Surg Endosc DOI 10.1007/s00464-015-4135-8

and Other Interventional Techniques

14th World Congress of Endoscopic Surgery and 22nd International Congress of the European Association for Endoscopic Surgery (EAES) Paris, France, 25–28 June 2014 Oral Presentations

Ó Springer Science+Business Media New York 2015 KARL STORZ—EAES AWARD SESSION

O001 - Intestinal, Colorectal and Anal Disorders

O002 - Intestinal, Colorectal and Anal Disorders

Variation in Outcome and Cost After Partial Colectomy for Diverticulitis in the United States

Sexual Dysfunction and Incontinence After Rectal Cancer Surgery. A Comparison of Results: After Laparoscopic and Open Technique in Color II

H. Fuchs, R. Broderick, C.R. Harnsberger, D.C. Chang, S. Ramamoorthy, S. Horgan University of California, San Diego, La jolla, CA, United States of America

G.S. Abis1, J. Andersson2, M. Gellerstedt2, E. Angenete2, U. Angera˚s2, M.A. Cuesta1, J. Rosenberg3, H.J. Bonjer1, E. Haglind2, P. Jess4 1

Background: Outcomes after surgery for diverticulitis across the United States are of continued interest to improve quality of care. Determining the variations in mortality, length of stay, and patient charges between the states are the aim of this study. Methods: A retrospective analysis of the Nationwide Inpatient Sample (NIS) database was performed. Patients with diverticulitis who underwent laparoscopic or open partial colectomy were identified by ICD-9 diagnosis codes and then subdivided by state. Patients younger than age of 18 years were excluded. Multivariate analyses examined mortality, length of stay (LOS), and total charges. Results were adjusted for age, race, gender, Charlson comorbidity index, and insurance status. Results: From 1998–2010, 148,348 patients had partial colon resection for diverticulitis. 90048 procedures were performed in hospitals with less than 5 % laparoscopic operations for diverticulitis. Using California as the comparison state, and after adjusting for other covariates, in-hospital mortality was significantly higher in the State of New York (adjusted OR 1.28; 1.10–1.51 95 % CI; P \ 0.05) and Mississippi (adjusted OR 2.75; 1.21–6.23 95 % CI, P \ 0.015). While California had a comparatively low mortality, Wisconsin even had a significant lower mortality rate (adjusted OR 0.72; 0.57–0.91 95 % CI, P \ 0.004). LOS was 1.2 days longer in New York and 0.54 days shorter in Wisconsin than in California (P \ 0.001). Patients with age [ 40 years and patients without private insurance had higher in-hospital mortality and longer length of stay. Average hospital charges differed dramatically between the different States in the observation period. Highest charging states were California, Nebraska, and Nevada while lowest charging states were Maryland and Utah. Conclusions: Patients who undergo surgical treatment for diverticulitis have high variation in mortality, LOS, and hospital charges when controlled for demographic and socioeconomic factors. Further analysis should be performed to identify the causes of outlier states in each category, with the goal of improving and standardizing best practices for all states.

VU University Medical Centre, Amsterdam, The Netherlands, Sahlgrenska University Hospital, Go¨teborg, Sweden, 3Herlev Hospital, Herlev, Denmark, 4Roskilde Hospital, Roskilde, Denmark

2

Aims: Health related quality of life (HRQL), as reported by patients, has become increasingly important when comparing surgical techniques. Earlier studies have suggested worse decreased sexual function in men after laparoscopic rectal resection compared to open surgery. This analysis compared sexual function and micturition symptoms 24 months after laparoscopic versus open surgery in a subset of a randomized trial. Method: COLOR II (COLorectal cancer Laparoscopic or Open Resection), a non-inferiority, open-label, randomized trial, was undertaken in 30 centres and hospitals in eight countries. In the context of this multi-centre randomized trial comparing laparoscopic and open surgery for rectal cancer we analysed patient-reported HRQL regarding sexual function and micturition symptoms. Participation in the HRQL study of COLOR II was optional for the participating hospitals. Patients completed the European Organization for Research and Treatment of Cancer (EORTC) QLQCR38 questionnaire before surgery and 4 weeks, 6, 12 and 24 months after surgery. Differences over time and between the two techniques were calculated. Results: Between 2004 and 2010 1103 patients were included in The COLOR II trial. In total, 617 patients were eligible for the HRQL study. Thirty-three patients were excluded from the COLOR II trial postrandomization, as inclusion criteria had been violated, and another 199 were primarily eligible but were not included due to logistic difficulties in retrieving preoperative HRQL data, cognitive disabilities, language difficulties or lack of consent. Thus, 385 patients were included in this study and 260 were operated by laparoscopic surgery and 125 by open surgery. There were no significant differences between laparoscopic and open rectal cancer surgery at any of the time points. We found that sexual function was more impaired than urinary function. Conclusion: We suggest that it is the surgical procedure itself and not the surgical-technique, in terms of laparoscopic or open surgery, that affects the sexual function. It confirms that the urinary function is less affected than sexual function after rectal cancer surgery.

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Surg Endosc

O003 - Gastroduodenal Diseases

O005 - Intestinal, Colorectal and Anal Disorders

Clinical Outcome of Laparoscopic Proximal Gastrectomy Compared with Total Gastrectomy

Morbidity after Loop Ileostomy Closure: Influence of Time and Laparoscopic Approach

Y. Sato, M. Inokuchi, K. Kato, H. Sugita, O. Sho, A. Kamiya, M. Nakagawa, H. Yanaka, K. Kobayashi, K. Kojima

N. Freixas Lopez, E.M. Targarona, C. Balague, M.C. Martinez, J.L. Pallares, J. Bollo, M. Trias

Tokyo Medical and Dental University, Tokyo, Japan

Hospital de Sant Pau, Barcelona, Spain

Aims: This study aims to assess the feasibility, safety, and oncological outcomes of laparoscopic proximal gastrectomy (LPG) compared with those of laparoscopic total gastrectomy (LTG) Methods: Between March 1999 and December 2013, we analyzed 40 patients who underwent LPG comparing with 25 patients who underwent LTG for early gastric cancer (EGC) in the upper third of the stomach. 6 patients underwent esophagogastrostomy and 39 patients underwent double tract reconstruction after LPG. All of 25 patients underwent Roux-en-Y reconstruction after LTG. Clinicopathological characteristics, surgical and oncological outcomes were compared between 2 groups. Results: There were no significant differences in demographics, pT stage, pN stage and pStage between 2 groups. The median pathological lesion size was significantly larger in LPG group than in LTG group (23 mm vs. 35 mm, p = 0.007). The median operative time was significantly shorter in LPG group than LTG group (288 minutes vs 385 minutes, p \ 0.001). There was no significant difference in first flatus, oral intake and postoperative hospital stay between 2 groups. Early complications occurred in 9 patients (23 %) in LPG group and 7 patients (28 %) in LTG group, indicating no statistical difference (p = 0.768). Anastomotic stricture occurred more frequently in LPG group than in LTG group (4 patients (10 %) in LPG group and 1 patient (4 %) in LTG group). However, it indicated no statistical difference (p = 0.641). All patients in LPG group who had anastomotic stricture underwent esophagogastrostomy for reconstruction. Overall survival was not significantly different between 2 groups (p = 0.582). Conclusions: LPG can be a feasible and acceptable method for treating proximal EGC in terms of surgical and oncological safety compared with LTG. Reconstruction method should be contrived to prevent anastomotic stricture after LPG.

Introduction: A loop ileostomy to protect a low anastomosis within the context of colorectal surgery is associated to a lower rate of anastomotic leakage and may reduce the need for emergency reoperation. However, the creation of a derivative stoma carries a high rate of morbidity. For that reason, the early closure of a loop ileostomy would provide a reduction in morbidity rates and a shorter hospital stay. Methods: Patients undergoing surgery for closure of a protective ileostomy (2004–2013) were included. Analyzed data: demographic data, surgical approach, date of surgery. Date of ileostomy closure and type of anastomosis. Data related to immediate postoperative bowel-related complications, reoperation, morbidity/mortality rates. We compared patients undergoing early closure of a loop ileostomy (less than 3 months) to those undergoing a delayed closure (3 months or later). We also compared the group of patients with no complications and the group suffering one complication or more. Results: 138 patients undergoing closure of a loop ileostomy were included: 96 patients within the early closure Group (EC) and 42 patients within the delayed closure Group (DC). When comparing both groups, 28 % of patients in the DC group had a laparotomy approach, only 6,3 % in the EC group (p \ 0,05). The postoperative hospital stay was 5 days shorter in the EC group (p \ 0,001), there were 14 reoperated patients within the DC group and none in the EC group (p \ 0,005). Morbidity rates were higher in the DC group, being the most frequent complications: postoperative ileus and surgical site infection (p \ 0,05). The average time until the closure of ileostomy was 5.2 months in the group without complications vs 11.2 months in the other group (p \ 0,001). Multivariate analysis demonstrated: the early closure and the laparoscopic approach reduce the morbidity rate. In fact, the risk of complications increases 17 % each month after surgery and the laparotomy approach increases by 2,8 the morbidity rate. Conclusions: The early closure of derivative stomas is safe and should be done as soon as possible after laparoscopic colorectal surgery. This may shorten the postoperative hospital stay and reduce the reoperative rate. As it is very low, we may not observe differences in the current mortality rate.

O004 - Intestinal, Colorectal and Anal Disorders

O006 - Intestinal, Colorectal and Anal Disorders

Surgical Site Infections After Colorectal Surgery for Inflammatory Bowel Disease and Diverticulitis

Routine Sigmoidoscopy Does Not Improve Outcomes During Sigmoidectomy for Diverticulitis: Results: of a National Prospective Study

F. Haggar, R. Wu, M.S. Rashid, H. Moloo, J. Mamazza The Ottawa Hospital Research Institute, Ottawa, Canada Background: Surgical site infections (SSIs) can significantly impact length of hospital of stay, post-operative morbidity and mortality, quality of life and the cost of health care. The objective of this study was to determine risk factors for SSIs after colorectal resections for inflammatory bowel disease (IBD, ulcerative colitis and Crohn’s disease) and diverticulitis. Methods: All hospital admissions data of patients undergoing elective colorectal for diverticular disease and inflammatory bowel disease performed in Australia between January 2001 and December 2010 were obtained from a national hospital morbidity database. A logistic regression model was fitted to identify independent risk factors associated with SSIs after index colorectal resections for benigh conditions. Emergent cases and surgery for colorectal malignancies were excluded. Results: A total of 19013 colorectal resections for diverticular disease (n = 9986) and IBD (n = 9027) were included in the analysis. The majority of procedures were performed using the laparoscopic approach (73.8 %). Patients who developed SSIs had a significantly higher overall co-morbidity burden (p \ 0.001), higher perioperative complication rates (p \ 0.001) and longer length of stay (p \ 0.01) compared with those who did not develop SSIs. The type of surgical technique used was found to be an independent risk factor for developing SSIs. Patients undergoing laparoscopic procedures had a significantly reduced risk of SSI compared with the open surgery patients (Odds ratio: 2.81; confidence interval: 2.59–3.05, p \ 0.001). Other significant independent risk factors for SSI included advanced age, male gender, hemorrhage and hematoma, wound dehiscence, intestinal obstruction and co-morbidities such as anemia, liver disease, coagulopathy, fluid and electrolyte disorders, congestive heart failure, pulmonary circulatory disease and renal failure (all p-values \ 0.05). Conclusions: Patients with inflammatory bowel disease and diverticulitis confer a high risk cohort for developing SSIs following colorectal surgery. Not surprisingly, patients undergoing the laparoscopic procedure had a significantly reduced risk of SSIs compared with patients in the open surgery cohort. Irrespective of the surgical technique used, the presence of major comorbidities and surgical complications (hemorrhage and hematoma, wound dehiscence, intestinal obstruction) leads to a significantly increased risk of SSIs.

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S.W. Ross, B. Oommen, M. Kim, J.F. Bradley, A.L. Walters, B.T. Heniford, V.A. Augenstein Carolinas Medical Center, Charlotte, NC, United States of America Aims: Sigmoidoscopy for visualization of anastomosis and air leak test during sigmoidectomy is commonly practiced. However there is little data on the effectiveness of sigmoidoscopy during sigmoid resection to improve patient outcomes. Methods: The National Surgical Quality Improvement Program database was queried from 2005–2011 for all partial colectomy with primary anastomosis with diverticulitis as the primary diagnosis. Sigmoidectomy was stratified by surgical approach into laparoscopic (LSE) and open sigmoidectomy (OSE). Sigmoidoscopy was further divided into those that underwent rigid (RSO) or flexible sigmoidoscopy (FSO). Patient outcomes were compared for the whole population and within approach strata by sigmoidoscopy status and by sigmoidoscopy type using standard statistical methods. Results: Among 12,317 sigmoidectomies that met inclusion 5,642 were LSE and 6,675 OSE. There were 706(5.7 %) patients that underwent sigmoidoscopy during sigmoidectomy, with 262 FSO and 444 RSO. For the total population, patient characteristics were similar between those that did not and those that had sigmoidoscopy: age (57.1 ± 12.7 vs 57.6 ± 12.7 years), male (46.3 % vs 47.5 %), BMI (29.4 ± 6.3 vs 29.4 ± 6.1 kg/m2), diabetic (9.3 % vs 7.7 %), smoker (22.4 % vs 24.9 %), Charlson Comorbidity Index (0.2 ± 0.7 vs 0.2 ± 0.5), and preoperative WBC (7.9 ± 3.3 vs 7.8 ± 3.0); p [ 0.05. However, cases using sigmoidoscopy were less likely to be emergent (5.7 % vs 2.0 %) or occur in patients with preoperative sepsis (5.8 % vs 2.9 %); p \ 0.05. Outcomes were similar between those that did not and those that had sigmoidoscopy: wound complications (11.5 % vs 12.6 %), minor complications (18.4 % vs 20.8 %), major complications (5.9 % vs 5.0 %), length of stay (6.8 ± 7.4 vs 6.6 ± 5.2 days), readmission (9.3 % vs 9.4 %), and death (0.5 % vs 0.1 %); p [ 0.05. NSQIP does not capture anastomotic leak as a variable but similar colorectal studies have used reoperation as a surrogate; rates of reoperation were similar (4.8 % vs 4.4 %); p [ 0.05. Furthermore, the outcomes were equivalent for those with and without sigmoidoscopy regardless of surgical approach. When sigmoidoscopy type was examined, outcomes between RSO and FSO for open and laparoscopic strata were similar. Conclusion: While rates of sigmoidoscopy were low in this population, sigmoidoscopy during sigmoidectomy did not improve patient outcomes or reduce re-operative rates when compared to sigmoidectomy alone. Operative approach and type of sigmoidoscopy also did not change outcomes.

Surg Endosc

O007 - Emergency Surgery Laparoscopic Approach to Appendectomy Reduces the Incidence of Long-Term Adhesional Bowel Obstruction: Meta-Analysis S.R. Markar1, M. Penna2, A. Harris2 1

St Mary’s Hospital, Imperial College, London, United Kingdom; Hinchingbrooke Healthcare NHS Trust, Huntingdon, United Kingdom

2

Aims: Laparoscopic appendectomy (LA) when compared to open appendectomy (OA) has been shown to improve short-term outcomes including postoperative pain, length of stay and wound infection rates. The aim of this meta-analysis was to determine the effect of a laparoscopic approach to appendectomy on shortterm and long-term postoperative bowel obstruction. Methods: Medline, Embase, trial registries, and reference lists were search for trials comparing the incidence of bowel obstruction following LA and OA. Subset analysis was performed for pediatric patients, patients who presented with perforated appendicitis, studies with long-term follow-up with surveillance for bowel obstruction, and surgery for bowel obstruction. Results: Overall 29 studies comprising 159729 patients (60875 LA vs. 98854 OA) were included with 42286 undergoing surgery for perforated appendicitis and 2007 laparoscopic converted to open procedures. 20 studies were focused on the pediatric population (37259 LA vs. 69274 OA). Follow-up period for the studies was highly variable however ten studies did describe a follow-up period of more than 3 years and were included in the long-term analysis. LA was associated with a significant reduction in the incidence of postoperative bowel obstruction in the general population (Pooled odds ratio (POR) = 0.43 (95 % CI 0.3–0.63)). Subset analysis demonstrated LA significantly reduced the incidence of postoperative bowel obstruction in pediatric patients (POR = 0.48 [95 % CI 0.3–0.78]) and patients with perforated appendicitis (POR = 0.44 [95 % CI 0.26–0.74]). Furthermore LA was associated with a significantly reduced incidence of long-term bowel obstruction (POR = 0.33 [95 % CI 0.19–0.56]) and bowel obstruction requiring surgery (POR-0.31 [95 % CI 0.2–0.48]). Conclusions: Appendectomy is a common surgical emergency and the long-term sequelae of surgical treatment have rarely been investigated. This present meta-analysis provides objective evidence to clearly demonstrate the benefits of a laparoscopic approach to appendectomy as reflected by a reduction in shortand long-term adhesive bowel obstruction. Important future areas for assessment include the influence of surgical approach on long-term quality of life following appendectomy and the effect of single-incision laparoscopic appendectomy upon long-term bowel obstruction. EAES Technology Award Session

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Surg Endosc EAES TECHNOLOGY AWARD SESSION

O008 - Basic and Technical Research

O010 - Training

Multispectral Imaging of Tissue Oxygenation and Perfusion in Bipolar Radiofrequency Induced Anastomoses: A Study of Tissue Viability in the Acute Porcine Model

The New 3D Visual System and Surgical Performance; How Stressed Are You?

S. Arya1, N.T. Clancy2, V. Chalau3, H. Kudo4, R.D. Goldin4, D.S. Elson2, G.B. Hanna3 Imperial College, London, United Kingdom; 2Hamlyn Centre, Imperial College, London, United Kingdom; 3Department of Surgery and Cancer, Imperial College, London, United Kingdom; 4 Department of Cellular Pathology, St. Mary’s Hospital, London, United Kingdom

A. Youssef, A. Bouhelal Barts Cancer Institute - Queen Mary, University of London, London, United Kingdom

1

Aims: Advanced bipolar radiofrequency (RF) energy is recognised to have the potential for forming bowel anastomoses. However, the optimal energy parameters are currently unknown. This study utilised a multispectral imaging (MSI) system to measure tissue oxygenation, a surrogate indicator of tissue viability, in bipolar RF induced anastomoses formed using different energy parameters. Similar measurements were additionally made in hand-sewn and stapled anastomoses, the current gold standard techniques. Methods: Twenty-three small bowel anastomoses (15 RF-induced side-to-side using three energy algorithms (n = 5 per algorithm), 4 hand-sewn end-to-end and 4 stapled side-to-side) were formed in six pigs and examined with a laparoscope mounted xenon light source. Backscattered light from the tissue was collected and transmitted to an attached spectral detection camera system. Sequential images were acquired of the tissue at multiple wavelengths of visible light (500–620 nm) to construct a reflectance spectrum at every point in the field-of-view. These were processed using a specifically developed algorithm to generate images showing relative concentrations of oxy- and deoxyhaemoglobin and hence, overall bowel oxygen saturation (SaO2). Six spectral measurements (three pre- and three post-anastomosis formation) were made at each anastomosis site to generate bowel SaO2 plots; from each of these, three 50 ± 50 pixel regions of interest (ROIs) were selected for analysis. The mean pre- and post-anastomosis SaO2 were compared across all regions of interest using a two-sample t-test (N = 414 ROIs). Results: Anastomoses were imaged at a mean of 210 minutes after formation (range 38–420 minutes). Mean pre- and post-anastomosis SaO2 across the ROIs in the five anastomosis groups were as follows: bipolar RF energy algorithm 1 (56 % vs. 36 %; p = 0.00004), bipolar RF energy algorithm 2 (55 % vs. 41 %; p = 0.0054), bipolar RF energy algorithm 3 (66 % vs. 35 %; 0.00001), hand sewn (73 % vs. 56 %; p = 0.0004), stapled (74 % vs. 57 %; p = 0.0014). Anastomosis site multi spectral imaging demonstrated a consistent and statistically significant drop in tissue perfusion and oxygenation following the creation of all anastomoses. Conclusion: Multispectral imaging is a promising technique for intraoperative visualisation and quantification of tissue oxygenation. Future studies will investigate the correlation between the acute drop in oxygen saturation and intermediate outcomes for different anastomoses.

Aims: The new emerging visual system is rapidly embraced in the surgical fields due to its proven superior positive impact, particularly in decreasing errors and increasing accuracy. However, despite its established expediency as a vision system, its effect on the physiological status of the surgeon and correlation to his/her surgical performance remains under-investigated. In our study we explored the physiological impact of 3D vision system and potential stress manifestation on the operating surgeon and it’s bearing on performance Methods: 26 medically fit surgeons with homogenous experience level were randomly recruited and objectively assessed using a validated curriculum with proficiency criteria. The blood pressure (BP) and heart rate (HR) of the candidates were measured at pre-set interval in a standardized manner periodically throughout the task. Data was collected and analyzed and correlation was performed using Pearson. Results: All surgeons demonstrated statistically evident superior performance in terms of less slippage errors (P-value = 0.003) and gap errors (P-value = 0.015). The mean baseline of BP prior to training was measured at 124/83 mmHg with systolic range of 108–154 and diastolic range of 71–102 mmHg with mean HR of 88 bpm and range on 73–103. During and throughout training the average BP recorded was 127/87 with systolic range of 100–156 and diastolic range of 68–107 mmHg and mean HR of 91 bpm and range on 66–124. Although Pearson’s correlation was positive as HR and BP was measured throughout the task (HR = 0.06, Systolic BP = 0.23 and Diastolic = 0.31), that did not demonstrate statistical evidence in terms of increased HR (P-value = 0.61) and BP (Systolic BP: P-value = 0.11 and Diastolic BP: P-value = 0.08). Conclusions: 3D offers superior visual feedback that positively reflects in accuracy and precision of surgical performance without any evident substantial physiological impact on the operating surgeon.

O009 - Robotics, Telesurgery and Virtual Reality

O011 - Technology

Bio-Elastic Patient-Specific Organ and Abdominal Cavity Replication Using Multi-material 3D Printer for Robotic Surgical Simulation

Evaluation of a Hands-Free Pointer for Surgical Instruction in Minimally Invasive Surgery

M. Sugimoto Kobe University, Kobe hyogo, Japan The multi-material 3D printer allows the creation of surgical models of realistic nature and mimicking real tissues. We developed new organ and abdominal cavity replica enabled manufacturing patient-specific bioelastic 3D organ and abdominal cavity models using 3D printing system of Bio-Texture Modeling by simultaneous jetting of different materials. We evaluated its benefit in robotic laparoscopic surgery simulation. Based on MDCT data, after generating an STL-file of the organ surface, the inkjet 3D printer created a 3D organ model. Simultaneously we manufactured the transparent whole abdominal wall replica from the maps of inner shape of the abdominal cavity by regenerating patient-specific MDCT data. This system enabled the simultaneous use of three different rigid and flexible materials to form 3D organ textures and structures. The patient individual 3D printed models were used to plan and guide the successful surgical procedures in 10 robotic laparoscopic surgeries. The 3D organ replicas using combination of transparent and soft materials allowed creation of translucent models that show visceral organs, tumors blood vessels and other details, overcome the limitation of the conventional image-guided navigation. The actual size transparent organ model with vessels and tumor such kidney and liver could be manufactured and be handled. The elastic GI tract, bile duct, and solid organs (liver, pancreas, etc.) and bony structure were useful for simulation and educational aspects. Our transparent abdominal and pelvic replica is delivered with a set of several interchangeable anatomies that represent different surgical procedures. These anatomies enable the trainee to virtually encounter and learn various pelvic conditions before they perform the exam on a live patient. Trainees gain the ability to recognize normal and abnormal gastrointestinal and urological findings and practice using the proper techniques to perform laparoscopic surgery. These provided reduction of operation time and better anatomical reference tool as a tailor-made simulation and navigation in robotic surgery and contribute to improvement of the medical education for students and trainees. We believe that our sophisticated personalized bio-elastic organ and abdominal wall replication can provide anatomically realistic recreations of many operations and offer obvious benefits, especially in mastering counterintuitive techniques in minimal access surgery.

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L. Siroen1, S. Hossain2, C.D. Ward3, A.L. Trejos3, R.V. Patel3, M.D. Naish3, C.M. Schlachta3 London Health Sciences Centre, London, Canada; 2Schulich School of Medicine, London, Canada; 3Lawson Health Research Institute, London, Canada 1

Training surgeons to perform Minimally Invasive Surgery (MIS) requires surgical residents to operate under the direction and supervision of a consultant. However, the inability of the instructing surgeon to point at the laparoscopic monitor without releasing his or her surgical instruments remains a barrier to efficient instruction in the operating room. The Wireless Hands-Free Surgical Pointer (WHaSP) has been developed to aid instruction during MIS. The objective of this study was to evaluate the efficiency and value of the WHaSP as an instructional tool as compared with conventional instructing methods during MIS. A total of 101 laparoscopic cholecystectomy procedures were randomized with respect to using or not using the WHaSP. Audio and video from the surgeries were recorded and periods in which instruction was taking place were extracted and analyzed. Instructing surgeons provided feedback through a post-operative questionnaire that used a five-level Likert scale. The time-based measures extracted from the video were compared by means of a multivariate analysis. The questionnaire results were analyzed using a two-sided Pearson chi-square test. The use of the WHaSP resulted in a slight increase in surgery time (2112 s vs. 2099 s, p = 0.015). The questionnaires showed that WHaSP users found it to be comfortable to wear (4.86), easy to use (4.44), easy to move (4.14), easy to keep stationary (4.43) and if given the choice, use a commercially available WHaSP (4.54). Compared to when the WHaSP was not used, users found communication to be more effective (4.62 vs. 4.15, p = 0.008), locations were easier to communicate (4.64 vs. 4.02, p = 0.022), and instructions were easier to follow (4.52 vs. 4.08, p \ 0.001). Overall, the WHaSP was well liked and was perceived as significantly improving communication while instructing within the operating room.

Surg Endosc

O013 - Technology

O014 - Clinical Practice and Evaluation

Electrostatic Precipitation is a Novel Way of Maintaining Visual Field Clarity During Laparoscopic Surgery. A Double Blind Randomised Controlled Pilot Study

A Randomized Controlled Trial on Comparison of AirsealÒ Versus Standard-CO2 Pressure Pneumoperitoneum Insufflator in Visceral Surgery

J. Ansell1, N. Warren1, P. Wall1, K. Cocks1, S. Goddard1, R. Whiston2, M. Stechman2, D. Scott-Coombes2, J. Torkington2

R. Luketina, M. Knauer, G. Ko¨hler, O. Koch, K. Strasser, M. Egger, K. Emmanuel

1 WIMAT, Cardiff, United Kingdom; 2University Hospital of Wales, Cardiff, United Kingdom

Krankenhaus der Barmherzigen Schwestern Linz, Linz, Austria

TM

Aims: Ultravision is a new device that utilises electrostatic precipitation to clear surgical smoke. The aim is to evaluate its performance during laparoscopic cholecystectomy. Methods: Patients undergoing laparoscopic cholecystectomy were randomised into ‘active (device on)’ or ‘control (device off)’. Three operating surgeons scored the percentage effective visibility and 3 reviewers scored the percentage of the procedure where smoke was present. All assessors also used a 5-point scale (1 = imperceptible/excellent and 5 = very annoying/bad) to rate visual impairment. Secondary outcomes were the number of smoke related pauses, camera cleans and pneumoperitoneum reductions. Mean results are presented with 95 % Confidence Intervals (CI). Results: In 30 patients (active n = 13, control n = 17) the effective visibility was 89.2 % (83.3–95.0) for active cases and 71.2 % (65.7–76.7) for controls. The proportion of the procedure where smoke was present was 41.1 % (33.8 to 48.3 %) for active cases and 61.5 % (49.0 to 74.1) for controls. Operating surgeons rated the visual impairment as 2.2 (1.7 to 2.6) for active cases and 3.2 (2.8 to 3.5) for controls. Reviewers rated the visual impairment as 2.3 (2.0 to 2.5) for active cases and 3.2 (2.8 to 3.7) for controls. In the active group, 23 % of procedures were paused to allow smoke clearance compared to 94 % of control cases. Camera cleaning was not needed in 85 % of active procedures and 35 % of controls. The pneumoperitoneum was reduced in 0 % of active cases and 88 % of controls. Conclusions: UltravisionTM improves visibility during laparoscopic surgery and reduces delays in surgery for smoke clearance and camera cleaning.

Aims: AirSealÒ is a novel class of valve-free insufflation system that enables a stable pneumoperitoneum with continuous smoke evacuation and CO2 recirculation during laparoscopic surgery. Comparison data to standard CO2 pressure pneumoperitoneum insufflators scares. The aim of this study is to evaluate the outcome and potential advantages of AirSealÒcompared to a standard CO2 insufflator. Methods: Between January 2013 and January 2014, patients undergoing elective laparoscopic cholecystectomy, colorectal surgery and hernia repair were randomized using a webbased randomization system to the AirSealÒ (group A) or standard pressure CO2 insufflator (group S) approach. Primary outcome were measured by operative time and level of postoperative shoulder-tip pain by using the visual analog score (VAS). Secondary outcome were the evaluation of immunological values through blood tests, anaesthesiological parameters, surgical side effects and length of hospital stay. Results: A total of 198 patients were randomized into group A (n = 101) and group S (n = 97). There was no difference between the two groups regardless indication for operation. Five patients from the group A and no patients from group S were converted to an open procedure (p = 0.06). There was no significant difference in operative time (p = 0.226). The VAS for pain was significantly lower in the group S on first postoperative day compared with the group A (1.14 ± 1.93 vs. 2.23 ± 2.52, p = 0.01). Thrombocyte count at suture was significantly higher in the group A than in the group S (p = 0.01). There was a significant difference in postoperative tidal volume and respiratory minute volume between the groups (p = 0.013; p = 0.025). There was no significant difference in length of hospital stay and surgical side effects. Conclusion: AirSealÒ has no advantages in operating time and is not superior for outcomes regarding shoulder-tip pain compared to standard CO2 insufflators in elective laparoscopic surgery. Registration number: NCT01740011 (http://www.clinical trials.gov) EAES - EUROPEAN CUP SESSION

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Surg Endosc EAES - EUROPEAN CUP SESSION

O316 - European Cup

O319 - European Cup

Long-Term Follow-Up and Management of Partial Cholecystectomy

Transanal Endoscopic Microsurgery After Endoscopic Polypectomy

S. Khan, K. Lee, D. Gooch, D. Menzies, J. Reed

S. Arolfo, A. Arezzo, M. Migliero, M.E. Allaix, F. Cravero, M. Morino

United Kingdom

University of Torino, Italy

Background: Traditionally difficult laparoscopic cholecystectomies were converted to open cholecystectomies. With wider experience of advanced laparoscopic skills and the advent of interventional radiology this practice has changed and the incidence of open cholecystectomies has decreased significantly. In difficult cholecystectomies, surgeons now often perform subtotal cholecystectomy with the expectation that no further intervention will be required or that any further symptoms could be treated by radiological intervention or a laparoscopic redo total cholecystectomy. Methods: Retrospective analysis of patients undergoing sub-total cholecystectomy from 2001 to 2013 were analyzed. Data was collected for patients who had persistent symptoms, which required further re-admission or subsequent radiological or surgical interventions. Results: 4396 cholecystectomies including elective and emergency were performed during the period 2001 to 2013. Out of 4396 cholecystectomies, 140 patients underwent subtotal/partial cholecystectomy. 48 out of 140 (34 %) required ERCP, 42 out of 140 had bile lead (30 %). 8 out of 140 sub-total cholecystectomies underwent laparoscopic redo total cholecystectomy. Conclusions: 3.2 % risk of sub-total cholecystectomy in patients who undergo laparoscopic cholecystectomy 1 in 3 sub-total cholecystectomies will require further ERCP. 6 % of subtotal cholecystectomies will require a further total cholecystectomy. Recommendation: Sub-total cholecystectomy is a good option for difficult cholecystectomy preventing major duct/vascular injury. 40 % of sub-total cholecystectomy will require further intervention. Patients requiring a completion laparoscopic cholecystectomy after previous sub-total cholecystectomy should be referred to upper G.I surgeon.

Objective: To assess the results of Transanal Endoscopic Microsurgery (TEM) after endoscopic polypectomy in terms of residual disease, recurrence and need of further surgery. Methods: 238 TEM were performed between 2008 and 2012 in our centre. 39/238 patients underwent a TEM to radicalize an endoscopic polypectomy (EP). Mean age was 67.7 ± 10 years. Mean distance from the anal verge was 7.41 ± 2.58 cm. Pathological examination of the lesion removed by EP revealed a cancer in 27 cases (69.2 %) and an adenoma in 12 cases (30.8 %), 9 High Grade Dysplasia (HGD) and 3 Low Grade Dysplasia (LGD). Macroscopic residual disease after EP was identified by rigid rectal endoscopy and confirmed by multiple biopsies. Results: 4/27 patients with cancer, with or without macroscopic residual disease, had a pT2 cancer at post TEM histology, and underwent salvage surgery (3 Total Mesorectal Excisions, TME, and 1 Abdominoperineal Resection). Post TEM Histology revealed HGD Adenoma in 4/27 cases and no residual disease in 19/27 (70 %). Among the 12 patients with adenoma, 3 without macroscopic residual disease turned out fibrotic tissue. 9/12 patients had macroscopic residual disease: post TEM Histology showed in 1/9 a pT2 cancer (who underwent TME), in 4/9 a HGD adenoma, in 2/9 a LGD adenoma and in 2/9 fibrotic tissue. Patients who underwent salvage surgery (5/39) are free from disease at 8, 22, 29, 30, 32 respectively. Patients with a previous cancer diagnosis without residual disease at post TEM Histology (19/39) are free from disease with a mean follow-up of 12.95 ± 12.31. None of the 10 patients with a post TEM Histology showing adenoma (4/10 with a previous cancer diagnosis) had a recurrence, even benign, with a mean follow up of 13.2 ± 12.98. Conclusion: Full thickness TEM, even after endoscopic resection of rectal lesion, represents an adequate treatment, resulting curative in a high percentage and useful in a limited number of cases to orient towards a radical surgery

O318 - European Cup

O320 - European Cup

Transvaginal-Assisted Laparoscopic Colorectal Resection

Laparoscopic Peritoneal Lavage or Sigmoidectomy for Generalized Peritonitis Due to Perforated Diverticulitis; Results: Of a Multicenter Randomised Trial (The Ladies Trial)

J. Noguera Hospital General Universitario de Valencia, Valencia, Spain The minimally invasive surgery through natural orifices has revolutionized the laparoscopic surgery for abdominal procedures. The use of the vaginal approach is not new for gynecologists but it is a new concept for the non-gynecological laparoscopic surgeons. The use of this new approach has been used to perform some procedures and to extract specimens after a laparoscopic surgery. There are few papers with clinical experience and a lot of philosophical papers about NOTES. The transvaginal approach has shown safe with the previous experience of gynecological surgery. Thanks to this experience, we have learned that the general complication rate is low and with easy resolution as well as serious complications like rectal, bladder or vascular injury is extremely low. Besides, the vaginal wall opening and closing is simple for surgeons with some experience in pelvic surgery. The experience of the transvaginal approach in colorectal surgery has enrolled in the world a low number of patients (around 250 patients). Most experience in this type of surgery comes from caseseries grouped in most studies of 10 to 20 patients. The transvaginal route is used in colorectal surgery primarily for extracting the specimen. In some cases there had been any surgical gesture from the vagina, as the section of the mesenteric vessels, colorectal section or assistance to the preparation of the anastomosis. In these procedures, the use of rigid instrumental from vaginal access is the standard, with a minimal experience in the use of the flexible endoscope. The most common procedure performed is right hemicolectomy, being the standard procedure the intracorporeal anastomosis and transvaginal specimen extraction. The removal of assistance laparotomy is the great advantage of transvaginal assistance, eliminating the morbidity resulting from this laparotomy, mainly surgical wound infections and postoperative ventral hernias. The left colectomy and rectal approach are the other procedures performed using the transvaginal approach, in many cases to avoid the laparotomy for specimen extraction. In the presentation we can see the surgical way to reach the abdominal cavity through the vagina, the possibility of transvaginal instrumentation and the way to extract the resected colon and to assist the anastomosis, as well as the ease and safe closure of the vagina.

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S. Vennix1, G.D. Musters1, H.A. Swank1, I.M. Mulder2, E.C.J. Consten3, M.A. Boermeester1, S. Van Dieren1, J.F. Lange2, W.A. Bemelman1 1

Academical Medical Center, Amsterdam, The Netherlands, Erasmus Medical Center - Havenziekenhuis, Rotterdam, The Netherlands, 3Meander Medical Center, Amersfoort, The Netherlands

2

Background: Perforated diverticulitis of the sigmoid colon can result in a life threatening condition requiring emergency surgery. There is neither evidence nor consensus what operation should be done in case of both generalised purulent and feculent peritonitis. The aim of the Ladies study was to compare the morbidity and mortality rate of laparoscopic lavage with sigmoidectomy in case of purulent peritonitis (LOLA-arm) and sigmoidectomy with or without primary anastomosis in purulent and faecal peritonitis (DIVA-arm). We will report on the LOLA-arm that was prematurely closed by the data safety monitoring board. Methods: In a multicentre trial, patients with generalised purulent peritonitis due to perforated diverticulitis were randomised between laparoscopic lavage and sigmoidectomy. Before randomisation, diagnostic laparoscopy was performed to confirm the diagnosis. The primary outcome for the LOLA-arm was a combined endpoint of severe morbidity and mortality at 12 months follow up. The study was conducted according to the Good Clinical Practice guidelines and was registered with ClinicalTrials.gov, number NCT01317485. On site monitoring was performed by an independent clinical research associate at regular intervals according to a predefined plan. An independent data and safety monitoring board evaluated the results after every 25 included patients. Results: Preliminary results of the terminated LOLA arm including the 12 month follow up will be presented. Conclusion: Laparoscopic peritoneal lavage is not superior over sigmoidectomy for treatment of generalized purulent peritonitis following perforated diverticulitis. Funding: This research was funded by a ZonMW Dutch Governmental grant. EAES - WORLD CUP SESSION

Surg Endosc EAES - WORLD CUP SESSION

O322 - World Cup

O324 - World Cup

Does Simulation Improve Learning of the Fundamental Use of Surgical EnergyTM (Fuse) curriculum? A randomizedcontrolled trial in surgical trainees

Laparoscopic-Assisted Robotic Sphincter-Saving TME: Hybrid Approach

A. Madani, Y. Watanabe, MC Vassiliou, P Fuchshuber, DB Ones, S Schwaitzberg, GM Fried, LS Feldman McGill University, Montreal, Canada Introduction: While energy devices are ubiquitous in the operating room, they remain poorly understood and can result in significant complications. The Fundamental Use of Surgical EnergyTM (FUSE) program was created to address this safety gap. The purpose of this study was to investigate, in surgical trainees, the effectiveness of the FUSE curriculum for electrosurgical training and estimate the extent to which the addition of a novel simulation-based component improves educational outcomes. Methods and Procedures: First and second year surgical residents participated in a 1-hour didactic electrosurgery (ES) course, based on the FUSE curriculum. They were then randomized to one of two groups: an unstructured hands-on session where trainees used ES devices (control group) or a goal-directed simulation training session (Sim group). The one-hour simulation session included four bench-top modules designed to teach the safe use of ES devices. Pre- and postcurriculum knowledge of the safe use of ES was assessed using separate 35-item multiple-choice examinations. Self-perceived competence with each course objective and comfort with the performance of 7 tasks related to the safe use of ES were measured using Likert scale questionnaires. Data are expressed as median (interquartile range). Mann-Whitney-U test determined significance (p \ 0.05). Institutional ethics approval was obtained. Results: Fifty-six (29 control; 27 Sim) surgical trainees completed the curriculum (median age 27; 64 % male). Baseline characteristics, including pre-curriculum exam and questionnaire scores, were similar between the two groups. Total score on the exam improved from 46 % (40–54 %) to 84 % (77–91 %), p \ 0.0001 for the entire cohort, with higher post-curriculum scores in the Sim group compared to controls (89 % (83–94 %) vs 83 % (71–86 %), p = 0.02). This difference was due to better performance for the Sim group on the exam sections ‘Principles of Electrosurgery’ (91 % (86–100 %) vs 82 % (73–91 %), p = 0.004) and ‘Electrosurgery-Related Adverse Events’ (86 % (82–93 %) vs 71 % (64–86 %), p \ 0.0001). On the pre-curriculum questionnaires, participants in both groups reported feeling ‘Uncomfortable’ for all 7 tasks or ‘Not Competent’ with most of the 35 course objectives (Sim: 33/35 objectives; control: 31/35 objectives). Post-curriculum, the majority of participants felt either ‘Comfortable’ or ‘Very Comfortable’ for all 7 tasks, and either ‘Partially Competent’ or ‘Fully Competent’ for all 35 objectives. A higher proportion of the Sim group felt ‘Very Comfortable’ or ‘Fully Competent’ (Sim: 3/7 tasks and 28/35 objectives; control: 0/7 tasks and 10/35 objectives). Conclusion: A two-hour curriculum based on the FUSE program improved surgical trainees’ knowledge and comfort in the safe use of electrosurgical devices. The addition of a structured interactive bench-top simulation curriculum further improved learning.

H. Cheung Pamela Youde Nethersole Eastern Hospital, Hong Kong In the past few years, a number of reports in the literature suggest that Robotic Total Mesorectal Excision (RTME) may overcome some of the hurdles of conventional laparoscopy, resulting in low rates of conversion and positive resection margins. In contrast to RTME, the use of robotic surgery for colon resections has met with little enthusiasm. Few laparoscopic colon surgeons have seen a benefit in routinely adopting robotics, and no study so far has suggested a significant advantage of robotic compared with conventional laparoscopic colectomy. The reasons for this includes: firstly, during robotic surgery, attention to adjacent or distant operative field usually requires cumbersome repositioning of the camera and robotic arms leading to the extreme of undocking and redocking and this may result in longer learning curve as well as longer operating time. Secondly, the advantages of using the robot over laparoscopy are less applicable in robotic colonic surgery, since the access to the operative field in colonic surgery can be adequately achieved by using standard laparoscopy. Robotic platform is actually best suited for surgical approach in a confined visual field. Up till now, the current evidence suggested that robotic-assisted laparoscopic rectal resection represents the main indication for the use of the robotic system in colorectal surgery. Not only the robotic approach can offer a superior exposure during pelvic dissection and a better counter-traction but there are also reduction in the circumferential margin positivity rates and improved autonomic nerve preservation as showed in some recent published studies with earlier and better recovery of the sexual and functional outcomes after robotic TME as compared with laparoscopic TME to justify its increased cost. So here-in I am going to show you a video of robotic-assisted laparoscopic sphinctersaving TME (hybrid approach) for a 54 years-old man diagnosed to have locally advanced carcinoma of rectum underwent robotic-assisted laparoscopic sphincter-saving TME after a long course neoadjuvant chemoirradiation. The operative time was 175 minutes with blood loss around 30 ml. He has uneventful recovery and pathology showed T3N0 carcinoma of rectum with clear margins. He was discharged home on postoperative day 6.

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O015 - Morbid Obesity

O017 - Pancreas

Comparison of Two-Year Outcomes of Laparoscopic Greater Curvature Plication Versus Laparoscopic Sleeve Gastrectomy

Laparoscopic Pancreatic Resection for Invasive Pancreatic Ductal Adenocarinoma

V.V. Grubnik1, O.B. Ospanov2, K.A. Namaeva2, V.P. Golliak1, M.S. Kresun1

A. Cho, H. Yamamoto, O. Kainuma, H. Yanagibashi, T. Tonooka, A. Ikeda, H. Souda, Y. Nabeya, N. Takiguchi, M. Nagata

Odessa national medical university, Odessa, Ukraine; 2Medical University Astana, Astana, Kazakhstan

Chiba Cancer Center Hospital, Chiba, Japan

1

Introduction: Laparoscopic greater curvature placation (LGCP) is a new restrictive bariatric procedure witch has a similar restrictive mechanism like laparoscopic sleeve gastrectomy (LSG) without potential risk of leak. Aims: of the study was to compare effectiveness and safety of LSG and LGCP. Methods: Multicenter prospective randomized study was started in 2010. A total 54 patients with morbid obesity were allocated either to LGCP group (n = 25) or LSG group (n = 27). Main exclusion criteria were: ASA [ III, age [ 75, BMI [ 65 kg/m2. There were 40 women and 12 men, mean age was 42,6 ± 6,8 years (range 35–62). Data on the operation time, complications, hospital stay, body mass index loss (BMIL), percentage of excess weight loss (%EWL), loss of appetite and improvement of comorbidities were collected during the follow-up examination. Results: All procedures were completed laparoscopically. The mean operative time was 92,0 ± 15 min for LSG and 73 ± 19 min for LGCP (p [ 0,05). The mean hospital stay was 4,0 ± 1,9 days in the LSG group and 3,8 ± 1,7 days in LGCP group (p [ 0,05) One year after surgery, the mean %EWL was 59,5 ± 15,4 % in LSG group and 45,8 ± 17 % in LGCP group (p [ 0,05). After 2 years, mean %EWL was 78,9 % ± 20 % in the LSG group and 42,4 ± 18 % in the LGCP group (p \ 0,01). Loss of feeling of hunger was 28 % in LGCP group and 76 % in the LSG group (p \ 0,05). The comorbidities including diabetes, sleep apnea and hypertension, were markedly improved in both group after surgery. Conclusions:The short-term outcomes of the study demonstrate the equal effectiveness of both procedure, but longer follow-up showed that LGCP is worse than LSG as a restrictive procedure for weight loss.

Aims: Laparoscopic pancreatic resection for invasive pancreatic ductal adenocarcinoma(PDAC) is still not universally accepted as an alternative approach for open surgery because of technical difficulties and a lack of consensus regarding the adequacy of this approach for malignancy. The present study aimed to compare laparoscopic and open pancreatic resection for PDAC to investigate their outcomes. Methods: 30 patients with PDAC who underwent laparoscopic pancreatic resection for PDAC were age, BMI, gender, surgical procedure, and preoperative stage-matched with 30 patients treated by conventional open pancreatic resection in the same period. Intraoperative factors, postoperative morbidity, and survival were compared between the laparoscopic pancreatic resection (LPR) and the conventional open pancreatic resection (OPR). Results: There was no significant difference in preoperative characteristics between the two patient groups. There was no significant difference in blood loss and operation time. The degree of lymphnode dissection and number of retrieved lymph nodes did not differ between the two groups. There were no significant differences in postoperative courses or overall and disease-specific survival. Conclusions: Analyses between the LPR and OPR groups showed similar results LPR for pancreaticcancer may be both feasible and safe. However, it will be necessary to conduct a welldesigned randomized controlled trial comparing short-term and long-term outcomes between LPR and OPR in a larger number of patients.

O016 - Intestinal, Colorectal and Anal Disorders

O018 - Training

A Prospective Video-Controlled Study of Genito-Urinary Disorders in 35 Consecutive Laparoscopic TME for Rectal Cancer.

Eye and Hand Fatigue in Minimal Invasive Surgery; 2D Vs. 3D: RCT

A. Costanzi, G.. Mari, L. Rigamonti, J. Crippa, A. Miranda, D. Maggioni Ospedale di Desio, Desio, Italy Genito-urinary disorders (GUD) for radical rectal cancer surgery range from 10 to 30 %. This study primary endpoint is to prospectively assess their incidence in patients undergoing Laparoscopic Total Mesorectal Excision (LTME) without neo-adjuvant Chemo-Radiation (NCR). Secondary endpoint is to detect the potential lesion site evaluating video-recordings of surgery. Patients and Methods: A court of 35 consecutive patients treated by LTME for extra-peritoneal rectal cancer not subjected to NCR, M:F = 23:12, median age 70, was evaluated preoperatively by uroflowmetry and US postvoid residual urine measurement (PVR), International Prostatic Symptoms Score (IPSS) and International Consultation on Incontinence Modular Questionnaire (ICIQ) and at 1 and 9 months. Evaluation of sexual function was carried out by International Index of Erectile Function (IIEF) in males. Data were analyzed performing Fisher and paired samples t tests. Surgical videos of patients affected by GUD were reviewed to identify lesion sites. Results: Urinary function: IPSS average score: baseline 6.03 ± 5.51, 8.93 ± 6.42 (p = .005) at 1 month, 7.26 ± 5.55 (p = .041) at 9 months. ICIQ baseline 2.67 ± 5.42, 4.27 ± 6.19 (p = NS) at 1 month, 3.63 ± 5.23 (p = NS) at 9 months. Maximum urine flow rate baseline 15.95 ± 4.78 ml/sec, 14.23 ± 5.27 after 1 month (p = .041), 15.22 ± 4.01 after 9 months (p = NS). Mean urine flow rate baseline 9.15 ± 2.96 ml/sec, 7.99 ± 4.12 ml/sec at 1 month (p.044), 8.54 ± 4.19 ml/sec at 9 months (p = NS). PVR baseline 59.62 ± 54.49, 64.59 ± 58.71 (p = NS) at 1 month, 68.82 ± 77.72 (p = NS) at 9 months. Sexual function: IIEF baseline 19,38 ± 6,25, 14.06 ± 8.65 at 1 month (p = .011), 15.4 ± 8.41 at 9 months, (p = NS). Video review of patients with disorders showed potential damage at the site of ligation of IMA (high hypogastric plexus) in 1 case, lateral and posterior mesorectum dissection (hypogastric nerves) in 2 cases, anterior dissection of the Denonvillers fascia from seminal vesicles in 2 cases. Conclusions: GUD at 1 month from LTME for rectal cancer are significant but improve at 9 months. Surgical video review of patients with GUD provides an important tool for detection of lesion sites.

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A. Youssef, W.S. Elbakbak, A. Bouhelal, B. Patel Barts Cancer Institute - Queen Mary, University of London, London, United Kingdom Aims: The available data reports the efficacy of the three-dimensional (3D) vision system and its superiority over two-dimensional (2D). However the physiological effects of 3D on surgeons remain unaddressed. To address such gap in literature; we aimed to objectively investigate the effects of 3D on ocular and hand muscles fatigue in comparison to 2D and its impact on surgical performance in novices. Methods: We conducted a stratified randomised comparative study with cross-over of 26 novices. Eye fatigue was assessed using Visual Stress Test (VST), Visual Acuity (VA) and post-study display questionnaire. Hand fatigue was assessed using grip dynamometer. Surgical performance was evaluated using a validated curriculum with proficiency criteria Fundamentals of Laparoscopic Surgery curriculum (FLS). Results: The VST showed a higher mean score in the 3D group of 3.92 in comparison to the 2D group with mean of 3.15, (P-value = 0.23). It is apparent from VA test that the 3D group had a better VA on both eyes compared to the 2D group after performing the suturing task (right eye; P-value = 0.29, left eye P-value = 0.47). There was no statistical difference in handgrip strength between both display groups (right hand; P-value = 0.55, left hand P-value = 0.70). The 3D group demonstrated statistically evident superior performance in terms of less slippage errors (P-value = 0.003) and gap errors (P-value = 0.015), number of repetitions and accuracy were similar in both groups (P-value = 0.81 and Pvalue = 0.20 respectively Conclusion: 3D offers superior visual feedback that positively reflects on the VA and accuracy, which in turn favorably impact training and patient safety

Surg Endosc

O019 - Robotics, Telesurgery and Virtual Reality

O021 - Intestinal, Colorectal and Anal Disorders

Fluorescent Cholangiography in Single-Site Robotic Cholecystectomy: Our Experience in More Than 100 Patients

Laparoscopic vs Open Management of Perforated Appendicitis: A Prospective Randomized Clinical Trial

G. Spinoglio, A. Marano, G. Formisano, F. Priora, L.M. Lenti, F. Pagliardi, D. Piscioneri

A.I. Talha1, A.H. Ghazal2

SS. Antonio and Biagio Hospital, Alessandria, Italy Aims: Bile duct injury (BDI) is a serious and feared complication of cholecystectomy, especially during single-incision laparoscopic surgery. Our aim is to evaluate the safety and effectiveness of fluorescent cholangiography (FC) in real-time identification of extra-hepatic biliary anatomy during Single-Site robotic cholecystectomy (SSRC). Methods: From July 2011 to December 2013, 104 patients underwent SSRC with Indocyanine green (ICG) fluorescent cholangiography (FC) for symptomatic cholelithiasis and gallbladder polyposis. We conducted a retrospective analysis on prospectively collected data of patients characteristics and perioperative outcomes. Results: We successfully performed SSRC with FC in all patients. Five out of 104 patients suffered from acute cholecystitis (4.8 %). Mean BMI was 24.7 kg/m2. Mean hospital stay was 1.6 days. Mean operative time and mean console time were 71 and 24.1 minutes, respectively, and no additional time was required to perform FC. There were no BDIs, intraor postoperative complications or adverse events related to ICG administration. The rates of visualization of the cystic duct, the common hepatic duct and the common bile duct were 94 %, 71 %, 74 % prior to Calot’s dissection, respectively, and 99 %, 93 %, 98 % after Calot’s dissection, respectively. At least one biliary structure was visualized in 100 out of 104 patients (96 %) before Calot’s dissection, and in 100 % of cases after Calot’s dissection. Moreover, FC allows visualization of aberrant ducts as well as of anatomical variations of extra-hepatic biliary tree. Conclusions: FC is a simple, fast, safe and effective procedure that allowed clear real-time identification of extra-hepatic biliary anatomy in almost all patients, thus implementing the well-known advantages of SSRC over the traditional single-incision laparoscopic approach. Further investigation is needed in the setting of acute cholecystitis and obesity.

1 Medical Research Institute, Alexandria University, Alexandria, Egypt; 2Faculty of Medicine, Alexandria University, Egypt

Background: In the treatment of patients with complicated appendicitis, no surgical method has been clearly established as superior. This study carried out to compare the surgical outcomes of perforated appendicitis with either open or laparoscopic techniques. Methods: 106 patients with a preoperative diagnosis of complicated appendicitis were included in the study, 56 in the laparoscopic appendectomy (LA) group and 50 in the open appendectomy (OA) group. The primary outcome measure was the rate of postoperative septic complications. Secondary outcome measures were the operative time, start of oral feeding, the length of hospital stay, postoperative pain score, duration of abdominal drainage, wound cosmoses, conversion to open and quality of life score. Results: There were four conversions, due to extensive adhesions and friable appendix. LA took longer time to perform (p = 0.002) but with less use of analgesics (p \ 0.000), shorter hospital stay (p \ 0.0003), shorter duration of abdominal drainage (p \ 0.0002) and lower incidence of wound infection (p = 0.0005). Four patients in LA and two patients in OA group developed intra-abdominal abscess treated successfully with ultrasound guided percutaneous drainage. Postoperative ileus was recorded in two patients in LA group and three patients in OA group, chest infection in six patients; three in either group, incisional hernia in two patient in OA group . Overall complications were significantly lower in laparoscopy group and managed conservatively with no mortality in either group. With significantly higher quality of life score in LA group. Conclusion: The laparoscopic approach to appendectomy in patients with complicated appendicitis is feasible and safe with lower incidence of complications than OA and should be the initial choice for all patients with complicated appendicitis.

O020 - Intestinal, Colorectal and Anal Disorders Single-Port Colonic Resections: The First (Almost) 100 Resections ´ vila-Pin˜a, J. Tinoco, S. Morales-Conde, I. Alarcon-del Agua, R. A M. Rubio-Manzanares, J. Can˜ete, A. Navas, H. Cadet, J. Padillo, M. Socas-Macias, A. Barranco-Moreno University Hospital Virgen del Rocio, Seville, Spain Introduction: Single port surgery is becoming an alternative to conventional laparoscopic surgery. Large series an prospective analysis of the first experience worldwide are needed to demonstrate that this could be an alternative for the future. Objective: Our aim is to demonstrate that Single-port colonic resection (SPCR) could be an alternative approach for the management of malignant and benign colorectal disease, since the morbidity and the oncological results are, at least, similar to conventional laparoscopic multi-port results published. We report the results from our first (almost) 100 procedures performed. Material and Methods: Analysis of morbi-mortality and oncological results of 99 SPCR, 58 were right colonic resections while 41 were left resections. All cases were performed with pure single port approach, placed transumbilical, with no additional trocars. Data from the series was collected prospectively. Results: Median follow-up was 25,6 months. Mean age was 65,3 years and mean BMI was 26,4. Two third of the patients were carcinoma (65 %). Mean surgical time was 119,3 min. The mean hospital stay was 4,6 days. There were only one conversion (1 %) due to profuse bleeding. One patient in our series died, corresponding to previous patient. Overall postoperative complications no related to surgical wound was 7: 2 abscesses, 2 leaks, 1 paralytic Ileus, 1 hemoperitoneum and 1 intestinal occlusion. Wound Complications was 11: 1 cellulitis, 5 seroma, 5 deep infections. Hernias was detected in 6 patients Our oncologic results of the 65 patients were: iS: 2; Stage I: 17, Stage II: 23; Stage III: 13; Stage IV: 5. At a median follow-up: 27,7 months, global survival was 100 % and patients with free disease (is,I,II,III): 93,8 %. The mean number of lymph nodes was 13,9. Conclusions: SPCR is a safe and feasible technique with similar short and medium term morbidity and oncological results compared to the multiport laparoscopic series published in the literature, showing a reduction in postoperative hospital stay. It is necessary, however, randomized clinical trials in order to provide higher level of evidence and to demonstrate the potential advantage of this approach.

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O022 - Gastroduodenal Diseases

O024 - Basic and Technical Research

Robot Assisted Surgery for Gastric Cancer-Results: From the Retrospective Korean Multicenter Analysis on 1043 Patients

Reducing the Cost of Laparoscopy: Reusable Laparoscopic Instruments

D. Reim1, Y.W. Kim1, W.J. Hyung2, S.A. Han3, S.S. Park4, K.W. Ryu1, K.Y. Song5, H.K. Yang6, M.C. Kim7, J.Y. An2, H.I. Kim2, J.W. Cho8, D.J. Park9, H.J. Lee6, T.K. Ha10, B.J. Suh11, J. Oh12, J.H. Lee1, S.W. Ryu13, S.J. Oh11, J.M. Park14, S.Y. Ryu12, S.H. Choi15, J.J. Kim16, Y.H. Kim17, Y.K. Park12, J.W. Kim15, J.H. Lee18

D.K. Manatakis, V. Kalles, N. Stamos, N. Georgopoulos

1 National Cancer Center Korea, Ilsan, Korea; 2Yonsei University Severance Hospital, Seoul, Korea; 3Ajou University Hospital, Ajou, Korea; 4Korea University Hospital, Seoul, Korea; 5Seoul St. Mary’s Hospital, Seoul, Korea; 6Seoul National University Hospital, Seoul, Korea; 7Dong-A University Hospital, Busan, Korea; 8Hallym University Hospital, Anyang, Korea; 9Seoul National University Bundang Hospital, Bundang, Korea; 10Hanwang University Hospital, Seoul, Korea; 11Inje University Haeundae Paik Hospital, Busan, Korea; 12Chonnam National University Hwasun Hospital, Kwangju, Korea; 13Keimyung University Hospital, Deagu, Korea; 14Chung Ang University Hospital, Anseong, Korea; 15Gangnam Severance Hospital, Seoul, Korea; 16Incheon St. Mary’s Hospital, Incheon, Korea; 17KyungHee University Hospital, Seoul, Korea; 18Ewha Womans University Mokdong Hospital, Seoul, Korea

Athens Naval and Veterans Hospital, Athens, Greece Aims: Cost-effectiveness in health care management has always been a major issue. The situation in debt-stricken Greece is further aggravated by the financial crisis and constant National Health System expense cut-downs. In an effort to minimize the cost of laparoscopic surgery, without compromising quality of health services, our Department introduced reusable laparoscopic instruments (RLI) in December 2011, under the pressure of budget limitation. The aim of this study was to assess cost reduction of laparoscopic operations performed between January 2012 and December 2013, in the field of general surgery. Methods: Hospital records, invoice lists and operative notes between January 2012 and December 2013 were retrospectively reviewed and data were collected on type and number of laparoscopic operations, instrument failures and replacement needs. Maintenance was calculated as the sum of resterilization, repackaging, repair and replacement expenses. Total expenditure was the sum of initial acquisition cost plus maintenance cost, and was compared with retail prices of disposable laparoscopic instruments. Results: Initial acquisition cost of 5 basic RLI sets was 21,422 euros. Each set consisted of a dissector, two atraumatic grasp forceps, Metzenbaum scissors, a suction-irrigation device, a Veress needle, a Hasson cannula, two 12 mm and two 5 mm bladeless trocars. Over the following 24 months, they were used in 623 laparoscopic procedures, with a total maintenance cost of 11,487 euros. Based on an average retail price of 490 euros per set, estimated cost of 623 operations with disposable instruments would amount to 305,270 euros, thus creating savings of 272,361 euros over the two-year period under study. Conclusions: Despite the seemingly high purchase price, each set amortized its acquisition cost after only 9 laparoscopic procedures and instrument cost depreciated to less than 55 euros per case after the first two years. According to our results, disposable instruments cost 9 times more than reusable ones, and their high price would almost equal the total hospital reimbursement by social security funds for most common laparoscopic procedures.

Purpose: Robot-assisted surgery is an emerging technique in the oncologic field. However, the true benefit of robotassisted gastrectomy for cancer was not elucidated yet. The purpose of this multicenter-analysis was to report on the oncologic outcomes of robot-assisted gastric cancer (GC) surgery in 11 Korean institutions. Patient and Methods: We included 1043 patients who underwent robot-assisted gastrectomy for cancer in Korea between 2005 and 2012 and compared them to a cohort of 771 patients who received laparoscopy-assisted resection in the same period. Intergroup comparisons were performed by ? 2-testing, T-tests or Wilcoxon-tests were used whenever appropriate. Survival-rates were analyzed by the Kaplan-Meier-method and statistical differences were evaluated by the log-rank test. Associations between prognostic factors and survival were estimated by the uni- and multivariate Cox proportional hazards model. P-values \ 0.05 were considered statistically significant. Results: 1043 patients received robot-assisted surgery, 771 patients laparoscopy-assisted surgery. There were statistical significant differences between the groups for age (p \ 0.0001), pT-stage (\ 0.0001), pN-stage (p \ 0.0001), UICC-stage (p = 0.002), tumor location (p = 0.07), tumor size (p \ 0.0001) and Lauren histotype (p = 0.005). Tumor differentiation, presence of lymphatic vessel infiltration and completeness of tumor resection (R-stage) were comparable between the groups. Total gastrectomy was performed more frequently in the robotic-group (p = 0.0006) and there was a higher frequency for D1 + ß lymph-node dissections in the robot-group (p \ 0.0001). Operating-time was comparable between groups. There was no statistically significant difference in the number of retrieved lymphnodes. Overall postoperative complications rates were comparable and Clavien-Dindo complications grade 3–5 were significantly less frequent in the robot-group (p \ 0.0001). Positive predictors for the occurrence of postoperative complications were age (p \ 0.0001), total gastrectomy (p \ 0.0001) and operating-time (p = 0.001) in the robotgroup. Recurrence rates were comparable between groups. Five-year survival rates were 95 % without statistically significant differences (p = 0.334). In multivariate regression analysis postoperative complications (p = 0.008), recurrence (p \ 0.0001) and UICC-stage (p \ 0.0001) were significantly related to overall-survival Conclusions: Robot-assisted surgery for GC can be considered safe and feasible for surgical and oncologic outcomes with a probability of less Clavien-Dindo grade 3–5 complications. Prospective studies are proposed to further investigate on this matter.

O023 - Intestinal, Colorectal and Anal Disorders

O025 - Morbid Obesity

Postoperative Peritonitis After Laparoscopic Colorectal Surgery: Minimally Invasive Management

Failed Gastric Band: Our Experience. Removal and Revisional Surgery

F. Borghi, G Giraudo, L. Pellegrino, M.C. Giuffrida, N. Pipitone, G. Sapia, H. Dalcorso

R. Gonzalez-Heredia1, E. Elli1, M. Masrur2

Aso Santa Croce E Carle, Cuneo, Italy Aims: The aim of this study is to address the role of laparoscopy for the treatment of postoperative peritonitis after colorectal laparoscopic surgery (CLS). Methods: All patients who underwent elective CLS with primary anastomosis for benign or malignant colorectal disease between 2010 and 2013 were collected prospectively. Within this group a retrospective study was carried out, focused on patients who presented a postoperative peritonitis managed laparoscopically. Results: In this period, 237 patients (pts) underwent a laparoscopic colorectal resection with intestinal anastomosis at our department. Postoperative peritonitis occurred in 11 patients (4.6 %); 2 females (18 %) and 9 males (82 %) with a mean age 72 ys (range 60–85). The mean time from the primary operation to laparoscopic reintervention was 3.25 days. The cause of postoperative peritonitis were: anastomotic leakage (6 pts), iatrogenic colonic injury (2 pts), peritonitis ‘sine materia’ (3 pts). Laparoscopy was systematically performed for all patients; one patient was converted to laparotomy for fecal peritonitis after major anastomotic leakage, and required a redoanastomosis. The laparoscopic surgical procedures performed in the other 10 pts were: peritoneal lavage with drainage (3 pts), colorectal redoanastomosis with ileostomy (1 pt), lavage with drainage and ileostomy (3 pts), direct anastomotic suture (1 pt) and iatrogenic colonic suture (2 pts). Mean operative time was 107 min (range 75–195). Post-operative complications were prolonged post-operative ileus (2 pts), arhythmia (1 pt) and pneumonia (1 pt). Abdominal wall complication was observed in the patient who was converted to laparotomy . No mortality was observed. Median total post-operative stay was 12.5 days (range 7–19). Conclusion: Prompt laparoscopic reoperation in postoperative peritonitis after CLS seams feasible and safe with low conversion rate. The laparoscopic reintervention could be associated with short length of hospital stay and low rate of postoperative morbidity.

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1 University of Illinois Hospital and Health Sciences System, Chicago, United States of America; 2UIC, Chicago, United States of America Introduction: Gastric band surgery has a high rate of complications or failure leading to the removal of the band, as well as conducting additional medical procedures in many patients. This study describes our experience with failed gastric band cases, band removal and revisional bariatric procedures Material and Methods: This single-center retrospective analysis includes all consecutive patients who underwent a gastric band removal and/or a revised surgery in our hospital from 2008 to 2013. There were three groups. One group had the gastric band removal (n = 41) and the two others groups had a convertion to sleeve (n = 20) and a convertion to rouxen y gastric bypass (n = 12) as a revisional surgery. Patient demographics, date of gastric band placement, indications for revision, postoperative morbidity and mortality, operating time, blood loss, length of stay and EWL were recorded. Results: Forty patients underwent a gastric band removal and no other surgical treatment was performed at the same time. Out of 67 patients, 21 underwent a conversion to sleeve gastrectomy as a revisional surgery, performed during the same surgery in 16 patients and in a second stage in 5 patients. Out of 67 patients, 12 underwent a conversion to Roux-en-Y gastric bypass as a revisional surgery, performed in 11 patients during the same procedure.The mean BMI at the time of revision was 48.37 kg/m2 (SD = 8.58) and 44.17 kg/m2 (SD = 5.47) in the gastric band to sleeve and to gastric bypass, respectively . The mean operative time was 144.8 min (SD = 57.55) in sleeve and 222.1 min (SD = 84.39) in bypass. The mean hospital stay was 3 days (SD = 1.37) and 2.7 days (SD = 0.95) respectively. There were no complications and the conversion rate was 0 % after revisional surgery. The mean EWL was 42.64 % (SD = 26.09)in sleeve and 35.32 % (SD = 28.80)after bypass. Conclusions: Patients who received either a sleeve gastrectomy or roux-en-y gastric bypass after a failed gastric band had low postoperative rate complications and an aceptable EWL in the follow up. Larger studies with longer follow up are required to determine whether one procedure is associated with greater weight loss and few complications after failed gastric band surgery.

Surg Endosc

O026 - Technology

O028 - Endocrine Surgery

Use of a Motion Capture Data Glove for Hand and Wrist Ergonomic Analysis During Laparoscopy

The Efficacy of Intraoperative Neuromonitoring (IONM) During Robotic Thyroidectomy: Prospective, Randomised Case-Control Evaluation

F.M. Sanchez Margallo, F.J. Perez Duarte, J.A. Sanchez-Margallo, M. Lucas Herna´ndez, A.M. Matos Azevedo, I. Dı´az-Guemes Minimally Invasive Surgery Centre, Ca´ceres, Spain

H.Y. Kim1, H.Y. Kwak2, M.Y. Kim3, H.Y. Lee1, S.P. Jung1, J.W. Bae1 1 Korea University College of Medicine, Seoul, Korea; 2Catholic University of Korea College of Medicine, Seoul St. Mary’s Hospital, Seoul, Korea; 3Konkuk University College of Medicine, Seoul, Korea

Objectives: This study aims to analyze the surgeons’ hand spatial configuration during the use of two different instrument handles for laparoscopy, by obtaining information from the data glove CyberGloveÒ, and establishing possible risk levels for wrist disorders. Material and Methods: Fifty surgeons participated in this study, and were distributed in three groups according to their previous experience in laparoscopic surgery. Each subject carried out suturing and dissection tasks on physical simulator, using axial-handled or ringhandled instruments, respectively. Hand and wrist positions were registered by the CyberGloveÒ and a modified RULA method was applied to establish appropriate risk levels for wrist disorders. Results: When comparing data obtained during the performance of both tasks we found statistically significant differences between them in seven of a total of eleven analyzed sensors, numbers 16, 1, 4, 8, 6, 11 and 12, revealing significant differences in the surgeons’ spatial configuration between both instrument handles. After applying the RULA method to obtained data, we found that all subjects, with the exception of the experts using an axialhandled instrument (wrist angle of 51.24 ± 3.46 and RULA score of 3), assume a prejudicial wrist posture (RULA score of 2) during the practice of suturing and dissection tasks on simulator. Conclusions: Obtained results show that the data glove CyberGloveÒ allows for the distinction between two laparoscopic exercises performed with different instruments. Also, laparoscopic intracorporeal suturing when performed with an axial-handled needle holder entails a more ergonomic posture for the wrist joint. Our results further indicate that previous minimally invasive surgical experience is a positively influencing factor on the surgeons’ adopted postures of the wrist during laparoscopy.

Background: This study evaluates the efficacy of intraoperative neuromonitoring (IONM) on voice performance after robotic thyroidectomy. Methods: The study was based on a prospective randomized series. Between June 2011 to September 2012, 50 patients with thyroid cancer who underwent robotic thyroidectomy were enrolled. Both the IONM and non-IONM groups consisted of 25 patients each. Voice handicap index (VHI), voice range profile (VRP) and laryngoscopy were used to test the patient’s voice function. All voice evaluations were performed before surgery and at 2 weeks, 3 months and 6 months after operation. Results: The non-IONM and IONM groups had similar VHI results. In laryngoscopic finding, there was no palsy observed in both groups. VRP minimum frequency & intensity were more rapidly recovered in IONM group.VRP maximum frequency & intensity were not different between the two groups. Conclusions: This study is the first prospective randomized series of patients undergoing robotic thyroidectomy with the use of IONM. We found that IONM group could recover voice function more rapidly.

O027 - Oesophageal Malignancies

O029 - Robotics, Telesurgery and Virtual Reality

Worldwide Trends in Endoscopic Surgical Techniques in the Treatment of Esophageal Cancer

Comparison of Surgical Outcomes of Robot-Assisted and Laparoscopy-Assisted Pylorus Preserving Gastrectomy for Gastric Cancer: A Propensity Score Matching Analysis

L. Haverkamp1, J.P. Ruurda1, J. Boone2, R. van Hillegersberg1, T. Weijs1 1

2

University Medical Center, Utrecht, The Netherlands; Academic Medical Center, Amsterdam, The Netherlands

Background: Surgical resection is the cornerstone in the treatment of esophageal cancer. Worldwide surgical strategies vary between countries and surgeons. The aim of this study was to evaluate the trends in surgical techniques over the past 6 years. Materials & Methods: An international survey was performed amongst surgical members of the International Society for Diseases of the Esophagus (ISDE) and the World Organization for Specialized Studies on Disease of the Esophagus (OESO). The participants filled in a web based questionnaire about surgical strategies for esophageal resection. The findings of this survey were compared to a similar survey that was conducted in 2007. Results: In total 230 surgeons filled in the survey in 2013, of which 72 (31 %) were OESO members and 158 (69 %) ISDE members. In 2007 a total of 269 surgeons responded, who functioned as a reference group. The responders from 2013 represented 40 countries from 6 different continents. In 2013 the preferred approach to esophagectomy was minimally invasive transthoracic in 42 %, compared to 14 % who preferred minimally invasive esophagectomy in 2007. A right sided incision for throracomtomy was preferred in 94 % in 2013, which is comparable to 91 % in 2007. The preferred lymph node dissection was 2-field in 86 % in 2013, which was favored by 73 % of surgeon in 2007.A gastric conduit was the preferred method of reconstruction in 96 % in 2013, compared to 85 % in 2007. The preferred location of the anastomosis was cervical in 52 % in 2013, which is comparable to 56 % in 2007. The preferred technique of construction of the cervical anastomosis was hand-sewn in 64 % and stapled in 36 %, whereas the intrathoracic anastomosis was stapled in 77 % and hand-sewn in 23 % in 2013. These last figures were comparable to those found in 2007. Conclusion: This international survey shows a preference for transthoracic esophagectomy with 2-field lymph node dissection and gastric conduit reconstruction. A strong worldwide trend towards minimally invasive surgery was observed with a 3 fold increase.

D.S. Han, Y.S. Suh, S.H. Kong, H.J. Lee, W.H. Kim, H.K. Yang Seoul National University Hospital, Seoul, Korea Background: There have so far been no studies about robot-assisted pylorus preserving gastrectomy (RAPPG), or case control studies comparing robot-assisted and laparoscopyassisted gastrectomy. The purpose of this study is to evaluate the feasibility and safety of RAPPG, and to compare the perioperative outcomes and oncologic safety between RAPPG and laparoscopy-assisted pylorus preserving gastrectomy (LAPPG) for middle-third early gastric cancer Methods: Between June 2008, and August 2012, we collected data from 42 patients with RAPPG and propensity score matched 84 patients with LAPPG at Seoul National University Hospital. The covariates for propensity score matching were; age, sex, American Society of Anesthesiologists score, body mass index and operators. Clinicopathologic characteristics and surgical outcomes were compared between the two groups. Results: All RAPPG cases were performed successfully without open or laparoscopic conversion. Patient demographics and perioperative outcomes did not differ between two groups except in operation time (261.0 min vs. 194.7 min, P \ 0.001). There was no significant difference in complication rates between the two groups (16.7 % vs. 20.2 %, P = 0.630). There was no difference in the number of lymph nodes for each station between RAPPG and LAPPG group although the mean number of examined lymph nodes was lower in the RAPPG group compared with the LAPPG group (33.8 vs. 38.5, P = 0.038). Conclusions: RAPPG can be performed safely for middle-third early gastric cancer. However, RAPPG has no benefit over LAPPG in terms of operation time and examined lymph nodes.

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Surg Endosc

O030 - Liver and Biliary Tract Surgery

O033 - Training

Single-Port Laparoscopic Liver Surgery 1

1

1

1

1

1

Y.K. You , E.Y. Kim , S.H. Lee , S.K. Park , J.H. Han , G.H. Na , H.J. Choi2, T.H. Hong1, Y.C. Yoon3, S.J. Kim4, D.G. Kim1 1

The The 3 The 4 The 2

Catholic Catholic Catholic Catholic

University, University, University, University,

St. St. St. St.

Mary’s Mary’s Mary’s Mary’s

Hospital, Hospital, Hospital, Hospital,

Seoul, Korea; Bucheon, Korea; Incheon, Korea; Daejeon, Korea

Introduction: Single-port laparoscopic liver surgery has been performed sporadically. The aim of this study is to assess our experience with single-port laparoscopic liver surgery as one of the usual treatment modality for various kinds of hepatic diseases. Methods: and Procedures: We retrospectively review the medical records of 232 patients who performed single-port laparoscopic liver surgeries between Dec 2008 and Nov 2013 at the Catholic University Seoul St. Mary’s hospital. Results: 232 patients underwent single-port laparoscopic liver surgeries for variety of hepatic lesions. Of these, 117 were single-port laparoscopy-assisted right hepatectomy (right liver mobilization for donor right hepatectomy in living-donor liver transplantation). In 115 patients, various kinds of single-port laparoscopic liver resection were performed for hepatocellular carcinoma (n = 57), metastatic liver tumor (n = 24), intrahepatic duct stone disease (n = 9), cholangiocarcinoma (n = 7) and others (n = 16). For these patients, partial liver resection was carried out in 83 cases. 14 were left hepatectomy, 13 were left lateral sectionectomy, 5 were right hepatectomy. Four procedures were converted multiport laparoscopy due to instruments length limitation and 18 cases were converted to open liver resection. There was no major perioperative complication in this study. Conclusion: Single-port laparoscopic liver surgery seems to be a feasible approach for various kinds of liver diseases.

Evaluation of the National Training Programme for Laparoscopic Colorectal Surgery of England H. Mackenzie1, D. Miskovic2, M. Ni1, G. Coleman3, B. Hanna1 1 Imperial College London, United Kingdom; 2The Leeds Teaching Hospitals, Leeds, United Kingdom; 3Derriford Hospital, Plymouth, United Kingdom

Aims: The National Training Program (NTP) for Laparoscopic Colorectal Surgery (LCS) aimed to safely disseminate LCS whilst truncating the autodidactic learning curve of 150 cases. This study assessed the safety, efficiency and efficacy of the NTP. Methods: Between February 2008 and November 2013, 139 specialist surgeons (delegates’) performed supervised training cases in 11 national centres in England. Safety was assessed using, prospectively collected, clinical outcomes for the supervised NTP training cases. Assessment of efficiency utilised learning CUSUM curves, derived from a Global Assessment Score (GAS). Three methods were applied to evaluate efficacy; (i) Influence of NTP training volume on summative sign-off’ technical appraisal of blinded video-recordings using the Competency Assessment Tool (CAT) (ii) Impact of technical performance in sign-off on clinical outcomes (iii) Analysis of clinical outcomes of cases performed independently within 12 months of sign-off’. Case mix was analysed using the validated Lapco Risk Score. Results: Within the study period 1561 training and 677 post sign-off, independent, cases were performed. Clinical outcomes were respectively; surgical complication—13.6 % & 10.7 %, leak rate—2.2 % & 2.1 %, re-admissions—3.1 % & 4.1 %, re-operation—4.0 % & 5.2 % and mortality—1.0 % & 0.5 %. Conversion increased from 5 % in training to 12.7 % in independent practice, however there was a proportional increase of high-risk’ cases from 8.9 % to 21.3 %. The overall learning curve according to the GAS was 26 cases (simple operative steps 7, pedicle dissection and colon mobilization 24 and for mesorectal dissection [ 30 cases). 89 surgeons were assessed summatively (sign-off), the pass rate was 71 % (69 surgeons). Successful delegates had performed more NTP cases (16.1 vs 10.6, p \ 0.001) and pass cases had fewer complications (22.0 % vs 7.8 %, p = 0.011), greater lymph node harvest (13.4 vs 17.3, p = 0.010) and a safer resection margin (2.9 cm vs 4.1 cm, p = 0.011). Conclusions: Supervised training within NTP was safe, shortened the learning curve, improved technical performance in sign-off and benefited clinical outcomes. The excellent clinical outcomes are maintained in independent practice. The NTP provides a new standard for surgical training and the introduction of new technologies.

O031 - Intestinal, Colorectal and Anal Disorders

O034 - Flexible Surgery

A Step Towards Notes Total Mesorectal Excision for Rectal Cancer: Endoscopic Trans Anal Proctectomy (ETAP)

Initial Experience with Peroral Endoscopic Esophageal Myotomy

J.J. Tuech1, M. Karoui2, B. Lelong3, C. de Chaisemartin3, V. Bridoux1, G. Manceau2, J.R. Delpero3, L. Hanoun2, F. Michot1

W. Breithaupt, T. Schulz, G. Varga, J. Kremer, B.B. Babic, K.H. Fuchs Markus Hospital, Frankfurt am main, Germany

1

Rouen University Hospital, Service de Chirurgie digestive, Rouen, France ; 2Pitie´ Salpeˆtrie`re University Hospital, Department of GI Oncology and Laboratory of Clinical Investigation; 3Institut PaoliCalmettes, Department de Chirurgie, Marseille, France Aims: Previous publications suggested that Endoscopic TransAnal Proctectomy (ETAP) seems to be a promising technique and may be an alternative to conventional low anterior resection for rectal cancer. The aim of this study was to evaluate the technical feasibility of ETAP with particular focus on postoperative and oncological results, and on functional outcomes. Methods: This study was a multicenter prospective study of unselected consecutive patients with low rectal cancer requiring proctectomy and coloanal anastomosis. All patients underwent a standardized procedure. The study endpoints were safety and adequacy of oncological resection criteria: intact mesorectum; distal and circumferencial margins; and number of lymph nodes retrieved. The Wexner fecal incontinence questionnaire was administered after stoma closure. Results: Fifty six consecutive patients (41 men) underwent ETAP between February 2010 and June 2012. Median age was 65 years (39–83); median BMI was 27 (20–42). No intraoperative complications were encountered. There was no postoperative mortality, and a 26 % morbidity rate. The mesorectum was complete in 47 cases (84 %) and a nearly complete in 9 cases (16 %). The median lymph node retrieved was 12 (range 7–29) per patient. Median radial and distal margins were 8 mm (0–20) and 10 mm (3–40). R0 resection was achieved in 53 patients (94.6 %). The median Wexner score was 4 (3–12). Thirteen (28 %) patients reported stool fragmentation and difficult evacuation. Conclusion: ETAP is a feasible alternative surgical option to conventional laparoscopy for rectal resection and may represent a promising step toward rectal NOTES Surgery

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Introduction: Recently Natural orifice transluminal endoscopic surgery has been introduced in esophageal disease by peroral endoscopic esophageal myotomy (POEM). After extensive experimental training, our team has established this technique in clinical practice. Aims: The purpose of this study is the assessment and documentation of the learning curve of introducing a NOTES Technique into clinical treatment. Methods: IRB-approval was applicated for and granted. The technique was learned from T Roesch and H Inoue. Patients were selected after extensive diagnostic work-up including endoscopy, barium studies, high resolution manometry and impedance pH monitoring, to document the presence of Achalasia or Diffuse Esophageal Spasm (DES). A submucosal tunnel was established with a triangle knife. Above the myotomy a mucosal overlap of the tunnel was left over 5 cm and later clipped for closure. The duration of the procedure, the length of the myotomy, all intra- and postoperative problems were documented. Pre-and postoperative Eckhard score, Quality of Life measurements were analysed. Results: n = 30; Achalasia: n = 26; DES: n = 4. There were no major complications, Disturbing emphysema over days occurred in 4 patients. 1 patient had a pneumothorax. No persisting damage nor problems occurred. Pre/post 6 months : Eckard Score 9/1; GIQLI 96/118; reflux postop 30 %; dysphagia recurrence 1 year: 10 % Conclusion: The initial experience with POEM seems promising, however post-myotomy reflux remains an issue of concern.

Surg Endosc

O035 - Intestinal, Colorectal and Anal Disorders

O037 - Different Endoscopic Approaches

The Price of Decreased Mortality in the Operative Treatment of Diverticulitis

Single Port Surgery By Trans-Axillary Video-Assisted Breast Surgery is Beneficial for Low-Complications and High-Aesthetics

R.C. Broderick, H. Fuchs, C.R. Harnsberger, D. Chang, S. Ramamoorthy, S. Horgan

K. Yamashita, H. Takei

University of California San Diego, San diego, United States of America Background: Healthcare costs in the United States are increasing. It is thought that as cost increases, outcomes should improve. The aim of this study is to analyze patient charges and mortality in the operative management in diverticulitis over time. Methods: A retrospective analysis of the Nationwide Inpatient Sample (NIS) database was performed. Patients with diverticulitis who underwent laparoscopic or open partial colectomy were identified by ICD-9 codes. Patients younger than age of 18 years were excluded. Multivariate analyses examined in-hospital mortality and total charges. Results were adjusted for age, race, gender, Charlson comorbidity index, surgical approach (open versus laparoscopic), and insurance status. Results: From 1998–2010, 148,348 patient files were obtained that had a partial colectomy for diverticulitis. After adjusting for other covariates and inflation, the average charge of hospitalization per admission increased by $34,057 from 1998 to 2010. In the same observation period, adjusted in-hospital mortality decreased significantly by year 2005 (OR 0.77, 95 % CI: 0.68–0.88; p \ 0.001) and remained unchanged in the rest of the study period. Additionally, laparoscopic management was associated with lower charge increases compared to open management (p \ 0.05). Conclusion: In-hospital mortality following partial colectomy for diverticulitis has improved over time, with significant improvement by the year 2005. Declining mortality comes at the price of increased hospital charges. Despite the fact that in-hospital mortality reached a plateau in 2005, overall charges continued to rise steadily, most significantly in patients undergoing open colectomy. Laparoscopic charges appear to have reached a plateau with a slow decline in recent years. This data suggests that increased spending between 1998–2005 positively impacted patient outcomes. In recent years, however, increased hospital charges have not translated into better outcomes.

Nippon Medical School, Tokyo, Japan Aims: Endoscopic surgery for the early breast cancer is outstanding in native aesthetics without damaging the breast skin. We called it as video-assisted breast surgery (VABS). However, the conventional skin incision at the edge of the areola makes the risks of deformation and dislocation of the nipple and the areola, and also of neuropathy of the sensory nerve in the breast skin. We devised the trans-axillary retro-mammary (TRAM) approach of VABS. It needs only one skin incision in the axilla and can treat any tumor even in the medial or lower side of the breast without making any injuries on the breast skin. And it can preserve skin touch sensation. After ten years from the start of this surgery, we evaluated its usability and safety worth a standard treatment for early breast cancer. Methods: We made an axillary skin incision long to 2.5 cm. We dissected major pectoral muscle fascia to detach retro-mammary tissue. We cut the mammary gland vertically to the skin at the proximal cut margin, and dissect the subcutaneous tissue above the tumor. Then we cut the gland with clear surgical margin, and removed it through the axillary port. In the pretumoral TARM, the resection area behind the tumor was not dissected before dissecting above the gland. Results: We have performed VABS on 350 patients since December, 2001. And we performed TARM on 120 patients of early breast cancer, stage I and II, and the new pretumoral approach on 30 patients. The tumor size was 2.1 cm. The average patient age was 50.7 years old. Surgical margins were all negative. There was no serious complication after surgery. The original shapes of the breast were preserved well. 5-year survival rate is 100 %. The skin incision only in the axilla made better looks and shapes of the breast. It could shorten the operation time and minimize the resection volume. The postoperative esthetic results were excellent and better. The sensory disturbance was minimal. All patients expressed great satisfaction. Conclusions: TARM is worth a standard treatment for early breast cancer.

O036 - Intestinal, Colorectal and Anal Disorders

O038 - Abdominal Cavity and Abdominal Wall

Laparoscopy for Rectal Cancer is Oncologically Adequate. Results: Of A Systematic Review and Meta-Analysis

A Risk Prediction Model for Chronic Postoperative Inguinal Pain

A. Arezzo1, R. Passera2, A. Salvai1, S. Arolfo3, M.E. Allaix1, G. Schwarzer4, M. Morino1 1

Department of Surgical Sciences, University of Torino, Italy; 2 Division of Nuclear Medicine, University of Torino, Italy; 3 University of Torino, Italy; 4Institute of Medical Biometry and Statistics, University Medical Center Freiburg, Germany Background: After assessing in a systematic review and meta-analysis short-term benefits of laparoscopy in rectal cancer treatment, we aimed at reviewing oncologic outcomes. Methods: A systematic review from January 2000 to September 2013 was performed searching the MEDLINE and EMBASE databases (PROSPERO Registration number: CRD42013005076). We included randomised clinical trials (RCTs) and non-randomised prospective controlled clinical studies (non-RCTs). Primary endpoint was the clearance of the circumferential margin. A meta-analysis was conducted by a fixed-effect model, performing a sensitivity analysis by a random-effect model, and comparing RCTs and nonRCTs, while a subgroup analysis was performed only on extraperitoneal cancers series. Relative Risk (RR) and Mean Differences (MD) were used. Results: Twenty-seven studies, including 10,861 patients, met the inclusion criteria; 8 were RCTs for a total of 2,659 patients. The analysis showed a significant less involvement of the circumferential margin after laparoscopy (RR 0.68, p \ 0.001), although driven by nonRCT studies and not confirmed in the subgroup analysis of only extraperitoneal series. Although significantly more lymph-nodes were retrieved in the surgical specimen after open surgery, the MD of -0.56 is of marginal clinical significance. No other significant difference was observed between laparoscopic and open surgery, including rate of R0 resections, distal margin clearance, mesorectal fascia integrity and local recurrence at 5 years, including sensitivity and subgroup analyses. Conclusions: Based on evidence of both randomised and prospective controlled series, in selected patients, laparoscopy offers similar oncologic outcomes compared to open surgery.

H.R. Langeveld1, Y. Vergouwe1, H. Smedinga1, M. van ‘t Riet2, W. Weidema3, H.J. Bonjer4, J.J. Jeekel1, J. Lange1 1 ErasmusMC, Rotterdam, The Netherlands; 2Reinier de Graaf Hospital, Delft, The Netherlands; 3Ikazia hospital, Rotterdam, The Netherlands; 4VU medical centre, Amsterdam, The Netherlands

Aims: Chronic postoperative inguinal pain (CPIP) is the most common complication of inguinal hernia surgery. Our aim was to identify risk-factors on CPIP and to develop a risk prediction model to estimate patient’s individual risk on CPIP. Methods: The model was developed with data of 489 patients from a randomised controlled trial: Total Extraperitoneal Procedure (TEP) versus Lichtenstein. Individual, general, preoperative, intraoperative and postoperative risk factors on CPIP were identified. Predictors for CPIP were combined with multivariable logistic regression analysis. The model was internally validated with a bootstrapping procedure. Results: We found that the strongest predictors of persistent pain were: young age, preoperative pain, bilateral hernia, ASA 2 or 3, level of experience of the surgeon and postoperative pain after 1 and 3 days and after 4 weeks. The area under the receiver operating characteristic curve was 0.65 after correction for optimism as estimated with bootstrapping. Conclusions: A prognostic model was designed using the preoperative characteristics: age, pain, bilateral hernia and ASA-classification to discriminate between patients with and without persistent pain at one year after inguinal hernia repair. The model’s predictions could be used to inform patients and physicians on patient’s individual risk on chronic pain after inguinal hernia repair.

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Surg Endosc

O039 - Basic and Technical Research

O041 - Liver and Biliary Tract Surgery

Biomechanical Ventral Hernia Modeling—The New Idea of Mesh Fixation Systems Evaluation

Development of Real-Time Navigation System for Laparoscopic Hepatectomy

K. Bury1, M. Maciej2

T. Igami1, H. Hayashi2, T. Hirose1, T. Ebata1, Y. Yokoyama1, G. Sugawara1, T. Mizuno1, M. Fukaya1, K. Uehara1, K. Itatsu1, Y. Yoshioka1, K. Mori2, M. Nagino1

Medical University of Gdansk, Poland; 2Ceynowa Hospital, Wejherowo, Poland

1

1

Background: The aim of this study was to determine the mechanical properties of mesh fixation systems (staples and sutures) in combination with commercially available meshes used in hernia repair operations on the possibility of a recurrence, and attempt to determine the optimal combination of the fixing system. Methods: Experimental studies that have been carried out for the work, the models of hernia, a variety of connections of fascia and mesh required a special tests made in sepecially developed pressure chamber. The aim for the pressure chamber was to simulate as precisely as possible the conditions occurring in the peritoneal cavity during intensive cough. The credibility of the tie-model assumptions and the accuracy of theoretical calculations were verified by Finite Element Modelling. Results: The experiments included in total 177 tests on different combination of fixation system. Tests were performed in a pressure chamber for hernia rings 5 cm and 8 cm. The results of the experiments showed that more positive results were obtained for samller hernia. These results do not deviated from expected. Results of theoretical model and FEM modeling agree with the experimental results obtained with the selected model connection. Conclusion: Flexibility of hernia mesh, not the kind of the mesh plays a key role in the recurrence of hernia and most likely plays a key role in the pathogenesis of chronic pain. The more flexible mesh is the lower pulling forces acting on the staple or suture are. Local strength of mesh fibers and weaves plays most important role in the global strength of the fixating system and should be taken into account when constructing connection. Combinations of fixation systems that don’t provide sufficient mechanical strength to support the system were identified. The key seems to be in the appropriate selection of the mesh and stapler for a specific fascial defect.

Nagoya University Graduate School of Medicine, Nagoya, Japan; Information and Communications Headquarters/Graduate School of Information Sci, Nagoya, Japan

2

Background: Laparoscopic hepatectomy for an invisible small tumor even by intraoperative ultrasonography is technically demanding. In such situation, intrahepatic vessels are recognized as important indicators of determination of resection area and preoperative 3D liver images reconstructed by MDCT are utilized as surgical assist. We are going to try development of real-time navigation system for laparoscopic hepatectomy, which resembles a car navigation system. We report our real-time navigation system and surgical procedure. Methods: Virtual 3D liver and body images are reconstructed using ‘New-VES’ system developed by Nagoya University Graduate School of Information Science—Mori’s Laboratory. These images correspond to maps of car navigation system. Some of patient’s body parts are registered in virtual 3D liver and body images using a magnetic position sensor. Patient’s body after registration corresponds to The Earth. A transmitter for magnetic position sensor, which corresponds to an artificial satellite, is placed about 30 cm above patient’s body. A micro magnetic sensor, which corresponds to GPS antenna, fixes on the handling part of a laparoscope. Laparoscopic hepatectomy is performed using both real operative and virtual monitors. Fiducial registration error (FRE, which means an error between real operative and virtual lengths) is utilized to evaluate accuracy of real-time navigation system. Results: We performed laparoscopic hepatectomy using this system in 12 patients. All procedures were completed successfully. Mean FRE of initial 5 patients was 17.7 mm (range 12.2 to 24.3 mm). Mean FRE of last 7 patients, whose MDCT were taken using radiological markers for registration of body parts, was 10.5 mm (range 6.0 to 16.5 mm) and decreased (p = 0.025). When performing laparoscopic hepatectomy, we could anticipate both exposing position and running direction of intrahepatic vessels. Conclusions: Our real-time navigation system can assist laparoscopic hepatectomy. However, FRE is still large margins; therefore, further improvement of our system is necessary to represent an alternative to an intraoperative ultrasonography.

O040 - Spleen

O042 - Different Endoscopic Approaches

Clinical, Anatomical and Pathological Grading Score to Predict Technical Difficulties in Laparoscopic Splenectomy

The Single Incision Laparoscopic Surgery, Does it Make Sense? Based on the Results: Of Randomized Comparative Study of Lap Cholecystectomies

C. Rodriguez-Otero Luppi, E.M. Targarona, C. Balague, J.L. Pallare´s, M. Trias

Y.G. Starkov, S.V. Dzhantukhanova, M.I. Vyborniy, L.V. Shumkina

Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

A.V.Vishnevsky Institute of Surgery, Moscow, Russia

Objectives: We aimed to devise a classification for elective laparoscopic splenectomy according to preoperative parameters to grade the surgical difficulty of this procedure to predict surgical morbidity and to standardize and compare results. Methods: We retrospectively assessed morbidity in 423 patients operated of laparoscopic splenectomy between 1993 and 2013 for different pathologies. Medical and surgical records were reviewed and analyzed. Three operative outcome were measured (operative time, intraoperative bleeding and surgical conversion) and compared with preoperative known factors (demographic, clinical, pathological, anatomical, laboratory and radiological). Uni and multivariate analysis were performed to detect variables variables with statistical significance. Results: Four preoperative parameters correlated significantly with the rate of development of surgical complications (longer operative time, significant bleeding and conversion to open surgery): age, sex, type of pathology and spleen size (based on final spleen weight). With this results, we create an artificial classification in 3 grades of difficulty: low (=4 points), medium (between 4 and 6 points) and high (=6 points) based in those four preoperative aspects with a highly significant statistical correlation (p = \ 0,001). The correlation coefficient and p value for each grade (low, medium and high) were respectively: Operative time (0,254 and \ 0,001), bleeding (0,201 and \ 0,001) and conversion (0,143 and 0,003). The area under the ROC curve was 0,671 (95 % CI: 0,596–0,745). Conclusions: This grading score can be easily calculated from physical examination, laboratory tests and CT images and could predict the technical complexity of the laparoscopic approach to the spleen and decide preoperative whether is feasible to be performed by a low-experience surgeon or should be transferred to a high-volume center. Using this scoring system, surgeons within learning curve for laparoscopic splenectomy could preoperatively select less difficult patients in a controlled manner.

Background: Laparoscopic cholecystectomy is the most common laparoscopic procedure performed worldwide. The goal of decreasing post-op trauma and increasing the cosmetic results by minimizing the number of skin incisions is the part of up-to-date discussion about Single Incision Laparoscopic Surgery (SILS). Methods: In a period from 2011 to 2012, 85 patients underwent laparoscopic cholecystectomy, using standard laparoscopic (45 patients) and SILS technique (40 patients). There were 69 females and 16 males with median age of 56 (25–75) years. A surgical interventions were performed using the standard four-trocar technique with insertion of two 10 mm trocars and two 5 mm trocars and through a single skin incision inside the umbilicus using the Single-Port device. The comparative study of two groups included the following parameters: skin incision complications, post-op pain, cosmetic results, hospital stay and operating time. Results: There were no complications observed during operations and in the post-operative period, however there were significant intraoperative challenges during SILS procedures. Introducing of multiple instruments through a single port in parallel plane leads to crowding of instruments causing hand collisions externally and difficulties of instrument manipulation internally and increased operation time as a result. Using curved and articulated instruments can ameliorate some of this, but still the training is required. Postoperative pain level was significantly lower in the SILS group (2,4 vs 3,0). The cosmetic results were better after SILS in comparison with standard technique, but no statistically significant difference was observed. There was no significant difference in complication rate between the two groups as well. The duration of surgical procedures was greater in the group of single access (107 min vs 65 min), which also depends on the experience of the surgeon. Conclusion: Thus, the development of SILS technique matches with the current trends of minimizing access surgery (reduced-port surgery), reducing post-op pain and achieving better cosmetic results. Using curved and articulated instruments along with surgeon experience makes this procedure to be feasible and safe approach.

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Surg Endosc

O043 - Different Endoscopic Approaches Endoscopic Internal Drainage for Treatment of Leaks Following Sleeve Gastrectomy for Morbidity Obesity G. Donatelli1, S. Ferretti2, B.M. Vergeau1, P. Dhumane3, J.L. Dumont1, S. Derhy1, T. Tuszynski1, A. Carloni1, J.M. Catheline4, G. Guillaume2, I. Ibraim2, B. Meduri1 1

Hoˆpital Prive´ des Peupliers, Ge´ne´rale de Sante´, Paris, France ; Hoˆpital Universitaire Antoine Be´cle`re, APHP, Paris, France; 3 Lilavati Hospital and Research Center, Mumbai, India; 4Centre Hoˆspitalier de Saint-Denis, Saint-denis, France

O045 - Oesophageal and Oesophagogastric Junction Disorder Current Evidence and Dogmas in the Management of Paraesophaegeal Hernias: Establishing an European Expert Consensus. E.M. Bonrath1, T.P. Grantcharov1, Expert Group:2

2

St. Michael’s Hospital, Toronto, Canada; 2European Advisory Board Paraesophageal Hernias, Canada

The most common complications of sleeve gastrectomy (SG) are gastric line leaks (GLL). The aim of this study is to report our experience about the endoscopic internal drainage (EID) of leaks, using pigtail stents, coupled to an enteral nutrition which are maintained between 4 to 6 weeks until healing. 25 pts (20 F), 41.88 y (23–65) presented GLL 23.6 days (4–98) from surgery. 4 patients underwent single port and 21 laparoscopic SG. 19 patients underwent a second surgery at 11.4 (0–97) days from SG. 6 out 25 ` , Boston patients presented peri-gastric collections and fever. One or two plastic pigtail stents (AdvanixO ` ), according to orifice’s size, were delivered with the one end in the collection and the other one ScientificO in the stomach. In all patients a naso-jejunal feeding tube was inserted and kept NPO. Endoscopic control was performed systematically between 4–6 weeks, with either re-stenting (if the leak was still present), or removal (if no extravasation of contrast medium in the peritoneal cavity was detected), or closure with an ` (if contrast material passed through the crossing stent without concomitant detection in the periOTSCO toneal cavity). EID was possible in all patients. 21 out of 25 patients underwent endoscopic control at 30.1 days (26–45) ` . At a second control, from stenting. 5 out of 21 patients presented leak sealing, and 2 needed OTSCO 29.1 days (26–42) from first EID, 9 out of 14 respected criteria of good outcome, 3 presented a sealed fistula, ` 6 needed OTSCO. Five patients required re-stenting. One patient, at third control, 28 days later, was treated ` . Overall, 7 patients (28 %) are still under treatment, 1 died for pulmonary embolism, and 17 with OTSCO (68 %) were healed with an average time of EID treatment of 52.3 days (29–84), they are now symptomfree, on a normal diet at a median follow up of 108.8 days (5–201). EID coupled with enteral nutrition is a promising therapeutic approach for the treatment of leaks following SG, despite the need of multiple endoscopic sessions.

Aims: For surgeons, the treatment of paraesophageal hernias remains a challenge due to diversity in clinical and anatomical presentations, lack of consensus regarding principles of treatment and conflicting results in the present literature. Surprisingly, high quality empirical evidence to determine best practice is lacking, therefore the objective of this study was to achieve expert consensus on key topics and provide an overview over current surgical practice. Methods: A Delphi-survey was conducted and combined with a face-to-face meeting. The panel comprised experts in foregut surgery from European high-volume centers. The panel generated survey items in round one using an open questionnaire. Topics included pre- and postoperative diagnostics, indication for operative treatment, surgical techniques, follow-up, defining recurrence, and reporting complications for quality control. In subsequent rounds, the panel rated agreement with statements on a 5-point Likert-scale. Internal consistency (consensus) was pre-defined as Cronbach’s a [ .80. The level of ‘positive’ or ‘negative’ agreement was determined for each item. Items that [ 70 % of the panel either rated as irrelevant/unimportant (=2), or relevant/important (=4) were selected as consensus items, while topics that did not reach this cut-off were termed ‘undecided/ controversial’. Results: Three survey rounds were completed: 19 experts from 10 countries completed round one, 18 experts from 10 countries continued through rounds two and three. During the face-to-face meeting definitions were clarified and further topics of interest specified. Agreement was high for the overall survey in rounds two and three (a [ .90). Fifty-eight additional/ revised items derived from free-text entries and comments made during the meeting were included in round three. After three rounds, 118 items had been retained, consensus agreement as defined was achieved in 70 items. Topic areas with the most ‘undecided/controversial’ items were follow-up (64 %) and postoperative care (60 %). Conclusions: This consensus initiative provided an overview of topics regarding the management of paraesophageal hernias on which opinion leaders across Europe agreed. The resulting consensus list can be used as practice recommendations; however it also identified areas with substantial variability in opinions reflecting the current lack of empirical evidence. Further research efforts should be directed towards providing evidence-based guidelines in these areas.

O044 - Oesophageal and Oesophagogastric Junction Disorder

O046 - Oesophageal and Oesophagogastric Junction Disorder

Long-Term Results: Of Laparoscopic Lightweight Mesh Repair of Large and Giant Hiatal Hernias

Long-Term Follow-Up of a Case Series of Patients Operated Upon for Type II-IV Hiatal Hernia

A.V. Malynovskyi, V.V. Grubnik

S. Mattioli1, N. Daddi2, M. Lugaresi1, O. Perrone1, S. Mattioli1

Odessa national medical university, Odessa, Ukraine

1 University of Bologna, Italy; 2Division of Thoracic Surgery University of Perugia, Italy

Introduction: Many studies proved that usage of mesh decreases recurrence rate following laparoscopic hiatal repair. Usage of lightweight mesh may prevent oesophageal complications. It is still unknown whether this technique is effective for large hiatal hernia (i.e., with HSA size of 10–20 cm2 according to recently published original classification), and, particularly, for giant hiatal hernia in the long-term follow-up period. This study was aimed to assess long-term results of laparoscopic lightweight mesh repair of large and giant types II, III, and IV hiatal hernias. Methods: First, results of 192 procedures performed from 2001 to 2011 were studied, with a mean followup period of 28,3 ± 7,5 months (range 10–47). The original method of sub-lay lightweight mesh repair (Ultrapro, Ethicom, Inc.) was used. These patients were divided into 2 groups. Group 1 had 142 patients with HSA size 10–20 cm2 (large hernias). Mean HSA in the group was 12,5 ± 2,3 (range 10,3–18,8). Group 2 had 50 patients with HSA exceeding 20 cm2 (giant hernias). Mean HSA in the group was 26,9 ± 8,7 (range 20,3–64,7). Then, results were reassessed in a later period in 183 patients, with a mean follow-up period of 58,8 ± 7,2 months (range 24–93 months) using questionnaires, barium study, endoscopic examinations, and 24 h pH testing. Results: After mean follow-up period of 28,3 months, recurrence rate was 4,9 % for group 1, and 20 % for group 2 (p = 0,0028). Dysphagia rate was 2,1 % for group 1, and 2 % for group 2 (p = 0,7216). After mean follow-up period of 58,8 months, recurrence rate was 5,8 % for group 1, and 19,1 % for group 2 (p = 0,0069). Dysphagia rate was 2,2 % for group 1, and 2,1 % for group 2 (p = 0,9748). Thus, delayed long-term results did not change significantly. Conclusions: 1. For large hiatal hernias (HSA 10–20 cm2), original technique of sub-lay lightweight mesh repair is safe and effective. 2. Using of our method for giant hiatal hernias (HSA [ 20 cm2) is also safe but requires improvement because of high recurrence rate.

1

Aims: Many studies in the medical and surgical literature highlight the risk of bias in interpreting the results of surgery for gastro-oesophageal reflux disease and particularly for type II-IV hiatal hernia. This bias may stem from the incomplete nature and the brevity of postoperative follow-up. Since the early eighties our group collected prospectively data of patients undergoing antireflux surgery. These patients underwent a timed clinical-instrumental follow-up. In order to clarify some of the actual questions on the long-term results of surgery for type II-IV hiatus hernia, we analyzed a series of cases operated upon in a span of thirty years. Method: From 1980 to 2010, 100 patients (median age 68 years) with type II-IV hiatal hernia underwent surgery according to the same surgical decision-making process and technical principles. In the follow-up patients were interviewed, asked to swallow barium and then subjected to endoscopy. The results were considered to be poor in the case of patients who experienced a relapse in symptoms, any grade of endoscopic oesophagitis, hiatal hernia of any size or type, or the need for any post-operative lifelong or subcontinuousanti-reflux medical therapy. The follow-up time was calculated from the time of surgery to the last follow-up. Results: The cumulative rate of post-operative mortality was 3/100; 97 patients were followed up for a median period of 96 months (IQR 25.5–201). Satisfactory results were obtained in 92.8 % of patients (excellent in 39.2 %, good in 43.2 %, fair in 10.4 %); poor results were obtained in 7.2 % (6 cases of hiatal hernia relapse, 1 case of oesophagitis without a hiatal hernia relapse). Conclusion: Surgery for type II-IV hiatal hernia can achieve satisfactory results in the long-term.

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Surg Endosc

O047 - Oesophageal and Oesophagogastric Junction Disorder

O049 - Oesophageal and Oesophagogastric Junction Disorder

Laparoscopic Nissen Fundoplication; Is It Possible To Achieve Better Functional Results: With Rossetti Modification?

Preliminary Results of a Prospective Multi-Center Trial on the Clinical Feasibility of A New Full Thickness Endoscopic Plication Device for Patients With Gerd

L. Avtan1, C. Sormaz1, A Baysal1, C. Avci2 1

Istanbul Faculty of Medicine, Department of General Surgery, Turkey; 2Istanbul University Continuous Medical Education and Research Center, Turkey Aims: Laparoscopic Nissen fundoplication is commonly used technique for the surgery of gastroesophageal reflux disease. In this study, we aimed to compare the functional outcomes of patients operated with the techniques of Nissen-Rossetti and Nissen fundoplications. Methods: We compared the result of 50 cases of Nissen-Rossetti (group1) and 50 cases of Nissen (group2) fundoplications operated by the same surgeon consecutively, between 2007–2012. For both groups standardized floppy fundoplication with cruroraphie and gastropexy were used. Zero nonabsorbable suture used for cruroraphie and 2–0 nonabsorbable two suture (1.5 cm interval, the second-distal one passed through the muscular layer of oesophagus) used for floppy Nissen technique to create a 3 cm height of wrap. For group1, we did not touch the vessels of fundus, thanks to anterior surface of stomach which used for wrap creation. For group2, liberalization of fundus performed by division of gastrica breves vessels on 1/3 to 1/2 proximal of grater curvature with electrosurgery. Last step was similar for both groups as rigth side gastropexy with a sutures 2–0 nonabsorbable between the wrap and right hiatal crus. Dermographic characteristics, recurrens of reflux, operation time, complications and functional results (disphagia, epigastric discomfort and gas bloating) at 6 and 12 months postoperatively compared. Results: Dermographic characteristics of both groups were similar and the reflux recurrens was not exist at 12 months postoperatively. Operation time was shorter in group1 (average 13 ± 4 minutes). Transient disphagia was exist for 6 cases in group1 (%12) and 5 cases for group2 (%10), dissolved at 1 to 3 months postoperatively. In group1, 6 cases (%12) suffered from gas bloating while 11 cases (%22) in group2 at 6th month (%4 and %12 for 12th month). Conclusions: Laparoscopic Nissen-Rossetti provided similar reflux control with Nissen fundoplication, but complaints releated gastric atony were less often seen with Nissen-Rosetti. With better functional outcomes Nissen-Rosetti may be preferred techniques.

O.O. Koch1, G.O. Spaun1, S.A. Antoniou2, G. Ko¨hler1, R.R. Luketina1, A. Kaindlstorfer2, K. Emmanuel1, R. Pointner2 1 Barmherzige Schwestern Linz, Austria; 2Krankenhaus Zell am See, Austria

Background: Endoscopic Full Thickness Plication with the PlicatorTM device has shown efficacy regarding quality of life, symptom scores and reduction of PPI-use in patients with gastroesophageal reflux disease (GERD), but the device was commercially no longer available. Recently, the Plicator technology has been taken over by a new company and they have produced a single use device (GERDxTM). So far no data with the new device exists. Patients and Method: Prospective multi center trial evaluating the outcome of patients with GERD treated with the GERDxTM device. As primary endpoint of the study changes in the Gastrointestinal Quality of Life - Index (GQLI) was defined. Secondary endpoints are improvement of symptom scores, surgical aspects, esophageal acid exposure characteristics and lower esophageal sphincter pressure. Forty patients with documented GERD and persistent symptoms despite medical treatment, with hiatal hernia \ 2 cm and endoscopic Hill grading Type II-III will be enrolled in the study and undergo endoscopic full-thickness-gastroplication with one or more implants using the GERDxTM device. Gastroscopy is routinely performed six weeks after the procedure. Evaluation of GIQLI, symptoms typically related to reflux, gas-bloat and bowel-dysfunction as well as esophageal manometry and impedance-pH-monitoring are performed at baseline and three months after the procedure. Results: Until submission deadline 16 patients underwent the procedure without any intraoperative complications. One patient developed a pneumonia after the procedure requiring treatment with antibiotics. Routine gastroscopy has been performed in 12 patients so far and an intact wrap was found in 10/12 patients which were subjectively free of GERD symptoms. Two patients showed partly dispersed plication and also claimed persisting symptoms. Three month follow up data was available at deadline in six patients. Mean GIQLI score and general and reflux specific scores improved in these patients (p \ 0.05). Manometric data was virtually unchanged. Mean DeMeester scores reduced in 4/6 patients. Conclusion: Endoscopic Full Thickness Plication using theGERDxTM device is a safe and well tolerated procedure. Quality of Life and GERD symptoms seem to improve after the procedure. However, firm conclusions will be possible after inclusion of all patients in the study.

O048 - Oesophageal and Oesophagogastric Junction Disorder

O050 - Oesophageal and Oesophagogastric Junction Disorder

Functional Evaluation of Laparoscopy-Assisted Proximal Gastrectomy With Toupet-Like Partial Fundoplication

Long Term Results: of the Thoracoscopic Collis-Laparoscopic Nissen for the Treatment of Severe Gerd With Acquired Short Oesophagus

N. Katada1, S. Sakuramoto2, K. Hosoda1, H. Moriya1, H. Mieno1, K. Yamashita1, S. Kikuchi1, M. Watanabe1

S. Mattioli1, N. Daddi2, O. Perrone1, M. Lugaresi1, S. Mattioli1

1

2

Kitasato University, Sagamihara, kanagawa, Japan; Saitama Medical University International Medical Center, Hidaka, Japan Aims: We reported the clinical usefulness of laparoscopy-assisted proximal gastrectomy (LAPG) with reconstruction by esophago-gastrostomy with Toupet-like partial fundoplication (TPF) (J Am Coll Surg 2009; 209:344–351). Our aims of study was the functional evaluation of LAPG with TPF. Methods: Seventy five patients with early cancer at the upper part of the stomach underwent LAPG with TPF. Of those, 25 patients underwent 24-hour pH monitoring (pHM) and enrolled into this study. Age was 69.1 ± 6.1 years (mean ± SD), and male/female ratio was 20/5. In addition, 7 patients underwent multichannel intraluminal impedance and pH study (MII-pH). Results: Esophageal %time pH \ 4 at pHM (preoperative?postoperative value) was 2.0 ± 4.8 % ? 4.8 ± 8.8 % (p = 0.18), and gastric %time pH \ 4 was 49.4 ± 27.8 % ? 21.0 ± 30.8 % (p \ 0.01). Of 25 patients, 6 patients (24 %) showed pathological acid reflux (pH positive group) which was defined as esophageal %time pH \ 4 was greater than 4.2 %, and 19 patients (76 %) showed physiologicalreflux (pH negative group) after surgery. We compared these pH positive and negative groups. Esophageal %time pH \ 4 at pHM (preoperative? postoperative value) was 1.9 ± 2.3 % ? 17.9 ± 9.8 % (p \ 0.05) in pH positive group, and 2.1 ± 5.4 % ? 0.6 ± 1.1 %(NS) in pH negative group. Gastric %time pH \ 4 was 41.6 ± 30.3 % ? 34.3 ± 31.9 % (NS) in pH positive group, and 51.8 ± 27.3 % ? 16.9 ± 30.0 % (p \ 0.001) in pH negative group. The results of MII-pH (n = 7) indicated that all reflux %time was 0.9 ± 0.7 ? 2.9 ± 3.0 (p = 0.09), and Non-acid %time was 0.6 ± 0.5 ? 2.7 ± 2.3 (p = 0.08). Conclusion: 24 % of patients with LAPG with TPF showed pathological acid reflux after surgery. Acid secretion of remnant stomach of all enrolled patients significantly decreased after surgery. However, acid secretion of remnant stomach of patients with pathological acid reflux did not significantly decrease and was preserved after surgery, which were thought to be the cause of postoperative acid reflux. According to the results of MII-pH, non-acid reflux tends to increase after surgery, and LAPG with TPF does not sufficiently prevent the reflux its self. Further development of the surgical technique of LAPG which certainly prevent the reflux is required.

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University of Bologna, Italy; 2Division of Thoracic Surgery University of Perugia, Italy 1

Aims: Purpose of this study is to present the long term results of the thoracoscopic Collis + laparoscopic Nissen performed for the treatment of severe GERD associated with short oesophagus. Materials and methods: GERD patients were assessed before surgery with interview based on semi-quantitative scales for grading of symptoms, oesophagitis from 0 (no symptoms and oesophagitis) to 3 (severe symptoms and oesophagitis), global evaluation (excellent, good, fair, insufficient), endoscopy + hysthology, barium swallow, manometry; after surgery every year, alternating interview and tests (same questionnaires as above) except routine manometry, according to a protocol. Intraoperatively the length of the addominal oesophagus after maximal mediastinal mobilization of the oesophagus was measured with a validated technique; true short oesophagus was diagnosed when the submerged segment was \ 1.5 cm. After surgery, result in patients receiving medical therapy or with recurrent hernia, although asymptomatic, was classified as insufficient. Results: From 1996 to 2013, 329 minimally invasive procedures for GERD were performed. In 66/329 (20 %) short oesophagus was assessed. The left thoracoscopic Collis gastroplasty was associated with 1 Toupet and 1 Dor (motility disorders), with the Nissen floppy fundusplication in 64 patients (26 women, 38 men, mean age 55.2 ± 13.3 years, range 20–77). 5 procedures were converted at the beginning of the experience. Mortality was 1.5 % (1/64), morbidity 10.9 % (7/64). The mean follow-up was 92.2 ± 37.2 months (range 12–144).Excellent results were obtained in 27 % (17) good in 64 % (40), fair in 3 % (2) and poor in 6 % (4) of patients. Conclusions: : With the thoracoscopic Collis-laparoscopic Nissen in patients affected by severe GERD and true short oesophagus, satisfactory long-term results were achieved in 94 % of cases.

Surg Endosc

O051 - Oesophageal and Oesophagogastric Junction Disorder

O053 - Abdominal Cavity and Abdominal Wall Rising Insights in Inguinal Lipomas; A New Nomenclature

National Outcomes of Laparoscopic Heller Myotomy: Operative Complications and Risk Factors For Adverse Events S.W. Ross, B. Oommen, J.F. Bradley, K.B. Williams, A.L. Walters, B.T. Heniford, V.A. Augenstein Carolinas Medical Center, Charlotte, nc, United States of America Aims: Laparoscopic Heller myotomy (LHM) has supplanted the open approach given decreased morbidity and the broad experience with laparoscopic esophageal surgery. However, little data exists on the overall complications of the procedure. Our goal was to quantify the incidence of perioperative complications and identify risk factors for adverse outcomes in LHM. Methods: All LHM were queried from 2005–2011 from the National Surgical Quality Improvement Program database. Adverse outcomes were identified and univariate statistics used to identify risk factors. Stepwise logistic regression (MVR) was then performed to quantify degree of independent association. Statistical significance was set at a p = 0.05. Results: There were 1,237 LHM in the study period. Patient averages were: age 51.9 ± 16.8 years, BMI 27.3 ± 6.6 kg/m2, Charlson Comorbidity Index (CCI) 0.2 ± 0.6. The population was 52.2 % male, 8.6 % diabetic, 15.8 % smokers, 2.9 % COPD, 4.0 % coronary artery disease, 98.9 % were functionally independent before surgery, but 15.3 % had [ 10 % body mass loss in the pre-operative six months. Surgery were 99.0 % elective, 10.2 % underwent concomitant EGD, and mean operative time (OpTime) was 141.6 ± 63.4 minutes. There were no esophageal perforations, 7 (0.06 %) wound complications, 22(1.8 %) minor complications, and 30(2.4 %) major complications. Average length of stay (LOS) was 2.8 ± 5.5 days. There were 11(0.09 %) readmissions, 9(0.07 %) reoperations, and 4(0.03 %) deaths. Given the low number of occurrences, there were no significant risk factors for wound, minor and major complications, reoperation, readmission and death on MVR. OpTime was found to be significantly longer by: 35.3 (CI 26.3–44.3) minutes for inpatients, 43.1 (CI 10.4–75.7) minutes in functionally dependent patients, 50.0 (CI 3.9–96) minutes in pre-operative septic patients, and 17.2 (CI 5.7–28.7) minutes with concomitant EGD (p \ 0.01 for all). LOS was found to be longer by: 1.9 (CI 1.0–2.7) days for inpatients, 1.8 (CI 1.0–2.5) days in ASA category = 3 and 1.2 (CI 1.0–1.8) days per one point increase in CCI (p \ 0.001 for all). Conclusion: LHM has an low incidence of operative complications and mortality despite preoperative malnutrition. Increased operative time is notable for inpatients, those who are functionally dependent, septic, and if intraoperative EGD is performed. Predictors of increased LOS include inpatient admission, increased ASA and higher comorbidity.

O052 - Oesophageal and Oesophagogastric Junction Disorder Evaluation of the Need for Routine Esophagram After Peroral Endoscopic Myotomy (POEM) E. Teitelbaum, N.J. Soper, C.B. Harmath, B.F. Santos, J.E. Pandolfino, P.J. Kahrilas, E.S. Hungness Northwestern University, Chicago, United States of America Introduction: All published POEM series have described the use of a contrast esophagram (CE) and/or endoscopy in the immediate postoperative period. We reviewed the findings of CEs after POEM in order to evaluate the utility of such studies. Methods: POEM was performed using an anterior submucosal tunnel and selective myotomy of the circular muscle layer. A routine CE was obtained on the first postoperative day. If the CE was negative for leak, patients were advanced to a liquid diet. For this study, radiologists’ interpretations of these CEs were reviewed and charts were reviewed to determine which patients had a clinical indication for CE, defined as abnormal symptoms or physical exam findings potentially indicative of an esophageal leak. Results: 71 patients underwent POEM for achalasia. Mucosal perforations occurred during 4 (6 %) cases. Needle decompression of pneumoperitoneum was required in 26 (37 %) cases. On postoperative CE, 1 patient had an esophageal leak at the EGJ. The patient was retching and had abdominal pain, and was brought back to the OR. Laparoscopy and endoscopy failed to identify a discrete perforation and drains were placed. Another patient had subcutaneous emphysema on CE without esophageal leakage, a finding which was also present on physical exam. The patient remained in the hospital an additional day and the emphysema resolved. No other patients had a clinical indication for postoperative CE. Four (6 %) patients had a small amount of contrast in the distal submucosal space on CE, without a defined point of extravasation. All were without abnormal symptoms or physical exam findings, and were advanced to a liquid diet without issue. 36 (51 %) patients had pneumoperitoneum on CE, but none required intervention. 27 (38 %) patients had delayed esophageal emptying on CE. None had postoperative dysphagia or regurgitation, and all tolerated liquid diet without issue. Mean length of stay was 1.2 days. Conclusions: In this series, 2 (3 %) patients had a clinical indication for CE after POEM, and in both cases the study confirmed the causal complication. In all other patients (97 %), CE did not alter clinical management. Routine CE after POEM may not be necessary.

B. van den Heuvel1, J. van den Broek2, B.J. Dwars2 1

VUMC, Amsterdam, The Netherlands; 2Slotervaartziekenhuis, Amsterdam, The Netherlands

Aims: With the expansion of laparoscopic inguinal hernia repair, new insights in the preperitoneal anatomy appeared. We have discovered different kinds of inguinal lipomas in the preperitoneal space, that have not been described previously. We have found two distinct types of inguinal lipomas, both from different origin. This study describes the anatomy of different fatty entities in the groin, their clinical relevance and treatment. Methods: We have analyzed 854 consecutive laparoscopic trans-abdominal preperitoneal inguinal hernia repairs (TAPP). In case of presence of an inguinal lipoma we specified the origin and location of the lipoma, type of inguinal hernia and presence of a peritoneal sac. Results: In 204 repairs (24 %) some kind of inguinal lipoma was found. In 42 cases (21 %) no peritoneal sac was present. In 139 cases (68 %) the lipoma originated from the peritoneal fat from the visceral compartment of the preperitoneal space attached to the plica umbilicalis medialis; we designate these as a ‘visceral preperitoneal plica lipoma’. These lipomas herniate either through an insufficient fascia transversalis as a direct hernia, or herniate through the internal ring as an indirect hernia. This plica lipoma has a close relation with the peritoneum and retraction of the lipoma will result in reposition of the hernia sac. In 65 patients (32 %) a lipoma originating from the parietal plane of the preperitoneal space was found and herniated through the internal ring along the spermatic cord. This superficial parietal plane lies between the fascia transversalis and the membranous layer of the extraperitoneal fascia and contains loose connective tissue and fat. We designate these lipomas as ‘Parietal preperitoneal lipoma’ and has no relation with the peritoneum, as the visceral preperitoneal plica lipomas do. Conclusions: Inguinal lipomas are commonly encountered during laparoscopic hernia repair. Visceral preperitoneal plica lipomas should be regarded as incipient true inguinal hernias and should be treated as such. Parietal preperitoneal lipomas are found along the spermatic cord, and may mimic an indirect inguinal hernia. They are not true hernias and treatment is optional.

O054 - Abdominal Cavity and Abdominal Wall Relationship Between Hernia Size and Intra Abdominal Pressure: Dynamic In-Vivo Measurement H. Qandeel, P.J. O’Dwyer Glasgow University, Glasgow, United Kingdom Aims: It is an understandable concept that the ventral hernia size will increase when the Intra Abdominal Pressure (IAP) is increased; however, the literature lack the evidence about how much this increase is in vivo. We aim to objectively measure the change in the ventral hernia size when the intra-abdominal pressure changes and also aim to find out if this change in size is significant or not. Methods: During laparoscopic ventral hernia repair, the size of hernia was measured from inside the abdomen using sterile paper ruler. The horizontal (width) and vertical (length) measurements of the defect were taken at two pressure points: (IAP = 8 mmHg) and (IAP = 15 mmHg) by changing the pressure settings in the insufflator. The hernia size was calculated as an oval shape. Patient’s height and weight were recorded pre-operatively. Results: 12 ventral hernias were included in our study (5 Males:7 Females). Patients’ median age = 59 yr (43–69); Body Mass Index (BMI) mean = 30.75 (24.1–37.6). The mean width measurements were 2.88 cm (SD = 1.86) and 3.27 cm (SD = 2.21) at 8mmhg and 15mmhg IAP; respectively. The mean length measurements were 3.18 cm (SD = 2.39) and 3.46 cm (SD = 2.52) at 8mmhg and 15mmhg IAP; respectively. The mean calculated sizes of the hernia ‘as an oval shape’ were 9.91 cm2 (SD = 13.38) and 12.28 cm2 (SD = 16.97) at 8mmhg and 15mmhg IAP; respectively. Statistically, changing the IAP has significantly changed the horizontal measurements (P = 0.002), the vertical measurements (P = 0.002), and the calculated sizes (P = 0.002) of the ventral hernia. No correlation found between BMI and the change in size of hernial defect (P = 0.2). Conclusions: Dynamic, rather than static, measurements of ventral hernia size during laparoscopy provide a simple but an important way of in-vivo measurement that helps the surgeon choosing the appropriate size of mesh.

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Surg Endosc

O055 - Abdominal Cavity and Abdominal Wall

O057 - Basic and Technical Research

Laparoscopic Totally Extraperitoneal Hernia Repair: SingleCenter Experience and Outcomes

Mesothelial Cells Isolated from Human Omentum Colonize Polypropylene Prosthesis in A Composite Form For Hernia Repair

N. Georgopoulos, V. Kalles, D.K. Manatakis, G. Boutsikos, I. Tsakiris, I. Chatzimichalis Naval and Veterans Hospital of Athens, Athens, Greece

R.A. Canuto1, M. Oraldi1, E. Paiuzzi1, V. Festa1, F. Festa2, A. Chiaravalloti3, C. Buemi3, G. Muzio1 1

Aims: Laparoscopic surgery has a significant role in the modern treatment of abdominal wall hernias, and contributes significantly to the workload of a general surgeon. The totally extraperitoneal (TEP) hernia repair technique is currently favored by most laparoscopic surgeons. We present our experience with TEP hernioplasty, and investigate the possible correlation between technical details of the procedure and patient outcomes. Methods: 412 patients (383 men/29 women) with a mean age of 45,08 (range 19–82 years) years underwent elective, laparoscopic TEP repair for inguinal or femoral hernia. 88 hernias were bilateral, whereas 36 were recurrent. All operations were performed under general anesthesia by the same surgical team, and a mesh was placed in all cases. Technical details of the operation, postoperative pain at 12 and 24 hours, as well as intraoperative, early and late complications were recorded and analyzed. Results: The mean operative time was 56 min (range 35–240 min). Excluding cases of bilateral hernia repair, there was no difference in the operative time between different types of hernias (direct, indirect, femoral), or between primary and recurrent hernias. There was one case of intraoperative vascular injury (inferior epigastric vessels injury) and no case of conversion to open technique. Postoperative complications were encountered in 6,8 % of the cases, with scrotal emphysema being most common (4,4 %). The mean VAS pain score was 4,1 and 3,7 at 12 and 24 h postoperatively. Fixation of the mesh with sutures or stapling devices was associated with increased pain at 12 h and 24 h postoperatively (p \ 0,05 and p \ 0,05, respectively), as well as with increased operative time (p \ 0,05). Mean postoperative hospital stay was 1,47 days (range 1–6 days). Two cases of recurrence were observed during the follow-up period (mean 32, 1 months). Conclusions: Laparoscopic totally extraperitoneal hernia repair is a safe and effective technique for hernia repair, with low complication and recurrence rates in the hands of experienced laparoscopic surgeons. Our results show that fixation of the mesh is not associated with lower recurrence rates, but significantly affects both postoperative pain and operative time.

University of Turin, Italy; 2Maria Vittoria Hospital, 10144 Turin, Italy; 3Dipro Medical Devices s.r.l., San mauro torinese, Yurin, Italy

Aims: Mesothelial cells are specialized cells covering serosal cavities, including peritoneum. In physiological conditions they slowly renewing, but in case of wound a large percentage of mesothelial cells bordering edge shows mitotic activity. In abdominal wall repair, mesothelial cells module inflammation, cell proliferation and extracellular matrix synthesis. This research aimed to investigate growth of mesothelial cells isolated from human omentum specimens and seeded on the two polypropylene layers of composite prosthesis. Methods: The CMC prosthesis (DIPROMED srl) is comprised of two polypropylene layers, one macroporous light meshes and one thin transparent film. Human mesothelial cells were isolated from omentum specimens obtained from patients during abdominal surgery under approved protocol by Ethics Committee. Specimens were incubated with trypsin/EDTA (0.125 %/0.01 %) for 15 minutes at 37 °C. Isolated cells were collected by centrifuging 500 g for 5’, and cultured in M199 medium supplemented with FBS (10 %), 2 mM glutamine, 5 mM insulin-transferrin-selenite, 1 mM hydrocortisone, 0.1 % streptomycin/penicillin. Vimentin expression was examined as marker of mesothelial cells. After subculturing, mesothelial cells were seeded on CMC (meshes side), on meshes or on film alone. At different experimental times, cell growth, viability, and vimentin production were examined. Results: Vimentin evaluation confirmed that isolated cells were mesothelial cells. When seeded on CMC, meshes or film, cells colonized CMC and its separated components, being the major growth on CMC and meshes. No induction of cell death was observed. Increasing number of cells on CMC, meshes, and film was confirmed by increased staining for vimentin. Conclusions: The research evidenced that human mesothelial cells well growth on CMC and its separated component. The proliferation of cells on film, even if lower than that on meshes, could be very important in favouring abdominal wall repair, both restoring peritoneum and producing biological molecules crucial in wound healing. The expression of growth factors, pro/anti-inflammatory cytokines, angiogenic factors in mesothelial cells grown on prosthesis is currently under investigation.

O056 - Radiology/Imaging

O058 - Abdominal Cavity and Abdominal Wall

Is Body Fat Composition Related To Hernia Recurrence?

Follow-Up After Inguinal Hernia Repair, Can It Be Done By Phone? A Prospective Study in 300 Patients, The PINQ-phone

H. Qandeel, E. Douglas, P.J. O’Dwyer Glasgow University, Glasgow, United Kingdom Aims: Obesity often has been cited in literature as a risk factor for ventral hernia recurrence. Measurement of visceral and subcutaneous adipose tissue area and muscle area by CTscan is considered the gold standard modality. The aim of this study is to examine the relationship between CT measured parameters of body composition (fat and muscles) and the recurrence in patients with ventral hernia. Methods: 35 Patients with ventral hernia were categorised into two groups: Primary (15patients) versus Recurrent (20patients) ventral hernia. Patients’ height, weight, ASA score were obtained from preoperative assessment records. CT image analysis using NIH ImageJ software was undertaken for all patients. Subcutaneous fat, visceral fat and total skeletal muscles cross-sectional areas (cm2) were measured at the level of L3 (upper edge) using standard Hounsfield unit ranges (adipose tissue: 2 190 to 2 30; skeletal muscle: 2 29 to +150). To test inter-observer ‘absolute agreement’, each parameter was measured independently by two investigators and reliability analysis performed. Additionally, right and left rectus muscles cross sectional areas (cm2) were measured separately. Results: The Primary and Recurrent groups were similar in their age (mean = 61 yr Vs 65 yr), weight (mean = 87 kg Vs 87 kg), height(mean = 164 cm Vs 166 cm), BMI (mean = 31.9 Vs 31.5) and ASA(2 Vs 2), respectively. Reliability analysis for CT-measured parameters showed very high ‘Interclass Correlation Coefficient (ICC)’ as follows: Subcutaneous fat index, ICC = 0.993; Visceral fat index, ICC = 0.995; Skeletal muscle index, ICC = 0.968. The difference between the two groups was not statistically significant for the CT-measured variables of subcutaneous fat (P = 0.92), visceral fat (P = 0.98), total skeletal muscles (P = 0.88), right (P = 0.99) and left rectus (P = 0.62) muscles crosssectional areas. Conclusion: No relationship was found between ventral hernia recurrence and body composition (fat and/or muscles). Other factors need to be considered in determining why recurrence occurs.

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B. van den Heuvel1, J.A. van Jarwaarde2, P. Wichers2, E.S.M. de Lange1, H.J. Bonjer1, B.J. Dwars2 1 VUMC, Amsterdam, The Netherlands; 2Slotervaartziekenhuis, Amsterdam, The Netherlands

Aims: The most important long-term complications after inguinal hernia repair are chronic pain and recurrence. Previous follow-up studies showed that physical examination is the only reliable method of follow-up to detect recurrences. However, physical examination is laborious and time consuming. We designed a telephone questionnaire as a method of follow-up after inguinal hernia surgery; the PINQ-PHONE (Post-INguinal-repair-Questionnaire by telePHONE). The aim of this study is to validate the PINQ-PHONE for detecting both asymptomatic and symptomatic recurrences. Methods: This prospective study contained 300 randomly selected patients after inguinal hernia repair. All patients were contacted by telephone and the PINQ-PHONE was carried out. The PINQ-PHONE contains four elements; three questions and a do-it-yourself Valsalva manoeuvre. Subsequently, all patients were seen in clinic and physical examination (gold standard) was done. Results: The majority (96 %) was male and the mean age was 66 (range 26–93) years old. The mean interval between surgery and study inclusion was 58 (range 6–141) months. In five (1.7 %) patients a recurrence was found. All of them replied positively to one or more elements of the PINQ-PHONE. Two-hundred-fifty-two (84 %) patients replied negatively to all elements and none of them had a recurrence. The overall sensitivity was 100 and the overall specificity 086. Conclusion: This study validated the PINQ-PHONE. It is a reliable, practical and simple method of follow-up after inguinal hernia repair to detect both symptomatic and asymptomatic recurrences.

Surg Endosc

O060 - Abdominal Cavity and Abdominal Wall

O062 - Endocrine Surgery

Be Awared: Plastic (Absorbable and Permanent) Fixation Methods Could Be Related To An Increase Of Recurrence Rate During Laparoscopic Ventral Hernia Repair

Single-Incision Endoscopic Thyroid Surgery (SIET) For Thyroid Carcinoma

S. Morales-Conde1, M. Sanchez-Ramirez2, M. Socas1, I. Alarco´n1, H. Cadet1, F.J. Padillo1, A. Barranco1 1

University Hospital ,,Virgen del Rocı´o,,, Sevilla, Spain; 2Hospital Universitario Puerta Del Mar, Cadiz, Sevilla, Spain

Introduction: Laparoscopic ventral hernia repair (LVHR) using the Double Crown technique (DC) is a safe alternative with a similar recurrence rate and less surgical wound infection. The evolution of the technique, looking for decreasing postperative pain, has been toward a reduction of the numbers of conventional metal tackers to one third together with fibrin glue. The results show similar recurrence rate with lower surgical pain, but potential complications like adhesions and bowel obstructions with metal tackers, news methods of fixations help to prevent it. Material and Methods: Between July 2012 and July 2013, we compared our series of DC with PTFE-e mesh fixed with one third of tackers and fibrin glue with the same technique and mesh fixed with different plastic, permanent (PermafixÒ)and absorbable (Securestrap Ò) tackers. Thirteen patients were included, using PermafixÒ in 6 and Securestrap Ò in 7. Ten patients had an incisional hernia (77 %) and three of them, a primary hernia (33 %). Six patients had a previous repair with a mesh (46, 1 %). A CT-scan was performed in all patients one month after surgery to evaluate the presence of preprothesic and retroprothesic seroma and recurrences. Patients were clinically evaluated using a visual analogue scale for pain (VAS) in rest and after first week, 4 weeks and 3 months after surgery. Results: The average operative time was 49 minutes, by the same surgeon. All patients were discharged on day one; no intraoperative or postoperative complications were detected. All patients were followed in the first week, first month, 3 months and 6 months after surgery. The VAS score was less than 1 at first week in six patients (46 %), and less than 4 in seven patients (54 %). VAS scored was lees than 1 in all patients at 3 and 6 months. The recurrence rate at 6 months was 15,4 %. Conclusion: The recurrence rate of 15,4 % forced us to abandon this study since the recurrence rate was higher than expected, based in our historical data that showed 2 % of recurrences after our conventional DC and 3 % after the DC with one third of the tackers and fibrin glue.

M. Tori Osaka Police Hospital, Osaka, Japan Background and Aims: Video-assisted neck surgery could not be standardized because of incompatibility to invasive cases. On the other hand, small-incision surgery has a problem of operative window. We already developed hybrid-type endoscopic thyroidectomy (HET) which combines the merits of each. Three hundred cases were performed with HET for 3 years, without any perioperative complications and recurrence. As further step, we have developed single-incision endoscopic thyroid surgery (SIET) for thyroid carcinoma. We now present our new method for the first time in the world. Patients and Methods: Since January 2013, SIET was performed for 30 malignant cases, and among them, 18 patients underwent lobectomy, and 12 total thyroidectomy. As to the operative indication, tumor size is \ 4 cm, with or without tracheal invasion needing shaving. They all consist of papillary carcinoma. These cases were clinically examined retrospectively. Evaluation of cosmetics and pain scale were added to the results. Op procedures: Single small color incision (1.5–2.0 cm) is made just above the clavicle of the tumor side (both in lobectomy and total thyroidectomy). Before SIET port is attached to the incision, central lymph node dissection is performed. To obtain enough working space, anterior neck muscles are divided longitudinally at the midline, and after dissection of the space between thyroid and the muscles, both side of the anterior muscles are pulled toward each side supported by L-shaped steel lift fixed to the edge of the operating table. Three 5 mm trocars are inserted on the SILS port. By using some useful retractors, recurrent nerve and parathyroids are clearly visible, and finally lobectomy or total thyroidectomy can be done. Result: Average operation time: lobectomy + CCND (central); 101 min, total thyroidectomy + CCND; 135 min. Average blood loss \ 50 ml. Postoperative course was all uneventful. No complications including recurrent nerve palsy were encountered. Average hospital stay was 4.1 days in lobectomy and 4.8 days in total thyroidectomy. All of the patients were satisfied with the cosmetic result and postoperative pain (7pod). Conclusion: Our findings support the idea that SIET is a feasible, practical, and safe procedure, with excellent cosmetic benefits. SIET will be a standard operative procedure for expert endoscopic thyroid surgeons.

O061 - Intestinal, Colorectal and Anal Disorders

O065 - Endocrine Surgery

The Use of a Composite Synthetic Mesh for Laparoscopic Prophylaxis and Repair of Parastomal Hernia. Does it Increase the Risk of Short Term Infective Complications?

Thyroid Remnant After Robotic Assisted Transaxillary Total Thyroidectomy: A Retrospective Comparison With Minimally Invasive Video assisted Approach

S. Anwar, S. Shiralkar, A. Bilkhu, A. Saha

B. Mullineris1, G. Colli1, A. Gurrado2, B. Madeo1, F. Minerva2, I.F. Franco2, M. Testini2, M. Piccoli1

Calderdale and Huddersfield NHS Trust, Huddersfield, United Kingdom Aims: The use of synthetic meshes in potentially infected operative fields is controversial. This study describes our experience with the use of a synthetic composite mesh for laparoscopic prophylaxis and repair of parastomal hernias, where the mesh came in close proximity to the bowel. Methods: Data were collected prospectively over a 5-year period from July 2008 -2013. An IPOM (DynaMeshTM) was used during creation of the stoma to reinforce the abdominal wall around the stoma and during surgical repair of existing parastomal hernia by a key hole or sandwich technique. All procedures were performed laparoscopically. Clinical outcomes, morbidity and in particular any infective wound complications were noted. Results: There were 26 patients during the study period; with a male to female ratio of 18:8. Median age was 69.9 years (range 39.4–91.5). Eleven patients had a prophylactic mesh repair (PMR) (key hole technique) at the time of primary surgery- 8 abdominoperineal resections and 3 Hartmann’s procedure (all for cancer). Fifteen patients had repair of parastomal hernias (RPH) (6 key hole and 9 sandwich techniques).Only one patient in the RPH group had a superficial wound infection around the stoma site and underwent an incision and drainage. There was one seroma and one wound haematoma around the stoma site. No other infective complications were recorded. There was one conversion; this patient had ischaemic bowel incarcerated in the parastomal hernia and died 48 hours post surgery. Conclusions: The use of a synthetic mesh for laparoscopic prophylaxis and treatment of parastomal hernias even in the presence of a potentially infected surgical field, such as colorectal surgery, is safe and feasible.

1 Nuovo Ospedale Civile Sant’Agostino Estense, Modena, Italy; 2Unit of Endocrine, Digestive and Emergency Surgery, Bari, Italy

Background: Total thyroidectomy (TT) can be performed by different approaches. The aim of this study was to compare the thyroid remnant(TR) after robotic assisted transaxillary(RAT) approach or minimally invasive-video assisted thyroidectomy (MIVAT). Methods: From January 2011 through December 2012, 693 patients underwent TT at two departments of general surgery in Italy. A retrospective study was conducted on 50 patients affected by benign or follicular disease (benign or malignant = 1 cm diameter) treated by RAT total thyroidectomy (Group A, N = 25; 23 females and 2 males; mean age: 38, range: 25–64 years) using da VinciÒ Sirobotic system or by MIVAT (Group B; N = 25; 19 females and 6 males; mean age: 47, range: 26–69 years). In each group, TTs were performed by the same surgeon with high level of experience in RAT thyroidectomy, or in MIVAT, respectively. According to our follow-up schedule, an ultrasonagraphy (US)was performed five months after the operation by a single operator with high level of experience, in order to evaluate the potential TR. Results: In both groups all procedures were completed without conversion to open surgery. The mean postoperative hospital stay was 2.2 days (range: 1–5)in Group A vs3.0 (range: 2–6) in B (P \ 0.001). USshoweda TR in 13 (52.0 %) patients in Avs0 in B (P \ 0.001). In Group A the remnant showed a mean size of 6.3 mm (range: 0–27.0) prevalently found on the opposite side with respect to the axillary skin incision (N = 11, 85 %). Conclusion: This is the first study ultrasonographically comparing TR after RAT total thyroidectomy with MIVAT. The US remnant evidence was significantly higher in RAT total thyroidectomy vsMIVAT. However, when malignancy is found, TR is small enough to be successfully managed by radioiodine therapy in most cases. Moreover, the incoming of endowrist camera could avoid the higher incidence of controlateral TR. TT for benign and follicular disease can be safely performed also through RAT and MIVAT approaches, according to their own guidelines and to the surgical team training.

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Surg Endosc

O066 - Robotics, Telesurgery and Virtual Reality

O068 - Endocrine Surgery

Effect of Spray 0.25 % Levobupivacaine on the Postoperative Pain and Patient Controlled Analgesia (PCA) After BABA Robotic Thyroidectomy: Prospective and Randomized Trial

Influence of Laparoscopic Gastric Plication on Carbohydrate Metabolism in Patients With Type 2 Diabetes Mellitus. Our Experience

C.K. Yom1, J.H. Ryu2, A.Y. Oh2

Y. Havrysh, O. Lukavetskiy, Y. Havrysh, M. Kondratuk, I. Kravchuk

Myongi Hospital, Goyang-si, Korea; 2Seoul National University Bundang Hospital, Seongnam, Korea

Lviv Regional Clinical Hospital, Lviv, Ukraine

1

Background: Robotic thyroidectomy (RoT) is frequently performed due to its excellent cosmesis and recovery profiles. However, postoperative pain in operating field after RoT is remained as concerns due to extensive tissue dissection and tension during the operation. The aim of this study is to evaluate the anterior chest pain and the effect of levobupivacaine spraying on postoperative pain control after RoT via bilateral axillo-breast approach (BABA). Methods: Fifty-five adult patients scheduled for BABA RoT were randomized into control group (group A, n = 27) or levobupivacaine group (group B, n = 28). At the end of surgery, patients in group A and B were sprayed with the same volume (30 ml) of normal saline and 0.25 % levobupivacaine, respectively, on flap dissection area. Total intravenous anesthesia with propofol and remifentanil was used for the induction and maintenance of anesthesia. Pain scores, the consumption of patient controlled analgesia (PCA), and other adverse effects were assessed at 1 h, 6 h, 24 h, and 48 h postoperatively. Results: Patients in group B showed less pain scores than those of group A at 1 h (50 [0–100] vs. 80 [20–100]; P = 0.004), 6 h (30 [0–90] vs. 70 [30–90]; P \ 0.001), 24 h (30 [0–80] vs. 30 [10–80]; P = 0.016) and 48 h (10 [0–80] vs. 30 [10–80]; P \ 0.001) postoperatively. PCA consumption of group B was less than that of group A at 6 h, 24 h and 48 h after surgery. There were no significant differences in PONV, headache, and dizziness. Adverse effects related with local anesthetics were not observed. Conclusion: Levobupivacaine spray on operative field at the end of surgery reduced postoperative pain and PCA consumption without adverse events after BABA RoT .

Aims: To study the impact and long-term effects of laparoscopic gastric plication (LGP) to the individual parameters of carbohydrate metabolism in patients with type 2 diabetes mellitus (DM2). Methods: From September 2011 to January 2014, we operated 43 patients with DM2. 30 patients were women, 13 - man. The age of patients was from 22 to 63 years. The disease lasts from 5 to 14 years. All patients were divided into three groups: 1st group–13 patients treated with hypoglycemic drugs plus insulin therapy, 2nd group- 18 patients treated with hypoglycemic drugs, 3rdgroup- 12 patients treated with diet therapy. BMI of patients was from 28 to 45. We performed laparoscopic gastric plication in all of the patients. The average operation time was 110 min (80–150 min). We measured blood glucose, glycated hemoglobin (A1c), parameters of lipid and carbohydrate metabolism in all patients before surgery. After operation, we measured blood glucose daily, glycated hemoglobin (A1c) and parameters of lipid and carbohydrate metabolism after 3, 6, 12, 24 months. Results: 1 complication was observed: on the 2nd day patient had pulmonary embolism which was treated with conservative therapy. No mortality. 3 months after operation we noted blood glucose level normalization in 7 (54 %) patients without insulin therapy and in 6 patients (46 %) reduction of insulin dose from 1st group; in 10 (55 %) patients from 2nd group we noted blood glucose level normalization without taking hypoglycemic drugs and in 12 (100 %) patients from 3rd group blood glucose level normalization without a diet. We got similar results 6, 12, 24 months after surgery. We noted improvement of general state of health in all patients. Conclusions:

1. 2.

LGP has a positive effect on the normalization of parameters of carbohydrate metabolism in patients with type 2 diabetes mellitus. Effect of LGP on the course of type 2 diabetes needs further investigation and research

O069 - Endocrine Surgery O067 - Endocrine Surgery Single-Port Laparoscopic Left Adrenalectomy (SILS): Three Years Experience of A Single Institution O. Vidal, D. Saavedra, J. Ordo´n˜ez, M. Valentini, C. Ginesta, E. Astudillo, L. Ferna´ndez-Cruz, J.C. Garcı´a-Valdecasas Hospital Clinic de Barcelona, Spain Background: Laparoscopic adrenalectomy via three or four trocars is a well-established procedure This report describes the initial experience with single-incision laparoscopic surgery (SILS) using the transperitoneal approach for left adrenalectomy. Methods: Between April 2010 and January 2013, all consecutive patients with adrenal masses who agreed to undergo SILS adrenalectomy were included in a prospective study. The left 2.5 cm subcostal incision was the sole point of entry. Data of patients undergoing SILS adrenalectomy were compared with those from an uncontrolled group of patients undergoing conventional laparoscopic adrenalectomy during the same study period. Results: There were 40 patients in each study group. SILS was successfully performed and none of the patients required conversion to an open procedure. In one case of SILS procedure, an additional lateral 5 mm port was needed for retraction of the kidney. The mean (standard deviation, SD) duration of the operation was 80 (20) min in the SILS group and 75 (8) min in the conventional laparoscopic adrenalectomy group (P = 0.150). There were no intraoperative or postoperative complications. No intraoperative or postoperative complications occurred. Differences between the two study groups in postoperative pain, number of patients resuming oral intake within the first 24 hours, final pathologic diagnosis (Conns’ syndrome, Cushing’s adenomas, non-functioning adrenal tumors) and length of hospital stay were not observed. Conclusions: SILS left adrenalectomy is a technically feasible and safe procedure in carefully selected patients and appears to have results similar to conventional approach in our initial comparison.

123

Comparative Study Between Laparoscopic gastrodeudenal Bypass And Ileal Transposition (DJB &IT) in the Management Of Type 2 Diabetes Mellitus (DM) in Obese Patients A.T. Abdelhafez, M. Mahfouz, A. Hefny, A. Ibraheem, T. Abuzaid Northern area armed forces hospital, Hafar albatin, Saudi Arabia Background: The prevalence of obesity and T2DM has increased dramatically worldwide, becoming a serious global public health problem. Bariatric surgery should be considered as an alternative line of treatment for patients with a BMI of 30–35 kg/m2 when DM cannot be controlled by medical regimen. With the exception of omentectomy, which has proven to be totally ineffective, the newly developed operations specifically designed for T2DM treatment ‘ gastroduodenal bypass and ileal transposition (DJB &IT) were inspired by the two known hypothesis(hindgut & foregut theory).Both have been proposed to explain T2DM remission after metabolic surgery in addition to decreased calorie intake after surgery and surgical-induced weight loss .This study is a randomized control trial, comparing gastroduodenal bypass and ileal transposition regarding their efficacy in management of type II diabetes mellitus (DM) in obese patients. Patients and Methods: A prospective randomized control trial study using the closed envelop method was done in Ain Shams univeristy hospitals, from June 2010 up to June 2013 upon 40 obese patients with BMI between 30–35 suffered from type II DM for antidiabetic surgery comparing between gastroduodenal bypass and ileal transposition as regard their effect on glycemic control. Results: In this study, the 20 patients whose had DJB, the FBG decreased from 257 mg/dl to 106 mg/dl, and the 2H-PP value also decreased from 335 mg/dl to 161 mg/dl with improvement of HbA1c from 9 gm % to 5.7 gm %. The S. insulin level was increased from 9.8 miu/ml to 12.4 miu/ml, with associated increased C-Peptide from 0.9 ng/ml to 1.2 ng/ ml.

Surg Endosc

O070 - Endocrine Surgery

O072 - Intestinal, Colorectal and Anal Disorders

Resolution of Type 2 Diabetes and Prediabetes Following Laparoscopic Sleeve Gastrectomy

The Laparascopic Approach is An Essential Part of the ERAS Protocol in Colorectal Surgery in Achieving Fast Track Principles

M. Rubio-Manzanres Dorado1, S. Morales-Conde2, P.P. Garcia Luna1, A.J. Martinez1, L. Romero1, I.J. Jimenes1, J.L. Pereira1, P. Serrano1, I. Alarco´n1, J.M. Cadet1, A. Barranco1, M. Socas1

P.A. Neijenhuis, M. Hermans

1

University Hospital Virgen del Rocio, Seville, Spain; 2Sevilla, Spain, Spain

Aims: Gastric Bypass is considered the gold standard surgical option for type 2 diabetes mellitus (T2DM) in obese patients meeting surgical criteria. The aim of this study is to determine the impact of LGS on the resolution of T2DM and Prediabetes (PDM) in obese patients, as well as possible improvements in other comorbidities. Material and Methods: Retrospective descriptive study. We included all patients with T2DM or PDM who underwent LSG in our center between years 2009 and 2012. PDM was defined as having at least two values of HbA1c between 5.7 and 6.4 %. Weight, Body Mass Index (BMI) and HbA1c, as well as other comorbidities related to obesity (Hypertension [HT], dyslipidemia [DL], arthropathy and Obstructive Sleep Apnea [OSA]) were compared at baseline and after LSG, with a follow-up period of 1–4 years. T2DM remission criteria were fasting plasma glucose (FPG) \ 100 mg/dl and HbA1c \ 6 % in the absence of oral hypoglycemic agents (OHA) or insulin use. Results: Quantitative variables are defined as median [Interquartile range]. *TDM2 group: n = 36 (24 women); age 50.5 [45–57] years. Follow-up period 18.5 [12–22] months. Comorbidities at baseline: HT 77.8 % (n = 28),DL 69.4 % (n = 25), OSA 52.8 % (n = 19), arthropathy 30.6 % (n = 11). Post-LSG weight was 93.8Kg [81–110], BMI was 36.2 Kg/m2[31–41] and HbA1c 5.7 %[5.4–6.4] (p \ 0.0001 post-LSG vs pre-LSG) After LSG, T2DM improved in 97.6 % (n = 35) patients, with a remission rate of 58.3 % (n = 21). Overall improvement or resolution of comorbidities was as follows: DL 64 % (n = 16), HT 39.3 % (n = 11), OSA 26.3 % (n = 5). Regarding arthropathy, 100 % of patients showed better functional status in comparison to baseline. *PDM group: 44 patients (26 women); age 41.5 [36.5–47] years. Follow-up period 16 [11–24] months. Post-LSG weight 90.4 Kg[80–102], BMI 31.9 Kg/m2 [29–36] and HbA1c 5.3 % [5.1–5.4] (p \ 0.0001 post-LSG vs pre-LSG) Conclusion: LSG effectively achieves improvement or remission of T2DM or PDM, as well as other comorbidities, in obese patients meeting surgical treatment criteria.

Rijnland Hospital, Leiderdorp, The Netherlands Background: The Enhanced Recovery After Surgery (ERAS) protocol has been developed in 2005 to improve postoperative recovery in colorectal surgery. Although it has shown to be effective in shortening hospital stay, the aim of a 5-day during stay might be difficult with expanding numbers of elderly patients. This study evaluates the factors that influence a hospital stay longer than 5 days. Method: S: Between 2010 and 2012, 289 patients underwent colorectal resection surgery and were included in this study. All data were prospectively gathered in an electronic database. Complications and patient characteristics of patients with a hospital stay of 5 days or less were compared to those who were discharged after 6 days or later. Results: A total of 134 patients stayed in the hospital for less than 5 days, 154 patients stayed longer. The median age in the = 5 days in hospital group was significantly lower than the median age in the [ 5 days in hospital group (= 5 days: 66 years [range: 41–88 years], [ 5 days: 70 [range: 45–93 years], p-value 0,0006). Of all procedures, 62 % was performed laparoscopically with a conversion rate of 8 %. Laparoscopic surgery was less common in the [ 5 days group (51 %), in the = 5 days group this rate was higher (75 %).. An open approach leads to an almost threefold increase chance of a prolonged hospital stay OR 2,8 [1,5–5,4]. Conversion had a OR of 1,6 [0,5–4,9] (= NS). Surgery related complications were reported in 89 patients (31 %), in all cases resulting in a [ 5 days hospital stay. The largest group of complications accounting for a delay in recovery, were the non-surgery related (35 %). Of the surgery related complications, ileus (29 %) and anastomic dehiscence (11 %) were most noted. Conclusion: These results show that high age, open surgery and non-surgery related complications due to co-morbidity, contribute to a longer hospital stay after colorectal surgery. This suggests that laparoscopic surgey is a cornerstone of the ERAS principles. In the meantime more attention has necessary in the postoperative phase in elderly and patients with co-morbidity.

O071 - Intestinal, Colorectal and Anal Disorders

O073 - Intestinal, Colorectal and Anal Disorders

Impact of Training Systems in Laparoscopic Colorectal Surgery. Comparative Analysis Between General Surgery Residents, Colorectal Surgery Fellows and Colorectal Surgeons

Preoperative Quality-of-Life Predict Serious Surgical Complications and Readmission Independent of Minimally Invasive or Open Surgical Approach

M. Galvan, S. Guckenheimer, E. Grzona, A. Canelas, M. Bun, M. Laporte, C. Peczan, N Rotholtz

J. Bingener, J. Sloan, P. Novotny, B. Pockaj, H. Nelson

Hospital Aleman de Buenos Aires, Buenos aires, Argentina Aims: To compare the results when laparoscopic colorectal surgery is perform by colorectal surgeons, colorectal surgery fellows and general surgery residents and determine if the procedure is perform safely during their learning curve. Methods: A retrospective study was performed using a prospective collected database. Elective laparoscopic resections of right and left colon were analyzed in the period June 2000 - June 2012. The series was divided into three groups: procedures performed by staff colorectal surgeons (GI), colorectal surgery fellows (GII) and general surgery residents (GIII). Patients demographics data, operative time, postoperative recovery variables, hospital stay, morbidity and mortality rate were compared. Complex colonic resections and rectal surgeries were excluded. Results: 619 laparoscopic resections were included; GI: 332 (53.6 %), GII: 141 (22.8 %) and GIII: 146 (23.6 %). Right colectomies were done as follows: GI 96 (15.6 %), GII 42 (6.8 %), GIII 62 (10 %). Left colectomies: GI 236 (38.1 %), GII 99 (15.9 %), GIII 84 (13.6 %). There were no differences in parients demographic data between the groups. Conversion rate was higher in GI (GI: 7.5 % vs GII: 4.9 % vs GIII: 4.7 %; p \ 0.05). Intraoperative complications rate was comparable between the groups and there was no difference in recovery parameters. Hospital stay was comparable. The rate of postoperative complications was lower in GI (GI: 72 (21.6 %) vs GII: 40 (28.3 %) vs GIII: 42 (28.7 %); p \ 0.05). There were no differences in the anastomotic leak rate nor in the mortality rate between groups. Conclusions: General surgery residents and colorectal fellows can perform laparoscopic colectomies safely during their training.

Mayo Clinic, Rochester, United States of America Aims: Decreased survival after colon cancer surgery has been reported in patients with deficient baseline quality-of-life (QOL) as reported in a recent secondary analysis of the COST (Clinical Outcomes of Surgical Therapy) trial. We hypothesized that deficits in preoperative QOL are also associated with postoperative complications and readmission. Methods: A secondary analysis of the COST trial 93-46-53 (INT 0146) was performed. Patient demographics, surgical complications (grade 0–4), composite and single item QOL scores were used for univariate and multivariate analysis. QOL deficit was defined as an overall QOL score \ 50 on a 100 point scale. 416 patients provided the power to identify + 5 points (0.5 standard deviation) difference in the global QOL scale with a 95 % confidence interval. Results: Eighty-one (19 %) of the 431 patients who were enrolled in the QOL portion of the COST trial, experienced complications prior to discharge. 42 % of the complications were serious (grade 2–4) including two deaths (0.5 %). 55 patients (13 %) had a QOL score \ 50 at baseline. Patients with a baseline QOL deficit were more likely to have a serious complication than patients without a QOL deficit (16 vs 6 %, p = 0.0234). Patients with a complication were 3 years older (p = 0.03) and more likely ASA III (p = 0.0034). Gender, race, tumor stage and laparoscopic or open approach were not associated with an increased frequency of complications. Patients with complications experienced a 3.5 day longer hospital stay (p = 0.0001). Preoperative pain distress was a significant predictor for being readmitted to the hospital (OR 1.61, CI 1.11–2.34, p = 0.0125) after adjusting for age, gender, race, tumor stage, ASA and operative approach. Conclusion: The QOL assessment was initially included in the COST trial to compare two surgical approaches for their impact on the patient. Together with other reports this study suggests that QOL tools also can provide an early indicator for patients at risk of complications. Further studies are needed to evaluate whether preoperative assessment of QOL may assist in reducing postoperative complications, length of hospital stay and readmission.

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Surg Endosc

O074 - Clinical Practice and Evaluation

O076 - Clinical Practice and Evaluation

Predictors of Enhanced Recovery After Surgery (ERAS) Outcomes in Colorectal Surgery: A Systematic Review

Predictive Factors for Perioperative Blood Transfusions in Laparoscopic Colorectal Surgery

D. Messenger1, A. Jones1, E.L. Jones1, N.J. Smart2, N.K. Francis1

Y. Abu Ghanem, H. Mahajna, R. Ghinea, I. White, R. Inbar, S. Avital

1

Meir Medical Center, Kfar saba, Israel

Yeovil District Hospital NHS Foundation Trust, Yeovil, United Kingdom; 2Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom Introduction: Enhanced recovery after surgery (ERAS) programmes have been widely adopted in colorectal surgery and have been shown to reduce length of stay (LOS) and morbidity when compared to traditional care. Not all patients achieve successful outcome and the aim of this study was to identify which factors were predictive of its outcome. Methods: A systematic search was undertaken of the MEDLINE and EMBASE databases between 2000 and 2013. The search strategy captured terms relating to predictive factors and outcome measures of enhanced recovery after colorectal resection. Results: From 5486 abstracts, 16 studies were selected: 14 cohort studies and two randomised controlled trials described 6774 patients. The definition of outcome from ERAS was heterogenous with LOS the most commonly reported outcome measure (13 studies). Pathophysiological factors that were predictive of increased LOS included old age, male sex, ASA [ 2 and raised CRP. Non-compliance with early post-operative mobilisation, fluid restriction and catheter removal were the ERAS elements most frequently associated with increased LOS. Four studies showed the laparoscopic approach to be associated with shortened LOS. In six studies, non-compliance with post-operative fluid restriction and catheter removal, as well as raised inflammatory markers, were associated with increased morbidity. Conclusions: ERAS outcome is most frequently defined by length of stay and morbidity. In this respect, pathophysiological markers, the laparoscopic approach, intravenous fluid restriction and early mobilisation would appear to be the key predictors of outcome. In view of the heterogeneity of outcome measures, a definition of what constitutes success and failure is required.

Background: Allogeneic perioperative blood transfusion (PBT) has been associated with higher rates of postoperative complications in patients undergoing colorectal surgery and increased tumor recurrence in cancer patients. Our aim is to evaluate possible predictive factors for PBT, specifically, in patients undergoing laparoscopic colorectal surgery, in order to identify patients who could benefit from alternatives to allogenic PBT such as erythropoietin administration, autologus blood transfusion and possibly preoperative blood transfusion. Methods: Five-hundred patients who underwent laparoscopic colorectal surgery between the years 2003–2011 were reviewed. Patient demographics, clinicopathologic variables were collected prospectively. Other clinical data were collected directly from the computerized records of the in-hospital blood bank. PBT was defined as transfusion of allogenic red blood cells during the day of operation or within the postoperative hospitalization. The associations between PBT and patients variables were assessed by univariate and multivariate analysis. Results: Of the 500 patients, 134 patients (26.8 %) received PBT. Multivariate analysis revealed four preoperative variables as significant risk factors for PBT: Preoperative hemoglobin (P = 0.001), lower rectal surgery (P = 0.009), Charlson comorbidity score (P = 0.001), and malignancy (P = 0.024). Conclusions: Preoperative Charlson score, hemoglobin level, carcinoma and lower rectum pathologies were found to be independent risk factors for PBT in patients undergoing laparoscopic colorectal surgery. Evaluation of these risk factors prior to surgery may be helpful in selecting the patients who could benefit from possible alternatives to perioperative allogeneic blood transfusion and help constitute guidelines for a more responsible use of these alternatives.

O075 - Clinical Practice and Evaluation

O077 - Intestinal, Colorectal and Anal Disorders

Survey Study to Define the Assessment of Clinical Outcome Parameters Following Laparoscopic Colorectal Surgery

Laparoscopic Versus Open Colon Surgery: Quality Of Life 1 to 5 Years Post-Diagnosis, A Population-Based Study

S.R. Markar1, T. Hettiarachchi2, H. Mackenzie1, M. Coleman3, R.J. Davies2

A.M. Smulders1, M.S.Y. Thong2, G.D. Slooter1

1

St Mary’s Hospital, Imperial College, London, United Kingdom; 2 Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge, United Kingdom; 3Department of Colorectal Surgery, Plymouth Hospitals NHS Trust, Plymouth, United Kingdom Background: The publication and reporting of outcomes following colorectal surgery at an institutional and individual surgeon level has recently commenced in the United Kingdom (UK). The aim of this survey study is to assess how surgeons across Great Britain and Ireland are currently reporting outcomes following laparoscopic colorectal surgery (LCRS). Methods: A ten-question survey was emailed to members of Association of Coloproctology Great Britain and Ireland (ACPGBI) and the United Kingdom national training programme in laparoscopic colorectal surgery (LAPCO) during 2013. Responses were collated over a three-month period. Results: Eighty-two colorectal surgeons responded to the survey giving an overall response rate of 30.7 %. Twenty-four percent of responders had performed LCRS [ 10 years, with 56.1 % performing [ 25 resections per year. The majority of responders (67.5 %) defined conversion to an open procedure as an incision size greater than initially anticipated. Fiftyfour percent stated that they currently record in-hospital, 30-day and 90-day mortality following LCRS. More than 80 % of responders typically record anastomotic leak (96.3 %), DVT/PE (80.5 %), wound infection (81.7 %), length of hospital stay (93.3 %), re-admission (93.3 %) and unplanned return to theatre (96.3 %). However, blood transfusion, ICU stay, and discharge location were recorded in less than 50 %. Seventy-three percent only grade complications as a binary occurrence with no assessment of severity. The most commonly utilised assessment of medical co-morbidity was Possum (44 %). Eighty-seven percent of responders agreed that a standardised system for reporting of complications would be useful in practice and in reporting of comparative outcomes. Discussion: There is currently a large degree of heterogeneity in the recording and assessment of post-operative complications by laparoscopic colorectal surgeons across the United Kingdom. A standardised system for reporting complications following LCRS is required in order to allow robust data collection in future clinical studies and permit accurate institutional comparison.

123

1 Maxima Medical Centre, Veldhoven, The Netherlands; 2CoRPS Centre of Research on Psychology in Somatic Diseases, Tilburg, The Netherlands

Aims: (1) assessing the impact of laparoscopic colon surgery (LCS) and open colon surgery (OCS) on Health Related Quality of Life (HRQoL) among resected colon cancer survivors 1 to 5 years post-diagnosis, and (2) assessing HRQoL among LCS and/or OCS resected colon cancer survivors 1 to 5 years post-diagnosis compared to an age and gender matched normative population. Methods: Patients operated between 2005–2009, at Maxima Medical Centre (MMC) (LCS n = 75, OCS n = 53, conversion n = 14), VieCuri Venlo (OCS n = 125) and St Elisabeth Tilburg (OCS n = 90), were selected. Since 2005, MMC uses LCS as the treatment of choice for colon cancer and OCS was the treatment of choice in VieCuri and St. Elisabeth until 2009. Of the normative population, who are representatives of the Dutch-speaking population, 308 were selected and age- and gender-matched. Primary outcomes were HRQoL and physical -, role -, emotional -, cognitive - and social functional scales, assessed with EORTC-QLQ-C30. Secondary outcome measures were body image, sexual functioning and defecation problems. Results: No significant differences were found in HRQoL (p = 0.067). However, survivors experienced significant restrictions in physical -, role -, emotional -, cognitive - and social function compared to the normative population. On the secondary outcome measures, patients within MMC reported a better body image in LCS than conversions (p = 0.022). Regarding defecation problems (p \ 0,001) and sexual functioning (p \ 0.001), the normative population scored significantly better compared to the cancer survivors, except for constipation problems, where open procedure reported more clinically relevant problems than LCS (p \ 0,001). Conclusions: We conclude that LCS is not inferior compared to OCS 1 to 5 year postdiagnosis, expressed in HRQoL and functional scores. Thereby, open procedure reported clinically relevant more constipation problems than LCS and the normative population. Colon cancer survivors report up to 5 years significant restrictions on functional scales compared to a normative population independent of the surgical approach. Previous research proved LCS to be oncological safe, cost-effective and with better short-term results. Our study indicates no disadvantages of LCS on the long-term compared to OCS, concluding that it is advisable to perform LCS in the treatment of colon cancer.

Surg Endosc

O079 - Intestinal, Colorectal and Anal Disorders

O081 - Liver and Biliary Tract Surgery

Safety of Fast Track Program in Colorectal Surgery in Elderly Patients

Role of Routine Fluorocholangiography in 21st Century Biliary Surgery

F. Borghi, L. Pellegrino, G Giraudo, N. Pipitone, G. Sapia, M. Meineri, D. Donati, M.C. Giuffrida

A. Mirza, Z. Samer, H. Qandeel, A. Nassar

ASO SANTA CROCE E CARLE, Cuneo, Italy

Aims: Since the introduction of laparoscopic cholecystectomy (LC), the routine use of intraoperative cholangiography (IOC) has declined. Pre-operative endoscopic cholangio-pancreaticography and magnetic resonance cholangio-pancreaticography are being employed to diagnose common bile duct (CBD) stones. Our aim was to evaluate the routine use and clinical benefit of IOC during laparoscopic biliary surgery. Methods: A prospective study of patients undergoing LC and IOC (n = 3176) over 18 years was analysed. The pre-operative, intra-operative findings and post-operative course was analysed. A size 4 French ureteric catheter within an open cannula is used to perform IOC through subcostal port. Results: There were 1372 abnormal cholangiograms, filling defects (692), dilated ducts (545) stricture (22) and abnormal ductal anatomy (24). 1156 patients (36 %) had risk factors for CBD stones. IOC identified 652 (21 %) with CBD stones. 133 patients (4.2 %) with no risk factors for CBD stones were found to have CBD stones. Conclusions: IOC can be safely and routinely performed with laparoscopic cholecystectomy. It helps in the identification of CBD stones even in patients with no known CBD stone risk factors, recognition of bile duct injuries and the facilitation of single stage management of CBD stones.

Aims: The aim of this single centre study was to evaluate the safety of Fast-Track (FT) rehabilitation program in colorectal surgery in elderly patients. Methods: From April 2010 to October 2013, 304 patients (mean age of 67.5 ± 10.8 years) underwent colorectal resection with primary anastomosis within FT program, in our centre. Exclusion criteria were urgent surgical procedures and creation of derivative stoma. Data relevant to comorbidity, ASA score, type of postoperative analgesia, surgical procedure, intraoperative complications, operative time, postoperative length of hospital stay (POS), readmission rate, and 30-days post-operative morbidity, graded according to Dindo-Clavien classification, were collected in a prospective database. A comparative analysis was performed between the group of patients older than 70 years (OG) and the group of patients younger than 70 years (YG). Results: 124 patients (40.8 %) with mean age of 77.6 ± 5.1 years were included in OG and 180 patients (59.2 %) with mean age of 60.5 ± 7.8 years in YG. The two groups were comparable in term of gender, body mass index, previous abdominal surgery, type of colorectal resection and mean operative time. Epidural analgesia was adopted in 91.9 % in OG and in 93.3 % in YG (p = ns). Laparoscopic approach was used in 81.2 % without differences between groups. Age, comorbidities, and ASA score = III were significantly higher in OG. Conversion to laparotomy occurred in 1.6 % in OG, and in 5.5 % in YG (p = ns). Mortality was nil. Total postoperative complications were 37,1 % in OG and 32.2 % in YG (p = ns). Major complications (DindoClavien 3a, 3b and 4) occurred in 7.2 % in OG and in 5 % in YG (p = ns). Mean POS was 5.5 ± 3.5 days in OG and 4.7 ± 4.3 days in the YG (p = ns). Readmission rate (2.6 %) was comparable in two groups. The rate of patients discharged within the 3rd postoperative day was significantly lower in OG (29.8 % vs 48.9 %; p \ 0.05). Conclusions: FT in colorectal surgery can be safety applied in patients older than 70 years. Our study shows no difference in term of postoperative outcomes between OG and YG, except for discharge within 3rd postoperative day.

Monklands District General Hospital, Cheadle, United Kingdom

O080 - Liver and Biliary Tract Surgery

O082 - Liver and Biliary Tract Surgery

Atom: EAES Classification of Bile Duct Injuries During Laparoscopic Cholecystectomy. Retrospective Analysis of a Single Institution Experience

Specific Complications of Therapeutic ERCP

A. Paganini, A. Balla, S. Quaresima, F. Salvatori, F. Fiocca, M. Rossi, P. Lucatelli, N. Guglielmo, P.P. Berloco Sapienza University, Rome, Italy Aims: The rate of bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is higher than with open cholecystectomy. Several classifications of BDI during LC are described but none encompass the anatomy of damage/occurrence of vascular injury (A), the timing of (To) detection and the mechanism of damage (M)(ATOM). Aims of this study is to validate the all-inclusive EAES classification to a series of patients with BDI. Methods: From June 2008 to December 2013, 19 patients (11 males, 8 females, mean age 59,6 years, range 34–78) were retrospectively enrolled in the study. Patients experienced BDI during LC and were classified. Results: BDIs were as follows: MBD 3, OC, LS0, VBI-, Ep, Me(2); MBD 3, DC, LS0, VBI-, Ep, Me(2); MBD 5, DP, LS (1,5 cm), VBI-, Ep, Me(1); MBD 3, OC, LS0, VBI-, L, Me(1); MBD 5, DC, LS0, VBI-, Ep, Me(1); MBD 1, OC, LS0, VBI-, Ep, Me(1); MBD 5, OC, LS0, VBI-, Ep, Me(1); MBD 4, OC, LS (2 mm), VBI-, L, ED(1); MBD 4, OC, DC, LS (1 cm), VBI-, Ep, Me(1); MBD 2, DC, LS (6 cm), VBI + MV, Ep, Me + ED(1); MBD 5, OC, LS (2 cm), VBI-, Ep, Me(1); MBD 3, DC, LS (1,2 cm), VBI-, Ep, Me(1); MBD 4, DC, LS0, VBI + (RHA), Ep, ED(1); MBD 4, DC, LS0, VBI-, Ei, Me(1); NMBD, LS0, VBI-, Ep, Me(3)

M.Y Nychytaylo, P.V. Ogorodnik, A.G. Deynichenko, O.I. Lytvyn National Institute of Surgery and Transplantology named by A.A.Shalimov, Kiev, Ukraine Nowadays, endoscopic retrograde cholangiopancreatography is almost exclusively a therapeutic modality for different pancreatic and biliary disorders. This procedure can cause a spectrum of mild and severe complications, including hemorrhage, pancreatitis, cholangitis and retroduodenal perforation. Over a 13 - year period, from 2000 to 2013, a total of 11235 endoscopic transpapillary interventions were analyzed. Therapeutic ERCP included: sphincterotomy with common bile duct stones removal—6525 (58,1 %), mechanical lithotripsy 2920(26 %), sphincterotomy in patients with sphincter Oddi dysfunction—786 (7 %), suprapapillary choledochoduodenostomy 422(3,8 %), endobiliary stenting in cases of biliary or pancreatic malignancy 481(4,3 %), transpapillary dranaige of pancreatic pseudocysts 42(0,4 %), dilation and stenting of biliary strictures—32 (0,3 %) and endoscopic papillectomy—27(0,2 %) patients. Needle-knife sphincterotomy was performed in 29 % of cases. Success rates was 97.5 % for biliary cannulation. There were 495(4.4 %) complications, 38 (0.34 %) of which were severe and 3 were fatal (0.02 %). Acute pancreatitis occurred in 230 (2.05 %) of procedures, hemorrhage—235 (2.09 %), acute cholangitis—25(0.2 %) and perforation 5 (0.05 %). Two patients with perforation were treated surgically, one of them died. Overall complications were statistically more likely among individuals with suspected sphincter of Oddi dysfunction. Post-ERCP pancreatitis was more likely to occur after a pancreatogram, after difficult bile duct cannulation, among subjects with nondilated ducts and in cases of suspected sphincter Oddi dysfunction. Bleeding complications were more common in the setting of preexisting coagulopathy. This study characterizes a large number of ERCP procedures from our institution and outlines the incidence and predictors of complications.

All patients were treated by radiologic/endoscopic rendez-vous procedure (PTC + ERCP). Mean number of procedures was 8,68 (range 2–31). One patient (5.2 %) underwent open surgery for right hepatic artery injury, with ligature of common hepatic artery.Two patients (10,5 %) died from sepsis. Seventeen patients (89.5 %) are alive with no untoward sequelae. Mean treatment duration was 18,2 months (range 2–60). Conclusions: In the absence of major vascular injury the rendez-vous procedure is a safe and effective approach. The all-inclusive EAES classification is not intended to replace existing classifications of BDI but it encompasses the entire spectrum of vasculo-biliary injuries. This classification should be validated by larger patient series, in order to identify guidelines for treatment. The management complexity of these patients requires specialized referral centers with a multidisciplinary team.

123

Surg Endosc

O083 - Liver and Biliary Tract Surgery

O086 - Liver and Biliary Tract Surgery

The Preoperative Clinical Factors Can Help T0 Select the Most Appropiate Single-Stage Treatment of CholecystoCholedocholithiasis

Results of Medium Fifteen Years Follow-Up After Laparoscopic Transverse Choledochotomy For Ductal Stones

A. Bove University ‘‘G.D’Annunzio’’, Chieti, Italy Introduction: Given the benefits reported in terms of cost and length of hospitalization, there is a consensus to approach the cholecysto-choledocholithiasis with a single stage treatment. Numerous options include trans-cystic clearance (TC-CBDE), intraoperative papillotomy rendez-vous (ES-RV) and direct exploration through choledochotomy (LCBDE). But the single best option is not available with each procedure because of the different characteristics of the pathology (number and dimension of the stones, presence of acute inflammation, and anatomy of the biliary tree). Therefore, the surgical technique that is the most appropriate method to each specific case must be selected. Method: From January 2006 to Decemberl 2013, we treated 1820 patients with symptomatic bile stones. In 190 patients bile duct stones where also present, of whom 182 underwent a single stage .We arranged 2 groups: group A (jaundice with bilirubin \= 2gr/ dl, biliary duct diameter \ 1 cm, and stones diameter \ = 1 cm) with 143 patients underwent TC-CBDE and group B (jaundice with bilirubin [ 2gr/dl, biliary duct diameter [ 1 cm, and stones diameter [ 1 cm) with 39 patients underwent ES-RV.The principal outcome measure was the successful of the single stage treatment and secondary outcomes were percentage of success for proposed surgical method, intra- and post-operative complications and hospital stay . Results: No intra- or post-operative mortalities were observed. Eleven patients (6 %; 7 patients undergoing TC-CBDE and 4 ES-RV) of procedures required conversion. Singlestage treatment was possible in 164 patients (90 %). The overall complication rate was 8 % (14 patients). The median hospital stay was 4 ± 3 days (range 3–21). The success rates for the two procedures differed: 130 (90 %) of the 143 patients undergoing TC-CBDE and 35 (89 %) of the 39 undergoing ES-RV. Conclusion: Single-stage treatment for cholecysto-choledocholithiasis was possible in 90 % of the cases. Preoperative clinical and echography characteristics can be helpful for selecting the most appropriate technique to use.

A. Paganini1, S. Quaresima1, A. Balla1, M. Guerrieri2, G. Lezoche2, R. Campagnacci2, G. d’Ambrosio1, G. Intini1, E. Lezoche1 Sapienza University, Rome, Italy; 2Universita` Politecnica delle Marche Ospedali Riuniti, Ancona, Italy 1

Aims: In a previously published article the authors reported the long term follow-up results in a series of 138 consecutive patients who underwent laparoscopic transverse choledochotomy (TC) during laparoscopic cholecystectomy (LC). Aims of this study is to evaluate the results at 12–23 years of follow-up in the same series. Methods: One-hundred-twenty-one patients are the object of this study. The patients were evaluated by clinical visit or phone interview with symptoms’ questionnaires form completion, blood assay and abdominal ultrasound (US) at mean follow-up time of 180,8 months (range 149–276). Results: Out of 121 patients, 61 (50.4 %) elderly patients died from unrelated causes but were asymptomatic until passing away, as declared by their relatives. Fourteen patients (11.5 %) were lost to follow-up. In the 46 (38,1 %) remaining patients, ductal stone recurrence with cholangitis occurred in one patient (0.8 %) 16 years after surgery, that was successfully managed by endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy (ERCP-ES). Except for the single patient with stone recurrence, no other patient showed biochemical signs of bile stasis. No patient, including the single one with ductal stone recurrence, showed any imaging (US, ERCP) evidence of common bile duct stricture at the site of the laparoscopic transverse choledochotomy. Conclusion: Laparoscopic transverse choledochotomy during laparoscopic cholecystectomy for stones has proven to be safe and effective also at longer term follow-up, with no evidence of common bile duct stricture.

O084 - Liver and Biliary Tract Surgery

O088 - Different Endoscopic Approaches

Combined Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy for Treatment of Cholelithiasis With Choledocholithiasis

Extra-Anatomical Endoscopic-Radiological Reconstruction of Iatrogenic Complete Transsection of Hepatics or Common Bile Duct

M.M. Anwar, A. Elsharif, M.A.F. Selimah, M. Samir

G. Donatelli1, B.M. md Vergeau1, S. md Derhy1, J.L. md Dumont1, T. md Tuszynski1, P. Dhumane2, B. md Meduri1

Department of Experimental and Clinical Surgery, Medical Research Institute, University of Alexandria, Alexandria, Egypt

1

Hoˆpital Prive´ des Peupliers, Ge´ne´rale de Sante´, Paris, France ; Lilavati Hospital and Research Center, Mumbai, India

2

Aims: To evaluate the feasibility and benefit of one stage combined endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) for the treatment of cholelithiasis with choledocholithiasis. Methods: Eighty patients with cholelithiasis and choledocholithiasis (as determined by preoperative radiological and laboratory investigations) presented to the surgical department, Medical Research Institute Hospital, University of Alexandria from June 2012 to November 2013, were randomly divided into 2 groups. Group A (40 patients), common bile duct stones (CBDS) were extracted by intraoperative ERCP and endoscopic sphincterotomy (EST) immediately before LC. Group B (40 patients), CBDS were extracted within 48–72 hours before LC. To compare the results of the two groups in respect to the operative time, the incidence of post-ERCP complications, the rate of intra and post surgical complications and the length of hospitalization. Results: The success rate was 100 % in both groups as there were no missed stones detected in the biliary tree after the procedure. There were no statistical difference between the two groups regarding the number of post-ERCP and postcholecystectomy complications. The mean hospitalization time was 1.58 ± 0.82 days in group A and 4.66 ± 0.81 days in group B. Conclusions: One stage combined ERCP and LC for treatment of cholelithiasis and choledocholithiasis seems to be feasible, safe and effective as two stage procedures. Moreover, it results in a one step operative and anesthetic procedure and shorter hospitalization.

123

Introduction: Iatrogenic transsection of Bile Duct (BD) is a troublesome complication of open or laparoscopic hepatic-biliary surgery. Difficulty in promptly recognizing and technically demanding surgery makes the primary repair a difficult option. We report our experience of Extra-Anatomical Endoscopic-Radiological reconstruction (EAERr) of iatrogenic injured BD. Method: Since 1/2008 an EAERr was attempted in 22 symptomatic patients (12F), with median age of 56.47 (31–89) years, having iatrogenic complete transsection of hepatics or common bile duct diagnosed by impossibility to pass a guidewire in the intra-hepatics bile ducts during endoscopic retrograde cholangiography. Extra-Anatomical rendezvous between radiologically inserted guidewire through percutaneous Transhepatic cholangiography access and endoscopically pushed distal guidewire permitted plastic stenting. Stents were changed every three months, for maximum 24, till a good caliber of BD gets reconstructed over the stents as confirmed by cholangiographic picture. Results: In 21/22 (95.5 %) patients, EAERr was possible. In 1 (4.5 %) EAERr failed. The median time duration between surgery and EAERr was of 58.1 (3–365) days. 5 pts (25 %) needed a double EAERr (right and left), to obtain complete drainage of all liver segments. At 01/2014 one patient is lost to follow up, 5 (25 %) are still under treatment, 14 (70 %) patients are declared cured and 1 (5 %) was addressed to surgery seen the inability to achieve a good caliber of reconstructed duct. The median time of stents in place, was of 14 months (8–24) and at a median follow up of 18 months (6–51) they are clinically well with normal liver test. The median number of stents delivered was of 7.8 (3–22) and a median of 9 (6–14) endoscopy sessions was necessary per patient. Conclusion: EAERr, of iatrogenic complete transected BD, seems to be a valid miniinvasive alternative to re-established continuity of transected duct with no mortality and low morbidity related, despite multiple endoscopic sessions.

Surg Endosc

O091 - Training

O094 - Training

Consensus Views on the Optimum Training Curriculum for Advanced Laparoscopic Surgery: A Delphi Study

Objective Evaluation of Laparoscopic Performance Using Motion Analysis and Global Operative Assessment of Laparoscopic Skills

B.E. Jervis1, F.J. Carter2, S. Paus-Buzink3, J.D. Foster1, R. Palmen4, J. Jakimowicz3, N.K. Francis1

F.M. Sanchez Margallo, J.A. Sanchez-Margallo, S. Enciso Sanz

Yeovil District Hospital, Yeovil, United Kingdom; 2South West Surgical Training Network, Yeovil, United Kingdom; 3LSS FOUNDATION, Veldhoven, The Netherlands; 4EAES, Veldhoven, The Netherlands

Minimally Invasive Surgery Centre, Ca´ceres, Spain

1

Aims: Application of laparoscopic techniques has expanded to include increasingly complex surgical cases. While evidence exists regarding individual aspects of training in basic laparoscopic surgery, very little agreement has been reached with regard to the overall structure and delivery of an advanced laparoscopic surgery (ALS) training curriculum. Agreement on a framework for a curriculum is required to define training in these techniques Methods: A reiterative modified-Delphi questionnaire study was conducted involving 57 leading international surgical experts with major track records in training and education in ALS. A webbased platform was used to seek a consensus on optimum methods for delivering training in ALS. Questions addressed the following areas: entry criteria; trainers and training centre attributes; components of the curriculum; quality assurance and assessment. Results: The first round questionnaires were completed by 57 experts, and 28 completed the second round (49.1 %). Majority consensus was reached on completion of basic laparoscopic training and recommended numbers of basic laparoscopic and open cases required prior to training in ALS (30–50 laparoscopic appendicectomy 79.6 %; 30–50 laparoscopic cholecystectomy 85.7 %). Regarding selection of trainers, 78.6 % of experts agreed that each mentor should have completed 100–150 ALS cases. 60.7 % of experts agreed trainers should have 5 to 10 years’ experience in the specialty. Mentor attendance at a ‘Training the Trainers’ course was desirable to 67.9 % of experts. Provision of physical and animal models were deemed to be the minimum requirements of a training centre, in addition to the leading trainer’s educational profile. Essential elements of the ALS curriculum were clinical mentoring, coaching for decision making, didactic teaching of knowledge, and technical skills training. There was strong consensus on the importance of quality assurance for both training centres and courses. Criteria for summative assessment should be blinded analysis of unedited surgical video using a structured checklist or use of competence assessment tools. Conclusions: A framework for training curriculum for ALS has been defined through an international consensus process, including entry criteria, selection of trainers and units, quality assurance and assessment tools. Further studies are required to validate this curriculum.

O092 - Training

O097 - Training

Basic Laparoscopic Skills Training in Surgical Education 1

Objectives: The goal of this study was to compare the results of a motion analysis of laparoscopic performance with those obtained using a validated assessment method of laparoscopic skills. Material and Methods: A group of novice (N, \ 10 laparoscopic surgeries), intermediate (I, 11–100 laparoscopic surgeries) and expert (E, [ 100 laparoscopic surgeries) surgeons performed an intracorporeal suturing task on a porcine ex vivo stomach using a laparoscopic box trainer. Subjects used a laparoscopic needle holder with the dominant hand and a laparoscopic dissector with the non-dominant hand. Two blinded experienced surgeons rated the task using the Global Operative Assessment of Laparoscopic Skills (GOALS) method. Surgeon performance was analysed through ten motion-related metrics computed by a motion analysis tool, which consist of a laparoscopic instrument tracking method based on a third generation optical pose tracker (MicronTrackerÒ3 Hx60; Claron Technology Inc., Canada). Spearman correlation between motion metrics and GOALS scores was analysed. Results: Thirty-two surgeons took part in the study: 14 novices, 10 intermediates and 8 experts. Expert surgeons required less time to perform the task and intermediate group less than novices (N: 277.467 ± 42.899 s.; I: 173.845 ± 36.797 s.; E: 119.65 ± 26.926 s.; p \ 0.005). For GOALS scoring system, the expert group scored significantly higher than the novice and intermediate surgeons, and intermediates higher than novices (N: 14.133 ± 2.031; I: 19.700 ± 1.476; E: 23.063 ± 1.321; p \ 0.005). Cronbach’s alpha for inter-examiner reliability was measured at 0.908. Time-related metrics concerning the use of the needle holder showed statistical differences between novices and experts as well as between novices and intermediates (p \ 0.005). Path length travelled by the dissector showed statistically significant differences between the three groups of surgeons (N: 9885.554 ± 3056.182 mm; I: 7151.267 ± 2118.324 mm; E: 5886.871 ± 1989.051 mm; p \ 0.005). Correlation has been found between all parameters rated by GOALS and motion metrics of time, speed, path length, economy of area and economy of volume (Spearman’s rho [ 0.5). Conclusions: Suturing performance was successfully assessed by the GOALS method as well as the motion analysis of laparoscopic instruments. There was found a good relationship between parameters rated by GOALS and motion analysis metrics of time, speed, path length, economy of area and economy of volume

2

1

M. Drungilas , G. Simutis , P. Petrik , E. Petrik

1

Vilniaus Universitetas, Vilnius, Lithuania; 2Of Gastroenterology, Nephrourology and Surgery, Center of Abdominal Surgery, Vilnius, Lithuania 1

Introduction: Training and evaluation of laparoscopic skills has become very important to maintain medical safety in abdominal surgery. Virtual-reality (VR) simulators helps surgical trainees become familiar with specific psychomotor skills before performing procedures in the operating room. Aims: The purpose of this study was to determine the learning curves for VR training in an effort to quantify the amount of training that may be appropriate. Material and Methods: The study cohort consisted of trainees allocated to two groups: medical students (group A, n = 16) and junior surgical residents (group B, n = 16). All the participants performed nine attempts of three basic skills tasks (‘Instrument navigation’ (IN), ‘Cutting’ (C). ‘Clip applying’ (CA)) on the LapSim VR simulator during 3 sessions within 1 month. Assessment of laparoscopic skills was based on a cumulative score for each task measured by the computer system. Results: We found a significant difference in mean age between group A and group B (22.2 ± 1.3 years vs. 26.1 ± 1.3 years, P \ 0.001). Overall performance scores were significantly different between A and B groups after first-week session (IN: 100 % (0 %) vs. 76 % (20 %); C: 90 % (19 %) vs. 56 % (8 %); CA: 91 % (17 %) vs. 64 % (8 %); P \ 0.001), and second-week session (IN: 100 % (0 %) vs. 85 % (8 %); C: 95 % (8 %) vs. 70 % (10 %); CA: 98 % (10 %) vs. 70 % (3 %); P \ 0.001). There were no differences in IN performance scores after sixth attempt (100 % (0 %) vs. 100 % (1 %); P = 0.073), in C performance scores after eighth attempt (100 % (0 %) vs. 99 % (4 %), P = 0.080), and in CA performance scores after seventh attempt (100 % (1 %) vs. 100 % (6 %), P = 0.287) between A and B groups. After the fourth-week session, there were no significant differences between trainees groups practice in any of three tasks (P [ 0.05). Conclusions: Our data demonstrates that younger trainees acquire laparoscopic skills significantly faster compared to older trainees (P \ 0.001). Six-seven-fold surgical simulation task repetition provides long-term skill acquisition. These findings suggest that laparoscopic VR training should be integrated in medical education much earlier in order to benefit laparoscopic surgical skills.

Learning Curve with Straight and Curved Instruments in SinglePort Surgery O. Kakucs, P. Lukovich, B.V. Sionov, N. Dobo´, B. Figura, L. Harsa´nyi 1st Department of Surgery, Semmelweis University, Budapest, Hungary. Aims: To compare novices’ learning curve in single-port setting with curved and straight instrumentation and highlight the importance of a special laparoscopic training curriculum. Methods: Twenty medical students were prospectively randomized into two groups. Each group performed two tasks on box trainer in single-port setting. Group-S used conventional straight and Group-C used curved laparoscopic instruments. Learning curves were obtained by daily measurements recorded in seven-day sessions. On the last day, the two groups switched instruments between each other. The data was correlated with results from a previous study as well where conventional two-port laparoscopic learning curves were analyzed at the same tasks. Members of Group-I performed the tasks individually, while Group-P was divided into pairs, performing the tasks by holding a single instrument and co-operating with their pairs. Paired t- and Mann-Whitney U test was used to evaluate the data, where a level of p \ 0.05 was considered statistically significant. Results: AlthoughGroup-S performed all tasks significantly faster than Group-C on the first day, the difference proved to be non-significant on the last day. All participants achieved significantly shorter task completion time on the last day than on the first day, regardless of the instrument they used. Group-S showed progression of 63.55 %, Group-C 69.05 %, Group-I 62.26 % and Group-P 71.83 % by the end of the session. After swapping the instruments, Group-S reached significantly higher task completion time with curved instruments while Group-C showed further progression of 8.95 % with straight instruments. Conclusions: The number of surgical interventions performed in single-port access is growing; however, the number of articles on the efficient teaching of minimal invasive surgical techniques is still insignificant. This study shows that training with curved instruments allows for a better acquisition of skills in a shorter period of time. For this reason, there is need for proficiency-based conventional, but also for a single-port laparoscopic training curriculum in general surgery residency education.

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Surg Endosc

O098 - Training

O100 - Different Endoscopic Approaches

A Stepwise and Structured Traing for Laparoscopic Colectomy in Taiwan

Trocar-Less Laparoscopic Appendectomy, A Simple and Inexpensive Method

C.C. Yeh1, I.R. la2, H.S. Lai3, J.T. Lian3

C. Valencia1, C.A. Melo1, M. Zuluaga2, U.O. Cardona1, I. Siljic3

1

National Taiwan University Hospital, Taipei, Taiwan; 2Department of Surgery, National Taiwan University Hospital, Tapei, Taiwan; 3 Department of Surgery, Medical College, National Taiwan University, Taipei, Taiwan

Clinica Farallones - Clinica Salud Coop, Cali, Colombia; 2Clinica Farallones - Hospital Universitario del Valle, Cali, Colombia; 3 Hospital Universitario del Valle - Clinica de Occidente, Cali, Colombia

Purpose: Using laparoscopic approach for performing colectomy is emerging. The key for committing the surgical quality and safety of laparoscopic colectomy (LapCo) is providing an intensive training of doing this procedure. In this study, we introduced a stepwise and structured training for LapCo in Taiwan and evaluated its effect. Materials and Methods: We set up the training for LapCo in a stepwise and structured format which included a basic laparoscopic skills training for junior trainees, a hands-on training with a novel model for LapCo, an advanced laparoscopic training course by using live animals for senior trainees and fellows, experts mentoring by observing LapCo in the operating theatres, and assisting LapCo performed by the experts. We used self-evaluations for improving skills competency and questionnaires for overall satisfactions for all training courses. The effect of learning in the clinical setting were evaluated by interview trainees. Student t-test was used for data analysis. Results: The training program started in 2009. 3 basic laparoscopic skill training courses were organized annually, one hands-on training course, and one advanced training course have been done and total 50 trainees participated. The overall satisfactions for these courses were 4.5 ± 0.8, 4.13 ± 0.52, and 4.2 ± 0.7 with the Liker scale 1–5. Trainees thought their surgical competency for performing LapCo improved significantly after attending these training course (pre-training 2.8 ± 1.2; post-training 3.9 ± 0.9, p = 0.01) 12 trainees assisted experts in the operating theatre and they were benefited because of human anatomy, live tissues dissections, experts’ experiences sharing, and hands-on experiences on real patients under supervising. Conclusion: We has established a stepwise and structured training for laparoscopic colectomy in Taiwan. Short terms results showed that surgical trainees gained competency by hands-on experiences in these training courses and learned the procedures by assisting experts’ operations. Long term effect of this training model needs further investigation.

We present a series of 100 patients, who underwent laparoscopic appendectomy, using a unique approach, by umbilical route, without using any type of trocar. In the period between June 2012 and December 2013, 100 patients underwent surgery at two hospitals of level 1, in Cali, Colombia, between the ages of 5 and 31 years old The approach is done through the navel, with a vertical incision of about 10 to 15 millimeters, with Modified Hasson’s technique (Cali Technique). Then, a Nelaton catheter of 14 or 16 fr is inserted through the navel and CO2 is bubbled to create a pneumoperitoneum. The next step is to insert a 5 mm telescope angled 30 or 45 degrees, to fully visualize the cavity and confirm the diagnosis of acute appendicitis. After confirming the diagnosis, the anatomical location of the appendix and the severity of the case is verified. If it’s not rupture in the appendix or not severe inflammatory reaction or firm adhesions, we proceed to insert a Grasper forceps and take the appendix from the tip to remove it through the navel, at the same time that the instruments are removed. After we dissect the mesoappendix with an electric knife all the way to the base the artery it’s cauterized and we ligand the base with the same suture used to close the umbilical fascia. Then the appendix it’s removed and the procedure finish with a systematic revision of the abdominal cavity and finally the closing up of the navel. This type of surgery has not shown any kind of mayor complication to the date. Laparoscopic appendectomy without trocars, is a simple, safe and inexpensive procedure, when this procedure is performed in selected patients and selected cases.

O099 - Different Endoscopic Approaches

O102 - Different Endoscopic Approaches

Spider Surgical System Versus Multiport Laparoscopic Surgery: Performance Comparison Using a Surgical Simulator

Surgical Workload for Single Port Cholecystectomy Using a Randomized Trial

D. Giannotti, G. Casella, G. di Rocco, G. Patrizi, L. CastagnetoGissey, A. Metere, A.R. Vestri, A. Redler

M.S. Hallbeck, J. Bingener, B.R. Lowndes, A. Mcconico, M.S. Hallbeck

Sapienza,,- University of Rome, Rome, Italy

Mayo Clinic, Rochester, United States of America

Aims: The interest for minimally invasive conducted to the development of laparo-endoscopic single site (LESS) surgery. With such novelty, surgeons have to face new and different technical challenges. The SPIDER surgical system aims to overcome some of these challenges. The end-point of our study is to compare conventional laparoscopy with SPIDER technical performance on a surgical simulator, using standardized tasks from the Fundamentals of Laparoscopic Surgery (FLS). Methods: Twenty participants were divided into two groups according to their personal laparoscopic experience: 10 PGY1 residents were included in the inexperienced group and 10 surgeons trained in laparoscopy in the experienced group. The FLS pegboard transfers (Task 1) and pattern cutting (Task 2)were evaluated on a laparoscopic box trainer. Objective task scores and subjective questionnaire rating scales allowed to compare laparoscopy and SPIDER surgical system. Results: Both groups performed significantly better in the FLS scores on the standard laparoscopic simulator compared to the SPIDER. Inexperienced group: Task 1 scores (median 252.5 vs. 228.5; p = 0.007); Task 2 scores (median 270.5 vs. 219.0; p = 0.005). Experienced group: Task 1 scores (median 411.5 vs. 309.5; p = 0.005); Task 2 scores (median 418.0 vs. 331.5; p = 0.007). Same aspects were evident in the subjective evaluations, except for the inexperienced surgeons who found both devices equivalent in terms of ease of use only in the peg transfer task. Conclusions: The SPIDER is a revolutionary device, nevertheless our study proved that it is less intuitive to approach than multiport laparoscopy independently from surgical experience. Such challenges could be outflanked with designed training programs and simulation methods. This may represent an effective way to deliver training, achieve mastery and prepare surgeons for their future clinical experience.

Background: Recent studies report increased patient satisfaction with single port compared to 4-port laparoscopic cholecystectomy. In the simulation setting surgeon experience a higher physical and mental work load for single incision surgery compared to traditional laparoscopy has been demonstrated. The goal of this study was to measure surgeon stress after single incision (SILC) and traditional 4-port laparoscopic cholecystectomy using SurgTLX. Surg-TLX is a surgical workload tool, modified from NASA-TLX used in aeronautics. Method: This study was conducted during an ongoing randomized controlled trial comparing SILC with 4 port laparoscopy (NCT0148943). At anesthesia induction, patients were randomly assigned to SILC or 4-port cholecystectomy using computerized randomization, stratified by gender, age and BMI. After the procedure, the surgeon completed the SurgTLX questionnaire with subscales of procedural complexity, physical and mental workload, temporal demand, situational awareness and distractions for an overall measurement of workload. Kruskal-Wallis ANOVAs were used for statistical analysis with a = 0.05. Results: Forty-one procedures were studied, 16 SILC with a median procedure time of 67 minutes and 22 4-port cholecystectomies, median time of 71 min. Three SILC procedures required additional port placement (conversion from SILC to 4-port) due to inflamed tissues and had a median procedure time 121 minutes. Intention to treat analysis revealed no difference between the procedure duration for the two approaches. Treatment received analysis revealed that patients requiring conversion had significantly longer procedure times. Surgical workload was not significantly higher for SILC (ITT: SILC 43/120 points vs 4-port 34/120 points). The workload for technically difficult procedures requiring conversion with additional ports was significantly higher with 67/120 points (p = 0.038). Excluding these difficult procedures, Surg-TLX subscale analysis revealed that physical demand was significantly higher for SILC compared to 4-port cholecystectomy (8.5/20 vs 5.5/20 points, p = 0.017), the remainder of the subscales did not differ significantly. Conclusion: Surg-TLX was able to clearly distinguish between routine and difficult procedures. Differences between the routine procedures were primarily physical. Mental demand was not different, possibly due to the surgeon’s familiarity with SILC.

123

1

Surg Endosc

O103 - Intestinal, Colorectal and Anal Disorders

O105 - Intestinal, Colorectal and Anal Disorders

Single Port Laparoscopic Surgery for Patients with Complex and Recurrent Crohn’s Disease

Learning Curve and Surgical Outcome for Single Incision Laparoscopic Right Colectomy in 60 Consecutive Cases

A. Ronan, F. Narouz, M. Cunningham, M. Moftah

W. Watanabe, .M. Murakami, Y. Ozawa, A. Fujimori, K. Otsuka, T. Aoki, T. Kato

Beaumont Hospital, Dublin, Ireland

Japan, Tokyo, Japan

Background: Single port laparoscopic surgery (SPLS) is a modified access technique that allows grouping of instruments at a single parietal site. It is intuitively appealing specifically for patients with Crohn’s disease (CD) as its minimal invasiveness favors cosmesis and facilitates any future (re)operation. Methods: Consecutive patients presenting either electively or urgently for resectional surgery for CD over a 36 month period were considered for SPLS using, by preference, a transumbilical ‘Surgical Glove Port’. Standard, straight laparoscopic instrumentation were used without additional resources. Results: Of 33 consecutive, unselected patients, 28 (92 %) had their procedure initiated by SPLS including those needing urgent intervention (n = 15) and those with prior abdominal operation (n = 8), obstruction (n = 7), mass (n = 6), fistula (n = 6) and/or abscess (n = 4). The median (range) age and BMI of the patients was 31 (17–69) years and 21.3 (18.6–28) kg/m2 respectively. 31 had ileocolonic resection (6 with recurrent disease) while two underwent segmental colectomy. No-one suffered intraoperative or anastomotic complication. Both conversion (15 %) and postoperative complication (13 Clavian-Dindo complications- I:8; II:2;IIIa:3) rate were predominantly reflective of patient and disease complexity. Median (range) postoperative day of discharge was 6 (3–33) overall and 5 (3–18) in those completed by SPLS. There was one early readmission (for c. difficle colitis) and median follow-up is now 21 months. Conclusions: Crohn’s resections (including complex and recurrent disease) can be performed by SPLS in the majority of patients presenting elective or urgently for surgery. The surgical glove port performs capably and, by minimizing cost, can facilitate broad embrace of this approach.

Aims: The aim of this study was to investigate the learning curve of single incision laparoscopic right colectomy (SILRC) and evaluate the surgical outcomes. Methods: Between September 2010 and December 2013, 60 consecutive patients with an indication for right colectomy underwent a single incision laparoscopic approach without bias in selection by a single surgeon. The clinical data of 60 patients were retrospectively analyzed and the operative time was used to define the learning curve. Results: The operation was performed for 33 female and 27 male patients.The median age was 73 years (range 44–91 years). The median body mass index was 23 kg/m2 (range 19–33 kg/m2). The operative blood loss was 36 ml (range 1–410 ml). There were no conversions to open laparotomy. One additional port was needed in 9 of the patients (15.0 %). No intraoperative complications were encountered. A total of 4 patients (6.6 %) experienced postoperative complications, including 2 superficial surgical site infection and 1 paralytic ileus and 1 bleeding. All of the pathologic findings were adenocarcinoma, and all surgical margins were negative. The median number of lymph nodes harvested was 18 (range 8–53). The median length of hospital stay was 11 days (range 6–30 days). There was no readmission caused by postoperative complication. The mean operative time for the first 10 cases was 145 minutes (range 115–180 minutes), and it was 115 minutes (range 80–210 minutes) for the subsequent 50 cases (P = 0.016). There were no significant the operative blood loss between the first 10 cases and the last 50 cases. Conclusions: SILRC is a safe and feasible procedure. Our preliminary analysis showed that surgeons who are experienced in multi-port laparoscopic right colectomy are likely to pass the learning curve smoothly and safely after performing 10 cases of SILRC.

O104 - Intestinal, Colorectal and Anal Disorders

O106 - Intestinal, Colorectal and Anal Disorders

Improving the Results of Minimally Invasive Colorectal Surgery: Single Port Left Colonic Resection with Transanal Specimen Extraction

Single Port Laparoscopic Right Colectomy Versus Standard Laparoscopic Right Colectomy for Colorectal Disease A Case Control Study

S. Morales-Conde, J.A. Navas, A. Barranco, I. Alarco´n, M. Rubio´ vila, J. Tinoco, H. Cadet, F.J. Padillo, M. Socas Manzanares, R. A

E. Chahine, J. Abdullah, N. Schoucair, Z. Radwan, V. Greco, E.K. Chouillard

University Hospital Virgen del Rocı´o, Sevilla, Spain

Centre Hospitalier Poissy/Saint-Germain-en-Laye, Poissy, France

Aims: Single port approach in colorectal surgery tries to improve the results of conventional laparoscopic surgery, by reducing the potential complications associated with the surgical wound. Transanal natural orifice specimen extraction is a step forward in order to decrease surgical incision and avoid wound complications associated. Methods: A total of 17 patients with benign or malignant left colonic diseases were proposed to single port left colectomies. Selection for this approach was based on the BMI \ 30 kg/m2 and the tumor size less than 4 cm in preoperative studies. Pure transumbilical single port approach was performed using transanal natural orifice specimen extraction in all cases. Results: Mean age of the patients was 64 years old (42–88), being 76 % of them females. Mean BMI was 24.55 kg/m2 (17,1–30). Recurrent diverticular disease was presented in 4 patients; 13 patients presented malignant disease (endoscopically non-resecable polips or adenocarcinoma). Surgery was performed successfully in all cases through transverse transumbilical incision, placing a SILS portÒ device. The specimen was removed through the rectum, which was protected by a plastic device. Transanal anastomosis was performed, using a circular stapler, being placed the anvil through the transumbilical incision. Mean operative time was 123,53 minutes. There were no intraoperative or postoperative complications. Mean skin incision length was 24,70 mm (16–38). Mean hospital stay was 3,18 days. Pathologist exam confirmed the initial diagnosis, with free resection margins and more than 12 nodes presented in malignant specimen. Conclusions: Single port colonic surgery with transanal natural orifice specimen extraction (NOSE) is a safe procedure in selected patients achieving similar oncological results than conventional laparoscopic approach. The advantages of the combination of single port and transrectal extraction is based on the fact that the anvil could be placed through the single port incision while in conventional laparoscopic surgery using this method of extraction the anvil need to be introduced in the cavity through the anus and being placed laparoscopically. On the other hand, the advantages over single port approach with transumbilical extraction is that this technique avoids enlarging the incision and decrease surgical wound complications, as has been observed in our series.

Background: The use of laparoscopy for the treatment of colorectal disease is now an acceptable surgical option. Because Natural Orifice Translumenal Endoscopic Surgery (NOTES) is an emerging surgical approach. However, human applications of ‘pure’ NOTES techniques in are still slowed down by major technical hurdles. Concomitantly, ‘Hybrid’ variants of NOTES and single incision laparoscopy have been increasingly reported. By further reducing the invasiveness of the standard laparoscopic approach, we may further reduce post-operative pain, decrease overall morbidity, preserve the abdominal wall, and ultimately preserve cosmesis. Such techniques have been applied to many procedures including cholecystectomy, bariatrics, and colorectal surgery. We have developed a ‘single Port’ variant of laparoscopic right colectomy (sRC) for patients with either benign or malignant disease. The aim of this study is to compare the short-term results of sRC to the standard laparoscopic right colectomy (lRC) in patients with colorectal disease. Methods: sRC was attempted in 27 patients. Exclusion criteria were morbid obesity (BMI of more than 40 kg/m2) and the presence of major prior abdominal surgery. The study was approved by the local Ethics Committee. The written patient’ informed consent was always required. The technique was performed using a transumbilical incision with three abdominal ports located on a special platform. Results: The procedure was completed in 25 patients (92.6 %). In 2 patients, conversion to standard laparoscopy (1 patient) or laparotomy (1 patient) occurred. The mean operative time was 119 minutes (range 50–245). The post-operative rate of complications was 11.1 % and 7.4 %, in Group sRC and lRC, respectively. No hemorrhage, no surgical site infection and no fistula were encountered. The mean length of hospital stay was 4.7 days (range 3–14). Conclusion: Our Single Port variant of laparoscopic right colectomy (sRC) was found to be as sure and as feasible as standard laparoscopic right colectomy for colorectal disease.

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Surg Endosc

O107 - Technology

O110 - Gastroduodenal Diseases

Transanal Total Mesorectal Excision with Single Port Laparoscopic Surgery With/Without One Additional Trocar for Rectal Cancer: Initial Experiences

Feasibility of Laparoscopic Gastrectomy for Advanced Gastric Cancer; Comparative Study to Open Gastrectomy

Y.M. Chae, S.H. Yun, W.Y Lee, H.C Kim, Y.B Cho, J.W. Huh, Y Park Samsung medical center, Seoul, Korea Aims: Single-port laparoscopic surgery has attracted attention in the field of minimally invasive colorectal surgery, and transanaltotal mesorectal excision (TA-TME) is a new approach to performing minimally invasive rectal resection. Here, we report our initial experiences of transanal TME with single-port laparoscopic low anterior resection(SPLLAR) with/without one additional trocar for rectal cancer. Methods: Between June and December 2013, nine consecutive selected patients with rectal carcinoma underwent surgical excision of rectal tumors by means of transanal TME with SPL-LAR via transumbilical or future ileostomy site with glove port and per anal Gelpoint path. Colorectal anastomoses were made with single stapling technique or hand-sewn method Results: The primary indication for transanal TME was mid-rectal cancer. Six males and three females underwent transanal TME with curative intent. Patient median age and BMI at the time of surgery were 50 years (range 38–78) and 24.4 kg/m2 (range 20.0–26.8), respectively. Tumors were located an average of 7 cm (range 4–9) from the anal verge. Two patients had preoperative chemoradiation therapy. Median duration of operation was 293 min (range 223–400) and median abdominal incision was 3.0 cm (range 2.5–4.0). There was no postoperative mortality. Surgical complications included uterine abscess (n = 1), Anastomotic site bleeding (n = 1), Intraperitoneal bleeding (n = 1). Pathologic examination of TME specimens demonstrated complete or nealy complete mesorectal excision in all cases with negative distal, and radial margins. Conclusions: Transanal TME with single port laparoscopic low anterior resection with/ without one additional port is a feasible and safe method for oncologic resection of midrectal cancer with curative intent in selective cases, especially for patients with obesity and anatomic constraints such as a narrow male pelvis. But, evaluation of long-term functional and oncologic outcomes of this approach is needed.

S. Tsunoda, H. Okabe, E. Tanaka, S. Hisamori, H. Kawada, M. Harigai, Y. Sakai Kyoto University, Kyoto, Japan Aims: Although laparoscopic gastrectomy (LG) for early gastric cancer has become popular, the evidence of LG for advanced gastric cancer remains limited. The aim of this study is to investigate the feasibility of LG for advanced gastric cancer. Methods: Patients who underwent gastrectomy for advanced gastric cancer ([=StageIIA) between June 2005 and July 2013 were retrospectively reviewed and perioperative result was compared between open gastrectomy (OG) and LG. Results: Among a total of 711 gastrectomies, 193 cases (78 OG and 115 LG) had advanced gastric cancer. There were 57 males and 21 females in OG and 82 males and 33 females in LG. Median age was 69 (35–87) in OG and 70 (30–91) in LG. Clinical stage (StageII/II/IV) was as follows; OG: 37/38/3, LG: 55/53/7. Neoadjuvant chemotherapy was given to 32 % of OG patients and 38 % of LG. There was no statistically significant difference in patients’ background. D2 lymphadenecomy was performed in 90 % in OG and 69 % in LG and combined resection (except for cholecystectomy) rate was 38 % in OG and 14 % in LG, which reached statistically significant difference. There was no difference in the type of gastrectomy (total vs distal) and number of harvested lymphnodes (53.5:54). The operation time was significantly longer in LG (282 min vs 344 min), but intraoperative blood loss was significantly reduced in LG (569 g vs 55 g). Postoperative morbidity was 32 % in OG and 24 % in LG (p = 0.2198) and postoperative mortality was 0 % in OG and 1.7 % in LG (p = 0.2417). Conclusion: LG for advanced gastric cancer took longer operative time with less intraoperative blood loss. In terms of short term outcome, LG for advance gastric cancer is safe and feasible.

O108 - Gastroduodenal Diseases

O111 - Gastroduodenal Diseases

The Impact of Laparoscopic Surgery on the Complication Following Gastrectomy for Gastric Cancer: Prospective Analysis Based on the Clavien-Dindo System

Vascular Injury in Laparoscopic-Assisted Distal Gastrectomy With D2 Lymphadenectomy for Gastric Cancer: A Retrospective Study Based on Laparoscopic Surgery Recording

K.G. Lee1, H.J. Lee1, S. Bard2, Y.S. Suh1, S.H. Kong1, S.Y. Oh1, H.K. Yang1

L.Y. Zhao, G.X. Li, J.M. Wu, J. Yu, H. Liu, Y.F. Hu, T.Y. Mou

1

Seoul National University College of Medicine, Seoul, Korea; 2 Department of Surgery, Rabin Medical Center, Campus Beilinson, Petach tiqwa, Israel Aims: The purpose of this study was to prospectively analyze all the complications after gastrectomy according to severity using Clavien-Dindo classification and to identify risk factors related to postoperative complications, with special interest in laparoscopic surgery. Methods: Complication data was collected prospectively through weekly conferences with all gastric adenocarcinoma patients who underwent gastrectomy between March 2011 and February 2012 at Seoul National University Hospital. Complications were categorized according to the Clavien-Dindo classification. The effect of surgical approach (open vs. laparoscopic gastrectomy) was also evaluated. Results: A total of 881 patients underwent open gastrectomy (n = 434) or laparoscopic gastrectomy (n = 447) for gastric cancer. Among them, 197 patients (22.4 %) had complications with 254 events (28.8 %). The numbers of grade I, II, IIIa, IIIb, IVa, and V complications according to the Clavien-Dindo classification, were 71 (8.1 %), 58 (6.6 %), 108 (12.3 %), 8 (0.9 %), 5 (0.6 %), and 4 (0.5 %), respectively. Overall complication rates after laparoscopic gastrectomy (LG) were significantly lower than those after open gastrecomy (OG) (15.4 % vs. 29.1 %, p \ 0.001). However, only age and the extent of operation, not surgical approach, were revealed as independent prognostic factors predicting overall, severe (grade = IIIa), local and systemic complications. In patients who underwent subtotal gastrectomy alone, overall complication rates in the LG group were lower than in the OG group (14.0 % vs.21.8 %, p = 0.010), and severe complications also occurred less frequently in LG group. (7.2 % vs. 12.9 %, p = 0.050). Laparoscopic surgery, as well as age, was found to be independent prognostic factor predicting overall complications in patients receiving subtotal gastrectomy alone. Conclusion: The complication rates after laparoscopic gastrectomy were lower than those after open gastrectomy for gastric cancer. In patients with subtotal gastrectomy alone, laparoscopic approach can reduce the risk of postoperative complications.

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Nanfang Hospital, Southern Medical University, Guangzhou, China Background: Laparoscopic surgery in treatment of gastric cancer has used worldwide during past decade. Intraoperative vascular injury (IVI) is not uncommon in laparoscopic gastrectomy and the consequence of major vascular injuries may be quite devastating, but its incidence can be reduced by understanding the mechanisms of injuries. This study was performed to analyze the anatomic characteristic of IVI and its risk factor in laparoscopicassisted distal gastrectomy (LADG) with D2 lymphadenectomy for gastric cancer. Methods: This study enrolled 136 consecutive patients who underwent LADG with D2 lymphadenectomy for gastric cancer between January 2007 and December 2012. IVI and the vascular anatomic characteristics were evaluatedby reviewing unedited version of laparoscopic surgical videotapes. Risk factors of IVI and the impact of IVI on the operation were evaluated by analyzing linking to an established database in our institute. Results: Eighty four (61.76 %) of the 136 patients underwent IVIs. Two (1.47 %) patients experienced left gastric artery and right gastric artery injury and required open conversion. One patient died from the delayed major bleeding caused by the thermal damage of ultrasonic scalpel to the gastroduodenal artery. The most injured vessel was right gastroepiploic vein (43/136, 31.62 %) and followed by left gastric vein (23/136, 16.91 %). Right gastroepiploic vein and left gastric vein were present with the complex location variations. And that, age over 55 years (OR, 2.304; 95 % CI, 1.072–4.950; P = 0.032), tumor large than 3.5 cm (OR, 2.318; 95 % CI, 1.027–5.232; P = 0.043), and lymph node involvement (OR, 5.015; 95 % CI, 1.348–18.656; P = 0.016) were independent risk factors for IVI. IVI was associated with longer hospital stay (9.46 + 3.59d vs. 8.10 + 2.43d, P = 0.017), more blood loss (140.95 + 107.45 ml vs. 63.46 + 35.25 ml, P \ 0.0001), and longer time for lymphadenectomy (98.34 + 21.72 min vs. 84.81 + 17.12 min, P \ 0.0001). The postoperative complication rate was higher (30.43 % vs. 3.28 %, P = 0.019) when the IVI caused major bleeding. Conclusions: IVIs in LADG with D2 lymphadenectomy are common, mainly due to vascular anatomic variations. Besides, advanced age, large tumor, and the lymph node invaded were independent risk factors for IVIs.

Surg Endosc

O113 - Gastroduodenal Diseases

O116 - Gastroduodenal Diseases

The Evolution of Radical Total Gastrectomy for Advanced Gastric Cancer: 8-Year Experience of A Laparoscopic Leading Institute in China

Safety and Feasibility of 3D Laparoscopy Assisted Surgery for Gastric Cancer

T. Mou, Y. Hu, H. Liu, J. Yu, G. Li Nanfang Hospital, Guangzhou, China

D. Reim, Y.W. Kim, K.W. Ryu, H.M. Yoon, B.W. Eom National Cancer Center Korea, Ilsan, Korea

Aims: Despite the rapid development and wide acceptance of laparoscopic surgical techniques, the application of laparoscopic total gastrectomy (LTG) has been limited because the complex vascularization and lymphatic drainage makes lymphadenectomy and esophagojejunal anastomosis difficult and requires more special skills compared with open total gastrectomy (OTG) especially for advanced gastric cancers. Our aim was to evaluate our institutional experience and surgical technique for radical total gastrectomy (TG) over an 8-year period. Methods: Through a review of our prospective gastric cancer database and electronic medical records from August 2004 to December 2012, 156 patients with advanced gastric cancer underwent TG were identified. Results: During the first five years, 22 percent of TG were performed laparoscopically, compared with 75 percent since 2010. Laparoscopic series yielded significantly lower estimated blood loss (141 vs. 295 ml), lower number of metastatic lymph nodes (4 vs. 7), higher number of retrieved lymph nodes (23 vs. 15) and faster recovery course (first ambulation: 3 vs. 5 days; first flatus: 4 vs. 6 days; resume liquid diet: 5 vs. 7 days; resume soft diet: 8 vs. 10 days) compared with open series. Mean tumor size, operating time, TNM stage were comparable between the two series. 30-day postoperative morbidity rate was similar between OTG (12.9 %) and LTG (9.3 %) series. There was no mortality occurred in either series. Conclusion: After initiation of laparoscopic gastrectomy in 2004, with the accumulation of laparoscopic surgical techniques and experiences, LTG boomed at our institute since 2009. LTG with D2 lymphadenectomy are comparably safe and feasible with OTG, whereas high efficacy and minimal invasive benefits could be achieved through LTG for advanced gastric cancer.

Purpose: 3D visualization in laparoscopic assisted surgery is an emerging technique in the surgical field. However, safety and feasibility of the devices are not reported yet. The purpose of this analysis was to demonstrate safety and feasibility of a 3D laparoscope in oncologic gastric cancer surgery. Patient and Methods: We identified 179 patients who underwent laparoscopic oncologic resection for early gastric cancer by a single surgeon from the prospectively documented gastric cancer database of the National Cancer Center Korea between 2012 and 2013. Comparative and quantitative analyses were performed in order to evaluate the surgical outcomes. Intergroup comparisons were evaluated by ?2-testing, continuous variables are presented as mean standard deviation. T-tests or Wilcoxon-tests were used whenever appropriate. Results: 101 patients received 2D laparoscopy assisted surgery, 78 patients 3D laparoscopy assisted surgery. Baseline characteristics such as age, gender, BMI, frequency of comorbidities, tumor size, histological differentiation, Lauren histotype, lymphatic vessel infiltration, pT-/UICC-stages and completeness of resection (R-stage) were comparable between the two groups. There was no statistically significant difference in conversion rates. Postoperative complications rates were comparable between the groups. LAPPG was performed statistically more frequently in the 3D-group than in the 2D-group. Procedure times and postoperative hospital stay were comparable without statistical differences. Further, there were no statistically significant differences in the number of retrieved lymph nodes (p = 0.48). Estimated blood loss was significantly lower in the 3D-group (130 ± 63 vs. 189 ± 163 ml, p = 0.03). Conclusions: 3D laparoscopy assisted surgery for early gastric cancer can be considered safe and feasible with a probability of less blood-loss. 3D-laparoscopy devices may be enabling tools to facilitate complex laparoscopic procedures such as laparoscopy assisted pylorus-preserving gastrecomy. Prospective studies are proposed to further investigate on this matter.

O115 - Gastroduodenal Diseases

O117 - Day Surgery

Augmented Rectangle Technique (Art) as a New Billroth-I Anastomosis in Totally Laparoscopic Distal Gastrectomy for Gastric Cancer

Ambulatory Laparoscopic Cholecystectomy: Day-Case vs. Overnight Surgery

T. Fukunaga, S. Mikami, T. Enomoto, T. Matsushita, O. Saji, H. Hoshino, H. Nakano, N. Miyajima, T. Otsubo St. Marianna University, School of medicine, Kawasaki, kanagawa, Japan Background: We have reported that laparoscopy-assisted distal gastrectomy (LADG) with extended lymph node dissection for gastric cancer was technically feasible and had favorable oncologic outcomes compared to the open gastrectomy (Ann Surg Oncol 2013 20:2676–2682). Unlike the extracorporeal anastomosis performed during the LADG, a standardized reconstruction method has not been established for the Billroth-I (B-I) gastroduodenostomy in the totally laparoscopic distal gastrectomy (LDG). A triangle anastomosis or a delta-shaped anastomosis is reported for the LDG without associatedlaparotomy. However, these two methods seem complicated for the LDG because of the need of stay-sutures, and further have the risk of ischemia or stenosis postoperatively. Therefore, we have developed an ‘augmented rectangle technique (ART)’ as a new B-I anastomosis performed during the LDG. The ART does not need stay-sutures, and therefore facilitate the LDG. The purpose of this report is to introduce the technical details of the ART and also evaluate the technical feasibility and safety of this method. Methods: The ART reconstructed true end-to-end gastroduodenostomy easily and formed a quadrilateral-shaped cross section of the anastomosis using 3 cartridges of Tristapler intracorporeally. Thirty-seven patients underwent the LDG reconstructed with the ART for the B-I anastomosis between Jan 2012 and Dec 2013. Among them, 32 patients underwent a typical 5-multiport surgery and the other 5 patients did a reduced-port surgery. Results: The mean operating time for the anastomosis was only 9 minutes. There were no intraoperative complications. No conversion to the open surgery was needed in the 37 patients. In addition, neither anastomotic leakage nor stenosis was observed postoperatively. Conclusions: The ART is considered a feasible and safe procedure of the reconstruction during the LDG.

C. Gonzalez, O. Garcia Plaza, E. Uzcategui Paz, C. Paredes Zambrano, J. Plata Patin˜o, .D. Gil, F. Noboa Bustamante Hospital Universitario de Los Andes, Merida, Venezuela Aim: To compare day case and overnight stay in elective laparoscopic cholecystectomy and to evaluate the applicability and safety of ambulatory laparoscopic cholecystectomy (ALC) in our institution. Methods: 422 patients undergoing elective laparoscopic cholecystectomy were included in a randomized clinical trial between August 2011 and July 2013. They were distributed in two groups: those with ambulatory postoperative management called cases group (CLA) and those with conventional or overnight management called control group (CG). Costs, postoperative complications, pain, nausea and vomiting and readmissions patients were registered after surgery. Results: There were 211 patients in each group with no difference in age, sex, BMI or pathological history. Also there were no differences as regards in surgical time, surgical findings or conversion rate. There was no reoperations or mortality. In CLA group 199 patients (94,3 %) were discharged the same day of surgery, with only 12 patients (5.7 %) requiring remain hospitalized, and just 4 were readmitted representing 1.9 %. With a final overall effectiveness of 92.4 % for ALC. The mean in length of stay was significant lower in CLA group (8,0 vs. 25,5 hours, p \ 0,001) and also the hospital costs (p \ 0,001). There were no significant difference between the groups in complications (p = 0,70), but the postoperative pain and the time to return to activity were lower in the CLA group (p = 0,033 and p \ 0,001 respectively). The overall satisfaction rate with ALC was 93,8 %. Additionally a relation between history of pancreatitis or ERCP and the fail of ALC was observed, with a relative risk of 15 and 11 respectively. Conclusion: CLA is a technique that can be performed safely in selected patients, with good results, low morbidity and high patient satisfaction. In addition, the ALC may improve bed availability reducing hospital length of stay and costs.

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Surg Endosc

O118 - Liver and Biliary Tract Surgery

O120 - Liver and Biliary Tract Surgery

Improving Reaching Critical View of Safety in Laparoscopic Cholecystectomy with Teaching Interventions

Single-Incision Versus Standard 4-Port Laparoscopic Cholecystectomy: An Expert Surgeon’s Experience

M.A.J. Nijssen, J.M.J. Schreinemakers, G.P. van der Schelling, R.M.P.H. Crolla, A.M. Rijken

N. Kameyama

Amphia Hospital, Breda, The Netherlands Aims: To prevent serious bile duct injuries in laparoscopic cholecystectomy, guidelines recommend that a critical view of safety (CVS) should be obtained in laparoscopic cholecystectomies. In a previous study we noticed that in cases with complications, CVS was not reached frequently. In an effort to improve these results, we gave a lecture for all surgeons and residents and send everyone an update on CVS along with a teaching video on how to perform a laparoscopic cholecystectomy and pitfalls. After nine months we repeated this educational intervention. Methods: Of 257 consecutive patients we reviewed 178 available videos of laparoscopic cholecystectomies. Videos before and after the teaching interventions were reviewed by a senior surgical resident and a surgical intern on whether CVS was reached or not (360° view on cystic duct, two window view between cystic duct and cystic artery and freeing of 1/3rd of the gallbladder from the liver). We prospectively collected demographic data, data of the procedure and complications. Results: Most patients underwent laparoscopic cholecystectomy for symptomatic cholecystolithiasis. The mean age was fifty-two years. In 68.5 % of the pre-intervention patients (n = 54) CVS was reached compared to 74 % after the first teaching intervention (n = 77) and 80.8 % after the second intervention (n = 50) (n.s.). The complication rate was 24 % before, 19 % after the first teaching intervention and 14 % after the second intervention (n.s.). In which respectively two, three and one cases with biliary injury. In all six cases it concerned a type A biliary injury. Conclusion: By giving lectures and providing teaching information and videos to surgeons CVS was reached more frequently. Even though there was no significant improvement and the teaching intervention did not have the effect we hoped. We believe that to improve the complication rate, especially major bile duct injuries, after laparoscopic cholecystectomies a teaching intervention is useful. Although it was not significant, CVS was reached more often after the teaching interventions (80.8 % vs. 68.5 %) and less complications were observed.

International Goodwill Hospital, Yokohama, Japan Background: We introduced the single-incision laparoscopic cholecystectomy (SILC) in May 2009 for selective cases with less inflamed gallbladders. Our indication of SILC was expanded for all the cholecystectomies in August 2009. This single institute retrospective study by an expert surgeon was aimed to evaluate the surgical outcomes of pure SILC compared to 4-port laparoscopic cholecystectomy (LC). Methods: Between May 2009 and November 2013, we performed 285 SILC, of which an expert surgeon performed 247(87 %) cases. He performed 134 LC before starting SILC at our institute. Eleven patients with gallbladder cancer or pairing cholecystectomy with other intra-abdominal surgery were excluded, and 370 cases (SILC, n = 244; LC, n = 126) were analyzed. A 1.5 cm vertical transumbilical incision was used for SILC, followed by the glove method using the Alexis wound retractorTM (XXS size) with two 5-mm laparoscopic ports and the Roticulator Endo DissectTM inserted directly through the hole of cut fingertip. An additional port was inserted when required. The indication of SILC was identical with LC after August 2009, he performed SILS for all the cholecystectomies including patients with severe cholecystitis or history of upper abdominal operation. Results: There were no differences in patient characteristics. There were no statistical differences in operative time (SILC vs. LC; 69 min vs. 70 min), lengths of hospital stay (3.8 days vs. 4.4 days), and postoperative complications [12/244 (4.9 %) vs. 9/126 (7.1 %)]. Twelve complications in the SILC group were fat lysis (6 cases), wound infection (3 cases), biloma (1 case), and incisional hernia (1 case). Nine complications in the LC group were fat lysis (3 cases), wound infection (3 cases), biloma (1 case), small-bowel injury (1 case), and incisional hernia (1 case). Conversion to laparotomy was significantly less in SILC [1/244(0.4 %) vs. 3/126(2.4 %)]. In the SILS group, a supplemental miniport was required for 21 cases (8.6 %). Conclusions: Pure SILC is a feasible and safe procedure in the hands of expert laparoscopic surgeons. Pure SILC is the first choice for the treatment of most patients with gallbladder disease, and we have to make a decision for additional ports, if necessary.

O119 - Liver and Biliary Tract Surgery

O121 - Liver and Biliary Tract Surgery

Reduced Port Laparoscopic Cholecystectomy

Meta-Analysis of Laparoscopic Versus Open Cholecystectomy in the Elderly Patients

N. Tagaya, Y. Kubota, M. Takegami, N. Makino, K. Saito, T. Okuyama, S. Koketsu, E. Takeshita, H. Yoshiba, Y. Sugamata, S. Sameshima, M. Oya Dokkyo Medical University Koshigaya Hospital, Saitama, Japan Introduction: Reduced port laparoscopic cholecystectomy (RPLC) consisted of singleincision (SILC) and needlescopic (NC) procedures. In the abdominal field, it has been developed step by step. However, the introduction of new devices and the development of surgeon’s skill are mandatory. We report our experience of RPLC using several convenient instruments and needlescopic ones with fluorescence imaging of biliary anatomy using ICG. Patients and Methods: We performed RPLC (SILC: 181, NC: 178) in 359 patients. They were 169 males and 189 females with a mean age of 55 years (range: 16–86 years). Their diagnoses were 337 gallbladder stones and 21 polyps. Initially, we made a 2.5-cm skin incision at umbilicus and the incision was applied a wound retractor and surgical glove. We used three ports technique. After retracting the gallbladder upward using an Endo-Grab, the cystic duct and artery were identified using fluorescence imaging of ICG through an infrared laparoscope and dissected using pre-bending forceps through the MIT port and laparoscopic coagulating shears (LCS). The cystic artery was divided by LCS, and the cystic duct was also divided by shears after clipping. The gallbladder was freed from the liver bed using LCS. The specimen was retrieved from the umbilical wound. Results: All procedures were completed without any intraoperative complications under laparoscopic procedures. SILC and NC required additional ports in 11 (6.1 %) and 8 (4.5 %) patients, respectively. The mean operation time was 72 min (range: 32–252 min) in SILC and 96 min (54–180 min) in NC. Biliary tract was clearly identified during procedure in all cases. Endo-Grab eliminated the retraction of the gallbladder by grasping forceps. The MIT port and pre-bending forceps reduced the clashing between the instruments and laparoscope at the intra- and extra-peritoneal cavities. There were no serious postoperative complications during the follow-up period. Conclusion: RPLC is feasible and safe to perform under the laparoscope without severe complications. ICG fluorescence imaging becomes an useful tool as same as ordinally intraoperative cholangiography. We need a further improvement for obtaining the better outcomes of the patients in this field.

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A. Andreou1, S. Antoniou1, G. Antoniou2, O. Koch3, R. Pointner3, F. Granderath4 University Hospital Of Heraklion, Heraklion, Greece; 2Department of vascular surgery, Red Cross Hospital, Athens, Greece; 3 Department of general and visceral surgery, Hospital of Linz, Austria; 4Center for Minimally Invasive Surgery, Neuwerk Hospital, Mo¨nchengladbach, Germany 1

Aims: Laparoscopic cholecystectomy has induced a revolution in the treatment of gallbladder disease. Nevertheless, surgeons have been reluctant to implement the concepts of minimally invasive surgery in older patients. This study aims to investigate the comparative effect of laparoscopic and open cholecystectomy in elderly patients. Methods: A systematic review of Medline was embarked on, up to June 2013. Studies which provided outcome data on patients aged 65 years or older, subjected to laparoscopic or open cholecystectomy were considered. Mortality, morbidity, cardiac and pulmonary complications were the outcome measures of treatment effect. The methodological quality of selected studies was appraised using valid assessment tools. The random-effects model was applied to synthesize outcome data. Results: Thirteen articles reporting on the outcome of 101,559 patients (48,195 in the laparoscopic and 53,364 in the open treatment group, respectively) were identified. Odds ratios (OR) were constantly in favor of the laparoscopic approach, in terms of mortality (OR 0.24, 95 % confidence interval 0.17–0.35), morbidity (OR 0.44, 95 % confidence interval 0.33–0.59), cardiac (OR 0.55, 95 % confidence interval 0.38–0.80) and respiratory complications (OR 0.55, 95 % confidence interval 0.51–0.60). Critical analysis of solid study data, demonstrated a trend towards improved outcomes for the laparoscopic concept, when adjusted for age and co-morbid diseases. Conclusion: Current data do not definitively support the use of laparoscopic or open cholecystectomy in older patients. Further high-quality evidence is necessary to draw definite conclusions, although best-available evidence supports the selective use of laparoscopy in this patient population.

Surg Endosc

O122 - Liver and Biliary Tract Surgery

O125 - Different Endoscopic Approaches

Systematic Review of Cholecystostomy in Acute Cholecystitis: Is There Enough Evidence?

The Selection of Choices of Minimally Invasive Surgical Treatment of Patients Suffering From Different Forms of Calculous Cholecystitis

F.C. Campanile1, A. Carrara2, M. Motter2, F. Greco3, F. Agresta4 ASL VT, Civita castellana, Italy; 2Ospedale S. Chiara, Trento, Italy; ,,Andosilla,, Hospital - AUSL VT, Civita castellana, Italy; 4ULSS19 del Veneto, Adria (ro), Italy

I.V. Mikhin, Y.V. Kukhtenko, O.A. Kosivtsov, M.B. Doronin, A.I. Mikhin, E.I. Abramian

Introduction: Among the several alternatives proposed for the emergency treatment of acute cholecystitis in elderly or critically ill patients, percutaneous tube cholecystostomy (followed or not by surgery) is extensively reported in the recent literature, and recommended in international guidelines. However, percutaneous gallbladder drainage has never been proven to be an effective alternative to early surgery. Methods: A systematic literature search has been done in PubMed starting from 1990through February 2013. Analogous search has covered the Cochrane Collaboration database and the Google Scholarin order to gather all the remaining evidence. Results: After exclusion of duplicates, publications with no abstract and of low interest in the specific topics, 73 papers were selected for full text revision. There are no controlled studies evaluating the outcome of cholecystostomy vs cholecystectomy and all the papers reviewed are observational. The quality of the evidence reported was poor; the results and even the conclusions reached by different authors are largely non-homogeneous. Procedure mortality for cholecystostomy is low. However, the reported 30-day mortality varies between 4 and 50 % (vs 4.5 % after early cholecystectomy in published series of similar patients) and its morbidity ranges between 8.2 and 62 %. Conclusion: Despite the interest, also related to recent guidelines recommendations, the evidence about the role of percutaneous cholecystectomy is largely conflicting. In absence of stronger literature support, percutaneous cholecystostomy cannot be recommended as part of a routine protocol for treatment of acute calculous cholecystitis.

The aim: is to improve treatment outcomes of patients with calculous cholecystitis by applying modern minimally invasive technologies. Methods: in the period from 2011 to 2013 we performed 341 laparoscopic cholecystectomies (LC). Using the technology of the unified laparoscopic access with additional troacar support (SILS +) we have carried out 124 LC attempts (main groupA): 71 (57.3 %) – concerning chronic calculous cholecystitis (CCC), 29 (23.4 %) – acute catarrhal calculous cholecystitis (ACCC), 24 (19.3 %) – acute obturative calculous phlegmonous cholecystitis (AOCC). ‘‘SILS+’’ surgeries have been successfully completed with 118 (95.2 %) patients. Out of them 103 (subgroup A1) have been subjected to LC, 15 (subgroup A2) have been subjected to a surgery combined with LC. 40 patients (main group B) have been subjected to the attempts of ‘‘TUES’’ technology cholecystectomy, out of which 32 (80.0 %) surgeries have been completed via one access route: 22 – concerning CCC, 10 – concerning ACCC. 40 patients (main group C) have been subjected to the attempt of combined minilaparoscopic cholecystectomy (CMC): 26 (65.0 %) – concerning CCC, 14 (35.0 %) – concerning ACCC. 37 (92.5 %) surgeries have been successfully completed, 3 laparoports have been used. 33 patients (subgroupC1) have been subjected only to CMC, 4 (10 %) – surgeries in combination with CMC. 137 patients have been subjected to cholecystectomy according to the traditional laparoscopic method (TLC). Control group D was composed from them: with CCC - 74 (54.0 %), with ACCC – 41 (30.0 %), with AOCC – 22 (16.0 %) cases of monitoring. We have verified the credibility of the survey comparing the results obtained in each of 3 main groups against the control group – p1, as well as against themselves – p2 and p3. Results: the most serious decrease in cholecystectomy duration, the least intensive pain syndrome and the shortest length of hospital stay care have been detected: with CCC after the use of ‘‘TUES’’ and CMC technologies (p1 \ 0.05; p2 \ 0.05; p3 [ 0.05), with ACCC – ‘‘SILS+’’, ‘‘TUES’’and CMC (p1 \ 0.05; p2 [ 0.05; p3 [ 0.05), with AOCC – ‘‘SILS+’’ (p1 \ 0.05). Conclusion: we consider that there are the optimal technologies (‘‘SILS+’’, ‘‘TUES’’ and CMC) to treat different forms of calculous cholecystitis.

O124 - Pancreas

O126 - Paediatric Surgery

Original Endolifting System Implementation in Surgical Treatment of Acute Calculous Cholecystitis in Patients With a High Index of Polymorbidity

Efficacy and Adverse Events of Laparoscopic Gastrostomy Placements in Children: Results of a Large Cohort Study

1

3

B.S. Zaporozhchenko, V.V. Kolodiy, A.A. Gorbunov, P.T. Muraviov Odessa National Medical University, Odessa, Ukraine Topicality: Despite the progress in laparoscopic surgery postoperative complications rate remains high. The aimwas to improve the results of surgical treatment of acute calculous cholecystitis in patients with severe concomitant diseases of cardiovascular and respiratory systems. Materials: To achieve these objectives the clinic staff of the department has developed the original :lifting system for laparoscopic surgeries implementation in the ‘gas-free’ mode. With the use of our own endolifting technology 47 of patients with acute calculous cholecystitis were operated on. The control group consisted of 49 of patients operated with minimal intraabdominal pressure (4–6 mm Hg). In all patients before surgery was observed complex polymorbid Background: angina of 2nd and higher functional classes, myocardial infarction, atrial fibrillation, hypertension, the results of stroke, chronic nonspecific lung disease, diabetes and other diseases. Middle age was 69.8 ± 44 years. Results: In 20.4 % of patients in control group and in 10.6 % of in main group postoperative complications were found. Postoperative pain intensity according to visual analogue scale was evaluated after 5–6 hr and 24 hr after surgery (prior to injection of the analgesics). After 3–4 days of postoperative period, most of patients experienced almost no discomfort. However, the intensity of pain during first days in main group was significantly lower compared with controls. In the group with laparoscopic cholecystectomy with carboxyperitoneum mortality was 6.1 %, and in the study group 2.1 % (p \ 0,05). Length of hospital stay of patients after laparoscopic cholecystectomy with minimal pressure in the abdominal cavity was 10.9 ± 1.2 bed-days in the study group - 6.8 ± 1.1 bed-days (p \ 0.05). Conclusions: Thus, by reducing of bed-days number lifting laparoscopic cholecystectomies economically more profitable in comparison with classical laparoscopic surgery. Lifting techniques laparoscopic surgery decreases the amount and severity of postoperative complications, exacerbations of chronic diseases, the intensity of postoperative pain and reduce mortality.

The Volgograd State Medical University, Volgograd, Russia

J. Franken1, F.A. Mauritz1, N. Suksamanapun2, D.C. van der Zee1, M.Y.A. van Herwaarden-Lindeboom1 1

Wilhelmina Children’s Hospital, University Medical Center Utrecht, The Netherlands; 2Siriraj Hospital, Mahidol University, Bangkok, Thailand Aims: A gastrostomy is frequently performed in pediatric patients who require long-term enteral tube feeding. However, data on efficacy, (perioperative) complications and postoperative gastroesophageal reflux (GER) after laparoscopic gastrostomy (LAG) placement is limited. The aim of this study is to evaluate long-term efficacy and adverse events after LAG in a large cohort and determine the value of current routine preoperative 24-hour pH monitoring on predicting postoperative GER. Methods: A retrospective observational cohort study was performed including 300 patients (75 % neurologically impaired) that underwent LAG. Results: After a median follow-up of 2.63 years, feeding was successful in 95.9 % of patients. Weight-for-length z-scores significantly increased (p \ 0.0005). Major complications were seen in only 6 patients (2.0 %), but minor complications occurred frequently (73.6 %). Overall incidence of GER remained unchanged after LAG. Sensitivity and specificity of preoperative pH monitoring were respectively 17.5 % and 76.9 %. Conclusions: LAG in pediatric patients leads to successful feeding in 96 % of patients and serious adverse events seldom occur. However, the minor complication rate is high. Overall incidence of GER does not increase after LAG. Preoperative 24-hour pH monitoring is not a reliable tool to predict postoperative GER. Therefore this invasive investigation technique should not be routinely performed.

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O127 - Paediatric Surgery

O129 - Paediatric Surgery

Esophageal Mucosal Integrity Recovers After Laparoscopic Fundoplication in Children with Gastroesophageal Reflux Disease

Laparoscopic Fundoplication in Children with Gastroesophageal Reflux Disease Increases Health-Related Quality of Life

F.A. Mauritz1, N.F. Rinsema2, L.W.E. van Heurn2, P.D. Siersema3, D.C. van der Zee1, J.M. Conchillo2, M.Y.A. van HerwaardenLindeboom1

F.A. Mauritz1, M.J. Harmsen1, C.E.J. Sloots2, L.W.E. van Heurn3, P.D. Siersema4, D.C. van der Zee1, M.Y.A. van HerwaardenLindeboom1

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Aims of the Study: Esophageal intraluminal baseline impedance levels reflect the electrical resistance of the esophageal wall and may serve as an instrument for in vivo evaluation of esophageal mucosal integrity in gastroesophageal reflux disease (GERD) in children. Laparoscopic fundoplication (LF) as treatment for GERD aims to reduce (acid) reflux events and restore mucosal integrity. This could be reflected by increased intraluminal baseline impedance levels after LF. The aim of this study was to evaluate the effect of LF on mucosal integrity by assessing intraluminal baseline impedance levels before and after LF in children with GERD. Methods: Eleven children (5 males) with therapy-resistant GERD were included. Median age was 6.5 years (1.6–18.2) at the time of LF. Twenty-four hour multichannel intraluminal impedance pH monitoring (MII-pH monitoring) was performed before and 3–4 months after LF. For every consecutive two hour intervals in the 24-h tracings, intraluminal baseline impedance levels were measured over a period of = 30 seconds not containing any swallows or gastroesophageal reflux episodes. Intraluminal baseline impedance levels were calculated over four segments (3, 5, 7 and 15 cm above the LES). Main Results: Fundoplication was successful in reducing total acid exposure time (11.4 % ± 2.3 % to 0.9 % ± 0.3 %, p \ 0.001) and overall number of reflux episodes (106.5 ± 20.1 to 19.7 ± 3.9, p = 0.001). The mean distal baseline impedance level increased after fundoplication (2423 ± 414 O to 3560 ± 328 O, p \ 0.01). Baseline impedance levels also increased at 5 cm (2969 ± 428 O to 4105 ± 300 O, p = 0.02) and 7 cm segments (3124 ± 459 O to 3980 ± 248 O, p = 0.04) above the LES. In the proximal segment, no significant changes were found after fundoplication. Prior to fundoplication, mean distal baseline impedance level showed a negative correlation with acid exposure time (r: -0.78, p \ 0.01). Conclusion: Reduction of acid exposure and number of reflux episodes by laparoscopic fundoplication leads to a significant increase in intraluminal baseline impedance levels in pediatric GERD. This may indicate repair of mucosal integrity and success of therapy.

Aims of the Study: Laparoscopic fundoplication (LF) is frequently performed in children with therapy-resistant gastroesophageal reflux disease (GERD). Primarily fundoplication aims to decrease (acid) reflux events and reduce reflux symptoms. It is unknown if the reduction of reflux symptoms improves quality of life which is increasingly recognized as an essential part of patient care outcome. The aim of this study was, therefore, to evaluate the effect of LF on health related quality of life (HRQoL) by using the validated PedsQL 4.0 Generic Core Scales before and after LF in children with GERD. Methods: Eighteen children (9 males) undergoing LF for therapy resistant GERD in three Dutch Academic Centers were included. Median age was 7,7 years (1,22SD) at the time of operation. Caregivers and neurologically normal children ([ 4 years) were asked to fill-out the validated The PedsQL 4.0 Generic Core Scales before and 3–4 months after LF. This score involves 4 scales: Physical, emotional, social and school functioning. The physical health summary (PH-HS), the psychosocial health summary (PS-HS) and the total score were calculated and transformed to a 0–100 scale. The height of the score correlates to the HRQOL. Furthermore, we assessed GERD parameters before and after operation using 24-hour multichannel intraluminal impedance pH monitoring (MII-pH monitoring) and a validated pediatric GERD questionnaire. Main results: Reflux assessment showed a significant reduction in reflux symptoms and in (acid and non-acid) reflux events. The overall HRQoL score significantly increased after LF compared to baseline (from 78.0 ± 5.1 to 87.2 ± 4.1, p = 0.024). Separate analysis of the physical and psychosocial health summary showed that the physical health summary increased significantly (from 83 ± 5.7 to 90.0 ± 4.9, p = 0.028) and the mean psychosocial health summary went from 73.0 ± 6.4 preoperatively to 84.3 ± 5.4 postoperatively (p = 0.057). Conclusion: Laparoscopic fundoplication effectively reduces reflux in pediatric GERD patients. Moreover, HRQoL also shows a significant improvement after fundoplication. This may prove to be even more important than standard GERD assessment tests.

Wilhelmina Children’s Hospital, University Medical Center Utrecht, The Netherlands; 2Maastricht University Medical Center, Maastricht, The Netherlands; 3University Medical Center Utrecht, The Netherlands

Wilhelmina Children’s Hospital, University Medical Center Utrecht, The Netherlands; 2Sophia Children’s Hospital, Erasmus Medical Center Rotterdam, The Netherlands; 3Maastricht University Medical Center, Maastricht, The Netherlands; 4University Medical Center Utrecht, The Netherlands

O128 - Paediatric Surgery

O130 - Paediatric Surgery

Reliability of Laparoscopic Identification of the Level of a Ganglionosis in Hirschsprung’s Disease

Laparoscopic Repair of Recurrent Inguinal Hernia in Childhood

A. Yehya, R. Shalaby, M. Ismail

Al-Azhar University, Cairo, Egypt

Al-Azhar University, Cairo, Egypt

Background: Open repair of recurrent inguinal hernias [RIH] in infancy and childhood is difficult and there is a definite risk of damaging the vas deferens and testicular vessels. Laparoscopic repair of RIH has the benefit of avoiding the previous operative site. The aim of this study is to present our experience with laparoscopic repair of RIH either after open or laparoscopic hernia repair with stress on technical refinements to prevent recurrence. \/b[ Patients and methods: This is a retrospective study of laparoscopic repair of recurrent inguinal hernia. Records of patient that have been subjected to laparoscopic inguinal hernia repair for RIH were reviewed and evaluated . All patients were subjected to laparoscopic repair of 31 recurrent hernia defect. The main outcome measurements of this study included; operative time, intra and post-operative complications, recurrence, hydrocele formation, iatrogenic ascent of the testis and testicular atrophy. Results: In this study 30 children with 31 recurrent hernia defects were operated upon laparoscopically. There were 28 male and 2 female with a mean age of 2.54 + _ 1.989 years (range = 0.58 -10.00 years). In 29 hernial defects the recurrence occurred after open herniotomy, while in 3 hernial defects it occurred after laparoscopic repair. All procedures were completed laparoscopically without any conversion. Mean operative time was 15_ + 2.3 minutes for unilateral and 20 + _1.7 minutes for bilateral inguinal hernia. All patients achieved full recovery without intra or postoperative complications and were discharged on the same day of admission. Two patients developed hydroceles that responded well to conservative management. At 1 year follow up, there was no recurrence, no testicular atrophy or ascent of the testis. Conclusion: Laparoscopic repair of recurrent inguinal hernia in infancy and childhood, developed after either open or laparoscopic repair, avoids entering a fibrotic inguinal canal, making the procedure easier, safer and shorter. It is a good alternative option in recurrent childhood hernia.

Background: It is crucial to identify the exact level of transition to normal ganglion cells in instances of Hirschprung’s disease (HD). Open leveling biopsies carry the same complications the definitive repair has. Frozen section biopsies interpretation is not available in every center and if error occurs, it has a significant impact on the child. The correlation between the laparoscopic localization of the transitional zone (TZ) and the histopathological level of a ganglionosis has not been well studied. Objective: The aim of this study was to assess whether the laparoscopic visualization of apparent TZ could be a reliable methods for the diagnosis of the pathological level of HD. Patients and Methods: The study included 150 children with diagnosed HD. All patients were subjected to laparoscopy for identification of transitional zone (TZ) and any colonic dilatation. Laparoscopic seromuscular suture was applied as a marker 3 cm proximal to the level of TZ. In cases of non visualization of any TZ, laparoscopic seromuscular biopsies were taken from rectosigmoid, sigmoid, descending colon, splenic flexure, transverse colon. Appendectomy was done for histopathological study in case of identification of TZ at the terminal ileum. Results: The study included 100 male and 50 female with HD. Their mean age was 2 years old (range; 3 months to 6 years). All cases were completed laparoscopically without conversion. The mean operative time ranged from 15 to 20 minutes. Laparoscopic view of the TZ and dilated zone coincided with the pictures of preoperative barium enema in 125 cases. While in 25 cases without definitive TZ in preoperative barium enema, laparoscopic visualization of TZ was identified. Laparoscopic view of the TZ and dilated zone coincided with the histopathological study in all cases. No intra-operative complications were reported apart from incidental injury of colonic mucosa in 2 cases. Conclusion: Laparoscopic identification of TZ and leveling are feasible, safe and decisive technique for diagnosing the leveling of aganglionosis in HD.

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A. Yehya, R. Shalaby, S. Gouda

Surg Endosc

O131 - Paediatric Surgery

O134 - Technology

Laparoscopic Sleeve Gastrectomy in Morbid Obese Teenagers 1

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A. Iossa , F. de Peppo , G. Cavallaro , R. Caccamo , M. Rizzello , A. Contursi2, O. Iorio1, E. Ceriati2, F. de Angelis1, V. Nobili2, G. Silecchia1

Experience on 245 Laparoscopic Procedures Using the Combined Ultrasonic and Bipolar Energy Device Thunderbeat (Tm) D.C. Steinemann, A. Zerz, S.H. Lamm Cantonal Hospital Baselland, Bruderholz, Switzerland

1

Division of General Surgery & Bariatric Center of Excellence,,,la Sapienza,,Rome, Latina, Italy; 2Department of General Paediatric Surgery, Bambin Gesu`, Passoscuro, Italy Introduction: The morbid obesity in young population is a worldwide growing problem. The noninterventional treatment programs fail, especially in super-obese patients. Recently international guidelines recommend laparoscopic bariatric surgery in morbidly obese adolescents with concomitant co morbidities. Laparoscopic Sleeve Gastrectomy (LSG) has been proposed as safe and effective procedures also in teenagers. The aim of the paper was to report the preliminary experience of the a cooperative adolescent surgical bariatric program offering LSG as first stage of duodenal switch or as definitive procedure. Materials and Methods: From April 2012 to December 2013 15 (10 M/5F) teenagers (mean age 16.3 ? 2.2 years) were submitted to LSG. Mean pre-operative BMI was 48.2 ? 4.5 kg/m. All patients had a history of failure of conservative weight loss program plus in 10 cases (67 %) intragastric balloon placement (Bioenteric BIB). Pre-operatively the patients had a psychological assessment (involving parents) and dietician counselling. All patients showed obesity-related comorbidities (Hypertension 60 %, DMTII 53 %, OSAS 70 %), and 4 cases were affected by genetic syndrome obesity-related (3 Prader-Willy, 1 Bardet-Biedl). The preoperative workup was carried out by a devoted paediatric multidisciplinary team. Results: All procedures were completed laparoscopically. Mean operative time was 110 ± 34 min; mean post-operative hospital stay was 5 days. Mortality rate was 0 %. No major intraoperative and postoperative complications were recorded. A case of transient postoperative dysphagia (6.6 %) resolved within 40 days was observed. After a mean follow up of 9.3 ± 5 months the EWL was 57 ? 4.3 %. Co-morbidities resolution occurred in 70 % of pts (improvement in 23.3 %). All patients attended the scheduled follow-up visit Conclusions: These preliminary results confirmed that LSG is a safe and effective option for surgical treatment also in morbid obese adolescent population. The possibility to perform a second stage in adult-age when needed, the absence of relevant nutritional deficiency, the good results in term of EWL and co-morbidities resolution increase the attractiveness of this procedure also in teenagers. Further evaluations in large population with long-term follow-up are mandatory to confirm the preliminary results.

Introduction: In modern laparoscopic surgery the use of an energy device for dissection and preparation is indispensable. Advance energy devices may also be used for vessel sealing reducing the need of vessel clips and vascular staplers. Blood loss and time of surgery are reduced. Experience on the first 245 laparoscopic procedures using the combined ultrasonic and bipolar energy device Thunderbeat TM are reported. Material and Methods: Operative data and outcome of a consecutive series of 245 patients undergoing laparoscopic procedures using the combined ultrasonic and bipolar energy device Thunderbeat TM is analyzed. Results: In total 245 laparoscopic procedures in all field of visceral surgery and gynecology have been performed. Among 133 colorectal operations were 113 resections. 64 (57 %) of those were performed in NOTES technique using a transvaginal (39) oer transrectal (25) access. In upper GIsurgery 37 procedures were performed including Roux-en-Y gastric bypass (12), mesh augmented hiatoplasty (9), total gastrectomy (3). Furthermore 2 left pancreatectomies, 2 splenectomies and one liver wedge resection. Thunderbeat was used for adhesiolysis (19), intraperitoneal onlay mesh repair of incisional hernia (4), lymph node dissection (4) and omententectomy (3). In gynecology Thunderbeat TM was used in hysterectomy (20), adnexectomy (15) and colposacropexy (5). In none of those procedures additional vessel clips or vascular staplers and no other energy device have been used. The total conversion rate to open surgery was 4 % (9) for following reasons: anatomical (4), big inflammatory tumours (2), severe adhesions (2) and in one splenectomy case with a necrotic spleen after interventional coiling. There were 6 % (14) surgical complications: wound infection in two patients (grade I), peranal bleeding in two patients (Dindo-Clavien grade II), ileus (grade II), intraabdominal abscess nececitating drainage (grade IIIa), intraabdominal heamatoma in two patients after reuptake of oral anticoagulation (grade IIIb), colonic perforation (grade IIIb) and anastomotic leakage in four patients (grade IVb). Conclusions: In 245 advanced laparoscopic procedures using ThunderbeatTM we observe no device related conversion or surgical complication. There was no need for additional vessel clips or vascular staplers. The use of Thunderbeat TM in laparoscopic surgery seems to be safe.

O132 - Abdominal Cavity and Abdominal Wall

O135 - Technology

Clinical Feasibility of an Instrument (Or Camera) Positioning System During Laparoscopic Procedures and its Added Value for the Operating Room (Or) Staff

Ergonomics and Performance of a Novel Handheld Articulating Laparoscopic Instrument Driven by Robotic Technology During Laparoendoscopic Single Site Surgery

S.L. Been1, J.M. Bosma1, A.A.W. Geloven van2, A.E. Boeken Kruger2, J.E.N. Jaspers1

F.M. Sanchez Margallo, F.J. Perez Duarte, J.A. Sanchez-Margallo, B. Ferna´ndez Tome´

1

Minimally Invasive Surgery Centre, Ca´ceres, Spain

University Medical Center Utrecht, Utrecht, The Netherlands; Tergooi Hospital, Hilversum, The Netherlands

2

Laparoscopic procedures provide many advantages for the patient. However, the surgeon performing this procedure faces tasks with higher complexity, compared to open surgery. A drawback for the surgeon is the indirect control over the view on the surgical field, because an assistant positions the camera. This disadvantage can be reduced by replacing the ‘human camera positioner’ by a passive mechanical camera positioner (trocar holding system) which is attached to the operating table. Previous studies showed that passive holders perform as well as human control1,2 University Medical Center Utrecht has developed a prototype trocar holding system for clinical evaluation, called MOVIX. This system consists of a reusable holder in combination with a dedicated disposable trocar. With this system, the surgeon can intuitively reposition the camera with one hand, thus does not need help from an assistant to perform this task. The aim of this clinical evaluation is to show the feasibility of this trocar holding system during laparoscopic procedures and its added value for the surgeon and the OR staff. 10 laparoscopic cholecystectomies were evaluated with the MOVIX trocar holder and 10 without the use of the MOVIX (control group). The surgical procedure was performed by 7 different (resident) surgeons. The average installation time of the MOVIX trocar holder was 4 minutes. The average operating time was 36 minutes (SD 8) while using the MOVIX, and 35 minutes (SD 7) without (p = 0.43). While using the MOVIX, the number of camera movements was 14 (SD 4) versus 98 (SD 23) in the control group (p \ 0.05, T-Test). Analysis resulted in a significant reduction of camera movements while no significant increase in operating time is found. The surgeons confirm that the trocar holding system is a user friendly, single-handed operated device that helps to provide a stable endoscopic view. This system can be used for surgical instruments (eg retractors) as well and will be able to reduce OR costs for minimal invasive surgery by omitting an extra pair of hands on the working table. References Arezzo et al, Surgical Endoscopy 2000 Den Boer et al, Surgical Endoscopy, 2001

Objectives: To evaluate the ergonomics and performance using a novel laparocopic instrument with an articulated distal end driven by robotic technology during laparoendoscopic single site (LESS) surgery. Materials and Methods: Four surgeons with different experience levels in LESS took part in this study. They were asked to pass the suture needle through a set of four pair of entry and exit dots in both vertical and horizontal plane marked on a training plate. Surgeons used both a traditional laparoscopic needle holder (Group L) and the robotic laparoscopic instrument in its needle holder set up (Group R). In order to assess their training learning curve participants repeated the exercise nine times in a period of two months. During the first (T1) and the last (T9) repetition muscular activity of biceps brachii, triceps brachii, forearm flexors and extensors, and trapezius muscles was registered through surface electromyography (EMG). Additionally, during T1 and T9 the completion times and the accuracy value of the correct pass of the needle through the marked dots on the training plate was measured. Results: During T1 muscular activity of forearm flexor was significantly higher using the novel laparoscopic instrument (L17.29 ± 8.30 vs R40.73 ± 16.57), whereas muscular activity of trapezius muscle was significantly lower (L30.75 ± 12.35 vs R20.68 ± 13.58). During T9 lower significant differences in muscular activity of trapezius muscle were showed using the robotic instrument (L24.35 ± 7.53 vs R16.03 ± 6.12). A significant decrease in muscular activity of forearm flexors was shown between T1 and T9 (T1 L40.73 ± 16.57 vs T9 R9.57 ± 6.08) with the robotic instrument. The accuracy in the use of the needle was significantly higher for the traditional needle holder during T1, while during T9 both instruments obtained similar results. As with the EMG results, group K obtained significantly better accuracy results during T1 than T9. Completion times were similar in all cases. Conclusions: results showed that there is a clear positive learning curve using the novel robotic laparoscopic instrument concerning ergonomics and performance. At the end of this learning curve the results of the robotic instruments were similar or even better than the traditional instrument.

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O136 - Technology

O138 - Basic and Technical Research

Preliminary Assessment of a Novel Robotic Needle Holder During Laparosopic Suturing

Validation of the ScopeControl Endoscope Test System in Six Hospitals in The Netherlands

F.M. Sanchez Margallo, J.F. Ortega Mora´n, J.A. Sanchez-Margallo, L.F. Sanchez Peralta, J.L. Moyano Cuevas, J.B. Pagador Carrasco

H.J. Noordmans1, M. de Braak2, R. Wientjes1, E.G.H.J. Martens3, K. Lindenhovius1, P. Swart1, D.C. van der Zee1, J.E.N. Jaspers1

Minimally Invasive Surgery Centre, Ca´ceres, Spain

UMC Utrecht, Utrecht, The Netherlands; 2DOVIDEQ Medical, Deventer, The Netherlands; 3Maastricht University Medical Center, Maastricht, The Netherlands

Aims: To analyse the comfort, efficiency and usability of a novel robotic needle holder during a laparoscopic suturing. Methods: Nine surgeons with experience in laparoscopy but not in robotic surgery (5 experts -E- and 4 novices -N-) performed an intracorporeal suture with double knot in a porcine ex vivo tissue without incision with a time limit of five minutes using a Robot DEX (PRESURGY, S.L, Madrid, Spain) needle holder. The performance was objectively assessed through a Global Operative Assessment of Laparoscopic Skills (GOALS) and a validated suturing checklist. At the end, participants completed a questionnaire concerning usability, efficiency and general features using a 1–5 Likert scale. Results: Results show significant differences between groups for the checklist scores (E: 8.20 ± 1.30, N: 4.25 ± 1.26 novices; p = 0.016). Experts achieve higher scores than novices (E: 16.20 ± 2.95, N: 11.25 ± 1.71; p = 0.063) on GOALS rating scale without significant differences. Concerning the subjective questionnaire, it shows similar score for all topics, which are evaluated as acceptable for both groups, with slightly better score from the expert group. Conclusions: Differences between groups are small because none of the surgeons had experience in robotic surgery. However, obtained objective results (suturing checklist and GOALS rating scale) are similar to previous studies carried out with conventional laparoscopic tools. Hence, the Robot DEX needle holder achieves similar performance (both expert and novice surgeons) than conventional surgical tools without previous training period. In conclusion, the overall impression of surgeons about comfort and usability is positive, although additional studies should be performed to assure ergonomics improvement of this device.

1

Aims: As rigid endoscopes are being re-used after each minimal invasive surgery, they degrade over time. To prevent loss of time and image quality during surgery, endoscopes should be checked after cleaning and before sterilization at the department of sterilization. As manual checks appear difficult to be performed objectively, an endoscope test system, called ScopeControl, has been developed. It is able to measure several optical parameters of an endoscope, like light transmission through the lenses, color correctness, sharpness (focus), fiber light transmission, view angle and field of view. By comparing these values with reference values from a database, endoscopes with good optical quality can be discriminated automatically from those with bad optical quality. In this study, the performance of the ScopeControl has been assessed in clinical practice. Methods: To evaluate the performance of the ScopeControl, five ScopeControls SV (study version) have been tested in six hospitals in the Netherlands from April to August 2013. Aspects such as robustness, correctness and usability of the measured data, definition of acceptation criteria and user aspects have been determined. Results: Based on 3580 measurements on clinically used endoscopes, it appears that the ScopeControl is stable over time, can measure the lens light transmission, color correctness and focus with 5 % accuracy, angles with 2 % accuracy and fiber transmission with 10 % accuracy. Moreover, it enables discrimination between good and bad endoscopes based on set margins and fits in the process at the department of sterilization. The time to perform a measurement is 2–3 minutes. Conclusions: The ScopeControl SV fulfills the demands to objectively guarantee the optical quality of endoscopes in a clinical environment. Its results are reproducible and have sufficient quantitative resolution and accuracy. It is easy to use and fits in the workflow of the department of sterilization. Recently the ScopeControl PV (product version) has been released providing several adaptations to improve the quality and efficiency of performing measurements, like including a datamatrix scanner, a clip-on fiber sensor, better focus measurement and automatic reporting.

O137 - Robotics, Telesurgery and Virtual Reality

O139 - Robotics, Telesurgery and Virtual Reality

The Mechanical Master-Slave Manipulator: An Instrument Improving Surgeons Ergonomics in Standardised Task for Endoscopic Surgery.

Attention Deployment During 3D Minimally Invasive Surgery

J.E.N. Jaspers1, S. Aarts2, J.M. Bosma1, A.E. Boeken Kruger1 UMC Utrecht, Utrecht, The Netherlands; 2Delft University of Technology, Delft, The Netherlands 1

Background: In endoscopic surgery the surgeon is often working in a non-ergonomical and asymmetrical posture, which results in wrist, shoulder, neck and back pain. Robotic surgery improves the working posture of the surgeon, but unfortunately the use of robotics is a very complex and expensive solution for this ergonomic problem. Therefore, a comparable but more economical master slave system was developed to improve the working conditions for the surgeon. This study aimed at evaluation of the ergonomics of this mechanical minimally invasive manipulator for endoscopic surgery as compared to conventional laparoscopic surgery, in an experimental setting. Methods: 10 laparoscopic experts and novices performed three different tasks in a pelvic trainer box using either conventional endoscopic instruments or a mechanical manipulator. In the conventional setting the trainer box was positioned on a surgical table with the participant standing next to it, resembling a real surgical setting. In the manipulator setting, the participant sat in a chair with armrest, interacting with the handles of the manipulator right in front of him. From all participants the EMG signals of wrist, shoulder and neck muscles (Trapezius, Lateral Deltoid and Wrist Flexor) were recorded, as well as their posture and movements. Afterwards, a questionnaire about the physical and mental load was filled in by the participants. Results: A significant difference in muscle tension was found between the two settings, up to a doubling in EMG signals of the shoulder and neck muscles in the laparoscopic session compared to the manipulator setting. Also the results of the questionnaire showed that performing tasks in the laparoscopic setting is considered both physically and mentally harder than performing tasks in the manipulator setting, Conclusions: The results of the task in both the laparoscopic and manipulator setting, clearly demonstrated the ergonomic potential of the mechanical manipulator. Considering the fact that a prototype of the mechanical manipulator was tested, modifications are to be expected in a next model further improving the results.These experiments show the potential of the mechanical manipulator, and it is expected to be a competitive and economical instrument for endoscopic surgery in the near future.

123

R. Smith1, A. Day1, D. Windridge2, T. Rockall1, M.E. Bailey1, I.C. Jourdan1 1

Minimal Access Therapy Training Unit, Guildford, United Kingdom; 2University of Surrey, Guildford, United Kingdom

Introduction: Disparity cues influence eye movement behaviour while watching 3D cinematic productions. This study investigates the impact of stereoscopic motion cues on both novice and experienced surgeon’s visual attention performance while viewing minimally invasive surgery. Methods: 20 surgeons (10 expert and 10 novices) were randomized to view 10 high definition video sequences of minimally invasive surgical procedures in 2D followed by 3D or in the reverse order. Depth maps were used to calculate peak disparity velocity and the Eyelink 1000 recorded eye movement behaviour throughout each viewing session. Results: Novice surgeon’s median (IQR) fixation count and saccadic peak velocity were significantly increased during 3D v 2D viewing (22 (18.3–25) v 19 (16–22), p = \0.01 and 149.1 (100–235.6) v 145.2 (93.3–222), p = 0.02 respectively). Experts exhibited similar visual attention patterns during each viewing session. Overall, there was no difference in 2D v 3D fixation count when motion sequences were normalised for peak disparity velocity. Conclusions: Novice surgeon’s visual attention deployment is influenced by salient stereoscopic stimuli. Perceptual adaptation during extended viewing and the thresholds for attention fatigue require further evaluation while performing 3D minimally invasive surgery.

Surg Endosc

O140 - Technology

O142 - Abdominal Cavity and Abdominal Wall

Three Dimensional Vision Increases Speed in Laparoscopic Suturing

Laparoscopic Transabdominal Inguinal Hernia Repair: A Randomized Study of Fibrin Sealant Versus Absorbable Tack to Fix the Mesh

E. Caruana, J.H. Robertson, B. Tang, I.S. Tait, K.L. Campbell Cuschieri Skills Centre, Dundee, United Kingdom Aims: This study aimed to assess the impact of a three dimensional (3D) versus a two dimensional (2D) system on the laparoscopic suturing performance of surgeons of various levels of expertise. Methods: Surgical consultants and trainees were recruited to perform a standardised laparoscopic suturing task, requiring the placement of as many high quality simple interrupted sutures as possible in the space of seven minutes. Each candidate performed the same task twice, once each using the 3D and 2D mode of a Karl Storz 3D TIPCAM in random sequence. The scope remained attached to a Karl Storz Endoskope HD stack and a standard training box. Candidates were grouped according to overall and suturing-specific experience at laparoscopy. Paired Student’s t-tests were used to assess for significance of differences in performance using each modality. Results: 27 surgeons, 81.5 % male (n = 22) were recruited. 44.4 % (n = 12) of candidates had seven or more years’ laparoscopic operating experience, whilst 29.6 % (n = 8) reported five or more years’ experience in laparoscopic suturing. 3D offered no advantage over 2D in candidates experienced in laparoscopy (mean knots tied 3.16 ± 0.98 vs 3.16 ± 1.09, p = 1.00) or laparoscopic suturing (mean knots tied 3.18 ± 1.13 vs 3.25 ± 1.25, p = 0.86). However, candidates with less than seven years’ experience in laparoscopy (mean knots tied 2.93 ± 0.98 vs 2.27 ± 0.75, p \ 0.05) or less than five years’ experience in laparoscopic suturing (mean knots tied 2.97 ± 0.92 vs 2.42 ± 0.80, p \ 0.01) derived significant advantage. Conclusions: The use of 3D laparoscopic systems allows surgeons with up to 7 years of laparoscopic experience and up to 5 years of laparoscopic suturing experience to place sutures faster; but has no impact on the operating speed of more highly experienced surgeons.

F. Agresta, C. Tordin ULSS19 Del Veneto, Adria, Rome, Italy Laparoscopic TAPP approach for Inguinal hernia repair is well documented as an excellent choice in numerous studies, with the fibrin glue as the widely used way to fix the mesh. In this report we evaluate a randomized study of 80 of patients operated on with a trans abdominal (TAPP) laparoscopic bilateral inguinal repair focusing on the methods used to fix the mesh and the peritoneal flap: fibrin glue plus absorbable suture versus absorbable stapler. Materials and Methods: Between July 2012 and March 2013, a total of 80 consecutive patients, at ‘Civil Hospital’ in Adria (RO), underwent Trans- abdominal laparoscopic inguinal hernia repair. In half of them (group A) the mesh and the peritoneal flap were fixed and closed with an absorbable stapler, in the other half (group B) the fibrin glue were used to fix the mesh and the peritoneum was closed with an absorbable suture. Results: The mean operative time was 33.40 (±10.3) in the group A and 43.50 (±13.2) in the group B (p \ 0.005). All the procedures were done on a Day Surgery basis. In both group there were no conversions to open repair or deaths in both our series. The mean follow-up is 10.5 months. No patients reported severe pain at 10 days at a 3 months follow up. There were no reports of night pain at 30 days. About 90 % of the patients had a return to physical-work capacity within two weeks, the remaining within 30 days maximum. All patients’ were completely satisfied at the 3-month follow up. Conclusions: The analysis of the short post-operative outcomes of our experience enabled us to conclude that using an absorbable stapler to fix the mesh and close the peritoneum might be an alternative to glue fixation during a TAPP procedure, taking into account that in experienced hands it allows to spare operative time. It should be incorporated into the surgeon’s armamentarium when approaching laparoscopically an inguinal hernia.

O141 - Abdominal Cavity and Abdominal Wall

O143 - Abdominal Cavity and Abdominal Wall

A Prospective, Randomised, Controlled-Trial to Compare SinglePort Endo-Laparoscopic Surgery and Conventional Total ExtraPeritoneal Inguinal-Hernia Repair

The Incidence and Natural Course of Occult Inguinal Hernias During TAPP Repair

I. Wijerathne, N. Agarwal, D. Liem, D. Lomanto, A. Ramzi National University Health System, Singapore Aims: The success of laparoscopic surgery was due to less surgical trauma and better cosmesis. Objective of our study is to compare the surgical outcome of Total-Extra-Peritoneal (TEP) inguinal hernia repair using either single-port or conventional surgical technique. We aim to report our interim results in the first 50patients. Methods: Our study is a prospective, randomised, controlled clinical-trial conducted from August-2011 to June-2013 in a single institution. 50 patients aged 21–80 years undergoing surgery for unilateral inguinal-hernia were randomised into 2 groups: one group underwent conventional 3-port laparoscopic TEP repair while the other group had single port TEP repair. Clinical-data on patient demographics, surgical technique/findings, post-operative complications and pain scores were collected and analyzed. Results: 26 underwent single-port TEP repair and 24 had conventional repair after randomisation. Mean operative time was 51.7(± 13.4) min in the conventional group and 59.3(± 14.9) min in the single-port group respectively (p = 0.064). Mean hospital stay was 19.7(± 4.8) hours in the conventional group and 22.1(± 4.5) hours in the single-port group (p = 0.079). No significant differences were observed between the two groups for postoperative complications and no recurrence reported at 11 months follow-up. Mean VAS at 6 hours post-surgery was 2.7 ± 1.7 in the conventional group and 2 ± 1.8 in the single-port group (p = 0.187). VAS was 0 in both groups at 6 months. Size scar in the single port group was 13 mm Conclusion: The outcomes after laparoscopic TEP inguinal hernia repair with a single-port device is similar to the conventional 3-port technique, adding the obvious effect on a better cosmesis.

B. van den Heuvel1, N. Beudeker2, J. van den Broek2, A. Bogte3, B.J. Dwars2 VUMC, Amsterdam, The Netherlands; 2Slotervaartziekenhuis, Amsterdam, The Netherlands; 3University Medical Center Utrecht, The Netherlands 1

Aims: One of the proposed advantages of laparoscopic inguinal hernia repair is complimentary inspection of the contra-lateral side and possible detection of occult hernias. Incidence of occult contralateral hernias is as high as 50 %. The natural course of such occult defects is unknown and therefore operative rationale is lacking. This study aims to analyse the incidence of occult contralateral inguinal hernias and its natural course. Methods: 1681 patients were diagnosed pre-operatively with an unilateral inguinal hernia. None of these patients had complaints of the contralateral side pre-operatively. All patients underwent laparoscopic inguinal hernia TAPP repair. Operative details were analyzed retrospectively. Patients with occult contralateral defects were identified and tracked. Patients with an evident occult hernia received immediate repair. Patients with a smaller beginning or incipient hernia were followed. Results: In 218 (13 %) patients an occult hernia was found at the contralateral side during peroperative exploration. In 129 (8 %) patients an occult true hernia was found. In 89 (5 %) patients an occult incipient hernia was found. An incipient hernia was defined as a beginning hernia. All patients with an incipient hernia were followed. The mean follow-up was 112 (range 16–218) months. Twenty-eight (31.5 %) patients were lost to follow-up. In the 61 remaining patients 13 (21 %) occult incipient hernias became symptomatic requiring repair. The mean time between primary repair and development of a symptomatic hernia on the contralateral side was 88 (range 24–210) months. Conclusion: This study shows that the incidence of occult contralateral hernias is 13 % during TAPP repair of unilateral diagnosed inguinal hernias. In 5 % of the cases the occult hernia consisted of a beginning hernia. Eventually 1 in 5 will become symptomatic requiring repair. These outcomes support immediate repair of occult defects, no matter its size.

123

Surg Endosc

O144 - Abdominal Cavity and Abdominal Wall

O146 - Abdominal Cavity and Abdominal Wall

Laparoscopic Ventral Mesh Hernia Repair for Complex Ventral Abdominal Hernias: Combining Radicality with Minimal Access!

Glue for Mesh Fixation in Laparoscopic Ventral Hernia Repair. An Experimental Comparison with Conventional Fixation

S.J. John, P. Bhatia, S. Kalhan, M. Khetan, S. Saroj, S. Wadhera, N. Bansal, A. Bhardwaj, J. Bhat

E.I. Reynvoet, S.G. van Cleven, A.K. van Lander, I.V. van Overbeke, R.I. Troisi, F.G. Berrevoet

Sir Ganga Ram Hospital, New delhi, India

Ghent University Hospital and Medical School, Ghent, Belgium

Aims: Laparoscopic ventral abdominal hernia repair (LVHR) has gained acceptance in the surgical community and among patients on account of its multiple minimal access benefits. Laparoscopic hernia repair in complex ventral abdominal hernias is however contentious. We endeavour to lay this contention to rest by detailing our experience in this segment of hernias. Methods: We prospectively evaluated our experience of LVHR in complex ventral abdominal hernias operated at our institute from February 2010 to February 2012. Results: 57 complex ventral abdominal hernia patients were operated. The patients were followed up for 12 months. 31.6 % were male and 68.4 % were female. The mean age was 50.8 + 12 years (range 26–79 years); BMI was 29.1 + 6 kg/m2 (range 18–53 kg/m2). 84.4 % of the patients had incisional hernias and only 15.6 % had a primary hernia. 15.9 % of hernias were irreducible and 5.3 % presented with acute intestinal obstruction. 66.7 % of those who presented with irreducibility had recurrent incisional hernias. An average of 1.4 + 0.7 abdominal operations had been performed earlier for each of the patients with incisional hernias. A laparoscopic intra-peritoneal onlay mesh hernia repair was attempted in all the patients and was completed in 94.7 % of them using a tissue separating mesh. 5.3 % of the patients were converted to an open mesh hernia repair using a polypropylene mesh. The average size of the dominant defects was 5.5 + 3 cms (2–15 cms) x 4.7 + 2 cms (2–15 cms) with 35.1 % of the hernias having additional Swiss-Cheese defects. The weakened area measured 80.5 + 23 sq.cms and was covered with a mesh area of 368.3 + 20 sq.cms. Operative duration was 178.5 + 80 minutes. The length of stay was 2.6 + 1.5 days. There was no recurrence at one year post repair and the patients enjoyed a satisfactory quality of life. Conclusions: LVHR offers an excellent surgical modality for the radical repair of complex ventral abdominal hernias. Longer follow-up of these patients is required to comment on long-term clinical and quality of life outcomes.

Background: The use of glue for mesh fixation in laparoscopic ventral hernia repair is gaining popularity as it is atraumatic to the peritoneum and results in less postoperative pain compared to penetrating fixation. Methods: A total of 21 sheep were operated using a hernia model with two fascial defects of 2 cm2 at the linea alba. One week later two polypropylene meshes (DynameshÒ) were implanted laparoscopically, using cyanoacrylate glue (IfabondÒ) or conventional fixation (SecurestrapÒ). In half of the animals the fascial defect was closed before mesh placement. After 1 day (n = 6), 2 weeks (n = 8) and 6 months (n = 6) a second laparoscopy was performed at which hernia recurrence, mesh integration and adhesion formation were evaluated. After euthanasia, meshes and abdominal wall were excised to perform burst strength testing and to prepare samples for histopathological evaluation. Results: One animal died because of intestinal incarceration and was not used in the analysis. No recurrences were diagnosed in all 20 animals. Mesh placement was satisfying with good incorporation in both groups. Adhesions could hardly be observed after one day but were omnipresent at two weeks and six months. No significant difference in adhesion formation was seen between straps and glue. Burst strength testing exceeded 100 N in all samples, independent of the fixation device used. Not after 1 day, but after 2 weeks the inflammatory cell response was significantly higher in the glue group. Foreign body reaction (FBR) was most pronounced at two weeks but no difference was seen between both fixation groups. Conclusion: Using a standardized biomechanical testing system, synthetic glue can be considered an effective fixation in laparoscopic ventral hernia repair for relatively small mesh sizes. The possible tissue toxicity of cyanoacrylates does not lead to an increased FBR. No difference in burst strength was observed for closing or not closing the defect.

O145 - Abdominal Cavity and Abdominal Wall

O147 - Abdominal Cavity and Abdominal Wall

Laparoscopic Incisional Hernia Repair: Influence of Surgical Technique on Recurrence Rate. A Systematic Review of the Literature

Optimal Methods: Of Laparoscopic Repair of Incisional Hernia

M.M. Poelman1,2, J.D. Deelder1, E. de Lange2, H.J. Bonjer3, W.H. Schreurs1

Odessa national medical university, Odessa, Ukraine

1

Medisch Centrum Alkmaar, Alkmaar, The Netherlands; VU University Medical Center, Amsterdam, The Netherlands

2

Introduction: Recent studies reported that laparoscopic incisional hernia repair is at least as effective as the open approach. The technique of laparoscopic incisional hernia repair has not been standardized. Methods: A systematic review of the literature was performed to evaluate the surgical technique of laparoscopic incisional hernia repair with outcomes. PubMed was searched using the following key words; incisional hernia, ventral hernia, mesh, fixation, laparoscopy, endoscopy and combinations of these words. Relevant articles published prior to August 2012 were selected. Methodological Index of Nonrandomized Studies (MINORS) criteria were adapted for this topic. Two independent researchers appraised all the publications with the use of these modified MINORS criteria to assess their methodology. Primary outcome was recurrence rate. A meta-analysis was performed for the influence of three factors (number of transfascial sutures, type of mesh and overlap of the mesh) on recurrence rates. Forest plots were used as a graphical design to display the relative strength of each individual study. Results: Twenty-one articles, with a total number of 2353 patients were selected for evaluation. Indications for repair were unclear in almost all studies. Mesh was employed in all studies. The conversion rate to an open procedure was 2.8 %. Relaparotomies were performed in 2.7 % of all patients in less than a week after index surgery. Recurrences were determined based on physical examinations, the reported recurrence rate was 5,2 %. Analysis of the subgroups (overlap of \ 3 cm vs overlap of [ 5 cm/use of = 4 TFS vs use of = 2 TFS/ Dual mesh vs Parietex mesh) did not show any significant difference in recurrence rates. Discussion: In spite of numerous reports on laparoscopic incisional hernia repair, a preferred surgical technique has not yet been determined.

123

V.V. Grubnik, K.O. Vorotyntseva

Introduction: Many articles have shown that laparoscopic repair of ventral hernia is preferred over open repair. The aim of the study was to compare different types of mesh and fixation methods for laparoscopic repair of incisional hernia. Methods: Prospective randomized controlled study was conducted from 2008 to 2013. Total enrollement was 63 patients (men - 24, women - 39) with a mean age of 45.9 ± 10.6 (range 22–72). They were prospectively randomized into two groups: group I included 32 patients where lightweight PTFEe mesh with peripheral nitinol frame (Rebound, MMDI, Inc.) was used, and group II included 31 patients (composite PTFEe mesh (Dualmesh, Gore, Inc.). In group I mesh was fixed to abdominal wall using only 3–4 transfascial sutures. In group II was fixed with double row of spiral tackers. Two groups of patients were statistically comparable. Results: The mean mesh fixation time was higher in group II compared to group I (27.8 ± 6.8 min versus 41.1 ± 10.9 min, p \ 0.05). The mean operative time was also higher in the group II (68.5 ± 8.2 min versus 108.2 ± 12.8 min, p \ 0.05). There were 2 conversions to open repair in both groups. The mean pain score (visual analog scale) was significantly lower at 24 and 48 hours in the patients of group I (2.74 vs. 3.82, p \ 0.05). The rate of complications was 9.4 % (3 patients) in group I and 12.9 % (4 patients) in group II (p [ 0.05). Recurrence at mean follow-up of 36 months was in 2 patients (6.25 %) of group I, and in 3 patients (9.6 %) of group II (p [ 0.05). Conclusions: The new type of mesh with nitinol frame is better for laparoscopic repair of incisional ventral hernia. Fixation of such mesh is very simple. The absence of shrinkage of the mesh makes the probability of recurrence to be minimal. We consider that the new type of prosthesis can significantly improve results of laparoscopic incisional hernia repair.

Surg Endosc

O148 - Abdominal Cavity and Abdominal Wall

O150 - Liver and Biliary Tract Surgery

Laparoscopic Versus Open Incisional Hernia Repair: A MetaAnalysis of Randomized Controlled Trials

Harness Traction Technique (Harness): Novel Method for Controlling the Transection Plane During Laparoscopic Hepatectomy

H.H. Eker1, M.M. Poelman1, J. Lange2, J. Jeekel2, H.J. Bonjer1, N. Van Veenedaal1 1

2

VU Medical Center, Amsterdam, The Netherlands; Erasmus Medical Center, Rotterdam, The Netherlands

O. Itano1, G. Oshima2, M. Kitago1, K. Suzuki3, S. Hayatsu4, M. Shinoda1, Y. Abe1, T. Hibi1, H. Yagi1, N. Ikoma2, A. Aiko2, Y. Kitagawa1 1

Background: Incisional hernia keeps being the most frequent long-term complication after midline laparotomy. In a large number of randomized clinical trials laparoscopic and open repair seem to be safe and effective approaches in the treatment of incisional hernia. Methods: A systematic review of randomized clinical trials is performed. Trials comparing laparoscopic and open incisional hernia repair that included data on safety and efficacy were included in this meta-analysis of the literature. Results: Ten studies met the inclusion criteria. The experimental group with laparoscopic incisional hernia repair had significantly less postoperative Surgical Site Infections (SSI) (OR = 0.14, 95 % CI 0.08–0.26). None of these infections however lead to mesh removals. Intraoperative complications in terms of bowel injury were significantly higher in the laparoscopic group (OR = 3.29, 95 % CI 1.35–8.01). The recurrence rates during follow up were comparable for laparoscopic and open incisional hernia repair (OR = 1.25, 95 % CI 0.75–2.09). Conclusion: Laparoscopic incisional hernia repair seems to be an effective and safe method in the treatment of incisional hernia with comparable outcomes on the longer term. Hence, longer follow-up controls of the included RCTs needs to be studied to evaluate recurrence rates on the longer term.

Keio University School of Medicine, Tokyo, Japan; 2Eiju General Hospital, Tokyo, Japan; 3Kitasato Institute Hospital, Tokyo, Japan; 4 Saitama National Hospital, Saitama, Japan Background: In laparoscopic hepatectomy, the main technical challenge is controlling the dissection line. Therefore, we developed a novel method for controlling the transection plane, known as the Harness Traction Technique (HARNESS). Herein, we present our experience using HARNESS and evaluate its usefulness. Methods: At the pneumoperitoneum, the arterial and portal branches of resected segments were clipped and divided. Occasionally, an anatomical major liver resection was performed using the Glissonian approach. After a transection line was decided based on the demarcation line and laparoscopic ultrasonography examination, the superficial hepatic parenchyma on the line was transected at 1–2-cm depth using an ultrasonic dissector, and 5-mm tape was placed along the groove of the line and tied to prevent it from slipping off. The deeper portion of the parenchyma was dissected using a laparoscopicultrasonic surgical aspirator (Sonosurg, Olympus Inc, Tokyo, Japan). After 50 % of parenchymal transection was performed, HARNESS was used. The tape around the transection line was pulled using forceps to obtain bleeding control, moving the transection point to the appropriate position and creating good tension for parenchymal transection at the transection point. The HARNESS tape was also a good landmark to maintain the precise dissection line. Results: Three left hepatectomies, 10 right hepatectomies, 4 anterior sectionectomies, 8 posterior sectionectomies, 2 subsegmentectomies, and 3 partial hepatectomies were performed using HARNESS. Median operative time was 427 minutes. Median blood loss was 300 mL, and 1 patient required blood transfusion. There were no conversions to laparotomy or intraoperative complications. One patient had a postoperative complication (ascites). Median postoperative hospital stay was 8 days (range 5–26 days). There was no mortality. Pathological examination showed R0 resections in all cases. Conclusion: HARNESS is useful for controlling the dissection line during laparoscopic hepatectomy, leading to precise and safe laparoscopic liver parenchymal dissection.

O149 - Abdominal Cavity and Abdominal Wall

O151 - Liver and Biliary Tract Surgery

Comparison of Two Different Concepts of Mesh and Fixation Technique in the Laparoscopic Operations for Ventral and Incisional Hernia

The Standardization of Laparoscopic Hepatic Resection—Our Experiences and Procedures

M. Pawlak, M. Smietanski, A.L. Lehmann Ceynowa Hospital, Wejherowo, Poland Aims: The desire to improve outcomes and to reduce the number of complications triggers the development of new materials and techniques of operations. Currently there are many prosthesis and fixation systems, which are dedicated for IPOM procedure. Studies are comparing only one part of the system: mesh or fixation device. Our previous publications have shown that the result of the operation is influenced by the whole mesh-fixation-fascia system behavior. In presented study authors compare two different concepts of mesh and fixation system dedicated for the IPOM operation. Methods: A single-center, prospective, patient-blinded study was conducted. The CRF form was based on the EuraHS platform. In two groups of 25 patients each Phisiomesh with Securestrap and Ventralight ST with Sorbafix was used. In the postoperative period number of recurrences, complications and intensity of pain was measured. Follow-up had been conducted after 7 and 30 days and then after 3 and 6 moths since the operation. Results: Recurrence rate was higher in the Phisiomesh group and reached 25 % in first 6 months. In the Ventralight group there were no recurrences. After 7 days pain was present in 88 % of patients in the first group and in 44 % in the second group, after one month in 44 % and 8 %, after 3 months in 8 % and 0 % respectively. Six moths after operation there was no patient reporting pain. There was also a difference in the intensity of symptoms. After 7 days median VAS score was 4 in the first group and 2 in the second, after 1 month 2 and 0 and after 3 months 1 and 0 respectively. Conclusions: The elastic mesh was superior to the stiff mesh in terms of number of incidence of postoperative pain and its intensity. Stiffness of the mesh could be an independent factor causing recurrences.

Y. Nakamoto Chiba Medical Center, Chiba city, Japan Background: Although laparoscopic hepatic resection (LHR) is becoming a standard procedure, effective surgical techniques and appropriate equipment to dissect the liver are required. The aim of this study is to review our experiences and to present what techniques and equipment were effective for the standardization of LHR. Methods: We reviewed the clinical profiles of 60 patients who had undergone LHR between December 2006 and September 2013. Results: Out of the 60 patients, 40 had hepatocellular carcinomas with liver cirrhosis. The mean value of indocyanine green dye retention at 15 minutes was 23.7 % (range: 6.2–56.3 %). The mean tumor size was 24 mm (range: 10–60 mm). Thirty-four patients underwent partial resection of the hepatic segment (S2, 3, 4, 5, 6, 7, 8), and five patients underwent lateral segmentectomy. The mean operation time was 188 min (range: 40–448 min). The mean blood loss was 99 ml (range: 5–448 ml). The mean postoperative hospital stay was 5.2 days (range: 2–13 days), except for one patient. On the other hand, of the 20 patients with no cirrhosis (seventeen patients with metastatic liver tumors and three patients with gallbladder tumors), sixteen of them had partial resections of the hepatic segment (S1, 2, 3, 4, 6, 7, 8 and gallbladder bed). Four patients underwent lateral segmentectomy, and two underwent right hepatectomy. The mean operation time was 192 min (range: 70–450 min). The mean blood loss was 39 ml (range: 5–340 ml). No postoperative complications were identified. The mean postoperative hospital stay was 7.4 days (range: 4–33 days). Crushing with BiClamp forceps followed by the use of a vessel sealing system or laparoscopic coagulation shears was effective in dissecting a cirrhotic, hard liver. Lately the CUSA with VIO system has been effective in the same way as open surgery especially for novices. Conclusions: LHR using various surgical instruments can be safely performed even in a cirrhotic hard liver. There is a difference in the surgical procedures adopted, depending on the hardness of the liver. The use of CUSA and Biclamp are useful for novices towards the standardization of the procedures for laparoscopic liver resection.

123

Surg Endosc

O152 - Liver and Biliary Tract Surgery

O154 - Liver and Biliary Tract Surgery

Evaluation of the Learning Period for Laparoscopic Hepatectomy

The Comparison of Oncologic Outcome of Laproscopic Liver Resection for Hepatocelular Carcinoma

C. Lin Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan

H.J. Kim, M.K. Kim, D.S. Lee Yeungnam Uiniversity Hospital, Daegu, Korea

Background: The application of laparoscopic surgery for hepatocellular carcinoma (HCC) remains controversial and difficult, especially in patients with liver cirrhosis. This study proposes to evaluate the feasibility and learning curve of laparoscopic hepatectomy for HCC patients. Methods: The study included 100 HCC patients who underwent laparoscopic hepatectomy from May 2008 to October 2013. Patient characteristics, operative data, and surgical outcomes were prospectively collected and analyzed. Results: The median size of tumor was 2.5 cm and all surgical margins were free of malignancy. The median operation time was 200 minutes and median blood loss was 200 ml. All tumors in the study series were proved to be HCC and 68 patients (68 %) revealed moderate to severe liver cirrhosis pathologically. Only one complication of bile leakage developed and a second surgery was needed. There was no 90-days postoperative mortality. The analysis of learning curve was based on the incidence of prolong operation time longer than five hours and major perioperative blood loss more than 1000 ml. The CUSUM analysis demonstrated that incidence of major peri-operative event was increasing until the 22nd patient. Conclusions: In carefully selected HCC patients, even those with liver cirrhosis, laparoscopic hepatectomy is feasible. The learning period of laparoscopic hepatectomy may be overcome after 22nd patient experience.

Purpose: We evaluate the operative outcome and oncologic outcome of laparoscopic liver resection for hepatocellular carcinoma (HCC), and compare with open liver resection. Method: From January 2004 to December 2012, clinical data of 70 patients who underwent laparoscopic liver resection for HCC (Laparoscopic liver resection group, lapa-Group) were collected and analyzed retrospectively. Control group (Open liver resection group, opengroup) were retrospectively matched, and compared with lapa-group. Results: Laparoscopic major liver resections were performed in 4 patients. Laparoscopic anatomical resections and non-anatomical resections were performed in 39 patients, and 31 patients, respectively. Mean operative time was shorter in lapa-group (215.5 ± 121.84 minutes vs. 282.30 ± 80.34, p = 0.001), mean intraoperative transfusion volume was small in lapa-group (148.57 ± 3354.98 cc vs. 311.71 ± 477.01 cc). Open conversion was occurred in 6 patients (8.57 %) because of bleeding, inadequate resection, invisible mass on intraoperative ultrasonography, and tumor rupture. In lapa-group and open-group 3-year disease free survival rate (DFS) were 58.3 ± 0.08 %, and 62.6 ± 0.06 %, respectively (pvalue : 0.773). In lapa-group and open-group 3-year overall survival rate (OS) were 65.3 ± 0.8 %, and 65.7 ± 0.6 %, respectively (p-value : 0.610). Conclusion: Laparoscopic liver resection for HCC is feasible and safe in a large number of patients, with reasonable operative and oncologic results.

O153 - Liver and Biliary Tract Surgery

O155 - Liver and Biliary Tract Surgery

Postoperative Stress Response Indicators After Laparoscopic and Open Liver Resection (Experimental Study)

5- and 10-Years Outcomes After Laparoscopic Liver Resection of Colorectal Liver Metastasis: Predicted and Actual Survival

D.N. Panchenkov1, G.B. Aleksanyan1, N.K. Akhmatova2, D.A. Astakhov1, V.S. Chugunov1, A.A. Nechunaev1

˚ .A. Fretland, B.I. Røsok, L. Barkhatov, A.M. Kazaryan, A M. Shmavonyan, B. Edwin

1

Oslo University Hospital - Rikshospitalet Oslo, Norway, Oslo, Norway

A.I.Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia; 2I.I. Mechnikov Scientific Research Institute of Vaccines and Serums RAMS, Moscow, Russia Background: Components of the immune system affected after surgery in the majority of cases: the phagocytosis, humoral and cellular immunity, that leads to an increase of postoperative morbidity and mortality. Laparoscopic versus open surgery reduced surgical trauma, the inflammatory response and infectious complications and minimize immunosuppression. Numerous clinical studies have demonstrated a significant reduction postoperative pain, length of hospital stay, postoperative morbidity and recovery times. Currently, questions remain concerning laparoscopic liver surgery case of extensive resections and its benefits remains to be determined. Materials and Methods: The study consisted of 40 rabbits (Chinchilla), of mixed sexes, weighing up to 3 kg. Primary outcome measures - significant decrease stress response (immunological status of metabolic liver function) in laparoscopic techniques . Secondary outcome measures include immediate outcomes of surgical treatment, the life quality and survival. The experiment consists of two groups: primary (20) laparoscopic liver resection (extensive, ‘small’ wedge resections), the control group (20) : open liver resection (extensive, ‘small’ wedge resections) . Blood samples were collected before surgery, 4 hours after surgery, and 1, and 7 days after surgery. Leukocyte, neutrophil, IL- 1, IL- 2, IL - 6, IL -8, IL- 10, heat shock proteins, total leukocyte count, proliferative and cytotoxic activity of lymphocytes, phagocytic activity, bilirubin, AST, ALT were measured at each time point. Blood samples were taken from an ear vein. Procedures were performed under general anesthesia (Zoletil and Vetranquil at recommended doses). The control group: in a supine position, an incision across the right upper abdomen, below the ribcage. All rabbits underwent resection of the left liver lobe. Hemostasis was performed using bipolar coagulation. In the main group underwent laparoscopic liver resections using three trocars. Liver resections were performed in a supine position, using LigaSure 5 mm, staplers with vascular cartridge. Conclusion: Group with open liver resection had an increased stress indicators in postoperative period. The first results showed statistically significant minimization of stress response in groups with laparoscopic resection compared with open surgery. Further results during and after laparoscopic surgery should be further explored.

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Background: Laparoscopy seems to become a dominating approach to resect liver malignancies. However, long-term outcomes are poorly reported for this cohort of patients. The goal of this study is to compare predicted (calculated with Fong’s score and Basingstoke Predictive Index (BPI) and actual survival. Patients and Methods: During August 1998 and December 2013, 375 laparoscopic liver resections for colorectal liver metastasis were performed. Out of this amount, 100 patients had an observation time [ 5 years. 10 of them had previous open liver resection and were excluded, i.e. 90 patients with primary laparoscopic resection formed a ground of the study. Out of these patients 27 had an observation time [ 10 years. Median number of resected tumors was 1 (range 1–4), with bilobar distribution in 27 % and unilobar in 73 %. Median largest diameter of tumors was 32 mm (range 10–120 mm). Eight patients had extrahepatic metastasis at the time of liver resection (lung metastasis n = 5, omentum n = 1, peritoneal n = 1, and para aortal lymph node n = 1). Results: Median operating time was 189 min (range 41–550). Median peroperative blood loss - 400 ml (range 20 to 5000 ml). Median hospital stay - 3 days (range 1 to 26 days). R0 resection was performed in 88 % (79 of 90 cases). In 10 cases local ablation was performed as an additional procedure the same day or after few days. Mean preoperative BPI score was 6.2, predicting a 47 % 5-years survival. Mean Fong score was 1.8, predicting a 41 % 5-years survival. Actual 5-years survival was 52 %. Actual 10-years survival - 22 % (6 of 27 patients) Conclusion: Good correspondence between predicted and actual survival was found, however actual 5-years survival is better than predicted values based on BPI and Fong’s scores. Actual 10 year survival corresponds to the best values reported in the literature for open liver resection for colorectal liver metastases.

Surg Endosc

O156 - Liver and Biliary Tract Surgery

O158 - Liver and Biliary Tract Surgery

Ablation of Colorectal Liver Metastases by Irreversible Electroporation Results of the Coldfire-I Ablate-and-Resect Study

Totally Laparoscopic Right Donor Hepatectomy for Adult Living Donor Liver Transplant

K. Nielsen, H.J. Scheffer, A.A.J.M. van Tilborg, J.M. Vieveen, R.A. Bouwman, G. Kazemier, H.W.M. Niessen, S. Meijer, C. van Kuijk, M.R. Meijerink, M.P. van den Tol

K.H. Chen, S.D. Chen, J.M. Wu, Y.D. Chen, K.S. Jeng

VU University Medical Center, Amsterdam, The Netherlands Objectives: Irreversible electroporation (IRE) is a new, non-thermal ablation technique that relies on high-voltage electrical pulses. This clinical study evaluates the pathological response of colorectal liver metastases (CRLM) treated with IRE and the clinical safety and feasibility of the technique. Methods: Ten patients with resectable CRLM were included. Main exclusion criteria were cardiac arrhythmias and epilepsy. During laparotomy, the metastases were treated with IRE and resected 60 minutes later. Safety and feasibility were assessed based on adverse events, laboratory values, technical success and ultrasound confirmation of the ablation zone. Tissue response was assessed using triphenyl tetrazolium chloride (TTC) vitality staining and (immuno) histochemical stainings (HE, complement-3d and caspase-3). Results: Ten lesions with a mean diameter of 2.4 cm were successfully treated with IRE and resected, on average, 84 minutes later (range 51–153 minutes). One minor adverse event, a mild transient arrhythmia without hemodynamic consequences, occurred during IRE. Ultrasonography showed a sharply demarcated hypoechoic ablation zone around the tumor. TTC showed avitality of all lesions, covering the complete tumor in 8/10 lesions. Immunohistochemistry confirmed irreversible cell damage in and around the tumor. Conclusion: This ablate-and-resect study demonstrated physiological and immunohistochemical cell death caused by IRE of liver metastases of colorectal origin in humans. Future studies should focus on long-term effects and minimal invasive use of the technique.

Far Eastern Memorial Hospital, New taipei city, Taiwan Aims: To evaluate the feasibility of totally laparoscopic right donor hepatectomy for adult living donor liver transplantation. Methods: From March 2012 to October 2013, total 6 donors of adult living donor liver transplantation received totally laparoscopic right donor hepatectomy were collected. Surgical procedure: The donors were placed in modified lithotomy position, 5 trocar technique was used. The right hepatic artery and right portal vein were dissected. For grafts without MHV, branches larger than 5 mm in diameter will be preserved for reconstruction on the back table. Cryoperserved vascular allograft was used for reconstruction of branches and trunk of MHV in this series. The cut point of bile duct was determined by real time fluoroscopic intraoperative cholangiography. Then a Pfinestiel incision or extended umbilical wound was made. All vascular pedicles were divided. The graft was put in a retrieval bag and removed. Venoplasty for the right hepatic vein and reconstruction of the branches of middle hepatic vein were done on back table. Results: All donor operations were completed by pure laparoscopic approach. The mean age of the six donors were 27.5 years (19 * 39). The mean graft weight was 777 g (550 * 950). The mean graft to recipient weight ratio (GRWR) was 1.03 (0.84 * 1.43). Cryopreserved vascular graft was used for hepatic vein reconstruction in all six grafts. Three donors were found to have bile duct trification and needed intracoporeal bile duct plasty to close the left bile duct. The mean blood loss was 258 ml. (50–450). No donor needed blood transfusion during surgery. The operation time ranged from 385 min to 500 min (mean 445). The mean postop hospital stay was 9.5 days (6–15). There was no surgical complication except one wound hematoma. One recipient experienced duodenal ulcer bleeding and need endoscopic intervention. All recipients recovered well. There was no bile duct complication in recipients at follow-up of 6 months. Conclusion(s): Laparoscopic right donor hepatectomy is feasible in highly selected cases with current laparoscopic techniques. However, this approach involved complex expertise in living donor liver transplantation and advanced laparoscopic hepatobiliary surgery. It should be reserved for teams with appropriate experiences in both fields.

O157 - Liver and Biliary Tract Surgery

O159 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Versus Open Liver Resection for Colorectal Liver Metastases: A Single Centre Case-Matched Comparison

Are Caecal Photos Taken During Colonoscopy Accepted by Others as Evidence of Caecal Intubation?

S. Rehman, S.M. Robinson, S.K.P. John, J.J. French, R.M. Charnley, D.M. Manas, S.A. White

M. Salama, B. Meshkat, P. Ellanti, B. Sami, C. Buckley, I. Ahmed

Freeman Hospital Newcastle upon Tyne, Newcastle upon tyne, United Kingdom Introduction: Laparoscopic liver resection is increasingly utilised as an alternative to open surgery in patients with colorectal liver metastases. The aim of this study was to compare outcomes between these two approaches. Methods: All patients who underwent laparoscopic liver resection for colorectal metastases (n = 62) between August 2007 and August 2012 were identified and compared to a casematched control group (n = 68) undergoing open surgery. Data were analysed using nonparametric tests with median values presented. p \ 0.05 was considered significant. Results: The patient groups were well matched with regard to age, BMI, ASA grade, anaerobic threshold, maximum tumour size, extent of liver resection, and tumour number. 7 patients in the laparoscopic group were converted to an open approach. As compared to open surgery a laparoscopic approach was associated with a lower blood loss (280 mls vs. 458 mls; p \ 0.001) and shorter hospital stay (5 vs. 9 days; p \ 0.001). There was no difference with regard to operating time (250 vs. 282minutes, p = 0.128) and the presence of a positive resection margin (11 % vs. 16 %; p = 0.488). The overall complication rate (11 % vs. 14 %; p = 0.40) and thirty-day mortality were also similar (n = 0 vs. n = 1; p = 0.178). Recurrence free survival (14 vs. 14 months; p = 0.178) and over survival (42 vs. 44 months; p = 0.503) were comparable. The 3 year overall survival was identical in both groups (72 %; p = 0.53). Conclusion: A laparoscopic approach to liver resection can be utilised in appropriately selected patients with colorectal liver metastases without compromise to either immediate perioperative outcomes or medium term patient survival.

Our Lady of Lourdes Hospital, Drogheda, co. louth, Ireland Introduction: Caecal intubation rate is an important part of quality control for colonoscopies. Photographic evidence of caecum is often used as evidence of caecal intubation. Aims: To evaluate whether caecal photographs taken during colonoscopy to confirm caecal intubation by the endoscopist can be used as reliable tool to convince others as a photographic evidence of completion of the colonoscopy. Methods: One hundred consecutive colonoscopies (we plan to recruit 500 cases) to the caecum confirmed by photographic evidence were prospectively followed and copies of the caecal photograph made. These colonoscopies were performed by five surgeons and two gastroenterologists. The copies of caecal photographs were subsequently sent to two separate reviewers for rating. Both reviewers have the experience of performing more than 2000 colonoscopies. A three point Likert scale was used (1 = definitely caecum, 2 = likely caecum, 3 = unlikely caecum) for rating by the reviewers who were blinded, and did not know the identity of the endoscopist and the results of the other reviewers rating of the photograph. 10 photographs were repeated and shown to the reviewers for the second time to see whether they change their rating when challenged again with the same photo. Results: First reviewer identified 35 % of photographs as definitely caecum, 60 % as likely caecum and 5 % as unlikely caecum while second reviewer identified 72 % as definitely caecum, 19 % as likely caecum and 9 % unlikely caecum. There was only a 46 % correlation rate between the reviewers. The majority of correlation between reviewers were photographs thought to be definitely caecum at 67 % (n = 31), followed by 30 % (n = 14) which were thought likely caecum and the remaining 2 % (n = 1) thought to be unlikely caecum. There was no change in opinion by both reviewers on any of the photos shown for the second time. Conclusion: Our initial result on the first 100 cases shows there is great variation in interpretation of an isolated photograph of what the endoscopist believes to be the caecum. The photograph taken by the endoscopist as the caecum may not convince the others at a later stage as a proof of completion of colonoscopy.

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Surg Endosc

O160 - Intestinal, Colorectal and Anal Disorders

O162 - Intestinal, Colorectal and Anal Disorders

Intraocular Pressure Variation During Colorectal Laparoscopic Surgery: Standard Pneumoperitoneum Leads to Reversible Elevation in Intraocular Pressure

Impact of Splenic Flexure Mobilization in Laparoscopic Colectomy

A. Grosso1, G. Scozzari2, F. Bert2, E. Galietti2, M.E. Allaix2, R. Siliquini2, C. Panico1, M. Morino2, J. Crowston3

A. Sanchez Ruiz, E. Grzona, M. Bun, A. Canelas, M. Laporte, C. Peczan, N. Rotholtz, S. Guckenheimer Hospital Alema´n, Buenos aires, Argentina

1

Torino Eye Hospital, Torino, Italy; 2University of Torino, Torino, Italy; 3University of Melbourne, Melbourne, Australia Aims: Intraocular pressure (IOP) may rise during laparoscopic colorectal surgery (LCR), particularly when a Trendelenburg position is necessary. Surprisingly, in some patients the IOP persists elevated for several months after surgery. This study aimed to evaluate the potential fluctuations of IOP during colorectal laparoscopic surgery Methods: For this prospective study 45- to 85-year-old patients undergoing LCR were enrolled after a thorough ophthalmologic assessment. The study protocol included measurement of IOP before, during, and after surgery using a contact tonometer (Icare, Finland) in both eyes. Results: The study enrolled 29 patients: 17 (58.6 %) with Trendelenburg position placement during surgery and 12 (41.4 %) without Trendelenburg positioning. The two groups did not differ in terms of gender, age, body mass index (BMI), American Society of Anesthesiology (ASA) class, or operative time. In all the patients, pneumoperitoneum induction led to a mild rise in IOP, averaging 4.1 mmHg. The patients with Trendelenburg positioning showed a greater increase than the patients without it (5.05 vs 4.23 mmHg at 45 min; p = 0.179), but IOP evaluation 48 h after surgery showed no substantial differences between the two groups. Among the 29 patients, 17 (58.6 %) showed an increase in IOP of 5 mmHg or more during surgery. A greater percentage of the patients who underwent Trendelenburg positioning showed an IOP increase of 5 mmHg or more (76.5 vs 33.3 %; p = 0.020). At the multivariate analysis, no potential predictors of increased IOP during surgery was identified. Conclusions: Standard pneumoperitoneum (B14 mmHg) led to mild and reversible IOP increases. A trend was observed toward a greater IOP increase in patients with Trendelenburg positioning. Thus, the patient’s position during surgery may represent a stronger risk factor for IOP increase than pneumoperitoneum-related intraabdominal pressure.

Aims: To evaluate the outcomes asociated with splenic flexure mobilization (SFM). Methods: A retrospective analysis on patients who underwent procedures that potentially required SFM over a 12 year period was performed. The series was divided into three groups: left colectomy (LC), sigmoidectomy (S) and low anterior resection (LAR). These were also divided in those with (LC1; S1; LAR1) or without (LC2; S2; LAR2) SFM. Surgical time, morbidity, anastomotic leak rate, hospital length of stay, bowel recovery, number of lymph nodes retrieved and length of the specimen were analyzed. Results: Over1076 laparoscopic colorectal surgeries performed 593 were procedures with potential SFM. In 359 (60.5 %) of cases the SFM was not performed. Subgroups were distributed as follows: LC1: 161 (27.1 %); S1: 326 (55 %); LAR1: 106 (17.9 %); LC2: 118 (73 %); S2: 69 (21.3 %); and LAR2: 47 (44.3 %). LC2 had a longer operative time; more intraoperative complications, fewer lymph nodes retrieved and increased length of the specimen. There were no differences in the anastomotic leak rates. In the S group, longer operative time was found in subgroup S2. LAR2 had longer operative time and specimens; but the number of lymph nodes removed was lower compared with LAR1. No differences in the leak rate were found between groups. Conclusions: SFM increases surgical time and intraoperative complications without reducing the risk of anastomotic leak. Based on these findings SFM should not be carried out routinely.

O161 - Intestinal, Colorectal and Anal Disorders

O163 - Intestinal, Colorectal and Anal Disorders

Sentinel Lymph Node Identification with a Fluorescent Dye in Colorectal Cancer; One Step Closer to an Accurate Intraoperative Detection Technique

Short-Term Result of Reduced Port Surgery by Colon Lifting Technique in Colorectal Cancer

M. Ankersmit, J.W.J. de Haan, M.A.J.M. Jacobs, N.C.T. Grieken van, J.B. Tuynman, W.J.H.J. Meijerink

S. Fujii, Y. Fukushima, T. Akahane, A. Horiuchi, K. Nakamura, T. Hayama, H. Yamada, T. Tsuchiya, K. Nozawa, K. Matsuda, Y. Hashiguchi

VUmc, Amsterdam, The Netherlands

Teikyo University School of Medicine, Tokyo, Japan

Aims: One of the major problems of SLN mapping in colorectal cancer is the lack of an optimal dye and technique for identification of the nodes. In this study we used the NearInfrared (NIR) dye Indocyanin Green (ICG) to identify nodes with a newly developed NIR laparoscope. We compared two different injection techniques; subserosal and submucosal injection. Methods: Patients planned for a laparoscopic resection of a colorectal carcinoma without distant metastases were included. Dye was injected in the subserosa or submucosa of the bowel. Ten minutes after injection we searched for fluorescent nodes with the NIR laparoscope. Fluorescent nodes were harvested and analyzed by the pathologist using H&E and additional immunohistochemistry. Results: In total 25 patients were included. The dye was injected in the subserosa in 14 patients and in the submucosa in 13 patients. In all patients that were injected in the subserosa, we identified at least one fluorescent node, non of which was positive for metastases. In 4/14 patients, non-fluorescent regional nodes were positive for metastases. Using the submucosal injection technique, 9/13 patients showed at least one fluorescent node, in 6 patients these were negative for metastases. Of the remaining three patients, the fluorescent lymph was positive for metastasis in one. Another node, negative on fluorescence but positive for metastasis, was identified in that same patient. In the other two patients, fluorescent positive nodes contained isolated tumour cells as only indication of metastatic disease. In 1/13 we could not identify fluorescent nodes probably because of a fatty mesentery. In 3/13 we did not identify the true SLN. The lymph nodes which contained the metastatic disease were large and greatly involved. Conclusion: Laparoscopic identification of the SLN in colorectal cancer seems possible by using the NIR-dye ICG. The submucosal dye administration appears a promising technique in the identification of colorectal lymph nodes. A future study will focus on combining a fluorescent dye with a radioactive tracer to improve tissue penetration, to enable preoperative visualization of the SLN and thereby detectability during the operation.

Background: Reduced Port Surgery (RPS) is a promising procedure in view of minimuminvasiveness and cosmesis. However, it often requires the device to keep counter traction and operative view in order to accomplish both a radical cure and safety. Purpose: To show the technique and short-term outcomes of Colon Lifting Technique (CLT) in RPS Procedure: The platform for the single port is installed at the umbilicus. The string is induced to the abdominal cavity, and penetrates to the mesocolon. It is lifted up anteriorly and is fixed to the abdominal wall in order to give tension to the main feeding artery. Sufficient counter traction is obtained, and allows for an easier lymphadenectomy around the main feeding vessels. Interference with the laparoscope can be avoided by use of curved forceps. Vessel sealing system is useful as an energy device, because it has low mist generation. One port is added to insert the abdominal drainage tube in the rectal cancer. [Indication] The tumor size \ 4 cm and Clinical T1-4a Result: RPS was performed on 76 patients in 2009–2014. The single port procedure was performed on 67 patients and a two port procedure was performed on 7 patients. Tumor sites were; 31 right, 1 transverse, 29 left colon, and 15 rectum. The details of procedure consisted of 32 right colectomies, 27 left colectomies, 1 left and right colectomy, 9 anterior resections of rectum, 6 intersphincteric resection, and 1 total colectomy. The mean operation time was 184 min (114–417). The mean blood loss was 22 ml (5–145). There was no conversion to open surgery. There were two patients that required one extra port. The complications of Grade 2 or more occurred in 9 patients (11.8 %). The complication of Grade 3b or more was none. The mean postoperative stay was 7 days (5–45). The mean number of dissected lymph nodes was 23.6 (8–94). All pathological cut margins were negative Conclusion: RPS in the colorectal cancer was able to be performed safely without deterioration of the radical cure by use of CLT. CLT is a useful procedure in RPS.

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Surg Endosc

O164 - Different Endoscopic Approaches

O166 - Intestinal, Colorectal and Anal Disorders

Needlescopic Versus Conventional Laparoscopic Surgery For Colorectal Cancer: A Comparative Study

Efficacy of Endo-VAC Therapy for the Treatment of Colorectal Post-Surgical Leaks

M. Tsuruta, H. Hasegawa, Y. Ishii, K. Okabayashi, M. Yahagi, Y. Kitagawa

A. Arezzo, M. Verra, A. Salvai, L. Rapetti, M. Morino

Keio university school of medicine, Tokyo, Japan Introduction: Laparoscopic surgery (LS) has been already accepted as a basic strategy for almost all stage of colorectal cancer (CRC). Recently, reduced port surgery or single incision LS have been reported to achieve less invasiveness and better cosmetics in this field, though long-term outcome or educational task are controversial due to their technical hurdle. Instead, needlescopic surgery (NS) is expected to overcome such problems and to be an alternative to conventional multiport LS (MPS) for CRC. Aims: The aim of this study is to manifest whether NS is comparable in terms of surgical outcome to conventional MPS for CRC. Patients and Methods: Our institution opted 2 mm needle forceps in July, 2012. Basically we performed 5 ports methods with 3.5 cm umbilical incision for extraction and reconstruction in MPS for CRC. One or two 5 mm ports were exchanged to 2 mm needle forceps following induction of NS while all surgical procedure was same as previous MPS. We investigated short-term outcome of consecutive 80 patients who underwent curative resection of CRC by NS (July, 2012 - September, 2013) and consecutive 80 CRC patients by MPS before then (January, 2011 - June, 2012). Results: Baseline clinicopathological characters are similar between two groups except for clinical stage. NS group significantly included more patients with CRC below submucosal invasion comparing to MPS, though there was no difference of the maximum size of the tumor (3.8 vs 3.6 cm). Operative time and blood loss in NS group were comparable to MPS group (282 vs 280 min p = 0.8553, 42.7 vs 53.2 ml p = 0.3951), and NS group showed shorter postoperative hospital stay significantly (9.8 vs 12.4 days, p = 0.0341). The average number of dissected lymph nodes were 34 in both groups (p = 0.9620). No mortality was occurred in both groups and similar morbidity and conversion rate were observed (8.75 vs 12.5 % p = 0.4415, 1.25 vs 7.50 % p = 0.053). Conclusions: NS is a feasible and secure procedure with preserving surgical quality comparing to conventional MPS for CRC. Further prospective randomized studies are required to confirm long-term oncologic outcome and satisfaction of the patients.

Department of Surgical Sciences, University of Torino, Torino, Italy Background: Post-surgical leaks are a significant complication after colorectal surgery with high morbidity and mortality. Aims: of this study was to evaluate the efficacy of Endo-VAC therapy in the treatment of colorectal post-surgical leaks. Methods: We reviewed our personal series of post-surgical colorectal leaks treated with Endo-VAC therapy. Indications were all cases of acute or chronic leak in the presence of extraluminal abscess. The presence of generalized peritonitis or haemodynamically unstable patient was considered a contraindication to endoscopic treatment. Results: Endo-VAC therapy was applied in 14 patients with colorectal leak that occurred, in almost all cases, after rectal anterior resection. Two cases were complicated by rectovaginal fistula. Overall success rate of Endo-VAC therapy was 79 % (11/14). Success rate was 90 % (9/10) in acute leaks (\ 60 days) and 50 % (2/4) in chronic leaks, 100 % (8/8) in patients with derivative stoma and 50 % (3/6) in patients without stoma (P = 0.02), 71 % (5/7) after neoadjuvant radiotherapy while 86 % (6/7) in preoperatively untreated patients. An average of 16 sessions per treatment were needed. No complication related to endoVAC therapy was observed. Further surgery was required in the 3 cases of non-success of endoscopic treatment. Conclusion: Endo-VAC therapy in the treatment of post-surgical leaks is a safe technique, with hight success rate in particular in presence of a derivative stoma. Chronic leaks represent a challenge, while neoadjuvant radiotherapy does not seem to represent a risk factor for failure.

O165 - Abdominal Cavity and Abdominal Wall

O167 - Intestinal, Colorectal and Anal Disorders

Self-Expanding Metal Stent for Acute Colonic Obstruction as a Bridge to Elective Surgery for Colorectal Cancer: Our Experience in a Single Italian Centre

Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) with Oxaliplatin as a Salvage Therapy in Patients with Peritoneal Carcinomatosis of Colorectal Cancer

P. Petronio1, T. Torricelli2, S. Bertozzi3, A.P. Londero3, I. Citro4, D. Capizzi4, A. Balani1

A. Reymond, W. Solass, U. Giger-Pabst, D. Strumberg, J. Zieren

Hospitals of Monfalcone and Gorizia, Italy; 2Hospital of Monfalcone, Italy; 3University of Udine, Italy; 4Hospital of Gorizia, Italy

Ruhr-University Bochum, Herne, Germany

1

Background: Placement of a self-expanding metal stent (SEMS) in patients presenting with malignant acute bowel obstruction results safe and efficace in reducing emergency surgery rates, as either a palliative measure or as a bridge to subsequent resection. We reviewed our experience with SEMS in a single Italian centre. Methods: We retrospectively collected data about patients recovered for malignant acute bowel obstruction in our Department of Surgery between 2005 and 2013, focusing on patients and tumor characteristics, technical and clinical success of SEMS positioning, eventual neoadjuvant treatments, timing and type of eventual surgical intervention. Data was analyzed by R (v. 3.0.1) considering significant p \ 0.05. Results: In the considered period we placed SEMS in 51 patients. SEMS placement resulted technically and clinically successful repectively in 96.1 % (49/51) and 80.4 % (41/ 51) of cases, with a prevalence of complications of 9.8 % of cases (5/51). Elective surgery was achieved in the 47.1 % (24/51) of cases, whereas 15.7 % (8/51) of patients underwent anyway emergency decompression surgery, and 37.3 % (19/51) were considered unoperable. Median time to surgery was 16 days (2–24). Laparoscopic surgery in case of planned or urgent intervention was achieved respectively in the 66.7 % (16/24) and 37.5 % (3/8) of patients. Overall survival resulted 61.1 % (95 % CI 48.8–76.5 %) at 1 year and 38.4 % (95 % CI 26.2–56.4 %) at 5 years. In the group treated with laparoscopy 5 years overall survival was 71.3 % (95 % CI 52.9–96.2 %), while in the group treated with laparotomy was 35.9 % (95 % CI 13.9–92.9 %). Conclusions: In patients presenting with malignant acute bowel obstruction, planned interventions rate was increased by SEMS placement, especially in case of clinical success and in the absence of endoscopic complications. Anyway, overall survival was very low in case of laparotomic or palliative interventions, suggesting a major influence of tumor characteristics on the prognosis rather than SEMS placement success.

Introduction: Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) is a laparoscopic procedure delivering chemotherapy directly into the closed abdomen as an aerosol under pressure. Promising preliminary results in ovarian and gastric cancer with cisplatin and doxorubicin have been published. First results obtained with PIPAC in platin-resistant PC from colorectal cancer (CRC) are now presented. Methods: From 9.8.2012, 34 PIPAC procedures were performed in 19 consecutive patients with PC from CRC within an authorized compassionate use program. All but 2 patients had received previous platin-based systemic chemotherapy (SC). No patient was a candidate for cytoreductive surgery (CRS) and HIPEC. Mean age was 59 ± 13 years. Karnofsky-Index was 83 ± 20 %. Mean PCI was 18 ± 12. Patients were followed-up until 4.9.2013 or death. Tumor response was assessed with Peritoneal Carcinomatosis Index (PCI) and with histology. Oxaliplatin 92 mg/m2 body surface was applied at 12 mmHg and 37 ± C for 30 min. When possible, PIPAC was repeated q6 weeks. Results: In 2/19 patients, no access was possible due to adhesions. One access lesion was immediately repaired. Mean operating time was 86 min (PIPAC alone). PIPAC could be repeated in 10/17 patients (4x PIPAC: n = 1 patient; 3x: n = 5: 2x: n = 4). Two patients had combined CRS and PIPAC, one of which developed postoperative gastric perforation and bowel obstruction. Four further adverse events CTCAE [ 2 were registered (1x abdominal pain, 3x vomiting). Hospital mortality was zero. Out of 10 patients with repeated PIPAC, 4 showed complete tumor remission (CR), 3 high-grade tumor remission (PR) and one stable disease. Fourteen patients are alive. Overall survival after 271 days is 69,9 %, median survival has not been reached yet. Conclusion: Oxaliplatin-based PIPAC can induce regression of platin-resistant PC from CRC. Clinical Benefit Rate (CBR) was 8/10 in this first series of patients. PIPAC is very well tolerated but should not be combined with CRS. These preliminary results appear promising and confirm similar results of PIPAC in ovarian and gastric cancer. Efficacy of PIPAC with oxaliplatin in CRC and PC will now be investigated in a prospective trial.

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Surg Endosc

O168 - Oesophageal and Oesophagogastric Junction Disorder

O170 - Oesophageal and Oesophagogastric Junction Disorder

Audit of Revision Anti-Reflux Surgery

Laparoscopic Repair of Voluminous Symptomatic Hiatal Hernia Using Absorbable Synthetic Mesh: An Initial Experience with A Medium-Term Follow-Up

E. Folaranmi, A. Shrestha, S. Green, B. Darmas, B. Decadt Stockport NHS Foundation Trust, Salford, United Kingdom Objective: To determine whether the outcomes of revision anti-reflux surgery at our institution met the standards set by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Method: Casenotes of patients that underwent revision anti-reflux surgery between January 2007 and January 2014 were reviewed. Data was collected with a standard proforma. The primary outcome measures were: 30-day mortality (\ 1 %) and recurrence of reflux symptoms at 3 months (13 %). The secondary outcomes were: Postoperative dysphagia (3–17 %), Oesophagogastric perforations (11–25 %), Pneumothorax (7–18 %), Splenic injuries (2 %), Gas bloat syndrome (5–34 %), and Vagal nerve injuries (7 %). All patients were included in the data analysis Results: 215 anti-reflux procedures were performed from January 2007 - January 2014. 24 patients underwent revision anti-reflux surgery. In terms of the primary outcomes, the 30-day mortality was 0 % and the recurrence of reflux symptoms at 3 months was 4.1 %. In terms of the secondary outcomes, postoperative dysphagia occurred in 8.3 %. All other secondary outcomes were 0 %. Six patients underwent 2 revision anti-reflux procedures and 1 underwent 3 revision anti-reflux procedures. Four patients underwent a laparoscopic Collis gastroplasty as part of their revision surgery. The median length of follow-up was 7 months (range 2 months - 60 months). Conclusion: Revision anti-reflux surgery can be safely performed at a district general hospital, provided high volumes of anti-reflux surgeries are performed at this centre.

M. Berselli, L. Livraghi, L. Latham, L. Farassino, M. Parravicini, S. Segato, E. Cocozza Azienda Ospedaliera Ospedale di Circolo e Fondazione Macchi, Varese, Italy Aims: Repairing of voluminous hiatal hernias is still a controversial surgical topic. If patients begin symptomatic the surgical approach can be considered. The use of mesh reinforcement is suggested to avoid recurrence. An initial experience in the use of Absorbable Glycolic Acid/Trimethylene Carbonate Synthetic Mesh for laparoscopic voluminous hiatal hernia repair is reported. A medium-term follow-up analysis is performed. Methods: A retrospective analysis of voluminous (type III and IV) hiatal hernia repair from January 2010 to November 2013 was performed. The perioperative data and the follow-up were analyzed. After trocars placement and reduction of the hernia content the sac resection was performed. An adequate intraabdominal esophageal length was ascertained and a hiatoplasty was done. A 7 x 10 cm mesh was placed around the distal aesophagus and fixed via absorbable sticks and fibrin glue. A fundoplication (Nissen or Toupe) was finally carried out. In the second or third postoperative day a X-ray Gastrografin swallow was performed, the naso-gastric tube was removed and the oral intake was restarted. Results: Eight patients underwent hiatal hernia repair via the use of Absorbable Glycolic Acid/ Trimethylene Carbonate Synthetic Mesh. The median age and Body-Mass-Index were respectively 76,5 years and 26. The median operative time was 159 minutes. In one patient a contemporary colecistectomy was performed. A Nissen or Toupet fundoplication was performed respectively in 7 and 1 patients. All the defect sites were larger than five centimeters at intraoperative measurement. No postoperative morbidity or mortality occurred. With a median follow-up was of 17 months (range 10–37) no symptomatic recurrence occurred and all the patients are in good health. In a 80 years old female patient with preoperative history of giant hiatal hernia and recurrent pneumonia a little and asymptomatic recurrence was detected 12 months after surgery. Conclusions: Voluminous symptomatic hiatal hernias can be successfully treated with a low surgical impact in an experienced laparoscopic surgical centre. The use of an absorbable synthetic mesh can guarantee a low recurrence rate with hiatal continence avoiding the short and long-term risk of a traditional prosthesis. Further studies are necessary to confirm this and other few preliminary reports

O169 - Oesophageal and Oesophagogastric Junction Disorder

O171 - Oesophageal and Oesophagogastric Junction Disorder

Comparison of 2 Suturing Devices for the Endolumenal Treatment of Gastroesophageal Reflux Disease

New Method: Of Laparoscopic Repair of Giant Hiatal Hernias

G.S. Spaun, O. Koch, K. Emmanuel Sisters of Charity Linz, Linz, Austria Aims: One of the most promising devices (NDO plicator) for endoscopic treatment of gastroesophageal reflux disease (GERD) has vanished off the market. A new device (GerdX) for endoscopic suturing has been introduced, which uses the same concept of non absorbable expanded polytetrafluoroethylene (ePTFE) augmented pretied sutures. The aim of this study was to investigate the differences between the two systems and compare clinical use of the two devices. Methods: We tested the NDO plicator and the GerdX suturing device in a bench top comparison and report clinical experience in 12 patients using both systems. Symptomatic reflux patients qualified for the endolumenal procedure when presenting a Hill Grade 2 and 3 valve endoscopically, Hill Grade 4 was excluded. Pathologic findings in high resolution manometry and impedance pH measurement have been documented in all patients. The clinical usability was compared using a questionnaire and early outcome is reported using Hill Grading 1 to 4 for the gastro-esophageal valve. Constructive differences were documented. Results: 12 patients have been operated endoscopically for GERD, 5 with the NDO device, 7 with the GerdX. Mortality was nil. Morbidity was 1/12 (8,3 %), one patient developed pneumonia (Clavien Dindo Grade 2) and was treated successfully with antibiotics. Procedure time, blood loss, pain medication, patient satisfaction was similar. Two patients (16,7 %) presented Hill Grade 4 valve 6 weeks after the endolumenal procedure. One underwent uneventful laparoscopic Toupet fundoplication. The bench top comparison revealed differences in design: The working length of the GerdX is 18 % (850 mm vs 720 mm) increased, shaft diameter is 21,5 % (15,8 mm vs 19,2 mm) less, suture angle is 127 % steeper (25°vs 11°), opening angle is 28,6 % less (70° vs 90°). Both systems use non-absorbable monofilament sutures with 4 mm suture length between pledgets. Conclusions: The GerdX device can be used safely for the endoscopic treatment of GERD similar to the NDO plicator which is not longer commercially available. Changes in design are not hindering clinical and experimental performance. The first use of microhydraulics in an endoscopic device may overcome transmission losses seen with mechanical transmission of forces through endoscope channels.

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A.V. Malynovskyi, V.V. Grubnik Odessa national medical university, Odessa, Ukraine Introduction: Current techniques of laparoscopic mesh repair of giant hiatal hernias are not effective as rate of recurrence reach 40 %. Thus, creation of fundamentally new methods of prosthetic hiatal repair is necessary. The aim of the study was to assess mid-term results of laparoscopic tension-free repair of giant hiatal hernias with a new prosthesis. Methods: From 2010 to 2013, 44 laparoscopic repairs of giant hiatal hernias were performed. From them, 42 patients were followed within mean period of 17,8 ± 4,4 months (range 10–27) using questionnaires, barium study, endoscopic examinations, and 24 h pH testing. Mean hiatal surface area (HSA) was 37,5 ± 15,6 cm2 (range 21,7–75,4). Posterior tension-free hiatal repair was performed with new prosthesis - Rebound HRD-Hiatus hernia (Minnesota Medical Development, Inc.) which was fixed to crura with 3–5 separated sutures. The prosthesis is heart-shaped lightweight polytetrafluorethylene (PTFE) mesh with peripheral nitinol frame. Key advantages of this revolutionary technique are: 1. Peripheral nitinol frame maintain week tissues of the diaphragm, and, thus, prevents recurrence, 2. Easy fixation, 3. Small risk of oesophageal complications as prosthesis is made from new generation of lightweight PTFE. Results:All procedures were successfully completed. Mean time of fixation of the prosthesis was 24,8 ± 5,6 min (range 15–35). There were no intra-operative complications associated with the repair. There were 2 symptomatic reflux recurrences (4,7 %), and 3 false anatomical recurrences (7,1 %). True anatomical recurrences, and oesophageal strictures and erosions were absent. Conclusion: This fundamentally new method of laparoscopic repair of giant hiatal hernias is safe and provides absence of true anatomical recurrences in mid-term follow-up period. It apparently requires thorough assessment in long-term follow-up period, with further comparison with other techniques including randomized controlled trials.

Surg Endosc

O172 - Oesophageal and Oesophagogastric Junction Disorder Intraoperative Manometric Validation in Laparoscopic Achalasia Surgery T. Kanemura, K. Nakajima, Y. Miyazaki, T. Takahashi, Y. Kurokawa, M. Yamasaki, H. Miyata, S. Takiguchi, M. Mori, Y. Doki Osaka university graduate school of medicine, Osaka, Japan Background: Achalasia is a rare disorder which presents various clinical features and its etiology is still unknown. Extramucosal myotomy is the procedure of choice for achalasia, either by laparoscopy, or most recently, by flexible endoscopy. In any approach, full reduction of sphincteric high pressure zone (HPZ) is crucial. This step, however, has been validated only by visual confirmation of ‘adequate’ mucosal bulging. No objective parameters have been available to validate myotomy process during achalasia surgery. We have employed computer-mediated intraoperative manometry (IM) in laparoscopic Heller-Dor surgery (LHD). Aims: To review its detailed data, and to evaluate potential effectiveness of manometric validation of HPZ reduction in improving clinical outcomes of LHD. Methods: A retrospective analysis was conducted on 35 consecutive achalasia patients who underwent LHD between 1998 and 2013. Surgery was performed with five-port approach in early 22 cases and with single-incision approach in recent 13 cases. The data included patient demographics, IM measurements, and postoperative outcomes including manometric and endoscopic follow-up results IM was performed after completion of each procedural step: (1) induction of general anesthesia, (2) establishment of pneumoperitoneum, (3) esophageal mobilization, (4) Heller myotomy, and (5) Dor anterior fundoplication. A flexible 8-lumen tube was used under endoscopic guidance. The obtained pressure data were processed and presented as pressure vector volume (PVV), which represents sphincteric resistance consisted of circumferential pressures (mmHg) and length of HPZ (cm). Results: The baseline PVV after induction of general anesthesia was 2836 ± 2325 cm*mmHg2. The PVV increased significantly after establishment of pneumoperitoneum (3468 ± 2481 cm*mmHg2, p = 0.0325), and decreased after esophageal mobilization (2107 ± 1860 cm* mmHg2, p = 0.0002). The PVV further decreased after myotomy (396 ± 215 cm*mmHg2, p \ 0.0001), then recovered after fundoplication (601 ± 428 cm*mmHg2, p = 0.009). The overall reduction of PVV was 81.8 %. All patients showed relief of their clinical symptoms postoperatively, except for one case with residual passage disturbance. Postoperative manometric and endoscopic follow-up results were satisfactory and compatible to their clinical course. Conclusions: The reduction of PVV [ 80 % was considered reasonable and clinically acceptable as objective indicator of successful HPZ reduction. IM with PVV measurement might be effective in standardizing myotomy process, and in improving clinical outcomes of any type of achalasia surgery.

O173 - Oesophageal and Oesophagogastric Junction Disorder Long-Term Results of the Heller-Dor Operation for the Treatment of Oesophageal Achalasia S. Mattioli1, N. Daddi2, A. Ruffato1, M. Lugaresi1, O. Perrone1, S. Mattioli1 University of Bologna, Italy; 2Division of Thoracic Surgery University of Perugia, Italy

1

Objective: Quality of outcome of the Heller-Dor operation is sometimes different between studies, likely because of technical reasons. We analyze the details of myotomy and fundoplication in relation to the results achieved over a 30-year single center’s experience. Methods: From 1979–2008, a long oesophagogastric myotomy and a partial anterior fundoplication to protect the surface of the myotomy was routinely performed with intraoperative manometry in 202 patients (97 men; median age, 55.5 years; interquartile range 43.7–71 years) through a laparotomy and in 60 patients (24 men; median age,46 years; interquartile range 36.2–63 years) through a laparoscopy. The follow-up consisted of periodical interview, endoscopy, and barium swallow, and a semiquantitative scale was used to grade results. Results: Mortality was 1 of 202 in the laparotomy group and 0 of 60 in the laparoscopy group. Median follow-up was 96 months (interquartile range 48–190.5 months) in the laparotomy group and 48 months (interquartile range 27–69.5 months) in the laparoscopy group. At intraoperative manometry, complete abolition of the high-pressure zone was obtained in 100 %. The Dor-related high-pressure zone length and mean pressure were 4.5 ± 0.4 cm and 13.3 ± 2.2 mm Hg in the laparotomy group and 4.5 ± 0.5 cm and 13.2 ± 2.2 mm Hg in the laparoscopy group (P = .75). In the laparotomy group poor results (19/201 [9.5 %]) were secondary to oesophagitis in 15 (7.5 %) of 201 patients (in 2 patients after 184 and 252 months, respectively) and to recurrent dysphagia in 4 (2 %) of 201 patients, all with end-stage sigmoid achalasia. In the laparoscopy group 2 (3.3 %) of 60 had esophagitis. Conclusions: A long oesophagogastric myotomy protected by means of Dor fundoplication cures or substantially reduces dysphagia in the great majority of patients affected by oesophageal achalasia and effectively controls postoperative oesophagitis. Intraoperative manometry is likely the key factor for achieving the reported results.

O175 - Oesophageal Malignancies Video-Assisted Thoracoscopic Esophagectomy for Esophageal Cancer K. Otsuka Showa University, Tokyo, Japan Introduction: To evaluate the safety and efficacy of video-assisted thoracoscopic esophagectomy (VATS-E) in esophageal cancer. Method: From November 1996 to December 2013, 650 patients with intrathoracic esophageal cancer, excluding T4 cancers, underwent thoracoscopic and video-assisted radical esophagectomy (595 squamous cell carcinoma, 47 adeno, 5 adeno-squamous, 3 small cell). Operation method) Position is lt lateral position. 5 ports were inserted through the thoracic cavity (2 ports were 12 mm and 3 ports were 5 mm size.) Pneumothorax was kept at 8 mmHg using CO2 insufflation. Result: There were 462 men and 188 women. Median age was 65.2 years (range 42 to 93 years). Tumor location was in upper intrathoracic esophagus in 145 patients, the middle intrathoracic esophagus in 358, lower intrathoracic esophagus in 147. There were 3 conversion to open method by bleeding. Median ICU stay was 1.6 day (range 1 to 15 days) and median hospital stay was 15 ± 11 days. The mean volume of blood loss was 121 ± 88 ml, mean thoracoscopic surgery duration 188 ± 51 min. The mean number of lymph nodes dissected through thoracoscopy was 28 ± 14. Seven patients died within 30 days after surgery (1.1 %). Early postoperative complications included recurrent laryngeal nerve palsy 5 %, leak 3.6 % (Recent 4 years 0.6 %), and respiratory infection 4.7 %. There was one incidence of tracheal injury. At mean followup of 43 months (range 1 to 204 months), stage-specific survival was similar to open method. Conclusion: VATS-E is technically feasible, with a low incidence of respiratory complications and less blood loss. Our surgical experience with thoracoscopic and video-assisted esophagectomy indicate that it is a feasible and useful procedure.

O176 - Oesophageal Malignancies Short Term Results of Hybrid and Totally Minimally Invasive Esophagectomy: Should We Modify Our Indications? A. Melis, U. Fumagalli, M. Porta, F. Puccetti, R. Rosati Humanitas Research Hospital, Rozzano, Italy Aims: good postoperative results have been reported after totally minimally invasive esophagectomy (MIE) for cancer; in some case, surgeons have consequently proposed a more frequent use of MIE independent of tumor site and stage. We consider MIE for supracarinal tumors thus performing an extended nodal dissection in the upper mediastinum; infracarinal tumors are mainly treated with hybrid esophagectomy (laparoscopy/thoracotomy - HE). Aims of this work is to compare the short term results of HE and MIE in our latest experience to see if the results of MIE should prompt a change of indications. Methods: between November 2011 and November 2013, out of 117 patients submitted to esophagectomy with gastric pull-up, 73 and 14 patients underwent HE and MIE respectively. Our prospective database was reviewed to analyze operative results, postoperative morbidity and mortality rates after HE and MIE. Results: The two groups differed for tumor characteristics; patients in the two groups had similar age and rate of R0 resection. Operative time (mean 297 minutes vs 329), intensive care unit stay and length of hospitalization (mean 14 days vs 29) were longer for MIE. Patients submitted to HE had lower rate of relevant postoperative complication (pneumonia, recurrent nerve palsy, atrial fibrillation, anastomotic leak) (12,2 % vs 43 %) and mortality (1,36 % vs 14.2 %). Conclusions: in our experience the short term results of MIE do not justify a change of indication for subcarinal tumors based on minimal invasiveness. HE remains our standard approach for these tumors.

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Surg Endosc

O178 - Abdominal Cavity and Abdominal Wall

O180 - Emergency Surgery

Long-Term Results: of Laparoscopic Antireflux Surgery for the Treatment of Gastroesophageal Reflux Disease

Laparascopic Procedures for Liver Cirrhosis Complicated by Variceal Bleeding

C. Bergamini, A. Leahu, A. Todaro, G. Alemanno, A. Sturiale, C. Santi, A. Bruscino, P. Prosperi, A. Valeri

V.Y Grubnik, O.M. Iyzvak, Y.u.V. Grubnik, V.A. Fomenko

General Emergency and Minimal Invasive Surgery Unit, Firenze, Italy Introduction: Since more than two decades, the laparoscopic approach to anti-reflux surgery has been considered the gold standard treatement. However, the long term result of such procedure is far to be completely clarified and the percentage of failure (i.d. symptoms recurrence, need to proton pomp inhibitory) seem to remain still elevated. Aims: of our study was to retrospectively examine our wide series of patient including a long-term follow-up of 110 months, being long-term cure rates and quality of life the primary end-point. In case of major failure the possible causes have been stressed up too. Methods: A consecutive series of patients seen in our Dpt between January 1998 and December 2007 was retrospectively examined by mean of interne registry. All patients had been operated on for GERD and on call interviewed at yr 1, yr 3 and yr 5 by mean of the long-term cure rates and quality of life score. When symptoms of recurrence were identified gastroscopy and ph-metry was performed. Results: One hundred and thirty-four patients with a median follow up of 110 month were available for a long term evaluation. Gastroesophageal reflux was cured in 81 % at 5 years. Quality of life scores of patients with treatment success were similar to those of the general population but significantly lower in those with failed antireflux surgery. 93 patients reported that the outcome was better after antireflux surgery that with preoperative medical therapy and their operation a success. A small percentage of patiens presented decreasing effectiveness of laparoscopic antireflux for the long term. When a failure was clearly detected, most of the patients had some kind of incomplete or incorrect diagnostic iter at time of surgery. Conclusion: Long endoscopic/pH follow-up is necessary since failure may be late in appearing. Although most of the patients seem to have a quality of life similar to that of the general population, in some cases, the effectiveness decreases, usually due to some mistake in the surgical selection criteria

Odessa national medical university, Odessa, Ukraine Introduction: Laparoscopic devascularization of proximal stomach and distal oesophagus, and endovascular embolization of splenic artery and ascending branch of left gastric artery, is promising method of treatment of portal hypertension and variceal bleeding. The aim of the study was to analyze the results of this methods of treatment. Methods: From 2007 to 2013 we had 390 patients with liver cirrhosis. There were 150 Child-Pugh B patients, and 100 Child-Pugh C patients. There were 106 patients with severe bleeding, 191 patients with moderate bleeding, and 93 patients with small bleeding. 296 patients were treated endoscopically (158 patients with sclerotherapy, 128 patients with band ligation). In 10 patients with severe bleeding sclerotherapy was unsuccessful, thus placement of Denish stent was used. Endovascular embolisation of splenic artery was used in 82 patients following hemostasis. Laparoscopic devascularization of proximal stomach and distal oesophagus was done for 55 patients. Results: Bleeding recurrence was in 38 cases (41 %), and mortality was in 37 cases (39 %) following conservative treatment only which was used in 94 patients. Endoscopic hemostasis was sucsessfull in 240 cases (81 %). The most effective methods of endoscopic hemostasis were band ligation and placemaent of Denish stents. After 3 years observation of patients whom laparoscopic operations were done, only 2 patients died due to chronic hepatic failure. After 3 years observation of patients whom endovascular embolisation was done, only 4 patients died due to chronic hepatic failure, and 3 patients died due to rebleeding. Conclusions: The most effective methods of endoscopic hemostasis were band ligation and placemaent of Denish stents. Endovascular embolization of splenic artery and ascending branch of left gastric artery, and laparoscopic devascularisation proximal stomach and distal oesophagus reduce mortality in remote period.

O179 - Technology

O182 - Intestinal, Colorectal and Anal Disorders

Modified Dual-Ports Laparoscopic Distal Gastrectomy with Lymph Node Dissection for Gastric Cancer: Initial Experience From a Single Center

Laparoscopic Ventral Rectopexy Versus Stapled Transanal Rectal Resection for Obstructed Defecation Syndrome Secondary To Internal Rectal Prolapse: A Case-Control Study

Y.F. Hu, X. Lu, T.Y. Mou, J. Yu, G.X. Li

P. Sileri, A.L. Gaspari, I.C. Ciangola, I. Capuano, V. de Felice, L. Franceschilli, F. Giorgi

Nanfang Hospital Southern Medical University, Guangzhou, China Aims: There is an increasing interest in reduced port surgery using single port device for gastric cancer. However, the cost-effectiveness and surgical performance of SILSTM, or TriPortTM Access System were not always satisfactory. We introduced a modified dual-ports laparoscopic distal gastrectomy (DP-LDG) with lymphadenectomy adopting an economical and available solution in the study. Methods: A surgical glove, minilaparotomy wound protector, and three trocars were integrated as self-made single-site access system, which was inserted into a 4–5 cm upper abdominal midline minilaparotomy. Another 5 mm port was inserted at the right flank region of abdomen where a drainage tube used after surgery. Between January 2013 and January 2014, five patients with gastric cancer underwent DP-LDG with D2 lymph node dissection consecutively by a single surgeon. Results: All of the operations were performed without conversion to conventional laparoscopy nor open. There was no intraoperative complication. The mean operation time was 139.2 ± 9.7 min, and mean estimated blood loss was 59.0 ± 34.0 mL. The mean number of harvested nodes was 55.2 ± 9.6 per patient. The mean postoperative hospital stay was 5.6 ± 0.5 days. One patient experienced wound infection, while others with no postoperative complication. Conclusion: The modified dual-ports laparoscopic distal gastrectomy with lymphadenectomy might be a technical feasible procedure for selective patient with gastric cancer, however, prospective trial is needed to evaluate the surgical safety and oncologic efficacy.

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University of Rome Tor Vergata, Rome, Italy Background: Laparoscopic Ventral Mesh Rectopexy (LVR) corrects both internal and external rectal prolapse improving obstructed defecation symptoms (ODS). Similarly Stapled Trans-anal Rectal Resection (STARR) allows resolution of ODS. However data from observational or prospective trial comparing the two procedures for internal rectal prolapse (defined as recto-rectal or recto-anal intussusception) are absent. In this case-control study from our prospectively collected database we compared clinical results of these two procedures in order to better understand the ideal surgical approach. Patients and Methods: All patients underwent preoperative evaluation with defaecating proctography or pelvic dynamic MRI. Only patients with pure recto-rectal or recto-anal intussusception, rectocoele with or without enterocoele or sigmoidocoele were enrolled. Patients with concomitant middle and anterior pelvic compartment prolapses, were excluded. Two groups of patients were considered according to the surgical technique (LVR or STARR) and matched for demographics, symptoms and characteristics of the prolapse. Only patients with a minimum of 1 year follow-up were considerd. End-points were surgical complications and functional results expressed Wexner Constipation Score (WCS) and Faecal Incontinence Severity Index (FISI). Results: Twenty-seven patients underwent LVR and compared to 27 patients who underwent STARR. After LVR, overall complications rate was 15 % similar to STARR (11 %), all minor. After LVR, WCS after LVR significantly improved to 5 ± 3 from preoperative 15 ± 5 (p 0.03). Constipation improved in 89 % and was cured in 81 %. Similarly, after STARR, WCS score significantly improved to 6 ± 5 from preoperative 16 ± 11(p 0.03). Recurrence rate was 22 %. Constipation improved in 85 % and was cured in 78 %. No significative differences were observed between the two groups. Considering the incontinence, after LVR the FISI score significantly improved to 2 ± 2 from preoperative 7 ± 3 (p 0.02). Incontinence improved in 90 % and was completely cured in 90 %. After STARR, the FISI score significantly improved to 3 ± 2 from preoperative 8 ± 5(p 0.04). Incontinence improved in 54 % and was completely cured in 45 %. These percentages were significantly lower compared to those after LVR Conclusions: LVR and STARR seems to be equally valid to treat constipation in IRP, but LVR has greater chances to cure incontinence.

Surg Endosc

O183 - Intestinal, Colorectal and Anal Disorders

O186 - Pancreas

Impact of Rectal Mobilization, Fixation to Sacrum and Access on Recurrence Rates Following Rectopexy for Full-Thickness Rectal Prolapse: A Pooled Analysis of 532 Patients

Laparoscopic Management of Insulinomas

C.M. Bergamaschi, C. Foppa, M. Bishawi, S. Tou State University of New York, Stony brook, United States of America Purpose: This study was designed to determine what impact the extent of rectal mobilization, method of fixation to sacrum, and open and laparoscopic access have on recurrence rates (RR) following rectopexy for full-thickness rectal prolapse (FTRP). Methods: Individual patient data included age, gender, length of external prolapse, incontinence, constipation, ASA, previous abdominal surgery, comorbidities, access, rectal mobilization (anterior, posterior, circumferential), method of rectopexy (mesh, sutures, tacks), sigmoid resection. Recurrence was defined as the presence of FTRP after rectopexy on physical exam. Recurrence-free curves were generated and compared with KaplanMeier method and log-rank test. Results: There were 532 patients with age 54 years, 67.5 % females, length of external prolapse of 6.3 ± 4 cm, previous abdominal surgery 19.2 %. At univariate analysis history of constipation (p \ 0.001), sigmoid resection (p = 0.016), extent of rectal mobilization (p \ 0.001) and access (open vs. laproscopic) (p \ 0.01) were significant. At multivariate regression only the extent of mobilization was independently associated with recurrence (p = 0.026). The duration of follow-up ranged from 12 to 235 months. There were 46 recurrences (8.7 %) at a median follow-up of 60 months. Conclusions: Circumferential rectal mobilization was associated with decreased RR. The addition of mesh or sigmoid resection, and the type of surgical access did not influence RR.

A. Navarro, M. Marshall, J. Lynn, A. Martı´nez-Isla Northwick park and St. Mark’s Hospitals, London, United Kingdom Aims: Insulinomas are benign rare tumours. To make the diagnosis is necessary a high index of suspicion. Classically are treated by surgical resection. Laparoscopic approach has demonstrated advantages regarding less postoperative pain and recovery maintaining good outcomes. We present our experience in 25 cases. Methods: 25 patients have been treated by the same surgeon (AI) from January 2001 to October 2013. Diagnostic criteria have been based in clinical history, biochemical criteria (Glucose \ 2.2 mmol/L, serous insulin [ 43 pmol/L and raising of C-peptide with a negative sulfolinourea and oral anti-diabetics screening). Computed tomography (CT) scan, MRI, endoscopic US and stimulated calcium gluconate angiography were also performed. Results: Insulinomas were resected successfully. There was one conversion to an open approach in a patient who had insulinoma in the posterior aspect of the pancreas with a previous episode of severe necrotising pancreatitis. Four patients developed a post-operative pancreatic fistula. Surgical approach depended on the location of insulinoma. Left lateral position was used for tumours located in the posterior aspect of the head according to a technique previously described by the main surgeon. Supine position was used when insulinomas were located in the anterior aspect of the head and body-tail. Right lateral position was used in a patient with tumour located in the distal part of tail. Recently, we described the laparoscopic ultrasound-guided fine needle enucleation in three patients who had non-visible insulinomas in the head of the pancreas. This technique identified exactly the place where the pancreatotomy should be performed, minimizing the trauma. We recommend trying hardly enucleation for tumours located in the head of the pancreas, as the alternative is a Whipple procedure. Tumours located in body and tail should be treated by enucleation only with enough free margin (2–3 mm) to the pancreatic duct to avoid fistulas. Conclusions: Laparoscopic management of insulinomas is safe and feasible in expert hands. Preoperative localization is important in order to choose the position of the patient. Laparoscopic ultrasound is essential to locate the tumour and to assess the distance to the main pancreatic duct.

O184 - Intestinal, Colorectal and Anal Disorders

O187 - Pancreas

A New Laparoscopic Technique for Repair of Perineal Hernias

Does the Type of Suturing Technique in the Laparoscopic Pancreaticojejunostomy Influence the Outcomes After Laparoscopic Pancreaticoduodenectomy?

S.K. Allen, K.E. Schwab, A.R. Day, T.A. Rockall MATTU, The Royal Surrey County Hospital, Guildford, surrey, United Kingdom Aims: Although an uncommon complication of laparoscopic abdominoperineal excision of the rectum (APER), a perineal hernia can be a complicated and unsatisfying condition to treat. Options for repair include abdominal, perineal, or a combined approach, with no consensus as to the optimal technique, and risk of recurrence significant. We describe a new laparoscopic technique utilising two meshes to achieve a successful lasting repair. Methods: Our unit had five patients who underwent perineal hernia repair using this technique between 2003–2013. Patients were positioned as for laparoscopic pelvic surgery and initially adhesiolyis performed to allow easy access to the pelvis and hernial defect. We initially inserted a Polypropylene mesh over the hernial defect to reconstitute the pelvic floor. A second mesh (Bard SeprameshTM IP Composite) occluded the proximal pelvis, preventing small bowel contact with the Polypropylene mesh, and reducing downward forces into the pelvis. A Redivac drain was left in situ in the hernial sac. Results: One patient (a tertiary referral for recurrence) had a laparoscopic-assisted (perineal) repair due to dense adhesions from the primary repair, the other four were totally laparoscopic. At the time of operation, blood loss was minimal and mean operative time was 132 (107–162) minutes. There were no intra-operative complications. All patients mobilised on day one post-op and the Redivac drain was removed by the third postoperative day (output minimal). One patient required percutaneous drainage (100 ml) of a small seroma day 10 post-operatively, and all five patients remain free from recurrence at follow up (4–69 months). Conclusion: This laparoscopic technique for perineal hernia repair following APER is effective and safe, providing a sound repair with no recurrences to date. We would recommend this technique to other centres.

S. Tyutyunnik, I.E. Khatkov, V.V. Tsvirkun, R.E. Izrailov, A.O. Atroshchenko, I.Y. Feydorov, P.S. Tyutyunnik Moscow Clinical Scientific Center. MSUMD, Moscow, Russia Background: Pancreaticojejunal anastomosis is the most challenging part of pancreaticoduodenectomy and laparoscopic pancreaticoduodenectomy in particular. The question of the best technique for pancreatic anastomosis after total laparoscopic pancreaticoduodenalectomy (TLPD) is still open. For today technique of pancreaticojejunal anastomosis is not standardized in different hospitals. Purpose: To provide the most effective technique for pancreaticojejunal anastomosis during TLPD for patients with cancer of the head of the pancreas and periampullary area. Patients and Methods: From January 2007 to July 2013 60 pancreaticoduodenectomy were performed by total laparoscopic approach. Pancreaticojejunostomy is done 3 different ways: A) A two layer end-to-side anastomosis was done by using 2 semicircle running sutures (front layer) and separate precise sutures to the main pancreatic duct (inner layer). B) A single layer end-to-end dunking anastomosis by using 2 semicircle running sutures. C) A single layer end-to-side dunking anastomosis with interrupted sutures. As usual pancreaticojejunostomy is performed by Etibon 3/0. We did not use any tubes when performing the pancreaticojejunostomy. Results: Insufficiency of duct-to-mucosa pancreaticojejunal anastomosis was observed in 15,4 % of patients. Insufficiency of dunking pancreaticojejunal anastomosis was observed in 5,1 % of patients. The mean time of performing of duct-to-mucosa pancreaticojejunal anastomosis was 56,5 min (34–75 min). The mean time of performing of dunking pancreatojejunal anastomosis was 39.6 min (31–68 min). Conclusion: Total laparoscopic pancreaticoduodenectomy is a safe procedure. The single layer end-to-side dunking anastomosis with interrupted sutures provides more safety and less time of performing than duct-to-mucosa pancreaticojejunal anastomosis.

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Surg Endosc

O188 - Pancreas

O190 - Different Endoscopic Approaches

Fast Track Protocol for Totally Laparoscopic Pancreaticoduodenectomy

Percutaneous Transtrocar Endoscopic Necrosectomy And Drainage in Patient With Infected Walled-Off Pancreatic Necrosis: Is It Safe And Compatible?

A. Khisamov, E. Khatkov, E. Izrailov, V. Tsvirkun Moscow Scientific Clinical Center, Moscow, Russia Aims: The aim of this study is evaluation of the implementation of fast track protocol for totally laparoscopic pancreaticoduodenectomy. Methods: Beetween March 2013 and December 2013, 15 patients (10 male, 5 female; mean age 59.9 ± 13.4 years) were treated by fast track protocol that included earlier postoperative feeding, mobilization and removing of nasogastric tubes, abdominal drains and catheters. These patients were compared with 52 patients (18 male, 34 female; mean age 59.4 ± 9.6) who received a traditional programme from 2007 to 2013. Primary outcome was the length of stay in hospital after operation. Postoperative morbidity and mortality were secondary outcomes. Results: The median length of stay in hospital after operation significantly decreased after implementation of fast track protocol (22.15 ± 10.6 days versus 10.4 ± 6.3, p? = ?0.001). There was no significant difference in two groups in postoperative morbidity (46.1 % versus 40 %, p = 0,67) and mortality (5,8 % versus 6,7 %, p = 0.89). Conclusions: A first expirence of implementation of fast track protocol for totally laparoscopic pancreaticoduodenectomy significantly reduces length of hospital stay after operation without increasing of postoperative morbidity and mortality. But enhancement of outcome may be due to the learning curve of totally laparoscopic pancreaticoduodenectomy. Further applying of fast track protocols is needed to evaluate outcomes of enhanced recovery programmes after pancreatic surgery.

A.F.K. Gok1, M. Ilhan2, M. Ucuncu2, H. Yanar2, K. Gunay2, R. Guloglu2, C. Ertekin2, I.F. Amazat1 1

Istanbul Medical Faculty, Istanbul, Turkey; 2Istanbul Faculty of Medicine, Istanbul, Turkey

Aims: The aim of this study is present our new developed a percutaneous transctrocar endoscopic necrosectomy (PTEN) technique using flexible endoscope based on lumber retroperitoneal approach for treatment of patients with walled-off pancreatic necrosis (WOPN). Methods: All patient from November 2006 to August 2013 for management of necrotizing pancreatitis were retrospectively analyzed. Ten consecutive patients with infected pancreatic necrosis who have pancreatic and peripancreatic collections containing solid debris underwent percutaneous transtrocar endoscopic necrosectomy and drainage. Under computed tomography guidance, a 15 mm laparoscopic trocar was inserted into the infected cavity, between the lower pole of the spleen and the splenic flexure. A therapeutic double lumen flexible gastroscope, snare, and basket catheter was used to elimination of debris. After final operation, a Jackson-Pratt drain was placed into the distal end of the cavity at the end of the procedure. Results: A median 2 procedures (ranges 1–4) was necessary to remove all necrotic tissue. Complete resolution was achieved non-operatively in 10 patients. Timing of surgery from the initiation of acute pancreatitis was mean 44 days (range 22–84 days). Length of hospital stay was mean 84 (range 29–135) days. Four patients required ERCP and Wirsungotomy for incomplete pancreatic duct disruption. There was no technique-related mortality. Conclusions: Drainage, debridement, and necrosectomy of WOPN with PTEN are a safe alternative to other minimally invasive, laparoscopic and open technique. It can be done safely under direct visualization with transtrocar flexible endoscope. Percutaneous endoscopic transtrocar pancreatic necrosectomy should be considered among the first-line therapies of the selected patient with infected pancreatic necrosis.

O189 - Pancreas

O191 - Spleen

Transumbilical Laparoscopic Surgery for Pancreas and Spleen Through Zigzag Skin Incision of Umbilicus

Technical Refinements of Single-Incision Laparoscopic Splenectomy for Giant Spleen

K. Maemura1, Y. Mataki1, H. Kurahara1, S. Mori1, M. Sakoda1, S. Iino1, H. Shinchi2, S. Ueno3, S. Takao4, S. Natsugoe1

T. Misawa1, Y. Fujiwara1, R. Saito1, S. Yanagisawa1, T. Akiba1, K. Yanaga2

1 Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan; 2Kagoshima university Graduate school of Health Sciences, Kagoshima, Japan; 3Clinical Oncology, Kagoshima University Graduate School of Medical and Dental Sc, Kagoshima, Japan; 4Frontier Science Research Center, Kagoshima University, Kagoshima, Japan

1 Jikei University Kashiwa Hospital, Chiba, Japan; 2The Jikei University Hospital, Tokyo, Japan

Introduction: It is possible to acquire 6 to 7 cm width hole through zigzag skin incision at umbilicus with obscure scar. Gelport (Applied Medical, Orange County, CA) was introduced as an effective access port which made reduction of technical difficulties in laparoscopic surgery by keeping large-bore and performing hand assisted laparoscopic surgery (HALS) simultaneously. We introduced the combination of umbilical zigzag skin incision technique and Gelport as an effective procedure which reconciled reduction of technical difficulties and cosmetics for reduced port surgery in laparoscopic distal pancreatectomy (DP) or splenectomy. Methods: The brief procedure was described below; after marking a zigzag skin incision in the umbilical region, the skin was incised along this line. Then, a Gelport was equipped through the incision, which enlarged the diameter of the fascial opening to 7 cm. We added another two or three trocars of 5 mm in diameter according to the difficulty of manipulation. We evaluated the number of port, surgical incision status, perioperative status and complication. Results: Consecutive ten patients who all suffered from low malignant or benign disease were performed laparoscopic standard DP (n = 8) or splenectomy alone (n = 2) using this technique. The diameter of umbilical incision hole was 6.6 cm. The mean length of umbilical closed incision was 5.1 cm. The number of added trocar incision was 2.7 on the average. HALS was performed in part to 8 patients for palpation of tumor or holding operative field of view. We converted to open surgery for two patients due to severe adhesion around pancreas and huge size of splenic tumor. Other eight patients were taken all resected samples out through umbilical port without damaging tissue. Although one patient had Grade B (ISGPF) of pancreatic fistula in DP, there was no severe postoperative complication. The average of postoperative hospitalization was 12 days in DP and 7.3 days in splenectomy. Conclusion: We suggest that the trans-umbilical approach using Gelport through zigzag skin incision technique allows for an easy and safe reduced port surgery in laparoscopic DP or splenectomy without spoiling cosmetic effect.

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Aims: Despite the wide acceptance of single-incision laparoscopic surgery (SILS), SILS splenectomy (SILS-Sp) is regarded as highly challenging. Since our report of the first case of SILS-Sp in Japan, we have performed SILS-Sp for the largest number of cases worldwide, including cases of megaspleen (Surg Endosc 27:895–902, 2013). Herein, we describe the technical refinements of SILS-Sp. Methods: Our patient group comprised 8 men and 13 women aged 41 ± 19 years (mean ± SD). Indications for SILS-Sp were hematological disorder (n = 10), splenic disease (n = 9), and liver cirrhosis (n = 2). In all cases, access was achieved via a 2.5-cm mini-laparotomy at the umbilicus into which a SILSTM Port was placed. SILS-Sp was carried out with a 5-mm flexible scope, an articulating grasper, and straight instruments. Our SILS-Sp procedure is characterized by the following: a) frequent use of a vessel sealer to prevent bleeding, b) early ligation of the splenic artery to shrink the spleen, c) application of our original ‘tug exposure technique,’ which provides good exposure of the splenic hilum by retracting (tugging) the spleen with a small cloth tape (Surg Endosc 25:3222–3227, 2011), and d) use of a Penrose drain for safe introduction of a linear stapler into the splenic hilum. Results: SILS-Sp was successfully completed in 17 (81 %) patients. An additional trocar was required in two patients. Conversion to open surgery was necessary in two patients due to bleeding from the splenic hilum. Operation time (mean ± SD), blood loss, weight of the extracted spleen, and postoperative hospital stay were 217 ± 78 min, 157 ± 319 g, 317 ± 191 g (maximum 960 g), and 6.3 ± 3.9 days, respectively. No intra- or postoperative complication occurred. The postoperative scar was nearly invisible in all patients. Conclusions: Like conventional multiport laparoscopic splenectomy, SILS-Sp with technical refinements including the tug-exposure technique is safely performed for megaspleen (up to 1,000 g). SILS-Sp can be the procedure of choice in patients who are concerned about postoperative cosmesis.

Surg Endosc

O192 - Spleen

O194 - Intestinal, Colorectal and Anal Disorders

The Role of Laparoscopic Partial Splenectomy for Tumorous Lesion in Spleen

Clinical and Oncologic Safety of Laparoscopic Surgery in Patients with Stage III Colorectal Cancer

S.H. Lee, T.H. Hong, Y.K. You, D.G. Kim, E.Y. Kim

J.S. Kim, J.H. Park, K.H. Lee, J.Y. Kim

Seoul St.Mary’s Hospital, Seoul, Korea

Chungnam National University Hospital, Daejeon, Korea

Background/Purpose: Laparoscopic partial splenectomy (LPS) has emerged as a surgical option for splenic mass, with the goal of reducing postoperative complication while preserving splenic function. The authors report on the surgical outcomes and postoperative complications of LPS compared with laparoscopic total splenectomy (LTS). Methods: We retrospectively analyze the medical records of patients who underwent laparoscopic splenectomy for tumorous lesion of spleen at Seoul St. Mary’s Hospital between March 2008 and September 2013. Thirty one patients underwent laparoscopic splenectomy for tumorous lesion of spleen. Among them, 22 patients underwent LTS and 9 patients underwent LPS. The data of these patients were collected and included clinical presentation, age, gender, height, weight, BMI, laboratory studies, radiographic examinations, surgical procedure, visual analogue scale, hospital stay, intraoperative blood loss, need for blood transfusion, and complications. Result: All patients successfully underwent laparoscopic procedure. There were no statistical differences in the operation time (LPS: 177.2 ± 46.4 min, LTS: 151.5 ± 98.5 min, p = 0.462), intraoperative blood loss (LPS: 522.2 ± 329.9 ml, LTS: 337.3 ± 188.4 ml, p = 0.057), transfusion rate (LPS: 6/9, 66.7 %, LTS: 11/22, 50.0 %, p = 0.456), and periods of drain catheter maintenance (LPS: 4.3 ± 3.4 days, LTS: 3.2 ± 1.9 days, p = 0.258). However, there were statistical significant differences in the postoperative complications such as pneumonia (LPS: 0/9, 0 %, LTS: 5/22, 22.7 %, p = 0.021), pleural effusion (LPS: 0/9, 0 %, LTS: 10/22, 45.5 %, p = 0.013), splenic vein thrombosis (LPS: 0/9, 0 %, LTS: 10/22, 45.5 %, p = 0.013), and hospital stay (LPS: 2.9 ± 2.2 days, LTS: 6.3 ± 3.5 days, p = 0.011). Conclusion: LPS is feasible and safe surgical procedure, and it is effective approach to reduce postoperative complications such as pneumonia, pleural effusion and splenic vein thrombosis, in patients with tumorous lesion of spleen

Introduction: Laparoscopic surgery (LS) for colorectal cancer has been popular since several multicenter, randomized, prospective studies demonstrated oncologic non-inferiority of LS. However, there is still debate about laparoscopic approach to advanced stage of colorectal cancer. The purpose of this study was to compare clinical and oncologic outcomes of laparoscopic versus open surgery (OS) for stage III colorectal cancer in the single institute. Methods: The subjects of this retrospective study were 215 consecutive patients with stage III colorectal cancer, who underwent OS (n = 23) or LS (n = 192) with curative intent between January 2007 and March 2013. Clinicopathologic parameters were compared between the two groups and oncologic outcomes were evaluated. Results: There were no significant differences between OS and LS groups in terms of age, gender, previous laparotomy history, body mass index, number of retrieved lymph nodes, histologic type, and postoperative complications. LS group had shorter operation time (P = 0.048) and length of hospital stay (P = 0.009) than OS group. Five-year overall survival rate (P = 0.11) and recurrence-free survival rate (P = 0.155) did not differ significantly between the two groups. In multivariate analysis of survival revealed that advanced age (P \ 0.001 for overall survival and P = 0.015 for recurrence-free survival) and stage IIIC (P \ 0.001 for both overall and recurrence-free survival) were independent risk factors affecting 5-year overall and recurrence-free survival. Conclusions: LS provides shorter operation time and postoperative hospital stay compared with the open technique. Moreover, LS did not deteriorate short-term clinical and oncologic outcomes. Our study support that LS is safe and feasible for stage III colorectal cancer.

O193 - Intestinal, Colorectal and Anal Disorders

O195 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Versus Open Resection for Colon Cancer: 10-Year Outcomes of a Prospective Clinical Trial

Consecutive Endoscopic Submucosal Dissection of Rectal Tumors in Academic Hospital

M.E. Allaix1, G. Giraudo2, M. Mistrangelo1, A. Arezzo1, M. Morino1

M. Spychalski, A. Dziki

1

Medical University of Lodz, Lodz, Poland

2

University of Torino, Italy; Department of Surgery, Torino, Italy

Aims: Laparoscopic resection (LR) and open resection (OR) for colon cancer have similar oncologic outcomes at 5-year follow-up. However, results from studies with longer followup are limited. This study aimed to compare 10-year oncologic outcomes of LR and OR for non-metastatic colon cancer. Methods: A prospective non-randomized trial comparing patients undergoing LR or OR for non-metastatic colon cancer at a single institution was conducted. Statistical analyses were performed on an ‘intention-to-treat’ basis and by actual treatment. Kaplan-Meier curves were compared to analyze overall survival (OS) and disease-free survival (DFS). A multivariate analysis was performed to identify predictors of poor survival. Results: The study included 304 colon cancer patients: 154 patients underwent LR, and 150 underwent OR. Fifteen (9.7 %) had LR converted to OR. During a median follow-up period of 138 (range 120–220) months, no significant differences were observed between LR and OR patients in 10-year OS and DFS rates: 87.2 % versus 78.7 % (P = 0.182), and 80.9 % versus 76.8 % (P = 0.444), respectively. Conversion to open surgery was associated with a non significant reduction in OS and DFS. Stage-by-stage comparison showed no significant differences between the two groups. Both OS and DFS were similar between right colon and left-sided colon cancer patients. Univariate analysis found pT4 stage, stage 3 disease and lymph node ratio (LNR) of 0.20 or more to be significant risk factors for poorer OS and DFS, whereas an LNR of 0.01 to 0.19 showed a trend that did not reach statistical significance. On multivariate analysis, pT4 cancer and a LNR of 0.20 or more were the only independent predictors of both OS and DFS. Conclusions: The 10-year follow-up results confirm the oncological effectiveness of the laparoscopic approach to non-metastatic colon cancer.

Aims: Surgical treatment of rectal neoplasm carries a significant risk of intra- and postoperative morbidity and mortality. Moreover, some procedures (LAR, APR) are associated with decrease in patient’s quality of life. Nevertheless, surgery, often combined with radioor chemoradiotherapy remains treatment of choice when dealing with malignant tumors in the invasive stage. In the case of adenomas or adenocarcinomas in T1 SM1 stage, endoscopic submucosal dissection (ESD) pretends to be valuable alternative. The aim of the present study was to investigate therapeutic outcomes of rectal ESD at the Department of General and Colorectal Surgery, Medical University of Lodz, Poland. Methods: 20 consecutive cases of rectal ESDs were performed between June and December 2013 in our institution. Effectiveness of dissection, complications and the tumor recurrence after 3 months of treatment were than retrospectively investigated. Results: The mean age of patients was 72.8 years (range 48–83 years). The average size of the dissected tumor was 4.025 cm. In 13 cases, en bloc resection was achieved. The average size of tumor in this group was 3.48 cm. The percentage of curative resection was 95 %. Pathological analysis of the tumors reported: the 8 cases of adenoma with low grade dysplasia, the 8 cases of adenoma with high grade dysplasia, 2 cases of neuroendocrine tumor, 1 case of invasive cancer and 1 case of intraepithelial carcinoma. The postoperative course in one case was complicated by fever up to 38.5 degrees - in transrectal ultrasound examination, the fluid collection was observed in the pre-sacral space. Patient was successfully treated conservatively. No perforation or incidence of bleeding during and after the procedure was reported. Follow up examinations after 3 months were conducted in 11 patients. There was no local recurrence. Conclusions: ESD of the rectal tumors is a valuable alternative treatment method for adenomas and T1 SM1 rectal cancers. The risk of serious complications and local recurrence is low. Due to the risk of tumor understaging, when assessed endoscopically, it is advisable to closely monitor each patient after rectal ESD.

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Surg Endosc

O196 - Intestinal, Colorectal and Anal Disorders

O198 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Surgery for Locally Advanced (T4) Rectal Cancer: Long-Term Outcomes

The Individual Surgeon’s Laparoscopic Experience: 10 Years of Laparoscopic Surgery for Malignant Colorectal Disease

D. Saavedra-Perez, S. Delgado, R. Almenara, C. Adelsdorfer, J.P. Arribas, M. Bertrand, M.C. Pavel, M. Fernandez, D. Momblan, A Ibarzabal, R. Bravo, R. Corcelles, A.M. Lacy

S. Hossaini, B. Bharathan, C. Maxwell-Armstrong

Hospital Clinic of Barcelona, Spain Aims: To evaluate the technical feasibility and the surgical and oncologic long-term results of laparoscopic-assisted resection in locally advanced (T4) rectal cancer patients. Methods: From January 1998 to December 2012, patients admitted to our colorectal cancer unit with locally advanced (T4) clinical stage adenocarcinoma of the rectum were evaluated. Laparoscopic resection was carried out 10–12 weeks after neoadjuvant chemoradiotherapy initiation. The primary endpoint was cancer-related survival. Data were analyzed according to the intention-to-treat principle. Results: A total of 59 patients with a mean age of 63.3 years were enrolled in the study. Twenty-one patients (35.6 %) were classified as T4a and 38 (64.4 %) as T4b. Fifty-seven patients (96.6 %) were treated with neoadjuvant chemoradiotherapy. In 81.4 % (48/59) of the patients, a surgical procedure with sphincter preservation was performed. The rate of conversion to the open approach was 10.2 %. No intraoperative complications occurred. Twenty-one patients (35.6 %) developed postoperative complications (28.8 % grade I-II and 6.8 % grade III-V). The mortality rate was 1.7 % (1 death no surgically related). R0 resection was achieved in 83.1 %. Mesorectal quality was good in 91.5 % of the specimens. The median follow-up was 40.6 months (range 9–63). Five-year distant and local recurrence rates were 21 % and 19 %, respectively. Overall survival rate at 5 years was 62.2 % with a mean for survival of 84 months. Resection without sphincter preservation (p = 0.022), node positivity (p = 0.038) and circumferential margin involvement (p = 0.026) had a statistically significant impact on survival in the multivariate analysis. Conclusions: Aggressive management of clinical T4 rectal cancer is safe and feasible using the laparoscopic approach and with acceptable surgical and long-term oncologic outcomes. Multicenter randomized clinical trials are warranted to confirm these results.

Queen’s Medical Centre, Nottingham, United Kingdom Aims: Laparoscopic colorectal resection offers better short-term outcomes and oncological equivalence to open surgery and is offered to all patients with colorectal cancer. However, the steep learning curve and lack of critical volume of laparoscopically-trained surgeons means that only 40 % of all resections are laparoscopic in the UK. In keeping with the recent disclosure of surgeon-level data by the National Health Service in the United Kingdom, we aim to present individual surgeon outcomes for laparoscopic colorectal cancer surgery, from a national laparoscopic training centre. Methods: A prospectively validated database of laparoscopic colorectal cancer operations was used for data analysis. All procedures performed by an experienced laparoscopic consultant surgeon from July 2003 for 10 years were only included in this analysis. Short and long term outcomes were evaluated along with operative quality data. Results: A total of 212 patients (114 male, 98 female) of mean age 68.2 years (29–88) and mean BMI 26.8 kg/m2 (14.9–43.9) had a laparoscopic colorectal cancer resection; 92.5 % were performed with curative intent. The majority of patients were American Society of Anaesthesiology grade 2. A surgical trainee was the primary surgeon in 52.2 % of cases. In total there were 96 rectal, 84 right-sided, 29 left sided and 3 were combined left and right sided resections. The commonest pathological stage was Dukes B (41.5 %). In 91.5 % a primary anastomosis was made. The permanent stoma-rate was 4.7 %. Morbidity and inhospital mortality rates were 25.0 % and 1.4 % respectively (anastomotic leak rate 2.6 %). Mean lymph node yield was 13.2 (2–41). Mean postoperative stay was 6 days (1–115). 30-day readmission and reoperation rates were 9.9 % and 4.7 % respectively. The overall hernia rate was 13.7 %. The Kaplan-Meier estimate for overall 5-year survival was 72.5 %. Conclusions: The short term morbidity and mortality rates, as well as long term outcomes presented are comparable with current published data. The individual surgeon data supports laparoscopic colorectal surgery to be safe and oncologically robust.

O197 - Intestinal, Colorectal and Anal Disorders

O199 - Intestinal, Colorectal and Anal Disorders

Does Laparoscopic Tme Surgery for Rectal Cancer Increase Risk Of Rectal Recurrence? A Ten Year Series from Our Laparoscopic Colorectal Unit

Long-Term Oncologic Results of Laparoscopic Total Mesorectal Excision

K.E. Schwab, S. Allen, A. Day, I. Jourdan, T. Rockall

M. Galvan, J. Requena, J. Mella, E. Grzona, A. Canelas, M. Laporte, M. Bun, N Rotholtz

RSCH, Guildford, United Kingdom

Hospital Aleman de Buenos Aires, Buenos aires, Argentina

Background: There is no doubt that Total Mesorectal Excision (TME) Surgery has revolutionised rectal cancer treatment and survival in the last couple of decades. Rectal recurrence is still of great concern as it carries significant risk of morbidity and mortality. The evolution of laparoscopic techniques and enhanced recovery has reduced length of hospital stays and perioperative morbidity with regards colorectal cancer surgery but concern still remains regarding laparoscopic rectal surgery. Some believe laparoscopic rectal surgery may decrease the TME quality and lymph node haul, increasing risk of recurrence, as well as morbidity from risk of conversion. We present here our laparoscopic rectal surgery series and recurrences. Methods: We analysed our prospectively recorded colorectal database to identify all patients who underwent laparoscopic TME surgery for rectal cancer over the last ten years. Patient notes were then assessed and correlated with imaging, histopathology and MDT records to identify local recurrences and outcomes. Results: We identified 163 patients who underwent laparoscopic TME surgery between 2004 and 2013 at our unit (initially one laparoscopic surgeon until 2009). The distribution of operations were: 47 abdominoperineal resections, APR (4 converted), 109 low anterior resections, full TMEs (8 converted), and 7 panproctocolectomies (rectal malignant change in IBD patients, no conversions). 3 local recurrences were identified. All occurred in APR patients, 1 in a patient who underwent conversion, with T3 primary tumours. The recurrences were detected at 4 years (n = 1) and 5 years (n = 2) post initial surgery. Conclusions: Over a 10 year period, our unit demonstrates a local recurrence rate of 1.8 % with 93 % of laparoscopic TME surgery for rectal cancer completed unconverted. Heald originally reported recurrence rates of less than 5 % with TME for rectal cancer, although other reported TME series achieve 6–12 % local recurrence rates (mix of laparoscopic and open). Our series shows that quality rectal surgery is feasible laparoscopically with excellent patient outcomes and low rectal recurrence rates.

Aims: To analyze long-term oncologic outcomes obtained in laparoscopic approach of middle and lower rectal cancer. Methods: A retrospective study was performed using a prospective collected database. Elective laparoscopic total mesorectal excision (TME) were analyzed in the period December 2003 - December 2012 with a minimum follow up of 6 months. Three and 5 years recurrence and cumulative survival analysis, adjusted by cancer and disease free were performed using Kaplan-Meier method. The survival was compared according to stage using the log rank test. Results: 1139 colorectal laparoscopic procedures were performed in the analized period. 123 were operated for rectal adenocarcinoma and 87 cases underwent TME. 78 patients achieved the minimum follow up of 6 months. From the total 42 cancers were located at the middle (54 %) and 36 at the lower rectum (46 %). 69 (88.5 %) patients had laparoscopic sphincter-saving TME. The mean follow up was 45.1 (7–120) months. Local and distal recurrence were 8.9 and 17.9 %. Global recurrence was 24.3 % with a 3 and 5 years disease free survival of 88 and 68.5 % respectively. The overall and cancer related mortality were 15.3 and 11.5 % respectively. There was significant difference in the survival adjusted by stage (log rank = 0.001). Conclusion: Laparoscopic TME offers adequate long-term recurrence and survival rates.

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Surg Endosc

O200 - Intestinal, Colorectal and Anal Disorders

O202 - Morbid Obesity

Validation of the Anastomotic Leakage Risk Model in Laparoscopic Rectal Cancer Surgery: A Decision-Making Tool for the Choice of Protective Stoma

Prospective Randomized Clinical Trial Comparing Single Incision Laparoscopic Sleeve Gastrectomy and Conventional Laparoscopic Sleeve Gastrectomy

H.J. Kim, G.S. Choi, J.S. Park, S.Y. Park, J.I. Choi, J.A. Park

S. Morales-Conde, I. Alarcon-del Agua, M. Socas-Macias, J. Pereira, P.P. Garcia-Luna, J. Padillo, A. Barranco-Moreno

Kyungpook National University Medical Center, Daegu, Korea

University Hospital Virgen del Rocio, Seville, Spain

Background: There is no clear evidence for the optimal choice of protective stoma in laparoscopic rectal cancer surgery. We compared the anastomotic leakage rate in the periods before and after the application of this model to validate the anastomotic leakage risk model. Methods: The anastomotic leakage risk model was created based on the results from the recently published multicenter study. Male, low rectal cancer and preoperative chemoradiation were the risk factors that were chosen for the model. Patients with two different time periods (Group A, 2008–2010; Group B, 2012-May 2013 after application of the model) were included. Results: After the application of the model, a protective stoma was created in the patients with more than two risk factors. The rate of protective stoma was changed from 14 of 345 patients (4.1 %) in Group A to 51 of 205 patients (24.9 %) in Group B (P \ 0.001). The incidence of preoperative chemoradiation increased in Group B (20.9 % vs. 29.8 %, P = 0.023). The anastomotic leakage rate decreased from 11.3 % in Group A to 4.9 % in Group B (P = 0.013). The initial hospital stay also decreased in Group B (9.0 ± 6.7 days vs. 7.7 ± 6.5 days, P = 0.024). In the risk stratification, the leakage rate in the patients with two risk factors (male and low rectal cancer) and three risk factors significantly decreased in Group B (24.3 % vs. 4.2 % in the patients with 2 risk factors; 16.3 % vs. 5.7 % in the patients with 3 risk factors). The stoma-related readmission rate and the stoma repair-related complications were 11.8 %, respectively. The total hospital stay including the scheduled and unscheduled readmission was similar between the two groups (12.3 ± 10.0 days in Group A vs. 11.8 ± 10.1 days in Group B, P = 0.470). Conclusions: The anastomotic leakage risk model may be a valuable decision making tool that can help surgeons reliably identify patients at high risk for anastomotic leakage. Protective stoma might be mandatory in patients with two or more risk factors based on decreased leakage rate and acceptable stoma-related complications. A further large-cohort study is required to generalize this single-center study.

Aims: To assess the effects of Single Incision Surgery in the results of Sleeve gastrectomy compared to Conventional laparoscopic approach. Methods: Randomized clinical trial was performed of Single Incision Laparoscopic vs conventional laparoscopic sleeve gastrectomy in 30 patients suitable for bariatric surgery. Intraoperative (complications, blood loss, operative time) and postoperative (Pain scores, blood tests, Cosmetic Satisfaction score) data was collected in successive consults one month, three months and six months after surgery Results: There were no significant differences in weight (LAP:118,4 vs SILS: 119,7 Kgs), age (LAP: 46,8 vs SILS: 41,2), BMI (LAP: 45,5 vs SILS: 44,4) or comorbid conditions between the two groups. Mean operative time was 61,2 vs 69,3 minutes in LAP and SILS group respectively (p = 0,1). No differences were observed in blood loss, intraoperative complications or hospital stay. There were no perioperative complications in either group. No significant differences were observed in levels of C-Reactive protein (CRP) and serum Cortisol at 1, 2 and 3 postoperative days between both groups. Pain scores at movement at Visual Analoge Scale were significantly lower in SILS group compared with LAP group at 1 Postoperative day (34,7 vs 49,8, p = 0,04) and 2 postoperative day (22,1 vs 35,4, p = 0,04). The cosmetic results were significatly higher in SILS Group at 1,3 and 6 months postoperatively in a 1–10 satisfaction VAS (9,83 vs 7,66, p = 0,001; 9,79 vs 6,86, p = 0,001; 9,88 vs 6,53 respectively). No difference were noticed regarding weight loss in terms of %EWL at 1,3 and 6 months in SILS and LAP groups (20,61 vs 21,13, p = 0,2; 40,3 vs 36, p = 0,4; 56,9 vs 53,3, p = 0,42). Conclusion: Single-incision sleeve gastrectomy presents similar operating times, rate of complications, blood loss hospital stay and weight loss when compared with Conventional laparoscopic surgery, while has some advantages such as significantly lower postoperative pain and better patient satisfaction related to cosmetic results

O201 - Intestinal, Colorectal and Anal Disorders

O203 - Morbid Obesity

Laparoscopic En Bloc Resection of Rectum and Prostate: A Case Series

The Utility of Routine Post-Operative Upper Gastrointestinal Swallow Study Following Laparoscopic Sleeve Gastrectomy

K.E. Schwab, S. Allen, C. Eden, T. Rockall

I. Mizrahi, A. Tabak, R. Grinbaum, N. Beglaibter, A. Eid, N. Simanovsky, N. Hiller

RSCH, Guildford, United Kingdom Background: Prostate and rectal cancers are the commonest pelvic cancers in males and can be discovered simultaneously, providing clinicians with challenging management decisions. We present our experience of combined laparoscopic en bloc excisions of prostate and rectum for concurrent cancers, which we believe is previously undescribed in the literature. Methods: Between October 2009 and December 2013, 5 patients underwent this combined laparoscopic procedure at our unit. The consultant urological surgeon initially performed a radical prostatectomy dissection anteriorly with lymph node harvest. The colorectal surgeon then performed a rectal resection in the posterior and lateral mesorectal plane. This was part of an abdominoperineal resection in 3 patients, completion proctectomy in 1 (for malignant change in rectal stump of UC patient), and low anterior resection in 1 (primary anastomosis and covering ileostomy rather than end colostomy in others). After colonic transection, the prostate was divided from bladder and distal urethra and en bloc specimen was extracted either perineally after intersphincteric dissection in 4, or through mini pfannenstiel in 1. Post operatively patients were managed according to our colorectal enhanced recovery programme. Results: All patients’ surgery was laparoscopic, with no conversions. Mean operating time was 373 minutes (range 281–506 minutes) with no immediate perioperative complications. Length of stay was 3–11 days, median 4 days. Delayed discharge in one patient related to ileus. Complications post discharge are one seroma and one DVT in the same patient, one port site hernia requiring repair and one persistent urethrovesical anastomotic leak. At follow up (minimum follow up 2 weeks, maximum 208 weeks) there has been no tumour recurrence. Conclusions: We present our experience of a challenging and complex combined laparoscopic procedure for the successful and effective management of synchronous prostatic and rectal malignancies. We have shown this procedure can be safely performed laparoscopically to the benefit of patients recovery with good oncological outcomes.

Hadassah Medical Center, Jerusalem, Israel Aims: Laparoscopic sleeve gastrectomy (LSG) has grown in popularity in recent years for the treatment of morbid obesity. Controversy exists regarding the usefulness of upper gastrointestinal (UGI) swallow studies on the first postoperative day, in detecting possible complications. The aim of our study was to determine the efficacy and cost benefit of routine UGI studies on the first postoperative day following LSG. Methods: We retrospectively reviewed the hospital’s records to identify patients who underwent LSG between January 2012 and June 2013. All patients had Iodine based contrast swallow study on the first postoperative day. Reports from all imaging studies and medical files were retrospectively reviewed, and complications were recorded. The Institutional Review Board waived the requirement for informed consent. Results: During the study period a total of 722 patients (237 males, 485 females) underwent LSG at our institution. Mean age was 41 years (range 14–70), and mean BMI was 43 kg/ cm2 (range 25–70). Five patients (0.7 %) developed leaks on post-operative days 2, 5, 7, 23, and 90. No leaks were detected on UGI studies (sensitivity-0 %). All leaks were eventually detected using CT scans. One patient (0.1 %) developed a complete obstruction due to an incarcerated hiatal hernia presenting on the first post-operative day, as detected by the UGI study. The total cost of these examinations was 180,500 $. Conclusion: Performing routine UGI studies on the first postoperative day following LSG is clearly not cost-benefit. UGI contrast studies are not efficient to screen for suture line leaks. We recommend obtaining a CT scan when there is clinical suspicion for a complication.

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Surg Endosc

O204 - Morbid Obesity

O206 - Morbid Obesity

Laparoscopic Sleeve Gastrectomy in Patients Over 60 Years: Impact of Age on Weight Loss and Comorbidities Improvement

Laparoscopic Vertical Gastric Plication as an Alternative to Sleeve Gastrectomy: Comparison of Postoperative Complications and Short Term Outcome. A Case Control Study

C. Rodriguez-Otero Luppi, C. Balague, E.M. Targarona, S. Mocanu, M. Trias Hospital de la Santa Creu i Sant Pau, Barcelona, Spain Background: Advanced age was considered historically as a relative contraindication to bariatric surgery due to increased perioperative risk and a lower weight loss. Observed the success of operated patients and the rising life expectancy, potential benefits of bariatric surgery in older patients are reconsidered. Objective: The aim of this study is to report the outcomes of our series of laparoscopic sleeve gastrectomy (LSG) in the older (60 years or more) obese patients and compare with the younger group. Material and Methods: Between November-2008 and November-2013, 130 patients underwent LSG in our institution, being 28 patients (21,5 %) aged 60 years or older. Outcomes in terms of perioperative complications, short and medium-term weight loss, remission or improvement of comorbidities and medication requirements were extracted from our prospectively held database. Results: A low rate of complications was observed in our series, short-term mortality was 0 % and 30-day complication rate was similar in both groups (17,8 % vs 17,6 %) without significant differences. Average LOS was 2.8 ± 1.4 days in the older group vs 3.5 ± 6.6 days in the younger group (p = 0,57). At 12 months post-surgery, patients aged 60 or more had a percent excess weight loss ( %EWL) of 49 % compared with 60 % of those younger (p \ 0,012). At 2 years the results were similar (45 % vs 60 % with p \ 0,015). In terms of failure of the procedure (according to Reinhold score) 7 patients in the older group (30 %) at 1 year did not attained the objectives compared with 11 (14 %) in the younger group (p \ 0,001).In 65 % of all the patients in the older group there was an improvement of at least one major comorbidity. The average of preoperative different medications of the older group was 4,29, these were reduced to 2,74 at 1 year (p \ 0,001) and 2,93 at 2 years (p \ 0,001). Conclusions:Patients of advanced age can safely undergo LSG as a primary treatment modality for morbid obesity but it is expected that younger patients manifest greater weight loss. Older patients demonstrated as well significant reduction in daily medication requirements. Therefore, patients aged 60 years or more can be considered good candidates for bariatric surgery for the substantial health benefits observed.

N. Schoucair, V. Carroni, E. Chahine, B. Othman, R. Daher, E. Chouillard CHIPS Centre Hospitalier Intercommunal Poissy et Saint germain en Laye, Poissy, France Backgroud: Obesity is a major public health problem. Surgery is considered the best treatment for morbid obesity. Laparoscopic sleeve gastrectomy (LSG) is nowadays the most commonly performed bariatric procedure in France. However, newer surgical and endoscopic techniques are emerging. Among these, laparoscopic vertical gastric plication (LVGP) is presented as an alternative for LSG with theoretical advantages including mainly lower postoperative morbidity and reversibility. The goal of our retrospective, case-control study is to compare early morbidity and mortality as well as short term outcome in two groups of patients with morbid obesity who had LVGP or LSG, respectively. Methods: From March 2011 to January 2013, 40 patients had LVGP (Group I) for morbid obesity. During the same period, 280 patients had LSG. Of these, 40 (Group II) were matched with Group I patients according to age, sex, and body mass index (BMI). The primary endpoint was morbidity and mortality rates. Secondary endpoints included operative time, hospital stay, cost, and 6-months and 12-months percentage of excess weight loss (EWL) as well as the outcome of associated comorbidities. Results: No postoperative mortality was observed in either group. No reoperation was needed. Overall morbidity rate (including nausea/vomiting) reached 20 % in Group I and 10 % in Group II (P = 0.04). The most common complication was nausea. No clinical or radiological leak occurred. Mean operative time was 91.5 ± 18.6 min in Group I and 81 min ± 16.8 min in Group II (P = 0.104). Average total Operating Room (OR) cost was 1736 euros for LVGP compared to 2842 euros for LSG (P \ 0.001). At 12-months follow-up, mean EWL was 56.5 % ± 9.8 % in Group I and 71.3 % ± 10.4 in Group II (P = 0.041). Conclusion: LVGP is a sure and feasible bariatric procedure with low rates of serious complications. As compared to LSG, LVGP is associated to relatively higher postoperative rate of nausea. As for direct OR cost, LVGP is more efficient than LSG, saving more than 1000 euros per procedure. However, LVGP is associated to lower EWL at 12-months follow-up (P = 0.041). Additional prospective comparative studies with longer term follow-up data are required.

O205 - Morbid Obesity

O207 - Morbid Obesity

Neofundus Development After Laparoscopic Sleeve Gastrectomy. Is Fundectomy Safe and Effective as Revisional Surgery?

Laparoscopic Roux-En-Y-Gastric Bypass Increases Esophageal Exposure to Weakly Acidic Reflux

F. de Angelis1, A.B. Albanese2, M. Rizzello3, A. Iossa3, O. Iorio3, L. Liguori3, M. Avallone3, G. Cavallaro3, M. Foletto2, G. Silecchia3

F. Rebecchi, M. Allaix, C. Giaccone, P. Merlo, M. Morino

Sapienza University of Rome, Latina, Italy; 2Bariatric Unit -Padova University, Padova, Italy; 3Division of General Surgery& Bariatric Center of Excelence. University of Rome, Latina, Italy 1

Introduction: Laparoscopic sleeve gastrectomy (LSG)has become a popular bariatric procedure because of its effectiveness and safety profile.Weight regain,inadeguate weight loss and severe reflux symptoms can require surgical revision.The neofundus residual or its development,can be one of the failure causes.The aim of this retrospective study was to evaluate if fundectomy plus hiatoplastic,in case of hiatal hernia, can represent a safe and effective revisional technique after primary LSG in terms of GERD symptoms control and weight loss. Methods: From January 2011 to December 2013 19 patients(17F),mean BMI of 35,4 underwent to laparoscopic fundectomy indicated for severe GERD symptoms,non responding to medical therapy,and/or weight regain. The neofundus was demonstrated in all cases by swallow upper GI series plus in 9 cases by a CT Scan.The symptomatic GERD was assessed by a specific questionnaire followed by an upper gastro-intestinal endoscopy. Results: In 8 patients (42,1 %) the LSG was performed as revisional procedured after band removal for inadeguate weight loss. 6 patients(31 %)were superobese before primary LSG. The mean interval time from LSG to fundectomy was 38,7 months(range 12–80 months).The indications to fundectomy were weight regain/inadequate weight loss in 5 patients(26,3 %),severe GERD symptoms in 7 patients(36,8 %)and both in 6 patients(31,5 %).In 10 patients (52,6 %) the radiological evaluation showed a hiatal hernia associated with a sleeve migration. The volumetric CT scan performed in 9 patients showed a gastric volume [ 220 cc. All fundectomies were completed laparoscopically using a bougie size 34–36 Fr. In 10 patients a concomitant cruroplasty was carried out.In all cases the staple line was reinforced (Seamgard or fibrin glue).No intraoperative complications occurred.5 postoperative major complications occurred(26,3 %): 2 stapler line bleeding,1 mid-gastric stenosis,and 2 upper gastric leak. All the complications were successfully treated by endoscopy/radiological intervention except a patient who developed a chronic gastric fistula and underwent to surgical revision. At 24 months follow-up 11 out of 13 patients with severe GERD had an improvement of their symptoms. Conclusion: Fundectomy associated with hiatoplastic can represent an alternative as revisional surgical procedure. The high complications rate suggests to perform this technique in selected cases only. Long-term results are awaited to prove the fundectomy efficency.

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Department of Surgical Sciences, Torino, Italy Aims: Only a few studies with short follow-up have investigated the esophageal function after LRYGB. The aim of this study was to evaluate the occurrence and long-term effects of weakly acidic reflux (WAR) in patients undergoing laparoscopic Roux-en-Y-gastric bypass (LRYGB) for morbid obesity. Methods: Consecutive morbidly obese patients selected for LRYGB were included in a prospective clinical study. Gastroesophageal function was assessed by clinical validated questionnaires, upper endoscopy, esophageal manometry and 24-hour multichannel intraluminal impedance pH (MII-pH) monitoring before, 12 and 60 months after LRYGB. Results: From May 2007 to May 2008, 65 morbidly obese patients entered the study; 56 (86 %) completed the 5-year protocol. Among them, 21 (37.5 %) patients had preoperative pathologic gastroesophageal reflux (GER patients) (15 acidic, 6 acidic + weakly acidic). Quality of life according to Gastroesophageal Reflux Health-Related Quality of Life scale improved in GER patients (p \ 0.001), while no differences were observed in patients without GER (No-GER patients), at 12 and 60 months. In the 21 GER patients, 24-hour MII-pH monitoring showed reduction of acidic reflux episodes (66.22 ± 21.80 vs. 14.76 ± 7.06, p \ 0.001), but increase of the number of WAR episodes (12.53 ± 6.01 vs. 47.04 ± 20.72, p \ 0.001) at 60 months. Pathologic WAR was diagnosed in 22 (63 %) of the 35 No-GER patients at 60 months. No significant changes were observed over time in lower esophageal sphincter pressure and esophageal peristalsis amplitude in both groups of patients. Esophagitis was present in 8 (12 %) patients preoperatively, and in 26 patients (46 %) at 5-year follow-up (p \\/i [ 0.001). Metaplasia without dysplasia was found in 3 (5 %) patients preoperatively and in 5 (4 GER +1 No-GER) (9 %) patients at 5-year follow-up. Conclusions: Distal esophagus exposure to WAR is increased in patients undergoing LRYGB for morbid obesity. Therefore, the long-term management of these patients should include endoscopic surveillance to rule out the presence of esophagitis, metaplasia or dysplasia.

Surg Endosc

O208 - Morbid Obesity

O210 - Emergency Surgery

Long Limb Omega-Loop Vertical Gastric Bypass (Llov GBP): A Safe and Effective Alternative to RYGBP and Mini Gastric Bypass

Surgical Hot Clinic—An Effective Pathway of Reducing Unnecessary Hospital Admissions and Cost of Care

M.E. Elbanna, O.F. Fouad Faculty of Medicine, Ain Shams University, Cairo, Egypt Introduction: The complications associated with Mason Gastric Bypass with loop gastrojejunostomy lead to the development of Roux-en-Y gastric bypass (RYGBP). The morbidities and mortalities associated with RYGBP lead to the development of mini-gastric bypass (MGBP). MGBP has been criticized due to the biliary gastric reflux. We modified the technique of omega-loop single anastomosis gastric bypass with the objective of minimizing the complications of both RYGBP AND MGBP. Patients and Methods: We perform a small gastric pouch similar to RYGBP, a long jejunal limb 200–250 cm from the ligament of Treitz, similar to that of MGBP, a vertical gastro-jejunal anastomosis, and a wide stoma gastro-jejunostomy. The small size of the pouch combined with the wide stoma gastrojejunostomy reduces the intragastric pressure and enhances drainage of gastric contents. The long jejunal limb reduces the amount of active bile in the jejunum connected to the gastric pouch. The construction of a vertical anastomosis minimizes reflux of the jejunal contents into the gastric pouch. From October 2011 to September 2013, 74 patients underwent the long limb gastric bypass with omega-loop gastrojejunostomy (LLOV GBP). They were 24 men and 50 women, with a mean age of 28.2 years. Fifteen patients had type 2 diabetes mellitus (20 %). The safety and efficacy of LLOV GBP was assessed. Results: Two cases were converted (2.7 %). Mortality was 0 %, and 4 cases experienced complications. Two cases developed postoperative DVT, one of them developed pulmonary embolism. Both were successfully treated. One patient developed early postoperative small bowel obstruction due to incarcerated trocar site hernia and one had incarcerated diphragmatic hernia. Bile reflux was symptomatic with endoscopic findings in one case (1.35 %), and controlled by medical treatment. The average weight loss was 8.1 % of total body weight at 1 month, 16.2 % at 3 months, 23.5 % at 6 months, and 33.6 % at one year. Conclusion: Long limb omega-loop vertical gastric bypass is an effective and safe procedure that resulted in weight loss comparable to that of RYGBP. The technical modifications we performed proved effective in minimizing bile reflux gastritis.

V. Shatkar, W. Lynn, J. Jeggard, M. Wain, T. Amalesh Queens Hospital, Romford, United Kingdom Aims: Many emergency admissions to the NHS are surgical in nature and these cases are a significant financial burden and need careful assessment and treatment planning. The aim of this audit is a review of a ‘surgical hot clinic’ service developed to improve surgical emergency care and benefits to the care provider Methods: A Surgical hot clinic service was started in a busy Hospital in London. GPs and the emergency department were given direct access to the clinic through the on-call team. The clinic is run by an experienced general surgeon. Rapid access to investigations including USS and CT was available. A prospective study of all patients attending the hot clinic over a period of 6 weeks (Feb - Apr 2013) was undertaken. The patient demographics, reason for attendance, procedures carried out and admission prevention were recorded. The outcome of the attendance was recorded as were follow up attendances. In patients discharged or asked to return for follow up a clinical judgement was made as to admission prevention. Results: 341 patients attended the hot clinic during the study period. 172 were new referrals. The age range of patients was 16–92, mean 47 years (M = 148 F = 193). 145 were direct GP referrals and 27 were referred from the emergency department. 97 (28 %) attendances were the follow-ups from the hot clinic and 61 (17.80 %) attendances were from the ward. A wide range of surgical pathology was seen the most common attendance reasons being abdominal pain, anal pathology or post operative wound problems. There were 38 admissions at primary attendance. Primary admission was prevented in 133 patients. The cost per day at BHRUT is £300. This translates to a saving of £39,900 over the 6 weeks period of the study even if patients were only admitted for one day or £345,800 over a 12-month period. Conclusions: The advent of the surgical hot clinic reduced admissions. There are obvious advantages to patients affording rapid access to the surgical service for assessment. It is also financially beneficial to the health care provider and helps in better utilisation of hospital beds

O209 - Morbid Obesity

O211 - Clinical Practice and Evaluation

Symptomatic Mesenteric Internal Hernia After A Gastric Bypass: Does Closure of the Defect Reduce the Incidence?

The Precious Trial: A Step-Up Approach, CRP First Followed by CT-SCAN Imaging to Ensure Quality Control After Major Abdominal Surgery

D. Losada, F. Julien, J.D. Yelle, J. Mamazza The Ottawa Hospital, Ottawa, Canada Background: Internal Hernia (IH) is a well-known and potentially serious complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Surgeons are increasingly performing primary closure of the mesenteric defect to mitigate the risk of IH, but definitive evidence in favor of this technique has not been fully elucidated. The objective of this paper was to investigate the incidence of acute symptomatic mesenteric internal hernia after LRYGB, with a focus on the influence of mesenteric defect closure on the incidence of IH. Methods: A cohort of 470 consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass procedures performed from December 2011 to December 2012 was selected from a prospective hospital database. Chi-squared test was used to compare the incidence of acute symptomatic internal hernia between patients who did not have a mesenteric defect closure (Group 1) and patients who had a mesenteric defect closure (Group 2). Results: Patients in Group 1(n = 271) and Group 2 (n = 199) were similar for baseline characteristics, age, sex and BMI. A total of 14 (3 %) patients presented with acute symptomatic mesenteric IH. Of these, 12 were in patients who did not have a closure (Group 1) and 2 in patients who had a closure (Group 2). The mean follow-up was of 1.7 years. A significantly higher proportion of IHs occurred in patients in Group 1 (n = 12) compared with those in Group 2 (n = 2) (p-value = 0.03). In Group 1 the mean interval from initial surgery to IH repair was 412 days. Of the 12 patients, 1 (8.3 %) presented with ischemic bowel and 2 (16.7 %) required a conversion to laparotomy to reduce the hernia. In Group 2 the mean interval from initial surgery to IH repair was 407 days. In these 2 cases the IH repair was done laparoscopically. Conclusion: The overall incidence of acute symptomatic IH after LRYGB is relatively low. Bariatric patients who had a mesenteric defect closure appear to have a decreased likelihood of IH. However, more research is needed to confirm our results and evaluate long-term IH outcomes.

J. Straatman, D.L. Peet, van der, S.S. Gisbertz, R. Holman, M.A. Cuesta VU Medical Center, Amsterdam, The Netherlands Objective: Evaluate the effect of a standardised postoperative monitoring protocol (including CRP and CT-scan imaging) on morbidity and mortality due to major postoperative complications after Major Abdominal Surgery (MAS). Rationale: After MAS, 20 % of patients will have a major complication, which requires invasive treatment and is associated with increased morbidity and mortality. A quality control algorithm after MAS aimed at early identification of patients at risk of developing major complications can decrease associated morbidity and mortality. Literature studies show promising results for C-reactive protein (CRP) as an early marker for postoperative complications, however clinical significance has yet to be determined. Here we propose a randomised clinical trial in order to determine the effect of postoperative monitoring with standardised CRP measurements on morbidity and mortality. Methods: In this multicenter, randomised, clinical trial standard postoperative monitoring is compared to postoperative control according to the PRECious protocol, which implicates standardised measurement of CRP levels. If CRP levels exceed 150 mg/L on postoperative day 3,4 or 5, an enhanced CT-scan of the abdomen is performed. Primary outcome in this study is a combined primary outcome, entailing all morbidity and mortality due to postoperative complications. Preliminary Results: Several studies have found CRP as an adequate marker for postoperative complications after major abdominal surgery. Based on our own retrospective data of 399 patients that underwent MAS, a cut-off level of 150 mg/l is proposed for postoperative days 3,4 and 5, as a marker for major complications, with an overall sensitivity of 78,1 %, a specificity of 53,7 % and a negative predictive value of 89,1 %. Serum CRP is non-specific for location, thus additional imaging is required. CT-scan imaging is the current imaging modality of choice. In our retrospective data, CT-scan imaging showed a sensitivity of 91,7 % and specificity of 100 % for diagnosis of major complications. Expectations/Conclusions: CRP and CT scanning have shown to be able to differentiate between uncomplicated and complicated postoperative courses. Currently their use is only on demand. The here presented PRECious protocol is a postoperative Quality Control algorithm, which aims at early diagnosis and treatment of patients with major complications, thereby decreasing morbidity and mortality.

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Surg Endosc

O212 - Clinical Practice and Evaluation

O216 - Different Endoscopic Approaches

The Quality Control of Laparoscopic Technique

Video Assisted Ablation of Pilonidal Sinus. A New Endoscopic Minimally Invasive Treatment. Preliminary Results by a Prospective Comparative Study

P.I. Lukovich, O. Kakucs, I. Figura, N. Bere´nyi, N. Dobo´ Semmelweis University, Budapest, Hungary Aims: The precise effectuation of a laparoscopic surgical intervention is not only a matter of personal surgical skill, but it is important concerning patient safety as well. The aim of the study was to compare the current methods used for the laparoscopic quality control. Method: Data of 14 surgeons working at the 1st Department of Surgery, Semmelweis University from Budapest was processed. As objective factors the number of LC (laparoscopic cholecystectomies) performed, the average operation time and FLS (Fundamentals of Laparoscopic Surgery) task completion time on box trainer were recorded. Moreover based on personal surgical experience participants were asked to score each other’s laparoscopic technique on a scale from one to ten. A video of an ideal LC operation and FLS tasks performed on box trainer were recorded as well, which was then analysed by two experts in laparoscopic surgery and scored on the basis of the Japan ESSQS (Endoscopic Surgical Skills Qualification System) and GOALS (Global Operative Assessment of Laparoscopic Skills). Pearson Correlation was used to evaluate the data, where a level of p \ 0.05 was considered statistically significant. Results: The correlation between the objective factors (number of previous LC, operation time and task completion time on box trainer) proved to be negligible. At the same time moderate and strong correlation was demonstrated between the subjective factors (scoring each other’s laparoscopic technique, video scoring of the LC and FLS tasks by two experts). There was no correlation between the objective and subjective factors either. Conclusion: At the moment in several European countries novices have to perform a defined number of LC and rarely a laparoscopic course on box trainer that is mandatory for the surgical board examination. However this does not ensure a suitable quality control. For this reason there is a need for a specific qualification system based on video analysis in the general surgery residency education.

M. Milone, M. Musella, F. Milone University ,,Federico II,, in Naples, Naples, Italy Aims: Video assisted ablation of pilonidal sinus (VAAPS) is a new endoscopic minimally invasive treatment based on the concept of complete removal of the sinus cavity with a minimal surgical wound. In an attempt to validate the effectiveness of the VAAPS, we have designed a comparative study (clinicaltrial.gov NCT01963273) between the conventional and the new minimally invasive treatment. Methods: A prospective electronic database was analyzed. Two surgical procedures were evaluated: video assisted ablation of pilonidal sinus (Experimental group) and conventional excision with primary midline closure (Control group). Data obtained included age, gender, obesity, smoke, sinus characteristics, operative time, pain, time off work, time to walk without pain, time to sitting on the toilet without pain, recurrences, wound infections and satisfaction. Results: 102 patients were included in our analysis, 55 underwent video assisted ablation of pilonidal sinus (experimental group) and 47 conventional excision with primary closure (control group). Despite a longer operative time, pain scores were significantly lower at each time point evaluated and an immediate return to work and normal activity was obtained after VAAPS. Above all, whereas after conventional treatment, infection developed in 6 (12,7 %) patients and recurrence in 5 (10,6 %) patients, after VAAPS, only 1 (1,8 %) infection and 1 (1,8 %) recurrence were identified. Conventional treatment was associated with an increased risk of infection (OR: 11.6, 95 % CI: 1.028–132.5, p = 0.047) and with a trend towards a higher incidence of recurrence (OR: 8.1, 95 % CI: 0.938–69.965, p = 0.057). Furthermore Video assisted ablation of pilonidal sinus was associated with a higher patient satisfaction (beta = 0.541, 95 % CI: 0.520–0.987, p \ 0.001). Conclusion: In the new era of minimally invasive surgery, pilonidal sinus could become a disease that can be treated by an endoscopic approach. Although, further studies are needed to give definitive conclusion, our results are encouraging to consider the adoption of this technique the most effective way to treat pilonidal sinus.

O214 - Thoracoscopic Surgery

O217 - Intestinal, Colorectal and Anal Disorders

Minimally Invasive Treatment of Advanced Lung Cancer

May Peritoneal Aspiration Without Irrigation Decrease Postoperative Complication Rate in Perforated Appendicitis?

V.V. Grubnik, V.E. Severgin, A. Agrahari Odessa national medical university, Odessa, Ukraine Introduction: Currently, there is no effective treatment of advanced lung cancer. The aim of the study was to improve quality of life and survival of patients with advanced lung cancer using minimally invasive techniques. Methods: Minimally invasive treatment was used in 49 patients with central form of lung cancer, stages IIIA-IV, complicated by hemorrhage. There were 44 men, and 5 women. Age varied from 62 to 78 years. Morphologically, 32 patients had squamous cell carcinoma, 11 patients had adenocarcinoma, 6 patients had small cell carcinoma. 3 patients had lung cancer with massive tissue destruction. Technique: The first step included endovascular embolization of bronchial artery (EVEBA). After a short period, around 2 to 3 weeks, Nd-YAG laser recanalization of tumor stenosis was performed. Results: Stable haemostatic effect was achieved in 49 patients. In 2 patients embolization was repeated in 3 and 5 months. Recanalization of bronchi was successful in all the patients. Recurrent stenosis occurred after 4 months in 8 patients (16.3 %). Chemoradiation was used after embolization in every patient. Then, 7 patients underwent lobectomy and 2 patients underwent pulmonectomy. Finally, 9 patients (18.3 %) were operated radically. Conclusions: 1. EVEBA allows to achieve stable homeostasis in most of the patients with advanced lung cancer complicated by hemorrhage. 2. Using of laser recanalization of malignant stenosis, with further chemoradiation, can improve quality of life and survival of such patients. 3. Some of them may become radically resectable.

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N. Ozlem Samsun education and research hospital, Samsun, Turkey Introduction: no study has compared peritoneal lavage with irrigation + aspiration(IA)vs only aspiration without irrigation (AwI) in perforated appendicitis(pa). Objectives: Our aim is to determine if irrigation in pa decreases the postoperative complications(POC) (intra abdominal abscess(IAA),wound infection(WI),postoperative ileus(POI)rate,length of hospital stay(LOS),first oral intake(FOI) and operation time(OT). Material/Patients and Methods: A randomised prospective study, march 2011to august 2012 279 consecutive patients with acute apandicitis underwent appendectomy. Results: 14 of279 patients have pa.7of those had IA,7 had AwI.There are no differences between two groups in terms of age sex.4 patients suffered fromPOCs;2 have WIs,one has IAA, forth patient has POI.1of4 patient who has POC were in AwI group. the other 3-patients were in IAgroup.We found a lower overall complication rate in the AwIgroup,compared to the IA(14.2 %vs42.8 % p = 0.04) Conclusion: It is becoming common practice routinely irrigate the peritoneal cavity during appendectomy when perforation exists.However,no study has shown if a causative relationship exists between use of intraoperative irrigation and the development of postoperativeIAAs.Moore et al’s results show a trend toward an increase inpostoperative abscess with the use of irrigation.we comparedPOC rate between the two methods.this studymust be made on large group of patients According to our results, IA procedure increase postop complication in pa. It may be avoided peritoneal lavage even in pa.

Surg Endosc

O218 - Liver and Biliary Tract Surgery

O220 - Emergency Surgery

Subtotal Cholecystectomy Versus Total Cholecystectomy in Complicated Cholecystitis

Formation of Adhesions After Laparoscopic Appendectomy

V.V. Grubnik, V.V. Ilyashenko, M.V. Prikupenko, V.V. Grubnik Odessa national medical university, Odessa, Ukraine

S. Delibegovic1, M. Katica2, A. Koluh3 1

University Clincal Center Tuzla, Bosnia-Herzegovina; 2University of Sarajevo, Bosnia-Herzegovina; 3Cantonal hospital Zenica, BosniaHerzegovina

Introduction: In severe cholecystitis laparoscopic cholecystectomy (LC) can be technically difficult with a high risk of duct and arterial injury. To prevent injury, conversion to open cholecystectomy (OC) is usually made. Another solution is performing of laparoscopic subtotal cholecystectomy (LSTC). Aims: of the study was to investigate the safety and complications of laparoscopic subtotal cholecystectomy (LSTC) compared to conversion to OC for technically difficult cholecystitis. Methods: A retrospective review of 5708 LC performed from 2005 to 2013 in single center was done. In the 1st period, from 2005 to 2008, 2720 LC were performed. In technical difficulties conversion to OC was done. In the 2nd period, from 2009 to 2013, 2988 LC were performed. In technical difficulties LSTC was done. Results: During the 1st period, there were 127 patients (4,7 %) with technically difficult LC whom conversion to OC was done. Complication rate among these patients was 23 %, bile duct injuries were detected in 3 patients (2,4 %), mortality was 1,6 %. During the 2nd period, there were 84 patients with technically difficult LC, thus LSTC was performed for 69 patients of them. Therefore, conversion to OC was made for the remaining 15 patients (0,5 %). There were no bile duct injuries and no mortality in these patients. Complication rate after LSTC was 8,7 %. Quality of life was assessed 6–48 months after surgery in 102 patients whom conversion to OC was done, and in 58 patients whom LSTC was done. Quality of life was better in patients after LSTC. Conclusion: LSTC is good alternative to conversion to OC in complicated cases. It is good solution to prevent bile duct injury and save a principle of minimally invasive procedure in technically difficult LC, especially in high risk patients.

Background: Various methods of securing the appendix base are used in laparoscopic appendectomy. The use of different materials cause except different inflammation, foreign body reaction and infection, and different formation of adhesions in the surgical field. Adhesions potentially lead to chronic pain and intestinal obstruction. Methods: One hundred and twenty rats were sub-divided randomly into four experimental groups of N = 30 rats/group: Group 1: the appendix base was secured using a Vicryl ligature; Group 2: the appendix base was secured using a PDS ligature; Group 3: the appendix base was secured with a Hem-o-lok plastic clip, and in Group 4: the resection of the appendix was performed with a linear stapler. Ten animals from each experimental group were sacrificed on days 7-, 28- and 60- post-surgery, for the assessment of the formation of adhesion, according to the score of Surgical Membrane Study Group (SMSG). Results: The SMSG score was statistically significantly higher on Day 7 than on Day 28 (U = 466.5, p = 0.0005) and Day 60 (U = 154.0, p \ 0.0001). The PDS group had a statis-tically significantly lower score than the Hem-o-lok group (U = 15.5, p = 0.003), but it was not statistically different from the score of the Stapler group (U = 44.5, p = 0.343). The Stapler group had a statistically lower score than the Vycril group (U = 10.00, p = 0.0005) and the Hem-o-lok group (U = 5.9, p \ 0.0001). Conclusion: Considering our results, it may be said with caution that titanium clips which cause smaller formation of adhesions tissue reaction, may have an advantage as a method for securing the base of the appendix during a laparoscopic appendectomy.

O219 - Emergency Surgery

O221 - Emergency Surgery

Comparison of Traditional and Minimally Invasive Approach in the Treatment of Patients with Acute Complicated Appendicitis

Laparoscopic Lavage and Drainage as a Treatment Strategy for Perforated Diverticulitis with Generalizad Peritonitis. LongTerm Follow Up at Texas Endosurgery Institue

A.V. Sazhin1, B.K. Laipanov2, S.V. Mosin1, A.T. Mirzoyan2, A.A. Kodjoglyan2, M.A. Dzusov2 Russian state medical university, Moscow, Russia; 2Pirogov Russian National Research Medical University, Moscow, Russia

1

Laparoscopic appendectomy for acute appendicitis is one of the most common surgical operations. Our aim was to compare the results of laparoscopic and open approach in patients with appendicular mass, appendicular abscess and generalized peritonitis. Material and Methods: The results of treatment of 203 patients with acute appendicitis complicated for diffuse appendicular peritonitis, appendicular mass, appendicular abscess (pre- and intraoperative) and perforation at base of the appendix. Patients were divided in two groups depending on the approach used for surgical treatment. The main group included 104 patients from 2009 to 2012, who underwent a minimally invasive approach (laparoscopic appendectomy or ultrasound-guided draining technique). Control group included 99 patients treated by 2004 and 2008 with traditional open approach. Ultrasound-guided draining treatment of abscesses was performed in 17(16.3 %) patients in the main group and open surgery - in 18(18.2 %) in the control group. The remaining patients underwent laparoscopic or open appendectomy. We used intracorporal laparoscopic suturing for closing stump of the appendix in some cases. Results: the comparative description of intraoperative period we observed reduction in the duration of surgical treatment in the main group (58,8 ± 12,21 min) compared with control group (83,5 ± 10,83 min, ? = 0,032). Length of hospital stay in main group was less than in control group (7,4 ± 3,1 days and 10,4 ± 5,8 days, respectively, p = 0,047). We observed reduction in the number of inflammatory wounds complications after laparoscopic operations compared with open surgery (5–4.95 %, and 17–18.3 %, respectively, ? = 0,004). In the main group we noted the development of intra-abdominal abscess in 3(2.9 %) cases, 2 (1.9 %) of its were previously operated for diffuse appendicular peritonitis, an 1(1 %) had an appendiceal mass. All patients underwented successful ultrasound-guided draining of abscess. In the control group, 4(4.1 %) patients had abscess formation in the postoperative period (? = 0,371). In this group, treatment strategy was open approach. Differences between the two groups was not statistically significant. Conclusions: Minimally invasive treatment for acute complicated appendicitis should be the method of choice, and has a number of advantages, such as reducing the number of postoperative complications and duration of treatment.

M.A. Hernandez, M.E. Franklin Jr Texas Endosurgery Institute, San antonio, United States of America Background: The treatment of perforated diverticulitis is changing from the current standard of laparotomy with resection, Hartmann procedure, and colostomy to a minimally invasive technique. This study was designed to investigate a safer and more effective laparoscopic method for managing acute perforated diverticulitis with generalized peritonitis. In this article, we report our experience of a laparoscopic peritoneal lavage technique with delayed definitive resection when necessary. Methods: A consecutive series of patients who underwent emergent LLD (Laparoscopic Lavage and Drainage) for perforated diverticulitis at the Texas Endosurgery Institute from April 1991 to January2013 were identified from a retrospectively designed database. All procedure related information was collected and analyzed. Results: 97 patients were included in the study, 63 male and 34 female. The average patient age was 62 years. The average operating time was 60 minutes. There was one conversion to a LHP (Laparoscopic Hartmann Procedure) due multiple intestinal perforation. Three patients were re-operated, one re-lavage, two open Hartmann procedure for worsening of septic symptoms during post LLD. 55.3 % of the patients underwent elective laparoscopic sigmoid colectomy. During the mean follow-up of 96 months, no other patients required further surgical intervention. Conclusions: LLD of the peritoneal cavity can be performed safely and effectively in the treatment of severe diverticulitis with or without gross fecal contamination. It is associated with a decrease in overall cost of treatment; the use of a colostomy is avoided; patient improvement is immediate and there is a reduction in mortality and morbidity as definitive laparoscopic resection can performed nonemergent fashion. LLD does not remove the pathogenic source; however, the clinical application procedure to our patients showed significantly better short- and long-term clinical outcomes for managing perforated diverticulitis with various Hinchey classifications. Perhaps the most important benefit, other than avoiding a colostomy, is the association of fewer wound complications such as dehiscence, wound infection and risk of hernia formation due to laparotomy incision and stoma site. LLD should be considered in all patients in whom medical and/or percutaneous treatment is not feasible. It carries minimal morbidity and should be considered the standard of care.

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Surg Endosc

O222 - Emergency Surgery

O224 - Different Endoscopic Approaches

Videolaparoscopy in Diagnosis and Treatment of Early Acute Adhesive Small Bowell Obstruction Caused by Gynecological Abdominal Operations

Polymeric Clip Application for Stump Closure in Laparoscopic Appendicectomy: A Feasible Alternative

M.E. Timofeev, V.G. Breusenko, S.G. Shapovalyants, E. Fedorov, I.P. Marchenko, V.N. Kretzu Pirogov Russian National Research Medical University, Moscow, Russia Aims: to study the role and performance capabilities of Urgent Laparoscopic Interventions (ULI) in diagnosis and treatment of early acute adhesive small bowell obstruction (EAASBO) caused by surgery of gynecological pathology. Materials and Methods: between 1994 and 2012 ULI was performed in 42 patients with EAASBO following midline laparotomy (34) and laparoscopic (8) gynecological surgery. Age ranged from 18 to 51 years, mean 37,7 +\-5,7. In 28 patients operations, causing EAASBO were urgent in 14 patients, planned - in 28 patients: supracervical uterus amputation with (12) and without (8) oophorectomy, complete hysterectomy with oophorectomy and omentectomy (12), adnexectomy and\or ovarium resection - 5, tubectomy - 4, caesarian section - 1. Signs and symptoms of EAASBO appeared from 5 hours to 20 days past intervention, mean 9,3 +\-5,3 days. Diagnostic program, including plain abdomen radiography, enterography, abdominal ultrasound investigation and laparoscopy defined the EAASBO diagnosis in 39 (86,6 %) of patients while in 3 patients inflammatory infiltration of pelvis. In 20 patients with simple form of EAASBO endoscopic nasointestinal drainage was performed for 5–14 hours. Results: Laparoscopic instrumental revision defined the contra-indications for further laparoscopic manipulation in 12 (28,6 %) patients: total bowel dilatation more than 5 cm (3), solid adhesive small bowel mass (7), pelvioperitonitis (1), failure to create pneumoperitpneum due to anatomical and technical aspects. All underwent surgery thru median laparotomy. In 30 (71,4 %) patient laparoscopic operation was successfully performed. Adhesions were generally divided using soft bowel graspers and aquadissection, rarely - using scissors, unipolar coagulation, ultrasound SonoSurg (Olympus) scalpel. Operation time ranged from 34 to 110 minutes, mean 67,2 +\-19,3 minutes/ There were no intraoperative complications. Postoperative complications included EAASBO relapse (2), stump inflammation (1), bilateral salpingitis (1), generalized peritonitis and EAASBO relapse with generalized peritonitis. Three of them successfully treated by surgery thru median laparotomy. There were no lethal outcomes. Conclusion: EAASBO can occur after laparotomic and laparoscopic gynecological operations regardless to extent of operation. Combined with abdominal ultrasound investigation and enterography, laparoscopy helps to Laparoscopy is effective in minimally-invasive treatment of this pathology in 86,6 % of patients.

K. Hashmi1, S. Taribagil1, I. Ahmed1, N. Kansal2, C. Bastianpillai1, H. Granberg1, L. Couceiro Soares1 Barnet Hospital, Herts, United Kingdom; 2Newcastle University, Newcastle upon tyne, United Kingdom

1

Introduction: Laparoscopic Appendicectomy (LA) has largely replaced conventional open appendicectomy. Different techniques have been tried and reported in literature for safe appendicular stump closure. However, no gold standard technique has been accepted so far. Aims: To evaluate the feasibility, safety, cost-effectiveness and complications of polymeric nonabsorbable clips (Hem-o-lok) and to compare it with the standard technique of preformed endoloop application for closure of appendicular stump in LA. Method: We retrospectively compared application of conventional endoloops versus hem-o-loks for stump closure during LA by analysing the data over a 22 month period from September 2011 to July 2013 in a district general hospital. A total of (n = 142) patients were considered for diagnostic laparoscopy for suspected acute appendicitis. 20 patients were excluded as 11 patients did not need an appendicectomy and 9 patients were converted to open procedures. Remaining (n = 122) were divided into endoloop group (n = 58) and Hem-o-lok group (n = 57). Data regarding demographics, anaesthetic time, complications, re-operation, hospital stay and readmission was collected using patient records and operation room records. Results: A total of 122 laparoscopic appendicectomies were performed. The demographics were comparable between the two groups. The mean anaesthetic time for hem-o-lok group was 74.58 minutes vs 94.29 minutes for endoloop group (p = 0.301). The cost of endoloops was £54 vs. £31 for hem-o-lok. One patient in the hem-o-lok group developed an intra-abdominal collection requiring re-operation. There were 7 re-admissions; 4 in Hem-o-lok group and 3 in endoloop group. However, there was no statistical significance difference in complications or re-operation (p = 0.342) in the two groups. Conclusion: Polymeric clips application is an equally safe and relatively less time consuming technique of appendicular stump closure and should be deployed where feasible. Further prospective randomized controlled trials with detailed cost analysis will be needed to consolidate the use of this technique.

O223 - Emergency Surgery

O225 - Intestinal, Colorectal and Anal Disorders

Percutaneous Transhepatic Gallbladder Aspiration: Is a Good Alternative of Cholecystostomy for High Surgical Risk Patients with Acute Cholecystitis?

Laparoscopic Right Colectomy Versus Laparoscopic-Assisted Colonoscopic Polypectomy For Endoscopically Unresectable Polyps: A Randomized Controlled Trial

G. Ivakhov, N.S. Glagolev

C.M. Bergamaschi1, C. Foppa1, C. Lascarides1, P.I. Denoya1, J. Buscaglia1, S. Nagula1, J.C. Bucobo1, M. Bishawi1, S. Palmer1, L. Martinek2

First Moscow State Medical University, Moscow, Russia Background: The aim of this study was to evaluate the effectiveness and safety of percutaneous transhepatic gallbladder aspiration (PTGBA) and percutaneous transhepatic cholecystostomy (PTGCS) for the treatment of acute cholecystitis. US-guided cholecystostomy is now well-known and the most frequently used method of minimally invasive treatment for acute cholecystitis in critically ill and high surgical risk patients. Despite its efficacy and minimal invasiveness up to 12 % of patients after percutaneous cholecystostomy have serious complications like hematoma, biliary peritonitis, dislocation of catheter and pneumothorax. Some studies have reported decrease in quality of life in due to catheter needs to stay in the gallbladder for 2–4 weeks. The mortality rate of cholecystectomy in patients at high surgical risk may reach 18 %. Method: PTGBA was carried out at the operative table under local anaesthesia with a 3.5 MHz ultrasound sector transducer and 18G puncture needle by percutaneous transhepatic approach. In this prospective study were included 103 high surgical risk patients with acute cholecystitis (PTGBA was performed in 51 patients, PTGCS - for 52 patients) between October 2010 to January 2014. All patients were older than 60 years. Inclusion criteria with signs of acute cholecystitis, lack of effect of conservative therapy during 12–24 hours after admission, ASA III-IV grade. Patients with jaundice, choledocholithiasis were excluded. Results: Successful therapy was obtained in 49 patients with PTGBA (96 %) and in 49 patients with PTGBD (94,2 %). In 3 cases after single PTGBA as result of lack improvement was needed 1 repetitive gallbladder puncture, 2 gallbladder drainage with good clinical response in 72 hours. Complication rate for cholecystostomy group were 11,5 % (6 patients), 3 of them (5,8 %) had serious complications need emergency operation. One of this patients died (mortality rate 1,9 %). No complications or procedure-related deaths occurred in group with gallbladder aspiration. Mean hospital stay after PTGBA and PTGCS was 10,5 days and 21 day respectively (p \ 0,05). Conclusion: PTGBA is a safe and effective procedure that can be performed without any severe complications. At this stage of the study was revealed significant advantage of PTGBA over PTGCS in treatment of acute cholecystitis for high surgical risk patients.

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State University of New York, Stony brook, United States of America, 2Czech Republic

Introduction: A randomized controlled trial was conducted to test the hypothesis that there is no difference in efficacy between laparoscopic right colectomy (LRC) and laparoscopic-assisted colonoscopic polypectomy (LACP) for endoscopically unresectable polyps. Methods: This was a single-center RCT. Patients with endoscopically unresectable polyps were allocated to LRC or LACP. Patients with non-lift sign, high-grade dysplasia, adenocarcinoma or familiar adenomatous polyposis were not included. Efficacy was a composite endpoint including diagnostic accuracy, complication rates, and length of hospital stay. Results: Fourteen LRC patients were comparable to 14 LACP patients for age (p = 0.634), gender (p = 0.58), BMI (p = 0.95), ASA class (p = 0.53), or previous abdominal surgery (p = 0.151). There was no difference in preoperative morphology (p = 0.50), location (p = 0.264), size (p = 0.474), and histology of the polyps (p = 0.199). LRC patients had longer operating time (179 vs. 95 min, p = 0.001), more estimated blood loss (63 vs. 13 cc, p = 0.001), and required more IV fluids (3.1 vs. 2.1 liters p = 0.049). LRC patients took significantly longer to pass flatus (2.88 vs. 1.44, p = 0.002), resume solid food (3.94 vs. 1.69, p \ 0.001), and leave the hospital (4.94 vs. 2.63, p \ 0.001). Postoperative complications (p = 0.381), readmissions (p [ 0.9), and reoperations (p = 0.515) did not differ. There was no difference in accuracy of diagnosis (p = 0.366), or size of polyps (p = 0.474). Conclusion: This study did not show a difference in efficacy between LRC and LACP for endoscopically unresectable polyps.

Surg Endosc

O227 - Intestinal, Colorectal and Anal Disorders

O229 - Intestinal, Colorectal and Anal Disorders

A Time-Motion Study for Elucidation of Technical Issues Pertaning to Laparoscopic Low Anterior Resection for Rectal Cancer

Nerve-Preserving Operation for Prophylaxis of Pelvic Organs Disorders After Complex Treatment for Rectal Cancer

I. Takemasa, U. Uemura, J. Nishimura, T. Mizushima, H. Yamamoto, Y. Doki, M. Mori

S.V. Pozdnyakov1, I.E. Khatkov1, Yu.A. Barsukov2, A.O. Atroshchenko1 1

Graduate School of Medicine, Osaka University, Suita, Japan

Moscow State University of Medicine and Dentistry, Moscow, Russia; 2Russian Cancer Research Institute, Moscow, Russia

Background: Laparoscopic surgery for rectal cancer is technically difficult and somewhat limited for routine application. Problematic issues include technical challenges due to the introduction of multiple forceps into the narrow pelvic cavity and contamination of the laparoscope lens often making it difficult to perform scope work for good operative visualization. In addition, transection of the rectum and low-level anastomosis are particularly difficult. Surgeons have different learning curves for acquisition of surgical skills. No detailed study has yet been attempted to elucidate specific problems associated with the procedure. Objective: The study was conducted to identify technical issues related to laparoscopic low anterior resection (LAR) for rectal cancer and examination of measures to overcome those issues. Methods: A time-motion analysis of laparoscopic LAR as performed by experts and by beginners was used to elucidate technical problems. The study included 50 cases treated by 5 surgeons (2 experts and 3 beginners) who performed the procedure in 10 cases each. In addition, the intraperitoneal procedure was divided into 5 modules. Measurements pertaining to each module were performed. Results: Sufficient exposure of the surgical field achieved by the experts immediately after the start of surgery resulted in smooth flow of subsequent maneuvers, infrequent need for removal of the small intestine from the surgical field, relatively short operation time, and minimal blood loss. For beginners, exposure of the surgical field immediately after the start of surgery was insufficient, the small intestine appeared in the surgical field many times during surgery, unstable maneuvers were noted, the operation time was relatively long, and blood loss was increased. Conclusions: The time-motion analysis identified problems in surgical steps performed during laparoscopic LAR. Complete exposure of the surgical field at the start of surgery, a fully medial-to-lateral approach, and appropriate surgical techniques that reduce bleeding improve quality of the surgery. Awareness of these factors in performing the surgical procedure will ensure rapid acquisition of stable skills and may lead to a more rapid increase in the penetration of laparoscopic rectal resection, leading to better surgical outcomes and improved quality of life for patients.

Background: Complex treatment and laparoscopic surgery for rectal cancer increased rate of pelvic organs disorders: anal inconsistency, urogenital disorders. It depends of sphincter and vegetative nervous system damaging. Aims: to estimate the role of nerve-sparing surgery as prophylaxis of pelvic organs disorders Materials and Methods: Prospective nonrandomized trial. Since 2011 to 2013y. 73 patients underwent complex treatment scheme for rectal cancer T2–4 N0–2 M0–1 stage (43-male and 30- female). Average age -55.3 ± 13,0 year. All patients underwent preoperative chemoradiotherapy. Operations with vegetative nerve-preserving (NP) performed in 49 patients, 10 patients -underwent partial NP procedure, 14 patients with local advanced cancer complete autonomic nervous resection (CANR). Evaluation of pre-and postoperative patient conditions performed according to the IPSS, QoL, Wexner scales, manometry, sphincterometry. Results: in NP group: self urination restored in 37 patients up to 5th day; 9 patients -from 6th to 9th day; 2 patients-to12ve day and 1 patient-14th day after surgery. According to the IPSS scale, 46 patients after surgery had worse results in comparison with primary data, but 6 weeks later there were no differences. All patients with partial NP had self urination restoration from 5th to 12ve day after surgery but all of them had pore IPSS parameters, which restored only in 2 patients. Indicators of QoL in these groups have not changed significantly in postoperative period. 12ve patients, who underwent operation CANR had repeated bladder catheterization, 4 of theme -bladder myostimulation; IPSS parameters was significantly pore 3 moth later after surgery and restored only in 2 patients; QoL indicators pointed expressed dissatisfaction state of urination in all patients. The function of the anal continence 2 months after: in group with full NP- 96 % had disorders; in groups with partial NP and CANR -disorders admitted in 100 % of cases. 6 month after surgery a marked improvement was admitted at first two groups: 46 % and 44 % respectively, and at group with CANR -lack of improvement; QoL indicators - expressed dissatisfaction of urination in all patients. Conclusion: nerve-preserving operations could reduce incidence and degree of urological disorders and preserve anal sphincter function

O228 - Intestinal, Colorectal and Anal Disorders

O230 - Intestinal, Colorectal and Anal Disorders

Laparoscopic-Assisted Rectal Cancer Resection: Long-Term Outcomes in A 15-Year Cohort From a Single Center

Safe Radical Lymph Node Dissection Along the Middle Colic Artery by Wide Separation of the Mesocolon

D. Saavedra-Perez, S. Delgado, R. Almenara, A Ibarzabal, M.C. Pavel, J.P. Arribas, M. Bertrand, C. Adelsdorfer, D. Momblan, X. Morales, R. Bravo, R. Corcelles, A.M. Lacy

K. Yamamoto, D. Uematsu

Hospital Clinic of Barcelona, Barcelona, Spain Aims: The aim of this study was to evaluate the surgical and long-term oncological outcomes of patients submitted to laparoscopic rectal cancer resection in our Institution. Methods: In a prospective manner, from March 1995 to December 2010, patients diagnosed with adenocarcinoma of the rectum were enrolled. Demographic, surgical and pathological and oncological characteristics were evaluated. Primary endpoint was overall survival; secondary endpoints were disease-free survival and surgical related morbidity. Data were analyzed according to the intention-to-treat principle. Results: A total of 522 patients were evaluated. The mean follow-up was 42 months (0–127 months). The procedure was performed with intention-to-cure in 86.8 % of the cases. Tumors below 10 cm from anal verge were seen in 70.2 % of the patients. Postoperative complications were present in 167 patients with anastomotic leakage representing the 12.2 %. The 30-day postoperative mortality was 1.3 %. Overall survival rates were 95 % at 1 year, 81 % at 3 years and 68 % at 5 years. Cancer-specific survival rates were 97 % at 1 year, 87 % at 3 years and 79 % at 5 years. Disease-free survival was 87.6 % at 1 year, 68 % at 3 years and 62 % at 5 years. Local recurrence was diagnosed in 26 patients (4.9 %). Conclusions: This series confirms the feasibility and safety of laparoscopic resection in rectal cancer, with adequate oncologic long-term results Diagnosis, treatment and follow-up protocols are vital to continue this trend.

Saku central hospital, Saku, Japan Aims: Since radical dissection of regional lymph nodes is considered to improve oncologic surgery outcomes, the lymph node dissection along the middle colic artery can be necessary for advanced cancer located in transverse colon or ascending colon near the hepatic flexure. However, the feasibility and safety of dissection around the root of the middle colic artery has not been fully verified. We present a safe procedure of lymph node dissection for laparoscopic colectomy to dissect the regional lymph nodes along the middle colic artery. The heart of this procedure is the wide separation of the transverse mesocolon into two layers in order to expose and identify the course of the middle colic artery and its branches. Methods: Between October 2009 and October 2013, 67 patients of advanced colon cancer underwent curative laparoscopic colectomy using medial approach with radical lymph node dissection along the middle colic artery. The mesocolon is dissected between the superficial layer of the fat tissue including lymph nodes and the deep layer of the vascular sheath along the superior mesenteric artery and middle colic artery continuously. After exposing the course of middle colic artery and its branches, supplying and draining vessels can be cut at their roots. Then, the colon is mobilized, and the specimen is retrieved through the small incision. Results: No serious intraoperative complications occurred. The median number of harvested lymph nodes was 29 (range 13–58). The median total operative time was 243 (range 118–320). The intraoperative blood loss was minimal (range 0–20 g). The postoperative course was uneventful for all patients. Conclusion: We consider this to be one of feasible and safe methods for middle colic lymph node dissection during laparoscopic colectomy.

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Surg Endosc

O231 - Intestinal, Colorectal and Anal Disorders

O233 - Intestinal, Colorectal and Anal Disorders

Down-To-Up Transanal Notes TME Resection for Rectal Cancer: Preliminary Results of a New Therapy Concept

Two Years Oncologic Outcomes of 100 Robotic Rectal Resections for Cancer

R. Zorron1, H.N. Phillips2, C. Bothe3, T. Junghans3

W. Petz, F. Luca, I. Monsellato, G. Scifo, R. Biffi, P.P. Bianchi

1

European Institute of Oncology, Milan, Italy

Klinikum Bremerhaven Reinkenheide, Bremerhaven, Germany; Hospital Universitario Gafree Guinle UNIRIO, Rio de janeiro, Brazil; 3Division Innovative Surgery, Klinik fu¨r Allgemein-, Viszeral-, Thorax- und Gefa¨s, Bremerhaven, Germany

2

Objectives: The treatment of rectal cancer is facing a paradigm shift in the last few years, with the impact of new endoscopic and neoadjuvant concepts. The new concept of Downto-Up transanal TME resection using an adapted single port platform (TAMIS-transanal minimally invasive surgery) was first clinically introduced by our group in 2009. The present study describes the clinical experience of oncologic Down-to-Up TME for malign disease. Methods: Surgical resection was indicated for 11 patients with diagnosed rectal adenocarcinoma at middle and lower third of the rectum and 8 patients with rectal adenomas. IRB approval was obtained at the institution for the study, and the patients signed informed consent Total mesorectal resection and rectosigmoidectomy was performed using single port device directly inserted inside the rectum, and dissection was progressed proximally using perirectal dissection. Laparoscopic assistance was used for IMA ligation and left colon mobilization. Specimens were extracted transanally, and stappled or sutured transorificial anastomosis was performed. . Full thickness resection of large adenomas in middle and upper rectum was performed with transanal single port. Results: All 19 patients were submitted to TAMIS. Operative time was a 240 min for rectal resection with TME and a mean of 48 min for adenomas. One patient was converted to laparoscopic surgery and one to open surgery due to bulky tumors. One patient presented necrosis of the coloanal anastomosis and was reoperated. One patient required readmission for bleeding. The postoperative course of the other patients at 30 days was uneventful. A mean of 12 lymphnode count, and adequate free margins were obtained. Conclusion: The present study shows that Down-to-Up TME is technically feasible, with adequate oncologic parameters. TAMIS can successfully replace many indications of previous TEM for benign disease. The technique can be performed with available technology and reduced learning curve. NOTES access for TME is a promising new therapy besides existing laparoscopic and open surgery to improve patient care.

Background: Robotic surgery for rectal cancer is a feasible technique, but few series have evaluated its oncologic safety. This study focuses on oncologic results of a consecutive series of patients. Methods: From July 2008 to December 2013, 100 patients with a rectal tumour (adenocarcinoma, squamous cell carcinoma or melanoma) \ 15 cm from the anal verge received a robotic assisted total mesorectal excision (TME). Preoperative assessment is performed with colonoscopy with biopsies, thoraco-abdominal CT scan, pelvic magnetic resonance (MRI) and endoscopic ultrasound; in the case of a T3 or N positive rectal adenocarcinoma, a preoperative radiochemotherapy is performed. Surgery is performed eight weeks after treatment completion. Results: Patients’ median age was 64 years (range 33–85), median BMI was 24 kg/m2 (range 16–32). ASA status was 1 in 16 patients (16 %), 2 in 69 patients (69 %), 3 in 15 patients (15 %). 45 patients (45 %) received a neoadjuvant treatment. Pathological AJCC stage of patients with adenocarcinoma or SCC was 0 in 15 patients (15 %), I in 23 patients (23 %), II in 18 patients (18 %), III in 32 patients (32 %) and IV in 9 patients (9 %). Distal resection margin was positive in one patient, median distal resection margin was 3 cm. Circumferential resection margin was positive in three patients: in one a locally advanced tumour involved the radial margin; the second had an incomplete mesorectal excision and in the third a positive lymph node had a distance from radial margin inferior to 1 mm. Median number of removed lymph nodes per patient was 19 (range 4–49). Local recurrence was diagnosed in three patients (3 %). Four patients presented with synchronous pulmonary lesions, surgically resected in three of them; five other patients presented with synchronous hepatic lesions and received perioperative systemic chemotherapy. Among the eighteen patients who developed distant metastases, ten (55 %) were amenable to local treatment of the metastatic disease. At a median follow up of 25 months (range 1–60), overall survival is 90 % and disease-free survival is 71 %. Conclusions: Robotic-assisted surgery of the rectum is a feasible technique with oncologic results comparable to those of open and laparoscopic techniques.

O232 - Intestinal, Colorectal and Anal Disorders

O234 - Education

Laparoscopic Colorectal Surgery: Minimally Invasive Procedure Can Be an Ideal Option for Elderly Patients

Maximum Use of Human Cadavers for Multiple Laparoscopic Procedures Training in Different Specialties and Time

T. Kanazawa, T. Tanaka, S. Ishihara, E. Sunami, T. Watanabe

B. Tang1, A. Alijani2, K. Campbell2, G. Nabi2, R. Eisma1, I. Tait1

Tokyo University, Tokyo, Japan

University of Dundee, United Kingdom; 2Ninwells Hospital and Medical School, Dundee, United Kingdom

Aims: In Japan, as the increase in the aged population, an increasing number of elderly patients are being treated for colorectal cancer. Elderly patients are regarded as high risk for surgery, because of a lack of physiological reserve and associated comorbidities. Laparoscopic colorectal surgery is regarded as a minimally invasive procedure despite of its longer operative time. The current study was designed to elucidate the less invasiveness of laparoscopic colorectal surgery for elderly patients. Methods: A retrospective analysis of 42 patients aged 80 years or older who underwent surgery for colorectal cancer between June 2011 and April 2013 was performed. Exclusion criteria were emergency surgery and cases with hemodialysis. Blood samples were taken on days 1, 3, and 5 after surgery and urinary volume was measured postoperatively. The time to refiling phase (Ref) is defined as the duration from end of surgery to the time when urine volume increases more than infusion volume. Also as indicators of inflammation, white blood cells (WBC) and C-reactive protein (CRP) were measured. Results: All patients had some kind of preoperative comorbidities; most common were cardiovascular (64.3 %). None of 21 laparoscopic surgeries was converted to an open procedure. The overall mortality rate was 0 %. Compared to open surgery, patients with laparoscopic resection had a shorter Ref (38.3 vs. 19.7 hours; p = 0.005), less blood loss (419 vs. 35.4 ml; p \ 0.001). There was no difference with respect to the type of postoperative complications in the two groups. There were no laparoscopy- specific complications associated with pneumoperitoneum or fixed body position The mean values of WBC (9723 vs. 7876) and CRP (7.59 vs. 5.76) on one day after surgery were significantly higher in open surgery group than that of laparoscopic surgery group (p \ 0.005). Conclusions: Surgical stress, as reflected by the time to refilling phase, WBC and CRP was less after laparoscopic surgery than after open resection of colorectal cancer in elderly patients. These findings suggest that the laparoscopic approach should appear to be the ideal surgical choice for elderly patients.

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Aims: Human cadaver provides the most realistic model for advanced laparoscopic surgery training. Thiel embalming method that is different from the fresh-frozen technique to preserve a body makes long-lasting preservation possible, which provides opportunity to plan multiple laparoscopic procedures training in different specialities in different time range. The aim of this study was to describe a strategy of planning course using Thiel fixed human cadavers for multiple laparoscopic procedures training in different specialities and different time scale. Material and Methods: Thiel fixed cadavers were used in an intensive 2 day training programme. Careful plan of courses for differently specialties according to the anatomy involved was carried out before the courses being conducted, which maximize the use of the body. Training courses were conducted for different specialities in different time of year and the same bodies were reused for different procedures until all the related anatomies provided their use. All participants completed a five-point Likert scale satisfaction questionnaire after their training sessions. The quality of cadaveric tissue and the training session were assessed with particular emphasis placed on the ease of patient positioning, trocar placement, the preservation of tissue planes, quality of tissue dissection, and the quality of tissue preservation. Results: 70 laparoscopic trainees attended the course during 2011 to 2013. 35 Thiel method preserved human cadavers were used for different laparoscopic training courses. Oder of courses were sequenced as laparoscopic gastric banding, sleeve gastrectomy, gastric bypass, laparoscopic right hemicolectomy, left hemicolectomy, anterior resection, and laparoscopic nephrectomy. All participants highly rated the overall quality of the cadaveric tissue embalmed by Thiel’s method (mean scores for quality on the five-point Likert scale (maximum of 5) were 4.6 and 4.4 by the trainees and experienced laparoscopic surgeons, respectively). All of the steps of laparoscopic renal resection were rated 4.4 or more on the Likert scale by both trainees and faculty members. Conclusions: Thiel method preserved human cadavers can provide a highly realistic training model for many commonly laparoscopic procedures. Courses can be planned for multiple laparoscopic procedures training based on the speciality and time for the full use of the cadavers.

Surg Endosc

O235 - Education

O237 - Education

Trainee Gender and Intellectual Capabilities Effect on Performance of Laparoscopic Surgery: A Prospective Study

Exercise on Laparoscopic Trainer for Assessment of Manual Abilities of Medical Student

S.M. Alaraimi, W.S. Elbakbak, A.A. Bouhelal, B. Patel

W.D. Majewski, J. Kowalski

Barts Health NHS, London, United Kingdom

Pomeranian Medical University, Szczecin, Poland

Aims: To examine if gender, interest in surgery and playing video games have an effect on performance of minimally invasive skills in novices using validated laparoscopic tasks. Methods: A prospective study recruited 50 novices; who were trained toward proficiency. The assessment was applied using the validated Fundamentals of Laparoscopic Surgery (FLS) tasks. The performance of individuals were analysed using general liner modal to find out the effect of gender, interest in surgery and playing video games in the performance of FLS tasks. Results: There were 21 males and 29 females (Table1). Novices playing video games [ 3hr/wk completed the curriculum faster with less repetitions but surprisingly with more errors than those with limited video game experience (Table2). 13 were not interested in a surgical carrier, and 37 were interested. Novices interested in surgery completed the curriculum faster with more repetitions and more errors compared with those with no interest in surgery (Table 3). Conclusions: Gender and interest in surgical carrier does not carry influence on laparoscopic skills performance. Candidates playing more video games tend to perform better but that was not statistically significant.

Aims: Medical students often have problems with decision in which part of medical profession build up their future career, in an interventional medicine or other one. The aim of the study was to investigate whether an exercise on laparotrainer may be helpful to enable to undertake the proper decision. Methods: 780students of fourth year of Medical Faculty of Pomeranian Medical University in Szczecin, Poland, 309male and 471female, 579 being taught in Polish language and 201 in English, first time in their life performed only once an exercise on laparotrainer -pulling thick thread suture through 8 ‘O’ shaped hooks within 5 minutes under laparoscopic control. Assessing score gives one point for every passed hook in this time. When student fulfilled the task in shorter time than 5 minutes the number of minutes left was added to the score e.g. when 8 hooks were passed in time between 4 min 1sec and 4 min 59 sec - 9 points etc. Male and female groups, students taught in Polish versus taught in English (mostly from Western Europe countries) were compared. Comparison included a group of students who afterwards decided to take part in laparotrainer workshop organized in the faculty as well. Results: the mean score for whole group was 4,34 (95 % CI 4.18–4.50); SD ± 2,27;between 0 and 12 (the best score were 1 min 51 sec, 1 min 53 sec, 1 min 57 sec, all women); male students had significantly better score than female ones (p ? 0,0001); (95 %CI for male students 4.59–5.13 and for female students 3.80–4.19); there was no difference in score between groups studying in Polish and in English (p = 0.22), the group of students who later took part in laparoscopic workshop had better score than the rest of the group (p = 0,01) (95 %CI for participants 4.60–6.26 and for the rest 4.14–4.46). Conclusions: despite the fact that best score was obtained by women, male students have shown better in manual abilities; education models in Poland and in Western Europe countries have no impact on manual abilities of students, but student’s manual abilities influence on their medical interest in future. Exercise on laparotrainer proved its usefulness in discovering manual abilities of medical students.

O236 - Education

O239 - Education

Statistics in the Surgical Training: What Is The Benefit? 1

1

1

1

S.M. Alaraimi , B. Patel , W.S. Elbakbak , A.A. Bouhelal , S.J. Sarker2 Barts Health NHS, London, United Kingdom; 2Barts Cancer Institute, London, United Kingdom 1

Aims: To determine the view of surgical tutors and trainees in their current level in interpreting statistics, probability and epidemiological methods and if such skills are useful in practice and how much undergraduate education they received in statistics. Methods: Trainees and consultants surgeons were interviewed through filling a validated questionnaire that investigates issues of interpreting statistics, probability and epidemiological methods in their current practice. There are five main domains (demographics, current work, undergraduate teaching in statistics, opinion about current undergraduate and interpretation of research findings) with multiple subheadings which were collected. Descriptive statistics carried out on each response and data analysed using SPSS and Stata. Results: The average year of qualification was 2000; 24 % (n = 30) were consultants and 72 % (n = 89) were trainees.36 % had post graduate research qualifications (MRes, MD, MSc, MPhil, PhD). Surgeons response to that probability and statistics is useful for activities like: accessing clinical guidelines and evidence summaries were (74 %), explaining levels of risk to patients (70.7 %), interpreting results of screening tests (59.3 %), reading research papers and publications (71.5 %), using research publications to explore management options(45.5 %), and analysing numerical data (65 %).51.8 % hope they know more about statistics and if they had better understanding this will be highly manifested in the quality of their future surgical research.42.7 %suggested that current curriculum should give medical students more basic and applied statistics to make it related to their future training. Conclusions: Most of the surgeons admit on the importance of the statistics only 63.3 % received undergraduate education which reflect a great gap in our current curriculum, a problem that needs addressing. Furthermore teaching statistics in medical school should be more correlated to address medical research.

Learning Curve After Rapid Introduction of Laparoscopic Appendectomy- Are There Any Risks of Surgical Resident Participation? E. Ma´n University of Szeged, Szeged, Hungary Aims: With the spread of minimally invasive technique laparoscopic appendectomy (LA) is used more and more frequently with excellent results. It can be used as a training modell for surgical residents for more complex techniques. Laparoscopic appendectomy was introduced rapidly into our clinical practice. The purpose of our work was to establish the learning curve period in our clinic and to evaluate the impact of surgical trainees’ participation in LA. Methods: Laparoscopic appendectomy was introduced quickly, over a mere six months into our clinical practice in 2006. Beetween 2006 and 2009 laparoscopic appendectomies performed by 5 surgical trainees (Group A) and 5 senior surgeons (Group B) were evaluated by means of demographic data, operation time, blood loss, conversion rate, hospital stay and postoperative complications. The number of operations needed in the learning curve period was also established by statistical methods. For statistical analysis we used SPPS 20 program. Results: During the study period 600 laparoscopic appendectomies were performed (Group A n = 319, Group B n = 281). There were no differences in demographic data, blood loss (45 mL vs. 55 mL, p = 0.505), conversion rate (7.4 % vs. 7.2 %, p = 0.664) and hospital stay (3.6 days vs. 3.3 days, p = 0.385). Postoperative complications and negative appendectomy rate (NAR: 8.5 % vs. 7.8 %) were also similar in the two groups. We found significant difference in the operation time (63.5 vs. 49.2 min, p \ 0.05). Based on statistical analysis the learning curve for LA was 20 cases in our practice. Conclusion: Quick introduction of LA has no risks and it’s a safe procedure for surgical residents as well, furthermore it’s an important step in their training for more complex laparoscopic skills.

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Surg Endosc

O241 - Education

O243 - Paediatric Surgery

The Role of Technology Enhanced Learning in Surgical Education As Perceived By Stakeholders

The Effects of CO2-Insufflation With 5 And 10 Mmhg During Thoracoscopy On Cerebral Oxygenation And Hemodynamics In Piglets

C. Va˚penstad1, E.F. Hofstad2, T. Langø2, R. Ma˚rvik3, M. Chmarra4, J. Dankelman4, D.G. Garcia5, L.S. Peralta6, J.B.P. Carrasco6, F.M. Sa´nchez-Margallo6, I. Oropesa7, E.J. Gomez7 1 The Norwegian Univeristy of Science and Technology, Trondheim, Norway; 2SINTEF Technology and Society, Trondheim, Norway; 3St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; 4 University of Delft, The Netherlands; 5Everis BPO, A corun˜a, Spain; 6 Centro de Cirugı´a de Mı´nima Invasio´n Jesu´s Uso´n, Ca´ceres, Spain; 7 Universidad Polite´cnica de Madrid, Spain

L.J. Stolwijk, S.H.A.J. Tytgat, K. Keunen, M.Y.A. Herwaarden, N. Suksamanapan, P.M.A. Lemmers, D.C. van der Zee UMC Utrecht Wilhelmina Kinderziekenhuis, Utrecht, The Netherlands

Aims: The use of online Technology Enhanced Learning (TEL), e.g. e-learning can enrich traditional surgical training. By incorporating assessment, interactivity and feedback functions, it can enable competence based education. The MISTELA project (www.mistelaproject.com) aims at developing a pedagogically founded TEL solution based on user needs from the European surgical community. A TEL environment will provide a collaborative tool for training in minimally invasive surgery (MIS) based primarily on shareable, community-developed surgical video repositories. Methods: Semi-structured interviews were held with stakeholders in surgical education from the Netherlands, Norway and Spain. They were asked to describe their experiences with different learning approaches with a focus on TEL today, in addition to clinical requirements for TEL in the future. Results: Sixteen persons were interviewed: eight surgeons with experience in surgical education, seven residents and one non-surgeon who organizes courses in MIS.Hands-on (N = 8), discussions (N = 6) and access to good visual content (N = 4) were mentioned as valuable learning approaches. Important features of TEL were: interactivity (N = 9), accessibility (N = 10) and relevant and/or individualized content (N = 8). Factors discouraging use included slow or bad user-interfaces (N = 10), low security (N = 1), high cost (N = 3), lack of scientific quality, e.g. no peer-review (N = 8), and low quality content (N = 4). All residents thought that a video repository should be part of TEL. Five of the surgeons with teaching experience would act as online tutors, whereas two would not so, due to the lack of face-to-face contact. Conclusion: TEL was seen as an important add-on to surgical education, and a combination of different learning approaches would be optimal (blended learning). User-centered design and content with strong pedagogical foundations are success-factors of a TEL approach in MIS.

Aims: An increasing percentage of surgical interventions in neonates is performed by minimal invasive techniques. Near infrared spectroscopy is a non-invasive method that can be used to assess changes in cerebral oxygenation, an estimator of cerebral perfusion, by monitoring regional cerebral oxygen saturation (rScO2). Values below 40 % are related with brain damage. rScO2 can be influenced by mean arterial blood pressure (MABP), mean airway pressure, arterial saturation (SaO2) and pCO2. Recently, concerns have been raised regarding a decrease of cerebral oxygenation in neonates during thoracoscopy as a result of CO2-insufflation (Bishay 2013). Methods: Piglets were anaesthetized, intubated, ventilated and surgically prepared for CO2-insufflation and insertion of a trocar in the right hemithorax took place. Insufflation was done with 5 or 10 mmHg CO2 during one hour. Physiologic parameters SaO2, heart rate (HR), MABP and rScO2 were monitored. cFTOE, an estimator of cerebral oxygen extraction ((SaO2 - rScO2)/SaO2)) was calculated. Arterial blood gases were drawn every 15’: pre(T0), during(T1-T4) and after CO2insufflation(T5). Results: Ten piglets (4 kg) were randomized for 5(P5) and 10(P10) mmHg CO2-insufflation.Two P10 piglets needed resuscitation after insufflation, none P5.P5 showed stable SaO2, HR and MABP during the entire procedure. pCO2 (mmHg) increased from 36 ± 4 at T0 to 70 ± 19 at T4 (p \ 0.05) and rScO2( %) from T0 42 ± 3 to 57 ± 1 at T5 (p \ 0.001). P10 showed a decrease of MABP (mmHg) from 84 ± 8 at T0 to 54 ± 21 at T3 (p \ 0.05). HR increased from T0 152 ± 18 to 218 ± 9 at T3 (p \ 0.05), pCO2 (mmHg) from 35 ± 6 at T0 to 74 ± 8 at T3 (p = 0.01), rScO2 (%) from 37 ± 4 at T0 to T5 50 ± 5 (p = 0.05). cFTOE in P10 compared to P5 was higher at all time points and significant at T5(p \ 0.05). Conclusion: Insufflation of CO2 during thoracoscopy with 10 mmHg caused more severe hemodynamic instability compared to 5 mmHg. Although higher CO2-levels are related with higher brain perfusion by cerebral vasodilation insufflation with 10 mmHg seemed to be related with a decrease of cerebral perfusion as represented by a higher oxygen extraction.CO2-insufflation of 5 mmHg for thoracoscopy seems to be safe for cerebral oxygenation.

O242 - Education

O244 - Physiology, Pathophysiology, Immunology

Experiences with Implementation of A National Urological Practical Skills Training Program: Do’s and Don’ts

Analysis of Incisional Pain According to the Length and the Location of the Incision in the Rat Model

A.H. de Vries1, B.M.A. Schout2, J.J.G. van Merrie¨nboer3, R.C.M. Pelger4, E.L. Koldewijn1, C. Wagner5

D.W. Lee, S.H. Kim, J. Kim, J.M. Kwak, H.D. Kwak, D.W. Kang, N.S. Sung

Catharina Hospital, Eindhoven, The Netherlands; 2Medical Centre Alkmaar, The Netherlands; 3Maastricht University Medical Centre, Maastricht, The Netherlands; 4University Medical Centre Leiden, The Netherlands; 5EMGO Institute for Health and Care Research, Amsterdam, The Netherlands

Korea University Anam Hospital, Seoul, Korea

1

Aims: Practical skills training is gradually being integrated into urological curricula worldwide to meet with modern technology and patient safety issues. Recently, the Dutch Urology Practical Skills (DUPS) training program has been developed and piloted. This program focuses on basic and procedural skills training in the local hospital setting, with usage of simulation models and peerteaching principles. This study aims to answer the questions : ‘Are simulation-based training programs such as DUPS of value in addition to current residency training?’ and ‘What are suggestions for future implementation of such programs?’ Methods: After the pilot phase which comprehended implementation of eight training modules in eight hospitals, a questionnaire was sent to residents and supervising urologists. The questionnaire focused on 1. Practical/logistic aspects, 2. The DUPS-program in general, and 3. Training-specific matters. Answer options included five-point Likert scale and open-ended questions. Chi-square and Mann-Whitney U-tests were used to analyze differences in respectively categorical and continuous variables. Results: Response rate was 87 % (n = 41) for residents and 82 % (n = 23) for supervisors. According to 98 % of residents a supervisor was present during all training sessions. Training sessions did not always proceed according to plan according to 46 % of residents vs. 14 % of supervisors (p \ 0.01). Reasons mentioned were: inadequate planning (31 %), supervisor not present (25 %), and problems with materials (22 %). 59 % of residents and 55 % of supervisors considered the DUPS-program useful in addition to current training. Overall, positive points were familiarizing with equipment of the local hospital, repeated application of theory and skills, and uniformity in skills. Remarks for future programs are suitability of models, adaptation of training level to junior and senior residents, and financial constraints. Conclusions: Residents and supervisors consider the implementation of a national urological practical skills program, which comprehends mastering of equipment and skills in the local hospital setting, a useful addition to current residency training. Points of attention for future implementation of DUPS and similar practical skills training programs include: Improving the educational value by making it adaptive for junior and senior residents, using suitable models and applying a manageable cost model.

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Introduction: Minimally access surgery has an advantage for the reduced pain compared with open surgery. We investigated the differences of incisional pain according to the length and location of the abdominal wall incision in the rat minimally access surgery and open surgery model. Methods: A total of 32 rats were divided into four groups according to the length and the location of the abdominal wall incision. Group A represented open surgery had 3 cm midline incision; Group B represented minimally access surgery with additional long incision for the specimen extraction had 3 cm midline incision with two 0.3 cm separate incisions; Group C represented minimally access surgery had three 1 cm separate incisions; and Group D was control. For analysis of incisional pain, we investigated withdrawal response to the pain by giving stimulus with von Frey filaments and Writhing test on postoperative 2-hour, 1, 2, 3, 5 and 7-day Results: The score for withdrawal response to the pain was lower in Group C and increasing Group B and A in order. There was a significant difference between Group A and C (p = 0.004). In Writhing test, there was a significant difference between Group A/B and Group C (p \ 0.0001). Conclusions: Although the total length of incision was same, incisional pain induced by small separate incisions was significantly less than that induced by long single incision. And one long incision could offset the pain induced by additional small separate incisions.

Surg Endosc

O245 - Basic and Technical Research

O248 - Basic and Technical Research

Comparison of Peritoneal Immune Responses After Surgery in Rats

Does Macroporous Monofilament Mesh Sustain Infection in a Contaminated Field? (Experimental Rat Model)

J. Dohmen, T. Schwandt, H. Matthaei, N. Konieczny, G.S. Hong, S. Wehner, J.C. Kalff, P. Lingohr

K. Bury1, M. Maciej2

University of Bonn, Bonn, Germany

1 Medical University of Gdansk, Poland; 2Ceynowa Hospital, Wejherowo, Poland

Aims: Recent studies consistently attributed benefits to laparascopic surgery (LS) compared to conventional surgery (CS). These benefits are often explained by a better postoperative preservation of the local immune system. So far in vivo experimental evidence proving this hypothesis is inconsistent and lacking for a realistic resection model in rats. Methods: After establishing a laparoscopic cecum resection model we operated rats (n = 105), randomized in 5 groups: Laparoscopic cecum resection (Group1), conventional cecum resection (Group2), laparoscopic sham operation (Group3), conventional sham operation (Group4) and no treatment (Group5). Postoperatively laparoscopic peritoneal lavages were performed after 24 h, 72 h, 120 h and analysed by flow cytometry for eosinophils (HIS48+), neutrophils (CD11b/cint), monocytes (CD11b/chighCD43+) and macrophages (CD11b/chighCD43-). Gating was verified through cell sorting and following histopathology. In a subsequent experiment another set of rats (n = 35) were operated, as described above. After 24 h peritoneal leucocytes were harvested, cultivated and stimulated in vitro with LPS (10 ng/ml). After 4 h incubation IL-6 and TNF-a level in supernatants were determined by ELISA. To measure differences in macrophages’ phagocytic activity the harvested fluid specimens were stimulated with pHrodoTM and after incubation analysed by flow cytometry (CD11b/chighCD43-/pHrodo+). Results: We detected a distinct influx of neutrophils and monocytes in the peritoneal cavity 24 h after surgery in Group 1–4. After 72 h the influx decreased gradually, Group 3–4 returned back to homeostasis. Group 1–2 reached homeostasis after 120 h. Group 1–2 showed a significantly higher neutrophil and monocyte proportion (p \ 0.05) compared to Group 3–5 after 24 h and 72 h. Between Group 1 and 2 no significant differences in neutrophil and monocyte fraction were measured at any time. Following LPS stimulation cells from Group 1–4 showed significantly reduced TNF-a and IL-6 secretion compared to Group 5. The phagocytic activity of the resection groups was significantly higher compared to control group. Conclusions: The infiltration of immunocytes into the peritoneal cavity as well as the phagocytic activity and cytokine production of macrophages are comparable after LS and CS. Restimulation after an operational stimulus increases the phagocytic activity and lowers the cytokine production compared to a control group. Benefits associated with LS do not result from differences within local peritoneal phagocyte function.

Background: The aim of this study was to evaluate whether the type of the mesh and proper surgical technique can influence the outcome of a tension-free hernia repair in a contaminated filed. Materials and Methods: This study was based on the model of bacterial peritonitis in rats induced with a mixture composed of E. coli and Bacteroides fragilis. Ten animals were used as a control group without induced peritonitis and with mesh implanted inside of the peritoneal cavity. For the 20 animals in the studied group, bacterial fluid was applied into the abdominal cavity together with the mesh implantation. In 10 cases,the mesh was fixed flatly upon the surface of the peritoneum; in the other 10, the mesh was rolled and then fixed within the peritoneal cavity. After 5 weeks, the animals were operated on again, and the meshes, the peritoneal fluid and, if present, any granulomas were taken for bacterial cultivation. Results: The results of the bacterial cultivation of the material from the control group (without mesh) and from the rats with flatly fixed mesh were almost completely negative (0/ 10 and 1/10, respectively). In 9 outof 10 rats that were exposed to the rolled mesh for 5 weeks, the colonisation of meshes with both Bacteroides fragilis and E. coli was found (p \ 0.0198). Conclusions: When properly fixed, flat mesh, even in a contaminated field, may allow for a proper mesh healing and does not influence the ability to cure bacterial peritonitis in an animal model. A bad surgical technique, such as inadequately positioned or rolled mesh, may cause persistent peritoneal bacteraemia.

O246 - Basic and Technical Research

O249 - Abdominal Cavity and Abdominal Wall

Ileoproctostomy Through a Transanal Access Route is Feasible in Human Cadavers

Do Meshes Maintain All Their Mechanical Properties Under Small Forces?

L. Polese1, E. Lezoche2, A. Porzionato1, G. Lezoche3, G. Da Dalt4, V. Macchi1, C. Stecco1, R. de Caro1, L. Norberto1, S. Merigliano4

H. Qandeel, K.E. Tanner, P.J. O’Dwyer

University of Padova, Italy; 2Department of General Surgery, Surgical Specialities and Organ Transplantation, Rome, Italy; 3 Polytechnic University of Marche, Ancona, Italy; 4University of Padova, 3rd Surgical Clinic, Padova, Italy

Glasgow University, Glasgow, United Kingdom

1

Aims: Transanal ileoproctostomy could be an advantageous treatment of colonic stenosis that could be used as an alternative to endoscopic stenting or ostomy. This study aimed to verify the procedure’s technical feasibility in human cadavers. Methods: A Transanal Endoscopic Microsurgery (TEM) device and endoscopic instruments were utilized to carry out the procedure in four human cadavers. The procedure’s principal steps include: placement of the TEM device; rectal perforation above the peritoneal reflection; peritoneoscopy using a standard gastroscope; grasping the small bowel with retrieval forceps and pulling it through the rectal hole; suturing the ileum and the rectum together with single-layer, continuous, semi-circular sutures that are fixed with clips; the bowel wall is opened from the rectal side and the peritoneal cavity is inspected.

Aims: Manufactures indicates that their meshes withstand the literature evidence based ‘Maximum Physiological Abdominal Pressure’; i.e. 16Newtons force. However, do meshes maintain all their mechanical properties under small forces? These small forces occur similar to what is produced by physiological activities like coughing which may produce a force 2Newtons? We, independently, aim to test the Mechanical Properties of 2 types of Meshes, commonly used in ventral hernia repair. Methods: Meshes obtained from 2 manufacturers (A & B) were subjected to mechanical ‘Failure’ testing by Zwick-Roell machine according to the British Standards Institute. 25 Samples (140 mm long by 25 mm wide) were cut in both the longitudinal and transverse directions of the mesh. The normalised force per fabric width (N mm-1), the strain and finally the load at Failure were measured. The change from elastic to plastic properties for each mesh was also calculated. Results: The Quasi static mechanical properties of the meshes tested in the different directions are shown in the table. Mesh’s properties significantly change by changing the mesh’s orientation. Conclusions: Small forces, like coughing, could potentially alter mesh’s behaviour from elastic to plastic. Over the time, the mesh may elongate significantly without being broken and subsequently contribute to developing hernia recurrence.

Results: Completed utilizing a single transanal access in all four cases, the mean procedural time was 90 minutes. At anatomical dissection, the by-pass was patent and the anastomosis uniting the intraperitoneal rectum and the terminal ileum was leak-proof. Conclusions: Although still at an experimental stage, ileoproctostomy through a transanal access is technically feasible in human cadavers. Use of this procedure in the future may broaden the alternatives to ostomy to treat some types of colonic strictures.

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Surg Endosc

O250 - Intestinal, Colorectal and Anal Disorders

O252 - Intestinal, Colorectal and Anal Disorders

Intracorporeal Anastomosis for Left Side Colorectal Tumor Do Not Increase The Risk of Intra-Abdominal Contamination

Are there Differences Between Right and Left Colectomies When Performed By Laparoscopy?

S.C. Chang, W.T.L. Chen

V. Turrado Rodriguez, A. Carrasquer Puyal, B. Espina Perez, N. Freixas Lopez, C.E. Rodriguez Otero Luppi, J.L. Pallares Segura, J. Bollo Rodriguez, E.M. Targarona Soler, M. Trias Folch

China Medical University Hospital, Taichung, Taiwan Background: Natural orifice specimen extraction (NOSE) for colorectal tumor may reduce abdominal incision, decrease postoperative pain and wound related complication. But there are concepts about intra-abdominal contamination by the procedure of intracorporeal anastomosis (ICA). Aims: The aim of study compared the risk of intra-abdominal infection of laparoscopic anterior resection with NOSE with ICA and conventional laparoscopic assisted approach (LAP) with extracorporeal anastomosis (ECA) for the left side colorectal tumor. Patients and Method: Since July 2011 to Jun 2012, we prospectively collected patients underwent laparoscopic anterior resection. Left side colorectal cancer and non-bulky tumor size (less than 5 cm in diameter) were the two criteria for patient inclusion. Exclusion criteria were designed as following: ASA [ 3, BMI [ 33, emergent surgery (bowel perforation or obstruction), pre-operative infection or abscess formation, underwent Hartmann’s procedure or APR, procedure conversion. All patients were divided into two groups, one is ICA group and the other is ECA groups. All procedures were completed by the same colorectal surgical team. Patient’s characteristics, surgical data and post-operative condition were recorded. Peritoneal fluid samples were collected on the post-operative day 1 (POD1) for bacterial culture. The end point of this study was to compare clinical surgical morbidity and bacterial culture of peritoneal fluid between ICA and ECA after LAP. Results: During this period, there were 95 patients collected in this study, including 40 patients underwent laparoscopic anterior resection (Lap. AR) with ICA and NOSE and 55 patient performed Lap. AR with ECA. Compare clinical results between ICA and ECA group, major surgical complication rate had no significant difference (15 % : 14.5 %). Although no abdominal wound infection occurred in ICA group, there were two patients had specific morbidity of anal fissure, related to trans-anal specimen extraction. Respect to surgical morbidity risk of intraperitoneal infection, including intraabdominal abscess, anastomotic leakage and prolong ileus, ICA group had 3 patients (7.5 %) and ECA group had also 3 patients (5.5 %) that did not reach significant difference after compare. Although the clinical outcome was equal, we found higher positive ascites culture results was noted in ICA group than ECA group (17.5 % : 7.3 %) with significant difference (p \ 0.05). Conclusion: Intracorporeal anastomosis may result increasing risk of intraperitoneal bacterial growth but few patients resulted clinical ill presentation and symptoms of inctraperitoneal contamination.

Hospital de la Santa Creu i Sant Pau, Barcelona, Spain Objectives: To analyze the differences in the postoperative curse of the patients with RC and LC and to determine the influence of the surgical disease on the postoperative curse of this patients. Background data: Over the last years, laparoscopic colectomy has become the standard of care for colonic diseases. There is an extended believe that left colectomy(LC) is technically more demanding and that it is associated with more postoperative complications than right colectomy (RC). Methods: We retrospectively analyzed 1000 consecutive patients operated between 1998 and 2012 of a laparoscopic RC or LC. We studied intraoperative complications, surgical time, postoperative complications, length of stay, reinterventions and mortality. The DindoClavien classification for postoperative complications was used. Both groups were divided in four subgroups: neoplasia, diverticular disease (DD), polyps and others. Results: We found that LC was associated with more postoperative complications (29.5 % vs 18.3 %, p \ 0.0001) than RC and with more operative time (139 vs 117 minutes, p \ 0.0001). There were no differences in the rate of conversion, reintervention or death. This results were similar in the neoplasia group. There were no differences between the neoplasia and DD group in the LC except for a extended operative time in the DD group (155 vs 136 minutes, p = 0.002). The rate of anastomotic leak was 5.5 % with 4.8 % of reinterventions. 1.2 % of patients suffered hemoperitoneum that required surgical management. Conclusions: LC is associated with more postoperative complications and more operative time than RC. Nonetheless there are no differences in the anastomotic leak, conversion, reintervention or death rates. DD is associated with more surgical time than neoplasia but there are no statistically significant differences on the postoperative evolution. The results of our study are similar to those of COLOR, MRC-CLASSICC or COST studies.

O251 - Endocrine Surgery

O253 - Intestinal, Colorectal and Anal Disorders

Long-Term Safety of Intracorporeal Anastomosis in Right Hemicolectomy in Comparison with Extracorporeal Anastomosis S.Y. Park, G.S. Choi, J.S. Park, H.J. Kim, J.I. Choi

Extraction Site Location Does Not Affect Postoperative Pain and Quality of Life Scores: Vertical Versus Transverse Wound in Laparoscopic Anterior Resections

Kyungpook National University Medical Center, Daegu, Korea

W.S. Tan, M.H. Chew, J. Yatim, J. Lai, C.L. Tang

Background: With advancement in minimally invasive surgery, intracorporeal anastomosis after right hemicolectomy has been developed to modulate the surgical extent and location of specimen extraction. This study assessed the long-term oncological outcomes of intracorporeal anastomosis after right hemicolectomy of colon cancer. Methods: From a prospectively collected database, 172 patients who underwent laparoscopic right colectomy with curative intent for colon cancer between March 2007 and October 2010 were identified. One hundred and fifteen patients underwent extracorporeal anastomosis (ECA) and 57 patients underwent intracorporeal anastomosis (ICA). The overall survival and disease-free survival rates were analyzed using the Kaplan-Meier method, and the two groups were compared using the log-rank test. Results: Comparing clinicopathological characteristics of the two groups showed similar proportion with regard to age, American Society of Anesthesiologists score, tumor location, and pathologic stage. During the postoperative period, postoperative infectious and noninfectious morbidity rates did not differ between the two groups. No 30-day mortality was noted. After a median follow-up period of 42.0 months, the overall tumor recurrence rates were 11.3 % in the ECA group and 8.8 % in ICA group with no intergroup difference. The overall local recurrence rates were 0.9 % in the ECA group and 1.8 % in the ICA group. The 3-year disease-free survival rates were similar between the two groups, whether the comparison involved were compared with overall patients or compared with the stage I to III, respectively. Conclusion: In this study, ECA and ICA showed similar oncological outcomes with regard to overall survival, disease-free survival, and local recurrence rates. Although a further follow-up period is required to confirm our results, we found that the two methods of anastomosis could be used ?? carefully abiding by the oncologic principles.

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Singapore General Hospital, Singapore, Singapore Background: Some studies have found transverse incisions to be associated with better outcomes as compared to vertical incisions for both open and laparoscopic colorectal surgery, including lower wound infection and incisional hernia rates. There have been no studies thus far comparing post-operative outcomes and quality of life scores of vertical versus transverse incisions for tumour extraction in laparoscopic colorectal surgery. Materials and Methods: Using estimated pain scores of 1–5 on day one and two postoperatively and power of 80 %, calculated sample size per arm was 16. Forty patients undergoing laparoscopic anterior resection were randomized to vertical periumbilical (n = 20) or transverse left iliac fossa wound (n = 20). Randomization was performed using computer model generator and placed in sealed envelopes. Primary endpoint was postoperative pain. Secondary endpoints were operative time, time to ambulation, wound comesis using Hollander Cosmesis Score and quality of life assessment using EQ-5D at 2 weeks and 2 months post-operatively. Results: Median pain score on the first post-operative day was 2 in both groups (p = 0.360). There was no significant difference in wound infection rates, operative time, time to ambulation or recovery of bowel function. Cosmesis scores and EQ-5D scores were also similar in both groups. At a median follow up of 30 months, the incidence of incisional hernias at extraction site was similar. Conclusion: Transverse and vertical incisions in laparoscopic colorectal surgery have similar post-operative outcomes, with similar pain scores, cosmesis scores, quality of life scores and incisional hernia rates.

Surg Endosc

O254 - Intestinal, Colorectal and Anal Disorders

O256 - Different Endoscopic Approaches

Totally Laparoscopic Colectomy with Transvaginal Specimen Extraction Versus Conventional Laparoscopically Assisted Colectomy

Totally Laparoscopic Right Hemicolectomy with Intracorporeal Anastomosis and Natural Orifice Specimen Extraction: Transvaginal Approach. TEI Experience

M. Nakano1, A. Nishimura2, M. Kawahara1, Y. Tajima1

M.A. Hernandez, M.E. Franklin Jr

Japan / Nagaoka Chuo General Hospital, Nagaoka, Japan; 2Nagaoka Chuo General Hospital, Nagaoka, Japan

Texas Endosurgery Institute, San antonio, United States of America

1

Aims: Natural orifice specimen extraction (NOSE) was developed to decrease the incidence of surgical wound complications. The vagina is a preferred route for NOSE because of its high healing capacity and elasticity. However, only a few studies have evaluated the decreased invasiveness of laparoscopic colectomy with transvaginal specimen extraction (TVSE). The present study aimed to compare the clinical outcomes of patients undergoing totally laparoscopic colectomy with TVSE. Methods: We compared clinical outcomes between patients with colorectal cancer who underwent totally laparoscopic colectomy with TVSE and those who underwent conventional laparoscopically assisted colectomy between October 2010 and June 2013. Patients who underwent simultaneous surgery for other organs or other parts of the colorectum or for trasanal specimen extraction were excluded. We have performed totally laparoscopic colectomy with TVSE for colorectal cancer since October 2010. This procedure was indicated for menopausal women with clinical stage T3 or lower primary tumors located from the cecum to the upper rectum, while it was contraindicated for obese patients and patients with tumors covering more than half the colon circumference. The AlexisÒ wound retractor and Free AccessTM were attached to the transvaginal route for transvaginal assistance and specimen extraction. Results: There were 21 and 200 patients in the TVSE and conventional groups, respectively. The surgical duration was significantly longer in the TVSE group than in the conventional group [median (range), 227 (172–300) min versus 196 (89–407) min; P = 0.003]. Estimated blood loss, duration of hospitalization and surgical morbidity were comparable between groups. Patients in the TVSE group experienced significantly less pain compared with those in the conventional group on days 2 and 5 after surgery [numeric rating scale scores: mean (standard error), 2.3 (0.3) versus 4.2 (0.7); P = 0.01 and 1.1 (0.4) versus 2.1 (0.4); P = 0.05, respectively]. After a median follow-up of 14 (range 9–38) months in the TVSE group, there was no transvaginal access-site recurrence or posterior colpotomy-related complications. Conclusion: Totally laparoscopic colectomy with TVSE appears to be feasible, safe and oncologically acceptable for selected cases of colon cancer.

Background: Since the first laparoscopic approach for colonic disease, minimal access techniques have revolutionized colonic surgery. Natural orifice specimen extraction (NOSE) offers the advantages of laparoscopic surgery and allows performing the anastomosis and extraction of the surgical specimen without enlarging any trocar incision. This study was designed to evaluate the outcomes of patients who underwent to a totally laparoscopic right hemicolectomy with intracorporeal anastomosis and transvaginal specimen extraction. The predicted benefits of transvaginal extraction in colorectal surgery are to reduce incision-related morbidity such as pain, a reduced rate of surgical site infection and incisional hernias by avoiding minilaparotomy for specimen extraction. Methods: We analyzed a prospectively designed database of consecutive patients who underwent totally laparoscopic right colon surgery with transvaginal extraction for different pathologies between April 2007 and January 2014 at Texas Endosurgery Institute. The selection criteria for the NOSE approach were based on a disease entities, site and size of the tumors. Results: A total of 31 patients underwent to right hemicolectomy with NOSE approach and vaginal extraction. The operative time for the procedure was 159 ± 27.1 min and the estimated blood loss was 83.5 ± 14.4 ml. Intraoperatively, trasvaginal extraction was associated with 2 complications; with no post operative complications. The length hospital stay was 5.5 ± 2.5 days. Conclusion: The NOSE approach is possible with favorable short-term surgical outcomes. This novel technical approach is feasible and safe, eliminates the need for extraction through minilaparotomy with a potentially shorter recovery time, earlier ambulation, bowel function, fewer complications, decreased drugs use, and improved cosmesis; it might be considered for patients requiring abdominal right hemicolectomy.

O255 - Intestinal, Colorectal and Anal Disorders

O258 - Intestinal, Colorectal and Anal Disorders

Total Laparoscopic Left Colectomy with Transanal Specimen Extraction: Lessons Learned From 145 Cases

Endoscopic Submucosal Dissection of Colorectal Tumors: Early Results of 36 Consecutive Cases in Single Academic Institution in Poland

S. Saad, C. Lindlohr, D. Politt Clinic Gummersbach, Gummersbach, Germany

M. Spychalski1, A. Dziki1, S.E. Kudo2 Medical University of Lodz, Poland; 2Showa University Northern Yokohama Hospital, Japan

1

Total laparoscopic left colectomy (TLC) with transanal specimen extraction avoids a minilaparotomy and has the potential to reduce postoperatve wound-related morbididty (pain, infection, hernia). Aims: We investigated whether TLC is a safe and feasible operative technique in a prospective observational study over a time period of four years in a German Academic Teaching Hospital. Methods: From Nov 2009 to Dec 2013 we performed TLC in 145 patients. Indications for left colectomy were diverticular disease, rectal prolaps, benign and malignant tumors up to 4 cm. Operative colon dissection was performed using 3 to 4 ports, the specimen was extracted via the anus with the help of a TEO-rectoscope. Colonic anastomosis was done with a circular stapler in end-to-side or end-to-end fashion. (Technical aspects will be presented in a short video clip.) Various parameters of technical performance and patient outcome were recorded during hospital stay and at a 1 month follow-up. Results: Mean operating time for TLC was 124 min., ranging from 140 min in the first 20 cases to 90 min in the last 20 cases. In 4 patients conversion to laparoscopic assisted colectomy with minilaparotomy (LAC) was necessary due to a bulky inflammatory colon specimen. Postoperative complications required reoperation in 4 patients fo anastomotic leakage(3) and ileus(1) and colonoscopic intervention in 2 patients for anastomotic bleeding (1) and stenosis (1), resulting in a 6 % overall complication rate. Mean hospital stay was 5.8 days due to reduced pain intensity and fast recovery of gastroinstenial function. The proportion of TLC to LAC was 76 % in 2010, 85 % in 2011, 93 % in 2012 and 95 % in 2013 at our department. Conclusion: In the majority of patients undergoing minimally invasive left colectomy TLC is a safe operation and can substitute LAC in order to further enhance patient outcome.

Aims: Endoscopic submucosal dissection (ESD) represents an important alternative for surgery in treatment of lateral spreading tumors (LST) of colon and rectum. With comparable oncological outcomes, when in experience hands, ESD has a potential to become a method of choice in treatment of adenomas and early carcinomas of colon and rectum. The aim of the study was to analyze early results of colon and rectal ESD performed at the Department of General and Colorectal Surgery, Medical University of Lodz. Methods: 36 consecutive cases of colorectal ESDs performed in our center between June and December 2013 were analyzed. Effectiveness of dissection, complications and the tumor recurrence after 3 months of treatment were than retrospectively investigated. Results: The first ESD in our department was performed in June 2013, preceded by the training in Japanese center, specializing in the diagnosis and endoscopic treatment of gastrointestinal tract malignancies - Showa Digestive Disease Center, Yokohama. From June to December 2013 36 ESD procedures were performed; 20 in the rectum, 6 in the sigmoid colon, 1 in the transverse colon, 7 in the ascending and 2 in the cecum. The average size of the removed tumors was 36.4 mm. The average operating time was 118 minutes. Perforation occurred in 3 cases (8,3 %). Two of them were managed with endoclips. Curative resection was obtained in 35 cases (97 %). In 22 cases en block resection was performed (61,1 %). In this group, 95 % cases were R0 resection, which was latter confirmed in the histopathology report. In a follow-up examination after 3 months, 1 of 20 patients (5 %) had recurrent adenoma, which was successfully endoscopically removed. Conclusions: These results confirm that the ESD is an effective and safe treatment modality for LSTs in the colon and rectum.

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Surg Endosc

O259 - Intestinal, Colorectal and Anal Disorders

O261 - Intestinal, Colorectal and Anal Disorders

Disappointing Results: Of Neoadjuvant Short Term Radiotherapy Followed By Transanal Endoscopic Microsurgery for T1-T2 Extraperitoneal Rectal Cancer

Long Term Outcome of Local Excision After Pre-Operative Chemoradiation For ypT0 Rectal Cancer

A. Arezzo1, S. Arolfo2, M.E. Allaix1, F. Munoz3, P. Cassoni4, U. Ricardi3, M. Morino1 1

Department of Surgical Sciences, University of Torino, Italy; University of Torino, Italy; 3Department of Oncology, University of Torino, Italy; 4Department of Medical Sciences, University of Torino, Italy

2

Objective: To assess in a pilot study short-term results of neoadjuvant short-term radiotherapy (RT) followed by Transanal Endoscopic Microsurgery (TEM) for T1-T2 extraperitoneal rectal cancer.Summary Background Data: Recent studies suggest that neoadjuvant RT followed by TEM is safe and has comparative results to abdominal resection in early extraperitoneal cancer treatment. Methods: We planned a consecutive series of 25 patients with extraperitoneal T1-T2 N0 M0 rectal adenocarcinomas who should undergo 5 Gy per 5 days (25 Gy), followed by TEM 4–10 weeks later. Results in terms of safety, efficacy and acceptability had to be compared to different historical groups of with similar rectal cancer stage and treated in different ways. Results: The study was interrupted after 12 patients underwent 25 Gy RT followed by TEM an average of 7 weeks (range 4–10) later. While no peroperative complication was observed, four weeks after surgery 7 patients (58 %) presented a complete dehiscence of the suture, in 2 cases associated with an enterocutaneous fistula in the sacral area, in 1 case requiring a colostomy. Quality of life at 1 month assessed through EORTC QLQ-C30 decreased of 22.9 ± 19.1, compared to 9.4 ± 4.4 after TEM following 46 Gy radiotherapy (P = 0.04), 7.0 ± 3.5 after TEM alone (P \ 0.001) and 16.5 ± 8.2 after curative abdominal or abdomino-perineal rectal resection (P = 0.11) for similar disease. With an average follow-up of 10 months (range 1–26) we observed one recurrence at 6 months who required an abdomino-perineal resection. Conclusions: Short-term RT followed by TEM for early rectal cancer is burdened by a too high morbidity, in terms of painful dehiscence of the suture line and enterocutaneous fistula, significantly higher that TEM alone and TEM following long-term RT, which forced us to stop the study.

A. Burza, F. Stipa, E. Soricelli San Giovanni Addolorata Hospital, Rome, Italy Introduction :The aim of the study was to evaluate the long-term clinical outcome of a selected group of ypT0 rectal cancer patients, submitted to local excision with transanal endoscopic microsurgery (TEM) as a definitive treatment. Methods: Between 1993 and 2013, 38 patients with rectal adenocarcinoma underwent complete full-thickness local excision with a TEM procedure after a regimen of preoperative external beam radiation therapy with 5-fluorouracil (5-FU)-based chemotherapy. In all patients rectal wall penetration (uT stage) was preoperatively assessed by endorectal ultrasound (ERUS) and/or magnetic resonance (MRI). Indications for CRT and TEM were: patients refusing radical procedures (TME or Miles) or patients unfit for major abdominal procedures. Results: In 25 patients partial or absence of tumour CRT response was observed (66 %). In thirteen patients (34 %), no residual tumor in the surgical specimen was found (ypT0). In this ypT0 group, 2 patients had a temporary proctitis and 2 patients had a dehiscence of the rectal wound. One patient was readmitted 18 days post-op for rectal bleeding which was treated conservatively. Postoperative mortality was nil. After a mean follow-up of 85 months (range 5 -166), no local and distal recurrences were observed. In all ypT0 patients no tumor related mortality was observed. Conclusions: Local excision with TEM can be considered a definitive therapeutic option in patients with rectal cancer treated with preoperative CRT, when no residual tumor is found in the specimen. In this selected group local excision offers excellent results in terms of survival and recurrence rates. In the presence of residual tumor, TEM should be considered as a large excisional biopsy.

O260 - Intestinal, Colorectal and Anal Disorders

O262 - Intestinal, Colorectal and Anal Disorders

Endoluminal Locoregional Resection by Transanal Endoscopic Microsurgery After Incomplete Endoscopic Removal or Local Recurrence of Rectal Tumor

Quality of Mesorectal Excision and Depth of Circumferential Resection Margin in Rectal Cancer: A Matched Comparison of First 20 Robotic Cases

S. Quaresima, A. Balla, A. Paganini, G. d’Ambrosio, M.V. Antonica, F. Mattei, E. Lezoche

C.M. Bergamaschi1, C. Foppa1, M. Barnajian1, D. Pettet1, E. Kazi2, F. Iordache2

Policlinico Umberto I, Rome, Italy

1 State University of New York, Stony brook, United States of America; 2Emergency Clinical Hospital Bucharest, Romania

Aims: Endoscopic treatment is considered adequate for rectal cancer with submucosal invasion of \ 1000 lM. Polyps larger than 2 cm, lymphovascular invasion and piecemeal technique are considered unfavorable prognostic factors. Endoluminal Locoregional Resection (ELRR) by Transanal Endoscopic Microsurgery (TEM) is a valid alternative to Total Mesorectal Excision (TME) after R1 endoscopic resection or local recurrence after operative endoscopy. Aims of this study is to evaluate recurrence rate and overall survival in 17 patients who underwent ELRR by TEM after operative endoscopy. Methods: From 2001 to 2013, 7 patients (5 males, 2 females, mean age 68, range 30–84) were admitted after incomplete endoscopic resection of rectal lesions or unfavorable prognostic factor (Group A) and 10 patients (5 males, 5 females, mean age 66,5, range 45–78) for local recurrence after endoscopic removal (Group B). Patients preoperative data Group A: mean distance from anal verge6,5 cm (range 2–10), mean diameter 1,7 cm (range 1–3), histology after polipectomy: TisR1 3 patients, T1R1 3 patients, T1R0G3 1 patient. Group B: mean distance from anal verge5,9 cm (range 2–10), mean diameter 2,1 cm (range 1–3), histology after polipectomy: TisR0 8 patients, T1R0 2 patients. Mean time of local recurrence was 9,5 months (range 3–24). Mean diameter of recurrence was 1,9 cm (range 1–3). All patients underwent ELRR by TEM as previously reported. Results: In Group A mean operative time was 143,5 minutes (range 80–290), mean hospital stay 6,4 days (range 3–9). Complications were nil. Definitive histology was: moderate dysplasia (1), T0N0 (2), TisN0 (1), T1N0 (1), T2N0 (2). T2 patients underwent salvage laparoscopic TME. In Group B mean operative time was 147,5 minutes (range 40–300), mean hospital stay 7,6 days (range 1–18). Complications occurred in two patients: fluid collection and hematochezia. Definitive histology was: moderate dysplasia (3), T0N0 (2), TisN0 (3), T1N0 (2). Mean follow-up were 77,2 months (range 36–147) in Group A and 75,3 months (range 11–150) in Group B. All patients are alive and disease free. Conclusions: ELRR by TEM is a valid alternative to TME in patients after R1 endoscopic resection or local recurrence after operative endoscopy.

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Aims: There are concerns about the impact of robotic proctectomy on total mesorectal excision (TME) quality and laparoscopic proctectomy on of circumferential resection margin (CRM) depth. The aim of this study was to compare TME quality and CRM depth of the first 20 consecutive robotic proctectomies with matched open and laparoscopic cases by same surgeon. Method: Data on the first 20 consecutive patients undergoing robotic proctectomy by one surgeon were extracted from a prospectively maintained database. Propensity matching selected open and laparoscopic patients based on gender. Rectal cancer was within 12 cm from verge. TME quality was complete, nearly complete, or incomplete. CRM was reported in mm. Learning curve in robotic proctectomy was defined at 20 cases. Results: Matching of 20 robotic patients left 20 conventional and 20 laparoscopic patients. Age (p = 0.481), POSSUM physiology (p = 0.537), operative severity score (p = 0.338), predicted mortality (p = 0.758), co-morbidities (p = 0.237), previous abdominal surgery (p = 0.741), tumor distance (p = 0.932), location (p = 0.796), stage (p = 0.848), neoadjuvant chemoradiation (p = 0.435), operating time (p = 0.076), blood loss (p = 0.285), ileostomy (p = 0.934), conversion (p = 0.362), resection type (p = 1.000), flatus (p = 0.327), diet (p = 0.389), stay (p = 0.997), complications (p = 0.367), reoperations (p = 0.804), reinterventions (p = 0.521), readmissions (p = 0.349), tumor size (p = 0.529; p = 0.522; p = 0.282), distal margin (p = 0.090), nodes harvested (p = 0.148), and pathology stage (p = 0.553) did not differ. TME quality did not differ statistically (95:5:0 vs. 90:5:5 vs. 80:5:15 %; p = 0.153). CRM was increased in robotic patients (8.925 vs. 7.655 vs. 16 mm; p = 0.026). Conclusion: Robotic proctectomy decreased TME quality reflecting the learning curve. CRM was increased after robotic proctectomy despite the learning curve.

Surg Endosc

O263 - Robotics, Telesurgery and Virtual Reality

O265 - Robotics, Telesurgery and Virtual Reality

Robotic Intersphincteric Resection with Coloanal Anastomosis for Low Rectal Cancer: Lessons Learned From an Initial 102 Consecutive Procedures

Robotic Surgery Versus Laparoscopic Surgery for Rectal Cancer: Case Control Matching Analysis of Oncologic Outcomes

J.S. Park, G.S. Choi, S.Y. Park, H.J. Kim, J.I. Choi Kyungpook National University Medical Center, Daegu, Korea Background: As the use of a surgical robot allows for improved dexterity and visual field, we successfully conducted intersphincteric resection (ISR) and perineal coloanal anastomosis (CAA) for a very low lying rectal cancer. The aim of this study was to evaluate the technical feasibility, effectiveness, and safety of robotic ISR with CAA, using the da Vinci system through analyses of our initial series of 102 consecutive patients. Methods: A review of a prospectively designed database at our institute from January 2008 to December 2013 revealed a series of 102 consecutive robotic ISR with CAA patients with a low rectal cancer. The surgical procedures included 5 steps: colonic mobilization with ligation of inferior mesenteric vessels, total mesorectal excision, intersphincteric dissection with rectal transection, specimen retrieval, and coloanal anastomosis. Clinicopathologic characteristics and surgical outcomes were analyzed. Results: All operations were performed successfully without open or laparoscopic conversion. The median operation time was 230 minutes, and the median estimated blood loss was 65.0 mL. No intraoperative-related or robotic system-related morbidities were observed. There were 9 postoperative high grade morbidities and 5 postoperative anastomotic leakage. The first flatus was noted on postoperative day 2.4, soft diet was started on postoperative day 4.5, and the mean postoperative hospital stay was 8.8 days The number of complete resections (margin [ 1 mm) was 98 (96.0 %). In ten patients, complete transabdominal ISR were conducted without perineal dissection phase. Conclusions: This study demonstrated that robotic ISR with CAA can be applied safely and effectively for patients with gastric cancer.

J.I. Choi, G.S. Choi, J.S. Park, S.Y. Park, H.J. Kim Kyungpook National University Medical Center, Daegu, Korea Purpose: The aim of this study was to compare the oncologic outcomes of Robotic surgery (RS) with those for laparoscopy-assisted surgery (LAS) for non-metastatic rectal cancers. Methods: We reviewed the prospectively collected records of all patients undergoing RS or LAS for rectal cancer from January 2008 to December 2012 at Kyungpook National University Hospital. We undertook case control matching analyses and compared outcomes for the RS and LAS groups in a 1:1 matched cohort. Covariates in the model for case control matching included age, gender, preoperative tumor marker level, preoperative chemoradiation status and tumor height from the anal verge. Our primary endpoint was estimated three year oncologic outcomes. Results: We analyzed the data by case control matching method and there were one hundred fifty five cases included in each groups. There were no perioperative mortality and converted open surgery. There were no significant differences in surgical outcomes including overall morbidity and pathological quality between two groups. Median follow-up was twenty six months. The estimated three year local recurrence rates were similar in the two groups. (4.1 % in RS group, 2.8 % in LAS group; p = 0.831) Also, the estimated three year disease free survival rates for RS and LAS were 82.2 % and 84.2 %, respectively.(p = 0.834) Conclusion: Robotic surgery for rectal cancer is safe and feasible with acceptable oncologic outcomes. Further prospective multicenter trials with long term follow-up are warranted.

O264 - Robotics, Telesurgery and Virtual Reality

O266 - Clinical Practice and Evaluation

The Complete Mesocolic Excision in Robotic Right Colectomy with Intracorporeal Anastomosis: Our Experience

Does Competency in Laparoscopy Make the Learning Curve Redundant for Performing Robotic Rectal Resections?

G. Spinoglio, G. Formisano, A. Marano, F. Priora, F. Ravazzoni, F. Melandro, V. Maglione, M. Lodin

L. Khan, J. Foo, H. Patel, N. Siddiqi, A. Parvaiz

SS. Antonio and Biagio Hospital, Alessandria, Italy Aims: Minimally invasive surgery has gained worldwide acceptance in the treatment of colonic cancer in the last decades. Robotic assistance with DaVinciÒ system has been postulated to improve results by overcoming pitfalls of traditional laparoscopic surgery. We report a large, single institution case-series of complete mesocolic excision (CME) in robotic right colectomies for cancer with intracorporeal anastomosis, attempting to better elucidate the technical, clinical and oncological benefits of robotic surgery. Methods: We conducted a retrospective analysis on prospectively collected data of 101 patients who underwent robotic right colectomy with CME and intracorporeal anastomosis at our institution between October 2005 and November 2013. Clinical and pathological outcomes, disease-free survival and overall survival were analysed. Results: Fifty-seven male and forty-four female patients underwent robotic right colectomy. Mean age was 71.2 years. Conversion rate to open surgery was 1.9 % and mean operating room (OR) time was 279.5 min, but the duration has a tendency to decrease as the experience of the team improves. Anastomotic leak rate was 0.9 %. Mean number of harvested lymph nodes was 28.2. The 3-year disease-free and overall survival rates were 87.8 % and 92.6 %, respectively. Conclusions: To date and to the best of our knowledge, this is the largest case-series of robotic right colectomy with CME and confirms that the use of robotic platform for rightsided colonic malignancies is feasible, safe and effective, with a high number of harvested lymph nodes and promising oncological outcomes. Robotic surgery could potentially make CME and intracorporeal anastomosis easier procedures to perform if compared to the traditional laparoscopic approach.

Minimally Invasive Colorectal Unit, Portsmouth, United Kingdom Aims: Minimal access surgery offers superior short-term and equivalent long-term oncological outcomes to open surgery. For surgeons performing laparoscopic rectal resections limitations with exposure and access represent a significant challenge. Robotic surgery addresses the limitations of laparoscopy while maintaining a minimal access approach. When adopting any new technology the potential advantages must be balanced with concerns for patient outcomes over the course of the associated learning curve. We evaluated whether competency gained in laparoscopy lessens the learning curve for performing robotic rectal resections. Methods: Outcome data from a consecutive series of the first 25 patients undergoing robotic total mesorectal excision (R-TME) was compared with the last 50 patients treated laparoscopically (L-TME). All operations were performed by a single surgeon (an experienced laparoscopic rectal cancer surgeon having performed over 400 laparoscopic rectal resections) at a single institution. Perioperative care was standardized within an enhanced recovery protocol. Differences in total operating time, lymph node yield, resection margin positivity, conversion, length of stay and anastomotic leak were analysed with logistic regression and Fisher’s exact test (p \/=0.05). Results: 75 patients (45 male, 30 female) underwent TME. Patients treated laparoscopically were younger (64.5 vs 68 years, OR 1.08; CI 1.01–1.16 p = 0.02). There was no difference in gender distribution, asa grade, body mass index or neoadjuvant chemo-radiotherapy treatment between groups. Comparing short term outcomes for the laparoscopic vs robotic group there was no significant difference in median operating time (210mins vs 220 mins), length of stay (6 days vs 7 days), lymph node yield (18 vs 18), anastomotic leak (1 vs 0), conversion to open or laparoscopic surgery (0 in both groups), resection margin positivity (2 vs 1) and 30 day mortality (0 in both groups). Conclusions: Our initial experience performing fully robotic rectal resections demonstrated no associated learning curve. We believe this is due to competency gained performing large numbers of laparoscopic resections and by using the same standardised technique for R-TME.

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Surg Endosc

O267 - Intestinal, Colorectal and Anal Disorders

O269 - Intestinal, Colorectal and Anal Disorders

Safety and Feasibility of Laparoscopic Ileocolonic Resection for Crhon’s Disease

Recurrence and Long Term Results: Of Laparoscopic Versus Open Ileo-Colonic Resection in Crohn’s Disease. A Prospective Longitudinal Study

T. Yamamoto, S. Umegae, K. Matsumoto Yokkaichi Social Insurance Hospital, Yokkaichi, Japan Aims: We have introduced laparoscopic ileocolonic resection for stricturing Crohn’s disease (CD). This study was to assess safety and feasibility of laparoscopic ileocolonic resection for CD. Methods: Twenty CD patients were treated with laparoscopic ileocolonic resection (LAP group). The outcomes of laparoscopic resection were compared with those of open resection conducted for 20 patients with stricturing CD (OPEN group). In this study, all patients were followed up for at least two years after surgery. Patients with active colonic disease at laparotomy were excluded. Results: Age at laparotomy, sex, CD duration before laparotomy, smoking habit, and preoperative medications (mesalazine, corticosteroids, immunosuppressants, biologic agents) were not significantly different between the groups. The main location of active CD was the terminal ileum in 7 patients and ileocecal region in 13 patients in both groups. Four patients in the LAP group and 3 patients in the OPEN group required strictureplasty for concomitant CD in the proximal small bowel. The mean length of the resected bowel was not significantly different between the groups. The mean operative time was 175 minutes in the LAP group, which was significantly longer than 151 minutes in the OPEN group. The mean intra-operative blood loss was not significantly different between the groups. Three patients (15 %; intra-abdominal abscess 1, small bowel obstruction 2) in the LAP group and 4 patients (20 %; intra-abdominal abscess 2, small bowel obstruction 2) in the OPEN group experienced postoperative complications (not significant). One patient in the OPEN group required laparotomy due to intra-abdominal abscess. At two years after laparotomy, clinical recurrence (CD activity index score = 150) was observed in 5 patients (25 %) of the LAP group vs 6 patients (30 %) of the OPEN group (not significant). At one to two years after laparotomy, endoscopic recurrence (Rutgeerts score = i2) was observed in 7/14 patients (50 %) of the LAP group vs 7/13 patients (54 %) of the OPEN group (not significant). One patient in the OPEN group required laparotomy for CD recurrence within two years after laparotomy. Conclusion: Laparoscopic ileocolonic resection is safe and feasible in the management of stricturing CD.

C. Fiorani University of Tor Vergata, Rome, Italy Introduction: Impairment in host immune response has been demonstrated in pathogenesis of Crohn’s disease (CD). Likewise laparoscopic resections for cancer have shown different immunitary modifications when compared to open techniques. Relationship between surgical approaches and the rates and severity of CD recurrence after ileo-colonic (IC) resections are unknown. Aims of this study was to assess whether the surgical approach might affect recurrence amongst 2 groups of CD patients undergoing either laparoscopic (LAP) or open ileo-colonic resection. Methods: 116 patients undergoing elective IC resection by either laparoscopic approach (LAP 40 %) or conventional open surgery (OPEN 60 %) were enrolled in a prospective longitudinal study. Study protocol includes 3-years follow up (FU). Recurrence was investigated by coloscopy and ileoscopy (RC-I) at 12 and 36 months in all patients, CDAI was assessed every 6 months. Patient’s satisfaction to different approach was also analysed with a specific Treatment Satisfaction Questionnaire as part of the protocol. Fisher Test and Chi-squared-test were used to statistically compare data as appropriate. Results: Endoscopy was performed in 91 patients (78 %) at 1 year and 62 patients (53 %) at 3 years. Endoscopic recurrence (Rutgeerts’ score = 2) was observed in 60 % LAP vs 83 % OPENat 1 year (p 0.03) and in 55 % LAP vs 80 % OPEN patients at 3 years (p 0.05). Three patients (1 in the LAP group and 2 in the OPEN one) underwent re-resection during the FU period. Clinical recurrence at 36 months was 2 (4,2 %) in the LAP group and 3 (4,3 %) in the OPEN group. Patients’ satisfaction by specific questionnaire was significantly in favour of laparoscopy also in the long-term assessment. Conclusions: Statistical difference was seen in endoscopic recurrence rate between groups at 1 year assessment. This difference is maintained also at the follow up at3 years. Treatment Satisfaction assessment shows a strongly significant preference of the patients for the mini-invasive approach.

O268 - Intestinal, Colorectal and Anal Disorders

O270 - Intestinal, Colorectal and Anal Disorders

Nutritional Aspects and Quality of Life of Patients Undergoing Ileo-Cecal Resection for Crohn’s Disease

Laparoscopic Total Colectomy for Severe Refractory Ulcerative Colitis: Prospective Single-Port Versus Multi-Port Comparative Cohort and Case Control Analysis

C. Fiorani University of Tor Vergata, Rome, Italy Background. Relationship between surgery, type of surgery (laparoscopic or open), quality of life (QoL) and nutrition in CD patients is still unclear. Aims of the study was to evaluate the QoL and nutritional aspect of a consecutive group of CD patients undergoing laparoscopic or open ileo-cecal resection. Methods: Eighty patients undergone ileocecal resection (I-C) for Crohn disease were randomly selected from database. Patients were divided into 2 groups: A laparoscopic and B open-resection. Data from patients were recorded before surgery and 6 and 12 months after the operation. The analyzed parameters were: Body Mass Index (BMI), biochemical levels of albumin, creatinine, urea, cholesterol, triglycerides, serum iron, ferritin and complete blood count (Hb hemoglobin and Ht hematocrit). Student’s T test and Chi Square test were used as appropriate. QoL questionnaires were administred. Results: Data from 68 patients (31group A and 37 group B) were completed in order to make comparisons. BMI significantly increase after surgery in the short and long term in group A (p 0.002 and 0.0001) and at 12 moths in group B (p 0.003).Albumin levels also showed a significant increase in both groups 6 months after surgery (A:p = 0.0001and B:p = 0.015), whilst a further increase at 12 months is seen only in group A (p = 0.04). Serum iron level is increased 12 months after I-C resection (group A p = 0.003; group B p = 0.02), and so is the Hb level (group A p = 0.02; group B p = 0.05). Significant differences in Ht were visible at 12 month only in group A (p = 0.02). Sixty-eight % of patients filled the IBDQ-QoL questionnaire. Mean score was 163\224 with no differences between the two groups. All patients filled the nutritional based questionnaire: 71.5 % of patients believe its QoL improved after I-C resection. No significant differences were noted between groups. Conclusion: Surgery has a positive impact on the nutritional status of the patients. Laparoscopic ileocecal resection compared to traditional surgery seems to play a role in the middle and long term outcome probably thanks to the shorter recovery time and the favorable acceptation among patients. Almost three quarter of the patients sees improvements in the QoL after ileocecal resection.

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A. Ronan, J. Burke, D. Toomey, F. Reilly, J. Deasy, D. Mcnamara Beaumont Hospital, Dublin, Ireland Background: Single port laparoscopic surgery allows total colectomy and end ileostomy for medically uncontrolled ulcerative colitis solely via the stoma site incision. While intuitively appealing, there is sparse evidence for its use beyond feasibility. Methods: All patients presenting electively, urgently or emergently over a three-year period at a tertiary referral centre under three specialist teams were studied prospectively. One team commenced its operative cohort via single access laparoscopy (SAL) via the stoma site on a near-consecutive basis using a ‘surgical glove port’ as compared to a conventional four trocar, multiport approach allowing group-comparative and case-control analysis. Standard, straight rigid laparoscopic instrumentation were used and no additional resources were allocated. Results: Of 46 consecutive patients requiring surgery, 39 (85 %) had their procedure begun laparoscopically. 27 (69 %) of these were commenced by single port access with an 89 % completion rate thereafter (three were concluded by multitrocar laparoscopy). SAL proved effective in comparison to multiport access regardless of disease severity providing significantly reduced operative access costs ([ €100/case) and postoperative hospital stay (median 5 days v 7.5, p = 0.045) without increasing operative time. It proved especially efficient in those with preoperative albumin [ 30 g/dL (n = 20). Its comparative advantages were further confirmed in ten pairs case-matched for gender, BMI and preoperative albumin. SAL has proved equally durable in the intermediate term (median followup = 20 months). Conclusions: Single port total colectomy proved useful in planned and acute settings for patients with medically refractory colitis, especially in non-toxic patients. Assumptions regarding duration and cost should not be barriers to its implementation.

Surg Endosc

O271 - Intestinal, Colorectal and Anal Disorders

O273 - Intestinal, Colorectal and Anal Disorders

Transanal Hybrid Sigmoid Resection Versus Traditional Laparoscopic Sigmoid Resection in the Treatment of Sigmoid Diverticulitis

Feasibilty of Transrectal Hybrid-Notes Anterior Resection for Diverticular Disease

B. Babic, W. Breithaupt, G. Varga, T. Schulz, K.H. Fuchs Agaplesion Markus Krankenhaus, Frankfurt am main, Germany Introduction: Transanal Hybrid rectal and colon resections have been introduced in the past 2 years in a few dedicated centers. The underlying Hybrid NOTES concept was to reduce access trauma and morbidity by using the anus as natural orifice for larger size access and restrict transabdominal access to maximum 3.-5 mm instruments. Aims: Evaluation of Transanal Hybrid Sigmoid Resection (TAHSR) and traditional Laparoscopic Sigmoid Resection (LSR) regarding intra and postoperative parameters. Methods: After finishing a initial pilot study on the new Hybrid technique, we started a comparative study non-randomized, between the 2 above mentioned operative techniques TAHSR versus LSR. Indication for surgery were sigmoid diverticulitis at least 5 weeks after the last inflammatory phase usually having had several phases with increasing severity. Transanal access was used for all operative steps requiring access of more than 5 mm, such as staplers, large graspers, swaps, specimen retrieval. Data acquisition and analysis was performed for OR-Time, complications, postoperative well being and pain score, quality of life. Results: Fifteen patients underwent TAHSR and 20 patients LSR. There were 13 males and 22 females, median age 58 (39–80). TAHSR// LSR: OR-Time: 139//117 min; conversions: 1//0; complications: 1//3; GIQLI pre//post : TAHSR 87 // 119; LSR 93// 117; no difference except postoperative wound infection and hernia. Conclusion: TAHSR is a realistic option for sigmoid resection and can have the potential in preventing wound and hernia complications.

S.H. Lamm, A. Zerz, D.C. Steinemann Bruderholz/Kantonsspital Baselland, Bruderholz, Switzerland Aims: Natural Orifice Transluminal Endoscopic Surgery is an evolving technique reducing the access trauma. Transvaginal cholecystectomy and anterior resection has been shown to be safe and feasible. Postoperative pain is reduced and recovery enhanced compared to conventional laparoscopic surgery. The transrectal access for anterior resection in diverticular disease promises similar advantages. Yet, its feasibility and safety have not been well studied. Material and Methods: Operative data and outcome of a consecutive series of 27 patients undergoing Hybrid-NOTES transrectal anterior resection have been prospectively recorded and analyzed. Results: 22 men and 5 women with a median age of 56 years (IQR 44–64) underwent Hybrid-NOTES anterior resection. Median time of surgery was 155 minutes (131–180). In 4 men (15 %) with a bulky mesenterium it was intraoperatively decided not to perform a transrectal specimen removal and a Pfannenstiel incision was performed. Median BMI was 23 (22–24) kg/m2 and 29 (26–31) in converted patients. In 3 patients (11 %) before transrectal specimen extraction the mesenterium was divided from the sigmoid colon due to a bulky specimen. In one women with an acute stenosing diverticulitis with severe adhesions after hysterectomy transrectal access was felt to be impossible. Median level of anastomosis was 12 cm above dentate line (range 10–14). Preoperative median level of CRP was 4 (4–5) mg/l, on the second postoperative day 127 (82–190) and 51 (36–88) on the fourth day. There were 4 (15 %) postoperative complications: urinary retention in one patients (Dindo grade 1), addison crisis requiring corticosteroids (grade 2), local pelvic peritonitis requiring laparoscopic lavage (grade 3b) and one patient with anastomotic dehiscence underwent laparotomy and received colostomy (grade 4a). Median hospital stay was 7 days (6–8). Conclusions: Transrectal Hybrid-NOTES anterior resection is feasible with a reasonable complication rate. Especially in men and obese patients the feasibility is limited by a size mismatch of the diameter of the rectum and the specimen. In case of bulky specimen transrectal removal might be difficult. Dividing the mesenterium from the colon sigmoideum in order to minimize the diameter before transrectal extraction should be considered. Further studies focusing on postoperative recovery, pain and functional outcome are awaited.

O272 - Intestinal, Colorectal and Anal Disorders

O274 - Clinical Practice and Evaluation

Recurrent Left-Sided Diverticulitis: Always the Same Spot?

Morbidity of Hartmann’s Procedure Followed by Laparoscopic Reversal Versus Rectosigmoid Resection with Loop Ileostomy Followed by Ileostomy Closure: A Case-Matched Study

M.A.W. Stam, W.A. Draaisma, B. Heggelman, I. Somers, I.A.M.J. Broeders, E.C.J. Consten Meander Medical Centre, Amersfoort, The Netherlands Aims: Recurrent episodes after uncomplicated diverticulitis occur in about 33 % of patients. Knowledge on the exact anatomic location of recurrent inflammation is very limited. Our aim was to investigate if recurrent episodes occur in the same location as the initial episode. Methods: Medical charts of all patients suffering from an episode of diverticulitis between 2008 and 2013 were reviewed. Patients with a minimal of two CT-proven episodes of diverticulitis were eligible for inclusion. Excluded were those with a complicated initial episode (classified by Hinchey stage II, III and IV), fistulas or stenosis, concomitant colon cancer or inflammatory bowel disease. CT scans were reviewed in terms of severity and location of disease by two independent radiologists. Statistical analysis was done using the chi-square test and a Spearman correlation. Results: 1044 patients were treated for diverticulitis between 2008 and 2012. Only 90 patients had two or more CT proven episodes of diverticulitis. 34 patients were eligible for inclusion, 22 women (65 %) and 12 men (35 %). Main reasons for exclusion were complicated diverticulitis and underlying colon cancer. The average age at onset of disease was 57 years. Median follow-up was 51.5 months (range 16–107). Diverticulitis was mainly localized in the horizontal part of the sigmoid. Recurrent episodes occurred in 76,5 % in the same location as the initial episode (Linear-by-Linear test p \ 0,05) and in 17,6 % in an adjacent segment and at distance in 5,9 %. Conclusion: Recurrent episodes of diverticulitis mostly occur in the same location as an initial episode. This may support the choice for limited laparoscopic resection in case of recurrent complaints.

D.C. Steinemann1, P.L. Limani2, S.H. Lamm1, A. Zerz1, T. Stierle1 1

Cantonal Hospital Baselland, Bruderholz, Switzerland, 2University Hospital Zurich, Switzerland Aims: Restorative colectomy with loop ileostomy (RC) is preferred to Hartmann’s procedure (HP) for left sided colon perforation. Reversal after HP may fail due to its complexity. Nevertheless, in daily surgical practice HP is commonly performed. Laparoscopic Hartmann’s reversal has been reported to have a low morbidity rate. This study aims to compare the morbidity of RC followed by ileostomy closure versus HP and laparoscopic reversal. Methods: All consecutive patients undergoing HP for left sided colon perforation between 2011 and 2013 at the Cantonal Hospital Baselland were compared to a cohort of patients undergoing RC controlling for age, Charlson index and indication. Results: 47 patients underwent HP for perforated diverticulitis (n = 24), iatrogenic perforation (n = 5), colon cancer (n = 7), colon ischaemia (n = 3) or anastomotic leakage (n = 8). 7 patients who died postoperatively and 7 with colonic cancer were excluded. 33 patients (14 men) with a median age of 72 (IQR 61–83) were eligible for Hartmann’s reversal and matched to 33 patients (15 men) with a median age of 70 (58–77; p = 0.7) with RC. Charlson index was 6 (4–9) in the Hartmann’s group and 5 (3–7) in the comparison group (p = 0.1). In HP group in 6 multimorbide patients, 3 patients with end-stage non-colonic malignancy and one patient with faecal incontinence reversal was declined. 23 patients (70 %) were underwent laparoscopic Hartmann’s reversal. Conversion to open reversal was necessary in 8 patients (35 %). In RC group 29 patients (85 %) underwent stoma closure (p = 0.1). Number of patients with a Dindo [ III complication was 8 following HP, 3 after HP reversal or 7 following RC and 2 following ileostomy closure. 11 patients (out of 23) in the Hartmann’s group and 9 (out of 29) in the RC group experienced a complication Dindo [ III either in the primary procedure or following stoma closure (p = 0.26). Conclusions: The perioperative morbidity of both therapeutic strategies is comparable. The reversal rate tended to be higher in RC with loop ileostomy. Emergency surgery often is performed by less-experienced surgeons so that Hartmann’s operation remains a safe alternative. Laparoscopic reversal is more demanding and reserved for experienced laparoscopic surgeons in an elective setting.

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Surg Endosc

O275 - Intestinal, Colorectal and Anal Disorders

O277 - Morbid Obesity

Reduced Incidence of Adhesive Small Bowel Obstruction in Laparoscopic Anterior Resections

Sleeve Gastrectomy, But Not Duodenojejunostomy, Lowers Hba1c and Induces Hypergastrinemia in Goto-Kakizaki Rats

M.H. Chang, W.S. Tan, M.H. Kam

E. Grong, I.B. Arbo, O.K. Thu, E. Kuhry, B. Kulseng, R. Marvik

Singapore General Hospital, Singapore

University of Science and Technology, Trondheim, Norway

Aims: Post-operative adhesions cause considerable morbidity, including need for re-admission and re-laparotomy. Laparoscopic colorectal surgery has been demonstrated to be associated with fewer adhesions than open surgery. It is, however, unclear if this translates clinically to a lower incidence of adhesive small bowel obstruction (SBO). The aim of our study was to evaluate the incidence of SBO after laparoscopic (LAR) versus open anterior resections (OAR). Methods: All elective anterior resections that were performed in our institution from January 2007 to December 2008 were included in our study. Patients with previous intraabdominal operations were excluded. Intestinal obstruction was defined as a combination of clinical and radiological findings of abdominal pain or distension, vomiting, constipation and dilated small bowel loops on abdominal radiograph or computed tomography scan. Adhesive small bowel obstruction was defined as an episode of small bowel obstruction found at laparotomy to be caused by adhesions, or for which no other cause of mechanical obstruction could be identified following non-operative management. Results: 716 patients underwent anterior resection during this study period [LAR n = 259 (36.2 %), OAR n = 325 (63.8 %)]. There was a significantly higher incidence of SBO in the OAR group (4.3 % vs 0.8 %; p \ 0.01). Similarly, more patients in the OAR group required surgery (2.5 % vs 0.5 %; p = 0.04). Within the OAR group, there was no significant difference in the incidence of SBO between patients with a horizontal (n = 256) and vertical (n = 69) incisions (7.2 % vs 3.5 %; p = 0.19). There was also no significant difference in the incidence of SBO between patients with a horizontal incisions (n = 249) and transanal extraction (n = 10) in the LAR group (2 vs 0; p = 1.00). In all patients with a horizontal incision, more patients in the OAR group developed SBO than the LAR group [OAR n = 249, LAR n = 256 (3.5 % vs 0.8 %; p = 0.04] and required surgical intervention for SBO (2.3 % vs 0.4 %; p = 0.062). Conclusion: LAR was associated with a lower incidence of adhesive SBO. This consequently reduces the incidence of re-admission and the need for additional surgical procedures. These findings suggest that the benefits of laparoscopic colorectal surgery extend beyond the initial peri-operative period.

Aims: Bariatric surgery has been proven to be an effective and designated treatment of type II diabetes mellitus (T2DM) in morbid obese patients. In addition to significant weight loss, the postoperative remission of T2DM may be due to altered secretion of gastrointestinal hormones. The role of bariatric surgery as intervention for T2DM in patients with a body mass index \ 35 kg/m2 remains unclear. We have studied the effect of bariatric surgery in an animal model whose diabetes is not related to obesity. Methods: Forty male Goto-Kakizaki (GK) rats and 15 age and sex matched Wistar (W) rats were randomized into duodenojejunostomy (DJ), sleeve gastrectomy (SG) and sham operation. Rats were followed up for 36 weeks during which we evaluated body weight, fasting blood glucose, glucose tolerance, glycosylated hemoglobin (HbA1c) and gastrointestinal hormones like glucagon-like peptide 1 (GLP-1) and gastrin. Results: Body weight was significantly lower for GK-DJ and GK-SG compared to GKsham only the first four weeks after surgery (P \ 0.05 for all). GLP-1 levels were significantly elevated for GK-DJ compared to GK-sham (P \ 0.05). On the 34th postoperative week, glucose tolerance was significantly better for GK-SG compared to GK-sham (P \ 0.05). Simultaneously, HbA1c levels were lower for GK-SG versus both GK-DJ and GK-sham: (median (75 %;25 %)) 5.2 (6.0; 4.3) % vs. 7.0 (7.5; 6.7) % and 7.3 (7.6; 6.7) % (P = 0.009). Serum gastrin levels were significantly elevated for GK-SG compared to the two other groups at six-and 36 weeks after surgery: 188.0 (318.0; 121.0) vs. 77.5 (114.0; 58.0) and 68.0 (90.0; 59.5) pmol/L (P = 0.004) and 192.0 (587.8; 110.8) vs. 65.5 (77.0; 59.0) and 69.5 (113.0; 55.5) pmol/L (P = 0.001). Conclusion: Sleeve gastrectomy lowers HbA1c and induces hypergastrinemia in GotoKakizaki rats. Duodenojejunostomy increases GLP-1 levels without impact on HbA1c levels.

O276 - Morbid Obesity

O278 - Morbid Obesity

Chance of Tableside Test of the Staple Line Competence of the Excised Stomach During Sleeve Gastrectomy

Impact of Laparoscopic Sleeve Gastrectomy on Micronutrient Levels and Bone Health in Morbidly Obese Patients

H. Abou Ashour1, M.S. Ammar1, M. Abd El Samie1, M. Farghaly2

S. Aggarwal, S. Anand, M. Misra, R. Khadgawat, A.K. Mukhopadhay, R. Jaiswal, S. Chumber

1

2

Minoufiya Faculty Of Medicine, Shibin al kom, Egypt; Al Seef Hospital, Kuwait, Kuwait Introduction:Too many laparoscopic sleeve gastrectomies LSG are performed everyday all over the world . One of the most serious life threatening complication of LSG is gastric leak . Early leak is due to technical problem and stapler misfiring. Various interventions are used for management of such condition with prolonged hospital stay,costs, staff exhaustion,mortality and negative bariatric surgery reputation. Aims: Benefits of correlation between leak outside in the excised stomach and current or potential intracorporeal leak. Material and methods : 483 sleeve gastrectomy patients underwent this intra operative tableside test. After the excised stomach was delivered, careful watching of the staple line for any misfires then a small hole was done at one pole of the discarded stomach then filling it with methelyne blue, a burse string suture was used to close the hole,then the excised stomach was examined passively and under pressure then classified into 3 groups,group A those who didn’t leak passively or under pressure, group B those who leaked passively and under mild pressure, group C those who only leaked under high pressure, then conventional methelyne blue test for the new stomach inside the patient was performed. Then correlation between the extracorporeal and intracorporeal sites of leak was evaluated finding out any link between them. Results: No extracorporeal leak occured in 449 excised stomach (93 %) in group A . In group B, extracorporeal staple line leak was found passively and under mild pressure in 13 cases, in group C,those examined under high pressure leak was found in 23 cases in. Typically no intracorporeal leak occurred as those in group A . 11 patients (84.6 %) showed intracorporeal bleeding and mirror image leak similar to those of group B (P \ 0.001). 1 patient (4.4 %) showed mirror image leak to those with group C (p [ 0.05). The average time for the tableside test was 4.8 min. Conclusion: Extracorporeal leak at the staple line of the excised stomach has a great significance of current or potential leak and selection of which case to perform suture re enforcement.

123

All India Institute of Medical Sciences (AIIMS), New delhi, India Background: Laparoscopic Sleeve Gastrectomy (LSG) is a popular weight loss for morbidly obese patients. Its impact on weight loss and co-morbidities is well established. In contrast to gastric bypass, LSG is thought to have minimal nutritional deficiencies. However, data on the outcome of LSG on micronutrient status is scarce. This study was undertaken to evaluate micronutrient levels and bone health in patients undergoing LSG. Methods: The study consisted of two groups. Group A comprised of 40 patients who had undergone surgery in the past and were evaluated for nutritional parameters at various time intervals after surgery. Group B comprised of 45 new patients who were enrolled in a prospective fashion. Patients were evaluated before surgery as well as 3, 6, 12 months postoperatively using a standard battery of laboratory tests including serum iron studies, Vitamin B12, folate, calcium, phosphate, Vitamin D, Parathormone (PTH) and 24 hour urinary calcium. Results: The mean body mass index (BMI) in Group A and B was 48.4 and 47.5 and mean % excess weight loss at maximum follow up was 67 % and 78.75 % respectively. More than 67 % of morbid obese patients had at least one micronutrient deficiency prior to surgery, mostly as Vitamin D deficiency. Deficient patients were started on oral vitamin D supplementation, which, in post op period showed improvement. However patients with normal pre op vitamin D levels showed decrease in its level post operatively. About 15 % patients developed de novo Vitamin B12 deficiency in the post op period. 45 % of patients developed low 24 hours urinary calcium (indicator of oral calcium intake) in 3 months postop, which improved in the subsequent follow-up period. There were no significant changes in iron and folate levels. None of the patients had a deficiency of serum calcium in the pre op and postop period. Conclusion: Micronutrient deficiencies are prevalent in morbid obese patients. Patients undergoing LSG develop Vitamin B12 and Vitamin D deficiency in the post op period and their supplementation should be started accordingly. Oral calcium supplements should be given in the initial post op period until their calcium intake in diet improves.

Surg Endosc

O279 - Morbid Obesity

O283 - Morbid Obesity

Effect on Vitamin B12 Levels After Sleeve Gastrectomy and Roux-En-Y Gastric Bypass: A Prospective, Matched-Cohort Study with One Year Follow Up

Roux-EN-Y Gastric Bypass after Failed Adjustable Gastric Band Can Be Accomplished With Similar Morbidity as Primary Bypass

A. Techagumpuch1, P. Vichajarn2, P. Chanswangphuvana2, S.U. Pungpapong2, C. Tharavej2, P. Navicharern2, S. Udomsawaengsup2

M.M. Kim, B. Oommen, S.W. Ross, A.L. Walters, V.A. Augenstein, D. Stefanidis, B.T. Heniford Carolinas Medical Center, Charlotte, United States of America

1

Thammasat University Hospital, Bkk, Thailand; 2Division of Bariatric Surgery, Chula Minimally Invasive Surgery Center, Bangkok, Thailand

Bariatric surgery is effective treatment for morbid obesity but it commutes with nutrient imbalance, vitamin B12 deficiency is common problem.Sleeve gastrectomy(LSG) is proposed to induce fewer nutritional deficiencies than gastric bypass (LRYGB). However,few studies have compared between two procedures. Our objective is to evaluate effect on vitamin B12 levels after LSG and LRYGB in Thai patients which have different dietary from western style. Patients who underwent bariatric surgery by Chula Minimally Invasive Surgery Center, were matched for age,gender, preoperative BMI and postoperative weight loss. After preoperative evaluation and successful procedure,dietary education and same protocol of nutritional supplements were prescribed. Data of preoperative and postoperative vitamin B12 level, symptom and additional requirement of vitamin B12 were collected. Eighty-eight consecutive Thai patients underwent bariatric surgeries in 2012. Subjects who presented with previous vitamin B12 deficiency or unable to follow up were excluded. Fifteen patients who underwent LRYGB and sixteen patients with LSG were informed and included in study. There were no difference in mean age(33.6 VS 38.8), preoperative BMI(47.7 VS 52.4), preoperative vitamin B12 levels(823 pg/ml VS 686 pg/ml) %EWL at 6 months(47.5 % vs 45.5 %) and at 1 year(63.1 % VS 55.7 %) in LRYGB group and LSG group respectively. Levels of vitamin B12 at 6 months were not significant changes from preoperative levels in both group and no difference from each other. After first year, only LRYGB group showed significant decrease of vitamin B12 level(from 824.66 ± 115 to 509.63 ± 67,p = 0.004). There was significant difference in the changes of B12 level between LRYGB and LSG group(408.18 ± 107 VS 34.83 ± 62, p = 0.001).Only one patient in LRYGB group who had preoperative B12 level low normal,has required for additional vitamin B12 supplement due to level of B12 decrease lower than 100 without any symptom. LRYGB gives no significant changes on vitamin B12 level result comparable to sleeve gastrectomy in first 6 months but the changes of levels decrease significantly in LRYGB group at 1 year. Preoperative nutrient deficiency should be treated before surgery and postoperative management and follow up are important to prevent adverse event especially in LRYGB. However randomize control trial should be initiated and necessary to determine proper nutritional supplement.

Introduction: Patients undergo adjustable gastric banding for surgical treatment of morbid obesity in the US largely due to reduced morbidity and faster recovery. Band malfunction or inadequate weight loss is a frequent indication for revisional surgery, and Roux-en-Y gastric bypass (RYGB) is often the treatment of choice. We hypothesized that gastric band revision to gastric bypass would have worse perioperative outcomes compared with those who underwent gastric bypass as their initial weight-loss procedure. Methods and Procedures: The AmericanCollege of Surgeons-NSQIP database was queried for all patients who underwent RYGB between 2005 and 2011. Patients were differentiated for concomitant gastric band revision or removal and gastric bypass only. Patients with age \ 18 years, cancer, pregnancy, or emergency operations were excluded. Patient characteristics, demographics, operative details and outcomes were evaluated and compared using standard statistical methods Significance was set at p \ 0.05. Results: 50,129 primary RYGB and 461 revisional RYGB after gastric band were identified. The groups were similar for age (44.9 ± 11.4 vs. 44.7 ± 10.7 years), but primary RYGB patients had more males (20.7 % vs. 11.1 %), Caucasian race (83.1 % vs. 78.3 %), higher BMI (47.4 ± 8.2 vs. 44.1 ± 6.5), higher mean modified Charlson Comorbidity Index (0.36 ± 0.57 vs. 0.21 ± 0.45), more diabetes (30.4 % vs. 18.0 %), hypertension (55.0 % vs. 43.4 %), dyspnea with exertion (26.1 % vs. 11.5 %), worse preoperative functional status, and more ASA class 3 (66.2 % vs. 58.1 %) and ASA class 4 (2.4 % vs. 1.8 %) patients; (for all p \ 0.01). Operative time (135.2 ± 56.8 vs. 179.0 ± 72.1 min) and length of stay (2.7 ± 3.2 vs. 3.1 ± 2.6 days) were increased in revisional RYGB (p \ 0.001), but infections, wound complications, overall minor and major morbidity, reoperation, readmissions, and 30-day mortality were not different between the groups (p [ 0.05). Conclusion: Outcomes after revisional RYGB for patients with failed adjustable bands are similar to primary RYGB despite the complexity of reoperative procedure, which supported by the longer operative time. Revision of gastric band to RYGB has an excellent safety profile.

O281 - Morbid Obesity

O284 - Morbid Obesity

A 7-Years Results of Sleeve Gastrectomy

Is There a Role for Enhanced Recovery in Laparoscopic RouxEn-Y Gastric Bypass?

J.M. Catheline, R. Dbouk, A.B. Kassem, Y. Bendacha, C. Bonnel, R. Cohen

N. Sengupta, C. Nagliati, J. Shalhoub, D. Raje, M. Barreca

Centre Hospitalier de Saint-Denis, Saint-denis, France

Luton and Dunstable University Hospital, Luton, United Kingdom

Aims: Our primary objective was to evaluate the efficacy and safety of sleeve gastrectomy (SG) at 7 years post SG. Methods: From May 2004 to November 2006, 64 patients underwent a SG. The percentage of excess weight loss ( %EWL), the percentage of excess BMI loss ( %EBL), as well as the presence of comorbidities, and surgical complications, were evaluated at 2 years according to our database, and at 7 years according to a patient survey conducted from April 2012 to December 2013. Results: A complete record was obtained for 55 patients (85.9 %), including 45 patients who only have had a SG, and 10 who have had a second bariatric procedure due to insufficient weight loss (7 gastric bypasses, 3 re-SG). The mean %EWL of 55 patients was 58.4 % at 2 years and 53.4 % at 7 years; the mean %EBL was 65.1 % at 2 years and 59.5 % at 7 years. Three patients (5.5 %) have had postoperative complications (2 fistulas (3.7 %), 1 hemorrhage (1.9 %). Three cases (5.5 %) of trocar site hernia were observed between 10 months and 37 months post SG. The group analysis of 45 patients who have had only a SG found a mean of 59.1 % of %EWL at 2 years and 50.4 % at 7 years; the mean %EBL was 66.1 % at 2 years and 56.5 % at 7 years. For these 45 patients we found a favorable evolution of comorbidities: 13 patients (28.9 %) had preoperative antidiabetic treatment and 6 (15.6 %) at 7 years post SG (decrease of 53.9 %); 17 (37.8 %) were treated preoperatively for hypertension and 9 (20 %) at 7 years (decrease of 47.1 %); 12 (26.7 %) had preoperative lipid-lowering therapy and 6 (15.5 %) at 7 years (decrease of 50 %); 25 (55.6 %) had a preoperative SAS and 8 (17.8 %) at 7 years (decrease of 68 %). Medical treatment for GERD was observed in 5 patients (11.1 %) preoperatively and in 15 patients (33.3 %) at 7 years post SG (increase of 200 %). Conclusion: At 7 years post SG, weight loss and reduction of comorbidities were satisfying. There was a tendency for decrease for the comorbidities but the frequency of GERD was increased.

Aims: Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is the gold standard surgical procedure for morbid obesity. With UK hospitals working at [ 95 % in-patient bed capacity, pressure exists to limit length of stay where safe. This study aimed to determine if application of enhanced recovery after surgery (ERAS) principles promotes early discharge and the factors influencing safe discharge on the first post operative day. Methods: Data for patients undergoing LRYGB under the care of a single surgeon entered prospectively into the National Bariatric Surgery Registry since 1 February 2011 were extracted. Patients experiencing an inpatient complication were excluded. Baseline factors and readmission data were compared for patients discharged on the first post operative day with those discharged later. Results: 172 patients underwent LRYGB, of which 163 (95 %) were enrolled in ERAS. 39 (24 %) were discharged on day 1 and 112 (69 %) discharged later. 12 (7 %) were excluded after surgery due to early complications. In the first year of this study, only 1 (2 %) went home on the first post operative day; the rate of discharge on the first post operative day in subsequent years has been between 41 % and 43 %. There was no significant difference in baseline BMI and gender, a trend towards lower ASA (p = 0.07) and significantly lower mean age in the day 1 discharge group (p \ 0.0001). There were 2 (1.2 %) readmissions after early discharge, of which none required reoperation. Conclusion: 23 hour admissions for LRYGB appears safe in younger (\ 45 years) and ASA II patients, and should be used to ease bed pressures. The learning curve for 23 hour LRYGB is 50 patients, with a low rate of readmission after early discharge.

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Surg Endosc

O285 - Intestinal, Colorectal and Anal Disorders

O288 - Intestinal, Colorectal and Anal Disorders

Predictive Factors of Conversion in Laparoscopic Colorectal Surgery. Analysis from 1090 Cases

A Prolonged Operative Time Nullifies the Postoperative Advantages of Laparoscopic Rectal Resection

F. Carballo, E. Grzona, M. Laporte, A. Canelas, M. Bun, C. Peczan, N. Rotholtz

M. Rottoli, J. van Dellen, M. George, A. Williams, A. Schizas

Hospital Alema´n, Buenos aires, Argentina Aims: A proper selection criteria allows a reduction in the rate of conversion in laparoscopic colorectal surgery. The purpose of this study is to identify factors that favor conversion in a large series of laparoscopic colorectal procedures. Methods: During a 12 year period 1090 patients who underwent laparoscopic colorectal surgery were prospectively analized. Univariate analysis to identify individual predictive factors was performed. All the analyzed values were included in a logistic regression model for multivariate analysis. Results: The series was divided in 2 groups: Patients operated on by laparoscopy (G2) and converted surgeries (G1). 101 (9,2 %) procedures required conversion. Age [ 65 years (p \ 0001), male gender (p \ 0.003) and ASA III (p \ 0.003) were factors associated with conversion, whereas ASA I was identified as a protective factor (p \ 0.003). Surgery for malignant disease was associated with conversion (p \ 0.001). Low anterior resection (p \ 0.006); complicated diverticulitis (p \ 0.0003); intraoperative complications (p \ 0.0001); and surgeries associated with other procedures (p \ 0.0001) were identified as predictive factors of conversion. The variables that proved to be independent in the multivariate analysis were male gender (p \ 0.0035); complicated diverticulitis (p \ 0.0003); and intraoperative complications (p \ 0.0001). G1 had a higher incidence of postoperative intensive care unit requirement (p \ 0.001); incidence of reoperations (p \ 0.02) and postoperative complications (p 0.001). Conclusion: In a large series of laparoscopic colorectal resections male patients, complicated diverticulitis, and intraoperative complications are predictive factors of conversion. These patients have a higher chances for having postoperative complications.

Guy’s and St. Thomas’ Foundation Trust, London, United Kingdom Aims: Laparoscopic rectal resection is associated with short-term advantages compared to open surgery. The effects of prolonged operative time on those benefits are yet to be defined. Methods: A prospective Enhanced Recovery Program database (2006–2013) was retrospectively analyzed. Anterior rectal resections for cancer or benign condition were included. The outcomes of laparoscopic rectal resections requiring more than 4 hours (4HRS) were compared to those of laparoscopic rectal resections requiring less than 4 hours (LAP) and of OPEN cases. The exclusion criteria included multivisceral resections, reoperations, and laparoscopic cases requiring conversion to open surgery. Fisher’s exact, chisquared or Wilcoxon Rank Sum tests were used as appropriate. P value \ 0.05 was considered significant. Results: Data were available for 35 4HRS, 53 LAP and 90 OPEN patients. No differences were observed in median age, ASA score and primary disease among the groups. LAP group had a decreased rate of low anterior resections compared to 4HRS (7.6 vs 22.9 %, p 0.04). The median operative time in 4HRS group (282 min) was significantly higher than LAP (190 min, p \ 0.001) and OPEN (154 min, p \ 0.001) groups. No major intraoperative complications were recorded. The 4HRS required a higher ileostomy rate than LAP patients (65.7 vs 13.2 %, p \ 0.001), and a median postoperative length of stay of 10 days, comparable to that of OPEN patients (11 days, p 0.3), but significantly longer than that of LAP cases (6 days, p 0.04). Earlier mobilisation was possible in LAP compared to 4HRS patients (2 vs 3 days, p 0.01), while flatus and first bowel movement time was comparable among the groups. The overall surgical complication rate in 4HRS group (42.9 %) was comparable to OPEN (45.6 %, p0.8) but significantly higher than LAP patients (15.1 %, p 0.003). The incidence of ileus (28.6 vs 13.2 %, p 0.05), anastomotic leak (8.6 vs 0 %, p 0.03) and intrabdominal collection (11.4 vs 0 %, p 0.01) were significantly higher in 4HRS than in LAP group. Conclusions: Increased operative time of laparoscopic anterior resection is associated with significantly worse postoperative outcomes. Preemptive conversion to open surgery is advisable when a prolonged operative time is expected.

O286 - Clinical Practice and Evaluation

O289 - Intestinal, Colorectal and Anal Disorders

Does Laparoscopic Colorectal Resection Increase the Re-Operation Rate?

Objective Assessment of Laparoscopic Rectal Cancer Resection Surgery

P.K. Dhruva Rao, T. Longworth, N. Naquib, A. Masoud

J.D. Foster1, A.S. Allison1, J.B. Ockrim1, E.J. Cooper1, G.B. Hanna2, N.K. Francis1

Prince Charles Hospital, Merthyr tydfil, United Kingdom

Yeovil District Hospital, Yeovil, United Kingdom; 2Imperial College, London, United Kingdom

1

Aims: To assess if laparoscopic colorectal resection was associated with higher re-operation rates, as has been suggested by a recent UK national audit* of 246469 patients undergoing elective colorectal resections. Methods: A retrospective review was made, of a prospectively maintained database, of all patients undergoing elective major colorectal resections, under a single surgeon, between August 2002 and February 2013. We defined re-operation as return to operation suite. Patients having re-operation within 30 days of their index operation were identified and association to variables including patient demographics, pathology, previous surgery, metastatic disease, rectal resection, neoadjuvant therapy, conversion, BMI, ASA grade and laparoscopic surgery analysed. Fisher’s Exact Test was used for statistical analysis. Results: A total of 482 (260 laparoscopic) patients have undergone elective colorectal resection. The median age was 70 years (24–93 yrs). Conversion rate was 10.3 %. Overall, 29 patients (5.9 %) underwent a re-operation within 30 days. There was no statistical difference between the laparoscopic and open groups for the studied variables. The reoperation rate for the laparoscopic group was 5.4 % (14/260) [anastomotic leak = 2, burst abdomen = 3, stoma complication = 2, internal hernia = 2]. The re-operation rate for the open group was higher at 6.8 % (15/222) [anastomotic leak = 4, collection = 3, burst abdomen = 2, secondary haemorrhage = 1]. Although the re-operation rate was lower for the laparoscopic group, this did not reach statistical significance. Conclusions: Our findings show no evidence of higher re-operation rates in laparoscopic colorectal surgery. * Burns et al. BMJ 2011;343:d4836 doi: 10.1136/bmj.d4836

123

Aims: Laparoscopic rectal cancer resection is technically challenging, however there has recently been a substantial increase in the use of this approach. Outcomes from this surgery are influenced by surgical technical performance. Observational Clinical Human Reliability Assessment (OCHRA) provides an ergonomic framework to systematically identify and categorise errors within an operation. The aim of this study was to use OCHRA to detail errors, their spatial distribution and consequences during laparoscopic rectal cancer resection surgery. Methods: Steps of laparoscopic rectal cancer resection were defined as a hierarchical task analysis through semi-structured interviews with international experts. Twenty consecutive patients undergoing laparoscopic rectal cancer resection by four experienced laparoscopic surgeons were prospectively enrolled in this study. Unedited videos of operations were evaluated using OCHRA. The procedural task, spatial location within the pelvis, and circumstances of all error events were logged. The reliability of the technique was assessed by test-retest. Validity was evaluated through correlation of error frequency with blood loss, operating time and with the TME quality score of the resected specimen as evaluated by a consultant histopathologist. Results: Median number of errors was 15 (IQR 7). Error rates did not vary significantly between surgeons. Significantly higher rates of errors occur during pelvic dissection tasks compared with abdominal tasks. More pelvic dissection errors were observed on the right side (total 118 errors) of the mesorectum than the left (total 92 errors) (p = 0.03). Testretest reliability was excellent (r = 0.97,p \ 0.01). There was significant correlation between error frequency with TME score (r = 0.52,p = 0.002), and blood loss (r = 0.609,p = 0.004), but not operating time (r = 0.265,p = 0.27). Conclusion: OCHRA provides a reliable and valid tool for evaluating technical performance of laparoscopic rectal surgery. The pelvic dissection is more technically challenging than the abdominal phase, and particular attention must be focussed upon technique during the right side pelvic dissection.

Surg Endosc

O290 - Intestinal, Colorectal and Anal Disorders

O292 - Basic and Technical Research

Conversion of Laparoscopic Rectal Surgery: Its Impact On Oncologic Outcomes

Three Ports Laparoscopic Resection Of Colorectal Cancer-Is It Surgically And Oncologically Feasible?

S. Guckenheimer, M. Galvan, E. Grzona, M. Bun, A. Canelas, C. Peczan, N. Rotholtz

T. Amin

Hospital Aleman, Buenos aires, Argentina Aims: the need for conversion to open surgery is an inherent problem of laparoscopic surgery. Despite not being considered a complication, this condition exhibits poorer perioperative outcomes. It remains to determine whether the conversion is a variable that changes the results in laparoscopic rectal cancer surgery or not. This study aimed to evaluate the impact of conversion to open surgery on early postoperative outcomes and survival among patients undergoing rectal resection for cancer. Methods: patients with extraperitoneal rectal cancer who were operated laparoscopically between January 2003 and December 2012 were included. They were divided into two groups: those who were converted (G1) and those without conversion (G2). Conversion was defined as the need for laparotomy not anticipated preoperatively. Demographic variables and survival analysis based on conversion were analyzed. The level of statistical significance was set at p \ 0.05. Statistical analysis was performed using the statistical package ‘SPSS 19’. Results: of 123 patients operated laparoscopically for rectal cancer, 87 cases were for mid or low rectal cancer. G1: 19 (22 %) and G2: 68 (78 %). In G1 the proportion of men was higher (74 % vs. 47 %). Age, BMI, ASA and previous surgeries did not differ between the two groups. Cancer mortality was 26 % in G1 (n = 5) and in G2 9 % (n = 6) [p = 0.132]. The laparoscopic surgery group showed 16 % of local recurrence vs 7 % in G2 (p = 0.679). Distant recurrence was 26 % and 14.7 % for G1 and G2 respectively (p = 0.853). Conclusion: conversion per se does not adversely affect oncologic outcomes.

Assiut University, South Egypt Cancer Institute, Assiut, Egypt Background: Reduced port surgery (RPS), in which fewer ports are used than that in a conventional laparoscopic procedure, is becoming increasingly popular for some surgeries. However; the application of RPS to the field of colectomy is still underdeveloped. Patients and Methods:We started laparoscopy assisted colorectal resection through a 10 mm umbilical port plus another two ports of 5 and 10 mm size (3 ports laparoscopyassisted colorectal surgery) as an RPS for colorectal cancer. In this series, we evaluated the outcome of laparoscopic colorectal resection using 3 ports technique for twenty four cases (13male and 11 female) of colorectal cancer. Results: Right hemicolectomy was performed for 10 cases, Left hemicolectomy with sigmoidectomy was performed for 3 cases and anterior resection was done for 7 cases. Subtotal colectomy with ileo-rectal anastomosis was performed for one case. Conversion was done in 2 cases. The mean estimated blood loss was 70 ml (40–90 ml). No major intraoperative complications have been encountered. The mean time for passing flatus after surgery was 36 hours (12–48 hrs). The mean time for oral fluid intake was 36 hours and for semisolid food was 48 hours. The mean hospital stay was 4 days (3–7 days). The perioperative period passed without events. All cases have free surgical margin. The mean number of retrieved lymph nodes was 15 lymph nodes (7–23). Conclusion: Three ports laparoscopy assisted colectomy looks to be safe, effective and has cosmetic advantages. The procedure could maintain the oncologic principles of cancer surgery.

O291 - Intestinal, Colorectal and Anal Disorders

O293 - Intestinal, Colorectal and Anal Disorders

What are the Risk Factors For Intestinal Fistulas Following Laparoscopic or Open Surgery For Rectal Cancer?

Laparoscopic Technique: Can We Improve the Surgical Treatment Strategy for Metastatic Colon Cancer?

B.V. Martian1, I. Diaconescu1, I. Dogaru2, M.R. Bratu1, G. Andrei1, I. Vacaroiu1, M. Beuran1

A.O. Atroshchenko1, I.E. Kharkov2, S.V. Pozdnyakov2

1

2

Emergency Clinical Hospital, Bucharest, Romania; Regional Hospital Constanta, Constanta, Romania

Aims: The aim of this study is to compare variables that determine fistulas formation after minimally invasive (LR group) or open surgery (OR group) for the treatment of rectal cancer. Materials and Methods: In this retrospective study were included 87 patients with rectal cancer operated between 2008 and 2013 by the same experienced colorectal surgical team. All cases were managed using the same standardized technique. We collected data about demographics, BMI, operation type (OP), blood loss (BL), neoadjuvant radiation therapy (RxT), protective stoma (PS) and analyzed if those are risk factors for inpatient anastomotic leak. A p-value smaller than 0.05 was considered statistically significant. Results: There were no statistically significant differences between demographics nor BMI data for the two groups. The most frequent OP was anterior resection. The overall fistula formation rate was 7.8 %, without a significant difference between the two groups. Perioperative BL was smaller for LR than for OR, but this wasn’t a determinant for fistula formation. Those patients who received RxT had a higher incidence of fistula formation regardless of the surgical approach. Patients with PS had a slightly lower rate of fistulas in OR group (p \ 0.05), but not in LR group. Conclusions: Laparoscopy has the same formation rate and risk factors for fistulas as open surgery in the treatment of rectal cancer.

1

Moscow State University of Medicine and Dentistry, Moscow, Russia; 2Moscow Scientific Research Institute of Gastroenterology, Moscow, Russia Background: Nowadays the colorectal cancer still one of the most common oncological disease in the World. Asymptomatic illness - this is a reason for the high incidence of advanced disease. Every third (29.4 %) patient with colon cancer in Russia after initial examination had distant metastases. Primary tumor removal helps to avoid the complications (bowel obstruction, bleeding, perforation etc.), optimize the subsequent chemotherapy and significantly increase two-year survival (18.2 % vs. 4.7 %) in comparison with symptomatic procedures (colostomy or bypass). The laparoscopic primary tumor removal could minimize the surgical trauma, reduce postoperative rehabilitation, percentage of complications and also speed up the launching of chemotherapy. Aims to compare the results of cytoreductive surgery by laparoscopic technique and laparotomy approach for patients with colon cancer and synchronous distant metastases. Materials and Methods: prospective randomize trial. Since 2010 to 2012yy. 89 patients with colon cancer and synchronous distant metastases (T1-4a Nany M1a-b) underwent primary tumor removal (44 by laparoscopic technique- main group and 45- laparotomy access-screening group). The groups were similar by the gender, age, stage, tumor and metastases localization. Results: simultaneous R-0 resection (primary tumor and all metastases) underwent 4 patients (in 2 at each group), staged R-0 resection-11(29.6 %) vs. 9(24.4 %), p = 0.05 respectively. Mean time: 230.1 ± 51.3 min- in group with laparoscopic procedure vs. 130.6 ± 38.6 min -open access group, ? \ 0.05; primary colon anastomosis performed in 40(90.9 %) vs. 37(82.2 %), p = 0.05 patients respectively. Average intraoperative blood loss: 134.1 ± 31.4 vs. 753.3 ± 46.1 ml respectively, ? \ 0.05. Postoperative complications: 3(6.8 %) vs. 8(17.8 %); reoperation: 2 and 3 respectively, p = 0.11. Bowel motility restoration: 1.2 ± 0.7 vs. 2.5 ± 1.2 days, p \ 0.05; first stool: 2.4 ± 1.3 vs. 3.8 ± 1.4 days, p = 0.63; time to patients activation: 1.2 ± 1.1 vs. 3.9 ± 0.9 days, p \ 0.05; first food taken: 2.0 ± 0.7 vs. 4.0 ± 1.3 days, p \ 0.05; duration of analgesia: 2.3 ± 1.4 vs. 4.4 ± 1.4 days, average hospital stay: 9.3 ± 3.9 vs. 13.4 ± 3.4, p \ 0.05 respectively. Time to start adjuvant chemotherapy after surgical treatment: 19.7 ± 3.4 vs. 27.5 ± 4.1 days respectively. The Kaplan-Meier overall 2-year survival: 69.5 % in patients, who underwent laparoscopic procedure and 61.6 %-in open access group, p = 0.96. Conclusions: the laparoscopic precision technique could improve postoperative patient restoration, reduce time to chemotherapy treatment and had a tendency to improve the rate of postoperative complications and 2-year overall survival.

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Surg Endosc

O295 - Liver and Biliary Tract Surgery

AT294 - Amazing Technologies

Simultaneous Laparoscopyc Operations in Patients with Liver Pathology

Intraoperative Assessment of Perianastomotic Perfusion Using Near Infra-Red Technology and Intravenous Indocyanine Green in Laparoscopic Colorectal Surgery

M. Nychitaylo, M. Zagriychuk, I.I. Bulik, Y.I. Masyk, A.V. Goman, V. Prisyagnyuk, A.V. Stokolos Ukrainian institute of surgery and transplantology name after A.A.Shalimov, Kiev, Ukraine Aims: Own experience of performed simultaneous laparoscopyc operations in patients with liver pathology and another surgical disorders of abdominal cavity and retroperitoneal space was evaluated. Methods: From 2008 to 2013 in our clinic 144 simultaneous operations from laparoscopyc approach in patients with liver pathology were performed. The median age was 53 ± 1.4 years. In 139 cases (96.8 %) we performed simultaneous operations from laparoscopyc approach, in 5 (3.2 %) was conversion to simultaneous combine laparoscopyc operations. Female was 98 (68.05 %), male 46 (31.95 %). Diagnostic tests used were: USS, CT of abdomen and MRCP and also CA 19-9, CEA, alfafetaprotein (AFP) and IG for echinococ screening. The median diagnostic time was 1.9 ± 0.9 days. Results: All 100 % patient undergone laparoscopyc surgery. Type and volume of operation depends from pathology combination, tumor localization and patients general condition. Cyst fenestration or deroofing and laparoscopyc cholecystectomy were in 62 (43,1 %), TAP/TEP hernioplastic in 18 (12,4 %), laparoscopyc adrenalectomy in 6 (4,1 %), laparoscopyc appendectomy in 4 (2,8 %), laparoscopyc ovaryectomy in 7 (4,9 %), laparoscopyc liver abscess drainage and laparoscopyc cholecystectomy in 12 (8,3 %), laparoscopyc appendectomy in 3 (2,1 %), laparoscopyc hernioplasty in 3 (2,1 %), atypical laparoscopyc liver resection and laparoscopyc cholecystectomy 22 (15,3 %), laparoscopyc hernioplasty 5 (3,5 %), laparoscopyc appendectomy 2 (1,4 %). Mean operation time was 89,4 ± 17,5 min. Postoperative complications were observed in 15 (10,4 %) cases. Main complications were: bleeding in 11 (7.6 %), bile leak in 4 (2.8 %) of patients. 3 cases (2.08 %) had relaparoscopy and drainage. Median hospital stay was 4.8 ± 1.4 days. Postoperative analgesia was minimal. Mean intraoperative blood lose was 372 ± 38 ml, only 6 (5,1 %) patients had blood transfusion, but no more than 500 ml. Mean follow-up time was from 1 to 4 years. Post-operative mortality was 0 %. Conclusion(s): Pain management, hospital stay, duration of preoperative observation, economic value, intraoperative and postoperative complication rate after simultaneous laparoscopyc operation in patients with surgical disease of the liver is comparable with treatment results after single operation on the liver only. Laparoscopyc simultaneous operation in patients with liver pathology is a method of choice in carefully selected patients, which in 96,7 % achieved permanent good results and non recurrence.

S. Nachiappan, A. Curry, A. Antoniou, J.T. Jenkins, O.D. Faiz St Mark’s Hospital, London, United Kingdom Background: Perianastomotic hypoperfusion has been implicated in postoperative anastomotic leakage. Intraoperative detection and rectification of hypoperfusion may reduce postoperative anastomotic leakage rates. Aim: To assess the utility of NIR imaging and Indocyanine green to detect hypoperfusion in perianastomotic tissue. Project description: NIR laparoscopic imaging (Olympus Corp) with intravenous Indocyanine green was used in elective resectional surgery to assess perianastomotic perfusion at four different time points.

1. 2. 3. 4.

Assess Assess Assess Assess

proximal resection line prior to resection. proximal and distal stump prior to anastomosis. perianastomotic tissue after anastomosis. perianastomotic tissue trananally after anastomosis.

Preliminary results: Four patients underwent laparoscopic anterior resections (3 side-toend and 1 end-to-end anastomoses). NIR imaging revealed hypoperfusion in the blind end of the proximal limb in one of the side-to-end anastomoses, which was rectified. No postoperative anastomotic leaks were noted in these four patients, and all were discharged within 1 week of surgery.

O296 - Intestinal, Colorectal and Anal Disorders

AT295 - Amazing Technologies

Laparoscopic Approach in Complicated Diverticular Disease

Novel Near-Infrared Laparoscopic Sentinel Lymphatic Mapping for Early Colonic Neoplasia

A. Canelas, S. Guckenheimer, M. Bun, M. Laporte, E. Grzona, C. Peczan, N. Rotholtz Hospital Aleman, Buenos aires, Argentina Aims: to analyze the results of laparoscopic colectomy in complicated diverticular disease. Methods: Patients who underwent laparoscopic colectomy for diverticular disease between July 2000 to June 2013 were included. The series was divided into two groups who were compared. G1: patients with complicated disease (abscess, perforation, fistula, or stenosis) and G2: patients undergoing surgery for recurrent diverticulitis. Results: 260 patients were included; G1: 72 (28 %) and G2: 188 (72 %). G1 consists of: 16 (22 %) pericolonic abscesses or severe inflammatory sequelae, 12 (17 %) Hinchey II, 22 (31 %) Hinchey III / IV, 14 (19 %) Fistulas (10 colovesical / 4 colocutaneous), and 8 (11 %) stenosis. Procedures performed in G1 were: 62 (86 %) sigmoidectomies; 6 (8 %) with proximal ileostomy, 3 (4 %) Hartmann‘s procedures and 1 (2 %) peritoneal lavage and drainage; and in G2 all were sigmoidectomies with unprotected primary anastomoses. G1 had higher conversion rate (16.6 % vs. 3.2 %; p = 0.001) and longer hospital stay (4.6 vs. 3.3 days; p \ 0.001).The anastomosis dehiscence rate was 3 %, with no statistical difference between both groups. When analyzing demographic data (BMI, ASA, and previous abdominal surgery), operative time, intraoperative and postoperative complications, no significant difference between both groups was observed. The mortality rate was 0.4 % (1 patient) represented by a death secondary to septic shock in G2. Conclusion: the laparoscopic approach in complicated diverticular disease is safe.

123

A. Currie1, A Brigic1, R. Cahill2, C.D. Fraser1, J.T. Jenkins1, S. Thomas-Gibson1, N. Suzuki1, O.D. Faiz1, R.H. Kennedy1 1 St Mark’s Hospital, Harrow, United Kingdom; 2Beaumont Hospital, Dublin, Ireland

Background: While lymphatic assessment is a cornerstone of definitive surgical resection for colonic cancer, however lymphadenectomy often provides little oncological benefit in early disease. Near-infrared (NIR) laparoscopy may allow intraoperative identification of sentinel nodes in patients with early-stage disease prior to radical basin resection. Aim: To identify sentinel nodes in T1/T2 colonic cancer using NIR laparoscopic lymphatic mapping. Project description: Consecutive patients with preoperatively radiologically-defined T1/ T2 colonic neoplasia underwent peritumoral endoscopic submucosal injection of indocyanine green (ICG) prior to standard laparoscopic oncological resection. Intraoperatively, a prototype NIR laparoscope (Olympus-Keymed) used fluorescence absorbance spectra (750 nm) to identify sentinel nodes prior to formal specimen dissection. Preliminary results: Eight patients were studied. Mesocolic sentinel nodes (median = 3/patient) were identified by fluorescence in the standard resection field within 10 minutes of dye injection in every case. NIR sentinel node mapping and excision may permit a tailored colonic cancer resection in the future.

Surg Endosc

AT297 - Amazing Technologies

AT299 - Amazing Technologies

Near-Infrared Fluorescence Imaging with Liposomal Formulation of an Indocyanine Green Derivative for Laparoscopic Detection of Sentinel Lymph Nodes

Discover-Diagnose-Destroy: A Three Stage Minimally Invasive Approach to Prevent Breast Cancer by Ductoscopy

H. Hayashi1, T. Toyota2, Y. Tamura1, T. Madono3, A. Oooishi1, R. Yahagi1, Y. Zhang1, M. Fujinami1, H. Matsubara1 1

Chiba University, Chiba, Japan; 2The University of Tokyo, Tokyo, Japan; 3Yamada Chemical Co. Ltd, Kyoto, Japan Background: Near-infrared (NIR) fluorescence navigation with the use of indocyanine green (ICG) has been attracting researchers to detect sentinel lymph nodes (SLNs) in the various fields of surgeries. This technique indicates high detection sensitivity of SLNs under fluorescence laparoscope guidance without the use of radioactivity. However, low molecular weight of the dye results in rapid diffusion beyond SLNs and requires quick identification of the nodes before it reaches to secondary nodes. Aim: To develop a novel NIR tracer which resides in SLNs much longer duration. Project description: We synthesized a ICG derivative tagged with an alkyl chain (ICGC18), and examined NIR-fluorescence imaging for LNs in a mouse and a porcine model using liposomal formulation of ICG-C18 (LP-ICG-C18). Preliminary results: LP-ICG-C18 showed much longer retention within primary LNs compared with ICG aqueous solution or LP-ICG in both models. This new tracer could drastically facilitate laparoscopic NIR fluorescence SLN navigation.

T. de Boorder UMCU, Utrecht, The Netherlands Background: Ductoscopy enables to inspect mammary ducts. It is applied in the UMC Utrecht for diagnosis and treatment of women with pathologic nipple discharge. The UMCU is extending the workfield of ductoscopy by introducing three high tech developments. Aim: This project aims to investigate three novel extensions to ductoscopy to prevent breast cancer(discover-diagnose-destroy) Project description: - Discover: Implementation of autofluorescence ductoscopy, which detects premalignancies lesions in different organs but has not been applied to the human breast.

– –

Diagnose: Development of a biopsy device for ductoscopy for biopsy and histologically diagnose of intraductal lesions. Destroy: Development of laser ductoscopy for non-invasive laser ablation of intraductal lesions. An ultra thin laser fiber (Lisa Laser Germany) has been developed

Preliminary results: The use of laser in ductoscopy is very feasible. The custom made Thulium laser fiber was used in eight fresh mastectomy specimens. Histopathological evaluation shows sufficient destruction of the duct wall.

AT298 - Amazing Technologies

AT300 - Amazing Technologies

New Wireless Endoscope with Integrated Rgb-Laser Light Source for High Contrast Visibility

Comparative Assessment Between Three-Dimensional and Conventional Laparoscopy On Intracorporeal Suturing Performance

B. Blase TU Berlin, Denmark Aims: Standard endoscopes for minimal invasive surgery feature a laterally connected light cable leading to an external and bulky light source. The cable’s weight and its unergonomic placement at the endoscope are troublesome to handle for the assistant surgeon in long sessions. A new endoscope with integrated light source is presented to overcome these downsides. Methods: By integrating a light source inside the endoscope’s handle, light cables are redundant. LEDs at the endoscope’s tip imply a hot spot and possible patient’s scalding, when contacting organs. Due to the LED’s broad emitting angle the coupling efficiency in light fibers leading to the tip of LEDs placed in the handle is poor. Laser diodes instead are very small and allow low-loss coupling with high power output. By combining and mixing three colors the resulting color temperature can be adjusted to the surgical site. This is obtained in a small volume with an optical system of gradient index lenses and polarizing beam combiners as well as dual wave retarding plates. Several optical designs have been tested and evaluated. The combined beams are then coupled in an internal light fiber leading to the tip. Experiments with suitable phase change materials (PCM) proved that heat-storage inside the endoscope is feasible. The remaining heat losses are stored in a latent heat-storage unit surrounding the laser module, by phase transition stabilizing the handle’s temperature during the surgery. Lasers produce coherent speckle patterns on illuminated surfaces, therefore different technical principles based on time-averaging to minimize the coherent pattern have been developed. Results: Successful adaptive color mixing, stable temperature management and integrated speckle reduction are combined in the endoscope. Conclusions: The new endoscope incorporates an integrated RGB laser light source with an adjustable optical system to form, guide and combine the light rays. Speckles are minimized by a speckle-reducing module. The thermal losses are stored during the surgery inside a PCM device. Together with the camera and the electronics a standard endoscope handle’s size is met.

F.M. Sanchez Margallo, S. Enciso Sanz, J.A. Sanchez Margallo Minimally Invasive Surgery Centre, Ca´ceres, Spain The objective of this study was to evaluate the effect of 3D imaging system on laparoscopic suturing performance. Thirteen novices (0–10 laparoscopic surgeries) and ten experts ([50 laparoscopic surgeries) were randomly assigned to two groups, starting with 2D (Karl Storz HD) or 3D (Karl Storz) imaging system. They carried out three sutures with each system. Score through a validated suturing specific-checklist was assessed by two blinded expert surgeons and total time was registered. Participants completed a questionnaire on a 5-point-rating scale regarding the image quality and the usefulness of the 3D imaging system. Statistical significant differences (p = 0.039) were observed between novices and experts for both imaging systems in time and score. Experts performed the suture faster with the 3D system (p = 0.045). Both novices and experts obtained higher scores with the 3D system (p = 0.045; p = 0.020). 64.29 % of participants preferred the 3D system and depth perception was the characteristic best rated (4.25 ± 0.59).

123

Surg Endosc

AT301 - Amazing Technologies

AT304 - Amazing Technologies

Robotic Laparoscopic Manipulator with Embedded Tracking Software: Preliminary Clinical Results

Automated Navigation Tools for Flexible Endoscopy

A. Szold1, A. Forgione2, I. Broeders3 Assia Medical Group, Tel Aviv, Israel; 2Niguarda Ca’ Granda Hospital, Milan, Italy; 3Meander Medical Center, Amersfoort, The Netherlands 1

Background: Camera manipulators take time to assemble and calibrate, and the interface is uncomfortable. Aim: To build a small, positioning device with tracking capabilities and a novel user interface. Technology: The device arm attaches to a standard operating room table. It has a low profile and assembles fast. The control is by miniature radiofrequency switches attached to an instrument or the surgeon’s finger. The system design and use of the video signal eliminates the need for calibration. Results: The arm was used in animals and recently a clinical human trial was launched. It was easily assembled, with good tracking abilities. Camera motion was smooth with a stable image, and was easily controlled by the surgeon. The surgeon satisfaction levels were high, and the camera was almost never removed for cleaning. Conclusion: The computerized arm with the automatic tracking and the unique interface results in an effective system.

N. van der Stap University of Twente/Meander Medical Center, Enschede, The Netherlands Background: Robot-assisted endoscopic surgery is becoming generally accepted. Increasingly complex interventions are being performed with flexible endoscopes as well. However, steering and navigation of endoscopes is difficult. Robotic assistance may solve this problem. Aim: To develop automated navigation tools for flexible endoscopic interventions. Project description: We have developed automated navigation tools for a robotic flexible endoscope system. Automated lumen centralization has been implemented and tested by experts performing colonoscopy on an anatomical model. Target locking has been implemented real-time and tested in vitro. Both tools are designed for robotic manipulators of currently available flexible endoscopes. Preliminary results: The automated lumen centralization experiment shows a qualitative added value for this tool for mucosal visualization. A quantitative significant advantage has not yet been demonstrated, but the last experiments are currently being conducted. The good in vitro results of the target locking tool can be demonstrated at the time of the conference.

AT302 - Amazing Technologies

AT305 - Amazing Technologies

Google Glass in Surgery Sharpen Your Vision

Robotic Uterine Manipulator (Rutor): A Novel Medical Device Inspired by Octopus

M.P. Schijven, M. Graafland, W.A. Bemelman Academic Medical Center Amsterdam, The Netherlands In our Hospital, Google Glass was used to livestream the first laparoscopic abdominal surgical procedure (Toupet Fundoplication) live to YouTube. Simulateneously, the surgeon was in direct contact with another surgeon wearing Google Glass (Glass2Glass) for realtime decision support. In our hospital, use of Glass has become part of scientific research and interest. A systematic inquiry was conducted exploring possibilities and needs for use of wearable technology to support health care providers. Based on those results, apps for Glass are currently explored such as the ‘ SurPassed!’ checklist app, the ‘ Surgical Radar’ for OR data streaming and the ‘ Fatigue Monitor’. This presentation addresses the results of the first experiences using Google Glass during surgery and first results from collaborations resulting in app development and co-creation for Glass. Issues such as data protection in cloud and data safety requirements are discussed, and future developments for Wearables to support health care providers addressed.

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C. Saaj1, S. Mustaza2, C. Lekakou2, Y. Elsayed2, T. Geng2, S. Chhaniyara2, K. Madhuri3 1 Surrey Technology for Autonomous Robotic Systems Lab, Guildford, United Kingdom; 2University of Surrey, Guildford, United Kingdom; 3Royal Surrey County Hospital, Guildford, United Kingdom

Current laparoscopic and robotic techniques for achieving a safe hysterectomy rely heavily on the ability to manipulate the whole uterus through the vagina using a hand-held, motorised or voice controlled uterine manipulator. The main shortcomings include rigid design that offers limited manouveribility, lack of intelligent sensing, haptic feedback and need for surgical assistants. This presentation introduces the concept of a novel robotic uterine manipulator inspired by octopus. RUTOR will be an innovative flexible and stiffness controllable soft continuum uterine manipulator using fiber optic sensing and haptic feedback. This portable device can be controlled remotely by the surgeon from the operating console. This paper presents the design and preliminary results on control of this innovative device that has a huge potential to advance the state of the art of minimally invasive gynaecological surgery.

Surg Endosc

AT306 - Amazing Technologies

AT308 - Amazing Technologies

Beyond the ‘B’: A New Concept of the Surgical Staple Enabling Miniature Staplers

Next Generation Platform Creates Transoral Anterior Fundoplication for Gastroesophageal Reflux Disease (GERD)

L. Swanstrom1, L. Demertzis2

A. Roy-Shapira1, M. Sonnenschein2, A. Govrin2, Y. Mintz3, S. Horgan4

IHU-Strasbourg, Portland, United States of America; 2Department of Cardiothoracic Surgery, University of Bern, Switzerland

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Background: Current staplers use ‘B’ staple form. This necessitates a 12 mm instrument. A ‘D’ shape staple allows a 3–5 mm stapler Aim: Compare D-shaped staple vs. B-form staples in survival swine model Project: 3 groups of anastamosis were studied with 3 month survival. Outcomes: stapleline completeness, hemostasis, and re-intervention. At sacrifice histo-pathology of anastamosis. Results: 40 animals (23 ‘D’ staple/17 ‘B’) were studied. No acute mortalities. 2/23 ‘D’staples required an added suture, 1/23 a manual extension of the cut. Acute hemostasis was 100 %. There was no late bleeding or leaks in any groups. One ‘D’ animal died day4 for a non-staple related cause. One died day 18 from a stricture/obstruction at the B-staple JJ. 90 day histopathology was unremarkable in all anastomosis. Conclusions: No difference in acute/chronic outcomes D-and B-shaped staples. long-term histopathology results were good. The D-shaped staple is safe and effective and offers the possibility of a 3–5 mm endoscopic stapler.

Soroka University Hospital, Beer Sheva, Israel; 2Medigus Ltd, Omer, Israel; 3Hadassah Hebrew University Medical Center, Jerusalem, Israel; 4UC San Diego Health System, San Diego, United States of America 1

Background: GERD treatments are evolving toward endoscopic solutions Aim: Transoral stapling procedure to restore functional flap valve Project description: Flexible endostapler (15.5mmOD) with CMOS miniature camera and LED illumination provides 140° FOV with HDMI output, without separate endoscope. As stapler tip is retroflexed, stomach and esophageal tissues are compressed. Ultrasonic guidance automatically activates to replace direct visualization. User interface illustrates distance between staple cartridge and anvil from initial tissue contact to full compression (50micron accuracy). Motorized staple ejection delivers five 4.8 mm titanium staples, positioned 3 cm proximal to GEJ. Alignment mechanisms ensure reliable closure and staple formation. Insufflation controls mitigate risk of air leaks. Software controls minimize user errors. The device is reloaded for additional stapling, to recreate a structural flap valve. Preliminary Results: Previous system studied in 69 subjects. New MUSE system has CE Mark and FDA clearance. Evaluation of new system performance in a larger number of patients planned.

AT307 - Amazing Technologies

AT309 - Amazing Technologies

Human Extensions: A Novel, Hand-Held Surgical Operating System

Robotic Add-On Steering Concept for Endoscopic Interventions

A. Szold

University of Twente, Enschede, The Netherlands; 2DEMCON, advanced technologies, Enschede, The Netherlands

Assia Medical Group, Tel Aviv, Israel Objective: Laparoscopic instruments have limited degrees of freedom and are not ergonomic. This results in severe limitations in performing tasks in surgery. Our goal was to combine the advantages of robotics with those of handheld laparoscopic instruments. Technology: We have built a hand-held electro-mechanical system that can support several end effectors. The instrument is composed of a sophisticated user interface that enables unrestricted hand movement, and a novel, motor driven articulating tool that is controlled by the interface. The system is cordless, lightweight, doesn’t require any set up time, and can be easily moved between laparoscopic trocars and perform complex motions in the surgical field. Preliminary results: We have validated the instruments in an animal model. The surgeon was able to perform complex tasks such as complex tissue manipulation and intra - corporeal suturing easily. Conclusions: the new hand held motorized system seems to address a real clinical need.

E.D. Rozeboom1, J.G. Ruiter2, I.A.M.J. Broeders1 1

Background: Controlling flexible endoscopes and its instruments is cumbersome, nonergonomic and requires a team of highly skilled physicians for complex interventions. We introduce an add-on robotic steering concept that allows one physician to steer the endoscope in an intuitive and user-friendly way. Aim: To evaluate effectiveness and efficiency of the steering concept. Project description: Experts and novices used the robotic system for camera steering, instrument positioning and colon intubation. We compared their achievements using the conventional system with: a joystick and touchpad, different control algorithms, and assisted vs. single-person control. All experiments were performed in a simulation setting to allow objective cross-subject comparison. Preliminary results: Experts show a short learning curve to reach their personal level of endoscope performance. The technical performance needs to be improved, but physicians value the system for its clinical opportunities. Novices are quicker, more accurate and experience a reduced workload when using the robotic system.

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Surg Endosc

AT311 - Amazing Technologies

AT314 - Amazing Technologies

Solutions and New Techniques for No-Incision Intra-Abdominal Retraction in Single Site Appendectomy Using T-Pea LifterÒ and Centry PortÒ

DORA - Digital Operating Room Assistant

R. Zorron, C. Bothe, E. Junghans, T. Junghans Klinikum Bremerhaven Reinkenheide, Bremerhaven, Germany Background: Obtaining adequate retraction for single site appendectomy is crucial for reducing operative times and add safety. Aim: The new concept of no-trocar retractor applying T-PEALifterÒ (Surgical Perspective, France) and single operative trocar CENTRY PORTÒ (BHIOSUPPLY, Brazil) may overcome difficulties in obtaining optimal exposure. This study describes the preliminary results and standardization of the technique for appendectomy. Project Description: 10 patients from both genders with body mass index (BMI) lower than 32Kg/m2 with indication for appendectomy were prospectively documented. The open insertion of the operative trocar CENTRY PORTÒ device transumbilical. Tips and tricks of changing the exposure allowing optimal traction and specimen extraction through T-PEALifterÒ are explained. Preliminary Results: The procedure was performed in all cases without conversions. Mean Op-time was 43 min. There were no postoperative complications. Mean postoperative stay was two days. Versa Lifter BANDÒ and CENTRY PORTÒ showed feasibility and safety, promoting good exposure with reduced port surgery.

L.S.G.L. Wauben, A.C.P. Gue´don, J. Dankelman, J.J. Van den Dobbelsteen Delft University of Technology, Delft, The Netherlands DORA implements smart technology and intuitive interfaces in OR to improve patient safety and efficiency of processes in the surgical trajectory. Currently, DORA consists of three modules that were designed and implemented in three hospitals. Patient Module: uses active RFID to track patients and inform staff/family/patients about the patient’s location and waiting times. It provides transparency of the surgical trajectory and aims to reduce waiting times and improve patient and staff satisfaction. Device Module: uses active RFID to monitor presence and safety status of OR devices and alerts staff about irregularities. Also, malfunctioning OR devices can be reported through this module. Procedure Module: uses several sensors (sound, light, colour) in OR to detect lighting conditions, sterile sheets, and the use of specific instruments to predict the end-time of surgery to improve the OR planning. Conclusion: DORA is a monitoring system that identifies potential risks and supports staff in their tasks.

AT312 - Amazing Technologies

AT315 - Amazing Technologies

Laparoscopic Gastro-Jejunal Anastomosis Using a New Radius Surgical System In An Ex Vivo Model

Articulating Tacking Device for Mis Hernia Mesh Fixation

M. Zdichavsky1, M. Krautwald2, T. Meile1, M. Feilitzsch1, D. Wichmann1, A. Ko¨nigsrainer1, M.O. Schurr3 University Hospital Tu¨bingen, Germany; 2Novineon CRO & Consulting Ltd, Tu¨bingen, Germany; 3Ovesco Endoscopy AG, Tu¨bingen, Germany

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Background: The feasibility and training effect of the new 5-mm r2-DRIVE instruments for laparoscopic gastro-jejunal anastomosis was evaluated in a phantom model for experienced and untrained laparoscopic surgeons. Methods: Three experienced and four untrained laparoscopic surgeons performed laparoscopic porcine gastro-jejunal anastomoses. Mean anastomosis time, anastomosis width and burst pressure was measured. Number of stitches, skipped stitches and dropped needles were counted. Results: Mean time for suturing decreased rapidly for all participants, but was more evident for untrained persons. Mean time per stitch and knotting was shorter for trained persons, whereas after 5 anastomoses no relevant improvement in anastomotic time was seen for the skilled group. Conclusions: Training was demonstrated to be effective for trained and untrained surgeons where only few cases were necessary to gain stable anastomoses times and a fast learning curve for all participants. Difficult suturing procedures can be performed safe and fast also for untrained persons.

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A. Szold Assia Medical Group, Tel Aviv, Israel Objective: Laparoscopic repair of incisional hernia may be challenging.. In order to facilitate it we have designed and tested an motorizes articulating fixation device. Technology: The device has a 5 mm replaceable shaft with different tacks. The handle is ergonomic and allows holding in different positions and by different size hands. The articulating tip can reach an angle of 110 degrees with respect to insertion angle, allowing the introduction of at least 10 tacks in a single load. Preliminary results: Several prototypes were built and tested in a pig model. All procedures were recorded for further evaluation. The devices allowed fixing a 20X20 cm mesh through a single port, with excellent fixation of the mesh. The tacks were inserted to the abdominal wall at 90 degrees regardless of surgeon and trocar position. There was not need for the surgeon to change position for the entire procedure

14th World Congress of Endoscopic Surgery and 22nd International Congress of the European Association for Endoscopic Surgery (EAES) Paris, France, 25-28 June 2014 : Oral Presentations.

14th World Congress of Endoscopic Surgery and 22nd International Congress of the European Association for Endoscopic Surgery (EAES) Paris, France, 25-28 June 2014 : Oral Presentations. - PDF Download Free
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