Surg Endosc (2007) 21: S256–S294 DOI: 10.1007/s00464-007-9274-0
Springer Science+Business Media, Inc. 2007

10th World Congress of Endoscopic Surgery 14th International Congress of the European Association for Endoscopic Surgery (E.A.E.S.) Berlin, Germany, 13–16 September 2006 Video presentations

EAES VIDEO AWARD SESSION V001 - Oesophageal and Oesophagogastric Junction Disorders

V002 - Oesophageal and Oesophagogastric Junction Disorders

LAPAROSCOPIC TRANSHIATAL ESOGASTRECTOMY FOR CORROSIVE INJURY G. Dapri, J. Himpens, A. Mouchart, B. Hainaux, R. Ntounda, R. Kefif, E. Capelluto, G.B. Cadie`re Saint-Pierre University Hospital, BRUSSELS, Belgium

LAPAROSCOPIC REDO FUNDOPLICATION AFTER ENTERIX INJECTION D. Mutter, B. Dallemagne, C. Bailey, J. Marescaux IRCAD-EITS / University Louis Pasteur, STRASBOURG, France

The movie shows a laparoscopic treatment of esogastric corrosive injury, in a 43-years-old man presenting at the Emergency Unit after ingestion of a corrosive fluid. Abdominal CT-scan showed a pneumoperitoneum with free subdiaphragmatic liquid. A gastroscopy showed a necrosis of the mild and lower esophagus with a perforation of the gastric fundus. Laparoscopic exploration confirmed the free peritoneal liquid and the necrosis of the upper part of the stomach. The procedure started with the dissection of the stomach along the greater curvature, respecting the gastro-epiploic vessels. The stomach was separated from the first duodenum by a firing of blue linear stapler. Dissection continued along the lesser gastric curvature. Lower esophagus was completely freed and hiatus opened by medial vertical section of the crus. Esophagus was proximally freed along the descending aorta up to the left inferior pulmonary vein. A partially opening of the esophagus allowed the introduction of the scope inside and the necrosis of the lower and mild part of viscera was confirmed. Hence a subtotal esophagectomy was decided; the stomach was divided from the lower esophagus by a firing of blue linear stapler and retrieved from the abdomen in a bag. A left cervicotomy was performed and the upper esophagus was freed and stripped. After esophageal resection, an esophagostomy was realized in the left part of the neck. A jejunostomy was performed and the procedure ended with the placement of 3 drains: in the hiatus, near the spleen and near the duodenal section.

Background: Enterix (Boston Scientific) is an endoscopic injectable treatment for gastro-oesophageal reflux disease (GERD). The technique of injection is critical to achieving clinically acceptable results and transmural injections through the wall of the oesophagus may result in adverse effects and failure of the procedure. We present a case of a patient with recurrent symptoms of GERD after Enterix injection who was treated using a conventional surgical approach which gave us an opportunity to perform a clinical control of the Enterix ring. Method: A 30 year old male patient was treated for GERD using Enterix 18 months ago. He presented with a symptomatic recurrence of GERD symptoms and a fundoplication procedure was planned. Results: The operation was conventionally performed using 5 ports. Exploration of the mediastinum showed a significant inflammation of the tissue which resulted in difficulty in recognising the surgical landmarks as well as a difficult dissection. The posterior vagus nerve was entrapped in the Enterix ring. A further difficulty was the identification of the Z line in order to correctly position the wrap. In this case, a 270 Toupet fundoplication was placed over the previously injected Enterix polymer. After the laparoscopic procedure, the patients symptoms improved spontaneously and were less than after the endoscopic Enterix injection even if the latter was not prospectively evaluated. Results: The post-operative course was uneventful with a complete resolution of the symptoms at 6 months. Conclusion: Enterix polymer injection is at the origin of inflammatory reactions and vagus nerve entrapment and deep injection of the product may result in further complications. Despite these adverse effects we found that a conventional surgical wrap can still be performed for such patients.

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V003 - Intestinal, Colorectal and Anal Disorders

V005 - Oesophageal and Oesophagogastric Junction Disorders

LAPAROSCOPIC REALLY DOUBLE-STAPLING TECHNIQUE TO PERFORM COLORECTAL ANASTOMOSIS S. Di Palo, A. Vignali, E. Orsenigo, A. Tamburini, G. Bissolotti, C. Staudacher San Raffaele Scientific Institute, MILAN, Italy

LAPAROSCOPIC HAND SEWN ESOPHAGOJEJUNOSTOMY AFTER TOTAL GASTRECTOMY A. Escalona, G. Pe´rez, F. Crovari, F. Pimentel, N. Devaud, S. Guzma´n, O. Llanos, L. Iba´n˜ez Pontificia Universidad Cato´lica de Chile, SANTIAGO, Chile

Aim: Laparoscopic (LS) surgery for rectal cancer is very difficult from a technical standpoint. Intracorporeal rectal transection requires a number of cartridges significantly increased and this may be responsible for a higher anastomotic leakage rate (5.7%-21%) that justifies some authors to recommend a covering ileostomy as a routine in LS low anterior resection. The aim of the film is to show the feasibility of LS intracorporeal rectal transection using a curved cutter stapler introduced throw a transverse sovrapubic 5-cm incision. This permits the use of a single cartridge, consenting a more safe closure of rectal stump. Methods: Initial port placement is performed using the open technique and pneumoperitoneum is induced by CO2. Four ports are then inserted (three 5-mm and one 10-mm) under LS guidance. A window is made between the mesocolon containing the arch of the inferior mesenteric vessels and the superior hypogastric nerve plexus. Legation of the inferior mesenteric artery was then performed with respect to superior hypogastric plexus and left ureter. Mobilization of left colon and splenic flexure is then performed. The LS procedure continues with mobilization of the rectum and mesorectum by sharp dissection and extended down to the level of the levator muscle. Before rectal transection we perform a 5-cm incision in the sovrapubic space protecting the wound. Throw this incision we introduce a curved cutter stapler and under LS guidance we transact the rectum by a unique cartridge. Now pneumoperitoneum is not required. The bowel is then exteriorised and divided completing low anterior resection. The procedure continues traditionally with the suture of the incision after inserting the anvil head of the circular stapler into the end of the proximal colon. Pneumoperitoneum is induced and anastomosis performed by a really ÔdoubleÕ-stapled technique. Conclusion: The safety of LS rectal transection using an endolinear stapler is one of the most technically difficult procedures in LS low anterior resection. LS intracorporeal rectal transection can be safety performed by introducing a curved stapler throw a transverse sovrapubic incision resolving the technical difficulties related to the use of an endolinear stapler and permitting to perform a really ÔdoubleÕ-stapling anastomosis.

Introduction: Total gastrectomy is a well-established procedure for treatment of proximal gastric cancer. The development of laparoscopic surgery has allowed incorporating this technology to the surgical treatment of this disease. The reconstruction of esophagojejunostomy is one of the challenges in total laparoscopic surgery. This anastomosis is usually performed with circular or linear stapler. Laparoscopic total gastrectomy with a hand sewn esophagojejunostomy is presented. This approach to laparoscopic total gastrectomy with lymph node dissection uses 5 ports. After dissection of the greater omentum duodenum is transected with 45-mm linear stapler. The duodenal stump is oversewn with Vicryl 3-0 in a running suture. Then lymph node disecction of group 8, 9 and 7 is performed. To create the Roux limb the small bowell is divided about 30 cm distal to the Treitz ligament. The enteroenterostomy between a Roux limb of about 60 cm and biliopancreatic limb is performed with a single intraluminal firing of a 45-mm endoscopic linear cutter. The enterotomy is hand sewn with 3-0 Vicryl suture in one layer. The mesenteric defect is closed with a 2-0 silk suture in a running fashion. The Roux limb is brought up through the transverse mesocolon. The distal esophagus is divided using the harmonic scalpel. The proximal end of the Roux -en-Y limb is opened in the antimesenteric border. Then hand-sewn esophagojejunostomy is performed using a single layer of absorbable suture (vicryl 3-0). The suture is performed from the left to the righ side in the posterior and anterior layer. The stomach and lymph nodes are removed though a Pfannestiel incision. The operation is completed after placement of two drainage tubes. One is placed next to the duodenal stump, and the other is placed next to the esophagojejunostomy. Laparoscopic gastrectomy is a feasible procedure with good inmediate postoperative and oncological results in this preliminary experience.

V004 - Liver and Biliary Tract Surgery

V006 - Gastroduodenal Diseases

LAPAROSCOPIC RIGHT HEPATECTOMY C. Palanivelu, P. Senthilnathan, R. Senthilkumar Gem Hospital, COIMBATORE, India

LAPAROSCOPY-ASSISTED DISTAL GASTRECTOMY WITH D2 LYMPH NODE DISSECTION K-Y. Song1, C-H. Park2, S-N. Kim2, J.J. Kim3 1 SEOUL, South-Korea 2 Kang Nam St. MaryÕs Hospital, SEOUL, South-Korea 3 The Catholic University of Korea, SEOUL, South-Korea

Liver is the last and the latest organ in the abdomen to come under the purview of minimal access surgery. The inherent difficulties associated with liver resection like inadequate exposure and the uncontrollable hemorrhage were the main reasons for slow adoption of minimally invasive approach to liver resection. But with the liver resection is now safe and feasible. With the background, we present our technique of laparoscopic right hepatectomy. Our indication for right hepatectomy is mainly hepatocellular carcinoma. After creating pneumoperitoneum, a thorough evaluation is done to rule out peritoneal secondaries and laparoscopic ultrasound is used to assess the extent of the lesion and its relation to major vascular structures. Once the operability of the tumor is confirmed we proceed to right hepatectomy whose principle is same as that of an open hepatic resection. We follow the single surgeon, two hands approach which we have developed instead of the widely practiced two surgeons, four hands approach. We achieve inflow control first by porta hepatic dissection. This followed by parenchymal division using various instruments like CUSA, harmonic shears and ligasure. The surface bleeders are controlled with Argon Beam Coagulator. Finally outflow control is achieved by dividing the right hepatic vein using endovascular stapler and specimen is retrieved. If necessary, hand port can be used during the final stages of parenchymal division. We will be showing our video laparoscopic right hepatectomy which is safe and feasible.

Background: Laparoscopy-assisted distal gastrectomy (LADG) with lymph node dissection for advanced gastric cancer is controversial. With technical advances, indications for LADG have been expanded to more advanced gastric cancers. However, little data are available on LADG with D2 lymph node dissection for patients with gastric cancer. To evaluate the feasibility and advantages of LADG D2 lymph node dissection, we compared the surgical outcomes of LADG with D2 dissection and that of conventional open distal gastrectomy in patients with early gastric cancer. Methods: Between Sep. 2004 and Aug. 2005, 44 patients who underwent LADG with D2 lymph node dissection for early gastric carcinoma diagnosed preoperatively and 31 patients who underwent conventional open distal gastrectomy (ODG) with D2 lymph node dissection were compared in terms of clinicopathologic characteristics, postoperative outcomes and courses and postoperative morbidities and mortalities. Results: The laparoscopic procedure was not converted to laparotomy in any patient. No significant differences were found between these groups in the number of retrieved lymph nodes (37.2 vs. 42.4, p>0.05) and perioperative morbidities (p>0.05). In the LADG group, although the operative time was significantly longer, perioperative recovery was faster than in the ODG group and consequently postoperative hospital stay was significantly shorter for the LADG group(7.7 vs. 9.4 days; p=0.003). The leukocyte count in LADG group was lower (11,046 vs. 13,384; p=0.003) on day 1 than that in ODG group. Conclusions: According to this study, LADG with D2 lymph node dissection is feasible and provides several advantages similar to those of limited lymph node dissection (D1+alpha or beta). With skilled hands and appropriate selection of patients, LADG can be used with D2 lymph node dissection for patients with advanced gastric cancers.

S258

V007 - Abdominal Cavity and Abdominal Wall

V009 - Abdominal Cavity and Abdominal Wall

OPPORTUNISTIC LAPAROSCOPY V. Maker, M. Dibildox MGH / University of Illinois, CHICAGO, United States of America

LAPAROSCOPIC REPAIR OF A FORAMEN OF MORGAGNI HERNIA B.A. Ryder, T. Ng Brown Medical School, PROVIDENCE, RHODE ISLAND, United States of America

Aim: Peritoneal carcinomatosis and other small metastatic deposits are difficult to diagnose with computerized tomography or ultrasound. Second look laparoscopies have been described to detect such cancer recurrence. Patients who undergo unrelated subsequent surgery have an opportunity to have this condition assessed with little or no added morbidity. We present an opportunistic use of laparoscopy in a patient with past history of pancreaticoduodenectomy for pancreatic carcinoma. Methods: A 61 year patient with history of pancreatic head cancer and resection returned to the operating room two years later for an unrelated right inguinal hernia repair. During the procedure, a second look laparoscopy through the hernia sac was performed. This procedure was pursued because a CT scan ordered one year post-op incidentally revealed questionable nodularities in the small bowel in the asymptomatic patient. The laparoscopy added 5 extra minutes to the conventional right inguinal hernia repair. Results: Besides the expected adhesions, the laparoscopy through the hernia sac allowed visualization of the visceral surfaces and peritoneum and did not reveal any evidence of recurrence or metastatic deposits. Additionally, peritoneal washings and cytology obtained during the procedure did not show malignancy. Conclusions: Opportunistic laparoscopy is useful in ruling out recurrence and peritoneal spread of pancreatic cancer after pancreaticoduodenectomy. This less invasive procedure did not add the morbidity of a second look laparotomy or a conventional laparoscopy by staying away from the extensive adhesions in the upper and mid abdomen. Opportunistic laparoscopies should be performed whenever possible for their advantage of direct visualization of viscera and the ability to obtain peritoneal washings for cytologic evaluation with little, if any, added morbidity.

Congenital diaphragmatic hernia is an uncommon surgical problem. A Foramen of Morgagni hernia is diagnosed in only three to four percent of all cases of diaphragmatic hernia. If abdominal viscera are found within the hernia sac, incarceration or strangulation can occur. For this reason, these hernias warrant repair. We present a case of a symptomatic Foramen of Morgagni hernia in a 35 year old woman. A primary repair via laparoscopy was performed. Controversies regarding hernia sac resection and primary versus secondary repair are addressed. Repair via laparoscopy is safe and effective for such hernias of the diaphragm

V008 - Abdominal Cavity and Abdominal Wall

V010 - Abdominal Cavity and Abdominal Wall

LAPAROSCOPIC PERITONEAL DIALYSIS CATHETER INSERTION UNDER LOCAL ANAESTHESIA G. Hadi, D. Pace Memorial University of Newfoundland, ST. JOHNS, Canada

MANAGEMENT OF SLIDING LIPOMA DURING ENDOSCOPIC TOTALLY EXTRAPERITONEAL INGUINAL HERNIOPLASTY H. Lau Queen Mary Hospital, HONG KONG, Hongkong

Video Description: The video is 8 min. 30 sec. in QuickTime format. It describes laparoscopic peritoneal dialysis catheter insertion with a two port technique under local anesthesia. The video will include the advantages of this procedure and the required equipment.

With an increasing experience of hernia repair, surgeons have now recognized that peritoneal sac is sometimes absent in patients who present with a reducible inguinal hernia. Sliding lipoma refers to a sliding herniation of retroperitoneal adipose tissue into the inguinal canal, forming a reducible indirect inguinal hernia without a peritoneal sac. There has been no consensus on the best management of this condition. The present video illustrates the excision of a sliding lipoma in a 57year old male, who presented with a reducible right indirect inguinal hernia. A 3-port technique was adopted during the endoscopic totally extraperitoneal inguinal hernioplasty. The posterior wall of inguinal canal was normal and no indirect peritoneal sac was idenfitied. After reduction of the sliding lipoma from the inguinal canal, it was excised and retrieved via the 10-mm subumbilical port. A 10 x 14 cm prolene mesh was introduced into the preperitoneal space to cover the deep inguinal ring, posterior wall of inguinal canal and femoral ring. Failure to recognize the presence of a sliding lipoma with the placement of a mesh posterior to the lipoma would leave the indirect inguinal hernia unrepaired. Sliding lipoma is a rare type of indirect inguinal hernia. Awareness and appropriate management of the sliding lipoma will help to reduce the risk of recurrence.

S259

V011 - Abdominal Cavity and Abdominal Wall

V013 - Abdominal Cavity and Abdominal Wall

LAPAROSCOPIC REPAIR OF TRAUMATIC DIAPHRAGMATIC HERNIA - CASE REPORT B. Lazarevic1, Z. Cvijanovic2, M. Korica2 1 City Hospital Valjevo, VALJEVO, Serbia and Montenegro 2 Klincki Centar Novi Sad, NOVI SAD, Serbia and Montenegro

TRANSABDOMINAL LAPAROSCOPIC INGUINAL HERNIA REPAIR: THE TRICKS WE HAVE LEARNED, WHICH WE WANT TO PROPOSE AND DISCUSS F. Agresta, G. Mazzarolo, N. Bedin Presidio Ospedaliero di Vittorio Veneto, VITTORIO VENETO (TV), Italy

Background: Traumatic diaphragmatic hernias are serious complications of blunt abdominal or thoracic trauma. In the early posttraumatic period, they are often missed, and they may be followed by a variety of subacute or chronic symptoms due to pulmonary or intestinal obstruction. Methods: We present the case of a 46-year-old patient who had a car accident steering 6 years previously. The patient complained of abdominal pain, getting easily tired and breathing difficulties. A diagnosis of traumatic diaphragmatic hernia was established by a contrast radiographic examination and CT scan he showed the stomach in the left thoracic cavity. Laparoscopy revealed a left hemidiaphragm 12-cm defect with an intrathoracic herniation of the omentum, the two upper thirds of the stomac, the splenic flexure of the colon, and the spleen. The stomach, colon, omenthum and spleen were reduced into the abdomen. The chest was washed out and the diaphragmatic laceration was repaired using a large Proceed mesh, covering the defect with 2-cm overlap. There was no intraoperative surgical or anesthetic complication. Postoperative course was uneventful and he was well on follow-up. Conclusion: We found that laparoscopy is a safe, successful, and gentle procedure. We recommend that surgeons with sufficient experience in laparoscopy use a minimally invasive approach to treat chronic as well as acute traumatic diaphragmatic hernias in hemodynamically stable patients.

The Authors present a video concerning a case of a laparoscopic repair of inguinal hernia with the trans-abdominal pre-peritoneal tecnique (TAPP) and discuss their last three years experience. the patient is a 35 year old man with a simptomatic left inguinale hernia. The operation is performed using 3 trocars of 5 mm including a 30 degrees optic. After the peritoneum is opened, the Cooper ligament is evidenced, the lipoma is pulled inside the abdomen and the peritoneal sac is gently and carefully divided from the structures of the spermatic cord. After the peritoneum flap is prepared all around, a 10 x 15 cm mesh is placed over and fixed with a fibrin glue. a particular attention is payed to the mesh used and to the way of its fixation. Most of the advantages of laparoscopy rely on the minimal access and sparing patients a wider skin incision in the trocar site might reduce the post-operative pain, increase prompt recovery of gastrointestinal functions, shorten hospitalization, help contain health-care costs and increases cosmetics. The authors believe that Tapp hernioplasty with instruments/trocars and optics less or equal to 5 mm with a lightweight composite mesh is feasible, effective and easy to perform in experienced hands with comparable results to the ones of classic laparoscopy.

V012 - Abdominal Cavity and Abdominal Wall

V014 - Abdominal Cavity and Abdominal Wall

LAPAROSCOPIC REPAIR OF PARASTOMAL HERNIA S.A. Kazmi, K.L. Campbell, M.A. Thaha, G.D. Adamson Ninewells Hospital, DUNDEE, United Kingdom

LAPAROSCOPIC TREATMENT OF LARREY-MORGAGNI HERNIA G. Dapri, J. Himpens, B. Hainaux, A. Roman, E. Stevens, E. Capelluto, O. Germay, G.B. Cadie`re Saint-Pierre University Hospital, BRUSSELS, Belgium

1. The laparoscopic repair of Ventral & Incisional Hernia is now a well extablished technique. 2. The same principals can be applicable to the laparoscopic repair of the Parastomal hernias, though with a difference. It is still an evolving technique with promising results so far. It is fairley a new procedure and is undertaken in a few centres. 3. This video shows the external & internal views of the of various stages of laparoscopic repair of a para-stomal hernia. 4. A Bard Parastomal Hernia Patch has been used in this procedure. 5. We have the experience of laparoscopic repair of incisional hernias and it was successfully employed in the repair of parastomal hernia.

The movie shows a laparoscopic treatment of Larrey-Morgagni hernia, in a 57-years-old lady, who presented an invalidated dyspnea. A 3D reconstruction CT-scan showed a typical Larrey-Morgagni hernia, containing the small bowel and part of the colon. Patient was placed in gynaecologic position, surgeon between the legs, cameraman at his left and assistant at his right. Pneumoperitoneum was created thanks to a Veress needle placed at the umbilicus. A 30 videoscope was inserted in and three other 5 mm trocars were placed on the right mid-clavicular line, on the left mid-clavicular line and below the xiphod process. Exploration of the abdominal cavity evidenced a diaphragmatic hernia originated at the anteromedial defect and interested the entirely right side of the diaphragm and also part of the left side. Total small bowel, transverse colon and omentum were contained in the hernia sac, without signs of occlusion. After the reduction of viscera, a typical Larrey-Morgagni hernia interesting the right pleura, the right lung, the ascending aorta and the left pleura was exposed. The hernia sac was completely freed and resected, in order to avoid a pneumothorax. The hernia gap was freed by adhesions and peritoneal fatty tissue. A running suture using 1 Polypropylene closed the hernia gap and drainage was left in the cavity. The procedure ended with the placement of dual-face prosthesis over the suture-line, overlapping the hernia cavity and fixed by clips.

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V015 - Abdominal Cavity and Abdominal Wall

V017 - Abdominal Cavity and Abdominal Wall

LAPAROSCOPIC HERNIA REPAIR (TEP) - TIPS AND TRICKS LEARNT FROM OVER 3000 CASES C.A. Simonsz Private Surgeon, CAPE TOWN, South Africa

LAPAROSCOPIC REPAIR OF LUMBAR HERNIAS S. Morales-Conde1, A. Utrera2, J. Valdes1, D. Bejarano2, A. Cano1, J.C. Bellido1, J.C. Go´mez1, P. Ferna´ndez1, I. Sa´nchez-Matamoros1, J. Cantillana1 1 University Hospital Virgen Macarena, SEVILLA, Spain 2 Hospital Juan Ramon Jimenez, HUELVA, Spain

This is a Video with Text superimposed at relevant sites. The attached video would be edited to shorten it and highlight practical tips.

Laparoscopic repair of incisional and ventral hernias is finding its place in the general surgical field. The advantages of the laparoscopic approach of ventral hernias include lower rate of morbidity and lower rate of recurrences comparing to convencional repair. But, some special hernias have become a challenge to surgeons, such us suprapubic, subcostal, lumbar or subxiphoid hernias. Lumbar hernias are considered another special hernias due to the fact to the difficulties to expose the area of the mesh. Patient is place in lateral position, and three trocar are introduced in the midline. In most of the cases, these hernias are very lateral and the colon should be mobilized medially and the psoas muscle should be exposed. Usually in this type of hernias the fatty tissue of the patient is very thick and need to be removed to guarantee a proper fixation of the mesh. Beside this fact, depending on the anatomy and the localization of the hernia, the defect could be close to costal margin and to guarantee a proper fixation of the mesh transfacial sutures should be introduced right below the costal margin or through the intercostals space, even if you usually perform a Double crown technique without sutures. Lumbar hernias are considered a challenge for surgeons, even in open surgery. The management of a lumbar hernia need a proper position of the patient and a proper mobilization of the colon and of the fatty tissue of the retroperitoneal space. The use of transfascial sutures through the first intercostals space is necessary if the defect is close to the costal margin.

V016 - Abdominal Cavity and Abdominal Wall

V018 - Abdominal Cavity and Abdominal Wall

LAPAROSCOPIC REPAIR OF RECURRENT INCISIONAL HERNIA P.A. Riccio1, P.A. Riccio1, F. Catena2, P. Mingolla1, R. Linguerri1, P.M. Pavanello1 1 Ospedale S. Maria della Scaletta, IMOLA (BO), Italy 2 Emergency Surgery, St.Orsola Univ. Hosp., BOLOGNA, Italy

LAPAROSCOPIC REPAIR OF SUBCOSTAL HERNIAS S. Morales-Conde1, A. Utrera2, J. Valdes1, D. Bejarano2, A. Cano1, J.C. Bellido1, J.C Go´mez1, P. Ferna´ndez1, I. Sa´nchez-Matamoros1, J. Cantillana1, J. Guerrero1 1 University Hospital Virgen Macarena, SEVILLA, Spain 2 Hospital Juan Ramon Jimenez, HUELVA, Spain

Introduction: An incisional hernia develops in 3% to 13% of laparotomy incisions. The use of prosthetic materials has decreased rate of recurrence from 25-52% to 11-21%. But because open procedures using mesh require extensive dissection, they are associated with increases of complications and infections. Laparoscopic surgical approaches have several advantages over traditional open procedures, including reductions in hospital stays, postoperative pain and time required for convalescence. This video shows the difficulties of lysis of adhesions and the tecnical details of hernia repair. Methods: The operative video shows a male patient with a recurrent large xipho-pubic incisional hernia and small bowel obstructions. The TC shows a very thicks addhesions between bowel and anterior abdominal wall. Adhesiolysis was the most difficult portion of the procedure because the polypropylene type mesh previously posizioned incorrectly in direct contact with intestine causing a reaction with dense adhesions formation between bowel and abdominal wall. Despite significant difficulty to safely dissect through the adhesions the correct plane of attachment was easier to see on the magnified laparoscopic immage than in open technique. Repeated tractions on bowel suffering for previous recurrent intestinal obstructions caused an enterotomy that was repaired laparoscopically. Many experiences show that when limited bowel lacerations with minimal spillage occur, if promptly reconaized and repaired, an intraperitoneal prosthesis can be safetly placed. Results: The operative time was 180 minutes. Postoperative period was uneventfull and the patient was discharged on the tenth postoperative day. After a follow-up of 12 months there is no evidence of recurrence.

Laparoscopic repair of incisional and ventral hernias is finding its place in the general surgical field. But, some special hernias have become a challenge to surgeons. Subcostal hernias are considered another special hernias due to the fact to the difficulties to fix the mesh to the costal margin. It is different to consider a subcostal hernia close to the middle line than to the lateral margin of the incision. The first ones are usually very close to the costal margin, while the lateral ones should be consider almost as a lumbar hernia. Three trocars are placed in the left flank of the anterior abdominal wall. Most of the adhesions to the midline subcostal hernias are from the liver and in most of the cases the fatty tissue of the round ligament should be removed, in order to guarantee the proper fixation of the mesh. The area of the defect is prepared to anchor the mesh, and during a regular ventral hernia repair we perform a Double Crown without sutures, although this case is the only one in which we use transfascial sutures to anchor the mesh, since tackers could produce pain, if they were achored to the rips, and because it is impossible to fix the mesh with tackers in this area due to the shape of the abdominal cavity in. The mesh chosen must be shaped to the area of the hernia, and transfascial sutures are place in the craneal area of the mesh and the suture passer is introduced through the first intercostal space. On the other hand, in those subcostal hernias at the lateral margin of the incision, transfascial sutures are not necessary since the hernia normally is further from the costal margin and the double crown of tackers could be performed. Subcostal hernias are considered a challenge for surgeons, even in open surgery. The management of a subcostal hernia is different if the hernia is close to the midline or to the lateral margin of the incision.

Conclusions: Laparoscopic repair of recurrent incisional hernia can be performed safely. The risk of small-bowel lesion due to extensive adhesions is not a controindications to laparoscopically repair and to posizioning mesh.

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V019 - Abdominal Cavity and Abdominal Wall

V021 - Abdominal Cavity and Abdominal Wall

A SIMPLE, SAFE, AND COST-EFFECTIVE TECHNIQUE FOR CLOSURE OF DIFFICULT LAPAROSCOPIC PORT SITES R. Guruswamy, J.G.N. Studley James Paget Hospital NHS Trust, LOWESTOFT/SUFFOLK, United Kingdom

LAPAROSCOPIC REMOVAL OF A BLADDER LEIOMYOMA: A CASE REPORT P. Delrio, F. Ruffolo, D. Scala, D.N. Ida`, S. Perdona`, V. Parisi Istituto Nazionale dei Tumori di Napoli, NAPOLI, Italy

Introduction: It is common practise to leave the abdominal wall sheath open in difficult and obese patients. As a consequence port site herniation and RichterÕs type of strangulation of the bowel is a recognised complication. Method: We present this operative video which demonstrates how an aneurysm needle can be modified and used to close port sites. Moreover port site bleeding, especially where the vessel is close to the sheath and in the pre-peritoneal fat, can be easily controlled using the technique shown. It can be undertaken blindly without risking trauma to intra peritoneal structures. Results: The above technique has been used successfully for both closure of difficult port sites and for port site bleeding. It was performed blindly in 80% of the cases without complications. Discussion: Using the aneurysm needle to close the sheath at port sites appears to be safe, quick and cost-effective. The technique can be easily learnt.

Aims: Bladder leiomyomas are unusual findings among the pelvic benign tumours. Reported treatment is generally performed trough cystoscopic resection or laparotomy. We here report on a case of bladder leiomyoma successfully treated by a laparoscopic approach. Case report: A 59 yrs old female patients with an history of acute pelvic pain was admitted to our Division. Nine years before she underwent a total vaginal hysterectomy. An abdominal ultrasound showed a 3 cms mass in the right lateral wall of the bladder, previously biopsied with an unconclusive histology by a CT guided FNA. Abdominal PET-CT scan and a transurethral cystoscopy confirmed the lateral wall bladder mass covered by normal mucosa. The patient underwent a laparoscopic excision of the mass through two 10 mms and one 5 mms trocars (infra umbilical, right and left lateral iliac space). Incision of the pelvic peritoneum along the right lateral border of the bladder exposed the peribladder space. The mass was then visualized and carefully excised from the bladder wall. Methylene blue was then injected through a Foley catheter in the bladder to check for wall integrity. Haemostasis was obtained and a 10 mm suction drainage was positioned in the lateral pelvic space, closing the peribladder and detrusorial muscle defect by clips. Postoperative course was uneventful and the patient was discharged at day 3 after urinary catheter removal. Histology showed a leiomyoma (actin+ desmin+) with a low Ki-67 proliferative index. Ultrasound control at three months showed no sign of relapse. Discussion and Conclusions: Bladder leiomyoma may be excised by diagnostic trans-urethral resection. The postoperative course is then characterised by the need of prolonged transurethral catheter, bladder calcareous plaques and eventual removal of tumor remnants with a second operation. Laparoscopic approach offers the advantages of obtaining diagnosis and resection in one step with no postoperative morbidity and a complete en-bloc excision of the tumour. A 3 trocars mini-invasive procedure can be performed and carries no late complications or distorsion of bladder anatomy with functional sequels. Laparoscopic mini-invasive removal of these benign tumours might be safe and effective.

V020 - Abdominal Cavity and Abdominal Wall

V022 - Abdominal Cavity and Abdominal Wall

LAPAROSCOPIC TREATMENT OF PARASTOMAL INCISIONAL HERNIAS A. Costanzi, G.C. Ferrari, S. Di Lernia, D. Maggioni, F. Sansonna, C. Magistro, A. Miranda, S. De Carli, P. De Martini, R. Pugliese Ospedale Niguarda, MILANO, Italy

NEW KEELE TECHNIQUE: AN INNOVATIVE APPROACH TO LAPAROSCOPIC INCISIONAL HERNIA REPAIR K. Moorthy, N.S. Balaji, C.V.N. Cheruvu Univ Hospital of North Staffordshire, STOKE ON TRENT, United Kingdom

Aims: Parastomal incisional hernias are difficult to treat by open surgery: relocation of the stoma is associated with a recurrence rate of 33-40%, primary fascial repair with a recurrence rate of 46-76%. The laparoscopic approach to incisional hernias may be beneficial also for parastomal defects.

Background: The laparoscopic approach to incisional hernia repair is accepted as an effective technique with a lower incidence of postoperative discomfort and a low recurrence rate. Generally, an intraabdominal inlay mesh is fixed to the abdominal wall with sutures or mechanical fixating devices. There are number of ways to perform this essential step and this video describes an innovative technique using the endoclaw device.

Methods: A 64 year old woman, operated in 2002 of laparoscopic abdomino-perineal amputation of the rectum because of adenocarcinoma, oncologically cured, developed a parastomal hernia medial to the colostomy. The patient was placed in lithotomy position, and insufflated in right flank with a Verres needle. An optic trocar was employed to enter the abdomen, two more trocars, 5 and 10 mm, were inserted. Adhesiolysis was unnecessary because of previous laparoscopic access. The colostomic loop was retracted and folded within the hernia. Dissection of the edges of the defect and of the peristomal sac was careful in order not to damage the mesenterium of the stoma. The fascial defect was flagged with spinal needles and measured on the skin. A 15 by 19 cm DualMesh Plus patch (ePTFE, WL Gore) was prepared with a central hole of 25 mm, a linear slit on the medial side to surround the colon and two sutures on the edges of the slit. The mesh was suspended through the sutures around the colon. The two edges of the slit were overlapped to strengthen the only point of weakness. Metal fixation to the abdominal wall was carried out by means of a double corown of Protack elical coils. The mesh was secured to the colon through 4 Gore-Tex sutures between the serosa of the colon and the mesh. Operative time was 208 minutes, oral fluid intake and mobilization was started on post-operative day 1, colostomy output started on day 3, discharge occurred on day 9 due to an access of atrial fibrillation. Conclusion: Laparoscopic treatment of parastomal incisional hernia is safe, effective and promises better prevention of post-operative complications as compared to open surgery.

Methods: The procedure was undertaken on a 37- year old male patient who had a 20 · 15 cm incisional hernia in the supra-umbilical region following a previous epigastric hernia repair. The repair was undertaken with the patient in the reverse Trendelenberg position with a 5 mm camera port in the umbilicus, one 10 mm port on either side of the umbilicus in the mid clavicular line and one additional 5 mm port in the right upper quadrant. The omentum was reduced with division of adhesions within the sac. A Surgisis (Cook Surgical) mesh of an appropriate size was introduced into the abdominal cavity and an endotacker (Ethicon Ltd) was used to optimally position the mesh over the defect. The mesh was then secured with 10 interrupted nonabsorbable sutures at appropriately spaced intervals with the endoclaw. The mesh was laid tension free well beyond the edges of the defect. A small calibre subcutaneous suction drain was inserted. All endoclaw entry sites were closed with steristrips. Results: The patient needed only one dose of parenteral opioid analgesia following which he was administered regular oral opioids and non-steroidals. Conclusion: This video demonstrates an innovative and effective method of securing a mesh for laparoscopic incisional hernia repair.

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V023 - Abdominal Cavity and Abdominal Wall

V025 - Complications and their Legal Consequences

LAPAROSCOPIC CORRECTION OF PARASTOMAL HERNIA USING AN INTRA-ABDOMIAL DUAL MESH - PRELIMINARY RESULTS AND VIDEO PRESENTATION M.I. van Berge Henegouwen, W.A. Bemelman Academic Medical Center, AMSTERDAM, The Netherlands

ABDOMINAL ESOPHAGUS PERFORTATION IN POSOPERATIVE AFTER LAPAROSCOPIC NISSEN FUNDOPLICATION N. Medina Bello1, S. Lo`pez Garcı` a2 1 PEMEX, CD.MADERO, Mexico 2 PEMEX, Hospital Regional, CD. MADERO, Mexico

Introduction: Parastomal hernia is a frequent encountered problem in patients with either an end ileostomy or colostomy, occurring in up to 50 % of patients. Management of this type of hernia may be troublesome, with a concomitant high recurrence rate. In the present study the preliminary results are presented of laparoscopic repair of parastomal hernia with a polypropylene(PP)/PTFE dual mesh(BARD parastomal hernia patch). A video presentation of the technique is shown. Methods: Four consecutive patients with a parastomal hernia (2 ileostomy; 2 colostomy) underwent laparoscopically correction of the hernia. The PP/PTFE dual mesh was placed after laparoscopic reduction of the hernia. The mesh, which contains a loop hole is placed around the protruding bowel and subsequently fixated to the abdominal wall (PTFE side towards bowel) using transabdominal sutures and a tagging device. Mean age of patients was 37 yr (23-50) and patients had a mean of 3.5 (2-6) previous laparotomies. Mean BMI was 29 (22-39). Results: In all 4 patients laparoscopic reduction of the stoma and placement of the mesh was successful. Three patients required additional adhesiolysis. Mean operating time was 116 (87-160) mins. There were no postoperative complications and patients had a mean hospital stay of 3 days (2-4). Short term follow up (mean 5 months) showed no recurrence of hernia, mesh infection or fistula in any of the patients. Conclusions: Laparascopic correction of parastomal hernia can be performed using a PP/PTFE dual mesh. Long term results have to be awaited, but short term results look promising.

Antecedents: Esophageal perforation is an uncommon event and is associated with high morbidity and mortality rates, particularly if not diagnosed and treated promptly. The most common cause of esophageal perforation is an iatrogenic disruption. Despite early diagnosis, advances in physiologic monitoring, antibiotic therapy, and nutritional support, as well as developments in both surgical technology and techniques that have led to significant progress in the management of esophageal perforation, it still remains one of the most difficult challenges for the surgeon. Material and Methods: The patient, a 27 years old, man with esophagitis grade II secondary a long standing gastroesophageal reflux disease (GERD), he underwent laparoscopic Nissen Fundoplication with intraoperative hemorrhage of the abdominal wall in dissecting port and it was solved without difficulties, the control erect chest X-ray and the esophagogram were normal. Starting from the postoperative fourth day begins accesses of hiccup. The patient presented emergency room at postoperative sixth day with several abdominal pain, dyspnea and fever. On psychical examination not there was no evidence of subcutaneous emphysema. The Computed Tomography (CT) and Upper Gastrointestinal (UGI) radiologic examination with iodine contrast given orally, showed extravasation of contrast along the lesser curvature and into the lesser sac. Results: The laparoscopic exploration demonstrated subfrenic hematoma and esophageal lineal perforation of 5 mm. at a level at the last point of stomachesophagus-stomach of the Nissen Fundoplication, The perforation was repaired laparoscopically involved primary closure of the tear followed by Nissen wrap. Extra-corporeal suture tying technique was used. Repeat CT scan and UGI series done 1 week after the event were normal. Conclusion: Most probably the etiology of the hematoma was a result of bleeding wall that conditioned diaphragmatic irritation, the presence of hiccup favoured the rupture of the esophageal. A trans-abdominal laparoscopic repair of lower esophageal perforation following GERD surgery is safe and well tolerated in properly selected patients. Early detection of the problem, preoperative studies documenting the absence of intra-thoracic extension, intraoperative wide exposure, and decisions regarding the feasibility of this technical approach are important.

V024 - Abdominal Cavity and Abdominal Wall

V026 - Different Endoscopic Approaches

LAPAROSCOPIC TRANSABDOMINAL EXTRAPERITONEAL REPAIR OF LUMBAR HERNIA U.C. Biswal, A. Satwik, P.K. Gupta Dr. Ram Manohar Lohia Hospital, NEW DELHI, India

VIDEO-ASSISTED SURGICAL APPROACH TO THE ÔPOTENTIAL ANATOMICAL SPACESÕ F. Rulli University of Rome Tor vergata, ROMA, Italy

Lumbar Hernias are rare defects, which have been conventionally and historically repaired by numerous complicated procedures involving muscle slides and muscle or facial flaps or grafts.

The spread of video-assisted surgery and its application in the management of diseases involving organs or anatomical structures placed in the ÔpotentialÕ spaces, rendered the surgical anatomy of these spaces (mediastinum, pre- and retroperitoneum, subfascial space of the leg, and neck etc,) less abstract. These issues are shared by different surgical specialities. Some of these are strictly connected with the general surgical and surgical subspecialities (i.e., endocrine surgery, vascular surgery), activities and therefore, once more, this testify that the videoassisted and endoscopic surgical approaches area ÔtransversalÕ ways to explore anatomical spaces. As stated by Meakins ÔSurgery in all disciplines has been undergoing a revolution over the last decade as our refinement of surgical technique increases, driven by patient-centred outcomes, competition for patients and new technology. Examples of patient-driven operative approaches can be seen in the estabilishment of laparoscopic cholecystectomy as the standard approachÕ. One of the problems in the introduction of new surgical approach is how to get the best training in the interest of the patients and in the interest of the transmission of the lessons learned in the experimental and clinical settings (i.e. training and teaching). Neverthless, we must underline that the relative anatomical notions, well codified by the traditional anatomy, are an important part of the time spent for the learning curve of the mini-invasive surgical approaches, and should be refined by assessing the possibilities of transforming a virtual space to a Ôreal cavityÕ (by gas insufflation or gasless procedures) in which is realistic the exploration and the operation. For the general surgeons these spaces are found classically, and endoscopically nowadays explored, in three main districts: the retroperitoneum, the neck, the leg.

Subsequent consensus was built around a prosthetic mesh repair laid between the peritoneum and the abdominal muscles, but this involved a large incision. We describe a case of a spontaneous left sided inferior lumbar hernia repaired by the Laparoscopic transabdominal approach along with a video presentation and enlist its advantages. Only fourteen such repairs have been reported.

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V027 - Different Endoscopic Approaches

V029 - Different Endoscopic Approaches

RIGHT ADRENALECTOMY USING A HARMONIC SCALPEL G.L. Carvalho, T.G. Vilac¸a, M.C. Luna, D.G. Araujo, F.W. Silva, C.H. Ramos, M.B. Botelho Pernambuco University, RECIFE, Brazil

LAPAROSCOPIC ACCESS TO THE UNCINATE PROCESS OF THE PANCREAS A.C.T. Wan, J. Arbuckle, P. Kekkis, A.M. Isla Charing Cross Hospital, LONDON, United Kingdom

Background: One of the most serious complication of laparoscopic adrenalectomy is hemorrhage, because glands are fed by numerous blood vessels, so surgeons need to be alert to bleeding during the procedure. The literature reports that after this vein has been isolated, it is usually controlled by using clips and stapplers. However, the control of the adrenal pedicle fully performed by using only the harmonic scalpel has not previously been reported. Objective: To report the case of a female patient with a right adrenal mass that was submitted to laparascopic adrenalectomy exclusively using a harmonic scalpel. Patient: A 41 year-old female patient with an adrenal mass detected on routine ultrasonography and confirmed by CT (computed tomography) and MRI (magnetic resonance imaging). Right adrenalectomy by videolaparoscopy was then indicated. Method: Patient was placed in left lateral decubits and 4 trocars were used. The dissection commences by an incision using a harmonic scalpel along the retroperitoneal attacht of the right lobe of the liver and the medial border of the inferior vena cava is carefully exposed while looking for the right adrenal vein. In this case there were 2 adrenal veins. Once the 2 Adrenal veins has been isolated, it was coagulated with ultrasonic sheasrs only. After the right adrenal veins has been controlled and divided, the dissection continued laterally, dividing small vessels and attachments until the gland was completely mobilized. After resection of the right adrenal mass, the abdominal cavity was washed with a saline solution. After removal of the liver retractor, an endobag was inserted through the epigastric trocar. The mass was placed in a plastic bag, which was then removed from the cavity. Results: There was no important bleeding during all the procedure. The patient was discharged on the same day of the surgery 8h after the ending of the procedure. Postoperative course was uneventhful and histopatologicalfindings confirmed that the mass was a non functionly adrenal adenoma. Conclusion: In the right adrenalectomy, laparoscopic tecnique can be safely performed, inclusively using only harmonic scalpel, with no clip and no stapplers reducting the cost of the procedure

Aims: With the advances of radiological imaging and laparoscopic techniques, anatomically favourable neuroendocrine tumours can now be removed successfully with enucleation with minimal morbidities. Nevertheless, posteriorly placed tumours in the uncinate process and head of the pancreas can still be difficult to localise and managed laparoscopically. We describe a laparoscopic technique in the enucleation of pancreatic insulinomas in the head and uncinate process of the pancreas. Methods: Two patients with biochemically proven insulinoma had preoperatively localisation and the proposed locations of these tumours were in the posterior aspect of the uncinate process and head of the pancreas, respectively. Both patients were placed in a left lateral position and pneumoperitoneum was achieved with CO2 insufflation. Two Nathanson retractors were used to give optimal exposure. The duodenum was kocherised to gain access to the retropancreatic space. Laparoscopic ultrasound (LUS) was used to validate the positions of the common bile duct, pancreatic duct and tumour. Pancreas overlying the tumours was incised and the insulinomas were enucleated with diathermy and harmonic scalpel dissections in both instances. LUS was used at completion to verify no residual tumour was present. Results: Both tumours were positioned posteriorly in the head and uncinate process of the pancreas, respectively as suggested by preoperative imaging. Laparoscopic dissection successfully mobilised the duodenum and the proximal pancreas allowing clear access to the retroperitoneal space behind the head of the pancreas. Neither of the tumours was visible to the naked eye but LUS confirmed their positions. The tumours were enucleated successfully by laparoscopic means and LUS confirmed complete resection. No immediate post-operative complication was encountered. Both patients remained asymptomatic and were complication free at follow-up. Conclusions: Laparoscopic access to the uncinate process of the pancreas is feasible and is facilitated by placing the patient in left lateral position retracting the right kidney posteriorly and the liver proximally, thus allowing easy kocherisation and satisfactory access to the posterior aspect of the pancreatic head. Intraoperative ultrasound assisted in identifying the ductal structures in relation to the tumour and inadvertent injury during laparoscopic enucleation was avoided.

V028 - Different Endoscopic Approaches

V030 - Different Endoscopic Approaches

ENDOSCOPIC THYROIDECTOMY S. Puntambekar, A. Gurjar, R.M. Sathe, R.J. Palep GALAXY Laparoscopy Institute, PUNE, India

RETROPERITONEOSCOPIC RIGHT ADRENALECTOMY FOR HCC METASTASIS IN LIVING RELATED LIVER TRANSPLANT PATIENT

Objectives: The incision for a thyroidectomy is situated on the most visible part of the neck, which is cosmetically embarrassing for the patient. Endoscopic thyroidectomy involves dissection in potential anatomical planes containing loose areola tissue unlike peritoneal or pleural spaces which are lined by epithelium. Hence it is technically more difficult. The aim of this study is to demonstrate the feasibility of endoscopic thyroidectomy for hemithyroidectony and total thyroidectomy Methods: This retrospective study included 20 patients operated on since September 2003 by the endoscopic approach. 18 patients had follicular adenomas (3 to 5 cm in size) for whom hemithyroidectomy was done and 2 patients had papillary carcinoma who underwent total thyroidectomy. Results: We have used three ports for performing endoscopic thyroidectomy. The camera port (5mm) is inserted 10 cm below suprasternal notch. Two working ports of 5 mm each are put supraclavicular. The average operative time was 70 min (range 45 to 90 minutes). There was no morbidity or mortality. The median hospital stay was 2 days (1 to 4 days). After three months of follow up, all the patients were satisfied, especially concerning the cosmetic results and the short recovery time. Conclusions: Endoscopic thyroidectomy is feasible and safe for performing hemi and total thyroidectomies

P. Marchesa1, L. Mandala`1, D. Cintorino1, S. Gruttadauria1, P. Mezzatesta2, G. Barranco2, G. Vizzini1, A. Arcadipane1, M.I. Minervini1, B. Gridelli1 1 ISMETT, PALERMO, Italy 2 Ospedale Civico, PALERMO, Italy Aim: Minimally invasive surgery using a retroperitoneoscopic approach is effective in the treatment of adrenal gland neoplasm. We present the first case report for the English medical literature of a living related liver transplant patient with an HCC (hepatocellular carcinoma) metastasis in the right adrenal gland who was successfully treated with the above mentioned approach. Method: In May 2003, a 58-year-old gentleman with a liver HCC on HCV (Hepatitis C Virus) related cirrhosis, preoperatively treated with intrarterial chemoembolization, underwent a living related liver transplant with no post-surgical complications (the Milano criteria for pre-liver transplant HCC staging were followed). A pathology exam showed two HCC nodules in the native liver. A follow-up CT scan performed two years later highlighted a 10mm solid lesion in the right adrenal gland, at which time the AFP (alpha-feto-protein) level was normal. Six month later, a new CT scan showed an increased volume of the lesion, which had grown to 22 mm. In September 2005 we performed a retroperitoneoscopic right adrenalectomy. The patient was placed in prone Jacknife position and three trocars were used in the right lumbar space. Results: Operative time: 3 hours; hospitalization time: 3 days. No post-operative complication was occurred. The pathology of the specimen showed metastatic hepatocellular carcinoma with the following pattern of special stains: Hep Par strongly positive; CAM 5.2 focal rare tumor cells positive; p CEA positive with canalicular pattern. Six months later, a total body CT scan did not show trocar site metastasis or retroperitoneal recurrence. Conclusion: Living donor liver transplantation has become the standard treatment for end-stage liver diseases in adult populations, mainly for HCC patients. Unfortunately, the post-transplant HCC metastasis is a well known long-term complication which affect overall survival. We reported the first case of a successful post-transplant treatment with minimally invasive surgery of a right adrenal gland HCC metastasis using a retroperitoneoscopic approach. The endoscopic treatment of adrenal gland malignant neoplasm can be indicated only for selected cases, and the retroperitoneoscopic approach can be useful after major abdominal surgery.

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V031 - Emergency Surgery

V033 - Emergency Surgery

Ô5MM INSTRUMENTS THREE TROCARS - LAPAROSCOPIC EMERGENCY CHOLECYSTECTOMY: IS IT TOO AN EXTREME APPROACH?Õ F. Agresta, G. Mazzarolo, N. Bedin Presidio Ospedaliero di Vittorio Veneto, VITTORIO VENETO (TV), Italy

EMERGENCY LAPAROSCOPIC REPAIR OF AN OBSTRUCTED BOCHDALEK HERNIA IN AN ADULT S.N. Akhtar1, K. Qurashi2, A.M. Isla2 1 Charing Cross Hospital, LONDON, United Kingdom 2 Ealing Hospital, MIDDLESEX, United Kingdom

We present a case of gangrenous cholecystitis in an overweight patient who underwent an urgent operation with a technique that has become our routine approach: two 5-mm trocars and a 10-mm one (which is necessary in order to remove the specimen) with a 30 degrees 5 mm optic. When some changes of a consolidated technique are proposed to the attention of the surgical world they must be easy, feasible, effective, reproducible in every situations and by every surgeon, with a morbidity, mortality rates and a costs/benefits ratio at least overlapping the ones of the consolidated technique and with a good perception by the patients. In Literature there are data, some perspective too, reporting the use of smaller (5 to 3 mm) and lesser in number (up to two) trocars. In the last 3 years we have standardize our laparoscopic cholecystectomy technique using two 5-mm trocars and one 10-mm trocar in more than 300 patients, in emergency as scheduled situations, with results overlapping the ones of the so-called classical technique. In only 10 % of the cases we needed to insert a fourth trocar in order to better control the Calots triangle. We want to underline that we have always used a 5-mm optic with images and vision similar to those obtained by a 10-mm one. In other experiences it is preferably used such last optic which in some step of the procedure is needed to be changed with a smaller one in order to perform some manoeuvres, and are added other manoeuvres such as put some stitches between the gallbladder and the abdominal wall to hang it up. As stated before, changes of a consolidated technique should not increase its complexity and difficulty! The technique must be reproducible: we routinely use 3 trocars in the laparoscopic cholecystectomy both in emergency as in scheduled cases and all the members of our staff are trained about it. Our positive experience in laparoscopic emergency cholecystectomy using three trocars and 5-mm instruments let us to state that what might appear ÔextremeÕ with the everyday practice can be considered to be safe and familiar.

Aims: Bochdalek Hernia (BH) does occur in adults and represents a complex diagnostic problem. The management options are reviewed. Methods: We present the case of a 27 year old male who successfully underwent the emergency laparoscopic repair of his obstructed BH with the involvement of a herniated spleen. Results: Postoperative recovery was quick and uneventful and the patient was discharged home well on day 3 following a normal barium study. Outpatient follow up at 1 year, examination and imaging confirmed no recurrence or complications. Conclusions: BH represents a complex diagnostic problem. We wish to reinforce that BH does exist in adults and should be considered in the differential diagnosis for gastro-intestinal obstruction in adults with concomitant chest signs. The complications of delayed or missed diagnosis may be catastrophic. Laparoscopic repair is not only feasible but should in fact be the surgical technique of choice in the repair of this rare anomaly. An extreme head up position is advisable and we recommend the use of an automatic anchoring device to fix the mesh to the posterior edge of the defect. We believe this to be the first laparoscopic repair of a BH with the involvement of a herniated spleen.

V032 - Emergency Surgery

V034 - Endocrine Surgery

LAPAROSCOPIC MANAGEMENT OF SUPPURATIVE PERFORATED STAMP APPENDICITIS FOLLOWING INCOMPLETE OPEN APPENDECTOMY O. Avrutis, J. Meshoulam, V. Michalevsky, L. Haskel, D. Aharoni Bikur Cholim Hospital, JERUSALEM, Israel

LAPAROSCOPIC LEFT ADRENALECTOMY FOR 6 CM VIRILIZING TUMOR G. French, C. Weber, D. Smith Emory University, ATLANTA, United States of America

Aim: The inflammation of the appendicial stump is a rare late complication after appendectomy. Its exact rate of incidence and its prevalence in the population are not truthfully defined. An extensive review of the medical literature to this date has produced a few reports of stump appendicitis. Authors present a case of laparoscopic management of perforated stump appendicitis. Case description: A 22-year-old man presented with a 3-day history of right lower quadrant abdominal pain associated with nausea and hyperthermia (38.5 C). He has uneventfully undergone open appendectomy for gangrenous appendicitis in our hospital 9 months before the current admission. Physical examination revealed guarding, tenderness and signs of peritoneal irritation over the right lower quadrant. Laboratory analysis showed leukocytosis with a left shift of the WBC (14,000/L). CT revealed a large, 5.5x6x6 cm on size, inflammatory mass with a small amount of a contrast material in the right iliac fossa. Exploratory laparoscopy was undertaken, discovering perforated appendicial stump with formation of an abscess. The stump was 2.5 cm long and containing a large, 1.0x1.3x1.5 cm on size, fecolith. The stump was extirpated out of the cecum with subsequent closuring of the bowel wall by means of intracorporeal sutures. Presented Video shows this anecdotic modus operandi. Results: The postoperative course was uneventful. Histopathological examination confirmed the presence of an appendix stump with acute suppurative appendicitis and perforation. Conclusion: Stump appendicitis is real, yet probably underreported entity. To our knowledge, the present case is the second report on laparoscopic management of acute stump appendicitis in the literature.

The patient is a thirty-five year old woman with signs and symptoms of virilization. Preliminary testing revealed elevated DHEA levels and excluded the possibility of a pheochromocytoma. A CT scan confirmed a 6 cm left adrenal mass. With a thus confirmed diagnosis of a left, virilizing adrenal tumour, the patient was prepared for a laparoscopic resection. The video begins with a description of the patient and her pre-operative workup, including presentation, bloodwork, and CT scanning. Following this introduction, the patient position in the OR, equipment setup, staff arrangement, and port selection is outlined. Next there is a narrated video of the steps in performing a laparoscopic left adrenalectomy. The video concludes with a still shot of the tumor, followed by closing comments about the patients post-operative clinical course.

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V035 - Endocrine Surgery

V037 - Endocrine Surgery

LAPAROSCOPIC RESECTION OF EXTRA ADRENAL (PELVIC) PHEOCHROMOCYTOMA B. Salky Mount Sinai Medical Center, NEW YORK, United States of America

TRANSPERITONEAL LEFT LAPAROSCOPIC ADRENALECTOMY G. Giraudo, F. Festa, E. Farinella, C. Garrone, M. Morino Ospedale Molinette, TORINO, Italy

This is a 22 year-old female with an extra-adrenal pheochromocytomy located ventral to the sacrum in close proximity to the right common iliac artery and the right ureter. The total excision of the tumor was accomplished with three ports. The key to the performance of the procedure was proper positioning of the patient to allow excellent exposure of the tumor. The anatomical dissection, including division of some of the pelvic nerves, is depicted. All biochemical tests returned to normal, and the preoperative back pain disappeared following excision. The cosmetic result was superior.

The video shows transperitoneal left laparoscopic adrenalectomy with the patient in right flank position. The pneumoperitoneum is induced with Veress needle at 12 mmHg of carbonic dioxide and 3, or exceptionally 4, trocars are placed along the subcostal margin. Once abdominal cavity had been explored, splenic flexure of the colon was retracted downward, while spleen and pancreas were en-block rotated medially, through division of spleno-colic and freno-lienal ligaments. Dissection continued into peri-adrenal fat to identify as landmarks: inferiorly the left renal vein, laterally the superior pole of the kidney, medially the tail of pancreas and the splenic vessels, and posteriorly the psoas muscle. Next, left adrenal vein was sectioned between clips applied at the eminence from the renal vein, whereas remaining dissection of the adrenal space was completed using Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, Ohio, USA). Specimen was entrapped in a plastic bag, Endo-cacth (Tyco Healthcare, AutoSuture, USSC, Norwalk, Connecticut, USA), and delivered through the port site. Between March 1995 and February 2006 we performed 239 transperitoneal laparoscopic adrenalectomies. There were 123 left laparoscopic adrenalectomies in 72 females and 51 males, with mean age of 50 (range 11-79) years. The mean operative time was 90 (range 45-150) minutes. There was no conversion to open surgery and the mean hospital stay was 3.93 (range 2-13) days. The mortality rate was 0.81 % (1/123) and the morbidity rate was 1.63 % (2/123).

V036 - Endocrine Surgery

V038 - Endocrine Surgery

A MODIFIED PROCEDURE FOR GASLESS ENDOSCOPIC THYROID SURGERY Y. Usui, M. Suda, Y. Mandai, T. Ohta Okayama Medical Center, OKAYAMA, Japan

LAPAROSCOPIC RIGHT ADRENALECTOMY FOT VIRILITZANT MALIGNANT TUMOR D. Del Castillo1, F. Buils1, M. Herna`ndez1, F. Sabench2, C. Dı´ az1, A. Sa´nchez Marı´ n1, J. Sa´nchez Pe´rez1, M. Abello´2, S. Blanco1 1 Universitary Hospital Sant Joan, REUS, Spain 2 Rovira and Virgili University, REUS, Spain

Background: Endoscopic thyroid surgery has been performed for more than five years in Japan. The procedure carried out in Japan is mainly gasless and via a subclavian approach invented by K. Shimizu. One of the authors (Y. Usui) developed new surgical instruments (a new camera trocar and a piercing muscle retractor) which will make it possible for only two people (an operator and a camera person) to perform it. Our procedure could become the standard procedure in Japan. Methods: The patients who underwent gasless endoscopic thyroid surgery in our hospital from 1999 to 2005 were analyzed. All endoscopic procedures were recorded on videotape. All procedures were performed or supervised by Y. Usui. Results: From 1999 to 2005, 135 patients underwent gasless endoscopic thyroid surgery. Surgical procedures were gradually modified by introducing new surgical instruments and techniques according to our experiences. In 2005 a standard procedure for lobectomy was established. After making a tunnel to the thyroid lobe, the isthmus is incised first. All vessels and thyroid tissue are incised by an ultrasonically activated scalpel. The recurrent laryngeal nerve is always identified and preserved. Our procedures were performed safely by only two people and we have been able to accomplish it in about 100 minutes recently. Conclusions: Our gasless endoscopic thyroid surgery has the potential of becoming the standard procedure for benign adenomas less than 5cm diameter and thyroid carcinomas less than 1cm diameter.

Introduction: Actually, the advantages and benefits of laparoscopic surgery on adrenal glands are widely accepted. A great number of adrenalÕs pathologies will benefits of this kind of surgery (adrenalectomy). Since then, this approach has become the gold standard for benign disorders. Controversy exists in case of large adrenal and malignancy tumors. Otherwise laparoscopic approach can be useful in these cases. Material and Method: We report a 20-year-old woman who presented amenorrhea, hirsutism, truncal obesity and clitoromegaly since two years. CT scan and MRI show a 7 cm right adrenal mass, well delimited, without affecting neighbor organs. The blood results show an excess of testosterona, dihydroandrosterone, androstendione. 46XY normal cariotyp. With the diagnostic of right virilizing tumor a right laproscopic adrenalectomy is indicated. A transperitoneal approach with full left lateral decubitus position, using 4 trocars. Our operative strategy is based on: 1- Section hepatic triangular ligament. 2- Gerotas fascia and posterior parietal peritoneum are oponed. 3- Dissection of the vena cava 4- The upper pole of the kidney is carefully dissected 5- Superior adrenal vessels are ligated 6- Main adrenal vein is ligated and tumor mobilization from the vena cava 7- The extraction of the tumor is performed through a trocar opening. Favorable immediate evolution. Hospital discharged to the 3 days. Histopathological result was carcinoma without capsular infiltration. End of adrenogenital syndrome at 5Th month. After 4 years patient is out of symptoms. Conclusion: We present an encapsulated medium size malignancy tumor. Laparoscopic approach due to a magnified view of the operative field and better dissection movements can offer better conditions to approach to this patology of the adrenal gland.

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V039 - Endocrine Surgery

V041 - Endocrine Surgery

LAPAROSCOPIC RESECTION FOR GASTRIC REMNANT CANCER J. Isogaki, I. Uyama, I. Yoshida, K. Inaba, S. Tonomura, Y. Nakamura, M. Shoji, Y. Komori, Y. Sakurai, M. Ochiai Fujita Health University, TOYOAKE, AICHI, Japan

LAPAROSCOPIC LEFT ADRENALECTOMY USING LATERAL POSITION M.K. Hussein American University of Beirut, BEIRUT, Lebanon

Background: Since laparoscopic gastrectomy is increasingly applied for gastric cancer resection along with the improvement in instrument and technique in Japan, laparoscopic surgery for gastric remnant cancer (GRC) is uncommon. We applied laparoscopic treatment for 5 cases of GRC and accomplished the surgical procedure laparoscopically in 4 cases. There are very few reports about laparoscopic GRC resection, we herein report our experience. Patients and methods: From April 2002 to January 2006, 5 patients received laparoscopic surgery for GRC. Three were male and 2 were female. Mean age was 67.8. The primary disease for the initial gastrectomy was peptic ulcer (n=2) and gastric cancer (n=3). All cases were defined as early stage. The mean latency period between the initial surgery and diagnosis of GRC is 19.9 years. Five to 7 port technique was used for laparoscopic procedure. The first trocar was introduced through infraumbilical or suprapubic incision. After survey of abdominal cavity and adhesiotomy, total gastrectomy with Roux-en-Y reconstruction was performed.

A large adrenal adenoma greater than 5 cm was removed laparoscopically using three trocar technique. The lateral position facilitated the exposure and ease of dissection. The mass was removed by extending one of the trocar site with muscle splitting using Endocatch 10 mm. Patient was discharged home within 24 hrs. The operative time was 45 minutes. The video will detail the technical aspects of the procedure.

Results: Mean operation time was 383 minutes. Out of the 5 cases, 4 cases were resected laparoscopically and one case was converted to open laparotomy. All laparoscopically resected cases underwent total gastrectomy and received curative resection. No patient received splenectomy in association of gastric resection. Conclusion: We applied laparoscopic surgery for GRC and accomplished curative resection laparoscopically in 4 (80%) cases out of 5 GRC cases. Although our limited experience, laparoscopic resection for GRC is feasible and might be a choice of treatment for GRC.

V040 - Endocrine Surgery

V042 - Flexible Surgery

LAPAROSCOPIC TREATMENT OF 2 PARAGANGLIOMAS A. Costanzi, M. Boniardi, D. Maggioni, S. Di Lernia, G.C. Ferrari, F. Sansonna, C. Magistro, I. Pauna, S. De Carli, R. Pugliese Ospedale Niguarda, MILANO, Italy

ENDOSCOPIC SUBMUCOSAL DISSECTION FOR EN BLOC RESECTION OF LARGE FLAT POLYPS OF THE LOWER DIGESTIVE TRACT A. Arezzo1, A. Repici2, M. Conio3 1 Ospedale Evangelico Internazionale, GENOVA, Italy 2 Istituto Clinico Humanitas, MILANO, Italy 3 Ospedale Civile, SAN REMO, Italy

Extra-adrenal pheochromocitomas (paragangliomas) represent 10% of all pheochromocitomas. They can develop anywhere there is presence of enterochromaffine tissue, mostly in the sub-diaphragmatic, paraaortic or interaortocaval regions. In the video we present 2 cases of paraganglioma localized in the left iliac region and in the paraortic region. VIDEO REPORT 1: A 60 years old male, admitted in the Department of Cardiology for recurrent episodes of acute hypertension. Biochemical investigations demonstrated an elevated concentration of urinary catabolites of cathecolamines. CT Scan and MRI showed a mass in left iliac fossa, positive to the MIBG Scintigraphy. The patient underwent a laparoscopy excision of the paranganglioma. Once placed in litothomy and reverse Trendelemburg position, three trocars were inserted, in the umbelical region, in left and right iliac fossa. After opening of the parietal peritoneum, the mass was carefully dissected by harmonic scalpel and its vascular pedicle was sectioned. VIDEO REPORT 2: The second case was diagnosed in a 18 years old woman affected by recurrent episodes of cephalea associated to hypertension. Investigations yielded the diagnosis of left paraortic paraganglioma, 4 cm in diameter. The resection of the mass was carried out by minimally invasive approach employing 3 trocars, one in the sovrapubic region, one in left and right iliac fossa. Dissection of the mass is performed by means of Harmonic scalpel. Results: In both cases the histologic examination confirmed the diagnosis of pheochromocitoma and the dosage of catecholamines and post-operative urinary catabolites resulted within range of normality. The post-operative course was uneventful for both patients. Conclusions: Our experience confirms the reliability, efficacy and safety of the laparoscopic approach in the treatment of extra-adrenal abdominal pheochromocitomas.

Aim: Since the beginning of operative flexible endoscopy the treatment of flat or sessile polyps of the digestive tract larger than 3 cm has been controversial. Methods: In 2001 a new endoscopic mucosal resection technique was described using an Insulated Tip Knife (ITK) from Olympus Endoscopy, defined as Endoscopic Submucosal Dissection (ESD), which should allow a better handling of the lesion. This technique is today widely used in Japan to treat large flat lesions of the upper GI tract. In Europe we experience more often the finding of large mucosal lesions of the colon and rectum, so the new technique was used in the lower GI tract. Results; We have treated 28 patients by ITK ESD. All lesions were flat or sessile larger than 3 cm, and positioned between two folds or behind a fold, so to be judged not suitable for standard snare EMR. Site of lesion was rectum in 14 cases, sigmoid colon in 9 cases, descending colon in 2 cases, transverse colon in 2 cases, and hepatic flexure in 1 case. The mean size was 4.5 cm (3-6 cm) on the specimen. All lesions were lifted by a mixed solution of fibrin glue and diluted epinephrine solution. All resections were completed by Argon Plasma application on resection margins. Specimens were collected en bloc in 14/28 cases (50%), in two parts in 10 cases (36%) and in three parts in 4 cases (14%). Mean procedure time was 65 minutes (50-125 min). Mean injected solution was 52 ml (4490 ml). We experienced 1 case of bowel perforation suddenly recognized and managed by endoscopic clipping, 1 case of early bleeding also treated by endoscopic clipping, 1 delayed bleeding which required 1 blood unit transfusion, 1 case of mild peritonitis managed conservatively by TPN and antibiotics. Conclusion: The use of IT knife in our experience represented an advantage in capability of performing a complete EMR, but not a definitive solution. Still the possibility of routine en bloc resection seems distant. There is no doubt that ITK ESD is an interesting new technique for flexible endoscopy, although skill demanding and operator dependent.

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V043 - Gastroduodenal Diseases

V045 - Gastroduodenal Diseases

A LAPAROSCOPIC DUODENOJEJUNOSTOMY FOR A DUODENAL OBSTRUCTION FROM LYMPHOMA J.S. Cyriac, J. Hagen, T. Penner, P. Sullivan, L. Smith, D. Weizman, D. Urbach, L. Klein University of Toronto, ONTARIO, Canada

LAPAROSCOPIC D2 LYMPHADENECTOMY M. Santamarı´ a, F.J. Iban˜ez, M.L. Almendral, A. Uranga, I. Zearreta, B. Mendez Hospital de Zumarraga, ZUMARRAGA, Spain

We present a patient with lymphoma of the third part of the duodenum causing a duodenal obstruction. The patient had a partial response with chemotherapy, but still was obstructed and was unable to eat. He was losing weight and chemotherapy had to be stopped. A gastrostomy tube was inserted for drainage as the stomach was quite distended. A jejunostomy tube was passed through the gastrostomy tube for feeds. The patient, however, did not tolerate the feeds. We show the video of a laparscopic bypass of the duodenum (from duodenum to jejunum) for this patient. The patient did very well after this and was able to tolerate an oral diet on the second post operative day. He was discharged home on the fourth post-operative day. He has since resumed chemotherapy and is doing well now two months out from surgery.

The use of laparoscopy to treat locally advanced gastric cancers remains unusual, although recently some authors have reported it in their results. Since September 2000 we have performed 50 video-assisted gastrectomies (total or distal, with D1 or D2 lymphadenectomy) for gastric cancer. Our video shows the technical aspects of D2 lymphadenectomy. For this purpose, we have joined images from two patients (one of them a total D2 gastrectomy with associated splenectomy and he other one a D2 distal gastrectomy) and pictures.

V044 - Gastroduodenal Diseases

V046 - Gastroduodenal Diseases

LAPAROSCOPIC TOTAL GASTRECTOMY S. Puntambekar, R.M. Sathe, R.J. Palep GALAXY Laparoscopy Institute, PUNE, India

LAPAROSCOPIC EXCISION OF GASTRO INTESTINAL STROMAL TUMORS (GIST) N. Waraich, F. Rashid, S.Y. Iftikhar Derbyshire Royal Infirmary, DERBY, United Kingdom

The dissection begins by clearing off the gastro colic omentum by making a window in it with the harmonic scalpel and advancing towards the gastro duodenal junction. All the omentum is taken with the specimen, taking care not to damage the colon. Once the gastroduodenal is reached, all gastroepiploic vessels are clipped or cut with the harmonic. A stay suture is taken at the level of the gastro duodenal junction to mark the site for the stapler. The left gastric artery is then tied and cut and all the lymph nodes and fibro fatty tissue at its origin dissected out along with the specimen. The harmonic is used to clear the fundic region of the short gastric vessels. All adhesions are separated and the specimen is totally lifted from its bed. The liver is lifted and the gastro esophageal junction cleared. The vagus nerve is identified and cauterized with the bipolar. A prolene purse string suture is taken at the lower end of the esophagus. The stomach is disconnected at the GE junction with an endo Gia stapler and similarly at the GD junction. A loop of jejunum is identified and taken retrocolically through the mesocolon. Till it reaches the lower end of the esophagus. The duodenal stump is completely buried with continuous suture of 20 vicryl. A small anvil of the circular stapler is passed through a separate incision on the abdominal wall. The other end is passed with its tip downwards via the esophagus and the prolene suture is tightened around it. A circular opening is made in the distal part of the jejunal loop for the stapler. The stapler is passed through a separate incision on the abdominal wall into this loop. The anastamosis inside is completed by connecting the two ends of the stapler and firing it. Hemostasis is achieved and the specimen is delivered out through the small incision.

Gastrointestinal stromal tumors (GIST) are uncommon but important mesenchymal tumors of the GI tract. Recently laparoscopic surgery has been adopted for the treatment of gastric tumors, including gastric cancer and gastric gastro-intestinal submucosal tumor (GIST). Although laparoscopic approach for gastric tumors has not been accepted worldwide, however it is safe and minimally invasive, promoting rapid recovery. Therefore its use has definitely increased. We present the video recording of laparoscopic excision of GIST. MethodÕs Summary: Four port approach was used. Liver retractor was used to retract left lobe of liver. Anterior gastrostomy was performed by using harmonic scalpel. GIST was retrieved via anterior gastrostomy and excised using Endo GIA 4.3 mm. Anterior gastrostomy was closed using Endo GIA as well. GIST and part of stomach was removed using burt bag.

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V047 - Gastroduodenal Diseases

V049 - Gastroduodenal Diseases

TECHNICAL DETAILS OF FIVE MINIMALLY INVASIVE APPROACHES FOR RESECTION OF GASTRIC STROMAL TUMORS S. Sereno, J. Leroy, D. Coumaros, B. Dallemagne, D. Mutter, M. Vix, J. Marescaux IRCAD-EITS / University Louis Pasteur, STRASBOURG, France

STANDARDIZATION OF TECHNIQUES OF LAPAROSCOPIC GASTRECTOMY FOR GASTRIC CANCER N. Hiki, T. Fukunaga, N. Hosoi, S. Ohoyama, T. Yamaguchi National Cancer Institute, TOKYO, Japan

Aims: Gastrointestinal stromal tumours (GIST) are the most common mesenchymal neoplasm arising in the stomach. Complete resection of the tumour is necessary to perform a pathological evaluation in order to determine the malignant potential. Location and number of lesions demand different types of approach. In this video we describe five cases of gastric stromal tumours completely resected with various minimally invasive surgical approaches. Materials and methods: One GIST tumour was a 1cm anterior fundic lesion. It was removed with a laparoscopic gastric wedge resection endoscopically assisted. In the second case, the GIST was a 2cm lesion located in the posterior aspect of the gastric fundus and transepiploic laparoscopic wedge resection was performed to remove it. Third case: a lesion lying in the posterior gastric wall which was removed by performing a laparoscopic intragastric resection. The fourth case was a 4cm pre-pyloric tumour which was removed by laparoscopic gastrotomy. In the fifth case a 5cm pseudooclusive antral lesion was removed by a laparoscopic antrectomy with Roux-en-Y reconstruction. Results: All operations were accomplished with a minimally invasive approach and there was no need for conversion. There were no complications and all pathological reports confirmed the presence of GISTs which had been completely resected with at least a 1cm margin. Conclusions: When treating GISTs tumours, surgeons must be aware of the possibility of multilocality. Size and location of gastric lesions dictate the type of resection. An array of different techniques can be used to safely manage these lesions by a minimally invasive approach.

Backgrounds: Recently laparoscopy and laparoscopy-assisted surgery have been used increasingly as less-invasive and better quality life alternatives to conventional open surgery. When performed by a skilled surgeon, laparoscopy-assisted distal gastrectomy (LADG) is a safe and useful technique for patients with gastric cancer and the LADG has been associated with less postoperative pain, an early return of bowel function, shorter periods of hospitalization and disability and better cosmetic results. However, LADG is still special technique only for skilled surgeon. Aim: To evaluate the role of the standardization of LADG, we compared the early operative outcome between the conventional (CLADG) and the newly fixed methods (FLADG). The procedure steps of FLADG were developed for trainer for better understanding of every procedure steps of LADG. Methods: Between April 2005 and March 2006, 112 patients with early gastric cancer underwent laparoscopic surgical intervention (CLADG: n=32, FLADG: n=80). The operation time, and blood loss, intra- or postoperative complication and degree of the lymph node dissection were compared. Results: Operation time of FLADG (205 9 min) was significantly shorter than that of CLADG (268 12 min (p<0.02)) and estimated blood loss of FLADG (56 8 mL) was about 50% less than that of CLADG (132 25mL (p<0.01)). The mean of the number of dissected lymph nodes were 36 2 in the CLADG and 35 2 (p=0.69) in the FLADG. Station dependent number of lymph node dissection also demonstrated no significant differences. Incidence of postoperative complication showed no significant differences between each groups. CLADG group showed 1 case of drainage tube trouble (3%) while FLADG showed no complication (0%). The total analgesics use, time to first flatus, time to start of oral intake and postoperative hospital stay showed no significant differences. Conclusion: Standardization of LADG procedures significantly stabilized an operation and improved early operative outcomes. Further long term observation should be recommended.

V048 - Gastroduodenal Diseases

V050 - Gastroduodenal Diseases

SENTINEL NODE MAPPING DURING LAPAROSCOPIC SUBTOTAL GASTRECTOMY C. Staudacher1, E. Orsenigo1, V. Tomajer1, E. Masci2 1 Scientific Institute San Raffaele, MILAN, Italy 2 Department of gastroenterology, MILAN, Italy

ENDOSCOPICALLY ASSISTED LAPAROSCOPIC REMOVAL OF GASTRIC FOREIGN BODY D. Stefanidis, B.T. Heniford, M. Scobie, T. Kuwada Carolinas Medical Center, CHARLOTTE, NC, United States of America

Aim: Sentinel lymph-node (SLN) is the first lymph node that receives drainage from a cancer. Accurate SLN diagnosis may enable surgeons to avoid unnecessary extended lymphadenectomy, as it has been shown in patients with breast cancer, melanoma, colon, pharynx and larynx. In gastric cancer, the lymphatic system may be more complicated than that in breast cancer or melanoma. However, some authors have recently succeeded in mapping SLNs during gastric cancer surgery. The aim of our video was to demonstrate the feasibility of SLN mapping during laparoscopic surgery for gastric cancer.

Foreign body ingestion is an uncommon occurrence in the adult population. Although most ingested foreign bodies pass spontaneously through the gastrointestinal tract, a small proportion fail to do so placing the patient at risk for perforation or obstruction. Foreign bodies lodged in the stomach are often amenable to endoscopic retrieval, but when this fails, surgery is indicated. This video describes our technique for laparoscopic removal of a gastric foreign body under endoscopic guidance. The patient is a 46 year old woman with history of bulimia. During an attempt to induce emesis with a plastic spoon, she swallowed a fractured piece of the spoon. Several days later the patient had failed to pass the spoon and developed cramping abdominal pain. Upper endoscopy visualized the spoon in the stomach. After multiple unsuccessful attempts at retrieval, the patient was brought electively to the operating room. The patient was placed in the supine position with both arms tucked at her side. Three trocars were placed; a 5mm camera port at the umbilicus and two working ports (5 mm and 12 mm) at the right upper quadrant along the midclavicular line. The anterior wall of the stomach was controlled with 2 stay sutures and a radially dilating 5 mm Versastep trocar was placed in the left upper quadrant and introduced into the stomach. Utilizing endoscopic visualization, the foreign body was grasped with a laparoscopic grasper and pulled against the stomach wall. Under laparoscopic view an anterior gastrotomy was created around the stomach trocar with the hook cautery allowing removal of the spoon. The spoon was placed into an Endocatch bag and retrieved through the enlarged 12mm trocar site. The gastrotomy was closed with the Endo-GIA (blue load) linear stapler. The patient had an uncomplicated postoperative course, was discharged home the next day and remains asymptomatic at 2 weeks follow-up. Endoscopically assisted, laparoscopic removal of gastric foreign bodies is a safe and minimally invasive alternative to laparotomy when endoscopic retrieval fails.

Methods: In the video, we present the case of 67 years-old man who underwent laparoscopic gastrectomy with D2 lymphadenectomy for carcinoma of the distal stomach. Results: After gastrocolic ligament dissection, 2 ml of 0.2% patent blue solution was injected endoscopically into the submucosal layer at four points around the tumour. Three minutes after the injection, we observed positive blue staining in lymph node station 8. After then, a subtotal laparoscopic gastrectomy with D2 lymphadenectomy has been successful concluded. Conclusions: Laparoscopic sentinel node mapping for gastric cancer seems to be feasible in laparoscopic surgery. Further study in a large number of patients may be necessary to confirm the applicability of the sentinel node concept to gastric carcinoma.

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V051 - Gastroduodenal Diseases

V053 - Gastroduodenal Diseases

LAPAROSCOPIC RESECTION OF A SYMPTOMATIC GASTRIC DIVERTICULUM: A MINIMAL INVASIVE SOLUTION S.C Donkervoort, M.J. van Hoogstraten, L.C. Baak, J.L.G Blaauwgeers, M.F. Gerhards Onze Lieve Vrouwe Gasthuis, AMSTERDAM, The Netherlands

LAPAROSCOPY ASSISTED PROXIMAL GASTRECTOMY FOR EARLY GASTRIC CANCER Y. Nagai, A. Takai, M. Hayashido, Y. Shirai, T. Maeda, Y. Umano Izumiotsu Municipal Hospital, IZUMIOTSU, Japan

Gastric diverticula are rare and occasionally symptomatic. Sensation of fullness in the upper abdomen immediately after meals is the most common. Dyspepsia and vomiting are less common. Ulceration with haemorrhage or perforation have been reported. If it is thought that complaints can be ascribed to the diverticulum and if proton pump inhibitors do not give relieve of symptoms, surgical resection is an option. Knowledge of the pitfalls in diagnose and treatment of a gastric diverticulum are essential for a successful and complete relief of symptoms. We present a 45-year-old women with an unusual complaint who was satisfactory treated by a laparoscopic resection of the gastric diverticulum. The laparoscopic procedure gave us a straightforward and relatively easy access to the posterior gastric fundus by dividing the gastrocolic ligament. The stomach was retracted ventrally and to the right to inspect the posterior part of the greater curvature. Short gastric vessels were divided sequentially. Dissection was continued up till the cardia and the diverticulum was found 2 cm distally from the GOJ at the cranial boarder of the pancreas. Dissection from its avascular adhesions to the retroperitoneum was performed until the saccular structure was clearly identified. The diverticulum was resected at the neck with the Endo Gia (Universal) The neck of diverticulum was retracted though the umbilical skin incision, a tip of the stapler line was cut open, the excrements were aspirated from the diverticulum and the collapsed diverticulum could be extracted though the small umbilical incision. The recovery of our patient was uneventful and the relieve of symptoms complete. If laparoscopic experience is available and familiarity with the diaphragmatic hiatus exists we recommend the laparoscopic resection, as a minimal invasive solution to a symptomatic gastric diverticulum.

Since 1993, we applied laparoscopy assisted gastrectomy for gastric cancer and 160 patients were treated until December, 2005. Laparoscopy assisted distal gastrectomy (LADG) was performed in 135 cases and total gastrectomy in 8 cases and proximal gastrectomy (LAPG) in 17cases. The indication of LAPG was limited in early gastric cancer of the upper 1/3 stomach. Esophago-gastrostomy was performed in 11 cases in whom resected stomach was within 1/3 and jejunal pouch was interposed in 6 cases who received over 1/3 of the stomach. The average operation time was 180 min. in esophago-gastrostimy cases and 300min in jejunal interposed cases. There is no anastomotic leakage, however anastomotic stricture occurred in only one patient (6%) who received successful endoscopic dilatation. No recurrence of gastric cancer was seen during 6 to 120 months follow-up period. We will show the technique of laparoscopic lymph node dissection and side to side esophago-gastrostomy using ENDO-GIA60 universal in VTR.

V052 - Gastroduodenal Diseases

V054 - Gastroduodenal Diseases

LAPAROSCOPY-ASSISTED TOTAL GASTRECTOMY WITH LYMPHADENECTOMY FOR GASTRIC CANCER E. Nagai, M. Watanabe, K. Nakata, S. Shimizu, H. Noshiro, M. Tanaka Kyushu University, FUKUOKA, Japan

LAPAROSCOPIC ASSISTED DISTAL GASTRECTOMY FOR LARGE ANTRAL GIST E.M. Targarona1, C. Balague1, P. Herandez1, C. Martinez1, R. Medrano1, J.L. Pallares1, R. Berindoague1, A. Savelli1, M. Trias1, A. Aldeano2, J. Navines2, S. Vela1 1 Hospital de la Sta Creu i St Pau, BARCELONA, Spain 2 Hospital Sant Pau, BARCELONA, Spain

Aims: Laparoscopy-assisted distal gastrectomy has been widely applied to the treatment of early gastric cancer because of its minimal invasiveness. However, there have been few reports on laparoscopyassisted total gastrectomy (LATG). We report here the surgical technique of LATG with lymphadenectomy for early gastric cancer. Methods: After mobilization of the greater curvature and dissection of infrapyloric and suprapyloric lymph nodes, duodenal transection was performed with a linear stapler. Then, dissection of lymph nodes along the common hepatic artery, celiac artery, and splenic artery was performed. The left gastric artery was divided using an ultrasonic coagulating shears after clipping. After transection of the esophagus, Rouxen-Y reconstruction was performed. Linear staplers were used to make an esophagojejunostomy. After pulling out the stomach through a 3 cm-long left subcostal incision, Roux-en-Y jejuno-jejunostomy was performed through this minilaparotomy. Results: Fifteen out of 220 patients who underwent laparoscopy-assisted gastrectomy for gastric neoplasm underwent LATG. Mean operation time was 331 min, blood loss 156g, and hospital stay 18 days. No complication was encountered in this series except for wound infection in the first case. Conclusion: LATG may be an excellent option of the surgical treatment for early gastric cancer because of its minimal surgical invasiveness and good postoperative quality of life.

Laparoscopic approach has been useful for treatment of selected cases of gastric GIST, specially when they are located in free or mobile parts of the stomach (great curvature, fundus or anterior or posterior wall of the stomach), and a segmental wedge resection can be done without problems. However, when the lesion is near the pylorus or too large, a formal antrectomy should be performed. Case report: A 50 y. old male was admitted for upper digestive hemorrhage. Upper Endoscopy showed a 6 cm ulcerated tumor located inn the posterior wall of the antrum. Surgical technique: the explorative laparoscopy showed a distal antral tumor, that precluded a wedge resection. A bilateral truncal vagotomy was performed initially. After section of the gastroepiploic epiplon, the pylorus was transected. A distal gastrectomy was finished with endostapler, A 8 cm subxyphoid laparotomy was performed, and the specimen excised. A Roux - Y loop was created extracorporally, and a gastrojejunostomy with 29 mm EEA was done. Pathological study showed a low grade C-kit+GIST.

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V055 - Gastroduodenal Diseases

V063 - Intestinal, Colorectal and Anal Disorders

LAPAROSCOPIC SIMULTANEOUS RESECTION OF TWO GASTRIC E.M. Targarona1, C. Balague1, C. Martinez1, P. Herandez1, S. Vela1, A. Savelli1, J. Navines2, A. Aldeano2, R. Medrano1, J.L. Pallares1, R. Berindoague1, M. Trias1 1 Hospital de la Sta Creu i St Pau, BARCELONA, Spain 2 Hospital Sant Pau, BARCELONA, Spain

LAPAROSCOPIC RECTOPEXY J. Nunoo-Mensah, J. Efron, T. Young-Fadok Mayo Clinic, SCOTTSDALE, ARIZONA, United States of America

Laparoscopic approach has been useful for treatment of selected cases of gastric GIST, specially when they are located in free or mobile parts of the stomach (great curvature, fundus or anterior or posterior wall of the stomach), and a segmental wedge resection can be done without problems. When the lesion is near the pylorus or too large, a formal antrectomy should be performed. However, in unexpected cases, multiple lesions can be found, challenging the possibility for a minimally invasive approach. Case report: A 65 y. old woman was admitted for upper digestive hemorrhage. Upper Endoscopy showed a 3 cm ulcerated tumor located in the great curvature at the antrum level. CT scan and endoscopic ultrasound showed additional 3 cm lesion at the fundus. Surgical technique: the explorative laparoscopy showed a distal antral tumor, and a fundic exofitic simulateous GIST. Wedge excison of both lesions were accomplished bay laparoscopic. Outcome was uneventful and the Pathological study showed a low grade C-kit+GIST.

Abdominal rectopexy (with or without concomitant resection) has been advocated as the treatment of choice for complete rectal prolapse. Recurrence rates are low raging from 0-8% and fecal continence has been documented to improve in 50-88% of patients. As most patients are elderly and not always fit enough to undergo open abdominal procedure, various perineal approaches have been advocated. Depending on the type and extent of the operation, these procedures tend towards having a higher recurrence of up to 21%. Laparoscopic rectopexy represents the latest development in the evolution of surgical treatment of rectal prolapse. This technique aims to combine the good functional outcome of the open abdominal procedure with the low postoperative morbidity of minimal invasive surgery. We present a video of laparoscopic rectopexy on a 72-year-old lady with a 10-year history of fecal incontinence and recent development of a full thickness rectal prolapse.

V056 - Gynaecology

V064 - Intestinal, Colorectal and Anal Disorders

LAPAROSCOPIC ANTERIOR EXENTERATION S. Puntambekar, A. Gurjar, R.J. Palep GALAXY Laparoscopy Institute, PUNE, India

LAPAROSCOPIC-ASSISTED RESTORATIVE PROCTOCOLECTOMY WITH COLONIC J-POUCH D. Vivas, D. Ruiz, S. Cera, S.D. Wexner Cleveland Clinic Florida, WESTON, United States of America

The dissection started by taking a peritoneal cut medial to the infundibulopelvic ligament. This exposed the ureter which was then pushed medially and the pararectal space lateral to the ureter was opened. The internal iliac artery was seen as the lateral limit of this pararectal space and tied in continuity with 2 0 vicryl. The same step was carried out on other side. The peritoneal cut was extended into the pouch of Douglas and to separate the rectum from the posterior vaginal wall. The dissection commenced in the pararectal space and uterine artery and the superior vesical artery were ligated or clipped and cut. This dissection was then carried caudally and medial to the obliterated hypogastic artey till the pubic bone was reached. The Mckenrodt and uterosacral ligaments were cut as laterally as possible using endo\GIA stapler. The paracolpos was also cut with Ligasure till the levator ani with its covering endopelvic fascia was seen. The uterus was then retroverted and the round ligament was cut with the harmonic shears and then extended through the round ligament upto the pubic bone. The bladder was then dissected with its covering peritoneum in the cave of Retzius. Finally the ureters were clipped and cut. The vagina was then cut with harmonic shears and this cut was extended anteriorly into urethra and entire specimen was disconnected. The infundibuloopelvic ligaments were finally ligated and cut.The entire specimen was then removed through the vagina and the vagina was again packed to prevent carbon dioxide leak.

The lymph node dissection started at the bifurcation of common iliac artery. The loose areolar tissue along the external iliac artery was swept till the inguinal ligament. All the fibrofatty tissue along the external iliac vein was then dissected. The nodes in the obturator fossa were swept from the pubic bone cranially. At this point the obturator nerve was exposed and all the nodes above the nerve were cleared. This dissection was done right up to the bifurcation of the iliac vein. The entirof the iliac vein. The entire fibrofatty tissue was then dissected medially till the internal iliac artery was exposed. This was the medial limit of dissection. The entire internal iliac artery was cleared off the fibrofatty tissue. The vaginal closure was done by laparoscopic intracorporeal suturing with a 30 mm 2-0 vicryl introduced through the 10 mm working port. The ureterosigmoidostomy was done by intracorporeal suturing.

A 48-year-old female diagnosed with a 3 cm ulcerated carcinoma in the upper third of the rectum, with the lower edge approximately 12 cm proximal to the anal verge. Laparoscopic-assisted restorative proctocolectomy with construction of a colonic J-pouch was planned. Placing a 10 mm port in the infraumbilical midline position using the Hasson technique, the camera is introduced and two 10-12 mm ports are located in the upper and lower right side of the abdomen. Mobilization of the sigmoid, left colon, and splenic flexure is performed in the lateral to medial fashion; division of the vascular pedicles is accomplished intracorporeally; the TME and transection of the rectum distal to the tumor are performed laparoscopically. An additional 10-12 mm port is inserted suprapubically in the midline, and the distal portion of the specimen is grasped with a Babcock clamp; a 5 cm Pfannenstiel incision is made using this port as a point of reference. The specimen is delivered through this incision and transected proximally. A 5 cm long stapled colonic J pouch is constructed extracorporeally, the anvil of the circular stapler is secured to the colonic J pouch with a purse string suture, and the bowel is reinserted into the peritoneal cavity; the Pfannenstiel incision is closed and the peritoneum reinsufflated. The circular stapler is introduced transanally and the pouch-anal anastomosis is constructed intracorporeally. Finally, a loop ileostomy is performed.

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V065 - Intestinal, Colorectal and Anal Disorders

V067 - Intestinal, Colorectal and Anal Disorders

LAPAROSCOPIC LOW ANTERIOR RESECTION AND TRANSANAL MUCOSECTOMY, WITH TRANSPERINEAL CONSTRUCTION OF COLONIC J-POUCH AND HANDSEWN COLOANAL ANASTOMOSIS FOR LOW RECTAL CANCER D. Vivas, B. Person, S. Cera, S.D. Wexner Cleveland Clinic Florida, WESTON, United States of America

LAPAROSCOPIC ANTERIOR RESECTION OF THE RECTUM THE REMIX VERSION R.C.T. Austin, R.W. Motson, M. Macheseney2 1 Colchester General Hospital, COLCHESTER, United Kingdom 2 Whipps Cross Hospital, LONDON, United Kingdom

A 50-year-old female presented complaining of intermittent rectal bleeding and discomfort for nine months. Physical examination showed a mobile and ulcerated rectal mass 3 to 4 cm within the anterior quadrant, 2 cm cephalad to the dentate line. Rectal ultrasound showed a UT3N0 lesion. The patient underwent neoadjuvant chemoradiation and was scheduled for a laparoscopic low anterior resection. The camera port is inserted through an infraumbilical port and 2 or 3 additional 12 mm ports are placed in the patients right side. Mobilization of the sigmoid colon, left colon, and splenic flexure are performed in a lateral to medial fashion and pelvic dissection to the level of the levators is carried out. Individual high ligation of the inferior mesenteric artery and vein is accomplished with the ETS-Flex45 Endoscopic Linear Cutter (Ethicon Endo-Surgery, Cincinnati, OH). Following complete laparoscopic mobilization of the left colon and rectum, the surgeon and first assistant are repositioned between the patients legs. The anus is effaced with the Lone-Star retractor (LoneStar Medical products, Inc., Stafford, TX). A circumferential fullthickness incision at the level of the dentate line is made, and the peritoneal cavity is penetrated. The mobilized rectum, sigmoid, and left colon are then delivered through the perineal incision. The left colon is extracorporeally transected with a linear cutter to a level that reaches the anus in a tension-free manner. A 5 cm colonic J-pouch is then created; the pouch is reduced back into the pelvis, and a circumferential hand-sewn pouch anal anastomosis is performed. The peritoneal cavity is re-insufflated, and the procedure is completed by laparoscopic creation of a diverting loop ileostomy.

This video takes digital video footage demonstrating a laparoscopic anterior resection and remixes it together with graphics and music. Whilst being a much more lighthearted look at the procedure than a specific teaching video, the important parts of laparoscopic anterior resection including total mesorectal excision and preservation of the pelvic nerves are clearly shown in a novel surgical video that lasts 2 minutes and 54 seconds. ÔYou know when you buy new video editing software and want to use all the available techniques at once? Well, this is that videoÕ

V066 - Intestinal, Colorectal and Anal Disorders

V068 - Intestinal, Colorectal and Anal Disorders

LAPAROSCOPIC ABDOMINOPERINEAL RESECTION OF THE RECTUM A SUPERIOR APPROACH R.C.T. Austin, R.W. Motson, T.H. Arulampalam Colchester General Hospital, COLCHESTER, United Kingdom

A LAPAROSCOPIC MANAGEMENT OF NON-HEALING COLOCUTANEOUS FISTULA O. Avrutis, V. Michalevsky, J. Meshoulam Bikur Cholim Hospital, JERUSALEM, Israel

Whilst the importance of total mesorectal excision (TME) during anterior resection of the rectum is well recognised, it has been suggested that when performed to completion during an abdominoperineal resection of the rectum, it leads to coning in towards the tumour at the pelvic floor, resulting in a specimen that appears to have a waist rather than being a cylinder shape and hence risking compromise of the tumour excision margins which may later lead to local recurrence.

Aim: Allowedly, surgical treatment of a chronic enterocutaneous fistula requires laparotomy, but the optimal site of incision is unclear. Laparoscopy and adhesiolysis may offer an alternative approach. Herein we present a case of laparoscopic management of non-healing colocutaneous fistula located in the left lower abdomen and arising from the sigmoid colon following transabdominal hysterectomy.

This video demonstrates an alternative laparoscopic approach to the low pelvic part of abdominoperineal resection. Rather than completing the TME laparoscopically, dissection stops as soon as the tip of the coccyx is reached. The pelvic floor is then divided, under vision, laparoscopically from above, possibly allowing a wider margin to be taken than might be achieved with the standard approach from below. In the video it can be seen that it was possible to continue the dissection from above right down through the ischiorectal fat to the perineal skin producing a cylinder shaped specimen with dissection being under vision throughout.

Procedure description: The optic 10-mm trocar was placed at the right mesogastrium using the Hasson technique with two additional 5-mm ports introducing under direct vision. In order to prevent a spillage of bowel content, a fistula was sheltered and than occluding by Foley catheter with inflating balloon positioning within the bowel lumen. After extensive adhesiolysis and clearing the anterior abdominal wall of all but the fistula-containing bowelÕs wall site, a skin incision was made circumferentially around the fistula. A short segment of the fistulous bowel was withdrawn through established 5-cm wound. Wide resection and primary anastomosis was performed in standard fashion. Limited separation allowed primary wound closure. Presented Video depicts the details of this procedure.

Video lasts 4 minutes 46 seconds. Results: The procedure took 40 minutes. The recovery was uneventful with good cosmetic result. In a 6-month follow-up the patient doing well. Conclusion: A laparoscopic management of chronic colocutaneous fistula seems to be safe and technically feasible.

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V069 - Intestinal, Colorectal and Anal Disorders

V071 - Intestinal, Colorectal and Anal Disorders

ENTIRE LAPAROSCOPIC RESECTION OF JEJUNUM FOR OBSTRUCTIVE ADENOCARCINOMA O. Avrutis, V. Michalevsky, J. Meshoulam, L. Haskel Bikur Cholim Hospital, JERUSALEM, Israel

LAPAROSCOPIC DIAGNOSIS AND MANAGING OF THE COMPLETE ACUTE SMALL BOWEL OBSTRUCTION DUE TO GANGRENOUS MECKELÕS DIVERTICULITIS O. Avrutis, V. Michalevsky, J. Meshoulam, L. Haskel Bikur Cholim Hospital, JERUSALEM, Israel

Aim: Cancers affecting the small bowel are rare, making up less than 5% of all bowel cancers. Traditional ÔopenÕ small bowel resection requires a long abdominal incision, which may entail a long period of recovery. This case report documents the successful removal of an obstructive jejunal adenocarcinoma with the aid of laparoscopy. Case description: A 45-year-old male presented with a 3-month history of intermittent abdominal colicky pain and vomiting. Abdominal x-ray showed distended proximal loops of jejunum. Succeeding CT revealed an obstructive lesion at a proximal jejunum with neither extraluminal infiltration nor enlarged mesenterial lymph nodes. At the time of laparoscopic exploration, an obstructive tumor has exposed at the proximal jejunum. The affected segment was resected and bowel continuity than restoring through an intracorporeal technique using a multifire linear stapler (Endo-GIA 45, Ethicon). The resected segment of the bowel has retrieved inside an Endo-Bag via a 12-mm port wound. Presented Video depicts the technical details of this procedure. Results: The surgery took 100 minutes. The patient discharged on postoperative day 6, tolerating the regular diet and enjoying an excellent cosmetic result. The pathologic diagnosis was adenocarcinoma (pT3N0G1). Conclusion: Entire laparoscopic small bowel resection can be performed safely in the setting of malignant disease and imparts many of the benefits of minimally invasive surgery.

Aim: Although, MeckelÕs diverticulum occurs in about 2 percent of the population, making it the most prevalent congenital abnormality of the gastrointestinal tract, it is often difficult to diagnose. Major complications include bleeding, obstruction, intussusception, diverticulitis and perforation. Herein we present a case of laparoscopic managing of gangrenous MeckelÕs diverticulitis lead to an acute small bowel obstruction. Case description: A 27-year-old male presented to the emergency department with a complaint of diffused cramping abdominal pain of two to three hours duration, with associated vomiting and anorexia. He mentioned having undergone appendectomy in another hospital 4 years before the current admission. Physical examination revealed distended abdomen and diffused tenderness with slight guarding and rebound. Abdominal x-ray was suggestive with incomplete small bowel obstruction. A conservative treatment has initiated including Gastrographin injecting through a nosogastric tube. Four hours late, in light of an exacerbation of abdominal pain, and a picture of complete bowel obstruction on abdominal x-ray, surgery was recommended. At the time of laparoscopic exploration, an axially torsed, gangrenous MeckelÕs diverticulum was found. The lead point for the complete small bowel obstruction was a fibrous band attached between the distal tip of the diverticulum and the peritoneal surface at the pelvic rim. The band was simple transsected, this completely releasing a strangulation of the distal ileum. Than, a necrotic MeckelÕs diverticulum was resecting using a linear stapler (Endo-GIA). The resected diverticulum has retrieved inside an Endo-Bag via a 12-mm port wound. Presented Video depicts the technical details of this procedure. Results: The surgery took 35 minutes. The patient discharged on postoperative day 5, tolerating the regular diet and enjoying an excellent cosmetic result. The histopathology showed gangrenous diverticulitis with ectopic pancreatic tissue. Conclusion: Entire laparoscopic resection of a complicated MeckelÕs diverticulum can perform safely in the setting of acute small bowel obstruction and imparts many of the benefits of minimally invasive surgery.

V070 - Intestinal, Colorectal and Anal Disorders

V072 - Intestinal, Colorectal and Anal Disorders

APPENDIX MASS LAPAROSCOPIC APPENDICECTOMY OR OPEN SURGERY M.R. Abbasi, S. Khan, A. Jamil, A.R.H. Nasr, I. Ahmed Louth County Hospital, DUNDALK,CO.LOUTH, Ireland

LAPAROSCOPIC EXCISION OF DUODENAL GASTROINTESTINAL STROMAL TUMOUR C. Staudacher, E. Orsenigo, S. Di Palo, G. Bissolotti Scientific Institute San Raffaele, MIALN, Italy

The treatment of appendix mass is a challenge is surgical practice. Traditionally patients are initially treated conservatively with antibiotics & later on subjected to interval appendicectomy unless they fail to respond to antibiotic treatment. Many surgeons believe surgery at the acute stage is hazardous, difficult & associated with a high rate of serious complications. Breaking the natural barrier of mass is a foolish attempt and it is safe to wait.

Aim: Gastrointestinal stromal tumour (GIST) most frequently present with either gastrointestinal bleeding, abdominal pain or a detectable mass on physical examination or by ultrasound imaging. A duodenal location is rare. Therapy consists in the radical excision of the tumour. Our aim was to demonstrate the feasibility of laparoscopic excision of a duodenal GIST.

In our unit from January 2001 to December2004 we performed 288 laparoscopic appendicectomies for acute appendicitis, 16 patients having appendiceal mass diagnosed by CT scan underwent laparoscopic surgery. 4 cases had to be converted to open surgery due to difficulty (Conversion rate 25%). The average operating time for the laparoscopic cases was 63 minutes (range 47 to 122 minutes). One patient in the laparoscopic group developed pelvic abscess which was treated with antibiotics. One patient in the converted group developed wound infection requiring secondary suturing at later stage. The average hospital stay in the laparoscopic group was 5.7 days (Range 4 to 15) and in the open group was 7.2 days (Range 6 to 20 days). This video demonstrates the different types of problems encountered during the laparoscopic procedure & our operative technique. The authors believe in the experienced hands laparoscopic appendicectomy for appendiceal mass is a safe procedure with acceptable rate of complication and reduced over all hospital stay for the patient.

Methods: We report the case of a 40-year-old male patient who presented with melaena and acute anaemia. Upper digestive tract endoscopy and computed tomography of the abdomen showed a centrally ulcerated, broad-based, polypoid projection of 2.5 cm in the duodenal wall. Endoscopic ultrasound examination revealed a lesion arising from the lateral wall of the second portion of the duodenum about 2 cm below the papilla of Vater. Because of this rare location, a very invasive procedure (duodenopancreatectomy) might have been required for tumour resection. We avoided this operation and implemented an alternative solution. Results: A laparoscopic resection of the duodenal tumour was successfully completed. Operating time was 200 min and blood loss 50 ml. The post-operative course was uneventful. Histopathological examination revealed that the duodenal submucosal tumor consisted of spindle cells, and immunohistochemical analysis revealed positive tumour staining for CD117, CD34 S-100. Based on these findings, the tumour was diagnosed as a GIST of low-grade malignancy, classified as the muscular type. Conclusions: Despite laparoscopic surgery requires more complex technique than open surgery and acquisition of advanced laparoscopic skills depending on prior laparoscopic experience, laparoscopic excision should be considered as a valid treatment for duodenal GIST.

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V073 - Intestinal, Colorectal and Anal Disorders

V075 - Intestinal, Colorectal and Anal Disorders

LAPAROSCOPIC ASSISTED RESTORATIVE PROCTOCOLECTOMY AND ILEAL POUCH ANAL ANASTOMOSIS FOR ULCERATIVE COLITIS: THE WAY FORWARD IN POUCH SURGERY? E. Nzewi, S. Hussain, P. Neary Adelaide and Meath Hospital, DUBLIN, Ireland

ULTRA-LOW ANTERIOR RESECTION USING A FOUR-ARM ROBOTIC SYSTEM J.H. Wang, A. Pigazzi City of Hope Medical Center, DUARTE, CALIFORNIA, United States of America

Aim: Restorative proctocolectomy and ileal pouch anal anastomosis for ulcerative colitis traditionally involves a long midline surgical incision, significant morbidity and prolonged inpatient stay (17.37 days, DOH 2003). We present a video demonstration of this surgery performed laparoscopically in a tertiary referral specialised colorectal unit. Methods: A single live case digitalised recording was performed and edited to presentation length DVD format. Results: A 25 year old female with a 10 year history of ulcerative colitis that was refractory to medical therapy was referred for surgical management. Her body mass index (BMI) was 21.7 kg/m2. She underwent a laparoscopic assisted restorative proctoctocolectomy with ileal pouch - anal anastomosis and a defunctioning loop Ileostomy as a one stage procedure. She was discharged home well on the eight post operative day. The operative time was 300 minutes and maximum incision length was 8cm. A DVD of the operative technique is presented.

Aims: To assess the feasibility a robotic ultra-low anterior resection for rectal cancer using the four-arm DaVinci system. Methods: This shows a case of a 53 year old male patient with low rectal cancer. The first part of the procedure is carried out laparoscopically with mobilization of the splenic flexure and mesocolon as well as division of the inferior mesenteric artery at the origin. Subsequently, the four arm robotic system is docked in between the patients legs. The fourth arm is used to provide retraction of the bowel and peritoneal folds. A total mesorectal excision with autonomic nerve preservation is carried out. An end-to end anastomosis and a diverting loop ileostomy are created. Results: Operative time was 4 hours and 15 minutes. EBL was 200 ml. Hospital stay was 3 days. There were no complications Conclusion: Four-arm robotic ultra-low anterior resection is feasible. This modality may render minimally invasive rectal operations easier for surgeons with inexperienced assistants in the operating room.

Conclusion: Laparoscopic assisted restorative proctocolectomy and ileal pouch anal anastomosis for Ulcerative colitis is technically feasible. It offers patients a minimally invasive approach to a complex surgical procedure with good functional outcome and a superb cosmetic result.

V074 - Intestinal, Colorectal and Anal Disorders

V076 - Intestinal, Colorectal and Anal Disorders

LOW SECTION OF THE RECTUM DURING LAPAROSCOPIC TOTAL MESORECTAL EXCISION USING THE CONTOURTM DEVICE. Technical report. E.M. Targarona, C. Balague, R. Berindoague, C. Martinez, P. Herandez, S. Vela, R. Medrano, J.L. Pallares, J. Garriga, M. Trias Hospital de la Sta Creu i St Pau, BARCELONA, Spain

TOTALLY LAPAROSCOPIC SIGMOID RESECTION FOR COLON CANCER: TECHNICAL STANDARDIZATION AND ADHERENCE TO ONCOLOGIC CRITERIA F. Rubino, J. Leroy, C. Bailey, J. Marescaux IRCAD/EITS University Louis Pasteur, STRASBOURG, France

After the definitive demonstration of the advantages of laparoscopic approach for colon cancer, evidence exist about its role for rectal cancer. Initial reports show technical feasibility, adequate oncologic clearance and optimal outcome. Conversion range between 0 - 20%, and anastomotic leakage is up 20%. Local anatomy (male pelvis, prostate volume and tumor size) may impairs adequate dissection, and the most challenge is the transection of the lower rectum. Available devices reach the transection line in an oblique direction, requires more than one staple cartridge and distal stump adquires an assimetric trapezoidal shape. Recently, an staple an cutting device for section of te distal rectum has been designed for open surgery (ContourTM, Ethicon). The aim of this report is to show the possible utility of this device in endoscopic surgery, and to suggest the need of improved staplers to ammeriolate the surgical task when operating in the low rectum. Surgical Techniques and Results: Once the rectal dissection is finished, a 6 cm pfanestiel incision is performed. A Lap Disc device (Ethicon) is inserted, and the ContourTM (Ethicon) is inserted trough it. The Lapdisc is closed and the pneumoperitoneum is recovered. The stapler is smoothly inserted in the lower pelvis. Pushing movements permit to locate the stapler in the adequate placement. The stapler is closed and fired, obtainig the simultaneous closure of the proximal and distal rectum ends The sigmoid-rectal segment is excised trough the Pfanestiel incision. Transanal double stapling colorectal anastomosis is performed under laparoscopic control. Between May- 2005- March 2006, 10 succesful transection of the lower rectum with a single shot with the ContourTM device was performed. There were no conversions, the instrument was used without problems and the anastomosis was fashioned without problems. Immediate surgical outcome was unremarkable in all cases. Conclusion: The ContourTM device has been developed for open surgery, but it design accomplishes the needs for a one shot regular transection of the rectum. Future directions in ancillary stapler designs for laparoscopic rectal transection should follow the main functional guidelines of this device.

Recent evidence from randomized clinical trials support the oncologic adequacy of the laparoscopic approach for colon cancer. It is easily predictable that this knowledge will spread the use of laparoscopic colectomy creating the need for dedicated training and education to guarantee standardization of the procedure and strict adherence to safe oncologic principles. We show the technical tips to achieve standardization of laparoscopic sigmoidectomy for colon cancer. The procedure can require five to six ports and relies on adequate exposure of the left mesocolon by appropriate retraction of the small bowel loops in the right upper quadrants of the abdomen. This maneuver facilitates the medial-tolateral approach in the dissection of the left mesocolon, which is key for early and safe proximal division of inferior mesenteric vessels. The rectum is transected intracorporeally by one or two applications of a linear cutting stapler. The proximal colon transection is also performed intracorporeally by using a linear cutting stapler. To prevent tumoral cells spillage, the specimen is put in an impermeable bag before being extracted through a mini-Pfannenstiel incision sheltered by a wound protector device (double protection). Mobilization of the splenic flexure can be performed through a lateral approach, by simply dividing the spleno-colic ligament, or, if extra-length is necessary, through a medial approach, dissecting the transverse mesocolon from the anterior surface of the tail of the pancreas. The video illustrates the technical steps of splenic flexure mobilization. Only the preparation of the proximal segment for stapled colo-rectal anastomosis is performed extracorporeally. Finally, laparoscopic end-to-end stapled colo-rectal anastomosis is performed with a Knight-Griffen technique.

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V077 - Intestinal, Colorectal and Anal Disorders

V079 - Intestinal, Colorectal and Anal Disorders

A MULTI-DISCIPLINED TOTALLY LAPAROSCOPIC APPROACH TO SEVERE ENDOMETRIOSIS OF THE RECTOVAGINAL SEPTUM C. Bailey, J. Leroy, V. Frenna, E. Ohana, A. Wattiez, J. Marescaux IRCAD-EITS / University Louis Pasteur, STRASBOURG, France

LAPAROSCOPIC TREATMENT FOR CROHNS DIDEASE J. Vazquez Echarri1, I. Kaibel Axpe2, J.M. Romeo Martinez1, V. Rojo Blanco2 1 Severo Ochoa, MADRID, Spain 2 Clinica ROKAVA, MADRID, Spain

Aims: Endometriosis is defined as the presence of glandular and stromal endometrial tissue outside of the uterus. Patients present for the most part with pelvic pain and fertility problems and in cases of severe endometriosis the only curative option is surgery, as medical treatment with GnRH analogues can halt progression but not induce regression of the disease. The aim of this video is to use a case of severe endometriosis of the rectal vaginal septum to demonstrate the laparoscopic techniques used to tackle this complex and difficult condition. Materials and Methods: The surgical team consists of digestive and gynaecological surgeons as severe endometriosis can affect the viscera throughout the pelvis. The case is of a 30 year old diagnosed with a 3cm nodule of endometriosis in the rectovaginal septum presenting with pelvic pain, dysmenorrhoea and infertility. The position of the lesion is localised using pre-operative MRI and intra-operative ultrasound scanning. The video demonstrates the technique used to perform an en bloc resection of the nodule including a low anterior resection and anastomosis and removal of a portion of the posterior vaginal wall.

Inflammatory bowel disease represents a percentage of abdominal surgical indications. A laparoscopic approach is being used more frequently everyday. In Crohns disease, surgery is performed facing a complication. These circumstances render such operations especially difficult. Case Report: 47 years old female diagnosed of Crohns disease long ago, and presently under medical treatment. The present condition causes poor medical response, intestinal occlusion and general deterioration. Gastrointestinal RX and abdominal CT show involvement of terminal small bowel and cecus with entero-enteric fistula. Surgery is performed trough a laparoscopic approach, with right hemicolectomy including a long tract of terminal ileus, and resection of another small bowel loop included in the inflamatory mass. The specimen is exteriorised trough an incision in the right upper quadrant. The anastomoses are performed extracorporealy and using mechanical suture devices. Postop course was uneventful, and hospital discharge carried out on the fifth day.

Conclusions: Laparoscopic surgery, with the benefits of a magnified intra-operative image, enhanced recovery and excellent cosmetic results, is ideally suited to performing surgery for endometriosis. However these are complex procedures that require a multidisciplined approach so that the surgical team can perform gynaecological and gastrointestinal procedures simultaneously to ensure complete resection of the pathology.

V078 - Intestinal, Colorectal and Anal Disorders

V080 - Intestinal, Colorectal and Anal Disorders

THE USE OF FOUR DIRECTIONAL RETRACTION IN LAPAROSCOPIC TOTAL MESORECTAL EXCISION FOR LOW RECTAL CANCER C. Bailey, J. Leroy, M. Simone, J. Marescaux IRCAD-EITS / University Louis Pasteur, STRASBOURG, France

LAPAROSCOPY ASSISTED SIGMOIDECTOMY FOR COLON CANCER IN A PATIENT WITH A SMALL PERITONEAL CAVITY: A TECHNICAL TIP N. Ueno, K. Sano, H. Kuroda, S. Ichii, K. Imanishi Rokko Island Hospital, KOBE, Japan

Introduction: Exposure is essential to perform a total mesorectal excision (TME) that delivers an oncological package and preserves the sympathetic and parasympathetic nerves that supply sexual and bladder function. The aim of this video is to introduce and demonstrate the technique of four directional retraction that is used to achieve perfect exposure to perform a laparoscopic low anterior resection in a male patient. Methods: Heald proposed the concept of three directional retraction (3DR) in open TME, this video shows the technique of laparoscopic four directional retraction (4DR) consisting of: 1. The assistant retracting the sigmoid and rectum cephalad, to maintain gentle traction on the rectum. 2. The assistant using specialized retractors introduced through the10mm suprapubic port, which lift the seminal vesicles and prostate anteriorly. 3. The surgeon using prototype non-traumatic retractors to hold the rectum and mesorectum to place the tissue to be divided under gentle tension, this is particularly important when monopolar diathermy scissors are used to perform the dissection. 4. The pressure of the pneumoperitioneum acting as a fourth retractor by opening up the planes as the peritoneum is breached and maintaining the tension on the tissues to be divided. Discussion: This video introduces the term four directional retraction for laparoscopic TME for the resection of low rectal cancer. It demonstrates how excellent retraction can be achieved to provide the exposure that is required to find and stay within the mesorectal plane and to visualize and preserve the nerves. This ensures that a complete oncological resection is performed and function is preserved.

Aims: In patients with a small peritoneal cavity or cases with relatively bulky intestine and mesentery as the peritoneal cavity, it is difficult to achieve static exposure and clear visualization of structures under pneumoperitoneum through the laparoscopic colectomy. It has been reported that morbidity and conversion rate is higher in such cases. We report one of cases which underwent laparoscopy assisted colectomy for colon cancer in spite of the difficulty, in order to show the feasiability and safety of the procedure. Methods: The patient was a female, aged 55 years, 136 cm in height and 49 kg in weight, with a diagnosis of sigmoid colon cancer. Laparoscopic sigmoidectomy was indicated. Preoperative CT scan already revealed her small peritoneal cavity. Five trocars were used: one supraumbilical 10 mm trocar for the laparoscope, one 10/11 mm trocar for the use of right hand and one 5 mm trocar for the left hand of the chief surgeon in the right midclavicular line, and two 5 mm trocars in the left midclavicular line for the assistant. Small intestine is usually to be displaced to the right hypochondrium in order of exposure of mesocolon and the origin of inferior mesenteric artery, but its small peritoneal cavity and dilated intestine disturbed it. Results: Surgical towel was delivered into the peritoneal cavity to keep the small intestine off the operative field. Only retroperitoneal dissection of the sigmoid mesocolon and sectioning the inferior mesenteric vessels with lymph nodes dissection was carried out laparoscopically and the sigmoid colon was finally excised with the associated mesentery extracorporeally through the mini-laparotomy made in the mid-subumbilical line. Colorectal anastomosis was carried out with circular stapler under laparoscopic guidance. Postoperative condition of the patient is fine. Conclusions: Even in the case with small peritoneal cavity and working space consequently, laparoscopy assisted colectomy is feasible and safe, maintaining the general benefit of laparoscopic surgery, in which the surgical towel as a retractor is efficient.

S275

V081 - Intestinal, Colorectal and Anal Disorders

V083 - Intestinal, Colorectal and Anal Disorders

LAPAROSCOPIC MANAGEMENT OF COMPLICATED DIVERTICULAR DISEASE H.M.P. Dowson, Y. Soon, A.H. Huang, T.A. Rockall MATTU, Royal Surrey County Hospital, GUILDFORD, United Kingdom

ENDOLUMINAL SURGERY: TRANSANAL ENDOSCOPIC MICROSURGERY RESECTION OF A SESSILE RECTAL POLYP J H Marks Lankenau Hospital and Institute for Med, WYNNEWOOD, United States of America

Introduction: The management of fistula disease secondary to diverticulitis has previously been a relative contra-indication to laparoscopic surgery. We present a video of the management of three such cases performed laparoscopically.

Sessile polyps of the mid to upper rectum present a difficult problem for the endoscopist and surgeon. Lesions too large to be removed endoscopically and not accessible transanally routinely require a low anterior resection. Transanal Endoscopic Microsurgery (TEM) allows the surgeon to maximize the minimally invasive approach by curatively resecting rectal tumors without any external incisions.

Methods: Three patients presented with symptoms of complicated diverticular disease. Further investigation confirmed the presence of 2 colovesical fistulae and 1 enterocolic fistula, each involving the sigmoid colon. Surgery was undertaken laparoscopically: the fistulae were disconnected, a sigmoid colectomy was performed using a medial to lateral technique, and a stapled rectal anastamosis completed the procedure. This video demonstrates our surgical technique in these complicated cases. Results: The mean age was 73 (range 57-82), and there were 2 men and 1 women. The mean operative length was 130 minutes. There were no conversions, but one patient required insertion of a hand-port. The mean size of suprapubic incision was 6cm. Diverticular disease was confirmed histologically in each case. All patients tolerated a normal diet on the day following surgery, and the median length of hospital stay was 4 days (mean 6, range 3-10). There were no post-operative complications.

Presented is a 65 year old woman, on Coumadin for repeated DVTs, with a 3.5 cm sessile polyp 10 cm above the anorectal ring. The gastroenterologist felt this unresectable colonoscopically and the patient was referred to a colorectal surgeon who recommended a LAR. The patient sought an additional opinion. A repeat colonoscopy was performed to confirm the polyp was not colonoscopically resectable, its position, and the absence of malignancy. Demonstrated is an application of endoluminal surgery utilizing the technique of TEM emphasizing the equipment, room set-up, and surgical approach. Key steps are highlighted including the proximal reach of TEM, polypectomy in a non-peritoneal fashion and anastomosis.

Conclusion: The laparoscopic management of colonic fistulas secondary to diverticular disease is safe and feasible, and is associated with a rapid post-operative recovery. We would advocate these techniques in the management of complicated diverticular disease.

V082 - Intestinal, Colorectal and Anal Disorders

V084 - Intestinal, Colorectal and Anal Disorders

HOW TO PERFORM LAPAROSCOPIC TME IN A MALE NARROW PELVIS: TIPS AND TRICKS S. Van Slycke OLV Hospital, AALST, Belgium

A TECHNICAL GUIDE TO SAFE LAPAROSCOPIC LYSIS OF ADHESIONS G.J. Mancini, K. Thaler, B.S. Benson University of Missouri, COLUMBIA, United States of America

Video with tips and tricks to perform a laparoscopic TME in a narrow male pelvis. Placement of trocars, how to staple and how to dissect.

Aims: Laparoscopic lysis of adhesions is increasingly associated with routine laparoscopic procedures. Adhesiolysis potentially adds to patient morbidity if not performed safely. Bleeding and bowel injury are important complications related to laparoscopic lysis of adhesions. This video demonstrates blunt dissection, sharp dissection, and energy source dissection techniques for safe laparoscopic adhesiolysis. Methods: Intra-operative video compilation (7.23 minutes) in DVD Format. Discussion: Laparoscopic lysis of adhesions can be complex and add morbidity to routine laparoscopic procedures. When using blunt dissection technique, limit distracting forces on adjacent sensitive structures. If energy sources are to be used, care must be taken to avoid its use near sensitive structures. Sharp dissection is safest when dividing adhesions between delicate structures.

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V085 - Intestinal, Colorectal and Anal Disorders

V154 - Intestinal, Colorectal and Anal Disorders

VL SUBTOTAL COLECTOMY WITH CECO-RECTAL ANASTOMOSIS FOR CHRONIC CONSTIPATION FROM SLOW TRANSIT

RECTO-VAGINAL FISTULA REPAIR BY TRANSANAL ENDOSCOPIC MICROSURGERY (TEM) E. Lezoche, G. DÕAmbrosio, A.M. Paganini, L. Solinas, F.P. DÕOstuni, F. De Laurentis, A. Rotundo, G. Lezoche Policlinico Umberto I, ROME, Italy

G. Conzo1, M.G. Esposito1, U. Brancaccio1, A. Palazzo1, F. Stanzione1, S. Celsi1, A Livrea2 1 Second University, NAPLES, Italy 2 IVDiv Gen surg&End.Sur.Second University, NAPLES, Italy Introduction: Chronic constipation from slow colonic transit is a rare condition for which a conservative treatment is generally indicated. A total colectomy with ileo rectal anastomosis may be indicated in those patients(5%), non-responding to medical treatment. A ceco-rectal anastomosis, after subtotal colectomy,might reduces the complications related to the total colectomy (diarrhoea and adherencial syndrome). Case Report: The Authors report a case of chronic constipation from slow colonic transit in a young man of 20ys old with paradox diarrhoea, severe constipation, encopresis, and colonic dilatation. In1995, the patient underwent internal sphincterotomy for erroneous diagnosis of Hirshprungs Disease. The instrumental diagnostic preoperative work up - pancolonoscopy, X-ray of the digestive tract -cofirmed a chronic constipation from slow colonic transit; anorectal manometry showed normal values with significant rectal hypo sensibility. Endoscopic biopsy excluded Hirshprungs disease. The patient underwent to a video laparoscopic subtotal colectomy and mechanical aniso-peristaltic latero-terminal (LT) ceco-rectal anastomosis. The operation was performed through 4 trocars 10 mm (supra umbilical, hypogastric, right and left lateral iliac space) in anti-Trendelemburg position(30). After mobilization of left colon, splenic and hepatic flexure, the colon went out from median mini laparotomy <7cm. A subtotal colectomy with a preservation of 10cm from ileocecal valve, appendectomy, and mechanical LT ceco-rectal anastomosis (EEAp34 Ethicon Endosurgery R) was performed. A trans rectal catheter Foley 24Ch was used for anastomotic decompression in the first p.o. days. In the IVp.o. the patient had an oral diet and in Xp.o. he was submitted to a gastrographin microclisma X-ray, that showed anastomotic integrity. At XIIp.o. the patient was discharged. Discussion: Total colectomy with ileo - rectal anastomosis represents the more common operation with a notable morbidity- severe diarrhoea and adherencial syndrome.The preservation of ceco, ileum and ileocecal valve allows an inferior number of daily evacuations. In the case reported the postoperative course was satisfactory in term of intestinal function. After 2months the patient reported three daily evacuations. Videolaparoscopic subtotal colectomy with ceco- rectal anastomosis represents a good surgical option in the treatment of chronic constipation from slow colonic transit.

Background: Recto-vaginal fistulas (RVF) are abnormal epitheliumlined communications between rectum and vagina. They are classified as low, intermediate and high depending on the location of the vaginal opening, with low RVF most commonly encountered. The causes of RVF include trauma, infection, inflammatory bowel disease (IBD), carcinoma and radiation therapy. Surgical treatment of RVF may be accomplished through different surgical routes: transanal, transvaginal, perineal and transabdominal, with success rates of 40-85%. The route that is chosen largely depends on the location of the fistulous tract. A laparoscopic approach has also been reported. The authors present the case of an iatrogenic RVF treated for the first time by a Transanal Endoscopic Microsurgery (TEM) approach. Method: A 70-years old woman underwent transvaginal hysterectomy, complicated by postoperative haemorrhage. She subsequently developed a RVF, confirmed both clinically and endoscopically, and a colostomy was performed. The patient was then referred to the authors institution for treatment of the RVF. With the patient in the prone position, the RVF was excised, the rectal and vaginal walls were separated and then sutured by TEM technique. The postoperative course was uneventful. Radiological and endoscopic control at one month showed complete healing of the RVF. The colostomy was then closed. Conclusion: The powerful light intensity and field magnification of TEM provide unparalleled surgical control of the rectal lumen. TEM is an innovative, minimally-invasive surgical technique for the treatment of RVF which proved in this case to be feasible and safe with excellent results.

V086 - Intestinal, Colorectal and Anal Disorders

V155 - Intestinal, Colorectal and Anal Disorders

LAPAROSCOPIC SURGERY IN COMPLEX CROHNS DISEASE P. Kessler, W. Hohenberger University of Erlangen, ERLANGEN, Germany

USE OF RADIONUCLEAR TECHNIQUE IN THE RADICAL TREATMENT OF RECTAL CANCER BY TEM E. Lezoche, G. DÕAmbrosio, A.M. Paganini, L. Solinas, F.P. DÕOstuni, G. Lezoche, P. Ursi, L. Barchetti Policlinico Umberto I, ROME, Italy

Introduction: In Crohns disease, satisfying laparoscopic management of frequent complications as fistulas, abscesses or multiple strictures and of recurrent abdominal procedures has hardly been described. Methods: Four different cases are presented. First, adhesions and fistulas have to be taken down to facilitate an exploration of the complete bowel and to determine the real extent disease. If technically feasible larger vessels should be transected. The bowel is mobilized laterally and eventually, fistulas to the urinary bladder and to the psoas region are separated. A periumbilical minilaparotomy is appropriate in most cases. Resection and hand-sewn end-to-end anastomosis are carried out extracorporeally. Results: In 26 laparoscopic-assisted operations in Crohns disease, there were 11 recurrences and/or preoperative complications had occurred like ileus, sealed perforations or abscesses (9) and fistulas (10) to the bladder or other bowel segments. In 20 cases, small and large bowel was resected, in 5 of these with extended segments of ileum or colon. In 3 cases, two separate segments of ileum and colon were resected. In 3 cases of recurrent Crohns disease, only small bowel was resected, in one of them with 6 additional strictureplasties. The median length of the minilaparotomy was 5.5 cm (4.0 8.0). The median time of operation was very variable, with a median of 215 min (135 290). There were no intraoperative complications and no reoperations. The median length of hospital stay was 7 days (6-13). Conclusions: Even complicated cases of Crohns disease with previous surgery, fistulas, abscesses and sealed perforations may be treated safely by laparoscopic technique.

Background: The surgical treatment of rectal cancer includes anterior resection of the rectum or abdomino-perineal amputation. These approaches may be complicated by anastomotic failures (4-42%) and genito-urinary dysfunctions (10-15%) and include a temporary or permanent stoma. In selected cases rectal cancer may be treated with local excision and minimallyinvasive techniques (TEM), with neoadjuvant radiochemotherapy in T2 N0 lesions. Local recurrence after TEM is between 2 and 15% in T1 and T2 rectal cancer. The sentinel node (SN) technique has been used by various authors in colon carcinoma with identification rates of 89%. However, since the rectum is anatomically different from the colon, with bulky mesentery and extraperitoneal location, the SN procedure is more difficult. Furthermore, pre-operative radiotherapy causes sclerosis of the perirectal tissues which modifies the lymphatic flow as a result of lymphatic obstruction. The authors used a modified SN technique in order to improve radical resection of rectal cancer by TEM. Methods: A 79-years old woman with rectal cancer located at 4 cm from the anal verge (T3-N0-M0) underwent neoadiuvant radio-chemiotherapy, with downstaging to T2-N0-M0. Due to the high anaesthesiological risk (ASA IIIIV) it was decided to perform a TEM approach. The radioactive tracer was injected peritumorally and a full thickness excision of the rectal tumor with perirectal fat was performed by TEM. Residual radioactivity was detected in the surgical field after local excision and a probe-guided mesorectal fat excision was performed. Upon final testing, the probe didnt show any residual radionuclide activity. Histological examination of the radial margin of the surgical specimen was negative. The postoperative course was uneventful. At 6 months of follow-up, there is no evidence of local or distant recurrence. Conclusion: Radioguided local excision of mesorectal fat after full thickness local excision of rectal cancer and adjacent fat by TEM may be a useful adjunct to achieve a more radical treatment in selected cases.

S277

V087 - Liver and Biliary Tract Surgery

V089 - Liver and Biliary Tract Surgery

ROBOTIC INSERTION OF HEPATIC ARTERY INFUSION PUMP A. Pigazzi, L.D. Wagman City of Hope National Cancer Center, DUARTE, United States of America

LAPAROSCOPIC TREATMENT OF MULTIPLE BILE DUCT LITHIASIS AFTER THE FAILURE OF COMBINED LAPAROSCOPIC CHOLECYSTECTOMY AND PERIOPERATIVE ENDOSCOPIC APPROACH J.Ph. Magema1, B. Navez2, J.P. Boeur1, L. Laloux1 1 CH Dinant, DINANT, Belgium 2 Hoˆpital Saint Joseph, GILLY, Belgium

Introduction: Hepatic artery chemotherapy can be given as adjuvant or salvage treatment of colorectal liver metastases. The operation is usually carried out in an open fashion and carries a substantial morbidity. Although technically possible, laparoscopic placement of the hepatic artery catheter into the gastroduodenal artery is a very challenging procedure. The advantages of robotic surgery include a stable camera platform, rotating instrument and three-dimensional vision. Here we describe and show our technique for totally robotic insertion of hepatic artery infusion pump. To our knowledge, this is the first video of this procedure ever presented. Methods: A 57 year old woman with unresectable liver metastases refractory to systemic chemotherapy was referred for placement of hepatic artery pump and subsequent systemic and hepatic chemotherapy. Using a five port technique a cholecystectomy was performed and the hepatic artery was dissected. The gastroduodenal artery was identified and dissected along its course. The artery was thus isolated proximally and distally using a laparoscopic bulldog clamp and ties. The catheter was easily inserted into the artery and tied into place. An accessory left hepatic artery was clipped. Results: Operative time was 3 hours and thirty minutes. Blood loss was minimal. The patient was discharged home on postoperative day two. Conclusion: Robotic placement of hepatic artery pump is feasible. This technique offers unique advantages when considering a minimally invasive approach for this procedure.

The management strategy of Common and IntraHepatic Bile Duct Stones (CIHBDS) still is subject of controversy. Laparoscopic Cholecystectomy (LC) combined with PeriOperative Endoscopic Sphincterotomy (POES) is a common technique for the treatment of Common Bile Duct Stones (CBDS) during a single operative procedure. Alternative to this procedure is the use of Laparoscopic Bile Duct Exploration (LBDE). This video illustrates the interesting case of the successful use of LBDE, in a second stage operation, as the treatment of multiple CIHBDS after failure of combined LC and POES. Clinical case, and details of the procedure are exposed.

V088 - Liver and Biliary Tract Surgery

V090 - Liver and Biliary Tract Surgery

TOTAL LAPAROSCOPIC EXICISION OF CHOLEDOCHAL CYSTS C. Palanivelu, P.S. Rajan, A. Roshan Shetty Gem Hospital, COIMBATORE, India

HAND-ASSISTED LAPAROSCOPIC LEFT LATERAL SEGMENTECTOMY FOR FOCAL NODULAR HYPERPLASIA C.N. Tang, M.K.W. Li Pamela Youde Nethersole Eastern Hospital, HONG KONG SAR, Hongkong

Choledochal cysts remain an interesting and intriguing congenital anomaly of the hepatobiliary tract. Even though bile duct cysts are diseases of childhood 20% of patients present in the adults. With the success of laparoscopic cholecystectomy, minimally invasive technique continues to evolve with an emphasis on developing techniques and applying new technologies to newer and more difficult and advanced surgical procedures. We have operated 23 cases of choledochal cyst from 1991 to 2005. Pre operatively all patients were assessed by symptoms, biochemical investigations, USG, CT and ERCP in selective cases. The submitted video describes about the procedure in brief. Patients are placed in supine position and pneumoperitoneum is created by the closed Veress needle technique. The choloedochal cyst is exposed and a lumbar puncture needle is inserted percutaneously into the cyst and bile is aspirated and sent for culture. Intraoperative cholangiogram by injection of dye into the cyst provides additional anatomical details and confirmation of anamoulous pancreatico biliary ductal junction. A transverse incision is made on the cyst and it is decompressed. And the posterior wall is carefully dissected off the portal vein by suction nozzle up to the undilated portion. Meticulous dissection with harmonic scalpel, precise hemostasis, proper use of suction nozzle helps to maintain a clear field of vision throughout the surgery. After excision of the entire cyst the continuity is restored by Roux en Y hepaticojejunostomy. The formation of Roux loop is done either by intracorporeal or extracorporeal technique. End to side hepatico jejunostomy is done intracorporealy using 4-0 vicryl (all layers, interrupted) by hand sewn technique. Percutaneous transjejunal jejunostomy was performed through the lateral port in the right flank for decompression. Till now we successfully operated on 23 patients of choledochal cysts form 1994 to 2005. (5 males and 18 females). Out of which 5 were under 10 years of age. Age group range from 2 years to 48 years. The detailed results will be presented follwoing the video. Excision of choledochal cyst and biliary enteric anastomosis by laparoscopic approach is highly effective and safe. Experience in Laparoscopic knotting and suturing is essential in performing such procedure.

Case Summary: We reported a hand-assisted laparoscopic left lateral segmentectomy for a 33 years old lady with focal nodular hyperplasia (FNH). She initially complained of epigastric discomfort for several months. CT scan revealed a hypervascular tumour at the left lateral segment measuring about 8-9 cm, showing characteristic central scar classical of FNH. She was initially managed conservatively. As her discomfort was getting worse and repeated CT showed increased size of the FNH. She requested laparoscopic excision of the tumour. Surgery was performed using 5-port approach (including 1 handport at right upper quadrant measuring 7.5 cm long). The surgery was completed within 105 minutes with operative blood loss of 100 cc. Pringle clamping was applied for about 15 minutes. She recovered uneventfully and required no parenteral analgesics. She was discharged on postoperative day 5 and had no complication noted upon a follow up of more than 6 months.

S278

V091 - Liver and Biliary Tract Surgery

V093 - Liver and Biliary Tract Surgery

BENEFICIAL EFFECT OF ENDOSCOPIC TRANSPAPILLARY GALLBLADDER STENT FOLLOWED BY PROMPT LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS M. Sugimoto, H. Yasuda, M. Yamazaki, T. Tezuka, T. Takenoue, C. Kosugi, S. Yamamoto, Y. Watayo, R. Ootaki, S. Naka, H. Yasuhara Teikyo University Ichihara Hospital, CHIBA, Japan

GALLBLADDER AGENESIS Z. Shaher Dawar Tamween, DEIREZZOR, Syria

Aims: Recent reports suggest that the optimal treatment of acute cholecystitis is urgent laparoscopic cholecystectomy (Lap-Chole). A delay from onset of symptoms leads to a higher conversion and increases risk of complications. However emergency biliary surgery for acute obstructive cholecystitis is associated with an increased hospital mortality. Methods: We therefore attempted to perform prompt Lap-Chole after drain gallbladder by placement of an endoscopic transpapillary stent (ETGBS) via nasobiliary (ENGBD) or duodeno-biliary (ERGBD) route, in patients who had acute cholecystitis and were at an increased urgent surgical risk. The advantages and techniques of ETGBS confer benefits on prompt Lap-Chole for 22 consecutive patients with acute cholecystitis were described. Results: ETGBS was successfully accomplished in 22 of the 25 patients (88.0%). An extension of the indications of such catheterization could be the disimpaction of gallstones and the drainage of obstructed gallbladder. Drainage is expected to achieve after being pushed back the obstructing stone into the gallbladder, either by flushing sterile water and contrast medium into the cystic duct or mechanical action of the system wire/ pusher catheter. This task has been accomplished in about 30 minutes, without complications. This resulted in effective bile drainage, obviating the need for emergency surgery in all patients. No procedure-associated morbidity or mortality was found. All patients experienced resolution of their symptoms immediately and accepted prompt Lap-Chole within 96 hours postprocedure. During Lap-Chole, ETGBS enabled to clarify inflamed cystic duct by signs of ÔPassingÕ, ÔSee-throughÕ and ÔReboundingÕ. ÔHolding methodÕ and ÔCutting down methodÕ revealed that ETGBS was placed in cystic duct, thereby made operative dissection easier. There were no bile duct injuries or mortalities. No intraoperative or postoperative complications occurred. Intraoperative blood loss, operative time and hospital day were decreased. Conclusion: ETGBS is a beneficial procedure to perfom safer urgent laparoscopic cholecystectomy for inflamed occluded cholecystitis.

Agenesis of gall bladder is an extremely rare condition with an incidence of 0.01-0.02%. This anomaly is transmitted as non-sex linked trait with variable penetration. Three groups of presentations were noted: a. Asymptomatic patients who are diagnosed as incidental finding on abdominal exploration for some other reason (35%). b. Symptomatic agenesis - One third of these patients will have dilated CBID and another one third will have stones in CBD (50%). c. Children with congenital anomalies like agenesis of lung, Tetralogy of Fallot, anomalous extremities, genitourinary, and rarely gastrointestinal anomalies. The complexity of the situation makes this patient incompatible with survival (15-16%). The diagnosis of gall bladder agenesis is probably impossible preoperatively and therefore it is diagnosed intraoperatively. In this video we will present the laparoscopic view of gallbladder agenesis.

V092 - Liver and Biliary Tract Surgery

V094 - Liver and Biliary Tract Surgery

RENDEZ VOUS ENDOSCOPIC TREATMENT FOR ASSOCIATED CHOLELITHIASIS AND CHOLEDOCHOLITHIASIS. DESCRIPTION OF A PERSONAL TECHNIQUE A. Arezzo1, G. Saccomani2, V. Durante2, M.R. Magnolia2 1 Ospedale Evangelico Internazionale, GENOVA, Italy 2 Ospedale Santa Corona, PIETRA LIGURE (SV), Italy

PRIMARY CONTROL OF THE LEFT HEPATIC VESSELS FOR LAPAROSCOPIC LEFT HEPATIC LOBECTOMY D. Mutter, B. Dallemagne, L. Soler, C. Bailey, J. Marescaux IRCAD-EITS / University Louis Pasteur, STRASBOURG, France

Aims: The advent of endoscopic techniques changed surgery in many regards. In the management of cholelithiasis laparoscopic cholecystectomy (LC) is today the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of options exist, including endoscopic sphincterotomy (ES) before LC in patients with suspected common bile duct (CBD) stones, laparoscopic bile duct exploration, open CBD exploration and postoperative ERCP. More recently the alternative technique of per-operative ES is emerging. Methods: We report our experience of routine intra-operative cholangiography followed either by per-operative ERC in one step, or by transcystic drain and post-operative ERC. In our personal technique to facilitate Vater papilla cannulation we inserted a 450 cm transcystic guidewire to be catched by a duodenoscope. Papillotome was then inserted over the guide wire to ensure cannulation of the CBD. Results: Thirty-six patients were treated successfully in one step and 27 in two steps, for a total of 63 rendez vous procedures. Operative time was 168 39 min for patients treated in one step, and 136 41 min for patients treated in two steps. Hospital stay was 6.4 3.4 days for one step procedures, and 8.7 4.0 days for two steps procedures. Eleven out of 36 patients (30%) treated in one step and three out of 27 (9%) treated in two steps had raised serum amylase which resolved spontaneously with no symptoms. No clinical pancreatitis was observed in each group. Four (5.9%) ERCP complications were observed, consisting of mild bleeding of the papilla. All cases were managed by endoscopic adrenaline injection. No mortality was observed. Conclusions: We believe per-operative ERC with the personal technique described should be considered as the treatment of choice for choledocholithiasis associated to cholelithiasis. When single stage treatment is not possible a two step rendez-vous technique should be preferred, although this is associated with a longer hospital stay and a possible risk of unsuccessfull endoscopic bile duct clearing. In our experience clearing of the bile duct was always obtained and no clinical pancreatitis was observed.

Background: Laparoscopy for systematic liver resection has been proposed for several years. This approach remains potentially difficult. It adds a risk of cancer dissemination due to manipulation of the tumour and the difficulty of resection on cirrhotic liver. Furthermore, there are specific risks of haemorrhage that can be difficult to control laparoscopically. Therefore, vascular control using a Pringle manoeuvre is recommended. However, when possible, selective control of the vessels of the segments to be resected is preferred. This may be ideally demonstrated for a left lateral segmentectomy. Materials: A 67 year old patient presented with a 3.5 cm hepato-cellular carcinoma (HCC) located between segment II and III of the liver. Liver transplant was contra-indicated due to previous head and neck cancer surgery. Methods: The patient was placed in supine position. Five ports were used. A loop was placed around the hepatic pedicle. The left hepatic artery was dissected until its division for the segment IV and the left lobe. This latter branch was selectively clipped and divided. The portal vein was isolated and the left and right branches identified. The division between the segment IV branch and the segment II and III divisions were controlled and selectively clipped. This resulted in a typical colour change of the left lateral segment. The bi-segmentectomy was performed using harmonic dissectors (Autosonix, Tyco Healthcare), bipolar cautery and clips. Portal pedicles of the segment II and III and the left hepatic vein were successively dissected and controlled by application of Endo GIA vascular staples (Tyco Healthcare). The specimen was placed in a bag and extracted after enlargement of the camera port.

Follow-up was uneventful and there was no elevation of hepatic enzymes or postoperative ascites. The patient left the hospital on the 5th postoperative day. Conclusion: Vascular control of the left lateral segment arteries and veins is ideal to prevent intra-operative bleeding during laparoscopic hepatectomy and the bloodless dissection also limits the risk of tumour dissemination. Furthermore it avoids a Pringle manoeuvre and the associated risk of postoperative hepatic failure in cirrhotic patients. The use of this approach is recommended where possible.

S279

V095 - Liver and Biliary Tract Surgery

V097 - Liver and Biliary Tract Surgery

LAPAROSCOPIC CHOLECYSTOLITHOTOMY (LCMY) IN A PATIENT WITH CHRONIC DIARRHOEA FOLLOWING RECONSTRUCTIVE PANPROCTOCOLECTOMY S. Mahmud1, B. Darmas2, M. Jameel2, A. Alhamdani1, I. Alam1, N. Rawat1, A. Baker2 1 Morriston Hospital, SWANSEA, United Kingdom 2 Wrexham Maelor Hospital, WREXHAM, United Kingdom

LAPAROSCOPIC RIGHT POSTERIOR SECTIONECTOMY (SEGMENTS 6 & 7) F. Rotellar1, F. Pardo2, V. Valentı´ 2, C. Pastor2, I. Poveda1, P. Marti1, C. Montiel2, J. A-Cienfuegos1 1 University Clinic, PAMPLONA, Spain 2 University Clinic of Navarra, PAMPLONA, Spain

Introduction: Cholecystholithotomy is not a standard treatment for cholelithiasis as invariably more stones will form within the gall bladder. We present technique of laparoscopic cholecystolithiasis in a patient with specific coexisting medical problem. Patient: 64-year old male with a history of pancolitis secondary to ulcerative colitis who underwent panproctocolectomy with formation of the ileo-anal pouch. Following the operation he developed chronic profuse diarrhoea up to 10 times a day. Pouchitis as a cause of his problem was excluded but patient remained symptomatic despite best medical treatment. It was believed that cholecystectomy, in this particular case, could worsen patients diarrhea and quality of life. Symptoms related to gallbladder consisted of attacks of biliary colic and cholecystitis of increasing frequency that up to date were treated conservatively. Method / technique: 3 standard working ports, open Scandinavian technique. Adhesions to anterior abdominal wall were taken down to improve visibility. Thickened distended gall bladder with dense adhesions, which were divided at the fundus only. Gall bladder contents aspirated with Veres needle Ôwhite bileÕ - mucocoele. GB opened at the fundus. Large single 3 cm in diameter stone impacted in the Hartmans pouch. After successful removal of the stone there was a back flow of bile into the GB. Cholecystostomy was closed with interrupted 2.0 vicryl suture on ski needle. Drain, positioned in the subhepatic space at the end of procedure, was removed the following day and patient discharged home. On telephone follow up he was not complaining of any more gallstones related pain and his diarrhoea has not worsened. He waits to have HIDA scan to confirm the function of GB. Conclusion: We believe that in highly selected group of patients there is still an option for laparoscopic removal of gallstones only with gallbladder left insitu. In this video we present short tour of this operation.

Aims: Though still in a developing phase, laparoscopic liver resection has experienced a great advance in recent years. We show in this video a completely laparoscopic resection of segments 6 and 7 (due to a 11 cm adenoma), paying attention to the technical aspects. Methods: The patient is placed in a left lateral position. Four trocars were used, following the subcostal line. After identification of the lesion, we proceed to the mobilization of the right lobe. Ultrasound study helps to define the transection line. Transection is done with use of Ligasure Atlas and endostapler. Finally Tissue-link is used to cauterize securely the transected surface of the liver. Specime was removed through a suprapubic incision. Results: Bleeding was 180 cc and there was no need of transfusion. Hospital stay was 6 days. No complications were registered. Conclusion: Completely laparoscopic liver resection is feasible and safe even in complex resections as can be a right posterior sectionectomy.

V096 - Liver and Biliary Tract Surgery

V098 - Liver and Biliary Tract Surgery

THE IMPACT OF NEW TECHNOLOGIES IN MINIMALLY INVASIVE HEPATIC SURGERY G. Celona Local Health Unit 5 - Pisa, PONTEDERA, Italy

LAPAROSCOPIC CHOLECYSTECTOMY INSTRUMENTS C. Matthijs, H. Martens ASZ, AALST, Belgium

Thanks to the increasing experience and the advancements in technology, laparoscopic surgery of the liver is expanding and is now recognized to be feasible and safe. Though most authors think that the laparoscopic approach should be indicated only for lesions located in the left lobe or in the anterior segments (IVa, V and VI) and limited to minor hepatic resection, laparoscopic major hepatectomies begin to be reported by skilled surgeons. Furthermore, malignancy and cirrhosis do not represent anymore a controindication to laparoscopic hepatic surgery. Failure to control bleeding during laparoscopic hepatic surgery is the main factor of morbidity and one of the most important causes of conversion to the open technique. The present availability of new tools for tissue dissection, closure of blood vessels and biliary ducts, such as ultrasonic scalpels or bipolar vessel-sealing devices, helps to reduce blood loss and biliary leakage after minimally invasive hepatic resection. The UltraCision and, more recently, the Harmonic ACE, both ultrasonically activated instruments, allow safe coagulation of vessels up to 5 mm of diameter with clear view resulting from the absence of smoke and minimal lateral thermal damage. The bipolar vessel sealing device, Ligasure, achieves a satisfactory hemostasis in liver transection, particularly when used in normal hepatic parenchyma. We report three cases, selected from our experience, in which laparoscopic hepatic resection was performed using different technologies: the pericystectomy of an hydatid cyst in the left lobe, the removal of a pedunculate hepatocellular carcinoma in cirrhosis and the resection of segment V for colorectal liver metastasis.

Laparoscopic cholecystectomy is one of the most standardized techniques all over the world. Most of the surgeons using the French technic with conventional four port technic using 2 trocards of 10 mm and 2 trocars of 5 mm. Looking for a way to be less invasive we found performant 2,7mm instruments. Initially they were developed to de laparoscopic pediatric surgery. We developed a technic to use them in adults to do cholecystectomys for cholecystolithiasis without acute cholecystitis. Therefore we slidely changed technic. We use a conventional 10mm trocard in the umbilicus for 0 scope. Then we put three 2.7mm trocards in a triangle position under the right subcostal margin around the target organ. We do classical exposure of Callots triangle and dissect the cystic duct of cystic artery. At that moment we dont clip these structures but do first a retrograde cholecystectomy. The gallbladder is totally free but the artery and cystic duct are not yet clipped. We first change our 0 10mm optical system four a 2.7mm 0 scope. We now put the scope in one of the small trocards and put clips on the artery en cystic duct and cut them through the 10mm umbilical port.

WITH

2.7

MM

Conclusion: By a small change in technic it is save and feasible to do cholecystectomy with 2.7mm instruments. We think that it is an improvement not only for esthetical reasons but also economical, because we believe that with some more experience it must be possible to do this in an outpatient clinic way.

S280

V099 - Liver and Biliary Tract Surgery

V101 - Morbid Obesity

LAPAROSCOPIC CHOLECYSTECTOMY WITH PURE SHARP DISSECTION, WITHOUT USING ANY ENERGY SOURCE B.B. Agarwal, S. Agarwal, M.Kr. Gupta, K.C. Mahajan Sir Ganga Ram Hospital, NEW DELHI, India

LAPAROSCOPIC REVISION OF OPEN VERTICAL BANDED GASTROPLASTY TO ROUX-EN-Y GASTRIC BYPASS I. Raftopoulos, O. Awais, A.P. Courcoulas University of Pittsburgh, PITTSBURGH, United States of America

Aims & Objectives: 1.To do laparoscopic cholecystectomy safely and conveniently. 2. Not to use electrosurgery or any other energy source.

This is a 48 year-old female who underwent an open vertical banded gastroplasty (VBG) with a gastrostomy tube placement 5 years ago. Her body mass index (BMI) and weight prior to the VBG was 45 Kg/m2 and 238 lbs respectively. Although the patient achieved a moderate weight loss of 68 lbs (lowest weight: 170 lbs), she developed severe gastroesophageal reflux disease (GERD) with heartburn, dysphagia, hoarseness and asthma-related symptoms recalcitrant to aggressive medical management with proton pump inhibitors. Diagnostic work-up including upper gastrointestinal series and esophagogastroduodenoscopy (EGD) revealed severe stenosis at the outlet of the pouch, as a result of the Goretex band. Despite multiple endoscopic dilations no significant improvement in her symptoms was achieved. At the time of revision the patients weight was 196.6 lbs with a BMI of 37.2 Kg/m2. Operative time (OT) including a cholecystectomy for symptomatic cholelithiasis was 275 min. Estimated blood loss (EBL) was 100 cc and length of stay (LOS) was 5 days. The patient had an uncomplicated recovery. Our experience includes an additional patient with a preoperative BMI of 35.3 Kg/m2 who underwent successful revision of VBG to LRYGB for recalcitrant GERD with an OT of 390 min and LOS of 3 days. In conclusion, revision of VBG to LRYGB is technically feasible and should be considered in patients with inadequate weight loss, or complications of the original operation, such as GERD and intractable vomiting. Keys for a successful outcome include: 1) complete lysis of all hepatogastric adhesions as close to the liver capsule as possible, 2) identification of the caudate lobe, vena cava and right crus, 3) repair of concomitant hiatal hernia, if present, 4) division of short gastric vessels and mobilization of retroperitoneal gastric attachments and angle His, 5) identification of the synthetic band and previous horizontal staple line and 6) creation of a small gastric pouch proximally to prevent postoperative GERD.

Materials & Methods: 56 consecutive patients undergoing Laparoscopic cholecystectomy for cholelithiasis since December 2005, without any exclusion, including patients having empyema, patients on thromboprophylaxis for cardiac conditions, and patients with CBD Stone needing choledocholithotomy. I perform Laparoscopic cholecystectomy by dissecting the triangle of Calot and the peritoneal apron of the gall bladder by scissors without using any energy source. Gall bladder is separated from the liver bed by teasing it away along the plane of loose areolar tissue. Even in presence of omental and visceral adhesions, I cut them sharply along the avascular plane which is usually identified by a little stretch/traction of the adhesion. Advantages of Not Using Energy Source: Advantages are avoiding the disadvantages of using energy source such as -Avoiding inadvertent recognizable and unrecognizable injury to the biliary ducts, small bowel including duodenum -Minimizing the risk of accidental perforation of the gall bladder -Avoiding the systemic immune response to energy. -Better view -Reduction in operating time -Hence, less morbidity and mortality Results & Conclusion: Laparoscopic Cholecystectomy can be performed without using electrosurgery or any other energy source.

V100 - Morbid Obesity

V102 - Morbid Obesity

LAPAROSCOPIC SLEEVE GASTRECTOMY A SAFE INITIAL BARIATRIC PROCEDURE FOR SUPER-OBESE PATIENTS M. Bueter, A. Thalheimer, J. Maroske, D. Meyer, M. Fein University of Wuerzburg, WUERZBURG, Germany

GASTRECTOMY OF THE BYPASSED STOMACH IN LAPAROSCOPIC ROUX-IN-Y GASTRIC BYPASS A. Escalona, G. Pe´rez, F. Crovari, N. Devaud, S. Guzma´n, L. Iba´n˜ez Pontificia Universidad Cato´lica de Chile, SANTIAGO, Chile

Aim/Introduction: Given the many co-morbidities of super-obese patients, a less invasive first stage operation is advocated for these patients. A safe initial procedure that is applied increasingly is the laparoscopic sleeve gastrectomy. The indication, technique, and results of this procedure are presented in this video.

Introduction: Morbid obesity is a major worldwide health problem and Roux-in-Y Gastric Bypass (RYGBP) an alternative for surgical treatment. Gastric cancer has evolved as an important cause of death due to malignant tumors. The post surgical evolution of the bypassed stomach after a RYGBP has this way become a controversial issue. Laparoscopic gastrectomy of the bypassed stomach during a RYGBP is presented Video: Laparoscopic RYGBP uses 5 ports. To create the Roux limb, the small bowel is divided about 30 cm distal to the Treitz ligament. The enteroenterostomy between the alimentary limb of 150 cm and biliopancreatic limb is performed with a single intraluminal firing of a 45-mm endoscopic linear cutter. The enterotomy is hand sewn with 3-0 Vicryl suture in one layer. The mesenteric defect is closed with a 2-0 silk suture in a running fashion. To create a 15 ml gastric pouch the lesser curvature is first dissected. Stapler is fired around a 34 F tube from the lesser curvature towards the diaphragm left crus. Greater curvature is diseccted using the ultrasonic scalpel from the mid stomach towards duodenum. The lesser curveture is next dissected and the pylorus is identified. Duodenum is finally transected using 45 mm linear stapler. After disecction of the proximal greater curvature the bypassed stomach is now completely free and ready to be extracted. Hand-sewn gastrojejunostomy is performed and a drainage tube is placed next to the duodenal stump. The stomach is removed though a 12 mm port in concluding this way the gastrectomy of the Laparoscopic RYGBP.

Material & Methods: From 12003 until 112005, eight (median BMI: 56 kg/m2, Range: 53 62 kg/m2) had a laparoscopic sleeve gastrectomy. The procedure was selected for patients with a BMI >60 and patients with severe co-morbidities. Results: The laparoscopic sleeve gastrectomy was identical in all patients: After separation of the greater omentum from the lateral stomach and mobilisation of the fundus, the greater curvature of the stomach was removed from the distal antrum to the angle of His. Laparoscopic stapler was used to create a gastric tube over a 48 French bougie. No intra- or postoperative complications were observed. The follow-up examinations demonstrated an excess weight loss of up to 60%. Conclusion: Laparoscopic sleeve gastrectomy is a safe initial bariatric procedure for super-obese patients. The selection of the start of the resection line at the distal antrum and the creation of a small lumen tube are the most important steps of the procedure. Good results in terms of weight loss and quality of life can be achieved. Laparoscopic sleeve resection may be useful as a one-stage restrictive procedure in selected patients or provide a significant risk reduction before a gastric bypass or duodenal switch.

Conclusion: High risk for cancer in the bypassed stomach indicates the gastrectomy during the gastric bypass. Laparoscopic RYGBP of the bypassed stomach is a feasible and safe procedure.

S281

V103 - Morbid Obesity

V105 - Morbid Obesity

ÔUCLA U LOOPÕ GASTRIC BYPASS D.A. DeUgarte, E. Dutson, B. Bertucci, J. Yadegar, A. Mehran, J. Hines, C. Gracia UCLA, LOS ANGELES, United States of America

LAPAROSCOPIC CONVERSION OF THE GASTRIC BYPASS INTO A NORMAL ANATOMY G. Dapri, J. Himpens, A. Mouchart Saint-Pierre University Hospital, BRUSSELS, Belgium We report a laparoscopic conversion of Roux-en-Y gastric bypass (RYGBP) into a normal anatomy, performed by one of the authors (JH).

The current gold standard for the surgical management of morbid obesity is the laparoscopic roux-en-Y Gastric Bypass. In this video, we describe a modification of the technique called the UCLA U Loop, which has the benefit of maintaining visuospatial orientation by keeping all anastomosis in the left epigastrium. The technique offers the potential to reduce steps, facilitate stapling, and avoid anatomical confusion. The surgeon and assistant are positioned ergonomically, and the procedure can be performed expeditiously (routinely less than 90 minutes). No leaks or deaths have been observed in over four hundred cases performed.

In June 2004 a laparoscopic RYGBP was performed in a 46-years woman, sweet eater with a BMI of 46 Kg/m2. After 7 months, the patient reported a significant and invalidating Dumping syndrome, without postprandial hypoglycemia. Hence a laparoscopic RYGBP conversion into a normal anatomy was performed. The BMI was 27 Kg/m2. The sequence of procedure was : 1) standard 5 trocars access, 2) adhesiolysis and identification of the gastrojejunostomy, 3) Petersens space opening, 4) identification of the alimentary loop, the jejunojejunostomy and the biliopancreatic loop, 5) deconstruction of the jejunojejunostomy, 6) deconstruction of the gastrojejunostomy, 7) preparation of the new proximal stomach and distal stomach, 8) reconstruction of the new end-to-side gastrogastrotomy by entirely handsewn method, 9) reconstruction of the new end-to-end jejunojejunostomy by entirely handsewn method, 10) closure of the new mesenteric defect, 11) leak-test of both anastomosis and position of a perigastric anastomosis drain. Operative time was 95 minutes and intraoperative blood loss was 150 ml. Patient had an uneventful recovery and was discharged home on the 5th postoperative day. At 6 months follow-up, the BMI was 27 Kg/ m2 and a barium swallow showed a good passage with a good gastric motility. After 1 year the BMI was still unchanged and the patient was doing well. RYGBP is no longer a non-reversible procedure, but the restoration of normal anatomy is technically feasible and sure. Its safety by laparoscopy is highly dependent on surgeon experience and specific training.

V104 - Morbid Obesity

V106 - Morbid Obesity

SCAR RING AFTER LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING

LAPAROSCOPIC DUODENAL SWITCH TECHNIQUE AFTER AN EXPERIENCE OF MORE THAN 400 CASES G. Dapri, J. Himpens, G.B. Cadie`re Saint-Pierre University Hospital, BRUSSELS, Belgium

CANCELLED

The aim of this video is to show our different techniques to perform a laparoscopic duodenal switch after an experience of more than 400 cases. The movie shows: 1)FIRST STEP: sleeve gastrectomy starts with the scored of the antrum at 6 cm from the pylorus, then the greater curvature is isolated until the left crus is reached. The sleeve is realized by multiple firings of linear stapler. Another technique is to perform before the gastric transsection by multiple applications of linear stapler and subsequently to separate the greater curvature from the greater omentum. The first duodenum can be sectioned by a firing of linear stapler, after its isolation from an anterior or posterior approach. The cholecystectomy and appendectomy always complete the procedure. 2)SECOND STEP: from the ileo-caecal valve, 75 to 100 cm of bowel is measured and scored at this level (common loop). An additional 175 or 150 cm is then measured (alimentary loop). The ileoileostomy can be performed by four different techniques: 1) entirely handsewn end-toside 2) entirely handsewn side-to-side, 3) entirely mechanical side-toside, 4) semi-mechanical side-to-side. No matter what type of ileoileostomy, the mesenteric defect is closed by a purse-string stitch. The alimentary limb is lifted cephalad. The duodenoileostomy can be realized by an entirely handsewn end-to-end or end-to-side method. No matter what type of duodenoileostomy, the Petersens space is closed by a purse-string stitch. The procedure ends with a leak-test of both anastomosis. Two drains are placed, in the vicinity of the sleeve gastrectomy and the duodenoileostomy; the trocar sites are closed in layers.

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V107 - Morbid Obesity

V109 - Morbid Obesity

A NEW DEVICE TO FACILITATE A TOTALLY INTRAABDOMINAL STAPLED GASTROJEJUNOSTOMY IN LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS M. Morino, M. Toppino, C. Garrone, G. Bonnet, G. Scozzari Ospedale Molinette, TORINO, Italy

CLOSURE OF PETERSENS DEFECT AFTER ANTECOLIC GASTROINTESTINAL ANASTOMOSIS FOR ROUX-EN-Y GASTRIC BYPASS: ANATOMIC LANDMARKS AND TECHNICAL TIPS F. Rubino, M. Vix, M. Simone, S. Sereno, A. Alzahrani, C. Bailey, J. Marescaux IRCAD/EITS University Louis Pasteur, STRASBOURG, France

The gastro-jejunal-anastomosis is a critical step in laparoscopic Rouxen-Y Gastric Bypass (RYGBP). When using a circular stapler, most reports describe the passage of the anvil transorally, with risks of oesophageal injury or bacterial contamination. The new device (Microfrance, Paris, France) facilitates the introduction of the anvil into the pouch by intraperitoneal technique. The instrument appears as an arrow, with a retractable end and a lateral notch in order to grasp a wire. The procedure begins with the performance of the lower part of the pouch with a linear cutter stapler. A small gastrotomy in the anterior gastric wall of the fundus is then carried out. The device penetrates the lower part of the pouch; once into the lumen, the pointed end is retracted and the instrument is driven through the stomach, until coming out through the gastrotomy. A wire connected to the pin of the anvil, which was previously percutaneously introduced in the abdomen, is then fastened to the notch of the device. Retraction of the device allows the anvil to penetrate into the stomach through the gastrotomy, being finally positioned with the pin through the lower end of the pouch. The gastrotomy is then closed by a linear cutter stapler and the upper part of the pouch is completed. The video shows the procedure, which we adopted in the last 15 cases without complications. In our opinion, this device allows to perform safely the gastro-jejunal anastomosis, avoiding the transoral anvil placement and its potentially dangerous consequences.

Background: Internal hernias are increasingly been reported after laparoscopic bariatric procedures. Although internal hernias are more common after retrocolic laparoscopic Roux-en-Y gastric bypass (RYGB), a fair incidence of internal hernias has also been described with the antecolic position of the Roux (alimentary) limb at the Petersen defect, located between the mesentery of the jejunal limb brought up to the gastric pouch and the transverse mesocolon. Accurate closure of the Petersen defect can be technically challenging. In fact, the anatomy of this defect is not intuitive, the space is difficult to expose, and intracorporeal suturing at this site is technically challenging due to the spatial orientation of the defect. Methods: The aim of our video presentation is to illustrate the anatomy of the Petersen defect, describe the technical steps of its closure and emphasize aspects of local anatomy that may lead to inaccurate closure of the defect. Results: Positioning the biliary limb to the left side of the abdomen and the Roux limb on the right, greatly facilitates the closure of the Petersen defect. The area is then best exposed by upward retraction of the transverse colon and retraction of the Roux limb toward the left. The video shows a running purse-string-like suture closed by using a knot-pushing device. A common mistake is to suture the jejunal mesentery against interposed epiploic appendages rather than directly against the transverse mesocolon. This indeed would leave the posterior part of the Petersen defect widely open and prone to herniation. This video also emphasizes the inclusion of the tenia coli in the running suture; in addition to strengthening the repair, this maneuver also ensures completeness of closure at the upper part of the Petersen defect. Conclusions: Prophylactic closure of Petersens defect during laparoscopic RYGB is advisable to reduce the risk of internal hernia. With proper knowledge of anatomic landmarks and appropriate technique of exposure this step of the procedure can be easily accomplished.

V108 - Morbid Obesity

V110 - Morbid Obesity

LAPAROSCOPIC INTRAGASTRIC REMOVAL OF A MIGRATED LAP-BAND DEVICE M. Vix, L. Mendoza-Burgos, F. Rubino, S. Sereno, D. Mutter, J. Marescaux IRCAD-EITS / University Louis Pasteur, STRASBOURG, France

LAPAROSCOPIC RECONVERSION OF A OPEN VERTICAL BANDED GASTROPLASTY TO GASTRIC BY-PASS J. Vazquez Echarri, M. Salvador, J. Martin Ramiro, J. Escudero, J. Romeo Martinez, J. Martin Benito, G. Chamoso, J.L. Martinez Veiga Severo Ochoa, MADRID, Spain

Aims: Intragastric migration is a well-described complication after band placement which may lead to further complications including sepsis. Removal of the band may be done by endoscopy in cases of complete migration or by laparoscopy in cases of partial migration. In some cases of partial migration, a combined procedure using endoscopy and laparoscopy may also be appropriate to remove the band. Methods: We present the case of a patient presenting with a 2/3 band migration into the stomach. A pure endoscopic approach was considered not to be appropriate since the band was not completely within the stomach. We started by a laparoscopic approach. However we could not see the band due to adhesions and inflammation, therefore we decided to perform an intra-gastric approach. Three trocars were introduced into the gastric cavity percutaneously under laparoscopic control. The insufflated gastric cavity provided ample space to work. Next, we divided the band, secured it to the nasogastric tube and extracted it orally. Gastric port sites were sutured, however the hole resulting from the migration of the band did not require closure as local adhesions appeared sufficient to prevent leakage. The postoperative course was uneventful. Discussion: The laparoscopic intra-gastric approach is a novel way to remove a partially migrated lap band device, and laparoscopic tools appear appropriate for this manoeuvre. This demonstrates the feasibility of removal using this combined approach and shows that the resulting defect can close spontaneously. It is a safe procedure avoiding the risk of dissection of the cardia in septic conditions and allows an easier secondary procedure such as a by-pass for these obese patients.

Obesity is a chronic and stigmatizing disease that has become a major health problem in most industrialized countries because of its high prevalence. During these years the ideal operation has change from purely restrictive operations (i.e., gastroplasty and gastric banding) to combined gastric restrictive and malabsorptive procedures like gastric bypass. In addition, long-term evaluations of the procedures suggest better results with the combined procedure. The high rate of weight regain with the restrictive operations is the cause of reinterventions. Case: A 36-year-old woman with morbid obesity and a body mass index of 55 kg/m2. was operated 15 years ago, performing a vertical banded gastroplasty (VBG) through a median laparotomy. Initially the evolution was satisfactory with weight loss and a body mass index of 32 kg/m2 two years after de procedure, although she experienced difficulties when eating and vomits. Six years later ameliorated her digestive tolerance and began to regain weight, with a body mass index of 43 kg/m2, and she presented obesity-related comorbidity that indicated the reintervention. The operation was performed via laparoscopy. After adhesiolysis a gastric bypass was performed. The jejunum was transected with an Endo GIA II stapler (U.S. Surgical), at approximately 50 cm from the ligament of Treitz, The Roux limb was then measured 200 cm distally, and a jejunojejunal anastomosis was created. The Endo GIA stapler (U.S. Surgical), was inserted and applied three or four times to staple and cut the gastric pouch proximal to the ring of neopilorus of the previous intervention. The Roux limb was then passed in a antecolic fashion to lie next to the gastric pouch The gastrojejunostomy was then created using a circular end-to-end anastomosis (EEA) stapled technique The anvil was passed through the esophagus into the pouch stem first, and the stem was passed out a small gastrotomy created with electrocautery. The postoperative evolution was favourable, and one year later the a body mass index is 28 kg/m2.

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V111 - Morbid Obesity

V113 - Oesophageal and Oesophagogastric Junction Disorders

LAPAROSCOPIC COMBINED ADJUSTABLE GASTRIC BANDING AND LIVER RESECTION IN MORBIDLY OBESE PATIENT G. Bonanomi, L. Maruzzelli ISMETT / UPMC, PALERMO, Italy

LAPAROSCOPIC NISSEN FUNDOPLICATION WITH RESECTION OF AN INTRAOPERATIVELY DIAGNOSED EPIPHRENIC DIVERTICULUM M. Bueter, A. Thalheimer, D. Meyer, M. Fein University of Wuerzburg, WUERZBURG, Germany

Introduction: Morbid obesity may be associated with irregular menses, infertility, polycystic ovarian syndrome [PCOS], liver steatosis and focal nodular hyperplasia [FNH]. Laparoscopic adjustable gastric banding is a recognized treatment for morbid obesity. Atypical liver neoplasms should be differentiated from FNH because of potential degeneration. Methods: A 34-year old morbidly obese female [BMI= 40 kg/m2] with a history of irregular menses, PCOS and birth control pill therapy presented for consultation for bariatric surgery. Preoperative ultrasound showed the presence of a 4 cm hypoechogenic neoplasm of the III liver segment. The neoplasm had atypical features on MRI study and was suspicious for hepatic adenoma. Preoperative fine needle biopsy was not diagnostic. Results: A laparoscopic combined gastric banding and liver wedge resection was performed. The adjustable gastric banding was placed first using 5 trocars and a standard pars flacida technique. The wedge resection of hepatic segment III including the neoplasm was carried out using ultrasonic dissection, argon plasma coagulation and fibrin glue sealing. Postoperative course was uneventful and the patient was discharged home on POD 4.

Aim/Introduction: Laparoscopic Nissen fundoplication (360 degrees) with posterior closure of the hiatus is the standard operation for the surgical management of gastroesophageal reflux disease (GERD) in our clinic. Methods: Since 1991 more than 750 patients suffering from GERD received a laparoscopic Nissen fundoplication in our department. In this Video we demonstrate our preferred technique of this procedure. Overthat we show the resection of a preoperatively unknown epiphrenic diverticulum not diagnosed until surgery. Results: Critical elements of the technique are demonstrated including a thorough dissection of the esophageal hiatus and mobilization of the gastroesophageal junction so that at least 3 cm of distal esophagus is below the diaphragm without tension. Short gastric vessels are divided from a point midway along the greater curvature of the stomach all the way to the angle of His. If enlarged the hiatal defect is closed with one or two posterior crural sutures. To avoid postoperative dysphagia the 360-degree wrap is performed over a 56 charrier bougie. As special feature the identification and resection of a preoperative unknown epiphrenic diverticulum is demonstrated, too.

Conclusion: Morbid obesity and atypical liver neoplasms can be successfully treated with a laparoscopic combined approach. Resection allows for definitive diagnosis although care should be taken to avoid damage and infection to the intracorporeal prosthesis.

Conclusion: Low rates of postoperative dysphagia and recurrence of reflux symptoms are possible using the demonstrated technique of laparoscopic Nissen fundoplication. Parallel resection of an epiphrenic diverticulum can be combined with laparoscopic Nissen fundoplication without any problems.

V112 - Morbid Obesity

V114 - Oesophageal and Oesophagogastric Junction Disorders

LAPAROSCOPIC BAND FOR MORBID OBESITY M.K. Hussein American University of Beirut, BEIRUT, Lebanon Laparoscopic band for Morbid Obesity done in 20 minutes as an Outpatient procedure.

LAPAROSCOPIC REPAIR OF A DISTAL ESOPHAGEAL PERFORATION FOLLOWING PNEUMATIC DILATATION FOR ACHALASIA K.E. Roberts, J.I. Kaufman, A.J. Duffy, R.L. Bell Yale University School of Medicine, NEW HAVEN, United States of America

Total 424 patients with Morbid Obesity, BMI range (34-105) underwent Laparoscopic Gastric Band placement over a period of 7yrs (1999-2006). Age range 13-71yrs, Male to Female ratio 1:2.3. The procedure was accomplished with minimal dissection using the paraflaccida technique and via four trocars only. With the refinement in technique the procedure can be performed in 20 minutes. The video will demonstrate the essential steps that save time and accomplish the goal with the least dissection. All procedures were completed Laparoscopically except for 2 patients earlier on the learning curve (among first 20 cases). The Morbidity rate 7.5% including migration, sleepage, pouch dilation and infection. All were corrected laparoscopically. One patient died from massive pulmonary embolism. Mean excess weight loss of 2 years is 73%. Therefore, Laparoscopic Gastric Band is effective, safe, with excellent weight loss, low morbidity, low mortality, minimal discomfort and early return to normal activities.

Esophageal perforation following pneumatic dilatation for achalasia occurs approximately in 2-5% of patients. Open left thoracotomy or thoracoscopic treatment has usually been performed in the emergent setting and open transabdominal repair has been used with distal esophageal perforations. Although laparoscopic repair has emerged as the standard of care for the elective treatment of achalasia recent literature reports only a few cases of a laparoscopic approach in the emergent treatment. We now present a video of a successful laparoscopic repair of an esophageal perforation following pneumatic dilation. This laparoscopic technique shows in detail the primary closure of the perforation as well as a longitudinal myotomy and a partial fundoplication. The patient is a 77yo M who underwent his first pneumatic dilatation for progressive achalasia. Post procedural severe back pain associated with subcutaneous crepitus was noted. An upper gastrointestinal series showed a perforation of the distal esophagus with extravasation into the mediastinum. Within 3 hours of the perforating event the patient was brought to the operating room. Positioned in lithotomy position and after adequate pneumoperitoneum was established, a right sided approach thru the lesser omentum was chosen. The right crus was easily identified and great care was taken not to injure the anterior or the posterior vagus during dissection of the esophagus. After complete mobilization of the distal esophagus an approximately 12mm perforation was encountered on the lateral aspect of the esophagus about 6cm proximal to the GE-junction. Primary repair with 2-0 polysorb sutures in an interrupted fashion using an intracorporal suturing technique was undertaken. Then, on the contralateral site just below the perforation, a longitudinal myotomy was performed and extended distally to 1.5cm onto the stomach. Endoscopic inspection and air-insufflation proved our repair and myotomy to be intact. Subsequently a Dor-fundoplication was performed. A postoperative upper gastrointestinal series showed no signs of a leak. The patient was discharged tolerating a regular diet with no signs of dysphagia or reflux. Our video presentation shows clearly that the transabdominal laparoscopic repair of a distal esophageal perforation is a safe procedure in the hands of an experienced laparoscopic surgeon and therefore should be recommended as the preferable treatment for emergent distal esophageal repair.

S284

V115 - Oesophageal and Oesophagogastric Junction Disorders

V117 - Oesophageal and Oesophagogastric Junction Disorders

LAPAROSCOPIC REPAIR OF TYPE IV PARAESOPHAGEAL HERNIA M. St. Jean, S. Dunkle-Blatter, A.T. Petrick Geisinger Medical Center, DANVILLE, United States of America

LAPAROSCOPIC DIAPHRAGMATIC HERNIA REPAIR USING CRURASOFT MESH. M. Santamarı´ a1, F.J. Iban˜ez1, E. Bollo1, D. Castillo1, F.J. Frı´ as1, A. Colina2 1 Hospital de Zumarraga, ZUMARRAGA, Spain 2 Hospital de Basurto, BILBAO, Spain

The enclosed video depicts the technical aspects and the method of laparoascopic repair of Type IV paraesophageal hernia utilitized at our institution. The case involves a 58 year-old mentally disabled gentleman with large hiatal hernia known by UGI. Endoscopy revealed normal mucosa, and diaphragmatic impingement on the gastric wall could not be visualized. The patient experienced recurrent aspirations c/b pneumonia and early satiety. Trocar placement for UGI lap cases at our institution is standard four 5mm and one 12 mm port. Right subcostal and paramedian ports as primary surgical sites; left paramedian and subcostal ports as assistant sites. Upon exploration, the mediastinum was found to contain splenic flexure, pancreas, majority of stomach and spleen. The pars flaccida was divided to the level of the right crus. A small accessory spleen was identifed and removed. Hernia sac incised at the level of the cura for 180 degrees. Tedious dissection of hernia sac from mediastinum with care not to violate the endothoracic fascia and pleura. Spleen and pancreas mobilized into abdomen. Short gastric vessels and posterior gastric attachments divided to fully mobilize fundus. Special attention is attributed to this portion of the dissection to avoid injury to the displaced posterior vagus nerve. Free mobilization of the pancreatic tail, spleen and splenic flexure was achieved. Significant fibrosis of the stomach to the mediastinal structures, including bronchus and aorta, is depicted. Sleeve gastrectomy over 60 Fr bougie with linear stapler 4.8mm loads created neo-esophagus rather than use of the severely fibrotic portion of herniated stomach. A floppy 2 cm 360-degree Collis-Nissen fundoplication inside the anterior and posterior vagus, both of which were dissected off the stomach and preserved. The wrap was created using 2-0 Surgidac sutures. Hiatal repair was initiated. However, despite mobilization of adhesions, the hiatus remained widely patulous. The hiatal defect was closed with two sheets of SurgiSis mesh, which were secured to the crura circumferentially with 2-0 Surgidac sutures and reinforced along the left hemidiaphragm with a surgical tacking device. Recently, when possible, we have performed primary closure of the crura with onlay Crurasoft mesh and remnant hernia sac interposition for large hiatal defects.

We report the case of a patient who was diagnosed preoperatively of gastric volvulus and paraesophageal hernia. He was operated on by laparoscopic approach and we found a posterior diaphragmatic hernia, next to the left pillar. We reducted the gastric volvulus and repaired the diaphragmatic defect using a Crurasoft mesh. The operation was completed with a Nissen funduplication.

V116 - Oesophageal and Oesophagogastric Junction Disorders

V118 - Oesophageal and Oesophagogastric Junction Disorders

TECHNICAL DETAILS OF LAPAROSCOPIC COLLIS-NISSEN OPERATION M. Santamarı´ a1, F.J. Iban˜ez1, F. Aranda1, A. Martin1, I. Roa1, A. Colina2 1 Hospital de Zumarraga, ZUMARRAGA, Spain 2 Hospital de Basurto, BILBAO, Spain

OUR RESULTS OF LAPAROSCOPIC HELLER MYOTOMYDOR OPERATIONS IN PATIENTS WITH ACHALASIA A. Karatas1, M. Paksoy2, M. Ertem2, V. O¨zben2 1 University of Istanbul, ISTANBUL, Turkey 2 Cerrahpasa Medical Faculty, ISTANBUL, Turkey

Laparoscopic Collis-Nissen operation is the treatment of choice for shortened esophagus, which can be associated to Barretts disease or paraesophageal hernia. This technique allows us to get a longer intraabdominal esophagus in order to perform an adecuate funduplication. Our video shows step by step the technical details of this operation.

Aim: Achalasia is a disease characterised by the inadequate relaxation of the lower oesephageal sphincter and the absence of the oesephageal peristalsism. Botulinum toxin application, endoscopic dilatation and surgical myotomy are the choices of treatment. Recently, laparoscopic Heller mytomy-Dor has been the first treatment of choice in most of the centers. Methods: We performed lap. Heller Mytomy-Dor operation to 12 patients with achalasia between the dates of January 2003 and January 2006.Baloon dilatation had already been applied to 8 patients. Barrium graphy, endoscopy and manometric studies were performed to all patients in the preoperative period. 5 trochars were used during the surgery. Myotomy was done 6-8 cms on the oesophageal side and 1-1.5 cms on the stomach side. The control of any perforation was determined with the introducton of 50-60 cc methylene blue dye to the oesophagus. This technique also provided the displacement of the unopened circular musle. Nasogastric tube was placed to all patients and taken away on the 24st hour. Oral regimen was started on the 48th hour. Results: 7 patients were male (58.3%) and 5 were female (41.7%). The mean age of the patients was 40.8 (18-68). The mean operative period was 75 minutes (60-95). All the operations were completed laparoscopically. One patient developed pneumothorax without any need for drainage. The mean hospital stay perio was 3.3 days (3-5). In the first postoperative month, soft food intake was encouraged. The patients were seen in the 1st, 6th and 12th postoperative month. Symptom scoring was performed fort he follow-up. Balloon dilatation was done to one patient who had recurrent dysphagia. Conclusion: The treatment methods fort he benign disorders should not bring any additional discomforts to the patients. Laparoscopic Heller mytomy-Dor for the treatment of achalasia should be the choice of surgical method to decrease dysphagia complaints, perforation risk and reflux symptoms. Laparoscopic experience has good effects on the outcomes.

S285

V119 - Oesophageal and Oesophagogastric Junction Disorders

V121 - Oesophageal and Oesophagogastric Junction Disorders

THE USE OF THE GEOMETRY TECHNIQUE FOR A TAILORED 360 FUNDOPLICATION P.R. Reardon, P.B. Lal, S.S. Mehta, J.C. Long, R. Davis, G. Davis

LAPAROSCOPIC CARDIOMYOTOMY FOR ACHALASIA M.K. Hussein American University of Beirut, BEIRUT, Lebanon

The Methodist Hospital, HOUSTON, United States of America We present our technique for performing a 360 fundoplication which uses a formula for predicting the esophageal circumference if a 60 Fr. Bougie had been placed. It allows us to accurately custom tailor the looseness or tightness of the fundoplication based on the patients height, weight, and age. This allows us to safely, accurately, and reproducibly perform the fundoplication without a bougie.

Suction irrigation technique and ultracision facilitates the dissection in case of Laparoscopic Cardiomyotomy for the treatment of Achalasia. Thirty cases of achalasia were done at the American University of Beirut Medical Center over a period of 5 years between 2000-2005. The myotomy was carried out using the ultracision 10mm and the suction irrigation technique. The planes were dissected safely with no incidence of mucosa injuries in all 30 cases. There was no incidence of bleeding. All cases were completed laparoscopically where a posterior anti reflux procedure was added. All patients did very well and were discharged home within 24hrs of procedure. Long follow-up revealed excellent results except for one patient who had stenosis one year postoperatively and was treated successfully by balloon dilatation. The video will detail the technical aspects of the procedure.

V120 - Oesophageal and Oesophagogastric Junction Disorders

V122 - Oesophageal Malignancies

BOERHAAVES SYNDROME: LAPAROSCOPIC MENT K. Singh, P.M. Wilkerson, I. Rybinkina Worthing Hospital, WORTHING, United Kingdom

MANAGE-

THORACOLAPAROSCOPIC ESOPHAGECTOMY FOR CARINOMA ESOPHAGUS MIDDLE THIRD C. Palanivelu, R. Parthsarathy, P. Anandprakash Gem Hospital, COIMBATORE, India

Aims: We present the case of a fit 64-year-old male with Boerhaaves syndrome, managed totally laparoscopically, with a successful outcome.

Minimally invasive esophagectomy had the potential to lower the morbidity of open operation and allow quicker return to normal function. The video describes the thoracoscopic esophagectomy in prone position approach. Thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy is done with the patient in prone position. The initial assessment is done and the azygos vein is dissected, ligated and divided. The esophagus is encircled with umbilical tape for retraction and esophagus is dissected from the chest wall. The lymph nodal clearance is completed along with the mobilization, which extends from the thoracic inlet to the esophageal hiatus. An ICD is inserted and ports are closed after removing trocars. The patient is turned to supine position and the mobilization of the stomach is done in the routine method using 5 ports. The esophagus is exposed by left cervical skin crease incision and transected 2-3 cm distal to UES. A nasogastric tube is sutured to cut end of the esophagus and whole specimen is advanced into the peritoneal cavity. The stomach and esophagus-NG tube assembly is exteriorized via a minilaparotomy made over the antrum, incorporating camera port and the esophagus is divided with adequate clearance with endostapler. A wide gastric-conduit (5-6 cm diameter) is fashioned and NG tube is sutured with gastric conduit and it is returned to abdomen. Pneumoperitoneum is recreated and gastric conduit is positioned into the mediastinum under laparoscopic guidance. Gastric tube is brought to neck wound and esophago-gastric anastomosis is fashioned in side-toside or end-to-end manner. The complete video is presented followed by the discussion of the results. We feel that thoracoscopic mobilization of the esophagus in prone position is ergonomically better technique compared with that of in left lateral position. TLE has the potential to change the practice of transthoracic esophagectomy, though this procedure is technically demanding.

Case History: The patient presented 12 hours after a sudden onset of difficulty in breathing, vomiting and chest pain 3 hours post-prandially. He had a left pleural effusion. A contrast swallow within 6 hours of admission demonstrated a distal oesophageal perforation. He was taken to theatre 12 hours post-admission and an intercostal drain was inserted, draining 2 litres of foul-smelling dark liquid. Endoscopic evaluation determined the level of the perforation, in the left anterolateral position just above the oesophago-gastric junction. A laparoscopic trans-hiatal dissection was performed and the perforation repaired with absorbable sutures. Drains were placed in the left subphrenic and sub-hepatic spaces, and trans-hiatally. A draining gastrostomy and feeding jejunostomy were sited. A nasogastric tube was inserted with extra fenestrations. His post-operative recovery was complicated only by a left empyema following removal of the intercostals drain. This was evacuated through the drain site, and the patient was never systemically unwell. A contrast swallow on day 7 demonstrated no leak, and oral diet was commenced and progressed successfully. The patient was mobile and ready for discharge by the second post-operative week, and at 6 week follow-up is recovering well. Conclusion: Laparoscopic management of distal oesophageal perforations is safe and feasible if the site of perforation is distal enough and the diagnosis is made promptly to allow timely intervention.

S286

V123 - Oesophageal Malignancies

V125 - Oesophageal Malignancies

LAPAROSCOPIC TRANSHIATAL ESOPHAGECTOMY S. Puntambekar, A. Gurjar, R.M. Sathe, R.J. Palep, A Patil GALAXY Laparoscopy Institute, PUNE, India

TOTALLY ENDOSCOPIC ESOPHAGECTOMY R. Corcelles, S. Delgado, D. Momblan, R. Bravo, A, Ibarzabal, C. Ginesta, R. Cosa, A.M. Lacy Hospital Clinic, BARCELONA, Spain

Objective: The aim of this study was to retrospectively evaluate, in a series of 60 consecutive patients, the technique, feasibility and benefits of laparoscopic transhiatal esophagectomy for lower third esophagus. Methods: Since August 2003, we have performed laparoscopic transhiatal esophagectomy in 60 patients of carcinoma of the lower third of the esophagus. Average age was 63.3 years (17 to 80). All patients had squamous carcinoma. 28 patients were male and 32 patients were female. Results: The average operative time was 240 min (range 195 to 300 min). The mean blood loss was 468 ml. (range 100ml to 1000ml). No cases were converted to open. Intraoperative complications occurred in 6 patients (10%). There was no intraoperative mortality. Total mortality was 13.33%. The median postoperative hospital stay was 8 days (range 6 to 13). The median follow-up was 15 months. Conclusions: Our results show that laparoscopic transhiatal esophagectomy can be done performed safely with acceptable morbidity and mortality.

Introduction: Esophagectomy is associated with surgical risks and high perioperative morbidity and mortality rates. Furthermore patients hospital stay is prolonged because of complications due to conventional open approach like wound infections, pneumonia and postoperative pain. These complications make conventional procedure unsuitable for high-risk patients and those with advanced disease that could benefit with laparoscopic techniques. Case: A 54 years old male with a middle third esophagus carcinoma (T2N1) and prior neoadjuvant treatment with radio-chemotheraphy.Complementary exams excluded extended disease. Technique: The procedure is performed in three different stages. In the first one the patient is placed in a left lateral decubitus position. Four trocars are introduced in the right chest for a thoracoscopic esophageal mobilization. The azygos vein is identified and divided with an EndoGIA stapler. Then the esophagus is mobilized from the hiatus up to the thoracic inlet. Lymphadenectomy is performed en bloc with the dissection of the thoracic esophagus. A chest tube is placed at the end of this part for a postoperative drainage. The second part of the operation is done in a supine position with 5 abdominal trocars. The greater curvature of the stomach is mobilized, with preservation of the right gastroepiploic vessels. Then the left gastric vessels are sectioned with EndoGIA stapler. Lymph nodes are ressected with the surgical specimen. A gastric conduit is created dividing the stomach on the lesser curvature until the angle of His. Then the gastric conduit is sutured to the surgical spicemen. Finally, the third step of this intervention is the cervical stage in which a neck incision is performed to communicate the cervical esophagus with the dissection plane previously achieved in the thoracoscopyc stage. The esophageal specimen with the gastric conduit are mobilized though the cervical incision. An esophagogastric L-L anastomosis is created by EndoGIA devices. Conclusions: Total endoscopic esophagectomy is a new technique which incorporates the laparoscopic approach for gastric mobilization and thoracoscopy for the assesment of the intrathoracic esophagus dissection. Our initial experience has been satisfactory with a low rate of perioperative complications and short hospital stay being this technique an option for patients with middle or lower third esophagus cancer.

V124 - Oesophageal Malignancies

V126 - Oesophageal Malignancies

RESECTION OF OESOPHAGUS IN THE CHEST USING A PRONE THORACOSCOPIC APPROACH (NEW TECHNIQUE) H. Ali, S. Biswas, N. Thairu, A. Taylor Kent Oncology Centre, MAIDSTONE, United Kingdom

MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL CANCER C. Staudacher, P. Baccari, T. Casiraghi, G. Bissolotti, M. Carlucci, P. Bisagni San Raffaele Scientific Institute, MILAN, Italy

Total Laparoscopic oesophagectomy is on the increase. Reservations remain about the extent of lymphadenectomy and the extent of radical resection, particularly during the chest phase. The main problem is access to the subcarinal paratracheal and thoracic duct lymph nodes. The three positions for the thoracoscopic phase are supine, right lateral and prone. The prone position was the most superior for the following reasons. The liver falls away reducing the dome of the diaphragm and increasing the space within the thorax, the lung falls away exposing the carina and the paratracheal lymph nodes, the heart falls anteriorly giving a clear view of the aorta and the aorta oesophageal recess, exposing the thoracic duct. This is a video of the thoracoscopic phase in a two phase oesophagectomy and includes lymphadenectomy as well as excision of the thoracic duct. The video demonstrates the planes and the techniques necessary for complete excision. The technique has been tested in 10 patients with reproducibility so far. We anticipate that the number done will exceed 20 by september 2006.

Objectives: We show a videoclip describing our approach to laparoscopic and thoracoscopic esophagectomy and we present our results after an initial experience with minimally invasive esophagectomy (MIE). Background: Esophagectomy for cancer with open technique has high rate of morbidity and mortality. Advances in minimally invasive surgical technology and the growing experience in major laparoscopic procedures have allowed surgeons to apply this technique with perioperative outcome advantages and less pulmonary morbidity. Methods: From 2002 to 2005, 27 patients underwent MIE for cancer, 13 for adenocarcinomas and 14 for squamous cell cancer. The operation was a transhiatal laparoscopic esophagectomy in 6 case. In 20 cases the procedure was laparoscopy associated to right toracoscopy. In one case the right thoracoscopic was associated to laparotomy for transverse colon mobilization and coloplasty. In all the patient anastomosis was created in the neck through a left cervicotomy. Results: There were 24 men and 3 women. The median age was 64 years (range 44-80). Mortality rate was 3.7 %. Respiratory complications were 14.8 %. Anastomotic fistulas were 18.5 %, all managed conservatively. Median length of procedures was 390 min (260-630). Median blood loss 200 ml (0-5200). Conversion rate was 7.4 %. Overall median stay in Intensive Care Unit (ICU) was 1 day (0-16). Overall median hospital stay was 20 days (10-64). Histopathology showed that the final staging of the tumour was: 22.2% Stage I, 14.8% IIA, 18.5% IIB, 37.1% III, 7.4% IV. The mean number of harvested lymph nodes was 20.5. No patient had proximal or distal positive margin of the specimen, in 3/27 patients the radial margin was microscopically positive. Conclusions: MIE seems a procedure feasible and safe if performed by surgeons with extensive experience in major laparoscopic operations. Oncologic results seem at present adequate in terms of margin of resections and lymphadenectomy, but need to be evaluated in the long-term in large groups of patients.

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V127 - Pancreas

V129 - Pancreas

LAPAROSCOPIC PYLORUS PRESERVING PANCREATICODUDENAL RESECTION FOR PERIAMPULLARY MALIGNANCIES - A VIDEO PRESENTATION C. Palanivelu, S. Rajapandian, M. Kumaar Gem Hospital, COIMBATORE, India

LAPAROSCOPIC DISTAL PANCREATECTOMY S. Puntambekar, R.M. Sathe, R.J. Palep GALAXY Laparoscopy Institute, PUNE, India

In this fast growing laparoscopic era more and more complex and challenging surgeries have been performed by laparoscopic method. The aim of this article is to emphasis the technical feasibility and safety of laparoscopic pylorus preserving pancreaticodudenal resections. Patient is positioned in the semilithotomy reverse Trendelenburg position with both legs abducted and with a left lateral tilt. The surgeon stands between the legs of the patient to gain access for suturing and assistants stand on either side. After creation of pnuemopertionuem with Veress needle technique and placement of the first port in the umbilical area others are inserted under video guidance. The position of ports are shown in the video. The initial assessment, staging and resectability of the lesion are performed with lap ultrasound. After kocherisation, right gastroepiploic vein and artery are clipped, divided and the first part of duodenum is divided using endo GIA stapler, 1-2 cm distal to the pylorus. The peritoneum covering the CBD is opened dissected free from the portal vein and common hepatic artery. The CBD is divided 2 cm above the pancreatic border. The gastro duodenal artery is identified and divided. Jejunum distal to the duodenojejunal flexure is divided using endo linear cutter and the divided end is displaced to supra colic compartment. Neck of pancreas is divided using harmonic scalpel. All the lymphofatty tissue including the lymph nodes are dissected out from the IVC, common hapatic artery (CHA), aorta, portal vein skeletonising the structure individually upto portahepatis and are placed into an endobag which is removed through the extended umbilical port site. This also facilitates the gastro intestinal continuity by extracorporeal approach. The edges of the duodenum are trimmed and end to side gastro duodenal anastomosis is performed. After replacing the bowel inside the peritoneal cavity the wound is closed and pneumoperitoneum recreated. The reconstruction is done intrcorporeally. Roux en y Choledochojejunal anastomosis and pancreaticjejunal anastomosis is done. We now prefer pancreaticogastric anastomosis. The complete procedure will be presented with which will be followed by the discussion of the results. Lap PPPD is technically feasible in a centre where advanced laparoscopic procedures are routinely performed.

Distal pancreatectomy with splenectomy is done for tumors of the pancreas situated in the body and tail of the pancreas. Five ports were used. Dissection begins by creating a window in the lesser omentum to enter the lesser sac by means of a harmonic scalpel. The dissection is carried out down towards the duodenum as well as along the border of the stomach towards the short gastric. Once the tumor is localized, the splenic vessels must be identified along superior border of the pancreas. The dissection is done along the upper border of the pancreas and once splenic vessels are isolated they are clipped, ligated and cut in continuity. The stomach is completely dissected off .The upper border of the pancreas is dissected laterally as the spleen has to be removed along with the distal pancreas. All the fibro fatty tissue along the lower border of the pancreas is dissected and the pancreas is lifted off its bed till we see normal tissue medially. The endoGia stapler is passed over the pancreas and fired. A silk suture placed distally helps in identifying this part. The splenic vessels are seen from below and are ligated by 2-0 vicryl. Additional proximal clip is placed. Once this control is achieved

V128 - Pancreas

V130 - Pancreas

LAPAROSCOPIC PANCREATIC CYSTGASTROSTOMY V.A. Moon, C. Choy, G. Coppa Staten Island University Hospital, NEW YORK, United States of America

LAPAROSCOPIC PANCREATICODUDENECTOMY S. Puntambekar, A. Gurjar, R.M. Sathe, R.J. Palep, N. Rayate GALAXY Laparoscopy Institute, PUNE, India

A 31-year-old woman with a history of acute gallstone pancreatitis and laparoscopic cholecystectomy, postoperatively developed a pancreatic pseudocyst. After maturation of the fluid collection, CT scan of the abdomen demonstrated the cyst to be 11 x 7.5 cm in size. Endoscopic internal drainage was attempted, but unsuccessful. The patient then underwent a laparoscopic cystgastrostomy. Procedure: The anterior gastric wall was opened at the center of the underlying cyst using harmonic scalpel. Confirmation of the cyst was performed by aspirating the clear pancreatic fluid. The cystgastrostomy was created by using the harmonic scalpel to resect a 1.5cm disc of the posterior gastric wall and abutting cyst wall. This tissue was removed for pathological review. The pseudocyst was evacuated of debris and the anastomosis was sutured laparoscopically in an interrupted fashion. The anterior stomach wall was then closed similarly. Results: The postoperative course was uneventful. Diet was started after a negative UGI series for leak, performed on post-operative day 2. Conclusion: Laparoscopic cystgastrostomy is a safe, reliable, and minimally invasive treatment for managing pancreatic pseudocyst.

Objective: Pancreaticoduodenectomy is a major surgical procedure performed for periampullary tumors in specialized centers in the world. This is due to high morbidity associated with the procedure. The technical expertise and surgical experience of the surgeon is also of paramount importance in deciding the final outcome. Methods: Since 1993 we have performed 85 open pancreaticoduodenectomies with 20% morbidity and 7% mortality. Recently we have done 5 laparoscopic pancreaticoduodenectomies in patients of periampullary carcinoma. Results: The mean operative time was 300 minutes. Average blood loss was 400ml. The mean postoperative stay was 5 days. There were no complications or mortality. No cases were comverted to open. Conclusion: Pancreaticoduodenectomy can be safely done laparosocpically with reduced morbidity and mortality.

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V131 - Pancreas

V133 - Pancreas

LAPAROSCOPIC PANCREATODUODENECTOMY: RESECTION (PART I) J.J. Sanchez Cano, I. Poves, J. Prieto, A. Morandeira, F. Buils, E. Baeta Hospital Universitari Sant Joan, REUS, Spain

LAPAROSCOPIC MODIFIED PANCREATICOJEJUNOSTOMY FOR CHRONIC PANCREATITIS R. Vilallonga, M. Caralt, J.J. Olsina, J. Balsells Hospital Universitari Vall DÕHebron, BARCELONA, Spain

Laparoscopic pancreaticoduodenectomy (LPD) is probably one of the most technically demanding procedures that can be performed in digestive surgery. There are very few cases of LPD reported in the literature. The supposed disadvantages attributed to the laparoscopic resection of the head of the pancreas are: prolonged operative time, high incidence of morbidity and the difficulty of oncologic resection. We present a case of a 76-year-old male who presented an obstructive jaundice due to an ampullary carcinoma. There was no evidence of metastasic disease in preoperative imaging study. A totally laparoscopic classic Whipple procedure was performed. The procedure was accomplished with a total of 5 ports technique and using a 30 laparoscope. Electric cautery (hook) and an auto-electric ligator (Liga-sure) were used for the dissection and section of the vessels. A 3.5 mm endo-stapler was used for sectioning the pancreas and a 2.5 mm one for sectioning the proximal jejunum beyond the ligament of Treitz. The resection started by opening the right half of the greater omentum. A complete Kocher maneuver was performed by upward and medial traction of the duodenum and was finished when aorta and vena cava were totally exposed. Cholecistectomy and lymphadenectomy of the hepatic ileum was performed after sectioning the hepatic duct. Gastroduodenal artery was sealed and sectioned when lymphadenectomy was finished. A retropancreatic tunnel in the neck of the pancreas was done while dissecting superior mesenteric, splenic and portal veins. The uncinate process was cleared from mesenteric vein using Liga-sure. Head of the pancreas, duodenum, distal gastrectomy, gallbladder and lymphadenectomy were in-bloc removed. Definitive pathologic diagnosis was a ampullary carcinoma T2 N0 (0/21). Operative time was 380 minutes. Postoperatory course was complicated with an intestinal obstruction in the distal jejunum due to adhesions one month after the operation. Conclusions: LPD is a technically demanding procedure than can be safely done by highly skilled teams in both pancreatic and laparoscopic surgery. LPD achieves adequate oncological radicality for tumors of the periampullary region.

Introduction: Laparoscopic surgery of the pancreas is still not fully developed. Several laparoscopic pancreatic procedures have been described. The most frequent is diagnostic laparoscopy for staging pancreatic neoplasm and, less frequently, treatment of pancreatic pseudocyst and resection of benign lesions of the pancreas. We report a laparoscopic modified Roux-en-Y pancreaticojejunostomy for chronic pancreatitis. Case report: A 39-year-old man, ex-drug abuser with positive hepatitis C and HIV since 1987 was diagnosed of recurrent chronic pancreatitis in 1993 with 12 subsequent episodes of pancreatic reactivation. In 1998, ERCP was performed and pancreas divisum assessed, sphincterectomy performed and a pancreatic endoprosthesis inserted. This stent was patent for 4 years with the patient asymptomatic. In 2002 he presented another episode of pancreatitis due to stent obstruction which was removed by endoscopy; dilation of pancreatic duct in body and tail was observed with normal major papilla, bile duct and Wirsung duct. Owing to other episodes of mild pancreatitis, dilation of distal pancreatic duct observed on the last CTscan, surgical derivation was indicated. A hand-sewn Roux-en-Y laparoscopic modified laterolateral pancreaticojejunostomy was performed. Surgery lasted 5 hours and 30 minutes. Postoperative period was uneventful and oral intake began on the 2nd postoperative day. Patient was discharged 6 days later. At 3month follow-up, he remained well. Discussion: Therapeutic laparoscopy of the pancreas is still described as experimental by many surgeons. Appropriate pancreas cases are few and randomized trials difficult to perform to ascertain which patients would benefit from minimally invasive surgery. Laparoscopic pancreaticojejunostomy is a feasible but demanding laparoscopic procedure, but offers significant benefit to the patient: reduced trauma to the abdominal wall, short hospital stay and a rapid postoperative recovery.

V132 - Pancreas

V134 - Pancreas

LAPAROSCOPIC PANCREATODUODENECTOMY: RECONSTRUCTION (PART II) I. Poves, J.J. Sanchez-Cano, J. Prieto, A. Morandeira, C. Diaz, E. Baeta Hospital Universitari Sant Joan, BARCELONA, Spain

LAPAROSCOPIC SPLEEN SPARING DISTAL PANCREATECTOMY U.P. Kokkalera, K.A. Chavda, A. Ghellai Guthrie Healthcare System, SAYRE, United States of America

Laparoscopic pancreaticoduodenectomy (LPD) is probably one of the most technically demanding procedures that can be performed in digestive surgery. To be able to perform safely a totally laparoscopic reconstruction of the pancreatic and hepatic anastomosis is the key to get sense to LPD. The complexity of the reconstruction procedure under laparoscopic observation is the strongest barrier for the surgeon. We present a case of a patient diagnosed as an ampullary carcinoma who was treated with LPD. A modified Childs reconstruction with a Roux-en-Y limb was performed. End to side pancreaticojejunostomy (PJ) was made with 5 interrupted knots (4-0 absorbable monofilament). An anastomotic lost stent was placed in the PJ. The hepaticojejunostomy (HJ) was performed with 3-0 absorbable trained suture (end to side). Posterior face of the HJ was fashioned in a continuous suture and anterior face using interrupted knots. Reconstruction of the both gastrojejunal and jejunojenunal anastomosis were made in the same manner using lineal endostapler and closure of the hole with interrupted knots (2-0 absorbable monofilament). No leakages were observed in the postoperatory course. Conclusions: Reconstruction of the Whipple procedure can be safely done by totally laparoscopic approach.

Introduction: Minimal access techniques for the diagnosis and treatment of pancreatic diseases are evolving. Techniques such as laparoscopic distal pancreatectomy are more commonly being reported. Our video demonstrates a laparoscopic spleen sparing distal pancreatectomy for a distal pancreatic lesion. Patients and Methods: Our 25 year old female patient presented with one week history of mid abdominal pain and loss of appetite. Prior history for alcohol abuse or pancreatitis was negative. Initial laboratory evaluation showed mildly elevated amylase and negative CA19-9 level. Ultrasound demonstrated 3 cm cystic lesion at the junction of the body and tail of the pancreas with a central solid component. Abdominal CT scan confirmed the presence the complex cystic lesion. Due to the pre-malignant potential of the lesion, surgery was advised. Laparoscopic spleen sparing distal pancreatectomy was performed. Under general anesthesia, patient was placed in a low lithotomy position. A 10 mm infraumbilical port and three 5 mm working ports were used. The gastrocolic omentum was opened and the stomach was retracted to the anterior abdominal wall using two silk sutures. Intra-operative ultrasound was used to locate the mass and assess margins. The splenic artery was identified and divided. A retropancreatic window was created. A 4.8 mm endo-GIA stapler with a seamguard was used to transect the pancreas. The spleen was preserved. Total operative time was 2.5 hours with minimal blood loss. Histology was compatible with congenital cyst. Her postoperative course was remarkable for a very low output pancreatic leak that resolved spontaneously. She was discharged on the 2nd post operative day. Conclusion: Distal pancreatectomy is the preferred treatment of neoplasms in the body or tail of the pancreas. In selected patients, minimally invasive techniques can be used for resection. If possible, spleen preservation is preferred. Experience with laparoscopic distal pancreatic resection has been favorable in terms of quicker post operative recovery, minimal morbidity and shorter hospital stay. We successfully performed the resection of the distal pancreas with the preservation of spleen laparoscopically.

S289

V135 - Pancreas

V137 - Robotics, Telesurgery and Virtual Reality

LAPAROSCOPIC SPLENOPANCREATECTOMY E. Orsenigo, V. Tomajer, S Di Palo, C. Staudacher Scientific Institute San Raffaele, MILAN, Italy

LAPAROSCOPIC REPAIR OF PARAESOPHAGEAL HERNIA WITH MESH REINFORCEMENT OF THE CRURA AND ROBOTIC-ASSISTED HELLER MYOTOMY

Aims: Laparoscopic surgery has been used increasingly as a less invasive alternative to conventional open surgery. Nevertheless, laparoscopic pancreatic surgery is technically demanding, and thus has not yet gained widespread acceptance. The aim of this report was to assess the feasibility of laparoscopic splenopancreatectomy in the treatment of neuroendocrine tumour of the distal pancreas. Methods: The authors report the case of a 83-year-old woman who developed a 3.5 cm neuroendocrine tumour of the distal pancreas involving the splenic vein. A laparoscopic operation under general anaesthesia was undertaken wit the patient in supine position with the legs abducted. Carbon dioxide pneumoperitoneum was established using Hassons method through a 10 mm over the umbilicus vertical incision. Three additional paraumbilical ports were inserted under laparoscopic guidance. The gastrocolic ligament was divided, and the corpus and the tail of the pancreas was exposed by retracting the stomach upwards. An incision along the superior and the inferior border of the organ and further retroperitoneal dissection by use harmonic scalpel allowed close visual inspection of the entire pancreas. Superficially located lesion within the pancreatic tail parenchyma was easily seen. Achieving a splenopancreatectomy was attempted. The pancreatic transection was performed by use an EndoGIA. The proximal cut duct was secured by use an endoscopic stich. In the proximal cut surface of the pancreas a closure with fibrin glue and TissueFleece has been performed. The splenic artery and vein has been divided by use a vascular EndoGIA. The resected pancreas and the spleen were then placed in a retrieval bag and extracted through a 6 cm Pfannestiel incision The post-operative course was uneventful. The patient walked by the second post-operative day. Passage of flatus per rectum occurred inside 48 hours after surgery. The hospital stay was 6 days. Conclusion: Laparoscopic splenopancreatectomy for neuroendocrine tumour is feasible, safe, and beneficial.

CANCELLED

V136 - Pancreas

V138 - Robotics, Telesurgery and Virtual Reality

LAPAROSCOPIC PYLORUS-PRESERVING PANCREATICODUODENECTOMY A. Costanzi, D. Maggioni, S. Di Lernia, G.C. Ferrari, F. Sansonna, M. Boniardi, D. Citterio, C. Magistro, R. Pugliese Ospedale Niguarda, MILANO, Italy

ROBOTIC-HAND-ASSISTED RIGHT DONOR NEPHRECTOMY

Aim: Laparoscopic distal resections of the pancreas are currently accepted while procedures on tumors of the pancreatic head are still experimenta but may be achieved safely in selected cases. Methods: From August 2002 to December 2005, in our Department we performed 18 laparoscopic pancreticoduodenectomies for tumors of the pancreatic head, successful in 6 patients, converted in the remaining cases. In our procedure, opening of the retrocavity of epiploon is followed by kockerization of the duodenum and its section 2 cm from the pylorus, opening of the hepatoduodenal ligament, isolation and section, once clamped, of the common bile duct by Harmonic scalpel. After creating a retropancreatic window and sling elevation of the pancreatic neck, the pancreas is sectioned by Harmonic scalpel. Cross mobilization of the first jeujunal loop, after its section by endolinear stapler, to the right of the lumbar spine completes the demolitive time together with section of the retroportal plane. Intracorporeal reconstructive time is performed on the mobilized jejunal loop beginning with a termino-lateral manual pancreaticojejunal anastomosis according to Cameron in double layer on a stent. At about 15 cm from the first anastomosis a termino-lateral hepaticojejunal anastomosis in double layer on a silastic stent is carried out. In Whipple procedures, the gastrojejunal anastomosis is a latero-lateral mechanical anastomosis by linear stapler on the posterior wall of the gastric stump. In a pylorus-preserving Traverso-Longmire procedure, a duodenojejunal termino-lateral manual anastomosis is carried out in double layer 40 cm distally from the hepaticojejunal anastomosis. Results: In the case presented in the video, a Traverso-Longmire procedure was carried out on a 64 year old woman affected by an adenocarcinoma of the distal common Bile Duct. Two drainages were left in place at the end of the procedure to protect the three anastomosis. The patient had a post-operative course complicated by pleuric effusion. Bowel opening occured at 4 days, oral intake at 7 days after a radiological control of the duodeno-jejunal anastomosis with water soluble contrast medium, discharge on day 14 from surgery. Conclusions: In selected cases, pancreaticodudoenectomy, when performed in experts hands reproduces safely the open procedure.

CANCELLED

S290

V139 - Robotics, Telesurgery and Virtual Reality

V141 - Robotics, Telesurgery and Virtual Reality

ROBOTIC ASSISTED RIGHT HEPATECTOMY

ROBOTICS IN PANCREATIC SURGERY S-M. Tosato, N. Menin, B. Termini, A. DÕAnnibale Ospedale P. Cosma, CAMPOSAMPIERO (PD), Italy

CANCELLED

Although minimally invasive pancreatic surgery is achieving worldwide acceptance and laparoscopic distal pancreatectomy and tumor enucleation are nowadays considered safe and feasible for patients with benign tumors and cystic lesions, few substantive data are available concerning pancreatico-duodenectomy for periampullary and pancreatic head tumors. A laparoscopic pancreatico-duodenectomy presents unique technical challenges and anatomic difficulties so many Authors consider the minimally invasive approach unsuitable because it is too prolonged and does not seem to offer any benefit to the patient. The laparoscopic resection of the head of the pancreas with the duodenum, gallbladder and lymphatics usually takes 4-5 hours. At the end of this step the surgeon is psychologically and physically tired, and now the very delicate phase of the digestive reconstruction and the anastomosis has to be performed. At this moment a great advantage can come from the use of a robotic system: thanks to the magnified 3D vision, the seven degrees of freedom of the instruments and the elimination of natural tremor, the robotic system allows to perform high-precision pancreaticojejunal and biliojejunal anastomosis and to tie perfect knots, with the surgeon at last sitting in a comfortable, ergonomical position. The lack of tactile feedback is not a real problem because it is compensated by the three-dimensional vision. Our experience is limited. In 4 cases of periampullary tumors we have performed 1 fully laparoscopic and 3 hybrid pancreatico-duodenectomies using conventional laparoscopy for pancreatic resection and robotic surgery (the Da Vinci robotic system) for pancreatic and biliary reconstruction.

We think - and we show it in our videos - that in the digestive reconstruction after a pancreatico-duodenectomy we can obtain a great benefit from robotics over conventional laparoscopy and the use of the robotic surgery can give a strong input to the development of a minimally invasive approach to the diseases of the ampulla and of the head of the pancreas.

V140 - Robotics, Telesurgery and Virtual Reality

V142 - Spleen

THE FOUR ARM ROBOTIC ASSISTED LAPAROSCOPIC GASTRIC BYPASS B. Clapp, E. Wilson, S. Yu, T. Scarborough Univer. of Texas Health Sciences Center, HOUSTON, United States of America

LAPAROSCOPIC SPLENECTOMY: SAFE AND FEASIBLE MODE OF TREATMENT IN MASSIVE SPLENOMEGALY AMONG OTHER SPLEEN PATHOLOGY N. Gatsoulis1, N. Roukounakis2, S. Spirou1, E. Sarakinou1, A. Mixos1, I. Kafetzis2 1 General Hospital, CORFU, Greece 2 General Hospital of Athens ÔPoliclinicÕ, ATHENS, Greece

The video shows the technique of laparoscopic gastric bypass that is performed with the DaVinci robot (four arms). We believe that the four arm technique has the advantage of being more versatile and faster than three arms. Being able to switch instuments without having to remove the robotÕs arms from the ports saves time and wasted motion. The video begins by showing the linear stapler technique used to create the jejujejunostomy. The ports are then changed to the robotic ports. The roux limb is then brought to the gastric pouch and the posterior suture line is created. The entero-enterostomy is then closed and the mesenteric defect is closed. The gastro-jejunostomy is then created using a harmonic scapel and the posterior inner layer is sewn. The anterior inner layer of the anastomosis is then created. The posterior layer is placed. An intraoperative EGD is performed by one of the surgeons and a leak test is conducted. Upon completion of over 100 robotic assisted gastric bypasses with no mortality or leaks, we believe that the four arm robotic assisted laparoscopic gastric bypass is a safe and efficient technique for laparoscopic gastric bypasses.

Various haematological disorders and other conditions require splenectomy. The laparoscopic technique is a feasible and safe option in most cases. However in cases of splenomegaly the spleen size present certain difficulties. We present our experience and technique in laparoscopic splenectomy for various disorders. Methods: During 2005, 4 patients required splenectomy in our departments. In 2 cases because of massive splenomegaly with hypersplenism in patients with - thalassaemia major and 2 patients due to posttraumatic splenic cysts. The laparoscopic technique was applied successfully in all cases with some differences. Results: Initially division of the splenic vessels and ligaments and dissection of the spleen itself was carried out laparoscopically. In the cases with massive splenomegaly we performed a hand assisted technique using a lap disk at the last stage. Intraoperative transfusion was required. Mean operating time was 200 minutes, and the splenic weight 800 gr and 1 kg respectively. In the other two cases no hand assisted technique was required, the operations were concluded faster (mean operating time: 120 min) and the specimen weight was less (390 and 460 gr). There were no postoperative complications. All patients were discharged within the next 5 days. Conclusion: Laparoscopic splenectomy is a well recognized operation. We believe that it is a safe and feasible mode of treatment even in cases of massive splenomegaly. However in these cases hand assisted extraction technique is frequently needed at the final stages to facilitate spleen removal. The giant spleen is not by definition a problem for laparoscopic surgery, as long as there is surgical experience.

S291

V143 - Spleen

V145 - Technology

HAND ASSISTED LAPAROSCOPIC SPLENECTOMY (HALS) IN CASES OF SPLENOMEGALY AND MALIGNANCY E.M. Targarona, C. Balague, S. Vela, C. Martinez, P. Herandez, R. Berindoague, A. Savelli, R. Medrano, J.L. Pallares, M. Trias Hospital de la Sta Creu i St Pau, BARCELONA, Spain

A NEW GENERATION ASPIRATOR/GRINDER APPARATUS FOR THE LAPAROSCOPIC TREATMENT OF HYDATID CYSTS C. Avci, L. Avtan Istanbul Medical Faculty, ISTANBUL, Turkey

Laparoscopic splenectomy (LS) is a well-accepted technique for cases with normal or slightly enlarged spleen. However, the difficulty of LS increases when the spleen is enlarged because of the manipulation of a big organ into the abdomen. Recently, some devices have designed to assist laparoscopic procedures with the hand inserted in the abdomen, while the pneumoperitoneum is maintained. This device permits to recover the tactile feeling and facilitate the mobilization and dissection of the organ. Finally, the organ is recovered through the minilaparotomy. The aim of this video is to show the main steps when HALS is used. 1.Lateral mobilization of the spleen, traction of the gastric big curvature and section of short vessels. 2.- Identification and clipping of the splenic artery. 3.- Section of the splenodiaphragmatic ligament. 4.Individualization and section of the splenic hilum, and 5.- Organ extraction. Material and Methods and results: Between feb-93 and January 2001, 151 LS were attempted. The last 8 consecutive cases with clinical and radiological signs of splenomegaly were approached by HALS. Mean age was 57 y. (44-72), mean operative time 111 min (85-165). Any case was converted and there were no postoperative complications. Mean stay was 3.6 d. (2-4) and spleen weight 1324 g. (720-3100). Conclusion: Hand assisted laparoscopic surgery facilitates significantly the surgical maneuvers during LS, while keeping the advantages of a purely laparoscopic approach.

Aspiration of a hydatid cyst is usually needed as a part of its surgical treatment followed by scolicidal injection and excision of the cyst. In order to prevent any anaphylactic reaction or dissemination and recurrence of the disease, it is important to avoid intraoperative spillage of the cyst contents. In the laparoscopic treatment, evacuation of cyst contents in a secure and suitable way is more difficult. Due to pneumoperitoneum, usage of classical aspirator for evacuation of cyst contents is not easy. Furthermore there is the possibility of the classical aspiratorÕs tube getting cloged easily with membranes and scolece thus disableing the effective use of the classical aspirator during surgery which increases the risk of dissemination. In our center, we have designed and developed a new generation Ôaspirator/grinder apparatusÕ which evacuates cyst contents in a more secure, effective, rapid and easy way with the minimum risk of dissemination. With this apparatus we are able to use the laparoscopic method to remove liver hydatid cysts contents. In this presentation, we demonstrate the technical aspect and specifications of this new aspirator/grinder apparatus and its detailed application in a liver hydatid cyst evacuations.

V144 - Spleen

V146 - Technology

THREE TROCAR TECHNQUE FOR LAPAROSCOPIC SPLEENECTOMY M.K. Hussein American University of Beirut, BEIRUT, Lebanon

ÔSUCTION AND SWIPEÕ DISSECTION TECHNIQUE FOR ADVANCE LAPAROSCOPIC PROCEDURES S. Mahmud1, B. Darmas2, M. Jameel2, A. Alhamdani1, N. Rawat1, I. Alam1, A. Baker2 1 Morriston Hospital, SWANSEA, United Kingdom 2 Wrexham Maelor Hospital, WREXHAM, United Kingdom

A large spleen greater than 1.4kg was removed laparoscopically by a new approach utilizing a Lt. lateral position and using three trocars only. The specimen was extracted through a low fenestil incision. The video will demonstrate the added benefit of the lateral approach. The procedure was performed safely without any difficulties. There was no need for transfusion of any blood product. The procedure was accomplished in 50 minutes. The patient did very well and was discharged home 48hrs post operation.

Introduction: Different techniques and instruments are described and used to dissect the tissue planes during the laparoscopic surgery. These could be very expensive, associated with long learning curve, increase instrument traffic and may require diathermy. Aim: This video will show the use of simple 5 mm blunt sucker end used for the dissection of the tissue planes in advance laparoscopic procedures. Patients and Methods: The end of the 5 mm sucker (blunt) is applied against the tissue and than low power suction is applied, while continuous suction the sucker is swiped and with the swiping repeated movements the planes are opened. The counter traction can be applied with other instrument in the other hand. Simultaneous suction will prevent the pooling of any oozing at the site of dissection. This video will show the clips of the use of this technique in the following procedures. Laparoscopic Nissan Fundoplication Laparoscopic Redo-Nissan Fundoplication Laparoscopic Abdominal Aortic Aneurysm Repair Laparoscopic Acute Cholecystectomy Laparoscopic HellerÕs Myotomy Laparoscopic Common bile duct exploration Conclusion: We have found this technique is simple, effective, and easy to learn and not associate with any increased cost. It is particularly effective for the dissection of inflammatory mass.

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V147 - Thoracoscopic Surgery

V149 - Urology

ROBOTIC ASSISTED RESECTION OF AN ESOPHAGEAL LEIOMYOMA M.S. Maish, C.E. Holmes, S. Valencia UCLA, LOS ANGELES, United States of America

RETROAORTIC RENAL VEIN IS NOT A CONTRAINDICATION TO LIVING DONOR LAPAROSCOPIC LEFT NEPHRECTOMY E. Orsenigo, C. Socci, V. Tomajer, C. Staudacher Scientific Institute San Raffaele, MILAN, Italy

Resection of esophageal masses is a technically challenging procedure. Until recently, these masses were removed by an invasive approach, requiring a posteriolateral thoracotomy for a safe resection. The morbidities associated with a thoracotomy, including pain, respiratory failure and cardiac arrhythmias, led to lengthy post-operative hospital courses. In addition, limited visualization often resulted in injury to the esophageal mucosa as the mass was being excised. With the advent of minimally invasive surgery, resections of masses in the chest have been attempted thoracoscopically by a handful of surgeons around the world. Robotic- assisted surgery has been limitedly applied to esophageal surgery. Our video demonstrates a robotic technique for removal of an esophageal mass in a healthy 50 year-old woman. Under lung isolating general anesthesia the surgery was performed through the right chest in 30 minutes with the aid of one operative assistant. There were no esophageal mucosal injuries and the estimated blood loss was minimal. The patient had an uncomplicated post-operative course and was discharged home on the second postoperative day on a regular diet and oral pain medications. As robotic-assisted surgery becomes more accessible, these advanced techniques can be applied to challenging esophageal operations to make them safer and less invasive. As a result, post-operative morbidity should decrease and patient outcomes will improve.

Aim: Laparoscopic live donor nephrectomy is now an accepted alternative to open surgery in donors with normal renal vasculature. However, the suitability of laparoscopy for donors with anomalous vasculature is less well known. The aim of our video was to illustrate the feasibility of laparoscopic living donor left nephrectomy in case of retroaortic left renal vein.

V148 - Thoracoscopic Surgery

V150 - Urology

RIGHT VIDEOTHORACOSCOPIC THYMECTOMY M. Congregado, J. Loscertales, R. Jimenez-Merchan Universitary Hospital Virgen Macarena, SEVILLA, Spain

LAPAROSCOPIC LIVING DONOR RIGHT NEPHRECTOMY C. Staudacher, E. Orsenigo, C. Socci, R. Sampietro Scientific Institute San Raffaele, MILAN, Italy

Objective: To show our experience and to describe our technique for right videothoracoscopic thymectomy.

Aim: Laparoscopic live donor nephrectomy is increasingly used by transplantation centers worldwide. As in open live donor nephrectomy, the left kidney is preferred; however, not all potential donors have anatomy conducive to left nephrectomy. The aim of our video was to illustrate the feasibility of a totally laparoscopic right nephrectomy with transperitoneal approach.

Methods: Since March 1993 we have performed 49 thymectomies through four 12 mm working ports. Patients were placed lying semisupine (30 angle). Surgical approach in the first three patients was via the left hemithorax, and in all the others we used the right-side approach. Hemostasis of the thymic veins (one or two) was performed with clips and in the last seven cases, a harmonic scalpel allowed perfect hemostasis. Gender: 23 males, 26 female; Age 45.4 years, range 14-74. Cause of thymectomy: Myasthenia gravis: 32, Thymoma: 17 (non invasive clinical nor in the videothoracoscopic exploration). Results: Almost all cases (83%) had no incidents, but we needed to performed two minithoracomy (4-5 cm) 1 because technical difficulties and 1 to extract a thymoma to big to get out through the workig port. Conversions: 3, 2 due to thymic vein bleeding and 1 to technical difficulties that unabled innominated vein dissection. Mean duration: 110 minutes (60-193). Postoperative stay: 4.2 days. In myasthenia patients no morbidity or mortality were reported. In thymoma patients there was one death in the postoperative period and other decease one year later because cerebral metastasis. Three patients were reoperated because suspected thymic residual tissue (pathology:fat tissue). Conclusion: Videothoracoscopic thymectomy is feasible and it is a safe procedure that avoid more agressives approach as sternotomy or thoracotomy. We prefer right thoracoscopy because the right-side approach affords perfect control of the left innominate vein and thymic veins.

Methods: We report the case of a 50-year-old female patient who presented with a left kidney with anomalous vasculature (retroaortic left renal vein). The patient was referred for laparoscopic living donor left kidney nephrectomy. Results: The procedure was successfully performed without vascular complications by use a totally laparoscopic technique. Operating time was 230 minutes and warm ischemia time 2.5 minutes. Recipient kidney transplant was successfully performed in a standard fashion. Conclusions: The presence of a major renal vascular aberrancy such as retroaortic renal vein does not contraindicate the minimally-invasive approach for left living donor nephrectomy. Nevertheless, a preoperative identification of all anomalies is mandatory.

Methods: A 58 years-old male was referred for laparoscopic right kidney donation. The indication for right-sided donor nephrectomy was the presence of multiple left renal vessels. A four-port transperitoneal approach has been used. Results: The procedure was successfully accomplished without technical or surgical complications. The surgical time was 200 min, with a warm ischemia time of 120 seconds. The post-operative course was uneventful. Conclusions: Right laparoscopic transperitoneal nephrectomy is a technically feasible, safe and reliable option for minimally invasive organ donation and should be considered when the left kidney is not suitable for transplantation.

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V151 - Urology

V153 - Vascular Surgery

LAPAROSCOPIC DONOR NEPHRECTOMY AT PADUA UNIVERSITY A SINGLE CENTRE EXPERIENCE N. Baldan1, R. Cadrobbi2, G. Margani1, L. Furian1, B. Ekser1, C. Silvestre1, L. Fabris1, P. Rigotti1, G. Zaninotto2 1 Kidney and Pancreas Transplantation Unit, PADOVA, Italy 2 Clinica Chirurgica 3, UNIVERSITY OF PADUA, Italy

LAPAROSCOPIC RELEASE OF CELIAC ARTERY COMPRESSION SYNDROME BY MEDIAN ARCUATE LIGAMENT OF DIAPHRAGM P. Baccari, L. Dordoni, E.M. Marone, T. Casiraghi, G. Bissolotti, C. Staudacher, R. Chiesa San Raffaele Scientific Institute, MILAN, Italy

Aims: Laparoscopic donor nephrectomy is an alternative to lombotomy for kidney donation. The aim of this study was a retrospective assessment of the safety of this technique and the outcome of renal transplantation from living donors who underwent laparoscopic nephrectomy at our centre. Methods: From January 2001 to December 2005, we performed 22 laparoscopic donor nephrectomies, all left nephrectomies, after excluding any renal vascular anomalies in all cases by Computed Tomographic angiography or Magnetic Resonance angiography. All laparoscopic procedures were performed by the same surgical team consisting of an expert laparoscopic surgeon and an experienced transplant surgeon. The donors mean age was 50.6 7.6 years (range 36-66), 32% of the donors were male, the mean Body Mass Index was 25.4 3.8 kg/m2, and in 4 cases the kidney was donated by an unrelated donor. The recipients were a mean 32 13 years old (range 9-64), 64% of them were male, and their mean time on dialysis was 33 49 months (range 0-120). Results: After a mean follow-up of 26.6 13.5 months, all donors and recipients are alive. The mean operating time was 271 41 min (range 225-360) and the mean warm ischemia time was 160 35 seconds (range 107-240). Surgical complications in the donors were one incisional hernia at the port site, and one case of post-operative pneumonia. The donors mean hospital stay was 5.3 1.6 days (range 3-10) and their mean serum creatinine at discharge was 111 21 mol/ L. There were no surgical complications in the recipients, and all transplants functioned immediately, except for one case of anaphylactic shock due to basiliximab (anti IL2R monoclonal antibodies used for immunosuppressive induction). Conclusions: laparoscopic nephrectomy from living donors was confirmed as being safe and effective, without any side effects on transplants. Expertise in laparoscopic and kidney transplantation surgery is crucial to minimise the side effects both of the laparoscopic surgery and for the transplant recipients.

Objectives: We show a videoclip (DVD) describing our approach to laparoscopic treatment of median arcuate ligament syndrome (MALS) and we present our results after an experience of 7 cases all operated on by laparoscopy. Background: MALS is an unusual condition caused by compression of the celiac artery by abnormally low insertion of the median fibrous arcuate ligament and muscular diaphragmatic fiber, determining luminal narrowing of the celiac trunk. Postprandial intermittent abdominal pain, weight loss and the presence of an epigastric bruit are the signs and symptoms characterizing the syndrome. Surgical treatment, traditionally performed by open technique, requires the skeletonization of the aorta and celiac trunk by division of the diaphragmatic pillars, median arcuate ligament and neural tissue overlyng the celiac axis. Laparoscopic approach has been recently reported for single cases. Methods: From 2002 to 2005, 7patients came up to our attention for MALS. Diagnosis was made by Doppler US and CT-angiogram or MR-angiogram. Operations were performed with patients in the supine position, reverse Trendelemburg, with four ports. All the steps of the procedure were laparoscopically completed and the celiac trunk skeletonized. Results: There were 5 men and 2 women. Mean age was 53 years (30-61). Mean BMI 22.8 (19.4-26.4). Mean length of procedures was 90 min (180-35), 141 min for the first 3 operations and 50 min for the last 3 operations. Mean blood loss was 10 ml (0-65). Conversion rate was 0 %. In all the cases the postoperative course was uneventful and patients did not experienced complications. Mean postoperative hospital stay was 2.3 days (2-3). Postoperative CT angiogram demonstrated in all the cases no residual stenosis of the celiac trunk. Patients remained asymptomatic on follow-up. Conclusions: Laparoscopic release of the median arcuate ligament appear to be feasible without complications if performed by experienced laparoscopic surgeons, with a short learning curve. Laparoscopic technique for treatment of MALS is becoming a safe alternative to open surgery, additional cases with longer follow-up are needed.

V152 - Vascular Surgery

V154 - Video - Intestinal, Colorectal and Anal Disorders

TECHNICAL ASPECTS OF SUBFASCIAL ENDOSCOPIC PERFORATING VEIN SURGERY M. Herna`ndez1, S. Blanco1, F. Sabench2, C. Dı´ az1, A. Morandeira1, F. Buils1, D. Del Castillo1 1 Universitary Hospital Sant Joan, REUS, Spain 2 Rovira and Virgili University, REUS, Spain

RECTO-VAGINAL FISTULA REPAIR BY TRANSANAL ENDOSCOPIC MICROSURGERY (TEM) E. Lezoche, G. DÕAmbrosio, A.M. Paganini, L. Solinas, F.P. DÕOstuni, F. De Laurentis, A. Rotundo, G. Lezoche Policlinico Umberto I, ROME, Italy

Background: Since the ÔLinton operationÕ, described in 1938, the subfascial perforating vein ligation technique has been modified many times in an attempt to minimize trauma and damage to diseased skin. Subfascial Endoscopic Perforator Vein Surgery (SEPS) is one of the best procedures and a good, minimally invasive option for treating chronic venous insufficiency (CVI). The aim of this paper is to explain our personal experience with SEPS that has been turned into a subaponeurotic approach without balloon, and to assess the possible advantages for both the surgical procedure and the patients postoperative period. Methods: The subaponeurotic space was entered by means of the VisiportR video assisted technique, which shows how the trocar should enter through the subcutaneous fatty tissue and the superficial aponeurosis of the leg. Once in position, a blunt retractor was inserted which, together with CO2 insufflation (20 mmhg), enabled the veins to be dissected. Ligation was performed using tripolar sealing (LigasureR) and a second trocar. In no case was a balloon used.

Background: Recto-vaginal fistulas (RVF) are abnormal epitheliumlined communications between rectum and vagina. They are classified as low, intermediate and high depending on the location of the vaginal opening, with low RVF most commonly encountered. The causes of RVF include trauma, infection, inflammatory bowel disease (IBD), carcinoma and radiation therapy. Surgical treatment of RVF may be accomplished through different surgical routes: transanal, transvaginal, perineal and transabdominal, with success rates of 40-85%. The route that is chosen largely depends on the location of the fistulous tract. A laparoscopic approach has also been reported. The authors present the case of an iatrogenic RVF treated for the first time by a Transanal Endoscopic Microsurgery (TEM) approach.

Results: There were no incidents such as hemorrhage or subcutaneous emphysema during the procedure. The patients (n= 206) remained in the hospital for less than 24 hours and suffered no post-surgical complications. Active ulcers were cured, with no relapses, in 100% of the cases.

Method: A 70-years old woman underwent transvaginal hysterectomy, complicated by postoperative haemorrhage. She subsequently developed a RVF, confirmed both clinically and endoscopically, and a colostomy was performed. The patient was then referred to the authorsÕ institution for treatment of the RVF. With the patient in the prone position, the RVF was excised, the rectal and vaginal walls were separated and then sutured by TEM technique. The postoperative course was uneventful. Radiological and endoscopic control at one month showed complete healing of the RVF. The colostomy was then closed.

Conclusions: This technique is a very effective method for treating advanced chronic insufficiency because it prevents local damage and the rate of postsurgical complications is low. Technically it has more advantages because the fact that it does not use a balloon means that it exerts less pressure on the tissues.

Conclusion: The powerful light intensity and field magnification of TEM provide unparalleled surgical control of the rectal lumen. TEM is an innovative, minimally-invasive surgical technique for the treatment of RVF which proved in this case to be feasible and safe with excellent results.

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V155 - Video - Intestinal, Colorectal and Anal Disorders

V156 - Robotics, Telesurgery and Virtual Reality

USE OF RADIONUCLEAR TECHNIQUE IN THE RADICAL TREATMENT OF RECTAL CANCER BY TEM E. Lezoche, G. DÕAmbrosio, A.M. Paganini, L. Solinas, F.P. DÕOstuni, G. Lezoche, P. Ursi, L. Barchetti Policlinico Umberto I, ROME, Italy

LAPAROSCOPIC ENUCLEO-RESECTION OF A GIANT HEPATIC HEMANGIOMA F. Prete1, P. Nitti1, R. Sebastiani1, G. Preziosa1, F.P. Prete2 1 University of Bari, BARI, Italy 2 University of Foggia, FOGGIA, Italy

Background: The surgical treatment of rectal cancer includes anterior resection of the rectum or abdomino-perineal amputation. These approaches may be complicated by anastomotic failures (4-42%) and genito-urinary dysfunctions (10-15%) and include a temporary or permanent stoma. In selected cases rectal cancer may be treated with local excision and minimallyinvasive techniques (TEM), with neoadjuvant radiochemotherapy in T2 N0 lesions. Local recurrence after TEM is between 2 and 15% in T1 and T2 rectal cancer. The sentinel node (SN) technique has been used by various authors in colon carcinoma with identification rates of 89%. However, since the rectum is anatomically different from the colon, with bulky mesentery and extraperitoneal location, the SN procedure is more difficult. Furthermore, pre-operative radiotherapy causes sclerosis of the perirectal tissues which modifies the lymphatic flow as a result of lymphatic obstruction. The authors used a modified SN technique in order to improve radical resection of rectal cancer by TEM.

Introduction: Definitive surgical treatment is usually required for Giant Hepatic Haemangiomas (GHH). The classical option is a formal hepatic resection with parenchymal transaction; enucleation has been highlighted as a more advanced and suitable procedure. We aim to show the feasibility of GHH enucleation by laparoscopy.

Methods: A 79-years old woman with rectal cancer located at 4 cm from the anal verge (T3-N0-M0) underwent neoadiuvant radio-chemiotherapy, with downstaging to T2-N0-M0. Due to the high anaesthesiological risk (ASA III-IV) it was decided to perform a TEM approach. The radioactive tracer was injected peritumorally and a full thickness excision of the rectal tumor with perirectal fat was performed by TEM. Residual radioactivity was detected in the surgical field after local excision and a probe-guided mesorectal fat excision was performed. Upon final testing, the probe didnÕt show any residual radionuclide activity. Histological examination of the radial margin of the surgical specimen was negative. The postoperative course was uneventful. At 6 months of follow-up, there is no evidence of local or distant recurrence. Conclusion: Radioguided local excision of mesorectal fat after full thickness local excision of rectal cancer and adjacent fat by TEM may be a useful adjunct to achieve a more radical treatment in selected cases.

Patient and method: The procedure shown in the video has been performed in a 29-years-old female athlete with a large haemangioma of the left hepatic lobe, causing subcontinous epigastric pain exacerbated by physical activity. By laparoscopy with four ports we preliminarily apply a vessel loop around the hepatic pedicle, for an eventual Pringle maneuver. Then, after incising the Glisson capsule at the borderline of the mass, we identify the narrow cleavage between hepatic parenchyma and haemangioma capsule. Careful dissection goes on along the interface of compressed hepatic parenchyma with meticulous haemostasis, until larger vessels, like a hilar pole of the haemangioma, are reached, isolated, clipped and cut. After verifying hemostasis and biliostasis, the residual hepatic bed requires no further treatment. Results: The patient was discharged five days later after an uncomplicated recovery. Comments: In selected cases of GHH, laparoscopic enucleation is feasible and seems the most appropriate procedure, minimizing surgical trauma and maximizing parenchymal sparing.