srinivasan, Tommy H Lee, Sumeet K Mittal, Creighton University Medical Center Introduction: High-resolution manometry (HRM) is the current gold standard for evaluation of esophageal motility. There are three commercially available HRM systems, namely Sierra: Manoview, MMS and Sandhill: Bioview. A Chicago Classification has been proposed and widely accepted based on Manoview. The objective of this study determine normal values using Bioview (Sandhill Scientific Inc., Highland Ranch, CO, USA) and assess any differences. Methods and Procedures: After Institution Review Board (IRB) approval, fourteen healthy volunteers underwent HRM at Creighton University Medical Center (CUMC) between April 2010 and August 2010. The pressure topography parameters were analyzed using Chicago Classification for ten liquid and viscous swallows. Basal lower esophageal sphincter (LES) pressure, integrated relaxation pressure (IRP), distal contractile integral (DCI), contraction front velocity (CFV), transition zone (TZ) were calculated. Results were expressed as Median (IQR) and Mean ± SD (SE). All statistical analyses were performed using SPSS version 17 (SPSS, Inc, Chicago, IL, USA). Results: The median (IQR) of basal LES pressure, IRP, DCI, CFV, and TZ was 26.4 (21.8–36.5) mmHg, 12.2 (8.8–14.7) mmHg, 2762 (2283–3051) mmHg-s-cm, 3.80 (3.46–4.09) cm/s, and 0.30 (0–1.0) cm respectively. Normative data presented at 5th and 95th was basal LES pressure (22.9–33.2 mmHg), IRP (9.8–15.3 mmHg), DCI (2241–3019 mmHg s cm), CFV (3.48–4.07 cm/s), and TZ (0–0.72 cm). Conclusions: Normal values for Bioview appear to be quite similar to those proposed in Chicago Classification using Manoview and hence it seems reasonable to extrapolate normal values and subsequent classifications based on variations to the Bioview analysis.

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CURRENT PRACTICE PATTERNS OF VENOTHROMBOEMBOLISM PROPHYLAXIS IN ADVANCED MINIMALLY INVASIVE SURGERY E Gilbert, MD, A Lamoshi, MD, S Markwardt, MPH, T Deloughery, MD, B Sheppard, MD, Oregon Health & Science University Introduction: Postoperative venothromboembolism (VTE) is a well known complication of surgery. Although there are guidelines for the use of prolonged (28 day) VTE prophylaxis following open surgery, indications for prolonged VTE prophylaxis in high risk patients following advanced minimally invasive surgery (MIS) are less clear. The purpose of this cross-sectional study was to determine the current clinical practice patterns of VTE prophylaxis in advanced MIS. Methods: An 11-point survey was sent to a sample population of members of the Society of Alimentary and Gastrointestinal Surgeons in three rounds 6 weeks apart from November 2010– March 2011. The questionnaire was designed to obtain basic demographic information and practice patterns of VTE prophylaxis of the respondents. All means, standard deviations, percentages and 95% confidence intervals were calculated using survey analysis techniques. Results: The response rate was 34.2% (315/920). Mean number of years in practice was 10.7 (±7.24) and mean number of operations performed was 387 (±185.56). Ninety-two percent (±28%) reported that more than 25% of their practice was MIS. Participants were equally likely to be affiliated with a teaching hospital as with a non-teaching hospital (52% vs. 47%). Preoperative VTE prophylaxis was used in [ 75% of case by 67% of surgeons who were more likely to have been in practice greater than 10yrs [29.3 (24.6, 34.4) vs. 38.1 (33.0, 43.4); a = 0.10]. Twelve percent (±33%) reported using prolonged prophylaxis in [ 5% of cases, 82% (±38%) reported they would provide prolonged VTE prophylaxis following MIS in certain clinical scenarios and only 17% (±38%) reported they would not use prolonged VTE prophylaxis following MIS. The most common indications indicated by respondents for prolonged VTE prophylaxis were hypercoagulability (n = 224), previous deep vein thrombosis (n = 204), immobilization (n = 132) and malignancy (n = 72). Conclusions: Although a minority of surgeons use prolonged VTE prophylaxis in [5% of their MIS cases, a majority report using prolonged VTE prophylaxis in a number of specific clinical indications. This variation in national practice patterns likely reflects an absence of specific guidelines for prolonged VTE prophylaxis utilization following advanced minimally invasive surgery.

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SUBCUTANEOSCOPIC EXCISION OF EXTERNAL ANGULAR DERMOID CYST IN CHILDREN: AVOIDING A SCAR ON THE FACE Julius Carillo, MD, Bethany Slater, MD, Ashwin Pimpalwar, MD, Division of Pediatric surgery, Michael E Debakey Department of surgery, Baylor college of medicine and Texas Children’s Hospital, Houston, Texas. Background: External angular dermoid cysts/ epidermoid inclusion cysts are a common subcutaneous tumor of the face. For the majority of these lesions, excision is relatively simple and performed through an incision immediately overlying the mass. Facial lesions in pediatric patients present a unique challenge in that a direct approach carries the potential for visible scar formation. We describe a subcutaneoscopic videoscopic technique that provides excellent visualization and avoids scars on the face. Objective: To describe a subcutaneoscopic technique for the removal of a epidermal inclusion cyst on the face. Study Design: This is a technical report on a pediatric patient who underwent excision of an epidermal inclusion cyst using the subcutaneoscopic method. Methods/Technique: A 2 year old child presented with a right sided external angular dermoid cyst (epidermoid inclusion cyst) of the face. The child was taken to the OR for subcutaneoscopic excision of this cyst. A 1.5 cm incision was made on the scalp above the hairline. Space was then created subcutaneously using Kittner’s dissectors and Foley’s balloon catheter up to the cyst. After creating a tunneled working space underneath the skin, a 3 mm telescope was inserted through the incision. The skin was retracted up with retractors and the dissection was completed with 3 mm laparoscopy instruments. The visualization provided was excellent and precise dissection was possible without much difficulty. The mass was sent to pathology and the wound was closed. Results: The mass was successfully removed with no adverse complications. Conclusion: The subcutaneoscopic technique has the advantage of improved visualization of the cyst, greater precision of dissection, and excellent cosmesis. One disadvantage is that this involves learning a new technique while the majority of surgeons are already comfortable with the open approach. However, it should be noted that basic laparoscopic skills translate well to this technique and competence can easily be achieved after only a few cases.

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SINGLE-INCISION LAPAROSCOPIC CHOLECYSTECTOMY USING A SURGICAL GLOVE PORT Naoki Ishida, MD, Tomoaki Okada, MD, Yoshitomo Ueno, MD, Kei Tamura, MD, Tetsuya Mizumoto, MD, Michiko Yamashita, MD, Masaru Matsumura, MD, Yoshinori Imai, MD, Taro Nakamura, MD, Hidenori Kiyochi, MD, Kenzo Okada, MD, Toshihiko Sakao, MD, Shinsuke Kajiwara, MD, Uwajima City Hospital, Uwajima, Ehime, Japan Introduction: Single-incision laparoscopic cholecystectomy (SILC) is expected to produce better cosmetic results and shorten the recovery period for patients. However, SILC is associated with difficulties in performing the procedure and decreased safety compared to conventional methods. SILC using a surgical glove port was adopted in selected cases, and the initial results were evaluated. Methods: The SILC with the surgical glove port method was performed as follows: A 3.0 cm skin incision was made in the umbilicus. A mini sized LAP PROTECTOR was placed through the umbilical wound. Subsequently, a non-powdered surgical glove (5.5 inches) was put on the LAP PROTECTOR through which two 5 mm slim trocars and one 3 mm trocar were inserted via the finger tips. Furthermore, one 3 mm trocar was punctured at the epigastrium. An additional 3 mm trocar was placed under the right costal arch for the first 8 cases. Results: A total of 30 cholecystectomies were performed using this method from December 2009 to May 2011 in our institute. All cases had cholelithiasis. Fourteen patients were male and 16 were female. Their mean age was 54.8 years, with a range from 31 to 83 years. The average length of the operation was 96.0 min, ranging from 48 to 166 min. Four cases were complicated by chronic cholecystitis. Among, these four cases, three cases were converted to three port laparoscopic cholecystectomy and one case required laparotomy due to hemorrhage from the gallbladder bed. The mean duration of the postoperative hospital stay was 4.3 days. Discussion: The cosmetic results and duration of postoperative hospital stay were satisfactory. However, the average length of the operation for SILC was much longer than that of our conventional laparoscopic cholecystectomy. This method was a feasible technique for cholecystectomy that was associated with good cosmetic results and less invasiveness. Further efforts should therefore be made to improve this surgical technique.

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FIRST REPORT OF SINGLE INCISION LAPAROSCOPIC APPENDECTOMY IN A PREGNANT PATIENT Jonathan D Svahn, MD FACS, Matthew R Dixon, MD, Joanna Lim, MD, Austin L Spitzer, MD, Kaiser Permanente East Bay, Oakland Campus Single incision surgery is becoming more popular as surgeons become more comfortable with this technique. While initial series reported on cholecystectomy and appendectomy, subsequent publications described its successful application for the treatment of other surgical diseases. These include colectomy, Nissen fundoplication, splenectomy, adrenalectomy, and gastrectomy to name but a few. There has, however, been only one reported case of single incision laparoscopic surgery undertaken in a pregnant patient. This case report detailed a successful laparoscopic cholecystectomy for acute cholecystitis. We present the first report of single incision laparoscopic appendectomy in a pregnant patient. A previously healthy 27 week pregnant patient (G6P1) presented to her obstetrician’s office with 24 h of worsening right lower quadrant pain. Surgical consultation was obtained. On physical exam she was afebrile with tenderness to palpation in the right lower quadrant over McBurney’s point. Blood work was significant only for a mildly elevated white blood cell count. The clinical diagnosis of appendicitis was made and she was offered single incision laparoscopic surgery. CT scan was deferred due to the potential radiation risk to the fetus. Our technique has been previously reported and involves the use of a home made single port device. Our ‘‘gloveport’’ is created using a small latex free glove and one 12 mm trocar. The trocar is placed through the thumb of the glove and secured with steri-strips. Similarly, a five mm 30 laparoscope and a five mm atraumatic grasper are secured through alternating fingers of the glove. A vertical incision is made through the base of the umbilicus and the fascia is divided sharply under direct vision. In this patient, the gravid uterus was easily visualized and not injured. A small wound protector was introduced into the abdomen and rolled until secure. The gloveport was then secured around the exteral portion of the wound protector. In this case, the abdomen was insufflated to only eight mm mg to allow visualization while minimizing the potential adverse effects of the pneumoperitoneum on the fetus. An inflamed and grossly suppurative appendix was identified. It was removed using two firings of an endoscope stapler in the standard fashion. The abdomen was copiously irrigated and the gloveport and wound protector were removed. The fascia was closed with interrupted sutures and a running subcutaneous stitch was used for the skin. The patient and fetus were monitored post operatively and discharged home the following day. Laparoscopic surgery in pregnant patients was initially considered risky. Subsequently data supported the use of laparoscopy for surgical emergencies in pregnant patients and was found to be both feasible and safe. However, trocar placement either blindly or under direct vision puts the gravid uterus and fetus at risk of penetrating injury. We feel that the use of single incision laparoscopic surgery and our technique, which involves no trans-abdominal trocar placement, obviates this risk. Further study is warranted but our initial experience suggests that single incision laparoscopic surgery may provide an additional benefit to the pregnant patient when compared to standard laparoscopic surgery.

Surg Endosc (2012) 26:S249–S430

39197

S403

P552

LAPAROSCOPY-ASSISTED DISTAL GASTRECTOMY WITH D2 LYMPH NODE DISSECTION: OUR INITIAL EXPERIENCE Masahiko Nishizaki, MD, Syunsuke Kagawa, MD, Futoshi Uno, MD, Hiroyuki Kishimoto, MD, Toshiyoshi Fujiwara, MD, Department of Gastroenterological Surgery, Okayama University Hospital, Okayama, Japan Background: To expand the indication of laparoscopy-assisted distal gastrectomy (LADG) for advanced gastric cancer, D2 lymph node (LN) dissection is required as the standard procedure in accordance with the guide line in Japanese Gastric Cancer Association. The most critical point in D2 dissection is the nodes along the hepatic artery (No. 12a) and the proximal splenic artery (No. 11p) in general. Because of difficulty to expose anterior walls of the portal vein in the hepatoduodenal ligament and the splenic vein along the proximal splenic artery by using limited laparoscopic view and forceps, the procedure need to be made comprehensible. Aims: We evaluated a novel laparoscopic approach that helps us to decide dorsal dividing line of No. 12a to p to accomplish suprapancreatic LN dissection precisely and safely. Methods: Prior to dissect No. 12a, we identify a border of No. 12a and No. 12p (LN behind the portal vain) from left side view of the hepatoduodenal ligament. We then cut the boundary line and expose the anterior wall of the portal vein, which enable deciding dorsal dividing lines of No. 12a. In the dissection of No. 11p, the left gastric artery is firstly isolated and the splenic vein will be seen from the cranial side by exfoliating a bare area between the gastric corpus and the pancreas body. Thereby we can dissect the anterior wall of the splenic vein as a dorsal border of the No. 11p dissection. Result: We performed this method for 14 cases of gastric cancer patients between Nov. 2010 and Sep. 2011. Mean operation time and blood loss were 273.1 min and 61.1 g, respectively. Mean retrieved number of LNs was 42.7, which was similar to other reports. There was neither conversion to open surgery nor postoperative complication. Conclusion: Our procedure of suprapancreatic lymph node dissection was thought to be a rational method and useful in standardization of D2 LN dissection for advanced gastric cancer in our department.

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ASSOCIATION OF PERIPHERAL WHITE CELL COUNT AND CRP LEVELS WITH POSTOPERATIVE COMPLICATIONS AFTER LAPAROSCOPIC-ASSISTED GASTRECTOMY Hiroaki Tanaka, MD, Kazuya Muguruma, MD, Katsunobu Sakurai, MD, Naoshi Kubo, MD, Hisashi Nagahara, MD, Eiji Noda, Yoshito Yamashita, MD, Kiyoshi Maeda, MD, Tetsuji Sawada, MD, Masaichi Ohira, MD, Kosei Hirakawa, MD, Department of Surgical Oncology, Osaka City University Graduate School of Medicine Introduction: Laparoscopic-assisted gastrectomy (LAG) has been proposed as the promising therapy for early gastric cancer in Japan, because LAG has advantages such as less postoperative pain and an earlier recovery. Nevertheless, severe complication could be likely to occur and result poor outcome after LAG. This study investigated relationship of peripheral white blood cell (WBC) count and C-reactive protein (CRP) levels with the features of postoperative complications after LAG. Methods and Procedures: We analyzed data from 164 consecutive patients who underwent a LAG for gastric cancer at Osaka City University Hospital between 2006 and 2010. The patients’ clinicopathologic characteristics, surgical outcome, and blood test data after surgery were retrospectively examined from their medical records. Clinical characteristics included age, sex, underlying systemic disease, body mass index, operation time, blood loss, WBC count and CRP levels at postoperative day 1. The normal reference level were WBC 4300–8000, CRP 0–0.4mg/dl. The operations were performed for patients with gastric cancer invading the submucosal layer or lower, a D1 or D1+ lymph node dissection according to the Japanese Gastric Cancer Guidelines. Results: The mean age of the patients was 66 years. 77 patients had underlying diseases such as cerebrovascular disease, ischemic heart disease, hypertension, chronic obstructive lung disease and diabetes. The mean BMI was 22.3. Distal gastrectomy was performed in 148 patients, total gastrectomy in 10 and proximal gastrectomy in 4. Postoperative complications occurred in 14 (8.5%) patients: anastomotic leakage in 5, pancreatic fistula in 5, pneumonia in 1, and enterocolitis in 1. Univariate analysis revealed the presence of underlying disease and WBC CRP level at postoperative day 1 were risk factors for postoperative complications after LAG. Odds ratio of postoperative complications was 2.22 in patients with high WBC count (more than 9500) and high CRP (more than 6.5mg/dl). Conclusion: Postoperative complications after LAG could be more likely to occur in patients with underlying systemic disease. To treat these patients with appropriate therapy, it is necessary to focus on WBC count and CRP level at postoperative day 1.

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REALITY CHECK FOR SILS AND NOTES: USING PUBLICATIONS TO PROVIDE PERSPECTIVE ON NEW PROCEDURES Tiffany Stoddard, MD, Igor Milosevic, MD, Stephen Kavic, MD, University of Maryland Medical Center Introduction: It has always been difficult to determine the true worth and utility of a new procedure. However, with the recent explosion in communication and social media, it may not be possible to assess a procedure objectively. Both single incision laparoscopic surgery (SILS) and natural orifice transgastric endoscopic surgery (NOTES) have attracted substantial headlines, but their relative merit remains controversial. Our goal was to attempt to use the totality of the surgical literature as a guide to the current status of these procedures. Methods: We performed a MEDLINE search for total number of references for SILS, stratified by year of publication. We then performed a similar search for NOTES, as a slightly more mature procedure that has remained outside the surgical mainstream. As a model of success, we repeated the search for the model of laparoscopic cholecystectomy (LC). All three procedures were then tabulated from year of first publication for comparison. Results: During our search we found the traditional LC remains a popular topic of discussion with roughly 400-600 publications per year. In contrast the peak number of publications referencing SILS was 88, similar to NOTES at 74. Further, the slope of the curve suggests that the popularity of SILS parallels NOTES moreso than LC. Discussion: Although SILS and NOTES may garner headlines, the volume of surgical literature may be an early guide to the ultimate fate of these procedures. To date, the dissemination of SILS is much more comparable to NOTES than to the initial phase of LC. We conclude that the volume of surgical literature may be an accurate indicator of the actual use and role of newer procedures such as SILS.

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THE EFFECT OF 3D MONITORING SYSTEM ON SINGLE INCISION LAPAROSCOPIC SURGERY Yoshihiro Nagao, MD, Munenori Uemura, MS, Hiroyuki Ishii, PhD, Kenoki Ohuchida, MD, Satoshi Ieiri, MD, Tomikawa Morimasa, MD FACS, Yoshihiko Maehara, MD FACS, Makoto Hashizume, MD FACS CAMIT, Department of Surgery and Science, Kyushu University, Japan Introduction: The purpose of this study is to clarify the difference in forceps’ impact to the ground between traditional laparoscopic surgery (LS) and single incision laparoscopic surgery (SILS), and to evaluate effectiveness of three-dimensional (3D) display in single incision surgery. Materials and Methods: We have developed a novel 3D dome-shaped display (3DD) system, CyberDome. We designed a task, ‘‘pulling a string’’. Thirty two medical students at Kyushu University Hospital were conducted this task. None of them had any experience of laparoscopic surgery. After laparoscopic training by using the same task for 1 h, the trainees did the task in LA and SILS with two-dimensional (2D) display and 3D display. The trainees conducted the task 4 times. The time required for the trainer, the number of errors, and the force added to the ground of this task were evaluated. In this study, Waseda– Kyotokagaku Suture No. 2 Refined II (WKS-2RII) was used. Trainees were required to do the task on the WKS-2RII and we recorded the force added to the WKS-2RII. Statistical analysis was performed by the Wilcoxon singed rank test for the variance. Results: In SILS with 2D display, time was extended (106.0 s vs 95.8 s) and errors (4.9 vs 3.0) and force (121.4 vs 90.4) were significantly increased compared with the LS with 2D display. The increase in force was remarkable in the horizontal direction of forceps. In LS, the 3DD system significantly reduced the number of errors (1.6 vs 2.8) compared with the 2D display in the task. On the other hand, force (87.3 vs 90.4) and time (97.1 s vs 94.0 s) was not improved significantly. In SILS with the 3DD system dramatically improved not only errors (2.0 vs 4.9) but force (94.3 vs 121.4) compared with the SILS with 2D display (Fig. 1). We further found that the 3DD system shortened the execution time (106.0 s vs 96.9 s). Conclusion: In SILS, trainees landed more forceps’ impact to the ground. SILS may require more rigid depth perception of surgeons than LS. The 3DD system is a promising tool for providing depth perception with high resolution to laparoscopic surgeons. The 3DD system demonstrates the effect especially in SILS.

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NEW APPROACH FOR TRANSPERITONEAL LEFT ADRENALECTOMY V.v. Grubnik, Prof, O.s. Burlak, V.v. Ilyashenko, Odessa national medical university Background: Endoscopic left adrenalectomy can be performed using either a retroperitoneal or transperitoneal approach. The aim of this study was to develop a new transperitoneal approach for left adrenalectomy, and evaluate the safeness of this surgical technique. Methods: Design of study-cohort prospective study. From 2009 to 2011, original transperitoneal approach was used in 36 patients. It is performed by transection of gastrosplenic ligament, posterior leaf of parietal peritoneum and retroperitoneal access to the gland. There were 22 incidentalomas, 9 pheochromocytomas, and 5 Conn’s adenoma. Results: Every procedure was performed successfully. There were no conversions. The mean blood loss was 82 ml (range, 70 - 112), mean duration of surgery was 55 min (range, 30–90). The need for placement of drain was in 35% of cases. Mean hospital stay was 4 days (range, 3–7). Conclusions: Novel transperitoneal approach to left adrenalectomy showed safeness. It requires further study to prospectively compare it with retroperitoneal one, in order to chose the best approach for left adrenalectomy.

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IMPACT OF FELLOWSHIP-TRAINED LAPAROSCOPIC SURGEONS ON RATES Garth H Ballantyne, MD MBA, Eric A Sommer, MD, Heidi Elliott, MD, Lawrence & Memorial Hospital Introduction: Many of the early pioneers of Laparoscopic General Surgery practiced in Community Hospitals. Although Evidence-Based Medicine demands the use of minimally invasive techniques, penetration of laparoscopic approaches to General Surgery procedures has remained poor at many community hospitals. Recently, two Fellowship-Trained Advanced Laparoscopic Surgeons and one senior Advanced Laparoscopic Surgeon joined the Medical Staff of a community hospital in SouthEastern Connecticut. The number of General Surgeons at this hospital had declined from 12 to three at the time of the arrival of the three Advanced Laparoscopic Surgeons in 2010. How did the arrival of these Advanced Laparoscopic Surgeons impact practice patterns at this hospital in the use of minimally invasive techniques? Aim: The aim of this study is to illustrate the impact of Fellowship-Trained Advanced Laparoscopic Surgeons on the rates of Open and Laparoscopic General Surgery Procedures in a Community Hospital. Methods: Corrected case logs for General Surgery Procedures at Lawrence & Memorial Hospital were obtained from the Operating Room Scheduling System for the years 1998 through September, 2011. Rates of Open and Laparoscopic Operations are expressed as percentage. Statistical comparisons of groups were accomplished using ANOVA (Data Analysis Package, Excel 2007, Microsoft). Results: Surgeons have performed Advanced Laparoscopic Operations at Lawrence & Memorial Hospital since at least 1998 when our data commences. The rate of Open Adult Appendectomies average 30% but dropped to 10% in 2010 and 0% in 1011. Rates of Open Elective Cholecystectomy have remained stable at about 3.5% throughout the 14 years of this study (see figure). Rates of Open Urgent Cholecystectomies have dropped from an average of 11.6% to 5.8% since the arrival of the Advanced Laparoscopic Surgeons. Open Adult Inguinal Hernias averaged 75% but dropped to 64% in 2010 and 51% in 2011. Rates of Open Elective Colorectal Operations dropped from 100% in 2003 to 36% in 2010 and 25% in 2011. Conclusion: General Surgeons in a Community Hospital performed Advanced Laparoscopic Operations throughout the last 14 years. The rates of Open Operations, however, significantly dropped after the addition of Fellowship-Trained Advanced Laparoscopic Surgeons to the hospital’s Medical Staff. Fellowship-Trained Advanced laparoscopic Surgeons speed the adoption of Advanced Laparoscopic Procedures in a Community Hospital.

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RESIDENT RURAL SURGERY ROTATIONS WITH ENDOSCOPY AND LAPAROSCOPY: IS MORE RESIDENCY TRAINING NEEDED IN THESE AREAS TO PREPARE RURAL SURGEONS? Geary D Bush, MD, Don K Nakayama, MD MBA, Martin L Dalton, MD, Mercer University School of Medicine / The Medical Center of Central Georgia Background: The workforce shortage is especially acute in rural regions, which attract few resident trainees. Methods: To enhance the profile of rural surgery and to expose residents to consider practice in small communities, in March 2010 we offered one month elective rotations to residents in their second and fourth post graduate years (PGY2, PGY4) with surgeons practicing in rural communities, populations 2,600, 11,600, and 17,000 (2010 census). Results. Over a 16-month period 8 residents spent elective rotations with rural practices (6 PGY2, 2 PGY4). The PGY2 residents performed an average of 39.3 cases, of which 5.0 (13%) were colonoscopy and upper endoscopy and 7.5 (19%) were laparoscopic operations. PGY4 residents did more cases, an average of 71, of which 34 (48%) were endoscopies and 7.5 (11%) laparoscopic operations. All residents rated their educational experience as exceptional after the rotation. Both PGY4 and 2 of 6 PGY2 residents will be entering rural practices at the completion of their training. Conclusions: Rotations with preceptors in rural practices provide experience in endoscopy and minimally invasive surgery, procedures that are in demand in small communities. Surgeons in rural practice serve as mentors and role models for residents considering small community settings.

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THE IMPACT OF MINIMALLY INVASIVE SURGERY (MIS) AND OPERATING ROOM (OR) TIME ON BLOOD TRANSFUSIONS AND SURGICAL SITE INFECTIONS Santosh J Agarwal, BPharm MS, Michael E Minshall, MPH, Ned Cosgriff, MD, Ross D Segan, MD MBA FACS, Gary V Delhougne, JD MHA, Covidien Objective: We hypothesized that each 30 min interval increase in OR time and open surgical procedures, independently, would be associated with an additional risk for blood transfusions, surgical site infections (SSI), higher total discharge costs, and increased hospital length of stay (LOS) among open and laparoscopic appendectomy, cholecystectomy, colectomy and gastric bypass (Roux-en-Y). Methods: We identified all adult surgical discharges from the Premier Perspective DatabaseTM for 2010 with principal procedures of open or laparoscopic appendectomy, cholecystectomy, colectomy and gastric bypass. We selected those discharges with OR time between the 1st and 99th percentiles (0.5 to 6.5 h). ICD-9-CM codes were used to identify procedures. We used multivariate logistic regression to estimate the adjusted relative risk of transfusions and SSI while accounting for OR time intervals, procedure and procedural approach (laparoscopic or open), patient characteristics (age, gender, race, anemia, Charlson comorbidity conditions, admission status), and provider characteristics (region, teaching hospital, urban hospital, bed size). We used generalized linear modelling to obtain the adjusted incremental total costs and LOS while adjusting for OR time intervals, procedure and procedural approach, blood transfusions, SSI along with patient and provider characteristics. Results: Of the 93,129 discharges that met the inclusion criteria, 7.7% discharges included blood transfusions and 1.5% discharges developed SSI. Open procedures were associated with 108% (RR: 2.08, 95% CI: 1.93–2.23) increased risk of blood transfusions and 174% (RR: 2.74, 95% CI: 2.38–3.15) increased risk of SSI compared to laparoscopic procedures. After risk adjustment, each 30 min interval increase in OR time increased the risk of blood transfusion by 21% (RR: 1.21, 95% CI: 1.19–1.23) and SSI by 20% (RR: 1.20, 95% CI: 1.17–1.24). Cholecystectomy, colectomy and gastric bypass had higher risk of blood transfusion than appendectomy. Colectomy had higher risk of SSI whereas cholecystectomy and gastric bypass had lower risk of SSI compared to appendectomy. After risk adjustment, open surgery increased total costs by $3,566 (95% CI: $3,331–3,801) and LOS by 2.25 days (95% CI: 2.16–2.33) compared to laparoscopic surgery. After risk adjustment, each 30 min interval increase in OR time increased total costs by $1,456 (95% CI: $1,399–1,514) and LOS by 0.31 days (95% CI: 0.29–0.33). Conclusion: Each 30 min interval increase in OR time and open surgical approach were independently associated with increased risk of blood transfusion and SSI, while also increasing total discharge costs and LOS for appendectomy, cholecystectomy, colectomy and gastric bypass. Efforts to adopt minimally invasive surgery and reduce OR time could improve outcomes and save resources for the healthcare system.

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SURGICAL WAY OF ADHESIONS FORMATION PREVENTION Vladimir M Demidov, PhD D Sci Medicine, Sergei M Demidov, PhD, Medicine Odessa National Medical University, Ukraine Afteroperation period characterizes by the possible numerous complication developments especially in the case of the intraabdominal surgical interventions. One could observe the immediate response inflammative reaction in case of peritoneum trauma (even mild). Clear that it’s impossible to make an operation even with the help of the modern laparoscopic technique without the peritoneal damage. The peritoneal response reaction starts within the first min and hours in the form of the intensive biochemical reaction resulted in the abdominal adhesions formation. The importance of our clinical observation lies in the range that we manage to provide the prophylaxis of the afteroperational adhesions formation in patients during the abdominal operation. 33 patients with acute pancreatitis (AP) and acute cholecystitis (ACh) were operated laparospopically during the last 3 years in the surgical department of the Odessa Municipal Hospital N10. According to their decision, 14 patients received intraabdominal Sandostatin (Novartis Pharma Stein AG, Switzerland) and thioctacid (thioctic or alpha-lipoic acid, Pliva, Croatia) infusions assuming their antiinflammative activities. The rest of the patients (group N2) were operated traditionally without the prophylactic antiadhesive procedures. Theses patients were followed 5–9 days in the hospital, 3, 6 and 12 months during the afteroperational period. Pain intensity and localization as well as abdominal cavity organs ultrasound investigation were performed. The average pain syndrome intensity 6 h after the operation in both groups’ patients was equal to 31.5 ± 5.7 and 34.0 ± 6.2 points, correspondently, that have no statistical difference. 24 h after the operation these data were differed insignificantly (19.7 ± 4.8 and 28.1 ± 4.2 points, correspondently; P [ 0.05). The visceral pain subjective expression 48 h and 5 days after the operation in the 1st group patients was 2.5 times less comparing the same index in the 2nd group patient. Analogous observation in these patients 3, 6 and 12 months after the operations revealed the expressed (in 3 till 7 times) less pain expression in the patients of these two groups. Performed ultrasound investigation 6 and 12 months after the operations showed less cases of the afteroperational adhesions formation in patients with intraoperational antiadhesive treatment. Thus, we report that it is reasonable to provide the prophylactic efforts aimed to prevent the adhesions formation during the laparoscopic operations on the abdominal cavity organs.

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COCOON FORMATION IN PATIENTS WITH MID-GUT NEUROENDOCRINE TUMORS-A RARE AND UNRECOGNIZED FINAL PATHWAY Yi-zarn Wang, MD DDS, Heather M King, MD, Louisiana State University Health Science Center Introduction: Mid-gut neuroendocrine tumors are in general a rare disease with an indolent course. As a result, treatment is often delayed, passive or sometimes omitted. Although the natural history is poorly understood, there is a commonly accepted final pathway for patients with advanced carcinoid cancer. Disease progression leading to death from the sequelae of bowel obstruction, ischemia or liver failure secondary to massive liver metastasis is well described. We have recently recognized a rare and distinct final pathway for patients with long term disease, namely a cocoon formation. Method: Seven patients in our center developed this rare condition in the last three years. Patients’ charts, operative reports, lab results, pathology and tumor markers were reviewed in an attempt to recognize any common denominator. We will also discuss our dismal experience in attempts to intervene or halt disease progression, the results and outcome. Results: No reliable predictor or precondition leading to the development of this condition was identified. Surgical treatment is only partially successful in dealing with these patients, namely those with a Type 1 cocoon. We propose that an advanced form of cocoon encasing the entire abdominal contents be included in the subtype 4. Conclusion: Cocoon formation in long term NET survivors is a rare but lethal terminal disease progression that was not previously recognized or reported. The best treatment is yet to be discovered. Currently, the best approach is to recognize the condition preoperatively if possible and treat expectantly. In contrast to cocoon patients without NETS, surgical treatment is not advisable with the exception of patients with Type 1 abdominal cocoon.

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LAPAROSCOPIC SMALL BOWELL ANASTOMOSIS Nestor F De La Cruz-munos, MD, Francisco J Jacome, MD, Marissa Montgomery UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE

SUBAXILLARY SUBMUSCULAR ENDOSCOPIC APPROACH FOR SUBCLAVICULAR TUMOR Yi-chen Chang, MD, Chun-wei Chang, MD, Far Eastern Memorial Hospital

Introduction: Laparoscopic small bowel anastomoses are completed using the same essential technique as an open anastomosis, but with different instruments. The traditional teaching is to make a transverse closure of the enterotomy. Because the instruments used for laparoscopic procedures are different, the technique needs to be modified to avoid the creation of a stenosis at the edge of the anastomotic ring during closure of the enterotomy. Methods: Three different anastomotic techniques were performed on pig intestine: double staple technique with transverse and longitudinal closures and a triple staple, bidirectional technique. A total of 30 anastomoses were created, 10 per type. Diameters along the anastomosis, including intestinal lumen at 3 anastomotic edges and the anastomotic ring, were measured with wooden spheres. The lumens of the bowel limbs 3 cm distal to the edges of the anastomosis were also measured for reference values. Results: Performing a small bowel anastomosis utilizing the double staple technique with a transverse closure in either a functional end-to-end anastomosis or a Roux-en-Y type anastomosis will compromise the lumen of the bowel at the edge of the anastomotic orifice, thereby creating a probable source for future small bowel obstruction. Performing the same anastomosis with a longitudinal closure will decrease the degree of stenosis and increase the size of the anastomotic lumen. Conversely, the triple staple, bi-directional technique places the enterotomy in the middle of the anastomosis, resulting in closure away from the bowel limbs and thereby avoiding the creation of a stenotic area. Placement of the transverse closure in the middle of the anastomosis decreases the actual orifice of the anastomotic ring, but this is insignificant due to its large size created by the bidirectional staple lines. Conclusion: We propose that a triple staple, bi-directional technique avoids the risk of postoperative partial small bowel obstruction due to anastomotic technique, by moving the enterotomy from the edge of the anastomosis to the middle of a much larger anastomosis, avoiding the creation of a stenosis in one of the limbs. Care must be taken to overlap the staple lines when creating the bidirectional anastomosis in order not to create a defect at the junction. We propose making this technique the standard of care for creation of stapled laparoscopic small bowel anastomosis.

Bilateral axillo breast approach (BABA) for thyroidectomy utilized artificial subcutaneous emphysema to create a space for endoscopic surgery of thyroid. We utilized the similar idea to approach a subclavicular mass via the ports at subaxillary area. Materials and methods: A 23 year-old young lady visited our hospital for a palpable left subclavicular mass. Chest tomography revealed a well-defined mass lesion about 2.3 9 3.7 9 4.3 cm in size, located between pectoralis minor muscle, thoracic cage and adhesion to the subclavian vasculature. Traditional approach was not accepted because the clavicle should be fractured and the scar is not acceptable. We tried endoscopic approach via submuscular space, similar to that of BABA. We incised at lateral aspect of the chest wall. The cuffed trocar was inserted into the plane just beneath the pectoralis major muscle. Then CO2 was insufflated, and the pressure was set at the 15 cm H2O. at the same time, blunt dissection was performed. The pectoral major muscle was lifted from the thoracic cage and we created an working space. After identifying the mass sitting on the subclavian vein, the tumor was carefully dissected and removed completely. Results: The patient’s postoperative recovery was uneventful and the drain tube was removed in the next day. Transient subcutaneous emphysema subsided in 2 days. The final diagnosis was Castleman’s disease. Conclusions: Subcutaneous or submuscular insufflating air to create a working space has been utilized in operations such as TEP and BABA. Now, we tried the similar idea at chest field. We can use the method for approaching other benign chest wall disease like benign tumor or even fixation of fractured rib.

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PROMIS FOR BASIC LAPAROSCOPY Juliane Bingener, MD, Jeff Sloan, PhD, Paul Novotny, MS, Mayo Clinic Background: Traditional physician reported outcomes (e.g. morbidity) have significant limitations when comparing minimally invasive surgical procedures. Interest in patientreported outcomes (PRO), such as pain and fatigue, have led to an NIH sponsored PatientReported Outcomes Measures Information System (PROMIS). PRO supplement physician reported outcomes in some more chronic disease states and have been reliable predictors of survival in advanced lung cancer patients. We wanted to test the performance of these previously validated, standardized PRO measures for use with minimally invasive surgical procedures. Methods: From May through August 2011, 20 patients undergoing basic laparoscopic procedures agreed to participate in this IRB approved study. The PROMIS global health short form, validated for 7-day recall and previously used for 24-h recall, the Linear Analog Self Assessment (LASA), validated for 24 h recall and the 10 mm visual analog scale (VAS) for pain assessment were obtained preoperatively, 4 hrs after surgery and on postoperative day 1 and 7. Each tool was scored and both the composite scores and single item responses were compared over time. Results: 21 patients underwent basic laparoscopic procedures (17 cholecystectomy, 3 diagnostic laparoscopy with biopsy and 1 cystic stump remnant resection) as outpatient procedures. Patients followed a standardized perioperative pain regimen with scheduled Acetaminophen, NSAIDS or Tramadol and weak opioids as necessary. For patients undergoing cholecystectomy the highest mean score was reported on postoperative day 1, (5.17; range 0–10), a 3 point increase from the baseline mean score of 2.06 (range 0–9). The PROMIS total-scores for mental and physical health did not vary over time. The single item PROMIS scores for social activity exhibited more movement from baseline around postoperative day 1 than the domains of pain, fatigue and physical activity. Changes from baseline in the LASA measurements were also noted on POD 1 in the domains of social activity, fatigue and pain, however not in overall physical health or physical activity. The VAS exhibited more change in scores than the pain items of the PROMIS or LASA tools. The pain score correlation (Bland Altman) was 0.82 for the PROMIS and LASA tools. Conclusion: Overall quality of life scores with 7-day recall have limited utility for the evaluation of minimally invasive procedures. Single items with 7-day recall appear more promising. Evaluation of 24-h recall for single items may be of value. Changes appear to occur from baseline to the first 24 h.

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RISK FACTORS FOR RESPIRATORY INSUFFICIENCY, ARREST AND FAILURE AMONG SELECTED OPEN AND LAPAROSCOPIC PROCEDURES—ANALYSIS OF 90,000+ PROCEDURES Scott D Kelley, MD, Santosh J Agarwal, BPharm MS, Mary G Erslon, RN MS MBA, Jen Seda, MD, David B Lautz, MD, Covidien, Brigham and Women’s Hospital Introduction: Appendectomy, cholecystectomy, colectomy and Roux-en-Y gastric bypass are the most common surgical procedures performed using either open or laparoscopic approaches. Respiratory insufficiency, arrest and failure (RIAF) are important perioperative complications, and have become a hospital focus under Medicare’s Inpatient Quality Reporting Program (Patient Safety Indicator #11). Risk factors for RIAF have been examined in a number of studies; however, there has been no estimate of the relative risk of developing RIAF following open versus laparoscopic procedures. We sought to examine independent procedural and patient risk factors for the development of RIAF after open versus laparoscopic abdominal surgery. Methods: We used the Premier Perspective (Premier, Inc.) Database 2010 to identify adults who underwent either open or laparoscopic appendectomy, cholecystectomy, colectomy and Roux-en-Y gastric bypass. ICD-9-CM codes were used to identify patients with respiratory insufficiency, arrest and failure (RIAF) and surgical procedures. Multivariate logistic regression analysis was used to determine the risk factors for development of RIAF. Procedure type, open/laparoscopic approach, OR time, provider characteristics, admission category, patient demographics, comorbidity index, obesity, sleep apnea and naloxone administration and comorbidity index, were used as independent variables. Results: There were 94,154 surgical discharges that met inclusion criteria. RIAF were present in 2,444 (2.6%) of discharges. Appendectomy procedures had the lowest incidence of RIAF. Compared to appendectomy, colectomy procedures had 251% increased risk of developing RIAF, gastric bypass had 166% increased risk and cholecystectomy had 103% increased risk. Open procedures were at 209% increased risk of developing RIAF than laparoscopic procedures (RR: 3.091, 95% CI: 2.767–3.453). Increased age, comorbidity index and non-elective surgeries were associated with increased risk of RIAF. Patient obesity (RR: 1.31, 95% CI: 1.16–1.48) sleep apnea (RR: 1.85, 95% CI: 1.59–2.15) and process-of-care variable increased OR time (RR: 1.04, 95% CI: 1.02–1.06) were associated with higher risk of RIAF development. Naloxone administration (RR: 3.03, 95% CI: 2.61–3.53) is a possible independent indicator of RIAF. Conclusions: The patient and procedure factors of obesity, sleep apnea, open surgical approach, and increased operative time were independently associated with increased RIAF rate in select abdominal surgery cases. Minimally invasive surgical approaches as well as monitoring for and management of respiratory compromise in this population could reduce the risk of developing RIAF.

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A CASE OF AN INFLAMMATORY PSEUDOTUMOR OF THE SPLEEN DIAGNOSED BY LAPAROSCOPIC SPLENECTOMY Hiroshi Tajima, Hiroki Kamata, Hiroyuki Katagiri, Kenichiro Ishii, Yusuke Kumamoto, Kazunori Furuta, Masahiko Watanage, Department of Surgery, Kitasato University School of Medicine, Sagamihara, Japan

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DOLLAR 5 LAPAROSCOPIC APPENDECTOMY Muhammad f Murad, MBBS MCPS FCPS, Qasim Ali, FCPS, Asif Zafar, FRCS FCPS, Farhat Jehan, MBBS, Holy Family Hospital, Rawalpindi

In many cases splenic tumor qualitative diagnosis before surgery is difficult, as diagnostic and treatment often require spleen removal surgery. We experienced a case of an inflammatory pseudotumor of the spleen witch was incidentally found and diagnosed by laparoscopic splenectomy. A 59-year-old woman admitted for medical examination of a hypoechoic tumor in the spleen found by abdominal echography had no complaints. Abdominal enhanced CT showed heterogeneous enhanced tumor of spleen in early phase and delay phase. We conducted laparoscopic splenectomy under a diagnosis of primary splenic tumor, because a possibility of malignancy could not be ruled out. The postoperative histological findings showed an inflammatory pseudotumor of the spleen. We often have difficulty in making diagnosis of inflammatory pseudotumors of the spleen by imaging methods before operation. Inflammatory pseudotumor is basically benign and has good prognosis. So if it can be diagnosed preoperatively in future, its clinical course can be observed. However, recent report have described that inflammatory pseudotumors include true neoplasm. We have to consider to perform operation for diagnosis as well as therapy.

Introduction: Laparoscopic Surgery is considered to be associated with high costs in developing countries. Apart from initial equipment cost, there are additional recurring expenses per procedure. Adopting to alternate procedural techniques in laparoscopic surgery using conventional gadgets reduces the procedural cost and can have a positive impact on wide practice of laparoscopy in surgical clinics. An experience of performing laparoscopic appendectomy using just one suture of Polyglactin is desribed. Materials and Methods: All laparoscopic appendectomies performed in holy family hospital from jan 2010 to aug 2011 are included in the study. all the procedures were performed using just one suture of polyglactin. Base of appendix is secured with loop knot of poly glactin and mesoappendix dealth with simple cautry or polyglactin loop tie. appendix was delivered through 10 mm working port without use of endobag. in this technique the reusable instruments were used bringing the per procedure sutgical item cost less than 5 dollars. Results: 506 laparoscopic appendectomies were performed during the period. Mean age of the group was 18.5 years (SD 3.6). Mean post operative stay was 18 h (SD 6.4). There was no incidence of significant intraoperative bleed from appendicular artery, secondary bleeding, leak of appendicular stump or wound infection. Conclusion: Use of self made loop knot to secure base of appendix and mesoappendix is safe and brings the cost of appendectomy procedure to less than 5 dollars

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LAPAROSCOPIC GASTRECTOMY FOR EARLY GASTRIC CANCER Waldemar Adelsdorfer, MD, Dulce Momblan, MD, Cedric Adelsdorfer, MD, Elizabeth Pando, MD, Salvadora Delgado, MD, Raul Almenara, MD, Ainitze Ibarzabal, MD, Antonio Lacy, MD, Hospital Clinic de Barcelona

LAPAROSCOPIC EXCISION OF LARGE RETROPERITONEAL CYSTIC LYMPHATIC MALFORMATION IN A 21 MONTH CHILD Bethany Slater, MD, Ashwin Pimpalwar, MD Division of Pediatric surgery, Michael E Debakey, Department of surgery, Baylor college of medicine and Texas Children’s Hospital, Houston, Texas.

Introduction: The incidence of early gastric cancer has increased in recent years, up to 50% in some countries, like Japan. Laparoscopic gastrectomy is a complex procedure and requires experienced surgeons. The aim of this study was to evaluate the surgical outcomes and oncological medium-term results of a series of patients undergoing laparoscopic gastrectomy for early gastric cancer. Patients and Methods: Prospective study of consecutive patients undergoing laparoscopic gastrectomy for early gastric cancer between January 2005 and October 2010. Early gastric cancer was defined according to Japanese Classification of gastric carcinoma. We analyze the demographic and clinical variables, surgical outcomes, morbidity and postoperative mortality, and oncologic outcomes. Results: 27 laparoscopic gastrectomy were performed, 15 total, 9 subtotals and 3 partial. The average age was 67 ± 16, 59.3% were female. 74.1% had co-morbidity. 63% were ASA II. 92.6% of the cases were symptomatic, 33.3% had anemic syndrome, 25.9% upper gastrointestinal bleeding and 25.6% abdominal pain. The location of the tumor was 11.1% in the upper third, middle third 55.6% and lower third 33.3%. pTNM Stage was 0 in 11.1%, 59.3% IA and 29.6% IB. Mean operative time was 243 min ± 81. Conversion in 1 patient due to difficulty in mobilizing the tumor. Regional lymphadenectomy in 18.5%. Lymphadenectomy D1 in 25.9% and D2 55.6% The average of lymph nodes retrieved was 12 ± 9. R0 resection was performed in 100% of cases. They had to be re-operated 3 patients, 1 for intraabdominal collection and 2 for bleeding. Operative morbidity was 22.2%, 1 patient presented suture failure of conservative management. There was no operative mortality. The hospital stay was 9 ± 6 days. The median follow-up was 26 months. Overall survival was 90.5% at 36 months. Specific disease-survival was 83.3% at 36 months. The overall recurrence rate was 7.4% (2/27), 1 with local recurrence (81 years) and 1 with liver metastases (84 years). Disease-free survival was 84% at 36 months. Conclusions: Laparoscopic gastrectomy in early gastric cancer is a feasible and safe procedure in hands of experienced surgeons with comparable oncologic outcomes to open surgery. The surgical outcomes and oncology results are similar to other publications. There was no operative mortality in our series.

Background: Lymphatic malformations of the retroperitoneum are large diffuse malformations extending across different planes. It is difficult to excise them completely whichever approach is used. Laparoscopic approach for their excision has not been described for children less than 2 years old. Purpose: To describe our laparoscopic approach for excision of large retroperitoneal cystic lymphatic malformation in a 21 month child. Material and Methods: The charts of the 21 month child with large retroperitoneal cystic lymphatic malformation were retrospectively reviewed. Technique: An incision was made in the scar of the umbilicus and a 3 mm one-step expandable port was introduced. Thereafter a 3 mm 30 telescope was introduced after pneumoperitoneum was achieved with CO2 of 5 l/min and a pressure of 12 mmHg. Once adequate pneumoperitoneum was achieved, two more ports were placed, one in the midline and one in the left flank. Both of them were 3 mm one-step ports. Using the grasper, it was found that there was a large retroperitoneal lymphatic cyst behind the cecum and the ascending colon going right up to the liver and into the pelvis. Using the hook diathermy, the cyst was gently and meticulously dissected. It was possible to completely remove the cyst with all its attachments without any problems. There were no complications. The rest of the peritoneal cavity looked pristine. At the end of the procedure, the mesentery of the appendix was taken down with a harmonic scalpel and the appendix was resected using three 2-0 PDS Endoloops and removed through a 5 mm port. The mesenteric cyst was also pulled out through the port site without difficulty. Once this was done, the peritoneal cavity was inspected again and the ports were withdrawn under vision. The umbilical fascia was closed with 2-0 Vicryl on a UR6 needle. Results: The child was on full feeds by 24 hrs and was discharged home in 48 h. At 3 months and 6 months follow up the child scars were almost invisible. US abdomen did not reveal any residual or recurrent lymphatic malformation. Conclusion: Laparoscopic excision of large retroperitoneal cystic lymphatic malformation in children less than 2 years old is feasible and safe, provides excellent cosmesis and has all the other advantages of laparoscopy. Laparoscopic approach may be attempted in selected cases to prevent large scars and morbidity associated with it.

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LAPAROSCOPIC RESOLUTION OF 30 CASES OF ACUTE SMALL BOWEL OBSTRUCTION IN AN UNIVERSITY CENTER Nicola´s Quezada, MD, Jose´ Salinas, MD, Alex Jones, MS, Isabella Passalacqua, MD, Paula Pino, MS, Enrique Norero, MD, Ricardo Funke, MD, Fernando Crovari, MD, Nicola´s Jarufe, MD, Camilo Boza, MD, Digestive Surgery Department, Hospital Clı´nico P. Universidad Cato´lica de Chile Introduction: Acute small bowel obstruction (ASBO) has been traditionally treated by laparotomy. Laparoscopy has emerged as an alternative but it is not widely accepted. The aim of this study is to show our initial results of the laparoscopic approach to ASBO in an university center. Methods and Procedures: A retrospective analysis of our prospectively collected clinical database. A laparoscopic approach was done in 30 out of 470 ASBO cases between June 2006 to June 2011. Demographic data and surgical variables, such as final diagnosis, surgery performed, technique to access to peritoneal cavity, conversion to open surgery, bowel resection, operative time, time to refeeding, complication and mortality were recorded. Results: Thirty (6.4%) cases were identified, 47% male, mean age 47 ± 12 years (range: 25–72). Seventeen patients had prior surgeries and thirteen had no previous intra abdominal surgeries. The technique selected to access the peritoneal cavity was Veress needle insertion in 5 patients (17%), Hassan technique in 13 (43%) and direct visualization with optic insertion in 12 (40%). There were no injuries to any organ with any selected technique. Laparoscopic exploration and resolution of the ASBO was possible in 25 (83%) patients, there were 5 conversions, 2 due to bowel ischemia and resection, 1 due to tumor resection, 1 due to difficulty lysis of adhesions and 1 due to uncertain diagnosis. Mean operative time was 69 ± 39 min (range: 25–180), but if converted patients are excluded, mean operative time is 56 ± 27 (range: 25–130). Refeeding was done 49 ± 31 h after surgery (range: 24 to 120) and hospital discharge was done 4.9 ± 2.3 days after surgery (range: 2–9). There were no reoperations in the same hospital admission and. There were only 1 atelectasis as a complication and we had no mortality in our series. Conclusions: Laparoscopy seems a feasible and safe approach to ASBO, especially in patients with no previous intraabdominal surgeries. In our series, we show a high rate of diagnosis accuracy (97%) and surgery could be concluded by laparoscopy un 83% of cases, similar to data reported in literature.

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SYSTEMATIC REVIEW OF ROBOTIC-ASSISTED COLON AND RECTAL SURGERY Aliyah Kanji, MD, Richdeep S Gill, MD, Xinzhe Shi, MPH, Daniel W Birch, MD, Shahzeer Karmali, MD, Department of Surgery, University of Toronto and University of Alberta Introduction: Colorectal surgery is one of the most common procedures performed by general surgeons with an increasing number being performed laparoscopically. Robotic technology is emerging as the next evolution in minimally invasive surgery, and may address some of the challenges and limitations of standard laparoscopy. In this study, we systematically review the literature regarding the safety and feasibility of robotic-assisted colorectal surgery. Methods: An electronic data search of MEDLINE, PubMed, Embase, Scopus, Dare, Clinical Evidence, TRIP, Health Technology Database, Conference abstracts, clinical trials, and the Cochrane Library database was completed. All case series and clinical trials assessing robotic-assisted colorectal surgery were included. The search terms used included robotic, robot, telerobotic, telerobot, computer assisted, computer aided, da Vinci, colorectal, colon, rectal, general surgery, abdominal surgery and gastrointestinal surgery. All human studies, limited to English, from 2000 to August 2010 were included. Two independent reviewers assessed the studies for relevance and inclusion, and extracted data from the full versions of the manuscripts. Data was pooled for statistical analysis. Results: After an initial screen of 347 titles, 20 studies met the inclusion criteria. A total of 854 patients were included with a mean age of 61 years and a body mass index of 25.5 kg/ m2. There were 27 anastomotic leaks from a total of 766 patients (3.5%). There were 10 post-operative bleeds in 854 patients (1.1%). The post-operative infection rate was 1.6% (14/854). There were no mortalities reported. Overall the conversion rate to either conventional laparoscopic or open surgery was 3.7%. Mean operative time was 236 min (range 154 to 384) and length of stay was 5.9 days (range 2.6 to 9.8). Conclusions: This systematic review demonstrates that robotic-assisted colorectal surgery is both a safe and feasible option. However, further research is needed to determine if the increased operational costs are warranted.

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NOVEL USE OF A SURGICAL ROBOT IN BILATERAL CORTICAL-SPARING RETROPERITONEOSCOPIC ADRENALECTOMY FOR PHEOCHROMOCYTOMA Nikolaos A Dallas, MD, Camilo Jimenez, MD, Steven G Waguespack, MD, Isabella M Iupe, Paxton V Dickson, MD, Elizabeth G Grubbs, MD, Nancy D Perrier, MD UT MD, Anderson Cancer Center Objective: For patients with bilateral pheochromocytomas, adrenalectomy with corticalsparing technique is a feasible option to reduce the need for lifelong steroid supplementation. The posterior retroperitoneoscopic adrenalectomy (PRA), both cortical-sparing and complete, has been described. Here we report a new technique using a surgical robot in treating this disease. Methods: A 39 yo female patient with multiple endocrine neoplasia 2A with bilateral pheochromocytomas was identified. The patient was positioned, ports were introduced, and the robot was docked as previously described for a left adrenal approach. The tumor was identified and the normal appearing medial adrenal cortex was separated from the masscontaining portion. The remaining adrenal cortex appeared viable after specimen removal. The robot was then repositioned for a right-sided approach and a total adrenalectomy was performed in standard fashion. Results: The patient’s operation was uncomplicated. Surgical time was 3:04 (hours:min). Blood loss was negligible. She was admitted to the hospital for 48 hrs. Final pathology revealed a 5.1 cm left- and a 3.5 cm right-sided pheochromocytoma. She had a normal response to a high-dose cosyntropin-stimulation test immediately after surgery and at 6 months post-operatively. Conclusions/Eepectations: This case represents the first reported robot-assisted bilateral cortical-sparing PRA with excellent results, demonstrating feasibility of this technique. This approach combines the advantages of the described retroperitoneoscopic technique and those of the surgical robot while preserving adrenocortical function. We expect this technique to be applicable for patients with bilateral disease.

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DIAPHRAGMATIC INJURY DURING ROBOTIC NEPHRECTOMY Alexander Ramirez Valderrama, MD, Gerald J Wang, MD, New York Hospital Queens With the widespread use of cross-sectional imaging, more asymptomatic solid renal masses are being detected. Robotic partial nephrectomy is more frequently performed for the treatment of incidentally detected small renal mass. We present a video of a 55 year-old male with a right inferior pole mass who underwent robotic radical nephrectomy. During the procedure two small diaphragmatic tearing was made with the laparoscopic grasper when liver separation was performed to expose the hepatorenal recess. This injury was identified and two intracorporeal sutures was placed to repair the defects. The patient did not develop intra-operatory clinical pneumothorax and a chest XR performed after the procedure was normal. The patient was discharge in the post operatory day four without any complications.

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HYBRID ROBOTIC RIGHT HEMICOLECTOMY FOR CANCER OF THE ASCENDING COLON: A CASE CONTROL STUDY Emilio Morpurgo, MD, Tania Contardo, MD, Antonio Zerbinati, MD, Camillo Orsini, MD, Roberta Molaro, MD, Department of Surgery; Center for robotic and laparoscopic surgery; Hospital of Camposampiero Introduction: The role of the robotic da Vinci system in right hemicolectomy is not fully understood. Aim of the study is the evaluate the operative and postoperative results of hybrid laparoscopic-robotic right hemicolectomy with intracorporeal anastomosis for adenocarcinoma of the ascending colon as compared with the standard laparoscopic approach with extracorporeal anastomosis in a case control study Materials and Methods: Thirty consecutive right hemicolectomies for cancer (January 2008–june 2011) with laparoscopic medial to lateral dissection, vascular ligation, bowel transection and robotic intracoporeal anastomosis with specimen extraction through a Pfannestiel incision (robotic group-RG) were compared with 30 consecutive laparoscopic hemicolectomies (january 2008–june 2011) with extracorporeal anastomosis and specimen extraction through a periumbilical minilaparotomy (laparoscopic group-LG). Patients were started on oral diet after the first passage of gas and discharged when fully functional. Operative and postoperative results were entered in prospectively maintained data base and analysed using Chi square and t-test when appropriate. Results: The 2 groups were comparable with respect of age, gender, stage of cancer, BMI. Operative time was significantly longer in RG (RG 268 ± 40 vs LG 228 ± 56 min, p \ 0.05). Length of specimen (RG 26 ± 7, LG 24 ± 3 cm), number of lymphnodes (RG 26 ± 13, LG 25 ± 13) did not differ between the 2 groups. Recover of bowel function (day of first bowel movement: RG: 3 ± 0.8; LG: 4 ± 1.2; p \ 0.05) and hospital stay (RG: 7 ± 3; LG: 9 ± 3.6; p \ 0.05) were shorter in RG. There were 3 anastomotic complications (1 twist of the anastomosis, 2 leaks) and 3 ventral hernias in LG and none in the RG (p = 0.07). Conclusion: This hybrid technique of laparoscopic mobilisation and dissection of the right colon with robotic intracorporeal anastomosis allows a faster recover when compared to standard laparoscopy. Anastomotic complications are lower with this technique even though the difference did not reach statistical significance, probably because of the small sample size. These results may be explained by the fact that robotic intracorporeal anastomosis is performed comfortably without pulling the bowel through a small minilaparotomy, without the need of an unnecessary mobilisation and manipulation of the transverse colon and under direct visualisation of the mesentery. In addition the Pfannestiel incision seems to have a lower risk of ventral hernia when compared to the periumbilical minilaparotomy that is needed to accommodate the transverse colon and the small bowel in order to perform the extracorporeal anastomosis

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ROBOTIC-ASSISTED COMMON BILE DUCT EXPLORATION AS AN OPTION FOR COMPLEX CHOLEDOCHOLITHIASIS Nawar A Alkhamesi, MD PhD FRCSGenSurg FRCS FRCSEd, Ward T Davies, MD FRCSC, Fiona R Pinto, BA, Christopher M Schlachta, BSc MD CM FRCSC FACS, Department of Surgery, Schulich School of Medicine and Dentistry, The University of Western Ontario Introduction: The objectives of this study are to describe our early experience with robotic-assisted common bile duct exploration (CBDE) for choledocholithiasis refractory to endoscopic therapy and to compare outcomes to equivalent patients undergoing an open technique. Material and Method: Fifty-five CBDE were performed in our institution between 2005 and 2011. All 19 robotic-assisted cases were unselected, elective referral for stone disease. Of 36 open procedures, emergency cases and exploration not for stone disease were excluded leaving 18 cases for analysis. Cases were analyzed on an intent-to-treat basis. Statistical significance was considered at p = 0.05. Results: There were no differences in patients’ demography, comorbidity, or presenting symptoms. Reasons for endoscopic failure in both groups were similar. Comparing robotic-assisted to open surgery, mean operating time was longer 220 ± 41.26 vs. 169 ± 65.81 min. (p = 0.01); however, median length of stay was shorter 4 vs. 11 days (p = 0.02). There were 4 conversions to open surgery (21%) due to severe adhesions. No statistical difference in T-Tube usage between the groups (74% vs. 61%, V2 = 0.667, p = 0.414). There were 2 deaths in the open group and one in the robotic cohort. Postoperative complications occurred in 10 open vs. 7 robotic cases (V2 = 0.703, p = 0.402), they were mainly cardiac and wound related in the open group and respiratory among robotic-assisted cases. Of the converted cases, 2 had similar complications to the open group. Postoperative ERCP for retained stones was performed in one open and 3 robotic case. Conclusion: Robotic assisted common bile duct exploration offers some benefit when ERCP fails. Ideal case selection may enhance success.

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ROBOTIC ASSISTED RESECTION OF COMPLEX RETROPERITONEAL SOFT TISSUE TUMORS IN AN OUTPATIENT SETTING Gary N Mann, MD, Eelco B Wassenaar, MD, Jonathan D Harper, MD, University of Washington Introduction: Central retroperitoneal tumors usually necessitate a major abdominal incision for their removal, with several days of inpatient recovery. This is because of their deep location and the relationship to critical viscera and major abdominal blood vessels. The purpose of this paper is to report our initial experience with roboticassisted laparoscopic excision of these masses in an outpatient setting. Patients: Two patients underwent robotic excision of central retroperitoneal soft tissue tumors. Both were female, 60 and 28 years of age, with an average BMI of 29 (27–32). Each tumor was incidentally detected on cross-sectional imaging done for evaluation of pain. Core needle biopsies confirmed schwannoma in both patients. One patient had a 2 cm right-sided lesion that was located posterior to the inferior vena cava and below the renal vein. The second patient had a 2.7 cm left-sided mass found at the junction of the aorta and the left renal vein. After discussion of options, the decision was made to excise these lesions. Results: Surgery was uneventful, successfully performed in a minimally invasive fashion, and greatly facilitated by the da Vinci robot after respective right and left medial visceral rotation. Operative time was 123 and 163 min respectively, with 30 cc of estimated blood loss. There were no complications, and patients were discharged the same day. Both were doing well in follow-up. Pathology confirmed schwannoma with margins free of tumor. Conclusion: In select patients, centrally located retroperitoneal tumors can safely be resected in an outpatient setting using robotic-assisted laparoscopic techniques.

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UROGENITAL FUNCTION AFTER ROBOTIC-ASSISTED LAPAROSCOPIC RECTAL CANCER SURGERY James Tak-kwan Fung, FRCSEd, Hester Yui-shan Cheung, FRACS, Lawrence Wing-chiu Ng, FRACS, Chi Chiu Chung, FRCSEd, Michael Ka-wah Li, FRCS FRCSEd, Department of Surgery, Pamela Youde Nethersole Eastern Hospital

SHORT-TERM OUTCOME IN INTERSPHINCTERIC RESECTION USING THE DA VINCI S SURGICAL SYSTEM FOR LOWER RECTAL CANCER Tsunekazu Hanai, MD, Koutarou Maeda, MD, Kouji Masumori, MD, Hidetoshi Katsuno, MD, Ichiro Uyama, MD, Department of Surgery, School of Medicine, Fujita Health University

Introduction : Despite improvement in surgical approach and technology, total mesorectal excision for low rectal cancer has been associated with significant postoperative sexual and urinary dysfunction. We hypothesize that robot-assisted laparoscopic total mesorectal excision can achieve maintenance of such functions by its more assured pelvic splanchnic nerve preservation. Method: We prospectively assessed the pre- and post-operative sexual and urinary function of male patients who received robot-assisted laparoscopic total mesorectal excision for rectal cancer since May 2009. The International Prostatic Symptom Score (IPSS) and International Index of Erectile Function (IIEF-5) were employed for such assessment. The baseline and the post-op 3 months assessments of sexual and urinary function were analyzed and compared. Results: In the 24-month period of study, twenty-six male patients were recruited. Their mean age was 64 years (range 33-85). Eighteen patients (69.2%) received sphincter-preserving resection of rectum. Eight patients (30.8%) had either neoadjuvant or adjuvant irradiation as a part of their treatment. The mean baseline and post-op 3 months IPSS were 3.8 and 4.0 respectively. There was no significant difference in IPSS after operation. Eleven patients (42.3%) were sexually active before the operation. The mean baseline and post-op 3 months IEFF-5 were 13.3 and 10.4 respectively. There was no significant difference in IEFF-5 after operation. Conclusion: In contrast to traditional open or laparoscopic total mesorectal excision, our preliminary data in robot-assisted laparoscopic rectal cancer excision is encouraging and suggests that robot is more than just a surgeon’s tool but the clarity of the surgeon’s view and the ease by which the surgeon operate can be translated into better functional outcomes in our patients.

Introduction: Robotic colorectal surgery underwent twenty-one patients since it was first used in Sep 2009 at the Fujita-Health University Hospital. We have performed 4 cases of intersphincteric resection with TME by using the da Vinci S Surgical System. The short-term outcomes and the procedure for it are described. Patient and Methods: Patients cT1 and pT1 were included as indication criteria. Operative techniques by using the da Vinci S Surgical System: A total of 6 port sites (using four 12 mm laparoscopic ports and three 8 mm da Vinci ports) were placed and the position of each port is detached 10 cm each. Total mesorectal excision with high tie of the superior rectal artery or the inferior mesenteric artery were all performed with the Robotic surgery in one cart position. After the procedure, the patient cart was detached from the patient bed. The specimen was pulled out peraually and the anastomosis was performed from the anus. Result: No conversion to open or laparoscopic surgery occured. The median operating time was 491 (range 426–571) min and the estimated blood loss was 90 (range 20–70) g respecting. Postoperatively, One patient had a pelvic abscess that could be managed with conservative therapy. The surgical margin was negative in all cases. The number of lymphnode harvested was 19 (range, 14–25) Conclusion: Intersphincteric resection by Robotic surgery was successfully accomplished. Further experience is needed to shorter the operative time.

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SHORT-TERM OUTCOME OF ROBOTIC SURGERY FOR MID OR LOWER RETAL CANCER AFTER PREOPERATIVE CHEMORADIOTHERAPY Yong Sok Kim, MD, Sung Chan Park, MD, Ji Won Park, MD, Dae Kyung Sohn, MD, Jae Hwan Oh, MD, Center for Colorectal Cancer, National Cancer Center, Goyang, South Korea

ROBOTIC SURGERY IN GYNECOLOGY: PROGRAM INITIATION AND EARLY OUTCOMES AT A COMMUNITY HOSPITAL Salim Abunnaja, MD, Lucian Paniat, MD, Mark Albini, MD, Issa Mirmehdi, MS, Jinesh Shah, MS, Juan Sanchez, MD, Saint Mary’s Hospital

Purpose: The short-term outcome of robotic surgery for mid or lower rectal cancer after preoperative chemoradiotherapy has not been well reported. The aim of this study was to evaluate the safety and feasibility of robot-assisted total mesorectal excision after preoperative chemoradiotherapy. Methods: From March 2010 to July 2011, twenty-six patients with cT3N0–2 mid or lower rectal cancer without distant metastasis underwent robot-assisted total mesorectal excision after preoperative chemoradiotherapy. Perioperative, pathologic, and postoperative outcomes were reviewed retrospectively. Results: There were 16 (61.5%) men and 10 (38.5%) women, with a mean age of 54.6 years (range, 35–74). Mean BMI was 23.5 ± 2.3 kg/m2 and mean distance from anal verge was 6.0 ± 1.6 cm. We performed 15 (57.7%) low anterior resections and 11 (42.3%) ultralow anterior resections with double stapling or with coloanal anastomosis. A protecting ileostomy was performed for all the patients. There were four cases of conversion to laparoscopic surgery (15.4%). Mean anesthesia time was 507 min (range, 365–685) and the mean console time was 251 min (range, 115–414). The mean blood loss was 217.3 ± 149.0 mL. There were no intraoperative complications in this series. The mean lymph node harvested was 21.2 ± 9.5 and the circumferential resection margin was positive in one patient (3.8%). According to the quality of total mesorectal excision, fifteen patients (57.7%) were complete, 10 patients (38.5%) nearly complete and one patient incomplete. The mean time of first flatus was 1.9 ± 1.1 days and mean length of stay was 10.0 ± 3.2 days. Postoperative complications included 12 patients (46.2%). One patient required reoperation because of anastomosis disruption. There was no postoperative mortality. Conclusion: Our preliminary results suggest that robot-assisted total mesorectal excision for mid or lower rectal cancer after preoperative chemoradiotherapy is a safe and feasible technique.

Introduction: Robotic surgery has become an integral part of gynecological surgery in major academic hospitals across the United States. Many smaller community hospitals are now initiating their own robotic programs. Our robotic gynecology surgery program was recently initiated we review our experience to date. Methods: We conducted a retrospective medical chart review of the first 215 robotic gynecological procedures from February 2010 to April 2011. Results: A total of 215 patients with benign or malignant conditions were operated on by five robotic surgeons using a double-console da Vinci surgical system. The procedures included 77 total hysterectomies, 65 total hysterectomies with salpingo-oopherectomy, 29 supracervical hysterectomies, and 44 other gynecological procedures. The average hospital stay was one day with only four patients staying more than 3 days. There were no mortalities in our series; only five procedures were converted to open procedures, with a conversion rate of 2.33%. The only significant early post operative complication was an incarcerated port site dehiscence in one patient. Conclusion(s): Our early experience with robotic surgery in gynecology shows that it is safe and feasible in a community setting. Patient recovery is excellent, and hospital stays are short .Use of the double console system increases participation by residents and new surgeons in robotic surgeries and appears to be a promising educational tool.

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ENHANCED LEARNING IN ROBOTIC SURGERY USING FEEDBACK AND DISTRACTION Irene Suh, MS, Kevin Clay, MD, Chad Lagrange, MD, Dmitry Oleynikov, MD, Ka-chun Siu, PT PhD, University of Nebraska Medical Center, University of Nebraska at Omaha, Omaha, NE, USA. Introduction: Distractions are recognized as a significant factor affecting performance in hospitals. Although operating rooms are generally full of distractions, little is known about the effect of distractions on robot-assisted surgical performance. Direct communication with the bedside assistant, nursing staff, and anesthesia is limited by the separation of the surgeon console from the sterile surgical field. However, the role of feedback in counteracting distraction on learning has not been well studied. The objective of this study was to investigate the role of feedback on skill learning in robotassisted surgery with the presence of distractions. Methods and Procedures: Eighteen subjects were randomly assigned into three groups: outcome feedback (OFD), process feedback (PFD) and control group without any feedback. Participants performed a suturing task using intracorporeal knot with the Da Vinci Surgical System (dVSS). PFD was provided while watching subjects’ previously recorded performance whereas OFD was provided based on the result of the performance. Subjects were exposed to three distractions intermittently during training: passive, active and interactive. Passive distraction entailed listening to background noise with a constant heart rate. Active distraction included listening to background noise with random heart rate changes from 60 to 120 bpm and subjects had to acknowledge this change. Interactive distraction involved answering math questions during the task. Kinematics [time to task completion (TTC) and total distance travelled (TD) of the dVSS instrument tips] were measured before and after training and again 2 weeks after training. Error rates during the training trials were also recorded. A one-way ANOVA was applied to test the differences in kinematics between pre- and post-test as well as pre- and retention test. Results: Significant learning effect was found in TTC and TD (p \ 0.001) for pre- to post-test and the learning effect was significantly sustained in retention test (p \ 0.001). There was greater reduction in TTC in OFD group (p = 0.008) than other groups between post- and retention test. The error rates were 28% less in OFD group and 16% less in PFD group than the control group. Subjects in OFD group exhibited a lower error rate (12%) than PFD group. Conclusions: Compared with process feedback, outcome feedback seems to be more prominent in minimizing the effect of distraction on learning in robotic surgery. This feedback could potentially be useful to enhance training regimen for surgical trainees. Further investigation is required to study the effect of feedback on robotic surgical learning in different skill levels of surgical trainees (e.g. medical students vs. residents) to confirm our findings.

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VALIDATION OF TRAINING PROGRAM FOR BASIC SURGICAL TECHNIQUES IN ROBOTIC SINGLE PORT SURGERY Gangmi Kim, MD, Byung Soh Min, MD, Huyk Hur, MD, Seung Hyuk Baik, MD, Kang Young Lee, MD, Nam Kyu Kim, MD, Yonsei University College of Medicine, Seoul, Korea Introduction: With increase in application of the robotic system to general surgery, there comes a necessity of a training program for surgical trainees or novices. However there is no standardized training program for robotic surgery. This study is aimed at verifying the efficacy of our training program for multi-port and single-port robotic surgery. Methods and Procedures: Three medical students and one surgical trainee participated. The program consists of basic skill training (grasping, rope running, bimanual carrying and needle passing) and suture. The da Vinci Surgical System with multi-port and single-port was used for training. Time to complete each task was recorded and scores for suture test were measured. After completion of each task, participants filled out a survey to score their performances by themselves. All tasks were performed in both multi-port setting and single-port setting, and were repeated 3 times. One way ANOVA test using SPSS was performed to validate the training effect between each time (Test 1, 2 and 3). Results: In basic skill tests, time to completion showed a tendency to be shortened as training proceeded. There was a significant shortening of completion time especially in a bimanual carrying task and a needle passing task in multi-port setting and a needle passing task in single-port setting (p = 0.002, p = 0.036 and p \ 0.0001, respectively). In suture test, the scores increased at the final test, although it showed no statistical significance. Survey showed an increasing feeling of mastery, familiarity with technique, performance satisfaction, self confidence, and decreasing feeling of difficulty, even though there was no statistical significance. When we especially look into the single port, participants took much longer time to finish tasks and gained much less score in suture at the first test, compared with multi-port, however the differences in time or in score between single port and multi-port were narrowed at the final test. In survey, similarly, participants scored less with single port at the first test, however they scored even or a little high with single port at the final test, even though the differences were very small. Conclusion: The results showed the training effect of our program. As program proceeded, participants adapted themselves well to robotic system and showed faster performances, and also they overcame the difficulty and revealed their confidence, satisfaction, and understanding of the technique, with multi-port and single-port. Moreover, our study showed the efficacy of the training program for the single port robotic surgery, exclusively. In general, single port approach is thought to be more challenging for surgeons than multi-port because of less freedom of movement with all instruments which enter the same port. However, our results showed an equivalent or superior training effect in single port surgery compared to multi-port. We suggest that such limitation of single port surgery can be overcome with a specifically designed training program. This is the first pilot study to verify a robotic surgery training program using multi-port and singleport. Further studies with more participants could contribute to establish a standardized training program for novices in robotic surgery.

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ASSESSMENT OF SAFETY OF MANIPULATION IN ROBOTIC SURGERY TRAINING Anand Malpani, BTech, Balazs Vagvolgyi, David D Yuh, MD, Chi Chiung Grace Chen, MD, Hiep T Nguyen, MD, Rajesh Kumar, PhD, Johns Hopkins University, Yale University School of Medicine, Children’s Hospital, Boston Introduction: Robotic surgery training methods are currently being developed using both real models and simulators. Training tasks, models, and metrics are all being developed and reported. However, published research quantifies skill as a monolithic quantity and do not associate metrics with specific aspects of robotic surgery (e.g. surgical skills, or man-machine interaction aspects) or specific aspects of skill (e.g. a proficient technique or safe approach). Methods: We describe analysis of data collected from a novel automated, objective framework in robotic surgery. Using a new portable recording system compatible with the da Vinci surgical system, we have acquired longitudinally (approximately monthly) stereo instrument video, timestamped and synchronized with instrument and hand motion data from several benchmarking training tasks (e.g. suturing) from 28 subjects (trainee and expert surgeons, with none to more than 20 years of medical experience) over an approximately 2 year period. Here we report on new analysis of the collected data aimed at detecting a subject’s ability to perform safe manipulation, as well style aspects of safe manipulation across trainee and expert subjects. Using the calibration parameters for the endoscopic cameras, the motion of the instruments was projected into the camera workspace with accuracy greater than 40 pixels, sufficient to overlay the motion vector visually on the instrument shaft. The instrument motion outside the field of view (unseen instrument motion, or placement of instruments outside the field of view) in the integrated motion and video data was then automatically segmented. This unseen motion then was analyzed with respect to its distance from the field of view, cumulative motion statistics, and for comparison across the two classes. In addition, the image zoom and camera field of view were also assessed for each skill class. Results: Results show that experts possess a much greater situational awareness. While the cumulative distance moved by the instruments outside of field of view—which is commonly used to assess safe motion—was greater for the experts (e.g. experts 0.7 m versus trainees 0.2 m in one test), the envelope of such motion around the field of view was smaller (as was the standard deviation), compared to the trainees. Therefore, unseen instrument motion alone was not representative of skill in our data. The location of such unseen with respect to the field of view was also important. This finding was confirmed by measuring the average working distance maintained by the subjects (experts \\ trainees), resulting in experts often moving or placing instrument outside of the smaller field of view, but in ‘‘safe’’ or ‘‘known’’ areas. Conclusions: We report on assessment of unseen instrument motion as a measure of safety during robotic surgery training. We are now incorporating the location of the motion into the unseen/ unsafe motion measurements to create better indicators of manipulation skill. Such measures will weigh the unsafe motion according to time (greater being worse), and distance (greater being worse) from the field of view of the camera.

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ROBOTIC-ASSISTED HEPATIC RESECTION: A SYSTEMATIC REVIEW OF MORTALITY AND MORBIDITY Jean-se´bastien Pelletier, MD FRCSC, Richdeep Gill, MD, Xinzhe Shi, MPH, Daniel Birch, MD MSc FRCSC, Shahzeer Karmali, MD FRCSC, University of Alberta, Centre for he Advancement of Minimally Invasive Surgery Introduction: Minimally invasive surgery continues to evolve and be integrated into increasingly complex surgical procedures. Currently, segmental hepatic resection are being performed with robotic systems. However, there is a paucity of evidence regarding potential advantages and outcomes of these procedures compared to either the open or laparoscopic approaches. The aim of this study is to systematic review the mortality and morbidity related to robotic-assisted hepatic resections for benign and malignant disease. Methods: A search of electronic databases, MEDLINE, PubMed, Embase, Scopus, Dare, Clinical Evidence, TRIP, Health Technology Database, Conference abstracts, clinical trials, and the Cochrane Library database was completed. The search terms used included robotic, robot, telerobotic, telerobot, computer assisted, computer aided, da Vinci, hepatectomy, pancreatectomy and pancreaticoduodenectomy. All human studies, limited to adults, that had been published between 2000 to August 2010 were included. Results: After an initial screen of 3672 titles, 158 abstracts were reviewed, and 19 studies met the inclusion criteria. After full-manuscript review, a total of 7 studies were included with a total of 171 procedures. The overall morbidity rate was 12.3% (range 0–43%) based on seven studies. There were no mortalities reported following robotic-assisted hepatic resection. Mean operative time was 260 min, with a mean hospital length of stay of 7.8 days. Rate of conversion to either conventional laparoscopic or open surgery was 2.5%. Cost was only reported in one study, however was greater than either laparoscopy or open hepatic surgery. Conclusions: Despite limited evidence, our systematic review suggests robotic-assisted hepatic resection is safe and feasible, with low mortality and morbidity rates. However, further research is needed to determine if oncological outcomes are similar. Furthermore, increased costs seems to continue to be a deterrent.

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RECTAL TUMORS ROBOTIC TREATMENT: THE SAVONA’S EXPERIENCE Antonio Langone, MD, Lorenzo Monteleone, MD, Ilario Caristo, MD, Domenico Aiello, MD, Massimo Bianchi, MD, Umberto Cosce, MD, Giorgio Gasloli, MD, Giovanni Sicignano, MD, Guido Griseri, MD, Angelo Schirru, MD SC, Chirurgia Generale, ASL2 Savonese Osp. S. Paolo Savona Introduction: The development of the robotic system ‘‘Da Vinci’’ (Intuitive Surgical) has gone over the main technical limitations of laparoscopic surgery, due to the inadequacy of the normal surgical instruments, which does not allow articulated movement, and lacks of 3D vision. These improved features, stand out especially in highly complex interventions such as rectal surgery. Materials and methods: In the period January 2007–June 2011 29 patients were subjected to TME resection of the rectum with robot technology; 12 patients with high rectal cancer and 17 patients with low rectal cancer. In 20 patients an anterior resection was performed with mechanical anastomosis, (3 of these resection with colo-anal anastomosis intersfinterica), in 8 patients amputation sec. Miles, and 1 patient a resection sec. Hartmann. All patients underwent radiotherapy/neoadjuvant chemotherapy. The series is mono/dual operator. Our technique involves the use of 3-arm robotic system (now an old design), plus one or two trocars for the laparoscopic assistance. The time to lower the splenic flexure was performed with conventional laparoscopic technique in 24 of 29 patients, while in 5 patients with a totally robotic technique. (5 patients with double set-up). The service access was a minilaparotomy sec.Pfannenstiel (about 7 cm). A protection ileostomy sec. Turnbull was performed in 21 cases. Results: Conversion rate was 6.8% (2/29 pcs), One because of advanced disease, one for anesthesiologic reasons. Morbidity rate was 6.8%: 1 anastomotic dehiscence and 1 post-operative bleeding which required laparoscopic revision. Average time of execution of the intervention was 320 min (240–445), in the last 5 patients of 290 cases. And the average time of use of the robot was 190 min (120–380). Average distance on the distal margin was 2.5 cm (0.6–3.8), average radial distance was 0.7 cm (0.1–1.5), average number of lymph nodes was 12 (4–20). We had no pelvic recurrences (in the short follow-up period). Conclusions: As there is are not randomized trials on robotic surgery of the rectum, according to data in the literature we believe that the method may be feasible, safe and effective and particularly suited for rectal surgery. The global increase in operative time and costs are outweighed by technical advantages (strereoscopica vision, endo-wrist, no tremor) and by benefits hard to classify such as greater safety feeling and efficacy in the dissection. We also consider the short learning curve, especially for our solid experience in videolaparoscopic colon surgery.

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DA VINCI ROBOTIC VENTRAL RECTOPEXY: A NEW TECHNIQUE FOR A WELL KNOWN PROBLEM Tiffany T Fancher, MD, David L Walters, MD FACS FASCR, St. Francis Medical Center

LAPAROBOTIC DUODENAL SURGERY: A SINGLE SURGEON’S 9-YEAR EXPERIENCE Jonas Mansson, MD, Anusak Yiengpruksawan, MD, Nino Carnevale, MD, Vikram Vattipally, MD, The Valley Hospital, Ridgewood, NJ

Introduction: The incidence of pelvic floor dysfunction is rapidly increasing and the repair techniques are evolving. One standard procedure in the treatment of rectal prolapse and complicated rectoceles is a rectopexy. The dissection in the rectopexy procedure can cause secondary autonomic nerve damage; the advantage of a ventral rectopexy is the anterior dissection avoids postoperative constipation. Reports have shown that the robotic approach is safe and feasible for rectal prolapse. This study is the first report of the Da Vinci robotic approach for the ventral rectopexy procedure (DVVR) used solely for a complicated rectocele or rectal prolapse. Methods and Procedures: After Institutional Review Board approval, a retrospective chart review was performed of all women who underwent DVVR by a single surgeon from May 2011 to October 2011. The procedure involves attachment of the perineal body and the anterior rectum to the anterior longitudinal ligament of the sacrum using a Restorelle Y Empathy mesh. Data analyzed included demographics, presenting symptoms, medical co-morbidities, past surgical histories, operative time, estimated blood loss, intra-operative complications, length of hospital stay, 30-day readmission rate and post-operative complications occurring within 6 weeks of surgery. A full clinical examination was performed prior to surgery and during each follow-up visit. Results: Nine women underwent DVVR for their rectal prolapse and/or rectocele. The mean age of the subjects was 57 years (range 44–75). The majority of women presented with symptoms of a rectal bulge and defecatory dysfunction. There were no conversions to conventional laparoscopy or laparotomy. There were no intra-operative complications including visceral injury, hemorrhage requiring transfusion or infection requiring intravenous antibiotics. Eight of the patients went home on the first post-operative day; 1 patient (who had concomitant cystocele repair was discharged on the second post-operative day after resolution of urinary retention. None of the women were readmitted within 30 days of their original surgery. At the postoperative appointment, all women reported subjective satisfaction with their postoperative course and results; on examination there was no evidence of rectal prolapse and/or rectocele. Conclusion: The principal goals of a ventral rectopexy procedure are to restore normal anatomy and to reestablish normal defecatory and sexual function. The minimally invasive approach to the surgical management of pelvic organ prolapse is a technically challenging procedure, requiring careful dissection, preservation of vital structures and suturing deep in the pelvis. Robotic assistance in such a procedure seems like a natural extension of its current applications and we present the first case series, and favorable outcomes following robotic ventral rectopexy to treat rectal prolapse and/or rectocele.

Background: Laparoscopic duodenal surgery has remained a challenge even among the experienced laparoscopic surgeons. This is due to disadvantages inherent to laparoscopic instruments that limit delicate maneuvers required in complex procedures. Application of the robotic surgical system with its unique endo-wrist instruments and 3-D high definition visual platform may allow these procedures to be done in a more efficient and safe manner. This report presents our 9-year experience with laparobotic (laparoscopic assisted robotic) duodenal surgery. Methods: Patients undergoing duodenal procedures were identified from the Valley Hospital prospective Robotic Surgery database (July 2002–2011). A retrospective review of medical records was performed for demographics, procedure type, duodenal location, operative time, conversions, complications, pathology and length of hospital stay. Preoperative or intraoperative esophagogastroduodenoscopy was used in all cases to evaluate and localize the lesion. The da Vinci Robotic System (Intuitive Surgical Inc., Sunny Vale, Ca., USA) was used for all cases. Results: Of the 600 cases performed over the nine year time period, 17 patients were identified (2.8%). The mean age was 65 (range 41–86) with 8 males and 9 females. Indications for surgery included: benign polyps (n = 6), malignancies (2 GIST, 1 carcinoid, 1 submucosal lipoma), diverticuli (n = 3), strictures (n = 2), duplication cyst (n = 1), and annular pancreas(n = 1). Distribution of lesion locations included D1 (n = 3), D2 (n = 10), D3 (n = 3), and D4 (n = 1). Operative procedures performed included: excision of polyp via duodenotomy (n = 3), duodenotomy and intraluminal Endo-GIA stapler excision of tumor or polyp (n = 3), tumor enucleation (n = 2), excision and plication of diverticulum (n = 1), Endo-GIA stapler excision of diverticulum (n = 2), duodenoduodenostomy with or without stricturoplasty (n = 3), excision of duodenal duplication cyst and suture closure (n = 1). The mean operative time was 112 min (range 60–180 min). There were 2 conversions due to inability to localize the lesions. One patient (5.9%) developed postoperative c. difficile infection and duodenal stricture. There were no deaths. The mean hospital length of stay was 3 days (range 1–16 days). Conclusions: Laparobotic technique is safe and effective technique for duodenal surgery. The multiple degrees of freedom of the robotic endo-wrist instruments and 3D stereoscopic vision significantly contribute to the ability to mobilize and dissect the duodenum. Intraoperative endoscopy compensates for the lack of tactile feedback in tumor localization. Future large multiinstitutional trials are needed to validate the use of laparobotics in duodenal surgery.

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MULTI-MODULE ROBOTIC SURGERY TRAINING FOR OTOLARYNGOLOGY WITH INTEGRATED OBJECTIVE ASSESSMENT Anand Malpani, Martin Curry, DO, Thomas Tantillo,, Amod Jog, Ray Blanco, MD, Patrick Ha, MD, Joesph Califano, MD, Jeremy Richmon, MD, Rajesh Kumar, PhD, Johns Hopkins University, Greater Baltimore Medical Center Introduction: Robotic surgery training studies in the literature often focus on massed training composed of a small set of console operated training tasks. To train our subjects in every aspects of robotic head and neck surgery, we report on a novel robotic surgery training regimen integrating objective skill assessment and consisting of four training modules of increasing complexity, including procedure specific training for transoral base of tongue surgery now being performed with the da Vinci robot. Methods: Over approximately one year in 2010–2011, 8 otolaryngology residents from an academic hospital participated in four distinct phases of robotic surgery training 1) didactic module, 2) operational skills module, 3) patient side system setup module, and 4) ex-vivo surgical extirpation of a simulated ‘‘tumor’’ located in the base of a porcine tongue. Trainees performed four iterations of each module approximately at a week’s interval. In addition to trainees, baseline performance data was obtained for four experts with two executions of each training module. Endoscopic and operating room scene video and instrument motion was recorded for each module and analyzed using offline automated analysis. All recorded sessions were also assessed by multiple experts using structured assessment (OSATS Likert scale). Results: Study results show experts and trainees are well separated at the beginning of each training module. Computed automated measures (for example, average task completion time 943 s, std.dev. 227 s for experts versus 1464 s, std.dev. 484 s for trainees for module 1 at week 1, and expert margin measurement time of 19.5 s compared to an average time of 62.6 s for trainees for module 2 at week 2) correlate with OSATS assessment for each module. Subjective assessment by experts, and measurement of margins for the removed tumor verified the clinical utility of the stage 3 surgical environment. A survey of trainees consistently rated it as very useful in progression to human operating room assistance. Conclusions: Structured multi-module training may provide a more complete training regimen for robotic surgery residents. Anecdotally, trainees performing their initial human surgeries have reported favorably on utility of their training experience. Automated objective assessment also promise to reduce the overhead for mentors, and measurements show trainees improving towards the better expert scores over the course of the training in each aspect of robotic operation. In contrast to current cumulative statistics and timed training rotations, we aim to use our developed methods and metrics to create a proficiency based regimen, where each trainee is graduated to the next module upon performing within the standard deviation of the experts to enhance overall efficiency of the training regimen.

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MINIMALLY INVASIVE CHOLECYSTECTOMY— RETROSPECTIVE STUDY COMPARING LAPAROSCOPIC VS ROBOTIC APPROACH David Calatayud, MD PhD, Venkata R Kakarla, MD, Francesco Coratti, MD, Paolo Raimondi, MD, Stefano D’ugo, MD, Luca Milone, MD, Federico Gheza, MD, Mario Masur, MD, Enrique F Elli, MD, Francesco Bianco, MD, Subashini Ayloo, MD, Pier C Giulianotti, MD FACS, University of Illinois at Chicago Medical Center Background: Laparoscopy is currently the standard approach to cholecystectomy. Large series of robotic assistance have yet to be performed Methods: In a university based fellowship program between 2007 and 2011, patients that underwent minimally invasive cholecystectomy were identified. Based on the initial operative approach, patients that underwent laparoscopic cholecystectomy (LC) were compared to robotic assisted (RC) cholecystectomy. Both Robotic assisted cholecystectomy and laparoscopic cholecystectomy were performed in standard fashion with four ports. The data elements that were reviewed included preoperative, intra-operative and post-operative variables. A univariate model was performed for statistical analysis. Results: We identified a total of 187 patients (RC 119 pts. vs LC 68 pts.) that underwent cholecystectomy for various indications including symptomatic cholelithiasis, acute and chronic cholecystitis, choledocholithiasis and pancreatitis. In both LC and RC groups, there were no statistical differences noted in the pre-operative variables including age (LC 44.6 years vs RC 43.67 years, p-value 0.71), sex (male 23.5% vs. 22%, female 76.5% vs. 78%, p-value 0.8586), BMI (LC 32.8 vs. RC 32.8, p-value 1) and ASA class. There was no difference in operative time (LC 89.45 min vs RC 90.81 min, p-value 0.76), but in the LC group, two cases were converted to open cholecystectomy while there were no conversions in the RC group (p-value 0.13). Complex procedures like CBD exploration were managed without conversion in the RC group. There were no significant differences in mortality or minor morbidity rates (Clavien 1&2: RC 19.3% vs LC 17.6%). However, one patient in the LC group had a bile leak requiring ERCP and another patient required an ICU admission after open cholecystectomy. Statistically these findings were not significant. Length of stay was similar in both groups (LC 1.37 days vs RC 1.39 days, p-value 0.90). Conclusion: The robotic approach is an alternative to laparoscopic cholecystectomy with similar outcomes. Its advantages in 3-D visualization of anatomy, ability to perform advanced procedures, low learning curves for trainees and safety may outweigh its increased costs.

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SAFETY AND FEASIBILITY OF ROBOTIC ABDOMINOPERINEAL EXCISION OF THE RECTUM Vamsi R Velchuru, FRCS, Slawomir J Marecik, MD, Marek Zawadzki, MD, Albalawi Saeed, MD, John J Park, MD, Leela M Prasad, MD, University of Illinois, Chicago, USA, Advocate Lutheran General Hospital, Park Ridge, USA

TRANSPERITONEAL LAPAROSCOPIC RADICAL NEPHRECTOMY AFTER MULTIPLE PREVIOUS ABDOMINAL SURGERIES AND INTRAPERITONEAL HYPERTHERMIC CHEMOTHERAPY: A CASE REPORT Yves Collin, MD, Robert Sabbagh, MD FRCSC, Anne Meziat-burdin, MD FRCSC, University of Sherbrooke

Introduction:- Aim of the study was to establish safety, feasibility and efficacy of robotic Abdomino-perineal resection (APR) for rectal cancer and recurrent anal cancer. Standard APR can be associated with higher rates of radial margin positivity and intra-operative perforations (IOP). This can lead to poor oncological outcomes and increasing local recurrence rates. In spite of the advances with surgical and stapling techniques, low rectal tumor with involvement of the sphincter is a definite indication for Abdomino-perineal resection. Newer techniques such as Extralevator APR have been developed to reduce CRM positivity and IOP’s. Methods: A retrospective review of a prospectively maintained database of 24 consecutive cases of robotic APR for rectal adenocarcinoma and recurrent anal cancers was performed. Study period was from April 2007 to August 2011. Patient demographics, perioperative outcomes and complications were evaluated. Independent t test was used for continuous variables such as length of stay, age, estimated blood loss, OR time, etc. Pearson Chi square test and Fischer exact test was used for categorical variables such CRM positivity, lymph node status and postoperative complications. All statistical analyses were performed using SPSS for windows, version 19.0 (SPSS Inc., Chicago, IL). Results: Twenty two patients had a robot assisted APR for rectal adenocarcinoma and two for recurrent anal cancer. Average age was 65.5 years, with fourteen being male. Average BMI was 27.3 (range, 17.6–38.1), with one third being [30. Twenty two patients had pre-operative chemo radiotherapy. In the adenocarcinoma group, 91% (n-20) were locally advanced tumors (T3/T4). Average estimated blood loss was 262 cc (range, 50–650 cc), with one patient needing blood transfusion in the post-operative period. The total OR time was 340 min, with total mesorectal excision time of 120 min. One patient was converted to open TME for a bulky tumor and very narrow pelvis. There were no robot associated intra-operative complications. Average hospital stay was 7.8 days (range 3–36 days). Six patients developed perineal wound infections. One patient died due to aspiration pneumonia in the post-operative period. Subset analysis, showed increased OR time and TME time along with higher estimated blood loss in males compared to females. This was not statistically significant. Circumferential resection margin was positive (\1 mm) in two patients (9%) in the carcinoma group. Mean lymph node harvest was 12 (range, 1–27). Conclusions: Robotic APR is safe and feasible with promising short term results. It may be beneficial for the narrow male pelvis however larger randomized studies are needed for definitive conclusion.

Introduction: Laparoscopic nephrectomy is the gold standard for a localized renal cancer. Laparoscopic indications are still growing but some relative contraindications are becoming indicated with the acquisition and development of new skills and expertise in the laparoscopic field. Some authors claim that previous abdominal surgery is a contraindication to laparoscopy but we report the case of an uneventful transperitoneal right radical nephrectomy for renal carcinoma in a 56-year-old white female with a hostile abdomen. Method: Our patient was a 56 year-old female known for appendicular adenocarcinoma with pseudomyxoma peritonei. The treatment of this condition had required five abdominal surgeries and intraperitoneal hyperthermic chemotherapy on a 4-year period. During follow-up for her adenocarcinoma, a right renal carcinoma was found. She was scheduled for transperitoneal right radical nephrectomy. A one cm incision lateral to the rectus muscle at 5 cm above the umbilicus was performed and the first port, an XcelTM bladeless trocar (Ethicon Inc, Somerville, NJ, USA) was inserted under direct visual entry with a 10 mm 0 lens. Once the peritoneal cavity was entered, extensive adhesions were noted and a pneumoperitoneum was set at 15 mmHg. Adhesions were carefully dissected using the blunt 10 mm 0 lens in order to make enough space to insert the remaining four trocarts. The rest of the nephrectomy was performed according to the following steps: right colon mobilization, control of the right renal artery and vein and dissection of the ureter, lower and upper pole. The kidney was retrieved by extending the 10 mm port’s incision. Results: Surgical time was 150 min and blood loss was 100 cc. Post-operative period was unremarkable and she was discharged after four days. Conclusion: In patients with multiples previous abdominal surgeries, transperitoneal laparoscopic surgeries are feasible in experienced hands. However, patient safety is paramount and conversion to open surgery should always be considered in case of complications.

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SINGLE INCISION LAPAROSCOPIC ADRENALECTOMY Nihat Yavuz, MD, Serkan Teksoz, MD, Sabri Erguney, MD, Mete Duren, MD, Tuna Yildirim, MD, Sirri Ozkan, MD, Istanbul University, Cerrahpasa Medical School, General Surgery Department and Acibadem Kadikoy Hospital, General Surgery Department Introduction: Running parallel to technological advances, laparoscopic surgery continues to evolve since its beginning. One of the recent advances in this field is laparoscopy performed through a single incision. In this study we present our first experiences on adrenalectomies through a single incision. Materials and Methods: From November 2009 to September 2010 we performed single incision laparoscopic adrenalectomy in 9 patients, seven of them being woman. The mean age was 43 (range: 40–56). Seven patients presented with Conn and two with Cushing syndrome. Seven adenomas were on the left side. The mean diameter of the adenomas was 2.25 cm (1.5–4.5 cm). The procedures were realized using a SILS portTM (COVIDIEN), flexible and articulated instruments (COVIDIEN) and energy sources as Ligasure),Ultracision) Results: Average operative time was 48 min (40–60 min). No any operation was converted to conventional laparoscopy with additional trochar or open procedure. No any peroperative,nor postoperative complication occured. Nonsteroid antiinflammatory agents had been sufficient for postoperative analgesia. Mean hospital stay was 1.4 day (1–3 day). Conclusion: With its advantages as unique incision and better cosmetic result, single incision laparoscopic adrenalectomy may be an alternative method to its multiport counterpart

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INCIDENTALLY DIAGNOSED PAPILLARY THYROID MICROCARCINOMA AFTER MINIMALLY INVASIVE VIDEO-ASSISTED THYROID (MIVAT) SURGERY: WHAT TO DO? Istvan Gal, MD PhD, Zoltan Szabo, PhD, Gyorgy Weber, MD PhD, Miklos Czobel, MD, Telki Private Hospital, Budapest-Telki, Hungary, M.O.E.T Institute San Francisco, CA, USA, Department of Surgical Research and Technique Semmelweis University Medical School of Budapest, Hungary The diagnosis of incidental papillary thyroid microcarcinoma (PTMC) submitted to thyroidectomy for benign disease quits frequent ranging from 1.3–22%, however its management remains controversial. Most guidlines recommend total thyroidectomy followed by radioiodine (RAI) treatment and TSH suppression therapy. According to other opinions, when the tumour is limited unilaterally, hemithyroidectomy of the affected side is the treatment of choice without postoperative RAI ablation. The medical records of 142 patients who underwent video-assisted minimally invasive thyroidectomy (MIVAT) for benign disease established by US guided fine needle aspiration cytology (FNAB) were analysed based on the final pathologic report. The following parameters were evaluated:frequency of PTMC, pathological lesion size, extrathyroidal tumour extension, vascular and or lymphatic invasion, multifocal disease, extent of thyroid resection and further surgical strategy and follow up evaluation results. In this series, authors found 8 cases (5.6%) of PTMC. The mean diameter of nodules characterised benign preoperatively by FNAB was 22.3 mm (14–31 mm). The mean diameter of PTMC-s was 5.6 mm (2–9 mm). Two of them were encapsulated forms at the final histology. None of PTMC-s showed extrathyroidal extension and vascular or lymphatic invasion.In one case, two foci of tumour were found in the affected lobe and in the isthmus. In all cases as a primary operation, a hemithyroidectomy was performed by MIVAT technique that is a complete extracapsular resection of the thyroid lobe together with the full isthmus and with the pyramidal lobe. A completion thyroidectomy by MIVAT technique followed by RAI was performed only in one case, where the tumour showed two tumourfoci. In the mean follow up of 23.2 ± 15.2 months (range 6–60 months) including laboratory and US investigations all the patients were free of recurrent disease. Conclusions: According literature data and authors’ experience incidental diagnosis of PTMC may be frequent, but PTMC shows a variable degree of aggressivenes. An appropriate surgical treatment strategy is needed for individual patients with PTMC to avoid overtreatment for the majority of patients with’’ innocent cancer’’.But longer follow up analysis should be done on these patients to make definite conclusions.

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LAPAROSCOPY DECREASES PULMONARY AND WOUND MORBIDITY AFTER SPLENECTOMY Neil H Bhayani, MD, Sharon Ong’uti, MD MPH, Tolulope Oyetunji, MD MPH, Erin Hall, MD MPH, Edward E Cornwell Iii, MD FACS FCCM, Howard University College of Medicine Department of Surgery, Georgetown University School of Medicine Department of Surgery Context: Minimally invasive surgery is considered the gold standard for some surgical diseases. Often the preferred technique, laparoscopy for splenectomy has not been studied in randomized or large observational trials. Objective: To evaluate the potential benefits of laparoscopic over open splenectomy. Design, Setting, Population: Analysis of a United States nationwide voluntary surgical outcomes database. All 1909 splenectomies performed electively for splenic disease between January 2005 & December 2008. Trauma, emergencies, and splenectomy for iatrogenic injuries were excluded. Outcomes: Odds ratio of death among those who underwent laparoscopic splenectomy after controlling for age, gender, ethnicity, and preoperative pulmonary, cardiac, renal and hepatic co-morbidities. Odds ratio of pulmonary, cardiac, wound and thromboembolic complications. Results: Our sample consisted of 1909 splenectomies where 1094 (57%) were laparoscopic. The study participants were 53% female and 47% Caucasian with a mean age of 54 years. The most common indication for splenectomy was idiopathic thrombocytopenic purpura (30.3%) . The crude mortality was 2.6%. On unadjusted analysis, odds of death were 50% lower in the laparoscopic group (p = 0.01). This difference disappeared after adjusting for co-variates (OR 0.82, 95% CI (0.5 - 1.6), p = 0.6). Patients undergoing laparoscopic splenectomy were 41% less likely to experience pulmonary complications (95% CI (0.4–0.9), p = 0.01) and 39% less likely to experience wound complications (95% CI (0.4–1.0), p = 0.05). There was no difference in cardiac events between groups (OR 0.98, 95% CI (0.4–2.5), p = 0.9) but there was a trend towards 43% less thromboembolic disease (95% CI (0.3–1.0), p = 0.06) Conclusions: Laparoscopic and open splenectomy groups had comparable mortality. Laparoscopic splenectomy is associated with less pulmonary and wound morbidity, and possibly less thromboembolism. Significant improvements in patient outcomes can be achieved through the use of laparoscopic instead of open splenectomy.

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ADRENAL MYELOLIPOMA: OPERATIVE INDICATIONS AND OUTCOMES Victoria M Gershuni, MS, James G Bittner Iv, MD, Jeffrey F Moley, MD, Mary Quasebarth, RN, L Michael Brunt, MD, Sections of Minimally Invasive Surgery and Endocrine and Oncologic Surgery, Department of Surgery, Washington University School of Medicine Introduction: Adrenal myelolipoma (AM), comprised of fat and bone marrow elements, is a benign adrenal lesion for which adrenalectomy is infrequently indicated. The purpose of this study was to review operative indications and perioperative outcomes for AM in a large single institution series of adrenalectomies. Methods: A prospective registry of patients who underwent adrenalectomy for any indication at a single high-volume teaching hospital from 1993 through 2010 was reviewed retrospectively. Patients who underwent laparoscopic adrenalectomy (LA) for AM or other adrenal pathology were compared for differences in characteristics, operative indications, perioperative outcomes, and morbidity using nonparametric tests (a = .05). Data are presented as proportions or mean with standard deviation. Results: In total, 422 adrenalectomies were performed in 402 patients, of whom 16 (4%) patients had AM confirmed on final pathology. Fourteen patients with preoperatively suspected AM subsequently underwent operation, of whom 13 (93%) had AM and 1 had an adrenal hematoma confirmed on pathology. Of 14 patients who underwent operation for AM, 5 (36%) had multiple indications including abdominal or flank pain (n = 6), tumor diameter [ 8 cm (n = 8), atypical radiologic appearance (n = 4), and/or inferior vena cava compression (n = 1). In this group, 13 (93%) underwent LA and 1 had an open adrenalectomy (OA) due to prior abdominal operations and morbid obesity (body mass index 48 kg/m2). Three patients with pathology-confirmed AM were incorrectly diagnosed preoperatively as symptomatic retroperitoneal mass (30 cm) concerning for malignancy, enlarging non-functioning cortical tumor (8 cm), and non-functioning adenoma (2.8 cm) in a kidney transplant candidate. In this group, 1 underwent LA and 2 OA due to mass size (30 cm) and concern for malignancy. Patients who underwent LA for AM (n = 13) were statistically similar to those who underwent LA for other adrenal pathology (n = 343) with respect to age (51.0 ± 8.7 vs. 49.4 ± 14.6 years), gender (female 62% vs. 54%), American Society of Anesthesiology classification (2.2 ± .4 vs. 2.5 ± .6), prior abdominal operation (46% vs. 46%), tumor side (left 54% vs. 52%), operative time (160 ± 64.6 vs. 159 ± 69 min), conversion to open (0% vs. 6.1%), estimated blood loss (B100 ml in 92% vs. 81%), intraoperative complications (0% vs. 3.5%), hospital length of stay (1.7 ± .9 vs. 2.6 ± 2.2 days), and 30-day morbidity (0% vs. 11%). However, patients with AM had a higher body mass index (35.2 ± 6.1 vs. 30.1 ± 7.5 kg/m2, p \ .01), and a larger preoperative tumor size (8.4 ± 3.0 vs. 3.1 ± 1.7 cm, p \ .01). Conclusions: LA is appropriate for patients with a preoperative diagnosis of adrenal myelolipoma and related abdominal or flank pain, large tumor size, and/or uncertain diagnosis after imaging. In selected patients, the safety and perioperative outcomes of LA appear similar for AM and other adrenal pathology.

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LONG TERM OUTCOMES OF LAPAROSCOPIC ADRENALECTOMY FOR ADRENAL MASSES Thomas Kang, MD, Asahel Gridley, MD, William S Richardson, MD, Ochsner Clinic Foundation Objectives The short term outcomes of laparoscopic adrenalectomy are well known. Our aim was to evaluate the long term outcomes of laparoscopic adrenalectomy. Methods Patients were identified for inclusion from a database using ICD9 and procedural codes for laparoscopic adrenalectomy from June, 2000 until September, 2010. Demographic, operative, postoperative and follow up data were obtained. Results 96 adrenal glands were removed from 95 patients. 18.9% were pheochromocytomas, 16.8% were aldostrinomas, 13.6% each were removed for either adrenal mass, subclinical cushing’s syndrome, atypical appearance on CT or metastatic cancer, 6.8% were removed for growth on follow up CT (all had benign pathology) and 3.1% were removed for other reasons. Length of follow up was 1050 ± 1019 days (almost three years). Two patients developed adrenal insufficiency (Cushing’s and Pheo). 36 patients had postoperative abdominal CT, MRI or PET studies and three patients developed new ispilateral nodules. One was originally a partial adrenalectomy for an aldostrinoma and was re-resected and two initially had resections for Cushing’s and were observed and follow up studies showed no growth. None had chemical recurrence of disease. 2 patients developed contralateral masses. One with renal cell cancer had a likely metastasis and one had an adenoma resected had CT showing likely adenoma which was observed. Mean BMI was 32.6 and at last follow up 32.3. There was no significant change in weight with any disease. 65 patients had hypertension which improved or resolved in 40% of all patients and 62% of patients who had aldostrinomas. Conclusions Regrowth of adrenal tissue can occur after adrenalectomy possibly due to increased ACTH and is likely to be inconsequential. Patient weight does not alter after adrenalecomy for Cushing disease. Laparoscopic adrenalectomy is a low risk procedure that improves adrenal related hypertension and thus possible complications due to adrenal related hypertension but does not resolve hypertension in most patients.

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LAPAROSCOPICALLY ASSISTED MASSIVE SPLENECTOMY : A PRELIMINARY REPORT OF THE TECHNIQUE OF EARLY HILAR DEVASCULARIZATION Pornthep Prathanvanich, Taksin Hospital

AN UNUSUAL CASE OF GALLBLADDER FIBROSIS Lowell S Su, MD, Christian W Ertl, MD FACS FACCWS, Leandra H Burke, BS, Michigan State University/Kalamazoo Center for Medical Studies

Background: Laparoscopic splenectomy has been safely performed for small spleens, but technical limitations have prevented massive splenectomy. We describe a technique of early hilar devascularization to enable massive splenectomy in five patients. Massive splenectomy was performed with minimal blood loss and no morbidity. Early laparoscopic control of the splenic artery and vein will enable the safe removal of the massive spleen, without major laparotomy. Morbidity of splenectomy may be reduced by laparoscopy. Method: The technique we describe is different than that described for idiopathic thrombocytopenic purpura (ITP) spleens where splenic mobilization has been performed first. Early isolation of the major blood supply allowed removal of massively enlarged spleens with minimal blood loss and exposure of the major vessels was not technically challenging. The use of preoperative splenic embolization has been reported but does not appear necessary if splenic blood supply is controlled early. Technique of laparoscopic splenectomy for massive splenomegaly The patient is supine position. Two 10-mm ports and three 5-mm ports are used to allow repositioning of the camera for visualization of the hilum and also the lower pole. 1. Dissection of the inferior aspect of the spleen and the splenic flexure of the colon is then mobilized to give access to the lower pole of the spleen. 2. Dissection of short gastric vessels (for exposed splenic hilum clearly) 3. Controlled splenic artery and vein respectively with suture ligated and then with endoclips 4. Dissection of the lateral and retroperitoneal attachments 5. Removing the spleen Result : The five patients underwent successful laparoscopic assisted massive splenectomy with minimal blood loss. All of them are thalassemia major. No transfusion of packed cells in our patients. There were no complications. There was no mortality. Length of stay varied between 4 and 7 days. PERIOPERATIVE OUTCOMES: The surgical times is 130–200 min. The estimated amount of blood loss is 50–200 ml. Pain score (VAS) at 1st and 2nd postoperative day is average 5 and 2 respectively. Conclusion From our limited initial experience it seems that laparoscopic splenectomy in the difficult setting of massive spleen patients is feasible as safe as the open approach. But extreme care is required in order to avoid hemorrhagic complication. We believe the technique of early hilar devascularization is the key to safe bloodless dissection of the massive spleen. This early experience is encouraging.

Introduction: Calculous biliary disease represents the most common cause of gastrointestinal illness requiring hospitalization in young, healthy individuals. Approximately two-thirds of symptomatic patients present with multiple attacks, suggesting ongoing inflammation, chronic obstruction, and histological changes within the gallbladder wall. Here we present a rare case of transmural fibrotic gallbladder in a patient with no known previous gallbladder disease. Case Report: A 35-year-old male presented to our care with ongoing sharp RUQ pain lasting several months with intermittent nausea and vomiting. The patient had a history significant for GERD for which he took Ranitidine for symptom relief. The patient had no previous surgical history. Examination revealed a soft, non-distended abdomen with positive Murphy’s sign and mild epigastric tenderness. WBCs were not elevated and all liver function results were within normal limits. Abdominal ultrasound yielded circumferential wall-thickening of the gallbladder with dependent sludge, and CT showed no identifiable gallstone or pericholestic fluid. A HIDA scan showed non-filling of the gallbladder after 90 min, and a decision was made to proceed with elective laparoscopic removal of the gallbladder. The patient’s abdomen was entered using standard Hassan technique. A 10- mm port was inserted for laparoscopy, followed by three 5-mm trocars in the standard sub costal positions. The abdomen was noted to have a white, fibrotic, hard gallbladder which prevented successful laparoscopic grasping of the gallbladder wall. Aspiration of 35 cc of cloudy, yellow-brown fluid was achieved and sent to pathology. An attempt to continue with laparoscopic dissection proved to be infeasible due to a difficult dissection, obliteration of the triangle of Calot, and a very fibrotic gallbladder with extensive inflammatory reaction and fibrinous adhesions to the peripheral tissues. The decision was made to convert to an open procedure to excise the gallbladder. The final pathology report found dense fibrosis and chronic inflammation within the entire thickness of the gallbladder wall. The gallbladder measured 9.5 9 5.5. 9 2.5 cm and was noted to be diffusely brittle and thick, to a maximum of 1.2 cm. Opening of the gallbladder revealed a shiny gray-white mucosal aspect with scattered foci of hemorrhagic discoloration. There was a single 1.2 cm yellow gallstone found impacted in the gallbladder neck. Cytology revealed abundant macrophages with no malignant cells. Postoperatively, the patient’s course was unremarkable and he was discharged home. He returned two weeks later with fluid collection which was treated with antibiotics and supportive management. Subsequent follow-up was negative for any complications. Discussion: We postulate that this is a case of chronic cholecystitis caused directly by stone impaction into the gallbladder neck leading to chronic inflammatory changes of the gallbladder which resulted in the stated pathology. Given time, chronic bile stasis results in inflammatory changes within the wall of the gallbladder, and fibrosis and scarring will eventually affect the entire wall. Most patients will become symptomatic before fibrosis occurs and consequently, the gallbladder is removed before the progression of the disease is observed. Here we present an unusual case of end-stage gallbladder fibrosis.

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PROSPECTIVE CASE-CONTROL STUDY OF SINGLEINCISION LAPAROSCOPIC CHOLECYSTECTOMY IN OBESE PATIENTS Toni Beninato, MD, David A Nissan, BS, Filippo Filicori, MD, David A Kleiman, MD, Elliot Servais, MD, Thomas J Fahey Iii, MD, Rasa Zarnegar, MD, New York Presbyterian Hospital - Weill Cornell Medical College Introduction: The objective was to compare surgical outcomes between obese (BMI [ 30) and non-obese (BMI \ 30) patients after single-incision laparoscopic cholecystectomy (SILC). A number of observational studies, case series, case controls, and most recently randomized controlled trials have suggested that SILC is a feasible alternative to conventional laparoscopic cholecystectomy. Few articles have investigated the use of SILC on obese patients, and most studies have specifically excluded patients with high BMIs. Methods and Procedures: This is a prospective study of 72 consecutive patients that underwent SILC by a single surgeon at a tertiary referral center in 2010 and 2011. There were no exclusion criteria. Endpoints included operative time, estimated blood loss, and percent conversion to conventional laparoscopic cholecystectomy. Complication rates were also evaluated. Statistical analysis was done with Student’s t-test or Mann–Whitney U test, where appropriate. Results: Of the 72 patients who received a SILC, 25 had BMIs greater than 30, with a mean BMI of 37.6 ± 8.3 and a maximum of 63. Mean BMI in non-obese group was 24.8 ± 3.3, with the lowest BMI of 17.3. There were no statistically significant differences between the two groups’ preoperative demographics. Indications for surgery included biliary colic, acute cholecystitis, and gallstone pancreatitis (44.0%, 28.0%, and 24.0% respectively in obese patients vs. 51.1%, 29.8%, and 14.9% in non-obese patients, p = 0.52). Obese patients had statistically significantly longer operative times (106.5 ± 32.9 min vs. 81.9 ± 30.4 min, p = 0.003), but did not show statistically significant differences in hospital stay (1.65 ± 0.9 days vs. 1.65 ± 1.2 days, p = 0.65) or estimated blood loss (median values 10 mL, range 5-300 mL vs. 10 mL, range 5-750 mL p = 0.89). Although there was a trend to increased conversion to conventional laparoscopic cholecystectomy in the obese, this was also not found to be significant (12% vs. 4.3% p = 0.29). There were no conversions to open cholecystectomy. There was one post-operative bile leak in a non-obese patient with a gangrenous gallbladder. The patient had a stent placed post-operatively and recovered completely. There were no complications in the obesity group. Conclusions: Obese patients require statistically significantly increased operative times compared to non-obese patients when performing SILC. There were no statistically significant differences in hospital stay, estimated blood loss, conversion rates, or perioperative morbidity. Single-incision laparoscopic cholecystectomy is feasible in obese patients with similar outcomes to non-obese patients and can be performed safely.

Table 1 Operative statistics for obese vs. non-obese patients undergoing singleincision laparoscopic cholecystectomy Obese (BMI [ 30) n = 25

Non-obese (BMI \ 30) n = 47

12 (48.0%)

26 (55.3%)

Acute cholecystitis

7 (28.0%)

14 (29.8%)

Gallstone pancreatitis

6 (24.0%)

7 (14.9%)

Operative times (min)

106.5 ± 32.9

81.9 ± 30.4

Hospital stay (days)

1.65 ± 0.9

LAPAROSCOPIC SPLENECTOMY FOR HEMATOLOGIC DISEASES: LESSONS FROM EARLY EXPERIENCE Rk Singh, MCh, J Abraham, MS, Hm Lokesh, MCh, A Prakash, MS, A Behari, MS, Ak Gupta, MCh, Vk Kapoor, MS, R Saxena, MS, Dept. of Surgical Gastroenterology & Liver Transplant, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India. Introduction: Splenectomy for hematologic diseases is now performed mostly laparoscopically. Laparoscopic splenectomy is an advanced surgical procedure with a definite learning curve. We present our initial experience of laparoscopic splenectomy for hematologic diseases with analysis of factors predicting conversion and postoperative morbidity. Methods: Forty-one consecutive patients underwent laparoscopic splenectomy for hematological diseases (Idiopathic Thrombocytopenic Purpura - 33, Hereditary spherocytosis 2,Thalassemia -2, Autoimmune Hemolytic Anemia -2, Miscellaneous- 2) at a single centre. Retrospective analysis was carried out for factors predictive of conversion to open splenectomy and postoperative morbidity. Statistical analysis was done with SPSS software and tests used were chi-square, t-test and Mann–Whitney test. Results: Mean age (SD) was 30.4 years (14.7) and gender ratio was M:F = 14:27. The mean operation time (SD) was 3.9 h (0.9). Conversion to open splenectomy was done in 9 patients (24%). The reason for conversion was intraoperative bleeding in 50% patients. The postoperative overall morbidity and mortality were 21.9% and 4.8% respectively. The age, gender, preoperative comorbidity, spleen size, intraabdominal adhesions, presence of splenenculi, duration of surgery, blood loss, preoperative and postoperative hemoglobin and platelet count, postoperative morbidity & postoperative stay were analyzed to assess the impact on conversion. None of the analyzed factors was found to correlate with conversion to open splenectomy. Postoperative morbidity predominantly consisted of postoperative fever & persisting low platelet count. Preoperative platelet count was the only factor that was predictive of postoperative morbidity (p = 0.001). Conclusions: Laparoscopic splenectomy has a high conversion rate in the initial experience. However, with a low threshold of conversion laparoscopic splenectomy can be carried out safely with acceptable morbidity and mortality .

Table 1 Variable

Lap splenec- Lap con- P value Post opmor- No postop P value tomy verted to bidity morbidity (n = 32) open (n = 10) (n = 31) (n = 9)

Age (years) mean

32

26

0.14

31.9

Sex (M:F)

12:20

29.9

0.72

2:7

0.39

3:7

11:20

0.7

4

0.35

2

11

0.36

Spleen size enlarged

12

1

0.13

3

10

0.89

Adhesions

2

1

0.6

1

2

0.7

Splenunculi

5

0

0.2

1

4

0.8

3.9

3.9

0.95

3.5

4.05

0.13

0.52

Surgery duration (h)

0.003

Blood loss (ml)

150

160

0.86

115

163

0.32

Pre op HB (g/dl)

10.4

11.1

0.46

11.5

10.3

0.21

Pre op platelets (9103 cmm)

66

33

0.13

18

72

.001

6

4

0.11

X

X

7

0.15

X

X

X

p

1.65 ± 1.2

0.65

Estimated blood loss (mL) 10 mL (range 5–300 mL)

10 mL (5–750 mL)

0.89

Conversion to multiple port

2/47 (4.3%)

0.29

3/25 (12%)

P600

Comorbidity 9

Indication for surgery Biliary colic

38892

Post op

morbidity

X Post op hospital stay (days)

5

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CONCOMITANT LAPAROSCOPIC SPLENECTOMY AND CHOLECYSTECTOMY FOR HEREDITARY SPHEROCYTOSIS CHILD WITH TECHNICAL REVIEW Masanobu Hagiike, MD PhD, Seiji Noge, MD, Hiroto Yamada, MD, Takuo Noda, MD, Takanori Oyama, MD, Hiroyuki Kubo, MD, Norikatsu Maeda, MD, Hirotaka Kashiwagi, MD, Masao Fujiwara, MD, Yasuyuki Suzuki, MD, Department of Gastroenterological and Pediatric Surgery, Kagawa University, Japan Pediatric laparoscopic treatment is now widespread because of its feasibility and patient’s quick recovery from operation. We performed concomitant splenectomy and cholecystectomy in a 13-year old girl with hereditary spherocytosis and cholelithiasis. Patient was operated on using right semi lateral position, tilting the table from right to left, with four-trocar technique. Splenectomy was performed first, and then cholecystectomy was achieved. First trocar was inserted from umbilical area. Two 5 mm trocars were inserted at upper midline area and left lower abdominal area. After adhesiolysis between spleen and colon, 10 mm trocar was inserted at mid left lower area for stapling device. Operator was using upper midline trocar and left mid trocar, and assistant using left lateral trocar. Scope was inserted from umbilical trocar. Spleen was dissected by using LCS and electric coagulator. Tilting bed was very useful for these two procedures. While dissecting lateral side of spleen, right lateral position made good visualization and while dissecting gastro-splenic ligament, near supine position was useful. Using gravity was very important during operation. Dissection between pancreas tail and spleen could be safely possible by LCS. Hilar section was performed by tri-stapler (New Endo GIA: three line stapling device which height are all different and invented for solid organ). We use plastic bag to remove spleen. Then Laparoscopic cholecystectomy was performed under supine head-up position. We use same trocar and did not add any trocar for this procedure. We used right lower semi lateral trocar for scope, midline upper trocar for right hand and umbilical one for left hand of operator. Inflammation of cholecystitis was not so severe and dissection was easy. Gall bladder was also collected by plastic bag. We put drain at the left sub phrenic area and close abdominal wall. Bleeding is 28 ml and operating time for both procedures was 256 min. Patient recovered rapidly and returned to unrestricted activity quickly. Laboratory data showed getting better value of Jaundice and anemia in a few days. Laparoscopic splenectomy and cholecystectomy is feasible and best procedure for hereditary spherocytosis child. The appropriate positioning of each laparoscopic trocar is essential for a good operative view and smooth access. Using gravity is also very effective and important. We report this case with discussions of reported papers.

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PREDICTIVE FACTORS FOR CONVERSION AFTER LAPAROSCOPIC ADRENALECTOMY Hector R Romero, MD, Victoria Cerecedo, MD, Mauricio Sierra, MD, David Velazquez, MD PhD, Nicholas Williams, FRACS, Alexander P Heinze, Instituto Nacional de Ciencias Me´dicas y Nutricio´n Salvador Zubiran Background: Laparoscopic adrenalectomy (LA) is associated with several advantages over the open equivalent such as less postoperative pain, use of lesser dose of analgesics, decreased morbidity, better cosmesis, an earlier return to work and regular activities, shorter hospital stay, reduced costs and greater patient satisfaction. However, the procedure has also been associated with limitations such as tumors larger than 6 cm, the diagnosis of pheochromocytoma or malignant lesions. There0 s still ongoing debate on which is the appropriate limit for laparoscopic resection regarding tumor size. It is traditionally said that LA should be avoided if evidence of periadrenal infiltration is recognized preoperatively because invasion may compromise peripheral structures and because the capsule should remain intact. There is still very few data concerning the identification of risk factors associated to conversion. The aim of this study is to identify risk factors that may predict conversion from a laparoscopic to an open procedure. Patients and methods: From August 1991 to January 2010, a total of 133 Laparoscopic Adrenalectomies were performed at National Institute of Medical Science and Nutrition Salvador Zubira´n. A retrospective analysis of variables, including tumor size, patient age, body mass index (BMI), sex, side, history of abdominal surgery and histology of tumor was performed to investigate about the risk of conversion in LA. Results. Our population had a mean age of 39.94 ± 14.74 years (15–78), 29 (21.8%) were men and 104 (78.2%) were women. The most frequent diagnosis was Cushing syndrome in 49 patients (36.8%) followed by after pheochromocytoma 28 (21.1%), aldosteronoma 25 (18.8%), adrenocortical cancer 2 (1.5%), myelolipoma 6 (4.5%), metastasis 3 (2.3%), lymphoma 3 (2.3%), cystic lesions 3 (2.3%), amyloidosis 2 (1.5%), non functioning adenoma 6 (4.5%), paraganglioma 2 (1.5%), hyperplasia 3 (2.3%) and one (0.8%) virilizing cortical tumor. 58 (43.6%) patients had history of previous abdominal surgery. We found that 38 (28.6%) lesions developed in the right side, and 52 (39.1%) on left side. 43 (32.3%) were bilateral. A total of 9 (6.8%) laparoscopic adrenalectomies required conversion. Significant predictors of conversion according to the univariate analysis were tumor size [7 cm, BMI [25 kg/m2 and diagnosis of paraganglioma. Multivariate analysis showed that the significant independent predictive factors for conversion were tumor size [7 cm with a frequency of conversion of 77.8% (OR 6.641; 95% confidence interval 1.35–34.42; P \ 0.013), and paraganglioma with a frequency of conversion of 22.2% (OR 0.053; 95% confidence interval 0.026–0.110; P \ 0.004). Malignant tumors were the reason for conversion in 42.9% of the cases (OR 17.25; 95% confidence interval 3.01–98.70; P \ 0.005) Conclusion: Knowledge of tumor size, patient0 s BMI and histology of the tumor should be considered predictive in terms of conversion to an open procedure. This data can be helpful in counseling our patients preoperatively.

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RIGHT ADRENAL PHEOCHROMOCYTOMA AND A 3 MM LESION ON THE LEFT ADRENAL GLAND. HOW TO APPROACH? Venkata S Kanthimathinathan, MD, Camila Manrique Acevedo, MD, Arthur Rawlings, MD, University of Missouri Health Care Introduction: Diagnosis of bilateral adrenal mass in any patient presents a management dilemma. We report an unusual case of a 51 year old female with 4.8 cm right adrenal pheochromocytoma and a 3 mm left adrenal lesion. Despite extensive work-up including blood, urine, CT scan, MRI, MIBG scan, we were unable to reach a definitive diagnosis on the left adrenal lesion. We performed laparoscopic right adrenalectomy for the right adrenal tumor. One month postoperative blood and urine work up revealed normal metanephrines. As there is no evidence of hormonally active tumor, we are observing the left adrenal lesion with biochemical and radiological investigations. Case Report: 51 year old Caucasian female with history of ulcerative colitis, referred to General surgery for evaluation of enlarging right adrenal mass. Mass was detected 6 years ago through CT scan done for GI symptoms. No further follow-up was done until this time. Patient reports intermittent bilateral flank pain, night sweats, and palpitations. Physical examination was unremarkable. Pertinent laboratory values include elevated urine metanephrine (1555), urine normetanephrine (262), serum normetanephrine (1.22) and serum metanephrine (5.82). She has normal aldosterone, renin, ACTH, DHEA and 24 h urine cortisol levels. Radiological investigations include CT scan of the abdomen and pelvis with IV contrast, MRI abdomen and MIBG scintigraphy with SPECT/CT scan. CT scan showed a 3.3 X 2.9 cm right adrenal mass that appears to be of soft tissue density with enhancement and rapid washout, suggestive of a pheochromocytoma. CT also showed a prominent cavernous hemangioma and a very subtle area of atypical density in the left adrenal gland that measures approximately 3 mm in size, relatively nonspecific in appearance. MRI confirmed CT scan findings. MIBG scan showed a large focus of increased uptake corresponding to a right adrenal mass on SPECT CT images and a small focus of increased uptake corresponding to the normal sized left adrenal gland. Patient was diagnosed with right adrenal pheochromocytoma and a non specific 3 mm lesion in the left adrenal gland. As the lesion on the left adrenal gland was too small to characterize, we performed a laparoscopic right adrenalectomy. Her surgery and postoperative course were uneventful and she was discharged on postoperative day 2. Pathology showed a 4.8 cm right adrenal pheochromocytoma with margins free of tumor. Repeat blood and urine work up one month after surgery revealed normal urine metanephrine, normetanephrine, serum metanephrine and normetanephrine. However, genetic testing returned SDHB mutation positive putting the patient at high risk for malignant disease and extra-adrenal tumors. As there is no evidence of hormonally active tumor, we are currently observing the left adrenal lesion with biochemical and radiological investigations.

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INFLAMMATION AND COAGULATION INTERACTION AFTER OPEN AND LAPAROSCOPIC LEFT PARTIAL HEPATECTOMY IN A PORCINE EXPERIMENTAL MODEL Constantinos S. Mammas, MD MSc PhD, Maria Kostoglou, Assistant Professor, George Kottis, Associate Professor, Chryssa Nikolaou, Associate Professor, Nicolaos Arkadopoulos, Assistant Professor, Nicolaos Kavantzas, Assistant Professor, Ismene Dontas, Professor, Antonios Analytis, MathematicianStatistician, George Arsenis, Associate Professor, Spyros Dourakis, Professor, Vasileios Smyrniotis, Professor, National and Kapodistrian University of Athens, Surgical Laboratory C.TOUNTAS Objectives: The project compares the systemic and regional inflammation to the coagulation response between Open (OLPH) and Laparoscopic (LLPH), left partial hepatectomy in a porcine model. Materials and Methods: Twenty-nine (N = 29) domestic pigs (21–32 kg), were randomly allocated into two groups, the open (N1 = 19) undergoing OLPH using a knife (A, n = 13) or a radiofrequency knife (RF knife) (B, n = 6) and the laparoscopic (N2 = 10) undergoing LLPH using a stapler (C, n = 5) or a stapler and a Radio-Frequency knife (RF knife) (D, n = 5), under general anaesthesia. By blood samples before (PD), after (PD0) operation, on the 1st (PD1) and on the 7th (PD7) postoperative day Hematological, Biochemical, Coagulation, Hormonal, Immunological parameters were measured. By two series of 29 stained liver tissue sections, taken on PD0 and on PD7 respectively, a regional inflammatory and a regional necrosis index were estimated by microscopic visualization. Results: Systemic and liver regional inflammation and coagulation analysis resulted in the following statistically significant differences: 1) CRPPD7(B [ D, p = .005), 2) Cortisol (A PD0 [ C PD0, p = .002) and (B PD7 [ C PD7, p = .004), 3) Fibrinogen (B PD7 \ CPD7, p = .0041), 4) PLTPD7(B \ D, p = .001) and (C \ D, p = .002), 5) aPTTPD1 (D [ A, p = .004). Conclusions: In the porcine model, only the systemic and not the liver regional inflammatory response seems to be more increased and extended, after OLPH and specially if an RF knife is used for liver resection (B). Coagulation seems to be significantly influenced in the early and the late postoperative period in the laparoscopic groups, irrelevantly to the systemic inflammatory response.

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SINGLE INCISION LAPAROSCOPIC SURGERY FOR SPLENECTOMY-NTUH EXPERIENCE Ching-yao Yang, MD PhD, I-rue Lai, MD PhD, Ray-hwang Yuan, MD PhD, Chiung-nien Chen, MD PhD, Yu-wen Tien, MD PhD, Ming-tsan Lin, MD PhD, Division of General Surgery, Department of Surgery, National Taiwan University Hospital Introduction: Single incision laparoscopic surgery (SILS) is a developing advanced laparoscopic technique in recent years. It was majorly applied in appendectomy, and cholecystectomy. But SILS laparoscopic splenectomy was reported in limited cases in the literature, and in Asia, it has only been reported from Korea. The purpose of this study is to report and share our experience of SILS laparoscopic splenectomy. Methods and Procedures: The clinical data and follow-up outcome were prospectively recorded in patients undergoing SILS laparoscopic splenectomy in June 2010. The perioperative parameters, morbidity, and follow-up results were analyzed. Results: All three cases were performed in June 2010. There’re one female, and two male patients with average 32.33 years old (10–57 years). Two patients was diagnosed as ITP, and another 10-year-old boy was a case of Burkitt lymphoma with suspected splenic abscess. All patients were placed in the right 45 decubitus position. A 2.5 cm incision was made at three fingers below left subcostal margin of the first patient, and the following two cases has wound in umbilicus. Covidien SILSTM Port were inserted through the single incision. A flexible-tip 5-mm HD scope (Olympus) was used. Dissection was performed with 5-mm grasper and 5-mm harmonic scapel (Ethicon EndoSurgery). Splenic hilum was transected with one EndoGIA (Covidien Autosuture Roticulator 45–2.0 mm). Spleen was put in EndoBag. Resected spleen was fragmented in ITP cases. The bag was pulled out through the umbilical incision. Hemostasis was checked. The average operative time is 90 min (70–120 min), and average blood loss is 46.7 cc (20–100 cc). All patients had oral intake on postoperative day 1, and discharged uneventfully within 3 days. Conclusion: SILS laparoscopic splenectomy is feasible, and safe. The major advantage of this advanced technique is better cosmetic outcome, and higher acceptable as a treatment option for female patients with thrombocytopenia. Due to limited experience, the advantage when comparing with conventional 3- or 4-port laparoscopic splenectomy need more comparative study in the future.

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SINGLE-INCISION LAPAROSCOPIC CHOLECYSTECTOMY AT COMMUNITY HOSPITALS IN HONOLULU, HAWAII: A CASE SERIES Cori-ann M Hirai, BS, Daniel Murariu, MD MPH, Andrew Oishi, MD, Steven Nishida, MD, Cedric S Lorenzo, MD, Racquel S Bueno, MD FACS, University of Hawaii John A. Burns School of Medicine, University of Hawaii Department of Surgery, Kuakini Medical Center, The Queen’s Medical Center, Honolulu, Hawaii, United States of America Introduction: We aim to demonstrate the feasibility of implementing single-incision laparoscopic surgery in a community setting. Minimally invasive surgical approaches have allowed for the achievement of equivalent outcomes to open surgical approaches while boasting less post-operative pain, improving cosmesis, decreasing lengths of hospital stay and wound-related complications. Surgeons are now attempting to reduce the incisional trauma even further by decreasing the number of incisions required to perform minimally invasive abdominal surgery to just one incision. We report our experience with single-incision laparoscopic cholecystectomy at two community-based hospitals in Honolulu, HI. Methods and Procedures: This is a retrospective case series of patients undergoing single-incision laparoscopic cholecystectomy at two community-based hospitals associated with a university accredited surgical program between September 2008 to June 2011. Chart review was conducted for basic demographic information, operating time, blood loss, conversion to open or traditional multi-incisional approach, length of hospital stay, and presence of intra-operative, peri-operative, and post-operative complications. All four surgeons utilized an umbilical incision as the primary, single-incision site. Results: 103 patients (79 females and 24 males) underwent single-incision laparoscopic cholecystectomy. The mean age was 49.8 years (range 18–88). 96 patients (93.2%) were elective cases while 7 patients (6.8%) had more urgent preoperative diagnoses consisting of gallstone pancreatitis (3.9%) and acute cholecystitis (2.9%). Mean operating time was 89.7 min (standard deviation 28.3 min) and the average blood loss was 33.7 milliliters (standard deviation 27.4 milliliters). Ninety-five (92.2%) of the cases were successfully completed as single-incision laparoscopic surgery and 8 (7.8%) were converted to multi-incisional approach. There were no conversions to an open approach. Most patients were discharged the same-day with mean length of hospital stay of 10.7 h (standard deviation 10.3 h). The post-operative complication rate was 7.4% (7/95) and included superficial wound infection (4%), biliary leak (1%), acute renal failure (1%), and urinary tract infection (1%). There were no postoperative incisional site hernias recorded within the follow up period. Conclusions: Our institutions’ outcomes for single-incision laparoscopic cholecystectomy are comparable to other case series reported in the literature. Our complication rates for single-incision laparoscopic cholecystectomy are also comparable to conventional multi-incision laparoscopic cholecystectomy. Single-incision laparoscopic cholecystectomy is a viable option for communitybased surgeons and can be implemented safely and without additional hospital resources, illustrating its feasibility in a community setting.

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COMPARING LAPAROSCOPIC MESH FIXATION STRENGTH BETWEEN TWO DIFFERENT TACK DEVICES Ram Elazary, Mahmoud Abu-gazala, Abed Khalaileh, Yoav Mintz, Department of Surgery, Hadassah-Hebrew University Medical Center, Campus Objective of the study: Laparoscopic mesh repair has become an increasingly common method for repairing incisional hernias. The current method for performing this repair includes tacking a mesh to the inner surface of the abdominal wall. The iMESH TackerTM (IMT) is a device which simplifies the procedure by enabling an articulation of the device’s tip. The study compares the strength of mesh fixation between the IMT and another commercial tack device (ACT). Both tacks are absorbable. Description of the methods: strips of mesh were surgically installed on the inner surface of the abdominal wall in three commercial pigs. Half of them were fixated by IMT and half were fixated by ACT. Euthanasia was done immediately to the first pig, following 14 days to the second and after 27 days to the third pig. The abdominal was harvested and the mesh strips were pulled while fixation force was measured. Samples from both groups were sent for histo-pathological examination. Statistical analysis was done using the two tailed t-test. Results: All mesh strips were found to be fixated. At the two survived pigs, the meshes were covered by peritoneum. After euthanasia the strips were pulled and the detaching force was measured. The average force in the first pig was 17.1 N ± 1.9 and 16.5 N ± 8.3 (IMT and ACT respectively). The average force in the second pig was 18.8 N ± 7.3 and 8.4 N ± 4.1 (IMT and ACT respectively, p \ 0.05). The average force in the third pig was 16.3 N ± 5.3 and 10.9 N ± 5.9 (IMT and ACT respectively, p \ 0.05). Conclusions: The iMESH TackerTM is both a feasible and easy to learn device for performing mesh fixation. The study showed that iMESH TackerTM creates average fixation force which is higher than ACT. We have also showed that iMESH TackerTM kept the fixation force throughout the study while the ACT showed a decreased force beginning from the 14th day.

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P608

THE VALUE OF ABDOMINAL ULTRASONOGRAPHY TO PREVENT IATROGENIC INJURY IN PERCUTANEOUS ENDOSCOPIC GASTROSTOMY Dennis Y Kim, MD, Justin Regner, MD, Leslie Kobayashi, MD, Jay Doucet, MD, Jeanne Lee, MD, Mark Talamini, MD, Raul Coimbra, MD PhD, Vishal Bansal, MD, University of California San Diego Background: Percutaneous endoscopic gastrostomy (PEG) is a commonly performed procedure. Iatrogenic injury, mostly liver and colon, is a known complication of PEG placement. In this study, we examine the role of abdominal ultrasonography (US) as an adjunct to PEG placement to avoid iatrogenic injury. Methods: A retrospective descriptive analysis was performed in patients who underwent PEG placement with US. Each PEG insertion was performed through a modified Seldinger technique and a safe tract for passage was verified via adequate trans-illumination, finger ballottement, gastric distension and confirmation of the absence of intervening tissue identified by US prior to finder needle placement. Data collected included demographics, indications for PEG, complications, mortality, and disposition. Results: Thirty-four PEG tube insertions were performed over a seven month period. The mean age was 53.8 ± 21 years and 85% (29/34) of patients were males. The most common indication for PEG tube insertion was prolonged dysphagia (22/34). PEG insertion was performed successfully in 32/34 patients. US identified 4 cases of an intervening left lobe of the liver at the proposed PEG site. Despite the presence of appropriate trans-illumination, 2 patients had intervening liver between the abdominal wall and stomach by US. Attempts at relocating the PEG insertion site were unsuccessful, and PEG tube was not performed in these patients. There was no iatrogenic injury in any patient studied. Conclusions: Commonly used indicators including trans-illumination may not be adequate in assuring a safe tract for PEG insertions. Adjunct use of US in PEG placement may help prevent iatrogenic injury. Further research will be needed to propose mandating US prior to PEG insertion.

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Surg Endosc (2012) 26:S249–S430

P609

TECHNIQUE OF ESOPHAGOJEJUNOSTOMY USING TRANSORAL PLACEMENT OF THE PRETILTED ANVIL HEAD AFTER LAPAROSCOPIC TOTAL GASTRECTOMY FOR GASTRIC CANCER S Sakuramoto, PhD, N Katada, PhD, H Mieno, PhD, T Shibata, PhD, K Yamashita, PhD, M Nemoto, MD, S Kikuchi, PhD, M Watanabe, PhD, Kitasato University School of Medicine Background: During esophagojejunostomy using a circular stapler after laparoscopyassisted total gastrectomy(LATG),placement of the anvil head via the transabdominal approach proved difficult. The authors report on a method modified for laparoscopy-assisted, esophagojejunostomy performed by placing the pretilted anvil head via the transoral approach. Methods: Between November 2007 and August 2011, esophagojejunostomy was performed using the transoral, pretilted anvil head in 83 patients after LATG. The anesthesiologist introduced the anvil while observing its passage through the pharynx. During the anastomosis, we kept the jejunum fixed in position with a silicone band Lig-A-Loops, thereby preventing the intestine from slipping off the shaft of the stapler. Results: Esophagojejunal anastomosis using the transoral anvil head was achieved successfully in 76 patients; for 1 patient, passage of the anvil head was difficult owing to esophageal stenosis. No other complications, such as hypopharyngeal perforation and/or esophageal mucosal injury, occurred during passage. No postoperative complications occurred, except for 3 patient who developed anastomotic stenosis, in whom mild relief was achieved using a bougie. Conclusion: Esophagojejunostomy using the transoral pretilted anvil head is a simple and safe technique.

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P610

SINGLE PORT SURGERY EXPERIENCE: 100 CASES AND WHICH IS THE BEST PORT? Sergio Rojas-ortega, MD, Jorge Garay Jr., MD, Cris Gomez, Nurse Hospital Beneficencia Espan˜ola de Puebla Single port surgery (SPS) has been adopted in our surgical practice during the last year. We decided to evaluate three different ports available at our Hospital and the different flexible laparoscopic instruments recommended for these procedures. At the end of each procedure we evaluated operative time, ergonomics, conversion to multiple port surgery, cost and cosmetic results. Material: From january 2010 to sept 2011 we operated 100 cases with single port surgery. We used three different surgical ports from Covidien (40), Olympus (40) and Applied (20). We performed 65 cholecystectomies, 25 appendectomies, 3 funduplications, 5 oophorectomies, 2 others. The scopes were 5 or 10 mm according to the device used. Results: We found that the operative time decreased from 120 min/surgery to 30 min in the last 30 cases. Regarding to the Covidien port we found that the flexible instruments were not simple to manage and did not had enough strength to fix the gallbladder. With the Olympus port we found air leaks at the plastic entrances and related to multiple changes in the instrumentation, ‘‘ sword fighting’’ was common. We needed and extra port in 5 cases of acute cholecystitis with this device. Applied port resulted in better ergonomic surgery, without the need of flexible instruments, and allowed to use 5 and 10 mm instruments and optic as needed with a shorter surgical time. We performed 10 cases of acute cholecystitis without extra ports. The cosmetic result were very good independency of the surgical device employed. Conclusion: We found in our practice that the surgical port is and important issue in terms of surgical time, ergonomics, without need for extra ports even in acute cases and lower cost related to shorter operating room time and the use of common rigid laparoscopic instruments.

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MULTIPLE SENSORS SYSTEM TO EVALUATE MINIMALLY INVASIVE SURGERY TRAINEES Sami Abusnaineh, MS, Brent W Seales, PhD, University of Kentucky The typical techniques for assessing the performance of minimally invasive surgery (MIS) for surgeons and trainees are direct observation, global assessments, and checklists. These techniques are more subjective than objective and provide for a large margin of bias. Therefore, evaluating the skills of MIS trainees objectively has become an increasing concern. MIS technical skills assessment can be improved using the new technology of computer vision and cameras. The integration of tools, arms, head, eyes, and ECG factors using advanced vision technology and strong statistical model will lead to great improvements to MIS technical skills assessments. The goal of this study is to build a new multiple sensors framework to extract novel fusion and non-fusion metrics to evaluate MIS trainee’s performance. Using multiple vision systems to study the assessment problem leads to extracting the relationship between different kinds of motions and developing a better metrics set for the assessment. For example, studying the motion and direction of the trainee’s head would lead to better assessment factors because it reveals the interaction between the surgeon and the surgery field of view. Also, tracking the surgeon’s eyes could lead to reliable assessment metrics such as fatigue and eye-hand coordination. The framework contains several camera sensors to capture the motion of the surgical instruments and trainee’s head, arms, eyes, and ECG rate synchronously. The sensors used are: Eight cameras installed in a circle on the room ceiling to track the trainee’s arms and head; two cameras attached to the surgery display to track the trainee’s eyes features; Laparoscopic camera used to track surgery instruments; finally, an ECG attached to the trainee’s body to track the heart rate. A robust synchronization algorithm is developed to synchronize the capture of these systems to sixteen milliseconds which makes the frame offset between subsystems one. Figure 1 explains the architecture of system. By coordinating those subsystems, we were able to extract a list of novel fusion and non-fusion metrics for the assessment. Some of these metrics are based on: • Kinematics data such as path, speed, acceleration, rotation, and working volume for laparoscopic instruments and trainee’s head and arms. • Fatigue level and the relationship between the fatigue and the motion features. • Eye saccade, closure, blinking change, object interaction. • Path, speed, acceleration, rotation, working volume for the instruments and the trainee’s arms while the instruments are not visible or the trainee is not looking at the display. Figure 1 The Framework’s Architecture • Gaze direction and the frequency at which the trainee changes the look between the display and the incision location. • Total looking time at different objects in the environment. In this study we have presented a framework using multiple sensors to evaluate MIS trainees. This framework is novel because it is the first system to integrate the tracking of several objects at a time. This integration led to extract non-fusion metrics by studying the object’s motion coordination. Those novel metrics are promising and can lead to valid and reliable correlation to the experience level.

Surg Endosc (2012) 26:S249–S430

38095

S421

P612

APPLICATION OF A NOVEL TECHNIQUE BY USING TRANSORAL PLACEMENT OF ANVIL AND INTRACORPOREAL GASTROJEJUNOSTOMY FOR PROXIMAL OR TOTAL GASTRECTOMY Li Xiaoyang, MD PhD, Xu Dongsheng, MD, Yu Hong, MD, The First Hospital of Harbin Purpose: To evaluate the feasibility and outcome of laparoscopy-assisted gastrectomy (LAG)by using the novel technique of transoral placement of anvil and intracorporeal gastrojejunostomy(the OrVil system). Materials and methods: A retrospective study of proximal or total gastrectomy from July 2008 to August 2011 was performed. 72 laparoscopy-assisted gastrectomy cases including 38 patients using the OrVil system and 34 patients using conventional method were enrolled in this study during the period. Operative time, blood loss, time to passage of flatus, postoperative hospital stay and complications were compared between the two groups. Results: Compared to the using conventional method group, operative time by using the OrVil system group was significantly shorter [(152.9 ± 15.1) min vs.(210.8 ± 35.3) min, P \ 0.05], blood loss was less[(94.3 ± 46.5) ml vs. (121.0 ± 26.4) ml, P \ 0.05], time to passage of flatus [(3.1 ± 0.2) d vs.(3.5 ± 0.4) d, P [ 0.05], postoperative hospital stay [(6.8 ± 1.2) d vs. (7.4 ± 1.8) d, P [ 0.05]. There was no anastomotic leakage or mortality during the early stages of the present study in the OrVil system group. Conclusions: It is believed that innovation of OrVil technique could bring us safer alternative reconstruction with better efficiency and quality for laparoscopic Roux-en-Y reconstruction.

38230

P613

LAPAROSCOPIC WEDGE RESECTION FOR GASTRIC SUBMUCOSAL TUMOR USING LAPAROSCOPIC AND ENDOSCOPIC COOPERATIVE SURGERY (LECS) Yasushi Rino, PhD, Norio Yukawa, PhD, Roppei Yamada, PhD, Tsutomu Sato, PhD, Masanori Inamori, PhD, Yasunobu Abe, PhD, Tomoko Koide, PhD, Takashi Oshima, PhD, Toshio Imada, PhD, Munetaka Masuda, PhD, Department of Surgery, Yokohama City University Background: Laparoscopic wedge resections are increasingly applied for gastric submucosal tumors such as gastrointestinal stromal tumor (GIST). Despite this, no defined strategy exists to guide the surgeon in choosing the appropriate laparoscopic technique for an individual case on the basis of tumor characteristics such as location or size. A laparoscopic and endoscopic cooperative surgery (LECS) is applicable for submucosal tumor resection independent of tumor location and size. Methods: We employed LECS for the resection of gastric submucosal tumors. Four patients underwent LECS for the resection of GIST. Both mucosal and submucosal layers around the tumor were circumferentially dissected using endoscopic submucosal dissection via intraluminal endoscopy. Subsequently, the seromusclar layer was laparoscopically dissected on the exact three-fourths cut line around the tumor. The submucosal tumor then was exteriorized to the abdominal cavity and dissected with a standard endoscopic stapling device. Results: In all cases, the LECS procedure was successful for dissecting out the gastric submucosal tumor. In one of four cases, the tumor was more than 5 cm in diameter and located in the lower gastric portion near the pyloric ring. In three of four cases, the tumor was located in the upper gastric portion near the esophagogastric junction. The mean operation time was 162 ± 13 min, and the estimated blood loss was 20 ± 20 ml. The postoperative course was uneventful in all cases. Conclusions: The LECS procedure for dissection of gastric submucosal tumors such as GIST may be performed safely with reasonable operation times, less bleeding, and adequate cut lines. In addition, the success of the procedure does not depend on the tumor location such as the vicinity of the esophagogastric junction or pyloric ring.

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TRANSUMBILICAL SINGLE-INCISION LAPAROSCOPIC APPENDECTOMY USING CONVENTIONAL INSTRUMENTS: SINGLE WORKING CHANNEL TECHNIQUE Zheng Pan, Md PhD, Xiao-hua Jiang, PhD MD, Jia-hua Zhou, MD PhD, Zhen-ling Ji, MD PhD, Department of General Surgery, Zhongda Hospital, Southeast University Medical College, Nanjing, China Abstract Background: This study aimed to evaluate the feasibility, safety, and cosmetic results of a novel technique: transumbilical single-incision laparoscopic appendectomy (TSILA) by using a single working channel with conventional instruments. Patients and Methods: The study enrolled 81 consecutive patients undergoing laparoscopic appendectomy for acute appendicitis. TSILA was performed using a single working channel and conventional laparoscopic instruments through a single 1.5 cm umbilical incision. Classic threeport laparoscopic appendectomy was performed using three trocars through three incisions. All the patients received a follow-up visit for 1 to 12 months. Results: The study cohort consisted of 33 patients undergoing TSILA with an average age of 27.1 (range 17–71) years. All 33 appendectomies were achieved through a single transumbilical incision. Forty-eight patients undergoing classic three-port laparoscopic appendectomy with an average age of 30.3 (range 17–80) years. The mean operative time of TSILA didn’t show difference when compared with classic procedure (90.6 min vs. 76.5 min). No operative complications occurred in patients undergoing TSILA while two patients undergoing classic procedure showed incisional infection. The average postoperative hospital stay was 3.9 days in TSILA group and 3.5 days in classic procedure group with no difference. At the follow-up visit, no patient showed any evidence of incisional hernia. The transumbilical incisions were minimally visible, and all the patients undergoing TSILA reported a highly favorable cosmetic outcome. Conclusion: The results of the study demonstrate that laparoscopic appendectomy can be achieved through a single umbilical incision and a single working channel using conventional instruments and that this approach is successful, safe, economic and aesthetic.

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PROSPECTIVE, MULTICENTER TRIAL COMPARING PAIN AND COSMETIC OUTCOMES IN THREE PORT AND FOUR PORT LAPAROSCOPIC CHOLECYSTECTOMY Eric M Pauli, MD, David M Krpata, MD, Melissa S Phillips, MD, Jeffrey M Marks, MD, Raymond P Onders, MD, University Hospitals Case Medical Center, Cleveland, OH and The University of Tennessee Health Science Center, Knoxville, TN Introduction: Four port laparoscopic cholecystectomy (4PLC), first introduced in 1985, is now considered standard of care. Recent advancements in minimally invasive techniques (single port laparoscopy and natural orifice surgery) offer theoretical advantages of reduced pain and improved cosmesis. We hypothesized that reducing the number of laparoscopic ports for cholecystectomy to three (3PLC) would result in reduced pain and improved cosmesis while at the same time avoiding the technical challenges posed by more novel minimally invasive methods. Methods: Data were culled from the standard cholecystectomy arm of a multicenter, prospective single blinded, randomized trial of single incision versus standard laparoscopic cholecystectomy sponsored by Covidien. 3PLC or 4PLC was determined by surgeon practice patterns. Data measures included patient demographics, operative time, estimated blood loss and procedure conversion (3PLC to 4PLC or 3PCL/4PLC to open). Pain (worst and average) was assessed at intervals over the first post-operative month and cosmetic scoring was performed by the patient at intervals over 12 months. Results: Eighty patients (63 4PLC and 17 3PLC) were included in the study. Patient characteristics, including age, sex, body mass index (BMI) and pre-operative pain scores were similar between the two groups. No patients required conversion of technique and blood loss was similar between the two groups (p = 0.32). There were no common bile duct injuries. 3PLC had a statistically shorter operative time than 4PLC (34.3 vs. 48.1 min, p = 0.003). The 3PLC group had significantly lower average pain scores on post-operative day one (3.47 vs. 4.66, p = 0.014), but on all other days (predischarge and Day 3, 5, 14, 30) worst and average pain scores were similar. The self-reported cosmetic scale demonstrated no significant differences between the 4PLC and 3PLC groups at 3 months and 12 months (p = 0.21 and p = 0.69 respectively). Conclusions: In this non-randomized, blinded, prospective, multicenter trial of 3PLC vs. 4PLC, 3PLC appears to be safe with a similar blood loss and procedural conversion rate. Reduced operative times in the 3PLC group can be explained by surgeon proficiency and reduced numbers of ports to place and to close. 3PLC had significantly reduced average pain on the first postoperative day. Pain scores were identical at all other times assessed during the first month. Cosmesis scoring did not favor 3PLC over 4PLC. 3PLC offers a safe alternative to 4PLC and may reduce early post-operative pain. 3PLC can be safely utilized as a training bridge for the techniques involved in single incision or reduced-port cholecystectomy.

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P616

ARE PROCEDURAL FIELDS PREPARED FOR DATA DRIVEN HEALTHCARE? Loren Riskin, MD, Dan E Azagury, MD, Oliver Varban, MD, Daniel J Riskin, MD MBA FACS, Stanford University, Stanford, California USA Objectives: The last decade has seen major advances in data driven healthcare at the research, clinical, and policy levels. The HITECH Act and the Affordable Care Act drive electronic health record infrastructure while reimbursement and cost drivers promote data use. Medical societies are gearing up for data driven healthcare, assuring discrete, structured data capture appropriate to their specialties. Compared to medical fields, procedural fields can be more challenging to study, particularly because medical history, medications, and laboratory values are rarely the most critical information. Use of unstructured narrative data (e.g. H&P, operative, and discharge notes) through natural language processing has been suggested as one process for extracting high quality, granular procedural technique and outcome data. But little discussion on unstructured data use has occurred at the society level. Our goal is to understand whether procedural societies could benefit from less reliance on manually captured registries and real consideration of unstructured data solutions. Methods: To evaluate critical processes underlying data driven healthcare in procedural fields, literature review and interviews were undertaken. Literature review focused on defined pathways to capture and use unstructured, granular data in clinical specialties. Manuscripts were separated based on reference to primary care, hospital-based care, procedural care and overall healthcare. Interviews were undertaken with experts in data mining and data-driven healthcare, as well as leaders in data use in anesthesia and surgical communities. Results: Literature reviews and interviews revealed a strong focus on using discrete data captured through manual processes. Interviewees theorized that early surgical leadership in analytics, via the National Surgical Quality Improvement Program (NSQIP) and other programs, supported registry creation with a focus on discrete data capture through a relatively narrow set of variables. This was the only possible process at the time these systems were developed and encompasses very low levels of procedural detail. Some interviewees expressed concern that capture of limited variables represented a bias within the registry system itself, suggesting that limited data acquisition translates to limited understanding of factors influencing outcomes. Conclusion: As healthcare advances into a more mature phase of meaningful data use, it has become clear that richer codified data are critically needed. While medical fields can effectively study clinical choices and outcomes on discrete structured data captured today by the electronic medical record, this may not be true for procedural fields that include a multitude of options in procedural technique. Narrative notes combined with natural language processing may represent a valuable option for capture of technique and post-procedural outcomes. We believe meaningful discussion within the procedural societies of effective capture and aggregation of narrative procedural and post-procedural content is warranted.

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A PROSPECTIVE RANDOMIZED TRIAL COMPARING TOTALLY LAPAROSCOPIC DISTAL GASTRECTOMY WITH LAPAROSCOPY-ASSISTED DISTAL GASTRECTOMY IN EARLY GASTRIC CANCER Joo-ho Lee, MD PhD, Joo Hyun Woo, MD, Ewha Womans University School of Medicine Introduction Most surgeons have performed laparoscopy-assisted distal gastrectomy (LADG) with extracorporeal anastomosis rather than total laparoscopic procedures because of the technical difficulties of intracorporeal anastomosis. However, recently totally laparoscopic distal gastrectomy (TLDG) has been reported to be safe, technically feasible, and more minimally invasive. We conducted this study to compare the short-term outcomes of LADG with TLDG to provide the basis for standardization of laparoscopic gastrectomy in early gastric cancer. Methods and Procedures In this prospective study, 35 patients with early gastric cancer were randomized to either TLDG or LADG with Billroth II anastomosis from February to August 2001. Clinicopathologic characteristics, operative details, postoperative course and quality of life were compared between two groups. Postoperative pain intensity at rest was measured on 100-mm visual analogue scale during hospital stay. Test of pulmonary function was performed on preoperative day and postoperative day 4. Quality of life was assessed using EORTC QLQ-C30, version 3 and the gastric module STO22 on first visit for follow-up after discharge. Approval of the institutional review board and written informed consent were obtained. Results TLDG (n = 18)

LADG (n = 17)

P-value

Operative time (min)

131.3 ± 90.3

233.1 ± 42.0

0.08

Estimated blood loss (mL)

131.3 ± 90.3

153.8 ± 82.8

0.50

Stapler devices used

4.2 ± 1.1

2.0 ± 0.0

0.01

The longest length of wound after skin closure (cm)

3.3 ± 1.4

5.2 ± 1.1

0.02

Postoperative pain score on day 5

2.5 ± 7.1

2.0 ± 4.2

0.85

Opioid consumption added to intravenous PCA

1.9 ± 2.5

2.6 ± 1.8

0.51

First flatus (days)

3.1 ± 1.0

2.8 ± 0.9

0.56

Liquid diet (days)

4.2 ± 1.1

3.8 ± 0.7

0.34

Postoperative hospital stay (days)

8.1 ± 3.1

7.4 ± 1.7

0.49

Decreased forced vital capacity (%)

19.8 ± 12.3

20.8 ± 17.0

0.87

Decreased forced expiratory volume in 1 s (%)

15.4 ± 10.6

16.7 ± 12.0

0.75

Physical function

81.7 ± 6.4

67.5 ± 13.5

0.03

Global health

66.7 ± 13.6

61.5 ± 14.7

0.57

Pain and discomfort

22.2 ± 20.3

29.2 ± 10.2

0.56

Emotional problem

22.2 ± 15.7

27.8 ± 16.8

0.59

Restriction of eating

27.1 ± 18.5

27.8 ± 16.8

0.84

Body image

24.9 ± 31.9

29.2 ± 27.8

0.82

Operative details

Postoperative course

Pulmonary function

Quality of life

Conclusion(s) This study suggests that TLDG with Billroth II anastomosis was safe and feasible as LADG in early gastric cancer. The statistically significant beneficial effect of TLDG were smaller wound below umbilicus compared with epigastric wound after LADG and more healthy physical function of quality of life. Our study is ongoing to overcome the limitation of small sample size.

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S423

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SILS APPENDECTOMY IS SAFE IN ALL PRESENTATIONS OF ACUTE APPENDICITIS Sathyaprasad C Burjonrappa, MD MS FRCSEd, Hrishikesh Nerkar, MD, Maimonides Medical Center Background: Single Incision Laparoscopic Surgery (SILS) has to date been applied to the management of non-complicated acute appendicitis. Its proponents advocate its use based on its cosmetic appeal. What is not known is its safety and applicability in perforated acute appendicitis. We evaluated the applicability of SILS in all presentations of appendicitis, in the pediatric population, and compared it to conventional laparoscopy (CL) performed over the same period. Materials and Methods: Children presenting with acute appendicitis at a large Children’s Hospital over a three month period were enrolled in the study after IRB approval. They were treated by one of three pediatric surgeons. While two surgeons offered patients CL the third offered patients older than 4 years SILS appendectomy as an alternative to CL. SILS was performed using the Olympus triport and associated equipment. A total of 20 consecutive patients who underwent SILS at initial presentation were included in this study and were compared to 20 patients who underwent CL over the same time period. Demographic characteristics, clinical features, operative finding, operative duration, conversion to traditional laparoscopy or open procedure, length of stay, and wound complications were evaluated. The primary endpoint was the incidence of complications. Secondary endpoints included length of stay, incidence of wound infection and intra-abdominal abscess, and need for subsequent interventions. Data was analyzed using the student’s t-test for continuous variables and the Fisher test for categorical data. A p \ 0.05 was considered to represent a statistically significant difference. Results: The mean age of the patients was 11.1 years (7–15) in the SILS group and 8.45 (2–17) in the CL group (p = 0.07). There were 7 females and 13 males in each group. The mean weight of the patients in the SILS group was 47. 3 Kg (21.1–87.8) and 31.62 Kg (13.4–62.6) in the CL group (p \ 0.05). The mean length of stay in the SILS group was 4.2 days (2–11) and 6.5 days (2–14) in the CL group (p = 0.06). The average cost of treatment in the SILS group was $34906 and $52288 in the CL group (p = 0.06). The preoperative clinical features including: duration of symptoms (1.85 vs 1.68 days), presence of fever (13 vs 11), and mean WBC count (16.2 vs 14.8) were not significantly different. There were 9 perforated appendicitis in the SILS group and 11 perforated in the CL group (p = 0.75). The operative time in the SILS group was 73 min (51–112) and 58 min (34–75) in the CL group (p \ 0.05). One patient in the SILS group underwent conversion to CL. There were no post-operative abscess in the SILS group and 4 in the CL group of whom 2 needed radiological abscess drainage (p = 0.1). There were no wound infections in either group. Conclusions: SILS appendectomy appears to be safe for all presentations of pediatric acute appendicitis in this pilot study. Performance of SILS appendectomy was associated with a significantly longer operative time but was not associated with any increase in costs. Bigger trials with larger patient populations would be useful to confirm the findings in this study.

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SINGLE INCISION SLEEVE GASTRECTOMY UTILIZING SPIDERÒ SURGICAL SYSTEM: CASE SERIES OF 18 PATIENTS Shyam Dahiya, MD, Tri-City Regional Medical Center, Hawaiian Gardens, CA Introduction: Single incision laparoscopic surgery has garnered wide interest in a number of specialties. A common limitation cited for many single incision methods is the lack of instrument triangulation and the need to cross instruments. The SPIDER Surgical System (TransEnterix, Durham, NC) is a technology for single incision surgery that provides instrument triangulation and eliminates instrument crossing. This is a report of a single surgeon case series of 18 laparoscopic, single incision sleeve gastrectomies utilizing the SPIDER Surgical system to assess feasibility. Methods and Procedures: A 12 mm trocar is inserted at the umbilicus in the left portion of the umbilical ring. Pneumoperitoneum is obtained and the abdominal cavity is inspected. The SPIDER device is inserted next to the 12 mm trocar within the same umbilical incision (through a separate fascial incision) on the right portion of the umbilical ring. The total skin incision length is approximately 3.5 cm. A 5 mm bariatric length scope is inserted through the SPIDER device for visualization. Two flexible, atraumatic graspers are inserted into the flexible instrument channels of the SPIDER device for retraction and manipulation of gastric tissue. A 5 mm laparoscopic vessel sealing device is then introduced at the umbilicus through the 12 mm trocar. The pylorus is identified, and the gastrolysis begins approximately 4 cm from the pylorus. The surgeon uses their left hand to control the left flexible instrument of the SPIDER, and uses their right hand to control the vessel sealer. The assistant controls the right flexible instrument of the SPIDER device for counter-traction and lifting of gastric tissue. Once the gastrolysis is complete, a 34 Fr gastric tube is inserted to guide the sleeve formation. An articulating stapler is introduced through the 12 mm trocar at the umbilicus, and the gastric tissue is manipulated into the proper position using the SPIDER flexible instruments. A buttress material is used with each stapler cartridge, and the stomach is divided to form the sleeve. The gastric specimen is grasped by a rigid grasper through the SPIDER device, and the specimen is removed as the SPIDER device is removed from the abdomen. Results: A total of 18 sleeve gastrectomies were done by a single surgeon utilizing the SPIDER Surgical System. The mean age of patients was 39 years (±13 standard deviation, 23 min, 61 max). The mean BMI was 43 (±1 5 standard deviation, 39 min, 59 max). The mean total operative time was 98 min (±58 standard deviation, 51 min, 200 max). The mean follow up period was 94 days (±78 standard deviation, 7 min, 311 max). In 16 of 18 cases, no Nathanson liver retractor was used because the SPIDER left flexible arm provided all necessary liver retraction. No interoperative or post-op complications were observed. No cases were converted to open, and no cases required additional ports. Conclusions: The SPIDER Surgical System appears feasible as a single incision system to perform gastric sleeves. Further study of this novel technology is recommended

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COMPARISON OF BILLROTH-I AND ROUX-EN Y RECONSTRUCTION IN EARLY OUTCOMES FOLLOWING LAPAROSCOPY-ASSISTED DISTAL GASTRECTOMY FOR GASTRIC CANCER Shuhei Komatsu, MD, Daisuke Ichikawa, MD, Kazuma Okamoto, MD, Atsushi Shiozaki, MD, Hitoshi Fujiwara, MD, Yasutoshi Murayama, MD, Yoshiaki Kuriu, MD, Hisashi Ikoma, MD, Masayoshi Nakanishi, MD, Toshiya Ochiai, MD, Yukihito Kokuba, MD, Eigo Otsuji Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine Background: Clinical course and complication rate following laparoscopy-assisted distal gastrectomy (LADG) are influenced by clinical technical expertise and experience because reconstruction is performed through a small mini laparotomy window. This study was designed to compare postoperative complications of Billroth-I and Roux-en Y reconstructions following LADG for gastric cancer. Patients and Methods: Between October 1997 and April 2009, 80 consecutive patients underwent LADG. These patients were classified into two groups: Billroth-I group (n = 49) and Roux-en Y group (n = 31), and the patient and tumor characteristics, surgical details, and postoperative complications were analyzed. Results: 1) Billroth-I reconstruction was performed more frequently in the lower portion of the stomach (p \ 0.05) and yielded shorter surgical durations (p \ 0.05) and reduced blood loss (p \ 0.01), although there were no significant differences in patient age, gender, BMI, pN-stage, pT-stage or extent of lymphadenectomy. 2) The overall postoperative complication rates did not significantly differ (p = 0.25). However, the rate of stasis was 19.4% in Roux-en Y group, which was higher than that in Billroth-I group (2.0%) (p \ 0.05). 3) Concerning the clinical factors associated with a long hospital stay, Roux-en Y group showed a tendency toward a longer hospital stay (p = 0.058). Postoperative complications (p \ 0.0001) and stasis (p \ 0.0001) were significantly associated with a longer postoperative hospital stay. Conclusions: Billroth-I technique is a feasible and safe reconstruction method and not inferior to Roux-en Y reconstruction following LADG for gastric cancer.

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COMBINED LEFT COLIC ARTERY PRESERVATION AND INFERIOR MESENTERY ARTERY LYMPH NODE DISSECTION DURING LAPAROSCOPIC LOW ANTERIOR RESECTION Sheng-chi Chang, MD, De-wei Ke, MD, William Tzu-liang Chen, MD, China Medical University Hospital, Taichung, Taiwan

SINGLE-INCISION LAPAROSCOPIC SURGERY WITH ONE ASSIST PORT (SILS-ONE) FOR RIGHT HEMICOLECTOMY Tao-wei Ke, MD, William Chen, MD, Sheng-chi Chang, MD, Huache Chiang, MD, Division of Colorectal Surgery, Department of Surgery, Center of Minimally Invasive Surgery, China Medical University Hospital, Taichung, Taiwan

During rectal surgery, management of inferior mesentery artery (IMA) can be divided in to high tie method and low tie method. High tie method means IMA was transected at base that caught harvest pedicle lymph nodes (LNs) and produced accurate cancer stage. Low tie means IMA was transected above left colic artery (LCA) that support better blood flow to the proximal colon stump. Most laparoscopic surgeon preferred high tie because the technique was easier than low tie method. However, our current method in doing IMA is combined laparoscopic low tie and IMA D3 LNs dissection that not only improved circulation of colon, but also clean all LNs. Since November 2010, we performed this method in most patient undergoing laparoscopic low anterior resection (LAR). I will introduce our standard flow procedure doing laparoscopic LAR with LCA preservation and D3 LNs dissection by video.

Background: Single-Incision Laparoscopic Surgery (SILS) right hemicolectomy is a safe and feasible procedure in benign and malignancy colon diseases. But SILS is still very situational, and requires more effort from the surgeon. We report a novel surgical technique of single-incision laparoscopic surgery with one assist port (SILS-One) which could be performed more easier and comfortable than conventional SILS right hemicolectomy. Methods: A periumbilical 3-cm longitudinal skin incision was made and carried down to the fascia layer. Three 5-mm trocars were placed through the incision and another 5-mm trocars was placed in the right lower quadrant. The inclusion criteria was lesions located at right side colon. Cases of obstruction or perforation that required emergent operation were excluded. The patient’s age, gender, surgical indication, intraoperative, postoperative and pathology were assessed. Result: A total of 62 patients (30 male and 32 female) underwent single-incision laparoscopic surgery with one assist port (SILS-One) right hemicolectomy. Surgical indication included colon cancer (48 cases), colon polyps (7 cases), diverticulitis (5 cases), appendiceal carcinoid (1 cases), appendiceal mucinous adenocarcinoma (1 cases). The mean age of patients was 62.23 years old, with a mean body mass index (BMI) of 23.63 kg/m2. The mean operative time and intraoperative blood loss was 168.92 min and 48.46 ml. The mean length of hospital stay was 6.26 days, mean length of specimen was 28.17 cm, and mean numbers of harvested lymph nodes were 25.63. There were no conversions to open surgery during any of the cases and no morbidity or mortality was associated with this technique. Conclusion: Compared with conventional SILS right hemicolectomy, the minimal invasive laparoscopic surgery method, so-called SILS-One, has better surgical triangulation traction and equal benefit in wound problems even cosmetic advantage. Operation can be performed more comfortably and smoothly with adding one port inserted in the right lower quadrant.

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LAPAROENDOSCOPIC SINGLE-SITE SURGERY (LESS) ABDOMINAL EXPLORATION IN ACUTE ABDOMEN: ONE UNIT EXPERIENCES WITH 90 CONSECUTIVE CASES Duo Li, MD, Chunbe Kang, MD, Jinhong Liu, MD, Dept. Surgery, Aerospace Center Hospital, Peking University Objective: Laparoendoscopic single-site surgery (LESS) is a newly emerging advanced minimally invasive surgical procedure. Patients suffering from acute abdomen may also benefit from such advancement; here we report our experience by using a single small incision through the umbilicus in surgical acute abdomen .We aimed to investigate the feasibility, safety and advantage of the LESS abdominal exploration in diagnosis and treatment of acute abdomens. Method: We review the clinical data of 90 cases of surgical acute abdomen admitted between Jan. and May 2011, which were judged need surgical intervention, and enroll in for laparoendoscopic single-site surgery (LESS) abdominal exploration at the Aerospace Center Hospital. The Procedures were performed by one group of surgeons through a 15 mm single umbilical incision and by 10 mm laparoscope with a 5 mm instrument channel with or without another 5 mm laparoscopic forceps. Results: In 90 patients, 76 cases were acute appendicitis and successfully performed appendectomy by pull out the appendix through the umbilicus using a grasper through the 5 mm instrument channel. 3 of them were converted two-port laparoscopic appendectomy and 1 was 3 port because of severe adhesion. None of them was converted to open appendectomy. 1 case with hemorrhage enteritis was performed small bowel resection through the umbilical single port. 2 were perforated ulcer by laparoscopic repair through the umbilical port. 2 cases were pelvic inflammatory disease performed peritoneal lavage. All the patients were cured within 7 days. The average operation time were 60 min, hospital stay were 3 days. The pain scales were 3-4 compare to 6-7 with open Surgery. The cosmetic effect was show in the picture. Conclusion: Our empirically study suggested single port exploration for acute abdomen is safe and feasible, especially for those when the diagnosis is not certain. Laparoendoscopic single-site surgery (LESS) evaluation facilitates easier manipulation for misdiagnoses at operation thereby reducing unnecessary extra trocar and conversion to open technique. The surgical procedures are easier than traditional laparoscopic acute abdomen procedure if the involved organ could be pulling out through the umbilicus. Cosmetic effect was better.

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FEASIBILITY OF MICRO LAPAROSCOPIC HELLER MYOTOMY Helmuth T Billy, MD, Ventura Advanced Surgical Associates Introduction: The goal is to assess the feasibility of utilizing micro laparoscopic instruments to perform a virtually scarless Heller Myotomy. Methods and Procedures: A 72 year old woman with chronic achalsia underwent successful laparoscopic Heller myotomy using 2.7 microlaparoscopic instruments. The patient was placed in slight reverse Trendelenburg. A total of two 2.7 mm ports were introduced, one in left upper quadrant and one in the right upper quadrant. A Nathanson retractor was used subxyphoid for liver retraction. Two 5 mm ports were introduced through a single incision at the umbilicus for visualization and introduction of sutures, suction irrigation and a 5 mm vessel sealer. Suture needles were skied to aid in insertion. The 2.7 mm instruments used were constructed with a novel titanium-ceramic shaft which reduced the deflection normally expected of micro laparoscopic instruments. The enhanced rigidity enabled the instruments to function with the integrity similar to 5 mm laparoscopic instruments. The Heller myotomy was performed in the usually laparoscopic fashion. 2.7 mm grasping instruments were used to provide retraction, and a 2.7 mm monopolar hook electrode was used for dividing muscle fibers. An endoloop was used to assist in retracting the esophagus, and a 2.3 mm Minilap instrument was percutaneously placed in the left upper quadrant and used to hold the loop in place. Three interrupted sutures were placed using 2.7 mm instruments to laparoscopically suture repair a posterior hiatal hernia. A partial anterior fundoplication was then performed. Results: The total operative time was 105 min. The patient received no ports larger than 3 mm outside of the umbilicus. An interoperative endoscopy was performed to confirm the adequacy of the myotomy. The patient had an uneventful recovery and was discharged after a 48 h hospitalization Conclusions: A micro laparoscopic approach to Heller Myotomy appears feasible using only sub 3 mm instruments outside of the umbilicus. This approach warrants further study as a potentially appealing option for patients that still allows for the completion of the procedure using the accepted standard laparoscopic approach.

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SEALED INCISION MULTIPORT (SIMPORT): A UNIFYING ACCESS DEVICE FOR TRANSABDOMINAL AND TRANSANAL LAPAROENDOSCOPY Deirdre F Waterhouse, Dr, Ronan A Cahill, Dr, European Institute of Surgical Research and Innovation (EISRI)

ENDOLUMENAL MANAGEMENT OF TUBULAR ESOPHAGEAL DUPLICATIONS Danielle S Walsh, MD FACS, Adam S Harris, MD, Maryanne L Dokler, MD FACS, Donald E George, MD, East Carolina University, Nemours Children’s Clinic, Mayo Clinic Jacksonville

Introduction: The new avenue of laparoscopy referred to as Single Incision Laparoscopy is often presented as an alternative to more conventional laparoendoscopic approaches whereas in fact it is really a complimentary procedure. The benefits of this technique’s principles can be of broader utility both to patients and surgical specialties if they can be harnessed to allow next-stage evolution through synergy with more mainstream practice. In particular, rather than device specificity what is needed is convergence of capability that the same surgeon can apply in differing scenarios depending on the individual patient/disease characteristics. We detail here the global, unifying applicability of a novel access device construct that allows the provision of simple and complex single port laparoscopy as well as contributes to multiport laparoscopic operations and transanal resections in a manner that is reliable, reproducible and extremely ergonomical. Methods: The Sealed Incision Multiport (SIMPORTTM) comprises a single piece of flexible, elastic material specifically configured for application onto either surgical incision sites (2–9 cm diameter) or natural orifices. Its design allows accommodation of standard laparoscopic trocars in a non-prescriptive fashion (i.e. full compatibility with all commercially available trocar sleeves 5–12 mm in internal diameter regardless of brand) with either four or five dedicated conduits mounted on its upper dome along with a separate outlet that mates with gas sufflation tubing. Its lower cylindrical chamber is designed to stretch hermetically over standard wound protector-retractors or circular anal dilator (CAD) devices in common use and thereby permit and maintain a pneumoperitoneum or pneumorectum respectively. It has been carefully designed to be fit for purpose either as a single port, an adjunct access during multiport procedures (especially those that involve incisions for specimen extraction or stoma maturation) or for transanal intraluminal working. To test its utility and effectiveness, a series of bench and biomedical tests were performed using different operators to gauge applicability in a variety of settings. Results: The SIMPORT proved an excellent fit both onto the commonest wound protectors and CAD devices and with a variety of conventional laparoscopic trocars (whether reusable, reposable or disposable). Once in situ either a box or porcine model, it was entirely compatible with all standard straight rigid laparoscopic instrumentation (allowing enhanced tip triangulation) and throughout rigorous testing involving multiple instrument exchanges and extreme positioning was secure, durable and leak-tight. In porcine testing (n = 2), at a variety of site placements, it facilitated full laparoscopy, cholecystectomy and ileal resection as well as anterior resection and re-anastomosis (for the lattermost procedures, additional wide diameter stapling instrumentation were readily accommodated alongside the optic and two other retracting instruments). Additionally, it enabled transanal operating equivalent to Transanal Endoscopic Microsurgery (TEM) by providing a stable platform for intrarectal resection. On examination during and after completion of the operative series, the device retained its configuration and performance characteristics in their entirety. Conclusion: Considerable preclinical testing has shown the SIMPORTTM possesses many of the ideal qualities of a single device that will encompass and unify many different access options for the contemporary laparoendoscopic surgeon.

Introduction: Tubular esophageal duplications are a challenging anomaly traditionally treated with resection via thoracotomy or thoracoscopy. An endoscopic approach to the esophagus with division of the common wall between the two lumens is an attractive and less invasive alternative to resection. We present our technique for endolumenal division of a tubular esophageal duplication. Case Presentation and Methods: A 17 year old male presented with acute chest pain and imaging studies revealed what appeared to be extralumenal air and contrast parallel the esophagus. Endoscopy demonstrated an esophageal opening 18 cm from the teeth and a CT scan confirmed the diagnosis of a tubular esophageal duplication extending from the level of the carina to the gastroesophageal junction. Endoscopic ultrasound was employed to visualize the thickness of the esophageal walls but resulted in flattening of the duplication as did not provide additional information over the CT scan imaging. An attempt at rigid esophagoscopy with division of the common wall using sealing devices was abandoned as the air insufflation via the flexible scope permits markedly superior visualization of the structures. A wire directed into the secondary esophagus was used to guide endoscopic needle cautery in the division of the mucosal and muscular wall between the two lumens. Results: A post procedure esophagram showed a single esophageal lumen with no evidence of contrast extravasation. The patient was discharged after 24 h of observation having required no pain medication. There has been no clinical evidence of esophageal dysmotility, dilation, or other complication. Conclusion: Endolumenal division of the common wall between the native and duplicate esophagus represents a viable treatment alternative for tubular duplication of the esophagus. As compared to trans-thoracic resection, endoscopic treatment resulted in a short hospital stay with minimal patient discomfort and prompt return to full function. To our knowledge, this is only the second case of tubular esophageal duplication treated with exclusively endoscopic techniques. We recommend consideration of this technique over more invasive approaches when this rare pathology is encountered.

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ENDOSCOPIC MANAGEMENT OF COLORECTAL ANASTOMOTIC STRICTURE WITH TEMPORARY STENT Y Saida, MD, T Enomoto, MD, K Takabayashi, MD, A Otsuji, MD, Y Nakamura, MD, M Katagiri, MD, S Nagao, MD, M Watanabe, MD, K Asai, MD, Y Okamoto, MD, J Nagao, MD, S Kusachi, MD, Toho University Ohashi Medical Center Purpose: Stenting of benign colorectal conditions has been described, but its role has been limited due to technical issues and lack of long-term data on permanent metal stents for nonmalignant disease. However, with the recent introduction of nonmetal esophageal stents, there is a growing interest and some experience with their role in the treatment of benign conditions, including postoperative complications following esophageal or gastric surgery. In this paper, we describe the results of endoscopic stenting in 5 patients with postoperative anastomotic stricture following colorectal surgery. Results: During October 1993 and August 2011, we have performed 147 stenting for colorectal stricture, including 102 cases of ‘‘bridge to surgery’’ stenting, 37 cases of palliative stricture relief, 6 cases of anastomotic stricture and 2 cases of inflammatory stricture. In total stenting cases, 136 cases (93%) could be successfully performed stenting. For the treatment of anastomotic stricture, 5 cases, that were all male with mean age of 67 and that showed no improvement by balloon dilation, were treated successfully by stenting. In these cases, stricture was immediately relieved after stenting. The insertion and efficacy rate was 100% in the 5 cases. There was no complication associated with stenting. Neither perforation nor additional surgical therapy was observed. All of these cases were undergone temporally stenting, which were removed later. Case 1 with wire guided (WG) stenting in the descending colon showed spontaneous passage of EMS in the 3rd month after the placement. Case 2 with through the scope (TTS) type stenting in the transverse colon was not able to be extracted due to firm fixation to the colon in the 6th month but was spontaneously eliminated in the 16th months after the placement. Case 3 with TTS type stenting in the descending colon was endoscopically extracted in the 1st month utilizing endoscopy. Case 5 with WG stent in Rs was removed endoscopically in the 1.5th month. There was no re-stricture in these 4 cases. Case 4, however, with WG stent in RS was removed in the 1.5th month and developed re-stricture. In the 2nd month after the removal, stent was re-placed under the same WG manner and in the 3rd month, it was extracted with endoscopy and no stricture has been observed until now for 4 years after the extraction. All stent were self-expandable metallic stent, and the size of stent placed in the intestine was 18-22 mm in diameter and 60-100 mm in length. Conclusion: Stenting for colorectal stricture has been clinically used for the palliation of malignant diseases and colorectal cancer ileus. This method has been described as less invasive and better patients’ QOL. Stenting, however, should be carefully applied for benign diseases, as it is a foreign body, though it is a feasible alternative in some cases to avoid extensive therapy such as surgery.

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RECONSTRUCTION OF THE ESOPHAGOJEJUNOSTOMY USING THE TRANSORALLY INSERTED ANVIL (OrVilTM) AFTER LAPAROSCOPIC TOTAL GASTRECTOMY Shinya Mikami, Tetsu Fukunaga, Hiroaki Itoh, Keizou Hataji, Ryuichi Oshima, Takeharu Enomoto, Jo Sakurai, Nobuyoshi Miyajima, Takehito Otsubo St. Marianna University School of Medicine, Department of Gastroenterological and General Surgery,

DETECTING ABNORMALITIES IN ENDOSCOPIC EXAMINATIONS BY COMBINING INFORMATION FROM MULTIPLE IMAGES Qian Zhao, Gerard E Mullin, MD, Max Q-h Meng, PhD, Themistocles Dassopoulos, MD, Rajesh Kumar, PhD, Johns Hopkins University, Chinese University of Hong Kong, Washington University School of Medicine

Introduction: Laparoscopic total gastrectomy (LTG) has not become as popular as laparoscopic distal gastrectomy because of the more difficult reconstruction technique. Although various reconstruction procedure have been reported, a standard technique has yet been established. As a reconstructive procedure after LTG, we perform Roux-en Y reconstruction of the esophagojejunostomy using the transorally inserted anvil (OrVilTM). We report our reconstructive procedure and strategies for LTG. Procedures: From April 2009 to September 2011, 27 patients with gastric cancer underwent LTG at our affiliated hospitals. The patient was placed in the supine position with the legs apart. A 30 oblique endoscope was inserted though the umbilical port, and a total of four ports inserted into the left upper, left flank, right upper and right flank quadrants. After Lymph node dissection of the perigastric and suprapancreatic areas, the duodenum was transected with an endoscopic linear stapler. The esophagus was transected with an endoscopic linear stapler. The jejunum 25 cm distal from the Treitz ligament was transected with an endoscopic linear stapler. Side-to-side jejunojejunostomy with an endoscopic linear stapler was performed to prepare a Y limb. The umbilical wound was extended to 4 cm. And, the jejunum limb was pulled out of the abdominal cavity. A circular stapler was inserted into the jejunal limb and fixed with the vessel loop. The circular stapler was introduced into the abdominal cavity. The OrVilTM tube was transorally introduced into the esophagus. A small hole was made on the right side of the esophageal stump. The tube was extracted through the hole until the anvil reached the esophageal stump. The tube was disconnected from the anvil by cutting the connecting thread and removed from the abdominal cavity. The anvil and circular stapler were connected and anastomosis was performed hemi-double stapling technique. The jejunal stump was closed with an endoscopic linear stapler. Results: The mean operative time for the 27 patients was 312 min, and the estimated blood loss was 113 g. One patient who had anastomotic leakage at the esophagojejunostomy recovered by conservative treatment. Another patient who developed anastomosis stenosis was successfully treated by endoscopic balloon dilatation. Conclusion: The circular stapling esophagojejunostomy using OrVilTM facilitates insertion and fixation of Anvil head. Also, this procedure does not depend on patients’ physical status and can be applied for high-level anastomosis.

Introduction: Endoscopic, and more recently wireless capsule endoscopic (CE) examinations produce large number of images (e.g. over 50,000 images for CE), not all of which are interpreted with equal emphasis by the reviewing clinician. It is a time-consuming and tedious task to review such large amounts of data for clinicians, and traditionally only selected images are used for clinical diagnosis. Such analysis focus on abnormality detection on an individual image, by treating images with best view of the abnormality as the only, individual, and independent observations. As a result, relevant information available in neighboring images is often discarded, or at least does not contribute to the clinical diagnosis. We present methods of combining information from multiple images containing the same abnormalities, permitting stronger inferences, more automatically. These methods can be used for decision support during endoscopy (including CE), or during any endoscopic surgery. Methods and Procedures: We have developed supervised statistical classification methods based on a Hidden Markov Model (HMM) framework. Using color, edge, and texture information extracted from each images in a sequence where an abnormality might be visible, a Support Vector Machine (SVM) classifier performs an individual binary normal/abnormal classification. The HMM framework then combines the classifier output from individual images into a sequence classification. We tested such classification on CE images containing bile, air bubble, extraneous matter, lesions, normal lumen and polyps. Additional analysis of CE and endoscopic images is ongoing. Results: The proposed method was evaluated using a CE image database containing 47 studies collected using a Johns Hopkins Institutional Review Board (IRB) protocol. Image sequences of varying lengths were extracted from these studies and abnormalities were annotated by a clinical expert. Table 1 shows the accuracy, precision and recall (sensitivity) comparison for individual image classification using the same SVM binary classifier and image sequence classification. The accuracy for all classes increase when classification uses multiple images. Conclusions: The proposed framework shows promising performance and has the potential to reduce the reading time for clinicians for offline data, and real-time performance for providing decision support during endoscopic procedures. It can also be used to summarize the studies for generation of a synopsis containing relevant images. Further work towards development of a semi-automated computer aided diagnosis system using these methods is ongoing.

Table 1 Performance (accuracy) for individual classification and image sequence classification

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Accuracy

Bile

Bubbles

Extraneous

Lesion

Normal

Polyps

SVM-RBF

0.88

0.84

0.82

0.77

0.75

0.88

HMM

0.99

0.90

0.85

0.83

0.83

0.93

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A NOVEL USE OF FLEXIBLE WALL STENT IN J POUCH ANASTOMOTIC STRICTURE Amalia Stefanou, MD, John Park, MD, Slawomir Marecik, MD, Leela Prasad, MD, Advocate Lutheran General Hospital, University of Illinois Chicago Hospital, Cook County Hospital Objective: We present a novel use of flexible stent for the treatment of small bowel stricture in a patient with inflammatory bowel disease. While the use of stents has been accepted in esophageal and in colonic obstructions, they rarely are used in the treatment of small bowel strictures. Stents have mainly been used for malignant or palliative obstruction, with increasing use in benign disease. Literature supporting the use of stents in small bowel pathologies has largely been absent. We present a case of ileoanal pouch anastomotic stricture in a patient with Crohns disease presenting as obstruction and the use of stent placement to avoid further need for operation. Methods: Patient is a fifty-five year old male who had a presumed history of ulcerative colitis and underwent proctocolectomy with ileoanal pouch anastomosis (IPAA) in 1993. Following this, he developed small bowel obstruction in 2004 and operative small bowel resection was performed for stricturing disease. Pathology from the specimen diagnosed Crohns disease. In 2005 he represented with significant symptoms of abdominal distention and decreased oral intake. Abdominal CT scan demonstrated small bowel obstruction. Flexible sigmoidoscopy at this time revealed a proximal afferent limb stricture within the pouch. Patient underwent operative exploration resulting in stricturoplasty of the proximal afferent limb stricture. The stricturoplasty resulted in only minimal relief of symptoms as the pouch re-strictured within 6 months. The patient was very reluctant to undergo the advised permanent end ileostomy. For this reason, placement of a flexible wall stent to the area of stricture was considered for dilation and management of the stricture. Initially, an 18 mm 9 12 cm Boston Scientific Polyflex Wallstent was used following balloon dilation with good results. Migration of the stent did occur after nearly six months, requiring removal and replacement. This time endoclips were placed at the distal end to prevent migration. After another six months, the stent again migrated requiring placement of a larger 25 mm by 15 cm Polyflex Wallstent with reversal of the flared end to prevent proximal migration. Sutures were placed at the distal end of the stent and secured with endoclips. This has provided the patient with long-lasting relief from his symptomatic stricture and has avoided the need for permanent ileostomy. Conclusion: The diagnosis and management of inflammatory bowel disease and its complications can be a challenge for both patient and physician. On review of the literature, there is very little discussion regarding the use of flexible covered nonmetallic stents in small bowl, and particularly in pouches. This novel treatment approach provides patients with opportunity for management of their disease without the risk of further surgery and bowel resection. Our experience suggests that using a flexible covered non-metallic stent with flare provides effective functional outcome. Securing the stent with sutures and endoclips is recommended.

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PERCUTANEOUS ENDOSCOPIC GASTROSTOMY WITH T-FASTENERS OBVIATES THE NEED FOR EMERGENT EXPLORATION AFTER EARLY TUBE DISLODGEMENT Poochong Timratana, MD, Kevin M El-hayek, MD, Hideharu Shimizu, MD, Matthew Kroh, MD, Bipan Chand, MD FACS, Cleveland Clinic Introduction: Despite technical refinements of percutaneous endoscopic gastrostomy (PEG), complications remain static. These complications include bleeding, tube site infection, and tube dislodgement. Tube dislodgement occurs more frequently in high risk patients such as those with altered mental status. The morbidity associated with early tube dislodgement is significant and often requires surgical exploration for gastrotomy repair and tube replacement. There is also risk of sepsis secondary to intraabdominal contamination. The purpose of this study is to review the experience from a high volume endoscopy center following the introduction of T-fastener placement in high risk patients. We hypothesize that procedure related morbidity will decrease when T-fasteners are used in patients with early tube dislodgement. Methods: We retrospectively reviewed PEG placement over the preceding 12 months (October 2010–September 2011) when our group began to selectively use T-fasteners in high risk patients. Patients with altered mental status deemed to have an increased risk for early tube dislodgement underwent T-fastener placement at the time of PEG placement. Charts were retrospectively reviewed and patients with PEG alone were compared with those patients who had PEG with T-fastener (PEG-T). Statistical analysis was performed using SPSS version 18. Results: A total of 195 patients underwent PEG placement during the study period. PEG alone was performed on 121 patients, while PEG-T was performed on 74 patients. Mean age for PEG alone versus PEG-T was 64.2 ± 15.1 and 71.0 ± 15.2 years respectively (p = 0.001). Indication was feeding access in 102/119 (86%) patients who had PEG alone and 68/74 (92%) who underwent PEG-T (p = 0.12). The other patients had PEG placement for decompression. Neurologic deficit (i.e. cerebrovascular accident, dementia) was identified in 64/121 (53%) with PEG and 58/74 (78%) with PEG-T (p \ 0.01). In an attempt to further identify an increased risk for early tube dislodgement, a clinical assessment involving communication with nursing teams as well as review of the electronic medical record was performed. There were 7 complications overall. In the PEG cohort, 1 patient had intraluminal bleeding requiring repeat endoscopy. Six patients had early tube dislodgement in the PEG-T cohort versus none in the PEG cohort (p = 0.003). Mean time to tube dislodgement following PEG placement was 5.0 ± 6.3 days. The first patient underwent diagnostic laparoscopy with replacement gastrostomy 2 days following tube dislodgement and was noted to have no contamination and an intact gastropexy. The subsequent 5 patients underwent non-emergent PEG replacement in the endoscopy unit within 48 h of tube dislodgement. In short term follow-up, no repeat dislodgements were noted. Overall mortality at last follow up was 38/195 (19.5%) and was related to underlying disease. Conclusion: Neurologically impaired patients constitute a high percentage of adults undergoing PEG placement. Subtle clues such as need for restraints prior to PEG may alert the clinician of a higher risk for early tube dislodgement. Placement of T-fasteners in this group may decrease overall morbidity if early tube dislodgement occurs. We have shown safety in non-emergent replacement of PEG in such patients. Need for PEG in adults remains a marker for mortality.

A CASE OF HUGE ESOPHAGEAL HAMARTOMA TREATED BY ENDOSCOPIC RESECTION Toshiyuki Sasaki, MD, Nobuo Omura, MD, Yuuichirou Tanishima, MD, Katsunori Nishikawa, MD, Norio Mitsumori, MD, Hideyuki Kashiwagi, MDPhD, Katsuhiko Yanaga, MDPhD, Departments of Surgery, Jikei University School of Medicine In general, hamartoma frequently occurs in the lung, heart, or hypothalamus, and its occurrence in the gastrointestinal tract is very rare. We report a patient who underwent excision of a giant esophageal hamartoma by endoscopic resection under general anesthesia and review the relevant literature. The patient was a man in his 40s with dysphagia. Upper gastrointestinal endoscopy demonstrated a giant pedunculated polyp that protruded from the esophageal entrance. Esophagography revealed a mass with a smooth surface measuring 13 9 4 9 3 cm in size, with a stalk measuring approximately 2 9 2 cm. Taken together with the chest CT and MRI findings, a tentative diagnosis of fibrovascular polyp was entertained. The tumor was successfully excised by endoscopic resection with a snare under general anesthesia. The final pathological diagnosis was hamartoma of the esophagus. The patient had an uneventful postoperative course and was discharged in good general condition 9 days after resection. He remains asymptomatic without recurrence as of 2 years after endoscopic resection.

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PEG FAILURES: SHOULD ANOTHER SPECIALTY ATTEMPT PLACEMENT? K A Zuberi, MD, B R Zagol, MD, V K Narula, MD, V C Memark, MD, J B Anderson, MD, W Scott Melvin, MD, J W Hazey, MD, The Ohio State University Medical Center: Center for Minimally Invasive Surgery, Columbus, OH, USA Introduction: Percutaneous Endoscopic Gastrostomy (PEG) tube placement is the preferred enteral access for patients unable to swallow or with pre-existing or anticipated malnutrition. We evaluated factors surrounding unsuccessful attempts at PEG placement at our institution, specifically reviewing repeat attempts of tube placement by a different service. Methods and Procedures: We retrospectively reviewed 2664 patients undergoing PEG placement at our institution from January 2003 to December 2010. Variables analyzed included: age, sex, BMI, indication for PEG, previous abdominal surgery, anesthetic type, and complications. Sub-group analysis of re-attempted PEGs by another service, were further reviewed. Analysis was performed by current SAS, (Statistical Analysis System) software. Results: A total of 2664 patients were evaluated. There were 1046 female patients and 1618 male patients. There were 2607 successful PEG tube placements representing a 97.86% success rate at first attempt by all providers. We identified 57 unsuccessful initial PEG tube attempts. Of the 57 patients that had a failed attempt, 23 patients underwent successful placement by a different service, with an average of 2.5 days between attempts. Failure to transilluminate was reported in 29 of the 57 patients and in all 23 patients that had successful placement of a PEG tube on the second attempt by a different service. There was an inability to pass the gastroscope in 11 patients, due to an obstructing lesion, there was difficulty in locating the tracker needle in 7 patients, 4 patients had an aborted procedure due to respiratory compromise, and the remaining 6 patients had a variety of reasons including: severe esophagitis, inability to palpate through the abdominal wall, and a non-distensible stomach. Of the patients that underwent successful re-attempt at PEG placement, 9 of the 23 patients required a general anesthetic. The remaining 34 patients were completely failed attempts and underwent some other procedure for feeding tube placement or no procedure at all. Sixteen of the 34 patients had a history of previous abdominal surgery. The most common procedure performed after failed PEG tube attempt was an Open G-tube in 15 patients and a Laparoscopic G-tube in 2 patients. 17 patients underwent no advanced procedure and were left with a nasoenteral feeding tube. Conclusion(s): An overwhelming majority of PEG tubes are placed at the first attempt. Failure to transilluminate should not be a reason to abort PEG tube placement. Failed attempts at PEG placement should be attempted by another service or different specialty privileged to perform PEGs, especially if unable to transilluminate on the first attempt.

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PATTERN OF OESOPHAGEAL STRICTURE POST ENDOSCOPIC INJECTION SCLEROTHERAPY K O Ba Hakem, MD, M A Ibn Ouf, Professor of surgery, M O Gadour, Professor of Medicine Ibn Siena Hospital, GI bleeding Centre, Sudan Background: Post endoscopic sclerotherapy oesophageal stricture is usually not fatal but may requires several sessions of oesophageal dilation as an effective palliative treatment yet has its own complications. Aim: The purpose of this study is to find out the predictors of sclerotherapy oesophageal stricture and to audit its treatment. Methods: This is a cross sectional descriptive study of the oesophageal stricture post sclerotherapy for the patients who were managed in the period from January 2000 through the June 2007 in endoscopic department at Ibn Sina Hospital. Post endoscopic sclerotherapy symptoms, signs, diagnostic and therapeutic methods were analysed to find out possible predictors of developing benign oesophageal stricture. Result: A total of 33 out of 10133 patients were included in this study, 91% of them were males, 88% were \60 years old and most of them were cases of hepatic periportal fibrosis. Only two patients had oesophageal varices secondary to viral hepatitis B liver cirrhosis. Their presentation was commonly with difficulty in swallowing and few cases presented with food impaction. The majority of patients were treated with wire guided endoscopic Savary Gilliard dilation. Conclusion: Oesophageal stricture following endoscopic injection sclerotherapy is a known morbidity; however the rate of these strictures is fairly acceptable. High dose of sclerotherapy in fewer sessions over a short period and other factors are potential predictors of oesophageal stricture. Key words: Oesophageal varices, sclerotherapy, benign oesophageal stricture by: Ba hakem K.O., Prof. Ibnouf M.A., Prof. gadour M.O.

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INNOVATIVE TECHNIQUE FOR TRANS-NASAL ANCHORAGE OF ESOPHAGEAL STENT TO PREVENT MIGRATION Jai Bikhchandani, MD, A J Davidson, Medical Student, Tommy Lee, MD, S K Mittal, MD, Creighton University Medical Center Introduction: Migration is a common problem of esophageal stenting. We present here an indigenous technique for transnasal anchorage of esophageal stent using silk sutures. This study compares the outcomes of esophageal stents placed with and without suture anchoring. Methods: Patients who underwent esophageal stenting at Creighton University Medical Center over the last 5 years were included in the study. Charts were retrospectively reviewed for demographics, operative details, outcomes and complications in short and medium term follow-up. An excel database was set up and queried for migration rates in—group A (without anchoring) versus group B (stent anchorage). The technique involved tying a 2-0 silk suture to the proximal flare end of the esophageal stent prior to loading it on to the stent deployment system. Following fluoroscopic guided placement of the stent, an endoscopic forceps was used to pull the suture first into the oral cavity and then out through the nostril to be secured posterior to the ipsilateral ear. Results: A total number of 41 esophageal stents were placed in 33 patients. Dysphagia was the commonest indication with anastomotic leak being the second most common. Prior to 2009, the conventional technique of esophageal stenting was used (N = 30). Since 2009, the self devised method of using trans-nasal silk sutures for stent anchorage was applied (n = 11). The mean age and gender distribution was similar in the two groups. Nine of the 30 stents migrated in group A (30%) while only 1 out of 11 stents migrated in group B (9.1%); p value 0.03. The displaced stent was removed in all patients except one in whom the stent placed for caustic stricture of esophagus migrated into the stomach and could not be retrieved endoscopically. One patient with stent migration had gastric ulceration with upper gastrointestinal bleeding requiring laparotomy. Globus sensation was reported by two patients with suture anchorage. Conclusion: This technique is simple and in-expensive for anchoring the esophageal stent proximally without adding significant time to the primary procedure. With promising results in this pilot study, future research would involve setting up a randomized controlled trial applying conventional technique versus the suture anchorage technique for esophageal stenting.

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ENDOSCOPIC STENTING VERSUS EMERGENCY SURGERY IN PATIENTS WITH METASTATIC COLORECTAL CANCERS PRESENTING WITH ACUTE INTESTINAL OBSTRUCTION Ker-kan Tan, FRCS Edin, Tian-zhi Lim, MBBS, Charles B Tsang, FRCS Edin FRCS Glasg, Dean C Koh, FRCS Edin FRCS, Glasg National University Health System Background: Operating in patients with obstructed colorectal cancers is associated with numerous morbidities. Self expanding metallic stents provide a promising alternative. The aim of this study was to compare the outcomes of endoscopic stenting versus emergency surgery in patients with metastatic colorectal cancers presenting with acute intestinal obstruction. Methods: A retrospective review of all patients with metastatic colorectal cancers who underwent either endoscopic stenting or emergency surgery for acute intestinal obstruction was performed. Results: Over a 4-year period from June 2007 to June 2011, 31 patients, median age, 68 (42–96) years formed the study group. The two commonest sites of the primary malignancy were the sigmoid colon (n = 11, 35.5%) and the rectosigmoid junction (n = 8, 25.8%). Hepatic and pulmonary metastases were seen in 25 (80.6%) and 8 (25.8%) patients, respectively. Eighteen (58.1%) patients had endoscopic stenting attempted. It was successful in only 12 (66.7%) patients. The other 6 (33.3%) patients who failed endoscopic stenting required immediate surgery to relieve the obstruction. The remaining 13 (41.9%) patients underwent immediate surgery with no prior attempt at endoscopic stenting. Patients who failed stenting (4/6) had worse grades of complications than those who were successfully stented (1/12) (p: 0.022). This trend was also observed when compared to those patients who were operated immediately (4/13), although the difference was not statistically significant. In addition, the median length of stay (5, range, 3 – 12, days) was shorter in the successful stented group (p: 0.005) compared to the operated group (11, range, 5- 40, days). Twenty-eight patients were discharged well. Only 16 (57.1%) underwent subsequent chemotherapy. The group that was successful stented had earlier commencement of chemotherapy (median: 3, range: 1-6, weeks) than the operated group (median: 10, range: 2- 48 weeks). There was no difference in the overall survival between the groups. Two major stent-related complications were encountered 4 and 5 months after the stent was inserted. Perforation at the tumour site was seen in both patients and required immediate surgery. Conclusion: Self expanding metallic stents for intestinal obstruction in patients with metastatic colorectal cancers are associated with superior outcomes and earlier commencement of subsequent chemotherapy. However, patients who fail endoscopic stenting may encounter significant complications.

P637 PROSPECTIVE, RANDOMIZED COMPARISON OF A PROTOTYPE ENDOSCOPE WITH DEFLECTING WORKING CHANNELS VS. A CONVENTIONAL DOUBLE CHANNEL ENDOSCOPE FOR RECTAL ENDOSCOPIC SUBMUCOSAL DISSECTION IN AN ESTABLISHED EXPERIMENTAL SIMULATION MODEL Yunho Jung, MD, Masayuki Kato, MD, PhD, Jongchan Lee, MD, Mark A. Gromski, MD, Navaneel Biswas, MD, Chuttani Ram, MD, Kai Matthes, MD, PhD, Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA Introduction: Visualization of appropriate anatomic layers during endoscopic submucosal dissection (ESD) is frequently challenging with current endoscopic technology. The R-scope (Olympus Japan, Inc., Tokyo, Japan) was designed to improve visualization and dissection tissue via dual working channels that deflect in differing planes. The efficacy of the R-scope for rectal ESD, however, is unknown. In this study, we evaluated the efficacy of the R-scope in comparison to a conventional double channel endoscope in regards to ESD resection of standardized lesions in the rectum of ex-vivo porcine colon specimens. Methods and Procedures: This is a prospective, randomized, ex-vivo study. 60 standardized artificial lesions measuring 3 x 3 cm were created in fresh ex-vivo porcine colorectal specimens using the EASIE-R simulator platform (Endosim LLC, Berlin, MA). The lesions were located approximately 5 cm from the anal verge. A total of 60 ESD resections were performed by two endoscopists (one advanced endoscopist without prior experience in ESD and one ESD expert with more than 300 human procedures performed). Each endoscopist completed each 15 cases with the R-scope and 15 cases with the conventional endoscope. Both types of endoscopes were compared using the following parameters: procedure time, specimen size, en bloc resection status, perforation, and injection frequency/amount. The results of each procedure were recorded by an independent observer. Results: All 60 lesions were successfully resected by the two endoscopists. The mean (±SD) size of resected specimens was 48 (±4.64) mm in the R-scope group, 51 (±5.41) mm in the conventional scope group, respectively. In the case of the first examiner (ESD novice), the mean submucosal dissection time (9.7 ± 0.9 vs 12.4 ± 0.92 min, P = 0.02) and total procedure time (16.3 ± 1.19 vs 20.5 ± 1.20 min, P = 0.01) were significantly shorter in the R-scope group in comparison with the conventional group. In the case of the second examiner (ESD expert), there was no significant difference between the mean circumferential resection time, submucosal dissection time (R-scope group: 7.3 ± 0.54, conventional scope group: 6.0 ± 0.64 min, P = 0.07), and total procedure time (R-scope group: 11.2 ± 0.89, conventional scope group: 11.0 ± 1.27 min, P = 0.37). The overall perforation (both groups: 0%) and en bloc resection rate (R-scope group: 97%, conventional scope group: 100%) were not significantly difference between the two endoscope types. Conclusion: In this ex-vivo prospective comparison study of the R-scope vs. conventional scope, the R-scope appears to be an easy, safe and reliable method for rectal ESD. It appears that there is a technical advantage for the ESD novice that results in a shorter procedure time, which is not present for the ESD expert.

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P638 ASSOCIATION OF HYPERTHYROIDISM AND DUODENAL ULCER Kamaran R Saeed, MD, MBCHB, Tahir A Haurami, PhD, Seriwan H Quaradaghi, PhD, Sulaiminyia Teaching Hospital, Association of Hyperthyroidism and Duodenal Ulcer Abstract Objectives: In this study, we present the Association of hyperthyroidism with Duodenal Ulceration in the North region of Iraq. Introduction: This is a cross-sectional study and involved with occurrence of hyperthyroidism together with Duodenal Ulcer in same patient. Patients and Methods: In the period between August-2007 & January-2010; a total of 124 patients who presented with Peptic ulcer to the Private clinical center of nutrition—out patient department and they had been diagnosed with hyperthyroidism . All patients answered a brief questionnaire that included identification data, age, and medications in use, medical history and thyroid disease history. Informed concern had been taken. They underwent clinical examination and electrocardiogram, and blood samples for thyroid function tests, investigating the thyroid hormones triiodothyronine (T3) and thyroxine (T4) and sensitive thyroid-stimulating hormone (TSH) and the patients sent for ultrasound examination of the thyroid gland, upper GIT endoscopy, specimen taking for Helicobacter pylori, searching for Helicobacter

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Surg Endosc (2012) 26:S249–S430 pylori infection via Lab rotary investigations. The diagnosis of hyperthyroid state was based exclusively on hormonal determinations, since diagnoses based on clinical grounds have been shown to have low sensitivity and specificity. 16 the criterion used for diagnosing hyperthyroidism was based on the guidelines of the American Thyroid Association. These suggest that virtually all types of hyperthyroidism encountered in clinical practice should be accompanied by serum sensitive thyroidstimulating hormone concentrations of less than 0.1 mU/l and not levels that are just below the normal range. T3, T4 and TSH were measured by radio-immune assay . The reference value for T3 was 70–231 ng/dl, T4 4.5–12.5 ng/dl and sensitive thyroid-stimulating hormone 0.32-5.0 mU/l. Patients with sensitive thyroid-stimulating hormone less than or equal to 0.1 mU/l were considered to have hyperthyroidism. While diagnosis of Duodenal Ulcer had been according to the guidelines of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Results: The total number of (124) patients who presented for peptic ulcers signs & symptoms had been diagnosed with hyperthyroidism and duodenal ulcer at the same time. Then the patients treated initially with anti-thyroid medications (except two patients who treated by radioactive iodine therapy initially with anti-thyroid medications (except two patients who treated by radioactive iodine therapy outside Iraq as this type of therapy was not available in the North of Iraq. Some patients had been operated surgically according to different scientific indication accordingly. Conclusion: The presence of duodenal ulcer in any patient do not exclude hyperthyroid state in the area of study which is characterized by low dietary iodine intake and well known with high prevalence of thyroid disorders.