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Surg Endosc (2007) 21: S1–S106 DOI: 10.1007/s00464-007-9272-2 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 Oral presentations

KARL STORZ E.A.E.S. AWARD SESSION O001 - Morbid Obesity

O002 - Liver and Biliary Tract Surgery

A PROSPECTIVE TRIAL BETWEEN LAPAROSCOPIC GASTRIC BANDING AND LAPAROSCOPIC GASTRIC SLEEVE: RESULTS AFTER THREE YEARS G. Dapri, J. Himpens, C. Vaz, G.B. Cadie`re Saint-Pierre University Hospital, BRUSSELS, Belgium

DO WE NEED AN ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) SERVICE IN EVERY HOSPITAL? A. Mirza, J. Murray, G. EL-Shallaly, I. Eid, A.H.M. Nassar Monklands General Hospital, AIRDRIE, United Kingdom

Background: The adjustable gastric banding (GB) is the most popular restrictive surgery for obesity realized in Europe. The sleeve gastrectomy (SG) is more invasive restrictive procedure, lesser common than GB. The aim of the study was to compare the results of laparoscopic GB and SG after 3 years of surgery. Methods: 80 patients candidates to laparoscopic restrictive surgery were operated consecutively, between January 1st and December 31th 2002, by a GB (7M, 33F) or by SG (9M, 31F) (NS). Median age was 36 ys (20–61) for GB vs 40 ys (22–65) for SG (NS). Median body mass index (BMI) was 37 kg/m2 (30–47) for GB vs 39 kg/m2 (30–53) for SG (NS). After three years, weight loss, feeling of hunger, sweet eating, symptomatic gastroesophageal reﬂux, late complications and re-operations were recorded. Results: After three years, the median weight loss was 17 kg (0–40) for GB and 29,5 kg (1–48) for SG (p<0,0001). Median decrease of BMI was 18 kg/ m2 (0–39) after GB and 27,5 kg/m2 (0–48) after SG (p=0,0004). Median % excess weight loss was 48% (0–124,8) after GB vs 66% after SG ()3,1– +152,4) (p=0,0025). Loss of feeling of hunger was 2,9% (GB) vs 46,7% (SG) (p<;0,0001). Loss of sweet eating was 2,9% (GB) vs 23,3% (SG) (NS). Development of gastroesophageal reﬂux was 20% (GB) vs 3,3% (SG) (NS). Complications after GB were: sholulder pain (8,5%), frequent vomiting (28,5%), poor choice of alimentation (48,5%), gastric ulcus (2,8%), pouch dilation (5,7%) and ineﬃcacy (8,5%); complications after SG were: frequent vomiting (16,6%), poor choice of alimentation (26,6%), vitamins and minerals deﬁcit (13,3%) and ineﬃcacy (6,6%). Re-operations were necessary for 14,2% of GB and 6,6% of SG. Conclusions: At three years after surgery: weight loss and loss of feeling of hunger are more important after SG. Onset of symptomatic gastroesophageal reﬂux was more frequent after GB than after SG. Number of complications and re-operations are less important after SG.

Aims: To evaluate the use, costs and complications of ERCP service before and after the establishment of a specialist laparoscopic biliary service. Method: The ERCP service in Monklands Hospital was discontinued in 2003 following the establishment of a specialist laparoscopic biliary service. All patients with suspected common bile duct stones (CBDS) who are ﬁt for surgery are managed by the specialist ﬁrm and undergo laparoscopic cholecystectomy (LC) with intraoperative cholangiogram (IOC) and LCBDE where appropriate (25.4% of cases have either transcystic exploration or choledochotomy). Patients who are not ﬁt for surgery are managed conservatively and are only transferred for ERCP if the episode does not resolve or if subsequent MRCP shows bile duct stones. Data from before and after 2003 about the management of patients undergoing LC with or without common bile duct stones was analysed including the utilisation, costs and complications of ERCP. Results: Since the establishment of the specialist laparoscopic biliary service, 111 fewer ERCPs have been performed per year. The total cost saving including disposables, drugs and hospital stay was estimated at 99,900 excluding complications, longer hospital stay and repeat ERCPs. Complications following ERCP include pancreatitis (incidence approximately 5.4%) which usually requires several days of inpatient care. Prior to 2003, the majority of patients had two-session management with delayed LC following discharge after emergency admission. In 2001–2002, 218 LCs (+84 open or converted) were performed compared with 316 from 2003– 2005. After 2003, 56% were performed during the emergency admission compared with 21% before. 0.6% of LCs were converted to open surgery compared with 9% before. The hospital stay for elective patients was 1.6 days compared with 5.2 days previously. For emergency cases the length of admission dropped from 9.8 days to 3.2 days. Additionally, the mean number of admissions per patient dropped from 2.2 to 1.05. These factors together contribute to a signiﬁcant cost saving. Conclusions: Establishment of a specialist biliary service can result in a signiﬁcant number of patients avoiding ERCP with a resultant reduction in complications and costs. Expansion of training and sub-specialisation of consultant surgeons can improve the results and outcomes for patients.

S2

O003 - Urology

O005 - Physiology, Pathophysiology, Immunology

HAND-ASSISTED LAPAROSCOPIC DONOR NEPHRECTOMY OF THE RIGHT OR LEFT KIDNEY: A RANDOMISED CONTROLLED TRIAL P.J. Van Koperen, S.W. Polle, M.M. Idu, F.J. Bemelman, R. Balm, W.A. Bemelman Academic Medical Center, AMSTERDAM, The Netherlands

MAJOR SURGERY INDUCES PROTEOLYSIS OF IGFBP-3 IN TRANSGENIC MICE, AND IS ASSOCIATED WITH A RAPID INCREASE IN SERUM LEVELS OF MATRIX METALOPROTEINASE-9 (MMP-9)

Aims: The (hand assisted) laparoscopic approach (HLDN) is an accepted method in live kidney donations. The beneﬁts are decreased postoperative pain and morbidity, a shorter convalescence for the donor and a better postoperative cosmetic result. Most centers prefer to use the left kidney for live kidney donation because of the longer renal vein. It has never been addressed which kidney can be used best for live kidney donation, in terms of operating time, morbidity, reconvalescense and transplant survival. Methods: From April 2002 to January 2006, 50 HLDN were performed. Donors were randomly assigned to undergo either a right- or left-sided donornephrectomy. Primary outcome parameters were operating time and length of hospital stay. Secondary parameters were donor morbidity, conversion, warm ischemia time, blood loss, graft survival and urological complications. Results: There were no conversions. The median blood loss was respectively 60cc (range 10–1000) and 55cc (range 25–1200) for left and rightsides donornefrectomies. Median operating time for HLDN was 179 minutes (range 110–274) in the left group versus 150 minutes (range 88– 221) in the right group (p=0.071). Median hospital stay was 4 days (range 2–7) in both HLDN groups. Warm ischemia time was 3 minutes in both groups. Median operating time for transplantation was 134 minutes (range 105–265) in the left group and 148 minutes (range 104–300) in the right group (p= 0.676). The surgical re-intervention rate due to a urological complication for respectively left-sided and right-sided harvested grafts were 2% and 4% respectively (p=0.55, Chi2-test). One year graft survival rate was 91% (23/25 patients) in the left group versus 96% (24/25 patients) in the right group (p=0.55, logrank). Conclusions: There are no diﬀerences in morbidity of donor and acceptor, hospital stay and transplant survival in HLDN of either the right or left kidney. Operating time of HLDN of the right kidney is 30 minutes shorter than HLDN of the left kidney.

We have previously demonstrated a signiﬁcant decrease in the plasma level of intact Insulin-like Growth Factor Binding Protein 3(IGFBP-3) following major open surgery in humans and have postulated that this decrease may have an important eﬀect on postoperative tumor growth. In contrast, the vast majority of patients that undergo laparoscopic surgery do not demonstrate an intact IGFBP-3 decrease after surgery. Our goal was to create an animal model which would allow further study of the eﬀect of surgical trauma on IGFBP-3. In addition, we set out to determine whether MMP-9, a known protease of IGFBP-3, is responsible for the degradation of IGFBP-3 observed after open surgery. Methods: 30 mice were divided into three groups. Sham Laparotomy(SL), CO2 Pneumoperitoneum(PP), and Anesthesia Control(AC). All mice were hIGFBP-3 transgenics on a CD-1 background. 48 hours prior and 24 hours following the procedure blood was drawn retroorbitally. Intact IGFBP-3 levels were measured using a combination of western blot analysis and ELISA at each time point. Serum and intracellular levels (mononuclear cell lysates) of MMP-9 were measured at each time point using zymography. Results: Plasma levels of intact IGFBP-3 were signiﬁcantly lower post SL when compared to preop levels. A mean decrease of 76.6% was found after laparotomy (P<0.05). Zymography analysis demonstrated signiﬁcantly higher MMP-9-related proteolytic activity post SL when compared to pre-operative levels (78.5RU vs. 42.3RU P<0.05). In the PP and AC groups no signiﬁcant change was found between the preoperative and postoperative levels of intact plasma IGFBP-3 or MMP-9. Mononuclear intracellular levels of MMP-9 were signiﬁcantly lower post SL when compared to preop (3RU vs. 37RU). Post procedure intracellular levels of MMP-9 were not signiﬁcantly decreased in the PP or AC groups. Conclusion: Plasma levels of intact IGFBP-3 were found to be signiﬁcantly decreased following SL. This decrease was not seen following PP. Depletion of intact IGFBP-3 following SL correlated with a rapid release of MMP-9 from mononuclear cells and an increase in circulating serum MMP-9 levels. This suggests that MMP-9 may play an important role in IGFBP-3 proteolysis post surgical trauma and that circulating mononuclear cells are an important source. This provides a reliable animal model in which to further study the mechanism of IGFBP3 proteolysis following surgical trauma and its eﬀect on postoperative tumor growth.

O004 - Intestinal, Colorectal and Anal Disorders

O006 - Oesophageal and Oesophagogastric Junction Disorders

PROSPECTIVE EVALUATION OF QUALITY OF LIFE OF PATIENTS WITH RECTAL CANCER AFTER LAPAROSCOPIC TOTAL MESORECTAL EXCISION S.O. Breukink1, H.J. van der Zaag-Loonen1, E. Bouma1, J.P.E.N. Pierie2, C. Hoﬀ2, T. Wiggers2, W.J.H.J. Meijerink2 1 University Medical Centre Groningen, GRONINGEN, The Netherlands 2 Medical Centre Leeuwarden, LEEUWARDEN, The Netherlands

THE INFLUENCE OF LAPAROSCOPIC ANTIREFLUX SURGERY ON DIETARY AND POSTURAL TRIGGERS OF GASTROOESOPHAGEAL REFLUX N.S. Balaji, K. Moorthy, D. Vasanth, M. Deakin, C.V.N. Cheruvu North Staﬀordshire University Hopsital, STOKE ON TRENT, United Kingdom

Objective: In various studies type of surgery, age and gender had diﬀerent impact on quality of life (QoL) of patients with rectal cancer. However, little is known about how the QoL of patients with rectal cancer changes after laparoscopic Total Mesorectal Excison (LTME). The aim of the present study was to investigate how the QoL of patients with rectal cancer is aﬀected after LTME. Methods and Procedure: The Medical Outcomes Study Short Form 36 (SF-36), and the European Organization for the Research and Treatment of Cancer (EORTC) QLQ-C30 (generic) and QLQ-CR38 (colorectal speciﬁc) questionnaires were administered to patients before LTME, on discharge home and at 3, 6, 12 months postoperatively. Patients were treated by laparoscopic low anterior resection (LAR) or laparoscopic abdominoperineal resection (APR). Non-parametric statistics were used to compare groups and questionnaire score over time. Results: Fifty-one patients with a mean age of 64 years participated in this study, of which 29 were male and 22 female. Thirty-eight patients received a LAR and 13 an APR. No signiﬁcant diﬀerences in preoperative score and one year postoperatively were observed for all scales of SF-36, and EORTC QLQ-C30. On the EORTC CR-38, at one year postoperatively, patients reported improvement in their perspective of the future (49 vs 69, p=0.49) as well as a decrease in weight loss (14 vs 1, p= 0.15). A trend toward less defecation problems was observed (31 vs 21, p=0.54). However, sexual functioning decreased signiﬁcantly (67 vs 39, p=0.10). From the third month until one year postoperatively, patients who underwent LAR reported signiﬁcantly better scores on the EORTC QLQ- CR38 for sexual function and body image than patients who underwent an APR. Conclusion: One year after LTME for rectal cancer, patients exhibited improvement in some QoL outcomes compared with the preoperative situation, including perspective of the future, despite a decrease in sexual function. Patients with laparoscopic APR experienced more impaired sexuality and had a worse body image postoperatively compared with patients who underwent laparoscopic LAR.

A. Belizon, I. Kirman, E. Balik, M. Karten, S. Jain, P.K. Horst, R.L. Whelan

Columbia University Medical Center, NEW YORK, United States of America

Background and Aim: It is known that some diets, beverages and posture can aggravate symptoms of Gastroesophageal reﬂux (GOR). The alleviation of reﬂux symptoms precipitated by these speciﬁc triggers after surgery is usually evaluated by global satisfaction scores or grading systems. We propose to investigate the results of laparoscopic antireﬂux surgery (LARS) on selected precipitants of GOR based on a trigger based evaluation tool. Methods: A prospective pilot study to identify dietary triggers formed the basis of a trigger speciﬁc questionnaire pre and post LARS. The triggers included diﬀerent food varieties (spicy food, fatty food, and chocolate), beverages (coﬀee, tea), alcohol, smoking and postures (supine, bending and exercise). The severity of symptoms related to these stimuli were graded prior to surgery as severely incapacitating (SI), moderately incapacitating (MI) or having no eﬀect (NE). The eﬀect and extent of relief after surgery were graded as complete relief (CR), signiﬁcant relief (SR) or no eﬀect (NE). Results: 25 patients (M: F- 18:7) with a median age of 44(IQR 32–54) were approached at a median follow up of 13 months from surgery to evaluate the GOR response pattern pre and post LARS. Spicy food was the most severe preoperative food trigger in 22/25 (88%) while oily and fatty food aﬀected 20 (80%) and 18 (72%). Alcohol and Citrus juices produced SI reﬂux in 17 (68%) and 9 (36%) respectively. Supine posture was the worst postural preoperative precipitant in 23/25 (92%) (SI reﬂux-17 or MI reﬂux6) of patients while bending and exercise aﬀected 20 (80%) and 19 (76%). However smoking had little eﬀect (SI reﬂux-0, MI reﬂux-2)

LARS resulted in complete relief in 20/22 (90%) after spicy food, 85% after oily food and 94% after fatty food. Resumption to reﬂux free alcohol intake was seen in 91% of patients. CR from supine reﬂux was seen in 21/23 (91%) and signiﬁcant relief in the rest. Conclusion: Spicy and fatty food, alcohol and supine posture and are signiﬁcant preoperative precipitants of GOR which are eﬀectively controlled with LARS. Speciﬁc trigger based questionnaires are also eﬀective tools in evaluating post operative symptom outcomes.

S3

TECHNOLOGY AWARD SESSION O009 - Robotics, Telesurgery and Virtual Reality

O007 - Robotics, Telesurgery and Virtual Reality TELE-SURGERY IN AN EXTREME ENVIRONMENT IN THE ABSENCE OF A LOCAL PHYSICIAN - THE NEEMO 7&9 MISSIONS 1

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M. Anvari , D. Williams , R. Thirsk , L. Morin , C. McKinley , T. Broderick , A. Kapoor1, H. Sebajang1, G. Hall1, A. Adili1, J. Dobranowski1 McMaster University, HAMILTON, Canada 2 Canadian Space Agency, Canada 3 National Aeronautics and Space Adm., United States of America 4 University of Cincinnati, OHIO, United States of America

1

STANDARD LAPAROSCOPIC VERSUS ROBOT-ASSISTED LAPAROSCOPIC NISSEN FUNDOPLICATION FOR GASTROESOPHAGEAL REFLUX DISEASE: A RANDOMIZED CONTROLLED TRIAL W.A. Draaisma, J.P. Ruurda, R.C.H. Scheﬀer, R.K.J. Simmermacher, H.G. Gooszen, H.G. Rijnhart-de Jong, E. Buskens, I.A.M.J. Broeders University Medical Centre Utrecht, UTRECHT, The Netherlands

Introduction: Telementoring, both with and without robotic assistance, can eﬀectively facilitate transfer of knowledge from one surgeon to another during live surgery. Recent experience with robotic-assisted remote telepresence surgery (RARTS) has demonstrated that a surgeon can safely perform advanced procedures from a distance. The scientiﬁc goal of the NEEMO missions is to evaluate the potential for these technologies to enable provision of emergency surgical care in an extreme environment in the absence of a physician. Methods: Coordinated by NASA, the NEEMO missions utilize the Aquarius undersea habitat as a training analogue for space missions. During NEEMO 7 (Oct. 11–21, 2004), experts at the Centre for Minimal Access Surgery (CMAS) in Hamilton, ON, used telementoring with robotic assistance to guide Aquarius crewmembers through several simulated surgical procedures including lap cholecystectomy, arterial anastomosis, cystoscopy and removal of a renal stone. NEEMO 9 (Oct. 3–20, 2005) will investigate the use of tele-presence surgery using a portable two-arm robot to allow a remote surgeon to carry out emergency surgery with latencies ranging from 150 ms to 2 seconds. For both missions, the Aquarius crew includes 3 astronauts, 2 habitat technicians and one surgeon as a control. Results: NEEMO 7 demonstrated that with proper telementoring technique, non-physicians could successfully be guided through all of the simulated surgical procedures, although not as quickly or as eﬃciently as the surgeon control. The mentoring skills of the remote surgeon and the image quality provided by the telecommunications network were found to be critical to successful telementoring. Telerobotic assistance could not be properly evaluated during NEEMO 7 because the robotic platform was too bulky for the conﬁnes of Aquarius. A newly developed and more compact system will be evaluated during NEEMO 9 in October 2005. Conclusions: The technologies evaluated during the NEEMO missions may play a signiﬁcant role in providing emergency medical and surgical care in extreme environments in the absence of a local physician, such as ﬁeld of battle or human space exploration, and also in remote regions around the globe.

Background and Aim: Robotic systems have been developed to enhance surgeonsÕ capabilities in minimally invasive surgery with the objective to improve patient outcomes. These systems may be of added value during procedures involving extensive dissection and suturing in conﬁned spaces, such as laparoscopic Nissen fundoplication. Therefore, the purpose of this single centre randomized controlled trial was to compare standard laparoscopic Nissen fundoplication (LNF) with the robot-assisted approach (RNF). Methods: Between 2003 and 2005, 50 patients with conﬁrmed refractory gastroesophageal reﬂux disease (GERD) were assigned to undergo either LNF (25) or RNF (25). Patients who had undergone previous antireﬂux surgery were excluded. Independent assessment of dysphagia, regurgitation, heartburn and general wellbeing were performed before and at six months after surgery using standardised clinical questionnaires. Objective outcome was studied six months after surgery by esophageal manometry, 24-hr pH monitoring, barium esophagram series and upper endoscopy. Results: Operating time, blood loss, post-operative pain scores, hospital stay and complication rate did not signiﬁcantly diﬀer between the two groups. Additionally, postoperative self-rated change in reﬂux symptoms and quality of life improved equally for both groups. Reoperation rates also did not diﬀer between the groups (one incisional hernia after LNF and one patient with redo Nissen after RNF due to persistent dysphagia). Reduction in esophageal acid exposure, increase in lower esophageal sphincter tone and mucosal healing were comparable between LNF and RNF at follow-up. Conclusion: RNF yields similar subjective and objective results as LNF in this study. Therefore, no additive value of robotic systems for this procedure could be detected up to six months after surgery.

O008 - Robotics, Telesurgery and Virtual Reality

O010 - Robotics, Telesurgery and Virtual Reality

EUROPEAN CONSENSUS ON A VIRTUAL REALITY TRAINING PROGRAM FOR BASIC ENDOSCOPIC SURGICAL PSYCHOMOTOR SKILLS; ACQUIRING CRITERION LEVELS FOR PROFICIENCY BASED TRAINING.

EFFECT OF THE LEARNING CURVE ON OUTCOMES AFTER ROBOTIC ASSISTED DONOR NEPHRECTOMY (RALN)

K.W. van Dongen1, L. Bonavina2, F. Carter3, T. Grantcharov4, C. Hogman5, A. Hyltander6, D. van der Zee1, I.A.M.J. Broeders1 1 UMC Utrecht, UTRECHT, The Netherlands 2

University of Milano, MILAN, Italy

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Cuschieri Skills Centre, DUNDEE, United Kingdom Western Pennsylvania Hospital, PITTSBURGH, United States of America 5 Karolinska University Hospital, STOCKHOLM, Sweden 6 Sahlgrenska University Hospital, GOTEBORG, Sweden 4

Virtual reality simulators are used to train residents in basic skills for endoscopic surgery. Adequate scientiﬁc research has demonstrated that a number of these simulators serve this purpose well. Also, these simulators allow assessment which oﬀers opportunities to deﬁne the skills level that allows progress to surgical training in the OR. However, the settings of training programs can be adjusted to the tutors choice which creates a need for validated training programs. First of all, consensus should be acquired on training settings. Second, this training program should be validated with expert performance as the guideline to deﬁne thresholds. The purpose of this study was to establish consensus on an international validated proﬁciency based training program. Methods: A meeting was organized for eight European teams with extensive experience with the LapSim V.R. simulator. Training goals and examination thresholds were determined based on expert scores of 25 experts (>100 endoscopic surgical procedures) of the paricipating centres. In order to show construct validity of the training curriculum 60 novices (no experience) were also ested. Construct validity for every single parameter was investigated by comparing novice and expert results. 8 exercises of the basic skills module and the suturing task of the LapSim 3.0 software were included in the proposed training program. 94 parameters were analysed and p<0.05 was set to be signiﬁcant. The thresholds were determined by the mean value of the second run of the experts. Results: Consensus was achieved on the structure of the training program. A mean number of 10 parameters per task were assessed. At the hard level 52 out of 94 parameters of this program (55%) showed construct validity. The number of valid parameters per task ranged from 3 to 10 (mean 6). Discussion: A training program was build in consensus by eight teams who all had personal experience in validating the LapSim V.R. simulator. The parameters that proved to be useful for assessment can be used to deﬁne the training program endpoints. By doing so, a proﬁciency based training program can be oﬀered to training centres that use this simulator for training basic skills in endoscopic surgery.

CANCELLED

S4

O011 - Robotics, Telesurgery and Virtual Reality

O012 - Robotics, Telesurgery and Virtual Reality

EXPERT AND CONSTRUCT VALIDITY OF THE SIMBIONIX GI MENTOR II ENDOSCOPY SIMULATOR FOR COLONOSCOPY

THE MINIMALLY INVASIVE MANIPULATOR; AN INSTRUMENT IMPROVING THE PERFORMANCE IN STANDARDIZED TASKS FOR ENDOSCOPIC SURGERY J.E.N. Jaspers Academic Medical Center, AMSTERDAM, The Netherlands

A.D. Koch1, S.N. Buzink1, J. Heemskerk1, S.M.B.I. Botden1, R. Veenendaal2, J.J. Jakimowicz1, E.J. Schoon1 1 Catharina Hospital, EINDHOVEN, The Netherlands 2 Leiden University Medical Center, LEIDEN, The Netherlands Objective: The main objectives of this study were to establish the degree of representation of real-life colonoscopies on the Simbionix GI Mentor II virtual reality colonoscopy simulation, as judged by experts and to determine whether this simulator can distinguish between experienced endoscopists and novices performing virtual reality colonoscopy. Methods: Four groups were selected to perform two virtual colonoscopy simulations and one hand-eye coordination task (EndoBubble level 1) on the GI Mentor II simulator. The ﬁrst group, novices, were deﬁned as participants without endoscopic experience. The second group was intermediate experienced deﬁned by the number of colonoscopies performed before, being less than 200. The third group consisted of experienced endoscopists, deﬁned as between 200 and 1000 colonoscopies performed. The fourth group consisted of experts, who all had performed more than 1000 colonoscopies. All persons were asked to ﬁll out a questionnaire about their previous experience in ﬂexible endoscopy and their appreciation of the reality of the colonoscopy simulations performed. Appreciation was expressed on various aspects on a 4 point scale varying from very unrealistic (1) to very realistic (4). The average time to reach the coecum was deﬁned as one of the main testparameters as well as the number of times the view of the lumen was lost. Results: The group of experienced and expert endoscopists rated the colonoscopy simulation 2.90 on a 4 point scale for reality overall. Novice endoscopists (N=22) reached the cecum in an average time of 25:59 (min:sec), intermediates (N=12) in 6:18, experienced (N=16) in 4:19 and experts (N=35) in 4:56. Novices lost the view of the lumen signiﬁcantly more often compared to the other groups. The EndoBubble task was also completed signiﬁcantly faster by increasing grade of experience. These diﬀerences are statistically signiﬁcant using a Kruskal Wallis Test (p<0.001). A separate analysis of experienced versus experts demonstrated no signiﬁcant diﬀerence in time to reach cecum. Conclusion: In this study we have demonstrated that the GI Mentor II simulator does oﬀer a convincing realistic representation of colonoscopy according to experts (expert validity) and that the simulator can discriminate between diﬀerent levels of expertise (construct validity) in colonoscopy.

Background: To evaluate the feasibility and eﬃcacy of a mechanical minimal invasive manipulator (MIM) for endoscopic surgery. The MIM consists of two purely mechanical, hand-controlled endoscopic arms with joints, which allow 7 degrees of freedom (DOFs). Material and Methods: 30 medical students and researchers performed 4 diﬀerent tasks in a pelvic trainer box. with two conventional endoscopic needle holders or with a set of MIMs. The tasks consisted of 4 diﬀerent tasks. All experiments were recorded on videotape (S-VHS) and data was analysed afterwards by an independent observer using a quantitative time action analysis. Results: A signiﬁcant diﬀerence between number of total actions (including failures) was shown in most groups: the coin -, running rope - and passing rings tasks required less actions in the MIM-group when compared to the laparoscopy-group; respectively median n = 32; range 30 67 vs median n = 48; range 32 86, p < 0.001; median n = 23; range 21 31 vs median n = 35; range 24 64, p< 0.001 and median n = 55; range 40 82 vs median n = 67; range 44 208, p = 0.02. A signiﬁcant diﬀerence in failures per task was shown in favour of the MIM-group when compared to the laparoscopy-group for the coins and the rope-running task; median n = 1; range 0 8 vs median n = 5; range 1 12, p< 0.001 and median n = 1; range 0 8 vs median 10; range 3 29, p <0.001. Conclusion: These tasks clearly demonstrated the eﬃcacy of the MIM, even though some technical ﬂaws emerged during the experiments. Considering the fact that a ﬁrst prototype of the MIM was tested, modiﬁcations are to be expected in a next model. These experiments show the potential of the MIM and it is expected to be a competitive and economical instrument for endocopic surgery in the near future.

ABDOMINAL CAVITY AND ABDOMINAL WALL O013

O014

LAPAROSCOPIC INCISIONAL AND VENTRAL HERNIA REPAIR RESULTS AFTER 5 YEARS M. Rohr, N. Kleemann, M. Geertsen KKH Gifhorn GmbH, GIFHORN, Germany

OPEN VS LAPAROSCOPIC VENTRAL HERNIA REPAIR: A PROSPECTIVE COMPARATIVE STUDY

Laparoscopic incisional and ventral hernia repair is used with increasing frequency for complex and recurrent hernias. The expierence with this technique about 5 years in 214 cases is reviewed and the ﬁnding and complications are presented. Methods: Data were collected retrospectively for 169 incisional and 45 ventral hernias more than 3 cm in diameter. Results: 1. Incisional hernia repair: The review showed an overall complication rate of 23.1%. There have been mostly low complications like postoperative paralysis longer than 2 days in 25 cases (14.8%), but no ileus for reoperation, only two cases (1.2%) there have been an infection and in one case (0.6%) a bowel injury. In 9 cases (5.3%) we have seen suture site pain. In all cases, founded by ultrasound, we have had a seroma in the old hernia sac, but only two persiting seromas (1.2%) until now. In only 6 cases (3.6%) we have seen a recurrence. Most of the recurrence located in the suprasymphatic region and patients with a BMI greater than 30 cm/m accounted in more than 75% of the recurrence. 2. Ventral hernia repair: Here we have had a lower complication rate (11.1%). In one case we have had a bleeding, one prolongated paralysis, none ileus and none infection. In 3 cases (6.6%) there has been a suture site pain. Until now we have no recurrence. Conclusion: The laparoscopic procedure may be safely performed with low complication and recurrence rate even in obesity. The laparoscopic technique should be considered for the repair of mostly all incisional and big ventral hernias requiring with mesh prosthesis. The suprasymphatic region is a problem for laparoscopic repair.

Since its introduction in 1992, laparoscopic incisional hernia repair has revolutionized the management of ventral hernia. To date, preliminary studies show that laparoscopic approach seems to have a better outcome than the historical conventional approach. In fact, open ventral hernia repair either after primary suture or after mesh repair is known to be associated with signiﬁcant morbidity and high recurrence rates. Laparoscopic approach is increasingly becoming an attractive option and may possibly replace open repairs. Our objective was to compare open versus laparoscopic repair for ventral hernia. 100 patients underwent 50 laparoscopic and 50 open ventral hernia mesh repairs from 2001 to October 2004. There were 86 female and 14 male patients (mean age 55.66 yrs; range 30–83 yrs) in the study. No signiﬁcant diﬀerence between the two groups was noted regarding patient demographics except that the mean hernia size for laparoscopic group was larger signiﬁcantly larger (94 cm2) as compared to open (55 cm2) (p<0.002) In the laparoscopic group 23.5% of the patients had a previous open repair while only 16.2% in the open group. In both groups the hernia was reducible in 65% of cases. Open repair was done using standard Rives-Stoppa technique with mesh while laparoscopic repair was performed using three trocars placed laterally in the abdominal wall. IPOM was utilized with both transfascial suture and spiral staplers for ﬁxation of double-layer polyester mesh coated with collagen membrane. The mean follow-up time was 18 months. We found no signiﬁcant diﬀerence in the operative time between the two groups (laparoscopic 110 min vs open 95 min). Pain score and analgesic requirement was not signiﬁcantly diﬀerent between the two groups for the ﬁrst 4 8hours but a signiﬁcantly less pain was noticed at 72 hours (p<0.02). Hospital stay was signiﬁcantly less in the laparoscopic group (2.2 vs 3.6 days, P < 0.02). There was no diﬀerence in overall complication rates (p= 0.072). Two patients in the open group vs one in the laparoscopic required the removal of the mesh for infection. There was two recurrence (4%) in laparoscopic group and 6 (12%) in open group. In conclusion, laparoscopic ventral hernia repair oﬀers signiﬁcant advantages and should be considered for repair of primary and incisional ventral hernias larger than 3 cm. In our series signiﬁcantly larger ventral hernias were repaired with better short and medium term outcomes.

D. Lomanto, A. Katara, S. Iyer, J. Domino, A. Shabbir, W-K. Cheah, J. So National University Hospital, SINGAPORE, Singapore

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TOTALLY ENDOSCOPIC EXTRAPERITONEAL INGUINAL HERNIA REPAIR: A SINGLE CENTRE EXPERIENCE WITH DIFFERENT MESHES

IS IT POSSIBLE FOR US TO REDUCE PERITONEAL ADHESIONS IN THE SURGICAL TREATMENT OF VENTRAL HERNIA USING INTRAPERITONEAL (LAPAROSCOPIC) PROSTHESIS?-EXPERIMENTAL STUDY IN ANIMAL. J.M. Sua´rez Grau1, J.A. Martı´ n-Cartes1, M. Socas1, F. Lopez Bernal1, J.M. Alamo1, M. Bustos1, S. Morales Conde2, H. Cadet1, J.D. Tutosaus1, S. Morales Me´ndez1 1 H.U. Virgen del Rocı´ o, SEVILLE, Spain 2 H.U. Virgen Macarena, SEVILLE, Spain

D. Lomanto, A. Katara, S. Iyer, J. Domino, A. Shabbir, W-K. Cheah National University Hospital, SINGAPORE, Singapore Laparoscopic hernia surgery is gaining its role because of the beneﬁts to patients that are evident from many published RCT when compared laparoscopic to open hernia repair: less postop pain and analgesic consumption, earlier return to normal activities and work, less chronic pain and permanent paraesthesia. A review of our experience was undertaken involving 280 consecutive patients who underwent 350 extraperitoneal inguinal hernia repair (1998–2003) at the National University Hospital, Singapore. We performed 234 unilateral repair and 116 bilateral repair. The hernia repair was performed using three diﬀerent methods. In group 1: polypropilene mesh was anchored with spiral tacker (n=229); group B, polypropylene mesh was not anchored using staplers (n=51) and in group 3 a multiﬁbre polyester anatomic mesh (Sofradim, Parientex ADP2) was utilized (n=70). The mean age was 49 years (range 20–81) and 85% were men. The overall mean operative time was 50 min (range: 35–180 min); bilateral repairs took 27% longer than unilateral repairs. Four pts had conversion to open surgery, and 20 pts (8%) developed minor complications (groin seroma). The recurrence rate was: 7.3% when the mesh was not anchored, 1.6% when the mesh was anchored and no recurrence was recorded when anatomic mesh was utilized (mean follow-up: 13.1 months). There was no recurrence detected in the last 112 cases (70:anatomic mesh; 42:polypropilene mesh and tacker). The mean inpatient hospital stay was 1.4 days, and of the last 30 cases, 70% were performed as outpatient. Laparoscopic inguinal hernia repair is a relatively new approach in the long history of groin hernia repair. To achieve an acceptable recurrence and complication rate, surgical technque is very important. An adequate anatomical dissection together with a correct mesh placement, orientation and anchoring are the key factors. Data from our study showed that using anatomic mesh we can achieve the same recurrence and morbidity rate as using mesh plus ﬁxation with tacker but with lesser cost and less post-operative chronic pain. Laparoscopic approach remains an alternative and feasible method to open hernia surgery. In our 6 years experience, TEP hernia repair can be done with minimum morbidity and in the majority of cases can indeed be performed in the Day Surgery setting especially once learning curve has to be overcome, and the repair can be accomplished.

Aims: Frequently we must leave a biomaterial into abdominal cavity for repairing deﬀects of abdominal wall. Its necessary to know how this biomaterial will act in that place and its relation with peritoneal adhesions. This ability of mesothelialisation we think is a predictable factor related with the genesis and appareance of peritoneal adhesions. Methods: Twenty pigs were included in this study and divided in two groups. Using helical staplers fasteners, performed four implants (squares 4 x 4 cms.): two of them (in an upper location) were in PTFE (Dualmesh Plus Corduroy), and two lowers polipropylene mesh. Group A: The implants located in the right side of animais were painted with ﬁbrin glue. Group B: Using the same technique right implants were painted with hyaluronidase gel. After a ﬁve week period, the pigs were re-operated, determinating the intraperitoneal adhesions ratio and grades, mesothelialisation percentil of the visceral surface of prosthetic materials, and evaluating the retraction of prosthesis and later sacriﬁced Samples having abdominal wall and implants were taken for histological study. Results: Intraperitoneal adhesions decreased both in implants painted wth ﬁbrin glue and hyaluronidase gel in a comparative study with implants located in left side of animals (not painted). In a comparative study intergroups group B have a better results. By the other hand a material said a typical producer of intraperitoneal adhesions is almost without any adhesion in many animals, whose had an high degree percentil of mesothelialisation. Retraction of PTFE implants arose a 70% in area, meanwhile in polypropylene mesh 8–10% only. Conclusions: Fibrin glue and hyaluronidase gel both reduce postoperative peritoneal adhesion ratio and grades, having an high degree of mesothelialised areas. By the other hand hyaluronidase gel has a great advantage: is a very cheap product.

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PATENT PROCESSUS VAGINALIS IN THE ADULT AS A RISK FACTOR FOR THE OCCURRENCE OF INDIRECT INGUINAL HERNIA R.N. van Veen1, M. Buunen2, K.J.P. van Wessem1, J.A. Halm1, M.P. Simons3, P.W. Plaisier4, J Jeekel1, J.F. Lange1 1 Erasmus Medical Centre Rotterdam, ROTTERDAM, The Netherlands 2 ALMERE, The Netherlands 3 Onze Lieve Vrouwe Gasthuis, AMSTERDAM, The Netherlands 4 Albert Schweitzer Hospital, DORDRECHT, The Netherlands

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING RESULTS WITH DIFFERENT BAND TYPES V.V. Grubnik, V.P. Gollyak, O.V. Grubnik Odessa State Medical University, ODESSA, Ukraine

Background: Inguinal hernias are a common entity with nearly 31.000 repairs annually in the Netherlands and over 800.000 in the United States of America. The aim of the present study is to determine whether a laparoscopically diagnosed patent processus vaginalis (PPV) is a risk factor for the development of groin hernia. Methods: The study population was originally composed of 599 consecutive cases (189 male, 32%) of laparoscopic transperitoneal surgery for different indications performed in 4 teaching hospitals in the Netherlands between November 1998 and February 2002. During laparoscopy the deep inguinal ring was inspected bilaterally. The PPV group was compared with the obliterative processus vaginalis (OPV) group. Results: After a mean follow-up of 5.5 years the studied population consisted of 337 cases (94 male, 28%). In this study 12% of the studied population appeared to have PPV in adult life. The percentage PPV of our study group is much higher than the percentage of hernia repairs performed in the Dutch population. A greater proportion (12%) of hernia repairs in the PPV group was found compared to the OPV group (3%). The chance of developing an inguinal hernia within 5.3 years is four times higher in the group with PPV. No signiﬁcant correlation between age and the prevalence of PPV was observed. Conclusion: This study demonstrates that PPV is an etiologic factor and a risk factor for acquiring an indirect inguinal hernia in adults.

Background: Laparoscopic adjustable gastric banding is one of the most eﬀective operation for morbid obesity. Many devices from diﬀerent companies are now available. The aim of this study was to compare the results of diﬀerent types of Lap-Band. Methods: randomized study was conducted from 2002 to 2005. two consecutive groups were analyzed. Group A consisted of 42 patients with morbid obesity (mean BMI=43.55.2 kg/m2; women 37, men 5, age 28–58 years) who received the Lap-Band (ÔInamedÕ, USA and ÔEndomedÕ, Ukraine). Group B consisted of 43 patients (mean BMI=45.86.4 kg/m2; women 34, men 9, age 30–56 years), who received the band (ÔMinimizerÕ, Germany) which contains eyelets. All the bands were placed above the lesser sac by the perigastric approach. Mean duration of laparoscopic operation in group A was 7215 min, in group B-6512 (p>0,05) Results: There were no postoperative mortality. 3 (7%) early complication were observed in group a (1 postoperative pneumonia, 2 early displacement of the band); and 1 (2.3%) in group B (1 bleeding from acute gastric erosion). After a follow-up of 3 years, the displacement rate of the band was 9.5% in group A and 0% in group B. two patients from group A had reoperation for band displacement. After 3 years, the average loss of excess weight was 47% in group A and 53% in group B (p>0,05) Conclusion: The eﬃcacy with respect to weight loss was equivalent with bath types of band. With the Minimizer band no band slippage was observed.

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TECHNIQUE OF LAPAROSCOPIC GEOMETRICAL REPAIR OF VENTRAL HERNIA - HOW I DO IT V. Golash Sultan Qaboos Hospital, SALALAH, Oman

COMPUTER AIDED SYSTEM FOR ERGONOMIC PORT LOCATIONS IN ABDOMINAL MINIMAL ACCESS SURGERY H. Arnarsson, G.B. Hanna, A. Cuschieri Cuschieri Skills Unit, DUNDEE, United Kingdom

Aim: The recurrence after the ventral hernia repair is a common problem worldwide. The laparoscopic mesh repair has shown lesser recurrences and also minimal morbidity. The technique of the laparoscopic repair is based on the principle described by Stoppa but with the diﬀerence that the hernial sac is not dissected and is left behind 1. This saves the diﬃcult dissection, blood loss and large incisions. The mesh in laparoscopic repair is ﬁxed intraperitoneally using tackers or dual method of tackers and sutures, but some kind of suture ﬁxation is mandatory. We describe here a technique of ﬁxing the mesh with sutures only. Method and results: Over a period of 52 months we repaired 247 ventral hernias using suture only technique. The mean size of defect was 9.12 cm (65.29 cm2) and mean size of mesh used was 19.34 cm (293.62 cm2). Our technique involves ﬁxing the mesh with sutures circumferentially in two circles. The tackers and staplers were not used. The sutures are placed at ﬁxed intervals, in ﬁxed numbers and in ﬁxed positions as mapped out with the help of circular protractors, compass and ruler. The protectors have helped us in standardizing the placement intervals of sutures and in the orientation of the mesh. The orientation is maintained even for a very large mesh. There was no infection of the mesh, recurrence and mortality. The patient experienced minimal wound pain and the recovery was quicker. Conclusion: This is the only technique of laparoscopic ventral hernia repair we are aware of in which the suture intervals, position of the sutures, the number of sutures are standardized. This approach is suitable for all types of ventral hernia. It is safe, cost eﬀective and so far recurrence free.

Background: Port locations and their resulting instrument positions are important for task performance, surgeons comfort and patient safety. Ideal instrument angles and distances have been studied inside laparoscopic box trainers. Patient abdominal topography is variable, may be signiﬁcantly altered intra-operatively and is paramount when considering port locations. Port location planning based on ergonomic principles that uses individual patient data seems feasible. Aim: To record current port locations for laparoscopic cholecystectomy and their resulting instrument positions in clinical setting and construct a computer aided system to examine and plan optimal abdominal wall port locations. Methods: System components were identiﬁed. Observational study was undertaken where anterior abdominal wall dimensions and region of interest (the gallbladder neck) were measured pre-operatively, instrument positions recorded intra-operatively and port locations measured post-operatively. The data was used to re-create port locations and their resulting instrument positions in virtual reality for laparoscopic cholecystectomy. Results: 18 patients were studied resulting in 213 measurements. Median port location co-ordinates in this study were as follows: Optical port (0, 17), Manipulation ports M1 (0, 2.5), M2 (12, 7) and M3 (14.5, 12.5) where the co-ordinates are distance from midline and xiphoid process in centimetres. The gallbladder neck projected onto the abdominal wall was 8 cm from midline and 1 cm above the Xiphoid process and its depth 7 cm within the abdominal cavity. Modiﬁed port locations were identiﬁed in four patients where the resulting instrument and laparoscope positions resulted in seemingly superior ergonomic proﬁle. A computerized port location system that places laparoscopic instruments, the laparoscope and target organ in an accurate virtual abdomen was constructed. Conclusion: Port locations and their resulting instrument positions were successfully measured in clinical setting and then re-created in virtual reality. The study identiﬁed a practice of modiﬁed port locations for laparoscopic cholecystectomy that result in more ergonomically ideal operating conditions than conventional port locations.

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SUTURING THE MESH IN LAPAROSCOPIC TOTAL EXTRA PERITONEAL (TEP) REPAIR OF INGUINAL HERNIA - HOW I DO IT V. Golash Sultan Qaboos Hospital, SALALAH, Oman

LAPAROSCOPIC TREATMENT OF ACHALASIA V.V. Grubnik, A.V. Malinovskiy, O.V. Grubnik Odessa State Medical University, ODESSA, Ukraine

Aim: For laparoscopic repair of inguinal hernia, total extraperitoneal approach is the procedure of choice. But the insertion of mesh in laparoscopic total extraperitoneal repair of inguinal hernia with proper orientation, spreading it without wrinkles and fold in preperitoneal space is diﬃcult to learn and practice. Prolene mesh is also known to shrink and sometime get displaced if not ﬁxed, in the preperitoneal space giving rise to recurrences. We describe here an easy technique of insertion of mesh and suture ﬁxation. The surgeon has full control over the mesh & placement is accurate. Method: We repaired 300 hernias in 225 male patients. Same technique was used in all the patients and by same surgeon. In our technique we used three midline ports. The dissection balloon and Tackers were not used. The mesh was ﬁxed by sutures at the anatomical line joining the two anterior superior iliac spines with the help of suture hook. We had no recurrence in 58 months of follow up. There were no intraoperative complications. Mean operative time was 35 minutes. There was no conversion to open or to intraperitoneal approach. We had no incidence of mesh or wound infection. Conclusion: There are doubts in the minds of many surgeons that recurrence rate will increase when mesh is not ﬁxed. Our technique of ﬁxing the mesh is easily reproducible and economical. TEP with suturing the mesh is now our standard approach for inguinal hernia.

Background: The aim of this study was to assess how subjective evaluation (heartburn, dysphagia, quality of life, satisfaction) correlates with objective data after Heller myotomy and Dor fundoplication for the treatment of achalasia in relation to the severity of the lesion. Methods: Laparoscopic Heller myotomy and Dor fundoplication were performed in 47 patients with achalasia. The therapeutic eﬀects of laparoscopic procedures were assessed in terms of operation time, intraoperative complications, postoperative hospital stay, symptoms improvement in relation to morphological type (spindle type, Sp in 24 patients, ﬂask type, Fk in 16 patients, sigmoid type, Sig in 7 patient). Subjective evaluation was done preop and postop using the Gastroesophageal Reﬂux Disease Health-Related Quality of Life scale (GERD-HRQL) and patient satisfaction scale. At 6 12 months postop patients were asked to undergo objective evaluation with 24-h pH testing, manometry, endoscopy and barium swallowing. Results: There were no conversion to open surgery. Esophageal mucosal perforation was seen in ﬁve of the 47 patients (10,6%), however, conversion to open surgery could be avoided by suturing the aﬀected area. Median average operation time was 11023 min. Median postoperative hospital stay was 5,52.2days. Degree of dysphagia relief was excellent in 39 (83%) patients, good in 7 (14,9%) patients and fair in one patient (2,1%). Excellent improvement was obtained in 87,5% of Sp patients, in 81,3% of Fk patients, and 57,1% of Sig patients respectively. There was no signiﬁcant relationship between GERD-HRQL score and pH test results. Lower esophageal sphincter pressure (LESP) decreased from 25 to 14 mm Hg (p<0,01). There was no relationship between dysphagia score and decrease in LESP after operation. Conclusions: Laparoscopic Heller myotomy and Dor fundoplication is an eﬀective treatment of achalasia. Subjective evaluation can show patient satisfaction but does not accurately reﬂect postop ferlux. Excellent symptomatic relief can be achieved in the patients with Sp and Fk morphological types.

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COMPARISON OF TRANSPERITONEAL AND RETROPERITONEAL APPROACHES FOR ENDOSCOPIC ADRENALECTOMY. V.V. Grubnik, S.V. Kalinchuk, S.V. Poltavets, V.V. Iliachenko Odessa State Medical University, ODESSA, Ukraine

RESULTS OF LAPAROSCOPIC AND OPEN SURGERY TREATMENT OF GASTRODUODENAL PERFORATION V.V. Grubnik, Y.V. Grubnik, V.A. Karluga, V.Y. Grubnik, V.V. Fomenko Odessa State Medical University, ODESSA, Ukraine

Background: Endoscopic adrenalectomy can be performed using either a retroperitoneal or transperitoneal approach. The aim of this study was to determine which of these is the optimal surgical technique. Methods: From 1995 to 2005, 138 laparoscopic adrenalectomies (transperitoneal in 74 patients and retroperitoneal in 56 patients) were performed in 130 consecutive patients. Tere were 70 right lateral and 52 left lateral procedures (8 patients had a bilateral procedures). The most prevalent indication was incidentaloma (36%), followed by pheochromocytoma (22.3%), and Conns adenoma (18.5%). Results: The laparoscopic procedures were performed successfully in 127 of 130 patients (97.7%). The conversion rate was 2.7% for the transperitoneal approach and 1.9% for the retroperitonal approach. No statistically signiﬁcant inﬂuence was noted for the parameters of intraoperative blood loss, rate of postoperative complications, and duration of hospital stay with regard to the surgical technique. The operative time and the learning curve proved to be signiﬁcantly longer for the retroperitoneal adrenalectomy. Tumor size (>5 cm) was a signiﬁcant factor inﬂuencing the operative time, whereas body mass index did not prove signiﬁcant. The analysis of the parameters of intraoperative and postoperative complications after left adrenalectomies had shown better results after retroperitoperitoneal approach in the patients with small tumors. Conclusion: The present results conﬁrm the high success rate and low risk reported for laparoscopic adrenalectomy. Diﬀerences between the two techniques in operative time and learning curves clearly favor the transperitoneal adrenalectomy. In the patients with small tumors (< 4cm) left retroperitoneal procedures demonstrated some beneﬁts.

Background: The aim of this study was to compare the outcome of laparoscopic and open approaches for the repair of gastroduodenal perforation. Methods: A retrospective review was conducted with 236 consecutive patients treated for gastroduodenal perforations during 10 years. These patients included 189 with perforated duodenal ulcers, and 47 with perforated gastric ulcers. There were 178 men and 58 women mean age of the patients was 46,8 12,6 years (range, 16–89 years). 25% of the patients had prolonged anamnesis of perforation (more then 24 hours) and presented with septic shock at admission. 108 (45,8%) patients were treated laparoscopically, 128 (54,2%) underwent open surgery. There were no signiﬁcant diﬀerences in the data for the two groups. Results: Laparoscopic repair was successful in 105 (97%) cases. The mean operative time was longer with the laparoscopic technique (82 vs 74 min), but the diﬀerence was not signiﬁcant. The postoperative analgetic requirements were signiﬁcantly lower after laparoscopic surgery (p < 0,01). The duration of postoperative nasogastric aspiration and time to resumed oral intake were shorter in the laparoscopic group (2,5 vs 4,3 days, and 3,6 vs 5,8 days, respectively; p < 0,05 ). Mortality was 1,9% in laparoscopic group and 2,4% in open surgery group (p >0,1). Overall complications rate was singiﬁcantly lower after laparoscopic surgery (9% vs 18,7%, p < 0,01). Where as, in the group of patients with anamnesis of perforation more then 24 hours, complications rate was higher in the laparoscopic group. There was no statistically signiﬁcant diﬀerence in hospital stay (5,6 vs 7,2 days, p> 0,05) between the two procedures. Conclusion: Laparoscopic repair of gastroduodenal perforations is an alternative treatment oﬀering some advantages. Patients with prolonged anamnesis of perforation and patients with severe comorbidities are not good candidates for laparoscopic repair.

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THE NEW METHOD OF REVISIONAL OPERATION FOLLOWING GASTRIC BANDING V.V. Grubnik, V.P. Gollyak, O.V. Grubnik Odessa State Medical University, ODESSA, Ukraine

LAPAROSCOPIC CHOLECYSTECTOMY IN CIRRHOTIC PATIENTS V.V. Grubnik1, O.L. Kovalchuk2, S.V. Kalinchuk1 1 Odessa State Mediacl University, ODESSA, Ukraine 2 Ternopyl State Medical University, TERNOPYL, Ukraine

Background: Laparoscopic adjustable gastric banding is a safe and eﬀective procedure for management of morbid obesity. However, band slippage and dysphagia are a common complication with variable presentation that can be rectiﬁed by a second surgical procedure. Methods: We studied case series of 32 consecutive patients who suﬀered from band slippage and dysphagia between 1989 and 2004 years from a group of 498 open and laparoscopic gastric banding procedures performed during this time. The decision of whether to remove/reposition or replace the band was made prior to the operation, although the speciﬁc method used when replacement or repositioning was deemed suitable was determined by the operative ﬁndings. In 13 patients with band slippage who had inadequate weight loss we used new method of revisinal operation. During reoperation band reposition was performed. After the reposition of the band we performed Roux-en-Y gastric bypass. The diameter of the stoma between proximal gastric pouch and jejunum was 5–7 mm. So this method of revisional operation includes the restrictive and shunting eﬀects. After operation we can control the diameter of the stoma between proximal and distal parts of the stomach so we can regulate the volume of food passing by natural way. Results: There were no mortality. 5 revisional operation were performed laparoscopically and 7 by open method. Wound complications were observed in 2 patients after open procedures. After a follow-up of 2,5 years all 13 patients were satisﬁed and had good results. The average loss of excess weight was 62.55.7%. There were no symptoms of dysphagia in all 13 patients, no symptoms of malabsorption were seen. Conclusion: Band slippage is not a raze complication after gastric banding. Combined revisional operations with band reposition and Roux-en-Y gastric bypass are aﬀective enough for achieving adequate weight loss without syndromes of malabsorption.

Background: Cirrhotic and portal hypertension have been considered relative or absolute contraindication to laparoscopic cholecystectomy (LC). This study aimed to assess the safety of LC in cirrhotic patients. Method: Between 1 September 1994 and 1 September 2004 4786 LC were performed, 138 (12,9%) patient had cirrhotic livers. The medical records of cirrhotic patient were reviewed, were analyzed demographics, severity of cirrhosis, laboratory data, operative morbidity, mortality and hospital stay. Based on the Child-Turcotte-Pugh (CTP) classiﬁcation of cirrhosis, there were 5 (3.6%) grade C, 32 (23.2%) grade B and 101 (73.2%) grade A patients. 79 (57,2%) patients were operated for acute cholecystitis, 36 (26%) had symptoms of jaundice. Results: Successful LC were performed in 99 (71.7%) cirrhotic patients. Operative roomtime ranged from 80 to 230 min, with the extent of coagulopathy correlating with the length of time needed to achieve satisfactory hemostasis. Complications occurred in 39 (28.3%) cirrhotic patients. Gastrointestinal bleeding from the esophageal varicose in early postoperative period occurred in 15 (10.8%) patients. In 12 patients admitted with obstructive jaundice preoperative ERCP and ES were performed. Laparoscopic bile duct explorations were successfully performed in 24 cirrhotic patients with choledocholithiasis. Blood product usage correlated with preexisting coagulopathy. 2 cirrhotic patients with acute cholecystitis died after operative due to bleeding from the esophageal varices associate with hepatocellular insuﬃciency. Postoperative mortality was 1.4%. Conclusions: Minor morbidity and shorter hospital stay can be achieved by applying LC to treat cirrhotic patients. Preoperative degree of coagulopathy and Childs class should guide the surgeons approach and expectations when LC is performed in a cirrhotic patient. Appropriate preoperative preparations and meticulous operative technique are required to reduce blood loss during LC.

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QUALITY OF LIFE FOR THE PATIENTS WITH GERD AFTER LAPAROSCOPIC FUNDOPLICATION WITH DIFFERENT METHODS OF HIATAL CLOSURE V.V. Grubnik1, A.A. Solomko1, O.V. Grubnik1, O.L. Kovalchuk2 1 Odessa State Medical University, ODESSA, Ukraine 2 Ternopyl State Medical University, TERNOPYL, Ukraine

LAPAROSCOPIC REPAIR OF INCISIONAL HERNIA: A RANDOMIZED TRIAL

Background: The aim of this study was to compare the preoperative and longterm postoperative HRQL in patients after laparoscopic fundoplication and to identify the morphological reason for recurrent or persistent dysphagia. Methods: Clinical assessment, endoscopy, 24-h pH manometry, and a previously, validated HRQL index were performed before and 3–5 years after surgery in 372 patients with GERD. Laparoscopic Nissen fundoplication was performed in 280 patients, Nissen-Rosetti fundoplication in 58, Toupet fundoplication in 34 patients. In 158 (42,5%) patients we used prosthetic hiatal closure. The hiatus was closed with the use of 2 · 3 cm polypropylene-vycril mesh in addition to simple sutures depending on the size of hiatal hernia. The patients were followed up clinically 6, 12, 36 and 60 months postoperatively. The course of clinical De Meester score, appearance and treatment of wraprelated side-eﬀects, long-term outcome and patients satisfaction were evaluated. Results: The 5-year follow-up rate was 82%. The esophageal mucosa returned to normal 3–5 years after laparoscopic fundoplication in 85% of the patients. Heartburn was absent or occasional in 93%, and 75% were free of antisecretory drugs. All postoperative HRQL items were signiﬁcantly improved (p<0,001). The median clinical De Meester score decreased from 4.11.7 points preoperatively (p<0.001). Of all operated patients, 4% had to be reinstalled on a regular PPI treatment because of postoperative GERD reappearance. Because of persistent postoperative dysphagia, 4.7% of the patients required endoscopic dilatation therapy. Wrap dislocation was identiﬁed in 3.2% of patients. Only in 8 (2.1%) patients presenting with the symptoms of dysphagia, the morphologic reason for obstruction was a problem of the fundic wrap. In the patients with wrap migration simple crurorraphy without mesh-ﬁxation was performed. Reoperation rate was 3.2%. Total morbidity was 10% and operative related mortality was 0%. Overall, 96% of patients were pleased with their outcome of late follow-up. Conclusion: Our long-term results show a low recurrence and morbidity rate of laparoscopic fundoplication. Postoperative dysphagia is more a problem of hiatal closure than a problem of the fundic wrap.

C.N. Tang, D.K.K. Tsui, J.P.Y. Ha, G.P.Y. Yang, M.K.W. Li Pamela Youde Nethersole Eastern Hospital, HONG KONG SAR, Hongkong Background: Traditionally, incisional hernias have been managed with either open suture or mesh repair; however recurrence and wound complications are not uncommonly seen. Patients and Methods: This prospective randomized controlled study is to compare laparoscopic versus open mesh repair in the management of incisional hernias. We include all incisional hernias without recent diagnosis of intraabdominal malignancy and previous attempted repairs. Patients with acute complications like strangulation and sign of active infection are also excluded. All enrolled patients would be informed about the study design, mechanism of repair and the potential risks and beneﬁts of the operation before randomization. The primary endpoint is postoperative length of stay and other secondary endpoints are complications, postoperative pain score and analgesic requirement as well as early recurrence. The results are analyzed according to intention-to-treat principle. Results: During the study period 2002–2006, there were 29 patients enrolled in the study. There were 13 open repairs and 16 laparoscopic repairs. The results were as follows:

Age ASA score BMI (Kg/m2) Size (cm2) No. hernia OT time (min) Pain score Stay (days) Complications Recurrence FU (mths)

Open (n=13)

Lap (n=16)

P-value

67.2 1.6 28.2 26.3 1.4 56.1 4.84 3.46 3 0 16.8

67.8 1.7 28.1 35.2 1.3 81.1 5.17 3.18 2 0 14.8

ns ns ns ns ns ns ns ns ns ns ns

*P < 0.05 is statistically signiﬁcant Conclusion: Our preliminary results of laparoscopic mesh repair seem quite comparable to open approach but requires longer operation time and there is no obvious reduction in hospital stay and postoperative pain.

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INCIDENCE OF UNDIAGNOSED CONTRALATERAL INGUINAL HERNIA DETERMINED AT THE TIME OF LAPAROSCOPIC INGUINAL HERNIORRHAPHY IN ADULTS

LAPAROSCOPIC REPAIR OF INCISIONAL HERNIA. OUTCOMES OF A MULTICENTER RANDOMIZED CONTROLLED TRIAL VS. OPEN MESH REPAIR

J.C. Long, L.A. Long, S.S. Mehta, P.B. Lal, G.B. Davis, R. Davis, P.R. Reardon The Methodist Hospital, HOUSTON, United States of America

J. Aguilo´1, F. Asencio2, S. Peiro´3, J. Carbo4, R. Ferry1, F. Caro4, M. Ahmad2 1 Lluis Alcanys, XATIVA, Spain 2 Arnau de Vilanova, VALENCIA, Spain 3 Valencian School of Public Health, VALENCIA, Spain 4 Francisco de Borja, GANDIA, Spain

Introduction: Contralateral inguinal exploration (CIE) of the asymptomatic side is routine practice for pediatric hernia repairs secondary to the high incidence of bilateral inguinal hernias. In adults, CIE is not common practice secondary to the presumed low incidence of asymptomatic contralateral inguinal hernias and the increased morbidity from open CIE. However, laparoscopic inguinal herniorrhaphy oﬀers the advantage of CIE without additional incisions or signiﬁcant morbidity. This study was undertaken to determine the incidence of undiagnosed contralateral inguinal hernia (CIH) determined at the time of laparoscopic inguinal herniorrhaphy in adults performed by a single surgeon. Methods: A retrospective review of patient records from June 1992 to December 1999 revealed 276 patients that underwent laparoscopic inguinal herniorrhaphy. One hundred seventy nine unilateral repairs were performed, and 97 bilateral repairs were performed. Results: Average age was 50 yrs (range 14 to 83), and the male to female ratio was 19:1. Fifty-one patients in the unilateral repair group did not have a CIE and were therefore excluded. Of the 225 patients that underwent bilateral inguinal exploration, 208 were repaired using a totally extraperitoneal approach, and 17 repairs were performed using a transabdominal approach. Sixty-two patients that underwent bilateral repair had a pre-operative diagnosis of bilateral inguinal hernia; therefore, 35 bilateral repairs were performed for an undiagnosed asymptomatic contralateral inguinal hernia. Of the 163 patients that had a pre-operative diagnosis of unilateral inguinal hernia, 21.5% (35/163) had an undiagnosed asymptomatic CIH. Discission: The results of this study revealed a 21.5% incidence of undiagnosed CIH, which is consistent with prior reports of 10–25%. Furthermore, Thumbe and Evans reported in a randomized control trial that 28.6% of incipient inguinal defects developed into symptomatic hernias requiring repair within 12 months. Therefore, in the present study, 10 patients (6%) would have required a second operation within 12 months had the incipient hernias not been identiﬁed and repaired at the time of the ﬁrst surgery. Conclusion: The incidence of undiagnosed asymptomatic CIH is much higher than most surgeons appreciate. Laparoscopic inguinal herniorrhaphy oﬀers the advantage of visualizing both inguinal regions with minimal morbidity and minimal extra operating time.

Aims: To compare surgical outcomes, pain, quality of life and recurrence in patients undergoing laparoscopic or open mesh repairs in the surgical treatment of ventral incisional hernias. Methods: Incisional hernias between 5 and 15 cm in diameter were randomly assigned to open (OMR) or laparoscopic (LMR) mesh repair. 83 patients (OMR=38; LMR=45) were included. The main outcome was quality of life. Secondary endpoints were: Perioperative complications, duration of the procedure, length of hospital stay, pain and recurrence rate. Postoperative pain and quality of life were evaluated by means of Euroqol-5D and visual analogical scales. Standard polypropylene meshes were utilized in the OMR and a doublecoated polypropylene/PTFE mesh was used in the LMR. The essential objective of this presentation is to analyze the one year recurrence rate. Results: Women:67%; men:33%; age:59.0 years. There were no diﬀerences between groups in preoperative characteristics. No statistical diﬀerences were found in terms of lapse to oral intake or length of stay. Operative time was longer in the LMR group (101.9vs.68.1 minutes; p<0,001). There were no deaths nor reoperations in either group. Five conversions occurred, generally secondary to technical diﬃculties (11%). There were more local complications in the LMR (28.8% vs. 5.3%; p<0,05), due to a larger incidence of seroma. One bowel perforation occurred in the LMR group. No signiﬁcant diﬀerences were detected in general complications (6.6% LMR vs. 2.6% OMR). No diﬀerences were found either in terms of pain scores, quality of life and health status measurements in days 1, 2, 3, 7, one month, three months and one year postoperative, with exception of a mild, but signiﬁcant, increase in pain scores in postoperative day 30 in the LMR group (p<0.05). The recurrence rate was 9.4% for the OMR and 10.5 for the LMR, the diﬀerence being non signiﬁcant. Conclusions. Our data, suggest that both procedures are equivalent in terms of recurrence, surgical outcomes, pain and quality of life except for operative time and local complications, both favorable to open procedure.

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REPAIRING PRIMARY AND RECURRENT PARASTOMAL HERNIAS WITH A MESH IS FEASABLE AND SAFE USING A LAPAROSCOPIC APPROACH: EARLY EXPERIENCES OF 55 CONSECUTIVE CASES

HOW MANY MESH FIXATION POINTS ARE NEEDED IN LAPAROSCOPIC INCISIONAL OR VENTRAL HERNIA REPAIR? AN EXPERIMENTAL BIOMECHANICAL APPROACH M. Gass, J.-M. Heinicke, D. Candinas, G. Beldi Inselspital, BERN, Switzerland

B.M.E. Hansson1, I.H.J.T. de Hingh2, R.P. Bleichrodt3 1 Canisius Wilhelmina Ziekenhuis, NIJMEGEN, The Netherlands 2 Catharina Ziekenhuis, EINDHOVEN, The Netherlands 3 Radboud University Medical Center, NIJMEGEN, The Netherlands Introduction: Parastomal herniation is a common complication of stomal formation and its operative treatment is notoriously diﬃcult. Recently we have described a new technique in which a 15 x 19 cm Gore-Tex Dual Mesh with a 2 cm central keyhole is laparoscopically fashioned around the bowel to close the hernia. Potentially this technique combines the advantages of a mesh repair with those of minimal invasive surgery. Methods: Since 2002 in total 55 consecutive patients (27 men, median age 63 yrs) with a symptomatic primary (n=45) or recurrent parastomal hernia (n=10) were electively operated using this technique. The demographic and perioperative data and early follow-up of these patients were prospectively collected and are presented. Results: Of the 55 procedures, 47 (85.5%) could be completed laparoscopically (median operation time of 120 min). Conversion to laparotomy was indicated because of dense adhesions prohibiting safe dissection (n=4) or bowel-injury (n=4). No in-hospital mortality occurred. Postoperative recovery was uneventful in 47 patients (85%) with a median hospital stay of 4 days. Non-surgical complications occurred in 4 patients (7.2%) being pneumonia (n=2) and prolonged ileus (n=2) which were treated with conservative measures. Relaparotomy was performed in 4 patients (7.2%) because of bleeding (n=1), small bowel injury (n=1) and mesh-infection (n=2). Early wound complications were common with swelling (n=18), seroma (n=15), haematoma (n=5), erythema (n=3) but no infectious complications. All patients were re-examined after 6 weeks (follow-up 100%). Mild pain at the site of the mesh was reported by 9 patients, all others were symptom-free. At physical examination 1 residual haematoma and 1 small and asymptomatic residual hernia were noted. Conclusion: This study represents by far the largest serie of laparoscopic repairs available and the results compare favourable to those reported in literature. Therefore it is concluded that the presented laparoscopic technique is feasible and safe and although longer follow-up is needed to draw deﬁnitive conclusions, early follow-up shows promising results.

Objective: Mesh repair of ventral and incisional hernias has been proven superior to direct suturing in terms of recurrence rate. With the advent of novel dual layer materials this technique is being widely applied but analysis of hernia recurrences show that correct mesh ﬁxation to the abdominal wall is of paramount importance. This is usually done by placing an arbitrary number of transabdominal sutures or tacks. We propose a formula based on a biomechanical rational in order to calculate the number of sutures or tacks necessary for a mesh ﬁxation. Material and Methods: The force required to disrupt the mesh ﬁxation (tensile strength) was measured by a dynamometer in pig cadavers for sutures and tacks. A formula was derived from Laplace‘s Law (Tension= Diameter x Pressure / 4x wall thickness) and the boiler equation (Force = Pressure x Area). Results: The tensile strength of 1 transabdominal suture (Prolene 2.0, Johnson & Johnson) was 3 N (mean). The value for the tacks (Pro-Tack, Tyco) was 1,8 N (mean). The maximum intraabdominal pressure is known to be about 150 mm Hg (coughing pressure). Based on measurements of abdominal CT scans the average internal diameter of the abdominal cavity is approximately 0,35 m. Derived from the same studies the average wall thickness of the abdominal wall is approximately 0,05 m. Using these values in the transformation of the aforementioned physical laws the number of ﬁxation points in relation to the ﬁxation device (constant K) and the size of the incisional hernia can be calculated as follows: number of ﬁxation points n = K (ﬁxation device) x (r (Hernia[cm]) + s (overlapping of the mesh[cm]) exp2. The constant values are K (sutures) 0,38 and K (tacks) 0,63. Taken into account that the mesh is overlapping the perimeter of the hernia and adding this overlap to the radius of the hernia in the formula, the calculated number of ﬁxation points includes a large safety margin. Conclusion: We propose a simple biomechanically derived formula which can be easily used to calculate the number of needed ﬁxation points depending on the ﬁxation device and the actual size of the hernia and the mesh.

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NATION WIDE SURVEY OF LONG-TERM OUTCOME AFTER LAPAROSCOPIC ANTIREFLUX SURGERY IN SWEDEN R.P. Sandbu1, M. Sundbom2 1 Sykehuset i Vestfold, TØNSBERG, Norway 2 Uppsala University, UPPSALA, Sweden

LAPAROSCOPIC TOTALLY EXTRA PERITONEAL INGUINAL HERNIA REPAIR: THE LEARNING CURVE S. Kattepura, A Saklani, J. Pattar, R. Duﬃeld, T. Philip The Princess Royal Hospital, TELFORD, United Kingdom

Aims: Excellent long-term results after laparoscopic antireﬂux surgery (LARS) has been reported from specialized clinics. However, these good results were not conﬁrmed when we did a national survey on patients operated on in 1995–1996 (Br J Surg 2002; 89: 225–30). Critics pointed out that this study included the learning curve of LARS which might explain the disappointing results. Therefore we repeated the survey four years later when more than 5000 LARS had been performed in Sweden. Methods: The Centre for Epidemiology at the Swedish National Board of Health and Welfare administers a register of all inpatient hospital care in Sweden. In total 1031 LARS were performed in 2000. A random sample of 236 patients was identiﬁed (Group I) and compared to a similar population of patients who had been operated on in 1995–1996 (Group II). Both groups received a disease-speciﬁc questionnaire 4 years after surgery. Results: In group I 12.4% of the patients complained of reﬂux symptoms several times a week, 16.7% used antireﬂux medications on regular basis and 6.7% had had a second procedure. In group II, the corresponding numbers were 11.0, 19.5 and 6.0% respectively. The number of dissatisﬁed patients was 14.8% in group I and 15.5% in group II. Treatment failure, deﬁned as global dissatisfaction, second operation or need of regular antireﬂux medication, was present in 25.4% in group I and in 29.0% in group II. The long-term outcome for patients operated on in 2000 did not statistically diﬀer from the outcome of patients operated on during the introduction of LARS. Conclusion: Long-term outcome after LARS in Sweden demonstrates that approximately one fourth of the patients experience some sort of treatment failure. The results have not improved even though the surgical method is well implemented after more than 8 years of common use.

Background: Laparoscopic Totally Extra Peritoneal (TEP) repair has been shown to be an eﬃcient method of treating inguinal hernias, with additional beneﬁts of minimally invasive surgery. Despite this, it is done only in 5% of General Surgeons in United Kingdom. We present our experience in Laparoscopic TEP inguinal hernia repair, its safety, complications and recurrence rates and reﬂect on the learning curve. Methods: Retrospective analysis of all Laparoscopic TEP inguinal hernia repair done by a single surgeon between January 2001 and December 2005 at The Princess Royal Hospital, Telford. UK. Herniae were classiﬁed by type and Nyhus grades. Two 5 mm and a 10 mm ports were used. 12X15 cms mesh with lateral ﬁsh tail used. Operating times, intra-operative and post-operative complications were studied. All the patients stayed overnight in the hospital. Results: One hundred and forty seven patients, 136 males and 11 females. The age range was 19 to 83 years. Median age was 58 years. Of 204 inguinal herniae, 72 were bilateral, 60 were unilateral. Two had incidental femoral herniae. Laparoscopic TEP hernia repair was attempted in all. Open conversion in four patients. Overall morbidity of 11.45% with no wound or mesh infections. Overall recurrence rate was 2.5%, including primary and recurrent hernia. Four recurrences in ﬁrst 100 and 1 recurrence in second hundred cases. Operating times and recurrence rates were compared with the published results. Conclusion: Laparoscopic TEP inguinal hernia repair is a safe and eﬀective operation with steep learning curve.

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LIGHTWEIGHT MESHES FOR ENDOSCOPIC HERNIA REPAIR EXPERIMENTAL BIOCOMPATIBILITY RESULTS OBTAINED IN A PORCINE MODEL C. Schug-Paß1, C. Tamme1, F. Sommerer2, A. Tannapfel2, F. Ko¨ckerling1 1 Hannover Hospital, HANNOVER, Germany 2 Inst. of Pathology, Ruhr University Boch, BOCHUM, Germany

VERESS NEEDLE PUNCTURE IN THE LEFT HYPOCHONDRIUM IN THE CREATION OF A PNEUMOPERITONEUM: A PROSPECTIVE STUDY USING TESTS, INTRAPERITONEAL PRESSURES AND INJECTED GAS VOLUMES J.L.M.C. Azevedo, O.A. Azevedo Federal University of Sao Paulo, SAO PAULO, Brazil

Background: A meticulous surgical technique, a mesh of adequate dimensions, and the use of a mesh with good biocompatibility properties are of decisive importance for the development of recurrences in endoscopic hernia repair surgery. Mesh ÔshrinkageÕ is a function of the biocompatibility of the mesh, that is, the properties of the mesh Materials and Methods: Utilizing a totally extraperitoneal technique in an experimental animal model, altogether 20 domestic pigs were implanted with a lightweight, large-pore polypropylene mesh containing an absorbable component consisting of poliglecaprone (Ultrapro) and a lightweight titanium-coated mesh (TiMesh extralight). After a period of 91 days, diagnostic laparoscopy followed by explantation of the specimens for macroscopic, histological and immunohistochemical evaluation was performed. Results: The mean mesh shrinkage was merely 1.9% and 5.1% resp.. The partial volume of the inﬂammatory cells was a low: 15.8% and 13,1% resp.. The markers of cell turnover, namely Ki67 and the apoptosis index, were also very low. The extracellular matrix showed a low value of TGF-beta. There was a signiﬁcant diﬀerence in collagen deposition (136.9 vs. 75,0). Conclusions: As a result of its good biocompatibility and elastic properties, the lightweight meshes showed only a very slight tendency to ÔshrinkÕ. Large-pore, lightweight polypropylene meshes possess the best biocompatibility, and the newly developed meshes meet these requirements. This renders it extremely well suited for clinical utilization in hernia repair surgery, and its minimal shrinkage characteristic, should help achieve low complication and recurrence rates.

Aims: To test the eﬃcacy of the Veress needle puncture in the left hypochondrium as an alternative method in the creation of the pneumoperitoneum. Methods: Patients were punctured by the Veress needle in the left hypochondrium (LH group=30) and in the abdominal midline (ML group=32). Needle positioning tests and the number of failed attempts at needle insertion for the creation of pneumoperitoneum were compared. In sequence, in 100 new patients (NLH Group), a left hypocondrium puncture was performed and tests regarding the positioning of the needle were evaluated: aspiration test (AT), resistance test (ResT), recovery test (RecT), dripping test (DT) and the test of initial intraperitoneal pressure (IIPT). The sensitivity (SE) and speciﬁcity (SP) of the tests were calculated, as well as their predictive positive values (PPV) and predictive negative values (PNV). Volume and intraperitoneal pressure were recorded at every 20 seconds, until a 12 mmHg pressure was reached inside the peritoneal cavity. During the creation of the pneumoperitoneum the variations of gas pressures and volumes were correlated as time passed. Results: A similar number of positive results for the needle positioning tests were observed in ML and LH groups. Two unsuccessful attempts at punctioning were recorded in the LM group and one in the HE group. In the NLH Group, concerning AT, the SE and the PPV could not be applied, and SP=100% and PNV =100%. In the ResT, SE =0%, SP =100%, PPV = did not exist and PNV =90%. Both in the RecT and in the DT, SE =50%, SP =100%, PPV =100% and PNV =94,7%. In the IIPT test, the SE, PPV and PNV =100%. The pressure curve displays a strong adjustment, = )2E)07x Time3 + 8E)0.5x Time2 + 0.0266x Time + 2.3083 with R2 = 0.801, and the values of intraperitoneal volumes recorded = 0.0157x Time + 0.1813 with R2 =0.9604. Conclusions: The left hypochondrium is an eﬀective location for insertion of the Veress needle to create a closed pneumoperitoneum. The studied tests are accurate and the prediction in respect of the values for pressure and volume in the most important moments of insuﬂation was accutately forecast.

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COMPOSITE MESHES FOR LAPAROSCOPIC INTRAPERITONEAL REPAIR OF ABDOMINAL WALL HERNIAS COMPARISON OF BIOCOMPATIBILITY IN AN EXPERIMENTAL STUDY USING THE PORCINE MODEL C. Schug-Paß1, C. Tamme1, F. Sommerer2, A. Tannapfel2, F. Ko¨ckerling1 1 Hannover Hospital, HANNOVER, Germany 2 Inst. of Pathology, Ruhr University Boch, BOCHUM, Germany

TOTAL EXTRAPERITONEAL PREPERITONEAL HERNIA REPAIR (TEP) OR LICHTENSTEIN REPAIR IN PATIENTS ABOVE 70 YEARS OF AGE A. Terzic, M. Mu¨ller, T.C. Bo¨ttger Klinikum Bremerhaven, BREMERHAVEN, Germany

Background: Despite numerous experimental studies, mostly carried out in the open small-animal model, the ideal structure for a mesh with maximum biocompatibility in the intra-abdominal region has yet to be found. Methods: Six pigs each underwent laparoscopic intra-abdominal placement of either a Dynamesh IPOM (Dahlhausen) or a PROCEED mesh (Ethicon), both of which were prepared for implantation in standardised fashion. After 129 days, the pigs were sacriﬁced and postmortem laparoscopy performed followed by the removal of the tissue embedding the mesh, to assess adhesions and shrinkage, and for histological work-up. The specimens were processed both histologically and immunohistochemically. Results: No intestinal adhesions were seen. In all cases, the greater omentum adhered, usually over discrete areas, to the meshes. In every case the omentum was separable from the mesh surface only by sharp dissection. With the Dynamesh, the average total adhesion area was 33.2% vs. 31.6% with PROCEED. In the case of the Dynamesh, the average shrinkage was signiﬁcantly smaller than in PROCEED (14% vs. 25%, p=0.029). Determination of the partial volume of the inﬂammatory cells showed no signiﬁcant diﬀerence (19.7% vs. 14.7%). Measurements of the proliferation marker Ki67 revealed no signiﬁcant higher values for PROCEED (10.8 vs. 7.2) than for Dynamesh. The apoptosis index was low in both cases (1.2 vs. 1.5). Conclusion: Without previous peritoneal lesions, we do not ﬁnd any adhesions to intestinal structures. Despite a good biocompatibility, composite meshes with cellulose (PROCEED) or PVDF (Dynamesh IPOM) cannot prevent adhesions to the greater omentum completely. Mesh shrinkage can be reduced by a certain elasticity of the material (Dynamesh IPOM). The optimal mesh for intraperitoneal use has still to be found.

Aim: The total extraperitoneal laparoscopic hernia repair (TEP) and the Lichtenstein repair, (a conventional tension free repair with mesh), are two competitive approaches for the repair of groin hernia in seniors. Method: From April 1st 2002 thru December 31st 2004, 483 surgeries for groin hernia repair were carried out in our surgical department. 354 of the surgeries were performed laparoscopically in the so called TEP approach and in 129 patients the conventional Lichtenstein repair was done. 76 patients (70 years and older), with a single or bilateral inguinal hernia were prospectively randomized for study purpose. After getting their informed concern, the patients were randomly allotted to groups undergoing either TEP- or Lichtenstein repair. Results: TEP was carried out in 37 patients and a Lichtenstein repair in 39 patients. 10 cases of bilateral groin hernia were simultaneously repaired laparoscopically whereas only 5 patients underwent a simultaneous Lichtenstein repair for bilateral inguinal hernia. The median duration of TEP repair for unilateral groin hernia was calculated at 50 minutes (28–75) and for unilateral Lichtenstein repair 55 minutes (30–135). The median duration of bilateral hernia repair was 73 minutes (35–115) for TEP and 85 minutes (30–140) for Lichtenstein repair respectively. The median postoperative hospital stay was 5 days (2–22) for the unilateral TEP repair, 6 days (4–14) for unilateral Lichtenstein repair, 5 days (3–6) for bilateral TEP repair and 7 days (5–11) for bilateral Lichtenstein repair. No case of wound infection was noted. 3 Patients allotted to the Lichtenstein repair group, developed postoperatively a scrotal swelling. 1 Patient randomized to either groups developed a haematoma. Conclusion: Both surgical procedures are comparable with respect to their hospital stay, duration of surgery and complication rates. However, laparoscopic herniorrhaphy for bilateral groin hernia tends to be associated with a speedy convalescence prompting an early hospital discharge. We therefore recommend the laparoscopic herniorrhaphy (TEP) for groin hernia repair in seniors older than 70.

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O039 LAPAROSCOPIC VENTRAL HERNIA REPAIR IN PATIENTS S.S. Ching, A. Yeung, A.I. Sarela, M.J. McMahon The General Inﬁrmary at Leeds, LEEDS, United Kingdom

O041 OBESE

LAPAROSCOPIC HERNIA REPAIR (TAPP) - MESHES AND FIXATION TECHNIQUES BIOCOMPATIBILITY - CLINICAL EXPERIENCES J-G. Schwarz, R. Bittner Marienhospital Stuttgart, STUTTGART, Germany

Aims: Laparoscopic repair of ventral hernias has several potential advantages compared to conventional open repair. This study aims to investigate the feasibility and safety of this technique in obese patients. Methods: Case notes were reviewed for 60 patients who underwent laparoscopic ventral hernia repair during April 2003 to January 2006. Data were collected with regard to patient age, body mass index, size of mesh, operating time, in-patient stay, complications and hernia recurrence. Results: There were 28 men and 32 women with a median age of 53 years (range 24–78 years). Hernias were incisional in 63% of the patients. Thirtyfour patients (57%) were obese (BMI > 30 kg/sq m) and, of these, 10 were morbidly obese (BMI > 40 kg/sq m). The two heaviest patients, with BMI 55 and 58 kg/sq m, had Roux-en-Y gastric bypass procedure concomitantly with the hernia repair. Four patients (BMI 25–42 kg/sq m) had previously undergone Roux-en-Y gastric bypass. There was no signiﬁcant diﬀerence in operating time between non-obese and obese patients (median 90 vs. 75 minutes, p = 0.712). The size of mesh used was also similar (median 300 vs. 225 sq cm, p = 0.598). The median in-patient stay was 2 days in both groups. Overall, there were 6 seromas (2 in non-obese, 4 in obese patients), 4 hernia recurrences (2 in non-obese, 2 in obese patients), and 7 patients had chronic postoperative pain (4 non-obese, 3 obese). Two non-obese patients developed skin ulceration over a polypropylene + ePTFE mesh, 18 or 28 months after operation, and needed subsequent removal of the mesh. Conclusion: Obesity is a common condition in patients undergoing laparoscopic repair of ventral hernia. We have shown that laparoscopic repair is a feasible technique associated with low rates of complication and hernia recurrence in the obese patients.

Introduction: The main questions about the Ôideal meshÕ and Ôhow to be ﬁxatedÕ in small and large hernias related to the biocompatibility for the beneﬁt of the patient are still not answered. In two prospective RCTs we evaluate these questions. Material and methods: Experiences of 13000 TAPP in the standard technique. Two RCTs with diﬀerent meshes and ﬁxation techniques. RCT(I) Ôsmall herniaÕ (until 3 cm) comparison Ti-mesh extralight (16g/m) with Prolene (90 g/m) without any ﬁxation;n=150/group. RCT(II) Ômedium sized herniaÕ (>3–5cm) comparison Ultrapro (28 g/m); Ti-meshlight (35g/m); Premilene (55 g/m) with Prolene (90g/m) and noninvasive glueﬁxation using 0,5 ml Tissucol (Baxter) at six standard ﬁxation points; n=150/group (n=500 recruited and analized). Standardized questionnaire peri-and postoperative. Double blind questioning, clinical examination, ultrasound at time preoperative, postoperative, 4 weeks, year and 1year. Visual/numeric analog scale (0–100). Objectives: inguinal and scrotal discomfort/pain with and without physical stress; foreign body feeling, physical impairment, analgetic consumption. Side objectives:seroma, recurrence-rate. Results: RCT(I) and RCT(II) no signiﬁcant diﬀerences according to analgetic consumption, foreign body feeling and physical imparement, follow up >1 year. RCT (I) 0.3%, RCT(II) 0.4% recurrence rate. The primary hernia situation of the recurrences were direct hernias. RCT(I) signiﬁcant diﬀerence at patients with inguinal pain (VAS >40) for the beneﬁt of the ultralight mesh after 4 weeks. In the RCT(II) we see similar tendences for the lower weighted meshes. But after one year we see nearly all patients free of discomfort and severe pain. No differences in both trials according to scrotal pain/discomfort. Signiﬁcant diﬀerence(p<0.05) in the early postoperative phase in seromas for the beneﬁt of the ultralight mesh (RCT I), no diﬀerence in the RCT II. No persistant seromas. Summary: In small hernias TAPP-repair by using a none-ﬁxated ultralight mesh is a safety and recommended procedure. None-invasive glueﬁxation of mediumweighted meshes in mediumsized hernias permits a practical and safety alternative ﬁxation technique. Preventing recurrency horizontal meshsize-modiﬁkation is recommended in direct hernias when using nonﬁxation-or glueﬁxation-techniques. In our opinion the future of the inguinal hernia repair in the TAPP technique is a herniadiameter- and herniatype-adapted mesh and ﬁxation procedure.

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THE ROLE OF ENDOSCOPIC AUTOPSY IN TRAUMA CASES (THE FIRST REPORT FROM IRAN) M. Talebpour, H. Peyvandi Tehran Medical University, TEHRAN, Iran

MESH SHRINKAGE AFTER LAPAROSCOPIC VENTRAL HERNIA REPAIR: A PROSPECTIVE STUDY M. Wagner, A. Lutz, E. Bruegger, G. Beldi, D. Candinas Inselspital, BERN, Switzerland

Aim: Traditional autopsy is not acceptable due to some religious restrictions in some countries. A new alternative is endoscopic autopsy (EA) mainly in thoracic and abdominal cases. The aim of this study is to access the accuracy of EA in abdomen. Material and method: All blunt trauma victims from Dec 2004 to Sep 2005 who died was selected in this study (n=50). In these fresh (<24 hours) cadavers EA were performed at ﬁrst. Intra abdominal and retroperitoneal exploration performed in all cases. Then traditional autopsy performed and the ﬁndings were compared statistically. Results: In 50 cases (F=6, M=44) (age=11 to 82 years) only 42% (n=21) cases had intra abdominal problems. Positive ﬁnding by EA was trauma to liver (n=11), spleen (n=8), stomach (n =1), small intestine (n =3), diaphragmatic rupture (n=4), colon (n=3), pancreas (n=2), gallbladder (n==1). Comparing to traditional autopsy ﬁnding, one liver trauma report was false positive due to cadaver changes, the grade of liver trauma was higher than was reported by EA in 2 case, one small intestine trauma was missed, the degree of trauma to pancreas was higher in one case, common bile duct cut was missed in one case. Sensitivity, speciﬁcity and accuracy of EA in intra abdominal problems were 73.3%, 97.1% and 905 respectively. The mean duration of EA was 75 min. Conclusion: EA is useful to access intra abdominal problems in cadavers and can use as an acceptable alternative of traditional autopsy in selected cases.

Aims: With the introduction of modern prosthetic materials the use of intraperitoneal prosthetic mesh has become widely accepted for the treatment of ventral hernias. Polypropylene meshes are associated with a very low rate of infections and an excellent biocompatibility. However mesh shrinkage has been described in vivo which could be associated with pain and hernia recurrence in patients. The aim of this prospective study was to examine the extent and the kinetics of mesh shrinkage after laparoscopic ventral hernia repair. Methods: A total of 133 consecutive patients underwent laparoscopic hernia repair between July 2004 and January 2006 at our institution. The boarder of the mesh (Parietene composite) was circumferentially marked with radiolucent titan clips. For mesh ﬁxation transfascial sutures or spiral tacks were used. Follow-up was performed using radiological controls before discharge, after 6 weeks and 6 months in prone position. Actual mesh size was measured by an independent observer using PACS (picture archiving & communicating system). For statistical analysis parametric tests (paired/unpaired t test) were used. Results: A total of 30 patients (6 female, 24 male) were included in the study (23 incisional/7 ventral hernia). Median size of implanted mesh was 400 cm2 (range 113–750). The overall mesh surface decreased by 6.2% (p = 0.004, 95% CI 2.2–10.2%) after 6 weeks in comparison to the postoperative radiological baseline measurement. In the subset of patients who had a follow-up after 6 months (n=15) no signiﬁcant changes have been observed (p = 0.82, 95% CI )9.4–7.5%). After 6 weeks shrinkage in patients with suture ﬁxation (n=19) was 5.8% compared to 6.8% in patients with ﬁxation by spiral tacks (n=11). Conclusion: In a clinical study we show a signiﬁcant reduction of mesh size within the ﬁrst 6 postoperative weeks after laparoscopic ventral hernia repair. No diﬀerence in mesh shrinkage was found between suture and spiral tacks ﬁxation after 6 weeks. Tissue ingrowth of polypropylene mesh leads to an early mesh shrinkage with a subsequent stabilization of mesh migration.

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POSTOPERATIVE PAIN FOLLOWING TISSUE ADHESIVE VERSUS STAPLER FOR MESH FIXATION IN LAPAROSCOPIC INGUINAL HERNIA REPAIR: A PROSPECTIVE, RANDOMISED OBSERVER BLINDED STUDY M. Wagner, R. Ipaktchi, G. Beldi, N. Haupt, M. Peter, D. Candinas Inselspital, BERN, Switzerland

OUR EXPERIENCE IN VIDEOSCOPIC TOTALLY EXTRA PERITONEAL REPAIR OF INGUINAL HERNIA M. Berbeoglu1, F. Ercan1, F. Balaban2, A. Gultekin2 1 ITEM (Adv.Medical Tech.Training Centre), ANKARA, Turkey 2 Sivas State Hospital, SIVAS, Turkey

Objective: The laparoscopic approach is widely accepted for inguinal hernia repair but requires mesh placement. However, mesh ﬁxation still merits further development in order to decrease postoperative pain and hyperalgesia without compromising the risk of recurrence. Therefore, the aim of this study was to compare mesh ﬁxation with tissue adhesive (N-butyl-2 Cyanoacrylat, Glubran) versus stapler (Protak) ﬁxation. Methods: Patients eligible for laparoscopic inguinal hernia repair were randomized in two treatment groups. In group A the mesh was ﬁxed using staplers and in group B tissue adhesive was used. Both, patients and physicians performing the postoperative follow-up at 6 wks and 6 mts were blinded. Included were all patients ﬁt for surgery with symptomatic uni- or bilateral groin hernias. Excluded were patients with scrotal hernias, incarcerated hernias or patients with recurrent hernias. In all included patients localisation, and intensity of pain and numbness in the groin was assessed using Ôvon Frey hairsÕ which is a means that allows a quantitative and qualitative sensitivity assessment. Visual analogue scale was used to assess postoperative pain. Values are indicated as mean SD. Results: At this interims analysis a total of 39 hernia operations have been performed. Stapler ﬁxation (group A) was performed in 18 and tissue adhesive ﬁxation (group B) in 21 procedures. No intra- and postoperative complication occurred. Mean length of stay was 4.5 d ( 0.7) and did not diﬀer between groups. There was no recurrence in either group at 6 months. At 6 weeks the intensity of pain (VAS) in group A was 1,7 0,7 versus 0,4 0,2 in group B (p=0,03). After 6 months the intensity of pain (VAS) in group A was 1,5 0,6 and in group B 0,8 0,4 (p=0,3). Conclusion: The use of tissue adhesive instead of stapler for mesh ﬁxation signiﬁcantly lowers the incidence of postoperative pain following laparoscopic groin hernia repair without increasing recurrence rate.

Aims: The aim of this study was to evaluate videoscopic totally extra peritoneal repair (TEP) of inguinal hernia. Methods: Between June 1994 and December 2005, 9646 videoscopicTEP repair of inguinal hernia was performed on 8348 patients by ITEM (Advanced Medical Technologies Training Centre) surgeons team. With the patient in the Trendelenburg position, the anterior rectus fascia was opened through a 1,5–2 cm infraumbilical oblique incision placed slightly toward the side of the hernia. Working space was created with distention balloon in the space of Retzius. After the peritoneum was dissected away from the rectus abdominis structural balloon and two 5mm trocars were inserted. Obturator, femoral, hasselbach and bogro spaces were dissected. Indirect, direct and femoral hernial sacs were dissected and reduced until an area suﬃcient for mesh placement was created. Standard 15 · 11 cm polypropylene mesh was manipulated to cover the pubic tubercle, the internal ring, CooperÕs ligament, the femoral canal, obturator area, the rectus abdominis medailly and spina iliaca laterally. The mesh was ﬁxated to CooperÕs ligament and the anterior abdominal wall with the 5 mm mesh ﬁxation devices. The mean operative time, peroperative complications, postoperative pain, persistent pain, postoperative complication, recurrences were recorded. The recurrence was evaluated among 4667 patients who were followed up to 75 months, according to their own descriptions on the telephone. Results: The mean operative time was 17 minutes for a side of hernia. Seroma was found most common postoperative complication in 5.13% (n=427) patients. The 75-months recurrence rate was 0.12% (n=6). Conclusions: With the experienced team, TEP repair of inguinal hernia is associated with short operative time, less postoperative complications and recurrence rate. We belive that no more discussion reqiure for TEP repair.

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OBJECTIVE ASSESSMENT OF LONGTERM NUMBNESS AND PAIN AFTER OPEN AND LAPAROSCOPIC INGUINAL HERNIA REPAIR M. Wagner1, G. Beldi1, N. Haupt1, M. Curatolo2, D. Candinas1 1 Inselspital, BERN, Switzerland 2 Department of Anesthesiology, INSELSPITAL BERN, Switzerland

CHRONIC PAIN AFTER LAPAROSCOPIC REPAIR OF VENTRAL AND INCISIONAL HERNIA S. Rakic, E.B. Wassenaar, J.T.F.J. Raymakers Twenteborg Hospital, ALMELO, The Netherlands

Aim: Chronic pain is an important outcome variable after inguinal hernia repair which is generally not assessed by objective methods. The aim of this study was to objectively compare chronic pain and hypoesthesia after inguinal hernia repair comparing open suture, open mesh and laparoscopic operations. Methods: A total of 96 patients were investigated with a median follow-up of 4.7 years. Patients were divided in open suture repair 40 patients (group A), open mesh repair 20 patients (group B) and laparoscopic repair 36 patients (group C) Numbness and pain was assessed using von Frey monoﬁlaments. Quality of life was investigated with the short form 36. Results: Pain occurring at least once a week was found in 7 (15.6%) patients of group A, in 5 (21.7%) patients of group B and in 6 (12.0%) patients of group C. Somatic pain occurred in 19 (61%), neuropathic in 9 (29%) and visceral pain in 3 (10%) of the patients with postoperative pain. In patients with postoperative pain hyposensibility was increased. Conclusions: In patients with persistent pain after inguinal hernia repair, area and amount of hyposensibility is increased. This eﬀect is pronounced in patients with open mesh and non mesh repair in comparison to laparoscopic repair.

Introduction: After laparoscopic repair of ventral/incisional hernia, some patients suﬀer chronic postoperative pain that may tend to reduce the overall beneﬁts of the procedure. We analysed this complication in a series of 325 patients who underwent laparoscopic repair of incisional (n=138) or ventral (n=187) hernia in an attempt to identify important details in their prevention and handling. Methods: In all patients, a DualMesh (WL Gore) prosthesis overlapping hernia margins by 3 cm was ﬁxed with either tacks (ProTack, TycoUSS) alone (n=102) or tacks and sutures (n=223). Pain resistant to conservative treatment >6 months was deﬁned as a Ôchronic painÕ. Fishers exact test was used for statistical analysis. Result: Five patients (1.5%), all with incisional hernias (p<0.05) and with mesh ﬁxation that involved sutures (p>0.05), experienced a chronic pain. These patients underwent relaparoscopy and removal of all sutures. Postoperatively, 3 patients had complete pain relief and 2 patients remained with moderate or marked pain. Conclusions: An obviously existing entity of chronic postoperative pain following laparoscopic repair of incisional/ventral hernia has got little attention so far. Patients with incisional hernia seem to be in a higher risk for occurrence of chronic pain than patients with ventral hernia. General opinion that sutures are a source of chronic postoperative pain did not reach statistical signiﬁcance in this series. Removal of sutures deemed responsible for pain in this series was less eﬀective than previously assumed.

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LAPAROSCOPIC HERNIA REPAIR WITH TWO ACCESS PORTS V. Zivanovic, G. Vasic KBC Dr D.Misovic, BELGRADE, Serbia and Montenegro

HERNIA RECURRENCE IN RIGHT SUBCOSTAL INCISIONS AFTER LAPAROSCOPIC REPAIR E.B. Wassenaar, D.R.J. Kempink, J.T.F.J. Raymakers, S. Rakic Twenteborg Ziekenhuis, ALMELO, The Netherlands

Aim: Laparoscopic incisional and recurrent hernia repair using a double layer mesh in an intraabdominal position after complete adhesiolysis with two access ports. Methods: From August 2003 till April 2006 we perform 172 operations for ventral incisional, recurrent ventral incisional, inguinal recurrent hernia and bilateral inguinal hernia. We use double layer mesh (Parietene composite, Sofradim, Villefranche sur Saonne, France) marked with titanium clips. Pneumoperitoneum was created with open technique. After creating adequate pneumoperitoneum (12–14 mmHg), we introduce 5 mm working port in manner that its position was at list 10 cm away from camera port. After thorough exploration we perform complete adhesiolysis and than we introduce mesh with preformed tranfascial sutures thru camera port. Mesh was ﬁxed with transfascial nonresorbable sutures. Minimum over-lap around the defect was 4 cm. Results: There were 55 patient with ventral hernia of which 60% recurrent (1 till 6 previous surgical attempts) on procedure after complete adhesiolysis there was 2,45 (range 1–7) defects per patients, and 117 patients with recurrent or bilateral inguinal hernia. Patients mean age was 56 year with BMI 35,2 kg/m2. With previous surgical history 84,4%. Mean time for procedure was 87 min and mean postoperative stay was 1,76 days. Local complications - seroma at seven patients. 22 patients have extended pain (2–4 weeks postoperatively). Conclusion: Laparoscopic hernia repair with two ports is eﬀective and safe using adequate mesh (4–5 cm over lapping). Short hospital stay and small postoperative pain are most important short term beneﬁt.

Objective: All hernia recurrences in a series of 135 patients who underwent laparoscopic repair of incisional hernia were analyzed to identify factors responsible and preventive measures. Aims. In all patients, a DualMesh (WL Gore) prosthesis overlapping hernia margins by =3 cm was ﬁxed with either tacks (ProTack, TycoUSS) alone (n=36) or tacks and sutures (n=99). Fifty-ﬁve of the hernias were in a midline incision, 22 in a right subcostal incision, 33 in another site, and 25 were recurrences after ventral hernia repair. During follow-up, 4 patients (3%) developed a recurrence, which was repaired laparoscopically. Operative reports and videotapes of the initial repairs and repairs of the recurrences were examined. Results: All recurrences were after mesh ﬁxation with tacks and sutures in a right subcostal cholecystectomy incision. In 3 patients, the recurrent hernia was attached to the mesh at the site of previously suﬃcient incisional scar; the fourth patient had a new hernia in another part of the subcostal scar. All initial repairs were performed technically correct. Repair of the recurrences involved placing a new, larger mesh over the entire subcostal incision, not just the hernia. No re-recurrences have been observed during follow-up (95 months). Conclusions: Laparoscopic repair of incisional hernia in a right subcostal incision appears to have a higher risk of failure than in other locations. Our experience indicates that the entire subcostal incision carries a signiﬁcant potential for hernia development. Initial repair of hernias in this speciﬁc site should address the entire scar and not only the hernia.

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DIFFERENT TACKS IN LAPAROSCOPIC VENTRAL HERNIA REPAIR (IPOM)- MATHEMATICAL MODEL AND IN VITRO STUDY M. Smietanski, J. Bigda, P. Gumiela, K. Bury, Z. Sledzinski Medical University of Gdansk, GDANSK, Poland

IPOM TECHNIQUE SELECTION OF PRIMARY ACCESS FOR THE FIRST TROCAR G. Vasic1, D. Vasic2, V. Zivanovic1 1 CHC Dr Dragisa Misovic, BELGRADE, Yugoslavia 2 DZ Rakovica, BELGRADE, Yugoslavia

Aims: Laparoscopic ventral hernia repair becomes a popular technique of good results and fast postoperative recovery. The mesh is placed directly under the peritoneum and anchored with transabdominal sutures and tacks. However the shape and surface of mesh is well known the role of the sutures and the amount of tacks remains to be not described. Methods: To assess the forces acting on a single tack mathematical model of the ventral hernia was created. The force was described in accordance to surface of the hernia oriﬁce and pressure in abdominal cavity. Diﬀerent types of the mesh (Proceed knitted mesh, Dual Mesh ePTFE ﬂat mesh, Shelhigh biological ﬂat mesh) and diﬀerent tacks (Protack, Anchor and EMS) were examined in vitro. On a pig model the forces needed to destroy the connection between mesh and tissue has been measured to describe a place of destruction (mesh, tissue or tack) and the force needed. Results: The force acting on a single tack proportionally depends on the surface of the hernia oriﬁce and pressure in abdominal cavity. The force needed to disconnect the tissue and mesh reached 8.97 N (0.11) for Protac, 2.67 N (0.22) for Anchor and 6.67N (1.32) for EMS. This values do not allowed holding the mesh in the right position, whenever the oriﬁce exceeds 10 cm for Protac and EMS and 5cm for Anchor The disconnection of EMS and Protac junction destroys the tissue. Anchor tacks are insuﬃcient to hold the mesh and stays in the tissue. Conclusions: In the case of small hernias (diameter <10cm) EMS or Protac used alone are enough to hold the mesh. For the larger hernias transabdominal sutures are needed for the procedure. We do not recommend the Anchor used alone in any hernia.

Aim: Problem of an incisional hernia is where and how to place ﬁrst trocar for a certain intake into abdominal cavity. The aim of this study is to determine the most convenient place and way of insertion of a trocar in regard of a previous abdominal operations and adhesion formation. Method: With patients to whom laparoscopic incisional hernia repair was performed (LIHR), the most crucial phase is the access to the peritoneal cavity and to decide where the ﬁrst trocar will take a place. Previous abdominal surgical history and size of one or more fascial defect, ultrasound examination of abdominal wall and adhesion formation, dimension of a mesh and positioning of it with transfascial sutures determines adequate choice for the ﬁrst trocar. It is necessary to determine right distance from the fascial defect and of a mesh which must overlap edge of defect for atleast 3–4 cm for safe work and for ﬁxing of a mesh. Upper left quadrant of abdomen of our patients was exact and safe place of scarves and adhesion formation. Place of a ﬁrst trocar is laterally moved away enough from the edge of a mesh and from the left costal arc as well because of undisturbed manouver and of the ﬁxation of a mesh. Open-access technique is mandatory for pneumoperitoneum creation. Results: From August 2003 till April 2006 on 55 patients with recurent incesional hernia was performed intraperitoneal on lay mesh techniqueIPOM. Preoperativly we have performed palpation of fascial defect and ultrasound examination of abdominal wall and with surgical ﬁnding of existance of a fascial defect and adhesion formation, it was noticeable that upper left quadrant of abdominal wall is the place where has no adhesion and open-access technique is safe to create pneumoperitoneum. On this way 53 patients have been approached (96,3%). There was none visceral injuries, no major vascular or epigastrical vessel injuries nor signiﬁcant bleeding and other complications on the place of the ﬁrst trocar. Conclusion: Upper left quadrant of abdominal wall stands for optimal place as an open-access technique ﬁrst trocar placing and is recommended to access the abdominal cavity.

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ABDOMINAL WALL MUSCLE FUNCTION AND INTEGRITY AFTER LAPAROSCOPIC AND OPEN DONOR NEPHRECTOMY

LAPAROSCOPIC VENTRAL/INCISIONAL HERNIA REPAIR: ONE CONSULTANTS LEARNING CURVE USING THE CUSUM AND VLAD

E. Sporn1, M. Herceg2, R. Steininger2, F. Mu¨hlbacher2, K. Kubin2, T. Paternostro-Sluga2, J. Zacherl2 1 Medical University of Vienna, VIENNA, Austria 2 MUW, VIENNA, Austria

S.A.L. Samlalsingh1, J.K. Birdi2, S.P. Wijeyekoon2, A. Bhargava2 Barking Havering & Redbridge NHS Trust, LONDON, United Kingdom 2 King George Hospital, LONDON, United Kingdom

1

Aims: In order to alleviate the access trauma to the abdominal wall laparoscopic donor nephrectomy (LDN) has been introduced. It has been shown that postoperative recovery was faster after LDN when compared with open donor nephrectomy (ODN). We aimed to compare LDN with ODN regarding functional integrity of the abdominal wall. Methods: Between 2000 and 2005 123 patients underwent DN. Of them 39 patients (26 females) entered this study. Among them 22 had ODN (lateral retroperitoneal access) and 17 LDN (Pfannenstiel minilaparotomy), since 2 patients of the LDN had conversion to ODN. Mean BMI (26 vs. 28 kg/m2), mean interval between surgery and evaluation (FU) (21 vs. 22 months), median age (43 vs. 48 yrs) and gender distribution were comparable between groups. At FU abdominal wall investigations included measurement of the rectus muscle strength by isometric measurement with the Biodex System 3 at 30, 20, 10 and 0 ventral abdominal ﬂexion. Mean strength index (Nm/kg) of 3 measurements was calculated for each angle. According to Kendall, bilateral trunk raising forward (TRF) test and lateral trunk raising test in lateral position (LTR) was applied (oblique and transverse abdominal muscles). Additionally, persisting access site morbidity was evaluated clinically. Results: Median TRF score was 5 vs 3 (p=0.01), Kendall LTR score at the donation side was 5 vs 3 (p=0.02) and median Kendall LTR score of the contralateral side was 5 vs 3.5 (p=0.04) for LDN vs ODN. Isometric muscle strength measured with the Biodex System 3 showed no signiﬁcant diﬀerence between groups at any angle. Clinically, 5/22 (22.7%) of the patients in the ODN group developed asymmetry of the abdominal wall. 13/22 (59.1%) patients in the ODN group had hypaesthesia and dysaesthesia, whereas none of the patients in the LDN-group showed asymmetry nor dysaesthesia/hypaestesia. Conclusion: Comparing subcostal transretroperitoneal ODN with LDN we could demonstrate that access sequels to the abdominal wall are remarkably lower after LDN regarding lateral muscle function and lateral esthesia. Obviously, with respect to isometric rectus muscle function both methods showed comparable long-term outcome.

Aims: We evaluated the learning curve of a single consultants series of LVHR performed at our institution using the novel method of the CUSUM and VLAD.

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ROLE OF DYNAMIC ULTRASOUND IN LAPAROSCOPIC MANAGEMENT OF OCCULT GROIN HERNIAS P.C. Munipalle, M.W. Mahmalat, J.R. Dean, Y.K.S. Viswanath The James Cook University Hospital, MIDDLESBROUGH, United Kingdom

OUTCOME OF LAPAROSCOPIC VENTRAL HERNIA REPAIR IN MORBIDLY OBESE PATIENTS WITH BMI> 35 Kg/m2 I. Raftopoulos, A. Courcoulas University of Pittsburgh, PITTSBURGH, PENNSYLVANIA, United States of America

Aim: Occult groin hernia is characterised by persistent inguinal pain in the absence of clinically evident hernia and is hence diﬃcult to diagnose. Dynamic ultrasound is reported to be of value in the assessment of these patients. During dynamic ultrasound examination, the groin area is scanned both at rest and during straining (coughing and/or valsalva manoeuvres) in supine and erect posture. This technique is non-invasive and cost eﬀective. We prospectively evaluated the role of dynamic ultrasound in accurate preoperative diagnosis of occult groin hernias, which will greatly beneﬁt the management of these hernias especially by laparoscopic route. Methods: All patients clinically suspected with occult groin hernia based on history and clinical ﬁndings were subjected to dynamic ultrasound of the groin. The results were corroborated with operative ﬁndings. Results: A total 16 patients with suspected occult groin hernia underwent dynamic ultrasound during the study period (2004–06). A total of 19 hernias were diagnosed in 15 patients (4 patients had bilateral hernias) and all of them underwent surgery by Transabdominal preperitoneal (TAPP) repair. The presence of hernia was conﬁrmed in all these cases at operation. The single patient with negative dynamic ultrasound scan underwent surgery on clinical grounds, which revealed unilateral hernia. The positive predictive value (PPV) of dynamic ultrasound in diagnosing occult groin hernias is 95%. Conclusion: Dynamic ultrasound scanning of occult groin hernias has high positive predictive value. It should be the ﬁrst choice of investigation in this category of patients.

Background: Laparoscopic ventral hernia repair (LVHR) in morbidly obese patients with a body mass index (BMI) >35Kg/m2 has not been well investigated. Methods: Hernia recurrence was evaluated by surveillance computed tomography. x2 test was used for statistical analysis of categorical data. P <0.05 was considered signiﬁcant. Results: Between January 2004 and 2006 LVHR was attempted in 23 patients with a BMI > 35Kg/m2. One patient (4.3%) was converted to an open approach due to bladder injury resulted by incorporation of the bladder to the previous abdominal wall closure. Of the remaining 22 patients there were15 females and 7 males with a mean age of 47 (33–59) years. Mean BMI was 46.9 (35–70.9) Kg/m2. Five (22.7%) patients underwent emergency LVHR due to small bowel obstruction (SBO). There were 5 (22.7%) patients with primary ventral hernia (PVH), 4 (18.2%) with recurrent PVH (RPVH), 9 (40.9%) with incisional ventral hernia (IVH) and 4 (18.2%) with recurrent IVH (RIVH). Concomitant LVHR with laparoscopic Roux-en-Y gastric bypass was performed in 8 (36.4%) patients. Mean operative time (OT) and length of stay (LOS) were 190.7 (100–480) minutes and 3.6 (1–11) days. Porcine submucosal small intestine extracellular matrix (Surgisis Gold Cook Biotech Inc, West Lafayette, IN) mesh was used in 12 (54.5%) patients, Goretex dual plus (W.L. Gore & Assoc., Flagstaﬀ, AZ) mesh in 8 (36.4%) patients and Composix mesh (C.R. Bard Inc., Cranston, RI) in 2 (9.1%). Mean hernia and mesh size were 138.3 (12–450) cm2 and 303.2 (117–880) cm2 respectively. Complications occurred in 4 (18.2%) patients including re-exploration for SBO and ileus in 2, re-admission for ileus in 1 and Clostridium diﬃcile colitis in one. Recurrence occurred in 5 (22.7%) patients during a mean follow-up of 7.5 (6–17) months. BMI (<50, or >50 Kg/m2) emergency setting, hernia type, hernia size, concomitant LRYGB and mesh type had no eﬀect on morbidity or recurrence rates. Conclusions: LVHR in morbidly obese patients is safe and feasible and it should be considered even at an emergency setting. Recurrence rate after LVHR in morbidly obese patients is high and independent of demographic, technical, or hernia characteristics.

Methods: A prospective cohort study performed between 1st June 2004 and the 1st December 2005, of the ﬁrst 50 patients having LVHR with Gortex Dualmesh. Data evaluated included demographic characteristics, defect area, mesh area, clinical number of defects, number of defects found at laparoscopy and time to completion. As the mean was highly skewed the median was better for description of the data. From the worldwide literature the average operation time has been reported as 103 min which we took as the gold standard. The ﬁrst assumption of success was deﬁned as completion in <103 min. The CUSUM was calculated. To eliminate case-mix factors we developed a statistical model and performed VLADS or risk adjusted CUSUM. Results: The median age was 56 years (38–88). 25 (50%) were female. 80% of the cohort was incisional and 20% were primary ventral hernias. 37 (74%) had 1 clinical defect and 13 (26%) had 2. However 20 (40%) were found to have 1 defect intraoperatively. The median area of defect was 78cm (4–576); median area of mesh used was 285cm (150–1120); median operating time was 80mins. (40–180). The CUSUM showed inferior performance compared to the gold standard for the ﬁrst 11 cases. The curve then plateaued suggesting that performance was as expected. Thereafter there was an upward trend showing improvement in performance. There was a sudden drop in performance after the 42nd case suggesting deterioration in operator performance. However when we performed VLADS we found a similar pattern of performance below the gold standard for the ﬁrst 11 cases but once there was improvement, performance remained above the gold standard for the series. This suggested that the dip in the later part of the CUSUM curve was due to patient not operator factors. Conclusion: Our results suggest that a surgeon who has reasonable laparoscopic skills can rapidly achieve a sustainable performance and CUSUM and VLADS can be used to assess personal learning curves for new procedures.

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INCISIONAL HERNIA RATES AFTER LAPAROSCOPIC COLORECTAL RESECTION. ANOTHER ADVANTAGE OF THE LAPAROSCOPIC APPROACH A.H. Engledow1, S. Reshwalla2, S. Cook2, P. Tozer2, S.J. Warren2 1 , LONDON, United Kingdom 2 Chase Farm Hospital, ENFIELD, United Kingdom

TISSUE ADHESIVE VERSUS STAPLER FOR MESH FIXATION IN LAPAROSCOPIC INGUINAL HERNIA REPAIR: A PROSPECTIVE, RANDOMISED OBSERVER BLINDED STUDY R. Ipaktchi1, G. Beldi1, N. Haupt2, M.H. Wagner1, D. Candinas1 1 Inselspital, BERN, Switzerland 2 University of Bern, BERN, Switzerland

Introduction: Published incisional hernia rates in series with adequate follow up after laparotomy are between 11 and 20%, with 60–90% occurring within two years of surgery. This generates a substantial workload for the general surgeon. We review our incisional hernia rates after laparoscopic colorectal resection. Methods: 80 patients undergoing laparoscopic colorectal resections were included. Data were recorded prospectively into a database. All wounds were closed in an identical fashion to the way our open procedures are closed utilising mass closure with a 0 Maxon and a subcuticular vicryl suture to the skin. All patients were examined in an outpatient setting by a surgeon not involved in the original procedure. Results: There were 80 patients. 44 female. Median age 68 years (range 20– 91). Median incision length 6cm (range 3–11). A total of 6 (7.5%) patients had developed incisional hernias of which two had already been successfully repaired laparoscopically. Only one of the remaining 4 patients was symptomatic and requesting correction. Median follow up was 25 months (range 3–71). Conclusion: The advantages of laparoscopic surgery in the form of shorter hospital stay, earlier return to normal activities, less analgesic requirements and better cosmesis are well documented. Incisional hernia rates would also appear to be lower than with open surgery. This has obvious advantages not only for the patient, but also for the surgeon by reducing their workload due to decreasing the number of incisional hernia repairs. In these times of ﬁnancial constraint this is a further advantage of the laparoscopic approach and may play a role in the planning of service provision.

Objective: The laparoscopic approach is widely accepted for inguinal hernia repair but requires mesh placement. There is an ongoing debate on the ideal mesh ﬁxation technique as this might relate to postoperative pain and hyperalgesia. Aim of this randomised study was to compare mesh ﬁxation with tissue adhesive (N-butyl-2 Cyanoacrylat, Glubran) versus stapler (Protak) ﬁxation. Methods: At this interims analysis a total of 39 hernia operations were included. In group A the mesh was ﬁxed using staplers (n=18) and in group B tissue adhesive was used (n=21). Both, patients and physicians performing the postoperative follow-up at 6 wks and 6 mts were blinded. In all patients localisation, and intensity of pain and numbness in the groin was assessed using Ôvon Frey hairsÕ which is a means that allows a quantitative and qualitative sensitivity assessment. Visual analogue scale was used to assess postoperative pain. Values are indicated as mean SD. Results: No intra- and postoperative complication occurred. Mean length of stay in both groups was 4.5 d ( 0.7) without statistical signiﬁcant difference. There was no recurrence in either group at 6 months. At 6 weeks the intensity of pain (VAS) in group A was 1,7 0,7, in group B 0,4 0,2 (p=0,03). After 6 months the intensity of pain (VAS) in group A was 1,5 0,6 and in group B 0,8 0,4 (p=0,3). Conclusion: The use of tissue adhesive instead of stapler for mesh ﬁxation signiﬁcantly lowers the incidence of postoperative pain following laparoscopic groin hernia repair without increasing recurrence rate.

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ADHESION FORMATION AFTER LAPAROSCOPIC INCISIONAL HERNIA REPAIR WITH SILICONE COVERED POLYPROPYLENE MESH: A PROSPECTIVE STUDY USING ABDOMINAL ULTRASOUND Gy. Weber, T. Rosta´s, I. Taka´cs, J. Baracs University of Pe´cs, PE´CS, Hungary

COMPARISON OF LAPAROSCOPIC TO OPEN GROIN HERNIA REPAIR FOR PATIENTS SATISFACTION & IMPROVEMENT IN QUALITY of LIFE & CHANGE IN CHRONIC PAIN M. Hussain1, K. Akhtar2 1 Stepping Hill Hospital, STOCKPORT, United Kingdom 2 Rochdale Inﬁrmary, ROCHDALE, United Kingdom

Aims: The intraperitoneal position of a polypropylene mesh entails risks of adhesions and ﬁstulas. The goal of this study was to determine whether bowel adhesions and their attendant complications could be prevented by silicone covering as it has been proved with previous, extensive animal experiments. The silicone covered polypropylene mesh (LOPROSI) is a large pore, low weight polypropylene net covered with an ultrathin siliconelayer using a special technology. Methods: A prospective study was performed for 24 consecutive patients with ventral hernias who underwent laparoscopic repair at our institutions between November 2004 and February 2006. The mean size of the defects was large at 96 cm2 (range: 16–380). In all cases, laparoscopic repairs were performed using LOPROSI mesh (Proszilomed, Hungary) with a minimum of 3 cm overlap circumferentially with normal fascia and secured with spiral tacks every 3–4 cm and transparietal sutures. In order to assess the visceral adhesion to mesh an ultrasound examination using visceral slide technique was initially validated (pre-operative prediction vs. per-operative ﬁndings) and then used during the follow-up. Results: Clinically, after 7-month mean follow-up (range of 1 to 16 month), no complication related to post-operative adhesions to the mesh was noted. There were six minor complications: seroma lasting more than 4 weeks (four cases) and suture site pain lasting longer than 4 weeks (two cases). Seventeen patents had no sonographically detectable adhesions. Six patients demonstrated adhesions between the mesh and omentum and in one case of bowel adhesion to the edge of the mesh was found. Conclusion: Laparoscopic ventral incisional hernias repair with LOPROSI mesh is not associated with visceral adhesions in the majority of patients. Ultrasound examination represents a suitable tool to evaluate postoperative adhesions to the abdominal wall.

Background: Laparoscopic groin hernia repair attracts controversy despite widespread-acceptance of minimal access surgery in various surgical specialities. Aim: to compare the outcome of laparoscopic repair i.e. trans-abdominal pre-peritoneal (TAPP) with open approach for patientÕs satisfaction, improvement in quality of life (QoL) and change in postoperative chronic groin pain in single surgical unit district general hospital. Methods: This retrospective study involved 204 patients (102/group) with 226 herniae repaired during May 2000-April 2004. Mean age was 55 & 57; 12 & 10 patients had bilateral herniae repaired whereas 12 & 15 were recurrent in laparoscopic and open group respectively. Median follow-up was 30months (range12–48months). Size of trimmed prolene mesh used was 15 · 10 cm. Written questionnaires with visual analogue scoring system, used as an assessment, sent to 145 patients in each group. First 102 replies per group were analysed after excluding 8 & 13 replies for laparoscopic & open group. Chi-square and t-test was used at p<0.05. Results: PatientsÕ response rate to questionnaire was 75% & 79% for laparoscopic & open groups respectively. Satisfaction rate were 96% and 87%, p<0.023; while, Mean improvement in quality of life (QoL) were 3.75 & 2.17 (mean diﬀerence )1.57) for laparoscopic and open groups, p< 0.001. The diﬀerences were signiﬁcant. Mean post-operative chronic pain reduction was 3.25 & 3.80 (mean difference was )0.5), p< 0.19 which was insigniﬁcant. Conclusions: PatientsÕ satisfaction rate and improvement in QoL were signiﬁcantly higher for laparoscopic group as compared to open; however, there was no signiﬁcant reduction in postoperative groin pain.

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COMPARISON OF EARLY VERSUS DELAYED LAPAROSCOPIC CHOLECYSTECTOMY IN THE TREATMENT OF ACUTE CHOLECYSTITIS

LAPAROSCOPIC VS OPEN REPAIR OF INCISIONAL AND PRIMARY VENTRAL HERNIA: RESULTS OF A PROSPECTIVE RANDOMIZED STUDY M.C.M. Misra, M. Kulkarni, V.K. Bansal, D.K. Pawar, A. Kumar All India Institute of Medical Sciences, NEW DELHI, India

F. Paziar1, R. Sharif2 1 Jundi-Shapur Medical University, AHWAZ, Iran 2 ARIA Hospital, AHWAZ, Iran Background: Acute cholecystitis is one of the most common emergency admissions in surgical practice. About 20% of patients with acute cholecystitis need emergency surgery. The timing of surgery for the remaining 80% of patients without evidence of gangrene or perforation is under debate. The aims of this prospective study were to analyze and compare the results of the treatment of acute cholecystitis with early or delayed laparoscopic approach in a 2 year period. Patients and Methods: During 2004 and 2005, 152 patients with clinical picture of acute cholecystitis were randomly operated (early or delayed laparoscopic cholecystectomy). The type of approach remained unknown to the department staﬀs involved in the preoperative ÔcoolingÕ process and postoperative care. Results: Eighty two (54%) patients were operated within the ﬁrst 96 hours of admission after receiving antibiotic regimen (Ceftriaxon 1 gram every 12 hours and Metronidazole 500 mg every 8 hours). The remaining seventy patients were scheduled for delayed laparoscopic cholecystectomy. The two groups were similar with respect to demographic and clinical characteristics. There were no signiﬁcant diﬀerences in rate of postoperative complications and pain. In eight patients (11.5%) of the second group the laparoscopic procedure was converted to open cholecystectomy. Median operating time was 90 minutes (range 30–155) and 80 minutes (range 40–140) in the delayed and early laparoscopic groups respectively (P = 0.040). The direct medical costs were signiﬁcantly lower in the ﬁrst group in comparison to the second group (P=0.030). Although median hospital stay was 7 days in the delayed group, it was signiﬁcantly shorter in the early laparoscopic group with 3 days of hospitalization (P = 0.011). Conclusion: Main advantages of early laparoscopic cholecystectomy are lower conversion to open surgery, shorter operation time, lower doses of antibiotics and analgesics in comparison with the patients operated in their second admission. Besides, lower cost of treatment and faster return to everyday activities point to another signiﬁcant advantage of the early laparoscopic cholecystectomy (within 96 hours) maybe due to shorter hospital stay, faster recovery and relieving of the pathology.

Background: Incisional hernia is an important complication of abdominal surgery. Its repair has progressed from a primary suture repair to various mesh repairs and laparoscopic repair. Laparoscopic mesh repair is a promising alternative and in the absence of consensus needs prospective randomized controlled trials. Methods: Between April 2003 and April 2005, 66 patients with incisional primary ventral and recurrent hernias were randomized to receive either open retrorectus mesh repair or laparoscopic mesh repair. They were followed up at 1, 3 and 6 months interval thereafter for a mean of 12.17 months for open repair group and 13.73 months for laparoscopic repair. Results: Lower abdominal hernias following gynecological operations constituted majority of hernias (50%) in both groups. There were no signiﬁcant injury to viscera in either group and no conversions. The defect size was 42.12 cm2 and 65.66 cm2 in open (group I) and laparoscopic groups (group II) respectively and meshes size 152.67 cm2 and 203.83 cm2 respectively. The hospital stay in open group was 3.43 days and 1.47 days in laparoscopic group (p=0.007). There was no signiﬁcant diﬀerence in the pain scores in either group. The wound related infectious complications were more in open group (33%) than in laparoscopic group (6%) (p=0.013 ).There was one recurrence in the open repair group (3%) and 2 recurrences in laparoscopic group (6%) (P=0.55) Conclusions: Laparoscopic repair of incisional and ventral hernias is superior to open mesh repair in terms of signiﬁcantly reduced blood loss, wound complications, hospital stay and excellent cosmetic outcome.

Key words: Delayed and early Laparoscopic cholecystectomy and acute cholecystitis.

O059-S1

O059-S3

HERNIA REPAIR - COMPARISON TEP WITH OPEN TECHNIQUE LICHTENSTEIN F. Derbel, J. Mazhoud, S. Youssef, A. Ben Ali, R. Ben Haj Hamida University Hospital Sahloul, SOUSSE, Tunesia

POOLED DATA ANALYSIS OF LAPAROSCOPIC VS OPEN VENTRAL HERNIA REPAIR: 13 YEARS OF PATIENT DATA ACCRUAL R.A. Pierce, M.M. Frisella, B.D. Matthews, M. Brunt Washington University School of Medicine, SAINT LOUIS, United States of America

Objective: Our aim is to compare the outcome, complications and analgesic requirement between total extraperitoneal (TEP) repair and Lichtenstein open repair. Patients and Methods: A prospective study was done over a one year period, between the beginning of November 2002 to end of October 2004 on 100 patients presenting with reducible inguinal hernia. Patients were randomized into two groups: 50 patients for laparoscopic TEP repair and 50 patients for Lichtenstein open repair. The two groups were comparable in age, sex, and type of hernia. Results: Analgesic requirement postoperatively was signiﬁcantly greater in Lichtenstein open repair group (P< 0.001). Postoperative complications encountered during the study were in the form, wound haematoma and seroma. These developed in 2 patients after Lichtenstein open repair and in one patient in laparoscopic TEP repair. In our study, laparoscopic TEP repair required less analgesia and lead to signiﬁcantly fewer complications than Lichtenstein repairs and none of the cases required conversion. Two patients presented a recurrence of the hernia Six month and 8 month after TEP procedure. Conclusion: Laparoscopic TEP repair has advantages over Lichtenstein open repair. There were less postoperative complications and less analgesia was required. Hence, it is a suitable procedure for bilateral inguinal hernia repair and recurrent inguinal hernia repair with very low rate of recurrence.

Introduction: The purpose of this study is to analyze the published perioperative results and outcomes of Laparoscopic (LVHR) and Open (OVHR) ventral hernia repair with a focus on complications and hernia recurrences. Methods: Perioperative outcomes, complications and follow-up data were compiled from all English-language reports of LVHR published from 1996 through August 2005 that accrued patients over a 13 year period (from 1991 through October 2003). Series with fewer than 20 cases of LVHR, those that did not report details of complications, and those in which the patients were included in a later or larger series were excluded. Data were extracted from 28 reports that dealt with LVHR alone (Unpaired Studies) and 12 that directly compared LVHR to OVHR (Paired Studies). Statistical methods used were Chi square analysis and FisherÕs exact test. Results: A total of 5196 patients who underwent repair of 5223 hernias reported in 40 published series were included (LVHR, 4342 patients; OVHR, 854 patients). In the overall analysis (combined Paired and Unpaired Studies), LVHR was associated with signiﬁcantly fewer wound complications (3.7% vs. 15.8%, p <.0001), total complications (22.1% vs. 33.0%, p <.0001), and hernia recurrences (5.0% vs. 13.4%, p<.0001). Each of these outcomes maintained statistical signiﬁcance when only the Paired Studies were analyzed. LVHR was also associated with fewer neurologic complications (0% vs. 0.2%, p=0.027) but a higher incidence of prolonged suture site pain (1.8% vs. 0.4%, p=.0015); neither of these outcomes reached statistical signiﬁcance in the Paired Study analysis. No diﬀerences in GI, cardiac, pulmonary, urinary, or thromboembolic complications were found. The overall mortality rate was 0.09% with LVHR and 0.12% with OVHR (p=NS). An overall trend toward shorter hospital length of stay was also observed for LVHR. Conclusions: The early published literature on LVHR indicates fewer wound-related and overall complications, and a lower rate of hernia recurrence compared to OVHR. Further controlled trials are necessary to substantiate these ﬁndings and to assess the health care economic impact of this approach.

S17

ANAESTHESIOLOGY O060 PRE-INCISIONAL LOCAL INFILTRATION WITH LEVOBIVUCAINA REDUCES PAIN AND ANALGESIC CONSUMPTION AFTER LAPAROSCOPIC CHOLECYSTECTOMY L. Boni, A. Benevento, L. Giavarini, M. Di Giuseppe, F. Cantore, G. Dionigi University of Insubria, VARESE, Italy Background: Post-operative painstill remains the most important patients complain after laparoscopic cholecystectomy. The concept of pre-emptive anaesthesia is based on the treatment of pain before the causing injury occurs and stimulate the nervous pain receptors. Aims of the Study: The aim of this study is evaluate the role of trocar sites inﬁltration by local long lasting anaesthetic, for post-operative pain control after laparoscopic cholecystectomy comparing pre- versus post-incision inﬁltration. Methods: All the patients scheduled for elective laparoscopic cholecystectomy for symptomatic gallbladder were enrolled in the study. Using a double-blind randomised study design, the patients were preoperatively assigned to receive pre-incision (PreI) or post-incision (PostI) local anaesthetic inﬁltration. In the PreI group the local anaesthetic was administered,prior skin incision, while in the Post I group inﬁltration was performed at the end of the procedure after trocar removal. Pain assessment was performed by standard as well as ÔincidentalÕ visual analogue scale (VAS, IVAS) at the awaking, 3, 6, 24 and 36 h post operatively. I.V. ketoralak was used in case of pain, on patients request. Students t test was used to compare the two groups and p<0.05 was considered signiﬁcant. Results: From October 2004 to March 2005 50 patients (32 female 18 male, mean age=5912 year) were eligible for the study. There were no intra-postoperative complications and no patients suﬀered from adverse reaction due to local anaesthetic inﬁltration. The mean i.v. ketoralak post-operative use was 339 mg versus 124 mg for the PostI and PreI group respectively; this diﬀerence was statistically signiﬁcant (p=0,04). The mean VAS was 10,7 vs 5,1 for the PostI and PreI group respectively (p=0,02). Also the IVAS was statistically better in the PreI group vs the PostI (14.8 vs 8.8, p=0,03). 60% of the patients in the PreI vs 40% of the PostI were discharged without any need for i.v. analgesic.

Conclusions: Our Study demonstrated that inﬁltration of the trocars site with long lasting anaesthetics is extremely eﬀective for the treatment of post-operative pain control after laparoscopic cholecystectomy. Pre-incision inﬁltration is able to obtain better results than post-incision both in term of patients pain perception and i.v. analgesic requirement.

BASIC AND TECHNICAL RESEARCH O061

O062

HIGHER CO2-INSUFFLATION PRESSURE INHIBITING THE ADHESION AND INVASION POTENTIAL OF COLON CANCER CELLS WAS ASSOCIATED WITH INHIBITED EXPRESSION OF ADHESION MOLECULES

HEPATIC CELLULAR IMMUNOLOGICAL ANTI-TUMORAL DEFENCE AND HEMATOGENOUS COLORECTAL TUMOR SPREAD AFTER CO2- AND HE-LAPAROSCOPY COMPARED TO LAPAROTOMY IN AN EXPERIMENTAL MODEL

M. Zheng, B. Feng, J. Ma Ruijin Hospital, SHANGHAI, China

1

Background and Aim: Laparoscopic CO2-insuﬄation was reported to correlate with the growth and metastasis of colorectal cancer. But few study concerned how CO2-insuﬄation impact the biological behavior of the colorectal cancer. The aim of this study is to investigate the inﬂuence of CO2-insuﬄation and its pressure on the expression of E-cadherin, ICAM-1, CD44 and E-selectin, which were related to metastasis of colorectal cancer, and how the changes of these molecules impact the adhesion, invasion and metastatic potential of the colon cancer cell. Experimental Design: With an artiﬁcial pneumoperitoneum model in vitro, SW1116 human colon carcinoma cells were exposed to CO2-insuﬄation of 4 diﬀerent pressure groups: 6 mmHg, 9 mmHg, 12 mmHg and 15 mmHg, respectively for 1 hour. Control group was exposed to room air. Expression of E-cadherin, ICAM-1, CD44 and E-selectin was measured at 0, 12, 24, 48 and 72 hours after CO2-insuﬄation by using ﬂowcytometry. The adhesion and invasion capacity of SW1116 cells before and after exposed to CO2-insuﬄation was detected by cell adhesion/invasion assay in vitro. Each group of cells was injected intraperitoneal into 16 BALB/C mice (1106 cells/mouse). 14 days later, 10 mice of each group were sacriﬁced, and the number of visible abdominal cavity tumor nodules was counted. The rate of viscera metastasis and survival time of remain mice were also recorded in each group. Results: The expression of E-cadherin, ICAM-1, CD44 and E-selectin in SW1116 cells were changed (increased or decreased) signiﬁcantly following exposure to CO2-insuﬄation of different pressure groups (P<0.05). The expression of these adhesion molecules was returned to control level or even below control by 72 h. With CO2-insuﬄation pressure ascending, the expression of the E-cadherin, CD44 and ICAM-1 decreased, especially at 0 h after CO2insuﬄation (P<0.05). The adhesive/invasive cells also decreased gradually at the same time point with the pressure ascending (P<0.05). When 72 h after exposure, the CO2-insuﬄation pressure did not changed the invasion/adhesion of the cells signiﬁcantly. In animal study, the number of abdominal cavity tumor nodules in 15 mmHg group was also signiﬁcantly lower than that in 6 mmHg group (29.79.91 vs 41.714.90, P=0.046). However, the survival rate of each group did not have a statistically signiﬁcant. Conclusion: The expression of these adhesion molecules were aﬀected temporarily and bidirectionally after continuous CO2-insuﬄation. CO2-insuﬄation also induced a temporary change in the adhesion and invasion capacity of cancer cells in vitro. Higher pressure of CO2insuﬄation could inhibit the adhesion, invasion and metastatic potential in vitro and in vivo, which is associated with inhibited expression of adhesion molecules.

D.T. Inderbitzin1, G. Marti1, S. Eichenberger1, L. Kraehenbuehl2 Hopital Cantonal Fribourg, FRIBOURG, Switzerland 2 University of Fribourg, FRIBOURG, Switzerland

Introduction: The inﬂuence of laparoscopy and gas quality on hepatic cellular immunological anti-tumoral defence and hematogenous tumour spread is still under debate. As hepatic macrophages play a key-role in hepatic anti-tumoral reaction, this study aims to assess the overall intra-hepatic macrophage count and hematogenous tumor load in an experimental model. Method: 27 male syngenic WAG/Rij rats were randomized into three operative groups: CO2- and He-laparoscopy at 12 mmHg (CO2-/He-LS; n=9 each) and laparotomy (LT; n=9) as negative control. Total operating time was 90 min. At 45 min after setup rats were given a deﬁned intra-portal injection of CC531s colon adenocarcinoma cells by a silicon catheter. Animals were sacriﬁed on days 7, 14 and 28 after surgery. Mean density of macrophages (Antibodies: Total ED1, tissue resident ED2 and freshly homed ED1–ED2) over the whole of the liver parenchyma as well as hepatic tumour load was determined by local stereology (immuno-ﬂuorescence / confocal laser scanning microscopy). Results: TABLE Post-operative hepatic macrophage density was signiﬁcantly higher after He-LS followed by LT and by CO2-LS. Accordingly, hepatic tumor load was signiﬁcantly lowest after He-LS and highest in CO2-LS (Mann-Whitney). Conclusion: This study demonstrates a decreased cellular anti-tumoral immunological defence after CO2-LS and higher post-operative hepatic tumor-load after colorectal tumorcell injection into the portal vein compared to more protective LT and He-LS. Whether these ﬁndings are of clinical relevance needs further investigation. 7d ED1

14d ED2

ED1–ED2 ED1

LSCO2 17.4* 12.8* 4.6 LSHe 27.6* 22.6* 5.0 LT 26.0 21.3 4.7

28d ED2

ED1–ED2 ED1

18.8* 12.4* 6.4 35.5* 26.5* 9.0 30.4 21.7* 8.7

ED2

ED1–ED2

17.3* 10.9* 6.4 27.2* 22.2* 5.0 24.4 20.0 4.4

Results given as median cels /250x250x100 pM, *p<0.05 compared to LT (Mann Whitney)

S18

O063

O065

EXPLORING NEW TECHNOLOGIES TO CREATE INTESTINAL ANASTOMOSES USING RADIO FREQUENT ENERGY (LIGASURE) J.F. Smulders, I.H.J.T. de Hingh, J.J. Jakimowicz Catharina Hospital, EINDHOVEN, The Netherlands

A HAND FOR AN EYE IN HAND-ASSISTED LAPAROSCOPIC SURGERY S. Manasnayakorn1, A. Cuschieri2, G.B. Hanna3 1 Chulalongkorn University, BANGKOK, Thailand 2 Cuschieri Skills Centre, DUNDEE, United Kingdom 3 Imperial College London, LONDON, United Kingdom

Objective: LigaSure equipment has recently been added to the armamentarium of the laparoscopic surgeon for sealing and transecting vessels with a diameter of up to 7 mm. However, creating intestinal anastomoses still requires conventional stapling or suturing and thus laparoscopic equipment has to be changed repeatedly during complex procedures. Ligasure acts by denaturing collagen and elastin in the vessel wall and since this is also abundantly present in the intestinal wall, the possibility to create intestinal anastomoses using the Ligasure technology was investigated in an experimental study. Methods: For this purpose a new-generation RF generator and a prototype of the Ligasure Anastomotic Device (LAD) have been developed. The generator incorporates a closed loop control system which monitors tissue fusion, compares it with a mathematical model of ideal fusion based on the density and compliance of intestinal tissue and adjusts energy output accordingly. With the LAD both RF-energy and mechanical pressure can be applied by pulling the intestinal wall between the jaws of the device Results: In total 8 anastomoses were created using this method in a porcine model (4 pigs, 2 anastomoses each). Inspection of the seals both immediate after creation and at the 7th day when the pigs were re-operated showed a normal macroscopic appearance. Between operations all pigs appeared healthy and had normal intestinal passage. Histological examination of the anastomotic sites showed successful fusion with granulation tissue, viable collagen in the submucosa and re-epithelialization at the borders of the seals. Conclusion: These experimental results show that Ligasure-technology can be applied to create intestinal anastomoses in an animal model. Once this technology becomes available for clinical laparoscopic usage, this will contribute to the ideal of minimizing the need to change laparoscopic equipment during complex laparoscopic procedures.

Aim: The aim of the study is to test the hypothesis that one of the beneﬁts of hand-assisted laparoscopic surgery is the use of the proprioceptive sense to compensate for the loss of stereoscopic view in conventional laparoscopic surgery. Methods: Ten non-medical postgraduate students were divided into two groups, one using the hand-assisted technique and the other using conventional laparoscopic technique. All participants completed two tasks set in a laparoscopic trainer box. In the passing thread task (task 1), the subject had to pass a 10-cm 0 Ethilon through small 4 metallic loops for 5 rounds whereas in the intracorporeal knot tying task (task 2), the subject had to tie 30 square 3-throw intracorporeal knots. All tasks were video-recorded for subsequent past-pointing count analysis. Results: In task 1, overall past-pointings occurred signiﬁcantly less in the hand-assisted group, compared to the conventional group (median (IQR): 18(8), 12(6), 15(6), 7(6) and 9(11) for the hand-assisted group, and 46(36), 24(18), 18(14), 12(21) and 21(35) for the conventional group; MannWhitney test, P = 0.001). In repetition 1, there were fewer past-pointings in the hand-assisted group (Mann-Whitney test, P = 0.009). In task 2, the hand-assisted group was also associated with fewer past-pointings (MannWhitney test, P <0.0005). Furthermore, past-pointings occurred less frequently when the thread was in contact with the other instrument (repeated measures ANOVA, P = 0.031). Conclusions: The hand-assisted laparoscopic technique is associated with signiﬁcantly fewer past-pointings. The possible explanation is the presence of the hand in the operative ﬁeld compensates for the lack of a stereoscopic view in conventional laparoscopic surgery by utilizing the proprioceptive information from the intracorporeal hand.

O064

O066

IS CARBON DIOXIDE THE MOST APPROPRIATE GAS FOR PNEUMOPERITONEUM IN LAPAROSCOPIC SURGERY? ADVANTAGES OF NITROGEN PNEUMOPERITONEUM A. Umemoto, J. Honda, T. Yoshida, J. Seike, H. Yamai, M. Goto, A. Tangoku University of Tokushima Graduate School, TOKUSHIMA, Japan

IS HAND-ASSISTED LAPAROSCOPIC SURGERY ASSOCIATED WITH A SHORTER PROFICIENCY-GAIN CURVE (LEARNING CURVE)? S. Manasnayakorn1, A. Cuschieri2, G.B. Hanna3 1 Chulalongkorn University, BANGKOK, Thailand 2 Cuschieri Skills Centre, DUNDEE, United Kingdom 3 Imperial College London, LONDON, United Kingdom

Aims: Carbon dioxide gas is presently the only gas used for pneumoperitoneum in laparoscopic surgeries. In carbon dioxide pneumoperitoneum, the gas is readily absorbed from the peritoneum and may result in hypercapnia. Serious hypercapnia lowers cardiac output, and induces pulmonary hypertension, tachycardia, and arrythmias; acidosis is exacerbated. We report good results with the use of nitrogen gas for pneumoperitoneum as an alternative to carbon dioxide gas for patients with markedly reduced pulmonary function and pulmonary hypertension. Methods: In a mini porcine model, (1) the eﬀects of nitrogen pneumoperitoneum and carbon dioxide pneumoperitoneum on blood gas data were compared, and (2) the eﬀects of pneumoperitoneum pressure on the inferior vena cava (IVC) pressure and arterial pressure were examined. In patients with decreased pulmonary function, we investigated (3) whether nitrogen pneumoperitoneum was eﬀective in improving hypercapnia. Results: (1) When carbon dioxide pneumoperitoneum was changed to nitrogen pneumoperitoneum, pCO (2) decreased by approx. 10 mmHg. (2) When pneumoperitoneum pressure was set at 8, 12, and 15 mmHg, arterial pressure increased to the value in which the pneumoperitoneum pressure was added to the original arterial pressure while the IVC pressure increased to a value equivalent to that of the pneumoperitoneum pressure. (3) In all six patients with decreased pulmonary function, pCO(2) gradually increased after carbon dioxide pneumoperitoneum but improved by a change to nitrogen pneumoperitoneum. For all the patients, increase and decrease in pCO(2) caused directly opposite changes in pH. Discussion: The solubility of nitrogen gas is approx. 1/40th that of carbon dioxide gas. Although gas-induced embolism is still a concern, we demonstrated that the intravascular ﬂow of nitrogen gas opposing the pressure of the IVC system in surgery under conventional pneumoperitoneum is almost impossible. Nitrogen gas was very useful as a pneumoperitoneum gas for patients with markedly reduced pulmonary function.

Aim: The aim of the study is to test the hypothesis that hand-assisted laparoscopic surgery is associated with a shorter proﬁciency-gain curve (learning curve). Methods: Ten non-medical postgraduate students were divided into two groups, one using the hand-assisted technique and the other using conventional laparoscopic technique. All participants completed two tasks set in a laparoscopic trainer box. In task 1, the subject had to pass a 10-cm 0 Ethilon through 4 small metallic loops 5 times whereas in task 2, the subject had to tie 30 square 3-throw intracorporeal knots. Results: In task 1, there was an improvement in the completion time in the conventional group (median (IQR): 414(184.0), 261(206.0), 177(148.0), 110(84.5) and 164(267.5); Friedman test, P = 0.019), but not in the handassisted group (median (IQR): 200(194.5), 109(60.5), 117(58.0), 77(65.5) and 116(60.0); Friedman test, P = 0.058). In contrast, the hand-assisted group showed decreasing number of past-pointings (median (IQR): 18(8), 12(6), 15(6), 7(6) and 9(11); Friedman test, P = 0.008) whereas the conventional group did not show any improvement (median (IQR): 46(36), 24(18), 18(14), 12(21) and 21(35); Friedman test, P = 0.092). In task 2, there were signiﬁcant reductions in the completion time in both groups (Friedman test, P < 0.0005 and P = 0.001 for the hand-assisted and the conventional group respectively), and past-pointings count in the handassisted group (Friedman test, P = 0.044). However, there was no improvement in both groups in terms of the knot quality score (Friedman test, P = 0.965 and P = 0.280 for the hand-assisted and the conventional group respectively), and in past-pointings count in the conventional group (Friedman test, P = 0.191). Conclusion: The hand-assisted laparoscopic technique is related to a shorter proﬁciency-gain curve, compared to conventional laparoscopic technique when the more complex task is utilized.

S19

O067

O069

LAPAROSCOPIC COLONIC SURGERY ENHANCES POSTOPERATIVE MOTILITY: LAPAROSCOPIC SURGERY IS INDISPENSABLE FOR A FAST-TRACK PROGRAM P.A. Neijenhuis1, V. Brehm1, R.P. Bleichrodt2, H.M. Schuttevaer1 1 Rijnland Hospital, LEIDERDORP, The Netherlands 2 UMCN St Radboud, NIJMEGEN, The Netherlands

A DIFFERENT SURGICAL MESHES AND ADHESION FORMATION: AN EXPERIMENTAL STUDY ON RATS Z. Perko, Z. Pogorelic, M. Prkut, K. Bilan, D. Srsen, D. Kraljevic, N. Druzijanic, J. Juricic Clinical Hospital and Medical School, SPLIT, Croatia

Aim: to demonstrate the the gastrointestinal tract is recovering faster using a laparoscopic approach in colonic surgery when compared to the traditional open approach. Method: A consecutive group of patients scheduled for left sided colectomy received a set amount of radio opaque markers during 5 days starting on the day of surgery. Radiographs were taken on day 1,3 & 6. Radiological progression was calculated as the segment number where the median pellet was positioned so that the higher the number the faster the GI-transit. Clinical signs e.g. bowel sounds, passage of ﬂatus and stool were evaluated daily. All patients received epidural for postoperative analgesia. No nasogastric tubes were used and feeding and mobilization was encouraged from day 1 onwards. Bowel preparation consisted of a fosfate clysma only. Patients: Initally 48 patients were operated by open surgery and these were compared with 20 operated laparoscopically after introduction of the laparoscopic method in our unit. Characteristics are equal for sex, age, ASA and indication. Results: Bowelsounds are present in over half of the patients on day 1 in the laparoscopic group, in the open group the only start resuming on day 2. Flatulence day 2 for laparoscopy and day 3 for open. Bowel movement day 3 for laparoscopy and from day 4 onwards in the open group. Radiological assesment showed that the median marker position is one segment higher(=faster transit) on day 1,3 and 6 in the laparoscopic group. Only in the laparoscopic group a number of patients had all marker excreted on day 6. Conclusion: for left sided colonic resection with standarized care with fasttrak components the laparoscopic approach showed enhanced GI recovery as noted by clinical signs and radiologic assessment.

Introduction: The determining factor for the success of the hernia surgery is the right choice and use of surgical mesh as the support material. One of the most common complications of operations involving placement of surgical mesh, is the formation of adhesions. Aim of this paper is to determine whether there is a statistic diﬀerence between diﬀerent surgical meshes in lab environment. Methods: We used 200 g Wistar rats as the experimental model. The animals were etherized and anesthetized with ketamin hydrochlorid, dose of 10 mg per animal. After the anaesthesia, the animals underwent a procedure in which a 1x1 cm complete defect of the abdominal wall was made, but the skin was left intact. The diﬀerent meshes were placed directly on the internal organs. Each experimental group consisted of 15 animals, which were divided into 3 groups depending on the time they were planned to be sacriﬁced: after ona, two and four weeks. The experiment was considering four diﬀerent meshes from the same manufacter: polypropylene (Prolene), polypropylene/polyglactin I and II (Vypro) and polypropilene/polydioxanon/oxidized regenerated cellulose (ORC) (Proceed). After the set time period, the animals were sacriﬁced and the amount of formed adhesions was evaluated based on the modiﬁed Diamond scale. Results: An impartial examiner evaluated the amount of adhesions on the implanted meshes. Immediately after the ﬁrst week we found a statistically signiﬁcant diﬀerence in the adhesion occurrence rate between tested materials (p= 0.026). The smallest amount of adhesions was caused by polypropilen/polydioxanone/ORC mesh (medium score = 1.48; SD0,2020), and the most by polypropylene mesh (medium score = 3.21; SD0,0,2753). Polypropylene/polyglactin meshes showed signiﬁcant reduction in the formation of adhesions between the tested weeks. Conclusion: In conclusion we can conﬁrm manufacters recommendation that polipropylene/polydoxanone/ORC (Proceed) mesh is superﬁne for ventral hernias operation, because those defects are the ones that come in close contact with the internal organs and it is desirable to have the smallest amount of adhesions.

O068

O069-S1

LAPAROSCOPIC-ASSISTED TRANSHIATAL DISTAL ESOPHAGECTOMY AND ESOPHAGOGASTRIC ANASTOMOSIS WITHOUT THORACIC ACCESS - EXPERIMENTAL STUDY

THE EFFECT OF PNEUMOPERITONEUM ON CRANIAL OXYGEN SATURATION O. Kurukahvecioglu1, M. Sare2, A. Karamercan2, B. Gunaydin2, E. Tezel2 1 Gazi University Medical School, ANKARA, Turkey 2 Gazi University, ANKARA, Turkey

V. Bintintan1, A. Mehrabi2, S. FanyYazdi2, H. Fonouni2, Z.A. Mood2, M.W. Buechler2, C.N. Gutt2 1 University of Medicine and Pharmacy, CLUJ NAPOCA, Romania 2 Chirurgische Universitaetsklinikum, HEIDELBERG, Germany Aims: Creation of an esophagogastric intrathoracic anastomosis after transhiatal esophageal resection has not been extensively investigated although it may avoid some of the main disadvantages of total esophagectomy. The present study evaluates the technique of laparoscopic distal esophageal resection coupled with laparoscopic-assisted intrathoracic esophagogastric anastomosis without thoracic access. Methods: The abdominal and thoracic esophagus up to the level of tracheal bifurcation was dissected by a laparoscopic transhiatal approach in ten German Landrace pigs in general anesthesia. After transection of the esophagus with EndoGIA staplers, the anvil of an ILS stapler was inserted trans-orally and positioned into the esophageal stump under laparoscopic guidance. Through a midline laparotomy, a gastric tube was created from the greater curvature. The ILS stapler introduced into the gastric tube was advanced into the mediastinum through the hiatus and connected to the anvil under laparoscopic control. At the end of the procedure animals were sacriﬁced and the quality of the anastomosis and injuries to neighbouring organs were evaluated through a right thoracotomy. Results: Resection of the distal esophagus was performed in all cases within 3 cm from tracheal bifurcation. Development of a feasible system for trans-oral delivery of the anvil and for anastomosis creation was completed within the ﬁrst six operations. The last four cases were standardised and easily reproducible, all procedures being performed safely under the view oﬀered by the laparoscope. On average, the resection phase lasted 127.5 min, further 127 min being necessary for placement of the anvil, creation of the gastric tube and anastomosis. The mean length of the resected distal esophagus was 125 mm. All anastomosis were in good condition and, except for pleural injury, no other incidents were revealed by the ﬁnal evaluation. Conclusions: Transhiatal creation of esophagogastric anastomosis without thoracic access after laparoscopic distal esophageal resection is feasible. Laparoscopy oﬀers accurate dissection and guidance for placement of the anvil. A short laparotomy seems to be necessary for proper positioning of the gastric tube and stapling device into the mediastinum while guidance oﬀered by the laparoscope made possible creation of the anastomosis through the narrow hiatus even in a remote area.

Aims: It has been shown that intracranial pressure increases with the increase in intrabdominal pressure during laparoscopic surgery. Data from recent studies showed that intracranial pressure increases with increasing intracranial blood volume as a result of decreased cerebral venous return with no signiﬁcant change in the cerebral blood ﬂow. In this study, the changes of cerebral oxygen saturation in laparoscopy were recorded. Methods: The patients undergoing laparoscopic cholecystectomy were randomly assigned into two groups. Study group consisted of the patients in whom intermittent sequential compression(ISC) applied to the lower extremities whereas the control group patients were observed without pneumocompression. The cerebral oxygen saturation, peripheral blood oxygen saturation, heart rate, mean blood pressure and associated changes were monitored and recorded during the operation. Each group consisted of 30 patients who were ASA I or II. The measurements were recorded before (baseline) and after the anesthesia, during the pneumoperitoneum in every ﬁve minutes until the end of the operation. In the study group, an additional measurement was done after the ISC was stopped before the end of the anesthesia. Results: There was a signiﬁcant diﬀerence between two groups in the cerebral oxygen saturation and the heart rates (p=0,0001). The diﬀerence was found more prominent after the 35th minute of the operation and continued to increase until the end of the operation. No signiﬁcant diﬀerence was seen in the peripheral oxygen saturations and mean blood pressures between two groups. Conclusion: In this study we found that cerebral oxygen saturation decreases during laparoscopic surgery which was reversed by the use of ISC. ISC forces the retained blood in lower extremities to the systemic circulation which reverses the changes in cerebral oxygenation caused by increased intraabdominal pressure. The signiﬁcantly increased heart rate in the control group can be explained by a compensatory mechanism that the heart should work harder to maintain adequate perfusion. It can be concluded that I during the operation can be useful particularly in the patients with high ASA score since prolonged operation time can easily disrupt the hemodynamic stability and cerebral oxygenation.

S20

BREAST SURGERY O070

O071

VIDEO-ASSISTED BREAST SURGERY AND SENTINEL LYMPH NODE BIOPSY GUIDED BY 3D-CT LYMPHOGRAPHY K. Yamashita Nippon Medical School, KAWASAKI, Japan

CAN SENTINEL NODE LOCALISATION BIOPSY BE A FEASIBLE ALTERNATIVE TO AXILLARY NODE DISSECTION? M. Hussain1, G.N. Khatoon2 1 Stepping Hill hospital, STOCKPORT, United Kingdom 2 Rochdale Inﬁrmary, ROCHDALE, United Kingdom

Aims: Video-assisted breast surgery (VABS) is less invasive and better esthetic operation for benign and malignant breast diseases and for the sentinel lymph node biopsy (SLNB). We performed 130 cases of VABS since December, 2001. We examined the usefulness of 3D-CT lymphography (LG) to detect precise sentinel lymph nodes (SLN) and the cosmetic and treatment results of VABS. Methods: We made 2.5 cm axillary skin incision (1.5cm for SLNB) and kept working space by retraction. Under endoscope, we cut oﬀ mammary gland, did SLNB, and dissected axillary lymph nodes (level I and II). 3D-CT LG was performed in the day before the operation to mark the sentinel lymph nodes on the skin. 2 ml of Iopamidol 300 was injected into subcutane near the areola and above the tumor. 16-channnel multidetector-row helical CT scan image was taken after one minute and reconstructed to 3D image. Results: VABS was done for 18 benign and 112 malignant diseases. We performed 108 breast conserving therapy, 4 skin-sparing mastectomy, and 86 SLNB (45 with 3D-CT). In contrast with the conventional operations, there was no signiﬁcant diﬀerence in operation time and blood loss. There was no serious postoperative complication. There was no remnant cancer cell in surgical margin pathologically. The wound scar was inconspicuous. The cosmetic results were good or excellent evaluated by original scoring system (ABNSW: asymmetry, breast shape, nipple shape, skin condition, wound scar). The postoperative follow-up time was max 52 months and average 27 months. There was no local recurrence. 3D-CT LG revealed precise SLN, which was proved by the cases of only one lymph node metastasis, and showed accurate relationships between lymph ducts (LD) and SLN, which was classiﬁed into four patterns (one-LD to one-LN: 8 cases; multiLD to one-SLN: 9 cases; one-LD to multi-SLN: 2 cases; multi-LD to multi-SLN:5 cases). SLNB can be done safely by 3D-CT LG, and less-invasively by VABS. Conclusions: VABS can make good local control and be a safety treatment. 3DCT LG is useful to perform the precise SLNB.

Introduction: Axillary node status has important prognostic implications in breast cancer. Sentinel biopsies may become the surgical staging procedure of choice in the assessment of the axilla. Intraoperative lymphatic mapping with identiﬁcation of the ﬁrst draining lymph node (sentinel node) is under investigation as a possible axillary staging procedure in breast cancer patients. Aim: To determine the role of sentinel node biopsy as an alternative to formal axillary node dissection in a district general hospital breast unit. Patients and Methods: It was prospective study between November 1998 and August 2001, 122 suitable patients, between the ages of 28 and 82 (mean age 56), underwent sentinel node excision with subsequent axillary sampling, in combination with either mastectomy or a breast-conserving procedure. Features considered to be exclusion criteria to the procedure were a 1) heavy axillary tumour burden as assessed clinically, 2) previous axillary surgery, 3) multifocal disease and therapeutic localisation biopsy. Results: 122 patients underwent sentinel node biopsy, using a blue dye technique. The sentinel node was identiﬁed in 113 patients, and accurately predicted the status of the axilla in 108 patients (96%). Of 39 patients who were node positive, the sentinel node was the only positive node in 11 cases (26%). There were ﬁve false negatives in patients that have a node-positive axilla. Conclusion: We therefore suggest that sentinel node biopsy may be a feasible and reliable alternative to formal axillary node dissection in certain patients and that the lack of access to radioisotope facilities in a district general hospital need not preclude such an approach.

CLINICAL PRACTICE AND EVALUATION O072

O073

A COST-EFFECTIVENESS ANALYSIS OF LAPAROSCOPIC VS OPEN ANTERIOR RESECTION FOR RECTAL CANCER B. Feng, M. Zheng, A. Lu, J. Li, M. Wang Ruijin Hospital, SHANGHAI, China

LAPROSCOPIC VS OPEN TOTAL MESORECTAL EXCISION FOR RECTAL CANCER: CHINESE EXPERIENCE

Background: Laparoscopy has gradually become accepted for the treatment of colorectal cancer after a long period of questions regarding its safety and higher hospital costs. Studies comparing the costs of anterior resection of rectum by laparoscopic and open approaches are still not available so far. The purpose of this study is to compare the cost and the composition of the direct cost of laparoscopic anterior resection for rectal cancer comparison with those of the open procedure. Methods: From January 2003 to May 2005, 87 patients with rectal cancer underwent laparoscopic anterior resections of rectum (LAP), while 86 cases were performed open procedures (OPEN). The direct cost including the cost for operations, drugs, transfusion, nutritional support, bed time, treatments for post-operative complications and reoperations were prospectively evaluated, as well as the productivity loss as the main indirect cost. The data of direct cost, indirect cost and the total cost were collected for the minimal cost analysis. The composition of the direct cost was analyzed to investigate the availability of the healthcare resources. Results: The median direct cost were not signiﬁcantly diﬀerent between LAP and OPEN groups (26787.00 versus 24865.50; P=0.375). The indirect cost of the LAP group was signiﬁcantly lower than that of the OPEN group (1,206.02 versus 2,071.58; p <0.01). And the total cost was not signiﬁcantly diﬀerent (27922.645 versus 27054.42; P=0.859). The composition of the direct cost in the two groups was diﬀerent. For LAP group, the cost percentage for operations, drugs, the hospitalization were 75.90%, 11.28%, 2.18% respectively. Compared to that of the OPEN group, 54.50%, 29.09%, 3.35% respectively, the percentage of operations in the LAP group was higher and the percentages of drugs and hospitalization were much lower. Conclusion: The total economical burden for patients in hospital was not signiﬁcantly diﬀerent between LAP and OPEN groups. The availability of the healthcare resources was higher in the LAP group due to its technical predominance, and the frequent bed turnover.

Background: Laparoscopy has gradually become accepted for the treatment of colorectal cancer after a long period of questions regarding its safety. Total mesorectal excision (TME) is the surgical gold standard treatment for middle and low third rectal cancer. Although many studies have been reported about the laparoscopic approach for colorectal cancer since the last twenty years, deﬁnitive long-term results are not yet available. The aim of this study was to examine prospectively our experience with laparoscopic TME, to evaluate the surgical outcomes and oncologic results, and to discuss the cost-eﬀectiveness of this procedure in the treatment of rectal cancer. Methods: Between September 2001 and December 2005, all patients who underwent laparoscopic TME (LAP) and all patients who underwent open procedure(OPEN) for low rectal cancer in our center were enrolled prospectively in this study. Data collection included preoperative, operative, postoperative, oncologic results, costeﬀectiveness and follow-up results. Results: A total of 140 patients underwent laparoscopic TME and 144 patients underwent open procedure for low rectal cancer were enrolled in this study. Conversion to open surgery occurred in 3 cases (2.1%). No signiﬁcant diﬀerences were observed in terms of mean operation time, post-operative complications, hospital stay and total hospital cost between LAP and OPEN groups. The average intraoperative blood loss was 79.5073.97ml in LAP group, which was signiﬁcantly less than that of the OPEN group. Mean time to ﬂatus passage, time to resume early activity, and time to semiliquid diet in the LAP group were signiﬁcantly shorter than those of the OPEN group (2.21.40 vs 3.31.37 d, 3.31.88 vs 5.52.72 d, 4.92.20 vs 7.63.87 d respectively). As to the lymph node yield, the specimen length, and distal margin, there was no significant diﬀerence between these two groups. The cost for operation in LAP group was signiﬁcantly higher than that in ORH group. While the cost for drugs in LAP group was signiﬁcantly less than that in ORH group. No signiﬁcant diﬀerence was observed in the total cost for operation and drugs between the two groups. Local recurrence rate and metachronous metastases rate had no marked diﬀerence between the two groups. Overall survival and Disease free survival at 45 months in LAP group (77.3% and 74.8%) was not obviously diﬀerent compared to the OPEN group (75.6% and 72.0%). Conclusion: Laparoscopic TME for rectal cancer is feasible and safe. The short- and long-term outcomes are comparable with those of conventional surgery.

M. Zheng, A. Lu, J. Li, M. Wang, B. Feng, Y. Zong, J. Ma Ruijin Hospital, SHANGHAI, China

S21

O074

O076

RELIABLE ASSESSMENT OF LAPAROSCOPIC PERFORMANCE IN THE OPERATING ROOM USING VIDEOTAPES

WHO SHOULD BE PERFORMING LAPAROSCOPIC CHOLECYSTECTOMY - A 10 YEAR AUDIT A.P. Boddy, S. Ranka, J. Bennett, M. Rhodes Norfolk and Norwich University Hospital, NORWICH, United Kingdom

N. Hogle1, L. Chang2, M. Sinanan3, R. Bailey4, D.L. Fowler1 1

Columbia College of Physicians and Surg., NEW YORK, United States of America Boston Medical Center, BOSTON, MA, United States of America University of Washington, SEATTLE, WA, United States of America 4 MIAMI, FL, United States of America 2 3

Background: Evaluation of operating room performance by videotape review is generally unreliable without the use of a validated assessment tool. GOALS (Global Operative Assessment of Laparoscopic Skills) has been used to objectively evaluate technical performance of surgery residents during laparoscopic cholecystectomy and laparoscopic appendectomy. We hypothesized that GOALS assessment of a videotape would reliably diﬀerentiate between an experienced (Expert) and an inexperienced (Novice) laparoscopic surgeon based upon video review of a laparoscopic cholecystectomy. Methods: Ten board-certiﬁed surgeons actively engaged in the teaching and practice of laparoscopy assessed the operative performance of laparoscopic cholecystectomy by one novice and one expert surgeon using GOALS to assess a videotape of the procedure. Scores for both the expert and the novice video tape reviews for the 5 domains (depth perception, bimanual dexterity, eﬃciency, tissue handling and overall competence) were recorded. Biostatistical analysis was performed using single factor ANOVA. Results: n the domains of depth perception, bimanual dexterity, eﬃciency, and overall competence the expert scored higher than the novice. There was no diﬀerence between the two for tissue handling.

Domain

P-value

Depth Percept Bimanual Dexter Eﬃciency Tissue Handle Overall Compet

0.0049 0.00054 0.0000901 0.072 0.0098

Conclusions: GOALS is a valid objective assessment tool for evaluating technical performance of laparoscopic cholecystectomy using a videotape of the procedure. GOALS can reliably diﬀerentiate the surgical performance of an expert from a novice.

Aims: Laparoscopic cholecystectomy is one of the commonest operations in general surgery. Both Upper GI/Hepatobiliary surgeons and general surgeons with other interests undertake laparoscopic cholecystectomy. We have performed an audit of all cholecystecomies performed in a large regional hospital from 1996 to 2005 and compared the results of Upper GI specialists with other general surgeons. Methods: A search was made of the computerised theatre and hospital coding databases for cholecystectomies performed from 1996 till 2005. Data regarding the type of operation performed, operation time, length of hospital stay and 30 day mortality were extracted and compared over time and between consultant specialities. Detailed morbidity data was collected by a review of case notes in patients who stayed in hospital longer than four days. Results: In the ten years from January 1996 to December 2005, 4513 cholecystectomies were undertaken, of which 89% were elective admissions. This proportion did not signiﬁcantly alter over the period of the audit. Overall, 55% of cases were performed under the care of Upper GI surgeons (this increased from 36% in 1996 to 67% in 2005). Signiﬁcantly more cholecystectomies performed by Upper GI surgeons were completed laparoscopically (96.4% of elective cases and 89.0% of emergency cases) compared to non Upper GI surgeons (84.1% of elective cases and 43.0% of emergency cases, p<0.001 for both). Post operative hospital stays were also signiﬁcantly shorter for Upper GI surgeons compared to non Upper GI surgeons (mean 1.8 vs 3.0 days for elective and 3.9 vs 9.1 days for emergency, p<0.001 for both). Overall, 30 day mortality was 0.4% for elective admissions and 2.6% for emergencies. Conclusions: Cholecystectomies performed by specialised Upper GI ﬁrms were more likely to be completed laparoscopically and patients had a signiﬁcantly shorter hospital stay compared to cholecystectomies performed by non Upper GI specialists.

O075

O077

PROSPECTIVE ANALYSIS OF SHOULDER PAIN FOLLOWING LAPAROSCOPY L.L. Swanstrom, S. Kanneganti, G. Sclabas, Y. Khajanchee, K. Thaler, M. Alexander

SIGNIFICANCE OF LAPAROSCOPY IN LIVE DONOR NEPHRECTOMY- COMPARISON OF DIFFERENT TECHNIQUES J. Treckmann, A. Paul, O. Witzke, S. Nadalin, M. Malago´, C.E. Broelsch University Hospital Essen, ESSEN, Germany

Legacy Health System, PORTLAND, OR, United States of America Objective: One of the major beneﬁts of laparoscopic surgery is a decrease in the patientÕs pain post op. Unfortunately a percentage of patients have referred shoulder pain which can decrease the early beneﬁts of this approach such as shorter hospital stay and less need for postoperative analgesia. The objective of our study is to establish the incidence and to identify patient or operative factors that are predictive for postop shoulder pain. Methods: A total of 44 consecutive patients (mean age 52.7 (SD14.8), male 22.7%) undergoing various laparoscopic procedures at our institution from July 1- Aug 31, 2005 were included in the study. Complete pre and postoperative pain assessment and QOL were recorded. Patient demographics, operative procedure, length of procedure, complications and length of hospital stay were collected prospectively as well. Univariate and multiple logistic regression analysis were performed to identify factors signiﬁcant for postop shoulder pain and comparisons were done using appropriate tests. P-values of <0.05 were considered signiﬁcant. Results: 30(68.1%) patients underwent laparoscopic upper abd surgery and 14 (31.9%) had laparoscopic lower abd surgery. Mean hospital stay was 2.8 days. A total of 22 (50%) patients had postoperative shoulder pain. 12/22 (54.5%) patients had moderate to severe pain (mean analog pain score = 3.8, SD 0.7). The mean analog pain score for incisional site pain in these patients was 1.7 (SD 1.2). There was no diﬀerence in the incisional pain score between the patients having shoulder pain vs no shoulder pain (p=0.8). Mean duration of shoulder pain was 7.6 days (SD 4.6) vs 6.5 days (SD 5.4) for non shoulder pain patients. Patients undergoing upper abd procedures had signiﬁcantly greater odds of having postoperative shoulder pain (OR 6.3, CI 1.4–27.7, p=0.01). Odds also increased in male patients (OR 1.6, CI 0.4–7.1), younger patients (OR 4.3, CI 1.0–19.3) and in patients where duration of procedure was longer than 2 hrs (OR 1.6, CI 0.4–7.3), none of these were signiﬁcant. Conclusion: We have found that referred shoulder pain is present in over half of post laparoscopy patients. The severity of this pain exceeds the pain from the abdominal incisions by a factor of 2.1. Risk factors include upper abd surgery, young males and long surgeries. This indicates the need for signiﬁcant investigations into the causes and treatments of referred shoulder pain and its eﬀect on length of hospital stay.

Aims: The purpose of this study was to compare laparoscopic assisted live donor nephrectomy (LAP) with conventional open approaches regarding feasibility, safety and morbidity. Methods: A consecutive series of n= 142 live donor nephrectomies performed between 1/97 and 12/05 was analysed. Kidneys were retrieved either by median laparotomy (ML n=22; initial experience), ﬂank incision (FI n= 57) and more recently by an anterior extraperitoneal approach (AEA n= 32) or since 1999 by laparoscopy in selected cases (LAP n= 31). Beside standard intra- and postoperative parameters, complications were documented. Pain in rest and motion was assessed with a visual analogue scale (VAS) until day 5. Results: Survival of the live donors (Age 51 [24 –75] years, 61 Male/67 Female ) was 100%. Complications were higher for ML with 13,6% and comparable for FI 8,7%, for AEA 5,5% and for LAP 6,4%. Bleeding complications were more frequent in LAP, while wound infection and hernia formation or abdominal wall relaxation complicated more often ML and FI. One patient in LAP group developed a pancreatic ﬁstula. In the AEA group one patient developed a small bowel obstruction. Postoperative pain scores were signiﬁcantly higher after ML. All grafts except one functioned initially well and 1 year graft survival reached 90%. Conclusion: Due to increased morbidity laparotomy should be avoided. FI and especially AEA gave superior results. LAP resulted in more serious complications. Safety aspects of LAP have to be monitored closely especially in small and medium volume centers.

S22

COMPLICATIONS AND THEIR LEGAL CONSEQUENCES O077-S1 MEDICAL LIABILITY INSURANCE CLAIMS OF ENTRY RELATED INJURIES IN LAPAROSCOPY J. Wind1, J. Cremers2, D.J Gouma1, F.W. Jansen3, W.A. Bemelman1 1 Academic Medical Center, AMSTERDAM, The Netherlands 2 MediRisk, UTRECHT, The Netherlands 3 Leiden University Medical Center, LEIDEN, The Netherlands Aim: In laparoscopy there are two methods to enter the abdominal cavity; the open and closed (blind) entry. The latter is performed by Veress needle or ﬁrst trocar insertion. In the open entry a blunt-tipped trocar is inserted under direct vision followed by insuﬄation. The aim of this study was to assess the amount of entry related injuries (ERI) in medical liability insurance claims for laparoscopic surgery and the incidence of open and closed entries at ERI. Methods: A retrospective chart review study was performed including all malpractice claims ﬁled at MediRisk concerning ERI. MediRisk is presently the largest insurer for medical liability in The Netherlands. The claims were categorized in certain ERI or uncertain ERI. In the latter group other causes for injury could not be excluded (e.g. coagulation). Results: From January 1993 to January 2006, 50 claims were identiﬁed consisting of 35 (70%) certain and 15 (30%) uncertain ERI. There were 28 (56%) intestinal, 10 (20%) vascular, 7 (14%) combination of vascular and intestine, and 5 (10%) other ERI. In more than 90% a closed entry was performed. All the vascular ERI were caused by closed entry. The vascular ERI were in 76% of retroperitoneal origin. There were 47 females and 3 males and median age was 36 years. The ratio between general surgery and gynecology was 1:1.3. Residents were involved in 16% of the claims. Only 38% of the patients had a normal BMI (20–25 kg/m2) and 45% of the patients had a history of prior abdominal surgery and/or an infectious event. In 42% the ERI was diagnosed during the index procedure resulting in a conversion. In the other cases the diagnosis was established later, median on post operative day 2, and resulted in one or more reoperations. Sixty-four percent of the patients were admitted to the ICU for a median of 5 days. Total indemnity payment was 237.322 euros (range 0–34.034 euros). Conclusions: ERI are roughly equally divided between general surgery and gynaecology in the Netherlands. Most ERI were caused by the closed entry technique and the closed entry technique exclusively caused vascular injury.

DAY SURGERY O078

O079

SHIFT IN PARADIGM OF LAPAROSCOPIC ANTIREFLUX SURGERY FOR GORD - DAY CASE LAPAROSCOPIC FUNDOPLICATION

PREDICTORS OF EARLY POST-OPERATIVE PAIN AND DYSPHAGIA IN PATIENTS UNDERGOING DAY CASE NISSENS FUNDOPLICATION K. Moorthy, N.S. Balaji, A. Jaipersad, A. Khan, C.V.N. Cheruvu Univ Hospital of North Staﬀordshire, STOKE ON TRENT, United Kingdom

N.S. Balaji, K. Moorthy, R. Nijjar, M.I. Khan, C.V.N. Cheruvu North Staﬀordshire University Hopsital, STOKE ON TRENT, United Kingdom Background: Laparoscopic antireﬂux surgery (LARS) is the accepted approach to surgery for reﬂux disease (GORD). With advances in optimisation of perioperative anaesthetic, antiemetic and analgesic regimes, day case approach for LARS is an attractive option, although less frequently adopted. Aims: To present our initial results of a prospective study of day case LARS (<11 hour ward). Methods: Day case LARS was performed in ASA1–2, fully independent, patients over an 18 month period. A 360 degree ﬂoppy fundoplication was performed. The perioperative protocol included standardised anaesthetic, antiemetic and analgesic regimes. The primary end points were early postoperative symptom scores, MVSS (Modiﬁed Visick Symptom Score) and global satisfaction proﬁles. The secondary endpoints of the study were postoperative complications and readmission rates. Results: 28 consecutive patients (M: F-22:6) with a median age of 45(IQR 35–48) and BMI of 29(IQR27–35) underwent day case LARS over the study period. Preoperative evaluation tools included endoscopy and manometry pH studies in all patients. The median operating time was 100 min and the median hospital stay was 6.75 hours after surgery. No perioperative complications or failure of same day discharge protocol were encountered. There were no readmissions, although there was one re attendance with gas bloat secondary to inappropriate prescription of eﬀervescent analgesia outside protocol. The pain, dysphagia and nausea scores (Visual Analogue Scale of 0–10) on the 1st week after surgery are. MVSS and overall satisfaction scores were obtained in all patients at a median follow-up of 6 months (IQR 5–9.5) after surgery. MVSS grade 1 or 2 was recorded in 23/25(93%) with median overall satisfaction score of 10/10 (mean 9.8). 2 patients had MVSS of 3 or 4 secondary to dysphagia and gas bloat respectively, in spite of complete absence of reﬂux.

Pain Dysphagia Nausea

Day 0

Day 3

Day 5

Day 7

5 3 0

3 2 0

2 0 0

2 0 0

Conclusion: Day case LARS is an attractive option with reduced costs and waiting times for the patient and hospital with excellent early satisfaction and intermediate eﬀectiveness (MVSS) scores. This can be achieved with careful patient selection, and standardised surgical and perioperative protocols.

Background: Laparoscopic anti-reﬂux surgery is increasingly being performed on a day case basis. The aim of this study is to identify factors that would predict short-term post-operative pain and dysphagia in patients undergoing day case Nissens fundoplication. Methods: prospective study of patients undergoing Nissens fundoplication on a day case basis. Day case selection was based on age, BMI and ASA status. All patients underwent a 360- degree fundoplication and crural repair was performed in all cases. However, the number of PTFE mesh patches to augment the crural sutures was variable. 10- point Visual Analogue scales (VAS) was used to assess pain and dysphagia prior to discharge and on days 3,5 and 7. A number of patient and surgical factors were analysed using univariate and multivariate analysis. Results: 28 patients (22 males, 6 females) underwent the procedure over a 2year period. The mean age and BMI was 43 (SD-9.4) years and 26.6 (SD-3.6) respectively. Younger patients were more likely to have higher pain scores on days 5 (p=0.04) and 7 (p=0.02) and hiatal mobilisation was associated with a higher pain score on day 7 (p=0.02). There was a signiﬁcant association between pain scores on days 0 (p=0.02) and 3 (p=0.01) and the number of crural mesh patches used. Younger patients experienced signiﬁcantly more dysphagia (p=0.04) which has settled in all but one patient on longer followup. There was also a signiﬁcant correlation between the number of crural patches and dysphagia scores (p=0.04). On multivariate analysis no factor was predictive of post-operative pain and dysphagia. Conclusion: Our results suggest that nearly all patients, suitably selected, will experience satisfactory post-operative outcomes. Younger patients and those with large hiatal defects undergoing day case Nissens fundoplication are more likely to experience greater pain and dysphagia in the immediate post-operative period.

S23

DIFFERENT ENDOSCOPIC APPROACHES O080

O082

LOW COST CLIPLESS MINILAPAROSCOPIC CHOLECYSTECTOMY - A STUDY OF 624 CASES

SELF EXPANDING ENDOLUMINAL STENTS ARE EFFECTIVE IN THE TREATMENT OF COMPLICATIONS AFTER UPPER GI SURGERY

G.L. Carvalho, T.G. Vilac¸a, M.C. Luna, D.G. Araujo, F.W. Silva, C.H. Ramos, G. Loureiro Pernambuco University, RECIFE, Brazil

M. St. Jean, S. Dunkle-Blatter, F.A. Syed, A.T. Petrick Geisinger Medical Center, DANVILLE, United States of America

Introduction: With the recent advances in minimally invasive surgery, it has been possible to use more accurate items of equipment with a reduced diameter, which has led to state-of-the-art 2-mm instruments (needle trocars). Nevertheless, because of the increased cost of this procedure it has not been described in the literature with a large patient series. Objective: To present modiﬁcations to the mini-laparascopic technique which may make it possible to conduct mini-lap procedures safely and eﬀectively, thereby considerably reducing the cost of this type of surgery. Method: From Jan 2000 to Jun 2006, 624 consecutive patients underwent minilaparoscopic cholecystectomy (MLC). The patients were suﬀering from chronic lithiasic cholecystitis at various stages of the disease or gallbladder polyps and were submitted to MLC, including acute cholecystitis and intraoperative cholangiography. Technique After performing the pneumoperitoneum at the umbilical site, four trocars are inserted; two of 2-mm (support trocars), one of 3-mm (work trocar) and one of 10-mm diameter, through which a 10-mm 30-degree laparoscope is inserted. Neither the 3-mm laparoscope, nor clips, nor expensive endobags are used. The cystic artery is safely sealed by electrocautery, near the gallbladder and the cystic duct is sealed with surgical knots. Removal of the gallbladder is carried out, in a bag made with a glove wrist, through the 10-mm umbilical site. Results: MLC was attempted in all 624 patients (80.9% females; mean age, 46.6 yr; range 14–94 yr). The total operative time was 32 min; range 13–105 min. The average hospital stay was 18 hours (96% were discharged within 24 h). There was no conversion to open surgery; 3,4% of patients (underwent conversion to standard (5-mm) lap-chole because of diﬃculty with the procedure; there were 2.5% minor umbilical site infections and 1.7% incisional herniations. There was no mortality, no bowel injury, no reoperation, no bile leakage, no bile duct injury and no postoperative hemorrhage. Conclusion: Mini-lap chole is a safe and eﬀective procedure which results in a better esthetic eﬀect for the patients, when compared with conventional laparoscopy. The modiﬁcations to the technique allow for a considerable reduction in costs, associated with the original MLC procedure, since neither clips, nor endobags, nor mini-loops are used. Furthermore, no 3-mm laparoscope is used, which is the most expensive component of the mini-lap instruments.

Background: Self expanding endoluminal stents (SEES) have expanded options for management of surgical complications after upper gastrointestinal (UGI) surgery. The objective of this study was to review our initial experience with SEES & to deﬁne the risks & beneﬁts associated with SEES placement after UGI surgery. Methods: All patients undergoing SEES after esophageal or gastric surgery from Sept. 2001 to Sept.2005 were retrospectively reviewed. Data was stored in a password protected database for patient information was collected by review of an electronic medical record (EPIC Systems). Statistical method: FisherÕs Exact Test. Results: 20 pts (15M & 5F) with a mean age of 62 yrs [range, 43–85] underwent a total of 40 procedures [range, 1–6/pt]. A total of 37 stents were deployed (ave1.85/pt, range 0–10) with a stent migration rate of 50% including two complete migration of a stent through the GI tract s/p RYGBP. Stent migration led to restenting in 4 pts (20%) while the total # of restenting procedures required was 12 (30%) in 9 pts (45%). Reasons for initial stenting procedures included benign stricture n-4 (20%), malignant strictures n-8 (40%), anastomotic leak n-7 (35%) & ﬁstula n-1 (5%). UGI tract procedures prior to stenting:Esophageal resection n-7 (35%); Esophageal Ca nonoperative n-3 (15%); PEH repair n=2 (10%); Lap Nissen n=1(5%); RYGBP n-3 (15%); MI esophagectomy n-4 (20%). 7 pts with leaks & 1 ﬁstula were treated w/stenting (40%). Median durations to radiographic or endoscopic evidence of resolution of leak or ﬁstula was 9.5 days (range 2–33) with return to po diet median 8.5 days (range 1–40). Patients managed conventionally had median resolution in 12.5 days (range 3–60) and resumed po intake in median 11days(range3–60). SEPS were more prone to migration than SEMS 62.5% vs 17.2% (p=.02). No pts experienced procedure related morbidity or mortality. Conclusions: SEES seem to be an eﬀective means of treating postoperative complications in the upper GI tract & may avert reoperation in selected pts. Pts with stents resolved leaks & ﬁstulas more quickly than similar pts managed with observation & drainage. The time to oral feeding was also improved in the stented pts. There was no mortality & morbidity related to repeat procedures due to stent migration. The rate of migration of the SEPS in our series was much higher than previously reported in the literature.

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HOW TO HAVE OPTIMAL RESULTS PERFORMING LAPARASCOPIC INCISIONAL HERNIA REPAIR R. den Boer, K. Thijssens Groningen University Medical Center, GRONINGEN, The Netherlands

STENTIMPLANTATION AS A TREATMENT OPTION IN PATIENTS WITH THORACIC ANASTOMOTIC LEAKS AFTER ESOPHAGECTOMY W.K. Kauer1, H.J. Stein2, H.J. Dittler1, J.R. Siewert1 1 Klinikum rechts der Isar, TU Mu¨nchen, MU¨NCHEN, Germany 2 St Johanns-Spital, SALZBURG, Austria

Background: Many reports of laparascopic incisional hernia repair have been published over the last decade reﬂecting the possibilities of a new and therefore possibly better technique. The aims of this study were to distinguish the tricks to get optimal results performing laparascopic incisional hernia repair. Method: Since 1998, 132 patients underwent a laparascopic incisional hernia repair in the University Hospital in Groningen. The method with intraperitoneal technique of a PTFE- mesh ﬁxated with tackers and transfascial sutures after argon lasering was used most frequently, after having tried several other techniques. The results were compared with the other laparascopic incisional hernia repairs in this center as well as they were compared with a group of 90 patients with an open repair. The patients were matched for age, sex, Body Mass Index, ASA classiﬁcation, hernia size and previous hernia repairs. Results: In the laparascopic group the operation time was longer (90 versus 72 minutes; p<0.05), the hospital stay was shorter (5.4 days versus 7.5 days; p=0.004). There were less seromas and less recurrences (p<0.05). The use of argon caused less seroma (P<0.05). Inlay technique was superior over onlay in terms of recurrence. Meshes attached high up to the costal rim were prone to recurrences. Extra sutures tackers to resolve this problem, caused less recurrence though the complains of pain were signiﬁcantly higher. In case of severe adhesiolesions, the laparascopic repair caused bowelwall damage in 3 cases. This serious complication was easier to avoid and therefore did not occur in the open series. There were less woundinfections in the laparascopic group. Patients were more satisﬁed after the laparscopic repair because of the minimal access used. Conclusions: When severe intraabdominal adhesions and hernias up to the costal rim are excluded, laparascopic incisional hernia repair using the intraperitoneal technique with a PTFE- mesh ﬁxated with tackers and transfascial sutures and argon lasering, is the method of preference in this centre.

Background: In patients with esophagectomy and gastric pull up for esophageal carcinoma anastomotic leaks are a well known complication and a major cause for morbidity and mortality. Objective: Is stentimplantation a treatment option in patients with thoracic anastomotic leaks after esophagectomy? Methods: 269 patients with esophageal cancer (Adenocarcinoma n=212, Squamous Cell Carcinoma n=57) had undergone esophagectomy and gastric pull up with an intrathoracic anastomosis between 1/98 and 12/ 2005. A thoracic anastomotic leak was clinically and endoscopically proven in 12 patients (4,5%). Endoscopic insertion of a self expanding covered metal stent (CHOO) at the site of the anastomotic leak was performed in 10 patients, two patients were treated with ﬁbrin glue. Results: Stents were successfully placed in all patients without complications. In all but one patient (n=9) radiologic examination showed a complete closure of the leakage. In one patient the stent was endoscopically corrected and a complete closure could be achieved as well. The stent could be removed after 6 weeks in 5 patients. Stentmigration occurred in 4 patients. In all but one patient (n=7) leak occlusion was obtained. Two patients died during the in-hospital time due to reasons not related to the stent placement. Conclusion: Stentimplantation in patients with thoracic anastomotic leaks after esophagectomy is an easily available and eﬀective treatment option with a low morbidity but stent migration does occur.

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D.O. OTT (18551929) THE FOUNDER OF ENDOSCOPIC SURGERY V. Olovyanny1, S. Glyantsev2 1 Northern Medical Centre, ARKHANGELSK, Russia 2 Cardiovascular Surgery Centre, MOSCOW, Russia The article highlights the priority of the Russian scientist D.O. Ott in inventing and intro-ducing ventroscopy (laparoscopy through colpothomic hole).

ENDOSCOPIC FULL-THICKNESS RESECTION AND CLOSURE OF DEFECT WITH ENDOSCOPIC SUTURING.ENDOSCOPIC FULLTHICKNESS RESECTION AND CLOSURE OF DEFECT WITH ENDOSCOPIC SUTURING P.O. Park1, M. Bergstro¨m1 A. Fritscher-Ravens2 K. Ikeda3 A. Mosse2 P. Swain2 1 Sahlgrenska University Hospital/O¨stra, GOTHENBURG, Sweden 2 t MaryÕs Hospital, LONDON, United Kingdom 3 ikei University School of Medicine, TOKYO, Japan

G. Kellin (1901) and H. Ch. Jacobeus (1910) used cystoscop Nitze for the examination of the abdominal cavity. However chronologically the ﬁrst laparoscopy and laparoscope were absolutely of another kind. The other method was reported by Dmitry Ott several months before G. KellingÕs experiments. As an endoscope he used traditional devices for endoscope of that time - metal mirrors and a head reﬂector. At the tip of the mirror Doctor Ott ﬁtted an electric bulb. Ott named his method - ventroscopia or a method of lightening the abdominal cavity organs. According to the author these mirrors gave him an opportunity not only to distinctly iden-tify pathologic changes, but also to make surgery. He started using his method in practice in 1899, as he mentioned later in his articles. In 1902 D. Ott delivered speeches on ventroscopia at medical congress in Berlin. D.O. Ott formulated the main directions for the use of his method. Ventroscopia can be used: 1. for identiﬁcation of bleeding and proper hemostasis; 2. for the organ adhesiolysis; 3. in stead of exploratory laparotomy; 4. for peritoneumÕs lavage after the surgery; 5. for diagnostics of appendicitis and the other internal organs diseases; 6. for educational demonstrations. In 1908 the author reported about 1500 operations were done with the help of ventroskopy (extirpation of uterus; operations in case of abdominal pregnancy, dissection of intra-abdominal commissures, appenndectomy). The author used special surgical instruments 35 cm and more long. To prove the eﬀectiveness of the method the author cited attained lethality rate of 1,48% against 9,09% in case of similar operations through laparothomy. Conclusions: The idea of the examination of human bodyÕs closed cavities with the help of lighting in-struments belongs D.O. Ott, who was not only to realize it, but also foresaw the laparoscopy prospects for many years ahead. D.O. Ott was the ﬁrst who perform endoscopic operations on the organs of the abdominal cavity. Therefore the authors contend that D.O. Ott should be considered the pioneer and founder of endoscopy surgery.

Background: Large benign polyps or small precancerous lesions of the stomach are commonly removed with a small resection at laparotomy or laparoscopy. If these procedures could be performed at ﬂexible endoscopy it would mean a smaller trauma for the patient and presumably a quicker recovery. Materials and methods: Full-thickness resections of the stomach were performed at ﬂexible endoscopy in acute and survival studies in pigs (28–35 kg), using a double channel gastroscope. The planned resection was marked with a needle knife. Two stiches were placed, one on each side of the planned resection. By puncturing the stomach wall with the needle knife a guide-wire could be passed into the abdominal cavity. Using a sphicterotome held in place by the guide-wire a semi-circular incision of the stomach wall was made. The ÔtumorÕ was then hold by a grasping forceps and the rest of the circle was cut with a polyp-snare. The stitches were then locked together. Suturing was performed using a 19 gauge needle on a ﬂexible shaft passed through one channel of the double channel gastroscope and threads were locked together in pairs. Further double-stitches were placed until the defect was tightly closed. Results: The technique was used in 4 pigs including two survival studies. Incisions were 2–3 cm in diameter. 3 or 5 pairs of stitches were placed in each animal. There was no signiﬁcant bleeding or other complications. The surviving animals appeared fully recovered on awakening from the anesthetic. Post-mortem examination showed eﬀective healing of the sutured defect and there was no evidence of peritoneal inﬂammation or peritonitis. Conclusions: Fullthickness resection and closure of the gastric wall defect can be accomplished using a simple ﬂexible endosurgical technique and a new ﬂexible suturing system.

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NONGYNECOLOGICAL PREGNANCY

LAPAROSCOPIC

SURGERY

DURING

O. Avrutis, V. Michalevsky, J. Meshoulam, O. Sibirsky, A. Durst Bikur Cholim Hospital, JERUSALEM, Israel Aim: Once thought to be absolute contraindication during pregnancy, laparoscopic procedures are becoming more widely accepted during pregnancy as evidenced by numerous encouraging reports in the literature. We report our experience of laparoscopic surgery during pregnancy in 40 women. Methods: Medical records of 62 pregnant women who underwent open (22) or laparoscopic (40) nongynecological surgical procedures at our hospital from 1995 to 2006 were reviewed. Results: Twenty appendectomies (8 in the 1st trimester, 6 in the 2nd trimester, and 6 in the 3d trimester), one splenectomy for traumatic rupture (3d trimester), and one closure of perforated gastric ulcer occurring at delivery were performed by conventional open surgery. Histological examination of appendix showed no pathology in 4 (20%) of cases. One fetal loss occurred after open appendectomy in a patient at her 8th gestational week (GW). Forty patients underwent laparoscopy. There were 9 laparoscopic cholecystectomies (5 in the 2d trimester, and 4 in the 3d trimester), and 30 laparoscopies for suspected appendicitis (11 in the 1st trimester, 12 in the 2nd trimester, and 7 in the 3d trimester). The diagnosis was proven in 25 cases, in which laparoscopic appendectomy (LA) was performed. Histopathology of appendix showed various degree of inﬂammation in all 25 cases. In 4 cases other pathology was established and managing laparoscopically (2 ruptured ovarian cyst, 1 torsion of Fallopian tube, 1 torsion of epiploic appendix), and in remainder one case laparoscopy was negative. There was one unique case of perforated gastric ulcer in a 20-year-old primigravida at her 26th GW managed by laparoscopic omentopexy. There were 2 fetal losses after LA (both in the 1st trimester). Among the remaining 38 patients no complications occurred and all women carried on their pregnancies to term and delivered healthy babies. Conclusions: Laparoscopic treatment of appendicitis and symptomatic gallstones can be safely performed during all stage of gestation with minimal fetal and maternal morbidity when accepted management guidelines are followed. Laparoscopy improves diagnosis and reduces unnecessary appendectomies in pregnant women. Reviewing the literature, we realized that laparoscopic repair of a perforated peptic ulcer occurring during pregnancy has not been previously documented.

ROBOTIC VS. COMBINED LAPAROSCOPIC AND MEDIASTINOSCOPIC ENDODISSECTION VS. OPEN TRANSHIATAL TOTAL ESOPHAGEAL RESECTION EXPERIMENTAL STUDY V. Bintintan1, A. Mehrabi2, J. Koeninger2, A. Kashﬁ2, M.W. Buechler2, C.N. Gutt2 1 University of Medicine and Pharmacy, CLUJ NAPOCA, Romania 2 Chirurgische Universitaetsklinikum, HEIDELBERG, Germany Aims: The disadvantages of open transhiatal total esophagectomy may be avoided by a minimal-invasive approach. However laparoscopic dissection of the upper esophagus is diﬃcult while mediastinoscopy is not standardized, the various techniques being performed rarely and only in highly specialized centers. Some of these limitations may be overcome by the da Vinci robotic system with its special features. The study evaluates comparatively these three techniques of total transhiatal esophageal resection. Methods: Robot-assisted transhiatal esophagectomy was performed in four German Landrace pigs in general anaesthesia. A gas-chamber mediastinoscopic procedure was added to a conventional laparoscopic transhiatal dissection in another group of nine pigs and open transhiatal esophagectomy was performed in further eight animals. Perioperative parameters were recorded in all cases. Results: The success rate in the robotic group was 100%, dissection being completed up to the cervical area on average in 76 min with 15 ml mean blood loss. The combined laparoscopic and mediastinoscopic approach was successful in all cases. Upwards and downwards dissection were joined at the level of tracheal bifurcation after mean 69 min and 29 min respectively. Pleura, aorta, membranous trachea, the right and left bronchi, azygos vein arch and paraesophageal and subcarinal lymph nodes were identiﬁed during the procedure while blood loss was minimal. Pleural injury occurred in three robotic and all nine combined endoscopic cases, the side eﬀects of pneumothorax being successfully managed by lowering the abdominal CO2 insuﬄation pressure and adjusting the ventilatory parameters. The open procedure was performed on average in 38.62 min without incidents except one case with spleen injury and another one with alterations of cardiopulmonary parameters. Blood loss was under 100 ml. Conclusions: The gas-chamber mediastinoscopic technique is valuable for dissection of the upper esophagus. Combined with the conventional laparoscopic transhiatal technique it allows a safe totally endoscopic esophageal resection. The robot-assisted esophagectomy approach is feasible, the articulated long instruments making it less technically demanding than the combined laparoscopic and mediastinoscopic procedure. Longer operative times required by the minimal-invasive techniques are justiﬁed by increased accuracy of mediastinal dissection and better lymph node staging.

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MENTORING CONSOLE IMPROVES COLLABORATION AND TEACHING IN SURGICAL ROBOTICS E.J. Hanly, B.E. Miller, R. Kumar, C.J. Hasser, E. Coste-Maniere, M.A. Talamini, A.R. Aurora, N.S. Schenkman, M.R. Marohn Johns Hopkins University, SAN DIEGO, United States of America

ADVANCED TELECOMMUNICATION SYSTEM FOR ENDOSCOPIC SURGERY IN ASIA: TRANSMISSION OF ORIGINAL QUALITY OF IMAGES OVER HIGH-SPEED INTERNET

Introduction: One of the most signiﬁcant limitations of surgical robots has been their inability to allow multiple surgeons and surgeons-in-training to engage in collaborative control of robotic surgical instruments. We report the ﬁrst experience with a ground-breaking two-headed daVinci surgical robot that allows two surgeons to: 1) simultaneously operate and actively swap control of the robots four arms; or 2) share control of two of the robots arms (nudge mode). Methods: The utility of the mentoring console operating in its two collaborative modes was evaluated through a combination of dry lab exercises and animal lab surgery. Results from surgeon-resident collaborative performance of complex three-handed surgical tasks were compared to results from single-surgeon and single-resident performance. Statistical signiﬁcance was determined using the students t-test. Results: Collaborative surgeon-resident swap control reduced the time to completion of complex three-handed surgical tasks by 25% compared to single-surgeon operation of a four-armed daVinci (p < 0.01) and by 34% compared to single-resident operation (p < 0.001). While swap mode was found to be most helpful during parts of surgical procedures that require multiple hands (such as isolation and division of vessels), nudge mode was particularly useful for guiding a residents hands during crucially precise steps of an operation (e.g. proper placement of stitches). Conclusions: The daVinci mentoring console greatly facilitates surgeon collaboration during robotic surgery and improves the performance of complex surgical tasks. The mentoring console has the potential to improve resident participation in surgical robotics cases, enhance resident education in surgical training programs engaged in surgical robotics, and improve patient safety during robotic surgery.

Aims: Telecommunication gains its popularity by recent technological innovation, but telemedicine is still of limited use due to deteriorated images transmitted over narrow band network. We previously reported the establishment of a new telemedical system between Korea and Japan using big broadband Internet which could completely preserve the quality of transmitted moving images (Surg Endosc 20:167–170, 2006). The expansion of this innovating system to other Asia-Paciﬁc regions is now studied. Methods: Kyushu University Hospital in Fukuoka, Japan, was connected with an optic ﬁber to major hospitals, universities, and meeting venues in Korea, China, Taiwan, Thailand, Singapore, Hawaii, and Australia, using domestic research network in each area and Asia-Paciﬁc Advanced Network as international lines. The digital video transfer system (DVTS), which can transform digital video signals directly to Internet Protocol with minimal time delay, was set-up with a free software and a regular personal computer (PC) and was connected to a conventional surgical unit. The necessary bandwidth was 30 Mbps per channel and a security program was used to protect the patients privacy. Results: Among 55 international teleconferences performed between February 2003 and February 2006, 25 dealt with the contents of endosocpic surgery. The subjects were stomach in 11, colon in 4, and others in 10. Ten were accompanied with live surgical demonstration and other 15 were with teleconferences with video or PC presentation. Korea was connected 22 times, China 6, and others twice each. Seven events were performed in multi-station conﬁguration. The frame rate was 30 per second and the delay was restricted to 0.3–1.0 sec depending on the connected locations. Conclusions: Transmission of exactly the same quality of surgical images to other remote areas is an ideal condition both for clinics and surgical education. We have successfully expanded our advanced telesurgical system to many Asia-Paciﬁc countries, which is easy to perform and economical with ordinary equipments. Because patientfriendly endoscopic surgery spreads rapidly and the conditions diﬀer by regions and countries, this telesurgical system should be a promising tool for learning specialized skills and updating new knowledge beyond geographic borders. It is on further development and will be applicable worldwide.

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CAN INNATE VISUOSPATIAL ABILITIES PREDICT THE LEARNING CURVE FOR ACQUISITION OF TECHNICAL SKILLS IN LAPAROSCOPY? A. Andalib, L.S. Feldman, J. Cao, A.L. McCluney, G.M. Fried McGill University, MONTREAL, Canada

VALIDATION OF THE PROMIS HYBRID SIMULATOR USING A STANDARD SET OF LAPAROSCOPIC TASKS G.M. Fried, A.L. McCluney, L.S. Feldman McGill University, MONTREAL, Canada

Background: Acquisition of skills follows a learning curve, which can be characterized mathematically according to the rate of learning and the performance that can be theoretically achieved with extensive practice. We assessed whether innate abilities (visuospatial perception) impact the rate and/or the performance potential for learning a fundamental laparoscopic transferring skill. Methods: 32 nave ﬁrst year med and dental students were tested for innate visuospatial abilities using 3 tests. Card Rotation (CR) and Cube Comparison (CC) test spatial orientation; Map Planning (MP) tests spatial scanning abilities. Each student performed the FLS peg transferring task 15 times and a learning curve was generated. Learning potential and learning rate were calculated from these curves. A linear regression model was used to test for correlation between task performance and each visuospatial test. Observed diﬀerences were tested for signiﬁcance using StudentÕs t test. Results: There was signiﬁcant correlation of learning potential with both CR (r = 0.36, P < 0.05) and CC (r = 0.46, P < 0.05). Learning rate correlated with scores for CR (r = 0.37, P < 0.05), but not CC (r = 0.26; P = 0.15). MP did not correlate with either learning rate or potential. Students scoring > 120 on CR had signiﬁcantly greater learning potential (100 vs. 95; P < 0.05) and rate (6.6 vs. 4.0; P < 0.05), than those scoring < 120. Similarly, those scoring > 22 on CC also had greater learning potential (101 vs. 95) and rate (6.4 vs. 4.0) than those <22 (P < 0.05). Those with higher learning potential (>94) fared signiﬁcantly better in CR (122 vs. 105; P < 0.05) and CC (23 vs. 14; P< 0.05). Students with interest in surgical specialties had signiﬁcantly higher learning potential than students with no interest in surgery. Conclusion: Innate spatial orientation abilities, but not spatial scanning abilities, correlate with the rate of learning and the learning potential during the learning curve for the fundamental laparoscopic skill of bimanual transferring using a monocular optical system.

S. Shimizu, N. Nakashima, K. Okamura, M. Tanaka Kyushu University Hospital, FUKUOKA, Japan

Introduction: SAGES Fundamentals of Laparoscopic Surgery (FLS) tasks are validated measures of technical skills, however FLS scoring requires a trained proctor. The ProMIS simulator (Haptica; Dublin, IR) is a hybrid system with physical and virtual reality tasks. It has the ﬂexibility to incorporate any physical task and score it with ProMIS metrics. Metrics are automated and report motion analysis data as instrument path length (PL) and instrument smoothness (IS). The purpose of this study was to test for construct and concurrent validity using FLS tasks in the ProMIS simulator. Methods: 5 laparoscopic novices and 5 experts performed FLS tasks in both the standard FLS simulator box and the ProMIS simulator. Assessments were made based on FLS metrics, as well as PL and IS. Students ttest was used to compare the mean (SD) of total scores for novices and experts. Pearsons correlations were calculated for standard FLS scores in relation to ProMIS FLS scores, total PL, and total IS. Signiﬁcance was deﬁned as p< 0.01 (*). Results:

Total Scores

Std FLS

ProMIS FLS

Total PL

Total IS

Novice Expert

35 (11) 89 (12)*

17 (10) 76 (11)*

6258 (780) 857 (383)*

3137 (1403) 1306 (584)*

Standard FLS scores correlated strongly with ProMIS FLS scores (r=0.90), total PL (r=)0.83), and total IS (r=)0.78) (p<0.01). Conclusions: FLS tasks performed in ProMIS, when scored by either traditional FLS metrics or by intrinsic ProMIS metrics, discriminate eﬀectively between novices and experts. Based on the observed correlations, ProMIS FLS scores, total PL, and total IS are excellent predictors of scores in the standard FLS simulator.

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EFFECTIVE EDUCATION FOR ENDOSCOPIC SURGERY M. Waseda, N. Inaki, J.R. Torres Bermudez, G. Manukyan, I. Gecek, L. Mailaender, G. Buess University Hospital Tuebingen, TUEBINGEN, Germany

SPATIAL ABILITY CAN PREDICT LAPAROSCOPIC SKILL PERFORMANCE OF NOVICE SURGEONS K.N. Birbas1, C.S. Tzafestas2, I.G. Kaklamanos1, A.A. Vezakis3, G. Polymeneas1, G. Bonatsos1 1 University of Athens, ATHENS, Greece 2 National Technical University of Greece, ATHENS, Greece 3 Tzaneion Hospital, PEIRAIAS, Greece

Background: Training for laparoscopic surgery is essential to perform an operation safely and to avoid technical problems and complications. The Tuebingen Training Center for minimally invasive surgery was established in 1989. In this training center, a trainer for integration of animal organs is used as a training device. Using this method, participants can feel the real haptic sense of organs and practice the operative procedure repeatedly. The aim of this study was to evaluate the learning eﬀects of laparoscopic cholecystectomy (LC) in Tuebingen Training Center. Material and Method: 13 participants who had experienced less than 20 cases of LC in clinical situation joined this study. The training of LC was performed in the Tuebingen MIC-trainer using swine liver with gall bladder. Every participant performed 10 LCs as an operator and 10 LCs as an assistant in a 3 days program. Operation time and frequency of complications (perforation of gall bladder, liver injury, cystic duct injury and vessel injury) were documented and analyzed. Result: Operation time during 10 training sessions was reduced. The difference of average operation time from the ﬁrst attempt and the last attempt (29.5 9.4 min versus 19.6 4.2 min) was signiﬁcant (p<0.05). Frequency of perforation of gall bladder was reduced from the ﬁrst to the last attempt (from 81.8% to 14.2%). Frequency of liver injury was also reduced from the ﬁrst attempt to the last attempt (from 45.6% to 0.0%). Cystic duct injury and vessel injury were found at the ﬁrst attempt (9.1% and 18.2%, respectively) but disappeared at the last attempt (0.0% and 0.0%, respectively). Conclusion: In our training course, participants could obtain the training eﬀect not only on operating time but also on frequency of complications. We would like to recommend this training program for beginners of endoscopic surgery as one of the most eﬀective educations for endoscopic surgery.

Background: There is a dichotomy in the surgical literature regarding the value of individuals spatial abilitiy as predictor of laparoscopic performance. Most authors accept that spatial abilities correlate only with the initial laparoscopic performance of novice trainees which shortly after approach the same laparoscopic performance level independently of the spatial score achieved. Methods: Twentyone subjects were recruited from basic laparoscopic courses attended by participants with minimal laparoscopic experience. Two measures were obtained: spatial abilities score and laparoscopic performance score generated by MIST. Spatial abilities were measured with Purdue Spatial Visualization Test by Roland Guay, consisted of three parts: ÔDevelopmentsÕ, ÔRotationsÕ and ÔViewsÕ. Participants were also asked to accomplish ten trials of each of three predeﬁned tasks, of increasing diﬃculty, in MIST simulator. The simulator assesses trainees performance based on recording of speciﬁc errors and other performance parameters such as Time of completion and Economy of movement. Results: A signiﬁcant correlation (r=0.72) was found between spatial ability and laparoscopic skills even when the correlation was controlled for age, gender, years of surgical experience, computer use and videogames consoles exposure. The correlation remained statistically signiﬁcant during the ﬁnal trials of the two more demanding tasks. Conclusions: Structured spatial ability test can predict MIST performance (which has already proven its value as an assessment tool of laparoscopic performance) of novice laparoscopic surgeons. It is also evident that the variance attributed to the spatial ability is equally important not only in the initial approach but also during the next phase of the laparoscopic learning curve.

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E-EDUCATION IN MINIMALLY INVASIVE SURGERY: A LIMITFREE WAY OF LEARNING AND PROMOTING CONTINUING MEDICAL EDUCATION D. Mutter, G. Temporal, T. Parent, C. Bailey, J. Leroy, B. Dallemagne, F. Rubino, M. Simone, J. Marescaux IRCAD-EITS / University Louis Pasteur, STRASBOURG, France

GAZE DOWN THREE DIMENSIONAL ÔOPEN-BOXÕ TRAINING SHORTENS THE LEARNING CURVE FOR A COMPLEX LAPAROSCOPIC TASK R. Aggarwal, P. Boshier, G.B. Hanna, A. Darzi Imperial College London, LONDON, United Kingdom

Background: The Internet represents a major tool for e-education. http:// www.websurg.com is a web-based information resource dedicated to continuing education in minimally invasive surgery. It uses cutting edge multimedia, video streaming technologies to deliver a wide range of data incorporating text-based chapters of surgical procedures, ﬁrst-rate color drawings, animations and highresolution videos. Expert advice given through interviews bridges the gap between theory and real-time practice. Aim: The study was conducted to evaluate acceptability and usage modalities of a website dedicated to surgical education via the analytical results of Internet connections. Materials and methods: WeBSurg.com encompasses 135 interactive operative technique chapters using Flash technology with thorough descriptions of laparoscopic procedures authored by world-renowned experts. Over 370 videos of surgical procedures, and 770 expert opinions are available in diﬀerent media players (Windows Media, RealOne or QuickTime players) and encoding bit rates (180 Kilobits per second up recently to 2 Megabits per second 640X480 for high resolution videos). Access is free, securized with password. Evaluation criteria were number of pages viewed, hits on videos, origin of visitors and session timing in 2005, and evolution of such data between years 2004 and 2006. Results: A total of 49,000 monthly visitors sessions (mean connection time: 12 minutes) and 2,837,000 viewed pages were observed. As for videos, 965,000 were viewed, with an average viewing length of 20 minutes but 51,366 hits were obtained over the last 5 months on the 2 new high-resolution videos only. It has led to a 725% increase in the hits on videos (from 14,007 in January 2004 to 115,260 in February 2006). The distribution of a visit breakdown is the following: Europe 170,000 North America 130,000 Asia 90,000 South America 40,000 Africa 25,000, and Oceania 10,000. Conclusion: Websurg.com represents an outstanding model of Internet-based continuing surgical education. It epitomizes the concept of e-education in minimal access surgery by integrating multimedia e-learning and e-training models using the latest technologies to display videos, texts and illustrations simultaneously. Its exponential growth exempliﬁes the essential role and place of the Internet in the ﬁeld of surgical education.

Introduction: Laparoscopic procedures require surgeons to manipulate instruments whilst viewing a two-dimensional video display. Threedimensional vision has been proposed to improve operative performance, though its eﬀect on rapidity of skills acquisition has not been evaluated. The aim of this study was to determine whether the learning curve for a complex laparoscopic task is shortened by preliminary training with gazedown three-dimensional open-box training. Methods: 20 laparoscopic novices were recruited to the study and their baseline surgical skills were conﬁrmed on 10 repetitions of open bench-top knot tying. Following randomisation, 10 subjects (group A) performed 60 intracorporeal knots in a standard laparoscopic box-trainer set-up. Group B (10 subjects) performed 30 knots with a gaze-down three-dimensional open box, followed by 30 standard laparoscopic knots. Performance was recorded with a validated motion tracking device to provide objective measures of dexterity, i.e. time taken (Tt) and total number of movements (Tm). Non-parametric tests of signiﬁcance were employed, with p<0.05 deemed signiﬁcant. Results: There were no baseline diﬀerences on open knot tying between groups A and B at the tenth trial for Tt (median 62.4 vs 71.2 seconds, p=0.971) and Tm (52 vs. 50, p=0.912). Learning curves on standard laparoscopic knots for group A did not show further signiﬁcant improvement beyond the 20th (Tt) and 29th (Tm) repetitions (p>0.05), and for group B at the 10th (Tt) and 9th (Tm) sessions (p>0.05). There were no signiﬁcant diﬀerences for standard laparoscopic knot tying between the two groups at the outset of training for Tt (356.6 vs. 320.1 seconds, p=0.315) and Tm (198 vs. 176, p=0.796), nor at the end of training: Tt (179.3 vs. 163.6 seconds, p=1) and Tm (117 vs 115, p=0.739). Conclusions: The length of the learning curve for acquisition of a complex laparoscopic skill such as intracorporeal suturing can be halved by initial training on an open-box trainer. This is a cheap, easily available and eﬀective mode of practice which should be integrated into laparoscopic training curricula.

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O096 TEACHING LAPAROSCOPIC HERNIA REPAIR (TAPP) LEARNING CURVE OF YOUNG TRAINEES IN A HIGH VOLUME CENTER U.W. Bo¨keler, J. Schwarz, R. Bittner Marienhospital, STUTTGART, Germany Introduction: The TAPP is a diﬃcult and detailed operation. This study analyses how quickly and safely a young surgeon can learn this operation. Material and Methods: The study was based on 13000 operations performed by 20 doctors at the department of general surgery at Marienhospital Stuttgart. The ﬁrst part of the study analysed the recurrence rate, the duration of the operation and morbidity after TAPP of high-volume and low-volume surgeons. In the second step two groups have been examined, the ﬁrst consisted of 4 pioneers (elder surgeons) and the second group of 5 trainees (with institutional experience). Once again the recurrence rate, the duration of the operation and the morbidity of the two groups were analysed. Results: The high volume surgeons performed the operation in average between 38 and 45min, the low volume surgeons took on average between 45 and 72 min. The recurrence rate of both groups was similar. In the highvolume group between 0,3 an 0,91%, in the low volume group between 0,46 and 0,58%. The morbidity rate varied on average in the high volume group between 0,9 and 3,7% and in the low-volume group between 1,3 and 4,5. During the ﬁrst 50 operations the recurrence rate was on average at 4, 2% for the pioneer group and at 0,5% for the trainees group. After the ﬁrst 50 there was a drop in the Pioneer-Group for the recurrence rate to approximately 0, 5%. In the trainee group it remained at 0, 5%. Conclusion: The recurrence rate and the morbidity are independent of the surgeons experience with this technique. However the length of the operation will be based on the surgeons experience. In sum, this technique can be learned quickly, skilfully and safely by young surgeons in a high volume center when a standardized technique is used.

EMERGENCY SURGERY O097

O098

APPENDICITIS IN ELDERLY- A CHANGE IN THE LAPAROROSCOPIC ERA

INTRAOPERATIONAL MONITORING WITH THE ANALYSIS OF IMAGES AT LAPAROSCOPIC OPERATIONS IN EMERGENCY SURGERY

C. Paranjape, S. Dalia, J. Pan, A. Salvator, M. Horattas Akron General Medical Center, AKRON, OHIO, United States of America

N.A. Gurevich1, A.N. Lyzikov2, A.R. Gurevich1 Mogilev Town Urgent Hospital, MOGILEV, Republic of Belarus 2 Gomel State Medical University, GOMEL, Republic of Belarus

1

Introduction: Appendicitis in elderly patients is associated with signiﬁcant morbidity and mortality. Early and correct diagnosis along with minimal invasive surgery can lead to more favorable outcomes as compared with pre-laparoscopic era. Methods: Retrospective review of 116 elderly patients (age > 60) from 1999– 2004 is compared with our previously published studies from 1978– 1988 (N=96) and 1988–1998 (N=113) respectively. Results: In our present series (1999–2004), more cases were done laparoscopically (n=68) than open (n=48). Perforated appendicitis had signiﬁcantly more Length of Stay (LOS), more complications and longer Operating time as compared with non-perforated cases. The laparoscopic cases had signiﬁcantly less LOS, fewer complications and comparable Operating time compared with open cases.

LOS (days CT scan done Accurate of CT COMPLICATIONS OR Time (min)

Lap (n=68)

Open (n=48)

p-value

5.3 +/) 4.3 75% 92% 18% 82.5 +/) 39.4

9.8 +/) 9.7 85% 97% 37% 80.4 +/) 48.1

.0001 0.17 0.25 .02 .40

Compared with our previous studies from (1978– 1988) and (1988–1998), the present series (1999–2004) has patients presenting with fewer classical symptoms. CT scanning was more accurate in the present study and was more routinely used. Patients in the present series had more correct pre-operative diagnosis. Perforated appendicitis was encountered less frequently and was associated with fewer complications. The 4% mortality rate in the previous two series decreased to less than 1% in this series. Conclusion: Minimally invasive surgery combined with increased use and accuracy of pre-operative CT scans have changed the clinical management of acute appendicitis in elderly patients leading to decreased length of stay, decreased mortality and more favorable outcomes.

The important problem of laparoscopy in emergency surgery is precise visualization and image recognition from the monitor, as it inﬂuences on further intraoperational tactic. Till now the image interpretation was based only on surgeon experience, which determines the character of inﬂammation. Most diﬃculties occur in diagnostic of initial stages of it when it is localized in mucosa and submucosa. Laparoscopy not estimates authentically the degree of pathomorphological changes. Experience of 9088 laparoscopic operations (3709 (41%) of them were urgent operations), shows that the problem with precise diagnosis occurs frequently in diagnostic laparoscopy when the indirect laparoscopic features determine intraoperation situation (in 8.4% cases at appendicitis, 37% at acute pancreatites, 15% at perforating ulcer, 22% at trauma of abdomen). For solution of this task was developed computer complex for diagnosis veriﬁcation from endoimage. Quantitative morphology in anatomic research allows to deﬁne optical, geometrical and topological characteristics for separate objects, and for the whole pathological picture. In the Mogilev Town Urgent Hospital it is developed and since 2005 the hardwaresoftware complex for remote control by the operational surgical module takes root into a practice. It is constructed on modern technologies and unites in a complex the diagnostic and operational equipment, quickly receiving trustworthy information from operation, registration and display of data, and the computer technics. The goals of a computer complex: specialized processing of endoimages; calculation of color and morphometric attributes of organs; introduction the information-expert system for operative diagnosis of diseases from endoimages; archiving of an electronic patient card with endoimages and operational protocols; creation of the video-atlas of typical and atypical situations; training of surgeons; selection from archive and data transfer for telediagnosis. Under the control of the given system, over a round-the-clock operating mode 285 operations (204 of them at urgent pathology) are executed. All operations have been lead under the control of the surgeon-moderator over use of a photo and video capture. Thus, use of modern information systems expands opportunities of a laparoscopy in diagnostics and treatment of acute surgical diseases.

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A PROVINCE-WIDE POPULATION SURVEY OF APPENDICITIS IN CANADA. NEW TWISTS TO AN OLD DISEASE. J-P. Gagne´, M. Billard, R. Gagnon, M. Laurion, A. Jacques Centre Hospitalier Univ. de Que´bec, QUE´BEC, Canada

FLEXIBLE VERSUS RIGID ENDOSOCPY FOR TREATMENT OF FOREIGN BODY INGESTION: PROPOSAL OF A THERAPEUTIC ALGORISM D. Gmeiner1, B.H.A. Von Rahden2, J.H. Hutter2, J.H. Stein2 1 Univ. Klinik, SALZBURG, Austria 2 Univ. Klinik fu¨r Chirurgie, SALZBURG, Austria

Objectives: This study, sponsored and conducted by Le Collge des Mdecins du Qubec, audited the management of acute appendicitis in the Province of Qubec (7,25 million population), Canada, during one year (April 2002– March 2003). Methods: A questionnaire was sent to the Health Records Department of all hospitals treating appendicitis in the province. Data from 85 (100%) hospitals was received and reviewed. Results: During the study period, 7599 appendectomies were performed and 5707 (75%) were selected for study (55% men). The rate of normal and perforated appendix was 6.0% and 17.1% respectively. Median hospital stay for simple and perforated appendicitis was 2.5 and 5.7 days respectively. At least one imaging procedure was done in 86% of cases (23% CT scans, 55% ultrasounds). Antibiotics were not given at all in 7% of cases and inadequately given in 8% of patients with a perforation. Sixteen percent of patients did not receive preoperative or intraoperative doses and 69% of patients received unnecessary doses. Laparoscopy was used in 35% of cases and was associated with a reduction in postoperative stay for simple (2.2 vs 2.6 days, p<0.001) and perforated appendicitis (4.6 vs 5.8 days, p<0.001). A low rate of laparoscopy (<25%) was found in 53% of teaching and 45% of non-teaching institutions. Conversion rates were 10.3% for simple appendicitis and 28.5% for perforated ones (p<0.001). Conclusion: Although results of this survey compare to similar published series, a few concerns emerge. Many have to do with non compliance with recommended antibiotic usage for acute appendicitis. Although laparoscopy seems to be slowly making its way into the surgical armamentarium, the low rate of laparoscopic appendectomies in teaching hospitals raises the issue of appropriate resident training.

Aims: To elucidate the value of ﬂexible endoscopy (FE) versus rigid endoscopy (RE) for removal of ingested foreign bodies. Methods: We herein propose a therapeutic algorism, based on a consecutive series of 139 patients with foreign body ingestions. During a period of 6 years, 69 male and 70 female patients (median age 64 [0.7 – 97] years) had undergone either rigid (n=62) or ﬂexible (n=76) endoscopic foreign body removal. Results: Foreign body management with FE was successful in 71 of 76 patients (93.4%) whereas in 5 cases (6.6%), managment with FE failed, and a RE was required. No severe complications occured when foreign body ingestion was attempted with FE (0 of 76 cases; 0.0%), whereas rigid endoscopy was associated with esophageal rupture in 2 of the 62 cases (3.2%; p <0.002), requiring immediate surgical management. Only a minority of patients undergoing FE for foreign body removal required general anaesthesia (13%), whereas rigid endoscopy was always performed with general anaesthesia (100%; p<0.0001). Patient comfort was signiﬁcantly diﬀerent between patients undergoing FE and RE (p < 0.0001), which was also reﬂected by the signiﬁcantly higher rate of dysphagia after rigid endoscopy (48%) compared to ﬂexible endoscopy (15%; p<0.0001). RE was more frequently used in FBs of the upper esophagus (p<0.0001), wheras FE was the predominating approach to FBs in the lower esophagus (p<0.001). Conclusion. A tailored approach for the treatment of foreign body ingestions is recommended. Selection of either ﬂexible or rigid endoscopy for diagnosis and treatment should be based on the anticipated localization of the foreign body. Due to the lower rate of severe complications (0% in our series), the better patient comfort with lower rate of dysphagia, and the lack of requirement for general anaestesia, it should be the preferred ﬁrst line approach to foreign bodies. Rigid endoscopy has its place as second line therapy.

O100

O102

SECURING THE APPENDICEAL STUMP WITH THE GEA EXTRACORPOREAL SLIDING KNOT DURING LAPAROSCOPIC APPENDECTOMY IS SAFE AND ECONOMICAL R. Arcovedo Sharp Medical Center, South Bay, CALIFORNIA, CHULA VISTA, United States of America

MINIINVASIVE TECHNOLOGIES IN TREATMENT OF ACUTE CHOLECYSTITIS A.N. Tokin, A.A. Tchistyakov, L.A. Mamalygina, D.G. Gelyabin, G.Yu. Osokin, D.N. Panchenkov, M.V. Meshkov Semashko Railway Hospital, MSMSU, MOSCOW, Russia

Introduction: Laparoscopic appendectomy has become very popular. One of the criticisms is its cost. An alternative to the expensive linear stapler most commonly used, would be a suture ligature of the base of the appendix. To prove that the Gea extracorporeal sliding knot is a safe method of closing the stump after laparoscopic appendectomy, I carried the following retrospective study. Methods: During the past 4 years, all the 83 laparoscopic appendectomies performed by myself in which I utilized the Gea knot were reviewed. The Gea knot is created with a 0 prolene in the manner already described. During the same four years, another 83 appendectomies performed by other surgeons utilizing the stapler were reviewed. The main end point was the presence or absence of stump blowout, leak or ﬁstula from the appendiceal stump. Secondary end points were abdominal sepsis, wound infection, need for readmission or reoperation. The results were analyzed and the diﬀerence in groups were compared with the Mann Whitney test. Results: Out of the 83 laparoscopic appendectomies in which the Gea knot was utilized was considered group A. Group B represented the 83 laparoscopic appendectomies performed with the stapler. Both groups were similar in terms of their characteristic i.e. age, gender, perforated versus suppurative. Within group A, none developed a stump blowout. There was one patient who developed interloop abscesses, which required percutaneous drainage. The abscesses were in remote areas to the cecum. This patient had a ruptured appendix at the time of surgery. Also, within this group there were two wound infections, directly related to contamination at the time of extraction of the specimen.In group B, none developed problems with the stump. There were 2 patients who developed prolonged ileus and one who developed a wound infection. There were no statistical diﬀerences noted between groups. Conclusions: There are surgeons who routinely use sutures to secure the stump of the appendectomy. We try to demonstrate that the Gea extracorporeal knot is as secure as the stapler to close the appendiceal stump. Moreover, as previously published, the Gea knot takes 19 seconds to be tied and secured, the 0 prolene suture can be passed through a 5 mm trocar. The Gea knot seems like a good alternative to the stapler.

Aim of Study: to determine the reasons of denials from the laparoscopic cholecysrectomy (LC) in cases of acute cholecystitis and to work out a complex of measures for the increasing of the percentage of (LC) in patients with an acute cholecystitis. Materials and Methods: from the moment of mastering of the (LC) we have an experience of treatment of 700 patients with acute cholecystitis. 530 (75,7%) patients had a destructive cholecystitis. 287 (41%) patients had the compications of the acute cholecystitis: inﬁltration of the region of Ligamentum gastroduodenale, perivesicular abscess, bile peritonitis. 59 (8,4%) patients had cholangiolithiasis with obstructive jaundice in 26 (3,7%) patients. The complications of the acute cholecystitis started to develop from the 4th from the beginning of disease. Severe concomitant diseases were in 24 (3,4%) patients. 2 groups of patients were assigned with 400 and 300 people in them accordingly. In the ﬁrst group LCE was performed by the standard (French) method. In the second group the mobilization of the bile duct and biliar artery was performed by ultrasound dissector; the mobilization of the gallbladder and the hemostasis were performed by argon intensed coagulation. The both groups were comparable in all the parametres. Results: in the ﬁrst group LCE was performed in 140 (35%) patients. The reasons of denials from the LCE were: inﬁltration of the region of Ligamentum gastroduodenale, perivesicular abscess, bile peritonitis, not sanated cholangiolithiasis, long-term conservative therapy, that has impaired the local condition, refusal of the patients from the operation. In this group of patients we used active waiting technique. The complications were in 15 (3,75%) patients, among them injuries of bile ducts in 3 (0,75%) patients. In the second group of patients LCE was performed in 165 (55,7%) patients. The using of improved method enabled to decrease the number of complications to 1,3There were no injuries of bile ducts. Conclusion: An active surgical tactics and using of the improved method of LCE with an ultrasound dissection and argon coagulation broadened the possibilities of performing LCE in the patients with acute cholecystitis as well as decrease the number of intra and postoperative complications.

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O105

EMERGENCY LAPAROSCOPY LIMITS AND APPLICATIONS: A PROSPECTIVE STUDY BASED ON B.U.E.S.R.(BOLOGNA UNIVERSITY EMERGENCY SURGERY REGISTRY) P.A. Riccio1, F. Catena2, L. Ansaloni2, S. Gagliardi2, F. Gazzotti2, S. Di Saverio2, G. Calo`2, S. Peruzzi2, A. De Cataldis2, P. Cambrini2, M. Taffurelli2 1 Ospedale S. Maria della Scaletta, IMOLA (BO), Italy 2 Emergency Surgery, St.Orsola Univ. Hosp., BOLOGNA, Italy

IS LAPAROSCOPY STILL INDICATED FOR BLUNT ABDOMINAL TRAUMA? A.E. Nicolau, V. Merlan, V. Veste, B. Micu, R. Mehic, M. Beuran Emergency Hospital Floreasca, BUCHAREST, Romania

Introduction: While laparoscopy in elective conditions is becoming well standardized, emergency laparoscopy has still unknown limits and applications. Aim to this study is to analyse these data in the B.U.E.S.R.(Bologna University Emergency Surgery Registry) in a 2-years consecutive series of patients. Methods: From January 2004 up to January 2006 all patients submitted to emergency surgery procedures by three Consultant Surgeons of the DPTÕs were evaluated for a laparoscopy treatment. All data were collected prospectively and included in the BUESR. Results: 571 consecutive patients were enrolled. Mean age was 72.1+ 6.5 and male/female ratio was 0.68. 235 were escluded from laparoscopic approach for anesthesiological problems. 158 out of remaining 336 patients were escluded for surgical contraindications (obstructed patients with intrabdominal pressure more than 25 cm H2O, subjects with more than 2 previous laparotomies, patients haemodinamic instability, subjects with Apache II score more than 30 points, organizational problems). Out of 178 laparoscopically treated patients the conversion rate was 35.3%. Discussion and Conclusions: Emergency laparoscopy has diﬃcult applications in the emergency surgery setting with an high conversion rate.

With the progress in noninvasive imagistic diagnosis (CT scan and US) of the blunt abdominal trauma (BAT), especially in patients with multiple lesions, remains the question whether diagnostic laparoscopy (DL) is of present interest. DL is criticized due to its speciﬁc contraindications (hemodynamic instability, GCS = 11, myocardial contusion), invasiveness, incidents/accidents/speciﬁc complications, missed lesions of hollow viscus, the inability to see the retroperitoneal organs and also due to the small number of experienced emergency laparoscopic surgeons. Unnecessary (negative or non-therapeutical) and/or delayed laparotomies signiﬁcantly rise the morbidity and mortality. DL may be used for screening in selected cases with equivocal clinical and imagistic diagnosis, in order to decide between laparotomy or observation. Experienced laparoscopic surgeons may try to identify all visceral lesions. Is unanimously accepted that DL is the most eﬀective way to diagnose diaphragmatic tears. We evaluated DL in emergency for 38 patients with BAT; 31 of these had multiple injuries. Before DL, diagnostic peritoneal lavage was used for 4 patients, only US for other 4 and CT scan and US for the remaining patients. In 35 cases, DL was decided for peritoneal ﬂuid (PF) and hemoperitoneum was conﬁrmed in 32 patients. Visceral lesions were found at 25 patients. Amongst the 10 patients with PF with no solid organ lesion at CT or US, but with suspicion of hollow viscus lesion, an ileal lesion was conﬁrmed only in one case. After DL, laparotomy was necessary in 14 cases, therapeutic laparoscopy was possible in 4 cases and in 20 cases simple observation was enough. We had no omitted lesions, no postoperative complications or deaths imputable to DL. Unnecessary laparotomy was avoided in 24/38 cases. Conclusions. DL remains a viable diagnostic and therapeutic option in well selected cases of BAT with equivocal clinical and imagistic diagnosis: spontaneous hemostasis conﬁrmation in solid organ lesions, suspicion of hollow viscus lesions, patients with general anesthesia for extra-abdominal surgery. The major role is to reduce the unnecessary laparotomies.

O104

O106

LAPAROSCOPIC TREATMENT OF LIVER HYDATID DISEASE IN CASES OF CYST RUPTURE IN CHILDREN V.I. Kotlobovsky Regional Peadiatric Hospital, AKTOBE, Kazakhstan

LAPAROSCOPIC APPENDICECTOMY HAS REDUCED WOUND INFECTION RATES COMPARED TO OPEN APPENDICECTOMY J. Khan1, A. Naqvi2, T. Fayyad3, T. Cecil3, B. Moran3 1 Salisbury District Hospital, EASTLEIGH, United Kingdom 2 Frenchy Hospital, BRISTOL, United Kingdom 3 North Hampshire Hospital, BASINGSTOKE, United Kingdom

Aim: Evaluation of eﬃciency of laparoscopic treatment of liver hydatid disease in cases of cyst rupture in children. Materials: Since 1993 about 114 children ranging from 4 to 15 (7,3 +)3,2) years of age with liver hydatid disease have undergone laparoscopic surgery. There were 8 urgent cases of acute peritonitis because of cysts rupture. In 5 (62,5%) cases cyst rupture was associated with trauma. In 3 (37,5%) cases it happened spontaneously. We used abdominal ultrasonography, CT scan as diagnostic procedures before surgery. Fore trocar approach was performed (10, 6, 6, 22 mm). Free hydatid ﬂuid was identiﬁed and aspirated from abdomen cavity. In 6 (75%) cases ruptured echinococcus cysts were localized in the right lobe, in 2 (25%) cases in the left. We used 22 mm trocar for vacuum extraction of endocyst. Abdomen cavity was irrigated by saline solution (5 –10 l.) We performed 2% formaldehyde solution for the processing of ﬁbrous capsule. One tube was used for draining of every residual cavity, one or two - for draining of the abdominal cavity. All patients accepted 10 mg/kg of albendazolum postoperatively during 6 weeks. Operation time, conversion rate, complications rate, length of hospital stay were analyzed. Results: No mortality. Conversion rate 0 (0%) cases. Duration of operation time 67.1+–14.2 min. Major surgical complications rate 1 (12,5%) cases. No recurrence. Duration of the hospital stay ) 10.6+–1.3 days. Conclusion: Laparoscopic approach could be successfully performed for the treatment of liver hydatid disease in cases of cyst rupture. It demonstrates good post-operative results, low rate of complications and recurrence, short duration of operation and hospital stay.

Introduction: Despite the reported advantages of laparoscopic appendectomy (LA), there is ongoing debate about a possible increase in postoperative infectious complication rates. It has been postulated that intraabdominal infections may be more frequent in laparoscopic compared to open appendicectomy and that wound infection rates are high unless wound protection is utilized. Methods: All consecutive appendicectomies (open and laparoscopic) performed over four months at two district general hospitals were included in this prospective study. Demographic details, operative time, time to conversion, infective postoperative complications and delay in discharge were recorded. The patients were divided into three groups as laparoscopic (LA), laparoscopic converted to open (LCO) and open appendicectomy (OA). Results: A total of 103 appendicectomies were performed. 67 LA, 27 OA and 9 LCO. 17 (17%) appendices were perforated at the time of operation. The mean age was 24 years (range 7–63). There were 57 females and 46 males. Operating time in LA was longer with mean duration of 51.3 minutes compared to 40.6 minutes in OA. An extraction bag was used in 42/67 LA patients. Wound infection was recorded in 7 cases in total (5/27 in OA and 2/67 in LA). The site of wound infection was the port of specimen extraction in laparoscopic group and neither two had an extraction bag used. Wound infection delayed hospital discharge by an average of 2 days. Intra abdominal abscess formation complicated the outcome in two patients (one in LCO and one in OA) Conclusion: Wound infection is less common in LA compared to OA and an extraction bag is recommended. Intra-abdominal infection rates do not appear to be increased though the numbers in this study are relatively small. The longer operating time is minimal given the better results and LA is the optimal approach to the diagnosis and management of acute appendicitis.

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STAPLED LAPAROSCOPIC PARTIAL CAECECTOMY FOR COMPLICATED APPENDICITIS S. Sereno, M. Simone, D. Parini, L. Mendoza-Burgos, C. Bailey, J. Leroy, B. Dallemagne, D. Mutter, J. Marescaux IRCAD-EITS / University Louis Pasteur, STRASBOURG, France

IS DIAGNOSTIC LAPAROSCOPY AN EFFECTIVE TOOL IN THE MANAGEMENT OF SUSPECTED ACUTE APPENDICITIS? K.T.J. Khoo, F. Mohamed, S. Bawa, J. Guest Wansbeck General Hospital, ASHINGTON, United Kingdom

Aim: Controversy remains whether laparoscopy is justiﬁable in patients with complicated appendicitis where reported conversion rate, morbidity and mortality are 2.7–47%, 5.9–42% and 0–5% respectively. The aim of the study was to investigate the safety of laparoscopic stapled partial caecectomy in septic conditions for complicated appendicitis. Methods: We reviewed the charts of patients who underwent laparoscopic stapled partial caecectomy in complicated appendicitis from January 2000 to December 2004. Stapled partial caecectomy was deﬁned as resection of part of the caecum adjacent to the appendix, preserving the ileo-caecal valve and performed with an endoscopic stapling device on healthy tissue. Complicated appendicitis was deﬁned as the presence of perforation or abscess. Studied variables were indications for partial caecectomy, type of appendicitis, morbidity and conversion rate. Results: A total of 55 patients received laparoscopic stapled partial caecectomy for complicated appendicitis. Indications were: 3 (5.5%) necrosis of the base of the appendix, 38 (69%) severe inﬂammation of the base of the appendix and 14 (25.5%) questionable viability of the caecum adjacent to the appendicular base. The complication rate was 3.6% (1 case of residual abscess and 1 trocar site hernia). No cases were converted and there was no mortality. Conclusions: This study shows that in cases of complicated acute appendicitis stapled laparoscopic partial caecectomy is safe and eﬀective as shown by the absence of conversion, mortality, and the low morbidity rate.

Aims: The use of diagnostic laparoscopy (DL) proceeding to laparoscopic appendicectomy (LA) in suspected acute appendicitis is increasingly common. The diagnostic and therapeutic advantages of laparoscopic surgery may reduce unnecessary open appendicectomy (OA). It is important that surgical trainees attain the skills required to achieve competency in DL and LA. Our aim was to assess the value of DL in suspected acute appendicitis and when combined with LA, its feasibility as a training procedure. Methods: From a prospective electronic database all adult patients who underwent OA, or emergency DL with or without LA for suspected acute appendicitis over a 2 year period at our institution were selected. Operative data, complications and histopathological reports were analysed. Results: A total of 50 open appendicectomies and 187 diagnostic laparoscopies were performed. Of the 50 patients who underwent OA, 92% (46/50) had histologically-proven appendicitis, 2 had normal and 2 had indeterminate appendix histology. Of the 187 diagnostic laparoscopies, 75% (141/187) proceeded to LA while in 25% (46/187) no appendicectomy was performed as the appendix appeared macroscopically normal. Of the 141 patients who underwent LA, 92% (130/141) had histologically-proven acute appendicitis; 2 had carcinoid tumour in-situ, 4 had normal and 5 had indeterminate appendix histology. Of the 46 patients who had no appendicectomy, a cause for their symptoms was found in 19, but not in the remaining 27 patients. LA median operating time was 50 minutes for Consultants and 60 minutes for Trainees. Operative time for LA was signiﬁcantly longer than OA for Trainees, but not for Consultants. Median LA postoperative stay was 2 days for both Consultants and Trainees, but was signiﬁcantly longer following OA at 4 days and 3 days respectively. Complication rates were lower for LA at 3.9% and 3.1% for Consultants and Trainees respectively compared with 16.7% and 12.5% for OA. Conclusions: Diagnostic laparoscopy can reduce unnecessary open appendicectomy. When combined with LA operative outcomes are no worse than OA for both Consultants and Trainees. These data suggest diagnostic laparoscopy combined with laparoscopic appendicectomy is a feasible training procedure and an eﬀective tool in managing suspected acute appendicitis.

FLEXIBLE SURGERY O109 IMPROVING RATES FOR SCREENING COLONOSCOPY B.W. Miedema, M.V. Geana, N.J. Rangnekar, G.T. Cameron University of Missouri, COLUMBIA, United States of America Colonoscopy is an eﬀective modality for colorectal cancer screening. The objectives of this study were to identify colorectal cancer knowledge and barriers to screening colonoscopy in the general US population. Methods: Data was obtained from the Health Information National Trends Survey (HINTS I), conducted by the NCI and completed in December, 2003. The dataset (n=6369) included responses to a 34 question survey on colorectal cancer knowledge. The inﬂuence of age, race, gender, education, income, media usage, and interactions with health care providers were evaluated to establish knowledge, attitudes, and behavior regarding screening for colorectal cancer with colonoscopy. Both descriptive statistics and between subjects analysis were used to evaluate the impact of the independent variables. Results: Most respondents felt they were at low risk of developing colon cancer (62%) and rarely or never worried about getting colon cancer (75%). The term colonoscopy is recognized by most participants in the survey (80% over age 35), however only 35% of the respondents perceive it as a major method for colon cancer screening. Hispanics had the least awareness of colonoscopy for screening (16 vs. 39% non-Hispanic). Female gender, education, and income all correlated with the knowledge and use of colonoscopy as a screening method for cancer. In respondents over age 50, 41% stated that they had undergone colonoscopy. The respondents who had undergone an endoscopic examination were more convinced that it increased the chances of ﬁnding a treatable cancer (84 vs. 71%). There is a positive correlation between media usage and having a colonoscopy (r = .095, p<.01). Having a health care provider was strongly correlated with having undergone a colonoscopy (r = .249, p < .01); the most common reasons for not having colonoscopy were no reason (29%), doctor didnt order it (24%), and didnt know I needed the test (15%). Regarding media preferences for receiving cancer related material, personalized materials ranked 1st (85%). Conclusions: Knowledge of and participation in screening colonoscopy is low in the US population, especially among Hispanics. The most important immediate action is to increase physician referral for screening colonoscopy. Tailored education materials focused on speciﬁc socio-demographic segments and targeted communication campaigns need to be developed to encourage screening.

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O111

COMPLICATED APPENDICITIS: LAPAROSCOPIC OR CONVENTIONAL SURGERY? B. Kirshtein, M. Bayme, S. Domchik, S. Mizrahi, L. Lantsberg Soroka Medical Center, BEER SHEVA, Israel

INDEPENDENT RISC FACTORS FOR REBLEEDING AND MORTALITY IN UPPER GASTROINTESTINAL SYSTEM BLEEDINGS H. Alis, B. Dodur, M. Kalayci, B. Ede, E. Tulubas, E. Aygu¨n Bakirko¨y Training Research Hospital, ISTANBUL, Turkey

Aim: The surgical treatment of complicated appendicitis remains controversial. This study attempts to evaluate the role of laparoscopy in comparison with open surgery in the treatment of complicated appendicitis. Patients and methods: We reviewed the medical records of all patients who underwent an appendectomy for complicated appendicitis between January 2001 and August 2005. Factors evaluated included age, gender, weight, ASA classiﬁcation, duration of procedure, resumption of oral intake, length of intravenous antibiotic treatment, postoperative complications, histopathology results, postoperative hospital stay, and 30-day readmissions. Interval appendectomies were excluded from the study. Complicated appendicitis was deﬁned by the ﬁnding of a gangrenous or perforated appendix, as well as the presence of an intraabdominal abscess. Results: A total of 819 patients underwent appendectomies during the study period: 525 patients with open surgery, 281 patients with laparoscopy, and 12 cases with an attempt at laparoscopy until conversion to open surgery. This total includes 98 (12%) patients with complicated appendicitis: 42 that presented with perforation, 32 with a periappendicular abscess, and 24 with a gangrenous appendix at surgery. Diagnosis was conﬁrmed histopathologically in all cases. Of these 98 patients, 48 patients underwent an open appendectomy, 42 a laparoscopic appendectomy, and 8 (16%) underwent an initial laparoscopy with conversion to open surgery. The reasons for conversion include: diﬃcult dissection and unclear anatomy in 4 cases, an unclear diagnosis, intra-abdominal bleeding, a periappendicular mass and an iatrogenic bowel tear in one case each. Older patients, patients with co-morbidities and female patients were more likely to have been oﬀered a laparoscopic appendectomy. Operating time, time to solid oral intake and hospital stay were prolonged in the laparoscopic group, but non-signiﬁcantly. There was no mortality observed in either group, and the complication rate was similar in both groups. More readmissions occurred after laparoscopic surgery. Conclusion: Laparoscopic appendectomy is a safe and acceptable procedure for complicated appendicitis, with the same rate of infectious complications as the conventional approach.

Preface: Upper gastrointestinal system bleedings consists the very high ratio of the applicants to emergency surgery units. Althought It is hard to prove the useful relation with mortality, having risk level and scoring method classiﬁcation in triaj period, will eﬀect the decisions in medical treatment and cure positively and will reduce the costs and the use of medical resources. Material Method: Between January 2001 August 2005, in Bakirkoy Dr. Sadi Konuk Education and Research Hospital surgical clinic, 1321 patients examined who have diagnosis of non variseal upper gastrointestinal system bleeding. They are evaluated for rebleeding in one month and independent risk factors of mortality. Findings: The average age of patients was 54.7 (17–110), 934 man and 387 women. In 30% of the patients, side medicines were said to be used. The examined highest ratio of secondary disease was, diabetes mellitus, hypertension, cardiac failure, hepatit and serebrovascular ilness. The initial ailment was melena, hematemesis and hematochesia orderly. The nazogastrik aspiration ratios were 51.7% with clean bile, 38.1% with bleeding, and 10.1% hematemesis. On rectal examination, 91% melena, and 1.6% hematochesia were examined. In laboratory evaluations Hb: 9.3 (3.03–15.4), Hct: 27.6 (9.0–47.4) and WBCt 11400, urine 76,0 (8–633) were determined. Mortality causes and their percentages were 3.49% (36) by provable rebleeding, and %2.52 (26 patient) by side illnesses. In the experiments, the independent risk factors with relation to mortality were; age((p<0,05, r =0,332), having bloody nazagastrik aspiration (p<0,05, r =–0,223), shock(p<;0,05, r =)0,346), high urine value(p<0,05, r =0,286), and having operation due to rebleeding(p<0,05, r =0,233). The rebleeding facts were only related with endoscopic ﬁndings(p<0,05, r =0,288).

Result: The number of patients with ailment of upper gastrointestinal system bleeding and their individual maintenance costs are hight. Also, ﬁnding the diagnosis and treatment of ilnesses should be fast. As a result, risk scoring algorithms can conﬁdently be used in decisions of treatment and lying in hospital.

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O112

ACUTE BILIARY PANCREATITIS (ABP) TREATED WITH LAPAROSCOPIC APPROACH P. Gregoric, Dj. Bajec, D. Radenkovic, A. Karamarkovic, N. Ivancevic, B. Stefanovic, B. Karadzic Clinical Center of Serbia, BELGRADE, Yugoslavia

EMERGENCY RELAPAROSCOPY FOR DIAGNOSIS AND TREATMENT OF POSTOPERATIVE COMPLICATIONS S. Domchik, B. Kirshtein, S. Mizrahi, L. Lantsberg Soroka University Medical Center, BEER-SHEVA, Israel

Aims: Biliary stones are the main couse of acute pancreatitis (AP). Development of laparoscopic surgery enables use of this approach in the treatment of patients with AP. The results of laparoscopic management of this patients, with ABP are present. Methods: This prospective study included 82 patients with ABP treated with laparoscopic approach between 2002–2005. All patients after admission were treated conservatively and ERCP with endoscopic sphinterectomy (ES) were done if cholangitis and/or obstructive joundice were present. In patients with mild ABP, laparoscopic cholecystectomy (LC) with intraoperative cholangiography (IC) were performed within 10 days of admission while in patients with severe ABP this procedure was done 4–6 weeks after the admission. If the common bile duct stones (CBD) were found on IC patients received ERCP with ES after the surgery.In cases were clearance of CBD failed open surgery were performed. Results: There were 62 (76%) patients with mild and 20 (24%) with severe ABP. ERCP with ES with clearance of CBD were done in 6 patients with severe and in 2 with mild ABP before the LC. During the LC in 76 (93%) patients IC were done while in the remaining 5 patients due to narrow cystic duct failed. In 6 of 76 (8%) IC showed CBD stones. In those 6 patients after the operation ERCP with ES and clearance of CBD were done, but in 2 was unsuccessful. They additionally received open surgery with CBD clerance. Mortality and morbidity rate were 1,2% (one patients died), 8% respectively. Conclusion: Result of this study suggest that LC with IC could be used safely in both form of ABP and foolowed with endoscopic procedure in selective cases could be a deﬁnitive treatment for those patients. IC as less invasive procedure could replace routinely preoperative ERCP in patients suﬀered for ABP without the symptoms of cholangithis and obstructive jaundice. Laparoscopic approach in severe form needs further investigation until became the standard of treatment.

Aim: With expansion of opportunities and accumulation of experience the laparoscopy is more often used as repeated operation for suspected intra-abdominal complications of laparoscopic and open surgery. However, there is no unequivocal attitude to a laparoscopy, as to means in diagnosis and treatment of postoperative surgical complications. Patients and Methods: Medical records of the patients underwent emergency relaparoscopy from 2000 to 2005 were reviewed retrospectively. Demographic and clinical variables included age, sex, ASA score, type of primary surgery, indications for repeated operation, time between surgeries, length, diagnostic accuracy and therapeutic possibilities of relaparoscopy, morbidity and mortality rate. Results: In total relaparoscopy was performed in 64 patients (15 men and 49 women) with mean age of 51 years old (range, 20–96). There were 28 emergency and 36 elective operations; 50 laparoscopies and 14 laparotomies. 24 cholecystectomies, 5 appendectomies, 9 hernia repairs, 10 operations for morbid obesity, 3 adhesiolysis were done before second operation. Indications for repeated surgery included: postoperative pain out of proportion in 18 cases (28%), peritonitis in 22(34%), intraabdominal sepsis in 8(12%), intestinal obstruction in 6(9%), jaundice and bile or bowel content from wounds and drains 5(7.8%), second look laparoscopy in 5(7.8%). Mean time between initial and second operations was 3.6 days (range, 1–26). Mean operation time was 34.2 min (range, 5–90 min). There were no ﬁndings during relaparoscopy in 19(29%) patients. Laparoscopic lavage and/or drainage of blood/ﬂuid was performed in 9(14%), lavage and drainage of puss or bile in 8(12%), adhesiolysis in 3(4.6%), suture/ repair of leak from gallbladder bed or cystic duct in 5(7.8%), repair of perforated viscus or iatrogenic tear (stomach, small bowel, colon) in 9(14%) cases. There were no complications and no cases of misdiagnosis. No relaparoscopy-related death was observed. Conclusions: Relaparoscopy is the eﬀective tool for diagnosis and treatment of postoperative complications after open and laparoscopic surgery It has low level of complications and high diagnostic opportunities. Therapeutic possibilities of relaparoscopy avoided unnecessary laparotomy. We consider that the repeated laparoscopy can be recommended for diagnosis and treatment of early postoperative complications, especially at the ﬁrst 48 hours after initial surgery.

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O112-S1 DIAGNOSTIC AND THERAPEUTHIC LAPAROSCOPY TRAUMA: PROSPECTIVE EVALUATION OF 102 CASES

FOR

R. Zorron1, M. Vinicius Dantas2, E. Kanaan2, J. Luis Pantaleao Falcao2, I. Drummond2, G. Meneguesso2 1 University Hospital Tereso´polis, RIO DE JANEIRO, Brazil 2 Hospital Municipal Lourenc¸o Jorge, RIO DE JANEIRO, Brazil Objective: Laparotomy is still advocated for most penetrating abdominal trauma, despite morbidity of unnecessary laparotomy. The objective of the study was evaluate results and etablish indications for rational use of diagnostic and therapeuthic laparoscopy in abdominal trauma in stable patients, in a trauma center in Rio de Janeiro, Brazil. Methods: 102 consecutive patients submitted to laparoscopy in the same institution were propectively documented, in a 5-year period. There were 42 patients with blunt trauma, 33 with penetrating stab injury, and 27 patients with penetrating shotgun wounds. All patients were hemodinamically stable at admission. Os pacientes foram submetidos a exame fsico criterioso, exames de imagem (TC, USG, RX), e laboratoriais, assegurando-se a estabilidade hemodinmica para realizao do procedimento. Results: Diagnostic laparoscopy was successful in all patients with blunt trauma and in most patients with penetrating trauma. No missed lesions were later founded in patients submitted only to laparoscopy. Re-intervention was necessary in 2 patients within 30 days, one with expanding urinoma treated by CTguided punction, the second for small bleeding of omental vessels, submitted to laparotomy. Diagnostic laparoscopy was positive for penetration in 45 of 60 cases of penetrating injury, and identiﬁed hemoperitoneum in 27 cases of blunt trauma. Correct identiﬁcation of organ injury was possible in 51 patients. Therapeuthic laparoscopic procedures were bladder suture, diaphragmatic suture, small-bowel resection, right colectomy, and liver and spleen hemostasis. Conversion was required in 21 (20,6%) patients because of inadequate inventory, inexperience of the surgeon, or lesions not suitable for laparoscopic therapy. Unnecessary laparotomy was avoided in 43 patients(42,2%). Conclusion: Unnecessary laparotomy can be avoided in many patients victims of penetrating abdominal trauma, using conservative therapy or laparoscopy. Laparoscopy for shotgun and stab wounds is useful to identify abdominal penetration, allowing therapy mostly for stab injuries. Thoraco-abdominal penetrating trauma was the most suitable for therapeutic procedures. We strongly recommend the use of diagnostic laparoscopy in the stable patient with penetrating trauma by expert surgeons, allowing diminish the rate of unnecessary laparotomy.

ENDOCRINE SURGERY O113

O114

POSTERIOR RETROPERITONEOSCOPIC ADRENALECTOMY: THE IMPACT OF SURGICAL EXPERIENCE ON THE LEARNING CURVE. M. Barczynski1, A. Konturek1, F. Golkowski1, S. Cichon1, B. Huszno1, K. Peitgen2, M. Walz2 1 Jagiellonian Univ. College of Medicine, KRAKÕW, Poland 2 Center for Minimally Invasive Surgery, ESSEN, Germany

SUBTRACTION SCINTIGRAPHY VS. ULTRASONOGRAPHY WITH QUICK INTACT PTH ASSAY IN PARATHYROID ASPIRATES IN DIRECTING SURGICAL APPROACH FOR MINIMALLY INVASIVE PARATHYROIDECTOMY.

Aims: Today, the posterior retroperitoneoscopic technique has become a standard procedure in adrenal surgery. The procedure allows a direct access to the adrenal glands but seems to be diﬃcult due to the uncommon anatomic view. This study compares the learning period of the new procedure of posterior retroperitoneoscopic adrenalectomy (PRA) in the primary invention phase and a secondary introductory phase in a diﬀerent hospital 10 years later. Methods: Analysis included 100 posterior PRAs and involved 50 procedures in each center. Group A consisted of 44 patients (14M, 30F; age: 48.714.5y.) undergoing surgery between 07/1994 and 8/1996 (24 right, 26 left; 8 Cushingadenomas, 14 Conn-adenomas, 11 pheochromocytomas, 7 non-functioning adrenocortical adenomas, 10 ACTH-depending adrenal hyperplasias). Group B consisted of 50 patients (12M, 38F; mean age 59.310.7y.) operated between 01/ 2004 and 01/2006 (28 right, 22 left tumors; 5 Cushing-adenomas, 12 Connadenomas, 4 pheochromocytomas, 29 non-functioning adrenocortical adenomas). All PRAs were performed in prone position with 3–4 trocars placed caudally the 11th and 12th rib. In group A, the surgical team was establishing the technique of PRA themselves. Before their ﬁrst PRA, the surgical team of group B was introduced to the technique by the group A surgeons and afterwards supervised continuously.

Aims: To determine the sensitivity and positive predictive value (PPV) of subtraction scintigraphy (SS) versus ultrasonography of the neck (US) combined with quick intact parathyroid hormone (iPTH) assay in US-guided ﬁne-needle parathyroid aspirates (FNA) in preoperative localization of parathyroid adenomas and in directing surgical approach. Methods: The results of SS for localization of parathyroid adenoma were determined in 121 patients with primary hyperparathyroidism and compared with ﬁndings at surgery and with the results of US alone (in patients without nodular goiter) and US in combination with iPTH assay in US-guided FNA of suspicious parathyroid lesions (in patients with concomitant nodular goiter). SS was performed with 99mTc-sestamibi and 99mTc-pertechnetate. High-resolution US of the neck was performed by a single endocrine surgeon and combined with US-guided ﬁne-needle aspirates of suspicious parathyroid lesion in all patients with nodular goiter (n=43). Results: Sensitivity and PPV of SS were signiﬁcantly higher in patients without vs. with goiter (89.3% and 95.7% vs. 74.3% and 76.5%; p<0.001). Sensitivity and PPV of US were signiﬁcantly higher in patients without vs. with goiter (96% and 97.3% vs. 67.7% and 71.9%; p<0.001). Intact PTH assay of US-guided FNA of suspicious parathyroid lesions in patients with nodular goiter signiﬁcantly improved both sensitivity and PPV of the US imaging (90.7% and 100%, respectively) allowing for accurate choice of surgical approach in 118 (97.5%) of 121 patients. SS was more accurate than US alone in detection of ectopic parathyroid adenomas. However, US alone had higher sensitivity in detection of small parathyroid adenomas (< 500mg) in typical sites (p<0.01). Conclusions: Both sensitivity and PPV of SS and US alone are comparable, with signiﬁcantly less accurate results obtained in patients with goiter. In cases of equivocal results of US and/or in patients with concomitant goiter, iPTH assay in US-guided FNA of suspicious parathyroid lesions can be used to establish the nature of the mass and to distinguish between parathyroid and non-parathyroid tissue (goiter, lymph nodes) and improve the accuracy of US parathyroid imaging allowing for successful directing of surgical approach in vast majority of patients.

Results: Group A experienced 7 conversions to open surgery whereas group B had one conversion and one early reoperation due to bleeding (p = 0.03). Mean operative time was 11741min vs. 8335min (group A and B respectively; p <0.001). Estimated blood loss was similar in both groups (47.246.2ml vs. 5416.3ml, group A vs. B, respectively; p = 0.36). Conclusions: The study demonstrates the feasibility, safety and reproducibility of the new surgical method of PRA in the early phase of invention as well as for learning surgeons. After detailed teaching, operative time and conversion rate are dramatically reduced allowing for a short learning curve.

M. Barczynski, F. Golkowski, A. Konturek, M. Buziak-Bereza, S. Cichon, A. Hubalewska-Dydejczyk, B. Huszno, Z. Szybinski Jagiellonian Univ. College of Medicine, KRAKOW, Poland

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O115

O117

THE LEARNING CURVE IN LAPAROSCOPIC ADRENAL SURGERY: COMPARISON OF RIGHT AND LEFT ADRENALECTOMY

TWO YEARS OF MINIMALLY INVASIVE VIDEO-ASSISTED THYROIDECTOMY IN GOITER REGION M. Barczynski, A. Konturek, S. Cichon Jagiellonian Univ. College of Medicine, KRAKÕW, Poland

S. Perretta1, A.M. Paganini2, M. Guerrieri1, R. Campagnacci1, A. Desanctis1, F. Crosta1, G. Lezoche2, E. Lezoche2 1 University of Ancona, ANCONA, Italy 2 University La Sapienza, ROME, Italy Background: Laparoscopic Adrenalectomy (LA) has become the procedure of choice for the surgical management of most adrenal tumors. Its learning curve varies among surgeons, it may be inﬂuenced by patients selection, operative complexity and technique, lesions side and size. Aim: multidimensional analysis of the learning curve in LA: right-sided versus left-sided adrenalectomies. Methods: This is a single-center study using prospective collected data from 241 patients who underwent LA between August 1992 and August 2005. The preoperative variables considered were patient-speciﬁc (age, gender, BMI,comorbid conditions) and disease-speciﬁc (histology, side and size of the lesion). The level of experience of the surgical and anaesthesia team and surgical approach (anterior, ﬂank, submesocolic) was also considered. Outcome measures studied were: operative time (OpT), conversion rate (CR), intraoperative and postoperative complications. Multifactorial logistic Regression analysis was used to identify patient-, surgeon/anaesthesiologist-, and procedure-related factors associated with conversion. A risk-adjusted Cumulative Sum model was used for evaluating the learning curve for right and left-sided resections. Results: There were 9 (3%) CR to open surgery: The CR for right-sided adrenal resections was 1.25% (n =3) compared with 2.5% for left-sided LA (n = 6). Independent predictors of CR were BMI (odds ratio [OR] = 3.46 per unit increase), and side (left versus right procedures, OR = 2.85). The level of experience of the surgical and anaesthesia team was also a signiﬁcant predictor. Tumor histology and size, and surgical approach did not aﬀect the CR nor OpT with any of the techniques used. Mean OpT for right (141 pts) and left adrenalectomy (100 pts) was: 91 min and 121 min. As the experience of the operative team increased, the OpT decreased signiﬁcantly. OpT correlated signiﬁcantly with BMI increase for both right and left LA. The learning curve, was of 28 and 41 cases for right and left LA respectively. Postoperative complications did not change throughout the series and were not dependent on operative experience and side. Conclusions: Several preoperative factors, such as BMI, side of the adrenal tumor as well as surgeons experience and technique can signiﬁcantly aﬀect outcomes in LA. Consideration of these factors may help in case and approach selection, estimation of OpT, risk of CR and complications.

Aim: To assess two years of experience with minimally invasive video-assisted thyroidectomy (MIVAT). Material and methods: Since December 2003 a group of 2410 goiter patients underwent surgery. Fifty-nine (2.45%) of them were qualiﬁed for MIVAT. Inclusion criteria were: a single thyroid nodule, not bigger than 3cm in diameter on ultrasound of the neck and goiter smaller than 25ml in volume. Fine needle aspiration was mandatory. Thirty ﬁve follicular tumors, 20 toxic adenomas, 2 papillary cancers and 2 Graves diseases were operated on. The gasless operative technique described by Miccoli was used. The analysis included percentage of patients eligible for MIVAT, the operative time, analgesia requirements and cosmetic eﬀects. Results: Only 2.45% (59 of 2410 individuals) were suitable for MIVAT. Exclusion reasons were: goiter larger than 25ml in volume (84.6%), thyroid cancer larger than T1 (8.4%) or within a large goiter or previous neck surgery (4.6%). MIVAT was successfully completed in all the patients. Fifty-ﬁve lobectomies and 4 total thyroidectomies were performed including 2 central lymphnodes dissections. Radioiodine uptake after total thyroidectomy for cancer was 1.2% and 2.1% respectively. In 8 cases MIVAT was combined with one-step video-assisted parathyroid adenomectomy (MIVAP). The mean operative time was 51.219.3min. One transient laryngeal nerve paresis and two transient hypocalcemia occurred. Mean analgesics consumption was 79.333.1mg of ketoprofen on postoperative day ﬁrst. Patients were mobilized in 6 hours following surgery and were allowed to eat and drink. The mean postoperative hospital stay was 1.20.5days. The cosmetic results were assessed after 1 and 6 month follow-up as excellent by 79.6% and 91.8%, as very good by 20.4% and 8.2% of patients respectively. Conclusions: MIVAT is suitable for surgeons experienced in thyroid and videoassisted surgery. It is feasible for well selected patients including cases of T1 thyroid cancer, Graves disease and concomitant parathyroid adenoma as MIVAT can be successfully extended from lobectomy to total thyroidectomy and completed with one-step MIVAP. It oﬀers decreased analgesics consumption, shorter hospital stay and improved cosmetic results when compared to conventional thyroid surgery.

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MINIMALLY INVASIVE GAMMA PROBE GUIDED REOPERATIVE PARATHYROID SURGERY - INITIAL REPORT M. Barczynski, A. Hubalewska-Dydejczyk, F. Golkowski, A. Konturek, S. Cichon, B. Huszno Jagiellonian Univ. College of Medicine, KRAKÕW, Poland

COMPARISON OF THE AXILLARY APPROACH AND THE ANTERIOR CHEST APPROACH IN THE GASLESS VIDEO-ASSISTED THYROIDECTOMY USING THE LIFTING METHOD K. Kayano, H. Mizutani, M. Kojo, S. Nishioka Ako Central Hospital, AKO CITY, Japan

Background and aims: Reoperations for recurrent or persistent hyperparathyroidism (HPT) remains diﬃcult even in the most experienced hands. In repeat operations, the success rate is 10–15% lower than the primary procedure, with increased perioperative complications including recurrent laryngeal nerve damage and hypoparathyroidism. The aim of this study was to evaluate the usefulness of the method of minimally invasive gamma probe guided reoperative parathyroid surgery. Material and methods: The study included 8 patients undergoing surgery between 06/2005 and 03/2006 (mean age 51.36.7 years; F:M ratio 7:1), with biochemically conﬁrmed persistent HPT in one case, recurrent primary HPT in 3 cases and recurrent secondary renal HPT in four cases. Preoperative localization procedures included high-resolution ultrasound (US) of the neck and subtraction parathyroid (SS) scintigraphy (99mPertechnectate and 99mTc-MIBI) of the neck and mediastinum. Patients were administered 5mCi of 99mTc-MIBI i.v. 30 minutes prior to surgery. Gamma Finder II handheld wireless gamma probe was used (World of Medicine, Orlando, USA). The site of the neck with radioactivity at least 20% higher than background was considered to harbor the hyperactive parathyroid gland and directed the initial skin incision (3cm in length). Surgery was terminated after successful removing of hyperactive parathyroid gland (tissue to background ratio higher than 20%) and obtaining remarkable decrease of serum iPTH level (Future-Diagnostics, Wijchen, The Netherlands). Results: Preoperative localization with US and SS was concordant in 4 cases only. The gamma probe successfully identiﬁed the site of the neck harboring a solitary hyperactive parathyroid tissue in 7 patients in which focused parathyroidectomy was performed. In one patient the gamma probe scanning of the neck was negative. That patient underwent bilateral neck exploration with ﬁnal transcervical dissection of left thymus harboring an ectopic hyperactive parathyroid gland. There was no postoperative morbidity. Conclusions: We do ﬁnd that radioguidance is a valuable adjunct to reoperative parathyroid surgery. It allowed for focused skin incision and focused neck exploration instead of conventional bilateral neck exploration usually undertaken in cases of reoperative parathyroid surgery. Radioguidance was also helpful in identiﬁcation of the ectopic hyperfunctioning parathyroid tissue localized in ectopic site (upper mediastinum).

We have developed video-assisted thyroidectomy via the axillary approach using the lifting method without carbon dioxide. In this study, we compared our method with another video-assisted thyroidectomy via the anterior chest approach with regard to surgical factors and patients complaints after surgery. Method: Our procedure (axillary: A) was performed in 22 patients (age 58.63.3, Male 4 Female 18). The patient was placed in a supine position with the neck extended and the arm on the tumor side lifted over the forehead. A 40 mm vertical incision was made in the axilla, another 5 mm incision in the lateral neck for video scope. After the subcutaneous tissue was dissected from the axilla to the neck, the skin was lifted up by Kirschner wires to make the working space. Thyroidectomy was performed through the axillary incision using an ultrasonic scalpel. Another procedure (anterior chest: AC) via the anterior chest incision was performed in 12 patients (age 50.35.2, All female) using the similar method. Results: No visible scars were left in AX, however the scars remained in AC. Benign and hemilateral tumors sized to less than 5 cm (2.30.2 cm in AX, 2.70.3 cm in AC ) were operated. The mean duration of operation in AX (18712 min.) is longer than that in AC (15916 min.). Each group was divided at the ﬁrst and latter half term. Duration of operation and complications were gradually decreased in both groups. Duration of operation at the latter term (1198 min) was signiﬁcantly shorter than that at the ﬁrst term (18821 min) in AC. Five complications (temporary hoarseness 2, skin injury 2, artery injury 1) were experienced at the ﬁrst term, no complications were revealed at the latter term in AX. One complication (hoarseness) was revealed at the ﬁrst term in AC. Conclusion: Most of women satisﬁed cosmetic results in both groups, and younger women especially prefer our axillary approach because of completely hidden scars. The axillary approach is more diﬃcult for the obese person than the anterior chest approach, however further practice will be able to lower duration of operation and to prevent complications.

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ENDOSCOPIC BILATERAL NECK EXPLORATION VERSUS QUICK INTRAOPERATIVE PARATHORMONE ASSAY (QPTHA) DURING ENDOSCOPIC PARATHYROIDECTOMY. A PERSPECTIVE RANDOMIZED TRIAL.

LAPAROSCOPIC AND OPEN RESECTION OF NEUROENDOCRINE PANCREATIC TUMORS E.Th. Slotema, B.A. Bonsing, J. Kievit, J. Ringers Leiden University Medical Centre, DEN HAAG, The Netherlands

G. Donatini1, P. Berti1, G. Materazzi1, L Fregoli2, P Miccoli2 1 S. Chiara, PISA, Italy 2 Department of General Surgery S. Chiara, PISA, Italy Background: Quick intraoperative parathormone assay (qPTHa) during paratyroidectomy has become a standard procedure for patients with Primary Hyperparathyroidism. In this report we compare endoscopic bilateral neck exploration versus qPTHe during minimally invasive video-assisted parathyroidectomy (MIVAP). Endpoints of the study were: mean operative time and outcome of the surgical procedure (PTH and calcemia normalization at 1 month after the operation). Materials and Methods: 40 patients with Primary Hyperparathyroidism were randomly allotted in 2 groups. In the ﬁrst group (QM) 20 patients (16 women/4 men, mean age 57.2 years) underwent focused endoscopic parathyroidectomy (MIVAP tecnicque) according to localization studies (Ultrasonography evaluation and 99Tc-MIBI scan), waiting for qPTHe results: the procedure was ended when qPTHa showed a reduction of at least 50% of the basal PTH value and within normal limits. In the second group (BE) (17 women/3 men, mean age 59.9 years) an endoscopic bilateral exploration was performed removing the localized adenoma and searching for the integrity of the three remaining glands: the procedure was entirely carried out endoscopically. Results: There were no signiﬁcant diﬀerences between groups at baseline. All the procedures in both groups were carried out endoscopically. No postoperative complication (bleeding, laryngeal nerve palsy, wound infection) were reported in both groups. Mean operative time was 33.1 min. in QM group vs 25.0 min. in BE group. In 4 patients of BE group a second enlarged gland was removed, but pathology report showed normal parathyroid glands in three patients and a slightly hyperplastic gland in the fourth patient. All patients were discharged on 1st post-operative day. Calcemia levels were normalized in all patient of both groups, despite persistently high level of serum PTH in 1 patients of both groups. Conclusions: Our experience suggests that endoscopic bilateral neck exploration is feasible and safe and has the same eﬀectiveness of MIVAP with qPTHa in patients with Primary Hyperparathyroidism. Endoscopic bilateral neck exploration might allow surgeons to reduce costs (avoiding qPTHe) and mean operative time, but might lead to unjustiﬁed removal of parathyroid glands slightly enlarged but not necessarily pathologic.

Our experience in laparoscopic pancreatic resection of neuroendocrine tumors (NET) has reached the phase in which we need to evaluate the results in order to improve the quality of patient care, aiming at high quality care required for this rarity of surgical disorders. The aim of this study was to compare the feasibility, limitations, safety and outcome of laparoscopic and open resection of neuroendocrine neoplasm in order to adjust our protocol if necessary. Through retrospective medical record review 26 cases (9 men: 15 women; 40% MEN1-syndrome; mean age 47 years) were identiﬁed who were surgically treated for neuroendocrine pancreatic lesions between 2000 and 2005. The indications were 8 insulinoma, 7 gastrinoma, 1 glucagonoma, 7(non-)malignant NET. For tumor localization helical CTscanning, somatostatin receptor scintigraphy and MRI were applied in 92%, 65% and 35% of patients respectively. Intraoperative ultrasound was performed in half the number of patients, but despite an intraoperative ultrasound no pathology was found in two patients. The median tumor size was 19mm (range, 7–85mm); 70% were located in the left pancreas. Surgical procedures included 8 laparoscopic/8 open enucleations, 2 laparoscopic/1 open distal pancreatectomy with splenic preservation, 5 pancreatoduodenal resections (depending on localization, proximity to pancreatic duct and tumor size). The overall conversion rate was 9%. After median follow-up of 2.2 years surgical reoperation rate was 23% (36% laparoscopic; 13% open procedures; 3 out of 6 gastrinomas). Two pancreatic ﬁstula and one major bleeding (requiring portal vein reconstruction) occurred following open procedures (none in laparoscopic procedures). In our hospital laparoscopic resection of pancreatic NET is feasible and safe and should be the preferred technique compared to open procedures. The use of endoscopic ultrasound preoperatively and routine application of intraoperative ultrasound might further enhance the quality of care provided in this academic setting.

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LAPAROSCOPIC LATERAL ADRENALECTOMY VERSUS ANTERIOR SUBMESOCOLIC ADRENALECTOMY: RESULTS OF RETROSPECTIVE COMPARATIVE STUDY F. Crosta1, A. De Sanctis1, G. Lezoche2, G. DÕ Ambrosio2, L. Organetti1, M. Nisi1, M. Guerrieri1, E. Lezoche2 1 Cl. Chir. Gen. Universita` Politecnica, ANCONA, Italy 2 Universita` La Sapienza, ROMA, Italy

PURE ENDOOSCOPIC THYROIDECTOMY BY THE AXILLARY APPROACH Y. Ikeda, Y. Sasaki, R. Miyabe, N. Morita, H. Takami Teikyo University School of Medicine, TOKYO, Japan

Aim: Laparoscopy plays an important role in adrenal gland surgery. The most frequently performed approach is the ﬂank transperitoneally. Our study compares the ﬂank approach and the anterior submesocolic access to perform laparoscopic left adrenalectomies. Patients and methods: Out of 251 patients underwent laparoscopic adrenalectomies from January 1994 to September 2005, 24 cases were treated by ﬂank intraperitoneal approach (group A) and 23 by submesocolic transperitoneal approach (group B). BMI, operative time (total and from the start of the skin until adrenal vein closure), hospital stay, tumour size, deﬁnitive histology between the two approach were analysed. The imaging study was performed with TC scan or MRI. Associated surgical procedures in the submesocolic approach were: cholecystectomies (2) and uterine myomectomy (1). Results: There were not conversions to open surgery. Mean BMI was similar between group A and B: 26,7 (range 20,7–33,2) vs 25,9 (range 21,3–32,6), respectively. Mean operative time was 75 min (range 50–140) vs 61,75 (range 40– 130) between group A and B, respectively (p<0,05). Mean operative time from the start of the skin until adrenal vein closure was 42 min (range 34–57) vs 21 (range 16–27) between group A and B, respectively (p<0,05). There were not complications in both groups. Oral feeding was started at postoperative hour 12 in both group. Mean hospital stay was 3,2 days vs 2,1 between group A and B, respectively (p<0,004). Mean tumor size was similar between group A and B: 3,6 (range 1,5–6,5) vs 3,8 (range 2–6), respectively. Deﬁnitive histology between group A and B were: Cushing Adenoma (6 vs 3), Conn Adenoma (5 vs 6), Pheochromocytoma (3 vs 9), Incidentaloma (7 vs 4). Moreover 1 myelolipoma, 1 metastases and 1 adreno-genital adenoma were observed in group A and 1 carcinoma was observed in group B. Conclusions: Submesocolic approach provides a signiﬁcantly shorter operating time and hospital-stay. The identiﬁcation and early closure of the adrenal vein with minimal gland manipulation resulted the main beneﬁt of this approach. Selected cases of left adrenalectomy can be safely performed by laparoscopic submesocolic access.

Background: Minimally invasive surgery is widely employed for the treatment of thyroid diseases. We have performed endoscopic thyroidectomy by an axillary approach from 1999. In this study, we evaluate the eﬃcacy of this surgical procedure. Patients and Methods: The indications for these procedures included the basedow disease and the presence of a follicular nodule with a maximum diameter of less than 6cm, as observed during a preoperative ultrasonography examination. Our procedure is pure endoscopic thyroidectomy with carbon dioxide insuﬄation from an axillary portion. This procedure was performed in 100 cases. Results: Conversion was necessary three cases (diﬃcult dissection in two cases and large nodule size in one ). Thyroid partial recection was successfully accomplished in 21 cases, thyroid lobectomy in 71 cases and subtotal thyroidectomy in 5 cases. Major vessel bleeding such as superior or inferior thyroid artery during surgery was 2 cases, however, these complications were able to be controlled in endoscopic procedure. Postoperative complications included 3 transient recurrent nerve palsies, and 1 postoperative arm pain. The cosmetic result was excellent. Conclusion: The indications for pure endoscopic thyroidectomy are still limited. None theless, in selected patients, it seems a valid option for thyroidectomy and even preferable to conventional surgery because of its signiﬁcant advantages, especially in terms of cosmetic result.

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TOTAL VIDEO-ENDOSCOPIC THYROID RESECTION VIA AXILLO-BILATERAL-BREAST-APPROACH (ABBA) T. Benhidjeb, S. Anders, M. Barth, M.W. Strik HELIOS Klinikum Berlin-Buch, BERLIN, Germany

VIDEO-ASSISTED THYROIDECTOMY FOR PAPILLARY THYROID CARCINOMA: EVALUATION OF THE COMPLETENESS OF THE SURGICAL RESECTION

Conventional thyroid surgery is standardized since more than 100 years. Among some extra cervical approaches that have been proposed the AxilloBilateral-Breast-Approach (ABBA) is a procedure that allows thyroidectomy without scar at the neck, thus aiming to improve cosmetic outcomes. This procedure is performed under general anaesthesia. The patient is placed in supine position. A 5 mm incision is performed along the upper margin of both mammary areolas, and an additional 10 mm one is made in the right axilla. After blunt dissection of the subcutaneous tissue of the breast, a subplatysmal working place is created using CO2 gas at a pressure of 4–8 mm Hg. Dissection is performed wit the help of a 5 mm harmonic scalpel. After dissection of the strap muscles both lobes of the thyroid are fully exposed. First, the isthmus is divided along the central line of the trachea. Following that, dissection continues at the lower pole and proceeded to the upper pole of the gland. The resected specimen is retrieved through the axilla trocar. Between February 2005 and March 2006, 26 female patients with thyroid nodules underwent resection using the ABBA technique. The mean age was 39 (25–62) years. The voulme of the gland was 24,6 (6–69,4) ml. Subtotal thyroid resection war performed in 25 patients. Mean operative time was 117,7 minutes after one side subtotal resection and 187 minutes following subtotal resection of both sides. There was no intraoperative complications, no mortality, and no conversion. One patient showed in the ﬁrst postoperative days a transient paresis of the arm plexus due to incorrect position on the operating table. Another one suﬀered from a transient recurrent laryngeal nerve palsy and hypocalcemia. Hospital stay after surgery was 2,7 (2–168) days. Our experience with the ABBA technique in selected patients conﬁrm its feasibility and safety. Primary aim of this method is a cosmetic one (no scar at the neck!). In our opinion, this procedure should be performed in referral centres with extensive experience on the ﬁeld of minimally invasive and thyroid surgery.

C.P. Lombardi, M. Raﬀaelli, P. Princi, A.G. Spaventa Ibarrola, M. Salvatori, P. Castaldi, R. Bellantone Universita` Cattolica del S. Cuore, ROME, Italy Aim: In spite of some concerns, video-assisted thyroidectomy (VAT) has been proposed also in case of small papillary thyroid carcinoma (PTC).The aim of the present study was to evaluate the completeness of the surgical resection in patients undergoing VAT for PTC. Methods: VAT is performed under endoscopic vision through a single 1–5–2.0 cm skin incision. Eligibility criteria are: thyroid nodules 35 mm; thyroid volume <30ml; no previous neck surgery. Small low risk PTC are eligible. Among 583 patients who underwent VAT between June 1998 and November 2005, 198 showed at ﬁnal histology a PTC and were included in the study. The completeness of surgery was determined by neck ultrasonography, qualitative evaluation with 131I whole body scan (WBS), quantitative 131I neck uptake (RAIU) and TSH-stimulated Tg levels. Results: Video-assisted total thyroidectomy was performed in 177 patients, lobectomy in 21, with conventional completion in 6 and video-assisted completion in 14. Central neck nodes were removed by the same access in 78 patients, with a complete central neck dissection in 16. The following complications were observed: 45 with transient hypocalcemia (23%), 3 deﬁnitive hypoparathyroisdism (1.5%), 4 transient recurrent laryngeal nerve palsy (1% of nerve at risk), 1 case of post-operative haemorrhage requiring video-assisted re-exploration. No other complication occurred. The cosmetic result was considered excellent by most of the patients. Complete follow-up is available for 124 patients. Fifty-seven patients underwent 131I ablation (RAI) with post-therapy WBS (TxWBS). Sixty-seven patients were evaluated by diagnostic WBS (DxWBS) and TSH-stimulated thyroglobulin (Tg), without RAI. The remaining 74 patients were followed in other Institution. Postoperative ultrasonography showed no residual thyroid tissue in all the patients. Six patients (4.8%) that showed negative DxWBS, RAIU < 1% and undetectable Tg. Among the remaining 118 pts. (95.2%), mean RAIU was 2.74.7% and mean serum Tg oﬀ LT4 was 7.3+12.5ng/ml. Conclusion: Our results show that the completeness of the surgical resection is comparable to that reported for conventional surgery. VAT is safe in case of PTC and could be oﬀered to low risk PTC patients. A longer follow-up is necessary to draw deﬁnitive conclusions about the clinical outcome.

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MINIMALLY INVASIVE VIDEO-ASSISTED THYREOIDECTOMY (MIVAT) RESULTS IN 246 PATIENTS T. Benhidjeb, M. Barth, S. Anders, M.W. Strik HELIOS Klinikum Berlin-Buch, BERLIN, Germany

ENDOSCOPIC ADRENALECTOMY: COMPARISON OF THE LATERAL TANSABDOMINAL AND POSTERIOR RETROPERITONEOSCOPIC APPROACHES C.P. Lombardi, M. Raﬀaelli, C. De Crea, L. Oragano, R. Bellantone, P. Princi Universita` Cattolica del S. Cuore, ROME, Italy

Endoscopic approaches are increasingly used in thyroid surgery. Aim of the MIVAT technique is to reduce the scar size on the anterior surface of the neck in a cosmetically unfavourable location. The operation is performed under general anaesthesia. The patient is placed in supine position with the neck slightly extended. A 2–3 cm small cervical incision is performed and the midline incised. The thyroid space is disssected gasless with the help of a 5 mm harmonic scalpel and 30 ﬁberoptic endoscope. First, the isthmus is divided along the central line of the trachea. Following that, dissection continues to a complete mobilzation of the upper pole of the gland. After removing the endoscope and the forceps, the thyroid lobe is pulled out by performing gentle traction over the lobe. After dissection of the lower pole the lobe is ﬁnally resected by the conventional way. Between October 2003 and Juli 2005, 246 patients (216 female and 30 male) with thyroid nodules underwent resection using the MIVAT technique. Selection criteria were thyroid volume less than 35 ml, no previous neck surgery, and no malignancy. The mean age was 43,4 (17–79) years. Subtotal resection war performed in all patients. Mean operative time was 32 minutes after one side subtotal resection and 66 minutes following subtotal resection of both sides. A conversion was necessary in 2 cases. There was no intraoperative complications, and no mortality. Following complications occurred: hypocalcaemia (2,4%), transient recurrent laryngeal nerve palsy (3,3%), and wound infection (1,2%). Mean hospital stay after surgery was 3,1 days. Our experience with the MIVAT technique in selected patients conﬁrm its feasibility, safety, and eﬃcacy in experienced surgeon hands.

Aims: Transperitoneal Lateral Laparoscopic Adrenalectomy (TLA) and posterior Retroperitoneoscopic Adrenalectomy (RA) are standardized operative procedure used for surgical removal of adrenal. There is still some debate about the indications and the access used. We reviewed current concept and results of TLA and RA in our experience. Methods: Treatment and clinical outcome of all patients who underwent either TLA or RA for adrenal disease were analysed retrospectively. Results: Sixty patients (18 men and 42 women) aged 13 to 73 years (mean age, 46,8 14.1) underwent successfully TLA (30 right, 28 left, 2 bilateral), and 20 patients (5 men and 15 women) aged 31 to 73 years (mean age, 52 12.1) underwent successfully RA (8 right, 10 left and 2 bilateral). In the TLA-group 33 patients (55%) were treated for hormone hypersecretion, 11 for incidentaloma, 6 for ganglioneuroma, 5 for myelolipoma, 3 for adrenal cysts, 2 for metastatic neoplasm. In the RA-group 15 patients (75%) were treated for hormone hypersecretion, 4 for incidentaloma, 1 for metastatic neoplasm. Previous abdominal surgery was registered in 15 cases (25%) of TLA-group and in 9 cases (45%) of RA-group. The mean operative time, was 135.6 45.4 minutes (range 60–240) for TLA and 137.8 57.3 minutes (60–270) for RA. In bilateral procedures the mean operative time of TLA was signiﬁcantly longer (285 21.2 versus 25056.5 minutes) (P<0.001). The mean tumour size was signiﬁcantly larger in TLA-group (42.9 19 mm - range 10–90 - Vs 32.6 10.8 mm - range 12–60) (P<0.05). Postoperative complications included 1 bleeding from trocar port and 1 pulmonary embolism in TLA-group and 2 temporary relaxation of abdominal wall in the RA-group. The mean hospital stay was 5.85 days and 5.5 2.3, respectively for TLA- and RT-group. Final histology showed malignancy in 9 cases in TLA-group (2 adrenocortical carcinoma, 4 malignant pheochromocytoma, 3 metastases) and in 2 of RAgroup (1 malignant pheochromocytoma, 1 metastasis). Conclusions: Both approaches were eﬀective and safe in our experience. We prefer TLA approach for tumour larger than 6 cm and RA approach for bilateral procedures and in patients who underwent previous abdominal surgery.

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RESULTS OF VIDEO-ASSISTED CENTRAL NECK LYMPH NODE DISSECTION FOR PAPILLARY THYROID CARCINOMA

9 YEAR EXPERIENCE OF ADRENAL SURGERY IN A DISTRICT GENERAL HOSPITAL. IS ADRENALECTOMY WORTH DOING? A. Aghahoseini, K. Tipper, J. Wilson, D. Alexander United Kingdom

M. Raﬀaelli, C.P. Lombardi, P. Princi, A.G. Spaventa Ibarrola, M. Salvatori, P. Castaldi, R. Bellantone Universita` Cattolica del S. Cuore, ROME, Italy Aims: Video-assisted thyroidectomy (VAT) has been proposed for small Papillary thyroid carcinoma (PTC). We attempted to remove by the video-assisted approach also central neck lymph nodes that were unexpectedly found enlarged during VAT for PTC. In this study we report on the series of patients who underwent VAT and concomitant video-assisted lymph nodes removal (VALD=video-assisted lymph node dissection). Mehods: Two-hundred ﬁfty patients underwent VAT for PTC. Among them 78 patients underwent concomitant VALD and were included in this study. The procedure is performed by a gasless video-assisted technique through a single 1.5–2.0 cm central skin incision. Dissection is performed under endoscopic vision using a technique very similar to conventional surgery. Only macroscopically enlarged lymph nodes were removed in 78 patients. In 16 patients a complete video-assisted central compartment neck dissection (VA-CCD) was carried out. Results: There were 69 women and 9 men with a mean age of 42.213.8 years (range: 19–71). The mean number of removed lymph nodes in case of VA-CCD was 83.5 (range:6–18). Central neck dissection took about 16 minutes. Mean postoperative stay was 2.91.2 days (range: 2–6). Six transient and three deﬁnitive postoperative hypocalcemias, one transient recurrent nerve palsy were registered. No other complication occurred. Final histology showed lymph node metastases in 15 patients (with micrometastases in 3) and reactive changes in all the others. The mean number of lymph node metastases in case of VA-CCD was 2+2.6. Mean follow up was 17.910.6 months (range: 2–40). Mean postoperative serum thyroglobulin on LT4 was undetectable (<1 ng/ml) in all the patients. Postoperative ultrasonography showed no residual thyroid tissue in all the patients. The mean pre-ablation radio-iodine up-take (RAIU) was 1.4% (range 0.1–6.8). All the patients considered the cosmetic result as excellent. One patient developed jugular lymph node recurrence two years after VAT and needed a latero-cervical lymph node dissection. Conclusions: Our experience demonstrates that video-assisted central compartment lymph nodes dissection is feasible and safe. The completeness of surgery is comparable to those of conventional surgery as well as the lymph node recurrence rate. Anyway, for deﬁnitive conclusions larger series and longer follow-up are necessary.

Introduction: pathology of adrenal gland is varied and ranges from hyperplasia and functional adenomas to adenocarcinomas. Iindication for surgical intervension is mostly for functional adenomas and their pathophysiological sequel.these include ConnÕs and CushingÕs syndromes and phaeochromocytomas. Trans-coelomic laparoscopic adrenalectomy is becoming the gold standard for the treatment of such conditions. One of the criteria by which the success of this type of surgical intervention can be judged, is the eﬀect of the operation on the patientÕs patho-physiological condition and their disease speciﬁc medications. This paper looks at our experience in York hospital, a tertiary referral centre for adrenal surgery, during the last 9 years, looking particularly at the eﬀectiveness of the intervension. We also looked at the eﬀect of optimisation with alpha and beta blockage for phaeochromocytoma cases on the haemodynamic stability of the patients during the operation. Method: from a total of 37 patients who had undergone adrenalectomy in York hospital over the last nine years, the case notes of 35 patients were retrospectively examined for a comprehensive range of information. The other two sets were not available. Results: male to female ratio was 19:17 the age range was from 33 to 82 years of age out of 35 patients 9 had open procedures and 27 laparoscopic with the conversion rate of 11% (3 out of 27) post op complication rate was 28% (10/35) which include wound and chest infection as well as post op bleeding and haematoma. 3 patients had to be taken back to theatre for bleeding (8.5%) the average length of stay in hospital was 6.4 days. (range 2–18) the histology report was available in 34 of the cases. these include: one adenocortical carcinoma, one vascular tumour, one ganglioneuroma, 16 cortical adenomas, one normal histology, 4 hyperplasia, 8 pheaochromocytoma, one non speciﬁc tumour and one pseudocyst. There was a good correlation between pre op diagnosis and histological ﬁndings. Out of 24 patients with functional adenomas (13 ConnÕs, 3 cushingÕs, 8 phaeos) 17 patients stopped disease related medications, 4 did not have medication preop, 1 with no change and 1 with reduced doses.

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COMPARISON OF INTRA-ABDOMINAL PRESSURES USING THE GASTROSCOPE AND LAPAROSCOPE IN TRANSGASTRIC SURGERY O.R. Meireles, S.P. Shih, S.V. Kantsevoy, A.N. Kalloo, S.B. Jagannath, E.J. Hanly, D.M. Beitler, M.R. Marohn Johns Hopkins University, BALTIMORE, United States of America

PATIENT FACTORS ASSOCIATED WITH A FASTER INSERTION OF THE COLONOSCOPE R. Arcovedo, C. Larsen Sharp Med. Center, South Bay California, CHULA VISTA, United States of America

Introduction: Peroral transgastric endoscopic (PTE) approach for intraabdominal procedures appears feasible, although multiple aspects of this approach need further development. Aim: To measure and compare intra-peritoneal pressure in a porcine model using the gastroscope and the laparoscope as insuﬄation sources. Methods: All experiments were performed on 50-kg female pigs under general anesthesia. Standard upper endoscope was advanced perorally through the gastric wall incision and peritoneal cavity was insuﬄated with operating room air. The intra-peritoneal pressure was measured by a standard laparoscopic insuﬄator manometer through the endoscope biopsy channel and through a 5mm trans-abdominal laparoscopic port. The source of insuﬄation was then switched to the standard laparoscopic insuﬄator, using CO2 and intra-peritoneal pressures were measured again. Results: Six acute experiments were performed. The pressure measurement showed good correlation regardless of measurement sites, independent of the type of gas used for insuﬄation; room air or CO2. The hand-activated insuﬄation using the gastroscope revealed a wide variation of pressures (ranging from 4 to 32 mmHg) while the standard laparoscopic insuﬄator demonstrated minimal ﬂuctuation (8 to 15 mmHg) around the predetermined value. Conclusion: Use of a gastroscope as the single insuﬄation source revealed large amplitude of pressure variation that could potentially cause hemodynamic instability, compared with the well calibrated and controlled pressures generated by a standard laparoscopic insuﬄator. The PTE approach for intra-abdominal surgeries may promises a less invasive option, and although its underlying physiology needs further investigation, the already established insuﬀaltion from standard laparoscopy may minimized the risks of intra-abdominal hypertension in PTE.

Introduction: There are many factors, which account for a diﬃcult colonoscopy. I chose to study the ﬁrst half of the colonoscopy to try testing the hypothesis that colonoscopy is more diﬃcult in thin patients. To try to prove the above and to better understand the characteristics of the patients in which the insertion of the colonoscope is quicker and easier, the following prospective study was undertaken. Methods: During 2 years, in a prospective fashion, 435 consecutive patients who underwent elective colonoscopy by one surgeon were included in the study. Patients with prior colectomy, with cancer other than the cecum or having an emergent endoscopy were excluded from the study. The time of insertion of the colonoscope from the anus to the cecum was recorded and rounded to the nearest minute. Gender, Age, BMI, abdominal girth, diagnosis, presence or absence of prior surgery, need for external compression, quality of the bowel preparation were considered in the statistical analysis. The Mann-Whitney test was utilized to compare the median of each sample, which seemed to have demonstrated a diﬀerence. Results: There was no direct correlation between the BMI, abdominal girth, presence or absence of prior abdominal surgery and the length of insertion of the endoscope. Statistical signiﬁcance was reached between the gender male versus female. The quality of bowel preparation, the application of external compression and the successful insertion of the endoscope into the terminal ileum, correlated with the length of time of insertion of the endoscope. The median time to insert the colonoscope in the males was 7 minutes (mean 8.14 minutes) and the median to insert the endoscope in the females was 10 minutes (mean 10.6 minutes). Conclusions: Contrary to my hypothesis, the body habitus of the patient does not seem to play a role in the diﬃculty of insertion of the colonoscope. Poor bowel preparation and female gender had a direct relationship with length of time of insertion. Diﬃculty Colonoscope insertion seems more diﬃcult in females as demonstrated by the statistical diﬀerence between the means.

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THE UTILITY OF THE MAGNETIC ENDOSCOPE POSITION DETECTING UNIT AS A VISUAL AID AND MEANS OF POLYP LOCALIZATION

IS EN BLOC RESECTION OF LARGE FLAT POLYPS OF THE LOWER DIGESTIVE TRACT FEASIBLE AND INDICATED BY MEANS OF FLEXIBLE ENDOSCOPY ? A. Arezzo1, A. Repici2, M. Conio3 1 Ospedale Evangelico Internazionale, GENOVA, Italy 2 Istituto Clinico Humanitas, MILANO, Italy 3 Ospedale Civile, SAN REMO, Italy

T. Arazani1, V.A. Moon2, T. Arnell1, D. Feingold1, K.A. Forde1, E. Balik1, N. Sakellarios1, C. Bailey1, D. Markowitz1, R. Rosenberg1, O. Ebwohl1, R.J. Garcia-Carrasquillo1, H. Frucht1, R. Whelan1 1 Columbia University Medical Center, NEW YORK, United States of America 2 Staten Island University Hospital, NEW YORK, United States of America Introduction: The endoscope position detecting unit (EPDU) utilizes magnetic imaging and a specialized colonoscope to give a 3 dimensional view of the position of the colonoscope during colonoscopy. The objective of this study was to determine if the EPDU provides an accurate visual portrayal of the position of the colonoscope within the colon, thereby acting as a visual aid for the endoscopist in determining polyp location. Materials and Methods: The EPDU was used during colonoscopies by 9 experienced endoscopists over a period of 21 months. An external locating probe connected to the main unit was used to localize polyps by position of the scope tip against the abdominal wall and visualizing the probe location compared with the localized positions of the hepatic and splenic ﬂexures. True polyp location was veriﬁed both surgically and in cecal polyps in which the ileocecal valve or terminal ileum were clearly visualized. Results: There were 348 patients who underwent colonoscopy with the EPDU. Patients having undergone colon resections were excluded (41) for a total of 307 study patients. A total of 235 polyps were located using the EPDU in 85 patients. There was one polyp in 55 patients (64.7%), 2 polyps in 16 (18.8%), and 3 or more polyps in 14 patients (16.5% range 3–9). The location of 35 were conﬁrmed at the time of operation (12) or based on location within the right colon (23). There was 100% accuracy for the twelve polyps in 11 patients veriﬁed at the time of operation. Of those polyps conﬁrmed via operation, 4 were hepatic ﬂexure (30.8%), 4 sigmoid (30.8%), 1 rectosigmoid (7.7%), 1 descending colon (7.7%), 1 cecal (7.7%), and 1 distal transverse colon (7.7%). Two polyps, one in the sigmoid and the other in the descending colon were located with the EPDU and veriﬁed within the same patient at operation. Discussion: The EPDU accurately located all 12 polyps in patients undergoing operation. Additionally, the shape of the EPDU colonoscope was accurate in conﬁrming the cecal and ascending location of polyps conﬁrmed by anatomical markers (terminal ileum and ileocecal valve). The EPDU is a safe and eﬃcient way to locate lesions within the colon during colonoscopy.

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 (44–90 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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TRANSPAPILLARY AND TRANSMURAL DRAINAGE OF PANCREATIC PSEUDOCYSTS D. Coelho Neto, J.F.E. Coelho, J.M.R. Eulalio, J.E. Manso, R.A. Reﬁnetti Universidade Federal do Rio de Janeiro, RIO DE JANEIRO, Brazil

OVERCOMING THE CHALLENGES FACED IN SETTING UP ADVANCED LAPAROSCOPY IN A VILLAGE: A PERSONAL EXPERIENCE FROM RURAL INDIA. A.A. Masurkar, S.A. Masurkar Masurkar Multi-Speciality Medical Centre, GOKAK, India

Background: Endoscopic drainage of pseudocyst using the transpapillary and transmural approaches has been reported. Between January 2003 and June 2005, we evaluated endoscopic drainage in 38 patients with symptomatic pancreatic pseudocysts in whom conservative management had failed. Methods: After preliminary endoscopic retrograde pancreatografy, transpapillary drainage was attempted in 14 patients with pseudocysts that communicated with the main pancreatic duct. Transmural drainage of pseudocysts in contact with the stomach or duodenal wall was attempted in the remaining 24 patients and 17 patients selected for combined trasnpapillary and transmural drainage. Results: Endoscopic drainage was technically successful in 36 patients (94, 6%), of whom 36 had complete pseudocyst resolution. Complications occurred in 7, 9% and bleeding (n = 1), after transmural drainage, and pancreatites (n=1) after transpapillary drainage; stent clogging (n = 1). Mean follow up was 18 months (range, 1 to 30 months). Conclusion: Transpapillary and transmural drainage are highly eﬀective in patients with pancreatic pseudocysts demonstrating suitable anatomy for these endoscopic techniques.

We have been performing advanced laparoscopic procedures in Gokak, a village in Rural India for over eight years. Our training was in very good medical colleges in the city of Mumbai. Settling in a low currency and under-developed area raised many challenges in our path. The town lacked many basic amenities like supply of clean water with added problems of power ﬂuctuation and failure. Amongst all the hurdles, the greatest challenge was to provide low budget surgery by ÔCutting Costs Not CornersÕ. Our imagination led us to think on how to ÔImprovise without CompromiseÕ. From inventing simple low cost gadgets, servicing our own equipment, to newer ways to popularise laparoscopy among the masses; we came a long way. It was very diﬃcult to get trained operation theatre assistants and scrub technicians. We employed high school dropouts and could train them to become excellent camera assistants and O.R. technicians. By simplifying commands to a new paradigm understood by them; they were taught the delicate skill of camera work using a 30 degree telescope. The past years brought us experience in educating the uneducated. We realize that laparoscopy workshops for the low currency areas should be conducted diﬀerently. Surgeons in smaller towns are an isolated lot and expert help is hard to come by. Here, tele-mentoring and setting up of helplines is the need of the hour. The rural surgeon is under pressure to provide services in a broad spectrum of cases; and is therefore required to be a multispecialist with good multi-tasking skills. In these areas it is the proverbial Ôjack-of-all-tradesÕ who will win rather than the Ôking-of-oneÕ.

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GASTRODUODENAL DISEASES O136

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SPLENECTOMY WITH ENDOSCOPIC VARICEAL LIGATION IS SUPERIOR TO SPLENECTOMY WITH PERICARDIAL DEVASCULARIZATION IN THE TREATMENT OF PORTAL HYPERTENSION. B. Liu The Third Aﬃliated Hospital, GUANGZHOU, China

POSTOPERATIVE AND LONG-TERM RESULTS OF LAPAROSCOPIC SURGERY IN ADVANCED GASTRIC CANCER: A SERIES OF 130 PATIENTS M. Santamarı´ a1, J.S. Azagra2, F.J. Iban˜ez1, M. Goergen2, M.L. Almendral1, J.M. Erro1, M.J. Madina1, M. Clemares1, A. Beriain1 1 Hospital de Zumarraga, ZUMARRAGA, Spain 2 Centre Hospitalier de Luxembourg, LUXEMBOURG, Luxembourg

Although both surgical operation and endoscopic management are eﬀective in preventing re-bleeding in patients with portal hypertension, complications have been reported. The aim of this study was to compare the therapeutic eﬃcacy and complications of splenectomy with endoscopic variceal ligation (EVL) and splenectomy with pericardial devascularization (i.e. Hassabs operation) in patients with portal hypertension. A total of 103 patients with liver cirrhosis and portal hypertension were randomly selected to receive either splenectomy with EVL (n=53, group A) or Hassabs operation (n=50, group B). The portal blood ﬂow volume, the presence of portal vein thrombosis, gastric emptying time and free portal venous pressure (FPP) before and after the operation were determined. Patients were followed up for up to 64 months with an average of 45 months, and the Dagradi classiﬁcation of variceal veins and the grading of portal hypertension gastropathy (PHG) were evaluated. It was found that all esophageal varices were occluded or decreased to grade II or less in both groups. There was little diﬀerence in the recurrence rate of esophageal varices (11.9% vs. 13.2%) and the re-bleeding rate (7.1% vs. 5.3%) between groups A and B. The incidence of complications and the percentage of patients with severe PHG after the operation were signiﬁcantly higher in group B (60.0% and 52.0%) than those in group A (32.1% and 20.8%, both P<0.05). No patients died from operation related complications. There was no signiﬁcant diﬀerence in gastric emptying time, FPP and the portal blood ﬂow volume between the two groups. The results suggest that splenectomy with EVL achieves similar therapeutic eﬃcacy to that of Hassabs operation in terms of the recurrence rate of esophageal varices and the rebleeding rate, but the former results in fewer and milder complications.

Background: The objective of our paper is to report on the remote results of patients with gastric cancer treated by mini-invasive surgery as a surgical tool with the Ôintention to treat with laparoscopyÕ. Patients and methods: Between June 1993 and January 2006, 130 patients comprising 94 men and 36 women with gastric adenocarcinoma were prospectively selected by two surgical teams in three hospitals, based on prior agreement (the CHU Charleroi, Belgium, Centre Hospitalier de Luxembourg, Luxembourg and Zumrraga Hospital, the Basque Country, Spain). Patients with adenocarcinoma of the cardia were excluded. Average age of the patients was 68 (37–85). Results: Post-operative mortality within 60 days of operation was of 6 patients; 109 patients were therefore properly followed-up for an average of 49 months (2–153). Average survival time for 10 non-resected patients was 4.5 months. Average survival rate of the 14 palliatively resected patients was 6.9 months. Actuarial 5-year survival rate RO-type surgery was 35%. The global actuarial 5-year survival rate after resective surgery was 31%. Conclusions: Laparoscopic gastrectomy with any kind of lymphadenectomy are heavy but safe operations, and produce acceptable mortality and morbility rates in patients with advanced gastric cancer in a general poor condition. Laparoscopic gastrectomies for locally advanced cancers are equivalent to those reported by laparotomy as far as long-term oncological results are concerned.

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TOTALLY LAPAROSCOPIC GASTRECTOMY IN KOREA: PRELIMINARY EXPERIENCE J.J. Kim1, K.Y. Song2, W. Kim2, H.M. Chin2, H.M. Jeon2, S.M. Park2, K.W. Lim2, C.J. Ahn2, S.N. Kim2, W.B. Park2, C.H. Park2 1 Our Lady of Mercy Hospital, INCHEON, South-Korea 2 The Catholic University of Korea, SEOUL, South-Korea

PROSPECTIVE RANDOMIZED BLINDED TRIAL FOR LAPAROSCOPIC ANTIREFLUX SURGERY E. Montalvo-Jave1, M. Moreno1, M. Rojano1, A. Carrasco2, J.M. Trevino1 1 Hospital General ÔDr.Manuel Gea Gonzalez, MEXICO CITY, Mexico 2 UNAM, School of Medicine, MEXICO CITY, Mexico

Aims: We analyzed our preliminary clinical data of totally laparoscopic gastrectomy(TLG) to validate the eﬀectiveness in terms of minimal invasiveness and the technical feasibility and reproducibility of this procedure. Methods: Forty ﬁve patients who underwent TLG in Our Lady of Mercy Hospital, The Catholic University of Korea between June, 2004 and February, 2006 were enrolled in this study. There were 26 men and 19 women, mean age was 58.811.2 years and their mean body mass index was 23.23.1. In all cases only laparoscopic linear staplers were used for intracorporeal anastomosis. Results: The reasons for gastrectomy were gastric cancer in 41 cases, benign disease in 3 cases and gastrointestinal stromal tumor in 1 case and the types of surgery were 40 cases of distal gastrectomy, 4 cases of total gastrectomy and 1 case of pyloruspreserving gastrectomy. Among the distal gastrectomy, Billroth I (40) was the most frequent procedure and then uncut Roux-en-Y gastrojejunostomy (14) and Billroth II (1) in order. The mean operation time was 31479 minutes and the average time for intracorporeal anastomosis was 4122 minutes and the estimated blood loss was 150183 ml. There was no case of conversion to an open procedure. The ﬁrst ﬂatus was observed at 2.90.8 th postoperative day and liquid diet was started at 3.71 th postoperative day. The average postoperative analgesic use was 1.42.2 times and the mean postoperative hospital stay was 117.8 days. Postoperative complication occurred in 6 patients (13.3%) and there was no postoperative mortality. There were 2 cases of delayed gastric empting and 1 case of anastomotic leakage, anastomotic stenosis, intraabdominal bleeding and ventral hernia in each. Reoperations were performed in anastomotic leakage and intraabdominal bleeding with laparoscopic approach. Endoscopic balloon dilatations were performed in anastomotic stenosis and one case of delayed gastric empting. Hernioplasty was performed for ventral hernia. The remained one case of delayed gastric empting was improved with conservative management. Conclusion: TLG was technically feasible and we could get acceptable short term clinical outcomes in terms of minimal invasiveness. Like laparoscopy-assisted gastrectomy TLG could be performed safely with relevant learning curve.

Introduction: Gastroesophageal Reﬂux Disease (GERD) is a common disease in adult population, a Nissen fundoplication is one of best choices for this groups of patients. The aim of this study was to evaluate the surgical outcomes of three laparoscopic antireﬂux procedures, compared symptoms, complications and follow-up. Methods and Procedures: Between 1993 and 2001, a group of 100 consecutive GERD patients underwent a laparoscopic antireﬂux surgery, agreed to be prospectively randomized to Nissen (n=40), Toupet (n=25) and Gea (n=35) groups. The same experienced surgical attendings performed all operations. All procedures utilized general anesthesia and posoperative follow-up was 4–10 years. Results: There were no signiﬁcant diﬀerent (SD) in operative time, blood loss and postoperative improvement in symptoms in the Nissen and Gea groups. Failure and reoperation rate was higher in Nissen than Gea groups, but no SD were noted (4 vs.2). No mortality was noted. Conclusion: Our ﬁndings suggest that Nissen and Gea groups can be safely and successfully performed in adults with GERD. We consider that Gea surgical procedure is feasible and could be applicable to the patients with GERD.

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INTERNAL HERNIA AFTER LAPAROSCOPY-ASSISTED DISTAL GASTRECTOMY FOR GASTRIC CANCER I. Kaneda, S. Ishibashi, K. Hatugai, I. Inoue, H. Sarashina Ishinomaki Red Cross Hospital, ISHINOMAKI, Japan

LONG-TERM EXPERIENCE WITH THE LAPAROSCOPIC SOLUTION OF UP SIDE DOWN STOMACH L. Kmet1, V. Drahonovky2, L. Vrbensky2 1 Mediterra Ltd., PRAGUE, Czech Republic 2 City Hospital, NERATOVICE, Czech Republic

Background: We reported that a late complication such as an incidence of bowel obstruction as a result of postoperative adhesions following laparoscopy-assisted surgery for gastric cancer was signiﬁcantly lower than that in open surgery. However, we observed a much higher incidence of internal hernia underneath the Roux limb mesentery after the laparoscopic procedure, as it was never seen in our open patients. Although lack of postoperative adhesions is one advantage of laparoscopic surgery, this is also responsible for a higher incidence of internal hernia. Methods: Data was obtained on 88 consecutive patients from August 2002 to February 2006 and analyzed retrospectively. During the course of this series, a change in surgical technique occurred August 2004 as we became aware of the increased prevalence of internal hernia. Initially, we used an antecolic technique in 59 patients then switched to a retrocolic technique to prevent Petersen hernia (space between mesentery of Roux-limb and transverse mesocolon). In an antecolic technique, Petersens space was not addressed. Then, in a retrocolic technique, we used interrupted absorbable sutures to close Petersens space. We compared 59 consecutive antecolic operations with 29 consecutive retrocolic operations. Results: There was an 8.5% rate of internal hernia in antecolic group and a 3.4% rate of internal hernia in retrocolic group. All herniations were behind the Roux limb mesentery. The diﬀerence in hernia formation after the change in technique was signiﬁcant (p<0.05). Conclusions: Internal hernias are more common following laparoscopic gastrectomy than open surgery. With a change in technique, however, the incidence of internal hernia behind the Roux limb mesentery may be signiﬁcantly reduced.

Aim: We present our long-term experience with diagnosis and laparoscopic operations of the large hiatal defects and especially with the group 56 patients with diagnosis up side down stomach. Till the end of 2005 we have performed in our hospital 2479 fundoplications for the gastroesofageal reﬂux disease GERD and the hiatal hernias. In this group altogether 2239 hiatal defects were identiﬁed and from this number 56 of the type up side down stomach. The diagnosis was veriﬁed by endoskopy and X-ray contrast examination. Methods: As a standart laparoscopic operation we have performed deliberation of the stomach and oesophagus, sac resection, crural suture and fundoplication of the type Nissen Rossetti. In the solitary cases actually huge hiatal defects we have used furthermore mesh application on the crura and laparoscopic gastropexy. We didnt had to use any lengthening procedure. Results: We have only one exitus owing to mediastinitis, one conversion to the classical operation, from the 6 recurrences we reoperated 4 patients with the good result, remaining 2 patients with the small defect are with the result of the ﬁrst operation satisﬁed and the reoperation refused. The good therapeutic eﬀect of laparoscopic aproach we have evaluated by Eypaschs test gastrointestinal quality life index GIQLI. From the sent questionaires 36 returned, quality of life index in our group is 116,3 points with the comparison of the healthy population index 119 points. Conclusion: On the basis of our experience we consider the laparoscopy to be the ﬁrst option method for the solution up side down stomach. The gastrointestinal quality life index GIQLI operated patients is near to healthy population index.

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LAPAROSCOPIC INTRALUMINAL SURGERY A SAFE APPROACH FOR GASTROINTESTINAL DISEASE J.M. Trevino, M.E. Franklin, J.J. Gonzalez, G. Kim Texas Endosurgery Institute, SAN ANTONIO, United States of America

LAPAROSCOPIC VERSUS OPEN SUB-TOTAL GASTRECTOMY WITH LYMPHADENECTOMY C. Staudacher, E. Orsenigo, V. Tomajer, M. Carlucci, S. Di Palo, A. Tamburini Scientiﬁc Institute San Raﬀaele, MILAN, Italy

Overview: Advances in laparoscopic surgery have allowed its application in endoluminal surgery. Laparoscopic-assisted endoluminal surgery has been used for a variety of indications. We review our experience with this technique to determine its safety, feasibility and eﬃcacy in the hands of an experienced laparoscopic surgeon. Methods: Between 1996 and 2005, data was collected retrospectively of all patients having undergone laparoscopic endoluminal surgery at the Texas Endosurgery Institute. All patients underwent endoluminal port placement using a 5mm ballon trocar for the camera and 2mm for working ports, under direct visualization after a pneumoperitoneum was established. All the operations were performed in conjunction with upper endoscopy for assistance in port placement under intraluminal visualization, insuﬄation, and specimen retrieval. The endoluminal port sites were then closed with laparoscopic intracorporeal suturing after the intraluminal portion of the operation was completed. Results: Thirty ﬁve patients from 1996 to 2005 underwent laparoscopic endoluminal surgery. Indications for the procedure were varied and included: diagnostic procedure, carcinoid tumors, pancreatic pseudocysts, gastric and esophageal polyps, duodenal webs, gastric adenocarcinoma, and benign obstructing ulcer disease. All cases were completed successfully with no recurrence of the original pathology and minimal complications. Conclusions: We were able to successfully complete procedures and establish diagnoses in all 35 patients using this technique and found it to be a safe, feasible, and eﬀective alternative to more conventional therapies. It is a technique that will likely have more applications in the future as our experience and instrumentation improves and should be performed by anyone with previous experience in advanced laparoscopic surgery.

Aim: The role of laparoscopic resection in the management of gastric cancer is still debated. The aim of our study was to compare the perioperative results for two unselected groups of patients undergoing either laparoscopic or open sub-total gastrectomy for gastric cancer. Methods: This retrospective nonrandomized study was based on a series of 145 consecutive patients operated on by using the same type of surgical technique (sub-total gastrectomy with lymphadenectomy). The only difference was the type of access, which was either laparoscopic (LPS) or open (LPT). Results: Between January 2000 and December 2005, 72 patients underwent a laparoscopic sub-total gastrectomy with lymphadenectomy; at the same time, 73 patients were treated via an open approach. There were no differences between the two groups when we compared: patient age (mean 65 and 62 in LPS and LPT group, respectively), male/female ratio, TNM stage. The mean operative time was similar (247 and 218 minutes in LPS and LPT group, respectively; p=ns). Conversion rate was 9%. The mean number of lymph nodes retrieved was signiﬁcantly higher in the laparoscopic group (LPS: 3115; LPT: 2512; p=0.03). The mean time of hospital stay was similar in the two groups (LPS: 11 5; LPT: 126; p=ns). No statistically signiﬁcant diﬀerence between the laparoscopic and open group was observed for morbidity and mortality. Conclusions: These results suggest that laparoscopic gastrectomy with lymphadenectomy for gastric cancer can be performed safely, with morbidity and mortality comparable to those of open surgery. Nevertheless, in our experience, the number of lymph nodes retrieved is higher in patients treated with laparoscopic approach.

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THE LONG-TERM AFFECTION OF LAPAROSCOPIC FUNDOPLICATION ON BARRETTS ESOPHAGUS V. Drahonovsky1, L. Kmet1, J. Hnuta2 1 Mediterra Ltd., NERATOVICE, Czech Republic 2 City Hospital, NERATOVICE, Czech Republic

SURGERY FOR GASTROINTESTINAL STROMAL TUMORS (GIST) OF THE STOMACH G.R. Silberhumer1, M. Schindl1, T. Birsan1, E. Wenzl2, G. Prager1, F. Laengle1, J. Zacherl1 1 Medical University Vienna, VIENNA, Austria 2 LKH Feldkirch, FELDKIRCH, Austria

Aim: The cause of mucosal changes of Barretts esophagus is gastrooesophageal reﬂux. The laparoscopic fundoplication evidently decreases an exposition of the mucosa in distal oesophagus to acid or alcalic reﬂux. Consequently, it is considered to expect the improvement of the mucosal state in long-lasting eﬀect only by the laparoscopic fundoplicaton. Methods: We have been observing the development of mucosal changes, in the retrospective study, for more than 5 years (5 – 9) from the operation was performed. This development of changes was assessed by 14 cooperative gastroenterologists, who were indicating the patients for the operation, they were watching them and then they made control endoscopical and histological examination within the frame of the study. Results: In the period of time 1995 – 1999, we operated 29 patients with Barretts esophagus, proved by histological examination. Now 23 of them were examinated and the results were evaluated. There are 6 patients, who are inaccessible to the control. The average age, in the time of operation, was 48,3 years, the average duration of gastrooesophageal reﬂux symptoms, perceived by patients, was 13 years. (3 – 23). From the number 23 were 4 patients on continuing therapy, 3 of them had reﬂux symptoms and were without improvement of the mucosal state. Those patients present 50% of the group with no diference in oesophageal mucosa. There were no patients with conﬁrmed aggravation of the mucosal state to dysplasia. 5 patients were without detecable Barretts esophagus 5 with improvement in macro aspect and without metaplasia 7 with improvement in macro aspect but with intestinal metaplasia 6 with no diﬀerence in mucosal state These results exactly correlate with the score of gastrointestinal quality life index - GIQLI, which was made for all this group. Conclusion: The successful laparoscopic fundoplication aﬀects positively the mucosal changes in conﬁrmed Barretts esophagus and consequently, it means the right prevention of the eventual progression to metaplastic and dysplastic changes, caused by long-lasting gastrooesophageal reﬂux.

Background: Gastrointestinal stromal tumors (GIST) are the main mesenchymal neoplasmas in the gastrointestinal tract (GI), but represent less than 1% of all malignant GI-tumours. Tumour size and mitotic rate correlate with potential malignancy and frequency of recurrence. Method: Between 1998 and 2005 39 patients (15 female, 24 male; median age 6115,7a) underwent a gastric resection because of GIST. In more than 50% tumours were asymptomatic. All patients returned for follow-up. Follow up investigations included gastroscopy in 27, CT in 23 and endosonography in 19 patients. Results: The mean tumour size was 5,54,3cm, mainly located in the corpus (50%), followed by the antrum (30%). One patient additionally suﬀered from synchronous liver metastasis, mesothelial inﬁltration and peritoneal spreading. Open atypical gastric resection of was done in 17 patients, remnant gastrectomy in 2, antrectomy in 2 and other surgical procedures in 4. Laparoscopic gastric resection was intended in 13 patients, conversion rate was 2/13 (15,4%). Overall, R-0 resection was reached in 4/38 (10,6%) patients. No perioperative deaths occurred. 3 tumours histologically were classiﬁed as malignant, one as semimalignant. All tumours smaller than 7cm were considered benign at histology. One patient received Glivec preoperatively, another patient received additive treatment with Glivec but was switched to Taxotere due to toxicity. 3/39 tumours (7,5%) were c-kit negative. After a median follow up of 3,7 years GIST recurrence rate was 2 (5,2%) among patients with R-0 resection. Overall, 5 patients died during follow-up, only one death was caused by GIST. Conclusion: Histologically proven complete resection is an eﬀective treatment for gastric GIST. Laparoscopic procedures were established with adequate quality in selected patients depending on tumour size. Endosonography may enhance diagnostic accuracy during follow up.

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LAPAROSCOPIC ASSISTED DISTAL GASTRECTOMY FOR THE TREATMENT OF EARLY STAGE GASTRIC CANCER: FIVE-YEAR EXPERIENCE IN A REGIONAL HOSPITAL D.K.K. Tsui, K.H. Wong, M.K.W. Li Pamela Youde Nethersole Eastern Hospital, HONG KONG SAR, Hongkong

LAPAROSCOPIC SLEEVE GASTRECTOMY FOR DELAYED GASTRIC EMPTYING W. Breithaupt1, J. Maroske2, M. Fein2, I. Hammer1, K-H. Fuchs1 1 Markus Hospital, FRANKFURT AM MAIN, Germany 2 University of Wuerzburg, WUERZBURG, Germany

Aim: Laparoscopic assisted distal gastrectomy (LADG) is well established for early gastric cancer (T1) in Japan. Its role for more advance stages of gastric cancer remains controversial. The purpose of this study was to review our initial experience of LADG in the treatment of early stage (Stage I & II) gastric cancer. Method: This was a retrospective review of LADG during the period from January 2001 to December 2005. Stage I & II gastric cancer underwent LADG (either Hand port assisted or Laparoscopic assisted) were included. Outcome parameters including operative time, blood loss, complication, hospital stay, number of lymph nodes harvested, recurrence and mortality were evaluated. The results were compared with the same historical counterpart for open surgery during the same period of time. Results: Twenty four patients received LADG during the study period (Hand port assisted = 10, Laparoscopic assisted = 14). There were 18 male and 6 female with median age of 68 (range 43 – 84). The median number of ports used was 4 (range 3 5), median wound length was 5cm (range 2.5 11), median operative time was 240 mins (range 125 300), median blood loss was 100ml (range 50 – 1000), median hospital stay was 10 days (range 7–58) and median number of lymph node harvested was 19 (range 6 – 43). There were no 30-day mortality, two patients required laparotomy for duodenal stump leakage and secondary haemorrhage respectively. The other major complications include intra-abdominal collections and nosocomial pneumonia. When compared to the open group, there was signiﬁcant less in blood loss and longer in operative time in the laparoscopic group (p<0.05) but no statistical signiﬁcant diﬀerences in hospital stay, complications, recurrence and mortality. Conclusion: Laparoscopic assisted distal gastrectomy is a safe and feasible procedure. Adequate lymph node clearance can be achieved for early stage gastric cancer.

Introduction: Delayed gastric emptying (GE) is a relevant clinical problem in patients with gastoparesis. Most of these patients are refractory under medical therapy due to massive gastric dilatation. Until now surgery had been unsuccessful because distal gastric resection can not inﬂuence fundic dilatation and solid food retention. The purpose of this study is the experimental and clinical evaluation of surgical reduction of the dilated stomach into a tube, the left lateral or sleeve gastrectomy. Methods: Experimental Study: 10 mongrel dogs were evaluated by radiographic barium emptying studies. Left lateral gastrectomy was performed to transform the stomach into a tube. 2 months after the procedure emptying studies were repeated in order to document changes. Clinical study: Based on the experimental data patients with year-long history of gastroparesis with nausea, vomiting and reduced quality of life wre carefully selected for possible candidates for surgery. Preoperative work-up consisted of antroduodenal manometry, gastric emptying scintigraphy and pH-monitoring and radiographic barium sandwich emptying. Laparoscopic sleeve gastrectoms was performed with resection of the left lateral part of the stomach along the greater curvature, using straight linear stapling devices with a bougie in the gastric lumen to calibrate the tube. Postoperative evaluation was performed by repeating the preoperative studies. Results: Experimental Study: radiographic GE pre-/postop: 2 hour emptying 60%/80%; 4 hour emptying 80%/100%, p< 0.02. Clinical study: 4 patients: age 54 (43–63), 3 femals, 1male; history 4 years (1 6); pre-/postoperative assessment: radiographic GE 2h: 30%/70%; GE-scintigraphy T1/ 2:>120 min / 90 min; GIQLI 88/116. Complications: 1(4) with recurrent delayed GE reoperation by distal resection Conclusion: Laparoscopic sleeve gastrectomy is a feasible method to treat delayed gastric emptying in patients with reduced quality of life suﬀering from nausea and vomiting due to gastric dilatation.

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GYNAECOLOGY O150

O147 EXPERIENCE OF COMPARATIVE USE OF VARIOUS MODELS OF HYSTEROSCOPES 1

2

1

L. Zlobina , A. Korotkevich , J. Revitskaya Hospital Nr.29, NOVOKUZNETSK, Russia 2 Advanced Medical School for Doctors, NOVOKUZNETSK, Russia

1

The purpose. To compare eﬃciency of use of various hysteroscopes models in routine practice of gynecology department. Material and methods: Results of medical cards of the women who had treatment in gynecology department and undergone out-patient hysteroscopy from 2002 to 2005 were analyzed. Hysteroscopy carried out without anesthesia, under local an-esthesia by 2% lidocaine solution of 10–12 ml, intravenous anesthesia and tracheal intubation. Used oculus technique and videocameras OTV-F3 (Olympus) for ﬁberhysteroscope and Endocam (Storz) for rigid hysteroscopy. Estimated duration of research, volume of a liquid, necessity of cervical dis-tension, frequency of complete and un complete investigations and their reasons, complications, convenience of work of the doctor. Results: In total, results of 416 hysteroscopy - 398 ﬁberhysteroscopy and 18 rigid hys-teroscopy were analyzed. Duration of procedures in ﬁberhysteroscopy and rigid hysteroscopy was 111,1 minutes and 161,3 minutes accordingly (p <0,5). Investigation time depend of the woman constitution - at ex-cess weight average procedures time at these women in 1,5 times exceeded average duration of in-vestigation on 80,8 minutes at ﬁberscopy and on 12,31,5 at rigid hysteroscopy (p <0,5). The volume of distension media at ﬁberscopy was 560100,7ml, at rigid hysteroscopy 78090,0ml (p <0,2). The basic charge and increase in volume of a liquid have been connected to necessity of cervical distension, with a myoma or excess weight of the woman. Cervical distension in ﬁberhysteroscopy was required from 376 women (94,5%) against 10 (60%) at rigid hysteroscopy (p <0,02). Without cervical distension is carried out accordingly 22 (5,5%) and 8 (40%) hysteroscopies. Complications at ﬁberhysteroscopy are marked in 1 case (0,3%) acute endomethritis, at rigid hysteroscopy complications has not been marked. Conclusions: ﬂexible hysteroscopy and rigid hysteroscopy cannot be opposed each other, and should supplement each other. Departments of gynecology should have both types of hys-teroscopes, that will allow to increase frequency of successful diagnostics and it is essential to re-duce number of unsuccessful examinations.

LAPAROSCOPIC MANAGEMENT OF NON OBSTRETIC EMERGENCY IN THE THIRD TRIMESTER OF PREGNANCY A. Upadhyay1, A. Upadhyay2, S. Stanten1, G. Kazantsev1, R. Horoupian1, A. Stanten1 1 St. Rose Hospital, Hayward, CALIFORNIA, United States of America 2 Alta Bates Summit Medical Center, CALIFORNIA, United States of America Aims: Laparoscopic management of non obstetric acute abdominal pain during pregnancy remains controversial and represents a unique challenge. A gestational age of 28 weeks has been considered an upper limit for laparoscopy by some authors. Most reported cases are in the ﬁrst and second trimester. We report a case series of Laparoscopic surgery in the third trimester of pregnancy. Methods: Medical records of third trimester patients who underwent open or Laparoscopic surgery between 1997 and 2005 were reviewed. Results: There were total twelve patients in this study. Eight patients underwent laparoscopic surgery while four had open surgery. In the Laparoscopic group, there were three appendectomies, three cholecystectomies and two adenexal surgeries. In the LS group the procedures were successfully completed using laparoscopic approach in seven patients, these had no complications and subsequently had normal full term deliveries. One patient in the LS group had to be converted to an open approach; she subsequently developed post operative hemorrhage and pre-term labor, requiring a cesarean section on the 3rd post operative day. The OS group included two appendectomies and two patients at 37 and 38 weeks who underwent a planned cesarean section followed by a total colectomy and Right hemicolectomy. In summary, we show that the even in the third trimester of pregnancy, access is easily obtained, space is generally not a problem, trocar placement can be optimized and there is minimal uterine manipulation. Conclusions: Our study shows that laparoscopic surgery is feasible and can be safely performed in the third trimester with an acceptable risk to both the fetus and the mother.

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EARLY LAPAROSCOPY AT ACUTE PELVICE INFLAMMATION IN WOMEN L. Zlobina1, J. Revitskaya1, A. Korotkevich2 1 Hospital Nr.29, NOVOKUZNETSK, Russia 2 Advanced Medical School for Doctors, NOVOKUZNETSK, Russia

VIRTUAL REALITY LAPAROSCOPIC SIMULATOR, FACE VALIDITY AND CONSTRUCT VALIDITY FOR THE USE IN GYNECOLOGY S.J. Roeleveld, H.W.R. Schreuder, K.W. van Dongen, I.A.M.J. Broeders University Medical Centre Utrecht, UTRECHT, The Netherlands

The purpose: to estimate eﬃciency of application of early treatmentl and operative laparoscopy at acute pelvice inﬂammation in women. Material and methods: medical cards of 46 women who are taking place on treatment in gynecol-ogy department in 2005 with acute pelvic inﬂammation are investigated. Age from 16 till 43 years. Used ultrasonic, a diagnostic and treatment laparoscopy in 1–2 day from receipt. A laparoscopy car-ried out under local anesthesia. Laparoscopic operations carried out under endotracheal anesthesia. Studied time of recourse of clinical complaints, operative activity, quality of the postoperative pe-riod, the hospital stay. Results: The anamnesis of disease was from 3 till 10 day (5,82,1). In 1–2 day the laparoscopy is executed 34 (74%) of women, without laparoscopy 12 (26%) women were operated. From 34 women ultrasonic examination has revealed up to laparoscopy inﬂammatory mass in 7 cases (21%), peritoneal ascytis at all women. At all women were a pain and hyperthermia. At laparoscopy have been found: peritoneal ascytis in 34 cases (100%), pelvic peritonitis - 10 (29%), inﬂammatory mass - 2 (6%), purulent salpingitis - 3 (9%), chronic inﬂammation - 27 (79%). Laparoscopic lav-age and drane are executed to 27 women (79%), laparoscopic oophorectomy - 2 (6%), laparoscopic salpingectomy - 3 (9%), laparoscopic massectomy - 2 (6%). Complaints have disappeared in 2 day at 27 (79%) women, in 3–4 day at 7 (21%) women. The hospital stay was 8 day. In 12 women without laparoscopy at ultrasonic examination peritoneal ascytis is found out in all cases. On operation the peritonitis and inﬂammatory masses are found in all cases. The volume of operation has consisted of hysteroresection at 5 women (42%), massectomy at 5 (42%), extirpation of uterus at 2 (16%). Complaints have disappeared after 4 day at all women. The hospital period was 16 day. Conclusions: the early laparoscopy allows to avoid ÔopenÕ operations, reduces the hospital stay and is eﬀective treatment method of acute purulent pelvic diseases at women.

Aims: The applicability of virtual reality simulation for training endoscopic surgical skills in surgery has been evaluated with positive outcomes. Although some of the virtual reality software is designed especially for training gynecologists, research to evaluate its merits is scarcely done. The objective of this study was to validate computed virtual reality simulation as a tool to assess laparoscopic surgical skills in gynecology by establishing the extent of realism of the simulation to the actual task (face validity) and by investigating the ability of the simulator to diﬀerentiate between the performance of subjects with varying laparoscopic experience (construct validity). Methods: Subjects (N=56) were divided in three groups: novices (no laparoscopic experience, n=15), intermediates; (between 1 and 75 laparoscopic procedures, n=20) and experts; (>75 laparoscopic procedures, n=21). Face validity was determined by using a questionnaire of 27 statements after ﬁnishing the training program. All participants completed three repetitions of a training program that consisted of four basic exercises and three simulations of gynecologic procedures. The simulator (LapSim, Surgical Science Ltd., Gothenburg, Sweden) measured performance in seven to fourteen parameters per task. The performance was compared between groups using a post hoc t test with the Bonferroni technique. Results: The questionnaire was completed by 52 participants. The opinion about the realism and training capacities of the tasks was favorable among the groups, although experts were signiﬁcant more critical than novices and intermediates. The degree of prior laparoscopic experience was reﬂected in the performance parameters of the tasks. Experts achieved signiﬁcant (p< 0.05) better scores on speciﬁc parameters in the basic skills camera navigation, instrument navigation and coordination, and in the gynecologic simulations sterilization and salpingectomy in ectopic pregnancy. Conclusion: The questionnaire demonstrated reasonable face validity. Analysis of training results demonstrated signiﬁcant diﬀerentiation between subjects with diﬀerent laparoscopic experience and thereby construct validity for the use in gynecology was established.

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O152 LAPAROSCOPIC ANTERIOR RECTAL RESECTION FOR RECTOVAGINAL ENDOMETRIOSIS N. Kenney, J. English, K. Baig Worthing Hospital, WORTHING, United Kingdom Introduction: Rectovaginal endometriosis can cause chronic pelvic pain, dyschezia and an impaired quality of life. There is currently no consensus as to the best surgical approach to manage this debilitating condition. We believe that surgical resection of the aﬀected bowel is the most eﬀective treatment as it will remove microscopic and multifocal disease and so reduce the chance of recurrence. In all cases we aim to perform the surgery laparoscopically. We report on 45 patients who underwent anterior rectal resection as part of the radical resection of pelvic and abdominal endometriosis. Method: A retrospective analysis of all patients undergoing rectal resections between 2000 and 2005, focusing on the operative details and any surgical complications. A postal survey was sent to the patients to identify pain scores and quality of life post operatively. Results: Of the 45 rectal resections, 53% were performed entirely laparoscopically. The uterus was conserved in 64% of patients. In 71% of cases the rectal resection was completed without the need for a temporary stoma. Histology of the rectal specimens conﬁrmed endometriosis in 91% of cases with severe scarring or ﬁbrosis in the remaining specimens. In 29 cases (64%), there were no signiﬁcant complications. Three patients returned to theatre in the immediate post-operative period due to pelvic sepsis, two of whom had an ileostomy formed. Two patients have developed a rectovaginal ﬁstula. One patient developed a ureterovaginal ﬁstula following extensive bladder resection. There have been six rectal anastamotic strictures all successfully managed using ballon dilatation. There has been one case of ureteric transection. Patient Response: The mean follow up period for assessing patient response was 8 months. 83% of patients felt that following surgery their pain was either completely gone or greatly improved. Quality of life using an EQ5D questionnaire was comparable to a normal population and patients visual analogue pain scores have shown minimal change over time. Conclusion: Anterior rectal resection is a relatively safe procedure and an eﬀective treatment for rectovaginal endometriosis.

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LAPAROSCOPIC COLONIC RESECTION IN FAST TRACK PATIENTS DOES NOT ENHANCE SHORT TERM RECOVERY AFTER ELECTIVE SURGERY. G. Mackay1, U. Ihedioha1, P. Duﬀy1, A. McConnachie2, M. Serpell1, R. Molloy3, P.J. OÕDwyer1 1 Western Inﬁrmary, GLASGOW, United Kingdom 2 University of Glasgow, GLASGOW, United Kingdom 3 Gartnavel General Hospital, GLASGOW, United Kingdom

OUTCOME FOLLOWING CURATIVE RESECTION FOR COLORECTAL CANCER U.C. Ihedioha1, G. Mackay1, E. Leung1, R. Molloy2, P.J. OÕDwyer1 GLASGOW, United Kingdom 2 Gartnavel General Hospital, GLASGOW, United Kingdom

Background: Laparoscopic colorectal surgery has been claimed to enhance recovery when compared with open surgery. The aim of our study was to investigate whether laparoscopic colorectal resection improved recovery with the use of a multimodal rehabilitation program. Methods: We carried out a prospective study of 80 patients undergoing elective colorectal resection between November 2003 and March 2005. A fast track protocol with early feeding, mobilisation and a ﬂuid and sodium restriction regime was applied to all patients. Recovery was measured in terms of return of gastrointestinal function, hospital stay, complications and quality of life measures. Results:Of the 80 patients in the trial 22 underwent laparoscopic resection and 58 had open surgery. Patients were well matched for all baseline characteristics. The groups were not signiﬁcantly diﬀerent in terms of opioid or antiemetic use. They were also similar in median time to ﬁrst ﬂatus (69hrs vs 69hrs, p=0.36) and median time to ﬁrst bowel motion (127hrs vs 101hrs, p=0.07). There was no diﬀerence in median hospital stay (5.8days vs 5.9days, p=0.87) or complications (p=0.46) between the laparoscopic and open group. There were no signiﬁcant diﬀerences in SF36 scores between the two groups for any of the components measured. Conclusions: Laparoscopic colorectal resection does not appear to enhance recovery with the use of a multimodal rehabilitation regime. Further large randomised trials are required to conﬁrm these ﬁndings.

Background: Colorectal cancer has been shown to be responsible for approximately 20,000 deaths in the UK annually. Recent studies have shown that the 5 year survival rate following potentially curative surgery for colorectal cancer ranged from 40 to 51%. The aims of our study were to determine the mortality rate for patients who had undergone potentially curative resection in our unit and the causes of death in this group of patients. Methods: A prospective study was performed on 699 consecutive patients, who presented with symptomatic colorectal cancer between January 1997 and October 2005 in a single surgical unit. All resections were carried out by a team of dedicated colorectal surgeons and a standard protocol was used for all pre- and post-operative care. All patients were followed up immediately after surgery and at set intervals in the outpatient clinic. At the end of the study, all the case records were also reviewed to include any deaths or complications presenting to other non-surgical disciplines. Results: The patients in our study had a median age of 69 years (range 37 to 92) and a similar male-to-female ratio. Altogether, 551 (78.8%) patients had resections with curative intent and only 5 (0.9%) were found to have positive resection margins. Our overall mortality rate was 15%, but our thirtyday mortality was only 3.3% and most were due to cardio-respiratory complications. At a median follow-up of 3 years, only 5.8% of patients died from recurrent or metastatic colorectal cancer whereas a similar proportion of 5.1% died from non colorectal cancer related causes. Conclusion: Our results suggest that patients who had a curative resection for colorectal cancer are as likely to die from other causes as from recurrent or metastatic colorectal cancer.

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LAPAROSCOPIC COLECTOMY IS ASSOCIATED WITH LESS POSTOPERATIVE GASTROINTESTINAL DYSFUNCTION E. Hashavia, D. Rosin, Y. Munz, M. Shabtai, A. Ayalon, L. Dinur, O. Zmora Sheba Medical Center, TEL HASHOMER, Israel

LAPAROSCOPIC VS OPEN COLORECTAL CANCER RESECTION USING SAME CLINICAL PATH S. Yamaguchi, H. Morita, M. Ishii, S. Saito, A. Maeda, K. Uesaka Shizuoka Cancer Center, NAGAIZUMI, Japan

Objective: Major abdominal surgery is associated with early postoperative gastrointestinal dysfunction, which may lead to abdominal distention and vomiting, requiring nasogastric (NGT) tube insertion. The aim of this study was to compare the rate of early postoperative NGT insertion following open and laparoscopic colorectal surgery. Methods: A retrospective chart review of patients who underwent colorectal surgery in whom NGT was removed upon completion of surgery was performed, to identify those who required re-insertion of the tube on the early post operative course. Re-insertion rate in patients who had laparoscopic surgery was compared to the open group. Results: There were 103 patients in the open group and 227 in the laparoscopic one, of which 42 were converted to open surgery. Reinsertion of NGT was required in 18.4% of patients in the open group, compared to 8.6% in patients in whom the procedure was completed by laparoscopy (p= 0.02). Conversion to open surgery resulted in reinsertion rate of 17%. Conclusion: laparoscopic colorectal surgery is associated with less postoperative gastrointestinal dysfunction, resulting in signiﬁcantly lower rate of NGT reinsertion.

Purpose: Using same clinical path (plan of postoperative course), laparoscopic (Lap) and open (Open) colorectal cancer resection were assessed. Patients & Method: Consecutive one hundred forty-eight colon and upper rectal cancer patients were included for this study from August 2004 to June 2005. Actual number of Lap was 86, and that of Open was 62. Indication of Lap was stage I and II, stage III indicated Open resection. According to our clinical path, soft diet should be started on Day3, discharge date should be Day7. Results: Mean age was Lap:64.5, Open:65.9, Male/Female was Lap:62/24, Open:35/27, Cancer location/iColon/Rectum/j was Lap:66/20, Open:48/14, cStage/iI/II/III/jwas Lap:28/58/0, Open:4/22/36, Mean operating time was Lap:207min./iColon192, Rectum 260/j, Open:175/iColon170, Rectum191/j, Blood loss count was Lap:45g/iColon42,Rectum56/j, Open:182g/iColon 163, Rectum 250/j. Median diet start was Day3 in both Lap and Open, Median /mean discharge date was Lap:7 /8.5, Open:9 /12.8. Factors of late discharge were Open Male: 15.3Days, Lap Rectum: 12.4, Open Rectum: 15.2, Open Long Op: 14.5, Open much Blood Loss: 17.4. Postoperative complications were Lap: 12.3%, Open: 29.0%. Details were in turn of Lap: Open, intestinal obstraction 2.3%: 6.5%, Anastomotic leak 4.7%: 8.0%, wound infection 2.3%:8.0%, etc. Conclusion: Laparoscopic resection resulted in good outcome of discharge. Frequency of postoperative complication may cause this outcome.

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LAPAROSCOPIC LYMPHATIC MAPPING AND SENTINEL LYMPHNODE DETECTION IN COLON CANCER. TECHNICAL ASPECTS AND PRELIMINARY RESULTS P.P. Bianchi, C. Ceriani, V. Panizzo, M. Rottoli, M. Montorsi Istituto Clinico Humanitas IRCCS, MILAN, Italy

LAPAROSCOPIC VS. OPEN SURGERY FOR ACUTE ADHESIVE SMALL BOWEL OBSTRUCTION E.M. McDermott, M. Khaikin, N. Schneidereit, S. Cera, D. Sands, E. Weiss, J. Nogueras, S. Wexner Cleveland Clinic Florida, WESTON, United States of America

Introduction: The application of sentinel lymphnode (SL) technique to colon cancer is a method to improve staging still under evaluation. Aim of this study is to evaluate the feasibilty and accuracy of lymphnode mapping in laparoscopic resections of the colon. Material and Methods: Twenty patients were enrolled from March 2004 to July 2005 in the study. The ﬁrst ﬁve cases were excluded because the learning curve. Polyps endoscopically removed were tattooed or clipped before surgery to permit laparoscopical localization of the tumor site. Before surgical dissection 2 ml of Patent Blu V dye were injected subserosally in four sites around the tumor with a 22 gauge spinal needle percutaneously. The needle was extracted with mild aspiration and the site of injection was carefully protected to avoid dye diﬀusion. The lymphnodes coloured in 2 to 5 minutes were tagged as sentinel with metallic clips and the operation was completed with standardized resection. All sentinel lymphnodes were examined by hematoxylin and eosin (H&E) staining with multiple sectioning of 3–5 micron slices and 200 microns interval. Immunonhistochemical (IHC) evaluation with CK-antibodies was applied only to doubtful cases. Results: Of the ﬁfteen patients studied ten neoplasms were located in the left and ﬁve in the right colon. Lymphatic mapping caused no complications and added 10 to 15 minutes to the overall operative time. Detection rate of SL was 100%, in an obese patient was performed an ex vivo technique, with subserosal injection of dye on the specimen after removal. The total number of lymphnode examined was 322 (range: 8–36, average 21). SL was 34 (average 2.3). Of the 15 patients four (26.6%) had lymphnode metastasis. In 3 of these 4 patients both SL and non-SL detected metastasis, the one false negative case (25%) was registered in a large cecal tumor staged as IIIc (T3N2). In one patient SL was the only positive lymphnode. One doubtful case, evaluated with IHC, revealed isolated tumor cells (ITC) and was classiﬁed pT3N0(i+). Accuracy, Sensitivity and Negative Predictive Value (NPV) were respectively 93.3%, 75% and 91.6% Conclusions. Laparoscopic lymphatic mapping in colon surgery with blue dye is a feasible and relative simple technique. The detection rate of SL reaches 100%, performing a salvage Ôex vivoÕ technique. The high false negative rate (25%), in this preliminary cases, may be reduced with selection of patients and exclusion of III stages.

Background: The aim of this study was to compare laparoscopy for acute adhesive small bowel obstruction (AASBO) to open surgery. Methods: Data regarding demographic and clinical characteristics, surgical details, and postoperative course were retrospectively reviewed over a period of 6 years. Results: 31 patients underwent laparoscopy for AASBO. They were compared to 31 consecutive patients who underwent laparotomy for AASBO. There were no signiﬁcant diﬀerences in age, ASA score, BMI, number of previous operations, episodes of small bowel obstruction, and duration of symptoms before admission. The procedure was successfully completed by laparoscopy in 17 patients (55%), whereas in 10 patients (32%) the procedure was converted to laparotomy, and in 4 patients (13%) the procedure was completed as a laparoscopically assisted case to facilitate segmental resection. The median operative time was 78 minutes in the laparoscopic group and 70 minutes in the laparotomy group. The overall morbidity rates were 16% and 48%, respectively (p=0.007). There were no anastomotic leaks, missed injuries, or intraabdominal abscesses in the laparoscopy group, compared to one mortality and ﬁve septic complications in the laparotomy group. Median hospital stay was 7 days and time to ﬁrst bowel movement was 3 days in the laparoscopic group, compared to 13 and 6 days in the laparotomy group (p=0.0007 and p=0.001), respectively. These diﬀerences were also found between laparoscopic assisted and converted groups compared to the laparoscopic group (p=0.01 and 0.02, respectively). However, there were no diﬀerences in length of stay and time to ﬁrst bowel movement between the laparoscopic assisted and converted groups (p=0.6 and 0.53, respectively), or between assisted and converted subgroups and laparotomy group (p=0.15 and 0.46, respectively). Conclusions: Laparoscopy for AASBO is feasible in half of the patients with the advantages of a shorter hospital stay, faster recovery of bowel function, and decreased morbidity. The outcome of laparoscopic assisted and converted surgery do not signiﬁcantly diﬀer from laparotomy.

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MINIMALLY INVASIVE COLORECTAL SURGERY: OUR EXPERIENCE E.M. McDermott, D. Ruiz, D. Vivas, D. Sands, E. Weiss, J. Nogueras, S. Wexner Cleveland Clinic Florida, WESTON, United States of America

THERE IS A STEPWISE INCREASE IN POSTOPERATIVE PLASMA VEGF ELEVATIONS FROM LAPAROSCOPIC-ASSISTED TO HAND-ASSISTED TO OPEN COLORECTAL RESECTIONS

Introduction: Since the introduction of laparoscopic surgery in early 1990s, many more complex procedures have been attempted. As techniques of laparoscopic colorectal surgery have improved and better selection criteria deﬁned, more complicated cases have been considered. The aim of the study is to describe our institutional experience since 1991. Methods: After Institutional Review Board approval, a review of the prospective database for patients who underwent laparoscopic surgery between January 1991 and December 2004 was undertaken. Results: 773 patients of a mean age of 55.9 (12–93) years (395 female and 378 male) were included. More than 25% of the indications were for malignancy, approximately 20% for diverticular disease and 20% for inﬂammatory bowel disease. The procedures included: right colectomy in 140, sigmoid colectomy in 120, stoma creation in 96, ileocolic resections in 64, total colectomy in 48, left colectomy in 30, small bowel resection in 20, Hartmanns procedure in 17, and Hartmanns reversal in 18 patients. Length of surgery was 167.0+71.2 (10–365) minutes. The time to resume a normal diet was 4.1+2.6 (1–20) days, time to ﬁrst bowel movement 3.6+2.0 (1–15) days and the length of hospital stay was 6.5+4.5 (1–60) days. There were 58 (7.5%) intraoperative and 183 (23.6%) postoperative complications and no mortality. Conclusions: Laparoscopic colorectal surgery can be safely undertaken for a wide variety of indications with a high expectation of success.

Intro: Elevated plasma VEGF levels may stimulate tumor growth. We previously showed that open colectomy (OC) and, to a signiﬁcantly lesser extent, laparoscopicassisted colorectal (LC) resection are associated with signiﬁcantly increased plasma VEGF levels after surgery and that the VEGF increase correlated with incision length. This studys purpose was to assess VEGF levels in patients undergoing hand-assisted colorectal resection for cancer (HAL) and to compare these results to those of LC and OC cancer patients. Methods: HAL cancer patients were assessed. Plasma samples were obtained preoperatively and on postoperative days (POD) 1 and 3. Plasma VEGF levels were determined using an Enzyme Linked Immunoabsorbant Assay (ELISA). The VEGF levels from the HAL group were compared to previously determined VEGF levels from patients undergoing laparoscopic assisted or open colectomy for cancer. Wilcoxons matched pairs test and the Mann Whitney U Test were used where appropriate to determine statistical diﬀerences and a p value of less than 0.05 was considered significant. Results: A total of 19 HALs patients were studied. The mean incision length was 9.3 cm (Range: 7cm–15cm). Preoperatively, the mean VEGF level was 147.3pg/ml, on POD1 it was 212.6pg/ml, and on POD3 it was 328.6pg/ml. The mean POD3 level was signiﬁcantly higher than the preop level (p=0.0067); there was no signiﬁcant diﬀerence between POD1 and the preop VEGF levels. When the HALs results were compared to VEGF levels after LC for cancer (mean incision size= 5.1cm), signiﬁcantly higher VEGF levels were noted in HAL patients on both POD#1 and POD#3 (POD#1: LC=121 pg/ml, p=0.0025; POD#3 LC=211.pg/ml, p=0.0363). When the HALs results were compared to the OC results (mean incision = 19.9cm) no signiﬁcant diﬀerence was found on either POD#1 (POD#1: OC=175.6 pg/ml, p=NS) or POD#3 (OC=358.9 pg/ml, p=NS). Conclusion: HALs postoperative VEGF levels and mean incision length fall between the results of LC and OC. The HALs groups postop results were signiﬁcantly higher than the LC results yet not signiﬁcantly diﬀerent than the OC groups. Thus far, the clinical signiﬁcance of elevated VEGF levels postoperatively has not been established, thus it is not possible to state that the diﬀerences in postop VEGF levels between the 3 surgical methods are meaningful. In theory, VEGF elevations may be detrimental for cancer patients with retained tumor cells after surgery.

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LAPAROSCOPIC VERSUS OPEN RIGHT HEMICOLECTOMY: PATIENT OUTCOMES AND IMPACT ON HOSPITAL CHARGES E.M. McDermott, N. Schneidereit, M. Khaikin, S. Cera, D. Sands, E. Weiss, J. Nogueras, S. Wexner Cleveland Clinic Florida, WESTON, United States of America

DOES INCISION LENGTH TO BMI RATIO BETTER PREDICT CLINICAL OUTCOMES IN HIGH BMI PTS AFTER LAP-ASSISTED COLECTOMY? - A NOVEL DEFINITION OF CONVERSION

Background: The aim of this study was to compare perioperative outcomes and hospital charges for laparoscopic and open right hemicolectomy performed for colonic neoplasia. Materials and Methods: After Institutional Review Board approval, data regarding clinical outcomes as well as itemized operative charges and total hospital charges from the time of admission to the time of discharge were reviewed from January 2002 to September 2005. Results: The data were analyzed in an intent to treat fashion and consisted of two groups; there were 49 patients who underwent laparoscopically assisted right hemicolectomy (LARHC), including 8 patients in whom the procedure was converted to a laparotomy. This group was compared to 26 consecutive patients who underwent open right hemicolectomy (ORHC). There were no signiﬁcant diﬀerences in age or BMI however the ORHC group had a signiﬁcantly higher ASA at 2.6 in comparison to the LARHC group at 2.3 (p=0.02). The mean operative time was signiﬁcantly longer in the LARHC group at 170 minutes in comparison to the ORHC group at 123 minutes (p=0.0005). However, mean postoperative hospital stay was signiﬁcantly shorter for the LARHC group at 5.9 days in comparison to the ORHC at 9.6 days (p=0.03). There were no anastomotic leaks, missed injuries or intraabdominal abscesses in the LARHC group, however 20% of patients did have a postoperative complication, most commonly a prolonged ileus. In the ORHC group 28% of patients had a postoperative complication, most commonly pneumonia, and prolonged ileus. Mean operative charges were signiﬁcantly higher in the LARHC group at $17, 858 in comparison to the ORHC group at $13, 944 (p=0.0002). While not statistically signiﬁcant there was a trend towards decreased overall mean hospital charges in the LARHC group versus the ORHC group at $34, 612 and $44,093, respectively (p=0.13). Conclusions: LARHC is safe and despite a longer operative time, is associated with shorter hospital stays in comparison to ORHC. LARHC is also associated with higher operating room charges, however there is a trend towards overall decreased total hospital charges compared to ORHC.

A. Belizon, E. Balik, I. Kirman, P.K. Horst, S. Jain, V. Cekic, V. Moon, R.L. Whelan Columbia University Medical Center, NEW YORK, United States of America

A. Belizon, P.K. Horst, E. Balik, V. Moon, V. Cekic, T. Azarani, D. Feingold, T. Arnell, R.L. Whelan Columbia University Medical Center, NEW YORK, United States of America What constitutes a conversion for laparoscopic-assisted colectomy (LC) is unclear. Where cited, the most commonly used criteria is incision length (IL). To better compare abdominal wall trauma among patients (pts) of varying body habitus the inﬂuence of BMI should be considered to avoid misclassiﬁcation of high BMI pts who require larger incisions for extraction. This studys purpose was to determine if the IL/BMI ratio more accurately predicts clinical LC outcome in high BMI pts when compared to IL criteria alone. Methods: A retrospective review of 216 LC pts, in whom BMI data was available, who had LC between 2003 and 2005, was carried out. Two conversion criteria were assessed; IL alone and the IL/BMI score (IL/BMI X 100). Conversion was deﬁned as IL greater than 7 cm or by an IL/BMI score greater than 30. The mean IL, length of stay (LOS), major morbidity, and overall morbidity was determined. Results: Using the 7 cm IL criteria, 62 pts (29%) were converted and 71% completed; the average LOS was 9.3 and 5.9 days (p<0.0001), the rate of major morbidity was 15.2% and 6.3% (p=0.0014), and the overall morbidity was 45.8% and 16.6% (p<;0.0001), respectively. When the IL/BMI criteria was applied, a total of 19% of the pts were considered converted and 81% completed; the average LOS was 10.3 and 6.1 days (p<0.0001); the rate of major morbidity was 17.1% and 6.9% (p=0.0021) while the overall morbidity was 53.7% and 17.7% (p<0.0001), respectively. Eighteen pts judged to be converted by the IL method (29% of all IL conversions) were considered completed via the IL/BMI criteria (mean BMI 31); their average LOS (7.5), major (11.1%) and overall morbidity (27.8%) rates were not signiﬁcantly diﬀerent from the results of completed pts (incision < 7cm). Nine of the 18 had a BMI greater than 30 (mean BMI = 40.5) and mean incision size of 9cm. For this high BMI group, the rate of major morbidity (0) and the overall morbidity (22.2%) were signiﬁcantly lower than the results of the IL converted group (p<0.0001), however, no LOS diﬀerence was noted. Conclusion: Using this IL/BMI criteria, 1/3 of IL conversions were considered completed. Their outcome results were more similar to the IL completed group (<7cm) than to the converted pts(>7cm); half had a very high BMI and big incision yet had low morbidity rates. A standardized conversion criteria that considers BMI and IL more fairly assesses high BMI pts who, using strict IL criteria, are viewed as converted.

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IMPACT OF AN EXPERT LAPAROSCOPIC SURGEON ON THE INSTITUTIONAL OUTCOMES OF LAPAROSCOPIC COLECTOMY FOR CANCER A. Pigazzi, I.B. Paz, J.D. Ellenhorn City of Hope National Cancer Center, DUARTE, United States of America

LAPAROSCOPIC COLON RESECTION FOR CANCER IN THE ELDERLY. STRICT AVOIDANCE OF COMPLICATIONS WARRANTS GOOD RESULTS J-P. Gagne´, A. Bouchard, R.C. Gre´goire Centre Hospitalier Univ. de Que´bec, QUE´BEC, Canada

Introduction: Laparoscopic colectomy is a diﬃcult operation with long learning curves and conversion rates inversely proportional to the surgeons experience. Methods to help train surgeons outside of fellowship programs have been poorly analyzed. This study was undertaken to assess the impact of an experienced laparoscopic surgeon on the outcome of laparoscopic assisted colectomy for cancer in a single institution Methods: In August 2004 a fellowship-trained laparoscopic surgeon with extensive experience in laparoscopic colectomy joined the surgical staﬀ of an NCI-designated Cancer Center. This surgeon served as a laparoscopic colectomy preceptor for 6 surgical oncologists with no formal training in laparoscopic surgery. Clinical and pathologic data from all attempted laparoscopic colectomies for primary colon cancer after the recruitment of the preceptor was compared with the outcome of laparoscopic colectomies prior to the preceptors arrival. Results: In twelve months following the arrival of the preceptor, 28/28 (100 percent) of eligible colectomies were approached laparoscopically, compared with 28/47 (59 percent) in the 20 months before (P <0.001), while the rate of conversion decreased from 42 to 15 percent (P=0.04). The preceptor was present in over 70 percent of all laparoscopic colectomies attempted and the absence of the preceptor in the operating room increased signiﬁcantly the chances of conversion (P=0.003). The overall complication rate and number of lymph node harvested were not aﬀected by the presence of the preceptor in the department. Converted cases had greater blood loss (P<0.001) and longer hospital stay (P0.05) than non-converted ones. Conclusions: Recruitment of appropriate utilization of a properly trained laparoscopic surgeon can help institutions introduce laparoscopic-assisted colectomy for cancer.

Objective: The purpose of this study was to compare the outcome of laparoscopic colon resection (LCR) for cancer between patients above and below 70 years of age. Methods: This is a retrospective study of consecutive LCR for cancer done by a single surgeon at one academic health sciences center over a decade. In the absence of any contraindication related to the tumor itself, all patients were oﬀered a laparoscopic resection. Charts and billing data were reviewed. Data extracted included demographics, American Society of Anesthesiology (ASA) classiﬁcation, complications and 30-day mortality. The patients were divided in two: Group A, Above 70 years-old and Group B, Below 70 years-old. Results: Over a twelve-year period (1993–2005), 165 cases, divided equally between the two groups, were done. Median age was 77 (70–92) for Group A and 63 (45–69) for Group B. ASA Classes 1, 2 and 3 were respectively divided as follows: Group A, 6%, 69%, 23%; Group B, 31%, 60%, 6%. The complication rate for the whole group was 31.5% (Group A: 46%, Group B: 17%). Median hospital stay was 7 days for Group A and 4 days for Group B. For uncomplicated cases, the median hospital stay was similar (4 days) in both groups. However, in the occurrence of any complication, it increased to 13 days in Group A and to 6 days in Group B. There were 3 post-operative deaths in Group A and 1 in Group B. Conclusion: Our study suggests that the complication rate of LCR for cancer is higher in the elderly. But, in the absence of any complication, outcomes of LCR for cancer in this subset of patients might be similar to those of younger patients. This ﬁnding should prompt surgeons to apply extra caution regarding the operative and hospital courses of elderly patients undergoing LCR. This might also suggest that aged patients are not ideal candidates for surgeons into their learning curve of LCR.

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OUTCOME OF ROBOTIC AND LAPAROSCOPIC-ASSISTED TOTAL MESORECTAL EXCISION A. Pigazzi, J.D. Ellenhorn, I.B. Paz City of Hope National Cancer Center, DUARTE, United States of America

LAPAROSCOPIC SURGERY FOR COLORECTAL CANCER: EXPERIENCE IN 500 SUCCESSFUL CASES H-M. Wang, J-B. Chen, F-F. Chiang, C-C. Chen Taichung Veterans General Hospital, TAICHUNG, Taiwan

Introduction: Robotic operating systems are best suited for surgery in small operating ﬁelds or if great precision in the dissection is required. This study describes our experience with robotic-assisted total mesorectal excision for rectal cancer and compares it with conventional laparoscopic-assisted surgery. Methods: From September 2004, all patients with primary, non metastatic mid and low rectal cancer in our institution were assigned to undergo either robotic or laparoscopic-assisted proctectomy with total mesorectal excision. Clinical and pathologic data from these patients were entered in a prospective database. Results: Nine patients underwent laparoscopic and 11 underwent roboticassisted operations in a one-year period. There was one conversion to open surgery in the laparoscopic group. Mean number of lymph nodes resected was 16 in the robotic and 15.6 in the laparoscopic group. No signiﬁcant diﬀerences were observed in blood loss, operative time, length of stay, and margins (Table). The incidence of complications was similar in the two groups. There were no mortalities. The subjective operative experience for the surgeon was deemed superior during robotic operations Conclusions: Robotic and laparoscopic-assisted total mesorectal excision are safe and feasible and have similar postoperative outcomes and oncologic results. Because of greater comfort for the surgeon, robotic surgery may have a unique niche in the minimally invasive treatment of rectal cancer.

Distal margin OR Time Blood loss Hospital stay

Laparoscopy

Robotic

P-value

4.6 cm 4.5 hrs 270 ml 4.4 d

4.4 cm 5.4 hrs 155 ml 4.7 d

NS NS NS NS

Aim: Controversial issues surrounding the use of laparoscopic surgery (LAP) for colorectal cancer include high conversion / high complication rate / port site recurrence and poor outcome than open surgery (OPEN) previously reported. The purpose of this single center, prospective study was to assess the oncological outcomes achieved after curative LAP for cancer. Material & Methods: We enrolled 514 consecutive patients with colorectal cancer undergoing LAP between July 1998 and May 2004. The data were including patient proﬁle / operative complication / pathology and oncological outcome. We compared the oncologic outcomes achieved using LAP and OPEN during period from July 1998 to June 2001. Patient followup ranged from 36 to 72 months. The follow-up rate was 95%. We recorded the ﬁnal status of all cancer patients as of June 30, 2004. Results: We attempted to perform LAP in 514 patients and 14 patients (2.7%) needed conversion to open surgery. The LAP was successfully in 500 patients with 308 males and 192 females, age from 26 to 96 years, av. 64.2 years. Of the 500 LAP patients, 85 (17.0%) experienced complications & 42 (8.4%) patients had major complications that required further surgery. Major complication of LAP for rectal cancer was higher than colon cancer: 11.4% (34/298) vs. 4.0% (8/202). There were three (0.6%) operative mortality due to sepsis, CVA and hepatic failure. We examined the oncologic results achieved in 185 patients who had curative LAP between July 1998 and June 2001. The 3Y-DFS between LAP and OPEN were no diﬀerence in stage I (94.2% vs. 93.9%), stage II (79.7% vs. 73.4%), stage III (57.2% vs. 56.7%) and over-all (75.8% vs. 70.3%). There were two (0.4%) port site recurrence found in LAP patients. Conclusion: The LAP for cancer was feasible for the acceptable morbidity rate & operation time. The oncological results are encouraging and equal to OPEN.

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DOES INCISION SIZE PREDICT LAPAROSCOPIC COLECTOMY OUTCOMES?

ENERGY SOURCES FOR LAPAROSCOPIC COLECTOMY: A PROSPECTIVE RANDOMICED COMPARISON BETWEEN CONVENTIONAL ELECTRO SURGERY, BIPOLAR COMPUTER-CONTROLLED ELECTROSURGERY AND ULTRASONIC DISSECTION

E. Balik1, V.A. Moon2, A. Belizon1, D. Feingold1, T. Arnell1, K.A. Forde1, V. Cekic1, P. Horst1, T. Arazani1, R. Whelan1 1 Columbia University Medical Center, NEW YORK, United States of America 2 Staten Island University Hospital, NEW YORK, United States of America Intro: Conversion to open methods is necessary in some undergoing laparoscopic-assisted colectomy (LC). Conversion rates range from 5 to 26%. In most series, conversion is associated with higher complication rates. There is no consensus about what constitutes a conversion and, thus, it is diﬃcult to compare series. This studys purpose was to determine whether conversion as deﬁned by incision length alone is useful in predicting the outcome of patients undergoing LC. Although this is an arbitrary method it can be easily applied and, if widely utilized, would permit straight forward comparison between series. Methods: A retrospective review of patients that underwent LC (no hand assist or hybrid procedures) between 1992–2005 at a single hospital was carried out. Data concerning demographics, indication, type of operation, largest incision length, complications, and length of stay (LOS) were collected. A conversion was deﬁned as any case in which an incision larger than 7 cm was made. Results: A total of 637 (M 320:F 317) patients underwent LC. The indications for surgery were: cancer 301 (47%), benign neoplasm 174 (27.3%), diverticular disease 106 (16.6%), and other indications 56 (8.8%). There were a total of 131 conversions (20.6%) as deﬁned by the above criteria. The converted group (CG) and non-converted group (NCG) were compared in terms of median incision length (12 vs. 5cm, respectively, p<0.001), median blood loss (500 versus 250cc, p<0.001), and median LOS (7 versus 5 days, p<;0.001). There were 7 (5%) anastomotic leaks in the CG, compared with 7 leaks (1%) in the NCG (p value <;0.01), 11 (8%) wound infections in the CG compared with 12 (2%) in the NCG (p value<0.003) and 21 patients (16%) in the CG had prolonged ileus versus 45 (9%) in the NCG (p value<0.01). There was one post-operative death in each group. Conclusion: The greater than 7cm incision length conversion criteria identiﬁed 2 signiﬁcantly diﬀerent groups. Conversion was associated with signiﬁcantly higher morbidity and greater length of stay when compared to completed LC cases. The use of a strict length criteria is arbitrary and may not be ideal for high BMI patients and those with bulky pathology. However, until a better, more comprehensive, conversion criteria is devised, the use of a strict incision length criteria to deﬁne conversions is recommended.

E.M. Targarona, C. Balague, J. Marin, R. Beringoade, C. Martinez, J. Garriga, M. Trias Hopital Sant Pau, BARCELONA, Spain Success of lap surgery is linked to technical advances in instrumentation. Evolution of energy sources permits design of more eﬀective hemostatic devices, as alternative to electrosurgery. Ultrasonic energy avoids the use of electricity, with eﬀective control of medium size vessels and cutting ability. Bipolar computercontrolled technology avoids disadvantages of electricity and is able to control large vessels. The supposed advantage is to facilitate surgical performance with reduction of blood loss and op. time. However, they increase the cost of lap procedures, and evidence-based data is scarce. Aim: to compare the eﬃcacy of 3 diﬀerent energy sources on left colectomy. M & M: 38 patients requiring left colon resection were randomized. Inclusion criteria: lesion above 15 cm of the anus and below the splenic ﬂexure. Colon resection was done with a standard 4 trocars technique. GI, n:11, Electro surgery: all dissection performed with electro surgery and vessels controlled with clips. GII, n: 12, Ultrasonic:.5 mm ultrasonic shears used for dissection and vascular section. Large vessels controlled with endostapler. GIII, n:15, Bipolar electro surgery computer-controlled: All vascular and mesocolon section done with a 10 mm device. Age, sex, BMI, Op.t, conversion, blood loss, morbidity, hosp. stay and cost were recorded. An intention to treat principle was followed. Results: Conclusion: High energy power sources reduce op. time and blood loss, and it may be considered cost-eﬀective when using left colectomy as a model.

Op. time Blood loss Conversion Stay Cost (?)

I. Electrosurg.

II. Ultrasonic

III. Bipolar

180(90–210) 180(90–210) 3/11 7(6–32) 2995

120(65–220)* 100(0–150)* 0/12 8(4–18) 2928

110(70–210)* 100(0–450) 1/15 6(6–16) 2664

*: p<0.01.

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ENDOSCOPIC POSTERIOR MESORECTAL RESECTION: A NEW APPROACH TO TREATMENT OF T1-CARCINOMAS OF THE LOWER THIRD OF THE RECTUM I. Tarantino1, B.P. Mu¨lle-Stich2, M. Zu¨nd1, J. Lange1, A. Zerz1 1 Kantonsspital St. Gallen, ST. GALLEN, Switzerland 2 Ruprecht-Karls-University, HEIDELBERG, Germany

MINIMALLY INVASIVE APPROACHES TO COLORECTAL CANCER J-I. Tanaka, F. Ishida, S. Endo, S. Kudo Showa University Northern Yokohama Hosp., YOKOYAMA, Japan

Background: Transanal excision (TE) of T1 carcinomas of the lower third of the rectum (T1-clr) has become an established procedure although a not negligible risk of loco-regional recurrence has been reported. This potentially increased risk is tolerated due to the known high morbidity and mortality rates after transabdominal rectal resection. Dorsoposterior extraperitoneal pelviscopy makes it possible to remove the relevant lymphatic ﬁeld of the lower third of the rectum from perineal, in the sense of a rectum-sparing endoscopic posterior mesorectal resection (EPMR). Methods: A TE was performed in patients with a tumour of the lower third of the rectum endosonographically conﬁned to the mucosa or submucosa and no evidence of malignant lymph nodes. After completion of the usual staging we oﬀered patients with histological conﬁrmation of a T1-clr, as an alternative to simple clinical controls every three month, an EPMR. This second intervention was performed four to six weeks after the TE. Results: We operated on thirteen patients with T1-clr by TE in combination with EPMR as a two stage procedure. It was possible to perform a complete excision of the primary and to resect the posterior part of the mesorectum in all cases. There was no intraoperative bleeding and the operating time ranged from 45 to 125 minutes. In two cases an intraoperative rectal perforation occurred with no prostoperative relevance. Postoperative morbidity consisted of two transient neurological complications and a pulmonary embolism. There was no perioperative mortality. Histological analysis revealed a median of 8 (range, 4–20) lymph nodes within the resected part of the mesorectum. Two patients diagnosed with lymph node metastases received an adjuvant radiochemotherapy. After a median follow-up of 48 (range, 4–78) months there was no evidence for locoregional recurrence. In one patient with negative lymph nodes but vessel inﬁltration liver metastasis was detected 8 month postoperatively. Conclusion: In conclusion the EPMR is a safe and eﬀective option in treatment of T1-clr after TE. It has to be considered whether EPMR in combination with TE allows for local radicality and an adequate tumor staging in T1-clr, in terms of a better directed therapy planning compared to TE alone.

We report minimally invasive approaches to colorectal cancer (CRC) using both endoluminal treatments and laparoscopic surgery. According to our clinicopathological analysis of 23,204 patients with CRC, no lymph node metastasis was found in early stage of CRC with cancer penetration up to one third of submucosal layer, meanwhile lymph node metastasis was observed in 37 out of 341 (10.9%) with penetration beyond the one third of submucosal (sm) layer in early stage of CRC. While endoluminal treatments such as endoscopic polymectomy (EP), mucosal resection (EMR) or submucosal dissection (ESD) can be applied to early stage of CRC without lymph node metastasis, surgical resection is needed for CRC patients with possible lymph node metastasis. Forty patients out of 509 who underwent endoluminal treatment were added surgical resection due to sm massive inﬁltration and 5 patients out of 40 (12.5%) suﬀered from lymph node metastasis histologically. We have experienced 311 patients who underwent laparoscopic colorectal resection (LAC) out of 507 patients with advanced CRC for the last 4 years. LAC for advanced CRC was comparable to open surgery in terms of operation time and morbidity. Our strategy of endoluminal treatments in combination with LAC as minimally invasive approach can be clinically feasible.

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LAPAROSCOPIC RESECTION FOR RECTAL CANCER AFTER PREOPERATIVE CHEMORADIATION PERIOPERATIVE RESULTS M. Skrovina, S. Czudek, J. Bartos, L. Adamcik, R. Soumarova J.G. Mendel Oncological Center, NOVY JICIN, Czech Republic

NEW SUTURELESS TECHNIQUE OF ILEOSTOMY AND COLOSTOMY M.V. Phadke WAKEMED /Aﬃliated with UNC Chapel Hill, RALEIGH, NC, United States of America

Aim: Authors present results of laparoscopic resection for rectal cancer. In prospective study ﬁrst 72 patients operated between January 2005 and December 2005 at Department of Oncological Surgery J.G. Mendel Oncological Center Novy Jicin. Method: In study they compare groups of patients operated curativ (A1), operated curativ after preoperative chemoradiation (A2) and patients group after palliative resection (B). There were not patients with open resection of rectal cancer, with early conversion of laparoscopic procedure and unresective procedure included. Results: 31 patients with mean age 66,6 were cathegorised into the group A1, 28 patients with mean age 61,6 into the group A2 and 13 pacients with mean age 59,5 into the group B. In group A1 there was perfomed low anterior resection 25 times with mean lymph nodes 23,4 in specimen. Anastomotic leakage occured 4 times. There were 6 patients with abdominoperineal resection with mean lymph nodes 26,7 in specimen. In group A2 there was perfomed low anterior resection of rectosigma 13 times with mean lymph nodes 10,8 in specimen and 15 times abdominoperineal resection with mean lymph nodes 14,0 in specimen. There was anastomotic leakage twice. In group B there was perfomed low anterior resection 8 times (mean lymph nodes 23,4) and 5 times abdominoperineal resection (mean lymph nodes 30,0). There were not serious complications. In group A2 was higher number of conversions (35,7%) compared to A1 (6,5%) and B (15,4%). So in gorup A2 was lower number of lymph nodes. Duration of surgery and postoperative hospital stay was not diﬀerent. Conclusion: There was not higher percentage of complications, longer operation time and postoperative hospital stay in group A2. According to NCCN there were not worse perioperative results in our study.

Introduction: The objective is to prevent infection and subsequent complications of Ileostomy and Colostomy. The study is based on the principle of angiogenesis and delayed-primary wound closure. Methods & Procedures: The procedure was discovered in 1986 by serendipity during a Brooke Ileostomy. It is applicable to both, Ileostomy and Colostomy. It is founded on established scientiﬁc principles. The stapled stoma is ﬁxed to the opening in rectus sheath. The stoma is covered with an appliance having a transparent pouch. The intentional obstruction is continued during the period of paralytic ileus. Angiogenesis develops on the surface of serosa. The bulging stoma conﬁrms return of peristalsis. Stoma is opened with electrocautery as a bedside procedure. The mucosal cuﬀ protrudes, everts and advances with each peristaltic wave. The cuﬀ ÔgraftsÕ itself on the bed of angiogenesis over a single layer of serosa. The margin of the cuﬀ fuses with the circumference of the opening in dermis. The stoma matures naturally and on its own. Absence of sutures reduced the tissue trauma and foreign body reaction resulting in a better wound healing. This new procedure was named DELAYED-PRIMARY SELFMATURATION (DPSM). Results: 17 colostomies and 3 ileostomies were performed using DPSM. Infection in the stomal and/or main wound and subsequent complications were prevented. Conclusions: DPSM is scientiﬁc and easier to do than a conventional stoma and is recommended for all types of stomas.

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CONVERSION RATES FOLLOWING LAPAROSCOPIC COLORECTAL SURGERY. A 13 YEARS EXPERIENCE D. Vivas, D. Ruiz, A. Pikarsky, E.G. Weiss, J.J. Nogueras, D.R. Sands, S. Cera, S.D. Wexner Cleveland Clinic Florida, WESTON, United States of America

LAPAROSCOPIC TOTALLY HANDSEWN ANASTOMOSIS IN COLORECTAL SURGERY J. Himpens, G. Dapri, D. Lipski, G.B. Cadie`re Saint-Pierre University Hospital, BRUSSELS, Belgium

Introduction: The aim of this study was to assess the characteristics of conversion following segmental colon resections during a 13-year period. Method: All consecutive patients who underwent laparoscopic segmental resections between January 1992 and December 2004 were assessed. Patients in whom the procedure was converted to laparotomy were identiﬁed. Parameters reviewed included age, gender, diagnosis, procedure performed, operative time, intraoperative and postoperative complications, indications for conversion and length of hospital stay. Patients were divided into three groups: Group I patients operated upon between January 1992 and December 1995, Group II patients between January 1996 and December 1999, and Group III patients from January 2000 to December 2004. Results: Between January 1992 and December 2004, 700 patients underwent laparoscopic colorectal surgery from which 516 underwent segmental colon resections (73.9%). Group I included 90 patients [mean age 58 (range 16–87) years], Group II included 135 patients [mean age 65 (range 21–89) years] and Group III included 291 patients [mean age 59 (range 18–93) years]. There were 16 patients (17.7%) in Group I, 23 patients (17.0%) in Group II, and 67 patients (22.9%) in Group III who underwent a conversion to laparotomy, with a statistically signiﬁcant diﬀerence in gender among the three groups (p=0.02). Similarly, there was a signiﬁcant difference among the three groups relative to previous history of laparotomy (p<0.005). No diﬀerence was observed among groups in terms of conversion rate, age, or surgical indications. Reasons for conversion in these groups included severe adhesions, bleeding, unclear anatomy, specimen size, and unidentiﬁed urether with a signiﬁcant increase in patients who were converted due to severe adhesions in the latter group (p=0.01). Mean operative time was 191, 243 and 211 minutes in Groups I, II and III, respectively (p=NS). Length of hospitalization was longer in Group I (10.6 days), compared to Groups II and III (7.2 days) (p=0.005). There were fewer postoperative complications in Group III (p=0.03); there was no mortality in this series. Conclusion: The feasibility of laparoscopic colorectal segmental resections has been well established. Following an initial learning curve, a plateau was reached and with a large volume of cases the conversion rates and indication for conversion remained stable while hospital stay and post operative morbidity decreased.

Background: Advanced surgical laparoscopic procedures invite surgeons to perform totally laparoscopic handsewn anastomosis (TLHA), considering late complications and cost due to stapling. We report our early experience to perform TLHA in colorectal surgery. Methods: Between October 28th 2004 and January 28th 2006, 19 patients (10M, 9F) were submitted to TLHA. Median age was 58,2 years (33–82). At pre-operative workup the diagnosis was: 3 right colic complicated inﬂammatory diseases, 4 right colic cancers, 1 left colic ischemia, 5 left colic diverticulitis, 1 left colic cancer, 1 left sigmoid cancer, 1 constipation after bariatric procedure, 1 sigmoidal volvulus, 1 rectal prolapsus and 1 rectal cancer. Diﬀerent types of TLHA were performed: ileocolic (3end-to-side, 3side-to-side, 2end-to-end) (movie), colocolic (2side-to-side, 1side-to-end) (movie), colorectal (6end-to-end, 1side-to-side) (movie), ileo-rectal (1endto-end). Results: Average total operative time was 119,9 minutes (60–195). Noperoperative morbidity was registered. Early morbidity was 15,7% (3/19): a leak at the duodenoileostomy at 3rd day, probably due to dissection in patient previously submitted to a bariatric procedure, a bladder leak after left hemicolectomy for cancer at 6th day, a rectovaginal ﬁstula after total colectomy for diverticulitis at 12th day. Median hospital stay was 9 days (5–66). During a mean follow-up of 5,7 months (1–16), one patient presented after 30 days a right subfrenic abscess treated medically and nonanastomotic stenosis were achieved. Conclusions: TLHA in colorectal surgery are feasible and could be considered during procedure diﬃcult to treat by laparoscopic mechanical anastomosis. The relative morbidity must be considered. Safety is highly dependent on surgeon experience and speciﬁc training.

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QUALITY OF LIFE AFTER TRANSANAL ENDOSCOPIC MICROSURGERY AND TOTAL MESORECTAL EXCISION IN EARLY RECTAL CANCER P.G. Doornebosch1, R.A.E.M. Tollenaar2, M.P. Gosselink3, L.P. Stassen4, C.M. Dijkhuis5, W.R. Schouten6, E.J.R. De Graaf3 1 Rijnland Hospital, LEIDERDORP, The Netherlands 2 Leiden University Medical Center, LEIDEN, The Netherlands 3 IJsselland Hospital, CAPELLE AAN DEN IJSSEL, The Netherlands 4 Reinier de Graaf Group, DELFT, The Netherlands 5 Oosterschelde Hospital, GOES, The Netherlands 6 Erasmus Medical Center, ROTTERDAM, The Netherlands

A RANDOMIZED TRIAL COMPARING HAND-ASSISTED LAPAROSCOPIC RIGHT HEMICOLECTOMY VERSUS CONVENTIONAL OPEN RIGHT HEMICOLECTOMY C.C. Chung, C.H. Wong, K.K. Yau, C.K. NG, K.W. Li Pamela Youde Nethersole Eastern Hospital, HONG KONG SAR, China

Background and aims: Total Mesorectal Excision (TME) is the gold standard in rectal cancer, if curation is intended. Transanal Endoscopic Microsurgery (TEM) is a much safer technique and seems to have comparable survival in early rectal cancer. Impact of both procedures on quality of life (QOL) has never been compared. In this study we compared QOL after TEM and TME. Patients and methods: 54 Patients underwent TEM for T1 carcinomas. Only patients without known locoregional or distant recurrences were included, resulting in 36 eligible patients in whom quality of life after TEM was studied. The questionnaires used were the EuroQol EQ-5D, EQ-VAS, EORTC QLQ-C30 and EORTC QLQ-CR38. The results were compared to a sex-and age-matched sample of T+N0 rectal cancer patients who had undergone sphincter saving surgery by TME and a sex- and age matched community-based sample of healthy persons. Results: The overall response rate was 86%. Quality of life from the patients and social perspective diﬀered not between the groups. Compared to TEM, signiﬁcant defecation problems were seen after TME (p< 0.05). A trend towards better sexual functioning after TEM, compared to TME, was seen, especially in male patients, although it did not reach statistical signiﬁcance. Conclusion: TEM and TME do not seem to diﬀer in QOL postoperatively, but defecation disorders are more frequently encountered after TME. This diﬀerence could play a role in the choice of surgical therapy in (early) rectal cancer. Further prospective studied are needed to conﬁrm our conclusions.

Objectives: Laparoscopic colectomy has been proven to be feasible. However, it has been criticized for lack of tactile sensation, steep learning curve, long operating time, technical diﬃculty and possibly inferior tumour clearance. With the emergence of hand-assisted laparoscopic technique, these problems hopefully can be overcome. This randomized trial aims to compare hand-assisted laparoscopic right hemicolectomy (HALC) with open right hemicolectomy (OC) in the management of right-sided colonic cancer. Methods: Patients with non-metastatic carcinoma of the caecum or ascending colon were recruited into the trial. Patients with tumour bigger than 6.5cm in any dimension on preoperative imaging were excluded from the study, as extension of the hand-port wound is usually necessary to allow safe and intact specimen delivery. Patients are randomly allocated by means of sealed envelopes to undergo either conventional open surgery (OC) or hand-assisted laparoscopic right hemicolectomy (HALC). Outcomes measured include operation time, blood loss, hospital stay, perioperative morbidity and mortality, as well as disease recurrence and survival. Results: Since June 2001, ﬁfty patients were recruited. Twenty-six patients underwent HALC, and 24 patients underwent OC. Age, sex distribution and tumour staging were similar in both groups. Blood loss was signiﬁcantly less in HALC group. Wound infection rate was less in HALC group as well. Operating time and hospital stay were similar in both groups. Cardiopulmonary complications were more common in OC group but the diﬀerence was not statistically signiﬁcant. With a median follow-up of 18 months, recurrence rate and survival were similar in both groups. Conclusions: Hand-assisted laparoscopic right hemicolectomy confers deﬁnite short term beneﬁts. With a median follow-up of 18 months, no detriments on oncological clearance were observed.

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HAND-ASSISTED LAPAROSCOPIC RESTORATIVE PROCTOCOLECTOMY FOR ULCERATIVE COLITIS: OPTIMIZATION OF INSTRUMENTATION TOWARDS STANDARDIZATION K. Nakajima1, Y. Kai1, K. Yasumasa2, T. Ito1, T. Nishida1, R. Nezu2 1 Osaka University, OSAKA, Japan 2 Osaka Rosai Hospital, OSAKA, Japan

CLINICAL AND FUNCTIONAL OUTCOME OF LAPAROSCOPIC POSTERIOR RECTOPEXY (WELLS) FOR FULL-THICKNESS RECTAL PROLAPSE-A PROSPECTIVE STUDY A. Mahajna, P. Wintringer, J.L. Dulucq Bagatelle Hospital, TALENCE-BORDEAUX, France

Introduction: Hand-assisted laparoscopic restorative proctocolectomy (HALRP) has gradually gained clinical acceptance as a practical option in the surgical treatment of ulcerative colitis (UC). However, its optimal instrumentation, e.g. hand device for extensive Ôfour-quadrantÕ abdominal access; energy device for safe division of friable mesentery, has yet to be determined. Aims: The aims were to review chronological changes in HALRP instrumentation in single surgical team, and to evaluate their impact in standardizing HALRP for UC. Methods: 66 consecutive cases with HALRP for UC (1998–2006, 36 males/30 females, median age of 33.5 years) were retrospectively analyzed. The principle of HALRP was constant in the series: with the help of the hand inserted via Pfannenstiel incision, lateral-to-medial bowel mobilization, followed by intracorporeal mesenteric division was performed intracorporeally under pneumoperitoneum; proctectomy, ileal-pouch construction and stapled ileal-pouch anal anastomosis was done under direct vision via opened access device. Cases were divided into groups according to 1) hand access devices and 2) surgical energy sources for vascular control, and their intraoperative and postoperative outcomes were compared. Results: All groups had compatible background including age at surgery, male/ female, body mass index, type of colitis, surgical indications, preoperative morbidity periods, and total dose of steroid. 1) The hand access devices changed from Hakko ÔLapDiscÕ (1998–1999; 14 patients), via Smith & Nephew ÔHandPortÕ (1999–2003; 25 pts) to Applied Medical ÔGelPortÕ (2003-present; 227 pts). Operative time was the shortest in GelPort group (GelPort: 26659 vs. LapDisc: 35784; HandPort: 30462 min). 2) For vascular control, laparosonic coagulating shears (LCS, Johnson & Johnson) with clips were used in early 29 pts (1998– 2001), and bipolar vessel sealing system (LigaSure, Valleylab) alone in recent 37 pts (2001-present). Operative time was shorter and blood loss was less in LigaSure group (LCS: 34276 min/479426 mL vs. LigaSure: 26752 min/225209 mL). No diﬀerences were seen in postoperative outcomes including complication rate and length of hospital stay. Conclusion: New instrumentation, e.g. Gelport and LigaSure, improve intraoperative outcome of HALRP. With positive adoption of evolving technologies, HALRP can become more comfortable and standardized procedure for UC.

Background: Laparoscopic rectopexy oﬀers the advantages of the open transabdominal approach while decreasing the surgical co-morbidity. The aim of this prospective study is to asses the clinical and functional outcome of laparoscopic Wells procedure for full-thickness rectal prolapse. Methods: Between 1999 and 2005, 77 patients underwent laparoscopic modiﬁed Wells procedure for full-thickness rectal prolapse. Postoperatively, the patients were evaluated for resolution of the prolapse and functional outcome, as well as for their satisfaction level regarding the procedure. Results: Laparoscopy was successful in all but one case. There were no major intra or postoperative complications and the mean length of hospital stay was 4.9 days. Approximately half of the patients had some degree of fecal incontinence preoperatively. At long term follow up, 89 percent experienced alleviation of symptoms. Constipation was improved in 36 percent of the cases. Eighteen percent of the patients suﬀered a new onset of constipation. Recurrent prolapse observed in one patient. Ninety percent of the patients were satisﬁed at long-term follow-up. Conclusion: Laparoscopic Wells procedure for rectal prolapse has good functional results, low recurrence rate and is proven to be a feasible and safe procedure. Postoperative constipation remains a problem, which should be solved.

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DUODENAL GASTROINTESTINAL STROMAL TUMOURS (GIST) UNCOMMON TUMOURS? J. Deguara1, E.M. Chisholm2 1 LONDON, United Kingdom 2 St.PeterÕs Hospital, CHERTSEY, SURREY, United Kingdom

LAPAROSCOPIC RIGHT COLECTOMY. A COST-BENEFIT ANALYSIS M. Frasson, M. Braga, A. Vignali, W. Zuliani, V. Di Carlo San Raﬀaele Hospital, MILAN, Italy

Objective: Gastro intestinal stromal tumours (GIST) occur most frequently in the stomach and small bowel. Duodenal GISTs account for only 4% of these tumours. We present the clinical features and management of three patients, who over a one-month period, underwent operative surgery for duodenal GIST. Methods: Further details were obtained from case notes, radiological investigations and histopathological reports. Results: A 73-year old lady presented with an upper gastrointestinal bleed and a palpable right upper quadrant mass. She underwent an oesephagogastroduodenoscopy and the bleeding site was identiﬁed in the distal duodenum. CT-scans highlighted the origin of this mass lesion. The night prior to surgery this lady experienced increasing abdominal pain. At laprotomy there was free intraperitoneal blood from the ruptured GIST. The 12x10x9cm tumour was excised oﬀ the duodenum. Concurrent colonic mesentery inﬁltration dictated a right hemicolectomy. Two other patients presented with epigastric discomfort, an epigastric mass of >10cm and anaemia. All 3 tumours were removed from the duodenum by a linear stapler after careful dissection from the surrounding tissue. Histopathology conﬁrmed complete surgical excision and low mitotic rate in all patients. Immunohistochemistry showed strong CD117 positivity in all pathological specimens. Despite favourable histological features, GISTs >10cm require close surveillance because of their high risk of aggressive behaviour. Conclusion: GISTs usually present with abdominal pain, gastrointestinal bleeding and a palpable mass. Occassionally they may present with an acute abdomen from a ruptured tumour with intraperitoneal bleeeding. Complete excision can be achieved with simple local excision of the duodenal wall without a major duodenal reconstruction.

Aims: advantages from laparoscopic (LPS) right colectomy in comparison with open conventional approach are not fully demonstrated. The aim of this study is to carry out a cost-beneﬁt analysis in a randomised series. Methods: 150 patients with cancer of the right colon were randomly assigned to LPS (n=76) or open (n=74) resection. All the operations were performed by the same surgical team which was well trained in both LPS and open surgery. In all patients hand-sewn extracorporeal ileo-colonic anastomosis was carried out. Trained members of the surgical staﬀ who were not involved in the study registered postoperative complications according to a priori deﬁnition. Follow-up for postoperative complications was carried out for 30 days after hospital discharge. The following costs were calculated: surgical instruments, operative room occupation, routine care, postoperative morbidity, hospitalisation. Results: the two groups of patients were homogeneous for age, gender, ASA score, and BMI. Conversion rate in the LPS group was 2.6% (2/ 76).Operative time (minutes) was slightly longer in the LPS group (171 vs 151, p=0.46). No diﬀerence in operative blood loss and in transfusion rate was found. Reoperation was necessary in 3 patients (4.0%) in each group. Postoperative morbidity rate was 17.6% in the open group and 10.5% in the LPS group (p= 0.31). Postoperative stay (days) was longer in the open group (7.4 vs 6.4, p=0.16). The additional operative charge in the LPS group was 1005 per patient randomised ( 821 due to surgical instruments and 184 due to longer operative time). The saving in the LPS group was 384 per patient randomised ( 153 due to shorter postoperative stay and 231 due to the lower cost of postoperative morbidity). The net balance resulted in 622 extracost per patient randomly allocated to the LPS group. Conclusions: LPS slightly reduced both postoperative stay and morbidity rate. This translated in a saving which covered about 40% of the operative extracost. Cutting down the economic impact of surgical instruments seems to be crucial to facilitate the diﬀusion of LPS right colectomy.

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ADVANCED AGE IS NOT A RISK FACTOR IN PATIENTS UNDERGOING LAPAROSCOPIC COLORECTAL RESECTION M. Frasson, M. Braga, A. Vignali, W. Zuliani, V. Di Carlo San Raﬀaele Hospital, MILAN, Italy

OUTCOME OF LAPAROSCOPIC COLORECTAL SURGERY IN OCTOGENARIANS C. Balague´, E.M. Targarona, C. Martinez, P. Hernandez, V. Alonso, S. Vela, R. Medrano, J.L. Pallares, J. Garriga, M. Trias Hosp. Sta. Creu i St. Pau, BARCELONA, Spain

Aims: The purpose of this study is to evaluate the impact of age on shortterm morbidity in patients undergoing either laparoscopic (LPS) or open colorectal resection. Methods: 535 patients with colorectal disease were randomly assigned to LPS (n=268) or open (n=267) resection. We analyzed separately 201 (37.6%) elderly patients (age 70 years) and 334 (62.4%) young patients (age < 70 years). Trained members of the surgical staﬀ who were not involved in the study registered postoperative morbidity and decided the day of hospital discharge. Follow-up for postoperative complications was carried out for 30 days after hospital discharge. Findings: Among elderly patients, no diﬀerence with respect to age was found in LPS (mean 75.2, SD 4.2) or open group (mean 76.6, SD 5.2). In both groups elderly had a higher ASA score compared to young patients (p = 0.0001). Operative time was shorter in the open group compared to LPS in both young (p<0.0001) and elderly patients (p=0.001). In the open group, elderly had higher morbidity rate (37.5% vs 23.9%, p=0.02) and longer postoperative stay (13.0 vs. 10.6, p = 0.007) compared to young patients. In particular, elderly had more wound infections (p=0.08), abdominal abscess (0.13) and cardiovascular complications (0.13). In the LPS group, conversion rate (4.5% vs. 5.0%), morbidity rate (20.2% vs. 15.1), and postoperative stay (9.5 vs.9.1) were similar in elderly and young patients, respectively. In elderly patients, LPS reduced morbidity rate (20.2% vs. 37.5%, p= 0.001) and postoperative stay (9.5 vs. 13.0, p=0.001) compared to open approach. In young patients, the advantages due to LPS on morbidity rate (15.1% vs. 23.9%, p=0.06) and postoperative stay (9.1 vs. 10.6, p= 0.004) were less pronounced. Conclusion: Advanced age was not a negative prognostic factor in patients undergoing LPS colorectal surgery. LPS reduced both short-term morbidity and postoperative stay in elderly patients, while in young patients beneﬁts were less pronounced.

Proportion of patients aged >80 years are increasing. Open colorectal surgery in octogenarians patients is associated with an increased morbidity and mortality. Laparoscopic colorectal resection can be done safely in elderly patients. However, the surgical outcomes of laparoscopic colorectal resection in octogenarians are not enought documented. Aim: To evaluate the surgical outcomes of laparoscopic colorectal surgery in a prospective serie of 112 patients older than 80 years diagnosed of colorectal cancer. Material and Methods: Between January/98 and February/06 have been performed 507 consecutive laparoscopic resections for colorectal cancer and data have been prospectively recorded. Patients have been divided in three

Table I Surgical and postoperative results

N Mean age Sex m-f Comorbid. Prev surg T4 Op time Per compl Conversion Postcompl Anast leak Hosp stay(d.) Reoperat Mortality

Group I

Group II

Group III

210 60 120–90 36% 29% 19% 152 30% 15% 32% 4% 7 2% 0.5%

185 75 126–59 55% 39% 21% 152 32% 18% 33% 6% 8 9% 2.7%

112 84 61–51 47% 43% 13% 148 30% 20% 34% 3% 9 3.5% 1%

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Right hemi Left hemic Sigmoid Ant. Res APR Colectomy Hartmann Palliative Global

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Group I

Group II

Group III

42 (20%) 13 (6%) 72 (34%) 49 (23%) 26 (12%) 0 (0%) 7 (3%) 1 (0.5%) 210

61 (33%) 16 (9%) 50 (27%) 34 (18%) 19 (10%) 0 (0%) 4 (2%) 1 (0.5%) 185

36 (32%) 4 (3%) 28 (25%) 20 (18%) 14 (12%) 1 (0.8%) 7 (6%) 2 (1.7%) 112

groups of age: Group I: <70 years (n:210), Group II: 70–79 years (n:185) and Group III: >80 years (n:112) and we have compared the results. Results: See Table I and II: Conclusion: Laparoscopic colorectal resection is safe and feasible in elderly patients. Postoperative recovery and quality of life have to be evaluated.

VASCULAR CONSTRAINTS IN RIGHT COLECTOMY FOR CANCER. IMPLICATIONS FOR EXTENT OF LYMPH NODE HARVEST. D. Ignjatovic1, S. Sund2, B. Stimec1, R. Bergamaschi1 1 Forde Health System, FORDE, Norway 2 Forde Central Hospital, FORDE, Norway Background: 3-D relations between the ileocolic (ICA), right colic artery (RCA) with the superior mesenteric vein (SMV) are not described in detail in context with radical right hemicolectomy. The aim of this study was to deﬁne the diameter, length and 3-D position of the ICA and RCA to the SMV. Methods: Corrosion casting of specimens from 30 fresh human cadavers. Methylacrylate was injected into the SMV and SMA. Diameter, length and position of ICA and RCA to the SMV were assessed. Results: RCA occurred in 19 specimens (63.33%), 16 (84.21%) passed anterior to the SMV. Length of crossing was 20.63+8.09 (6.3–35.7)mm. The ICA was constant passing under the SMV in 19 (63.33%). Length of crossing 17.01+7.84 (7.09–42.89)mm. Conclusions: RCA occurs in 63.3% specimens, passes over the SMV in 84.2% specimens and leaves a 20.6mm stump. ICA is constant, passing under the SMV in most cases, leaving a 17.01mm stump.

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LAPAROSCOPIC INTRACORPOREAL COLECTOMY FOR RIGHT COLON CANCER: OUTCOMES IN 107 CONSECUTIVE CASES D. Ignjatovic, E. Schochet, L. Ludwig, S. Rossi, M. Van Dusen, M. Burke, J.P. Arnaud, R. Bergamaschi Forde Health System, FORDE, Norway

LATE CONVERSION FROM LAPAROSCOPIC TO OPEN SURGERY RESULTS IN INCREASED TUMOR GROWTH IN AN EXPERIMENTAL RAT MODEL M.A. Thome1, D. Ehrlich2, R. Koesters2, U. Hinz1, M.W. Bu¨chler1, C.N. Gutt1 1 University of Heidelberg, HEIDELBERG, Germany 2 German Cancer Research Centre (DKFZ), HEIDELBERG, Germany

Randomized trials have failed to prove the superiority of laparoscopicassisted colectomy for colon cancer over the conventional approach. The aim of this study was to assess the safety of laparoscopic intracorporeal right colectomy (LIRC) for right colon cancer. From July 2002 to June 2005, consecutive patients with histologically proven and colonoscopically inked right colon cancer underwent a standardized LIRC with medial to lateral approach encompassing six sequential steps: 1) ligation of vessels, 2) identiﬁcation of ureter and duodenum, 3) division of omentum, 4) transection of bowel, 5) stapled side-to-side anastomosis, and 5) delivery of specimen through an enlarged suprapubic port site in a bag. Procedures were performed by supervised trainees. All patients followed a standard perioperative care plan. Values are median (range). 107 consecutive patients were included in the study aged 64.9 (40–85) years. There were 54 women and 53 men each with a BMI of 32.3 (23–43). 37% of patients had prior open abdominal surgery. Operative time was 119 (50–600) minutes. Estimated blood loss was 69 (50–600) ml. Conversion rate was 4.7%. Length of enlarged port site was 3.6 (3–4.4) cm. There were no major complications. Length of stay was 4.1 (2–10) days. Tumor size was 3.5 (1.6–6.8) cm. 11.3%, 52.8%, 34.9%, and .94% of the tumors were stage T1, T2, T3, and T4, respectively. 29 (4–41) lymph nodes were harvested; 77%, 21%, and 2% were N0, N1, and N2, respectively. At follow-up of 22.2 (5.4–36) months, 94.3% were alive no evidence of disease, and 4.7% lost to follow-up. One patient with stage IV disease at surgery died at 13 months. One patient is alive with disease following re-resection for local recurrence of a T4 lesion. Results demonstrate the safety of LIRC and raise the question whether a randomized trial comparing laparoscopic intracorporeal colectomy to its open counterpart deserves consideration in the quest of the superiority of the laparoscopic method.

Aims: Conversion from laparoscopy to open surgery occurs in up to 40% of the cases of colorectal tumor resection. The aims of this study were to investigate the oncological consequences of early and late conversion from laparoscopic to open surgery using a standardized small animal model. Methods: 60 male WAG-Rij rats were randomized into four operation groups: Laparotomy (LT group, n= 15), laparoscopy (LS group, n= 15), laparoscopy followed by early conversion after 20 minutes (EC group, n= 15) and laparoscopy followed by late conversion after 40 minutes (LC group, n= 15). Total procedure time for the ﬁrst three groups was 60 minutes and for the late conversion group 80 minutes. Metastatic spread was induced in each operation group by tumor cell inoculation into the portal vein after 15 minutes of surgical intervention. A cecal resection was performed after 30 minutes in the ﬁrst three groups compared with 50 minutes in the LC group. On day 28 after surgery hepatic tumor growth was evaluated (diameter, tumor volume, weight of the liver and cancer index). The statistical analysis of tumor growth parameters was performed using the Kruskal-Wallis test, the Mann-Whitney u test and the FisherÕs exact test. Distribution of the data is presented as median value with interquartile range and graphically as box-and-whisker plot. Results: Hepatic tumor volume was signiﬁcantly increased following late conversion in comparison with laparotomy (p= 0.042) and early conversion (p=0.0094). There was not a signiﬁcant diﬀerence between LC and LS (p= 0.81). Conclusions: Early conversion from laparoscopic to open surgery does not lead to a signiﬁcant increase of hepatic tumor volume compared with the same procedure being performed in conventional open technique. It even leads to a signiﬁcant decrease of hepatic tumor volume compared to the same procedure being performed entirely laparoscopic. On the other hand late conversion is accompanied by signiﬁcantly stronger tumor growth than laparotomy and early conversion. From the oncological point of view an early decision for conversion seems to be recommended as soon as technical or anatomical problems occur.

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QUALITY OF LIFE, SEXUAL AND URINARY FUNCTION AFTER LAPAROSCOPIC SIGMOID RESECTION FOR DIVERTICULAR DISEASE. A PROSPECTIVE STUDY A. Forgione, J. Leroy, M. Simone, C. Bailey, F. Rubino, D. Mutter, J. Marescaux EITS-IRCAD / University Louis Pasteur, STRASBOURG, France

PROSPECTIVE FIVE-YEAR FOLLOW UP OF PATIENTS WITH SYMPTOMATIC DIVERTICULAR DISEASE

Introduction: Colonic diverticular disease aﬀects quality of life. After acute episodes of diverticulitis the indication and timing of surgery are a matter of debate and must be weighed up with the morbidity of the surgical procedure. The aim of this study was to evaluate quality of life, sexual and urinary function after laparoscopic sigmoid resection for diverticular disease. Materials: From March to December 2005 all patients undergoing elective laparoscopic sigmoid resection for diverticular disease were recruited prospectively. Age, sex, BMI, ASA status, comorbidities, episodes of acute diverticulitis, operative and perioperative data were recorded. To evaluate quality of life the GIQLI (Gastrointestinal Quality of Life Index) was used. To asses sexual and urinary function the IEEF-5 (International Index of Erectile Function) and IPPS-6 (International Prostate Symptom Score) were used for male pts and the UDI-6 (Urogenital Distress Inventory) for female pts. Patients were interviewed before the operation, 3 and 6 months postoperatively. Results: Sixteen males and 16 females underwent laparoscopic sigmoidectomy. Mean age was 58 years (37–78), mean BMI 27 (21–38). Mean episodes of preceding attacks of acute diverticulitis was spare. There were 20 pts ASA I,10 pts ASA II and 2 pts ASA III. Postoperative complications occurred in 3/32 pts (9%): 1 intrabdominal haematoma in a patient with coagulopathy and 1 perianastomotic abscess both drained percutaneously and 1 anastomotic inﬂammatory stenosis requiring a defunctiong colostomy. Mean follow-up was 8,4 months (3–12). Preop GIQL index was 98 (55–135) and was improved at 3 months to 110 (66–137) and at 6 months to 106 (56–138), p < 0.05 ANOVA. Preop IEFF-5 was 19(10–25) and 19 (6–25) at 3 months and 19 (13–25) at 6 months, p=ns. Preop IPPS-6 was 6.4 (0–21) and 5 (0–11) at 3 months and 5.3 (1–9) at 6 months, p=ns. Preop UDI-6 was 3(0– 11) and 2 (0–6) at 3 months and 3.2 (0–9) at 6 months, p=ns. Discussion: Quality of life was signiﬁcantly improved six months after laparoscopic sigmoid resection without impairment of sexual and urinary functions. If long term results conﬁrm these ﬁndings it may support the decision to operate on patients with diverticular disease.

A. Salem1, R.G Molloy2, P.J. OÕDwyer3 1 Royal Alexanra Hospital, GLASGOW, United Kingdom 2 Gartnavel General Hospital, GLASGOW, United Kingdom 3 Western Inﬁrmary, GLASGOW, United Kingdom Aims: The natural history of diverticular disease is largely unknown. Most studies are retrospective and treatment recommendations are derived from outdated literature some 30–50 year old. The present study is a prospective long term assessment of the development of complications in patients with symptomatic diverticular disease. Methods: All patients with conﬁrmed diagnosis of symptomatic diverticular disease between August 1999 and April 2001 were followed up prospectively for an average of 5.5 (average 4.2 - 6.7 yrs). A computerised search through our hospital discharge database was conducted to conﬁrm if any patient in our study population has been admitted with a complication related to diverticular disease. A telephone questionnaire was conducted for all patients (and/or their general practitioner).This questionnaire included speciﬁc questions relating to the development of any complications related to diverticular disease and any previous or recent surgery for diverticular disease. Patients were asked about symptom severity and eﬀect on daily activities. The cause of death was obtained for those who died during the study period. Results: One hundred and sixty three patients were identiﬁed, 106 females with median age of 55 years (IQR 63.5–80). Diagnosis was conﬁrmed through colonoscopy (106), ﬂexible sigmoidoscopy (57) and barium enema (31).Indications for referral for large bowel investigations were; change in bowel habit (148), rectal bleeding (123), abdominal pain (67) and others (69). Associated pathology included; polyp (24), haemorrhoids (22), colorectal cancer (3) and others (12). Nineteen (11.7%) patients were lost to follow up and further19 (11.7%) died from unrelated causes. Of the remaining 144 patients (88.3%), only two patients were treated for an episode of acute diverticulitis (1.4%) with no further episodes during follow up. One patient underwent a sigmoid colectomy for recurrent symptoms due to diverticular disease (0.7%). The remaining 141 patients (97.9%) described their symptoms as either minimal or mild and not aﬀecting their daily activities. Conclusion: In this prospective long term study, symptomatic diverticular disease seems to run a long term benign course with a very low incidence of subsequent complications. Symptomatic disease, acute diverticulitis and complicated diverticular disease seem to constitute distinct categories with hardly any cross-over between groups.

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THE PATTERN OF RECURRENCE AFTER LAPAROSCOPIC SURGERY FOR COLON CANCER IS DIFFERENT FROM OPEN COLECTOMY: A MATCHED CASE-CONTROL STUDY H. Hasegawa1, K. Okabayashi1, H. Nishibori1, Y. Ishii1, T. Endo1, M. Watanabe2, M. Kitajima1 1 Keio University, TOKYO, Japan 2 Kitasato Universi, KANAGAWA, Japan

LAPAROSCOPIC RESECTION FOR ADVANCED COLORECTAL CANCER- SHORT AND LONG TERM RESULTS OF OVER 300 CASES N. Francis, S. Delgado, D. Momblan, R. Bravo, A. Ibarzabal, R. Corcelles, R. Almenara, A.M. Lacy Hospital Clinic, BARCELONA, Spain

Introduction: Randomised controlled trials showed that laparoscopic colectomy (LAP) for colon cancer was equivalent as open colectomy (OPEN) in terms of short- and long-term outcome. However, the pattern of recurrence has not been analysed. The aim of this study was to clarify the pattern of recurrence after laparoscopic colectomy compared to open colectomy. Methods: Between 1990 and 2003, 2060 patients with colorectal cancer underwent laparoscopic (589) or open (1471) procedures in our institute. Of these, 147 patients undergoing LAP with curative intent were compared with patients undergoing OPEN matched for the age, sex, tumour site, stage, and histology. All patients were followed up for the minimum of two years. Chi-squared test, paired t-test, logistic regression models and logrank were used for statistical analysis. Results: The patient details are as follows: the age (64.8 years), gender (M:F, 182:112), tumour site (C and A; 45, T; 15, D; 8, S; 69), stage (I; 134, IIa; 78, IIb; 8, IIIa; 14, IIIb; 44, IIIc; 16). There were no signiﬁcant differences in the mean follow-up between the two groups (LAP:OPEN; 65.6 vs 70 months, p=0.134). 16 patients in LAP group and 13 patients in OPEN group developed recurrences (LAP:OPEN, liver: 3:7, lung: 0:3, bone: 1:0, peritoneum/ abdominal lymph nodes: 12:3). The incidence of peritoneal metastasis was signiﬁcantly higher in LAP than in OPEN group (odds ratio: 4.267, p= 0.027). The 5-year overall survival rates for all stages (LAP:OPEN, 91.9%:87.3%, p=0.657), and for stages I/II/III (LAP:OPEN, stage I; 96.3%:89.2%, II; 95.3%;90.4%, III; 78.3%:80.4%) did not diﬀer between the LAP and OPEN groups. In the multivariate analysis, stages IIB/IIIB/IIIC and LAP were the independent predictive factors for peritoneal metastasis. Conclusions: The peritoneal recurrence occurred more frequently after laparoscopic colectomy than open colectomy, however, the overall survival rates did not diﬀer.

Aim: Study the perioperative and long term outcomes of laparoscopic resection for advanced colorectal cancer stage III. Methods: The results of 306 patients with stage III colorectal cancer (206 colon and 110 rectal) underwent laparoscopic resections at our institution between 1994 and 2006 were analyzed with respect to perioperative morbidity and mortality and long term results of recurrence and survival with follow up ranged from 3 to 145 months (median 62). Kaplan-Meier method was used for the survival analysis. Results: There were 118 males and 88 females in the colon disease, with mean age of 70, while 70 males and 40 females with a mean age of 66 years for rectal disease. The colonic resection involved 82 right hemicoloectomy, 102 left hemicolectomy and 12 others. For rectal disease, 90 patients received anterior resection while 20 patients were subjected to abdominoperineal and Hartmanns resection (18%). The intention of surgery was curative in over 95% of all cases. The mean of operation time was 132 and 170 minutes for colonic and rectal resections. The conversion rate was 8% for colonic and 22% for rectal resections with mean hospital stay of 5.28 for colon and 6.6 days for rectal. 88% of colonic cancers were T3 and T4 while 75% for rectal disease. The mean number of lymph nodes were retrieved were 16 and 12 for colon and rectal surgery respectively with adequate distal margins in all resections. Major postoperative complications, included wound infection (5%) and ileus (6%) with leak rate of 2% in colonic and 7% in rectal resection. The local recurrence rate was 2% and 12% for colon and rectal tumours (14 pelvic recurrence, with one anastomotic recurrence in the rectal group) and one trocar site implants. The overall cancer related mortality was 12% and 22% for colon and rectal cancer respectively. The overall 5-year overall survival was 80% and 54% and disease-free survival was 68% and 44% for colon and rectal cancer respectively. Conclusions: laparoscopic resection for stage III colorectal cancer is technically feasible and oncologically adequate with comparable short and long term results to that of traditional open surgery.

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TRANSANAL ENDOSCOPIC MICROSURGERY FOR RECTAL CANCER M.E. Allaix, M. Caldart, R. Rimonda, C. Garrone, M. Morino Ospedale Molinette, TORINO, Italy

NOVEL TRAINING PHANTOM FOR SKILLS ACQUISITION IN LAPAROSCOPIC RECTAL RESECTION L.S. Christie1, F.J. Carter1, K.L. Campbell2 1 Cuschieri Skills Centre, DUNDEE, United Kingdom 2 Ninewells Hospital & Medical School, DUNDEE, United Kingdom Aims: To develop a training phantom for rehearsal of techniques in laparoscopic rectal resection.

Aims: Resection of the rectum is associated with a signiﬁcant morbidity, in particular referred to sphincteric, urinary and sexual dysfunctions. To reduce these complications, the Transanal Endoscopic Microsurgery (TEM) is an eﬀective minimally invasive technique for local excision of rectal cancers in highly selected patients. This study evaluates the results of local excision in patients with extraperitoneal rectal neoplasms. Methods: Preoperative assessment included digital examination, proctoscopy, colonoscopy, transanal ultrasound, CT scan and an anorectal manometry. The parameters evaluated included operating time, morbidity and mortality rate, hospital stay, histological and staging discrepancy and oncological results. Results: From January 1993 to January 2006, TEM was performed in 236 patients. Preoperative indications were 174 adenomas, 47 carcinomas and 15 various pathologies. Mean operative time was 70.9 minutes. Intraoperative complications consisted of 9 cases of inadvertent peritoneum opening, treated in 6 cases by intraoperative transanal repair using TEM and in 3 cases by conversion to laparoscopic anterior resection (2 cases of adenoma) or to laparotomic anterior resection. The rate of conversion to abdominal surgery was 1.27% (3/236). There was no mortality. The overall incidence of morbidity was 7.2% (17/236). Mean hospital stay was 4.7 (range 2–14) days. At ﬁnal histology there were 29 T1, 28 T2 and 13 T3, with 23 new cases of cancer (13.2%). Staging discrepancy rate was 18.9%. Mean follow-up was 57 (3–130) months, with a recurrence rate of 0% in pT1, 21.4% in pT2 and 38.5% in pT3. After the TEM procedure, among the pT2 patients, 11 underwent postoperative radiotherapy, 6 surgical eradication. Three pT3 patients underwent postoperative radiotherapy, two a laparoscopic surgical resection and postoperative chemotherapy. Overall estimated 5-years survival was 93%; the disease-free survival rate was 89%. The 5-years cumulative survival rate was 100% for pT1, 95.5% for pT2 and 65.5% for pT3 carcinomas. The 5-years disease-free survival rate was 100% for pT1, 92% for pT2 and 55% for pT3. Conclusions: Local excision by TEM is a safe and eﬀective approach in the treatment of rectal T1 carcinomas. Adjuvant radiotherapy and surgical resection of recurrences allow to obtain good long term results in T2 patients.

Methods: The abdomen and pelvis of a 45kg whole male pig was prepared by removing the liver, stomach, spleen, small intestine, kidneys and colon spiral. The bladder, sigmoid colon and rectum were left in situ to provide anatomical landmarks for dissection. The whole specimen was placed inside a simulated abdominal wall (Bodyform, Limbs & Things Ltd, Bristol, UK), with an access point created at the pelvic outlet for the circular stapler. After the initial development work, the phantom has been used to train 54 colorectal surgeons in the skills for laparoscopic rectal resection. The trainees were a mixture of specialist registrars (in the latter years of training) and consultants. Each trainee completed an evaluation form, which was then analysed for their feedback regarding the training phantom. Results: Each trainee was able to dissect the colonic mesentery, with realistic tissue planes down to the inferior mesenteric artery. After ligation and division of this vessel, and further dissection, linear staplers were deployed to transect the colon and the free section of bowel could be externalised through a 6cm incision created in the synthetic abdominal wall. Once the anvil of the circular stapler was inserted, the section of colon could be returned to the abdominal cavity and the anastomosis completed with the stapler gun introduced through the simulated anus. The mean response for feedback on the training phantom was 4.4 out of a possible 5. Speciﬁc comments from individual trainees included rectal dissection practical very good, best thing was the practical operation on the pig model and hands-on training on the pig cadaver was excellent. Conclusions: This training phantom is an eﬀective tool for colorectal surgeons to acquire skills in laparoscopic rectal resection.

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UROGENITAL COMPLICATIONS OF LAPAROSCOPIC TOTAL MESORECTAL EXCISION M.E. Allaix1, G. Monasterolo1, D. Parini1, U. Parini2, M. Morino1 1 Ospedale Molinette, TORINO, Italy 2 U.B. Chirurgia Generale, Osp. regionale, AOSTA, Italy

LAPAROSCOPIC LYMPH NODE DISSECTION OF THE TISSUES OF THE LATERAL SIDES OF THE PELVIS IN TREATMENT OF THE LOW RECTAL CANCER V.B. Alexandrov, C.N. Tsaranov, G.I. Gadjiev, L V Kornev, C.S. Gorshkov MOSCOW, Russia

Aims: In the treatment of rectal cancer, both functional and oncological results are important. Bladder and sexual dysfunctions are serious complications of rectal surgery for cancer. One of the advantages of laparoscopy is the clear visualization of the smallest structures, including the autonomic nerves. Nevertheless, data concerning the functional outcome of laparoscopic total mesorectal excision (LTME) are lacking. The aim of this retrospective study is to evaluate the functional complication rate after laparoscopic surgery for lower and mid rectal cancer. Methods: Fifty male patients younger than 75 years, without urologic diseases, who underwent radical LTME for mid and low rectal cancer with a minimum follow-up of 12 months, were given a standardized questionnaire about postoperative functional outcomes (IPSS and IIEF) and quality of life (QoL). Results: The sexual desire was diminished in 42.2% of cases. The ability to engage in intercourse was maintained by 68.9% of the patients. Seventeen patients (37.8%) maintained their ability to achieve orgasm and had normal ejaculation. Multiple regression analysis showed that the type of procedure (anterior vs abdomino-perineal resection) was the only independent factor (p<.05). Mean IPSS value was signiﬁcantly higher after surgery (p<.05). Multivariated analysis revealed that the type of surgery and the stage had a negative inﬂuence on the urinary function, particularly in terms of incomplete bladder empting, intermittence and nicturia. Age, distance from the anal verge and neoadjuvant therapy were not negative factors. No signiﬁcant diﬀerences were noted in term of QoL. Conclusions: LTME with nerve sparing technique for rectal cancer is feasible and can be performed safely, with sexual and urinary outcomes similar to the data reported in major open series. The psychological impact of a deﬁnitive stoma may play an important role on the sexual function. Further prospective and eventually randomized trials will be necessary to conﬁrm these results.

Last time discussions have been held over the expediency to ablate more area of tissues of the lateral sides of the small pelvis than it was suggested by Miles in his time, when localizing cancer in the inferior 5–7 cm. of the rectum. Aims: In view of the appearance of the new technology it was decided to work out the execution of lateral lymphadenectomy using laparoscopic technology (LT) and study the eﬃcacy of this operation. Material: We tested 2 groups of patients operated on October 2003 November 2004. The main group (17 patients), who had undergone excision of the tissues of the lateral sides of the pelvis using LT. The control group (18 patients) treated in the same period of time who had undergone laparoscopic abdominoperineal resection of the rectum with standarted lymph node dissection. Additional treatment of both groups was executed according to the similar method: preoperative radiotherapy (25 Gy) and adjuvant chemotherapy (Mayo scheme). Results: The operation consists of the excision of the tissues of the lateral sides of the pelvis and of the tissues in the zone of obturator holes. The selection of the lymph nodes was executed by means of clearing technique and all lymph nodes were examined according to the histological and immunohistochemistry methods. 4 patients (23.6%) were noted to have lesion of lateral pelvis lymph nodes was noted, other 2 - macrometastasis and other 2 - micrometastasis N1(mi). All 34 patients of control and main group have been examined. The control observation lasted from 16 to 28 months. Probability of survival was calculated according to the method of Kaplan-Meier. During the mentioned period the main group did not show local recurrence of cancer in the pelvis. The results of the control group were worse - 4 patients (18,75%) had cancer generalization, two of them (9,4%) was noted to have local relapses of cancer in small pelvis area. Conclusions: 1. The experiment showed a possibility to execute dissection of the tissues of the lateral sides of the pelvis using LT. 2. Relapse-free survival was better in the main group that in the control one.

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LAPAROSCOPIC TECHNOLOGIES IN CROHN DISEASE, ULCERATIVE COLITIS, FAMILIAL ADENOMATOUS POLYPOSIS TREATMENT V B Alexandrov, V.V. Sologubov, Y.A. Vinogradov, L.V. Kornev, V.N. Razbirin, A.L. Goncharov MOSCOW, Russia

RESULTS OF THE DOPPLER GUIDED HEMORRHOID ARTERIAL LIGATION (HAL) TECHNIQUE USING LOCAL ANAESTHESIA AND SEDATION J.P. Eitenmueller, E. Volckmann, A. Dembek St. Rochus-Hospital, CASTROP-RAUXEL, Germany

Aims: Surgical treatment of these diseases including total mobilization of colon and rectum. This study aimed to determine eﬃcacy of using laparoscopic technologies in this procedure. Material and Methods: From 1995 to 2005, we performed 39 attempts of total laparoscopic abdominal colon and rectum mobilization (TLACPM). There were 32 cases of laparoscopic total abdominal colproctectomies, and 7 subtotal colproctectomies with pull-through of ascending colon in anus. Preoperative diagnoses included ulcerative colitis (n=16), CrohnÕs colitis (n=9), and familial adenomatous polyposis (n=14). 9 patients had cancer as complication of these diseases. Male 19, female 20. Age 16–59 (med 36). Results: Total mobilization of large bowel was completed in 61,5% (n=24 cases) using only laparoscopic technologies. Conversion rate was 38,5% (n=15). Reasons of conversion: bowel perforation (n=4), bleeding (n=6), assumption of damaging colon wall (n=3), local spreading of cancer (n=2). After colon mobilization, distal ileum cuted with EndoGIA. Colon extracted through small incision on rear perineum or minilaparotomy in right iliac area, place of ileostomy. 7 patient underwent pull-trough of ascending colon in anus, 3 - pull-through of ileum (1 with Jpouch), 3 had low ileorectal (<4 cm) anastomosis. All patients underwent laparoscopic sanation of peritoneal cavity 2 days after operation. 2 patients with symptoms of peritonitis before main operation had two sanations. There were no deaths and serious postoperative compications. In 1995 ﬁrst operations length was 470min, but in 2004 mean time was 360 min (n=9). It depends on gained great experience of clinic in laparoscopic surgery of colon and rectum (1700 operations). Conclusions: TLACPM is technically challenge and requires a skillfull team. Surgeons need to make time brakes and possible team rotation during procedure

Introduction: Hemorrhoids are commonly treated in the outpatient clinic using banding. Inpatient treatment usually involves Milligan-Morgan or circular stapled hemorrhoidectomy. We report a novel outpatient based technique of Doppler guided hemorrhoidal arterial ligation (HAL). Methods: In a 5 year period 900 consecutive patients were treated using this technique. Patients with stage 2 and 3 hemorrhoids were included in the series. The method was used in the outpatient setting. Patients were sedated with a short acting benzodiazepine and local anaesthetic used. An operating proctoscope incorporating an 8MHz Doppler probe was used. Sutures were inserted via a window in the proctoscope to obliterate the vessels detected using the Doppler. After the procedure patients were given standard oral analgesia and advised on ﬁbre and stool softeners. Postoperatively only those with problems were seen but all patients were assessed with a telephone questionnaire. Results: 500 Patients completed the questionnaire. There were no deaths. Pain during the procedure was rated as none (66%), very little (20%), tolerable (22%) and severe (2,6%). All discomfort had resolved at 14 days post-procedure. 6 patients required removal of a suture due to inappropriate placement. Postoperative hemorrhage was seen in 6 cases, all of them required surgery. 4% patients have recurrence of hemorrhoids requiring other modern operative treatment. Conclusion: HAL technique is a safe, relatively pain free technique for the outpatient treatment of hemorrhoids. There is a 96% success rate with few postoperative omplications. We continue to assess our longterm results.

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LAPAROSCOPIC RE-OPERATION FOR ANASTOMOTIC LEAKAGE AFTER PRIMARILY LAPAROSCOPIC COLORECTAL SURGERY; A COMPARATIVE STUDY J. Wind, A.G. Koopman, J.F. Slors, D.J. Gouma, W.A. Bemelman Academic Medical Center, AMSTERDAM, The Netherlands

THE COSTS OF LAPAROSCOPIC COLORECTAL SURGERY H.M.P. Dowson, A.H. Huang, Y. Soon, T.A. Rockall MATTU, Royal Surrey County Hospital, GUILDFORD, United Kingdom

Aim: Anastomotic leakage (AL) after colorectal surgery is associated with high morbidity and even mortality. Morbidity includes several abdominal wall complications due to reinterventions and wound sepsis. The aim of this study was to evaluate the potential beneﬁts of a laparoscopic reintervention in patients with AL that had primarily a laparoscopic operation. Methods: During a three year period (January 2003 until January 2006), all patients who underwent a laparoscopic colorectal resection and subsequently developed AL were operated on laparoscopically. A relaparotomy was performed in patients who had primarily open surgery. Data were collected in a retrospective manner. Fishers exact test was used for binomial data and MannWhitney test for continuous data. Results: Twenty-ﬁve patients were included, 10 patients were operated on laparoscopically after a prior laparoscopic procedure, and 15 patients underwent a relaparotomy for suspicion of anastomotic leakage. Patients in both groups had similar ages, gender, co-morbidity, body mass index, indications for surgery and ASA and APACHE scores. Median length of time from ﬁrst operation to reintervention was 6 days in both groups. In all patients a stoma was constructed. Conversion rate was 0% in the laparoscopic group. The median operating time was not signiﬁcantly diﬀerent in the laparoscopic group compared to the open group (116 versus 105 minutes; P=0.52). Four patients (27%) in the open group underwent a second look operation or a reintervention for a dehiscent fascia. Median length of ICU admission was shorter in the laparoscopic group (1 versus 3 days; P=0.002). Postoperative morbidity within the ﬁrst 30 days was not diﬀerent between the laparoscopic and open group (30% versus 60%; P=0.23). Resumption of liquid and solid diet and ﬁrst stoma output occurred signiﬁcantly earlier in the laparoscopic group. Median hospital stay was not signiﬁcantly shorter in the laparoscopic group (9 versus 13 days; P=0.06). There was no statistically signiﬁcant diﬀerence in the presence of incisional hernias at longterm follow-up (0 versus 27%; P=0.13) Conclusion: These preliminary data suggest that a laparoscopic reintervention for anastomotic leakage after primarily laparoscopic surgery is feasible and associated with a faster recovery and fewer abdominal wall complications as compared to relaparotomy.

Background: Recent studies have conﬁrmed the clinical eﬃcacy of laparoscopic colorectal surgery (LCS). Its use, however, has not yet become widespread. One of the reasons for this are perceived cost implications. A systematic review was undertaken examining the costs of LCS. Methods: Electronic databases were searched for papers comparing LCS and open surgery. Primary outcome measures assessed were operating room costs, direct hospital costs, and indirect costs; secondary outcomes were conversion rates and length of hospital stay. The percentage diﬀerence in costs between laparoscopic and open groups was used for comparisons between studies. Results: 29 relevant articles were identiﬁed in which economic data was presented (total number of patients 3681); all were considered to be of moderate or poor methodological quality with regards to economic data, with only six randomised trials. Operating room costs were greater for LCS than open surgery in all studies (median diﬀerence 50%, IQR 27–78%, p<0.001). There was no overall diﬀerence in total hospital costs (median diﬀerence 0%, IQR )17.5 to +21%). Only 2 papers collected data on indirect costs, with both in favour of LCS. Hospital stay was shorter for LCS in all studies (median diﬀerence 2.8 days, IQR 1.3–3.7, p<0.001). Median conversion rate was 7.8% (mean 14%, IQR 6–21%). Conclusions: Operating room costs are greater for LCS than conventional open surgery. However, total hospital costs are similar; the main economic determinants are conversion rates and hospital stay. There may be societal beneﬁts associated with lower indirect costs for LCS. Further studies of good methodological quality are required, but it appears that cost should not be a deterrent to performing laparoscopic colorectal surgery.

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LAPAROSCOPIC VERSUS OPEN TOTAL MESORECTAL EXCISION; A COMPARATIVE STUDY ON SHORT-TERM OUTCOMES A.A.F.A. Veenhof1, A.F. Engel2, M.E. Craanen1, S Meijer1, D.L. Van der Peet1, M.A. Cuesta1 1 VUmc, AMSTERDAM, The Netherlands 2 Zaans MC, ZAANDAM, The Netherlands

EARLY RECTAL MALIGNANCIES LAPAROSCOPIC RESECTION WITH HARMONIC SCALPEL IN A SERIES OF 15 CASES A.P. Zameer Shanawaz Hospital, TRICHY, India

Background and aim: Several recently published randomized series have shown that laparoscopic colonic resection has short-term beneﬁts over open colonic resection for colon cancer, without a compromise in oncological outcome. Therefore, the laparoscopic approach is now being used more frequently in rectal cancer. The aim of this study was to analyze the diﬀerences in short-term outcomes between open TME and laparoscopic TME. Methods: In this study, the short-term outcomes of 100 patients undergoing TME for proven rectal cancer were analyzed through a review of patient charts, of operation and anesthesia notes, of pathology reports and of follow-up reports. Results: Two groups of ﬁfty patients underwent an open or laparoscopic TME for rectal cancer. Both groups were comparable. Patients having had a laparoscopic TME suﬀered from signiﬁcantly less per-operative complications and recovery of bowel peristalsis occurred sooner. The total number of major and minor complications, within 30 postoperative days was comparable between both groups, as was the length of hospital stay. Median follow-up was 17 months for the laparoscopic group and 22 months for the open group. The survival analyses between the open and laparoscopic group showed no statistical diﬀerence on disease free and overall survival. Conclusion: This study has shown that laparoscopic TME is a safe and feasible technique with some short-term beneﬁts over open TME, but without compromising oncological short-term outcome.

In India malignancies anywhere the presentation is mostly late for multifactorial reasons. But the early presentation along with rectal bleeding and haemorrhoids, the detection easy but counselling is an up hill task. Colostomy is frowned upon. Laparoscopy oﬀers easy acceptance. Early cases (21) in no. where there is no permuossal invasion, lymphademopathy and secondaries, laparoscopic dissections of the descending sigmoid and rectal cloonic dissection is easy and pararectal delineations with arterial ligation done and suturing after wide excision of rectal growth is done from anal margins. This followed by post - operative radio and chemotheraphy oﬀers excellent long term results. Colostomy is averted. This study is presented to highlifht low morbidity, long follow up with counselling and patients acceptance. Presentation supported with multimedia movie presentations.

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EVALUATION OF COLORECTAL POSSUM SCORE IN LAPAROSCOPIC COLORECTAL SURGERY H.M.P. Dowson, C. Schwab, A. Huang, T.A. Rockall MATTU, Royal Surrey County Hospital, GUILDFORD, United Kingdom

GASLESS HAND ASSISTED LAPAROSCOPIC SURGERY (GASLESS HALS) FOR COLORECTAL CANCER: LOW BUDGET AND LESS INVASIVE SURGERY Y. Miura1, Y. Ichiba1, T. Maeoki1, S. Ikeda2, Y. Ojima2, M. Okajima2 1 Shinmei Clinic, HIROSHIMA, Japan 2 Hiroshima University Hospital, HIROSHIMA, Japan

Introduction: This study evaluated the Colorectal Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (CR-POSSUM) in patients undergoing laparoscopic colorectal surgery. Methods: The CR-POSSUM score is prospectively collected for all patients undergoing laparoscopic colorectal procedures in our unit. The predicted and observed mortality rates were compared. Results: CR-POSSUM score was available for 60 consecutive patients (63% female). The median age was 68 years (IQR 44–78). There were 29 cancers, 5 patients had diverticular disease, and 5 inﬂammatory bowel disease. 14 patients had endometriosis (of whom 6 required an anterior resection). The most common operations were anterior resection (n=22) and right hemicolectomy (n = 20). There were three conversions (5%). The mortality rate predicted by CR-POSSUM was 5.5% (mean). The observed mortality and morbidity rates were 1.7% and 10% respectively. There was one death in an 86 year old patient who had had an anterior resection. She was discharged home well on Day 4, but was re-admitted with an acute myocardial infarction 4 days later. The CR-POSSUM score in the 27 patients aged over 70 was 9.7% (observed 3.7%). Conclusion: CR-POSSUM overestimates the mortality risks in patients undergoing laparoscopic colorectal surgery. This should be considered when assessing the ﬁtness of patients for surgery, particularly in the elderly.

Gasless laparoscopic surgery has both aspects of open and laparoscopic procedures. Without any inﬂuence of pneumoperitoneum and with hand coordination, it is a good option for the patients with poor cardiovascular reserve and for the operator with less experience in laparoscopic surgery. Aim: To introduce a gasless HALS, surgical procedure including the retractor designed for gasless HALS is demonstrated by video. The brief outcome of gasless HALS and laparoscopic assisted colectomy (LAC) is compared (non randomized study). Method: Nine patients received gasless HALS and 10 patients undertook LAC. The selection was not randomized and the patients with less cardiopulmonary reserve were more likely to be involved in the gasless HALS. Average age and ASA physical status score receiving gasless HALS and LAC was 71.7 vs. 68.0 and 2.6 vs. 1.9 respectively. 3 cases of gasless HALS were scheduled to stay a couple of days in ICU. Results: (Gasless HALS vs. LAC) Operation time (220min, 230min), ileus period after operation (2.3days, 1.9days), body temperature(37.0, 37.4), WBC count(8270/mm3, 8730/mm3)and CRP (6.4, 5.8) on the ﬁrst day were almost the same although gasless HALS resulted in more bleeding (203g, 88g). Pedometer evaluation showed an earlier recovery in LAC than in gasless HALS within 10 postoperative days. Conclusion: Although body movement recovery after operation in gasless HALS group was not as good as in LAC group, it might be inﬂuenced by the preoperative ASA score assessment. Gasless HALS could be applied to the patients with less cardiopulmonary reserve and can be an option as a low budget surgery as it does not need pneumoperitonum and pneumoperitoneum-related instruments.

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FAST-TRACK PERI-OPERATIVE CARE VERSUS TRADITIONAL CARE IN PATIENTS REQUIRING ELECTIVE SEGMENTAL COLORECTAL RESECTIONS; A COMPARATIVE STUDY S.W. Polle, J. Wind, J.W. Fuhring, J. Hoﬂand, D.J. Gouma, W.A. Bemelman Academic Medical Center, AMSTERDAM, The Netherlands

LAPAROSCOPIC SIGMOIDECTOMY FOR DIVERTICULITIS - RESULTS COMPARED TO OPEN SURGERY C.A. Wauschkuhn, M. Ulrich, R. Bittner Marienhospital, STUTTGART, Germany

Fast track (FT) programmes are supposed to reduce morbidity, accelerate recovery and shorten hospital stay. However, the evidence is still limited to justify wide implementation. Aim of this study was to evaluate the results of implementation of a FT programme in our unit and to compare the results with patients treated in a traditional care programme. Methods: All patients, scheduled for an elective abdominal segmental colonic resection in the period August 2004 to July 2005, were treated in a FT programme (FT group). Data were recorded prospectively and compared to a control group operated on for elective colorectal resections in the period June 2003 to December 2003 and treated in a traditional care programme on the same surgical ward (TC group). Discharge criteria for both groups were equal. Both laparoscopic and open procedures were included in the FT and TC group. In a separate analysis the diﬀerences between open and laparoscopic procedures in both groups were evaluated. Main outcome parameters were overall morbidity rate, primary hospital stay, overall hospital stay, and re-admission rate. Results: A total of 107 patients were included in this study: 55 were operated in a FT programme and 52 in a TC programme. Median age between the two groups was comparable (49 vs. 47 years in the FT and TC group respectively) as was the POSSUM operative severity score (median 7 in both groups). Median primary hospital stay was 4.0 days in de FT group vs. 6.0 days in de TC group (p<0.05) and morbidity rate was equal (30.9% vs. 27.3%). The number of readmissions was not signiﬁcantly diﬀerent (FT 10.9% vs. TC 5.8%). Median overall hospital stay (including readmissions) was 4.0 days in de FT group vs. 6.5 days in de TC group (p<0.05). Within the FT group, laparoscopic patients had a shorter primary (4.0 vs. 4.5 days) and overall hospital stay (4.0 vs. 5.0 days) compared to patients that underwent open resection. Conclusions: FT shortens primary and overall hospital stay without increasing postoperative morbidity and readmission rate. Moreover, this study supports the hypothesis that a combination of laparoscopic surgery and FT further reduces hospitalisation.

Objectives: Diverticular disease is a common condition with high morbidity and mortality related to its complications. In the course of the last decade the feasibility of laparoscopic sigmoidectomy for diverticular disease has been well established. But so far the exact advantages of laparoscopic compared to open surgery are still in discussion. Methods: We have reviewed our prospectively collected patient database from December 1997 until now and have compared the intraoperative data and postoperative outcomes of patients who underwent laparoscopic sigmoidectomy for diverticulitis with a historical comparison group also treated in our department and published previously. All cases have been classiﬁed in four subgroups according to a modiﬁed Hinchey classiﬁcation (stages 0–III). Results: Laparoscopic surgery (LS) has been carried out in 564 cases, open surgery (OS) in 445 cases. Both groups were similar with regard to age and gender. Overall, in the group operated laparoscopically the operation time was longer [min] 163 (LS) vs. 127 (OS), morbidity was lower [%] 15.2 (LS) vs. 26.5 (OS), lethality was also lower [%] 0 (LS) vs. 1.6 (OS) and the length of stay in hospital was shorter [days] 12.5 (LS) vs. 19.1 (OS). These results were the same as in the subgroupanalysis (number of cases [n and %]; duration of operation [min]; morbidity [%]; postoperative length of stay in hospital [days]) stage 0: (LS vs. OS) n=283 (50.1%) vs. n=74 (16.6%); 156min vs. 125min; 13.1% vs. 23% and 12days vs. 19days; stage I: (LS vs. OS) n=164 (29.1%) vs. n=161 (36.2%); 165min vs. 125min; 15.2% vs. 20.5% and 13days vs. 19days; stage II: (LS vs. OS); n=113 (20.1%) vs. n=177 (39.7%); 178min vs. 133min; 21.2% vs. 30.5% and 14days vs. 20days; stage III: (LS vs. OS) n=4 (0.7%) vs. n=33 (7.4%); 179min vs.127min; 0% vs. 42.4% and 13days vs. 25days. Conclusion: The laparoscopic sigmoidectomy is a safe operation technique, it seems to have advantages compared to open surgery. However for a deﬁnite rating randomised studies analysing the long-term outcome are required.

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LONGTERM SURGICAL RECURRENCE, MORBIDITY, QUALITY OF LIFE AND BODY IMAGE OF OPEN VS LAPAROSCOPIC-ASSISTED ILEOCOLIC RESECTION FOR CROHNS DISEASE: A COMPARATIVE STUDY S.W. Polle1, E.J. Eshuis1, D.W. Hommes1, J.F.M. Slors1, A. Gerritsen van der Hoop2, R.A. Van Hogezand2, D.J. Gouma1, W.A. Bemelman1 1 Academic Medical Center, AMSTERDAM, The Netherlands 2 Leiden University Medical Center, LEIDEN, The Netherlands

TOTAL LAPAROSCOPIC VERSUS HAND-ASSISTED LAPAROSCOPIC RESTORATIVE PROCTOCOLECTOMY: A PROSPECTIVE COMPARATIVE STUDY S.W. Polle, S. Maartense, J.F.M. Slors, D.W. Hommes, D.J. Gouma, W.A. Bemelman Academic Medical Center, AMSTERDAM, The Netherlands

The objective of this study was to compare long-term results in terms of both clinical outcome and quality of life (QOL) in patients after open vs. laparoscopic-assisted ileocolic resection for Crohns disease. Patients and Methods: Seventy-six patients who underwent an ileocolic resection for Crohns disease between 1995 and 1999 were retrospectively analysed; 48 consecutive patients underwent open resection in the Academic Medical Center, Amsterdam vs. 28 laparoscopic-assisted resection in the Leiden University Medical Center. Main outcome parameters were incidence of reoperation for disease recurrence, clinical signiﬁcant small bowel obstruction and the incidence of incisional hernia. Secondary outcome parameters were QOL as measured by the SF-36, and cosmesis and body image, both measured by the body image questionnaire. Results: Patient characteristics as sexe, BMI and age were comparable for both groups. Median length of follow-up was 8.6 vs. 8.3 years in the open vs. laparoscopic group (P = NS). No signiﬁcant diﬀerences were found between the open and laparoscopic group in the incidence of reoperation for disease recurrence (22.7% vs. 22.2%; P=NS). None of the patients was readmitted for clinical signiﬁcant small bowel obstruction. In the open group 7% had surgery for incisional hernia compared to none in the laparoscopic group. Although there was a tendency to higher scores in the laparoscopic group on all subscales of the SF-36, none of these diﬀerences was statistically signiﬁcant. Body image was not diﬀerent, but cosmesis scores were signiﬁcantly higher in the laparoscopic group (score 14 vs. 21 on a maximum potential score of 23, P <0.001) Conclusions: Laparoscopic-assisted ileocolic resection does not reduce the number of reoperations for disease recurrence, but it likely reduces the incidence of incisional hernia. The most important long-term beneﬁt of the laparoscopic approach is the superior cosmesis.

A randomised trial comparing hand-assisted laparoscopic with open restorative proctocolectomy did not show advantages for the hand-assisted laparoscopic approach with respect to early recovery. This unexpected ﬁnding might be explained by a combination of the hand-assisted laparoscopic colectomy with an open proctectomy via the Pfannenstiehl incision. A total laparoscopic approach (i.e. laparoscopic colectomy nd proctectomy) might show an accelerated recovery compared to the hand-assisted approach. Aim of this study was to compare early recovery after total and hand-assisted laparoscopic proctocolectomy. Methods: Thirty patients who underwent total laparoscopic proctocolectomy between April 2004 and January 2006 were prospectively analysed (TLP group). Patients were compared with 30 patients who underwent hand-assisted laparoscopic proctocolectomy between August 1999 and August 2003 (HALP group) as part of a randomised trial comparing hand-assisted laparoscopic with open restorative proctocolectomy. Only patients with ulcerative colitis or familial polyposis coli without previous bowel resections were included. Primary outcome parameters were operating-time, number of intra-operative complications, morbidity and length of postoperative hospital stay. Secondary parameters were results of VAS-scores for postoperative pain and morphine-requirement. Results: The groups were comparable for patient-characteristics as sex, body-mass index and age. None of the procedures required conversion and there were no intraoperative complications. Median operating-time was signiﬁcantly longer in the TLP than in the HALP group (298 vs. 215 minutes, P = < 0.001). Ten patients in the TLP group received a primary protecting loop ileostomy versus 8 in the HALP group (P = 0.779). Neither minor nor major morbidity diﬀered statistically and there was no diﬀerence in the number of patients requiring surgical re-intervention (5 vs 3 patients in the TLP and HALP group respectively). Median postoperative stay was 10 days in the HALP group and 9 days in the TLP group (P = 0.147). VAS-scores were not diﬀerent. Although daily and total morphine-requirement were lower in the TLP group, the reduction was not statistically signiﬁcant. Conclusions: Total laparoscopic restorative proctocolectomy requires considerable longer operation time and has no signiﬁcant advantages over the handassisted laparoscopic approach in terms of early recovery, morbidity and morphine-requirement.

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DIFFICULTY GRADE SCORE FOR THE LAPAROSCOPIC APPROACH OF RECTAL CANCER A.A.F.A. Veenhof, D.L. Van der Peet, S. Meijer, M.A. Cuesta VUmc, AMSTERDAM, The Netherlands

COLONIC OBSTRUCTION TREATMENT WITH SELF-EXPANDABLE METALLIC STENT OR SURGERY? E. Angenete, M. Bergstro¨m, P-O. Park Sahlgrenska Universitetssjukhuset/O¨stra, GO¨TEBORG, Sweden

Background and aim: In order to improve the preparation and planning of laparoscopic rectal surgery and to enhance training there is a necessity to deﬁne the diﬃculty grade of laparoscopic surgery in rectal cancer. Furthermore it could be important in comparison between diﬀerent series by stratifying the results and thus permitting a more accurate assessment. Methods: Twelve factors were prospectively evaluated in 50 consecutive patients who underwent laparoscopic surgery for rectal cancer. Combining scores for each of these factors resulted in a ﬁnal diﬃculty grade score for the 50 individual laparoscopic procedures. -Patient characteristics; body mass index (BMI), male or female pelvis, localization of the cancer (high, mid or low rectum), preoperative radiation therapy, previous abdominal surgery -Operative characteristics; operative time, blood loss, performed omentoplasty, mobilization of the splenic ﬂexure, type of anastomosis, peroperative complications/ conversion -Diﬃculty grade surgeon; a scale from 1 through 10 was created Conclusion: According to the studied parameters, a scale of diﬃculty grade can be observed. High rectum tumors (male and female) and mid rectal cancer in female patients are the Ôless diﬃculty gradeÕ, whereas low rectal tumors (in female and male patients) can be considered as mid diﬃculty grade and ﬁnally the mid rectal cancers in male patients are the most diﬃcult to operate laparoscopically. Taking into account this diﬃculty grade score in laparoscopic rectal surgery, future planning, training and publication regarding laparoscopic rectal surgery will be enhanced.

Aims: Self-expandable metallic stents (SEMS) have become an increasingly accepted alternative to surgery in patients with colorectal obstruction. The aim of this study was to compare the results of SEMS with patients undergoing surgery at our hospital between August 2003 and December 2006. Methods: Patients with colonic obstruction or stricture of the colon received a SEMS either as a palliative procedure or as bridge-to-surgery. The patients were followed prospectively. Two endoscopists carried out the SEMS procedures. Patients admitted to the same hospital with acute colonic obstruction treated with surgery, were reviewed retrospectively. Results: A total of 47 patients were treated with the intent of placing a SEMS. 45 patients received a SEMS. Median age 78(48–90) years. The stricture was caused by colorectal cancer (36), ovarian cancer (3), diverticulitis (2) and unknown diagnosis (3). 21 patients were treated due to acute obstruction, out of which 4 were treated as bride-to-surgery. 2 more patients were treated as bridge-to-surgery due to stricture. 45 patients were considered a technical success, 7 patients needed more than one SEMS during the same procedure. 5 patients received surgery related to SEMS. 34/47 patients received no further treatment than their SEMS. No procedure-related mortality was observed. Median hospital-stay after the procedure was 3 (0–9) days. Median follow-up time: 5 (0–25) months. During the same period of time 31 patients were operated on due to colorectal obstruction. Median age 77 (51–94) years. The stricture was caused by colorectal cancer (26), carcinosis (1) and other causes (3). Only three patients had disseminated disease. 30-day mortality was 5/31 and 16/31 received a stoma. 7 patients had procedure-related complications. Median hospital-stay after surgery: 10 (2–45) days, and median follow-up time: 14 (0–27) months. Conclusion: SEMS is a safe and eﬀective procedure in the treatment of colonic obstruction and involves short hospital stay. In selected patients it is a good alternative to surgery especially if the patient has disseminated disease.

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NATIONWIDE IMPACT OF LAPAROSCOPIC LYSIS OF ADHESIONS IN THE MANAGEMENT OF INTESTINAL OBSTRUCTION IN THE UNITED STATES G.J. Mancini, G. Petroski, W-C. Weih, K. Thaler University of Missouri, COLUMBIA, United States of America

LONG-COURSE NEOADJUVANT RADIOCHEMOTHERAPY FOR RECTAL CANCER. A MONOINSTITUTIONAL EXPERIENCE S. Di Palo, A. Tamburini, E. Orsenigo, A. Vignali, N. Osman, C. Staudacher San Raﬀaele Scientiﬁc Institute, MILAN, Italy

Aims: The treatment of adhesion related complications is cost intensive and presents a considerable burden to the health system. Potential beneﬁts laparoscopy may confer have not been conclusively deﬁned yet. This study compares laparoscopic lysis of adhesions (LLA), open (OLA) and converted procedures in the treatment of intestinal obstruction (IO) based on a representative sample. Methods: The ICD-9 diagnosis code for IO and procedure codes for LLA, OLA and conversion were identiﬁed from the 2002 National Inpatient Sample, which represents 20% of all U.S. hospital discharges. Three way analyses were performed to compare LLA, OLA and conversion. Riskadjusted end-points included postoperative morbidity and mortality, length of stay (LOS), and in-hospital costs. Multiple linear and logistic regression analyses were used to control for confounding variables including demographics and comorbidity indicators. Results: 6,165 patient discharges were analyzed. 88.6% of the patients underwent OLA and 11.4% LLA. 17.2% required conversion. Postoperative mortality for LLA and conversion was lower when compared to OLA (1.7% vs 1.7% vs 3.4%, p < .001). Postoperative morbidity was less for LLA than for conversions and OLA (17.6% vs 31.4% vs 30.0%, P <.0001). The same was true for risk adjusted median LOS (LLA, 4.8 days vs conversions, 6.8 days vs OLA, 7.5 days, P <.0001) and median costs (LLA, $8,217 vs conversion, $10,130 vs OLA, $9,992, P = < .001). LLA was correlated with a 34% decrease of LOS (p < .001), and an 18% reduction in overall costs (p < .001) compared to conversion and OLA. Conclusions: Laparoscopic lysis of adhesions is underutilized in the treatment of intestinal obstruction. When laparoscopic treatment can be successfully completed, our data suggest a reduction in postoperative morbidity, hospital stay, and costs. Conversion to open lysis of adhesions is less favorable, though yielding equivalent outcomes to a traditional open procedure.

Aims: Because it oﬀers many advantages over postoperative therapy, preoperative chemoradiation for advanced rectal cancer (stage II and III) has become the standard at many institutions. Aim of this study is to evaluate the prognostic role of uTNM and yTNM in a group of patients submitted to neoadjuvant radiochemotherapy for advanced rectal cancer. Patients and method: From January 1998 to May 2005, 138 consecutive patients (86 male, 52 female, mean age 61.4 years), with advanced rectal cancer (stage II and III established by EUS, MR and CT) were submitted to a Ôlong-courseÕ radiochemotherapy and, after 4–6 weeks, operated on. Kaplan-Meier estimates, log-rank tests, and Cox regression analyses were used to correlate uTNM and yTNM with 5-years overall-survival. A p value < 0.05 was considered signiﬁcant. Results: 115 patients (83%) showed a clinical stage (uTNM) II and 23 (17%) a clinical stage II. No major complications were observed and all the patients have completed the course of therapy. A complete or partial response was observed in 48.5% of the patients (67/138). We observed a signiﬁcant clinical (uTNM) down staging (p < 0.004). Two patients with no residual tumour, refused intervention. Surgical procedures (71 of which laparoscopic) were: 114 AR (83.8%), 19 APR (14%) and 3 TEM (2.2%). Mean nodal-sampling was 14.9. Concerning yTNM, 19/136 patients (13.9%) were in stage 0, 36/136 (26.4%) in stage I, 33/136 (24.2%) in stage II and 50/136 (36.7%) in stage III. Five-years overall-survival and disease-free-survival were respectively 73% and 60%. Pre-treatment clinical stage (uTNM) had no prognostic signiﬁcance (p=0.9321). On the contrary, postoperative yTNM was signiﬁcant (p=0.0021) for yT (p<0.001) and yN (p<0.0003). The variable with higher prognostic signiﬁcance was yN (p < 0.0003). With a mean follow-up of 39 months, local recurrence rate was 5.7%. Conclusions: The prognosis of patients with advanced rectal cancer submitted to neoadjuvant radiochemotherapy depends on their response to therapy (yTNM) and not on uTNM.

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TOTAL MESORECTAL EXCISION (TME) WITH LAPAROSCOPIC APPROACH. 132 CONSECUTIVE CASES S. Di Palo, A. Vignali, A. Tamburini, R. Sampietro, E. Orsenigo, C. Staudacher San Raﬀaele Scientiﬁc Institute, MILAN, Italy Aims: This study aims to review the operative results and local recurrence rate of Total Mesorectal Excision (TME) with laparoscopic (LPS) approach for cancer of the middle and low rectum, in a series of unselected patients operated on with sphincter-saving procedure from 1998 and 2005. Methods: Patients with cancer of the middle and low rectum who underwent elective LPS-TME with sphincter-saving procedure over a 8 year period (January 1998, December 2005) in our Department of Surgery were prospectively evaluated. All patients underwent pelvic MR and EUS. In case of uStage II and III a Ôlong-courseÕ preoperative radiochemotherapy was implied and these patients were operated on after 4–6 weeks from the end of the therapy. The operation procedures were conducted according to the guidelines advocated by Heald: posteriorly, along the Ôholy planeÕ downward to the level of levator ani muscle, anteriorly, in front of Denonvilliers fascia and laterally, the lateral ligaments were sharply cauterized at the medial part. The resected bowel was reconstructed with doublestapling technique or colo-anal hand-made anastomosis. Patients were monitored for 30-days postoperative complications and with oncologic follow-up with particular attention to local recurrence rate. Results: 132 consecutive patients (72 male, 60 female, mean age 64.5, mean ASA score 2.3) underwent LPS-TME, 89 of them (67.4%) after neoadjuvant radiochemotherapy. The mean distance from the anal verge was 5.1 cm. Conversion rate was 9.8% (13/132). Diverting stoma was made in 95/ 132 (71.9%) patients. Overall 30-days morbidity rate was 28.0%. The incidence of anastomotic leak was 14.3%. No patient died in the postoperative period. Reoperation rate was 6.0% (8/132). Mean hospital stay was 10.4 days. The mean number of lymph nodes collected was 16.3 and the mean length of the distal margin was 2.7 (2) cm. After a median follow-up time of 39.5 months local recurrence rate was 5.3% (7/132). Conclusion: By laparoscopic approach, the TME for rectal cancers can be safely performed with satisfactory surgical outcome and acceptable rate of local recurrence. It represents a safe option in patients with rectal cancer and we believe that it can be performed in the majority of them.

THE TECHNIQUE OF ENDOSCOPIC POSTERIOR MESORECTAL EXCISION J. Ko¨ninger1, B. Mu¨ller1, J. Weitz1, A. Zerz2, M.W. Bu¨chler1, C.N. Gutt1 1 University of Heidelberg, HEIDELBERG, Germany 2 Chirurgische klinik, Kantonsspital St. G, ST. GALEN, Switzerland Aim: Local excision of rectal cancer is limited to early stages of the disease. Consensus on transanal resection exists regarding well-diﬀerentiated small tumours (T1, G1–2). More advanced tumours should be resected transanally only in highly selected cases, in which perioperative risk of low anterior resection (LAR) exeeds the risk of local recurrence due to nonresected mesorectal lymph nodes. The principle of Endoscopic Posterior Mesorectal Excision (EPME) is the excision of mesorectal fatty tissue and lymph nodes by means of an endoscopic paracocyceal approach to expand the indication for organ preserving therapy of rectal tumours. Methods: Patients included in this observational trial had histologically proven adenocarcinoma of the rectum. Preoperative staging was performed by MRT/CT and rectal ultrasound examination. Only patients with T1/2 stage and well-diﬀerentiated tumor (G1/2) were included. Suspected positive lymph nodes led to exclusion from the trial; these patients were treated by conventional LAR. Rectal tumors in patients which met the inclusion criteria were excised by a transanal approach or TEM. Patients in which histological examination of the specimen conﬁrmed a T1/2 rectal cancer underwent EPME 4–6 weeks after primary surgery. Further management of the patients was determined by the result of histological examination of the mesorectal tissue. Patients without positive lymph nodes received no further treatment. Postoperative radio/chemotherapy was applied to patients in whom positive lymph nodes were conﬁrmed by histopathological examination. Patients were followed up by endoscopy, rectal ultrasound and CT scan every 3 months after surgery. Results: In this presentation we demonstrate that this approach to welldiﬀerentiated stage one rectal cancer is feasible and safe and we present data of the ﬁrst patients treated in Heidelberg according to the protocol. Conclusion: EPME is a viable option to extend the indication for organ preserving surgery in patients with rectal cancer.

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LAPAROSCOPIC COLECTOMY FOR TRANSVERSE COLON CARCINOMA A. Bar-Dayan, D. Rosin, Y. Munz, M. Shabtai, A. Ayalon, O. Zmora Sheba Medical Center, TEL HASHOMER, Israel

LAPAROSCOPIC COLORECTAL SURGERY BY RADIOFREQUENCY DISSECTOR AS SOLO DEVICE FOR DISSECTION, HEMOSTASIS, CUTTING AND GRASPING M. Carlini, F. Castaldi, R. DellÕAvanzato, C. Giovannini, E. Mercadante S. Eugenio Hospital, ROME, Italy

Aims: Laparoscopic resection of transverse colon carcinoma is considered technically demanding, and is not included in most of the large prospective trials of laparoscopic colectomy. The aim of this study is to assess the safety, feasibility and outcome of laparoscopic resection of carcinoma of the transverse colon. Methods: Retrospective review of a prospectively entered database was performed to identify all patients who underwent laparoscopic resection of transverse colon carcinoma (group A). Demographic and clinical characteristics, operative data, and post operative outcome were compared to patients who had laparoscopic resection for right (group B) and sigmoid colon (group C) carcinoma. Results: 22 patients (14 males, mean age 68 years) underwent laparoscopic resection for transverse colon carcinoma between 1999 and 2005. 68 patients who operated for right colon and 64 for sigmoid colon cancer served as comparison groups. There was no signiﬁcant diﬀerence in demographic and clinical pre-operative characteristics between the 3 groups. Intraoperative complications occurred in 4.5% of group A patients, compared to 5.9% and 7.8% in groups B and C respectively (p=0.8). Early postoperative complication rate was 45% in group A compared to 50% and 37.5% in groups B and C respectively (p=0.4). Conversion rate, late complications, and tumor recurrence also did not signiﬁcantly diﬀer between the groups. Conclusions: Laparoscopic colon resection for transverse colon carcinoma is associated with comparable results to resection of right and sigmoid colon cancer. These results suggest that laparoscopic resection of transverse colon carcinoma may be safe and feasible. Randomized trials of laparoscopic versus open resection are worthwhile to deﬁne the role of laparoscopy in the treatment of transverse colon tumors.

Introduction: New devices are reducing costs and length of the laparoscopic colorectal resections and are making it technically easier. Patients and Methods: Sixtysix patients were submitted to laparoscopic colorectal resection using only one device, the radiofrequency dissector Ligasure AtlasTM for dissection, grasping, major vessels sealing, haemostasis and cutting. Fiftyﬁve were aﬀected by carcinoma: 18 of the rectum, 3 of the recto-sigmoid junction, 14 of the sigmoid, 6 of the left colon, 2 of the left colonic ﬂexure, 2 of the right transverse and 10 of the right colon. Eleven cases were aﬀected by benign disease: 6 sigmoid diverticulitis, 3 left colon adenomas, 1 megacolon and 1 ulcerative colitis. The procedures consisted of 17 colorectal resection with total mesorectal excision, 5 colorectal resection with partial TME, 18 sigmoidectomies, 9 left hemicolectomies, 3 trasverse resections, 12 right hemicolectomies, 1 Hartmann procedure and 1 total colectomy. All the steps of the procedures were performed with the radiofrequency dissector only. Scissors, clips, stiches, ties, monopolar or bipolar coagulators or other devices were not used in any case. Ten anastomoses were hand made and 56 were mechanical. Results: Four procedures was converted to open surgery, due to the extension of the tumour. The 62 laparoscopic colo-rectal resections required a mean time of 116 minutes (range 60 205. The intraoperative blood loss was null and the operating ﬁeld was clean in all cases. The postoperative course was uneventful in 57 cases. Three anastomotic leaks, one jejunal hemorrage due to angiodisplasya and successfully treated by angiographic embolyzation and two infections were observed and conservatively treated. In 3 cases hemotrasfusions (one unit for each patient) were necessary. No reoperations were done and the post operative mortality was null. Discussion: The laparoscopic colectomies performed by the Ligasure AtlasTM solo, appeared feasible, eﬀective and reproducible. The instrument reassumed the functions of many instruments and devices, allowing to save money and time (no need to change instrument during the operation). The ﬁeld cleaning was improved, the section margins were sharpened and the specimen integrity was excellent.

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MY EXPERIENCE IN TRANSANAL EXCISION FOR VILLOUS ADENOMA INTRODUCTION J.A. Gonza´lez Garcia American British Cowdray Med. Center, Mexico

A SYSTEMATIC REVIEW OF SHORT-TERM OUTCOME AFTER LAPAROSCOPIC (-ASSISTED) ILEOCOLIC RESECTION FOR CROHNS DISEASE S.W. Polle, J. Wind, D.Th. Ubbink, D.J. Gouma, W.A. Bemelman Academic Medical Center, AMSTERDAM, The Netherlands

Villous adenomas are benign tumors, frequently observed in the rectum, they can be pedunculated or sessile but usually they are sessile. Rectal bleeding and mucous discharge are the most frequent presenting complaints. A unique symptom complex associated with villous adenoma is hipokalemia and dehydration, attributed to the loss of copious ﬂuid and electrolytes from the mucus-secreting tumor. Transanal excision is my preferred operation. I combine surgical excision and laser photoablation with carbon dioxide laser system. Methods: In a three year revision I attended 82 patients; the median age was 65 years (range 35–82 years), one third presented large lesions with prolapsed through the anal canal. Rectal bleeding and mucous discharge were the predominant symptoms, 35 patients were suﬀering dehydration attributed to the loss of copious ﬂuid and electrolytes. In 75 patients sigmoidoscopy demonstrated the presence of the lesion. The site of the tumor was in the rectum between 8–12 ems from the anal verge. In all patients the operation of choice was transanal surgical excision combined with laser photoablation. I placed a suitable anal retractor and adjusted to give maximum exposure. Some sutures are located in place around the lesion and then I performed a round incision through the mucosa. The lesion is gradually excised using sharp dissection in the submucosal plane. After the lesion has been removed entirely the defect in the mucosa-submucosa surface is repaired using the stay sutures. Finally I employ the carbon dioxide laser. The laser beam destroys the remainder tissue. Results: The relieve of symptoms were achieved immediately after surgery; the patients were free of bleeding and mucous discharge. The wound healed in six weeks. Discussion: In Villous adenoma and benign rectal tumors, the surgical treatment is transanal surgical excision with laser photoablation, the average of stay in the hospital was one night, and most of the patients resume their normal activities four days after the operation. I never had a postoperative complication, and the evolution was painless, without any discomfort. All the patients were pleasant with this management.

O215 ENDO-LAPAROSCOPIC APPROACH VS CONVENTIONAL OPEN SURGERY IN THE MANAGEMENT OF OBSTRUCTING LEFT-SIDED COLONIC CARCINOMA: A RANDOMIZED TRIAL C.H. Wong1, C.C. Chung1, W.W.C. Tsang1, S.Y. Kwok1, M.K.W. Li2 1 Pamela Youde Nethersole Eastern Hospital, HONG KONG SAR, China 2 PYN Eastern Hospital, HONG KONG, Hongkongcases. Management of obstructing left side colonic cancer is complicated. Patients are often left with a long abdominal incision, and a colostomy seems unavoidable in many Objective: To compare endo-laparoscopic (EL) approach with conventional open (OPEN) surgery in the management of obstructing left side colonic carcinoma. Method: Patients with obstructing left side colonic cancer situated between splenic ﬂexure and rectosigmoid junction as shown on contrast enema studies are recruited. Those patients with features of peritonism or strangulation are excluded. Patients are randomized into EL or OPEN group. In the OPEN group, patients will receive emergency laparotomy, and the exact type of operation would be chosen at the discretion of the surgeon. In the EL group, patients will undergo initial endoscopic stenting. Laparoscopic colectomy under full bowel preparation will be performed within 3 weeks following successful decompression. The postoperative course as well as total length of hospital stay are assessed and compared. Results: Forty patients, aged between 27 to 86, were recruited, with 20 patients in each group. The age and gender distribution is similar between the two groups. In the open group, 14 patients (70%) received primary anastomosis whereas 6 patients (30%) had HartmannÕs procedure initially. In the EL group, two patients (10%) had failed endoscopic decompression and ended up in HartmannÕs procedure. Eighteen patients (90%) went on to receive laparoscopic colectomy and among these, one patient (5.6%) had conversion to open surgery. Signiﬁcantly more patients in the EL group received successful one-stage procedure as compared to the open group (83.3% vs 60%), and signiﬁcantly more perioperative morbidities were observed in the open group. The length of stay was also longer in the open group. Conclusion: Our study shows that this endo-laparoscopic approach not only helps to avoid surgery in the acute stage but also allows patients with obstruction to enjoy the full beneﬁts of minimally invasive surgery. Postoperative morbidity is reduced.

Patients requiring ileocolic resection for Crohns disease (CD) might beneﬁt from a minimal invasive approach. At present, no consensus exists whether ileocolic resection CD should be carried out by a laparoscopic or open approach. A systematic review was undertaken to assess the evidence of short-term advantages of a laparoscopic approach compared to an open approach in patients undergoing ileocolic resection for CD. Methods: A systematic search of the literature was conducted over the period January 1991 up to February 2006. Only randomised controlled trials (RCTs), clinical controlled trials and comparative studies that compared laparoscopic or laparoscopic-assisted with open resection for ileocolic CD were included. A quality assessment by using a therapy checklist as proposed by the Dutch Cochrane Collaboration was done for all retrieved full-text articles. Primary outcome parameters were operating times, conversion rates, major and minor morbidity, time to resumption of normal diet and length of hospital stay. Results: A total of 14 publications encompassing 729 patients met the inclusion criteria. Two studies were randomised controlled trials, both of moderate to good quality, and 12 were non-randomised controlled trials (non-RCTs) generally of fair quality. In most of the studies a laparoscopic-assisted rather than a total laparoscopic technique was used. Pooling the data of operating times was not possible due to statistical heterogeneity, but operating times were longer for the laparoscopic procedure in most of the individual studies. The reported conversion rate varied between 0 and 16.7% depending on deﬁnitions used. Pooled data of the number of postoperative complications requiring re-operation and reported overall morbidity, showed no diﬀerence between the open and laparoscopic procedure (risk diﬀerence )0.01 and )0.05 respectively). The time to resumption of normal diet was 1.12 days shorter after the laparoscopic procedure (conﬁdence interval (CI): 0.64 1.61). Length of hospital stay was 1.90 days shorter after the laparoscopic procedure (CI: 0.83 - 2.97). Conclusions: There is evidence that laparoscopic (-assisted) ileocolic resection for CD is associated with shorter hospital stay compared to conventional open ileocolic resection, while morbidity rates are equal and conversion rates are acceptable.

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INDICATION FOR AN IMMEDIATE REOPERATION AFTER A CHOLECYSTECTOMIE FOR AN INCIDENTAL GALLBLADDER CARCINOMA V. Paolucci, T. Goetze Ketteler- Krankenhaus, OFFENBACH, Germany

LAPAROSCOPIC TREATMENT OF INTRAHEPATIC DUCT STONE IN THE ERA OF LAPAROSCOPY H-S. Han, Y-S. Yoon, Y-S. Choi Seoul National University,College of Med, SEONGNAM-SI, GYEONGGI-DO, South-Korea

Introduction: The immediate reoperation after a cholecystectomie for an incidental gallbladder carcinoma is disscussed controversly. For a T1 tumor a cholecystectomie is enough. For T2 and more advanced stages a reoperation is permitted. The reoperation includes a resection of the liver and lymphnode exstirpation. In which T- stage such a reoperation should be undertaken is discussed controversly. Some authors recommend a reoperation in case of T1b- stage and improve the 5 year survival from 60 to 100%.Others recommend it only when the margins are positive or when the subserosal invasion is > 2mm.The question is, if T1 tumors proﬁt from a reoperation or if this is only an additional lethality. Material and method: To obtain data we use the CAES/CAMIC-register. Results: 417 cases of incidental gallbladder carcinomas a registered.In 64 patients with T1- tumor there was no reoperation.In 21 patients with T1tumor there was a reoperation.Graph 1 shows survival according to Kaplan- Meier for T1- tumors. There is a prognostic advantage for T1tumors with a reoperation. In 105 patients with T2- tumor there was no reoperation.In 75 patients with T2- tumor there was a reoperation. Graph 2 shows survival according to Kaplan- Meier graph for T2- tumors with a prognostic advantage for T2- tumors with reoperation. Graph 3/ 4 shows no better survival for T3/4- tumors after reoperation. (tabel) Discussion: There is a higher survival for T1 and T2- tumors after an immediate reoperation (log- rank>0,05) in our patients. For T3/4- tumors there seems to be no prognostic beneﬁt according to the survival.

Introduction: Until now, laparoscopic surgery for intrahepatic duct (IHD) stone has been rarely reported. The aim of this study is to analyze our experiences of laparoscopic surgery for IHD stone and evaluate its role in the management of IHD stone. Methods: From October 1998 to December 2004, 47 cases of laparoscopic surgery for IHD stone (22 laparoscopic IHD exploration (LIHDE), 25 laparoscopic hepatectomy(LH): 9 left hepatectomy, 16 left lateral segmentectomy) were performed. The choice between LIHDE and LH was based on the presence and severity of IHD stricture determined by preoperative cholangiography and intraoperative choledochoscopy; LIHDE was performed in case of no or mild stricture (>5 mm), and LH in case of moderate (2–5mm) or severe stricture (<2 mm). We retrospectively analyzed the clinical outcomes of these 47 patients. Results: The mean operation time (LIHDE vs. LH) was 281.4 and 414.4 minutes, and the open conversion rate was 18.2% (4 cases) and 4.0% (1 case), respectively. The mean postoperative hospital stay was 14.9 and 13.0 days. Postoperative complications occurred in 2 cases (9.1%) of LIHDE group and 3 (12.0%) of LH group, all of which responded to the conservative medical management. There was one case of postoperative mortality in LH group due to sepsis. Remnant stone was identiﬁed by postoperative T-tube cholangiography in 4 cases (18.2%) of LIHDE group and 3 (12.0%) of LH group. Of these, 3 cases were not managed due to asymptomatic small stones and the remaining 4 underwent choledochoscopic removal. Recurrent stones were detected in CBD by follow-up ultrasonogram in 1 case (4.5%) of LIHDE group and 3 (12.0%) of LH group, all of which were treated with endoscopic sphincterotomy and lithotripsy. Conclusions: This study suggests that laparoscopic surgery could be a safe and eﬀective option in the management of IHD stones.

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LAPAROSCOPY-ASSISTED AND TOTAL LAPAROSCOPIC METHODS IN ANATOMICAL LIVER RESECTION H-S. Han, Y-S. Yoon, Y-S. Choi Seoul National University,College of Med, SEONGNAM-SI, GYEONGGI-DO, South-Korea

SIX-YEAR EXPERIENCE WITH LAPAROSCOPIC CHOLECYSTECTOMY PERFORMED BY ULTRASONIC DISSECTION

Objectives: Anatomical liver resection can be performed by using the laparoscopy-assisted or the total laparoscopic methods. We describe our experiences of laparoscopic hepatic resection using these two procedures and methods. Method: We retrospectively reviewed the results of 10 cases of laparoscopyassisted (Lap-Assist) and 25 cases of total laparoscopic (Total-Lap) anatomical liver resection registered between April 2001 and June 2004. Results: Indications for laparoscopic anatomical liver resection included 25 cases of IHD stones, 7 cases of HCC (cholangiocarcinoma were conﬁrmed postoperatively in 2 cases) and 3 cases of benign tumors. In Lap-Assist group, there were 7 cases of left lateral sectionectomy, and one case each of left hemihepatectomy, right hemihepatectomy, and open conversion. In Total-Lap group, there were 11 cases of left hemihepatectomy, 12 cases of left lateral sectionectomy, one case of right posterior sectionectomy, and one case of S5,6 bisegmentectomy. The respective sizes of the incisions were 8.7cm and 4.6cm (p<0.001) for these two procedures. No diﬀerences between two groups (Lap-Assist vs. Total-Lap) were observed in operation time (351.0 vs. 411.8 minutes), transfusion amount (1.8 vs. 1.6 units), starting day of diet (3.7 vs. 3.8 days), complication rates (30% vs. 8%) or the duration of hospital stay (8.7 vs. 12.2 days). Postoperative mortality occurred in one patient of Total-Lap group due to sepsis. However, the remaining postoperative complications (2 atelectasis, 1 minimal bile leakage, 1 infarction of one segment) responded to the conservative management. Conclusions: Both the laparoscopy-assisted method and the total laparoscopic method are feasible for anatomical liver resection.

M.M. Lirici1, C. Hu¨scher2, M. Di Paola2, C. Ponzano2, G. Sgarzini2, M.G. Fava1, F. Salerno1 1 BMM Hospital, REGGIO CALABRIA, Italy 2 San Carlo Hospital, MILAN, Italy Preliminary results of lapchole (LC) totally performed by means of ultrasonically activated device were ﬁrst reported by the Authors in 1999. From 1999 to 2005 a prospective nonrandomized trial was carried on in 2 centers to assess the beneﬁts of US dissection in LC. Primary endpoint was to evaluate the possible reduction of BD thermal injury risk. Secondary endpoint was to evaluate whether US dissection may aﬀect (improve) the surgical technique. Overall 1075 LC were performed by US dissection. Pts. were divided in 2 groups: LC totally performed by US with no need of cystic duct (CD) ligature 744 (69.2%), and LC with US dissection where CD was further secured by absorbable loop or clip 331 (30.8%). Each arm was divided in 2 subgroups: expert and surgeon-intraining. Morbidity, mortality, operating time, conversion rate, lenght of p.o. stay were analyzed using Statistica for Windows 5.0 software (Statsoft)- StudentÕs ttest, chi-square, Yates corrected chi-square and FisherÕs exact tests were used for data analysis; p value = 0.05 was considered signiﬁcant. US lapcholes with CD further secured by loop or clip were mainly performed in severe acute cholecystitis or when CD was >3 mm. In those cases an upsidedown procedure was mostly performed. In all cases the US device was the only working instrument beside the grasper. Complications were divided into major (MC) and minor (mC) according to the Clavien classiﬁcation. MC (grade 2–4) were 4.0% and mC (grade 1) were 7.2%. Overall mortality rate was 0.46%: mortality in emergent ASA IV pts. was .28% while that in elective pts. was .18%. No death was related to BDI. BDI rate was 0.37%, bile leaks were 1.30% (conservative management .65%, surgical management .65%). No statistically signiﬁcant diﬀerence was found between the 2 groups. MC, BDI and bile leaks were signiﬁcantly diﬀerent in the expert and surgeon-in-training subgroups (p respectively = .026, .03, .049). Compared to BDI and BDI related mortality in major cumulative series published in the literature, BDI rate in our series was pretty low and BDI related mortality was nil. Furthermore in those diﬃcult cases with unclear anatomy US dissection allows to perform an upside-down procedure with an almost bloodles ﬁeld. Overall ergonomics of surgery is improved. Nevertheless, a learning curve in the use of US shears is required to reduce the risk of thermal damage to the bowel in case of visceral adhesions.

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PREOPERATIVE SCORING SYSTEM PREDICTING DIFFICULTY OF LAPAROSCOPIC CHOLECYSTECTOMY M. Soltes1, P. Pazinka1, J. Petrovicova2 1 Nemocnica Kosice Saca a.s., KOSICE-SACA, Slovak Republic 2 Institute of Medical Informatics, UPJS, KOSICE, Slovak Republic

SYSTEMATIC LAPAROSCOPIC TREATMENT OF RECURRENT PYOGENIC CHOLANGITIS C.N. Tang, D.K.K. Tsui, J.P.Y. Ha, G.P.Y. Yang, M.K.W. LI Pamela Youde Nethersole Eastern Hospital, HONG KONG SAR, Hongkong

Aims: To investigate potential preoperative risk factors (RF) associated with increased diﬃculty of laparoscopic cholecystectomy (LC). Based on those, to deﬁne and evaluate risk score of diﬃculty (RSD) that may enable to predict diﬃculty of LC and thus to improve: selection of adequatly experienced surgeon for individual patient, indication of primary open cholecystectomy, evaluation of risk of conversion, identiﬁcation of patients suitable for one-day cholecystectomy, operating room time planning and evaluation of eﬀectiveness of operating teams. Methods: Prospective unicentric clinical cohort study. Every patient udergoing elective LC between March 2001 and December 2003 was included. Data on presence of 11 deﬁned RF, operating time (OT), postoperative subjective evaluation score (PSES), peroperative perforation of gallbladder, conversion, bile duct lesion, reoperation and readmission were recorded prospectively. Records were divided into groups according to presentation of speciﬁc RF and statistically tested for diﬀerences in measures of diﬃculty. RSD was then deﬁned and calculated for every patient and all records subdivided into ﬁve groups respecting its value. Further statistical testing was carried out to prove hypothesis that diﬃculty of operation is growing with increasing RSD. Results: 586 patients underwent elective LC 430 females, 156 males. Mean age 50,3113,07 years, mean OT 59,8724,61 minutes, mean PSES 0,931,02, conversion rate - 3,41%. 9 RF were identiﬁed as independently predictive for increased diﬃculty of operation RSD was deﬁned as sum of present RF increased for 1 in case that previous supraumbilical abdominal surgery was recorded. 5 groups of diﬃculty were proposed - OT, PSES and conversion rate were increasing with growing RSD signiﬁcantly (p<0.01). Conclusion: Proposed RSD is valid tool predicting diﬃculty of elective LC from preoperative RF stratifying patients into 5 groups with well deﬁned diﬃculty and risk of conversion. This allows to select appropriately skilled surgeon for particular patient and provide accurate information about risk of conversion. Patients with RSD=4 should be selected for open cholecystectomy due to almost 100% risk of conversion while those with RSD 0–1 are best candidates for oneday LC. Systematic clinical application of RSD allows to calculate operating room time for LC and monitor eﬀectiveness of operating teams.

Background: Recurrent pyogenic cholangitis (RPC) is still a prevalent disease in Southeast Asia and is characterized by repeated cholangitis secondary to frequent stone recurrence and stricture formation.

Patients & Methods: Patients with RPC are ﬁrstly managed with antibiotics and biliary decompression for acute exacerbation followed by detailed imaging studies, including PTC / ERCP / CT / HIDA scintigraphy, to outline stones and strictures distribution. HALS is indicated for multiple intrahepatic ductal stones located in the atrophic left lateral segment (II & III). On the contrary, if the biliary stones are mainly located in extrahepatic duct, LCD is our treatment of choice. Combined treatment would be considered for patients with both intrahepatic and extrahepatic stones. The exclusions are bilobe intrahepatic ductal stones and also those with evidence of malignant transformation whereas previous open biliary surgery is not an absolute contraindication. Ductal clearance is based on operative choledochoscopy and postoperative imagings. Both groups of patients are followed up with regular liver function test and imaging studies. Results: There were 48 laparoscopic procedures performed in 44 patients with RPC during the period 1995–2006. There were 15 HALS and 33 LCD, and 4 patients received combined HALS / LCD. There were 15 male and 30 female of mean age 63.3 +/) 14.4. Open conversion was required in three patients due to bleeding from left hepatic vein, lost broken tip of ultrasonic dissector and signiﬁcant bleeding during choledochotomy respectively. The mean operating time was 156.9 +/) 59.1 minutes and operative loss was 129.7 +/) 210.4 ml. Mean postoperative stay was 10.3 +/) 9.2 days. Complications occurred in 10 patients (22.7%), which included 5 bile leaks (11.4%), 5 wound infections (11.4%), 2 collections (4.5%) and 1 incisional hernia (2.3%). There were 1 patient with residual stone (stone clearance 97.7%) and two recurrences upon a mean followup of 46.7 +/) 33.6 months. Conclusion: With the systematic approach together with eﬀective laparoscopic treatment modalities, the long-termed outcome of RPC remains quite favorable.

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VISUALLY ASSESSING THE LIVER AT SURGERY RELIABLY PREDICTS BUT DOES NOT EXCLUDE SEVERE LIVER DISEASE IN PATIENTS UNDERGOING BARIATRIC SURGERY

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

CANCELLED

Aim: This study is to review the combined use of hand-assisted laparoscopic segmentectomy (HALS) and / or laparoscopic choledochoduodenostomy (LCD) in the treatment of RPC.

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 sphinterotomy (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.

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ULTRASOUND GUIDED RADIOFREQUCY ASSISTED SEGMENTAL ARTERIO-PORTAL VASCULAR OCCLUSION IN LAPAROSCOPIC SEGMENTAL LIVER RESECTION

ARE T-TUBES (T-T) NEEDED AFTER LAPAROSCOPIC COMMON BILE DUCT EXPLORATION? S. Mahmud, A. Alhamdani, S. Caplin, T. Brown Morriston Hospital, SWANSEA, United Kingdom

G. Navarra1, F. Rinaldi1, M. Bartolotta2, C. Scisca1, A. Barbera1, G. Bartolotta1 1

University of Messina, MESSINA, Italy

2

G. Martino, MESSINA, Italy

Laparoscopic liver resection has been shown to be feasible and safe. However intra-operative blood loss aﬀects conversion rate, postoperative morbidity, mortality and long term survival in malignant disease. In this setting, segmental hepatectomy is appealing since it allows a reduction of intraoperative blood loss and blood replacement by dividing tissues along the anatomical planes. A simple technique guided by intraoperative ultrasound is described here to facilitate laparoscopic liver segmentectomies. It uses radio-frequency energy to create coagulative desiccation of the segmental arterial and portal vessels and to demarcate the area to be resected. Firstly an IOUS is performed to identify the segmental or subsegmental arterial and portal branches feeding the area including the tumour. The coagulative desiccation of these feeding vessels is then induced with application of a cooled-tip RF probe with a 500 kHz- RF Generator under ultrasonographic control. The intrahepatic parenchymal change induced by RF can be monitored by using IOUS revealing an absence of Doppler signal. Following the application of RF to destroy the feeding vessels to that segment, an area of marked discolouration on the surface of liver becomes obvious. Finally, liver resection can be carried out without any form of hepatic inﬂow occlusion. The major advantage is that it is safe and eﬀective, and has the potential to make laparoscopic liver segmentectomies and subsegmentectomies easier to perform.

Background: Prior to laparoscopic surgery bile duct exploration was usually followed by t-tube drainage. Laparoscopic common bile duct exploration (LCBDE) is now a possibility but there is ongoing debate regarding the need and indications for post operative t-tube drainage. Aims: To review our experience of LCBDE comparing indications, complications and outcome with primary closure or t-tube drainage. Methods: All patients undergoing LCBDE are entered into a computer database incorporating demographic and clinical data. These data includes the indication for surgery, the type of LCBDE performed, the use of t-tubes and the clinical outcome. Results: Between Nov 2000 and Dec 2005 126 patients underwent LCBDE. The male to female ratio was 1:2 and the median age 57 (range 22 89). The indications were failed ERCP with apparent ductal stones 26%, jaundice 17%, pancreatitis 13%, cholangitis 5.5%, pre-operative imaging 12%, positive intra-operative cholangiogram 21% and others 5.5%. 68 Trancystic explorations,1 case needed T-T. 58 choledochotomies with primary closure in 49 cases and T-t in 9 cases. The indications for placing a t-tube included surgical learning curve, diﬃculty in ensuring complete clearance of duct and operative decision related to anatomy. Complication rate was 1/10 (10%) with a t-tube and 7/49 (14%) with primary closure. 7 patients (5.6%) were converted to open ECBD and 5 of these occurred in the ﬁrst 35 procedures. 1 patient required re-operation and placement of a t-tube. Median post-operative stay was 5 days with primary closure and 8 days with t-tube. Conclusion: Primary duct closure following LCBDE is safe, with no increase in complications, hospital stay or conversion rate. We would not recommend routine use of a t-tube but reserve this for particular indications.

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EARLY VERSUS DELAYED LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS A META-ANALYSIS OF RANDOMISED CLINICAL TRIALS A. MacDonald, T. Siddiqui, P.S. Chong, J. Jenkins Southern General Hospital, GLASGOW, United Kingdom

BACK TO THE FUTURE - OPERATIVE CHOLANGIOGRAPHY IN THE LAPAROSCOPIC ERA J.E. Abela, J. Murray, A. Mirza, A. Hamouda, A.H.M. Nassar Monklands District General Hospital, GLASGOW, United Kingdom

Aims: The appropriate timing for laparoscopic cholecystectomy in the treatment of acute cholecystitis remains controversial. Early reports suggested that laparoscopic surgery for acute cholecystitis was associated with increased complication rates, prolonged operation times and increased conversion rates. Initial conservative management with subsequent elective laparoscopic cholecystectomy therefore became accepted practice. More recent evaluation has indicated early laparoscopic surgery may be a safe option in acute cholecystitis though conversion rates may be higher. There remains no conclusive evidence establishing best practice in terms of clinical beneﬁt. We conducted a meta-analysis of current randomised evidence for early vs delayed laparoscopic cholecystectomy in patients with acute cholecystitis. Methods: All randomised clinical studies published between 1987 and 2006 comparing early v delayed laparoscopic cholecystectomy for acute cholecystitis were analysed. Data sources employed were Ovid Medline, Embase, Cochrane Library and Google Scholar for all years. Inclusion criteria were all randomised clinical trials assessing early and late laparoscopic cholecystectomy irrespective of language, blinding, or publication status. Early was deﬁned as within seven days of the onset of symptoms and late deﬁned as six weeks following admission. Exclusions were trials that were quasi-randomised, with inadequate follow-up description or allocation concealment. Endpoints included conversion rates, post-operative complications, total hospital stay and operation time. Both random and ﬁxed eﬀect models were employed to aggregate the study endpoints and assess heterogeneity. Results: Four studies containing 362 patients were included. No signiﬁcant study heterogeneity was identiﬁed between studies. No publication bias was found. There was no signiﬁcant diﬀerence in conversion rates [OR=0.889 (95%CI 0.547–1.445);p=0.634] and post-operative complications [OR=1.0 (95%CI 0.509–1.963);p=0.999] between both early and delayed groups. There was a signiﬁcant reduction in operation time [Standardised mean diﬀerence (SD) = 0.427 (95%CI 0.154–0.699);p=0.002] with delayed cholecystectomy and signiﬁcantly reduced total hospital stay [SD= )0.904 (95%CI ()0.626)()1.18));p=0.0005] with early cholecystectomy. Conclusions: The current randomised data suggests early cholecystectomy allows signiﬁcantly shorter total hospital stay at the cost of a signiﬁcantly longer operation time with no signiﬁcant diﬀerences in conversion rates or complications.

Aim: The use of operative cholangiography, once a routine part of open cholecystectomy, appears to have declined in the laparoscopic era. Endoscopic retrograde cholangiography and more recently magnetic resonance cholangiography now assume an important role in the management of bile duct stones. We continue to adopt the conventional approach of singlestage management of suspected duct stones, performing operative cholangiography routinely and managing ductal stones laparoscopically. We aim to evaluate our results and demonstrate the beneﬁts of routine cholangiography during cholecystectomy. Methods: A prospective study of 1688 patients over 13 years was analysed. The median age was 51.5 years (interquartile range = 25) and the male: female ratio was 1:4. We divided our patients pre-operatively into two groups. Group 1 had 530 subjects (31.4%) with one or more risk factors for choledocholithiasis; jaundice (40%), acute pancreatitis (18%), altered liver function tests (93%) and ultrasonongraphically dilated ducts or duct stones (50%). Group 2 consisted of 1158 patients (68.6%) with no pre-operative risk. Results: In Group 1, duct stones were conﬁrmed at cholangiography in 247 cases (47% yield). In Group 2, 73 patients (6.3% yield) were actually found to have duct stones at surgery. A total of 323 common bile duct explorations were performed 173 (53%) had laparoscopic trans-cystic clearance, 150 (43%) had laparoscopic choledochotomy. Exploration was converted to open surgery in 15 patients (4%) - 3 had trans-cystic clearance and 12 had choledochotomy. We subdivided Group 2 into four age groups and performed sub-group analysis. We found that with increasing age, operative cholangiography has a statistically signiﬁcant higher stone yield (p>0.001) in patients not previously suspected to have duct stones: 2.2% in patients aged 29 or less (n=131), 4.4% in those aged 30 to 49 (n=461), 6.9% in those aged 50 to 69 (n=475) and 24% in patients aged 70 or more (n=91). Conclusion: Routine operative cholangiography facilitates single-session management of bile duct stones without need for pre- or post-operative ERCP. Moreover, it detects unsuspected choledocholithiasis in a signiﬁcant percentage of low risk subjects. In this group of patients there is a significant incremental stone yield with advancing age.

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SIX YEARS EXPERIENCE USING THE SEMIRIGID TELESCOPIC CHOLEDOCHOFIBERSCOPE FOR THE LAPAROSCOPIC COMMON BILE DUCT EXPLORATION T. Jurisic General Hospital Sibenik, SIBENIK, Croatia

LAPAROSCOPIC BILE DUCT EXPLORATION IS SAFER WITH TRANSCYSTIC BILIARY DRAINAGE I. Eid, J.E. Abela, Y. Goh, A. Hamouda, S. Mahmud, A.H M. Nassar Monklands Hospital, AIRDRIE, United Kingdom

Aims: The treatment of cholelithiasis and common bile duct (CBD) stones in the same session is the most appropriate therapy for patients. This method is described as a complicated procedure reserved for specialized centers. Our aim is to show that the dedicated instruments are crucial factors for the transformation of this method from exclusive to a routine one. Methods: From January 1993 to January 2006, 280 laparoscopic CBD explorations (LCBDE) were performed. Since June 1998 in 48 cases LCBDE was performed with the ﬁberscope CHF-10 (Olympus, Japan). From June to October 1999, in 63 cases the CHF-CB20 was used. In the ﬁrst group of 111 patients the choledochotomy approach and the T-tube were used. Since 1999 in the second group of 169 cases (118 transcystic, 51 choledochotomy) the CHF-CB30S was used, which with the rigid telescopic introducer (Olympus Winter& IBE, Germany) was transformed to the semirigid telescopic choledochoﬁberscope (SRT-CHF). In 51 patients from the second group the drainage was performed with the micro-drain through the lateral CBD wall. We analyzed the CBD clearance, complication, mortality and the time needed for exploration (ET) from the moment when choledochoscope was introduced into the CBD to the end of the control cholangioscopy. In the choledochotomy cases, the time needed for biliary drain introduction and suturing (DST) was registered. Results: For the ﬁrst group, the mean ET was 85 minutes. The mean DST was 62 minutes. There were 3 conversions (2.7%) and one retained stone (99% CBD clearance). In the second group, the mean ET was 15 minutes for the transcystic approach, and 20 minutes for the choledochotomy. The mean DST was 11 minutes. In the second group the CBD clearance was 100%. In neither of the groups there was not procedure related complications nor perioperative mortality. Conclusions: SRT-CHF is the ﬁrst dedicated cholangioscope. The use of dedicated instruments enables substantially simpliﬁed choledocholithiasis treatment with manifold operative time reduction. Using SRT-CHF it is possible to perform LCBDE routinely even in the small community hospitals.

Aim: Biliary drainage is a risk factor for complications after laparoscopic bile duct exploration (LCBDE). We aim to evaluate the use and complications of transcystic tubes (TCT) and T tubes. Methods: We reviewed patients undergoing LCBDE and the method of biliary drainage, comparing drain-related complications, postoperative cholangiography results and readmission rate. In our unit, TCT is the ﬁrst choice biliary drain following exploration. A postoperative cholangiogram is done within 48 hours and the patients are discharged to come back 14 days postoperatively for TCT removal. Results: Over 14 years, 1732 cholecystectomies were done including 315 LCBDE (18.1%). 149 patients (47.3%) had no biliary drains, 143 after transcystic exploration (TCE) and 6 after choledochotomy. 116 patients (36.8%) had a TCT biliary drainage, of which 53 patients had a choledochotomy with closure of the CBD and 63 patients had TCE. 50 patients (15.9%) underwent choledochotomy with insertion of T tube. In the T tube group, 7 patients required readmission (14%). 2 patients had cholangitis, one had elevated liver function tests (LFT) and a normal ultrasound scan (USS), one had non-speciﬁc abdominal pain and one patient had free ﬂuid on the USS. They all settled with conservative management. One patient had a defective T tube which required re-operation and replacement of the T tube. One patient required laparoscopic re-insertion of T tube after accidental dislodgment on the second postoperative day. There was no technical diﬃculty encountered with T tube cholangiography. In the TCT group, 11 patients were readmitted (9.5%). 6 patients had non-speciﬁc abdominal pain, 3 had cholangitis and 2 were readmitted because of a blocked tube and dehydration respectively. They all settled with conservative management. There were 2 mortalities in this group which were not related to the procedure. On repeat cholangiography, 3 TCTs had slipped, 2 tubes were blocked and 2 tubes were diﬃcult to remove (total 5.1%). Conclusion: The use of T tubes for post exploration biliary drainage has discouraged many surgeons from adopting the laparoscopic CBDE technique. TCT drainage oﬀers a safe alternative with minimal complications. This could encourage more surgeons to adopt this approach.

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DO THE ACUTE COMPLICATIONS OF GALLSTONE DISEASE ALTER THE FEASIBILITY AND OUTCOME OF PRIMARY COMMON BILE DUCT CLOSURE IN LAPAROSCOPIC COMMON BILE DUCT EXPLORATION?

IS FOLLOW UP NECESSARY AFTER LAPAROSCOPIC CHOLECYSTECTOMY? I. Eid, A. Mirza, J. Murray, A.H.M. Nassar Monklands Hospital, AIRDRIE, United Kingdom

M Jameel Wrexham Maelor Hospital, WREXHAM, United Kingdom Aim: To Compare the Feasibility and Outcome of Primary Common Bile Duct (CBD) Closure in Laparoscopic Common Bile Duct Exploration (LCBDE) among Patients with & without Acute Complications of Gallstone Disease. Method: 50 patients undergoing LCBDE by one Surgeon from February 2004 to march2006 were prospectively divided into two groups based on clinical, laboratory & operative ﬁndings. Patients in group1 had acute complications of gallstone disease (including acute Cholecystitis, acute Pancreatitis, acute cholangitis, empyema & perforated gallbladder etc) and patients in group2 didnt had any acute complications. Final decision to explore the CBD was based on routine intra-operative cholangiograms ﬁnding. Operation time, hospital stay, conversion and complication number and type were recorded for both groups & analyzed using SPSS12.0 for Windows. Results: There were 26 patients in group1, 8 males and 18 females. Median age was 72. Diagnosis included acute Cholecystitis(38%), perforated gallbladder(4%), acute Pancreatitis(15%), acute cholangitis(12%),acute-on-chronic Cholecystitis (12%) and obstructive jaundice with acute Cholecystitis (19%).ASA grade included I & II (69.5%), III (30%) and IV (4.5%). 8% patients in group1 had elective surgery and 92% had during same emergency admission LCBDE. In group 2 there were 24 patients, including 5 males and 19 female, median age being 64. Diagnosis included biliary colic (42%), chronic Cholecystitis (21%) and obstructive jaundice (37%). ASA grade was I & II (66%), III (33%) and none was IV. 83% patients in group2 had elective surgery and 17% had same admission surgery. Mean operating time was 99.4 versus 92 minutes, post operative stay 4.4 versus 3.9 days for group1 & 2 respectively. There was one conversion in group1and two in group2. Group1 had one mortality from mesenteric ischemia & four complications including, urinary retention, tachycardia, hyperkalaemia, and bile leakage from choledochotomy. Group2 had two complications including bile leakage from choledochotomy, and one from liver bed. Conclusion: LCBDE with primary closure is feasible and safe in both groups with a slightly longer mean operating time and hospital stay in group1, being statistically insigniﬁcant (p-value 0.083 and 0.65 respectively). Similarly conversion and complication rates between the groups dont diﬀer signiﬁcantly (pvalue 0.51 & 0.142 respectively).

Aim: The challenges facing health services require an appraisal of the traditional postoperative follow up visit. We aim to evaluate the need for routine follow-up after laparoscopic cholecystectomy (LC). Analysis of the rate of complications in a large series of patients who were followed up for 14 months postoperatively is a good indicator of the frequency of complications and the value of follow up. Methods: A prospectively collected database on 1732 patients undergoing LC under the same surgeon over 14 years was analysed. Patients were seen in the clinic 6 weeks and 14 months postoperatively. Recorded parameters included postoperative wound infection, ongoing dyspepsia and whether they had undergone Upper GI endoscopy since surgery. Clinical examination included an assessment of the presence of an umbilical port incisional hernia. Results: The majority of patients who developed wound infection were seen and treated by their GPs. Only one patient required readmission for treatment. The majority were reported at the 6 week appointment and had resolved by then. 5 patients were found to have incisional hernia during follow up (0.3%). 4 were at the umbilical port site. One patient had had a wound infection and in two the recurrence was of a known sizeable umbilical hernia - out of 63 patients with preexisting umbilical defects of various sizes - which had been repaired at the time of initial LC. One patient developed herniation at the epigastric and umbilical sites and required two procedures. One small bulge did not justify repair. 40 patients (2.3%) reported ongoing dyspepsia at the 6 week review appointment and 25 patients (1.4%) had an Upper GI Endoscopy to investigate the dyspepsia. 5 patients (0.28%) had positive ﬁndings requiring further treatment. Conclusion: Complications following LC in this large series were low. Wound infections were usually seen and treated by GPs by the time of initial clinic review at 6 weeks. The majority of incisional hernias were asymptomatic bulges. The policy of patient self referral back to the clinic if they have any postoperative problems or ongoing symptoms would be a more cost eﬀective use of clinic resources than routine follow up.

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IS HYPERAMYLASEMIA FOLLOWING LAPAROSCOPIC BILIARY SURGERY (LBS) OF CLINICAL SIGNIFICANCE? J. Witherspoon, J. Murray, A. Mirza, S. Mahmud, A.H.M. Nassar Monklands General Hospital, AIRDRIE, United Kingdom

SINGLE-STAGE MANAGEMENT FOR PATIENTS WITH UNCOMPLICATED ACUTE GALLSTONE PANCREATITIS PRE-OPERTIVE MRCP AND ERCP ARE NOT NECESSARY!

Aims: To evaluate the incidence and clinical outcome of hyperamylasemia (serum amylase > 100 iu/l) following LBS in a unit where suspected common bile duct stones (CBDS) are managed by intraoperative cholangiogram (IOC) followed by laparoscopic common bile duct exploration (LCBDE) where appropriate. Methods: A database containing prospectively collected data about all patients undergoing laparoscopic cholecystectomy (LC) under the care of one surgeon was used to record postoperative serum amylase levels on the ﬁrst morning following surgery. Results: Postoperative serum amylase levels were recorded in 412 patients (19% male and 81% female with a mean age of 52) who underwent LBS over a 5 year period. 52% were elective and 48% were emergency admissions. The preoperative diagnosis was gallstone dyspepsia in 168 (41%), acute biliary pain in 97 (24%), acute cholecystitis in 36 (9%), gallbladder dyskinesia or polyps in 33 (8%) and pancreatitis in 46 (11%). 80 (19%) patients were jaundiced at the time of surgery and 186 (45%) patients had risk factors for CBDS. LCBDE was performed in 99 patients (64 transcystic and 35 choledochotomy). Open conversion was necessary in 2 cases (0.5%). 36 (9%) of patients had postoperative hyperamylasemia (101 to 3379 iu/l, median 186), 8 of whom were known to have had pancreatitis preoperatively. Two patients who did not have CBDE developed clinical pancreatitis post operatively. One of these patients had initially presented with pancreatitis. Both cases resolved with conservative management but discharge was delayed by a few days. Of the group undergoing LCBDE, 13 developed hyperamylasemia postoperatively, all of whom had transcystic exploration. Only 3 patients developed clinical pancreatitis following LCBDE who had normal preoperative amylase levels. In all cases this resolved quickly with conservative management. Conclusions: Serum amylase should be measured post LCBDE to allow early detection and appropriate management of pancreatitis. Postoperative hyperamylasemia does occur following LC with or without LCBDE but is of no clinical signiﬁcance. The risk of postoperative pancreatitis following LCBDE in this series is 3% which is lower than that following ERCP (approximately 5.4%). The risk post LCBDE appears to be related to the transcystic approach.

J.E. Abela, A. Mirza, J. Murray, G. ElShallaly, A.H.M. Nassar Monklands District General Hospital, AIRDRIE, GLASGOW, United Kingdom Aim: Gallstone pancreatitis is a risk marker for choledocholithiasis. Therefore, patients are frequently referred for magnetic resonance (MRCP) and/or endoscopic retrograde cholangio-pancreatography (ERCP), before laparoscopic cholecystectomy. We perform operative cholangiography routinely and bile duct exploration is done laparoscopically during the same session. Our aim is to study the outcome of patients suﬀering from uncomplicated pancreatitis treated in this way. Methods: Over a ten-year period 96 patients with uncomplicated acute gallstone pancreatitis were followed up in a prospective study. All had elevated serum amylase levels on admission and ultrasound evidence of cholelithiasis (multiple stones in 98%). The median age was 52 years (interquartile range = 29). The male: female ratio was 1: 4. Jaundice was present in 30% of cases. All patients were operated in the course of their index admission. Results: The full cohort of patients was successfully managed laparoscopically. Twenty-four patients (25%) had a positive operative cholangiogram. Transcystic exploration and basket trawling was performed in 23 subjects. One patient required a formal choledochotomy, clearance and T-tube placement. No perioperative deaths were recorded. Major peri-operative morbidity was recorded in 2 patients (2% overall). Release of post-operative adhesions was complicated by a small bowel perforation in one patient. This was recognised intra-operatively and at the end of the biliary procedure, it was managed with wedge resection and anastomosis through a mini-laparotomy. Post-operatively, 1 patient developed pancreatic a abscess which was successfully managed conservatively. Age and gender proved not to be useful predictors for bile duct stones. Likewise, we did not ﬁnd a statistically signiﬁcant link between jaundice in cases of pancreatitis and choledocholithiasis (p=0.07) - 18 jaundiced subjects (62% of this subset of patients) had normal cholangiograms. Although statistically signiﬁcant (p<0.01), ultrasound evidence of bile duct stones had a positive predictive value of only 48%. Conclusion: Operative cholangiography in the course of laparoscopic cholecystectomy for acute uncomplicated gallstone pancreatitis is negative for residual bile duct stones in 75% of patients. In patients with positive cholangiography, single-stage management with laparoscopic bile duct exploration is safe and eﬀective. We conclude, therefore, that pre-operative MRCP and/or ERCP are not necessary in such patients.

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STONES OR NO STONES IS LAPAROSCOPIC CHOLECYSTECTOMY ANY DIFFERENT? J.E. Abela, I. Eid, A.H.M. Nassar Monklands District General Hospital, AIRDRIE, GLASGOW, United Kingdom

RISK FACTORS FOR OPEN CONVERSION DURING LAPAROSCOPIC CHOLECYSTECTOMY - RESULTS FROM A DEDICATED BILIARY UNIT IN A DISTRICT GENERAL HOSPITAL M. Alam, J.E. Abela, A Mirza, A.H.M. Nassar Monklands General Hospital, AIRDRIE, United Kingdom

Aim: In this study our objective is to explore the relationship between the number of gallstones and the course of laparoscopic cholecystectomy. Methods: A total of 1594 patients were divided into 3 groups, based on the number of gall bladder stones detected at laparoscopic cholecystectomy. Group 1 (n=47) had no discernible gall bladder stones at operation. In this group 32 had gall bladder dysfunction which, following a negative ultrasound, was conﬁrmed pre-operatively by a positive technetium 99m pertechnate iminodiacetic acid (HIDA) scan. The other 15 had gall bladder polyps. Group 2 (n=197) had a solitary gallbladder stone; whereas Group 3 patients (n=1350) had multiple gallbladder stones. Group 1 patients were signiﬁcantly younger than Group 2 and 3 patients (median age of 41 years and interquartile range of 22 compared with 52 years and an IQR of 15, p=0.03). The male: female ratio was approximately 1: 3 in all groups. In our unit, operative cholangiography is performed routinely. Results: No bile duct stones were detected in Group 1 and as expected, we conﬁrmed a signiﬁcant diﬀerence in the presence of bile duct stones between Groups 2 and 3 (7.6% compared with 16.4% respectively, p<0.01). In order to further assess the three groups accurately, patients who had bile duct exploration (228 in total) were excluded from all subsequent analyses. By comparing Groups 2 and 3 we did not ﬁnd a signiﬁcant relationship between number of stones and the dissection diﬃculty grade (p=0.78). Likewise, there were no diﬀerences between these two groups when considering the degrees of peri-cholecystic adhesions documented (p=0.68). The rate of intra-operative gallbladder perforation and bile spillage was similar in the three groups (p=0.57). Duration of surgery was signiﬁcantly shorter in Group 1 when compared with groups 2 and 3 (median 43 minutes in Group 1 compared with 60 minutes in the others, p=0.01). Conclusions: Patients with acalculous gall bladder disease are more likely to be younger than their counterparts with calculous cholecystitis. In the former group, operating time is signiﬁcantly shorter. In patients with stone disease, the number of stones does not inﬂuence the diﬃculty grade for cholecystectomy.

Aim: The rate of conversion to open surgery during laparoscopic cholecystectomy (LC) varies according to experience, clinical setting and selection of cases. At present, published rates are between 1.5% and 10%. We analysed our conversions with a view to identifying useful risk markers. Methods: Prospective data for 1682 LCs over a 14-year period were analysed. No cases were pre-selected for open surgery and all comers, including emergency cases and bile duct stones were treated in one-session. The mean age was 51.3 years (SD: 15.7, range 14 - 89) and the male: female ratio was 1: 4. The clinical presentations included jaundice in 12%, acute pancreatitis in 6.1% and acute cholecystitis and empyema in 5%. Five hundred and thirty-ﬁve patients (32%) had had previous abdominal surgery. At operation 96 patients had mucoceles and 13 had Mirizzi syndrome. Laparoscopic bile duct exploration were performed in 323 cases and 96% were completed laparoscopically. Results: There were 27 conversions over 14 years, an overall rate of 1.6%. In the last 1200 cases only 5 cases were converted (0.4%), none in elective cholecystectomy. Age was a poor predictor for conversion (p=0.21). Gender did not impart a signiﬁcant conversion risk (2.4% in males, 1.6% in females, p=0.11). Previous abdominal surgery, mucocoele and acute cholecystitis did not quite reach statistical signiﬁcance as risk markers in our series (p=0.06 for each variable). On the other hand, we found signiﬁcant associations with jaundice, choledocholithiasis, ASA score of 3 or higher, empyema and Mirizzi syndrome (p<0.01 for each), as well as a thickened contracted gall bladder (p=0.02). The sub-group of patients with choledocholithiasis had common bile duct exploration during the same session and the conversion rate was only 4%. Conclusion: Within a specialised unit, adapting laparoscopic techniques and dissection methods and instruments helped us to reduce the conversion rate to a minimum. This also applies to a high volume (60%) of emergency LCs including bile duct exploration. In contrast to other reported series, the traditional risk factors of male gender, previous abdominal surgery and acute cholecystitis do not appear to signiﬁcantly inﬂuence our decision to abandon laparoscopic surgery.

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ÔSLEEPING COMMON BILE DUCT STONESÕ. WHAT IS THE ALTERNATIVE TO CHOLANGIOGRAPHY? A. Mirza, J. Murray, G. EL-Shallaly, J. Witherspoon, A.H.M. Nassar Monklands General Hospital, AIRDRIE, United Kingdom

HIGH (16MMHG)VERSUS LOW (8MMHG) PRESSURE PNEUMOPERITONEUM IN LAPAROSCOPIC LIVER RESECTION REDUCES BLEEDING BUT WITH AN INCREASED RISK FOR GAS EMBOLISM K. Eiriksson1, C. Kylander2, D. Fors3, S. Rubertsson3, D. Arvidsson2 1 Stavanger University Hospital, STAVANGER, Norway 2 Karolinska University Hospital, STOCKHOLM, Sweden 3 Uppsala University Hospital, UPPSALA, Sweden

Aim: To evaluate the incidence of silent common bile duct (CBD) stones diagnosed during routine laparoscopic cholecystectomy in patients with no risk factors for choledocholithiasis. Method: Data from 982 patients undergoing elective LC with no risk factors for ductal stones was collected prospectively and analysed. During the study 45 patients (4.6%) (Group A) were found to have silent CBD stones and 937 patients (95.4%) (Group B) had normal cholangiography. Intraoperative cholangiography was routinely performed in all patients. The two groups were compared looking at sex, age, biliary symptoms, operative ﬁndings, diﬃculty grading, length of surgery and hospital stay. Results: The male to female ratio in both groups was1:4. Mean age in patients with CBD stones was 58.5 years, signiﬁcantly higher than in patients with no CBD stones (48.5). The presence of single or multiple stones on ultrasound made no statistical diﬀerence in either group (p=0.108). Comparing the level of diﬃculty of gall bladder dissection, a signiﬁcant increase was observed in patients with CBD stones (p<0.027). Mean length of surgery for patients with CBD exploration was 118.57 minutes, double that for patients with no CBD stones 62.59 minutes. All 45 bile duct explorations for silent stones were completed laparoscopically. There were no retained stones and no postoperative ERCPs was necessary. Conversion to open cholecystectomy was necessary in six patients with no CBD stones and one required readmission. Mean hospital stay for Group A was 6.3 days and that for Group B was 4.4 days. Readmission was necessary in 3 patients (6.6%) in those undergoing ductal exploration and in 7(0.7%) who had no CBD stones. Conclusions: Although the incidence of CBD stones is 4.6% in patients who undergo elective cholecystectomies without CBD stone risk factors, their ultimate presence changes the surgical management. Routine cholangiography helped us to identify CBD stones which would have otherwise been missed, increasing the risk of complications and subsequent medical or surgical re-intervention with potential for increased morbidity.

Introduction: Laparoscopic liver surgery is increasing. In general, CO2 pneumoperitoneum is used, although various recommendations exist regarding which intraabdominal pressure (IAP) to use. Higher pressure might reduce the bleeding from the resection surface of the liver. Fear for gas embolism refrain many surgeons from using a high IAP. The aim was to investigate the eﬀects of different pressure levels during resection of liver in pigs. Material and methods: 16 pigs were randomised to be operated with either 8 or 16 mm Hg CO2 pneumoperitoneum. The lateral left lobe was resected. The left liver vein was dissected free and a standardised lesion into the vein was performed. The vein was kept open for 3 minutes, and then closed and the resection ﬁnished. All animals were monitored for heart rate, cardiac output, arterial, pulmonary arterial, PCW and central venous pressures, on line blood gases and oesophageal echography of the right heart and EtCO2. Operating time and bleeding was recorded. Results: Operating time and bleeding was reduced at 16 mm Hg. In most of the 16 mm Hg animals there was minimal bleeding from the open vein. But massive gas embolism was instead conﬁrmed by echography, a fall in EtCO2, pO2 and pH while pCO2 increased. Blood gas changes were signiﬁcantly diﬀerent from the 8 mm Hg group throughout the later part of the operation and also during the resting period after surgery, indicating a sustained shunting in the lungs in the 16 mm Hg pigs. Conclusion: In laparoscopic liver resection with CO2 pneumoperitoneum one must pay special attention to the intraabdominal pressure. As in open liver surgery central venous pressure is of vital importance. In laparoscopic liver surgery CVP is balanced against IAP in such a way that a larger gradient (IAPCVP) between these pressures reduces bleeding but at a cost of increased risk for gas embolism. Patients undergoing laparoscopic liver resection should be carefully monitored. An overlooked venous lesion might not bleed and CO2 embolism can occur. Changes in heart rate and arterial pressure occur very late during embolization.

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COMPARISON OF LAPAROSCOPIC AND OPEN LEFT LATERAL SEGMENTECTOMY K.A. Carswell, F.G. Sagias, M. Rela, N. Heaton, A.G. Patel KingsÕ College Hospital, LONDON, United Kingdom

LAPAROSCOPIC LIVER RESCTION. EXPERIENCE FROM 40 PATIENTS D. Arvidsson1, U. Jersenius2 1 Uppsala University Hospital, UPPSALA, Sweden 2 Karolinska Univeristetssjukhuset, STOCKHOLM, Sweden

Introduction: there are no true comparison studies or randomised controlled trials published comparing laparoscopic versus open left lateral segmentectomy performed over the same time period. This study compares laparoscopic verus open left lateral segmentectomy +/) intraoperative ultrasound in our instituition since 2002. Methods: Patients undergoing laparoscopic left lateral segmentectomy (n= 8) were compared with patients undergoing open left lateral segmentectomy (n= 8) at the same institution between 2002 and 2006. The laparoscopic operations were performed by a single surgeon and the open operations were performed by a group of two surgeons. Both groups had similar characteristics in terms of age, sex and type of lesion. Exclusion criteria included previous liver resections; polycystic liver disease; liver cirrhosis and synchronous operations. Results: Benign and malignant lesions were resected: in the laparoscopic group 50% (4/8) were malignant versus 38% (3/8) for the open group. There were no mortalities in either group and the morbidity rates were similar (no wound or chest infection in either group). The conversion rate was 13% (1/8). There was no statistically signiﬁcant diﬀerence in operating time between the laparoscopic and the open group (median time 235 min versus 169 min, p=0.13). The laparoscopic group had a statistically signiﬁcantly lower postoperative need of opiod analgesia than the open group (median 2 days versus 4 days, p=0.02). Surgical margins for all malignant lesions were clear in both groups. The median post-operative in-hospital stay for the laparoscopic group was 6 days (range 4–7) compared to 9 days (range 6–23) for the open group, which was statistically signiﬁcant (p=0.01, Mann-Whitney-U test). Conclusions: Laparoscopic left lateral segmentectomy is safe and feasible. Patients undergoing the laparoscopic approach beneﬁt from requiring less postoperative opiate analgesia and a shorter in-hospital stay. We believe that left lateral segmentectomy should preferentially be performed through a laparoscopic approach.

Aim is to describe our 3-year experience of laparoscopic liver resections. Patients and results: 40 patients were operated with subsegmentectomies (n=24), resection of 1–2 segments (n=17) or hemihepatectomy (n=2) for benign (n=20) or malignant lesions (n=23). 2 operations were converted due to bleeding (n=1) or failure to identify lesion (laparoscopic sonography failure=1). Operating time was mean 80 minutes (range 35–360). Only one patient needed transfusion. One patient was reoperated with laparoscopy because of bleeding. In-hospital stay was 3 days on average. Conclusion: Laparoscopic liver resection is a feasible technique provided one has training in both liver surgery and advanced laparoscopy. Patient positioning and equipment are extremely important, including laparoscopic sonography. A to narrow margin is a potential hazard due to the eﬀect of magniﬁcation.

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LAPAROSCOPIC VERSUS OPEN CHOLECYSTECTOMY IN PATIENTS WITH LIVER CIRRHOSIS

OPTIMIZED HIGH-TECH RADIOFREQUENCY ABLATION OF ÔINOPERABLEÕ MALIGNANT LIVER TUMOURS H.G. Weiss1, A. Klaus1, W. Mark1, P. Kovacs2, M. Haidu2, R. Margreiter1, R. Bale2 1 Medical University Innsbruck, INNSBRUCK, Austria

CANCELLED

Background: In patients with multi-focal liver tumours, multiple co-morbid conditions or tumour inﬁltration in central vascular pedicles surgical therapy may not be suitable. As a sparing alternative radiofrequency (RF) ablation is considered in those patients although it might be hampered by various parameters such as anatomical adjacencies of surrounding organs (including heart, lungs, oesophagus, stomach and bowel) or imprecise needle positioning. This study describes a novel technique for optimized computer navigated ablation by use of laparoscopic liver packing. Material and Methods: Patients who were not suitable for surgical liver resection or standard RF ablation were included in this ongoing pilot study (n=8). Laparoscopic liver mobilisation was performed and the liver was packed using swabs soaked with 5% glucose solution. Thereby all tumours in the liver were isolated from the adjacent organs. Bile-duct cooling was accomplished in one patient. The patients were subsequently treated by RF ablation which was carried out by means of the Treon navigation system (determination of the accuracy of needle placement with a fusion of the intra-operative CT with the planning CT). Then all swabs were removed laparoscopically. Results: Laparoscopy could be carried out in all patients. All visible tumours of the liver (n>2/patient, range of particular tumour size: 5–9cm) could be reached by navigated CT-guided radiofrequency ablation (9–12 RF-probes/patient). Liver packing eﬀectively prevented organ injury in all patients. Patients were discharged from hospital on postoperative day 4. A follow-up CT-scan after three to twelve months described suﬃcient focal tumour necrosis. Conclusion: For the ﬁrst time an eﬀective multi-modal treatment including laparoscopic liver packing and high-tech RF ablation is described for patients with liver malignancies unsuitable for surgical resection or standard RF ablation.

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LAPAROSCOPIC LIVER RESECTION FOR HEPATOCELLULAR CARCINOMA H-S. Han, Y-S. Yoon, J-Y. Jang, S-W. Kim, Y-H. Park Seoul National University Bundang Hosp., SEOUL, South-Korea

PREOPERATIVE ENDOSCOPIC SPHINCTEROTOMY VERSUS LAPARO-ENDOSCOPIC RENDEZ-VOUS IN PATIENTS WITH GALLBLADDER AND BILE DUCT STONES: A PROSPECTIVE RANDOMIZED TRIAL F. Baracchi, M.E. Allaix, C. Miglietta, N. Furlan, A. Garbarini, M. Morino Ospedale Molinette, TORINO, Italy

Aim: The aim of this study is to evaluate the role of laparoscopic liver resection in the treatment of HCC by reviewing our experiences of laparoscopic resection for HCC. Methods: We retrospectively analyzed the clinical outcomes of 21 patients who had undergone laparoscopic liver resection for HCC among 49 cases of laparoscopic liver resection between May 2003 and February 2006. Results: The patients were composed of 19 men and 2 women, with a mean age of 59.3 years. Operation procedure included 13 cases of tumorectomy, 3 cases of left lateral sectionectomy, 2 cases of left hepatectomy, 3 cases of right posterior sectionectomy, and 1 cases of right hepatectomy. Mean size of tumors was 2.9 cm, and mean distance of safety margin was 1.3 cm. Intraoperative transfusion was needed in 6 patients (28.6%) with a mean amount of 1.3 units. Mean postoperative hospital stay was 11.9 days. Postoperative complications developed in 6 cases (28.6%), all of which was improved by conservative management. However, there was no postoperative mortality. Recurrence was detected in 5 cases (19.0%) after a mean period of 13.5 months from operation, of which 3 cases had multiple recurrences. Conclusion: Our experiences conﬁrmed that laparoscopic resection for HCC was an eﬀective and safe treatment. Therefore laparoscopic liver resection, although its long term results are necessary, is expected to be a useful treatment modality for HCC in terms that it is less invasive than open liver resection and oﬀers complete removal of the lesion compared to non-operative managements.

Aims: To compare success rate, length of hospital stay, clinical results, and costs of sequential treatment (endoscopic retrograde cholangio pancreatography followed by laparoscopic cholecystectomy) versus the laparoendoscopic Rendez-vous in patients with cholecysto-choledocholithiasis. The ideal management of common bile duct (CBD) stones in the era of laparoscopic cholecystectomy (LC) remains controversial. Methods: 91 patients with cholelithiasis and CBD stones diagnosed at magnetic resonance cholangiography (MRC) were included in a prospective, randomised trial. The patients were randomised in two groups. Group I patients (45 cases) underwent a preoperative endoscopic retrograde cholangio pancreatography (ERCP) with endoscopic sphincterotomy (ES) followed by LC in the same hospital admission. Group II patients (46 cases) underwent LC associated to intra-operative ERCP and ES according to the rendez-vous technique. Results: The rate of CBD clearance was 80% for Group I and 95.6% for Group II (P = 0.06). The morbidity rate was 8.8% in Group I and 6.5% in Group II (P = NS). No deaths occurred in either group. Hospital stay was shorter in Group II than in Group I: 4.3 days versus 8.0 days (P < 0.0001). There was a signiﬁcant reduction in mean total cost for group II patients versus groupI patients: 2829 vs 3834 (p<0.05). Conclusions: When compared to preoperative ERCP winth ES followed by LC the laparoendoscopic Rendez-vous technique allows a higher rate of CBD stones clearance, a shorter hospital stay and a reduction in costs.

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LAPBAND VERSUS SWEDISH ADJUSTABLE GASTRIC BAND (SAGB) A RETROSPECTIVE STUDY OF 127 PATIENTS M. Bueter, A. Thalheimer, T. Stingl, J. Maroske, D. Meyer, M. Fein University of Wuerzburg, WUERZBURG, Germany

ROUTINE USE OF INTRAOPERATIVE ENDOSCOPY DECREASES GASTROJEJUNOSTOMY (GJA) RELATED MORBIDITY OF LAPAROSCOPIC GASTRIC BYPASS (LGB) R.M. Peterson, A. Averbach, K. Singh St. Agnes Hospital, BALTIMORE, United States of America

Aims/Background: Gastric banding (GB) is one of the most common bariatric procedures. Weight loss can be excellent, but varies widely. It has been hypothesized that the type of band is of importance in the outcome. Methods: Some 127 patients (1997–2004) were analysed retrospectively after laparoscopic GB (Lapband: n=60, SAGB: n=67) in terms of preoperative characteristics, weight loss, comorbidities, complications and overall quality of life. Results: Preoperative characteristics including gender, age, weight and Body mass index (BMI) were identical in both groups. No diﬀerences were observed for presence and improvement of comorbidities. Incidence of postoperative complications showed no diﬀerence in band leakage, gastric perforation, band migration, port infection, or dislocation. Band slippage (30% vs 7,5%, p= 0,01) and pouch dilatation (28,3% vs. 7,5%, p=0,01) occurred more often in the Lapband group. Total number of reoperations was signiﬁcant higher after Lapband (21 vs. 7, p= 0,008), too. After median follow up of 63 months (range 2–104) Extra Body Weight loss (EBWL%) was identical in both groups (Median EBWL%: 50,6). 50% of the patients achieved an excess weight loss of at least 50% in both groups. All patients reported an increase in overall quality of life after surgery. Conclusions: Our results suggest that GB is safer with the SAGB while weight loss shows no diﬀerence between both SAGB and Lapband. There is no diﬀerence in improvement of comorbidities. 50% of the patients will achieve suﬃcient weight loss, and about 20% will develop severe complications requiring reoperation.

Objective: GJA is a crucial component of LGB. Circular stapler technique is associated with 1.5–5.8% leak rate and 1.6–6.3% stricture rate. Use of a GIA stapler and partially hand-sewn GJA is an alternative that can be associated with higher complexity and morbidity. Methods: LGB was attempted in 886 and completed in 873; open bypass was performed in 12 cases. Average BMI was 50.7 (35–100.3). Two thirds of the inner layer was stapled with Endo-GIA 45/3.5 and the anterior 1/3 was completed with 2.0 Surgidac Endostitch (SES) with a diameter of the anastomosis between 12–16 mm. The outer layer was hand sewn with a running 2.0 SES. In 26 open cases the exact same technique was utilized short of using SES. At completion of the GJA, the Roux limb was clamped and upper peritoneal cavity ﬁlled with saline. Proximal pouch and Roux limb were distended with air and visually inspected with intubation of GJA. Results: Average added OR time was 10 min. Endoscopy related complications occurred in 0.33% and no resultant postoperative morbidity. Intraoperative air leak was detected in 55 (6.1%) cases and suture line was reinforced in 37 of them; in 7 cases airleak was transient with high insufﬂation pressure and could not be reproduced. Clinical leaks developed in 4 cases (0.44%) with the rate of 3.7% in intraoperative endoscopy positive and 0.23% negative cases. In 3 (0.33%) cases GJA appeared too tight and was reconstructed. Postoperative anastomotic leak all cases was managed conservatively. There were no early strictures. Delayed strictures requiring endoscopic dilatation developed in 6 patients (0.68%). Conclusions: Routine intraoperative endoscopy allows veriﬁcation of patency and integrity of GJA thus reducing potential anastomotic related morbidity by 92.7% (from 6% to 0.44% (<0.05). Procedure associated morbidity is minimal and did not result in postoperative problems.

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GASTRIC BYPASS VERSUS GASTRIC BANDING IN THE SUPEROBESE N.R. Joshi, S. Lyass, M. Gaon, M. Hagiike, S. Cunneen, G.K. Nishi, E. Phillips, T.M. Khalili Cedars Sinai Medical Center, LOS ANGELES, United States of America

RESULTS OF LAPAROSCOPIC GASTRIC BYPASS (LGB) IN PATIENTS WITH BMI >60 R.M. Peterson, A. Averbach, K. Singh St. Agnes Hospital, BALTIMORE, United States of America

Objective: To analyze our institutions experience with superobese patients (preoperative BMI greater than or equal to 50) undergoing gastric bypass surgery (GBP) and gastric banding (GBD), and determine which option is superior in this demographic group. Methods: We performed a retrospective study of all superobese GBP and GBD patients at our institution from a prospectively maintained database of over 1000 patients from December 1999 to January 2005. Data collected included demographics, operative time, estimated blood loss, length of stay, morbidity, mortality, and percentage of excess body weight loss (EWL). Results: 398 patients meeting criteria for superobesity (mean preoperative BMI 57 [range 50–83]) underwent GBP (386 laparoscopic, 12 open) at our institution during the study period. Over the same time period, GBD was performed on 76 (74 laparoscopic, 2 open) superobese patients (mean preoperative BMI 57 [range 50–72]). Preoperative comorbidity proﬁles in the GBP and GBD groups were similar. 53 GBP patients (13.3%) experienced medical or surgical complications compared to 17 GBD patients (22.4%). Complications in the GBP group included anastomotic leak (1.0%), intraperitoneal hemorrhage (1.0%), small bowel obstruction (0.5%), and acute gastric dilatation (0.3%). Complications in the GBD group included band obstruction (1.3%), esophageal dilatation (1.3%), and band slippage (5.3%). There were no deaths in either study group. 12 months after surgery, mean EWL was 56.2% (range 27.5–92.5%) in the GBP group and 30.4% (range )0.6%–78.4%) in the GBD group (p<0.0001). The average BMI of the GBP group 12 months after surgery was 38.1 (range 24.3–58.5) compared to 46.2 (range 31.2–67.9) in the GBD group (p<0.0001). Conclusion: In superobese patients, gastric bypass surgery is superior to gastric banding in terms of weight loss achieved, with only minor diﬀerences in perioperative morbidity and mortality.

Objectives: Megaobesity is considered a relative contraindication to LGB. Some investigators raised the limit to BMI >60 or >70 and reported the feasibility of a laparoscopic approach in this group of patients. Anumver of authors consider the open approach as the only available alternative. Methods: LGB was performed with 5 ports and a Nathanson liver retractor technique. Length of Roux limb was based on BMI<50 (50 cm) and BMI>50 (150 cm). Retrocolic, retrogastric gastrojejunostomy was constructed with articulating EndoGIA 45/3.5 stapler and 2.0 Surgidac Endostitch with a hand sewn outer layer. Intraoperative endoscopy was routinely used to verify patency and integrity of anastomoses. Results: Of 886 patients, 105 (11.8%) had BMI of 60–100.3 (average BMI 66.5, weight 184.4 kg) and cionstitutes study group. Remaining 781 patients with BMI 35–59.9 (average BMI 48.2, weight 137.5 kg) were included in control group. No signiﬁcant diﬀerences in age, gender and co-morbidities were noted between groups. Conversion rate was 4.7% and 1.1%, respectively. Conversions in the study group were for: stiﬀ abdominal wall (3), adhesions (1) and colon malrotation (1). Average surgery time was 158 and 151 minutes. Morbidity appeared higher in the study group (12.8% vs. 5.7%; p<0.05). Major morbidity occurred with similar frequency (5.1% vs. 4.6%). Anastomotic leak rates were 0% and 0.5%. Re-operations were required in 1.2% and 0.98%. Mortality in the study group was 1.04% (1 patient - pneumonia) and 0.28% (PE and MI one patient each (P<0.05). With 70% follow-up at 1 year average BMI and%EBWL were 44.6 ()21.9) and 50.5% in the study group compared to 33.5 ()14.7) and 61% in the control group, respectively. Study group patients had statistically lower rate of resolution / improvement of diabetes and hypertension. Conclusion: LGB in patients with BM>60 can be performed with acceptable results that favorably compare to national statistics. Morbidity and mortality are only slightly higher than in patients with BMI<60.

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THE SAFETY OF LAPAROSCOPIC GASTRIC BYPASS (LGB) WITH RESIDENT PARTICIPATION R.M. Peterson, K. Singh, A. Averbach St. Agnes Hospital, BALTIMORE, United States of America

LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS: EXPERIENCE IN THE PONTIFICIA UNIVERSIDAD CATOLICA DE CHILE A. Escalona, N. Devaud, G. Pe´rez, F. Crovari, F. Pimentel, S. Guzma´n, A. Raddatz, L. Iba´n˜ez Pontiﬁcia Universidad Cato´lica de Chile, SANTIAGO, Chile

Objectives: With LGB being one of the most frequently performed laparoscopic procedures the issue of residents training is increasingly important. Limited information is available on safety of LGB performed with participation of surgical residents. Methods: Retrospective analysis of 886 patients who underwent LGB at a teaching hospital from 2002 - 2005 was performed. Study endpoints included operative time, intraoperative complication rates (IOC), reoperation rates, leak rates, and overall morbidity. There were a total of 21 residents (PGY 2–5) assisting/performing LGB. They were grouped by the number of cases: Group 1 - 1 to 20 cases (n=12); Group 2 - 21 to 40 cases (n=5) and Group 3 - >40 cases (n=4). The initial 100 cases were excluded to account for attending learning curve and cases performed by two attending served as the control. LRYGP was performed in a retrocolic, retrogastric fashion with partially stapled, partially hand-sewn gastrojejunostomy. Routine intraoperative endoscopy was utilized to conﬁrm patency and integrity of anastamosis. Results: There were no signiﬁcant diﬀerence in patients characteristics between the groups. Average age of patients was 42.4 (18 - 68), BMI 50.7 and weight 143.9 kg. Conversion rate was 1.46%, reoperation rate - 0.85%, morbidity - 7.54% and mortality was 0.34% with no diﬀerence across all study groups. For Groups 1, 2 and 3 respectively the average time was 189.5, 144.5 and 147.9 min.; IOC rates were 26.9, 10.8 and 9.2%; leak rates were 2.34, 0 and 0.39%. Diﬀerences between Group 1 and Groups 2/3 were statistically signiﬁcant. For control group these parameters were respectively: 153.3 min., 11.5% and 1%. Conclusions: Results indicate that LGB can be safely performed with resident participation, with morbidity, mortality and conversion rates comparable to attendings only and national benchmarks. It appears that basic laparoscopic skills develop after at least 20 LGB. After 40 cases experience residents can advance to performing LGB under supervision.

Introduction: Laparoscopic Roux-en-Y gastric bypass (RYGBP) is one of the alternatives of choice in the surgical treatment of the morbid obesity. The aim of this study was to evaluate the experience in the treatment of morbid obesity with this method at our institution. Methods and procedure: Information was obtained from the prospective database of all patients who underwent laparoscopic RYGBP from August of 2001 to August of 2005. The median follow up is of 21 months. Results: In this period 754 patients were underwent RYGBP. Mean age was 36 10 years and 75% are women. Mean body mass index (BMI) was 41 5 (Kg/ m2). The presence of HTA, DM II, and dyslipidemia was observed in 29, 13 and 41 percent of patients respectively. In 11 patients (1,4%) conversion to open surgery was needed. The mean operative time was 114 39 minutes. The hospital stay was 4,0 2,5 days. Postoperative complications were observed in 68 patients (9%). In 16 of them (2,1%) reoperation was needed. There were no deaths. The excess of weight loss to the 12 and 24 months was of 95 and 93 percent respectively. Conclusion: Laparoscopic Roux-en-Y gastric bypass is a good alternative of surgical treatment of the morbid obesity.

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SIZE MATTERS: GASTRIC POUCH SIZE CORRELATES WITH WEIGHT LOSS FOLLOWING LAPAROSCOPIC ROUX-Y GASTRIC BYPASS K.E. Roberts, J.I. Kaufman, A.J. Duﬀy, J.D. Dziura, R.L. Bell Yale University School of Medicine, NEW HAVEN, United States of America

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING (LAGB): PREOPERATIVE BMI AFFECTS THE RESULTS

Introduction: The identiﬁcation of relevant components of successful weight reduction surgery is the most important endeavor in the latest research aiming to increase excess weight loss. Over the past twenty years there has been ongoing discussion about the importance of gastric pouch size as one of the key factors inﬂuencing weight loss after restrictive weight reduction surgery. The goal of our analysis is to determine the relationship between gastric pouch size and weight reduction following laparoscopic Roux-Y gastric bypass (LRYGB). Methods: Between August 2002 and March 2005, 321 LRYGB were performed at the same institution. Patient demographics were entered into a longitudinal, prospective database. Upper gastrointestinal series was performed in all patients on postoperative day one. Assuming that pouch depth remained constant, pouch size was calculated as area (cm2) utilizing digital imaging technology and internal standardization for measurement. Linear regression analysis was performed to determine the association between pouch size and weight loss at 6 and 12 months postoperatively. Adjustment was made for age, gender, and preoperative BMI. Results: Mean age was 41 years (range, 17–64); 262 patients were female (81.6%); mean preoperative BMI was 51.1 kg/m2 (range, 36.1–89.9 kg/m2). Mean 6 month %EWL was 50.5 (range, 13.4–85.5%) and mean 12 month %EWL was 62.5 (range, 14.6–98.1). Mean pouch size was 63.9 cm2 (range, 8.6–248.0 cm2). A statistically signiﬁcant inverse correlation between pouch size and %EWL was found (at 6 month r = )0.40035, p<0.001 and at 12 month r = )0.43379, p<0.001). No signiﬁcant correlation was found between pouch size and age or preoperative BMI. Conclusion: Our analysis demonstrates that gastric pouch size is one important component for successful weight reduction following LRYGB. The creation of a small gastric pouch should be encouraged as the initial step towards ideal weight loss.

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COMPARISON OF OUTCOMES AFTER LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING (LAGB) BETWEEN ADOLESCENT AND ADULT POPULATION

UNREVELING THE MYTH: SIZE DOES MATTER. COMPARISON OF OUTCOMES BETWEEN THE 10 AND 11 CM (VG) LAP BAND

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LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING (LAGB) AS AN OUTPATIENT PROCEDURE

IS THE SWEETEATING BEHAVIOR A PREDICTOR OF OUTCOME AFTER LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING? F. Moser, M.V. Gorodner, C.A. Galvani, S.A. Horgan University of Illinois, CHICAGO, United States of America

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Background: It has been proposed that laparoscopic adjustable gastric banding (LAGB) should not be oﬀered to sweet eaters patients, since it is a predictor of bad outcome after purely restrictive procedures. Our goal is to assess our initial experience in the US, evaluating the inﬂuence of the sweet eating behavior on the outcome after LAGB. Methods: Between November 2000 and October 2004, 495 patients underwent LAGB placement at our institution. Three hundred and twenty two had a follow up of 1 year or more. Of those, 57 patients ﬁlled out a scored questionnaire about their sweet eating habits, pre and postoperatively. The median score was 36. Patients were divided in 2 groups based on their score. Group A: Sweet Eaters, score >= 36 and Group B: Non Sweet Eaters, score<=36. Results: Follow up was 21+)7 months. Results are shown on the table as mean+)SD.

# of Patients Age (years) Gender (F/M) BMI preop (kg/m2) Score preop Score postop BMI postop (kg/m2) % EBWL

Sweet Eaters

Non Sweat Eaters

27 42±11 20/7 46±7 49±10 27±8 34±6 53±30

30 46±10 22/8 45±6 28±7 21±7 32±6 57±22

p

NS NS <=0.001 <=0.005 NS NS

Conclusions: Our study shows that preoperative sweet eating behavior is not a predictor of failure in terms of weight loss after LAGB placement. Sweet eating behavior should not condition the surgeon, when choosing the bariatric procedure suitable for each patient.

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COMPARISON BETWEEN LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING, ROUX-EN-Y AND SINGLE-ANASTOMOSIS GASTRIC BYPASS, BPD, BPD-DS AND GASTRIC STIMULATION SINGLE CENTER EXPERIENCES R.A. Weiner, I. Pomhoﬀ, W. Karcz, M. Schramm, S. Weiner KH Sachsenhausen, FRANKFURT, Germany

THE SURGICAL TREATMENT OF MORBID OBESITY WITH AN ABSORBABLE GASTRIC BAND A MULTICENTRIC STUDY A. Mahajna, P. Wintringer, J.L. Dulucq Bagatelle Hospital, TALENCE-BORDEAUX, France

Background: Further research is needed to examine the morbidities, frequency of complications and eﬃcacy in controlled trials comparing the various surgeries for morbid obesity. Methods: 1042 consecutive patients (F 82,5%) underwent between 2/2001 1/2005 diﬀerent procedures. During secondary RNYGB 4 conversions registered. Gastric banding (A: 224), primary RNYGB (B:658), primary single-anastomosis gastric bypass (C:64), secondary RNYGB (D:84), BPD (E:54), BPD-DS (F:134), sleeve gastrectomy (G:52) and gastric pacing (H,I:14) were performed by a single surgeon. Mean BMI of all was 46,4 +/ ) SD 7,2 kg/m2. Mean follow-up was 27 months (60 3 months. Results: The hospital lethality was in all series 0%, excepted in the BPD-DS group (F:1,5% letality). In the one-year mortality one death after RNYGB (0,15%) and a late death after BPD-DS (0,75%) were reported. The morbidity (%) was A: 0,8, B:20,6, C:6,2, D19:, E:3,7, F: 24, G:13,6, H:0, I:8,3. The rate of early reoperations was higher in the stapled than in the nonstapled surgery (4% versus 0%). The OR- time (min) was A: 38, B:58, C: 42, D:118, E: 62, F: 166, G:52, H:43, I:126 min. The mean excess weight loss (%) one year after was A:54, B:72, C:74, D:48, E:74, F:82, G:, H:18, I:32. Conclusions: Diﬀerences in excess weight loss, risks and metabolic changes are arguments for a tailored therapy concept in bariatric surgery.

Background: Laparoscopic gastric banding as a surgical treatment for morbid obesity has become the most common bariatric procedure performed worldwide. Yet, this method is associated with considerable bandrelated complications: band slippage, erosion and penetration, tube leak and disconnection and port dislocation and infection. The absorbable band was planned to overcome the above band-related complications as it introduced without the use of port and is reabsorbed two years following itsÕ placement. Objective: This study was designed to evaluate prospectively the clinical outcome following the use of absorbable band for the treatment of morbidly obese patients. Data were obtained from a multi-centric European study group. Methods: Between September 2003 and June 2004, patients with morbid obesity from several centers in Europe who underwent laparoscopic insertion of absorbable band (Sofradim-Tyko), were enrolled prospectively in this study. Data collection included operative, postoperative and weight loss results. Results: Thirty six patients (30 females and 6 males) with a mean age of 34 10 years and a BMI of 42 + 3 kg/m2 underwent laparoscopic absorbable band insertion. Mean operative time was 42 + 12 min with minimal blood loss. There were no intraoperative complications or conversion. The mean hospital stay was 3 + 1 days. The excess weight loss after 1,3,6 and 12 months of follow up was 17.8%, 26.4%, 32.4% and 36.2%, respectively. There were neither band-related complications nor re-operations during the follow up period. Conclusion: The laparoscopic insertion of absorbable band system has a very low morbidity rate and it yields satisfactory weight loss. Longer follow up and bigger series are needed to conﬁrm our results

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INITIAL CLINICAL EXPERIENCE WITH TELEMETRICALLY ADJUSTABLE GASTRIC BAND R.A. Weiner1, M. Korenkov2, E. Matzig1, S. Weiner1, W. Karcz1, I. Pomhoﬀ1 1 KH Sachsenhausen, FRANKFURT, Germany 2 Universita¨t Mainz, MAINZ, Germany

TREATMENT OF THE SUPER SUPEROBESITY BY SLEEVE GASTRECTOMY J.M. Catheline Avicenne Hospital, BOBIGNY, France

Background: The Achilles heel of adjustable gastric banding is the access port, with port-related complications constituting a signiﬁcant part of all complications. Further, adjustment of hydraulic gastric bands is a fairly lengthy, uncomfortable and not precise procedure. Methods: We implanted the ﬁrst telemetrically adjustable gastric bands (EASYBAND, EndoArt Medical Technologies, Switzerland) in 37 morbid obese patients (aged 368 years, BMI 434.6 ) during the period 06 until 11/ 2005. EASYBAND is a purely mechanical gastric band, where the adjustment is achieved by means of an embedded micromotor, controlled by an external control unit using telemetry. The exact band diameter is displayed continuously during adjustment on the external control unit screen. Results: No serious adverse events were found in relation to the device. A mean of 3.5 ?0.7 adjustments per patient were performed during the 6month follow-up period, with the band diameter set to 29 mm (fully open) at implantation, 24.50.5 mm at 1 month, 23.30.7 at 3 months and 23.01.0 at 6 months. Mean excess weight loss was 10.24.5% at 1 month, 23.88.8% at 3 months and 29.510.2 at 6 months. Conclusions: This initial study shows that the new telemetrically adjustable gastric banding device is implanted and operated safely, allows for atraumatic band adjustments with superior patient comfort. Longer-term follow-ups and larger population studies are needed to establish the

Background: The sleeve gastrectomy is a restrictive procedure that reduces stomach capacity by 75%. We present here a preliminary experience for patients with super super morbid obesity (body mass index (BMI)> 60 kg/ m2). Methods: A prospective study of the initial 10 patients who underwent laparoscopic sleeve gastrectomy was performed. Study evaluated operative time, complication rates, hospital length of stay and percentage of excess weight loss (%EWL). There were 8 women and 2 men, with a mean age of 37 years (range 19 to 55 years), with mean preoperative BMI 65 kg/m2 (range 61 to 78 kg/m2). Mean preoperative weight was 171 kg (range 147 to 228 kg). One patient had situs inversus totalis and another one had previous restrictive surgery. Mean operative time was 160 minutes (range 130 to 200 minutes). No patient required conversion. We noted a postoperative complication in only one patient (subdiaphragmatic abcess treated by drainage). Median hospital stay was 12 days (range 7 to 28 days). There were no mortality. Average weight loss at 12 months was 50 kg (range 31 to 72 kg). Average %EWL and BMI at 12 months were 49% (range 32 to 66%) and 20 kg/m2 (range 12 to 28 kg/m2) respectively. Conclusion: These preliminary results suggest that the sleeve gastrectomy is associated with few perioperative complications and oﬀers rapidly eﬀective treatment for super super morbid obesity. It can be a ﬁrst stage procedure before gastric bypass or duodenal switch or a one-stage restrictive procedure if long-term results are good.

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THE EFFECT OF PREOPERATIVE LOW CARBOHYDRATE DIET ON LIVER VOLUME IN MORBID OBESE PATIENTS N. Beglaibter1, L. Gindi2, M. Weinberg2, O. Benjaminov2, M. Rubin2 1 Hadassh University Hospital Mount Scopus, JERUSALEM, Israel 2 Beilinson campus Rabin Medical center, PETAH TIKVAH, Israel

THE REPORT OF LAPAROSCOPIC TOTAL GASTRIC VERTICAL PLICATION IN MORBID OBESITY IN IRAN M. Talebpour, B. Saadat Amoly Tehran Medical University, TEHRAN, Iran

Background: Hepatomegaly in the morbid obese patient can be a serious obstacle to laparoscopic bariatric surgery and may even necessitate conversion to an open procedure . This study evaluates the eﬀect of an isocaloric very low-carbohydrate diet on the volume of livers in morbid obese patients candidates for bariatric surgery. Method: A total of 14 morbid obese patients were studied. 9 females and 5 males with a mean age was 33.4 years and a mean BMI of 45.9 kg/m2. All patients underwent base-line abdominal CT scan and were put on a diet of about 1520 kcal/day (out of which only about 210kcal (14%) were contributed by carbohydrates) for a 4 weeks period. At the end of the 4 weeks the patients underwent abdominal CT scan which was compared to the base-line scan with regard to volume and density of the liver. Results: A signiﬁcant decrease in body weight was noticed. Volumetric and density studies performed on the CT scans before and after the diet period, show signiﬁcant diﬀerences in liver volume and density. Liver density increased from an average of 36 Haunsﬁeld Units (HU) to 43 HU (p=0.05), while liver volume decreased from an average volume of 2717 ml before the diet to an average volume of 2495 ml at the end of the study period, a change of 8.1% (p=0.01). The spleen, an organ almost devoid of fat, showed no change in density or volume. The reduction in liver volume was correlated with decrease in body weight (R= 0.89, P<0.001) Conclusion: Very low carbohydrate diet causes a reduction in liver fat content and liver size, as evidenced on pre and post diet CT studies. This may render bariatric operations, or any foregut operation in a morbid obese patient, less diﬃcult and mark the importance of low carbohydrate diet preoperatively.

Aim: The aim of this study is to introduce a new technique ÔTotal Gastric Vertical PlicationÕ (TGVP) in decreasing gastric volume with the least risk of complication and the same result of weight loss as other techniques without any extraordinary cost especially in third word countries. Method: This technique used during 2 years by one surgeon in private hospitals, Tehran, Iran. Patients are placed in supine with 30-degree reverse terendelenbourg position. Trocars inserted based on ergonomic assessment (Three 5 mms and a 10 mm). After release of greater curvature by ligasure instrument, by continuous oo nylon suturing from fondues to 3 cm to pylorus a vertical plication in one or two layers performed. Distance between stitch and lesser curvature in anterior and posterior and between each stitch is 2 cm and all of them are extra mucosal and far away of acid eﬀect. The volume of stomach in this condition is 100 cc but just one half of it is eﬀective due to painful muscular movement. Results: In 42 middle aged (35 years old, SEM=2.4) cases; mostly female (F/M=31/11) and with average BMI=46 (36–51) it performed. The mean weight loss in our patients is 21.4% of ÔExcessive Weight LossÕ (EWL) after one month of operation, 55% after 6 months, 61% after 12 months and 62.3% after 24 months. The average time of follow up is 11 months. The mean time of operation is 107 (75152) minutes and all of them discharged from hospital after an average time of 24 hours of operation. Postoperative complications include permanent vomiting (1 case), liver hematoma producing abscess and adhesion (2 cases), lack of co working in 3 cases and promoting silent disease (asymptomatic hypercalciuria) in one case. Conclusion: The percentage of EWL in this technique is comparable to other gastric volume restriction methods but EWL appears more rapidly. Early postoperative complication of this method is minimal, without any important late complications. This technique needs more expertise and more time consuming.

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ONE STAGE LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS SURGERY IS SAFE AND EFFECTIVE IN SUPER-OBESE PATIENTS E.M. Basseri, T.M. Khalili, S.A. Cunneen, G.K. Nishi, S. Lyass, N.R. Joshi Cedars-Sinai Medical Center, LOS ANGELES, United States of America

THE RISK OF GASTRIC CANCER AFTER ROUX-EN-Y GASTRIC BYPASS H. Inoue1, F. Rubino1, Y. Shimida1, V. Lindner2, M. Inoue1, P. Riegel1, M. Vix1, J. Marescaux1 1 IRCAD-EITS University Louis Pasteur, STRASBOURG, France 2 Hopital Hautpierre, STRASBOURG, France

Aims: Many authors advocate two-stage laparoscopic Roux-en-y gastric bypass (LRYGB) for super-obese patients. The objective of our study was to review our experience with one stage laparoscopic roux-en-y gastric bypass in super-obese [BMI>50] patients. Methods: A retrospective analysis of all patients who underwent LRYGB from January 1999 to January 2005 was performed. Super-obese [BMI>50] patients were compared to morbidly obese [BM>50] patients. Data collected included demographics, comorbidities, operative time, and length of stay. The two groups were compared with regard to perioperative complications and postoperative weight loss. Perioperative complications included anastomotic leak, bleeding, pulmonary embolus, deep vein thrombosis, and bowel obstruction. Results: During the study period, 314 super-obese patients and 536 morbidly obese patients underwent LRYGB. Mean BMI in the super-obese group was 56 (range 50–77) versus 44 (range 35–49) in the morbidly obese group. The overall complication rate in the super-obese group was 8.6% versus 9.5% in the morbidly obese group. Speciﬁc complication rates in the super-obese and morbidly obese groups, respectively, were as follows: anastomotic leak (1.3% vs 0.7%), bleeding (0.0% vs 0.7%), pulmonary embolus (0.6% vs 0.6%), deep venous thromboses (1.3% vs 0.6%), bowel obstruction (1.0% vs 1.9%). There were no deaths or conversions to open surgery in either group. Mean %EWL was 56.5 in the super-obese group versus 68.8 in the morbidly obese group at one-year follow up. Conclusion: One-stage laparoscopic roux-en-y gastric bypass surgery can be safely performed in super-obese patients with excellent postoperative weight loss and no additional perioperative morbidity.

Background: In many geographic areas with high incidence of gastric cancer surgeons may be reluctant to perform RYGB, an eﬀective bariatric operation that leaves 95% of the stomach inaccessible to endoscopic exploration. The aim of this study was to evaluate the risk of gastric cancer after Roux-en-Y gastric bypass (RYGB). Methods: Fifty-ﬁve Fischer-344 rats randomly underwent one among RYGB, duodeno-jejunal bypass (DJB), a modiﬁed-RYGB that involves the same Roux-en-Y reconstruction as in standard RYGB but without gastric exclusion, or a sham operation. Postoperatively, rats underwent a protocol of cancer induction by both continuous (200 ppm in tap water for 16 weeks) and intermittent (50 mg/kg intra-esophageal injection, once a week, for 12 weeks) administration of N-methyl-N-nitrosourea. At the end of the experimental period, 17 weeks after operation, pathologic examination of the whole stomach was performed in all animals to assess for the presence of cancer and/or pre-malignant lesions. Gastric bilirubin concentration, bacterial ﬂora and any other pathological ﬁndings were also recorded. Results: In sham-operated controls and DJB animals the incidence of gastric cancer was 85% and 75% respectively (P=NS) whereas only 23% of RYGB animals developed gastric cancer (4-fold reduction; P<0.01). The remnant stomach of RYGB rats also showed lower bilirubin concentration (P <0.01), and lower bacterial count (p<0.05) compared to both DJB and sham groups. Conclusion: This study shows that RYGB reduces the risk of gastric cancer in an experimental model of dietary-induced carcinogenesis. Lack of direct contact with carcinogens, lower bile reﬂux and fewer bacteria concentration in the gastric content may be responsible for these observations. These data suggest that RYGB may be a safe option for the treatment of morbid obesity even in areas with high gastric cancer incidence.

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ESOPHAGEAL FUNCTION AND ESOPHAGEAL ACID EXPOSURE AFTER LAPAROSCOPIC VERTICAL BANDED GASTROPLASTY C. Giaccone, F. Rebecchi, L. Pellegrino, M. Toppino, M.E. Allaix, M. Morino Ospedale Molinette, TORINO, Italy

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING WITH DUODENAL SWITCH (BANDINARO). DUODENO-ILEAL RUNNING SUTURE M. De Luca1, G. Segato2, F. Favretti2 Ospedale San Bortolo, VICENZA, Italy 2 San Bortolo Hospital, VICENZA, Italy

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Aims: Controversial ﬁndings about the relationships between obesity and gastro-esophageal reﬂux have been reported, as well as about the eﬀects of weight loss and bariatric surgery on reﬂux. The aims of this study were to evaluate the eﬀects of laparoscopic vertical banded gastroplasty (LVBG) on esophageal motility and esophageal acid exposure in obese patients. Methods: 70 obese subjects (BMI 35–54 kg/m2), 31 men, 39 women, 20–50 years old, admitted for elective LVBG, underwent pre-operative clinical evaluation, esophageal manometry and 24 hours pH monitoring. Evaluations were repeated 12 months after surgery. Results: 12 months mean percentage of excess weight loss (EWL) was 30%. The prevalence of heartburn and acid regurgitation among patients treated with LVBG increased from 23% (16/70) and 24% (17/70) to 29% (19/70) and 30% (21/70), respectively (n.s.). The 24-hour reﬂux time was essentially unchanged in patients treated with VBG (4.6% vs 4.2%) and there was a non signiﬁcant increase of the post-operative DeMeesters score (16.5 vs 17.2). The lower esophageal sphincter pressure and esophageal motility were unaﬀected by surgery. Conclusions: LVBG is an eﬀective bariatric procedure that does not inﬂuence esophageal function and esophageal acid exposure.

Background: Laparoscopic Biliopancreatic Diversion with Duodenal Switch and Stomach Preservation and Restriction (Band-Inaro) is usually considered a second choice operation in our experience. Its main indications are: failure of restrictive procedure and/or second step in the sequential treatment of super obese patients. Diﬀerent kinds of anastomosis were performed. Methods: The operation is a restrictive procedure followed by a BPD DS with a 200cm alimentary channel and 50cm common channel. The stomach is left intact. Two anastomosis are performed (duoedeno-ileal and ileo-ileal anstomosis). The malapsorbitive procedure was performed laparoscopically in the last 20 cases. The laparoscopic duodeno-ileal anstomosis was performed by hand with a prolene non adsorbable running suture. From Sept 1993 to January 2006, 57 patients underwent a sequential treatment (ﬁrst step: restriction; second step: malabsorption). Surgical morbility and mortality is reported for the entire series. Results: At the time of the original restrictive procedure (VBG, ASGB, LAPBAND) the mean body weight was 133.223.1 kg (BMI 49.87.3); When the Duodenal Switch (DS) procedure was added to the previous restrictive one the mean weight was 119.719.9 Kg, (BMI 45.37.2; %EWL 16.121.8). 1, 3, 5 and 7 years after the DS the body weight (kg) was 92.916.5, 86.3+)16.9, 91.8 +) 16.6 and 80.2 +) 17.7 respectively. The BMI dropped to 34.75.4 at the ﬁst year and to 28.1+)6 at 7 years. The % EWL reached 81.7 at 7 years. As major complication of the DS open series we registered 1 case of pancreatitis (requiring reoperation) and 1 case of internal hernia (requiring reoperation). The DS laparoscopic series registered 1 case of mortality (myocardial infarction), 1 case of hemoperitoenum requiring reoperation and 2 cases of duodenal-ileal ﬁstulas not requiring reoperation. Conclusions: Laparoscopic Biliopancreatic Diversion with Duodenal Switch and Stomach Preservation and Restriction (Bandinaro) is considered a second choice operation. These data suggest that laparoscopic Bandinaro is feasible, with good results in terms of weight loss and acceptable morbidity rate. Laparoscopic duodeno-ileal anstomosis by prolene non adsorbable running suture could be considered the suture of choice. The laparoscopic preliminary experience requires a larger study with longer follow up.

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OUTCOME OF 24-HOUR OESOPHAGEAL PH MONITORING AND OESOPHAGEAL FUNCTION AFTER LAPAROSCOPIC VERTICAL BANDED GASTROPLASTY AND GASTRIC BANDING: A RANDOMISED CONTROLLED TRIAL F. Rebecchi, C. Giaccone, G. Bonnet, M. Toppino, M. Morino Ospedale Molinette, TORINO, Italy

THE LAP-BAND SYSTEM: THE ITALIAN EXPERIENCE WITH 5,624 OPERATED PATIENTS N. Di Lorenzo, F. Favretti, F. Furbetta, L. Angrisani, A. Micheletto, E. Lattuada, M. Paganelli, M. Lucchese, N. Basso, F.D. Capizzi, A. Cascardo, L. Di Cosmo, A. Gardinazzi, C. Giardiello, G. Lesti, A. Veneziani, F. Puglisi, M. Alkilani, P. Forestieri, A. Iuppa, P. Bernante, G. Coscarella, M. Lorenzo GILB, NAPLES, Italy

Aims: One of the co-morbidities frequently associated with morbid obesity is gastro-esophageal reﬂux disease (GERD). Among a group of 100 patients selected for a randomised controlled trial comparing laparoscopic vertical banded gastroplasty (LVBG) to laparoscopic gastric banding (LGB), 33 patients underwent a complete gastro-oesophageal functional study. Methods: 17 patients underwent LVBG and 16 patients underwent LGB. Symptoms of GERD, oesophageal manometry, and 24 Hours oesophageal pH monitoring were recorded in all patients preoperatively, and at 3 months and 1 year postoperatively. Results: Among patients submitted to LGB 31.3% (5/16) presented heartburn and 25% (4/16) presented acid regurgitation; 1 year postoperatively the frequence of both symptoms increased: 68.7% (11/16) and 62.5% (10/ 16) respectively. Heartburn and acid regurgitation were present before surgery in 23% of patients treated with LVBG, percentages unchanged by the procedure. The 24-hour reﬂux time increased signiﬁcantly from 4.8% to 18.6.% in patients treated with LGB but was essentially unchanged in patients treated with LVBG (4.1% and 4.6%). There was a signiﬁcant increase of the post-operative DeMeesters score only in LGB group (19.6% to 28.4) The lower esophageal sphincter and esophageal motility were unaﬀected by surgery in both group. Conclusions: The prevalence of GERD was unchanged by LVBG, but LVBG did not demonstrate antireﬂux properties. The incidence of GERD increased markedly after LGB.

The Lap-Band System procedure is currently one of the most common bariatric surgical procedures performed world-while. Despite its diﬀusion little is known about long term results on very large population of operated patients. Aim of this study is to report the experience of the Italian Collaborative Study Group for Lap-Band System on 5,624 operated patients. Methods: Data were collected on a speciﬁcally created electronic database (MS Access 2000). Items regarding mortality, laparotomic conversion, intra and postoperative complications, BMI, and %EWL were considered. Data were expressed as mean±standard deviation except as otherwise indicated. Results: From January 1996 to February 2006, 5,624 patients (F/M: 4431/ 1193; age: 37.1±12 years; BMI: 44.8±9.1 kg/m2; EW: 56.3±21.7 Kg; %EW: 88.2±32.9) underwent Lap-Band System. Intraoperative mortality was absent. Postoperative mortality rate was 0.2%, mainly due to cardiovascular complications. Laparotomic conversion rate was 109/5624 (1.9%) due to technical diﬃculties (85/109) or complications as bleeding (13/109) or gastric perforation (11/109). Major post-operative complications were pouch dilation (407; 7.2%), intra-gastric band migration (89; 1.6%) and tube-port related complications (331; 5.8%). Patients drop out at each time of follow up ranged between 25–32%. Weight loss has been evaluated at the following intervals: 12, 36, 60, 84 and 108 months, with BMI of 37.1±4.8, 35.8±6.6, 33.2±7.2, 29.8±6.9, and 32.1±7.8 respectively. At the same intervals %EWL was: 46.7±12.9, 51.8±16.8, 53.7±16.9, 59.9±18.9, and 54.2±19.1 respectively. Conclusions: Lap-Band System placement is a surgical procedure with a very low mortality rate, low morbidity, and satisfactory weight loss also in long term follow up.

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LAPAROSCOPIC, BARATRIC, REDO SURGERY: TECHNIQUE AND SOLUTIONS F. Furbetta, B. Lo Iacono, S. Gennai, F. Gragnani, F. Guidi, C. Masetti Casa di Cura ÔLeonardoÕ, VINCI, EMPOLI (FI), Italy

LAPAROSCOPIC VERTICAL SLEEVE GASTRECTOMY FOR MORBID OBESITY IN 216 PATIENTS: REPORT OF TWO-YEAR RESULTS

Background: Laparoscopic procedures are the gold standard treatment in the ﬁeld of obesity; late complications and failures requiring revisional surgery are predictable for any bariatric operation. Restrictive, hybrid and malabsorbitive procedures are the group of operations ordered according to a diminishing reversibility, invasiveness, necessity of patients compliance and rising eﬃcacy. There is general agreement that redo surgery should go from restrictive to hybrid and malabsorbitive procedures if the failure is related to the patient compliance, otherwise every solution is suitable. The approach for this more demanding surgery is controversial. Materials and Methods: Casistic: October 95 - March 06: 1380 procedures. 1208 lap-band (L-B, Inamed, Santa Barbara, CA, USA), 67 functional gastric bypass (FGB, personal technique), 105 redo operations. All the operations have been successfully performed laparoscopically without complications. Among the redo surgery there are: 4 standard gastric bypass (GBP) from vertical banded gastroplasty (VBG), 3 L-B from VBG, 3 L-B and entero-entero anastomosys after jejunum-ileal bypass, 1 jejunostomy (ﬁrst step after jejunum-ileal bypass), 2 lap-band after bilio-pancreatic diversion, 47 FGB as second step after lap-band, 2 re-conversion from FGB, 43 rebanding, 15 band removal. Conclusions: Redo surgery is foreseeable for all bariatric procedures in order to solve complications and inadequate weight loss. We treated all the patients with a laparoscopic procedure without complications. Redo surgery is easier after a laparoscopic gastric banding and more solutions to weight loss failure are oﬀered after restrictive operations. The more demanding redo surgery should be reduced and favoured by a rational laparoscopic sequential treatment to cut down risks and select patients for more invasive procedures.

C.M. Lee, J.J. Feng, P.T. Cirangle, G.H. Jossart California Paciﬁc Medical Center, SAN FRANCISCO, United States of America Introduction: The vertical gastrectomy (VG) is the restrictive part of the technically diﬃcult biliopancreatic diversion with duodenal switch operation (DS). The VG was originally conceived of as an independent operation - the ﬁrst stage of a two-stage DS that would reduce mortality and morbidity in the high-risk superobese because of a shorter OR time and no anastomoses. This abstract presents the ﬁrst two-year data after VG. Methods: Laparoscopic VG was performed in a non-randomized fashion in obese patients that met the NIH criteria for bariatric surgery. By using 5–7 ﬁrings of 45– 60mm linear 3.5mm GI staplers along a 32 Fr bougie, a greater curvature gastrectomy is performed to create a 100–120 ml gastric tube. Results: Between Nov 2002 and Aug 2005, 216 patients underwent VG. The mean age was 44.7 years (range 16–64) and 173 (80%) were female. The mean preop weight and BMI was 30277 lbs and 4911 kg/m2, respectively. Of the 216 patients, 5 (2.3%) had a BMI >80 kg/m2, 6 (2.8%) had a BMI of 70–80 kg/m2, and 25 (11.6%) had a BMI of 60–70 kg/m2. The mean OR time was 6611mins (range 45–180), the mean EBL was 2913 cc, and the mean length of stay was 1.91.2 days. Complications occurred in 20 (6.3%) of patients (vs. 7.1% after lap band). Leaks occurred in 3 (1.4%) of patients, reoperations were performed in 26 (7.8%), and no conversions to open or deaths occurred. Weight loss on par with the DS and RGB was achieved with just the VG alone (see table). A weight loss plateau (<10lbs lost/6mos) was found in only 9 (4.2%) of patients.

Weight (lbs) BMI (kg/m2) Wt Loss (lbs) EWL (%)

0 Mos

12 Mos

24 Mos

302 49.2 0 0

242 36.8 60 58.5

179 27.7 123 83.1

Conclusions: The VG operation is able to achieve signiﬁcant weight loss on with morbidity comparable to that of lap band placement . These two-year data suggest that very few patients require a second-stage operation for weight loss plateau. Further studies are needed to determine if these promising results are borne out with time.

O268 AN PATIENT TAILORED PROCEDURE, DUODENAL SWITCH IN TWO STAGES N. Reijnen Scheperziekenhuis, EMMEN, The Netherlands Obesity has become an worldwide epidemic. Diﬀ. methodes has been developed, to gain permanent weightloss they can be divide in Restrictiv and malabsorbsion procedures and an combination of both. In the choice of the procedure one has to concider the BMI < or > 50 and the habits of the patients the existance of Gerd and DM. The super obese patients (BMI >50) need an more diﬀeranciated procedure to minimize the operation risks. The duodenal switch laparoscopic in two stages is an possible pocedure. First there will be an sleeve resektion, with weightloss, patients will recover very quickly and the hospital stay is not longer then 3–4 days, the 2nd. step will follow when there is nomore weightloss for 3 to 6 month. The patients than are in a far more better condition, most of their comorbidities are less severe. The 2nd step is an ileo-duodenalstomie end too side creating an allimantary channel of 250 cm, an ileo-ileostomie side too side at 100 cm of the ileocoecal valve, so the result is an common channel of 100cm. Presentation of our ﬁrst experience in 50 patients.

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SURGICAL REINTERVENTION AFTER ANTIREFLUX SURGERY FOR GASTROESOPHAGEAL REFLUX DISEASE; A PROSPECTIVE COHORT STUDY IN 130 PATIENTS W.A. Draaisma, E.J.B. Furnee, I.A.M.J. Broeders, A.J.P.M. Smout, H.G. Gooszen University Medical Centre Utrecht, UTRECHT, The Netherlands

DEFINING FAILURE AND ITS OUTCOMES AFTER HELLER MYOTOMY FOR THE MANAGEMENT OF ACHALASIA

Background & Aim: Surgical reintervention after antireﬂux surgery for gastroesophageal reﬂux disease (GERD) is required in 3–6% of patients. The subjective outcome after reintervention has been reported in several studies, but objective results after these reoperations have hardly been published. The purpose of this study was to assess the symptomatic and objective outcome in patients who underwent reoperation because of recurrent reﬂux symptoms or troublesome dysphagia after primary antireﬂux surgery. Methods: Between 1994 and 2005, 130 patients (mean age 48.4 14.1 years) undergoing surgical reintervention after antireﬂux surgery for GERD were prospectively studied. Symptomatic outcome was determined by questionnaires and esophageal manometry and 24-hr pH monitoring were performed to assess the objective outcome. Results: 144 reinterventions were performed in 130 patients, for recurrent reﬂux in 75 (65.3%) and troublesome dysphagia in 43 patients (34.7%). Belsey Mark IV fundoplication through a left-sided thoracotomy was performed in 78 (54.2%) and re-Nissen or partial fundoplication in 66 patients (45.8%), including 16 laparoscopic procedures. After a mean follow-up of 60.1 37.2 months, heartburn and dysphagia on a daily basis were absent or signiﬁcantly improved in 70% of patients. Esophageal acid exposure was normalised in 70.2% of patients who underwent reoperation for recurrent reﬂux at follow-up. In this group of patients, there was a signiﬁcant correlation between acid reﬂux and usage of proton pump inhibitors. In contrast to those who needed a thoracotomy, objective results were better in patients with dysphagia who had a laparotomy and correlated with the decrease in lower esophageal sphincter pressure. Conclusion: Reoperative antireﬂux surgery yielded good symptomatic and objective results in 70% of patients in this prospective cohort study. Morbidity is far from negligible so expectations should be discussed in detail before reoperation.

A. Stival, L. Howell, V. Swaﬀord, J.P. Hunter, D. Smith Emory University School of Medicine, ATLANTA, United States of America Objectives: Heller myotomy for the management of Achalasia has realized considerable success in 90–95% of patients. However, little is written about the failures, including long-term outcomes. Herein we report our experience with 209 patients undergoing laparoscopic Heller myotomy speciﬁcally focusing on failures. Methods: Data on all patients undergoing foregut surgery are collected prospectively. Between 1994 and 2004, 209 patients underwent Heller myotomy for Achalasia, with nearly all also receiving a fundoplication (99.5%). A management algorithm and standardized operative technique was followed by the two surgeons caring for the majority of these patients. Average follow-up was 21 months (1 to 91). Symptom questionnaires were used at diﬀerent intervals during follow-up. Failure was deﬁned as persistence or recurrence of severe symptoms, need for endoscopic intervention(s), repeat Heller myotomy or esophagectomy. In these 209 patients there were 26 failures (12%). Results: Among the 26 failures, all had a concurrent fundoplication: 76% Toupet, 20% Dor, and 4% a modiﬁed Dor. None experienced an intraoperative complication during initial procedure (i.e., perforation). Nineteen patients (73%) had undergone a preoperative endoscopic intervention (pneumatic dilation and/or botox injection) compared to only 7 (27%) of those without failure (p<0.05). Six patients (23%) had undergone a prior foregut operation compared with only 2.7% among the nonfailure patients (p<0.05). Moderate to severe dysphagia was the main complaint for 92.3% of these patients, followed for regurgitation (50%), and heartburn (38.5%). Their control included expectant management and reassurance in 12 (46%), endoscopic dilation in 7 (27%), redo Heller myotomy in 3 (12%) and esophagectomy in 4 (15%). Conclusion: Treatment of Achalasia with Heller myotomy is successful in the vast majority of patients. Among those who fail, prior endoscopic treatment and mismanagement with prior fundoplication is more common. Over of those who fail will require some intervention for management. Prior to Heller myotomy patients should be speciﬁcally counseled about the consequences of failure, including the possibility of esophagectomy.

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LAPAROSCOPIC TREATMENT OF ACHALASIA PROVIDES DURABLE CONTROL OF SYMPTOMS AND IMPROVED QUALITY OF LIFE

LAPAROSCOPIC MESH-AUGMENTED HIATOPLASTY AS AN ALTERNATIVE TO LAPAROSCOPIC FUNDOPLICATION - EARLY AND MID-TERM RESULTS OF A PROSPECTIVE STUDY IN 27 PATIENTS

A. Okrainec, G.N. Polyhronopoulos, L.S. Feldman, L.E. Ferri, S. Mayrand, G.M. Fried McGill University, MONTREAL, ON, Canada Purpose: To assess the durability of laparoscopic cardiomyotomy and Dor fundoplication (LCD) on symptoms and quality of life using validated questionnaires. Methods: 55 consecutive patients with achalasia (28M:27F) were evaluated prospectively before and serially after LCD performed by a single surgeon (1999–2005). Outcomes measured were dysphagia (5 pt scale), disease speciﬁc quality of life (GERD-HRQL, 0=best, 45=worst), and general health related quality of life (SF-12 physical component and mental component summary scores, PCS and MCS). The proportion of patients with daily bothersome symptoms of dysphagia (score > 2) was calculated for each follow-up period. QOL data are reported as mean (SD). Pre-op and 6 month data were compared using McNemar test or paired t-test; change over time with ANOVA; post-hoc analysis was performed using Tukey procedure. Results: Mean age was 53 (16) years. Twenty-two patients (40%) had received prior treatment for achalasia. Complete follow-up was obtained for 89% of patients, with mean follow-up time of 24 (19) months. There was a signiﬁcant change in dysphagia (p=.000), GERD-HRQL (p=.000), PCS (p=.000) and MCS (p=.001) at 6 months when compared to pre-op. ANOVA revealed signiﬁcant improvement in dysphagia from preop to all postop intevals but no signiﬁcant change over the duration of follow-up. Conclusion: Laparoscopic cardiomyotomy and Dor fundoplication provides durable control of achalasia up to 48 months after surgery, with no signiﬁcant increase in GERD symptoms over this same time period. Mental and physical QOL improve to and remain at levels equal to or better than population norms after surgery. Time

Preop

6 mo

12 mo

24 mo

36 mo

>48 mo

n Dysphagia% GERD-HRQL PCS MCS

53 87% 14 (9) 46 (10) 45 (12)

44 7% 3 (4) 52 (8) 52 (10)

42 14% 7 (8) 49 (10) 54 (9)

23 13% 8 (5) 48 (11) 51 (10)

17 0 8 (8) 53 (7) 51 (16)

11 18% 8 (4) 54 (5) 50 (12)

B.P. Mu¨ller-Stich1, G. Linke2, M. Francesco2, J. Borovicka2, R. Warschkow2, J. Lange2, A. Zerz2 1 Ruprecht-Karls-University, HEIDELBERG, Germany 2 Kantonsspital St. Gallen, ST. GALLEN, Switzerland Introduction: Laparoscopic fundoplication (LF) is the standard anti-reﬂux procedure and it is also recommended in addition to hiatal hernia repairs. Since fundoplication-related side-eﬀects are frequent we have evaluated laparoscopic mesh-augemented hiatoplasty (LMAH) as an alternative. The method tends to achieve an anti-reﬂux barrier solely by narrowing the hiatus and lengthening the intraabdominal part of the esophagus. The prevention of recurrences is strived for by mesh-reinforcement. Methods: Twenty-eight (12 m, 16 f) consecutive patients underwent LMAH instead of LF in the period of 2001 to 2004. Perioperative and follow-up data was collected prospectively. Symptomatic changes were analyzed using a modiﬁed Gastrointestinal Symptom Rating Scale (GSRS) questionnaire. Further diagnostics included preoperative 24-h pH monitoring, upper GI barium contrast series and esophagogastroscopy. All examinations apart from the esophagogastroscopy were repeated 3 months postoperatively. One-year follow-up was done by a GSRS questionnaire and an esophagogastroscopy. Results: All patients were diagnosed with a hiatal hernia, 61% of them with paraesophageal involvement, and 82% of the patients had a gastroesophageal reﬂux disease (GERD). The median operation time was 115 minutes (70–216). There were 2 intraoperative minor complications and postoperative problems occurred in 7 patients with 1 death due to a cardiac tamponade. Three months postoperatively total reﬂux fell to 3.5% (0.2–28.4) from 11.0% (0.0–64.6) preoperatively (p=0.001). After one year 89% of the patients had improved with their initial complaints and assessed the operation result as good up to excellent, 93% would re-undergo the operation. The reﬂux score decreased from 3.5 (+/)2.1) to 1.8 (+/)1.4) after 1 year postoperatively (p<0.001), 18% of the patients were still under proton pump inhibitors. Gas-bloating was existent in 21% of the patients vs. 48% preoperatively and dysphagia was reported by 17% of the patients vs. 30% preoperatively. Small recurrent sliding hernias were detected in 22% of patients. Conclusions: LMAH seems to be eﬀective in the treatment of both GERD and hiatal hernias. It should be evaluated as an alternative to LF since it bears the potential of avoiding fundoplication-related side-eﬀects.

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COMPARATIVE STUDY OF HASSABS OPERATION WITH ADDED GASTRIC SUTURES VERSUS WARRENS OPERATION ON OESOPHAGEAL VARICES DUE TO SHISTOSOMAL HEPATIC INFESTATION

NISSEN FUNDOPLICATION (NF) AS A SALVAGE PROCEDURE AFTER FAILURE OF MEDICAL MANAGEMENT FOR GASTROESOPHAGEAL REFLUX DISEASE (GERD): DETAILED ANALYSIS OF CLINICAL OUTCOMES OVER SEVEN YEARS M.K. Jamal, E.J. DeMaria, I. Belyanski, A.M. Carbonell, J.M. Johnson, B.J. Carmody, L.G. Wolfe University of Iowa Hospitals and Clinics, IOWA CITY, United States of America

CANCELLED

Surgical literature suggests that NF has inferior outcomes in patients with severe GERD who fail medical management. We report a single surgeon experience in a group of 123 patients who underwent NF as a salvage procedure after failed symptom control with medical management. Patients undergoing NF between 1998 and 2004 were included in this retrospective analysis. Pre- and post-operative symptom scoring (SS) in 7 categories was carried out using a standard questionnaire. Patients were asked to quantitate their symptoms on a scale of 0 to 3 based on severity (0=none, 1=mild, 2=moderate, 3=severe). A total SS was calculated as the sum of scores in all symptom categories. Demographic characteristics included a male:female ratio of 2:3, mean age of 49 years and a lengthy mean duration of symptoms of 80 months before NF. The group included patients with prior failed NF (16%), those on combined PPI and H2 blocker therapy (14%) and patients with Barretts esophagus (8.7%), peptic stricture (6.5%) and hiatal hernia (56%). The most severe symptoms were in a sub-group of 72 patients (59%) with positive SS in 3 or more categories despite medical management. Forty-one patients underwent 24-hr pH testing with a mean DeMeester score of 56 (33%), 95 had an upper endoscopy (77%) and 88 had manometry (72%) prior to NF. NF was completed laparoscopically in 102/103 patients while 20 patients were treated open. The average hospital stay was 3.3 days in the laparoscopic group and 8.7 days in the open group. Forty one patients (33%) were discharged within 24 hours of the procedure. The mean duration of follow-up was 1 year. There were 12 minor complications and 1 death in the group (0.8%). Whereas only 15% of patients were free of all symptoms after NF, there was a signiﬁcant postoperative improvement in SS for heartburn (1.84 1.08 vs. 0.63 0.91, p<0.0001), regurgitation (0.89 1.09 vs. 0.45 0.88, p<0.0003), vomiting (0.77 1.09 vs. 0.07 0.28, p<0.0001), nocturnal cough (0.74 1.08 vs. 0.45 0.80, p<0.005) and chest pain (1.01 1.22 vs. 0.59 0.89, p<0.0012). Of the 72 patients with more than 3 positive symptoms before NF, the majority (60%) showed elimination or improvement of all preoperative symptoms and reduction in total SS (8.6 2.5 vs. 3.8 4.0, p<0.0001). Our results show that NF is an eﬀective Ôsalvage procedureÕ in patients with severe GERD who fail medical management. It can be safely performed laparoscopically with minimal morbidity.

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LONG TERM RISK OF MORTALITY AFTER ANTIREFLUX SURGERY S.R. Lopushinsky, D.R. Urbach University of Toronto, TORONTO, Canada

RE-OPERATIVE (RNF) AND PRIMARY NISSEN FUNDOPLICATION (PNF) HAVE SIMILAR OUTCOMES IN TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE

Introduction: The objective of this study was to examine long-term mortality of patients with complicated gastroesophageal reﬂux disease (GERD) undergoing anti-reﬂux surgery. A randomized controlled trial conducted in Veterans Aﬀairs hospitals suggested that patients having antireﬂux surgery are at greater risk of death as compared with patients treated medically. Methods: We developed a population-based inception cohort of 43,992 adult patients newly diagnosed with complicated GERD between the years 1991 and 1994, using administrative data. In Ontario, Canada, administrative health databases contain information on all residents receiving health services. Cox-proportional hazard models were created to compare mortality rates between patients undergoing surgery and those that did not. Antireﬂux surgery was modeled as a time-dependent variable. Patients were followed until death or December 31, 2002. Hazard ratios (HR) and 95% conﬁdence intervals (CI) are reported. Results: Of the 43,992 patients with complicated GERD newly diagnosed between 1991 and 1994, 1,827 patients went on to have an anti-reﬂux procedure. At the time of index GERD diagnosis, patients who eventually had surgery tended to be younger (46.6 vs. 55.1 years; p < 0.0001), female (53.48% vs. 50.83%; p = 0.0267), and had fewer comorbid conditions (Charlson comorbidity score, 0.086 vs. 0.21; p < 0.0001). Overall, 11,377 patients died during the study period. The unadjusted HR of death associated with surgery was 0.42 (95% CI, 0.36 to 0.49). After adjustment for confounding variables, the HR was 0.83 (95% CI, 0.71 to 0.97). Age, gender, Charlson score, and GERD severity were independent predictors of mortality. Conclusion: In a population-based cohort study, we found no evidence that anti-reﬂux surgery is associated with higher rates of mortality as compared with medical therapy.

M.K. Jamal, E.J. DeMaria, J.W. Maher, B.J. Carmody, J.M. Johnson, L.G. Wolfe University of Iowa Hospitals and Clinics, IOWA CITY, United States of America Nissen fundoplication (NF) provides alleviation of symptoms of GERD. Minimal data exists in surgical literature on clinical outcomes after RNF for failed primary operations. We reviewed the data in our series of NF performed over seven years. A retrospective analysis of 123 patients undergoing NF at an academic institution was carried out from Jan 1998 to Nov 2004. Patients were divided in 2 groups based on PNF or RNF. Pre- and post-op symptom scoring (SS) in 7 categories was carried out using a standard questionnaire. Patients were asked to quantitate their symptoms on a scale of 0 to 3 based on severity (0=none,1=mild,2=moderate,3=severe).A total SS was calculated as the sum of scores in all symptom categories. The study group comprised of 73 female and 50 male patients with a mean age of 49 years and 80 months duration of symptoms before NF.103 patients underwent PNF whereas 20 patients underwent RNF. The most severe symptoms were in a sub-group of 72 patients with positive SS in 3 or more categories despite medical management.41 patients underwent 24-hr pH testing with a mean DeMeester score of 56(33%), 95 had an upper endoscopy (77%) and 88 had manometry (72%) prior to surgery. NF was completed laparoscopically in 102/103 patients while 15 patients (75%) in the RNF and 5 patients (5%) in the PNF group were treated open. The average hospital stay was 3.3 days in the laparoscopic and 8.7 days in the open group.41 patients (33%) were discharged within 24 hours of the procedure. Mean follow-up was 1 year. There were 12 minor complications and 1 death in the group(0.8%). Pre-op SS in the 2 groups were comparable for 6/7 symptom categories. Nocturnal cough was a predominant pre-op symptom in the RNF group(p<0.05).In the PNF and RNF groups, mean pre-op SS were 6.26 and 6.45 that declined to 2.91 and 4.6 post-op, respectively. Post-op resolution of symptoms was also comparable between the 2 groups in most categories. Atypical symptoms were more persistent in the RNF group as evidenced by their total SS. These included nausea(p<0.04),nocturnal cough(p<0.001),asthma(p<0.05) and abdominal pain(p<0.05). Although the total number of symptoms was comparable between the 2 groups before surgery (3 and 3.25 in PNF and RNF), the post-op number of symptoms was statistically signiﬁcant in the PNF and RNF groups (1.79 and 2.75,p<0.04). Although RNF provides excellent surgical cure for GERD patients with failed PNF, atypical symptoms may still persist and require further medical management.

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LONG-TERM RESULTS AFTER LAPAROSCOPIC REPAIR OF PARAESOPHAGEAL HERNIA

ESOPHAGEAL CIRCUMFERENCE AND THE TAILORED 360 FUNDOPLICATION P.R. Reardon, E.S. Craig, J.T. Salmon, C.C. Miller The Methodist Hospital, HOUSTON, United States of America

E. Devyatko, A. Bohdjalian, T. Mang, M. Riegler, J. Miholic, G. Prager, J. Zacherl Medical University of Vienna, VIENNA, Austria Background: Although the incidence of paraesophageal hernias (PEH) is low, their clinical importance is represented by potentially life-threatening complications. Laparoscopic repair is a feasible and established method of PEH management and provided excellent early postoperative results. Long-term outcome is still unclear through absence of prospective studies. Methods: Forty-four consecutive patients (33 female, 6515 years old, BMI 29 kg/ m2) who underwent laparoscopic PEH repair in our centre during the last 10 years were included in this analysis. Clinical evaluation and radiological follow up was performed after a median follow up period of 44 (1 – 102) months. Results: 40 primary and four re-operations were performed for 20 type II, 23 type III and one type IV PEH. Surgical procedure included laparoscopic hernia sac resection and crural closure (with mesh implantation in 12 cases). Additionally, gastropexy was performed in 21 patients. 30 patients (68%) underwent an antireﬂux procedure (26 Nissen, 5 Toupet). Median operative length was 152 minutes. In 3 out of 44 cases (6.8%) intraoperative splenic lesion required a conversion to open procedure for splenectomy. Postoperatively esophageal stent implantation was needed for one patient because of leakage. Median length of stay was 7 days. In-hospital and 30-day mortality was zero. Until follow up two patients died due to cardiac diseases. Clinical follow up performed in 40/42 patients (95%), radiological re-evaluation in 37/42 patients (88%). 28/40 patients (70%) were completely asymptomatic. Among them 24 (89%) do not need proton-pump inhibitors. Mild symptoms as borderline dysphagia or heartburn were revealed in 13/40 patients (28%). Radiological follow up demonstrated recurrent hernias in 7/37 patients (19%). Five of these recurrences were sliding hernias less than 3 cm. One sliding hernia larger than 3 cm and one paraesophageal recurrence (2.7%) was observed. This patient required re-operation seven months after primary repair. Among patients with recurrent sliding hernias four showed mild clinical symptoms. Two patients needed surgery for incisional hernia after conversion to open procedure. Conclusion: Long-term results of laparoscopic PEH repair are comparable with early postoperative data. The majority of recurrences are not large, do not cause signiﬁcant symptoms, and do not require re-operation.

Objective: The purpose of this study was to deﬁne the diameter of the 60-Fr bougie-ﬁlled esophagus in a population of patients undergoing surgery for hiatal hernia (HH) and/or gastroesophageal reﬂux disease (GERD). Methods: In 250 consecutive laparoscopic 360 fundoplications and/or HH repairs, the circumference of the 60-Fr bougie-ﬁlled esophagus was measured with a ﬂexible plastic ruler. Results: Mean values SD: Body Surface Area (BSA), 1.91 0.23 m2; Measured esophageal circumference (c), 8.15 0.47 cm; Calculated esophageal diameter (d), 2.59 0.15 cm. There was a strong correlation between c and age and BSA with signiﬁcant p values for age (<0.0001) and BSA (<0.0001). The relationship can be deﬁned by the regression equation: c = [ 6.17 + (age 0.0085) + (BSA 0.8138)]. Conclusions: The diameter of the 60-Fr bougie-ﬁlled esophagus in adult patients undergoing fundoplication for GERD and/or hiatal hernia repair is regular and predictable. It is signiﬁcantly correlated to age and BSA. Some surgeons utilize a 60 Fr bougie in the performance of a 360 fundoplication. For these surgeons, this knowledge allows them to safely and reliably perform a reproducible 360 fundoplication without the use of a bougie.

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PRE-CLINICAL TRIAL OF A MODIFIED GASTROSCOPE THAT PERFORMS A TRUE ANTERIOR FUNDOPLICATION FOR THE ENDOLUMINAL TREATMENT OF GERD A. Roy-Shapira1, H.J. Stein2, D. Watson3, M. Sonnenschein4, J. Unger5, M. Voget6 1 Soroka Univ. Medical Center, BEER SHEVA, Israel 2 University Hospital, SALZBURG, Austria 3 Flinders University, ADELAIDE, Australia 4 MediGus Ltd., OMER, Israel 5 Charite - Virchow Clinic, BERLIN, Germany 6 Econ Inc., LUBECK, Germany

A COMPARATIVE RESULT OF EITHER DILATION OR LAPAROSCOPIC SURGERY AS A THERAPEUTIC OPTION FOR PATIENTS WITH ACHALASIA N. Katada, S. Sakuramoto, N. Kobayashi, N. Futawatari, S. Kikuchi, M. Watanabe Kitasato University, SAGAMIHARA, KANAGAWA, Japan

Objective: Feasibility and safety of a new device that enables a totally endoluminal anterior fundoplication (similar to Dor-Thal fundoplication) for the treatment of GERD. Test article: The device is a modiﬁed video gastroscope which incorporates a surgical stapler (using standard 4.8 B shaped surgical staples) and an ultrasonic sight. The cartridge is mounted on the shaft, and the anvil is at the tip. This enables accurate stapling of the fundus to the esophagus, using the ultrasonic sight to guide distance and alignment of the anvil and cartridge. Method: 16 female swine of mixed breed were used in the study, 12 underwent the endoscopic procedure, and 4 were used as controls to monitor weight gain. The 12 study animals were sacriﬁced at 2, 4, and 8 weeks (four pigs each time) and visually inspected for complications, healing and fundoplication. The study was sponsored by MediGus ltd, and monitored for compliance with GLP regulations by an external company, Econ Inc., which is GLP certiﬁed by the German Federal Government. It was conducted at the animal testing facility of the Charite Virchow Clinic in Berlin. Results: The procedure went smoothly in all pigs, and net procedure times (excluding positioning and anesthesia) were 20–30 minutes. At sacriﬁce, the stapled area healed well, all animals had a satisfactory 180 deg anterolateral fundoplication, and there were no procedure related complications. Conclusions: Creating a satisfactory anterior fundoplication with the new device is feasible, easy, and safe. Proof of eﬃcacy must await clinical trials, which are underway.

Aims: Our aim of this study is to compare the short-term results of esophageal dilation treatment with those of laparoscopic surgery for patients with achalasia from the functional point of view. Materials and Methods: Patients with achalasia were divided into two groups according to the treatment methods; esophageal dilation treatment group (DG, n=24) and surgical treatment group (SG, n=30). All patients complained dysphagia before treatments. The age was 40.714.2 years (meanSD) in DG and 41.811.8 years in SG (NS; no signiﬁcant diﬀerence). M/F ratio was 15/ 9 in DG and 12/18 in SG (NS). In DG, the balloon is directly introduced through an endoscope, and the lower esophageal sphincter (LES) is dilated without ﬂuoroscopic control. In SG, laparoscopic Heller myotomy with a Toupet fundoplication was performed. The esophageal function was prospectively assessed on the basis of esophagography and esophageal manometry before and 3 months after treatments. Results: The change of the maximum transverse diameter of the esophagus on esophagography before and 3 months after treatments (before-after) was 5.31.4–4.31.3cm (p<0.01) in DG and 5.51.0–3.81.1cm (p<0.001) in SG. The change of LES pressure was 38.412.4–25.26.2mmHg (p<0.01) in DG, and 35.212.6–15.06.7mmHg (p<0.001) in SG. The change of LES relaxation rate was 66.217.1–74.814.5% in DG (NS) and 62.416.2–81.59.7% (p<0.01) in SG. The change of esophageal body peristaltic pressure was 30.120.8–32.226.2mmHg in DG (NS) and 19.18.3–19.511.3mmHg in SG (NS). Conclusions: Although both dilation and laparoscopic surgery showed good short-term treatment results for patients with achalasia, laparoscopic surgery is likely superior to dilation therapy in terms of more decreased LES pressure and more increased LES relaxation rate, thus possibly more relieving dysphagia.

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LONG TERM OUTCOMES AFTER LAPAROSCOPIC AND TRANSTHORACIC COLLIS GASTROPLASTY WITH FUNDOPLICATION FOR THE SHORT ESOPHAGUS S.K. Mittal, A.M. Bachelani, A.M. Lundeen, L. Esberg, C.J. Filipi, A. Goyal Creighton University, OMAHA, United States of America

SHORT AND LONG TERM RESULTS OF THE LAPAROSCOPIC HELLER-DOR MYOTOMY. THE INFLUENCE OF AGE AND PREVIOUS CONSERVATIVE THERAPIES

Background: Collis gastroplasty with fundoplication is an accepted treatment for the short esophagus. Eﬃcacy and need for this procedure has been questioned. Few studies have reported long term follow-up for patients undergoing a Collis gastroplasty. Methods: Operative data for all patients undergoing anti-reﬂux surgery at Creighton University was prospectively entered into a data base. A retrospective review was completed to identify patients who underwent an esophageal lengthening procedure. Data regarding pre-operative risk factors and operative procedures was collected. Patients were contacted by phone and administered a questionnaire regarding their symptom control, medication usage and satisfaction after surgery. Symptoms were scored on a scale of 0–3. and satisfaction on a scale of 1–10. Patients were also asked if they would recommend the procedure to a friend. Results: Seventy patients (F= 41) aged 33–81 years underwent laparoscopic (n =33) or transthoracic (n=37) Collis gastroplasty with fundoplication between Jan 96 to May 2005. Fifty three were primary and 17 re-operative procedures. There was one in-hospital death due to a pulmonary embolism and sepsis 42 days after a trans-thoracic procedure. Three patients have died during follow-up from unrelated causes while 8 patients could not be contacted. For the remaining 58 patients mean follow-up was 42.8 months (range 3–111). Fifty patients were more than 1 year postoperative, 33 more than 3 years and 14 more than 5 years. Mean dysphagia, heartburn and chest pain scores are 0.46, 0.41 and 0.17 respectively with the majority of patients (71%, 78% and 83% respectively) reporting no symptoms in these categories. Seven (12%) report signiﬁcant gas-bloat. Overall, 81% (47 out of 58) patients were satisﬁed with their outcome (satisfaction grade 8 or higher). Only 8 patients (13.7%) were dissatisﬁed with the results (grade <= 5), and the remaining patients experienced no signiﬁcant improvement. Eighty-ﬁve percent (49/58) said they would recommend the procedure to a friend. There was no statistically signiﬁcant diﬀerence between sub-groups trans-thoracic vs. laparoscopic or primary vs. re-do procedure as related to symptom outcome. Conclusions: Collis gastroplasty with fundoplication results in excellent longterm patient satisfaction and symptom control.

Aims: Evaluation of perioperative and long-term outcome and of quality of life data, including patientsÕ satisfaction, to assess both the potential inﬂuence of age, i.e. lasting of symptoms, and of the diﬀerent conservative procedures on the laparoscopic surgical treatment. Background: Current therapies for achalasia canÕt restore normal motility but can palliate dysphagia. Other symptoms may persist which are diﬃcult to quantify and to compare. In order to understand if they could inﬂuence results, besides the analysis of short and long-term results, correlated to age and previous conservative treatments, we introduced a speciﬁc QoL test for comparing outcomes of surgery. Methods: Functional examinations (endoscopy, 24 hours-pH-manometry, upper GI x-rays) and Gastrointestinal Quality of Life Index (GIQLI) were used before and after laparoscopic Heller-Dor myotomy. The data were analyzed by Student t-tests and Mann-Whitney U test. Results: From January 1996, 31 consecutive patients of 35 diagnosed achalasia were operated on laparoscopically, for I-III clinical stages. Two groups were identiﬁed using the break point of 70 years of age, (respectively 15 younger and 20 older) and two subgroups according to the conservative therapy performed (21 none, 14 some). All patients underwent at least one instrumental control as referred, within 18 months. In 78% of patients dysphagia disappeared, the incidence of gastro-oesophageal reﬂux was of 11%. The incidence of postoperative complications was signiﬁcantly diﬀerent between the subgroups as far as the conservative treatments are concerned, (p< 0.05). Age doesnÕt inﬂuence surgical outcome. Patients completed a GIQLI questionnaire preoperatively and after 18 months. Median preoperative GIQLI score was 78 (range 38–109) out of a theoretical maximum score of 144. At a median follow-up of 38 months (range 18–72), the score had signiﬁcantly improved to 115 (range 71–140). All the items assessing gastrointestinal symptoms and physical, social, and emotional function were signiﬁcantly improved. There is no diﬀerence between the groups identiﬁed. Conclusions: The laparoscopic Heller-Dor myotomy is an eﬀective palliation for acalasia, the outcome is aﬀected by the preoperative conservative treatment but not by the age of the patients The GIQLI is a reliable instrument to compare the impact of achalasia symptoms on health-related QoL.

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ENDOLUMINAL FUNDOPLICATION FOR THE TREATMENT OF GERD - FEASIBILITY STUDY OF A NEW TECHNIQUE G.B. Cadie`re1, A. Rajan2, G. Dapri1, M. Rqibate1, O. Germay1, J. Himpens1 1 Saint-Pierre University Hospital, BRUSSELS, Belgium 2 Clinique du Parc Leopold - CHIREC, BRUSSELS, Belgium

ENDOLUMINAL FUNDOPLICATION FOR GERD PAST, PRESENT AND FUTURE A. Arezzo Ospedale Evangelico Internazionale, GENOVA, Italy

Background: A feasibility study was undertaken with a new treatment for gastroesophageal reﬂux disease (GERD) that emulates surgical fundoplications and recreates the anti-reﬂux barrier by forming a one-way gastroesophageal valve. This new endoluminal fundoplication technique involves inserting the EsophyX device transorally with the goal of creating a 3–5cm, 180–270 circumference valve by delivering multiple fasteners under direct visualization by an endoscope. The technique was evaluated in patients with GERD, dissatisﬁed with long term proton pump inhibitor (PPI) therapy, and referred for a Nissen fundoplication. Methods: 19 patients referred for laparoscopic Nissen fundoplication were enrolled from June to October 2005. Inclusion criteria included chronic GERD, demonstrated PPI dependence, and the absence of signiﬁcant esophageal motility disorder or other esophageal pathology. One patient was not treated due to preexisting esophageal stricture precluding device introduction. Within the remaining 18 treated patients (10F, 8M), 1 patient was treated but excluded from the analysis due to a 6 cm hiatal hernia. Mean age was 38 years (23–58). The mean duration of GERD symptoms was 8.6 years with average duration of PPI use of 6.1 years. Results: GERD-HRQL scores at 3 months improved on average 53% (21.6 baseline to 10.1 p<0.001). PPI use was eliminated in 15 of 17 patients with a mean follow-up of 5.5 months. 3 Month pH was normal in 10 of 11 patients in whom 24 hour pH was available. Procedure related adverse events included mild to moderate throat irritation and epigastric pain, resolving in the ﬁrst post-op week except in 1 patient readmitted for assessment of persistent pain. No clinical sequelae or anatomical correlate was identiﬁed. Pain resolved spontaneously. Conclusion: This study demonstrated feasibility and safety of this technique. Early symptom scores, pH and PPI dependency were improved. Further follow-up on this cohort and a larger study are planned to demonstrate long-term eﬃcacy.

G.P. Ferulano, S. Dilillo, M. DÕAmbra, R. Lionetti, R. Brunaccino, D. Fico, D. Pelaggi University of Naples, NAPLES, Italy

Before the advent of laparoscopy Gastro Esophageal Reﬂux Disease (GERD) was treated surgically by either Belsey Mark IV technique or Nissen fundoplication, both eﬀectively. The introduction of laparoscopy forced surgeons to prefer laparoscopic Nissen fundoplication for the easier recovery of the patient. In the following years intriduction on PPI drugs reduced dramatically the need of surgery for GERD. In the same years ﬁrst attempts to realize an endoluminal device for GERD treatment were done. Diﬀerent techniques have been tried in recent years, including suturing devices, injecting materials, radiofrequency, all with disappointing results. No minimally invasive approach existed that restored the anatomy and cured GERD. Now, a novel procedure as been conceived for the treatment for GERD that emulates the invagination of the esophagus into the cardias, and recreates the anti-reﬂux valve. The EsophyX device rides over a standard endoscope and is inserted through the throat to access the stomach. Through a clear window in the shaft of the device, the z-line can be visualized. A suction technique is engaged that allows elongation of the esophagus and advancing the z-line to the level of the diaphragm to reduce hiatal hernia. In the stomach, a helical retractor is then used to engage the fundus and pull a 3–5 cm long ﬂap. This ﬂap is held in place with polypropylene sutures. The entire procedure is performed under direct visualization by the endoscope. The goal of the endoluminal fundoplication procedure is to create a 2–3 cm, 240–270 circumference valve by delivering multiple fasteners. The technique has been evaluated in a Phase 1 feasibility study and additional Phase 2 studies are ongoing and will be presented. This new endoluminal fundoplication technique oﬀers signiﬁcant potential to reduce hiatal hernia, restore the angle of His, create a GE valve and possibly be a non-invasive method for long-term treatment of GERD. Although additional studies and long-term follow-up are needed to demonstrate the long-term safety and eﬃcacy, this technique is an interesting and potentially promising approach, not just as a second line therapy to avoid surgery, but as a ﬁrst line therapy to avoid long term PPI therapy.

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HERNIATION AFTER LAPAROSCOPIC ANTIREFLUX SURGERY M. Arenas-Sanchez1, B. Dallemagne1, D. Francart2, J. Weerts2, C. Jehaes2, D. Mutter1, J. Marescaux1 1 IRCAD-EITS / University Louis Pasteur, STRASBOURG, France 2 CHC-Les Cliniques Saint Joseph, LIE`GE, Belgium

LONG-TERM OUTCOME OF OPERATED AND UNOPERATED ESOPHAGEAL EPIPHRENIC DIVERTICULA G. Portale, G. Zaninotto, C. Costantini, E. Guirroli, L. Nicoletti, E. Ancona Clinica Chirurgica III, PADOVA, Italy

Background: Herniation of the fundoplication with the gastro-esophageal junction (fundoplication migration), herniation of the gastro-oesophageal junction through the fundoplication (slipped fundoplication) and paraesophageal herniation are well known complications of laparoscopic antireﬂux surgery (LAS).They are responsible for 40 to 80% of reoperations. Symptoms are variable, from dysphagia and recurrence of reﬂux symptoms to less comprehensible symptoms, such as pain, bloating, and hiccups. The mechanism responsible for these complications is poorly understood. The aim of this study was to evaluate the outcomes of reoperations for herniation after LAS and to investigate possible predisposing factors for this type of complication. Patients and Methods: We reviewed our series of re-interventions for herniation after LAS. Postoperative outcomes were evaluated including barium swallow and assessment of quality of life by Gastro Intestinal Quality of Life Index (GIQLI). Patients data at the time of ﬁrst LAS were also analysed to determine possible predicting factors. Results: Forty patients were reoperated for herniation. Pattern of herniation was fundoplication herniation (19 pts), slipped fundoplication (18 pts) and paraesophageal herniation (3 pts). Reoperations were performed laparoscopically in all the patients. Median follow up after re-intervention was 36 months (range 2–124). At the time of submission of the abstract, 70% of patients underwent at least one barium swallow study and 72% had undergone QOL assessment. An intact and functional fundoplication was demonstrated in only 18/28 patients (64%). Mean GIQLI score was 95.13 (range 39 138; normal individuals: 125). Notably, at the time of the initial LAS, these patients had more incidence of non-reducible hiatal hernia and Barretts esophagus when compared to a series of 1000 consecutive patients. Conclusions: Reoperation for herniation after LAS is associated with a signiﬁcant incidence of re-herniation. Anatomical and pathophysiological factors (i.e Barrett, non-reducible hiatal hernia) at the time of initial LAS seem to play a role in the mechanism responsible for this complication.

Esophageal epiphrenic diverticula (ED) are uncommon; they tend to be associated with motility disorders. The natural history of ED is not entirely clear and the decision whether to operate or not is often based on the personal preference of the physician and patient. The aim of this study was to evaluate the long-term fate of operated and unoperated ED patients. Clinical, radiological and motility ﬁndings, operative morbidity and longterm outcome of 37 ED pts referred from 1993 to June 2005 were analyzed. All pts were reviewed at the outpatients clinic or interviewed over the phone. A symptom score was calculated using a standard questionnaire and subjective patient assessments. 20 pts (10M:10F, median age 60 years) were operated. One pt underwent surgery for spontaneous rupture of a large ED. Operative mortality was nil; postoperative morbidity was 26%, the most severe complication being suture leakage (4 pts, managed conservatively). The median follow-up was 53 mos. 18 pts (7M:11F, median age 70 years) were not operated. 2 pts received pneumatic dilations. The median follow-up was 37 mos. No patients in either group died for reasons related to their ED. Recurrent ED was observed in 1 pt. A better subjective outcome was reported in 85% and 22% of operated and non-operated patients, respectively as compared to 15% and 78% worse or unchanged outcome in operated and nonoperated patients (p=0.0002). Four pts in the operated group had GERD symptoms and/or esophagitis. Surgery is an eﬀective treatment for ED, but carries a signiﬁcant morbidity, mainly related to suture leakage. Even in the long term, unoperated patients do not die of their ED, though a better subjective symptom outcome is reported by operated patients. A non-interventional policy can safely be adopted for cases of small, mildly symptomatic ED.

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LONG-TERM COMPARISON BETWEEN LAPAROSCOPIC NISSEN AND TOUPET FUNDOPLICATION: EVALUATION OF SYMPTOMS AND QUALITY OF LIFE B. Sgromo, L.A. Irvine, F. Polignano, D.J. Exon, A. Sir Cuschieri, S.M. Shimi Ninewells Hospital, DUNDEE, United Kingdom

ROLE OF ROUTINE PLACEMENT OF NASOGASTRIC TUBE IN PREVENTING IMMEDIATE GAS-BLOAT SYNDROME FOLLOWING LAPAROSCOPIC NISSENS FUNDOPLICATION A PROSPECTIVE COMPARATIVE STUDY P.C. Munipalle, Y.K.S. Viswanath The James Cook University Hospital, MIDDLESBROUGH, United Kingdom

Background: Laparoscopic antireﬂux surgery has become an established method of treatment in gastro-oesophageal reﬂux disease. This study compares the long term outcome of Nissen and Toupet fundoplication, performed in a single institution, by evaluating symptoms and quality of life. Methods: 266 Patients who underwent laparoscopic Nissen or Toupet fundoplication completed a pre-operative reﬂux symptom questionnaire. A post-operative reﬂux symptom evaluation, outcome satisfaction and quality of life questionnaires were sent to these patients in Dec 2004. The two groups were compared for each item non-parametrically. Results: Completed questionnaires were received from 161 patients (61%). Ninety nine patients had a laparoscopic Nissen fundoplication and 62 patients had a laparoscopic Toupet fundoplication. Both procedures were equivalent in improving reﬂux symptom scores long term. Both groups had equivalent quality of life scores. Although more than 80% of patients were improved by either procedure, 51% of the Nissen group were asymptomatic vs 37% of the Toupet group (p< 0.05). Conclusion: Laparoscopic complete (Nissen) or partial (Toupet) fundoplication are equally eﬀective in the management of gastro-oesophageal reﬂux disease with a sustained improvement in symptoms in more than 80% of patients. There is no evidence from the current study that either procedure is more superior in either long-term outcome or quality of life.

Aim: Gas-bloat syndrome is a signiﬁcant problem in the immediate postoperative period following laparoscopic Nissen - Rosettis fundoplication (LNRF). There is anecdotal evidence to suggest that intraoperative placement of nasogastric tube (NGT) can prevent this complication in these patients. We aim to evaluate the role of routine placement of NGT during LNRF through this comparative study. Methods: Group 1 is made of 40 consecutive patients who had NGT placed during LNRF and Group 2 has 37 consecutive patients that did not have NGT placed intraoperatively. The incidence of gas-bloat syndrome in the immediate postoperative period (up to 5 days) is observed and compared between these two groups. Results: One patient form group 1 and three patients from group 2 developed signiﬁcant gas-bloat syndrome in the immediate postoperative period (p>0.05). This necessitated endoscopic decompression of stomach in the patient from group 1 and placement of NGT in the patients from group 2, with satisfactory results. Conclusion: There is no evidence from this study to support the routine prophylactic placement of NGT during LNRF. Selective NGT placement and decompression is eﬀective in post LNRF gas-bloat syndrome.

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PRESERVATION OF ANTERIOR PHRENO-OESOPHAGEAL MEMBRANE IN LAPAROSCOPIC NISSEN FUNDOPLICATION S. Velmurugan, A. Ali, R. Parameswaran, S. Adjepong, A. Sigurdsson Princess Royal Hospital, BIRMINGHAM, United Kingdom

DIFFERENTIATING PPI RESISTANT VS PPI DEPENDANT REFLUX- DOES IT REALLY MATTER? N.S. Balaji, K. Moorthy, M. Seenath, I. Joseph, C.V.N. Cheruvu North Staﬀordshire University Hopsital, STOKE ON TRENT, United Kingdom

Aims: There is some evidence supporting that the restoration of integrity of phreno-oesophageal membrane (POM) in Laparoscopic Nissen fundoplication (LNF ) improves the functional outcome. We hypothesised that leaving the anterior part of POM intact in patients without hiatus hernia may result in better functional outcome. Methods: 30 patients who underwent LNF with preservation of POM over three year period were asked to complete a standardized and validated questionnaire. 24 (80%) patients responded. A group of 24 matched patients who underwent LNF without preservation of POM was used for comparison. Results: 12 patients in POM preserved group and 15 patients in non-preserved group had dysphagia for solids (p=0.56#). Mean visual analogue scale (VAS 0–10) dysphagia score for solids was 2.00 in preserved and 2.79 in non-preserved (p=0.32*). Mean composite dysphagia score was 32.92 in preserved and 30.42 in non-preserved (p=0.49*). The mean overall satisfaction scores (0–10) were 7.04 and 8.54 in the preserved and non-preserved groups, respectively (p=0.28*). Control of heartburn, abdominal bloating, ability to burp, excessive ﬂatus and diarrhoea were also similar in both groups. #Fishers exact test *Two tailed Mann Whitney U Test validated score 0–45 Dakkak.M et al Conclusions: Preservation of anterior phreno-oesophageal membrane in laparoscopic Nissen fundoplication does not seem to make signiﬁcant diﬀerence in the functional outcome and in the overall patients satisfaction.

Background and Aims: Historically patients with PPI dependant (PPID) reﬂux are reported to have better symptomatic outcomes following Laparoscopic antireﬂux surgery (LARS) than those with PPI resistant (PPIR) reﬂux. We aim to compare the variation in outcomes between the above cohorts of patients (PPID Vs PPIR). Methods: Diagnosis of PPIR or PPID reﬂux was achieved after careful history taking at initial presentation. Preoperative evaluation included endoscopy, oesophageal manometry and pH studies. All patients underwent a ﬂoppy 360 degree fundoplication. Post operative outcomes were measured using the modiﬁed Visick Symptom score tool (MVSS) (1–4) for Reﬂux, Dysphagia and Gas bloat. Comparison was performed by analysing diﬀerences in outcome (Good- MVSS Grade 1, 2 in all and Worse MVSS Grade 3, 4). Results: 91 patients underwent laparoscopic 360 degree fundoplication between 2000 and 2005. The study cohorts included PPID group (n=45) and PPIR group (n=46). They were all matched for sex, age, BMI, preoperative symptoms, manometry and pH proﬁles (p=ns for all variables). Post operative MVSS scoring was obtained in 86 patients at a median FU of 9 (SD 5.5) months. Good outcome (grade 1–2) was seen in 97.7% for reﬂux, 98.8% for Dysphagia, and 95.3% for gas bloat when globally analysed (n=86). However 6/43 patients had worse outcome (grade 3–4) in the PPIR cohort when compared to 1/43 in the PPID cohort (p<0.05). Conclusions: Our study concludes that there is a noticeable diﬀerence in outcomes between PPID vs. PPIR cohorts. Hence a guarded approach in patients with PPIR reﬂux is advised in the preoperative counselling and consenting stages.

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OUTCOME OF DAY CASE VERSUS INPATIENT ANTI-REFLUX SURGERY FOR GASTRO-OESOPHAGEAL REFLUX S. Nijjar, I. Joseph, N.S. Balagi, K. Moorthy, C.V.N. Cheruvu North Staﬀordshire University Hospital, STOKE-ON-TRENT, United Kingdom

ENDOSCOPIC DILATATION OF CHILDRENS ESOPHAGEAL STRICTURES CONSEQUENT TO CAUSTIC INGESTION IN SIERRA LEONE S. Contini University of Parma, PARMA, Italy

Introduction: We compare the outcome of day case (DC) with inpatient (IP) Nissen fundoplication. The primary end points were post-operative symptom assessment using the validated Modiﬁed Visick Symptom Score (MVSS), whilst secondary end points were post-operative complications and patient satisfaction. Methods: Data was collected prospectively for 55 patients undergoing laparoscopic fundoplication during 2003–2005. All patients were assessed with endoscopy, pH and manometry studies. Suitable patients were oﬀered DC surgery according to set criteria (ASA grade 1&2 and living within close proximity to the hospital with a responsible carer) and follow up data was obtained in clinic or with telephone interview by an independent nurse practitioner. Results: The study included 25 DC and 30 IP patients. There were no conversions in either group. Early post-operative morbidity for DC patients was 4% (port site infection) and 3.2% (acute pulmonary oedema) for the IP cohort. The median inpatient stay was 6.5 hours versus 1.5 days between the DC and IP groups respectively. The mean follow up was 5.6 and 7.4 months for DC and IP patients respectively. The majority of patients scored Visick grade 1 & 2 (excellent and good) for post-operative symptoms of heartburn, dysphagia and gas bloat. One DC patient had subjective symptoms of reﬂux at follow up but is waiting objective pH testing and one patient in the IP group had signiﬁcant dysphagia requiring re-operation. There were no re-admissions in the day case group and the mean global satisfaction score (1–10) for DC surgery was 9.8/10. At ﬁnal follow up 24/25 DC and 29/30 IP patients were happy with the clinical outcome and would recommend the procedure to a friend. Conclusion: Our study shows that day case fundoplication is safe and eﬀective with comparable results to an inpatient procedure. Patient counselling preand post-operatively in combination with modiﬁed anaesthesia and back up hospital care is key to the success of our day case programme. In the current climate of ﬁnancial constraints and high demand on inpatient beds, day case fundoplication is an attractive option for both hospitals and patients.

Aims: To assess the feasibility and the outcome of dilatation of esophageal strictures due to caustic soda ingestion in children in a non teaching hospital of a developing country. Methods: In 4-years 40 children were admitted to the Emergency Surgical Center in Sierra Leone for oesophageal caustic lesions due to caustic soda ingestion, 40% of them complaining oesophageal perforation due to a previous blind dilatation (death rate:22.5%). Endoscopy was not available until November 2005. Follow up was possible in only 17 patients (42.5%), ﬁve with a gastrostomy still in place. Since November 2006, with availability of endoscopic devices, dilatation (13 with Savary dilators, 4 by a balloon catheter) was carried out. Interval between caustic injury and dilatation was more than three months. Results: 40 endoscopic dilatation procedures were performed during 2 months, under general anesthesia and ﬂuoroscopic control. When gastrostomy was present, dilatation was done in a retrograde fashion. Two esophageal perforations (11.7%) were observed, one treated conservatively, the other by surgical exploration and gastrostomy. All children had severe strictures at the upper third of the esophagus, with further strictures at the middle and lower segment. In 3 patients (17.6%) the stricture was not overcome by the guidewire. Eleven patients (64%) had a progressive dilatation with good food swallow. Three children (17.6%) were dilated only partially. At least three dilatation sessions were needed for an acceptable result. No deaths were observed. Conclusions: High, multiple and tortuous strictures are the rule in our experience. This fact, together with the severe ﬁbrosis for the long interval after injuries, makes dilatation dangerous and diﬃcult. Several dilatations and long-term follow-up are required. Dilatation should begin early (3–4 weeks after injury when possible).In these countries several patients are lost to follow-up. Proper and early treatment is frequently unavailable for the lack of adequate facilities.

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LONG-TERM RESULTS OF LAPAROSCOPIC ANTERIOR SEMIFUNDOPLICATION IN PATIENTS WITH NON-EROSIVE (NERD) AND EROSIVE REFLUX DISEASE (ERD) I. Gockel, M. Domeyer, A. Heintz, T. Trong Trinh, W. Kneist, T. Junginger Johannes Gutenberg University, MAINZ, Germany

COMPLETE THORACOSCOPIC LYMPHADENECTOMY IS A REAL POSSIBILITY FOR TWO PHASE OESOPHAGECTOMY H. Ali, A. Taylor, A. Yasser, S. Biswas, N. Thairu Kent Oncology Centre, MAIDSTONE, United Kingdom

Background: Laparoscopic semifundoplication results in eﬀective reﬂux control and is - as compared to 360 Nissen fundoplication - associated with less frequent side- eﬀects as dysphagia and gas-bloat syndrome. The aim of our study was to evaluate the long-term results of laparoscopic anterior semifundoplication in non-erosive (NERD) and erosive (ERD) reﬂux disease. Patients and methods: Enrolled in this study are 226 patients with laparoscopic anterior semifundoplication as the ﬁrst operation for gastroesophageal reﬂux disease (GERD) and a minimal follow-up of 6 months postoperatively. The study includes the interval between May 1997 and July 2005. In all patients, upper GI-endoscopy was performed. The severity of reﬂux esophagitis was classiﬁed according to Savary and Miller (grade IIV). A standardized questionnaire was used for follow-up and the modiﬁed symptomatic DeMeester score was assessed. Results: Patients with non-erosive reﬂux disease (n=98) were with 58 (27– 80) years signiﬁcantly older than patients with erosive reﬂux disease (n=128) (48 (15–84) years) (p=0.0001). Duration of reﬂux symptoms did not diﬀer between both groups (p=0.679). The size of the hiatal hernia was 5 cm in median in both groups (2–10 cm in NERD versus 1–8 cm in ERD) (p=0.272). Duration of follow-up was shorter in patients with NERD compared to ERD (40 (6–106) months versus 47 (7–98) months) (p=0.166). Patients with NERD had a lower modiﬁed symptomatic DeMeester-score postoperatively of 0 (0–4) as compared to patients with ERD (1 (0–5), though without statistical signiﬁcance (p=0.188). Conclusion: Laparoscopic anterior semifundoplication leads to comparable long-term results in both, non-erosive (NERD) and erosive (ERD) reﬂux disease as assessed by the symptomatic DeMeester-score.

Introduction: Total laparoscopic two phase oesophagectomy is possible with comparable outcomes to open surgery and the consistent advantages of the laparoscopic approach. However the operation remains controversial due to uncertainty about the extent of thoracic lymphadenectomy. Aim: To prospectively audit the extent of lymphadenectomy in the chest for thoracoscopic oesophagectomy when compared to the gold standard open procedure. Method: 10 patients who under went lymphadenectomy in the chest during total two phase laparoscopic oesophagectomy were prospectively compared to outcomes from 10 patients who under went an open procedure. Results: 10 patients (age 61–78, median 70), 7 patients were T3N1, 2 were T2 N1 and 1 T2NO who underwent total two phase laparoscopic oesophagectomy were compared with 10 patients (age 58–77, median 69), 8 patients were T3N1, 1 patient was T2N1 and 1 patient was T2N0 who underwent two phase open oesophagectomy in a prospective audit. All were type 1 or 2 tumours. The total number of lymph nodes harvested from the thoracic phase via the laparoscopic approach as compared to the open approach ranged from (10–19, median 15) as compared to (8–21, median 14) lymph nodes respectively without signiﬁcant diﬀerence (P>0.05). Conclusion: It is possible to perform total laparoscopic oesophagectomy without compromising oncological principles. More numbers are needed in a randomised trial to conﬁrm this initial ﬁnding. We anticipate to be able to present ﬁgures for around 20 cases by september 2006.

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IS HARMONIC SCALPEL AN EFFECTIVE TOOL FOR OESOPHAGECTOMY? N. Waraich, J. Ahmed, F. Rashid, D. Mulvey, P. Leeder, S.Y. Iftikhar Derbyshire Royal Inﬁrmary, DERBY, United Kingdom

PROSTHETIC MESH REPAIR OF LARGE AND RECURRENT DIAPHRAGMATIC HERNIAS N. Lubezky, B. Sagie, A. Keidar, A. Szold Sourasky Medical Center, TEL AVIV, Israel

Introduction: Use of electrocautry in oesophagectomy is standard; however, the introduction of the harmonic scalpel (HS) and its use has changed the methodology of oesophagectomy in recent years. We have assessed the eﬃciency of HS in oesophageal cancer surgery. The parameters studied were blood loss, transfusion rates, and post-operative complications. Methods: Our cohort included 142 patients who underwent elective oesophagectomy from January 1999 to December 2004. The control group was the patients undergoing electrocautery oesophagectomy (n= 98) between 1999 and 2002. Furthermore, 44 patients who were operated with the HS were included in the study group. Results: The numbers of units transfused were signiﬁcantly less in HS group (median 0) in comparison with controls (median 2), p = 0.003. Median blood loss in HS and the controls was 500 and 700 mls respectively, although not signiﬁcant (p= 0.123). Mortality in HS group was 2.27% compared to 3.06% in controls. The complication (principally respiratory) rate was only 13.6% of patients in HS group compared to 17.3% in the controls. Conclusion: Our study shows that HS reduces transfusion rates and post operative complications, highlighting it as a safe and cost eﬀective alternative to traditional electrocautery.

Background: laparoscopic repair of large paraesophageal hernias (PEH) is associated with recurrence rate of up to 42%. Failures are caused by crural breakdown and migration of the wrap to the mediastinum. Use of a prosthetic mesh to complete a tension free or buttressed repair of the hiatus has been suggested to decrease recurrence rate. Study aim: report the outcome of patients with large PEHs (either primary or recurrent) that underwent laparoscopic repair with prosthetic mesh.

Methods: between 1996 and 2004 59 patients with large (n=44) or recurrent (n=15) PEH were operated using the laparoscopic approach with the use of prosthetic mesh. Operative technique included reduction of hernia sac, dissection in the mediastinum to free the esophagus, primary crura repair using interrupted sutures, placement of mesh (PTFE or polypropylene) around the esophagus, and Nissen fundoplication. Patients were followed with oﬃce visits and phone interviews. All patients were referred for barium studies regardless of symptomatology. Results: perioperative complications occurred in 6 patients (11%), including pleural bleeding (n=2), pneumothorax (n=1), and esophageal perforation (n=1). There were no perioperative mortalities. Follow-up was completed in 56 (95%) patients. Mean follow-up time was 28.4 months. 40 patients (74%) had signiﬁcant relief of all symptoms. In the remaining patients the predominant symptoms included heartburn, epigastric pain and dysphagia. Barium studies were performed in 45 patients (80.3%), including all symptomatic patients. 25 patients (55%) had abnormal barium esophagram study: 15 patients (33%) had a small type I sliding hernia, 6 patients (13.3%) had recurrent PEH, and four patients (8.8%) had narrowing of the gastro-esophageal junction. Presenting symptoms of patients with recurrent PEH included vomiting (n=2), epigastric pain (n=3), and heartburn (n=1). These patients underwent laparoscopic mesh repair. Most patients with small hiatal hernias were symptomatic (60%), the most prominent symptoms were epigastric pain and heartburn, none of them required surgery. Conclusions: laparoscopic repair of large and recurrent PEH with reinforcement mesh is feasible and safe with excellent short term results. Long term follow-up shows a low PEH recurrence requiring reoperation, but a signiﬁcant number of patients develop symptomatic recurrent small hiatal hernias that can be managed nonoperatively.

S80

OESOPHAGEAL MALIGNANCIES O297-S2 LAPAROSCOPIC VERSUS OPEN TRANSHIATAL RESECTION FOR MALIGNANCIES OF THE DISTAL ESOPHAGUS: A COMPARISON OF TWO COHORTS J.J.G. Scheepers, D. van der Peet, C. Sietses, M.A. Cuesta Vrije Universiteit Medical Center (VUMC), AMSTERDAM, The Netherlands Introduction: Resection of the esophagus remains the only curative therapy for esophageal cancer. Conventional resections are right sided thoracotomy in combination with laparotomy, and the transhiatal approach according to Orringer. An alternative approach is laparoscopic transhiatal resection, which combines perfect visualization of the esophagus during mediastinal dissection with the known advantages of laparoscopy. This study evaluates the outcome of two groups of patients treated for distal esophageal cancer by means of a laparoscopic or open transhiatal esophagus resection. Patients and methods: 50 laparoscopic transhiatal esophageal resections (between 2001–2004) were compared with a historical control group of 50 open transhiatal resections (between 1997–2001). Results: Operating time was not signiﬁcantly longer in the laparoscopic group (300 vs 280 minutes), but laparoscopic esophageal resection was associated with less blood loss 680 vs 1125 ml (p <0,05), shorter ICU stay 1,4 vs 4,3 days (p<0,05), and shorter hospital stay 14 vs 18 days (p<0.05). There were no diﬀerences in pathological staging, morbidity and mortality. The Kaplan Meier analysis of laparoscopic vs open resection at 5 years shows an overall survival of 24% vs 26% (p=NS) with the same disease free survival at 5 years (p=NS). In the laparoscopic group, conversion to an open procedure was necessary in 10 patients (20%). Conclusion: Laparoscopic transhiatal esophagus resection is a safe procedure with important advantages to the open procedure such as less blood loss and shorter ICU stay. Moreover there are no diﬀerences in overall and disease free survival between both groups.

PAEDIATRIC SURGERY O298

O299

THE USE OF ACELLULAR DERMIS IN THE REPAIR OF PARAESOPHAGEAL HERNIA FOLLOWING FUNDOPLICATION IN CHILDREN S.A. Kapfer, M.D. Rollins, T.H. Keshen Washington University School of Medicine, ST. LOUIS, United States of America

LONG TERM RESULTS AFTER LAPAROSCOPIC INGUINAL HERNIA REPAIR IN CHILDREN M. Bahr1, Ch. Baur2, K.K. Richter3 1 Friedrich Schiller University Jena, JENA, Germany 2 Dept. of Surgery, Hospital Nuernberg, LAUF, Germany 3 Department of General and Visceral Surg., JENA, Germany

Objective: To develop a reinforced diaphragmatic crural closure utilizing a biologic graft material for the repair of recurrent gastroesophageal reﬂux with paraesophageal hernia in children. Methods: Two neurologically impaired children, ages 13 and 14 months, with recurrent gastroesophageal reﬂux and retching, underwent redo laparoscopic Nissen fundoplication and repair of large paraesophageal hernia. Following hernia reduction, excision of the sac, and cruraplasty, an onlay patch of acellular dermis (Alloderm) was placed as reinforcement over the crural repair. The patch was fashioned to recreate the arc of the crura around the esophagus and was secured with multiple interrupted sutures. The fundoplication was then completed and anchored to the esophagus and diaphragm. Results: The operations were accomplished laparoscopically, despite a history of previous laparoscopic fundoplication and gastrostomy button placement in both children. The Alloderm handled well in the laparoscopic setting. It stretched over the crura and around the esophagus, holding the suture well and remaining stationary during the anchoring process. Enteral feedings were started on postoperative day one, and the patients were discharged home on postoperative days two and three. Neither child has had recurrence of symptoms. Conclusions: Recurrent reﬂux due to cruraplasty failure and paraesophageal herniation is a signiﬁcant problem in children, especially those that are neurologically impaired. Alloderm has been used with excellent results in the pediatric population in the treatment of abdominal wall defects and diaphragmatic hernia. As a biologic graft material that is incorporated into the surrounding tissues, Alloderm has many potential advantages including low infectious risk, minimal adhesion formation, low migratory potential, and strengths comparable to synthetic materials. Its use in reoperative surgery for gastroesophageal reﬂux disease and paraesophageal hernias in children appears promising and warrants further investigation.

Background: Laparoscopic inguinal hernia repair has become a popular method since it has ﬁrst been published in 1998. It has been suggested that this minimally invasive surgery is a safe procedure with better cosmetic results compared to open hernia surgery. However, few follow-up data are available that assessed recurrence rates and complications. Therefore, we evaluated the long term results after laparoscopic hernia repairs performed at our institution. Materials and Methods: Between June 1997 and November 2003 428 laparoscopic inguinal hernia repairs have been performed in children at our department. Date of birth, hernia side, suture material, operation time and special intraoperative ﬁndings were documented. Recurrence rates and parents/patients satisfaction levels regarding cosmetic results, recovery time and postoperative complications were assessed using a standardized questionnaire that was sent to the parents of each patients in August 2004. Results: 396 questionnaires were returned. The median follow-up time was 3,88 years (range 1,06 7,54 years). Thirteen patients developed a direct inguinal Hernia (3.2%), 2 patients showed a hernia en pantaloon (0,5%). Thirty six patients (9.1%) developed a recurrent hernia that required re-operation. There were no diﬀerences in recurrence rates among the diﬀerent surgeons (4). Parents satisfaction with this laparoscopic technique and cosmetic result were very high. Recovery time of each patient was very short (mean time after surgery ?). Four patients (1%) developed hydroceles after laparoscopic hernia repair and one patient showed an atrophy of the right testicle (0.25%). Conclusion: Thirty six out of 396 patients developed a recurrence after laparoscopic hernia surgery that required re-surgery (median time 3,88 years). Implications of suture material, learning curve, and surgical technique on recurrence rates and complications are still controversial. Longer term follow-ups are required to further assess the eﬀectiveness of laparoscopic hernia repair in children.

S81

O300

O302

THE EFFECT OF INSTRUMENT SIZE ON PERFORMANCE IN PAEDIATRIC ENDOSCOPIC INTRACORPOREAL KNOT TYING A.C.H. Lee1, M.J. Haddad2, G.B. Hanna1 1 Imperial College London, LONDON, United Kingdom 2 Chelsea & Westminster Hospital, LONDON, United Kingdom

THORACOSCOPIC TRACHEO-AORTOPEXIA FOR THE TREATMENT OF LIFE-THREATENING EVENTS IN TRACHEOMALACIA D.C. van der Zee, N.M.A. Bax U.M.C. Utrecht, UTRECHT, The Netherlands

Aim: To study the inﬂuence of instrument size (3mm vs. 5mm) on task outcome and physical impact to the surgeon in paediatric endoscopic intracorporeal knot tying. Methods: Sixteen surgeons participated to tie 40 surgeons knots inside an infant simulator with an endoscopic ﬁeld of 40mm, using paired 3mm vs 5mm needle-holders in a randomised order. 3/0 silk were used to tie the knots around a tube housed inside synthetic skin pad. Knot quality score (KQS) and wrap length were used as indices of knot quality and wrap tightness. Timed electromyographic (EMG) recordings from of the upper limbs muscle groups were used to indicate muscular recruitment. A questionnaire on discomfort and instrument preference was also completed by the surgeons. Mann-Whitney U and Fishers exact tests were used as appropriate. Signiﬁcance level was set at 5%. Results: A total of 640 knots were analysed. Two sutures were broken or pulled out whilst tying with the 5mm needle-holders. Median time were shorter using 3mm needle-holders than 5mm needle-holders (94s vs 102s; z=)2.084; p=0.014) however KQS (0.271 vs 0.260; z=)0.765; p=0.444) and the tightness around the tube (86mm vs 86mm; z=)0.583; p=0.297) were not signiﬁcantly diﬀerent. The proportion of completely slipped knots were also similar (19% vs 22%; p=0.322). Normalised EMG were significanty higher (p<0.001) when using the 5mm needleholders in trapezius, deltoid, biceps, triceps, forearm ﬂexors, forearm extensors (p=0.032) and 1st dorsal interosessus except left forearm extensors (p=0.460). The surgeons generally reported less discomfort with the 3mm needleholders and 13 surgeons expressed overall preference for them. Conclusion: Endoscopic knot tying was performed faster in an infant simulator using 3mm needle-holders without compromising the quality of knot quality. There were also reduced muscular recruitment resulting in less fatigue and discomfort for the surgeon.

O301 INITIAL EXPERIENCE WITH ONE PORT LAPAROSCOPIC ASSISTED APPENDECTOMY IN CHILDREN AND ADOLESCENCE V. Kapuller, M. Grunspan Kaplan Medical Center, REHOVOT, Israel Appendectomy is the most common intra-abdominal operation in Israel. Laparoscopic approach has been widely adopted for this operation for its ability to reduce morbidity and hospital stay and good cosmetic results. On the other hand, traditional approach is safer, cheaper and (especially at the beginning of learning curve) faster. Although an experienced surgeon can perform an appendectomy through a small incision, the scar grows with the child, and in the future can cause an aesthetic problem. A new approach combines the beneﬁts of both techniques: an appendix is extracted from abdominal cavity by operating laparoscope through one umbilical port, after then the operation is completed in the traditional open manner. Methods: The authors operated on 25 children (Group 1) with acute appendicitis through one umbilical port. Records of 25 children (Group 2), who underwent open appendectomy previously, were also evaluated. Observations were made regarding intra- and postoperative complications, postoperative analgesic requirement, and postoperative hospital stay. Results: One port trans-umbilical laparoscopic assisted appendectomies were performed in 23 children; in one case additional 5 mm port was placed for the mesentery release. Conversion to open procedure was performed due to extremely short appendix in one case. There were no intra-operative complications. The post-operative analgesic requirement, mean postoperative stay were similar in both groups. One postoperative complication (intra-abdominal collection that resolved after antibiotic treatment) was in each group. Cosmetic results were excellent in the Group 1. Conclusions: One port trans-umbilical laparoscopic assisted appendectomy is the simple method that combined the advantages of the minimal invasive surgery with the safe classic approach.

Introduction: Life-threatening events due to tracheomalacia is a wellknown complication in infants with esophageal atresia. As the aortic arch and trachea are closely related, elevation of the aortic arch against the sternum will pull up the trachea too, and thus alleviate the complaints from the collapse of the anterior and posterior wall of the trachea. This procedure is usually performed by a transjugular approach. With the advent of minimal invasive surgery (MIS) the procedure can also be performed by thoracoscopic MIS. Patients: Between January 2002 and December 2005 six children with esophageal atresia were treated by MIS for life-threatening events due to tracheomalacia. Mean age at the time of operation was 5 months (14d– 12m). Mean weight was 5.5kg (3–9kg). There were 3 girls and three boys. The procedure was started with a tracheoscopy. ÔKissingÕ of the ventral and posterior tracheal wall were an indication for thoracoscopic tracheo-aortopexia . After the sutures were placed and pulled against the posterior surface of the sternum, tracheoscopy was repeated to determine the eﬃcacy of the tracheo-aortopexia. Results: All patients tolerated the thoracoscopic procedure well and tracheo-aortopexies could be carried out thoracoscopically. Tracheoscopy at the end of the procedure showed a clear improvement of the trachial diameter. In two patients recurrence of life-threatening events occurred after two and four weeks respectively, for which a thoracoscopic redotracheo-aortopexia was performed with good results. With a follow-up of 28m (3–48m) all patients are doing well and have had no more lifethreatening events. Conclusion: Thoracoscopic tracheo-aortopexia for life-threatening events due to tracheamalacia is feasible and safe. In two instances in which symptoms recurred after an interval, thoracoscopic redo-procedure was successful in alleviating tracheomalacia symptoms.

S82

PHYSIOLOGY, PATHOPHYSIOLOGY, IMMUNOLOGY O303

O305

REDUCING THE OXIDATIVE STRESS FOLLOWING PNEUMOPERITONEUM, BY USING INTERMITTENT SEQUENTIAL PNEUMATIC COMPRESSION (ISPC) LEG SLEEVES A. Bickel1, A. Drobot1, M. Aviram2, A. Eitan1 1 Western Galilee Hospital, NAHARIA, Israel 2 Rambam Medical Center, HAIFA, Israel

VALIDATION OF ESOPHAGEAL DOPPLER FOR NON-INVASIVE HEMODYNAMIC MONITORING DURING PNEUMOPERITONEUM G.M. Fried, A. Okrainec, S. Bergman, L.S. Feldman, S. Demyttenaere, F. Carli, G.M. Fried McGill University, MONTREAL, Canada

Background: Increased intra-peritoneal pressure during laparoscopic operations may lead to decreased cardiac output (CO) and visceral perfusion, and possible ischemia-reperfusion eﬀects. Using ISPC device was shown to improve CO and visceral perfusion during PP. Aim: To validate ischemia-reperfusion mechanism during laparoscopic cholecystectomy, and to assess the reduction of oxidative stress by ISPC device. Patients and methods: Twenty patients undergoing elective laparoscopic cholecystectomy were enrolled in a randomized prospective controlled study and divided into two groups: 1. Study group (10 patients), activation of ISPC together with creation of PP. 2. Control group, without ISPC. Lipid peroxidation and glutathion levels (as indicators of oxidative stress) as well as liver and renal function tests, were measured before and at the end of PP, and at 30 minutes, 4 and 24 hours afterwards, together with hemodynamic and respiratory parameters. Results: There was no signiﬁcant diﬀerence between both groups concerning liver enzymes and billirubin, as well as hemodynamic parameters. In the control group, increased lipid peroxides levels were noted 4 hourd after PP termination, in comparison to pre-PP levels (560.4 to 649.2 mmol/ liter, p=0.002). In the study group (ISPC) such changes were not inspected. Reciprocal decreased glutathion levels were noted in the control group. Conclusions: Our study validates the ischemia-reperfusion mechanism following laparoscopic surgery. The use of ISPC device decreases the oxidative stress (secondary to relative ischemia-reperfusion insult) following PP, due to improved CO and visceral perfusion

Introduction: Commonly used perioperative measurements of hemodynamics, like Swan-Ganz catheters, are invasive and may not be reliable under pneumoperitoneum. The purpose of this study was to validate the use of esophageal doppler (ED) for noninvasive hemodynamic monitoring under pneumoperitoneum in an experimental pig model. Methods: Eleven female pigs were submitted to two 30 min study periods: 1) Baseline: no interventions, 2) Pneumoperitoneum: 12 mmHg CO2 pneumoperitoneum. One pig was excluded due to tachycardia >140 at baseline. A Swan-Ganz pulmonary artery catheter was used to measure cardiac output (CO-SG), CVP (CVP-SG), and pulmonary capillary wedge pressure (PCWP). An ED was inserted and stroke volume (SV-ED), cardiac output (CO-ED), and corrected ﬂow time (FTc), an index of preload, were recorded. Transthoracic echocardiography was used to measure left ventricular end-diastolic diameter (LVEDD) and cardiac output (COTTE). Pearson correlation was used to assess individual associations between measured hemodynamic parameters. Results: There was good correlation between CO-ED and CO-SG (R=.529, p=.000). There was excellent correlation between CO-ED and CO-TTE (R=.815, p=.000). SV-ED correlated well with SV-SG (R=.508, p=.002) and SV-TTE (R=.732, p=.000). These relationships were consistent when analyzed separately at baseline and under pneumoperitoneum (data not shown). There was no correlation between FTc and LVEDD or PCWP. Conclusion: Esophageal doppler monitoring is a valid non-invasive method to measure cardiac output and stroke volume at baseline and during pneumoperitoneum in a porcine model. Corrected ﬂow time did not correlate with other estimates of preload at baseline or during pneumoperitoneum.

O304

O306

FILTERED SIGNAL-AVERAGED P-WAVE DURATION DURING PNEUMOPERITONEUM IN PATIENTS UNDERGOING LAPAROSCOPIC CHOLECYSTECTOMY A. Bickel1, M. Marinovski2, A. Shturman3, N. Roguin3, A. Eitan4 1 Western Galilee Hospital, NAHARIA, Israel 2 Western Galilee Hospital, Anesthesiology, NAHARIA, Israel 3 Western Galilee Hospital, Cardiology, NAHARIA, Israel 4 Western Galilee Hospital, HAIFA, Israel

IMMUNOLOGICAL CONSEQUENCES OF LAPAROSCOPIC VERSUS OPEN TRANSHIATAL RESECTION FOR MALIGNANCIES OF THE DISTAL ESOPHAGUS AND GASTROESOPHAGEAL JUNCTION C. Sietses, I.I.G. Scheepers, M.A. Cuesta Vrije Universiteit Medisch Centrum, AMSTERDAM, The Netherlands

Background: Induction of pneumoperitoneum (PPP) may lead to adverse cardiac functions secondary to decreased venous return, hypercarbia, etc. The assessment of cardiac electrical activity by signal averaging may reﬂect various hemodynamic derangements and may serve as a prognostic marker to arrhythmias. Aims: To examine characteristic electrocardiographic changes that may occur during PPP, by using signal averaged P-wave analysis. Patients and methods: Twenty healthy (ASA I-II) patients were enrolled in a prospective paired-control study, and underwent an elective laparoscopic cholecystectomy. A standard ECG together with computerized ﬁltered signal averaged P-wave duration measurement (leads X,Y,Z) were done during awareness, anesthesia before and during PPP, and after CO2 evacuation. Depth of anesthesia was controlled by bi-spectral index (BIS). Results: A signiﬁcant increased duration of P-wave was inspected during PPP in comparison to the anesthesia phase before PPP (11120 to 11518 msec, t-test and Wilcoxon signed rank test). A signiﬁcant increase was also detected concerning the maximal value of P-wave duration between those phases of the operation (11721 to 12324 msec). The number of patients that had an increased duration of at least 5 msec. was found to be signiﬁcant too. Conclusions: Primarily, a decreased P-wave duration was expected, due to cardiac autonomic sympathetic predominance during PPP. A prolonged Pwave duration during PPP may reﬂect some cardiac pathophysiologic (structural and functional) changes, maybe through an inﬂuence on cardiac ion channels during depolarization. Usually, clinical consequences related to laparoscopic cholecystectomy are absent, but considering the above, physicians should be aware of cardiac diseased patients undergoing prolonged laparoscopic procedures.

Background: Surgery remains the only curative therapy for esophageal cancer. The best approach to the dissection and its extent are controversial. Recently we have compared the short- and long-term results of patients with cancer of the distal esophageal and gastro-esophageal junction who were approached by a minimally invasive procedure or a conventional open procedure. Signiﬁcantly less blood loss, shorter ICU stay and hospital stay was found in the laparoscopic transhiatal approach. These data suggest that laparoscopic esophageal resection is less traumatic when compared with the open procedure. Postoperative metabolic and immunologic changes are proportional to the degree of surgical trauma and subsequent changes may be implicated in the development of septic complications and tumor metastasis formation. Methods: seventeen patients undergoing laparoscopic or open surgery were included in the study. Postoperative inﬂammatory response was assessed by measuring the soluble TNF receptor p55 and p75 (sTNFr), interleukin (IL) -1 and and IL-6. Post-operative immune function was assessed by measuring monocyte HLA-DR expression. To further evaluate the fysiologic response after extensive and long laparoscopic procedures we measured lipopolysaccharide-binding protein (LBP) and bactericidal/permeabilityincreasing protein (BPI). LBP and BPI are highly speciﬁc markers for Gram-negative infection and markers for bacterial translocation. Results: Il-1 and IL-6 increased more in the patients who received open surgery, as compared to the laparoscopic group (p=0.041, resp. p=0.036). No diﬀerence was observed between the groups with respect to the TNF response (TNF 55/60: p=0.319; TNF 75/80: p=0.245). LBP and BPI increased signiﬁcantly more in the laparoscopic group, as compared to the group who received open surgery (p=0.011 resp. p=0.035). No diﬀerence was found in HLA-DR expression between both techniques. Conclusion: although both laparoscopic and conventional esophageal resection results in an activation of the inﬂammatory response, this study suggests that this response could be less after the laparoscopic approach.

S83

O307

O309

HAEMODYNAMIC STABILITY DURING LAPAROSCOPIC ADRENALECTOMY FOR PHAEOCHROMOCYTOMAS COMPARED TO OTHER ADRENAL TUMOURS

PORTAL VEIN FLOW DOES NOT ALWAYS DECREASE WITH CO2 PNEUMOPERITONEUM IN A PORCINE MODEL

C.N. Parnaby1, J.T. Jenkins1, P.S. Chong1, M. Serpell2, J. Connel1, P.J. OÕDwyer2 1 Southern General Hospital, GLASGOW, United Kingdom 2 Western Inﬁrmary, GLASGOW, United Kingdom Aims: Adrenalectomy for phaeochromocytoma can induce high levels of catecholamine release that may result in episodes of severe hypertension and cardiac arrthymia with subsequent cardiovascular collapse. Laparoscopic adrenalectomy (LA) has been shown to be safe in phaeochromocytoma resection without increase in cardiovascular complications. We aimed to characterise the haemodynamic changes during laparoscopic resection of phaeochromocytoma compared to other adrenal tumours. Methods: Adrenalectomy patients were identiﬁed from a prospective database (Jan 1999 and Jan 2006). All patients with suspected phaeochromocytoma received an intravenous phenoxybenzamine infusion the day before surgery. All patients underwent LA through a lateral trans-abdominal approach. Analysis of peri-operative haemodynamic parameters was conducted by assessment of anaesthesia records. Results: 81 consecutive patients were identiﬁed with adrenal tumours that underwent LA. 21 phaeochromocytomas and 60 other adrenal tumours (23 Conns, 14 Cushings syndrome, 6 Cushings disease, 2 adrenal carcinomas, 9 incidentalomas and 6 others) were identiﬁed. One patient with phaeochromocytoma was excluded due to incomplete data. There was no mortality in either group. The phaeochromocytoma group were more likely to have a persistent intraoperative systolic blood pressure (SBP) >180mmHg (>10 minutes) compared to other adrenal tumours [OR 4.75 (95% CI 3.07–7.34)]. The use of antihypertensive medication was increased in the phaeochromocytoma group [OR 4.55 (95% CI 2.54–8.12)]. No patients had persistent SBP >200mmHg. No signiﬁcant diﬀerence existed for persistent SBP <80mmHg or heart rate >120 beats per minute between groups. No signiﬁcant diﬀerence existed for recovery pulse and blood pressure between groups. No signiﬁcant diﬀerence existed between the two groups in terms of conversion to an open procedure, operative time, intensive care admissions or post operative stay. Conclusions: Phaeochromocytoma resection by LA was associated with persistent intra-operative hypertension with increased anti-hypertensive use however, there was no diﬀerence in cardiovascular complications and post-operative outcomes were comparable to other adrenal tumours.

N. Alexakis1, K. Albanopoulos1, K. Dimitriou2, A. Fingerhut3, J. Bramis1, E. Leandros1 1 University of Athens, ATHENS, Greece 2 Foundation for Biomedical Research, ATHENS, Greece 3 Centre Hospitalier Intercommunal, POISSY, France

Aim: To investigate the changes of hepatic blood ﬂow during CO2 pneumoperitoneum at various time points in a porcine model. Methods: 10 white pigs (mean weight 35.2 kg) were anesthetized and ventilated in the supine position. We measured heart rate, aortic ﬂow, hepatic artery ﬂow, and portal vein ﬂow (using ﬂow probes) before and after the establishment of pneumoperitoneum at 12mmHg at 10 minute intervals for 2 hours and 10 min after desuﬄation. Values are given as mean +/) SEM. Data were analysed with the ANOVA test followed by a Tukey test. Results: There was a statistically insigniﬁcant (p=0.62) decrease in the hepatic artery ﬂow from 163 ml/min (at 0 hours), to 146.4 (at 10 min), 144 (at 20 min), 139.2 (at 30 min), 130.7 (at 40 min), 126.3 (at 50 min), 126.8 (at 60min), 117.7 (at 70min), 115 (at 80min), 110.4 (at 90 min), 113.5 ml/min (at 100 min), 110.4 ml/min (at 110 min), 110.3 ml/min (at 120 min) and 105 (after desuﬄation). There was a statistically not signiﬁcant (p=0.99) increase in portal vein ﬂow: 1190 ml/min at 0 hours, 1240 (at 10 min), 1280 (at 20 min), 1312 (at 30 min), 1302 (at 40 min), 1335 (at 50 min), 1406 (at 60 min), 1395 (at 70 min), 1367 (at 80 min), 1359 (at 90 min), 1464 (ay 100 min), 1370 (at 110 min), 1389 (at 120 min) and 1378 (after desuﬄation). Conclusion: Hepatic artery ﬂow deceased and portal vein ﬂow increased with CO2 pneumoperitoneum at 12 mmHg. The anaesthesiology protocol, animals used, and timing of measurements may account for diﬀerences in our compared to similar studies in the literature.

O308

O309-S1

DIAGNOSTIC VALUE OF C-REACTIVE PROTEIN, WHITE BLOOD CELL CONCENTRAYION AND OTHER MARKERS OF INFLAMMATION FOLLOWING OPEN OR LAPAROSCOPIC CHOLECYSTECTOMY S. Koulas, C. Charalambous, I. Koutsourelakis, D. Tsiouris, K. Christodoulou, P. Christou Hospital of Corfu, CORFU, Greece

PERITONEAL ACIDOSIS MEDIATES CO2-LAPAROSCOPY IMMUNOPROTECTION

Background: CPP, WBC, C3, C4, IgA, IL-1, IL-6, and others represents an early marker of systemic inﬁammatory response and tissue damage. Aim: The goal of this study is to evaluate the diﬀerences in immune system after laparoscopic or open surgery. Patients-method: Two groups of patients undergoing laparoscopic cholecystectomy: Twenty patients in laparoscopic group (group A) and ten patients in open group (group B). All cholecystectomies are performed by three surgeons. Blood sample was taken before surgery, immediatly in the end of the operation and 24 hours later, in both groups. CPP, WBC, C3, C4, IgA, IgM, were the main parameters under examination. Results: Statistically signiﬁcant increased of CPP, WBC was seen in group B in comparison of group A (p<0,0001), while increase of PLT but not statistically signiﬁcant (p>0,1), was observed in group B. In both groups was seen increase of C3, C4 and IgA, not statistically signiﬁcant (p>0,1). Conclusion: This ﬁndings suggedting that increase of WBC and CRP are useful markers of inﬂammation and tissue damage mainly in open cholecystectomy. Additionally, it would be interesting to evaluate, in further extended studies, IL-6 as a very important early marker of inﬂammation in open and laparoscopic cholecystectomies.

E.J. Hanly, A.R. Aurora, S.P. Shih, J.M. Fuentes, M.R. Marohn, A. De Maio, M.A. Talamini Johns Hopkins University, SAN DIEGO, United States of America

Introduction: Abdominal insuﬄation with CO2 increases plasma levels of IL-10 and attenuates TNFa production while improving survival among animals with LPS-induced sepsis. The eﬀect of CO2 is not due to changes in systemic pH, although the peritoneum is locally acidotic during abdominal insuﬄation with CO2. We tested the hypothesis that acidiﬁcation of the peritoneum via means other than CO2 insuﬄation produces alterations in the inﬂammatory response similar to those associated with CO2 pneumoperitoneum (pneumo). Methods: 42 rats were randomized into 7 groups (n=6): 1) LPS only, 2) Anesthesia control, 3) Electrolyte lavage, 4) Helium pneumo, 5) CO2 pneumo, 6) Acid lavage, and 7) Acid lavage + helium pneumo. Animals received anesthesia and their respective abdominal treatment (pneumo and/or lavage) for 30 min followed immediately by stimulation with LPS (1 mg/kg, IV). Results: Peritoneal pH decreased signiﬁcantly following CO2 pneumo, buﬀered acid lavage, and buﬀered acid lavage + helium pneumo. Compared to LPS only control, IL-10 was similarly elevated and TNFa similarly reduced for all three groups with acidic peritoneal cavities regardless of the presence or absence of pneumo.

LPS Only He CO2 Acid Acid + He

pH Change

IL–10

TNFa

n/a 7.10 7.16 7.06 7.03

326 177 1096 360 1212 275 1817 385 1255 219

7478 2313 1835 937 1090 127 604 131 499 197

ﬁ ﬁ ﬁ ﬁ

6.95 6.44 6.20 6.38

Conclusions: Acidiﬁcation of the peritoneal cavity whether by abdominal insuﬄation with CO2 or by peritoneal lavage with buﬀered acid solution increases serum IL-10 and decreases serum TNFa in response to systemic LPS challenge. These results demonstrate that the mechanism of pneumoperitoneummediated attenuation of the inﬂammatory response following laparoscopic surgery is via peritoneal cell acidiﬁcation through local dissolution of CO2 gas.

S84

RADIOLOGY / IMAGING O310

O312

USE OF INTRAOPERATIVE ULRASOUND IN LAPAROSCOPIC CHOLECYSTECTOMY - A BOON FOR SURGEONS NOT DOING INTRAOPERATIVE CHOLANGIOGRAPHY

MINIMAL INVASIVE THERAPY IN CT-BASED NAVIGATION H.W. Krause1, M. Nagel2, R.M.M. Seibel1 1 MRI - Mu¨lheim Radiology Institute, MU¨LHEIM / RUHR, Germany 2 Institute of Medical Physics, ERLANGEN-NU¨RNBERG, Germany

M. Varma1, R.C. Shah2 Private-Kanpur - [email protected], KANPUR, India 2 NHL Municipal Medical College, AHMEDABAD, India

1

Objectives: Intraoperative cholangiography (IOC) requires radiation, takes time & sometimes fails. Laparoscopic ultrasonography (LUS) is comparatively quick, safe & non-invasive. This study aims to bring forth recent literature on LUS to assess its potential as an alternative to IOC. Methods: Internet search was done for literature on LUS available from year 2000 to 2005; ﬁndings are presented here. Results: LUS is a relative latecomer due to need for development of specialized transducers that could ﬁt through trocars. Quality, reliability & ease of use have evolved rapidly, so that LUS may now be performed routinely. It looks into the tissues being operated upon, thus compensating for inability to palpate tissues. Hence it has helped to mimic open surgery & also reﬁned techniques of laparoscopic surgeries. With increasing availability of equipment, as well as training in this modality, it is quickly becoming an essential tool for laparoscopic surgeons. For detecting CBD stones during laparoscopic cholecystectomy (LC) results are comparable to IOC. Sensitivity is 92 – 96% for LUS & 86 – 95% for IOC. The speciﬁcities are 100% & 99% respectively. The false-negative rate of both is <1%. Though LUS & IOC are complementary, as combination of both maximizes results; LUS is noninvasive, fast, repeatable & can corroborate real-time visualization of operative ﬁeld. LUS requires less time than IOC: 10.2 minutes versus 17.9 minutes (P=0.0001). Post-clipping LUS can conﬁrm that clips are applied to cystic duct & not to the hepatic duct or common bile duct. LC with LUS is associated with fewer CBD injuries, bile leaks & retained CBD stones than LC without adjunctive imaging. LUS can be performed in all cases but some say that anatomical anomalies are often missed. Individual training is necessary to optimize eﬃcacy as there are considerable learning curves. Success rate of LC in cases of acute cholecystitis is slightly higher when LUS is used. It is recommend to routinely use LUS when performing LC, particularly in acute cholecystitis. Reports go on to state that LUS of the bile duct is superior to IOC & could replace it. As experience with ultrasound cholangiography increases, there may be little indication for IOC except for rare questions concerning anatomy & during therapeutic maneuvers for CBD stones. Conclusion: LUS with LC is important for patientÕs safety if IOC is not being done. With LUS there are considerable learning curves.

O311 INCIDENCE OF BLADDER CANCER IN ONE-STOP CLINIC I.A. Yakasai1, M. Allam2, A.J. Thomson3 1 Southern General Hospital, GLASGOW, United Kingdom 2 Monklands General Hospital, WISHAW, United Kingdom 3 Royal Alexadra Hospital, PAISLEY, United Kingdom Introduction: Postmenopausal bleeding (PMB) is a common presentatation in the gynaecology clinic. Patients with abnornal vaginal bleeding had transvaginalscan (TVS) and endometrial sampling where indicated. We search for the presence of bladder tumour among these women using TVS and urine cytology. Objective: The aim of the study is to demonstrate the importance of TVS in the detection of bladder tumours, among women presenting with PMB. Design and Method: Clinical, ultrasound and histological data for consecutive women attending the PMB clinic between September2001 and May 2004 were analysed. All women underwent TVS by a single operator. Result: Seven hundred and ﬁfty three new referrals to one-stop clinic were seen. From this group 17 cases of endometrial cancer were subsequently detected. Three bladder tumours were among the extra-endometrial malignancies detected. Urine cytology did not reveal any cancer cells in these women. All cases had cytoscopy carried out which was consistent with the TVS ﬁndings. Histology conﬁrmed malignant transitional carcinoma in all three that were completely excised. Conclusion: Eleven percent (11%) of all extra-endometrial malignancies were bladder cancers in women with PMB attending our clinic Careful assessment of all pelvic organs is required in women presenting with PMB.

Purpose: A novel CT-based navigation system was tested regarding the accuracy. We were able to prove the accurate puncture of diﬀerent targets in two phantom studies reproductively. In two sets of measurements the technical accuracy as well as the accuracy of positioning were demonstrated. In the next step the system was used in clinical testing. Method and Materials: The navigation system (CAPPA IRAD, CAS Innovations AG, Erlangen, Germany) is a setup consisting of a standard PC with a touchscreen serving as an input interface and the navigating software (IRAD) with a passive optical tracking system (Polaris, NDI, Canada). It is completed by a needle holder, a patient-ﬁx-kit (BodyFix, Medical Intelligence, SchwabMnchen, Deutschland) and a patient frame with optical and CT markers. In phantom testing both phantoms were ﬁxed securely on the CT-table. The patient frame was positioned above and the setup was scanned The ﬁeld of measurement was selected in a way that all CT-markers were within the ﬁeld. All data were gathered in DICOM format; an exchange to the navigation system was easily possible. We used an acrylic glass phantom for technical accuracy and a spine phantom for accuracy of positioning. The setups were scanned and with help of the planning device of the navigation software a typical target approach was deﬁned and performed. For clinical testing the procedures mentioned above were performed in analogy. Results: For technical accuracy we measured an average distance of 0.7 mm (SD + / ) 0.2 mm) needle to target and an average distance of 0.5 mm (SD + / ) 0.2 mm) for the perpendicular. For accuracy of positioning we found an average distance of 0.8 mm (SD + / ) 0.35 mm) needle to target and an average of 0.7 mm (SD + / ) 0.36 mm) for the perpendicular. Several minimal invasive procedures have been performed without any problems. Conclusions: The proven accuracy of the novel system allows to even puncture smallest targets reproductively that in conventional techniques are diﬃcult to aim at. With regard to standard CT-guided approaches high precision intervention seem possible even with an angulated 3-dimensional approach.

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ROBOTICS, TELESURGERY AND VIRTUAL REALITY O313

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A COMPUTERIZED ANALYSIS OF ROBOTIC VERSUS LAPAROSCOPIC TASK PERFORMANCE

THREE YEARS OF ROBOTIC SURGERY: 109 CASES, ONE SURGEON

V.K. Narula, W.C. Watson, S.S. Davis, K. Hinshaw, B.J. Needleman, D.J. Mikami, J.W. Hazey, J.H. Winston, P. Muscarella, M. Rubin, V. Patel, W.S. Melvin

A.L. Rawlings, J.H. Woodland, J.D. Hursey, D.L. Crawford University of Illinois, COLLEGE OF MEDICINE AT PEORIA, United States of America

The Ohio State University, COLUMBUS, United States of America Introduction: Robotic technology has been postulated to improve performance in advanced surgical skills. We utilized a novel computerized assessment system to objectively describe the technical enhancement in task performance comparing robotic and laparoscopic instrumentation. Methods and Procedures: Advanced laparoscopic surgeons (2–10 yrs experience) performed 3 unique task modules using laparoscopic and Telerobotic Surgical Instrumentation (Intuitive Surgical, Sunnyvale, CA). Performance was evaluated using a computerized assessment system (ProMIS, Dublin, Ireland) and results were recorded as time (sec), total path (mm) and precision. Each surgeon had an initial training session followed by two testing sessions for each module. A Paired Students T-Test was used to analyze the data. Results: 10 surgeons completed the study. Objective assessment of the data is presented in the table below. 8/10 surgeons had signiﬁcant technical enhancement utilizing robotic technology

Conclusions: The ProMIS computerized assessment system can be modiﬁed to objectively obtain task performance data with robotic instrumentation. All the tasks were performed faster and with more precision using the robotic technology than standard laparoscopy.

This study describes 109 consecutive cases and the evolution of case selection using the DaVinci Robotic System by one MIS fellowship trained surgeon at a tertiary hospital. This study is based on information prospectively collected in an Excel database from 9/2002 to 8/2005. The data consists of type of case, port setup time, robot time, and total case time. The procedures were: Nissen (36), Right Colectomy (19), Sigmoid Colectomy (15), Heller Myotomy (13), Hiatal Hernia (7), Splenectomy (5), Gastric Tumor (4), Adrenalectomy (3), Pyloroplasty (3), Cholecystectomy (2), and Toupet (2). Average port setup time was 30.3 8.7 [14–53] minutes. Average robot time was 113.3 49.2 [31–306] minutes. Average case time was 188.2 57.0 [94–380] minutes. Advantages were: 1) Enhanced view of the operative ﬁeld; 2) Wristed instruments facilitate dissection; 3) Surgeon controlled camera; 4) Reduced surgeon fatigue; 5) Increased marketability of surgeon as regional MIS expert. Disadvantages were: 1) Inconvenience of altering camera/instrument placement during case; 2) Diﬃculty working in far lateral extensions of operative ﬁeld; 3) Diﬃculty changing table position during case; 4) Loss of tactile sensation; 5) Need for additional ports in some cases. The DaVinci has been in use at this institution for three years. Case diversity accounts for the wide range in robot and total case time. Port setup time is most consistent from case to case. Of the six operations, three are no longer done. Two cholecystectomies were done in the ﬁrst month to become familiar with the equipment. The last splenectomy was done at six months and the last adrenalectomy was done nineteen months into the systems use. These last two procedures were dropped because they required an additional port and held little advantage over standard laparoscopy. The robot is still used for three operations. Fundoplications have proven to be good cases on which to train residents in the use of the system. Colectomies are still being performed as part of an on going research project. Heller myotomy best utilizes the robots enhanced visualization and dexterity during the delicate esophagomyotomy. Over three years, case diversity has narrowed to those with speciﬁc advantages for our training program, research interests, and patients. Increased utilization of the DaVinci system in general surgery is less likely than in other ﬁelds where minimally invasive approaches are less common.

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REMOTE STEREOSCOPIC ROBOTIC TELESURGERY USING THE PUBLIC INTERNET E.J. Hanly, B.E. Miller, B.C. Herman, M.R. Marohn, T.J. Broderick, S.P. Shih, J. Sterbis, C. Doarn, B.R. Harnett, C.J. Hasser, M.A. Talamini, O. Meireles, G.R. Moses, R. Marchessault, N.S. Schenkman Johns Hopkins University, SAN DIEGO, United States of America

ROBOTIC VS LAPAROSCOPIC COLECTOMY A.L. Rawlings, J.H. Woodland, P. Gatta, R. Vegunta, D.L. Crawford University of Illinois, COLLEGE OF MEDICINE AT PEORIA, United States of America

Laparoscopic vs Robotic

Module 1 Module 2 Module 3

Time (sec) 210 vs 161 # 119 vs 68 * 77 vs 55 *

Total Path(mm) 11649 vs 5571 * 5573 vs 1949 * 4488 vs 2390 *

Precision 1434 vs 933 * 853 vs 406 * 552 vs 358 *

# = p < 0.009 * = p<0.001

Introduction: Providing surgeons the ability to mentor and perform procedures from remote locations will have a profound impact on the quality and type of care that rural patients receive in their towns and that soldiers receive on the battleﬁeld. Remote telesurgery using monoscopic vision has been performed clinically with the Zeus surgical robot, but at a great ﬁnancial cost >$1M). Because of its complexity, the daVinci Surgical System -an advanced surgical robot with stereoscopic vision- has never been used for remote surgical applications. Methods: The daVinci Surgical System was modiﬁed to enable network communication between multiple Surgeons consoles and a single patient-side cart (the robot). Two low latency video CODECs were used at each site to enable stereoscopic video streaming. Unlike previous telesurgery models, Internet-based connectivity was used to establish a cost-eﬀective solution applicable to a wide variety of clinical settings (cost to lease for 6 months the telecommunications equipment and bandwidth used in this study is <$100K). The utility of the system to facilitate remote collaborative stereoscopic telesurgery was evaluated through a combination of dry lab exercises and animal lab surgery. Results: Surgeons located in Cincinnati, Ohio, and in Denver, Colorado, successfully operated with residents in Sunnyvale, California (approximate distances of 2,400 and 1,300 miles, respectively) to perform nephrectomies in six Californian swine. The modiﬁed daVinci system was capable of shared control between the remote surgeon and the local resident. Remote surgical task performance data is presented in detail. Round-trip latency was high (550–980 ms), but remote surgeons quickly adapted and performed telesurgical nephrectomies in the pigs without complication. Conclusions: This low-cost, proof-of-concept study represents a number of surgical and telemedicine milestones including the ﬁrst U.S.-based telesurgery, the ﬁrst telesurgery using the daVinci Surgical System, the ﬁrst use of stereoscopic (3D) surgical video streaming, the ﬁrst robotic collaborative telesurgery (two consoles), and the ﬁrst telesurgery over the Internet using non-dedicated lines. In this conﬁguration, the daVinci Surgical System oﬀers a unique opportunity to develop a network of machines at various remote locations which may all be used to extend the reach of expert specialty surgeons.

This study compares thirty robotic colectomies with twenty-seven laparoscopic colectomies done by one MIS fellowship trained surgeon at a tertiary institution. Since the introduction of the DaVinci Robotic System, minimally invasive surgeons have explored its use for a variety of procedures. This study is based on information that was prospectively collected from 9/2002 to the present. Data analyzed (SPSS 12.0 for Windows) included indications for surgery, gender, age, BMI, EBL, length of operation, length of stay (LOS), complications, and average OR cost of operation. Male to female ratios, patient age, BMI and EBL were similar between the groups (p<0.05). Operations included 13 robotic and 12 lap sigmoid colectomies and 17 robotic and 15 lap right colectomies. Preop diagnosis for robot: Cancer (5); Diverticulitis (8); Polyp (16); Carcinoid (1). Preop diagnosis for lap: Cancer (9); Diverticulitis (12); Polyp (5); Crohns (1). Total right colectomy case time (minutes): Robot 218.9 vs Lap 169.2 (p=0.002). Total sigmoid colectomy case time (minutes): Robot 225.2 vs Lap 199.4 (p=0.128). LOS right colectomy (days): Robot 5.2 vs Lap 5.5 (p=0.8). LOS sigmoid colectomy (days): Robot 6.0 vs Lap 6.6 (p=0.9). Robotic complications: 1) Patient slid oﬀ OR table to ﬂoor after the robotic portion of the procedure; 2) Persistent left hip paresthesia; 3) Transverse colon injury from ultrasound shears; 4) Cecal injury from cautery; 5) Anastomotic leak; 6) Urinary retention beginning POD 5. Laparoscopic complications: 1) Anastomotic leak; 2) Partial small bowel obstruction. Two robotic and two lap cases were converted to open. Average OR cost for lap was $6,464 (OR time $1,131, personnel $249, supplies $5,084). The average OR cost for robotic was $8,117 (OR time $1,378, personnel $485, supplies $6,254), a diﬀerence of $1,653 per case. Conclusions: Indications for surgery, gender, age, BMI, EBL, length of hospital stay, and number of conversions to open were statistically similar between the groups. The diﬀerence in the length of operation was statistically signiﬁcant only in the right colectomy group. The reason for this is the completely intracorporeal anastomosis performed in a robotic right colectomy. Complications in the robot group were more numerous but not attributable to equipment. The average OR cost of robotic colectomy at our institution is $1,653 (25.5%) higher than when done laparoscopically.

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NATURAL ORIFICE SURGERY WITH A WIRELESS ENDOLUMINAL MOBILE ROBOT D. Olegnikov, M.E. Rentschler, J. Dumpert, S.R. Platt, S.M. Farritor Nebraska Medical Center, OMAHA, United States of America

APPLICATION OF ROBOTICS IN GENERAL SURGERY

In vivo robotics has evolved to provide wireless endoluminal mobile robotic capability. Such an approach provides a distinct beneﬁt compared to conventional laparoscopy where multiple entry incisions are required for tools and cameras. A miniature robot that is inserted thought the mouth would then be able to enter the abdominal cavity through a gastrotomy thereby obviating the need for any skin incisions. In this study we developed an endoluminal robot capable transgastric exploration under esophagogastroduodenoscopic (EGD) control. A miniature, wireless robot was developed and inserted into 2 anesthetized pigs. The robot has a built in camera, wheels and biopsy capability. The robot measures 15mm by 75mm and is cylindrical. Under EGD control a gastrotomy was created and the miniature robot was deployed into the abdominal cavity under remote control. The robot was able to explore the porcine organs, perform a biopsy and was then retrieved. The ability to explore the abdominal cavity though a natural oriﬁce, allows the surgeon to perform procedures without an abdominal incision. The Miniature robot was able to provide an enhanced ﬁeld of view of the abdominal cavity from multiple angles. The built in grasper was capable of obtaining a biopsy from a variety of abdominal organs. Ultimately, future procedures will include a family of robots working together inside the luminal and abdominal cavities after insertion through the esophagus. Such technology will help reduce patient trauma while providing surgical ﬂexibility.

CANCELLED

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THE LEARNING CURVE FOR ROBOTIC-ASSISTED LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS (RA-LRYGB) IS 25 PATIENTS

ROBOTIC ASSISTANCE IMPROVES INTRACORPOREAL SUTURING PERFORMANCE AND SAFETY IN THE OR WHILE DECREASING SURGEON WORKLOAD D. Stefanidis1, J.R. Korndorﬀer Jr2, F. Wang2, B.T. Heniford1, J.B. Dunne2, C. Touchard2, D.J. Scott3, T. Kuwada1 1 Carolinas Medical Center, CHARLOTTE, NC, United States of America 2 Tulane University Health Sciences Center, NEW ORLEANS, United States of America 3 University of Texas Southwestern, DALLAS, TX, United States of America

CANCELLED

Aims: Intracorporeal suturing is one of the most diﬃcult advanced laparoscopic tasks to accomplish. The aim of this study was to assess the impact of robotic assistance on novice suturing performance, safety and workload in the OR. Methods: Medical students (n=34), without prior laparoscopic suturing experience were enrolled in an IRB-approved, randomized protocol. After viewing an instructional video, subjects were tested in intracorporeal suturing on two identical live porcine Nissen fundoplication models; they placed three gastrogastric sutures using conventional laparoscopic instruments in one model and robotic assistance (da Vinci) in the other in random order. Each knot was objectively scored based on time, accuracy and security errors. Injuries to surrounding structures (i.e. liver, esophagus, etc) were recorded. Workload was assessed using the validated NASA-TLX questionnaire which measures the subjects self-reported performance, eﬀort and frustration as well as mental, physical, and temporal demands of the task. Analysis was by paired t-test; p < 0.05 was considered signiﬁcant. Results: Compared to laparoscopy, robotic assistance enabled subjects to suture faster (595 22 vs. 459 137 seconds, respectively; p<0.001), achieve higher overall scores (0 1 vs. 95 128, respectively; p<0.001) and commit fewer errors per knot (1.15 1.35 vs. 0.05 0.26, respectively; p<0.001). Overall scores did not improve between the ﬁrst and third repetition for laparoscopic suturing (0 0 vs. 0 0; p=n.s.) but improved signiﬁcantly for robotic suturing (49 100 vs. 141 152; p<0.001). The suturing task was more diﬃcult to perform with conventional laparoscopic instruments compared with robotic assistance (99 15 vs. 57 23 on NASA-TLX; p<0.001). Conclusions: Compared to standard laparoscopy, robotic assistance signiﬁcantly improves intracorporeal suturing performance and safety in the OR while decreasing workload. Moreover, the robot signiﬁcantly shortens the learning curve of this diﬃcult task. Further study is needed to assess the value of robotic assisted suturing for surgeons of variable skill and validated robotic training curricula need to be developed.

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ROUX-EN-Y GASTRIC BYPASS FOR MORBID OBESITY DONE WITH THE DA VINCI ROBOT SYSTEM: IS IT WORTH IT? J.A. Hubens, L. Balliu, M. Ruppert, B. Gypen, T. van Tran, W. Vaneerdeweg University Hospital Antwerp, EDEGEM, Belgium

ROBOTIC REPAIR OF INDIRECT INGUINAL HERNIA A. Al Dahian, O. Alobied, M. Alnaemi, M. Elegaly, M. Alsalamah King Saud University, RIYADH, Saudi Arabia

Introduction: Due to the need for anastomosing techniques, Roux -en Y gastric bypass procedure (RYGBP) for morbid obesity is still considered an advanced laparoscopic surgical procedure. The da Vinci robot system with itÕs enhanced degrees of freedom and 3D vision is theoretically designed to overcome these problems. Materials and Methods: Between october 2004 and february 2006 42 patients (11M) with a mean BMI of 42,5 (36,1–62,0) underwent a RYGBP with the da Vinci robot system for morbid obesity. Both gastrojejunostomy and enteroenterostomy were done completely handsewn. Set up times, operating times, per and postoperative complications and costs per procedure were noted. Results: Mean total operating time varied from 272 minutes in the ﬁrst 20 cases to 208 minutes in the last 22 cases. The last 10 cases were done in a mean time of 155 minutes. Total setup time remained constant at about 30 minutes. Three patients (7.1%) had to be converted to open surgery because of intestinal lacerations while bringing up the feeding loop to the gastric pouch; ﬁve more patients (12%) were converted to traditional laparoscopic surgery because of inadequate set up of the robotic arms. All these conversions occured during the ﬁrst 30 procedures. No anastomotic leaks were seen postoperatively. One patient (2.4%) required endoscopic dilatation for anastomotic stenosis. No peroperative mortality was noticed. Costs were higher than standard laparoscopic RYGBP only when additional equipment such as ultrasonic devices were used. Conclusion: RYGBP can be done safely with the da Vinci robot system with a learning curve of about 30 procedures. However larger studies are needed to recommend it as a standard procedure.

Robot is used to repair the defect of indirect inguinal hernia. The procedure is performed to 8 patients over 1 year. Three trocars are used. The defect is identiﬁed and herniotomy at the neck of the sac is performed. The roof and ﬂoor of the patent defect (deep ring defect) is approximated using synthetic non-absorpable suture. Through follow up, no recurrence was noticed. Robot has the merits of easy suturing which is used in hernia repair. The longer follow up will show the proper use of these technique.

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THE USAGE OF 3D VISUALIZATION SYSTEM DURING DIFFERENT LAPAROSCOPIC PROCEDURES I.E. Khatkov1, V.K. Agapov2, R.G. Biktimirov2, E.M. Makhonina1, T.V. Volkov1, K.V. Agapov2 1 Moscow State Medical Stomat.University, MOSCOW, Russia 2 Clinical Hospital 119 of FMBA, MOSCOW, Russia

VIRTUAL REALITY TRAINING FOR ENDOSCOPIC SURGERY; VOLUNTARY OR OBLIGATORY? K.W. van Dongen, M. Schijven, I.H.M. Borel Rinkes, I.A.M.J. Broeders UMC Utrecht, UTRECHT, The Netherlands

Objectives: To evaluate the particular features of usage of 3D visualization system during diﬀerent laparoscopic procedures. Methods: The comparison of surgeons subjective feelings with measurement of operation time is based on performing diﬀerent types of laparoscopic procedures (totally 17) by one experienced surgical team. Results: During one week usage of the 3D visualization system () one experienced in laparoscopic surgery team performed the following procedures: pelvic lymphadenectomy with radical prostatectomy and radical nephrectomy in case of prostate and renal cancer in one patient, two pyeloplastics in cases of hydronephrosis due to vasorenal conﬂict, one uretherolytotomy, four cholecystectomies, two hernioplastics, two adneksectomies, one conservative myomectomy, two total hysterectomies. Totally 17 procedures in 15 patients. There were no any intra- or postoperative complications. The mean operating time in all this patients, except one with multicentric cancer, was 54 15,2 min, which is absolutely the same to the patients with this types of operations, performed with usage of traditional laparoscopic equipment. The major simultaneous procedure, mentioned above, was performed in 7 hours with 200 ml blood loss. According to the opinion of the surgeons, the system provides better viewer of anatomical structures in operating ﬁeld. It was of the most important in preserving neuro-vascular bundles during radical prostatectomy. The level of tiredness of the team was much more lower, especially in case of major procedure. Although every member of the team underlined the necessity of adaptation for the work with the system during the ﬁrst 15 25 min. Conclusions: The usage of 3D visualization system ÔViking SystemÕ doesnÕt inﬂuence on operating time and complication level in standard laparoscopic procedures, performed by experienced surgical team. At that time the system provides better viewer of anatomical structures in operating ﬁeld and the most comfortable conditions for the surgeons, especially during long complex procedures, demanding precision technique. This can make the laparoscopic surgery much more safety.

Aim: Shortened working hours and evolution in surgical techniques are of signiﬁcant inﬂuence on the educational programs of surgical residents. Training in the operating room is under pressure, due to planning issues and the changes in ethical perspectives. Virtual reality simulators are currently developed to train basic endoscopic surgical skills outside of the operating room (O.R.). Several training programs have been evaluated adequately and transfer of skills to the OR has been demonstrated. Discussion rises how to implement these simulation based training opportunities in the surgical training curriculum. Residents claim that access to the simulators is insuﬃcient and that readily available access would be an incentive for independent training. This study was commenced to investigate voluntary skills training by surgical residents on a readily accessible VR simulator training and to evaluate the inﬂuence of stimulation on the intensity of the training. Methods: 21 residents in surgery had 24 hours access to a V.R. simulator for a period of four months. The next four months a competition was started with scores of the residents made public every second week to the complete department of surgery. The winner was awarded with a prize. Results: In the ﬁrst period of four months only two out of 21 residents (9.5%) have been training on the simulator for a total of 163 minutes. Intensive stimulation in a comparative period of time has led to the use of the simulator by 7 out of 21 residents (33.3%). Together they have been training for 738 minutes, of which 424 minutes (57.6%) during a nightshift. Discussion: Free access to a VR simulator without obligation or assessment resulted in our setting in a minimal and unsatisfactory eﬀect on the motivation of the surgical residents to improve their skills level. Stimulation by adding a competitive element had a marginal eﬀect only on the intensity of training. The acquisition of expensive devices for training basic skills for endoscopic surgery is probably only of use when the training method is an elementary component of an obligatory curriculum with assessment as the basis for progression in the individual training program.

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FROM INTERACTIVE TO AUTOMATED AUGMENTED REALITY TO IMPROVE SAFETY AND EFFICIENCY IN MINIMALLY INVASIVE GENERAL SURGERY F. Rubino, L. Soler, S. Nicolau, D. Mutter, B. Dallemagne, J. Leroy, J. Marescaux IRCAD/EITS University Louis Pasteur, STRASBOURG, France

EVALUATION OF AN ENDOSCOPE GUIDANCE ROBOT WITH OBJECT EXTRACTION METHODS

Background: Augmented Reality (AR) is the superimposition of virtual reconstructions on real images resulting in virtual transparency of structures. We recently reported the ﬁrst Interactive AR-guided laparoscopic adrenalectomy in humans, using a software developed at our Institution with manual registration of image and instrument tracking. To overcome the inherent limitations of this system such as the need for manual tracking and a user-dependent accuracy we developed a new laparoscopic guidance system to replace manual procedures with automatic model registration and tool tracking for AR. Materials and Methods: Patient model registration is achieved by using 20 radio-opaque markers stuck on the patient skin while a CT-scan is performed with the patient lying in the same position as required to carry on the surgical procedure. Two FireWire cameras are connected to a classical Pentium IV personal computer. Both internal and external anatomic landmarks are used to track structures under external and laparoscopic view. Experiments on inanimate models were performed to measure accuracy of the system whereas preliminar clinical evaluation has been performed in 2 patients undergoing laparoscopic adrenalectomy. Results: Automated tracking of patients anatomic structures and laparoscopic instruments was feasible during the initial steps of the surgical procedure (external view) as well as under laparoscopic view. The users interface of this system oﬀered a virtual transparency of all structures that had been modelled in 3 D before the operation. The experiments on inanimate models showed a fair degree of precision of the tracking system with an accuracy of 2 mm. Conclusion: Automated real time AR is feasible for abdominal operations. Potential advantages of the use of AR include the adaptation of dissection planes or resection margins and avoidance of injury to invisible structures. By enabling Ôthrough-skinÕ visualization of intra-abdominal structures AR might improve safety and eﬃcacy, while integration of AR and robotic technology may in the future allow for automation of surgical tasks.

W. Korb1, R. Grunert1, P. Liebmann1, S. Kehrt1, M. Thalheim1, M. Hofer2, C. Trantakis3, J. Meixensberger3, J. Wahrburg4, A. Dietz2, G. Strauss2 1 University Leipzig, ICCAS, LEIPZIG, Germany 2 University Hospital, Otorhinolaryngology, LEIPZIG, Germany 3 University Hospital, Neurosurgery, LEIPZIG, Germany 4 University Siegen, ZESS, SIEGEN, Germany Aims: Functional Endoscopic Sinus Surgery (FESS) is characterised by single-hand preparation and guidance of the endoscope by non-dominant hand. Surgical workﬂow analysis showed that the change of the instrument because of one-handed surgery is up to 17%. The aim of this study is the conception of an automated assistance system for FESS and to measure system properties in a realistic setup. The Siegen MODICAS-Robot-System was evaluated as an Endoscope Guidance System. The relevance of such a system was shown with surgical workﬂow analysis before. In this study the evaluation within a pre-clinical setup based on a surgical realistic environment is shown. Methods: Two experiments were performed. In the ﬁrst experiment the physician moved the endoscope to an intra-nasal target position in a force-controlled mode (FCMode). In a second experiment the robot moved automatically (Auto-Mode). In the experiments the time was measured for all the steps in the surgical procedure including the pre-operative planning of the target endoscope position. The accuracy of the ﬁnal endoscope position was evaluated with the following method: 1) mechanical measuring of the deviation in z-axis of the robot movement with a FARO-Measuring system and 2) the evaluation of the deviation in x-y-plane perpendicular to the z-axis with image processing of the endoscopic images (with object extraction methods). For step 1 a contact point was taken outside of the nose of the phantom. Results: Time needed for segmenting and planning of the target position was 15.2 minutes. Automated guidance (Auto-Mode) of the endoscope to an intranasal position needed 7.3s. The accuracy along the trajectory in z-direction was 0.26 mm and 0.12 mm in X- direction and 0.13 mm in Y- direction. Manually driven (FC-Mode) the target position was reached in 12.6 s. The accuracy was 2.49 mm in Z-direction and 0.75 mm in X- direction and 0.55 mm in Y- direction. Conclusion: The image evaluation of the endoscopic images allows a contact free evaluation of the accuracy and therefore does not inﬂuence the setting. The phantom needs not to be touched. Based on the workﬂow and the technical investigation, the clinical study should be the next step.

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INFLUENCE OF VIRTUAL REALITY SIMULATOR ON THE LEARNING CURVE IN LAPAROSCOPIC SURGERY I. Bajraktari1, A. Berghold2, S. Uranu¨s1 1 University Clinic of Surgery, GRAZ, Austria 2 Institute for Medical Informatics, GRAZ, Austria

THE OR-INTELSUN.- A ROBOTIZED SURGICAL LAMP E. Laporte1, N. Bejarano1, A. Casals2, J. Amat2, X. Giralt2, M. Frigola2 1 Hospital de Sabadell, SABADELL, Spain 2 CREB - Universitat Polite`cnica de Catalu, BARCELONA, Spain

Background: Though current literature suggests that virtual reality simulators are useful tools for learning laparoscopic skills outside the operating room, there is as yet no clear preference for a particular system. The objective of this study was to determine whether it is more advantageous to learn laparoscopic skills with a virtual reality simulator than with conventional training methods. Methods: Twenty-six medical students at the Medical University of Graz, without prior experience in laparoscopic surgery, were randomized into two groups: Lap SimOne and Pelvi Trainer. All subjects attended eight training sessions over a period of four weeks (two training sessions per week), with four weeksÕ break in between; each training session lasted 60 minutes. There were three subject assessments: after the fourth training session, before the ﬁfth training session and after the eighth training session. Assessment included time of performance and error score. Results: The subjects in both groups show no signiﬁcant diﬀerences in time of performance. There were, however, diﬀerences in time of performance between the subjects in the same group when the three evaluations were compared. Time needed to complete the task in the ﬁrst evaluation was longer then in the second evaluation and also longer in the second than in third evaluation. Conclusions: The virtual simulation appears to have a positive eﬀect as compared to conventional training methods, particularly for reﬁning laparoscopic skills.

Among the diﬀerent apparatus integrated in the OR, the surgical lamp is a fundamental element to carry out the operations with the necessary security for the patient. In some types of operations, frequent lamp displacement is needed to frame adequately the surgical ﬁeld. The design of the surgical lamp, that usually it is positioned manually, can be completely reconsidered using present technology. In cooperation with the Department of Automatic Engineering (ESAII) of the Polytechnical University of Catalonia (UPC) we developed the present proposal. The aim of this robotized lamp is to improve the surgeon comfortability as well as the task of the circulating scrub nurse optimizing the operation time. The project being developed is a multifunctional device operated either manually or through a computer program. Present prototype consists of a platform with 144 lights of LED controlled electronically, 4 cameras connected for the positioning system and a projector, for adaptation of a virtual tactile screen, without physical contact. In synthesis we are - developing an original system of intelligent illumination using new types of luminous cold source - obtaining dynamic changes in the form of direction of the luminous beams avoiding the attention of the surgeon or of the nurse - optimizing workspace using the same device of illumination to integrate the control of other new instruments of the OR - enhancing the correspondence of the space positions of determined parts of the body with images CTscan or MRI previously available (visual navigator). - facilitating the OR activity data control

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A NEW JOYSTICK INTERFACE FOR MANAGING LAPAROSCOPIC EQUIPMENT P.H. Hourlay1, R. Polet2, J. Andre´3, L.F. Ferrie`re3 1 Salvator Hospital, HASSELT, Belgium 2 St Luc Univ Hospital, BRUSSELS, Belgium 3 Medsys, GEMBLOUX, Belgium

TELECONFERENCE AND TELEMENTORING FOR LAPAROSCOPIC SURGERY USING ADVANCED RESEARCH NETWORK AND HIGH QUALITY VIDEO CONFERENCE TOOL Y-W. Kim1, K-W. Chung1, S-Y. Jeong1, J-M. Bae1, S. Shimizu2, C-H. Kang3 1 National Cancer Center, GOYANG-SI, South-Korea 2 Kyushu University, FUKUOKA, Japan 3 School of Electrical Engineering, SEOUL, Korea

In classical surgery, the surgeons two hands are working under the direct control of the surgeons eyes; in laparoscopic surgery, however, the surgeon has to sacrify either one hand to manipulate the laparoscope, either the vision control when two hands are used to hold the instruments. The development of the LapMan(c) (Medsys, Belgium) dynamic laparoscope manipulator was initiated to render the surgeon with the direct control of his two hands and vision, a feeling he lost with the introduction of the laparoscope in the surgical armentarium. The system has been validated for gynaecologic, abdominal and urological surgery. Several scientiﬁc publications have underlined the advantages of the LapMan(c) to the surgeon: stability of image (lower eye stress), direct vision control (better coordination, overall diminished stress, less scope cleaning). As it is essential for a vision control system to respond instantaneously to the surgeons command, a new ergonomic RF coded remote control system was built directly mounted on the laparoscopic instrument. Joysticks activated by the index ﬁnger command the three dimensional displacement of the laparoscope held by the LapMan(c). Pushing on the sticks initiates the move of the system; releasing it instantaneously stops the course. Directing the movements of the holder is then possible at any time, while the surgeon keeps his two hands available for working with his surgical instruments, making solo-surgery possible in several applications. Whereas the Lapstick(c) (patent pending) has been initially developed for the LapMan(c), it could be used to manage other equipments in the operating room in the future. This new, intuitive and ergonomic interface combined with the remarkable image stability provided by the Lapman(c), gives the surgeon all chances to beneﬁt from the advent of High Deﬁnition cameras and monitors in operating rooms.

Problem: The speed of development and accumulation of knowledge of medical science is geometrically increasing. To disseminate new knowledge and techniques, technology of information and communication can be useful. Transmission of high quality motion picture is essential for various medical applications of telemedicine; diagnosis, treatment, research, education, conference, second opinioning etc. which permit overcoming time restriction and geographical borders, and sharing limited number of experts in speciﬁc ﬁelds of medicine. The purpose of this study is to develop medical teleconference system by establishing a gigabit broadband network between hospitals using Digital Video Transport System (DVTS) on TCP/IP protocol. Method: The Korea Advanced Research Network (KOREN) 1 G bps network was installed to our institute. KOREN users and international gigabit research network users could connect with broadband network to communicate each other. DVTS streaming was done with 30 M bps bandwidth for two channels on IPv4 network. Audiovisual equipment was setup for echo canceling and projecting to the screen. Network security was built with virtual private network solution to guarantee protecting patientÕs privacy. Results: The teleconference and live laparoscopic surgery transmission with DVTS on Internet protocol was successfully performed. We could keep enough bandwidth of 60 Mbps for two-line transmission. The quality of the transmitted moving image had no frame loss with the rate of 30 frames per second with 720x480 pixels quality. The sound was also clear and the time delay was less than 0.3 sec. Conclusion: We have established an international medical telesurgicalconference system with 720x480 quality video transmission over internet protocol using international gigabit network. Establishing an advanced network in medical ﬁeld will not only be essential information infrastructure for advanced telemedicine, but also provide ﬁne platform of developing next generation internet technology for various applications.

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SHIFTING THE FOCUS FROM ROBOTICS TO ARTIFICIAL INTELLIGENCE; A POTENTIAL SOLUTION FOR MINIMAL ACCESS SURGERY LIMITATIONS S.M.Q. Qadri Cuschieri Skills Center, POTOMAC, United States of America

ROLAF STUDY: ROBOTIC VS. LAPAROSCOPIC FUNDOPLICATION M.A. Reiter1, J. Koeninger1, V. Bintintan2, P. Kienle1, M.W. Buechler1, C.N. Gutt1 1 University Hospital Heidelberg, HEIDELBERG, Germany 2 University of Medicine and Pharmacy, CLUJ NAPOCA, Romania

Aims: Much has been written on robotics and its application to surgery and minimal access surgery (MAS). However, there has been little, if any work providing insight about the nature and characteristics of artiﬁcial intelligence (AI). Many surgeons, with good working knowledge of robotics and even using them in their day to day practice, are not fully aware of AI to recognize its potential for development of MAS. This work attempts to ﬁll this gap, by analyzing and presenting some of the relevant aspects of AI in a way understandable to minimal access surgeons. Method: A literature search was done using Pubmed, Medline, ISI-Web of Knowledge, and other miscellaneous AI devoted resources to obtain and digest and organize the information on this diﬃcult subject. Results: AI is a versatile and complex array of concepts. Only a small and relatively simpler domain of it provided the basis for surgical robotics. In this account most of the themes pertinent to MAS are introduced to the surgeon by oﬀering brief explanations in an easily comprehended and appreciated manner. Overshadowed by information on the mechanical nature of robotics, it is not frequently realized that AI, as its name shows, could carry and incorporate all avenues of human intelligence into technical solutions of various problems faced by MAS today. Various elements and themes of AI are introduced like logical AI, searching, pattern recognition, representation, inference, common sense and reasoning, learning and experience, planning, epistemology, ontology, heuristics, and genetic programming. Conclusion: AI, as a modality on its own right, has not been well known by the surgical community. Its know-how may be beneﬁcial to the minimal access surgeon for exploring the endless possibilities it oﬀers ranging from ergonomics to training.

Aims: Accurate preparation of the gastroeosophageal junction and construction of the gastric wrap are the main reasons for unsatisfactory results after surgical treatment of gastroesophageal reﬂux disease and hiatus hernia. The da VinciTM robotic surgical system has already demonstrated a beneﬁt in speed and precision for tasks requiring high accuracy in limited working spaces. In a randomized, double blinded study conventional laparoscopic Nissen fundoplication has been compared with the robot-assisted procedure in terms of peri-operative outcome and long-term results. Methods: Two groups of 20 patients each were formed: a conventional laparoscopic and a robotic group. The former included 8 female and 12 male patients with an average age of 51 years compared with 10 female and 10 male patients with an average age of 58 years in the latter group. A set of surgical and non-surgical parameters such as frequency of various complications, mean duration of the procedure, postoperative hospital stay, regression of esophagitis and of disease-related symptoms were analyzed. The postoperative quality of life was assessed using standardized Ôquality of life measurement toolsÕ with follow-up at 1, 3, 6, and 12 months after the operation. Results: The mean overall operative time was 102 min in the conventional group vs. 88 min in the robotic group. These ﬁgures include an average set-up time of 20 vs. 23 min respectively. There were no conversions or re-operations in either group. Only minor complications were encountered: two cases of minor bleedings in the conventional group and one pneumothorax in the robotic group. Hospital stay averaged 3.5 vs. 2.8 respectively. Postoperative dysphagia persisted in two conventional and one robotic case and was managed conservatively. So far, reﬂux control was suﬃcient in all patients. Long-term follow up will be ﬁnished in August 2006. Conclusion: The only signiﬁcant diﬀerence between the two approaches was the shorter eﬀective operative time in the robotic group. The da VinciTM robotic system has the potential to improve further the already excellent results obtained by conventional laparoscopy by oﬀering more accurate dissection and quicker suturing in small and remote areas.

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ROBOTIC VERSUS HUMAN THORACOSCOPIC CAMERA CONTROL: A RANDOMIZED COMPARISON S. Okada, S. Takamori, S. Ishimori, M. Ishigami, H. Watanabe Chiba Tokushukai Hospital, FUNABASHI, Japan

LAPAROSCOPIC VIRTUAL REALITY SIMULATOR TRAINING LEADS TO A SHORTENING OF THE LEARNING CURVE ON REAL CASES R. Aggarwal, J. Ward, I. Balasundaram, A. Darzi Imperial College London, LONDON, United Kingdom

Background: Several robotic systems have been introduced to enhance the eﬃciency of the operative procedure and diminish costs and human resource utilization during surgery. However, there is no conclusive evidence of beneﬁt of the use of robot in thoracoscopic surgery. Methods: We have compared the results of voice-controlled robot assisted single-surgeon thoracoscopic (robotic group) and conventional thoracoscopic surgery (human assistant group). Results: 120 patients were recruited. Demographic features were similar. All procedures were completed by only one surgeon in the robotic group. The mean number of times of that the thoracoscope was removed from the thoracic cavity to clean the tip was statistically for the human assistance (p<0.05). There were no signiﬁcant diﬀerences between the two groups in operation time, setup time, break down time, the weight of resected lung, the amount of blood loss, conversion rate to open thoracotomy, analgesic requirement, hospital stay, or hospital mortality. There were no major intraoperative complications in either group. No notable complications were associated with the use of the robot during the follow-up period. Conclusions: We conclude that a voice-controlled robotic arm as a substitute for a surgical assistant in thoracoscopic surgery is feasible and safe in experienced hands.

Introduction: It is now generally accepted for technical skills training to commence in the skills laboratory on simulated tissues. The aim is to reduce the length of the learning curve on real cases, which should lead to improved patient safety. Though simulator-based training has been shown to transfer to improved performance in the operating room, there have been no studies to date to analyse the persistence of this eﬀect over time. The aim of this study was to assess the degree to which completion of a proﬁciencybased virtual reality (VR) training curriculum improves ongoing performance, when compared with traditional modes of training. Methods: 20 novice laparoscopic surgeons were recruited to the study. All subjects underwent a baseline test of basic laparoscopic skill on a video-box trainer, followed by a half-day didactic session on laparoscopic techniques. Subjects were then equally and randomly divided into two groups: group A each completed ﬁve cadaveric porcine laparoscopic cholecystectomies (LCs) on a video-box trainer over a period of two weeks; group B completed a proﬁciency-based VR training curriculum on a laparoscopic simulator and then performed three cadaveric porcine LCs each. Assessment of laparoscopic technical skill on the LCs was by a validated motion analysis device which derives parameters of time taken, path length and number of movements, and video-based global rating scores (out of 35). Results: There were no baseline diﬀerences in laparoscopic skill between the two groups. There were signiﬁcant diﬀerences in performance on the ﬁrst LC between groups A and B for time taken (median 4590 vs. 2165 secs, p=0.038), total path length (169.2 vs. 86.8 metres, p=0.001), total number of movements (2446 vs. 1029, p=0.009) and video rating scores (10 vs 22, p=0.009). The two groups achieved equivalence of performance at the ﬁfth (group A) and third (group B) LCs for all parameters. Conclusions: A proﬁciency-based VR training curriculum leads to a shortening of the learning curve on real laparoscopic procedures when compared to traditional training methods. This is a more cost and timeeﬃcient approach, and strongly supports the need for simulator-based training to be integrated as a part of standard practice.

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PANCREATIC COMPLICATIONS OF LAPAROSCOPIC SPLENECTOMY A.M. Tsigelnik, A.A. Shapcin, A.G. Vertkov Kemerovo Regional Hospital, KEMEROVO, Russia

DIFFERENT METHODS OF DISSECTION DURING LAPAROSCOPIC SPLENECTOMY R. Gelmini1, F. Romano2, A. Andreotti1, R. Caprotti2, C. Franzoni1, A. Scaini2, M. Saviano1, F. Uggeri2 1 Policlinico di Modena, MODENA, Italy 2 San Gerardo Hospital, MONZA, Italy

Laparoscopic splenectomy (LS) is a standard of care for the removal of the spleen in hematologic disorders. However, the incidence of a postoperative pancreatitis, remains poorly understood. This complication is related with peculiarity of relationships between pancreas and spleen. It is supposed that risk of pancreatitis following LS is underestimated. Aim: The aim was to investigate the true incidence of the postoperative pancreatitis following LS. Methods: The 44 patients with hematologic disorders who underwent laparoscopic splenectomy at our institution were included. The size of spleen varied from 11 to 30cm. All patients underwent elective LS, using lateral approach. Spleen attachments were dissected, using electrocautery, hilar vessels were divided by clips. A blood amylase level was tested in12 hours after surgery. On postoperative day 3 all patients underwent ultrasound scans of pancreas, subphrenic space and a left pleural cavity, added in some cases by computed tomography (CT). Results: All operations were completed without conversions. 14 patients had a moderately elevated blood amylase level. In all cases the amylase level became normal during next 24 hours. Ultrasonography of subphrenic space and left pleural cavity in 24 – 48 hours after the LS pointed out that 9 patients had little postoperative ﬂuid in a spleen bed. In 7 cases ﬂuid collections resolved spontaneously, but in 2 transformed in abscesses. CT demonstrated that ﬂuid collections were in a close connection to a pancreatic tail. Ultrasonography guided percutaneous drainage was performed and pus with little steatonecrosis were evacuated. There was no mortality. Conclusion: temporaly amylasemia and local interstitial postoperative pancreatitis are results of a contact or traction of a pancreatic tail during splenectomy. Added by electrocautery injury it supposed to be the reason of local parapancreatitis and deep abscesses.

Background: Laparoscopic splenectomy (LS) is considered the gold standard for the treatment of hematologic disease of the spleen. Intraoperative bleeding is the main complication and main cause of conversion during laparoscopic splenectomy. Splenic and hilar dissection are sometimes difﬁcult and diﬀerent technologies have been applied to achieve it. We here present our experience with 110 LS using two diﬀerent instruments for spleen dissection and hilar vascular control . Methods: We have performed a total of 110 LS in nine years period in two aﬃliated University Hospitals. There were 50 males and 60 females (median age 34 yrs) and we employed a 4 trocars technique with right semilateral position. Indications were as follows: 41 thrombocytopenic idiopatic purpura (ITP), 30 hereditary spherocytosis, 9 ? talassemia, 25 Limphoma, 2 leukemia and 3 splenic cysts. Associated procedure were present in 32 cases (28 cholecystectomy and four liver/lymphnodal biopsies). Patiens were divided in two group according with method of dissection and hilar section (group 1 Endostapler + electrocoagulation 40 pts; group 2 Ligasure vessel sealing system 70 pts). Results: Groups were well matched according to age, indications, spleen sizes, procedures associated. Conversion rates (10 cases, 9%, ﬁve in each group), postoperative hospital stay (median 4 days in each group), intra and postoperative complications were similar in the 2 groups without mortality in each group, while intraoperative blood loss (less of 100 ml in 55 patient of group 2, 78%, and in 21 of group 1, 52%), transfusion rates (8 pts in group 1 versus 4 in group 2) and operative mean time (150 min in group 1 versus 125 min in group 2) were less in the Ligasure vessel sealing device group. Conclusions: The approach to spleen dissection and hilum section was safe and eﬃcacy in each case otherwise the use of LigasureTM results in a gain of time. Furthermore the average intraoperative bleeding of this series is lower in group 2.

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LAPAROSCOPIC SPLENECTOMY BY EXTENSIVE HILAR DISSECTION M. Talebpour, G. Toogeh Tehran Medical University, TEHRAN, Iran

ORGAN PRESERVING LAPAROSCOPIC SURGERY OF THE SPLEEN K. Peitgen Knappschaftskrankenhaus Bottrop, BOTTROP, Germany

Aim: To assess the safety and clinical outcome of laparoscopic splenectomy with extensive hilar dissection and intracorporeal suturing or clips ligation of vessels; a cost beneﬁt technique especially in third world countries. Method: All consecutive patients referred for laparoscopic splenectomy to a tertiary centre were included in this study. Open splenectomy was carried out on those with huge splenomegaly. Patients were positioned at 60 degrees semi-supine. Exploration of upper abdomen was carried out routinely for presence of accessory spleen. Extensive dissection of the main vessels as an important part of this study to prevent any pancreatic trauma or incomplete homeostasis performed. Homeostasis of vessels performed by intracorporeal suturing routinely and in some conditions by clips. Spleen put in a bag after emptying of its blood by cutting hilar vein and removed from bag by splitting. Results: During 30 months 48 laparoscopic splenectomies were performed; 43 ITP, 2 spherocytosis with gallstone and 3 moderate splenomegaly with hypersplenism. Mean splenic size was 11.5 x 6.3 x 4.3 cm, with the biggest spleen measured at 30 x 12 x 9 cm. Splenic vessels were tied using intracorporeal suturing (30 cases) or clips (17 cases). There was one case of conversion to open surgery. Four cases of ITP did not respond ideally to splenectomy. In cases of moderate splenomegaly, spleen was divided into 2 or 3 parts prior to use of bag. Mean eﬀective operative time was 60.72 min; and mean length of hospital stay was 3.7 days. All patients discharged from hospital without any morbidity. One 71 years old patient died due to emboli 10 days after operation. Conclusion: Laparoscopic splenectomy by this method; even in cases with moderate splenomegaly is safe, with good patient outcome and without any complications about trauma to the tail of pancreas or incomplete homeostasis. The cost of this technique is lower comparing to traditional technique saving about 800 $ in each case.

Introduction: Laparoscopic splenectomy has become a minimally invasive standard procedure with widely accepted indications. Only few reports exist concerning organ preserving laparoscopic surgery of the spleen. We report on our methods and results with laparoscopic splenic cyst unrooﬁng, splenopexy for wandering spleen, splenic partial resection and resection of multiple accessory spleens and selective accessory spleen preservation. Methods and patients: From 3/1994 to 5/2006, splenectomies were performed in 147 patients whereas organ preserving procedures were performed in 22 patients including splenic cyst unrooﬁng (n=14), splenic resections (n=4), splenopexy for wandering spleen (n=2), accessory spleen resection for multiple accessory spleen syndrome (n=1), splenectomy with selective accessory spleen preservation (n=1). Results: Procedure time was signiﬁcantly shorter in organ preserving procedures compared to splenectomies (65 44[45–120min.] vs. 10741[50– 185min.]). No perioperative complications occurred in organ preserving surgery, in the splenectomy group, perioperative complication rate was 6%, respectively. No transfusions were necessary in organ preserving procedures compared to 7% in the splenectomy group. Discussion: Organ preserving laparoscopic splenic surgery is safe and feasible and represents a valuable option for patients with selected benign and malignant splenic pathology.

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MINIMALLY INVASIVE SPLENECTOMY IN THE MANAGEMENT OF MYELOFIBROSIS A. Savelli1, R.N. Berindoague2, P. Torelli1, E. Targarona2, C. Balague2, S. Vela2, C. Martinez2, P. Hernandez2, M. Casaccia1, B. Troilo1, M. Folch2 1 Institute San Martino, GENOVA, Italy 2 Hospital Sant Pau, BARCELONA, Spain

LONG TERM FOLLOW-UP AFTER LAPAROSCOPIC SPLENECTOMY FOR ITP I. Nachmany1, S. Gruner1, A. Keidar2, G. Lahat1, A. Szold1 1 Tel Aviv Sourasky Medical Center, TEL AVIV, Israel 2 Hadassah, JERUSALEM, Israel

Background: Idiophatic myeloﬁbrosis is a rare disease for which a speciﬁc therapy is unknown, generally attending a course with massive splenomegaly. Splenectomy is indicated in patients who present massive and symptomatic splenomegaly. Despite the diﬃculty, minimally invasive techniques have shown that an enlarged spleen can be managed successfully, with a quicker and safer recovery, and a reduction in pulmonary and infectious complications. Methods: Forty-one minimally invasive splenectomies were performed in two institutions in patients with idiophatic myeloﬁbrosis. The surgical technique was chosen according the spleen size and the preference of the surgeon: Minimal Access Splenectomy (MAS) through a small incision up to 14 cm or a Laparoscopic Splenectomy (LS). Result: Minimal Access Splenectomy (MAS) was performed in 26 patients (63%). The median of splenic longitudinal diameters was 27 cm and median operating time 100 min. Two patients (7%) developed major complications (pleuric collection, hemoperitoneum), one of them reoperated. Two patients (7%) deceased for blastic crisis. The median postoperative hospitalization was 7 days. Laparoscopic Splenectomy (LS) was realized in 15 patients (37%). Four of these submitted to Hand-Assisted procedure (HA) and 11 patients submitted to Pure Laparoscopic Splenectomy (PLS). The median of longitudinal diameters was 24 cm (26 for HA and 23 for PLS) and the median operating time was 155 min (200 min. HA and 120 min. PLS). Conversion to open surgery was made in one patient (6%) of PLS technique. Three patients (20%) developed major complications (pleuric collection, hemoperitoneum, pancreatic lesion) being two patients (13%) reoperated. One patient (6%) deceased for blastic crisis. The median postoperative hospitalization was 5 days. Conclusion: The using of minimally invasive techniques in patients with splenomegaly due myeloﬁbrosis is safe, with low index of morbidity and mortality even in patients with bad general clinical conditions. These good results depending of a complete evaluation of the patient, of the splenic dimensions, the choice of the best surgical approach and the experience of the surgeon.

Aims: Idiopathic thrombocytopenic purpura (ITP) is the most common indication for elective splenectomy. Since 1995 we have performed over 150 laparoscopic splenectomies (LS) for drug resistant or steroid-dependant ITP. Several groups, including our own, have reported a follow-up of 20 to 43 month, but the long-term outcome of these patients, is unclear. Our early follow-up of 110 consecutive patients, after three years, showed a very high response rate, with 84% of patients achieving normal platelet counts and no bleeding events. Other hematologic complications, such as hypercoagulable state, were not reported. We are presenting the long-term follow-up after LS for ITP. Methods: Retrospective cohort study that was conducted in a tertiary care university-aﬃliated medical center and included 32 patients. Results: 32 patients (22 females; 10 males) were followed for 69 to 141 month (average 106 month [8.8 years]). After more then 8 years, 30 patients (94%) have a normal platelet count (> 150 X 109/L) of whom 26 (81%) are free of treatment. 6 patients (19%) are dependant on medical treatment. One patient, with a platelet count of less then 5 x 109/L, suﬀered from recurrent epistaxis occurrences. Since the operation, no patient suﬀered a signiﬁcant infectious disease, which could be related to the post-splenectomy state. 5 patients (16%) suﬀered a signiﬁcant medical condition, associated with arterial hypercoagulable state, such as TIA or non-hemorrhagic CVA (3 patients; 4 events) and Myocardial Infarction. Those patients do not suﬀer from thrombocytosis. Conclusions: Laparoscopic splenectomy for chronic ITP achieves good results in terms of platelet counts and bleeding events. In the long run, however, splenectomy in ITP patients may confer a hypercoagulable state.

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PARALLEL OCCLUDING CONDUCTIVE HEATING (POCH) VESSEL SEALER, AN INITNITIAL STUDY D.A.G. Reyes1, A. Cuschieri2, S.I. Brown2, C. Song2, L. Cochrane2 1 University of Dundee, DUNDEE, SCOTLAND, United Kingdom 2 Ninewells Hospital and Medical School, DUNDEE, SCOTLAND, United Kingdom

3-D-PICTURE-IN-3-D-PICTURE: A NOVEL MULTI-APPLICATION SURGICAL TECHNOLOGY E.J. Hanly, B.C. Herman, N.S. Schenkman, R.H. Taylor, M.A. Talamini, M.R. Marohn Johns Hopkins University, SAN DIEGO, United States of America

The growth of minimal access surgery (MAS) has been brought about by the application and the need for new technologies in surgery. This has resulted in new techniques for tissue apposition and sealing. Tissue welding is being developed to address the surgical needs imposed by the MAS approach. The present study was designed to determine the optimal variables for tissue welding. Temperature, apposition force and clamping time were tested in a vessel sealing model. A parallel occluding conductive heating (POCH) vessel sealer was constructed. The POCH jaws seal vessels by the application of heat and pressure simultaneously. The quality of vessel seals was assessed by determining the bursting pressure of seals created. Associated tissue damage was predicted by ﬁnite element analysis and compared with thermographic studies. Histologic sections were taken to validate both the mathematical model and results of thermography. Statistical analysis was carried out with a Bonferroni analysis of variance. The results revealed the optimal apposition force and clamp time. The variables exhibited positive interaction in pairs and collectively at p-values< 0.0001. Optimal conditions determined in this study can be applied in the ﬁnal design of a novel vessel sealer using conductive heating.

Introduction: The widespread adoption of videoendoscopic techniques has fundamentally changed surgery as the surgeons view of the operative ﬁeld is now digitized and remotely displayed. While this paradigm shift creates unique challenges for the modern surgeon, it also provides an ideal opportunity to design and implement augmented reality systems for surgery. Methods: We created a computer system that manipulates multiple video streams enabling augmented reality stereoscopic output. The system consists of a high-end desktop computer running Linux, conﬁgured with software written in C++ that utilizes object-oriented paradigms to create a command and control console that manipulates multiple video streams enabling stereoscopic output. The system was tested with multiple applications on the daVinci Surgical Systems 3-D visualization platform. We then produced a proof-of-concept 3-D instructional video that teaches basic robotic suturing technique. Results: Our system enables a picture-in-picture window that can be moved to any plane of depth in or behind the operative ﬁeld of view. All visually represented data can be displayed in this window including, intra-operative ultrasound imaging, wide-angle camera view, real-time patient physiologic data, and even 3-D imaging such as our instructional video or 3-D reconstructed radiographic data (3-D ultrasound, 3-D computed tomography, etc.). Conclusions: 3-D-picture-in-3-D-picture allows surgeons operating with a stereoscopic view of the operative ﬁeld to view clinically relevant 3-D data while maintaining visual contact with the operative ﬁeld. Proper image registration will allow overlay of 3-D radiographic data on the operative ﬁeld. Our augmented reality system allows the modern videoendoscopic surgeon operating in a stereoscopic environment to view simultaneously all pertinent information in a single stereoscopic display.

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COMBINED LAPAROSCOPIC GASTRIC BANDING AND STOMACH REDUCTION FOR SUPER OBESE PATIENTS UNLIKELY TO BENEFIT FROM GASTRIC BANDING OR SLEEVE RESECTION ALONE E. Frezza, M.S. Wachtel Texas Tech University Health Sciences Ce, LUBBOCK, United States of America

THE EXCALIBUR FORCEPS, WITH A NEW REVOLUTIONARY HANDLE K. Uchida1, T. Naitoh2, K. Kasama3, E. Kanahira3, N. Haruta1, M. Okajima4, M. Yamamoto5 1 Takanobashi Central Hospital, HIROSHIMA, Japan 2 Sendai Open Hospital, SENDAI, Japan 3 Yotsuya Medical Cube, TOKYO, Japan 4 Hiroshima University, HIROSHIMA, Japan 5 Adachi Kyousai Hospital, TOKYO, Japan

Aims: The obesity epidemic has yielded a harvest of bariatric procedures. Laparoscopic gastric banding (LGB) was thought to be the perfect procedure because it did not require cutting and sewing of intestinal parts, but excess weight loss only averages 45% at 18 months. For the super-obese, a 45% reduction is likely to be insuﬃcient to control comorbidities, meaning that a second procedure would be required. Another minimally-invasive, low morbidity procedure, sleeve gastrectomy (SG) has mainly served as a ﬁrst step before gastric bypass or biliopancreatic diversion. To preclude the need for a second operation, we combined into a single operation laparoscopic gastric banding and sleeve (restrictive) gastrectomy (GBSR). The initial successful results of patients who underwent this new procedure are reported. Methods: A retrospective evaluation of ten patients was performed after IRB approval with six months followup. LGB and SG were combined in GBSR. Results: One man and nine women, with a median BMI of 66.5 kg/m2 (range 64–79 kg/m2) and multiple serious comorbidities, underwent GBSR without complications. At six months, BMI decreased by a median 38% (range 34%–42%). Conclusion: Based on our initial experience, GBSR should be further studied as a procedure for super obese patients who are unlikely to suﬃciently beneﬁt from either laparoscopic sleeve gastrectomy or adjustable gastric banding alone and is safe in the superobese (BMI > 55) avoiding complications secondary to anastomosis.

Laparoscopic knot tying is probably the most indispensable and stressful technique employed during laparoscopic surgery. As such, many instruments have been developed to assist in laparoscopic surgery. We developed a laparoscopic needle holder, called the Excalibur. The Excalibur diﬀers from most conventional forceps in that the hinge is designed to stick out. The suture is hooked on the projected hinge, where it is controlled with ease. The knotted loop is secured around the forceps by hooking the thread with both hinge and opposed jaw. By manipulating the suture in this way, touch conﬁrmations are automatically performed. The hinge is stored out of the way when the forceps are closed, preventing the thread accidentally catching. The Excalibur is especially useful when tying knots in limited spaces or when both pairs of forceps are at an acute angle. The Excalibur was further reﬁned with the addition of a new ergonomic handle, with a gyro handle grip and recoilless ratchet. The gyro handle grip is designed to ﬁt neatly into the thenar eminence, helping relieve hand and arm fatigue during use. It also stabilizes forearm rotation when performing precise laparoscopic suturing. The recoilless ratchet can be released with minimal action, from the thumb alone. These innovations bring to the Excalibur not only easy control of the thread, but also fatigueless manipulation and precise tissue approximations.

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THE HARMONIC ACE SCALPEL TO TRANSECT AND LIGATE CYSTIC DUCTS IN A PORCINE BILIARY MODEL R.A. Pierce, J.A. Perrone, N. Gangopadhyay, V.J. Halpin, M. Brunt, C. Eagon, M.M. Frisella, B.D. Matthews Washington University School of Medicine, SAINT LOUIS, United States of America

SEEING THE HEAT - DEVELOPMENT AND EVALUATION OF AN INFRARED ENDOSCOPE C. Song1, B. Tang2, F. Carter2, T. Frank1, C. Campbell1, W. Sibbett3, A. Cuschieri2 1 University of Dundee, Ninewells Hospital, DUNDEE, United Kingdom 2 University of Dundee, DUNDEE, United Kingdom 3 Univ.of St. Andrews, Physics & Astronomy, United Kingdom

Introduction: Energy sources have facilited laparoscopic surgery by providing eﬃcient and reliable control of vascular pedicles although the utility of these devices on bile ducts has not been established. The purpose of this study is to evaluate the eﬀectiveness of a novel, new generation ultrasonic coagulator, the Harmonic ACE Scalpel, to transect and ligate cystic ducts to determine its eﬃcacy in biliary surgery. Methods: After Institutional approval, 18 domestic female pigs were randomized into two groups: Group I (n=12), laparoscopic cystic duct transection/ligation with clips (n=6) or the Harmonic ACE Scalpel (n=6) and Group II (n=6), laparoscopic cystic duct transection/ligation with clips (n=3) or the Harmonic ACE Scalpel (n=3) after common bile duct ligation with clips to simulate biliary obstruction. Group I was sacriﬁced on POD #21 and the cystic ducts were harvested for burst pressure testing (mmHg). Group II was sacriﬁced on POD #6 due to morbidity of prolonged biliary obstruction. Statistical diﬀerences (p value < 0.05) were measured using a two-tailed t-test Results: No cystic duct stump leaks occurred in Groups I or II. The mean maximum pressure exerted on the cystic ducts was 1028 mmHg 562 for clips and 887 mmHg 32 for the Harmonic ACE Scalpel (p = ns) without stump failure. Conclusions: The Harmonic ACE Scalpel is an eﬀective technology to ligate and transect cystic ducts in a porcine model of laparoscopic cholecystectomy with and without biliary obstruction. The utility of the Harmonic ACE Scalpel for laparoscopic biliary and/or hepatic surgery remains investigational.

Aims: A novel infrared endoscope has been developed and constructed to investigate the thermal collateral damage to tissues during energy-assisted laparoscopic surgery. Methods: The infrared endoscopic system consisted of an endoscope measuring 10mm in diameter and 300mm in length. Within the endoscope, there are three Hopkins relays and objective lens made of Germanium, which has excellent transmission of infrared light in 3–5 micro meter. The endoscope is directly coupled to a state-of-the-art thermal camera Cedip Jade, which has a 320 by 240 pixels focal plane array, and is sensitive to temperature gradations as small as 0.02 degree C. The system was set up with an endoscopic surgery training box (simulator) that incorporates artiﬁcially perfused tissues with the aim of detecting key vessels that requires ligation during the course of various operations. The LigaSure vessel sealing system was used with three diﬀerent interchangeable heads. In situ dynamic thermography was undertaken with the Cedip infrared camera, digital images and movies were recorded for advanced thermal analysis by imaging processing software. Results: The infrared endoscope had an excellent thermal resolution that can identify a warm blood vessel at 1m distance with a minor temperature diﬀerence of 0.1 degree C, it also has the ability to distinguish diﬀerent tissue types by detecting their respective temperature diﬀerences. During the energized coagulation experiments, thermographic measurement showed that the average thermal spread with the LigaSure LS1000 10mm device on liver and short gastric tissues was 4.4mm, and even the exposed surface of the instrument tip developed a temperature of approximately 100 degree C. The more technologically advanced LS1100 10mm laparoscopic instrument exhibited a superior performance with only 1.8mm thermal spread and with a maximal temperature on the jaws well within tolerable limit 35C during surgery. Conclusions: It is proved that infrared endoscope is a very useful adjunct to conventional visible endoscopy, particularly for the detection of key vessels and monitoring energized dissection/coagulation during laparoscopic surgery.

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ENDO-LAP OR: AN INNOVATIVE ÔMINIMALLY INVASIVE SURGERY THEATREÕ DESIGN M.K.W. Li PYN Eastern Hospital, HONG KONG, Hongkong

LAPAROSCOPIC PARTIAL GASTRECTOMY BY A NEWLY DEVELOPED LESION-LIFTING PROCEDURE USING A MUCOSANONDAMAGING, DIRECTIONAL, POTENT MICROMAGNETIC CLIP T. Ohdaira, H. Nagai Jichi Medical University, TOCHIGI-KEN, Japan

Background: A newly constructed Endoscopic-Laparoscopic operating room (Endo-lap OR) started to operate in our department since January 2005. A prospective study was conducted to evaluate its feasibility, eﬃcacy, safety and staﬀÕs satisfaction. Patients and Method: From January 2005 to September 2005, all patients with operation done in this Endo-Lap OR were included in the study. PatientÕs diagnosis, types of operating procedures, incidents of operating failure (either due to the hardware or the software of Endo-Lap OR) that leading to delay in patientÕs transfer or total operating time were recorded. In addition, questionnaires regarding the satisfaction of the new theatre were distributed to nursing staﬀs, anesthetists and surgeons. Result: A total of 640 cases were operated in the study period. There were 245 cases of open surgery, 282 cases of laparoscopic surgery, 82 cases of endoscopic surgery, 17 cases of video-assisted thoracoscopic surgery and 14 cases of combined endoscopic-laparoscopic surgery. There were no reported incidents of operating failure due to hardware or software problem. The overall satisfaction grading was excellent. Conclusion: The integration of endoscopic and laparoscopic surgery in this newly constructed Endo-Lap OR is feasible and safe. The running of the theatre was smooth and it gains high acceptance and satisfaction from diﬀerent staﬀs. Key words: Minimal Invasive Surgery - Laparoscopy - Endoscopy Operating Room

Background: It is diﬃcult to detect an early-stage cancer from the gastric wall serosal surface during laparoscopic gastrectomy. However, it is necessary to resect the stomach while constantly detecting the site of lesion. We succeeded in the development of a laparoscopic, lesion-lifting procedure using a newly developed micromagnetic marking clip with special magnetic directivity. This new type of magnetic microclip allows gastric resection while easily detecting the site of early-stage cancer and constantly chasing the site according to a marking clip-detecting and -chasing system (MCDCS). Methods: Preoperative gastroscopy was conducted to place a micromagnetic clip to the lesion periphery, and a stick-like device, which easily allows the change in tip magnetic ﬂux density, was used to conduct gastrectomy by lesion lifting during surgery. The prototype lesion-grasping magnetic clip for MCDCS was incapable of passing through the forceps hole of an endoscope. However, a micromagnetic body which we developed this time can easily pass through the forceps hole of an endoscope. Furthermore, the micromagnetic clip was designed and magnetized in such a manner to be endowed with special directivity to emit magnetic traction force in a direction which constantly does not damage the gastric mucosal surface. Results: The marking site was detected in 15 patients in a clinical study which used the prototype micromagnetic body. The mean length between the detection site and the clip along the longitudinal axis of greater curvature was 11.5 mm (SD: 8.4). The mean detection time was 16.2 sec (SD: 5.6). The micromagnetic body for MCDCS, which we developed this time, demonstrated its striking easiness for marking and its nondamaging activity on the gastric mucosa. Conclusion: A lesion-lifting procedure, which uses a mucosa-nondamaging, potent, micromagnetic clip and MCDCS, was suggested to possibly provide safety, eﬀectiveness, and simplicity in laparoscopic partial gastrectomy.

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3D NAVIGATION IN LAPAROSCOPIC SURGERY T. Langø1, G.A. Tangen1, B. Ystgaard2, Y. Yavuz3, J.H. Kaspersen1, A. Wolf1, O.V. Solberg1, T.A. Nagelhus Hernes1, R. Ma˚rvik3 1 SINTEF Health Research, TRONDHEIM, Norway 2 St. Olavs Hospital, University Hospital, TRONDHEIM, Norway 3 National Center for Advanced Lap. Surg., TRONDHEIM, Norway

EVALUATION OF THE LIGASURE SEALING DEVICE FOR CLOSURE OF MESENTERIC DEFECTS IN LAPAROSCOPIC SURGERY S. Sereno, A. Forgione, J. Leroy, D. Mutter, M. Simone, C. Bailey, B. Dallemagne, J. Marescaux IRCAD-EITS / University Louis Pasteur, STRASBOURG, France

In laparoscopic surgery the surgeon has to rely on endoscopic camera visualization without haptic feedback. This might limit the usefulness of laparoscopy. Material & Methods: To counteract this we have developed a navigation system based on 3D preoperatively acquired magnetic resonance (MR) images or x-ray computed tomography (CT) data sets. This provides the surgeon with an overview of structures beneath the surface of organs not visible with conventional endoscope visualization. We have attached a tracking device on the video-laparoscope that allows the surgeon to have interactive visualization of preoperative data based on the position and orientation of the video-laparoscope during the procedure. Fiducials were attached to the patients prior to MR/CT imaging. The patients were registered on the operating table and the images were displayed using our own visualization and navigation software. We believe abdominal 3D image navigation using the video-laparoscope as an interactive navigation pointer is feasible and beneﬁcial in laparoscopic surgery. In particular, this system is useful where vessels and anatomical relations might be diﬃcult to identify using the video-laparoscope only.

Aims: Closure of mesenteric defects is recommended after laparoscopic bowel surgery but it is technically demanding and time consuming. We aim to study the eﬃcacy of a 5 mm Ligasure sealing device (5mm-LD) to close defects and compare this with suturing and stapling. Methods: Four mesenteric defects were created laparoscopically in 6 pigs. Defects were closed by sealing (2–3 applications of 5mm-LD), running suture (polypropylene), or staples (Endopath, Ethicon). Timing was measured for each technique. Mechanical resistance of the mesenteric scar tissue was evaluated at 30 days by applying 1 kg traction. Samples from the scar were sent for pathological examination. Results: All defects were securely closed apart from one that had been closed using staples. The mean time for sealing and stapling were 1.95 minutes (range 1.4–3.03 mins) and 2.1 minutes (1,6–3,1) respectively, and they were signiﬁcantly quicker than the mean time for suturing which was (2.93–6.98), (p<0.05, Student T test). Pathological examination found no diﬀerence in ﬁbroblast inﬁltrate and ﬁbrosis between techniques, and all scars showed the same resistance to traction. Conclusion: Ligasure application is faster than suturing and seems to be more eﬃcient than stapling. It has the same strength and scar characteristics as conventional suturing methods. It may be considered a valuable tool for the closure of mesenteric defects compared with other methods.

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FUTURE OPERATING ROOM IN TRONDHEIM T. Langø1, B. Ystgaard2, Y. Yavuz3, J.H. Kaspersen1, G.A. Tangen1, T.A. Nagelhus Hernes1, R. Ma˚rvik3 1 SINTEF Health Research, TRONDHEIM, Norway 2 St. Olavs Hospital, University Hospital, TRONDHEIM, Norway 3 National Center for Advanced Lap. Surg., TRONDHEIM, Norway

WEBSURG ON HANDHELD DEVICES: A REVOLUTION IN THE POCKET, TOWARDS BRAND-NEW CONCEPTS OF WIRELESS EDUCATION AND PODCASTING EDUCATION IN MINIMAL ACCESS SURGERY A. Forgione, T. Parent, D. Mutter, G. Temporal, C. Bailey, M. Vix, M. Simone, B. Dallemagne, J. Marescaux EITS-IRCAD / University Louis Pasteur, STRASBOURG, France

With the challenges that the health sector now faces in accordance to readjustments and demands for increased eﬃciency, resource utilization and innovation, we have initiated a project to develop the future operating rooms for advanced laparoscopic surgery and endovascular treatment. To share experiences and avoid re-conducting the same mistakes as others, we ﬁnd it suitable to build operation theatres for research and development where we can try out and study new equipment, logistics and communications, operation forms and new technology which both beneﬁt the establishment of the hospital and the establishment of other hospitals and laparoscopic operating rooms nationally and internationally. The main goals in the project are, through research and development to reveal information and develop technology and methods to establish a more eﬃcient and prospective patient treatment, focused on quality. Furthermore, the new ORs are focused on education and training through an interactive integrated surgical auditorium. The project is deeply rooted in the established research environment in Trondheim. The goal is also that this will result in the establishment of new industry. Examples from ongoing research activities and projects related to the OR for laparoscopic surgery will be shown in the presentation.

Background: The spread of Internet use marks a profound change in the development of continuing medical education. Even though the Internet is accessible worldwide, computer access is felt as restrictive. However, recent developments in high-speed wireless Internet and podcasting oﬀer the possibility of getting remote access to web-based educational websites without any time or space constraints merely using cell phones, personal digital assistants (PDAs), or portable digital media players (iPods). This study has been conducted to test and evaluate the possibilities of broadcasting of WeBSurg.com, http://www.websurg.com, a website dedicated to surgical education, and of viewing surgical videos on lightweight wireless PDAs and digital podcasts. Materials and methods: The educational website WeBSurg.com has been used as a working base. Its multimedia scientiﬁc contents were broadcast on commercially available diﬀerent PDAs: Palm pilots, pocket PCs, smart phones (Qtek9000). Videos experimentally hosted on WeBSurg were downloaded on iPod generation 5 (30 GB hard disk drive). Results: Wireless technologies with portable devices provide 135 WeBSurg operative technique chapters, 370 surgical videos, 770 expert opinions, which can be viewed easily pushing the standard buttons available on any such device. Podcasts work as a modulable hard disk drive with a storage capacity that allows access to regularly updated downloadable new videos. The latest iPod generation 5 weighs 136 grams and has a storage capacity of 136 hours for a 30 GB hard disk drive, which provides a reliable neat image with a good acceptance level. Conclusion: Thanks to both wireless Internet technologies, and podcasting, webbased educational resources are available anywhere on lightweight handheld devices, hence marking a revolution that occurs in the pocket. Broadening access to education for physicians implies giving them the possibility of using the latest innovative lightweight communication devices without the constraints of cumbersome computer environments any time anywhere. Handheld devices are now available to healthcare professionals and may be used for continuing education, preoperative, intraoperative advice and also for patient information. It heralds the advent of a new technological era serving educational and telementoring purposes.

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USABILITY OF EQUIPMENT CONTROL IN A STERILE ENVIRONMENT USING THE GYROMOUSE AND A NEW INTERFACE, THE UI WAND J. Dankelman1, C.N. Stefels1, R.G. Aarnink2, P. Kaufholz2, C.A. Grimbergen3 1 Delft University of Technology, DELFT, The Netherlands 2 Philips Medical System, BEST, The Netherlands 3 Medical Physics, AMC, AMSTERDAM, The Netherlands

LOW-BUDGET LAPAROSCOPIC SPLENECTOMY: MINIMIZING COSTS FOR DEVELOPING LANDS R. Zorron, A. Barros Lima, S. Henriques Cunha Neto, E. Kanaan, L.C. Carlos Maggioni, M. Filgueiras University Hospital Tereso´polis, RIO DE JANEIRO, Brazil Objectives: Techniques for reducing costs in laparoscopic splenectomy were evaluated, and patients data prospectively recorded, in a series of patients with Imune Thrombocytopenic Purpura submitted to the technique in the Institution between 2003 to 2005. Methods: 39 pacientes with Imune Thrombocytopenic Purpura with indication for laparoscopic splenectomy were prospectively recorded. Technical aspects included no use of disposable instruments, high-tech electrosurgery, nor disposable vascular stapplers. Laparoscopic splenectomy was performed using knot ligatures with non-absorbable yarn, bipolar energy, and a plastic bag found in general supermarkets for food storage. Using threetrocar technique and monopolar energy, the spleen vessels were isolated and ligated with polipropilene 2.0. Short gastric vessels were bipolar coagulated. For extraction of the specimen, the bag was exteriorized and no morcelator was used, the spleen was sectioned by conventional instruments in the bag and extracted in many pieces. Results: In 39 patients submitted to the technique, it was successfully concluded in 38, using the concept of low-budget laparoscopic splenectomy. There was one conversion to open surgery because of maintained bleeding after the procedure due to the purpura. Complications occurred in 4 patients (17,6%): 1 subcutaneous; 1 pancreatic pseudocyst (conservative management), and 2 trocar site hernias. There were no deaths nor reoperations. Operative time was 132,9min, and postoperative stay was 2,53 days. Platelet transfusion was preoperatively necessary in three patients. Accessory spleens were founded and ressected in 8 patients (20,5%). Response to splenectomy was positive in 31 patients (79,5%), with no response in 7 pacients (23,5%). There was no use of disposable instruments, energy, or vascular staplers. Conclusions: Available technology facilitates laparoscopy but are unnafordable for developing lands. The alternative Low-Budget technique is feasible, safe, and available for any surgical institution. Techniques avoiding expensive high technology instruments have the same learning curve of others, allowing surgeons and patients to receive the beneﬁts of minimal invasive surgery around the world.

Introduction: Providing the surgeon with steering devices that avoid the need for interference of an assistant could enable more direct control and reduce errors due to miscommunication or misinterpretation. Therefore, the need for an input device controlling equipment from the sterile environment is high. We evaluated the usability of two hand-held devices; an acceleration-sensitive Gyromouse and the User Interface Wand (UIWand), a prototype pointing device. Method: The evaluation consisted of a quantitative evaluation in a laboratory setting and a qualitative evaluation in a simulated clinical setting. A quantitative tapping task was performed on a computer screen using target objects of diﬀerent size and positioned at diﬀerent distances, resulting in diﬀerent indices of diﬃculties (IDs) based on Fitts Law [1]. A qualitative task was performed in a simulated clinical setting, where a.o. images can be viewed and manipulated, music can be selected, and a printer controlled. Results: In the quantitative evaluation, the Gyromouse showed to be 20+/ )3% (mean+/)SD, n=11, p<0.05) faster during the tapping task than the UIWand for IDs>2.5 bits and equally fast for IDs <2.5 bits. In the qualitative evaluation 10 of 11 subjects preferred the UIWand above the Gyromouse and the UIWand was considered to enable the quickest control. Conclusion: Both input devices are able to control equipment from the sterile environment. With the Gyromouse, often the cursor has to be searched for after activating, because the cursor remains where it is left and shifts because of drift. Although slower, the UIWand is preferred due to the direct pointing characteristic; the cursor is where you are pointing at and, therefore, it is always clear where the cursor is. [1] Soukereﬀ RW, Mackenzie IS. Towards a standard for pointing device evaluation. Int. J. Human-computer Studies 61, 751–789, 2004

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LAPAROSCOPIC COLORECTAL RESECTION IS CHEAPER THEN CONVENTIONAL OPEN RESECTION E. Boyle, P.F. Ridgway, F.B. Keane, P. Neary AMNCH, DUBLIN, Ireland

COMPARISON OF LONGITUDINAL AND TORSIONAL MODE ULTRASONIC COAGULATING SHEARS IN MEDIUM- AND LARGE-SIZED ARTERIES S.S. Ching, M.J. McMahon The General Inﬁrmary at Leeds, LEEDS, United Kingdom

Aims: International randomised trials have endorsed the routine use of laparoscopic techniques in colorectal surgery. The authors prospectively establish the cost beneﬁt analysis of delivering laparoscopic colorectal resection to an Irish population. Methods: This was a prospective case matched study of consecutive patients undergoing laparoscopic resection between July 2005 and February 2006. Intraoperative (costs, duration, incision length) and postoperative (morbidity, length of stay, readmission) parameters were examined. Instituitional open controls and national validated ﬁgures were used for costings. Results: Thirty-ﬁve laparoscopic and 53 open resections were evaluated. Median length of stay was 5 days in the laparoscopic group versus 12 days in the open group (p=0.001) There were 2 conversions (5.7%) and 2 readmissions. Mean operative cost of laparoscopic resection was 1557.08 euro, 2.4 bad days need to be saved to recoup cost. The actual median save is 7 days (p=0.031) A mean of 4591.38 euro and 7 bed days per case is saved by performing the resection laparoscopically. Sub group analysis of laparoscopic resections demonstrate similar trends. Conclusions: The instituitional saving is over 150,000 euro and 245 bed days during the study period. Despite higher operative spending, laparoscopic colorectal resections are signiﬁcantly cheaper then conventional open resections.

Background: Recently a torsional mode ultrasonic coagulating shears (UCS) has been developed for endoscopic surgery. The current investigation was conducted to compare the eﬀectiveness of this device with a longitudinal mode UCS for the hemostasis of medium- and large-sized arteries. Methods: Porcine carotid arteries were prepared by removing the surrounding connective tissues in vitro. Each vessel was coagulated and cut by both devices at diﬀerent sites. Each seal was then tested for the acute burst pressure. A catheter was placed into the open end of the vessel and secured with a ligature. The catheter was connected to a pressure monitor and saline was gradually infused to increase the arteryÕs intraluminal pressure until there was leakage from the sealed end. Statistical diﬀerences were evaluated by Mann-Whitney U test. Results: A total of 104 seals were made on the vessels. Fifty-two seals were made with the torsional mode device (mean 5.0 mm, range 3.7–7.4 mm) and 52 seals were made with the longitudinal mode device (mean 4.8 mm, range 3.3–7.2 mm). The burst pressures for both torsional and longitudinal mode devices in the 3.3–4.2 mm and 4.3–5.2 mm groups were not statistically different (medians 321 and 354 mmHg vs. 479 and 317 mmHg, p = 0.193 and 0.579 respectively). The burst pressure for torsional mode device was signiﬁcantly higher than that of the longitudinal mode device for vessels 5.3–7.4 mm in diameter (median 378 vs. 203 mmHg, p = 0.027). There was no signiﬁcant correlation between the burst pressure and the diameter of vessels for the torsional mode device (r =0.109, p = 0.441). However, a signiﬁcant correlation was obtained between the burst pressure and the diameter of the vessels for the longitudinal mode device (r =0.552, p = 0.000). Conclusions: Both torsional and longitudinal mode UCS can achieve secure hemostasis on vessels up to 5 mm in diameter. The torsional mode device has the extended ability to coagulate larger-sized vessels up to 7 mm in diameter with the same degree of conﬁdence. On the contrary, increasing vessel size is correlated with lower burst pressures for the longitudinal mode device.

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THE OR LOGBOOK E. Laporte1, J. Vila`2, B. Sales2, J. Pe´rez1, J. Planell1 1 Hospital de Sabadell, SABADELL, Spain 2 Fundacio´ Parc Taulı´ , SABADELL, Spain

COMPARISON OF A NOVEL LIPID-BASED, BIOABSORBABLE BARRIER MESH TO COMMERCIALLY AVAILABLE MESHES FOR INTRAPERITONEAL PLACEMENT IN VENTRAL HERNIA REPAIR R.A. Pierce1, J.M. Perrone1, J. Ferraro2, A. Nimeri1, J.A. Spitler1, J. Walcutt1, M.M. Frisella1, B.D. Matthews1 1 Washington University School of Medicine, SAINT LOUIS, United States of America 2 Atrium Medical Corporation, HUDSON, NH, United States of America

The ability to record and store information about particular aspects of the surgery process -a childbirth or any other therapeuthical invasive procedure, should yield to an increase in the safety rates in the health environment for both users and health professionals. The OR logbook is a piece of software designed speciﬁcally to record the various processes and overall activity at the OR. As in a ship logbook, the system shows on a computer screen all of the data and activity information that occurred, video, and any other activity information from other devices in the OR. The interface is straightforward and intuitive. Monitoring data is displayed synchronous with video recorded during the operation. From a technology standpoint, the application is a speciﬁc implementation of a technological platform called Monsurin. As a whole, the system is built out of three basic components: a. data grabbing: vital signals from monitoring devices, operational state of laparoscopy devices and multiplexed video and audio. b. data processing: UMDD (Universal Monitoring Device Driver), video compression (H.264) and audio, vital signals, metadata and other related parameters, HIS integration through HL7, and security. c. storage and transmission of data: client-server architecture and web services. HL7 and DICOM. All in all, the scientiﬁcal value of this platform will come from the analysis of the information recorded in an integrated way. It cannot be underestimated the value of having access to a huge and uniﬁed database that will be built over time. Techonology areas involved are basically digital signal processing of vital data, state-of-the-art digital video handling, and last but not least, the IT engineering required to design the architecture of the high perfomance hardware and software systems needed to support such a high demanding solution both in processing speed and storage terms.

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Aims: This study evaluates a new, lipid-based, bioabsorbable layer applied to macroporous lightweight polypropylene mesh as a barrier to adhesion formation after intra-abdominal placement. This protective barrier remains intact for at least 90 days, which is signiﬁcantly longer than the 7 day time period during which reperitonealization occurs after surgery. We evaluated the propensity of this novel mesh (Atrium Coated Mesh) to undergo adhesion formation and contraction compared to other meshes currently available for ventral hernia repair. Methods: Seven meshes were tested in a New Zealand white rabbit model. After randomization, 3 x 3 cm pieces of ProLite Ultra (PLU), Atrium Coated Mesh, Composix, Parietex, Proceed, Sepramesh, and DualMesh were sewn to intact peritoneum on either side of a midline incision in 41 animals. Necropsy was performed at 120 days and explants were evaluated for adhesion grade, adhesion amount (% surface area covered by adhesions), and mesh contraction. Statistical diﬀerences were calculated using nonparametric ANOVA and Dunns multiple comparisons tests. Results: The lipid-based barrier Atrium Coated Mesh performed well in all 3 categories tested. It exhibited minimal adhesion formation, with a mean of only 3% of the surface covered by adhesions and a mean adhesion grade of 1.2 (Scale, 1–4). However, there were no statistically signiﬁcant diﬀerences between this barrier mesh and the others tested in terms of these 2 parameters. The Atrium Coated Mesh was also found to have the lowest degree of contraction at 3.3%, which is signiﬁcantly less (p<0.05) than that seen with either DualMesh or Proceed . Conclusions: Placing lightweight polypropylene mesh with a novel, lipid-based barrier against an intact peritoneum results in 120-day adhesion characteristics similar to other commercially available meshes made for ventral hernia repair. Additionally, the lesser degree of contraction makes the Atrium Coated Mesh a viable alternative to several of the other meshes currently on the market. Further studies will be needed to compare the histology of the above materials.

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DEVELOPMENT AND PRESENTATION OF AN OPTICAL NAVIGATION SYSTEM FOR THE MINIMALLY INVASIVE ESOPHAGECTOMY 1

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H.G. Kenngott , J. Neuhaus , I. Wolf , M. Vetter , H.P. Meinzer , M.W. Bu¨chler4, C.N. Gutt4 1 Universita¨tsklinik Heidelberg, HEIDELBERG, Germany 2 Deutsches Krebsforschungszentrum, HEIDELBERG, Germany 3 Univ. Mannheim of Appl. Sciences, MANNHEIM, Germany 4 University of Heidelberg, HEIDELBERG, Germany Aims: Minimal invasive esophagectomy for patients with distal esophageal carcinoma and Barretts esophagus could be improved by providing a better overview and orientation in the thorax through a navigation system. The system should be usable with the daVinci Surgical system (Intuitive Surgical Inc.) as well as with classic laparoscopic instruments. Methods: The DaVinci surgical system is used because of its ergonomics, longer instruments, stereoscopic view and seven degrees of freedom which allow a faster dissection of the esophagus. Nonetheless important limitations of minimal invasive esophagectomy are the limited space for dissection, a partial lymphadenectomy and the insecurity about the current position of the instrument in the thorax in relation to the location of the carcinoma. In order to overcome these constraints a navigation system based on optical tracking (Polaris, NDI Inc.) has been developed which enables the operator to orientate himself in the thorax. Patient movement and organ deformation are reduced by using a patient immobilization device consisting of a vacuum mattress ﬁxed to a stretcher equipped with CT-markers. The workﬂow begins with the acquisition of a CT-dataset of the immobilized patient. Next the tumor and vital structures like the aorta or vena cava are segmented. Then the immobilized patient is transferred to the operation room where the optical markers are attached to the stretcher and the daVinci instrument. During the operation the instrument tip, the segmented tumor, and affected lymph nodes can be displayed in the navigation system by tracking the optical markers and setting them into relation to the CT-markers. Results: The system is working in real-time and it integrates well into the operational workﬂow. In preliminary tests the navigation system showed a precision of 1.64mm. Furthermore the system can be applied to operations using classic laparoscopic instruments. Conclusion: The system gives the surgeon real-time information about the position and orientation of the laparoscopic instrument, especially about its height within the thorax and about its relation to the tumor. Consequently a better lymphadenectomy seems to be feasible and anastomosis can be placed in adequate distance to the tumor border. Following clinical studies have to prove these eﬀects.

DEVELOPMENT OF A ROLLING STENT ENDOSCOPE P. Breedveld Delft University of Technology, DELFT, The Netherlands Aims: Colonoscopy is a medical procedure in which a long and ﬂexible endoscope is inserted into the rectum for inspection of the colon and for simple interventions. The colonoscope is moved forward through the colon by pushing at its rear side from outside the patient. Pushing the long and ﬂexible colonoscope from behind leads easily to buckling, causing the colonoscope to loop or to wind and making it diﬃcult to move the tip further. Looping or winding can stretch the intestinal wall, leading to painful cramps and a risk of perforation, which can be potentially fatal. Method & Intended Results: A way to avoid buckling is to use the friction with the intestinal wall to pull the tip forward. At the Delft University of Technology, a Rolling Stent Endoscope is being developed consisting of a colonoscope with a number of rolling donuts that are positioned around the tip and around the ﬂexible shaft. Each donut is constructed out of three stents that generate high friction with the intestinal wall. The stents perform a rolling motion, pulling the colonoscope forward along the intestinal wall. The donuts are able to pass curves and can be changed in diameter to facilitate manoeuvring through enclosed gas-bubbles. The donuts are driven by cables that are guided through the ﬂexible shaft into a propulsion unit that is placed outside the patient. The rolling speed of the donuts is always equal to the speed of insertion into the anus. Buckling and looping are in this way avoided, thus reducing the risk of pain and perforation. Conclusion: The Rolling Stent Endoscope has been applied for two international patents (PCT). A prototype is being constructed for in vitro and in vivo evaluation in porcine colons. It is expected that the prototype will be ﬁnished in June 2006. We wish that the device will work well and oﬀer a fast and painful alternative for conventional colonoscopes.

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O362 SMALL AND DISPOSABLE ÔTENTACLEÕ MECHANISM FOR STEERABLE ENDOSCOPES, INSTRUMENTS AND CATHETERS P. Breedveld1, J. Scheltes2, M.J.S. Begemann2 1 Delft University of Technology, DELFT, The Netherlands 2 DEAM B.V., AMSTERDAM, The Netherlands Aims: Instruments with a steerable tip can improve the dexterity of a laparoscopic surgeon, enabling him/her to carry out more complex manipulations than with conventional instrumentation. Endoscopes with a steerable tip can be used to observe anatomic structures from diﬀerent sides and to look in cavities that are diﬃcult to reach with conventional endoscopes. Despite these advantages, steerable instruments and endoscopes are hardly used in laparoscopic practice. One of the most important limitations is that conventional steerable mechanisms contain complex ﬁne-mechanical parts such as little hinges, pulleys and gearwheels, making them diﬃcult to sterilize and hard to miniaturize at low costs. Method: At the Delft University of Technology, a new steerable ÔCableRingÕ mechanism has been developed. The mechanism is based on a biological study of the tentacle of a squid and consists of a ring of cables that is surrounded by two conventional coil springs. The mechanism contains no complex parts and is much simpler than conventional steerable mechanisms. The mechanism can be manufactured at very low costs and is suitable for disposable steerable instruments and endoscopes that require no sterilization in the hospital. Results: The Cable-Ring mechanism has been used to develop a series of prototypes of steerable instruments and endoscopes, varying from 5.0 mm to 1.3 mm in diameter. The mechanism has been used as well to develop a prototype of a long, steerable catheter with a diameter of only 0.9 mm. All prototypes work very well, with tips that can be bent in all directions over a large bending angle. Conclusions: The Cable-Ring mechanism can be constructed at much smaller diameters and at much lower costs than conventional steerable mechanisms. The mechanism has been applied for an international patent (PCT) and is being commercialized by the company DEAM B.V., a startup company from the Delft University of Technology. We wish that our eﬀorts will lead to a number of new, useful tools for laparoscopic surgery and other medical applications.

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VIDEO-THORACOSCOPIC THYMECTOMY FOR MYASTHENIA GRAVIS BY SUBXIPHOID BILATERAL APPROACH C.P. Hsu1, N.Y. Hsu2 1 Taichung Veterans General Hospital, TAICHUNG, Taiwan 2 China Medical University Hospital, TAICHUNG, Taiwan

T2 VERSUS T2,3 ABLATION IN THORACOSCOPIC SYMPATHECTOMY FOR HYPERHYDROSIS D. Lomanto, A. Katara, W-K. Cheah, J. So National University Hospital, SINGAPORE, Singapore

Aims: Previous experience using the left/right transthoracic or transcervical approach for thymectomy although demonstrating promising eﬃcacy, involves some compromise of the surgical exposure. We develop a valid approach which can retrieve as much thymic bearing tissues as sternotomy can. Methods: We design a subxiphoid bilateral thoracoscopic approach for extended thymectomy. Between 2001 and 2005, we had conducted SxVATET (Subxiphoid Video-Assisted Thoracoscopic Extended Thymectomy) procedures in 30 myasthenic patients. The patients included 6 males and 24 females with a mean age of 36.9 years (23 to 80). Results: The mean operation time, weights of resected specimen, and thoracic drainage period were 134 minutes (95 to 200 minutes), 62.1 grams (25 to 100 grams), and 3.4 days (2 to 10 days), respectively. Except in one patient who developed chylothorax which seals oﬀ spontaneously, there were no surgical mortalities or complications. Pathology revealed thymoma in 4 patients. Short term follow-up (2 to 56 months, mean 26.0) demonstrated complete remission, improvement, and stationary status in 12, 16, and 2 patients, respectively. Conclusions: Our experience demonstrates that SxVATET provides excellent view of the bilateral pleural cavities. Subsequently, extended thymectomy, resecting ample mediastinal fatty tissue in addition to the thymic glands, can be safely undertaken as it is performed via sternotomy.

Aim: Thoracoscopic sympathectomy is popularly performed for patients with palmar hyperhidrosis. Surgeons vary worldwide in the level of the sympathetic nerves ablated. Our aim is to compare the blockade of the 2nd thoracic sympathetic ganglion (T2) with ablation of levels T2 and T3. Methods: Our usual practice for patients undergoing bilateral thoracoscopic sympathectomy for palmar hyperhidrosis is to ablate T2,3 levels bilaterally. 25 consecutive patients in our series had unilateral T2 and T3 ablation followed by contralateral ablation of T2 level only. Patients were followed up for mean period of 23 months (range 2 to 65 months). The patients were analyzed for comparison of symptoms bilaterally, compensatory hyperhidrosis and levels of satisfaction postoperatively. Results: Our study group consisted of 25 patients with a male: female ratio of 3:2 and a mean age of 32 years (range = 19 to 50 years). All 25 patients conﬁrmed that their palmar sweating resolved postoperatively, both palms being equally dry. 20 out of 25 (80%) patients complained of compensatory hyperhidrosis in other parts of the body, which was also bilaterally symmetrical. The areas involved were trunk (80%), lower limbs (32%) and armpits (12%). Overall, 80% were very satisﬁed with the procedure, 20% were satisﬁed with mild to moderate compensatory hyperhidrosis not aﬀecting their lifestyle. None were dissatisﬁed with procedure. Summary: T2 ablation in thoracoscopic sympathectomy for palmar hyperhidrosis is equally eﬀective as ablation of T2,3 levels in terms of symptomatic relief, recurrence, compensatory hyperhidrosis and patient satisfaction.

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THORACOSCOPIC EXTENDED THYMECTOMY FOR THYMOMA USING AN ORIGINAL STERNUM-LIFTING TECHNIQUE S. Takeo, T. Kometani, H. Matsuzawa, Y. Otsu National Kyushu Medical Center, FUKUOKA, Japan

RESECTION OR TRANSECTION FOR PRIMARY PALMAR HYPERHIDROSIS: A PROSPECTIVE RANDOMIZED TRIAL A. Assalia, H. Bahouth, A. Ilivitzki, Z. Assi, M. Hashmonai, M. Krausz Rambam Health Care Campus, HAIFA, Israel

Objective: To evaluate the feasibility and outcome of thoracoscopic extended thymectomy using an original sternum-lifting technique (Ann Thorac Surg 2001;71: 1721–3.) in patient with thymoma. Methods: Twenty-one patients with thymoma underwent thoracoscopic extended thymectomy between 1998 and Feb.2006. The thoracoscopic procedures were performed using six ports (5mm) and two incisions (neck 4cm, abdomen 6cm). Results: Sex was ﬁve men and 16 women. The average age was 64.7 years old (range 49 to 81yr). All 21 patients underwent thoracoscopic-assisted extended thymectomy using an original sternum-lifting technique. The thoracoscopic procedure was uneventful in all patients; no patient required conversion to open thoracotomy. The mean surgical time was 252 minutes (range 140 to 393), and average blood loss 48g (range 5 to 200). In the latest operation case, the mean surgical time has become in about 3 hours. Histological examination conﬁrmed that 9 in MasaokaÕs Stage I, 11 in Stage II, and 1 in stage III thymoma. In the WHO classiﬁcation, 1 in Type A, 5 in Type AB, 9 in B1,3 in B2,and 3 in Type B3. The maximum diameter of the tumor was 5.3 cm (range 1.5–9.0). There were no postoperative deaths or major complications, but 3 patients had minor complications. During a mean of 39 months of surveillance (range, 1 to 89 months), there was no recurrence in any of the patients. Conclusions: The use of this new technique oﬀers many advantages but requires extensive experience in thoracic surgery and thoracoscopic skills. Our experience suggests that these thoracoscopic procedures should be indicated in MasaokaÕs Stage I, II and some Stage III (invasion to lung and narrow range of pericardium). However, this method is not indicated for patients with thymoma with mediastinal lymph node swelling and invasion to the vessels.

Upper dorsal sympathectomy is the only successful therapeutic method to arrest idiopathic palmar hyperhidrosis (IPHH). However, the techniques for sympathetic ablation are still debated in the literature. It has been reported that the same surgical procedure obtains in diﬀerent patients diﬀerent results. Therefore, the authors felt that comparison of two techniques should be performed according to the present model. Our study compared two basic methods of sympathetic ablation: resection of T2-T3 ganglia versus transection of the chain and ramicotomy over ribs 2, 3, and 4. During the period 9/2000 to 6/2002, 32 patients with IPHH were operated. There were 14 males and 18 females, aged 18.8?2.7 years. The study was approved by the local ethical Committee and each patient signed an Informed Consent Form. Operations were performed under general anesthesia through two 5 mm trocars, using electrocautery. Resection was done on one side and transection on the other, both sides during the same operation. The sides of resection/transection were switched on each operation alternately. All patients were examined at 2 weeks and one month postoperatively. During 12/2005, patients were approached by telephone questionnaire, the follow-up period being 3.8–0.9 years. Twenty six patients could be located (15 females/11 males, mean age= 19.1–3.2). All hands were dry one month post-op and remained so on follow-up with the exception of two: one with recurrent hyperhidrosis and one which remained dry but became cold, both on transected sides. Compensatory hyperhidrosis was reported by 19/26 patients. Our results suggest that to obtain dry hands in IPHH, sympathetic resection may be superior to transection.

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CAN A THORACOSCOPY BE A REAL ALTERNATIVE TO COMPUTED TOMOGRAPHY FOR DESCENDING NECROTIZING MEDIASTINITIS?

THORACOSCOPIC SURGERY FOR PREVENTING RECURRENT PNEUMOTHORAX IN LAM PATIENTS REQUIRING LUNG TRANSPLANTATION IN THE FUTURE (TOTAL PLEURAL COVERING METHOD) M. Kurihara, K. Kakizawa, H. Kataoka Nissan Tamagawa Hospital, TOKYO, Japan

CANCELLED

Purpose: LAM is the unsolved disorder characterized by dyspnea, bloody sputum and recurrent spontaneous pneumothorax. LAM forms diﬀuse pulmonary bullae. Chemical pleudesis has therefore been done for recurrent pneumothorax. Eﬀects of chemical pleudesis is however not useful because of individual difference. Chemical pleudesis is unstable for pneumothorax. To separate severely adhesive lung is technically diﬃcult and is accompanied with lots of bleeding in lung transplantation when chemical pleudesis is eﬀective. The thoracoscopic surgery, which prevents from not only adhesion but also recurrent pneumothorax, was devised in order to solve such a problem. Patients and Methods: For 16 LAM patients (20–51 years old), thoracoscopic surgery called total pleural covering technique (TPC) was performed. Fibrin Glue is thinly dropped on the surface after covering the whole visceral pleura with regenerated oxidized cellulose mesh (Surgicel Ethicon). It is a method to cover perfectly the whole visceral pleura including apex of lung, interlobular, mediastinal, and basal pleura with the absorbable mesh. Results: There is no postoperative recurrence of pneumothorax in 16 cases after TPC. There was no adhesion to the intrathoracic wall in all cases. The thoracoscopic and microscopic ﬁndings show that pleural surface has been thickened and covered with collagen ﬁbers and that pleural surface has no adhesion to the thoracic wall postoperatively in a maximum period of 40 months. Discussion: Chemical pleudesis has individual diﬀerence and is uncertainty for eﬀect of adhesion. The adhesion is however considerably strong if being eﬀective. As for the severe and broad adhesion, it would become a serious problem in maneuver in altitude when doing lung transplantation. Lots of bleeding during separation lung from intrathoracic wall becomes more serious to use of anticoagulants in particular. Total pleural covering method is a thoracoscopic surgery to cause thickness of visceral pleura without raising adhesion to ﬁnally prevent pneumothorax. Therefore lung transplantation will be able to easily be performed after it. Conclusions: The TPC technique can be expected as a superior method to prevent pneumothorax recurrence for LAM patients that should require lung transplantation in the future.

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TREATMENT OF ISOLATED ATRIAL FIBRILLATION WITH A RIGHT THORACOSCOPIC APPROACH M. La Meir1, L. De Roy2, D. Blommaert2, M. Buche2, J. Maessen1 1 AZM, MAASTRICHT, The Netherlands 2 UCL Mont-Godinne, YVOIR, Belgium

ENDOSCOPIC SURGERY AS A BASIS OF MODERN SURGICAL TACTICS IN TREATMENT OF CHEST TRAUMA K. Gestkov, O.V. Voskresensky, M.M. Abakumov First Aid Research Institute, MOSKOW, Russia The goal of this research is to develop modern surgical tactics in treatment of chest trauma.

For years surgeons have tried to create a procedure that could free the patient of atrial ﬁbrillation (AF) without compromising transport function of the atrium. James Cox proposed the Cox-Maze procedure, a complex intervention that includes a sternotomy, cardio-pulmonary bypass and cardiac arrest. Although this procedure has been simpliﬁed by replacing part of the cut and sew lines through the use of an alternative energy source, it is still considered too invasive by most cardiologists and patients for the treatment of isolated AF (AF without concomitant cardiac pathology). Therefore referrals are limited and widespread application has not been realized in this patient group. In order to have impact, cardiac surgeons must understand that the proposed technique should be able to stand side-to-side with a percutaneous endocardiac ablation. A generally accepted surgical procedure should be minimally invasive and performed through port-access, be epicardial and without cardiopulmonary bypass. This technique could be adopted by many surgeons and dramatically increase the number of patients referred for this operation. From January 2005 till January 2006 we have operated 33 patients with lone AF (22 permanent and 11 paroxysmal) with a procedure that answers to these demands. It consists of creating an electrical conduction block around the four pulmonary veins (box lesion) with the Flex10 microwave antenna through a mono-lateral right-sided 3 port-access thoracoscopy. The procedure is based on the knowledge that triggers originating from the pulmonary veins play an important role in generating AF, and the observation that exclusion of the posterior wall of the left atrium diminishes the substrate for AF. Since refractory periods are longer in the right atrium, which means that the right atrium on itself is mostly not able to sustain atrial ﬁbrillation, the lesion lines can be limited to the left atrium. Thoracoscopic treatment of isolated atrial ﬁbrillation is a true minimally invasive procedure available to surgeons today. It has the potential to become an important part of a surgeons practice, and it will create the basis for a multi-disciplinary approach with the electrophysiologist, either as a ﬁrst-line, or as a second-line treatment after an unsuccessful endovascular ablation.

Materials and methods: we have analyzed the experience of surgical treatment of 1022 patients with chest trauma Results: Lung wounds were revealed in 37.3%, diaphragm wounds - in 18.7%, heart wounds - in 9.4%, and bleeding from chest wall vessels - in 44.2% of the injured. In 81.3% of cases thoracoscopy allows to make a necessary operation on the damaged part, being a ﬁnal method of treatment. The conversion to VATS was required in 9.9%, and conversion to standard thoracotomy - in 8.8% of all the cases. In comparison with thoracoscopy Before VATS the expansion of access was connected with bleeding from intercostal arthery in 2.7%, with a wound of diaphragm in 10.8%, wound of a lung in 2.7%. The use of this surgical tactics allows to reduce lethality by 4.7%, to decrease the number of complications by 2.9, to completely avoid ÔdiagnosticÕ thoracotomies, to make mini-invasive operation in 91.2% cases, to reduce duration of the drain of pleural cavity, to shorten the stay of patients in reanimation and post-operation rehabilitation units. The application of thoracoscopy allows to reduce frequency of purulent complications caused by inadequate sanitation of pleural cavity, contamination of clotted haemothorax, delayed and incomplete lung expansion. Conclusion: endoscopic surgery allows to solve all basic tasks of operation on chest wounds: to diagnose anatomic character of trauma, stop the bleeding and restore integrity of the injured parts. Endoscopic operation is a highly informative, low-traumatic and safe method of diagnostics and treatment of traumas of chest parts and is an alternative to traditional operations. This method can play a signiﬁcant role in surgical treatment of a chest and abdominal trauma, as it possesses the reliability and eﬃciency of thoracotomy, which in case of invasiveness can be compared with drain of pleural cavity. Thorocoscopy does not replace therocotamy in treatment of patients with absolute indications for thoracotomy and in case of haemodynamic instability of the patients.

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THORACOSCOPIC ANATOMY OF THE UPPER SYMPATHETIC TRUNK. A CADAVERIC STUDY. F.M. Marhold, Ch.N. Neumayer, M.T. Tschabitscher Medical University, VIENNA, Austria

RESULTS OF ROBOTIC-ASSISTED THORACOSCOPIC THYMECTOMY J.C. Rueckert1, M. Ismail1, M. Swierzy1, H.K. Sobel1, Ch. Braumann1, Ch.A. Jacobi1, P. Rogalla1, R.I. Ru¨ckert2, M. Egert1, J.M. Mu¨ller1 1 Charite´ - Universita¨tsmedizin, BERLIN, Germany 2 Franziskus-Krankenhaus, BERLIN, Germany

Aims: Thoracoscopic sympathetic surgery for upper limb diseases requires profound anatomical knowledge on the autonomous nervous system. Aim of the study was to investigate the incidence of alternate sympathetic pathways in the ﬁrst intercostal space and to present their thoracoscopic view. Methods: This endoscopic anatomic study comprised 21 cadavers. Videoassisted thoracoscopy was performed in 33 thoracic cavities with 10 mm endoscops. For macro- and microdissections the anterior wall of the chest was removed. The upper sympathetic trunk, the incidence and the anatomy of the nerve of Kuntz were studied. In addition, a review of the literature with special reference to anatomical and clinical papers will complete our results. Results: Diﬀerent autonomous pathways of the sympathetic trunk have been described to the upper limb, most of them being found in the ﬁrst intercostal space. There are various deﬁnitions of the nerve of Kuntz depending on anatomical or surgical considerations. The incidence in our study was 61% leaned on the originally described deﬁnition from Albert Kuntz in 1927. There are only a couple of anatomical studies providing similar results. In contrast, the vast majority of surgical papers report an incidence of about 10%. In 73% a vein was found in the ﬁrst intercostal space parallel to the nerve of Kuntz. This vein was equally situated on the medial or lateral side of the nerve. In only 10% this vein was not paralleled by the nerve of Kuntz. Conclusion: The nerve of Kuntz is obviously more frequently present than in many clinical papers reported. In 73% this intrathoracic nerve was paralleled by veins which may serve as anatomical landmarks in the soft fat tissue beneath the parietal pleura. These ﬁndings might attribute to reduce the number of overlooked nerves of Kuntz which have been made responsible for primary failure in endoscopic thoracic sympathetic surgery for upper limb diseases.

Background: Complete thymectomy (Thx) is an essential part in the treatment of myasthenia gravis (MG) and thymoma. Fourteen diﬀerent surgical approaches for Thx illustrate the search for the most suitable approach. Is there evidence for an advantage of robotic-assisted thoracoscopic Thx (rThx)? Methods: A prospective study analyzed 77 consecutive rThx (1/2003–3/ 2006, 45 female, mean age 40.7+/)17.7 years, range 7–75) by a 3-trocar left-sided technique using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, California). Technical reﬁnements of rThx were compared to conventional thoracoscopic technique, median sternotomy, and cervical approach. All patients with MG (70/77) were analyzed for quantiﬁcation of improvement of MG and postoperative morbidity according to the MGFA classiﬁcation. Furthermore, the worldwide development of rThx was analyzed. Results: Complete rThx required 187 +/)50 minutes (90–310). The majority of MG-patients (66%) had MGFA-Stage 2b, 3a and 3b. The conversion rate was 2.6% (2/77, all with thymoma). There was no recurrence in rThx for thymoma (12/77). With zero mortality the overall postoperative morbidity rate was 1.3%. The dominant histological ﬁnding was follicular hyperplasia of the thymus (30/77, 39%). The cumulative complete stable remission rate of MG was 35%, with a median follow up of 17 months (0–38). Between January 2003 and December 2005, more than 50 institutions had carried out 358 rThx worldwide. The present series represents the largest single center experience to date. Conclusions: Advantages of rThx for mediastinal dissection translated into improved outcome for MG, as compared with 80 own conventional thoracoscopic Thx. Therefore, rThx proved to be the most promising technique for minimally invasive Thx.

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VIDEO-ASSISTED THORACOSCOPIC SURGERY CAN AVOID AN URGENT THORACOTOMY FOLLOWING CHEST TRAUMA P. Moreno de la Santa, E. Toscano Povisa Hospital, VIGO, Spain

EFFECT OF ENDOSCOPIC THORACIC SYMPATHECTOMY ON VASCULAR DISORDERS C. Neumayer Medical University of Vienna, VIENNA, Austria

Objectives: To prove that video-assisted thoracoscopic surgery in selected cases is an alternative to urgent thoracotomy following open chest trauma. Materials and Methods: Retrospective analysis of case reports of patients operated for chest trauma during 1998–2005 was analyzed. Results: During 1998–2005, 982 patients with chest trauma were admitted. Forty six patients underwent video-assisted thoracoscopy (VATS): 18 cases due to persistent air leak, 13 cases due to haemothorax, 8 cases due to a persistent clot, 4 cases due to empyema and 3 due to other causes (pericardial injury and diaphragmatic injury). 25 patients were converted through thoracotomy incision: 13 cases due to severe pulmonary injury, 8 cases due to vascular injury and 4 cases due to mediastinal injury. At time of VATS all patients were hemodynamically stables. The duration of drain presence in the pleural cavity after video-assisted thoracoscopy was 3.57 days and after urgent thoracotomy ) 7.98 days (p<0.05). Duration of post-operative treatment after video-assisted thoracoscopy was 8.21 days and after urgent thoracotomy - 19.89 days (p<0.05). After VATS pain control was managed with non narcotic analgesic. Conclusions: Videoassisted thoracoscopy is minimally invasive method of thoracic surgery allowing for the evaluation of injuries in the lung, pericardium, diaphragm, mediastinum, thoracic wall and pleura, and in many cases allow a deﬁnitive therapy. The number of early post-operative complications following video-assisted thoracoscopy is lower. Compared to operations through thoracotomy incision, video assisted thoracoscopies entail the shortening of the duration of drain presence in the pleural cavity and the duration of post-operative treatment. Video-assisted thoracoscopy should be performed on all patients with open chest trauma and stable hemodynamics and the respiration function. Video-assisted thoracoscopy is an informative diagnostic and treatment method allowing for the selection of patients for urgent thoracotomy.

Aims: Endoscopic thoracic sympathectomy (ETS) has been used for treatment of vascular disorders of the upper limb. However, reports on limited number of patients gave controversial results. The aim of our study was to analyze the eﬀect of ETS on patients with vaso-spastic and occlusive diseases. Methods: Between 1965 and 2004 59 patients underwent 89 ETS procedures. 32 patients had primary, 17 secondary Raynaud‘s disease and 9 had vasoocclusive diseases (including 5 patioents with Buerger‘s disease) and one patients suﬀered from thromboembolic ischemia. Median follow-up was 12 years, available from 15 patients, 15 had died from cardiovascular events and 30 patients have been lost. Results: 16.8% had minor (primarily subcutaneous emphysema and residual pneumothorax) and 2.2% major morbidities (one patient with temporary ptosis, one with stenocardia). 75% of patients reported subjective improvement lasting for 6 to 8 months. Most of the patients had already ﬁnger tip necroses at time of operation. Nevertheless, ulcer healing rate was 64%. Moreover, intractable pain was diminished in all of the patients (9.6 0.4 before ETS versus 2.4 0.5 after ETS, p < 0.05) as assessed by a visual analogue scale from 0 (no pain) to 10 (maximal pain). Conclusion: Endoscopic thoracic sympathectomy can be recommended for patients with limb threatening end-stage upper limb vascular disorders. Although the vasodilatory eﬀect is not long-lasting, a high rate of healed necrotic digits and pain relief in all of the patients are convincing arguments for this surgical procedure.

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EFFICACY OF INTERLOBAR FISSURE NON-SPARING ACCESS TECHNIQUE IN VIDEO-ASSISTED THORACIC SURGERY FOR LUNG CANCER M. Oda1, Y. Tsunezuka2, N. Tanaka2, T. Takayanagi2 1 Kanazawa University Hospital, KANAZAWA, Japan 2 Ishikawa Prefectural Central Hospital, KANAZAWA, Japan

COMPENSATORY SWEATING AFTER ENDOSCOPIC THORACIC SYMPATHETIC BLOCK AT T4 P. Panhofer1, J. Zacherl1, R. Jakesz1, G. Bischof2, C. Neumayer1 1 University Clinic of Surgery, Med.Univ., VIENNA, Austria 2 St. Josef Hospital, VIENNA, Austria

Aims: Incomplete lobar ﬁssures make video-assisted thoracic surgery (VATS) lobectomy diﬃcult. We evaluated the usefulness and safety of interlobar non-sparing access technique (INTACT) in video-assisted thoracic surgery for lung cancer. Patients and Methods: Among 205 consective lung cancers resected between August 2004 and March 2006, 15 patients underwent VATS with INTACT. In INTACT, incomplete lobar ﬁssures were not spared and divided after divisions of vessels and bronchus. Results: There were 10 men and 5 women underwent VATS lobectomy with INTACT except 1 who underwent segmentectomy. Sites of resection were right upper lobe in 11, right upper and middle lobe in 1, right S6 in 1, left upper lobe in 1, and left lower lobe in 1. Mean intraoperative blood loss was 82 (10–285) ml, mean duration of operation was 175 (150–220) min, median duration of chest tube drainage was 3 (1–14) days. There was no operative and hospital death. Conclusion: INTACT in VATS for lung cancer was safe and time sparing way for patients who had incomplete lobar ﬁssures.

Aims: Endoscopic thoracic sympathectomy is the treatment of choice for patients with primary hyperhidrosis (HH). Compensatory sweating (CS) is the most frequent unwanted side-eﬀect of this surgical procedure. Recently, clip application (endoscopic sympathetic block, ESB) has been introduced as it provides reversibility. The aim of the study was to analyze the outcome of patients treated by ESB at the level of T4 with special reference to CS. Methods: Between 2001 and 2005 112 patients (mean age 30.4 9.1 years) prospectively underwent 223 procedures. Satisfaction rates and quality of life scores have been evaluated. Mean follow up was 21.9 10.1 months obtainable from 106 patients (94.6%. Results: 103 patients (92.0%) had palmar, 87 (77.7%) axillary and 75 (67.0%) combined HH. At follow-up, all patients with palmar and 88.3% with axillary HH were completely or nearly dry. CS was observed in 18 (17.0%) patients. Most frequently, the back (72.2%), the thighs (38.9%), the abdomen and the feet (33.3%) and breasts (22.2%) were aﬀected. In 38.9% one single body region was aﬀected, in 27.8% two and in 22.2% three regions became humid. CS signiﬁcantly diminished quality of life (p<0.05 for both questionnaires). Consequently, 16.7% were unsatisﬁed with the ﬁnal outcome. However, the vast majority of patients were completely or almost completely satisﬁed. Conclusions: ESB at T4 gives excellent results for palmar and good results for axillary HH. However, CS diminishes patients‘ quality of life. Nevertheless, CS is relatively low after ESB at T4 compared to other sympathetic procedures.

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CAN A NOVICE LAPAROSCOPIST ACHIEVE LEARNING OF A SIMPLE AND A COMPLEX TASK IN EIGHT ATTEMPTS? N. Hogle1, W.M. Briggs2, D.L. Fowler1 1 Columbia College of Physicians and Surg., NEW YORK, United States of America 2 Weill Medical College, CORNELL UNIVERSITY, NEW YORK, United States of America

OBJECTIVE ASSESSMENT FOR TRAINING LAPAROSCOPIC MOTOR SKILLS WITH THE SIMENDO VIRTUAL REALITY SIMULATOR E.G.G. Verdaasdonk1, L.P.S. Stassen2, M.P. Schijven3, J. Dankelman1 Delft University of Technology, DELFT, The Netherlands 2 Reinier de Graaf Gasthuis, DELFT, The Netherlands 3 University Medical Centre Utrecht, UTRECHT, The Netherlands

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Background: The purpose of this study is to document the amount of time required to demonstrate proﬁciency of two tasks on a virtual reality training simulator in laparoscopic surgery (LapSim). The modeling of the general learning curve is useful in designing training programs. Methods: Twenty-nine medical students participated in eight attempts of two tasks: camera navigation (CN), a simple task and lifting and grasping (LG), a complex task. For each attempt at CN the following variables were recorded by computer: time to completion, drift, number of misses, path length, angular path length, number of instances of tissue damage, and maximum tissue damage. For each attempt at LG, time to completion, number of misses for the left (L) and right (R) hand, L and R path length, L and R angular path length, number of instances of tissue damage, and maximum depth of penetration of tissue damage were recorded. Learning curves for all 16 outcome variables were generated after eight attempts. Results: A discernable amount of learning occurred for most subjects as evidenced by a decrease in value of all variables. This decrease for each person is called a learning curve. A plateau in the learning curve (learning has occurred) was achieved within 8 attempts for 3CN and 1 LG variables. A plateau in the learning curve was nearly achieved for 4 CN and 2 LG variables. Six LG variables had a downward trend to the learning curve over eight sessions, but did not reach a plateau. Conclusion: A learning curve for each outcome variable for CN and LG has been documented for rank novices. For many of the variables, the learning curve reached a plateau in 8 hours or less, indicating that 8 attempts is enough for the purposes of training. For some variables, the learning curve did not reach a plateau, which indicates the task is more complex and that more training is required.

Aim: The SIMENDO is a relatively new and aﬀordable virtual reality (VR) simulator designed to train basic laparoscopic motor skills (eye-hand coordination). For structural implementation in a surgical training curriculum it is paramount to determine if the scores measured in this simulator can be related to various experience levels (construct validity). The aim is to establish construct validity and to determine to what extend training is useful in subjects with varying endoscopic experience by measuring the diﬀerences in the learning curve. Methods: The SIMENDO VR simulator was used with 6 installed SimSoft 1.0 exercises. Participants were divided into four groups according to their experience with laparoscopic procedures: experienced (group A, > 50 procedures performed, n=15); intermediate (B, >1 and <50 procedures, n=18); endoscope navigation (C, endoscopic camera navigation only, n=14); novices (D, no endoscopic experience, n=14). They performed at least 3 repetitions of the 6 exercises. Parameters studied were task time, path length of the instruments and number of errors (collisions). Some participants continued training up to 10 repetitions to get insight in the learning curve. Results: The expert group A outperformed all the other groups (B, C and D) in total median task time (p<0.05), groups C and D in path length, and group D only in collision frequency in the ﬁrst two repetitions. The intermediate group B outperformed the novices (D) in total time and endoscope path length for all repetitions and the camera navigation group (C) outperformed the novices for the ﬁrst repetition. Compared to experts (A), total task time was longer up to 10 repetitions in the novice- (D) and the camera navigation group (C), and up to 8th repetition in group B with limited laparoscopic experience, (p <0.05). Conclusion: Construct validity was stablished for the total training program in the simulator under study. The learning curve revealed that the simulator training is useful for subjects with no or limited endoscopic experience. Furthermore, previous endoscopic camera navigation already improves motor skills to more than basic level.

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WIRELESS ROBOT ASSISTANCE IN TRAINING FOR MINIMALLY INVASIVE SURGERY S. Sereno, D. Mutter, F. Rubino, A. Forgione, C. Bailey, J. Leroy, B. Dallemagne, J. Marescaux IRCAD-EITS / University Louis Pasteur, STRASBOURG, France

PERFORMANCE DURING DISTINCT PHASES IN LAPAROSCOPIC SURGERY M.K. Chmarra1, F.W. Jansen2, M. Wentink3, C.A. Grimbergen4, J. Dankelman1 1 Delft University of Technology, DELFT, The Netherlands 2 Department of Gynaecology, LEIDEN, The Netherlands 3 DelltaTech, DELFT, The Netherlands 4 Academic Medical Center, AMSTERDAM, The Netherlands

Introduction: Minimally invasive surgery has been taught by experts during hands-on training courses. The presence of specialized instructors can be limited due to time and geographical constraints. The aim of this study was to evaluate the possibility of using a wireless, mobile and remotely controlled robot for surgical telementoring. Methods: We used the Remote Presence Robot (RP-6, Intouch Health, Santa Barbara, USA), a wheeled device with mobile screen, camera, microphone and driving assistance systhem, controlled from a computer through internet WiFi connection. From a separate room two instructors mentored trainee surgeons to perform laparoscopic intracorporeal suturing in pigs. Trainees assessed the overall performance of the robot (sound, image, and movements) on a 0-to-10 scale. To test the feasibility of longdistance telementoring, on one occasion the trainees at our Institute in Strasbourg were instructed by a surgeon operating the robot from the Emory University School of Medicine of Atlanta, (GE), USA. Results: Thirty-six surgeons were trained using robotic-assisted telementoring. All the trainees completed the manual tasks as instructed. There was no interruption or interference of audiovisual signals during the telementoring sessions allowing continuous videoconferencing. Trainees scored the robot mentoring at an average of 7.7 (range: 5–10). Transatlantic telementoring was feasible and did not result in deterioration of image and sound quality. Conclusions: RP-6 robot can be used as a valuable tool in telementoring minimally invasive techniques. Robotic-assisted telementoring may enhance educational opportunities and the quality of hands-on-training courses by implementing local tutoring with expert assistance from remote locations.

Aims: Laparoscopic surgery requires a high degree of hand-eye coordination from the surgeon. To facilitate the learning process, objective assessment systems based on analysis of the instruments motion, are being developed. To investigate the inﬂuence of performance on motion characteristics, we examined simple goal-oriented movements in a box-trainer and hypothesized that they can be split into two phases: retracting and goal-seeking. Methods: Eight experts (experience >75 laparoscopic procedures), eighteen residents (10–75 procedures), and ﬁve novices (no experience) performed a onehand pointing task in a box-trainer. Movements of the laparoscopic instrument were tracked with our newly developed TrEndo tracking system. Movements from point A to point B were projected to the plane that passes through A and B, and that is perpendicular to the plane deﬁned by A, B, and pivoting point. The point with the maximum distance from the plane deﬁned by A, B, and pivoting point, is called M. The movement A-B was divided into two phases: A-M (retracting) and M-B (goal-seeking). The path lengths of the trajectories A-M and M-B were calculated and divided by the distance of the shortest path. Intuitively, a higher path length indicates less eﬃcient movement and lack of experience. Results: For trajectory A-M, we found no signiﬁcant diﬀerence between experts, residents, and novices (Mean+/)SD: 136+/)26, 149+/)42, and 156+/)29, respectively). In the second phase, M-B, we did ﬁnd a signiﬁcant diﬀerence (p<0.05) between experts, residents, and novices (242+/)76, 266+/)78, and 365+/)101, respectively). Moreover, within each group, a signiﬁcant diﬀerence (p<0.05) between movements A-M and M-B was observed. Conclusions: The goal-oriented movements in laparoscopy can be split into two phases: a retracting and a goal-seeking phase. Novices are less eﬃcient in this later phase of movement. The cause of the observed diﬀerence is that they are not yet used to the limited depth perception. Dividing the motion into two distinct phases gives a better overview on the movements characteristics that deﬁne diﬀerences in performance. Furthermore, the eﬀect of training can be objectively measured with this technique in the near future.

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DESIGN OF PHYSICAL TRAINING MODELS FOR THE LEARNING OF RESECTION SKILLS FOR TRANSURETHRAL RESECTION OF THE PROSTATE (TURP) AND OF BLADDER TUMOUR (TURBt) B. Tang1, F.J. Carter1, L. Christie1, D. Byrne2 1 University of Dundee, DUNDEE, United Kingdom 2 Ninewells Hospital, DUNDEE, United Kingdom

DETERMINING THE OPTIMAL FREQUENCY OF SKILL LABS FOR TRAINING ON ENDOSCOPIC SUTURING G. De Win, D. De Ridder, M. Miserez CST KU, LEUVEN, Belgium

Aim: The aim of this study was to design and compare physical training models for the learning of resection skills for TransUrethral Resection of the Prostate (TURP) and TransUrethral Resection of Bladder tumour (TURBt) Method and materials: 4 types (apple, plum, synthetic model, porcine kidney) of physical training models were developed for the skills acquisition for TURP. The diﬀerent types of model were tried and compared for the simple resection skill exercise and complex resection skills for TURP. Two types of lifelike bladder tutors (superﬁcial and ﬂat) were restructured using the cadaveric animal bladder tissue for the diagnostic and resection exercise skills for TURBt. Diﬀerent levels of cutting power setting for the TURBt training model were tested. Assessment forms were developed and used for the evaluation of the diﬀerent models. Feasibility to prepare, reality of shape and colour, sensation of texture, feeling of resection, conductibility of current, safety and eﬃcacy were the end point used for assessment of the models. The assessment criteria for each component were excellent (5), good (4), acceptable (3), reasonable (2), and unacceptable (0). Result: 4 consultant urological surgeons and 12 participants tried 4 types of diﬀerent models for TURP and two types of simulated bladder tumours (biological tissue) for TURBt. Analysis the result from assessment of the models by the consultants and trainees, it demonstrated that plum model is scored higher than the apple model and synthetic model (commercialised by a company) for simply resection skill exercise for TURP (P<0.001). Restructured kidney model is cored higher than synthetic model for complex skill exercise for TURP (P<0.001). Score obtained for restructured bladder tutor for TURBt was19. The power setting required for the restructured bladder tumour is higher (200–300 watts) than the normal setting on human. Conclusion: eﬃcient models could be developed and used for the transurethral resection skills exercise, which are better than the synthetic models. Current setting required for restructured bladder tumour is higher than on the real patient.

Introduction: This study was undertaken to determine the optimal distribution of training sessions to teach intracorporal endoscopic suturing, in medical students. Methods: A total of 145 novice subjects (medical students between age of 18 and 23) were recruited for this study. After baseline tests for spatial ability, motivation and ambidexterity, to ascertain comparability between the groups, the students were randomized into six groups to receive 6 training sessions of 1.5 h in laparoscopic intracorporal suturing. Group A received 3 training sessions per day with a rest period of 20 minutes in between during 2 consecutive days, Group B 2 sessions per day during 3 consecutive days, Group C 1 session per day during 6 consecutive days, Group D 1 training each 2 days, Group E 1 training session a week, and group F 1 training session a week with a possibility for Ôself-trainingÕ in between. The exercises performed in each group were similar. Each student did get the same standard feedback at the same time. After the ﬁnal training session, all groups had a 30-min rest period, followed by an evaluation test. A 5 cm chicken skin incision had to be closed with 3 knots, using the learned suturing technique. Cumulative time to adapt the skin edges adequately was used as endpoint for qualitative and quantitative analysis. The mean time (and SEM) for performance in each group was calculated. OneWay ANOVA analysis of variance (P<0.05) was used to assess statistical signiﬁcance. A TukeyÕs Multiple Comparison Test was used to ﬁnd differences between the 6 groups. Results: All groups were similar at the start. P value was 0.0030. The Tukey test revealed a statistical diﬀerence between group A and C (P<;0.01), group B and C, group C and E and group C and F (P<0.05). Conclusions: One training session of 1.5h a day seems the most beneﬁcial for learning intracorporal endoscopic suturing. We will now determine the long term retention of these suturing skills at 1 and 6 months after the training course.

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A NEWLY DEVELOPED PIG BLADDER MODEL: FUTURE FOR TRAINING OF THE TRANS-URETHRAL TUMOUR RESECTION (TURT) PROCEDURE IN UROLOGY B.M.A. Schout, V.E.M.G. Dolmans, N.A.M. De Beer, A.J.M. Hendrikx Catharina Hospital, EINDHOVEN, The Netherlands

ASSESSMENT OF TRAINEES FOR THEIR LAPAROSCOPIC TECHNICAL ERRORS BY EXTERNAL ERROR MODES (EEMs) IDENTIFICATION: Observational Clinical Human Reliability Analysis Technique M. Hussain1, B. Tang2, A. Cuschieri3 1 Stepping Hill hospital, STOCKPORT, United Kingdom 2 Surgical Skills Unit, Ninewells Hospital, DUNDEE, United Kingdom 3 Scuola Superiore SÕ Anna di Studi Univ., PISA, Italy

Background: Performance of a trans-urethral resection tumour (TURT) procedure requires endourological skills. Nowadays these skills are frequently trained in a manner in which the patient is the ﬁrst training subject for the inexperienced resident. Training on a model can shorten the learning curve, prevents unnecessary complications, and is more acceptable than direct training on the patient. Aim: To develop and validate a model for training the TURT procedure in order to obtain better-trained residents performing their ﬁrst TURT procedures on the patient. Methods: We developed a TURT model, consisting of a prepared pig bladder on a metal plate that functions as earth/ground. In the bladder mucosa we created papillary tumours. The entire model is placed inside a box. Six urologists and four residents performed a TURT procedure on this model. Afterwards they ﬁlled in a questionnaire. Results: The average score for realism was 8.0 on a scale of 1 to 10 (10 is good). Usefulness was scored as 8.6 on a scale of 1 to 10. The global score of the model was 8.5 on a scale of 1 to 10. The judgement of urologists was signiﬁcantly higher (Wilcoxon, p<0.05) when compared to residents for questions about usefulness of this simulator for training eye-hand coordination (9 vs. 7.8), three-dimensional vision training (8.8 vs. 7.3) and learning the cystoscopy procedure (8.8 vs. 6.5). Conclusion: This newly developed TURT-model is very promising. In a future study we will investigate whether questionnaire scores are biased by task performance. Also, the eﬀect on task performance of repeated training will be studied.

Aim: To identify external error modes (EEMs) i.e. underlying causative factors responsible for common technical errors committed by trainees of varying surgical experience during laparoscopic courses. Methods and materials: 62 surgical trainees were recruited for this study from essential and advanced laparoscopic courses with 34 and 28 of participants respectively. Animal (non-live) hepatobiliary restructured specimens were used for performance of simulated laparoscopic cholecystectomy by all trainees which were videotaped. Unedited recorded procedures were analysed for Calots triangle dissection and endoclipping. Observational Clinical Human Reliability Analysis Technique (OCHRA) technique was used to identify committed errors. Errors were classiﬁed as procedural (omission/ re-arranged steps) or executional (failure to correctly execute steps). Errors were further categorized as consequential or inconsequential based on their impacts. Commonly observed EEMs were I (not done), III (repeated), VII (too much force/depth), IX (wrong point in space) & X (wrong object or plane). Mann-Whitney-U test was used for statistical analysis with 5% signiﬁcance level. Results: Median for common EEMs III, VII, IX and X resulting in errors, were higher for basic course trainees compared to advance (i.e. 14.4 v 1.5, 13.0 v 5.5, 11.3 v 4.3 & 9.5 v 4.0 respectively) and the diﬀerence was signiﬁcant with p-value < 0.001 for each external error mode. While median for EEM I for basic and advance courses were 18.4 v 15.0 with insigniﬁcant diﬀerence; p-values <0.16. Conclusion: OCHRA helps us identify common causative factors (EEMs) responsible for frequently recurring errors committed by trainees. This would enable in setting-up ﬂexible and individually designed laparoscopic courses thereby minimizing the frequently occurring EEMs, subsequent errors and complications.

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DEVELOPMENT OF MAS IN THE ÔTHIRD WORLDÕ - MUTUAL BENEFIT AND NEW CHANNELS OF COMMUNICATION HERALD THE FUTURE? A. Schoucair Hochtaunuskliniken Bad Homburg, FRANKFURT AM MAIN, Germany

IMPLEMENTATION OF MOTOR SKILLS TRAINING TO COMPETENCE LEVEL PRIOR TO A BASIC LAPAROSCOPIC COURSE E.G.G. Verdaasdonk1, L.P.S. Stassen2, J.F. Lange3, J. Dankelman1 1 Delft University of Technology, DELFT, The Netherlands 2 Reinier de Graaf Gasthuis, DELFT, The Netherlands 3 Erasmus Medical Center Rotterdam, ROTTERDAM, The Netherlands

Despite limited economical resources MAS has spread to the so-called ÔThird WorldÕ with astonishing speed. In this presentation development of MAS in India as observed by a German surgeon is described. Factors inﬂuencing training of Indian surgeons, spread of modern techniques and quality control are identiﬁed. The importance of national and regional conferences is emphasized. The close contact and the regular communication between Indian and European surgeons are delineated. The thesis that both sides beneﬁt tremendously is examined. New channels of communication such as regular contact via internet (e-mails, mailing-lists) are evaluated. The author presents his 7 year personal experience from repeated visits to India with intensive, active participation in conferences and workshops. He depicts a new modality in exchanging experience rather than old-fashioned transfer of knowledge as a promising model for the future.

Aims: Laparoscopic skills courses with animal models are an important tool for training inexperienced residents. However, it is desirable that residents acquire competence in basic endoscopic motor skills (eye-hand coordination) prior to training in expensive animal models. The aim of the present study was to evaluate the feasibility and usefulness of eye-hand coordination training to a predeﬁned competence level prior to a laparoscopic course in animal models. Methods: The SIMENDO virtual reality (VR) simulator, installed with 6 SimSoft 1.0 exercises, was used. Ten surgical trainees entered the program and continued simulation until competence scores (75th percentile of predeﬁned expert scores in 3 consecutive task repetitions) were reached. Additional training to expert scores (50th percentile) was voluntarily. A questionnaire was ﬁlled out before and after the training in the simulator. Results: Most trainees (90%) had experience with assisting and even some (40%) with performing certain parts of laparoscopic procedures. Median simulator training time to competence level was 62 minutes (range, 20–77). Total number of repetitions needed to reach competence level varied widely between participants (median 52, range 31–75). The 25th percentile for the total number of repetitions needed was 38 compared to 59 for the 75th percentile. 30% of the trainees needed > 15 repetitions for both the 30 degree endoscope navigation and delicate needle handling compared to the other 30% that needed < 7 repetitions. Usefulness of this preparatory training was rated between 6–9 (median 8; on a scale of 1–10). 70% stated that the competence criteria were good, 30% thought it was too easy. All stated that the expert score were well deﬁned, although they completed only some of the exercises on expert level. Furthermore, the trainees indicated that the measured parameters in the simulator gave useful feedback and could objectively measure hand-eye coordination necessary for laparoscopy. Conclusion: Level of motor skills varies widely among surgical residents entering courses. VR simulation until required competence criteria is a useful and feasible method to prepare trainees before a basic laparoscopic course. With the use of the competence level the training is tailored to the level of the trainee.

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LAPAROSCOPIC RADICAL NEPHRECTOMY IN THE UK - NEW CONSULTANTS EXPERIENCE A.H. Engledow1, R. Marrireddy2, P. Tozer2, M. Hussain2, F. Mumtaz2, G. Webster2 1 LONDON, United Kingdom 2 Chase Farm Hospital, ENFIELD, United Kingdom

CO-OPERATION BETWEEN SPECIALTIES IS BENEFICIAL IN LAPAROSCOPIC UROLOGICAL TRAINING

Introduction: Laparoscopic radical nephrectomy is fast becoming the gold standard surgical treatment for renal malignancies in the United Kingdom (UK). The accepted beneﬁts of laparoscopic surgery must not be at the expense of oncological outcome. Concerns exist in the UK about urological laparoscopic training opportunities. We present the experience of two newly appointed consultant urologists in the UK. Methods: 56 consecutive patients with a pre-operative diagnosis of a renal malignancy on contrast enhanced multi-detector computerised tomography (ceMDCT) underwent attempted laparoscopic radical nephrectomy. Data entered prospectively into a database included age, sex, operative time, intra and post-operative complications, in hospital stay, conversion to an open procedure and histological resection margins. Results: 56 patients were included (23 female). Median age 66.7 years (range 33–88). Median operative time 177mins (range 75–266). Median in hospital stay 5 days (range 36 hours to 50 days). Four patients (7%) developed complications. Two patients had post-operative myocardial infarction. Clostridium diﬃcile diarrhea was treated successfully in one patient with oral metronidazole and one sub hepatic collection required radiological drainage. 13 (23%) procedures were converted to an open procedure, 10 through technical diﬃculties and failure to progress, and 3 for laparoscopically uncontrollable bleeding. There was one death. Final histology showed renal cell carcinoma (56). All had clear resection margins. Conclusion: Laparoscopic radical nephrectomy can be performed safely by newly appointed consultants oﬀering the beneﬁts of laparoscopic surgery when compared with the traditional open approach. Oncological outcome in the form of resection margins was not compromised.

A.H. Engledow1, P. Tozer2, R. Marrireddy2, M. Hussain2, S.J. Warren2, G. Webster2 1 LONDON, United Kingdom 2 Chase Farm Hospital, ENFIELD, United Kingdom Introduction: Laparoscopic training opportunities in general surgery are increasing rapidly in the United Kingdom. This is not necessarily the case in Urology. Many trainees are required to seek training opportunities abroad and junior consultants are forced to seek mentors who are in short supply. We suggest that combined operating, utilising the laparoscopic skills of the general surgeons, will advance laparoscopic urology in the UK. Methods: A combined operating list was set up for a newly appointed consultant urologist, and an experienced laparoscopic colorectal surgeon. 10 laparoscopic nephrectomies were performed as a combined procedure followed by 56 consecutive laparoscopic nephrectomies performed by the urologist alone. Data entered prospectively into a database included age, sex, indications for surgery, operative time, intra and post-operative complications, in hospital stay, conversion to an open procedure and histological resection margins for malignant resections. Results: 66 patients were included (31 female). Median age 64 years (range 33– 88). Indications for surgery were suspected malignancy (56) and non-functioning kidney (10). Median operative time 177mins (range 75–266). Median in hospital stay 5 days (range 36 hours to 50 days). Five patients (7%) developed complications. Two patients had post-operative myocardial infarction. Clostridium diﬃcile diarrhea was treated successfully in one patient with oral metronidazole, one sub hepatic collection required radiological drainage and one patient required re-operation for bleeding from an epigastric vessel at the extraction site. 13 (19%) procedures were converted to an open procedure, 10 through technical diﬃculties and failure to progress, and 3 for laparoscopically uncontrollable bleeding. There was one death. Final histology for the malignant cases showed 55 renal cell carcinomas and one squamous carcinoma all with clear resection margins in all cases. There were no signiﬁcant diﬀerences between the combined cases and the operations performed by the urologist alone. Conclusion: Laparoscopic urology is becoming more widely practiced. Co-operation between specialties may aid in skill acquisition. There may be a place for trainee laparoscopic urologists spending a period of training with established laparoscopic general surgeons to gain the necessary skills prior to consultant appointment.

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RADICAL PROSTATECTOMY: OPEN OR LAPAROSCOPIC? I.E. Khatkov1, A V Morozov2, R G Biktimirov3, T V Volkov2 1 Moscow State Medical Stomat.University, MOSCOW, Russia 2 Clinical Hospital N 6 of FMBA, MOSCOW, Russia 3 Clinical Hospital 119 of FMBA, MOSCOW, Russia

ULTRASOUND IN PROSTATE LITHIASIS DIAGNOSIS AND IN ENDOSCOPIC TREATMENT GUIDANCE

Purpose: To evaluate and compare prospectively the convalescence of patients after open radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and extraperitoneal laparoscopic prostatectomy (ELRP). Methods: The study included 85 patients after LRP, ELRP and RRP. The postoperative care of these patients was uniform and standardized. Results: From the 85 patients, 55 underwent RRP, 30 laparoscopic: 20 by transperitoneal, 10 by extraperitoneal approaches. The diﬀerences in mean age, preoperative prostate-speciﬁc antigen level, Gleason score, time to oral intake, and hospital stay were not statistically signiﬁcant between the LRP and RRP groups. The operating room time was signiﬁcantly longer (316 42 min. vs 189 18.9 min., P < 0.0001) and the estimated blood loss was signiﬁcantly lower in the LRP group (489 136 mL vs 1236 285 mL, P <0.001) than in the RRP group. Pain medication use was signiﬁcantly less in the LRP, ELRP groups (88 33 mg. vs 163 41 mg. tramadol, P <0.001), as was the time to complete convalescence (28 4 days vs 42 7 days, P <0.002). Mean catheter duration time (7.3 vs. 12 days, p < 0.001) and hospital stay (8.6 vs. 15 days, p < 0.001) were signiﬁcantly shorter in LRP and ELRP groups. There was no statistically signiﬁcant diﬀerence in complication rate in both groups (p = 0.139). Conclusions: LRP and ELRP are safe and more comfortable procedures for the patient. Complications do not appear more often than after open operation. In LRP and ELRP we detected shorter mean catheter duration time, shorter hospital stay and less blood loss. ELRP seems to be more comfortable to the surgeon because of better view of operating ﬁeld, and excluding of intraabdominal complications. This procedures demands perfect technical laparoscopic skills. All these types of procedures should be performed in specialized high technology centers.

N. Popescu, C. Tiu Municipal Hospital Campina, CAMPINA, Romania Background: After total gastrectomies or Bilroth II resections-, the duodenum remains excluded from the digestive circuit. Neither radiology nor endoscopy are of any use.Based on his own experience and also on the scientiﬁc literature concerning the ultrasound diagnosis of duodenal pathology, the author makes a simple proposal, proving the value of transcutaneus ultrasonography (TCUS) in the identiﬁcation of the restant duodenum. Material and Methods: First 2400 pacients are included in screening ultrasound examinations. There are checked the normal values of the wall thickness, the structure, the mucosal folds, the contain, the relationship with neighbour organs. On a 51 pacients lot with excluded duodenum after surgery for gastric cancer or non tumoral pathology, was applied an ultrasound protocol of investigation using Color Doppler and Power Doppler devices with 2,6 MHz, 3,5 MHz and 5 MHz, 6 MHz, 7 MHz frequence probes. Results: As a ﬁrst point of interest, we obtain concludent details about duodenal stump with a normal healing process of about 6–8 weeks, but also about pathological evolutive signs: leaks, local abscess and pneumoperithoneum. On the same time we obtained relevant data concerning the relation with Common Biliary Duct, Wirsung Duct, Pancreas. An enlarged duodenal wall with hipoecogenity of submucosal layers was correlated in two cases with histopathological aspect of chronic duodenitis. A diameter less than 50 mm, accompanied by alimentary fragments can be considered normal ﬁndings in long term evolution of excluded duodenum. A larger duodenum up to 90 mm with an higher intraluminal echogenity conduce to the suspicion of aferent loop syndrome Discussion: The screening showed a 2.6 mm average thickness of duodenum wall. For any preoperative ultrasound examination of the duodenum, to identify the pilor is mandatory. In postsurgical patients the landmarks for duodenal location are: the Portal Vein, the Common Duct, the Gall Blader and the Head of Pancreas. In these patients ultrasonography earns importance because of the particular missing of eﬃciency of the endoscopy and XRay. Conclusions: TCUS (performed by surgeons) could be of a real beneﬁt after eso or gastro-jejunal anastomosis, remainig the only one real-time imaging method suitable to following-up of the duodenum.

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TOTAL LAPAROSCOPIC AORTIC ANEURYSM REPAIR R. Kolvenbach, A. Puerschel, E. Schwierz, S. Wassiljew Augusta Hospital, DUESSELDORF, Germany

SUBFASCIAL ENDOSCOPIC PERFORATOR VEIN SURGERY: A PROSPECTIVE STUDY D. Lomanto, A. Katara, W-K. Cheah, J. So National University Hospital, SINGAPORE, Singapore

The following article describes our technique and results with total laparoscopic aortic aneurysm repair. Material and Methods: A transperitoneal left retrorenal access was used in al cases. Special laparoscopic clamps often in combination with balloon catheters were used to occlude the aorta and the renal arteries. Exactly the same techniques like in open surgery were used. Either a tube graft repair or a bifurcated graft anastomosed with the iliac bifurcation or the femoral artery was implanted to exclude the aneurysm. Results: In a four year period 131 patients with abdominal aortic aneurysms were operated using a total laparoscopic approach. In 55% a tube graft repair was performed and in the remaining, in 59 patients a bifurcated graft could be implanted. The mortality was 3% and major non lethal complications occurred in 17.5%. Conversion was required in 12 cases (9.1%). Conclusion: Laparoscopic surgery is becoming a third way to perform aortic repair. In contrast to EVAR it can oﬀer to aneurysm patients the same deﬁnitive outcome which we have in open surgery.

Aims: Subfascial endoscopic perforator surgery (SEPS) for ligation of incompetent perforator veins is a surgical option for patients with ulcers resulting from incompetence of superﬁcial and perforating veins, with or without deep vein incompetence. Methods: 21 patients (16F:5M) (42–82 yrs, means 60) with chronic venous insuﬃciency underwent SEPS procedure. Preoperative assessment of the limbÕs vascular status consisted of color-ﬂow duplex ultrasound imaging, ascending and descending phlebography, with venous mapping. Results: A total of 34 limbs (13 bilateral and 8 unilateral) underwent SEPS procedure. According to CEAP classiﬁcation for venous limb disease, 16 limbs belonged to group C5 (skin changes, pigmentation, venous eczema, lipodermatosclerosis, healed ulcer) and 5 limbs to group C6 (skin changes and active ulceration). SEPS was performed utilizing two trocars (12mm, 5mm). The subfascial space was dissected upto the medial malleolus and all perforator veins encountered were isolated and transacted, using clips (n=11) or ultracision (n=10)(Ethicon Endosurgery, USA). There was no signiﬁcant morbidity: 2 wound infections, 1 hematoma. Intraoperatively a mean of 5 perforator veins (range: 3–8) were detected and ligated. Saphenofemoral ligation was also performed in 32 limbs (94%). Of the 5 limbs in class C6 all showed ulcer healing within the follow-up period of 12 weeks. Conclusions: This study demonstrated the eﬀectiveness of the SEPS procedure for patients with chronic venous insuﬃciency. Minimal postoperative complications accompanied by ulcer healing and relief of lower extremity symptoms were achieved for all patients, underscoring the important role of incompetent perforator veins in the formation of chronic venous insuﬃciency.

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ROBOT ASSISTED LAPAROSCOPIC SURGERY OF THE INFRARENAL AORTA; THE EARLY LEARNING CURVE J. Diks, D. Nio, H.J. Bonjer, J.A. Rauwerda, W. Wisselink VU University Medical Center, AMSTERDAM, The Netherlands

MINIMAL ACCESS REPAIR OF INFRARENAL ABDOMINAL AORTIC ANEURYSM (MARAAA) M. Kakollu, S. Mahmud Wrexham Maelor Hospital, WREXHAM, United Kingdom

Introduction: Laparoscopic aortic surgery to date has not been widely embraced among vascular surgeons. This lack of faith is probably due to the technical diﬃculties, especially concerning the aortic anastomosis. Recently, robot assisted laparoscopic surgery (RALS) has been introduced to facilitate endoscopic surgical manipulation. Increasing the degrees of freedom, introducing 3-D visualization and facilitating hand-eye coordination, it potentially reduces the learning curve, thereby stimulating recognition of laparoscopic aortic surgery among vascular surgeons. Materials / Methods: Between February 2002 and May 2005, 17 men, median age 55 (range: 36–72), were treated in our institution with robotassisted laparoscopic aorto-bifemoral bypasses (ePTFE) for aortoiliac occlusive disease. Five patients were operated with the Zeus system between February 2002 and February 2003. In January 2004 our institution acquired a da Vinci surgical system and between February 2004 and May 2005 an additional 12 patients were operated. Dissection was performed laparoscopically and the robot was used to make the aortic anastomosis. Results: Median operative time was 365 minutes (range: 225 – 589), with a median clamp-time of 86 minutes (range: 25 – 205). Median blood loss was 1000 ml (range: 100 – 5800). A robot-assisted anastomosis was successfully performed in ﬁfteen patients. Three patients were converted to a laparotomy, one due to bleeding of an earlier clipped lumbal artery after completion of the robotic anastomosis, the others due to diﬃculties with laparoscopic exposure of the aorta and technical failure of the robotic system. One patient died unexpectedly on post-operative day 3 as a result of a massive myocardial infarction. Median hospital stay was 4 days (range: 3 – 57). Conclusions: Our experience with RALS shows it is a feasible technique for aortoiliac bypass surgery. After an initial learning curve, operation time, aortic clamp-time and hospital stay have been decreased to a fairly acceptable range. Reduction of the learning curve for laparoscopic aortic surgery with the use of a robotic surgical system might stimulate wide implementation of laparoscopic treatment for aortoiliac disease.

Objectives: To evaluate the use of Minimal Access Repair for Abdominal Aortic Aneurysm (MARAAA). Methods: Retrospective study of 40 patients who underwent elective minimal access repair of their AAA between 1998 and 2004. Outcomes recorded were duration of the operation, blood loss, number of days postoperative epidural, return of gastrointestinal function and hospital stay. The results were compared with a group of 9 patients who underwent conventional open repair performed through the full midline laparotomy. Results: The patients in the MARAAA group had a mean incision of 8cms compared to 28.5cms in the conventional group. The patients in the MARAAA group, showed earlier resumption of oral intake and hospital stay, in comparison with those in the conventional group, (solid diet 2.5 days versus 4.3 days: median hospital stay 5.6 days versus 14 days), post operative epidural (2.5 days versus 3.7 days) and blood loss (1039ml versus 1200ml) with comparable mortality and morbidity rates. Cardiac events were the most common complications followed by chest infections, transient renal failure and wound infection. There was no diﬀerence between the MARAAA and conventional repair groups for operating time (130 minutes versus 145 minutes). Follow up reveal average 2cm shrinkage of the scar. Conclusion: Minimal access repair is technically feasible and is believed to be relatively safe and eﬀective. It has the beneﬁts of a small incision and it appears to reduce patient recover time. Now the unit is moving towards completely laparoscopic repair of AAA.

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A STRATEGY FOR IMPLEMENTING ENDOSCOPIC AORTIC SURGERY I. Flessenkaemper Center for Vascular Diseases Berlin Mitt, BERLIN, Germany

TOTAL LAPAROSCOPIC AORTIC REPAIR FOR OCCLUSIVE AND ANEURYSMAL DISEASE: FIRST 120 CASES J. Cau, J.B. Ricco, M.C. Marchand, K. Benbelkacem University Hospital of Poitiers, POITIERS, France

Introduction: At the end of the nineties we saw a ﬁrst period some authors worked in the ﬁeld of aortic endoscopic surgery. Technical diﬃculties and errors combined with exhausting operating times were reasons against acceptance in the vascular surgical community. After the year 2000 some authors developed diﬀerent strategies in this area which created feasibility for this surgery.This was the moment for us to introduce this method into clinical practice. We found a beneﬁt for the patients, but as well dangers and pitfalls. The aim of this presentation is to describe a strategy derived from our experience for minimizing the learning curve during the introduction of aortic endoscopic surgery into clinical practice. Technique: The technical development concerns the positioning of the patient, material, suturing technques and details that simpliﬁed the method. Patients: 37 patients were operated. 14 patients were operated at the beginning in a videoscopically assisted manner. Planned conversion was part of the method at this time. 18 patients were treated for aortic occlusive disease with the intention to perform a complete endoscopic procedure, but in 2 cases we converted. 5 patients were operated for AAA with a complete endoscopic approach with one conversion to accept. Results: 21 patients got a full endoscopic procedure, but 24 had been planned to be treated this way. In the group of patients with full endoscopic treatment for aortic occlusive disease there was 1 death, 2 urologic complications, 1 inguinal bleeding, 5 lymphatic ﬁstulas and 1 postoperative delirium. Conclusion: Beside to some events that were not directly correlated to the endoscopic method there were two severe complications and one death occurred. This happened though there had been an intense preparation before starting the method. This learning curve might be ﬂattened by regarding a strategy for the implementation of this surgery. Part of the strategy is the right patient selection. Furtheron time management is important during the introduction as otherwise there might be the danger to stress patients, surgeons and the whole team.

Objectives: To analyze the outcome of our preliminary experience with total laparoscopic aortic repair in patients with occlusive or aneurysmal disease. Material and methods: From September 2002 to december 2005, we performed 120 consecutive total laparoscopic aortic repair procedures including 85 for aortic occlusive disease (Group A) and 35 for abdominal aortic aneurysm (Group B). Results: In group A, mean operating time was 207 +/) 40 minutes with a mean clamp time of 54 +/) 18 minutes and surgical conversion was required in two cases (2.3%). No postoperative death occurred but there were three postoperative complications necessitating re-intervention, i.e., retroperitoneal hematoma, embolic ischemia, and early prosthetic infection. Mean duration of hospitalization was 8 days (range, 4 to 42 days). All grafts were patent at two months. In group B, mean operating time was 242 +/) 45 minutes with a mean clamp time of 91 +/)15 minutes and surgical conversion was required in 7 cases (20%). There was one postoperative death (2,8%) due to pulmonary embolism and one non-fatal complication, i.e., retroperitoneal hematoma. Mean duration of hospitalization was 7 days (range, 4 to 16 days). All grafts were patent at two months. Conclusion: Total laparoscopic repair appears to be feasible and safe for occlusive and aneurysmal aortic disease. Operators must acquire perfect knowledge of human anatomy by performing anatomic dissection and skilful technique by training intensively on a pelvitrainer.

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MORBID OBESITY O396 THE IMPORTANCE OF VIDEO INTUBATION TECHNIQUES IN BARIATRIC SURGERY, (BS) G. Berci, M. Kaplan, R. Kariger, R. Naruse, A. Sloninsky, R. Tamman, H. Masanobu Cedars Sinai Medical Center and UCLA, LOS ANGELES, United States of America The astronomical increase in Bariatric Surgery would not be possible if it were not for basic laparoscopic advantages such as magniﬁed anatomy for easier manipulation, and the possibility of coordinated assistance oﬀered by the video image seen by the entire team. The ﬁrst step of a successful Bariatric surgery, following appropriate patient selection, assessment and preparation is rapid, uncomplicated, securing of the airway. The anatomy of the upper airway is often distorted due to a large tongue, the protrusion of abundant adipose tissue, etc. The extent of adipose deposition cannot be accurately assessed preoperatively, but only at the time of laryngoscopy. The rigid laryngoscope, (used in the vast majority of intubations), provides a limited keyhole view. Multiple intubation attempts resulting in oozing or edema of the glottic area are not unusual. In some cases, the ﬂexible intubating scope has to be used requiring additional skills and extending procedure time. The authors modiﬁed a standard Macintosh Laryngoscope by inserting a small TV camera into the handle. The image light carrier is built into the interchangeable blade. The Video Macintosh was used in 100 consecutive cases; 80 females, 20 males; BMI range 37–68 with an average of 48.5. 98 patients were intubated on the ﬁrst attempt, and only 2 cases required a second attempt.The bougie catheter was utilized to facilitate intubation in 38 cases. In no instance, was it necessary to use the ﬂexible scope. Every patient was extubated in the OR. No repeat intubation was required in the post-operative period. The video laryngoscope is of a great beneﬁt, especially in the morbidly obese patient who often presents a challenging airway anatomy, to complete intubation in a rapid and eﬃcient way. We feel that video technique is a great advantage in teaching laryngoscopy and tracheal intubation. (During the proposed oral presentation, a few video clips will be included.)

Abstract

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