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

Surg Endosc DOI 10.1007/s00464-015-4137-6

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 Video Presentations

Ó Springer Science+Business Media New York 2015 EAES VIDEO AWARD SESSION

V001 - Video - Oesophageal and Oesophagogastric Junction Disorder Key Points of Lymphadenectomy and Anastomosis for Laparoscopic Lower Esophagectomy and Proximal Gastrectomy for Siewert’s Type II Cancer M. Nakauchi, F. Oike, T. Hori, T. Tanaka, G. Gunji, N. Okada Mitsubishi Kyoto Hospital, Kyoto, Japan Aims: Esophago-gastric junction is defined by Siewert’s classification. In the field of surgery, the ranges of resection and lymphadenectomy are still controversial. Laparoscopic surgery has an advantage for minimal surgical incisions and a less pain in comparison with conventional laparotomy. Methods: Currently, for Siewert’s type II cancer, the resection without thoracotomy is recommended, though extended resection with thoracotomy had been previously performed. Previous documents demonstrated that lymphoid metastases in upper and middle intrapleura, lower greater omentum (i.e., LN# 4d in Japanese Classification of Gastric Carcinoma, Tokyo, Japan) and peripylorus (i.e., LN# 5 and 6) were rare in Siewert’s type II cancer. Therefore, from the viewpoint of lymphadenectomy, dissections of lower mediastinal LNs (i.e., LN# 110 and 111), diaphragmatic LNs (i.e., LN# 19 and 20), proximal gastric LNs (i.e., LN# 1, 3, 7 and 9). For patients with Siewert type II cancer, we employed laparoscopic lower esophagectomy and proximal gastrectomy accompanied with optimal lymphadenectomy, and subsequent overlap anastomosis of esophago-gastric tube. During laparoscopic intramediastinal procedures, an intrapleural trocar and traction sutures of diaphragm crus were placed, in order to make an adequate surgical field. We present our technical innovations by our actual surgical video. Results: Laparoscopy and an intrapleural trocar and traction sutures of diaphragm crus made us possible to dissect lower mediastinal LNs precisely and to perform esophago-gastric tube anastomosis safely. Four patients underwent this operation from January to June in 2013. We had no major complications, except for a slight pyrosis in one case. Conclusion: The feasibility of laparoscopic surgery for Siewert’s type II cancer is still controversial around the world. We suggested that our technique of laparoscopic lower esophagectomy and proximal gastrectomy has a large advantage in usefulness and safe for patients with Siewert’s type II cancer.

V002 - Video - Intestinal, Colorectal and Anal Disorders Laparoscopic Total Pelvic Exenteration to Locally Advanced Rectal Tumor Y.F. Fukunaga Cancer Institute Hospital, Tokyo, Japan Background: Total pelvic exenteration (TPE) may be the only curative procedure for locally advanced rectal tumor contiguous with the adjacent organs and pelvic wall. Laparoscopic surgery for rectal diseases have been developed for these two decades based on magnified view through a recent developing sophisticated optical instrument. We have adopted laparoscopic surgery for rectal malignancies requiring TPE and experienced 3 cases for this latest year. Aims: We describe our experience of laparoscopic TPE for locally advanced rectal gastrointestinal stromal tumor (GIST) after neoadjuvant imatinib chemotherapy by video. Patients: Two patients were the rectal cancer invading to the prostate and one was the rectal GIST contiguous with the prostate. The 2 rectal cancer patients have had a neoadjuvant chemoradiotherapy. Surgical Technique: The patient is placed at lithotomy position under general anesthesia and 5 ports are put to perform the conventional laparoscopic surgery under 10 mmHg pneumoperitoneum. The pelvic mobilization is initiated from posterior side following to vascular clipping and sigmoid colon transection. The lateral side mobilization is performed along the internal iliac artery reaching the pelvic floor sacrificing all autonomic pelvic nerves. The paravesical and the Retzius space are dissected along the pelvic wall down to the endopelvic facia. The patient is changed to prone position for sacral to perineal approach. The urethra is divided following to dissection of Santorini venous plexus continuing to the abdominal dissection plane and the specimen is removed including a huge GIST. The patient is moved on supine position and the sigmoid colostomy and the ileal conduit are created through the stoma site incision. Results: The operating time was 540, 831, 1323 minutes and the estimated blood loss was 280, 600, 1560 ml without transfusion. The postoperative pelvic abscess occurred in a rectal cancer patient and small bowel obstruction in another rectal cancer patient but 1 rectal GIST case without any postoperative event. The postoperative hospital stay was 17, 29, 68 days. Laparoscopic TPE may have a merit of obtaining a magnified view of the deep pelvis resulting decreasing blood loss without transfusion.

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V003 - Video - Flexible Surgery

V006 - Video - Intestinal, Colorectal and Anal Disorders

P.L.E.C.S.A: P.O.E.M. Laser Endomicroscopic Confocal Study for Achalasia

Laparoscopic Double Colostomy Reversal in a Patient with Giant Incisional Hernia and Double Parastomal Hernias

S. Perretta1, H. Neumann2, P. Halvax3, M. Diana3, J. Marescaux3, B. Dallemagne3

E. Filip, B. Smeu, I. Hutopila, M. Priboi, I. Balescu, C. Copaescu

IRCAD-IHU, Strasbourg, France; 2Universita¨ts-Klinikum Erlangen Medizinische Klinik I, Erlangen, Germany; 3IRCAD-IHU, Department of Digestive and Endocrine Surgery, Strasbourg, France

Ponderas Hospital, Bucharest, Romania

1

Background: Achalasia is a primary esophageal motor disorder characterized by degenerative changes of the myenteric plexus. To date all treatment forms are palliation and adequate length of the myotomy, surgical or endoscopic, is unknown and guided by extrapolated clinical, manometric and radiological findings. So far the only investigations of the myenteric plexus come from esophagectomy specimens and biopsies taken at Heller myotomy. Recent data showed that myenteric neurons could be selectively visualized with confocal laser endomicroscopy (CLE) by using acriflavine hydrochloride or a fluorescent neuronal molecular probe as contrast agents. Nevertheless no neuron-specific fluorescent stain is available for human use. In contrast, intravenously injected fluorescein sodium is widely used as the contrast stain for CLE in humans. Aims: To assess the feasibility and value of fluorescein guided CLE in the study of the myoenteric muscular plexus of the esophagus accessed via an esophageal submucosal tunneling technique in a porcine model. Methods: With the pig under general anesthesia a submucosal tunnel was performed by a previously described technique. Afterwards, the CLE probe was advanced through the scope and applied onto the newly created muscular pit within the submucosal space. CLE was performed after intravenous injection of 2.5 ml of 10% Fluorescein Sodium, using blue laser light (488 nm) for fluorophore excitation, and returning light was detected from 505 to 550 nm. Optical sections were collected with 12 frames per second, a lateral resolution of 1.4 lm, an optical sectioning of 10 lm and a 240 lm field of view. The pigs were then euthanized, and the studied sites were sampled and fixed in 10% formalin for subsequent histopathological analysis. Conclusions: Fluorescein guided CLE successfully identified the myoenteric muscular plexus in the pig model. This pioneer preliminary work holds great potential in that CLE scanning could lead to the identification and mapping of the diseased esophagus and the characterization of achalasia and other primary motility disorders tailoring and refining current forms of treatment.

Introduction: Laparoscopic approach in colostomy reversal result in lower morbidity and faster recovery than open technique that carries significant rates of wound infection, anastomotic leaks and incisional hernias. Incisional hernia repair and colostomy closure site hernia prevention with mesh performed concurrently with colostomy reversal is accepted but presumable associated with significant risks of infection and recurrence Aims: Our video present a staged approach of this difficult case: 1 step-laparoscopic double colostomal reversal and fascial closure of the colostomy sites and 2 step1 year delayed laparoscopic incisional hernia mesh repair and colostomy closure site mesh reinforcement Method: The video material present the case of a patient with double colostomy and giant incisional hernia with loss of housing domain of content and double parastomal hernia consecutive of a series of complex surgeries. A staged approach was decided: ostomy reversal as the first step and incisional hernia repair for the second step (14 months latter). The preoperative work-up and the both staged surgical interventions are presented and the technical aspects are commented. Results: The staged approach of surgical treatment in this particular case with double colostomy and giant incisional hernia and associated double parastomal hernia proved to be a safe and effective method with excellent result. Conclusion: Laparoscopic approach can be safely used in restoration of intestinal continuity. Concurrent incisional and/or parastomal hernia mesh repair should be judicious decided on a case-by-case basis for patients undergoing bowel surgery.

V005 - Video - Gastroduodenal Diseases

V007 - Video - Oesophageal Malignancies

Totally Video-Robotic Complete Resection of the Remnant Stomach for Gastric Cancer

Minimal Invasive Thoracic Esophagectomy in Prone Position

G. Ceccarelli, A. Bartoli, A. Spaziani, A. Patriti, A. Biancafarina Spoleto Hospital, Spoleto, Italy Background: In patients having carcinoma in the remnant stomach, total resection of the remnant stomach with lymph node dissection with or without splenectomy is the standard technique. Totally laparoscopic complete gastrectomy (TLCG) for gastric remnant cancer was described in literature. Video: The video clip shows the main steps of two patients with gastric remnant cancer treated by video-robotic technique. Successfully performed without adverse events during and after surgery. The patients were a 68 years old man and a 62 years old woman. The median operative time was 310 min; blood loss was 50 ml. No complications occurred postoperatively, and patients were discharged the eight and ninth postoperative day. Conclusions: Laparoscopic total gastrectomy for gastric remnant cancer is a challenging technically difficult operation that requires a time consuming lysis of adhesion and intracorporeal esophago-jejunal anastomosis, robotic technology in our opinion give advantages about vision, precision and anastomosis steps. Long-term follow-up is mandatory to validate oncological outcome.

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S.P. Puntambekar, A. Patil Galaxy Care Laparoscopic Institute, Pune, India In the current era more and more esophageal resections are being performed with minimal invasive approach mainly to reduce pulmonary morbidities associated with open technique. Most studies report thoracic part of esophageal mobilization done in left lateral decubitus position but short and long term outcomes with this approach have been very obscure. Recently prone position has been proposed as it is associated with improved pulmonary function owing to uniform distribution of pulmonary perfusion in this position. We present here a case of transthoracic esophageal mobilization in prone position for carcinoma esophagus.

Surg Endosc

V008 - Video - Thoracoscopic Surgery Port-Access Thoracoscopic Simultaneous Pulmonary Resection: Right Middle Lobectomy with Anterosuperior Segmentectomy, and Right Anterobasal Subsegmentectomy H. Kato, H. Oizumi, M. Endoh, H. Watarai, M. Sadahiro Yamagata University, Yamagata city, Japan Aims: Recent developments in thoracoscopic surgery and three-dimensional (3D) computed tomography (CT) have enabled the performance of various segmentectomies or subsegmentectomies. We describe a simultaneous thoracoscopic lobectomy, segmentectomy and subsegmentectomy using 3D-CT simulation for lung tumors in an unmarried woman who strongly desired the cosmetic result of minimally invasive surgery. Case: A 38-year-old woman presented with masses extending to the anterosuperior segment from the middle lobe and a nodule on the anterobasal segment of the right lung, diagnosed as mucosa-associated lymphoid tissue lymphoma. Technique: We used one 20-mm, one 10-mm, and two 5-mm ports. Each skin incision was made at sites normally covered by a brassiere. The vessels were identified pre- or intra-operatively using a 3D-CT simulation. The middle pulmonary vein was divided and the middle bronchus (B4 + 5) was cut using a stapler. The middle pulmonary artery (A4 + 5) was divided using a bipolar sealing device (BSD). Because of incomplete lobulation between the upper and middle lobes and tumor extension to the anterosuperior segment, anterosuperior segmentectomy combined with middle lobectomy was planned. The intrasegmental vein (V3ab) and artery (A3) of the anterosuperior segment were divided using a BSD. Continually, the subsegmental artery (A8b) of the anterobasal segment was divided. The segmental and subsegmental bronchi (B3 and B8b) were dissected, and 3-0 and 4-0 monofilament threads were passed through and closed with a modified Roeder knot; the bronchi were cut after the right lung was inflated to visualize an intersegmental and intersubsegmental plane for dissection along the anatomical plane. Thus, the inflation-deflation line could be clearly identified. The intersegmental veins (V1b and V2c), identified by 3D CT, were divided. The parenchyma of the pulmonary hilum was dissected along the inflation-deflation line and the intersegmental vein using an electrocautery and BSD; staplers were used in the peripheral lung tissues. Removal of the resected lung required a 25-mm extension at the 20-mm port site. The operative time was 270 minutes, and bleeding was scant. Chest-tube removal and discharge occurred on postoperative days 3 and 7, respectively. Conclusion: Port-access thoracoscopic simultaneous lobectomy, segmentectomy and subsegmentectomy can be performed with good cosmesis using 3D-CT simulation.


V010 - Video - Oesophageal and Oesophagogastric Junction Disorder Laparoscopic Repair of Large Paraesophageal Hernia with Concurrent Sleeve Gastrectomy N.R. Obeid, B.F. Schwack, M.S. Kurian, C.J. Ren-Fielding, G.A. Fielding New York University Medical Center, New York, United States of America Aims: We present an interesting case of laparoscopic repair of a giant paraesophageal hernia with simultaneous bariatric surgery. The technical aspects of this challenging operation are reviewed. The video also highlights the resulting major morbidity that can occur. Methods: A 66 year-old woman was diagnosed with a type IV paraesophageal hernia including stomach, colon, and pancreas in the left chest. She was scheduled for laparoscopic repair of the hernia defect, expressing interest in concurrent bariatric surgery. Intraoperatively, the gastroesophageal junction could not be pulled into the abdomen without significant tension. We extended the Collis gastroplasty to perform a concomitant sleeve gastrectomy. The details of the operative approach are illustrated. Results: On postoperative day 2, an esophagram revealed normal passage of contrast without leak or obstruction. However, on postoperative day 6, she became febrile, with persistent tachycardia and leukocytosis. A CT scan showed a large mediastinal fluid collection consistent with a leak. The patient was taken emergently to the OR for EGD, thoracotomy, decortication, and repair of distal esophageal perforation with muscle interposition graft. On postoperative day 7 after esophageal repair, an esophagram revealed contrast extravasation from the distal esophagus. The patient underwent a repeat thoracotomy, debridement, and esophageal resection with exclusion due to necrosis, placement of pharyngostomy tube, as well as laparotomy, gastrostomy and jejunostomy tube placement. The patient was eventually discharged to a nursing facility after a prolonged hospitalization with pulmonary and infectious complications. She required multiple readmissions for tube maintenance and infectious complications. Several months later, after nutritional optimization, she is recovering from a right thoracotomy and Roux-en-Y esophagojejunostomy. Conclusions: Large paraesophageal hernias can cause debilitating symptoms, and laparoscopic repair is often complex in nature. In morbidly obese patients, extending the Collis gastroplasty into a vertical sleeve gastrectomy can help to address the morbid obesity. However, patients must be counseled on the many serious risks and complications associated with this procedure.

V011 - Video - Oesophageal and Oesophagogastric Junction Disorder

Minimally Invasive Esophagectomy with Complete Removal of Recurrent Nerve Lymphatic Chains

Laparoscopic Resection of Epiphrenic Esophageal Diverticulum

H. Okabe, E. Tanaka, S. Tsunoda, S. Hisamori, H. Kawada, M. Harigai, Y. Sakai

C. Rodriguez-Otero Luppi, E.M. Targarona, C. Balague, J. Bollo, M. Trias

Kyoto University, Kyoto, Japan

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

Backgrounds: Recurrent nerve lymphatic chains are the most frequent regions of lymph node metastasis in esophageal cancer. Complete removal of these lymph nodes is important for better local control. However, it is technically demanding and could cause recurrent nerve palsy and aspiration pneumonia, which ruins the benefits of minimally invasive esophagectomy (MIE). In the upper mediastinum, the esophagus is surrounded by the visceral sheath together with the trachea. The recurrent nerves and lymphatic chains run within the sheath. Understanding of the anatomical background can facilitate the safe dissection. A video showing our minimally invasive technique of upper mediastinal dissection along the recurrent laryngeal nerves will be presented. Methods: The patient was placed in the prone position. After the azygos vein was transected, the pleura was cut along the right vagus nerve and the right subclavian artery was identified. Above the subclavian artery, the visceral sheath overlying the right recurrent nerve was isolated from the right carotid artery upward, until the inferior thyroid artery was identified. The sheath was then cut to expose the recurrent nerve. By dividing the esophageal branches of the nerve cephalad, the right recurrent nerve nodes were removed until reaching the level of lower pole of the thyroid. On the left side, the visceral sheath containing the left recurrent nerve nodes was isolated from the aortic arch and the left subclavian artery. The thoracic duct was preserved. The left recurrent nerve nodes were separated from the trachea and removed, while the left recurrent nerve was preserved. Results: From May 2010 to Dec 2013, 85 patients underwent MIE. Mean thoracoscopic procedure time was 297 min and mean number of harvested intra-thoracic lymph nodes was 29. Mean blood loss was 108 g. Postoperative complications occurred in 25 patients (29%), including pneumonia (11%), and leakage (8%). Recurrent nerve palsy occurred in 14%. Inhospital death occurred in one patient with gastric tube necrosis (1.2%). Conclusions: By understanding the anatomical compartment of the upper mediastinum, MIE with complete dissection along recurrent nerves can be performed with reasonable low complication rates. To avoid injuries to recurrent nerves, precise dissection under minimally invasive approach is useful.

Introduction: Epiphrenic diverticulum are uncommon disorders of the lower oesophagus, which are symptomatic in only 15–20% of cases. They are usually found in the lower third of the esophagus in middle-aged or elderly persons. There is usually an associated motility disorder of the esophagus (50–100%). In the past, thoracotomy represented the traditional approach for the treatment of epiphrenic diverticulum, at present mini-invasive approach seems to be the treatment of choice as many series have been published in the recent years. Historically the high morbidity associated with thoracotomy dictates that only patients with disabling symptoms or complications should be treated. The optimum treatment modality remains an esophageal diverticulectomy with long myotomy with an antireflux operation to prevent the formation of a fistula. Material and Methods: We report the case of a 64 years-old man with a 6-month history of pyrosis, coughing and regurgitation, diagnosed by fibrogastroscopy of epiphrenic diverticulum. Preoperative study was completed by esophageal transit confirming the findings and esophageal manometry which was normal. Given the patient’s symptoms surgical intervention is decided laparoscopically. Results: The video presented is the laparoscopic approach of an esophageal diverticulum epiphrenic through transhiatal dissection and removal thereof through endostapler section, with subsequent realization type Heller myotomy and Dor fundoplication. The procedure lasted 120 min. There was no intraoperative complication. An esophagram with Gastrografin was performed on postoperative day 2 showing no leakages and diet was started. He made an uneventful recovery and was discharged on fourth day. He remained asymptomatic on follow up. Conclusion: Laparoscopic approach and repair of symptomatic esophageal epiphrenic diverticulum is a safe, feasible and effective technique with minimal postoperative pain and morbidity.

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V012 - Video - Flexible Surgery


Poem in a Patient with Type III Achalasia and a Right-Sided Aortic Arch

Blue Dye Injection into the Submucosal Layer of the Stomach to Determine the Resection Line for Totally Laparoscopic Distal Gastrectomy

E. Teitelbaum, N.J. Soper, J.E. Pandolfino, P.J. Kahrilas, E.S. Hungness Northwestern University, Chicago, United States of America Introduction: Peroral endoscopic myotomy (POEM) is a novel operation for the treatment of achalasia that creates a controlled myotomy across the esophagogastric junction (EGJ) completely endoscopically. POEM may offer an advantage over traditional laparoscopic Heller myotomy for patients with type III achalasia, as the myotomy can easily be extended proximally in order to ablate any spastic segments of the esophagus. Procedure: This video shows a POEM procedure performed in a 77 year old man who presented with worsening dysphagia. The patient also had a history of coronary artery disease, had previously undergone coronary artery bypass grafting, and was on aspirin therapy. His dysphagia was initially thought to be due to a right-sided aortic arch that was causing posterior compression on the esophagus. However, high-resolution manometry demonstrated a non-relaxing EGJ with spastic and hypertensive swallows, thus establishing a diagnosis of type III achalasia. The patient elected to undergo POEM, and the steps of the procedure are shown and described. A functional lumen imaging probe (FLIP) is used to assess EGJ distensibility at baseline. The operation then begins with a submucosal injection of saline and indigocarmine dye, taking care to avoid the posterior aortic compression. A mucosotomy is then created and the endoscope is maneuvered into the submucosal space. A submucosal tunnel is created using a combination of blunt and electrocautery dissection and its length is verified by identifying blue dye through the gastric mucosa. Although the patient was maintained on aspirin throughout the perioperative period, there was no increased bleeding during tunnel creation. An extended myotomy is then performed, starting 10 cm proximal to the EGJ, as opposed to our usual proximal distance of 6 cm. This is done to disrupt the entire length of the patient’s spastic swallows, as measured on preoperative manometry. After a final FLIP measurement demonstrates a dramatic increase in EGJ distensibility, the mucosotomy is closed with endoscopic clips and the procedure concludes. Conclusions: POEM allows for easy proximal myotomy extension, which may be of benefit in patients with type III achalasia. Aspirin therapy does not seem to cause additional bleeding during POEM.

K. Ehara1, M. Nakagawa2, K. Noda1, I. Kikuchi1, Y. Yamada1, Y. Kawashima1, Y. Tanaka1 1 Saitama Cancer Center, Saitama, Japan; 2Tokyo Medical and Dental University, Tokyo, Japan

Background: Recently, laparoscopic distal gastrostomy (LDG) for gastric cancer has been well accepted as a minimally invasive surgery in Japan. Furthermore, the intra-abdominal anastomosis (IAA), which is required to perform totally LDG without upper abdominal incision, has been performed more and more. However, it is often difficult to determine the proximal resection line. In IAA, identifying lesions by palpating or opening the stomach is essentially impossible, in contrast to the extra-abdominal anastomosis. Therefore we introduce a useful method of the tumor identification for totally LDG followed by IAA. Method: After inducing general anesthesia, ‘a mixture of sodium hyaluronate and patent blue (blue dye)’ is injected into the submucosal layer of the proximal margin, under intraoperative-gastroendoscopy. The blue marking spots can be detected on the serosal side of the stomach laparoscopically. The resection line is decided to make sure that all marking spots are on the resected side. In all cases, the proximal margin was examined histologically by frozen section during the operation. After checking up the margin, reconstruction was completed laparoscopically. Results: IAA was performed in 227 patients out of 340 patients who underwent LDG for gastric cancer between October 2009 and September 2013. Billroth-I and Roux-en-Y reconstruction were performed in 147 and 80 patients, respectively. Margin positive occurred in only 2 cases (0.88%). One case underwent subsequent total gastrostomy, and the other case required additional resection with Roux-en Y reconstruction. The mean ± standard deviation length of the proximal margin was 29.3 ± 11.3 mm. It takes about 7 min to complete the procedure. IAA was successfully achieved in all cases. There was no complication related to the identification procedure, such as allergy. Conclusions: In totally LDG followed by IAA, this procedure appears accurate, safe, and rapid.



Lapaloscopy and Endoscopy Cooperative Surgery for Submucosal Tumor of Cardiac Region of Stomch

Laparoscopic Radical d2 Gastrectomy for Carcinoma of the Stomach: Presentation of the Technique and Collective Experience

A. Miki, H. Kinoshita, Y. Sakamoto, K. Okada, T. Yamamoto, K. Inoguchi, S. Yao, M. Kondo, S. Yagi, K. Uryuhara, H. Kobayashi, H. Hashida, S. Kaihara, R. Hosotani Kobe City Medical Center General Hospital, Kobe, Japan Aims: Recently, laparoscopy and endoscopy cooperative surgery (LECS) has brought less invasive surgery for removal of submucosal tumor (SMT). In our facility, we started LECS for gastric submucosal tumor since 2008, and have had good outcome. However, the difficulty of LECS depends on tumor size and its location. Especially LECS for cardiac SMT is technically challenging because is hard to keep good operative field. As a result, complications such as stenosis or damage to the cardia may arise. In this sturdy, we make a presentation of our LECS procedures against cardiac lesion and report the outcome. Method: Our indication of LECS for cardiac SMT is as below: tumor size is less than 5 cm, no ulceration, and intraluminal type. Operation is performed with 5 ports. First, we cut all of short gastric arteries and veins, and detach the left side of pedicle of left gastric artery from the crura of the diaphragm to increase mobility of cardiac stomach and keep good operative field. Next, endoscopist places the endoscope into the stomach, and dissects submucosa around SMT circumferentially, and then makes a small hole at the anal side of SMT endoscopically. Next we surgeons laparoscopically extend the full-layer incision from small hole to the both side of SMT along the line which was made endoscopically, about three quarters of SMT. Finally we resect the tumor with linear stapler closing the opening site of the stomach. We experienced 33 patients who received LECS for gastric SMT from April 2008 to December 2013, and we analyzed 7 cases of those, which tumor location was around cardia. Result: The mean age was 56 years. 4 patients were men, and 3 were women. Duration of operation was 174 minutes, average blood loss was 6 g, average tumor size was 4.06 cm, and average hospital stay was 7.7 days. There was no complications, such as anastomotic leakage, stenosis leakage. Conclusion: LECS is feasible and safe for SMT of cardiac lesion of stomach.

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M. Shoukry Hafez Al Salam Oncology Center, Cairo, Egypt, Cairo, Egypt Introduction: Diagnostic laparoscopy has been an important part in staging carcinoma of the stomach, and the technique evolved to attempts at radical d2 gastrectomies aided by the advances in technologies and building of experience. Patients and Methods: We present our experience in 25 patients treated by laparoscopic radical 2 gastrectomy. We use classical 5 ports approach, perform a d2 lymphadenectomy after staging. We either perform a total or subtotal gastrectomy depending on the location of the primary lesion. We perform all anastomosis intracorporeally, in cases of total gastrectomy an esophagojejunostomy, and in subtotal gastrectomy a gastrojejunostomy. Results: We had no conversions in our experience. The average hospital stay for the subtotal gastrectomy cases is 4 days, for the total gastrectomy cases is 8 days. No cases required intra operative transfusion. We had one leak from a gastrojejunal anastomosis which was managed laparoscopically. The oncological outcome was satisfactory with all cases achieving negative margins and the average nodal number was 35. Conclusion: Laparoscopic d2 gastrectomy is a safe and oncologically adequate procedure that takes advantage of the magnification and quality of the high definition pictures that laparoscopy offers to do a precise and detailed nodal dissection in a minimally invasive way.

Surg Endosc

V017 - Video - Vascular Surgery


Laparoscopic Autotransplantation for Complex Renal Artery Aneurism Using Fluorescence

Standardised Technique of Single Dock Totally Robotic Total Mesorectal Excision

G. Borroni, E. Cassinotti, E.M. Colombo, G. David, L. Giavarini, S. Spampatti, G. Soldini, M. Tozzi, L. Boni

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

Ospedale di Circolo-fond. Macchi - University of Insubria, Varese, Italy Aims: Near-infrared fluorescence imaging (NIR) using indocyanine green (ICG) is a promising, innovative, and noninvasive method for the intraoperative identification of vascular anatomy during nephrectomy and to visualize the organ reperfusion after the kidney transplant. Renal Artery Aneurism (RAA) are uncommonly encountered in clinical practice, and estimates of their prevalence vary from 0.09% to 1.3% of general population. Although most RAA can be treated with in vivo repair or endovascular techniques, these may not be possible in patients with complex RAA beyond the renal artery bifurcation. Methods: A 53 year-old man with 2 cm aneurysm involving the secondary inferior branch of the right renal artery underwent to angiography and an attempt of endovascular repair with stent-graft alone was done but there was a technical failure due to the morphology and localization of the aneurism. Another Computed Tomography (CT)-scan after the attempt of endovascular treatment pointed out a slight edema of the right kidney and two ischemic lesion localized in the lower pole. Results: The patient underwent a Laparoscopic Nephrectomy (LN) as for living donor nephrectomy and renal artery reconstruction ex vivo, followed by the autotransplantation of the reconstructed kidney. NIR laparoscopy in conjunction with ICG was used during LN. Fluorescent angiography can provide a reliable roadmap of the renal vessels and ureter anatomy, enabling surgeons to avoid injuring and bleeding during the dissection. During the backbench preparation of the kidney the aneurysm was resected. Furthermore, a thrombectomy of the secondary medial branch of the right renal artery was done, a dissecting flap was removed. Kidney transplantation in the right iliac fossa was accomplished followed by fluorescent visualization during revascularization of the reconstructed kidney that confirmed a good perfusion of the re-implanted organ. Conclusion: ICG fluorescence technology can give objective data as a real-time image, indicating the perfusion status of the transplanted kidney. In the present case ICG fluorescence was used to visualize kidney reperfusion, to evaluate the revascularization of the two previous ischemic lesions localized in the lower pole and to assess the patency of the secondary medial branch of the right renal artery and the patency of the anastomosis.

Minimally Invasive Colorectal Unit, Portsmouth, United Kingdom This video demonstrates standardised steps for performing single dock totally robotic total mesorectal excision (R-TME). The steps include patient positioning and docking, port placement, vascular isolation and division, medial to lateral dissection, splenic flexure mobilisation and technique for TME. The aim is to reproduce these steps and follow oncological surgical principles in a structured way. With a highly standardised technique for R-TME reproducible excellent patient outcomes can be achieved.



Laparoscopic Complete Mesocolic Excision for Advanced Transverse Colon Cancer; Total Medial Approach to Vessels with Pincer Movement

Transanal Minimally Invasive Surgery for Total Mesorectal Excision: A New Approach for Low Rectal Cancer

M. Kondo Kobe City Medical Center General Hospital, Kobe, Japan

E. Cassinotti1, G. David2, E.M. Colombo2, L. Giavarini2, G. Borroni2, A. Marzorati2, S. Spampatti2, V. Quintodei2, L. Boni2 1

Minimallly Invasive Surgery Research Center, Varese, Italy; Minimally Invasive Surgery Research Center, University of Insubria, Varese, Italy

2

Aims: The most difficult aspect of laparoscopic surgery for advanced transverse colon cancer is complete mesocolic excision with division of the middle colic vessels, because the transverse mesocolon is complicated anatomically around duodenum and pancreas including colic vessels abnormalities. We have a ordered, sequential method for transverse colectomy under total medial approach ensuring the oncological safety, and aim to present in detail our established procedure. Methods: We place five trocars (one is an umbilical camera port, others are at the square placement) in the lithotomy position. Firstly, exposure of superior mesenteric vein at the root of ileocolic vein is followed by dissecting and visualizing the duodenum surface, head of pancreas and gastrocolic trunk along superior mesenteric vessels through medial approach. Using ultrasonic cutting devices, right gastroepiploic vein can be taken down after accessory right colic vein is clipped and divided while maintaining the mesocolic fascia. Secondly, to cut the mesocolic fascia at the lower edge of pancreas body just above Treitz ligament results in opening omental bursa on the left side of middle colic vessels. Then the root of middle colic artery and vein is easily and safely dissected with ‘pincer movement’ from right and left. Finally, we mobilize the hepatic-flexure and splenic-flexure by almost medial-to-lateral approach and transect greater omentum in order that the transverse colon can be mobilized, cut and anastomosed. Results: From November 2012 to December 2013, 185 patients with colorectal cancer were operated laparoscopically. There were 17 cases of transverse colon cancer, included 5 extended right hemicolectomies, 12 transverse colectomies using this approach. There were no conversion to open surgery and no postoperative complications more than Grade ? in the Clavien-Dindo Classification. Conclusions: This method can lead to early ligation of tumor feeding vessels, removal of total transverse mesocolon preventing exposure of potentially involved lymph nodes before mobilizing the transverse colon as indicated. We believe this is easy to learn and oncologically safe, feasible as a non-touch isolation theory in advanced transverse colon cancer.

Introduction: The introduction of total mesorectal excision (TME) in surgical treatment of rectal cancer has substantially improved oncologic outcomes and increased sphincter preservation rate; nevertheless laparoscopic TME is still associated with long operative time and technical challenges in pelvic dissection. Transanal minimally invasive surgery (TAMIS)-TME appears to be a safe and feasible procedure, a new alternative approach compared to standard laparoscopic surgery. Aim: This video shows our technique of TAMIS-TME for low rectal cancer. Methods: Patient is placed in lithotomic position and trocars are inserted as for a standard laparoscopic left hemicolectomy. High ligation of inferior mesenteric vessels is carried out, following by dissection of Toldt’s fascia and full mobilization of the splenic flexure and sigmoid colon up to the peritoneal reflection, that is not opened. At this point a standard device for transanal endoscopic microsurgery (Karl Storz, Tuttlingen, Germany) is inserted. The rectum is insufflated with CO2 at 9–10 mmHg pressure and a full thickness purse string suture is placed 2 cm below the tumor. The rectum is transected distally until the mesorectal plane is reached using a combination of standard monopolar electrocautery and advanced bipolar energy (Ligasure Advance, Covidien, Mansfield, MA). TME is then performed following the ‘holy plane’ until the peritoneal reflection, that will be opened. The rectosigmoid specimen is then extracted transanally, the descending colon is divided and a colo-rectal end to side stapled anastomosis is performed using EEA 33 (Covidien, Mansfield, MA). At the end of the procedure the anastomosis is checked with idro-pneumatic test and a diverting loop ileostomy is created. Conclusions: TAMIS-TME for low rectal cancer is a feasible and safe procedure that offers several advantages such as precise identification of the distal margin of the tumor, fairly easier dissection of distal mesorectum compared to standard laparoscopy and avoids the need of minilaparotomy, without compromising oncological principles of rectal surgery. Nevertheless this approach requires an high specialized team and long-term outcome evaluation is needed before consider this procedure a valid alternative to laparoscopic TME.

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V024 - Video - Pancreas

Laparoscopic Resection of Splenic Flexure Tumors

Spleen Preserving Laparoscopic Distal Pancreatectomy

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

F. Stipa, E. Soricelli, A. Burza

Hospital Alemań de Buenos Aires, Buenos aires, Argentina Purpose: Malignant tumors of the splenic flexure only represent between 3 and 5 % of all the colorectal cancers. There are no differences between segmental and extended resection in terms of oncologic results. On the other hand, there is scarce data referring the laparoscopic approach of these tumors. The aim of this video is to show the technique for the laparoscopic resection of splenic flexure tumors. Methods: We present a video from different patients describing the steps for the laparoscopic resection of splenic flexure tumors. Description of the Video: Four 12 mm trocars are used in the umbilicus, both flanks and the right upper quadrant. With the patient in a reverse Trendelenburg position the small bowel is displaced to the pelvis. Identification of two important landmarks: the ligament of Treitz and the inferior mesenteric vein. Using a medial to lateral dissection the transverse mesocolon is sectioned. The lesser peritoneal cavity is reached and the greater gastric curve is visualized. The medial colic artery is ligated. Another option is to begin the medial to lateral dissection on the left colon. The mesocolon is sectioned beside the left colic artery. The retroperitoneal elements are taken down. The body and tail of the pancreas are descended downwards. The left colic artery is ligated and transected. Colo-epiploic detachment from left to right and movilization of the splenic flexure. Trough a wound protector the colonic flexure is extracted and transected. Finally an end to end handsewn transverse-descendent anastomosis is performed.

San Giovanni Addolorata Hospital, Rome, Italy Purpose: Laparoscopic distal pancreatectomy (LDP) may represent an effective surgical option for the management of small cystic neoplasms in the body or tail of the pancreas in selected patients. When achieved with en-bloc splenectomy, clinical outcome of LPD may be affected by post-operative complications such as leukocytosis, thrombocytosis and some degree of immunodeficiency. During spleen-preserving LPD (SPLPD) both splenic artery and vein are preserved. Methods: The video shows a SPLPD in a 61 y.o. female with a history of mammary carcinoma operated one year before, presenting with an undefined 2 cm cystic lesion of the pancreatic tail. Magnetic resonance imaging was suspicious for internal septa and mucin content. Following the division of the gastrocolic ligament, the splenic vessels were isolated along the superior border of the pancreas and dissected free from their pancreatic vascular branches. Once the body and the tail of the pancreas were completely freed, a distal pancreatectomy was performed by means of a sealing and cutting device. The pancreatic stump was reinforced with adsorbable suture and fibrin sealant placement. Pathology showed a serous cystoadenoma of the pancreatic tail with clear resection margins. Post-operative course was uneventful and the patient was discharged five days later.


V025 - Video - Liver and Biliary Tract Surgery

Usefulness of the Pancreas Head Hanging Maneuver on Laparoscopic Pancreaticoduodenectomy

Totally Laparoscopic Anatomical Hepatectomy Exposing the Major Hepatic Veins from The Root Side

T. Ito, D. Yagi, T. Nishikawa, Y. Kamada, Y. Hattori, M. Sugano

G. Honda, M. Kurata, S. Kobayashi, Y. Okuda, K. Sakamoto

Sugita Genpaku Memorial Obama Municipal Hospital, Obama, Japan

Tokyo Metropolitan Cancer and Infectious diseases Center Komagome Hospital, Tokyo, Japan

Laparoscopic pancreaticoduodenectomy (LPD) is becoming more popular in the management of pancreaticoduodenal diseases due to improved laparoscopic expertise and advancement in endoscopic technology and equipment. To dissect behind superior mesenteric vessels is one of the challenging steps in PD, because of its anatomical complexity, a poor surgical view, and congestion of the specimen. To establish safe LPD, we developed the pancreas head hanging maneuver in LPD, based on the liver hanging maneuver. This technique allowed us to dissect the space between superior mesenteric vessels and pancreas head easily, to create an appropriate coaxial direction and a clear laparoscopic view for dissection even under the limited instrumental angles, and to prevent bleeding from the specimen by its congestion. After the division of the pancreas neck and the inferior pancreaticoduodenal vessels from the caudal side, the terminal duodenum is pulled through behind the superior mesenteric vessels toward the right side. The pancreas head hanging maneuver is done using a cotton tape hanged over pancreas head. The cranial side (top) of the hanging is the left or right side of the common hepatic duct, whereas the caudal side (bottom) of the hanging is the uncinated process. The operator is located between the patient’s both legs on the lithotomy position. The tape is tied, held by the needle holder, and pulled toward right caudal side by the assistant on the right side of the patient. The neural plexus behind pancreas is precoagulated by the VIO soft coagulation systems and transected by laprosonic coagulating shears or vessel sealing devices. By means of this approach, the superior pancreaticoduodenal vessels can be easily identified, clipped, and cut under the clear laparoscopic view without accidental vascular pulling off by extensive countertraction. Although LPD is a technically demanding and time consuming procedure, it can be safely performed by the suitable approaches with use of the clear laparoscopic view.

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Aims: We performed totally laparoscopic anatomical hepatectomy for 84 patients from August, 2008 to December, 2013. We will present our standardized procedures exposing the major hepatic veins from the root side. Methods: The patient was a 75-year-old man with liver cirrhosis associated with hepatitis C. At a periodic checkup, a solitary HCC of 1.5 cm was noted in the right anterior sector and right anterior sectorectomy was scheduled. A trocar as a scope was placed at the umbilicus and 4 trocars for the instruments were placed beneath the costal arch. A tourniquet system for Pringle’s maneuver was prepared and was initiated when the field could not be kept dry. The liver was divided, exposing the major vessels by CUSA without precoagulation. After encircling and clamping the anterior Glissonian pedicle, the cutting lines were marked. The inferior aspect of the middle hepatic vein was then exposed near the hilum. Exposing the entire length of the middle hepatic vein, the cutting plane was extended and the major hepatic fissure divided. After transection of the anterior Glissonian pedicle, the right hepatic vein was exposed from the root side toward the peripheral side by lifting the excised liver and the resection was completed. Results: The operation time was 269 min. Blood loss was 130 g. He was discharged to home on day 8 without any complications. Conclusion: This procedure can avoid splitting the bifurcation of the hepatic vein by moving CUSA from the root side toward the peripheral side as well as utilizing the unique view from the caudal side in the laparoscopic approach.

Surg Endosc



Laparscopic Distal Pancreatectomy with Warshaw Technique for Solid Pseudopapillary Neoplasm? Report of a Case?

The Difficult Gallbladder - How to Deal with Intra-Operative Complications

K. Inoguchi

A.M. Harris

Kobe City Medical Center General Hospital, Kobe-shi, Japan

Hinchingbrooke Hospital, Huntingdon, United Kingdom

The solid pseudopapillary neoplasm (SPN) of the pancreas is a rare neoplasm, representing 0.13% to 2.7% of all pancreatic tumors. This neoplasm is more common in young women between the third and fourth decade of life. It may produce nonspecific symptoms and in many cases is asymptomatic, being diagnosed incidentally. We present the case of laparoscopic distal pancreatectomy with Warshaw technique for SPN. A 22-year-old woman with no previous medical history presented abdominal pain for the last 4 months. A computed tomography showed clinical features of enteritis, and incidentally showed cystic tumor in the tail of the pancreas. After further investigation, she was diagnosed with SPN. She underwent a laparoscopic spleen-preserving distal pancreatectomy. The tumor was very close to the splenic vein, it was unable to preserve splenic vessels. We therefore underwent Warshaw technique. CT at the fourth postoperative day showed fluid around the splenic hilum. We diagnosed as pancreatic fistula Grade B according to the International Study Group of Pancreatic Fitula definition. Although we used antibiotics and octreotide, she evolved favourably and was discharged at the thirteenth postoperative day. The pathological diagnosis of the surgical specimen was a solid pseudopapillary neoplasm. Follow up CT after 2 month showed no fluid around the spleen, no splenic infarction, nor gastric varices

Laparoscopic cholecystectomy is the gold standard of treatment for symptomatic gallstones. Although usually straightforward, it can be a very difficult operation requiring skill and experience to complete without conversion. This video presents three types of difficulty that may be encountered during this operation and how to deal with them. 1. Vascular anomaly. 2. Perforated gallbladder with subphrenic abscess. 3. The shrunken fibrotic gallbladder. In each case intra-operative footage is shown with a demonstration and explanation of the techniques that help to complete the procedure safely. Training programmes are of vital importance to the safe and appropriate progression of surgical trainees. This is intended to be the first of a series of educational videos for trainees with further collections currently being prepared for this and other types of common laparoscopic surgery.



Pure Laparoscopic Anatomical Liver Resections Using 3D Computer-Assisted Simulation and Navigation

Laparoscopic Left Hepatectomy with Tumor Thrombectomy in Patients with Hepatocellular Carcinoma Concomitant with Advanced Portal Vein Tumor Thrombus

Y. Abe, O. Itano, M. Shinoda, M. Kitago, H. Yagi, T. Hibi, Y. Kitagawa Keio University School of Medicine, Tokyo, Japan Aims: Theoretically, anatomical liver resection provides the best oncological results for hepatocellular carcinoma (HCC); however, it requires in-depth understanding of liver anatomy and is technically demanding even by laparotomy. We describe 3 cases of pure laparoscopic anatomical liver resections using 3D computer-assisted simulation and navigation (3D-CASN). Methods: Case 1. 66-year-old man had a 2.5 cm HCC located in segment VI (2 feeding portal pedicles) with 2 other portal pedicles coming from the adjacent segments (dorsal branches of segments V and VIII). Case 2: 75-year-old man had a 2.4 cm HCC in segment V with a single portal pedicle. Case 3: 66-year-old female had a 2-cm HCC in segment V with 3 separate branches diverging from the right anterior portal pedicle. Precise preoperative evaluation by 3D imaging enabled us to identify each portal pedicle and hepatic vein at the tertiary levels and simulate the cutting plane of the liver while securing adequate tumor margins. In the operating room, we started from isolating the main inflow portal pedicles to the tumor at the hepatic hilum (extrahepatic/extrafascial approach), which could be done easily with the magnified view of laparoscopy. Then, the transection of the liver parenchyma followed the demarcated line by selective clamping of portal pedicles. Once we get inside the liver, the small branches of hepatic veins, which were already identified preoperatively, served as beacons of the boundaries between the resecting liver and the remnant. Results: By identifying all anatomical structures and reproducing the transection plane that was planned preoperatively, we successfully performed pure laparoscopic liver resections in all 3 cases. Operative time and blood loss for cases 1, 2, and 3 were 309 min, 100 ml; 304 min, 270 ml; and 270 min, 100 ml, respectively. Surgical margins were all negative. Conclusion: With the combination of precise understanding of the vascular anatomy using 3D imaging and the luxury of magnified view as well as decreased blood loss by laparoscopic surgery, we can now perform a more accurate, ‘truly’ anatomical liver resection according to each tumor location. Pure laparoscopic liver resection and 3D-CASN has taken anatomical liver resections to the next level.

S. Nakahira, Y. Takeda, Y. Katsura, Y. Kagawa, K. Nitta, M. Okishiro, A. Takeno, H. Sakisaka, H. Taniguchi, C. Egawa, T. Kato, S. Tamura Kansai Rosai Hospital, Amagasaki, hyogo, Japan Although laparoscopic hepato-biliary-pancreatic surgery has been widely adopted, use of laparoscopic resection for hepatocellular carcinoma (HCC) with advanced portal vein tumor thrombus (PVTT) is uncommon. From June 2010 through December 2013, 215 laparoscopic hepatectomies were performed in our hospital. Three patients with HCC concomitant with PVTT in the portal trunk or the opposite branch underwent laparoscopic hepatectomy with tumor thrombectomy. The median operative time was 592 min (range, 555–891 min), and median estimated blood loss was 1182 ml (range, minimal–4800 ml). The median length of hospital stay was 19 days (range, 9–22 days). Laparoscopic hepatectomy for HCC with advanced PVTT is a safe and feasible procedure in selected patients, when performed by surgeons with expertise in hepatic surgery and minimally invasive techniques. Video Presentation: The patient was a 61-year-old woman who had multiple HCC caused by chronic hepatitis B classified as Grade A on the Child-Pugh classification. She underwent 8 transcatheter arterial chemoembolization sessions and open surgery for lymph node metastasis of the hepatoduodenal ligament at another hospital. She was referred to our hospital because advanced PVTT developed from the main tumor of the left lobe. We decided to perform pure laparoscopic left hepatectomy with tumor thrombectomy. The patient was placed in the supine position, and 4 laparoscopic trocars were positioned. The left lobe was completely mobilized, and lymphadenectomy of the hepatoduodenal ligament was performed. The left hepatic artery was then divided, and hepatic parenchymal transection was performed with BiClamp using a modified hanging maneuver; the left hepatic duct and the left hepatic vein were dissected and divided using a linear stapler. The left portal vein was divided with the portal trunk and the right portal vein clamped with endovascular clips. The PVTT in the right portal vein was retrieved, and the stump of the left portal vein was sutured. Total operative time was 594 min, and the blood loss was minimal. The patient was discharged on the 9th postoperative day without any adverse events. She was treated with sorafenib 1 month after palliative resection, and survived for 3 postoperative months, during which, decreased tumor marker levels were observed.

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Evaluation of Laparoscopic Gastrectomy with Radical Lymphadenectomy: Experience in 98 Cases

Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery Syndrome

T. Yamamoto, A. Miki, H. Kinoshita, Y. Sakamoto, K. Okada, S. Yao, K. Inoguchi, M. Kondo, S. Yagi, K. Uryuhara, H. Kobayashi, H. Hashida, S. Kaihara, R. Hosotani

A. Navarro, S. O’Brien, P. Shorvon, A. Martıńez-Isla

Kobe City Medical Center General Hospital, Kobe, Japan Aims: There are a lot of gastric cancer patients in Japan, and laparoscopic distal gastrectomy has been widely spread for early gastric cancer. In our facility, we conduct laparoscopic gastrectomy with D1+ lymphadenectomy for Stage IA gastric cancer, and in 2012, for Stage IB, we started D2 lymphadenectomy laparoscopically. In this study, we will present the surgical techniques of laparoscopic gastrectomy with radical lyphadenectomy and report its safety. Methods: We analyzed the 98 patients with gastric cancer who received laparoscopic distal gastrectomy from April 2010 to May 2013, and compared the result and the safety between D1+ and D2 lymphadenectomy. In D2 lymphadenectomy, in addition to D1+, we expose the wall of proper hepatic artery and portal vein to dissect lymph nodes around proper hepatic artery-No. 12a lymph nodes-, and we expose splenic artery and vein to dissect lymph nodes around splenic artery-No. 11p lymph nodes-. Results: The mean age was 66.8 ± 11.5 years. 62 patients were men, and 36 were women. The clinical TNM stage was Stage IA in 86 (87.8%) and Stage IB in 12 (12.2%). We conducted D1+ lymphadenectomy for Stage IA and D2 lymphadenectomy for Stage IB patients. In comparison between these two groups, average duration of operation was 270.6 ± 50.6 vs. 275.2 ± 52.4 minutes (p = 0.64), average blood loss was 37.5 ± 60.0 vs. 12.1 ± 15.3 g (p = 0.21), average number of dissected lymph nodes was 35.3 ± 12.6 vs. 34.3 ± 8.6 a patient (p = 0.84), and average hospital stay was 13.9 ± 10.6 vs. 12.0 ± 4.0 days (p = 0.30). As for the complication, in the Stage IA group, wound infection occurred in 3 patients, intra-abdominal abscess in 2, post-operative bleeding in 1, and delayed gastric emptying in 3, while in the Stage IB group, intra-abdominal abscess occurred only in one patient. There was no pancreatic fistula in either group. There was no statistical difference between these two groups. All these complications improved by conservative management. Conclusion: Laparoscopic distal gastrectomy with D2 lymphadenectomy for Stage IB gastric cancer patients can be safely conducted.

Northwick park and St. Mark’s Hospitals, London, United Kingdom Aims: We would like to present a video showing the technique of laparoscopic duodenojejunostomy performed in a patient suffering from Superior Mesenteric Artery (SMA) Syndrome. Methods: A 23 year-old woman was referred to our unit because of 8 months history of postprandial epigastric pain, vomiting and weight loss. Physical examination was unremarkable. Oesophago-gastro-duodenoscopy (OGD) showed bile content in a dilated stomach and proximal duodenum without mucosal abnormality. Gastric emptying study was performed showing gastroparesis and distended proximal duodenum, demonstrating the typical impression of SMA on the third part of the duodenum. Magnetic resonance imaging (MRI) could not demonstrate compression of SMA on the duodenum. Results: In views of the lack of response to prokinetics and after discussion on the upper gastrointestinal multidisciplinary team (MDT) a laparoscopic duodenojejunostomy was decided. The patient was placed supine, in a 30° head-up position. Pneumoperitoneum was established through umbilical Hasson port and a 30° telescope was used. A 5 mm and 10 mm ports were inserted at the right and left flanks at the height of the umbilicus together with another 5 mm at the left upper quadrant. The transverse colon was lifted-up and the dilated second and third part of the duodenum was identified and dissected with endoscissors. Once this was fully mobilized, the first loop of jejunum was brought up and the posterior layer of the anastomosis was done using a 3-0 barbed suture and completed with a 65 mm endostapler. Postoperatively, water-soluble contrast meal showed a good passage of the contrast through anastomosis. The patient’s symptoms have improved and she has gained weight. Conclusion: SMA Syndrome is a rare condition in which the surgical management has a main role, even more in a long-term history of symptoms. Duodenojejunostomy is the most frequently used and it is occasionally successful; this can be done laparoscopically in experienced surgeons.



Laparoscopic Dissection of Lymph Node No. 7, 9, and 11p for Advanced Gastric Cancer

Laparoscopic Treatment of Duodenal Diverticulum: A Case-Controlled Series

Y. Ishida, T. Tanaka, K. Kikuchi, S. Furuta, K. Ishikawa, K. Suda, S. Satoh, I. Uyama

G. Tomasch, S. Uranues

Fujita Health University, Toyoake, Japan Laparoscopic D2 lymph node dissection for advanced gastric cancer, especially supra-pancreatic lymphadenectomy, is a very difficult technique. However, the high magnification levels afforded by laparoscopy, which is one of the advantages of laparoscopic surgery, can help surgeons to recognize the correct layers and the proper dissection lines for lymphadenectomy in the oncologic surgeries. This advantage of laparoscopic surgery will facilitate safer and more invasive interventions. In our institution, supra-pancreatic lymphadenectomy for gastric cancer is performed by the medial approach. In this approach, after the left gastric artery is separated with dissecting lymph node no. 7, Toldt’s fascia becomes apparent and some no. 9 lymph nodes are dissected, while maintaining Gerota’s fascia. Meanwhile, along the splenic artery no. 11p lymph nodes are dissected toward the back of the pancreas to the splenic vein. To ensure perfect dissection of no. 9 lymph nodes, Gerota’s fascia is broken around the celiac artery, to reveal the lymph flow from no. 9 to no. 16. During dissection of the left side of the suprapancreatic lymph nodes, it is very important that the assistant gently turns the pancreas down with gauze or by grasping the nerve around the artery. This approach has been used to perform lymphadenectomy of lymph nodes 7, 9, and 11p for advanced gastric cancer.

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Medical University Graz, Graz, Austria Background: Duodenal diverticulum (DD) is a rare mucosal sac-like anomaly usually found in the second portion of the duodenum. It is generally asymptomatic but the patients can develop postprandial abdominal pain, pancreatitis or gastrointestinal (GI) hemorrhage. Diagnosis is made by upper GI series, CT or endoscopy. Bleeding or upper abdominal discomfort normally call for surgery. Aims: This video shows the most important steps of the operation, with technical hints for successful laparoscopic resection. Material and Methods: This case-controlled series includes 5 patients, all male, who underwent surgery from 2008 to 2013. The main symptoms were recurrent abdominal pain or upper GI bleeding. After preoperative endoscopy and a contrast study, the patients underwent elective laparoscopic surgery. Results: No patient required conversion to open surgery. The video shows the procedure step by step with important suggestions for handling problems that may occur with the laparoscopic approach. Intraoperative endoscopy excluded leakage and proved successful resection. Three months after surgery, the patients were re-examined with follow-up endoscopy and a contrast study. Conclusions: Laparoscopy is a safe and effective procedure with excellent cosmesis that offers patients all the benefits of minimally invasive surgery.

Surg Endosc



Total Inverse Transgastric Resection with Transoral Specimen Removal

Technical Aspects of Laparoscopic Total Gastrectomies with D2 Lymph Node Dissection in Patients with Gastric Cancer

S.H. Lamm1, R. Stoll1, G.R. Linke2, A. Zerz1, D.C. Steinemann1

A. Karachun, Y.u.V. Pelipas, D.V. Gladyshev, E. Voschinin, P.A. Sapronov, A. Petrov

1

Bruderholz/Kantonsspital Baselland, Bruderholz, Switzerland; Department of General, Visceral and Transplantation Surgery, University Hospital, Heidelberg, Germany

2

Scientific-Research Institute of Oncology named after Professor Petrov N.N., Saint-Petersburg, Russia

Background: Laparoscopic local excision is accepted for gastrointestinal stromal tumors (GIST) and benign lesions of the stomach. Yet, tumors at the gastroesophageal junction, on the posterior wall, or in the distal antrum are difficult to approach. Such tumors often must be exposed via gastrotomy or using a rendezvous maneuver. We describe a novel method for total intragastric laparoscopic resection using ‘pneumogastrum’, a rigid laparoscope and conventional laparoscopic instruments. Methods: Two cases of total inverse transgastric resection involved resection of a submucosal gastrointestinal stromal tumor (GIST), one at the front wall of the cardia, and the other on the posterior wall of the antrum. The third case required excision of a large prepyloric cystic lesion leading to a gastric outlet stenosis. After insertion of three to five 5- to 12-mm trocars under laparoscopic control, a 12-mm Versastep TM trocar was introduced into the stomach and ‘pneumogastrum’ was established. Two additional 5-mm trocars were intragastrically placed. Intragastric endoscopy with a rigid 5-mm optic provided an excellent view. The tumor was exposed resected with a linear stapler. The specimen was inserted into a Endo Pouch TM which was sutured to an orally inserted gastric tube. The Endo Pouch TM was gently pulled transorally. After removal of the intragastric trocars the entrance points were laparoscopically closed. Results: From the first and second cases, we retrieved GIST tumors (pT2). In the third case, we retrieved a gastritis cystica profunda. Postoperative course was uneventful. Conclusions: Total intragastric resection of submucosal lesions using a pneumogastrum enables the use of optimal rigid instruments, including endo staplers and laparoscopic suturing. The use of a rigid laparoscopic endoscope instead of a gastroscope optimizes exposure. The possibility of transoral specimen removal makes the procedure a full laparoscopic operation. In cases with bulky specimens, the specimen could alternatively be removed through a 12-mm trocar or by enlarging the trocar entrance site. Lesions in the fundus and back-wall cardia, which are difficult to reach by gastroscope, become accessible.

Laparoscopic total and subtotal gastrectomies are gaining popularity nowadays. We report about some technical aspects of how these surgeries can be performed. Firstly, ligamentum gastrocolica together with the larger omentum is dissected from transverse colon in left to right direction until descending duodenum can be clearly visualized. Right gastroepiploic vein is then clipped and transected next to the place where it conjuncts with inferior pancreaticoduodenal vein forming Henle trunk. After that, gastroduodenal artery is visualized and right gastroepiploic artery is clipped and transected at the place of its origin, safely removing subpyloric lymph nodes (#6). After transecting the duodenum, anterior surface of hepatoduodenal ligament is exposed allowing to dissect 12a group after visualization of a hepatica propria and portal vein. Lymph node dissection is then continued medially along common hepatic artery (#8), coeliac trunk (#9), left gastric artery (#7) and proximal segment of splenic artery (#11p). As the next step we consider the most convenient not to perform the dissection in the direction of 11d and 10 lymph node groups, but to move towards crus of diaphragm and anterior surface of left adrenal gland until the spleen is reached - this allows to form a ‘sail’, which makes dissection of 11d and 10 groups much easier and safer. After clipping left gastroepiploic vessels, gastroepiploic ligament is transsected at the place of splenic hilum. Then, right paracardial lymph nodes (#1) can be reached by extending the dissection in the plane of group #7. Dissection of left paracardial lymph nodes (#2) is performed after transection of gastrosplenic ligament and short gastric arteries. When using DST SeriesTM EEATM OrVilTM for esophagoenteroanastomosis the esophagus is transected proximal to cardia, while in case of side-to-side anastomosis gastrotomy is performed to insert linear stapling device prior esophagus transection. In our experience the latter way is preferable. For the jejunum we use Roux procedure in the majority of cases. The anastomosis is performed intracorporeally with circular or linear staplers. In conclusion, we presume, that the described technique allows to perform safe and adequate lymph node dissection in patients with gastric cancer.



Laparoscopic Partial Gastrectomy in Adult with Intestinal Malrotation

Laparoscopic Treatment of Acutely Perforated Duodenal Ulcer with Primary Closure and Highly Selective Vagotomy

A.V. Sazhin1, A.V. Kolygin2, S.V. Mosin1, A.T. Mirzoyan2

R.C. Broderick, C.R. Harnsberger, G. Gallo, H. Fuchs, M. Berducci, A. Coker, B.J. Sandler, G.R. Jacobsen, S. Horgan

1

2

Russian state medical university, Moscow, Russia; Pirogov Russian National Research Medical University, Moscow, Russia

Introduction: Clinical manifestation of intestinal malrotation in adults is rare. Intestinal malrotation in adults show signs of intestinal obstruction syndrome, chronic upper abdominal pain and gastric ulcer. Intestinal malrotation in this case was difficult recognizable because it was combined with gastric ulcer. The authors present a laparoscopic partial gastrectomy in a patient with intestinal malrotation. This anomaly was revealed during elective laparoscopic partial gastrectomy for recurrent peptic ulcer of the stomach. The video shows the steps of laparoscopic surgery. Trocars were placed as for partial gastrectomy. Visual survey of the abdominal cavity, abnormal position of the internal organs was found, ie: malrotation of stomach, duodenum and intestine and dystopia of pancreas and mesentery above them. The last one compressed the duodenum. Mobilization of the stomach and duodenum. The stomach and duodenum were cut by EndoGIA. Gastrojejunoanastomosis and then cholecystectomy (for related cholecystolithiasis) were performed. Conclusion: Intestinal malrotation can be a rare finding in patients with chronic abdominal pain and stomach ulcer. Laparoscopic gastrectomy in patients with this anomaly is a safe method of treatment.

University of California San Diego, San Diego, United States of America Provided is a case report in the laparoscopic treatment of acutely perforated duodenal ulcer as a result of peptic ulcer disease. The patient is a 53 year old male with acute presentation requiring emergent surgery. Laparoscopy is becoming an increasingly utilized option at major centers for easily located acute perforations; laparoscopic improvements in management include easier dissection of the hiatus and more selective visualization of nerve fibers for highly selective vagotomy. In this case, we prove the feasibility and positive short term outcome for laparoscopic primary duodenal ulcer repair followed by posterior vagotomy, highly selective vagotomy, and omental patch.

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V040 - Video - Abdominal Cavity and Abdominal Wall


Totally Extraperitoneal Inguinal Hernioplasty with Medium Weight Polypropylene Mesh: Our Experience

Laparoscopic Management of Mesh Erosion into Small Bowel and Urinary Bladder Following Laparoscopic Repair of Left Inguinal Hernia

A. Bhardwaj, S. Kalhan, P. Bhatia, M. Khetan, J. Suviraj, V.K. Bindal, J. Bhat

S. Aggarwal, P. Kokkula, K. Sreesanth, N. Rao, P. Singh

Sir Gangaram Hospital, New Delhi, India

All India Institute of Medical Sciences (AIIMS), New Delhi, India

Aims: Totally extraperitoneal inguinal hernioplasty (TEP) has become the procedure of choice for bilateral, recurrent as well as primary unilateral inguinal hernias, when performed by trained and experienced laparoscopic surgeons. This study was conducted to evaluate the result of medium weight mesh (60 g/m2 polypropylene-OptileneTM Braun) in TEP repair. Methods: A retrospective study of patients who underwent TEP repair using medium weight polypropylene mesh was conducted using patients from a single academic institution between January 2012 and July 2013. Patient’s demographic data, characteristics of the hernia, operative details, and post-operative outcomes were recorded and analyzed. Results: A total of 108 patients who underwent TEP repair using medium weight mesh were evaluated (All men; mean age 49.83 years). Seventy eight (72.22%) patients had unilateral hernia while 30 (27.77%) had bilateral hernias. Seventy (64.81%) patients had indirect sac while 38 (35.18%) had direct defect. Mean operative time was 40 minutes (range 30–65 minutes) for unilateral hernias, 70 minutes (range 65–130 minutes) for bilateral hernias. Out of total 108 patients, twelve patients were operated for recurrent hernias (previous open repair). The average length of stay was 1.2 days (range 1–3 days). VAS scoring were done in post-operative period at 6 hrs, 18 hrs, 24 hrs and at time of discharge. Patients were reevaluated at follow up in OPD at one week, 3 weeks and 6 weeks. Only 3 patients who had large congenital complete hernial sacs developed significant seroma which resolved on conservative management. This was appreciably lower than our previous experience with heavy weight mesh (120 g/m2) where the incidence of post operative long term discomfort was higher as also was the incidence of seroma formation. During follow up of 12 months (range 1–12 months), none of the patients (0%) develop recurrence. Conclusions: TEP repair of inguinal hernias with medium weight mesh results in less post operative pain & decreased seroma formation. These meshes may be the logical choice to decrease the mesh plate fibrosis produced by heavy weight mesh and safer than light weight mesh in terms of recurrence.

Mesh erosion following totally extraperitoneal (TEP) laparoscopic repair of inguinal hernia is uncommon. Most of the reported migrations have occurred into urinary bladder. We report a case of mesh erosion into both small bowel and urinary bladder in a 62-year old man who had undergone TEP 1 -year back in another hospital. The management required small bowel resection and anastomosis which was done totally laparoscopically. The patient presented with recurrent episodes of urinary tract infections and groin pain following TEP done 12 months back. During evaluation, a contrast enhanced computed tomography (CECT) of the patient revealed mesh erosion into wall of urinary bladder. Small bowel loops were adhered to the left lower anterior abdominal wall. Cystoscopy revealed some granulation tissue; however no mesh was visible. The patient was planned for transperitoneal laparoscopic management. A 3-way Foley’s catheter was inserted following induction of general anaesthesia. Four ports were used. Small bowel loops were found adherent to the left lower abdomen and a small bulge was seen in the left lateral wall of the urinary bladder. During adhesiolysis, mesh erosion into a small bowel loop was detected. About 5 cm of mesh had migrated into the bowel. The entire mesh, about 15 cm x 15 cm, could be pulled into abdomen using gentle steady traction using graspers. The affected portion of the ileal loop was resected and anastomosed in a side to side fashion using Echelon 60 stapler (Ethicon Endosurgery Inc) using white cartridges. The common enterotomy was closed using a single continuous layer of 2-0 polydiaxonone PDS). The bladder was filled with about 400 ml of saline and checked for leak which was negative. A 16 French suction drain was placed in pelvis and left paracolic region after thorough irrigation with warm saline. The resected bowel and the mesh were placed in a bag and extracted from 12 mm port. The patient recovered well and was discharged with the urinary catheter on 5th postoperative day. The catheter was removed after 10 days of surgery. The patient is asymptomatic at present. Laparoscopic management of mesh erosion into small bowel following TEP is feasible.



Total Extraperitoneal Procedure the Retropubic Anatomy as We Acknowledge It

Techniques in Laparoscopic TEP Repair of Incarcerated Femoral Hernia

M. Matei, I. Olteanu, B. Martian, R. Bostina

C.H. Tan1, J. Rao2, K.S. Lim2

Bucharest Floreasca Emergency Hospital, Bucharest, Romania

1

Background & Aims: The anatomy of the retropubic space yet defies explicit description in a form agreeable to all. One cannot find consensus yet among a wide variety of anatomic models based on cadaveric dissections or imaging findings (CT, MRI). Methods: This material presents a compilation of TEP surgical videos that best demonstrate the anatomy of the infraumbilical preperitoneal space. We present two technical alternatives of TEP: one anterior (performed in an ‘anterior Retzius’) and a posterior TEP our current approach. During our dissection we try to correctly identify and demonstrate retropubic anatomic elements and structures and discuss their characteristic features: Retzius and Bogros spaces, transversalis fascia (TF), posterior rectus sheath, the spermatic sheath. Also, we are reviewing the most representative anatomic concepts from the recent literature in order to confront the descriptive anatomy with intraoperative findings and estimate the actual practical value of the current models. Conclusions: It seems that written descriptions of the anatomy aren’t enough to merge different anatomic representations attributed for this region in one coherent model. Therefore, maybe the intraoperative video materials that laparoscopic surgery provides and a panel of experts that can agree upon will take over classical textbooks and articles and eventually will come up with a workable unambiguous strategy for this approach. We plead for a simple surgical anatomic model consisting of only those meaningful elements that are recognizable and proved their practical use.

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Khoo Teck Puat Hospital, Singapore; 2Tan Tock Seng Hospital, Singapore

Indication for Surgery: Incarcerated femoral hernia Diagnostic Study: CT abdomen and pelvis Position: Supine Trocar Placement: Sub umbilicus, 2 and 4 fingers breathe below sub umbilicus Summary: Miss A is a 30 year-old-lady who complained of an irreducible left groin lump for 1 week duration. CT abdomen and pelvis showed a femoral hernia containing omentum within the hernia sac. Laparoscopic TEP repair of incarcerated femoral hernia was performed for her. Intraoperatively, the pre peritoneal plane is created and femoral sac is identified. The femoral sac is incised and different techniques of reducing the omentum from the narrow hernia neck is shown in the video. Omentum is reduced into the peritoneal cavity and peritoneal layer approximated. A light weight mesh is chosen and absorbable tacker device used to anchor the mesh in place. Results: Miss A was discharged well on post operative day 1. On clinic follow up at 1 month and 3 months, there was no recurrence. Conclusion: Laparoscopic incarcerated femoral hernia repair via TEP is a feasible and safe procedure with many advantages over open hernia repair. Some techniques will be described in the video Learning Points: Current literature is for incarcerated femoral hernia to be repaired in the open technique. Sometimes diagnostic dilemma of incarcerated inguinal or femoral hernia will result in varying approach to surgery. The advantage of laparoscopic repair is that it uses the same approach with reduction of hernia sac and placement of mesh whether it is inguinal or femoral hernia. Femoral hernia is known to have a narrow neck and a need to incise the hernia neck. Doing under direct vision in laparoscopy avoid potential injury to nearby vessels. This will be described in the video

Surg Endosc



Laparoscopic Treatment of Lumbar Incisional Hernia

Laparoscopic Management of Recurrent and Re-recurrent Ventral Hernias; Patience and Prudence

E. Martıń Martıń, A. Reyhani Calvo, A. Go´mez Portilla, E. Lo´pez de Heredia Armentia, L.A. Magrach Barcenilla, B. Ezurmendia Sinisterra, E. Palacios Bazan, M. Larranãga Zabaleta, A. Etxart Lopetegui HUA -Santiago, Vitoria, Spain Introduction: Lumbar hernias are a relatively rare phenomenon. They occur through the superior lumbar triangle (Grynfeltt-Lesshalft), inferior lumbar triangle (Petit), or can be considered also as diffuse lumbar hernias. Typically they are divided into congenital and acquired, the acquired group is further split into primary or secondary (to trauma, infections, or previous surgery). We present the case of an acquired superior triangle (Grynfeltt) lumbar hernia in a 52 year-old-woman after a previous renal surgery 22 years ago, treated by laparoscopic approach. Case Report: A 52-year-old woman who’s history was notable for hypothyroidism, appendectomy, and lumbotomy due to a renal abscess at the age of 30. The patient was admitted because of right lumbar pain and sensation of mass located in the lumbotomy scar. Computed tomography was performed and a right kidney herniation through Grynfeltt’s triangle was confirmed. Under general anesthesia, the patient was placed in a lateral position, right side up. Insufflation and introduction of three laparoscopic trocars were performed. One 10 mm on the right side of the umbilicus, and two 5 mm endoscopic ports were placed at the middle clavicle line; the third sleeve was introduced between the umbilicus and xiphoid. Adhesions from her previous surgery were dissected; the right kidney was dissected and reduced and the borders of the defect were cleared up. A 10 9 15 cm piece of ComposixÒ mesh was used to occlude the hernia defect, and was fixed to the lumbar abdominal wall by a 5 mm tissue tacker (ProtackÒ). Results: There were no intraoperative or postoperative complications, and she was discharged asymptomatic on her 1st postoperative day. After 1 year follow-up, no recurrence of the hernia has been recorded. Conclusions: The use of laparoscopic techniques to repair lumbar hernias enables the exact location of the anatomic defect, avoiding the need for a wide exploration and dissection of the lumbar region. It presents all the advantages of the laparoscopic approach (less postoperative pain, hospital stay, and wound infection, as well as better cosmetic results). We believe that the laparoscopic approach could be considered as the best method available for repairing lumbar hernias.

S. Wadhera, S. Kalhan, M. Khetan, P. Bhatia, S.J. John Sir Ganga Ram Hospital, New Delhi, India Aims: To reiterate the virtues of patience and prudence during laparoscopic management of recurrent and re-recurrent ventral hernias. Methods: 63 cases of Recurrent and Re-recurrent Ventral Hernias were operated between January 2010 and December 2013. An average of 3 ports (one 12 mm/ 15 mm and two 5 mm) were used for the laparoscopic Intraperitoneal Onlay Mesh (IPOM) approach. Pneumoperitoneum was created with a Veress Needle at the Palmar’s point. Omental and bowel adhesion to the abdominal wall and previously placed meshes were evaluated. Careful adhesiolysis was done with HARMONIC ACETM and blunt dissection. Note was made of previously placed mesh(es) and the defect(s). Peritoneal flaps were raised in all cases of lower abdominal defects till Bilateral Coopers ligaments to prevent bladder injury. The defect(s) were sized in vertical and horizontal aspects using SILK suture for appropriate sizing of the mesh. Mesh was inserted and positioned in a cranio-caudal direction. Mesh was fixed at lower end to B/L Coopers Ligament with tacks and to the anterior abdominal wall with tacks and transfascial sutures. Results: Out of 63 cases, 23 were of recurrent Incisional hernias,15 were re-recurrent hernias and 25 were recurrent ventral hernias. The average size of the defect was 12 cm ± 3 cm. All patients underwent diagnostic laparoscopy. We were able to manage the recurrent hernias entirely laparoscopically in 51 cases (80.9%). 8 cases required limited open conversion with Laparoscopic IPOM mesh placement (12.6%). Open Conversion was required in 4 cases. The most commonly used mesh in Laparoscopic IPOM was PROCEEDTM of size 25 9 20 cm. In the open repair PROLENETM mesh of 30 9 30 cm was mostly used. Conclusions: With gaining experience it is possible to laparoscopically repair recurrent and re-recurrent ventral hernias. Careful and patient adhesiolysis is the key to a successful repair manage. Accurate mapping and sizing of the mesh is imperative. Short video demonstrations highlight our technique for the management of these challenging situations. A low threshold for conversion should be paramount in mind of the operating team.



Laparoscopic Ventral Hernia Repair with the Use of a New Mesh Positioning System

Simultaneous Laparoscopic Adhesiolysis, Bowel Obstruction Liberation and Ventral Hernia Repair in an Older Patient

I.R. Reynvoet, S. van Cauwenberge, T. Feryn, B. Dillemans

J. Hernandez1, R. Nassar1, N. Zundel2

Sint Jan Hospital Bruges, Belgium

1 Hospital Universitario Fundacion Santa Fe de Bogota, Universidad de los Andes, Bogota, Colombia; 2Florida International University, Miami, United States of America

Introduction: Correct intra-abdominal positioning of the mesh in laparoscopic ventral hernia repair can be challenging, especially for large ventral hernias. The mesh should be placed in the middle of the fascial defect with an overlap of at least 3–5 cm. We present the use of a new device to position the mesh during fixation to the abdominal wall. Methods: All patients underwent a laparoscopic ventral hernia repair with the use of the echo PS positioning systemÒ (Davol Inc., C.R. Bard, USA). The lightweight mesh is introduced in the abdominal cavity through one of the trocars. In the middle of the fascial defect the insufflation tube is picked up with an EndoClose needle. By insufflating the balloon, the mesh deploys and can be positioned easily against the abdominal wall and tackered. Results: Between June 2012 and December 2013 36 patients (M/F: 1/1) were operated with a mean age of 60.1 years. Two patients had an epigastric hernia, 34 were incisional hernias. Hernia size ranged from 2.16 cm2 to 510 cm2 (mean 112.02 cm2). Mesh size was adapted to hernia size with a minimum overlap of 3 cm at all edges. In all patients resorbable tacks were used to fix the mesh. The operative time ranged from 40 to 192 minutes (mean 84.94 minutes). In two cases the repair was followed by another procedure, one gastric bypass and one abdominoplasty. The mean hospitalisation time was 3.25 days (range 1–9 days). All patients were seen at the outpatient clinic six weeks postoperatively. No hernia recurrences were seen. Four patients suffered from remarkable pain, while the others were comfortable by that time. Conclusion: The use of a mesh positioning system has satisfying results intraoperatively and in the early postoperative period. This system eliminates the need to use transfascial sutures, reducing the operative time and the risk for nerve damage.

Aims: To present a video where small bowel obstruction (SBO) is corrected and simultaneously a mid-size ventral hernia is repaired using a minimally invasive approach. In adhesive SBO, surgical management is traditionally used only when medical, non-operative treatment has failed. The manipulation of dilated, ischemic bowel loops during SBO is difficult and not free of complications under any approach. On occasions, SBO is accompanied by ventral hernia. A laparoscopic approach is seldom used due to the difficulty in manipulation of bowel. Methods: An 86 years-old female patient presented to emergency with abdominal pain, distension and vomiting following a diarrhoea presented in several occasion before. After medical treatment, surgery was decided due to an unresolved episode of SBO confirmed by a CT scan. Patient consented to a laparoscopic exploration to assess the feasibility of adhesiolysis and ventral hernia repair via minimally invasive surgery. Results: With the patient in supine, ports were placed at both flanks in case the ventral hernia could be repaired. Laparoscopic lysis of thick and chronic adhesions was carried out. All small bowel loops were freed and inspected for strictures or intraoperative lesions. Two places where the adhesions left a distinctive pressure mark and a change in diameter were found. Once the need of bowel resection or the presence of perforations were ruled out, a 20 9 20 cm polyester mesh covered by a layer of cellulose was placed to correct the ventral hernia. The three-hour long procedure was completed uneventfully. After a four-day ileus, the patient resumed oral intake and recovered without complication. She was discharged on the seventh postoperative day. After a two-years follow up, the patient remains free of obstructive symptoms and no ventral hernia is found. Conclusions: Laparoscopic approach of different obstructive pathologies can be practiced with good results. Care and experience in bowel manipulation are fundamental to avoid damages. Simultaneous ventral hernia repair is feasible but only should be carried out if no contamination is present.

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New Technique for Closing the Defect During Laparoscopic Ventral Hernia Repair

Anatomical Landmarks in Nerve-Sparing Laparoscopic Total Mesorectal Excision

S. Morales-Conde1, A. Barranco1, M. Sanchez-Ramirez2, J. Go´mezMenchero3, H. Cadet1, F.J. Padillo1, I. Alarcoń1

M.E. Allaix, A. Arezzo, M. Mistrangelo, M. Morino

University Hospital Virgen del Rocıó, Sevilla, Spain; 2Hospital Universitario Puerta del Mar, Cadiz, Sevilla, Spain; 3Hospital de Rio Tinto, Huelva, Spain

University of Torino, Italy

1

Introduction: Laparoscopic ventral hernia repair (LVHR) is a well-accepted worldwide technique, but there are still points of discussion related to different aspects of the technique, such as the type of fixation, the type of mesh, manoeuvres to avoid the seroma, etc. One of the last discussions arises from the need or not of closing the defect before to place the mesh since this technique could decrease seroma formation and could be related to a better functionality of the abdominal wall. In order to establish the potential advantages of closing the defect described by some authors and to analyze if the pain increase due to this manoeuvres, we have designed a prospective study comparing our historical series of the conventional double crown (DC) technique versus the DC technique with closure of the hernia defect. Method: Analyzing the studies published, we have seen that most authors close the defect by interrupted suture what could be related by an increase of the postoperative pain, since different sutures are tied at the subcutaneous tissue. The first step of our study was to determine the way of closing the defect, trying to avoid these number of transfascial sutures. For this reason, we decided to perform a running intraperitoneal suture with a double-loop PDS/maxon, knotting the end of the suture at the subcutaneous tissue, avoiding the rest of transfascial knots. The two ends of the suture are removed through the abdominal wall with an endocloseÒ using the same entry in the skin and different entry at the fascia. Once the defect is closed, the e-PTFE mesh was placed following our DC technique with one third of the conventional metallic tackers and fibrin glue. The size of the mesh used wad based on the original size of the hernia before to close the defect. Video: We present the video of this new surgical alternative for closing the defect during the DC technique, which might be related to similar postoperative pain of our historical series with a re-approximation of the rectus muscles and a reduction of the rate of seroma.

Aims: Postoperative urinary and sexual dysfunctions resulting from inadvertent damage to splanchnic nerves are recognized complications of rectal resection for cancer. Methods: In this video we illustrate several landmarks that the surgeons must recognize in order to prevent nerve injuries during laparoscopic nerve-sparing total mesorectal excision for extraperitoneal rectal cancer. Results: The first video shows the inferior mesenteric artery (IMA) dissection and ligation. Incision of the sigmoid mesentery starts at its basis at the level of the sacral promontory while the sigmoid colon is hold with a grasper. The opening of a window below the mesosigmoid allows to keep the nerve protected by a protective fascia. Dissection then proceeds up to the origin of the IMA, with preservation of the sympathetic nerves that form the superior hypogastric plexus located at the level of the sacral promontory. The IMA is divided 1 cm from the aorta. The second video shows how a safe dissection at the level of IMA origin can be performed with scissors if adhesions are present. Injury at this point results in incontinence and retrograde ejaculation. In order to minimize the risk of nerve injury, the surgeon performs a sharp dissection with limited use of monopolar and bipolar energy instruments. The third and fourth videos show the posterior dissection of the mesorectum in the avascular holy plane. The landmark at this point is the upper margin of mesorectal fascia that allows to identify and preserve the hypogastric nerves that run laterally down to the pelvis. The preservation of the parietal layer of the pelvic fascia allows to avoid injury to the superior hypogastric plexus and the left and right hypogastric nerves. A damage to the hypogastric plexus determines mixed genitourinary dysfunctions secondary to injury to both sympathetic and parasympathetic fibers. Conclusions: Several anatomical landmarks help minimize the risk of nerve injury during laparoscopic total mesorectal excision for rectal cancer.



Totally Laparoscopic Colectomy with Transvaginal Specimen Extraction: A Technique for Natural Orifice Surgery Combined with Reduced-Port Surgery

Low Anterior Resection of the Rectum with Natural Orifice Specimen Extraction

A. Nishimura, M. Kawahara, Y. Tajima Nagaoka Chuo General Hospital, Nagaoka, Japan Aims: Natural orifice specimen extraction (NOSE) has been developed as a means of decreasing the incidence of surgical wound complications. However, previously reported NOSE have been performed using a conventional multi-port technique. We performed totally laparoscopic colectomy with transvaginal specimen extraction (TVSE) using the reduced port surgery (RPS) technique. We documented this simple and safe technique. Methods: We prospectively collected data on 23 patients who underwent totally laparoscopic colectomy with TVSE for colorectal cancer between October 2010 and June 2013. This procedure was indicated for patients with clinical stage T3 or lower primary tumors. We inserted a multiport access device (GelPOINTÒ advanced access platform; Applied Medical, USA) through a 15 * 20 mm length mini-laparotomy in the navel. Transverse transvaginal posterior colpotomy was then performed. We inserted one of a pair of AlexisÒ Wound Retractor (Applied Medical, USA) rings into the peritoneal cavity through the vagina. The other white ring placed outside of the vagina was then covered with a Free AccessTM to maintain the pneumoperitoneum and insert some ports. In cases of anterior resection, a laparoscope and a 3 mm port for surgeon’s left hand were placed in the GelPOINT. The third port was a 5 mm surgeon’s operating port in the right lower quadrant. In cases of right hemicolectomy, we inserted a laparoscope through the vagina. The surgeon operated through the GelPOINT using single port surgery technique. Lymph node dissection, mobilization and transection of the colon were performed with transvaginal assistance. The specimen was then extracted transvaginally. Double-stapling technique or functional end-to-end anastomosis was performed intracorporeally. After the Alexis had been removed, the vaginal incision was closed transvaginally. Results: We completed transvaginal extraction in all 23 cases. The median operation time was 227 min. One case was complicated by incisional hernia. The median hospital stay was 6 days. Eleven patients required no analgesics after removal of the epidural catheter on postoperative day 1. All patients remained disease-free. Conclusion: Totally laparoscopic colectomy using TVSE with RPS appears to be feasible, safe, and oncologically acceptable for selected cases.

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S.S. Rua, H. Capote, G. Fialho Jose Maria Grande Hospital, Lisbon-Almada, Portugal This is the case of a young woman presenting with a rectal neoplasia at 6 cm from the anal verge. Surgery occurs 8 weeks after radiotherapy and chemotherapy. Following adenectomy, resection of the rectum is performed along with a total mesorectal excision. Surgical specimens are extracted after vaginal opening. Histology reveals ypT3N1aM0 adenocarcinoma well differentiated the patient is on chemotherapy. Conclusion: Natural Orifice Specimen Extraction is interesting to prevent infection of the abdominal wall, adhesions post mini-laparotomy of classical laparoscopy and incisional hernia.

Surg Endosc



Particularities of Colorectal Laparoscopic Approach in Morbidly Obese Patients

Transanal Endoscopic Microsurgery for Giant Circumferential Rectal Adenomas: Tips and Tricks

I. Smeu, I. Priboi, I. Filip, A. Balescu, E. Hutopila, A. Copaescu

A. Arezzo1, S. Arolfo2, M.E. Allaix1, A. Bullano1, M. Morino1

Ponderas Hospital, Bucharest, Romania

1

Department of Surgical Sciences, University of Torino, Italy; University of Torino, Italy

2

Background: Nowadays, the laparoscopic approach tends to cover more and more of the surgical indications for colorectal benign and malign pathology, the major advantage being the decreased abdominal wall trauma. Due to the important morbidity associated with abdominal wall complications after the open approach, the morbidly obese patients can benefit the most from the minimally invasive approach. Objective: This video emphasizes the advantages of laparoscopic approach for colorectal resection in morbidly obese subjects. Methods, Results: The surgical technique is demonstrated in details, commenting on the particular aspects of colorectal laparoscopic approach in morbidly obese patients, highlighting the most difficult steps regarding vascular and lymphatic dissection. Due to the abdominal wall thickness, we discuss the need for a total intraperitoneal laparoscopic anastomosis and minimizing the incision length needed for specimen extraction. We also comment the need for a specialized technique endowment. We present our experience, with 16 morbidly obese patients with colorectal pathology treated by laparoscopic approach. The mean BMI was 47.7 kg/m2 (40–67 kg/m2). The postoperative course was favorable, without major complications and a mean hospital stay of 4 days. Conclusions: Although laparoscopic approach for colorectal pathology in morbidly obese patients demands high surgical skills, the advantages of the minimal invasive technique with the consecutive lower abdominal wall morbidity and quicker recovery recommend it as a viable option for the surgical treatment in this pathology.

Background: Transanal Endoscopic Microsurgery (TEM) was originally conceived for the treatment of large sessile extraperitoneal rectal adenomas. Although considered challenging, step by step it expanded its indications to ‘low risk’ rectal cancers, palliative treatment of advanced invasive cancers and, more recently, transanal total mesorectal excision. Methods: We reviewed our experience of circumferential lesions treated by TEM, to verify the feasibility and safety of the technique, highlighting tips and tricks that might influence the outcome. Results: Ten consecutive patients underwent TEM with TEO equipment for giant circumferential adenomas. While in the first cases a longitudinal incision at twelve hours was performed through the adenomatous tissue in order to reach the proximal margin and continue dissection, in the last cases the cylinder was removed en-bloc tunnelling the perirectal fact till the proximal margin. An end-to-end anastomosis is completed endoscopically. In no case conversion to abdominal resection, nor stoma formation was required. In 2 cases a partial leakage was treated conservatively, in a further case with the aid of Endo-VAC therapy. No infectious complication was reported. In one case the discovery of a pT2 cancer forced to an Abdomino Perineal Resection, in another case of a pT3 cancer, the patient refused further surgery for the high risk due to comorbidities. Neither stool incontinence nor urinary/sexual dysfunction was observed. Four patients required endoscopic balloon dilatation for stenosis. Conclusion: With the expedients described, TEM demonstrated to be a relatively simple and safe technique, with satisfactory post operative outcomes and minor complications.



Laparoscopic Ventral Mesh Rectopexy Using Articulating 3D Laparoscope and Articulating Tissue Sealer

Laparoscopic Splenic Flexure Mobilization for Colorectal Tumor Resection

C. Fu, A. Stevenson

H. Hamada, M. Hatta, H. Ryota, T. Sakaguchi, M. Oishi, H. Mukaide, J. Fukui, T. Ozaki, K. Tokuhara, T. Michiura, I. Inoue

Royal Brisbane and Women’s Hospital, Brisbane, Australia Aims: Laparoscopic ventral mesh rectopexy (LVMR) is a novel surgical procedure that has gained popularity over the last decade. Indications for LVMR include rectal prolapse, rectal intussusception and symptomatic rectoceles. Some of the challenges associated with this procedure are the limited views and difficulty in manipulation of instruments within the confines of a deep Pouch of Douglas. Laparoscopic suturing is a key component of this procedure which is also often time consuming and technically demanding. The 3D laparoscope is a new breakthrough in surgical optics that provides high definition laparoscopic images with depth perception. In this video, we demonstrate the use of the articulating 3D laparoscope as well as an articulating energy device in LVMR for full thickness rectal prolapse. Methods and Results: A standard four port technique was employed. A 3D laparoscope with an articulating tip provided excellent visualisation of the deep pelvis. Anterior rectal mobilization and excision of the redundant peritoneum overlying the Pouch of Douglas was performed using an articulating energy device (ENSEALÒ G2 Articulating Tissue Sealer). This device provided greater manoeuvrability for dissection in the deep pelvis. Biological mesh was used for the rectopexy and fixation to the sacral promontory. Laparoscopic suturing during mesh fixation and peritoneal closure was aided greatly by the depth perception of the 3D views provided by the laparoscope. Conclusion: Articulating instruments and enhanced surgical optics can contribute to the success of laparoscopic ventral mesh rectopexy.

Kansai Medical University, Osaka, Japan As laparoscopic splenic flexure mobilization (LSFM) for colorectal tumor resection is a technically difficult and risky procedure, a more effective approach of this procedure should be developed to decrease operation time and improve surgical safety. We report our novel surgical technique of LFSM. Most of the reported technique of LSFM is retroperitoneal dissection continued over Gerota’s fascia and behind the pancreas. In this procedure, injury of the adjacent organs may be induced. On the other hand, the fusion fascia above IMA is not fused tightly, dissection plane can be detected in this fusion fascia over the parietal peritoneum. Selecting this dissection plane, we can minimize the risk of injury of adjacent organs. Technique: First, the surgeon stands on the right side of the patient and incises the gastrocolic ligament as close to the splenic flexure as possible, incises the posterior wall of the mesogastrium just below the pancreas, and then reaches the fusion fascia between the transverse mesocolon and posterior surface of the mesogastrium. Further dissection of the fusion fascia reveal the proximal end of the mesocolon of the splenic flexure is based on the IMV. If required, using the medial approach at the ventral side of the inferior mesenteric vein, avascular plane between the parietal peritoneum and descending mesocolon is entered easily and then penetrated to the lateral edge of the fusion fascia. With this procedure dissection plane is over the peritoneal plane and is not migrated under the pancreas. Results: From December 2010 to December 2013, we performed our technique of LFSM for colectomy in 21 cases. Male female ratio was13 to 8. All but one were colon cancer patients. 8 cases were transverse colon, 11 cases were descending colon and one case was lower rectum. Another one case was diverticulitis of sigmoid colon. Mean blood loss was 32 ml. No case encountered intra-operative accident. No case was converted to open surgery. Postoperative course of every patient was uneventful and mean hospital stay was 9.8 days. Conclusion: Selecting adequate dissection plane enable us to perform LFSM safely avoiding injury of the adjacent organs.

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Single-Incision Laparoscopic Anterior Resection Using New Stapler

Appendicular Mucocele: Should It be Treated by Laparoscopy?

I. Ito, H. Nagata, N. Nakao, N. Ohashi, T. Nonami Aichi Medical University, Nagakute, Japan

E. Tarcoveanu1, N. Danila1, N. Vlad1, A. Vasilescu1, G. Dimofte1, F. Crumpei2, R. Moldovanu3 1

University of Medicine and Pharmacy Iasi, Romania; St. Spiridon,,Hospital, Iasi, Romania; 3Hopital Les Bonnettes, Arras, France; University of Medicine and Pharmacy Iasi, Romania 2

Single-incision laparoscopic surgery (SILS) started several years ago. The SILS procedure involved widespread cholecystectomy, appendectomy and oophorectomy for a few years. Some specialists performed single-incision laparoscopic colectomy, but it was not common. Especially, single-incision laparoscopic anterior resection (SILAR) was performed very rarely, because there were few good instruments to dissect the rectum. Approach from the umbilical wound make it difficult to dissect the rectum, even using a bendable stapler. With an approach from the navel, the stapler became parallel with the rectum. To resolve this difficulty, we made an additional port. Recently, the Endo GIATM Radial Reload with Tri-StapleTM technology (Covidien) was placed on the market. This instrument made it easier to perform SILAP, giving natural to access to the rectum and ease if cutting. We performed this procedure using only a 3 cm incision. EZ Access Oval type for single port surgery (Hakko, Japan) is the platform to perform the SILS. The oval shape make insertion of the Radial Reload easy into the abdominal cavity. In this presentation, we show a video on how to perform this SILAP procedure and use the Endo GIATM Radial Reload with Tri-StapleTM technology.

Background: Appendicular mucocele (AM) represents a dilatation of the appendiceal lumen as a result of mucus accumulation that may be related to various neoplastic and non-neoplastic processes. Most of AM are discovered incidentally. Treatment consists in complete resection avoiding rupture in the peritoneal cavity which can induce a catastrophic complication such as ‘pseudomyxoma peritonei’ (PMP). Therefore, the laparoscopic approach is controversial. Material and Methods: We present a series of 8 cases of AM operated by laparoscopic or open approach. Results: The men to women ratio was 6 to 2. The median age was 59 years old (range 36–79). The diagnosis was done preoperatively in 2 cases (25%), intraoperatively in 4 cases (50%) and postoperatively on pathological exam in the other 2 cases (25%). The laparoscopic appendectomy was performed in 4 cases (one conversion). Cecal resection was associated in two cases. A right colectomy was performed in one case in which the histological exam revealed a mucinous cystadenocarcinoma. In all the other cases the pathological exam diagnosed mucinous cystadenoma. The postoperative was uneventful. All the patients are doing well and disease free at 2 to 5 years follow-up. Conclusions: In our opinion the AM is not a contra-indication for laparoscopic surgery. Appropriate precautionary measures have to be taken to avoid AM rupture in the peritoneal cavity.


V060 - Video - Emergency Surgery

Use of an Inguinal Sac for Specimen Extraction in Laparoscopic Anterior Resection

Laparoscopic Excision of Mesenteric Cyst

T.S. Longworth, N. Naguib, P.K. Dhruva Rao, M. Abedeldayem, P. Shah, A.G. Masoud Prince Charles Hospital, Cheltenham, United Kingdom Mesh infection is a known risk when combining laparoscopic anterior resection and laparoscopic hernia repair. To reduce infection and avoid a second anaesthetic, specimen delivery via the inguinal hernia sac and a suture repair may be considered. We present a 79 year old male patient with 2 flat sigmoid polyps and a Left sided inguinal hernia. Both polyps were tattooed prior to the operation. Methods: The operation begins by forming pneumoperitoneum and identification of anatomy. Unfortunately the preoperative tattoo was not visible on the serosal surface. Medial mobilisation of the rectum was performed with identification of both ureter’. The IMA was divided between hemolock clips. Upper rectum and sigmoid colon were mobilised. The upper rectum was divided using endostaplers. A 5 cm incision was made over the left inguinal region and the hernia sac and cord were dissected. The sac was opened. A wound protector was inserted via the deep ring for specimen extraction. On palpation of the specimen only one polyp was identified and so pneumoperitoneum was reestablished, by covering the wound protector with a size 6 glove. Rigid sigmoidoscopy was then performed to identify the remaining polyp. This was facilitated by decreasing the intensity of the laparoscopic light to allow the level of distal polyp to be noted. A grasper was used to mark the position of the polyp and the rectum was further mobilised and divided distal to the polyp with a subtotal mesorectal excision. The lower rectum was divided with flexible endostaplers and a cross stapled anastomosis was performed. Air insufflations showed no air leak. The hernia was repaired using sutures. Results: The Histology of the excised lesion showed sigmoid diverticular disease and low grade dysplastic polyps. The groin wound and laparoscopic wound healed well with no evidence of infection or recurrence of hernia. Conclusion: The Inguinal canal can be used safely for specimen extraction in selected cases in laparoscopic colorectal surgery. Extra care is required when tattooing small lesions and modification of technique may be required if tattoo is not visible.

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A. Abdelaal Hmc. Doha, Qatar 28 years old Syrian female known to be healthy presented to emergency with complaint of abdominal pain. Her pain located in left upper quadrant area radiated to epigastric area, increased by movement from side to side and decreased by laying down. The symptoms not associate with nausea or vomiting or any change in bowel habits. No history of fever, chills or night sweats. No History of jaundice or previous pain like this. She had history of spontaneous abortion 2 weeks before her presentation with bicornuate uterus anomaly. The review of the rest of her systems was normal. Vital signs upon admission were within normal range. Laboratory studies showed mild elevation in white blood cells (12000) with normal liver function test and normal amylase and lipase. CECT abdomen done in emergency and showed fairly well-circumscribed 4.1 *5 cm, predominantly fat containing structure in the left upper abdomen, in close of proximity to the small bowel loops and mesentery, devoid of calcification, and demonstrating subtle peripheral enhancement and a small layer of dependent debris. The diagnosis based on the previous data was chylous mesenteric cyst. The patient admitted to the hospital and underwent laparoscopic exploration and excision of the mesenteric cyst by blunt dissection of the cyst away from the bowel and aspiration of the content of the cyst that showed to be milky fluid. Laparoscopic excision of the cyst was successfully completed by using ultracision. The histopathology report confirmed the diagnosis of mesenteric cyst. Postoperative course was uneventful and patient discharged to home post operation day 3 and followed later in outpatient clinic with no complications.

Surg Endosc



Thoracoscopic Repair of Perforated Oesophageal Barrett’s Ulcer 1

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A. Navarro , H. Ashrafian , D. Sherman , S. Gould , A. MartıńezIsla1 1

Northwick Park and St. Mark’s Hospitals, London, United Kingdom; Central Middlesex Hospital, London, United Kingdom

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Aims: We would like to present a video showing the thoracoscopic management of a perforated oesophageal Barrett’s ulcer. Methods: A 67 year-old patient institutionalised due to schizophrenia was referred to our unit with one-day history of right chest and abdominal pain with dyspnoea. On examination he was tachypneic, heart rate of 85 bpm and blood pressure of 70/40 mmHg. Abdominal examination was unremarkable. Thoracic auscultation revealed decreased sounds in right chest. Chest X-Ray showed right side hydropneumothorax. After right chest drain insertion and resuscitation computed tomography (CT) scan with oral contrast suggested perforation of the distal third of the oesophagus. Results: The patient was transferred to theatre for surgical intervention. Intraoperative oesophago-gastro-duodenoscopy (OGD) confirmed the oesophageal perforation. On prone position on a Montreal mattress and after intubation with a double-lumen endotracheal tube, two 10 mm trocars were placed in 5th and 7th intercostal space and one 5 mm trocar in 9th intercostal space. A 3 mm Johanne was inserted in the 9th intercostal space medially for assistance. A 3 cm fibrotic perforation was found in the lower oesophagus with an extensive mediastinal contamination and fibrosis. After carefully dissection the limits of the perforation were well defined and closed over a T-tube using interrupted 3-0 vicryl. Two chest drains were left in the pleural cavity. The operation was complemented with a laparoscopic feeding jejunostomy. The patient recovered well and was discharged 40 days after the procedure and after a percutaneous endoscopic gastrostomy (PEG) insertion. The PEG and the T-tube were removed two months and 10 days after the procedure under OGD control; extensive Barrett’s disease was seen and confirmed on histopathology. The patient is currently asymptomatic. Conclusion: Spontaneous oesophageal perforation of a Barrett’s ulcer is a rare condition that is associated with a high morbidity and mortality. It occurs as a result of a missed diagnosis of underlying Barrett’s oesophagus or due to unresponsiveness to medical management. Due to the life-threatening nature of this disease, emergency surgical intervention is indicated. In patients with a poor physiological reserve, a damage control surgery should be considered, and this can be done minimally invasive in experienced hands.

Emergency Laparoscopic Repair of a Strangulated Interstitial Inguinal Hernia. Is It Feasible? J. Go´mez-Menchero, J. Bellido Luque, J.M. Suarez Grau, J. Garcia Moreno, I. Duran Ferreras, R. Moreno Romero, E. Ruiz Lupian˜ez, J.F. Guadalajara Jurado Hospital General Basico de Riotinto, Minas de riotinto. (huelva), Spain Aims: Interstitial inguinal Hernia was described in 1797 as a hernia sac found between the various layers of the abdominal wall, and they are rare (0.07% of all hernias). They often presents as an incarcerated or strangulated hernia and the physical examination in these patients can be very challenging. It is not described in the literature the optimal approach to repair these hernias even in emergency surgery, that is controversial. We present a case of a strangulated interstitial inguinal hernia repaired using a laparoscopic TAPP technique. Case Report: A 65 male affected by abdominal pain and sickness from 24 hours is attended in emergency department. The physical examination showed a right lower quadrant abdominal pain, abdominal distension, and no groin hernia was detected. Abdominal X-Rays showed small bowel distension so a CT was performed and a small bowel volvulus or interstitial hernia was demonstrated between the internal oblique muscle and peritoneum. Methods: A laparoscopic approach was performed using 3 ports (11 mm umbilicus, 5 mm left flank and right) and a loop of small bowel strangulated in the hernia sac was revealed below the abdominal wall layers, on the right inguinal region. Hernia ring section was practised and a 15 cm long of ileus with irreversible ischemic damage was reduced into the abdominal cavity. Inguinal hernia was repaired by a Trans-Abdominal Preperitoneal technique (TAPP) and a Bard 3DMaxTM mesh was placed, fixed by resorbable tackers. Recovery maneuvers using hot fluids were performed unsuccessfully, so damaged intestine was pull out trough the umbilicus surgical port site and an extracorporeal intestinal resection and a mechanical anastomosis was performed. There were not any postoperative complications and it was discharged in 48 hours. Conclusions: Laparoscopic approach can be useful and feasible in the diagnosis and emergency treatment of the complicated groin hernia, more in these cases of atypical hernias, with a shorter hospital stay, a lower complications rate and a higher postoperative comfort compared to conventional surgery.



Laparoscopic Management of an Inguinal Fecal Fistula After Bilateral TAPP Repair

An Uncommon Cause of Hemoperitoneum: A Complication of Celiac Trunk Stenosis

M. Zdichavsky, W. Wichmann, T. Meile, M. Feilitzsch, A. Ko¨nigsrainer

J. Possoz, B. Majerus, J.P. Haxhe

University Hospital Tu¨bingen, Tu¨bingen, Germany Aims: Bowel lesions after TAPP (transabdominal preperitoneal patch plastic) repair are rare, but serious and sometimes life-threatening lesions. Intra-operatively decisions must be made like: to end in a colostomy or primary bowl anastomosis, to remove the mesh of the other side and how to deal with the contaminated inguinal region. We present a colonic lesion with a fecal fistula after bilateral TAPP repair that was managed completely laparoscopically as an emergency operation. Methods: A 58-year old male with symptomatic bilateral inguinal hernias underwent bilateral TAPP repair using a polyester mesh without fixation. The patient was discharged the next day after surgery without complaints. On the fifth post-operative (p.o.) day fever and inguinal pain occurred. An inguinal hematoma was diagnosed and treated conservatively. On the ninth p.o. day fever was 38.2° C and a swelling of the inguinal region appeared. Ultrasound confirmed the small hematoma that was relieved by an inguinal incision where purulent secretion and an infected hematoma were detected. Although only the swelling of the inguinal region with a slight hyperthermia was conspicuous two days later fecal secretion was drained via the inguinal drain. Results: A fecal fistula due to bowel lesion was assumed although no peritonitis appeared. Diagnostic laparoscopy was performed immediately. No fecal peritonitis was detected. The sigmoid colon appeared thickened and inflamed and was adherent to the left inguinal region. After blunt dissection the sigmoid lesion was identified. Fecal material was drained into the inguinal area exclusively. First, decision was made to perform a sigmoid resection with primary anastomosis without an ileostomy using a three-trocar technique. Secondly, polyester meshes were removed from both sides. Inguinal regions were left open whereas the left side as well as the lesser pelvis was drained. Further patient’s course was uneventful. Inguinal incision healed as an uncomplicated secondary wound healing. The patient was discharged on p.o. day 8. Conclusions: Although the sigmoid lesion was detected delayed this severe complication after TAPP repair could be managed minimally invasive without a stoma. Patient’s benefit was a fast recovery; minimal wound incisions and minor wound healing complications. Six months later the patient is without complaints.

Clinique Saint Pierre, Ottignies, Belgium Aims: We present a rare late complication of ruptured aneurysm of pancreaticoduodenal arteries (PDA) secondary to celiac trunk stenosis. Methods: Our patient was a 57 year old woman admitted in the emergency room (ER) with hemoperitoneum. Initial treatment was radiologic embolization and the patient was discharged without the need of surgical exploration. CT Scan examination evoked the presence of a coeliac trunk stenosis due to his arcuate ligament and responsible for PDA aneurysm. 15 days later she presented again in the ER with small bowel obstruction due to internal hernia into a ruptured mesenteric hematoma. Results: We describe the laparoscopic treatment consisting in reduction of the hernia and section of the arcuate ligament. Conclusion: This complication has never been described. We discuss the pathophysiology of this condition and review the current management of celiac trunk stenosis.

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Laparoscopic Emergency Treatment After Bariatric Procedures

Laparoscopic Treatment of Acute Abdomen

A. Franceschi, R. Galleano, A. Langone, M. Bianchi, I. Caristo, U. Cosce, D. Aiello, P. Aonzo, E. Benatti, A. Schirru

A. Langone, A. Franceschi, R. Galleano, M. Bianchi, I. Caristo, D. Aiello, E. Benatti, P. Aonzo, A. Schirru

San Paolo Hospital, Savona, Italy

San Paolo Hospital, Savona, Italy

Aims: To assess the feasibility of laparoscopic treatment in different emergent conditions complicating bariatric procedures. Methods: Four cases are reported. The first deals with a 38 years old morbidly obese women who complained for abdominal pain 9 days after intragastric ballon placement. Free air at abdominal X-ray and clinical conditions lead to emergent laparoscopic exploration. A perigastric peritonitis caused by two longitudinal lacerations of anterior gastric wall was found. Second case refers to a 41 years old woman who developed a sepsis in 2nd postoperative day after gastric by pass for morbid obesity. Relaparoscopy revealed a perisplenic and perigastric peritonitis with a thin passage of contrast at methylene blue test at the top of mechanical gastrojejunal anastomose. Third patient was a 43 years old morbidly obese man who had gastric juice in the abdominal drainage few hours after gastric by pass. Emergent laparoscopy showed a gastric remnant staple line dehiscence. Last patient (man, 49 years) had abdominal hemorrhage occurring few hours after gastric by pass for morbid obesity. At exploration a blood clot and a bleeding at the jejunal staple line was found. Results: All the patients were treated laparoscopically. In the first case, after removal of the ballon through an opening made at the level of the biggest laceration, two mechanical linear sutures were stapled to repair the stomach. Second patient was treated by interrupted suture to close the defect after section of the mesentere to reduce the tension at the leak site. Third patient was treated by performing a double layer suture. Last patient had an abdominal washing with removal of the clot; hemostase was then assured by interrupted suture over the jejunal staple line. Discharge of the four cases was respectively in 4th, 17th, 7th and 7th postoperative day. Conclusion: Laparoscopy proved to be safe and effective in emergency treatment of complications of bariatric procedures.

Aims: Laparoscopy in acute abdomen is commonly utilized as last diagnostic tool in case a complete diagnose at intervention is not achieved. As a treatment option, its efficacy has already been highlighted in a consensus statement by EAES then revised in 2010. In this video authors show some cases taken from their routinely experience in abdominal urgencies, in which laparoscopy helped both diagnose and therapy. Methods: About 2030 patients had been laparoscopically treated in last 15 years for abdominal urgencies. Pneumoperitoneum is usually achieved by open laparoscopy and a Hasson trocar is inserted (Veress needle is used selectively). Trocars are positioned opposite to the site we have to explore. Two monitors at both patients sides are made available in case we need to change the operative field. Contraindication to laparoscopy access are important distention of intestine or expected multiple adhesions. We present 6 cases: first case deals with a 45 years old man with a gastric wall perforation; second patient is a female (60 years) with suspected appendicitis that at exploration had a double bowel perforations by bezoar; third case refers to a man (75 years) with a sigmoid perforation after colonoscopy; fourth and fifth cases deals with the same patient who underwent a laparoscopy for perforated sigmoid diverticula and needed a second look for enteric liquid in the abdominal drainage; last patient is a 77 years old man reoperated for bleeding complicating a laparoscopic sigmoid resection. Results: Our laparoscopic experience in treating abdominal urgencies has an overall conversion rate of 16%. Morbidity rate is 7% and mortality 0.2%. In cases selected for video, we utilized interrupted sutures to close the perforated site in first, second and third patients. The patient with repeated intervention had initially a running suture to close the sigmoid defect and an accurate washing at relaparoscopy. Last patient was explored and washed by laparoscopy and treated endoscopically by positioning a clip. Apart from fourth operation, all the postoperative courses were uneventful. Conclusion: In our experience laparoscopy in acute abdomen is a valid and successful surgical option.


V068 - Video - Gyneacology

Small Bowel Obstruction After Laparoscopic Feeding Jejunostomy Using Barbed Suture

The Concept of Conserving Surgery for Deep Bowel Endometriosis

A. Navarro, H. Ashrafian, S. Bokhari, A. Martıńez-Isla

V. Puchkov1, K. Puchkov2, V. Korennaya1

Northwick Park and St. Mark’s Hospitals, London, United Kingdom

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Aims: We would like to present a video showing the laparoscopic management an of a small bowel obstruction secondary to the use of barbed suture used to perform a laparoscopic feeding jejunostomy. Methods: A 63-year-old woman whose past medical history included right partial maxillectomy and right neck dissection for squamous cell carcinoma of right maxilla. She was admitted to our unit with abdominal pain, vomiting and bowels not opening for 5 days after a Laparoscopic jejunostomy performed seven days before. Barbed suture was used to fix the jejunal loop to the parietal peritoneum. On examination the abdomen was distended without signs of peritonitis. Computed tomography (CT) scan was reported as small bowel obstruction secondary to an internal hernia with a clear transition point. Results: Diagnostic laparoscopy was performed using the same access than the previous surgery: umbilical 10 mm port for the camera, and two 5 mm placed 10 cm above and below the umbilicus. Small bowel was dilated and the barbed suture used was fixed to the mesentery root forming an axis were the small bowel rotated on it producing bowel obstruction as well as an ischaemic impression of an ileal loop. The barbed suture was cut and removed. The small bowel was fully examined and within minutes the ischaemic mark improved and the serosa was reinforced with stitches. The patient was discharged two days after the procedure. Conclusion: Several reports have been published regarding complications of using barbed sutures. When used it is important for the surgeon to have these complications in mind. We recommend burying the distal end to avoid complications.

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Swiss University Clinic, Moscow, Russia; 2Ryazan Medical University, Ryazan, Russia

Deep endometriosis involving the bowel often is treated by segmental bowel resection. The most common method of extraction of the specimen is Pfannenstiel minilaparotomy or extraction through an additional incision on the abdominal wall. Extracting the specimen through the vagina or rectum allows us to refuse from laparotomy, which reduces surgical trauma and leads to a faster recovery in the postoperative period. Objective: To develop the concept of the choice of method of extraction of the resected colon specimen, depending on the location and length of the pathological process. Materials and Methods: From 2007 to 2013 we have performed 338 operations for deep bowel endometriosis. 72 operations were - circular resection of colon. The average age of patients was 35.2 years, body mass index (BMI) from 23.2 kg/m2 to 28.4 kg/m2. Of 72 operations, in 37 (51.4%) cases was found endometriosis lesions of the rectum and in 35 (46.8%) cases - the sigmoid colon. In 18 (25%) cases, in addition to colon resection was done the resection of vaginal wall. Of the 37 cases in 9 (24.4%) the endometriosis lesion located in 8–12 cm from the anus and in 28 (75.6%) cases - in 12–20 cm, below the rectosigmoid junction. Results: 35 patients underwent resection of the sigmoid colon with the extraction of the specimen in the left iliac region. In 28 cases, the extraction in the specimen was done thought the Pfannenstiel incision (the location of endometriosis lesion – 12–20 cm from anus), in 8 cases, we’ve performed sparing resection of the rectum with transvaginal extraction of the specimen and in one case - with transanal extraction of the specimen (the location of endometriosis lesion - 8–12 cm from anus). The time of operation varied from 88 minutes up to 106 minutes. Pathological examination of the specimen showed that the length of resected colon ranged from 5 to 12 cm, while the indentation from endometriosis lesions ranged from 0.6 to 1.8 cm The post operative hospital stay ranged from 3.8 to 4.1 days. Conclusion: Our results shows the possibility of performing such operations using minimally invasive techniques.

Surg Endosc

V069 - Video - Urology


Laparoendoscopic Single Site Plus One Port (LESS POP) Nephroureterectomy

Videolaparoscopic Arteries Ligation in the Treatment of Type II Endoleak After Endovascular Repair of Abdominal Aortic Aneurism

Y. Stanevsky1, A. Tsivian1, M. Tsivian2, S. Benjamin1, A. Sidi1 1 Wolfson Medical Center, Holon, Israel; 2Duke University Medical Center, Durham, United States of America

F. Ceriani, F. Caravati, E. Galfrascoli Multimedica Santa Maria, Castellanza, Italy

Introduction: Nephroureterectomy (NU) and bladder cuff excision is the gold standard treatment for upper urinary tract urothelial cancer. Herein we present a video and report our initial experience with laparoendoscopic single-site plus one port (LESS POP) technique for NU and bladder cuff excision. Patients and Methods: We retrospectively reviewed the records of consecutive patients undergoing LESS POP NU between 2011 and 2013. We described in detail our surgical technique and summarized the outcomes in this initial series. Results: Thirteen patients (9 male, 4 female) aged 55–84 underwent LESS POP NU. There were no conversions to open technique or additions of conventional laparoscopic ports. Median (range) operative time was 217 minutes. Specimens were extracted through the umbilical incision in 5 patients, and through an extension of the lower quadrant port in 8. One patient experienced urine leak followed by umbilical wound dehiscence (Clavien grade 3b complication). Conclusions: In this series, LESS POP NU was feasible with encouraging outcomes. We believe that it is possible to extend the benefits of LESS to patients with upper tract tumors while adhering to strict oncological principles.

Aims: Many reports are in literature about the laparoscopic ligation of the Inferior Mesenteric Artery for the treatment of tipe II endoleaks after EVAR (Endovascular Aneurism Repair). Transcatheter embolization of lumbar and hipogastric arteries is a safe and effective endoleak’s treatment but sometimes is not technically possible. The purpose of this study was to evaluate the possibility of videolaparoscopic treatment of type II endoleaks after abdominal aortic aneurysm endovascular repair in patients not suitable for transcatheter embolization. Methods: In the last 18 months 2 patients with type II endoleak were treated. The first endoleak was supplied by right hypogastric artery and the second by a right lumbar artery, after endovascular repair of infrarenal and iliac aneurysms. Intravascular transfemoral embolization was not possible because of concomitant stump closure of right iliac aneurysm and femoral cross-over. The C.T. study showed the origin of endoleak in one case from the right hypogastric artery end the other case from a right lumbar artery. Open ligation of these arteries was the only established therapy. Videolaparoscopic ligations of hypogastric and lumbar arteries with metal clips were performed; in order to achieve a mini-invasive treatment. Results: Aneurism growth was arrested in both patients, as documented on CT scan (weeks after treatment), with complete exclusion of the sacs and no signs of recurrence endoleaks. No complications occurred and the patients were discharged the day after the procedure. Conclusion: Videolaparoscopic ligation of the arteries supplying the endoleaks may be considered a safe, sure and effective alternative to embolization of hypogastric and lumbar artery, when not technically possible. This technique permit to avoid laparotomic surgery in these patients

V070 - Video - Urology


Laparoscopic Living Donor Nephrectomy 1

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O. Dalpiaz , G. Tomasch , H. Mu¨ller , D. Kniepeiss , K. Pummer , R. Zigeuner4 1

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Medical University of Graz, Austria; Department of Surgery, Graz, Austria; 3Division of Transplantation Surgery of the Department of Surgery, Graz, Austria; 4Department of Urology, Graz, Austria Background: Improvement in technology and endoscopic techniques have contributed to early recovery and increased quality of life. Due to minimal invasive equipment and surgical skills, the laparoscopic approach is expanding the indication also in live kidney donors. Aims: To present a standardized technique of laparoscopic living donor nephrectomy (LLDN) performed at our Department since 2011. Methods: The surgery is performed by a urologist with long-standing laparoscopic expertise and it has been planned in collaboration with the Division of Transplantation Surgery of the Department of Surgery. Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: transperitoneal approach, preparation of the ureter, mobilization of the kidney, vascular approach with preparation of artery and vein, hand-assisted extraction of the kidney through a suprapubic incision. Results: Overall, 21 patients underwent LLDN predominantly females (86%). The mean age of the donors was 52 ± 7 years. The median operative time was 147 ± 26 minutes and warm ischemia time 2 ± 1 minutes. Duration of hospital stay was 4 ± 1 days with a quick return to activity. One donor (5%) developed an umbilical hernia and underwent surgical repair 5 month postoperatively. No other clinically significant intra- or postoperative complications occurred. Conclusion: LLDN is a safe procedure with minimal morbidity and it has completely replaced open live donor nephrectomy at our Departments. The performing surgeon should have advanced laparoscopic experience in order to best serve the donor and the recipient.

Spleen Preserving Laparoscopic Resection of Splenic Artery Aneurysm F. Stipa, A. Burza, E. Soricelli, F.M. Reedy, P. Paolantoni San Giovanni Addolorata Hospital, Rome, Italy Purpose: The splenic artery is the most common visceral artery to become aneurysmal. Indications for the treatment of splenic artery aneurysms include symptomatic and/or enlarging aneurysms, aneurysms larger than 1.5 cm and aneurysms in women who are pregnant or of childbearing age. The treatment is not well standardized and could consist of radiological embolization or resection with or without splenectomy via either a laparotomy or laparoscopy. Methods: The video shows a laparoscopic resection of a splenic artery aneurysm, with preservation of the spleen, in a 48 years old healthy woman. The procedure was performed through an anterior approach. Once the gastroepiploic ligament was divided, the aneurysm was dissected free from the splenic vein. The splenic artery was isolated proximally and distally to the aneurysm and resected with a linear stapler. Post-operative course was uneventful. CT-arteriography performed one week and six months after surgery showed hypoperfusion of the spleen with areas of hypotrophy and regeneneration, with blood flow coming from left gastric and superior mesenteric arteries collateral branches.

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V073 - Video - Spleen


Laparoscopic Splenectomy in Patient with Cirrhosis and Splenomegaly C. Rodriguez-Otero Luppi, E.M. Targarona, C. Balague, J. Bollo, J.L. Pallare´s, M. Trias Hospital de la Santa Creu i Sant Pau, Barcelona, Spain Introduction: The first laparoscopic splenectomy was first described more than 20 years ago, being this technique of a slow but progressive acceptance. Hypersplenism associated to thrombocytopenias in cirrhotic patients could compromiso life quality and also, to limit therapeutic options, such as Interferon treatment. Material and Methods: We present a 48 years old woman with history of parenteral drug abuse, HCV/HIV coinfection, cirrosis (Child-Pugh B). Treatment with Interferon and antiretrovirals therapy must be suspended for severe thrombocytopenia, therefore arises laparoscopic splenectomy as a therapeutic measure. Results: In this video we present the laparoscopic approach of a splenectomy in a cirrhotic patient, with splenomegaly and hypersplenism in order to start interferon and antiretrovirals treatment. Is possible to see the presence of collateral circulation, cirrhotic liver and moderate splenomegaly (Final spleen weight: 735 grams). Conclusions: Laparoscopic access is a safe and affective approach in case of cirrhotic patients to extend therapeutical options of their underlying diseases and also could improve the Child-Pugh score.

V074 - Video - Robotics, Telesurgery and Virtual Reality Does Simulation Curriculum and Animal Model Training Improve Operative Room Performance? - A Prospective Study at GSL Medical College Simulation Laboratory 1

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S. Nayak , G. Bhaskara Rao , J.J. Jackimowicz , G. Kumuda , S. Ganni1 1

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GSL Medical College, Rajahmundry, India; Registered Chamber of Commerce, LSS Foundation, Veldhoven, The Netherlands

Background and Objectives: Training of surgical residents in operating room during Laparoscopic Cholecystectomy poses a great challenge for surgical educators. These challenges can be overcome in a comprehensive training program that includes cognitive, clinical and technical skills education. Distinctive ergonomics, prolonged learning curve, and increased awareness of patient safety, ethical constraint for operating directly on patient made the trainer to seek a safer & structured environment for practice. Material Methods: Eighteen laparoscopic ally inexperienced residents were randomized to either (1) Simbionix mentor training until a predefined expert level of performance was reached or (2) the control group. The training groups were allowed to practice on laparoscopic mentor for 4 to 6 weeks until proficiency in manipulation, peg transfer, diathermy and complete laparoscopic cholecystectomy task was achieved. Their competency in handling instruments, tissue, and use of non-dominant hand was assessed by competency assessment tool (CAT). All 18 residents did laparoscopic cholecystectomy in operating theater in presence of trainer and assessed with global assessment scoring system (GAS). Results: The error in cystic pedicle dissection and gall bladder separation was reduced in comparison with the control group. Hand eye co-ordination, use of diathermy and to identify the Critical View of Safety (CVS) was much superior to the control group. Conclusion: The study shows that simulation based training to a level of proficiency is effective in improving OR performance in terms of identifying CVS, procedural errors and tissue maneuvers. Hence, it is recommended to include simulator-based training in the surgical training curriculum to enhance the quality of laparoscopic surgery and for better postoperative outcomes.

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Gastric Submucosal Tumors Difficult Location. Laparoscopic Management J. Navarro Sanahuja, C. Munõz Tabernero, F. Perez Bote, A. Bargallo´ Garcia, D. Bargallo´ Carulla CMI Diagonal, Esplugues de llobregat Barcelona, Spain The location of gastric submucosal tumors determines the difficulty of the surgical treatment, those located in the greater curvature are very accessible to laparoscopic resolution, the problem appears when located in areas of difficult access or high surgical risk. Introducing the resolution by laparoscopic transgastric access and resection with stapler. Methods: We present the video of 4 cases of gastric submucosal tumors located at the gastroesophageal junction, between 2.5 and 3 cm in maximum diameter studied by endoscopy, EUS with biopsy study. Results: Surgical criteria established practiced in all Laparoscopic resection with success without surgical complications, postoperative follow-up and discharge correctly in 72 h. Conclusions: The treatment of gastric submucosal tumors of difficult location is safe for laparoscopic access, if performed as part of a unit with sufficient laparoscopic experience.

V076 - Video - Oesophageal and Oesophagogastric Junction Disorder ‘Mini-Instruments’ Laparoscopic Enucleation of Horse ShoeShaped Esophageal Leiomyoma C. Rodriguez-Otero Luppi, E.M. Targarona, C. Balague, V. Turrado, M. Trias Hospital de la Santa Creu i Sant Pau, Barcelona, Spain Introduction: Leiomyoma is the most common benign tumor of the esophagus, arising usually in the inner circular muscle layer of the distal esophagus. Middle-aged men are most frequently affected. Most patients remain asymptomatic and the when become symptomatic, the main symptoms usually are dysphagia and epigastric pain, but they are not specific for the disease. Malignization is rare but should not be ignored. Minimally invasive approach of these tumors allows complete extirpation with minimal morbidity and provides excellent results. Material and Methods: We present a 31-years-old woman with no medical history, who underwent a CT scan for other reason (urinary symptoms), finding at the gastroesophageal junction a 3 cm homogeneous, low attenuated mass. Endoscopic ultrasound is performed: showing a 50 mm horse shoe-shaped tumor affecting of the esophageal circumference. For clinical deterioration, mainly dysphagia, elective surgery was decided. Results: In this video is possible to appreciate the laparoscopic enucleation of this horseshoe shaped tumor, which depends from distal esophageal wall, mainly with blunt dissection. The intervention is completed with a Toupet fundoplication. This procedure is performed using an 11 mm umbilical port, a 3 mm and a 5 mm port are used in each upper abdominal quadrant. Postoperative course was uneventful, being discharged at the third postoperative day, with the resolution of the symptoms that motivates the intervention. Conclusions: Minimally invasive laparoscopic resection of distal esophageal benign tumors is technically safe and provides the well-known advantages of laparoscopic access, achieving a quick recovery and a short hospital stay. Some authors recommend performing an ant reflux procedure, in order to protect the area of surgical resection and thus prevent complications due to the weakening of the lower esophageal sphincter, such us reflux symptoms.

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Laparoscopic Resection of Subphrenic Esophageal Diverticulum Complicated by Perforation and Abscess Formation

A Case of Esophageal Achalasia Operated by Reduced Port Laparoscopic Heller-Dor Operation

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

C. Tono1, A. Sasaki2, K. Iseya1, T. Saito1, M. Imazu1, S. Obara1, H. Endo1, G. Wakabayashi2

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

Iwate Prefectural Kamaishi Hospital, Kamaishi-city, Japan; 2Iwate Medical University School of Medicine, Morioka, Japan

1

Background: Subphrenic esophageal diverticulum is a rare disorder that may present with a variety of vague abdominal symptoms. Knowledge of the pitfalls in diagnosis and treatment of subphrenic diverticulum is essential for successful and complete relief of symptoms. We report a successful laparoscopic approach as a minimally invasive solution to a symptomatic subphrenic esophageal diverticulum, complicated by perforation and abscess formation Methods: A 71-year-old female was admitted with complains of indigestion and epigastric pain for few months. Upper GI endoscopy showed a distal esophageal diverticulum close to the gastroesophageal (GE) junction up to 3 cm in diameter, containing pus and food residues with fistula formation at the bottom of the pouch. Endoscope was pass through fistula into the cavity of irregular shape sizes up to 4 9 5 cm with purulent contents. A barium study and CT-scan confirmed a presence of diverticulum, localized in a subphrenic part of esophagus, consisting of two communicating cavities 3 and 5 cm in size. Laparoscopic resection was decided on. With the patient under general anesthesia, laparoscopic access to the peritoneal cavity was obtained by a paraumbilical trocar placement and additional four trocars, placed in similar fashion as for a fundoplication. A liver retractor was used to obtain a good upper abdominal view. The lesion was founded located at GE junction in dense adhesions with left liver lobe, anterior gastric wall and abdominal wall. After mobilization of lesion with ultrasound scissors, it has been found that it comes from the bottom of the diverticulum pouch and the neck of diverticulum located 2 cm above the GE junction. The diverticulum was resected at the neck with the EndoGIA Universal liner stapler (2 green cartridges) with subsequent removal of the specimen in container through the port incision. Results: Operating time was 165 min. The drain tube was removed on the 2nd postoperative day; Recovery was uneventful and patient was discharged on the 5th day after surgery. Histology showed a gastric diverticulum with signs of diverticulitis, perforation and abscess cavity formation. Conclusion: If laparoscopic experience is sufficient laparoscopic resection for subphrenic esophageal diverticulum can be recommended as minimally invasive technique.

Patient: 55-year-old man. He had a right-sided chest pain from 9 years ago. And the symptoms of difficulty swallowing, regurgitation, and vomiting also have emerged from a year ago. Upper intestinal endoscopy showed a stenosis of the esophagogastric junction and the residue in the esophagus. He was diagnosed as esophageal achalasia. The esophageal fluoroscopy showed stenosis findings in esophagogastric junction. That was linear type esophageal achalasia. And the diameter of the esophagus could measured the 33 mm so called grade 1. There is a relaxation failure of the lower esophageal sphincter and loss of esophageal peristaltic waves. LES (lower esophageal sphincter) pressure was 40.1 mmHg. So the reduced port laparoscopic Heller-Dor surgery was performed under general anesthesia. Operative Methods: Surgery position was lithotomy position. Surgeon stood between the patient’s legs, first assistant stood patient’s left side, camera assistant stood on the right side. We used the umbilical region port (GelPOINT TM). Insert three 5 mm ports in the umbilical region port. 5 mm scope and two device were used from umbilical region port. And another 5 mm port was used on the left flank for the right-hand of the operator. Retraction of the liver for expansion of the field of view were used hook type retractor (Nathanson flex arm system TM). We used two types of energy device. One was bipolar integrated ultrasonic energy (Thunder beat TM5 mm, 45 cm) and another was hook-type electric cautery. We realized esophagogastric junction with intra esophageal endoscopy on the operation. Thunder beat TM was used for dissection of the esophageal muscle layer for 5 cm, and the hook-type electric cautery dissected oblique muscle layer of stomach for 2 cm from esophago-gastric junction each other. After fundoplication, we made sure the expansion of the junction using endoscope and flowing the air. There was no damage to the mucosa. Operation time was 2 hours 15 min, and bleeding that could be measured was 1 g.



Management of Intraoperative Complications of Laparoscopic Heller Myotomy

Conversion of Nissen Fundoplication to Dor with Re-myotomy in a Patient with Achalasia Previously Treated by Open Surgery

M.E. Allaix, F. Rebecchi, G. Bonnet, M. Morino

A. Navarro, H. Ashrafian, L. Sańchez, A. Martıńez-Isla

Department of Surgical Sciences, Torino, Italy

Northwick Park and St. Mark’s Hospitals, London, United Kingdom

Aims: Laparoscopic Heller myotomy is considered the gold standard for the treatment of esophageal achalasia. Intraoperative mucosal injury is the most feared complication. The aim of this video is to show how intraoperative mucosal perforation can be managed laparoscopically. Methods: Three patients diagnosed with esophageal achalasia underwent laparoscopic Heller myotomy complicated by intraoperative esophageal perforation. Results: In the first case, the esophageal perforation occurred secondary to nasogastric tube insertion. The treatment consisted of retrieval of the nasogastric tube and closure of the mucosal hole with interrupted sutures. In the second case, the perforation of the esophageal wall was detected at the end of the myotomy and was closed with interrupted sutures. An upper endoscopy showed the complete closure of the defect, with no air leak. In the third case, the esophageal perforation was caused by the electrocautery used during the myotomy. The treatment included direct suture and use of glue on the suture. After construction of the partial anterior fundoplication, a drain was placed in the anterior mediastinum. The postoperative upper gastrointestinal series did not show leaks, with regular esophageal emptying of contrast into the stomach. Conclusions: Laparoscopic management of intraoperative esophageal perforation during laparoscopic Heller myotomy is feasible and safe.

Aims: We would like to present a video showing the conversion of a Nissen fundoplication to a Dor with extension of the oesophageal myotomy. It was performed in a patient with dysphagia who had an open myotomy and 360-degree fundoplication through a left subcostal incision 11 years ago for achalasia. Methods: A 28 year-old man who underwent an open oesophageal myotomy and Nissen fundoplication 11 years before for achalasia was referred to our unit for dysphagia and weight loss for a year. Barium swallow showed a holdup of barium at gastro-oesophageal junction with abnormal rat-tail appearance and a dilated proximal oesophagus. Oesophagogastro-duodenoscopy (OGD) confirmed the radiological findings. The patient did not tolerate the manometry. Decision was made to convert the wrap to an anterior 90-degree plus extension of the myotomy Results: In the video we show the surgical technique. The abdomen was accessed using blunt 10 mm trocar in left upper quadrant; 5 mm trocar was placed 10 cm subxiphoid for the camera, 5 mm in right hypochondrium and 5 mm in left flank for assistance. We inserted a Nathanson from the epigastrium for liver retraction. The previous fundoplication was stuck to the left lobe of the liver. After carefully dissection and adhesiolysis with scissors the previous fundoplication was identified and undone. The anterior vagus was identified slung and preserved. Once the oesophagus was mobilized, the previous myotomy was extended. Intraoperative OGD showed no lesion of the mucosa and normal gastro-oesophageal junction (GOJ) with good passage. The procedure was completed with an anterior Dor fundoplication. The patient had uneventful recovery and is currently asymptomatic. Conclusion: The association of an anti-reflux technique after oesophageal myotomy has been discussed and fundoplication is recommended to avoid post-operative reflux and to cover the myotomyzed area and not to treat gastro-oesophageal reflux. Probably the associated Nissen fundoplication gave to our patient his symptoms as the myotomy was widely opened. And Nissen is known to produce dysphagia even in normal patients.

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Thoracoscopic Enucleation of Intramural Esophageal Tumor with Endoscopic Navigation

Techniques of Preservation of Vagus Nerves at the Lower Oesophagus and Cardia During Minimally Invasive Surgery for Functional Oesophageal Diseases

M. Stasek, C. Neoral, R. Aujesky´, R. Vrba, J. Chudaćek, J. Hanuliak, J. Ikarda, M.J. Janı´kova´ University Hospital Olomouc, Olomouc, Czech Republic Aims: In a video presentation we refer a case of intramural esophageal tumor treated by combined thoracoscopic and endoscopic technique. Methods: Video projection of both thoracoscopic operative management and intraoperative endoscopy of a 59 year old man presenting with dysphagia and reflux symptomatology. The diagnostic work-up consisted of endoscopy, CT and EUS with findings of intramural esophageal tumor 26–30 cm from the incisives, 45 mm in width, adjacent to pars membranacea of the trachea. We decided to perform combined thoracoscopic enucleation with endoscopic navigation. Results: The postoperative course was without complications, pacient was dimitted on 3rd postoperative day, during the postoperative course the symptomatology remitted. The histological findings described esophageal leiomyoma. The main discussion topic is the sufficiency of local surgical therapy of intramural esophageal tumors and possible therapeutic approach. Conclusion: Minimally invasive thoracoscopic enucleation with endoscopic navigation is the appropriate therapeutic approach in intramural tumors of the thoracic esophagus. Other techniques (local transmural resection, esophagectomy) have to be considered in case of specific conditions (major tumors, intraoperative damage to the adjacent mucosa).


S. Mattioli1, N. Daddi2, A. Ruffato1 University of Bologna, Italy; 2Division of Thoracic Surgery University of Perugia, Italy

1

Aims: To show in a video the technical passages for the preservation of vagus nerves during benign oesophageal surgery. Methods: 76 consecutive minimally invasive procedures were reviewed. Results: The position of the vagus nerves from the cardiac level where the left vagus becomes anterior to the lesser curvature at the level of the branch of the nerves for the gallbladder is not variable; (2) the left vagus becomes anterior and adherent to the oesophagus between 6 and 9 cm above the apex of the hiatus; (3) vaguses can be visualized; their position is also assessed while passing over the cord with an endodissect device; (4) the safest way to manage the vaguses is to know exactly where they are during each step of the surgery; (5) the dangerous steps of the minimally invasive surgery are: (a) the isolation of the left nerve where it becomes anterior, (b) at the lesser curvature especially when resecting the fat pad or the sac of a II–IV hiatus hernia, (c) when dissecting posteriorly the oesophagus, in case of panmural oesophagitis. The following cases are presented: 1 case of normal ge-junction during GERD surgery, 2 cases of short oesophagus, 2 cases of type III– IV hiatus hernias, 2 Heller-Dor operation for achalasia. 2 cases of redo surgery for recurrent hiatus hernia. Conclusion: The video demonstrates several examples of booby traps for the vagus nerves integrity. When it is essential to mobilize adequately the lower oesophagus, the surgeon must know in every moment where the vagus nerves are, particularly in difficult situations.


Laparoscopic Management of Achalasia Cardia: Our Indian Experience

Laparoscopic Right Hemicolectomy with D3 Lymph Node Dissection and Complete Mesocolic Excision for Stage III Right Colon Cancer

S. Kalhan, A. Bhardwaj, P. Bhatia, M. Khetan, J. Suviraj, V. Bindal, S. Wadhera

I.A. Tulina, P.V. Tsarkov, A.Yu. Kravchenko, S.K. Efetov, D.R. Markaryan, Yu.E. Kitsenko

Sir Ganga Ram Hospital, New Delhi, India

Sechenov First Moscow State Medical University, Moscow, Russia

Aims: Laparoscopic cardiomyotomy has become the procedure of choice for Achalasia Cardia, when performed by trained and experienced laparoscopic surgeons providing satisfactory symptomatic relief. We present our experience of 21 patients and discuss the relevant issues. Method: From January 2010 to March 2013, 21 patients with Achalasia underwent laparoscopic cardiomyotomy (LCM) in a single surgical unit. A diagnosis of Achalasia was made on the basis of clinical symptoms, barium swallow studies, oesophago-gastroscopy and manometry. Our standard technique includes a five-port approach with limited mobilization of the oesophagus to expose its anterior surface without disturbing the posterior attachments, identification and preservation of the anterior vagus, clearance of fat pad at the GEJ, and the cardiomyotomy extending 6 cm on the oesophagus and approximately 2 cm on the stomach across the GEJ. We routinely mobilise short gastric vessels at the fundal area for Dor’s fundoplication to cover the cardiomyotomy and as an anti-reflux procedure. Preoperative endoscopy is done routinely to rule out any mucosal leak. On the postoperative Day 1, all patients undergo a Gastrografin swallow study to rule out any mucosal leak. Patients are discharged on postoperative day 2 with diet chart. Results: 21 patients included 12 males and 9 females; average age was 38.4 years (range 21 to 66). Mean duration of symptoms was 26 months. 14 patients had previous endoscopic oesophageal dilatation. The average operating time was 130 minutes. Mean postoperative hospital stay was 2.4 days. Patients were reevaluated at follow up in OPD at one week, 3 weeks and 6 weeks, 3 months and 6 months. In addition to symptomatic improvement, manometry was performed at 3 months for documentation of effectiveness of procedure. Dysphagia improved in 87% of the patients with nil mortality over a mean follow-up of 14 months. In one patient, small esophageal mucosal perforation detected intra-operatively and closed with interrupted 3-0 vicryl sutures along with Dor’s fundoplication. Patient recovered well with no complications. Conclusions: Laparoscopic cardiomyotomy with Dor’s fundoplication is a safe and effective treatment of Achalasia Cardia.

For this video we present the technique of medial-to-lateral right hemicolectomy for ceacal cancer. The patient is positioned in a modified lithotomy position, the table is turned in Trendelenburg with left side down to move the small intestine to the left upper quadrant. The first 10 mm port for the camera is placed in the paraumbilical region. The first step is identifying the ileocolic pedicle. The peritoneum above terminal ileum is incised. Then an opening is made in the mesoileum and the last iliac branch of superior mesenteric artery is visualized. The peritoneum is incised in cranial direction until finding superior mesenteric vein. The dissection is performed along the lateral border of superior mesenteric vein up to the origin of ileocolic vessels. The latter are divided with bipolar coagulation at the root. The dissection is continued in cranial direction. In case of lacking right colic vessels we move towards middle colic vessels. Middle colic artery usually has two branches - right and left. In right hemicolectomy we need to divide its right branch at the origin. After the colon is devascularized it is essential to find the right plane for mesocolic dissection. The great omentum is divided in halves and the line for transverse colon division is marked. This area is cleaned off and a cutting stapler is applied. After that mesocolic dissection is performed in medial to lateral direction. The ileum is divided the same way. For intracorporeal anastomosis the lumen of both bowel limbs is opened. We use ultrasonic scalpel for less bleeding. The side-to-side anastomosis is performed with endoscopic stapler with blue cartridge. The second stapling is performed across the first line to close bowel openings. To ensure safe healing additional single stitches are applied to close the area of two staple lines intersection. The specimen is removed through Pfannenstiel minilaparotomy.

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Management of Anastomotic Failures in Laparoscopic Colorectal Surgery

Transanal Natural Orifice Specimen Extraction Sigmoidectomy: The Step Before Colorectal Natural Orifices Transluminal Endoscopic Surgery

N. Naguib, T. Longworth, P.K. Dhruva Rao, P. Shah, A.G. Masoud Prince Charles Hospital, Merthyr Tydfil, United Kingdom Introduction: Anastomotic failure is one of the most serious complications of colorectal surgery, and caries significant morbidity and mortality. Many cases of failure occur intraoperatively. We present the laparoscopic management of a series of anastomotic failures that occurred at the time of operation. Method: Case 1: A small rectal defect next to the spike of the circular stapler may be incorporated by manipulating the rectal stump. Case 2: A large central defect in the rectal stump may be managed by single intracorporeal stitching. Ideally, management should be with the one stitch on either side of the defect. Case 3: The cross stapled anastomosis was perforated by a Foley’s catheter at the time of air insufflation test. In cases of major anastomotic failure (cases 2&3), a re-anastomosis should be performed at the lower rectal level. Case 4: A small air leak on air insufflation was managed by a covering loo ileostomy and antegrade wash out with Foley’s catheter placed in the caecum via the distal ileostomy limb. Case 5: A major failure of the low rectal anastomosis. Transanal excision of the lower rectum was performed, followed by a pull through anastomosis. This technique included a 6 cm J pouch, which was brought down under vision using a transanal balloon port. A transanal hand sewn anastomosis was the performed. Results: All patients with intraoperative failure shown in this video had uneventful, normal length recoveries. Conclusion: This series highlight multiple laparoscopic strategies for dealing with anastomotic failures in colorectal surgery.

N. Rama, P. Alves, R. Garcia, O. Andril, V. Faria Centro Hospitalar - Leiria, Portugal Aims: Laparoscopic surgery for colorectal cancer requires an abdominal incision to extract the resected specimen; we emphasize one option that introduce transanal specimen extraction in laparoscopic sigmoid resection, which avoid an abdominal incision. Methods: The group describes a technique for laparoscopic resection of an early-stage sigmoid cancer, previously resected during colonoscopy (R1 resection), in a 43-year-old man followed by transanal specimen delivery, hence avoiding the need of any additional abdominal incisions for retrieving the specimen. After the medial-to-lateral mobilization of the sigmoid colon, followed by the division of the inferior mesenteric vessels, we transected the upper rectum, distal to the tumour. After introducing the anvil, transanally, via an opening in the rectal stump, the proximal colon was transected, the anvil inserted through an opening in the proximal colon, and finally closed with a laparoscopic stapler. The specimen was retrieved transanally, via the opening in the rectal stump, which was also closed with a laparoscopic stapler. The next step was the colorectal anastomosis completed intracorporeally, followed by a negative ‘Jacuzzi test’. Results: Postoperative recovery was uneventful, and the patient discharged on the fifth day. Histology confirmed a pT0pN0 sigmoid cancer. Nowadays, the patient is asymptomatic with a 14 months ‘disease-free period. Conclusions: In order to minimize surgical trauma and postoperative pain, natural orifice specimen extraction techniques have been attempted. This procedure, safe and effective, may be applicable to benign tumours and early colorectal cancer. Therefore, it may be considered a bridge towards Natural Orifice Transluminal Endoscopic Surgery, without scars.



Laparoscopic Total Mesorectal Excision with Transanal Natural Orifice Specimen Extraction

Laparoscopic Low Anterior Resection, Anastomotic Leak, Now What?

P. Alves, N. Rama, R. Garcia, O. Andril, V. Faria

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

Centro Hospitalar - Leiria, Portugal

Texas Endosurgery Institute, San Antonio, United States of America

Aims: Standard laparoscopic surgery for colorectal cancer requires an abdominal incision to extract the resected specimen. Our colorectal group emphasize one option that introduce transanal specimen extraction in laparoscopic total mesorectal excision (TME), as a step before Natural Orifice Transluminal Endoscopic Surgery (NOTES), which try to avoid an abdominal incision. Methods: The group describes a technique for laparoscopic resection of an early-stage lower rectal polyp-cancer, with a previous incomplete (R1) endoscopic resection, in an obese (BMI 37.1 kg/m2), 61-year-old woman followed by transanal specimen delivery, hence avoiding the need for making any additional abdominal incisions for retrieving the specimen. Laparoscopically, after freeing up the sigmoid colon from medial-to-lateral, we took down the splenic flexure and divided the inferior mesenteric vessels. Then, rectum mobilization and TME dissection was done, the upper and lower margins of the tattooed tumor determined and rectum was transected. Next, on the perineal step, the anus was dilated and the specimen was extracted transanally. The anvil of the circular end-to-end anastomosis stapler was placed extra corporally, re-introduced down on the pelvis, followed by a purse string suture in the distal rectal stump; and finally, the head of the circular stapler was passed per anal, and a circular anastomosis was created. Results: Postoperative recovery was uneventful, and the patient discharged on the seventh day. Histology confirmed a rectal carcinoma in situ: intraepithelial neoplasia (pTis pN0).Three months later, the patient keeps asymptomatic and disease-free. Conclusions: This case report seems to show that Natural Orifice Specimen Extraction (NOSE) is safe and feasible to perform laparoscopic TME for benign tumours and early rectal cancer, allowing the retrieval of the specimen without scar on abdominal wall. NOSE appears to be associated with little incisional pain and rapid recovery. We believe in NOSE approach as a stepping stone in the transition to future incisionless NOTES proctectomy.

Background: It is thought that laparoscopic low anterior resection for lower rectal cancer improves quality of life of these patients. However, it is a highly demanding surgical procedure. Despite an increasing surgical experience in high volume hospitals, anastomosis leak still remains a challenge. Anastomosis leakage after laparoscopic low anterior resection with a rate of approximately 10% despite rapid advances still remains a substantial problem. This study describes the treatment options when the anastomosis leak test is positive in Low Anterior Resection. Material and methods: Texas Endosurgery Institute Experience between January 1991 and January 2014, 253 consecutive patients underwent Laparoscopic Low Anterior Resection with Intracorporeal Anastomosis for Rectal cancer. We prospectively collected the leak rate and the treatment of those cases. Results: From January 1991 and January 2014 a total of 253 Laparoscopic Low Anterior Resection with Intracorporeal Anastomosis. In 10 (4%) procedures the anastomotic leak test was positive. In 9 cases the anastomosis was repair with sutures. In one case the anastomosis was redo without diversion. In all cases the anastomotic leak test after repair was negative. Conclusions: The Laparoscopic Low Anterior Resection with intracorporeal anastomosis is a technically difficult procedure, but it greatly improves the quality of life of patients. Texas Endosurgery Institute experience in perform this procedure has had 10 positive anastomotic leak tests, which were adequately repaired without increasing patients morbidity and mortality. The Low Anterior Resection with Intracorporeal anastomosis performed in rectal cancer patients is a safe procedure and performing the anastomosis leak test the surgeon can realize anastomotic leak and repair it in the moment, knowing the treatment options.

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Laparoscopic ‘No-Touch’ Intersphincteric Rectal Resection: Three Step Technique

Laparoscopic Lateral Pelvic Lymph Node Dissection for Lower Rectal Cancer

I.A. Tulina1, P.V. Tsarkov1, A.Yu. Kravchenko1, D.R. Markaryan1, M.I. Bredikhin1, A.O. Tananyan2

H. Bando, M. Kotake, D. Yamamoto Ishikawa Prefectural Central Hospital, Kanazawa, Japan

1

Sechenov First Moscow State Medical University, Moscow, Russia; 2 National Oncology Center, Erevan, Armenia For this video we used a clinical presentation of a low T2N0 rectal adenocarcinoma located 3 cm above dentate line. The operation is performed 7 weeks after chemoradiation. The procedure consists of three major steps. The first step is proximal isolation of tumor by laparoscopic paraaortic lymph node dissection and high ligation of inferior mesenteric artery. The patient is in modified lithotomy position, the table is turned in Trendelenburg with right side down. The first 10 mm port for the camera is placed paraumbilically. Two manipulation 5 mm ports are placed in right lateral and right iliac regions. Another assistant 5 mm port is placed in left lateral region. Paraaortic lymph node dissection with vessels skeletization allows removing of all the lymph nodes at the root of inferior mesenteric artery. So the vessel can be oncologically safely divided at the level of superior rectal artery allowing a longer bowel segment for anastomosis. Inferior mesenteric vein is divided at the same level. As a result the lymphovascular pedicle of specimen is formed. The second step is distal isolation of tumor by perineal dissection. The table is turned horizontally. Lone Star retractor helps better visualize the anal canal and the inferior tumor margin. Circular incision of mucosa is made at dentate line. Ultrasonic scalpel is used to perform intersphincteric dissection. Bowel lumen is closed and the dissection is continued upwards to the level of lower mesorectum. Here 7 cm of the rectum is mobilized from below. After tumor is devascularized from above and isolated from below the third step is performed. This is laparoscopic total mesorectal excision. The patient is returned in original position. Rectum is mobilized in avascular plane circumferentially. Seminal vesicles are carefully drawn anteriorly. On both side walls pelvic plexuses are preserved. Deeper in the pelvis abdominal plane of dissection joins previously performed perineal plane. Ileostomy is created and the specimen is pulled through the anal canal. Because of low ligation of inferior mesenteric artery the splenic flexure mobilization is not needed. The coloanal anastomosis is performed with interrupted sutures. Specimen examination reveals integral mesorectal fascia and 5 mm distal resection margin.

Introduction: The effect of lateral pelvic lymph node dissection for lower rectum has been controversial. But five-year survival rate of lymph node dissection is about 40% in the case of metastatic pelvic lymph node. It is equivalent to hepatectomy for liver metastasis. Our preliminary data of laparoscopic lateral pelvic lymph node dissection (LLPLND) is reported. Material and method: Since the beginning of 2010, we performed 53 cases of laparoscopic pelvic lymph node dissection. The LLPLND was started after anterior resection of rectum. At first the tissue between internal iliac artery and pelvic plexus was dissected. Thereafter the ureter was isolated by tape. The laparoscopic coagulating shears was useful for dissection. The dissection proceeded along common and external iliac artery downward. And the adipose tissue between external and internal was dissected from medial to lateral. It was important to grasp the tissue strictly and keep traction. This made the border between dissected tissue and pelvic wall clear. The obturator artery and vein were resected. When pelvic lateral lymph nodes were diagnosed as metastatic, pelvic plexus and internal vessels were resected. Results: The patients were 30 male and 23 female. Their age was 38 to 83 years (average 62 years). Unilateral dissection took about 60 minutes. And it took 180 minutes by resection with blood vessels. Blood loss was 5 to 450 ml (average 24 ml). Eight patients had lateral lymph node metastases. Three needed self-catheter for neurogenic bladder. But all could terminate it within 2 months. Conclusion: The most serious problem of LLPLND was time-consuming. But this procedure could be performed safely with little blood loss. Permanent neurogenic bladders have never occurred in any patients.


V095 - Video - Different Endoscopic Approaches

Single Site Laparoscopic Excision of Mesocolic Cystic Lymphangioma

Transanal Minimally Invasive Surgery Using Articulating 3D Laparoscope and Gelpoint Path Transanal Access Platform

A. Ronan, M. Moftah

C. Fu, A. Stevenson

Beaumont Hospital, Dublin, Ireland

Royal Brisbane and Women’s Hospital, Brisbane, Australia

Cystic lymphangioma (formerly cystic hygroma) is a benign tumor that is especially rare in the abdomen and retroperitoneum. Experience of their surgical resection when symptomatic is extremely limited with most of the previous reported cases relating to laparotomy and only very recently multiport laparoscopy. Here, we detail a 33 year old female patient (body mass index 23 kg/m2) presenting recently with acute abdominal pain found on imaging to be secondary to a mesocolic cystic lymphangioma that we excised curatively by single port laparoscopy. To perform her operation, we utilized a surgical Glove port (as is our preference for single port access) placed transumbilically via a 3 cm incision. Intraoperatively, standard straight laparoscopic instruments only were used along with Liagsure (Covidien) as an energy sealer/cutter. A complete excisional biopsy was performed preserving the ileocolic artery (and therefore terminal ileum and right colon), duodenum and Gerota’s fascia (see Video). After formalin fixation, the mass measured 60 9 45 9 25 mm. Histological examination revealed the characteristic findings pathognomic of a cystic lymphangioma. Our patient had an uncomplicated convalescence and was discharged home on post-operative day 5. She remains symptom-free now two years later.

Aims: TransAnal Minimally Invasive Surgery (TAMIS) is an increasingly popular technique as it is easy to adopt and provides good quality local excision of benign and earlystage malignant neoplasms in the distal or mid rectum. The 3D laparoscope is a new breakthrough in surgical optics that provides high definition laparoscopic images with depth perception. In this video, we demonstrate the use of the 3D laparoscope as well as our operative techniques in TAMIS for a large villous polyp of the mid rectum. Methods: The patient was positioned in a right lateral position and a transanal access platform (GelPOINT Path, Applied Medical) was introduced into the anal canal. Pneumorectum was established and an articulating 3D high definition laparoscope was introduced through one of the 3 self-retaining ports. Other standard laparoscopic instruments such as graspers, energy devices and needle drivers were used for the TAMIS procedure. We also used a specially designed flat tipped suction-irrigation device to enable hydro-dissection and identification of the plane for submucosal resection of the benign rectal lesion. Results: The transanal access device provides a convenient and stable platform that allows easy access to rectal lesions that are in the mid rectum, which are difficult to reach with conventional transanal instruments. The 3D laparoscope together with its articulating tip also provides excellent visualisation of the lesion within a confined space where manipulation of laparoscopic instruments is limited. Depth perception offered by the 3D images greatly enhances the ease of suturing of the rectal wall defect. Conclusion: Combined with the appropriate instruments, TAMIS is a safe, effective and economical technique that is ideal for local excision of selected rectal lesions.

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The Single Incision Laparoscopic Wedge Resection for Stomach Gist

Laparoscopic Testicular Traction for the Treatment of IntaAbdominal Testis

Y.G. Starkov, E.N. Solodinina, S.V. Dzhantukhanova, M.I. Vyborniy, N.A. Kurushkina

R. Shalaby1, I. Maged2

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

Al-Azhar University, Cairo, Egypt; 2Al-Azhar University Hospital, Cairo, Egypt

Background: Gastrointestinal stromal tumors (GIST) are rare neoplasm with malignant potential, which have determined active surgical tactics requiring complete resection for cure. Laparoscopic access considered reasonable and has been widely accepted as a curative approach. We intent to report the efficacy of single incision laparoscopic resection for the management of stomach GIST. Methods: A 59 year old female presented with upper abdominal discomfort and generalized weakness. Ultrasound and CT scan revealed a 4 9 5 cm mass lesion in epigastrium area, most like coming from stomach. Endoscopic ultrasound confirmed the presence of neoplasm originating from 4th layer of the stomach wall (muscular layer) with mainly extraorganic growth. Echographic pattern corresponds gastrointestinal stromal tumor. Patient underwent laparoscopic wedge resection of stomach through a single incision inside the umbilicus using the Single-Port device (Olympus Quardport). Intraoperatively, tumor with the size up to 5 cm was found located on the lesser curvature of the stomach just above the stomach angle. Laparoscopic ultrasound showed heterogeneous structure of tumor, consisting of multiple nodes and no signs of lymphadenopathy or liver mts. Labeling of tumor margins was carried out with laparoscopic ultrasound. Tumor was mobilized from adhesions using ultrasound scissors with subsequent resection, indenting 1 cm from tumor margin, using endostapler. Resected specimen with the tumor was removed in container through the single incision. Results: Operation time was 150 min. Recovery was uneventful and patient was discharged on the 5th day after surgery. The follow-up abdomen CT and upper GI endoscopy 6 month later showed no pathological changes. Skin incisional scar was without signs of inflammation. Histology and immunohistochemistry confirmed GIST with no requiring of adjuvant therapy. Conclusion: This case shows the feasibility and the superior cosmetic results of single incision laparoscopic resection in selected patients with stomach GIST.

Background: The undescended testes is one of the most common disorders of childhood, affecting 0.8–1.8% of infants at 1 year of age, 3% of full-term newborns. Approximate 20% of these cases represent non-palpable testes [NPT]. In recent years, laparoscopy has been used for localizing and treating the NPT. Several studies have confirmed the higher testicular atrophy rate when testicular vessels are transected during Fawler-Stephen laparoscopic orchiopexy. Gradual testicular traction is a new modality for the treatment of NPT. The study was performed to assess the benefit of gradual traction for the management of intra-abdominal testis with short vessels by lengthening instead of dividing the testicular vessels. Description of the Technique: This study was conducted at Al-Azhar University Hospitals, Cairo, Egypt in the period from 2010 to 2012. A total of 23 cases with abdominal testes were managed by laparoscopic gradual traction after obtaining institutional ethics board and parental consents. The procedure starts by laparoscopic localization of the testis and after assessment indicated short vessel length and inability of the testis to reach the contralateral internal inguinal ring. The posterior parietal peritoneum lateral to the spermatic vessel was incised with scissors and blunt dissection. The testis was attached with a 2/0 Prolene stitch to the opposite side of the lateral abdominal wall without tension. A second stage laparoscopic assisted orchiopexy was done after 3 months. Results: Ages ranged between 1 and 4 years (mean 2.32 ± 1.2 years). Sixteen testes were right-sided and 7 left-sided. In 2 cases slipping of the traction suture occurred and the patient was subjected to retraction. Eighteen cases showed adequate elongation after traction and were successfully positioned in the scrotum. Follow-up was 12–26 months (mean 14.21 ± 1.2 months). On follow-up, 18 testes were found at the base of the scrotum with a normal size and consistency. Five cases were found at the neck of the scrotum and were subjected to second stage orchiopexy. The technique will be seen and discussed with a video presentation.



Reduced Port Laparoscopic Low Anterior Resection; Left Ileostomy Site Approach

Laparoscopic Omental Harvest - A Novel Approach for Bronchopleural Fistula

J.S. Park, S.H. Yun, J.A. Yun, Y.A. Park, H.J. Wook, Y.B. Cho, H.C. Kim, W.Y. Lee

T. Truong, A.M. Rebecca, D.E. Jaroszewski, L.A. Bryant

Samsung Medical Center, Seoul, Korea Single incision laparoscopic low anterior resection may not be suitable to be applied for every rectal cancer patients. It is hard to achieve the total mesorectal excision through single incision. To overcome several limitations, the use of additional port at right low quadrant is more beneficial. The aim of this video is to show the feasibility of reduced port laparoscopic low anterior resection for rectal cancer. The patient was 71-years old male who had an operation of gastrectomy due to perforation of gastric ulcer about 30 years ago. He was underwent neoadjuvant chemoradiotherapy. The cancer was located above 7 cm from anal verge and the clinical stage was cT3N2M0. Under general anesthesia, the patient was placed on surgical table with lithotomy position. 3 cm skin incision was made at left ileostomy site which was marked before surgery. Handmade glove port was placed. Adhesiolysis was performed through single port incision. After adhesiolysis, additional port was inserted at right low quadrant. After that, all the procedure was performed as usual laparoscopic low anterior resection technique. IMA was divided by low ligation manner. Two linear cartilages were used for transection of distal rectum. Anastomosis was made by double stapler technique. A protective loop ileostomy was made through single incision port site at left abdomen. Estimated blood loss was 50 ml and total operation time was 219 minutes. The reduced port low anterior resection for rectal cancer was safe and feasible approach.

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Mayo Clinic Arizona, Phoenix, United States of America Introduction: Pulmonary coccidiomycosis is typically treated with antifungal therapy. However, invasive intervention is sometimes needed and lung resection can result in further difficulties. Bronchopleural fistula remains a highly morbid complication after intrathoracic surgery. Reinforcement of the bronchial stump with well-vascularized tissue has been described and several autologous tissue flaps have provided excellent results. Pedicled omental flaps have been used with good functional but poorly aesthetic results; patient and physician dissatisfaction with the operative methods has widely limited its use. Advances in laparoscopy have allowed surgeons to harvest omentum without the morbidity of a formal laparotomy. We successfully describe three cases of laparoscopic-assisted omental harvest for bronchial stump closure. Methods: A retrospective review of three cases was performed following laparoscopic harvested omental flaps. The characteristics and findings of these cases were analyzed. Results: All three patients presented with a history of coccidiomycosis complicated by lobectomy or pneumonectomy through an open thoracotomy incision, followed by recurrent bronchopleural fistula (BPF). Two patients had a right BPF and one had a left BPF. Each patient also had failed previous pedicled myocutaneous or muscle flaps for attempted closure of the fistula. Due to previous repair failures as well as current overall patient health, the morbidity of an open laparotomy incision was avoided with a minimally invasive approach. Using laparoscopic assistance, an omental flap was then harvested based on either the right or left gastroepiploic pedicle. Once adequate length was achieved and viability confirmed, an appropriate-sized transdiaphragmatic window was created for intrathoracic placement. The flap remained viable in all three cases, and all patients are doing well without complications or recurrence. Conclusions: Laparoscopic-assisted omental harvest with transdiaphragmatic mobilization results in less post-operative pain and potential wound-healing complications. The technique described in these cases is safe and effective. Successful transposition of omentum decreases the physiologic stress of laparotomy while yielding excellent aesthetic and functional outcomes.

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Single Incision Transgastric Access in Intramucosal Tumors 1

2

2

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J. Bellido , B.G. Blas Gomez , A. Bellido Luque , J. Suarez Grau , J. Gomez Menchero1, J. Garcıá Moreno1, I. Duran Ferreras1, J. Guadalajara Jurado1 Riotinto Hospital, Minas de riotinto, Huelva, Spain; 2Quiroń Sagrado Corazoń Hospital, Seville, Spain

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Intragastric polypoid tumors affecting the mucosa and submucosa, are usually resected by gastroscopy except tumors with a size that prevent their endoscopic removal or wide base. In previous years the only option was atypical laparoscopic gastric resection or intragastric laparoscopic access with three trocars in the anterior gastric wall. With the development of single port surgery, management of gastric lesions has acquired a new concept. Once Single port device is placed, an intragastric pneumoperitoneum is performed and resection of tumors is performed through a 1–2 cm single incision in the gastric wall. We present a 65 years old patient, unremarkable history, which is studied by upper gastrointestinal bleeding. The gastroscopy shows a 3 cm wide base polypoid tumor on the subcardial region of the lesser curvature. Due to the location of the lesion, it is impossible the resection by gastroscopy. Echoendoscopy identifier 3 cm size subcardial tumor affecting mucosa, submucosa and muscle layer minimally. Transgastric resection is proposed for single port. 3 cm incision on the left flank is practiced. Once identified the anterior wall of the gastric antrum, it is extracted and a 2 cm incision gastrotomy is practiced. Subsequently Triport single port device (OlympusÒ), which keeps the gastric wall in contact with the abdominal wall. A 10 mm 30° optic is used. Once the tumor is identified, traction stich is placed to elevate it and facilitate resection. The resection is practiced using two EndoGIA 30 white cartridge, which facilitates the mobilization and intragastric resection of the lesion. Its necessary check the tightness of the suture and the absence of involvement of the esophagogastric junction. Subsequently gastrotomy closure is performed with continuous monofilament suture. The minilaparotomy is closed using continuous suture. The postoperative course was uneventful. The pathologic report was informed as a tubulovillous polyp with high-grade dysplasia and tumor free margins. Conclusions: Minimal invasive Single port transgastric surgery is a new approach that provides advantages, facilitating maneuvers of location and intragastric tumors resection through a 2 cm size single incision in the gastric Wall.

Transanal Total Mesorectal Excision with Single Port Laparoscopic Assisted Low Anterior Resection J.S. Park, S.H. Yun, J.A. Yun, Y.A. Park, H.J. Wook, Y.B. Cho, H.C. Kim, W.Y. Lee Samsung Medical Center, Seoul, Korea Transanal total mesorectal excision (TME) is a new approach to perform minimally invasive rectal resection and offers a solution to difficult cases in rectal cancer surgery like an access to the distal rectum in obese male patients with a narrow pelvis. The aim of this video is to show the feasibility of transanal TME for rectal cancer. The patient was 45-years old male. The cancer was located above 5 cm from anal verge and the clinical stage was cT1N0M0. Under general anesthesia, the patient was placed on surgical table with lithotomy position. At first, transanal port is placed. 3.5 cm midline vertical skin incision was made at umbilicus. Hand-made glove port was placed. All the procedure was performed as usual laparoscopic low anterior resection technique. IMA was divided by high ligation manner. Splenic flexure mobilization was done fully. After that, transanal TME was started. Rectal lumen is closed by purse string suture 1 cm distal to the tumor. Circumferential incision is made on the rectal wall 1 cm distal to the purse string suture. Circum-incision is deepend to the level of rectal fascia propria and posterior dissection is performed first. After dissection, the specimen was extracted through anus. And an end-to-end anastomosis was made by circular stapler. Estimated blood loss was 400 ml and total operation time was 261 minutes. Transanal TME for rectal cancer was feasible approach.



Endoscopic Full Thickness Suturing with an Endoscopic Suturing Device on Porcine Sigmoid Colon

Laparoscopic Appendectomy - Securing the Base of the Appendix with Hem-O-Lok Clip and Z-Stitch

P. Halvax, L. Swanstro¨m, M. Diana, S. Perretta, A. Legner, Y.Y. Liu, S. Cho, A. Alzaga, J. Marescaux

B. Cerna, M. Vrany´, D. Sˇimeckova´, M. Man

IRCAD and Image Guided Minimally Invasive Surgical Institute (IHU Strasbourg), Strasbourg, France Introduction: Intraluminal, minimally invasive endoscopic resection for early stage colon lesions are increasingly performed. The risk for perforation in the colorectal tract during endoscopic mucosal resections (EMR) or endoscopic submucosal dissections (ESD) is relatively high and has slowed acceptance of the approach. The incidence for transmural injury ranges from 5 to 14% depending on the operator’s experience, size of the excision and the chosen technique. The aim of this video presentation is to demonstrate the feasibility and optimal technique of full thickness suture repair of colotomies s in a porcine model. Methods: Two 50 kg adult swine were bowel prepped and placed in left lateral decubitus position. To maintain satisfactory sealing and for tissue protection a dedicated overtube was inserted. At 12 cm from the anal verge 3 cm transverse full thickness incisions on the posterior wall was created. Full-thickness depth of the incision was confirmed. The suturing device was mounted on a double channel endoscope, the tag needle was loaded and the suturing was started from the left side and the proximal edge of the incision. For optimal tissue apposition figure of eight stitches were used. The required number of stitches was recorded and the integrity of the closure evaluated by visual assessment. The bowel segment was harvested and the suture line was inspected from the outside. Leak pressure test was performed by using dyed saline and an intravascular cannula measure system. Results: Satisfactory suturing was achieved in both animals. Two sutures were required for each model. Suturing time was 34 and 25 minutes. On air leak tests no perforations were observed. Three out of four stitches were full thickness. In the first case the marker dye appeared in the subserosal layer without definitive leak at 64 mmHg. In the second model the suture line resisted up to 240 mmHg. Conclusion: This preliminary data shows that an on the scope suturing device is able to close a full thickness perforation or incision in the distal colon. The endoluminally placed suture line can be resistant to pressures even beyond physiologic limits. Further confirmation by testing in survival animal models is being planned.

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Hospital Jablonec nad Nisou, Jablonec nad Nisou, Czech Republic Background: Appendicitis is the most common acute surgical condition of the abdomen. Acute appendicitis is typically managed by surgery. Appendectomy may be performed by laparotomy or laparoscopy. The laparoscopic appendectomy is the minimally invasive surgical technique. During the laparoscopic appendectomy, the base of appendix is usually secured by an endoloop ligature, by a stapler or a Hem-o-lok clip. Methods: In this video we will show our experiences in securing the base of appendix by plastic Hem-o-lok clip supplemented with Z-stitch during laparoscopic appendectomy. This technique is very common at General surgery department in Jablonec n/N. Results: We have good experience with this method mainly due to these reasons. Firstly we didn’t have any increase of postoperative complications such as abscess, bleeding, bowel obstruction, etc. Moreover this technique is cheaper than cost for stapler or endoloop. Conclusion: The choice of technique in securing the base of the appendix depends on the course and the conditions of the surgical procedure. Usually in case of gangrenous appendicitis most of the surgeons decide to use stapler. But for catarrhal or phlegmonous appendicitis we often use plastic hem-o-lok clip with Z-stitch.

Surg Endosc



ICG Mediated Fluorescence and Image Enhancement System During Laparoscopic Cholecystectomy

Our Experience of Total Laparoscopic Roux-en-Y Cholangiojejunostomy

L. Giavarini, E.M. Colombo, E. Cassinotti, G. David, G. Borroni, S. Spampatti, V. Quintodei, A. Marzorati, L. Boni

T. Tanaka, D. Gunji, M. Nakauchi, T. Hori, F. Oike, N. Okada

Minimally Invasive Surgery Research Centre, Varese, Italy Aims: Laparoscopic cholecystectomy (LC) is the ‘gold standard’ treatment for cholelitiasis and acute cholecystitis. Nevertheless biliary tract injuries (BTI) incidence after LC is still double in comparison to ‘open’ cholecystectomy. One of the main causes of BTI is misidentification of the bile three anatomy especially in case of abnormality or acute settings; sometime BTI is associated to vascular injury. Intraoperative cholangiography (IOC) is useful to early identification of injuries or anatomical variations but IOC poses various challenges such as safe insertion of a cannula, use of contrast material, radiation exposure as well as many logistic and organizing problems. A novel fluorescent cholangiography technique that involves the preoperative intravenous injection of indocyanine green (ICG) has been recently developed. ICG, once injected intravenously binds with albumin and is quickly excreted with bile. Protein-bound ICG emits fluorescence light with a peak wavelength at around 830 nm when illuminated with near-infrared light and this fluorescence can be detected using a special camera and scope. Using this principles it is possible to identify the biliary anatomy as in standard cholangiography. Methods: We have performed this procedure for all patients undergoing laparoscopic cholecystectomy for symptomatic cholecystolithiasis and acute cholecystitis. ICG (3 ml, 2.5 mg/ml/kg) was injected intravenously 15 min before the operation. The fluorescent imaging system consists of a charge-coupled device camera and a xenon light source that can filter light with wavelengths between 800 and 810 nm; a 10 mm, 30° laparoscope that contains specially lenses that transmit near-infrared light. Results: This video shows our technique for laparoscopic cholecystectomy with bile duct visualisation with indocyanine green fluorescence that was also used to identify the vascular anatomy using an ‘acute’ injection of ICG. Conclusion: Fluorescent cholangiography was successful in all cases with a good visualization of the extra hepatic biliary and vascular anatomy also in case of acute cholecystitis

Mitsubishi Kyoto Hospital, Kyoto, Japan Introduction: Laparoscopic surgery is largely accepted in the world, but total laparoscopic Roux-en-Y cholangiojejunostomy (TLRCJS) is still not a general operative method. According to that we applied total laparoscopic Roux-en-Y reconstruction for gastrectomy, relatively a general method in Japan, to TLRCJS. Case: A 70 year-old female patient presented with recurrent choledocholithiasis and cholangitis. She had been taken EST three times but her symptom got repeated. CT scan showed dilated common bile duct up to 2 cm with almost full of bile stones. Laparoscopic common bile duct exploration and TLRCJS were finally performed. Surgical Technique: The patient was placed in supine position. An operator was on her left side, an assistant was on her right side and a camera assistant was between her legs at first. Trocars were placed in almost same way as other laparoscopic upper GI surgeries, especially as total laparoscopic gastrectomy. A 12 mm camera port was inserted in the umbilicus. Other 12 mm ports were in the right flank area and in the left subcostal area. 5 mm ports were in the right subcostal area and in the left flank area. First of all common bile duct was exposed after adhesion was dissected. Subsequently the anterior wall of common bile duct was cut and bile stones were removed. Jejunum was divided 25 cm distal from Treitz ligament. A jejuno-jejunal anastomosis was made 30 cm distantly from the oral end of long jejunal limb. After that, cholangiojejunal anastomosis was made. Results: She discharged from the hospital 8 days after the surgery without any complication. She does not have any problem at follow-up after 6 months. Conclusions: This method has a lot of same procedures with other laparoscopic upper GI surgeries, especially with total laparoscopic Roux-en-Y reconstruction for gastrectomy. For that reason TLRCJS is not so difficult to performed by surgeons who have an experience of a certain amount of laparoscopic upper GI surgeries.



Laparoscopic Major Hepatectomy for hcc

Pre-operative Image Simulation and Intra-operative Feedback for Avoiding Spatial Disorientation in Pure-Laparoscopic Liver Surgery

M. Shoukry Hafez Al Salam Oncology Center, Cairo, Egypt, Cairo, Egypt Introduction: Laparoscopic hepatectomy is currently increasingly used in specialised centers. It has special importance for cirrhotics who are liable to developed post operative ascites and wound complications. Patients and Methods: We present our technique for laparoscopic hepatectomy for hcc, demonstrating a left hepatectomy. Results: The procedure was completed laparoscopically without conversion, the patient started oral intake the next day, was discharged in four days after removal of drains. The patient received one unit of blood and two units of plasma. Pathology showed negative margins. Conclusion: Laparoscopic major hepatectomy is a safe, oncologicaly sound and reproducible technique that should be only performed in highly specialised centers.

F. Oike, D. Gunji, T. Tanaka, M. Nakauchi, T. Hori, N. Okada Mitsubishi Kyoto Hospital, Kyoto, Japan Introduction: The merit of pure-laparoscopic liver surgery (Pure-Lap) is not only the less invasiveness due to the small incisions. The visual precision by magnification and the controllability of venous bleeding thanks to the abdominal air pressure may open up a new dimension for liver surgery. In Pure-Lap, however, it is difficult to gain a panoramic perspective in the whole surgical field, which might lead spatial disorientation and result in fatal misdirection for parenchymal resection. To make up for this weakness and to secure the safety of this innovative procedure, pre-operative simulation using 3D analysis of CT image and intra-operative feedback can be of invaluable help. Purpose: The video in the case of liver metastasis of sigmoid cancer is displayed in order to illustrate the process of image simulation and feedback for Pure-Lap. Video Case: Three metastatic tumors of 7–8 mm were located close to each other in the segments 4, 5 and 8 and were resected en bloc. Before operation, the cut plains were designed based on the intrahepatic vascular anatomy and the cut points of vascular structure were decided in advance on the 3D-image simulation as described below. A medial branch of G5 Glisson, two V5 branches of middle hepatic vein and a medial branch of G8 vent Glisson are supposed to be divided on the right-side resection line. V8 branch of middle hepatic vein (anterior fissure vein) is exposed and identified on the cranial resection line. The left-side resection line is set from umbilical portion to the bifurcation of middle and left hepatic veins. G4 Glissons are divided from the left hilar plate. During the Pure-Lap procedure, these reference points were identified one by one to validate the proper direction of cut plain. A main unit of pen tablet connected to the computer was placed under a clean sheet and the surgeons reviewed the simulation images by handling a pen in a clean plastic bag. Summary: In order to prevent spatial disorientation in Pure-Lap, definite landmarks for parenchymal resection should be set on vascular anatomy by using 3D simulation images.

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Laparoscopic Liver Surgery Guided by Virtual CT Sonography with Magnetic Navigation System

Laparoscopic 1st Stage Hepatectomy, Right Portal Vein Ligation for Planned 2 Stage Hepatectomy

T. Aoki

A. Chiow, N. O’Rourke

Showa University, Shinagawaku, Tokyo, Japan

Royal Brisbane Womens Hospital, Queensland, Australia

Background: Ultrasound (US) is the most commonly used form of image guidance during liver surgery because it is non-invasive and images can be obtained in real time. However, reliability of laparoscopic intraoperative ultrasonography (IOUS) has been poorly evaluated. The virtual computed tomography (CT) sonography (VCTS) with magnetic navigation system is a technological system that was developed in an attempt to resolve such problem. Aims: The VCTS with magnetic navigation system was applied on patients with hepatic disease who received laparoscopic hepatectomy (LH) to investigate its usefulness and potential. The objective of this work is to access how the target lesion was correlated with the anatomical landmarks in LH. Methods: Eighteen patients who suffer from liver neoplasm were performed LH in Showa University hospital. The preoperative CT volume data was pre-stored into the device and the real-time ultrasound image was displayed simultaneously while the virtual view is reconstructed as a CT-multiplanar reconstruction image from the stored volume data. Just after general anesthesia, the dye was injected into the anatomical landmarks (portal branches) surrounding the liver tumors under the guidance of VCTS (tattooing techniques). During operation, the surgical instrument attached to electromagnetic tracking sensor was used for navigating the direction of accurate liver transection under reference guidance using VCTS. Results: All of patients successfully performed the navigation using VCTS during surgery. Average registration time was \ 2 min. Average set-up time was approximately 7 min per procedure. CT objectivity in real-time sonographic images makes it easy to understand the structure and positional relationship between the tumor lesion and the surrounding vessels. Moreover, this system provided the surgeon the detailed imaging information for diagnosis lacking in conventional B-mode IOUS. Therefore, the landmarks of liver, which stained by tattooing techniques were easily identified and safely transected with VCTS (16/18, 88.8%). Mean blood loss in LH was 65 g. Mean histologic resection margin was 18 mm. Conclusions: Here, we describe LH procedures using VCTS that enables the surgeons to navigate accurate and safe ultrasound-based guidance. We strongly believe that this technology might cause a change of the IOUS examination in LH.

We present a 77 year old man with synchronous low rectal cancer with bilobar liver metastases. Staging imaging with MRI liver/PET CT did not reveal extrahepatic metastases. He underwent neoadjuvant chemoradiotherapy prior to laparoscopic abdominal perineal resection for his low rectal cancer. Liver metastases was bilobar involving segment 3, 4b, 5/6 and 7. He underwent laparoscopic clearance of segment 3, 4b of liver with right portal vein ligation. Intraoperative ultrasound showed no lesions on segment 2, 4a and 1. This video illustrates our technique in laparoscopic left side clearance with portal vein ligation for planned 2 stage hepatectomy. We use a 5 port technique with the site of the port insertion illustrated. We used ligasure combined with copious irrigation to resect parenchyma. Haem-o-lok clips and/or staplers are used for control of larger inflow structures. The importance of identification of bile leak and control is illustrated. Steps for safe R portal vein dissection with ligation is showed with discussion of the pitfalls of this procedure. The patient has subsequently underwent a lap converted to open R hemihepatectomy for completion of liver metastectomy with good recovery. All resections were R0 with clear margins.


V111 - Video - Robotics, Telesurgery and Virtual Reality

Laparoscopic Management of Type III Mirizzi Syndrome S. Kalhan, S. Wadhera, P. Bhatia, M. Khetan

Robotic Right Lobectomy for Living Donor of Liver

Sir Ganga Ram Hospital, New Delhi, India

Y.M. Wu

Aims: To evaluate the feasibility and outcome of Laparoscopic Management for Type III Mirizzi Syndrome. Methods: 29 patients of Mirizzi syndrome were studied between January 2010 and July 2013. Patient were classified according to Csendes classification into Type I (10); Type II (8); Type III (5); Type IV (2); Type V-a (2). Our technique entails pre operative ERCP and stenting. For Type II & Type III Mirizzi’s, we start with taking down the adhesions to the Gall Bladder with a combination of blunt and sharp dissection. After identification of the important landmarks viz; Hartman’s Pouch, Cystic Lymph Node of Lund, Rouvierre’s Sulcus we are able to site the Gall Bladder-Common Bile Duct (CBD) interface. We start dissection with a fundus first-retrograde approach remaining close to the liver margin. We open the Gall bladder around 1 cm from the interface and we extract all the stones in the gall bladder and the CBD. The stent guides us within the CBD. We clear all the stones from the Hepatic Ducts and CBD. The free flow of bile from the Hepatic Ducts confirms the clearance of stones. The stent is repositioned in the mid CBD. The opening is closed with a 0.5–1 cm flap of gall bladder with a Vicryl 2-0 running suture. Patients were followed up for a period of 6 months. None of the patients developed any biliary morbidity. Results: We were able to manage 27 out of 29 cases laparoscopically (93 %). Two cases of Type IV required open conversion and Roux-En-Y Hepaticojejunostomy. Two cases of Type Va (Cholecystoduodenal fistula without gall stone ileus) were also managed laparoscopically. Conclusions: Our technique is quite similar to the open Subtotal cholecystectomy that was described in 1985 by Bornman. We have been able to adapt the principals of open technique to laparoscopic surgery and have been able to manage this vexing and challenging problem. We conclude that Laparoscopic management of Mirizzi syndrome in a high volume and experienced minimal access centre is a feasible option.

National Taiwan University Hospital, Taipei, Taiwan

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Minimal invasive surgery has been evolved rapidly throughout the world during the last decade. Laparoscopic liver resection need higher demand of surgical technique, and got progression slowly in the beginning. But this procedure has been applied widely in recent ten years contributed by the accumulation of preliminary experience and availability of instruments. The feasibility, safety, and potential benefits have been documented by several reports, although the prospective, randomized studies are still pending. Some procedures (lateral segmentectomy, etc) have been recommended to perform regularly by laparoscopic approach in the worldwide consensus meeting. Even some challenging procedures (right lobectomy, living donor harvest, etc) have been performed smoothly by experienced surgeons. We had set up the laparoscopic liver surgery program in NTUH since 2007, and performed 69 cases till the end of 2011, including 48 patients (63%) with liver malignancy and 28 patients with non-malignant liver diseases (37%). Patients in our series with laparoscopic approach for liver resection have the benefits of shorter hospital stay, less postoperative pain and better cosmesis. From 2012, we set up the program of robotic liver resection and performed 92 cases till now. The previous experience of laparoscopic liver resection helps us to get used and handle this high technique system quickly. The consistency and three-dimensional vision of this system have the potential benefits for minimal invasive liver resection in our preliminary experience. These accumulated experience help us to extend the criteria and clinical application of minimal invasive liver resection. We performed three living donor harvest for living-related liver transplantation with robotic assistance, including two right lobes and one left lobe this year. Here we will share some experience and surgical technique in robotic right lobectomy for living donor of liver.

Surg Endosc



Visualization of the Biliary Ducts and Anatomical Segments Using Indocyanine Green-Fluorescence Imaging

Subtotal Gastrectomy in Locally Advanced Gastric Cancer

Y. Kawaguchi1, T. Nomi2, D. Fuks2, N. Kokudo1, B. Gayet2

C. Fiorani1, C. Fiorani2, A. Divizia2, R. Pezzuto2, G. Maggi2, G. Tema2, E. Iaculli2, A.L. Gaspari2, G. Sica2

1 The University of Tokyo, Tokyo, Japan; 2Institut Mutualiste Montsouris, Universite´ Paris Descartes, Paris, France

1 University of Tor Vergata, Rome, Italy; 2Tor Vergata University Hospital, Rome, Italy

Aims: Although laparoscopic hepatectomy has been increasingly performed in the last decades, its disadvantages lacking in hepatic overview and tactile feedback may cause the biliary ducts and anatomical segments to be resected unidentifiable during surgery, resulting in specific postoperative complications. Herein, we demonstrate the performance of laparoscopic hepatectomy under the navigation of indocyanine green (ICG)-fluorescence imaging for more accurate intraoperative detection of the biliary ducts and anatomical segments. Methods: Subjects consisted of 4 patients who underwent laparoscopic right (n = 1) and left (n = 1) hepatectomy and laparoscopic anatomical resection of segment IV (n = 1) and VI (n = 1). For fluorescence cholangiography, 1 mL of ICG (2.5 mg) was intravenously injected after intubation in the operating room. For identification of segments as fluorescence, ICG (0.025 mg in 10 mL of normal saline) was administered into the portal branch with interest. In contrast, for identification of segments as the defect of fluorescence, ICG (2.5 mg in 1 mL of normal saline) was intravenously injected after clamping of the Glissonian pedicle with interest. Results: Among 2 patients who underwent laparoscopic hemi-hepatectomy, fluorescence cholangiography clearly visualized the confluence of the left hepatic duct and the right hepatic duct and guided to ligate the hepatic duct. This technique was also useful to distinguish the biliary ducts from the hepatic vessels in the hepatoduodenal ligament with severe adhesions in one patient who underwent previous portal hepatic lymphadenectomy. In the remaining 2 patients who underwent laparoscopic anatomical resection, segments to be resected were identified using fluorescence imaging. This technique visualized a segment as fluorescence after administration of ICG into the portal branch through a needle after its puncture in one patient, whereas it identified a segment as the defect of fluorescence after intravenous injection of ICG, following temporarily clamping of the Glissonian pedicle with interest in the other patient. Fluorescence imaging was applied to detect the possible bile leak after resection for all patients. Conclusions: Fluorescence imaging techniques enable visualization of the biliary duct and anatomical segments during laparoscopic hepatectomy in real-time. These techniques are expected to complement conventional intraoperative imaging technique, enhancing the safety and efficacy of laparoscopic hepatectomy.

Gastric cancer is the second most common cause of cancer death in the world. It is a difficult disease to cure in Western countries, mainly because most patients present with advanced disease. Surgical resection is the primary treatment, based on open gastric resection and regional lymph node dissection. The minimally invasive approach is currently being adopted for ever more complex procedures in order to improve post-operative outcomes. Laparoscopic surgery may offer some advantages in oncologic patients: less surgical stress, less blood loss and complications, better cellular immunity and cytokine release pattern. We performed a subtotal gastrectomy in locally advanced gastric cancer at fundus.



Laparoscopic Left Hepatectomy for a Large Breast Cancer Metastasis with Left Portal Vein Involvement

Gastrointestinal Reconstruction in a Patient with Intestinal Malrotation

A.V. Ariyarathenam, D. Bunting, S. Aroori

J.R. Torres Bermudez, S. del Valle Ruiz, J.B. Lo´pez Espejo, G. Sańchez de la Villa

Plymouth Hospitals NHS Trust, Plymouth, United Kingdom Aims: Liver resection for Breast cancer metastases is not routinely performed at present in most centres. We present here a case of laparoscopic left hepatectomy for a large breast cancer metastasis with portal vein involvement. Method: We present a case of laparoscopic left hepatectomy for breast cancer metastasis. The patient, aged 52, underwent bilateral mastectomy two years prior to diagnosis of liver metastasis for node negative breast cancer. Follow up Computerized tomography showed a large solitary metastasis in the left hemi liver with left portal vein involvement. Results: At laparoscopy, there was a large solitary liver metastasis involving the left hemiliver with portal vein involvement. A laparoscopic left hepatectomy and cholecystectomy was performed. Left portal vein, hepatic duct and venous outflow were divided intrahepatically with vascular stapler. The specimen was removed through a Pfannenstiel incision. The patient made a good recovery and was discharged home on postoperative day 5. Histology of the resected specimen showed a 120 9 130 9 75 mm moderately differentiated adenocarcinoma consistent with metastatic breast cancer. It was completely excised. Patient is well at 10-month follow up. Conclusion: Left hepatectomy for a bulky breast cancer metastasis with portal vein involvement can be successfully performed laparoscopically with excellent outcome.

Hospital Rafael Meńdez, Lorca, Spain Aims: To show a laparoscopic gastrointestinal reconstruction in a patient with Intestinal malrotation (IM) operated on a distal gastrectomy for adenocarcinoma (ADC). Methods: We report the case of a 53 year old woman presented with a tumoral stenosis at the antrum. The endoscopic biopsy was not conclusive. A laparoscopic distal gastrectomy with a D2 lymphadenectomy was accomplished after confirmation of ADC by a intraoperative biopsy. Incidentally, we found a IIc IM according to Ravitch’s classification. The third part of the duodenum was located anterior to the superior mesenteric artery and the small bowel covered by a right mesocolic bursa. We opened widely the bursa and performed a retrocolic hand-sewn Roux-en-Y gastro-jejunal anastomosis. Results: There were no postoperative complications. Liquid oral intake was resumed on the 2nd postoperative day. Total postoperative stay was 11 days. Histological examination confirmed a stage III (T3N1) diffuse type poorly differentiated ADC. The patient was sent to adjuvant radiochemotherapy. Conclusions: Laparoscopic gastrectomy and lymphadenectomy for early gastric cancer is feasible and safe with satisfactory oncological results. Intestinal Malrotation is a very rare intraoperative diagnosis which could be managed laparoscopically.

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Single Port Duodenojejunostomy for Treatment of Superior Mesenteric Artery Syndrome

Laparoscopic Subtotal Gastrectomy for Advance Gastric Cancer

S. Morales-Conde, J.A. Navas, M. Socas, A. Barranco, M. RubioManzanares, J. Can˜ete, H. Cadet, F.J. Padillo, I. Alarcoń University Hospital Virgen del Rocıó, Sevilla, Spain Aims: Upper gastrointestinal symptoms like abdominal pain and distension and vomiting may be caused by different conditions like complicated peptic/duodenal ulcer, gastritis or hiatal hernia. However, these symptoms are uncommonly produced when there is narrowing of the mesenteric angle and shortening of the aortomesenteric distance. This uncommon medical condition is known as superior mesenteric artery syndrome (SMAS) or Wilkie’s syndrome. Surgical intervention is needed for failed long-term medical management, performing an anastomosis from the duodenum to the jejunum. New technical developments are improving recovery after this surgical procedure as it is shown in this case. Methods: We report the case of a 23-year-old female patient, BMI 19.9 kg/m2, without previous abdominal surgery, presented with abdominal pain and vomiting after meals of long evolution. She refers weight loss in last two months. An upper gastrointestinal series shows gastric and duodenal dilatation at the junction of the duodenum with the superior mesenteric artery, suggesting the diagnosis of SMAS or Wilkie’s syndrome. The suspected diagnosis is confirmed by performing a CT angiography scan. Elective pure transumbilical single port duodenojejunostomy is proposed. Results: The operative time was 70 minutes. There were no intraoperative complications. The single port device was placed transumbilically and no additional trocars were used to assist the procedure. The anastomosis was performed using the endostich with V-loc suture. No intraoperative or postoperative complications occurred. The transumbilical skin incision length was 1.9 cm. Oral tolerance started at 1st day, being discharged on day 2. The longterm follow-up has been uneventful. Conclusions: Single-port approach for SMAS is a feasible and reproducible procedure as in multiple-port laparoscopic surgery. V-loc with endostich makes suturing easier by this approach. This approach could be related to a potential reduce of complications coming from multiple-port trocar sites, better cosmetic results and a potential faster recovery with less discomfort.

A. Delitala, M. Scotti, P. Riva, M. Garancini, A. Giani, E. Bolzonaro, F. Villa, F. Cicchiello, M. Polese, A.D Dilucia, V. Giardini HSGererado, Monza, Italy Laparoscopic Gastrectomy is not still considered in literature the reference standard technique in advance gastric cancer; meanwhile it’s well accepted in Early Gastric Cancer. Our Department of Advanced Laparoscopic Surgery after learning curve of 30 cases of Laparoscopic Gastrectomy has recently standardized the surgical procedure obtaining results those appears oncologically safe ad feasible. Consequently could be considered a valuable alternative to laparotomic approach. We present a case of a 70-year-old man presented with anemia and distal gastric lesion identified during upper endoscopy; mucosal biopsies revealed poorly differentiated adenocarcinoma. These finding was confirmed by abdominal CT scan and Endoscopic Ultrasound. No lymphadenopathy, no ascites, no dilatation of the intra and extra hepatic bile ducts, no liver lesions were found. There was no history of jaundice or weight loss. Abdominal examination revealed upper abdominal tenderness and normal bowel sound. The patient underwent laparoscopic subtotal gastrectomy plus lymphadenectomy D2 for distal gastric cancer with Braun reconstruction. Operative time was 220 minutes. The resected specimen was diagnosed as gastric carcinoma with lymphoid stroma infiltrating the subsierosa with a total of 47 lymph nodes without metastasis (T3N0). The naso-gastric tube was removed in seventh postoperative day. Besides oral intake was started and the patient was discharged on the eleventh postoperative day without any complication. These type of neoplasms have a better prognosis probably due to the lymphoid reaction that takes place in the tumoral stroma; lymph node metastases are unusual in such tumors.



GIST Sleeve Gastrectomy

Intragastric Single Port Surgery (IGS): New Technique for Large Benign Gastric Tumors - Video

C. Fiorani University of Tor Vergata, Rome, Italy Case Report: We report the case of a 53-years-old man suffering from epigastric pain. With a gastric mass on the posterior surface of the stomach greater curvature. Gastroscopy and endoscopic ultrasonography revealed a smooth, hemispherical mass of 6 cm in diameter on the posterior surface of the stomach greater curvature with homogenous echogenicity originating from the gastric muscular layer. Routine biochemical and hematological investigations were normal. A laparoscopic sleeve gastrectomy was performed. After histological evaluation, the resected lesion was determined to be a gastrointestinal stromal tumor. Conclusions: Gastrointestinal stromal tumors (GIST) is a rare mesenchymal tumor of the gastrointestinal tract and it’s more frequently found in the stomach. Surgical resection is the gold standard for non metastatic GIST treatment. A laparoscopic sleeve gastrectomy for GIST resection is a feasible approach if there’s a safe distance between the lesion and other structures such as pylorus or gastroesophageal junction if negative margins want to be obtained. Laparoscopic approach allows pain reduction and a shorter hospital stay compared with other methods.

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R. Zorron1, M. Holtmann2, T. Junghans2 1

Klinikum Bremerhaven Reinkenheide, Bremerhaven, Germany; Division Innovative Surgery, Klinik fu¨r Allgemein-, Viszeral-, Thorax- und Gefa¨s, Bremerhaven, Germany

2

Objectives: Benign gastric tumors, depending on location and size, may represent a potential challenge for endoscopic and surgical therapy. Partial gastric resection is usually indicated for tumors larger than 3 cm, when endoscopic resection is not possible, resulting in unnecessary resection of considerable amount of healthy gastric tissue. Besides the crescent intraabdominal use of Single Port surgery for gastric resection, intragastric surgery with Single Port platform is rarely described. This study describes the aplication of this new intraluminal technique for resection of large intragastric masses. Methods: A 61-year-old female patient with previous heartburn had endoscopic diagnosis of a submucosal 6 cm diameter intragastric mass in gastric fundic region compatible with gastrointestinal stromal tumor. Preoperative biopsy showed no presence of malignancy, and the surgical treatment was indicated. Intraoperative endoscopy helped in retreating the mass and assuring free stapling margins. A 2.5 cm incision was made subxiphoid and allowed exteriorization of the gastric wall, and a SILS Port was introduced under direct view. Intragastric sleeve resection of the tumor was performed using consecutive charges of 60 mm stapling. The specimen was extracted through the single port without extraction bag. The gastrotomy was closed percutaneously with conventional single layer absorbable suture. Results: The procedure time was 58 min. There were no intraoperative complications. Histopathologic examination confirmed a GIST diagnosis. Postoperative the patient underwent regular diet on the next day, and was dismissed on the 3rd postoperative day. At 6th day follow-up the patient required drainage of a wound abscess that was posteriorly managed at ambulatorial basis. Histopathology showed tumor free-margins. Conclusions: The new concept of intragastric percutaneous Single Port partial gastrectomy (IGS) allows the resection of large intragastric benign tumors with free margins thus avoiding sacrifice of unnecessary healthy tissue. It can be indicated when the endoscopic resection is not possible and for large specimens requiring full-thickness therapy.

Surg Endosc


V122 - Video - Morbid Obesity

Laparoscopic Management of Gastric Diverticulum

Laparoscopic Adjustable Gastric Banding of Gastric Pouch from Prior Roux-en-Y Gastric Bypass

I.C. Hutopila, S. Filip, B. Smeu, M. Priboi, I. Balescu, C. Copaescu Ponderas Hospital, Bucharest, Romania Gastric diverticula are rare (0.01% - 0.11 % at upper gastrointestinal endoscopy). Most of them are asymptomatic and detected incidentally during routine investigations, some others may present with variable symptoms (abdominal pain, reflux, bloating). We report the case of a 46 years old woman, with upper abdominal pain for a long period of time (20 years), who was diagnosed at the computed tomography and upper gastrointestinal endoscopy with a posterior gastric fundal diverticulum. The patient underwent laparoscopic excision of gastric fundal diverticulum. This video shows the endoscopic aspect, the radiological studies and the surgical technique that includes dissection of the gastrosplenic ligament with division of the short gastric vessels for a direct approach. The diverticulum was resected with a linear stapler. Recovery from the operation was uneventful. Laparoscopic resection of the gastric diverticula should be the procedure of choice.

N.R. Obeid, B.F. Schwack, M.S. Kurian, C.J. Ren-Fielding, G.A. Fielding New York University Medical Center, New York, United States of America Aims: Bariatric surgery has proven to be the most effective treatment for sustained, longterm weight loss. However, surgeons are encountering some patients with weight regain and ‘weight-loss failure.’ Revisional bariatric surgery is becoming more common. Our video highlights gastric banding of the gastric pouch as a feasible option for revisional surgery. Methods: The case is a 55 year-old man with morbid obesity who underwent Roux-en-Y gastric bypass 10 years prior to presentation. He suffered from significant weight regain and was again classified as morbidly obese. Workup included an upper GI series, which demonstrated a dilated gastric pouch. The patient elected to undergo gastric banding of the gastric pouch in order to provide restriction and facilitate weight loss. Operative details are illustrated. Results: The patient was discharged to home the same day and has had an uneventful recovery. Most recently, at the 4-month postoperative visit, the patient has lost 30 pounds. Conclusions: Revisional bariatric surgery is becoming more prevalent, especially for weight regain. Depending on the patient’s symptoms, surgical anatomy, and preoperative workup, the ‘band over bypass’ technique is a feasible option for revisional surgery and is effective in managing weight regain after gastric bypass.



Different Ways to Reconstruct After Completed Laparoscopic Radical Gastrectromy for Gastric Cancer

Hiatoplasty with BIO-A Mesh During Sleeve Gastrectomy in Case of Hiatal Hernia Associated with Esophageal Reflux

T.J. Tsai, C.W. Lin, T.Y. Cheng

S. Morales-Conde, M. Socas-Macias, A. Navas Cuellar, G. Jimenez Viera, V. Camacho Marente, I. Alarcon del Agua, J. Can˜ete Gomez, R. Avila, M. Rubio Manzanares, J.M.H. Cadet Dussort, J. Padillo Ruiz, A. Barranco Moreno

Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan Video shown current different ways for reconstruction after laparoscopic radical gastrectomy including linear stapler delta method Billroth I and Roux-en-Y reconstruction.

HUVROCIO, Seville, Spain Introduction: Sleeve gastrectomy has been standardized as a definitive stand-alone procedure due to the excellent results in terms of %EWL and control of comorbidities. Indications for SG include patients with BMI between 35 and 60 with or without comorbidities. The presence of esophagitis is considered a contraindication, being recommended in case of hiatal hernia and reflux the closure of the crura. We propose in those cases to associate a hiatoplasty to reinforce the area. Surgical Technique: Before the hiatoplasty, we perform the dissection of the greater curvature upwards, until the angle of Hiss dividing the remainder posterior fundus attachments to the pancreas. And distally up to 5–6 cm from the pylorus. We continue the procedure dividing the gastrohepatic ligament. Dissection is continued across the hiatus incising the peritoneum anterior to the GE junction, maintaining downward traction on the stomach. The esophagus is dissected free from areolar tissue along 4–5 cm in mediastinum. We proceed to close the crura with 2–3 non-absorbable stitches. We measure the area to be reinforced and place an absorbable mesh (BIO-A Gore-Tex, Flagstaff, AZ) fixed with two non-absorbable stitches to the medial part of the crura, and the rest with fibrin glue in spray. Prior to the gastrectomy the anesthesiologist inserts a 40 Fr bougie. The stapler is positioned close to the bougie, but symmetrically all the way between the anterior and posterior gastric wall, avoiding the twisting of the staple line, and close enough to allow the smooth mobilization of the bougie during all the procedure, especially at the level of the crow’s foot. We routinely use buttressing material in all the cartridges to protect the staple line from bleeding, and perform a methylene blue test. Conclusion: The addition of the hiatoplasty to the closure of the crura is a simple step little time consuming, which minimizes the risk of recurrence of the hiatal hernia and reflux, after the loss of weight. The main advantage of this type of mesh, is that it reinforces the area, without leaving any kind of foreign material, which could lead to potential complications in the long term (erosion or migration).

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Laparoscopic Adjustable Gastric Band Removal with Three Different Surgical Techniques

Is Laparoscopic Gastric Sleeve Resection Justified as the First Step for Obese Patients with Complicated Incisional Hernia?

R.C. Broderick, C.R. Harnsberger, H. Fuchs, M. Berducci, C. Beck, B.J. Sandler, G.R. Jacobsen, S. Horgan

C. Copaescu, B. Smeu, I. Hutopila, S. Filip, M. Priboi, I. Balescu

University of California San Diego, San Diego, United States of America As the prevalence of morbid obesity is increasing in the United States and internationally, more bariatric procedures are being performed as sustainable and effective treatment. One major operation has been laparoscopic adjustable gastric band placement (LAGB). However, it has been discovered over the past decade that some patients develop complications from a gastric band which requires removal. For LABG, the main reasons for removal are infection, slippage with concern for gastric necrosis, chronic pain, and erosion. The video presented shows the varying methods and techniques for removal of a LAGB based on clinical scenario. The three techniques shown are: acute removal for infection/slippage, non-acute removal for chronic pain and inadequate weight loss prior to future sleeve gastrectomy, and an entirely endoscopic removal for an eroded band. Each of these techniques is essential for a general or bariatric surgeon to have in their arsenal.

Ponderas Hospital, Bucharest, Romania Background: Obesity is an important risk factor for the recurrence of incisional hernias while their repair represents a therapeutic challenge. The surgical management of incisional hernias in obese patients is difficult task. Aims: Our goal is to present the technical aspects of a tailored approach to complex incisional hernias repair in morbidly obese patients. Methods: In patients with complex incisional hernias a tailored approach consisting of laparoscopic sleeve gastrectomy as the first step of the therapeutic strategy was applied. The inclusion criteria for complex incisional hernia were multiple recurrences, technically considered difficult, giant defect, losing of housing domain or risky obese patients. The feasibility of a staged approach was analyzed. The laparoscopic incisional repair was performed 12–18 months after the metabolic operation. All the operations were performed in a Bariatric Center of Excellence. Results: Laparoscopic sleeve gastrectomy was performed in all included cases. The particular technical aspects of developing the working space into a peritoneal cavity with modified anatomy and steps of performing the metabolic procedure are presented and discussed in details in the video. The laparoscopic incisional hernia repair was latter performed in all the cases and the excellent technical conditions obtained at that time in the same patients are demonstrated in the video. Conclusions: The tailored approach to complex incisional hernias repair in morbidly obese patients is safe and feasible carrying important technical and medical advantages to the patients.



Diagnosis and Management of the « Candy Cane Syndrome » After Roux en Y Gastric Bypass

Laparoscopic Gastric Bypass with a Robotically Controlled Needle Holder

L. Marx, M. Nedelcu, S. Perretta, M. Vix, J. Marescaux, D. Mutter

F. Reche, P.A. Waroquet, C. Arvieux, J.L. Faucheron

Service de Chirurgie Digestive NHC, IRCAD, IHU, Strasbourg, France

University Hospital of Grenoble, La Tronche, France

Introduction: After Roux en Y Gastric Bypass (RYGBP) an excessive length of nonfunctional Roux limb proximal to the gastrojejunostomy can cause abnormal upper gastrointestinal symptoms. Methods: A 51-year-old female underwent a robotically one loop gastric bypass (February 2013) with handsewn gastrojejunostomy anastomosis. Five months later she developed an internal hernia with intestinal necrosis which necessitated 1.5 m bowel resection and conversion to RYGBP by laparotomy in emergency setting. The postoperative outcome was significant for mild chronic pain feeding related that was relieved after vomiting. The upper endoscopy and Gastrografin swallow revealed an important candy cane syndrome twisting the gastro-jejunal anastomosis with no evidence of ulceration or stricture. Results: An initial laparoscopic exploration and evaluation of anatomy revealed no evidence of internal hernia. The gastrojejunal anastomosis was identified and the ‘Candy cane’ limb was observed adherent to the gastric remnant. After its sharp dissection, the mesentery was divided along of the bowel edge to the level of the gastrojejunostomy which seemed to be dilated. A intraoperative endoscopy was performed and a transection of the candy cane limb was carried out and a reduction of the anastomosis completed the stapling. Specimen was removed in endobag. An endoscopic control of the staple line was realized. The postoperative outcome was uneventful with definitive relief of the symptoms. Conclusion: A long, nonfunctional Roux limb tip may cause persistent nausea, postprandial epigastric pain, and, even, a lack of satiety. Surgeons should attempt to minimize the length of the blind bowel loop during the primary procedure. Limiting the length and orienting the roux limb to aid in gravity drainage at the initial operation may prevent this syndrome.

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Aims: Minimally invasive surgery creates new challenges for the surgeon. The use of long rigid instruments through rigid ports limits intra-abdominal degrees of freedom. The objective is to evaluate a new concept of robotic instrument to overcome difficulties inherent to suturing task of laparoscopic gastric bypass procedure. Methods: The tested instrument offers two motorized distal degrees of freedom: bending of the shaft to adjust needle positioning into the appropriate plane and unlimited axial rotation of the end effector to drive the needle through the tissue, while keeping an outer diameter of 5 mm. The patient was a 32 year old female with a body mass index of 44. The instrument was used to perform the Roux-en-Y anastomosis during a laparoscopic gastric bypass. Results: Laparoscopic suturing to create the conduit and the closure of mesenteric defects are an advanced skill and mastering this skill is a difficult process, especially because the angle between the needle holder and suture line is unparallel and triangulation is limited. The combination of distal shaft bending and rotation of the end effector of the robotic needle holder offers fully articulating tip for easy maneuverability and unparallel access. Conclusion: The use of this robotic instrument is a great help to perform anastomosis during laparoscopic gastric bypass by facilitating and improving surgeon gesture

Surg Endosc



Laparoscopic Management of Ischemic Gastric Perforation and Sepsis Following Plicated Banding

Single Port Gastric Bypass and Single Port Sleeve Gastrectomy: Technical Differences in Position and Steps - Video

A.A. Hussain, A. Khan, S.S. El-Hasani

R. Zorron1, J.C. Marchesini2, T. Junghans3, A.C. Ramos4, M.P. Galvao4

King’s College Hospital NHS Foundation Trust, Orpington, United Kingdom

1

Klinikum Bremerhaven Reinkenheide, Bremerhaven, Germany; Clinica Marchesini, Curitiba, Brazil; 3Division Innovative Surgery, Klinik fu¨r Allgemein-, Viszeral-, Thorax- und Gefa¨s, Bremerhaven, Germany; 4Gastrobeso Center, Sao paulo, Brazil

2

Aims: To show the vital role of the urgent laparoscopy in diagnosis and management of ischemic gastric perforation following adjustable gastric band plication for morbid obesity. Method: This was a 27 years old patient Body Mass Index of 52 who underwent laparoscopic adjustable gastric band plication and was discharged after 4 days but readmitted with acute abdomen a week later, a pulse rate of 110/minute, respiratory rate of 28/minute, temperature of 37.8° and normal blood pressure. White cell count was 19.2 109/L and C-Reacting Protein (477 mg/L). Arterial blood gas showed acidosis and high base excess and an urgent Computerized Tomography confirmed free gas and fluids (larger than what is expected after recent laparoscopy) and possible abscess at the upper abdomen. Gastrografin study showed suspicious leakage. An urgent laparoscopy showed mucky fluids in the abdomen, the second (outer layer of the plication) was dismantled and a perforation (1 cm in diameter) was seen at an ischemic gastric fundus. The first (inner layer of plication was dismantled as well). The perforation was closed in two layers and three drains were fixed. The patient was managed by nil by mouth, total parenteral nutrition (TPN) for 7 days and antibiotics. Results: Although she developed left side pneumonia, she had made an excellent recovery and was discharged home after two weeks. Conclusion: An urgent laparoscopy is crucial for saving the life of a patient who developed acute septic complications of bariatric surgery including ischemic gastric perforation.

Objectives: Laparoscopic sleeve gastrectomy is currently the second most performed primary bariatric procedure for morbid obese patients, with good postoperative results and achieving adequate excess weight loss (EWL). Current techniques include a small laparotomy site for extraction of the specimen and use of 5 to 7 trocars. The evolution of the technique with application of Single Port Roux-Y Gastric Bypass (SPGB) and Single Port Sleeve Gastrectomy (SPSG) allowed the standardization of operative steps and is presented in our clinical series. Methods: Single Port bariatric surgery was applied in a selective group of 48 patients and prospectively documented. BMI was a mean of 42.2 (35.1 to 52). Development of technical standardization included: 1. Open access using a supra-umbilical incision, 2. Insertion of 3 laparoscopic instruments; 3. Liberation of the greater curvature with ultrasonic energy; 4. Stapling sleeve gastrectomy including antrectomy over a 36 Fr Bougie; 5. Systematic oversewing of the staple line and drainage; and 6. Single port extraction of the specimen without retrieval bag. 7. Gastric Bypass performed with 2 additional 3 mm ports. 8. Positioning of the surgeon at the right side of the patient. Results: All procedures were performed using Single Port technique, with no conversions to open surgery. Incision was a standard transversal 4 cm. Procedure time lasts from a mean 88 min for SPSG and mean 86 min for SPGB with minimal operative blood loss. Intraoperative complications were 1 bleeding from short gastric vessels and one liver bleeding. One patient had a leak after SPGB and recovered well with drainage and parenteral nutrition. Follow up on the patients for a minimum of 6 months showed adequate excess weight loss. Conclusions: Single Port Sleeve gastrectomy is now performed in a standard technique, allowing a feasible and safe procedure for selected cases. It has the potential advantage of reducing postoperative hernia sites and presenting good cosmetic result.



Failure of the Gastric Vertical Plication - Reoperation Technique

Laparoscopic Management of Hinchi III Diverticular Disease in an Acute Emergency Set Up

D. Simeckova, M. Vrany, B. Manova, M. Man Hospital Jablonec nad Nisou, Jablonec nad nisou, Czech Republic Aims: Bariatric procedures are widely accepted as procedures leading to weight reduction and as a treatment of number of diseases. As a number and variety of operations is increasing, the percentage of complications and failure of the operation is significantly growing also. In our video we want to show the way we deal with the patients after the failed bariatric surgery-laparoscopic vertical plication with the BMI over 40. Methods: In our video presentation we want to show the reoperation of the stomach due to the malfunction of the gastric vertical plication (for instance loosen stitches are very common). We want to stress the most common failures we had to deal with. There will be shown the replication of the stomach followed with the duodeno-ileal bypass. Results: Besides all, the combination of two basic techniques has a great effect on the weight loss. We followed-up a significant weight loss in all our patients. Economic aspect is also very important. Conclusion: Duodeno-ileal bypass with total gastric vertical replication is a procedure, which fulfils all requirements of restrictively malabsorptive operation. In case of failure of the vertical gastric plication it can be easily redone and then convertible into the duodenoileal bypass

B. Ip1, K.L. Campbell2, D. Ziyaie2 1 Tayside Health Board, Dundee, United Kingdom; 2Ninewells Hospital & Medical School, Dundee, United Kingdom

Aims: Whilst the benefits and the indications for laparoscopic colonic surgery is well established, similar approach in an emergency set up remains controversial. Moreover we are faced with ever increasing incidence of acutely presenting complicated diverticular disease in the younger population. Resection of the diseased segment remains the gold standard. Provided degree of sepsis and inflammation together with patient’s suitability for major surgery are not the limiting factors, resection and primary anastomosis would decrease the burden of end colostomy and delayed resumption of the bowel continuity. This combined with a laparoscopic approach would incorporate early recovery, discharge and return to work Methods: We present a case of a fit and well young female who presented with peritonitis secondary to a Hinchi III perforated diverticular diseas. Following preoperative optimisation patient was managed with a laparoscopic abdominal lavage, sigmoid resection and primary anastomosis. The step by step evaluation of feasibility of performing the procedure laparoscopically and contemplating primary anastomosis is demonstrated. Results: There were no serious adverse postoperative outcomes. Patient was mobile within 24 hours with return of bowel function in 48 hours. Total hospital stay under 4 days. Conclusion: Emergency laparoscopic management of complicated Hinchi III diverticular disease is a safe and feasible option in carefully selected patients in centres with experience in large volume laparoscopic colonic surgery. Patient selection and surgeon’s preparation for conversion to open when indicated are key elements in ensuring an enhanced outcome.

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Laparoscopic Total Proctocolectomy with Intersphincteric Dissection and Ileal Pouch-Anal Anastomosis for the Treatment of Familial Adenomatous Polyposis

Laparoscopic Ileo-Caecal Resection for Crohn’s Disease: The Inferior Approach

S. Guckenheimer, E. Grzona, M. Bun, F. Carballo, A. Canelas, M. Laporte, N. Rotholtz Hospital Aleman, Buenos aires, Argentina Aims: Familial adenomatous polyposis (FAP) is an inherited disease characterized by the development of hundreds of colorectal adenomas, leading to a 100% lifetime risk of colorectal cancer. In some cases the rectal polyps may compromise the upper portion of the anal canal. The aim of this video is to show a laparoscopic total proctocolectomy with intersphincteric dissection and ileal pouch-anal anastomosis for the treatment of familial adenomatous polyposis Methods: We present a video of a 26 year old female patient with rectal bleeding and the diagnosis of familial adenomatous polyposis with extension into the anal canal. Description of the Video: With the patient in a modified lithotomy position, six 12 mm trocars are used in the umbilicus, both upper quadrants, both lower quadrants and suprapubic. Trough a medial to lateral approach we consecutively mobilized the right, transverse and left colon. Then the rectal dissection was performed until the exposition of the levator ani muscle. Thereafter the perineal part of the operation began. A self-holding retractor was used to expose the anal canal. After submucosal injection of physiological solution, a circumferential incision of the mucosa and internal anal sphincter was performed just above the dentate line. The rectum was mobilized proximally on the intersphincteric plane until the level of the laparoscopic pelvic dissection was reached. The colon and rectum were pulled through the anal canal and resected. The reconstruction consisted in a hand-sewn ileal pouch-anal anastomosis. Finally, a diverting loop ileostomy was created.

A. Majbar, M. Elalaoui, M. Raiss, F. Sabbah, A. Hrora, M. Ahallat Clinique Chirurgicale C, Rabat, Morocco Aims: To demonstrate the advantages of the inferior approach in ileo-caecal resection for Crohn’s disease. Methods: This is the case of a 25 years-old patient with obstructive symptoms secondary to ileo-caecal Crohn disease. The coloscopy showed a stenosis of the last ileal loop and the biopsy was compatible with crohn disease. The pre-operative work-up also included oesogastric and duodenal endoscopy and enteral computed tomography. The patient did not respond to medical therapy and the surgical resection was decided by the multidisciplinary team. Results: The patient was operated in supine position. A four technique trocar was used. After meticulous exploration of the abdominal cavity, an inferior approach was used to free the ileum and the right colon. The inferior and posterior attachments of the mesentery and the caecum were opened, allowing the dissection between the mesocolon and the gerota fascia. This dissection was carried out upwardly, with clear identification of posterior structures (ureter and genital vessels) and the duodenum, until reaching the lateral attachments of the right colon and the attachments of the transverse mesocolon. These attachments were then released to complete the liberation of the right colon. The ileo-caecal resection was then performed through a small incision in the right iliac fossa and the anastomosis done manually. Conclusion: In ileo-caecal resection for Crohn’s disease, the classical vascular approach is technically difficult due to the important inflammation of the mesentery. The inferior approach helps avoiding the difficulties by allowing the surgeon to work in a non inflammatory space.



Endoscopic Posterior Merosectal Resection (EPMR) After Local Excision of Unexpected Invasive Rectal Cancer

Standardized Technique of Laparoscopic Panproctocolectomy and Ileo-Anal Pouch for Ulcerative Colitis

A. Arezzo1, A. Zerz2, M.E. Allaix1, M. Morino1, S. Arolfo3

N.N. Siddiqi1, L. Khan1, S. Alvi2, J. Khan1, A. Parvaiz1

Department of Surgical Sciences, University of Torino, Italy; 2Klinik fu¨r Chirurgie, Kantonsspital Baselland, Spital Bruderholz, Bruderholz, Switzerland; 3University of Torino, Italy

2

1

Correct preoperative staging of suspected adenomas or early rectal cancer is achieved in \ 80% of cases. Not rarely surgeons face the situation in which a suspected benign or non-invasive malignant lesions removed by transanal local excision, turns out to invasive instead. Total Mesorectal Excision (TME) should be the choice for oncologic reasons, but reveals often more difficult as a secondary procedure, than it is already as a primary one, not considering the risk of a loop ileostomy and severe complications. Endoscopic Posterior Merosectal Resection (EPMR) may represent a valid alternative, by removing the relevant lymphatic drainage of the mid and low rectum while respecting the rectum. A 64 years old women, BMI 34.4, underwent Transanal Endoscopic Microsurgery (TEM) for a suspected adenoma of the posterior mid-low rectum. Final histology showed a pT2 adenocarcinoma, G2, no lympho-vascular invasion and low budding. The postoperative course was uneventful and the endluminal scar appeared regular, 5 cm above the anal verge. After discussion with the patient, we obtained informed consent for an EPMR procedure. The video shows the procedure. In general anaesthesia, the patient was placed in prone jackknife position. Through a perineal 10-mm incision, the pelvic floor was penetrated between the anus and the tip of the coccyx by blunt dissection. The retrorectal space was reached by finger and dilated, so that a distention balloon system (PDB 1000i, Tyco Healthcare) could be inserted and distended. A CO2 pneumoretroperitoneum was established at 12 mmHg. Two additional 5-mm trocars were placed left and right of the coccyx. The retrorectal space was further enlarged bluntly up to the sacral promontory. By use of a Thunderbeat device (Olympus), the perirectal fascia was incised first laterally, then in the lowest area and the posterior part of the mesorectum was dissected from the posterior wall of the rectum creating a wide opening of the peritoneum. The resected tissue was finally removed in a retrieval bag. EPMR represents a possible option to achieve local lymphadenectomy in unexpected invasive rectal cancer previously removed by TEM, and may represent in selected cases, an alternative to TME.

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1

Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom; Queen Alexandra Hospital, Portsmouth, United Kingdom

Aims: To present the technique for single stage laparoscopic panproctocolectomy and Ileoanal pouch for ulcerative colitis. Description: 42 year old male who had ulcerative colitis for 7 years which was not responding to medical therapy, underwent single stage laparoscopic panproctocolectomy and ileoanal pouch procedure. Conclusion: A meticulous approach and standardised technique is required to achieve good clinical outcomes in non-selective patient group requiring pouch surgery.

Surg Endosc



Tamis for Local Excision of Rectal Tumours: Our Experience

Laparoscopic Management of Cholecysto-Colic Fistula

A. Leventi, E. Ypsilantis, P. Ng, P. Nastro, A. Pancholi, H.P. Wegstapel

N. Naguib, T. Longworth, P.K. Dhruva Rao, P. Shah, A.G. Masoud

Medway Maritime Hospital, Gillingham, kent, United Kingdom In this video we present our technique in TransAnal Minimally Invasive Surgery in Medway Maritime Hospital, UK

Prince Charles Hospital, Merthyr Tydfil, United Kingdom Introduction: Laparoscopic Cholecystectomy is a standard operation which is performed frequently throughout the world. On occasion, a complex pathology is encountered which may require conversion to an open procedure, or a change in the tactic to allow completion of this operation safely. We present a case of laparoscopic cholecystectomy with an unexpected finding of cholecysto-colic fistula. Method: A 71 year old male presented as an emergency with acute cholecystitis. Ultrasound and CT scan confirmed the presence of a perforated gallbladder and inflammatory mass. Following conservative treatment the patient was discharged but complained of intermittent fevers and rigors. The patient attended for an elective laparoscopic cholecystectomy. During dissection of omentum from the inflammatory mass, a fistula was found between the gall bladder and the colon. The focus was then to delineate the anatomy and identify both the duodenum and gall bladder. Once confident of the anatomy, an endoscopic flexible stapler was used on the colonic side of the fistula. Specific care was taken not to compromise the colonic lumen while stapling. A combination of blunt, sharp and hydro-dissection was used to delineate anatomy at Calot’s triangle. Hartmann’s pouch, Common Bile Duct and Common Hepatic Duct were all clearly identified. A subtotal cholecystectomy was performed using the endoscopic stapler. The Gall bladder was then dissected from the liver bed, and both staple lines were checked. Results: The postoperative period was uneventful with the drain being removed and patient discharged on the first postoperative day. A follow up clinic at 6 weeks showed the patient to have made a full recovery. Conclusion: This case highlighted an option for laparoscopic management of cholecystocolic fistula. Clear identification of anatomy is the cornerstone for maintaining a safe procedure.



Simultaneous Laparoscopic Right Hemicolectomy and Abdominoperineal Resection

Needlescopic Grasper Assisted Single Incision Laparoscopic Cholecystectomy and Choledocholithotomy with Primary Clousre of the CBD in Patients with GB and CBD Stone

K. Albanopoulos, N. Memos, N. Natoudi, D. Linardoutsos, G. Zografos, E. Leandros University of Athens, Athens, Greece Aims: A case of combined laparoscopic right hemicolectomy for pappilovillous adenoma and abdominoperineal resection for rectal cancer are presented to illustrate the technical aspects of performing two concurrent laparoscopic bowel resections with sequential anastomosis. Case Presentation: A 56 years old patient with rectal adenocarcinoma and synchronous large cecal pappilovillous adenoma admitted to our hospital for surgical excision. The patient underwent laparoscopic right hemicolectomy with ileotransverse anastomosis and cylindrical abdominoperineal resection. After excision of rectum, the right hemicolectomy specimen was retrieved through the perineal trauma. An end stoma was finally performed in the predefined position of the abdominal wall. The postoperative course of the patient was uneventful with liquid diet beginning at 1st postoperative day and fecal in stoma at 2nd postoperative day. The patient was discharged from the hospital at 5th postoperative day. Conlusion: Combined laparoscopic assisted right colectomy and low anterior resection can be performed for synchronous colorectal malignancies with curative intent.

K.H. Kim, C.H. An, J.S. Kim, I.Y. Park, D.G. Kim, T.S. Kim Uijeongbu St. Mary’s Hospital, The Catholic University of Korea, Uijeongbu, Korea Aims: Traditionally, the CBD is closed with T-tube drainage after choledochotomy and removal of CBD stones. Surgeons have tried to minimize the scars and reduce the port sites and achieve this. We believe that primary closure can be as safe as closure with T-tube drainage. We reviewed our experiences to evaluate the safety and feasibility of primary closure of the CBD after laparoscopic choledochotomy in patients with CBD stones using single port access. Methods: Between November 2011 and December 2013, 7 patients underwent single incision laparoscopic cholecystectomy and choledocholithotomy with needlescopic infundibular retraction for gallbladder disease in single institute by one surgeon, Uijeongbu St. Mary’s hospital. 7 patients with a mean age 67.1 years (range 42 to 81) were identified. We used a SILSTM (Covidien, Tyco health Medical) single-port device for operation. Single port device was placed through umbilicus. A (2 mm) needlescopic retractor (Stryker, San Jose, CA) was placed in the right flank region directly through the abdominal wall for retraction of the gallbladder infundibulum in an anterior and cephalad direction. And snake retractor was used for liver retraction. Results: Patient all had a pathologic diagnosis of acute gangrenous and chronic cholecystitis. ASA class averaged 1.75 (range 1 to 2). Operative times averaged 264.7 minutes (range 143 to 365 minutes). Postoperative hospital stays averaged 4.1 days. There were no instances of bile leak, soft tissue infection, abscess, hernia or bile duct injury. Conclusions: Single incision cholecystectomy and choledocholithotomy with primary closure of the CBD is safe and feasible for acute and chronic cholecystitis even in suppurative cholecystitis. Liver retraction using a snake retractor is very useful in obtaining a critical view of safety.

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Single-Site Robotic Cholecystectomy - Experience from 177 Consecutive Cases

Laparoscopic Lateral Pancreaticojejunostomy in Chronic Pancreatitis

K.M. Konstantinidis, S. Hiridis, F. Antonakopoulos, C. Chrysoheris, P. Hiridis, M. Georgiou

A. Voynovskiy, A. Shabalin, A. Indeykin, V. Petrov, S. Yudenkov, S. Kolesova

Athens Medical Center, Athens, Greece

The Main Military Hospital of the Internal Ministry, Moscow, Russia

Introduction: Modern trends for less invasive surgery has raised interest in single site surgery. Use of robotics have exemplified single site procedures by restoring the correct hand-instrument alignment and providing stable, stereoscopic visual field. New instruments from the manufacturers promise to enhance these capabilities even more. Material: From March 2011 till December 2013 we have performed 177 roboticallyassisted single site cholecystectomies. All patients were informed on the benefits of the technology prior to their procedures and gave their written consent. Our team was extensively trained prior to the first operation especially for the process of docking and undocking the single-site platform. All perioperative data was registered in an electronic database. Results: All our 177 cases of single site robotic cholecystectomy completed successfully. There were no intraoperative complications. One patient was reoperated on the same day due to postoperative bleeding. Patient had an associated history of coagulopathy. To our knowledge, no incisional hernia has been recorded in our series. Minor postoperative wound ecchymoses were noted in 56 patients and wound infection 7 patients. Incision and closure techniques are presented in this paper. Integrity of the abdominal wall was verified by ultrasound scan in an outpatient basis in 47 cases. Mean length of stay was 1.34 days, which is less than the corresponding LOS for our laparoscopic group of 3304 patients (LOS = 1.79). Conclusions: Use of the robotic system may be justified in single site procedures, since it restores natural hand-instrument alignment and a stable visual field. Increased costs in comparison to conventional laparoscopy may be justified in large-volume centers performing more complex cases as well. Although use of robotics appears to simplify single site surgery, further randomized trials are expected to prove true benefit minimally invasive single access surgery in comparison to multiport.

Aims: To present the results of the first laparoscopic pancreatojejunostomy in chronic obstructive pancreatitis. Methods: 45 years old male has been sick for 10 years when he fell ill with pancreatic necrosis. Two years later there was a recurrence of acute pancreatitis and a diagnostic laparoscopy was performed. Annual recurrent acute pancreatitis followed. After 5 years from the onset of the disease diabetes was diagnosed with the progression of the disease and decompensation at the time of hospital admission. The patient entered the hospital with complaints of general weakness, fatigue, 10 kg weight loss during a year, dry mouth, epigastric pain, blurred vision. CT scan revealed atrophy of the parenchyma, the heterogeneity structure with multiple calcifications. In Wirsung duct concrement detected 7 mm above the expansion and deformation of the lumen of the duct. An operation was performed: laparoscopic longitudinal pancreaticojejunostomy using a Roux-Y jejunal loop. Pancreatojejunostomy was performed by linear stapler (blue tape) between the jejunum and expanded to 1.0 cm pancreatic duct. Results: The postoperative period was uneventful. Wounds healed by first intention, the stitches were removed on day 7. Conclusion: First experience of laparoscopic pancreatojejunostomy in chronic pancreatitis allows to speak about the prospects of this method, which can be successful with careful patient selection based on the anatomical features of the pancreas and its ductal system in each case.



‘Basket-Inside-Catheter’ Technique for Laparoscopic TransCystic CBD-Stone Extraction

Personal Experience in Laparoscopic DCP

H. Qandeel1, S. Zino2, A. Mirza2, M.K. Nassar2, A.H.M. Nassar2 1 Glasgow University, Glasgow, United Kingdom; 2Monklands Hospital, Glasgow, United Kingdom

Aims: If common bile duct (CBD) stones are detected during laparoscopic cholecystectomy, insertion of baskets via the cystic duct (CD) to extract the stones can be difficult and cause complication. We demonstrate a new technique ‘Basket-inside-catheter’ for laparoscopic trans-cystic CBD exploration. Methods: When cannulation of the CD is difficult due to duct anatomy it is likely that insertion of the, usually stiffer, Dormia basket would also be difficult or cause CD perforation/false passage. So, after performing trans-cystic cholangiography, the cholangiography catheter (CC) (Ureteral catheter 5Fr, open-end straight tip, 70 cm long, CookÒ Limerick-Ireland), is left inside the duct. A basket (Helical 3Fr, 120 cm long, Boston ScientificÒ Hemel Hempstead-UK) is inserted into the CC and advanced until the basked is exposed in the bile duct. Once the basket is opened, gentle shaking of the basket traps the CBD stone inside it. While a gentle occlusion of the common hepatic duct (to prevent the stone from slipping upward into the hepatic duct) is applied, the catheter and basket are both pulled back together to extract the stone. Results: Trans-cystic insertion of CC is easier than insertion of a basket. The basket’s tip is more difficult to negotiate a torture cystic duct, risking perforating the duct or creating a false passage. Additionally, once a stone is engaged sliding the CC down onto the basket offers better control on the trapped stone. Conclusion: We demonstrate a technique to facilitate the insertion of extraction baskets into the cystic duct using the cholangiogram catheter as a guide ‘Basket-inside-catheter’.

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N.A. Palasciano, B. Pascazio, P. Pannarale, M. Milella, A. Prestera, C. Lozito, G. Casamassima, M. Sederino, M. Minafra, F. Ferrarese Universita` degli studi di Bari, Italy Laparoscopic DCP is unusual procedure, every surgeon prefers to approach pancreatic or duodenal disease open or eventually robotic. From 2004 up to 2013 we performed 22 DCP, 8 of which performed laparoscopically. Each patient with duodenal or pancreatic cancer initially underwent laparoscopic full abdominal exploration for an accurate staging and to assess the resectability of the cancer. The main purpose of this review is to focus on some technical aspects related to the learning curve of this procedure.

Surg Endosc



Laparoscopic Spleen Preserving Distal Pancreatectomy

Laparoscopic Corporocaudal Pancreatectomy and Splenectomy Following Clockwise Technique for Neuroendocrine Tumor

S.P. Puntambekar, N. Mookim, A. Patil Galaxy Care Laparoscopic Institute, Pune, India Distal pancreatectomy with en-bloc splenectomy has been considered the standard technique for management of benign and malignant pancreatic disorders. Splenectomy in these patients has an unfavourable impact on long-term survival after resection. Preserving spleen has advantage of preventing overwhelming infections in postoperative period. Laparoscopic spleen-preserving distal pancreatectomy is feasible and safe. Laparoscopic spleen-preserving distal pancreatectomy may be preferable for the advantages of a minimally invasive approach. This video depicts a case of laparoscopic spleen preserving distal pancreatectomy.

J. Mejıás, N. Garcıá, R. de la Fuente, J. Soteldo, A. Ferre´, L. Go´mez Hospital Clıńicas Caracas, Venezuela Objective: To present a case of patient with neuroendocrine tumor of body and tail of pancreas in which we performed a corporocaudal pancreatectomy and splenectomy with minimal invasive surgery following clockwise technique. Methods: We report the case of a female, 25 years old patient, who was referred to our center for incidental body and tail pancreatic injury. Echosonographic control was performed showing body and tail pancreatic tumor of 7 9 5 cm. CT evidenced cystic tumor of 8 9 5 cm. Laparoscopic corporocaudal pancreatectomy following clockwise technique and splenectomy was performed with no complications. Conclusions: Anatomopathology report indicated neuroendocrine tumor grade I according to WHO classification, free edges of tumor and 14 nodes free of neoplastic lesion. Minimally invasive surgery for addressing injuries in body and tail of the pancreas, following clockwise technique, is a safe and feasible procedure.



Laparoscopic Distal Splenopancretectomy for a 10 cm Mucinous Cystic Adenocarcinoma

Laparoscopic Splenic Preserving Distal Pancreatectomy

A. Belli1, L. Cioffi2, G. Russo2, C. Fantini2, A. d’ Agostino2, G. Belli2 1

Istituto Nazionale Tumori Fondazione G. Pascale,,- IRCCS, Napoli, Italy; 2Division of General and HPB Surgery - Loreto Nuovo Hospital, Napoli, Italy Laparoscopic distal pancreatectomy is progressively becoming the standard of care for the surgical treatment of left-sided pancreatic lesions. The minimally invasive approach can offer better short-term post-operative outcomes than standard open distal pancreatectomy with similar pancreatic fistula rate. Nevertheless diagnosis of malignancy and tumor size [ than 5 cm are still considered relatively contraindications to the laparoscopic approach. In this video we present a 65 year old female with a history of a previously excised pT2aN0 melanoma diabetes and hypertension who underwent a computed tomography (CT) scan because of recurrent abdominal pain. The CT scan revealed a 10 cm cystic lesion of the pancreatic tail. The serum CA 19–9 was normal. Further investigation with endoscopic ultrasound (EUS) revealed that the lesion was unilocular with multiple endoluminal hyperechoic spots and without communication with the non-dilated ductal system (Wirsung duct diameter = 3 mm). The patient underwent a pure laparoscopic distal splenopancreatectomy. The operative time was 135 minutes with an estimated blood loss of 150 mL. No blood transfusion was necessary. The postoperative course was uneventful with the abdominal drain removed on postoperative day 4. No evidence of clinical, biological or radiological pancreatic fistula, were observed. The patient was discharged on postoperative day 6. The histological finding revealed mucinous cystic adenocarcinoma of the pancreas pT1pN0. In this video we report the feasibility of laparoscopic distal splenopancreatectomy for very large pancreatic tumors in center with a proven experience in both open and laparoscopic pancreatic surgery.

M. Ghellai National Cancer Institute, Misurata, Libia Pancreatic cysts are diagnosed with increased frequency because of the wide use of cross sectional imaging. Cystic neoplasms must be differentiated from pseudocysts. All complex true cysts of the pancreas require resection. Recent advances in minimally invasive surgery are applied in the management of these lesions. We present a 25 year old female with a complaint of abdominal pain and decrease appetite. Computerized tomography (CT) scan revealed a 3 cm complex cystic mass in the tail of the pancreas. She underwent a laparoscopic resection of the distal pancreas with preservation of the spleen. Intraoperative ultrasound was used to locate the tumor and ensure complete resection. Total operative time was 140 minutes with an estimated blood loss of 25 cc. On third post operative day, she was discharged home on oral diet. Histopathological examination demonstrated a mucinous cystic neoplasm with no malignant changes. Laparoscopic distal pancreatic resection with splenic preservation is safe. The postoperative course appears to be quicker with no apparent increase in complications.

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V150 - Video - Endocrine Surgery


Laparoscopic Redo Left Adrenalectomy for A 15 cm Pheochromocytoma Using Lateral Position and Through Three Trocar Technique

Transperitoneal Laparoscopic Adrenalectomy in Children: Initial Experience

M.K. Hussein American University of Beirut Medical Center, Beirut, Lebanon Aims: Twelve years experience at the American University of Beirut Medical Center for Laparoscopic Adrenalectomy. A total of 55 cases were done laparoscopically with no conversion and minimal complication one case of pulmonary edema treated successfully. The average operative time is 40 mins. Methods: The video will show the various steps used for Lap redo (Lt) adrenalectomy for a 15 cm pheochromocytoma using the lateral position and through 3 trocars. Attempts to remove the pheochromocytoma in Iraque was complicated by cardiac arrest treated successfully and patient referred to the American University of Beirut Medical Center. Results: Patient had smooth postoperative course following laparoscopic adrenalectomy and patient discharged 3 days later with no complications. Conclusion: Even large adrenal masses can be completed laparoscopically in advanced experienced centers in laparoscopy.

R. Gelmini, B. Catellani, S. Acciuffi, P.L. Caccarelli, A. Cacciari University of Modena and Reggio Emilia, Modena, Italy Purpose: The use of mini-invasive approach for adrenalectomy is poorly defined in pediatric patients, although laparoscopic adrenalectomy is considered a standard procedure in adults. The aim of our study is to describe the safety and feasibility of minimally invasive adrenalectomy in children based on surgical skills and results. Materials and Methods: This is a retrospective study of four pediatric laparoscopic adrenalectomies performed in our centre between 2009 and 2012. All patients underwent transperitoneal lateral laparoscopic adrenalectomy two of which were right adrenalectomies and two were left. Results: Four laparoscopic adrenalectomies were performed. Indications for surgery were neuroblastoma in two patients, secernent adrenocortical tumor in one patient and adrenocortical nodular hyperplasia in the last one. Patients had a mean age of 87 months (range 17–156) at diagnosis and the average lesion size was 3.23 cm (range 0.7–6.4). All laparoscopic adrenalectomies were successful, no conversions to open surgery were required and no post-operative complications or deaths occurred. The average operating time was 105 minutes (range 80–130), blood loss during surgery was minimal and the mean postoperative hospital stay was 3.75 days (range 3–5). None of the patients showed signs of recurring disease at 15-months follow-up. Conclusions: Laparoscopic adrenalectomy is a safe, feasible and reproducible technique offering numerous advantages including shortening of operating times and post-operative hospital stays, as well as reduction of blood loss and complications. It also provides good visibility and easy access to other organs



Endoscopic Retroperitoneal Approach to Adrenal Tumors: Tips and Tricks

Laparoscopic Management of Recurrent Pheochromocytoma

G. Giraudo, L. Rapetti, A. Salvai, M.E. Allaix, M. Morino University of Torino, Torino, Italy Aims: The aim of this video is to show our endoscopic retroperitoneal approach for the treatment of adrenal tumors. Methods: Our indications for endoscopic retroperitoneal adrenalectomy (ERA) are: adrenal tumors smaller than 6 cm, previous abdominal surgeries, and BMI less than 40 kg/m2. Results: The patient is placed in prone position. A 1.5-cm transverse skin incision is made below the lowest tip of the 12th rib. The abdominal wall is opened and the retroperitoneal space entered. A 5-mm trocar is inserted through a second incision medially to the first, guided by a finger inserted through the first incision. A third incision for another 5-mm trocar is made along the lowest margin of the 11th rib 4–5 cm laterally to the first incision. A 10-mm blunt ballooning trocar is inserted through the first incision and CO2 is initiated to 20 mmHg. After creating the retroperitoneal working space, Gerota’s fascia is opened, perinephric fat dissected, and the kidney upper pole is mobilized to expose the adrenal gland. Gland dissection starts with lower margin detachment from the upper kidney pole in a lateral to medial direction. After dissecting the adrenal gland from surrounding adipose tissue and medial isolation of the adrenal central vein, the vessel is sealed by using a radiofrequency device. Finally, the gland is placed in an endobag and retrieved through the 12-mm trocar site. Between April 2012 and December 2013, we performed 16 ERAs for Conn’s syndrome (8), Cushing syndrome (3), pheochromocytoma (4), ganglioneuroma (1). Median operative time was 80 (range, 45–135) minutes. We had 1 (6%) conversion to the transabdominal laparoscopic approach. Intraoperative complication rate was 6%. Four patients experienced postoperative retroperitoneal hematoma that was treated conservatively in all cases. There was no mortality. Conclusions: ERAs is a safe and effective alternative to laparoscopic transabdominal adrenalectomy in selected patients.

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S. Aggarwal, K. Sreesanth, M. Uppal All India Institute of Medical Sciences (AIIMS), New Delhi, India Recurrence of pheochromocytoma after a total adrenalectomy is uncommon. Such recurrent tumors are mostly managed by the open technique with only 2 other cases of laparoscopic management reported. We report a case of laparoscopic management of a recurrence of pheochromocytoma after total adrenalectomy for left adrenal pheochromocytoma. A 18-years-old female underwent laparoscopic total left adrenalectomy for 3.8 9 3.2 cm left adrenal pheochromocytoma in our hospital 2 years back. Her postoperative course was uneventful and at discharge she had a normal blood pressure on Tab Amlodipine 2.5 mg OD. The histopathology revealed features suggestive of pheochromocytoma. The capsule was intact and rest of the adrenal was normal. She was readmitted to Endocrinology department of our hospital 2 years later with palpitations, headache and breathlessness suggesting a recurrence of pheochromocytoma. Her urinary nor adrenalin and normetanephrines were raised. MRI of abdomen showed 2 cm 9 2 cm mass in left suprarenal fossa appearing hyper intense on T2 weighted image. However, Meta-Iodo-Benzyl Guanidine (MIBG) scan did not show any uptake but FDG PET showed a metabolically active lesion in left paraaortic region. The patient was taken up for laparoscopic excision of the mass. On laparoscopy, mild adhesions were present, which were lysed using ultrasonic shears. The tumor was seen medial to upper pole of left kidney. The previously applied clip on left suprarenal vein was seen anterior to the tumor. The tumor was going posterior to the upper edge of left renal vein. The tumor was carefully excised taking care to prevent injury to the left renal vessels. A drain was placed after ensuring hemostasis. The post-operative period was uneventful and the patient was discharged on 4th postoperative day without any anti-hypertensive medication. The histopathology revealed features of pheochromocytoma. Two separately sent lymph nodes were reported to have features of necrotizing granulomatous inflammation, negative for Acid Fast Bacilli (AFB) staining Recurrence following adrenalectomy for adrenal pheochromocytomas may suggest a malignant behavior. Approximately 10% of Pheochromocytomas and 35% of extra-adrenal Pheochromocytomas are malignant. Only the presence of metastases defines malignancy. Complete resection for a resectable lesion is the treatment of choice in case of recurrence.

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V155 - Endocrine Surgery


Laparoscopic Approach of a Infrarenal Paraganglioma: Case Report

Initial Retrocolic Endoscopic Tunnel Approach (IRETA) for Laparoscopic Radical Right Colectomy for Cancer Colon: An Oncologically Complete and Ergonomic Approach

J. Ordon˜ez, O. Vidal, G. Diaz del Gobbo, M. Valentini, C. Ginesta, G. Guerson, L. Fernańdez-Cruz, J.C. Garcıá-Valdecasas Hospital Clinic de Barcelona, Spain

S.J. John, P. Bhatia, S. Kalhan, M. Khetan, S. Saroj, S. Wadhera, N. Bansal, A. Bhardwaj, J. Bhat Sir Ganga Ram Hospital, New Delhi, India

Background: Paraganglioma (PGL) is rare neuroendocrine tumor that arise from the extraadrenal chromaffin tissue of the autonomous nervous system. PGL may be functioning or nonfunctioning. It is important to suspect, confirm, localize and resect pheochromocytoma for several reasons: hypertension is curable with surgical resection of the tumor, there is a risk of sudden death, at least 10% of the tumors are malignant and detection in cases of familial condition may result in the early diagnosis of other family members. Aims: Describe the diagnostic and management of a young female patient with PGL. Methods: It is a 36 year-old female patient who presented high blood pressure. Laboratory detected elevated plasma metanefrina, norepinephrine and urinary metanefrina. Abdominal computed tomography scan revealed a large left retroperitoneal mass (5 cm in diameter). The tumor was infrarenal and beside of the aorta. The PET did not showed any other abnormal metabolic activity. The genetic study revealed an alteration in the SDHB gene (cause of hereditary paraganglioma). With the diagnosis of functioning PGL, surgical treatment was indicated. Preoperatively a- and b- adrenergic receptor blockers were administered. The patient was placed in the right lateral position. Minimally invasive access was performed. Pneumoperitoneum was done with Veress. Three ports were placed, one of 12-mm at the left hypochondrium for a 30° camera, and two working ports of 5 mm, one at epigastrium and the other at the left flank. Dissection was performed by Ligasure, the stomach and the left colon were mobilized. The specimen was placed in a retrieval bag and removed by enlarging the 12-mm port site. There were no intraoperative complications. Nasogastric tubes or drains were not used. Results: There were no postoperative complications. The hospital stay was 4 days. The patient was restored to normal life. Histopathological examination confirmed a diagnosis of paraganglioma. The patient is free from disease at six moth of follow up. Conclusions: Like other authors, we believe that laparoscopic surgery for larges paragangliomas tumors is feasible and safe. This approach is associated with a shorter hospital stay, faster recover, return to normal activity and better cosmetics results compared to open surgery.

Aims: Radical laparoscopic cancer surgery represents a promise as well as a challenge for better oncological care of patients with potentially curable colo-rectal cancer. We present our experience for the Initial Retrocolic Endoscopic Tunnel Approach (IRETA) an ergonomic, modified medial to lateral, laparoscopic technique for radical resection of cancer of the right colon as described earlier in literature by Palanivelu et al. Methods: Standard pre-operative work-up, optimisation and regimen were implemented. Patients were placed in a modified lithotomy position. Post-diagnostic laparoscopy, dissection was commenced with a four port strategy. An initial retro-colic dissection was made to mobilise the ascending colon till the hepatic flexure with the lateral peritoneal reflection left intact initially to maintain intra-corporeal specimen stability. This raised the medial extent of the specimen as a distinct lympho-vascular sheath, leading to optimal medial highligation of ileo-colic, right-colic and relevant middle-colic vasculature with a resultant welldefined en-bloc radical resection. Dissection was continued to release superior and lateral peritoneal attachments. The specimen was delivered through a lower-midline laparotomy, resected and an extra-corporeal anastomosis performed. The gut was returned to the abdomen and a check laparoscopy performed after closure of the abdomen. Results: Five patients (age 54 + 16 years) were operated by the IRETA technique. The operating time was 159 + 14 minutes and blood loss 54 + 19 ml. An R0 resection was effected in all patients, proximal and distal margin lengths were 10–32 cm and 12–22.5 cms respectively. An average of 22.2 + 7 lymph nodes were resected. Patients were usually fed on the second post-operative day and fit for discharge by the third. On follow-up (26 + 7 months) all patients were disease-free. Conclusion: The IRETA technique for laparoscopic radical resection of the right colon appears to be an ergonomic and an oncologically-sound approach for oncological resection of cancer of the right colon. Greater numbers of patients with long term follow-up need to be assessed to inform us better about the oncological and technical soundness of this approach.



The Use of the EndograbTM Port-Free Endocavity Retractor in Single-Incision Laparoscopic Right Hemi-Colectomy

Laparoscopic Ventral Mesh Rectopexy for Obstructed Defaecation Using Biologic Mesh

Y. Hirano, M. Hattori, K. Douden, Y. Ishiyama, R. Ishibashi, Y. Hashizume

L. Bonomo1, D. Ziyaie1, L. Campbell2

Fukui Prefectural Hospital, Fukui, Japan Aims: The EndoGrabTM Port-Free Endocavity Retractor is an internally anchored retracting device that enables surgeons to reduce not only the number of incisions but also the number of assistant surgeons. Our institution performs single-incision laparoscopic colectomy (SILC) as a routine procedure. To perform SILC safely while maintaining the minimal invasiveness and the quality, the use of this retractor is essential, especially in difficult situations, such as an unfavorable visual field when performing a lymph node dissection around middle colic vessels. We report on our surgical procedures with this retractor. Methods: First, the right colon was mobilized using a modified medial approach. One of the two grasping ends of this retractor was attached to the mesenteric tissue, including the ileocolic vessels, while the other was anchored to the abdominal wall. Thus, the mesenteric tissue, including the ileocolic vessels, was retracted. The superior mesenteric vein was exposed and the ileocolic vein was divided at its origin. The ileocolic artery was divided at its roots, and all of the soft tissue anterior to the superior mesenteric vein was removed. Next, the mesentery of the transverse colon was anchored directly to the endocavity wall with this retractor. Consequently, the middle colic artery was exposed, and all of the soft tissue around the middle colic artery was also removed (D3 lymph node dissection). The right branch of the middle colic artery, the middle colic vein, and the accessory right colic vein were also divided at their roots. After mobilizing the colon, the specimen was extracted through the small incision. Resection was achieved, and the anastomosis was performed using staplers. Results: 49 patients underwent a curative resection of the colon cancer. The mean skin incision was 2.62 cm. The mean operative time and blood loss were 191.2 min and 59.6 ml, respectively. The mean number of harvested lymph nodes was 35.3. Postoperative complications occurred in two patients. The patients were discharged on 11.3 postoperative days. Conclusion: To perform laparoscopic colectomy safely while maintaining the minimal invasiveness of SILC and the quality of the lymph node dissection, the use of the EndoGrab Retractor is essential, especially in difficult situations.

1

Ninewells Hospital, Dundee, United Kingdom; 2Cuschieri Skills Centre, University of Dundee, United Kingdom Background: Anterior or Ventral Mesh Rectopexy (VMR) is established as a nerve sparing approach to correct rectal prolapse. Increasing experience with this approach focussing on the middle compartment of the pelvis has shown its ability to improve features of obstructed defaecation syndrome (ODS) and correct rectocele, enterocele and intusussception. The approach is greatly facilitated by laparoscopy but careful attention to details of the technique is required to achieve consistent results. Methods: This video of a 55-year-old woman with ODS illustrates the technique. Careful evaluation including anorectal physiology and video proctography are necessary. In this case rectocele, enterocele and intussusception are demonstrated and all three corrected by the technique. Critical steps include dissection in the rectovaginal septum down to the intersphincteric level and exposure of the sacral promontory. Peritoneum is excised at the Pouch of Douglas to deal with enterocele. Secure fixation of mesh to rectal muscle with a series of sutures is required prior to tack fixation of the mesh at the promontory. The mesh is fixed to the posterior wall of vagina with absorbable sutures to prevent enterocele and resolve vault prolapse. The peritoneum is sutured closed to exclude the mesh and tacks. There is increasing concern regarding the long term risk of synthetic mesh in the pelvis. We have used biological (porcine dermis) mesh as illustrated in this video. Results: In a series of 74 VMR procedures in our institution (23) 31% have been undertaken for ODS. All patients have shown significant improvement in the short term with no long term recurrences reported in those returning questionnaires (40.9%) Morbidity has been limited to temporary urinary dysfunction with no mesh related complications but one case of significant sacral discitis. Conclusion: With careful attention to detail laparoscopic VMR has the potential to significantly improve pelvic floor dysfunction. We have found this technique using biological mesh to be safe and effective in this complex group of patients.

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Hyperthermique Intraperitoneal Chemotherapy Through Single Incision Laparoscopic Surgery After Single Incision Laparoscopic Sigmoidectomy for Colon Cancer

Laparoscopic Right Colectomy with Intracorporeal Anastomosis and Liver Metastasectomy for Colon Cancer

F. Trelles, E. Chahine, R. Daher, E. Chouillard

E. Grzona, F. Carballo, M. Bun, A. Canelas, M. Laporte, J. Requena, P. Capitanich, N. Rotholtz

Hoˆpital de Poissy / Saint Germain-en-Laye, Poissy, France

Hospital Alemań, Buenos aires, Argentina

Introduction: The presence of peritoneal carcinomatosis (PC) decreases long-term survival in patients with non operable metastasis from colorectal cancer. Cytoreductive surgery (CRS) and hyperthermique intraperitoneal chemotherapy (HIPEC) has shown to be an effective treatment to increase long-term survival in multiple types of malignant tumors with peritoneal spread. Although it is feasible and allows long-term survival, it carries significant perioperative morbidity (grade 3–4, 25–50%) and mortality (3–6%). Laparoscopic CRS and HIPC may reduce postoperative complications and length of stay. We aim to present the feasibility and safety of HIPEC performed through single incision laparoscopic surgery (SILS). Materials and Methods: A 57-year-old male underwent SILS sigmoidectomy for stenotic colon cancer treated initially by self-expandable stent placement. Perioperatively, we removed a single 1-cm-malignant nodule in the mesentery. Histologically, the tumor was a moderately differentiated adenocarcinoma of the colon (pT4N + M0). Six cycles of adjuvant chemotherapy (FOLFOX) was administered with good tolerance and minimal digestive and neurological toxicity. At the end of chemotherapy, FDG-PET CT scan was negative for local and distant malignant disease. The patient underwent exploratory laparoscopy and HIPEC through SILS. Patient was placed in the split-leg position (French position). Ready access to the abdominal cavity was obtained through the navel. The multichannel platform (Gelpoint) is placed through the skin incision. Exploratory laparoscopy did not show malignant peritoneal spread. HIPEC was administered during 30 min through the multiport channel: Oxaliplatin 460 mg/m2 in 2 l/m2 of 5% dextrose at a temperature of 42–44 °C. Results: The patient tolerated well the procedure. Operative time was 240 min. Postoperative course was uneventful. Patient resumed diet on day 1 and was discharged on day 4. Final pathology of specimens (peritoneal granulations) was negative for malignancy. Conclusion: Exploratory laparoscopy and HIPEC through SILS is feasible and safe. This approach may contributes to reduce systemic inflammatory response associated with reduced parietal trauma and may impact on per operative outcomes.

Purpose: The ideal timing for patients with colorectal cancer to undergo surgery for resectable synchronous liver metastases remains under debate. Laparoscopic-assisted combined colon and liver resection is a feasible and safe procedure for the treatment of primary colorectal cancer with synchronous liver metastases. Methods: We present a video describing the steps for the laparoscopic right colectomy with intracorporeal anastomosis and liver metastasectomy for colon cancer. Description of the Video: Four 12 mm trocars are used in the umbilicus, left upper quadrant, left lower quadrant and suprapubic position. After rejecting liver and peritoneal metastasis the first step is to identify the tumor location cephalic traction of the cecum and identification of two important landmarks: the terminal ileum and ileocolic artery. Medial to lateral dissection is performed. The retroperitoneal elements are taken down. The ileocolic artery and medial colic artery are identified and ligated using a vessel sealer. The gastrocolic attachments are transected and the greater omentum is preserved with the specimen. After lateral dissection and complete mobilization of the colon a side to side intracorporeal anastomosis is performed. The specimen is placed in a protective bag and left in the hypogastric region while performing the liver resection. Mobilization of right liver. Intraoperative ultrasound is performed to rule out other metastases. The metastasectomy is performed with harmonic scalpel. Specimen is also placed in a protective bag. Liver hemostasis with argon plasma coagulator. A Pfannenstiel incision is performed to retrieve specimens.



The ‘Triple-Track’ Ergonomic Technique for a Laparoscopic Proctocolectomy in Colonic Neoplasia

Laparoscopic Low Anterior Resection with Transvaginal Specimen Extraction

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

F. Stipa, E. Soricelli, A. Burza

Sir Ganga Ram Hospital, New Delhi, India Aims: Colo-Rectal Cancer ranks among the top seven malignancies in India. We present an ergonomic technique for laparoscopic proctocolectomy in two cases of adenomatous polyposis coli, with one having malignancy in the descending colon. Methods: A complete oncological evaluation was completed pre-operatively. The operation was conducted through four 12-mm, two 5-mm ports and completed through three sets of dissection. The initial, ‘left-track’ dissection was begun ante grade, mobilising the sigmoid to distal transverse colon with transection of the inferior mesenteric vasculature. The second, ‘right-track’ dissection was begun pro grade with retrocolic mobilisation of the ascending colon and hepatic flexure. The ileocolic, right colic and middle colic vasculatures are then taken followed by a full mobilisation of colonic attachments. A mesorectal dissection in the ‘pelvic-track’ mobilises the rectum, which was transected at the ano-rectum. The specimen is extracted through a midline sub-umbilical incision. This staggered sequence was followed to avoid obscuring of vision by the bulky mobilised colon and mobile small bowel. An ileal ‘J’-pouch was created extra-corporeally, and a lap-assisted ilealpouch anal anastomosis performed by a 29-mm circular stapler. A diversion loop ileostomy completed the procedure. Results: Operative time was 280–480 minutes, blood loss 80–100 ml. Return to ambulation and liquid diet took 9 hours and 5 days respectively. The length of colo-rectum resected was 100–110 cms and the number of lymph nodes resected was 15–63. Duration of hospital stay was 10 days. Both patients are well at a follow up of 8.5 + 4 months. There was no complaint of urinary disturbance, impotence or dyspareunia. Conclusion: Laparoscopic proctocolectomy provides good oncological resection and quality of life outcomes in the short-term. Synchronous lesions with multiple quadrant dissection are not a hindrance to the mainstream performance of major laparoscopic colorectal oncological respective and reconstructive procedures. Greater numbers of patients with long term follow-up need to be data based to inform us better about the oncological and technical soundness of this approach natively.

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San Giovanni Addolorata Hospital, Rome, Italy Purpose: Total intra-abdominal laparoscopic colo-rectal resection avoids extensive mobilization of the left colon and the minilaparotomy. Natural orifice specimen extraction (NOSE) enhances the benefits of minimally invasive surgery. For female patients, transvaginal specimen extraction appears a feasible option. Methods: The video shows a laparoscopic low anterior resection in a 89 healthy female, who presented with a two months history of rectal bleeding. Pre-operative CT scan and combined virtual colonoscopy diagnosed a 3 cm stenosing rectal adenocarcinoma at 8 cm from the anal verge. The procedure started with the complete medial-to-lateral mobilization of the sigmoid colon and the ligation of the superior rectal artery. The mesorectum was excised along the lateral and posterior aspect of the mesorectal fascia and the rectum was completely freed from the levator ani muscles. A side-to-end colo-rectal anastomosis with a 31 mm circular stapler was performed. The anvil was introduced in the abdomen through one of the trocar incisions and inserted in the descending colon through a colotomy. At the end of the procedure the specimen was extracted through the vagina. The colpotomy was repaired laparoscopically. The postoperative course was uneventful and the patient was discharged in fifth post-operative day.

Surg Endosc



Single-Incision Laparoscopic Right Colectomy Without SinglePort Devices

Single Port Laparoscopic Ileocolic Redo Resection for Recurrent Crohn’s Stricture

A. Canelas, E. Grzona, M. Bun, M. Laporte, M. Galvań, N. Rotholtz, S. Guckenheimer

A. Ronan, F. Narouz, M. Cunningham

Hospital Aleman, Buenos Aires, Argentina Background: Single incision laparoscopic colectomy (SILC) is safe and feasible, although technically more difficult than straight multiport laparoscopic colectomy. SILC may have cosmetic advantages but additional cost in devices. The aim of this video is show the SILC technique without the use of single-port devices. Methods: We present a video describing the steps for the single-incision laparoscopic right colectomy without single-port devices. Description of the Video: This is a 61 year old female with a 3.5 cm villous adenoma with high grade dysplasia located on the ileocecal valve. After pneumoperitoneum was established a 4 cm midline umbilical incision without opening the fascia was performed. A 10 to 12 mm port was placed at the top of the incision and two 5 mm ports were aligned distally. The 5 mm camera was placed in the middle port. Using a medial to lateral approach the right mesocolon is sectioned beside the ileocolic pedicle and dissected away from the retroperitoneal structures. The ileocolic vessels were clipped and ligated and the right mesocolon sectioned. The right colic and right branches of the middle colic vessels were also ligated. The ascending colon and the hepatic flexure are detached laterally. The cecum is hold with a 5 mm grasper and the specimen is extracted through the midline incision using a wound protector. A stapled side to side ileocolic anastomosis was performed. The single midline incision was closed with absorbable sutures. Postoperative evolution was uneventful and the patient was discharge on the second day after surgery.

Beaumont Hospital, Dublin, Ireland Background: Single port laparoscopic surgery (SPLS) initiates its pneumoperitoneum via a 3–4 cm incision. It is therefore quite applicable and may be preferable for reoperations. Here we demonstrate the technique in a patient with Crohn’s disease and recurrent anastomotic structuring despite prior ileocaecal resection and medication. Patient: A 21 year old female presented with postprandial, crampy abdominal pain on a background of prior surgery and medication for Crohn’s disease. A Magnetic Resonance Enterogram (MRE) confirmed a short fibrotic stricture at the site of her ileocolonic anastomosis and so she was scheduled for redo ileocolic segmental resection by a single port laparoscopic technique. Procedure: The procedure commenced with a 3 cm transumbilical incision. After safe peritoneal entry, a wound protector-retractor was placed into the wound and then sealed for laparoscopy with a ‘Surgical Glove Port’. Thereafter the operation proceeding using a 30 degree high definition laparoscope with sterile in-line cabling (ENDOEYE, Olympus Corp) along with other standard, rigid instrumentation (primarily an atraumatic grasper and a LIGASURE sealer-cutter, Covidien). The strictured anastomotic segment was cleared of an omental adhesion and mobilized laterally with the patient in a head-up, right side-up position. The proximal colon was also fully mobilized and the duodenum as well as right gonadal vessels and ureter clearly identified and preserved. After medialisation of the diseased intestinal segment, the Glove Port was removed and the ileocolic portion for resection extracted (without further fascial extension) via the Single Port access site. A side to side stapled anastomosis was performed in the usual fashion and relaparoscopy performed after return of the bowel into the peritoneum. The single surgical site was closed over a tunneled bupivacaine infusion catheter to ensure local anaesthesia for the first 30 hours postoperatively. Outcome: The patient made an excellent recovery being mobilized and recommenced on oral diet the evening of the operation. Her bowel worked on the first postoperative day and she was discharged home on the morning of the third postoperative day. She remains well and has been recommenced on her medical therapy. Her pathology confirmed recurrent Crohn’s disease with resection margins clear of active inflammation.


V167 - Video - Thoracoscopic Surgery

Perforated Jejunal Diverticulum. Laparoscopic Management

Laparoscopic Transabdominal Transdiaphragmatic Excision of Pericardial Cyst

F.J. Buils Vilalta, J.J. Sańchez Cano, J. Dome`nech Calvet, R. Prieto, E. Raga, M. Parı´s, A. Munõz, D. del Castillo Hospital Sant Joan, Reus, Spain Aims: Diverticulae can occur anywhere along the digestive tract, but are most common in the colon. The incidence of diverticulae in the small bowel ranges from 1.1% and 2.3% of total intestinal diverticulae. Asymptomatic in 60–70% of cases and cause symptoms or surgical complications in 10–19%. We present a patient with complicated jejunal diverticulum managed totally by laparoscopy. Methods: 75 years old male with a history of colonic diverticulosis with diverticulitis episodes history by entering new episode of rectal bleeding. On the 4th day of admission, the patient presents abdominal pain of sudden onset associated with peritoneal irritation, suspecting complications of diverticular disease. On CT shows pneumoperitoneum secondary to transverse colon microperforation in the context of diverticular disease versus large jejunal diverticulum microperforation. The patient was placed in a supine position with the legs spread open in a 30° reverse Trendelenburg position. Exploratory laparoscopy is performed observing peritonitis secondary to a large perforated jejunal diverticulum, performing laparoscopic diverticulectomy using a linear stapler and abdominal cavity drainage. Results: The patient had good postoperative recovery with drains removal on the 6th day after surgery and was discharged at seventh day. The histopathology report revealed a jejunal diverticulum perforation in the wall. Discussion: The value of laparoscopy in patients with acute abdomen is known since the 50 s, but has been in the last decade when it has begun to be used in surgery as a diagnostic method, and in the majority of cases, also therapeutic. Most authors advocate economic intestinal resection in cases of perforated jejunal diverticulitis. In our case due to the large size of the diverticulum was feasible to implement diverticulum resection without intestinal resection.

M.K. Hussein American University of Beirut Medical Center, Beirut 1107 2020, Lebanon Aims: This video demonstrates the steps used to excise a pericardial cyst. Method: Through an incision done in the right diaphragm using monopolar cautery and the use of Ligasure to excise the cyst from the pericardium. Precaution was used to rule out Hydatid Cyst by deflation of the cyst followed by inflation with citramide. Results: The diaphragm post excision was sutured with 2-0 prolene continuous sutures. Conclusion: Transabdominal Transthoracic approach to remove intra thoracic lesion is feasible with no morbidity.

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Thoracoscopic Mesh Repair of Congenital Diaphragmatic Hernia

Laparoscopic Resection of Esophageal Diverticulum Followed by Lap Cardiomyotomy and Lap Toupet

M. Ismail lotfalla, R. Shalaby Al Azahar University, Giza, Egypt Background/Purpose: Repair of recurrent diaphragmatic hernia continues to be a difficult problem. The aim of this study is to detect the size of diaphragm defect in need of transthoracic mesh application to avoid recurrence. Methods: A retrospective analysis Showed 52 cases of congenital diaphragmatic (CDH) who underwent repair at Al Azaher University hospitals along the last eight years. Their age ranged from one week to 8 years (1.6 years on average). They were 22 males and 30 females. The diaphragmatic defect was found to be more than 1 cm in 16 cases suffered from recurrence. The diaphragmatic defect does not reach the thoracic wall in all cases. ECHMO was not used in any case. Thoracoscopic correction of the recurrent cases using double face mesh was done. Follow-up was available in all children and ranged from 2 to 4 years (average, 1.5 years). Results: Age at recurrence ranged from 1 month to 48 months (average, 18.6 months), and the average time between initial repair and recurrence was 6.2 months (range, 1 to 12 months). There were no recurrences after the transthoracic double face mesh diaphragmatic repair. Conclusion: Primary mesh application in all diaphragmatic hernia with a defect more than 1 cm is recommended to avoid or at least minimize recurrence. The transthoracic repair of recurrent diaphragmatic hernias using a nonabsorbable prosthetic double face mesh represents an excellent approach to a difficult problem.

M.K. Hussein American University of Beirut Medical Center, Beirut, Lebanon Aims: Esophageal diverticulum is a rare clinical presentation due to Motility dysfunction and high pressure at the distal esophagus. Methods: 55-year-old lady presented to the American University of Beirut Medical Center with severe dysphagia and chronic cough. Investigational studies revealed large distal esophageal diverticulum measuring 7 9 5 cm. Patient underwent Lap resection of esophageal diverticulum followed by Lap cardiomyotomy and anti reflux Toupet. Results: Patient had smooth postoperative course and discharged from hospital 7 days later. Conclusion: The video will demonstrate clearly the steps used to complete the procedure.



Thoracoscopic Mediastinal Lymph Node Dissection for Lung Cancer by the Energy Device (LigasureÒ)

Thoracoscopic and Laparoscopic Esophagectomy

K. Nishioka1, T. Iwazawa2, R. Watanabe1, E. Nakao1, N. Tsujimura1, T. Ohtsuru1, T. Matsumoto1, H. Takemoto1, K. Takachi1, T. Aoki1, S. Iijima1, Y. Uemura1, K. Kobayashi1 Kinki Central Hospital, Hyogo, Japan; 2Toyonaka Municipal Hospital, Osaka, Japan 1

We evaluate the feasibility of thoracoscopic mediastinal lymph node dissection for lung cancer by the energy device, Ligasure Ò. We performed VATS lobectomy and mediastinal lymph node dissection with 2 access windows both 3 cm lengths and 1 camera port completely under thoracoscopic view. We use a energy device called Ligasure blunt tipÒ(COVIDIEN), which is very convenient and safe especially to dissect the medistinal lymph node with no ligations or clippings. Now we present a video of thoracoscopic superior mediastinal lymph node dissection for lung cancer after right upper lobectomy by Ligasure blunt tipÒ. In addition, we examined the perioperative data of these operations. Up to now, we have performed aforementioned operation for 50 lung cancer patients. Perioperative data were as follows; (1) (2) (3) (4) (5)

Median duration of the mediastinal lymph nodes dissection: 33 minutes (10–83) Median blood loss including lobectomy: 25 ml (10–160) Median day of drain removed: 3rd (1–8) POD (Post Operative Day) Median dissected lymph nodes: 10 (2–35) Complication: arrhythmia; 2 cases (4%)

Thoracoscopic mediastinal lymph node dissection for lung cancer by Ligasure blunt tip is feasible.

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A. Paganini, A. Balla, S. Quaresima, T. de Giacomo, I. Onorati, P. Bruschini, F. Francioni Sapienza University, Rome, Italy Aims: Open esophagectomy is at a high risk of morbidity and mortality. Mini-invasive esophagectomy (MIE) with hybrid approaches has been reported. Aims of this preliminary study is to describe mini-invasive McKeown technique for non-advanced esophageal cancer. Methods: From July 2013, four patients (3 males, 1 female), mean age 59.5 years (range 38–76) were enrolled. Inclusion criteria were: Barrett’s esophagus with high grade dysplasia, iT1–T2–T3 iN0 cancer. Diagnostic workup included: endoscopy with biopsies, total body CT scan, Esophagogram, Bronchoscopy. Preoperative staging was: iT2N0 (3), iT3N0 (1). The latter patient underwent neoadjuvant radiochemotherapy (nRCT). All patients underwent thoraco-laparoscopic esophagectomy with cervical anastomosis with the following technique: first, the patient is placed in left lateral decubitus position with 4 trocars in the right chest, the esophagus is circumferentially mobilized from the hiatus to the thoracic inlet preserving the azygos vein and including surrounding lymph nodes and periesophageal tissue. Then, the patient is turned in supine position with 5 abdominal ports placed under vision. Mobilization of the greater curvature of the stomach preserving the right gastro-epiploic vessels is performed. After opening the lesser omentum, the left gastric vessels are divided and local lymphadenectomy is carried out. After left cervicotomy, the esophagus is identified and divided with linear stapler, preserving the laryngeal nerve. A tape is sutured to the distal stump. The esophagus and stomach are delivered through a minilaparotomy and a long gastric conduit is created extracorporeally by dividing the stomach with linear stapler. The gastric conduit is sutured to the tape and pulled through the mediastinum to the cervicotomy. A stapled side-to-side esophagogastric anastomosis is performed. Results: Mean operative time was 478 minutes (range 455–500). No conversion to open surgery, no morbidity and no mortality were observed. Mean hospital stay was 11.6 days (range 10–13). Oral intake started on 7th p.o.day. Final staging was: ypT0N0M0 G2 (1), pT2N0M0 G2 (1), pT3N0M0 G2 (1). For the last patient final histology is ongoing. Mean lymph nodes’ harvest was 12 (range 8–18). Conclusion: Combined thoraco-laparoscopic MIE for cancer is safe and effective with low morbidity. Longer patients series are required for definitive results.

Surg Endosc


V176 - Video - Basic and Technical Research

Three-Field Esophagectomy by Thoracoscopy, Laparoscopy and Cervicotomy in Oesophageal Carcinoma

Single-Port Nephrectomy for Live Kidney Donation with the r2 Curve System in a Pig Model

A. Delitala, M. Garancini, E. Pirondini, V. Bedini, P. Riva, A. Giani, M. Scotti, E. Bolzonaro, V. Giardini

M. Zdichavsky1, K. Krautwald2, T. Meile1, M. Feilitzsch1, A. Ko¨nigsrainer1, M.O. Schurr3

HSGererado, Monza, Italy

1

From January 2009 and June 2013 we treated surgically 28 cases of oesophageal carcinoma. 16 of them underwent to three-field total esophagectomy with thoracoscopic, laparoscopic and cervicotomy approach. The video shows our technique with particular procedure features: thoracoscopy in semiprone position, nodal dissection, external gastric tubulization without piloroplasty neither kocher maneuver, anterior muscle-sparing cervicomy

University Hospital Tu¨bingen, Germany; 2Novineon CRO & Consulting Ltd, Tu¨bingen, Germany; 3Tu¨bingen Scientific Medical, Tu¨bingen, Germany

Aims: Single-port laparoscopic donor nephrectomy provides low morbidity, and satisfactory cosmetic results in experienced centers. Curved laparoscopic instruments support dissection in difficult angles while ergonomic hand and arm position are assured. The aim of this animal study was to demonstrate feasibility and establish a surgical technique of laparoendoscopic single-site (LESS) living donor nephrectomy using novel curved instruments. Methods: For left LESS donor nephrectomy the animal was placed in a right lateral decubitus position and for right LESS kidney dissection the animal was turned to the opposite side. A vertical 5 cm-subumbilical incision was performed and a single-access device was inserted into the abdomen. A 10 mm 30° extra long laparoscope was used, and two r2-curved instruments (Tuebingen Scientific Medical) were inserted via the single-port device. Graspers, Maryland dissectors and bipolar scissors were used for mobilization of the kidney and dissection of the vessels, which were closed with an Endo GIA vascular load device. Results: After exposing the left kidney in the retroperitoneum the peritoneum was removed ventral and caudal from the kidney. The adrenal gland was separated off the upper pole of the kidney with the bipolar scissors. The renal hilum was carefully dissected, and the renal vein was cleared from the surrounding tissue and separated from the renal artery. Finally, the ureter was elevated off the psoas muscle and divided at the iliac artery. After stapling of the vessels using a linear stapler the kidney was mobilized from the remaining retroperitoneal attachments. After complete exposure of the kidney, the organ was easily removed via the singleport. For right kidney donation, the dissection was performed equivalent to the left side except for the mobilization of the peritoneum which was done ventral to the kidney at the level of the vena cava. The average mean OR time per nephrectomy was 50 minutes. Conclusions: In this animal study we could demonstrate that the new curved and deflectable instruments enable technically simple and fast laparoscopic organ harvesting, comparable to conventional laparoscopic procedures. Single port laparoscopic nephrectomy might be more patient-friendly and improve the willingness of potential donors to donate live organs.

V174 - Video - Basic and Technical Research

V178 - Video - Robotics, Telesurgery and Virtual Reality

Results: of the First-in-Human Trial of the LiVac Laparoscopic Liver Retractor System

Laparoscopic and Robotic Right Colectomy with Complete Mesocolic Excision and Intracoroporeal Anastomosis

S.L. Gan

W. Petz, I. Monsellato, G. Scifo, A. Gatti, P.P. Bianchi

St John of God Hospital, Warrnambool, Australia

European Institute of Oncology, Milan, Italy

Aims: The LiVac Laparoscopic Liver Retraction System is a novel surgical device, which utilises suction to adhere the liver to the diaphragm and thereby attain retraction of either the right or left lobes of liver without requiring additional skin incisions. A First-in-Human Proof of Concept trial was designed to evaluate the performance and safety of this retractor, which was not commercially available at the time of the study. Methods: A multi centre (2), open-label non-randomised study was conducted by one surgeon on ten patients. Healthy adults patients who were scheduled to undergo elective laparoscopic cholecystectomy, primary gastric banding or fundoplication were eligible. Performance was measured by the achievement of milestones for the device components, and safety outcomes by the recording of Adverse Events (AEs), Serious Adverse Events (SAEs), and Device Related Adverse Events (DRAEs). Success was determined by the attainment of all milestones in = 80% of assessable patients. Data was recorded by Clinical Trials Coordinators and verified by Trials Monitors. Any DRAEs were required to be reported to an independent expert surgeon and the two Human Research Ethics Committees. The Trial was conducted over October to December 2013, and was supported by an Australian Federal Government grant. Results: The LiVac Retractor was used on the right lobe for 3 SILSTM Cholecystectomies and 3 reduced port cholecystectomies (Hasson technique), 3 reduced port laparoscopic adjustable gastric bandings (LAGB) and 1 reduced port laparoscopic hiatus hernia repair with anterior fundoplication. All milestones were attained for all components of the LiVac Retractor System, in all ten patients with no Device Related Adverse Events. Summary data will be presented along with a video demonstration of the device. Conclusion: The LiVac Laparoscopic Liver Retraction System achieves safe and effective liver retraction of either the right or left lobes of liver, without requiring additional skin incisions.

Background: Minimally invasive surgery is an established treatment for resectable colon cancer, but technical details of laparoscopic (LAP) and robotic (ROB) right colectomy (RC) are still not standardized. Complete mesocolic excision (CME) has demonstrated to reduce recurrence rate after colectomy. The video shows technical aspects of LAP and ROB RC with CME and intracorporeal anastomosis (IA). Methods: The patient is positioned in dorsal decubitus with the table in slight Trendelenburg and 10 degrees left rotation. In LAP RC four trocars are inserted: Two of ten mm (left paraumbilical for the optical system and in left hypochondrium) and two of five mm (sovrapubic and subxifoid). In ROB RC, one accessory trocar is inserted in the left flank; the robotic cart comes from the patient’s right shoulder. The first step of intervention is exposure of the right margin of superior mesenteric vein, to dissect and ligate ileo-colic vessels at their origin. This permits to realize a CME proceeding cranially with vascular dissection and ligating the right colic vessels and the right branches of middle colic vessels. The duodenal plane and the venous Henle trunk are identified and respected. Colo-epiploic detachment permits to mobilize the hepatic colic flexure. The transverse mesocolon and the mesentery are then dissected to the prefixed transection points on the transverse colon and the ileum; then bowel transection is performed by linear endostapler. An intracorporeal side to side mechanical anastomosis is performed, a manual running suture is realized to close the stapler insertion holes and the specimen is extracted through a Pfannenstiel mini-laparotomy. Results: Eighty-two patients with right colon cancer underwent minimally invasive right colectomy with CME and IA (64 LAP, 18 ROB). Mean operative time was 230 minutes and blood losses were negligible. Median number of harvested lymph nodes was 26, resection margins were negative in all patients. First bowel movements were observed on third postoperative day and median hospital stay was 6 days. No local recurrence occurred. Conclusions: Minimally invasive RC (LAP and ROB) with CME and IA is a feasible technique and permits to obtain highly satisfactory oncologic results.

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V179 - Video - Technology

V181 - Video - Technology

The Use of ICG Fluorescence to Control Vascularization of the Bowel During Laparoscopic Colorectal Resection

Bipolar Radiofrequency Induced Intestinal Anastomosis in an Acute Porcine Model - A Pilot in Vivo Study

C. Colombo1, E. Cassinotti2, L. Giavarini2, D. David2, A.L. Marzorati2, S. Spampatti2, G. Borroni2, V. Quintodei2, L. Boni2

S. Arya1, N.T. Clancy2, V. Chalau3, H. Kudo4, R.D. Goldin4, D.S. Elson2, G.B. Hanna3

1

Imperial College London, 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

Ospedale di Circolo - Fondazione Macchi, Varese, Italy; Minimally Invasive Surgery Research Center, Varese, Italy

2

Aims: Inadequate vascularization of the anastomosed bowel is one of the most important factor related to postoperative anastomotic leaks. Using fluorescence induced by nearinfrared (NIR) light from indocyanine green (ICG) the microcirculation of the bowel can be assessed before the anastomosis is performed. Material and Methods: NIR camera associated to special NIR light source and 10 mm. 30° scope equipped with a special lent (Karl Storz GmbH, Tuttlingen, Germany) is used during a standard laparoscopic colorectal resection. ICG is a sterile, water-soluble, tricarbocyanine compound that once injected intravenously rapidly binds to plasma protein. Once excited by NIR, ICG release fluorescence that can be detected by the system providing the visualization of vascular structures giving proof of perfusion of the bowel segments. Results: The video shows our initial experience using NIR to evaluate blood supply in colorectal surgery. We used this technology in several colorectal procedures such as left, right colectomies as well as anterior rectal resection, to assess blood supply to bowel segments prior transection of the segment to be anatomised as well as after the anastomosis is completed. All the procedures were carried out in the standard fashion. The optimal point of transection was marked by the surgeon under white light, followed by intravenous injection of 3–4 mg of ICG. The bowel was then visualized with near-infrared camera, showing the perfusion. Fluorescence response in the mesenteric blood vessels and tissue was visible within 50 seconds of the injection of the fluorescent dye. In some cases NIR demarcated an ischemic zone in the colon stump, so the surgeon could then decide to revise the point of transection. Conclusions: Real-time identification of bowel perfusion can help surgeons to choose the best possible bowel to be used for a correct anastomosis. This could be especially relevant with in non-standardized colic resection where vascular abnormalities can impair blood supply. ICG fluorescence is a safe, feasible and effective technique in colorectal surgery and may play a role in anastomotic tissue perfusion assessment affecting the anastomotic leak rate and improving the patient outcome.

V180 - Video - Technology Transvaginal Hybrid-Notes Anterior Resection Using an Articulating HD 3D Laparoscopic Surgical Video System S.H. Lamm, A. Zerz, D.C. Steinemann Bruderholz/Kantonsspital Baselland, Bruderholz, Switzerland Objective: Although, in standard laparoscopy anterior resection can usually be performed using two five millimetre incisions and two twelve millimetre trocar (for insertion of the Endostapler), there remains the need for a minilaparotomy for specimen removal. The removal of the specimen through the vagina avoids a minilaparotomy and therefore additional harm to the abdominal wall. In our opinion the rigid hybrid-NOTES technique is the perfect tool to convert laparoscopically assisted operations into totally laparoscopic procedures. Methods: In this instructive HD 3D video we present our technique of transvaginal hybridNOTES anterior resection in diverticular disease. The film combines intra- and extracorporal pictures, simultaneous taken during the operation in HD 3D quality with computer animations of each operation step. Results: After positioning of the patient the procedure is started with our standard medial mobilization of the left hemicolon. Afterwards the infrapancreatic ligation of the inferior mesenteric vein and the central ligation of the inferior mesenteric artery are performed using an energy device. The mobilization is completed from lateral. Afterwards the proximal rectum is prepared and dissected. The specimen is extracted through the vagina, followed by an extracorporal preparation of the descending meso and purse-string suture after insertion of the anvil in the oral colon. Afterwards, the vaginal wall is sutured. A circular stapler is inserted transanally and the end-to-end anastomosis is performed. Conclusion: In our experience on more than 200 patients the transvaginal hybrid-NOTES anterior resections is a safe and feasible evolution of the standard laparoscopic procedure. The 3 D depth perception improves the accuracy and precision of surgical tasks.

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Aims: Bowel anastomosis is required to restore enteric continuity following resection. However, it may be technically challenging in some situations leading to anastomotic leakage, peritonitis and death. Bipolar radiofrequency (RF) energy is commonly utilised to attain consistent tissue dissection and haemostasis and is additionally recognised to have the potential for rejoining luminal structures. This video describes a novel in vivo technique for forming bipolar RF induced intestinal anastomoses in an acute porcine model. Methods: Fifteen bipolar RF induced side-to-side small bowel anastomoses were formed in vivo in three pigs using a commercial (LigaSure ImpactTM) and prototype RF sealing device powered by a closed loop, feedback controlled radiofrequency generator (Covidien, Boulder, CO, USA). The prototype device was used to seal and divide a bowel segment and following adequate alignment of the remaining proximal and distal loops, two enterotomies were created. Each jaw of the LigaSure impactTM device was placed into a single bowel lumen and clamped. RF energy was applied at a constant pressure and end impedance (100 ohms) but the speed of application (ramp) was varied to 0.01, 0.05 or 0.001 ohms/ms, resulting in a seal cycle of 10, 20 or 100 s. A total of four fusions were made to complete neo-lumen formation. The enterotomy site was closed using the prototype sealer and oversewn. The anastomosis was then returned to the abdominal cavity and re-examined prior to excision for histological analysis. Results: In total 15 anastomoses were formed (5 at each ramp level). The mean time to reexamination following completion was 153.9 minutes (38–311 minutes). Fourteen anastomoses (93%) were intact on assessment with one technical failure. All seals were found to be grossly viable with none of the intact anastomoses demonstrating leak when subjected to clinical stress. Furthermore, on histological examination the seals in these anastomoses were fully formed. Conclusion: In this video we have demonstrated the technical method of forming radiofrequency induced small bowel anastomoses in the acute porcine model with clinical and histological evidence of good short term viability. Radiofrequency technology has the potential for future use as an alternative method of bowel anastomosis.

V183 - Video - Oesophageal and Oesophagogastric Junction Disorder Accidental Injury of Left Hepatic Vein After Simple Liver Cyst Unroofing During Laparoscopic Nissen Fundoplication K. Albanopoulos, N. Memos, N. Natoudi, G.Z. Vrakopoulou, G. Zografos, E. Leandros University of Athens, Athens, Greece Introduction: Unexpected complications following Laparoscopic Nissen fundoplication. A rare case and its treatment. Aims: We aimed at reporting accidental left hepatic vein injury during Simple liver cyst unroofing. Case Video Presentation: A 75 year old female patient was admitted to our hospital for laparoscopic Nissen fundoplication due to a large sliding hiatal hernia. The patient had a large simple cyst in the left lobe of the liver that was tested negative forechinococcialorigin. Patient was placed in a low lithotomy position and reverse Trendelenburg. The cyst was in front of our operating field and we performed unroofing of the cyst. During our efforts near the right crus, the left hepatic vein was partially injured. We stopped the bleeding with endoclip without deviation. We then performed typical Nissen fundoplication. One drain was placed near the right crus draining the unroofed cyst. The patient followed uneventful post-operative course with liquid diet at first postoperative day and removal of drain on the 2nd post operative day. The patient was discharged from the hospital on the 4th post operative day.

Surg Endosc



Laparoscopic/Thoracoscopic Surgery for Complex Type II–IV Hiatus Hernias

Robotic Wedge Resection of Gastric Mesenchimal Tumours

S. Mattioli1, N. Daddi2, A. Ruffato1 University of Bologna, Italy; 2Division of Thoracic Surgery University of Perugia, Italy

W. Petz, I. Monsellato, G. Scifo, A. Gatti, P.P. Bianchi European Institute of Oncology, Milan, Italy

1

Aims: In order to demonstrate the feasibility and the corner stones of the minimally invasive surgical technique for the treatment of type II–IV hiatus hernia we show the case of a 66-year-old woman with 20 years history of GERD symptoms, dyspnoea with orthopnea, erosive oesophagitis and recurrent sideropenic anaemia. Barium swallow shows a paraesophageal hiatus hernia. We present a second case of a 56-year-old man complaining severe GERD symptoms since six years with painful dysphagia, erosive oesophagitis. Barium swallow shows a non-reducible 10 cm diameter massive incarcerated hiatus hernia. Methods: The steps of the surgical procedure are: (1) complete resection of the hernia sac and fat pad with preservation of the vagus nerves, (2) localization of the position of the gastro-oesophageal junction with respect to the apex of the hiatus with a combined endoscopic-laparoscopic procedure, (3) measurement of the length of the submerged oesophageal segment, (4) isolation of the mediastinal oesophagus, (5) Collis gastroplasty in case of short oesophagus, (6) hiatus alloplasty, (7) Nissen floppy fundus plication. Results: After maximal oesophageal mobilization, in the first patient the gastro-oesophageal junction was placed 2.5 cm below the hiatus and a standard fundus plication was performed, in the second case the gastro-oesophageal junction was placed across the hiatus and a combined laparoscopic-left thoracoscopic Collis gastroplasty was necessary. Conclusion: The minimally invasive approach for complex hiatus hernias appears feasible.

Background: Surgical resection with negative margins is the treatment of choice of gastrointestinal stromal tumors (GIST) and of gastric symptomatic benign tumours. Robotic approach can allow a minimally invasive approach even to gastric lesions located near the oesophago-gastric junction or the pylorus. Methods: The video presents 2 cases of robotic wedge resections. The first was a 52-year old man with a preoperative diagnosis of a 3 cm PET positive right paracardial lesion; the second was a 52-year old woman with a histologically proven 7 cm mesenchymal tumour of the gastric lesser curve. Radiologic diagnosis was made with CT scan and endoscopic ultrasound. With patients in dorsal decubitus and open legs, one optical supraumbilical trocar, three 8 mm robotic trocars in left and right hypochondrium and two accessory trocars in the left flank were inserted. Intraoperative ultrasonography confirmed the exact localization of the lesion. In the first patient, after opening the lesser sac by sectioning the gastro-colic ligament, the lesion was separated from the esophago-gastric junction wall and an intraoperative endoscopy confirmed the absence of esophageal iatrogenic perforation. In the second patient, a gastrotomy was performed and the tumour resected by harmonic scalpel. The gastrotomy was closed by two-layer absorbable manual running sutures. Results: Operative time was 180 minutes, blood loss was negligible, no intraoperative and postoperative complications occurred. Oral feeding was started on third postoperative day after a negative radiographic contrast study, and patients were discharged on fourth postoperative day. Histopathological examination revealed a leiomyoma in the first patient and a high risk GIST with negative resection margins in the second patient, who was addressed to adjuvant treatment. Conclusions: Robotic resection of gastric GIST and benign lesions is a feasible and safe procedure even if tumours are located in difficult anatomic regions. Robotic assistance allows precise dissection of tumors and facilitates fine surgical gesture as gastric wall suture.



MIS in Boerhaave’s Syndrome

A Porcine Model of Laparoscopic Reoperation After Prosthetic Hiatoplasty

J. Sanchez Cano, F. Buils Vilalta, R. Prieto Butille, J. Domenech Calvet, M. Paris, E. Raga, A. Munõz, D. del Castillo Dejardin Hospital Sant Joan de Reus, Spain Introduction: The spontaneous rupture of the esophagus (Boerhaave’s syndrome) was first described by Herman Boerhaave. Since then, different treatment proposals have been performed ranging from conservative options (non-operative means) to extended procedures such as esophagectomy. Minimally invasive surgery (MIS) and endoscopic procedures have broadened the therapeutic options. Patient and Method: SA 42 year-old male with sudden epigastric pain after vomiting for 24 hours. Laboratory tests showed septic criteria but there were no other SIRS criteria. The thoracic-abdominal CT-scan showed a small contained leak in the lower third of the esophagus. The initial non-operative management was changed two days after the admission due to laboratory tests and CT-scan images worsening. A laparoscopic approach was performed. We found a 5 centimetres-long esophageal longitudinal rupture in the left side of the oesophageal-gastric junction. We performed a primary repair of the rupture (discontinuous suture) and Nissen fundus plication. Results: The patient was kept on parenteral nutrition. After a normal esophago-gastric swallow on the 10th postoperative day, the patient started progressive diet with no other complications. He was discharged the 15th postoperative day. Discussion: The small contained leaks without signs of sepsis in patients with Boerhaave’s syndrome can be managed non-operatively with a good outcome. Aggressive surgical management with direct repair is associated with good survival when sepsis progresses while its delay is associated with increased mortality. MIS can be used to achieve oesophageal epithelisation and resolution of sepsis.

C. Markakis1, A.E. Papalois2, P. Dikeakos1, E. Spartalis1, N. Psychalakis2, D. Perrea1, M. Safioleas1, P. Tomos1 1 University of Athens, Greece; 2ELPEN, Experimental Research Centre, Pikermi, Athens, Greece

Aims: Use of prosthetic materials to reinforce hiatoplasty during hiatal hernia repair has been shown to reduce recurrence rates. However recurrences and complications do occur and, in these cases, reoperative intervention can be challenging. The rarity of these cases means that it is difficult for surgeons to acquire experience in dealing with these difficult patients. The aim of this study is to present a video showing how a porcine model can be used to help surgeons gain experience in dealing with reoperation after prosthetic hiatoplasty. Methods: The operation was performed on 24 domestic pigs (26–37 kg bodyweight), using 5 trocars. The phrenoesophageal ligament and crura were dissected free and a posterior cruroplasty was performed. The dimensions of the crura were measured and a piece of either biological (Surgisis, small intestinal submucosa), synthetic bioabsorbable (GORE BIO-A, Polyglycolic acid-Trimethylene Carbonate), autologous (fascia lata) or synthetic non-absorbable (polypropylene) material was tailored and fixed to the crural repair. Two months after surgery the animals were re-operated upon laparoscopically. Adhesions were evaluated and then taken down and the crural region was dissected free. Both operations were recorded in order to analyze their technical aspects. Results: The operation was completed successfully on 22/24 animals, while two animals died, both in the immediate postoperative period. Minor bleeding from the liver and spleen was observed in 9 animals, while gastric perforation occurred in one animal. Reoperation was completed laparoscopically in 15/22 animals, while the rest of the animals had dense adhesions, which prevented dissection of the crura. The difficulty of the dissection varied significantly according to the type of prosthetic material used on each animal. Conclusions: Reoperative intervention after prosthetic hiatoplasty is challenging in clinical practice and this has also been confirmed in our porcine experimental model. Use of this model enables the surgeon to appreciate the differences in adhesion formation and incorporation of each prosthetic material and could be a valuable tool in the effort to improve outcomes in these difficult cases.

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Surg Endosc



Laparoscopic Nissen Fundoplication and Hiatal Hernia Repair Using Polyglycolic Acid: Trimethylene Carbonate Mesh for Large Paraesophageal Hernia

Hellers Cardiomyotomy and Anterior Fundoplication for Achalasia - An Educational Video

G. Casella, E. Soricelli, D. Giannotti, G. di Rocco, G. Patrizi, A. Redler ,,Sapienza,, University of Rome, Rome, Italy Background: Clinical outcome of mesh hiatoplasty are burdened by a low but not negligible incidence of complications such as dysphagia, stricture, and erosion of mesh into the esophagus and stomach, which can require a surgical management. Biologic mesh seems to reduce the incidence of these complications but it appears to be less effective in preventing the recurrence of hiatal hernia (HH) when compared with synthetic mesh. More recently an absorbable mesh has been introduced (GORE BIO-A Tissue Reinforcement; W. L. Gore, Flagstaff, AZ). It consists in a polymer of polyglycolic acid:trimethylene carbonate (PGA:TMC) which is completely absorbed and replaced with the patient’s own connective tissue after six months. This may be advantageous in avoiding complications such as erosion and infection by minimizing foreign body presence. Preliminary data shows that BIO-A is handy and easy to place, with a reasonable low incidence of hiatal hernia recurrence and no mesh related complications. Video: The video shows a laparoscopic Nissen fundoplication and hiatal hernia repair with GORE BIO-A absorbable mesh in a 75 years old female presenting with a symptomatic large hiatal hernia. A five trocars technique was used (two 12 mm and three 5 mm trocars). At laparoscopy the hiatal defect appeared to be more than 5 cm wide. The herniated stomach was reduced into the abdomen. The phrenogastric ligament was divided and the hernia sac was dissected free from its attachments. Two shorts gastric vessel were divided in order to achieve an adequate mobilization of the gastric fundus. Then the lesser sac was divided and the diaphragmatic pillars were dissected. Intramediastinal isolation of the esophagus was carried out until at least 4 cm of the esophagus were brought into the abdomen. The hiatoplasty was performed by means of three non absorbable stitches. Then GORE BIO-A was placed and fixed with Tisseel. Finally a 2 cm ‘‘floppy’’ Nissen fundoplication was tailored using two nonabsorbable stitches. Operative time was 180 minutes. Post-operative course was uneventful and patients was discharged four days after surgery with a semisolid diet. Six months after surgery the patient was asymptomatic and the barium swallow showed no HH recurrence.

V190 - Video - Oesophageal and Oesophagogastric Junction Disorder New Prosthetic Material and Fixing Method: For Laparoscopic Repair of Large Hiatal Hernias S. Morales-Conde, J. Can˜ete, A. Barranco, J.A. Navas, M. RubioManzanares, M. Socas, H. Cadet, F.J. Padillo, I. Alarcoń University Hospital Virgen del Rocıó, Sevilla, Spain Aims: Laparoscopic repair of large hiatal hernias (LRLHH) is still considered a challenge for surgeons, since the rate of recurrences of these hernias seems to be high and meshrelated complications, such as erosion of the esophago-gastric junction, are being described as a life-threatening complication. Biological an absorbable meshes have been proposed as alternative to permanent prosthetic materials in order to avoid these complications, but the rate of recurrences when using these meshes are high, being very poor the promising results originally expected. Method and Video: In order to minimize the risk related to the placement of permanent meshes in the hiatus and to maintain the recurrence rate low, we have changed our technique described years ago. The basic steps of the hiatal hernia repair are followed, such as a correct dissection and reduction of the hernia sac, a correct abdominalization of the esophago-gastric junction and a proper dissection of the both pillars. The crus is closed alternating posterior and anterior double suture, trying to have the esophagus resting on natural muscular tissue. The hiatorraphy performed is reinforced by using a mesh posterior and lateral to the esophagus, which should not be in contact with it, being placed one centimetre apart from the esophagus. The mesh should not be fixed using tackers since complications has been described related to this method of fixation, using fibrin glue as fixation method for this reason. Based in our experience in laparoscopic inguinal hernia repair with non-traumatic fixation, we were looking for a large pore mesh of a permanent material that could be placed intraperitoneally. A large pore PTFE-c is placed in the hiatus being stabilized with two sutures, being fixed with fibrin glue using the laparoscopic spray applicator devices, that allows the small drops to go through the mesh and to fix it properly. The natural tissue that the fibrin glue creates around the mesh also avoids the mesh contacting with the esophagus. Excellent results have been demonstrated with this technique after a 18 months follow-up, what open a new perspective of this technique for the future.

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A.M. Harris Hinchingbrooke Hospital, Huntingdon, United Kingdom Achalasia is a rare condition causing dysphagia, regurgitation and consequent weight loss. This video presents a demonstration of the technique involved in performing an adequate cardiomyotomy followed by an anterior fundoplication in order to prevent acid reflux. Ports are placed in usual position for fundoplication; the oesophago-gastric junction is displayed by a combination of blunt and harmonic dissection. The cardiomyotomy is demonstrated in close detail with confirmation of adequacy of dissection and no mucosal perforation confirmed on endoscopy. The final step is a standard anterior fundoplication. The patient made a good post-operative recovery and six months later was able to enjoy a full diet with no dysphagia, resulting in weight gain and complete satisfaction. This is intended to be an educational video for senior laparoscopic trainees or consultants wishing to learn this operative technique.

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.

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Abstracts of the 21st International Congress of the European Association for Endoscopic Surgery (EAES), 19-22 June 2013, Vienna, Austria.

Early rectal cancer: the European Association for Endoscopic Surgery (EAES) clinical consensus conference.

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Editorial: International Plant Proteomics Organization (INPPO) World Congress 2014.

Reports from the International Liver Cancer Association (ILCA) congress 2014.

Abstracts of the European Vitreoretinal update 14th Euretina Congress, 2014, London, England.

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Abstracts of the Joint Congress of European Neurology, 31 May-3 June, 2014, Istanbul, Turkey.

CARS 2014: Computer Assisted Radiology and Surgery--Proceedings of the 28th International Congress and Exhibition Fukuoka, Japan, June 25-28, 2014. Preface.

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Abstracts of the 22nd Congress of the European Sleep Research Society, 16-20 September, 2014, Tallinn, Estonia.

Second International Congress on Pediatric Pulmonology Nice, France, June 2–5, 1996.

Abstracts of the 14th Annual Congress of the French Speaking Society of Transplantation, 2-5 december, 2014, Caen, France.

The Seventh World Congress of Pediatric Cardiology and Cardiac Surgery, Istanbul, Turkey, June 19-24, 2017: "Bridge together".

World Congress of Cardiology.

The Fourth World Congress of the International Society of Plastic Regenerative Surgeons: Another Successful Scientific Forum for Regenerative Surgery.

Abstracts of the 11th Annual Congress of the European Cardiac Arrhythmia Society, April 19-21, 2015, Paris, France.

Abstracts of the 11th World Congress of the International Hepato-Pancreato-Biliary Association, 22-27 March 2014, Seoul, Korea.